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Based on observation, record review, staff interviews, and review of hospital documentation on all days of the survey from 11/5/13 to 11/8/13, the Hospital failed to have an effective Governing Body legally responsible for the conduct of the Hospital.

Findings included:

1. The Governing Body failed to ensure that a deficiency cited at the follow-up complaint survey completed on 8/12/13 was corrected. Please refer to A 409.

2. The Governing Body failed to ensure that the hospital had an organized communication system for the dietary department in place to address the nutritional needs of the patients. Please refer to A 618.

3. The Governing Body failed to ensure that the Dietitian working at the satellite campus of Kindred Hospital Northeast, located in Natick within the campus of another hospital (host hospital) was accountable to the Governing Body of Kindred Hospital Northeast-Stoughton. Please refer to A 621.

4. The Governing Body failed to ensure physician's orders to limit patients' fluid intake were followed, diets were followed and patients had current diet orders. Please refer to A 630.

5. The Governing Body failed to ensure that emergency medical resuscitative equipment on the Code Carts were inspected, checked for functionality monthly, in accordance with the Hospital's Code Cart policy, and easily accessible in the event of a medical emergency requiring intubation. Please refer to A 1151.

6. The Governing Body failed to ensure that the Intubation Kits on the Code Carts were inspected, checked for functionality monthly, in accordance with the Hospital's Code Cart policy. Please refer to A 1160.

Based on record review and staff interview the facility failed to have an organized dietary department which ensured that the nutritional needs of the patients were met and the dietician covering the satellite campus did not share accountability with the host hospital in which the satellite campus was located. Findings include:

1. For 11 sampled patients and 11 additional non-sampled patients, the facility failed to ensure that the patients had current diet orders and the current diet orders were being followed by the kitchen staff.
Please refer to A 630.

2. The dietician who covers the Natick satellite campus, was not accountable to Kindred Hospital Northeast Stoughton as required.
Please refer to A 621.

Based on observations, review of facility policy and staff interview, the hospital failed to ensure that emergency medical resuscitative equipment on the Code Carts were inspected, checked for functionality monthly, in accordance with the Hospital's Code Cart policy, and easily accessible in the event of a medical emergency requiring intubation.

Findings include:

The respiratory staff were responsible to check the Intubation Boxes (which were part of the Code Carts), monthly to ensure all the equipment and supplies were available, not expired, and fully functioning if needed for an emergency. During survey, the Intubation Box for the Outpatient Clinic was last checked on 6/18/12. The Intubation Boxes on NRU#2 and NRU#4 had not been checked monthly by the Respiratory Department per the Hospital policy.

Please see A1160.


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Based on staff interview and record review, the Hospital failed to ensure that every patient was provided with written response to their grievance. The findings include:

1. The Hospital Patient Complaint/Grievance Process Policy #H-PC 05-007 revised 02/2013 includes:

- a Grievance is defined as: a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative regarding any aspect of the patient's care, account or other aspect of the stay that cannot be resolved on the spot by the staff present.
- if the issue is not resolved immediately, (on-the-spot by staff present), it is a grievance and requires a letter. A letter must be sent within seven days of the receipt of the grievance whether it is resolved or is still being investigated.

2. Review of the hospital complaint log on 11/05/13 included the following entries:

- a patient complained regarding the behavior of a radiology technician. The hospital contacted the radiology contractor to investigate and address the complaint.
- a patient complained a respiratory therapist threatened the patient with restraints. The hospital conducted an investigation.
- a patient complained the call bells were not answered and bed pans were not provided promptly on the night shift. The manager planned to address with the night staff.
- a patient complained of rude behavior by a therapist.

The above complaints were logged between February and July. None of the complaints were able to be resolved immediately as all required investigations and/or staff follow up. There was no evidence in the Grievance log that a letter of response was sent within seven days of receipt of the grievance as per hospital policy.

