HospitalInspections.org

Based on observation, interview and record review the facility failed to:


A. ensure a safe setting for patients seeking care at the Rehabilitation Hospital. Failure to maintain the floor tiles in the hallways, patient activity room (Daily Living Room) and the bathroom in the physical therapy gym posed risk for injury to patients.
The facility failed to ensure a safe and clean enviroment, prevent falls, document nursing asessments, and put safety devices in place in 3(#22, 25, and 30) of 10 (#21-31) charts reviewed.

Refer to tag A0144 for additional information.



B. ensure staff followed their policy and procedures. The facility failed to conduct a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint. The facility failed to correctly inform the patient of their legal rights involving the administration of psychoactive medications in 1(20) out of 10 (22-31) charts reviewed.

Refer to tag A0160 for additional information.

Based on document review and interview, the facility failed to insure informed consents for treatment was obtained for 2 (#3 and #12) of 31 sampled patients.

This deficient practice had the likelihood to cause harm in all patients.
Findings include:

On 1/22/15 at 2:00 p.m. in the medical records department the electronic medical record (EMR) for patients #3 and 12 were reviewed and revealed the following:

Patient (Pt/pt) #3's consent for services and financial responsibility had no patient or patient representative signature. The only documentation found was on the line identified for "Reason individual is unable to sign". The statement read, "pt has AMS (Altered Mental Status)". A two letter initial was observed below as the witness. No other staff signature or discipline was found on the consent form. Pt #3 resided in a nursing home and the documentation provided by that facility indicated pt #3 had two (2) persons listed with emergency contact information.

Pt #12's consent for services and financial responsibility had no patient or patient representative signature. The only documentation was found on the line identified for "Signature of patient or Legal Representative for Health Care". The statement read, "pt unable to sign r/t (related to) dementia". A two letter initial was observed below as the witness. No other staff signature or discipline was found on the consent form. Pt #12 resided in a nursing home and the documentation provided by that facility indicated pt #12 had two (2) persons listed with emergency contact information.

The above lack of documentation was confirmed by staff #28.

Based on observation and interview the facility failed to:

A. ensure a safe setting for patients seeking care at the Rehabilitation Unit. Failure to maintain the floor tiles in the hallways, patient activity room (Daily Living Room) and the bathroom in the physical therapy gym posed risk for injury to patients.

A tour of the facility at approximately 9:30 am on 1/22/15 was conducted with staff #9. Throughout the hallways of the facility where concrete joint were placed during the construction of the building, the floor tile was broken and chipped. Pieces of the tile were missing causing a potential tripping hazard and prevented proper cleaning and disinfecting of the floors. The rubber molding (baseboard) around the walls had released from the surface it was attached at different points throughout the hallways.
The tour continued to the patient activity room (Daily Living Room). Located in the area were a wall of cabinets and a sink. The Formica covering the cabinets had released from the surface it was attached. Along the back of the cabinets and at different points on the cabinets the Formica posed a risk of cuts and injury to the patients using this area for rehabilitation. The cabinets were cluttered and had the appearance of not being cleaned.
The rubber molding (baseboard) around the walls had released from the surface it was attached at different points throughout the room. The released molding posed a tripping hazard and injury to the patients using this area for rehabilitation.
A door leading to an outdoor court yard was observed. On each side of this door at the point of the floor the rubber molding (baseboard) had released from the wallboard it was attached posing a tripping hazard and injury to the patients. The wallboard was exposed, broken and chipped. The wallpaper had released from the wallboard and was tattered and torn. Staff #9 confirmed these defects were a result of water damage occurring over a long period of time.
To the right of the door was a support column that had been covered with wallboard measuring approximately two feet by 4 feet. At the base of the column the wallboard was bubbled and peeling; at eye level was a blackish/grey spot approximately 10 inches across. A closer observation of the spot revealed a black, fine hairy substance. When the area was pointed out to staff #9 it was commented by staff #9, "that looks like mold. It looks like water is coming off the roof and draining down the inside of the wallboard".
The tour continued to the Physical Therapy Gym/ Treatment area. The floors had the appearance of being un-kept, in need of cleaning and maintained. A unisex bathroom was observed being dirty and un-kept. The floors were in need of cleaning. Around the toilet were black stains on the floor. There was a wear pattern on the floor leading from the entry of the bathroom to the toilet. Outside of this wear pattern (common walking area) the black stains were worn away. At the base of the toilet it appeared there were multiple attempts to patch the toilet. There was a calk buildup covered with the black stain.
An ongoing interview throughout the tour with staff #9 was conducted. Staff #9 confirmed the findings. When asked if there was a housekeeping department in the building, staff #9 replied "yes". When asked again if there was a properly staffed housekeeping department in the building, staff #9 replied "no". "We could probably use more staff".





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B. ensure a safe and clean enviroment, prevent falls, document nursing asessments, and put safety devices in place in 3(#22, 25, and 30) out of 10 (#21-31) charts reviewed.


During a tour of the Crisis Unit on 1/22/15 revealed the curtains in each patient room were not break away curtains. The curtains could be used as a hanging device that could cause possible harm or death.

An interview on 1/22/15 with staff #9 revealed he was not aware the curtains were not break away and would have them removed.

During a tour on the Adult and Geriatric Units revealed bed alarm floor mats in patient rooms. The mats had extended electrical cords. The electrical cords can be used as a hanging device that could cause possible harm or death.

An interview on 1/22/15 with staff #9 confirmed the mats were in patient rooms. Staff #9 reported the facility had some cordless bed alarms but they have been lost so the facility put the corded mats back in the patient rooms.

During a tour on the Adult and Geriatric Units revealed all doors leading into the patient rooms had three regular door hinges instead of continuous hinge. The current door hinges can accommodate a hanging device. A hanging device could cause possible harm or death.

