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Based on a review of eight closed records, it was determined that the medical records for four out of four Medicare recipients lacked the second Important Message from Medicare.

Review of the medical records for Patients #1, #2, #5, and #7 had inpatient stays from four to eight days in September 2014. Each of these Medicare recipients had one Important Message scanned into the Electronic Medical Record date the day of admission. All four patients had planned discharges. There was no records that any of the four had a second required Important Message two days prior to discharge.

The policy for the Important Messages requires the case manager to deliver the second notice within two days of discharge, yet none were found on the records.

Based on interview, review of the hospital policy and ten grievance files, it was determined that while the hospital policy spells out a prompt resolution process, in practice, the hospital fails to meet policy parameters for resolution of grievances.

Hospital policy #1.008 Customer Concern of Care and Grievance reveals in part, "All investigations should be completed within 7 days of receipt of the concern. If the concern cannot be resolved within 7 days, the customer should be informed that the hospital will follow up with a written response within a stated number of days."

Interview with the Director of Quality Improvement on 11/19/2014 reveals a grievance process which delegates investigation of the each grievance to the unit cited in the grievance. On review of ten grievance files, it is noted through filed emails that investigations are performed. However, it cannot be determined when the grievances were actually resolved, if at all, since the involved units do not report back to the Director of Quality Improvement.

Based on review of the hospital policy and ten grievance files, it was determined that none of the files contain close letters to the complainants. This finding was confirmed with an Interview with the Director of Quality Improvement on November 18, 2014.

Hospital policy #1.008 Customer Concern of Care and Grievance reveals in part, "All investigations should be completed within 7 days of receipt of the concern. If the concern cannot be resolved within 7 days, the customer should be informed that the hospital will follow up with a written response within a stated number of days."

Interview with the Director of Quality Improvement reveals a grievance process which delegates investigation and closure to the unit cited in the grievance. Further review of the Grievance policy states in part, "If a written response is required, the Manager will draft the written response. All written responses will be reviewed by the Quality Department/Risk Manager prior to being presented to the customer."

On review of ten grievance files, it was noted that no written responses were sent to complainants related to grievances filed with the hospital. While the unit mangers may be sending out letter to the complainants at the conclusion of the grievance investigation, they are not sending them to the Director of Quality Improvement as required by this regulation and by hospital policy. Therefore there is no way to determine if written notice is sent to the complainants. Lacking documentation, the only conclusion is that the hospital failed to formally inform complainants of the results of their investigation as required by regulation, and thus failed to honor the rights of the complainants.

Based on a review of the medical staff bylaws and eight closed electronic medical records (EMRs), as well as interviews with the Director of Health Information Management (HIM) and the President of the Medical Staff conducted on November 18 and 19, 2014, it was determined that, while the bylaws of the medical staff require history and physical exams (H&Ps) to be done within 24 hours of admission, four of the reviewed records contained H&Ps that were either written or authenticated beyond the 24 hour time frame.


Patient no. 1 was inpatient from September 23 -30, 2014. The patient's H&P was dictated on September 25 and filed on October 6, 2014. In the hospital's electronic medical record (EMR), the term "filed" refers to the date the document was authenticated.


Patient no. 3 was inpatient from September 17 -28, 2014. This patient's H&P was dictated September 18 and filed on September 28, 2014.


Patient no. 4 was inpatient from September 11 -19, 2014. The H&P was dictated on September 12 and filed on September 23, 2014.


Patient no. 6 was inpatient from September 19 -23, 2014. The H&P was dictated September 22, 2014.


Once the H&P, or any other report, is dictated, there is a slight delay before it becomes part of the medical record. The dictated report is available to be viewed but is not considered a permanent part of the official medical record until it is filed, or authenticated. The policy "Requirements: History & Physical Examination Documentation (12.015, eff. date 10/13)" requires the medical H&P to be signed off within 30 days after discharge. This policy is not consistent with the capabilities and features of the EMR. The medical staff bylaws require a H&P to be done within 24 hours of admission, but do not address time frames for authentication. Since the document is not considered official until it is authenticated, the authentication should take place as soon as the document is viewable on the medical record.


