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Based on document review and interview, it was determined that for the Medical Staff Bylaws and Rules and Regulations, the Hospital failed to ensure completeness to include who is qualified to perform medical screening exams. This potentially affected all patients presenting to the emergency department.

Findings include:

1. The Hospital's Medical Staff Bylaws (effective date September 19, 2014) and Rules and Regulations of the Medical Staff (adopted and approved March 21 2002) were reviewed on 2/19/15. The documents failed to include the requirement of who is qualified to perform the medical screening exam in the Emergency Department as required by 489.24(r) and 489.24(c). Which includes:

"Applicability of provisions of this section.
(1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must (i) provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and..."

2. The Interim Director of Quality stated during an interview on 2/19/15 at approximately 10:00 AM that the only reference to the medical screening exam is in a Board of Directors meeting 02/21/2002 and a Credentials Committee dated 09/04/12.

Based on document review and interview, it was determined, for 2 of 2 psychiatric patients (Pts. #33 & 34), the Hospital failed to ensure patients were informed about and signed a psychotropic medication consent, prior to psychotropic medication administration.

Findings include:

1. On 2/18/15 at 1:30 PM, Hospital policy #PC78 I005, titled, "Informed Consent for Medication Administration", effective 1/25/15, was reviewed. The policy required, "All patients admitted to the inpatient psychiatric units... who are prescribed psychotropic medications, will be provided information so that informed consent can be obtained... The LIP's [Licensed Independent Practitioner] and the patient's signatures on the Consent for Medication and Treatment form documents that the patient has given informed consent for administration of psychotropic medications."

2. On 2/18/15 at 10:45 AM, Pt. #33's clinical record was reviewed. Pt. #33 was a 58 year old female, admitted on 2/12/15, with diagnoses of acute schizophrenia and psychosis. Pt. #33's medication administration record (MAR) dated 2/15/15 at 6:05 AM, included Ativan (Anxiolytic) and Haldol (anti-psychotic) were administered for agitation. Pt. #33's psychotropic medication consent, dated 2/14/15 did not include Ativan or Haldol.

3. On 2/18/15 at 1:10 PM, Pt. #34's clinical record was reviewed. Pt. #34 was a 64 year old male, admitted on 2/3/15, with diagnoses of suicidal ideation and depression. Pt. #34's physician's order dated 2/3/15, included Ativan and physician's order dated 2/7/15, included Zyprexa (anti-psychotic). Pt. #34's psychotropic medication consent, dated 2/4/15 did not include Ativan or Zyprexa and a subsequent medication consent form was not found. Pt #34's MAR included that he had received Ativan 1 mg on 2/3/15 at 9:20 PM.

4. On 2/18/15 at 1:20 PM, an interview was conducted with a Vice President of Patient Care Services (E #2). E #2 reviewed Pts. #33's & 34's psychotropic medication consent forms and stated Pt. #33 refused to sign the form and Pt. #34's Zyprexa was ordered after the psychotropic medication consent form was completed.

5. The Hospital's "Psychotropic Drug List) was reviewed on 2/20/15. The list included: Haldol; Zyprexa; and Ativan.

Based on document review, observational tour, and interview, it was determined, for 2 of 2 blue pills on the floor, nursing staff failed to ensure psychiatric patients swallowed their medication when administered, potentially affecting the safety of 11 patients on the 4 South unit on 2/18/15.

Findings include:

1. On 2/19/15 at 10:30 AM, Hospital policy # PC78-A005, titled, "Administration of Medications on Psychiatric Units", effective 1/24/11, was reviewed. The policy included, "1. Registered nurses (RN) are the only nursing personnel permitted to administer medications on psychiatric units." The policy failed to include monitoring patients for medication compliance after the administration.

2. On 2/19/15 at 9:40 AM, a policy for mouth check for psychiatric patients during medication administration was requested from the Vice President of Patient Care Services (E #2). E #2 stated there is no policy.

3. On 2/18/15 at 10:00 AM, an observational tour was conducted on 4 North/South, an adult psychiatric unit. At 10:25 AM, in 4 South, outside room 466, two (2) blue pills were found on the floor.

4. On 2/18/15 at 10:25 AM, an interview was conducted with the registered nurse (E #4) who passed the morning medications on 4 South. E #4 stated that she observed all the patients taking their medications and she did not administer any blue pills today.

5. On 2/18/15 at approximately 1:00 PM, an interview was conducted with the Outcomes Manager (E #7). E #7 stated the Manager of In-patient Psychiatry (E #1) thought the blue pill was Paxil (anti-depressant).

