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Based on observation, staff interview, and policy and procedure review, the facility failed to:

1) Ensure there was adequate space for provision of services in the respiratory department, that biohazard medical waste was stored according to State licensure law and that the patient care environment was clean and orderly during two (2) of two (2) days of survey.

2) Properly protect corridors in accordance to NFPA 101 sections 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5.

3) Properly provide and maintain the smoke barrier walls in accordance to NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.


Findings Include:

Observation of the respiratory department on 06/07/16 from 3:10 p.m. to 3:35 p.m. revealed the pulmonary function test equipment was located in the respiratory department office and the stress test equipment was located in the respiratory clean supply storage Room #213. During an interview on 06/07/16 at 3:25 p.m. Respiratory Technician (RT) #1 confirmed both observations and stated, "There is no other place for the equipment to be used."

Observation of the biohazard storage area, made with the Housekeeping Director on 06/07/16 at 3:40 p.m. revealed an 18 inch to two (2) foot opening between the top of the cyclone fence and the bottom of the roof on the entrance side of the biohazard storage area.

Observation of the medical/nursing environment on 06/08/16 from 8:45 a.m. to 10:10 a.m. revealed:

The family visitation room had brown colored stained ceiling tiles at the door entrance, wallpaper ceiling border was peeling off the wall, broken floor tiles, door entrance threshold was loose, restroom toilette was leaking, restroom floor had broken floor tile, vending area had broken and grey stained ceiling tiles and the south entrance door had broken sheetrock at the bottom right corner wall.

The clean linen storage room had five (5) holes in the wall ranging from ¼ inch to one (1) inch.

The medical/nursing floor shower room had red and brown colored stained grout lines.

The medical/nursing floor bathing room had grey stained grout lines in the floor tile and broken silicone around the shower.

Room #215 had marred walls and grey stained grout lines in the bathroom floor tile.

Room #216 had grey stained grout lines in the bathroom floor tile.

Room #217 had grey stained grout lines in the bathroom floor tile.

Room #225 had grey stained grout lines in the bathroom floor tile and the lavatory light was not working.

Room #226 had grey stained grout lines in the bathroom floor tile and paint peeling off the entrance door facing and frame.

Room #230 had grey stained grout lines in the bathroom floor tile and paint peeling off the entrance door facing and frame.

Room #234 had grey stained grout lines in the bathroom floor tile.

Room #238 had a broken threshold at the entrance door.

Room #245 had pink colored stains on the bottom of the shower wall extending up the wall one (1) foot.

During an interview on 06/07/16 at 10:10 a.m., the Director of Nursing (DON) confirmed all observations made on medical/nursing floor environmental tour. When asked who is responsible for environmental cleaning and repair, she stated, "I will make housekeeping aware."

During an interview on 06/08/16 at 11:30 a.m. the Housekeeping Director confirmed he had been made aware of all the environmental concerns identified on tour and stated, "We are working on them."

Review of the facility's "Medical Waste Management Plan" policy (reviewed) 05/18/16, revealed: "...B. Medical Waste: ...a ...stores all medical and infectious wastes safely and securely, out of public view, away from animals ...".

Review of the facility's "Housekeeping Department Introduction" policy (reviewed 05/18/16) revealed: "The purpose of the Housekeeping Department ...is to keep the hospital in a clean, healthy, and sanitary condition in order to provide an environment important to welfare and care of patients ...".

Review of the facility's "Housekeeping Services Plan" policy (reviewed 05/18/16) revealed: "Policy: ...to ensure that the hospital environment is properly maintained ...Procedure: Housekeeping Services personnel are assigned a specific area ...Ancillary Departments and Offices: ...a ...All tile floors are to be mopped daily or more often if needed. Floors are to be stripped, waxed and/or buffed at intervals if necessary. b. The bathrooms in the specific areas are to be cleaned daily or more often if needed ...Patient Rooms: Patient rooms are cleaned according to specific guidelines as outlined in policy ...Daily Cleaning Of Patient Room: ...7. Dust-mop floors with treated dust mop ...8. Damp-mop patient room floor ...Daily Routine Assigned Areas: ...Area II: Monday-Friday ...Visitor restrooms, patient restrooms ...Area III: Monday-Friday: ...Family Room. Clean patient rooms. Area IV: Monday-Friday ...shower and tub room ...Area V: Floor care is maintained by one janitor during the week ...Stripping and waxing of the patient's rooms can be done during the day time."

Review of the facility's "Guidelines for Infection Control Engineering and Maintenance" policy (reviewed 05/18/16) revealed: "Policy: The engineering and maintenance department provides a hygienically clean environment by systematic inspection and preventive maintenance ...of the entire physical structure ...Patient Environment: ...B. Maintenance of Buildings ...1. All surfaces, such as floors, walls and ceilings require constant inspection and immediate repair when necessary in order to maintain smooth, dry and cleanable surfaces. 2. Any opening or breaks in the walls, foundations ...etc. require immediate repair in order to preserve a clean environment .... ".

