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Based on record review, policy review and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by: (A 117) failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights; (A 144) failure to provide patient care in a safe setting; (A 168) failure to ensure that restraint orders were completed and authenticated by a physician; (A 170) failure to notify the patients attending physician as soon as possible after being placed in restraints when the attending did not originally give the order; (A 171) failure to provide complete restraint orders and (A 175) failure to monitor patients in restraints as ordered.

Based on medical record review, interview, and policy review the facility failed to ensure 7 of 9 patients (#18, #27, #28, #34, #35, #38, and #39) received the Important Message from Medicare (IMM).
Findings include:
During medical record review on 11/19/12 at approximately 1400 it was revealed that patient #18's medical record failed to have the required IMM. During an interview with staff EE on 11/19/12 at approximately 1415 it was confirmed that the IMM was not in the medical record. Staff EE stated "I looked and it's not in there. "
During medical record review on 11/21/12 between the hours of 1000 - 1115 it was revealed that the medical record for patients #34, #35, #38, and #39 failed to have the required IMM. During an interview with staff FF on 11/21/12 at approximately 1100 it was confirmed that the IMM was not available for these patients. Staff FF stated " I can't find it. "



30988

During medical record review of patient #27 and #28 on 11/19/2012 at approximately 1330 (1:30 PM) , it was revealed that the IMM had not been given to, or signed by the patient or his/her representative. Patient #27 had been admitted on 11/17/2012 and had signed consent for treatment, however, did not have signed IMM. Patient #28 was admitted on 11/05/12 and had signed consent for treatment, however, did not have signed IMM.

Review of the "Management Operating Directive- 4 SGH MOD 001 001" revealed #3. If the patient or his/her representative refuses to sign the first IMM, the admitting staff member will notate "refused to sign" and add their name and date to the bottom of the form....#4. Patients who are unable to sign due to sedation, pain, mental status, or acuity, the admitting staff should contact the patient rep and the IMM should be read to the representative. The admitting staff should document who they spoke with including name and phone number even if the pt rep refused to listen to the IMM. Documentation that the attempt was made is important.

These findings were confirmed during interviews with staff FFat approximately 1330 (1:30 PM) on 11/19/12 and with staff S on 11/20/12 at approximately 0830 (8:30 AM).

Based on observation, interview and document review, it was revealed that the facility failed to take steps to ensure patient safety in 1 out of 10 patient's hemodialysis stations observed. Findings include:

On 11/19/12 at approximately 1100 during facility tour on 4-East, revealed in the in-patient hemodialysis unit, the patient at station #10 was dialyzing, lying in bed, covered from head to toe with a blanket, including the access site. Interview with Staff O, the unit's nursing manager on 11/19/12 at 1100 confirmed that the patient was covered from head to toe and said "he shouldn't be covered like that".

On 11/19/12 at approximately 1530, during review of facility policy titled "Hemodialysis - Initiation" dated 4/1/12 revealed "...15. Keep lines and access visible to nursing staff..".

On 11/19/12 at approximately 1330 (1:30 PM) during medical record review of patient #27 it was discovered that restraint orders were written on 11/16/12 at 18:17 (6:17 PM) by a medical resident and discontinued on 11/16/12 at 07:38 (7:39 AM) by a different medical resident. The orders have not been counter signed by the attending physician.

On 11/19/12 at approximately 1345 (1:45 PM) during medical record review of patient #28 it was discovered that restraint orders were written on 11/09/12 at 21:48 (9:48 PM) by a medical resident and discontinued on 11/12/12 at 21:41 (9:41 PM) by a PA-C , restraints were ordered again on 11/19/12 at 17:15 ( 5:15 PM ) by the PA-C and then discontinued. The orders have not been counter signed by the attending physician.


29955

Based on medical record review, interview, and policy review the facility failed to ensure restraint orders were ordered or authenticated by the attending physician for six out of eight patients (#2,#3,#4,#27,and #28) resulting in the restraint of a patient without an order.

On 11/19/2012 at approximately 11:00 am during the medical record review of patient #2 it was revealed the patient #2 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/10/2012 at 10:06 am and the order was rejected by the attending physician on 11/17/2012 at 06:26 am. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order".

