HospitalInspections.org

Based on observation, record review and interview, the facility was determined to be out of compliance with 42 CFR 482.13 Condition of Participation on Patient Rights based on the facility's failure to: 1-ensure patient privacy and safety related to visitation; 2-honor the patient's right to receive care in a safe setting; and 3-inform the patient and/or family of their visitation rights. Refer to A-0142, A-0144 and A-0216.

Based on observation, record review and interview, the facility failed to ensure patient privacy and safety related to visitation in one (#1) of 10 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 930am revealed that most visitors walked through the main entrance without checking in at the front desk.

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 10:01am to 10:18am until the family members came and questioned who the unknown visitor was.


Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 1:35pm confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 2:15pm confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Discussion with the Chief Operating Officer, Chief Nursing Officer and Assistant Chief Nursing Officer conducted on 6-26-12 at 4:00 pm confirmed the need to protect patients from unauthorized visitors, especially the confused and/or disoriented elderly patients.


On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in , nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, record review and interview, the facility failed to honor the patient's right to receive care in a safe setting in one (#1) of 10 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 1001am to 1018am until the family members came and questioned who the unknown visitor was.

Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 930am revealed that most visitors walked through the main entrance without checking in at the front desk.

Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10:00 am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 1:35pm confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 2:15pm confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Discussion with the Chief Operating Officer, Chief Nursing Officer and Assistant Chief Nursing Officer conducted on 6-26-12 at 4:00 pm confirmed the need to protect patients from unauthorized visitors, especially the confused and/or disoriented elderly patients.

On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in , nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on record review and interview, the facility failed to provide and reinforce patient and/or family information specific to the patient's need for safety and privacy with regards to visitation rights in 5 (#2, #3, #4, #5 and #6) of 6 interviewed sample patients/family.

The findings include:

Review of the facility Policy#2-11-4-002: Patient/Significant Other Education, Interdisciplinary conducted on 6-26-12 included but not limited to: "All patients admitted will receive the following admission instructions at a minimum (1) orientation to call light system, telephone, bed control, visiting hours; (2) patient's rights; and (3) encouragement to report any safety concerns to the hospital staff."

Interview with SP#2 conducted on 6-26-12 at 1035am revealed that visiting hours and privileges were not explained to her.

Interview with SP#3 conducted on 6-26-12 at 1045am revealed that she was not informed of her visitation rights.

Interview with SP#4's spouse conducted on 6-26-12 at 1055 revealed that visiting hours, visitation rights and privileges were not explained to her.

Interview with SP#5 conducted on 6-26-12 at 1105am revealed that he would divulge information to anyone asking him because he thinks of the inquiring party as a Hospital staff/employee. He explained that he believes security checks have already been done at the front desk and at the nurse's station and that he does not have to worry about someone asking him information.

Interview with SP#6's spouse conducted on 6-26-12 at 1115am revealed that he comes to visit SP#6 different times during the day. He stated that the staff did not discuss visiting hours and visitation rights with him.

Interview with the Chief Nursing Officer conducted on 6-26-12 at 215pm revealed that patients and/or family members are given a handbook on admission. She stated that the handbook has the information as stated in the Policy. She confirmed the need for reinforcement of safety information related to visitation. She concurred that not all patients/family members read through the handbook. She recognized the need for staff and patient education regarding safety measures related to visitation. She concurred that this will increase awareness on patient safety and aid in preventing the occurrence of another incident.

Based on observation, record review and interview, the facility was determined to be out of compliance with 42 CFR 482.21 Condition of Participation on Quality Assessment and Performance Improvement based on the facility's failure to: (1) monitor the effectiveness of the risk reduction strategies enumerated in the Root-Cause Analysis performed. (2) assume full responsibly and accountability for ensuring the prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor incident of 1 of 10 sampled patients ( SP #1). and (3) ensure prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor of sampled patient (SP) #1.

Refer to A-0275, A-309, and A-0311.

Based on observation, record review and interview, the facility failed to monitor the effectiveness of the risk reduction strategies enumerated in the Root-Cause Analysis performed.