1. Review of patient #30's chart revealed he had experienced a fall on 12/10/2014 at 2:18 AM. Review of the nurse's notes dated 12/10/2014 at 10:31 PM revealed the patient's bed alarm was activated with appropriate settings. Patient #30 was documented as a "High Fall Risk" Review of the nurse's notes dated 12/10/2014 at 1:02 am revealed the patient was still awake and asked if he needed anything by the nurse. Patient #30 reported he was fine and the nurse will continue to monitor. Review of the nurse's notes dated 12/10/2014 at 2:25 am stated the following;
" While tech was making his rounds, found patient on floor face down when checked and called his name, patient answered, when asked what happened stated that he cannot remember either his legs buckled on him or possibly had a slight seizure since he cannot remember why he ended up on the floor. No knot noted on his face, no bruising noted on his face, when asked if he is hurting anywhere different from his chronic pain stated "no I ' ll be fine." Asked if he wanted to go to the emergency room to get check, patient refused asked if he can roll over to get up, patient was able to roll over to sitting position then assisted up when sitting on the bed patient complained that his left shoulder was hurting from the fall if he could have some pill for breakthrough pain like his Narco, again encouraged patient and explained that if he got some pain on shoulder that he really needs to go to the emergency room but patient still refused to go stating that his shoulder always hurt, prn Narco given about 2:19am, vital signs checked as follows BP= 125/85, PR=84, RR=20, called the hospitalist and informed her of fall."
Review of patient #30's chart revealed he had a history of seizures and was on anti- convulsant drugs to prevent seizures. Patient #30's admission information revealed he weighed 300 lbs and was 60 years of age. There was no evidence found of patient 25's wife notified of the fall.
Review of patient 30's chart and incident report revealed no found evidence of a head to toe assessment. Patient #30 revealed he fell out of the bed onto the floor and was having shoulder pain. There was no assessment found of a neurological examination, skin assessment, shoulder range of motion, or a pain level documented. The nurse had documented the patient had a bed alarm. There was no documentation found if the bed alarm was working or alerted staff.
Review of nurse's notes dated 12/10/14 at 3:16 PM revealed the patient was still complaining of right shoulder pain and was "sent to the hospital for shoulder X-ray." There was no assessment documented of the patients shoulder pain level, range of motion, or skin assessment found. There was no documentation of patient #30's condition when he left the unit, what time he left, and with whom. There was no further information documented on when the patient returned to the unit and in what condition. There was no further documentation on pain or pain levels. Failure to complete a head to toe nursing assessment, after an unwitnessed fall, can lead to severe disabilities and/or possible death.
Review of the "Falls Precautions Guidelines" Stated, "Post fall assessments will be completed on every patient to determine the severity of the fall."
2. Review of patient #25's chart revealed he was admitted to the geriatric psychiatric unit on 11/18/14 at 5:30 PM with Major Depressive Disorder. Review of the nurse's notes on 11/18/14 at 6:00 PM revealed the patient had been put on safety and fall precautions. He was admitted from the physician office with visual hallucinations and falling at home.
Review of patient #25's nurse's notes for 11/18/14 at 7:30 PM revealed the patient #25 was found sitting on floor by his bed. Patient #25 denied pain and was able to move all extremities. He refused to go to the emergency room. Vital signs were obtained and within normal range. Patient #25 had voided all over the bathroom floor. He was trying to void in the urinal. There was no documentation found of patient explanation of being on the floor, was the fall witnessed or unwitnessed, no evidence of a head to toe assessment, no evidence of a neurological check, what safety measures were put into place, and was the physician or family notified. Failure to complete a head to toe nursing assessment, after an unwitnessed fall, can lead to severe disabilities and/or possible death.
Review of patient #25's nurse's notes revealed patient #25 received a floor mat alarm on 11/19/2014 at 2:50 am, a total of 7 ½ hours after admission. Documentation was found on the incident report dated 11/23/14 of patient #25's alarm mat. Patient #25's mat had a green indicator light on, but did not sound when he fell. There was no further documentation of the mat alarm as to if it was tested or replaced.
Review of patient #25's nurse's notes revealed on 11/22/14 at 9:24 pm a test was performed on "clinical alarms" for the patient. The section states, "Clinical alarm used" was left blank. There was no documentation found of what alarms were tested. On 11/23/14 at 1:30 am the mental health technician sponged off the patient, put on a clean pull up, and gown.
Review of patient #25's nurse's notes revealed on 11/23/14 at 2:34 am revealed the following;
"Pt found by mental health technician in bathroom on floor. Pt was awake and oriented and denied pain. Pt helped back into bed. House supervisor and nurse practitioner notified as well as pt nephew. Pt has contusion above right eye. Will continue to monitor. Nurse practitioner advised to continue to monitor pt and not send to ER."
Review of patient #25's nurse's notes revealed on 11/23/14 at 2:34 am revealed no documentation of a neurological exam, head to toe assessment, range of motion to extremities, or continuation of monitoring for concussion or pain. There was no documentation found of contusion size, location, or color. No further nursing documentation found until 4:29 am.
Review of patient #25's nurse's notes revealed on 11/23/14 at 4:29 am that patient #25 was sent to the emergency room due to complaints of pain in neck from ground level fall. There was no nursing assessment documented for assessment of the patient, pain level, or neurological status.
Review of patient #25's nurse's notes revealed on 11/23/14 at 6:33 am patient #25 returned from the emergency room. The note states, "Pt returned from ER. Head and neck CT negative." There was no further nursing documentation on how the patient was transported to the ER. Who was with the patient, if the family was made aware of patient #25's ER visit, and no assessment found upon patient #25's return from the ER.
3. Review of patient #22's chart revealed she was admitted to the geriatric psychiatric unit on 12/12/14 with exacerbation of bipolar disorder.
Review of the nurses notes dated 12/15/14 at 10:30 AM stated,

"PARTICIPATING IN GROUP AND ACTIVITY DIRECTOR DOING EXERCISE AND REPORTED PT.LOST BALANCE AND SAT ON THE FLOOR,GOOD ROM DENIED PAIN AT THIS
TIME.REMINDED TO LIMIT AN UNNECESARRY ACTIVITY AT THIS TIME.DR.BRAZEAL HERE AND AWARE.SPOKE WITH THE PT.ON TREATMENT PLAN AND ABLE TO ANSWER QUESTIONS AND PARTICIPATED WELL DURING TREATMENT TEAM MEETING BUT THOUGHT CONTENT WITH DELUSIONS.WILL START ON HALDOL AS ORDERED."

Review of patient #22's incident report dated 11/15/14 revealed that patient #22 sat on the floor and bumped her head on a wooden wall. Under assessment it states, "patient assessed (vitals)." No documentation of family notification. Review of the nurse's notes and incident report revealed no documentation of a neurological exam or a head to toe assessment.

Based on chart reviews, policy and procedures, and interviews the facility failed to follow its own policy and procedures. The facility failed to conduct a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint. The facility failed to correctly inform the patient of their legal rights involving the administration of psychoactive medications in 1(20) out of 10 (22-32) charts reviewed.

Review of patient #20's chart revealed she was brought to the Emergency Room(ER) by EMS on 12/9/14 at 6:09 PM.

