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Based on Life Safety Code (LSC) survey, St. Vincent Mercy Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This three story facility with a basement was determined to be of Type II (111) construction and was fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors and patient rooms. The facility has a capacity of 25 and had a census of 5 at the time of this survey.

Based on LSC survey and deficiency found (see 2567L), it was determined that the facility failed to ensure 1 of 1 oxygen storage rooms where oxygen transfer was occurring was separated within a one hour fire barrier enclosure, failed to ensure a sign posted on the oxygen storage room door indicating the transfer of oxygen was being conducted at this site and failed to ensure 1 of 1 switches and 2 of 2 outlets were positioned five feet above the floor in the oxygen storage room on third floor, south hall where oxygen transfer occurs (see K 143).

Based on observation, policy and procedure review and staff interview, the facility failed to implement its policy related to proper refrigerator and freezer temperatures on the medical/surgical nursing unit for the patient refrigerator.

Findings:
1. at 2:30 PM on 7/13/11, review of the food services policy "Refrigerator Food Service Temperature Checks" indicated:
a. under "Policy", it reads: "To ensure that food is stored at the proper temperature in the refrigerator, a log will be kept on the outside of the refrigerator. A department staff member will check the thermostat on the refrigerator each day and write the temperature and initials on the log. At any time the refrigerator is not 38 - 41 degrees F, the manager will make out a maintenance work order, and document a description of actions taken to correct the problem."

2. at 12:45 PM on 7/13/11, while on tour of the medical/surgical nursing unit in the company of staff member NI, it was observed that the patient refrigerator was not checked as per policy as follows:

a. the patient refrigerator and freezer log:
A. instructed/stated above the refrigerator tracking graph: "If temperature above 41 degrees or below 36 degrees document corrective action below."

B. had notes reading: "1. Record date, time, your signature and corrective action plan to recheck temperature in one hour. 2. Recheck temperature in one hour. If within standard, record new temperature on chart indicating second reading. No further action is needed. 3. If on second reading, temperature is outside of standard, take refrigerator out of service and report to Maintenance."

C. above the freezer tracking graph, had a note that read: "If temperature above 0 degrees document corrective action below."

D. lacked documentation in May 2011 for:
I. the refrigerator relating to having been checked on either 5/1/11 or 5/7/11
II, the refrigerator as being out of range on 5/2/11, 5/3/11, 5/4/11, 5/6/11 and 5/9/11 with no indication of corrective action taken
III . had freezer documentation of a temperature above 0 degrees on 5/7/11, 5/8/11, 5/9/11, 5/10/11, 5/12/11, 5/16/11, 5/18/11, 5/24/11, 5/25/11, 5/26/11, 5/28/11, 5/29/11, 5/30/11 and 5/31/11 with no indication of corrective action taken
IV. lacked documentation of having checked the freezer on 5/1/11

E. lacked documentation in June 2011 for:
I. the refrigerator as being out of range on 6/4/11, 6/12/11, 6/21/11 and 6/22/11 with no corrective action noted
II. the freezer of a temperature above 0 degrees on 6/8/11, 6/9/11, 6/10/11, 6/11/11, 6/15/11, 6/16/11, 6/17/11, 6/19/11, 6/23/11, 6/24/11, 6/26/11, 6/27/11, 6/28/11, 6/29/11, and 6/30/11 with no corrective action noted

F. lacked documentation in July 2011 for:
I. the refrigerator relating to having been checked on 7/1/11 and 7/10/11
II. the refrigerator as being out of range on 7/11/11 and 7/12/11 with no documentation of corrective action taken
III. had freezer documentation of a temperature above 0 degrees on 7/3/11 and 7/4/11 with no documentation of corrective action taken
IV. lacked documentation of having checked the freezer on 7/1/11

3. interview with staff member NI at 2:30 PM on 7/13/11 indicated:
a. the refrigerator/freezer log attached to the food services policy "Refrigerator Food Service Temperature Checks" is not the same log being utilized by nursing staff
b. the food services policy "Refrigerator Food Service Temperature Checks" states the approved food temperature is 38 - 41 degrees F, but the log being used reads 36 to 41 degrees on the May and June logs and 33 to 41 degrees on the July log
c. nursing does not have a policy and procedure specifically related to refrigerator/freezer temperature check
d. nursing has not been following the instructions on the logs related to rechecking refrigerator/freezer temps in an hour (if out of standard), initialing, and calling maintenance if the appliance continues to be out of compliance with standard temperatures

Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage rooms where oxygen transfer was occurring was separated within a one hour fire barrier enclosure, failed to ensure a sign posted on the oxygen storage room door indicating the transfer of oxygen was being conducted at this site and failed to ensure 1 of 1 switches and 2 of 2 outlets were positioned five feet above the floor in the oxygen storage room on third floor, south hall where oxygen transfer occurs.

