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Based on observation and interview, the facility failed to protect the personal privacy of patients who were admitted to the hospital by posting the first three letters of the patient's last name on large, wall mounted, white dry erase boards located in public areas of the units. The facility census was 169. This deficient practice affected at least the patients on 5 North, 3 West, 4 West, 4 North and the Critical Care Unit.

Findings included:

1. Observation on 04/11/11 at 2:34 PM, on 5 North showed a large white erase board located across from the nursing station, in public view. The first three letters of the last name of the patients on this unit were shown.

During an interview on 04/11/11 at 2:35 PM, Staff PP, Nurse Manager, stated that staff wrote the first three letters of the last name of each patient on the dry erase board and if the patient had a three letter last name, staff would only write the first two letters of the last name.


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2. Observation on 04/12/11 at 9:20 AM, on the 3 West Unit showed a large white erase board on the wall, behind the nursing station, in public view. The listed the first three letters of the last name of the 18 patients on this unit.

During an interview on 04/12/11 at 9:25 AM, Staff A, Regional Director of Resource Management, stated that all of the boards in the facility had the first three letters of the patient's last name.


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3. Observation on 04/12/11 at 12:55 PM, of the 4 West Unit showed a large white dry erase board on a wall in the nursing station, in public view. The first three letters of the last name of each patient on the unit were written next to the room number.

During an interview on 04/12/11 at 1:00 PM, Staff R, Nurse Manager, stated that the written letters represented the first three letters of the patient's last name.

4. Observation on 04/13/11 at 10:00 AM, on the 4 North Unit showed a large white dry erase board on a wall in the nursing station, in public view. The first three letters of the last name of each patient on the unit were written next to the room number.

During an interview on 04/13/11 at 10:10 AM, Staff T, Nurse Manager, stated that the written letters represented the first three letters of the patient's last name.


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5. Observation on 04/14/11 at 9:30 AM, on the Critical Care Unit showed a large white dry erase board on a wall in the nursing station, in public view. The first three letters of the last name of each patient on the unit were written next to the room number.

During an interview on 04/14/11 at 9:30 AM, Staff G, Performance Improvement Coordinator, verified that the letters on the board were the first three letters of patient's last names.

Based on observation, facility policy review, record review and interview, the facility failed to obtain complete order to restraint three (#30, #31, and #32) of three patient records reviewed for restraint orders. The facility census was 169.

Findings included:

1. Record review of the facility's policy titled "CH Use of Restraints", revised 12/8/10, showed the following direction: the physician's verbal or written order must indicate the reason for restraint, the type of restraint and the time limit for restraining the patient.

2 Observation on 04/12/11 at 1:30 PM, showed current Patient # 30 had soft restraints on the right and left wrists.

Record review of current Patient #30's medical record showed:
-A physician order sheet titled "Physical Restraint Order/Renewal", dated 04/12/11 at 9:00 AM;
-No reason for restraint indicated;
-No physician order for the specific type of restraint to be applied;
-Physician order directed nursing to utilize most effective and least restrictive type of restraint after attempting alternative methods;
-No documentation of the specific type of restraint or reasoning for the restraint type that was chosen.

Record review of current Patient #30's medical record showed:
-A physician order sheet titled "Physical Restraint Order/Renewal", dated 04/11/11 at 11:45 PM;
-No reason for restraint indicated;
-No physician order for the specific type of restraint to be applied;
-Physician order directed nursing to utilize most effective and least restrictive type of restraint after attempting alternative methods;
-No documentation of the specific type of restraint or reasoning for the restraint type that was chosen.

3. Record review of current Patient #31's medical record showed:
-A physician order sheet titled "Physical Restraint Order/Renewal", dated 04/12/11 at 12:00 Noon;
-No physician order for the specific type of restraint to be applied;
-Physician order directed nursing to utilize most effective and least restrictive type of restraint after attempting alternative methods;
-No documentation of the specific type of restraint or reasoning for the restraint type that was chosen by nursing staff.

4. Record review of current Patient #32's medical record showed:
-A physician order sheet titled "Physical Restraint Order/Renewal", dated 04/12/11 at 11:00 AM;
-No physician order for the specific type of restraint to be applied;
-Physician order directed nursing to utilize most effective and least restrictive type of restraint after attempting alternative methods;
-No documentation of the specific type of restraint or reasoning for the restraint type that was chosen by nursing staff.

5. During an interview on 04/12/11 at 2:30 PM, Staff R, Nurse Manager, stated that he/she understood why the type of restraint should be indicated and he/she was not aware of any education to nurses about how to choose the least restrictive type of restraint.

Based on interview, record review and policy review, the facility staff failed to ensure appropriate monitoring and nursing documentation during the use of a restraint for two (#7, #5) of two patients reviewed. This lack of monitoring placed the patients at risk for negative outcome. The facility census was 169.

Findings included:

1. Record review of the facility's policy dated 02/09/03 and titled "CH Use of Restraints" showed direction for facility staff to monitor, assess and re-evaluate by direct observation every two (2) hours, restrained patients. Evaluation of the patient will include assessing circulation as appropriate, providing for hydration and toileting needs and assessing overall safety.

2. Review of current Patient #7's restraint assessment form showed:
-On 04/09/11 no two-hour restraint assessment was documented at 11:00 PM
-On 04/10/11 no two-hour restraint assessment was documented at 4:00 PM, 6:00 PM, 10:00 PM and midnight.

During an interview on 04/12/11 at 10:30 AM, Staff LL, Registered Nurse (RN) verified the lack of assessment for Patient #7 during restraint interventions on 04/09/11 and 04/10/11.

3. Review of current Patient #5's restraint assessment form showed:
-On 04/08/11 no two-hour assessment at 10:00 PM.

During an interview on 04/11/11 at approximately 10:30 AM, Staff H, RN intensive care unit manager (ICU) verified the missing restraint assessment documentation.

Based on policy review and interview, the facility failed to have a policy documenting the training requirements for physicians in the use of restraint or seclusion. This had the potential to affect all patients placed in restraints or seclusion. The facility census was 169.

Findings included:

1. Review of the facility restraint policies showed that no policy addressws restraint or seclusion training requirements for physicians.

2. During an interview on 04/14/11 at 1:25 PM, Staff G, Regional Director of Performance Improvement, stated that the facility does not have a policy addressing the training requirements for physicians regarding the use of restraint or seclusion.

3. During an interview on 04/14/11 at 1:25 PM, Staff I, Chief Medical Officer, stated that the facility does not have a policy addressing the training requirements for physicians regarding the use of restraint or seclusion.

Based on interview, restraint training record review, and personnel file review, the facility failed to ensure staff providing care for patients in restraints received basic first aid training related to incidents and nursing care required while the patient is restrained (e.g., a patient choking on food while restrained, or a patient who needs to toilet while restrained, etc.). This failure potentially impacts all patients placed in restraints. The facility census was 169.

