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Based on document review and interview, it was determined for 2 of 2 (Pt. #1 and #2) patients on 3 East assessed as a falls risk upon admission, the Hospital failed to ensure the patients were placed on falls precautions as per fall policy.

Findings include:

1. The Hospital policy titled, "Fall Prevention (revised 5/10)" was reviewed on 6/13/17. The policy required, "...C. If the score is greater than or equal to 10, place the patient on fall precautions: ...G. A yellow color coded fall alert wrist band will be placed on all patients assessed to be at risk for falls. A yellow falling star will be placed on the door frame of the room for patients at risk for falls".

2. The clinical record of Pt. #1 was reviewed on 6/13/17. Pt. #1 was a 45 year old male admitted on 6/12/17 with the diagnoses of chest pain and depression with suicidal ideation. The admission fall assessment completed on 6/12/17 at 12:42 PM included, "Check here if patient on fall precautions - yes. Score -35". Pt. #1 did not have a yellow identification band on the wrist or a star magnet on the door.

3. The clinical record of Pt. #2 was reviewed on 6/13/17. Pt. #2 was a 52 year old male admitted on 6/11/17 with the diagnosis of Acute Psychosis. The admission fall assessment completed on 6/11/17 at 3:52 PM included, "Check here if patient on fall precautions - yes. Score - 20". Pt. #2 did not have a yellow identification band on the wrist or a star magnet on the door.

4. During an interview on 6/13/17 at approximately 11:00 AM, the charge nurse (E#1) on 3 East stated, "there should be a star on the door and a yellow arm band on each patient at risk for falls". E#1 stated there were no stars or bands available on the unit and had to get them from the nursing office before they could be applied.

Based on document review and interview it was determined for 2 of 2 (Pt. #10 and #11) contact isolation patients on the intensive care unit, the Hospital failed to ensure the plan of care was updated to include the patients were placed on contact isolation.

Findings include:

1. On 6/13/17 at approximately 11:00 AM, the clinical record of Pt. #10 was reviewed. Pt. #10 was a 60 year old male admitted on 6/1/17 with a diagnoses of chronic obstructive pulmonary disease and pneumonia. The clinical record of patient #10 included a physician's order for contact isolation dated 6/6/17. However, as of survey date 6/13/17, the plan of care had not been updated to include the contact isolation.

2. On 6/13/17 at approximately 11:15 AM, the clinical record of Pt. #11 was reviewed. Pt. #11 was a 86 year old female admitted on 4/29/17 with a diagnoses of peripheral vein disease and gangrene of the right foot. The clinical record of Pt. #11 included a physician's order for contact isolation dated 5/25/17. However, as of survey date 6/13/17, the plan of care had not been updated to include the contact isolation.

3. On 6/13/17 at approximately 1:30 PM, the Hospital's policy titled, "Clinical Care Station Multi-Disciplinary Care Plan" (revised 11/11) was reviewed and required, "...The care plan will incorporate patient specific goals... Procedures:...B. The...problems requiring obvious nursing intervention or patient/family education are to be included on the patient's care plan."

4. On 6/13/17 at approximately 11:30 AM, the above findings were discussed with E #2 (Infection Control Practitioner/RN). E #2 stated that the care plan should have included contact isolation.

Based on interview and document review, it was determined that the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. The Director of Health Information Management (HIM) (E #8) was interviewed on 6/14/17. E #8 stated that as of 6/14/17, there are delinquent medical records. The Director stated that the Hospital require all patient records to be completed within 30 days of discharge.

2. The above findings were discussed with the Senior Vice President for Quality and Compliance (E #11) on 6/14/17 at approximately 2:00 PM, who stated that all medical records should be completed within 30 days of discharge.

3. The Hospital policy titled, "Medical Record Guideline for Chart Completion by the Physician" (rev. 5/26/10), was reviewed on 6/15/17. The policy required, "The quality of the medical record is contingent upon the timeliness... Procedure: ...Records shall be completed and authenticated within 30 days of the patient's discharge."

4. On 6/15/17 a letter of attestation signed by E #8, indicated that as of 6/15/17 there were 807 delinquent charts.

Based on observation, interview and document review it was determined that the Hospital failed to ensure adherence to Food and Nutrition policies. This potentially affected all 87 patients on census.

