HospitalInspections.org

Based on record review, observation, and interview, the hospital failed to ensure patients' rights were enforced for current and /or discharged patients.


1) The hospital failed to provide a safe patient care environment and adequate supervision for 33 patients at the time of survey. Patients had access to multiple objects potentially usable for self-strangulation, poisoning, choking, and /or harm to others.

Cross refer to A 0144


2) Multiple documents dating back to 11/2015 which displayed protected patient information including names, ages, medical and psychiatric diagnoses, medications, comorbidities, orders, and staff comments, were left accessible to unauthorized view in an unlocked cabinet in a patient care area. Potentially disclosed patient information included medication administration records of 39 patients, diet information of 21 patients, and patient census sheets disclosing private patient information of at least 17 patients.


Cross refer to A 0147

Based on record review, observation, and interview, the hospital failed to ensure that 33 of 33 current patients (Patients #7, #9, #10, #11, #16, #17, #23, #25, #27, #28, #30, #34, #36, #38, #39, #44, #45, #48, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78) received care in a safe setting.


1) Long exercise bands as used in physical therapy and long elastic bandages (ACE wraps) were accessible to patients and could potentially be used in self-strangulation.


2) Patient beds on the unit had metal frames and side rails with multiple individual bars which potentially provided for a sheet and/or object to be tied to in an attempt to self-harm.


3) Thirteen compact discs and a metal box with domino stones which could be broken into sharp pieces could be used by patients for self-harm by cutting or ingesting were observed during the initial rounds on 02/17/16. Approximately 32 hours later, compact discs were still available and accessible to patients in a different activity room. In addition, patients had access to three plastic bags, a whole box of plasticware with the potential for breakage into sharp pieces, and multiple electrical cords and batteries that could be used for self-strangulation or bodily harm.


4) Items with the potential of poisoning when ingested were accessible to patients on the inpatient unit.


5) Staff did not document the location and/or behavior of five current patients for more than 30 minutes.


6) A bottle, that was hand labeled to contain "water" had a chemical smell and could have caused harm in patient care.


7) Multiple objects that could be used in self-harm or to harm others were patient accessible at the hospital's lobby, the patients' initial point of entry.


Findings included:


1) During observations on the inpatient unit's Group Room #319 on 02/17/16 at 1205, three elastic latex-like exercise bands ("Therabands"), two peach colored and one red colored, each approximately five feet in length, were noted. The exercise bands were located on an open shelf and accessible to patients. Employee #2 acknowledged the findings at that time.


Employee #31 was interviewed on 02/18/16 at 1315, and stated the Therabands were used on the inpatient unit during the patients' physical and/or occupational therapy sessions. She stated the equipment was "usually not accessible for patients but it did happen yesterday." Employee #31 denied having training in psychiatric emergencies.


Ten rolls of long ACE elastic bandages in the unit's medication room were observed on the unit on 02/19/16 at 1450.


Employee #13 and Employee #12 confirmed that ACE wraps were used in patient care to secure splints during interviews on 02/18/16 at 1340 and 1450.


2) Observations in Room #3021 on 02/17/16 at 1230 reflected two metal beds and side-rails with multiple bars with the potential for ligature.


Employee #13 stated at that time that the hospital had 36 metal beds "and all have side rails."


3) Observations in the hospital's Noisy Activity Room on 02/17/16 at 1245 reflected 13 compact discs (CDs) that could be broken into sharp pieces to be used in self-harm or to harm others. The CDs were accessible for patients in an unlocked cabinet. In addition, patients had access to two CD players with multiple electrical cords, which are stangulation risks.


A bendable metal box containing domino stones was observed accessible to patients on the cabinet shelf on 02/17/16 at 1245.


On 02/18/16 at 1720, the unlocked cabinet in Group Room #319, accessible to patients, was observed with a stack of multiple CDs, a plastic bag, a Wii [video game] console with four controllers. One controller did not have batteries in it.


Two plastic bags were observed in the patient accessible refrigerator in Group Room #315. A whole box of multiple plastic forks was noted in the cabinet to the right of the sink in Group Room #315 on 02/18/16 at 1740. The items were removed by Employee #13 at that time.


A large plastic bag lined the trash can in the patient dining room on 02/19/16 at 1030. Employee #13 and #1 acknowledged the findings at that time.


