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Based on observation, record review, and interview, the facility failed to provide consent forms and all pertinent patient rights documentation in a manner in which the patient or his/her representative can understand, prior to receiving treatment for 10 (P#14-P#23) of 10 patients sampled. This failed practice has the potential for patients to misunderstand or not understand the care they are receiving and also has the potential for patients to be exploited and/or discriminated.
The findings are:

A. On 12/09/19 at 1:57 pm during interview, S#32 Admitting Director stated the Admissions Department Staff discuss all paperwork with the patients being admitted. The patients are then asked to initial and sign the documentation.

B. On 12/09/19 at 2:30 pm during the admission process admission clerks S#29 and S#30 were observed providing admitting documentation to admitting patients. Documentation included patient rights, advanced directives, consent for treatment which were highlighted in a space indicating patient initials and signatures. Patients #2 and P#3 were told, "This is your consent for treatment/release of information/rights and responsibilities [etc.]. Initial on the highlighted parts and sign and date on the signature area. Take this [the paperwork] with you, read through it, and if you have questions, come back and we can discuss it." At no point were any of the documents or reasons for consent forms discussed with the admitting patients.

C. On 12/09/19 at 2:45 pm during interview, S#32 Admitting Director was asked what provisions are made for patients who cannot read or have other learning barriers, do not speak English, or who are Deaf or Blind. S#32 Admitting Director stated, "We don't ask patients if they can't read, we just assume they can. If they need an interpreter, we have an interpreter service, but they have to tell us they need an interpreter. If a patient is deaf, the House Supervisor has an app on her phone that we use. If we know what time the [deaf] patient is coming in, we can schedule a [sign language] interpreter to be here. I don't know what we would do with a blind person. We've never had one."

D. On 12/09/19 at 2:55 pm admission clerks were observed providing admitting documentation to admitting patients. Documentation included patient rights, advanced directives, consent for treatment which were highlighted in a space indicating patient initials and signatures. Patient #2 and P#3 were told, "This is your consent for treatment/release of information/rights and responsibilities [etc.]. Initial on the highlighted parts and sign and date on the signature area. Take this [the paperwork] with you, read through it, and if you have questions, come back and we can discuss it." At no point were the admitting patients asked if the patient needed assistance with reading, needed an interpreter for languages other than English, or Sign Language.

E. Record review of [Facility Name] Admitting: Conditions of Admissions Policy Effective date 09/24/19 did not reveal any process or procedure for providing admitting documentation in any language or method the patient and his/her representative can understand. No process or procedure was indicated that accommodations could be provided if necessary.

Based on record review, and interview, the facility failed clearly explain to each patient the procedure to submit either a written or verbal grievance to the hospital for 12 (P#2- P#3, P#14-P#23) of 10 patients. This failed practice does not allow the patient the ability to file a grievance.
The findings are:

A. Record review of 10 (P#14-P#23) patient charts revealed all 10 patients signed documentation stating receipt and understanding of the process to file a grievance.

B. On 12/09/19 at 1:57 pm duirng interview, S#32 Admitting Director confirmed contact information to file a grievance is found on the patient's Rights and Responsibilities and the Notice of Health Information Privacy Practices. When asked if this information is explained to the patients upon Admission he stated, "We give them the packet of information to read. If they don't understand it, they have to come back to us and we'll call [risk manager's name]. She will then take the information from the patient."




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C. On 12/12/19 at 3:00 PM, during interview, S#29 Customer Service Coordinator, confirmed during the admission process patients are given the form Patient Rights and Responsibilities (Rev 05/16/14) listing a phone number and a mailing address if they want to file a grievance. Also, they are given the Notice of Health Information Privacy Practices (Rev 11/07) to file a report of abuse or neglect. When asked if this information is explained to the patients upon admission, she stated, "We give them the packet of information to read. If they want to file a grievance we will give them a list of phone numbers to call."

D. On 12/12/19 at 3:20 PM, during interview, S#30 Customer Service Coordinator confirmed what S#29 stated is the current process at the time of admission. They give the documents to the patient but do not explain how to file a grievance. S#30 provided the surveyor copies of the documents given to the patient at time of admission. On the Patient Rights and Responsibilities Page 3 of 3 there is information for complaints and grievances which lists the facility name, address and phone number.

E. On 12/12/19 at 3:45 PM, during interview, P#2 stated, "information was fully explained and she understood, it was explained to her interpreter services are available, however, there was no mention of special accommodations available and no mention of how to file a grievance."

F. On 12/12/19 at 3:45 PM, during interview P#3 confirmed at the time of admission alot of information was explained to him but was not told how to file a grievance if he needed to.

