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Based on a review of medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure the patient's right to have a family member and primary care provider notified of admission to the hospital for 16 of 16 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15 and MR16).

Findings include.

Review on October 15, 2015, of facility policy "Patient Rights and Responsibilities, effective date June 1, 2014," revealed "I. Purpose- It is the purpose of this policy to establish written guidelines delineating the rights and responsibilities of the patient and to affirm [facility] commitments to those rights ... Your rights(patient): Communication, You have the right to : have a family member, another person that you choose, or your doctor notified when you are admitted to the hospital."

Review on October 13, 14, 15, 16 and 19, 2015 of MR1,MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, and MR16 revealed that these patients were admitted to the hospital between the dates of May 2, 2015 thru October 16, 2015. There was no documented evidence patients were asked if they wanted family, designated representative and their primary care provider notified of their admission to the hospital. Further review of the medical records revealed that there was no documented evidence that a family member of the patient, designated representative for the patient and their primary care physician was notified by the facility of the patient's admission to the hospital.

Interview on October 15, 2015, at 12:04 PM, with EMP10 confirmed there was no documented evidence in the medical records asking patients whether they wanted a family representative and their primary care physician notified of their admission.

Based on observation, review of facility policy and interview with staff (EMP) it was determined the facility failed to maintain the security of medical records during transfer to the facility's main campus.

Findings include:

Review of facility policy "Physical Handling and Storage of Health Care Information," effective date February 1, 2010, revealed " ... II. Policy To assure that confidentiality health care information is kept secure ... III. Handling, 1) health care information is not to be displayed or reviewed during periods of transport ... 3) All health care information, regardless of the storage medium, is subject at all times to the stated policies and procedures for maintenance of confidentiality."

Review on October 15, 2015, of facility policy "Patient Rights and Responsibilities, effective date June 1, 2014," revealed "I. Purpose- It is the purpose of this policy to establish written guidelines delineating the rights and responsibilities of the patient and to affirm [facility] commitments to those rights ... Your rights(patient): Privacy and confidentiality- You(patient) have the right to: ... Expect all communications and records related to your care, ... to be treated as private ..."

Observation on October 13, 2015, at 1:15 PM, of the medical records office, at an offsite campus, revealed an orange plastic bin with a lid containing medical records.

Interview on October 13, 2015, at 1:15 PM, with EMP2 confirmed that the orange bin was used to transport medical records from the satellite campus to the main campus so that the facility can electronically scan the medical records into the patient's permanent file. Further interview confirmed the bin was not locked or secured during the transport.

Based on a review of medical records (MR), review of facility policy and interview with staff (EMP), it was determined the facility failed to ensure that restraints were used in accordance with a written modification to the patient's plan of care in seven of eight medical records reviewed (MR7, MR8, MR9, MR10, MR11, MR12, and MR15).

Findings include:

Review on October 16, 2015, of facility policy "Use of Restraints All Patient Care Areas (Acute Care and Rehab)," dated July 2012, revealed "... VI. Criteria for Use of Restraints A. Restraints shall be used only ... 2) in accordance with a written modification to the patient's plan of care ..."

Review on October 16, 2015, of MR7 revealed physician orders for hand mitts on July 17, 2015, and a "lapbelt (while in chair)" on July 18, 2015. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Review on October 16, 2015, of MR8 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for August 28, 30, 31, and September 1, 2015. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Review on October 16, 2015, of MR9 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for October 15, 16, and 17, 2015. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Review on October 16, 2015, of MR10 revealed a physician order for an "Enclosed Bed (while in bed) ..." restraint for September 16, 2015, at 5:30 PM. This order was valid for one calendar day. The patient was not placed in the bed until 10:26 PM. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Review on October 16, 2015, of MR11 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for August 30, 31, and September 1, 2015. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Review on October 16, 2015, of MR12 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for September 2, 3, and 4, 2015. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Review on October 16, 2015, of MR15 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for September 8, and 9, 2015. There was no documentation in the medical record that the use of restraints was in accordance with a written modification to the patient's plan of care.

Interview on October 16, 2015, with EMP21 confirmed there was no documented evidence of a written modifications to patient's plan of care for MR7, MR8, MR9, MR10, MR11, MR12, and MR15 regarding the use of restraints.