4) During observational rounds on 02/17/16 between 1215 and 1235, items that could be used for bodily harm included eight-ounce containers of body wash/shampoo labeled "external use only...if swallowed get medical help or call poison control immediately,"antiperspirant and perineal skin cleanser labeled "for external use only." These items were observed to be patient accessible in Patient Room #3023 and/or Patient Room #3021 and/or in the patient toilet across from Room #3023.


Employee #2 and Employee #13 acknowledged the findings at that time. Employee #13 stated patients' personal hygiene items were supposed to be picked up after use and placed in patient inaccessible storage.


Employee #5 stated during an interview on 02/18/16 at 1310, that personal hygiene items were to be stored out of patient reach after use. Patients "cannot have...[them] in their rooms."


5) On 02/18/16 at approximately 1725, Employee #17 was observed in hospital Group Room #315 assisting patients during their evening meal. Record review of patients' close observation sheets reflected that four out of five patients did not have any close observation documentation since 1645 (Patients #25, #44, #45, and #64). Patient #39's close observations were incompletely documented since 1645.


Employee #13 acknowledged the findings and stated it was "1730."


The hospital's Level of Observation Policy (ID 1663647) dated 05/2014 reflected "documentation of the observation is to be completed once the patient has been observed."


6) The storage closet in Group Room #315 had a clear plastic spray bottle whose chemical name tag had been taped over with an orange sticker. The sticker was hand written and read "water." Upon opening of the bottle, Employee #13 agreed that the clear liquid smelled of chemicals.


7) Observations on 02/17/16 at 1130, in Room 342, the kitchenette adjacent to and open to the hospital's lobby reflected multiple items that could be used in self-harm and/or to harm others. Those items included six five-gallon water jugs, plastic covers on Styrofoam cups, two plastic liners in the trash cans, a ceramic cup, seven red plastic plates, a stack of clear plastic plates, a drawer filled with plasticware, a microwave cover with sharp edges, a metal frame sized to frame a microwave oven, and four glass vases. Multiple plastic bags were observed in the kitchenette's refrigerator.


During an interview on 02/17/16, at approximately 1135, Employee #2 acknowledged the findings and confirmed that the lobby was the first point of entry to potential patients.

During an interview on 02/18/16 at 1140, Employee #7 was asked to state his view on the safety on the unit. He stated he had "not seen any sharp objects and not anything harmful." He acknowledged that Domino stones, metal boxes, CDs and side rails on metal beds could be safety concerns.


The hospital's Patient Rights' Policy (ID 952235) did not address the patients' rights to receive care in a safe setting.

Based on observation, record review, and interview, the hospital failed to ensure the right of privacy for 41 of 78 patients (Patients #1, #2, #6, #7, #9, #10, #15, #16, #17, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #40, #48, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, and #63) in that multiple documents with protected patient information, including patients' first names and last name initials, ages, medical and psychiatric diagnoses, medications, comorbidities, orders, and staff comments, were left accessible to unauthorized view for at least two months in an unlocked cabinet. Potentially disclosed patient information included:


1) Medication administration records of 39 patients,

2) Diet information of 21 patients,

3) Patient census sheets dated 11/26/15, 02/09/15, and 02/10/15, and

4) Program participation of Patient #40



Findings included:


During observational rounds on the hospital's inpatient unit on 02/18/16 at 1745, a stack of documents approximately five inches high was noticed in the unlocked cabinet next to the ice maker in Group Room #315. The documents included patients' private information on medication administration records, diet and meal verification information, census sheets, and a patient's group participation information.


1) Medication administration records of 24 patients (Patients #1, #7, #9, #10, #15, #16, #17, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #48) were dated 02/10/16 and reflected details regarding the patients' current and discontinued medications, patient allergies, date of admission, and patient record number. The documents noted the patients' acceptance or refusal of medications.


Medication administration records of additional 15 patients (Patient #6, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, and #63) were dated 11/24/15 and provided information regarding the patients' current and discontinued medications, patient allergies, date of admission, and patient record number. The documents noted the patients' acceptance or refusal of medications.


2) A document titled Diet and Meal Verification, dated 02/10/16, was observed on 02/18/16 at 1750 in an unlocked cabinet. The document reflected 21 patients (Patients #1, #9, #10, #15, #16, #17, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36,#37, and #48) and identified them with first names and initialed last names, and noted their diet orders and food allergies.