Based on record review and interview, the facility failed to provide consent forms which did not allow the patient to make informed decisions of his/her care including the right to refuse medical treatment, interventions, or procedures for 10 (P#14-P#23) of 10 patients. This failed practice has the potential for patient's information to be disclosed to other parties.
The findings are:

A. Record review of 10 (P#14-P#23) patient charts revealed consent for treatment forms indicating the type of information which will be disclosed to other parties, but did not contain any means, (i.e. blank spaces for initials or checkmarks) indicating the patient's right to refuse treatment, interventions, or procedures or participate in experimental research. The form also did not contain any means to identify (i.e. blank spaces for initials or checkmarks) which information is allowed by the patient to be disclosed. The form indicated:
"Release of Medical Information, Assignment of Benefits, Insurance Claims and Payment of Charges"
"I understand that [facility name] will use my information for the purposes of treatment, payment and health care operations
*I authorize [facility name] to and any physicians involved in my care to disclose all or any part of my medical record, including mental health and/or substance abuse treatment records, and/or infectious disease records including but not limited to blood-borne diseases to any organization or insurance company that may be liable or responsible for payment of charges associated with my care and for all other purposes of benefit payment.
*If my injury is work related, I authorize the hospital to release any information from my medical records to my employer and/or its designee or any insurance company that provides insurance.
*For any medical devices I may receive, I agree to the release of my social security number and other required information to the manufacturer and the Food and Drug Administration. I understand that this information may be used to locate me should there be an issue related to the medical device(s).
*I understand that information in my medical record is confidential but may be disclosed for purposes of medical education and research, professional review activities or review activities related to the cost, frequency and quality of patient services provided. Otherwise, my medical record information will not be disclosed without my consent or the consent of my legal representative, unless required by law or a court order.
*I understand that state law requires the reporting of certain positive test results such as hepatitis and the antibody for HIV/AIDS virus to the Health Department
*I understand that the costs of my medical treatment that are quoted to me prior to billing are estimates. Actual charges may be more or less, and additional charges such as consulting physician fees or costs of pharmacy, laboratory, and supplies may not be compiled prior to my discharge. All charges will appear on my monthly statement.
*I authorize and irrevocably assign payment directly to LHS for the full amount of medical insurance benefits payable under the terms of my policy(s) (sic).
*I understand that filing of an insurance claim dies not discharge my responsibility for payment of the charges incurred.
*I agree to pay the actual charges for my medical treatment, less the amount paid to LHS by third party payers, if any. [Facility name] may obtain a credit report on me from a credit reporting agency
*Should the account be referred for collection, I shall pay the reasonable cost of collection including attorney's fees."

B. On 12/09/19 at 1:57 pm during interview, S#32 Admitting Director, stated the Admissions Department Staff discuss all paperwork with the patients being admitted. The patients are then asked to initial and sign the documentation.

C. On 12/09/19 at 2:30 pm, during observation of 3 (P#2 - P#3) admitting patients, all admitting documentation including consent for treatment forms were highlighted in a space indicating patient initials and signatures. Patient's were told, "This is your consent for treatment/release of information/rights and responsibilities [etc.]. Initial on the highlighted parts and sign and date on the signature area. Take this [a patient copy of Rights and Responsibilities with no patient initials or signatures and the Notice of Health Information Privacy Practices with no patient initials or signatures] with you, read through it, and if you have questions, come back and we can discuss it." At no point were any of the documents or reasons for consent forms discussed with the patients. At no point were patients asked if they agreed or disagreed, approved or refused any the information given to them.

D. Record review of [Facility Name] Admitting: Conditions of Admissions Policy Effective date 09/24/19 did not reveal any process or procedure for providing admitting documentation allowing the patients to make informed decisions regarding the care they will receive.
1. Policy states: "It is the responsibility of all Admission Services personnel to obtain a signed, witnessed, time and dated 'Consent for Diagnosis and Treatment' Form. This form also includes release of information and a valuables release that should be signed by all patients upon admission or registration to [facility name].
2. Purpose states:
a. To document patient consent for procedures, administration of medications which are necessary for diagnosis and treatment
b. To release [facility name], its employees and the attending physician from any guarantees or warranties concerning the results of hospital izationand/or diagnosis,, treatment and examination.
c. To document patient consent for release of copies of his/her medical record.
d. To release [facility name] and its employees from responsibility for safekeeping valuables.
e. To provide a written copy of Patient's Rights and Responsibilities
f. To provide a written copy of the Incident Management System Program.

Based on interview, and observation, the facility failed to ensure the oversight of the Food and Nutrition Service not packaging bulk food correctly which affects all patients. This failed practice has the potential to cause harm from food borne illness.

