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Based on observation and interview, the facility failed to maintain a two hour fire protective construction between itself and a nonconforming building, to ensure corridor doors with self closing and latching hardware closed and latched the doors, to maintain the rating on its barriers, to ensure doors in rated barriers had self closers that closed the doors and if so equipped, latched the doors, to ensure doors to hazardous areas had self closers, to have corridors on the paths of egress free of obstructions, to ensure battery powered emergency lighting conformed to 7.9.2, National Fire Protection Association 101, 2000 edition, to ensure fire drills were held under varying time, to ensure each fire extinguisher was readily acceptable in accordance with National Fire Protection Association 10, 1999 edition, failed to ensure its sprinkler system complied with National Fire Protection Association 25, 1999 edition and failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.

Findings include:

See C231

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. This has the potential to affect all patients at the facility. The facility had a census of eight patients at the time of survey.

Findings include:

K11 Failed to maintain a two hour fire protective construction between itself and a nonconforming building.
K18 Failed to ensure corridor doors with self closing and latching hardware closed and latched the doors.
K25 Failed to maintain the rating on its barriers.
K27 Failed to ensure doors in rated barriers had self closers that closed the doors and if so equipped, latched the doors.
K29 Failed to ensure doors to hazardous areas had self closers.
K46 Failed to ensure battery powered emergency lighting conformed to 7.9.2, National Fire Protection Association 101, 2000 edition.
K50 Failed to ensure fire drills were held under varying times.
K64 Failed to ensure each fire extinguisher was readily acceptable in accordance with National Fire Protection Association 10, 1999 edition.
K62 Failed to ensure its sprinkler system complied with National Fire Protection Association 25, 1999 edition.
K67 Failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.
K72 Failed to have corridors on the paths of egress free of obstructions.

Based on observation, medical record review, policy review, and staff interview the hospital failed to ensure policies were reviewed annually C-0272, failed to provide hand hygiene per policy C-0278, failed to assess and monitor patients per policy C-0294, and failed to implement and monitor patient specific care plans C-0298. The cumulative effect of these systemic practices resulted in the hospital's inability to ensure patients' needs would be met.

Based on observation and interview, the facility failed to ensure the policy manual for diets was reviewed annually. This had the potential to affect all eight patients in the facility.


Findings include:


On 10/22/15 at 10:20 AM, during tour of the kitchen, the dietary manual was reviewed. The last review date of the manual was 07/15/12. This was confirmed with Staff D at the time of the observation. During an interview with Staff A on 10/22/15 at 3:25 PM, Staff A stated that all other manuals are reviewed and signed on an annual basis.

Based on observation and staff interview the facility failed to ensure dietary personnel followed the established hospital policy for handwashing, glove usage, and dishwasher sanitation monitoring in the hospital cafeteria. This had the potential to affect all eight patients at the hospital.

Findings include:

1) Observation of Staff H, a dietary aide, on 10/20/15 at 12:20 PM revealed Staff H was wearing gloves while handling the food and exchanging money. Staff H made sandwiches including touching bread, meats, cheese and with the same gloves on and exchanged money through four patrons. After the fourth patron Staff H, removed his/her gloves and donned new gloves with no hand hygiene in between.

Review of the personnel file for Staff H was completed on 10/21/15. Staff H was hired by the hospital on 9/15/15. The job description in the personnel file for Staff H entitled "Dietary" under Essential Job Functions, Item 9) "Knows and follows hospital and department policies and procedures include safety standards..." The document was signed by Staff H on 9/02/15.

The personnel file also contained a Hospital Orientation Checklist that was signed by Staff H on 10/14/15 revealing all items on the checklist were covered including the item, "Infection Control Book".

Interview with Staff J on 10/21/15 at 10:30 AM included an opportunity to review the aformentioned Infection Control book and contents. Included in the book is the hospital policy from the department of Infection Control for Hand Hygiene. The policy includes the indications for hand washing, ie; after touching food and after removing gloves.

