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.

RUTLAND REGIONAL MEDICAL CENTER 160 ALLEN ST RUTLAND, VT 05701 Sept. 22, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure that patients were notified of their rights in advance of furnishing patient care for 2 of 3 applicable medical records reviewed. ( Patients #3 & #20) Findings include:

Based on record review, the hospital failed to provide the standardized OMB approved"
Important Message from Medicare " within 2 days of admission to Patient #3, admitted on [DATE] and to Patient #20, admitted on [DATE]. This was confirmed on 9/21/11 at 3:05 PM by the Director of Health Information Management. Patient #20 was given the " Important Message from Medicare " to sign on 9/21/11.
VIOLATION: OUTPATIENT POST-ANESTHESIA EVALUATION Tag No: A1005
Based on staff interview and record review, the hospital failed to assure that post anesthesia evaluations were completed within 48 hours as required for 1 applicable outpatient record reviewed. (Patient #39) Findings include:

Per record review on 9/20/11 at 1:05 PM, there was no evidence that a required post anesthesia follow-up evaluation was completed for Patient #39. Patient # 39 underwent a dental procedure under anesthesia on 8/19/11. During interview on 9/21/11 at 9: 25 AM, the Chief Nursing Officer confirmed that the required post anesthesia follow-up had not been done.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on staff interview and closed record review, the hospital failed to comply with the advance directives for 1 applicable patient after a medical consult determined the patient lacked the capacity to make healthcare decisions. (Patient # 11) Findings include:

Per information received via a regulatory complaint, Patient #11 ' s legal representative (Durable Power of Attorney for Health Care Decisions) was not consulted regarding the patient ' s care after a psychiatrist ' s consult on 4/27/10 at 1540 hours determined the patient was unable to answer questions to determine his/her capacity. Another consult with a Psychiatric Nurse Practitioner (APRN) on 5/7/10 at 1640 hours stated the patient was " nonsensical ... illogical ...voicing grandiose delusions ...continues to lack capacity ...to understand ....decisions " . Review of the patient ' s closed medical record on 9/20/11 and 9/21/11 revealed a copy of a Durable Power of Attorney for Health Care (DPOAHC) which named a person to make decisions regarding health care issues if the patient were determined to be incapacitated. Another document in the medical record (Patient Card-x) stated under Advanced Directives, that the (named) attorney in the Rutland area had a DPOA for Healthcare Copy. There was no evidence that hospital staff attempted to contact the attorney and/or the DPOAHC regarding medical treatment and discharge planning for the patient subsequent to determining the patient lacked the capacity to make informed decisions. This failure to implement the DPOAHC was confirmed during interviews with the Director of Risk Management, the Director of Patient Advocacy and the Director of Quality Improvement on 9/21/11 at 10:35 AM.
Refer also to A-0396
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review, the hospital failed to ensure that 1 patient (# 36) was free from all forms of abuse and failed to report to the licensing agency (Vermont Adult Protective Services) within 48 hours of the alleged abuse. Findings include:

Per record review on 9/20/11 at 3:15 P.M., a staff Licensed Nursing Assistant (LNA) was observed by a staff Registered Nurse (RN) holding Patient #36 ' s arm down with his/her body and using vulgar language in a threatening manner on 4/6/11. The incident was reported as a mandatory self-report, resulting in a complaint investigation. The witnessing RN did not immediately report the incident as required by facility policy and within 48 hours per the Vermont Abuse Statute, reporting to a supervisor 4 days after the incident had occurred. The Unit Director was not informed of the incident until 4/14/11. The above was confirmed during a 9/20/11, 3:45 P.M. interview with the Unit Director and in a 9/21/11, 10:10 A.M. interview with the witnessing RN.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on staff interview and record review, the hospital failed to ensure that the nursing care plan for 1 applicable patient was revised to address the patient ' s identified needs. (Patient #11) Findings include:

