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Based on medical record review, staff interview, and hospital policy review the hospital failed to ensure one of one patient (Patient #22) reviewed in the Outpatient Cancer Care unit had a care plan developed and kept current by the nursing staff. This had the potential to affect all of the patients treated in the Outpatient Cancer Care and the Radiation Oncology units. At the time of the survey, the census of the Outpatient Cancer Care unit was 157 patients and the census of the Radiation Oncology unit was 23 patients. The inpatient census of the hospital at the time of the survey was 355 patients.

Findings Included:

The review of the medical record for Patient #22 was completed on 03/05/13 at 9:45 AM. Patient #22 was admitted to the Outpatient Cancer Care unit 05/30/12 with a diagnosis of pancreatic cancer. The medical record lacked a care plan for Patient #22.

In an interview with Staff F and Staff N on 03/05/13 at 9:45 AM, Staff F and Staff N confirmed care plans were not being done for patients in the Outpatient Cancer Care and the Radiation Oncology units.

The hospital policy #05.00 entitled Documentation: Plan of Care was reviewed 03/06/13 at 11:00 AM. The policy stated, " The Plan of Care, Clinical Pathway and/or Patient Care Guideline identifies desired outcomes for patients and recommends interventions to assist patients in reaching outcome goals. "

In an interview with Staff F and Staff H on 03/06/13 at 12:20 PM, Staff F and Staff H confirmed that each patient treated in the Outpatient Cancer Care and the Radiation Oncology units should have a plan of care.

Based on observations, staff interviews, and reviews of facility documentation, this Condition of Participation of Physical Environment is not met related to the Life Safety Code requirements. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 355.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7, and on 03/13/13 with staff E5, L9, and M10. It was verified with these staff the facility failed to meet the requirements for Life Safety Code during this visit. Refer to A0709 and A0710.

25760

Based on observations and interviews the facility failed to ensure the emergency pull cords in the patient bathrooms were accessible by the patients. This has the potential to affect all patients on the fifteenth floor. The total census was 355.

Findings include:
During a tour of the fifteenth floor on 03/04/13 at 1:30 PM it was noted in patient room #1512 a semi private room, the patient bathroom was observed with the emergency light cord wrapped several times around the pull bar along side of the wall by the toilet. Staff A was informed and she/he immediately unwrapped the emergency cord. Further down the hall, the bathrooms in rooms #1518 and #1519 were also observed, it was noted in both of these bathrooms that the emergency pull cords were also wrapped around the patient pull bar along the wall beside the toilet. Staff A and Staff B immediately unwrapped the emergency pull cords from the bar.

Observation on 3/05/13 at 11:00 AM on the Adult Psychiatric Unit in the seclusion room revealed the heater in this room was soiled in the controls with paper material and there was a sharp protrusions on the right edge of the heater that could cause injury to a patient.

Observation of the out-patient department on 3/06/13 at 8:30 AM revealed the male and female bathrooms had no call system to alert staff to potential needs of the patients that are using these bathrooms. This was confirmed by Staff E at that time.

Based on observations and staff interviews, the facility failed to ensure the Life Safety from fire requirements were met. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 355.

Findings include:

Facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7, and on 03/13/13 with staff E5, L9, M10. It was verified with these staff the facility failed to meet the requirements for Life Safety Code during this visit. Refer to A0710.

Based on observations and staff interviews, the facility failed to ensure the Life Safety from fire requirements were met. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 355.

Findings include:

A facility tour took place on 03/07/13 through 03/14/13 with staff members A1, B2, C3 and J7, and on 03/13/13 with staff E5, L9, M10. The following LSC requirements were found not met:
1. The facility failed to ensure doors were fire rated within a two hour fire separation. Refer to K11.
2. Vertical opening stairway doors were observed with painted fire rated labels which were not legible. Refer to K20.
3. Exit signs were not installed appropriately when the way out was not readily apparent. Refer to K22.
4. Smoke barriers were observed with penetrations. Refer to K25.
5. Fire and smoke barrier doors lacked fire resistance rated labels, and/or failed to latch. Refer to K27.
6. Severe hazard areas were observed with penetrations in the smoke barrier. Refer to K29.
7. One exit access was observed with impediments blocking the path to the exit. Refer to K38.
8. Exit discharges lacked adequate lighting. Refer to K45.
9. One exit discharge lacked a fire pull station. Refer to K51.
10. Sprinkler heads were observed dirty and/or with missing escutcheon rings. Refer to K62.
11. Fire extinguishers were observed located over 5 feet from the floor or were not readily visible. Refer to K64.
12. Space heaters were being used in the facility without knowledge of safety inspection and heater core temperatures. Refer to K70.
13. A trash chute discharge door was observed blocked with trash. The facility failed to ensure the trash and laundry chutes accesses were located within rooms used exclusively for that purpose. The facility also failed to ensure these rooms had at least a one hour fire rated construction and either the chute doors were equipped with a key lock or the door to the chute room was secured. Refer to K71.
14. Smoke detectors were located less than 36 inches from air supply diffusers. One exit ramp was observed snow covered and slick. The facility lacked follow-up for concerns identified on sprinkler inspection reports. There was no evidence of an annual ninety-minute light test on battery operated lights for one off-site facility. Refer to K130.
It was verified with these staff the facility failed to meet the requirements for Life Safety Code during this visit.