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Based on record review and interview, the facility failed to offer advance directive information to 3 of 3 inpatients (Patient #6, #1, and #15) inpatient medical records reviewed in a sample of 23.

Findings include:

Review of the facility policy titled "Advance Directives (Durable Power of Attorney)" dated 9/2012 revealed "Nursing Staff/Care Management/HUC: ...4) If the patient does not have an advance directive, the patient is offered the opportunity to execute one. An automatic referral is made to Care Management staff if "yes" is indicated in the Adult Admission History - "Patient wishes to receive further information on advance directives." ...6) Care Management staff will review the status of advance directives and will pursue the completeness of the process."

Review of Patient #6's admission history "Advance Directive. 'No'." on 10/23/2017 revealed no additional documentation or evidence in the medical record that Patient #6 was offered advance directive information or that a care management referral was triggered.

During an interview on 10/23/2017 at 2:20 PM, Clinical Informatics Nurse Q stated "it looks like we can only get to the screen to trigger a care management referral if 'yes' is marked by Advance Directive. Q confirmed, no additional advance directive information would be offered.


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Review of Patient #1's medical record on 10/24/17 at 11:00 AM revealed Patient #1 did not have advance directive and there was no evidence in the medical record that Patient #1 was offered information on completing an advance directive.

Patient #15's medical record was reviewed on 10/24/2017 at 12:10 PM. Patient #15 did not have advance directive information documented and there was no evidence in the medical record that Patient #15 was offered information on completing an advance directive.

Based on observation, staff interviews, and review of maintenance records the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients.

Building 03:
K-0161 (Building Construction Type and Height),
K-0291 (Emergency Lighting),
K-0293 (Exit Signage),
K-0321 (Hazardous Areas - Enclosure),
K-0341 (Fire Alarm System - Installation),
K-0345 (Fire Alarm System - Testing and Maintenance),
K-0353 (Sprinkler System - Maintenance and Testing),
K-0372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-0911 (Electrical Systems - Other).

Building 04:
K-0131 (Multiple Occupancies - Sections of Health Care Facilities & Facilities Classified as Other Occupancies),
K-0345 (Fire Alarm System - Testing and Maintenance),
K-0353 (Sprinkler System - Maintenance and Testing).

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623(d)(1).

Based on observation, staff interviews, and review of maintenance records, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients.

Building 03:
K-0161 (Building Construction Type and Height),
K-0291 (Emergency Lighting)
K-0293 (Exit Signage)
K-0321 (Hazardous Areas - Enclosure),
K-0341 (Fire Alarm System - Installation),
K-0345 (Fire Alarm System - Testing and Maintenance),
K-0353 (Sprinkler System - Maintenance and Testing),
K-0372 (Subdivision of Building Spaces - Smoke Barrier Construction) and
K-0911 (Electrical Systems - Other).

Building 04:
K-0131 (Multiple Occupancies - Sections of Health Care Facilities & Classified as Other Occupancies),
K-0345 (Fire Alarm System - Testing and Maintenance),
K-0353 (Sprinkler System - Maintenance and Testing) and

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623(d)(1) and were confirmed at the time of discovery with Staff.

Based on observation, record review and interview, facility staff failed to perform hand hygiene in 3 of 3 patient care observations (Patient #2, #6, and #19); failed to disinfect stethoscope between patient use in 1 of 1 patient care observation (Patient #6); failed to ensure hair nets are worn to cover all hair in 2 of 2 food service staff observed (Cook U, V); and failed to ensure urinary catheters are ordered for medical necessity in 2 of 5 inpatients reviewed (Patient #3 and Patient #6) in a sample of 6 staff and 5 inpatient observations.

Findings include:

Hand Hygiene

Review of the facility policy titled "Hand Hygiene" dated 5/2015 revealed "1. Indications for handwashing and hand antisepsis. ...Decontaminate hands before having direct contact with patients. ...Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient, phlebotomy). ...Decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient. Decontaminate hands after removing gloves that are not visibly soiled. Decontaminate hands after coming in contact with anything in the patient's environment."

