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.

REGIONAL HOSPITAL OF SCRANTON 746 JEFFERSON AVENUE SCRANTON, PA 18501 April 20, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility documents, observations, and staff interview (EMP), it was determined the Board of Trustees of the Regional Hospital of Scranton was in effective by failing to ensure the Medical Executive Committee made recommendations to the governing body and the CEO concerning the nursing shortages (A049); by failing to ensure the Director of Nursing followed the facility-established standards of nursing practices (A385); by failing to ensure the facility's staffing matrix was met for the Intensive Care Unit, the 4th floor telemetry unit, and the 7 East Medical/Surgical unit (A392); and by failing to ensure the facility was equipped, operated and maintained in the Cardiac Open Heart Intensive Care Unit, the Surgical Intensive Care Unit, the 4 East telemetry unit, the Short Procedure Unit, the 9 East Medical/Surgical Unit, the 8th floor Outpatient Chemotherapy Department, the 8th floor Medical/Surgical Unit, and the Emergency Department (A700).

Findings include:

Review of the "Commonwealth Health Regional Hospital of Scranton Board of Trustees Bylaws," last revised March 18, 2015, revealed "Article I - General Scope Be it resolved by the Board of Trustees of Regional Hospital of Scranton that the bylaws set out below shall govern the transaction of the business and affairs of the Hospital. 1.1 Purpose The purposes, goals and objectives of the Board of Trustees of Regional Hospital of Scranton shall be to: 1.1(a) Support, manage and furnish facilities, personnel and services; to provide diagnosis, medical, surgical and hospital care, outpatient care and other hospital and medically related services to sick, injured or disabled persons; provide well-care programs as appropriate and feasible, without regard to race, color, sex, national origin or disability; 1.1(b) Provide appropriate facilities and services to best serve the needs of the patients; ... 1.1(h) Provide for overall institutional planning, with the participation of the Medical Staff, nursing department, and such other individuals as the Governing Body deems appropriate; and ... "

Cross reference:
482.12(a)(5) Medical Staff - Accountability
482.23 Nursing Services
482.23(b) Staffing and Delivery of Care (nursing)
482.41 Physical Environment
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on review of facility documents and interview with medical staff (OTH), it was determined the medical executive committee failed to make recommendations to the governing body and the CEO concerning the shortage of nursing staff.

Findings include:

Review of the "Regional Hospital of Scranton Medical Staff Bylaws," reviewed October 21, 2014, revealed "... Article XII Committees [and] Functions ... 12.2 Medical Executive Committee ... 12.2(b) Functions The committee shall be responsible for governance of the medical staff, shall serve as a liaison mechanism between the Medical staff, Hospital administration and the Board and shall be empowered to act for the Medical staff in the intervals between medical staff meetings. ... The functions and responsibilities of the MEC shall include at least the following: ... (9) Assuring regular reporting of performance improvement and other staff issues to the MEC and to the Board of Trustees and communicating findings, conclusions, recommendations and actions to improve performance to the Board and appropriate staff members; (10) Evaluating areas of risk in the clinical aspects of patient care and safety and proposing plans and recommendations for reducing these risks; ..."

Review of the medical executive committee meeting minutes for the past 12 months revealed minimal discussion regarding the critical short staffing of the nursing services within the facility. There was no action plan identified on how to address the nursing shortages.

Interview with OTH1 on April 8, 2015, confirmed the nursing staffing shortage was an issue, and this was reported to Medical Executive committee. The committee was repeatedly told recruitment was an issue. OTH1 stated there was a problem with retention and many new staff was hired, get experience and then move on.

Interview with OTH2 on April 9, 2015, confirmed the nursing staffing shortage was discussed with Administration. No action seemed to be taken. OTH2 confirmed morale was low, and the nursing staff was overwhelmed. OTH2 also stated the staffing shortage on the medical surgical floors was worse.

Interview with OTH3 on April 9, 2015, revealed "short staffing issues never go away, most problems can be traced back to staffing. Staffing was discussed at every single meeting. When short staffing occurs all other issues snowball."

Cross reference:
482.23(b) Staffing and Delivery of Care
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of the facility's plan of correction, facility documents, and staff interview (EMP), it was determined the Director of Nursing failed to follow the facility-established standards of nursing practice by failing to ensure the facility's staffing matrix was met for the nursing units reviewed at the time of this unannounced investigation, the Intensive Care Unit, the 4th floor telemetry unit, and the 7 East Medical/Surgical unit (A392).

Findings include:

Review of the Plan of Correction submitted by the facility for deficient staffing in the Intensive Care Unit (ICU) following an investigation on October 4, 2013, revealed the following: "The Chief Nursing Officer (CNO) is responsible for services provided by the Patient Care Services Department and for ensuring appropriate nursing staff is available to provide patient care. The CNO has defined a written staffing guidelines grid to establish nurse patient ratios for the provision of care within critical care. Suggested RN, Certified Nurse Assistant, Unit Secretary, and Nurse Manager staffing per defined census values have been established. Additionally, the Plan of Care for Critical Care has been reviewed and updated to incorporate defined staffing within the unit. A Nursing Staffing Plan policy has been written to support a written policy on staffing plans for critical care. This policy addresses utilization of a daily staffing sheet to document staff within the critical care unit and of a Nursing Assignment Sheet to record actual nursing assignments on a shift-by-shift basis. The assignment sheets are maintained in a binder at the nursing station so they are available for assignment tracking and review. The utilization of assignment sheets started on 10/1/13. The nurse manager of the critical care unit and the nursing supervisors received education on the established guidelines. This was originally completed on 10/1/2013 when the new assignment tracking process was initiated. The nurse manager of the critical care unit and the nursing supervisors will receive education on the revised plan of care and the staffing plan policy by 11/4/2013. This will be conducted by the CNO during staff meetings or within 1:1 interactions.
Auditing to ensure compliance to the policy, plan, and guidelines is conducted on an ongoing basis. As per the staffing plan policy, each shift the nurse manager and/or nursing supervisor will review the assignments sheets within critical care and initial the form. Variations within assignments and schedules are addressed utilizing options defined within the staffing plan (floating in staff, calling in off duty staff, utilizing contracted agencies, limiting census within the critical care unit, triaging patients with the intensive care unit with the Physician Director of Critical Care and/or going on critical care bypass status.)
At a minimum of weekly, the CNO will review staffing results with the nurse manager of the critical care unit to ensure compliance to staffing guidelines. Overview of this review will be provided to the Chief Executive Officer (CEO) on a weekly basis. Results will be incorporated into the QI process by reporting to the Critical Care Committee, Patient Safety Committee, Quality Committee, and then the MEC and Governing Board monthly until 3 consecutive months of full compliance have been demonstrated."

