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Based on observations and a maintenance staff interview on 7/16/13 at 7:54 a.m., the facility failed to maintain minimum Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code. (See tags C0222 and C0228)

Based on observation and staff interview, the facility failed to ensure that patient care supplies in one of one emergency rooms and one of one medical floor supply rooms were maintained to an acceptable level of quality. The facility also failed to maintain one of one emergency generator to ensure immediate readiness in case of an emergency. The facility emergency generator failed to start within 10 seconds or at all based on an attempt by maintenance staff to do so on July 16, 2013.

Findings include:

1. During observation of the emergency department on 7/15/13 beginning at approximately 2:45 p.m., the surveyor noted the following outdated or unusable supplies which were available for use;
- two Ethilon 6-0 nylon suture on PS-3 cutting needles with the manufacturer's expiration date of July, 2012.
- four Sterile 2-pack cotton tipped applicators with the manufacturer's expiration date of 3/2012.
- one open 16 ounce bottle of Hydrogen Peroxide with the manufacturer's expiration date of 2/2012.
- one open 4 ounce bottle of Betadyne surgical scrub solution with the manufacturer's expiration date of 5/2013.

During an interview at approximately 3:00 p.m. on 7/15/13 with staff member F, a registered nurse, she stated that she had checked the area for outdates, but had missed those items.

2. During the observation of the main supply storage area on 7/15/13 at approximately 3:30 p.m., the surveyor noted the following outdated or unusable supplies available for use;
- three Replicare 4 in. x 4 in. Hydrocolloid dressings with the manufacturer's expiration date of 2/2013.
- seven packages of sterile 2 in. x 2 in. dressings with the manufacturer's expiration date of 5/2012.
- five packages of Johnson & Johnson Adaptic 3 in. x 8 in. petroleum gauze dressings with the manufacturer's expiration date of 2/2013.
- three Trele brand Hydropolimer dressings with the manufacturer's expiration date of 11/2012.
- six sterile packages of Tegaderm Absorbent 3 in. x 3 3/4 in. dressings with the manufacturer's expiration date of 4/2013.

The observation of the storage area was completed with staff member B accompanying the surveyor. Staff member B, the DON, verified the expiration dates of the supplies.

3. The facility failed to meet the Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code. The facility emergency generator failed to start on July 16, 2013 at 7:54 a.m. on an attempt requested by the LSC surveyor. See the attached CMS form 2567 for specific Life Safety Code deficiencies and details.












27244

Based on observations and staff interview, the facility staff failed to maintain a clean and orderly environment in one (the kitchen) of six observed patient/resident care areas. Findings include:

During observations of the kitchen area on 7/15/13 beginning at 3:45 p.m., the surveyor noted the following issues:
- Observed under the storage racks in the dry storage pantry area were multiple individual sugar and creamer packets, individual pancake syrup containers, dust and debris, and an open spilled package of instant oatmeal spread on the floor below the racks. There were two areas where an unknown liquid substance had dripped onto the floor under the racks and dried. The spill was not easily removed from the floor. Sharp particles were adhering to the floor in and around the spills.
- In the walk in cooler, creamer packets and a 1 lb. block of butter were observed on the floor of the cooler.
- small plastic beverage glasses, paper, dust, debris, and grapes were observed behind the freezer and in the area between the freezer and the reach in cooler.

During an interview with staff member D, the dietary manager, on 7/15/13 at 4:00 p.m., he stated that maintenance staff were tasked with sweeping the floors of the pantry. When asked about the cleaning schedule for the area, staff member D stated that he was not sure if there was a specified cleaning schedule for the pantry.

Based on observation and record review, the facility failed to meet the Standards of the 2000 Edition of the National Fire Protection Association's (NFPA) 101 Life Safety Code. No documentation was available that a monthly load tests had been conducted by the facility or that a annual load test had been conducted on the generator.
The findings include:

The generator test records and service reports were reviewed at the facility on 7/15/13 and 7/16/13. No documentation was available to demonstrate that the monthly load tests on the generator were conducted by the facility and met the 30 percent nameplate rating of the generator. No documentation was available to demonstrate that the generator had been tested by an independent contractor to meet the requirements of 6-4.2 of NFPA 110 for an annual load test. The emergency room emergency power is provided by the emergency generator. See the attached CMS form 2567 for specific Life Safety Code deficiencies and details.