The findings include:

Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 9:30 am revealed that most visitors walked through the main entrance without checking in at the front desk.


Review of the updated Root-Cause Analysis conducted on 7-10-12 revealed:

Review of Action Item#1 showed: "Visitors entering the hospital via its 2 main entrances (main west lobby area and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [Identification], sign in and be provided with a visitor sticker with their name and number of room which they will be visiting. Dates of Completion: 6-25 ED lobby entrance: 6-27. Measure: Random audit of surveillance video for verification of visitors signing in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#7 showed: "In cases where a visitor refuses to sign in, a Code 60 will be called with a detailed description of the person refusing to sign in to be relayed over the 2-way radio system to PBX [overhead paging system], Security, Engineering and Registration Personnel..." Dates of Completion: 6-21 and ongoing. Measure: Random audit of surveillance video for verification of visitors signing-in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#10 showed: "Employee awareness and inquiry guidelines for visitors will be incorporated in Risk Management Orientation and Annual Mandatory Education, Compliance and Ethics Annual Mandatory Education. Dates of Completion: Started 6-27 and ongoing. Measure: 100% of hospital employees to undergo inservice." There was no documented evidence of the content of the inservice and the employees who attended the planned staff education. There was no documentation on how staff education affected the effectiveness/failure of the plan.

Review of Action Item#12 showed: "Clinical staff's active interaction with visitors. Action item discussed during Departmental Unit-Based Patient Safety Committee meeting on June 26, 2012. Action item will also be discussed during unit staff meetings. Dates of Completion: Started 6-26 and ongoing. Measure: Random observation audits by "secret shopper" auditors." There was no documented evidence of the date/time and results of the observation audits made by the "secret shoppers" and how such observations contributed to the effectiveness/failure of the plan.

Telephone interview with the Chief Nursing Officer conducted on 7-10-12 at 1245pm revealed that she will follow-up on the matters discussed above.


On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in, nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, interview and record review the facility's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), and administrative officials failed to assume full responsibly and accountability for ensuring the prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor incident of 1 of 10 sampled patients ( SP #1).



The findings include:
Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 9:30 am revealed that most visitors walked through the main entrance without checking in at the front desk.

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

.

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 10:01 am to 10:18 am until the family members came and questioned who the unknown visitor was.


Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10 am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 1:3 confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 2:1 confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Review of the updated Root-Cause Analysis conducted on 7-10-12 revealed additional risk reduction strategies revealed:

Review of Action Item#1 showed: "Visitors entering the hospital via its 2 main entrances (main west lobby area and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [Identification], sign in and be provided with a visitor sticker with their name and number of room which they will be visiting. Dates of Completion: 6-25 ED lobby entrance: 6-27. Measure: Random audit of surveillance video for verification of visitors signing in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#7 showed: "In cases where a visitor refuses to sign in, a Code 60 will be called with a detailed description of the person refusing to sign in to be relayed over the 2-way radio system to PBX [overhead paging system], Security, Engineering and Registration Personnel..." Dates of Completion: 6-21 and ongoing. Measure: Random audit of surveillance video for verification of visitors signing-in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#10 showed: "Employee awareness and inquiry guidelines for visitors will be incorporated in Risk Management Orientation and Annual Mandatory Education, Compliance and Ethics Annual Mandatory Education. Dates of Completion: Started 6-27-12 and ongoing. Measure: 100% of hospital employees to undergo inservice." There was no documented evidence of the content of the inservice and the employees who attended the planned staff education. There was no documentation on how staff education affected the effectiveness/failure of the plan.

Review of Action Item#12 showed: "Clinical staff's active interaction with visitors. Action item discussed during Departmental Unit-Based Patient Safety Committee meeting on June 26, 2012. Action item will also be discussed during unit staff meetings. Dates of Completion: Started 6-26-12 and ongoing. Measure: Random observation audits by "secret shopper" auditors." There was no documented evidence of the date/time and results of the observation audits made by the "secret shoppers" and how such observations contributed to the effectiveness/failure of the plan.

