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Based on observation 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 June 27 & 28, 2017, the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on document review and interview it was determined that for 1 of 2 (Pt. #29) clinical records reviewed for restraints, the Hospital failed to ensure a written modification to the patient's care plan included restraint usage.

Findings include:

1. On 6/29/17 at approximately 10:30 AM, the policy entitled "Restraint and Seclusion" (revised 10/19/16) was reviewed and required "V...B...v. Use of restraints shall be added to the patient's plan of care..."

2. The clinical record of Pt. #29 was reviewed on 6/29/17. Pt. #29 was a 64 year old male admitted on 6/28/17 with diagnoses of respiratory failure and cardiac arrest. Pt. #29's clinical record contained a physician order dated 6/28/17 at 10:30 AM, for bilateral wrist restraints due to interfering with devices, tubes and drainage. Pt. #29's plan of care was not modified to include the implementation of restraints.

3. On 6/29/17 at approximately 11:18 AM, the above finding was discussed with the Director of Intensive Care Unit (E #16). E #16 stated the plan of care should have been updated immediately to reflect restraints usage.

Based on document review and interview it was determined that for 1 of 2 (Pt. #30) clinical records reviewed for restraints, the Hospital failed to ensure the patient was evaluated within one hour after the application of restraints as required.

Findings include:

1. On 6/29/17 at approximately 10:30 AM, the policy entitled "Restraint and Seclusion" (revised 10/19/16) was reviewed and required, "H. i. The LIP (Licensed Independent Practitioner) responsible for the patient in person within 1 hour of the initiation of the restraint...used for violent self-destructive behavior. A RN (registered nurse) or Physician Assistant with a documented competency may perform the in person evaluation within one hour...iii The in person evaluation must include: an evaluation of the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; the need to continue or terminate the restraint or seclusion..."

2. On 6/29/17 at approximately 10:35 AM, the clinical record of Pt. #30 was reviewed. Pt. #30 was a 25 year old male that arrived at the Emergency Department, via ambulance on 6/19/17, with a diagnoses of psychosis and marijuana use. The clinical record of Pt. #30 contained a physician order dated 6/20/17 for a "4 point restraint" (all extremities) due to elopement risk. The clinical record indicated that Pt. #30 was placed in restraints from 10:00 AM to 1:01 PM. The clinical record lacked documentation of the face-to-face evaluation within one hour of application of the restraints.

3. On 6/29/17 at approximately 10:45 AM, the Performance Improvement (PI) Coordinator (E #17) was interviewed. E #17 stated that the documentation for the face-to-face evaluation was not in the clinical record as required.

A. Based on document review and interview, it was determined that for 2 of 2 patients (Pt # 14 and Pt # 15) clinical records reviewed on the 4 South telemetry unit for pain management, the Hospital failed to ensure pain reassessments were completed.

Finding includes:

1. On 6/27/17 at approximately 3:15 PM, the Hospital's policy entitled "Assessment and Reassessment of Patients (April 2017)" was reviewed and required, "...When pain relief interventions are initiated, follow up reassessment for the effectiveness of the intervention is performed within one hour. If patient receive IV narcotics, the reassessment within 1/2 hour..."

2. On 6/27/17 at approximately 09:50 AM, Pt #14's clinical record was reviewed. Pt. #14 was a 90 year old female admitted on 6/14/17 after a fall at home. Pt. #14 was given the pain medication Morphine 2 mg IVP ( intravenous push) on 6/27/17 at 03:10 AM. The clinical record lacked documentation of the pain assessment before or after medication administration.

3. On 6/27/17 at approximately 10:30 AM, Pt. #15's clinical record was reviewed. Pt. #15 was a 63 year old male admitted on 6/6/17 with left leg cellulitis. Pt. #15 was given Norco (pain medication) 2 tablets on 6/27/17 at 06:38 AM. with a pain assessment of 5 out of 10 on a scale of 1-10 (10 being the worst). The clinical record lacked the documentation of pain reassessment after medication administration.

