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Based on record review and interview, facility staff failed to respond to patient grievances per policy in 2 of 3 patient grievances reviewed (Patient #8, Patient #9, Patient #10).

Findings:

Facility policy "Patient Rights and the Grievance Procedure" dated 7/2012 states in part: "The Client Rights Specialist shall investigate the facts and document the investigation, the decision, and the reasons for the decision...for hospital patients within 7 days. If more time is required to investigate the inpatient grievance, the Client Rights Specialist will notify the complainant that the grievance remains under investigation and that the Client Rights Specialist will provide the written report no later than 30 days from the date the complaint was received."

The facility's brochure "Client Rights and the Grievance Procedure for Inpatient Services", given to patients upon admission, states in part: "the Specialist will generally write a report within 7 days from the date you filed the grievance. If more time is required to investigate the grievance, the Specialist will notify you that the grievance is still under investigation and will provide the written report no longer than 30 days from the date you filed the formal grievance."

Patient #8 received inpatient services at the facility from 5/6/2015 through 5/12/2015. Patient #8's Power of Attorney filed a written grievance dated 6/1/2015 regarding the inpatient stay. The grievance record contains a written response to the complainant dated 9/28/2015.

Patient #9 received inpatient services at the facility from 8/4/2015 through 8/14/2015. Patient #9 filed a written grievance dated 8/6/2015. The grievance record contains a written response to the grievance dated 8/27/2015, more than 7 days after the grievance was filed.

Patient #10 received inpatient services at the facility from 5/29/2015 through 7/2/2015. Patient #10 filed a written grievance dated 6/29/2015. The grievance record contains a written response to the grievance dated 7/24/2015, more than 7 days after the grievance was filed.

During an interview on 4/11/2015 at 2:50 PM, Client Rights Specialist J stated the facility responds to complaints "within 30 days." In regards to Patient #8's grievance, J stated the facility did not receive the written complaint until "sometime in August." J went on to state "we don't know why we didn't get the complaint right away."

During an interview on 4/12/2015 at 1:00 PM, Administrator C stated the above grievances had all been responded to within 30 days from receiving the complaints. Administrator A confirmed the policy states grievances are responded to within 7 days for inpatients, not 30 days.

Based on record review and interview, the facility failed to track and trend quality indicators to identify trends with the potential to affect patient outcomes in 1 of 1 Quality Program.

Findings:

Facility document "Performance Improvement Plan" states in part: "Functions: The functions of the Performance Improvement Committee (Committee of the Whole meeting) shall be to: -Provide for organized systematic, on-going review and evaluation of patient care. ...-Serve as a resource for identifying problems that affect the quality of patient care and to implement actions."

During an interview on 4/12/2016 at 10:00 AM, Performance Improvement Nurse I stated the aggregate data for quality indicators "isn't compiled yet, I'm working on that." Nurse I stated there isn't a method in place to trend quality indicator results over time.

Based on record review and interview, the facility failed to track and trend patient incident data to identify trends with the potential to affect patient outcomes in 1 of 1 Quality Program.

Findings:

Facility document "Performance Improvement Plan" states in part: "Functions: The functions of the Performance Improvement Committee (Committee of the Whole meeting) shall be to: -Provide for organized systematic, on-going review and evaluation of patient care. ...-Serve as a resource for identifying problems that affect the quality of patient care and to implement actions."

During an interview on 4/11/2016 at 2:30 PM, Performance Improvement Nurse I stated the quality department is not involved in the review of incident reports. I stated "incidents go to [Supervisor H] for review."

During review of the facility's incident reports on 4/13/2016 at 11:00 AM with Supervisor H, H stated the incident report data is not aggregated in any way. Per H, "we don't do that at all." The incidents are reviewed individually as they come in, there is no system in place to allow for aggregate review to identify trends in errors and potential system-wide problems.

Based on a verification visit on 06/08/2016, including observations,staff interviews and review of maintenance documents, the hospital was in the process of correcting the outstanding deficiencies found during the Recertification Survey on 4/13/2016. The cumulative effects of these physical environment deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41- Condition of Participation: Physical Environment IS NOT MET. These deficiencies have the ability to affect 13 in-patients and an unknown number of outpatients, staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility had the following (8) life safety deficiencies outstanding.

K-18: Corridor Doors,
K-20: Shafts and Floor Separations,
K-25: Smoke Barriers,
K-29: Hazardous Spaces,
K-51: Fire Alarm Installation,
K-56: Sprinkler System Installation,
K-67: Heating, Ventilating & Air Conditioning Installation, and
K-130: Miscellaneous Life Safety Codes.

Please refer to the full description at the cited K-tags.

Based on a verification visit on 06/08/2016, including observations,staff interviews and review of maintenance documents, the hospital was in the process of correcting the outstanding deficiencies found during the Recertification Survey on 4/13/2016. The cumulative effects of these life safety deficiencies resulted in the hospital's inability to ensure a safe environment for the patients.

42 CFR 482.41(b) - Life Safety from Fire: IS NOT MET. These deficiencies have the ability to affect 13 in-patients and an unknown number of outpatients, staff and visitors who were present during the survey.

FINDINGS INCLUDE:

The facility still had the following (8) life safety deficiencies outstanding.

K-18: Corridor Doors,
K-20: Shafts and Floor Separations,
K-25: Smoke Barriers,
K-29: Hazardous Spaces,
K-51: Fire Alarm Installation,
K-56: Sprinkler System Installation,
K-67: Heating, Ventilating & Air Conditioning Installation, and
K-130: Miscellaneous Life Safety Codes.

Please refer to the full description at the cited K-tags.

Based on observation and staff interview, the dietary staff failed to cover the garbage container noted in 1 of 1 food service areas observed (kitchen).

Findings include:

Per observation on 4/11/16 at 11:00 AM in the kitchen, during patient food tray assembly, the garbage container was noted to be uncovered.

Requested policy from Food Service Specialist K on 4/11/16 at 11:30 AM regarding garbage containers being covered, Food Service specialist K stated in an interview on 4/11/16 at 11:45 AM, "the facility does not have a policy for covered garbage containers however we are aware the garbage container should be covered and the staff will be educated".

Based on record review, observation, and interview, the facility staff failed to disinfect the glucometer after patient use in 1 of 1 patients observed requiring blood sugar monitoring (Patient #13). This deficiency has the potential to affect all diabetic patients who have blood sugars checked.

Finding include:

Per review on 4/12/16 at 12:45 PM of policy titled, Care and Cleaning of Multi-Patient Equipment, no policy number, dated 12/2013 stated in part under 1. All multi-use products, glucometers must be cleaned and sanitized between patient use.

Per observation on 4/12/16 at 3:35 PM, Registered Nurse M used a multi-patient glucometer to check a blood sugar on Patient #13. Registered Nurse M did returned the multi-patient glucometer to the medication room, no disinfection noted.

Findings were shared with Registered Nurse Supervisor H on 4/12/16 at 10:55 AM. Per interview with Supervisor H on 4/12/16 at 11:00 AM, Registered Nurse Supervisor H stated the "nurses should be cleaning the glucometer between patient use."