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Based on review of facility documentation and employee interviews (EMP), it was determined that the facility failed to ensure that the governing body reviewed and resolved grievances, unless it delegated the responsibility in writing to a grievance committee.

Findings include:

1. Review, at approximately 1:15 PM on December 21, 2017, of "Complaints and Grievances Procedure," (no revision date available) revealed, "... Investigation ... b. Appropriate manager made aware of complaint/grievance c. Appropriate manager responds within seven days ..." Review did not reveal a requirement for the governing body, or a delegated grievance committee to review and resolve grievances.

2. An interview was conducted with EMP5 on December 20, 2017, at approximately 2:00 PM in relation to the Complaint/Grievance Process. EMP5 was asked who was on the Complaint/Grievance Committee. At that time, EMP5 stated, "We review any complaints in our meetings, however there isn't a persay committee, but they do get reviewed. We don't get a lot of complaints here, but they are addressed when we do." When asked if there were minutes to reflect the committee review, EMP5 stated, "No." When asked if the governing body had delegated the responsibility to review and resolve the grievances to a committee, EMP5 stated "No."

Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to ensure that all verbal orders were dated and timed by the ordering practitioner in accordance with Medical Staff Rules and Regulations for four of eight medical records containing verbal orders (MR3, MR4, MR5, and MR6).

Findings include:

Review, at approximately 1:20 PM on December 21, 2017, of the Ellwood City Medical Center Rules and Regulations, created October 17, 2017, revealed, "... Section 4. General Conduct of Care ... 4.2 Orders ... c. Phone orders: ... v. Phone orders must be signed by the Physician Member who gave the phone order or who is responsible for the care of the patient within forty-eight (48) hours of giving the order. ..."

1. Review, at approximately 11:00 AM on December 21, 2017, of MR3 revealed four phone orders that were co-signed by EMP6 with no associated date or time.

At approximately 2:27 PM on December 21, 2017, EMP5 confirmed that there was no date or time associated with EMP6's phone order co-signatures.

2. Review, at approximately 11:15 AM on December 21, 2017, of MR4 revealed three phone orders that were co-signed by EMP7 and EMP8 with no associated date or time.

At approximately 2:28 PM on December 21, 2017, EMP5 confirmed that there was no date or time associated with EMP7 and EMP8's phone order co-signatures.

3. Review, at approximately 11:30 AM on December 21, 2017, of MR5 revealed three phone orders that were co-signed by EMP9 with no associated date or time.

At approximately 2:29 PM on December 21, 2017, EMP5 confirmed that there was no date or time associated with EMP9's phone order co-signatures.

4. Review, at approximately 11:45 AM on December 21, 2017, of MR6 revealed eight phone orders that were co-signed by EMP7 and EMP10 with no associated date or time.

At approximately 2:30 PM on December 21, 2017, EMP5 confirmed that there was no date or time associated with EMP7 and EMP10's phone order co-signatures.

Based on review of facility documentation, observations and employee interviews (EMP), it was determined that facility failed to maintain supplies to ensure an acceptable level of safety.

Findings Include:

Review, at approximately 2:20 PM, on December 27, 2017, of "Crash Cart Maintenance" policy, reviewed September 2017, revealed, "... Policy ... 4. Crash carts in each department are to be thoroughly checked on a regular basis ensuring that all items are within expiration date. a. ER, ICU, Behavioral Health and Medical/Surgical Departments will perform their own routine checks of crash cart within their department."

1. During a tour of the Medical/Surgical Unit between 10:15 AM-11:00 AM on December 20, 2017, the following supplies and associated expiration dates were identified: one #4 Adult Tracheostomy Kit - August 2017; one Con Med 10" long - August 2017; six Ultrasite Valves (41510) - November 2017; and two Provent Arterial Blood Sampling Kits - August 2017.

EMP11, present for the tour, confirmed the above findings. EMP11 added, "We are aware our system for checking the crash carts needs updated. I could throw away about eighty percent of the supplies in this cart. [EMP5] and I will be developing a better plan the first of the year, because right now the nurses are spending probably three hours a month checking these supplies."

