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Based on a review of 78 open medical records and 32 closed records, it was determined that four Medicare recipients had not been informed of their rights to appeal discharge decisions. Specifically, the closed medical records for Medicare recipients number 104,108, 112, 114, 120, and 127 did not contain evidence that the patients had received the Important Message from Medicare. The medical records for patients 104 and 127 contained no Important Messages; the other records listed contained one each.

Based on observation and interview, it was determined that the hospital failed to maintain the personal privacy of at least one adult psychiatric patient. It was determined that patients on close observation on the Adult Psychiatric Unit (N11W) may have their beds pulled into the hallway overnight to facilitate monitoring by staff as evidenced by:

Patient # 62 is a 47 year old male admitted to the adult behavioral health unit on December 5, 2011 at 5:44 PM. Patient #62 has a history of Major Depressive Disorder, Post Traumatic Stress Disorder, alcohol dependence, substance abuse, and traumatic brain injury, who presented with suicidal (with plan) and homicidal ideation towards his girlfriend (with plan) who he states had been physically and mentally abusing him.

On surveyor entry to the unit between 8:45 and 9 am on December 6, 2011, patient #62 was observed sitting on the edge of his bed eating breakfast in the hall. On inquiry, one staff member stated that patient #62 was on close observation and stated that beds are usually put back in their rooms by this time. Another staff member later stated that staff "Pull beds out at night for close observation," and that "Some (patients) feel safer sleeping in the hall."

Review of hospital policy "Safety: Levels of Observation" (effective 5/1/2011) reveals that "Close Observation: Individual patients," is the "Continuous visual monitoring of an individual patient." Staffing for close observation is two patients to one staff person with the expectation of every 15 minute documentation. Review of the policy reveals no mechanism for maintaining safety and privacy for patients sleeping in the hallway, who are vulnerable to other passing behavioral health patients and visible to other patients and visitors, nor does the policy direct staff on how to maintain confidentiality in their interactions with patients being monitored in the hallways.

At the end of the surveyor unit review, patient #62 was noted to be in his bed, still in the hallway. At that time, he was lying down and dozing while other patients and staff passed by.

Review of patient #62's record revealed only that he was on close observation. No documentation indicated that patient #62 was in a bed in the hallway. Nor did documentation describe informing patient #62 of his right to privacy while on close observation. Of the other open patient records reviewed, the physical location of patients on close observation was noted only sporadically, so it is impossible to determine if, or how many, other patients are spending nights in the hall.

Based on a review of closed records, it is determined that patient # 118 was treated in an unsafe manner when he was sent back to the sending hospital following his transfer to the behavioral health unit.

Patient #118 is a 34-year-old male with Schizoaffective disorder, bipolar type, Post Traumatic Disorder, and cannabis abuse who on October 1, 2011 was transferred from an outside hospital (OSH) for direct involuntary admission to the adult behavioral health (BH) unit. On arrival to the BH unit at 10:55 PM, an RN writes, in part, the following note:

"Pt [patient] arrived by ambulance from (OSH) at 22:40. Examination of the original paperwork upon arrival showed that page 1 of the certification, the Application for Involuntary Admission, was not included. The nurse called patient's nurse at (OSH) who was occupied, so she spoke with the ED [emergency department] charge nurse who was able to find the original Application in pt's (OSH) chart. This RN advised the charge nurse that the ambo [ambulance] crew would be returning pt to (OSH) in order to pick up all of the necessary paperwork. Pt was not accepted by this nurse, nor was he let out of restraints .... "

The nurse proceeded to send the restrained patient back to the OSH with the ambulance crew, and he was returned to the unit approximately 40 minutes later.

The RN did not consult a physician, or any one else, prior to sending patient #118 back to the OSH. Therefore, no physician transfer risk/benefit assessment was completed. Review of the hospital policy for accepting involuntary admissions does not support the nurse's stated need for the original paperwork, and does not support sending a vulnerable restrained patient in the grips of a psychiatric disorder of such severity as to require involuntary admission back to the sending hospital to retrieve missing paperwork.

Interview with hospital Administrative staff revealed their surprise and understanding that this was an event which could have adversely affected the safety of the patient and which should not have occurred. They immediately began to implement corrective actions.

Based on the deficiencies noted on the Life Safety Code and phyical plan inspection, it was determined that the all fire prevention system were not maintained as required as evidenced by the deficiencies cited at the following tags:


1. A 714 due to the storage of gas powered snow removal equipment on the helipad support area
2. K 018 due to the fact that the strike plate on the custodial closet door was taped over preventing the closure of the door;
3. K 027 due to the failure to maintain smoke barrier doors;
4. K 029 due to the use of a non approved device to hold open a housekeeping closet door;
5. K 078 due to the failure to store medical gases with appropriate signage and secure;
6. K 106 due to the failure of have trained staff monitor the emergency generator annunciator panel; and
7. A 726 due to the failure to maintain the dishmachine and pot washer in optimal working condition;

Based on a review of 56 inpatient units, the following deficiencies of routine maintenance and supply oversight were noted.

1. The medication and patient food refrigerators in the Cardiac ICU were visibly dirty with growth on the bottom of one refrigerator.

