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Based on review of documents and interview it was determined that the facility failed to obtain consent for treatment from all patients or their representatives. 2 of 2 medical records reviewed in the NICU did not have signed and/or dated consents.

Findings were:
Facility Policy entitled "Consents", stated in part: "Consent for Treatment will be obtained and signed at the time of registration. This is obtained to ensure that each patient consents to routine procedures/treatment, which may be performed during hospitalization. It does not provide universal consent for all medical/surgical procedures, which requires a separate informed consent."

2 of 2 charts reviewed in the NICU did not have signed and/or dated "Consents for Treatment":
* Patient #19 (roster B), admitted on 03/21/2015, did not have a "Consent for Treatment" form filed in the medical record. The consent for treatment form was brought and filed in the medical record while the record was being reviewed. The consent was not dated or witnessed.
* Patient #21 (roster B), admitted on 01/29/2015, did not have a signed "Consent for Treatment" in the medical record.

The above deficits were confirmed by the NICU Unit Director on May 13, 2015.

Based on observation and a review of documentation, the Medical Staff bylaws did not comply with the Conditions of Participation for acute care hospitals.

Findings were:

CONTENT OF RECORD: DISCHARGE SUMMARY
CFR 482.24(c)(2)(vii)
All records must document the following, as appropriate:
Discharge summary with outcome of hospitalization,
disposition of care and provisions for follow-up care.
Page 7 of a facility document titled "Rules & Regulations of Medical and Dental Staff Providence Memorial Hospital" reveals the following:

"11. A discharge summary shall be written or dictated on all medical records of patients hospitalized more than 48 hour (sic)."

The above was verified in an interview with the PI Coordinator, the Administrative Director of HIM and the Assistant Administrative Director of HIM on the afternoon of 5-13-15 in the HIM Department.

Based on review of documentation and interview, it was determined that the facility failed to address patient needs determined by assessment and diagnosis.

Findings were:

Facility Policy entitled "Interdisciplinary Plan of Care" stated "The interdisciplinary plan of care will be initiated on admission by the registered nurse. The plan of care will be reviewed and/or updated each day to include ancillary departments ...
1. The plan of care will be initiated by the registered nurse upon admission of the patient.
2. The plan of care will be updated each day to include resolution of problems, interventions and expected outcomes towards goals.
3. The plan of care will be a collaborative effort between patient, nurse and other involved disciplines.
4. When a new problem is identified or is resolved the designated space will be completed by the nurse.
5. If ancillary staff are completing the plan of care, they will indicate by signing under the appropriate problem and identify which discipline is making the entry.
6. The teaching record will be completed with the plan of care.
7. A daily review and update of the plan of care will be noted on the last page with hospital day and initials of the nurse. Plan of care may be used for up to 60 days."

Tour of the OB/GYN nursing floors on May 13, 2015 revealed 2 of 4 medical records with Plans of Care that did not address current patient needs.
* Patient # 20 (Roster B) had a diagnosis of dysmenorrhea and anemia. Her plan of care did not address her anemia.
* Patient # 19 (Roster B) was a patient in the neonatal intensive care unit. According to the Unit Director, this patient's Plan of Care was only updated/reviewed every 60 days.
* Patient # 16 (Roster B) was admitted to the hospital on 4/20/15. The Plan of Care, dated 4/21/15, failed to provide estimated timetables to achieve its goals. The goals related to "anxiety, bleeding, comfort, communication, fluid balance, infection, and knowledge deficit," had the "expected date of resolution" as "discharge."

In interviews with the Director of Nurses, the Unit Director of NICU and the Charge Nurse of Postpartum on May 13, 2015 the above deficits were confirmed.

Based on observation and interview, it was determined that the hospital failed to secure confidential patient medical information.

Findings were:

Tour of the Medical Oncology nursing unit on May 12, 2015 revealed 2 stacks of unsecured patient medical information in a supply storage room. One stack consisted of "narcotic validation" documentation (patients who had received narcotics). The other stack consisted of copies of discharge summaries and patient instructions. According to the Director of Nursing, this paperwork was waiting to be filed.