3. The Chief Nurse was interviewed on 11/6/13 at 11:30 A.M. regarding the Hospital's Grievance process.

The Chief Nurse said staff who receive a complaint from a patient complete a complaint form and submit it to the supervisor. All complaints are discussed daily at the Hospital's "flash" (team) meeting. The complaints are tracked by the Director of Quality and written responses are sent within 7 days by the CEO.

The grievance log was reviewed with the Chief Nurse who said the log would indicate if response letters were sent. The Chief Nurse said there was no documentation that letters were sent in response to those grievances.

Based on record review, the facility failed to consistently follow the Hospital's policy and procedure titled "Transfusion Therapy."

Non-sampled Patient #2's (NS #2) Blood Bank record, dated 10/16/13, was reviewed at 2:00 P.M. on 11/6/13. The Blood Bank record indicated one unit of packed red blood cells was issued to the unit at 7:56 P.M and hung for infusion at 8:00 P.M. According to the Hospital policy titled "Transfusion Therapy", the transfusion must be completed within four (4) hours of the removal of the unit of packed red blood cells from the temperature controlled environment. The Blood Bank record indicated the infusion was complete at 12:15 A.M. on 10/17/13, four (4) hours and twenty (20) minutes after the unit of packed red blood cells was removed from the temperature controlled environment.

Based on record review and staff interview the facility at Kindred Hospital Northeast's satellite unit in Natick failed to provide a Dietitian who was accountable to Kindred Hospital Northeast Stoughton.

Findinds include:

Review of Exhibit A of the Purchased Services Agreement between A Host Hospital which rents space to Kindred Hospital Northeast - Natick states that the "Medical center dietitians and dietary staff shall consult with a patient's admitting and/or with the respiratory physician in charge of the patient in order to evaluate the needs of the patient and to plan, prescribe and implement the patient's diet.... The services of a state licensed, registered dietitian shall be available to the Unit forty hours per week."

During interview on 11/5/13 at 9:50 A.M. Dietitian #1 stated that the dietitian covering the satellite unit located in Natick was employed by the host hospital and was not an employee of Kindred Hospital Northeast as required.

Based on record reviews and staff interview, for 2 patients (#2 and #8), the hospital failed to ensure the physician's orders to limit the patient's fluid intake was followed, for 5 patients (#6, #7, #15, #27 and #28) the hospital failed to ensure these patients' had current signed diet orders, for 4 patients (#4, #10, #13 and #18) and an additional 11 non-sampled patients (E, F, G, H, I, J, K, L, M, N and O), the facility failed to ensure that the current diet orders were being followed by the kitchen staff in a total of 30 sampled patients and additional 11 non-sampled patients.

The findings include:

1. Patient #2 was a young adult with a diagnosis of a history of respiratory arrest with anoxic encephalopathy who had been in the hospital for six months. Review of Patient #2's medical record on 11/05/13, revealed an 8/18/13 physician's order for Patient #2's fluids to be restricted to 1,000 milliliters (ml) for each 24 hour period for 90 days.

On 11/05/13 at 3:30 P.M. the Neurorehabilitative (NR) Program Director was interviewed regarding Patient #2's fluid restriction. The Program Director said he would confer with nursing staff regarding the current physician's order for fluid restriction. Following that conference, the Program Director said the patient's fluids had been restricted due to a low sodium level. The Neurorehabilitative (NR) Program Director said the patient was not compliant with the fluid restriction and the nurses had notified the physician.

The surveyors requested the Program Director review Patient #2's orders in the medical record. The Program Director reviewed the orders and said Patient #2 did have a current order for a fluid restriction. The Program Director said the nurses were viewing another screen in the electronic record, and were neither aware of, nor implementing, the current fluid restriction order.
In addition, the kitchen staff was unaware that this patient was to follow a 1000 ml fluid restriction. The kitchen staff did not restrict the patients fluids.


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2. For Patient #8 the facility failed to ensure that the patient was following a 1500 ml fluid restriction.

Patient #8 was admitted to the facility in 10/2013 with diagnoses including acute respiratory deficiency, congestive heart failure, diabetes, alpha-1 antitrypsin deficiency and severe obstructive sleep apnea.

