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Based on fifty four of fifty four (#1-54) medical records reviewed and interview the facility failed to ensure all patients being treated at the facility received a copy of patient rights and responsibilities. Findings include:

On April 15, 2014 at approximately 1115 during medical records review it was discovered the facility could not produce evidence that patients receiving treatment (patient #s1-54) had received a copy of patient rights and responsibilities.

On April 16, 2014 at approximately 1400 during an interview with staff NN the question was asked if the facility could produce evidence that patients received a copy of patient rights and responsibilities. Staff NN stated that on the patient consent, revised in 2013, that there was an acknowledgment for receipt of patient rights and responsibilities but that the printer had supplied the 2012 consent, which did not include that acknowledgement for receipt of patient rights and responsibilities.

Based on medical record review, interview, and policy review the facility failed to ensure 7 of 17 patients (#1, #4, # 22, #35, #36, #43, and #44) received the Important Message from Medicare (IMM).
Findings include:
During medical record review on 4/16/14 at approximately 1350 it was revealed that patient #35's medical record failed to have the required IMM. During an interview with staff II on 4/16/14 at approximately 1355 it was confirmed that the IMM was not in the medical record. Staff II stated, "I do not see that form on this chart."
During medical record review on 4/16/14 at approximately 1400 it was revealed that patient #36's medical record failed to have the required IMM provided prior to discharge. During an interview with staff II on 4/16/14 at approximately 1405 it was confirmed that the second IMM was not in the medical record. Staff II stated, "No, it's not there, there is just the one."


29955

On April 15, 2014 at approximately 1115 during medical record review of patient #1 it was discovered the facility failed to deliver the Important Message from Medicare (IMM) within the 48 hours of admission on April 9, 2014.

On April 15, 2014 at approximately 1120 during an interview with staff A it was confirmed that patient #1 had not received the Important Message from Medicare within the 48 hours of admission on April 9, 2014.

On April 15, 2014 at approximately 1125 during medical record review of patient #4 it was discovered the facility failed to deliver the Important Message from Medicare within the 48 hours of admission on April 9, 2014.

On April 15, 2014 at approximately 1130 during an interview with staff A it was confirmed that patient #4 had not received the Important Message from Medicare within the 48 hours of admission on April 9, 2014.

On April 15, 2014 at approximately 1330 during medical record review of patient #22 admitted on April 9, 2014, it was discovered the facility failed to deliver the second Important Message from Medicare prior to discharge on April 15, 2014.

On April 15, 2014 at approximately 1345 during an interview with staff A it was confirmed that patient #22 admitted on April 9, 2014, had not received the second Important Message from Medicare prior to discharge on April 15, 2014.

On April 15, 2014 at approximately 1530 a review of the undated policy "An Important Message About Medicare" states "patient access will provide, explain and obtain the patient's (or patient representatives signature on the first notice" and "first notice must be provided to all patients who have original Medicare or a Medicare Advantage as their primary or secondary payer, within two (2) calendar days of an admission". According to the policy it further states "all charts will also include a copy of the second notice for use prior to discharge".


28273

On 04/15/2014 at 1100 a review of the medical record for patient #43 revealed that the patient was admitted on 04/08/2014 and was a recipient of Medicare. The first IMM form was noted to be on the patient record but unsigned.

On 04/15/2014 at 1110 staff EE (Director In-Patient Care Services) confirmed the lack of signature on the document. When queried as to who's job it is to complete the form she stated, "it is supposed to be done by registration."

On 04/15/2014 at 1300 a review of the medical record for patient #44 revealed that the patient was admitted to the facility on 04/08/2014 and was a recipient of Medicare. The first IMM form was not completed (signed) by the patient until 04/15/2014 approximately 7 days after the patient was admitted.

On 04/15/2014 at 1305 staff EE confirmed the date on the form and when queried as to the time frame for completing the first IMM form she stated, "I believe it is within 48 hours of admission."

