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Based on document review and interview, it was determined that for 1 of 1 (Pt #12) clinical record reviewed of a patient on one to one (1:1) precautions (monitoring patient at arms length at all times), the Hospital failed to ensure a daily order was written.

Findings include:

1. The Hospital's policy entitled, "Behavioral Health Precautions on Inpatient Psychiatric Unit," (last reviewed 12/2017) was reviewed on 11/27/18 and included, "...F. One-to-Ones may be ordered to prevent a patient from harming self or others...5...An order for one-to-one will be be renewed each 24 hour period if needed to continue."

2. The clinical record of Pt #12 was reviewed on 11/27/18 at approximately 1:30 PM. Pt #12 was a 94 year old male who was admitted on 11/9/18, with a diagnosis of dementia. Pt #12's clinical record contained physician's orders dated 11/17/2018 and 11/19/2018 that required, "1 to 1 sitter." Pt #12 was on a 1:1 sitter from 11/17/18 through 11/26/18. However, Pt #12's clinical record lacked physician's orders to renew the 1:1 on 11/18/2018 and 11/20/2018 through 11/26/2018.

3. The Chief Operating Officer of the Older Adult Behavioral Health Unit (Dementia Unit, E #7) stated, during an interview on 11/28/18, at approximately 10:30 AM, that the physicians have the option to order continuous 1:1 observation, however our policy does not have that option.

Based on document review and interview, for 1 of 1 (Pt #16) clinical record reviewed on the Medical Surgical Unit for restraint usage, it was determined that the Hospital failed to ensure the patient was monitored, at regular intervals as required.

Findings include:

1. On 11/27/18, the "Restraint Policy" (revised 8/2018) was reviewed on 11/28/18, and included, "Definitions: Restraint: Any...equipment that immobilizes or reduces the ability...Non-violent, Non-self-destructive: 1. The patient shall be monitored at regular intervals, at least every 2 hours, to be determined consistent with physician order and/or patient condition and will be documented assessments to assure patient is free from adverse events and to determine if restraints shall be continued..."

2. On 11/27/18 at approximately 10:13 AM, the clinical record of Pt. #16 was reviewed. Pt. #16 was a 72 year old female who was admitted on 11/21/18, with a diagnosis of hip fracture. Pt. #16's clinical record included a physician's order, dated 11/26/18 at 5:35 AM, that included, "Initiate and manage restraint, Medical (nonviolent), Enclosed bed, Prevent unintentional injury or harm..."

Pt. #16's flowsheets for 11/26/18 and 11/27/18 were reviewed. The clinical record lacked documentation of every 2 hour monitoring on 11/27/18 from 2:00 AM to 7:00 AM (total of 5 hours).

3. On 11/27/18 at approximately 10:17 AM, the Charge Nurse of the Medical Surgical Unit (3 South) (E #3) was interviewed. E #3 stated that, "It is required for the nurses to assess the patient in restraints every 2 hours and document on the patient's flowsheet."

A. Based on document review and interview, it was determined that for 1 of 3 (Pt. # 4) clinical records reviewed on the Mother and Baby Unit, the Hospital failed to conduct a pain reassessment, as required.

Findings include:

1. On 11/27/18 at approximately 11:20 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 27 year old female admitted to the Hospital with a diagnosis of pregnancy. The clinical record indicated that Pt. #4 was given Percocet (oral pain medication) on 11/27/18 at 4:46 AM, for abdominal pain. The clinical record lacked a pain reassessment 1 hour after the administration of the oral pain medication.

2. On 11/27/18 at approximately 12:30 PM, the Hospital's policy titled, "Pain Management" (revised 8/18) was reviewed and included, "... 5. Pain reassessment is the evaluation after a pain intervention to assess its effectiveness. Pain reassessment occurs following a pain intervention as outlined below... c. Within 1 hour after administration of an oral pain medication..."

3. On 11/27/18 at approximately 11:25 AM, findings were discussed with E #4 (Obstetrics Educator/Registered Nurse). E #4 stated that pain reassessment should have been done by the nurse 1 hour after administration of the pain medication.


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B. Based on observation, document review, and interview, it was determined that for 3 of 3 (Pts. #1, 2, and 3) patients on the 3 East Unit and 2 of 2 (Pts #11 and 12) patients on the Older Adult Behavioral Health Unit (Dementia Unit), that scored at high risk for fall, the Hospital failed to ensure all fall interventions were implemented.