According to the Director of HIM conducted on the morning of November 19, 2014, the medical record delinquency rate is 12%. This means that 12% of the medical records are not complete and signed within the 30 days after discharge allowed. The Director further stated that they track all delinquencies and provide a weekly report to the medical staff and follow up with individual providers. In an interview on November 19, 2014, the President of the Medical Staff explained the progressive discipline process used for addressing medical record delinquencies, but the hospital has no proactive approach to ensuring compliance with the requirements.

See also Tag A-0468

Based on a review of eight closed electronic medical records, it was determined that the nursing staff failed to document any nurses notes for the last three days of one patient's stay, inclusive of a clinical decline that caused him to be sent out emergently to an acute care hospital.

Patient no. 5 was admitted on September 9, 2014, after being treated for approximately 24 hours in an outside hospital for symptoms of a cerebral vascular accident (stroke). He initially seemed stable but apparently started deteriorating around day five. He was sent out emergently to the acute care hospital on September 17, 2014, with symptoms of sepsis and worsening mental status. The last note found from a nurse was dated September 14, and included no information about a change in his condition. The physician wrote a very informative discharge summary for the patient, detailing his decline and the physician's concerns about his condition, but no nursing documentation from his last three days in the hospital was found in the closed record.

See Tag A-0465

















15936

Based on medical record review and staff interviews, it was determined that the nursing staff failed to monitor meal intake as per the nursing Alteration in Nutrition Care Plan for 1 of 21 medical records reviewed and failed to record required weekly weights for 1 of 21 medical records reviewed . The findings include:
1. Patient # 19 has diagnoses including but not limited to recent weight loss. The physician ordered a regular, cardiac (low sodium, low fat, low cholesterol) carb controlled diet. Glucerna Chocolate BID. Offer and encourage 240 ml water three times a day between meals. The nutritional assessment on 11/12/14 stated that the patient experienced a significant amount of weight loss of at least 32 pounds over the past 2 months; UBW 217 pounds; Weight -11/12/14 - 185 pounds. The nutrition goal included PO ( by mouth) intake of at least 75% of meals and snacks. The nursing Alteration in Nutrition Care Plan included intervention of " Monitor diet (3 times daily with meals)." Review of the Intake and Output sheets revealed that the percentage of diet eaten by the patient was not documented or monitored from 11/15/14 through 11/18/14, 4 days.

2. Further, it was determined that the facility staff failed to obtain a weekly weight per facility policy for patient # 20.
Patient # 20 has diagnoses including craniotomy and dysphagia. The patient was admitted to the facility on 11/3/14. The admission weight on 11/4/14 was 140 pounds. Record review and interview with the dietitian confirmed that the weekly weight due on 11/12/14 was not obtained, despite policy to do so. Failure to obtain a weekly weight may potentially lead to delay in assessing a significant weight change or further nutritional decline. On 11/19/14, resident's weight was 153 pounds, a 13 pound (9.2%) weight gain in 2 weeks.

Based on a review of eight closed electronic medical records, it was determined that one patient did not have any nurses notes for the last three days of his stay, inclusive of a clinical decline that caused him to be sent out emergently to an acute care hospital.

Patient no. 5 was admitted on September 9, 2014, after being treated for approximately 24 hours in an outside hospital for symptoms of a cerebral vascular accident (stroke). He initially seemed stable but apparently started deteriorating around day five. He was sent out emergently to the acute care hospital on September 17, 2014, with symptoms of sepsis and worsening mental status. The last note found from a nurse was dated September 14, and included no information about a change in his condition. The physician wrote a very informative discharge summary for the patient, detailing his decline and the physician's concerns about his condition, but no nursing information from his last three days in the hospital was found in the closed record.

Se also Tag A-395

Based on a review eight closed records, two out of eight had late entry discharge summaries and one out of eight had no discharge summary found on the Electronic Medical Record.
Patient #1 was inpatient 9/23/14 to 9/30/14. The discharge summary found in the Electronic Medical Record was dictated on 10/9/14 and not authenticated until 11/3/14.
Patient #4 was inpatient from 9/11/14 to 9/19/14. The discharge summary was dictated on 9/25/14 and authenticated on 10/23/14.
Patient #3 was inpatient 9/10/14 to 9/17/14 and no discharge summary was found on the Electronic Medical Record. The discharge summary, dated 9/27/14, was later produced by the Medical Record staff but was not a part of the closed record.

