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Based on observation, staff interviews, and record review done during June 19 & 20, 2012, the facility failed to meet the Standards of the 2000 National Fire Protection Association (NFPA) 101 Life Safety Code. See the attached CMS form 2567 for specific Life Safety Code deficiencies and details.

Based on observation, staff interviews, and record review done during the June 19 & 20, 2012 life safety code survey, the facility failed to meet the Standards of the 2000 National Fire Protection Association (NFPA) 101 Life Safety Code. Areas of concern were as follows:

1.) maintenance of fire barriers,

2.) maintenance of smoke barriers,

3.) maintenance of hazardous area separation,

4.) maintenance of the automatic sprinkler system, and

5.) maintenance of the piped med gas system.

Based on record review, the facility failed to ensure that 18 (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 16, 17, 19, 25, 26 and 27) of 27 sampled patients had records that were properly authenticated. In addition, 43 closed records had not been completed timely. Findings include:

1. Patient #1 was admitted on 5/9/12 and discharged on 5/12/12. Review of the closed medical record showed the Discharge Progress Note dated 5/12/12 was not timed when written by the provider. On the same sheet were noted 2 Progress Notes that were dated 5/10/10.

2. Patient #3 was admitted on 2/23/12 and discharged on 2/25/12. Review of the closed medical record showed the Progress Report dated 2/23/12 was not timed when written by the provider.

3. Patient #4 was admitted on 2/23/12 and discharged on 2/25/12. Review of the closed medical record showed the Progress Report dated 2/25/12 was not timed when written by the provider.

4. Patient #5 was admitted on 2/15/12 and discharged on 2/18/12. Review of the closed medical record showed the Discharge Summary was not signed, dated, or timed by the provider.

5. Patient #6 was admitted on 4/18/12 and discharged on 4/19/12. Review of the closed medical record showed the Death Record that contained the OPO referral information was not signed by the person completing the form.

6. Patient #7 was admitted on 6/15/12 and discharged on 6/16/12. Review of the closed medical record showed the Death Record that contained the OPO referral information did not specify whether the patient was a donor candidate.

7. Patient #8 was admitted on 5/14/12 and discharged on 5/17/12. Review of the closed medical record showed Physician Orders dated 5/15/12 that were not timed when written by the provider.

8. Patient #9 was admitted on 12/4/11 and discharged on 12/7/11. Review of the closed medical record showed Progress Notes dated 12/7/11 were not timed when written by the provider.

9. Patient #10 presented to the ER on 6/18/12 and was discharged home the same day. Review of the closed medical record showed a Progress Note dated 6/18/12 that was not timed when written by the provider.

10. Patient #11 presented to the ER on 6/1/12 and was discharged home the same day. Review of the closed medical record showed the History and Physical had not been signed, dated, or timed.

11. Patient #13 presented to the ER on 6/6/12 and was admitted to the hospital. Review of the closed medical record showed a Progress Report dated 6/7/12 that was not timed when written by the provider.

12. Patient #14 presented to the ER on 6/8/12 and died while in the ER. Review of the closed medical record showed the ER Note was not signed, dated, or timed by the provider. The medical record also lacked an OPO notification form.

13. Patient #16 presented to the ER on 6/16/12 and left AMA after being seen. Review of the closed medical record showed a Consultation Note dated 6/16/12 that was not timed when written by the provider.

14. Patient #17 was admitted on 6/18/12. Review of the open medical record showed Physician Progress Notes dated 6/11/12, 6/18/12, and 6/19/12 (twice) that were not timed when written by the provider.

15. Patient #19 was admitted on 6/18/12. Review of the open medical record showed Physician Orders dated 6/18/12 (twice), and 6/19/12 were not timed when written by the provider.


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16. Patient #25 was admitted to swing bed on 6/17/11 and discharged on 6/20/11. Review of the closed medical record showed the admission orders dated 6/17/11 were not timed when written by the provider.

17. Patient #26 was admitted to swing bed on 4/22/12 and discharged on 5/21/12. Review of the closed medical record showed no time on orders for Cipro 500 mg BID dated 4/27 (There was no year written for this date.), Doxycycline 100 mg BID dated 4/29 (There was no year written for this date.), nystatin BID dated 5/4/12 and 5/6/12, and "up [unreadable] [with] BAT on [left] (FWB on [right])" dated 5/15/12. A progress note dated 5/10/12 was not timed when written by the provider.

18. Patient #27 was admitted to swing bed on 3/8/12 and discharged on 3/28/12. Review of the closed medical record showed no time on a reorder for the antibiotic Nystatin dated 3/15/12, on an order for a dressing change dated 3/17/12 and on an order for a narcotic dated 3/25/12.

19. At 9:00 a.m. on 6/20/12, staff member A1 , the Medical Records Supervisor, stated that currently there were 33 closed records over 30 days post-discharge and 10 closed records over 60 days post-discharge which were not complete. She said the facility was not following their policy regarding notification of providers and supervisors when records were not completed timely.