Based on policy review, record review and interview, the facility failed to ensure that staff documented the every 30 minute vital sign monitor during blood transfusion for two (2) of three (3) patients who received blood (#41 and #42) resulting in the potential for adverse reactions and poor patient outcomes. Findings include:

On 04/14/2014 at 1700 a review was conducted of the facility's procedure for blood administration titled, "Blood Component Administration, Procedure Number: 10.1.625, Effective Date: 7/87, Review Date 6/12/12. The procedure reads in the section titled "Administration Procedure: #7. Patient monitoring: c. Complete the times on the Blood Bank chart copy for 30 minutes intervals. d. Every 30 minutes, obtain vital signs, including temperature, and record by the appropriate time on the Blood Bank chart copy..."

On 04/15/2014 at 0900, review of the medical record for patient #41 revealed that the patient received a blood transfusion on 04/15/2014. Documented start time was 1635. The Blood Bank chart copy document contained an area for vital signs that were documented for "Pre 1635" and "15 min 1650." The document contained three (3) other sets of vital signs that did not contain documentation as to the time taken. The documentation supports that the transfusion ended at 1800.

On 04/15/2014 at 0930, review of the medical record for patient #42 revealed that the patient had received two (2) transfusions on 04/15/2014 with transfusion start times documented as 1230 and 1530. Documentation on the first Blood Bank record reveals that the transfusion started at 1230. The document contained a pre set of vital signs, documented as the same time that the transfusion started (1230,) and a 15 minute set of vitals (no time documented on the record). The next set of vitals does not contain documentation as to the time they were taken. There was then documentation of vitals for 1345 and not again until one hour later at 1445 and a post set of vitals taken 45 minutes later at 1530 when the transfusion ended.

Review of the second Blood Bank chart copy revealed that the patient's second transfusion started at 1530. The pre set of vitals and 15 minute vitals contain no documented time. The next set of vitals also lacked a documented time as to when they were obtained. The first documentation of time for vitals after the initial start time was 1620. The Blood Bank chart copy lacks documentation as to when the transfusion ended.

On 04/15/2014 at 1100, during an interview with staff EE (Director In-Patient Care Services) when queried about the findings on the Blood Bank documents she stated, "staff are aware and supposed to time and chart vitals every 30 minutes on patients that are receiving any blood products."

Based upon observation, document review and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care (Chapter 18 New Health Care). Findings include:
See the individually and below cited K-tags dated April 17, 2014.
Building 1
K-0015
K-0018
K-0027
K-0029
K-0033
K-0050
K-0056
K-0064
K-0070
K-0147
Building 2
K-0018
K-0025
K-0029
K-0051
K-0056
K-0062
K-0147
Building 3
K-0014
K-0015
K-0018
K-0029
K-0050
K-0076
K-0147