Interview with Staff D, manager, on 10/21/15 at 11:05 AM confirmed the observation of Staff H. Staff D could not confirm if Staff H had completed his/her departmental orientation where the infection control practices are reviewed.


2. On 10/22/15 at 11:04 AM Staff E was observed in the kitchen. Staff E had gloved hands and was observed to reach down and tie a shoe. Staff E then proceeded to pick two pens up from the floor and then began to pour hot water into coffee cups. Staff E did not remove gloves to perform hand hygiene after tying shoe or picking up pens from the floor.

3. At 12:55 PM Staff E was observed stacking the dish machine. When interviewed, Staff E stated she does not check the sanitizing solution to ensure dishes were properly sanitized. Staff G was then interviewed and stated the dishwashing sanitation wash is to be checked daily. There was no record of the dishwasher being checked for proper sanitation level. This was confirmed with Staff G. At 1:10 PM Staff F stated the sanitation strip should be around 100 parts per million (ppm). Staff F then checked the dish machine with a strip and stated the reading was between 10 and 50 and added, "50 would be generous". The manufacturer information noted the reading should be between 50-100 ppm for proper sanitation.

Interview with Staff D on 10/22/15 at 2:00 PM revealed the facility did not have a written policy for ensuring the dish machine sanitation. The latest vendor service report was reviewed and dated 08/31/15 which noted the dish washing machine was working properly.

In addition, the daily dishwasher temperature log noted on the wall in the dish room was not completed daily to ensure proper dish machine temperatures.




20866

Based on medical record review, staff interview, and policy review the facility failed to ensure vital signs were monitored, assessments were completed, and orders were followed per facility policy. This affected Patients #1, #5, #6, #7, #8, #9, #10, and #20. The hospital census was 8.

Findings include:

Hospital policy #G.N. 2.00, Assessment, Admission Nursing, revised 11/2014 documented the registered nurse is responsible for completing a head to toe assessment. Policy #G.N. 3.00, Assessment, Daily Nursing, revised 08/2014 documented the registered nurse will do an assessment of the patient within two hours of the beginning of the shift. Policy #G.N. 4.00, Vital Signs Routine - Adult, revised 08/2014 documented vital signs are to be taken on admission to the nursing unit and every four hours for the first 24 hours after admission.

1. On 10/19/15 the medical record of Patient #6 was reviewed and documented an admission on 10/19/15 at 12:07 PM with a diagnosis of pneumonia. Vital sign documentation during the first 24 hours included 1:00 AM, again at 7:04 AM (six hours later) and then again at 12:35 PM (five hours later).

2. On 10/19/15 the medical record of Patient #7 was reviewed and documented an admission on 10/18/15 at 1:29 PM with a diagnosis of Congestive Heart Failure. Vital sign documentation during the first 24 hours included 1:50 PM, again at 7:10 PM (five hours 20 minutes later), again at 12:19 AM (five hours later), again at 5:00 AM (four hours 40 minutes later), and again at 6:14 PM (13 hours 14 minutes later).

3. On 10/19/15 the medical record of Patient #8 was reviewed and documented an admission on 10/18/15 at 12:25 AM with a diagnosis of Acute Exacerbation of Congestive Heart Failure. Vial sign documentation during the first 24 hours included 12:00 AM, again at 6:25 AM (six hours 25 minutes later), again at 5:23 PM (11 hours later), again at 7:16 PM (two hours later), again at 12:14 AM (five hours later).

4. Review of the electronic medical record of (swing-bed) Patient #1 revealed an admission date of 10/17/15. Review of physician's orders revealed on 10/18/15, there was an order for intermittent pneumatic compression knee high device (used for embolism prevention). On 10/19/15 at 1:35 PM the pneumatic compression device was observed at the foot of the bed. The patient and spouse were interviewed and stated the device has never been used. Review of the electronic medical record with Staff C on 10/19/15 at 1:40 PM revealed no indication the device had been utilized. This was confirmed with Staff C.

