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Based on observation and interview, the facility failed to ensure separation of clean and dirty, failed to ensure hand hygiene was readily available, and failed to ensure standards of sterilization were followed in the surgery department; failed to ensure separation of clean and dirty and failed to ensure patient equipment was cleaned in the obstetrics department; and failed to ensure separation of clean and dirty in the Emergency Department.

The findings included:

Observation of the Surgery Department with the Director of Surgery and Infection Control, on June 16, 2010, from 9:00 a.m., until 10:15 a.m., revealed the following:
1. An equipment room contained dirty items including a hopper (used for the disposal of liquid waste) and dirty linen container stored with clean items including stirrups (used for patient positioning of legs during gynecological surgeries) and lead aprons.
2. Operating room #1 contained a sterile pack/drape and a package of sterile towels stored on top of a red biohazard container which contained a dirty glove.
3. Operating room #1 did not contain hand sanitizer or any method of hand hygiene available in the room.
4. Located in a cabinet, with sterile supplies, in operating room #2, were five peel packs of sleeves the facility had made from guaze and autoclaved.

Interview with the Director of Surgery and Infection Control on June 16, 2010, from 9:00 a.m., until 10:15 a.m., in the Surgery Department, confirmed clean supplies had been stored with dirty items; sterile supplies had been stored on top of a container used for dirty items; hand hygiene was not available in operating room #1; and the sterility of the gauze sleeves available for patient use during surgery in operating room #2 could not be validated.


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Observation in the Obstetrics Operating Room with the Charge Nurse of the Obstetrics hall on June 16, 2010, at 10:20 a.m., revealed the anesthesia multi patient use finger probe utilized for the measurement of a patient's blood oxygen saturation had a buildup of tape and sticky tape residue.

Interview in the Obstetrics Operating Room with the Charge Nurse of the Obstetrics hall on June 16, 2010, at 10:20 a.m., confirmed the probe was ready for patient use and was not clean.

Observation in the Obstetrics Operating Room with the Charge Nurse of the Obstetrics hall on June 16, 2010, at 10:15 a.m., revealed the cabinet containing clean linen had two surgical instrument containers situated on top of the clean linens.

Interview in the Obstetrics Operating Room with the Charge Nurse of the Obstetrics hall on June 16, 2010, at 10:15 a.m., confirmed the surgical instrument containers were not to be located on top of the clean linens.


Observation in the Emergency Department with the Charge Nurse of the Emergency Department on June 16, 2010, at 2:10 p.m., revealed the janitor closet contained brooms, mops, a mop bucket, and six new containers for the disposal of needles and sharps.

Interview in the Emergency Department with the Charge Nurse of the Emergency Department on June 16, 2010, at 2:10 p.m., confirmed the new sharps containers were for use in patient care areas and were not to be stored with dirty supplies.

Based on observation and interview, the facility failed to assure emergency equipment in the emergency room was functioning properly and failed to assure supplies in the Emergency Department had not expired.


The findings included:


Observation with the Charge Nurse of the Emergency Department, on June 16, 2010, at 3:30 p.m., of the patient emergency call light located between the Emergency Department patient chair #1 and chair #2, revealed the emergency call light system on the wall between the #1 and #2 chairs had no pull cords to activate the emergency call system.

Interview with the Charge Nurse of the Emergency Department, on June 16, 2010, at 3:30 p.m., confirmed the patient emergency call light system was not operational.


Observation with the Charge Nurse of the Emergency Department, on June 16, 2010, at 3:10 p.m., of the clean supply closet of the Emergency Department, revealed four 2 ounce bottles of (named) infant feeding formula with an expiration date of February 1, 2010; and four 2 ounce bottles of (named) infant feeding formula with an expiration date of April 1, 2010.

Interview with the Charge Nurse of the Emergency Department, on June 16, 2010, at 3:10 p.m., confirmed the eight bottles of infant feeding formula had expired and were available for patient use.

