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715 RICHLAND MALL

ONTARIO, OH 44906

NURSING CARE PLAN

Tag No.: A0396

Based on medical record review and facility policy and procedure review the facility failed to update plans of care on patients. This finding affected two patients (#10 and #15) of twenty patients reviewed for nursing care plans. The facility census was 14.

Findings include:

Review of the facility policy and procedure titled "Inpatient Nursing Plan of Care" with a most recent reviewed date of 08/23/19 directed that the plan of care will be updated every shift with appropriate changes noted. The updates will be documented on the plan of care.

1. Review of the medical record for Patient #10 revealed the patient was admitted on 02/09/2020 with diagnoses of chest pain and hypertension. The patient had a cardiac catheterization procedure on 02/10/2020. Review of the plan of care failed to address the change in status to reflect the risk for infection related to the puncture of the skin or the post cardiac catheterization complications to monitor for in the plan of care.

This finding was confirmed in interview with Staff E on 02/13/2020 at 8:00 AM during record review. Staff E verbalized the only plan of care Patient #10 had was the admission default, the record failed to reflect any patient specific plan of care to address the patient's needs.

2. Review of the medical record for Patient #15 revealed the patient was admitted to the facility on 02/09/2020 with diagnoses of supraventricular tachycardia, hypoxia and acute respiratory failure. The patient had a cardiac catheterization procedure on 02/10/2020. Review of the plan of care failed to address the change in status to reflect the risk for infection related to the puncture of the skin or the post cardiac catheterization complications to monitor for in the plan of care.

This finding was confirmed in interview with Staff E on 02/12/2020 at 2:00 PM during record review.

CONTENT OF RECORD: INFORMED CONSENT

Tag No.: A0466

Based on document review and staff interview, the facility failed to ensure the medical record contained properly executed informed consent forms for procedures and treatments. This affected four of 20 patients whose medical records were reviewed for informed consent, Patients' #1, #5, #7 and #21. The facility census was 14.

Findings include:

Facility policy A-RM-Consents (Revised 08/13/19) was reviewed. Page two of the policy specified "the patient should only sign a fully completed consent form."

Review of Patient #1's medical record revealed an incomplete Anesthesia Informed Consent and Risk Disclosure Form dated 02/10/2020. On page two of the two page document, the staff member who obtained the consent failed to document whether the patient did or did not "consent to intubation by anyone other than a CRNA or physician."

Review of Patient #5's medical record revealed an incomplete Anesthesia Informed Consent and Risk Disclosure Form dated 02/06/2020. On page two of the two page document, the staff member who obtained the consent failed to document whether the patient did or did not "consent to intubation by anyone other than a CRNA or physician."

Review of Patient #7's medical record revealed an incomplete Anesthesia Informed Consent and Risk Disclosure Form dated 02/10/2020. On page two of the two page document, the staff member who obtained the consent failed to document whether the patient did or did not "consent to intubation by anyone other than a CRNA or physician."

Review of Patient #21's medical record revealed an incomplete Authorization for Transfer form. On 01/27/2020 Patient #21 presented to the ED for complaints of acute chest pain. The decision was made to transfer Patient #21 due to a lack of available beds. Section VII of the Authorization for Transfer form, "Patient Consent to Medically Indicated, Patient Requested, or Patient Refusal for Transfer" was not filled out completely.

Staff C was made aware of and confirmed these findings on 02/13/2020 at 2:45 PM.

DIRECTOR OF DIETARY SERVICES

Tag No.: A0620

Based on observations during tour, staff interview and policy and procedures review the facility failed to cover all refrigerated and frozen foods, and ensure food preparations were out of the splash zone of food preparatory areas and failed to ensure utensils were not stored in the dry food. This finding has the potential to affect patients receiving services from the facility. The facility census was 14.

Findings included:

Review of the facility's policy and procedure titled "Unused Portions" with a recent review date of 12/17/19 directed that food portions not utilized in the service of a meal will be handled in one of the following ways to prevent contamination or spoilage. The procedure directed any prepared food is refrigerated in a shallow, covered, labeled and dated container for the amount of days provided by the state and local health requirements. Review of the position job description for the food and nutritional services manager with a date of January, 2014 directed the responsibility of the food service's manager was to manage food services procedures ensuring proper techniques were utilized and that established procedures and standards are maintained, including internal and external relations; and to maintain quality assurance records to ensure proper temperatures, appearance and palpability of food items served to patients and retail service; and to ensure infection control practices were maintained.