Review of the physicians history and physical patient #20 presented to the ER after sustaining a syncopal episode at home. EMS was called and patient #20 was brought to the ER for further evaluation. The physician history and pysical revealed the following;

"According to him (boyfriend), she began to act altered on Sunday evening as they were watching television. They got into an argument and he states "she was out of her mind". At 4:00 in the morning she was sitting in the car. The police were contacted because of the domestic dispute and the noise. Monday, the following morning, he noticed that she took three handfuls of her medications. He is unclear whether she was attempting to overdose or was confused about her appropriate medication. Yesterday, she had nausea and vomiting and stayed in bed all day. Apparently she woke up at 5:00 this evening very upset, confused, disoriented and had lost a large space of time. According to the patient she remembers going to the bathroom, sitting on the toilet and states that she then "passed out." It was after these events that her boyfriend and son finally convinced her to come to the hospital for evaluation."

Review of patient 20's physician history and physical revealed,

"At the time the patient was being assessed, she became erratic, started pounding on the door, demanding to be "let out." She literally bolted out the back door of the Emergency Department and stated she did not want to receive treatment. She proceeded to assault her boyfriend in front of the hospital and as the police arrived to escort her back to the Emergency Department for treatment, she was threatening to "kill him and cut his throat". She is very tearful and withdrawn. Emergency Department they did obtain a CT of the head which was read as no acute abnormality, no intracranial hemorrhage. Her laboratory data was essentially benign; however, she remained very argumentative, confrontational and agitated."

Review of the physician orders revealed there was no physician order found to hold the patient for a mental health examination. There was no evidence that patient #20 was in police custody.

Patient #20 was admitted to the Intensive Care Unit (ICU) for observation on 12/09/2014 at 10:35 PM with acute psychosis possibly secondary to medication non-compliance.

Review of the nurses notes dated 12/10/14 1:20 AM stated, "Pt now attempting to take out IV stating "I don't want it and I don't want to be here". Advised pt she is here under warrant and the Dr. ordered it so that we could give her medication. Pt states "I don't care". Pt also stated she wanted to talk to NP (nurse practitioner). Contacted NP and updated her on situation. She ordered pt to have 20 mg Geodon IM x 1 dose now and that she is on her way. Pt has all monitor wires off at this time. EMT-P at bedside, talking with pt. Pt crying, stating "I don't want to be here". At 0135 NP at bedside talking with pt. Pt continues to cry."

A medication order was found on 12/10/14 at 1:31 AM to administer Geodon (psychoactive) 20 mg IM now by the nurse practitioner. There was no order found of a protective custody warrant, physician hold order, or restraint order to force psychoactive medications on the patient. A Emergency Detention Warrant (EDW) was found dated 12/10/2014 at 12:35 PM eleven hours after the medication administration.

Review of patient #20's chart revealed there was no nursing interventions to implement alternatives to avoid chemical restraints.

Review of the policy and procedure "Restraints and Seclusion Definition" revealed the following;

"Chemical Restraint: The use of a chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individuals medical or psychiatric condition. Chemical restraints continues to be a prohibited practice.

Drugs Used As A Restraint: medications that are therapeutic agents used to treat behavioral symptoms that compromise the individuals regular medical regimen (including PRN medications) are not considered drug restraints when their purpose may be calm agitation, help individual concentrate, and make more accessible to interpersonal intervention. A drug used as a restraint would put a individual to sleep, rendering them unable to function as a result of the medication."

Review of patient 20's nursing notes dated 12/10/14 9:59 AM stated, "initial assessment completed as noted. received pt sleeping soundly in bed- pt received sedatives per night shift and remains sedated."

An interview with staff #9 and #31 on 1/21/15 confirmed the above findings.

Based on observation, interview and record review the facility failed to:


A. ensure accurate, thorough documentation of assessments of skin, pain, pain medication administration, high risk fall, respiratory status, cardiovascular status and implementation of turning and repositioning on patients. This deficient practice was found on 4 of 4 Patients (#s' 10,13, 14, and 18)).
Refer to tag A0395 for additional information.


B. ensure 1 of 1 patients who self -administered home medications was assessed, physician orders received and there was complete documentation of the medication administration (Patient #11).
The facility failed to ensure there was a policy and procedure that addressed the assessment of capacity to self- administer home medications and addressed how nursing should document administration in the patient's medical record.

Refer to tag A0412 and 413 for additional information.


C. ensure the nursing personnel had the appropriate education, experience, licensure, competence and specialized qualifications are assigned to provide nursing care for the patients in the psychiatric units.


Refer to tag A0397 for additional information.

Based on observation, interview and record review the facility failed to ensure accurate, thorough documentation of assessments of skin, pain, pain medication administration, high risk falls, respiratory status, cardiovascular status and implementation of turning and repositioning on patients. This deficient practice was found in 4 of 4 Patients (#s' 10,13, 14, and 18).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of an Emergency Department (ED) note revealed Patient #10 was a 90 year old female who presented on 01/20/2015 at 9:13 a.m.. Patient #10 presented with a diagnosis of pneumonia and was given an Acuity level of Urgent (3).
Review of a physician order at 9:13 a.m. revealed Patient #10 needed oxygen, but there was no complete order on how much to administer or directive for where to keep the patient's oxygen saturation.
Review of the ED note revealed at 9:17 a.m., Patient #10 had an oxygen saturation of 93 percent on room air. At 9:48 a.m. the oxygen saturation was 95 percent on 2 Liters of oxygen per nasal cannula.
Review of the nurses notes revealed Patient #10 was admitted to the floor on 01/20/2015 at 12:10 p.m. and was still on oxygen 2 Liters per nasal cannula.
Review of the nurses notes dated 01/21/2015 revealed Patient #10 was on oxygen 2 Liters per nasal cannula. As of 01/21/2015 there was still no complete order for oxygen therapy on Patient #10.
Review of the facility policy named "Oxygen Therapy" dated 01/2013 revealed "Oxygen will be administered as ordered by physician."
Review of the initial nursing admit assessment dated 01/20/2015 at 12:10 p.m. Patient #10 was at high risk for skin breakdown. One of the interventions mentioned was to turn the patient more frequently than every 2 hours.
Review of the record revealed no consistent documentation of Patient #10 being turned every 2 hours or more.
Review of the initial admit skin assessment dated 01/20/2015 at 12:20 p.m. revealed Patient #10 had an abrasion (bruised) to the front of the left and right lower legs and the coccyx was red. The section for measurements were left blank. Review of a skin assessment on 01/20/2015 at 7:30 p.m. revealed there was a laceration with steri strips to the front of the right lower leg. There was no documentation of the size of the laceration. Review of an assessment dated 01/21/2015 at 8:00 a.m. made mention of the laceration to the right lower leg. There was no documentation of the size nor any mention of the left leg or the coccyx.
Review of the initial fall risk assessment dated 01/20/2015 at 12:10 p.m., revealed Patient #10 was at high risk for falls and one of the interventions was for staff to lift two siderails. The fall risk assessment dated 01/21/2015 at 8:00 a.m., revealed Patient #10 was still at high risk for falls and one of the interventions was for staff to lift three siderails.
Review of the facility policy named "Fall Prevention Policy" dated 11/2014 revealed the following for patients classified as being at high risk for falls:
*Side rails will be regularly inspected and serve as a gentle reminder to the patient that they are not in their own bed.
*Keep 2-3 side rails up.
During an observation on 01/21/2015 at 2:45 p.m., Patient #10 was observed in bed tilted to her left side, totally dependent, side rails up x 4, and oxygen infusing at 2 Liters per nasal cannula.
The facility fall risk policy made no mention of using 4 side rails on the patients.
During an interview on 01/21/2015 2:45 p.m., Staff #8 confirmed the observation and the missing order and assessment in the chart.


