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Based on review of medical records (MR), review of facility documents, and staff interviews, it was determined that the facility failed to ensure that nursing care plans were developed upon admission for nine of 16 medical records reviewed (Patient (P) 8, P9, P10, P11, P12, P13, P14, P15, and P16) (A0396).

Cross Reference:

482.23(b)(4) Nursing Services: Nursing Care Plan

Based on medical record reviews, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that nursing care plans were developed upon admission for nine of 16 medical records reviewed (Patient (P) 8, P9, P10, P11, P12, P13, P14, P15, and P16).

Findings include:

On 8/23/24, a review of the nine medical records of patients on the 5 West unit lacked documented evidence of nursing care planning for patient treatment goals while in the hospital and discharge planning for post-hospital needs.

P8 was admitted on 8/8/24 for infective endocarditis.

P9 was admitted on 7/26/24 to rule out angina, with history of atherosclerotic arteries.

P10 was admitted on 7/26/24 for lower back pain, with history of cauda equina syndrome (nerve compression caused by a herniated disk) and spinal surgery.

P11 was admitted on 7/25/24 as a transfer from another facility for an unspecified infection of the skin and subcutaneous tissue. Per the physician admission notes, P11 was sent to the facility for monitoring and continuum of care. P11 has a past medical history of cardiac issues, dementia, high blood pressure, AKA (above knee amputation), high cholesterol, paraplegia (paralysis of lower extremities), Thiamine deficiency, Type 2 Diabetes Mellitus (DM), urinary tract infection (UTI), and Vitamin D deficiency.

P12 was admitted on 7/25/24 with a primary diagnosis of Multiple Sclerosis with limited mobility to lower extremities and was ordered physical therapy (PT) and occupational therapy (OT) services.

P13 was admitted on 7/25/24 as a transfer from another facility for a local infection of the skin and subcutaneous tissue in the right axillary with a positive culture for MRSA (methicillin resistant staphylococcal aureus) which required contact isolation.

P14 was admitted on 7/25/24 as a transfer from another facility for a history of anemia, anxiety, chronic suprapubic catheter with chronic UTI, constipation, depression, fatigue insomnia, left and right leg pain, polyneuropathy (nerve malfunction), and seizure. P14 was ordered PT and OT services.

P15 was admitted on 7/25/24 with congestive heart failure, DM, dilated cardiomyopathy, gastroesophageal reflux disease (GERD), hypertension, high cholesterol, myocardial infarction, and other multiple health issues, including a wound to the right lower abdomen.

P16 was admitted on 8/01/24 as a transfer from another facility with complaints of cramping, swollen legs and groin pain. P16 has a history of DM, GERD, and cerebrovascular accident (stroke), sacral decubiti stage II (wound), and atrial fibrillation (irregular heart beat).

In an interview on 8/23/24 at 2:05 PM, Staff 36, Case Manager, stated that the Interdisciplinary Team was doing rounds on 5 West and was "working out" the process with the insurance company.

A review of the facility policy titled, Nursing Standards of Care and Nursing Practice, reviewed July 2024, stated, "... Standard III - Plan of Care ... On admission a plan of care will be developed using the admission history information. ... The nurse will use the information to construct and apply an appropriate plan of care to ensure patient safety and reach discharge goals. Other disciplines will collaborate in forming patient goals as needed. ... The plan of care will work towards a common goal of a safe comfortable discharge. ..."

Based on observation, review of facility documents, and staff interviews, it was determined that the facility failed to ensure 1.) the heating and ventilation system was maintained and functioning for the safety and well-being of the patients (A0701); and 2.) temperatures in the medication room were maintained within an acceptable level (A0724). This failure resulted in and Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On 8/16/24, at 3:05 PM, an IJ was identified due to the facility's failure to ensure the maintenance of the building's air conditioning and to activate the internal disaster plan for HVAC (Heating, Ventilation and Air Conditioning) failure in order to maintain the safety and well-being of the patients in the hospital. On 8/16/24 at 3:58 PM, the IJ template was presented to the administration and a removal plan was requested.