3) A patient census sheet dated 11/26/15 reflected information of 17 patients (Patients #6, #24, #36, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, and #63) including their names and legal admission status, ages, allergies, multiple psychiatric and medical diagnoses, comorbidities, diet, orders for labs and vital signs, and comments including "...remains psychotic...attends group but does not participate...generally sleeping...need stool [sample]... "

The Patient Census Sheet dated 02/09/16 reflected information of 22 patients (Patient #1, #2, #7, #9, #15, #16, #17, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, and #48) including names, ages, allergies, multiple psychiatric and medical diagnoses, medications, comorbidities, diet, ordered labs and staff comments including "...aggressive, hitting staff and peers...delusional..."


The Patient Census Sheet dated 02/10/16 reflected information of 24 patients (Patient #1, #7, #9, #10, #5, #16, #17, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, and #48). Patients' personal information included first names and last name initials, ages, allergies, multiple psychiatric and medical diagnoses, comorbidities,diet, and/or ordered labs. Comments included "...[the patient] attacked peer at nursing home...wears onesies...pulled out...catheter...patient with stoma... "


4) Patient-specific information was observed on 02/18/16 at 1822 in an open shelf in the hospital's Noisy Activity Room. A document labeled "Participation/Group Notes" dated 10/07/15 reflected Patient #40's name and disclosed the patient's level of group participation and program attendance.


Employee #13 acknowledged the findings on 02/18/16 at 1800 and stated physicians used those documents during patient consultations. She stated she would shred the documents.

Based on record review, interview, and observation, the hospital failed to have an organized nursing service that provided nursing services and supervision by a registered nurse.


1) The RN (Registered Nurse) failed to supervise and evaluate the care for 1 of 1 recently discharged patient (Patient #15) who had been assessed on admission to require assistance for toileting. Patient #15 suffered two falls while toileting and required emergency care for a head injury,


2) The RN failed to evaluate/reassess and perform neurochecks for 1 of 6 patients (Patient #6) who sustained multiple falls during his hospitalization.


3) The nursing staff failed to follow a physician's order for 1 of 1 patient (Patient #3) that was to be on bedrest with no bathroom privileges. Patient #3 was out of bed and placed in a Geri-Chair without an order from a physician.

4) The nursing staff did not recommend a nutritional assessment for 1 of 1 patient (Patient #5) who was assessed as not eating for three days prior to admission. Patient #5 was transferred to a medical hospital for hyponatremia.


Cross refer to A0395.

Based on interview, record review, and observation, the RN (Registered Nurse) failed to:


1) supervise and evaluate the care for 1 of 1 recently discharged patient (Patient #15) who had been assessed on admission to require assistance for toileting. Patient #15 suffered two falls while toileting and required emergency care for a head injury,


2) evaluate/reassess and perform neurochecks for 1 of 6 patients (Patient #6) who sustained multiple falls,


3) follow a physician's order for 1 of 1 patient (Patient #3) that was to be on bedrest with no bathroom privileges, and


4) recommend a nutritional assessment for 1 of 1 patient (Patient #5) who was assessed as not eating for three days prior to admission.


Findings included:


1) Patient #15's Admission Psychiatric Falls Risk Assessment dated 01/21/16 at 1400 reflected the patient was a low fall risk. The nursing assessment noted that the patient had "muscle weakness," was wheelchair bound with one person assist "on transfer" for toileting. Patient #15's skin was noted to be intact.


Progress Notes dated 01/22/16 at 15:10 reflected Patient #15 "was found on floor in the bathroom...by BHT [Behavioral Health Technician] lying face down...wheelchair beside her...3 cm [centimeter] times 3 cm bruise noted to forehead."


Progress Notes dated 02/02/16 at 0025 reflected Patient #15 was "noted on floor by BHT." Patient #15 was noted to state she "...was trying to go to the bathroom." Patient #15 had a "skin tear at the upper arm...[and a] hematoma [bruise] on the back of the left side of her head." Patient #15 was transferred to emergency care.


Patient observation sheet dated 01/26/16 reflected Patient #15's location, activity, and behavior were not documented for at least one hour and 45 minutes between 1700 and 1845. Observational sheets dated 01/29/16 at 0545 did not reflect Patient #15's location, activity, and/or behavior.


Record review of hospital quality data dated 12/2015 reflected that approximately every fourth patient incident involved a fall. Quality data dated 01/2016 reflected that almost every other hospital incident involved patient falls (45 percent of incidents). Although the hospital identified the need to improve in this area, fall incidents continued to occur.