Based on observation the facility failed to provide a safe, maintained and sanitary environment resulting in the potential for transmission of infectious agents to patients served. Findings include:
It was observed that shower stalls connected to inpatient sleeping rooms in the older north and south nursing units as evidenced by the following examples did not have an emergency nurse call pull station provided within the stall making for a potentially unsafe environment as self showering inpatients would not be easily able to call for assistance:
1. Room 618 at Facility A campus, 04/15/2014 at 1119;
2. Room 609 at Facility A campus, 04/15/2014 at 1148;
3. Room 610 at Facility A campus, 04/15/2014 at 1149;
4. Room 422 at Facility A campus, 04/15/2014 at 1307.
It was observed that plumbing fixtures had been boxed in (fully enclosed in wooden cabinetry in the case of tubs) or removed in such a way that remaining hot and cold stagnate potable (drinking) water would collect in plumbing "dead legs" as evidenced by the following examples thereby allowing for growth of pathogens such as legionella which could contaminate the drinking water supply within the campus and infect the occupants (patients being the most susceptible to deleterious affects of the infection):
1. Former tub room 6026 at Facility A campus, 04/15/2014 at 1115;
2. Former tub room 4416 at Facility A campus, 04/15/2014 at 1313;
3. Former toilet room across from 2 South East nurse station at Facility A campus, 04/16/2014 at 0907.
Based on observation on 04/16/2014 at 1317 an improperly installed vacuum pressure breaker was found on the autopsy table at the Facility A campus, such that the drinking water supply within the campus could be contaminated with body fluids and infect the occupants (patients being the most susceptible to deleterious affects of the infection).
Unsanitary practices were observed in the pharmacies that could contaminate patient care products with harmful/infectious materials as evidenced by the following examples:
1. Storage of coats, personal lockers, coffee cups in general pick area at Facility A campus, 04/16/2014 at 14:53;
2. Coffee pot, 9 coffee cups, and microwave oven at Facility B campus, 04/17/2014 at 11:53;
3. Storage of coats and personal bag in general pick area at Facility B campus, 04/17/2014 at 11:56.
Poor housekeeping (heavy accumulations of dust and debris) were found under automatic dispensing units and cabinets that could harbor vermin and contaminate patient care products with harmful/infectious materials as evidenced by the following examples:
1. Under open base staff lockers in Facility A staff locker room 611, 04/15/2014 at 1154;
2. Under automatic dispensing unit in medication room 3544, 04/15/2014 at 1414;
3. Under cabinet in Facility A in pharmacy that wasn't sealed to the floor on 04/16/2014 at 1450;
4. Under sink in Facility B 1 East clean utility room, 04/17/2014 at 0902;
5. Under automatic dispensing unit in Facility B campus pharmacy, 04/17/2014 at 1155.
Based on observation on 04/17/2014 at 1203 the table pad in radiology room #2 at the Facility B campus was severely worn such that it was no longer impermeable to body fluids so that it was uncleanable and could retain body fluids and allow transmission of body fluids from one patient to another.

Based on observation, document review, and interview it was determined that the facility failed to ensure that: 1. refrigerators are clean, defrosted, temperatures are monitored and documented, 2. patient nutrition areas including drawers and microwaves are kept clean, 3.cleaning products taken out of one container and placed into another container are labeled with the containers' contents and concentration, 4.glucose strips containers have opened/expiration date label, 5.quality controls of the glucose monitor are run and documented 6.dietary department cleaning schedules are adhered to, resulting in the potential for patient harm for all patients being treated at this facility. Findings include:

On 04/15/14 at approximately 1130 during tour of 3 south the refrigerator in the medication room was found to have dirt and debris in the bottom and the freezer had a large build up of ice. Staff C stated, "its everyone's job to keep it clean and defrosted".

On 04/15/14 at approximately 1230 during tour of 3 Chi the patient nutrition room was found to have dirt and debris accumulation in the microwave, in all of the drawers with silverware and condiments, and in the refrigerator bottom. The top of the refrigerator also had a layer of dust. Staff B stated, "everyone is supposed to work together to keep this area clean". Further tour of the 3 Chi clean supply room revealed dust and debris accumulation in the stock bins and tubs. Saff B confirmed the findings on 04/15/14 at approximately 1230.

On 04/15/14 at approximately 1600 during tour of the outpatient urgent care facility review of the glucose monitor logs revealed inconsistent dates for quality controls being completed. When staff SS was asked when are the controls supposed to be done stated, "there is some confusion about that, so I don't really know." The quality control vials both high and low were open and undated, staff XX stated, "those should be dated, I'll dispose of those right now."

On 04/17/14 at approximately 0900 during a phone conference with staff YY undated policy 3421 titled "CLIA (Clinical Laboratory Improvement Amendment) Waived Specimen Collection Procedures was reviewed. page 2, (2). (d). Quality Control testing is done according to manufacture's instructions. The instruction manual for the "Nova StatStrip Xpress Glucose Hospital Meter" was reviewed- page 31 stated, "Run 2 different levels of the Statstrip Glucose Control Solutions during each 24 hours of testing, prior to testing of patient specimens and....." Staff YY stated, "I thought we only needed to run controls if we used the meter." When asked how do you know when it has been used to test a patient staff YY stated, "We don't keep a log or have a way to know when it has been used."