On 11/19/2012 at approximately 11:20 am during the medical record review of patient #3 it was revealed the patient #3 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/5/2012 at 10:08 am and the order was rejected by the attending physician on 11/16/2012 at 04:42 am. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order".

On 11/19/2012 at approximately 11:35 am during the medical record review of patient #4 it was revealed the patient #2 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/15/2012 at 12:33 pm and the order was rejected by the attending physician on 11/17/2012 at 14:21pm. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order".

According to Policy No. 1 CLN 008 "restraint us in the non-psychiatric, medical/surgical healthcare setting" (p.12) "the physician must be contacted prior to application or immediately following emergency application of restraints, face to face assessment by physician required, order good for a maximum of one calendar day". The attending physician refused to sign the restraint order and did not evaluate the order per the facility's policy and rejected the order subsequently days later.

Based on record review, interview, and policy review the facility failed to ensure that the attending physician who is responsible for the management and care of the patient was notified as soon as possible when the attending physician did not write the restraint order in 6 of 8 medical records of patients in restraints reviewed (#2, #3, #4, #27, & #28) . This has the potential to impact the care and safety of all patients in restraints.
Findings include:

On 11/19/12 at approximately 1330 (1:30 PM) during medical record review of patient #27 it was discovered that restraint orders were written on 11/16/12 at 18:17 (6:17 PM) by a medical resident and discontinued on 11/18/12 at 07:38 (7:39 AM) by a different medical resident. The orders have not been counter signed by the attending physician and there is no documentation of the attending physician being notified.

On 11/19/12 at approximately 1345 (1:45 PM) during medical record review of patient #28 it was discovered that restraint orders were written on 11/09/12 at 21:48 (9:48 PM) by a medical resident and discontinued on 11/12/12 at 21:41 (9:41 PM) by a PA-C , restraints were ordered again on 11/19/12 at 17:15 ( 5:15 PM ) by the PA-C and then discontinued. The orders have not been counter signed by the attending physician and there is no documentation of the attending physician being notified.

Review of policy# 1 CLN 008 titled "Restraint Use in the Non-Psychiatric, Medical/Surgical Healthcare Setting" states under Orders...#2 The ordering physician must consult the attending physician as soon as possible (within 1 hour) of application if the attending physician did not order the restraint.

Interview of staff FF on 11/21/12 at approximately 1000 (10:00 AM) confirmed there is no documentation that the attending physician was notified of the order.
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29955

On 11/19/2012 at approximately 11:00 am during the medical record review of patient #2 it was revealed the patient #2 was in bilateral soft restraints for medical necessity were ordered on 11/10/2012 at 10:06 am and the order was rejected by the attending physician on 11/17/2012 at 06:26 am. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order". The attending physician was not notified within one hour according to the facility's policy.


On 11/19/2012 at approximately 11:20 am during the medical record review of patient #3 it was revealed the patient #3 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/5/2012 at 10:08 am and the order was rejected by the attending physician on 11/16/2012 at 04:42 am. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order". The attending physician was not notified within one hour according to the facility's policy.

On 11/19/2012 at approximately 11:35 am during the medical record review of patient #4 it was revealed the patient #2 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/15/2012 at 12:33 pm and the order was rejected by the attending physician on 11/17/2012 at 14:21pm. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order". The attending physician was not notified within one hour according to the facility's policy.

On 11/19/2012 at approximately 11:00 am during the medical record review of patient #2 it was revealed the patient #2 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/10/2012 at 10:06 am and the order was rejected by the attending physician on 11/17/2012 at 06:26 am. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order". No renewal of orders occurred for the use of restraints from 11/10/2012 to 11/20/2012.

On 11/19/2012 at approximately 11:20 am during the medical record review of patient #3 it was revealed the patient #3 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/5/2012 at 10:08 am and the order was rejected by the attending physician on 11/16/2012 at 04:42 am. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order". No renewal of orders occurred for the use of restraints from 11/5/2012 to 11/20/2012.