Review of ED nurses notes revealed Patient #18 was a 84 year old female who presented on 01/19/2015 at 8:00 a.m. and was given an Acuity level of Urgent (3). Patient #18 had diagnoses which included Myocardial Infarction-non ST elevation, shortness of breath, congestive heart failure and chronic obstructive pulmonary disease exacerbation.
At 8:03 a.m. the vital signs were documented as a blood pressure of 110/74, elevated pulse 109, respirations 19, temperature 97.7 temperature, and oxygen saturation of 92 percent on room air. At 8:16 a.m. the oxygen saturation was 95 percent on 2 Liter per minute via NC. Additional documentation in the notes at this time revealed the following:
Respiratory: No deficits noted. Breath sounds with wheezes bilaterally at expiration. Reports shortness of breath, labored breathing. Initial Nebulizer treatment given as ordered. Patient was instructed and evaluated on procedure. Staff failed to document the blood pressure prior to the medication administration.
At 8:21 a.m. the oxygen saturation was 97 percent on 3 Liters per minute via NC and staff failed to document the blood pressure after medication administration. At 9:02 a.m. , 9:16 a.m., 9:48 a.m., and 9:49 a.m. staff recorded vital signs, but failed to document what the oxygen saturation was. The last documented vital signs were at 10:16 a.m. (24 minutes before discharge) and the pulse was elevated up to 113 beats per minute.
At 10:19 a.m., Patient #18 was admitted to Telemetry and left the ED at 10:40 a.m.
Review of the medication administration sheet revealed Patient #18 received Aspirin at 9:35 a.m. and nursing provided a follow-up response to the medication at 10:48 a.m. after the patient had been discharged from the ED.
Review of the ED record revealed no complete physician order for the administration of oxygen therapy.


Review of the ED nurses notes revealed Patient #14 was a 50 year old male who presented on 01/18/2015 at 7:57 p.m. and was given an Acuity level of Emergent (2). Patient #18 had diagnosis of chest pain.
Review of vital signs at 7:57 p.m.,revealed an elevated blood pressure of 177/109, pulse 98, respirations 20, temperature 98.2, oxygen saturation on room air was 97 percent and the pain level was 8 out of 10 (0 meaning no pain and 10 meaning severe pain).
Review of a physician order dated 01/18/2015 at 8:09 p.m. revealed an order for oxygen, but the rate was not indicated.
Review of nurses notes revealed at 8:20 p.m. Aspirin was administered and at 8:36 p.m. the vasodilator Nitro Bid ointment was applied transdermally.
Review of the physician's documentation at 9:23 p.m.(over an hour after presentation to the ED), revealed the patient or guardian reported chest pain that was located primarily in the anterior chest wall., left breast. The chest pain was throbbing. Duration: The patient or guardian reports multiple episodes, the episodes last approximately 10 second(s). Onset just before arrival. The pain does not radiate ...Severity of pain: At its worst the pain was moderate in the emergency department the pain was unchanged.
Review of vital signs at 9:27 p.m. and 9:42 p.m. revealed Patient #14's oxygen saturation dropped to 94 percent. There was no documentation of the patient still being on oxygen at this time or throughout the rest of the ED stay.
Review of vital signs taken from 8:27 p.m. - 10:13 p.m. revealed they were taken five more times during the ED stay and nursing staff failed to document what Patient #14's pain level was. At 10:13 p.m., Patient #14's blood pressure was still elevated at 164/108. Review of the ED notes revealed Patient #14 was to be admitted to Telemetry at 10:25 p.m.
Review of the medication administration record at 10:44 p.m.(31 minutes after the last blood pressure and 2 hours after administration of the Nitro Bid), staff documented administering the anti-hypertensive agent Clonidine by mouth. At the same time there was documentation that Patient #14 left the ED at 10:44 p.m..
Review of nursing documentation revealed a follow-up response was written to the Clonidine at 10:45 p.m after the patient had left the ED.
There was also no nursing assessment of what the pain level was prior to leaving the ED.


Review of an ED note revealed Patient #13 was a 58 year old female who presented on 01/19/2015 at 1:09 p.m. and was given an Acuity level of Semi-Urgent (4). According to the triage assessment at 1:10 p.m., Patient #13 was complaining of pain to the right femoral area and right hip. There was no documentation of what the level of pain was. Review of the vital sign sheet at 1:10 p.m. (at the same time) revealed documentation of the patient having no pain.
Review of nursing documentation at 1:19 p.m. revealed the patient's pain level was 10 out of 10.
Review of the physician assessment at 2:18 p.m. revealed an admit order and the documented preliminary diagnosis was a hip fracture ....
Review of the medication administration record revealed the first dose of pain medication Morphine was administered at 2:20 p.m (over an hour after presentation to the ED). At 2:30 p.m. nursing documented a follow-up response that the pain was decreased. There was no documentation of what level it was decreased to. There was no documentation of another assessment of the pain level after this while the patient was in the ED.
The last set of vital signs was at 2:53 p.m. (over an hour before leaving the ED).
Review of nurses notes revealed Patient #13 left the ED at 4:07 p.m.
During an interview on 01/22/2015 after 11:00 a.m., Staff #s' 2 and 20 confirmed the assessment problems.


Review of a facility policy named "Assessment Organization Wide" dated 12/2014 revealed the following:
Medical-Surgical
a. Assessment : the RN completes the initial assessment within twelve hours of admission.

