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Based on medical record review and interview, the facility failed to ensure inpatient Medicare beneficiaries signed and dated the standardized notice, "An Important Message from Medicare (IM)", within two days of admission for ten (Patients' #s 5 ,10, 11, 15, 16, 17, 19, 20, 21, and 23) of 30 medical records reviewed. The IM is to be signed and dated by the patient to acknowledge receipt.
Findings include:
The medical record for Patient #15 was reviewed on 12/05/12. The patient was admitted to the facility on 11/25/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
On 12/05/12, the findings were confirmed by Staff A.
The medical record for Patient #16 was reviewed on 12/05/12. The patient was admitted to the facility on 12/01/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
On 12/05/12, the findings were confirmed by Staff A.
The medical record for Patient #17 was reviewed on 12/05/12. The patient was admitted to the facility on 11/12/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
On 12/05/12, the findings were confirmed by Staff A.
The medical record for Patient #19 was reviewed on 12/05/12. The patient was admitted to the facility on 11/28/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
On 12/05/12, the findings were shared with Staff A and confirmed.
The medical record for Patient #10 was reviewed on 12/05/12. The patient was admitted to the facility on 12/01/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
On 12/05/12, the findings were confirmed by Staff A.
The medical record for Patient #5 was reviewed on 12/04/12. The patient was admitted to the facility on 12/01/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
On 12/03/12, the findings were confirmed by Staff A.
The medical record for Patient #20 was reviewed on 12/06/12. The patient was admitted to the facility on 11/30/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
The medical record for Patient #21 was reviewed on 12/06/12. The patient was admitted to the facility on 11/17/12. The patient was a Medicare beneficiary. The medical record lacked documentation an IM notice had been signed and dated within two days of admission.
The medical record review for Patient #11 was completed on 12/05/12. The patient was admitted to the intensive care unit (ICU) on 11/24/12 with diagnoses which included schizoaffective disorder, bipolar and psychosis. The patient was a Medicare beneficiary. "The Important Message from Medicare" contained documentation the patient was unable to sign. There was no date on the form as to when the patient was provided this notice and was unable to sign. The signature of the witness (Registered Nurse, Staff J) was not dated and it could not be determined when this staff had contacted the patient and was unable to obtain his signature on the Medicare notice. In addition, the medical record of Patient #11 lacked documentation of the date the staff had attempted to provide the patient with the information from the Medicare notice. The Important Medicare notice was not signed by Patient #11 until 12/05/12 after the surveyor had made Staff B aware on 12/04/12 at 4:22 PM.

The medical record for Patient #23 was reviewed on 12/05/12. The patient was admitted on 11/06/12 for schizoaffective disorder, bipolar. The patient was a Medicare beneficiary. The notice titled "Important Message from Medicare" was not signed within two days of admission. On 12/05/12 at 11:55 AM this finding was confirmed with Staff B. The medical record of Patient #23 revealed the staff had obtained the patient's signature on the Important Medicare notice on 12/05/12.


On 12/06/12, Staff F was interviewed. Staff F stated he/she was not aware the IM needed to be signed within two days of admission.


31597

Based on observation and staff interview, the facility failed to ensure care was provided in a safe environment for the 21 patients residing on the Intensive Care Unit, failed to ensure privacy of medical information for three patients during medication administration (Patients #3, 7, and 12), and failed to provide one patient with personal privacy (Patient #23). The patient sample size was 30. The patient census was 69.

Findings include:

On 12/04/12 between 9:39 AM and 10:10 AM medications were observed being administer by Staff L (Registered Nurse) to the patients on the ICU. At 9:44 AM Patient #3 walked to the nurses station to receive the morning medication. Staff L was observed to name each medication the patient was receiving and verbally explain the purpose of the medication the patient was taking. Patient #3's medications consisted of an antibiotic, an antipsychotic, an inhaler, and a vitamin and mineral supplement.
Patient #12 was standing directly behind Patient #3 while Patient #3 received their medication and was able to hear the discussion of Patient #3's medical information. There was no staff intervention to provide Patient #3 with privacy for his medical information.

At 9:58 AM on 12/04/12 Patient #12 was at the nursing station on the ICU. Staff L (Registered Nurse) was observed administering the morning medications to Patient #12. Staff L was observed verbally naming the medications and explaining the purpose of the medications to Patient #12.
Patient #12's medications consisted of inhalers, breathing medications, antianxiety medications, blood pressure medications, behavior medications, medications for constipation, and pain medication.

