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Based on Life Safety Code (LSC) survey, Triumph Hospital Northwest Indiana, Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This facility occupies the fifth and sixth floors of the A building, an eight story building with a basement, determined to be of Type I (332) construction and fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The facility has a capacity of 70 and had a census of 42 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 3 of more than 100 corridor doors were free from impediments to closing (see K 018), failed to have 1 of 1 written health care occupancy fire safety plans that incorporated all items listed in NFPA 101, Section 19.7.2.2. (see K 048), failed to ensure fire drills were conducted quarterly on each shift for 4 of the last 4 quarters (see K 050), failed to provide evidence of required maintenance of 1 of 1 fire alarm systems (see K 052), failed to ensure sprinkler gauges for 1 of 1 sprinkler systems were tested every five years (see K 056), failed to ensure 1 of 1 hood extinguishing systems in the kitchen was inspected and serviced every six months (see K 069), failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks for 4 generator sets (see K 144), failed to provide a complete written policy containing procedures to be followed to protect 70 of 70 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period (see K 154) and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period to protect 70 of 70 patients (see K 155).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, medical record review and staff interview, the facility failed to document the Medicare discharge rights form, "An Important Message from Medicare About Your Rights" for 5 of 15 (N3, N4, N5, N10 and N11) closed patient medical records reviewed as required per policy.

Findings:

1. 42 CFR 405.1205(b) states: "Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:"

2. Policy No. D02, titled "Discharge and Inpatient Chart Order", reviewed on 1/25/11 at 2:50 PM, indicated on pg. 1 and pg. 4, under Procedure section, "When inserting documents into records of in-house or discharged patients, the following list will be used to assemble the forms that will be separated by colored tab dividers...24. IM/UR (Important Message/Utilization Review)...Important Message from Medicare..."

3. Review of closed patient medical records on 1/25/11 at 1:45 PM, indicated patient:
A. N3 was a Medicare recipient as noted on the Patient Registration/Face Sheet dated 11/24/10 at 19:30 PM and lacked "An Important Message from Medicare About Your Rights" letter within two days
of admission and not more than two calendar days before the patient's discharge.
B. N4 was a Medicare recipient as noted on the Patient Registration/Face Sheet dated 8/24/10 at 19:45 PM and lacked "An Important Message from Medicare About Your Rights" letter within two days
of admission and not more than two calendar days before the patient's discharge.
C. N5 was a Medicare recipient as noted on the Patient Registration/Face Sheet dated 9/25/10 at 11:03 AM and lacked "An Important Message from Medicare About Your Rights" letter within two days
of admission and not more than two calendar days before the patient's discharge.
D. N10 was a Medicare recipient as noted on the Patient Registration/Face Sheet dated 11/13/10 at 11:37 AM and lacked "An Important Message from Medicare About Your Rights" letter within two days
of admission and not more than two calendar days before the patient's discharge.
E. N11 was a Medicare recipient as noted on the Patient Registration/Face Sheet dated 11/8/10 at 16:47 PM and lacked "An Important Message from Medicare About Your Rights" letter within two days
of admission and not more than two calendar days before the patient's discharge.

4. Personnel P9 was interviewed on 1/25/11 at 3:00 PM and indicated the above mentioned patient medical records were lacking documentation of "An Important Message from Medicare About Your Rights" letter within two days of admission and not more than two calendar days before the patient's discharge as required per facility policy and procedure.

Based on policy and procedure review, medical record review and staff interview, the facility failed to ensure the registered nurse supervised and evaluated the nursing care for each patient related to skin/wound assessment for 2 of 2 (N1 and N2) open patient medical records reviewed.

Findings:
1. Policy No. S02-N, titled "Skin Care, Assessment and Maintenance of", reviewed on 1/25/11 at 2:50 PM, indicated on pg. 1, under Policy section, "Skin assessment shall be performed at least every 12 hours...Any impairment in skin integrity shall be documented in the Nursing Flowsheet and Wound Documentation Form."

2. Review of open patient medical records on 1/25/11 at 10:45 AM, indicated patient:
A. N1:
i. had only 1 wound documented as coccyx area on Admission Database dated 1/21/11 at 17:00 PM.
ii. had 3 wounds documented as coccyx, stage II; right heel, stage I; and left arm ecchymosis on Wound Progress Note dated 1/22/11 at 12:30 PM.
iii. had only 1 wound documented as coccyx area on Wound Documentation form dated 1/22/11.
iv. had 2 wounds documented and photographed as coccyx, stage II and right heel, stage I on Wound Care Assessment dated 1/22/11.
v. had only 1 wound documented as coccyx area and no wounds documented on Daily Nursing Flow Sheets dated 1/22/11 and 1/23/11, respectively.