Findings include:

1. On 11/27/18 between 9:10 AM and 10:00 AM, an observational tour of the 3 East Unit and between 1:00 PM and 2:00 PM, tour of the Older Adult Behavioral Health Unit (Dementia Unit) were conducted. No signage to indicate high risk was posted at the room entrances for Pts #1, 2, 3, 11, and 12.

2. The clinical record for Pt. #1 was reviewed on 11/27/18 between 10:00 and 10:30 AM. Pt. #1 was a 61 year old male, admitted on 11/09/18 with diagnoses of cellulitis and status post left foot trans metatarsal amputation. The clinical record indicated high fall risk scores, ranging from 35-50 throughout the hospitalization. The last assessment, dated 11/26/18 at 8:00 PM, indicated a score of 50 (high risk). The signage at the entrance to Pt. #1's room did not include fall precautions.

3. The clinical record for Pt. #2 was reviewed on 11/27/18 between 10:00 and 10:30 AM. Pt. #2 was an 85 year old female, admitted on 11/26/18 with diagnosis of Fracture. The clinical record included an order for initiating fall precautions, dated 11/26/18 at 7:00 PM. The clinical record indicated high fall risk scores of 45 (high risk) on 11/26/18 at 3:00 PM, and 60 (high risk) on 11/26/18 at 9:00 PM. The signage at the entrance to Pt #2's room did not include fall precautions.

4. The clinical record for Pt. #3 was reviewed on 11/27/18 between 10:00 AM and 10:30 AM. Pt. #3 was a 74 year old female, admitted on 11/26/18 with diagnosis of Sepsis. The clinical record included an order for initiating fall precautions dated 11/27/18 at 2:12 AM. The clinical record indicated a high fall risk score of 60 (high risk) on 11/26/18 at 9:00 PM. The signage at the entrance to Pt. #3's room did not include fall precaution.

5. The Hospital policy titled, "Adult Fall Risk Assessment -Fall Prevention Program" (rev 1/2018) was reviewed on 11/27/18 at 11:00 AM. The policy required, "The nurse will complete the Fall Risk Assessment on admission...High Fall Risk (Morse Fall Score 45 and greater)...When the patient is determined to be at high fall risk for fall whether by the Morse Score of 45 and greater, or by clinical judgement, implement the following intervention in addition... Interventions: Fall Signage-posted at the entrance to the room..."

6. The 3 East Unit, Charge Nurse (E #1) was interviewed on 11/27/18 between 10:00 AM and 10:10 AM. E #1 indicated that any patient with a score of 45 or greater is a high risk for fall. E #1 indicated that an order is not needed to initiate fall precautions. E #1 indicated that the 11 inch by 8 inch laminated card signage, at the entrance of each door, and containing a yellow section indicating "Fall Precaution," should be marked to indicate that the patient is a fall risk. E #1 added, "If another nurse who is not the patient's nurse comes in to the room to check a patient they would know if the patient is on fall precautions before they enter the room, if the signage is marked."

7. The above findings were discussed with the 3 East, Unit Manager (E #2), during an interview on 11/27/18 at approximately 10:35 AM, who indicated that the expectation is to mark the signage for patients who are assessed at high risk for fall.


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8. The clinical record of Pt #11 was reviewed on 11/27/18 at approximately 1:15 PM. Pt #11 was a 92 year old male who was admitted on 11/19/18, with a diagnosis of dementia. Pt #11's fall risk score on 11/26/18 at 11:00 AM, was 50, on 11/26/18 at 8:00 PM the score was 55, and on 11/27/18 at 10:00 AM the score was 55. Pt #11's room door did not have signage posted, indicating the patient was at risk for falls.

9. The clinical record of Pt #12 was reviewed on 11/27/18 at approximately 1:30 PM. Pt #12 was a 94 year old male who was admitted on 11/9/18, with a diagnosis of dementia. Pt #12's fall risk score on 11/25/18 at 1:00 PM, was 110, on 11/25/18 at 9:00 PM the score was 110, and on 11/26/18 at 11:00 AM the score was 75. Pt #12's room door did not have signage posted, indicating the patient was at risk for falls.

10. The Chief Operating Officer of the Older Adult Behavioral Health Unit (Dementia Unit, E #7) stated during an interview on 11/28/18 at approximately 10:30 AM, that all of the patients on the Behavioral Health Unit are at risk, and as per our policy the doors should have signs posted.

Based on document review and interview, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. The Hospital's Medical Rules and Regulations of the Medical Staff (revised 7/20/17) was reviewed on 11/28/18 and required, "...Delinquent Medical Records...Delinquent status indicates that a physician has deficient records over 30 days post discharge..."

