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Based on observation, interview and documentation review, the facility failed to maintain the waiting area with smoke detector, exit signage on all paths of egress, penetrations in rated walls on all floors, door ratings that match wall ratings and ensure all doors required to latch, latched, hazardous areas with self closing door, exit signage in working condition, dirty sprinkler heads and escutcheons askew, portable fire extinguisher, chutes with doors kept closed or fusible link missing, medical gas shutoff valves with labels that matched room numbers, medical gas cylinders found outside in the extreme cold and safe use of power strips. (A709) The cumulative effect of these systemic practices resulted in the facility's inability to ensure the facility was maintained in a manner safe from fire. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Based on review of the governing body Code of Regulations, the hospital's medical staff bylaws, and staff interview, the hospital's governing body failed to ensure the hospital's Medical staff bylaws conformed to the Medicare Conditions of Participation for Hospitals by permitting the medical staff to grant temporary privileges. This has the potential to affect all patients who receive services at the hospital. The facility's census was 111 patients.
Findings include:

Interview with Administrative Staff B on 01/30/14 at 2:12 P.M. revealed the hospital's medical staff bylaws were routinely approved by the governing board and, as such, permission to grant temporary privileges was given to the Medical Staff and the facility's administrative staff.

Interview with Staff E on 01/29/14 at 11:51 A.M. revealed from 11/15/13 until 12/03/13 one physician, Staff S, was approved for temporary privileges by the Medical Staff until the physician's initial appointment was approved by the hospital's governing board. Staff E stated the hospital currently had no physicians practicing on temporary privileges.
Review of the facility's governing body code of regulations was completed on 01/30/14. This review revealed all the incorporated amendments were most recently approved as of 02/20/2013. Review of Article VII entitled Medical Staff Section 7.1 - Organization read: "The Board of Trustees shall organize the physicians and appropriate other practitioners granted practice privileges in the hospital into a Medical Staff under Medical Staff Bylaws approved by the Board of Trustees. The Board shall . . . appoint to the Medical Staff in numbers not exceeding the hospital's needs, physicians, and other practitioners who meet the qualifications for membership."
This Governing Body Code of Regulations failed to document any provision by the governing board for granting temporary physician privileges.

Review of the Medical Staff Bylaws was completed on 01/30/14. Article IV, Determination of Clinical Privileges Section IV.8 (B), Temporary Privileges, read: temporary privileges must be requested by the applicant, and the likelihood of positive final action on the application, and a demonstrated need or health care interest in the community. A completed application is defined as one that has met all of the requirements outlined in Article V.4, and is deemed ready for submission to the approval process. A clean application has no substantial controversial issues as defined in Article V.4. Temporary privileges are granted until final board action but no longer than 90 days.

Based on observation and staff interview, the facility failed to ensure medical records are protected from potential water damage. The facility's active census was 111.

Findings include:

During a tour of medical records department on 01/29/14 from 2:45 PM to 3:00 PM with Staff A, medical records were observed filed on open shelves in a room on the ground floor and in a room on the basement floor. Sprinkler heads were observed on the ceiling above the open shelves where the medical records were filed. During the tour, Staff A revealed the medical records filed on the shelves in the room on the ground floor were patient medical files for the years of 2010, 2011 and 2012. Staff A also indicated the medical records filed in the basement were from the months of July through December for the years of 2010, 2011 and 2012. Staff A revealed emergency room medical records were filed in the basement for the years of 2005 and 2006.

Staff A indicated none of these medical records had been scanned and there were no plans to scan these files. Staff A confirmed some emergency room files had received water damage after basement flooding had occurred.

On 01/29/14 at 3:10 PM, Staff Z confirmed the sprinklers were wet sprinklers.

Based on observation, staff interview and review of facility policy and procedure the facility failed to maintain food labels or discard outdated food items from the facility's refrigerator. This had the potential to affect any patient served from the facility's dietary service. The facility dietary department served a daily average of 460 dietary trays. The facility census was 111.

Findings include:

Environmental tour of the facility's dietary service on 01/27/14 between 1:05 P.M. until completion at 2:21 P.M. revealed the facility's walk in refrigerator was observed to contain a large rectangular stainless steel pan labeled tomato sauce. This label indicated the product was placed into the refrigerator on 12/20/13 and was to be used or removed by 01/20/14. Closer observation of this tomato sauce revealed two pea sized areas of what appeared to be bluish green mold in two corners of the pan. The top surface of the tomato sauce also had a quarter sized yellowish slimy looking area of a mold like growth.

Continued examination of the refrigerator revealed a pan of ham which was labeled as placed into the refrigerator on 01/21/14 and was to be discarded by 01/24/14. The refrigerator contained an opened 2.5 pound package of deli style sliced corned beef devoid of a label as to when it was opened or when it was to be discarded. Also, observed was a large rectangular pan which contained two five pound rolls of raw ground beef which indicated the rolls had been removed from the freezer to defrost on 01/10/14. This ground beef contained no other label.

Interview with Staff D on 01/27/14 at 2:21 PM verbalized the product was good for 14 days after removal from the freezer. The refrigerator also contained a pan of cooked turkey breast which was labeled as placed in the refrigerator on 01/17/14. Staff D verbalized the turkey was also good for 14 days before it needed to be discarded. Staff D verbalized the facility policy and procedure was that all foods placed into storage were to contain two dates, the first date was the date the item was placed into the refrigerator and the second date which directed when the item was to be discarded. The above findings were verified with Staff D on 01/27/14 at 2:21 P.M. at the conclusion of during the dietary department tour.

Review of the facility's policy and procedure entitled Food Storage Under Proper Conditions with a revision date of 05/04/10 revealed that food storage will be monitored and non conformances would be identified and tracked.

Interview with Staff D on 01/27/14 at 2:21 P.M. verified the facility was unable to provide documentation that refrigerator storage was monitored or tracked and the facility's walk in refrigerator contained outdated food items.

Based on observation, interview, and documentation review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility had a capacity of 224 patient beds with a census of 111 patients at the time of the survey completed on 01/30/14.

Findings include:

The waiting area was observed without smoke detector. Please refer to life safety code survey finding at K17 for further detail.

Paths of egress were observed without exit signage. Please refer to life safety code survey finding at K22 for further detail.

Multiple penetrations were observed in rated walls on all floors. Please refer to life safety code survey finding at K25 for further detail.

Observation of door ratings did not match wall ratings and not all doors required to latch, latched. Please refer to life safety code survey finding at K27 for further detail.

Hazardous areas were observed without self closing door. Please refer to life safety code survey finding at K29 for further detail.

Exit signage was observed not in working condition. Please refer to life safety code survey finding at K47 for further detail.

Oberservations were made of dirty sprinkler heads and escutcheons askew. Please refer to life safety code survey finding at K62 for further detail.

Portable fire extinguisher location was difficult to ascertain. Please refer to life safety code survey finding at K64 for further detail.

Chutes with observed with doors kept closed or fusible link missing. Please refer to life safety code survey finding at K71 for further detail.

Observation was made of medical gas shutoff valve label that did not match room numbers. Please refer to life safety code survey finding at K76 for further detail.

Observation was made of medical gas cylinders found outside in the extreme cold. Please refer to life safety code survey finding at K130 for further detail.

Power strips were observed in use in a daisy chain formation. Please refer to life safety code survey finding at K147 for further detail.