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Based on observation, document review, and interview, it was determined for 1 of 1 medication refrigerator on the C South Unit, the Hospital failed to ensure daily temperature monitoring of the medication refrigerator. This potentially affected all patients on census on the unit (C South) on 3/3/16 and 3/4/16, who would receive refrigerated medications.

Findings include:

1. On 3/8/16 at approximately 1:00 PM, an observational tour of C South unit was conducted. The medication refrigerator log for the month of March 2016 was reviewed. The log did not include the temperature was checked for 2 days (3/3/16 and 3/4/16). The refrigerator contained medications such as Insulin (diabetes medication) and Ativan (antianxiety medication).

2. Policy titled "Refrigerator Drug Storage," (revised 3/12) reviewed on 3/8/16 required, "Policy: All refrigerated drug storage areas will be inspected daily to ensure compliance with drug storage standards ...C. On patient units, Nursing Department staff are responsible for inspection of drug storage refrigerators. A daily record log of temperature readings will be maintained on the outside door of the refrigerator."

3. On 3/9/16 at approximately 9:00 AM, an interview was conducted with the Director of Nursing who stated that medication refrigerator temperature should be checked and documented every night by the charge nurse.

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

Finding include:

1. The Hospital's, "Medical Staff Bylaws and Rules and Regulations (approved 7/1/11) required, "...Medical Records...C. General Considerations...2. Medical records of discharged patients must be completed and filed within 30 days of discharge..."

2. On 3/10/16 at approximately 1:40 PM, the Hospital presented an attestation letter that indicated the Hospital had a total of 12 delinquent records past 30 days.

3. On 3/10/16 at approximately 1:45 PM the Director of Health Information Services stated that there are 12 incomplete medical records and our goal is zero.

Based on observation, document review, and interview, it was determined for 2 of 6 cold storage units, (refrigerator #3 and freezer #4), the Hospital failed to ensure unused, left-over foods were stored as required. This potentially affected the 110 patients currently on Hospital census.

Findings include:

1. On 3/9/16 at approximately 11:30 AM, an observational tour of the Food and Dietary department was conducted. The following observations were noted:

- In freezer #3 - A package of bacon was opened and out of its original package and a package of turkey sausage was opened and wrapped. Both items failed to include a label of the date opened and the content of the package.

- In refrigerator #4- 18 cups of poured juice with no label or date when opened and poured.

2. Policy titled "Left Overs" (reviewed 1/16) reviewed on 3/9/16 required, "...Storing Leftovers: At the end of meal service, left-over foods will be covered, labeled (with food item name and date stored) and refrigerated properly.

3. On 3/9/16 at approximately 11:35 AM, an interview was conducted with the Director of Support Services/Dietary who stated that the above food items should have been labeled and dated.

On March 8 - 10 2016, the Life Safety Code portion of a Full Survey Due to a Complaint was conducted. The surveyor finds 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 A 710

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on March 8-10, 2016 the surveyors find that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see K-tags.