2. During a tour of the Rehab Unit between 9:00 AM-9:30 AM on December 20, 2017, the following supplies and associated expiration dates were identified: 40 Non-Adherent Pad Prepack 8" X 3" - "10/2017;" 31 Prep Protective Skin Barriers - "11/2013;" four Abdominal Pads 7.5" X 8" - "8/2016;" and five Microorganism Collection and Transport Systems - "1/20/2017."

EMP25, present for the tour, confirmed the above findings.

3. During a tour of OR1, between 9:35 AM-9:40 AM on December 21, 2017, the following supplies and associated expiration dates were identified: two Adult CO2 Detectors - "11/2015" and "2/2017;" one 7.5 mm Cuffed Oral Tracheal Tube - "9/2017;" three Eyepads - "4/2017;" one IV Catheter 20 GA X 1.00 IN with a labeled expiration date of "7/2017;" one Adult Manual Resuscitator - "8/2016;" one Arterial Blood Sampling Kit - "10/2017;" two Radial Artery Catheterization Set - "2/2016;" one IV Catheter 14 GA X 1.75 IN - "1/2016;" one IV Catheter 20 GA X 1.00 IN - "7/2017;" one 1V Catheter 18 GA X 1.16 IN - "9/2017;" one Adult Size 4 Laryngeal Mask - "8/2017;" one Adult Size 5 Laryngeal Mask - "8/2017;" and one red lab tube - "12/6/17."

EMP5 and EMP22 confirmed the findings at the time of observation.

4. Additionally during this tour, the following sterile items, with open packaging were identified: one open yankauer attached to a suction container for future use with no patient present; eight open Steris Cleansed Tips; three open Medium Adult Airflex Cushioned Face Masks; one open Large Adult Airflex Cushioned Face Mask; one Ventolin 90 Mcg per use Canister was identified in a 60cc syringe with no packaging; 35 open tongue depressors with no packaging; one open 7.5 mm Cuffed Oral Tracheal Tube with a 10cc syringe attached; two open Laryngoscope Blades; and two open 20cc syringes.

EMP5 and EMP22 confirmed the findings at the time of observation.

5. During a tour of the Endoscopy Surgical Suite, between 9:50 AM-9:54 AM on December 21, 2017, the following supplies and associated expiration dates were identified: one 6.0 mm Cuffed Tracheal Tube - "7/2015;" one 8.0 mm Cuffed Tracheal Tube - "8/2017;" two Adult CO2 Detectors - "11/2015" and "2/2017;" one Adult Manual Resuscitator - "8/2015;" two Adult Size 5 Laryngeal Masks - "8/2015" and "8/2017;" one Adult Size 3 Laryngeal Mask - "12/ 2016;" and two Albuterol Sulfate 0.083% 2.5 mg/3 ml packages - "12/ 2016" and "9/2015."

EMP5 and EMP22 confirmed the findings at the time of observation.

6. Additionally during this tour, the following sterile items, with open packaging were identified: two open 7.5 mm Cuffed Tracheal Tubes with 10cc syringes attached; one face mask with oxygen tubing attached with no packaging; four Steris Cleansed Spray Tips with no packaging; one 60cc syringe with a Ventolin HFA 90 mcg canister inside with no packaging; one 20cc syringe with no packaging; and two tongue depressors with no packaging.

EMP5 and EMP22 confirmed the findings at the time of observation.

7. During a tour of OR2, between 10:00 AM-10:15 AM on December 21, 2017, the following supplies and associated expiration dates were identified: one Adult Manual Resuscitator - "8/2015;" two 1 mL syringes with 27G X 1/2 IN needles attached - "1/2017;" one red lab tube - "12/6/2017;" five IV Catheters 22G X 1 IN - (three) "11/2017," (one) "9/2015," and (one) "2/2015;" four IV Catheters 18G X 1.16 IN - "9/2017;" six IV Catheters 24G X 0.75 IN - "9/2017;" one Arterial Blood Sampling Kit - "9/2014;" one Rate Flow Regular Extension - "4/2012;" three T-Site Flexible Manifold Extensions - (two) "7/2017," and (one) "3/2016;" and one Insyte Autogaurd 14GA X 1.75 IN - "1/2016."

