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Based on medical record review, review of facility investigation, and staff interview, the facility failed to ensure an action plan was implemented after an adverse outcome (A286). The cumulative effects of this systemic practice resulted in the facility's inability to ensure the patients' needs would be met.

Based on medical record review, review of facility investigation, and staff interview, the facility failed to ensure an action plan was implemented after an adverse outcome for five of 34 medical records reviewed (Patient #16, #32, #15 #33, and #34). This had the potential to affect 575 patients identified by the hospital as having suicidal thoughts.

Findings include:

1. Review of Patient #16's medical record was completed on 05/12/17. Patient #16 presented to the Emergency Department on 05/28/16 at 1:49 PM stating, "I need to talk to someone." When a staff member asked the patient if he/she wanted to harm himself/herself, the patient stated, "Yes, I'm just not very happy right now." A nursing note at 2:19 PM revealed the patient was placed in a behavioral health triage room. It was further noted a security officer remained in the room with the patient while the room was being cleaned by housekeeping. After the room was cleaned, the security officer left the room leaving the patient alone. A nursing note revealed the patient came out of the room holding a razor blade in one hand and showing staff his/her cut wrist. The patient reported hiding the razor blade in his/her mouth until after the security guard left the room, when he/she then cut his/her wrist in an attempt to take his/her own life. At 2:21 PM, the patient informed staff he/she felt better after cutting himself/herself and wanted to be discharged home. A note at 2:35 PM revealed the patient was searched using a security wand metal detector. No other weapons were found. Four staples were required to close the cut to the patient's wrist which included a lacerated tendon. A behavioral health specialist was noted to be at the bedside of the patient for a psychiatric evaluation at 7:34 PM. His/Her assessment noted he/she felt the patient was safe for outpatient management as the patient did not exhibit signs that would suggest the patient was an imminent risk to himself/herself. The patient was discharged home at 8:22 PM on 05/28/16.

Staff A was interviewed on 05/12/17 at 5:15 PM. He/She was asked to provide documentation this incident was reviewed by quality improvement staff in order to implement preventive actions. The investigation of the incident was provided. Documentation of the investigation revealed this incident was reviewed on 06/01/16. The action plan revealed one staff to one patient (1:1) care would be considered, if available. It was further noted that all suicidal patients would be scanned with a security metal detector wand. Staff A was asked to provide a list of all suicidal patients presenting to the Emergency Department since 06/01/16. An eight page list of approximately 575 names was provided.

2. Patient #32 presented to the Emergency Department on 06/30/16 at 7:54 AM with complaints of feeling suicidal. The patient was admitted to the facility's Behavioral Health Unit at 2:15 PM for treatment. The medical record lacked documentation the patient was searched using a security wand metal detector.

3. Patient #15 presented to the Emergency Department on 02/08/17 at 5:02 PM after he/she attempted taking his/her life by cutting his/her wrist. The patient was admitted to the facility Behavioral Health Unit for treatment. The medical record lacked documentation the patient was searched using a security wand metal detector.

4. Patient #33 presented to the Emergency Department on 03/13/17 at 8:05 AM with suicidal thoughts. The medical record lacked documentation the patient was searched using a security wand metal detector.

5. Patient #34 presented to the Emergency Department on 05/07/17 at 2:37 PM reporting an addiction problem and suicidal ideations. The medical record lacked documentation the patient was searched using a security wand metal detector.

The facility policy titled Search Procedures was reviewed on 05/12/17 at 5:20 PM. According to policy any police officer or security officer was empowered to request to conduct reasonable searches of patients, visitors, providers, and employees on entering or exiting the facility. A police officer or security officer may also request to conduct reasonable searches of bags, purses, packages or other items carried on the property.

Staff B was interviewed on 05/12/17 at 5:30 PM. It was confirmed the medical records lacked documentation the facility implemented a plan to ensure the safety of suicidal patients. He/She was also asked to provide documentation staff was educated on the requirement to scan all suicidal patients with the wand metal detector. No education was provided.

Further interview with Staff B on 05/12/17 at 5:40 PM revealed the current facility policy did not address the use of the security wand metal detector on all suicidal patients presenting to the Emergency Department. Staff B stated there was no current written policy due to the facility being a part of a larger hospital system. He/She stated, "All policies must be system wide policies and the other facilities do not require wanding."

Based on medical record review, staff interview and policy review, the facility failed to ensure nursing staff followed the current facility policy related to physician notification of changes in the patient's condition for one of 34 patients reviewed (Patient #31). The facility's census was 100.