During observation of care on 10/23/2017 at 11:30 AM, Licensed Practical Nurse R entered Patient #2's room and donned gloves without performing hand hygiene. R performed a finger stick for blood sugar monitoring, removed gloves and exited Patient #2's room without performing hand hygiene. Licensed Practical Nurse R then walked to the common medication room and proceeded to prepare an insulin syringe for Patient #6 without performing hand hygiene. At 12:10 PM, R entered Patient #2's room, donned gloves and administered insulin to Patient #2 without performing hand hygiene.

During observation of care on 10/24/2017 at 10:20 AM, Laboratory Technician LL donned gloves to perform a lab draw on Patient #19. After obtaining the blood sample, LL exited the phlebotomy room, walked down the hall and entered the laboratory without performing hand hygiene and still wearing the gloves used to perform Patient #19's lab draw.

During observation of care on 10/24/2017 at 2:10 PM, Respiratory Therapist X entered Patient #6's room without performing hand hygiene. X assessed Patient #6, administered Patient #6's nebulizer treatment and proceeded to chart on the computer in Patient #6's room without performing hand hygiene. When the treatment was complete, Therapist X exited Patient #6's room without performing hand hygiene. Respiratory Therapist X performed various tasks in Patient #6's room for the duration of the treatment (approximately 15 minutes) and was not observed performing hand hygiene.

During an interview with Chief Nursing Operator B on 10/24/2017 at 2:00 PM, B stated staff are expected to perform hand hygiene "anytime [they] remove gloves for sure" and confirmed the observed findings were not compliant with the facility's hand hygiene policy.

Equipment Disinfection

Review of the facility policy titled "Equipment Cleaning" dated 3/2013 revealed "Stethoscopes: 18) Clean the diaphragm of the stethoscope between patients."

During observation of care on 10/24/2017 at 2:10 PM, Respiratory Therapist X entered Patient #6's room with a stethoscope and performed an assessment without first cleaning the diaphragm. Therapist X exited Patient #6's room at 2:25 PM without performing disinfection of the stethoscope, walked down the hall and proceeded to enter patient room 208 without disinfecting the stethoscope.

Food Service

Review of the facility policy titled "Food Handling and Safety" dated 12/2016 revealed "22) Safety training on the following topics must be completed through Serv Safe modules at hire and annually with all Nutrition and Food Service Associates on the following safely topics: ...-Hair Net Requirements." Review of the facility's document titled "Safety Topic: Personal Hygiene" states: "Wear proper hair restraints...All hair must be covered and restrained appropriately, wearing the hair restraint in a manner that keeps all hair off the face and shirt collar."

During observations in the kitchen on 10/24/2017 at 9:45 AM, Cook U and Cook V wore hair nets that only partially covered their hair. During an interview on 10/24/2017 at 9:45 AM, Cook U stated "it [the hair net] must have popped up, it's supposed to cover all our hair."

Urinary Catheter Use

Review of the facility policy titled "Urinary Catheter Care" dated 1/2014 revealed "Urinary catheters should be inserted only when medically necessary... Document alternative methods for bladder elimination prior to insertion of indwelling catheter. ... Patients with urinary catheters will have intake and output (I & O) recorded. However, urinary catheters are not to be inserted simply to monitor outputs with the exception of the intensive care units (ICU). Make use of other mean to monitor outputs in the incontinent patient, such as daily weights."

Review of Patient #3's medical record revealed Patient #3 was admitted to the facility on 10/18/2017 with weakness and fever. Review of Patient #3's flow sheets revealed that a urinary catheter was inserted on 10/21/2017 at 12:15 AM with an indicator documented as "Accurate I & O (ICU)." There is no documentation of the medical necessity for the catheter.

Review of Patient #6's medical record on 10/22/2017 revealed Patient #6 was admitted to the facility on 10/22/2017 with fever and chills. Review of Patient #6's medical record in nurse progress note dated 10/21/2017 at 11:06 PM revealed "patient ambulated with 2 assist, gaitbelt and walker to restroom...foley [urinary catheter] placed to allow for accurate I & O's." Patient #6 was not in the intensive care unit and there was no documentation of medical necessity for the catheter.

These findings were confirmed during an interview on 10/23/2017 at 2:25 PM with Chief Nursing Officer B.

