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Based on observation and interview the facility failed to ensure each smoke barrier was free of penetrations, each path of egress had illuminated signs, each sprinkler head was clean, humidity levels in the operating rooms were equal to or greater than 35 percent, and there were battery powered illumination in the generator room.

Findings:

See C231

Based on observation and interview, the facility failed to ensure it met the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association: failed to ensure each path of egress was marked by approved readily visible signs directing persons to reach an exit; failed to maintain the integrity of its smoke barriers; failed to have battery powered emergency lighting equipment in the generator room; failed to ensure sprinkler heads were clean and nothing was positioned within 18 inches of the sprinkler heads; failed to maintain the humidity levels greater than 35 percent in anesthetizing locations.
The facility's census was 9 patients.

Findings:

See K22 for findings of failed to ensure each path of egress was marked by approved readily visible signs directing persons to reach an exit.

See K25 for findings of failed to maintain the integrity of each smoke barrier.

See K46 for findings of failed to have battery powered emergency lighting equipment in the generator room.

See K62 for findings of failed to ensure sprinkler heads were clean and nothing was positioned within 18 inches of the sprinkler heads.

See K78 for findings of failed to maintain the humidity levels greater than 35 percent in anesthetizing locations

Based on medical record review, staff interview and facility documentation, the facility failed to implement comprehensive plans of care for two (Patients #3 and #4)of nine patients reviewed. The facility census was nine.

Findings included:

Review of the medical record for Patient #3 was completed on 03/26/13. Patient #3 was admitted to the facility on 03/24/13 at 4:30 P.M. with diagnoses that included acute respiratory failure, congestive heart failure with cardiac ischemia, chronic kidney stones, diabetes, hypertension, and a history of Parkinson's disease. The medical record revealed this 95 year old patient was a full code patient who was intubated and placed on a ventilator (mechanical breathing machine) for respiratory assistance. The physician's progress notes indicated the patient was provided a poor prognosis on 03/24/13. On 03/25/13 at 5:00 P.M. a decision to change the patient's code status from full code to a Do Not Resuscitate (DNR) Comfort Care status was made. Review of the plan of care on 03/26/13 at 10:15 A.M. revealed the patient had no plan of care for the delivery of nursing care during the patient's hospital stay, from 03/24/13 to 3/26/13.

Interview on 03/26/13 at 10:15 A.M. with Staff A, verified Patient #3 did not have a plan of care to direct the patient's end of life care or any plan of care. Staff A verbalized the facility's expectations would be that each patient had a plan of care and that revisions to the plan of care would be completed by the nursing staff on duty at the time changes in the patient's status occurred.

Review of the medical record for Patient #4 on 03/25/13 revealed Patient #4 was admitted to the facility on 03/23/13 with a history of shortness of breath, chronic obstructive pulmonary disease (COPD), and congested heart failure. The physician's assessment and plan documented the patient's shortness of breath was most likely secondary to an exacerbation of the patient's COPD. The plan documented the physician would add Spiriva (a once a day inhalant medication used in the management of COPD), Solu-Medrol (an anti inflammatory medication often used in the management of COPD), as well as an antibiotic medication.

Review of Patient #4's plan of care revealed the plan failed to address the patient's respiratory concerns. This finding was verified with Staff A on 03/25/13 at 4:20 P.M.

The facility's policy entitled, "Inpatient Care Services for Registered Nurses and Key Job Duties, Responsibilities and Projects", with an approval date of 07/06/11 was reviewed. This policy directed facility nurses to systematically identify patient care needs, organize patient care needs into a plan of care with measurable goals, communicate, implement and direct goals to the patient and health care team, monitor the patient's progress and revise the patient's plan of care and goals as necessary.

During interview with Staff A on 03/25/13 at 4:20 P.M., Staff A confirmed the facility failed to develop a comprehensive plan of care for the patient.