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Based on document review and interview, it was determined for 2 of 2 (Pt #10, #11) patients restrained for violent behavior, the Hospital failed to ensure patients were appropriately monitored per policy. This has the potential to affect all patients requiring restraint usage.

Findings include:

1. The policy titled "Initiation of Precautions" (reviewed 4/30/16) was reviewed on 8/2/16. The policy required "Suicide/Self Harm Precautions... For those that score 10 or greater, they are placed on a 1:1 status with a staff member assigned to that person... F. Constant 1:1 Precautions- used for those who are suicidal, homicidal, or grossly psychotic. These patients have a staff member assigned to them and are to be within arms reach of a staff member at all times..."

2. The clinical record of Pt #10 was reviewed on 8/2/16 at approximately 1:00 PM. Pt #10 presented to the ED on 7/11/16 with a diagnosis of acute psychosis. The record noted Pt #10 was placed in violent restraints on 7/12/16 from 6:15 AM to 9:00 AM and 7:16 PM to 11:37 PM. The Behavioral Health Observation Record noted on 7/12/16 from 6:00 AM to 7:00 AM and 7:30 PM to 11:45 PM, Pt #10's Behavior as "E= Appears asleep" with the number of respirations per minute next to it and Location as "3= Bedroom". The record lacked documentation Pt #10 was continuously monitored or identified as being in violent restraints. The nurse noted on 7/13/16 at 12:48 AM "Patient in restraints at the start of the shift with a 1:1 sitter in room... Restraints were removed at 2315 by security... Will continue to monitor per unit protocol..." The record did not identify who the sitter was or the time the sitter was present. The record noted on 7/13/16 at 4:34 AM, Pt #10 went out to the lounge, then returned to room hollering and slamming fists into the mattress, making verbal threats, security was called and medications were forced to calm the patient. The Behavioral Health Observation Record noted during this time period as Pt #10's Behavior as "E= Appears asleep" with the number of respirations per minute next to it and Location as "3= Bedroom".

During an interview on 8/2/16 at approximately 3:00 PM, E#8 (Nurse Educator) verbally agreed Pt #10's Behavioral Health Observation Record lacked documentation of continuous monitoring and had inaccurate documentation of assessments of Behavior, Location and restraint utilization.

3. The clinical record of Pt #11 was reviewed on 8/2/16 at approximately 2:00 PM. Pt #11 presented to the ED on 7/23/16 with a diagnosis of suicide attempt. Pt #11 was on suicide precautions with a 1:1 continuous sitter from 7/25/16 at 9:40 PM through 7/26/16 at 3:15 PM. The record lacked documentation of a sitter (continuous monitoring) and a suicide precaution assessment on 7/26/16 from 12:00 AM through 6:00 AM.

During an interview on 8/3/16 at approximately 2:00 PM, E#10 (Patient Care Manager of Intensive Care Unit) verbally agreed Pt #11's record lacked documentation of a sitter (continuous monitoring) on 7/26/16 from 12:00 AM through 6:00 AM.

During an interview on 8/4/16 at approximately 8:55 AM, E#1 (Quality and Patient Safety Specialist) stated the Medical Records department searched Pt #10's paper chart and was unable to find documentation of continuous monitoring on 7/26/16 from 12:00 AM through 6:00 AM.

4. During an interview on 8/2/16 at approximately 3:00 PM, E#8 and E#10 stated the Behavioral Health Observation Record was the documentation approved by the Hospital to document 1:1 monitoring and the 15 minute checks. E#8 and E#10 verbally agreed the Behavioral Health Observation Record did not identify if the form was being utilized for continuous monitoring or for 15 minute checks and the nursing assessments and narratives do not identify who the sitter is.

A. Based on document review and interview, it was determined the Hospital failed to ensure for 3 of 3 (E #15, #14, and #11) CRNA's (Certified Registered Nurse Anesthetist), that they were qualified and/or competent during the provisional period per policy. This has the potential to affect all patients who receive anesthesia provided by CRNAs.

Findings include:

1. The Medical Staff Bylaws (reviewed March 2016) was reviewed on 8/5/16 at approximately 11:00 AM. The Bylaws noted on page 36 "All new appointments to the Staff and all grants on initial or increase clinical privileges to new members... are provisional for a minimum period of twelve (12) consecutive months. The Medical Staff Rules and Regulations (reviewed November 2015) noted on page 14 "Clinical Privileges: Each clinical department shall formulate and implement a method for determining clinical privileges that fall within its clinical area..."