On 11/19/2012 at approximately 11:35 am during the medical record review of patient #4 it was revealed the patient #2 was in bilateral soft restraints for medical necessity were ordered by the medical resident on 11/15/2012 at 12:33 pm and the order was rejected by the attending physician on 11/17/2012 at 14:21pm. The rejected ordered stated "wrong clinician". Staff #G was asked why the physician did not authenticate the orders and he stated "it was a misunderstanding between the intensivist and attending physician who would authenticate the order". No renewal of orders occurred for the use of restraints from 11/15/12 to 11/20/2012.




30988

Based on medical record review , interview, and policy review the facility failed to renew restraint orders no less than once every calendar day based on face to face assessment of the patient in 6 of 8 restrained patients records reviewed (#2, #3, #4, #27, and #28). Resulting in the potential for patients to be restrained longer than necessary and without a physician order.

Findings include:

On 11/19/12 at approximately 1330 (1:30 PM) during medical record review of patient #27 it was discovered that restraint orders were written on 11/16/12 at 18:17 (6:17 PM) by a medical resident and discontinued on 11/18/12 at 07:38 (7:39 AM) by a different medical resident. The orders have not been counter signed by the attending physician and there is no documentation of the attending physician being notified. There are no orders to renew the restraints for 11/17/12, 11/18/12 and 11/19/12.

On 11/19/12 at approximately 1345 (1:45 PM) during medical record review of patient #28 it was discovered that restraint orders were written on 11/09/12 at 21:48 (9:48 PM) by a medical resident and discontinued on 11/12/12 at 21:41 (9:41 PM) by a PA-C , restraints were ordered again on 11/19/12 at 17:15 ( 5:15 PM ) by the PA-C and then discontinued. The orders have not been counter signed by the attending physician and there is no documentation of the attending physician being notified. There are no orders to renew the restraints for 11/10/12, 11/11/12, and 11/12/12.

Review of policy# 1 CLN 008 titled "Restraint Use in the Non-Psychiatric, Medical/Surgical Healthcare Setting" states under Orders...#5 A restraint order is good for a maximum of one calendar day....B Continued use of restraint beyond the first day requires an order by the physician no less than once every calendar day based on face to face assessment of the patient.

Interview of staff FF on 11/21/12 at approximately 1000 (10:00 AM) confirmed there are no further restraint orders.

Based on medical record review , interview, and policy review the facility failed to monitor restrained patients in 7 of 8 restrained patients records reviewed (#2, #3, #4, #5, #27, and #28). Resulting in the potential for physical harm to the patients. Findings include:

During medical record review on 11/19/12 at approximately 1330, it was revealed on the Electric medical record (EMR) a shift assessment is completed and restraint is a yes or no question there is no documentation of patient care during restraint.

Review of policy# 1 CLN 008 titled "Restraint Use in the Non-Psychiatric, Medical/Surgical Healthcare Setting" states under "Patient care during restraint...#2 when restraint is in place, the patient is assessed, monitored and re-evaluated based on the patients care needs, at a minimum of every two (2) hours.
#3 monitoring includes and determines:
A the proper application of the restraint
B. Skin integrity and circulation to affected areas
C Need to provide active/passive range of motion
D Protection of the patients rights, dignity, and safety
E Patients behavior/activity
F Physical comfort/safety
G Whether less restrictive alternatives are possible
#4. Nutrition/Hydration , Toileting , and Hygiene .

During an interview with staff S on 11/20/12 at approximately 0900 (9:00 AM) "the staff do hourly checks and write on the white boards but they do not have an every 2 hour documentation record". An interview with FF on 11/20/12 at approximately 1330 (1:00 PM) it was confirmed there is no documentation of reassessment every two (2) hours while in restraint.

Based on medical record review and interview the facility failed to ensure that nursing staff keeps a current care plan for each patient in 1 out of 2 (#40) medical records reviewed.
Findings include:
During medical record review on 11/19/12 at approximately 1430 it was found that patient #40 had not had an updated plan of care since 11/12/12. During this time frame the patient had a change in his mental health status and no update to the plan of care was completed.
During the medical record review on 11/19/12 at approximately 1430 staff EE was the person explaining the chart content to this surveyor and confirmed the lack of an updated plan of care for this patient.

Based on document review and interview the facility failed to ensure 100 medical records were completed within 30 days.

