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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 required to be fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors, in spaces open to the corridors and hard wired smoke detectors in all 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 deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 4 of 4 elevator equipment rooms throughout the facility were provided with sprinkler coverage and failed to ensure 1 of 2 exit access corridors in the basement were provided with sprinkler protection to ensure sprinkler coverage in all portions of the building (see K 056) and failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition (see K 062).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and staff interview, the facility failed to ensure the monitoring of a facility blanket warmer in 1 of 3 areas toured (emergency department).

Findings:
1. While on tour of the ED (emergency department) at 10:20 AM on 7/9/14, in the company of staff member #52, the RN (registered nurse) manager of the ED, it was observed that:
a. The blanket warmer (an older Blickman model with a dial for controlling the temperature) was noted to be hot to touch (on the inside shelves) and lacked a thermometer to alert staff to the internal temperature.

2. Interview with staff member #52, the ED nurse manager, at 10:20 AM on 7/9/14 and 3:55 PM on 7/10/14, indicated:
a. The ED does not monitor the temperature of the blanket warmer.
b. It is unknown what the maximum temperature is for blanket warmers.

3. At 11:35 AM on 7/10/14, interview with staff member #50, the director of nursing, indicated:
a. The facility utilizes the Lippincott nursing guide for nursing "standards of practice".
b. Per Lippincott, blanket warmers are to be monitored and at no higher than 130 degrees for blankets.
c. Currently, the facility has no policy and procedure related to monitoring blanket warmers to be certain they are no warmer than the 130 degrees recommended.

Based on observation and interview, the facility failed to ensure 4 of 4 elevator equipment rooms throughout the facility were provided with sprinkler coverage and failed to ensure 1 of 2 exit access corridors in the basement were provided with sprinkler protection to ensure sprinkler coverage in all portions of the building and failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition.

Findings:

1. Observations on 07/10/14 during the tour between 1:09 p.m. and 3:00 p.m. with MS1, Maintenance Supervisor, noted the following elevator equipment rooms were provided with smoke detector protection only:
1. one on first floor north hall by surgery entrance,
2. two in the basement, one next to maintenance office and the other by the fan room,
3. one on second floor next to specialty suites north hall.

2. In interview on 07/10/14 concurrent with the observations with MS1, it was acknowledged the elevator equipment rooms located in the aforementioned locations were not sprinklered.

3. In observation on 07/10/14 at 2:10 p.m. with MS1, it was noted the twenty foot long exit access corridor leading out of the west part of the basement was not provided with sprinkler protection.

4. In interview on 07/10/14 concurrent with the observation, it was acknowledge by MS1, the aforementioned twenty foot west hall was not equipped with sprinkler protection in order to provide complete sprinkler coverage to all areas of the facility

5. In observation on 07/10/14 at 3:17 p.m. with MS1, it was noted the electrical line from the fire alarm panel to the tamper switch on the Post Indicator Valve (PIV) had been cut.

6. In interview on 07/10/14 at 3:17 p.m. with MS1, it was acknowledged the facility knew about the failure of the tamper switch on the PIV, but repairs have not been done.

Based on review of medical staff bylaws, policy and procedure review, medical record review, and staff interview, the governing board failed to ensure the implementation of medical staff bylaws, and facility policy, regarding history and physicals for swing bed patients for 3 of 3 records reviewed (pts. #5, #6, and #7).

Findings:
1. Review of the medical staff bylaws, approved by the medical staff on 8/12/11, indicated:
a. on page 21,under section 4.2.21: "Status Upgrade Notes. Whenever a patient's status is changed from observation status to active status, or from active to skilled status, Members are required to provide a status upgrade note. Such a note will replace the requisite daily progress note, and comprise, at a minimum, data concerning the following: (a) Subjective data (b) Review of systems, including general condition plus at least two body systems/areas...".

2. Review of the policy and procedure "Skilled Care Documentation", policy number 645865, with an approved date of 11/2013, indicated:
a. under "Procedure", it reads: "A. 1. Upon admission to skilled care: a. If the patient has been admitted to acute care at St. Vincent Mercy Hospital (SVMH) within the previous seven (7) days and has a complete History and Physical examination note on record, the patient requires a Skilled Care Transfer Note (see below) completed within 24 hours of admission to skilled care...".
b. under "Procedure", it reads in "E. Definitions": "A skilled Care Transfer Note (SCTN) is a written or transcribed practitioner record containing details regarding the following aspects of a patient's clinical condition...". (repeats the information as written in 1. a. (a) and (b) above)

3. Review of the swing bed patient medical records #5, #6, and #7 indicated that a history and physical, or a SCTN, were absent from all three charts.