B. N2:
i. had 3 wounds documented as suprapubic catheter site-surgical; left heel, stage I; and right heel, stage I on Wound Progress Note dated 1/19/11.
ii. had only 1 wound documented as suprapubic catheter site on Wound Documentation form dated 1/19/11-1/22/11.
iii. had 3 wounds documented and photographed as suprapubic catheter site and left and right heels, stage I on Wound Care Assessment dated 1/19/11.
iv. had only 1 wound documented as suprapubic catheter site and no wounds documented on Daily Nursing Flow Sheets dated 1/20/11 and 1/21/11, respectively.

3. Personnel P9 was interviewed on 1/25/11 at 3:00 PM and indicated the above mentioned patient medical records had disjointed and/or lacking documentation of skin/wound assessments as required per facility policy and procedure. Wounds should be correctly assessed and documented on the required forms and should be uniform from form to form to ensure continuity of care.

Based on review of policies and procedures, patient records, and staff interview, the nursing services failed to administer blood transfusions in accordance with approved medical staff policies and procedures for 3 of 10 patient records reviewed.

Findings included:

1. Review of policies and procedures on 1-25-11 between 10:00 AM and 12:30 PM indicated:
a. A policy / procedure titled: "Blood / Blood Components Administration (Packed Cells, Plasma, Platelets, Cryoprecipitate)", last revised "05/01/01", which read: "For each separate infusion, vital signs (including temp) should be recorded...at 15 minutes..." and "In the event of any reaction to blood or blood components, the transfusion should be stopped immediately..."
b. A policy / procedure titled: "Blood Product Transfusion Reaction", last revised "02/06" which read: "In the event of any type of reaction to blood or blood components, the product will be stopped immediately." and "Signs and symptoms of blood product transfusion reaction...increase in temperature 1 degree C or 2 degrees F...increased 20% change in pulse rate...unexplained 20% change in systolic or diastolic blood pressure..."

2. Review of patient records on 1-25-11 between 10:00 AM and 3:10 PM indicated:
a. Patient #L1 was admitted on 9-22-10 and had a blood transfusion on 10-23-10. Pre-transfusion blood pressure, recorded at "0840", was "170/51" the 15-minute blood pressure, recorded at "0900", was "133/67" and the post-transfusion blood pressure, recorded at "0930", was "112/56", indicating a decrease in systolic blood pressure of more than 20% from the pre-transfusion blood pressure. Additionally, the respiration rate was not recorded as part of the 15-minute vital signs. Blood transfusion reaction protocol was not initiated for the change in systolic blood pressure, as required by approved policy / procedure.
b. Patient #L3 was admitted on 11-1-10 and had a blood transfusion on 11-27-10. Pre-transfusion temperature, recorded at "1315", was "98.0" and the post-transfusion temperature, recorded at "1630" was "100.1", indicating an increase of temperature of more than 2 degrees Farenheit. Blood transfusion reaction protocol was not initiated for the change in patient temperature, as required by approved policy / procedure.
c. Patient #L6 was admitted on 11-10-10 and had a blood transfusion on 11-16-10. The transfusion was imitated at "1235" and the 15-minute vital signs were documented at "1245", 10 minutes after the transfusion was initiated. The pre-transfusion pulse rate, recorded at "1205", was "77" and the 15-minute pulse rate, recorded at "1245", was "105", indicating an increase in pulse rate of more than 20%. The pre-transfusion blood pressure, recorded at "1205", was "86/55", the 15-minute blood pressure, recorded at "1245", was "115/58", and the post-transfusion blood pressure, recorded at "1250", was "138/95", indicating an overall increase of blood pressure (systolic and diastolic) of more than 20% from the pre-transfusion blood pressure. Blood transfusion reaction protocol was not initiated for the change in the patient's pulse and blood pressure, as required by approved policy / procedure.

3. In interview on 1-25-11 between 1:30 PM and 3:10 PM, Staff Member #L1 acknowledged the above findings and conveyed blood transfusion reaction protocol should have been initiated for the above mentioned transfusions.

Based on policy and procedure review, medical record review and staff interview, the facility failed to implement its policy and procedure related to transfer forms for 2 of 2 (N4 and N5) closed patient medical records reviewed of patients who were transferred to other acute care facilities.

