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Based on a review of medical records, hospital policy and procedure, and staff interview, it was determined that the hospital did not effectively notify and provide all patients of their rights prior to discharge as per policy titled, " Important Message from Medicare concerning their Rights " (IM). Ten of ten closed records reviewed did not have the Discharge (IM)s
Findings include:
A review of MR #45 on 7/25/13 at approximately 10:30 AM noted that an elderly patient was admitted on 4/18/13 with a diagnosis of Altered Mental Status and Acute Renal Failure. The patient was provided a copy of the admitting IM on 4/19/13 at 1:00 PM. A CAT scan was done that showed small vessel chronic ischemic disease. The patient was discharged home with a diagnosis of Altered Mental Status due to metabolic encephalopathy. The patient was discharged home on 4/25/13 without being provided the IM prior to discharge.
Similar findings were found in MRs #5, #8, #20, #30, #41, #46, #47, #48, #49.
Staff#27 The Utilization Management Director was interviewed on 7/25/13 at 10:30 AM.
The above records that reviewed by Staff#27 at the surveyor's request. Staff #27 was not able to provide the Discharge IMS on any of these records. Staff#27 stated that she had an employee was who was responsible for providing these notices to the patients. Staff #27 informed that this was "laid off in January and may have contributed to the IMS not being provided".

Based on a review of medical records and staff interview, it was determined that the facility's nursing staff failed to implement the hospital's policy on 1) Nutrition Screening to promote early nutrition intervention for patients identified at high nutritional risk and 2) the nutrition referrals concerning early nutritional intervention and the care of patients with pressure ulcers. (MR#20, 25, 33, 34, and 50)

Findings include:

1) A review of MR #25 on 7/23 at 2:10 PM in the presence of Staff #16, Dietitian Hospital Safety Officer/ VP of Long Term Care, noted that an adult patient was admitted to the hospital on 7/20/13 with the diagnosis of dehydration. There was no evidence that a Nutritional Screen was completed by the Nursing Staff at the time of admission.

The hospital's policy concerning Nutritional Screening stated that Nutritional Screens are to be completed within 24 hours of a patient's admission. In MR#25, the nutritional trigger for dehydration was not identified upon the patient's admission. As a consequence, the patient did not receive a Nutritional Assessment from the Dietitian. The Charge Nurse confirmed this finding. Subsequently, the patient developed two hospital acquired pressure ulcers on 7/23. There was no documentation that this patient had been seen by a Dietitian.

Similar findings were found in MR #34, #33 and MR #50.

2) A review of MR #26 on 7/23/13 at approximately 2:10 PM, noted that an adult patient was admitted to the hospital on 7/15/13 with the admitting diagnosis of generalized weakness and prostrate cancer. The patient arrived at the hospital with a stage II pressure ulcer on the left buttock. The nutritional screen did not identify that this patient had a pressure ulcer. There was no documentation that the Nursing Staff referred this patient to the Dietician regarding this patient's pressure ulcer.

Also, there was no evidence that this patient received a timely nutritional assessment from the Dietician. The first documented Nutritional Assessment by the Dietician was documented on 7/23, eight days after admission.

Similar findings of a lack of nutrition referral for patients with pressure ulcer were found in MRs #20, #25, #33, #34, and #50.