Findings include:

1. During the tour of Food and Nutrition Services conducted on 6/14/17, between 11:00 AM and 12:15 AM. The following were observed:

-Cooler #5 contained 6 boxes of potatoes (fries), 1 box was covered with melting ice chips that dripped from ice buildup within the cooler.
-Freezer 2 was filled, with approximately 3 boxes on top of shelving, touching the ceiling of the walk in freezer.
- A cooler condenser, behind the ice machine, was blackened and contained a thick accumulation of dust, debris and cob webs. Shelves containing baking pans, bowls and strainers was stored next to the condenser. Whisks and mixing paddles were hanging off the ceiling directly above the condenser.
- A tray of spices was stored next to a trash bin in the same corner as the condenser.
- In the dry storage area, an open bag of macaroni was labeled but not re-tied or sealed.
- The 3 compartment basin sink was overfilled and the rinse sink and the final rinse sink contained debris from the first pot wash sink, contaminating the rinse and final rinse and disinfection sink.

2. During the tour on 6/14/17 between 11:00 AM and 12:15 PM, the Director of Food and Nutrition (E #9) was interviewed. E #9 stated that cooler 5 needs to be cleaned from the ice buildup; boxes in the walk-in coolers and freezers should not be touching the ceiling, the condenser behind the ice machine should be cleaned; the trash bin should not be placed next to the spice rack, the open macaroni bag should have been sealed with a tie, and the wash basin should not be overfilled. E #9 stated that dishes should be dipped for about 15 seconds in the final rinse/disinfection compartment. E #9 also stated that they do not document the final rinse disinfectant concentration checks.

3. The Vice President (VP) of Special Projects (E #12) was interviewed on 6/14/17 at approximately 12:00 PM. E #12 acknowledged that the cooler condenser behind the ice machine and next to cooking and food preparation equipment was dirty and needed to be cleaned.

4. The Hospital policy titled, "HACCP Food Safety Program for Food and Nutrition Services" (rev. 7/2006) was reviewed on 6/14/17. The policy required, "Storage Procedure: Proper storage of food is essential to preserve its quality, prevent contamination and retract bacterial growth...Food will be stored... at least 2 inches away from walls...Dry storage...all opened food will be kept in light lid containers to prevent contamination and absorption of humidity... Refrigerated storage...raw food requiring cooking will be stored in a manner that precludes cross contamination..."

5. The Hospital policy titled, "Cleaning of Food Service Area" (rev. 7/2006) was reviewed on 6/14/17. The policy required, "The food service establishment must be kept clean to minimize attractants for insects and rodents, to prevent nuisance conditions, and to aid in preventing contamination of food and equipment...Procedure: 4. Pots and pans areas should be cleaned at end of meal shift... Food Service Supervisor shall complete sanitation checklist to ensure that the entire kitchen is thoroughly cleaned before closing department."

6. The Hospital policy titled, "Pot and Pan Washing" (rev. 7/2006) was reviewed on 6/14/17. The policy required, "The following are performed in the cleaning of pots and pans to insure proper cleaning and sanitation...3. Wash in the soap and water until clean and grease free in #1 pot wash sink; 4. Rinse pots and pans in #2 pot wash sink until free of detergent and abrasives; 5. Rinse pots and pans at least 1 minute in the #3 sink containing 100 ppm chlorine....8. Chlorine concentration must be checked minimum three times daily (8 am, 1 pm, and 6 pm)."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code Complaint Survey conducted on June 13-14, 2017, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code Complaint Survey conducted on June 13-14, 2017, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review, and interview, it was determined for 1of 2 isolation patients (Pt #10) on the intensive care unit, the Hospital failed to ensure isolation technique was maintained as required.

Findings include:

1. On 6/13/17 at approximately 10:15 AM, an observational tour of the intensive care unit was conducted. During the tour, a contact isolation sign was observed posted by the head of Pt. #10's bed. At approximately 11:55 AM, E #6 (Respiratory Therapist) provided respiratory care and suctioned Pt. #3 without wearing an isolation gown.

