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Based on interview and record review, the facility failed to ensure patient's rights for one of 31 sampled patients (Patient 12) when the Terms and Condition of Admission (COA) form was not provided for Patient 12 upon admission on 6/13/16.

The deficient practice did not ensure patient's right to decide about the medical treatment he was to receive.

Findings:

Review of the Admission and Registration Record indicated Patient 12 was admitted to the facility on 6/13/16 with the diagnoses that included urosepsis (is the acute condition of a systemic infection in the blood that develops secondary to a urinary tract infection (UTI) - an infection in any part of your urinary system such as the kidneys, ureters, bladder and urethra.) and urinary retention (inability to completely empty the bladder).

During review of the medical record of Patient 12 on 4/26/17 at 4:03 pm with the Medical Record Clerk (MRC) 1 present, there was no evidence of a completed Terms and Condition on Admission (COA) form.

In an interview on 4/28/17 at 11:08 am, the Admission and Eligibility Supervisor (AES) stated when a patient was to be admitted, the Admission Clerk would give the COA form to the patient for signature. AES stated the COA form was to authorize the hospital for treatment purposes.

In a follow-up interview on 4/28/17 at 4:10 pm, the AES verified there was no evidence that the COA form was obtained upon admission of Patient 12.

Review of the facility policy titled, "Standard Admission Agreement and Condition of Admission & Treatment, revision date: 7/31/13, indicated, "Policy: ....Every patient has the legal right to decide upon medical treatment he/she is to be given. Therefore, every patient .... must sign the .... commonly referred to as a COA (Condition of Admission) form granting consent for hospital services and medical treatment. "

Based on record review, the facility failed to maintain a complete record when the Terms and Condition of Admission (COA) Forms for two of 31 sampled patients (Patients 23 and 26) were not witnessed by two staff. Patients 23 and 26 were not able to sign the COA and there was only one facility staff who witnessed and signed the forms.

The deficient practice did not ensure that the patient and or their legal representative was aware of their rights to medical care and treatment.

Findings:

1. Review of the Registration and Admission Record indicated Patient 23 was originally admitted on 8/7/13 and re-admitted on 10/18/16.
The record also showed Patient 23's Conservator with the contact information. Patient 23 was admitted with diagnoses of gastro-intestinal bleed and altered level of consciousness.

Review of the Terms and Condition of Admission form for Acute Inpatient, Outpatient and Emergency Services indicated the form was dated 10/18/16. It showed "Unable to Sign" written on the patient or legal representative signature line. The form was signed by Hospital Eligibility Counselor 1 as the witness.

2. Patient 26 was admitted to the facility on 12/23/16. Review of a document titled, Resident Social History/Assessment " dated 12/23/16 indicated under Social /Marital History Section : "Very little is known about him (Patient 26) and he is severely cognitively impaired."

Review of Review of the Terms and Condition of Admission form for Acute Inpatient, Outpatient and Emergency Services indicated the form was dated 12/23/16. It showed "Unable to Sign" written on the patient or legal representative signature line. The form was signed by Hospital Eligibility Counselor 1 as the witness.

In an interview on 4/28/17 at 11:15 am, the Admission and Eligibility Supervisor (AES) stated when a patient was to be admitted but was unable to sign, two facility staff witnesses are required to sign on the COA form.

Review of the policy and procedure titled, "Standard Admission Agreement and Condition of Admission & Treatment " dated January 2010 indicated under Procedure: " the (name of the facility) utilizes the "Standard Admissions Agreement and Terms and Condition of Admission & Treatment forms to obtain and document each patient's consent to hospitalization and routine services, and to document the patient's assumption of financial responsibility for payment of charges for services rendered....General Guidelines...7. If the patient cannot sign and has no valid family member or other legal representative, the A & E Staff: Stamps the signature line (or writes) 'patient unable to sign' and document the reason the patient was unable to sign... c. In all cases when the patient cannot sign, two witnesses must sign as verification..."

Based on interview and record review, the facility failed to ensure the staff were trained in emergency procedures when one staff did not know how to respond in case of fire.

The deficient practice could potentially put patients, staff and visitors at risk for injury in case of fire.