2. In the Interventional Radiology unit, in room G2K04, an ice machine drain was observed going into an opening in the bottom a storage cabinet. The opening into the sewage system was not easily visible. This drain should be visible for inspection, to ensure that there is an adequate air gap. In case of a waste line blockage, the drain should not allow for sewage to back up unnoticed into the bottom of a cabinet.

3. In the Trauma Resuscitation Unit, a shower head was observed lying in the bottom of the shower. The shower head should be kept off the floor of the shower and stowed in a manner that prevents contamination.

4. In the Stoeler Pavilion, hand wash sinks in soiled utility rooms T5R51 and the first floor soiled utility room were observed without soap and paper towels.
5. Two reel hoses (pot machine room and main kitchen) were not equipped with pressure-type backflow preventers which eliminate the possibility of backsiphonage of contaminated water should a negative pressure occur in the water line.
6. Molecular Lab (Old Dark Room) - The drain of a floor sink under a faucet which is not used used requires capping to prevent the entrance of sewer gas into the room should the trap become dry. No evidence of sewer gas was detected.

7. Two vacuum breakers with missing caps were noted in Rooms W6L662 and W5L541.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to address the following miscellaneous safety issues:

The findings include:

During the initial survey on December 5,6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm each day that:

On the top floor helipad support areas in the Shock Trauma Building, there was a gas powered tractor and a gas powered snow blower - there was also a gas powered snow blower on the Mezzanine level just below the helipad - staff shall have a plan for storage and use of gasoline and other fuels for the operating season of the devices and a storage plan for the off seasons.

Based on a tour of the hospital it was determined that the following provision were inadequate to address the hospital needs as evidenced by:

1. Shelving in janitor's closets is deficient and has resulted in the storage of gloves, towels and toilet tissue on the floor and in the floor sinks.

2. Several instances of towel dispensers not having the proper type towels, not having any towels or not having a dispenser were noted.

3. For the most part storage under sinks absent but one area, Neonatal Lab, storage of laboratory supplies was found under a sink drain.

4. Dining areas for patients do not have choking posters.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment or supply storage in the following areas.

The findings include:

During the survey on December 5,6, 7 and 8, 2011, it was observed between 8:30 am and 3:00 pm each day that:

1. In the North Hospital on the 12th floor East wing there was a small patient laundry with a residential style washer and dryer - the dryer had a long exhaust duct behind the dryer that appeared to be crimped and staff could not determine when or if inspections and cleaning had been conducted on the dryer's exhaust - regular preventative maintenance (PM) and inspection for lint buildup shall be scheduled; and

2. In the South Hospital basement, in the plumbing shop, there were pressurized vessels of highly flammable gas - an unprotected acetylene tank under a work bench and an unprotected tank of oxygen next to it, both on the floor - these two tanks must be stored apart from each other as per OSHA guidelines; also, regular use of acetylene during construction by contractors needs to be monitored for safe use and storage;

3. Expired supplies were present on the supply carts on at least five units. These expired supplies included intravenous solutions, irrigation solutions, blood testing tubes, and point of care supplies.

4. Supplies were found on the floors of several of the clean supply rooms. There were multiple incursions noted into the walls in the clean supply rooms of several units from the supply carts.

5. Janitor ' s closets were observed with paper goods, including bathroom tissue and paper towels, stored in the mop sink. This was observed in the MT Critical Care-room T5R37, Gudelsky Building-rooms GG031 and G4K51, and the North Building-room N9W56.

6. The interior of many exhaust vents were not clean.

7. The floors under and behind ice machines and refrigerators in nourishment rooms are not clean.

8. General cleaning of the soiled utility room, North 11, Adult Psychiatry is needed.


On December 5, 2011 the surveyor accompanied by the food service director, the executive chef and the assistant food service director observed the following concerns in the main kitchen:

9. The nutritional shakes have a 14-day shelf life after thawing and were not labeled either individually or the container as to the thaw date.

10. The condensers on several refrigerators were dusty which may cause the motor to work harder or not allow the unit to maintain the proper temperature.

11. Scoop holders (ice and bulk ingredient) were not clean or may have had an accumulation of ingredient in them.

12. Several refrigeration units had bulbs that were burned out and/or were not shielded to prevent shattering into food products.

13. The door on the pot machine has a tear in the stainless steel that allows steam to exit in the room.

14. There is a sprinkler head in the pot machine closet, which has no escutcheon and is recessed into the ceiling tile.

15. Pot Machine Room - there appears to have been an roach infestation in the past and there are droppings on many surfaces in this room. There is however no evidence of a current infestation.

Based on observation it was determined that facility staff failed to maintain the facility to ensure the safety of the patient.

On December 5, 2011 the surveyor accompanied by the food service director, the executive chef and the assistant food service director observed the following concerns in the main kitchen:

(1.) Te final rinse temperature gauge on the pot machine was reading 166 degrees Fahrenheit. For sanitization to occur the manufacturer and state regulations state that the final rinse temperature be 180 at the manifold. Additionally the final rinse pressure gauge was reading 42 pounds per square inch (psi) per the gauge. The manufacturer in this case is recommending 20 to 22 psi and the state regulations for Food Service Facilities mandates 15 to 25 psi for machines using hot water for sanitization. An e-mail from the Food Service Director to the surveyor stated that all pots and pans would be washed and sanitized by hand in the three-compartment sink until the pot machine was repaired.

(2) The final rinse gauge on the dishmachine is broken.