Review on April 20, 2015, of the job description for "Position Title: CNO [chief nursing officer], last reviewed January 2015, revealed "Position summary: As a member of the Hospital's senior management team, the CNO will participate in functional decision-making processes necessary to the successful attainment of the hospital's mission in addition to maintaining an awareness of changes in healthcare clinical matters that could have an impact on the success of the hospital. Essential Duties and Responsibilities 1. Providing leadership to nurse employees that will enroll their support, create ownership of goals, and have them actively participate in decisions that impact the hospital 2. Maintaining necessary regulatory and compliance approvals and quality accreditations 3. Partnering with physicians who use, or will use, the hospital 4. Assisting in planning new services that generate additional sources of profitable revenue 5. Creating an environment that will encourage recruiting and retention of clinical employees 6. Managing costs by continually seeking data that will identify opportunities and take action to eliminate non-value costs 7. Establishing standards for nursing practices and maintain authority, accountability and responsibility for nursing services 8. Developing organizational patient care programs, policies and procedures that describe how nursing care is assessed, delivered and evaluated 9. Developing and managing the nursing services budget and ensuring sufficient number of qualified staff to assess patient needs 10. Plan and provide nursing care interventions and prevent complications, promote improvement and patient comfort and wellness 11. Analyzing areas in planning, promoting and conducting organization-wide performance improvement activities 12. Representing the nursing services at all meetings including medical staff and hospital board of director meetings; participates with leaders in designing and providing patient care and services ... "

Interview on April 10, 2015, at 9:30 AM with EMP13 confirmed the Intensive Care assignment sheets [required in the facility's Plan of Correction] were not always completed. The assignment sheets were reviewed with EMP13, and there were shifts missing or assignment sheets not completely filled out. EMP13 confirmed that on some of the worst staffing days, the staff were not completing the assignment sheets because they were too busy.

Cross reference:
482.23(b) Staffing and Delivery of Care (nursing)
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure adequate staffing for the nursing units reviewed at the time of this unannounced investigation, the Intensive Care Unit, the 4th floor telemetry unit, and the 7 East Medical/Surgical unit.

Findings include:

Review of Board Meeting Minutes dated January 21, 2015, revealed there were 34 Registered Nurse vacancies.

1) Review on April 9, 2015, of the facility's "Plan of Care Critical Care," dated reviewed October 2014, revealed "Goals Provide quality nursing care to all patients who enter the Critical Care area ... Unit Description The Critical Care area is licensed for 24 beds. It is located on the third floor of the Hospital. Each room is a private room. Eight of the beds have been designated as an area to perform inpatient dialysis. Scope of Services Adult and geriatric patients are served in this unit, whose major admitting diagnoses include, but are not limited to: Septic Shock Myocardial Infarction Cardiothoracic surgery Endovascular surgery Neurosurgery Diabetic ketoacidosis Renal Failure Respiratory Failure GI [gastrointestinal] Bleed The Critical Care Unit typically serves unstable medical or surgical patients. ... Staffing Each patient in Critical care is assigned to an RN [registered nurse] who is accountable for overall care. This includes assessment, re-assessment, and development of an individualized plan of care. The Critical Care hours per patient day is 19.05 targeted paid hours per patient day. A nurse manager oversees the functioning of the Critical Care Unit. The unit is continuously staffed with registered nurses. Support staff consists of Nursing Assistant and unit secretary. Staff assignments are the responsibility of the Nurse Manager/Charge Nurse. They are based on the acuity of the patient and the amount of supervision required. The general nurse to patient ratio is 1:2; patients that may require 1:1 nursing care include post-operative open heart patients and patients with devices that require frequent monitoring (balloon pump, central venous vascular hemodialysis, intracranial pressure monitoring). See Staffing plan policy for additional details. 1:3 ratios are considered during individual circumstances. Mitigating circumstances may occur when patients may be ordered for transfer out of the Critical Care Unit and no beds are immediately available, when patients are receiving supportive/futile care; or when discharge or transfer to another level of care has been delayed until a bed is available."

Review of the Intensive Care assignment sheets revealed the following patient census and staffing for the day shift (7:00 AM-3:00 PM, evening shift (3:00 PM-11:00 PM) and night shift (11:00 PM-7:00 AM):

March 21, 2015: Evening shift: 12 patients (5 patients were on ventilators) staffed with 6 nurses and 1 clerical from 7 PM to 11 PM, from 3 PM to 7 PM there were 4 nurses and 1 clerical. The facility matrix required 6 nurses, 1 clerical, and 1 aide.

March 19, 2015: Evening shift: 16 patients (10 patients were on ventilators, one patient was a 1:1) staffed with 7 nurses, 1 clerical, and 1 aide. The facility matrix required 8 nurses, 1 clerical, and 1 aide.

March 17, 2015: Night shift: 14 patients (8 were on ventilators) staffed with 7 nurses and 1 aide, from 3 AM to 5 AM there were 6 nurses and 1 aide. The facility's matrix required 7 nurses and 1 aide.

March 16, 2015: Night shift: 14 patients (8 were on ventilators) staffed with 7 nurses and from 2 AM to 7 AM there were 6 nurses. The facility matrix required 7 nurses and 1 aide.

March 15, 2015: Night shift: 14 patients (6 were on ventilators) staffed with 6 nurses. The facility matrix required 7 nurses and 1 aide.

March 14, 2015: Day shift: 13 patients (5 were on ventilators) staffed with 6 nurses, 1 clerical and 1 aide. The facility matrix required 8 nurses, 2 clerical and 1 aide.

March 13, 2015: Day shift: 15 patients (8 were on ventilators) staffed with 8 nurses, 1 clerical, and 1 aide. The facility matrix required 9 nurses, 2 clericals, and 1 aide.

March 10, 2015: Evening shift: 14 patients (5 were on ventilators, 2 were on 1:1) staffed with 7 nurses, 1 clerical, 1 aide until 7 PM and then 15 patients staffed with 6 nurses, 1 clerical, and 1 aide until 11 PM. The facility matrix required 8 nurses, 1 clerical, and 1 aide for 15 patients.
Night shift: 15 patients (5 were on ventilators) staffed with 7 nurses and 1 aide, and from 2 AM to 5 AM there were 6 nurses and 1 aide. The facility matrix required 8 nurses and 1 aide.

March 9, 2015: Evening shift: 15 patients (6 were on ventilators, 1 was on 1:1) staffed with 9 nurses, 1 clerical, and 1 aide, and from 7 PM to 11 PM 6 nurses, 1 clerical, and 1 aide. The facility matrix required 8 nurses, 1 clerical, and 1 aide.

March 6, 2015: Evening shift: 13 patients until 7 PM and then 14 patients staffed with 6 nurses, 1 clerical, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 1 aide for 14 patients and 8 nurses, 1 clerical, and 1 aide for 15 patients. One RN was assigned a second patient in addition to their 1:1 assignment from 7 PM to 11 PM.
Night shift: 14 patients staffed with 7 nurses and 1 aide. The facility matrix required 7 nurses and 1 aide. From 3 AM to 7 AM, there were 5 nurses.

February 12, 2015: Evening shift: 15 patients staffed with 7 nurses, 1 clerical, and 1 aide, and from 7 PM to 11 PM, there were 6 nurses. The facility matrix required 8 nurses, 1 clerical, and 1 aide.
Night shift: 15 patients staffed with 7 nurses. The staffing matrix required 8 nurses and 1 aide.

