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Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of the patient's rights in advance of furnishing care as 2 of 7 inpatient medical records reviewed did not contain admission forms signed by the patient which include receipt of the Patient Bill of Rights which resulted in an incomplete record and the patient being uninformed regarding his patient rights.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The record of patient #7 and 10 did not contain signed admission forms which included receipt of the Patient Bill of Rights. Review of the medical records revealed that patient #7 was admitted to the intensive care unit from the emergency department on 1/2/18 and patient #10 was admitted directly to the intensive care unit on 7/25/18. The record of patient #7 contained a Conditions of Admission form that had been checked off as "Patient is unable to sign" and an Important Message from Medicare form signed by the husband of patient #7 on 1/16/18. The record of patient #10 admitted on 7/25/18 did not contain any Conditions of Admission form.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign."

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical records of patients #7 and 10 did not contain signed Conditions of Admission forms.

Based on review of documentation and interviews with facility staff, the facility failed to inform a Medicare inpatient of a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization as there was no signed Important Message from Medicare form in the medical record of patient #10.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The medical record of patient #10 did not contain an Important Message from Medicare form. Review of the medical records revealed that patient #10 was admitted directly to the intensive care unit on 7/25/18.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Additional forms are required in the following situations: Important Message from Medicare ...if the patient is a Medicare or Managed Medicare Inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission ...In addition, the patient's or patient's representative's signature is required ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign."

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical record of patient #10 did not contain a signed Important Message from Medicare form.

Based on review of documentation and interviews with facility staff, the facility failed to determine upon admission if 2 of 7 inpatients reviewed had formulated advanced directives as the admission forms documenting the advanced directive statements were not completed by patient #7 and 10 upon admission which resulted in an incomplete record and the facility being unaware if patient #10 had an advanced directive.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The record of patient #7 and 10 did not contain signed admission forms which included the advanced directive statements. Review of the medical records revealed that patient #7 was admitted to the intensive care unit from the emergency department on 1/2/18 and patient #10 was admitted directly to the intensive care unit on 7/25/18. The record of patient #7 contained a Conditions of Admission form that had been checked off as "Patient is unable to sign" and an Important Message from Medicare form signed by the husband of patient #7 on 1/16/18. The record of patient #10 admitted on 7/25/18 did not contain any Conditions of Admission form.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign ...The Advanced Directives statements are contained within the Parallon standard COA (Conditions of Admission) and COS (Consent for Outpatient Services) forms ...Only one of three applicable PSDA (Patient Self Determination Act) statements is initialed or marked by the patient or legally authorized/legally empowered representative."

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical records of patients #7 and 10 did not contain signed Conditions of Admission forms.

Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of Privacy Practices and obtain Authorization for Release of Information as 2 of 7 inpatient medical records reviewed did not contain admission forms signed by the patient which include the Authorization for Release of Information form and the Notice of Privacy Practices form which resulted in an incomplete record and the patient being uninformed of confidentiality rights.

The findings were:

Electronic medical records were reviewed on 9/25-26/18 with the assistance of the staff #2 and 3. The record of patient #7 and 10 did not contain signed admission forms which included Authorization for Release of Information and the Notice of Privacy Practices. Review of the medical records revealed that patient #7 was admitted to the intensive care unit from the emergency department on 1/2/18 and patient #10 was admitted directly to the intensive care unit on 7/25/18. The record of patient #7 contained a Conditions of Admission form that had been checked off as "Patient is unable to sign" and an Important Message from Medicare form signed by the husband of patient #7 on 1/16/18. The record of patient #10 admitted on 7/25/18 did not contain any Conditions of Admission form.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign ...Procedure: Responsible Party, Patient Access. Action, Notice of Privacy Practices. The patient or legally authorized/legally empowered representative or family member initials this section to acknowledge receipt of the Notice of Privacy Practices."

In an interview with the VP of Quality, staff #1 on the morning of 9/26/18, staff #1 acknowledged that the electronic medical records of patients #7 and 10 did not contain signed Conditions of Admission forms.