See Tag A-0358. The failure of the medical staff to authenticate their documentation in a timely manner decreases the likelihood that these medical records can be used for continuation and coordination of care and the practice is inconsistent with the regulations.

Based on lunch meal observation, review of Tray Line Temperature Logs and staff interviews, it was determined that the food service director failed to have processes in place to ensure that safe food handling practices were employed based on the fact that staff failed to monitor temperature of cold foods, most importantly prior to meal service and failed to monitor the temperature of 3 reach-in refrigerators while utilized during tray line meal service and failed to have staff trained in a sanitary method to sanitize food thermometers. The findings include:
During lunch meal observation on 11/18/14, surveyor observed the food service staff open the doors of 3 reach-in refrigerators filled with multiple cold foods including milk and cold protein salad entrees. Surveyor observed a food service employee pull a tray of milk outside of the reach-in refrigerator and place the milks onto meal tray. This causes the temperature of the milk to increase above 40 degrees because it has been removed from the refrigerator.
Review of the Tray Line Temperature Logs revealed that the food service staff were not taking cold food temperatures prior to meal service but regularly checked hot food items. Interview with the food service manager confirmed that the staff were not taking temperatures of cold foods prior to meal service or at all. The food service manager and dietitian both confirmed that the reach-in refrigerators are manufactured to open the doors and also keep temperature of the cold food and the refrigerators in the proper cold temperature range.
Two internal thermometers indicated the temperature inside reach-in refrigerator #10, containing cold protein salad entrees, was 50 degrees, above required 40 degrees or below. The temperature of whole milk in the same refrigerator was 46 degrees, warmer than the proper range of below 41 degrees or below. The internal temperature of reach-in refrigerator #9 was also 50 degrees, above required 40 degrees or below. Fruit cocktail inside this reach in was 52 degrees, above 41 degrees or below. The dietitian and food service manager stated that they were unaware that the reach-in refrigerators did not maintain the proper temperature with doors open.
After surveyor intervention, cold foods including milks, were placed in ice to lower to proper temperature and maintain proper temperature. The staff indicated that the doors to the reach-in refrigerators will not be kept open throughout the meal service and only when items are removed. The bulk of the cold food items will be kept in the large reach in refrigerator behind tray-line and used as needed. In addition, temperature of cold foods will be taken 3 times during meal service.

Additionally, during lunch meal observation on 11/18/14, surveyor observed food service employee use and alcohol prep pad to sanitize the thermometer. Next, she took a towel, which was not sanitized, and wiped the thermometer. Then she placed the no longer sanitized thermometer into the green beans. Surveyor immediately informed the food service manager regarding this concern. After surveyor intervention, the thermometer was sanitized with the correct solution of quaternary sanitizer. In addition, the food service staff was educated not to wipe the thermometer with an un-sanitized towel after using sanitizing solution

Based on medical record review and staff interviews, it was determined that the nursing staff failed to notify the dietitian in a timely manner when a resident experienced a significant weight loss for 1 of 21 medical records reviewed. In addition, the facility failed to have a policy for notifying the dietitian and physician when a resident experiences a significant weight loss or gain. In addition, the facility failed to have a policy for weight verification/reweights, nor is there an appropriate threshold of alerting staff of a weight variance until it has progressed to 10% in a week. All of which potentially could lead to further weight loss and nutritional decline. The standard of practice for significant weight change necessitating assessment by the physician and dietitian is the following: >/=2% weight loss or gain in 1 week; >/= 5% loss or gain in 1 month; >/=7.5% loss or gain in 3 months, >/= 10% loss or gain in 6 months. The findings include:

Patient #21 has diagnoses including but not limited to TBI and Left above knee amputation (AKA) with approx. 18 pound weight loss. Resident has a gastrostomy tube feeding (Liquid nutrition and hydration via tube inserted into the stomach) of Two Cal HN 1 can bolus after each meal if resident eats < 50% of meals. 250 ml water flush every 6 hours. The physician order for by mouth puree diet, double portions with Magic Cup BID. Patient to be given 1 to 1 assistance eating meals.

