HospitalInspections.org

Based on document review and staff interview, it was determined the facility failed to ensure patients admitted to the facility were notified of the state survey agency phone number for filing grievances for 88 of 88 current patients and failed to have policies and procedures that clearly defined a process for identifying/resolving grievances. Findings include:

During the 8-19-10-10 review of the "Know Your Rights" pamphlet used by the hospital to notify patients of the right to file a grievance, it was noted that the form did not include the state agency complaint hotline phone number. It was also noted that the hospital's policies and procedures for patient rights and complaint resolution process did not include a clearly defined process for grievance identification and resolution.
During an interview on 8-19-10, the Director of Human Resources and Environment of Care (staff interview H) confirmed that the hospital did not have a process for notifying patients of how to file a grievance with the state survey agency and that the policies and procedures did not clearly define a grievance identification/resolution process..

Based on document review and staff interview, it was determined the facility failed to ensure that all discharged records were complete within 30 days of discharge. Findings include:

During the 8-18-10 review of the incomplete record listing, printed on 8-16-10, and confirmed by the Director of Health Information Management (staff interview G) during an interview on 8-18-10 at approximately 10:50, it was identified that there were 154 incomplete patient records beyond 30 days following the patient's discharge from the facility.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon observation, the facility failed to maintain the physical plant to ensure the safety of patients.

Findings Include:
On 8/18/10 at approximately 10:15 AM, based upon observation, the drain line from the ice bin in the ice machine at the ambulance entrance area was not properly air-gapped to waste.
On 8/18/10 at approximately 11:00 AM, based upon observation, the drain line from the ice bin in the ice machine at the main dining room beverage station was not properly air-gapped to waste.
On 8/18/10 at approximately 11:00 AM, based upon observation, the beverage station cabinet in the main dining room was discovered to be water damaged and deteriorating near the floor drain.
On 8/18/10 at approximately 11:00 AM, the spill tray drain line from the ice machine at the main kitchen beverage station was observed to be clogged and not draining properly. An accumulation of slime mold was observed at the discharge end of this drain line.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on August 18, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated August 18, 2010, for Life Safety Code.