Based on review of documentation and interviews with facility staff, an ICU patient who had level 3, 1:1 monitoring and observation suicide precautions ordered had inadequate documentation in the medical record that the ordered suicide precautions were in place which was a potential patient safety issue.

The findings were:

Electronic medical record of patient #8 was reviewed with the assistance of the director of quality staff #3 on the morning of 9/26/18. The medical record reflected that patient #8 was admitted from the ER to ICU for a Benadryl overdose and had suicide precautions, L3 - 1:1 monitoring and observation, ordered on 7/30/18 1031. The record contained a Suicide Patient Monitoring Form for 7/31/18 from 0700 - 1815 which documented every 15 minute observations. Facility staff were unable to find any other documentation of every 15 minute observations in the patient record. The only other documentation in the medical record related to the suicide precautions was an ER Note dated 7/30/18 1600 which reflected in part "Wife and sitter are at bedside" and a Multidisciplinary Team Note dated 7/31/18 0730 which reflected in part "Sitter at bedside." The record contained a nurses note dated 7/31/18 2340 which reflected in part "Pt (patient) D/C (discharge) to [a psychiatric facility]."

The facility policy entitled "Suicide Prevention Plan" #2306476 dated 4/16 reflected in part "Heightened Observations. Patients who are at risk for suicide will be placed on patient observation and monitoring as assigned by the RN and reassessed after the QMHP (qualified mental health professional) or assigned physician assessment is completed. The patient may be placed on Standard Observation, Line of Sight, or 1:1 monitoring as outlined in the definitions below as determined by the treatment team and physician order ...Level 3 - 1:1 Monitoring and Observation. The patient is never to be out of arms reach of the assigned and dedicated staff member ...Suicide Precautions. 1. Suicide precautions are to be clearly indicated on the assignment sheet and specific patient rounds sheets, and communicated during every transition of care (change of shift, breaks and lunches) through thorough hand-off communication. 2. Staff assigned to observe patients on suicide precautions shall immediately communicate to the Charge Nurse and carefully document significant signs of concern in the progress notes ..."

In an interview with the director of quality, staff #3 on the morning of 9/26/18 in a conference room, staff #3 acknowledged that there were gaps in the documentation of the ordered suicide precautions from the time of the order to the time the patient was discharged.

Based on observation, review of documentation and interviews with facility staff, the facility failed to properly store dry food and other food service supplies as boxes were stacked on the top shelves in the dry food storage room closer than 18" to the ceiling which was not in accordance with facility policy and was a potential fire hazard. A double door in the kitchen leading to the loading dock which latched in the center of the two doors had an opening to the outside approximately ¾" x 5" in the middle of the doors where daylight could be seen from inside the kitchen providing a point of entry for insects and rodents from the outside. This had been noted in a city health department inspection 8/14/18 and had not been repaired at the time of survey.

The findings were:

During a tour of the dietary department on the afternoon of 9/24/18 in the company of the director of food service, staff #10, the following observations were made. In the dry food storage room was stainless steel shelving in rows with aisles in between. On the shelving were boxes of food products, and food service supplies which were stacked to within 6 inches of the ceiling in several places on the shelving in the center of room.

In the kitchen, a double door leading to the loading dock which latched in the center of the two doors had an opening to the outside approximately ¾" x 5" in the middle of the doors by the latch where daylight could be seen from inside the kitchen providing a point of entry for insects and rodents from the outside.

City of Webster Food Establishment Inspection Report dated 8/14/18 reflected the facility had a demerit point for "Core Item #34. No evidence of insect contamination, rodent/other animals" with the remark "All doors leading to the outside shall seal completely allowing no light visible from the outside."

The facility policy entitled "Food and Non-Food Storage" #2066492 dated 1/16 reflected in part "1. Dry Storage ...c. All foods and non-foods must be stored 18" from the ceiling except for perimeter walls."

In an interview with staff #10 during the tour of the dietary department on the afternoon of 9/24/18, staff #10 acknowledged that items were stacked closer than 18" to the ceiling in the dry storage room and that there was an opening to the outside near the latch in the doors leading to the loading dock.