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Based on review of 5 open and 5 closed medical records, it was determined that the hospital failed to provide 4 of 5 Medicare recipients with the pre-discharge standardized notice, "An Important Message from Medicare" (IMM), within the appropriate time frame of two days prior to discharge.

Review of closed medical records showed that no discharge IMM were provided to patients #6, #7, and #8. During a staff interview on the High Intensity Care Unit on 08/27/19, hospital staff stated that these patients did not require IMMs since they were not discharged to home, but transferred to a subacute facility. As a result, patients #6, #7, and #8 were downgraded in care and transferred to different acuity setting without patients and/or their representatives receiving a discharge IMM within two days of discharge/ transfer of care setting.

Review of the closed medical record for patient # 9 showed that, despite patient #9's representative being present on the day of discharge, the IMM was not signed. The discharge IMM noted "spoke to and mailed [to patient # 9's representative] the day prior to discharge." The hospital provided a letter actually dated 21 days post discharge that was mailed to patient #9 's representative with the discharge IMM.

Review of the open medical record for patient #1 showed that the patient was prepared for discharge on the day of survey to inpatient hospice; however, no evidence that the hospital provided patient #1 with a discharge IMM was found in the chart.

In failing to provide the discharge IMM notices to patients #1, #6, #7, and #8, and to timely provide the discharge IMM notice to patient #9's representative, the hospital failed to inform these Medicare recipients of their hospital discharge appeal rights.

Based on observations of care, staff interviews, and review of policies and other hospital documentation, it was determined that the hospital failed to implement actions aimed at performance improvement after identification of persistent issues with hand hygiene compliance.

During a tour of the Behavioral Health Unit, an employee was observed exiting a patient's room and entering another patient's room without performing appropriate hand hygiene.

During an interview with the Directors of Quality Assurance/Performance Improvement and Infection Control, it was determined that hand hygiene compliance had been identified multiple times as an area of improvement within the last 6 months. The Infection Control Director stated that the goal was to have secret observers monitor other staff members for compliance with hand hygiene. When surveyors asked how the observations were being monitored, the directors explained that most of the time the secret observers were not documenting or tracking the staff that were non-compliant due to concern over creating a negative working environment. The directors attempted to resolve this situation by subjecting the observers to punitive consequences when they failed to monitor and/or report their observations by 'writing them up'. No other actions or monitoring for compliance were identified. Neither director could name staff specific interventions to improve hand hygiene compliance.

A review of Quality Assurance and Performance Improvement meeting minutes over the previous 6 months was conducted. Hand hygiene was documented during each month as an area of improvement and that improvement goals were not being met. No data was entered in the 'actions' or 'follow-up' columns during any of the 6 months. It was determined that Quality Assurance leadership failed to incorporate new interventions despite continued evidence of non-compliance with hand hygiene by clinical staff. A re-evaluation by the Performance Improvement and Infection Control departments were not implemented at any time over the last 6 months to address this ongoing issue.

Based on review of 6 nursing personnel files and policy titled "Performance appraisal-LBH", effective date 07/01/2017, it was determined that the hospital's nursing leadership failed to provide Introductory (90 day) or Annual Performance Appraisals for 5 of 6 nursing staff. In the absence of nursing performance appraisals, it is unclear how the hospital was able to accurately evaluate nursing knowledge, ability, skills, and overall performance in the care of patients in this specialized clinical setting.

The hospital presented for review a policy for "Performance appraisal - LBH," effective date 07/01/2017, which detailed that Performance Appraisals were to take place at 90-days of an Introductory period of employment and on an annual basis thereafter. Review of nursing personnel files showed that the hospital failed to follow their policy, as evidenced by 2 nursing personnel files lacking the Introductory Performance Appraisal and 3 nursing personnel files missing Annual Performance Appraisals for multiple years.

Review of nursing personnel files showed that 3 of the 6 nurses were newly hired. Two of these newly hired nurses, nurse #4 and #5, were hired in 2018, and both of these personnel files lacked an Introductory / 90-day evaluation which would have contained the initial assessment of skills and performance. Based on the above-mentioned policy, the Introductory Appraisal would be used to make a decision as to nurse's ability to progress or extend the orientation phase. It is impossible to determine which criteria were used to make the decision to advance these nurses beyond the introductory period of employment, since no Introductory evaluation was completed at 90 days.

Personnel file for nurse #2 showed that the most recent Annual Appraisal was from the 2017, but it was not completed and signed until April of 2019. There were no evaluations for 2018 or 2019.

Personnel file for nurse #6 showed that the most recent Annual Appraisal was signed and completed in 2017. There was no Annual Appraisal for 2018 or 2019.

Nurse #3's personnel file showed that the most recent Annual Appraisal was from July 2018, completed and signed April 2019. There was no Annual Appraisal for 2019.

Based on observations on the High Intensity Care Unit (HICU) and the Behavioral Health Unit, it was determined that the hospital staff failed to adhere to proper hand hygiene and cleanliness standards established by the hospital and infection control standards.

During review of the High Intensity Care Unit, several infection control issues were observed as follow. A personal cell phone was placed on top of a box of gloves on a patient care cart. Gloves used for patient care were seen laying on the floor in two of the rooms. Trash items were on the floor in at least 4 of 20 occupied rooms, and a temperature probe was also on the floor in one of those rooms. Multiple used alcohol wipes were found on the floor of a patient's room.

While on the Behavioral Health Unit, a staff member was seen exiting a patient's room and entering another patient's room, and no hand hygiene was observed.

Please see tag A-283.