2. The "Anesthesia - CRNA (Certified Registered Nurse Anesthetist) Focus Chart and Procedure Review Form Within 1 month of AHP (Advanced Health Practitioner) Privileges" form (revised 5/18/10) was reviewed on 8/4/16 at approximately 1:00 PM. The form noted CRNA's with 1 year of experience must have the following chart reviews: 3 General anesthesia cases, 2 Spinal, 1 Sedation, 1 MAC (Monitored Anesthesia Care), 2 Labor Epidural, 1 Bier Block and the following Direct Observations: 2 General anesthesia cases, 1 Spinal, 1 Spinal C-Section, 1 Labor Epidural, 1 Pediatric Case. The form noted new CRNA's who have just completed training must have the following chart reviews: 6 General anesthesia cases, 4 Spinal, 2 Sedation, 2 MAC, 4 Labor Epidural, 2 Bier Block and the following Direct Observations: 6 General anesthesia cases, 3 Spinal, 3 Spinal C-Section, 3 Labor Epidural, 2 Pediatric Case.

3. The CRNA Clinical Privileges for E#15 was reviewed on 8/4/16 at approximately 11:00 AM. The form noted Initial Privileges for E#15 were granted on 7/6/15. The Focus Chart and Procedure Review Form noted E#15 was a "New CRNA" and lacked the following chart reviews; 2 Epidurals and the following observations: 1 Spinal C-Section, 1 Epidural, 2 Pediatric Cases.

4. The CRNA Clinical Privileges for E#14 was reviewed on 8/4/16 at approximately 11:05 AM. The form noted Initial Privileges for E#14 were granted on 6/19/13. The Focus Chart and Procedure Review Form noted E#14 was a "New CRNA" and lacked the following chart reviews; 4 Spinal, 2 Sedation, 2 MAC, 4 Labor Epidural, 2 Bier Block and the following observations: 3 Spinal, 3 Spinal C-Section, 3 Labor Epidural.

5. The CRNA Clinical Privileges for E#11 was reviewed on 8/4/16 at approximately 11:10 AM. The form noted Initial Privileges for E#11 were granted on 2/15/12. The hospital lacked documentation of any chart reviews or observations.

6. The Hospital CRNA schedules for May 2016, June 2016 and July 1026 were reviewed on 8/4/16 at approximately 1:15 PM. The schedule noted E#11, E#14 and E#15 as the "In House CRNA 7 PM - 7 AM" on multiple dates.

7. The focused record review was conducted on 8/5/16 at approximately 9:00 AM. The following findings were noted:
a) Pt #37 was admitted 7/14/16 for labor. The Anesthesia Epidural Record dated 7/14/16 noted Pt #37 received an epidural by E#15.
b) Pt #38 was admitted 7/28/16 for labor. The Anesthesia Epidural Record dated 7/28/16 noted Pt #38 received an epidural by E#11.

8. During an interview on 8/4/16 at approximately 2:30 PM, E#16 (Quality and Patient Safety Specialist) stated "Once the provider is privileged by the Board, the file is sent to the Quality Department and we ensure the Focused reviews and observations are completed." E#16 verbally agreed the chart reviews and observations were not completed appropriately and should have been.

B. Based on document review and interview, it was determined for 3 of 3 (E #15, #14, and #11) CRNAs, that the Hospital failed to ensure CRNA's privileges were requested and the Department Chair made the recommendation to request privileges be granted. This has the potential to affect all patients who receive anesthesia provided by CRNAs.

Findings include:

1. The Medical Staff Bylaws (reviewed March 2016) was reviewed on 8/5/16 at approximately 11:00 AM. The Bylaws note on page 14 "Department Recommendation The Department Chairman and the members of the Department shall conduct an interview with applicant and forward to the Credentials Committee a written report evaluating the evidence of the applicant's training, experience, and demonstrated ability of stating how the applicant's skills are expected to contribute... The report shall state the Department Chairperson's recommendation as to approval or denial of...."

2. The CRNA Clinical Privileges for E#15 were reviewed on 8/4/16 at approximately 11:00 AM. The form noted Initial Privileges for E#15 were granted on 7/6/15. The Privileges lacked the Department Chair's Recommendation to recommend the requested privileges be granted.

3. The CRNA Clinical Privileges for E#14 were reviewed on 8/4/16 at approximately 11:05 AM. The form noted Initial Privileges for E#14 were granted on 6/19/13. The Privileges lacked which Core Clinical Privileges were requested and lacked the Department Chair's Recommendation to recommend the requested privileges be granted.

4. The CRNA Clinical Privileges for E#11 were reviewed on 8/4/16 at approximately 11:10 AM. The form noted Initial Privileges for E#11 were granted on 2/15/12. The Privileges lacked the Department Chair's Recommendation to recommend the requested privileges be granted.