Based on a review of medical records (MR), review of facility policy and interview with staff (EMP), it was determined the facility failed to ensure physician orders for pelvic restraints and/or bed enclosure restraints were not issued as PRN (pro re nata- when necessary or as needed) orders for six of eight restraint records reviewed (MR8, MR9, MR10, MR11, MR12, and MR15).

Findings include:

Review on October 16, 2015, of facility policy "Use of Restraints All Patient Care Areas (Acute Care and Rehab)," dated July 2012, revealed "... VII. Procedure ... B. Order Time Limits 1. Restraints may not be ordered as a standing or on an as needed basis (PRN). ..."

Review on October 16, 2015, of MR8 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for August 28, 30, 31, and September 1, 2015. These orders were valid for one calendar day. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of the bed, the pelvic restraint was reapplied. A new physician order for the restraints was not obtained for each episode when the patient was placed in a pelvic restraint or the enclosed bed. The restraints were used interchangeably.

Review on October 16, 2015, of MR9 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for October 15, 16, and 17, 2015. These orders were valid for one calendar day. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of the bed, the pelvic restraint was reapplied. A new physician order for the restraints was not obtained for each episode when the patient was placed in a pelvic restraint or the enclosed bed. The restraints were used interchangeably.

Review on October 16, 2015, of MR10 revealed a physician order for an "Enclosed Bed (while in bed) ..." restraint for September 16, 2015, at 5:30 PM. This order was valid for one calendar day. The patient was not placed in the bed until 10:26 PM.

Review on October 16, 2015, of MR11 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for August 30, 31, and September 1, 2015. These orders were valid for one calendar day. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of the bed, the pelvic restraint was reapplied. A new physician order for the restraints was not obtained for each episode when the patient was placed in a pelvic restraint or the enclosed bed. The restraints were used interchangeably.

Review on October 16, 2015, of MR12 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for September 2, 3, and 4, 2015. These orders were valid for one calendar day. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of the bed, the pelvic restraint was reapplied. A new physician order for the restraints was not obtained for each episode when the patient was placed in a pelvic restraint or the enclosed bed. The restraints were used interchangeably.

Review on October 16, 2015, of MR15 revealed physician orders for "pelvic holder (while in chair) ... Enclosed Bed (while in bed) ..." restraints for September 8, and 9, 2015. These orders were valid for one calendar day. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of the bed, the pelvic restraint was reapplied. A new physician order for the restraints was not obtained for each episode when the patient was placed in a pelvic restraint or the enclosed bed. The restraints were used interchangeably.

Interview on October 16, 2015, at 2:10 PM, with EMP20 confirmed that staff did not get new physician orders for each episode of restraints for MR8, MR9, MR10, MR11, MR12, and MR15. EMP20 revealed that these patients need to be continuously restrained because they have an extremely high risk of falling due to their traumatic brain injury condition. EMP20 indicated that the restraints are not used based on the patients' traumatic brain injury condition but due to the patients' high risk of severe bodily harm if a fall occurred. EMP20 confirmed it is for the patients' safety that the restraints are ordered simultaneously and with the words "while in bed" or "while in chair". EMP20 confirmed physicians order the pelvic lapbelt and enclosed bed restraints for staff to use as necessary. Patients can be removed from a pelvic or lapbelt restraint and be put in an enclosed bed restraint when patients are tired and need to sleep. Patients can then be removed from the enclosed bed restraint and put back in the pelvic or lapbelt restraint. EMP20 confirmed the applied restraints can be changed anytime of the day to meet the patients' needs depending on what activity the patients' are involved in.

Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that facility failed to develop a plan of care to address patient care needs related to dysphagia, diarrhea, and urinary urgency for one of ten medical record reviewed (MR1).

Findings include:

Review on October 13, 2015, of MR1 revealed that the patient was admitted to the Moss Rehab facility at Elkins Park on September 1, 2015 with the diagnoses of stiff person syndrome, dysphagia (difficulty swallowing), chronic diarrhea, urinary urgency, and history of falls status post discharge from an acute care hospital.
Review on October 13, 2015, of MR1's interdisciplinary care plans revealed they were developed between September 1, 2015 and September 13, 2015 and included "Fall Prevention, Discharge Planning, Caritas [concept of practicing care, loving kindness, faith/hope, sensitivity, healing environment ...], Impaired Mobility, Alteration in Comfort, Pressure Ulcer Prevention, and Anxiety."