During the medication administration Patients #7 and #31 were standing at the nurses station directly behind Patient #12. Patient #7 and #31 could hear the discussion of Patient #12's medical information with Staff L. There was no staff intervention to provide Patient #12 with privacy of his medical information.

At 10:10 AM on 12/04/12 Patient #7 was at the nurses station on the ICU. Staff L was observed administering the morning medications to Patient #7. Staff L was observed verbally naming each medication and explaining the purpose of each of the medications to Patient #7. Patient #7's medications consisted of laxative/stool softener, blood pressure medication, potassium supplement, and pain medications (one was a controlled narcotic).

During the medication administration and discussion, Patients #31, 32, and 33 were seen standing at the nurses station behind Patient #7. Patients #31, 32, and 33 were able to hear the discussion of Patient #7's medical information. There was no staff intervention to provide for the privacy for Patient #7's medical information.

On 12/04/12 at 10:30 AM Staff B stated the facility policy is to have only one patient at a time at the nurses station for medication administration. Staff B stated the staff are to redirect other patients to the dayroom and only have one patient given medications at a time. Staff B confirmed the unit staff should have redirected the patients not receiving medication back to the dayroom to provide for privacy of patient medical information.

On 12/04/12 at 3:57 PM Patient #23 was seen standing at the nurses station wearing a hospital gown. The hospital gown was open approximately two inches in the back. The patient was not wearing underwear and the patient's buttocks were exposed. There was a male staff member present in the hallway. Staff L (Registered Nurse) upon exiting the exam room from administering an injection to Patient #34, instructed the staff member in the hallway to put a second gown on Patient #23.

On 12/04/12 between 10:30 AM and 11:30 AM a tour of the ICU was taken by three surveyors, Staff L, Staff B, Staff N, Staff A, and Staff N. According to interview with Staff A and B on 12/04/12 at 10:30 AM
the ICU is a 22 bed unit that provides care to patients with psychosis, hallucinations, and aggression towards self and others. Observations revealed environmental safety concerns that consisted of a telephone jack cord measuring at least three feet in length at the front nurses station, a paper cutter in the top drawer of the cabinet at the nurses station, video tapes and a plastic DVD in an unlocked cabinet in the dayroom (which could be used to cut or wrap the tape around self or others), in room 127 there was a dresser drawer resting on the closet floor (object could be thrown, used to hit), in room 133 the plastic cover over the thermostat was loose, non secure, in room 133 there was a loose, non secure latch on the closet, and in room 128 there was a metal handle missing from the top dresser drawer. On 12/04/12 there were 21 patients on the ICU.

Based on medical record review, review of the policy titled "Nursing Reassessment, Vital Signs and Interventions", and staff interview, the facility failed to ensure the nursing staff monitored and evaluated three of 30 sampled patients (Patients #11,12, and 23) with elevated blood pressures. In addition, the facility failed to ensure the nursing staff re-evaluated one patient's abnormally low blood pressure (Patient #12) The facility failed to assess for siderails usage on the geripsychiatric unit. The facility census was 69.

Findings include:

Review of the Vital Sign Assessment/Intervention record for Patient #11 revealed on 11/25/12 at 10:00 AM the patient's blood pressure was recorded as 154/132. The medical record and vital sign assessment/intervention form did not record Patient #11's blood pressure had been taken until the next documented blood pressure reading at 11;00 PM which was documented as being 149/80. Further review of the vital sign assessment/intervention record revealed on 11/27/12 at 6:00 PM the patient's blood pressure was documented as being 157/105. There was no further documentation of the patient's blood pressure being monitored until 11:00 PM when the blood pressure was documented as being 161/103. The patient's blood pressure was not documented as being rechecked within one hour of the abnormal reading as required by the facility policy. These findings were confirmed during interview with Staff B on 12/04/12 at 4:22 PM.

Review of the Vital Sign Assessment/Intervention record for Patient #12 revealed on 11/30/12 at 10:00 PM the patient's blood pressure was recorded as 132/105. The patient's blood pressure was next documented on 12/01/12 at "7 a-7p" and was recorded as 106/69. The patient's blood pressure was not rechecked within one hour of obtaining an abnormal reading as required by the facility policy. In addition, on 12/04/12 at 7:30 AM the patient's blood pressure was recorded as being 89/59. The patient's blood pressure was not documented as being rechecked until 12/04/12 at 10:00 PM as being 123/75. These findings were confirmed with Staff B on 12/04/12 at 4:22 PM