Review of the ICU staffing roster revealed there were 38 RNs and one RN manager. One RN was on a leave of absence, one was per diem and one was on light duty. The roster included 3 unit clericals and 3 aides.

Review of facility documents revealed the open/available shifts were posted for nursing staff to fill prior to the actual nursing schedule being posted. The following unfilled openings were posted each week:

January 11-January 17, 2015, 48 openings, 30 (for an 8 hour shift) and 18 (for a 4 hour shift).
January 18-January 24, 2015, 47 openings, 21 (8 hr.) and 26 (4 hr.).
January 25-January 31, 2015, 53 openings, 20 (8 hr.) and 33 (4 hr.).
February 1-February 6, 2015, 39 openings, 16 (8 hr.) and 23 (4 hr.).
February 8-February 14, 2015, 56 openings, 28 (8 hr.) and 28 (4 hr.).
February 15-February 21, 2015, 62 openings, 31 (8 hr.) and 31 (4 hr.).
February 22-February 28, 2015, 46 openings, 21 (8 hr.) and 25 (4 hr.).
March 1-March 7, 2015, 52 openings, 23 (8 hr.) and 29 (4 hr.).
March 8-March 14, 2015, 60 openings, 28 (8 hr.) and 32 (4 hr.).
March 15-March 21, 2015, 66 openings, 32 (8 hr.) and 34 (4 hr.).
March 22-March 28, 2015, 48 openings, 19 (8 hr.) and 29 (4 hr.).
March 29-April 4, 2015, 52 openings, 21 (8 hr.) and 31 (4 hr.).
April 5-April 11, 2015, 42 openings 17 (8 hr.) and 25 (4 hr.).
April 12-April 18, 2015, 54 openings, 23 (8 hr.) and 31 (4 hr.).
April 19-April 25, 2015, 49 openings , 24 (8 hr.) and 25 (4 hr.).
April 26-May 2, 2015, 44 openings, 19 (8 hr.) and 25 (4 hr.).

Review of the Critical Care overtime report for March of 2015 revealed 1018.75 hours of overtime were used.

Interview with EMP13 on April 8, 2015, confirmed staffing was an issue for the past four to five months. EMP13 confirmed all agency staffing was stopped in December of 2014, and this made the staffing issues worse. EMP13 confirmed the staffing shortage was reported every month, as well as the amount of overtime utilized. Review of the Critical Care meeting minutes confirmed the staffing shortage was reported. EMP13 confirmed six of the nursing staff were not trained to provide care for the 1:1 [1 RN for 1 patient] open heart patients immediately post-operatively.

Interview with OTH1 on April 8, 2015, confirmed staffing has continued to be an issue, and this was reported to Medical Executive (Med Exec) committee. The Med Exec was repeatedly told recruitment was an issue. OTH1 further stated there was a problem with retention. New staff was hired, gets experience, and then moves on.

Interview with OTH2 on April 9, 2015, confirmed staffing was discussed with administration but no action seemed to be taken. OTH2 confirmed morale was low, and staff was overwhelmed. OTH2 also stated the staffing on the medical surgical floors was worse.

Interview with EMP6 on April 8, 2015, confirmed there were vacancies posted prior to the actual schedule being posted. EMP6 noted the amount of vacancies was ridiculous. EMP6 stated all staff are working overtime. EMP6 noted the loss of agency staffing made things worse. EMP6 stated the charge nurse almost always takes a nursing assignment. EMP6 stated the training for 1:1, specifically for open hearts, was not available.

Interview with EMP5 on April 9, 2015, revealed "a big problem is that they send us floats and one is an LPN, who is very limited in scope, and another RN with a full assignment has to cover [the LPN] " . EMP5 also stated that having an assignment with 3 patients use to be rare, and the 3 patients were stable patients. "Now, you could have 3 patients who are all unstable." EMP5 stated there is a long period of time for positions that are open to be posted, sometimes 4 months before they see postings. EMP5 noted this has caused people seeking positions to go elsewhere.

Interview with EMP7 on April 8, 2015, revealed there are at least 6 staff who are not trained on 1:1, specifically post-operative open hearts, and this is a problem. EMP7 also stated there were times they were assigned a 1:1 patient and also assigned another patient. EMP7 noted there is too much movement on the evening shift; patients are being transferred out for new admissions that could have been sent out earlier. EMP7 confirmed working 115 hours in last pay period.

Interview with EMP8 on April 9, 2015, confirmed feeling overwhelmed and fearful that with the short staffing it was often difficult to complete assignments and reposition patients, especially bariatric patients that require 2-3 people to turn. EMP8 also stated that if there is a rapid response or a transfer "you could be off the floor for a prolonged period of time and someone else who is already crazy busy has to cover your patients." EMP8 noted when you are already down [short] a nurse, this is difficult. EMP8 also confirmed having 3 patient assignments.

Interview with EMP9 on April 8, 2015, confirmed they did not have the training for the 1:1 for open heart patients, and it had not been offered. EMP9 confirmed it was difficult when the float assigned to the unit was an LPN and you had to cover [the LPN]. EMP9 noted this was not fair to the RN or LPN, putting them in a bad spot. EMP9 noted evening and night shifts were the worst staffed and stated the weekends were "awful," noting usually most of 7-3 staff works overtime to cover, and many of the staff are doing 16 hour shifts.

Review of the personnel files for PF1, PF2, PF3, PF4, PF5 PF6 confirm the training on care of the immediate post-operative open heart patient was not completed.

The facility was cited for inadequate staffing in the Intensive Care Unit in October of 2013.

2) Review of Telemetry/Medical/Surgical 4 East assignment sheets revealed the following patient census and staffing for the day shift (7:00 AM - 3:00 PM), evening shift (3:00 PM - 11:00 PM), and night shift (11:00 PM - 7:00 AM):

December 24, 2014: Evening shift: 23 patients staffed with 1 RN charge nurse, 4 nurses and 1 aide. The facility matrix required 5 nurses, 1 clerical, and 1 aide.

December 27, 2014: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, 1 LPN, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Evening shift: 28 patients staffed with 1 RN charge nurse, 3 nurses, and 1 LPN. The facility matrix required 6 nurses, 1 clerical, and 1 aide.
Night shift: 22 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 4 nurses and 0.5 aides.

December 28, 2014: Evening shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility matrix required 7 nurses, 1 clerical and 1 aide.
Night shift: 30 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 4 nurses and 2 aides.

December 29, 2014: Evening shift: 30 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 7 nurses, 1 clerical and 1 aide.
Night shift: 30 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 4 nurses and 2 aides.

December 30, 2014: Day shift: 30 patients staffed with 1 RN charge nurse, 6 nurses, and 2 aides. The facility matrix required 7 nurses, 1 clerical and 2 aides.
Night shift: 30 patients staffed with 1 RN charge nurse, 3 nurses, and 1 aide. The facility matrix required 4 nurses, 1 clerical and 2 aides.

