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Based on observation, staff interview and review of maintenance records between 10/18 and 10/19/2010, the facility failed to construct, install and maintain the building systems to ensure life safety to patients due to (i) lack of vision panels on smoke doors; (ii) failure to properly maintain the facility fire alarm system; and (iii) failure to perform 5 of 10 fire drills in the last 5 quarters.

The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients.

Findings include:
1. Failed to protect the life safety of patients from fire due to lack of clear glass vision panels on smoke doors;

2. Failed to protect the life safety of patients from fire due to failure to perform the testing of automatic dialer component of the facility fire alarm system; and

3. Failed to protect the life safety of patients from fire due to failure to conduct separate fire drills for the 2nd Shift in the last 5 quarters.

Refer to the following K tags for details:
K-28, K-50, and K-51

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

1. Failed to protect the life safety of patients from fire due to lack of clear glass vision panels on smoke doors;

2. Failed to protect the life safety of patients from fire due to failure to perform the testing of automatic dialer component of the facility fire alarm system; and

3. Failed to protect the life safety of patients from fire due to failure to conduct separate fire drills for the 2nd Shift in the last 5 quarters.

Refer to the following K tags for details:
K-28, K-50, and K-51

Based on MR review, policy/procedure review, and staff interview, this facility failed to complete a thorough pain assessment in 2 out of 15 Pt.'s assessed for pain out of a total of 30 MR reviewed (Pt. #9 and 21). By not assessing pain thoroughly, Pt. care needs cannot be met.

Findings include:

Facility policy titled, "Pain Management," with a review date of 9/2010, states on page 3, under Procedure, Initial Contact/Triage, #4. "Initial and ongoing pain assessment may include (but is not limited to) aggravating factors, relieving factors, and functional impact; current pain (location, intensity, and characteristics); and pain goal/intensity of pain is measured using either a numeric pain scale (adult or child). Pain Assessment: location, onset, aggravating factors, characteristics/quality, relieving factors, additional signs & symptoms, and treatment PRN [as needed].

A review of Pt. #9's closed inpatient MR was completed on 10/18/2010 at 3:40 p.m. Pt. #9 was admitted to the hospital on 11/8/2009 with abdominal pain. In the section for Comfort/Pain History on the Interdisciplinary Admission Interview form, the assessment consists of the following: the pain started after brunch, it is rated between 2-6, and it comes in waves. This assessment is incomplete and does not give an accurate description of the pain Pt. #9 is experiencing.

A review of Pt. #21's closed ED MR was completed on 10/19/2010 at 1:30 p.m. Pt. #21 came to the hospital on 1/4/2010 with chest pain and right shoulder pain. In the Initial Pain Assessment section on the Emergency Record, the assessment consists of the following: pain level 6, chest & shoulder. This assessment is incomplete and does not give an accurate description of the pain Pt. #21 is experiencing.

These findings were discussed with and confirmed by TL A and Dir. B on 10/19/2010 between 3:45 p.m. and 4:05 p.m., who agree that the pain assessments were not accurately documented.

Based on MR review and staff interview, this facility failed to record accurate data in the ED regarding assessment times in 2 out of 5 Pt's transferred to higher level of care facilities (Pt's #13 and #14) out of a total of 30 MR reviewed. By not recording accurate assessment times, a chronological time line of events for Pt. care cannot be established.

Findings include:

A review of Pt. #13's closed ED MR was completed on 10/19/2010 at 3:15 p.m. Pt. #13 was transferred to a higher level of care for closer monitoring of the heart after the physician diagnosed Congestive Heart Failure. The following times are recorded on the ED record for this facility: Arrival 7:13 a.m., triaged at 9:10 a.m.; time provider notified-7:22 a.m.; time provider arrived in room- 7:20 a.m. The Pt. is to be triaged prior to the provider seeing them and the provider cannot arrive to the room without being notified. These times are not accurately recorded and do not establish an accurate chronological time line for care.

A review of Pt. #14's closed ED MR was completed on 10/19/2010 at 3:20 p.m. Pt. #14 was transferred to a higher level of care for closer monitoring of the heart after the physician diagnosed Congestive Heart Failure. The following times are recorded on the ED record for this facility: arrival 10:14 p.m., triaged at 10:28 p.m., time provider notified: 10:20 p.m., time provider to room 10:20 p.m. The Pt. is to be triaged prior to the provider seeing them. These times are not accurately recorded and do not establish an accurate chronological time line for care.

These findings were discussed with and confirmed by TL A and Dir. B on 10/19/2010 between 3:45 p.m. and 4:05 p.m., who agree the time line is not accurately documented.

Based on MR review and staff interview, this facility does not ensure that all ED transfer consents are appropriately completed in 2 out of 5 transfers (Pt. #26 and 27) out of a total of 30 MR reviewed. By not completing consents, patients/families are not properly informed of the reasons for transfer.

Findings include:

A MR review was completed on Pt. #27's closed ED record on 10/19/2010 at 12:10 p.m. Pt. #27, an 11 year old, was transferred to a higher level of care facility after a reported alleged sexual assault. Arrangements were made with the alternate facility however a transfer form was not done.