On 04/16/14 at approximately 1000 during tour of the off-site rehab area an unlabeled spray bottle of liquid was found. Staff O was asked what it was used for stated, "we use that to clean the equipment in between patients, its a mixture of bleach."


29955

On April 16, 2014 at approximately 1015 during tour of the Geropsychiatric unit the patient food refrigerator in the patient care area was found to have spills in the bins and an accumulation of debris in the bottom of the refrigerator.

On April 16, 2014 at approximately 1017 during an interview with staff HH it was asked who was responsible for the upkeep and maintenance for refrigerator cleanliness. Staff HH responded it was the responsibility of nursing staff to maintain the cleanliness of the refrigerator due to the refrigerator being locked at all times. On April 16, 2014 at approximately 1017 Staff HH confirmed the refrigerator was in need of cleaning.


28273

On 04/15/2014 at 1000 during observation on 3 West with staff EE (Director In-Patient Care Services), a review was completed of the patient nourishment refrigerator temperature sheet. The document titled, "Nursing Unit Refrigerator/Freezer Temp (temperature) Sheet" contained documentation in regards to "Floor: 3 W(West), Month: April, Yr (Year): 2014. The temperature (monitoring) sheet contained staff documentation for April 1-11. On April 1 the refrigerator and freezer temperatures were recorded for both AM (morning) and PM (evening), staff placed their initials in the spaces provided and initialed in the area for the refrigerator being "Clean." All of the other ten days (April 2-11) the temperature was recorded for both the refrigerator and freezer only in the AM. The document also revealed a lack of documentation of any temperature (AM or PM) for April 12-15 AM.

The directions for monitoring the temperatures was noted on the bottom of the "Nursing Unit Refrigerator/Freezer Temp Sheet" and reads, "1. Record temps at 6:30am and 2pm daily."

On 04/15/2014 at 1020 during an interview with staff EE a query was made as to who's responsibility it was to monitor the temperatures for the nourishment refrigerators on the units. Staff EE stated, "it is the responsibility of the dietary staff to monitor the refrigerators." Staff EE confirmed that the temperatures were being completed only once a day and that the temperature sheet also lack documentation (both AM and PM) for the three (3) consecutive days prior to survey.

On 04/15/2014 at 1345 during the review of the Dietary Department with staff WW (Director Food Services.) a query was made regarding who's responsibility it was to monitor the nourishment refrigerator temperatures on the units staff WW stated, "it is the responsibility of the nursing staff to monitor the refrigerators on the patient units."

On 04/15/2014 at 1545 a review of the facility's policy/procedure reads, "Subject: Dietary Stock in Nursing Nourishment Stations, Scope: Food & Nutrition Services, Number: 300-8, Revised: 2/14, #11. It is the responsibility of traypassers to do daily temperature checks on all floor unit refrigerators and freezers, during the time of stock inventory."