December 31, 2014: Evening shift: 29 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 6 nurses, 1 clerical and 1 aide.

February 18, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 4 nurses and 1 LPN. The facility matrix required 7 nurses and 2 aides.

February 21, 2015: Day shift: 25 patients staffed with 1 RN charge nurse, 4 nurses, and 1 LPN. The facility matrix required 7 nurses, 1 clerical and 2 aides.

February 22, 2015: Day shift: 25 patients staffed with 1 RN charge nurse, 4 nurses, and 1 LPN. The facility matrix required 6 nurses, 1 clerical and 2 aides.

March 1, 2015: Evening shift: 26 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility matrix required 6 nurses, 1 clerical and 1 aide.

March 2, 2015: Evening shift: 24 patients staffed with 1 RN charge nurse, 4 nurses, and 1 clerical. The facility matrix required 5 nurses, 1 clerical and 1 aide.

March 4, 2015: Evening shift: 27 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility staffing matrix required 6 nurses, 1 clerical and 1 aide.

March 5, 2015: Evening shift: 30 patients staffed with 1 RN charge nurse with a 2 patient assignment, 5 nurses, 1 clerical and 1 aide. The facility matrix required 7 nurses, 1 clerical and 1 aide.

March 6, 2015: Evening shift: 26 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 6 nurses, 1 clerical and 1 aide.

March 7, 2015: Evening shift: 26 patients staffed with 1 RN charge nurse with a 2 patient assignment, 4 nurses, 1 clerical and 1 aide. The facility matrix required 6 nurses, 1 clerical and 1 aide.

March 11, 2015: Evening shift: 29 patients staffed with 1 RN charge nurse, 5 nurses, and 1 clerical. The matrix required 6 nurses, 1 clerical and 1 aide.

March 12, 2015: Evening shift: 30 patients staffed with 1 RN charge nurse with a 2 patient assignment, 5 nurses, 1 clerical, and 1 aide. The matrix required 7 nurses, 1 clerical and 1 aide.

March 13, 2015: Evening shift: 26 patients staffed with 1 RN charge nurse with a 2 patient assignment, 4 nurses, 1 clerical and 1 aide. The matrix required 6 nurses, 1 clerical and 1 aide.

March 14, 2015: Evening shift: 25 patients staffed with 1 RN charge nurse with a 2 patient assignment, 5 nurses, and 1 aide. The matrix required 6 nurses, 1 clerical, and 1 aide.

March 15, 2015: Evening shift: 27 patients staffed with 1 RN charge nurse with a 2 patient assignment, 5 nurses, and 1 aide. The matrix required 6 nurses, 1 clerical, and 1 aide.

March 17, 2015: Day shift: 27 patients staffed with 1 RN charge nurse, and 5 nurses. The matrix required 6 nurses, 1 clerical and 2 aides.
Evening shift: 29 patients staffed with 1 RN charge nurse, 4 nurses, 1 LPN, and 1 clerical. The matrix required 6 nurses, 1 clerical and 1 aide.
Night shift: 27 patients staffed with 1 RN charge nurse, 3 nurses, and 1 LPN. The matrix required 4 nurses and 2 aides.

March 27, 2015: Day shift: 28 patients staffed with 1 RN charge nurse, 4 Nurses, and 1 LPN. The matrix required 6 nurses, 1 clerical, and 1 aide.

March 20, 2015: Evening shift: 25 patients staffed with 1 RN charge nurse with a 2 patient assignment, and 5 nurses. The matrix required 6 nurses, 1 clerical and 1 aide.
Night shift: 28 patients staffed with 1 RN charge nurse, and 4 nurses. The matrix required 4 nurses and 2 aides.

March 22, 2015: Night shift: 26 patients staffed with 1 RN charge nurse, 3 nurses and 1 LPN. The matrix required 4 nurses and 1 aide.

March 25, 2015: Evening shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The matrix required 7 nurses, 1 clerical and 1 aide.

March 26, 2015: Evening shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The matrix required 7 nurses, 1 clerical and 1 aide.

March 27, 2015: Day shift: 28 patients staffed with 1 RN charge nurse, 4 nurses, and 1 LPN. The matrix required 7 nurses, 1 clerical and 2 aides.
Evening shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, 1 clerical and 1 aide. The matrix required 7 nurses, 1 clerical, and 1 aide.

March 28, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, and 5 nurses. The matrix required 7 nurses, 1 clerical and 2 aides.
Evening shift: 28 patients staffed with 1 RN charge nurse, and 4 nurses. The matrix required 6 nurses, 1 clerical, and 1 aide.
Night shift: 27 patients staffed with 1 RN charge nurse, and 4 nurses. The matrix required 4 nurses and 2 aides.

March 30, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, and 6 nurses. The facility matrix required 7 nurses, 1 clerical and 2 aides.
Evening shift: 30 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 7 nurses, 1 clerical, and 1 aide.

March 31, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, and 6 nurses. The facility matrix required 7 nurses,1 clerical and 1 aide.
Evening shift: 30 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 7 nurses, 1 clerical and 1 aide.
Night shift: 30 patients staffed with 1 RN charge nurse, 3 nurses, 1 LPN and 1 aide. The facility matrix required 4 nurses and 2 aides.

April 1, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility matrix required 7 nurses 1 clerical, and 2 aides.

April 2, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 2 aides. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Evening shift: 30 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 7 nurses, 1 clerical, and 1 aide.

April 3, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Night shift: 28 patients staffed with 1 RN charge nurse, and 4 nurses. The facility matrix required 4 nurses and 2 aides.

April 4, 2015: Day shift: 30 Patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Evening shift: 25 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 6 nurses, 1 clerical, and 1 aide.

April 5, 2015: Evening shift: 30 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 7 nurses, 1 clerical, and 1 aide.
Night shift: 28 patients staffed with 1 RN charge nurse and 4 nurses. The facility matrix required 4 nurses and 2 aides.
April 6, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 1 aide.
Evening shift: 30 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 7 nurses, 1 clerical, and 1 aide.
Night shift: 30 patients staffed with 1 RN charge nurse, 4 nurses, and 1 aide. The facility matrix required 4 nurses, and 2 aides.

April 7, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 2 aides. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Night shift: 27 patients staffed with 1 RN charge nurse, 3 nurses, and 1 LPN. The facility matrix required 4 nurses and 2 aides.

April 8, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, and 1 LPN. The facility matrix required 7 nurses 1 clerical, and 2 aides.
Evening shift: 30 patients staffed with 1 RN charge nurse and 5 nurses. The facility matrix required 7 nurses, 1 clerical, and 1 aide.
Night shift: 30 patients staffed with 1 RN charge nurse, 3 nurses and 1 LPN. The facility matrix required 4 nurses and 2 aides.

April 11, 2015: Day shift: 28 patients staffed with 1 RN charge nurse, 6 nurses, and 1 LPN. The facility matrix required 6 nurses, 1 clerical, and 2 aides.
Evening shift: 26 patients staffed with 2 RN charge nurses (split shift), with 1 patient assignment, 6 nurses, and 1 aide. Facility matrix required 7 nurses, 1 clerical, and 1 aide.

