DEPARTMENT OF HEALTH AND HUMAN SERVICES GEC 03 2016 FORM APPROVED ‘TERS FOR MEDICARE & AID SERVICES. 1391 [STATEMENT OF DEFICIENCIES —_{0C1) PROVIDERSUPPLERICLIA ay war TrLE CONSTRUCTION [oss oATe survey [AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘COMPLETED A BuLONG c 1p wc. eotat 410512040 [NANE OF PROMIER OR SUPPLIER [STREET ADDRESS, CITY, STATE, ZIP CODE ‘ONE HOSPITAL DRIVE, ROOM CE121, DCUS1,00 UNIVERSITY OF MISSOURI HEALTH CARE. COLUMBIA MO 88204 on “SURWARY STATEMENT OF DEFIGIENCIES 6 'PROVIDEIRS PLAN OF CORRECTION 4, PReri | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREF (BACH CORRECTIVE ACTION SHOULD BE | comPut NON Jao. | REGULATORY ORLSC IDENTIPANG INFORMATION TAS CHOSE REFERENCED TO THE APPROPANTE ATE. A000} INITIAL COMMENTS. A000) An on-site allegation survey was conducted from 4101/10 through 11/06/10 to determine compliance with 42 CFR 482.41 Conditions of Participation of Physical Environment and 42 CFR 482.42 Conditions of Participation of Infection Control in regards to compiaint MOQ00066197. The compiaint was unsubstantiated with unrelated deficiencies. A700) 482.41 PHYSICAL ENVIRONMENT A700) ‘The hospital must be constructed, arranged, and ‘maintained to ensure the safety of the patient, ‘and to provide factities for diagnosis and ‘treatment and for special hospital services appropriate to the needs of the community. ‘This CONDITION is not met as evidenced by: {As directed by Centers for Medicare & Medicaid Services (CMS), an unannounced on-site survey ‘was conducted on 11/01/10 to 11/05/10 at the University of Missouri Health Care System, Columbia, Missouri. As a result the hospital was found to be out of compliance with 42 CFR Part 482.41, Condition of Participation Physical Environment Based on observation, interviews, and review of facility polices, the hospital failed to clean and maintain wails, floors, ceilings and equipment to ensure a clean, sate and sanitary environment for patient care services in surgical euites, procadure rooms, kitchens and cooking facilities where food is stored, prepared ‘and served daily, potentially affecting staff, Visitors and patents, = failed to ensure expired or unusable supplies ‘were not available for patient use; and = failed to ensure mattresses and armboard’s {ABORATORY DIRECTORS Of PROVIOERSUPPLIER REPRESENTATNES SIGNATURE ThE TORE ‘Any deficiency silerent ending wih an asonak () denotes a denclency which the leslution may be excused fom carreing providing itis determing thet ‘other safeguards prove suficent protection tothe patients. (Seo mstrucions ) Except for nursing homes, te fndnge stated above are discisable 90 days {ollowing the dete of survey whether oF not a nan of corecton i provided. For nursing homes, the above findings and plans of corection are siscfosabio 14 ‘days folowing the dete these documents are mide avaluble fo tre lacy, Maeicencies are ced, an approved pan of coracton is requisite to continued ‘rogram pertlption, ‘FORM om 28874020) Prowows Version Obaset Evertip Gao Fount ota ‘Weonbnuation shoot Page 1 ofDEPARYMENT OF HEALTH AND HUMAN SERVICES ‘FORM APPROVED DICARE & MEDICAID SER' OMB NO. 1364 TATEMENT OF DEFICIENCIES [0&1) FROWDERSUPPLERGLA | (KMULTPLE CONSTRUGTON [xa)OATE SURVEY Mo maton Conmecrion [DERTFICATION NOMBER” SoMeTED | eunowe c 260141 owns. 4910812010 ‘am GF PROWDER OR SUPFUER STREET ADDRESS, ITY, STATE, ZF CODE ‘ONE HOSPITAL DRIVE, ROOM CE121, DCO31,00 COLUMBIA, MO_65201 we “SUMMARY STATEMENT OF DEFIGENCIES 70 "PROVIDER'S PLAN OF CORRECTION ro Pkerix | {@ACH DEFICIENCY MUST BE PRECEDED BY FULL PRE (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION TAG. | REGULATORY OR LSC IDENTIFYING INFORMATION) 7a6. GROSS REFERENCED 10 THE APPROPRIATE ‘are UNIVERSITY OF MISSOUR! HEALTH CARE ‘A700! Continued From page 1 A700) were replaced when the integrity was compromised (ripped, frayed, cul or tape | residue), > (Refer to AO701 and A724) The cumulative ettect of these systemic practices has the potential to affect all patients in the hospital. ‘The cumulative patient census of all facilities under this provider was 272. ‘AOS | 48244(0) MAINTENANCE OF PHYSICAL ATO PLAN’ ‘The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safely and well-being of patients are assured | ‘This STANDARD is not met as evidenced by: Based on observation and interview. the factity led to clean and maintain wals, floors, cellings Tand equipment to ensure a clean, safe and ~~ sanitary environment for patient care sevices in ‘surgical suites, procedure rooms, kitchens and ‘cooking faciities where food is stored, prepared : and served at ety affecting staff, visitors and patiénts. The cumulative patient census of all facilities under this provider was 272. Findings include: 4. Observation on 11/01/10 at 2:00 P.M. al the University Hospitats Same Day Surgery