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 medical records, policy and procedure and staff interviews, it was determined that the facility did not ensure consistent distribution of required notices to patients or their representatives upon admission and prior to discharge.

Findings include:
Review of MR# 5 on 9/13/11 it was noted that this [AGE] year old female was admitted on [DATE] with acute renal failure. A signed copy of the Important Message (IM) form acknowledging that she/or her representative were aware of her rights as a Medicare patient was not seen in the patient's record. Documentation in the medical record showed that the patient's daughter was very involved in her care.

The hospital failed to provide a follow-up IM notification within 48 hour in advance of the patient discharge or no less than four hours prior to discharge as required.
Social worker notes on 3/15/11 at 1:09 PM indicated that patient's family was provided with the Medicare notice after she contested the discharge.

Review of patient's record and interview with the Director and Assistant Director of Case Management on 9/16/11 it was noted that the hospital separated the IM into two forms (IM and Steps to Appeal Your Discharge). Based on staff interview the IM part is given out within 48 hours of admission and the second form 2 days prior to discharge. CMS requirement for provision of the standardized notice and the approved form cannot be altered from it's original format. The entire form should be provided within 48 hours of admission as required.
Similar patient were noted in the following records:
MR #6, MR #7 and MR #8.

Based on interview and review of medical record, it was determined that the physician and or other licensed health care practitioners failed to appropriately assess the patient ' s condition to plan an adequate course of treatment.

Findings include:

MR# 4

This [AGE] year old female patient was interviewed on 9/12/11 about 2:45pm. The patient stated that she had been admitted on Saturday because the ulcer on her leg was not healing. Review of the medical record indicated that the patient had multiple medical conditions and was admitted on [DATE] for evaluation and treatment of stasis ulcer, however there was no physician's order for treatment/dressing of the stasis ulcer. There was no evidence of treatment of the patient's stasis ulcer from 9/9/11 - 9/12/11.

Based on interview and review of medical record it was determined that nursing staff failed to execute the orders of physicians to assure that all patient care needs are met. This finding was noted in 1 of 8 applicable records reviewed.

Findings include:

MR # 1

This is an [AGE] year-old admitted on [DATE] with a history of persistent diarrhea. The patient was evaluated by pulmonary and gastrointestinal consultants with the impression of diarrhea, rule out infection. Both consultants recommended stool to be sent for culture and [DIAGNOSES REDACTED]icile toxin. A physician order was written on 9/9/11 for "[DIAGNOSES REDACTED]icile Routine" and "Stool culture Routine" . Although GI note on 9/11 indicated diarrhea improved, the patient upon interview on 9/12/11 at 3:00 PM complained of reoccurrence of diarrhea and had no previous knowledge of orders for stool collection. The review of patient's record found that orders for stool specimen were not implemented. The patient's nurse stated she was aware of the latest episode of diarrhea but could not obtain the specimen because the patient did not save the stool for inspection. The patient on 9/12 remained on contact isolation to rule out [DIAGNOSES REDACTED]icile toxin in stool.

Based on interview and the review of medical record, it was determined that nursing staff failed to collaborate with medical staff to assure that all patient care needs are met. This finding was noted in 2 of 20 medical record reviewed.

Findings include:

MR #2
This is a [AGE] year-old admitted on [DATE] for acute exacerbation of multiple sclerosis with loss of sensation below the waist. The initial nursing assessment identified a stage III pressure ulcers on the left buttock; 4cm x 2cm and on the crease of the buttocks; 2cm x 2cm. The nursing staff did not discuss the patient's pressure ulcer with the physician for further assessment and management as indicated in the facility's policy titled "Prevention and Management of Pressure Ulcers. "There were no physician's orders for the treatment of both ulcers until 9/13, seven days after admission of the patient.