April 12, 2015: Day shift: 30 patients staffed with 1 RN charge nurse, 5 nurses, 1 LPN, and 1 clerical. The facility matrix required 7 nurses, 1 clerical and 2 aides. 1 RN was covering the LPN ' s patients.
Night shift: 28 patients staffed with 1 RN charge nurse, 5 nurses and 1 aide. The facility matrix required 4 nurses and 2 aides.

April 13, 2015: Night shift: 30 patients staffed with 1 RN charge nurse (with an assignment of 6 patients) 3 nurses and 1 LPN. The facility matrix required 4 nurses and 2 aides.

Interview on April 10, 2015, at approximately 11:00 AM with OTH3 confirmed the nurses were short staffed. Short staffing issues never seemed to go away. OTH3 noted Administration was aware of the issues, "but it must be challenging for all parties involved to keep staffing levels acceptable and still stay in the confines of a budget. It's a difficult situation for everyone."

Interview on April 10, 2015, at approximately 11:15 AM with EMP16 confirmed staffing was always short but it was worse on the evening and night shifts. The LPN cannot do the cardiac medication drips so the RN has to do that part of the LPN's assignment. At times this is like having an extra patient added to your assignment. We all work together as a team and we still give good patient care but I can see nurses starting to get burned out. Sometimes the patient assignment is 10 patients to 1 nurse. Overtime is always an issue and some nurses do back to back shifts. On night shift the charge RN most times takes an assignment of 6 patients.

Interview on April 10, 2015, at approximately 11:30 AM with EMP17 confirmed the nurses were doing the work of the aides, along with the RN assignments. Families have voiced concerns about the nursing care. Staff on evening shift is leaving because they can't deal with the short staffing and the acuity of the patients. The patients we have on telemetry now are the kind of patients who just a few years ago were in the ICU or CCU [Intensive Care Unit or Critical Care Unit].

Interview on April 10, 2015, at approximately 11:45 AM with EMP21 confirmed short staffing was a major issue throughout the hospital. Nursing aides were rarely assigned on the weekends. The nurses do not get breaks or lunches. Agency nurses did help, but they were being used as staff and administration was not actively posting positions. When administration stopped using agency nurses, the floors just crashed as far as staffing was concerned.

Interview on April 10, 2015, at approximately 1:00 PM with EMP22 confirmed staffing on the medical/surgical floors was an issue. We all work together so patient care does not suffer and most of the time I help the staff with their assignments.

Interview on April 10, 2015, at approximately 3:30 PM with EMP18 confirmed short staffing was a major issue especially on evening and night shifts. EMP18 noted LPNs cannot manage drips and we rarely have clerical or aides. "We are not adequately staffed for our patient acuity levels. Telemetry is staffed like any other medical /surgical floor but our patients require more care. I'm afraid something bad is going to happen if staffing issues are not addressed. The salaries are low and the nurses on evening and night shifts leave generally after a year because of the work load. It's like a revolving door."

Review of Telemetry/Medical/Surgical 4 East staff roster revealed 1 RN Manager, 23 registered nurses, 3 licensed practical nurses, 4 clerical, and 6 aides. The total overtime for this unit from February 13, 2015, to April 10, 2015, was 1208.00 hours.

Review of facility documents revealed open/available shifts were posted for nursing staff to fill prior to the actual nursing schedule being posted. The following unfilled openings were posted each week:

January 19- January 25, 2015, 12 openings, 5 (for an 8 hour shift) and 7 (for a 4 hour shift).
January 26-January 31, 2015, 6 openings, 3 (8 hr.) and 3 (4 hr.).
February 1-February 7, 2015, 7 openings, 3 (8 hr.) and 4 (4 hr.).
February 8-February 18, 2015, 9 openings, 5 (8 hr.) and 4 (4 hr.).
February 21-February 28, 2015, 8 openings, 5 (8 hr.) and 3 (4 hr.).
March 1-March 7, 2015, 5 openings, 3 (8 hr.) and 2 (4 hr.).
March 8-March 15, 2015, 15 openings, 11 (8 hr.) and 4 (4 hr.).
March 16-March 22, 2015, 18 openings, 11 (8 hr.) and 4 (4 hr.).
March 23-March 29, 2015, 6 openings, 5 (8 hr.) and 1 (4 hr.).
March 30-April 5, 2015, 6 openings, 5 (8 hr.) and 1 (4 hr.).
April 6-April 11, 2015, 14 openings, 10 (8 hr.) and 4 (4 hr.).
April 12-April 19, 2015, 19 openings, 18 (8 hr.) and 1 (4 hr.).
April 20-April 25, 2015, 6 openings, 4 (8 hr.) and 2 (4 hr.).
April 26-May 2, 2015, 9 openings, 7 (8 hr.) and 2 (4 hr.).

3) Review of the 7 East Medical/Surgical unit assignment sheets revealed the following patient census and staffing for the day shift (7:00 AM-3:00 PM, evening shift (3:00 PM-11:00 PM) and night shift (11:00 PM-7:00 AM):

March 3, 2015: Day shift: 25 patients staffed with 4 RNs, 1 LPN 1 clerical, no aide. The facility matrix required 6 nurses, 1 clerical and 2 aides.
Night shift: 25 patients staffed with 4 RNs. The facility matrix required 4 nurses and 2 aides.

March 4, 2015: Day shift: 29 patients staffed with 5 RNs, 2 LPNs, 1 aide, and 1 clerical. The facility matrix required 7 nurses, 1 clerical and 2 aides.
Evening shift: 25 patients staffed with 4 RNs, 1 LPN, and 1 aide. The facility matrix required 6 nurses, 1 clerical and 1 aide.

March 5, 2015: Day shift: 25 patients staffed with 4 RNs, 1 LPN, 2 aides, and 1 clerical. The facility matrix required 6 nurses, 1 clerical, and 2 aides.
Night shift: 28 patients staffed with 3 RNs and 1 LPN. The facility matrix required 4 nurses and 2 aides.

March 6, 2015: Day shift: 30 patients staffed with 4 RNs, 2 LPNs, 1 aide for 4 hours, and an additional LPN at 11 AM. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Night shift: 30 patients staffed with 3 RNs and 1 LPN. The facility matrix required 4 nurses and 2 aides.

March 7, 2015: Day shift: 29 patients staffed with 5 RNs, 1 LPN, and 1 LPN until 11 AM. The facility matrix required 7 nurses, 1 clerical and 2 aides.
Evening shift: 25 patients staffed with 2 RNs, 3 LPNs, and 1 aide. The facility matrix required 6 nurses, 1 clerical, and 1 aide.
Night shift: 27 patients staffed with 3 RNs, 1 LPN, and 1 aide who was on a 1:1 assignment. The facility matrix required 4 nurses and 2 aides.

