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482.13 Condition of Participation: Patient Rights is Not Met as evidenced by the hospital's failure to ensure patient records are free from unauthorized access(K47), use of least restrictive restraint (A165), restraints used in accordance with policies and procedures relating to every two hour assessment (A167), restraints not used on an as necessary basis (A169), restraint use monitored by the physician (A175), the provision of education to document according to hospital policy and procedure (A205) and the reporting to CMS of patient deaths when a restraint was used in the last 24 hours of life (A214). These deficiencies included 28 patients served by this facility which had a census of 64 on 08/23/10 and a capacity of 139, which includes neonatal beds.

Based on observation and staff interview, it was determined that staff failed to ensure that the patient's medical record was secure and free from unauthorized access. This affected at least 15 patients. The hospital census was 64 on 08/23/10 with a capacity of 139.

Findings include:

Per observation on 08/24/10 at 5:00 PM it was noted that all of the chart boxes throughout the hallway on second floor (medical/surgical area) were open and contained patient bedside charts that were unattended by staff. These open charts exposed patient information to any passerby. Further observation on 08/26/10 at 9:08 AM revealed that the chart boxes located outside of the patient's rooms were open and contained patient bedside charts. The bedside charts include all nursing documentation. This observation included the patient's located in rooms 243 and 245 where the nursing care flow sheets were open and left unattended by staff in the hallway. This was confirmed with Staff A at the time it was discovered. Per interview on 08/27/10 at 11:00 AM with Staff A and B, there were 15 patients on the medical surgical floor on 08/24/10 at 5:00 PM.

Based on medical record review and staff interview, 1 of 5 records of patients physically restrained during their hospitalizations did not have evidence that the type of restraint used was the least restrictive. This includes Patient 12 and Staff B. Census was 64 on 08/23/10.

Findings include:

Per medical record review on 08/25/10, Patient 12 was admitted to the hospital on 05/20/10 with a diagnosis of pneumonia. The patient's medical record also included a diagnosis of developmental disability. A physician order for a soft restraint for the left and right arms was written at 9:15 PM due to the patient not being able to understand instruction, the patient doesn't respond to alternative measures and was disruptive with a necessary medical treatment. Nurses notes reviewed revealed there was a sitter at the patient's bedside on 05/20/10 at 10:45 PM in addition to the arm restraints. Documentation in the medical record did not support the use of both measures.

Per review of Patient 12's medical record, a second physician order for physical restraint was written on 05/21/10 at 8:30 AM after an intravenous access was established in the right foot. At that time, a soft restraint was ordered for the patient's left ankle only and the justification was that the patient was unable to understand/follow instructions.

Per review of Patient 12's medical record, a third restraint order was written on 05/22/10 at 9:00 AM which included restraints of the left and right leg with no type of restraint designated. The justification was that the patient was unable to understand/follow instructions.

Per review of Patient 12's medical record, a fourth restraint was written on 05/23/10 at 9:00 AM which included a soft limb restraint for the left and right legs. Justification was the same as for the first restraint ordered.

Since three of the four orders for physical restraint included different limbs involved, it is unclear if the restraints used were the least restrictive, particularly with the first restraint which was coupled with the presence of a sitter. These findings were verified by Staff B on 08/26/10 at 4:00 PM.

Based on review of medical records, review of restraint policies and staff interview, the policy relating to frequency of assessment was not followed for 3 of 5 patient records reviewed where physical restraints had been used. This included Patient 12, 16 and 33. Census was 64 on 08/23/10 in this 139 bed hospital.

Findings include:

Per review of the hospital's policy relating to the frequency of assessment of a restrained patient revealed the patient is required to be assessed at least every two hours if the restraint is used for non-violent/non-self destructive behavior.

Per review of Patient 12's medical record on 08/25/10, no documentation of every two hour reassessments were found on 05/22/10 between 2:01 AM-8:00 AM, on 05/23/10 between 4:00 PM-10:00 PM and on 05/24/10 after 6:00 AM. These findings were verified by Staff B on 08/25/10 at 4:00 PM.

Per medical record review, Patient 16 was admitted on 07/15/10 with shortness of breath leading to acute respiratory failure and intubation and ventilation. Restraints were ordered on 7/15/10 at 8:00 PM due to the patient's removal of his/her oxygen mask which contributed to more difficulty breathing. The every 2 hour restraint check of the patient was not filled in correctly or completely. Per medical record review on 08/26/10, Patient 16 expired on 07/17/10 at 4:59 AM. while in restraints. These findings were verified on 08/26/10 at 4:35 PM by Staff B.