Per closed record review on 9/20/11, Patient #11 had periods of delirium and delusional thinking throughout the inpatient stay commencing on 4/20/10. Based on record review, the " Patient Integrated Plan of Care " dated 4/20/10 was not revised to address the patient ' s emotional and mental health needs. The lack of care plan to address these needs was confirmed during interview with the Vice President of Nursing Services on 9/21/11 at 2:45 PM.
Refer also to A-0132
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, interview and record review, the Food Services Director failed to ensure that dietary staff adhered to dietary policies/procedures in accordance with accepted safe and sanitary food handling practices. Findings include:

1. Per observation and record review on 9/19/11 at 12:30 P.M., the facility failed to ensure proper sanitizer levels in the 3-bay pot sink were maintained. Per review of the daily sanitizer log, staff was checking the sanitizer levels once daily. Manufacturer's recommendations state that the water/sanitizing solution be changed every 4 hours. There was no procedure in place to check the sanitizer levels more than once daily, despite use of the sanitizer sink multiple times per day.

2. Per observation on 9/19/11 at 12:48 A.M., outflow fans in the meat and dairy walk-in refrigerators were heavily soiled with dust. Both fans were in operation at the time of the observation and were blowing over food products.

3. During tour on 9/19/11 at 4:25 PM with the Director of the Women and Children ' s Unit, the interior surface of the patient nourishment refrigerator was soiled with food spills and contained a large amount of ice buildup. In addition, temperature monitoring of the refrigerator was not consistently done AM and PM (twice a day), as indicated by the log and dietary personnel. Per review of the September 2011 temperature log, refrigerator temperatures were not documented for 9/3, 9/4, 9/13, 9/16, 9/17 & 9/18/11 and were documented only once daily on 9/1, 9/10, 9/11. The Retail Manager of Dietary Services confirmed during interview on 9/20/11 at 12:25 PM that dietary personnel were responsible for monitoring refrigerator temperatures.

The above observations were confirmed by the Retail Manager and the Food Service Director at the time of the observations.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations during the initial tour of the Rehabilitation Unit equipment storage areas and interview, the hospital failed to ensure that oxygen was stored in a safe manner. Findings include:

During a tour on 9/21/11 at 10:55 AM with the Director of Rehabilitation & Support Services, an unsecured oxygen tank was observed in the equipment storage room on the inpatient Rehabilitation Unit. This was confirmed by the Director of the Rehabilitation Unit. Per interview on 9/21/11 with the Director of Respiratory Therapy, oxygen tanks must be secured with a ring or a stack.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, hospital staff failed to implement an infection control measure and comply with a nursing infection control policy during 1 of 3 patient care observations (Patient #16). Finding includes:

Per observation of Patient #16's clean dressing change and confirmed with the Registered Nurse (RN) on 9/20/11 at 10:24 AM, the RN failed to perform hand hygiene after removing the old dressing and soiled gloves and prior to putting on clean gloves and applying a new dressing. The Nurse Surveyor observing Resident #16 ' s dressing change stopped the RN from applying clean gloves and proceeding with the dressing change after s/he failed to perform hand hygiene.

Per review of the Nursing Policy titled " Dressing Change " and confirmed with the Unit Manager on 9/20/11 at 11:06 AM, the purpose of the policy is to protect the wound from microorganisms and states " remove old dressing, remove gloves, and perform hand hygiene".
VIOLATION: INPATIENT POST-ANESTHESIA EVALUATION Tag No: A1004
Based on staff interview and record review, the hospital failed to assure that post anesthesia evaluations were completed within 48 hours as required for 1 applicable inpatient record reviewed. (Patient #3) Findings include:

Per record review, Patient #3, who was an inpatient, had an orthopedic surgical procedure on 9/13/11. The post-anesthesia evaluation was not completed until 9/17/11, four days following the procedure. There was no evidence per review of physician progress notes and the post-anesthesia evaluation form that the follow-up was completed within 48 hours as required. This was confirmed on 9/22/11 at 8:25 AM by the Director of Health Information Management. The " Post Anesthesia Rounds " policy & procedure stated " ...rounds shall be made by the anesthesiologist or a designated CRNA and shall be made between 24 and 48 hours postoperatively. "