Telephone interview with the Chief Nursing Officer conducted on 7-10-12 at 12:45pm revealed that she will follow-up on the matters discussed above.

On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in, nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, interview ,and record review the facility failed to ensure prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor of sampled patient (SP) #1.

The findings include:
Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 930am revealed that most visitors walked through the main entrance without checking in at the front desk.

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 1001am to 1018am until the family members came and questioned who the unknown visitor was.


Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 135pm confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 215pm confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Discussion with the Chief Operating Officer, Chief Nursing Officer and Assistant Chief Nursing Officer conducted on 6-26-12 at 4pm confirmed the need to protect patients from unauthorized visitors, especially the confused and/or disoriented elderly patients.

On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in, nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, record review and interview, the facility was determined to be out of compliance with 42 CFR 482.13 Condition of Participation on Patient Rights based on the facility's failure to: 1-ensure patient privacy and safety related to visitation; 2-honor the patient's right to receive care in a safe setting; and 3-inform the patient and/or family of their visitation rights. Refer to A-0142, A-0144 and A-0216.

Based on observation, record review and interview, the facility failed to ensure patient privacy and safety related to visitation in one (#1) of 10 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 930am revealed that most visitors walked through the main entrance without checking in at the front desk.

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 10:01am to 10:18am until the family members came and questioned who the unknown visitor was.


Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 1:35pm confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 2:15pm confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Discussion with the Chief Operating Officer, Chief Nursing Officer and Assistant Chief Nursing Officer conducted on 6-26-12 at 4:00 pm confirmed the need to protect patients from unauthorized visitors, especially the confused and/or disoriented elderly patients.


On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in , nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, record review and interview, the facility failed to honor the patient's right to receive care in a safe setting in one (#1) of 10 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 1001am to 1018am until the family members came and questioned who the unknown visitor was.

Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 930am revealed that most visitors walked through the main entrance without checking in at the front desk.

Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10:00 am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 1:35pm confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 2:15pm confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Discussion with the Chief Operating Officer, Chief Nursing Officer and Assistant Chief Nursing Officer conducted on 6-26-12 at 4:00 pm confirmed the need to protect patients from unauthorized visitors, especially the confused and/or disoriented elderly patients.

On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in , nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on record review and interview, the facility failed to provide and reinforce patient and/or family information specific to the patient's need for safety and privacy with regards to visitation rights in 5 (#2, #3, #4, #5 and #6) of 6 interviewed sample patients/family.

The findings include:

Review of the facility Policy#2-11-4-002: Patient/Significant Other Education, Interdisciplinary conducted on 6-26-12 included but not limited to: "All patients admitted will receive the following admission instructions at a minimum (1) orientation to call light system, telephone, bed control, visiting hours; (2) patient's rights; and (3) encouragement to report any safety concerns to the hospital staff."

Interview with SP#2 conducted on 6-26-12 at 1035am revealed that visiting hours and privileges were not explained to her.

Interview with SP#3 conducted on 6-26-12 at 1045am revealed that she was not informed of her visitation rights.

Interview with SP#4's spouse conducted on 6-26-12 at 1055 revealed that visiting hours, visitation rights and privileges were not explained to her.

Interview with SP#5 conducted on 6-26-12 at 1105am revealed that he would divulge information to anyone asking him because he thinks of the inquiring party as a Hospital staff/employee. He explained that he believes security checks have already been done at the front desk and at the nurse's station and that he does not have to worry about someone asking him information.

Interview with SP#6's spouse conducted on 6-26-12 at 1115am revealed that he comes to visit SP#6 different times during the day. He stated that the staff did not discuss visiting hours and visitation rights with him.

Interview with the Chief Nursing Officer conducted on 6-26-12 at 215pm revealed that patients and/or family members are given a handbook on admission. She stated that the handbook has the information as stated in the Policy. She confirmed the need for reinforcement of safety information related to visitation. She concurred that not all patients/family members read through the handbook. She recognized the need for staff and patient education regarding safety measures related to visitation. She concurred that this will increase awareness on patient safety and aid in preventing the occurrence of another incident.

