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Based on interview and record review, facility staff failed to administer blood consistent with facility policy.

Findings:

On 1/24/12, 5 open medical records were reviewed. 3 of 5 medical records lacked transfusion documentation of vital signs, transfusion start and end times, and the signature of the nurse who initiated and completed the transfusion. Facility policy "Blood Products Administration Protocol" (effective date 10/1/98; revised 6/21/11), and interview of the unit Nurse Director on 1/24/12 at 3pm confirmed nursing staff failed to administer blood consistent with facility policy.

Based on record review facility staff failed to time medical record entries.

Findings:

On 1/24-25/12, 26 of 39 medical records reviewed lacked complete documentation. Physician orders and progress notes were not consistently timed.

Based on record review, facility staff failed to authenticate verbal orders.

Findings:

On 1/24/12, open medical records were reviewed. The review found 4 of 6 open medical records lacked authentication of verbal orders within 48 hours. One of the open medical records reviewed identified verbal orders, received 4 months prior, lacked authenication.

Based upon observation and interview, hospital staff failed to maintain the hospital physical environment to ensure the safety and well-being of patients, visitors and staff.
Findings:
On 1/24/12 at 1005 hours while on tour of the hospital with administrative and facilities staff, an electrical panel box door on the 6th floor was observed to have a missing latch and locking device. During the tour the Director of Engineering acknowledged that the electrical panel box door lacked a latch and locking device.
On 1/ 24/12 at 1115 hours while on tour of the hospital with administrative and facilities staff, ceiling tiles in the 4th floor janitor's closet were observed to be stained. During the tour the Director of Engineering acknowledged the presence of the stained ceiling tiles.

Based on observation and interview, the facility failed to ensure the safety of the clinical equipment.

Findings:

On 1/24/12 at 1400 hrs during a tour of the emergency department with administrative staff and facilities staff, an infusion pump was observed at the nurses station with a white piece of paper taped to it stating "doesn't work". Facility procedure directs staff to remove the pump from service, place it in the dirty utility room and label the pump with a tag that states "Caution - Out of Order". During the tour, the Vice President of Clinical and Support Services acknowledged the facility equipment tagging procedure had not been met.

Based on observation, interview and policy review, the facility failed to maintain a safe and sanitary environment in the surgical suite.

Findings:

On 1/25/12 at 0945 hrs during a tour of the PACU area with administrative, facilities and operating room staff, it was noted that a partially used (soiled) IV bag was left to drain in the (clean) handwash sink. The Surgical Services Director acknowledged during the tour that the
handwash sink should not be used for draining soiled materials.

On 1/25/12 at 1000 hours while on tour of the operating rooms with the Surgical Services Director and Infection Control Practitioner, broken and cracked ceramic wall tiles were observed at floor level in Operating Room (OR) #1 and the scrub room entrance to OR #2.. Several cracks in the floor of OR#1 were also noted. During interview on 1/25/12 at 1400 hours the Director of Engineering acknowledged that ceramic wall tiles in OR #1 and the entrance to the OR#2 scrub room were cracked and broken and the floor in OR#1 was cracked.

Based on document review the facility failed to ensure that the operating room register included all required information.
Findings:
The operating room register must contain the following elements: Patient's name; Patient's hospital identification number; Date of the operation; Inclusive or total time of the operation; Name of the surgeon or any assistants; Name of nursing personnel ( scrub and circulating); Type of anesthesia used and the name of person administering it; Operation performed; Pre and post-op diagnosis; and Age of patient.
Findings:
Review of the operating room register revealed that the register failed to include:
1. Age of the patient
2. Inclusive or total time of the operation
3. Pre and post-op diagnosis
This was confirmed by the Operating Room Director on 1/15/12 at 1530.