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Based on medical record review, interview and policy review the facility failed to ensure that updates to the patient's plan of care were completed for 12 of 22 (#1, #8, #9, #12, #22, #23, #28, #34, #35, #36, #37, and #38) patient medical records, resulting in the potential for poor patient outcomes. Findings include:

On 1/27/15 at 1300 during medical record review of patient #22's care plan it was revealed that the patient had a care plan initiated on the date of admit 1/13/15. Review of the plan for "Pain/alteration in comfort" it was observed that the care plan was updated/reviewed once a day for the dates 1/14/15-1/20/15 with no updates again until 1/24/15. The plan for "Injury" was updated/reviewed daily from 1/15/15-1/20/15, and again on 1/22/15 and 1/26/15. The plan for "Skin integrity, surgical impaired", was updated/reviewed daily from 1/15/15-1/17/15, then once daily on 1/19/15, 1/20/15 and 1/26/15. The plan for "Infection, high risk", was updated/reviewed daily from 1/17/15-1/20/15 and not again until 1/27/15.

On 1/27/15 at 1400 during medical record review of patient #23's care plan it was revealed that the patient had a care plan initiated on the date of admit 1/14/15. Review of the plan for "Anxiety" it was observed that the care plan was only updated/reviewed on 1/18/15, 1/20/15 and 1/25/15. The plan for "Injury" was only reviewed/updated on 1/18/15 and 1/20/15.

On 1/28/15 at 1000 during medical record review of patient #34's care plan it was revealed that the patient had a care plan initiated on the date of admit 9/11/14. Review of the plan for "Knowledge deficit" it was observed that the care plan was updated/reviewed daily on 9/12/14, 9/13/14, 9/15/14, 9/17/14 and 9/20/14-9/22/14. The plan for "Injury, high risk" was updated/reviewed daily from 9/11/14-9/13/14, and not again until 9/18/14. The plan for "Confusion-change of mental status", was only updated/reviewed on 9/12/14, 9/13/14, 9/20/14 and 9/21/14. The patient was discharged on 9/23/14.

On 1/28/15 at 1030 during medical record review of patient #35's care plan it was revealed that the patient had a care plan initiated on the date of admit 10/18/14. Review of the plan for "Knowledge deficit" it was observed that the care plan was updated/reviewed only on 10/24/14 and 10/25/14. The plan for "Pain/alteration in comfort" was only updated/reviewed once daily from 10/22/14-10/25/14. The patient was discharged on 10/25/14.

On 1/28/15 at 1100 during medical record review of patient #36's care plan it was revealed that the patient had a care plan initiated on the date of admit 11/6/14. Review of the plan for "Skin integrity, surgical impaired" it was observed that the care plan was only updated/reviewed on 11/11/14 and 11/13/14. The patient was discharged on 11/14/14.

On 1/28/15 at 1130 during medical record review of patient #37's care plan it was revealed that the patient had a care plan initiated on the date of admit 11/18/14. The patient was admitted for a urinary tract infection and pressure ulcers/infection. The care plan failed to include a plan for infection. Review of the plan for "Knowledge deficit" it was observed that the care plan was only updated/reviewed on 11/23/14, 11/25/14 and 11/26/14. The plan for "Pain/alteration in comfort" was only updated/reviewed on 11/23/14, 11/25/14 and 11/26/14. The patient was discharged on 11/26/14.

On 1/28/15 at 1200 during medical record review of patient #38's care plan it was revealed that the patient had a care plan initiated on the date of admit 11/19/14. Review of the plan for "Fluid volume, alteration" it was observed that the care plan was only updated/reviewed on 11/23/14 and 11/25/14. The plan for "Cardiac output, decreased" was only updated/reviewed on 11/23/14 and 11/25/14. The plan for "Gas exchange, impaired" was only updated/reviewed on 11/23/14 and 11/25/14. The plan for "Breathing pattern, ineffective" was only updated/reviewed on 11/23/14, 11/25/14 and 11/27/14. The plan for "Skin integrity, impaired" was only updated/reviewed on 11/23/14 and 11/25/14. The patient was discharged on 11/28/14.

On 1/28/15 at 1215 during an interview with staff S, when queried as to how often care plans are supposed to be updated/reviewed, she responded, "At least every shift."