1. Observation of the hand washing sink located directly next to the cold salad preparation station revealed the salad preparation cart contained multiple bins of salad fixings which included, shredded carrot, tomatoes, cheeses, chicken and tuna salad, green peppers and onion and other salad fixings. This hand washing sink was within five inches of the salad preparation station and directly in the splash zone of the sink. This finding was confirmed at the time of observation on 02/10/2020 with Staff D.

2. Observational tour conducted on 02/10/2020 from 10:40 AM until 11:10 AM. revealed the facility's walk in refrigerator was observed to contain a cart which contained two trays with approximately 18 pork steak cutlets. There was no cover or identifying label on these cutlets. Staff D confirmed this finding at time of discovery and confirmed all food items should be covered, labeled and dated with the date prepared and the date to discard. Staff D verbalized these were just prepared for the day as these cutlets were still warm.

Observation of the facility's walk in freezer revealed multiple boxes and bags of food products including frozen cookie dough, beef paddies, bags of frozen vegetables and bags of frozen potatoes. All were opened to the freezer air. Staff D verbalized all the food should be covered, labeled, dated and protected from freezer burn. The temperature of the walk in freezer read -.8 degrees Fahrenheit and the fan was observed to be running.

3. Observation of the dry food storage room revealed a large plastic bin of granola. The product scoop was observed to be stored inside with the granola. This finding was confirmed at the time of observation with Staff D.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety related to the failure to ensure the approved building construction type was maintained in accordance with NFPA 101-2012 Edition, failed to ensure emergency exit doors were readily maintained, failed to ensure the exit corridors were free from storage, failed to ensure battery operated emergency lights were tested and maintained, failed to ensure hazardous area enclosures were maintained, failed to ensure fire alarm interface equipment was tested in accordance with NFPA 101-2012 Edition, failed to ensure smoke detectors were installed 36 inches away from air-handling systems, failed to ensure sprinkler protection was provided for all coverage areas, failed to provide a supply of spare sprinkler heads of all installed types, failed to ensure smoke barrier assemblies could resist the passage of smoke, failed to conduct quarterly fire drills on each shift with documented times, failed to ensure fire barrier doors installed in rated assemblies were tested and maintained, failed to provide documentation to validate the hospital grade electrical receptacles were tested and maintained, failed to provide an remote annunciator for the emergency stand by generator at constantly attended location, failed to ensure a diesel fuel quality test was performed on the 1500 kilowatt emergency generator, failed to ensure electrical equipment was maintained and failed to document the removal of the flammable germicide preps in accordance with NFPA 99-2012 Edition. (A709) The cumulative effect of this systemic practice resulted in the facility's inability to ensure an environment safe from fire. These findings have the potential to affect all patients receiving services in this facility. The facility census was 14.

LIFE SAFETY FROM FIRE

Tag No.: A0709

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically Chapter 18 of the applicable provisions of the 2012 new editions of the Life Safety Code of the National Fire Protection Association. At this survey, Avita Ontario Health System was found not in substantial compliance with the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 18, New Healthcare. This finding has the potential to affect all patients receiving services in this facility. The facility census was 14.

Findings included:

1. Refer to K 161 Building construction and type
2. Refer to K 222 Egress doors.
3. Refer to K 232 Aisle Width.
4. Refer to K 291 Emergency lighting.
5.. Refer to K 321 Hazardous areas.
6. Refer to K 344 Fire Alarm-System Controls
7. Refer to K 347 Smoke detection in corridors
8. Refer to K 351 Installation of sprinkler systems
9. Refer to K 353 Maintenance of sprinkler systems
10. Refer to K 372 Subdivision of smoke compartments
11. Refer to K712 Fire and Evacuation Drills
12. Refer to K 761-Maintenance Inspection and Testing of Doors
13. Refer to K 916 Electrical systems Generator Annunciator
14. Refer to K 914 Essential Electrical Maintenance and Testing
15. Refer to K 918 Generator equipment maintenance
16. Refer to K 920 Electrical equipment
17. Refer to K 933 Fire loss protection