4. Interview at 4:00 PM on 7/9/14 and 3:15 PM on 7/10/14, with staff member #58, the health information services/medical records manager, indicated:
a. A history and physical, or SCTN, cannot be found for patients #5, #6, or #7.
b. Medical staff bylaws and facility policy were not followed regarding a history and physical, or SCTN, within 24 hours of admission for three swing bed patients, as noted in 3. above.

Based on policy and procedure review, manufacturer package insert review, observation, and staff interview, the facility failed to ensure the implementation of the glucose monitoring policy in 1 of 3 areas toured (emergency department).

Findings:
1. Review of the policy and procedure "AccuChek Inform Glucose Monitoring", policy number 646953, last approved on 11/2013, indicated:
a. under "Reagents", it reads: "1...Advantage Key Test Strip bottles must be dated upon opening, and may be used until the expiration date printed on the bottle."
b. Under "Reagents", section 2., it reads: "Accu-Chek Comfort Curve Control Solutions, Level 1 and Level 2. When a new bottle of glucose control solution is opened, write the date opened on the label. Control solutions expire at 90 days after opening or the bottles' expiration date, whichever comes first. Write the expiration date on the bottles."

2. Review of the Accu-Chek Inform II package insert indicated:
a. "Write the date the bottle was opened on the bottle label. The linearity solutions are stable for 3 months from that date or until the use by date on the bottle label, whichever comes first."

3. While on tour of the emergency department on 7/9/14, at 10:30 AM, in the company of staff member
#52, the RN (registered nurse) manager, it was observed that:
a. The Level 1 and Level 2 control solutions had no date written on them when opened.
b. The glucometer test strip bottle was not dated when opened.

4. Interview with staff member #52, the nurse manager of the unit, at 10:30 AM on 7/9/14 indicated:
a. The control solutions and glucometer strips are to be dated when opened, as per facility policy, and this was not done.
b. The control solutions are also to be dated with the 3 month expiration date, and this was not done.

5. Interview with staff member #50, the director of nursing, at 12:30 PM on 7/9/14 indicated:
a. The current AccuChek policy (listed in 1. above) needs to be updated as new equipment is now in place (since approximately July first).

Based on policy and procedure review, observation, and interview, the facility failed to ensure that an expired medication had been properly disposed of in 1 of 3 areas toured (emergency department).

Findings:
1. Review of the policy "Disposal of Medications", with an effective date of 03/2014 and a policy number of 776815, indicated:
a. Under "Policy", it reads: "Any medication that is discontinued, outdated, recalled, or in containers with worn, illegible or missing labels shall be returned to pharmacy for proper disposal...".
b. Under "Non-Controlled Medication", it reads: "1. Any medication removed from the Pyxis medstation needing returned to pharmacy can be placed in the Pyxis internal return bin...The Pyxis return bin is emptied daily during routine pharmacy rounds."

2. At 10:25 AM on 7/9/14, while on tour of the ED (emergency department) in the company of staff member #52, the ED manager, it was observed that a vial of Cefazolin 1 gm (antibiotic) was lying on top of the Pyxis and had an expiration date of June 1, 2014.

3. Interview with staff member #52, the ED manager, at 10:25 AM on 7/9/14 indicated:
a. The Cefazolin was expired and should have been discarded.
b. It was unknown why the antibiotic was lying on top of the Pyxis, or for how long it had been there.

Based on policy and procedure review, observation, and staff interview, the facility failed to ensure the cleanliness of one patient nutrition refrigerator in the emergency department.

Findings:
1. Review of the policy and procedure "Refrigerator Cleaning", policy number 691632, with a last approved date of 01/2014, indicated:
a. under "Policy Statement", it reads: "Refrigerators must be cleaned monthly. Daily spot cleaning is performed by dietary or unit personnel as needed..."
b. under "Procedures", it reads: "...9. Document the refrigerator has been cleaned on the unit weekly task check list."

2. While on tour of the ED (emergency department) at 10:20 AM on 7/9/14, in the company of staff member #52, the RN (registered nurse) manager of the ED, it was observed that the patient nutrition refrigerator was sticky on the ledge of the vegetable drawers (where one grabs to open the drawers), and was dirty under the vegetable drawers, with at least one hair present.

3. Interview with staff member #52, the ED nurse manager, at 10:20 AM on 7/9/14 and 3:55 PM on 7/10/14, indicated:
a. There is no documentation of monthly cleaning for the nutrition refrigerator.
b. It is unknown the last time the nutrition refrigerator was cleaned.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that a nursing care plan was completed for 2 of 9 patients, as required by facility policy (pts. #8 and #9).