In an interview with the Director of Nurses on May 12, 2015, the unsecured patient medical information was confirmed.

Based on observation, interview, and record review the facility's dietary department failed to provide an organized dietary services, failed to maintain the minimum standards of a sanitary food production environment, failed to ensure acceptable hygiene practices of food service personnel, and the food and dietetic services was not integrated into the hospital-wide QAPI and Infection Control program.

Findings were:

During a tour of the kitchen on the morning of 5/12/15 from 9:25 AM to 10:15 AM, the following items were observed:
* The dish room did not contain a usable hand sink to provide for the washing of hands from dirty dishes to clean dishes. The provided hand sink was over ten feet away and did not contain hand soap, drying towels or a trash receptacle.
* A reusable spray bottle was labeled as containing odor deodorizer but actually contained a strong chemical degreaser.
* A carton of Diet Coke in use with an "Enjoy By" date of 2/22/15. In addition, there was a carton of Barq's root beer with an "Enjoy By" date of 4/20/15.
* Three (3) wet kitchen towels lying on the food production counters, three (3) wet kitchen towels in the dish room counters, and a small bucket of wet kitchen towels sitting on the floor of a janitor closet.
* Exhaust hood vents above the grills contained extensive grease residue and the wall had food debris and grease residue.
* Double stacked convention ovens contained built-up grease on the doors, racks, and grease drained out of the doors.
* Fryer had old grease and food debris running down the side and collected on the wheeled casters.
* The walk-in freezer revealed a large bag of chicken that was not labeled and dated.
* Freezer number #4 accumulation of ice built up on the three fans, freezer walls, food boxes, and shelves.
* A dietary employee walked through the kitchen into the food production area before donning a hair restraint and a non-dietary employee was observed walking through the kitchen with a baseball cap, his hair was exposed and hanging out from under the cap.
* Several large puddles of standing water were noted in the dish washing area.
* Two floor drains were noted with debris.
* The large floor drain under the double stacked food steamer had trash in the drain blocking the flow of water.
* An approximate 12 " x 12 " accumulation of ice near an air vent as well as a rim of ice around freezer #3's door.
* In refrigerator #1 there were trays of uncovered, unlabeled or undated bacon and fish.

Review of the facility outtakes refrigerator log dated May 2015 reflected:
* 5/2/15, no temperatures recorded for the am and the pm shift.
* 5/9/15, no temperatures recorded for the am and the pm shift.
* 5/10/15, no temperature recorded for the pm shift.
* 5/11/15, no temperatures recorded for the am and the pm shift.

Policy #F015, review of the facility provided SANITATION INSPECTION AND CHECKLIST (revised 1/14) states, in part "A basic sanitation inspection is conducted at least once per month to ensure that established procedures are being followed and that sanitation standards are maintained. A quarterly food safety and sanitation audit is conducted using the Food Safety and Sanitation Audit form."

On 5/12/15, the survey team requested the completed Basic sanitation checklists and the Food Safety and Sanitation Audit forms. The facility was unable to produce the completed checklists.

The facility provided only two completed Dietary survey forms, on 3/18/14 - A Hazard/Environmental Survey form was completed and on 12/11/13, an Environment of Care Rounding Tool was completed.

A review of Environment of Care (EOC) Rounding Data Analysis revealed results for March through April, 2015 and that 29 areas of the hospital were reviewed. Though one of the areas surveyed was the Kitchen, there were no results entered from the rounds. A review of the rounding form dated May 4-8, 2015, revealed the kitchen was no longer listed as one of the areas to be surveyed.

In an interview with the Safety Officer on the morning of 5/14/15 in the facility conference room, he identified the Performance Improvement Committee as the committee to which he reported on a quarterly basis on issues related to the hospital's environment of care. Meeting minutes were reviewed for the following dates: 1/14/15, 2/11/15, 3/4/15 and 4/8/15. The Safety Officer attended only the meeting on 2/11/15. The minutes included an "Environment of Care Committee Report to Leadership" section. Items discussed included review of 9 safety indicators, which included for example: Needlesticks/Sharps Injuries; Slips, Trips and Falls Injuries; Reduction of Patient Visitor Losses; and safety drills. There was no documented evidence of discussion of Environment of Care rounding in the dietary area.