1. Based on record review and interview, it was determined that the facility failed to ensure 1) that menus prepared in an event of a disaster, met the nutritional needs of all patients and 2) to label food containers with the name of the food item it contained.
Findings include:
1) On 7/23/13 at approximately 11 AM a review of the Food Service Department Emergency Preparedness Manual was conducted. Present at this review was Staff #16, Dietitian /Hospital Safety Officer/ VP of Long Term Care, and Staff #24, Operation Manager of Food Service.
The manual contained three (3) days of patient menus to be followed in the event of a disaster. These menus did not meet the patients' nutritional needs based on the Recommended Daily Intake nor did it meet the criteria necessary for menu planning. These menus provided less than 2100 calories, and did not list food portions. Some food items were generic and not specific (crackers, powdered milk) and entrees were repetitious. The pureed menu had Ensure Pudding for Lunch and Dinner and was also the entree for all three days.
2) A tour of the kitchen was conducted on 7/22/13 at approximately 10 AM. Staff #24, Operation Manager of Food Service accompanied the surveyor. It was observed that eleven (11) out of eleven (11) food containers had a label that did not document the food item in the container and only noted " Use by ".
While all food containers had a plastic wrapper on the top of the container, the contents of the container could not be visualized without removing the wrapper. The "milk box" a container that contained dairy products had either a package of egg salad or potato salad. The label did not state the contents of the container. It simply stated the " Use by " date.
A white plastic bin containing white powder had a label stating " Used by " the label did not identify the white powder as either flour or cornstarch. Chocolate pudding in a container had a label with a date but it was not identify if the pudding was "regular or diet".
In the salad area it was observed that the refrigerator had 5 bricks of cheeses and 5 different cold cuts wrapped in plastic wrap that had labels documented only with the date " Use by " . These cheeses and cold cuts were not identified by name.
There was no evidence that foods that were opened and placed in containers with plastic wrap were properly labeled with the name of the food item and date to be used. The name of the food items was missing on all covered containers or foods wrapped in plastic wrap.

Based on review of the Hospital 's Master Menus, (Nutrient Analysis) and staff interview, it was determined that the Food and Nutrition Department did not ensure that diets prescribed by physicians met the therapeutic needs of the patients.
Findings include:
Review of the Hospital's Master Menu was done on 7/23/13 at approximately 10 AM with Staff #18, Clinical Nutrition Manager, Staff #16, Dietitian /Hospital Safety Officer/ VP of Long Term Care, and Staff #24, Sodexho Area Support Manager-Clinical and Patient Services. The Diet Formulary was reviewed and compared to the Hospital's Master Menu. The Diet Formulary available for physician to reference (to order diets) consisted of 17 diets. A Nutrient Analysis is required to validate that the menus conform to the diet prescribed. Only six (6 ) of seventeen (17) diets available for physicians to reference had Nutrient Analyses. The Surveyor reviewed the content of the Nutrient Analysis and found the following:
1. The hospital has a three week cycle menu (21 days). The Surveyor was provided with Nutrient Analyses for 20 days. Nutrient analyses for week three (3) - day twenty-one (21) for all diets were not done.
2. The Nutrient Analysis for ten (10) of twenty (20) regular diets did not meet the National Standard titled " Recommended Daily Intake " for calories (2100 calories).
3. Sixteen (16) of twenty (20) menus did not meet the hospital's 225 grams of Consistent Carbohydrate diet. The menu for week one (1), day seven (7) of a Consistent Carbohydrate diet had 291 grams which is beyond the hospital standard of 225 grams of carbohydrate.
4. The Nutrient Analysis of the Renal Diet did not meet the requirement of 80 grams of protein in nineteen (19) of twenty (20) menus. The menu of cycle 1, day 3 was missing the Nutrient Analysis for the Renal diet.
5. There was no evidence that a Nutrient Analysis was completed for the Mechanical Soft or Pureed Diet.

Based on observation and staff interview, the condition of the physical plant and the overall hospital development was not maintained in such a manner that the safety and well-being of patients are assured.

The findings are:

1. On the morning of 7/22/13 observation of the Kitchen revealed that:

a) multiple damaged/broken floor tiles were found by the small kettles, the dish machine and the pot area entrance of the kitchen. Some of these tiles were partially patched up with an unknown slippery sealant.

b) the Kitchen ceiling tile grid system was broken/damaged.

c) there was a puddle of water behind the meat/cheese slicer counter in the Salad Preparation Room.

