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Based on facility tour, documentation review, observation and staff interview it was determined this facility failed to ensure the environment was maintained in a manner safe from fire by failing to meet the provisions of the life safety code of the National Fire Protection Association 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies in regard to no self closing devices on doors to hazardous areas, portable fire extinguishers lacked tags for immediate and proper identification and penetrations were noted in the smoke barrier. (C0231)

Based on observation during facility tour and staff interview it was determined the facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association (NFPA) 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies. This had the potential to affect all those utilizing this facility. The facility census at the time of the survey was 97.

Findings include:

K321 No self-closing devices on doors to hazardous areas.

K355 Portable fire extinguishers lacked tags for immediate and proper identification.

K372 Penetrations in the smoke barrier

Based on medical record review, staff interview, and policy review it was determined the nursing care plan failed to include relevant problems, interventions, and goals based on diagnoses. This affected two ( Patient's # 4 and #19 ) of twenty medical records reviewed. The active census was 13.

Findings include:


Review of Policy and Procedure for Plan of Care Number: P-100.063 states the plan of care is used to record goals, patient problems, and interventions. A member of the inter-professional team will identify relevant patient problems on admission and throughout the patient's stay. The team member will determine goals with expected end dates and select interventions for each problem. The outcome will be evaluated and the problem updated when care is initiated, upon the patient's progression or regression and upon discharge.


1. Review of the medical record for Patient #4 revealed the patient was admitted on 01/02/17 due to weakness and anemia due to blood loss from the gastrointestinal tract. Laboratory values confirmed a hemoglobin level of 9 which required two units of packed red blood cells to be administered by blood transfusion. The care plan failed to include the gastrointestinal bleed.

The finding was confirmed with Staff A on 01/12/17 at 2:44 PM.


2. Review of the medical record for Patient #19 on 01/11/17 at 12:15 PM revealed the diagnoses included acute renal failure (ARF), hyperkalemia, and high international normalized ratio (INR). The medical record did not include a careplan for these diagnoses.

This finding was confirmed with Staff B on 01/12/17 at 1:45 PM.




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Based on review of medical staff bylaws, policy review, and interview it was determined the facility failed to ensure medical records were completed following patient discharge. Ten medical records were confirmed delinquent and/or not completed. The active census was 13.

Fidnings include:


Review of the medical staff bylaws section five includes a medical records function which states the medical records will be reviewed on a monthly basis to determine that they reflect timely, legible and accurate completeness of such documentation as required by law and accrediting standards.


An interview was conducted with Staff D on 01/10/17 at 4:30 PM in the medical records area. It was determined the facility had ten delinquent medical records and/or the physician documentation was not complete 30 days following patient discharge. Further, it was confirmed the facility lacked policy and procedure to ensure medical records were completed timely post discharge.


Staff A stated in an interview on 01/11/17 at 11:45 AM the medical executive committee met the evening of 01/10/17 to determine how the facility will ensure medical records were completed timely following patient discharge. Further, the facility adopted the Ohio Health network policy on physician documentation number: MS.1300.0008H which includes a thirty day requirement for delinquent records with suspension.

Staff A stated the policy was to be approved and implemented beginning spring 2017.

Based on medical record review and staff interview it was determined the facility failed to ensure documentation in the record included the time the general consent for treatment was signed. This affected six (Patients #11, #16, #17, #18, #19, and #20) of twenty medical records reviewed. The active census was 13.

Findings include:


Review of the medical records for Patients #11, #16, #17, #18, #19, and #20 did not document the time the general consents were signed. Staff A stated in an interview on 01/12/17 at 1:45 PM the facility lacks policy and procedure for obtaining general consent for treatment.

This finding was confirmed with Staff B on 01/12/17 at 1:45 PM.




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