The findings are:

A. On 12/09/19 at 1:05 PM, during interview with S#5 Risk Management was asked for a copy of the policy on the process to store bulk food once opened. She stated, "There is no policy".

B. On 12/09/19 at 1:10 PM, during observation and interview, S#28 Director of Food Services confirmed in the dry product storage room there were two large containers, one had sugar and the other bread crumbs. They did not have lids on them, they were covered with a clear plastic which was all wrinkled up, however half of the top of the container was not covered.

C. On 12/09/19 at 1:15 PM, during observation, in the dry product storage room there were dry food items that were wrapped in clear plastic but did not have dates on them.

D. On 12/09/19 at 1:25 PM, during observation in the walk-in refrigerator
1. There were no dates on pasta and biscuits wrapped in clear plastic.
2. There were slices of cake wrapped in clear plastic, with no dates confirming when the package was opened.
3. There was meat wrapped in plastic on a tray with no dates confirming when the package was opened.

E. On 12/09/19 at 1:25 pm during interview, S#28 Director of Food Services, "they date the tray that had slices of cake not each individual slice of cake

F. On 12/09/19 at 1:30 PM, during observation and interview in the walk-in cooler, S#28 Director of Food Service confirmed there was some packages that didn't have dates and not sealed. 1. Tyson homestyle chicken tenderloins box was open and had no date when it was opened 2. Package of ribs wrapped in clear plastic the plastic was torn 3. Several containers need to be dated when the package was first opened.

G. On 12/09/19 at 1:30 pm during interview S#28 Director of Food Services, stated, "they mark the box not the single packages of chicken that were contained in the box".

H. On 12/09/19 at 1:45 PM, during observation there was a brand Classic soft box of salt opened and not sealed.

I. On 12/09/19 at 1:45 pm, during interview S#28 Director of Food Services confirmed the salt should have been in a bag with a date on it when it was opened.

J. On 12/09/19 at 1:50 PM, during observation, in the front area where anyone can select food items to purchase there were several bread rolls in packages but had no dates when they were first wrapped.

Based on record review and interview the facility failed to conduct and document performance improvement projects as part of the Quality Assessment & Performance Improvement (QAPI) program. This failed practice has the potential to affect health outcomes, patient safety, and quality of care by not identifying opportunities for improvement and implementing changes that will lead to improvement.
The findings are:


A. Record review of facility's QAPI meeting minutes dated 06/25/19 reveals no follow up documentation on performance improvement projects.

B. On 12/12/9 at 11:00 am during an interview, the Infection Control Nurse S#5 confirmed that Hand Hygiene was no longer a quality indicator for QAPI and was discussed during a QAPI meeting.

C. Record review of facility's QAPI meeting minutes dated 06/25/19 revealed no indication that Hand Hygiene had stopped as a quality indicator. Record further reveals this indicator as "on-going".

D. On 12/12/19 at 1:00 pm the Quality Director S#8 confirmed that the meeting minutes did not reflect QAPI activities.

Based on observation and interview, drugs located in the pharmacy were not monitored in accordance with applicable standards of practice which includes monitoring humidity levels in the area. This deficient practice could result in elevated humidity which could cause drug de-sterilization, irreversible destabilization and oxidative degradation because the proteins found in many drugs are sensitive. The findings are:

A. On 12/10/19 at 10:00 am during observation, no humidity monitoring device was observed in the pharmacy storage room.

B. On 12/10/19 at 10:30 am during interview, S#53 Pharmacy Technician confirmed the humidity monitor had been broken for 2-3 weeks.

C. On 12/10/19 at 10:35 am during interview, S#52 Pharmacist also confirmed the humidity monitor was broken.

D. Record review of CFR (code of federal regulations) Title 21 revealed, storage areas for medications should have humidity monitors.

Based on observation, record review and interview, the facility failed to have a system to keep outdated medications unavailable for patient use and removed from emergency carts when the medications expired. This deficient practice can result in the use of medications which are weak and ineffective. The findings are:

A. On 12/11/19 at 2:00 pm during observation of the contents of code cart (supplies used in the event of an emergency) the Breviblock Premix (medication used to treat heart problems) 250 mL (unit of measure) was noted to have a product expiration date of June 2019, 1000 mL Normal Saline (intravenous solution) expired November 2019 and 250 mL bag of Normal Saline expired November 2019.

B. On 12/11/19 at 2:10 pm, during interview S#7 RN (Registered Nurse) Manager confirmed the date of expiration for the Breviblock (June 2019) and the bags of Normal Saline (November 2019).