Review of the medical record revealed that on 10/28/13 the physician ordered Patient #8's fluids to be restricted to 1,500 ml for each 24 hour period for 90 days.

During an interview on 11/5/13 at 11:20 A.M., Dietitian #1 and the Food Service Director said that the kitchen staff was unaware of residents on fluid restrictions. They further stated that because they were not informed about the fluid restrictions they were unable to limit the amount of fluid being sent with each meal as required.

During interview on 11/6/13 at 10:20 A.M. Nurse #4 was asked to explain how the facility knew how much fluid the patient had consumed. Upon review of the I&O [Intake and Output] sheets the nurse said that he/she does "not think that the sheets were accurate." The nurse stated further that there appeared to be many shifts of nurses and CNA's that did not record fluid intake during, or at the end of each shift.

Nurse #4 explained that based upon the documentation available it was not
possible to ensure that Patient #8 consumed only 1500 ml each day.

In addition, the kitchen staff was unaware that patient #8 was to follow a 1500 ml [milliliters] fluid restriction. The kitchen staff did not restrict the patients fluids.


3. On 11/5/13 at 9:50 A.M. Dietitian #1 provided this surveyor with a copy of the Dietary Worksheet which contained information including the current diet order as ordered by the physician. At 9:59 A.M. Food Service Director #1 provided this surveyor with a copy of the Nutritional Care Plan Summary. Food Service Director explained that the Nutritional Care Plan Summary is the list used to prepare and send meals to the patients.

After a review of the two lists it was determined that 5 sampled patients #6, #7, #15, #27 and #28 had no current signed diet order. For these patients their diet orders were originally written on 7/20/13 and expired after 90 days. These patients did not have an active diet order since 10/18/13.

4. Four sampled patients [ #4, #10, #13 and #18] had diets ordered by the physician that were not the same diet order that was being used to prepare and send meals to the patients. The incorrect diet orders were as follows:

* Patient #4 - the kitchen staff prepared a 2200 calorie diet , although the doctor had ordered 2000 calories.
* Patient #10 - the kitchen staff documented that the patient's diet was both a 2 gm sodium and a 4 gm sodium diet, although the physician had ordered that the patient receive a 4 gm sodium diet.
* Patient #13 - the kitchen staff prepared an 1800 calorie diet, although the physician ordered that the resident receive a controlled carbohydrate, 4 gm sodium, 2-3 gm potassium diet.
* Patient #18 - the kitchen staff prepared a 4 gm sodium, low fat, low cholesterol diet, although the physician ordered that the patient receive a house diet.

During an interview on 11/5/13 at 11:20 A.M., Dietitian #1 and the Food Service Director explained that the kitchen staff has no access to the ProTouch computer system, which is used by the remainder of the hospital staff. The kitchen staff receives diet orders by a notice sent from nursing to the kitchen and a follow-up phone call from nursing. Dietitian #1 further explained that because the kitchen staff has no access to ProTouch and although a dietary staff member rounds on each floor on a daily basis, the diets served in the kitchen staff are not always consistent with the physician's orders.

On 11/5/13 at 11:20 A.M. Dietitian #1 and the Food Service Director explained that the kitchen always uses the last diet order received from the nursing staff, but not necessarily the last order placed into the ProTouch system.

5. Additionally, Dietitian #1 and the Food Service Director said that in reviewing current diet orders with what the kitchen staff were preparing, there was an additional 11 non-sampled patients (E, F, G, H, I, J, K, L, M, N and O) who were not receiving the correct diet or did not have a current diet order.