Based on observation and staff interview, the facility failed to ensure that outdated medications were not available for administration in one (emergency room) of three patient care areas. Findings include:

During the observation of the emergency room on 7/15/13 at approximately 3:15 p.m., the surveyor noted the following items;
- one open, partially used, multi-dose vial of 2% Lidocaine injectable solution. The vial was not labeled with the date that it had been opened.
- one unopened bottle of Bausch & Lomb sterile eye wash solution on the Eye Tray with the manufacturer's expiration date of 4/2013.

During an interview with staff member F, a registered nurse, on 7/15/13 at 3:30 p.m., she stated that nursing staff were instructed to label vials with the date they are opened but that the vial observed by the surveyor was not labeled. Nurses checked the supplies and medications monthly for outdates, but the eyewash was missed.

Based on document review and staff interview, the facility failed to ensure that the clinical records for 9 (#s 1, 2, 3, 5, 6, 7, 10, 11, and 14) of 24 sampled patients were complete and accurate. Findings include:

During the review of clinical records beginning on 7/16/13 at 3:00 p.m., the surveyor noted the following incomplete entries in the records;

1. Patient #1 came to the emergency room on 8/18/12 for care. The facility form that provided Discharge Instructions to the parent of the patient was not authenticated with the time that the parent's signature was obtained.

2. Patient #2 came to the emergency room on 7/30/12 for care. The facility form that provided Discharge Instructions to the parent of the patient was not authenticated with the time that the parent's signature was obtained.

3. Patient #3 came to the emergency room on 8/10/12 for care. The facility form labeled "Interfacility Transfer Authorization" was not authenticated with the time that the patient consented to the transfer to another facility for care.

4. Patient #5 came to the emergency room on 8/18/12 for care. The facility form that provided Discharge Instructions provided to the parent of the patient was not authenticated with the time that the parent's signature was obtained.

5. Patient #6 came to the emergency room on 10/11/12 for care. The facility form labeled "Interfacility Transfer Authorization" was not authenticated with the time that the patient consented to the transfer to another facility for care.

6. Patient #7 came to the emergency room on 10/28/12 for care. The facility form that provided Discharge Instructions to the patient was not authenticated with the time that the patient's signature was obtained.

7. Patient #10 came to the emergency room on 10/11/12 for care. The facility form labeled "Interfacility Transfer Authorization" was not authenticated with the time that the patient consented to the transfer to another facility for care.

8. Patient #11 came to the emergency room on 1/13/13 for care. The facility form that provided Discharge Instructions provided to the parent of the patient was not authenticated with the time that the parent's signature was obtained.

9. Patient #14 came to the emergency room on 2/20/13 for care. The facility form labeled "Interfacility Transfer Authorization" was not authenticated with the time that the patient's parents consented to the transfer to another facility for care.

During an interview with staff member B, the DON, on 7/16/13 at 4:45 p.m., staff member B stated that she was not aware that the forms were not being properly authenticated.

Based on document review and staff interview, the facility staff failed to ensure that consents for treatment and/or transfer were properly completed for 14 (#s 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 14, 15, 19, and 20) of 24 reviewed patients . Findings include:

1. Patient #1, (a minor), presented to the emergency room on 8/18/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the parent's signature and date. The time that the signature was obtained was not included in the documentation.

2. Patient #2 presented to the emergency room on 7/30/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature and date. The time that the signature was obtained was not included in the documentation.

3. Patient #3 presented to the emergency room on 8/10/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation. The patient was transferred to another facility for treatment. The facility form labeled "Interfacility Transfer Authorization" under the section for patient consent for transfer, included the patient signature and date, but did not include the time that the patient's signature was obtained.

4. Patient #5 presented to the emergency room on 9/23/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation.

5. Patient #6 presented to the emergency room on 10/11/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature and date. The time that the signature was obtained was not included in the documentation. The patient was transferred to another facility for treatment. The facility form labeled "Interfacility Transfer Authorization" under the section for patient consent for transfer, included the patient signature and date, but did not include the time that the patient's signature was obtained.

6. Patient #7 presented to the emergency room on 10/28/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature and date. The time that the signature was obtained was not included in the documentation.

7. Patient #8 presented to the emergency room on 11/5/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature and date. The time that the signature was obtained was not included in the documentation.

8. Patient #9 presented to the emergency room on 11/18/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation.

9. Patient #10 presented to the emergency room on 12/3/12. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation. The patient was transferred to another facility for treatment. The facility form labeled "Interfacility Transfer Authorization" under the section for patient consent for transfer, included the patient signature and date, but did not include the time that the patient's signature was obtained.