5. Review of the electronic medical record of (swing bed) Patient #5 revealed an admission date of 10/18/15. Review of nursing documentation revealed the nurse had documented the patient's blood pressure but no other vital signs were recorded at the time the admission nursing assessment was completed. This was confirmed with Staff C on 10/22/15 at 8:30 AM.

6. Review of the electronic medical record of (swing bed) Patient #9 revealed an admission date of 10/15/15. Review of nursing documentation revealed the nurse had documented the patient's vital signs at 1745 (5:45 PM) however the patient was not admitted to the unit until 1930 (7:30 PM). In addition, there was no head to toe nursing assessment completed. This was confirmed with Staff B on 10/22/15 at 8:25 AM.

7. Review of the electronic medical record of Patient #20 revealed the patient was admitted to the medical unit on 10/08/15 at 4:50 PM. There was no recorded vital signs for the patient until 7:25 PM. During an interview with Staff C on 10/22/15 at 9:00 AM, Staff C stated the vital signs should have been obtained within 2 hours of admission.

8. Review of the medical record of (swing bed) Patient #10 revealed the patient was admitted on 10/16/15. A nursing note dated 10/16/15 revealed the patient had an open area on right medial foot. On 10/19/15 a nurse had noted the patient had three abrasions on the back. Per interview with Staff C on 10/20/15 at 9:20 AM, Staff C confirmed the area was present upon admission however it was not documented until 10/19/15. Review of the medical record on 10/20/15 revealed no physician's order for treatment of the open area on right medial foot.

On 10/22/15 at 10:00 AM Staff A confirmed the lack of assessment, vital signs, and following physician orders per hospital policy.









30270

Based on medical record review, staff interview, and policy review the facility failed to ensure plans of care reflected and met the needs of the patients. This affected seven in-patient medical records reviewed including Patients #6, #7, #8, #11, #12, #19, and #20. The hospital census was 8.


Findings include:


Hospital policy #G.N. 46.00, Multidisciplinary Plan of Care, revised 08/2014 documented the plan of care is an individualized problem-oriented approach utilizing the information obtained from the assessment of all disciplines.

1. On 10/19/15 the medical record for Patient #6 was reviewed and documented an admission on 10/19/15 with a diagnosis of pneumonia.
The electronic care plan identified problem areas including (1) Breathing - Pneumonia: with no goals, interventions, or frequency marked, (2) Knowledge Deficit: with goals, interventions, and frequencies marked "PRN" (as needed), (3) Inadequate Airway Clearance: with goals, interventions, and frequencies marked as "Topical PRN", (4) Inadequate Gas Exchange: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (5) Infection: with goals, interventions, and frequencies marked as "PRN", (6) Activity Intolerance/Impaired Mobility: with goals, interventions, and frequencies marked as "PRN", (7) Nutrition: with goals, interventions, and frequencies marked as "PRN", (8) Low Risk for Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (9) Difficulty with Activity - Pneumonia: with no goals, interventions, or frequencies, and (10) Breathing: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN".

2. On 10/19/15 the medical record for Patient #7 was reviewed and documented an admission on 10/18/15 with a diagnosis of Congestive Heart Failure (CHF). The electronic care plan identified problem areas including (1) High Risk For Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (2) Pain: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (3) Safety: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", and (4) Infection: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN.

3. On 10/19/15 the medical record for Patient #8 was reviewed and documented an admission on 10/18/15 with a diagnosis of Acute Exacerbation of Congestive Heart Failure (CHF). The electronic care plan identified problem areas including (1) Daily Care: with goals, interventions, and frequencies marked as "PRN", (2) Moderate Risk for Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (3) High Risk for Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (4) Pain: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (5) Pain:with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (6) Discharge Barriers: with goals, interventions, and frequencies marked as "PRN", (7) Hemodynamic Status: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (8) Excessive Fluid Volume: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", and (9) Inadequate Gas Exchange: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN".

