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Based on medical record review, staff interview and review of facility policy, the facility failed to ensure that patients in restraints were monitored according to hospital policy for one of two patients reviewed with restraints, Patient 6. The facility census was 213.

Findings include:

On 02/29/12, the medical record review for Patient 6 was started. The record revealed that there was an order for four point "hard" restraints on 02/26/12. At 5:45 AM Patient 6 was placed in four point hard restraints as per the order. Per facility policy " Restraint and Seclusion", Patient 6 was required to be monitored every 15 minutes for "restraint status, removal of restraints for active or passive range of motion, change in patient's position, nutritional status and personal hygiene."

Review of the record revealed that Patient 6 was in the four point hard restraints from 5:45 AM-9:15 AM on 02/26/12. For the above stated period of time there was no documentation of Patient 6's nutritional status (fluids or toileting offered) or restraint removal for active or passive range of motion. There was also no documentation to support Patient 6's position was changed.

Further review of the record for Patient 6 revealed that he/she was again restrained using four point hard restraints on 02/27/12, per physician's order, at 5:29 AM. Patient 6 was then restrained from 5:29 AM - 8:45 AM. Per review of the documentation from 5:30 AM to 7:00 AM, there was no documentation of restraint removal for active or passive range of motion for Patient 6. From 5:30 AM to 8:45 AM, there was no documentation of Patient 6's nutritional status (fluids offered).

Staff D was made aware of and confirmed the above findings for Patient 6 while reviewing his/her record on 3/01/12 at approximately 2:00 PM.

Based on staff interview and review of Medical Staff By-Laws, the facility failed to ensure that all medical records were completed within 30 days following discharge.

Findings include:

During tour of the medical records area on Wednesday, 02/29/12, information in regard to the number of delinquent medical records, over 30 days from the date of discharge, was discussed with Staff E, the director. The current number of delinquent records was found to be 47. A list of all current delinquent records by physician was presented to the surveyor on Wednesday, 02/29/12, at approximately 12:30 PM. Staff E confirmed this number at this time.

Review of the Medical Staff By-Laws confirmed that all medical records must be completed by the 30th day after discharge or the physician would be placed on suspension. The delinquent records list contained 19 physician names for the 47 delinquent records. This list of physicians was also confirmed by Staff E on Wednesday afternoon, 02/29/12.

CONDITION LEVEL DEFICIENCY

Based on the life safety code inspection conducted on 02/27/12 thru 03/03/12, it was determined that this facility was not maintained in a manner safe from fire. This had potential to affect patients, visitors, and staff members. This facility census at the beginning of the survey was 213.

Findings include:

Please refer to A701 and A710.

Based on observation, staff interview and review of the hospital cleaning contract, it was determined that the facility failed to maintain food preparation and service areas in a clean and sanitary manner. This failed practice had the potential to affect any resident, visitor or staff consuming foods prepared in the main kitchen and/or the first floor deli. The facility census was 213.

Findings included.

During an initial tour of the facility's main kitchen conducted on 02/28/12 at 10:30 AM, the tiled floor surfaces by the cooler/freezer, pot and pan storage area, and stove areas were observed to have multiple chipped and cracked areas. The chipped and cracked flooring deemed it difficult to ensure adequate cleaning and sanitizing. This finding was verified by Staff A at the time of the tour.

A second tour of the facility's main kitchen was conducted on 02/29/12 at 8:25 AM. At the time of the tour, the salad cart (not in use at the time) was observed to contain dried spillage and debris. Other areas and equipment observed to contain dried debris or crumbs included the silverware bins, the combination oven, meat slicer (not in use at the time) and shelving in the meat cooler. These findings were verified by Staff A at the time of this tour.

A third tour of the facility's main kitchen and food storage areas was conducted on 02/29/12 from 9:07 AM to 10:00 AM. During this tour the following was observed: three sliced melon cups were noted to be dried out, uncovered and undated in the cooler for after hour meals; the breakfast serving cart was observed to contain two hot cereals, two varieties of fried egg, and breakfast sausage, all uncovered and open to air. During a 02/29/12, 9:16 AM interview, Staff B stated that food can be served to patients from the serving cart until 9:30 AM. At the time of the discovery, Staff A obtained a 136 degree Fahrenheit temperature for the breakfast sausage, and verified that the sausage can be safely held only at a minimum temperature of 140 degrees Fahrenheit. Additionally, Staff A verified that the grates above multiple food preparation/service areas (including the breakfast service area) were littered with dust and rust-colored debris. A tour of the dry goods storage area revealed ill-placed ceiling/wall tiles allowing access from behind the storage room walls.

During a 02/29/12, 9:40 AM interview, Staff A stated that a mouse was noted to have been eating peanut butter in the storage room (within the last two weeks) and mouse poison was being used with positive effect. At the time of the discovery, the mouse poison was observed on the floor in the corner nearest to the ill-fitting ceiling tiles. A second broken tile was observed adjacent to the dry storage room above the combination oven and excessive black dirt and debris was observed on the convection oven and was noted under most oven and preparation counter surfaces. The above findings were verified by Staff A at the time of discovery.

A tour of the facility's first floor deli area was conducted on 03/01/12 between 2:00 PM and 2:15 PM. At the time of the tour, the dried food storage closet was observed to contain excessive dust and debris on the ceiling as well as the sprinkler head. A gap between the ceiling and back wall of the storage closet was observed to create an open area approximately 5 inches in width and large enough to allow pests to enter. The lighting fixture above the food service area and the overhead ventilation grates in front of the service counter were noted to have an excessive amount of dirt and debris. These findings were verified at the time of discovery by Staff C.

During a 03/01/12, 3:10 PM interview, Staff C stated that the hospital did not have a policy regarding who is responsible for kitchen/deli cleaning and maintenance. Since there was no hospital policy, Staff C provided a copy of the facility's contract with Hospital Housekeepers of America, which commenced providing services on 11/28/11. Staff C stated that the contract outlined the responsibilities for the cleaning of the main kitchen areas, which excluded the deli. Review of the contract revealed that it was silent regarding Hospital Housekeepers of America's responsibilities for cleaning the main kitchen area. This was confirmed by Staff F, Director of HHofA.

CONDITION LEVEL DEFICIENCY

Based on the life safety code inspection conducted on 02/27/12 thru 03/03/12, it was determined that this facility was not maintained in a manner safe from fire. This had potential to affect patients, visitors, and staff members. The facility census at the beginning of the survey was 213.

Findings include:

Please refer to the following Life safety code violations:

The following are the Life Safety Code Areas that were cited: K-21 corridor and patient room doors failed to close properly; K-22 Exit access not clearly marked with signs; K-25 Penetrations in smoke barriers; K-29 hazardous areas not one hour protected; K-43 deadbolt lock mounted on patient room door; K-46 battery operated lights not documented clearly to determine proper monthly and annual testing; K-76 Medical gas room used for other storage; K-160 main lobby elevators lacked smoke detection and fire recall system.