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Based on a review of facility documents, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to follow their adopted policy by failing to ask patients if they have an Advanced Directive for two of 10 medical records reviewed (MR1, MR8), and by failing to document that patients who stated they did not have an Advance Directive, were asked if they would like printed information about Advance Directives for six of six applicable medical records reviewed (MR2, MR6, MR8, MR9, MR10, MR11)

Findings include:

A review of policy entitled Advance Directive, dated March 2017, revealed, "... Advance Directive will be initiated at Registration. 1. Registration personnel will ask the patient if they have an Advance Directive. If the patient does not have an Advance Directive, Registration personnel will ask the patient if they would like printed information about Advance Directives. 2. If patient requests additional information about Advance Directives, the material is to be supplied by Registration personnel. Registration personnel will document in Meditech ... ."

1. A review of MR1 and MR8 with EMP2, on April 5, 2017, revealed no documentation that patients were asked if they had an Advance Directive.

2. A review of MR2, MR6, MR8, MR9, MR10, and MR11, with EMP2, on April 5, 2017, revealed all had documentation which indicated that the patient did not have an Advance Directive. An interview with EMP1 on April 5, 2017, revealed that none of these records contain documentation that the patient was offered information on Advance Directives.

Based on a review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that physicians who are authorized to order restraint or seclusion have a working knowledge of hospital policy regarding the use of restraint or seclusion.

Findings include:

A review of policy entitled Restraints, dated March 2017, revealed, "... Initiation and Renewal of Orders. A. Physician orders for restraints include: Date and time restraint initiated, Type of restraint ... Length of time restraint to be utilized, If a patient is in restraints for longer than 24 hours, a new physician order with assessment documentation supporting the continued use of restraints must be present in patient's medical record, Reason or clinical justification for restraint, Physician name/signature/date and time order signed ... Staff Education/Competency 1. No staff member who has not completed initial orientation and does not have a yearly Skilled Competency Evaluation Checklist will be permitted to apply or monitor restraints. 2. Staff members who have direct patient care contact will have education and training regarding the use of restraints, during initial orientation, and annually with a review of current policy and complete the Skilled Competency Check List ... on a yearly basis. 3. Under the direction of an MD or RN, those staff members, (including security staff), who, in their job descriptions, may be required to assist in applying restraining devices or monitor a patient in a restraining device, will be required to review this policy and complete the Skilled Competency Evaluation Check List on a yearly basis. 4. Evidence of these competencies will be required at least annually through documented peer review and educational updates as necessary. 5. At a minimum, the following topics are included in education and training ... 7. For staff authorized to perform assessment of patients in need of and/or in restraints (Registered Nurse, Physician): Topics outlined for "direct care staff" as well as the following: Taking vital signs and interpreting/assessing the relevance of restraints, Assessing/reassessing nutrition and hydration needs and addressing as needed, Assessing/reassessing circulation and conducting range of motion of the restrained limb, Assessing/reassessing and addressing the physical and psychological status and comfort of the patient, Be aware of and assist the patient in meeting the criteria for discontinuation of restraints, Recognizing the readiness for discontinuation through continuous reassessment, Recognizing the need to contact the physician to evaluate and/or treat the patient as necessary ... ."

1. Surveyor requested documentation that physicians who are authorized to order restraint or seclusion, have a working knowledge of hospital policy related to restraint and seclusion.

2. Interview with EMP1 on April 5, 2017, revealed that there is no documentation of physician education related to restraints.

Based on a review of facility documentation, interview with facility staff (EMP) and tour of the Food and Nutrition Department, it was determined that the facility failed to follow adopted policies and failed to provide daily oversight to ensure that a safe, clean and sanitary environment was maintained.

Findings Include:

Review of Chan Soon-Shiong Medical Center at Windber Dining and Nutrition Services 2017-2018 policy manual dated March 2017, revealed, "Windber Medical Center Dining Services and Nutrition Department Scope of Service (Also referred to as Plan of Care) I. Scope The Dining Service and Nutrition Department of Windber Medical Center is Managed [sic] by Metz Culinary Management the policies, procedures and standards Are [sic] referenced, practiced, and enforced. The Dining Services and Nutrition Department prepares attractive, nutritious, and Satisfying [sic] meals under high standards of sanitation and safety and cares for Patients [sic] of all ages by assessment and reassessment of nutritional status. Priority levels of care and goals with emphasis on interdepartmental communication are routine. ... ."

Review of Windber Medical Center Department Policies and Procedures Dining Services and Nutrition Services ... Policy Number: IC 02 Subject: Equipment Cleaning & Operation ... Revised: February 12, 2017, revealed, "Policy. The Dining Services & Nutrition Department and Management Team trains staff and makes aides available to them for proper cleaning and operation of the equipment necessary to perform their tasks. Procedures. 1. The Department will use the Equipment & Sanitation Manual provided by ECOLAB for all general cleaning and sanitation references. ... ."