4. On 6/27/17 at approximately 10:45 AM, an interview was conducted with the Clinical Coordinator (E #2). E#2 stated that the pain should have been reassessed and documented for Pt #14 and Pt #15.


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B. Based on document review and interview, it was determined that for 2 of 5 (Pt. #12 and #19) clinical records reviewed for fall assessments, the Hospital failed to ensure assessments were completed as required.

1. On 6/27/17 at approximately 10:00 AM, the clinical record of Pt. #12 was reviewed. Pt. #12 was an 82 year old male, admitted on 6/26/17 with a diagnoses of CHF (congestive heart failure) and chest pain. The clinical record of Pt. #12 indicated that a nursing admission assessment was documented on 6/26/17 at 4:08 PM. However, an initial assessment for falls was not completed as part of the nursing admission assessment.

2. On 6/27/17 at approximately 2:00 PM, the Hospital's policy titled, "Fall Prevention Policy" (revised 3/16) was reviewed and required, "... C. RN/Licensed staff... a. To complete the fall-risk evaluation with the initial assessment... D... b. Complete fall-risk (re)assessments when: Patient transfers from one unit to another; With every shift assessment..."

3. On 6/27/17 at approximately 10:15 AM, the findings were discussed with E #21 (RN), who agreed that an assessment for falls was not completed upon the patient's admission to the unit.

4. On 6/27/17 at approximately 1:30 PM, the clinical record of Pt. #19 was reviewed. Pt. #19 was a 73 year old male, admitted on 6/22/17 with a diagnoses of dyspnea (shortness of breath), hyperkalemia (high potassium), and atrial fibrillation (irregular heart rhythm). The clinical record of Pt. #19 lacked documentation that shift assessment for falls were completed on both the morning and night shift on 6/26/17.

5. On 6/27/17 at approximately 1:45 PM, the findings were discussed with E #5 (Clinical Coordinator). E #3 agreed that shift assessments were not completed on 6/26/17.

C. Based on observation and interview, it was determined that for 1 of 1 patient (Pt. #36) receiving intravenous (IV) antibiotic, the Hospital failed to ensure the IV antibiotic tubing was labeled as required.

Findings include:

1. On 6/27/17 at approximately 9:30 AM, an observational tour of the 4North Telemetry Unit was conducted. During the tour, it was observed that Pt. #1 was receiving IV antibiotic (Piperacillin). However, the IV antibiotic tubing was not labeled to identify the date when the tubing should be changed.

2. On 6/27/17 at approximately 3:00 PM, the Hospital's policy titled, "IV Fluid Management - Peripheral Venous Line" (revised 8/16) was reviewed and required, "... 12. All tubing must be identified with a completed label... Secondary IV tubing will be labeled just below the drip chamber."

3. On 6/27/17 at approximately 9:35 AM, an interview was conducted with E #2 (Clinical Coordinator). E #2 stated that the IV tubing should have been labeled.

Based on document review and interview, it was determined that for 4 of 4 (Pt. # 14, Pt. # 15, Pt. # 18, and Pt. # 19) clinical records reviewed on 4South-telemetry unit and 5North-medical-surgical unit, the Hospital failed to ensure the Plan of Care was updated with new problems.

Finding includes:

1. On 6/27/17 at approximately 3:38 PM, the Hospital's policy entitled "Interdisciplinary Plans of Care Policy (April 2016)" was reviewed and required, "...The clinical system will identify potential Interdisciplinary Plans of Care (IPOCs) via diagnosis, problem list, initial admission assessment, past medical and surgical history of the patient...Documentation of care will be established according to the requirements of each individual patient...Updating of IPOCs will be required to be completed every 8-12 hours..."

2. On 6/27/17 at approximately 09:40 AM, Pt. #14's clinical record was reviewed. Pt. #14 was a 90 year old female admitted on 6/14/17 after a fall at home. Pt. #14 had a Foley catheter inserted for urinary retention on 6/25/17. The plan of care dated 6/27/17 lacked inclusion of urinary retention management.