5. During an interview on 8/4/16 at approximately 11:00 AM, E#13 (Manager of Physician Services) verbally agreed the Privileging forms for E#11, E#14 and E#15 were not completed appropriately and should have been.

Based on document review and interview, it was determined in 3 of 10 (Pt's #21, #22 and #23) behavioral health records reviewed, the Hospital failed to ensure all entries and/or orders were complete and accurately authenticated per policy. This has the potential to affect all patients that receive care at the facility, an average daily census of 61 patients.

Findings include.

1. The policy titled "Medical Record Entries" (revised 9/30/13) was reviewed on 8/3/2016 at approximately 4:00 PM. The policy indicated under "II. Every medical entry must be legible and complete, and must be dated, identified by author, and authenticated".

2. The medical record of Pt #21 was reviewed on 8/2/16 at approximately 11:00 AM. Pt #21 was admitted to the Behavioral Health Unit on 7/11/16 with the diagnosis of Bipolar Disorder with Psychosis. The "Interdisciplinary Treatment Plan Form" lacked the date and time the form was signed by the physician, patient and the staff member.

3. The medical record of Pt #22 was reviewed on 8/2/16 at approximately 11:10 AM. Pt #22 was admitted to the Behavioral Health Unit on 7/11/16 with the diagnosis of Major Depression. The Interdisciplinary Treatment Plan lacked the date and time the form was signed by the patient and the staff member.

4. The medical record of Pt #23 was reviewed on 8/2/16 at approximately 11:15 AM. Pt #23 was admitted to the Behavioral Health Unit on 7/29/16 with the diagnosis of Bipolar Disorder. The Interdisciplinary Treatment Plan lacked the date and time the order was signed by the patient. The form also lacked the physician signature.

5. An interview was conducted with the Behavioral Health Unit Manager (E #2) on 8/2/16 at approximately 11:25 AM. E#2 reviewed Pt #21, Pt #22, and Pt #23's record and verbally agreed that the records were missing the dates on times with the signatures. E#2 verbally agreed there was not a physician signature on Pt # 23's Interdisciplinary Treatment Plan Form.

Based on document review and interview, it was determined for 2 of 2 (Pts #29, #30) patients who underwent interventional cardiac services, the Hospital failed to ensure orders to implement physician order sets were obtained and authenticated by the physician. This has the potential to affect all patients where physician order sets are utilized.

Findings include:

1. The Hospital policies titled "Provider Order Sets" (revised 5/31/16) and "Receiving Physicians' Orders Procedure (revised 5/31/16) were reviewed on 8/5/16 at approximately 9:50 AM. Neither policy addressed the process for implementation and authentication of Provider Order Sets.

2. Pt #29's medical record was reviewed between approximately 8/3/16 at 4:15 PM and 8/4/16 9:50 AM. Pt #29 was admitted to the Catheterization (Cath) Laboratory (Lab) on 8/3/16 with the diagnosis Coronary Artery Disease with High Grade Stenosis and underwent Percutaneous Transluminal Coronary Angioplasty. On 8/4/16, nursing discharge documentation stated Pt #29 received "Post Cath Instructions (preprinted physician order set). The record lacked a physician order to implement the order set.

3. Pt #30's medical record was reviewed on 8/4/16 at approximately 1:30 PM. Pt #30 was admitted to the Cath Lab on 8/3/16 with the diagnosis Atherosclerosis of Native Artery of Left Lower Extremity and underwent Left Lower Extremity Angiogram with Possible Intervention of Angioplasty, Stent or Atherectomy. On 8/3/16, nursing discharge documentation stated Pt #30 received "Post Cath Instructions (preprinted physician order set). The record lacked a physician order to implement the order set.

4. An interview was conducted on 8/4/16 at approximately 3:00 PM with the Director of Outpatient Services (E#5 and the Nurse Educator E#8). Both had reviewed the records of Pts #29 and #30 and verbally agreed the records lacked orders to implement the "Post Cath Instructions" order set.

5. An interview was conducted with the Nurse Educator (E#8) on 8/5/16 at approximately 9:50 AM. E#8 had reviewed the polices and verbally stated "They don't state how they are to be implemented if that's what you're asking."

Based on document review and interview, it was determined for 4 of 30 (Pts #7, #8, #24, and #25) patients, the Hospital failed to ensure documentation was accurate and complete with all information necessary to monitor the patient's condition. This has the potential to affect all patients that receive care at the facility, an average daily census of 61 patients.