2. On 6/13/17, the Hospital's policy titled "Isolation Precautions" (revised 8/06) was reviewed and required, "...Policy: ...2. Transmission-Based Precautions... C. Contact Precautions...c... wear a gown when entering the room if you anticipate that your clothing will have contact with the patient..."

3. On 6/13/17 at approximately 12:00 PM, findings were discussed with E #2 (Infection Control/RN). E #2 agreed with the findings and stated, "He (E #6) should have worn an isolation gown."


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B. Based on interview and observational tour, it was determined, for 1 of 2 Ultrasound Technicians (E #5), the Hospital failed to ensure that staff food and drink were not in the radiology area.

Findings include

1. On 6/13/17 at 2:00 PM, an interview was conducted with the Director of Imaging Services (E #3). E #3 was asked for a policy regarding food and drink in the radiology area. E #3 was unable to locate a policy regarding food and drink in the radiology area, but stated food and drink is not permitted in the radiology area.

2. On 6/13/17 between 1:40 PM and 2:15 PM, an observational tour was conducted in ultrasound room #2. A large open bag of pop corn, 1 styrofoam cup of ice, 1 styrofoam cup of water, and 1 plastic water bottle containing water were in ultrasound room #2. An Ultrasound Technician (E #4) stated the water and pop corn belonged to the other Technician (E #5) and should not be there.

Based on document review and interview, it was determined for 3 of 4 (Pt.s #21, #22 and #23) patients requiring services upon discharge, the Hospital failed to provide a list of Home Health Agencies (HHA) or Skilled Nursing (SNF) Facilities to the patient.

Findings include:

1. The Hospital policy titled, "Discharge Planning (Revised January 2015)" was reviewed on 6/15/17. The policy required, "Assessment if the patient requires a HHA or SNF care. If so, list of HHAs, SNFs and hospice etc. to be given to the patient. The hospital informs the patient's family of his or her freedom to choose among participating Medicare providers".

2. The clinical record of Pt. #21 was reviewed on 6/15/17. Pt. #21 was a 94 year old female, admitted on 1/30/17, with the diagnosis of orthostatic hypotension (low blood pressure). Pt. #21 was admitted from home with a discharge plan for a new placement to a SNF. The clinical record lacked documentation that a list of facilities was provided to the patient.

3. The clinical record of Pt. #22 was reviewed on 6/15/17. Pt. #22, was a 23 year old male, admitted on 2/20/17, with the diagnosis of pressure ulcer left hip. Pt. #22 was admitted from home with a discharge plan for HHA services. The clinical record lacked documentation that a list of agencies was provided to the patient.

4. The clinical record of Pt. #23 was reviewed on 6/15/17. Pt. #23, was an 84 year old female, admitted on 4/16/17, with the diagnosis of heart failure. Pt. #23 was admitted from home with a discharge plan for HHA services. The clinical record lacked documentation that a list of agencies was provided to the patient.

5. During an interview on 6/15/17 at approximately 10:15 AM, the Vice President of Nursing Services (E#10) stated, "A list is provided. We must have just forgotten to document it".

Based on document review and interview, it was determined for 1 of 1 (Pt. #25) patient reviewed for readmission within 30 days, the Hospital failed to track or evaluate the previous discharge plan.

Findings include:

1. The Hospital "Performance Improvement Plan 2016/2017" was reviewed on 6/15/17. The plan included, "Clinical department and ancillary services will identify indicators related to the important patient care and organizational functions that it performs". The plan did not include any discharge plan specific indicators.

2. The clinical record of Pt. #25 was reviewed on 6/15/17. Pt. #25 was a 71 year old male, admitted on 5/27/17, with the diagnosis of oliguria (decreased urine output). Pt. #25 was discharged to a nursing home on 4/29/17 and readmitted on 5/27/17. Pt. #25 was not identified by the Hospital as a readmission within 30 days.

3. During an interview on 6/15/17 at 10:30 AM, the Vice President of Quality/Compliance (E#11) stated, "We send out our discharge information and receive a report back with readmission data (numbers). We do not analyze this data for any process improvement activities yet, because of our high readmission rate of our psychiatric patients. These patients are not triggered upon admission, but the staff has access to previous records to review if necessary".