3. On 6/27/17, at approximately 10:15 AM, Pt. #15's clinical record was reviewed. Pt. #15 was a 63 year old male admitted on 6/6/17 with left leg cellulitis. Pt. #15 was placed on contact isolation for C-diff (bacteria in the stool) with a positive C-diff laboratory result on 6/13/17. The plan of care dated 6/27/17 lacked isolation for C-diff management.

4. On 6/27/17, at approximately 10:40 AM, an interview was conducted with the Clinical Coordinator (E #2). E#2 stated that Pt. #14 and Pt. #15 should have had updated plans of care for new problems identified.


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5. On 6/27/17, at approximately 1:30 PM, the clinical record of Pt. #19 was reviewed. Pt. #19 was a 73 year old male, admitted on 6/22/17, with a diagnoses of dyspnea (shortness of breath), hyperkalemia (high potassium), and atrial fibrillation (irregular heart rhythm). The clinical record of Pt. #19 included a physician's order for contact isolation on 6/23/17. However, as of survey date 6/27/17, Pt. #19's care plan has not been updated to include contact isolation as a problem.

6. On 6/27/17, at approximately 1:45 PM, the findings were discussed with E #3 (5 North Nurse Manager). E #3 stated that contact isolation was not included in Pt. #19's care plan.

7. On 6/27/17, at approximately 1:15 PM, the clinical record of Pt. #18 was reviewed. Pt. #18 was an 84 year old female, admitted on 6/26/17, with a diagnoses of ESRD (end stage renal disease), DM (diabetes mellitus), and gangrene in the 1st left toe. As of survey date 6/29/17, Pt. #18's plan of care was not updated to include ESRD, DM, and gangrene in the 1st left toe as part of Pt. #18's problems.

8. On 6/29/17 at approximately 12:00 PM, the findings were discussed with E #17 (Performance Improvement Coordinator) who agreed that ESRD, DM, and left toe gangrene were not addressed in Pt. #18's plan of care.

Based on document review and interview, it was determined that for two of three (Pt #27 and Pt #28) clinical records reviewed for blood transfusions, the Hospital failed to ensure the administration of blood was completed in accordance with policy.

Findings include:

1. The Hospital's policy entitled "Blood & Blood Components Transfusion and Refusal" (revised 10/21/15) was reviewed on 6/29/17 and required, "A second verifier must check all information...at the bedside with transfusing RN [registered nurse]...Second verifier must computer sign under the I-View Blood Administration...Obtain initial set of and record vital signs and document...before blood is started...Vitals must be documented at minimum: Prior to transfusion; 15 minutes after blood enters patient; Every hour after first 15 minute vital sign; PRN [as needed], as patient condition warrants; At completion of transfusion ALL vital signs are to be documented in Blood Administration record in the EMR [electronic medical record] (vital signs to include blood pressure, pulse, temperature and respiratory rate).

2. The clinical record for Pt #27 was reviewed on 6/29/17 at approximately 9:30 AM. Pt #27 was a 63 year old female admitted on 6/2/17 with a diagnosis of anemia. Pt #27's clinical record included a physician's order, dated 6/2/17, for the transfusion of 2 units of packed red blood cells (PRBC). The transfusion record for the first unit of PRBC lacked the signature of a second verifier. The pre-transfusion vital signs were documented on 6/3/17 at 12:59 AM. However, the transfusion record lacked documentation of the transfusion start date and time.

3. The clinical record for Pt #28 was reviewed on 6/29/17 at approximately 9:45 AM. Pt #28 was a 22 year old female admitted on 6/17/17 with diagnoses of anemia and bilateral lower extremity edema. Pt #28's clinical record included a physician's order dated 6/17/17, for the transfusion of one unit of PRBC. The transfusion record lacked the signature of a second verifier.

4. On 6/29/17 at approximately 11:25 AM, an interview was conducted with the Director of the Intensive Care Unit (E #16). E #16 stated that a second nurse was not needed for a second verifier. The scanning of the patient's bar code serves as the second verification for a blood transfusion. E #16 stated that this process had been in place since June, 2016.

