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Based on record review, policy review, observation and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by: failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights (A 117); failure to provide the patient with written notice of grievance decision that contains the name of the hospital contact person (A 123); failure to provide a safe setting for patients to receive care (A 144): failure to implement restraint with safe and appropriate techniques as determined by hospital policy (A 167) and failure to ensure safe implementation of restraint by trained staff (A 194).

Based on observation and record review the facility failed to ensure that each patient/patient's representative was informed of patient rights and provided with information to file a complaint as stated in facility documents. The facility also failed to ensure that the "Important Message from Medicare" was provided as required, upon admission and prior to discharge. Findings include:

On 7/12/10 at approximately 1030, the facility's main enterance/lobby area was observed. No posting stating specifically how to file a grievance with the facility was noted.

During a tour of the psychiatric unit on 7/15/10 at approximately 0855, patient #58's medical record was reviewed. It was noted that patient #58 had not signed the Important Message from Mediare About Your Rights" letter found in his chart. There was no documenation to explain why it was unsigned. The Psychologist (BBB) confirmed these findings.



28273

During the tour of the cardiac unit on the 3rd floor on 07/12/10 at 1645, a review was conducted on patient # 24's medical record revealing that the patient had just been discharged earlier in the afternoon. The record contained the Important Message form Medicare when the patient was admitted on 07/07/2010 but did not contain one prior to discharge on 07/12/2010. The findings were discussed with the Manager of Cardiac/Telemetry unit at the above time and she was also unable to produce the document.



26688

On 7/12/10 at approximately 1430 review of the information sheet titled "Patient Bill of Rights" under the section titled "Grievances" it is written "The Citizen's Guide to Filing a Complaint Against a Health Care Facility - pamphlet is available in the lobbies of all Lakeland facilities."

On 7/12/10 at approximately 1445 a tour of the lobby at Campus 1 revealed that pamphlets regarding complaints and/or grievances were not available. This finding was confirmed at the time of the observation by staff #U.

Based on interview and file review, the facility failed to provide written notice of its decision in the resolution of a grievance for one of one (#8) grievances reviewed. Findings include:

On 7/12/10 patient #8 was interviewed in her room. Patient #8 stated that she and her daughter were unhappy with the supervision that she received upon admission. Patient #8 stated that she fell shortly after admission and sustained a hip fracture and that her daughter had communicated her displeasure (about the fall) to facility staff on many occasions.

On 7/13/10 at 0850 record review revealed that patient #8 sustained a fall on 6/19/10, within 24-hours of admission. Further record review revealed a 6/28/10 Social Work note stating: "Patient and daughter are not happy with fall..."

On 7/13/10 at 0920 the Orthopedic/Neurological Patient Care Manager stated that patient #8's daughter had verbalized discontent with with the supervision that her mother received around the time of the fall.

On 7/14/10 at approximately 1000 the Vice President of Legal Compliance confirmed that neither the patient nor her daughter had received written communication from the facility regarding the fall on 6/19/10.

According to facility policy CORP-69, last reviewed on 4/27/09:

2.1 "A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly upon the spot by the staff present, or...

2.6.7 Failure to ensure patient privacy and safety."

Based upon interview and record review, the facility failed to provide a safe environment in the Dialysis Unit of Campus #1 by ensuring safe levels of chlorine in dialysate solutions.

Findings Include:
On 7/14/10 at approximately 11:20 AM, review of daily chlorine test records showed that the RN on duty did not sign the log sheet on 7/13/10 and 6/29/10. Interview with BioMed Technician HHH confirmed that these areas should be filled in by the RN on duty at each patient shift.

Based on interview, medical record review, and policy review the facility failed to ensure that the restraint orders defined specific restraint requirements in 2 of 2 (#26, #27) patients medical records. Findings include:

On 7/13/10 at approximately 1310 during a medical record review of open records in the Intensive Care Unit (ICU) patient #26's medical record revealed on the form titled "Non-Aggressive/Non-Assaultive Restraint Patient Care Order" that a check box was checked for the restraint order of "2 points soft".
In addition, patient #27's medical record revealed on the form titled "Non-Aggressive/Non-Assaultive Restraint Patient Care Order" that a check box was checked for the restraint order of "2 points soft".