Based on observation and interview, the facility failed to ensure pediatric defibrillator pads were available on the crash cart on the medical surgical (Med/Surg) unit.

The findings included:

Observation of the crash cart on the Med/Surg unit on June 16, 2010, at 2:05 p.m., revealed the cart did not contain pediatric defibrillator pads for use during emergency care of children.

Interview with the Med/Surg Manager and the Med/Surg Charge Nurse on June 16, 2010, at 2:05 p.m., confirmed the unit did receive pediatric admissions and no pediatric defibrillator pads were available on the unit for pediatric emergencies.

Based on observation, interview, and record review, the facility failed to maintain the physical plant and environment.

The findings included:

Observation, interview, and record review, with the Maintenance Director, on June 16, 2010, between 10:00 a.m. and 3:00 p.m. confirmed the facility failed to maintain corridor fire and smoke doors, failed to maintain hazardous areas fire-rated construction, failed to maintain the fire alarm, sprinkler, medical gas, kitchen hood systems, failed to provide emergency lighting and remote annunciation for the emergency power system, and maintain proper clearance in front of electrical panels. (Reference Life Safety Tags: K018, K021, K029, K052, K062, K064, K069, K077, K078, K140, and K144.)

Based on observation and interview, the facility failed to ensure staff could access patient bathrooms in an emergency in the Same Day Surgery unit.

The findings included:

Observation of the Same Day Surgery unit on June 16, 2010, at 10:25 a.m., revealed the unit contained six patient rooms constructed with one bathroom for every two rooms. Observation of the bathrooms between 10:25 a.m., and 10:40 a.m., revealed each bathroom contained two doors, one to each patient room. Observation revealed each door locked from inside the bathroom with the outside of the door containing a hole for a key to be placed to unlock the door. Observation and interview with the Director of Surgery and Infection Control and with the Chief Clinical Officer on June 16, 2010, from 10:25 a.m., until 10:40 a.m., on the Same Day Surgery unit, confirmed the unit did not have a key to unlock the doors in case of a patient emergency and did not have quick access to a method of unlocking the doors if a patient was in distress and unable to unlock the door.

Based on observation and interview, the facility failed to assure a safe environment for patient care in the operating room of the Obstetrics hall; and failed to assure the safety of patient supplies located in the supply room of the medical surgical hall.


The findings included:


Observation of the operating room of the Obstetrics hall with the Charge Nurse of Obstetrics on June 16, 2010, at 10:20 a.m., revealed a 1 quart spray container of (named) chemical antiviral cleanser situated on a table with gloves, sutures, intravenous catheters, and alcohol wipes.

Interview in the operating room of the Obstetrics hall with the Charge Nurse of Obstetrics on June 16, 2010, at 10:20 a.m., confirmed the (named) chemical antiviral cleanser was not to be located with medical supplies.



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Observation of a storage room on the Med/Surg (medical surgical) hall on June 16, 2010, at 1:50 p.m., revealed a cabinet underneath a sink contained a one gallon container of distilled water. Interview with the Manager of Med/Surg on June 16, 2010, at 1:50 p.m., in the storage room, confirmed the distilled water was used for patient humidifiers and no patient items were to be stored under sinks.

Based on observation and interview, the facility failed to assure hospital trash was contained in a sanitary manner and failed to assure biohazards in the surgery department were disposed of in a safe manner.


The findings included:


Observation of the outside trash disposal containers with the Dietary Manager on June 16, 2010, at 9:15 a.m., revealed two industrial containers with the doors open and trash present in both containers. Observation revealed one container, elevated approximately 3 inches off the ground, with the bottom rusted out in one corner exposing an approximate 6 inch area of the ground surface.

Interview at the outdoor trash holding site with the Director of Dietary Services on June 16, 2010, at 9:15 a.m., confirmed the open doors and the rusted out bottom would allow for vermin and pests to enter the garbage and the trash container doors were to be closed.