On the afternoon of 5/12/15, during a telephone interview, the CEO stated the Basic Sanitation Checklists and the Food Safety and Sanitation Audit forms were not being conducted.

Policy #B005, "PROVIDED FOOD SUPPLY AND STORAGE (revised 1/00)" states, in part "All food, non-food items, and supplies used in food preparation shall be stored in such a manner at to maintain the wholesomeness of the food for human consumption."

Policy #B007, "STORAGE TEMPERATURES (revised 1/14)" states, in part "Temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies--Each morning at opening and evening at closing, record temperature of each storage unit."

Policy #E005, "DRESS GUIDELINES FOR FOOD SERVICE MANAGEMENT AND CLINICAL NUTRITION STAFF (revised 1/14)" states, in part "Hair restraints are worn by all when in the kitchen. This includes department associates, associates from other facility departments and guests, such as vendors."

Policy #F007, "HAND HGIENE (revised 1/14)" states, in part "In the food & Nutrition Services Department: All associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: after handling soiled silverware." "PROCEDURES- Use sinks designated for handwashing. All handwash sinks should be easily accessible in ...dishwashing areas. Handwash sinks, should be cleaned and stocked with soap, paper towels and a covered waste receptacle."

During an interview on 5/12/15 at 9:25 AM in the kitchen janitor closet, Roster C staff #10, Food Services Director confirmed the sink in the dishwashing room was moved three days prior and there was no provision for soap and hand towels.

During an interview with the Roster C Staff #10 , Food Services Director in freezer number (4) she stated, "The facility has been trying to correct the ice build-up for the past five years."

During an interview on 5/12/15 at 10:30 AM in the main kitchen, Roster C Staff # 10, Food Services Director stated all individuals must wear hair restraints while in the kitchen.

In the kitchen "dirty area" there was several large puddles of standing water. In an interview with Roster C Staff #10, the Food Services Director, during the tour, she stated, "I think the floor is just lower in those areas so the water doesn't really drain off. It just collects in those spots."

In freezer #3, there was an approximate 12" x 12" accumulation of ice near an air vent as well as a rim of ice around the door. A thick covering of ice was found in freezer #4 near the air vents and on the ceiling. In an interview with Roster C Staff #10, the Food Services Director, during the tour, she stated " That's been a problem as long as I've been here. " When asked how long she had been at the facility, she stated, "About five years."

On 5/12/15 at 10:00 AM in the kitchen, the Food Services Director confirmed all food items need to be covered, labeled and dated.

Policy #B006, "FOOD AND SUPPLY STORAGE PROCEDURES (revised 1/14)" states, in part: "Cover, label and date unused portions and open packages. Use the Morrison orange label; complete all sections on the label." "Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid." "Date and rotate items ..."

A tour of Café La Rista, on the 1st floor, revealed there was a carton of Diet Coke in use with an "Enjoy By" date of 2/22/15. In addition, there was a carton of Barq's root beer with an "Enjoy by" date of 4/20/15.

In a housekeeping closet there was a bin of wet, soiled rags with several of the rags draped over the rim and touching other items in the closet. Roster C, Staff #10 Food Services Director stated, "Those are probably there from last night."

Policy #F018, "SANITATION AND INFECTION CONTROL (revised 1/14)" states, in part "Wiping cloths must be stored in sanitizer solution. No more than 2 wiping cloths should be stored in a bucket." "Spray Bottles: Spray bottles are only approved for use on sanitizing equipment that must be cleaned in place because it is difficult or impractical to disassemble it. Spray bottles must be clearly labeled with name of sanitizer. Do not place sanitizer solution unlabeled or mislabeled bottles. Best practice: label spray bottles using pre-printed labels for the chemical used provided by the chemical supplier."

