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Based on observation, interview, review of the facility's Housekeeping Procedures/Basic Skills Policy and review of the facility's Room Log/Duty List it was determined the facility failed to provide a clean, sanitary environment as evidenced by observations of dirty surfaces in a terminally cleaned room on 10/20/11 at 11:32 AM.

The findings include:

Review of the facility's Cleaning Rolling Rack Procedure (Date issued- 08/01/09) revealed housekeeping staff was to ensure the base of all equipment was carefully cleaned and disinfected. When equipment was in use, staff was to spot clean when necessary, especially checking base for spillage.

Review of the facility's IV Pole Cleaning Procedure (Date Issued- 08/01/09) revealed housekeeping staff were to clean the entire IV pole from top to bottom and spot clean when necessary, especially checking the base for spillage.

Review of the facility's Dust Mopping Hard Floor Surfaces Procedure (Date Issued- 08/01/09) revealed housekeeping staff was to dust mop along all corners and edges of floor, including under and behind bed and furniture.

Review of the facility's Wet Mopping Hard Floor Surfaces (Date Issued- 08/01/09) revealed housekeeping staff was to mop entire floor including under and behind the bed and furniture, all edges and corners around room to doorway, to prevent dirt buildup.

Review of the facility's Scrubbing Hard Floor Surfaces Procedure (Dated 08/01/09) revealed housekeeping staff were to apply solution to baseboards, corners and edges of floors, scrub with a green hand-scrubbing pad, use putty knife when needed, and rinse with water. After cleaning the floor around the perimeter of the room, the remainder of the room was to be scrubbed with a low-speed floor machine.

Observation of Patient Room #319, on 10/20/11 at 11:32 AM, revealed a gritty, dirt-like substance on the floor on both sides of the bed; accumulation of gritty, dirt-like substance in the corner between the door and bathroom; dried accumulation of hand soap on the floor in the corner by the bathroom sink; a gritty substance on the base of two (2) over-the-bed tables; a blue, plastic port cap and a piece of paper on the floor behind the bedside chair; accumulation of dust on the floor under two (2) soiled linen carts; and a dried, brownish substance on the base of an IV pole.

Interview, on 10/26/11 at 1:52 PM, with Custodial Worker #1 revealed she cleaned Room 319 after the patient was discharged and she thought she had thoroughly cleaned it, however, she was shown what had not been cleaned. She and Custodial Worker #2 cleaned the room the same afternoon. Further interview revealed housekeeping staff were allowed thirty five (35) minutes to clean a patient room after a discharge. She stated she was afraid of taking too long to clean a room because she didn't want to get in trouble. Every morning housekeeping staff was to take the trash out, clean the bathroom, dust mop and wet mop the floors in each patient room. Every afternoon housekeepers were to take trash out of patient rooms if needed. She stated she had received Infection Control inservices and understood the importance of thorough cleaning to protect patients, visitors and staff.

Interview, on 10/21/11 at 5:10 PM, with the Director of Environmental Services revealed IV poles were to be cleaned upon discharge and spot cleaned when needed. Floors were to be dust mopped and wet mopped daily and shouldn't have a buildup of dirt. Furniture and items that were movable should be moved to ensure dirt and trash was removed and if not movable, should be dust mopped under and around to remove dirt and trash. Further interview revealed floor technicians buffed and shined floors once or twice per week if the patients allowed them to do so. He stated housekeeping staff was allowed up to 35 minutes to clean a room after a patient was discharged, their average was 31 minutes.

Based on interview, clinical record review and policy review it was determined the facility failed to ensure that proper notice was given concerning patient rights for two (2) of sixteen (16) patients as evidenced by the "Patient's Rights" form not being given at admission, as required per facility policy, "Patient Rights," Number P01-A, revised 01/01/10 for (Patients #6 and #12).

The findings include:

Review of facility policy, "Patient Rights," Number P01-A, revised 01/01/10, stated every patient/family admitted to the facility would receive a copy of the "Patient's Rights" form upon admission.

Review of Patient #6's clinical record revealed he/she was admitted 08/29/11 with a primary diagnosis of Stage IV Sacral Decubitus. The record further revealed he/she did not have a signed "Patient's Rights" form for the 08/29/11 admission. Review of Patient #6's clinical record from a prior admission to the facility, 07/13/11, revealed a signed "Patient's Rights" form signed by Patient #6 on 07/13/11.

Review of Patient #12's clinical record revealed he/she was admitted 10/07/11 with a primary diagnosis of Acute Respiratory Failure. The record further revealed a family member signed "Consent for Admission and Treatment" on 10/07/11, but the "Patient's Rights" form was not signed by the family until 10/11/11, four (4) days after admission.