On 7/13/10 at approximately 1310 an interview with staff #G and staff #II were both queried regarding the definition of the restraint orders in regards to what constituted a "2 points soft" restraint and neither were able to locate written material to define.

On 7/14/10 at approximately 0900 during review of the facilities policy titled "Restraint - Non-psychiatric Care Unit: Non-Aggressive/Non-Assaultive and Aggressive/Assaultive" was absent of a definition for what constitutes a "2 points soft" restraint. A written document titled "Restraint: Non-Aggressive/Non-Assaultive versus Aggressive/Assaultive Actions Table (for Non-Psychiatric Units)" was presented by staff #G and that was also absent of a definition for what constitutes a "2 points soft" restraint.

Based on interview, record review, and policy review the facility failed to ensure all staff were trained to implement restraints in a safe manner for 2 of 2 (#26, #27) patients. Findings include:

On 7/13/10 at approximately 1310 during a medical record review of open records in the Intensive Care Unit (ICU) patient #26's medical record revealed on the form titled "Non-Aggressive/Non-Assaultive Restraint Patient Care Order" that a check box was checked for the restraint order of "2 points soft" but the physician's order did not specify which extremities to restrain. In addition, patient #27's medical record revealed on the form titled "Non-Aggressive/Non-Assaultive Restraint Patient Care Order" that a check box was checked for the restraint order of "2 points soft" but the physician's order did not specify which extremities to restrain.

On 7/13/10 at approximately 1310 an interview with staff #G confirmed these findings.

On 7/14/10 at approximately 0900 during review of the facilities policy titled "Restraint - Non-psychiatric Care Unit: Non-Aggressive/Non-Assaultive and Aggressive/Assaultive" stated under section 4.11.13 "Knowledge of Policy: Physicians authorized to order restraint will have a working knowledge of the hospital policy regarding the use of restraint."

On 7/14/10 at approximately 1300 an interview with staff #G revealed that the physicians were trained via email delivery of the hospital's policy. The last delivery of the policy was completed on 6/24/10. When queried about how does the hospital verify if the physician has received and read the information she stated "I don't know". When queried if she could check the emails to verify she stated "she would find someone to do that". At approximately 1330 staff #G presented a list of all the physician's that the restraint policy was sent to and the list revealed that 470 out of 498 emails were transferred over to the physician's personal email which makes confirmation of delivery and notice unavailable. 17 out of 498 emails were read, and 8 out of 498 emails were delivered.

Based on record review and interview it was determined that the facility failed to reassess and keep current the nursing care plan for 1 out of 1 patients (#41). Findings include:

During record review and interview on 7-13-2010 at 1015 it was determined the facility failed to appropriately reassess and update patient #41 ' s nursing care plan. On 6-20-2010 at 1830 patient #41 received a change in assessment with a new diagnosis of lice, which should have prompted RN staff to update the nursing care plan. While reviewing the " Post-partum vaginal birth clinical pathway care plan " there was no documentation to confirm the patients care plan was updated by RN staff which included the new diagnosis of lice on 6-20-2010 at 1830.

These findings were confirmed during an interview with the Obstetrics Unit Manager #CCC.

Based on observation and interview the facilities (Campus 1 & Campus 2) failed to ensure that patient records are kept secure and that unauthorized individuals cannot gain access. Findings include:

During tour of the OB/GYN unit at Campus 1 on 07/12/2010 at 1230, it was noted that all of the patient rooms had a chart holder on the wall outside of the door for the rooms that were occupied with patients. The chart holders contained a binder with patient information. The chart holders were opened at the top and the binders slid down into it. There was no way of securing the information from any unauthorized use.

During tour of the Cardiac/Telemetry Unit at Campus 1 on 07/12/2010 at 1600, it revealed that outside of the patient rooms were drawers without locks, built into the walls and contained patient health information.

During the time of the observations, the findings were confirmed by the Consultant for Patient Care Services.