Findings included:

1. During an interview on 04/14/11 at 1:40 PM, Staff A, Regional Director of Resource Management, stated that staff was not trained in first aid related to restraint use. Staff A stated that there were extensive competency requirements on restraints and that Basic Life Support was required, but no specific first aid training for restraints were in place.

2. Review of the facility restraint training power point in-service presentations showed no training in the use of first aid as related to restraint use.

3. Review of the facility form, "Restraint-designated RN competency checklist," not dated, showed no requirement for first aid training.

4. Review of personnel records for five Registered Nurses and one patient care technician showed no evidence of first aid training related to restraint use.

Based on interview and record review facility staff failed to establish and maintain an effective, on-going Quality Assessment/Performance Improvement (QAPI) program encompassing clinical and non-clinical departments, with responsibity to the Governing Board for improved patient care. The facility census was 169.

Findings included:

-Facility staff failed to include all clinical (nursing; laboratory; pain, senior and neurodiagnostic clinics; discharge/case management and respiratory) and non-clinical services (maintenance and housekeeping) in a comprehensive QAPI program (A 0264).
-Facility staff failed to analyze collected data and establish quality indicators to assess important aspects of patient care. (A 0267).
-Facility leadership failed to ensure an effective, on-going QAPI program was in place (A 0309)

The cumulative effect of these systemic failures resulted in non-compliance with 42 CFR 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

Based on interview and policy review, the facility failed to implement a system that ensured that the Quality Assessment and Performance Improvement (QAPI) program encompassed all clinical and non-clinical departments and services in the facility that provided or related to patient care and services.

This lack of a system permitted a facility-wide failure in which:
-All laboratory services were not integrated into the hospital-wide QAPI program.
-Respiratory Services were continuously reporting data without structured QAPI projects.
-Pain Clinic, Senior Clinic and Neurodiagnostics Clinics functioned without QAPI projects.
-Nursing Services were not integrated into the hospital-wide QAPI program.
-Discharge/Case Management was not integrated into the hospital-wide QAPI program.
-Maintenance and Environmental Services were not integrated into the hospital-wide QAPI program.

The facility census was 169 and all patients were at risk for receiving less than optimal care and services or to minimize potential negative patient outcomes.

Findings included:

1. Review of an undated copy of the facility Performance Improvement (PI) and Patient Safety Plan showed the following:
-Quality and patient safety was every staff person's responsibility.
-The scope of the facility Performance Improvement (PI) and Patient Safety Plan was organization wide and encompassed all services, programs and departments of the facility.
-The facility strived to achieve optimal clinical patient outcomes in the safest environment possible.
-All departments were to be involved in performance improvement initiatives.
-Patient safety was a priority.
-An important aspect of PI was identification and management of processes and behaviors leading to potential or actual harm.

2. During an interview on 04/11/11 at 4:15 PM, Staff G, Regional Director of PI, stated that the main hospital laboratory and the respiratory therapy laboratory did not report their PI activities to the hospital wide PI Committee.

3. During an interview on 04/13/11 at 8:58 AM, Staff GG, Manager of Respiratory Service, stated that the department quality assessment projects included data collection such as quantity and quality of respiratory therapists' chart note entries and the data was submitted to the QAPI staff by placing it into a facility computer system folder. Staff GG further stated that he/she did not know if the submitted data was reviewed by the QAPI committee or if the data submitted was part of a facility QAPI project.

4. During an interview on 04/13/11 at 10:40 AM, Staff OO, Director of Pain Clinic, Senior Clinic and Neurodiagnostics Clinics stated that no QAPI projects or studies were conducted in the department.

5. During an interview on 04/13/11 at 2:04 PM, Staff G, Regional Director of PI, stated the following:
-The current facility QAPI efforts were in disarray and dysfunctional.
-Each area of the facility, both clinical and non-clinical, had submitted accumulated QAPI data, but the accumulated data was not in support of any identified QAPI projects or studies.


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6. During an interview on 04/14/11 at 10:00 AM, the Plant Services Director stated that he/she collated and reported performance improvement information internally to his/her supervisor, the Vice President of Facilities Management. The preventive maintenance data on all life-support-related equipment, results of testing, inspections and readiness was not reported up to the Board or Medical Staff or integrated into the facility-wide QAPI program.


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7. During an interview on 04/14/11 at 10:50 AM, Staff G, PI Coordinator, stated that PI for Nursing was under construction and that the Nursing department did not have any QAPI projects integrated into the hospital-wide QAPI program.


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8. During an interview on 04/14/11 at 11:00 AM, Staff QQ, Registered Nurse (RN) Director of Case Management, stated that the data for 2010 was not up to date and was not integrated into the facility-wide QAPI program.

Based on observation interviews, and review of hospital documents, the facility failed to identify all issues related to inconsistent patient care and services, by analyzing collected data, and implement systems to address issues that included:

- Incomplete orders and documentation for patients who were restrained;
- Inconsistent dating and changing of intravenous (IV) tubing following facility policy which placed patients with IVs at risk for infection,
-Failure to ensure staff followed the hospital policy to give medications timely;
-Failure by staff to remove outdated and/or expired multiple-dose bulk stock medications and diagnostic supplies (outdated or expired medications and supplies pose the risk of changes in their potency to not provide the desired patient response);
-Lack of maintenance to walls, floors, and doors;
-Failure to consistently implement systems to minimize the potential for patients to acquire infections; and
-Failure to evaluate the discharge planning process.
-Failure to ensure staff followed established policy for blood product administration.

The facility census was 169 patients and potentially all could be at risk for receiving less than optimal care and services.

Findings included:

1. See A 0168 where based on observation, facility policy review, record review and interview, the facility failed to obtain complete order (that is, included the reason for the restraint and the specific restraint to be used on each patient).

2. See A 0395 where based on observation, interview and facility policy review, the facility failed to follow their policy for dating and changing intravenous (IV) tubing. This placed patients with an IV at risk for an infection.

3. See A 0405 where based on observation, interview and record review, the facility failed to ensure staff followed the facility policy to give medications in a timely manner.

4. See A 0505 where based on observation and interview, the facility failed to ensure the staff removed outdated and/or expired multiple-dose bulk stock bottles and diagnostic supplies so they could not be used with patients.

5, See A 0701 where based on observation and interview, the facility failed to maintain walls, floors and doors in a condition that presents a well maintained, safe, clean environment with easily cleanable surfaces.

6. See A 0749 where based on observation, interview and facility's policy review, staff failed to implement systems to minimize the potential of infections or for patients and personnel to be exposed to potentially infectious substances.

7. See A 0843 where based on quality assessment review and interview, the facility failed to ensure there was a post-discharge evaluation of the discharge planning process.

