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Based on a review of 6 open and 5 closed medical records, it was determined the hospital failed to provide 3 of 3 Medicare recipients with the initial standardized notice, "An Important Message from Medicare," (IMM) within the appropriate time frame.

A review of patient #2's medical record revealed no evidence or documentation of an initial IMM given though the patient had been admitted for greater than 4 days. Review of Patient #7's and #8's records also revealed no evidence or documentation of an initial IMM after being admitted for greater than a weeks' time.

Based on the review of 6 grievance files, it was determined the hospital failed to demonstrate evidence of steps taken to investigate 3 of 6 patients' grievance and failed to provide each patient with a resolution letter that 1.) Addressed patient's concerns expressed in grievances and 2.) Brief explanation of investigatory measures taken to resolve grievances.

Review of grievance files revealed that in half of the files, there were a lack of documentation to show that an investigation was conducted. There was limited or no documentation of communications between the grievance department and unit(s) that were listed as conducting investigated.

A resolution letter was not found for Grievance #5. The resolution letters for Grievance #4 and #6, did not address the patient's expressed concerns. These two letter also lacked required element of the regulation to inform patients of measures taken to investigate and resolve grievance.

Based on review of 6 open medical records and 5 closed medical records, including two restraint records, it was determined the hospital failed to renew non-violent restraint orders for patient #2.

Per hospital policy "Patient Care Services Restraints. Patient Policy" (last revised 02/2018) section 3.1.9.26, "For non-violent restraints a new order is needed every calendar day."

Patient #2 was a 70+ year old on the intensive care unit. Patient #2 was justifiably placed on non-violent, medical restraints, 2 days into their admission. Patient #2 did not have a renewal order for the second and third day the patient was in non-violent restraints though nursing flow documentation revealed patient #2 remained in restraints. Therefore, patient #2 was restrained without a physician order for two calendar days.

Based on observations conducted while reviewing the Emergency Department, Behavioral Health Unit and Intensive Care Unit (ICU) it was determined staff failed to adhere to proper hand hygiene and cleanliness standards established by the hospital and infection control standards.

Observations in the ICU revealed two staff members, one Registered Nurse (RN) and one food service employee, exit patient rooms without hand washing or using alcohol-based hand sanitizers (ABHS). The RN was observed exiting two patient rooms without proper hand hygiene. The food service employee was seen exiting one room and then entering into another room without proper hand hygiene. While this employee was holding a tray, hand hygiene was not observed prior to picking up the tray from the cart to go into the patient's room or after placing the used tray in the cart when leaving the patient's room.

Tour of the Behavior Health Unit revealed that the bathroom in a "clean" unoccupied semi private rooms was not cleaned. The room was empty, classified as clean and ready to receive newly admitted patients. The semi-private room bathroom shower had empty bottles of shampoo, soap wrappers, and obvious collection of hair covering the drain. The bathroom toilet and sink also showed evidence of use with dried bodily fluid present.

During a walk-through of the emergency department (ED) there were gross breaks in infection control standard practices. In multiple patient treatment rooms, both empty and with patients present, were large amounts of used clinical products and packaging on counter, floors, tray tables, sinks and in one case on the bed with the patient.

In room ED1 soiled gloves were present on counter, no clinical person was present in the room. On the counter of room ED1 were two sets of soiled used gloves next to the sink. These soiled gloves pose health risk for patient, staff, and visitor. Due to potential health risk this was pointed out to ED Manager for mitigation. The nurse that came to correct this infection control breach did not perform hand hygiene practices upon entering the room and failed to use Personal Protective Equipment (PPE) in the handling of the soiled gloves. Room ED2 had used flushes, the wrapper that once was on the flushes on the tray table and on the counter, and there were multiple unidentified clinical wrappers on the floor. Room ED3 had packaging of clinical supplies on the bed with the patient, there was not a clinician in the room with the patient to indicate an active treatment was occurring. In other rooms were clinical wrappers and used items on the floor, tray tables and counters.