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Based on the life safety code survey conducted 07/25/16 through 07/28/16, the facility failed to ensure; access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit was not readily apparent to the occupants. Doors, passages or stairways that were not a way of exit that were likely to be mistaken for an exit have a sign designating "No Exit", that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3., that when an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas, the area was separated from other spaces by smoke resisting partitions and doors, that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills were to be held at unexpected times under varying conditions, at least quarterly on each shift. The staff was to be familiar with procedures and failed to ensure that medical gas storage areas were identified with a precautionary sign in accordance with 8-3.1.11.3 of the code.( A710)

Based on medical record review, policy review and staff interview, the agency failed to ensure all orders were co-signed by the registered nurse, failed to ensure all orders contained the date and time and failed to complete the 12 hour chart check per policy. This affected two out of two patients reviewed (Patient #6 and #7). The census was 23.

Findings include:

Review of the hospital policy titled "Orders, Physician", Number O02-G, revised 01/01/16, on page three, #6. Transcribing Orders, B(6), C, revealed "Nurses will date, time signature and title on the same line as order. Orders will be co-signed by the registered nurse (RN) to ensure accuracy and initiation by the end of each shift."

On page four, N. Chart Check, it was written "All physician orders for at least the past 12 hours are to be checked and additions, corrections and/or deletions made are indicated. The completion of the 12 hour chart check is documented by...writing 12 hour chart check completed with signature, title, date and time".

1. Review of the medical record for Patient #6 revealed two physician orders dated 07/18/16, but neither were timed, a third order dated 07/18/16, timed 3:50 PM and a fourth order dated 07/18/16 timed 6:59 PM with no documented evidence these orders had been transcribed or co-signed by an RN or that the "12 hour chart check" had been done.

On 07/26/16 at 2:58 PM per interview, the Director of Quality confirmed the physician's orders were not co-signed by a registered nurse or the 12 hour chart check was done per policy.

2. Review of the medical record for Patient #7 revealed a physician's order dated 07/22/16 at 9:43 AM and 07/26/16 at 6:40 PM, with no documented evidence these orders had been transcribed or co-signed by a RN or that the "12 hour chart check" had been done.

On 07/27/16 at 10:39 AM per interview, the Chief Nursing Officer confirmed the 12 hour chart check was not done, the physician orders were not co-signed and not complete with date and time of signature.

Based on medical record review and interview, the facility failed to ensure physician orders were timed for one (Patient #11) of 30 medical records reviewed. The census was 23.

Findings include:

1. The medical record review for Patient #11 revealed an order for restraints on 04/23/16. The order did not contain the time the order was written.

The findings were shared with Staff F on 07/28/16 at approximately 9:00 AM and confirmed.

Based on review of medical records and staff interview the hospital failed to ensure all dressing changes were done per physician's order. This affected one of one patient reviewed with dressing changes (Patient #22). The census was 23.

Findings include:

1. Review of the medical record for Patient #22 revealed a physician's order dated 07/22/16 for a wound dressing to the abdomen to be changed once a day. Review of the hospital form titled "Wound Documentation" revealed no evidence the dressing change to the abdomen had been done on 07/23/16 or 07/24/16.

2. Review of the physician's order dated 07/25/16 revealed dressing changes to the patient's abdomen increased to three times a day. Review of the Wound Documentation form revealed no documented evidence the wound dressing had been changed on 07/25/16, 07/26/16 or 07/27/16 as of 4:30 PM.

On 07/27/16 at 4:50 PM per interview, the Chief Nursing Officer confirmed there was no documentation the abdominal wound dressing had been changed.

Based on review of the facility schematic, tour of the facility, review of facility documentation and staff interview, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101 2000 edition of the Life Safety Code. Potentially all patients and visitors could be adversely affected. The facility census was 23.

Findings include:

On 07/25/16 through 07/28/16 a life safety code survey was conducted throughout the facility. The following findings were based on that life safety code survey:

K22, which addressed the facility's failure to ensure access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit was not readily apparent to the occupants. Doors, passages or stairways that were not a way of exit that were likely to be mistaken for an exit have a sign designating "No Exit".

K25, which addressed the facility's failure to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3.

K29, which addressed the facility's failure to ensure that when an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas, the area was separated from other spaces by smoke resisting partitions and doors.

K50, which addressed the facility's failure to ensure that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills were to be held at unexpected times under varying conditions, at least quarterly on each shift. The staff was to be familiar with procedures.

K141, which addressed the facility's failure to ensure medical gas storage areas were identified with a precautionary sign in accordance with 8-3.1.11.3 of the code.

The above findings were confirmed by facility staff. Please see the life safety code report for more specific details.

Based on observation and interview, the facility failed to identify expired supplies located in one of one respiratory boxes observed. This had the potential to affect all of the facility's 23 patients.

Findings include:

The facility's Respiratory Stat Box was observed on 07/26/16 at 10:47 AM. The box contained five packets of E-Z Lubricating Jelly lot # 974410 with an expiration date of June 2016.

The findings were shared with Staff G at the time of the observation and confirmed.

Based on observation, interview and review of policies and procedures, the facility failed to ensure staff performed hand hygiene and appropriate infection control practices before and during patient care for two (Patient #13 and #22) of two patients observed for patient care. The census was 23.

Findings include:

Review of policy and procedure for General Guidelines and Responsibilities (revised April 2013) revealed the policy of this hospital was to prevent the spread of communicable disease among patients, hospital personnel and visitors. Standard Precautions were used in the care of all patients at the hospital. In following standard precautions all patients and blood and body fluids were considered as potentially infectious.

Review of the policy and procedure for Hand Hygiene (revised July 2016) revealed hand hygiene should be performed before and after every patient contact, prior to donning either sterile or non-sterile gloves, between glove change, after removing gloves, after any contact with body fluids, dressings, and with patient linens.

1. On 07/26/16 at 9:20 AM Staff A was observed entering Patient #13's room for medication administration. Staff A failed to use proper hand hygiene after entering Patient #13's room and prior to donning gloves. Staff A was observed placing the patient's chart on the bed, placed a pill cutter on the dirty laundry cart prior to using it, and placed an intravenous (IV) cap on the tray table with no barrier prior to placing it on the patient's IV tubing.

Interview with Staff A at the time of the observation confirmed the above findings.

2. On 07/26/16 at 10:30 AM Staff B was observed during a dressing change for Patient #22. Staff B was observed to not use proper hand hygiene before donning gloves prior to removing the patients soiled abdominal dressing, or after applying the wet dressing. Staff B was also observed to not perform proper hand hygiene before donning gloves prior to removing the dressing of three abdominal drains and failed to perform hand hygiene and a glove change prior to the clean dressings were applied to the drains.

Interview with Staff B at the time of the observation confirmed the above findings.