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Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
See specific tags:

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

A-0724 - Failure to ensure supplies available for patient use are maintained in a clean and sanitary manner

Based on interview and record review the facility failed to ensure that all medical records were completed within 30 days after discharge for 48 discharged patient records resulting in the potential for inaccessible information necessary for health care staff to provide for the patient's health care needs. Findings include:

On 04/24/18 at approximately 1130, during record review with Staff C present, the combined delinquent medical records where reviewed from January 01, 2018 to present date (04/24/18). There were 19 medical records that were deficient 30-60 days, needing both nursing and physician signatures, and 29 charts that were deficient greater than 60 days, needing discharge summaries and signatures.

On 04/24/18 at approximately 1135, during an interview, Staff C said the facility had notification systems in place to remind all medical staff when documentation becomes deficient and/or delinquent but, despite utilizing these systems, some medical staff ("who only come here once a month or so") do not complete the required documentation in a timely manner. Staff C also said the facility had systems in place to suspend medical staff (admitting privileges) who do not complete required documentation in a timely manner. Staff C stated that there were "no physicians on suspension" at this time.

On 04/26/18 at approximately 1315, during review of facility policy titled, "Delinquent Medical Records" revised February 2018 defined medical record delinquency as, "Physician will have fourteen days from the date of discharge to complete a medical record". The policy also indicated, "After two day notice, if work is not completed, issuance of "notice of suspension of admitting privileges" (see attachment) will be issued".

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated December 2, 2015.
K-0291
K-0321
K-0324
K-0343
K-0345
K-0353
K-0355
K-0363
K-0372
K-0511
K-0521
K-0918
K-0923

Based on observation, interview and policy review 1) The facility failed to maintain single use patient supplies in a clean and sanitary manner. 2) the facility failed to ensure equipment used for multiple patients was properly cleaned and stored for future use, resulting in the potential to spread infectious agents to all patients served by the facility. Findings include:

1) On 04/24/2018 at 1040, during the initial tour of the facility's ED (Emergency Department) Trauma room II, (cleaned and ready for new patients) was entered. On the top of a supply cart, two cylinders were observed to be loaded with spandages (unpackaged) open to air ready for use. At 1041 Staff I, Registered Nurse Director stated, "in order to prevent possible cross contamination, the spandages should not be opened until we are ready to use them on a patient." Staff I was observed removing two spandages from the cylinders and discarding them.

On 04/24/18 at 1045 during tour of the ED Trauma room II an open oral airway was observed in a bin filled with packaged airways. Staff I stated "airways in that bin are clean, single use and should be packaged. I'll take that and throw it away"

2) On 04/24/2018 at 1115, during tour of the facility's L&D (labor and delivery) unit, a small ante room was entered, 3 portable vital sign machines were observed in the room. Staff J, Registered Nurse Director was asked if this room was a storage room. Staff J looked around the room then stated, "this room is not a storage room, it is where circumcisions are performed." Staff J was further queried as to whether the vital sign machines were clean or dirty and if they were to be used on multiple patients. Staff J stated, "they should be clean?" and "they are used for all our patients." During the time of Staff J's statement this surveyor ran a finger across the screen of each of the machines, accumulated dust was noted to fly up into the air. staff J went on to confirm that there was "no way to tell if the machines had been cleaned and they should not be stored in that room." On 04/24/2018 at 1125 a policy for cleaning bedside equipment was requested.

On 04/26/2018 at 0915 Staff B Chief Nursing Officer was asked to provide the bedside equipment cleaning and storage policy. Staff B stated, "it is being worked on." On 04/26/2018 at approximately 0945 a policy titled "CLEAN EQUIPMENT" dated "effective 04/2018 Author "xxxx Chief Nursing Officer, Policy Area: Hospital Wide, Purpose: To ensure clean equipment is used with patients to promote high standards of infection control. Procedure: (the area was left blank) Medical-surgical and ICU units: Patient unit will be cleaned by housekeeping including any patient care equipment in the room including but not limited to IV pumps, CPM's, PCA's and vital sign Machines, etc. xxxx"
"All other units nursing departments:
Nursing staff will be responsible for cleaning and wiping down patient unit and equipment.
Cleaning will be indicated by monitor cords coiled and placed on hook below monitor."