Findings:

During an interview on 4/26/17 at 12 PM with Radiology Technician 1, she was asked to describe the emergency procedure in case of fire in the Radiology Dept. She said she would activate the alarm but did not know where the red manual pull stations were located. She walked around the Radiology Dept. and did not find it. The Outpatient Clinical Support Manager who was present during the interview also helped look for the pull station. He found the closest red manual pull station was in the outpatient clinic.

Review of the facility policy and procedure titled, "Fire Response Plan" dated Sept. 9, 2014 indicated, "Procedure: 1. When you see Smoke or Fire: a. Follow the R.A.C.E. (Rescue, Alarm, Contain, Extinguish or Evacuate) acronym below for basic fire response steps:
i. Rescue persons in immediate danger while announcing "Code Red" to nearby staff.
ii. Alarm by continuing to shout "Code Red" to nearby staff and by activating the alarm using the nearest manual pull station..."

Based on observation, interview, and record review, the facility failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality when:

1. There were 14 individual packages of tracheostomy (a tracheostomy tube is a curved tube that is inserted into a tracheostomy stoma [the hole made in the neck and trachea [windpipe]), inner cannulas (one of the three parts of the tracheostomy tube that fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning) stored in the Clean Utility Room beyond expiration date.

2. There were six (6) packages of nutritional supplement (Juven powder), stored in the medicine cart beyond the expiration date.

3. There was no evidence of preventive maintenance check for the gym equipments in the Rehabilitation Area.

4. One autoclave machine (a machine to sterilize equipments that uses pressure and steam to reach and maintain a temperature that is too high for any microorganisms or their spores to live) in the Outpatient Clinic did not have evidence of preventive maintenance check.

5. There were heavily stained toilet bowls in rooms 48, 49, 51, 55 and 57.

These deficient practices had the potential to negatively impact the care and services rendered to patients.

Definition:

Preventive maintenance - a maintenance strategy where maintenance activities are performed at scheduled time intervals to minimize degradation and reducing instances where there is a loss of performance, as define in the State Operation Manual, Appendix A).

Findings:

1. During an observation of the Clean Utility Room, PM (pavilion Mezzanine), accompanied by the Registered Nurse (RN) 1 and the Nurse Manager (NM) on 4/26/17 at 10:30 am., there were fourteen (14) individual packages of tracheostomy inner cannulas inside an open box stored in one of the metal shelves. During concurrent interview, The RN 1 stated the expiration date was "11/2016".

Review of the facility policy dated 8/1/16 titled, "Reporting and Disposing of Obsolete and Expired Products" indicated, "...5. Expired items will be stored in a separate bulk location ..."

2. During an observation of the medication storage room on 4/26/17 at 9:24 am, the fourth drawer of the medication cart had six (6) packages of Juven powder (a nutritional supplement). Registered Nurse (RN) 1 stated the expiration date was "2/17".

In an interview on 4/26/17 at 9:26 am, RN acknowledged the six individual packages of Juven powder were stored beyond expiration date and stated it can cause stomach upset.

In an interview on 4/28/17 at 9:10 am, the Chief Dietitian (CD) stated the nutritional supplements were delivered by the Food Service Worker (FSW) from the kitchen to the nursing units and the FSW maintained daily supply. The CD also stated that if the nutritional supplements were stored inside the mediation storage room, the FSW had no access to it, therefore, it was the licensed nurse's responsibility to check any undated items. When asked what could potentially happen if patients received expired nutritional supplements. The CD stated, "Patients can get sick and it can cause harm to the patients."

Review of the facility Policy:1.144 titled, "Food Supply/ Food Storage" indicated, "Purpose: To ensure safety of the food supply while in storage. .. Procedure... 6. Food that is outdated ... will be properly identified with a sign and removed..."

3. During an observation on 4/26/17 at 11:30 am., the Rehabilitation Service Area (RSA) had several equipments that included treadmill machines, stationary bike and upper pull arm bike that did not have a facility or bio-med stickers for preventive maintenance check.