5. On 6/29/17 at approximately 11:30 AM, an interview was conducted with the RN Performance Improvement Coordinator (E #13). E #13 stated that the blood transfusion policy is in the process of revision. The revised policy will include the scanning of the patient's bar code as the second verifier. However, the policy had not been reviewed or in effect as of 6/29/17.

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

Findings include:

1. The Director of Health Information Management (HIM E #9) was interviewed on 6/14/17 at approximately 11:30 AM. E #9 stated that, as of 6/22/17, there are delinquent medical records. E #9 indicated that all patient records should be completed within 30 days of discharge.

2. The Hospital Medical Staff Bylaws Rules and Regulation (approved 5/2017) required, "2.16 Delinquent Medical Records: Patient medical records are required to be completed within thirty (30) days of discharge."

3. The Director of HIM (E #9) provided an attestation letter, on 6/28/17 at approximately 3:00 PM, which indicated that as of 6/28/17, there were 323 incomplete records greater than 30 days.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on June 27 & 28, 2017, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

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

A. Based on document review, observation, and interview, it was determined that for one of one (E #1) Patient Care Providers (PCP) observed completing point of care blood glucose checks and one (E #10) respiratory therapist, the Hospital failed to ensure the point of care equipment was disinfected after use per policy.

Findings include:

1. The Hospital's policy entitled "Cleaning, Disinfection and Sterilization of Equipment" (revised 10/19/16) was reviewed on 6/27/16 and required, "...Equipment: ...Cleaned by: Patient Care; Cleaned when: After use; Cleaned with: PDI [germicidal disposable wipes] Wipes..."

2. On 6/27/17 at approximately 11:10 AM, on the 5 South Medical Surgical Unit, E #1 (PCP) was observed completing a point of care blood glucose check on Pt #20 using the multi-patient use glucometer at Pt #20's bedside. After completion of the test, E #1 returned the blood glucose machine (glucometer) back to its case without disinfecting the machine. E #1 then took the glucometer to the docking station at the nurses' station and docked it there without disinfecting the machine.

3. On 6/27/17 at approximately 11:15 AM, an interview was conducted with the 5 South Manager (E #3). E #3 stated E #1 should have disinfected the glucometer immediately after use.

4. On 6/28/17at approximately 2:50 PM, an observational tour of Respiratory Services was conducted with a Respiratory Therapy Supervisor (E #11). While in the clean equipment and supply storage room, a respiratory therapist (E #10) entered with a bipap machine (a mechanical pressure support ventilation). E #11 began touching the bipap machine brought in by E #10. E #10 stated "don't touch that machine, it's dirty". E #11 asked E #10 why the machine was brought to the clean storage room before it was cleaned. E #10 stated the machine just came out of a patient room who expired, and did not clean the machine before bringing it to the clean storage area.

5. On 6/28/17 at approximately 3:00 PM, an interview was conducted with the Respiratory Supervisor (E #11). E #11 stated that E #10 should have disinfected the bipap machine after taking it out of the patient's room and before taking it into the clean storage room.


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B. Based on observation and interview it was determined that the Hospital failed to ensure the linen was stored as required. This potentially affected 114 patients on census.

Finding include

1. On 6/27/17 at approximately 1:00 PM, during an observational tour to the linen department the following was observed:

-Approximately 15 linen carts were open and exposed to air.
-Multiple carts containing scrubs for various departments (catherization lab, surgery and labor and delivery) had a protective barrier; however, the barrier did not fully enclose the cart, exposing the clean linen stored in the carts.
-There was one cart containing clean curtains that was stored near a corner of the room uncovered and exposed to all elements.
-There was a large piece of glass on the floor with a significant amount of dust on the floor.
-The large room containing the linen carts was also storage for multiple boxes of air filters.
-Broken tiles and a large amount of dust and debris around the linen carts were also observed.

2. On 6/27/17 at approximately 1:15 PM, the Production Manager (Laundry) (E #4) was interviewed. E #4 stated the linen carts are open because "we are prepping these carts for them to be delivered to the different units in the Hospital." E #4 stated that the environment services are to clean the linen area, sometimes they clean sometimes they don't."