During an interview on 02/17/16 at 1400 Employee #1 acknowledged that the "top reported incidents" were related to patient falls.


2) Patient #6's Nursing Assessment dated 11/12/15 timed at 1415 reflected, "Right total hip replacement, limited range of motion cannot raise arm above head...left and right total knee arthroplasty...confused walking in hallway."


The 11/13/15 Practitioner Order reflected, "Fall precautions..."


The progress note dated 11/29/15 timed at 0210 reflected, "Late entry for 11/28/15 timed at 0630...patient got pushed by another patient, fell to the floor and hit head...laceration to the back of head, slow bleed...send to ER (emergency room)...laceration cleaned and bandaged..."


The progress note dated 11/28/15 timed at 1335 reflected, "Patient came back from emergency room...at 1030...walking...has 7 stitches on the back of the head...stitches need to be removed in seven days...neurochecks every 4 hours times 24 hours."


The 11/28/15 Practitioner Order timed at 0650 reflected, "Send patient to ER (emergency room) for further evaluation after fall...at 1145...will do neurochecks times 24 hours...1315...neurochecks every four hours times 24 hours..." No neurochecks were found in the medical record for Patient #6.


The 12/02/15 Practitioner Order timed at 0230 reflected, "Neurochecks per protocol...x-ray right shoulder..." No neurochecks were found in the medical record for Patient #6.


The 12/02/15 progress note timed at 0400 reflected, "Patient screamed and found on the floor at 0215...sitting against the wall on her buttocks...soaking wet...staff assisted to bed...right shoulder x-ray this AM...neurochecks..."


The 12/06/15 progress note timed at 0830 reflected, "Patient found in bathroom floor of her room trying to get up on her own...found incontinent of stool...at 2315...patient in wheelchair at shift change...patient to room assessed to try and figure out what was hindering her from walking since she always ambulates independently...guarding her right side from shoulder down to hip...could hardly raise right hand and could hardly stand on right leg...x-rays ordered for right shoulder and right hip...right hand swollen around wrist...and bruising to hand noted...12/07/15 at 0630...called medical center spoke with...patient admitted with right neck femoral fracture."


The 12/06/15 Practitioner Order timed at 1750 noted "...stat x-ray for right shoulder and right hip..."


The 12/07/15 Practitioner Order timed at 0110 noted "...send to ER (emergency room) for further evaluation to rule out right hip fracture..."


The 12/07/15 progress note timed at 0630 reflected, "Called Medical Center...spoke with...patient admitted with right neck femoral fracture..."


On 02/19/16 from 1126 to 1215 Employee #13 was interviewed by telephone. Employee #13 was asked to review Patient #6's medical record. Employee #13 stated she could not find neurochecks for Patient #6.


3) Patient #3's "Discharge Summary" dated 2/18/16 at 10:15 AM included that Patient #3 was admitted "...for hospitalization as a result of increased disturbance in thought process to include psychosis as well as continued dementia symptoms...excessively decompensated and therefore admitted for inpatient crisis stabilization...patient was admitted to the inpatient program and initially placed on close observation status...bed rest with no bathroom privileges, with wound care to right hip that was healing noted related to pressure ulcer...subsequently assessed as having difficulty with hypernatremia as well as requiring necessary IV fluid hydration with the patient transferred to the emergency room for necessary medical interventions and stabilization effective 02/05/16..."


The hospital Patient Observations Sheet on 01/29/16 reflected Patient #3 had an assistive device "wheelchair." At 0800 Patient #3 was in the dining room until 0845. At 0900 until 0930, Patient #3 was in the group room and from 1815 until 1900 Patient #3 was in the dining room and from 1915 until 2345 Patient #3 was in the group room.


The "Psychiatric Progress Note" on 01/30/16 at 1230 included the "Interval History: Dementia/Seizures/Psychosis...In Geri-Chair, seen by medical team." There were no orders to take Patient #3 off of bed rest or to use a Geri-Chair.


Progress Notes on 01/30/16 at 0025 indicated Patient #3 was "...sleeping in Geri-Chair. At 0430 lying in Geri-Chair eyes closed."


The hospital Patient Observations Sheet on 02/03/16 indicated Patient #3 was in the dining room at 1700 until 1745 and in the Activity Room at 1800. He returned to his room at 1815 the remainder of the night. Patient #3 was in a "Geri-Chair."