Based on observations, staff interviews and record reviews, the Hospital failed to ensure that the environment of care on the Neurorehabilitative Units, emergency medical equipment for respiratory therapy and personal medical equipment was maintained at an acceptable level of quality and safety. The findings include:

1. During the tour of patient care areas on Neurorehabilitative Unit 2 (NRU 2) on 11/05/13 beginning at approximately 9:00 A.M., accompanied by the Neurorehabilitative (NR) Program Director and the Nurse Manager (RN #1), the following observations were made:

- the wooden bench seat in Shower room #2 was stained
- the bathroom wallpaper was peeling in room 207, the heat vent was rusty, the sprinkler head in the ceiling was missing a cover
- the electrical outlet in the library was missing a cover
- the library had an electrical outlet without a cover, the rug was stained and torn, the wall paint was scuffed and stained
- the wallpaper in the lounge was peeling
- the seclusion room inner door was missing, the radiator was banged up with scuffs and stains, and the wall paper was peeling
- the sprinkler was missing the cover in room 214's bathroom
- the ambient temperature in rooms 203, 204, 205, 206, 217 and 219 felt cold. The patient in room 203 demonstrated the loud noise caused by the heating fan when his/her room heater was turned on. The patient in room 217 was observed wearing a jacket in the room and said he/she was "freezing" and added, "I don't wear a jacket very often". The patient in room 219 said to the surveyor that he/she was cold. The (NR) Program Director said staff would immediately notify the maintenance service.
- shower room #1 had rusty ceiling vents, stained grout, peeling paint and an (approximate) two inch hole in the back wall.
- the rug in the unit corridor had two holes

2. During the tour of patient care areas on Neurorehabilitative Unit 4 (NRU 4) on 11/05/13 beginning at approximately 10:00 A.M., accompanied by the Neurorehabilitative (NR) Program Director and the Nurse Manager (RN #1), the following observations were made:

- room 411 had torn wallpaper
- room 412 had torn wallpaper
- room 413 had peeling wallpaper
- room 414 had peeling wallpaper
- room 415 had walls that were degraded at the base of the walls
- the lounge walls had chipped, stained paint
- the sensory room felt cold and was missing coving below the radiator
- the kitchen had a chipped, rusty radiator, the plaster had been patched and needed painting, the microwave was dirty.
-the patient nourishment refrigerator was observed to have a container of fruit dated 10/17/13. Small plastic containers of cole slaw and peaches were observed in the refrigerator that were not dated. Half gallon containers of apple and orange juice were open and not dated. The bottom shelf of the refrigerator was observed to have dried brownish-colored food stains dried on its surface.
- the bathroom off of the kitchen had holes above the sink
- the grout in the shower room tiles was stained
- the bathroom was missing approximately four tiles behind the toilet and the ceiling was stained.
- the water bubblers were dirty
- room 416 had torn wallpaper
- room 408 had two dressers with drawers in disrepair. The drawers were missing knobs and did not close properly.
- room 402 had a dresser drawer in disrepair, the wall was missing coving, the wallpaper was lifting.
- room 406 was missing coving and the wallpaper was torn
- room 403 had torn wallpaper across the wall at the height of a wheelchair, the radiator paint was stained
- room 405 had torn wallpaper

3. Interview with the Environmental Services (ES) Director at 11:00 A.M. on 11/05/13 revealed the hospital utilized a computerized system to report repair requests to the environmental services department. Review of computer records revealed the (NR) Program Director requested repair of the seclusion room's inner door on 10/03/13. Per interview with the ES Director, repair of the (NR) seclusion room door remained outstanding as it was pending fabrication of tempered, safety glass from the vendor.


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4. 11/07/13 at 11:00 A.M. the surveyor observed the Code Cart designated for use by the outpatient Pulmonary Clinic in the event of a medical emergency. The code cart was locked in a closet adjacent to the hallway immediately outside the door of the clinic. Initially, (Physical Therapy Assistant #1) PTA#1 was able to open the door where the code cart was stored. However, after closing the door to the closet that housed the code cart, PTA #1 was unable to open the door after multiple attempts of turning the key to the left and right and pushing the door. The maintenance staff member responded to a call from PTA #1 to open the door to the closet that housed the emergency cart. After multiple unsuccessful attempts to open the door by PTA#1 and the Director of Respiratory Care, the maintenance staff member was able to open the door using his/her master key and forcefully pushing the door open. The maintenance staff member said that the lock was sticking and that he/she would take it apart and repair it.