8. See A 0409 where based on observation, record review, interview, and policy review, staff failed to follow the facility policy on blood product administration which put those patients at risk for adverse blood transfusion reaction
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Based on interview the facility Governing Board, medical staff and administrative officials failed to ensure an effective ongoing Quality Assurance Performance Improvement (QAPI) program for improved patient care was in place and functional. This failure had the potential to affect all patients. The facility census was 169.

Findings included:

1. During an interview on 04/11/11 at 4:15 PM, Staff G, the Regional Director of Performance Improvement (PI), stated that the main hospital laboratory and the respiratory therapy laboratory did not report their PI activities to the hospital-wide QAPI Committee.

2. During an interview on 04/13/11 at 2:04 PM, Staff G, Regional Director of PI, stated the following:
-The current facility QAPI efforts were in disarray and dysfunctional.
-Each area of the facility, both clinical and non-clinical, had submitted accumulated QA data, but the accumulated data was not in support of any identified QAPI projects or studies.

Based on observation, interview and facility policy review, the facility failed to implement a system for dating and labeling intravenous (IV) tubing, and to follow their policy for dating and changing IV tubing for four (#7 on Intensive Care Unit (ICU), #16-on 4 W Unit, # 28 on 3 W Unit and #30-on 4 W Unit) of four patients reviewed. This failure on different units reflects a system failure and places all patients with IV tubing at risk for infection. The facility census was 169.

Findings included:

1. Record review of the facility policy titled "CH IV Infusion Pumps, Tubings, and Filters(Nursing)", dated 02/13/08, showed the following staff direction:
-Primary IV tubing shall be changed every 96 hours as recommended by Centers for Disease Control and Prevention (CDC).
-It is recommended that intravenous piggyback (IVPB) tubing be changed every 96 hours.
-All tubing shall be labeled when it is changed and documented online under the intervention: IV monitor

2. Observation on 04/13/11 at 10:05 AM, showed Patient #7's IV tubing was labeled "hung 04/08/11 at 11:00 AM, change 04/12/11 at 11:00 AM." (Therefore, the IV tubing had hung 119 hours at the time of observation).

During an interview on 04/13/11 at 10:30 AM, Staff Q, Registered Nurse (RN), stated, "I thought it was the 12th. I will change [it now]."


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3. Observation on 04/12/11 at 10:15 AM, showed Patient #28's IV tubing had no label which indicated when the tubing was placed into service or last changed.

During an interview on 04/12/11 at 10:20 AM, Staff SS, Director of Perioperative, stated that all IV tubing should have labels.



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4. Observation on 04/12/11 at 12:55 PM, showed Patient #30's IV tubing had no label which indicated when the tubing was placed into service or last changed.

Observation on 04/12/11 at 1:50 PM, showed Patient #16's IV tubing had no label which indicated when the tubing was placed into service or last changed.

During an interview on 04/12/11 at 2:00 PM, Staff R, Nurse Manager, confirmed that neither IV tubing for Patient #16 or Patient #30 had a label indicating the date placed in service or last changed. Staff R stated that all IV tubing should be dated.

5. During an interview on 04/13/11 at 3:00 PM, Staff Y, Infection Control Program Manager, stated that all IV tubing should be changed every 96 hours and that all IV tubing should be labeled with date placed in service or last changed. Staff Y stated that failure to do this would present an infection control risk to the patient.

Based on observation, interview, record review and facility policy review, facility staff failed to develop a comprehensive nursing care plan that was updated timely to ensure patient's care needs were met and response to interventions were assessed for two (#5, #6) of two critical care patients. The facility census was 169.

Findings included:

1. Record review of the facility policy "CH Patient Assessment (Nursing)", dated 12/2010, showed direction for facility staff to:
-Develop a plan of care to meet the patient's individual holistic needs.
-The patient problems will need to be activated from the plan of care routine by individually reviewing each goal and intervention for appropriateness/relevance. The plan of care can be further individualized by adding supplemental text to a goal and/or intervention or adding goals/interventions.
-The scope, intensity and frequency of reassessment of the patient is based on nursing judgment and/or physician order, taking in to account the patient's diagnosis, problems identified in the plan of care, change in condition and the patient's desire for and response to any previous care, treatment or services. The reassessment is documented, at a minimum, by each licensed nurse assigned to provide care to patient.

Record review of the facility policy "CH Patient Fall Prevention", dated 08/01/09, showed direction for facility staff:
-A registered nurse (RN) will assess the inpatient upon admission, every shift, and anytime the patient has a change in condition or is transferred to another level of care, by utilizing the Hendrich II Fall Risk Model Scorecard, in order to determine the inpatient's potential risk, for falls.
-Place yellow "Fall Risk" ID (identification) band on all inpatients that are identified to be at high risk for falls.
-Utilizing the nursing process, interventions will be initiated by the nurse addressing inpatient's specific factors which may contribute to the patient's risk for fall. These interventions will be individualized on the patient's plan of care.

2. Observation on 04/11/11 at 2:15 PM, showed Patient #6 in bed with a yellow bracelet on his/her wrist (indicating the patient was at risk for a fall).

Record review of Patient #6's record on 04/12/11 at 9:45 AM, showed he/she was admitted on 04/10/11. The record included no documentation of fall risk assessment for 04/10/11 and 04/11/11 and the care plan did not include the need for fall prevention.

During an interview on 04/12/11 at 9:45 AM, Staff J, RN, verified absence of a fall risk plan of care.

During an interview on 04/12/11 at 10:00 AM, Staff MM, RN, stated that Patient #6 was at risk for falls due to his/her impulsive behavior.

3. Record review of Patient #5 on 04/11/11 showed Patient #5 was admitted on 04/06/11 for a tonsillectomy with a history of Down's syndrome (a genetic abnormality that results in some mental/intellectual disability). Patient #5 had an endotracheal tube (a tube that is passed down the patient's throat into the windpipe and used to provide an airway) placed after surgery due to neck swelling. Review of Patient #5's care plan showed it did not address his/her special needs related to his/her Down's syndrome and critical care environment.

During an interview on 04/11/11 at approximately 4:00 PM, Staff H, RN manager, stated, "I don't think the patient's care plan covers the psychosocial needs and the fears related to patient's new surroundings."

Based on observation, interview and record review, the facility failed to ensure staff followed the facility policy to give medications in a timely manner for three (#28, #14, #19-4 E Unit) of eight patients observed during medication pass. This failure occurred on three nursing units (3 west-medical unit, critical care unit and the 4E-medical unit) and showed a system failure throughout the hospital. The facility census was 169.