Based on interview and record reviews, the facility staff failed to develop and implement appropriate care plans based on the needs of the patient for 3 of 16 patients whose care plans were reviewed (Patient #3, #22 and #23) and failed to modify a care plan to reflect the use of physcial restraints for 1 of 2 patients reviewed for restraints (Patient #11) in a sample of 23.

Findings include:

Review of the facility policy titled "Interdisciplinary Plan of Care and Patient Education" dated 7/2013 revealed "The IPOC [Interdisciplinary Plan of Care] can/will be individualized based on documentation of clinical findings, additional diagnosis, and clinical progress toward reaching outcomes. ...Problems may be added to the patient's IPOC in the following ways: -Triggered by nursing documentation and/or entered orders... Problems that are triggered will populate as "suggested plans"... Review suggested plans. If appropriate for patient's plan of care, choose accept, initiate, and modify to meet individual needs."

Review of Patient #3's medical record on 10/23/2017 revealed Patient #3 was admitted to the facility on 10/18/2017 with a chief complaint of: "Feeling weak, had loose stools x2, minor cough, low-grade temp going for almost 5-7 days" and the admitting assessment and plan: "1. Generalized weakness and dehydration. 2. Mild to moderate leukocytosis [elevated white blood cell count]... 3. Acute on chronic anemia [low red blood count] without any gross evidence of GI [gastrointestinal] bleed but suspect upper or lower GI bleed. 4. Metabolic acidosis, probably secondary to diarrhea. 5. Two loose stools, could be stomach flu. ...Will check [diagnostic tests]. ...7. Low-grade temp, probably related to upper respiratory tract infection... 8. New onset Afib [cardiac dysrhythmia]... 9. Past history of chronic anemia, coronary artery disease, CKD [chronic kidney disease], gout, past stroke... 10. Uncontrolled systolic hypertension."

Patient #3's care plan included a plan for Knowledge Deficit, Readmission Prevention and Risk for Falls/Injury. Daily nursing assessment documented on 10/18/2017 through 10/23/2017 note Patient #3 was dependent on oxygen to maintain saturations levels above 90% and had a chronic cough. There is no care plan implemented to help Patient #3 meet any clinical care outcomes related to respiratory status. On 10/23/2017, 5 days after admission, Patient #3 was moved to the intensive care unit with shortness of breath and low blood oxygen levels.

During an interview on 10/24/2017 at 1:45 PM, Registered Nurse W stated Patient #3 was in the Intensive Care Unit due to #3's "respiratory status deteriorated." When asked about care planning for patients, W stated "I base it off what they are admitted for" and Patient #3 "would have had a care plan for fluid overload or breathing but there's not one in here for that."

During an interview on 10/24/2017 at 2:45 PM, Chief Nursing Officer B stated staff is expected to individualize care plans.


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Per medical record review with Registered Nurse (RN)/Clinical Supervisor C, on 10/24/2017 at 9:20 AM, Patient #22 presented to the Emergency Department on 4/08/2017 at 8:46 AM with confusion, weakness, diarrhea and acute kidney injury. Patient #22 was admitted to the facility on 4/08/2017 at 12:04 PM. Review of the Admission History and Physical revealed acute (sudden onset) kidney injury, probable acute sepsis (complication of infection), and encephalopathy (altered mental state) and Patient #22 was started on broad spectrum antibiotics. The care plan included risk for falls, knowledge deficit, and anxiety. There were no care plans for potential for infection, fluid volume deficit or altered tissue perfusion to meet the needs of the patient's most critical clinical findings.

Per medical record review with RN/Clinical Supervisor C, on 10/24/2017 at 9:45 AM, Patient #23 was admitted to the hospital on 9/30/17 at 10:46 PM with weakness and decline in function. Admitting diagnosis included probable sepsis with leukocytosis (elevated white blood cell count commonly the result of infection). Patient #23 was treated with intravenous antibiotics and discharged with a PICC (peripherally inserted central catheter) line to receive an additional 9 days of antibiotics as an outpatient. The care plan included risk for falls, alteration of comfort, urinary dysfunction and knowledge deficit. There were no care plans for potential for infection, fluid volume deficit or altered tissue perfusion to meet the needs of the patient's most critical clinical findings.