Weight 10/24/14- 162 pounds ; 11/12/14-155 pounds; Patient experienced a 7 pound (4.3%) weight loss in 1 week. During medical record review on 11/19/14, surveyor noted resident experienced a significant weight loss in 1 week; however, there was not a nutrition assessment or weight verification.
Interview with the dietitian the same day revealed that she was not aware of the patient's significant weight loss, 7 days later. The delay in nutritional assessment and interventions could potentially lead to further weight loss and nutritional decline. Further interview revealed that the facility does not have a policy for verifying a significant change in weight or notifying the dietitian and physician regarding a significant change in weight. In addition, the threshold for weight change is 10%, significantly above the standard of practice.
After surveyor intervention, the dietitian completed a reassessment of the patient on 11/19/14, a week after the significant change. She documented the patient's weight was 159.5 pound, a 4.5 pound increase in a week with overall involuntary 11% UBW (usual body weight) loss x 3 months related to AKA and catabolic condition. The dietitian recommended tube feeding removal with water flushes until it is done with po ( by mouth) diet and supplements to remain the same.

Based on meal observation, review of medical records and diet batch lists and staff interviews, it was determined that the facility staff failed to ensure that the cardiac (low sodium, low fat, low cholesterol) diet ordered by the physician in the medical record for about 30 patients is consistent with the diet provided by the kitchen. In addition, the diet instruction materials provided at discharge to patients with a physician order in the medical record for a cardiac (low sodium, low fat, low cholesterol) diet is not consistent with the cardiac diet provided at the nursing home. The findings include:
On 11/18/14, review of medical records and diet batch lists revealed about 30 physician orders for cardiac (low sodium, low fat, low cholesterol) diet. Interview with the dietitian and review of the heart healthy diet policy revealed 3-4 gram sodium, 300 mg cholesterol and 30% of calories from fat is provided by the facility kitchen. This diet is not a low sodium (less than 2 gram sodium/day) or low cholesterol (less than 200 mg/day). The physician ordered diet in the medical record; therefore, is not consistent with the diet provided by the kitchen. Interview with the dietitian revealed that upon discharge she provides education materials to residents, receiving a liberalized cardiac diet from the kitchen, which includes " Limit ...cholesterol ...to less than 200 mg per day. Limit ...sodium ...to less than 2000 mg per day. " This is more restrictive than what is provided at the facility. After surveyor intervention, the dietitian stated that she would ensure that the inconsistency in the physician ordered diet would be corrected. In addition, she stated she would modify the discharge education materials to be consistent with the diet provided in the facility.

Based on the deficiencies on the Life Safet Code survey it was determined that the Condition of the Physical Environment was not met as evidenced by the following cited deficiencies :

K046 due to an inoperable emergency light;

K062 due to lapses in maintenance to the sprinkler system;

K067 due to lapses in the maintenance of the exhaust flue from a fuel fired appliance

K147 due to observations of non compliant electrical appliactions in the the hospital; and

K056 due to failure to have an automatic sprinkler system in some storage areas of the hospital.

Based on a tour of the hospital for environment of care issues it was determined that the hospital had not maintained the following in a manner that was safe . The findings are:

1. During a tour of the swimming pool area on 11/18/2014 at approximately 3:00PM, it was observed that the hydrant with an attached hose in the pool maintenance room lacked a back flow prevention device to prevent contamination of the potable water supply from back siphonage.

2. During the tours of the patient inpatient units on 11/18/2014 the surveyor observed some unused training bathrooms and unused soiled utility rooms being used for storage. These rooms all contained fixtures connected to the facility's plumbing system . On 11/18/2014 in room G516 a training bathroom the surveyor observed that the toilet bowl was completely dry. While it was impossible to determine if there was water in the trap, there were no odors indicating the presence of possible sewer gases. The toilet was flushed by facility staff which primed the drain. A second room (a soiled utility room) containing a handsink and hopper had shelves of wheelchair parts. Hospital staff indicated that there was no established process to prime unused plumbing fixtures in rooms currently used for storage nor were there plans to remove the fixtures and cap the sewer lines. The hospital must establish a process to prime the traps on a regular basis for all unused plumbing fixtures when rooms are not being used for their intended purpose.