3. On 6/28/17 at approximately 1:00 PM, the Chief Quality Officer presented the environmental cleaning schedule. The cleaning schedule indicated that the "store room and storage room" is cleaned once a week on a Wednesday.

4. Policy entitled: "Infection Control Guidelines for Linen Handling and processing" (rev 6/15/17) was reviewed and required "II E...Stored linen is to remain covered until distributed for patient use."

C. Based on observation, document review, and interview, it was determined that for 1 of 1 patient (Pt. #37) in the Intensive Care Unit receiving intravenous infusion, it was determined that the Hospital failed to change the intravenous tubing as required.

1. On 6/30/17 from 9:00 AM to 10:00 AM, an observational tour of the Intensive Care Unit (ICU) was conducted. During the tour, Pt. #37, an 82 year male admitted to the ICU on 6/23/17 with diagnoses of cerebro vascular accident (CVA) and myocardial infarction (MI), had multiple intravenous continuous medication infusion. Two of these infusion tubings had a label that indicated that the tubing was to be used from 6/25/17 to 6/29/17.

2. On 6/30/17, the policy entitled "IV Fluid Management- Peripheral Venous Line" (revised 8/2/16) was reviewed and required "12...All tubing (primary, secondary...) must be changed every 96 hour..."

3. On 6/30/17 at approximately 9:35 AM, the Registered Nurse (RN) (E #23) was interviewed. E #23 stated the intravenous tubing will be changed depending on the medication that is infusing. E #23 stated she is waiting for pharmacy to deliver the medication to change the IV tubing system.

4. On 6/30/17 at approximately 9:45 AM, the findings were discussed with the Director of ICU (E #16). E #16 stated that the tubing should have been changed.

D. Based on observation, document review and interview, it was determined that for 1 of 2 (E #24) Respiratory Therapist observed for hand hygiene, the Hospital failed to ensure infection control practices were followed as required.

1. On 6/30/17 from 9:20 AM to 9:40 AM, during an observational tour of the Intensive Care Unit (ICU), the following was observed:

- at 9:20 AM, the Respiratory Therapists (E #24 and E #25) were preparing the equipment to change the circuit of the ventilator for Pt. #37. E #24 donned gloves and reached toward the patient to adjust the securing device of the endotracheal tube by the mouth of the patient.
- at 9:23 AM, E #24 removed gloves and discarded and donned a new pair of gloves. No hand hygiene was observed. E #24 changed the circuit, removed and discarded her gloves, walked out of the room, and performed no hand hygiene prior to exiting the room. E #24 walked toward the Nurse's Station, obtained a patient label, returned to the room and placed the label on the intravenous bag that was connected to the ventilator.
-at 9:30 AM, the Respiratory Therapist (E #25) was orally suctioning the patient (Pt #37). E #24 did not don gloves, took an unlabeled container by the sink, filled it with tap water, and told E #25 to flush the Yankauer and suction tubing. After E #25 flushed the tubing, E #24 discarded the water.

2. On 6/30/17 at approximately 10:10 AM, the policy entitled "Hand Hygiene" (revised 10/19/16) was reviewed and required, "II. Purpose: ...A...Hand antisepsis purpose to remove or destroy transient microorganism. Method antimicrobial soap or alcohol based hand rub for at least 15 seconds...B. Indications for hand hygiene ...3. After touching wounds or anybody surface likely to contain body fluids or microorganism. 4. After contact with inanimate environmental sources likely to be contaminated. 5. After contact with all patients and equipment. 6. After removing gloves..."

3. On 6/30/17 at approximately 10:30 AM, the findings were discussed with the Infection Control Officer (E #36). E #36 stated the expectation is that the staff should perform hand hygiene when gloves are removed.

Based on document review and interview, it was determined for 1 of 2 (Pt. #32) clinical records reviewed for patients discharged home with home care services, the Hospital failed to ensure the discharge plan was discussed with the patient or the patient's representative as required.