2. On the afternoon of 7/22/13 observation of the Emergency Department revealed that:

a) the latching plate for the Staff Lounge door was covered with tape.

b) the door frame of the Soiled Utility Room was dented/damaged.

c) the wall across from the Emergency Department Psychiatry Exam Room 10 had non tamperproof screws in it.

d) the Emergency Department Psychiatry Department door handles were looping hazards.

3. On the morning of 7/23/13 observation of the 5 th. Floor Medical/Surgical Unit revealed that:

a) inside room Shower Room the sloped concrete bevel for handicapped accessibility was cracked/damaged.

b) in the Patient Room 521 bathroom there were 3 loose wall tiles, and the sink was not flush with the wall.

c) non-tamper resistant electrical outlets were installed in Room 521, one of pediatric Medical/Surgical beds. One of the walls in this room was also dented/damaged.

d) the lower portion of the Janitor's Closet walls in the 5 th. Floor Medical/Surgical Unit was dented/damaged.

e) in the Patient Room 511 bathroom there was a uncovered wall cut-out located over the shower head.

f) in the Patient Room 511 bathroom the exhaust vent in this room was dust laden.

g) an open/exposed wall box was found in the Nuclear Medicine Room.

h) a wheeled oxygenator was being stored in the Biohazard Room. This is an infection control issue.

4. On the morning of 7/23/13 observation of the 4 th. Floor Medical/Surgical Unit revealed that:

a) in Room 403 revealed that there were four stained ceiling tiles.

b) the lower portion of the Janitor's Closet walls in the 4 th. Floor Medical/Surgical Unit was dented/damaged.

5. On the morning of 7/23/13 observation of the Ground Level Fire Pump Room revealed that miscellaneous boxes and supplies were being stored in that room. This is a fire hazard, as well as, improper storage.

6. On the morning of 7/24/13 observation of the Intensive Care Unit revealed that:

a) there was a hole in the floor of Room 710.

b) the lower portion of one of the walls in Room 711 was dented/damaged.

7. On the morning of 7/24/13 an observation of the Respiratory Unit revealed that miscellaneous housekeeping supplies (i.e. cardboard boxes with different cleaning products, etc.) were being stored below the hand-wash sink.

8. On the morning of 7/24/13 an observation of the Ambulatory Surgery Center revealed that a wheelchair and a blood pressure cuff machine was being stored in the Women's Dressing Room. A wheelchair was also being stored in the Phase 2 Recovery Discharge Room.

9. On the afternoon of 7/24/13 an observation of the Pharmacy revealed that:

a) the backsplash behind the Pharmacy hand-washing sink was delaminating from the wall.

b) there were two stained ceiling tiles.

c) various shelving, broken cardboard boxes,etc. was being stored in the gap between the Metal Barrier of the moveable medicine racks and the Pharmacy wall.

10. On the morning of 7/25/13 an observation of the 2nd. Floor Psychiatry Unit revealed that:

a) a metal corner bead was exposed on one of walls in Room 205.

b) the lower part of the radiator was missing in the Quiet Room.

c) an electrical outlet located by the hand-wash sink was not tamper-resistant.

d) the windows located in the vicinity of the Emergency Exit Stairwells, each had three metal protrusions. These protrusions are potentially hazardous to the safety of the patients and staff.

e) in the Dining Room there was an exposed ice machine cord and a non-breakaway water faucet. These were both looping hazards.

f) in the Activity Room there was an exposed lock cable, various loose electrical wires, and the cabinet knobs. These are all looping hazards.
g) the handles of the nightstands in Rooms 206, 207, and 209 were looping hazards.

h) opposite the Nursing Station there was a protruding metal bracket supporting a wall observation mirror. This a looping hazard.

i) both of the water fountains in this unit had non-breakaway spouts and therefore looping hazards.