26688

During tour of Campus 2 on 07/12/2010 at 1700, the 2nd floor medical/post surgical unit had unsecured wall units that contained patient health information. Tour of the medical telemetry unit 3rd floor revealed that charts containing patient health information were hanging unsecured throughout the hallway on the handrails. The findings were verified at the time of tour by the Hospital Administrator of Campus 2 and the Director of Nursing Support Services Campus 2.





27065

During the initial tour of the in-patient rehabilitation unit on campus #on 7/12/10 at approximately 1145, patient #8's medical record was observed stored in a wall rack outside the patient's room. This finding was confirmed by the In-patient rehabilitation unit manager. There was not a continuous presence of staff in the hallway outside the patient's door, ensuring confidentiality of the record.

Based on medical record review and interview the facility failed to ensure that all medical records are completed, dated, timed, and authenticated consistent with hospital policies and procedures in 6 of 9 (#21, #22, #23, #28, #29, #32) patient medical records. Findings include:

On 7/13/10 between the hours of 0830 and 1100 during a tour of Campus 2 patient care units with staff #X the following was noted in open medical records:
Patient #21: The patient agreement consent was not dated
Patient #22: The "Pre-procedure Esophagogastroduodenoscopy/Colonoscopy Patient Orders" was noted by an RN but nothing was ordered by a physician.
Patient #23: The patient agreement consent was not dated

The above findings were confirmed with staff #X.

On 7/13/10 at approximately 1200 during medical record review of closed records the following was noted:
Patient #28: On the "physician orders" dated 12/8/10 two different telephone orders were taken by an RN and authentication by a physician was not present.
Patient #29: On the "Routine Admission Physician Orders" and the "Home Medications and/or Physician Order" forms the physician did not date and time when the orders were authenticated.
Patient #30: On the "physician orders" dated 12/2709 the physician did not date and time when order was authenticated.

On 7/14/10 at approximately 1200 review of the facilities policies and procedures the following was noted:

In the policy and procedure titled "Verbal & Telephone Orders" section 3.2 titled "Telephone Orders" states "Authentication. Each telephone order must be signed, timed and dated by the prescribing physician or by a covering practitioner at the next patient visit or alternatively during the daily rounds of the attending physician."

In the facilities Medical Staff Bylaws section titled "Medical Records 1." it states "The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient."


27408

During record review and interview on 7-15-2010 at 0930 at campus #1, it was found that 2 out of 16 patients closed medical records revealed the following:
Patient #50 revealed that no time was noted on the " Physician operative record/history and physical "
Patient #51 revealed that no time was noted on the " Physician operative record/anesthesia pre-operative patient care order "
The Director of Surgical Services campus #1 confirmed these findings.

During record review and interview on 7-13-2010 at 0930 at campus #2, it was found that 2 out of 16 patients closed medical records revealed the following:
Patient #46 revealed that no date and time was noted on the " Post anesthesia care unit admission/patient care orders "
Patient #48 revealed that no date and time was noted on the " Sliding scale insulin (SSI) patient care orders "
The Director of Surgical Services at campus #2 confirmed these findings.

During record review and interview on 7-14-2010 at 1530 at campus #3 (an outpatient surgery center), it was found that 2 out of 16 patients closed medical records revealed the following:
Patient #52 revealed that no time was noted on the " Home medication and/or physician orders (medication reconciliation). "
Patient #55 revealed that no signature, date or time was noted on the " Anesthesia pre-and-post operative cataract and eye surgeries patient care orders "
The Director of Surgical Services at campus #3 confirmed these findings.






26688

On 7/12/10 at approximately 1315 upon reviewing open emergency department patient medical records during a tour of the Emergency Department 4 of 8 (#1, #2, #5, #11) were without dates and/or times. These findings were confirmed by staff #A.

Based on record review and interview, the facility failed to ensure that verbal (telephone) orders are signed within 48 hours in 2 of 4 records reviewed. Findings include:

During review of patient #24's medical record with the Consultant for Patient Care Services on 07/12/2010 at 1445, it revealed that 4 of 4 telephone orders had not been signed by the physician within 48 hours. Three telephone orders taken by staff on 07/03/2010 had been signed by the physician on 07/06/2010 and the fourth order dated 07/04/2010 had not been signed by the physician at time of survey on 07/12/2010.
These finding were verified at the time of the findings with the Consultant for Patient Care Services.