6. On 2/19/15 at 9:40 AM, an interview was conducted with the Vice President of Patient Care Services (E #2). No patient on the South section of the 4th floor psychiatric unit was taking blue pills. There was a patient (Pt. #35) on the North section taking a blue pill. Patients on the North section can not enter the South section, but South section patients can enter the North section for group therapy. E #2 stated it is possible Pt. #35 gave the medication to a South section patient during a group meeting and that patient carried the blue pills to the South section.

Based on interview and document review, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of discharge.

Findings include:

1. The Director of Health Information Management (HIM) was interviewed on 2/19/15 at approximately 9:45 AM. The Director stated that there are delinquent medical records greater than 30 days.

2. The Director of HIM presented an attestation letter dated 2/19/15 at approximately 1:00 PM, indicating there are 162 delinquent medical record as of 2/19/15.

3. The "Rules and Regulations of the Medical Staff" (adopted 3/2/02) required, 'The attending physician shall be held responsible for preparation and completion of the medical record for the hospital files within a reasonable length of time as designed in the bylaws...."

4. The "Medical Staff Bylaws" (adopted 9/11/14) required, "16.4 Automatic Administrative Suspension Initiation. Medical staff membership and clinical admitting privileges shall be automatically administratively suspended or limited under the following circumstances... A Medical Staff member who has: i. three (3) or more delinquent Medical records including operative reports in a thirty (30) day period...."

Based on document review, observational tour, and interview, it was determined, for 4 of 4 psychiatric discharged patients (Pts. #36 - 39), the hospital failed to ensure medication prepared by the outpatient pharmacy were given to the patients before discharge.

Findings include:

1. On 2/19/15 at 10:55 AM, Hospital policy # PC70-RX-430, titled, "Discharged Medications", effective 7/3/13, was reviewed. The policy included, "Policy: 4. All prescriptions written out for the patient upon discharge must be sent or taken to the outpatient pharmacy or an outside pharmacy for filling... Procedure: 1. Discharge instructions with medication and the indications for the medications and prescriptions are given to the patient.

2. On 2/19/15 at 10:50 AM, Hospital policy # PC78-A005, titled, "Administration of Medications on Psychiatric Units", effective 1/24/11, was reviewed. The policy included, "7. Medications released by the physician and left by discharged patients, will be sent to the Pharmacy for disposal."

3. On 2/18/15 at 10:00 AM, an observational tour was conducted on 4 North/South, an adult psychiatric unit. At 10:10 AM, in the 4 North medication room, 4 bags (Pts. #36 - 39) containing 2 or more vials of medication were found. Pts. #36 - 39 had been discharge home (Pt. #36 on 10/29/14, Pt. # 37 on 11/26/14, Pt. #38 on 12/12/14, & Pt. #39 on 1/29/15). The medications had neither been provided to the patient nor returned to the pharmacy.

4. On 2/18/15 at 10:10 AM, an interview was conducted with the Vice President of Patient Care Services (E #2). E #2 stated the medication prepared by the outpatient pharmacy should have been returned to the pharmacy if the patients did not take it with them.

Based upon observation, staff interview, and document review during the life safety code portion of a full survey due to complaint conducted on February 17 - 19, 2015, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of life safety code deficiencies that were found. Also see A710.

Based upon observation, staff interview, and document review during the life safety code portion of a full survey due to complaint conducted on February 17 - 19, 2015, , the surveyor finds that the facility does not comply with NFPA 101, Life Safety Code, 2000 edition.

This is evidenced by the severity, variety, and number of life safety code deficiencies that were found. Also see K-tags cited for survey dated 02/15/2015.

Based on document review and interview, it was determined that for 1 of 1 (E # 8) Infection Control Practitioner, the Hospital failed to ensure the practitioner was qualified as required by the job description. This potentially affected all patients on census, as of 02/19/15.

Findings include:

1. The job description for "Infection Control Practitioner" (revised date March 2012)reviewed on 2/19/15, required, "General Job Requirement: ...Bachelor's degree in healthcare related field required."

2. The personnel file for E #8 was reviewed on 2/19/15. E #8's employment application dated 5/13/14 listed E #8's education/training as: "Course of study- Nursing; No. of Years Completed-2; Type of Diploma or Degree-ADN (associate degree in nursing)."

3. The above finding was discussed with the Interim Director of Quality during an interview on 2/19/15 at approximately 1:45 PM who stated that E #8 is the current Infection Control Practitioner.