Per medical record review on 08/26/10, Patient 33 was admitted on 09/30/09 for shortness of breath and was intubated and restrained. In the nursing documentation required every 2 hours, the area for "cognitive distress" was consistently marked as "no" except on 10/03/09 where it was marked that the patient was sedated for cognitive distress. In the area of the form where it asked if the restraint was on or off, only a check mark was noted. On 10/01/09 thru 10/04/09, there were sections of time where there was no documented evidence of the every 2 hour nursing check of the patient. The medical record revealed that the patient was a "terminal wean". The patient was noted to be extubated on 10/05/09 at 12:45 PM and to expire at 11:30 PM on 10/05/09. These findings were verified on 08/26/10 at 4:35 PM by Staff B.

Based on medical record review, policy review and staff interview, 2 of 5 patients who were physically restrained during their hospitalization had physician orders for restraint renewal after the restraint had been removed. (Patient 18 and 31). Census in this 139 bed hospital was 64 on 08/23/10.

Findings include:

Per review of the facility's policy for physical restraints on page 2 of 19, "Staff cannot discontinue a restraint or seclusion intervention , and then re-start it under the same order. This would constitute a PRN order."

Per review of Patient 18's medical record on 08/26/10, the patient's first order for physical restraint was written on 06/12/10 at 11:00 PM for soft left and right arm restraints valid for 24 hours if needed. This patient had been admitted on 06/12/10 at 10:00 PM after a cardiac arrest at home. The patient had also been started on a paralytic intravenous drip at 10:20 PM when intubated and placed on a ventilator. The rationale for the restraint was that the patient did not understand/follow directions, did not respond to alternative measures and was disrupting necessary medical treatment.

Per review of Patient 18's medical record, a second physician order for physical restraint was written on 06/13/10 at 11:00 PM good for 24 hours for a soft restraint on the left and right arms. Review of the medical record revealed the restraint was removed on 06/13/10 at 12:00 PM and not re-instated through the remainder of Patient 18's hospitalization which included the patient's death on 06/15/10. Staff B confirmed on 08/26/10 at 9:43 AM that there was no need for the renewal order for the physical restraint on 06/13/10 at 11:00 PM as the restraint had not been used for 11 hours prior to the renewal order or after the order was written. Staff B also verified how that could be viewed as a PRN restraint order.

Patient 31 was noted to be admitted on 03/08/10 with the diagnoses of Lung Cancer, Methicillin Resistant Staph Aureus, pleural effusion, malnutrition, tracheostomy on a ventilator. The patient was admitted due to an increase in shortness of breath. The patient underwent a bronchoscopy and intubation due to respiratory failure. Notes written by the physician stated that the patient was a difficult extubation. The results of the bronchoscopy revealed that the patient's cancer had returned and worsened and that there was a complete obstruction of the right middle and right lower lobe of the lung with a complete collapse of the right lung.
On 03/11/10, a pre-printed form used by the facility for restraint orders was noted to be signed by the physician on 03/12/10 but no time when they signed, but not noted until 03/13/10 at 8:55 PM.
On 03/12/10, an order was written for the use of a restraint. On the pre-printed form used by the facility for ordering of restraints, the following was marked: Restraint Non-violent/non self destructive behavior; Patient unable to understand/follow instructions; Patient does not respond to alternative measures; Patient disrupting a necessary medical treatment. Also check marked were soft limb right and left arm, and 4 side rails up. The form was signed by the physician but without a time noted when it was signed.
The only other restraint order was noted to be dated 03/15/10 and that it had been "noted" at 7:45 PM. There was a physician's signature on the order but no date or time and none of the other information was completed in regard to type of restraint or what limb(s) were to be restrained and why.
Review of nursing documentation on 03/14/10 timed at 10:00 PM revealed that the patient's daughter was present and refused to let the patient be "tied down" even when the daughter was not in the patient's room. The noted further stated that the patient had been sedated.
Review of the documentation for the restraint use revealed that the restraint had been started on 03/09/10 and continued until 03/14/10 at 8:00 PM when at the request of the daughter it was discontinued. The information documented on the restraint use form lack complete information. Check marks were used in areas requiring more accurate information such as a "yes" or "no" to whether the restraint was on or off, the condition of the skin and if range of motion was done. It was further noted that under the category of distress on all of the forms, it was continually documented that the patient was not in distress.
On 03/15/10 at 9:50 AM the physician wrote a note in regard to the patient being extubated and a Do Not Resuscitate, Comfort Care only. Documentation in the medical record revealed a physician order at 10:20 AM for Ativan to be given IV every hour. The patient did expire on 03/15/10 at 5:29 PM.