Emergency Department
1. Nursing Assessment (some of the items listed that should be included)
a. All patients presenting for treatment in the Emergency Department are assessed by an Emergency Department triage Registered Nurse (RN).
j. Vital signs ....
m. Pain assessment
2. The triage will categorize patients as they present for triage as follows: ( Level 1-V were listed)
b. Level II
2. Vital signs every 15-30 minutes until stable then every 2 hours.
3. Patient is reassessed at every hour until stable then every 2 hours.
4. Reassess comfort level every 30 minutes until pain relieved then hourly.
5. Reassess after all interventions, treatments, and pain meds.
6. Reassess vital signs within 15 minutes of discharge.
c. Level III
4. Reassess comfort level every 30 minutes until pain relieved then hourly.
5. Reassess after all interventions, treatments, and pain meds.
6. Reassess vital signs within 15 minutes of discharge.
d. Level IV
5. Reassess after all interventions, treatments, and pain meds.
6. Reassess vital signs within 15 minutes of discharge.
8. The Emergency Department RN will obtain and document on-going vital signs as indicated by patient's condition.
15. The Emergency Department RN/LVN will reassess abnormal findings throughout the patient visit in the Emergency Department, and 15 minutes prior to discharge of the patient.
16. Abnormal Vital Signs Parameters are defined as follows by age group:
18-adult RR>20 or <8 HR>90 or <60 B/P(systolic)>140 or <90

Based on interview and record review the facility failed to ensure that the nursing personnel had the appropriate education, experience, licensure, competence and specialized qualifications are assigned to provide nursing care for the patients in the psychiatric units.

This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the nursing schedules for the adult and geriatric psychiatric units revealed multiple shifts with only one RN assigned on each unit.

An interview with staff #10 on 1/21/15 reported that she has relieved the RN staff on the psychiatric units many times. On weekends and at nights staff #33 and staff #34 have been pulled from the rehabilitation unit to relieve the RN staff on the psychiatric units.

Review of staff #10's employee file revealed she did not have the required handle with care training, a current CPR card, psychiatric experience or orientation to the units.

Review of staff #33 and #34 employee files revealed neither nurse had handle with care training, psychiatric experience, or orientation to the units.

Based on interview and record review the facility failed to ensure 1 of 1 patients who self - administered medications was assessed, physician orders received and there was complete documentation of the medication administration (Patient #11).
The facility failed to ensure there was a policy and procedure that addressed the assessment of capacity to self- administer medications and addressed how nursing should document administration in the patient's medical record.
This deficient practice had the likelihood to cause harm to all in-patients who self- administered medications.
Findings include:

Review of the "Patient Assessment Report" revealed Patient #11 was a 70 year old male who was a direct admit on 01/19/2015 at 6:20 p.m. Patient #11 was admitted with a diagnosis of chest pain.
Review of a physician history and physical dated 01/19/2015 revealed Patient #11 had a history of Non-insulin dependent diabetes mellitus.
Review of physician orders dated 01/19/2015 at 11:34 p.m., revealed a sliding scale order for Humulin Regular insulin, subcutaneous. The scale included one of the following instructives:
From 251-300 give 4 units
Review of the glucometer results revealed Patient #11 had a blood sugar of 263 on 01/20/2015 at 8:51 P.M.
Review of patient care notes revealed on 01/20/2014 at 9:21p.m.,Patient #11 had a blood sugar of 263. There was documentation the patient took his own home insulin per patient dose. Patient tolerated well, patient took own home medications per patient request.
Review of the record revealed no documentation of an assessment, education, physician order, nor care plan addressing self -administration. There was also no documentation of amount of insulin the patient administered.
Review of the facility policy named "Medication Administration Guidelines" revealed the following:
G. Patients Home Medications
Medications from home must be sent back with family members whenever possible. If this is not possible, list on the personal property inventory sheet all medications and sent to pharmacy for security and storage.
5. Patient's own medication should not be used at the facility. Nursing and Pharmacy will notify the patient, family and the physician of the policy. If the patient insists in using their own medication or if an interruption in patient therapy may occur. If the medication is not commercially available or the medication is not on the facility's formulary, a Physician Order must be obtained prior to the patient's home medication being used.
H. Patient Self Administration of Medication left at Bedside.
1. Medication may be ordered by the Physician to be left at the patient's bedside for self-administration. This practice is discouraged.
2. Physician orders are required for medications to be left at the bedside for patient self-administration.
3. These orders will be entered into the computer with a notation to be left at the bedside.
4. Orders will be transcribed onto the MAR, which includes "Medication may be left at Bedside" and self administered, if appropriate, in the comments section.
5. The patient will notify the nurse when self administering medications left at the bedside.
6. Nursing personnel will verify and observe patient administration. Nursing personnel will chart each patient's self administered dose on the MAR.
Review of the facility policy did not list the insulin as a medication that had been approved by the Pharmacy and Therapeutics Committee to be left at the bedside.
Review of the policy did not address the procedure for assessment of the capability prior to self-administration or usage of home medications. The policy did not address how nursing should document medication administration in the medical record for these patients.

Based on interview and record review the facility failed to ensure 1 of 1 patients who self -administered home medications was assessed, physician orders received and there was complete documentation of the medication administration (Patient #11).
The facility failed to ensure there was a policy and procedure that addressed the assessment of capacity to self- administer home medications and addressed how nursing should document administration in the patient's medical record.
This deficient practice had the likelihood to cause harm to all in-patients who self- administered home medications.
Findings include:

Review of the "Patient Assessment Report" revealed Patient #11 was a 70 year old male who was a direct admit on 01/19/2015 at 6:20 p.m. Patient #11 was admitted with a diagnosis of chest pain.
Review of a physician history and physical dated 01/19/2015 revealed Patient #11 had a history of Non-insulin dependent diabetes mellitus.
Review of physician orders dated 01/19/2015 at 11:34 p.m., revealed a sliding scale order for Humulin Regular insulin, subcutaneous. The scale included one of the following instructives:
From 251-300 give 4 units
Review of the glucometer results revealed Patient #11 had a blood sugar of 263 on 01/20/2015 at 8:51 P.M.
Review of patient care notes revealed on 01/20/2014 at 9:21p.m.,Patient #11 had a blood sugar of 263. There was documentation the patient took his own home insulin per patient dose. Patient tolerated well, patient took own home medications per patient request.
Review of the record revealed no documentation of an assessment, education, physician order, nor care plan addressing self -administration. There was also no documentation of amount of insulin the patient administered.
Review of the facility policy named "Medication Administration Guidelines" revealed the following:
G. Patients Home Medications
Medications from home must be sent back with family members whenever possible. If this is not possible, list on the personal property inventory sheet all medications and sent to pharmacy for security and storage.
5. Patient's own medication should not be used at the facility. Nursing and Pharmacy will notify the patient, family and the physician of the policy. If the patient insists in using their own medication or if an interruption in patient therapy may occur. If the medication is not commercially available or the medication is not on the facility's formulary, a Physician Order must be obtained prior to the patient's home medication being used.
H. Patient Self Administration of Medication left at Bedside.
1. Medication may be ordered by the Physician to be left at the patient's bedside for self-administration. This practice is discouraged.
2. Physician orders are required for medications to be left at the bedside for patient self-administration.
3. These orders will be entered into the computer with a notation to be left at the bedside.
4. Orders will be transcribed onto the MAR, which includes "Medication may be left at Bedside" and self administered, if appropriate, in the comments section.
5. The patient will notify the nurse when self administering medications left at the bedside.
6. Nursing personnel will verify and observe patient administration. Nursing personnel will chart each patient's self administered dose on the MAR.
Review of the facility policy did not list the insulin as a medication that had been approved by the Pharmacy and Therapeutics Committee to be left at the bedside.
Review of the policy did not address the procedure for assessment of the capability prior to self-administration or usage of home medications. The policy did not address how nursing should document medication administration in the medical record for these patients.