March 8, 2015: Day shift: 25 patients staffed with 3 RNs until 11 AM and then 1 RN supervisor, 1 aide, and 1 clerical. The facility matrix required 6 nurses, 1 clerical, and 1 aide.
Evening shift: 24 patients staffed with 3 RNs, 1 LPN, 1 clerical, and 1 aide.
Night shift: 25 patients staffed with 3 RNs, and 1 LPN. The facility matrix required 4 nurses and 1 aide.

March 11, 2015: Night shift: 29 patients staffed with 3 RNs, 1 LPN, and 1 aide. The facility matrix required 4 nurses, and 2 aides.

March 13, 2015: Day shift: 29 patients staffed with 3 RNs, 2 LPNs, 2 aides, and 1 clerical, with an additional LPN at 11 AM. The facility matrix required 7 nurses.
Evening shift: 25 patients staffed with 4 RNs, 1 LPN, 1 clerical, and 1 aide who was on a 1:1 assignment. The facility matrix required 6 nurses, 1 clerical, and 1 aide.

March 14, 2015: Day shift: 28 patients staffed with 5 RNs, 1 LPN, and 1 clerical. The facility matrix required 6 nurses, 1 clerical, and 2 aides.

March 17, 2015: Day shift: 29 patients staffed with 4 RNs, 1 LPN, 1 clerical, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Night shift: 29 patients staffed with 3 RNs and 1 LPN. The facility matrix required 4 nurses and 2 aides.

March 18, 2015: Day shift: 29 patients staffed with 4 RNs, 2 LPNs, 1 aide, 1 aide on a 1:1 assignment, and 1 clerical. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Evening shift: 26 patients staffed with 4 RNs, 1 LPN, 1 clerical, and 1 aide. The facility matrix required 6 nurses, 1 clerical, and 1 aide.
Night shift: 30 patients staffed with 4 RNs. The facility matrix required 4 nurses and 2 aides.

March 19, 2015: Day shift: 26 patients staffed with 4 RNs and 1 LPN. The facility matrix required 6 nurses, 1 clerical, and 2 aides.
Evening shift: 26 patients staffed with 4 RNs, and 1 LPN. The facility matrix required 6 nurses, 1 clerical, and 1 aide.
Night shift: 29 patients staffed with 3 RNs, 1 LPN, and 1 aide on a 1:1 assignment. The facility matrix required 4 nurses and 2 aides.

March 21, 2015: Day shift: 25 patients staffed with 3 RNs, 2 LPNs, 1 clerical, and 1 aide. The facility matrix required 6 nurses, 1 aide, and 1 clerical.

March 23, 2015: Day shift: 30 patients staffed with 4 RNs, 1 LPN, a second LPN at 11 AM, 1 clerical, and 2 aides. The facility matrix required 7 nurses, 1 clerical, and 2 aides.
Evening shift: 30 patients staffed with 4 RNs, 2 LPNs, 1 clerical, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 1 aide.

March 24, 2015: Evening shift: 26 patients staffed with 3 RNs and 2 LPNs. The facility matrix required 6 nurses, 1 clerical, and 1 aide.
Night shift: 28 patients staffed with 2 RNs, 1 LPN, plus an additional LPN at midnight. The facility matrix required 4 nurses, and 2 aides.

March 26, 2015: Evening shift: 29 patients staffed with 4 RNs and 2 LPNs until 7:00 PM, then down 1 RN. The facility matrix required
6 nurses.
Night shift: 29 patients staffed with 4 RNs. The facility matrix required 4 nurses and 2 aides.

March 27, 2015: Evening shift: 30 patients staffed with 5 RNs, 1 LPN, and 1 clerical. The facility matrix required 7 nurses, 1 clerical, and 1 aide.
Night shift: 30 patients staffed with 4 RNs. The facility matrix required 4 nurses, and 2 aides.

March 28, 2015: Evening shift: 30 patients staffed with 4 RNs and 2 LPNs. The facility matrix required 7 nurses, 1 clerical, and 1 aide.

March 29, 2015: Evening shift: 28 patients staffed with 3 RNs, 2 LPNs, 1 clerical, and 1 aide. The facility matrix required 6 nurses, 1 clerical, and 1 aide.

March 30, 2015: Evening shift: 30 patients staffed with 4 RNs, 2 LPNs, 1 clerical, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 1 aide.

March 31, 2015 Evening shift: 30 patients staffed with 5 RNs, 1 LPN, 1 clerical, and 1 aide. The facility matrix required 7 nurses, 1 clerical, and 1 aide.

Review of the overtime for 7 East from February 13, 2015, thru April 10, 2015, revealed a total of 1939.75 overtime hours.

Review of the staff roster for 7 East revealed the following staff: 23 RNs plus 1 RN nurse manager, 4 were per diem staff, 5 LPNs, 3 clerical, and 6 (CNA) certified nursing assistants. There were 30 medical surgical beds on 7 East.

Interview with EMP15 on April 13, 2015, revealed the usual ratio was 6 patients to one nurse. EMP15 confirmed on the evening shift (11:00 PM - 7:00 AM) if there were 30 patients, 2 staff were assigned to 7 patients and 2 staff was assigned to 8 patients. EMP16 confirmed staff calling off sick was impactful, and there were occasions when the patient to nurse ratios increased. EMP16 confirmed the RN staff was co-assigned to cover the LPN who would not be able to complete an admission assessment or administer the intravenous push medications.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on review of facility documents, observations, and staff interview (EMP), it was determined the facility failed to be equipped, operated, and maintained in the Cardiac Open Heart Intensive Care Unit, the Surgical Intensive Care Unit, the 4 East Telemetry Unit, the Short Procedure Unit, the 9 East Medical/Surgical Unit, the 8th floor Outpatient Chemotherapy Department, the 8th floor Medical/Surgical Unit, and the Emergency Department. These were the units toured at the time of the unannounced investigation.

Findings include:

EMP25 and EMP26 confirmed there were no facility policies/procedures for maintenance, work orders or follow up on the completion of work orders.

1) An unannounced tour was conducted on April 8, 2015, at approximately 6:30 PM of the facility's Cardiac Open Heart Intensive Care Unit and Surgical Intensive Care Unit. The following issues were identified.

Cardiac Open Heart Intensive Care Unit: The nurses' station chairs were dirty, torn, and threadbare. The nurses' station Formica countertop was broken, cracked and chipped in numerous areas. The carpeting in the nurses' station was torn. The carpet was duct taped in four locations. The paint on the walls of nurses' station was peeling. The tile in the unisex public restroom #1, located in the hallway between the Open Heart Intensive Care Unit and the Surgical Intensive Care Unit, was moldy. The toilet was pulling away from the wall. There was a hole in the wall behind the toilet approximately 3" x 4". The caulking around the toilet was cracked and missing, leaving unsealed areas. The wallpaper was peeling off the hallway wall between the Cardiac Open Heart Unit and Surgical Intensive Care Unit. In the Medical Waste Room, the walls were discolored and soiled. The floor tile was dirty and cracked. The nourishment room floor tile was cracked. There were broken toilets in patient rooms 307, 318, 323, and 324. The toilets were designed to be in a cabinet next to patient's bed. A rod was supposed to be secured to the toilets from the cabinet door so the toilet would come out of the cabinet when the cabinet door was opened. These rods were missing. Staff had to pull the toilet out of the cabinet by hand. In patient room 307, there was a hole, approximately 2" x 2.5," in the ceiling. The hole was filled with a white material, leaving open areas. The white material appeared to be tissue or white tape. A rust-like substance was observed on the back wall of the patient bed area, on the molding where the wall met the floor, and around the electrical outlets. A rust-like residue was present on the vertical light cover on the side of the patient's bed. The vertical light cover was ajar. Dirt and dust covered the window screens. The white assignment board was taped to the wall using what appeared to be gauze tape. The hot water temperature was tepid. The hot water temperature was tepid in patient rooms 304, 318 323 and 324.

