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Based on observation, staff interview and review of maintenance records between 01/07/19 and 01/08/19, the HSHS St. Clare Memorial Hospital failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K321 Hazardous Areas- Enclosure
2. K347 Smoke Detection
3. K351 Sprinkler Systems - Installation
4. K363 Corridors-Doors

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interview and review of maintenance records between 01/07/19 and 01/08/19, the HSHS St. Clare Memorial Hospital failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K321 Hazardous Areas- Enclosure
2. K347 Smoke Detection
3. K351 Sprinkler Systems - Installation
4. K363 Corridors-Doors

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview, nursing staff failed to develop and maintain an individualized care plan for 1 of 2 patients in restraints out of a total universe of 21 patient records reviewed.

Findings include:

On 1/7/18 at 10:00 AM reviewed policy titled "HSHS Restraint and Seclusion Policy" dated 6/7/1. This policy states "B.3. The patient plan of care is modified to include restraint management."

Patient #2's medical record was reviewed on 1/8/19 at 4:00 PM. This record states that Patient #2 received an order for restraints on 10/14/18 at 4:26 AM for confusion and pulling on medical equipment. Restraints continued through 10/15/18. The care plan for Patient #2 does not contain a care plan with goals, interventions and progress related to restraint use.

Conducted an interview with Director of Patient Care Services A on 1/8/19 at 4:10 PM. Director of Patient Care Services A stated the care plan "should have been updated to include restraints."

Based on record review, observation, and interview, the facility failed to secure medical records in 1 of 1 area (lower level Health Information Management [HIM] room) from unauthorized access.

Findings include:

Review on 1/8/2019 of policy titled, "Technical, Physical, and Administrative Safeguards" #HP-05, dated October 11, 2013 revealed, "Where paper copies of Protected Health Information will be stored on HSHS premises, such information will be stored in locked cabinets or rooms. Access to such cabinets or rooms will be limited to Workforce members who require access to perform their job duties."

Per observation on 1/8/2019 at 10:00 AM of the HIM room, the door was propped open and an open shelving unit containing stacks of patient medical records was noted. Per HIM Associate S, the records were "clinic charts".

During an interview on 1/8/2019 at 10:00 AM, HIM Associate S stated the door to the room is to be closed and locked when staff not present. When asked how the room was secured when staff leaves the room for lunch, HIM Associate S stated the door was not closed nor locked during those times. "I turn off the lights, but I do not lock the door, no". HIM Services Manager R was present and confirmed the expectation that the door be locked when HIM staff left the room.

Based on interview and record review the facility failed to ensure a comprehensive, daily program of activities offered designed around patient interests for swing bed patients in 2 of 2 swing bed patients reviewed (Patient #'s 6 & 7).

Findings include:

The facility policy titled "Almost Home Program" (swing bed program title) #PR-019 (with no last reviewed date) was reviewed on 1/9/19 at 2:30 PM this document revealed on page 5 "Activities: A. The occupational Therapy department provides general supervision for the Almost Home activities program. B. The activity program shall be provided to all Almost Home patients. C. The program shall be multi faceted and be appropriate to the needs and interests of each patient and shall be planned to encourage self-care, resumption of normal activities, and maintenance of optimal level of psychosocial functioning. D. Participation is based on the patient's interest and consent to engage in activities with others. E. Some activities offered include: crafts, cards, bingo, board games, letter and card writing."

An interview was conducted with Occupational Therapy Director R on 1/9/19 at 4:00 PM who stated in regards to activities on swing bed patients "I do the activities and if I am not here whoever is here from Occupational Therapy will do it. We offer activities on Monday's and Thursdays and the evaluation is completed with our OT evaluation under "Therapy Leisure". When asked if activity calendar is provided to patients or posted on the unit Occupational Therapy Director R replied "no it's not given to them but the nurses have access to it on Outlook in the computer."

Patient #6's medical record was reviewed on 1-9-19 at 2:30 PM. Patient #6 was an 81 year old and was admitted to swing bed on 10/23/18-10/26/18 and had a medical history of hypertension and rheumatoid arthritis who had developed left hip pain and was found to have a hip fracture with resulting arthroplasty on 10/18/18. On 10/24/18 at 12:18 PM a "Almost Home Occupational Therapy Initial Evaluation" was completed and documented "Therapy Leisure: Gardening; Visit with family and friends; Cooking (very active)"

There was no documented offering of independent or group activities during Patient #6 swing bed stay. This was confirmed on interview by Occupational Therapy Director R at 3:16 PM who said "Yes there is no documented activity offering and there should have been."

Patient #7's medical record was reviewed on 1/9/19 at 2:50 PM. Patient #7 was admitted to swing bed on 10/4/18 and discharged on 10/13/18. Patient #7 was an 88 year old with a medical history of congestive heart failure, coronary artery disease, chronic kidney disease state III, atrial fibrillation, cirrhosis, osteoarthritis, hypertension, polymyalgia rheumatica and osteoporisis who had an acute care hospital inpatient stay after a fall at home. Was admitted to swing bed for physical rehabilitation. A "Almost Home Occupational Therapy Initial Evaluation" was completed by Occupational Therapy Director R on 10/5/18 at 2:11 PM. That evaluation had the following completed: Reason for admission, comorbidities relevant to OT (Occupational Therapy), previous occupational therapy, ordering provider, precautions (brace/sling), subjective, type of home, home layout, home accessibility, bather showeer/tub, bathroom toilet, bathroom equipment, bathroom accessibility, prior function level of independence, fall history, lives with, ADL (activities of daily living) assistance, homemaking assistance, comments, pain, activity tolerance/endurance, vision, overal cognitive status, arousal/alertness, attention span, memory, orientation level, following commands, safety judgment, awareness of errors, deficits, perseveration, affect, overall extremity assessment, hand function, sensation, grooming assistance, bed mobility, functional transfers, performance skills deficits, clinical decision making, prognosis, OT recommentdations and plan. There was no documented comprehensive evaluation of Patient #7's interests, activity preferences and preferred level of participation (i.e. alone or in groups) or providing Patient #7 of facility activity calendar.

On 10/4/18 at 4:27 PM a Occupational Therapist Progress Note completed by Occupational Therapy Director R documented "Patient declined opportunity to participate in group activity this date." There was no documented offering of independent activity or group activities at a later time.

On 10/9/18 at 9:08 AM a Occupational Therapist Progress Note completed by Occupational Therapy Director R documented "Due to procedure today patient will not have the opportunity to participate in group activities this date." There was no documented offering of independent activity or group activities at a later time.