4. On 10/20/15 the medical record for Patient #11 was reviewed and documented an admission on 10/19/15 with a diagnosis of pneumonia. The electronic care plan identified problem areas including (1) Knowledge Deficit: with goals, interventions, and frequencies marked "PRN", (2) Inadequate Airway Clearance: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (3) Inadequate Gas Exchange: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (4) Infection: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (5) Activity Intolerance/Impaired Mobility: with goals, interventions, and frequencies marked as "PRN", (6) Nutrition: with goals, interventions, and frequencies marked as "PRN", (7) High Risk for Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (8) Pain: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (9) Safety: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (10) Daily Care: with goals, interventions, and frequencies marked as "PRN", (11) Psychosocial Needs: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", and (12) Discharge Barriers: with goals, interventions, and frequencies marked as "PRN".

5. On 10/20/15 the medical record for Patient #12 was reviewed and documented an admission on 10/19/15 with a diagnosis of bilateral pneumonia. The electronic care plan identified problem areas including (1) Moderate Risk for Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (2) Pain: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (3) Safety: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (4) Daily Care: with goals, interventions, and frequencies marked as "PRN", (5) Psychosocial Needs: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN", (6) Discharge Barriers: with goals, interventions, and frequencies marked as "PRN", and (7) Low Risk for Falls: with goals, interventions, and frequencies marked as "PRN" and "Topical PRN".

6. Patient #19 was admitted to the facility on 10/07/15 with a diagnosis of cellulitis. Review of the plan of care revealed there were no interventions related to the patient's skin integrity. The plan of care did not note any specific issues related to the patient's diagnosis of cellulitis. This was confirmed with Staff C on 10/22/15 at 10:35 AM.

7. Patient #20 was admitted to the facility on 10/08/15 with a diagnosis of GI bleed. Review of the electronic medical record with Staff C on 10/22/15 revealed that the patient had a EGD (esophagogastroduodenoscopy) and received two units of blood. Review of the plan of care revealed it was not specific, no mention, of the EGD or units of blood. The plan of care was reviewed with Staff B and Staff C on 10/22/15 at 12:00 PM who verified the plan of care was not specific regarding these issues.

On 10/22/15 at 10:00 AM Staff A confirmed the electronic care plans were not individualized and incorrectly reflected the intervention frequencies.




30270

Based on observation, medical record review, policy review, and staff interview the hospital failed to ensure consents were signed per policy C-304, failed to ensure medical records were signed by physicians upon patient discharge C-307, and failed to ensure stored medical records were safeguarded against potent destruction C-0308. The cumulative effect of these systemic practices resulted in the hospital's potential inability to maintain and safeguard clinical records.

Based on medical record review, staff interview, and policy review the hospital failed to ensure informed consents were completed per hospital policy. This affected Patients #1, #3, #5, #7, #8,#11, and #13. The hospital census was 8.


Findings include:


Policy #A.D. 3.01.09, Informed Consent, revised on 01/2012 documented the consent of every capacitated adult patient should be obtained prior to treatment and is required for all procedures. If a patient is not capable of giving consent because of incompetence or other incapacity, consent should be obtained from a person who is empowered to act on the patient's behalf.

Policy #AD-3.01. entitled Patient's Rights and Responsibilities, item 5 Consent, documents "the patient has the right to receive from his/her physician, information necessary to give informed consent prior to the start of any procedure and/or should include, but not necessarily be limited to the specific procedure."

1. On 10/19/15 the medical record of Patient #7 was reviewed and documented an admission on 10/19/15 at 1:29 PM. The general consent for treatment was signed by the patient's spouse. On 10/20/15 at 11:30 AM Staff B stated Patient #7 was not incapacitated and confirmed Patient # 7 should have signed the consent form.

