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Based on observations, review of the facility's building schematics, the facility's documentation, and staff interviews during the life safety code inspection, it was determined the facility failed to ensure the three of three buildings surveyed were maintained in a manner to ensure patients are safe from fire in regard to the following: the protection of vertical openings in the smoke barrier, the identification of an exit egress, ensuring the smoke barriers and the smoke barrier doors are maintained free of penetrations and close securely, without gaps, ensuring hazardous areas have intact smoke barriers to maintain the fire resistant rating, testing of emergency battery operated lights, smoke detectors mounted incorrectly, ensuring a complete suppression system in all required areas, ensuring quarterly tests on the suppression system, proper mounting of portable fire extinguishers, ensuring medical gas cylinders were secured and all electrical components within a medical gas room was mounted correctly and maintaining acceptable humidity levels in operating rooms.
Please see C231 for details.
The cumulative effects of these systemic practices resulted in the facility's inability to ensure the patients were safe from potential injury from fire.

Based on observations, review of the facility's building schematics, and the facility's documentation, and staff interview it was determined this facility failed to maintain three of three buildings in a manner that ensured the patients were safe from fire, This has the potential to affect all patients, staff and visitors utilizing these buildings. The patient census at the beginning of the survey was nine.

Findings include:

The facility failed to ensure all fire barrier doors, in Building 1, which protect the building's vertical openings latched securely. Please see K-20.

This facility failed to ensure all exit accesses in Buildings 1 and 3 were marked with exit signs that were readily visible. Please see K-22.

This facility failed to ensure all smoke barriers in Buildings 1 and 3 were maintained to provide at least a one half hour fire resistance rating thereby ensuring all smoke compartments remained intact. Please see K-25.

This facility failed to ensure all doors in smoke barriers in Buildings 1 and 3 would resist the passage of smoke when in the closed position. Please see K-27.

This facility failed to ensure all hazardous areas in Buildings 1 and 3 were protected with at least a one hour fire resistance rating and rooms, utilized to store quantities of combustible materials, were constructed with at least a one hour fire resistance rating. Please see K-29.

This facility failed to ensure all smoke detectors in Buildings 1 and 3 were mounted in areas where air flow devices would not compromise the normal operation of the smoke detectors. Please see K-54.

This facility failed to ensure the sprinkler system in Building 1 was installed to provide complete coverage to all areas. Please see K-56.

This facility failed to ensure all portable fire extinguishers in Building 1 were mounted so that the top of the fire extinguisher was not greater than five feet from the floor. Please see K-64.

This facility failed to ensure the medical gas room in Building 3 was constructed with all electrical switches and electrical control boxes mounted greater than five feet from the floor; all cylinders were secured and all components of the medical gas system was properly maintained. Please see K-76.

This facility failed to ensure the humidity levels, in all anesthetizing locations in Building 1, were maintained with relative humidity levels at or greater than twenty percent. Please see K-78.

The facility failed to ensure all battery operated emergency lights, in Building 2, were tested monthly for 30 seconds and annually for 90 minutes. The facility failed to ensure the sprinkler system was tested for three of the four quarters in 2013. Please see K-130.

Based on observation, staff interview, and policy review, the facility failed to ensure staff followed the policy for infection control hand hygiene for one (Patient # 6) of five patients observed during the medication pass/treatments. The facility census was 9.

Findings include:

Review of the medical record, completed on 01/22/14 at 12:30 PM., for Patient #6, revealed an admission date of 01/15/14, and diagnoses of acute bronchitis and cellulitis.

On 01/22/14 at 11:45 AM., Staff H was observed obtaining a blood sample with a lancet from Patient #6 for a fingerstick blood test. Staff H, wore gloves to obtain the blood sample. Then, without removing the contaminated gloves, Staff H proceeded to type on the computer keyboard to document the test results, and contaminated the computer keyboard.