03193

Based on medical record review, policy review and staff interview, 2 of 5 patients who had been physically restrained during their hospitalization, did not have his/her condition monitored by the physician at least every 24 hours. This included Patient 18 and 31. On 08/23/10 the census in this 139 bed hospital was 64.

Findings include:

Per review of the hospital policy relating to restraint/seclusion on page 2 of 19 stated, "If a telephone order is obtained, this order must be countersigned, dated and timed by the ordering physician within a 24 hour period ".

Per review of Patient 18's medical record on 08/26/10, the physician orders for the physical restraints on 06/12/10 and 06/13/10 were signed by the physician on 07/19/10 at 8:00 AM. Time required for the authentication of the physician order was 36 days rather than 24 hours. This finding was confirmed on 08/26/10 at 9:43 AM.

Patient 31 was noted to be admitted on 03/08/10 with the diagnoses of Lung Cancer, Methicillin Resistant Staph Aureus, pleural effusion, malnutrition, tracheostomy on a ventilator. The patient was admitted due to an increase in shortness of breath. The patient underwent a bronchoscopy and intubation due to respiratory failure.

On 03/11/10, a pre-printed form used by the facility for restraint orders was noted to be signed by the physician on 03/12/10 but no time when they signed. This order was noted by the registered nurse on 03/13/10 at 8:55 PM.

On 03/12/10, an order was written for the use of a restraint. On the pre-printed form used by the facility for ordering of restraints, the following was marked: Restraint Non-violent/non self destructive behavior; Patient unable to understand/follow instructions; Patient does not respond to alternative measures; Patient disrupting a necessary medical treatment. Also check marked were soft limb right and left arm, and 4 side rails up. The form was signed by the physician but without a time noted when it was signed.

The only other restraint order was dated 03/15/10 and the nurse had "noted" the order at 7:45 PM. There was a physician's signature on the order but no date or time and none of the other information was completed in regard to type of restraint or what limb(s) were to be restrained and why.

Review of nursing documentation on 03/14/10 timed at 10:00 PM revealed Patient 31's daughter was present and refused to let the patient be "tied down" even when the daughter was not in the patient's room. The note further stated the patient had been sedated.
Review of the documentation for the restraint use revealed that the restraint had been started on 03/09/10 and continued until 03/14/10 at 8:00 PM when at the request of the daughter it was discontinued. The information documented on the restraint use form lacked complete information. Check marks were used in areas requiring more accurate information such as a "yes" or "no" to whether the restraint was on or off, the condition of the skin and if range of motion was done. It was further noted that under the category of distress on all of the forms, it was continually documented the patient was not in distress. Patient 31 expired on 03/15/10 at 5:29 PM.

Based on medical record review, staff education and staff interview, 5 of 5 patient records reviewed did not have documentation consistent with the hospital policies and procedures relating to monitoring the physical and psychological well-being of each patient restrained. This includes Patients 12, 16, 18, 31, and 33. This 139 bed hospital had a census of 64 on 08/23/10.

Findings include:

Per interview with Staff B on 08/26/10 at 9:43 AM, evidence of staff competency relating to documentation included in the restraint/seclusion policy has not been completed. Training related to the application of physical restraints has been included in staff education under the category of national patient safety goals, according to Staff B. Staff B continued by saying the documentation piece will be completed by 08/31/10.

Per review of Patient 12's medical record on 08/25/10, the nursing staff failed to document every two hour assessments on 05/22/10 from 2:01 AM-8:00 AM and on 05/23/10 from 4:00 PM-10:00 PM. No type of restraint was designated on 05/22/10. The physician failed to sign the physical restraint order dated 05/20/10 at 9:15 PM for left and right arm. These findings were verified by Staff B at 4:00 PM on 08/25/10.