27065

On 7/13/10 at 1445 patient #8's medical record was reviewed with the Consultant for Patient Care Services. Unsigned verbal orders for patient #8 were noted on 6/19/10.

Based on record review and interview, the facility failed to produce consents for treatment in 5 of 6 records reviewed. Findings include:

During the review of patient ' s # 33, #34, #35, #38 and #39"s medical record with the Consultant for Patient Care Services on 07/12/2010, the records did not contain a consent for treatment. At the time of the review, the Consultant for Patient Care Services was unable to produce the consents from either the electronic medical records or the hard copy of the records.

On 7/12/10 at approximately 1330 during a tour of the chest pain unit on Campus 1 a 1000ml bag of normal saline was found in the crash cart located in the hallway to be expired as of 7/1/2010.

On 7/12/10 at approximately 1625 during a tour of the chest pain unit on Campus 2 a bottle of Nitrostat 0.4mg tablets was found to be open and not dated on a bedside table in an empty room.


27065

On 7/12/10 at 1230, at Campus 1, one bottle of sodium chloride with an expiration date of 7/1/10 was observed on the Pediatric unit's crash cart. At approximately 1250 on on the Psychiatric unit on Campus 1, the following open multi-use containers with no date opened were observed: one bottle of Kaopectate and one container of Delsym. These findings were confirmed by the Psychiatric Unit Manager . Per facility policy 7700-M-2, "All multi-dose containers/vials will be labeled with the date that they are opened."


27408

Based on observation and interview the facility failed to ensure that outdated, unusable drugs at Campus #2 were not available for patient use. Findings include:

During tour of the obstetrics unit on 7-13-10 at 0930, Campus #2, it was revealed the pyxis system contained two 1000 ml bags of magnesium sulfate, both with an expiration date of 05/2009.

The manager of the obstetrics unit #CCC confirmed these findings.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon observation the facility failed to maintain the environment to ensure the safety of patients.

Findings include:
On 7/13/10, 7/14/10, and 7/15/10 between the hours of 8:00 AM and 3:00 PM, drain lines were observed to not be provided with the required 1 inch minimum air gap in the following locations: ice machine in the clean room in the Endoscopy suite of Campus #1; ice machine in the pantry of 2nd Floor Heart Center of Campus #1, two of two food preparation sinks in the main kitchen of Campus #1; ice machine in the kitchen of Campus #2; steamer drain line in the main kitchen of the Niles campus.

On 7/13/10 at approximately 11:30 AM, the clinical sink in the soiled utility room in the Emergency Department of Campus #1 was observed with a shutoff valve on the handheld sprayer, located downstream from the atmospheric vacuum breaker (AVB).

On 7/15/10 at approximately 11:00 AM in the janitor ' s closet serving the kitchen at Campus #2, the atmospheric vacuum breaker (AVB) was observed missing the protective cap and with hardness deposits around the device. This mop sink faucet was also observed with a " wasting tee " attached, but with shut off valves on the discharge end, subjecting the built in AVB to constant pressure.

On 7/13/10, 7/14/10, and 7/15/10 between the hours of 8:00 AM and 3:00 PM, damage to the physical environment was observed in the following locations: the beverage cabinet in the Psychological unit of Campus #1; plastic laminate countertop in the isolation room of the Endoscopy suite of Campus #1; floor coving and ceiling water damage in the Morgue of Campus #1; ceiling tiles observed repaired with blue tape in the Sterile Core of Campus #1; handsink cabinet in the Dialysis Unit of Campus #1; handsink cabinet in the ICU at Campus #2; drywall damage in Physician ' s Room of Emergency Department of Campus #2; drywall damage behind the hand sink in the Medication Room of Campus #2; handsink cabinet in the Medication Room of Campus #2; drywall damage at the ambulance entrance report area at Campus #2; handsink cabinet in the lab of Campus #2, sink cabinet in the glassware washing room of the lab of Campus #2.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on July 27, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated July 27, 2010, for Life Safety Code.