Findings:
1. Policy No. D02, titled "Discharge and Inpatient Chart Order", reviewed on 1/25/11 at 2:50 PM, indicated on pg. 1 and pg. 4, under Procedure section, "When inserting documents into records of in-house or discharged patients, the following list will be used to assemble the forms that will be separated by colored tab dividers...20. DC (discharge) Planning...Transfer Forms..."

2. Review of closed patient medical records on 1/25/11 at 1:45 PM, indicated patient:
A. N4 was transferred to another acute care facility on 9/5/10 and was lacking documentation of a Transfer Form.
B. N5 was transferred to another acute care facility on 9/29/10 and was lacking documentation of a Transfer Form.

3. Personnel P9 was interviewed on 1/25/11 at 3:00 PM and indicated the above mentioned patient medical records were lacking documentation of a Transfer Form as required per facility policy and procedure.

Based on document review, medical record review and staff interview, the facility failed to ensure a discharge summary was written and/or dictated by the physician and in the medical record for 8 of 15 (N4, N6, N7, N8, N10, N11, N12 and N14) closed patient medical records reviewed.

Findings:

1. Review of Medical Staff Rules and Regulations on 1/25/11 at 2:12 PM, indicated on pg. 9, point 8., "A discharge summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized...All summaries shall be authenticated by the responsible practitioner."

2. Policy No. D02, titled "Discharge and Inpatient Chart Order", reviewed on 1/25/11 at 2:50 PM, indicated on pg. 2, under Procedure section, "When inserting documents into records of in-house or discharged patients, the following list will be used to assemble the forms that will be separated by colored tab dividers...3. "H&P(History & Physical)/Consults/DC (Discharge) Summary...Discharge Summary..."

3. Policy No. D01, titled "Medical Record Analysis", reviewed on 1/25/11 at 2:50 PM, indicated on pg. 2, point E., "The discharge summary shall be completed and signed within 30 days of discharge..."

4. Review of closed patient medical records on 1/25/11 at 1:45 PM, indicated patient:
A. N4 was discharged on 9/5/10 and date of discharge on Discharge Summary was documented as 8/24/10. Also, the Discharge Summary was dictated on 10/25/10 at 12:13 PM, which was past 30 days from discharge.
B. N6 was discharged on 11/23/10 and was lacking documentation of a Discharge Summary.
C. N7 was discharged on 12/20/10 and was lacking documentation of a Discharge Summary.
D. N8 was discharged on 8/10/10 and was lacking documentation of a Discharge Summary.
E. N10 was discharged on 11/29/10 and was lacking documentation of a Discharge Summary.
F. N11 was discharged on 12/19/10 and was lacking documentation of a Discharge Summary.
G. N12 was discharged on 12/30/10 and was lacking documentation of a Discharge Summary.
H. N14 was discharged on 8/2/10 and was lacking documentation of a Discharge Summary

5. Personnel P11 was interviewed on 1/25/11 at 3:12 PM and indicated the above mentioned patient medical records were lacking documentation of a Discharge Summary and/or date of discharge was incorrect on Discharge Summary and/or Discharge Summary was not dictated within 30 days from discharge as required per facility policy and procedure.

Based on review of dietary policies and staff interview, the hospital failed to ensure the approved therapeutic diet manual was readily accessible to all nursing staff members.

Findings included:

1. Review of dietary policies on 1-24-11 between 1:50 PM and 2:30 PM indicated a policy titled: "Nutrition Care Manual", last approved by the current dietitian in 2009, which read: "The Food and Nutrition Services Department uses the current edition of the Nutrition Care Manual, a web-based product published by the American Dietetic Association." and "Access to the Nutrition Care Manual is available throughout the facility via the computer." The policy did not indicate how to access the "Nutrition Care Manual" via the computer.

2. In interview on 1-25-11 between 3:10 PM and 3:50 PM, Staff Member #L33, a Registered Nurse, conveyed there was no approved dietary manual accessible to the nursing staff.

Based on observation, record review and interview, the facility failed to ensure 3 of more than 100 corridor doors were free from impediments to closing, failed to have 1 of 1 written health care occupancy fire safety plans that incorporated all items listed in NFPA 101, Section 19.7.2.2., failed to ensure fire drills were conducted quarterly on each shift for 4 of the last 4 quarters, failed to provide evidence of required maintenance of 1 of 1 fire alarm systems, failed to ensure sprinkler gauges for 1 of 1 sprinkler systems were tested every five years, failed to ensure 1 of 1 hood extinguishing systems in the kitchen was inspected and serviced every six months, failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks for 4 generator sets, failed to provide a complete written policy containing procedures to be followed to protect 70 of 70 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period to protect 70 of 70 patients.

