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Based on review of the Patient Directory and interview, it was determined the facility failed to provide the State Agency's name, address and phone number in the patient grievance procedure section. Failure to provide patients with the State Agency's name, address and phone number did not allow patients the opportunity to contact the State Agency to file a written or verbal complaint. The failed practice affected all patients on 06/17/13. Findings follow:

A. Review of the Patient Directory provided by the Chief Nursing Officer at 1400 on 06/19/13 revealed the State Agency's name, address and phone number were not listed in the patient grievance procedure section or anywhere else in the Directory.
B. The above was verified by the Chief Nursing Officer at 1600 on 06/19/13.

Based on review of policy, review of Acudose-RX Discrepancy reports and interview, it was determined the facility failed to complete audits of controlled substances each shift change in that audits were not done on 18 of 93 shift changes in the Emergency Department (shift changes occurred at 0700 and 1900) between 1900 on 05/01/13 and 1900 on 06/16/13. By not completing the controlled substance audits each shift change, the potential existed for discrepancies to be in the inventory and for the discrepancies to go unresolved. Findings follow:

A. Review of policy titled "Automated Medication Dispensing System" stated "Before the conclusion of each shift the Charge Nurse is responsible for resolving all discrepancies on the system."
B. Review of Acudose-RX Discrepancy reports from 1900 on 05/01/13 through 1900 on 06/16/13 revealed the following missing shift change audits:
05/08/13 0700
05/09/13 0700
05/11//13 0700 & 1900
05/13/13 0700
05/17/13 0700
05/21/13 0700
05/30/13 0700
05/31/13 0700
06/01/13 1900
06/02/13 0700
06/05/13 0700
06/08/13 0700
06/09/13 0700
06/12/13 0700 & 1900
06/13/13 0700
06/15/13 0700
C. Findings were verified, through interview with the Chief Nursing Officer on 06/17/13 at 1310.

Based on kitchen hood fire suppression system maintenance documentation, observation and interview it was determined the hospital did not meet requirements related to the regular maintenance of kitchen hood fire suppression systems, the use of roller latches, the maintenance of penetrations of smoke barrier walls and the automatic closing and latching of smoke barrier doors. The failed practices had the potential to affect all patients, staff and visitors. The facility had a census of 38 patients on 06/17/13. See Tags K18, K25, K27 and K69.

Based on observation and interview, it was determined the facility was utilizing roller latches on five of six patient room doors in the Intensive Care Unit. The failed practice had the potential to affect all patients, staff and visitors due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire event. The facility had a census of 38 patients on 06/17/13. This is a recurring deficiency from the Medicare recertification survey conducted 06/23/09 to 06/25/09. See K18.

Based on interview it was determined the facility did not ensure regular inspections by the local fire control agency due to a lack of documentation available for review. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the Fire Department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of 38 patients on 06/17/13. The findings follow:

In an interview on 06/18/13 at 1040 the Maintenance Director verified there was no documentation of Fire Department inspection available for review.

Based on clinical record review and interview, it was determined eight of eight (#13, #18, #22 - #24, #26, #29 and #30) clinical records, of patients who underwent operative procedures, contained operative reports that did not contain the time of surgery. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports revealed the time of surgery was not documented for Patient #13, #18, #22 - #24, #26, #29 and #30.
B. Findings were confirmed by the Chief Nursing Officer on 06/20/13 at 1125.

Based on review of the Swing Bed Policy and Procedure Manual and interview, it was determined the Facility failed to ensure patients were fully informed in advance of expected care and treatment, as well as any changes in care and treatment. The failed practice did not allow patients to receive information and make informed decisions regarding their care and treatment. The failed practice affected all patients admitted to Swing Bed status in the facility. Findings follow:
A. Review of the Swing Bed Policy Manual provided by the Chief Nursing Officer (CNO) at 1330 on 06/19/13 revealed the facility did not have a policy or procedure specific to the patient's right to be fully informed in advance of expected care and treatment. The facility did not have a policy or procedure specific to informing the patient in advance of any changes to the patient's care and treatment.

B. The above findings were verified by the Quality Improvement Director at 1427 on 06/19/13.

Based on review of the Swing Bed Policy and Procedure Manual and interview it was determined the Facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. Failure to develop and implement written policies and procedures did not allow the facility to have in place an effective system to prevent mistreatment, neglect and abuse of residents and misappropriation of resident property. Findings follow:

A. Review of the Swing Bed Policy Manual provided by the Chief Nursing Officer at 1330 on 06/19/13 revealed there were no written policies and procedures to prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property.

B. The above findings were verified by the Quality Improvement Director at 1440 on 06/19/13.

Based on personnel record review and interview, it was determined the Facility did not employ a qualified professional to direct the Swing Bed Activities Program. Failure to employ a qualified professional did not ensure the Swing Bed patients were receiving activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. The failed practice affected all Swing Bed patients on 06/19/13. Findings follow:

A. Review of the personnel file of the Quality Improvement Director revealed the employee was not a qualified therapeutic recreation specialist, was eligible for certification as a therapeutic recreation specialist or activities professional by or after 10/01/90, was a qualified occupational therapist or completed a State approved training course.
B. The above findings were verified by the Quality Improvement Director at 1444 on 06/19/13.

Based on interview, it was determined the facility did not have a Dentist on staff or an agreement with a Dentist to provide 24 hour emergency dental care. Failure to ensure the availability of dental care to the Swing Bed patients did not ensure the needs of the patient would be met. The failed practice affected all Swing Bed patients on 06/19/13. Findings follow:

During an interview with the Quality Improvement Director at 1450 on 06/19/13 she stated the facility did not have a dentist on staff or an agreement with a Dentist to provide dental care to the Swing Bed patients.