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Observation of operating room #2 on June 16, 2010, at 9:30 a.m., revealed a large needle box (used for disposal of sharps), placed by the anesthesia cart, was greater than ? full. Interview with the Director of Surgery and Infection Control on June 16, 2010, at 9:30 a.m., confirmed the needle box was beyond the level allowed for safe closing and locking it for disposal.

Based on observation, review of facility policy, and interview, the facility failed to ensure medications and biologicals were properly labeled and stored in the operating room, endoscopy room, and obstetrics department.

The findings included:

Observation of the Surgery Department with the Director of Surgery and Infection Control, on June 16, 2010, from 9:00 a.m., until 10:15 a.m., revealed the following:
1. The supply room contained two bottles of Betadine 16 ounces (used to clean surgical sites prior to surgery) with an expiration date of April, 2010.
2. Operating room #1 anesthesia cart contained Labetolol (for blood pressure) 100mg/20ml (milligrams/milliliters) and Esmolol (for abnormal heart rhythms and rate) 100mg/10ml opened and not dated when opened.
3. The warmer contained one bag Lactated Ringers 1000 ml intravenous solution, one bottle Normal Saline 1000 ml irrigation, and two bottles Normal Saline 500 ml irrigation, not dated when placed in warmer.
4. Operating room #2 anesthesia cart contained 5 ml vial Glycopyrrate 0.2mg/ml opened and not dated when opened.

Interview with the Director of Surgery and Infection Control on June 16, 2010, from 9:00 a.m., until 10:15 a.m., in the Surgery Department, revealed all medications are to be dated when opened and disposed of after thirty days; and fluids placed in the warmer must be dated for expiration because manufacturer's recommendations included disposing of warmed fluids after 14 days for bags of intravenous fluids and 30 days for plastic bottles of irrigation fluids. Further interview confirmed the medications had not been dated when opened and the fluids had not been dated when placed in the warmer.

Observation of the Endoscopy room on June 16, 2010, at 10:45 a.m., revealed a medication drawer contained one vial of Humulin-R insulin opened and not dated when opened. Interview with the Director of Surgery and Infection Control on June 16, 2010, at 10:45 a.m., in the endoscopy room, confirmed the medication had not been dated when opened.





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Observation of the Obstetrics Operating Room with the Director of Quality Management and the Obstetrics Charge Nurse on June 16, 2010, at 9:50 a.m., revealed an approximate 10 gallon container with a 8 inch by 4 inch opening for the disposal of used needles and sharps. Observation of the contents of the container revealed a partially full 10 ml (milliliter) vial of Succinylcholine, a paralytic agent, and a partially full 10 ml vial of Naropin, a local anesthetic.
Interview in the Obstetrics Operating room with the Obstetrics Charge Nurse and the Director of Quality Management on June 16, 2010, at 9:50 a.m., confirmed the unused medication was to be discarded in an area such as the sink and had not been disposed of properly.

Based on medical record review, review of facility policy, and interview, the facility failed to report an adverse drug reaction to the pharmacy for one patient (#1) of twenty patients reviewed.

The findings included:

Patient #1 was admitted to the facility on June 16, 2010, for an outpatient surgery procedure of Left Inguinal Hernia Repair and Left Orchiectomy. Medical record review of the Nurse's Remarks dated June 16, 2010, at 12:25 p.m., revealed, "Morphine 4 mg IV (milligrams intravenous) given for c/o (complaint of) incision site pain..." Medical record review of the Nurse's Remarks dated June 16, 2010, at 12:30 p.m., revealed, "Pt (patient) c/o itching up arm where IV is. Morphine D/C (discontinued) Demerol 12.5 mg IV given per orders."

Review of the facility's policy Adverse Drug Reaction Reporting revised April 14, 2010, revealed, "A nurse is responsible for reporting any suspected drug reaction to the physician and pharmacist...An adverse drug reaction is defined as any unexpected, unintended, undesired, or excessive response to a drug that: Requires discontinuance of the drug, changing of the drug therapy...C. Complete adverse drug reaction form. D. Return form to pharmacy..."