A. Based on observation, interview, and document review, it was determined that for 1 of 1 (E #3) staff observed, the Hospital failed to ensure aseptic technique was maintained when drawing medications from vials, as required by Hospital policy.

Findings include:

1. An observation of OR (operating room) 4 was conducted on 2/18/15 between 9:20 AM and 10:00 AM. E #3 (certified registered nurse anesthetist) was observed drawing and preparing medications for a surgical case. After removing the top, E #3 failed to wipe clean the rubber top of each vial of medication prior to inserting a needle and drawing the medication.

2. The Interim Director of Surgical Services was interviewed on 2/18/15 at approximately 9:25 AM and stated that the vial top is sterile and does not need to be wiped clean with an alcohol pad, and that only multidose vials are wiped clean the second time it is entered with a new needle.

3. The Hospital policy titled, "Safe Injection Practices: Single and Multidose Vials" (effective 9/25/14), reviewed on 2/18/15 required, "Use aseptic technique at all times to maintain the sterility of the drug/vial. A. Use vigorous mechanical friction and an alcohol/Chlorhexidine, 70% alcohol or providone iodine preparation to disinfect the rubber septum/diaphragm before each entry. Allow the disinfectant to air dry before accessing the vial."

4. The above findings were discussed with the Interim Director of Surgical Services on 2/19/15 at 1:30 PM who stated she contacted AORN (Association on Operating Room Nurses) and confirmed that medication vial septum should be wiped clean before each entry.


B. Based on document review and staff interview, it was determined that for 1 of 1 isolation room in the pediatric unit, the Hospital failed to ensure the room was appropriate for airborne isolation.

Findings include:

1. The Hospital policy titled " Standard and Transmission Based Precautions" reviewed on 2/19/15 required, "1) Use Airborne precautions for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei 2. Place the patient in a private airborne infection isolation (AII) room that has a. Monitored negative pressure room b. Appropriate exhaust of air outdoors."

2. The Hospital policy titled " Standard and Transmission Based Precautions" reviewed on 2/19/15, indicated: "c. If all negative airflow rooms are occupied, consult Infection Prevention and Control, place the patient in a private room and obtain a portable HEPA filter from Central Supply." The policy allows for an airborne precaution patient to be placed in a room without negative pressure.

3. An interview with the Manager of Pediatrics (E #9), was conducted on 2/19/15 at approximately 11:30 AM. E #9 stated that the room, identified as an isolation room used for TB patients, is not a negative pressure room, but that a HEPA filter would be placed in the room to clean the air. E #9 stated that the last rule-out TB patient was 2 years ago.

4. An interview was conducted with the Director of Plant Maintenance (E #10) was conducted on 2/19/15 at approximately 1:00 PM. E #10 stated that there are no logs documenting testing of negative pressure for the isolation room, and that the room is not certified as a negative pressure room.

5. The Chief Nursing Officer interviewed on 2/19/15 at approximately 2:30 PM, stated the room should be a negative pressure room if an airborne precaution patient is to be housed in that isolation room.

Based on document review and interview, it was determined that for 1 of 1 (Pt #29) clinical record reviewed of a patient transferred from a nursing home, the Hospital failed to ensure the patient was appropriate to return to the pre hospital setting.

Findings include:

1. Hospital policy entitled, "Assessment and Reassessment for Discharge Planning and Referrals," (effective date March 27,2014) reviewed on 2/19/15 required, "Policy: 2. An ongoing assessment will be performed by the CM, MSW/LSW, and CW to ensure that discharge needs are met through reassessment...and coordinating services according to the clinical needs ...from admission to post hospitalization."

2. The clinical record of Pt #29 was reviewed on 2/18/15. Pt #29 was a 42 year old female admitted on 11/26/14 with a diagnosis of suicidal ideation. Pt #29's psychiatric evaluation dated 11/27/14 included that the patient was admitted from a nursing home. Pt #29's social service followup note dated 12/4/14 included that Pt #29 was discharged back to the nursing home. The clinical record lacked documentation during Pt #29's stay of reassessments that indicated Pt #29 was appropriate to return and was accepted back at the nursing home from which she was admitted.

3. The Manager of Acute Care Case Managers stated during an interview on 2/18/15 at approximately 9:45 AM that the clinical record lacked documentation regarding the patient's discharge plans back to the nursing home.

Based on document review and interview, it was determined that for 1 of 1 (Pt #32) clinical record reviewed of a patient discharged to hospice, the Hospital failed to ensure the patient/family received a listing of hospices in the patient's area.