Findings included:

1. Record review of the policy titled "CH Standard Medication Administration and Reconciliation Times (Nursing)", revised 01/23/11, showed the following:
-Medications are administered to patients thirty (30) minutes either side of scheduled time, which may vary in accordance with meal times on each unit.
- If a medication is given outside the 1-hour window from the scheduled time, the time should be crossed out with a single line. The nurse shall write the actual administration time and place his/her initials beside the actual time, and the reason the medication was given off schedule.

2. Observation on 04/12/11 at 10:10 AM, showed Staff Z, Registered Nurse (RN), administered six oral medications and one intravenous medication to Patient #28 on the 3 west medical unit.

Record review showed these medications were ordered by the physician to be given at 9:00 AM.

Further observation showed Staff Z documented on Patient #28's Medication Administration Record (MAR) that each medication was given at 9:00 AM, and failed to follow the policy by crossing out the 9:00 AM time and writing in the actual administration time of 10:10 AM.

During an interview on 04/12/11 at 10:20 AM, Staff Z RN stated that he/she did not give the medications on time.


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3. Observation on 04/13/11 at 9:50 AM, showed Staff NN, RN, administering seven oral medications and one medication patch at 9:50 AM to Patient #14, critical care unit.

Record review showed seven of the medications were ordered by the physician to be given at 9:00 AM, one of the medications was ordered to be administered at 7:30 AM.

During an interview on 04/13/11 at 1:30 PM, Staff NN stated that 9:50 AM was the first time he/she had prepared medication for Patient #14. Staff NN stated that he/she had one hour leeway to give medication from the time the medication was scheduled.


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4. Observation on 04/13/11 at 10:45 AM, showed Staff W, RN, administered seven medications by mouth and one medication via spray into each nostril, to Patient #19 on the 4 East Unit.

Record review showed these medications were ordered by the physician to be administered to Patient #19 at 9:00 AM.

During an interview on 04/14/11 at 9:55 AM, Staff T, Nurse Manager, stated that he/she was not aware why Patient #19 medications were administered late.

During an interview on 04/14/11 at 9:55 AM, Staff W, RN, stated that the medications were administered after the ordered time.

Based on observation, record review, interview, and facility policy review, facility staff failed to follow the facility policy on blood product administration for one (#6) of two patients reviewed receiving blood products. This has the potential to affect all patients receiving blood products. Bacterial contamination occurs rarely but can cause acute, severe, and sometimes life-threatening effects when blood products fail to be administered in the two - four hour time frame for blood administration. The facility census was 169.

Findings include:

1. Record review of the facility's policy titled "CH Blood Product Transfusion (Nursing)", dated 06/21/10, found it showed direction for facility staff:
-One registered nurse (RN) and one other health care provider (physician, RN, or licensed practical nurse (LPN)) will verify the transfusion record and the compatibility label on the unit for name, medical record number, unit number, blood type, wristband number and expiration date.
-Both RN and other health care provider sign transfusion record, or document individually in the computer.
-Increase rate appropriate for the patient blood infusion to infuse between two to four hours, or as rapidly as necessary to stabilize the hemodynamic status.
-A single blood component infusion set may be used for one to two units, not to exceed a total infusion time of four hours.
Practice Guidelines for Blood Transfusion, published by the American Red Cross, Second Addition, dated April 2007 states in the APPENDIX: SIDE EFFECTS AND HAZARDS OF BLOOD TRANSFUSION on page 47:
-Bacterial contamination occurs rarely but can cause acute, severe, sometimes life-threatening effects. Onset of high fever (=2 C or =3.5 F rise in temperature), severe chills, hypotension, or circulatory collapse during or immediately after transfusion should suggest the possibility of bacterial contamination and/or endotoxin (toxins associated with certain bacteria) reaction.
Review of the report published by the College of American Pathologist, dated as published June 1, 2006, states the following in part:
.....Approximately 10-12 patients are thought to die annually in the US from bacterially contaminated red cell units. Annual deaths from bacterially contaminated platelets is likely even higher.

2. Observation on 04/11/11 at 2:15 PM, showed Staff F, RN, prepared a blood administration for Patient #6. Staff F completed the following:
-Physician order stated transfuse one unit PRBC (packed red blood cells) over three to four hours.
-Blood verification with Staff H, RN unit manager
-Blood initiation at 2:15 PM

However, review of Patient #6's medical record on 04/12/11 showed the following blood administration documentation:
-Blood administration started at 04/11/11 at 1:15 PM (observed hang time of blood unit was 2:15 PM)
-Blood unit verified by Staff F and Staff TT (observed verification by Staff F and Staff H)
-Blood administration completed at 6:20 PM (5 hours and 5 minutes after initiation)

During an interview on 04/12/11 at 9:45 AM, Staff J, RN, verified the documentation of blood administration. Staff I, Chief Medical Officer, on 04/12/11 at 10:00 AM verified observation blood initiation time of 2:15 PM on 04/11/11.

Based on observation and interview, the facility failed to ensure the staff removed outdated and/or expired multiple-dose bulk stock bottles and diagnostic supplies so they could not be used with patients. This had the potential to affect care of all patients in the in-patient areas and the emergency department. The emergency department treats an average of 100 patients a day. The facility census was 169.

Findings included:

1. Record review of the policy provided by the facility titled "CH Multiple Dose Pharmaceuticals and Expiration Dates" (Pharmacy), last revised 09/19/2009, showed the following:

POLICY:
It is the policy of the pharmacy department that the use of multiple dose vials be avoided when practical. Multiple dose vials (containing preservatives) or bottles opened and manipulated in any patient care area will be dated according to this policy. Multiple dose pharmaceutical products (bulk stock bottles) used outside of the pharmacy will be dated with a 28 day expiration date from the date opened.

2. Observation on 04/11/11 at 1:50 PM, on the 3rd floor Room 10 showed four bottles of opened Providone Iodine (an anti bacteria product), one Skin Cleanser (used to remove the ink from the bottom of a baby's foot) and two Scanning Gel (transmits sound waves when checking a pregnant women's baby's heartbeat) with no date or time when opened.

During an interview on 04/11/11 at 2:00 PM, Staff E, Manager of 3 South, stated that he/she was not aware of the need to date these supplies.


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3. During observation in the South Emergency Department nurses station on 04/11/11 at 1:45 PM found the following:
-3 opened bottles of Gastrocult developer (used to determine if there is blood in stomach contents) lot numbers 1014, 1019 and 1028;
-3 opened bottles of Hemoccult developer (used to determine if there is blood in stool) lot numbers 10, 14 and 29.
The facility staff failed to record either the date when opened or a date of expiration on these six bottles.

4. During an interview on 04/11/11 at 1:55 PM, Staff II (Regional Director), stated that the developers would be good for 30 days after being opened. Staff II agreed that none of the six bottles had dates recorded when the bottles were opened or when they would expire. Staff II stated that if the bottles are not dated "we don't know" when they would expire.

