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Based on observation and interview, it was determined that the facility was not always maintained in a manner to ensure staff and patient safety.

Findings were:

Tour of the facility on 2/12/19 revealed the following:

* Missing baseboards in the laboratory
* Raised and swollen floor tiles in the pharmacy and laboratory
* heavy water damage behind and around the sink in the pharmacy
* the double doors in the old CT area that opened to the outside loading dock needed weather stripping. The open area between the doors could allow vectors into the facility.

In an interview with the Administrator on 2/12/19, the above issues were acknowledged.

Based on record review and interview the facility's Governing Body failed to provide care in a safe setting when the Medical Staff were not required to request or have approval for individual clinical privileges.

Findings include:

Review of the facility provided By-laws of the Medical Staff (undated) reflected, " ...To provide to the Board, recommendations for medical staff membership delineated clinical privileges, and the scope of patient care services that each member may provide independently in the hospital .... Responsibilities of the Medical Staff ... Provide patient care within the scope of the individual delineated clinical privileges approved for each Medical Staff member ...."

During an interview on the afternoon of 2/13/19, in the facility conference room, when asked if the Medical staff including the Nurse Practioners had been required to request specific procedures to be performed, Staff #16, Administrative Assistant stated, "I complete the credentialing files ... We haven't been having them request privileges ...."

Based on observation and interview, it was determined that the facility did not always practice effective infection control.

Findings were:

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

Tour of the facility on 2/12/18 revealed the following:

* corrugated shipping boxes stored with clean supplies throughout the hospital including the pharmacy, laboratory and the supply storage room.
* stained ceiling tiles in the laboratory and the Physical Therapy room. These stained tiles could indicate water leaks.
* The vinyl covering on an arm support and the plinth table in the Physical Therapy department were torn. These tears made the objects impossible to clean and could lead to cross contamination. A soiled towel was found in a wheelchair used to transport an in-patient to the PT area. The patient was not undergoing rehab at the time, yet the chair was not sanitized between patients.

In interviews with the Administrator, the Director of the Laboratory, the Director of the Pharmacy and the Physical Therapy Director on 2/12/19, the above findings were confirmed.

Based on interview and record review the facility's Dietitian failed to assess for the adequate nutritional needs for (2) two patients with large wounds. (Patients #15 and 14)

Findings include:

Review of Patient #14's nutritional interview/screen, completed by the Food Service Director, dated 11/12/18 reflected a 90-year-old-male admitted with decubitus ulcers on 11/10/18. The patient has a history of poor appetite, difficulty swallowing. The assessment did not include the calorie, protein and fluid needs required to promote wound healing. The record did not reflect that the facility's Dietitian had assessed the patient.

Review of Patient #16's nutritional interview/screen, completed by the Food Service Director, dated 11/26/18 reflected a 65-year-old-male admitted with decubitus ulcers on 12/7/18. The patient is 6ft 3 inches tall and weighed 199 lbs. The patient was placed on an 1800 calorie diet. The assessment did not include the calorie, protein and fluid needs required to promote wound healing. The record did not reflect the facility's Dietitian had assessed the patient.

During an interview on the morning of 2/13/19, in the facility conference room, Staff #7, Dietitian, when asked if the 1800 calorie diet was enough food to promote weight maintenance and wound healing for Patient #16, based on his height and weight and stable blood sugars stated, " ...that's low ...I wasn't aware of these patients ..." When asked if the facility had a nutritional analysis of the menus Staff #15 stated, "No" and confirmed the findings.

Based on record review and interviews, it was determined that not all medical records contained timely Histories and Physicals and Discharge Summaries.

Findings were:

Facility policy entitled "Medical Record Guideline for Physicians" stated in part "All entries must be timed, dated and authenticated. Records shall be completed and authenticated within 15 days following patient discharge. In no event shall the completion of a medical record exceed 30 days following patient discharge ...History and Physical Examinations shall be completed within the first 24 hours of admission .... Discharge Summary should be dictated within 24 hours following patient's discharge except in unusual situations where pathology or autopsy findings are awaited."

Review of 10 randomly selected discharged patients revealed the following:

* Patient # 14, discharged 12/7/18, had no History and Physical in the medical record.
* Patient # 16, admitted 1/28/19, had no History and Physical in the medical record.
* Patient # 18, discharged 12/20/18, had no Discharge Summary or History and Physical in the medical record.

The above missing documentation was confirmed in interviews with the Director of Nurses and the Medical Records Clerk on 2/13/19.

Based on review of medical records and interview, it was determined that medical records in the facility were not always completed in a timely manner.

Findings were:

Facility policy entitled "Medical Record Guideline for Physicians" stated in part "All entries must be timed, dated and authenticated. Records shall be completed and authenticated within 15 days following patient discharge. In no event shall the completion of a medical record exceed 30 days following patient discharge ...History and Physical Examinations shall be completed within the first 24 hours of admission .... Discharge Summary should be dictated within 24 hours following patient's discharge except in unusual situations where pathology or autopsy findings are awaited."

Review of 10 randomly selected discharged patients revealed the following authentication errors:

* Patient # 13, discharged 11/20/18, had a Discharge Summary unsigned by the physician
* Patient # 14, discharged 12/7/18, had an unsigned Discharge Summary, an unsigned lab report dated 11/10/18, and an unsigned MD order dated 11/13/18.
* Patient # 15, discharged 12/5/18 had an unsigned Discharge Summary.
* Patient # 16 had unauthenticated physician orders dated 1/28/19 and 1/29/19.
* Patient # 18, discharged 12/20/18, had an unsigned MD order dated 12/18/18.
* Patient # 20, discharged 12/6/18, had an unsigned Discharge Summary.

The above missing physician authentication was confirmed in interviews with the Director of Nurses and the Medical Records Clerk on 2/13/19.