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Based on record review and interview the facility staff failed to provide the Important Message from Medicare (IMM) on admission and discharge for 1 patient (Patient #23) out of 11 patients with Medicare out of a total universe of 25 medical records reviewed.

Findings include:

The Facility policy, titled "Issuance of the Important Message from Medicare Policy" last revised 3/24/2021, revealed "3.1 Issuance of original and copy of IMM: a. The hospital's admitting representative will provide, explain the IMM and obtain the beneficiary signature (or that of his or her representative) on the IMM within 2 days of admission. d. The second notice will be delievered by Case Management."

Record review of Patient #23's closed medical record revealed, Patient #23 was admitted on 7/3/2021 at 4:36 PM under Inpatient status and discharged home on 7/6/2021. Patient #23 has a Medicare Advantage Plan for insurance. There is no evidence that the IMM was given on admission or discharge.

During an interview on 7/21/2021 at 9:30 AM, RN supervisor H stated "The IMM should be given on admission and discharge."

During an interview on 7/21/2021 at 9:45 AM, Case Manager II, stated "When I am not working, the house supervisor delivers the IMM. For Patient #23 the house supervisor delivered the Medicare Outpatient Observation Notice (MOON) instead of the IMM."

Based on observation, record review, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0131: Multiple Occupancies
K-0353: Sprinkler System - Maintenance and Testing
K-0711: Evacuation and Relocation Plan

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure live safety from fire was safe for patients and staff. The cumulative effects of these deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0131: Multiple Occupancies
K-0353: Sprinkler System - Maintenance and Testing
K-0711: Evacuation and Relocation Plan

Based on record review and interview, nutrition services failed to complete a dietary consult per policy and procedure in 1 of 18 patients (Patient #1) and nursing staff failed to complete a nutrition assessment for a therapeutic diet in 2 of 18 patients (Patients #4 and #19) in a total of 20 inpatient medical records reviewed.

Findings include:

Review of facility policy, "Food and Nutrition-Initial Screening, Prioritization and Assessment", policy 6SFRNCUTZF5D-3-728, last reviewed 2/19/2021 under initial screening, nursing section revealed: "Nursing gathers information within 24 hours of admission, completes nutrition screen and documents in the medical record." Under additional resources section revealed: "A Malnutrition score of 2+ automatically enters a referral to nutrition services."

Patient #1 was admitted on 6/24/2021 with a diagnosis of cancer and weakness. The nursing admission assessment of 6/24/2021 revealed Patient #1 scored a 2 on the nutritional screen, indicating the need for a Dietary consult. There was no consult in the medical record, a dietary assessment was not completed.


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Patient #4 was admitted to the facility on 6/21/2021 with a diagnosis of RTHA (Right total hip arthroplasty) (hip replacement). Patient #4 was discharged on 6/24/2021. Review of the medical record did not reveal a dietary assessment.

A record review on Patient #19's closed medical record revealed, patient was admitted as a surgical patient on 07/12/2021 at 8:25 AM for "Removal of Prosthesis, irrigation & debridement" of left shoulder after total left shoulder replacement surgery at a different facility. Patient #19 was transferred from the facility's Post Anesthesia Care Unit after surgery to the Medical/Surgical floor on 07/12/2021 at 1:30 PM. Initial Nursing Assessment was done on 07/12/2021 at 1:52 PM. Patient #19 was discharged from the facility on 07/14/2021 at 6:40 PM. There was no documentation in Patient #19's medical record that a nutritional screening was completed during Patient #19's inpatient stay.

In an interview with Medical/Surgical Supervisor H on 07/20/2021 at 3:29 PM regarding nutritional screening of patients admitted to the Medical/Surgical floor; Supervisor H stated that patients should be getting a nutritional screening within 24 hours of being admitted to the floor (per policy). When asked if there was a nutritional assessment done on Patient #19 while admitted on the Medical/Surgical floor, Supervisor H stated "No, there was no nutritional assessment done."