EMP5 and EMP22 confirmed the findings at the time of observation.

8. Additionally during this tour, the following sterile items, with open packaging were identified: 38 tongue depressors with no packaging; one open 18 French Suction Catheter; one open 20cc syringe; one open 10cc syringe; one open Safety Nitroglycerin Set; one open Adult Size 5 Laryngeal Mask; one open yaunker; one open Medium Airflex Plus Air Cushioned Face Mask; four open Laryngoscope Blades; one 60cc syringe with a Ventolin HFA 90 mcg canister inside with no packaging; one open 7.5 mm Cuffed Tracheal Tube with a 10cc syringe attached; one Adult CO2 Detector - "11/2015;" 42 tongue depressors with no packaging; one open McGill Forceps; one open 3 mL syringe; five stylets with no packaging; one open oxygen mask with oxygen tubing connected; and one oxygen tubing with no packaging.

EMP5 and EMP22 confirmed the findings at the time of observation.

9. During a tour of OR3, between 10:16 AM-10:31 AM on December 21, 2017, the following supplies and associated expiration dates were identified: four Eye Protectors - (two) "9/9/2014," (two) "3/2013;" one open 20cc syringe; one Adult Size 5 Laryngeal Mask - "3/2017;" one 8.5 mm Cuffed Tracheal Tube - "5/2013;" one open 6.5 mm Cuffed Tracheal Tube - "10/2011;" one 6.0 mm Cuffed Tracheal Tube - "4/2009;" one Hot Fluid Warming Set - "7/2007;" one red lab tube - "12/6/2017;" one Acoustascope 18 Fr - "12/2014;" one Adult Manual Resuscitator - "8/2016;" four 1 Hand with Strips and Label IV Bandage - "11/2015;" and four Adult Size 4 Laryngeal Masks - "8/2017."

EMP5 and EMP22 confirmed the findings at the time of observation.

10. Additionally during this tour, the following sterile items, with open packaging were identified: one open 7.5 mm Cuffed Tracheal Tube with a 10cc syringe attached; six Stylets with no packaging; eight Steris Cleansed Spray Tips with no packaging; two 10cc syringes with no packaging; two Laryngoscope Blades with no packaging; one open yaunker; and one open Medium Adult Airflex Plus Air Cushioned Mask.

EMP5 and EMP22 confirmed the findings at the time of observation.

11. During a tour of the PACU, at approximately 10:40 AM on December 21, 2017, three open yankauers with suction tubing attached, were identified.

EMP5 and EMP22 confirmed the findings at the time of observation.

12. At approximately 12:30 PM on December 21, 2017, EMP4 stated, "Yes, we realize there is a problem in the OR; and we had a meeting with the staff member responsible for checking supplies. ... [He/She] resigned ... then changed [his/her] mind."

13. At approximately 1:00 PM on December 21, 2017, EMP5 stated, "I met with [EMP33] regarding the supplies in the OR, ... [EMP33] did turn in [his/her] resignation."

14. At approximately 1:40 PM on December 21, 2017, review of meeting documentation regarding supplies, revealed, "December 15, 2017: Meeting with [EMP33] and [EMP34]. ... [EMP35] stated at times that [he/she] witnessed that in the anesthesia cart that there are supplies that are outdated or evening missing all together. ... [EMP33] ... stated [he/she] does check the carts on a routine basis and [he/she] does [his/her] job. ... On the way out, [EMP33] stated that [he/she] is putting her two weeks in and will provide a letter to Human Resources on [his/her] last day. ... Signed [EMP5]."

15. At approximately 1:50 PM on December 21, 2017, review of email documentation from EMP36 to EMP4, EMP5, and EMP34, revealed, "Subject: resignation ... [EMP33] called to put in [his/her] notice today and will be done on Friday, December 22, 2017. ... Signed: [EMP36]."