Findings include:

1. Hospital policy entitled, "Hospice Referral," (effective date 02/11/13) reviewed on 2/18/15 required, "Procedures: 2. A. CPOE (computerized physician order entry) or written order is documented in the MR (medical record). 4. The case manager and/or social worker must document in the patient's medical record that the list was presented to the patient or the individual acting on the patient's behalf."

2. The clinical record of Pt #32 was reviewed on 2/18/15. Pt #32 was a 69 year old male admitted on 11/26/14 with a diagnosis of chronic obstructive pulmonary disease, in stable condition. Social Service documentation dated 11/28/14 included that Pt #32 was admitted from home, had homemaker services 5 days a week, around the clock caregiver services, and a hospital bed. Physician documentation dated 12/4/14 included, "family has agreed for...and hospice care." Nursing documentation dated 12/4/14 included that Pt #32 was "transferred to hospice." Pt #32's clinical record lacked a physician's order for hospice care and lacked documentation that the patient and/or family received a listing of hospices.

3. The Manager of Acute Care Case Managers stated during an interview on 2/18/15 at approximately 9:45 AM that the clinical record lacked documentation of a physician's order for hospice, and lacked documentation that the patient and/or family had received a listing of hospices.

Based on document review and interview, it was determined that for 1 of 1 (Pt #21) clinical record reviewed for a patient discharged with home health, the Hospital failed to ensure all discharge planning was documented in the patient's clinical record, to include home health information.

Findings include:

1. Hospital policy entitled, "Home Care Referrals," (effective date 2/11/13) reviewed on 2/18/15 required, "Purpose: To ensure that all patients admitted to the Hospital receives any necessary post-hospital home health care needs and/or equipment." The policy failed to include the requirement that patients' clinical records include documentation that a list of home health agencies was provided to the patient and/or family.

2. The clinical record of Pt #21 was reviewed on 2/18/15. Pt #21 was a 77 year old male admitted on 12/11/14 with a diagnosis of cancer of the lung with brain metastasis. Pt #21's clinical record contained a physician's order dated 12/22/14 that included social service referral to arrange for home care equipment and an order dated 12/23/14 that included "Discharge home with home health." Pt #21's clinical record lacked documentation that the patient and/or family was provided a list of home health agencies in the patients community.

3. The Case Manager stated during an interview on 2/18/15 at approximately 9:45 AM that the patient was a medicare HMO that contracted with certain agencies and the record did not contain a list of agencies approved by the patient's HMO.

A. Based on document review, observation, and interview, it was determined for 1 of 1 operating room (OR) on the Labor and Delivery unit, the Hospital failed to ensure the flooring was maintained to allow for proper disinfection, allowing for the potential for cross contamination.

Findings include:

1. The Hospital's policy entitled, "Surgical Area Cleaning (Terminal and Between Case)" (revised 03/2014) required, "...wet mop the floor of the OR Suite with approved disinfectant solution and microfiber mop, working from around OR table to periphery...Report any potential maintenance concerns for surfaces/items in need of repair..."

2. During a tour of the operating room on the Labor and Delivery unit on 2/19/15 at approximately 9:30 AM, a two inch long separation in the seam of the flooring was observed, rendering it unable to be disinfected in accordance with policy.

3. During an interview with the Manager of Perinatal Services (E #4) on 2/19/15 at approximately 9:35 AM, E #4 stated that the floor was unable to be properly disinfected, and a work order for repair had been submitted on 2/18/15.


B. Based on document review, observation, and interview, it was determined that for 3 of 4 waste carts and 2 of 2 prep tables in OR #4, the Hospital failed to ensure equipment was free from rust to enable thorough disinfection, potentially affecting the patient (1) scheduled for surgery in OR #4 on 2/18/15.

Findings include:

1. The Hospital's policy entitled, "Surgical Area Cleaning (Terminal and Between Case)" (revised 03/2014) reviewed on 2/18/15 required, "...Remove gross dirt from equipment wheels, followed by washing with approved disinfectant solution...Report any potential maintenance concerns for surfaces/items in need of repair..."

2. During a tour of the surgical suite on 2/18/15 between 7:30 AM and 8:45 AM, rusty wheel bases were observed on 2 of 2 prep tables and 3 of 4 waste carts located in OR #4 rendering them unable to be properly disinfected.

3. During an interview with the Director of Surgical Services (E #5) on 2/18/15 at approximately 8:45 AM, E #5 stated that there should not be rust on the wheel bases of the equipment.