During an interview on 02/18/16 at 1515, Employee #13 was asked if she remembered Patient #3. Employee #13 said that "...he had a difficult time taking care of himself and he was sent out for dehydration." When asked why Patient #3 was in a Geri-Chair, Employee #13 said, "I am not so sure." When asked to review Patient #3's chart and show the surveyor where Patient #3 had received new orders to be taken off of bedrest with no bathroom privileges, she indicated, "You are right there is no new orders." When asked if there were orders for Patient #3 to be placed in a Geri-Chair at any time, Employee #13 stated, "There are no orders, he should have stayed on bedrest." When asked if she informed the staff to remove Patient #3 and place him in a Geri-Chair, Employee #13 responded, "No. I did not tell staff that he can be out of bed, because he was non-weight bearing."


4) The Nursing Assessment dated 01/16/16 timed at 1820 included that Patient #5 was "Admitted from skilled nursing facility...refusing care and medications...diagnosed with UTI (urinary tract infection)...facility was unable to treat due to patient refusal medications...non-compliant..."


The History and Physical Exam dated 01/17/16 at 1545 noted Patient #5 was "well nourished, well-hydrated...no acute distress."


The Psychosocial Assessment dated 01/17/16, not timed, indicated Patient #5 was not eating for three days prior to admission. Physician orders dated 01/19/16 at 2000 noted to monitor Patient #5's intake and output. The orders dated 01/20/16 at 1910 noted to "maintain adequate hydration." Orders dated 01/23/16 noted to "close monitor of Intake." Orders on 01/31/16 at 2200 reflected "stat BMP (basic metabolic panel) and CBC (complete blood count)." Orders dated 02/01/16 at 1300 noted to send Patient #5 "...out for hyponatremia (low blood sodium)."


The nursing progress notes dated 01/19/16 timed at 1120 reflected, "Drank 240 cc (cubic centimeters) free water...monitor fluid intake...01/20/16...1230...refusing fluids and food...01/20/16...refused fluids, refused dinner...took some water...01/21/16...at 1015...refused breakfast, refused fluids...nurse successful to give 240 cc of water...refused to give urine sample...01/25/16 at 1550...drank fluids...patient refused breakfast...boost 240 cc...01/26/16 at 1350...patient ate 30% at breakfast, lunch...drank 680 cc this shift...01/30/16...refused fluids...poor appetite...240...boost...02/01/16 transfer to hospital due to hyponatremia..."


The medical record did not include a nutritional screen or a nursing referral for a nutritional screen for Patient #5.


During an interview on 02/18/16 at 1049, Physician #7 was asked if the dietician was a part of the medical team meetings. Physician #7 indicated he did not recall her ever being a part or involved and did not know why she was not a part of the meeting.


During a nursing interview on 02/18/16 at 1215, Employee #5 was asked about patients' transfer to acute care due to electrolyte imbalance with dehydration and stated that it happened "quite frequently." Employee #5 commented that the unit's hydration station was "not consistently" used and patients "are not getting their snacks and water."


During a nursing interview on 02/18/16 at 1705, Employee #13 stated that the hydration cart was inconsistently used because the patients refused hydration. On 02/18/16 at 1810, Employee #13 identified a cart as the unit's "hydration cart." It was empty. The cart was stained with yellow and red spots and had an area of brown discoloration on top.

Based on record review, interview, and observation, hospital administration failed to ensure that the hospital-wide quality assessment and performance improvement program addressed infection control concerns.


1) Broken and unclean geri-chairs, identified as quality concern by administration during the 01/2016 quality meeting, were observed stored next to clean linen.


2) Multiple environmental infection control concerns were identified during the survey and included spillage in refrigerator, freezer, and hydration cart, a lab freezer in need of defrosting, open packages of cookies and crackers in patient snack drawers, uncovered bed sheets in the clean linen storage, a personal Christmas gift amidst food storage in the kitchen, expired milk in the hospital kitchen's refrigerator, food in the medication room, and personal patient belongings, including underwear and socks, on the floor in the patient storage room



Findings included:


1) Observations on 02/19/16 at 1000 AM in the hospital's Central Storage reflected one geri-chair and one wheelchair. The items were identified by Employee #1 as broken and "not marked as clean." A second geri-chair had a ripped arm rest cover. Employee #13 was asked how infection control ensured the chair was thoroughly cleaned for infection prevention and did not offer an answer. Wheelchair and geri-chairs were in close proximity to 14 sets of clean comforters stored on shelves.


Infection Control Meeting minutes were surveyor requested during the survey entrance meeting on 02/17/16 at 1000. None were provided.