Interview with the Pharmacist on June 16, 2010, at 4:45 p.m., in the pharmacy, confirmed the nursing documentation indicated the patient had an adverse drug reaction and the pharmacy had not received notification of the adverse drug reaction. Interview with the Chief Clinical Officer (CCO) on June 16, 2010, at 5:00 p.m., in the CCO's office, confirmed the nurse caring for the patient was off duty and had left the hospital, and the nurse had not completed the adverse drug reaction form to send to pharmacy.

Based on observation and interview, the facility failed to assure the dietary department was maintained in a sanitary condition and failed to assure sanitary storage of patient nutritions on the medical surgical hall.



The findings included:


Observation with the Dietary Manager on June 16, 2010, between 8:45 a.m., and 9:20 a.m., revealed the following: the vent hood over the cook top had a buildup of dust and a brown substance; and the walk in freezer had a buildup of ice on the door frame, the floor at the door area, and from the condenser on the ceiling to the shelf located approximately 24 inches down from the condenser.

Interview with the Dietary Manager in the dietary department on June 16, 2010, between 8:45 a.m., and 9:20 a.m., confirmed the vent hood over the cook area was to be free of dust and grime; and the walk in freezer was not to have ice buildup.





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Observation of the patient nutrition refrigerator on the medical surgical (Med/Surg) unit on June 16, 2010, at 1:50 p.m., revealed a paper bag containing a Styrofoam container of mashed potatos and a Styrofoam container of gravy. Observation of the bag revealed the only identification on the bag was a patient room number.

Interview with the Med/Surg Manager on June 16, 2010, at 1:50 p.m., at the Med/Surg patient nutrition refrigerator, confirmed the bag had been brought in from outside the hospital, and did not contain any identification as to whom the food belonged to or a date of when it had been obtained.

Based on medical record review and interview, the facility failed to assure a current Care Plan was maintained for five (#4, #5, #10, #11, and #19) of twenty medical records reviewed.

The findings included:

Patient #10 was admitted to the facility on June 15, 2010, with a diagnosis of Intrauterine Pregnancy. Medical record review of the Care Plan, dated June 15, 2010, revealed no documentation of discharge planning needs. Continued review of the physician's office records, present in the medical record, revealed the patient's newborn had been diagnosed in-utero with Polycystic Kidney Disease.
Interview at the Obstetrics nurses' station with the Obstetrics Charge Nurse on June 16, 2010, at 9:45 a.m., confirmed the patient's newborns status for discharge follow up planning had not been evaluated and care planned.

Patient #11 was admitted to the facility on June 15, 2010, with a diagnosis of Vaginal Delivery. Medical record review of the Care Plan, dated June 15, 2010, revealed no documentation of discharge planning needs. Continued review of the physician's office records, present in the medical record, revealed the patient had been diagnosed in-utero with Polycystic Kidney Disease.
Interview at the Obstetrics nurses' station with the Obstetrics Charge Nurse on June 16, 2010, at 9:45 a.m., confirmed the patient's status for discharge follow up planning had not been evaluated and care planned.

Patient #19 was admitted to the facility on May 9, 2010, with diagnosis of Right Lower Lobe Pneumonia. Medical record review revealed the patient required the use of a mechanical ventilator, a blood transfusion, and the use of physical restraints while hospitalized. Medical record review of the Care Plan, dated May 9, 2010, revealed no documentation in the Care Plan of the use of the mechanical ventilator, the blood transfusion, or the use of physical restraints.

Interview in the conference room with the Director of Quality Management on June 16, 2010, at 6:15 p.m., confirmed the patient's care plan would need to include the use of the mechanical ventilator, the blood transfusion, and the use of the physical restraints.





