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Based on review of 12 medical records, review of hospital policies, and staff interviews, it was determined that the hospital failed to provide a patient with the initial "Important Message from Medicare" (IMM) within 2 days of admission and another patient with the second IMM notice prior to discharge. The IMM is a form that notifies Medicare inpatients of their discharge rights and is required to be provided to all Medicare beneficiaries within 2 days of admission and again within 2 days of discharge.

Patient #9 was transferred to the hospital on 1/30/2016 from another area hospital. Patient #9's medical record was reviewed on 2/4/2016. At the time of the review an IMM had not been completed and placed in the patient's medical record. Staff #H confirmed that no IMM had been completed and that according to hospital policy it is the responsibility of the registration department to notify or attempt to notify patients about their discharge appeal rights and to document the attempts.

Patient #8 was admitted on 12/22/2015 and was discharged on 1/14/2016. A review of her medical record on 2/4/2016 revealed that the second IMM had not been provided to the patient within 2 days of discharge. According to hospital policy the case managers are responsible for providing the patient the IMM within 2 days of discharge.

Failure to provide Medicare patients the Important Message from Medicare has the potential to violate the patient's right to the discharge appeal process.

Based on review of Patient #8's medical record it was determined that the hospital failed to obtain consent from the patient or her representative prior to a blood transfusion.

Patient #8 was transferred from another area hospital on 12/22/2015 after a cardiac catheterization procedure for a blockage and for a possible Coronary Artery Bypass Graft (CABG). The patient had a wound on her groin at the site of the catheterization. During her hospital stay the wound developed a hematoma. On 12/29/2015 at 10:44 AM the patient had an acute drop in Hemoglobin (Hgb), Red Blood Cells (RBCs) and Hematocrit (hct) and the groin hematoma worsened. At 11:38 AM a blood transfusion was ordered. Consent for the transfusion was not obtained at that time. Due to the patient being positive for antibodies there was a delay in obtaining blood that was appropriately typed and cross matched. The patient deteriorated during the next five hours requiring rapid response at 5:05 PM. The blood was received and administered during the rapid response.

The hospital had failed to obtain consent from the patient while she still had capacity to do so earlier in the day. The consent was completed the following day, 12/30/2015.

Based on review of 7 Registered Nurse (RN) employment files, review of the nursing orientation education, and interviews with the Human Resources staff and the nurse manager of Weinberg 6/Gudelsky 6 it was determined that the hospital failed to complete and validate the necessary orientation restraint education for a Staff RN prior to the RN working independently on the assigned unit.

Staff RN #D was an agency nurse contracted by the hospital to staff and provide care to patients on Guldelsky 6 (cardiac step-down unit). Review of the RN's education and competency evaluation with the Human Resources staff and the manager of Guldelsky 6 on 2/5/2016 revealed that the hospital failed to validate competency of the nurse's knowledge of how to safely apply restraints, how to document their use, and how to reevaluate the need for restraints according to hospital policy.

The Human Resources staff provided documentation from the employee's agency indicating that the employee had taken "competency exams" including "The Use of Restraints." However, the documentation did not indicate what that exam had included in regard to the restraint process, what types of restraint holds were taught (CPI, PMAB, etc.), or what equipment in which the nurse was competent in applying to patients.

The "Core RN Orientation Blueprint- Agency/Travelers-Critical Care Units" is a document that is used to validate through different teaching methods, such as return demonstration or observations, that the nurse is competent to perform various skills. RN #D did not have documentation that restraint skills had been validated prior to her working independently on the unit. The unit manager revealed that restraint skill validation would not be signed until the nurse was caring for a patient who required restraints.

Restraint education and policies for restraint holds and practices may vary in different patient care settings in which the agency nurse may have been employed/contracted. Also, devices for restraint use may vary from hospital to hospital. As part of their initial orientation as well as on a periodic basis, nurses are required to be competent in restraint practices prior to the need for initiating restraint practices. Failure of the hospital to provide education and validation of skill competencies related to restraints for nurses prior to the nurses working independently on their assigned units places patients and staff members at risk for harm/injury.