During interview with Registered Nurse/Clinical Supervisor C, during chart review on 10/24/2017 at 9:45 AM, RN C stated that s/he would expect to see care plans addressing the critical findings of both Patient #22 and Patient #23, which were not included.




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The facility policy titled "RESTRAINTS, CARE OF PATIENT" was reviewed on 10/24/17 at 10:10 AM revealed on page 11 under "Restraint use for the management of non-violent or non-self-destructive behavior (Medical Restraint)" subcategory #2 "Assessment Requirements for Restraint and/or Seclusion for Non-Violent or Non-Self Destructive Behavior" #3 "Documentation", bullet point #7 "A modification to the patients Individualized Plan of Care recognizing restraint use, and related outcomes should be completed within 8 hours of restraint initiation and reviewed every shift."

Patient #11's medical record was reviewed on 10/24/17 at 10:09 AM. Patient #11 was admitted on 4/27/17 for epigastric (stomach) pain and had gallbladder removed. Post surgical care in intensive care unit restraints were placed for "medical management" related to sedation and multiple medically needed tubes/lines. Patient #11 had care plan problems for: Impaired skin integrity, Knowledge Deficit, Alteration in Comfort, and Medication Education. There is no documented evidence of a care plan problem for the initiation of restraints post surgery.

The above deficiency was confirmed in interview at the time of Patient #11's medical record review with RN (Registered Nurse) Clinical Informatics Q and Clinical Supervisor C who both stated it would be expected that there would be a problem on the patient care plan addressing the use of "Medical Management Restraint" upon initiation of restraint.

Based on record review and interview, outpatient therapy staff failed to document patient progress in 2 of 2 outpatient records reviewed (Patient #17 and Patient #18).

Findings include:

Facility policy "Documentation Procedures" dated 11/2013 states: "4) Outpatients: ...ii. A progress note will be completed every 10 visits or 30 days, whichever comes first."

Per medical record review, Patient #17 received an initial physical therapy evaluation on 4/17/2017 for low back pain. There is no progress note until 6/8/2017, 52 days after the initial evaluation.

Per medical record review, Patient #18 received an initial physical therapy evaluation on 9/18/2017 for spinal stenosis. There is no progress note until 10/24/2017, 30 days after the initial evaluation.

During an interview with Rehab Director MM on 10/24/2017 at 10:30 AM, MM stated staff are expected to document progress notes every 30 days.

Based on observation, medical record review, and interview this facility failed to ensure an up-to-date history and physical was documented before performing surgery in 2 of 5 surgical records (Patient #13, #16), failed to follow the facilities hand hygiene policies in 1 of 1 surgical observations (Surgical Department), and failed to document a post-anesthesia evaluation in 3 of 5 surgical records (Patient #1, #15 and #17) out of a total sample of 23 records reviewed.

Findings include:

Review of the facility policy titled "Hand Hygiene" dated 5/2015 revealed "1. Indications for handwashing and hand antisepsis. ...Decontaminate hands before having direct contact with patients. Decontaminate hands before donning sterile gloves...Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient, phlebotomy). ...Decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient. Decontaminate hands after removing gloves that are not visibly soiled... Decontaminate hands after removing gloves that are visibly soiled...Decontaminate hands after coming in contact with anything in the patient's environment."

Review of the facility policy titled "Surgical Attire and Donning Techniques" dated 6/2011 revealed "2) Head covering: Personal entering the semi-restricted and restricted areas should cover the head, hair and facial hair." This document also states "b) Surgical masks should be discarded after each procedure and whenever it becomes wet or soiled. A fresh surgical mask should be donned before each new procedure...f) Surgical masks should not be worn hanging around the neck."

Review of the facility policy titled "Traffic Flow Patterns" dated 5/2012 revealed "3) Movement of personal is kept to a minimum while surgical procedures are in progress and doors are kept closed."

Review of the facility Bylaws, Rules and Regulations revealed "When the history and physical is conducted prior to admission or registration, an update must be completed and recorded within twenty-four hours after admission or registrations, and updated by the proceduralist prior to any surgery or procedure requiring anesthesia services."

On 10/23/2017 between 11:30 AM and 12:30 PM the following observations were made in the surgical suite with Chief Operating Officer (COO) B.