11. On the morning of 7/25/13 observation at the Family Health Center Extension Clinic revealed that:

a) the wall between Room 111 and Room 112 had exposed/unsealed wall penetrations.

b) an outlet cover was missing in the Telephone Room.

c) the cove base along the bottom of the Waiting Room walls were missing.

d) in room 154, the Janitor's Closet, there were 7 stained ceiling tiles.

e) the latching plates for the doors of Room 112 and Room 145 were covered with tape.

f) that a fan, a half full container of soda, and a roll of flooring material was being stored in the Telephone Room.

g) in two of the patient bathrooms (i.e. Room 111 and Room 112) the nurse call bells have not been installed. Also, in the facility's other two bathrooms (i.e. Room 113 and Room 145) the nurse call bell was not working.

h) a VAV Control Box located near Room 113 was being held onto the wall with medical tape.

12. On the afternoon of 7/25/13 observation in the Decontamination Room revealed that the cove base was delaminating from the wall.

13. On the afternoon of 7/25/13 observation of the 3rd. Floor Psychiatry Unit revealed that:

a) the water fountain in this unit did not have a non-breakaway spout and therefore is a looping hazard.

b) a patient wheelchair was being stored in Room 315, the Dirty Utility Room.

c) in the Patient Room 310 Bathroom the sink was not flush with the wall.

14. On the morning of 7/26/13 an observation of the Operating Rooms revealed that:

a) within the ante room between Operating Rooms #1 and #2, one of the sinks did not have warm water.

b) within the ante room between Operating Rooms #3 and #4, one of the sinks did not have warm water. Another sink in this room did not turn on.

15. On the morning of 7/26/13 an observation in the Alcohol Rehabilitation Clinic Male Bathroom revealed that

a) there were missing wall tiles throughout the room. Several missing floor tiles were also found in this room.

b) In the Alcohol Rehabilitation Clinic Female Bathroom there was cove base missing on one of the walls.

c) there were four stained ceiling tiles in Room 17.

d) the solid ceiling of the Medical Records Room was water stained and damaged.

e) the latching plate for the Janitor's Closet door was covered with tape.

f) miscellaneous items (i.e. an outdoor grill, a metal rake, floor cleaner, 5 gallons of latex paint, holiday decorations, multiple boxes of lights, etc.) were being stored in the Medical Record Room. This is an infection control issue, as well as, a safety hazard.

g) miscellaneous items (i.e. 1 gallon of paint, loose cardboard on the floor, etc.) in the Janitor's Closet. This is an infection control issue.

h) there were tears in the fabrics ,of two of the couches and several chairs in the facility. This is an infection control issue.

i) the vent inside the Female Bathroom was dust laden.

All of the above mentioned observations were concurrently confirmed by Employee #17.

Based on observation, record review, and staff interviews, the facility's staff was not familiar with the hospital's fire drill procedures.

The findings are:

a) On 7/22/13 at approximately 11:45 AM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #18 stated he would i) use the fire extinguisher; ii) call #7140; iii) pull the Fire Alarm Pull Station; and iv) evacuate. Employee #18 did not know the differences between the ABC fire extinguisher and the water-based fire extinguisher.

On 7/22/13 at approximately 12:00 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, staff #19 stated he would: i) yell fire!, fire!; ii) remove himself from the kitchen; iii) alarm by calling #7140; iv) close the doors; v) evacuate.

On 7/22/13 at approximately 12:10 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the kitchen, Employee #20 stated he would: i) call code 3; i) use the fire extinguisher; iii) yell fire!, fire! and tell people to get out of area; iv) close doors and evacuate.

On 7/26/13 record review of the Food Service Personnel section of the Fire Regulations Policy, which was effective March 12, 2004, confirmed that the food service personnel were not aware of the proper procedures in case of a fire. It also revealed that the Food Service Personnel fire regulations were different from the Hospital and Nursing Home Personnel fire regulations that were revised January 1, 2007.

b) On 7/24/13 at approximately 2:30 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the 5 th. Floor Medical/Surgical Unit, E #21 stated she would: i) call code 7140 and then code 3; ii) remove patients; iii) contain the fire; iv) evacuate patients. Although staff #21 never mentioned "pull the Fire Alarm Pull Station", she was able to identify the location of the closest pull station.