2. On 11/28/18, the Manager of Health Information Management (E #9) presented the surveyor with a letter of attestation which included, "This letter is to certify that there are 160 delinquent medical records at [Hospital] as of November 28, 2018."

3. On 11/28/18 at approximately 3:00 PM, an interview was conducted with E #9. E #9 stated that the physicians are able to view and sign the records electronically, and medical records should be completed within 30 days of discharge.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Full Survey due to a Complaint conducted on November 27-28, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of Full Survey due to a Complaint was conducted on November 27-28, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on observation, interview, and document review, it was determined that for 2 of 2 code carts (adult and pediatric catrs), in the Surgical Department, the Hospital failed to ensure that staff completed a full inspection of the code carts (emergency cart).

Findings include:

1. An observational tour of the surgery department was conducted on 11/28/2018 between 9:00 AM and 9:50 AM. The adult and pediatric code carts' (used for patient emergencies) logs indicated that staff failed to complete an inspection of the ECG (electrocardiography- electric activity of the heart) monitor during the daily inspection of the code carts on 11/26/18 and 11/27/18.

2. On 11/28/2018 at approximately 9:40 AM, an interview was conducted with the Operating Room Supervisor (E #8). E #8 sated, "The person doing the crash cart check should also run an EKG strip. It looks like they missed it the last two days (11/26/18 and 11/27/18)."

3. The hospital's policy titled, "Code Cart Replacement and Maintenance" (revised 6/2018) included, " ...B. Maintenance/inventory check ...designee will perform a documented inspection of the code cart every day to assess proper functioning of equipment ...a. Verify that the instrument is connected to power ...b. Check for ECG (electrocardiogram) leads, electrodes and cables ...c. Check the Delivered Energy on AC power ...d. A brief automatic recorder also provides documentation of the test ..."

Based on observation, interview and document review it was determined that for 1 of 1 Nurse (E #5) in the Intensive Care Unit, observed performing point of care testing, the Hospital failed to ensure infection control practices were followed.

Finding include:

1. On 11/27/18 at approximately 11:17 AM, a nurse (E #5) was observed conducting a glucometer finger stick (point of care instrument, used to monitor blood sugar) on a patient in the Intensive Care Unit. During the test: E #5 placed the glucometer on the patient's bed; obtained the blood sample; ran the test using the blood sample; and then placed the glucometer on the patient's bedside table. E #5 then discarded the needles and strip; walked toward a counter available in the patient's room; removed her gloves; performed hand hygiene; removed the glucometer from the patient's room without cleaning or disinfecting it; and placed it on the loading dock, at the Nurses' station where it was available for use. E #5 then answered her phone.

2. On 11/ 28/18 at approximately 11:20 AM, it was discussed with E #5 on not disinfecting the glucometer after being used on the patient. E #5 stated, "Oh yeah, I did not do it."

3. On 11/28/18 at approximately 11:39 AM, the policy "Cleaning and Disinfection of Non-Critical, Reusable Patient Care Equipment and Workstations on Wheels" (Rev. 7/2018) was reviewed and included, "...Procedures: 1. All reusable equipment must be cleaned and disinfected...immediately after use on patients, using a hospital approved cleaner and/or disinfectant..."

Based on observation, document review and interview, it was determined that for 1 of 2 (MD #1) anesthesiologists observed in the Surgical Department, the Hospital failed to ensure adherence to dress code policy.

Findings include:

1. On 11/28/18 between 8:55 AM and 9:30 AM, an observational tour of the Hospital's Surgical Department was conducted. In the Operating Room (OR) 2, at approximately 9:15 AM, while a sterile field was opened, MD #1 entered the room with approximately 2 inches of hair exposed from her surgical cap in the frontal area. MD #1 was also wearing a necklace and a ring.

2. On 11/28/18 at approximately 10:00 AM, the Hospital's policy titled, "Surgical Attire" (revised 12/2017) was reviewed and required, "... 5. Jewelry, including rings... necklaces... will not be worn. Jewelry that cannot be contained will be removed before entry into the semi-restricted and restricted areas...I. All personnel will cover head and facial hair...when in the semi-restricted areas."

3. On 11/28/18 at approximately 9:35 AM, the findings were discussed with E #6 (OR Charge Nurse/Registered Nurse). E #6 stated that hair should not be exposed. E #6 said, "I saw her (MD #1) wearing the necklace and told her (MD #1) to remove it... Ring is not permitted."