On 8/19/24, at 11:05 AM, an acceptable removal plan was received. The facility implemented the following to address the IJ: Patients located on the behavioral health units were transferred out to accepting facilities; Patients on the 3 West Unit were transferred to the 2 West Unit where temperature readings were within normal range; the air chiller that controlled the HVAC for the Intensive Care Unit (ICU) was repaired; Temperatures were continued to be monitored on patient care units by the facility every four hours to ensure adequate cooling. The IJ was removed on 8/19/24, at 4:07 PM, after the State Survey Agency verified the full implementation of the removal plan, and the Condition level non-compliance remains (A0701).

Cross Reference:
482.41(a) Physical Environment: Buildings
482.41(d)(2) Physical Environment: Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality

Based on observation, document review, staff interviews, and review of facility documentation, it was determined that the facility failed to ensure the heating and air conditioning system is maintained and functioning for the safety and well-being of all patients.

Findings include:

On 8/16/24 at 11:00 AM, during a tour of the 5 West Unit, located on the 5th floor, the following room temperatures were measured and confirmed by Staff (S) 2, the Facility Manager: (Normal inpatient room temperatures 70-75 degrees Fahrenheit)

Room #558, #563, #565, and #566: 76.0 degrees Fahrenheit (F)
Room #561: 79.0 degrees Fahrenheit

On 8/16/24 at 11:20 AM, during a tour of the Intensive Care Unit (ICU) located on the 5th floor, the following room temperatures were confirmed by S2:

Room #511, unoccupied (available for patient use), Isolation Room: 81.9 Degrees Fahrenheit
Room #524, occupied: 83.4 degrees Fahrenheit
Room #523, occupied: 84.7 degrees Fahrenheit
Room #517, occupied: 81.0 degrees Fahrenheit
Room 500-1, occupied: 83 degrees Fahrenheit
Room 500-6, occupied: 81.1 degrees Fahrenheit
Nurses' Station: 84.2 degrees Fahrenheit

On 8/16/24 at 11:40 AM, during a tour of the Behavioral Health Unit 4 Main located on the 4th floor. Patients and staff were observed with visible sweat-stained clothing. The following room temperatures were confirmed by S2:

Group Room: 86.6 degrees Fahrenheit
Dining Room: 86.5 degrees Fahrenheit
Behavioral Health Unit Corridor: 85 degrees Fahrenheit
Room #405: 86.4 degrees Fahrenheit
Seclusion Room #1: 87.0 degrees Fahrenheit
Seclusion Room #2: 87.7 degrees Fahrenheit
Room #406: 86.7 degrees Fahrenheit
Room #408: 87.0 degrees Fahrenheit
Quiet Room: 88.5 degrees Fahrenheit
Nurse's Station: 87.0 degrees Fahrenheit
Room #410: 86.1 degrees Fahrenheit
Room #412: 87.4 degrees Fahrenheit
Room #413: 88.7 degrees Fahrenheit
Room # 414: 89.6 degrees Fahrenheit
Room #415: 88.7 degrees Fahrenheit
Activity Room: 86.1 degrees Fahrenheit
Medication Room: 91.2 degrees Fahrenheit

On 8/16/24 at 12:40 PM, during a tour of the 3 Main Unit (Medical/Surgical) located on the 3rd floor, the following room temperatures were confirmed by S2:

Room #312: 82.5 degrees Fahrenheit
Room #318: 78.0 degrees Fahrenheit
Room #327: 88.7 degrees Fahrenheit
Room #329: 89.7 degrees Fahrenheit
Room #330: 88.4 degrees Fahrenheit
Room #331: 89.7 degrees Fahrenheit
Room #336: 85.6 degrees Fahrenheit
Room #338: 86.0 degrees Fahrenheit
Medication Room: 87.1 degrees Fahrenheit

A review of work orders from the HVAC contractor dated 5/14/24, 5/22/24, and 8/7/24 identify the reason for the visit as a "repair."

During an interview on Friday, 8/16/24 at 11:00 AM, S2 stated the HVAC Contractor was on-site working on the air conditioning and that the repairs to the air conditioning system would not be completed until Monday or Tuesday of next week. S2 added, temperatures on patient care units have been elevated since 8/4/24.

