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Based on document review and interview the facility failed to inform each patient or their representative of patient's rights in 15 of 33 medical records reviewed (patients #2, 3, 15, 22, 23, 24, 25, 28, 29, 30, 31, 32, 36, 37 & 39), obtain a written consent to treat in four of 33 medical records reviewed (#2, #3, #36 & #37), and obtain a consent to transfuse in one of one medical record (#31) in advance of furnishing patient care, resulting in uninformed patients and the potential for poor patient outcomes. Findings include:

On 9/18/13 at approximately 1630, during medical record review of open and closed records, it was determined that there was no documentation of the patients rights folder being given, who it was given to, or a date when it was given.

On 9/19/13 at approximately 0900, during medical record review and interview with staff H (Director of Patient Access), an electronic review of the medical record for patient #15 was conducted to locate documentation of patient's rights being given. Documentation that patient's rights had been given for patient #15 could not be found. Staff H stated, "the patient rights folder is given to the nurse to give to the patient when the patient is being admitted through the Emergency Department (ED). Staff H stated, "No one follows up to see if it (patient's rights material) has been given or if the documentation has been completed."


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On 09/18/2013 between 1300-1600, a review of closed medical records with staff S (Health Information Management Clerk), revealed the following:
A review of a document titled "Consent for Treatment and Release of Medical Information" revealed that the document contained an area for staff to record that the patient received or declined information regarding their rights as a patient. Records for patients #22-25, 28-32 & 39 all lacked documentation that these patient's had been given/offered the patients rights folder by staff, prior to providing treatment.

During the medical record reviews cited above with staff S, when queried about the missing documentation, she stated, "That is where the staff document that the patient has been given their patient's rights information or staff document if the patient declines it."

Further review of the medical records, revealed that records for patients #36 and #37 lacked signed consents for treatment.

On 09/18/2013 between 1300-1600, a review of the medical record for patient #31 revealed that the patient had received a transfusion of a blood derived product on 04/05/2013. Staff S was unable to locate a consent for transfusion on the patient's (#31) record.

When queried about the consent to transfuse, staff S replied, "There's not one there."

On 09/18/2013 at 1645 a review of the document titled "West Shore Medical Center Nursing Blood and Blood Product Administration", reads on page 2, "Explain the procedure to the patient. Obtain informed consent."

On 09/18/2013 at 1645 all of the above findings were confirmed with staff S during the medical record review. Staff S also confirmed that the above records reviewed were completed and closed medical records.


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On 9/17/13 at approximately 1415 during review of patient #2's medical record, a generalized, "consent upon admission for medical treatment" (form), was found. When staff D was queried regarding what this document represented, in terms of consent for treatment at the facility, she replied, "The nursing home (Manistee County Medical Care Facility) has their residents sign one (consent to treat) every year." Staff D was then asked if patients sign a hospital consent to treat form that is specific to this facility, to which staff D replied, "no." Documentation was not presented which demonstrated that the patient had received their "patient rights" upon admission to the facility.

On 9/17/13 at approximately 1425 during review of patient #3's medical record, the consent for treatment was not signed. Staff D was asked why the patient had not signed the consent, to which she replied, "She has a court appointed guardian." The court document which revealed the named appointed guardian was then provided to this surveyor. Upon review, the court paper showed that it had not been reviewed nor signed since 6/24/04. When staff D was queried as to why the patient's guardian had not been in to sign the consent to treat required documents or make required medical treatment decisions for this admission for patient #3, she replied, "She has a lot of people assigned to her." No documentation was found with verbal phone consent nor any other form of consent by patient #3's guardian.

Based on medical record review, interview and policy and procedure review, the facility failed to ensure that an individualized Plan of Care (POC) was developed for 10 out of 19 (#2, #3, #7, #8, #10, #11, #13, #21, #26 and #31) patient medical records reviewed. This has the potential for poor medical outcomes for all patients. Findings include:

On 9/17/13 at approximately 1415 during patient #2's medical record review, no POC review nor goal dates were found for the patient to be reevaluated and updated on the treatment plan. On 9/17/13 at approximately 1420, staff T was asked if any other documentation was available for review in regards to the POC, to which he replied, "No."

On 9/17/13 at approximately 1430 during patient #3's medical record review, no POC review nor goal dates for the patient to be reevaluated and updated on their treatment plan were found. On 9/17/13 at approximately 1440 staff T was asked if any other documentation was available for review in regards to patient #3's POC, to which he replied, "No."

On 9/18/13 at approximately 1000 during patient #10, #11 and #13's medical record review, a POC had not been developed during the intraoperative periods. On 9/18/13 at approximately 1020 staff K was asked if there was any other documentation in regards to the development of POCs intraoperatively for patient #s 10, 11 and 13, to which she replied, "No, there's not (a POC developed)."

On 9/18/13 at approximately 1400 during policy and procedure review, a policy was found titled, "Plan of Care" , which stated, "2. Care Plan: A. Prepare an electronic care plan for each patient that is relevant to their admission diagnosis and information gathered from admission assessments. B. The care plan should be customized with goals and interventions and frequencies that are specific to each patient's needs. C. The care plan will be reviewed a minimum of every shift and updated as the patient's condition and/or diagnoses change."