Employee #13 stated on 02/19/16 at 1545 that the hospital had not had an infection control meeting since hospital opening.


2) Rounds were conducted on the inpatient unit with Employee #13 and/or Employee #2 and/or Employee #1 on 02/17/16 between 1205 and 1250, on 02/18/16 between 1715 and 1815 and on 02/19/16 between 1000 and 1120.


Patient #9's wheelchair was observed in the "long hallway" with dust and/or grime on the left wheel on 02/17/16 at 1205.


A medication wrapper of Lorazepam was observed on the floor of Group room #319.


The housekeeping closet had trash in the tub, and the biohazard room had a dirty floor.


The freezer in the lab adjacent to Exam Room #356 was covered with ice. Employee #13 stated at that time that it needed to be defrosted.


The hospital's Central Storage was observed with trash on the floor. On the shelf were six uncovered bags of incontinence wear. Employee #13 acknowledged the findings at that time and stated employees took individual undergarments out of the bags as needed during patient care.


An uncovered roll of toilet paper was observed on an open shelf in the hospital's Noisy Activity Room. It was accessible to all patients.


The paint on the wall next to the door leading from the Noisy Activity Room to the hallway was scraped off, leaving it difficult to clean.


Observation in Room #3022's bathroom reflected some reddish grime on the shower bar on 02/18/16 at 1715.


A pillow case on the sofa in Group Room #319 was observed with a yellowish dried spot the size of approximately three quarters on 02/18/16 at approximately 1720.


On 02/18/16 at 1805 in the hospital's Group Room #315, two drawers with patient snacks had debris on the bottom. Open packages of cookies and/or crackers were observed.


The refrigerator in Group room #315 was observed stained on 02/18/16 at 1810. The freezer had pink and yellow spillage in it.


On 02/18/16 at 18:05 a cart identified by Employee #13 on 02/18/16 at 1810 as the unit's "hydration cart" was observed stained with yellow and red spots and had an area of brown discoloration on top.


A dead cricket-like insect was observed in the hospital's oxygen storage room on 02/19/16 at 1020. Employee #13 and Employee #1 acknowledged the finding.


The clean linen storage had an open, uncovered bag containing flat bed sheets on 02/19/16 at 1020.


A red medication capsule was observed on 02/19/16 at 1020 underneath a chair in front of the nurses' station. Employee #13 identified the capsule as Colace, a stool softener.


Observational rounds were conducted in the hospital's kitchen on 02/19/16 at 1032. Observed was a cloth chair. Employee #23 was asked at that time how the hospital ensured that the chair was sanitized. Employee #23 did not offer an answer but stated the chair had "always been there."


A green storage shelf in the hospital's kitchen was observed with white dust particles underneath the bins filled with flower and sugar. A red scrub top was observed next to the cherry gelatin mix. Employee #23 removed the scrub top at that time.


Crumbs were observed on top of the turbo oven. The inside of the oven was grimy.


An item identified by Employee #23 as a personal Christmas gift was observed on top of the food storage cart on 02/19/16 at 1045.


The hospital's freezer had debris on the bottom. The refrigerator had white and red spots on the bottom. Seven half- pint-size containers of 2 percent milk with an expiration date of 02/14/16 were observed in the kitchen refrigerator.


A less-than full glass of maraschino cherries marked as received on 08/31/15 did not have a date when it was opened.


Observations in the patient storage room were made on 02/19/16 at 1105. One pair of male underwear, a pair of socks, and one pair of female blue underwear were on the floor. A black travel bag, a pink and black travel bag with adult undergarments, a red suitcase, and a gray travel bag were located in the middle of the room on the floor. Two of three plastic bags on the floor had patient labels. Employee #13 stated at that time that it was her expectation that every patient had a storage cube in the patient storage room.


Observations on the nursing unit's medication room on 02/19/16 at 1450 reflected an open bag of chips on the counter close to the sharps container. Employee #32 and Employee #5 acknowledged the finding.



Quality Council/Safety Meeting's Infection Control Report dated 01/22/16 did not address environmental infection control concerns as noted during the survey. The Environment of Care/EOC Report noted broken geri-chairs.


The hospital's 2016 Infection Prevention Plan noted that "to reduce risks for healthcare acquired infection, cleaning and disinfecting environmental surfaces is extremely important." The Plan recommended for the infection prevention Committee to meet "at least quarterly."