Interview with the Chief Nursing Officer (CNO) on 10/28/11 at 4:30 PM revealed if the patient was a return admission, not as much paper work was signed and the previous admission "Patient's Rights" form was relied on as documentation that the patient had been notified of his/her rights. This was the circumstance for Patient #6. She further stated the Admissions Coordinator (AC) talked with the patient/family when at the facility (typically Monday through Friday, 08:00 AM to 4:30 PM) and gave the "Patient's Rights" form to the patient/family to be signed. If the AC was not at the facility upon the patient's admission, fewer papers were signed upon admission. The papers not signed upon admission, were signed when the AC returned. This was the circumstance for Patient #12.

Based on interview, record review, review of the facility's policy, and review of the Medical Staff Bylaws it was determined the facility failed to ensure Physician's orders were obtained for the use of restraints for five (5) of sixteen (16) sampled patients (Patient #1, #2, #12, #15 and #16). Additionally, the facility failed to ensure verbal orders were signed by the Physician for restraints and/or were signed by the Physician within forty-eight (48) hours as per the facility's Medical Staff Bylaws for five (5) of sixteen (16) sampled patients (Patient #1, #11, #12, #15 and #16).

The findings include:

Review of facility policy, "Restraints and Seclusion", number R02-N, revealed "...3. Obtain a physician's order prior to the application of a restraint".

1. Review of Patient #1's clinical record revealed an admission date of 08/31/11, and diagnoses which included Decubitus Ulcer, Chronic Cachexia, Malnutrition. Review of the History and Physical dated 09/01/11, revealed the patient was noted to be alert with confusion.

Review of the "24 Hour Patient Record & Plan of Care" forms dated 09/10/11, 09/11/11, 09/12/11, 09/17/11, 09/22/11, revealed Patient #1 was noted to be in restraints related to the potential for dislodging tubes, poor judgement, and inability to understand the need for treatment. Review of the Physician's Orders for these dates revealed no evidence of orders for the restraints utilized.

2. Review of Patient #12's clinical record revealed an admission date of 10/07/11, and diagnoses which included Acute Respiratory Failure, Dysphagia and Atrial Fibrillation.

Review of the "24 Hour Patient Record & Plan of Care" forms dated 10/11/11, 10/12/11, 10/20/11 and 10/24/11 revealed Patient #12 was in bilateral soft wrist restraints due to restlessness and pulling of the tracheostomy tube. Review of the Physician's Orders for these dates revealed no evidence of orders for the restraints used.
3. Review of Patient #15's clinical record revealed an admission date of 03/24/11, and diagnoses which included Acute Respiratory Failure with severe Chronic Obstructive Pulmonary Disease (COPD) exacerbation, and level of consciousness changes.

Review of the "24 Hour Patient Record & Plan of Care" forms dated 04/08/11, 04/15/11, 04/29/11, 04/30/11, 05/04/11, and 05/05/11, revealed Patient #15 to be in restraints related to the potential for dislodging tubes, poor judgement, and inability to understand the need for treatment. Review of the Physician's Orders for these dates revealed no evidence of orders for the restraints used.

4. Review of Patient #16's clinical record revealed an admission date of 05/31/11, and diagnoses which included Respiratory Failure, Open Abdominal Wound and Atrial Fibrillation.

Review of the "24 Hour Patient Record & Plan of Care" forms dated 06/02/11, 06/05/11, 06/09/11, 06/10/11, 06/14/11, 06/15/11, 06/30/11, 07/01/11, 07/02/11, 07/03/11 and 07/05/11 revealed Patient # 16 to be in bilateral soft wrist restraints due to restlessness and pulling of the tracheostomy tube. Review of the Physician's Orders for these dates revealed no evidence of orders for the restraints used.

5. Review of Patient #2's clinical record revealed an admission date of 12/18/10, and diagnoses which included Respiratory Failure, Congestive Heart Failure, Chronic Kidney Disease, Metabolic Encephalopathy and Sepsis.

Review of the "24 Hour Patient Record & Plan of Care" forms dated 02/02/11 and 02/08/11 revealed Patient #2 to be in bilateral wrist restraints due to pulling at trach collar and tubing. Review of Physician's Orders revealed no evidence of orders for the restraints used.

Interview on 10/21/11, at 2:35 PM with the Chief Nursing Officer revealed anytime a patient is placed in restraints there should be a Physician's Order.

Review of the facility's Medical Staff Bylaws revealed, "...D. General Conduct of Care... all orders for treatment shall be in writing. A verbal order shall be considered to be in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff...the responsible practitioner shall authenticate such order within forty-eight (48) hours...".