Findings:

1. Observations made between 1:20 p.m. and 2:30 p.m. on 01/25/11 indicated the corridor doors to patient rooms 5213, 5216 and 6216 were blocked open by infection control boxes hung on the corridor side of the resident room doors. 19.3.6.3

2. MS#1and A#1 stated they were not aware of the problem and would come to a mutual solution.

3. Record review on 01/25/11 at 11:30 a.m. indicated the facility lacked a complete written health care occupancy fire safety plan or procedure. The Evacuation Policy lacked procedures for residents being safely transferred to a specific meeting area or have a transfer agreement with another facility, staff being periodically trained in specific duties to be performed in the event of an evacuation and preparations to evacuate immediate areas, smoke compartments and the building. 19.7.1.1

4. A#1 stated at the time of the record review, he/she was aware of the requirements but could not produce emergency policies or procedures for direct care staff and patients.

5. Review of the facility's Fire Drill records on 01/24/11 at 2:25 p.m. indicated there was no record of first quarter fire drills for any shift, a first shift fire drill for the second quarter, a second shift fire drill for the third quarter or a second and third shift fire drill for the fourth quarter of 2010. 19.7.1.2

6. A#1 stated at the time of record review, he/she was not aware of the problem.

7. During an alarm system test with MS#1 and A#1 on 01/25/11 between 1:15 p.m. and 1: 45 p.m., the strobes connected to the alarm system failed to activate. The system failure was observed to have affected only the fifth and sixth floors. 9.6.1.4

8. MS#1 stated at the time of observations, the failure had been noted by Simplex on 12/14/10. He/she also stated he/she had no idea or plan as to when the failure of the strobes would be repaired.

9. Review on 01/24/11 at 2:50 p.m. of the Simplex inspection reports dated for 2010 lacked indication the sprinkler pressure gauges had been replaced or recalibrated. 19.3.5

10. MS#1 stated at the time of record review, he/she was sure the gauges lacked a calibration sticker indicating the date calibrated or replaced, and he/she stated the gauges had not been replaced or calibrated.

11. Review of the hood extinguishing system inspection documentation at 1:20 p.m. on 01/25/11 indicated the kitchen hood extinguishing system had been inspected and serviced on 01/14/11. The service paperwork for the hood cleaning indicated the previous inspection was 01/20/10, a period greater than six months. 19.3.2.6, NFPA 96

12. MS#1 stated at the time of record review, the kitchen hood exhaust system is cleaned and inspected professionally annually.

13. Review of the generator logs on 01/24/11 at 2:45 p.m. indicated the facility did not test or exercise the emergency generator battery at seven day intervals. 3.4.4.1

14. MS#1stated at the time of record review, he/she did not understand the seven day inspection requirement.

15. Review of the facility's policy and procedure book on 01/25/11 at 11:35 a.m. indicated the fire watch procedure for an out of service automatic sprinkler system was incomplete. The procedure lacked the telephone number for the Indiana State Department of Health and the local fire department and did not include staff trained and designated to perform fire watch rounds. The policy lacked a statement regarding what procedures are to be implemented in the event the sprinkler system should be out of service. 9.7.6.1

16. At the time of the record review, the A#1 indicated no other policy or procedure was available to review.

17. Review of the facility's policy and procedure book on 01/25/11 at 11:35 a.m. indicated the fire watch procedure for an out of service automatic alarm system was not complete. The procedure lacked the telephone number for the Indiana State Department of Health and the local fire department and it did not include staff trained and designated to perform fire watch rounds. The policy lacked a statement about what procedures are to be implemented in the event the fire alarm system should be out of service.

18. At the time of record review, A#1 indicated no other policy or procedure was available to review.

Based on document review and interview the facility failed to ensure services performed under contract are included in the hospital's quality assessment and improvement program (QAPI) for 7 of 8 contracted services and failed to ensure the hospital lab was part of the QAPI program.

Findings included:

1. Review of QAPI/Safety Committee minutes and reports for previous 12 months indicated lack of documentation that the contracted services of bioengineering, biohazardous waste, housekeeping, laundry/linens, dietary and maintenance and hospital lab services were monitored by the QA program and reported to the governing board.

2. At 1:00 PM on 1/25/2011, staff member A10 indicated the following contracted services are not assessed in the quality assessment program: bioengineering, biohazardous waste, housekeeping, laundry/linens, dietary and maintenance and hospital lab.