On 1/28/15 at 1400 during policy and procedure review, it was revealed in the policy titled, "Individualized Care Plans," with an effective date of "12/16/14", stated under procedure, "Within 8 hours of admission, the RN (registered nurse) will initiate at minimum of two Individualized specific diagnosis on the Care plan. The care plans will be initiated based on the patient's individual plans/problems, diagnosis and assessment...For all inpatients, all pertinent problems on the Nursing Care Plan will be reviewed and evaluated on EVERY SHIFT."


27408

On 01/27/15 at 1300 during medical record review for patient #1"s care plan, it was revealed that the patient had a care plan initiated on the date of admission, 01/24/15. The patient went to the operating room on 01/25/15. Review of the plan revealed that there were no updates on patient #1's care plan since he returned from the operating room.

On 01/27/15 at 1545 during an interview with staff K, when queried as to how often care plans are supposed to be updated/reviewed, she responded, "They should every shift and especially when something pertinent happens."


29955

On 1/27/2015 at approximately 1535 during medical record review of patient #12's medical chart it was revealed the patient was admitted on 1/15/2015 and an interdisciplinary plan of care was created on 1/19/2015. On 1/27/2015 at approximately 1545 staff O was asked if the patient's plan of care had been updated since 1/19/2015. Staff O searched for an update to the plan of care and returned to state there was not an update to the plan of care since 1/19/2015.

On 1/27/2015 at approximately 1555 staff O was asked when plans of care were updated in the behavioral health unit. Staff O responded "plans of care are reviewed and updated weekly."


30988

On 1/28/2015 at 1300 the electronic medical records were reviewed for care plan initiation and updates. Patient #8 was admitted on 1/19/2015. The initial care plan was dated for 1/20/2015, where five problems/diagnoses were identified. Problem #5 for Pain and comfort was updated on 1/27/2015. The other four problems were not reevaluated or updated since 1/19/2015.

Patient #9 was admitted on 1/20/2015. The initial care plan was dated for 1/20/2015, where three problems were identified. Problem #3 for pain and comfort was updated on 1/26/2015. The other two problems were not reevaluated or updated since 1/20/2015.

Patient #28 was admitted on 1/15/2015. The initial care plan was dated for 1/16/2015, where five problems were identified. Problem #2 change in mental status, was reevaluated/updated on 1/17/2015 and 1/26/2015. Problem #3 nutritional status was reevaluated/updated on 1/20/2015, 1/22/2015, & 1/24/2015. Problem #4 skin integrity, was reevaluated/updated on 1/23/2015. Problem #5 open wound/infection was reevaluated/updated 1/20/2015, 1/24/2015, & 1/26/2015. There were no updates for problem #1 since 1/20/2015.

On 1/28/2015 at 1400 staff W and HH, who were navigating the electronic charts for me both stated, "there are no other updates documented in the care plan or the progress notes. We have been reeducating the nurses on our policy to document reassessment of the care plan every shift, we have 12-hour shifts here so that means (care plans are updated) twice a day."

Based on document review and interview the facility failed to ensure medical records were complete with a final diagnosis within thirty days of the discharge of the patient resulting in incomplete records. Findings include:

On 1/28/2015 at approximately 1515 during document review, it was revealed that 337 medical records were beyond 30 days of completion. An interview with staff CC was conducted on 1/28/2015 at approximately 1525. Staff CC was asked what was the process for alerting physicians of incomplete records. Staff CC responded, "Our policy is to send reminders to physicians when charts remain open. We send notices to the physicians' practices, e-mail, and also will call. We then move to a penalty system that with each open record the physician is fined three dollars per incomplete chart that is greater than 30 days without being completed."

On 1/28/2015 at approximately 1540 a review of the policy titled, "Medical/Allied Health Staff delinquent medical record fines policy number 6" occurred. The policy stated, "The intent of this policy is to ensure all medical records are completed within the required CMS (Centers for Medicare and Medicaid) guidelines which state 'The record must be completed promptly after discharge in accordance with State law and hospital policy but no later than 30 days after discharge.'"