Review of the Vital Sign Assessment/Intervention record for Patient #23 revealed on 11/23/12 at 7:00 AM the patient's blood pressure was recorded as being 149/102. The next documented recording of the patient's blood pressure was on 11/23/12 at 10:00 PM and was recorded as being 153/204. There was no evidence of the patient's blood pressure being rechecked within one hour of the abnormal readings as required by the facility policy. Further review revealed on 11/25/12 at 9:00 AM the patient's blood pressure was 146/101. The next blood pressure documentation was on 11/25/12 at 10::00 PM and was recorded as being 136/101. The next documented blood pressure reading was 11/26/12 at 9:00 AM and was recorded as being 152/105. On 11/27/12 at 6:00 PM the patient's blood pressure was recorded as being 170/118. The next documented blood pressure was 11/27/12 at 10:00 PM and was recorded as being 150/101. The record was silent to a recheck of the abnormal blood pressure within one hour. On 11/28/12 at 9:00 AM the patient's blood pressure was documented as being 176/107. an intervention form documented the Registered Nurse had placed a call to the physician at 9:00 AM and was awaiting a return call. The intervention form checked to recheck abnormals every hour. The form instructed/documented "all rechecked vitals must be documented on the front." Review of the Vital Sign Assessment/Intervention documents for 11/28/12 revealed a documented blood pressure at 10:00 PM that was 172/152 and again at 10:38 PM as being 198/112. A note by the Registered Nurse on 11/29/12 at 10:38 PM documented interventions of check new orders, no new orders received, and will notify am shift of issues with elevated blood pressure. The section recheck abnormals documented "other, 20 minutes times one." The next documented blood pressure reading was on 11/29/12 at 8:00 AM and was recorded as being 161/110. These findings were confirmed during interview with Staff B on 12/06/12 at 10:00 AM.

The policy titled, "Nursing Reassessment, Vital Signs and Interventions", Number CS-200.61, Revised 09/2012 documents #4. "If vital signs are abnormal the vital sign(S) should be repeated within one hour, if continue to be abnormal the Physician/NP is to be notified for further intervention and orders." In addition, the policy documents #6. "Nurse will document the vital signs on the vital Signs Record." and #7. "Any follow up assessment and intervention should be documented under intervention on the vital signs form."

Review of the "Vital Signs/Assessment/Intervention" document revealed a section titled "Normal Ranges" that documented blood pressure systolic (top reading) 100-150 and blood pressure diastolic 60-90.

Interview with Staff B on 12/06/12 at 4:22 PM revealed these ranges are to be used as guidance.


22432

Tour of the Generations geri-pyschological unit on 12/03/12 from 1:30 P.M. and 12/04/12 at various times revealed all 20 beds on the unit were observed to have bilateral upper side rails in the raised position on all the beds.

Review of the medical record for Patient #1, 5, 14, and 29 revealed the records were silent to any nursing assessment for the appropriateness of side rails on the bed.

Interview with Staff B on 12/04/12 at 12:30 P.M. revealed we used to do side rails assessments a while back but we don't do that any more. All patients who resided on the Generations unit automatically had bilateral upper side rails in the up position on the bed as a safety measure.

Review of the facility's policy and procedure entitled "Risk Assessment for Geriatric Beds", with a date of March 2012 was silent to any mention of side rails on the beds.