During exit conference on 06/08/16 at 3:45 p.m. these findings were discussed. No further documentation was submitted for review.


20543



On 6/7/16 at 11:00 a.m. observations made by the Life Safety Code Surveyor and the Maintenance Supervisor revealed the facility was unable to provide the locations of the smoke barrier walls of the facility. An attempt was made to locate the smoke barrier walls, but the walls observed were unsealed and not continuing through the entire facility.


On 6/7/16 between 11:20 a.m. and 2:00 a.m. observation made by the Life Safety Code Surveyor and the Maintenance Supervisor revealed the corridor walls had numerous unsealed penetrations above the suspended ceiling in the Central and West Wings of the facility. It was also observed the one hour rated solid ceiling above the corridor walls of the Central and West Wings were damaged, contain open penetrations, and partial removed. An unrated window assembly was also installed in the corridor wall near the Wound Care Area of the facility. This facility was not protected by automatic fire sprinkler system.


These findings were acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16 at 3:00 p.m..

Based on observation, staff interview, and policy and procedure review, the facility failed to:

1) Ensure there was adequate space for provision of services in the respiratory department during two (2) of two (2) days of survey.

2) Properly protect corridors in accordance to NFPA 101 sections 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5.

3) Properly provide and maintain the smoke barrier walls in accordance to NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.

Findings Include:

Cross Refer to C0220 for the facility's failure to ensure there is adequate space for provision of services in the respiratory department.


20543


On 6/7/16 at 11:00 a.m. observations made by the Life Safety Code Surveyor and the Maintenance Supervisor revealed the facility was unable to provide the locations of the smoke barrier walls of the facility. An attempt was made to locate the smoke barrier walls but the walls observed were unsealed and not continuing through the entire facility.


On 6/7/16 between 11:20 a.m. and 2:00 p.m. observations made by the Life Safety Code Surveyor and the Maintenance Supervisor revealed the corridor walls had numerous unsealed penetrations above the suspended ceiling in the Central and West Wings of the facility. It was also observed the one hour rated solid ceiling above the corridor walls of the Central and West Wings were damaged, contain open penetrations, and partial removed. An unrated window assembly was also installed in the corridor wall near the Wound Care Area of the facility. This facility was not protected by automatic fire sprinkler system.


These findings were acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16 at 3:00 p.m..

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure biohazard medical waste was stored according to State licensure law during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to C0220 for the facility's failure to store biohazard medical waste according to State licensure law.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the patient care environment was clean and orderly during two (2) of two (2) days of survey.

Findings Include:

Cross Refer to C0220 for the facility's failure to ensure the environment was clean and orderly.

Based on observations and staff interviews, the hospital failed to properly protect corridors in accordance to NFPA 101 sections 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5. and to properly provide and maintain the smoke barrier walls in accordance to NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5. This had the potential to affect patients, visitors and staff in the facility.


Findings Include:

On 6/7/16 at 11:00 a.m. observations made with the Maintenance Supervisor revealed the facility was unable to provide the locations of the smoke barrier walls of the facility. An attempt was made to locate the smoke barrier walls, but the walls observed were unsealed and not continuing through the entire facility. The Maintenance Supervisor confirmed this during the observations.


On 6/7/16 between 11:20 a.m. and 2:00 p.m. observation revealed the corridor walls had numerous unsealed penetrations above the suspended ceiling in the Central and West Wings of the facility. It was also observed the one hour rated solid ceiling above the corridor walls of the Central and West Wings were damaged, contain open penetrations, and partial removed. An unrated window assembly was also installed in the corridor wall near the Wound Care Area of the facility. This facility was not protected by automatic fire sprinkler system.


These findings were acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16 at 3:00 p.m.

Based on observation and staff interview, the facility failed to ensure respiratory staff followed manufacturer guidelines when using oxygen connectors on one (1) of two (2) days of survey.

Findings Include:

Observation of the respiratory department office/pulmonary function test room on 06/07/16 at 3:10 p.m. revealed one (1) oxygen connector was attached to the oxygen hookup source and another oxygen connector was lying on the cabinet beside the oxygen hookup source. During an interview on 06/07/16 at 3:15 p.m., Respiratory Technician (RT) #1 confirmed all equipment supplies are one-time use/disposable. When asked RT#1 about the oxygen connectors, she stated, "I do not always change the adaptor in the pulmonary function room." She confirmed she cleaned the oxygen adaptors between patients with an approved disinfectant wipe.

During an interview on 06/07/16 at 3:30 p.m. RT#1 and the Purchasing Manager confirmed the XMAS Tree Adaptor (oxygen connector) was disposable/single use. When asked why the oxygen connectors were being reused RT#1 stated, "I was not aware they (oxygen connectors) were disposable."

During an interview on 06/08/16 at 10:15 a.m., the Respiratory Director confirmed all respiratory equipment supplies should be used according to manufacturer instruction.