On 01/22/14 at 11:50 AM., Staff H wore gloves to administer insulin (a medication to treat high blood sugar) by subcutaneous injection to Patient #6. Then without removing the contaminated gloves, Staff H proceeded to type on the computer keyboard to document the medication administration, and contaminated the keyboard.

During an interview, on 01/22/14 at 11:55 AM., Staff H confirmed the above findings.

During an interview, on 01/22/14 at 12:00 PM., Staff D revealed the facility's expectation for appropriate hand hygiene and infection control requires the gloves to be removed after patient contact, as the gloves are potentially contaminated with blood or body fluids, and are expected perform hand washing or use hand sanitizer prior to typing on the computer keyboard.

Review of the facility's policy "Infection Control Hand Hygiene" policy number IC.04.06, effective 12/27/11, and reviewed 06/25/13, revealed hands are to be cleaned with soap and water and or hand sanitizer after patient contact and after the removal of gloves.

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Based on medical record review, staff interview and policy review it was determined the facility failed to ensure the general consent for treatment was thoroughly completed for 10 (Patients #6, #8, #15, #13, #16, #17, #18, #19, #25, and #26) of 26 patients whose medical records were reviewed. The facility census was 9.

Finding include:

1. Medical record review, completed on 01/21/14, for Patient #6, revealed an admission date of 01/15/14, and diagnoses of acute chronic bronchitis, cellulitis and possible congestive heart failure.

Review of the general consent for treatment form revealed there was no witness signature and was not dated when the consent was signed.

An interview with Staff D, on 01/21/14 at 4:00 PM., confirmed the above finding.

2. Medical record review, completed on 01/21/14, for Patient #8, revealed an admission date of 01/20/14, and diagnoses of cellulitis, and bronchitis.

Review of the general consent for treatment revealed there was no witness signature and was not dated when the consent was signed.

An interview, with Staff D, on 01/21/14 at 4:00 PM., confirmed the above finding.

3. Medical record review, completed on 01/22/14, for Patient #15, revealed an admission date of 11/16/13, and a diagnosis of pneumoplerisy.

Review of the general consent for treatment revealed there was no witness signature and was not dated when the consent was signed.

An interview with Staff D on 01/22/14 at 3:00 PM., confirmed the above finding.

4. Medical record review, for Patient #13, was completed on 01/22/14, and revealed an admission date of 01/21/14, and diagnoses of chest pain, back pain and pylenonephritis. The medical record revealed an informed general consent for treatment form, which did not have a date as to when it was signed, there was no witness signature the consent, relation to the patient if someone else signed the consent, and the patient's signature.


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5. Medical record review was completed on 01/22/14, at 4:00 PM., for Patient #16, and revealed an admission date of 12/01/13, with a diagnosis of a transient ischemic attack.
Review of the general consent for treatment form revealed it did not contain a witness signature and was not dated when the consent was signed.
An interview with Staff A on 01/22/14 at 4:30 PM, confirmed the above finding.
6. Medical record review was completed on 01/23/14, at 1:15 PM., for Patient #17, revealed an admission date of 04/07/13, and a diagnosis of acute bronchitis with COPD exacerbation.
Review of the general consent for treatment form revealed there was no witness signature, and was not dated when the consent was signed.
An interview, with Staff A on 01/23/14 at 1:30 PM., confirmed the above finding.
7. Medical record review was completed, on 01/23/14 at 1:30 PM., for Patient #18, and revealed an admission date of 05/07/13,s and a diagnosis of acute bronchitis with COPD exacerbation.
Review of the general consent for treatment failed to contain a witness signature and date the consent was signed.
An interview with Staff A on 01/23/14 at 1:35 PM., confirmed the above finding.
8. Medical record review was completed, on 01/23/14 at 1:20 PM., for Patient #19, revealed an admission date of 07/13/13, and a diagnosis of pneumonia.
Review of the general consent for treatment form revealed there was no witness signature and there was no date consent was signed.
An interview, with Staff A, on 01/23/14 at 1:38 PM., confirmed the above finding.
9. Medical record review was completed, on 01/22/14 at 3:15 PM., for Patient #25, revealed an admission date of 1/10/14, and a diagnosis of decreased responsiveness and seizure.
Review of the general consent for treatment form revealed there was no witness signature and there was no date when the consent was signed.
An interview, with Staff A on 01/22/14 at 3:20 PM., confirmed the above finding. Staff A reported that registration goes to the patient's bedside in the emergency department to complete the registration process.
10. Medical record review was completed on 01/22/14 at 3:15 PM., for Patient #26, revealed an admission date of 08/29/13, and a diagnosis of an an elevated PT/INR.
Review of the general consent for treatment form revealed there was no witness signature and there was no date when the consent was signed.
An interview, with Staff A, on 01/22/14 at 3:20 PM., confirmed the above finding. Staff A reported that registration goes to the patient's bedside in the emergency department to complete the registration process. A completed general consent form includes the patient's signature, date, and a witness signature.