3. The wall in the linen chute room was observed to be damaged on 11/18/2014.

4. Based on observation and interview of the Ground Outpatient Rehabilitation Staff and the CMR (Chronic Medical Rehabilitation ) Unit Nursing staff on 11/18/14 and 11/19/14, regarding staff response to an activated bathroom emergency call light from the Outpatient Rehabilitation training bathroom which is located off a large rehabilitation room, it was determined that some nursing staff lacked knowledge about their role as a potential back up for assistance in an emergent situation. This was evident in two of two surveyor observations and activations of the bathroom emergency call light on the noted dates. The findings were:
At approximately 2:30PM on 11/18/14 the bathroom emergency call light was activated by the surveyor. The call light registered on a small screen (box type 4x 6 inch screen) located at the CMR Unit nurse's station. Two staff members were observed at the nurse's station while the call continued to register. However, when the staff member sitting at the station was asked what the screen meant she replied she did not know.
On 11/19/14 at 10:24AM, the surveyor activated the bathroom emergency call light from the Outpatient Rehabilitation Training bathroom. The call registered on the small call screen at the nurse's station where one staff member was observed. A staff member proceeded to check the call light status.
Interview with nursing staff on 11/19/2014 revealed that the patients are under the supervision of their therapist when using this bathroom with the therapist being the intended responder to any emergency needs of their assigned patient. Visual and audible signals were operational in the therapy room. The annunciator panel, however, is located in the adjacent nursing unit despite the fact that the facility staff state that the system was not intended to have nursing staff as the first responders. Nursing staff indicated that they would respond if the therapy staff required their assistance. The therapy area is locked and not accessible to patients when therapists are not on duty. Therefore there should be no need for nursing to respond to that bathroom when therapy staff are not present. Nonetheless, staff at the annunciator panel were unable to describe their role to the surveyor when questioned on two occasions during the survey potentially placing the patients at risk.

Based on patient interviews and observations, the hospital has failed to maintain an acceptable level of safety for patients who may have wandering behaviors on the Traumatic Brain Injury Unit.

The unit observed to have a wander guard alarm on the entrance/exit door which will alarm when patients identified by the treatment team as a potential elopement risks, wear arm bands that beep when the patient is close to the door and alarms or exits the door. However, during a tour of the TBI unit on the morning of 11/18/2014, there were several lockable rooms on the hallways including the bathrooms that were observed to be unlocked. These rooms could be locked by the patient once inside. These unsecured areas pose a potential risk to the patient with cognitive deficits, including potential falls or getting hold of unsafe objects stored in these areas.

Based on review of the infection control program, dashboard data, policies and procedures, Interviews with staff and observation of care , the hospital has a robust Infection Control Program however, the following breaches of good infection control techniques were observed:

1. Based on observation of 2 out of 6 nursing staff, 1 dental assistant and 1 family member, the hospital failed to prevent the potential transmission of infection due to breach of contact isolation protocol and failure to appropriately don and doff PPE (Personal Protective Equipment) and follow contact isolation protocol.

Review of the hospitals policy for contact isolation reveals that the policy outlines the guidelines which include private room or cohort patients with the same infection, gown and gloves must worn before entering the patient rooms, and new gloves donned if coming into contact with infective material such as fecal and wound drainage. The gloves and gowns are to be removed before leaving the room. In addition, per policy all isolation guidelines are to be followed by the visitors. Section D and E of the policy addresses the transport of patients from the rooms to the Gym and Radiology. If therapy staff is assisting with transportation of the patient they are to follow the same guidelines to don and doff PPE. Once the patient reaches the destination the staff is to wear gown and glove for patient contact during therapy. The contact isolation patients use the same Gym as other patients on the unit. Per interview with physical therapist the equipment and any items touched by the patient are wiped down with antimicrobial wipes. The policy under contact isolation does not address cleaning of equipment and items touched by the patient but the policy on enhanced contact isolation used for C. difficile does address the cleaning of common equipment and items prior to use by another patient. Of concern, nursing and physical therapy staff don PPE when they think they may come into contact with the patient but they do not consider when the unexpected may happen that might require them to touch the patient as an example if the patient was choking. There may be a loss in time providing care for the patient while donning PPE.

On November 18, 2014 at approximately 9:30am and 10:30am, the surveyor observed two breaches in contact isolation protocol by two different nurses, one family member visiting a patient on contact isolation and one dental assistant who failed to remove her surgical cap and booties before leaving the surgical services area on the second floor.