Portable air conditioning units were dispersed throughout the hospital but were not alleviating the high temperatures based on a review of the facility provided temperature logs. Temperatures of patient care areas were taken every four (4) hours by the facility's maintenance staff.

During an interview with S2 on 8/19/24 at 1:30 PM, he/she confirmed the routine preventative maintenance is not preformed on the HVAC system. S2 confirmed the contractor was only called to make repairs as needed.

During a review of facility provided temperature logs dated 8/4/24, elevated temperatures were found on the following patient care units:

7:00 AM:
5-West: Between 76 and 78 degrees Fahrenheit,
4-Main: 78-81 degrees Fahrenheit,
ICU 5th Floor: 78-80 degrees Fahrenheit,

3:00 PM:
2 West: 77-79 degrees Fahrenheit,
5-West: 77-78 degrees Fahrenheit,
4-Main: 76-78 degrees Fahrenheit,
4-West: 77-78 degrees Fahrenheit,

11:00 PM:2 West: 77-78 degrees Fahrenheit,
5-West: 76-77 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/5/24, elevated temperatures were found on the following patient care units:
7:00 AM:
2 West: 76-78 degrees Fahrenheit,
4-Main: 76-79 degrees Fahrenheit,

3:00 PM:
2 West: 76-77 degrees Fahrenheit,
5-West: 78-79 degrees Fahrenheit,
ICU 5th Floor: 77-78 degrees Fahrenheit,
4-Main: 76-79 degrees Fahrenheit,
4-West: 76-78 degrees Fahrenheit,

11:00 PM:2 West: 76-78 degrees Fahrenheit,
5-West: 78-79 degrees Fahrenheit,
ICU 5th Floor: 77-78 degrees Fahrenheit,
4-Main: 78-79 degrees Fahrenheit,
4-West: 77-78 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/6/24, elevated temperatures were found on the following patient care units:

7:00 AM:
2 West: 76-78 degrees Fahrenheit,
4-Main: 79-81 degrees Fahrenheit,
4-West: 76-78 degrees Fahrenheit,

3:00 PM:
4-Main: 76-79 degrees Fahrenheit,

11:00 PM:
2 West: 76-78 degrees Fahrenheit,
5-West: 77-78 degrees Fahrenheit,
ICU 5th Floor: 77-78 degrees Fahrenheit,
4-Main: 77-78 degrees Fahrenheit,
4-West: 77-78 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/7/24, elevated temperatures were found on the following patient care units:

11:00 PM
2 West: 76-78 degrees Fahrenheit,
5-West: 78-79 degrees Fahrenheit,
4-Main: 77-78 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/8/24, elevated temperatures were found on the following patient care units:

3:00 PM:
2 West: 76-78 degrees Fahrenheit,
4-Main: 81-82 degrees Fahrenheit,

11:00 PM
2 West: 76-78 degrees Fahrenheit,
5-West: 76-78 degrees Fahrenheit,
4-Main: 77-78 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/9/24, elevated temperatures were found on the following patient care units:
7:00 AM:
4-Main: 79-81 degrees Fahrenheit,
ICU 5th Floor: 77-79 degrees Fahrenheit,

3:00 PM:
ICU 5th Floor: 78-82 degrees Fahrenheit,
4-Main: 81-83 degrees Fahrenheit,

11:00 PM:
ICU 5th Floor: 79-81 degrees Fahrenheit,
4-Main: 79-82 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/10/24, elevated temperatures were found on the following patient care units:
7:00 AM:
4-Main: 81-83 degrees Fahrenheit,
ICU 5th Floor: 80 degrees Fahrenheit,

3:00 PM:
ICU 5th Floor: 78-84 degrees Fahrenheit,
4-Main: 78-84 degrees Fahrenheit,
5-West: 77-78 degrees Fahrenheit,