Based on observation, interview and record review the facility failed to ensure there was consistent documentation of monitoring/inspections of emergency equipment and medications inside the crash carts on 2 of 2 floors (Medical/surgical and Emergency Department).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:

During observations on 01/21/2015 after 9:45 a.m. on the Medical/Surgical unit and on 01/22/2015 after 11:00 a.m., in the ED trauma room crash carts were opened and found to contain the laryngoscope (equipment used during trachea intubation) inside enclosed packets, emergency medications and emergency supplies. Staff #s' 2, 8 and 20 reported the laryngoscopes were checked at the first of every month when the tray was opened to check for expiration dates.
Review of the Crash Cart Checklist for the crash carts revealed the following instructions:
"On the first of the month, day shift will open the cart check each tray for expiration dates. Whenever a tray's seal is broken or an expiration date has been reached the tray is to be exchanged and a new cart seal applied." Staff was to sign and date when this was done.
Review of the January 2015 crash cart checklist for the Medical/Surgical unit revealed no documentation this was done.
Staff #8 confirmed staff had not signed the sheet.
Review of December 2014 and the January 2015 crash cart checklist for the Trauma Room #1, December 2014 Trauma Room #2 and December 2014 Pediatric Cart revealed no documentation this was done.
Staff #2 and 20 confirmed staff had not signed the sheets.

Based on observation, interview and record review the facility failed to ensure 1 of 1 medication carts was locked (Intensive care unit).
This deficient practice had the likelihood to cause harm to patients on the unit.
Findings include:
During observations on 01/21/2015 after 9:45 a.m. the following was found:
An Ear, Nose and Throat (ENT) cart was stored outside of Room #6 in the hallway. The cart was unlocked and contained such medications as the antibiotic Gentamycin and Lidocaine vials (anesthestic agent).
During an interview Staff #8 confirmed the observation.

Review of a policy named "Medication Administration Guidelines" dated 08/2014 revealed:
Areas where medication is stored (Acudose, medication room, crash carts, medications carts, etc.) are to be locked at all time when not in use.

Based on observation and interview the facility failed to maintain the floor tiles in the hallways, patient activity room (Daily Living Room) and the bathroom in the physical therapy gym. Findings were observed in the Rehabilitation Unit.
This deficient practice had the likelihood to cause harm to patients on the unit.
Findings include:

A tour at approximately 9:30 am on 1/22/15 of the facility was conducted with staff #9. Throughout the hallways of the facility where concrete joint were placed during the construction of the building the floor tile was broken and chipped. Pieces of the tile were missing causing a potential tripping hazard and prevented proper cleaning and disinfecting of the floors. The rubber molding (baseboard) around the walls had released from the surface it was attached at different point throughout the hallways.
The tour continued to the patient activity room (Daily Living Room). Located in the area were a wall of cabinets and a sink. The Formica covering the cabinets had released from the surface it was attached. Along the back of the cabinets and at different points on the cabinets the Formica posed a risk of cuts and injury to the patients using this area for rehabilitation. The cabinets were cluttered and had the appearance of not being cleaned.
The rubber molding (baseboard) around the walls had released from the surface it was attached at different point throughout the room. The released molding posed a tripping hazard and injury to the patients using this area for rehabilitation.
A door leading to an outdoor courtyard was observed. On each side of this door at the point of the floor the rubber molding (baseboard) had released from the wallboard it was attached posed a tripping hazard and injury to the patients. The wallboard was exposed, broken and chipped. The wallpaper had released from the wallboard was tattered and torn. Staff #9 confirmed these defects were a result water damage occurring over a long period of time.
To the right of the door was a support column that had been covered with wallboard measuring approximately two feet by 4 feet. At the base of the column the wallboard was bubbled and peeling; at eye level was a blackish/grey spot approximately 10 inches across. A closer observation of the spot revealed a black, fine hairy substance. When the area was pointed out to staff #9 it was commented by staff #9, "that looks like mold. It looks like water is coming off the roof and draining down the inside of the wallboard".
The tour continued to the Physical Therapy Gym/ Treatment area. The floors had the appearance of being un-kept, in need of cleaning and maintained. A unisex bathroom was observed being dirty and un-kept. The floors were in need of cleaning. Around the toilet were black stains on the floor. There was a wear pattern on the floor leading from the entry of the bathroom to the toilet. Outside of this wear pattern (common walking area) the black stains were worn away. At the base of the toilet it appeared there were multiple attempts to patch the toilet. There was a calk buildup covered with the black stain.

An ongoing interview throughout the tour with staff #9 was conducted. Staff #9 confirmed the findings. When asked if there was a housekeeping department in the building, staff #9 replied "yes". When asked again if there was a properly staffed housekeeping department in the building, staff #9 replied "no". "We could probably use more staff".

Based on observation, interview and record review the facility failed to ensure a sanitary environment was maintained in 8 of 8 departments (Main campus and Pyschiatric Dietary departments, laundry department, Pyschiatric unit, Rehab unit, Medical/Surgical unit, Emergency Department unit and Intensive care unit).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:



A. On 1/21/2015 at 9:00 AM during a tour of the main hospital campus dietary department, the following was observed and confirmed by staff #6 and #23:

In front of the walk in refrigerator was a deep sink. Observed sitting at an angle in the sink was a large pan of raw chicken. A stream on water was running over the top right quarter of the pan. Three quarters of the pan of raw chicken was warming at room temperature. Kitchen staff, which was immediately available, was told this was not a safe method of thawing chicken. After 10 minutes the kitchen staff had to be told to thaw the chicken properly (thawed in fresh ice water or all of the chicken under cool running water) or otherwise protect it at a safe temperature for human consumption.
A stack of thirty (30) baking sheets was observed with black residue around the outer rim and brown residue on the inside corners. The baked on oils and carbon build up made the baking sheets unable to be properly sanitized.
The stainless steel warming carts were observed with dust, and food crumbs on the surface.