Review of Windber Medical Center Department Policies and Procedures Dining Services and Nutrition Services ... Policy Number: LD Subject: Department Organization ... Revised: February 12, 2017, revealed, "Policy. WCM Administrators Client and Final Decisions ... District Manager & General Manager. Leadership in all daily operations to meet Client and Metz's expectations and contractual agreement ... Clinical Dietician. Inpatient, regulatory and therapeutic care. Outpatient needs as Scheduled assigned. ... WMC Dining Services Staff. All aspects of service and production for the food delivery within WMC, WRI, and other campus functions. Ultimately reports to GM & AGM, but also have the leadership and assistnace of the Lead cook, and Dietician as appropriate."

Review of Windber Medical Center ... Policy Number: EC-201 ... Department: Dining Services & Nutrition Services Subject: Equipment Management Program ... Revised February 12, 2017, revealed, "Policy The Dining Service & Nutrition department recognizes the importance of thorough training and safe operational practices in regard to the various equipment routinely used in the daily operations and production functions and keeps detailed and references to facilitate a well-functioning program. Procedures 1. The Dining Services Department follows all established industry procedures and manufacturer's instructions for equipment and references their used manuals when available. ... 4. In-house maintenance will be the first contact for all relevant equipment repair evaluations. ... 6. A log of all repairs is maintained by the management staff in the Equipment Management Manual. 7. Service reports are maintained in the Equipment Manual. ... ."

Review of Windber Medical Center ... Policy Number: EC-101 ... Department: Dining Services & Nutrition Services Subject: Safety Program ... Revised: February 12, 2017, revealed, "Policy The Dining & Nutrition department recognizes all policies & procedures regarding safety will utilize as a standard practice at Windber Medical center. In addition, all Emergency codes and procedures and safety programs as established by the facility will be recognized, reviewed with employees frequently and upheld. Procedure 1. The dining Services and Nutrition department follows the established safety practices of the Windber Medical Center."

1) Review of facility documentation entitled Metz Culinary Management Job Description Position: General Manager, revealed, "The General Manager has an overall responsibility of food service. He/she institutes company cycle menus and recipes; plans and overseas [sic] purchasing, employee personnel programs, scheduling , bookkeeping, customer and client relations; overseas the food preparation service and sanitation; and is accountable for the total operation results. ... ."

2) Review of facility documentation entitled Daily Master Cleaning List, dated March 5, 2017, through April 1, 2017, revealed, "1. Sweep Walk In Coolers 2. Sweep Freezer 3. De-lime Dish Machine 4. Clean Oven. Convection Oven Cleaning Schedule. Schedule will repeat after all 5 weeks are complete. Week 1 AM Cook Week 3-Pm Cook Week 5-Cafe Cook Mop Walk Ins and Freezer-Monthly. ... ."

3) Review of facility documentation entitled Metz ... Master Cleaning Checklist-Back of House, revealed, "Convection Oven-Bi-Weekly. Oven Cleaner, Rubber gloves, Hot water, Clean towels, Newspapers to protect floor, Green Scrubbing pad ... Rotating schedule; Am Cook 1st week, pm cook 2nd week, Cafe cook 3rd week. Schedule will repeat. ... Walk In Freezer ... Daily ... Broom Dustpan ... Walk In Cooler ... Daily ... Broom Dustpan Mop and Bucket ... Dishmachine ... Weekly -7:00 a.m. Monday ... ."

4) Review of the Daily Master Cleaning List revealed that the cleaning schedule was incomplete as per the requirement of the "Metz ... Master Cleaning Checklist." The documentation revealed initials on three of 28 daily occurrences for the Walk In Coolers, three of 28 daily occurrences for the Freezer, zero of four weekly [Monday] occurrences to De-lime Dish Machine, and one of four bi-weekly occurrences for the Convection oven.

5) A tour of the Food and Nutrition Department was conducted with EMP3, EMP4, and EMP5 on April 5, 2017, at approximately 2:00 PM. During the tour it was noted that the tile on the multiple floor areas was absent exposing the wooden floor structure. These areas included the floor beneath the pre-pot wash sink/soap/rinse/sanitizer, the floor beneath the employee handwashing sink, the floor beneath the food wash only sink, and the floor area beneath the production refrigerator. It was also noted that 11 of 11 sprinkler heads, several ceiling tiles, and a large pot rack holding many pots were dusty.

Interview with EMP3, EMP4 and EMP5 on April 5, 2017, at approximately 2:15 PM confirmed the above findings during the tour.

Based on a review of facility documents and interview with facility staff (EMP), it was determined that the facility failed to ensure that all surgeons working at Windber Medical Center will be educated annually on the policy of Preoperative Skin Preparation of Patients.

Findings Include:

Review of policy Preoperative Skin Preparation of Patients, reviewed December 2016, revealed, "... 2) Clear manufacturer warnings and instructions are available to staff and surgeons with each application. Staff is in-serviced at fire safety on alcohol based products usage annually. Surgeons are educated annually. ... ."

Review of facility documentation entitled Skin prep annual education, no date, revealed, "... Copy of policy and this education will be sent to all surgeons working at WMC and will be completed annually.

1. Review of facility documentation entitled, "Educational Inservice Staff Meeting Reports Program Fire Safety[sic] & Skin Prep Date December 20, 2016, revealed no documented evidence that surgeons participated or received the education.

2. Interview on April 6, 2017, with EMP1, confirmed the findings and revealed, "No education for alcohol based skin prep for the physicians can be produced. The Nursing Staff completed it, but not the doctors."