11:00 PM:
4-Main: 78-79 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/11/24, elevated temperatures were found on the following patient care units:
7:00 AM:
2 West: 76-78 degrees Fahrenheit,
4-Main: 80-83 degrees Fahrenheit,
5-West: 77-79 degrees Fahrenheit,

3:00 PM:
ICU 5th Floor: 78-84 degrees Fahrenheit,
4-Main: 77-78 degrees Fahrenheit,
5-West: 77-78 degrees Fahrenheit,

11:00 PM
4-Main: 78-79 degrees Fahrenheit,
4-Main: 76-78 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/12/24, elevated temperatures were found on the following patient care units:

7:00 AM:
2 West: 76-78 degrees Fahrenheit,
4-Main: 80-83 degrees Fahrenheit,
5-West: 77-79 degrees Fahrenheit,
ICU 5th Floor: 77-78 degrees Fahrenheit,

3:00 PM:
ICU 5th Floor: 78-84 degrees Fahrenheit,
4-Main: 77-79 degrees Fahrenheit,
ICU 5th Floor: 77-78 degrees Fahrenheit,

11:00 PM
4-Main: 77-79 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/13/24, elevated temperatures were found on the following patient care units:

7:00 AM:
4 West: 79-80 degrees Fahrenheit,
4-Main: 81-82 degrees Fahrenheit,

3:00 PM:
4-Main: 81-83 degrees Fahrenheit,

11:00 PM
4-Main: 77-79 degrees Fahrenheit,

During a review of facility provided temperature logs dated 8/14/24, elevated temperatures were found on the following patient care units:

7:00 AM:
4-Main: 82-85 degrees Fahrenheit,
5-West: 76-78 degrees Fahrenheit,
ICU 5th Floor: 77-78 degrees Fahrenheit,

3:00 PM:
3-Main: 78-85 degrees Fahrenheit,
ICU 5th Floor: 78-84 degrees Fahrenheit,
4-Main: 84-86 degrees Fahrenheit,
ICU 5th Floor: 77-83 degrees Fahrenheit,
5-West: 76-78 degrees Fahrenheit,

Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure temperatures in the medication room were maintained within the acceptable temperature range (68-77 degrees Fahrenheit).

Findings include:

On 8/16/24 at 12:00 PM, during a tour of the 4 Main Unit, the counter in the medication room was observed to have medications labeled with patient's names for distribution. The medication Invega Sustenna, an antipsychotic medication, was on the counter. The box of the medication stated, "Store at room temperature (77 degrees Fahrenheit, 25 degrees Celsius); excursions between 59 degrees Fahrenheit and 86 degrees Fahrenheit (15 degrees Celsius and 30 degrees Celsius) are permitted." The temperature in the medication room, per the wall thermostat, read 89.4 degrees Fahrenheit. Staff (S) 2, the Facility Manager, confirmed the finding at the time of discovery and used his/her infrared thermometer device (a handheld device for temperature measurement) to determine the accuracy of the wall thermostat. The temperature reading per the infrared thermometer was 91.2 degrees Fahrenheit.

The medication room also contained an Omnicell, a medication storage system. At 12:11 PM, upon request, the door to the Omnicell was opened and a temperature was recorded at 93 degrees Fahrenheit. A paper temperature log was observed hanging on the side of the Omnicell for the month of August 2024. The log indicated "MedRoom Temp Range: (normal 68-77 degrees Fahrenheit)." Each day, the temperature was checked at 7 AM, 3 PM, and 11 PM. Per the log, temperatures in the medication room were documented to have been out of range starting on 8/1/24 at 3 PM. Forty-five temperature checks were completed for August 2024, 39 out of 45 temperature checks were documented above the normal range. Documentation next to the abnormal value stated "notified" in the column of the log marked "DOP [Director of Pharmacy] notified when out of normal room temp range."