On 04/15/2014 between 1345 and 1430 an observation was conducted of the Dietary Department with staff WW and revealed the following:
In an area identified by staff WW as a "clean area" there was a cart of plate covers that contained four (4) rows of covers. The two (2) bottom rows of covers contained a thick layer of dust on them. When staff WW was queried about the dusty items she stated, "these are extra covers for when we have a high number of in-patients. Staff would wash them prior to using them." When queried further as to why the covers on the top two(2) rows did not contain the dust and the covers on the bottom two (2) rows contained a thick layer of dust she replied, "the ones on the top were probably used more recently." When asked if staff are then placing clean with dirty since the top ones were "probably" used more recently and then placed back "clean" onto the cart with the dirty ones when they were no longer needed, staff WW replied, "I would probably have to say, yes."
Observation of another cart that contained "clean" pans turned upside down, contained a thick black grime substance around the edge of the shelf that housed the pans.
In the kitchen area there was an industrial mixer that contained a large amount of thick black grime build up along with a white substance covering a large amount of the machine. When staff WW was queried if the machine was clean she stated, "the mixing bowl and attachments are clean." It was noted at this time that next to the mixer was a stainless cabinet that contained several areas of splattering of dried food substances. When staff WW was queried about the splattering from the mixer she stated, "the cabinet should have been wiped down."
The kitchen area also contained a meat slicer that had a thick build up of grime on the slicer base. Across from the meat slicer was a table that had several areas of dried food substances along the edge. When staff WW was queried in regards to if the substances were from the lack of cleaning of the table of from the trash can that sat right up against the edge of the table, staff WW replied, "I get your point, I cannot really say what it is from."
During the observation, staff WW was queried about a cleaning schedule for the kitchen area and if monitoring occurs she stated, "staff have different areas that they are assigned to clean and yes it is monitored." A request was made to staff WW for a copy of the cleaning schedule and documentation of monitoring of the process. Staff WW stated, "I will get them for you."

On 04/16/2014 at 1000 staff WW provided the documents that were request from the previous day. The review concluded that all areas above are assigned to staff for cleaning on a daily/weekly schedule. The documents all contain the statement "Before leaving please sweep your area and ensure your area is NCO (Neat,Clean, and Orderly)." When staff WW was queried about how staff are monitored to ensure that they are following the cleaning schedule she stated, "we have daily check off sheets, audit sheets that staff need to complete before they leave for the day." When asked to see the documentation staff WW replied, "we don't keep those sheets, once they are done at the end of the day they are thrown area."


29313

On 04/15/2014 at approximately 1130 during an observational tour of the Birthing Unit, a review was completed on the patient nourishment refrigerator temperature sheet. The document titled "Nursing Unit Refrigerator/Freezer Temp Sheet" contains documentation in regards to "Floor: OB (Obstetrics), Month: April, Yr (Year): 2014. The temp sheet contains staff documentation for April 1-15. On April 10 the refrigerator and freezer temperatures were recorded for both AM and PM, staff placed their initials in the space provided. Four of the days (April 3, 4, 7 and 13) had no temperature documented for the refrigerator or freezer. The remainder of the other days (April 1, 2, 5, 6-12, 14 and 15) contained only recorded temperatures for the refrigerator and freezer in the AM. On 04/15/2014 at approximately 1130 staff G confirmed the findings.

On 04/15/2014 at approximately 1250 during an observational tour of 2 SE-Oncology/Medical Unit, a review was completed on the patient nourishment refrigerator temperature sheet. The document titled "Nursing Unit Refrigerator/Freezer Temp Sheet" contains documentation in regards to "Floor: 2 SE, Month: April, Yr: 2014. The temp sheet contains staff documentation for April 1-15 and the document contained only recorded temperatures for the refrigerator and freezer in the AM. Staff F confirmed these findings and when staff F was asked why the temperatures were not being documented twice a day, she replied, "I think we changed the policy to do temperatures once a day, but didn't change the forms."

The bottom of the "Nursing Unit Refrigerator/Freezer Temp Sheet" the instructions read, "1. Record temps at 6:30am and 2pm daily."

On 4/15/14 at approximately 1140 during an observational tour of the OB unit it was found that three (3) bottles of blood glucose test strips had no opened or expiration date recorded. This finding was confirmed by staff G on 4/15/14 at approximately 1140. When staff G was asked why the bottles were not dated, she responded, "They should have been (dated) when they were opened."

On 4/15/14 at approximately 1130 while on an observational tour of the Birthing Unit it was found in the clean utility/pantry room that refrigerator bottom was dirty with dried juice and debris. The freezer also had debris and food particles on the bottom. The ice machine had residue build up in the catch basin and the grate had a white film build up. Findings were confirmed at the time of observation on 4/15/14 at approximately 1130 with staff G. Staff I was queried as to whose responsibility it was to clean the refrigerator, freezer and ice machine to which she replied, "I think dietary but I need to find out for sure."

