HospitalInspections.org

Based on observation, interview, document review, record review and policy review the hospital failed to ensure they met the requirements for the Nursing Services Condition of Participation.

The cumulative effect of the hospital's failure to provide safe and effective nursing care placed patients at risk for falls, injury, inadequate staffing, lack of care, lack of qualified/trained staff and medications errors that may cause an unsafe outcome with physical and emotional harm and distress.

Findings Include:

1. The hospital nursing staff failed to ensure safe and effective nursing services by not supervising, assessing, and evaluating patient care (Refer to A0395);

2. The hospital failed to ensure nursing staff develops, and keeps current, a nursing care plan for each patient (Refer to A0396);

3. The hospital failed to ensure medications were administered in accordance with Federal and State law (Refer to A0405).

Based on observation, interview, document review and policy review the hospital failed to ensure the facility was constructed, arranged and maintained to ensure patient safety and to provide appropriate services and treatments.

The cumulative effect of the hospital's failure to ensure the hospital was constructed, arranged and maintained to ensure patient safety has the potential for all patients to protected from respiratory and food borne illnesses and diseases.

Findings Include:

1. The hospital failed to ensure the overall physical environment was maintained to ensure the safety and well-being of patients served (Refer to A0701);

2. The hospital failed to meet the life safety code from fire requirements (Refer to A0709); and

3. The hospital failed to ensure refrigerator/freezers maintained food within normal temperature ranges (Refer to A0726).

Based on interview, record review, document review, and policy review the hospital's governing body failed to ensure an effective operation of the grievance process by failing to identify alleged abuse complaints and investigate them as grievances, by failing to report all alleged abuse to the state agency, and by failing to implement the hospital's grievance policies and procedures for two of nine patients reviewed (Patients 1 and 3). The governing body's failure to ensure implementation of the grievance process places all patients receiving services at risk for abuse, neglect, and exploitation.

Findings Include:

Review of the hospital policy titled, "Client/Patient Grievance/Complaint process," last revised 05/05/21 showed "The Grievance Official is responsible for . . . coordinating with state and federal agencies as necessary in light of specific allegations."

Review of the hospital policy titled, "Abuse, Neglect, Exploitation," dated 01/12/17, showed "The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrator's designee. Local law enforcement, the state survey agency and the [human services agency] (if appropriate) will be notified in accordance with federal and state law." Further review showed, "protection to the patient during an investigation . . . temporary separation from other patients if a patient's behavior poses a threat of abuse or violence, temporary or permanent room change . . . temporary one on one supervision of a patient." The policy showed, "Incidents of alleged abuse, neglect, or misappropriation of patient property must be reported to the appropriate local, state, and federal agencies . . . The results of all investigations will be reported to . . . officials in accordance with state law (including the state survey and certification agency) within five (5) working days of the incident."

Review of the hospital policy and procedure titled, "Facility Investigation Procedures," labeled attachment C, undated, showed, "The purpose of this investigation is to address all types of abuse (verbal, physical, mental) and to identify staff member(s) responsible for the initial reporting of results to the proper authorities . . . Critical investigation approaches: a. begin investigation immediately upon notification that an incident has occurred. b. Review all statements for any needed clarification or expansion. c. Immediately follow up on all information gathered during the investigation. d. Notify the appropriate agencies, family members, physicians, and criminal authorities in a timely fashion. Conclusion: a. Review all information gathered. b. Report the results of the investigation within five (5) working days . . . d. Follow-up on any needed corrective action . . ."


Patient 1

Patient 1's record review showed a 31 year old female initially admitted to Meadowbrook Rehabilitation Hospital on 5/21/20 for inpatient rehabilitation from anoxic encephalopathy (lack of blood flow to the brain tissue). due to an accidental cocaine and methamphetamine overdose on 3/16/20. She has been in a near-vegetative state since, with severe aphasia (loss of ability to understand or express speech), not consistently tracking or following commands, and with extremity contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). She receives all nutrition and medications through a percutaneous endoscopic gastrostomy (PEG) tube. Patient 1 obtained a stage IV pressure ulcer at the facility. Patient 1's family member (F1) provided a audio/video device for Patient 1's room so that she could look in on her and provide verbal stimulus to Patient 1 and calm her down when she was agitated.

Review of [brand, model] manufacturer's video calling device showed, "make hands-free calls to the [app] or another [device] . . . devices are built with multiple layers of privacy protection. From the mic/camera off button and build-in shutter to the ability to delete your voice recordings, you have transparency and control over your [device] experience . . .Voice and video calling allow you to easily stay in touch with those who matter most.
You can also use [device] to drop in . . . Use drop in to open an instant conversation between your devices or with your [device] contacts. When you receive a drop in, the light indicator on your [device] pulses green and you connect to your contact automatically.

Staff C, DQRM sent an email on 03/09/21 at 2:11 PM to Patient 1's Durable Power of Attorney (DPOA) (legal representative chosen or appointed in the event a person cannot make decisions for themselves) showed that, "Going forward [facility] will not allow use of devices with active settings that allow for automatic drop in utilizing a video/camera to be set up in patient's rooms. We will place the [device] in [Patient 1]'s room and when you want to utilize the video/camera settings you can call into the 500 hall nurses' station and request staff turn those settings on . . . [staff] will reach out to you today around 3:30 (PM) to troubleshoot the settings of the [device]. She will then set the device in [Patient 1]'s room.

During an interview with F1 on 08/13/19 at 2:45 PM, she indicated that the nursing staff were always too busy to get the device from the office and place it in Patient 1's room. She was often told to call back later and rarely was able to communicate or see Patient 1 using the device. Even after the device was put in Patient 1's room unplugged, the staff would rarely plug the device in for use.

During an interview on 08/17/21 at 12:55 PM Staff C, DQRM stated that she locked the device in the life skills office most of the time and at times was in Patient 1's room unplugged. Staff C stated that she felt F1 was using the device to check that the staff was turning Patient 1 every two hours rather than being used for F1 to help keep Patient 1 calm. Further interview on 08/19/21 at 10:44 AM, Staff C, DQRM, stated that the use of recording devices such as cell phones, echo dot, computers, iPad, ETC., is decided on a case by case basis. It can be in patient room but cannot be on 24-7. They must call the nurse to have the device turned on and connect the device. It cannot run constantly. The facility failed to have a policy about use of these devices.

The hospital kept the device from the patient's room. The family had to purchase another device without a screen to place in the patient's room.The hospital failed to investigate the family's continued concerns about the ability to use the audio/video device to contact Patient 1 as a grievance. The hospital failed to provide evidence of interviews, client protections, and a letter of resolution to the DPOA in a timely manner. The hospital failed to ensure follow up actions were taken.


Patient 3

Review of Patient 3's record showed a 63-year-old with multiple medical problems including sepsis, obesity, end stage renal disease, diabetes, atrial fibrillation, and chronic anticoagulation. The patient was at Meadowbrook Rehabilitation Hospital and going to dialysis. The patient had a blood culture that was positive for vancomycin resistant enterococcus (VRE) and she was sent to the emergency room and was treated in the hospital. The patient had another line placed on 06/10/21. The patient transfers back with significant debility. The patient remains on antibiotics, her blood sugars are monitored and insulin titrated. The patient is doing well, however, she is still not able to ambulate.

Review of hospital document titled, "Grievance/Concern Report," dated 07/09/21 showed that Patient 3's daughter expressed "She has wounds and part of the recovery is proper nutrition. Her food is always cold and not what she orders. She feels like she's ignored at times, also. She said they get mad at her, her wc (sic) (wheel chair) is making sores on her hips. She has only had one shower since she's been here. She refuses to eat the food because it isn't good at all." Further review show actions taken: "Lots of staff training on wounds and wound care. Results of action taken: wound care PIP (performance improvement plan) put in place." The form fails to describe the resolution taken. Review of follow up letter to Patient 3's family showed "I have thoroughly reviewed your concerns and would like to share with you that necessary corrective actions have been taken to prevent recurrence of several of your concerns. Education and training has been and will continue to be provided to staff regarding customer service and patient rights. We are committed to providing quality care and will continue to make the necessary adjustments to ensure improved quality is provided."

During an interview on 08/19/21 at 10:34 AM, Patient 3's family member (F2) was asked if she has received a response from the hospital concerning the grievance filed on 07/06/21 and she stated that she has not. She recalled an unknown nurse helped her fill out a complaint about the food and apologized for the care her mother received.

During an interview on 08/19/21 at 12:41 PM, Staff C, DQRM, verified the grievance dated 07/06/21 for Patient 3 showed the investigation for the abdominal wounds was completed on 07/09/21, and the investigation for the bilateral thighs was completed on 07/13/21. Staff C sent a conclusion letter to F3 on 07/13/21 for both issues. Staff C stated that the results showed there were a lot of areas not followed properly, they started a performance improvement plan (PIP) on wounds 07/21/21, and we are presently preparing an extensive training for the providers. Staff C explained they are working on getting corporate to help them change the electronic medical record (EMR) to be more user friendly, and they are working on developing check lists for providers and staff assessments and documentation to use going forward. Staff C stated that they have completed a lot of education.

Based on interview, record review, document review, and policy review the hospital failed to ensure they promoted the exercise of rights for one of nine patients (Patient 1). The hospital's failure to promote the exercise of rights has the potential to affect all patients and may potentially cause harm or other adverse outcomes.

Findings Include:

Review of the hospital policy titled, "Client Rights and Confidentiality," last revised 05/07/21 showed, "It is the policy of [Facility] to assure all clients their rights . . .Clients have the right to a dignified existence, self-determination and access to persons and services inside and outside the facility. The facility will protect and promote the rights of each client. The facility will promote the exercise of rights for each client, including any who face barriers (e.g. (example) communication problems, hearing problems, cognition limits) in the exercise of these rights." Further review showed, "To receive care in a safe setting and be free from all forms of mental and physical abuse and harassment . . . to retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the rights of other clients . . . To have reasonable access to telephones to make or receive confidential calls . . . A client's rights, as set forth above, may be denied or limited only for good cause which shall be evidenced by the written order of the attending physician and may only be denied or limited if such denial or limitation is otherwise authorized by law. Reasons for denial or limitation of such rights shall be documented by the attending physician in the client's health record."

Review of the hospital policy titled, "Patient Rights," last revised 02/09/12, showed, "The patient shall be permitted to personal possessions unless doing so would infringe upon the rights of other patients or unless medically contraindicated as documented by the patient's physician in the medical record. Use of personal possessions must not interfere with therapy or other patient rights.