6. Review of Patient #1's clinical record revealed verbal orders for restraints dated 09/23/11, 09/24/11, 09/25/11, 09/26/11, and 09/29/11 that were not signed by the Physician until 10/03/11.

7. Review of Patient #12's clinical record revealed a verbal order for restraints dated 10/13/11 that was not signed by the Physician until 10/19/11.

8. Review of Patient #15's clinical record revealed verbal orders for restraints dated 04/03/11 with no evidence of a Physician's signature. An order dated 04/04/11 that was not signed by the Physician until 04/21/11 and an order dated 04/09/11, not signed by the Physician until 04/13/11.

9. Review of Patient #16's clinical record revealed verbal orders for restraints as follows: one (1) dated 06/17/11 that was not signed by the Physician as of 10/28/11; and one (1) dated 07/13/11 that was not signed by the Physician until 07/16/11.

10. Review of Patient #11's clinical record revealed an admission date of 10/12/11, and diagnoses which included Acute Respiratory Failure, Enterocutaneal Fistula and Intra-abdominal Sepsis, Congestive Heart Failure and Encephalopathy.

Review of the Physician's Orders revealed verbal orders for restraints as follows: one (1) dated 10/17/11 was not signed by the Physician until 10/24/11; one (1) dated 10/21/11 was not signed by the Physician as of 10/28/11; and one (1) dated 10/24/11 was not signed by the Physician as of 10/28/11.

Interview on 10/21/11, at 2:35 PM with the Chief Nursing Officer, revealed verbal orders should be signed within twenty-four (24) to forty-eight (48) hours as per Medical Staff Bylaws.

Based on interview and clinical record review it was determined the facility failed to ensure that nursing care and treatments were done in a timely manner as evidenced by 1) nursing staff not answering call lights promptly for two (2) of sixteen (16) patients (Patient #3 and #9) and 2) a dialysis treatment being performed one day later than ordered by the Physician for one (1) of sixteen (16) patients (Patient #3).

The findings include:

1. Interview with Patient #3, on 10/19/11 at 2:36 PM, by telephone, revealed he/she had surgery on his/her right foot and required assistance to get on the bedside commode. He/she further revealed he/she would ring his/her call bell, and it would take a long time for it to be answered. Interview with the daughter of Patient #3, on 10/19/11 at 1:58 PM by telephone, revealed she witnessed staff pass by call lights and not answer them. Interview with Patient #9, on 10/20/11 at 10:30 AM in Room 301, revealed he/she thought reponse to call lights by the staff was slow. He/she further stated it took on an average about twenty-five (25) minutes for someone to answer his/her call light. Also, he/she stated fifty (50) percent of the time, the call light would be turned off without any staff responding to it.

Review of Patient #3's clinical record revealed he/she underwent surgery for a partial foot amputation to his/her right lateral forefoot prior to admission to the facility and required assistance to get on the bedside commode. Further review of the clinical record, "24 Hour Patient Record & Plan of Care" for 02/20/11, revealed at 10:20 AM Patient #3 was placed on the bedside commode with assistance and was not taken off until 10:40 AM, a twenty (20) minute period.

2. Interview with Patient #3, on 10/19/11 at 2:36 PM by telephone, revealed he/she believed his/her dialysis treatments were not done as ordered. Interview with Patient #3's daughter, on 10/19/11 at 1:58 PM, revealed Patient #3 was supposed to be dialyzed three (3) times per week. She further stated she believed Patient #3 had not received dialysis treatments as ordered.

Review of Patient #3's clinical record revealed he/she was admitted 02/08/11 with a primary diagnosis of End-Stage Renal Disease. Further review of the clinical record, "Physician's Orders," dated 02/13/11, revealed an order written by the Physician for hemodialysis every Monday, Wednesday and Friday during his/her admission. Review of Patient #3's clinical record, "UK Health Care, Good Samaritan Hospital, Dialysis Flowsheet Patient Assessment", revealed Patient #3 received dialysis on Saturday, 02/19/11, instead of Friday, 02/18/11.

Interview with the Chief Nursing Officer (CNO), on 10/21/11 at 2:35 PM, revealed she could not find any documentation in Patient #3's medical record to explain why he/she did not receive dialysis on Friday, 02/18/11, as ordered by the Physician and instead received it on Saturday, 02/19/11. Interview with the CNO, on 10/26/11 at 2:55 PM, revealed the facility had no written policy or procedure on the process for ordering dialysis. She revealed the usual process was a note was posted at the Unit Secretary's station for him/her to FAX the dialysis order sheet to the Dialysis Clinic, which was located on the fourth floor of UK Health Care, Good Samaritan Hospital.