Findings:
1. Review of the policy and procedure titled "Care Plan for Patients", policy number 970322, with a last revised and approved date of 07/2014, indicated:
a. Under "Policy", it reads: "An individualized plan of care must be in place for all in-patients, as well as outpatients. The nurse is responsible for initiating the care plan within 24 hours of the patient's admission...".
b. Under "Guidelines", it reads: "...7. A time limited goal will be hand written under each documented care plan..."

2. Review of patient medical records indicated:
a. Pt. #8 was admitted on 3/20/14, discharged on 3/24/14 (death), and lacked a care plan.
b. Pt. #9 was admitted on 5/28/14, discharged on 5/30/14, and had a pre printed care plan for "Cellulitis" that lacked any other documentation, or personalization, by nursing staff.

3. At 3:15 PM on 7/10/14, interview with staff member #58, the health information services/medical records manager, indicated:
a. No nursing care plan could be found for patient #8.
b. The pre printed care plan for "Cellulitis" found for pt. #9 does not meet facility expectations for a comprehensive care plan with time limited goals, and individualization.

Based on document review and interview, the facility failed to inform 3 of 3 swing bed patients of services that might not be covered by their medicare benefits, prior to, or at the time of, admission (pts. #5, #6, and #7).

Findings:
1. Review of the medical records for patients #5, #6, and #7, indicated:
a. The "Patient Rights in Swing Bed" document provided to, and signed by, the patients indicated in item #9: "The patient has the right to be informed in writing, at the time of admission of: a. The items and services that are included in hospital services under the State plan and for which the patient may not be charged. b. Those other items and services that the facility offers and for which the patient may be charged, and the amount of charges for those services.".

2. Interview with staff members #50, the director of nursing, and #57, the case manager, at 11:35 AM on 7/10/14, indicated:
a. Charges that a patient might be responsible for would include transportation costs to a physician provider, such as a dentist.
b. Other charges that a patient might be responsible for would include dental services.
c. The current "Patient Rights" document does not describe the possible charges a patient may be responsible for, and which are not provided as part of their Medicare benefit.

Based on employee file review, patient medical record review, and staff interview, the facility failed to ensure that an assessment/evaluation, to determine the patient's interests, physical, mental and psychosocial needs, was performed for 3 of 3 swing bed patient charts, and failed to ensure that activities conducted were appropriate for the patient's needs and contributed to the comprehensive care plans for these patients (pts. #5, #6, and #7).

Findings:
1. Review of the activity director's employee file (staff member N1), indicated:
a. The job description lists the "Position" as: "Activities Director - Swing Beds Medical-Surgical Service", and indicates this staff member is supervised by the "Manager of Case Management".
b. In the section titled: "Medical Record/Patient Charges", it reads: "1. Initiates and maintains the swing bed patient's activity evaluation."

2. Review of swing bed patient medical records (closed records--there were no current swing bed patients), indicated:
a. The medical records for patients #5, #6, and #7 lacked an assessment/evaluation form, or documentation, by staff member N1 of a comprehensive evaluation being performed .

3. Review of the medical record for patient #5 indicated:
a. Notes by the activity director on 6/20/14 (day of admission as swing bed patient) indicated:
A. At 7:15 AM, a "5 minute morning greeting and prayer" was conducted.
B. At 11:50 AM, it was noted: "Patient participated in Rat Pack activity with minimal help from A.D.(activity director)."
b. A note on 6/23/14 (day of discharge) at 7:20 AM read: "10 minute morning greeting. Patient accepted prayer and talked of going to nursing home. Patient stated [he/she] was feeling good about this idea."
c. The form titled "Multidisciplinary Treatment Team Notes" had a notation by the activity director on 6/20/14 that read: "Patient does activities to [his/her] ability".

4. Review of the medical record for patient #6 indicated they were admitted to swing bed status on 5/16/14 and dismissed to home on 5/21/14 and that:
a. The only note by the activity director was on 5/19/14 that read: "11:25 10 minute meet and greet Patient accepted prayer", and 4:05 PM: "30 minute activity. Patient participated in [unreadable] no doubles activity. Patient stated [he/she] enjoy (sic) the activity and the visit from A.D."
b. The form titled "Multidisciplinary Treatment Team Notes" for 5/19/14 had a date attended written by the activity director as 5/18/14 and a note: "Attended treatment team.".