The white assignment boards were taped to the wall in patient rooms 304, 318, 323 and 324 with what appeared to be a gauze tape. The molding in patient room 304 was pulling away from the wall where it met the floor. A hole, approximately 5" x 3," was observed in the ceiling of Open Heart Intensive Care Unit conference room.

Surgical Intensive Care Unit: The nurses' station chairs were dirty, ripped and threadbare. The hand washing sink at the nurses' station leaking. There was caulking that was cracked with open gaps. The nurses' station carpet dirty, ripped, and torn. These areas were repaired with duct tape.

In the area for dialysis, a contracted service, located in the Surgical Intensive Care Unit area, in rooms 313, 315 and 316, the toilets had brown residue in the entire toilet bowel, milky colored water, and a blue crystallized substance on the toilet seats. The rods to open the toilets were broken. The toilets had to be opened from the cabinets manually. There were several pairs of used gloves on the floor. There were streaks of an unidentified nature on the walls. The waste cans were overflowing. The sinks and countertops were dirty. The Formica counter in the sink area of the nurses' station was warped, broken, and had a brown residue on the sides. These issues were identified and brought to the attention of maintenance and administration on April 8, 2015. These issues remained unresolved at the end of survey on April 14, 2015.

There was a hole, approximately 12" x 6," observed behind the sink in the men's restroom located in the family waiting area.

The area between Intensive Care Unit and the Operating Room, used as a soiled utility area, had approximately 20 infectious material (red) bags and approximately 15 regular garbage bags intermingled in a grey garbage bin and on the floor. Debris, such as "packing peanuts," cardboard, and empty boxes were also scattered on the floor. On the outside, beneath this soiled utility area, was a loading dock. There was debris on the ground next to and around the dumpster.

Interview on April 8, 2015, at approximately 3:00 PM with OTH1 confirmed the observations in the Open Heart Intensive Care Unit. OTH1 confirmed the housekeeping was neglected. OTH1 confirmed the unit had not been upgraded in years and was consistently deteriorating. This issue was addressed several times with management. OTH1 noted "it feels like the place is falling down around us." Further interview with OTH1 on April 9, 2015, noted that since the Department of Health has been here (referencing this investigation), there hasn't been this much activity in the units by maintenance and housekeeping in years.

Interview on April 8, 2015, at approximately 2:00 PM with EMP4 confirmed the condition of the unit was deplorable. EMP4 confirmed Room 307 had a hole in the ceiling, rust on the electrical outlets, and a broken toilet. Further interview with EMP5 confirmed the screens in the windows were dirty and had not been cleaned.

Interview on April 8, 2015, at approximately 2:30 PM with EMP13 confirmed work orders were submitted to maintenance for environmental repairs.

Interview on April 8, 2015, at approximately 3:30 PM with EMP5 confirmed the unit was getting worse environmentally for years. About a year or so ago the carpet at the nurses station was cleaned, and the staff began to develop rashes on the lower part of their legs with red raised areas that itched. Administration was made aware and offered to pay for any medication the staff needed to combat the rash. EMP5 confirmed the carpet was torn and repaired with duct tape in several areas. EMP5 stated administration said the environmental issues of the unit would be addressed, but they were not.

Interview on April 8, 2015, at approximately 4:30 PM with EMP6 confirmed the environmental issues in the units were never corrected. EMP6 confirmed the carpeting, chairs, and Formica on the countertops at the nurses' stations were awful and in disrepair for years.

Interview on April 8, 2015, at approximately 5:15 PM with EMP17 confirmed the patients and patients families made uncomplimentary statements and observations about the poor condition of the patient care units.

Interview on April 8, 2015, at approximately 5:30 PM with EMP8 confirmed embarrassment working in the unit because of the poor conditions. EMP8 noted the following "You don't even want to tell anyone you work here because it's so bad. I can't imagine what the patients and their families think of this unit. The toilets are broken; sinks leak; there are issues with hot water for the patients; the carpets are ripped and mended with duct tape; there are holes in the walls ... I can go on and on. It's embarrassing."

Interview on April 8, 2015, at approximately 5:45 PM with EMP9 confirmed the red bagged infectious waste and regular garbage were routinely overflowing. When the infectious red bag waste and regular garbage pile up, a telephone call is made to environmental services in order to have it picked up. EMP9 noted the entire unit was in bad condition. Administration is made aware at ICU and CCU meetings, and nothing is fixed.

Interview on April 8, 2015, at approximately 7:00 PM with EMP11 confirmed multiple rooms on the unit have problems with hot water or no hot water. EMP11 noted "I can't remember room numbers because it affects different rooms at different times, and we have to find a room with working hot water and get our assigned patient's hot water from there."

Review on April 9, 2015, of the "Critical Care Meeting Minutes" for the months of November 2014 through February 2015 revealed no documentation of discussion concerning employee complaints or concerns about environmental or maintenance issues.

3) An unannounced tour of the facility's 4 East Telemetry Unit was conducted on April 9, 2015, at approximately 9:30 AM. The following issues were identified. The nourishment room sink had caulking that was cracked and peeling, leaving gaps around sink and wall. The nourishment room sink had a steady and constant drip. The medication room sink had caulking that was cracked and chipped, leaving gaps around the sink and wall. The hot water in the medication room was tepid. The medication room floor was dirty and cracked. The sink outside of the soiled utility room had a constant and steady drip. It was caulked with cracked and peeling caulking. The hot water temperature was tepid.

Interview on April 9, 2015, at approximately 10:00 AM with EMP18 confirmed that several sinks on the floor leaked, and the caulking was peeling away. Work orders were submitted. EMP18 noted the work was slow to be completed or not completed at all.

Interview on April 9, 2015, at approximately 10:30 AM with EMP20 confirmed the hot water problems, especially in the morning. EMP20 noted the hot water was barely warm. EMP20 confirmed the patients' morning care was affected by this issue.

Interview on April 10, 2015, at approximately 10:45 AM with EMP19 confirmed work orders were submitted to maintenance for environmental repairs.