Findings:

1. Observation on 07/12/11 at 11:50 a.m. with #MS1 indicated the fire rating tag found on the corridor door to the oxygen transfer room on third floor south hall was a twenty minute fire rated door.

2. In interview on 07/12/11 at 11:51 a.m. with #MS1, it was confirmed that the door to the oxygen storage room where oxygen transfer occurs was a twenty minute fire rated door which would not maintain a one hour fire rated enclosure.

3. Observation on 07/12/11 at 11:55 a.m. with #MS1 indicated the oxygen transfer room where oxygen transfer occurs on third floor, south hall lacked a sign posted on the oxygen storage room door indicating the transfer of oxygen was being conducted at this site.

4. In interview on 07/12/11 at 11:57 a.m. with #MS1, it was confirmed oxygen transfers take place but a sign to indicate such procedure was not posted on the door or available anywhere else in the facility.

5. Observation on 07/12/11 at 11:59 a.m. with #MS1 indicated there was one electrical switch installed inside the oxygen room on the east wall located four feet above the floor and two electrical outlets installed inside the oxygen room on the south wall which were located eight inches above the floor.

6. In interview on 07/12/11 at 12:02 p.m. with #MS1, it was confirmed that the electrical wall fixtures were located less than five feet above the floor.

Based on personnel file review, policy and procedure review, and staff interview, the facility failed to ensure CPR (cardiopulmonary resuscitation) competency for 1 of 5 RN files reviewed. (P1)

Findings:
1. at 4:45 PM on 7/13/11, review of the policy and procedure "Basic Life Support (CPR) Competence", indicated:
a. under "Purpose", it reads: "In keeping with the Core Value...this policy to ensure that all health care workers who provide direct patient care are competent in cardiopulmonary resuscitation (CPR);..."
b. under "Procedure", it reads: "...3. Documentation of current BLS (Basic life support) training must be on file in the associate's Human Resources file...5. If an associate has let their BLS training expire, s/he may not be scheduled to work until successful completion of the BLS training course has occurred."

2. review of personnel files at 2:30 PM on 7/12/11 indicated:
a. RN P1 had CPR documentation that expired 6/1/11

3. interview with staff member NI at 3:00 PM on 7/12/11 indicated:
a. there is supposed to be a "tickler" file to be reminded of employees nearing expiration of CPR certification so that they can sign up for classes prior to the expiration
b. P1 has not been exempted from work since the expiration date, as policy dictates


4. at 5:30 PM on 7/13/11, interview with staff member NH, indicated:
a. this staff member supervises P1 and "missed" reminding P1 of the expiration date to have CPR classes scheduled timely

Based on personnel file review and staff interview, the facility failed to ensure documentation of current TB (tuberculosis) testing for 1 of 3 rehab services staff (P8) and 1 of 5 RN files (P3), and failed to ensure that the TB test for 1 of 5 RNs (P5) was read within 48 to 72 hours.

Findings:
1. review of personnel files at 2:30 PM on 7/12/11 and 3:00 PM on 7/13/11, indicated:
a. P3 had no TB documentation in the personnel file for 2010 (the last documented TB test was 8/10/09)
b. P5 was lacking the time given and the time read for the TB test of 5/11/11, making it unclear if the test results were read within 48 to 72 hours as the form indicates is the appropriate time frame
c. P8 had a documented TB test given at 1430 on 7/30/10, but was lacking documentation of having the TB test read

2. interview with staff member NI at 1:45 PM on 7/13/11 indicated:
a. TB tests were required for all staff in 2010 and the facility performed these in July
b. staff member P3 stated that they had a TB test given and read in July of 2010 by the safety person/RN, but the safety staff member is out of the office and no documentation can be found that would support this information
c. staff member N8 indicated their TB test, that was given on 7/30/10, was read by the safety person who is out of the office and nothing can be found to support this
d. the excel spread sheet from the office of the safety staff member was found, but it, too was lacking documentation of having the 7/27/10 TB test for staff member P3 read and was lacking a reading documentation of the 7/30/10 TB test for P8