Patient 1

Patient 1's record review showed a 31 year old female initially admitted to Meadowbrook Rehabilitation Hospital on 5/21/20 for inpatient rehabilitation from anoxic encephalopathy due to an accidental cocaine and methamphetamine overdose on 3/16/20. She has been in a near-vegetative state since, with severe aphasia, not consistently tracking or following commands, and with extremity contractures. She receives all nutrition and medications through a percutaneous endoscopic gastrostomy (PEG) tube. Patient 1 obtained a stage IV pressure ulcer at the facility. Patient 1's family member (F1) provided a audio/video device for Patient 1's room so that she could look in on her and provide verbal stimulus to Patient 1 and calm her down when she was agitated.

Review of [brand, model] manufacturer's video calling device showed, "make hands-free calls to the [app] or another [device] . . . devices are built with multiple layers of privacy protection. From the mic/camera off button and build-in shutter to the ability to delete your voice recordings, you have transparency and control over your [device] experience . . .Voice and video calling allow you to easily stay in touch with those who matter most.
You can also use [device] to drop in . . . Use drop in to open an instant conversation between your devices or with your [device] contacts. When you receive a drop in, the light indicator on your [device] pulses green and you connect to your contact automatically.

Review of an email written by Staff C, DQRM, on 03/09/21 at 2:11 PM to Patient 1's Durable Power of Attorney (DPOA) (legal representative chosen or appointed in the event a person cannot make decisions for themselves) showed that, "Going forward [facility] will not allow use of devices with active settings that allow for automatic drop in utilizing a video/camera to be set up in patient's rooms. We will place the [device] in [Patient 1]'s room and when you want to utilize the video/camera settings you can call into the 500 hall nurses' station and request staff turn those settings on . . . [staff] will reach out to you today around 3:30 (PM) to troubleshoot the settings of the [device]. She will then set the device in [Patient 1]'s room.

During an interview with F1 on 08/13/21 at 2:45 PM, she indicated that the nursing staff were always too busy to get the device from the office and place it in Patient 1's room. She was often told to call back later and rarely was able to communicate or see Patient 1 using the device. Even after the device was put in Patient 1's room unplugged, the staff would rarely plug the device in for use.

During an interview on 08/17/21 at 12:55 PM Staff C, DQRM stated that she locked the device in the life skills office most of the time and at times was in Patient 1's room unplugged. Staff C stated that she felt F1 was using the device to check that the staff was turning Patient 1 every two hours rather than being used for F1 to help keep Patient 1 calm.

During an interview on 08/18/21 at 10:20 AM Staff CC, RN, stated that after the incident the device was suspended from use. The family ended up using an alternative device (without a screen) to call Patient 1. Staff CC stated that it was important that Patient 1 had a device that could be used without requiring physical manipulation as she was very contracted.

Review of Patient 1's record failed to show a physician's order denying her the use of the audio/video calling device as required by the facility's policy.

The hospital kept the audio/video device from the patient's room. The family had to purchase another device without a screen to place in the patient's room.

Based on observation, interview, record review, document review, and policy review, the hospital failed to follow manufacturer instructions for the safe use (MFU) and operation of durable medical equipment, specifically a Hoyer lift (an assistive device used to transfer a person that is unable to transfer otherwise) for one of one transfer oberved (Patient 18).

The hospital staff's failure to follow instructions for use of the Hoyer lift has the potential for patients to be harmed or injured during transfers.

Findings Include:

Review of the hospital policy titled, "[Mechanical] Lift," last revised 11/12/15, showed "Position wheelchair and lock brakes. Swing patient/resident's feet off bed; when patient/resident has been lifted off bed, grasp steering handles and move patient/resident over chair. U-base of lifter fits around wheelchairs. Lower patient/resident . . . push gently . . . on knees as they are being lowered into chair so correct position will be obtained. Lower patient/resident slowly. Guide patient/resident's descent."

Review of the hospital document titled, "[Manufacturer] user manual for the [electronic mobile patient lift]," undated, showed, "The legs of the lift must be in the maximum open position . . . for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only if (sic) it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately." Further review showed the steps of operation: "1. Ensure the legs of the lift (with patient) are in the open position. 2. Move the wheelchair into position. 3. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. 4. Position the patient over the seat with their back against the back of the chair. 5. Begin to lower the patient either by opening the control valve or by pressing the down button. 6. With one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward."

Observation on 08/11/21 at 3:41 PM showed Staff U, Physical Therapist, and Staff V, Certified Occupational Therapy Assistant (COTA) transferring Patient 18 from a tall physical therapy table to a transport wheelchair with a mechanical lift. Staff U was operating the mechanical lift and Staff V was positioning the wheelchair by picking it up and attempting to put it between the legs of the mechanical lift. Staff U operated the lift so that the support legs begin to narrow with the patient still in the air. Staff V places the wheelchair over one of the lifts legs and rolls it so that it is under the patient. Staff U lowers the lift and the patient is lowered into the wheelchair but against the chair's back. The wheelchair begins to tip backwards with the front wheels raising in the air about six inches. Staff V grabs onto the front of the wheelchair and holds onto it while spreading her legs far apart. Staff U holds onto the back of the wheelchair while operating the lift, bringing the patient fully down and then they lower the wheelchair onto its front wheels.

During an interview on 08/11/21 at 4:28 PM Staff A, CEO, acknowledged the misuse of the mechanical lift and directed Staff B, Chief Nursing Officer (CNO), to follow up with therapy staff.

Based on observation, interview, record review, document review and policy review, the hospital failed to ensure nursing supervised, assessed, and evaluated care for each patient regarding wound care, bathing, turning/re-positioning, dietary needs, consultations, and care planning for three of six patients (Patients 8 and 3). The facility's failure to ensure nursing supervises, assesses, and evaluates patient care concerning, patient's skin, bathing, turning/re-positioning, dietary needs, consultations and care planning has the potential for all patients to develop wounds, deterioration of wounds, deterioration of current illness, infection, and mortality.

Findings Include:

Review of a policy titled, "Pressure Injury Prevention Guidelines," dated 01/01/20, showed "The goal and preferences of the resident and/or authorized representative will be included in the plan of care ... Interventions will be documented in the care plan and communicated to all relevant staff ... Compliance with interventions will be documented in the medical record. A. For at-risk residents: treatment or medication administration records. B. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting ... The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound ... Consult dietician for nutritional screen for each resident who is at risk for a pressure injury, or has a pressure injury present ... Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition ... utilize small shifts in repositioning ...reposition when in bed, and out of bed ..."

Review of a policy titled, "Wound Treatment Management," dated 01/01/20, showed " ... Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change ...Treatments will be documented on the Treatment Administration Record (TAR) ... The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. ... Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage ... the facility will follow specific physician orders for providing wound care.

Review of a policy titled, "Skin Assessment," dated 01/01/20, showed " ...A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury ... Begin head to toe, thoroughly examining the patient's skin for conditions. Pay close attention to pressure point, bony prominences, and underneath medical devices. Remove any special garments or devices, if not contraindicated or ordered to remain in place. Remove any dressings, using clean technique, and note findings. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions ... Considerations for a bariatric Patient: Perform assessment with at least one other staff member to assist with mobility and positioning of body parts ... thoroughly inspect each surface of a skin fold ... Documentation of skin assessment: a. Assessment documented in Point Click Care under "Weekly Skin Assessment" b. Include date and time of the assessment, your name, and position title. c. Document observations (e.g. skin conditions, how the patient tolerated the procedure, etc.). d. Document type of wound. e. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). f. Document if patient refused assessment and why. g. Document other information as indicated or appropriate."

Review of a policy titled, "Pressure Injury Risk Assessment," dated 01/01/20, showed " ... Pressure injury risk assessments will be conducted by a licensed or registered nurse on admission/re-admission, weekly times four weeks, then quarterly. Assessments may also be conducted after a change of condition or after any newly identified pressure injury ... Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment."

Review of a policy titled, "Turning and Repositioning," dated 01/01/20, showed " ... Patients at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition ... The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hour. A maximum of thirty minutes before or after the scheduled time will be allotted for compliance with the schedule ... Type of pressure redistribution support surface in use (turning and positioning is still required on specialty surfaces ...)"

Review of a policy titled, "Bathing a Patient," (policy has no implemented or revised date), showed it is the practice of the facility to assist patients with bathing to maintain proper hygiene and help prevent skin issues."

Review of a document titled, "Wound Care-Infection Control (job code NRN1)," revised 02/11/16, showed " .... The Infection Control/Wound Care Nurse will be responsible for infection control, wound care and education of staff. This position will access wounds and determine both intermediate treatment needs and long-term treatment plans, will work with supervising physicians regarding case management. ... This individual will have oversight over all infection control and prevention related activities within the organization. Will be required to establish and implement infection control and employee health programs. Responsible for policies and procedures within the organization related to infection control and employee health. Responsibilities/Accountabilities: 1. Assessment ... 2. Care Planning ... 3. Implementing Care ... 4. Managing patient care ... Specific Educational/Vocational Requirements: 1. Graduate of an approved school of nursing is required. 2. Must be currently licensed by the State Board of Nursing. 3. Experience is preferred in rehabilitative or geriatric nursing. ... Job Skills: 1. Current physical assessment skills and comprehensive knowledge of nursing principles required, including the ability to recognize and identify symptoms and manage emergency situations. 2. Knowledge of medications, their proper dosage, and expected results. 3. Ability to coordinate, delegate and supervise nursing functions, problem solve and make decisions as necessary. Ability to create a patient-centered environment. 5. Ability to communicate in English both orally and in writing. 6. Basic knowledge of computer use. ..."

Documentation of wound education and training was requested for five nursing staff, Staff D, H, R, Z, and EE. A document titled, "Clinical Competency Validation - Wound Dressing: Aseptic," revised 01/2014, was provided for three of five nursing staff, Staff D, Z, and EE. The document was not signed or dated by Educator for Staff D and Z. A document titled, "Clinical Competency Validation - Negative Pressure Wound Therapy (NPWT)," revised 01/2014, was provided for three of five nursing staff, Staff D, Z, and EE. The document was not signed or dated by Educator for Staff D and Z.