In an interview on 4/26/17 at 11:43 am, the Senior Physical Therapy Supervisor (SPTS) stated the patients had been using the machines like the stationary bike, upper pull arm bike. The SPTS acknowledged there were no stickers for PM check. SPTS was not sure who was responsible for the PM and stated she would refer to the Facility Management.

In an interview on 4/28/17 at 2:15 pm, the Director of Facility Management acknowledged there was no record of preventive maintenance check for the equipments in the RSA.

Review of the facility policy dated 8/16/16 titled, "Equipment Maintenance" indicated, "Policy: Top assure that ... equipments function properly... Procedure: 1. Annual equipment monitoring for proper functioning and safety is carried out... by the Materials Management Department... 2. Documentation of the tests is kept..."


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4. During observation in the Outpatient Department on 4/27/17 at 8:30 AM, accompanied by the Clinic Director and the Clinic Charge Nurse, one autoclave machine was found without a biomed sticker.

During a concurrent interview with the Clinic Charge Nurse, she stated that minor surgical procedures were done in the Surgical Clinic four days a week from 9AM to 12PM. She acknowledged there was no biomed sticker on the autoclave to indicate when the maintenance check was done.

During an interview with the Director of Materials Management and Central Supply on 4/28/17, at he said the contract with the Autoclave Company ended last year and there was no record of maintenance check done on the autoclave machine.
Review of facility policy and procedure titled, "Equipment Maintenance" dated 2/9/09 indicated, " Policy: 1. Biomedical equipment will be maintained in operational condition. 2. Contracts for repair and for regular maintenance of biomedical equipment will be established with appropriate vendors. Procedure: ...B. Regular maintenance is performed by a contract vendor under the supervision of the Facility Services..."

5. During initial tour on 4/25/17 at 9:15 AM accompanied by the Unit Manager and Director of Nursing, there were four toilet bowls with heavy brown and yellow stains in patient Rooms 48, 49, 55 and 57.

During an interview with Housekeeping Supervisor on 4/25/17 at 9:45 AM, she said she was aware of the stained toilet bowls . She said the facility purchased six or eight new toilet bowls because there was a plan to replace them.

During an interview on 4/27/17 at 11:30 AM, the Chief Operating Officer and the Director of Facilities stated that the facility could not determine the definite cause of the heavy stains in the toilet bowls. They said it was possible that the stains were due to the cleaning chemicals that was used to clean the toilet bowls.

Based on observation, interview, and record review, the facility failed to maintain proper water temperature control in 5 patient rooms (Rooms 48, 51, 55, 56, and 57).

The deficient practice could negatively impact the care and services to the patients.

Findings:

During the environmental tour on 4/27/17 at 10:10 AM accompanied by the Chief Engineer the water temperatures in the following patient bathrooms and showers were checked:
Rm. Shower Temperature Bathroom Sink water temp
48 100.8 degrees 104 degrees
51 102.7 degrees 105.8 degrees
55 101.8 degrees 110.6 degrees
56 100.8 degrees 104.5 degrees
57 72.5 degrees 110 degrees
81 (Spa 99.9 degrees 103.6 degrees
Room)
During an interview with the Chief Engineer on 4/27/17 at 10:30 AM, he stated that water temperatures are checked in random rooms three times a day that the water temperature range should be between 105 to 120 degrees Fahrenheit.

Review of facility policy and procedure titled, "Domestic Hot Water Monitoring" dated 9/2015 indicated, "Policy: Watch engineers will maintain the domestic hot water temperature at a control range of 105 -120 degrees F. Procedure: A. Weekdays: The watch engineer will check and record the domestic hot water systems temperature after the mixing valve at the beginning of each shift for each building. The watch engineers shall also take and record a temperature reading at a patient sink in each building each shift. Engineers immediately shall report any water temperature readings which exceed the prescribed range limits to the Senior Engineer and follow his directions..."

Based on interview and record review, the facility failed to develop a discharge plan for five out of 31 sampled patients when there were no documented discharge planning in the Integrated Progress Notes for Patients 6, 16, 17, 18, and 20.

The deficient practice could not ensure patients would have a safe and orderly discharge from the facility.