Based on document review and interview, the facility failed to require a review all its patient care policies/procedures at least annually by a group that included at least one doctor of medicine (MD) or osteopathy (DO).
Findings:
1. Review of the facility Policy on Policies (last reviewed 7-2010) failed to require all patient care policy/procedures to be reviewed annually by an MD/DO in addition to a manager, director or administrative representative.
2. Review of the Organizational Improvement Plan (last approved 2-2011) failed to indicate the requirement for an annual review of patient care policies/procedures by an MD/DO and a manager, director, or administrative representative.
3. Review of pharmacy policy/procedures failed to indicate an MD/DO review.
4. During an interview on 07-12-11 at 1130 hours, employee #A2 indicated the facility was not requiring an MD/DO to review all of the patient care policy/procedures.
5. During an interview on 07-14-11 at 1220 hours, employee # A8 confirmed that an MD/DO was not reviewing the pharmacy policy/procedures on an annual basis.

Based on document review and interview, the facility failed to include one service in its list of contracted services provided to the facility.
Findings:
1. Review of service and preventive maintenance records for the facility indicated a provider for fire extinguisher service and maintenance.
2. The document Contract Spreadsheet failed to indicate a provider for fire extinguisher service and maintenance.
3. During an interview on 07-13-11 at 0900, employee #A2 confirmed the list of contracts had not been maintained.

Based on swing bed patient medical record review, medical staff rules and regulations review, and staff interview, the facility failed to ensure that a complete history and physical examination was performed within 24 hours of admission for 2 of 6 swing bed patients. (N7 and N11)

Findings:
1. at 4:45 PM on 7/13/11, review of the medical staff rules and regulations indicated in section 4.2.18, "Physician Examination and Medical History", that: "All Medical Staff Members shall ensure that a complete physical examination and medical history are performed (7) days prior to date of admission to the Hospital and shall be documented in the medical record of the patient with a durable, legible copy of the report and changes noted in the record upon admission; or, the medical history and physician examination shall take place within twenty-four (24) hours after the patient's admission to the hospital. A complete history and physical examination shall, at a minimum, contain data regarding the following elements: (a) Chief complaint (b) History of present illness (c) Past medical, surgical history (d) Family history (e) Psychosocial history..." [etc. through item (l)]

2. review of swing bed patient medical records at 10:05 AM on 7/12/11 and 9:45 AM on 7/13/11 indicated:
a. pt. N7 was admitted to swing bed status on 3/1/11 with only a very brief history and physical examination documentation by the physician
b. pt. N11 was admitted to swing bed status on 1/14/11 and had the acute care history and physical dated 1/11/11 with no note by the physician of an update or changes

3. interview with staff member NI at 2:30 PM on 7/12/11 Indicated:
a. the history and physical in the medical record for pt. N7 was so brief that it did not meet the standards of (a) through (l) of the requirements for a history and physical as stated in the medical staff rules and regulations

4. interview with staff member NP at 11:15 AM on 7/13/11 indicated:
a. the acute care history and physical dated 1/11/11 was not updated after the patient was admitted as a swing bed patient on 1/14/11

Based on document review and interview, the facility failed to require a review of its health care policies/procedures at least annually.
Findings:
1. The facility Policy on Policies (last reviewed 7-2010) failed to require all health care policy/procedures to be reviewed annually.
2. The Organizational Improvement Plan (last approved 5-2008) failed to indicate the requirement for an annual review of all health care policies/procedures. The plan indicated the following; The Organizational Improvement Plan is reviewed and revised annually as necessary. The Plan failed to indicate a review date more recent than 05-2008.
3. The policy/procedure Safety Management Program (last reviewed 6-2011) indicated the following; departmental safety policies and procedures shall be reviewed as frequently as necessary, but at least every three years. The policy failed to require an annual review for all departmental safety policy/procedures.
4. During an interview on 07-12-11 at 1130 hours, employee #A2 confirmed the facility was not reviewing all of its health care policy/procedures annually.