Based on interview and record review, the hospital failed to ensure 2 of 5 patients (Patient #4 and Patient #6's) inpatient treatment plan addressed individualized comprehensive physical/medical needs.


Findings included:


1) Patient #4's Psychiatric Evaluation dated 12/15/15 reflected, "Past history of high blood pressure, coronary artery disease, dyslipidemia, dementia, who was exhibiting increased aggressions and agitation...psychotic, disorganized, confused..."


The Radiology Report date 12/13/15 timed at 1107 reflected, "Bilateral lower extremity venous ultrasonography...on the left, the veins are relatively noncompressible from the common femoral vein on through the distal superficial femoral vein and poplieteal vein...suggests a subacute to old phlebothrombosis with recanalization of vessels..."


The Practitioner Order dated 12/13/15 timed at 1215 reflected, "Start Lovenox 80 mg (milligrams) subcutaneous every twelve hours...Coumadin 5 mg po (by mouth) at 1700 from 12/14/15..."


The Interdisciplinary Treatment Plan reflected, "Date of admission...12/11/15...master problem list...12/13/15 agitation/aggression...axis III hypertension, coronary artery disease with left sided hemiparesis..." No short term/long term goals nor any documentation was found in the treatment plan which addressed the blood clot to Patient #4's left leg, nor was anticoagulation treatment addressed in the treatment plan.


On 02/19/16 from 1126 to 1215 Employee #13 was interviewed by telephone. Employee #13 was asked to review Patient #4's treatment plan. Employee #13 verified Patient #4's treatment plan did not address blood thinner treatment for a blood clot to Patient #4's lower extremity.


2) Patient #6's Nursing Assessment dated 11/12/15 timed at 1415 reflected, "Right total hip replacement, limited range of motion cannot raise arm above head...left and right total knee arthroplasty...confused walking in hallway."


The 11/13/15 Practitioner Order reflected, "Fall precautions..."


The progress note dated 11/29/15 timed at 0210 reflected, "Late entry for 11/28/15 timed at 0630...patient got pushed by another patient, fell to the floor and hit head...laceration to the back of head, slow bleed...send to ER (emergency room)...laceration cleaned and bandaged..."


The progress note dated 11/28/15 timed at 1335 reflected, "Patient came back from emergency room...at 1030...walking...has 7 stitches on the back of the head...stitches need to be removed in seven days...neurochecks every 4 hours times 24 hours."


The 11/28/15 Practitioner Order timed at 0650 reflected, "Send patient to ER (emergency room) for further evaluation after fall...at 1145...will do neurochecks times 24 hours...1315...neurochecks every four hours times 24 hours..."


The 12/02/15 Practitioner Order timed at 0230 reflected, "Neurochecks per protocol...x-ray right shoulder..."


The 12/02/15 progress note timed at 0400 reflected, "Patient screamed and found on the floor at 0215...sitting against the wall on her buttocks...soaking wet...staff assisted to bed...right shoulder x-ray this AM...neurochecks..."


The 12/06/15 progress note timed at 0830 reflected, "Patient found in bathroom floor of her room trying to get up on her own...found incontinent of stool...at 2315...patient in wheelchair at shift change...patient to room assessed to try and figure out what was hindering her from walking since she always ambulates independently...guarding her right side from shoulder down to hip...could hardly raise right hand and could hardly stand on right leg...x-rays ordered for right shoulder and right hip...right hand swollen around wrist...and bruising to hand noted...12/07/15 at 0630...called medical center spoke with...patient admitted with right neck femoral fracture."


The 12/07/15 Practitioner Order timed at 0110...send to ER (emergency room) for further evaluation to rule out right hip fracture..."


The 12/07/15 progress note timed at 0630 reflected, "Called Medical Center...spoke with...patient admitted with right neck femoral fracture..."


The Interdisciplinary Treatment Plan with an admission date of 11/12/15 reflected, "Axis I agitation/Aggression...Axis III Hypertension..."


The Treatment Plan Update dated 11/20/15, 11/25/15 and 12/04/15 reflected, "Agitation, Hypertension..." No documentation was found which addressed Patient #6's falls sustained while inpatient. No short and long term goals and interventions were found in Patient #6's treatment plan.


On 02/19/16 from 1126 to 1215 Employee #13 was interviewed by telephone. Employee #13 was asked to review Patient #6's medical record. Employee #13 stated Patient #6's treatment plan did not address Patient #6's falls.