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated January 29, 2015.
Building 1
K-0025
K-0029
K-0050
K-0054

Building 2
K-0050
K-0054
K-0062

Building 3
K-0029
K-0050
K-0054

Based on observation and interview, the facility; failed to ensure that the hot water supply at the west campus was being maintained at a safe temperature resulting in a potential burn hazard for all staff and up to 20 Rehab patients in this facility and the facility failed to ensure that the water supply to at risk (e.g. immunocompromised) patients at the main campus was safe from harmful microorganisms which could result in a serious health care acquired infection to the Oncology and PACU (post-anesthesia care unit) at the main campus . Findings include:

On 01/28/2015 at 0850 during tour and observation of the Rehab (rehabilitation) Unit at West Campus with staff KK, the hot water temperature at the sink in patient Room 881 measured 127 F. This is 7 degrees over the maximum safe limit of 120 F.

On 01/28/2015 at 1030 during tour and observation of the Rehab Unit at West Campus with staff JJ, the hot water temperature at the sink in the Rehab Dining room measured 126 F.

On 01/28/2015 at 1130 during tour and observation of the PACU with staff KK, the faucet spouts were observed to have aerators. Staff KK confirmed that these faucet aerators were not on any routine maintenance schedule for periodic cleaning and disinfection.

On 01/27/2015 at 1510 during tour and observation of the # East Oncology Unit with staff KK, the faucet spouts were observed to have aerators. Staff KK confirmed that these faucet aerators were not on any routine maintenance schedule for periodic cleaning and disinfection.

1. Based on observation and interview, the facility failed to ensure adequate backflow protection for the potable water supply at both campuses resulting in the potential harm to all patients, visitors and staff from chemical and biological contamination of the water supply. Additionally, the facility failed to provide adequate and safe code approved electrical power to identified areas of the facilities observed to be using heavy duty extension cords called "power cubes" which could potentially result in harm to patients in the vicinity of the cord due to electrical shock, fire, or other overload issues Findings include:

On 01/28/2015 at 0840 during tour and observation of the Rehab Unit at West Campus with staff KK, the vacuum breaker on the water supply to the automated chemical dispensing unit in the housekeeping closet by radiology was not appropriately protected from prolonged static pressure by means of a wasting tee or equivalent.

On 01/28/2015 at 1045 during tour and observation of the Rehab Unit at West Campus with staff KK, the vacuum breaker on the water supply to the automated chemical dispensing unit in the housekeeping closet by the Rehab gym was not appropriately protected from prolonged static pressure by means of a wasting tee or equivalent.

On 01/29/2015 at 0820 during tour and observation of the Endoscopy area at the main campus with staff KK, the vacuum breaker on the water supply to the automated chemical dispensing unit in the Endoscopy housekeeping closet was not appropriately protected from prolonged static pressure by means of a wasting tee or equivalent.

On 01/29/2015 between 1100 and 1200 during tour and observation of the main campus with staff KK, observed one power cube extension cord in use in Cath (cardiac catheterization) [invasive heart test) Lab 5 and one power cube extension in use in the CT (computerized tomography) (diagnostic imaging) room. Both power cube extension cords were not UL (underwriters laboratory) approved for use in a patient care vicinity and had no UL rating labeling.

Based on observation and interview the facility failed to maintain room cleanliness resulting in the potential for soiled and damaged product as well as acquisition of a hospital acquired infection for all patients. Findings include:

On 01/27/2015 at 1115 during tour and observation of 6 West patient unit with staff JJ observed a cardboard box with clean medical supplies stored on the floor of the 6 West medication room.

On 01/27/2015 at 1515 during tour and observation of 3 East Oncology with staff JJ observed dust accumulation on the top of the Omnicell unit in the 3 East medication room. Also observed two cardboard boxes of "irrigation fluid" being stored on the floor in this medication room.

On 01/27/2015 at 1545 during tour and observation of the 3rd floor Pharmacy with staff JJ, observed dust and debris accumulation (including five vials of pharmaceutical product) under various shelving units.

On 01/28/2015 at 1130 during tour and observation of the West Campus Pharmacy with staff JJ, observed accumulation of dust and debris under the pharmacy shelving units.

On 01/29/2015 at 0810 during tour and observation of 3 East Oncology with staff JJ, found two pneumatic tubes stored on top of the Omnicell in the Endoscopy Medication Room, making it difficult to clean the surfaces.