Review on October 13, 2015, of MR1's video swallow study conducted on September 4, 2015, revealed "... Patient with regurgitation of swallowed material from esophagus into distal pharynx on every tested consistency ... Patient with significant esophageal dysphagia."

Requests were made on October 16, 2015, to EMP1 for a facility policy on care plans. EMP1 indicated that the facility did not have a policy addressing the development and revision of care plans.

Interview on October 15, 2015, at 1:55 PM, with EMP2 confirmed that there was no plan of care developed to address the patient's dysphagia, urinary frequency, and diarrhea during the patient's stay on September 1, 2015 through September 13, 2015. EMP2 also confirmed there was no policy for the development of care plans.

Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined the facility failed to maintain clear, complete and accurate documentation related to notifying the physician and documenting the abnormal heart rates in the patient's medical record for one of 10 medical records reviewed (MR1).

Findings include:

Review on October 15, 2015, of facility policy "Vital Signs," dated January 31, 2015, revealed "... Responsibilities A. The nurse will: ...2. Notify the physician and document when significant deviations in vital signs occur. ..."
Review on October 15, 2015, of MR1's physician progress note, dated September 2, 2015, revealed "...Tachycardia - none now, will keep checking for increased HR [heart rate] ..."
Review on October 15, 2015, of MR1's vital signs flowsheet, dated September 10, 2015, 7:32 AM, revealed the heart rate was 117 beats per minute.

Review on October 15, 2015, of MR1's vital signs flowsheet, dated September 11, 2015, 8:00 AM, revealed the heart rate was 122 beats per minute.

Review on October 15, 2015, of MR1's vital signs flowsheet, dated September 12, 2015, 7:59 AM, revealed the heart rate was 126 beats per minute.

Review on October 15, 2015, of MR1's vital signs flowsheet dated September 13, 2015, 10:35 AM, revealed the heart rate was 127 beats per minute.

Interview on September 15, 2015, at 1:55 PM, with EMP2 confirmed that the patient's heart rates of 117, 122, 126, and 127 beats per minute is considered a deviation from the normal vital signs. EMP2 confirmed there was no nursing documentation in MR1 about notifying the physician regarding the patient's abnormal heart rates on September 10, 11, 12, and 13, 2015.

Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to document a patient's intake and output for one of ten medical records reviewed (MR1).

Findings include:

Review on October 13, 2015, of MR1 revealed the patient was admitted to the Moss Rehab at Elkins Park on September 1, 2015, with the diagnoses of stiff person syndrome, dysphagia (difficulty swallowing), chronic diarrhea, urinary urgency, and history of falls status post discharge from an acute care hospital.
Review of MR1's progress notes from September 1-13, 2015, revealed no documented evidence that intake or output was recorded in the patient's medical record on the following dates: September 10, 11, 12, and 13, 2015.

Review of physician's orders, dated September 1, 2015, revealed "Time void q [every] 4 hours."
Review of the patient's adult nutrition initial assessment/plan, dated September 2, 2015, revealed "Pt [patient] moderate nutrition risk."

Review of a video swallow study, conducted on September 4, 2015, revealed "... Patient with regurgitation of swallowed material from esophagus into distal pharynx on every tested consistency ... Patient with significant esophageal dysphagia."

Review of a physician progress note, dated September 3, 2015, revealed "...urinary/bowel urgency."

Review of a rehabilitation medicine progress note, dated September 3, 2015, revealed "...+ [positive] urinary urgency progressively worsening over past several weeks, 9/2 u/a [urinalysis] negative, monitoring."

Review of a physician progress note, dated September 11, 2015, revealed "Cc [chief complaint]: watery diarrhea with abd. [abdominal] cramps for last 2 days ... Poor appetite."

Review of a physical medicine and rehabilitation attending note, dated September 12, 2015, revealed "Pt [patient] reports persistent diarrhea."

Review of a nursing narrative note, dated September 13, 2015, revealed "Weight was taken and was 176.2 lbs. Last weight on 9/9 was 187 lbs."