At approximately 9:30am while making observational rounds the surveyor noted nurse #1 standing in the doorway of room #635 which was identified as a room with a patient on contact isolation. The nurse was documenting on paper and on her computer while still dressed in her gown and gloves after administering medication to the patient on contact isolation.

As the surveyor's rounds continued at approximately 10:30 am, the surveyor observed nurse #2 inside room #904, also identified as room with a patient on contact isolation. Nurse#2 was not wearing a gown or gloves. The nurse was noted to exit the patient's room, gel her hands, put on her gown and gloves then re-enter the room. The nurse was also observed to remove her gloves, provide medication to the patient and then re-apply another pair of gloves. Upon interview the nurse stated she had requested the patient return to his room so she could give him medication before going to therapy. Upon interview nurse #2 stated she receive infection control /education yearly and she last received training in March 2014. It was also noted that the patient 's mother was in the room and was not wearing a gown or gloves. Interview of the mother of the patient in room #904 revealed that she does not remember getting any formal education from staff about contact isolation but knows what should be done since her son was on contact isolation while at the acute care hospital before transfer for rehabilitation.

On November 18, 2014 approximately at 12:45pm a staff member exited the stairwell to the Terrace level wearing her scrubs, cap and booties. She identified herself as a Dental Assistant and had no valid reason for leaving the surgical services with her booties and cap on. This is a breach of infection control practice as well as breach of surgical service policy and procedure. The hospital staff failed to follow protocol, policy and procedure for the prevention and control of infection as evident by three staff failure to appropriately don and doff PPE and failure to ensure family members adhere to the policy and procedure.

On November 19, 2014, the surveyor observed in operating room #3 that the base from which the ceiling light protrude was pushed up through the ceiling tiles leaving a 2 inch gap on one side of the base and approximately a 1 inch gap on the other side which could lead to dust sprinkling over the OR table. The OR table that converts into a chair to perform the surgery. There are several red straps that appear to have be the consistency of Velcro attached to the table. When the surveyor asked what the straps are made of and how the straps are cleansed, a technician was not sure of the type of material but stated when they appeared soiled they are changed. Both the gaps in the ceilings and the straps on the table could lead to potential infection with air flow in the OR and particles of dust coming from the ceiling and straps made of a material that cannot be effectively cleaned between patients.

3. Review of the staff training for infection control contains a slide which states "Care givers who have direct patient contact may not wear artificial fingernails or extenders," and "Care givers who have direct patient contact should have natural nails not longer than ? (inch)."

During an observation of a straight-catheterization for a patient on the Spinal Cord unit on November 19, 2014, it was observed that RN #10 was wearing a pair of non-sterile blue gloves. She stated to the surveyor that she likes to keep blue gloves under the sterile gloves so she could (for instance) "cover the patient for privacy, and push back the curtain" following the procedure. RN#10 put a pair of sterile gloves on over the blue gloves.

RN #10 proceeded to use sterile technique in order to perform the straight-catheterization of the patient. Following the procedure, RN #10 removed the sterile gloves but the blue gloves remained on her hands. At that time, RN #10 asked the surveyor to see that since she had left the blue gloves on with the intention of using the presumably clean gloves to cover the patient for privacy, and to move the curtain back to exit the area.

Following this observation, the surveyor related to the Nurse Manager what had been observed regarding the fingernails and gloves. The Nurse Manager stated, "Yes, some RNs like to do that."

The surveyor was interviewing the patient at the conclusion of the procedure and could not observe RN #10 performing hand hygiene. However, the assumption that the use of non-sterile gloves were not possible vectors for infection while covering patients and pulling aside curtains, is inaccurate as it assumes the integrity of the sterile gloves was not breeched during the treatment or removal.

3. During a tour of the service area of the hospital on 11/18/2014 at approximately 2:00 pm, observations of the linen chute room were made by the surveyor. Bags of linens were noted on the floor of the room and the wall adjacent the door was damaged and not cleanable. Staff indicated that the bags of linens were supposed to fall into a bin but the bin was not present. Staff would be required to pick up the bags of soled linens and place them in a bin for removal from the room There were no provisions for handwashing in the area and no gowns, gloves or booties to prevent contamination of the environmental services employees' clothing. There was also no other provisions for hand hygiene for employees involved in the handling of soiled laundry or bags.