On 4/15/14 at approximately 1250 while on an observational tour of 2 SE-Oncology/Medical Unit it was found in the clean utility/pantry room that the refrigerator was dirty with food particles and dried spills on the bottom. Findings were confirmed at the time of observation on 4/15/14 at approximately 1250 with staff F. Staff F was asked who was responsible to clean the refrigerator to which she replied, "I'm not sure, I will find out and get it cleaned."


32164

On 4/15/14 at approximately 1120 while on observational tour of the Emergency Department it was found in the clean utility/pantry room that refrigerator bottom was dirty with dried spills. The pantry cabinets and drawers had dried spills and crumbs accumulated. The ice machine had residue build up in the catch basin and the grate had a white film build up. Findings were confirmed at the time of observation on 4/15/14 at approximately 1120 with staff I. Staff I was queried as to whose responsibility it was to clean the refrigerator and pantry area to which he replied, "I think dietary but we can get this cleaned up now."

On 4/15/14 at approximately 1235 while on observational tour of 6 west it was found in the clean utility/pantry room that the microwave was dirty with dried spills and crumbs. Findings were confirmed at the time of observation on 4/15/14 at approximately 1235 with staff J. Staff J was queried as to whose responsibility it was to clean the microwave to which she replied, "I think housekeeping but we all should be doing it."





02902

At the following times it was determined based on interviews with surgical staff involved in the actual work, that they did not know the manufacturer ' s instructions for the required concentration of enzymatic detergent to ensure proper cleaning of instruments being prepared for immediate use steam sterilization ("flashing"):
1. At Facility A campus, 04/16/2014 at 1051;
2. At Facility B campus, 04/17/2014 at 1105.
Based on record review on 04/17/2014 at 8:55 there had been approximately 4,100 immediate use steam sterilizations done at both campuses for approximately 30,000 surgical cases in the preceding 18 months. This incidence rate is considered excessive, putting patients at undue risk for harm from improper reprocessing of surgical instruments versus using the Sterile Processing Department who personnel are specifically trained and equipped to provide professionally recognized methods for reprocessing of surgical instruments.
Based on observation on 04/17/2014 at 1205 the exposure control in room A1002 H/M was not secured and could easily endanger the operator by allowing the operator to be fully exposed to ionizing radiation during patient exposure.

Based on observation the facility failed to provide sufficient artificial illumination in two of nine ( #2 & #8) operating rooms resulting in the potential for patient harm. Findings include:
Inadequate levels of artificial illumination were measured in 2 of 9 operating rooms at the Facility B campus as evidenced by the following examples;
1. 102 footcandles (fc) versus the required 150 fc in O.R. #8 on 04/17/2014 at 11:24;
2. 122 fc versus the required 150 fc in O.R. #2 on 04/17/2014 at 11:25.

Based on document review and interview, the facility failed to disclose it's financial interest in a Home Health agency resulting in the potential for the patient and/or patient's representative to not be fully informed prior to making a decision. Findings include:

On 04/15/2014 at approximately 1030 during an interview with staff AA (Manager Case Management) a request was made for the documentation that would be provided to a patient or the patient's representative in regards to choices for Home Health services. Staff AA provided a pamphlet immediately that read on the front cover "Home Health Service Provider List." An inquiry was made to staff AA regarding if {Facility A} had a financial interest in any of the agencies in the pamphlet to which Staff AA replied, "Yes," and pointed to the first facility listed in the pamphlet. A review of the document revealed that it lacked any information disclosing {Facility A's} financial interest. When staff AA was queried as to how they would inform the patients or the patient representative of {Facility A's}financial interest in the Home Health Agency she stated, "if they ask we would tell them."