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Based on interview and record review, the hospital failed to provide and explain each patient's rights in a language or manner that the patient (or the patient's representative) understands for 3 (P #2, 6 and 9) out of 21 (P #1 through P #21) patients reviewed for patient rights. This deficient practice could lead to patients and families not making informed decisions about care without the required information. The findings are:

A. On 03/13/18 staff identified P #2, P #6 and P #9 as Spanish Speaking only.

B. Record review of medical face sheets for P #2, P #6 and P #9 revealed their primary language as Spanish.

C. On 03/13/18 at 9:30 am during interview, the Medical Records Supervisor (MRS) revealed the facility has both English and Spanish admissions documentation and presented surveyors with both. MRS stated when patients are identified as Spanish Speaking Only, admission documents such as Patient's Rights, Consent for Treatment, etc, are provided to the patient in Spanish. MRS confirmed that not all the documents read and signed by Patient #2, #6 and #9 were in Spanish.

D. On 03/14/18 at 11:30 am, during exit interview, the Hospital Administrator stated that although the hospital staff use Language Line (telephonic language support provider), the hospital staff does not document its use and therefore cannot confirm that patients received information regarding their rights in the patient's language of preference.

E. Record review of the hospital policy titled "Patient Rights, Responsibilities, and Grievance Procedure," dated October 2007 (revised 03/17), revealed the following under "Article 1":
"[Section 3] A patient, legally authorized person, or any person authorized in writing by the patient has the right to receive complete and accurate information, to the extent permitted by law, concerning his illness, course of treatment and prognosis for recovery in terms that the patient can understand."
"[Section 12] The patient has the right to have access to an interpreter if he does not speak the English language, or if he depends on manual communication."

F. Record review of medical records for patients #2, #6 and #9 (identified by staff as Spanish speaking only), revealed that there was no documentation to support when hospital personnel interpreted admission documentation or when the Language Line was used for interpretation services.

Based on interviews and record review, the hospital failed to respond in a timely manner to complaints filed by 6 (P #28, #29, #32, #34, #35, and #36) of 38 (P #1 through P #38) patients sampled for complaints and grievances. If the hospital is not responding to complaints and grievances in a timely manner, patients can feel as if their opinions are not being heard. The findings are:

A. On 03/14/18 at 8:45 am, during an interview, the Compliance Officer confirmed that there were a few patient complaints that were not followed up within seven days as required by Hospital policy. The Compliance Officer further confirmed that she had only received one patient complaint within the last 6 months.

B. On 03/14/18 at 9:30 am, during an interview, COTA#2 (Certified Occupational Aide), PTA (Physical Therapy Assistant), and PT (Physical Therapist) stated that they have had complaints from patients within the last 6 months regarding room temperatures, meals, and staffing concerns. All 3 personnel stated that they typically do not document the complaint and have maintenance, kitchen personnel or their supervisor address the issue. All three personnel confirmed that none of the complaints were referred to the Compliance Officer.

C. Record review of the hospital policy #20-5 titled "Patient Rights, Responsibilities, and Grievance Procedure," dated October 2007 (revised 03/17), revealed the following under "Article III Patient Grievance Procedure, Section 7":
"Documented Patient / Client complaint / grievances will be reported to the Compliance Officer and a letter will be sent to the person making the grievance no more than 7 days from the day that the complaint was received by the staff."

D. Review of patient complaints #28, #29, #32, #34, #35, and #36, revealed that all had exceeded the 7-day timeline as specified by policy #20-5 Patient Rights, Responsibilities, and Grievance Procedure, dated 10/07 and revised 03/17.

Based on observation and staff interview, the hospital failed to provide a safe environment for patients in its Detoxification Unit by leaving the medication room unlocked. This deficient practice exposed all 3 patients on the detoxification unit to the potential of physical harm. The finding are:

A. On 03/13/18 at 2:35 pm during observation, a surveyor walked into an unlocked medication room on the detoxification unit.

B. On 03/13/18 at 2:39 pm during observation, another surveyor walked into the same unlocked medication room.

C. The pharmacist was asked if the medication room should be left open. He stated, "It (med room) should be locked."

D. On 03/13/18 at 3:15 pm during an interview, Director of Nursing stated the medication rooms should always be kept locked.

E. On 03/13/18 at 3:55 pm during an interview, Administrator stated, "The medication room should be locked at all times".