Findings include:

1. Pt #7's medical record was reviewed on 8/2/16 at approximately 1:20 PM. Pt #7 was admitted to the Hospital on 6/20/16 with the diagnosis Diarrhea, Unspecified. On 6/22/16, the Pre Anesthesia assessment lacked the time as to when it was performed. Between 6/21/16 and 7/2/16, approximately eight dictated physician notes, signed as complete by the physician, contained blanks which had not been filled.

An interview was conducted with the Nurse Educator (E#8) on 8/3/16 at approximately 12:00 PM. E#8 had reviewed Pt #7's record and verbally agreed the Pre Anesthesia assessment lacked the time as to when it was performed and the dictated physician notes contained blanks and "They are suppose to read them and fill in any blanks before they sign them. Once they sign them, the entry is considered complete."

2. Pt #8's medical record was reviewed on 8/3/16 at approximately 2:30 PM. Pt #8 was admitted to the Hospital on 5/24/16 with the diagnoses Gastroenteritis and Colitis Due to Radiation. On 6/9/16, the "Post Anesthesia Assessment" lacked the time as to when it was performed.

An interview was conducted with the Nurse Educator (E#8) on 8/4/16 at approximately 3:00 PM. E#8 reviewed Pt #8's record and verbally agreed the Post Anesthesia Assessment lacked the time as to when it was performed.

3. Pt #24's record was reviewed on 8/3/16 at approximately 9:00 AM. Pt #24 was admitted to the Outpatient Oncology Center on 8/3/16 with the diagnosis Endometrial Cancer and underwent laboratory testing, accessing of Vascular Access Device (VAD), physician assessment, intravenous (IV) potassium, and then discharged home. The record lacked the following:
a. times as to when Pt #24 was admitted/discharged to/from the Outpatient Unit
b. who/when the VAD was accessed
c. whether VAD was flushed post laboratory draw with Normal Saline
d. concentration of Heparin flush
e. when the patient saw the physician
f. when the patient was taken to the treatment area
g. concentration of Potassium infusion
h. who performed each intervention
i. times of each intervention

4. Pt #25's record was reviewed on 8/3/16 at approximately 9:15 AM. Pt #25 was admitted to the Outpatient Oncology Center on 8/2/16 with the diagnosis Pancytopenia and underwent
peripheral IV insertion, oral premedication, and transfusion of two units of packed red blood cells, discontinuation of the peripheral IV line, and discharge from the Unit. The record lacked the following:
a. times as to when Pt #25 was admitted/discharged to/from the Outpatient Unit
b. who/when the peripheral IV was accessed/discontinued
c. when the patient was taken to the treatment area
d. hanging of Normal Saline with the blood transfusion
e. who performed each intervention
f. times of each intervention

5. An interview was conducted with the Patient Care Manager Outpatient Oncology (E#6) on 8/3/16 at approximately 8:45 AM. When asked to describe the flow of patients arriving for outpatient services, E#6 stated the patients are registered, taken to the intake room (where vital signs are taken, laboratory tests are drawn, and intravenous accesses was performed), then they (the patients) may see the physician if scheduled or will be taken to the treatment area for ordered treatments. E#6 stated the Unit is staffed with three Registered Nurses who assist in each area and the nurse who admits the patient and the one who gives (starts and/or stops) the treatment(s) was not the same nurse.

A follow-up interview was conducted with E#6 on 8/3/16 during the record reviews. E#6 reviewed the records of Pts #24 and #25 with the surveyor. When asked as to when the patients arrived, times in each area, who performed the interventions, concentration of medications, documentation of Normal Saline with the blood transfusion, et cetera, E#6 verbally agreed "You wouldn't be able to tell that (the above items). A nurse charts usually after the patient leaves and that's the only name you'll see on the record. Even if a different nurse has opened the chart, only the nurse's name who closes the chart will be there."

Based on document review and interview, it was determined in 1 of 3 (Pt #8) patient clinical record reviewed of a patient discharged for greater than 30 days, the Hospital failed to ensure the Discharge Summary was completed as per policy. This has the potential to affect all patients that receive care at the facility, an average daily census of 61 patients.

Findings include:

1. The "Medical Staff Rules and Regulations" (November, 2015) were reviewed on 8/3/16 at approximately 2:30 PM. The Rules and Regulations stated "Discharge Summary: A complete discharge summary shall be entered into the medical records... no greater than 30 days after the discharge."

2. Pt #8's medical record was reviewed on 8/3/16 at approximately 2:30 PM. Pt #8 was admitted to the Hospital on 5/24/16 with the diagnoses Gastroenteritis and Colitis Due to Radiation and expired on 6/18/16. The Discharge Summary was dictated 7/20/16, greater than 30 days after discharge.