Review of the manufacture guidelines for the "Christmas Tree Adaptor Nut & Nipple ..." revealed: "...Disposable, Single-use ...Oxygen Connector ...".

These findings were discussed during exit conference on 06/08/16 at 3:45 p.m. No further documentation was submitted for review.

Based on review of the facility's "Deficiency Report by Physician" report, and Medical Records Policy and Procedures, and staff interview, the facility failed to maintain complete, accurately documented clinical records.

Findings Include:

Review of the facility's "Deficiency Report by Physician", received from the Registered Health Information Administrator (RHIA) on 06/08/16 at 10:30 a.m., revealed a total of 67 delinquent, closed clinical records, greater than 30 days past discharge. The deficiencies included incomplete or missing Physician signatures, interpretation of x-rays, and lab results, history and physicals, discharge instructions, assessments and final diagnosis, and involved eight different physicians.

Review of the facility's "Incomplete and Delinquent Chart Procedure" policy revealed: "Medical Staff Bylaws of (Hospital) ...all discharge summaries must be completed within fifteen (15) days of discharge and the remainder of the chart completed within thirty (30) days or they will be considered delinquent."

During an interview on 06/08/16, the RHIA confirmed there were 67 delinquent, closed clinical records, greater than 30 days past discharge and that this has been an ongoing problem she has addressed in medical staff meetings over the last several months.

Review of the facility's "Medical Staff/Medical Staff CQI Committee Meetings" minutes from February 10, 2016 revealed: " ...III. f. Enforcement of Bylaws for Incomplete Records: Discussion was held regarding continued issues with incomplete records, including dictation of history and physicals and discharge summaries. (RHIA) noted that currently our Medical Staff Bylaws/Rules and Regulations state that delinquencies will result in immediate suspension of privileges, but this is not being enforced ...".

Review of the facility's "Medical Staff/Medical Staff CQI Committee Meetings" minutes from March 9, 2016 revealed: " ...V. Old Business:...f. Incomplete records/enforcement of Bylaws: The continued issue with incomplete/delinquent records was discussed ...".

Review of the facility's "Medical Staff/Medical Staff CQI Committee Meetings" minutes from April 20, 2016 revealed: " ...III. Priority Business ...b. Clinical Documentation Improvement (CDI) Project: (RHIA) discussed the recently organized CDI committee and summarized the committee ' s goals, including streamlining the process for identifying, reporting and completing chart deficiencies, enforcing bylaws for non-compliance with chart completion, implementing electronic queries and concurrent coding...IV. New Business: a. Establishment of effective/enforceable delinquent records process: (RHIA) again expressed the need to either follow our current bylaws related to suspending privileges for delinquent charts, or to establish new rules and regulations to address this issue. There were no directives provided by the Staff regarding this process ...".

During exit conference on 06/08/16 at 3:45 p.m. these findings was discussed. No further documentation was submitted for review.

Based on observation, patient interview, staff interview, and policy and procedure review, facility failed to have an ongoing program of activities based on patient assessments of interest and needs, and psychosocial well-being of each patient for four (4) of four (4) patients. Affected patients were #7, #8, #9 and #10.

Findings Include:

Medical record review revealed there was: no activity assessment; no activity care plan; no activity progress note; and no documentation of provision of activities for Patients #7, #8, #9, and #10.

An interview with Patient #7 on 06/08/16 at 11:15 a.m. revealed that no activities have been provided for her during her hospitalization. She has been a swing bed patient since 5/30/2016.

An interview with Patient #8 on 06/08/16 at 11:30 a.m. revealed that no activities have been provided for him during his hospitalization. He has been a swing bed patient since 5/31/2016

Observation of the activity area on 06/07/16 at 11:30 a.m. revealed no activity was documented on the activity calendar.

An interview with the Social Worker/Activity Director on 06/07/16 at 1:50 p.m. confirmed no activities were documented on the activity calendar.

During an interview with the Director of Nurses (DON) on 06/08/16 at 10:20 a.m. the findings of no activity calendar, no activity assessment, no activity care plan, and no provision of activities documented were discussed. At that time the DON indicated agreement with all findings.

Review of the facility's "Swing Bed Program Activities" policy revealed:
"Policy: It is the policy of the (Hospital) Swing Bed Program that the Activity Director or assistant coordinator is responsible for the following activities documentation.
A. Narrative Assessment Plan: A comprehensive narrative activities assessment plan is prepared within 48 hours of admission. The activity assessment plan is prepared with the patient/sponsor input and is reviewed at least every seven days.
B. Activity Progress Notes are prepared weekly and reflect frequency of participation, a description of the patient and the participations in the activities program, therapeutic results being achieved along with patient's interaction. Also any new problems/needs with appropriate goals/approaches...
F. Review of Activity Care Plan: The Activity plan of care shall be reviewed with the patient, (and sponsor of the patient when patient medically incapable of understanding) at least every seven (7) days."