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On 09/18/2013 at 1115 a review of the electronic medical record for patient #7 (current inpatient) admitted on 09/09/2013 to the medical/surgical unit revealed that no plan of care (POC) had been developed during the patient's 10 days of hospitalization. The patient had been admitted with a diagnosis of Duodenal obstruction.

On 09/18/2013 between 1300-1600 during a review of a closed medical record for patient
#8, revealed that the record did not contain a plan of care for the entire inpatient admission duration. The patient had been admitted with a diagnosis of Anemia.

On 09/19/2013 at 0850 the findings were discussed and confirmed with Staff F (Vice President of Patient Care Services).When queried, Staff F was unable to give an explanation as to why a plan of care had not been developed for patient #7. Staff F was not employed at the facility during patient #8's admission so he could not speak to why the record did not contain a POC.

Further review of closed medical records on 09/18/2013 between 1300-1600, revealed the lack of a POC for patient #21, who had been identified with a "sacral decubitus ulcer". The POCs identified for patient #21 "Nutrition Less Than Body Requirements, Infection, Altered Sleep Pattern and Knowledge Deficit," all lacked a timeframe for completion of each of the identified goals.

Review of the closed medical record for patient #26, revealed a POC for "Infection, Pain, Altered Urinary Elimination Pattern, Knowledge Deficit, Fatigue and High Risk for Injury," that identified goals and interventions, however the POC lacked timeframes for completion for the identified goals.

Review of the closed medical record for patient #31 revealed a POC for "Knowledge Deficit, UTI, Altered Urinary Elimination Pattern, Pain and Infection," that identified goals and interventions, but lacked timeframes for completion of the identified goals.

On 09/19/2013 at 0850 the above findings were all reviewed and confirmed with staff D (Vice President Performance Improvement) and staff F (Vice President Patient Care Services). Staff D made the comment that "a lot of our nursing leadership is new and with the addition of the new staff I feel confident that we can address and correct these issues."

Based on policy review, record review and interview, the facility failed to ensure the form that was used to transfer patients between facilities was completed for three patients (#22, 25 and 27), in a review of seven transferred patients. Findings include:

A review of the West Shore Medical Center policy titled "Completion Of Emergency Room Records" revised 03/30/2012 reads "The Emergency Room record shall include the following required documentation, "1. Physician Documentation: j. Other required documentation to support treatment rendered and level of care provided using current procedural terminology (CPT) Evaluation and Management guidelines."

On 09/18/2013 between 1300-1600 during a review of closed medical records with staff S revealed that the facility had transferred three patients (#22, #25, #27) from this facility to another hospital.
Review of the medical record for patient #22 revealed that the form titled, "Authorization for Transfer" lacked documentation in sections "VII. Patient Consent to 'Medically Indicated' or 'Patient Requested' transfers."
Review of the medical record for patient #25, revealed that the form titled, "Authorization for Transfer" lacked documentation in the following sections: "I. Medical Condition: Diagnosis: "(area blank). "Section I. Medical Condition: Diagnosis:" also lacked documentation identifying the patient as stable, unstable or no emergency medical condition identified. In section "III Risk and Benefit for Transfer:" the document lacked documentation of the "Medical Risk." "Section V. Receiving Facility and Individual:" the form lacked documentation of the "Person Accepting Transfer".
Review of the medical record for patient #27 revealed the form titled, "Authorization for Transfer," and a lack of documentation in the following sections: "I. Medical Condition, Diagnosis" (area blank), "Section II. Reason for Transfer," (area blank), "Section III. Risk and Benefits for Transfer," (no risks or benefits identified and area also blank regarding to whom the risk/benefits were explained). "Section IV. Mode/Support/Treatment During Transfer as Determined by the Physician," lacked documentation for mode of transport. "Section V. Receiving Facility and Individual," lacked documentation identifying the receiving facility and the person accepting the transfer. "Section VI. Accompanying Documentation," lacked documentation identifying that records/medical information was sent to the receiving facility.

On 09/18/2013 at 1700 during an interview with staff D (Vice President of Performance Improvement), the lack of documentation on the documents for patient #s 22, 25, and 27 were confirmed and discussed in detail. Staff D stated, "At one time we tracked compliance for completion of the transfer document and (it) was at 100%; so the tracking was stopped. Now I can see that we need to start looking at this again and it will be a performance improvement plan that will be developed, initiated and monitored."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and community and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include:

See the individually and below cited K-tags dated September 19, 2013.
K-0017
K-0021
K-0025
K-0029
K-0050
K-0054
K-0062
K-0147



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Based on observation and interview, the facility failed to maintain operating room cleanliness resulting in the potential for acquisition of a hospital acquired infection for all patients who have surgery in the operating room suites. Findings include:

On 9/17/13 at approximately 1630 during a tour of the operating room suites, visible dust accumulation was found on flat-topped surfaces of the task lights, the top of the baby warmer machine, and the tops of monitors in operating room number one. In the clean storage room of the surgical suite, accumulated and visible dust was found on flat-topped surfaces above 68 inches of height. Additionally, accumulated and visible dust was found on the top of the Steris Machine in the central sterile repository (CSR) storage room.

On 9/17/13 from 1630 to 1715, staff T, the facility manager who rounded with the engineer surveyor, had confirmed the findings as they were found.