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A. Based on document review and interview, it was determined that for 6 of 6 patients (Pt. #23, #24, #25, #26, #27 and #28) emergency department (ED) clinical records reviewed, the Hospital failed to ensure that patient's were informed and provided a copy of the patient rights while in the ED.

Findings include:

1. On 12/11/19 at approximately 11:10 AM, the clinical record of Pt. #23 was reviewed. Pt. #23 was admitted to the ED on 12/11/19 at 8:13 AM, with a chief complaint of flu like symptoms.

2. On 12/11/19 at approximately 11:15 AM, the clinical record of Pt. #24 was reviewed. Pt. #24 was admitted to the ED on 12/11/19 at 6:26 AM, with a chief complaint of left flank pain.

3. On 12/11/19 at approximately 11:20 AM, the clinical record of Pt. #25 was reviewed. Pt. #25 was admitted to the ED on 12/11/19 at 2:40 AM, with a chief complaint of low back pain.

4. On 12/11/19 at approximately 11:25 AM, the clinical record of Pt. #26 was reviewed. Pt. #26 was admitted to the ED on 12/11/19 at 9:19 AM, with a chief complaint of left flank pain.

5. On 12/11/19 at approximately 11:30 AM, the clinical record of Pt. #27 was reviewed. Pt. #27 was admitted to the ED on 12/11/19 at 7:37 AM, with a chief complaint of left inguinal hernia (bulging of internal organ at groin).

6. On 12/11/19 at approximately 11:35 AM, the clinical record of Pt. #28 was reviewed. Pt. #28 was admitted to the ED on 12/11/19 at 4:30 AM, with a chief complaint of fever.

7. The clinical records of Pt. #23, #24, #25, #26, #27 and #28 did not have a copy of the Patient Rights being provided to the patient during registration.

8. The Hospital policy titled, "Patient's Rights and Responsibilities" dated 02/17/19 was reviewed on 12/11/19 at approximately 12:30 PM. The policy included, "...Hospital respects the rights of the patient, recognizes that each patient is an individual with unique health care needs ...Procedure: A. Patient Right and Responsibilities document is provided to all admitted patients, as well as Emergency Department patients ..."

9. On 12/11/19 at approximately 11:45 AM, the Access Specialist/ER (Emergency Room) Registration staff (E #8) was interviewed. E #8 stated that, the patient rights should have been given to the patients upon registration. E #8 continued to say that, "I am not sure why they did not give it to the patients."

10. On 12/11/19 at approximately 11:50AM, the Manager of Quality (E #9) was interviewed. E #9 stated that, the patients' rights should have been given to the patients' or seen in the chart.

B. Based on observation and interview, it was determined that, the Hospital failed to ensure the Patient Rights and Responsibilites was posted in the Emergency Department (ED). This has the potential to affect all the 125 average daily census of patients' seen in the ED.

Findings include:

1. On 12/11/19 between 10:15 AM - 12:15 PM, during the observational tour of the Emergency Department, the patients rights and responsibilities was not seen posted in the area.

2. On 12/11/19 at approximately 11:55 AM, the Director of Nursing (E #6) was interviewed. E #6 stated that, he is not aware when they removed the posting, that was near the registraion. E #6 continued to say that, probably due to construction, the posting was removed.

Based on document review and interview, it was determined that the Hospital's Medical Record Department failed to ensure medical records were completed within 30 days following patient discharge.

Findings include:

1. On 12/10/19, the Hospital's Medical Staff Bylaws, Policies, and Rules and Regulations (reviewed by the hospital June 22, 2018) was reviewed and included, "3.8 Delinquent Medical Records: b) Medical records will be completed within 30 days following the patient's discharge or they will be considered delinquent."

2. On 12/11/19, the Manager of Medical Records (E #10) presented an attestation letter which included, "...the following is the number of delinquent medical records at 30+ days. Total deficiencies at 30+ days: 3."

3. On 12/11/19 at 11:45 AM, an interview was conducted with E #10. E #10 stated that, the physicians are notified of delinquent records, and medical records should be completed within 30 days following discharge.

A. Based on observation, document review and interview it was determined that, for 3 of 15 (E #1, E #2 and E #3) dietary staff observed in the Kitchen for safe handling of food, the Hospital failed to ensure that, the hair and beard restraints were worn by staff while in the kitchen. This has the potential to contaminate the food for 127 patients on census as of 12/10/19.

Findings include:

1. On 12/10/19 between 10:00 AM to 11:30 AM, during the observational tour of the kitchen the following were observed:

- The Cook (E #1) was seen cooking fish for lunch without the hairnet and with a cap on exposing 2 (two) inches of hair all through the back of his neck and three (3) inches of side burns.

- The Cook (E #2) was seen preparing salad for patient lunch without hairnet exposing two (2)inches of hair at the back of his neck.

- The Food Services Worker (E #3) was seen cleaning dishes at the sanitation area without hairnet and beard restraints exposing three (3) inches of beard around his chin.

2. The Hospital policy titled, "Personal Hygiene" dated 10/2017 was reviewed. The policy included, "Hair restraints or appropriate hat worn in all food services areas at all times. 3. Men must be clean-shaven or maintain a clean, trimmed and groomed moustache and/or beard and wear an appropriate hair restraint."

3. On 12/10/19 at approximately 10:40 AM, the Food Services Worker (E #3) was interviewed. E #3 stated that, he forgot to wear the hairnet. Upon asking about the beard and his hair being exposed, he (E #3) stated that he will wear a hair net and beard restraints right away.

4. On 12/10/19 at approximately 10:50 AM, the General Manager of Dietary Services (E #4) was interviewed. E #4 stated that, the hairnet must be worn while in the kitchen. Before, the staff enter the kitchen, all staff are required to wash their hands and wear hairnet for safe handling of food. E #4 continued to say that, it is time to provide education and training to the staff.

B. Based on observation, document review and interview it was determined that Hospital failed to ensure that the expired food was disposed. This has the potential to affect 127 patients on census as of 12/10/19.

Findings include:

1. On 12/10/19 between 10:00 AM to 11:30 AM, during the observational tour of the kitchen the following were observed:

- The cook's refrigerator had a container with twenty-five (25) percent of cut veggies with expiration date 11/27/19, labeled on the container.

- The cool storage area had a container with horseradish two (2) pounds with expiration date 12/09/19 labeled on the container.

2. The Hospital policy titled, "Label and Dating of Prepared Foods" dated 10/2017, was reviewed. The policy included, "4. For foods served in disposable serviceware, the expiration date is placed on the disposable container, using either a label and date stamp or a permanent marker. 6. Any food in storage after its expiration date is discarded. It is recommended that all colleagues of the department know the importance of and following the dating of food items."

3. On 12/10/19 at approximately 11:10 AM, the General Manager of Dietary Services (E #4) was interviewed. E #4 stated that, the staff should have checked for the expiration dates and tossed it. I will toss it right away. E #4 continued to say that, it is time to re-educate all the staff.

Based on observations during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on December 10-11, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on December 10-11, 2019, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.