An interview was conducted on 8/19/24 at 12:11 PM with S14, Director of Pharmacy, regarding the above findings. S14 stated that he/she had not received any notifications regarding the abnormal temperatures on 4 Main. S14 stated that the staff of the unit documents on the log and he/she was not sure where the notifications went. S14 stated that the pharmacy staff has monthly inspections in the units and that the inspection for August 2024 had not been completed yet. S14 further stated that the inspections are not on specific days or at regular intervals, just that they have to occur once a month. S14 stated that on 8/16/24, upon notification of the out of range temperatures, S14 did an inspection of the medication room on the 4 West/4 Main Unit and removed all medications from the room and the Omnicell for destruction. The medication room and Omnicell was then set up on the 4 East Unit to accommodate the patient's needs on the 4 West and 4 Main Units. S14 confirmed that if medications are stored outside of the the acceptable temperature range for an extended duration of time then the medications could be potentially unsafe for use.

On 8/19/24 at 1:25 PM, an interview was conducted with S13, Chief Nursing Officer, who stated that there was no definitive process in place and that the facility should have one. S13 confirmed that without a process for monitoring and accountability of the temperature logs, the result could be harmful to patients.

Facility policy titled, "Pharmacy - Medication Management - Storage" stated, "... Medications, biologicals, and devices shall be stored to ensure their integrity, stability, and effectiveness ... STORAGE OF MEDICATIONS BETWEEN RECEIPT AND ADMINISTRATION ... The drug should not be left on or in any area exceeding 25 degrees C [Celsius] (80 degrees Fahrenheit) for any extended period of time. The Pharmacy Director will engage Facility Services to mitigate any heat liability ... STORAGE CONDITIONS ... Medications shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, organization, segregation, safety, and security. Temperatures and ventilation in the work areas shall ensure the integrity of medications ... Room temperatures in medication storage areas shall be monitored twice daily (minimum 8 hour interval) including documentation on an appropriate temperature log displayed in the room itself ..."

Based on review of medical records, review of faciltiy documents, and staff interviews, it was determined the facility failed to ensure that discharge planning evaluations were included in nine of 16 medical records reviewed (Patient (P) 8, P9, P10, P11, P12, P13, P14, P15, and P16) (A0808).

Cross Reference:

482.43(a)(3) Discharge Planning: Discharge Planning Evaluation

Based on medical record reviews, staff interviews, and a review of the facility documents, it was determined the facility failed to ensure that discharge planning evaluations were included in nine of 16 medical records reviewed (Patient (P) 8, P9, P10, P11, P12, P13, P14, P15, and P16).

Findings include:

On 8/23/24, a review of nine medical records on the 5 West, Medical/Surgical Unit, revealed that nine of nine medical records lacked documented evidence that a discharge planning evaluation was conducted and that case management interdisciplinary rounds were conducted on a daily basis in accordance with the facility policy:

P8 was admitted on 8/8/24 for infective endocarditis.

P9 was admitted on 7/26/24 to rule out angina, with history of atherosclerotic arteries.

P10 was admitted on 7/26/24 for lower back pain, with history of cauda equina syndrome (nerve compression caused by a herniated disk) and spinal surgery.

P11 was admitted on 7/25/24 as a transfer from another facility for an unspecified infection of the skin and subcutaneous tissue. Per the physician admission notes, P11 was sent to the facility for monitoring and continuum of care. P11 has a past medical history of cardiac issues, dementia, high blood pressure, AKA (above knee amputation), high cholesterol, paraplegia (paralysis of lower extremities), Thiamine deficiency, Type 2 Diabetes Mellitus (DM), urinary tract infection (UTI), and Vitamin D deficiency.

P12 was admitted on 7/25/24 with a primary diagnosis of Multiple Sclerosis with limited mobility to lower extremities and was ordered physical therapy (PT) and occupational therapy (OT) services.

P13 was admitted on 7/25/24 as a transfer from another facility for a local infection of the skin and subcutaneous tissue in the right axillary with a positive culture for MRSA (methicillin resistant staphylococcal aureus) which required contact isolation.

P14 was admitted on 7/25/24 as a transfer from another facility for a history of anemia, anxiety, chronic suprapubic catheter with chronic UTI, constipation, depression, fatigue insomnia, left and right leg pain, polyneuropathy (nerve malfunction), and seizure. P14 was ordered PT and OT services.