Findings include:

Review of Patient #31's medical record was completed on 05/12/17. Patient #31 presented to the Emergency Department on 03/15/17 at 2:28 AM with complaints of numerous episodes of vomiting, diarrhea and abdominal pain for three to four days. The emergency department physician noted the patient had a past medical history of congestive heart failure, diabetes, and chronic hepatitis C. The patient reported having a colonoscopy scheduled for his/her complaints of abdominal pain, but was unable to attend after being in a motor vehicle accident. The patient was admitted to a medical surgical unit for treatment at 6:33 AM. A nursing note less than ten minutes after admission, at 6:42 AM, stated the patient experienced an episode of coffee ground emesis. The medical record lacked documentation a physician was notified of the coffee ground emesis.

At 4:41 PM on 03/15/17, a nurse noted the patient was very tired throughout the shift. A nursing note stated when the nurse walked into the patient's room at 3:30 AM on 03/16/17, he/she had shallow breathing with respirations at six breaths per minute. A rapid response team was called. The patient's blood glucose was too low to read and his/her blood pressure was elevated at 181/98. It was further noted the patient was flaccid and unresponsive to pain. A physician was notified and a computed tomography (CT) scan was ordered. The CT scan showed no changes from a previous CT scan. The patient was transferred to the intensive care unit at 4:50 AM on 03/16/17. The patient was intubated at 8:00 AM when he/she remained unresponsive. The patient recovered, was extubated and transferred back to the medical surgical unit on 03/19/17 at 5:00 PM.

The Intake and Output flowsheet on admission noted the patient's last bowel movement was on 03/14/17, prior to admission. The flowsheet noted the patient was incontinent of a large tan, watery bowel movement on 03/19/17 at 9:00 PM. A second bowel movement was noted at 9:08 PM. At 11:00 PM the Intake and Output flowsheet noted the patient had five bowel movements described as loose. Another bowel movement was noted at 11:48 PM. The medical record lacked documentation a physician was notified of the eight episodes in which the patient was incontinent of bowel movements noted to be loose. On 03/21/17 three more episodes of loose stools were noted. Again, the medical record lacked documentation a physician was notified.

A nursing note on 03/23/17 at 4:35 PM revealed that either the patient coughed up or vomited red mucous. The note further revealed a physician was notified of this abnormal finding and the physician stated the patient should be discharged as planned. The patient was discharged to a nursing home for rehabilitation at 5:00 PM on 03/23/17.

The patient was transported by ambulance to the Emergency Department two days later on 03/25/17 at 10:36 AM. Staff at the nursing home reported the patient was increasingly weak and had coffee ground emesis that morning.

The facility policy titled Critical Care Physician Notification Circumstances was reviewed on 05/12/17 at 3:00 PM. Review of the policy revealed nursing staff were required to notify the physician as soon as possible within 60 minutes of significant negative changes in patient assessment. Staff were further instructed to thoroughly document all communications.

Staff A was interviewed at 3:15 PM on 05/12/17. It was confirmed that the medical record lacked documentation a physician was notified of the patient's coffee ground emesis.

Based on observation, interview, and document review, the facility failed to ensure each door in the three hour barrier between it and a building occupancy had a rating, and all penetrations were filled with fire stopping material (K133). The facility failed to ensure penetrations in the fire barrier between floors were filled with fire stopping material (K161). The facility failed to ensure each of its exit discharges were free of all obstructions to full use (K211). The facility failed to maintain three hour rating in barrier between the 1959 and 1982 building (K226). The facility failed to have directional indicator on its exit signage that showed each path of egress (K293). The facility failed to maintain stated rating protecting its vertical openings (K311). The facility failed to maintain stated rating for barrier protecting hazardous areas (K321). The facility failed to ensure its fire alarm system was tested and documented in accordance with NFPA 72, 2010 edition, 14.6.2.4 (K345). The facility failed to ensure areas that were open to corridors had smoke detection systems (K347). The facility failed to have a sprinkler system maintained in accordance with NFPA 25 (K353). The facility failed to ensure all corridor doors closed, and where so equipped, latched (K363). The facility failed to ensure penetrations into its smoke barriers were capable of restricting the transfer of smoke (K372). The facility failed to ensure each door in a smoke barrier self closed and double doors did not have a gap of greater than one eighth of an inch (K374). The facility failed to conduct fire drills under varied conditions and to include participation of any physicians (K712). The facility failed to ensure its medical gas shut off valves complied with NFPA 99, 5.1.4.8.7, 2012 edition (K902). The facility failed to have emergency lighting that conformed with NFPA 99, 6.3.2.2.11, 2012 edition (K911). The cumulative effect of these systemic practices resulted in the facility's inability to ensure that patients would be safe in the event of a fire.

Based on observation, interview, and document review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The facility census was 100 patients.

Findings include:

K133 Failed to ensure each door in the three hour barrier between it and a building occupancy had a rating, and all penetrations were filled with fires topping material.

K161 Failed to ensure penetrations in the fire barrier between floors were filled with fire stopping material.