Per medical record review, Patient 16 was admitted on 07/15/10 with shortness of breath leading to acute respiratory failure and intubation and ventilation. Restraints were ordered on 7/15/10 at 8:00 PM due to the patient's removal of his/her oxygen mask which contributed to more difficulty breathing. The every 2 hour restraint check of the patient was not filled in correctly or completely. Per medical record review on 08/26/10, Patient 16 expired on 07/17/10 at 4:59 AM. while in restraints. These findings were verified on 08/26/10 at 4:35 PM by Staff B.

Per review of Patient 18's medical record on 08/26/10, the physician failed to sign the physical restraint orders for 06/12/10 and 06/13/10 within 24 hours. The orders were signed on 07/19/10 at 8:00 AM. This finding was confirmed by Staff B on 08/26/10 at 9:43 AM.

Patient 31 was noted to be admitted on 03/08/10 with the diagnoses of Lung Cancer, Methicillin Resistant Staph Aureus, pleural effusion, malnutrition, tracheostomy on a ventilator. The patient was admitted due to an increase in shortness of breath. The patient underwent a bronchoscopy and intubation due to respiratory failure.

On 03/11/10, a pre-printed form used by the facility for restraint orders was noted to be signed by the physician on 03/12/10 but no time when they signed. This order was noted by the registered nurse on 03/13/10 at 8:55 PM.

On 03/12/10, an order was written for the use of a restraint. On the pre-printed form used by the facility for ordering of restraints, the following was marked: Restraint Non-violent/non self destructive behavior; Patient unable to understand/follow instructions; Patient does not respond to alternative measures; Patient disrupting a necessary medical treatment. Also check marked were soft limb right and left arm, and 4 side rails up. The form was signed by the physician but without a time noted when it was signed.

The only other restraint order was dated 03/15/10 and the nurse had "noted" the order at 7:45 PM. There was a physician's signature on the order but no date or time and none of the other information was completed in regard to type of restraint or what limb(s) were to be restrained and why.

Review of nursing documentation on 03/14/10 timed at 10:00 PM revealed Patient 31's daughter was present and refused to let the patient be "tied down" even when the daughter was not in the patient's room. The note further stated the patient had been sedated.
Review of the documentation for the restraint use revealed that the restraint had been started on 03/09/10 and continued until 03/14/10 at 8:00 PM when at the request of the daughter it was discontinued. The information documented on the restraint use form lacked complete information. Check marks were used in areas requiring more accurate information such as a "yes" or "no" to whether the restraint was on or off, the condition of the skin and if range of motion was done. It was further noted that under the category of distress on all of the forms, it was continually documented the patient was not in distress. Patient 31 expired on 03/15/10 at 5:29 PM.

Per medical record review on 08/26/10, Patient 33 was admitted on 09/30/09 for shortness of breath and was intubated and restrained. In the nursing documentation required every 2 hours, the area for "cognitive distress" was consistently marked as "no" except on 10/03/09 where it was marked that the patient was sedated for cognitive distress. In the area of the form where it asked if the restraint was on or off, only a check mark was noted. On 10/01/09 thru 10/04/09, there were sections of time where there was no documented evidence of the every 2 hour nursing check of the patient. The medical record revealed that the patient was a "terminal wean". The patient was noted to be extubated on 10/05/09 at 12:45 PM and to expire at 11:30 PM on 10/05/09. These findings were verified on 08/26/10 at 4:35 PM by Staff B.

Based on staff interview and documentation relating to patients who expired within 24 hours of being restrained, the facility had failed to report 9 patients who were restrained within 24 hours of expiration. This includes Patients 31, 33, 38, 39, 40, 41, 42, 43 and 44. There were a total of 180 patient between 08/31/09-08/15/10 who were physically restrained and from whom the 9 patient records were retrieved.

Findings include:

Per interview with Staff A and B on 08/25/10 between 12:12 PM-12:30 PM , Staff A and B reported they were made aware of the failure of the hospital staff to ensure all patients restrained within 24 hours of death in the intensive care unit between 08/31/09-08/15/10 were not reported to the Centers of Medicare/Medicaid (CMS) as required. The requirement is that each death must be reported to CMS by telephone no later than the close of business the next day following knowledge of the patient's death. Per interview, Staff A and B were made aware of the failure to report on 08/17/10. As a result, 180 patient medical records were reviewed for the period of 08/31/09-08/15/10 . All of the 180 patients had been restrained during their hospitalizations. From that medical record review, the determination was made that deaths within 24 hours of restraint had not been reported for Patients 31, 33, 38, 39, 40, 41, 42 and 44 to CMS.

