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Based on record review and interview, the facility failed to provide the results of the grievance, and the date of the completion for 3 (P#5, 6, and 7) of 7 (P#1-7) patients grievances. This failed practice puts patients at risk of not receiving proper care and unmet patient needs.
The findings are:

A) Record review of the facility's grievance log revealed P#7 filed a grievance for an Outpatient Physical Therapy appointment regarding rude and unhelpful staff in obtaining approval by the patient's insurance provider. The letter sent by the facility to the patient indicated that the patient became upset and was yelling at staff. There was no resolution to the grievance; only that "action may include anything from sensitivity training for employees or coaching. Your concerns have been investigated and that the correction action has been taken, according to policy."

B) On 05/07/19 at 8:35 am during interview, the Director for Patient Relations stated, "This letter that went to the patient is a little bit harsh. It does sound like we are blaming the patient. The person who wrote this letter is new, I will have to talk to her."

C) Record review of the facility's grievance log revealed P #5 filed a grievance for care received in the Urgent Care department. The grievance response letter stated, "the doctor became to (sic) busy to help you with your medical needs and did nothing for you." The response letter from the facility only reiterated the Urgent Care visit and did not indicate a date and/or resolution of the grievance and states, "Your concern has been shared with hospital management for consideration in their quality improvement efforts. Your dissatisfaction with the treatment by the provider as well as the compliments to the staff will be shared with the staff involved in your care."

D) Record review of the facility's grievance log revealed P#6 filed a grievance for service received in the facility's Emergency Department (ED). The letter to the patient reiterates the patient's grievance and does not indicate any date and/or resolution of the grievance. The letter states, "It is an expectation that our staff respond to our patient's requests promptly, courteously and professionally and most importantly, in a timely manner, and our patients should indeed expect nothing less. We truly regret this was not your experience. This is being reviewed through our internal process and the appropriate action will be taken."

Based on observation and interview, the hospital failed to provide a safe setting for its patients in the Rehabilitation area, ensuring staff and visitors follow standard precautions for infection control. This failed practice places patients at risk for injury and has the potential to delay emergency care in the area due to close proximity of equipment and places patients and visitors at risk to exposure of infectious diseases. The findings are:

A. On 05/08/19 at 10:00 am, observation of the Rehabilitation Area revealed Elliptical Machines and Treadmills in close proximity. Observation further revealed it was difficult for a person to walk between stationary machines and did not provide enough space between machines for wheelchair or hospital beds (gurneys) to maneuver through in an event of an emergency. Observation also revealed two stationary bicycles which did not have electrical cords secured to the floor. The cords were covered with a gray rubber liner which was not affixed to the floor and was a potential slip / trip hazard.

B. On 05/08/19 at 10:15 am, during interview, S#2 (Emergency Director) confirmed that the equipment was too close, and the electrical cords to the stationary bicycles were not secured to the floor.


C. On 05/6/19 at 2:00 pm, observation of the progressive care unit revealed a patient's family member entering room #206 that was a contact precaution room. The family member did not put on a gown or gloves on before entering the room. Observation further revealed staff members. what was observed about staff members?

D. On 05/8/19 at 3:30 pm, observation of the progression care unit revealed a patient care technician came out of room # 213 that had a sign indicating the patient had C- Diff (Clostridium Difficile Colitis - bacterium which infects the colon) with gloves on and a glucometer in her right hand. She walked over to the sink just outside of the room and cleaned the glucometer with a Germicidal wipe and not a bleach wipe.

E. Record review of hospital policy PC.PDS.199 Transmission - Based Isolation Precautions dated 07/01/18 reveals " #5 Contact Precautions-D 5.3 Upon discharge, reusable items removed from the room will be disinfected with bleach wipes (1:10 dilution). "

Based on record review and interview the facility failed to supervise and evaluate the nursing care for 2 (P#s14 and 15) of 3 patients (P#s14, 15 and 16). This deficient practice has the potential to result in a failure to evaluate the care received by dialysis (removal of waste products from the blood) patients assigned to nursing staff. The findings are:


A. On 05/06/19 at 2:00 pm during interview S#28 (RN) Registered Nurse confirmed P#15 was scheduled for dialysis between 3:00 and 4:00 pm. S#28 was informed by the dialysis provider that the dialysis contract nurse would arrive within the next hour.