Based on observation and interview, although the hospital had a system to maintain the physical environment of the hospital in a safe and clean manner with easily cleanable surfaces, the facility failed to implement the system to do so. This actually or potentially affected a total of 149 inpatient rooms located on the second, third, fourth and fifth floors. The facility census was 169.

See the deficiency at A 0701.

The cumulative effect of these systemic failures resulted in non-compliance with 42 CFR 482.41 Condition of Participation: Physical Environment.

Based on observation and interview, the facility failed to maintain walls, floors and doors in a condition that presents a well maintained, safe, clean environment with easily cleanable surfaces for a total of 149 inpatient rooms located on the second, third, fourth and fifth floors. The facility census was 169.

Findings included:

1. Observation on 04/11/11 at 2:10 PM through 04/14/11 at 11:00 AM of 5 North and 5 South showed damage in varying degrees of severity to the walls, floors, doors and doorframes of 31 patient rooms (Rooms 501 through 516 on 5 North and rooms 533 through 548 of 5 South.). Examples were as follows:
-Gouges, paper tears, and scrapes in wallpapered patient rooms exposed unfinished white gypsum board (rooms 547, 544, 543);
-Stains, dry stained drip marks and black marks on walls below hand sinks in all patient rooms with individual handwash sink adjacent to door;
-Numerous scratches and chips of paint peeled and missing from door frames to all patient rooms, soiled and clean utility rooms and janitor's closets which exposed multiple colors from previous paint jobs;
-Numerous severe gouges, missing veneer surface pieces and splintered corners to the wood doors at the entrance to each room (the most severe damages occurred to the hinge edge, or back of the door and to the front or meeting edge that closed into the door frame). Splintered, missing pieces of veneer up to two-inches wide by six-inches high and one-sixteenth inch thick were chipped on doors and exposed rough wood surfaces that could not be easily cleaned or sanitized (widespread damage to all 31 patient rooms, soiled utility, clean utility and janitors closets);
-Dirty and stained floors, with what appeared to be particles of dirt and debris in corners, black stains below sinks, along baseboards, behind doors and under baseboard registers in corridor dead ends, scratched and blackened areas under office desk areas located in corridor dead ends, buffer burn marks on tile, ill-fitting floor tiles with uneven surfaces between old and replacement tiles, chipped, missing corner pieces exposed black adhesive, and black soiled remnants of adhesive strips across thresholds of patient room door. The most severe damage to floors were noted in Rooms 538, 539, 544, 547, 545, 544 a nearby med room entrance and corridor dead end spaces, north and south (near doors 5315.00, 5115.00, and 5116.00.)

During an interview on 04/11/11 at 9:10 AM, Staff VV, Maintenance Engineer for 5th floor, stated that he/she usually does not have enough time between patient discharges and new admissions to do any painting or replacement of wall surfaces.

2. Observation on 04/11/11 at 2:10 PM through 04/14/11 at 11:00 AM, of 4 North, South, East and West wings showed damage in varying degrees of severity to the walls, floors, doors and doorframes of 55 patient rooms (Rooms 401-415 on 4 North, 417-432 on 4 East, 433-448 on 4 South, and 449-464 on 4 West). Examples were as follows:
-Gouges, paper tears, and scrapes in wallpapered patient rooms exposed unfinished white gypsum board;
-Stains, dry stained drip marks and black marks on walls below hand sinks in patient rooms;
-Numerous scratches and chips of paint peeled and missing from door frames to all patient rooms, soiled and clean utility rooms and janitor's closets which exposed multiple colors from previous paint jobs;
-Numerous severe gouges, missing veneer surface pieces and splintered corners to the wood entrance doors to each room; the most severe damages occurred to the hinge edge, or back of the door and to the front or meeting edge that closed into the door frame. Pieces of veneer up to one-sixteenth-inch thick were chipped and missing from doors and exposed splintered or rough wood up to two-inches deep by six-inches high;
-Dirty and stained floors, with what appeared to be debris and dirt particles in corners and black stains below sinks, closet doors, along baseboards, behind doors and under baseboard registers in corridor dead ends, buffer burn marks on tile, ill-fitting floor tiles with uneven surfaces between old and replacement tiles, chipped, missing corner pieces and black soiled remnants of adhesive strips across thresholds of patient room doors. The most severe damage to doors, and floors with soiled, blackened, scratched corner recesses was noted in Rooms 401, 402, 418, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428 and floor areas under desks and baseboard registers in the dead end spaces at both corridor ends of 4 West.

3. During an interview on 04/12/11 at 10:15 AM, Staff WW, Director of Environmental Services (EVS) stated that the damaged doors are not on the work order list or do not get a work order number assigned unless they malfunction, or fail to close properly, to latch, or cored so badly they need to be replaced. He/she stated that they tried repainting and repairing everything one room at a time, but that didn't work.

4. During an interview on 04/11/11 at 3:10 PM, the Vice President of Facilities Management stated that the turnaround time could be much faster as nursing accepts the plan and cooperates with moving patient care areas and patient census to free up rooms. He/she stated that the hospital has been full (at capacity) and it was hard to get an open area of rooms to properly teardown and renovate a set of rooms.

5. During an interview on 04/12/11 at 11:00 AM, Staff WW stated that he/she has been trying to work with nursing management to get EVS in to thoroughly clean, strip, wax and buff floors in the patient care areas, but has been unsuccessful. Staff WW stated that they could make a big difference on the floors if they had a weekend or even as little as four hours in an evening. Staff WW stated that housekeeping services' hands were 100 percent tied and "we're just chasing our tail." Staff WW stated that he/she has developed action plans targeting the floors identified that are in most dire need of thorough cleaning and refinishing, but cannot follow through because there is no cohesive multidisciplinary approach to resolving the problem, and that has been the biggest disappointment.

6. Observation on 04/13/11 at 9:00 AM, of 3 West showed the following:
-Dirt in corners and along edges of baseboards and dark soiled areas under hand washing sink in rooms 350, 353, and 362;
-Black adhesive exposed between floor tiles below hand washing sink in room 355;
-Paper tears, and chipped paint in wallpapered of room 356;
-Numerous severe gouges, missing veneer surface pieces and splintered corners to the wood entrance doors to each room; the most severe damage occurred to the hinge edge, or back of the door, and to the front or meeting edge that closed into the door frame in rooms 350, 352, 354, 358, 360, 362, and 364.

7. Observation on 04/13/11 at 9:00 AM to 10:00 AM, on 3 North showed the following:
-Chips of veneer, one-inch wide and five-inches high missing from the front edge and one- quarter-inch wide by two-inches high missing from the back edge of the entrance door of room 310;
-Chip of veneer door surface one inch square missing from the bottom front edge of entrance door of room 311;
-Chips of veneer door surface one-half-inch wide by three-inches high missing from the front edge of the entrance door to room 316.

