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 record review and interview the facility failed to provide documentation that a patient's care needs was evaluated when there was a change in the patient's condition. Citing one patient (#9)named in a complaint.


Review of a cardio pulmonary arrest record for Patient (#9) revealed documentation that Cardiopulmonary Resuscitation was initiated on 11/10/ 2012 at 23:08 and the procedure was terminated on 11/10/2013 at 23:34 hours.
Review of physician's progress notes dated 11/10/2013 revealed documentation by a physician that he responded to a code blue that was called on Patient (#9) on 11/10/2013 around 11:05 pm and found the patient to be in cardiopulmonary arrest.

Review of nursing documentation dated 11/10/2012 revealed there was no documentation that the patient had a change in condition, what time the change occurred nor what the nursing interventions were.

The last nursing documentation for the patient was on 11/10/2012 at 19:38 that Patient(#9) had pain in lower left leg at a severity of 10/10, aching and heavy, aggravated with movement. He was medicated and repositioned.

There was no documentation of a follow up assessment of the patient's response to the pain medication.

All subsequent nursing documentation entered as late entry, were done on 11/11/2012 after 8:00 pm more than 12 hours after the patient was pronounced dead.

During an interview on 6/10/2013 at 1:40 pm with the Quality Director she stated nursing documentation is required when a patient develops a change in their medical condition.
Based on observation, interview, and record review the facility failed to enforce their infection control policies/procedures to ensure staff practice proper isolation measures ; wash their hands after changing gloves and handle food in a safe manner to prevent the spread of infection. Citing six (6) random observations.


Observation on 6/10/2013 at 10:45 am in the room of Patient (# 10) revealed RN(#4) picked up dirty towel from the floor with ungloved hands. The Nurse put on clean gloves handled patients equipment in the room including the Computer on Wheels (COW), she picked up a soiled towel from the floor put the soiled linen in a linen hamper, change gloves, put clean gloves on and handled the patient ' s IV access site. The staff failed to wash her hands after changing her soiled gloves and prior to handling the patient's IV access .

Observation on 6/10/2013 in the room of Patient (# 11) a Respiratory Therapist was observed assisting with repositioning of the patient in bed, the patient was on contact isolation. The Staff changed her gloves, put on clean gloves handled the clean COW and did not wash her hands after removing her soiled gloves.

Further observation on 6/10/2013 at 11:20 am revealed Staff(# 5) RN, cleaned a stethoscope, changed her gloves and did not wash her hands. The staff checked the residue in the patient ' s NG tube, checked for placement then poured a capsule in her gloved hand and prepared the medication for NG tube administration. The Nurse did not change gloves and wash her hands after checking residue and placement and prior to handling the medication she prepared and administered.

Observation on 6/10/2013 at 11:30 am revealed Staff (#7) RN was in a room just vacated by a patient on contact isolation, the Staff was not wearing PPE was cleaning the Computer on Wheels (COW) after completing that task the Staff used the soiled telephone in room then touched the cleaned COW with her soiled gloved hands.

Observation on 6/10/13 at 10:50 am at the Nursing Station of the ICU revealed Staff (# 1) put on a pair of gloves; reach over the desk and picked up a patient ' s chart, flipped through the chart, then put her right hand in her pocket. She walked behind the desk still with the gloves on; picked up the thermometer, went into the room of Patient (# 10) and took the patient ' s temperature. Staff(#1) then placed the thermometer on the bedside cabinet, lowered the commode cover with the same gloves, and handled the thermometer again before taking off the gloves.

Observation on 6/11/2013 at 11:45 am in the cafeteria used by patients, staff and visitors revealed the serving staff were using gloved hands to handle cooked food and cold ready to eat foods with the same gloved hands that they use to handle raw breaded meats, refrigerators, boxes with supplies and other items in the serving areas without changing their gloves and washing their hands. One server did not have her hair covered.

Review of the facility's hand Hygiene policy/procedure dated 6/13/2013
revealed the policy instructs staff to "wash hands after removing gloves or before donning gloves and before handling medication".
Review of the facility's Isolation Policy/ Guidelines dated 6/15/2012 documented the following information:
" while cleaning the isolation room , If the patient has been on Contact Precautions, cleaning staff must wear a gown and gloves."
During an interview on 6/10/2013 at 11:55 am with the Nurse Manager she stated staff will be in-serviced on proper infection control measures.