On 7/21/2021 at 9:30 AM in interview with Nurse Supervisor H, Nurse Supervisor H stated, "There was not a dietary assessment completed on Pt. #1 and Pt. #4." When asked if this should have been completed, Nurse Supervisor H stated, "Yes, this should have been completed."

Based on record review and interview, facility staff failed to complete a nursing admission assessment for 1 of 20 patients (Patient #4) in a total of 20 inpatient and 5 outpatient medical records reviewed.

Findings include:

Review of facility policy: "Patient Centered Documentation and the Nursing Process," policy KT2N6QC5SZES-3-2176 last reviewed on 5/13/2021, under the admission, assessment and screening section revealed, "The RN (Registered Nurse) performs and documents an initial assessment to the acute care units within 2 hours of admission or as soon as patient care needs allow."

Patient #4's medical record revealed Patient #4 was admitted on 6/21/2021 for a right total hip replacement and discharged on 6/24/2021. A nursing admission assessment was not completed.

On 7/21/2021 at 9:30 AM in interview with Nurse Supervisor H, Nurse Supervisor H stated, "The nursing admission was not completed and it is expected this is to be completed within 2 hours of admission."

Based on observations, record review, and interview, the facility failed to follow nationally recognized standards of care for 1 of 8 surgical patients (Patient #25) in 1 of 1 surgeries observed and staff failed to use proper personal protective equipment in 1 of 1 pulmonary function outpatient procedures observed (Patient # 26) in a total of 4 procedures observed.

Findings include:

Review of AORN (Association of Operating Room Nurses) "GUIDELINES FOR PERIOPERATIVE PRACTICE" 2020 Edition revealed, "....7.2 Scrubbed team members should not ...turn their backs on the sterile field."

Observation in Operating Room 1 was conducted on 07/21/2021 between 9:40 AM and 10:10 AM for Patient #25. The following observations were made: Between 9:42 AM and 10:00 AM Surgical Technician MM was observed turning his/her back to the sterile field 3 times while attending to the sterile field during Patient #25's surgical procedure; Technician MM turned his/her back while assisting in draping the patient and twice while moving around the sterile field during the surgical procedure.

An interview with Surgical Technician MM was conducted on 07/21/2021 at 12:25 PM, regarding acknowledgment of AORN standards for sterile field practices; Technician MM stated, "Yes, I follow these standards." When asked if he/she was aware of turning his/her back on the sterile field during the surgical procedure for patient #25 on 07/21/2021, Technician MM stated "Yes, but I thought I was keeping a safe distance from the table. When I was trained it was 6 inches away." Technician MM stated he/she was aware his/her back was turned from the sterile table when giving the Surgeon the drape for Patient #25.

An interview with Operating Room Manager L was conducted on 07/21/2021 at 1:30 PM, regarding standards of practice for surgical services; Manager L stated that the facility follows AORN standards. When asked if there is a facility policy about turning back on sterile field during surgical procedures, Manager L stated "There is no policy about turning their backs."



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Review of facility policy, "Standard Precautions" policy 4FAR5N4RSFP7-3-240, last reviewed 4/14/2021, under section for personal protective equipment revealed, "Gloves must be worn whenever there is a possibility of touching blood, or other infectious body fluids, mucus membranes, non-intact skin, or when handling items or surfaces soiled with blood and/or potentially infectious body fluids."

Review of Lippincott Procedure, "Spirometery, Ambulatory care, last reviewed on 5/20/2021 under Implementation section revealed, "Gloves are to be put on prior to performing the procedure."

On 7/20/2021 at 1:15 PM during an observation of a PFT (Pulmonary Function Test) (a test to measure lung volume) performed by Staff O on Patient #26, Staff O did not don gloves for the procedure.

During an interview on 7/20/2021 at 2:00 PM when Staff O was questioned why gloves were not used during the above procedure, Staff O stated, "I should have been wearing gloves since I was wearing eye protection and a mask, but I just didn't."