8. Observation on 04/13/11 at 11:00 AM, of 2nd floor showed the following:
-Black adhesive remnants on threshold, dingy below sink and double door closet in room 204;
-Scratched and peeled paint off bathroom door exposed lighter colors (when the room had been previously painted) in room 206;
-Dark soiled areas in corridor along wall where cove base meets the vinyl tiled floor outside of rooms 209-211;
-Dirt particles behind door and under the sink in room 211;
-Dirt particles behind door in corners and scratches on the painted walls of room 215;
-Two tiles broken with exposed black adhesive and two tiles with broken corners over an expansion joint, next to the nurse's desk.
-Black areas of adhesive remnants under the toe kick of a double closet in room 218.

Based on observation and interview the facility failed to dispose of expired food supplies for patients on the 4 East and 4 South units and failed to ensure cleanliness of the microwave. These deficient practices had the potential to affect all patients in these areas of the facility. The facility census was 169.

Findings included:

1. Observation on 04/13/11 at 11:15 AM, of the 4 South galley (a room used to store patient nourishments, a refrigerator and a microwave) showed the inside of the microwave with black, crusty debris in the back corners on both sides. The front door of the microwave had rust along the inside bottom of the door.

2. Observation on 04/13/11 at 11:15 AM, of the 4 South galley refrigerator showed two sandwiches in separate plastic containers. Each container was labeled with hand written dates of 4/9 - 4/12. Facility staff failed to remove these expired food items.

3. During an interview on 04/13/11 at 11:20 AM, Staff HH, Hospitality Associate, stated that he/she did not know what the dates meant. Staff HH stated that items usually have a label with a single date indicating the date it expired and needs to be discarded.

During a concurrent interview Staff T, Nurse Manager, stated that he/she was not sure what the dates meant.

Based on observation, interview and facility's policy review staff failed to implement systems to minimize the potential of infections or for patients and personnel to be exposed to potentially infectious substances when staff failed to:

-Follow the hospital's standard of practice for isolation precautions for one (Patient #27) of one patients observed on isolation precautions;
-Failed to follow the hospital's hand hygiene policy for one (Patient #6) of one patients receiving blood administration and for one (Patient #18) of one patients receiving medications;
-Failed to follow standard precautions for infection control for one (Patient #17) of one patient receiving medications and for one (Patient #21) of one patients observed during Foley catheter (urinary catheter) care;
-Prepare and serve patients, staff and clientele foods in a sanitary manner;
-Maintain walls, floors and doors in a condition that presents a safe, clean environment with easily cleanable surfaces to discourage transfer of infections and assure a high quality of patient care services in a total of 149 inpatient rooms located on third, fourth and fifth floors; and
-Clean and disinfect patient equipment and contact surfaces in the Outpatient Rehabilitation and Sports Medicine Center.

The facility census was 169 patients.

Findings included:

1. Record review of the facility policy titled "CH Isolation Transmission Based Precautions (Infection Control)", dated 12/18/09, showed direction for facility staff:
-Place patients known or suspected to be infected or colonized with specific resistant microorganisms that can be transmitted by direct contact with the patient or the environment in contact precautions.
-Diseases requiring contact precautions, included but not limited to patients with colonization or infection with multi-drug resistant organisms i.e., Methicillin resistant staph Aureus (MRSA), Vancomycin resistant Enterococcus (VRE)
-Wear gloves and gown when entering room if contact was anticipated with patient or patient environment.

Record review of facility training policy titled "Sequence For Donning Personal Protective Equipment (PPE)", an undated policy provided by the educator, showed staff were directed to fasten a gown at the neck and waist.

Record review of facility policy titled "CH Hand Hygiene", dated 01/09/09, found staff were directed to perform hand hygiene after removing gloves.

2. Observation on 04/11/11 from 2:00 PM to 2:30 PM showed Staff F, Registered Nurse (RN) preparing blood for infusion into Patient #6. Staff F touched the blood product, then the patient and various items in the patient's environment, while wearing gloves. Staff F applied and reapplied gloves three times during blood administration. However, Staff F failed to wash hands before and after glove removal/re-application for these three times.

During an interview on 04/11/11 after blood administration observation, Staff H, Nurse Manager, stated hand hygiene needed to be performed after glove removal.

3. Observation on 04/12/11 at 11:15 AM, showed Staff KK, patient care technician (PCT), pulling Patient #27 in his/her bed in the hallway. Patient #27 was on contact precautions for MRSA in a wound. However, Staff KK failed to have Personal Protective Equipment (PPE)/gown tied at his/her waist. Staff KK's uniform came in contact with Patient #27's bed and room environment, placing Staff KK at risk for carrying MRSA to other patients.

During an interview on 04/12/11 following observation of Patient #27's bed transport, Staff I, Chief Medical Officer, verified the lack of appropriate PPE application by Staff KK. Staff I stated PPE gown should be tied at the waist.


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4. During observation of medication administration to Patient #17 on 04/13/11 at 8:40 AM, Staff U, RN (Registered Nurse), obtained the following medications:
-Flomax (used to treat symptoms of enlarged prostate) 4 mg. (milligrams, a unit of dosing measurement) PO (take by mouth) and
-Guaifenesin (a decongestant) 600 mg. PO.

While obtaining these medications, Staff U dropped the paper medication cup on the floor. Staff II, RN picked the medication cup from off the floor (considered a potentially contaminated surface) and placed it in front of Staff U. Staff U then placed the pre-packaged unit dose medications into the cup. While in Patient #17's room the medications were opened from unit dose packages and placed into the contaminated paper medication cup and given to the patient. The patient consumed the medication.

5. During observation of medication administration to Patient #18 on 04/13/11 at 8:55 AM, Staff U, RN, obtained the following medications:
-Celexa (for depression) 20 mg. PO
-Ativan (for anxiety) 1 mg. PO
-Miralax (a laxative) one package reconstituted in apple juice PO and
-Rocephin (an antibiotic) 1 gram (unit of measure) IV (intra venous-direct infusion into vein via a catheter inserted for such purpose).

Upon entry to Patient #18's room Staff U did not cleanse hands before putting on gloves. Staff U then assessed the patient by listening to the patient's lungs and heart, felt the patient's feet and ankles, and helped the patient to sit up in bed. Staff U then opened the unit dose medications and gave the medication to the patient. Staff U then reconstituted the laxative in apple juice and gave to it to the patient. Staff U then administered antibiotic by placing IV tubing into a bag containing medication and placed tubing on a pump for administration to the patient. Staff U did not cleanse hands upon entry into room or change gloves in between assessment of patient and medication/IV administration.