On 11/19/2012 at approximately 3:00 pm during a meeting with medical records administration it was revealed 100 records were not completed within 30 days. Seventy four records were within the 30 to 59 day range, 15 records within 60 to 89 days, 4 records within 90 to 119 days, 3 records within 120 to 149 days, 1 record within 150 to 179 days, 3 records within 200 plus days. When asked if the physicians had been made aware of the records were not completed it was stated "yes. Physicians are notified in writing and by fax that they have delinquent records. Their offices are also notified. The department heads are notified. We have done everything to try to get physicians to complete records, yet some still do not fall in compliance".

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based on interview and observation, the facility failed to provide an environment that ensures the safety and well being of patients. Findings include:

During the facility tour on the morning of November 19, 2012, three patients on stretchers were observed unattended in the corridor of the Nuclear Med Suite. Interview with the Nuclear Med Manager during the facility tour revealed that the patients either were waiting transport or waiting to enter a Nuclear Med Room. It was also stated during the interview that on average a patient is waiting unattended in the corridor for about 20 or 30 minutes. During this time, the patient has no device to call for staff during an emergency unless they are physically able to yell loud enough that staff can hear the staff which are usually in a room off of the corridor.

During the facility tour on the morning of November 19, 2012, dead flies/insects were observed in the light fixtures throughout the radiology department located on the 6th floor of the facility.

During the facility tour on the morning of November 20, 2012, the floor in the Decon room in Central Sterile looked stained/soiled. Interview with the Central Sterile Manager revealed that the floor is cleaned each night but some stains cannot be removed which makes the floor look dirty even after cleaning.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated November 20, 2012 for Life Safety Code.

Based on observation and interview, the facility failed to provide proper ventilation to the inpatient dialysis unit. Findings include:

During the facility tour on November 20, 2012 it was observed that two portable air conditioning units were within the inpatient dialysis unit. Interview with the Dialysis Manager revealed that these units had been installed a while back and are utilized year round. It was also stated that the unit was originally designed as a infusion unit and converted to dialysis. The existing ventilation was not designed to account for the dialysis machine heat load. The portable air conditioning units were connected to the plumbing under the hand wash sinks and one of the two air conditioning units was blocking access to the hand wash sink.

Based on observation, policy and procedure review and interview the facility failed to, maintain a sanitary environment and ensure staff are using personal protective equipment according to policy, resulting in the potential for the spread of infectious agents to patients. Findings include:
During the tour of the facility on 11/19/12 between the hours of 1130-1500 the following was observed:
1-West:
1. In room 114-west the sink was dirty with debris
2. The freezer in the nourishment room on 1-west was dirty with debris and had a large amount of ice build up.
3. In room 106-west there was a lack of high dusting throughout the room, including the cabinets and closets. The front of the cabinets were soiled and dirty from not being cleaned appropriately.
This was all confirmed by staff CC at the time of the tour observations.
2-East
1. In room 107-E the inside of the closets were dusty and high surfaces had dust build up.
2. In room 110-E the bath tub and sink were dirty and high surfaces through out the room had dust build up.
This was all confirmed by staff DD at the time of the tour observations.
5-South
1. The dietary room was unsanitary, it had debris on the counters, cabinets had dried material on it, fingerprints could be seen.
2. The seclusion rooms bathroom was unsanitary, it's toilet, shower and sink appeared to not have been cleaned after the last patient that occupied the room.
3. The medication room had patient equipment and care items on the counter next to the sink with the risk of contamination by the splashing/dripping of water. The pill crusher had left over residue from the previous medication that was crushed on it.
This was all confirmed by staff EE at the time of the tour observations.
During the tour of the facility on 11/20/12 between the hours of 1000-1200 the following was observed:
Rehabilitation Unit
1. The shower and tub on the rehabilitation unit was unsanitary, they had debris and dirt inside of them
2. The rehabilitation gym had dirty parallel bars and floor runner dirty with debris
3. The rehabilitation refrigerator was dirty with debris and dried on liquid.
4. the rehabilitation kitchen was unsanitary, the cabinets and drawers had a lot of debris and dried on liquid that had not been cleaned. Finger prints were visible on the outside of the cabinets.
This was all confirmed by staff CC at the time of the tour observations. When staff CC was asked how the unit ensured the equipment was disinfected between patient usage, he replied that the staff cleaned them between patients, but there was no type of check list or terminal cleaning list to ensure that it was being completed, housekeeping wiped down the equipment periodically.