MR # 3
The patient an [AGE] year old male with multiple medical conditions was transferred from another facility on 8/26/11. Nursing admission progress notes on 8/26/11 indicated a stage II sacral decubitus ulcer. The sacral area is noted to be intact on 8/27/11 at 1:10pm. On 8/31/11 nursing documentation indicated a new wound to the left buttock measuring 5x3x1cm, stage II. There was no further documentation until 9/3/11, nursing indicated that the ulcer measured 7 x 6 cm, thin slough mild odor however there was no dressing indicated. There was no physician's order for decubitus care/treatment until 9/8/11 as nursing documentation noted the ulcer to be stage IV with moderate exudate.
Based upon observations, interviews and review of the facility's policy and procedures and other facility documents, it was determined that the facility failed to be constructed, arranged and maintained to ensure the safety of patients. Therefore the accumulative effect of the Hospital Regulation standard level deficiencies is that the Condition of Participation for Physical Environment is not met as evidenced by:

Failing to maintain the physical plant to assure patient safety and well-being. (See A 701).
Based on observations, record review, and interview during tours of the facility between 9/12/11 through 9/16/11, the hospital did not ensure that the condition of the physical plant and the overall hospital environment was developed and maintained in a manner to ensure the safety and well being of patients.

Findings include:

During a tour of the Emergency Department (ED) on the morning of 9/12/11 the following environmental deficiencies were identified:
1- The TSI (monitor system) of the two isolation rooms of the ED were observed not to be working. The door of the isolation rooms were held open and the monitor system's green light was on all the times indicating normal (negative pressure); no alarm sounded and the red light did not turn on.
2- Floor tiles in front of room # 123 were observed to be broken imposing tripping hazard.
3- The electrical room #123 that has a two hour fire rated walls was found to have many penetration around pipes at the corners of one wall that was not sealed with the proper fire stops.
4- The supply room in the ED had many items that were stored very close to the ceiling, < 18 inches from the ceiling of the sprinklered room which defeats the function of the sprinkler system in the event of fire.
5- 16 oxygen cylinders were noted to be stored next to the ambulance exit door. Oxygen cylinders must be secured in a room with the proper ventilation and fire rated walls and door as per NFPA 99.

Ambulatory Surgery Suite:
6- The pipes underneath the hand-wash sink of the handicapped bathroom in the Ambulatory Surgery suite was not insulated or otherwise configured to prevent abrasion and or burn of the wheel chaired patients.
7- The ambulatory surgery suite was observed to be cluttered and had many items that were stored in the patient cubicles. Examples of the stored items included but were not limited to three (3) wheelchairs, two chairs, linen cart, gown cart, etc.

Medical Surgical Unit - Briger 2:
1- The call bell of the patient bathroom #2269 was activated; no staff member responded to the alarm of the call bell for more than 5 minutes.
2- The ceiling tiles of the isolation rooms of the medical surgical units - Briger 2 and 3 were noted to be of the regular ceiling tiles not the smooth and washable ceiling tiles that are required for this type of rooms in order to be easily cleaned and to prevent the spread of infection.
3- The inside of the chute of ice machine of the medical surgical unit - Briger-2 was found to be dirty. The air supply vent of the ice machine room was also dirty and had black dots on its surface.

Psychiatric Unit:
1- The facility used two metal bars that are affixed to the wall surface as toilet paper holders in all the patient bathrooms. The metal protrusions extended more than two inches above the wall surfaces imposing a risk of self-injury.
2- An exposed electric wire was noted hanging from the ceiling in the corridor outside room #307.
3- All the patient shower rooms in the Psychiatric Department have hand held shower faucet with flexible metal hoses that are approximately 8 feet long. This type of hand held faucet imposes a looping hazard.
4- The shower and the temperature control knob are protruded metal bars that extend more than 2 inches above the surface of the wall and impose a looping hazard.
5- The door of closet # 315 was not locked or secured to prevent patient from hiding in this closet.
6-The Temperature Thermostat on the corridor outside room # 3320 was noted to be broken, falling apart and attached to the wall with adhesive tape.
7- Two space heaters were observed; one was found in the nursing station next to the pharmacy pneumatic tubes and the second space heater was found in office # 3324. Space heaters are prohibited in health care facilities and imposes fire hazard.
8- The door of housekeeping closet was noted to be rusty with peeling paint.
9- The seclusion room was partly padded; however, the window of the room was not padded, it has sharp metal edges which is a potential for self harm to patients.
10- The fire door of the TV room had a chain on the top part that imposes a looping hazard.
11- The surface of the refrigerator in the nourishment room was noted to be very dirty.
12- The dining room had many floor tiles that were cracked or broken which imposes a tripping hazard. Also, the floor of the dining room was very dirty and the room had a bad smell.