C. Record review of a facility document, "Order Express" dated 11/26/19 indicated the product (Breviblock Premix) was available in limited quantities (3), but does not indicate the expired medication found in the code cart was safe for use.

Based on record review and and interview the facility failed to have proper safety precautions implemented to protect staff from ionizing radiation (Xrays). This deficient practice could result in staff developing cataracts (clouding of the lens of the eye which can result in blindness). The findings are:

A. Record review of the "International Atomic Energy Agency Health professionals" website article undated revealed, "Performing a few fluoroscopic procedures (Xray procedues) per week that require only a few minutes of fluoroscopy time per procedure (i.e. less than 5 minutes), sufficient protection of the eye lens can be achieved by using a lead screen or wearing lead glass eye wear. But if protection is not used, there can be a risk (cataracts).

B. On 12/12/19 at 10:00 am during interview, S# 75 (Radiology Manager) was asked if staff was educated about the risks of radiation to their eyes and replied "yes."

C. On 12/12/19 at 10:30 am during interview, S#78 Radiology Technician was asked if she was educated about wearing protective eyewear and replied, "we don't have any, so we don't wear any."

Based on observation, and interviews, the Infection Control Program Coordinator failed to:

1. Have a system in place to ensure the Endoscopy Suite ( dedicated area where medical procedures are performed with endoscopes, which are cameras used to visualize structures within the body, such as the digestive tract and genitourinary system) was cleaned and sanitized after a procedure was conducted.
2. Have a system in place to ensure a clean and safe environment in the Operating Rooms.
3. Have a system in place to oversee infectious control measures are taken in Dietary.
4. Have a system in place to oversee infectious control measures are taken in the Pathology (the science of the causes and effects of diseases, especially the branch of medicine that deals with the laboratory examination of samples of body tissue for diagnostic or forensic purposes) room.

Findings:

1. Endoscopy Suite:

A. On 12/11/19 at 10:00 am during observation a white substance was noted to be dripped down a red anesthesia (insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs before surgical operations. cart and trash in the trash can.
B. On 12/11/19 at 10:05 am during interview, S#76 Endoscopy Tech stated that she believed the substance was propofol (medication used to induce anesthesia). S#76 also confirmed she was unaware of when the room was last cleaned or when it was scheduled to be cleaned. S#76 confirmed no cases had been done that day, but cases were performed the previous day.

2. Operating Rooms:

A. On 12/10/19 at 2:30 pm, during observation of operating rooms (#1, 2, 4 and #5) in the surgical suites revealed;
1. Cracks on the surgical floors where the flooring joins on corner walls.
2. Seals in light fixtures were coming off in the surgical suites.
3. Surgical Suite #4 had a crack in the ceiling between light fixtures approximately 4 inches long.
4. Rust at the base of the wheels on the intravenous pole (IV) in surgical #4.
5. Surgical Suite #1 had a light fixture that was broken.

B. On 12/10/19 at 2:45 pm during interview, S#3 (compliance manager) confirmed cracks on the floors were present, seals in light fixtures were not affixed, crack in the ceiling, rust at the base of the IV pole and broken light fixture.

C. On 12/10/19 at 3:15 pm during interview, S#5 (risk manager) confirmed not being aware of the issues that were found in the surgical suites.

3. Dietary:

A. On 12/09/19 at 11:40 am during observation of the dietary area revealed:
1. Products in dry storage area did not have open dates
2. Ceiling in dry storage area had a green-colored stain
3. Walk-in refrigerator contained pasta and and biscuits with no dates
4. Some meat products were not dated
5. Walk-in freezer contained chicken tenderloin was undated
6. Package of ribs was torn open
7. Ice machine filter had no date
8. Used band-aid was found in food warmer

B. On 12/09/19, during review of the dietary area, Dietary Director confirmed findings.

4. Pathology Room:

A. On 12/11/19 at 12:00 pm during observation, the pathology room was noted to have stained chux (plastic lined absorbent material), a rusty blade sitting on base of fume hood (used by physician when preserving specimens including tissues removed during breast biopsies), rusty hood base, trash in the garbage can, a dirty sink which also had debris in the drain strainer and an unknown red substance on the edge of the cryostat (machine used for freezing specimens).

B. On 12/11/19 at 12:10 pm during interview S#11 (Lab tech) confirmed the trash in the trash can was the same trash she observed the day prior and did not know the cleaning schedule for the room. S#11 removed the red substance from the cryostat and confirmed the room needed to be cleaned.

C. On 12/11/19 at 12:15 pm during interview, S#31 (RN) confirmed the room was cluttered and dirty.