Based on a tour of the medical records area and staff interview it was determined that the hospital failed to ensure medical records were protected from damage from fire and water. This included outpatient medical records from 2003 through 2005. The hospital census is 64.

Findings include:

The tour of the medical records department was conducted on 08/25/10 at 1:30 PM with Staff II. During the tour this surveyor was taken to the medical records storage area located in the hospital's south building on the lower level. This area was sprinklered and it was noted that in order to make room for more inpatient records the outpatient records were stacked in over ten large open boxes on the floor. When questioned ,Staff II stated that these were awaiting pick up from an outside medical records storage company. The stacked open boxes full of outpatient records offered no protection from water in the event that the sprinklers were activated.

Based on review of medical records and staff interview, the facility failed to ensure that medical record entries were legible (Patients 1, 2, 17, 18, 31, 32 and 33) or dated and timed (Patients 1, 2, 12, 31, 32 and 33) by the person documenting in the medical record for 8 out of 34 records reviewed. Six patient medical records (12, 17, 31, 32 and 33) had been discharged and two (1 and 2) were current inpatients. The facility census was 64 patients on 08/23/10 in this hospital of 139 beds.

Findings include:

On Monday, 08/23/10, during review of two patient records in the intensive care unit with Staff B present, it was noted that for both Patients 1 and 2 there were entries made by physicians that were not timed or legible. This was confirmed at the time with Staff B.

On 08/25/10 during review of the patient medical records for patient 16 and on 08/26/10 for patients 31, 32 and 33, it was noted that physician entries were not timed when written or signed. This included orders for medications including an anti-anxiety drug and physician orders for the use of physical restraints. Progress notes written by the physician although dated, were not signed and several entries were not legible. This was confirmed at the time with Staff B.

Per Patient 12's medical record review on 08/24/10, a restraint order written on 05/20/10 was not timed. This was verified by Staff B on 08/25/10 at 4:00 PM.

Per Patient 17's medical record on 08/25/10, physician progress notes throughout the patient's three days of hospitalization were illegible. Legibility of physician orders and progress notes were discussed by Staff B throughout the survey.

Per Patient 18's medical record review on 08/25/10, physician progress notes throughout the three days of hospitalization were illegible. This was shared with Staff B on 08/25/10 at 4:00 PM.

Based on a tour of the medical records department and interview and confirmation with staff it was determined that the hospital failed to complete all medical records within 30 days. The hospital census is 64.

Findings include:

On 08/25/10 at 1:30 PM a tour was conducted of the medical records department. An interview was conducted with Staff II on 08/25/10 at 1:30 PM. Staff II stated that to date 14 physicians were on suspension for incomplete medical records that exceeded 30 days.