Requests were made on October 15, 2015 and October 16, 2015, to EMP1 for the facility's policy on recording intake and output. EMP1 revealed that the facility did not have a policy for recording a patient's intake and output.

Interview on October 15, 2015, at 1:55 PM, with EMP2 confirmed no intake or output was recorded for the patient on September 10, 2015 through September 13, 2015. EMP2 confirmed the time void was not recorded as ordered. EMP2 indicated that the practice of intake and output recording, for the Moss rehab, is every shift or, if more stringent, accordingly to the physician order. EMP2 confirmed there was no nursing policy for intake or output recording.

Based on observations, review of facility documents and interviews with staff (EMP), it was determined that the facility failed to ensure that the disposal of body fluids and soiled adult undergarments were disposed of in accordance with infectious waste guidelines; and failed to ensure that environmental services followed terminal cleaning procedures for the Surgical Suite.

Findings include:

1. Review of facility policy "Infectious Waste Management," effective January 16, 2014, revealed "Einstein Healthcare Network manages infectious waste in a manner to prevent spread of infection and in compliance with the PA Department of Environmental Protection. ... Infectious Waste - the term means municipal and residual waste which is generated in diagnosis, treatment ... which falls under one or more of the following categories: ... b. Pathological Wastes - Human pathological wastes, including tissues, organs and body parts ... and body fluids that are removed during surgery, autopsy, and other medical procedures ... e. Isolation wastes - Biological waste and waste contaminated with blood, excretion, exudates, or secretions from humans who are isolated, to protect others from highly virulent diseases ... Procedure: ... All waste identified as infectious will be placed in a labeled red bag ... ."

Observation on October 13, 2015, at 2:30 PM, following a colonoscopy procedure for PT3, revealed during the cleaning process of the procedure room EMP11 placed a vacuum cannister containing brown colored fluid (which included fecal particles/matter) that were products of the procedure into a regular plastic waste bag.

Interview on October 13, 2015, at 3:00 PM, with EMP12 confirmed that EMP11 placed the vacuum cannister, that contained a brown colored fluid, in the municipal plastic trash bag. EMP12 indicated that the facility did not consider the brown colored fluid to be infectious waste.

Review on October 14, 2015, of facility policy "Special Contact Precautions," dated July 15, 2015, revealed ... "To prevent transmission of Clostridium difficile infection (CDI) or norovirus by either healthcare workers or patient- care items ... 9. Patient Care equipment: discard disposable articles/equipment used in the isolation room in municipal trash ... ."

Interview on October 14, 2015, at 11:00 AM, with EMP22 revealed that soiled diapers from patients with "active" CDI are placed in the red trash/bag.

Interview on October 14, 2015, at 11:30 AM, with EMP14 confirmed that the facility did not consider the post colonoscopy procedure brown fluid (which contained fecal matter) to be infectious waste and the facility's "Infectious Waste Management" policy and procedure that followed the PA Department of Environmental Protection Guidelines was included in the Environmental Services Department Policies and Procedures.

Interview on October 15, 2015, at 2:00 PM, with EMP10 revealed that disposal waste containing fecal matter for patients with CDI are placed in the regular trash.

Review on October 16, 2015, of facility's staff education document revealed "... Infectious Waste ... Use gloves to discard items dripping with blood or body fluids ... into the infectious waste containers (red bag)."

Interview on October 16, 2015, at 11:00 AM, with EMP16 revealed that any item contaminated with body fluids was disposed of in the infectious waste red trash/bag.

Interview on October 16, 2015, at 11:30 AM, with EMP13 revealed that the main campus Gastrointestinal Department staff were disposing of vacuum filled cannisters, with post colonoscopy body fluids, in the infectious waste bag (red biohazard bags); however, the facility was in the process of reeducating staff, at the main campus, to dispose of the filled cannisters in the municipal regular waste plastic bags instead of the red biohazard bags.

Interview on October 16, 2015, at 1:00 PM, with EMP15 confirmed the facility's "Infectious Waste Management" policy was written directly from the Pennsylvania Department of Environmental Protection Guidelines.

Interview on October 16, 2015, at 2:30 PM, with EMP1 revealed that the facility considered the staff education training document for "Infectious Waste" as incorrect.