6. During observation of Foley catheter care on Patient #21 on 04/13/11 at 11:00 AM, Staff X, RN, prepared a basin of soapy water and placed two wash clothes in the water. Staff X then cleansed his/her hands, put on gloves and advised patient of the procedure. He/she took one wash cloth and cleansed the meatus (tip of penis). He/she then placed the first soiled wash cloth back in the soapy water (potentially contaminating the water) and then removed the second wash cloth and cleansed the tube of the Foley catheter where it entered the penis.

During an interview on 04/13/11 at 3:00 PM, Staff Y, Infection Control Program Manager, stated that:
-The lapses in infection control procedures with Patient #17, #18 and #21 were unacceptable;
-Anything dropped on the floor should be immediately discarded, the hospital had no policy that was that specific, but it would be considered common sense to discard something that dropped on the floor;
-Hand washing monitoring was being done in the clinical areas and that he/she was surprised about the lapse in hand washing procedures the surveyor observed; and
-That a wash cloth should not be placed back in the clean basin after use.


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7. Review of the facility's policy and procedure #4170 titled "Standards of Appearance," dated 03/19/09, found it stated the following:
-Hair must be clean and facial hair must be clean and neatly trimmed.
-Hair must be neat and conservative.
-Food and Nutrition staff must wear a hairnet in the kitchen.

8. Record review of the Food and Drug Administration (FDA) 2005 Food Code, Chapter 2-4, Hygiene Practices, Subpart 2-402.11 (A) (B) - Hair Restraints Effectiveness revealed the following:
-(A) Except as provided in & (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipments, utensils, and linens; and unwrapped single-service and single-use articles.
-(B) This section does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single use articles.

(The Food Code is considered a nationally-accepted standard of practice for the food industry.)

Observation on 04/13/11 at 10:10 AM until 11:30 AM, showed staff failed to prepare and serve patients and/or facility's staff and clientele foods in a sanitary manner, to include the following:
-Staff EE (Cook) prepared patients' foods and failed to wear a facial hair restraint over beard and moustache. Staff EE also assembled hot foods on patients' lunch trays. Staff EE's beard measured approximately ¼ inch long and his moustache measured approximately ½ inch long.
-Staff CC and DD (Cooks) prepared foods for facility's staff and clientele in the facility's dining room and they both failed to wear a hair restraint over their facial hair. Both Staff CC and DD's facial hair measured approximately 1/4 inch long.
-Staff UU (Lead Worker) failed to properly cover his/her hair. He/she prepared desserts and did not completely cover approximately 3 inches of hair in the front of her/his head.
-Staff WW (Lead Worker) conducted the final check of the patients' lunch meal trays for accuracy and he/she failed to cover approximately 3 inches of hair in the back of her/his head.

During an interview on 04/13/11 at 2:58 PM, Staff AA, Assistant Director of Non-Patient Services, stated he/she did not know he/she should follow the 2005 FDA Food Code Guidelines. Staff AA also stated he/she did not know facial hair should be covered with a beard restraint.

9. Review of facility's policy and procedure #3865, titled "Ice Machines," dated 01/05, directed nutrition staff to perform the following:
-Mark the ice machine as "Do Not Use" and clean inside and outside prior to putting it back in service if it becomes contaminated.
-Empty and sanitized ice machine bins biannually.

On 04/13/11 at 10:10 AM, showed staff failed to keep the department's ice machine sanitary when what appeared to be mold was found growing in the top of it.

Interview on 04/13/11 at 10:12 AM, showed both Staff AA and Staff BB, Chief Executive Chef, stated staff empty and sanitize the ice machine biannually and they check the cleaning of the ice machine between the emptying and sanitizing on a frequent basis, but failed to see the mold on the top inside of the machine. The ice machine contained ice for human consumption. The area containing the mold had a build-up of condensation and the mold contaminated condensation could possibly drip onto the clean ice.

10. Record review of the Food and Drug Administration (FDA) 2005 Food Code, Chapter 4-6, Cleaning of Equipment and Utensils, Subpart 4-602.12 (A) and 4-602.13 - Cooking and Baking on Food Contact Surfaces and Nonfood-Contact Surfaces showed the following:

4-602.12 Food-Contact Surfaces.
(A) The food -contact surfaces of cooking and baking equipments shall be cleaned at least every 24 hours.

4-602.13 Nonfood-Contact Surfaces.
Nonfood -Contact surfaces of equipments shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Observation on 04/13/11 at 10:47 AM until 11:30 AM, showed staff failed to prepare patients and/or facility's staff and clientele foods in a sanitary manner, including the following:
-A long-term accumulation of baked-on foods and debris covered the top and in-between the grates of the grill where staff grilled new food items.
-A long-term accumulation of baked-on foods and debris covered the top of the range and in-between the burners of the stove.

During an interview on 04/13/11 at 10:47 AM, both Staff AA and Staff BB stated the department had a cleaning schedule and staff used it, but apparently the staff did not do a good job in keeping the equipment clean.


04467

11. Observation on 04/11/11 at 2:10 PM through 04/14/11 at 11:00 AM, of 5 North and 5 South, showed damage in varying degrees of severity to the walls, floors, doors and doorframes of 31 patient rooms (Rooms 501 through 516 on 5 North and rooms 533 through 548 of 5 South). Examples were as follows:

-Gouges, paper tears, and scrapes in wallpapered patient rooms exposed unfinished white gypsum board, gypsum board on walls adjacent to entrance doors and behind furniture (rooms 547, 544, 543);
-Stains, dry stained drip marks and black marks on walls below hand sinks in all patient rooms with individual handwash sink adjacent to door;
-Numerous scratches and chips of paint peeled and missing from door frames to all patient rooms, soiled and clean utility rooms and janitor's closets exposed multiple colors from previous paint jobs;
-Numerous severe gouges, missing veneer surface pieces and splintered corners to the wood entrance doors to each room; the most severe damages occurred to the hinge edge, or back of the door and to the front or meeting edge that closed into the door frame. Splintered, missing pieces of veneer up to two inches wide by six inches high and one sixteenth inch thick were chipped doors and exposed rough wood surfaces that could not be easily cleaned or sanitized (widespread damage to all 31 patient rooms, soiled utility, clean utility and janitors closets);
-Dirty and stained floors, with dirt particles in corners, black stains below sinks, along baseboards, behind doors and under baseboard registers in corridor dead ends, scratched and blackened areas under office desk areas located in corridor dead ends, buffer burn marks on tile, ill-fitting floor tiles with uneven surfaces between old and replacement tiles, chipped, missing corner pieces exposed black adhesive, and black soiled remnants of adhesive strips across thresholds of patient room door. The most severe damage to floors were noted in rooms 538, 539, 544, 547, 545, 544 a nearby med room entrance and corridor dead end spaces, north and south (near doors 5315.00, 5115.00, and 5116.00.)