Findings include:

1. On 6/29/17 at approximately 11:00 AM, the clinical record of Pt. #32 was reviewed. Pt. #32 was a 64 year old female admitted on 3/28/17 with a diagnosis of acute cholecystitis. Pt. #32's discharge plan dated 4/2/17 indicated the case manager's discussion with Pt. #32's nurse regarding the discharge plan. The clinical record lacked documentation that the discharge plan was discussed with Pt. #32 or with the patient's representative.

2. On 6/29/17 at approximately 1:30 PM, the Hospital's policy titled, "Discharge Planning" (revised 5/16) was reviewed and required, "... Results of the discharge planning... will be discussed with the patient/representative and results of this communication will be documented in the patient's medical record..."

3. On 6/29/17 at approximately 11:15 AM, the findings were discussed with E #19 (Discharge Planning Coordinator). E #19 stated that the discharge plan should have been discussed with the patient or her family.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #32) patients discharged home with home care services, the Hospital failed to ensure the patient was provided a list of available home care agencies.

Findings include:

1. On 6/29/17 at approximately 11:00 AM, the clinical record of Pt. #32 was reviewed. Pt. #32 was a 64 year old female admitted on 3/28/17 with a diagnosis of acute cholecystitis. Pt. #32 was discharged on 4/2/17 with a physician's order for home care services. The clinical record lacked documentation of a list of home care agencies being provided to the patient.

2. On 6/29/17 at approximately 1:30 PM, the Hospital's policy titled, "Discharge Planning" (revised 5/16) was reviewed and required, "... Patient Choice of Post Acute Service Provider... Case Managers provide patient/family members with a list of facilities or agencies that: 1. Provide the specific services requested by the physician... Documentation attested to by Discharge Planner and Patient/Representative regarding patient/representative freedom of choice will be completed, signed by both parties and included in the medical record."

3. On 6/29/17 at approximately 11:15 AM, findings were discussed with E #19 (Discharge Planning Coordinator). E #19 stated that there should have been a documentation that a list of home health agencies was provided to the patient.

Based on document review, observation, and interview it was determined that for 2 of 2 Respiratory Therapists (E # 24 and E # 25) observed providing respiratory care for a patient on mechanical ventilation, the Hospital failed to ensure infection control practices for respiratory care were followed as required.

Findings include:

1. On 6/30/17, the document "Endotracheal Tube and Tracheostomy Tube Suctioning" (revised 6/14/17) was reviewed and required, "...10. Perform oropharyngeal suctioning, typically using a Yankauer suction catheter, after the lower airway has been adequately cleared secretion, Use a separate suction catheter for this step....11. Rinse the catheter and connecting tubing with sterile normal saline solution or sterile water until clear. ...Open-Suction Technique...16. Rinse the catheter and connecting tubing with sterile normal saline or sterile water until clear. Suction unused solution until the tubing is clear."

2. On 6/30/17, the policy entitled Respiratory Equipment Change" (revised 6/14/17) was reviewed and required, "Procedure...6. In line suction catheters are to be cleared with saline solution post suctioning and changed in tandem with the ventilator circuit and PRN (as needed)."

3. On 6/30/17 from 9:20 AM to 9:40 AM, during an observational tour of the Intensive Care Unit (ICU), the following was observed:

- at 9:20 AM, the Respiratory Therapists (E #24 and E #25) were preparing the equipment to change the circuit of the ventilator for the patient (Pt. #37).

-at 9:30 AM, the Respiratory Therapist (E #25) disconnected the closed suctioning of the patient, attached the Yankauer to the suctioning tube and proceeded to orally suction the patient (Pt #37). E #24 did not don gloves, took an unlabeled container by the sink, filled it with tap water, and told E #25 to flush the Yankauer and suction tubing. After E #25 flushed the tubing, E #24 discarded the water."

4. On 6/30/17 at approximately 9:40 AM, the above findings were discussed with the Infection Control Officer (E #36). E # 36 stated that the therapist should have used sterile water to flush the tubing.