Hand Hygiene

On 10/23/2017 Registered Nurse (RN) N was observed leaving the OR and returning to the OR without performing hand hygiene, RN N donned sterile gloves to assist with surgical prep without performing hand hygiene, and RN N removed sterile gloves without performing hand hygiene.

On 10/23/17 at 12:22 PM observed RN O don sterile gloves on surgical prep of Patient #1, removed sterile gloves without performing hand hygiene.

An interview was conducted on 10/23/17 at 1:20 PM with COO B, B stated it is the expectation for staff to perform hand hygiene before and after any patient contact and before and after the donning and removal of gloves.

Surgical Attire

On 10/23/17 observed Surgeon L entering the Operating Suite without covering beard and sideburns.

On 10/23/17 at 1:25 PM observed RN T leave OR 3, where the sterile field was open, go into OR 1, and leave the sterile corridors with the surgical mask around RN T's neck. At 1:37 PM observed RN T go into OR 3 using the same surgical mask that was around RN T's neck.

An interview was conducted with Infection Preventionist (IP) Z on 10/24/17 at 9:00 AM, IP Z stated it is expected that surgical staff don a new mask each time they enter and leave the OR.

Traffic Flow

On 10/23/17 between 11:30 AM and 12:30 PM in Operating Room #2 with Patient #1, observed the Operating Room doors opened automatically with motion detection. Observed the doors open three times without anyone coming in or out of the Operating Room. During the observation, the sterile field was open and Patient #1 was being surgically prepped.

An interview was conducted with Infection Preventionist (IP) Z on 10/24/17 at 9:00 AM. IP Z stated IP Z was unaware that the surgical doors opened randomly with motion detection and this was the first IP Z heard of the problem.

History and Physical

Review of Patient #13's medical record revealed a history and physical dated 6/26/17. Patient #13 had a left total knee surgery on 7/11/17 without an update documented on the history and physical.

Review of Patient #16's medical record revealed a history and physical dated 8/18/17. Patient #16 had a left knee scope surgery on 8/22/17 without an update documented on the history and physical.

During an interview with COO B on 10/24/17 at 9:40 AM, COO B stated the facility was aware of the problem of not updating the history and physical and has educated the surgeon.

This facility failed to complete a post-anesthesia evaluation after the patient had time to recover. (Reference Tag C 322).

The cumulative effect of these deficiencies results in this facilitites' inability to ensure safe cares for all surgical patients.

Based on record review and interview, the facility failed to document a post-anesthesia evaluation after the patient had time to recover in 3 of 5 surgical records reviewed (Patient #1, #15 and #17) out of a total universe of 23 records reviewed.

Finding include:

The facility policy titled "Immediate Pre-Operative, Intra-Operative, PACU [Post Anesthesia Care Unit] and Post-Operative Responsibilities of the Anesthesia Department" dated 9/2017 was reviewed. This document in part "2) A post-anesthesia evaluation of all patients requiring the services of the anesthesia department will be made 30 minutes to 1 hour post operatively with documentation within the electronic health record ..."

Patient #1's medical record was reviewed on 10/24/17 at 11:00 AM. Patient #1 had right ankle surgery on 10/23/17. Anesthesia start time documented as 12:31 PM. Anesthesia end time documented as 1:41 PM. The post anesthesia evaluation was completed within six minutes at 1:47 PM and included vital signs timed before the procedure start at 9:59 AM.

Patient #15's medical record was reviewed on 10/24/17 at 12:10 PM. Patient #15 had a bowel resection surgery on 9/19/17. Anesthesia start time documented as 8:04 AM. Anesthesia end time documented as 9:51 AM. The post anesthesia evaluation was completed within four minutes at 9:55 AM.

Patient #16's medical record was reviewed on 10/24/17 at 12:20 PM. Patient #16 had a left knee scope on 8/18/17. Anesthesia start time documented as 8:32 AM and the anesthesia end time documented as 9:35 AM. The post anesthesia evaluation was completed within four minutes, at 9:39 PM, and included vital signs timed before the procedure start at 7:38 AM.

Interview on 10/24/17 at 9:35 AM conducted with Chief Operating Officer (COO) B, COO B revealed it would be the expectation that anesthesia perform a post anesthesia evaluation after the patient was recovered and not within minutes of the surgery case ending.