Based on document review and interview, the facility failed to evaluate 10 services (biohazardous waste, cardiac rehab, dietary, discharge planning, housekeeping, nuclear medicine, outpatient oncology, rehab services, respiratory therapy, and sleep lab) in their quality assurance program.

Findings:

1. Review of the Patient Safety and Quality program documentation lacked evidence to indicate 10 services (biohazardous waste, cardiac rehab, dietary, discharge planning, housekeeping, nuclear medicine, outpatient oncology, rehab services, respiratory therapy, and sleep lab) were being monitored.

2. During an interview on 07-12-11 at 1430 hours, employee #A17 indicated that the 10 services (biohazardous waste, cardiac rehab, dietary, discharge planning, housekeeping, nuclear medicine, outpatient oncology, rehab services, respiratory therapy, and sleep lab) were not being monitored through the Quality Assessment and Improvement plan.

3. During an interview on 07-13-11 at 1000 hours, employee #A1 confirmed that the 10 services were not being monitored by the facility.

Based on swing bed patient medical record review and staff interview, the facility failed to ensure that each resident was informed of their rights for 6 of 6 patients. (N7 through N12)

Findings:
1. review of swing bed patient medical records at 10:05 AM on 7/12/11 and 9:45 AM on 7/13/11 revealed there was no indication/documentation of notification to patients N7 through N12 of their right to:
a. choose a personal attending physician
b. refuse to perform services
c. send and receive mail that is unopened and to have access to stationery, postage, and writing instruments at the patient's expense
d. retain and use personal possessions and clothing
e. have married couples share a room, if both spouses consent to the arrangement

2. interview with staff members NI and NN at 4:45 PM on 7/11/11 indicated:
a. the hospital patients' rights, given at the time of admission, do not address Swing Bed specific patient rights such as those stated in 1. above
b. it was thought that the case manager might be addressing swing bed rights with patients on admission, but it was found that this was not happening
c. it cannot be determined that each swing bed patient/resident was informed of their specific rights as stated in 1. above

Based on swing bed patient medical record review, policy and procedure review, and staff interview, the facility failed to implement its policy related to advance directives for two of two patients requesting information and help in formulating advance directives. (N11 and N12)

Findings:
1. at 12:00 PM on 7/11/11, review of the nursing policy binder indicated the "Advance Directives" policy reads: "St. Vincent Mercy Hospital shall assist patients in the execution of an advance directive when requested."
a. under "Procedure", it reads: "1...a. during the inpatient admission interview,...b. In absence of the actual Advance Directive, the substance of the directive shall be documented in the patient's medical record. Registration will notify pastoral Care about the need for documenting the intent of the Advance Directive within 72 hours..."

2. review of swing bed patient medical records N11 and N12 at 9:45 AM on 7/13/11 indicated:
a. pts. N11 and N12 had documentation by registration and/or nursing staff that the patient/family requested help in executing advance directives, but lacked any documentation by the chaplain, or other staff, that this assistance was provided

3. interview with staff members NN and NQ at 11:15 AM on 7/13/11 indicated:
a. staff documented that a (phone) message was left for the chaplain, but there is no documentation in the medical records of pts. N11 or N12 that a contact was made, by the chaplain or other staff, related to assisting with advance directive follow up for the patient and/or family
b. there is no mechanism in place to monitor chaplain requests to see that follow up occurs within the 72 hour time frame as stipulated in the advance directives policy

Based on swing bed patient medical record review and staff interview, the facility failed to ensure that each resident was informed, prior to admission, and periodically during their stay, of their rights regarding services that are, and may not be, included under Medicare or the facility's per diem rate for 6 of 6 patients. (N7 through N12)

Findings:
1. review of swing bed patient medical records at 10:05 AM on 7/12/11 and 9:45 AM on 7/13/11 revealed there was no indication/documentation of notification to patients N7 through N12, prior to admission, or during their stay, related to services that might not be covered under the Medicare swing bed per diem rate