During an interview on 08/04/21 at 4:35 PM, Staff B, Chief Nursing Officer (CNO), stated that there are no set times for wound care this week as the wound nurse Staff E, RN, Infection Control/Wound Care (IC/WC) is on vacation. Staff B, CEO, stated that Staff EE, RN, divided the wound care up for day and night shift staff and Staff B, CEO, verified the paper she gave us to be the assigned wound care for the week showing:
Day shift is to perform wound care on Tuesday to room 408, Patient 33 - rash to back (this was done this am); and Thursday to room 522, Patient 13 - incision monitoring.
Night shift is to perform wound care on Tuesday to room 511, Patient 26 - recurring pressure ulcer; Wednesday room 519, Patient 8 - maceration (the softening or breakdown of skin resulting from prolonged exposure to moisture) to right and left thigh; and Thursday room 514, Patient 12 - sacral/coccyx area - on 07/30/21 was documented 100% closed.
If Staff BB, Wound Care Physician, rounds today he will see 511, 514, and 519.

During an interview on 08/06/21 at 8:35 AM, Staff B, Chief Nursing Officer (CNO), stated that the expectation for staff performing patient care, they should be documenting when they do the care. Staff B, CEO, stated that the time listed in chart should be considered the time that care was administered.

During an interview on 08/06/21 at 9:45 AM, Staff Y, Registered Nurse (RN), stated having no knowledge of a policy that requires nurses to document a weekly comprehensive skin assessment and that nurses perform a basic skin assessment every shift, but that assessment rarely involves a full head to toe assessment. Staff Y, RN, stated patients with wounds are assessed weekly by the wound nurse who takes photographs and wound measurements. Staff Y, RN stated being unaware of any wound care training or education provided by the facility and if there were questions or lack of knowledge, Staff Y, RN, would ask the wound care nurse for assistance.

During an interview on 08/10/21 at 11:45 AM, Staff EE, RN/Infection Control/Wound Care (IC/WC), stated being new to the position of Wound Care Nurse since approximately March 2021. Staff EE, RN stated having no specialized education, training or experience as a wound care nurse. Staff EE, RN, stated that it is the responsibility of the wound care nurse to perform weekly skin/wound assessments on all wound care patients and to collaborate with the wound care physician on wound status updates and inputting wound care orders. Staff EE stated that nurses are required to complete and document a comprehensive head to toe skin assessment on all patients per shift and to report changes/concerns to her or the physician. Skin assessment is to include turning patient, removing clothing and undergarments, inspection of scalp, all bony prominences including elbows, hips, sacrum, heels, inspection for moisture and rashes, " ... they should be looking at everything per shift by the RN ..." Staff EE, RN, stated that dietician consults for wounds are made on a case by case basis with most patients receiving a dietician consult. Staff EE, RN, stated that patients with superficial rashes may not require a dietician consult. When asked to identify situations that would prompt contacting the wound care physician, Staff EE, RN, stated that the physician would be notified of any new changes or concerns, worsening wound status, or a stall in wound healing. Staff EE, RN, stated that the wound care nurse is involved in the QAPI and that the facility had identified wound care as an area for improvement. The facility had identified a breakdown in communication among nursing staff as a contributing factor in wound care concerns. Staff EE, RN, stated that communication expectations had been printed and handed out to nurses and supervisors with a result of more communication among the nursing staff.

During an interview on 08/10/21 at 1:10 PM, Staff Z, Licensed Practical Nurse (LPN), stated that wound care training and education consisted of "a quick skills lab for wound vac and basic dressing change." Staff Z, LPN, stated, "If wound care is new to me, I will ask an experienced nurse on how to perform it. I believe we are supposed to have a skills check list in orientation package, but I'm not sure." Staff Z, LPN, stated that there has been no education from facility on different types of wounds, wound care, wound staging, or wound care supplies and that in the documentation system, there is only the option for a weekly wound assessment and no option for a weekly skin assessment. Staff Z, LPN, stated that nurses are to document a skin assessment every shift and stated, "They truly aren't a comprehensive head to toe assessment."

During an interview on 08/10/21 at 1:30 PM, Staff AA, RN, stated being a contracted agency nurse. Staff AA, RN, stated facility provided no education or training in orientation on wound care. "I've rounded with the wound care nurse. Wound care orders are fairly easy to follow, and everyone is helpful. If the wound nurse is not here and I notice a change in wound status, I would notify the physician."

During an interview on 08/10/21 at 3:25 PM, Staff BB,Wound Care Physician, stated that the role as wound care physician is to perform rounds, debridement of wounds if necessary, and care plans. Staff BB performs rounds with the wound care nurse weekly in assessing patients and giving orders for wound care or consults if necessary. Staff BB stated that the documentation system is difficult so orders are put in by the wound care nurse and if wound care nurse is not available, another RN will enter wound care orders. Staff BB stated that it would be the expectation of nursing staff to inform immediately of any changes in wound care status or development of new wounds and that orders are to be followed. Staff BB stated that " ... I'm fairly new to facility and not familiar with the wound experience of Staff EE, RN, IC/WC."

During an interview on 08/18/21, Staff EE, RN, IC/WC, stated that it is the expectation for the weekly "Skin/Wound Assessment" be completed in its entirety every week for patients with wounds. Staff EE, RN, stated that patient care plans should include wound care anytime wounds and wound care orders are present and that it is the responsibility of the nurse entering wound care orders to update the care plan. Staff EE, RN, stated that this responsibility is usually hers. Staff EE, RN, stated that her role in training staff is "not super defined right now. If someone is not trained on a wound vac, I will train them. We don't currently have anything specific in wound care training such as staging, wound description, healing, etc. I don't have any kind of training or certification in wound care but hoping to in the future."

During an interview on 08/19/21 at 12:25 PM, Staff B, CNO, stated that it is her expectation for nurses to complete a head to toe and Braden assessment each shift for patients with a wound. Staff B, CNO, stated that Staff EE, RN, IC/WC will take pictures and assess wound care for all wound patients.



Patient 8

Record review showed a wound care order "Optifoam to coccyx, change after shower and PRN at bedtime every Tue, Thu, Sat for pressure wounds -Start Date- 02/11/21 -D/C Date- 03/18/21."

Review of Patient 8's current medical record, "IRF Nursing Admit/Re-admit Assessment," dated 02/17/21 at 1:55 PM, showed that Patient 8 was evaluated with National Pressure Ulcer Advisory Panel (EPUAP) - Grade 1 (Non-blanchable erythema (redness of the skin) of intact skin; persistent redness in light pigmented skin) of the coccyx (the small triangular bone at the base of the spinal column). Review of the "Skin/Wound Evaluation," from dates 02/17/21 - 07/09/21, showed no documentation of this wound.

Review of "Skin/Wound Evaluation," from dates 02/17/21 - 04/02/21, showed documentation of wound care to the left ischium tuberosity (an area located at the hip joint) with film and foam dressing. Review of the medical record between 02/17/21 - 04/02/21, showed no documentation of a physician order for wound care to the left ischium tuberosity.

Record review of "Change of Condition Follow Up," dated 04/29/21 at 3:10 AM, showed that Patient 8 had developed two blisters on the left upper thigh that resulted from catheter tubing being too tight against skin.
Review of "Skin/Wound Evaluation," from 04/02/21 - 07/02/21, showed no documentation of this wound.

Record review of "Skin/Wound Evaluation," showed incomplete wound documentation on the dates of 03/26/21, 07/02/21, 07/10/21, and 07/30/21.

Record review between 04/02/21 - 07/02/21 showed no documentation of a weekly "Skin/Wound Evaluation" of the sacral, right gluteal, and left gluteal wounds.

Observation on 08/05/21 at 10:45 AM, Staff H, Licensed Practical Nurse, LPN, cleansed Patient 8's sacral (a large, flat triangular shaped bone nested between the hip bones), right gluteal (area of the buttocks), and left gluteal wounds with wound cleanser and gauze. Staff H, LPN, applied miconazole cream (a prescription medication to treat fungal infection) and zinc ointment (a topical preparation that is applied to the skin to protect from moisture and irritation) to the wound areas. Staff H, LPN, did not remove or replace any wound dressings.Staff H, LPN, stated that patient did not require any type of dressing with wound care and "...hasn't had any dressing on yesterday or today....has not had any type of dressing for a long time." The record revealed a physician order for a left gluteal abrasion dressing with a start date of 08/03/21 and a discontinue date of 08/06/21. "Cleanse area with wound cleanser, apply xeroform (non-adherent dressing used to maintain a moist wound environment, made of fine mesh gauze enriched with petrolatum and 3% Xeroform), and cover with adhesive foam daily at bedtime.

Record review showed a physician order, The Treatment Administration Record (TAR) on 08/04/21-08/05/21, showed Staff D, LPN, documented wound care as completed at 6:00 AM. The wound care was charted as completed past the one-hour window for timely administration. Staff D, LPN, later verified that this wound care, although documented, was not done.

Observation on 08/17/21 at 9:55 AM, Staff Z, LPN, performed wound care to Patient 8, cleansed sacral wound, left gluteal wound, right gluteal area, and thigh areas. Staff Z, LPN, applied Xeroform to the left gluteal wound and covered with Optifoam (a foam dressing with a silicone adhesive border) as ordered. Staff Z, LPN, applied Xerform and Optifoam to the right gluteal fold in which there was no wound and no order for wound care to the area. No wound dressing was applied to the sacral wound as ordered. When asked which wound the first dressing was applied to, Staff Z, LPN, stated that the dressing was applied to the sacral wound. When asked to identify where the sacrum is located on the body, Staff Z, LPN, was able to correctly described the sacral area. When asked again where the first dressing was applied, Staff Z, LPN verified that the dressing was applied to the left gluteal wound instead of the sacrum. When asked where the second dressing was applied, Staff Z, LPN stated it was applied to the right gluteal area. When asked to verify wound orders, Staff Z, LPN, verified there was no order for a wound care dressing to the right gluteal area. When asked to verify if the ordered wound dressing was applied to the sacral area, Staff Z, LPN, verified that ordered dressing to sacral area was not completed.

During an interview on 08/17/21 at 11:00 AM, Staff D, LPN stated that although she had documented wound care as completed, she had not performed the dressing change to the sacral wound.