Based on tour and observation of the dietary department and staff interview, it was determined that the food service director failed to ensure that safety practices were followed for the handling of food. This related to food temperatures above the maximum level for cold foods and too low temperatures for hot foods. The current hospital census is 64.
Findings include:
On 08/24/10 at 3:00 PM a tour of the dietary department was conducted with Staff U,V and W. During the tour of the kitchen it was noted that the refrigerator labeled as the " salad and miscellaneous " contained items that were perishable and not dated at the time of opening for use. These items included lemon juice, mustard, 4 containers of salad dressing and one large bag of shredded cheese that was not sealed and open at the top. This was confirmed with Staff V.
At 4:20 PM dietary staff were observed as they prepared for the evening meal tray line. Food temperature checks were completed by Staff U who is the Food Service Supervisor. During this observation it was noted that the prepared cold food had been placed into individual servings and was left uncovered on trays in the refrigerator. These foods included fruit plates, fruit cocktail and pasta salad. Temperatures were obtained for these items that were located in the refrigerator by Staff U and were noted to be 42.1 degrees Fahrenheit (F). Staff U stated per their policy, food needs to be less than 41 degrees Fahrenheit and he/she would contact maintenance regarding the functioning of the refrigerator or it may just be due to overcrowding of the food in the refrigerator. At 4:40 PM the last cart of trays started to be assembled with the remaining patient trays to be delivered to the floor. At 5:00 PM the remaining cart was delivered to the floor and a temperature check (on a tray specified to be tested) was performed prior to the food being served to the patient. The results showed that the temperature of the pasta salad was now 61 degrees F and the fruit cocktail was 51 degrees F. An interview with Staff U was conducted at this time and he/she was asked if this food was safe to serve because it fell below their policy of 41 degrees F. Staff U stated that it was safe to serve because it had not sat out for over 4 hours and that is when food becomes unsafe and there is a risk of food borne illness. The policy was requested and received. This policy instructed staff that once food is taken from the temperature controlled environment, temperatures must be maintained at 140 degrees F for hot foods and 41 degrees F and below for cold foods and a time and temperature method cannot be utilized to monitor food safety then the time only method is utilized. The temperature method was in use by staff at the time of observation and the cold food in the controlled environment was not kept above 41 degrees.
On 08/25/10 the surveyor was provided with test tray temperature results completed by staff for the previous 9 months. These results revealed the following: 12/7/09 vegetable was 110 degrees; 02/20/10 vegetable temperature was 92 degrees; 5/16/10 appetizer-salad was 48 degrees; 06/14/10 cold entree was 50 degrees and the cold beverage measured 52 degrees; 7/15/10 temperatures were 52 degrees for pineapple and the vegetable was 118 degrees; 7/31/10 the cold entree was 58 degrees and the vegetable was 116 degrees. These temperatures fell below the range of less than 41 degrees Fahrenheit for cold foods and 140-150 degrees Fahrenheit for hot foods per hospital policy. These findings were verified by Staff B on 08/26/10 at 3:49 PM.

Based on review of the personnel records, job description, interview and confirmation with staff, it was determined that the hospital failed to ensure staff and technical personnel are competent in their assigned duties related to food safety. This involved Staff U. The current hospital census is 64.

Findings include:

At 4:20 PM staff were observed as they prepared for the evening meal tray line. Food temperature checks were completed by Staff U who is the Dietary Supervisor. Temperatures were obtained for prepared foods prior to the start of the tray line. Foods that included pasta salad, fruit cocktail and fruit plates were located in the refrigerator by Staff U and were noted to be 42.1 degrees Fahrenheit. Staff U stated that per their policy food needs to be less than 41 degrees F. At 4:40 PM the last cart of trays had begun to be assembled and the remaining patient trays were waiting to be delivered to the floor. At 4:50 PM this surveyor requested a test tray. When the tray line was completed Staff U approached this surveyor with a tray and asked where I would like to take it. This surveyor related to Staff U that the intention was not to eat the food on the tray and that the test tray was to be completed to check food temperatures prior to the tray being delivered to the patient. This surveyor accompanied Staff U to the floor with the food cart. The results showed that the temperature of the pasta salad was now 61 degrees and the fruit cocktail was 51 degrees. An interview with Staff U was conducted at this time and he/she was asked if this food was safe to serve because it fell below their policy of 41 degrees. Staff U stated that it was safe to serve because it had not sat out for over 4 hours and that is when food becomes unsafe and there is a risk of food borne illness. These findings were shared on 08/25/10 with Staff A and B.

An interview conducted on 08/25/10 at 8:10 AM with Staff I, the infection control nurse revealed that the bacteria Staphylococcus and Salmonella grow much more quickly than 4 hours.

482.41 The Condition of Participation: Physical Environment is Not met as evidenced by the failure to ensure that the main hospital and two offsite facilities were in compliance with the 2000 Existing Life Safety Code. Based on observations, review of hospital documentation including fire watch plans, logs reflecting testing of emergency back-up lighting and fire drills and staff interview, the hospital failed to ensure that all requirements of the 2000 Existing Life safety Code were met relating to corridor walls, corridor doors, smoke barrier walls, door openings in smoke barriers, testing of emergency back-up, failure to ensure quarterly fire drills were conducted, smoke detectors to close to vents, fire watch plan for sprinkler systems and fire watch plan for fire alarm. Please refer to the findings at A709.

Based on observations made on 08/24/10 and 08/25/10 , review of hospital documentation including fire watch plans , logs reflecting testing of emergency back-up lighting and fire drills and staff interview, the hospital failed to ensure that all requirements of the 2000 Existing Life Safety Code were met relating to corridor walls (K17), corridor doors (K18), smoke barrier walls (K25), door openings in smoke barriers (K27), testing of emergency battery back-up (K46), failure to ensure quarterly fire drills are conducted (K50), smoke detectors too close to air vents (K130), fire watch plan for sprinkler systems (K154) and fire watch plan for fire alarm (K155). This includes deficiencies cited in the main hospital and two offsite locations.