On 7/24/13 at approximately 2:45 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the 5 th. Floor Medical/Surgical Unit, Employee #22 stated she would: i) call code 3 and then code 7140; ii) remove patients; iii) alarm by pulling alarm panel by the stairwell; iv) contain the fire; v) evacuate.

On 7/25/13 at 2:30 PM, observation and staff interview revealed that when asked what are the steps in case of a fire in the Decontamination Room, Employee #23 stated she would:first call 7140. Employee #23 was unsure on how to react when the surveyor asked her "what if the phone was broken". Upon further interview and observation, Employee #23 did not know where to find either the Fire Alarm Pull Station or the Fire Alarm Code Directory.

On 7/26/13 a record review of the Fire Regulations Policy, which was last revised January 1, 2007, revealed that the facility's order for fire regulations is Remove, Alarm, Start, Close, and Evacuate or Extinguish. The policy states that when a staff member alarms he/she would "Pull the nearest fire alarm and inform the operator by dialing ext. 7140 of the the location of the fire." The policy further stated that "upon discovery of fire, personnel should immediately take the following action: The discover should go to the aid of any endangered person, calling aloud the established code phrase, "Nurse Red. Upon hearing the established code phrase, personnel should activate the building fire alarm using the nearest manual alarm station and dial ext. 7140....."

The above mentioned observations were concurrently confirmed by Employee #17.

Based on observation and staff interview, the facility failed to ensure that aapropriate infection control practices were maintained. This was evident in 1) the ceiling tiles and 2) the cross contamination of sinks.

The findings are:

1. On the morning of 7/22/13, an observation of the Emergency Department revealed that the ceiling tiles in the Isolation Room was not washable.

2. a) On the morning of 7/25/13 an observation of the Family Health Center Extension Clinic revealed that a sink in Room 155, the Soiled Utility Room, was being used as a hand-wash sink and a utility sink. This is cross contamination between clean and dirty areas.

b) On the afternoon of 7/25/13 an observation of the Decontamination Room revealed that a sink was being used as a hand-wash sink and a utility sink. This is cross contamination between clean and dirty areas.

The above mentioned observations were concurrently confirmed by Employee #17.

Based on review of the Organ, Tissue and Eye Procurement Program Manual and staff interview, it was determined that the facility failed to ensure that this program was integrated into the Hospital Wide Quality Assurance Performance Improvement Program. (QAPI).
Findings include:
A review of the Hospital's Organ, Tissue and Eye Procurement Program Manual was conducted on 7/25/13 at approximately 12 PM. Tracking data concerning compliance with Time Notification was reviewed.
The definition of Time Notification is when the hospital contacts the Organ Procurement Organization by telephone after an individual or patient has died. The ideal turn around time should be one hour.
A review of this Time Notification data revealed that the compliance rate for Time Notification was at 67%.
The Surveyor interviewed Staff #9, VP of Nursing in charge of the Program. The VP of Nursing informed the Surveyor that the Organ, Tissue and Eye Procurement Program did not report its data to the Hospital Wide QAPI Program.
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Based on medical record reviews and staff interviews, it was determined that the hospital failed to ensure that all outpatients were appropriately assessed and treated, and failed to refer a patient to an inpatient setting if the center was unable to treat the patient at an offsite location. This was found in two (2) of four (4) medical records reviewed at the Family Health Center and Speciality Clinic. (MR #37 and #38)

Findings include:

1. Patients were not adequately assessed at the Family Health Center and Speciality Clinic. MR #37 is a forty-four year old patient who visited the center on July 16, 2013 at 10:42 AM with a complaint of Asthma. The patient who had a habit of smoking had a previous medical history of Asthma which was aggravated by smoke, strong odors/perfume and infection. The "associated symptoms included pleuritic pain and wheezing."