An interview, with Staff I on 01/22/14 at 4:00 PM., revealed the medical record department was aware the general consent forms were not always completed with the witness' signatures and dates when the consent form was signed but the medical record department did not track them because the patient would be discharged by the time the record was received by the department and there would be no way to correct the error.

An interview on 01/23/14 at 9:00 AM., with Staff E revealed all patients should sign a general consent for treatment form on admission to be witnessed by the registration staff and dated at that time.

An interview with Staff A on 01/22/14 at 4:05 PM., confirmed there was not an informed consent signed in Patient #26's medical record.

Interview, with Staff A on 01/23/14 at 10:30 AM., confirmed a staff person reviews at least 10 medical records per month and goes by a checklist.

A telephone interview, with Staff G on 01/23/14 at 11:15 AM., revealed he/she was not aware the general consents were not being completed on admission and the facility's expectation was the general consent forms need to be completed.

Review of the facility's policy and procedure for "Medical Record Content", policy number RC.10.03, effective 09/18/12, and reviewed 09/18/12, revealed the medical record must contain a general consent for medical treatment and care form signed by the patient or legal guardian. The policy did not contain a procedure for witnessing and the dating of the general consent form.

Based on medical record review, staff interview, observation, and review of the policy and procedure for medical record content, the facility failed to ensure the consent for treatment form used by the offsite rehabilitation and wellness center was accurate, dated, and included a witness' signature. This affected two (Patients #23, and #24) of two patients whose medical records were reviewed at the hospital's rehabilitation and wellness center.

Findings include:

1. Medical record review, completed on 01/22/14 at 11:15 AM., for Patient #23, revealed the patient was provided with physical therapy services for joint pain in the shoulder at the hospital's off site rehabilitation and wellness center location. The initial physical therapy assessment was completed on 11/06/13. The physical therapy orders included a frequency of two to three times per week, with the duration to be nine visits. Review of the general consent for treatment form revealed the form did not have a witness signature, and there was no date to identify when the consent was signed.
2. Medical record review, completed on 01/22/14 at 11:25 AM., for Patient #24, revealed the patient was provided physical therapy services for cervical spondylosis with myelopathy, at the hospital's offsite rehabilitation and wellness center location. The initial physical therapy assessment was completed on 12/27/13 . The physical therapy orders included a frequency of two to three times per week. Review of the general consent for treatment form revealed there was no witness signature and there was no date to identify when the consent was signed.
During an interview, on 11/22/14 at 2:20 PM., Staff A stated the offsite rehabilitation and wellness center is using an old form that does not reflect an accurate complete consent for treatment.
Review of the hospital's policy and procedure for "Medical Record Content", policy number RC.10.03, effective 09/18/12, reviewed 09/18/12, revealed the medical record must contain a general consent for medical treatment and care form, signed by the patient or legal guardian. The policy did not contain a procedure instructing the staff to obtain a witness's signature, and to date the consent form when it was signed.