10. Patient #11 presented to the emergency room on 1/13/13. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's parent's signature and date. The time that the signature was obtained was not included in the documentation.

11. Patient #13 presented to the emergency room on 1/19/13. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation.

12. Patient #14, (a minor), presented to the emergency room on 2/20/13. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's parent's signature and date. The time that the signature was obtained was not included in the documentation. The facility form labeled "Interfacility Transfer Authorization" under the section for patient consent for transfer, included the parent's signature, but did not include the date and time that the patient's parent's signature was obtained.

13. Patient #15 presented to the emergency room on 5/5/13. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature and date. The time that the signature was obtained was not included in the documentation.

14. Patient #19 presented to the emergency room on 6/3/13. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation.

15. Patient #20 presented to the emergency room on 5/2/13. The facility form labeled "Emergency Room/Treatment Room Record" under the heading "Authorization for Treatment" included the patient's signature. The date and time that the signature was obtained was not included in the documentation.

During an interview on 7/16/13 at 4:45 p.m. with staff member B, the DON, staff member B stated that she was not aware that times were not being documented on the consent forms.

Based on document review and staff interview, the facility failed to ensure that each entry into the clinical record included the date and time signatures of doctors or providers for 16 (#s 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, and 24) of 24 reviewed patients who were seen by physicians or providers. Findings include:

During the review of clinical records beginning on 7/16/13 at 3:00 p.m., the surveyor noted the following omissions:

1. Patient #5 came to the emergency room on 9/23/12 for care. The facility form labeled "E.R. Visit: 9/23/12" did not include the time when the entry was created, written, or dictated.

2. Patient #7 came to the emergency room on 10/28/12 for care. The facility form labeled "E.R. Visit: 10/28/12" did not include the time when the entry was created, written, or dictated.

3. Patient #8 came to the emergency room on 11/5/12 for care. The facility form labeled "E.R. Visit: 11/5/12" did not include the time when the entry was created, written, or dictated.

4. Patient #9 came to the emergency room on 11/18/12 for care. The facility discharge summary form dated 11/19/12 did not include the time when the entry was created, written, or dictated.

5. Patient #10 came to the emergency room on 12/3/12 for care. The facility form labeled "E.R. Visit: 12/3/12" did not include the time when the entry was created, written, or dictated.

6. Patient #11 came to the emergency room on 1/13/13 for care. The facility form labeled "E.R. Visit: 1/13/13" did not include the time when the entry was created, written, or dictated.

7. Patient #12 came to the emergency room on 1/19/13 for care. The facility form labeled "E.R. Visit: 1/19/13" did not include the time when the entry was created, written, or dictated.

8. Patient #13 came to the emergency room on 1/29/13 for care. The facility form labeled "E.R. Visit: 1/29/13" did not include the time when the entry was created, written, or dictated.

9. Patient #14 came to the emergency room on 2/20/13 for care. The facility form labeled "E.R. Visit: 2/20/13" did not include the time when the entry was created, written, or dictated.

10. Patient #15 came to the emergency room on 5/5/13 for care. The facility form labeled "E.R. Visit: 5/5/13" did not include the time when the entry was created, written, or dictated.

11. Patient #17 came to the facility on 3/25/13 for care. The facility forms labeled "History and Physical" and "Discharge Summary" did not include the time when the entries were created, written, or dictated.

12. Patient #18 came to the facility on 4/1/13 for care. The facility forms labeled "Admission History and Physical Examination" and "Discharge Summary" did not include the time when the entries were created, written, or dictated.

13. Patient #19 came to the facility on 6/3/13 for care. The facility forms labeled "Admission History and Physical" and "Discharge Summary" did not include the time when the entries were created, written, or dictated.

14. Patient #20 came to the facility on 5/2/13 for care. The facility forms labeled "ER/Admission History and Physical" and "Discharge Summary" did not include the time when the entries were created, written, or dictated.

15. Patient #21 came to the facility on 4/26/13 for care. The facility forms labeled "Admission History and Physical Examination" and "Discharge Summary" did not include the time when the entries were created, written, or dictated.

16. Patient #24 came to the facility on 1/5/13 for care. The facility forms labeled "Admission History and Physical:(Acute Care)" and "Discharge Summary" did not include the time when the entries were created, written, or dictated.

During an interview with staff member B, the DON, on 7/17/13 at 11:30 a.m., staff member B stated that she was unaware that the entries were incomplete. Staff member S, the medical records person, stated that the current system did not include the capability of adding a time stamp to document the time of provider dictations.