K211 Failed to ensure each of its exit discharges were free of all obstructions to full use.

K226 Failed to maintain three hour rating in barrier between the 1959 and 1982 building.

K293 Failed to have a directional indicator on its exit signage that showed each path of egress.

K311 Failed to maintain stated rating protecting its vertical openings.

K321 Failed to maintain stated rating for barrier protecting hazardous areas.

K345 Failed to ensure its fire alarm system was tested and documented in accordance with NFPA 72, 2010 edition, 14.6.2.4

K347 Failed to ensure areas that were open to corridors had smoke detection systems.

K353 Failed to have a sprinkler system maintained in accordance with NFPA 25.

K363 Failed to ensure all corridor doors closed, and where so equipped, latched.

K372 Failed to ensure penetrations into its smoke barriers were capable of restricting the transfer of smoke.

K374 Failed to ensure each door in a smoke barrier self closed and double doors did not have a gap of greater than one eighth of an inch.

K712 Failed to conduct fire drills under varied conditions and to include participation of any physicians.

K902 Failed to ensure its medical gas shut off valves complied with NFPA 99, 5.1.4.8.7, 2012 edition.

K911 Failed to have emergency lighting that conformed with NFPA 99, 6.3.2.2.11, 2012 edition.

Based on medical record review, observation, review of employee job descriptions, policy review and staff interview, the facility failed to ensure the operating room was supervised by an experienced registered nurse or doctor of medicine (A942). The facility failed to have a roster of surgical privileges readily available in the surgical area (A945). The facility failed to ensure all surgical staff followed hospital policy (A951). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients' surgical needs would be met.

Based on staff interview and review of employee job descriptions, the facility failed to ensure the operating room was supervised by an experienced registered nurse or doctor of medicine. This had the potential to affect all patients receiving surgical services. The facility census was 100.

Findings include:

Interview on 05/10/17 at approximately 10:30 AM with Staff C revealed he/she was the Director of Surgical Services with qualifications that included certified surgical technologist and certified surgical first attendant.

Interview with Staff A on 05/10/17 at approximately 2:58 PM revealed Staff C was the Director over the operating rooms who reported directly to him/her. Staff A verified that Staff C was not a registered nurse or doctor of medicine.

Review of the hospital's undated job description for the Director, job code position #481190 revealed the director should provide a focused leadership presence in his/her patient care operation division and enhance the coordination and promotion of services provided. The educational requirements for this position were either a Bachelor's degree in Nursing or Business.

Based on observation and staff interview, the facility failed to have a roster of surgical privileges readily available in the surgical area. This had the potential to affect all patients that would require surgical services. The facility census was 100.

Findings include:

During a tour of surgical services on 05/10/17 at approximately 10:30 AM, interview with Staff H revealed there was no roster listing surgeon privileges located on the unit. Staff H stated that he/she could pull up the list from the computer system.

Observation of Staff H attempting to access the list in the system revealed the list could not be retrieved. Staff H received the following response from the computer, "Privileges are not available." Staff H stated he/she would then call medical staff services to get the list and verified that the list was not readily available on the unit. This finding was verified with Staff B and C at that time.

Interview on 05/12/17 at approximately 10:22 AM with Staff G, revaled the hospital did not have a policy, procedure, or anything in writing in regards to having physician privileges readily available in surgery.

Based on medical record review, staff interview and policy review, the facility failed to ensure all surgical staff followed hospital policy for one of two medical records reviewed for verbal order compliance (Patient #29). The facility census was 100.

Findings include:

Review of the hospital policy titled PC-KHN Orders Management For Verbal, Telephone, Written, and Fax Orders Giving, Receiving and Authenticating- CPOM, approved on 11/04/14, revealed verbal orders would be accepted from a provider who was physically present, but unable to enter orders electronically only for the following situations: during an emergency, a code, or when sterile protocol was in use. The policy stated verbal orders were to be used only when it was impractical for the provider to personally place the order in the computer.

Review of Patient #29's medical record revealed the patient was admitted on 05/08/17 for a left hip fracture which required surgical intervention. Patient #29's post operation surgery orders dated 05/09/17 revealed the surgeon, Staff E, submitted verbal orders for oxycodone-acetaminophen (used to treat moderate and moderately severe pain) 5-325 milligrams(mg) one to two tablets by mouth every four hours, activity as tolerated, and to apply ice to the affected area. These orders were put into the computer by a registered nurse on 05/09/17 at 9:57 PM and then signed by Staff E at 9:58 PM.

Interview on 05/11/17 at approximately 12:11 PM with Staff B and Staff C, revealed that Patient #29's surgery was Staff E's last of the day and that the registered nurse put in the verbal orders a 9:57 PM and the orders were signed by Staff E at 9:58 PM a minute later. Staff C stated that they planned on working with Staff E to help him/her put his/her own orders in.