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Based on observation, interview, and record review the facility failed to implement their infection control program to prevent and control infections by 1) not washing hands after drawing blood from patients, 2) not using gloves when handing blood vials, and 3) not using cleaners and disinfectants in accordance with manufacturer's instructions, 4) reviewed contracted laundry service for infection control concerns. These deficient practices has the likelihood to spread infectious diseases throughout the hospital to patients, visitors and staff. The findings are:

A. On 03/13/18 at 2:20 pm during interview and observation, an observation was made on the Detoxification unit of three vials of blood laying on the counter at the nursing rotunda. When Psych Technician (PT #2), who was behind the rotunda at the time, was asked why they were there, stated, "The Registered Nurse (RN) is drawing blood from a patient". RN #8 was then observed coming out of a patient's room with gloves on. RN #8 took off the gloves and gathered all the vials of blood and prepared to place them in a bag with ice. As RN #8 was putting the blood vials into a bag of ice, surveyor stated, "You don't have gloves on." RN #8 stated, "Oh I do it all the time (does not wear gloves while handling blood vials)." RN #8 then put on a new pair of gloves and stated, "I have to obtain ammonia levels on another client," as RN #8 walked into another patient's room. RN #8 came out of that patient's room, took off one glove and laid it on the counter at the rotunda and walked into the medication room, which was observed to be unlocked. RN #8 then came out of the medication room, picked up the dirty glove from the counter she had deposited there earlier and threw it in the nearby trash can, grabbed the blood vials with her un-gloved hand and placed them into a bag with ice. RN #8 then walked off to another patient's room to draw blood.

B. On 03/13/18 between 2:20 pm and 2:35 pm, RN #8 was observed not washing her hands or using hand alcohol-based hand gel between patient contact and patient blood draws or while handling blood vials.

C. On 01/13/18 at 3:02 pm during interview RN #3 stated, "If a nurse draws blood, she should be wearing gloves; they should be wearing gloves if handling blood vials." When the above observation was explained to him, he stated, "That is not kosher, that is not acceptable".

D. On 03/13/18 at 3:05 pm during an interview, when surveyor discussed the above hand washing incident with Director of Nursing (DON), DON stated, "That's not ok ...they should be washing hands between patients." DON revealed the Hand hygiene policy is under infection control.

E. On 03/13/1 at 3:55 pm during an interview, Administrator stated, "Blood vials should not have been sitting on the counter ....I am at awe about the hand-washing incident" confirming that should not have happened either.

F. On 03/14/18 at 10:00 am during an interview when asked which policy addresses the handling of blood vials, RN #3 stated, "That is in the hand washing policy".

G. The facility's Hand Washing Policy effective 09/99, reviewed 08/17, states, "[Name of State]Rehabilitation Center personnel shall wash their hands, to prevent the spread of infection: Before applying and after removing gloves and between handling of individual patients." The policy failed to address hand washing when handling blood vials.

H. Record review of the Infection Control Nurse's "Hand Hygiene Compliance" audit for November 2017, December 2017 and January 2018 indicated 45 total observations among the nurses, therapist and dietary staff.
Two of the 45 observations was identified as a "not met."

I. Record review of the Hospital's Infection Control Policy titled "Standard Precautions" reviewed in 08/16 indicated: "Hand washing-Hands are to be washed after touching blood, body fluids, secretions, excretions or other contaminated items whether or not gloves have been worn. Hands should be washed immediately after removal of gloves, between patient contact and when otherwise indicated. This will help prevent transmission of microorganisms."

J. Record review of the Hospital's Infection Control Policy review in 08/16 titled "Alcohol Based Hand Gel" indicated the following: "Policy: [The Hospital] will provide alcohol based hand gel for employees use in appropriate areas as part of the hand hygiene program. Procedure: Alcohol based hand gel should not be used when hands are visibly soiled or contaminated with blood or body fluids!"

K. On 03/13/18 at 3:15 pm during interview, Housekeeper #1 was asked what disinfectant he used to clean the rooms. He produced a spray bottle unlabeled. He was asked what was in the bottle he produced a technical data sheet for "3 M HB Quat Disinfectant Cleaner Concentrate 25A, 25L and 25 H". He was asked what the wet time for the agent. He stated, "I am not sure, maybe 15 minutes." He was asked how he knew that. He stated he was not sure. He did not know to read the label for the answer. He was asked what personal protective equipment he should used. He stated, "I just wear gloves."

L. Record review of the data sheet for the 3 M HB Quat Disinfectant supplied by the hospital indicated the wet time was 10 minutes. It also recommended the use of eye goggles, glove and covering any exposed skin as in a gown.

M. On 03/14/18 at 10:15 am during interview, the Infection Control (IC) Nurse was asked when he talked with Housekeeper #1 about his job and how he cleaned. He stated, "I have never talked to him." He was asked how many Housekeepers the hospital has presently. He stated, "Two." The IC Nurse was asked when he confirmed the water temperature and the processes performed under a contract for laundry. He said he had not requested a verification of temperature or quality from the laundry provider during his time as IC Nurse, which was approximately 2 years.