B. On 05/07/19 at 10:15 am during interview S#28 (RN) confirmed the dialysis contractor arrived after the scheduled time on 05/06/19 and the dialysis treatment for P# 15 started 30 minutes later. In addition, S#28 confirmed the dialysis contractor did not have available the correct prescription dialysis solution (4.25% glucose) for P #14's treatment on 05/05/19 and the patient was not dialyzed per physician order. S#28 stated she did not know what the dialysis contract requirement for treatment start time was to be able to supervise the care provided. She also confirmed that a dialysis treatment start time and correct dialysis solution is important for patient safety especially if patients require emergent treatment.

C. Record review of P#14's physician order dated 05/05/19 revealed dialysis prescription order was for a 4.25% glucose solution (formulation used to remove fluid and excess electrolytes, such as potassium) during dialysis treatment), but a 2.5% solution was used.

D. Record review of dialysis treatment record provided by S#28 for P#14 dated 05/06/19 did not include prescription information or length of treatment provided.

E. On 05/07/19 at 10:00 am during interview, S#28 was asked for the dialysis records for P#s 14 and 15 and was unable to find the complete dialysis records in the facility electronic record. S#23, who was also present during the interview, confirmed the complete dialysis treatment record should be available for all staff to evaluate the treatment provided by the contract dialysis company. S#23 confirmed that this is an educational opportunity and all RNs (Registered Nurses) need to be able to view and evaluate what dialysis prescription was used, what time treatment started, and the length of treatment provided.

Based on record review and interview, the hospital failed to ensure medical records for 13 of 15 (P#22 through P#34) patients sampled were accurately written and promptly completed to include discharge summaries. This failed practice prevents the hospital from keeping patient records complete and accurate which may include interventions, treatments, discharge summaries and follow up care. The findings are:

A. On 05/08/19 at 3:00 pm, during interview, S#43 (Director of Quality) confirmed P#22 through P#34 did not have a dispostion on their medical record when they presented at the Emergency Department. S#43 further confirmed that Registration Clerks canceled visits in the electronic medical record as these patients left without being seen.

B. On 05/08/19 at 3:15 pm, during interview, S#43 stated that there was a need for educating registration personnel regarding documentation of patient information when patients leave without being seen or are seen by an outpatient service in the hospital.

C. Record review of Emergency Department Log (undated) reveals 30 patients in April (dates unknown) without disposition of care. P#22 through P#34 were selected as a sample to ascertain as to final disposition.

D. Record review of hospital policy PC.PDS.154 Patients Leaving Against Medical Advise dated 03/01/17 reveals "#3 Elopement: 3.5 Document as follows: Time patient's absence was discovered, time patient was last seen, time of physician notification, time of other notification (security department, Administrator on call, Department Director, Supervisor, Charge Nurse)."

Based on observation and interview, the hospital pharmaceutical services failed to control and distribute medications to promote patient safety for patients receiving respiratory therapy. This failed practice places patients at risk for delay in treatment which can potentially become life threatening. The findings are:

A. On 5/8/19 at 10:20 am, observation of the respiratory department, S#19 (Respiratory Therapist) removed a medication from the Pyxis (medication dispensing system) in the respiratory office located on the ground floor of the facility. S#19 placed the medication in his pocket and left the respiratory office and went to the inpatient unit on the 2nd floor of the hospital.

B. On 5/8/19 at 10:30 am during interview with S# 42 (Respiratory Therapy Manager) S# 42 confirmed that the Respiratory Therapist has to remove respiratory medications from the Pyxis in the respiratory office then taken them to the patient which can take several minutes.