Based on observation, interview and policy and procedure review the facility failed to ensure supplies were maintained at an acceptable level of safety and quality for patient use regarding dietary supplies and clinical supplies. Findings include:

On 7/13/10 at approximately 0845 during a tour of unit A-3 at Campus 2 one 4 ounce container of pudding was found that expired on 6/11/10 in the patient food refrigerator inside the nurses station. This finding was confirmed by staff #X.

On 7/13/10 at approximately 0900 during a tour of unit A-2 at Campus 2 one 4 ounces container of pudding was found that expired on 6/4/10 and seven 4 ounces containers of pudding were found that expired on 7/7/10 in the patient food refrigerator inside the nurses station. In addition, two bags of Lactated Ringers solution 3000ml was found in a cupboard inside the nurses station, one expired on 5/2009 and the other expired on 5/2008. This finding was confirmed by staff #X and staff #AA

On 7/13/10 at approximately 1000 an interview with food service staff #BB, #CC, and #EE and confirmed that the policies and procedures were not being followed.

On 7/13/10 at approximately 1015 during a review of the facility's policy titled "Floor Stock Distribution" under the section "Procedure 2. F." it is documented "Designated Food and Nutrition Services Department staff: Discard expired and unlabeled products from unit refrigerators."


27408

Based on observation and interview the facility failed to ensure that supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

During observation and interview on 7-15-2010 at 0950 on Campus #1 during tour of anesthesia work room it was revealed one size 7.0 endotracheal tube that was open and placed back onto shelf in clean area. In operating room #3, one endotracheal tube size 4.5 was left open and placed back into anesthesia cart.

This was confirmed by operating room manager intra-operative #ZZ.



26688

On 7/12/2010 at approximately 1620 while touring the Emergency Department at Campus 2 the following pediatric emergency kits were expired:
1) Two Red expired on 8/09
2) Two Purple expired on 10/09
3) One Yellow expired on 10/09
4) Four Blue- two expired on 8/09, one expired on 2/07, and one expired on 3/07
5) Two Green expired on 4/09

These findings were confirmed by staff #R at the time of the finding.

Based on observation, interview, and policy review the facility failed to ensure that temperature controls on a dietary refrigerator are not being properly monitored. Findings include:

On 7/13/10 at approximately 0900 during a tour of unit A-2 at Campus 2 the "Food Refrigerator Temperature Log" on the patient food refrigerator located inside the nurses station dated July had been documented on 2 (7/3 and 7/8) of 13 days in the month of July. This finding was confirmed by staff #X.

On 7/13/10 at approximately 1000 an interview with staff #BB, #CC, and #EE confirmed that the policies and procedures were not being followed.

On 7/13/10 at approximately 1015 during a review of the facility's policy titled "Floor Stock Distribution" under the section "Procedure 5." it is documented "Nutrition Services is responsible for daily temperature monitoring of the unit refrigerator(s) and freezer(s) on a posted temperature sheet, unless otherwise indicated."

Based upon observation and interview the facility failed to provide a sanitary environment to avoid transmission of infections.

Findings Include:

On 7/13/10 at approximately 12:40 PM, based upon observation, a cubicle curtain was discovered stored in a cabinet underneath the hand sink of Endoscopy Procedure Room #1 of Campus #1. Interview with Charge Nurse GGG at 12:45 PM, stated that the room had been cleared of unnecessary supplies for an upcoming procedure on a Clostridium difficile patient, and that the cubicle curtain had been removed from the track and placed underneath the hand sink for storage during the procedure because a cart that is usually used could not be located.

On 7/15/10 at approximately 11:00 AM, an employee beverage cup was observed on the clean dishware storage shelving in the dishwashing area of Campus #2.

On 7/15/10 at approximately 11:10 AM, based upon observation it was discovered that paper products including paper towel and toilet paper were being stored in the medical waste holding room of Campus #2.

On 7/15/10 at approximately 11:10 AM paper towels were observed stored on the countertop in the Lab of Campus #2.