Suite #1 showed approximately beck tory ees on, ‘the foor, varying in size, A layer dust coated the top horizontel surfaces of anesthesia cart and a fluoroscopic camera (a camera Used during procediires which shows ‘Weontinusion sheet Page 2 0f 47 FOR CS 2987 (02.98) Prous Venionw Obacee oreoDEPARTMENT OF HEALTH AND HUMAN SERVICES: CENT! [STATEMENT OF DEFICIENCIES [(K3) FROVIDER/SUPPLIERICLA |AND PUAN OF CORRECTION (GENTIFIGATION NUMBER 280141 ‘WAUIE OF PROVIDER OR SUPPLIER UNIVERSITY OF MISSOURI HEALTH CARE ‘STREET ADDRESS, CI, STATE, ZF CODE FORM APPRUVED ‘ONE HOSPITAL DRIVE, ROOM CE121, DCOS1,00 COLUMBIA, MO 65204 FoRM ens 0 ‘SUMAN STATEMENT OF GEPICENGES 2 PROWDERS PLAN OF CORRECTION 2. Patt | (GACHDERCIENCY MUST BE PRECEDED BY FUL, Ree (AORCORRECTIVE ACTION SHOULD BE | COUPLETON TRO | REGULATORY Of LSC IDENTIFYING INFORMATION) TAS, | OROSSREFERENCED TO THEAPPROPRIATE | PATE DERDENC — y ‘8701! Continued From page 2 ATO | X-rays in video) located above the surgical table. Ihen the surfaces were wiped, dust particles fell 10 the floor and onto the surgical table, winessed 9 Stats During an interview on 11/01/10 at 2:00 PM, Staff J stated that the anesthesia technician was responsible for cleaning the anesthesia cart and the cart should be cleaned between patient procedures as well as during the terminal Cleaning of the room. | | | \ 2 oteontionon inanoarsooee stan | University Hospitas Same Day Surgery Suite #1 | showed a thick layer of dust covered the horizontal base of a portable ultrasound machine. When wiped re hand, TWck ros of dust collected, which was witnessed by Staff, | Manager of Regulatory Affairs. 3. Observation on 11/02/10 at 9:20 AM, atthe University Hospital's main operating room) {OR) Suile #10 showed thick dust covering the top | horizontal surface of a monitor. Wiping the surlace caused thick clumps of dust to fall to the floor, which was witnessed by Staff C, Director of Surgical Services 4, Observation on 11/02/40 at 9:42 AM, at the University Hospital's main OR suite #6 showed dust on the top horizontal surface of an anesthesia cart. Wiping the surface caused dust particles to fall to the flocr, which was witnessed by Staff C. A short time later, the room had been cleaned: however, sticky adhesive residue from a partially removed sticker remained on sn instrurmén! table used to set up a stele field for procedures,” | | i { : | | i 557(02.09) Praia Versions Obaclela wet 0 GMO Feary 0200041 a ‘eontinuation sheet Page 3 of 4DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVI FORM APPROVED ‘OMB NO. 0938-0394 FATEMEN ITOF DEFICIENCIES [ptt) PROVIDERUSUPPLIERICLA (NO PLAN OF CORRECTION IDENTIFICATION NUMBER 26011 [pea MUCTIPLE CONSTRUCTION A BULOING vans. Joss owe suRvEY ‘COMPLETED c 2040 NAME OF PROVIDER OR SUPPLIER, UNIVER’ ‘oj 10 PREFIX TAG {SITY OF MISSOURI MEALTH CARE ‘STREET ADDRESS, CITY, STATE, ZIP CODE ‘ONE HOSPITAL DRIVE, ROOM CE121, DCO31,00 COLUMBIA, MO 65201 | SURWARY STATEMENT OF DEROIENGES (GACH DEPCENCY MUST Be PRECEDED BY FULL ECULATORY On Se ENTIPYING FOFMUATION) 1. ‘PROVIDERS PLAN OF CORRECTION 2), PREFX (EACH CORRECINE ACTION SHOULD BE | COMPLETON TAG. ‘GROSS REFERENCED TO THE APPROPRIATE. DATE DEFICIENCY) A701 ‘Continued From page 3 5. Observation on 14/02/10 at 5:30 P.M., at the | University Hospital's main OR suite #7 showed debris (paper and plastic) on the floor after the Yom hail Been Geaned. During an interview on 11/02/10 at §:30 P.M, Stalf C stated that he/she would expect the debris: | found on the floor to be removed during room cleanings. 6. Observation on 11/03/10 at 2:10 P.M, at the ] Women's and Children’s Hospital OR suite #10 ‘showed the floor around the head of the surgical table (after cleaning) had debris (plastic and | paper) and was dry. The remainder ofthe floor was wet from mopping During an interview on 11/03/10 at 2:10 P.M, ‘Staff UUU, Women’s and Children’s Hospital Preoperative (Peri-Op) Assistant stated that hefshe had mopped the floor in suite #10 in ‘preparation for another patient procedure. Steff DDD, Women's and Children’s Hospital OR ‘Supervisor stated that he/she expected the floor tobe cleaned. removing debris and mopping, in-between patient procedures. 7. Observation on 11/02/10 at 10:20 AM. at the University Hospital's pre-operative (pre-op) room #2 showed supplies Such as stenle gloves, suction tubing, and yankauers (a plastic toot used to suction a patient's mouth) in a storage bin located at the head of a patient cart. When these: supplies were pulled out of the storage bin, ‘clumps of qust were clinging to the bottom of the packaging } Observation of the adjacent pre-op Tom #3 stowed clumps of dust in the bottom of the storage bin where patient supplies were stored. FORM CME 7857(02 85) Prevais Vrions Coste Even Ganz A701 Foxtay iO 260167 Weontnustion sheet Page 4 of 47