Findings include:

Per observation in the main hospital on 08/24/10 and 08/25/10 while accompanied by Staff P, Q and R, penetrations in corridor walls in non-sprinklered areas above ceiling tiles on 2nd and 3rd floors were found. K17 was cited as the corridor walls failed to be separated from use areas with at least a 30 minute fire rating.

Per observation in the main hospital on 08/24/10 and 08/25/10 while accompanied by Staff P, Q and R, dutch doors did not meet the requirement which included positive latching of the upper and lower doors. K18 was cited.

Per observation in the main hospital on 08/24/10 and 08/25/10 while accompanied by Staff P, Q and R, penetrations in smoke barrier walls were found on 2nd and 3rd floors. K25 was cited.

Per observation in the main hospital on 08/24/10 and 08/25/10 while accompanied by Staff P, Q and R, a door in the smoke barrier wall on 3rd floor was observed with a door knob and dead bolt lock. K27 was cited.

Per hospital documentation review on 08/26/10, emergency battery back-up testing logs were not completed monthly. K46 was cited for this deficiency in the main hospital.

Per hospital documentation review, the offsite sleep laboratory (Building 3 of 3) did not have evidence of quarterly fire drills. K50 was cited.

Per observation on 08/24/10 at the offsite housing an urgent care, radiology and outpatient rehabilitation(Building 2 of 3) two smoke detectors were found which were located too close to air vents. On 08/24/10 and 08/25/10, smoke detectors in the main hospital were observed to be too close to air vents. All observations were made in the presence of hospital staff including P, Q and R. K130 was cited.

Per review of hospital documentation on 08/23/10, the fire watch plan to be implemented if the sprinkler system were to be non-functional did not include details relating to the hospital areas involved and the system to be implemented when needed. Staff P verified this on 08/23/10 .K154 was cited.

Per review of hospital documentation on 08/23/10, the fire watch plan to be implemented if the fire alarm were not functional did not include details relating to the hospital areas involved and the system to be implemented if needed. Staff P verified this on 08/23/10. K155 was cited.

Based on observations made of the medical surgical floors, telemetry floor and intensive care unit, review of medical records and policy and procedures and interview and confirmation with staff it was determined that the hospital failed to ensure that all staff adhered to infection control policies regarding personal protective equipment and medication administration. The hospital census was 64. This involved Staff Z,AA,CC,FF,GG,HH. This affected Patients #1,3,4,29,30,35,36,37.

Findings include:

The staff were observed as they entered the room of patients without the use of personal protective equipment when the patients were on isolation precautions. Observation of medication administration revealed that staff were administering the patients medications without gloves. See A 756.

Based on observations, review of facility policy and staff interviews, the facility failed to ensure that staff followed all policies and procedures in regard to infection control for 8 out of 10 patients that specific observations were made on during the survey. These observations related to observations of medication administration ( Patients 3, 35,36 and 27) and wearing personal protective equipment including gown and gloves in contact isolation rooms (Patients 1, 4, 29 and 30). This included observations of staff Z, AA, CC, FF, GG and HH. The facility census was 64 patients.

Findings include:

During the medication pass observation on Tuesday morning, 08/24/10, with 4 different nurses (1 in orientation) and four different patients, the following was observed. Prior to the medication administration, Staff FF had not provided care to Patient 37. The patient was described as being somewhat confused and Staff FF was unsure of the answers patient 37 would give to name and date of birth. During preparation of the medications, Staff FF was noted to remove a medication from it's package, place it in the pill cutter bare handed, split the pill , remove it from the splitter barehanded and place it in the souffle cup. Once the patient's identity was verified, Staff FF started to give the patient their medications. Staff FF offered to give the patient one medication at a time and after opening the medications and placing them in a souffle cup, she/he reached into the cup with their fingers and retrieved a medication. Staff FF placed the medication in Patient 37's mouth. Staff FF did not wear gloves during this observation.