Findings:

1. Review of the Admission and Registration Record indicated Patient 6 was admitted to the hospital on 10/13/16. The Physician Progress Note indicated the diagnoses that included fever and seizure disorder (a sudden surge of electrical activity in the brain), electronically signed (e-signed) and dated by the physician on 10/21/16 at 12:16 pm. The Physician's Order dated 10/17/16 at 8;00 am, indicated an order to discharge Patient 6 back to the Skilled Nursing Facility (SNF).

In an interview on 4/27/17 at 2:00 pm. the Quality Management Nurse (QMN) stated the discharge planning was done by the Social Worker (SW) and should have documented it on the Integrated Progress Notes (IPN).

In a concurrent review of the IPN form dated 10/14/16 to 10/18/16, the
QMN verified there was no documentation of discharge planning.

2. Review of the Admission and Registration Record indicated Patient 16 was admitted to the hospital on 5/29/16. The Physician Progress Note indicated the diagnoses that included sepsis (illness caused by an infection in any part of the body) and pneumonia (lung infection), e-signed and dated by the physician on 6/7/16 at 11:55 am. The Physician's Order dated 6/3/16 indicated an order to discharge Patent 16 back to the SNF.


In a concurrent record review and interview on 4/26/17 at 2:50 pm. the Medical Record Clerk (MRC) 1 verified the IPN form dated 5/30/16 up to 6/3/16 did not have documentation of discharge planning.


3. Review of the Admission and Registration Record indicated Patient 17 was admitted to he hospital on 9/12/16. The History and Physical Examination (HPE) form indicated the diagnoses that included squamous cell carcinoma (skin cancer) and HIV/(Human immunodeficiency - virus that attacks the immune system, the body's natural defense system) /AIDS (Acquired Immune Deficiency Syndrome:-a disease in which there is a severe loss of the body's cellular immunity, greatly lowering the resistance to infection and malignancy), e-signed by the physician on 9/13/16 at 9:01 am. The Physician's Order dated 9/19/16 indicated an order to discharge Patient 17 back to the SNF.

In a concurrent record review and interview on 4/26/17 at 3:09 pm, the MRC 1 verified the IPN form dated 9/17/16 to 9/18/16 did not have documentation of discharge planning.

4. Review of the Admission and Registration Record indicated Patient 18 was admitted tot he hospital on 5/2/16. The Physician Progress Note indicated the diagnoses that included respiratory distress (difficulty in breathing) and sepsis (illness caused by an infection in any part of the body). The Physician's Order dated 5/5/16 indicated an order to discharge Patient 18 back to the SNF.

In a concurrent record review and interview on 4/26/17 at 3:15 pm, the MRC 1 verified the IPN dated 5/2/16 up to 5/5/16 did not have discharge planning documentation.

5. Review of the Admission and Registration Record indicated Patient 20 was admitted to the hospital on 6/24/16. The HPE form indicated the diagnoses that included mild DKA (Diabetes Ketoacidosis is a serious complication of diabetes (blood glucose (often called blood sugar) is too high) that occurs when your body produces high levels of blood acids called ketones) and acute pancreatitis (inflammation of the pancreas), e-signed and dated by the physician on 7/8/16 at 8:50 am. The Discharge Summary indicated date of discharge on 6/29/16, e-signed by the physician on 8/10/16 at 5:03 pm.

In a concurrent record review and interview on 4/26/17 at 3:53 pm, the MRC 1 verified the IPN dated 6/24/16 to 6/28/16 did not have discharge planning documentation.

In an interview on 4/28/17 at 9:57 am, the Director of Social Services (DSS) stated the Social Worker would complete the initial assessment and the IPN form was completed for all patients. DSS stated the IPN should have one (1) to two (2) sentences stating patient was discharged.

Review of the facility policy titled, "Discharge Planning", with Rrevision date: 5/12/15 indicated, "Purpose: To implement safe and orderly discharge process ... Procedure: 1. Discharge assessment and planning is initiated on admission ... c. Social Worker... v. Completes the discharge assessment... Documents discharge planning efforts ... to ensure a safe and orderly discharge from the facility..."