Record review of "Documentation Survey Report V2" for "Turn and Re-position every two hours to maintain skin integrity," dated 03/01/21 - 03/31/21, showed no documentation that task was completed for 19/31 days on the following dates and times:
1. 03/01/21 from 12:00 AM - 2:00 AM
2. 03/03/21 from 12:00 AM - 4:00 PM
3. 03/04/21 from 12:00 AM - 4:00 PM
4. 03/05/21 from 6:00 PM - 11:00 PM
5. 03/06/21 from 12:00 AM - 6:00 AM and 4:00 PM - 6:00 PM
6. 03/07/21 from 6:00 PM - 11:00 PM
7. 03/10/21 from 12:00 AM - 4:00 AM
8. 03/12/21 from 12:00 AM - 2:00 AM
9. 03/14/21 from 12:00 AM - 2:00 AM
10. 03/16/21 from 12:00 AM - 2:00 AM and 6:00 PM - 11:00 PM
11. 03/17/21 from 12:00 AM - 6:00 AM and 8:00 PM - 11:00 PM
12. 03/18/21 from 12:00 AM - 6:00 AM and 6:00 PM - 11:00 PM
13. 03/20/21 from 6:00 AM - 6:00 PM
14. 03/21/21 from 12:00 AM - 6:00 AM
15. 03/22/21 from 6:00 AM - 6:00 PM
16. 03/25/21 from 2:00 AM - 6:00 AM
17. 03/26/21 from 12:00 AM - 2:00 AM and 6:00 AM - 11:00 PM
18. 03/28/21 from 12:00 AM - 2:00 AM and 10:00 PM - 12:00 AM
19. 03/29/21 from 6:00 PM - 10:00 PM


Patient 3

Review of Patient 3's current medical record showed a stage 2 pressure ulcer to the coccyx (superficial ulcer presenting as an abrasion or blister to the tailbone) upon admission 05/05/21. Review of Patient 3's record from 05/05/21 to 06/03/21 showed:

The H&P dated 05/05/21 showed Staff SSS, DO, ordered a consult for wound care at acute care hospital C for an open area to the coccyx. Review of nursing documentation showed from 05/06/21 to 05/17/21 a wound consult was pending. Review of provider orders to send Patient 3 to hospital C for wound care failed to be followed up and scheduled.

Review of weekly skin and wound evaluations showed wound assessment failed to be performed weekly per policy for the first three weeks the patient was admitted.

Review of nursing care plan showed nursing staff failed to add wound care interventions. This failure caused the turn schedule not to populate and so no turns are documented for this timeframe.

Review of provider orders for wound care showed:

From 05/09/21 to 05/25/21, Optifoam 4x4 dressing (a foam dressing with a silicone adhesive border and waterproof backing that can stay in place for seven days) to coccyx wound until evaluated by wound care nurse, change every other day and prn for soiled or damaged coccyx dressing.

From 05/25/21 to 06/03/21, Santyl (removes dead tissue from wounds) to coccyx daily at hour of sleep (HS), Silvadene cream (stops the growth of bacteria in a wound) to bilateral inner thighs daily at HS, InterDry (relieves itching or burning to skin and manages moisture and odors) to abdominal folds, and barrier cream to excoriated skin on the perirectal area.

Review of bathing record for Patient 3 showed he received a tub bath on 05/07/21 and 05/11/21; a shower on 05/26/21 and a bed bath on 05/19/21, 05/22/21 and 05/29/21 for a total of six baths in 26 days. There is no documentation to show that Patient 3 was bathed 20 of 26 days of his admission.

Review of provider notes from Staff VVV, Advanced Practice Registered Nurse (APRN), showed the exact same progress note on 05/27/21, 05/28/21, 05/29/21 and 06/01/21 and Staff VVV failed to address his wounds.

Review of provider note dated 06/03/21, Staff VVV, APRN, collaborated with Staff FFFF, Infectious Disease Doctor for wounds, VRE (vancomycin resistant enterococcus) and the patient was transferred to acute care hospital E.

Review of Patient 3's readmission record from 06/14/21 to 07/06/21 showed:

From 06/15/21 (no stop date), Santyl ointment 250mg/gm apply to coccyx topically at bedtime for sloughing (peeling of dead cells on the skin) of wound cover with gauze dry dressing. The MAR failed to show orders for apply Santyl to coccyx topically - cover with hydrofera blue (for wound protection and it addresses bacteria and yeast), and Santyl to LLQ and cover with hydrofera blue that was documented on the nursing assessments beginning 07/03/21.
Review of nursing care plan showed the nursing staff failed to add wound care orders with interventions. This failure caused the turn schedule not to populate and so, no turns are documented for this time.

Weekly skin and wound evaluation on 06/15/21 showed no documentation of wounds to the left lower quadrant of the abdoment (LLQ). Nursing staff failed to document wounds to the LLQ until about two weeks after readmission on 06/28/21.

Review of provider notes on 06/17/21 showed orders for Santyl to necrotic lesions on LLQ; on 06/22/21 and 06/23/21 wounds were not visualized, on 07/01/21 nursing stated wounds worsening, not visualized, discussed with wound nurse, LLQ wounds necrotic, Santyl not effective, contusions noted medial to these areas; on 07/03/21 STAT labs ordered, results reviewed, no new orders, 07/04/21 labs repeated, no new orders, 07/05/21 continue wound orders, follow up with Hospital C appointment, and on 07/06/21 patient discharged to hospital D's ED for worsening wounds and lab values.


Review of Patient 3's record showed an order on 06/14/21 for baths/showers every Tuesday, Thursday and Saturday on night shift from 6:00 PM to 6:00 AM. Nursing staff only documented a bed bath on 06/17/21 and 06/20/21 and a shower on 06/27/21. Nursing staff failed to document whether Patient received a bath/shower for the other six scheduled days.

Review of a grievance from a family member (F2) dated 07/06/21, showed Patient 3 has wounds and part of the recovery is proper nutrition. Grievance stated that food is always cold and not what was ordered. Patient 3 feels ignored at times and feels that staff gets mad at Patient 3. Also states that wheelchair is making sores on hips. Patient 3 has only had one shower during hospital stay. Patient 3 refuses to eat the food because it is not good at all.

During an interview on 08/19/21 at 10:59 AM, Staff EE, RN, IC/WC verified that Patient 3's bathing and turning failed to be documented, wound care documentation was incomplete, and some were not performed as ordered, and a nursing care plan for wounds was not started...Staff EE, RN, IC/WC, stated that Staff BB, Wound Care Physician, does not round on all wound patients weekly and only has time for about five patients each week...Staff EE, RN, IC/WC was asked if she is completing weekly skin assessments for patients at risk according to the Braden score and she stated she is working on that process. Staff EE, RN, IC/WC, stated that she looks at the Braden score upon each admission, but not each week.

During an interview on 08/19/21 at 11:57 AM, Staff EE, RN, IC/WC verified Patient 3 never went to hospital C for wound care; a consult for wound care failed to be addressed for nine days; weekly wound assessments failed to be performed for three of four weeks for the first admission and two of three weeks for the second admission; the nursing care plan failed to include wounds for both admissions; turns failed to be documented for both admissions, the dietician failed to reassess the nutritional needs of the patient for both admissions and the dietary department at the facility failed to address the patient/family issues with the quality and temperature of the food; bathing failed to be provided for six of 26 days on the first admission and for six of nine scheduled days for the second admission; new wound care orders failed to be added to the second admission; providers failed to consistently assess wounds on both admissions; and nursing documentation failed to show LLQ wounds on their skin assessments from 06/21/21 to 06/28/21.

During an interview on 08/19/21 at 8:41 AM, Staff UUU, Medical Director (MD) stated that the wounds to Patient 3's inner thighs were of great concern as they became necrotic. Staff UUU, MD, remembers having conversations with staff about the wounds and stated they were possibly related to dialysis, immobility, size and wanting to stay in the wheel chair. Staff UUU, MD, stated that it was difficult to manage the wounds and they did they best they could. ... Staff UUU, MD, was asked if wounds should be opened on the patient care plan and Staff UUU, MD, stated that wounds should have been addressed on the care plan. Staff UUU, MD, clarified the food being cold should have been addressed, and the Braden assessment, care plan and quality of food which led to poor food intake all would contribute to poor wound healing and her admission back to an acute care hospital.

Based on observation, interview, record review, document review and policy review, the hospital failed to ensure nursing services included wound care with interventions in the comprehensive plan of care for two of five patients (Patient 2 and 3). Failure to include wound care on the plan of care resulted in the failure to populate a turning/re-positioning schedule in the facility's documentation system. The hospital's failure to ensure a comprehensive patient plan of care that includes actual wound care with interventions has the potential for all patients to develop wounds, deterioration of wounds, deterioration of current illness, infection, and mortality.

Findings Include:

Review of the hospital policy titled, "Nursing Care Plans," dated 05/19/19 showed the care plan will be completed within 12 hours of patient's admission ...during the first 48-hour evaluation each assigned nurse will complete narrative nursing notes addressing actual/potential problems ...each nursing diagnosis, goals (long term and/or short term) will be established with specific interventions to help achieve goals ... each nurse caring for the patient will review the plan of care before assuming care of the patient ...each nurse assigned to the patient will evaluate the plan of care and when changes are noted, the nurse will document such changes in the care plan ...the nurse assigned to the patient will be responsible to interpret the plan of care to the CNA.

Review of the hospital policy titled, "Pressure Injury Prevention Guidelines," dated 01/01/20, showed "The goal and preferences of the resident and/or authorized representative will be included in the plan of care ... Interventions will be documented in the care plan and communicated to all relevant staff ... Compliance with interventions will be documented in the medical record. A. For at-risk residents: treatment or medication administration records. B. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting ... The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound ... Consult dietician for nutritional screen for each resident who is at risk for a pressure injury, or has a pressure injury present ... Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition ... utilize small shifts in repositioning ...reposition when in bed, and out of bed ..."

Review of the hospital policy titled, "Pressure Injury Risk Assessment," dated 01/01/20, showed " ... Pressure injury risk assessments will be conducted by a licensed or registered nurse on admission/re-admission, weekly times four weeks, then quarterly. Assessments may also be conducted after a change of condition or after any newly identified pressure injury ... Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment."

Patient 2

Review of Patient 2's record showed a 51 year old male with a history of stroke. He is non-verbal due to expressive aphasia and has right sided weakness. The patient was originally admitted to Meadowbrook Rehabilitation Hospital on 11/15/19. He has had complications with sepsis from urinary tract infection and has had problems with blood clot in his bladder requiring surgery. Patient 2 developed a wound at the facility with physician orders for dressing changes starting on 11/30/19.

Review of Patient 2's medical record, "Care Plan," for the dates 05/25/20 - 12/31/20 and 03/01/21 - 04/09/21, did not include "actual" impaired skin integrity or wound care with interventions as part of the plan of care. The plan of care only included "potential" for impaired skin integrity and listed interventions that were suppose to prevent breakdown.