His home medications included Albuterol Sulfate pump and Singulair tablets. When assessed by a nurse only the patient's B/P and temperature were taken which were 110/80 and 98.4 F respectively.

When assessed by the physician, it was noted that the patient was in "mild distress and had expiratory wheeze/congestion." There was no evidence that the patient's pulse or respiratory rate and oxygen saturation were assessed during the visit. The patient was discharged home on Advair Diskus 2 times every morning and evening and Prednisone daily in addition to the maintenance treatment of Albuterol Sulfate pump as needed every 4-6 hours and Singulair tablets that he had been previously taking.

There was no evidence that the patient received any immediate treatment for the respiratory distress or wheezing nor was there any evidence that the patient was reassessed during the visit despite his respiratory distress. Furthermore, the decision to discharge the patient home was inappropriate given the respiratory distress.

2. MR #38 a sixty-two year old patient presented to the center on July 22, 2013 to be referred to the hospital for anticoagulation of a thrombus. The patient had a history of Congestive Heart Failure (CHF), Sleep Apnea, Hypertension and Hepatitis C who presented with increased leg swelling, chest pain and increased fatigue.

The patient's ejection fraction was 20%. When assessed, the patient's vital signs revealed the temperature was 98.1 F, the pulse rate was 84 and irregular and the B/P was 152/72. There was no evidence that the patient's respiratory rate was assessed despite the increased fatigue and diagnoses of left leg thrombus and CHF.

These findings were confirmed by Staff #13, the Medical Director of Family Health Center on July 25, 2013 at approximately 12:25 PM.

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Based on medical record reviews, policy reviews and staff interviews, it was determined that the hospital failed to ensure that a patient was triaged in a timely manner, was assessed by a medical practitioner in a timely manner in the emergency room, and that blood tests were ordered and completed in a timely manner. This was found in one (1) of thirty- eight (38) patients that had visited the ED for emergency care. (MR#4)

Findings include:

1. Medical record #4's triage was not timely. MR #4 is a forty-four year old patient who arrived in the ED on April 9, 2013 at 10:16 PM with a complaint of chest pain radiating to the neck and back 3 hours prior to arrival. The patient stated to the triage nurse while he was being triaged at 12:31 AM on April 10, 2013 that the "pain was similar to a heart attack in the past." The patient had a previous medical history of cardiac stents x 2 and Myocardial Infarctions x 4. The patient had a history of cocaine and marijuana use. The patient's vital signs at the triage time were temperature 96.6 F, pulse 85, respiration 18 and B/P 152/85. The oxygen saturation was 96% on room air and the patient's pain score was 7 on a scale of 1 - 10. Given the patient's complaint of chest pain and prior medical history, the triage assessment which occurred more than 2 hours after arrival, was not timely.

The medical practitioner's screening examination was not timely. The patient was assessed by a medical practitioner at 1:06 AM almost 3 hours after arrival.

Laboratory tests were ordered at 1:06 AM but blood samples were not collected until 2:15 AM, 4 hours after the patient's arrival in the ED. The EKG was performed at 12:54 AM on April 10, 2013.

These findings were confirmed with Staff #9, the VP of Nursing on July 24, 2013 at approximately 10:30 AM. Staff #9 also stated that the registrars who are responsible for entering the patients names in the computer upon arrival, do not ask the patients the purpose of their visits and that it is possible that this patient did not tell the staff the purpose of his visit upon arrival. This practice is not acceptable as the members of staff are unaware of the purpose of the patients visits upon arrival.


The facility's policy titled "Triage in the Emergency Department" last revised on 3/10, states that triage classification 1 includes "potentially life-threatening conditions, possibly requiring immediate intervention" includes chest pain.


Therefore, the facility failed to follow its policy to treat a patient with a potentially life-threatening condition. Furthermore, the timeliness of the triage process and physician assessment as well as the delay in collecting the blood samples are not consistent with current standards of practice.