During an interview on 5/12/15 at 9:45 AM in the kitchen, Roster C staff #7 stated we clean the walls with the degreaser. We spray the degreaser on the wall with the spray bottle. She was not aware the bottle was labeled odor deodorizer. Roster C staff #10, the Food Services Director removed the spray bottle from use.

Based on a facility tour, a review of documentation and staff interviews, the facility failed to maintain the condition of the physical plant as dust was found on high horizontal surfaces, and chipped laminate, broken and ill-fitting ceiling tiles and other environmental issues indicating a general lack of upkeep were found throughout the facility.

Findings were:

Facility based policy entitled, "Environmental Cleaning in the Surgical Practice Setting" stated in part,
"2. It is recommended that all horizontal surfaces within the OR (e.g., furniture, surgical lights, equipment) will be wiped down prior to the first scheduled surgical procedure of the day...
9...Mechanical friction and use of a facility-approved agents are used to clean equipment and areas that should include, but are to limited to,...
f. Horizontal surfaces..."

During a tour of the Day Surgery area on 05/12/15, the following infection control issues were observed:
* In the day surgery operating room "E" dust was noted on high horizontal surfaces in the room, indicating ineffective cleaning of the room.
* In operating room "E", an arm board was noted stored on the floor of this room. In an interview the staff member # 12 confirmed this was used during procedures. This presents a risk of contamination to the arm board and cross contamination to stretcher when attached.
* In clean storage room, 8 arm boards were noted stored on the floor of this room. In an interview the staff member # 12 Roster D confirmed these were used during procedures. This presents a risk of contamination to the arm board and cross contamination to stretcher when attached.
* In the sterilization room a vent over autoclave #2 was observed to not be flush with the ceiling. One screw was loose, leaving a 1 inch gap at the end of the vent above the autoclave. This opening present a potential entry point for dust and pests into the sterilization area.
* In the cardiac catheterization lab room A, dust was observed on high horizontal surfaces, indicating ineffective cleaning of the room.



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On a tour of the hospital on 5/13/15 and 5/14/15, the following observations were made:

On the Pediatric Unit:
* In the medication room there were ill-fitting ceiling tiles above refrigerators containing patient medications. Openings in the ceiling allow dirt, dust and debris to fall on the area below and serve as an entry for insects.
* Room 343 contained a crib with chipped paint and rust on the rails that are accessible to infants. The staff nurse stated the infants like to teeth on the rails.
* In room 354 there was chipped laminate with sharp edges and wood exposed on the door. The sink had cracked laminate and the hand sink had separated from the wall because of missing caulk. In the patient room was an open electrical panel with multiple electrical wires.
* Room 627 contained a crib with chipped paint.

In the Emergency Department:
* In the entry there were loose and ill-fitting ceiling tiles.
* A chair in the "Fast Track" room had cracks in the vinyl leather which made thorough cleaning impossible.
* In room 6, rust and chipped paint was noted under the sink.
* In rooms 17 and 20, chipped laminate was observed above the gurney.
* In room 18, there was a hole in the wall between the rooms 18 and 19.
* Dust in the air vents was noted in room 19.

In the Radiology Department:
* There was thick dust on high horizontal surfaces in the holding area.
* Tape binding several cords connected to a monitor was noted by a patient bed. The gooey residue made cleaning impossible and the tape had blood on it.
* There were crumbling ceiling tiles and a gap in the ceiling above the patient bed of the MRI area. The nuclear medicine hallway had broken ceiling tiles.
* The floor included overt dust and debris.
* There were divets in the plaster of the wall in the injection room.
* The CT scan room had dust on the counters and on the CT machines extension arm

In the ICU:
* In the soiled utility room, there was a cabinet containing respiratory tubing ready for patient use.
* In the Respiratory Therapy office there was a large hole in the counter which led to another counter below which had two large holes in it. Debris was visible through the holes on the floor below.

In the Post- Partum unit:
* A patient shower room contained a usable toilet, a hand sink without a faucet, and no hand soap in the dispenser.
* In room 149, there was a large crack on the Stryker bed.
* A reddened stain on a patient chair was visible in room 152.