During an interview on 04/11/11 at 9:10 AM, Staff VV, the Maintenance Engineer for 5th floor, stated that he/she usually he does not have enough time between patient discharges and new admit to do any painting or replacement of wall surfaces either.

During an interview on 04/11/11 at 3:10 PM, the Vice President of Facilities Management stated that the turnaround time could be much faster as nursing accepts the plan and cooperates with moving patient care areas and patient census to free up rooms. He said the hospital has been full (at capacity) and it was hard to get an open area of rooms to properly teardown and renovate a set of rooms.

12. Observation on 04/11/11 at 2:10 PM through 04/14/11 at 11:00 AM, on 4 North, South, East and West showed damage in varying degrees of severity to the walls, floors, doors and doorframes of 55 patient rooms (Rooms 401-415 on 4 North, 417-432 on 4 East, 433-448 on 4 South, and 449-464 on 4 West). Examples were as follows:
-Gouges, paper tears, and scrapes in wallpapered patient rooms exposed unfinished white gypsum board on walls adjacent to entrance doors and behind furniture;
-Stains, dry stained drip marks and black marks on walls below hand sinks in patient rooms;
-Numerous scratches and chips of paint peeled and missing from door frames to all patient rooms, soiled and clean utility rooms and janitor's closets exposed multiple colors from previous paint jobs;
-Numerous severe gouges, missing veneer surface pieces and splintered corners to the wood entrance doors to each room; the most severe damages occurred to the hinge edge, or back of the door and to the front or meeting edge that closed into the door frame. Pieces of veneer up to one sixteenth inch thick were chipped and missing from doors and exposed splintered or rough wood up to two inches deep by six inches high;
-Dirty and stained floors, with dirt particles in corners and black stains below sinks, closet doors, along baseboards, behind doors and under baseboard registers in corridor dead ends, buffer burn marks on tile, ill-fitting floor tiles with uneven surfaces between old and replacement tiles, chipped, missing corner pieces and black soiled remnants of adhesive strips across thresholds of patient room doors. The most severe damage to doors, and floors with soiled, blackened, scratched corner recesses was noted in Rooms 401, 402, 418, 419, 420, 421, 422, 423, 424, 425, 426, 427, 428 and floor areas under desks and baseboard registers in the dead end spaces at both corridor ends of 4 West.

During an interview on 04/12/11 at 10:15 AM, the Maintenance Engineer for 4th floor stated that he/she tried repainting and repairing everything one room at a time, but that didn't work. He/she stated that they next tried blocking off rooms and areas like a whole wing, but the project was suspended due to unresolved issues with patient census, acuity and safety concerns.

13. During an interview on 04/12/11 at 11:00 AM, Staff WW, Director of Environmental Services (EVS) stated that he/she has been trying to work with nursing management to get EVS in to thoroughly clean, strip, wax and buff floors in the patient care areas but has been unsuccessful. Staff WW stated that they could make a big difference on the floors if they had a weekend or even as little as four hours in an evening. Staff WW suggested moving the patients or doubling some of them up for a few hours while housekeeping did one side of the corridor, then moving everyone back to the other side to repeat the process, however the nursing manager told him they "couldn't do that" and cited patient fragility, among other reasons. Staff WW stated that housekeeping services' hands were 100 percent tied and "we're just chasing our tail." Staff WW stated that he/she has developed action plans targeting the floors identified that are in most dire need of thorough cleaning and refinishing, but cannot follow through because there is no cohesive multidisciplinary approach to resolving the problem, and that has been his biggest disappointment.

14. Observation on 04/13/11 at 9:00 AM, of 3 West showed the following environmental concerns:
-Dirt in corners and along edges of cove base and dark soiled areas under hand washing sink in rooms 350, 353, and 362;
-Black adhesive exposed between floor tiles below hand washing sink in room 355;
-Paper tears, and chipped paint in wallpapered of room 356;
-Numerous severe gouges, missing veneer surface pieces and splintered corners to the wood entrance doors to each room; the most severe damage occurred to the hinge edge, or back of the door and to the front or meeting edge that closed into the door frame in rooms 350, 352, 354, 358, 360, 362, and 364.

15. Observation on 04/13/11 at 10:00 AM, of 3 North showed the following environmental concerns:
-Chips of veneer, one inch wide and five inches high missing from the front edge and one quarter inch wide by two inches high missing from the back edge of the entrance door of room 310;
-Chip of veneer door surface one inch square missing from the bottom front edge of entrance door of room 311;
-Chips of veneer door surface one half inch wide by three inches high missing from the front edge of the entrance door to room 316.

16. Observation on 4/13/11 at 11:00 AM, of 2nd floor showed the following environmental concerns:
-Black adhesive remnants on threshold, dingy below sink and double door closet in room 204;
-Scratched and peeled paint off bathroom door exposed lighter colors in room 206;
-Dark soiled areas in corridor along wall where baseboard meets the vinyl tiled floor outside of rooms 209-211;
-Dirt particles behind door and under the sink in room 211;
-Dirt particles behind door in corners and scratches on the painted walls of room 215;
-Two tiles broken with exposed black adhesive and two tiles with broken corners over an expansion joint, next to the nurse's desk.
-Black areas of adhesive remnants under the toe kick of a double closet in room 218.

17. Record review of the facility policy titled, "Equipment Cleaning" revised 01/08/08 showed direction for facility staff to perform the following:
-Outpatient Rehabilitation and Sports Medicine Center staff to clean and disinfect equipment and work surfaces when obviously soiled.
-Mats were to be cleaned and disinfected twice a day unless a patient has had skin or secretion contact with the mat.
-If the patient has had skin or secretion contact then clean and disinfect after their treatment was completed.

The policy does not provide direction to staff on cleaning and sanitation for cracked, ripped or torn surfaces of the mat.

However, observation on 04/12/11 at 2:55 PM, in the gym area of the Outpatient Rehabilitation and Sports Medicine Center showed staff failed to repair and maintain the surface covering of a treatment table mat with an approximate five-inch by one-half-inch tear exposing the foam interior core. The tear in the covering rendered the surface unsanitizable.

During an interview on 04/12/11 at 2:55 PM, Staff FF, the Associate Director of the Outpatient Center stated he/she was not aware of the unsanitizable, breached surface of the mat.

Based on quality assessment review and interview, the facility failed to ensure there was a post-discharge evaluation of the discharge planning process. The facility census was 169.

Findings included:

1. Review of the discharge planning process quality improvement documents showed no assessment or reassessment of the discharge planning process.

2. During an interview on 04/14/11 at 11:00 AM, Staff QQ, Registered Nurse (RN) Director of Case Management, stated that the data for 2010 was not up to date, but quality assurance activities did not include evaluation of the discharge planning process.