5. Review of the medical record for patient #7 indicated
a. The first activity note was on 4/4/14 (dated 4/14/14, but patient was admitted to swing bed on 4/4/14 and discharged on 4/9/14 so that a 4/14/14 note was not possible) and read: "10 minute meet and greet. Patient accepted prayer and Daily Bread."
b. A second activity note on 4/7/14 at 10:20 AM read: "10 minute morning greeting and prayer." And, at 2:30 PM that day: "20 minute activity. Patient participated in Egg roll and Toss activity with minimal assist from A.D."
c. The form titled "Multidisciplinary Treatment Team Notes" for 4/4/14 had activity director notes that read: "Attended treatment team.".
d. The form titled "Multidisciplinary Treatment Team Notes" for 4/7/14 had activity director notes that read: "Willing to do activities with moderate assist from A.D.".

6. Interview with staff member #59, the RN (registered nurse) manager of med/surg and manager of case management (see job description information 1. above), indicated:
a. This staff member supervises the activities director.
b. There is no evidence in the medical records, for patients #5, #6, and #7, that a comprehensive assessment/evaluation was conducted.
c. Documentation at the multidisciplinary team meetings, and in progress notes, were minimal and lacked reflection of the extent that activities were per the care plan and met the patients' assessments/needs.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that a comprehensive care plan, with measurable objectives and timetables, was created for three of three swing bed patients (pts. #5, #6, and #7).

Findings:
1. Review of the policy and procedure titled "Care Plan for Patients", policy number 970322, with a last revised and approved date of 07/2014, indicated:
a. Under "Guidelines", it reads: "...7. A time limited goal will be hand written under each documented care plan...Swingbed patients will have short-term and long-term goals...".

2. Review of the policy and procedure titled "Annual Plan for Patient Care Services", policy number 812194, with a last approved and revised date of 04/2014, indicated:
a. on page 7 under "Coordination of Care", it reads: "...Most patients require an interdisciplinary team approach. The team reflects their decisions on the problem list...".

3. Review of swing bed patient medical records for patients #5, #6, and #7, indicated:
a. The patients' strengths are not listed on the care plans and objectives are not based on patient strengths.
b. There are no time tables, goals, and measurable objectives noted on the care plans.
c. Documentation at multidisciplinary team meetings indicated that the patient "qualified" for services, or that the particular discipline "attended treatment team" meetings.

4. At 11:35 AM on 7/10/14, interview with staff member #50, the director of nursing, indicated:
a. The care plans for patients #5, #6, and #7 are lacking time tables and measurable goals/objectives for the swing bed patients.
b. The "Multi disciplinary treatment team notes" for each of the three patients are lacking documentation of how the patients were progressing related to goals, objectives, and patient strengths.
c. Documentation by team members, as listed in 3 c. above, does not give indication of patients' progress as a swing bed patient.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that the attending physician was involved in the preparation and review of the care plan for 3 of 3 swing bed patients (pts. #5, #6, and #7).

Findings:
1. Review of the policy and procedure "Multi-Disciplinary Patient Care/UR (utilization review) Committee (Treatment Team)", policy number 692418, last approved on 01/2014, indicated:
a. Under "Policy", it reads: "...6. All Patient Care/UR committee meetings will be documented via formal minutes outlining the facts of each case as well as the action/changes in care to be implemented...".
b. Under "Membership", it reads: "...A...2. Patient's attending physician (need not be present for the entire meeting, may give input and leave or the case manager may discuss with the physician in advance of Treatment team and share the physician's input--the minutes must reflect "per physician's input")...".

2. Review of three swing bed patient (#5, #6, and #7) medical records indicated:
a. There is no documentation in the patients' medical records that indicates the attending physician was involved in the preparation and review of the patient care plans.
b. There is no documentation in the patients' records, especially the multi disciplinary team meeting notes, that the physician was present or gave "input" to the team meetings.

3. Interview with staff member #57, the case manager, at 3:00 PM on 7/9/14, indicated:
a. The notes this staff member takes regarding team meetings, which reflect team discussion of a patient's treatment, needs, progress, and more, are not a part of the patient's medical record.
b. This staff member has a check list that notes who attended each team meeting and that the attending physician was "consulted" regarding the patients discussed, but this document is not a part of the patients' medical records, either.

4. At 11:35 AM on 7/10/14, interview with staff member #50, the director of nursing, indicated:
a. The information noted by the case manager regarding team meeting discussion, and attending physician input, is not being retained in the swing bed patient medical records.
b. Currently, documentation is lacking in the medical records for patients #5, #6, and #7 that would indicate the attending physician participated in the preparation of care plans and the review of care plans and patient progress, or changes needed, when the treatment team meets.