Staff FF was then observed preparing Patient 36's medications. Patient 36 had a medication that was a very large pill which the patient stated they would not be able to swallow. After asking if the patient would like the medication broken into pieces and the patient stated "yes", Staff FF, with bare hands reached into the medication cup and took out the large pills, broke the medication into 2 pieces and then placed them into the patient's mouth. No hand hygiene was observed afterward.

During medication administration for Patient 35, Staff GG was observed to handle the patient's pills bare handed until the patient stated that they could take the medication independently.

Staff HH was observed during medication administration for Patient 3. Although the patient was in isolation and gowns and gloves were required, Staff HH removed a glove to open the medication packages with one glove on and one glove off. After removing the medication from the packages, Staff HH replaced the removed glove without any hand hygiene being done.

On Thursday, 08/26/10, at approximately 2:10 PM, Staff JJ stated there was no specific hand hygiene policy for medication administration, nor was there a specific policy for medication administration. Instead, a facility policy was reviewed which directed each staff to wash hands after each patient encounter.





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Per observation on 08/25/10 at 11:20 AM with Staff Y in the Intensive Care Unit (ICU), Staff Z was in Patient 1 ' s room without wearing the personal protective equipment (PPE) required by policy for patients in contact isolation. Patient #1 was admitted on 08/16/10 with respiratory failure and diabetes and placed on contact isolation precautions. Hospital policy stated that prior to entering a contact isolation room staff or visitors must don gloves and a gown before entering the room. Staff Z was visualized in Patient #9 ' s room wearing only gloves. Staff Y walked to the door and held out a gown to Staff Z. Staff Z stepped out of the patient ' s room and donned a gown and gloves. Staff Y turned to this surveyor and stated that the nurse just had not gotten around to putting the personal protective equipment on.
An interview was conducted with Staff Y on 08/25/10 regarding the reason for Patient 1 ' s need for contact isolation. Staff Y reviewed Patient 1 ' s current medical record and was unable to find the reason why the patient was on isolation. Staff Y also discussed this with other ICU Staff Nurses and they looked through the current chart and chart from the previous hospital admission and were unable to give the rationale. Staff W was assigned to care for Patient 1 stated that he/she believed that it could be due to a positive sputum culture because the patient was diagnosed with chronic lung disease and the residential center that the patient was admitted from has several cases of MDRO (multi drug resistant organisms) which is any kind of bacteria that is resistant to many kinds of bacteria. Staff X the Director of the Intensive Care Unit was called and she stated that it was more than likely a result of the MDRO. There was no sufficient documented evidence to support the information received from the staff in regards to the reason why Patient 1 was currently placed on contact isolation precautions. This patient was awaiting transport back to the nursing home from where he/she had been admitted and transport staff also inquired as to why the patient was in isolation so that they donned appropriate PPE.
Per observation on 08/26/10 at 9:10 AM with Staff A, Staff AA ,a nurse aide, was observed walking into Patient 29 ' s room with no PPE on. Patient 29 was admitted on 08/25/10 with a lower gastrointestinal bleed and diarrhea and had tested positive for C diff (clostridium difficile) which is a bacterium that causes diarrhea. Healthcare workers can spread the bacteria to other patients or contaminate surfaces through hand contact. Staff AA walked into the room with no gown or gloves on and was stopped by Staff A as he/she exited the room. Staff A questioned Staff AA as to why he/she had not worn PPE to enter the patients room. Staff AA stated that PPE was not necessary because he/she was had just delivered the patient ' s orange juice and didn't touch the patient.
Per observation on 08/26/10 at 9:40 AM. ,Staff CC, a registered nurse, was noted in Patient 30 ' s room. This patient was in contact isolation with no PPE on. This surveyor observed Staff CC from the doorway and when Staff CC emerged from the room he/she was questioned in regards to the reason for Patient 30 ' s contact isolation. Staff CC stated that Patient 30 had cellulitis, a bacterial infection of the skin, and that the patient had been tested positively for MRSA (methicillin resistant staphylococcus aureus), a bacterium that causes infections in various parts of the body. Staff CC also stated that millions of people are carriers for MRSA and that we are wasting a lot of gowns. Staff CC then donned a gown and put on gloves prior to his/her return to Patient 30 ' s bedside as the surveyor watched. This was confirmed with Staff B on 08/26/10 at 3:49 PM. Staff B was questioned in regard to the amount of education staff have received about infection control and PPE usage. Staff B stated " clearly we haven't done enough " .