Based on medical record review, interviews, policy review, and observations, the facility failed to ensure all practitioner orders for the administration of drugs and biological included the route for three patients (Patient #5, #15, and #19), failed to ensure all practitioner orders for the administration of drugs and biological included the dose, route, and frequency for one patient (Patient #5), failed to ensure medications were discontinued per physician orders for one patient (Patient #10), failed to ensure patient safety by not identifying duplicative drug orders for one patient (Patient #9), and failed to transcribe the order to the medication administration record correctly for one patient (Patient #19). Thirty (30) patient medical records were reviewed. The facility census was 69.
Findings include:
The medical record for Patient #15 was reviewed on 12/05/12. On 12/04/12 at 1:00 AM, a registered nurse received a telephone order from a physician for nasal spray two sprays every four hours as needed for nasal congestion. The registered nurse did not receive and document right, left or both nares into which to spray the ordered medication. On 12/04/12 at 8:40 AM, the pharmacy sent the nurse a memo requesting the nurse to clarify what nasal spray the patient should be on. On 12/04/12 at 2:20 PM, a physician wrote an order for normal saline nasal spray two sprays every four hours as needed. The physician did not specify the right, left or both nares.
The medical record for Patient #17 was reviewed on 12/05/12. On 12/01/12 at 10:00 AM, a physician wrote an order for Visine (soothes and revives burning, irritated eyes) or equivalent two drops every four hours as needed. The physician did not document right, left or both eyes into which to instill the ordered medication. On 12/01/12 at 10:10 AM, a registered nurse noted the order and documented the order on the patient's medication administration record without clarifying which eye the drops were to be placed in. On 12/05/12 at approximately 10:00 AM, Staff C handed the eye drops to the patient and watched him/her instill two drops into both eyes without clarifying the order with the physician.
On 12/05/12, the findings were reviewed with Staff A and confirmed.
The medical record for Patient #19 was reviewed on 12/05/12. On 11/29/12, a nurse received a telephone order from a physician. The nurse documented the order as Pancrealipase (used in the treatment of digestive disorders) 2400 Units give before meals. The order did not contain a route. The nurse transcribed the order to the medication administration as Pancrealipase orally three times a day with meals. The transcription did not include a dose and the nurse did not receive a clarification order from the physician for the route. The nurse transcribed the Pancrealipase to be given with meals instead of before meals as the physician had ordered.
The medical record for Patient #10 was reviewed on 12/05/12. The record had a physician order to discontinue the Celexa on 12/02/12 at 11:00 AM. On 12/02/12 the pharmacy sent an order clarification note to the nurse stating the patient was not prescribed Celexa (treats anxiety and depression), but was prescribed Lexapro (treats anxiety and depression). The pharmacy requested clarification as to if the physician wanted the Lexapro discontinued instead of the Celexa. On 12/02/12 a nurse documented on the pharmacy's clarification request " OK per Staff E " . The nurse did not specify whether the Celexa was to be discontinued or whether the Lexapro was to be continued. On 12/05/12 at 9:00 AM, Staff A was interviewed regarding the discontinued order and the pharmacy clarification request. Staff A contacted Staff E and Staff E stated the Lexapro was to be discontinued. On 12/05/12 at 9:05 AM, Staff E wrote an order to discontinue the Lexapro. The patient received the Lexapro on 12/03/12 and 12/04/12. The patient did not receive the Lexapro on 12/02/12.
On 12/05/12, the findings were shared with Staff A and Staff A confirmed with Staff E the Lexapro was to have been discontinued on 12/02/12.
The medical record review for Patient #9 was reviewed on 12/04/12. On 11/29/12, the physician ordered Tylenol by mouth every four hours as needed for pain or fever. On 11/30/12 a physician ordered Tylenol Extra Strength 1000 mg orally every six hours as needed. On 12/04/12 the patient's medication administration record had both Tylenol orders listed as active orders.
On 12/04/12 Staff A was interviewed regarding the two Tylenol orders listed as active medications on the medication administration record. Staff A documented " New Order " on the Tylenol 650 mg order on 12/04/12.
The medical record review for Patient #5 was completed on 12/03/12. The patient was admitted to the facility on 12/01/12. On 12/02/12 at 1:30 PM, an order was written to " use Zithromax from home to finish out "antibiotic". The order did not include a dose, route, or frequency. On 12/02/12 at 2:30 PM the order was noted and documented on the medication administration record without a dose, route, or frequency. The facility did not administer the Zithromax to the patient on 12/01/12, 12/02/12, or 12/03/12. The nursing staff and the pharmacy did not receive a clarification order form a physician.
On 12/03/12 at 3:15 PM, the findings were shared with Staff A and confirmed. On 12/03/12 at 3:30 PM a clarification order was obtained by the facility stating the dose, frequency, and route.
On 12/06/12, the facility's policy "Medication Orders " was reviewed. The policy stated elements of the medication order are dosage, time or frequency and route. The policy stated to clarify the order if needed.

Based on observation, record review, and staff interview, the facility failed to ensure patient medical records were store in a manner that protected the records from water destruction in the event of activation of the sprinkler system. In addition, the facility failed to ensure the medical record for one patient (Patient #13) was properly filed, retained, and accessible. The sample size was 30. The facility census was 69.

Findings include:

On 12/07/12 between 11:30 AM and 12:30 PM observations were made in the Medical records Department. Observations revealed the medical records department was fully sprinkled. There was a row of large, metal, upright cabinets with at least four shelves per cabinet seen placed in proximity (approximately four to six inches behind) of a large, overhead pipe that contained at least two sprinkler heads. The metal cabinets were open with no protective front drop down. Hardcopy patient medical records were stored on the upright cabinets. Interview with Staff P (Medical Records Director) at 11:40 AM on 12/07/12 revealed these were patient medical records from 2009 until present (2012). Staff P stated there were approximately 350-500 medical records. Staff P stated there was no backup system to the hardcopy patient records. Staff P confirmed in the event of the sprinkler activation where the medical records would become water damaged there was no backup system in place to retrieve the medical records. Staff P stated all medical records are kept onsite in the medical records department for at least four years then the medical records are sent offsite for storage.