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Patient #4 was admitted to the facility on June 15, 2010, with Altered Mental Status and Confusion. Medical record review of a physician's order dated June 15, 2010, at 1:10 p.m., revealed the patient was placed in soft wrist restraints. Medical record review of the nursing documentation for June 15 and 16, 2010, revealed the patient was placed in wrist restraints from June 15, 2010, at 1:10 p.m., until June 16, 2010, at 7:00 a.m. Medical record review of the patient's care plan revealed the restraints were not addressed in the care plan.

Review of the facility's policy Restraints revised January 28, 2010, revealed, "...The use of restraints (including drugs used as restraints) is referred to in the patient's plan of care or treatment plan...The continued use of restraints (including drugs used as restraints) is referred to in the patient's plan of care or treatment plan...Documentation...Standard of Nursing & Plan of Care..."

Interview with the Med/Surg (medical surgical) Manager and the Charge Nurse on June 16, 2010, at 3:05 p.m., on the Med/Surg unit, confirmed the restraints were not addressed in the patient's care plan.

Patient # 5 was admitted to the facility on June 10, 2010, with diagnoses of Bronchopneumonia and Bilateral Decubitus. Medical record review of the nursing admission assessment, the nursing notes, and tracking for skin integrity and pressure ulcers, revealed the patient had pressure ulcers to the coccyx, both heels, left hip, both shoulders, back, and right arm on admission. Medical record review of the patient's care plan revealed the only problem identified in the care plan was Breathing Pattern.

Interview with the Med/Surg (medical surgical) Manager and the Charge Nurse on June 16, 2010, at 3:05 p.m., on the Med/Surg unit, confirmed the multiple pressure ulcers were not addressed in the patient's care plan.

Based on medical record review and interview, the facility failed to ensure the physician signed the anesthesia plan for one surgical patient (#5) of four surgical patients reviewed, and failed to ensure consent for treatment was obtained for three patients (#8, #9, and #10) of twenty patients reviewed.

The findings included:

Patient #5 was admitted to the facility on June 10, 2010, with diagnoses including Bronchopneumonia and Decubitus Ulcers. Medical record review revealed the patient underwent a Bilateral Heel Debridement for Bilateral Heel Decubitus Ulcers on June 15, 2010. Medical record review of the Anesthesia Evaluation dated June 15, 2010, at 9:30 a.m., revealed the anesthesia history, physical, evaluation, and anesthesia plan was completed and signed by a Certified Registered Nurse Anesthetist (CRNA), but the physician signature area had not been completed.

Interview with the Med/Surg (Medical Surgical) Manager on June 16, 2010, at 3:05 p.m., at the Med/Surg nursing station, confirmed the physician had not signed the Anesthesia Evaluation and Plan, indicating review and agreement with the evaluation and plan.



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Patient #8 was admitted to the Emergency Department (ED) on June 16, 2010, with Shortness of Breath. Medical record review revealed the Consent for Treatment form, dated June 16, 2010, was signed "witness: verbal consent given". Interview at the ED nurses' station with the ED Charge Nurse on June 16, 2010, at 3:30 p.m., confirmed the patient was able to sign the consent prior to discharge and the consent had not been signed by the patient.

Patient #9, a minor, was admitted to the ED on June 16, 2010, with a Right Thumb Laceration. Medical record review of the Consent for Treatment form, dated June 16, 2010, was signed "witness: verbal consent given". Interview at the ED nurses' station with the ED Charge Nurse on June 16, 2010, at 3:20 p.m., confirmed the patient's parent was able to sign the consent prior to discharge from the ED and the consent had not been signed by the patient's parent.

Patient #10 was admitted to the facility on June 15, 2010, with a diagnosis of Intrauterine Pregnancy. Medical record review of the Consent for Treatment form revealed the form was not signed by the patient. Interview at the Obstetrics Hall nurse's station with the Obstetrics Charge Nurse on June 16, 2010, at 9:45 a.m., confirmed the patient was able to sign the consent form and the form had not been signed by the patient.