HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to inform each patient and/or the patient's representative of the patient's rights on admission to the facility for twenty two (22) of twenty three (23) patients ( Patient # 1, # 2, # 3, # 4, # 5, # 6, # 7, # 8, # 9, # 10, # 11, # 12, # 13, # 14, # 15, # 16, # 17, # 18, # 19, # 20, # 21 and # 22).

The findings include:

During the clinical record review on October 22, 2019 from 10:00 a.m. to 3:00 p.m., it was revealed that the facility failed to follow their policy and have documentation that patients received information regarding patient rights on admission to the facility. The clinical record review for Patients # 1 through # 22 revealed there was no documentation of acknowledgement from the patients and/or patient's representative that they received Patient Rights. (Patient # 23 was received at the facility in full cardiac arrest with Emergency Medical Services (EMS) performing Cardiopulmonary Resuscitation (CPR). The facility continued resuscitation efforts and ultimately the patient was pronounced dead.)

The facility had patients admitted directly to the facility, Emergency Department (ED) patients, Outpatients and Medical Office patients. All patients sign the same consent form. The consent form utilized by the facility for Patients #1 - #22 lacked information on Patient Rights.

On October 22, 2019 at 10:50 a.m., an interview with Staff Member # 11 revealed "There is no way for the patients to acknowledge that they have received or been offered a copy of Patient Right's."

On October 23, 2019 at 9:10 a.m., a review of the Facility's policy titled "Patients' Rights and Responsibilities Statement Policy" provided by Staff Member # 2, read in part "It shall be the policy of [Name of Facility] that all patients receive information about their rights and the ability to be involved in the decisions or refusal of care. Upon admission or presentation to any [Name of Facility], the patient shall be presented with a brochure explaining the Rights and Responsibilities of the Patient and also be afforded the opportunity to ask questions about the rights and responsibilities outlined."

Staff Member # 2 was informed of the lack of documentation of Patient Rights on October 23, 2019 at 9:30 a.m. and stated "we will look at this".

Based on the scope and severity of physical environment deficiencies identified during the life safety code and health and safety surveys, the facility failed to substantially comply with this condition.

Cross reference A 0701 and A 0749.

Based on observations and interviews, the facility staff failed to ensure two (2) hospital departments, X-Ray and outpatient Bone and Joint, were maintained in a safe manner for patients and staff.

The findings include:

On 10/21/19, tours of the hospital and out patient areas were conducted by the surveyors and hospital staff. The X-Ray department was observed at approximately 11:00 A.M.

X-Ray Room #2 was found to have a loose and broken tile in front of the X-Ray table where a patient or staff would stand presenting a trip hazard.

The bathroom in X-Ray Room #2 had an emergency call bell on the opposite wall from the toilet. The surveyor observed that the call bell cord was out of reach for a patient sitting on the toilet.

Staff Member #22 stated at the time of the tour, "The bathroom in Room #1 is probably the same way."

Staff Member #16 stated, "We will get those fixed today."

On 10/21/19 at approximately 1:30 P.M., the Bone and Joint out patient facility was toured with Staff Member #15. The bathroom in this office was found to not have a call bell or manner in which a patient could alert staff of the need for help. Staff Member #15 was made aware of the lack of call bell during the tour.

Based on observation and interview, the facility staff failed to ensure they followed the Infection Control Plan by failing to repair chairs in the Infusion Center, and leaving scoops in the flour bin and ice machine.

The findings include:

In the Infusion Center, three unoccupied chairs were observed with Staff Member #3 at approximately 1:50 P.M. on 10/21/19. One (1) of the three (3) chairs had a tear on the flat surface of the chair arm and another tear on the seam line. The tears left an exposed porous surface that could not be cleaned and disinfected after patient use. Staff Member #3 stated, "We will pull the chair and see that it is repaired or replaced."

The facility food storage and preparation areas were observed on 10/22/19 at approximately 9:25 A.M. with Staff Manager #19, Dietary Manager, and Staff Members #2 and #21. In the dry storage area, an approximately half full 25 pound bag of flour was observed opened and accessed with no date as to when it was opened or accessed.

Staff Member #19 stated, "That should be poured into the covered bin and not sitting on the shelf." Staff Member #19 opened the bin and the scoop used in the floor bin was lying in the bottom of the bin. Staff Member #19 stated "that should be on the scoop hook here inside the bin." Staff Member #19 poured the undated opened bag of flour in the bin. The scoop was removed.

The ice machine in the hallway of the food preparation area was observed during the tour. The ice scoop was found stored inside the ice bin with the handle lying on the ice. The ice machine was equipped with a hook inside the ice bin to hold the scoop to prevent the ice from becoming contaminated by staff handling the scoop. Staff Member #19 stated "this (the scoop) should be on the hook."

On 10/23/19 at approximately 10:30 A.M. Staff Member #14, Infection Preventionist was informed of the findings and stated, "Thanks for letting me know about these issues. We will put these items on our rounding form to check on."