3. An interview was conducted with the Nurse Educator (E#8) on 8/3/16 at approximately 3:00 PM. E#8 reviewed Pt #8's record and verbally agreed the Discharge Summary was greater than 30 days after discharge.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on August 1 & 2, 2016, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation, document review, and interview, it was determined the Hospital failed to ensure its' preventive maintenance policy for patient care equipment was followed in its' off-site Rehabilitation and Wellness Center. This has the potential to affect all patients serviced by the Rehabilitation unit with an average daily census of 29 to 36 patients.

Findings include:

1. The Hospital policy titled "Medical Equipment Management Plan (effective 11/24/15) was reviewed on 8/5/16 at approximately 12:30 PM. The policy stated "Procedure 3. H. Equipment Testing and Planned Maintenance... 5....Planned maintenance frequency and procedures are determined at the time of initial evaluation and based on manufacturer recommendations along with consideration of various regulatory, risk, and historical factors..."

2. An observational tour of the off-site Rehabilitation and Wellness Center was conducted on 8/3/16 at approximately 10:25 AM with the Director of Rehabilitation Services (E#4) and the Quality and Patient Safety Specialist (E#1). The Center contained a "Therapy" area and a "Fitness Center". The Fitness Center was observed to have numerous types of equipment which could be utilized for patient care, with examples such as 4 treadmills, 2 recumbent bikes, 2 elliptical's, a Trotter Cable Crossover system, and A Trotter Galileo Tricep Extension. None of the patient care equipment located in the Fitness Center area was observed to have any preventive maintenance performed within the last year.

3. An interview was conducted with E#4 on 8/3/16 at approximately 10:45 AM. E#4 stated the Hospital acquired the Fitness Center area in January of 2015 and has changed who performs the preventive maintenance and "I'm wondering if when the change over occurred, the equipment (Fitness Center) didn't get transferred to their log (the Hospital's preventive maintenance)."

4. A follow-up interview was conducted with E#4 on 8/3/16 at approximately 11:15 AM. E#4 stated having contacted the personnel responsible for the preventive maintenance of the patient care equipment and "they don't have this equipment (Fitness Center) on their list and will have to do it."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on August 1 & 2, 2016, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated August 2, 2016.

Based on document review and interview, it was determined the hospital failed to monitor contracted laundry services to prevent cross contamination. This has the potential to affect all patients that receive care at the facility, an average daily census of 61 patients.

Finding includes:

1. On 8/4/16 at approximately 2:45 PM the hospital infection control policy " Infection Surveillance Plan and Methodologies " (revised 11/30/15) " The infection control department is responsible for hospital-wide safety infectious/communicable disease " .

2. Review of laundry service workload summary on 8/4/16 at 1:45 PM for the 3-3 Milnor CBW tunnel washer used for patient bath towels found July 2016 values of " desired temperature " were higher than " actual temperature " on the summary.

3. An interview was conducted on 8/4/2016 at 11:00 AM with the Infection Control Officer (E #9). E #9 confirmed that for at least two months (June/July 2016) contracted laundry services have not met washing machine temperature guidelines (115 degrees-145 degrees) for towels used for patient use. This situation has been discussed by E #9 with laundry service by email. The laundry service reported they have increased the disinfectant to offset the lower water temperature. However, E #9 reports the hospital and the contractual laundry service are still working to resolve optimal washing machine temperature. An additional interview with E #9 at 1:45 PM found that E #9 contacted the laundry service for further explanation of optimal washer temperatures. E #9 reports the optimal temperature is really a maximum temperature, not the temperature the machine needs to reach. The disinfection was added for the dirt volume not temperature. E #9 was not aware of the temperature the laundry service washer needs to reach for optimum cleaning. The hospital staff did not understand the summary values prior to 8/4/16 and therefore were unable to monitor the laundry services effectively

Based on document review and interview it was determined for 1 of 3 (Pt #28) patient reviewed for outpatient therapy services, the hospital failed to ensure orders included frequency, duration, and modalities. This has the potential to affect all patients receiving outpatient occupational therapy.

Finding includes:

1. Pt 28's record was reviewed on 8/3/16 at approximately 11:15 AM. Pt # 28 was admitted to the Outpatient Rehabilitation Center on 4/25/16 with the diagnosis of Bilat Leg Weakness/ROM. Pt #28's Occupational Therapy "Initial Evaluation" completed on 4/26/16 lacked frequency, duration and modality in the care plan.

2. An interview was conducted on 8/4/2016 at 11:00 AM with the Director of Rehabilitation Services (E#4). E#4 reviewed Pt #28's record. E#4 verbally confirmed Pt #28's care plan lacked the required frequency, duration and modality,