Patient 3

Review of Patient 3's current medical record showed a stage 2 pressure ulcer to the coccyx (superficial ulcer presenting as an abrasion or blister to the tailbone) upon admission 05/05/21. Review of Patient 3's record from 05/05/21 to 06/03/21 showed:

The H&P dated 05/05/21 showed Staff SSS, DO, ordered a consult for wound care at acute care hospital C for an open area to the coccyx. Review of nursing documentation showed from 05/06/21 to 05/17/21 a wound consult was pending. Review of provider orders to send Patient 3 to Hospital C for wound care failed to be followed up and scheduled.

Review of weekly skin and wound evaluations showed nursing staff failed to complete a wound assessment to be performed weekly per policy for the first three weeks the patient was admitted.

Review of provider orders for wound care showed:

From 05/09/21 to 05/25/21, Optifoam 4x4 dressing (a foam dressing with a silicone adhesive border and waterproof backing that can stay in place for seven days) to coccyx wound until evaluated by wound care nurse, change every other day and prn for soiled or damaged coccyx dressing.

From 05/25/21 to 06/03/21, Santyl (removes dead tissue from wounds) to coccyx daily at hour of sleep (HS), Silvadene cream (stops the growth of bacteria in a wound) to bilateral inner thighs daily at HS, InterDry (relieves itching or burning to skin and manages moisture and odors) to abdominal folds, and barrier cream to excoriated skin on the perirectal area. Review of Patient 3's medical record, "Care Plan," for the dates 05/05/21 - 07/06/21, did not include wound care with interventions as part of the plan of care.

During an interview on 08/19/21 at 11:57 AM, Staff EE, RN, IC/WC verified wound care was not added to the care plan (resulting in all wound interventions to include turning failed to be documented) for both admissions (05/05/21 and 06/14/21).

During an interview on 08/18/21, Staff EE, RN, IC/WC, stated that the patient care plans should include wound care anytime wounds and wound care orders are present and that it is the responsibility of the nurse entering wound care orders to update the care plan.

Based on observation, interview, document review and policy review the hospital failed to ensure medications were administered in accordance with Federal and State law and acceptable standards of practice concerning safe and therapeutic timing of medication administration for six of 15 patients (Patients 15, 26, 27, 31, 32, and 35), failed to monitor patient's response to medications for one of 15 patients (Patient 19), failed to monitor unattended medications for four of 15 patients (Patients 8, 9, 16, and 26), failed to administer medications using the correct route for one of 15 Patients (Patient 9), failed to waste a narcotic medication for one of 15 patients (Patient 9), failed to administer medications according to physician orders/parameters for four of 15 patients (Patients 1, 2, 5, and 8), and failed to identify patients prior to medication administration for seven of 15 patients (Patients 16, 19, 26, 29, 30, 31, and 32). The hospital's failure to ensure safe and therapeutic timing of medications, protect patient medication information, monitor patient's response to medications, monitor unattended medications, administer medications per the correct route, waste a narcotic medication administer medications according to physician orders/parameters and identify patients prior to medication administration has the potential for all patients to receive medications causing aspiration, allergic reactions, sedation, falls, injury, serious side effects, pain, and other adverse outcomes.

Findings Include:

Review of the hospital policy titled, "Administration of Medication," dated 10/2013 showed a tablet splitter may be used to avoid contact with the tablet...unused tablet portions are disposed of per hospital procedure for waste and must be witnessed when disposing a narcotic...medications may be crushed or capsules emptied out when a patient has difficulty swallowing or is tube fed...if the patient is tube fed, medications are crushed finely to prevent clogging the tube...medications are administered in accordance with written orders of the prescriber...obtain and record vital signs as necessary prior to medication administration...medications are to be administered at the time they are prepared ...patients are identified before medication is administered using at least two patient identifiers ...check identification band ...verify the patients name and date of birth ...verify identification with other hospital personnel ...medications are administered within 60 minutes before and after the scheduled time ...no medications are kept on top of the cart ...pages of the MAR (medication administration record) notebook containing patient health information must remain closed or covered when not in direct use ...once removed from the package/container, used medication doses shall be disposed of according to the hospital policy."

Review of the hospital policy titled, "Storage of Medication," dated 03/2011, showed all medications remain in secure locked area until administration.

Review of the hospital policy titled, "Confidentiality of Medical Information," dated 04/11/19, showed when in use within the institution, health records should not be left unattended in areas accessible to unauthorized individuals.


A. The following medications failed to be administered, according to hospital policy, within one hour prior to or after the scheduled time:

Observation on 08/05/21 at 9:15 AM of Patient 15 showed Staff M, Agency RN, administering Colace 100 milligrams (mg, medication provided for constipation) by mouth (PO), Propranolol 10 mg (medication for high blood pressure), PO both scheduled for 8:00 AM, at 9:15 AM (one hour and 15 minutes late), and Nicotine 14 mg (medication provided to decrease smoking sensation) patch placed on the patient's body, was documented as administered at 8:02 AM, but not actually given until 9:15 AM (one hour and 15 minutes late). Staff M verified the times the medications were scheduled and the actual time she administered them.

Observation on 08/04/21 at 10:07 PM of Patient 26, Staff R, LPN entered room 511 and administered Patient 26's scheduled 8:00 PM medications at 10:07 PM (two hours and seven minutes late).

Observation on 08/04/21 at 9:07 PM of Patient 27, Staff D, LPN, entered Room 502 and administered Patient 27's scheduled 8:00 PM medications at 9:06 PM (one hour and six minutes late).

Observation on 08/04/21 at 9:16 PM of Patient 31, Staff R, LPN administered Patient 31's medications scheduled for 8:00 PM at 9:12 PM (one hour and 12 minutes after the scheduled time).

Observation on 08/04/21 at 9:39 PM of Patient 32, Staff R, LPN entered room 504, and administered Patient 32's medications medications scheduled for 8:00 PM at 9:39 PM (one hour and 39 minutes late).

Observation on 08/04/21 at 10:15 PM of Patient 35, Staff D, LPN entered Room 503 and administered Patient 35's medications scheduled for 8:00 PM at 10:15 PM (two hours and 15 minutes late).

During an interview on 08/17/21 at 11:00 AM, Staff D, RN stated that the computer at the nurses' station is utilized to document medication administration on each patient's Medication Administration Record (MAR) and verified that on 08/04/21, six of six patient medication administrations were documented as given prior to actual administration. She verified that medications should not be documented as given prior to administration and stated, "but that's how it's done here". Staff D stated that per policy, medications may be administered up to one hour before and one hour after ordered administration time.

During an interview on 08/04/21 at 9:28 PM, Staff R, LPN was asked what the yellow line on the MAR means and she explained it shows when the medications are given on time, and when it turns pink that means the medications are past due. Staff R, stated that they are to give the medications one hour before or after the scheduled time, but you can still give them if it's not at the scheduled time.


B. The following patient had no vital sign parameters and nursing staff failed to notify the physician regarding the patient's blood pressures which were extremely elevated.

Review of Patient 19's medical record showed she was admitted on 08/02/21 at 2:00 PM with a diagnosis of cerebral infarction (stroke - damage to the tissues in the brain due to loss of oxygen in the area), hypertension (high blood pressure), hypertension urgency (very high blood pressures with minimal or no symptoms indicating acute organ damage), chronic kidney disease stage five (very close to failure), obesity, uremic myopathy (structural muscle abnormalities in patients with chronic kidney failure), and epilepsy (seizures).

Review of the vitals summary sheet showed the nursing staff failed to notify the physician of the following high blood pressures in a timely manner resulting in the patient requiring admission to acute care hospital B more than 24 hours later on 08/05/21 at 5:50 PM for a hypertensive emergency:

On 08/04/21 at 12:21 PM BP of 196/81
On 08/04/21 at 5:24 PM BP of 200/79
On 08/04/21 at 6:50 PM BP of 192/79
On 08/04/21 at 7:21 PM BP of 200/94
On 08/05/21 at 11:56 AM BP of 185/88

Observation on 08/04/21 at 7:21 PM of Patient 19, Staff R, LPN entered room 521 and the patient was very upset stating that she wanted all her blood pressure medications. Patient 19's blood pressure was 200/94.

Observation on 08/04/21 at 8:09 PM, Staff R, LPN returned to Patient 19's room (48 minutes later) with her medications and the patient stated, "I need something right away."

During an interview on 08/04/21 at 8:22 PM, Patient 19 stated that she is not receiving all the medications for her blood pressure that she had ordered at the previous place.

During an interview on 08/05/21 at 10:03 AM, Patient 19 stated that at the facility she left recently, her blood pressures were well controlled. She stated that she transferred to this facility three days ago (08/02/21) and she has had headaches, nausea, vomiting, and been so sick due to her high blood pressures.

During an interview on 08/16/21 at 2:33 PM, Staff UUU, MD, Medical Director, stated that review of the medications on Patient 19's disharge medications showed the following cardiac medications failed to be listed as "continue," Isosorbide (relaxes and widens blood vessels to blood can flow more easily to the heart), Nifedipine (for high blood pressure and chest pain), Carvedilol (for high blood pressure and heart failure), and Clonidine (for high blood pressure). Staff UUU, MD was asked what blood pressure (BP) parameters would be considered high and necessitate a call to the physician for further orders, and she stated that it depends on how the patient is clinically presenting and in general if the BP levels are raised above 160/90. Staff UUU, MD explained for some stoke patients the parameters could be higher. Upon review of Patient 19's medical record by Staff UUU she commented it showed she ran consistently high BP's and depending on her clinical presentation and symptoms, she would think 160/90 is a reasonable parameter to call a physician for further orders.


C. The following patient's medications were left unattended:

Observation on 08/04/21 at 7:29 PM, Staff R, LPN proceeded to take Patient 16's medications out of her pocket (a small plastic baggie with his identification sticker on and medications inside), placed them on the medication cart next to the nurse's station, checked them off the MAR, in the electronic medical record (EMR), and left them there when she went to answer a phone call. The medications were out of Staff R's sight when she took the phone call. Patient 16's medications were left unattended on top of the medication cart for a total of 31 minutes from 7:29 PM to 8:00 PM and could have been accessed by unautorized personnel.