Intensive Care Unit and Cardiac Care Units (ICU and CCU):
1- Neither the ICU unit nor the CCU unit has an isolation room. At least one isolation room should be provided for each unit as per AIA guidelines.
2- The ceiling tiles of all the patient rooms in the Intensive Care Unit and the cardiac care units (ten beds/each) are of the regular ceiling tiles, not the washable ceiling tiles that is required for this type of rooms.
3- The HVAC system in the ICU and CCU units was not working properly; this was evidenced by the presence of one fan in every room of both units. The fans were observed to be running during the tours of these two units in two successive days. Some of the running fans were noted to have dust on their surfaces and they were blowing air on the patients who were on ventilators in some of the rooms. This findings has an infection control concerns in addition to the fact that the HVAC system was not maintained to function properly.
4- The clean utility room of the CCU unit had negative air pressure instead of the required positive air pressure for this type of room.
5- The stove and the ice machine of the pantry room of the CCU unit were found very dirty.
6- The corridor of the CCU unit was blocked by chairs, carts, Hoyer lift and other equipment.

Burn Unit:
On the morning of 9/14/2011, a tour of the Burn Unit and the adjacent area of Podiatric Suite revealed the following:
1- The surfaces of podiatric chairs were noted to be cracked and torn. The condition of the chairs makes them not easy to properly disinfect or clean therefore constituting a potential for the spread of infection.
2- There was no nursing call bell in the patient bathroom of the hyperbaric suite.

TBI Unit:
The corridor of the TBI unit was noted to be blocked by a desk, three chairs, and a stretcher.

Radiology Department:
1- The nursing call bell of the bathroom of dressing area #28 in the radiology department did not have a cord that could be accessible to patients who might be on the floor. Instead it has a button that was mounted >36 inches above the floor.
2- The handicapped patient bathroom in Nuclear Medicine Suite did not have a call bell.
3- The housekeeping items and equipment used to clean the MRI room was not ferrous free. The handle and the wheels of the mopping bucket were from ferrous elements.

Central Sterile Supply (CSS):
On the afternoon of 9/15/2011, a tour of the Central Sterile Supply Suite revealed the following:

1- The preparation area (clean and sterile area) had negative air pressure in relation to the corridor, instead of the required positive air pressure for this type of area.
2- The preparation area did not have a hand- washing sink as required. When asked, the Manager of the CSS said that the staff uses the bathroom's hand washing sink.
3- The Decontamination area did not have a hand-washing sink. Upon interview staff said that they wash their hands in the instrument sink (clinical sink). This can cause cross contamination and is a breech of infection control.

Pediatric Unit:
1- Patient bedroom #1309 did not have hot water at the hand washing sink.
2- The soiled utility room of the pediatric suite had positive air flow, instead of the required negative air pressure of this type of room.
3- The smoke and fire partition between room 310 and 311 was not intact and had penetration in the area where the wall meet the floor. These penetrations allow the passage of smoke in the event of fire or smoke.
3- Some (at least Three) of the electric outlet in the corridor of the pediatric department did not have the tamper resistant outlets that are required for the pediatric areas.

Medical Gases:
Review of the medical gas report of 2011, revealed that the Medical Gas System was tested in April 2011, and numerous deficiencies were identified in many areas of the system; however, until the day of the CMS survey on 9/16/2011, there were still many deficiencies that have not been corrected.
The followings are few examples of the uncorrected deficiencies that are listed in the report:
1- There were no check valves between pumps and receiver on the 5th floor- Vent patients of DMRI Building.
2- The Vacuum Switch setting did not have automatic alternation as recommended by Medical Gas Vendor (Praxair Healthcare Services).

Basement Mechanical Room 0029 of Briger Building and Katz ER
3- There was no isolation Pad installed on pumps in the Basement Mechanical Room 0029
4-The main line shut-off valve was not properly labeled for gas as per NFPA 99 code requirement.
5- The main line shut-off valve was not properly labeled for area(s) served.
6- The main line shut-off valve was not properly labeled for warning (Emergency Only).

Medical gases of 4th floor TBI Department:
a- No Automatic Alternation.
b- The alarm Vacuum switch was not connected to master alarm panel.
c- The exhaust can not be isolated and did not have bypass valve.