The first of two deep well fryers was observed with a heavy coating of residual splattered oil down the side. This unused fryer was stationed immediately next to the fryer, which was observed in use during the tour.

The food prep tables were all observed with rust on the lower legs. There was an oily residue on all the lower stainless steel surfaces as well as dust attracted to the oil.

Debris (dust, onion skins and small food particles) were observed on the floor well beneath the prep tables.

The ceiling was observed with five (5) air conditioning vent covers. The vent covers were louvered metal. Four (4) of the five (5) vent covers were observed to have visible rust. The louvers from the fifth vent, was observed coated with a dark grey /black substance. The surrounding ceiling tiles were also observed this same color. These vents were positioned over the food prep tables.

The drain at the center of the kitchen was observed to have a dark black sticky substance which coated the entire drain below the grate.

Multiple shipping boxes were observed in the cooler, refrigerator, freezer and back stock room.

In the stock room, clean replacement stainless (Cooking pans and eating utensils), was observed stored up right without a cover. In the same stock room was cleaning products, recently delivered groceries, damaged and retired services items, liquid canned nutritional supplements, three tall bread carts with plastic covers and emergency water supplies. The entire room was in need of organization and cleaning.

On 1/22/2015 at 1:30 P.M. the facilities laundry service area was toured and the following was observed:

Beneath the three commercial washers the floor tile was missing.

The door leading from the dirty laundry side to the clean laundry side had missing floor tiles where the doorway had been enlarged.

In the general storage room, six (6) stocked clean linen carts were observed stored with housekeeping carts, unused biohazards boxes, 50 gallon drums containing liquid laundry chemicals (detergents, softeners, stain removers), and a grease coated generator in need of repair. There was no wall separating the clean linen from the soiled and contaminated items stored in the room. The same entrance to the room was used to place clean linen in the room and remove contaminated housekeeping carts and any other item requiring general storage. Staff #25 confirmed these observations.





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B. During a tour of the south campus dietary department on 1/20/2015 revealed the following:
Contaminated areas allow for possible food borne illnesses. The items below were observed and confirmed by staff #9, 10, and 31.
The frame of the door from the outside hallway, to the kitchen, was covered in dust and dirt. The threshold was missing rubber from the threshold stripping, a build-up of dirt and food particles were found in the floor of the threshold.
Disposable food containers were found out in the open, uncovered, and exposed to contaminates. A worker was sweeping the floor nearby allowing dust particles to settle in food containers for patients and visitors.
The bottom of a rolling work table was coated in dirt, dust, and food particles in the food preparation area.
A rack of two piece plate warmers were stacked uncovered. The top of five clean plate warmers were dirty. The inside contained residue, food particles, and exposed to the worker sweeping the floor.
Clean rolling food warmers were sitting in the designated dirty area of the kitchen.
A dual chamber plate dispenser was found full of plates. The plates were confirmed to be clean plates. Soiled plate lids were stacked on top and the top plates were covered in food debris and dust.
A pan of individually wrapped pie slices, fruit cups, pudding, ham slices, vegetables, and salad items found off the salad bar was found with no dates of preparation or discard. A pan of cooked meats in the cooler had no dates.
The floor, the wall, and pipes running along the wall by the fryers were coated in a greasy substance, dust, and hair in the food prep area.
The oven was soiled with dirty empty baking pans covered in dried food particles and carbon.
The grill was soiled with a greasy build-up, food particles, and carbon.
Sixteen serving pans and baking dishes were found stacked wet. Wet pans allows for bacteria to harbor in the pans. Serving food in these items can cause possible severe food borne illnesses or possible death.
Food preparation areas were covered in dried food particles. Stored under the microwave area four clean bowls were contaminated from spilled liquids and dried food particles.
A muffin pan was found on the clean shelf with dried food particles and carbon build-up on the top. The bottom of the muffin pan was sticky and covered in carbon.
The floor in the food preparation area was soiled with dirt, dust, hair, dried food particles, and large food particles. The floor was found with cracked tiles, hard water stains, and rust.
The lid handle to the fryer was broken. The first vat of grease in the fryer had a residue floating on top. Molded food particles were found floating in the grease. The vat smelled rancid. The kitchen worker reported he was unable to say how old the grease was. He reported they did not use that vat anymore it had been a long time.
Dishes and a punch bowl with cups were found stacked on a clean rack. The items were soiled with a greasy substance and dust. Staff #9 reported he did not know why these items were here.
Multiple shipping boxes were found in the cooler, freezers, storage areas around food, and food preparation areas.
The kitchen had a microwave in the kitchen preparation area and in the dining room. Both microwaves were rusted inside with missing enamel and paint. The microwaves were unable to be cleaned properly to avoid contaminates.
A tour of the south campus psychiatric unit on 1/20/2015 was found to have negative findings. The items below were observed and confirmed by staff #9, 10, and 31 revealed the following;
Multiple tiles in the hallways, day rooms, and patient rooms were cracked or broken. The floors in the dayroom were sticky causing the surveyors shoe to stick. Broken or cracked tiles prevent the floor from being properly cleaned.
Two carbonated drink and juice dispensers were found to be soiled in the patient dayroom. The filters were covered in thick dust. There were no maintenance stickers on the dispensers since 2011. Contaminated drink dispensers can cause water borne illness that can cause severe illness even death.
Wall paper in the dining room, dayroom, and hallways were found with tears in the paper peeling from the corners and door frames. Exposure to drywall does not allow the patient care areas to be cleaned properly.
Mildew and mold was found on the walls under the window units in the dayroom.
Gaps in the floor molding (base boards) in the patient care areas had dirt and debris.
The outside court yard is a smoking area for patients. Next to the patient sitting area is a large drain grate in the grass. Dirty latex gloves, empty pill cups, and cigarette butts were found in the grass next to the grate.
In the patient dining room 4 chairs were found to have tears in the seats allowing for spillage of food, dirt, and body fluids to embed in the cushion. The chairs smelled of urine.
An interview with staff #9 revealed the south campus has submitted a request to the cooperate office for psychiatric facility improvements. There has been no response as of this survey on secured allocated funds for improvement. Staff #9 reported he was aware of the unsanitary conditions of the unit. Staff #9 contributed the environment to poor housekeeping.




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C. During observations on 01/20/2015 after 1:30 p.m. the following was found:
Emergency Department (ED) triage room:
The base of the scale used to weigh patients had a buildup of dust and dirt.
The base on the DynaMap used to take vital signs was rusted and the pole which held it up was not stable.

ED Decontamination Room
Four boxes of jumpsuits and one box of coveralls were stored on a shelf still packed in the shipping containers.
"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (Association for the Advancement of Medical Instrumentation (AAMI) ST46-Section 5.2 Receiving Items)".