2. Review on October 16, 2015,of facility policy "Environmental Services ... Surgery, Cath Lab/Special Studies/Delivery/GI suite/ EPS Lab," undated, revealed the policy contained "... Terminal cleaning - daily - completed on 2nd shift ... High dust all areas above shoulder height ... damp wipe, using bleach wipes, overhead light fixtures, ledges, table/stretchers, monitors, IV poles/pumps, all rolling stock, all clinical equipment, and view boxes ... damp wipe, using bleach wipes, all items around perimeter of room - top to bottom, spot walls ... ."

Review on October 16, 2015, of facility document "Environmental Services Department Quality Improvement Inspection - OR , L&D, Cath Lab, Ambulatory Surgery," dated October 7, 2015, revealed a cleaning log that contained the following:

"Cysto Room #1 ... Overhead and ceiling lights free of dust and spots-No ... Room free from high dust- No ...
Cysto Room #2, ... Overhead and ceiling lights free of dust and spots - No ...
Surgical Room #4 ... Room free from high dust- no ...
Surgical Room #6 ... walls clean and free of spots- no ... Overhead and ceiling lights free of dust and spots - no
Surgical Room #10 and #11 ... Vents free of dust - no ... Room free from high dust - no
Surgical Room #12 ... Walls clean and free of spots - no ... Tables free of dust and blood - no ... ."

Review on October 16, 2015, of facility document "Environmental Services Department Quality Improvement Inspection - OR , L&D, Cath Lab, Ambulatory Surgery," dated October 6, 2015, revealed a cleaning log that contained the following:

"Cysto Room #1 ... walls clean and free of spots - no, table free of dust and blood - no,
Cysto Room #2 ... vents free of dust - no, room free from high dust - no
Surgical Room #5, #6, #7 and #11... Vents free of dust - no ... Room free from high dust - no
Surgical Room #10 ... Walls clean and free of spots - no,IV pokes, kick buckets, equipment clean and free of dust & blood - no, Vents free of dust - no ... ."

Review on October 16, 2015, of facility document "Environmental Services Department Quality Improvement Inspection - OR , L&D, Cath Lab, Ambulatory Surgery," dated September 22, 2015, revealed a cleaning log that contained the following:

"Cysto Room #1 ... table free of dust and blood - no ... Room free from high dust - No
Surgical Room #2 floor clean of dust, litter, blood - no, walls clean and free of spots - no, vents free of dust - no
Surgical Room #5, #6 and #11... Vents free of dust - no ... Room free from high dust - no
Surgical Room #12 ... windows clean - no, vents free of dust-no, room free from high dust - no ... ."

Review on October 16, 2015, of facility document "Environmental Services Department Quality Improvement Inspection - OR , L&D, Cath Lab, Ambulatory Surgery," dated September 21, 2015, revealed a cleaning log that contained the following:

"Surgical Room #2 ... walls clean and free of spots - no ... vents free of dust - no ... room free from high dust - no ...
Surgical Room #6 ... walls clean and free of spots - no ... table free of dust and blood - no ... vents free of dust - no ...
Surgical Room #7 ... IV poles, kick buckets, equip. clean and free of dust and blood - no ... overhead and ceiling lights free of dust and spots - no ...
Surgical Room #8 ... vents free of dust - no ... room free from high dust - no ...
Surgical Rooms #11 and #12 ... vents free of dust - no ... room free from high dust - no ... ."

Review on October 16, 2015, of facility document "Environmental Services Department Quality Improvement Inspection - OR , L&D, Cath Lab, Ambulatory Surgery," dated September 18, 2015, revealed a cleaning log that contained the following:

"Cysto #1 - walls clean and free of spots - no ... vents free of dust - no ... room free from high dust - no
Cysto #2 - IV poles, kick buckets, equipment clean and free of dust and blood - no ... vents free of dust - no ... room free from high dust - no ... ."

Interview on October 16, 2015, at 1:00 PM, with EMP15 revealed that the environmental supervisor failed to ensure that the deficiencies on the above logs were documented as corrected. Further interview with EMP15 confirmed the environmental supervisor had been in the position for six months and was not available to be an interviewed at the time of the survey.