A MR review was completed on Pt. #26's closed ED record on 10/19/2010 at 12:00 p.m. Pt. #26, a 4 year old, was transferred to a higher level of care facility after an alleged sexual assault with a foreign object. The transfer form does not specify services that cannot be provided by this facility.

These findings were reviewed and confirmed by TL A and Dir. B on 10/19/2010 between 3:45 p.m. and 4:05 p.m.

Based on review of facility documents and in two of two staff interviews (TL A and Dir. B), this facility does not inform Swing Bed patients about the ability to work or refuse to work while in the Swing Bed program. By not informing Pt's of this right the facility is prohibiting Pt's from making an informed decision.

Findings include:

Facility document titled, "Swing Bed Program," which is dated 10/20/08, and is attested to be the rights and responsibilities for Swing Bed Pt's's by TL A and Dir. B, does not include information about the right of Swing Bed Pt's's to decline or agree to work as a part of their plan of care while a Pt. in the program.

In an interview on 10/19/2010 at 8:00 a.m., TL A and Dir. B both confirm that they do not include information about "Work" in the rights/responsibilities for Swing Bed Patients.

Based on review of facility documents and in two of two staff interviews (TL A and Dir. B), this facility does not inform Swing Bed patients about the confidentiality of mailed items while in the Swing Bed program. By not informing Pt's of this right the facility is prohibiting Pt's from making an informed decision.

Findings include:

Facility document titled, "Swing Bed Program," which is dated 10/20/08, and is attested to be the rights and responsibilities for Swing Bed Pt's by TL A and Dir. B, does not include information about the right of Swing Bed Pt's to send and/or receive mail that has been unopened, in a prompt fashion. It also does not inform Pt's that they may have access to materials to write/send mail at their own expense.

In an interview on 10/19/2010 at 8:00 a.m., TL A and Dir. B both confirm that they do not include information about "Mail" in the rights/responsibilities for Swing Bed Patients.

Based on review of facility documents and in two of two staff interviews (TL A and Dir. B), this facility does not inform Swing Bed patients about the rights and responsibilities of married couples while in the Swing Bed program. By not informing Pt.s of this right the facility is prohibiting Pt.s from making an informed decision.

Findings include:

Facility document titled, "Swing Bed Program," which is dated 10/20/08, and is attested to be the rights and responsibilities for Swing Bed Pt.s by TL A and Dir. B, does not include information about the rights for married Swing Bed couples to share a room if the couple would be in the program together.

In an interview on 10/19/2010 at 8:00 a.m., TL A and Dir. B both confirm that they do not include information about "Married Couples" in the rights/responsibilities for Swing Bed Patients.

Based on policy and procedure review, review of the facility's patient rights brochure, review of facility document titled, "Swing Bed Program," and in two of two staff interviews (TL A and Dir. B), this facility does not include all of the requirements in writing for transfer/discharge from the Swing Bed program in a notification to patients and/or families.

Findings include:

The facility policy titled, "Swing Bed Admission and Discharge," dated 7/2010, was reviewed on 10/21/2010. This policy does not include a procedure that would include the following information to patients and/or their families or legal representatives: Notice in writing notifying the patient/family/legal representative for the reasons of discharge/transfer; Reference to 30 day advanced notice (or as soon as practical prior to transfer/discharge); The effective date of transfer/discharge; The location of where the patient will be discharged/transferred; The statement of the right to appeal to the State; and, the name, address and telephone number of the State long term care ombudsman.

The facility document titled, "Swing Bed Program" is a document handed out to Swing Bed patients by the facility which includes information about the Swing Bed program and is used to supplement the patient's rights and responsibilities brochure which is handed out to all inpatient admissions. According to Dir. B in an interview on 10/19/2010 at 8:00 a.m., it does not contain all of the information regarding transfer/discharge from the Swing Bed program.

TL A confirmed, in an e-mail to Surveyor #26711 on 10/21/2010 at 4:50 p.m., that a written notice to the patient/family/legal representative is not currently identified in the policy.

Based on MR review, policy/procedure review, and staff interview, this facility failed to complete an activity assessment for 1 out of 2 Swing Bed Pts. (Pt. #1). By not completing an activity assessment, facility staff cannot adequately engage Pt.s during their Swing Bed stay.

Findings include:

Facility policy titled, "Activities" for Swing Bed, with a last review date of 1/2010, states "...all Swing Bed patient[s] will be assessed for participation in the Activities Program."
"1. Patient assessment of activities will be performed within two working days of admission to the Swing Bed Program..."
"3. The Activities Coordinator will outline activities for the Swing Bed patient on the Activity History and Assessment."

A review of Pt. #1's open Swing Bed MR was completed on 10/18/2010 at 2:00 p.m. Pt. #1 was admitted to Swing Bed on 10/14/2010. A comprehensive assessment was completed on 10/14/2010, however an activity assessment was not completed at the same time and was not completed by the time of the MR review.

This finding was discussed with and confirmed by TL A and Dir. B on 10/19/2010 between 3:45 p.m. and 4:05 p.m.