Observation, in the 500-hallway lounge area, on 08/16/21 at 12:25 PM, showed that a pill cutter (device used to cut pills in half) was sitting on a portable work computer, with half a pill inside, and no staff present. Several unidentified patients were near the unattended medication.

During an interview on 08/16/21 at 12:50 PM, Staff TT, RN, stated that he thinks the medication in the pill cutter was from his morning medication pass from 8:00 am to 8:30 AM. Staff TT stated that he can't tell what medication it was, but he could look at the meds he gave this am to find out what medications it could possibly be. Staff TT verified that the medication should have been wasted immediately per policy, and that it was an "honest mistake." Review of patient charts, showed that the medication could be Baclofen 10 mg (a medication used to relieve pain, and muscle spasms) for Patient 26, or Carvedilol 6.25 mg (a medication used to treat HTN) for Patient 9.

Observation on 08/04/21 At 9:42 PM, Staff D, LPN verified Patient 8's order for Tramadol (a narcotic used to control pain) specified dosage as 0.5 tablet. She utilized a pill cutter to cut tablet in half and left the other half of the medication tablet in the pill cutter unattended at the nurses' station while she went to administer medications. There were no staff present at the nurses station when Staff D left and so the medication could have been accessed by unathorized users. An unidentified patient was noted wandering around nurses' station at the time.

During an interview on 08/17/21 at 11:00 AM, Staff D, LPN verified that unused narcotic medications require immediate wasting with a witness and verified that failure to waste a narcotic drug immediately without a witness was not documented or reported.

During an interview on 08/17/21 at 11:00 AM, Staff D, LPN verified on 08/04/21 at 8:12 PM she utilized a pill cutter to split a tablet of Carvedilol (a medication to control blood pressure) in half and left the other half of the tablet in the pill cutter which was left unattended and unsecured at the nurses' station. She verified that leaving medications unsecured and unattended could result in unauthorized staff, visitors, or patients obtaining access of prescription medications. Staff D, LPN, verified that the incident was not documented or reported. She verified that unused medications should be wasted immediately.

Observation on 08/04/21 at 8:12 PM, Staff D, LPN, entered Patient 9's room and he reported uncontrolled pain in right side of neck and head for the past 24 hours that was not relieved with prescribed acetaminophen. She stated that inquiry would be made for alternative medications for pain relief. Patient 9, informed her that his medications have been administered orally (by mouth) because administration through the gastrostomy tube (G-tube) (a tube inserted through the wall of the abdomen directly into the stomach) causes nausea. She informed the patient a double check of the medication orders would be performed before administering the medications. She took the medications to the nursing station and using the MAR, verified route of administration. The patient's medication orders stated all medications were to be administered via G-tube. She did not call the physician for clarification of orders or to confirm if medications may be administered orally. She did not notify a physician of the patient's complaint of uncontrolled pain. At 8:45 PM, she went back to the patient's room and allowed the patient to take the medications orally. This placed Patient 9 at risk for choking and aspiration.

During an interview on 08/17/21 at 11:00 AM, Staff D, LPN, verified that on 08/04/21 at 8:12 PM, Patient 9's medications were to be administered via G-tube (a tube inserted through the wall of the abdomen directly into the stomach) and was told by the patient that he preferred to take medications orally. Staff D, LPN verified that without contacting the physician for order change or clarification, the medication was administered to the orally. She verified that she did not document a medication administration error or report that medication had been administered incorrectly to anyone. Staff D, LPN stated that after giving it some thought, she should have notified the physician to inquire if the medication could have been administered orally. She stated that she has not seen the policy on documenting medication errors.


D. The following medications failed to be given according to providers orders and within prescribed parameters:

Review of Patient 1's MAR showed an order for Propranolol HCl (hydrochloride, a salt) (medication used to treat high blood pressure) tablet 20mg (milligram) give one tablet via peg-tube (a means to pass medication and nutrition directly into the stomach or intestines in order to bypass the mouth and throat) three times a day for hypertension. Hold for heartrate less than 55 and systolic blood pressure (SBP) (blood pressure when the heart is contracting) less than 100. Normal range is less than 120.

On 12/11/20 at 8:00 PM Staff VV, RN, gave Patient 1 propranolol with a blood pressure of 97/60 (SBP <100).
On 12/13/20 at 8:00 AM, Staff EE, RN, Infection Control and Wound Care Nurse (IC/WC), gave Patient 1 propranolol with a blood pressure of 95/60 (SBP <100).
On 12/16/20 at 8:00 PM Staff HHH, LPN, gave Patient 1 propranolol with a blood pressure 94/53 (SBP <100).
On 12/22/20 at 8:00 PM Staff VV, RN, gave Patient 1 propranolol with a blood pressure 93/51 (SBP <100).
On 12/30/20 at 2:00 PM Staff GGG, LPN, gave Patient 1 propranolol with a blood pressure of 90/56 (SBP <100).
On 12/31/20 at 2:00 PM Staff HHH, LPN, gave Patient 1 propranolol with a blood pressure of 89/54 (SBP <100).
On 01/02/21 at 8:00 PM Staff NN, RN, gave Patient 1 propranolol with a blood pressure of 99/64 (SBP <100).
On 01/13/21 at 2:00 PM Staff Z, LPN, gave Patient 1 propranolol with a blood pressure of 96/56 (SBP <100).
On 01/17/21 at 8:00 AM Staff GG, LPN, gave Patient 1 propranolol with a blood pressure of 92/50 (SBP <100).
On 01/29/21 8:00 PM Staff VV, RN, gave Patient 1 propranolol with a blood pressure of 95/54 (SBP <100).
On 02/05/21 at 8:00 PM Staff FFF, LPN, gave Patient 1 propranolol with a blood pressure of 91/54 (SBP <100).
On 02/07/21 at 8:00 PM Staff FFF, LPN, gave Patient 1 propranolol with a blood pressure of 97/54 (SBP <100).
On 02/14/21 at 8:00 AM Staff HH, LPN, gave Patient 1 propranolol with a blood pressure of 93/82 (SBP <100).
On 02/14/21 at 2:00 PM Staff HH, LPN, gave Patient 1 propranolol with a blood pressure of 93/82 (SBP <100).
On 03/22/21 at 8:00 AM Staff DDD, RN, gave Patient 1 propranolol with a blood pressure of 99/57 (SBP <100).
On 03/27/21 at 8:00 AM Staff EEE, RN, gave Patient 1 propranolol with a blood pressure of 95/59 (SBP <100).
On 04/02/21 at 8:00 PM, Staff SS, RN, gave Patient 1 propranolol with a blood pressure of 98/64 (SBP <100).
On 04/04/21 at 8:00 AM, Staff SS, LPN, gave Patient 1 propranolol with a blood pressure of 83/52 (SBP <100).
On 04/04/21 at 2:00 PM, Staff SS, LPN, gave Patient 1 propranolol with a blood pressure of 96/62 (SBP <100).
On 04/28/21 at 8:00 AM, Staff UU, LPN, gave Patient 1 propranolol with a blood pressure of 89/56 (SBP <100).
On 04/28/21 at 2:00 PM, Staff UU, LPN, gave Patient 1 propranolol with a blood pressure of 89/56 (SBP <100).
On 05/01/21 at 8:00 AM, Staff GGG, LPN, gave Patient 1 propranolol with a blood pressure of 99/55 (SBP <100).
On 05/01/21 at 2:00 PM, Staff GGG, LPN, gave Patient 1 propranolol with a blood pressure of 99/56 (SBP <100).
On 05/03/21 at 8:00 PM, Staff QQ, RN, failed to give Patient 1 propranolol with a blood pressure of 100/62.


Patient 2 had an order for Hydrochlorothiazide (HCTZ) (medication used to treat fluid retention and high blood pressure) 12.5 mg give 25 mg via peg-tube twice daily. Hold if SBP less than 120, Diastolic Blood Pressure (DBP) (the measurement of force against your artery walls as your heart relaxes) is less than 60, for essential primary hypertension.

On 03/02/21 at 8:00 AM, Staff XX, RN gave Patient 2 HCTZ with a blood pressure of 111/80 (SBP <120).
On 03/04/21 at 8:00 AM Staff WWW, LPN gave Patient 2 HCTZ with a blood pressure of 113/72 (SBP <120).
On 03/07/21 at 8:00 PM Staff XXX, LPN gave Patient 2 HCTZ with a blood pressure of 114/68 (SBP <120).
On 03/11/21 at 8:00 AM Staff II, RN gave Patient 2 HCTZ with a blood pressure of 111/76 (SBP <120).
On 03/17/21 at 8:00 AM Staff Y, RN gave Patient 2 HCTZ with a blood pressure of 111/89 (SBP <120).
On 03/18/21 at 8:00 AM Staff PPP, LPN gave Patient 2 HCTZ with a blood pressure of 114/71 (SBP <120).
On 03/21/21 at 8:00 PM Staff KK, RN, gave Patient 2 HCTZ with a blood pressure of 176/56 (DBP<60).
On 03/25/21 at 8:00 PM Staff XX, RN, gave Patient 2 HCTZ with a blood pressure of 111/65 (SBP <120).

Patient 2 had an order for Metoprolol (a medication to treat high blood pressure) 50 mg via peg-tube twice daily for essential primary hypertension. Hold if SBP is less than 120, DBP less than 60, and pulse is less than 60.

On 03/02/21 at 8:00 AM, Staff XX, RN gave Patient 2 Metoprolol with a blood pressure of 111/80 (SBP <120).
On 03/04/21 at 8:00 AM Staff WWW, LPN gave Patient 2 Metoprolol with a blood pressure of 113/72 (SBP <120).
On 03/07/21 at 8:00 PM Staff XXX, LPN gave Patient 2 Metoprolol with a blood pressure of 114/65 (SBP <120).
On 03/11/21 at 8:00 AM Staff II, RN, gave Patient 2 Metoprolol with a blood pressure of 111/76 (SBP <120).
On 03/17/21 at 8:00 AM Staff Y, RN, gave Patient 2 Metoprolol with a blood pressure of 111/89 (SBP <120).
On 03/18/21 at 8:00 AM Staff PPP, LPN gave Patient 2 Metoprolol with a blood pressure of 114/71 (SBP <120).
On 03/21/21 at 8:00 PM Staff KK, RN, gave Patient 2 Metoprolol with a blood pressure of 176/56 (DBP<60).
On 03/25/21 at 8:00 PM Staff XX, RN, gave Patient 2 Metoprolol with a blood pressure of 111/65 (SBP <120).