Based on review of 7 Registered Nurse (RN) employment files, review of the nursing orientation education, and interviews with Human Resource staff and the nurse manager of Weinberg 6/Gudelsky 6 it was determined that the hospital failed ensure that a non-employee licensed RN who was working in the hospital was appropriately oriented to the use of restraints prior to providing care.

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Failure of the hospital to provide education, validation of skill competencies, and to review polices and procedures specific to that hospital prior to the nurses working independently on their assigned units places patients and staff at risk for harm/injury.

Based on review of 12 medical records it was determined that the hospital failed to document justifications for restraints and the patient's condition while in restraints.

Patient #8 was transferred from an area hospital on 12/22/2015 after a cardiac catheterization procedure for a blockage and a possible CABG. The patient had a rapid response at 5:05 PM on 12/29/2015 due to altered mental status and level of consciousness decline. The patient was subsequently transferred to a higher level of care unit. An order for violent restraints was placed at 6:49 PM on 12/29/2015. Documentation to support the use of violent restraints or which restraints were to be applied was not found in the patient's medical record.

Per the hospital policy a patient in restraints should be monitored every 15 minutes for circulation, respiration, body alignment and skin condition. The continued need for the restraint is also to be assessed every 15 minutes. Every 2 hours staff is to offer the patient fluids, toileting and release for range of motion. There was no documentation of 15 minute assessments being performed during the restraint event. A new order for soft-limb nonviolent restraints was placed at 1:13 AM on 12/30/2015. At 9:00 PM a nursing note stated that the restraints were removed during the day shift. No time was noted. There was little and inconsistent documentation of the monitoring of the patient during the restraint events. Documentation every 2 hours from 9:00 PM on 12/29/2015 to 5:00 AM on 12/30/2015 was found in the patient's medical record. There was nothing else until the nursing note at 9:00 PM. Another nonviolent restraint order was made at 5:54 PM on 12/31/2015.

The lack of justifications for the restraints and the inconsistencies in the documentation of patient monitoring made it to ascertain when and why the patient was in restraints.

A review of 12 patient medical records revealed that the hospital failed to prescribe a diet to meet the nutritional needs of the patient.

Patient #8 was admitted on 12/22/2015. The patient had a history of Type II Diabetes, coronary artery disease, cerebral infarction, hypertension, peripheral vascular disease, hyperlipidemia and subclavian steal syndrome. One of patient #8's goals during her hospital stay was to control blood glucose levels, yet she did not receive a dietary consult until 1/11/2016.

On 12/22/2015 the patient was started on a heart healthy diet. On 12/23/2015 she was switched to a diabetic diet. Then on 12/29/2015 Patient #8 was ordered a wired jaw diet even though she did not have a wired jaw. On 12/30/2015 the patient was restarted on the heart healthy diet. On 1/5/2016 the patient was ordered a diabetic diet. On the same day 1/5/16 the patient #8 was also ordered a regular diet by her provider even though she did not meet the requirements to have a regular diet.

The diets ordered for Patient #8 throughout her hospital stay were inconsistent and did not meet her needs. The patient's blood glucose levels remained elevated during most of her hospital stay which may have been affected by the failure to determine the most appropriate therapeutic diet for the patient.

Based on observations in the Cardiac Surgical Intensive Care Unit (CSICU) on 2/4/2016, review of equipment management policies and logs and an interview with the Director of Regulatory and Compliance, it was determined that the hospital failed to make adequate provision to ensure the availability and reliability of equipment needed for its operations and services.

On 2/4/2016 the surveyor observed 2 emergency carts with defibrillators stored in the CSICU main hallways. The carts were plugged into electrical outlets that were not able to provide a continuous electrical source in the event of a power outage.

An interview with the Director of Regulatory and Compliance revealed that the hospital does differentiate between critical (lifesaving) and noncritical equipment in the equipment inventory logs. However, the hospital does not have a policy that requires critical equipment, such as ventilators, cardiac defibrillators, or extracorporeal membrane oxygenation (ECMO), to have a continuous electrical source should the hospital lose electric power. Electrical outlets that receive power from a generator in the event of a power outage are color coded red.

Failure to ensure that critical lifesaving equipment is stored and/or used without ensuring a continuous source of power should the hospital experience a power outage places patients at potential risk for harm.