P15 was admitted on 7/25/24 with congestive heart failure, DM, dilated cardiomyopathy, gastroesophageal reflux disease (GERD), hypertension, high cholesterol, myocardial infarction, and other multiple health issues, including a wound to the right lower abdomen.

P16 was admitted on 8/01/24 as a transfer from another facility with complaints of cramping, swollen legs and groin pain. P16 has a history of DM, GERD, and cerebrovascular accident (stroke), sacral decubiti stage II (wound), and atrial fibrillation (irregular heart beat).

In an interview on 8/23/24 at 2:05 PM, Staff (S) 35, Social Worker, and S36, Case Manager, stated that interdisciplinary (IDT) rounds were not being done on 5 West. S6 stated that he/she performs utilization review by reading the physician notes and sending each patient's clinical information to the insurance company. When asked for documentation of communication to the insurance company, both S35 and S36 were unable to provide the documentation.

A review of the facility policy titled, "Discharge Planning and the Continuum of Care," reviewed July 2024, stated, "It is the policy of (name of the facility) ... to maintain an interdisciplinary service that facilitates the continuity of patient care for medical and surgical patients which takes into consideration the unique contributions of all disciplines and departments providing patient care services. The discharge planning process is coordinated by the Continuing Care Department. ... PURPOSE: 1. To ensure that patients have a plan for post-hospital care that addresses their medical, nursing, psychosocial, functional, and financial needs, and that provides them ... with maximum information ... and other support services. ... SCOPE: Members of the interdisciplinary healthcare team include but not limited to the patient, the medical staff, the department of nursing, case management staff, physical rehabilitation, pharmacy, radiological services and food and nutrition. QUALIFICATION/RESPONSIBLE PARTIES: Continuing Care staff including case managers, social workers, and discharge planners. ... PROCEDURE: 1. All patients will be assessed to determine which patients are at risk to experience adverse health consequences without a discharge plan. ... 3. All patients are assessed and reassessed as applicable, and identify discharge planning needs including the need for specialized medical equipment or environmental modifiers. 4. Members of the interdisciplinary healthcare team responsible for patient care discuss the care of patients on a regular basis. 5. Each member of the interdisciplinary healthcare team determines the type of continuing care services to be provided and documents the plan in his/her progress notes. The social worker/care manager facilitates the recommendations of the healthcare team in the development of an overall discharge plan. ..."

A review of the facility policy titled, "Interdisciplinary Rounds," reviewed March 2024, stated, "Case Management interdisciplinary rounds will be held on all medical and surgical units on a daily basis ..."

Based on document review and staff interview on 8/22/24, it was determined that the facility failed to review and update the Emergency Preparedness Program at least annually.

Findings include:

During a review of the Emergency Preparedness Program at 1:50 PM, the last documented review date was 1/1/2019.

At 2:00 PM, during an interview with Staff (S)3, the VP of Operations, who oversees the Emergency Preparedness Program, S3 confirmed the Emergency Preparedness Program was last reviewed and approved on 1/1/2019. S3 further stated, "The Emergency Preparedness Program is currently under review and undergoing updating."

Based on document review and staff interview, it was determined that the facility failed to ensure policies and procedures are developed to ensure the safe evacuation of patients from the facility.

Findings include:

During a review of the facility Emergency Preparedness Plan (EPP) on 8/23/24, it was identified that the plan failed to address how an evacuation would be handled, to include communication with receiving facilities, coordination of transportation, or clear triggers for staff to activate the evacuation plan.

During a review of the EPP plan for Utility Failure, no guidance or triggers were identified to tell staff when to enact the policies and procedures related to the emergency transfer of patients to other hospitals.

On 8/19/24 at 1:30 PM, Staff (S1), Director of Quality and Informatics was interviewed concerning the sustained elevated temperatures that were not controlled despite the facility's use of portable air conditioning units in the patient care areas. S1 was asked if the EPP was activated due to the air condition failure and extreme temperatures in the building and S1 stated, "No." S1 was then asked when would the facility activate their EPP and relocate patients to appropriate facilities and S1 was unable to state what triggers would initiate the evacuation of patients under the utility failure EPP.