In the Pediatric ICU:
* In the supply area, there were ill-fitting ceiling tiles over patient supplies.
* Broken or chipped laminate was noted in a number of areas of the PICU. Broken laminate makes thorough cleaning impossible.

On the Neonatal ICU:
* A dead bug was visible in the light fixture in the patient supply area.
* A medication refrigerator on the counter was open and included a piece of paper on the bottom shelf which stated, "Refrigerator defrosting." A thick layer of ice was visible around the upper shelf in the refrigerator.
* Dust was found on the vertical surfaces of the infant incubators in use.

On the Labor & Delivery unit:
* In room 202, a call light located by the toilet did not function when pulled.
* There was cracked and shoddily patched flooring in the hallway.
* In the housekeeping closet, there were two wet rags on the floor.
* Patient/visitor chairs/sleepers had cracked vinyl leather or other covering.

In the Nursery:
* In the soiled utility room, there was a wet rag under the sink. Around the sink area, there was no soap dispenser visible.
* High horizontal surfaces included a thick layer of dust.
* In a housekeeping closet, there was a large hole in the plaster at the baseboard. An opening was visible into the area behind the wall.
* In the patient nutrition area, there was a dripping faucet.

On the Medical Oncology Unit:
* A dirty utility room had sagging tape blocking an air duct so that air was not being funneled up as needed.
* In room 439, there was no emergency call cord within reach of the toilet.

On the Telemetry unit:
* There were beverages found in a housekeeping closet. The closet also contained wet pads in a sink where continuous dripping water identified as condensation runoff, by Staff #C19, kept them constantly moist. The length of time the pads had been there was unknown.
* In a patient shower room, there were 4 telemetry stickers lying on the floor and a screen/canvas type chair that was not specified as a shower chair.
* In room 141, there were large areas of broken laminate on the counter and cabinet. One area was an approximate 12" square and the other was approximately 6"x4".
* The waiting area included two chairs with unidentifiable stains on the seats. One stain was reddish/brown in color.
* The waiting room had dirty air vents.
* In room 141, the counter had cracked laminate with sharp edges.

Throughout the facility in general there were a number of ill-fitting, stained or broken ceiling tiles, for example in hallways outside elevators or leading from one area of the hospital to another. In addition, dust was present on high horizontal surfaces in a number of areas.

In an interview with staff #C17, the Safety Officer, on the morning of 5/14/15, he stated that the Environment of Care (EOC) Committee met monthly. However, he stated they did not meet in February 2015 and, though they were requested several times, no minutes were available for the April 2015 meeting. Environment of Care Meeting minutes were reviewed for the following dates: 12/18/14, 1/14/15, and 3/4/15. There was brief discussion noted in the minutes of the meeting of 12/18/14 of results of EOC rounding. Beyond that, there was no documented evidence of discussion of Environment of Care rounding and no plans of correction in place for deficient findings.

The Safety Officer identified the Performance Improvement Committee as the committee to which he reported EOC findings on a quarterly basis. Minutes of the Performance Improvement Committee were reviewed for 2015. The Safety Officer attended only the 2/11/15 meeting. Several EOC indicators were discussed, but not the results of EOC rounding. No performance improvement plans were in place for deficient findings during the survey.

Facility policy, #EC.04.01.01 EP 12-14, last revised January 2010, stated in part:
"It is the policy of Providence Memorial Hospital to conduct regular environmental tours of all areas of the organization to evaluate the effectiveness of previously implemented activities to minimize or eliminate environment of care risks...
10. The Department Director/Manager will review the information sent and work on the issues and deficiencies that have been identified for the department to correct as soon as possible...
12. The Safety Officer will schedule, track, trend and analyze the environmental tour inspections...and provide completion, data, and issues to the Environment of Care Committee on a monthly basis."

The above findings were confirmed in an interview with the facility Chief Operating Officer and other administrative staff on the afternoon of 5/14/15 in the facility conference room.