2. interview with staff members NI and NN at 4:45 PM on 7/11/11 indicated:
a. the facility used to have an admission agreement (consent) form titled "Swing Bed Program Patients' Rights and Responsibilities" that included this language (copy of form supplied to surveyor)
b. corporate leaders advised the facility to stop using the form (listed in 2. a. above) and to only utilize the acute care consent for admission/treat form as the swing bed consent
c. the general (acute care) consent does not address specific swing bed components such as costs that might not be covered under the Medicare Swing Bed per diem rate
d. the hospital patients' rights, given at the time of admission, also do not address Swing Bed specific patient rights
e. it was thought that the case manager might be addressing swing bed rights with patients on admission, but it was found that this was not happening
f. it cannot be determined that, prior to admission and during their stay, swing bed patients are given their rights related to being informed of costs not covered under Medicare's swing bed per diem rate

Based on swing bed patient medical record review, multidisciplinary team meeting review, and staff interview, it cannot be determined that the physician is part of the multidisciplinary team or that all members are active and participating in the team meetings as per facility policy for 5 of 5 swing bed patients who were in the facility long enough for a multidisciplinary meeting to occur. (pts. N8, N9, N10, N11 and N12)

Findings:
1. at 4:20 PM on 7/12/11 and 12:15 PM on 7/13/11, review of the policy and procedure "Multi-Disciplinary Patient Care/UR [utilization review] Committee (Treatment Team)", indicated:
a. under "Policy", it reads: "...4. all ancillary services involved in the care of Swing Bed patients will be represented on the Patient Care/UR committee. 5. Input from the Medical Director will be encouraged for communication with the attending physicians as well as for overall guidance in planning patient care..."
b. under "Membership", it reads: "Regular Representatives: The following hospital personnel shall regularly attend bi-weekly Patient Care/UR Committee meetings for Swing Bed Patients: 1. Medical Records 2. Swing Bed Nurse Manager 3. Social Services 4. Physical Therapist 5. Financial Counselor 6. Dietician 7. Activities Therapist 8. Case Manager 9. Pharmacist 10. Floor Nurse
(PCN-[patient care nurse]) if possible..."

2. review of patient medical records at 9:45 AM on 7/13/11 indicated:
a. pt. N8 had a multidisciplinary team meeting on:
A. 2/18/11 in which the absentees (according to the policy) were: Medical records and a floor nurse--there was also no documentation/indication of input/participation from the physician
B. 2/21/11 in which the absentees included: Medical Records; the swing bed nurse manager; and no
documentation/indication of input/participation from the physician

b. pt. N9 had a multidisciplinary team meeting on:
A. 1/7/11 in which the absentees included: Medical Records; the swing bed nurse manager; the pharmacist; a floor nurse; and no documentation/indication of input/participation from the physician
B. 1/10/11 in which the absentees included: Medical Records; the swing bed nurse manager; the dietician; a floor nurse; and no documentation/indication of input/participation from the physician

c. pt. N10 had a multidisciplinary team meeting on:
A. 5/27/11 in which the absentees included: medical records; the activity director; and no documentation/indication of input/participation from the physician

d. pt. N11 had a multidisciplinary team meeting on:
A. 1/14/11 in which the absentees included: medical records; the swing bed nurse manager and no documentation/indication of input/participation from the physician
B. 1/17/11 in which the absentees included: medical records; the swing bed nurse manager and no documentation/indication of input/participation from the physician

e. pt. N12 had a multidisciplinary team meeting on:
A. 7/16/10 in which the absentees included: medical records; the swing bed nurse manager; the case manager; the pharmacist and no documentation/indication of input/participation from the physician

3. interview with staff member NA at 12:15 PM on 7/13/11 indicated:
a. it has not been determined what "regular" attendance at multi disciplinary meetings consists of
b. floor nurses cannot always get away to attend team meetings
c. physicians are unable to attend team meetings--this staff member shares information from progress notes as input from the physician
d. it is not clear in team meeting minutes/documentation that there is input from nursing and physicians when they are not able to attend

Based on policy and procedure review and staff interview, the facility failed to create a policy related to dental care, or to ensure that staff were knowledgeable of actions to take for swing bed patients related to routine and 24 hour emergency dental care.

Findings:
1. review of facility policies and procedures through out the survey process of 7/11/11 to 7/13/11, indicated there was no policy related to obtaining or providing dental care for swing bed patients

2. interview with staff members NN and NQ at 11:15 AM on 7/13/11 indicated:
a. it was unknown by these staff members that routine and 24 hour emergency dental care was required as a provision for swing bed patients
b. the facility has no policy related to providing dental care for swing bed patients that would assist staff in obtaining either routine or 24 hour emergency care