22432

Review of the medical record for Patient #13 in the afternoon of 12/05/12 revealed the patient was admitted to the hospital on 12/16/12 with diagnoses which included psychoses, schizoaffective disorder, hypertension and diabetes mellitus.

The social progress notes consisted of one sheet of paper which began with the first entry on 12/30/12 and the next entry was not until 01/24/12 despite the fact that the medical record contained multiple correspondences with many community agencies and institutions all related to the patient's upcoming discharge planning needs. The medical record had on going evidence of facsimile correspondence. The last entry on the single sheet of social progress notes was dated 01/24/12 at 2:30 P.M. when the social services staff documented "the patient feels he is ready to go home." The medical record documented elsewhere that the patient was discharged home with home health services and appointments with both community medical and behavior health centers appointments despite the fact the social service progress notes were silent to any of these plans.

Interview with Staff #F on 12/07/12 at 1:00 P.M. verbalized some of Patient #13's records are missing. "I know he has more than this! All patients are seen within the first 24 hours of admission and then every couple days after that. Closer to the discharge date patients are seen multiple times a day. We had three patients with the same last name during this same time, I am sure these social service notes are misfiled somewhere."

Based on observation, interview, and record review, the facility failed to ensure the occupancy was free of space heaters, have the proper construction type, maintain a two hour fire rating in a fire barrier, corridor doors resisted the passage of smoke, the generator was inspected weekly, fire drills were held under varying conditions, fire extinguishers were readily accessible, return air vents were clean to allow laminar air flow, and electrical wiring was in accordance with NFPA 70. This has the potential to affect all patients, staff, and visitors to the facility. The census at the time of the survey was 69 patients.

Findings include:

See A701, A709.

Based on observation and interview, the facility failed to have a preventative maintenance schedule that maintained optimal negative air flow in return air vents in the heating, ventilation and cooling system. This affected rooms 121, 125, 111, 112, 115, 117, 106 and 101. This has the potential to affect all patients, staff, and visitors who use the facility. The census at the time of the survey was 69 patients.

Findings include:

On 12/04/12 at 9:45 A.M. a tour of the dual diagnosis unit was conducted with Staff CC and DD. The tour revealed in each bathroom of room 121 and 125 there was a return air vent plugged with dust particles such that the negative air flow could not hold a piece of tissue paper.

During the tour Staff CC confirmed the findings.

On 12/04/12 at 11:20 A.M. a tour was conducted of the crisis stabilization unit with Staff CC and DD. The tour revealed in the bathroom and sleeping area of room 135 there were return air vents plugged with dust particles such that the negative air flow could not hold a piece of tissue paper.

The tour revealed in the bathrooms of rooms 111, 112, 115, and 117 had air vents plugged with dust particles such that negative air flow could only hold a piece of tissue paper in certain areas of the vent.

On 12/04/12 at 2:25 P.M. a tour was conducted of the geripsychiatric unit with Staff CC and DD. During the tour the return air vents in the living spaces of room 106, 109, and 110 were observed to be plugged with dust particles such that negative air flow could only hold a piece of tissue paper in certain areas of the vent.

During the tour the return air vents in the bathrooms of rooms 106 and 101 were observed to be plugged with dust particles such that negative air flow could only hold a piece of tissue paper in certain areas of the vent.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The census at the time of the survey was 69 patients.

Findings include:

Please refer to the following K tags of the Life Safety Code Survey Statement of Deficiencies for the identification of the deficient practices cited:
K11: failed to maintain a two-hour fire resistive fire rating in a fire barrier
K12: failed to have proper construction type
K17: failed to ensure each space that opened onto a corridor was properly protected
K18: failed to ensure doors that protected corridor openings resisted the passage of smoke
K144: failed to ensure the generator had documented weekly inspections
K50: failed to ensure fire drills were held at unexpected times under varying conditions
K62: failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition
K64: failed to ensure each fire extinguisher was readily accessible in accordance with NFPA 10
K70: failed to ensure no space heaters in the occupancy
K147: failed to ensure electrical wiring was in accordance with NFPA 70