Based on observation, record review and interview, the facility was determined to be out of compliance with 42 CFR 482.21 Condition of Participation on Quality Assessment and Performance Improvement based on the facility's failure to: (1) monitor the effectiveness of the risk reduction strategies enumerated in the Root-Cause Analysis performed. (2) assume full responsibly and accountability for ensuring the prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor incident of 1 of 10 sampled patients ( SP #1). and (3) ensure prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor of sampled patient (SP) #1.

Refer to A-0275, A-309, and A-0311.

Based on observation, record review and interview, the facility failed to monitor the effectiveness of the risk reduction strategies enumerated in the Root-Cause Analysis performed.

The findings include:

Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 9:30 am revealed that most visitors walked through the main entrance without checking in at the front desk.


Review of the updated Root-Cause Analysis conducted on 7-10-12 revealed:

Review of Action Item#1 showed: "Visitors entering the hospital via its 2 main entrances (main west lobby area and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [Identification], sign in and be provided with a visitor sticker with their name and number of room which they will be visiting. Dates of Completion: 6-25 ED lobby entrance: 6-27. Measure: Random audit of surveillance video for verification of visitors signing in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#7 showed: "In cases where a visitor refuses to sign in, a Code 60 will be called with a detailed description of the person refusing to sign in to be relayed over the 2-way radio system to PBX [overhead paging system], Security, Engineering and Registration Personnel..." Dates of Completion: 6-21 and ongoing. Measure: Random audit of surveillance video for verification of visitors signing-in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#10 showed: "Employee awareness and inquiry guidelines for visitors will be incorporated in Risk Management Orientation and Annual Mandatory Education, Compliance and Ethics Annual Mandatory Education. Dates of Completion: Started 6-27 and ongoing. Measure: 100% of hospital employees to undergo inservice." There was no documented evidence of the content of the inservice and the employees who attended the planned staff education. There was no documentation on how staff education affected the effectiveness/failure of the plan.

Review of Action Item#12 showed: "Clinical staff's active interaction with visitors. Action item discussed during Departmental Unit-Based Patient Safety Committee meeting on June 26, 2012. Action item will also be discussed during unit staff meetings. Dates of Completion: Started 6-26 and ongoing. Measure: Random observation audits by "secret shopper" auditors." There was no documented evidence of the date/time and results of the observation audits made by the "secret shoppers" and how such observations contributed to the effectiveness/failure of the plan.

Telephone interview with the Chief Nursing Officer conducted on 7-10-12 at 1245pm revealed that she will follow-up on the matters discussed above.


On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in, nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, interview and record review the facility's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), and administrative officials failed to assume full responsibly and accountability for ensuring the prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor incident of 1 of 10 sampled patients ( SP #1).



The findings include:
Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 9:30 am revealed that most visitors walked through the main entrance without checking in at the front desk.

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

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Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 10:01 am to 10:18 am until the family members came and questioned who the unknown visitor was.


Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10 am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 1:3 confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 2:1 confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Review of the updated Root-Cause Analysis conducted on 7-10-12 revealed additional risk reduction strategies revealed:

Review of Action Item#1 showed: "Visitors entering the hospital via its 2 main entrances (main west lobby area and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [Identification], sign in and be provided with a visitor sticker with their name and number of room which they will be visiting. Dates of Completion: 6-25 ED lobby entrance: 6-27. Measure: Random audit of surveillance video for verification of visitors signing in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#7 showed: "In cases where a visitor refuses to sign in, a Code 60 will be called with a detailed description of the person refusing to sign in to be relayed over the 2-way radio system to PBX [overhead paging system], Security, Engineering and Registration Personnel..." Dates of Completion: 6-21 and ongoing. Measure: Random audit of surveillance video for verification of visitors signing-in." There was no documented evidence of the random audits done, proving the effectiveness/failure of the plan in place.