Review of Patient 5's MAR showed an order for metoprolol tartrate (a medication used to treat high blood pressure) give 25 mg via peg-tube two times a day for high blood pressure hold for SBP less than 120 or pulse less than 60. The order was written on 03/29/21 and discontinued on 06/03/21.

On 04/05/21 at 8:00 PM Staff II, RN, gave Patient 5 metoprolol with a blood pressure of 104/70 (SBP < 120).
On 04/06/21 at 8:00 PM Staff JJ, CNA, gave Patient 5 metoprolol with a blood pressure of 119/72 (SBP < 120).
On 04/07/21 at 8:00 PM Staff KK, RN, gave Patient 5 metoprolol with a blood pressure of 117/21 (SBP < 120).
On 04/08/21 at 8:00 PM Staff LL, LPN, gave Patient 5 metoprolol with a blood pressure of 101/66 (SBP < 120).
On 04/09/21 at 8:00 PM Staff LL, LPN, gave Patient 5 metoprolol with a blood pressure of 116/76 (SBP < 120).
On 04/11/21 at 8:00 PM Staff MM, RN, gave Patient 5 metoprolol with a blood pressure of 93/59 (SBP < 120).
On 04/12/21 at 8:00 PM Staff NN, RN, gave Patient 5 metoprolol with a blood pressure of 111/60 (SBP < 120).
On 04/13/21 at 8:00 PM Staff OO, RN, gave Patient 5 metoprolol with a blood pressure of 107/61 (SBP < 120).
On 04/14/21 at 8:00 PM Staff PP, RN, gave Patient 5 metoprolol with a blood pressure of 106/59 (SBP < 120).
On 04/16/21 at 8:00 AM Staff F, LPN, gave Patient 5 metoprolol with a blood pressure of 100/56 (SBP < 120).
On 04/20/21 at 8:00 AM Staff GG, LPN, gave Patient 5 metoprolol with a blood pressure of 116/62 (SBP < 120).
On 04/22/21 at 8:00 PM Staff QQ, RN, gave Patient 5 metoprolol with a blood pressure of 105/56 (SBP < 120).
On 04/23/21 at 8:00 AM Staff HH, LPN, gave Patient 5 metoprolol with a blood pressure of 100/60 (SBP < 120).
On 04/23/21 at 8:00 PM Staff NN, RN, gave Patient 5 metoprolol with a blood pressure of 110/60 (SBP < 120).
On 04/29/21 at 8:00 AM Staff GG, LPN, gave Patient 5 metoprolol with a blood pressure of 102/59 (SBP < 120).
On 04/30/21 at 8:00 PM Staff RR, LPN, gave Patient 5 metoprolol with a blood pressure of 110/76 (SBP < 120).
On 05/07/21 at 8:00 AM Staff SS, LPN, gave Patient 5 metoprolol with a blood pressure of 86/58 (SBP < 120).
On 05/07/21 at 8:00 PM Staff PP, LPN, gave Patient 5 metoprolol with a blood pressure 106/75 (SBP < 120).
On 05/10/21 at 8:00 PM Staff HH, LPN, gave Patient 5 metoprolol with a blood pressure of 104/56 (SBP < 120).
On 05/11/21 at 8:00 PM Staff VV, RN, gave Patient 5 metoprolol with a blood pressure of 100/61 (SBP < 120).
On 05/12/21 at 8:00 PM Staff WW, LPN, gave Patient 5 metoprolol with a blood pressure of 109/58 (SBP < 120).
On 05/13/21 at 8:00 PM Staff XX, RN, gave Patient 5 metoprolol with a blood pressure of 114/64 (SBP < 120).
On 05/16/21 at 8:00 PM Staff MM, RN, gave Patient 5 metoprolol with a blood pressure 101/66 (SBP < 120).
On 05/30/21 Staff TT, LPN, gave Patient 5 metoprolol with a blood pressure of 112/50 (SBP < 120).
On 05/31/21 Staff UU, LPN, gave Patient 5 metoprolol with a blood pressure of 108/71 (SBP < 120).

Review of Patient 5's MAR showed the hold parameter orders for metoprolol tartrate changed on 06/03/21 to hold if SBP less than 110 or pulse less than 60.

On 06/09/21 at 8:00 PM, Staff WW, LPN, gave Patient 5 metoprolol with a blood pressure of 108/73 (SBP < 110).
On 06/25/21 at 8:00 AM, Staff HH, LPN, gave Patient 5 metoprolol with a blood pressure of 103/67 (SBP < 110).
On 06/28/21 at 8:00 AM, Staff UU, LPN, gave Patient 5 metoprolol with a blood pressure of 102/56 (SBP < 110).
On 07/17/21 at 8:00 AM, Staff AAA, RN, gave Patient 5 metoprolol with a blood pressure of 101/57 (SBP < 110).
On 07/27/21 at 8:00 AM, Staff Y, RN, gave Patient 5 metoprolol with a blood pressure of 107/59 (SBP < 110).
On 08/03/21 at 8:00 AM, Staff CCC, CNA, gave Patient 5 metoprolol with a blood pressure of 107/70 (SBP < 110).
On 08/04/21 at 8:00 AM, Staff CCC, CNA, gave Patient 5 metoprolol with a blood pressure of 106/84 (SBP < 110).


Review of Patient 8's MAR showed an order for midodrine HCl 5 mg tablets, give one by mouth twice a day for hypotension (low blood pressure), hold if SBP is greater than 140.

On 02/19/21 Staff YYY, RN, gave Patient 8 midodrine with a blood pressure of 142/85 (SBP > 140).

Review of Patient 8's MAR showed an order for oxycodone HCL 5mg, one per mouth every three hours as needed for pain.

On 03/11/21 Staff ZZZ, LPN, gave Patient 8 an oxycodone at 10:26 AM. Staff ZZZ gave another oxycodone at 12:14 PM, less than three hours from the previous dose.

Review of Patient 8's MAR showed an order for hydrocodone HCL 5 mg, one per mouth every four hours as needed for pain, order received on 03/19/21.

On 04/01/21 Staff EEE, RN, gave a hydrocodone at 8:40 AM. Staff EEE gave another dose at 12:20 PM, less than four hours from the previous dose.
On 04/12/21 Staff BBBB, RN, gave a hydrocodone at 8:47 AM. Staff BBBB gave another dose at 12:28 PM, less than four hours from the previous dose.
On 05/28/21 Staff EEE, RN, gave a hydrocodone at 8:16 AM. Staff EEE gave another dose at 12:09 PM, less than four hours from the previous dose.

During an interview on 08/17/21 at 12:55 PM Staff C, Director of Quality and Risk Management, (DQRM) was informed about the medication errors around blood pressure parameters. Staff C stated that she was not aware and does not have documentation about these medication errors.

During an interview on 08/17/21 at 11:59 AM Staff EE, RN, IC/WC stated that if a patient had a PRN (as needed) medication for every four hours the soonest it could be administered is four hours from the last dose. Staff EE stated that she would expect carvedilol and amlodipine to have blood pressure parameters with the order. Staff EE stated that she would contact the physician and get parameters if there weren't any included with the order. Staff EE was informed of Patient 1, Patient 5, and Patient 8's medication errors. Staff EE stated that she would consider them to be medication errors.


E. The following patients failed to be identified prior to medication administration per policy:

Observation on 08/04/21 at 8:00 PM, Staff R, LPN administered Patient 16's medications at 8:07 PM and failed to ensure patient identification prior to administering his medications.

Observation on 08/04/21 at 8:09 PM, Staff R, LPN returned to Patient 19's room addressed the patient by her first name but failed to ensure patient identification prior to administer medications.

Observation on 08/04/21 at 10:02 PM, Staff R, LPN entered room 511 and failed to ensure patient identification (Patient 26) prior to administering the medications.

Observation on 08/04/21 at 8:27 PM, Staff R, LPN entered room 509 and failed to ensure patient identification (Patient 29) prior to administering his medications.

Observation on 08/04/21 at 8:55 PM, Staff R, LPN entered the room of Patient 30 and failed to ensure patient identification prior to administering medications.

Observation on 08/04/21 at 9:01 PM, Staff R, LPN entered room 516 and failed to ensure patient identification (Patient 31) prior to administering the medications.

At 9:38 PM, Staff R, RN entered room 504 and failed to ensure patient identification (Patient 32) prior to administering the medications.

During an interview on 08/17/21 at 11:00 AM, Staff D, RN stated that she realized she forgot to ask for at least two patient identifiers on patients during medication administration. "I don't remember which patients, but I know I forgot to check on a couple." She verified that failure to check patient identifiers could result in a patient receiving the wrong medication and should be reported to the supervisor.

Based on observation, interview, document review, and policy review the hospital failed to ensure the overall hospital environment was developed and maintained for the safety and well-being of all patients including the kitchen, sanitary food preparation equipment and environment, sanitary laundry room, safe and clean floors and ceiling tiles, seals around the base of an outside door, use of extension cords, clean and sanitary patient common areas, preventive maintenance to patient equipment, and safe use of liquid oxygen. Failure of the hospital to ensure environmental safety is developed and maintained has the potential for all patients to encounter harm, injury, illness, disease, falls, inappropriate treatments and medications related to inaccurate vital signs.

Findings Include:

Review of the hospital policy titled, "Preventative Maintenance Program," dated 10/25/19 showed that the Director shall develop a calendar to assist with keeping track of all tasks, documentation shall be completed for all tasks, and kept for three years.

Review of the hospital policy titled, "Maintenance repair log," revised date 04/11/13 showed that a maintenance repair log be completed to help in regulating work as needed ...books are kept at the nurse's station.

Review of the hospital policy titled, "Pest Control Program," dated 10/25/19 showed that the facility will maintain an agreement with a qualified outside pest service. Facility will involve indoor and outdoor methods that are deemed appropriate by regulations.


Observation, in the 400-hallway, on 08/04/21 at 12:05 PM, showed an unidentified patient sitting in a wheelchair next to the wall. The patient was observed peeling the paint and plaster off the wall. An unidentified staff member acknowledged the patient's behavior, but did not ask him to stop.

Observation, in the 500-hallway kitchen, on 08/04/21 at 2:30 PM showed that there was rust in the bottom of the kitchen sink, and grease on the lids of the warm serving container lids.

Observation, in the 300-hallway patient laundry room, on 08/04/21 at 2:55 PM showed that there was dirt and hair around the lid of the washing machine, linens on top of the dryer, dirt on the floor around the dryer, socks in the dryer, and a full lint trap.