Based on observation, interview and document review, the facility failed to ensure that family and/or visitors were educated regarding isolation precautions for 3 of 10 (#21, #22 and #27) patients requiring contact isolation, resulting in the potential spread of infectious agents among all patients served by the facility. Additionally, the facility failed to ensure adequate lighting at hand wash sinks resulting in the potential spread of infectious agents among all patients served by the facility and the facility failed to ensure appropriate disposal of sharps waste resulting in the potential harm from needlesticks and blood/body fluid exposure for clinical and housekeeping staff working on the floor. Findings include:

On 01/27/2015 at 1400 during tour and observation of the 4 West unit (cardiac step down) with staff R (Register Nurse/Unit Manager), revealed that the door of patient #27's room (#433) had a sign that stated, "Contact Precautions (In addition to Standard Precautions) Visitors-Report to Nurses' Station Before Entering Room." When staff R was queried about the reason for the patient being in contact precautions, she stated, "He has MRSA (Methicillin Resistant Staphylococcus Aureus)." The observation further revealed that the patient was sitting up in a chair, a nurse was in the room providing care for the patient wearing an isolation cover gown and disposable gloves. The patient also had a visitor in the room who was sitting on the patient's bed who was not wearing any of the prescribed personal protective equipment (gown and gloves). When staff R was queried about the visitor sitting on the bed, she stated, "We educate them (visitors) about wearing the gown and gloves but they don't always do it." When queried if family and/or visitor education would be documented in the patient's medical record, she stated, "It should be."

On 01/27/2015 at 1415 during review of the medical record for patient #27, revealed that the record contained evidence of the patient being educated about the contact precautions but no documentation that family and/or visitors were educated regarding the precautions. When staff R was queried as to what the expectation for visitors regarding precautions would be, she stated, "We want them to wear the required PPE (Personal Protective Equipment) and to clean their hands when entering and leaving the room."

On 01/27/2015 at 1430, a review of the facility's policy titled, "Standard/Transmission based Precautions, # 3.1, Effective Date: September 2014," read, "C. Contact Precautions, 1. The use of Contact Precautions is used in addition to standard precautions for patients known to be infected (signs of illness) or colonized (presence of the bacteria but no signs of illness) with epidemiogically (study of health and disease in humans) important organisms. These organisms can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment. 3. Gloves and gowns should be worn when entering patient's room and removed just prior to washing or decontaminating hands and leaving the room."


29313

On 1/27/15 at 1315 during the initial tour of the 5 west cardiac/telemetry unit it was observed a patient, #21 in contact precautions (Room 535) with a visitor in the room. The visitor was observed without wearing the proper contact precautions attire (gown and gloves). Review of patient #21's medical record revealed that the patient had been educated on contact precautions, but family/visitor education was not documented.

On 1/27/15 at 1345 during the initial tour of the 5 west cardiac/telemetry unit it was observed a patient #22 in contact precautions (Room 541) with a visitor in the room assisting the patient with eating. The visitor was observed without wearing proper contact precautions attire (gown and gloves). Review of patient #22's medical record revealed that the patient had been educated on contact precautions, but family/visitor education was not documented.

On 1/27/15 at 1400 during an interview with staff R, she was queried as to if the family/visitors of patients in contact precautions were educated on the required attire while visiting patients in isolation, to which she responded, "Yes, but sometimes they refuse to wear it."


19647


On 01/27/2015 at 1430 during tour of the 4 East patient unit, the the isolation ante area foyer was very dim with only 7 footcandles of illumination at the handwash sink which is not adequate task lighting or lighting for proper hand hygiene (i.e. less than 30 footcandles of illumination).

On 01/27/2015 at 1555 during tour of the Obstetrical unit, the hand wash sink by the south end had a burnt out light in the fixture above resulting in an inadequate lighting level for proper hand hygiene (i.e. less than 30 footcandles of illumination) at the sink.

On 01/29/2015 at 1240 during tour of the Emergency Department, one of the sharps containers in the ED medication room was overfilled (i.e. more than 3/4 full and over the "fill line") and not yet sealed for removal so it could no longer be used. Infection prevention staff X confirmed that the facility policy is to remove sharps containers from service once the level of sharps reach the 3/4 full level.