On 7/15/10 at approximately 11:10 AM, based upon observation, the following was discovered in the Lab of Campus #2: spider web above shelving unit in middle of the room; dust accumulation on tops of all high shelving throughout; debris accumulation in the missing cover panel area of the white residential style refrigerator near the back of the Lab; debris and spider web accumulation were observed in the windows near the back of the room.

On 7/15/10 between the hours of 8:00 AM and 3:00 PM, based upon observation, dust accumulation was observed in the following areas of Campus #2: underneath shelving and tops of shelving in Pharmacy Narcotics room; top of storage and underneath shelving of Clean Storage of OB department; top of Pyxis dispenser in the Nursery; underneath ice machine and tops of storage units in Clean Supply of OB; underneath shelving of ER Supply Room; top of blanket warmer and ice machine in ER Medication Room; underneath pallet shelving in Surgery de-casing room.



27408

The facility failed to implement and maintain an active hospital wide prevention control for communicable diseases at campus #1 and #2.
(See tag A-749)

Based on observation, record review, and interview the facility failed to ensure the identification and control of infections. Findings include:

During a tour of the facility on 7/14/2010 at 1120 the surveyors observed staff #GGG entering and exiting room #4032 two times without implementing required Personal Protection Equipment (PPE) for contact isolation. In addition, the family member at the bedside was also observed entering and exiting the same room two times, and did not implement PPE. After witnessing the breach in isolation protocol patient #62's medical record was reviewed and revealed an order requiring contact isolation. This was verified during an interview with staff #G and staff #GGG.

On 7/14/2010 at 1345 in room 4032 the surveyor observed two family members at the patient's bedside not wearing the required PPE. This was verified with staff #G. Staff #GGG entered the room and instructed the family members to apply the appropriate PPE.

On 7/15/2010 at approximately 1430 during a tour of Campus 2's Emergency Department a bottle of betadine and paper towels located in a cupboard under the sink in the triage area were observed. This observation was confirmed at the time of the finding by staff #X.



28267

On 7/13/10 at approximately 0900 during a tour of unit A-3 on Campus 2 at approximately 0850 the following was noted:

In patient #21's room a visitor was sitting in a chair next to the patient's bed. A sign outside of the patient's room located on the door indicated "contact isolation", staff # Y was queried about the indication that patient #21 was in contact isolation and if the visitors were educated on utilizing personal protective equipment. Staff #Y stated "Yes she is in contact isolation" then proceeded to stated "We tell them to wash their hands when they leave the room."

On 7/13/10 at approximately 0920 an interview with patient #21 and visitor with patient #21 was conducted. The patient and visitor was queried if they were aware that the patient was in contact isolation and were they educated about taking precautions. Patient #21 stated "I don't know what you are talking about, the doctor didn't say anything" Patient #21's visitor stated "We haven't been told about any of this."

On 7/13/10 at approximately 0940 upon review of the patient #21's medical record on the form titled "Learning Record" there was no documentation that represented educating the patient or patient visitors regarding contact isolation precautions. This finding was confirmed by staff # Y.

On 7/13/10 at approximately 1040 during an interview with staff #DD the "Infection Control Preventionist" upon being queried if there was a policy about patient and patient visitor education regarding contact isolation, he stated "There is no policy about patient teaching" and "There is a fairly new process, where as we hand out a packet to the patients that explains this information, it was rolled out in the past couple months at staff meetings."

Based on record review and interview the facility failed to establish an appropriate discharge plan that included documentation of patient ' s participation. Findings include:

During record review and interview on 7-13-2010 at 0900 with Infection Control Preventionist #DD at campus #2, it was determined that the discharge plan did not reveal any documented patient participation in one of one patients charts , (patient #41).

Based on record review and interview the facility failed to ensure that each surgical case contained a completed post anesthesia evaluation in 14 of 19 open and closed medical records (patient's #13, #14, #16, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, and #56). Findings include:

During record review between 7-13-2010 and 7-14-2010 it was revealed that the following charts lacked a completed post anesthesia evaluation. The attending physician wrote an order for Anesthesia to discharge when criteria was met. Anesthesia did not complete an evaluation right before the patient was discharged from the facility.

This was confirmed by the Director of Surgical Services at Campus #1, #2, and #3.