29774

On 11/19/12 at approximately 1130 during observational tour of 4-East in-patient hemodialysis unit, observed Staff R, a hemodialysis nurse, in a private room, labeled Station #1, without gown or gloves. The private room was labeled with a sign "Contact Precautions...Gown and gloves required upon room entry". Staff R was asked why she didn't have the required gown and gloves on to which she replied, "I was just taking his vital signs". Staff O confirmed on 11/19/12 at 1130, that Staff R "should have worn the personal protective equipment listed on the sign".

On 11/19/12 at approximately 1540 a review of facility policy titled "DMC Isolation Policy" dated May 29, 2012 revealed "Contact Precautions...Used to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment....Gown and gloves required upon room entry. Discard PPE (personal protective equipment) before exiting room...".

On 11/19/12 at approximately 1150 during observational tour of 4-East in-patient hemodialysis unit revealed one of two blood glucose testing machines with white paper-tape around the base of one of the two machines. Staff Q, the certified nurse educator was asked how the machine is cleaned with residual tape remaining on the unit to which she replied, "they really can't clean it. We are going to be replacing these (blood glucose testing) machines this month."

On 11/19/12 at approximately 1145, during observational tour of 5-East revealed in the medication area a pill crusher soiled with residual white powder. Staff P, the charge nurse mentioned, "wow, look at that". Staff P was asked on 11/19/12 at 1145 what the cleaning policy was for using these pill crushers to which she replied, "they should be cleaned between uses for each patient".

Based on medical record review, interview, and policy review the facility failed to identify patients at an early stage of hospitalization in need of discharge planning according to their policy in four of six patients (#35, #36, #37, and #38,).
Findings include:
During medical record review on 11/21/12 between the hours of 1000-1115 it was revealed that patient #35 was admitted on 8/14/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The discharge plan was completed on 8/18/12, the day of discharge.
During medical record review on 11/21/12 between the hours of 1000-1115 it was revealed that patient #36 was admitted on 6/15/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The discharge plan was completed on 6/19/12, the day of discharge.
During medical record review on 11/21/12 between the hours of 1000-1115 it was revealed that patient #37 was admitted on 8/17/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The discharge plan was completed on 8/20/12 with a discharge date of 8/21/12.
During medical record review on 11/21/12 between the hours of 1000-1115 it was revealed that patient #38 was admitted on 8/16/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The medical record did not contain a social work assessment or discharge plan.
During an interview with staff FF on 11/21/12 at approximately 1110 when asked if he could produce any further social work documentation he stated " No. "
On 11/21/12 at approximately 1130 a review of the facility ' s policy titled " Initial Social Work Assessment " dated 01/01/10 revealed " It is the policy of the Clinical Resource Management Department Social Work staff to assess patient ' s needs for services, plans for discharge, and post acute setting health management services. Patients will be assessed based on the following trigger criteria for their need for services. The Social Work assessment form should be completed either after consultation or within 48 hours of admission. " Triggers include but are not limited to: Chronic disease/Complex needs with risk for readmission and history of falls, abnormal gait or unsteady gait. Each of the above listed patients had one or more triggers documented in their medical records.

Based on medical record review, policy and procedure review and interview the facility failed to ensure that the discharge plan was being reassessed for the appropriateness of the discharge plan in 1 out of 2 (#40) medical records reviewed.
Findings include:
During medical record review on 11/19/12 at approximately 1430 it was found that patient #40 had not had an updated discharge plan completed since 11/14/12. During this time frame the patient had a change in his mental health status and no update to the discharge plan of care was completed.
During the medical record review on 11/19/12 at approximately 1430 staff EE was the person explaining the chart content to this surveyor and confirmed the lack of an updated discharge plan for this patient.
During policy and procedure review on 11/20/12 at approximately 1000 it was found in the policy titled, "Discharge Planning" states, "Discharge planning is initiated on patient presentation to the health care setting and is continuously assessed and updated throughout the hospital stay".