The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on Policy and Procedure, Document Review and Interview the hospital failed to fully disclose all patient rights in 2 of 2 patient rights documents reviewed. Failure to provide all patient rights puts patients at risk for being uninformed of their rights and affects all patinets being admitted to the hospital.

Findings include:

- Document review on 8/3/16 at 1:00 PM "Patient Information Handbook" section titled "Patient Rights" failed to provide the following rights:

1. The patient has the right to formulate advanced directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with 489.100 of this part (Definition), 489.102 of this part (Requirements for providers), and 489.104 of this part (Effective dates).
2. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
3. The patient has the right to personal safety.
4. The patient has the right to receive care in a safe setting.
5. The patient has the right to be free from all forms of abuse or harassment.

- Policy and Procedure reviewed on 8/3/16 at 1:00PM titled "Patient's Rights and Responsibilities" failed to include the following patient rights:

1. The patient has the right to participate in the development and implementation of his or her plan of care.
2. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

Interview on 8/3/16 at 2:00 PM with Staff A and Staff B verified discrepancies on Patient Rights in the Policy and Procedure and Patient Information Guide. Both documents are incomplete concerning patient rights.
The hospital reported a census of ninety-five patients. Based on observations, staff interviews, and policy reviews the Hospital Infection Control Officer failed to ensure the infection control practices were followed for four of four staff members (staff W, P,T, F) observed performing hand hygiene, for two of two staff members (staff P, Staff T) observed performing glove changes after coming into contact with a contaminated body site, for two of two staff members (staff X, staff Y) observed wearing personal protective equipment and for one of one staff member (staff T) preparing a medication for injection. These deficient practices had the potential to expose all patients and healthcare workers to infectious diseases.

Findings Include:

- Telemetry unit observed on 8/1/2016 at 11:30 AM revealed Staff W leaving patient's room with patient's drinking cup without performing hand hygiene, walking toward the ice machine, placing their right hand on ice machine while dispensing ice into the cup. Then, Staff W walked back into patient's room without performing hand hygiene again.

Staff W interviewed on 8/1/2016 at 11:32 AM acknowledged they did not perform hand hygiene after leaving the patient's room and again entering the patient's room.

Staff B interviewed on 8/1/2016 at 11:33 AM acknowledged Staff W did not perform hand hygiene after leaving and reentering the patient's room.

- Medical surgery 6th floor observed on 8/1/2016 at 11:40 AM revealed Staff X in a patient's room with contact precautions (contact precautions are used when a person has a type of bacteria or virus on the skin or in a sore, or elsewhere in the body, such as the intestine, that can be transmitted to someone else if that person touches the infected individual or contaminated surfaces or equipment near the infected individual. The term " contact precautions " means that everyone coming into a patient ' s room is asked to wear a gown and gloves) posted on door without a gown. Staff X proceeded toward door and grabbed a gown but did not tie the back of their gown which exposed their uniform. Staff Y, already in the patient's room, had a gown on not tied in the back exposing their uniform.

Staff X interviewed on 8/1/2016 at 11:43 AM acknowledged they should have had a gown on prior to entering patient's room. Staff X stated it is in our policy.

- Observation on 8/3/16 at 5:10 AM revealed Staff P and Staff T giving a bed bath to a patient. Both of the staff did not use hand sanitizer before gloving and gowning to enter the contact precautions room. During the bath, both staff failed to change gloves and use hand sanitizer when going from dirty to clean in the bathing. The dirty linens were thrown onto the floor during the bath. The bag with the dirty linens had been tied up with dirty gloves after bathing and then carried to the soiled laundry area with bare hands.

- Observation on 8/3/16 at 6:35 AM revealed Staff F emptied urine from the patient's urinary bag and then took off her gloves and did not use hand hygiene before donning gloves again to help the patient who was vomiting.

- Observation on 8/3/16 at 6:50 AM revealed Staff T did not use an alcohol wipe to disinfect the top of the medication vials when giving a medication to a patient.

Interview on 8/3/16 at 5:55 AM verified Staff T and Staff P failed to use hand sanitizer between glove changes, failed to change gloves when going from dirty to clean during the bath and that they put the dirty laundry of this patient in contact precautions on the floor instead of directly into the laundry bag.

Interview on 8/3/16 at 6:50 AM Staff T verified no hand hygiene was performed between glove changes and Staff T verified the tops of the two medication vials were not cleaned with an alcohol wipe prior to use.

Policy titled "Hand Hygiene"reviewed on 8/1/2016 directed the hospital staff "...All personnel will use the hand hygiene techniques, as set forth in the procedures below "...before each direct patient contact...after contact with inanimate objects such as medical equipment/supplies in patient areas... "

Policy titled "Standard and Isolation Precautions" reviewed on 8/1/2016 directed the hospital staff " precautions ...don gown upon entry into the room ..."...standard precautions...gowns should adequately cover the user's clothing and afford protection enough to prevent passage of contaminants onto uniform/clothing.

Based on record review and interview, the hospital failed to provide written discharge medications for treatment of blood sugars in 1 of 2 discharged patient records reviewed (patient #1). Failure to provided medication treatment for blood sugars placed the patient at risk for having no means to control their blood sugar, physical complications, and re-hospitalization for uncontrolled blood sugars.

Findings include:

Record review on 8/4/16 at 8:15 AM Staff U and Staff W verified the discharge summary by Physician Staff ? failed to provide diabetic instructions for care of blood sugars to patient #1. Patient #1 ( an insulin dependent diabetic for over 40 years) was transferred by ambulance from a rehabilitation facility with a blood sugar of 31 (normal 80-110) on the morning of 6/17/16. The patient arrived to the emergency department and received Glucagon (a hormone that raises the level of glucose (a type of sugar) in the blood) the blood sugar came up to 41. The patient received Dextrose 50 (a type of sugar found in fruits and plants) one ampule (a sealed glass capsule containing a liquid, especially a measured quantity needed for injection) and her blood sugar raised to 155. A bag of normal saline was then given through their intravenous catheter (IV) (a tube that goes into the veins for medications and fluids). Patient #1 was transferred to the 6th floor and an IV bag of Dextrose 5% and normal saline was given to manage their blood sugars until the discharge on the afternoon of 6/18/16. On the 6th floor blood sugars were 54 at 3:16 PM, 114 at 4:19 PM, 87 at 5:04 PM, 166 at 6:10 PM, 163 at 7:07 PM, 220 at 9:41 PM, on 6/18/16 blood sugars were 158 at 3:21 AM, 186 at 7:34 AM, 293 at 10:50 AM and 260 at 1:29 PM prior to discharge. IV of Dextrose 5% and normal saline was discontinued and patient sent back to the rehabilitation facility with no orders for medication management for the blood sugars. Documentation of the medication Synthroid (a [DIAGNOSES REDACTED] replacement) was present on nursing discharge note.

Interview on 8/4/16 at 8:15AM Staff U and Staff W verified the facility failed to provide orders to manage patient #1's diabetes when transferring the patient back to the rehabilitation facility.

Nursing Standards reviewed on 8/4/16 at 8:30 AM states ...when a transfer in the level of care occurs, medications must be reinstated or discontinued by the physician utilizing the medication reconciliation process. "