4) An unannounced tour of facility's Short Procedure Unit was conducted on April 10, 2015, at approximately 9:30 AM. The following issues were identified. The utility room ice machine was dripping. The vents on front panel had a rust-like residue. The wallpaper in the patient area hallway was peeling. The electrical panel in the patient hallway was not flush with the wall. There were gaps present, as there was no caulking around the panel. The public water fountain at the end of the patient area was dirty with sediment, and a rust-like residue. The caulking was missing around the fountain and the wall. The clean supply room floor tile was dirty. The Cardiac Rehabilitation gym carpet was dirty and ripped. The rips were attempted to be repaired with duct tape. There was a 5" x 4" hole in the wall in the patient family waiting area behind the candy machine. The public men's restroom had a rust-like residue on the floor. The toilet was pulling away from the wall. The caulking around the toilet was cracked and missing in areas. There was no cover on the thermostat. The public ladies restroom ceiling tiles were stained.

Interview on April 10, 2015, at approximately 10:15 AM with EMP20 revealed EMP20 was unaware how long these environmental issues existed. Further interview with EMP20 revealed EMP20 was not aware if work orders were submitted to maintenance for environmental repairs.

5) An unannounced tour of facility's Medical/Surgical floor 9 East was conducted on April 10, 2015, at approximately 10:30 AM. The following issues were identified. The public ladies restroom had dirty walls. The sink was dripping. There was missing caulking. The public men's restroom toilet was pulling away from the wall and was missing the caulking. The floor tile was dirty. In patient room 902, the faucet was leaking. In patient room 910, the thermostat cover was missing. In patient room 928, the paint was peeling off the walls. Ceiling panels were stained. The nourishment room ice machine had a rust-like residue. The Medical Waste Storage room had a leaking faucet. The ceiling panels in the hallway were stained. The housekeeping closet sink was dirty and stained. There was missing caulking, leaving gaps between the sink and the wall.

Interview on April 10, 2015, at approximately 11:15 AM with EMP22 confirmed the numerous maintenance and environmental issues in the department. EMP22 noted there was an increase in complaints and concerns by patients and patients' families. The supervisors were made aware of these issues. Further interview with EMP22 confirmed work orders were submitted to maintenance for environmental repairs and noted there was no resolution to these problems.

6) An unannounced tour of facility's Outpatient Chemotherapy Department on the 8th floor was conducted on April 10, 2015, at approximately 1:00 PM. The following issues were identified. The medication room floor tile was dirty. The medication room door hinges had grease and oil dripping down the door frame/jamb to the floor.

7) An unannounced tour of facility's Medical/Surgical floor 8 was conducted on April 10, 2015, at approximately 1:30 PM. The following issues were identified. The public men's restroom walls and floor were dirty. The toilet was pulling away from the wall. The public ladies restroom walls and floor were dirty. The toilet was pulling away from the wall. The housekeeping sink was dirty, and areas of missing caulking were noted. The sink in the Medical Waste room had a rust-like residual on and around the faucet. The faucet was dripping, and the hot water temperature was tepid. In patient room 818, the bedside stand had broken drawers and a cabinet door. The ceiling tile in the hallway, near the overhead light, had a dark, black residue. The overhead light cover was missing from the light outside the public elevator.

There was a laminar flow hood for the previous cell transplant program that was not being utilized, as the cell transplant program was discontinued.

Interview on April 10, 2015, at approximately 1:30 PM with EMP23 confirmed the issues noted above. EMP23 confirmed the cell transplant program was discontinued approximately five years ago. EMP23 noted multiple requests were made to have the laminar flow hood removed. EMP23 confirmed work orders were submitted to maintenance for the environmental repairs.

8) An unannounced tour of facility's Emergency Department (ED) was conducted on April 10, 2015, at approximately 2:15 PM. The following issues were identified. The ED public men's restroom sink and faucet were corroded, leaking, and missing caulking. The ED ladies restroom was occupied at the time of tour. The carpet in the ED family room was dirty. The air exchange vent cover in ED room 11 was not secure and was hanging from the vent. Two cabinets in ED room 11, containing needles, syringes and intravenous tubing, were open and unlocked. Two patients were unattended in ED room 11 at this time. The Medical Waste storage room door was difficult to open and dragged across the floor making a high pitched noise when opening. In ED patient room 9, the floor molding was warped. In ED patient room 19 and 20, a sharps cabinet, containing sutures and Betadine was open and unlocked. The right side cabinet door was removed. The ED housekeeping closet walls were dirty and stained. The floor was dirty and stained. Dirty mops were stored directly on the floor. The sink was dirty, and the caulking was missing and chipped between the sink and the wall.

At the time of ED tour, the department was active, and patient care was being provided. There was no ED staff available for interview.

Review on April 14, 2015, of the July 10, 2014, Facility Environmental Tours Checklist for the Intensive Care Unit revealed the following observational comments: Carpet ripped and dirty at nurses' station, laminates cracked, windows are open not screwed shut, chairs ripped, chairs are worn out.

Review on April 14, 2015, of the March 19, 2015, Facility Environmental Tours Checklist for the Intensive Care Unit revealed the following observational comments: Hole in ceiling 'G' tile in conference room, more than 10 spots with cracked or torn countertops, nurses' station chairs are torn, old and dirty ... looks inappropriate for an ICU setting.

Review on April 14, 2015, of the March 12, 2015, Facility Environmental Tours Checklist for 4 East revealed the following observational comments: 3 tiles wet by room 402, sink at nurses' station needs repair and 6 chairs have rips at nurses' station.

Review on April 14, 2015, of the March 5, 2015, Facility Environmental Tours Checklist for the Emergency Department revealed no documentation of environmental comments.

Interview on April 14, 2015, at approximately 10:30 AM with EMP24 confirmed the environmental issues not identified by the "Functional Teams" that were identified by The Department of Health must have been missed. EMP24 noted documentation of work orders and compliance of repairs was unreliable on paper. EMP24 noted "We just know these things were done." Further interview with EMP24 confirmed the Maintenance Department did not have a policy or procedure for work order tracking or work order response. The Maintenance Department did not have a Performance Improvement Plan in place.

Interview on April 14, 2015, at approximately 11:00 AM with EMP25 confirmed the Maintenance Department has not had clerical personnel for over three years. The clerical person was in charge of tracking the work orders and the follow-up. The personnel who were doing the repairs were not closing out the work sheets so it was difficult to determine what was reported to be fixed and what was actually fixed. EMP25 noted the parts to repair the broken ICU toilets were no longer available. Further interview with EMP25 confirmed the facility's hot water heaters were "on demand" heaters, and there were problems with the valves located underneath the sinks.

Interview on April 14, 2015, at approximately 11:20 AM with EMP26 confirmed the terminal cleaning of the inpatient rooms was not performed. The inpatient rooms were no longer allowed to be taken out of service for terminal cleaning, and there was no documentation to track the terminal cleaning of the inpatient rooms since June of 2014. EMP26 noted management was aware of this. The last documentation of the inpatient rooms being terminally cleaned was June of 2014. Further interview with EMP26 confirmed there was no time frame for the cleaning or the terminal cleaning of the inpatient rooms.