Requested policies were not provided before the time of closing on 04/26/2018 at 1625 for single use supplies, unpackaged supplies, storage and identification of clean equipment.


27408


On 04/24/18 at approximately 1045, during tour of the facility's L&D (labor and delivery) unit, off in the small ante room, it was noted that there was a hard plastic infant silhouette base with two areas for straps to hold down each arm, and two areas for straps to hold down each leg, for immobilizing newborn male infants during their circumcision. There were two 2 (Circumstraint Newborn Immobilizer) straps noted sitting on a wash cloth next to the infant base, that appeared to "washed and laying out flat to dry". Staff J was queried in regard to the straps, she stated That the "straps are washed out and layed flat to dry after each circumcision is done". When queried if the straps were "single use" she stated she wasn't sure. The drawer right in front of the base (Circumstraint Newborn Immobilizer) was opened an it was observed that there were "many" straps located in the drawer. A policy regarding the straps was requested. Staff J stated she "didn't think there was one. Not really sure if the straps are single use".

On 04/26/18 at approximately 1625, requested policies were not provided before the time of exit for single use supplies, unpackaged supplies, storage and identification of clean equipment.


13069


On 04/25/2018 between the hours of 1100 and 1730 the following observations were made:

1. Multiple live water lines are left abandoned risking the potential for bacteria growth and leading to Legionella. The abandoned water lines are dead ends/legs and are throughout the facility including but not limited to the old x-ray film processing room, in vacant patient room's toilet room, and at central bathing facilities not in use on the second and third floors;

2. The available eyewash station serving the decontamination room and at the ambulatory surgery recovery area of the surgery department area at the facility did not meet the requirement of ANSI Z358.1-2004. Hands free type with tepid water eyewash station is required in all areas where staff and/or patients are subjected to blood pathogens, handling of cleaning products including chemicals and corrosive materials. It was discovered during the survey that only cold water is provided to this non-compliant eyewash station (hand held type) subjecting all working staff in this lab area to potential harm when an eye injury occurs. The typical eyewash station shall be provided to be hands free type with tepid water and readily accessible for use and to comply with applicable code. Areas where subjected to handling of blood and cleaning and handling of bleach and other corrosive materials are used to conduct daily services at this facility must have a fully compliant eyewash station(s) per OSHA/ANSI (Occupational Safety and Health Administration/American National Standards Institute) requirements ANSI Z358.1 - 2004;

3. High dusting is visible at various locations including but not limited to top of window sills serving the cast room; Mast arms of the task light of the typical patient treatment room and in room #8 of the emergency department and; on the mast arm of the CT (computed tomography) control room; and in CVL (cardiovascular lab) room and recovery holding area;

4. Damage to ceiling in Operating Rooms 1 and 3 leading to non-smooth and not cleanable surfaces promoting a potential for infectious diseases.

Above findings were confirmed by accompanying staff AA on 04/25/2018 at the time of the observation.

Based on observation, interview and policy review the facility failed to ensure staff comply with nationally accepted standards of practice requiring all personnel to cover their head and facial hair when in semi restricted and restricted areas of the surgical suites, resulting in the potential for contamination of sterile equipment and poor surgical outcomes.

On 04/25/2018 between the times of 0945 and 1230 during observations in the surgical services/operating room and sterile corridors, 4 male staff were observed in the restricted area to be wearing Skull caps (small disposable surgical caps). At 1130 Staff E Director of peri-op (perioperative) services was asked if skull caps were acceptable practice. Staff E stated "Absolutely not. I have to work on that." Staff E was asked for the policy regarding surgical attire to which she stated, "I'm not sure it's addressed but I know AORN (association of perioperative registered nurses, who set guidelines for accepted practice) is against skull Caps, I will get rid of them." Staff E then looked through a window to a room where staff were sitting and confirmed the male staff to be wearing skull caps, staff E proceeded to educate the registered nurse surgical coordinator whom was sitting at the nurses' station on why skull caps are not an acceptable standard of practice.

No policy regarding the restriction of skull caps or any surgical attire was provided prior to survey exit on 04/24/2018 at 1625.