C. On 4/26/19 at 10:00 am during interview S#19 confirmed that at certain times of the day multiple patient's medications were removed from the Pyxis at one time. He confirmed that having a Pyxis on 1st floor was not condusive to prevent medication errors when the administration of multiple individual patient medications on other floors of the facility was scheduled at or around the same time. S#19 confirmed that the Respiratory Department provides 39 different medications to patients on the facility units. S#19 confirmed the medication Racemic Epinephrine (used to treat Croup - works by relaxing muscles in the airways to improve breathing, also used to relieve occasional symptoms of asthma, such as wheezing, chest tightness, and feeling short of breath) is particularly time sensitive and should be readily available to the Respiratory Therapist working in the ED (Emergency Department) and not stored in a Pyxis located outside of the ED.

D. Record review of a professional journal article (Gaudy, Amanda, October 2014, When asthma escalates to an emergency, American Nurse Today, vol. 9, no.10) this topic indicated the following: "Asthma signs and symptoms range from mild to severe and may proceed to life-threatening complications, including respiratory failure and even death. What's more, an asthma attack can cause fear and anxiety, which can worsen symptoms. As asthma progresses, the patient may experience shortness of breath, cough, chest tightness, and wheezing. Treatment must be quick and effective to relieve symptoms and prevent further deterioration."



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Based on record review and interview, the facility failed to provide a discharge planning evaluation that included post-hospital services and the availability of the resources for 1 (P#16) of 6 (P#16-P#21) discharged patients reviewed. This failed practice does not address all of the required care needs or an evaluation to determine whether there are community-based services that are available to meet the patients needs while allowing the patient to continue living at home.
The findings are:

A. Record review of "Discharge planning Services Required Under CMS (Center for Medicare and Medicaid Services) Conditions of Participation" dated 09/01/18 revealed, "The case management department is responsible for the assessment of patient discharge needs and is initiated at the time of admission and continues throughout the hospital stay. The Case Management staff will identify causes for patient readmission and develop discharge plans that address these issues to help prevent future admissions." It further revealed, "The Case Manager and Social Worker to identify current and anticipated post-acute services and community services."

B. Record review of P#16's Plan of Care (POC) dated 05/07/19 revealed,
1. P#16 was admitted 05/01/19 for Legionella (disease caused by bacteria and can cause severe pneumonia) and pneumonia.
2. "What anxieties, fears, concerns, or questions do you have about your care?" "I am concerned about how I become sick"
3. "How to address anxieties/fears." " I don't' want to remain sick. I want to get better."
4. The POC did not reveal an intervention (action taken to improve a situation) to address the concerns stated by P#16.

C. Record review of discharge planning note dated 05/07/19 revealed, Staff #26 (S),Discharge Planner/Social Worker, documents "Spoke to [name of physician] and he request SW (Social Worker) check with [name of pharmacy] to see if they cover either moxifloxicin (antibiotic to treat bacteria) elevofloxicin (antibiotic to treat bacteria). [Name of pharmacist] indicates they have moxifloxicin in stock. Provided her patients' name and let her know that patient will be in with a hard script to fill". No evidence provided in the note addressing P#16's concern prior to discharge.

D. On 05/08/19 at 3:30 pm during interview, S#42 (Physician) stated, P#16 had a predisposing factor of alcoholism and denied all forms of exposure to include a hot tub and his swamp cooler which P#16 confirmed he had not turned on yet. S#42 further included during this interview, that P#16's mother and sister confirmed he was an alcoholic in and out of bars and rehabilitation was offered and declined. S#42 did not provide any information of after care instructions provided to P#16 to address concerns of becoming sick.

E. On 05/08/19 at 3:45 pm during interview S#26 confirmed she did not ask P#16 if additional resources were needed to discharge home or addressing anxieties, fears, concerns, or questions about his care per the POC goals identified by P#16.