Observation, in the facility kitchen, on 08/04/21 at 3:00 PM, showed that there was 1-2 cm of standing water in the walk-in refrigerator. Bath blankets were laying on the ground and soaked in water, a bucket was under a drain, and full of dripping water. Mold and leaking drain lines were observed in the dish room of the kitchen. Part of the wall was collapsing. Numerous lights are missing plastic coverings or were broken. Several lights were burned out and not replaced. A floor box fan was noted on the floor, covered in dirt and lint. The stove was covered in grease and oil. The stove had foil wrapped around handles, the hinges on the below door were broken. Bath blanket under a leaking sink next to the stove. The stove hood was covered in grease. All surfaces and equipment in the kitchen were stained and covered in grease.

Observation, in the basement hallway, on 08/05/21 at 2:15 PM, showed that there were numerous ceiling tiles broken, sagging, stained, or missing. Several floor tiles were peeling up, cracked, or missing part of the individual tiles. A leak was observed from the ceiling, and water on the floor.

Observation, in the 400-hallway, on 08/05/21 at 2:25 PM, showed that isolation carts were sitting on the floor, and plaster on the ground near the nurse's station. Room 405 has multiple sockets with plugins and extension cords plugged into it. Patient care items, Prevalon boots, were placed directly on the floor.

During an interview on 08/05/21 at 10:50 AM, Staff O, Dietary Account Manager with Health Care Services stated that the walk-in refrigerator has been leaking for over a month to two months. Stated that the refrigerator had "froze up" two months ago, maintenance was notified, and called contract workers to look at refrigerator. Stated that shortly after it was "fixed," the pipes started to drip. Maintenance then believed the drain was frozen, and attempted to fix the drain. States that the pipes continue to drip. There are buckets placed under the pipes to catch the water, that are emptied daily. There are bath blankets placed on the floor of the fridge for the water overflow. During a tour of the kitchen on 08/04/21 at 3:10 PM, there was visible water, 2-3 centimeters deep, bath blanket was completely saturated, and water was above the blanket. Staff O stated that a second refrigerator is nonfunctional, it stays at a temperature below freezing. Stated that refrigerator has not been used in one year. The refrigerator was last accessed by maintenance two to three weeks ago, and suggested it would be more feasible to buy a new one than fix the current refrigerator.

Review of text messages, dated 07/26/21 at 10:28 AM, showed that Staff A, CEO texted Staff O, Dietary Account Manager asking if the walk-in refrigerator was working. Text messages showed that Staff O responded that the walk-in refrigerator was working but still leaking. He stated that the double door refrigerator has been broken since last year.

Review of the facility email document dated 07/26/21 at 5:21 PM, showed that Staff P, Dietary District Manager contacted Staff A, CEO to provide her with a list of equipment that needed to be addressed, along with missing ceiling tiles, missing light covers, and mold in the dish room wall.

Review of the facility email document dated 07/26/21 at 11:06 AM, showed that Staff CC, Plant Operations Director contacted the corporate office to discuss the need to replace the walk-in refrigerator, dish room drain pipes, and stove.

During an interview on 08/05/21 at 3:00 PM, Staff CC, Plant Operations Director, stated that he has been employed at the facility for approximately nine weeks. He has had the regional office contact out the previous day to look at the mold in the kitchen dish room. He has provided corporate with a quote for a new walk-in refrigerator and stove. Staff CC stated that he did send corporate photos of the missing ceiling tiles, hood range over stove, the stove, double refrigerator, and missing floor tiles.

Observation, in the 400-hallway, on 08/09/21 at 1:30 PM showed that plastic bags were placed under the emergency exit door. Staff DDD, RN, stated that it is to prevent leaking into the hall when it rains.

Observation, in the 500-hallway, on 08/09/21 at 2:45 PM showed that a sit to stand lift had no preventative maintenance sticker on the equipment. A dynamap (machine used to check a patient's vital signs) had a preventive maintenance sticker stating it needed to be checked by 05/31/21.

Observation, in the 300-hallway kitchen, on 08/09/21 at 3:00 PM showed that an extension cord was being used with the computer items plugged in. A wheelchair leg was sitting on a chair. A bug sticky trap was lying in a window sill with dead bugs.

Observation, on the 500-hallway, on 08/12/21 at 10:00 AM showed a dynamap with a preventative maintenance needed date of 05/31/21, machine inventory number 14076. A wheelchair leg sitting on the floor. Gait belt sitting in a chair. Open, used K-N95 mask sitting on a side table in the tv lounge area. Open, used blue isolation gown sitting under a computer table in the tv lounge area. A top to a patient food tray, dirty, sitting on a side table in the tv lounge area. Feeding pumps in the supply room with no preventative maintenance dates.

Observation, on the 400-hallway, on 08/12/21 at 11:10 AM showed that a sit to stand lift, machine inventory number 13395, had a preventative maintenance needed date of 10/29/19.

During an interview on 08/18/21 at 4:15 PM, Staff CC, Plant Operations Director confirmed that there was equipment found without preventative maintenance stickers and out of date stickers that needed to be updated.


Observation in the 500 hallways supply room on 08/10/21 at 11:53 AM showed two large liquid oxygen tanks in the north east corner that were secured to the wall with a chain. There was no odor, or visual leaking, and a faint hissing sound was audible. One of the portable tanks had a sticker from Pure Air company, but failed to have a pressure gauge. There were four small portable tanks that are used by patients who need to go to appointments off campus. These tanks are filled as needed by trained certified nurse assistants (CNAs), Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and respiratory therapists (RTs). There were six full E-tanks (oxygen) secured under a sign marked "full," there was one E-tank secured under a sign marked "empty," and five E-tanks secured that were unidentified as full or empty. There were two grills attached to the top of the wall in the north east corner above the liquid oxygen that were not vented. There is a five-foot solid wall dividing the oxygen from the nursing supplies which are on metal shelves around the perimeter of the walls. The nursing supplies that showed to have potential combustible materials included packages of lanolin (to treat skin that is dry, itching or irritated), Vitamin D ointment, Vaseline, Xeroform (petroleum wound dressing), triple antibiotic cream, KY gel (lubricant), nail polish remover, alcohol prep pads, EZ patient disposable bath wipes, derma vera skin and hair cleanser, clean and free body wash/peri care, and bleach wipes.

During an interview on 08/10/21 Staff Z, LPN stated that she had been educated on how to use the liquid oxygen tanks. She stated that she thinks Pure Air is responsible for filling the tanks and it is the nursing responsibility to fill the small portable tanks from the two large tanks. Staff Z demonstrated if you hold the strap on the back of the small tanks it will display green if the tank if full.

During an interview on 08/10/21 at 12:14 PM, Staff LLL, Respiratory Therapy Director stated that all oxygen supplies for the rehabilitation hospital are located in the 500-hallway supply room. She explained Heartland Pro company comes every Tuesday and Friday to change the two present liquid oxygen tanks for two full ones. Staff LLL explained the hissing sound is oxygen offloading and it is needed for pressure release. She stated that about four to five years ago the fire department made recommendations for them to put up a five-foot wall to separate the oxygen from the medical supplies. Staff LLL was not aware the room failed to be ventilated. Staff LLL verified the five E-tanks failed to have signage to show if they are full or empty.

Based on observation, interview, document review, and policy review the hospital failed to ensure that the life safety from fire requirements are met. Failure of the hospital to meet life safety from fire requirements has the potential for all patients, visitors, and staff to be at risk for fire

Findings Include:

A Life Safety Code Survey conducted by the Office of the State Fire Marshal beginning on 08/09/21 and concluding 08/10/21 resulted in Meadowbrook Rehabilitation Hospital being found out of compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 2012 edition.

Refer to LSC Survey ASPEN #JL9521 for further details.

Based on observation, interview, documents review, and policy review the hospital failed to ensure proper temperature controls and ventilation for the health and safety of all patients by failing to ensure the temperature log for refrigerators and freezers showed daily documentation and corrective action for out of range temperatures for three of three refrigerator/freezers (main kitchen and the 300/400 hallways). The hospital's failure to ensure properly installed portable air conditioners and refrigerator/freezer food within normal temperature ranges has the potential for all patients to experience respiratory difficulty, infection and illness, and to experience food poisoning, illness, and other adverse reactions.

Findings Include:

The hospital failed to provide a policy regarding refrigerator/freezer temperatures.

Review of the hospital document titled, "Environmental and Infection Control Surveillance," dated 07/28/21 showed two areas as patient food refrigerator, temp is checked daily, as "not performed" with no corrective action noted; and cold storage temps are recorded daily and follow-up documentation when out of range as "yes."

Review of the hospital document titled, "Refrigerator Temperature Log of the walk-in refrigerator," dated 06/01/21 to 07/30/21 showed that a temperature was documented twice a day for all days, except for 06/09/21, 06/10/21, and 06/11/21. All temperatures were within the acceptable range of less than 41 degrees Fahrenheit except for three days: 06/09/21, 06/10/21, and 06/11/21. Staff documented "Not Working" in the "Corrective Action of Temperature >41 Degrees Fahrenheit" for these three days and staff failed to document any corrective action.

Review of the hospital document titled, "Freezer Temperature Log 300-400 hallway Kitchen," dated August 2021 showed that corrective action is to be taken if the temperature is over zero degrees Fahrenheit. Documentation showed eight dates with a temperature greater than zero. The staff failed to document any corrective action taken the eight days when the freezer temperature was greater than zero.

Review of the hospital document titled, "Temperature Log, 300-400 hallway Kitchen Fridge," dated August 2021, showed three days failed to have the temperature documented for a shift.

During an interview on 08/05/21 at 4:45 PM, Staff O, Dietary Account Manager stated that the walk-in refrigerator temperature log is recorded on the temperature log twice a day. The acceptable range is any temperature 40 degrees Fahrenheit or below. If a temperature of 41 degrees Fahrenheit or above is documented, a correction action must be performed and documented.

During an interview on 08/09/21 at 4:00 PM, Staff P, District Manager, stated that freezers are to be maintained at or below 32 degrees Fahrenheit. If a freezer or refrigerator becomes out of range, too high, staff are to shut it down, notify maintenance, remove all food, throw the food away, and notify all other staff the refrigerator is not to be used till fixed. Staff P acknowledged that they did not have a policy and procedure for staff to refer to regarding refrigerator and freezer temperatures and there is no documentation that staff took any action when the refrigerator/freezer temperatures were out of range or not documented.