2. On 10/19/15 the medical record of Patient #8 was reviewed and documented an admission on 10/18/15 at 12:25 AM. The general consent for treatment was signed by Patient #8, however, all other consents and acknowledgements were signed with the patient's name in the spouse's cursive handwriting. Several of the consents signed with the patient's name by the spouse were also witnessed with staff signatures. The spouse's own signature was never signed on the consent forms. On 10/20/15 at 11:30 AM Staff B stated Patient #8 was not incapacitated and confirmed Patient # 8 should have signed all consent and acknowledgement forms.

3. On 10/20/15 the medical record of Patient #11 was reviewed and documented an admission on 10/19/15 at 7:29 PM. The general consent for treatment was signed by Patient #11, however, other consents and acknowledgements were signed with a family members name. On 10/20/15 at 11:30 AM Staff B stated Patient #11 was not incapacitated and confirmed Patient #11 should have signed all consent and acknowledgement forms.

4. Review of the medical record of (swing bed) Patient #1 revealed a date of admission of 10/17/15. There was no general consent signed for treatment. This was confirmed with Staff B on 10/19/15 at 1:45 PM.

5. Review of the medical record of (swing bed) Patient #3 revealed a date of admission of 10/07/15. There was no general consent signed for treatment. This was confirmed with Staff B on 10/19/15 at 2:10 PM.

6. Review of the medical record of (swing bed) Patient #5 revealed a date of admission of 10/18/15. Review of the hospital consent revealed it had been signed by the patient but not dated and there was no witness signature on the consent. This was confirmed with Staff B and Staff C on 10/22/15 at 8:30 AM.


20866

7. Patient # 13 was admitted to the hospital on 10/20/15 for an outpatient surgical procedure. The Consent to Operation, Anesthetics and Other Medical Services form was signed by the patient on 10/20/15 at 8:53 AM. It was witnessed by the physician assistant to the patient's surgeon. The patient's surgeon signed the form on 10/20/15 at 9:30 AM attesting the he/she had explained to the patient for the above procedure, the risk involved, its benefits, its alternative and the possible complications. The procedure written on the form and referenced above was "Right Knee Arthroscope".

The post operative note completed by the operating physician listed the procedure performed as "arthroscopic partial medial meniscectomy".

The finding was confirmed with Staff A on 10/21/15 at 2:00 PM.





30270

Based on document review and staff interview the hospital failed to ensure medical records were completed with physician signatures upon patient discharge as outlined in the hospital bylaws. The hospital census was 8.

Findings include:

Hospital Bylaws dated 01/2014 documented the admitting practitioner shall complete the medical record at the time of the patient's discharge, including progress notes, final diagnosis and discharge summary. A written notice of delinquency will be given if the records are not completed within 15 days after discharge of the patient. If the medical record is incomplete four business days after the warning is given, all admitting privileges of the practitioner shall be suspended.

On 10/21/15 at 11:00 AM the Medical Records Director, Staff K, provided the Hospital Medical Record Statistics used for the facility's delinquency report for the period 10/01/14 through 09/30/15. The average monthly delinquency was 170.92 records with an average monthly rate of 25.71 percent delinquent. Staff K confirmed the delinquency statistics.

Based on observation, estimated inventory, and staff interview the facility failed to ensure medical records were stored in an area that was protected from potential destruction. The hospital census was 8.

Findings include:

On 10/21/15 the Medical Records Director, Staff K, provided a tour of stored medical records in a free standing storage building located on the hospital campus. The building lacked a water sprinkler system or safeguards to protect medical records from potential destruction.

Staff K prepared an estimated inventory of stored hospital medical records. The report documented an estimated 18,884 medical records from years 2006 through 2011 stored in the unprotected building.

Staff K revealed 11 hospital departments stored an additional estimated 10,000 medical records in the unprotected building.

Staff A confirmed a total of nearly 19,000 unprotected medical records in the free standing storage building located on the hospital campus.