ED medication room
Illinois Bone marrow needle expired 01/2014 stored in the room.
Drawers of a plastic needle bin was covered with soiled tape/labels.
Two tubes containing patients lab specimens were stored in an open wire rack on a cabinet next to the pill crusher.
Two I-Stat hand held blood analyzers were stored on the cabinet and soiled with spills.
Two plastic bins attached to a wall used for saline storage had a buildup of spills.

ED nutrition room
The ventilation panel on the ice machine had a buildup of dust inside and outside.
Unbagged patient use plastic forks, packets of sugar and patient ice bags were loose in a drawer and stored together.

ED Express unit
A supply cart stored in the hallway had an expired lumbar puncture tray (11/30/2014) and seven packets of expired Ethicon sutures (7/2014).

ED Obstetrics room
The reclining chair/bed used for patients had three tears in the plastic covering exposing the inside cushion. There was no way the chair could be sanitized with the tears. The foot pedal to the chair/bed had a buildup of dirt.
The sterile vaginal speculum packets were thrown in with Foley supplies and laceration trays. They were thrown in a bottom cabinet which was in close proximity to the floor.
According to the Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 75 revealed the following:
"Following the sterilization process, medical and surgical devices must be handled using aseptic technique in order to prevent contamination. Sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads).

Linen
A bag full of soiled linen in a thin clear plastic bag was stored outside of Exam Room #1 and one was outside the trauma rooms (in the hallway).
Staff # 8 confirmed all of the observations.

According to the Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC), 2003, pages 113-114 revealed the following:

3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics
The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients ' rooms, surgical/operating areas, and laboratories. Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas. Sorting or rinsing contaminated laundry at the location where contamination occurred is prohibited by OSHA. Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage. Single bags of sufficient tensile strength are adequate for containing laundry, but leak-resistant containment is needed if the laundry is wet and capable of soaking through a cloth bag. Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service.


During observations on 01/21/2015 after 9:45 a.m. the following was found:
Intensive care unit (ICU)
A bag full of soiled linen was in a thin clear plastic bag stored outside of Room #1 in the hallway. The linen on the bottom was saturated with blood.
An Ear, Nose and Throat (ENT) cart was stored outside of Room #6 in the hallway. A bucket marked Biohazard was stored on top of the cart next to a box of clean gloves and surgical mask. When opened the bucket was found to have equipment that was soiled. The cart also had a bottom storage area. The front door to the area was open and a wrapped bundle of sterile supplies were removed from the area. The bundle was of supplies had no sterilization date.
The sink in the ICU medication storage area was soiled with a white substance. The Formica countertops had sections of the tile that were missing exposing the particle board underneath. The countertops could not be sterilized with the particle board showing. A used surgical jacket was rolled up and stored in the cabinet with patient formula. The glucometer case had a buildup of dust on the inside. The pill crusher had a build-up of spills.
Two vials of insulin were stored in the medication refrigerator and were dated (01/15/2014 and 01/16/2014).
Review of a policy named "Medication Administration Guidelines" dated 08/2014 revealed;
Multi-Dose Vials and Insulin are disposed of 28 days after opening. All multi-dose vials and insulin must have the date of expiration written on the label once the vial is opened. All multidose vials (MDV) shall be issued from pharmacy with a 28 day expiration sticker affixed to each vial. If an MDV is found without an expiration sticker, contact pharmacy for replacement.

Medical/Surgical floor (3 Center)
A Dynamap used to take patient vital signs was found with a plastic graduated fluid collector stored in a basket on the equipment. Plastic thermometer covers were stored in the collector. The covers were exposed to the environment and there was no way to tell if they were used or not.
The top of the crash cart and had a buildup of dust. Inside the cart was an unbagged suction cannister which had the tubing and a Yaunkers suction catheter connected. The suction set- up was stored in the drawer underneath other supplies.
Staff # 8 confirmed all of the observations.
During observations on 01/22/2015 after 11:00 a.m. the following was found;
ED trauma room:
One mattress on a bed was soiled underneath with a dried red substance. The other mattress on the other bed was wet underneath and soiled with a red substance (with the appearance of blood).
Staff #s' 2 and 20 confirmed the observations.




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D. During a tour of the Rehabilitation Hospital on 01/22/2015 the following was observed:
A tour at approximately 9:30am on 1/22/15 of the facility was conducted with staff #9. Throughout the hallways of the facility where concrete joint were placed during the construction of the building the floor tile was broken and chipped. Pieces of the tile were missing causing a potential tripping hazard and prevented proper cleaning and disinfecting of the floors. The rubber molding (baseboard) around the walls had released from the surface it was attached at different point throughout the hallways.
The tour continued to the patient activity room (Daily Living Room). Located in the area were a wall of cabinets and a sink. The Formica covering the cabinets had released from the surface it was attached. Along the back of the cabinets and at different points on the cabinets the Formica posed a risk of cuts and injury to the patients using this area for rehabilitation. The cabinets were cluttered and had the appearance of not being cleaned.
The rubber molding (baseboard) around the walls had released from the surface it was attached at different point throughout the room. The released molding posed a tripping hazard and injury to the patients using this area for rehabilitation.
A door leading to an outdoor court yard was observed. On each side of this door at the point of the floor the rubber molding (baseboard) had released from the wallboard it was attached posed a tripping hazard and injury to the patients. The wallboard was exposed, broken and chipped. The wallpaper had released from the wallboard was tattered and torn. Staff #9 confirmed these defects were a result water damage occurring over a long period of time.
To the right of the door was a support column that had been covered with wallboard measuring approximately two feet by 4 feet. At the base of the column the wallboard was bubbled and pealing; at eye level was a blackish/grey spot approximately 10 inches across. A closer observation of the spot revealed a black, fine hairy substance. When the area was pointed out to staff #9 it was commented by staff #9, "that looks like mold. It looks like water is coming off the roof and draining down the inside of the wallboard".
The tour continued to the Physical Therapy Gym/ Treatment area. The floors had the appearance being un-kept, in need of cleaning and maintained. A unisex bathroom was observed being dirty and un-kept. The floors were in need of cleaning. Around the toilet were black stains on the floor. There was a wear pattern on the floor leading from the entry of the bathroom to the toilet. Outside of this wear pattern (common walking area) the black stains were worn away. At the base of the toilet it appeared there were multiple attempts to patch the toilet. There was a calk buildup covered with the black stain.
An ongoing interview throughout the tour with staff #9 was conducted. Staff #9 confirmed the findings. When asked if there was a housekeeping department in the building, staff #9 replied "yes". When asked again if there was a properly staffed housekeeping department in the building, staff #9 replied "no". "We could probably use more staff".