Review of Action Item#10 showed: "Employee awareness and inquiry guidelines for visitors will be incorporated in Risk Management Orientation and Annual Mandatory Education, Compliance and Ethics Annual Mandatory Education. Dates of Completion: Started 6-27-12 and ongoing. Measure: 100% of hospital employees to undergo inservice." There was no documented evidence of the content of the inservice and the employees who attended the planned staff education. There was no documentation on how staff education affected the effectiveness/failure of the plan.

Review of Action Item#12 showed: "Clinical staff's active interaction with visitors. Action item discussed during Departmental Unit-Based Patient Safety Committee meeting on June 26, 2012. Action item will also be discussed during unit staff meetings. Dates of Completion: Started 6-26-12 and ongoing. Measure: Random observation audits by "secret shopper" auditors." There was no documented evidence of the date/time and results of the observation audits made by the "secret shoppers" and how such observations contributed to the effectiveness/failure of the plan.

Telephone interview with the Chief Nursing Officer conducted on 7-10-12 at 12:45pm revealed that she will follow-up on the matters discussed above.

On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in, nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.

Based on observation, interview ,and record review the facility failed to ensure prompt and timely implementation of risk reduction strategies and safety measures on visitation immediately after the unauthorized visitor of sampled patient (SP) #1.

The findings include:
Observation of the Hospital Lobby Entrance conducted on 6-26-12 at 930am revealed that most visitors walked through the main entrance without checking in at the front desk.

Clinical record review of Sample Patient (SP)#1 conducted on 6-26-12 revealed that she was admitted to the hospital on 6-15-12 due to abdominal discomfort. Nursing documentation showed that SP#1 was "oriented to own ability" and "disoriented to situation and to time."

Review of the Hospital Policy#4-5-1-030: Visitation Hours and Control of Visitors conducted on 6-26-12 included but not limited to: "Visitation hours shall reflect a mutual understanding of patient's needs and staff responsibilities. A mechanism will be established to ensure that there is proper control of guests within the hospital."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that an unauthorized visitor was in and out of SP#1's room on 6-17-12 from 1001am to 1018am until the family members came and questioned who the unknown visitor was.


Review of the Hospital Corrective Action Plan conducted on 6-26-12 revealed that this Plan was formulated due to the unauthorized visitor incident. One of the corrective actions stated: "Visitors entering the hospital via its two main entrances (main west lobby and ED [Emergency Department] lobby area entrances) will be asked to present photo ID [identification] and sign in at all times."

Review of the Hospital-prepared Root-Cause Analysis conducted on 6-26-12 revealed that "Inconsistent visitor screening process at the Emergency Department lobby entrance" contributed to the occurrence of the unauthorized visitor incident.

Interview with the Hospital Compliance Officer conducted on 6-26-12 at 10am confirmed the incident that an unknown lady was found in SP#1's room that day, 6-17-12.

Interview with the Chief Operating Officer conducted on 6-26-12 at 135pm confirmed that the visitor screening process contributed to the occurrence of the incident. She explained "open visitation" practiced by the Hospital as "no entry checks within business hours."

Interview with the Chief Nursing Officer conducted on 6-26-12 at 215pm confirmed that an unauthorized visitor was in SP#1's room, compromising patient safety. She confirmed the need for more focused staff/patient education regarding safety measures related to the incident to prevent re-occurrence.

Discussion with the Chief Operating Officer, Chief Nursing Officer and Assistant Chief Nursing Officer conducted on 6-26-12 at 4pm confirmed the need to protect patients from unauthorized visitors, especially the confused and/or disoriented elderly patients.

On 7/9/2-12 at 1:20pm via a telephone interview with the Administrator and the Compliance Officer, the administrator stated that the visitors observed by the surveyor on 6-26-12 at 9:30 am at the Hospital Lobby Entrance were all employees of the facility. She then stated that they do not sign in, nor do they have to show their Identification badges because the front desk staff recognizes them as employees. The administrator also stated that the facility do not have a policy regarding employees having to show their badges at the front desk upon entering the building.