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 review of 11 open and 3 closed medical records, it was determined that in 2 out of 14 medical records reviewed, the hospital failed to provide patient #1 and patient #8 with notification of their discharge rights via the Important Message from Medicare (IM). Patient #11 had received her IM but no documentation could be found in the medical record.

Patient #1 was admitted on [DATE] and discharged on [DATE]. Review of the medical record revealed that no Important Message from Medicare was provided to the patient within 2 days of admission and discharge.

Patient #8 a [AGE] year old female admitted to the hospital. Review of the medical record revealed no Import Message from Medicare within in two days of admission.

Patient #11 was [AGE] years old, admitted to the facility on [DATE] for frequent falls. Medical record review revealed that the patient had signed the general treatment consent form on 11/12/13 which contained a statement in the consent that noted the patient had been given the Important Message from Medicare (IM). Interview of the first floor manager and charge nurse revealed that the patient did receive the (IM) because the patient had been given a copy. The charge nurse retrieved the signed copy of the (IM) from the patient and presented it to the surveyor. While the surveyor could confirm that the patient indeed did receive the (IM), the staff confirmed on interview that a copy was not on the patient's chart/medical record and that the staff seemed unaware of this requirement for validation of patient receipt.

Based on review of 2 out of 14 open medical records, it was determined that content (signatures) was illegible, no physician identifying numbers and correction of errors was performed improperly.
Patient # 9 is a [AGE] year old male admitted to the Step down Unit on November 13, 2013 with Anemia, [DIAGNOSES REDACTED], and Non-ST Elevation Myocardio infarction. At the time of the record review specifically the physician's hand written history/physical note it was determined that the physician had obliterated two entries in the history/physical note instead of following standard and acceptable practice of drawing one line through the entries, initialing and writing the word error. In addition, the surveyor, nursing manager or nursing administrator were not able to identify the physician's signature as it was illegible and did not have an identifying physician number behind the illegible signature.
Patient # 10 is a [AGE] year old female admitted to the ICU on November 13, 2013 for a drug overdose with suicide attempt. Review of the ICU Critical Care Medicine Patient Note dated November 14, 2013 at 07:33, specifically the Global Assessment section was found to be illegible and could not be read by the surveyor, nursing manager or nursing administrator at the time of the record review.
A tour of the first floor medical surgical unit on 11/15/13 was made with the presence of licensed nursing staff (Nurse Manager and Charge Nurse) starting at 9:05AM and revealed the following observations:
A needle in a red cap on the North side was observed lying on the counter top in the ante-partum room of the negative pressure room of #1104 at 9:05AM and not discarded into the sharps container.

Housekeeping closets #1310 and #1212 (not in view of the nurse ' s station) on the North side were found unlocked and accessible to anyone including patients. The closets contained cleaning chemicals, cleaning equipment, and space for a person to hide. Interview of the housekeeping staff at 9:25AM revealed that a closet key had been borrowed by a third floor employee approximately 2-3 months prior to the tour and was never returned. Additional interview of the housekeeping employee as to whether this had been reported to the housekeeping supervisor was explained that a call had been made at some point, but that to date another key had not been provided. Interview of the Environmental Services (EVS) Director at 2:13PM revealed that the housekeeping staff employee interviewed had signed out a key that morning and had been given a key. The procedure is for each housekeeping employees to obtain keys at the beginning of their shift, sign it out and return it at the end of the shift. This system per interview of the EVS Director was put in placed due to the frequent loss of keys by staff.

Observation at 9:38AM of the North Side clean utility room, revealed a room with multiple patient care supplies. A trash can upon entry on the left hand side of the doorway was full and overflowing with multiple intravenous (IV) wrapper bags lying on the floor with a small empty cardboard box that was labeled 0.9%NaCL Injection.

Observation of the Crash Cart at 9:40AM on the South side revealed that the yellow clip was broken and the cart had not yet been checked for 11/15/13. The drug drawer was opened on the cart by the nursing staff and revealed that the medications were sealed with clear cellophane, with no indication that the seal had been punctured /disturbed. Interview of the charge nurse revealed that she had not had an opportunity to check the cart this morning but would be doing so. Failure to ensure the crash cart completeness and readiness potentially places a patient at risk for a delay in care/treatment in the event of a cardiac or respiratory arrest.

During the ICU/Step Down unit tour specifically a tour of the Clean/Sterile supply room, it was determined that the floor was soiled and under each of the supply carts there was dust and debris. In addition, there were various supplies used for patient care e.g. blood tubes, sterile 4x4 dressing pads and other patient supplies items on the floor under the carts.

At the time of these findings the surveyor informed the nursing manager and administrator that the room needed to be immediately cleaned to ensure that items used for patient care were not compromised and that the debris be removed to prevent further contamination of the room.

A call was subsequently placed by the nursing manager to have the room cleaned however after having toured the entire unit, interviewing the unit manager and completing record reviews the surveyor re-inspected the room and found that the condition of the room and safety of supplies remained unaddressed.