The Code Cart stored in the closet included an Intubation Kit containing various airway management equipment inside it, i.e. laryngoscope, endotracheal tubes, batteries, etc. According to the hospital Code Cart Checks Policy-for Nursing and Respiratory, "The Supervisor or Nurse Manager will check the code cart once a month." The date of the last check of the Intubation Kit was listed as 6/18/2012. The (Respiratory Therapy Director) R.T. Director was interviewed on 11/7/13 at 11:07 A.M. He/she said that the Intubation Kit had not been checked by a respiratory therapist since 6/18/12. The R.T. Director said that the Intubation Kit was supposed to be inspected monthly to ensure that the box was complete and the equipment functioning. The R.T. Director said that the respiratory therapist that works nights should have checked the Intubation Kit monthly, per the hospital policy.

The CEO was interviewed, and present, on 11/7/13 at 11:07 A.M. when the closet door containing the Code Cart for the Outpatient Pulmonary Clinic could not be opened. The CEO said that there would be a delay in providing emergency care to a patient if the closed door where the Code Cart was stored could not be opened. The CEO also said that if the Intubation Kit equipment was not in working order, due to it not being checked monthly per the Hospital policy, it may delay emergency medical treatment to a patient who required it.


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5. The Surveyor observed the Code Cart (Emergency Equipment) on the fourth floor Neurorehabilitative Unit (NRU) at 8:30 A.M. on 11/06/13. The Intubation Kit (Respiratory/Airway Emergency Management) was not locked as required in the facility policy.

Staff were unable to provide a list of equipment that was to be stocked in the Intubation Kit and there was no way to determine if the Intubation Kit included all emergency equipment that was to be available and accessible in an emergency.

There was no documentation on the check list that indicated when the Intubation Box had last been checked. The check list indicated the Code Cart was not signed off as being checked on any dates in November. Nurse # 2 reported that the Respiratory Department was responsible for checking the Intubation Kit.

7. The Surveyor observed the Code Cart (Emergency Equipment) on the second floor Neurorehabilitative Unit (NRU) at 8:50 A.M. on 11/06/13. The check list indicated that the Code Cart had been checked daily as required. There was no documentation on the check list that indicated when the Intubation Box had last been checked. RN Unit Manager #2 reported that the Respiratory Department checked the Intubation Kit once a month and kept their own records.

The RT Director was interviewed on 11/06/13 at 9:10 A.M. and reported that the Respiratory Department did not check the Intubation Kits on the second and fourth floor Neurorehabilitative Units.


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8. The Surveyor observed the Code Cart (Emergency Equipment) on the first floor Medical Unit at 9:20 A.M. on 11/5/13. The Intubation Kit (contains Respiratory/Airway Emergency Equipment) check list indicated the equipment was not signed off as being checked in September 2013 (Code Cart #2), and October 2013 (Code Cart #1).


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9. For Patient #8 the facility failed to clean the patient's CPAP [continuous positive airway pressure] machine.

Review of the policy and procedure for cleaning CPAP equipment based on the directions from the Sleep Medicine Institute of Texas, Pa. indicated the following:

A) Daily Care
1. Wash your hands before handling or cleaning the CPAP machine.
2. Immerse the humidifier, tubing and mask in a sink of warm, soapy water. A mild detergent will properly clean your equipment; ensure the soap does not contain antibacterial agents, bleach, chlorine, alcohol, moisturizers or scents. Agitate the equipment in the water for several minutes.
3. Rinse the equipment in warm water until all traces of soap are gone.
4. Hang the tubing over a hanger, towel bar or shower rod and place mask and humidifier on a towel to dry.
5. Unplug the CPAP machine and wipe it down with a clean cloth dampened with water and mild soap. Go over the machine again with another clean, damp cloth to rinse away the soap.

B) Weekly Care
6. Remove the filter of the machine and rinse it by running tap water through the filter. Squeeze it to ensure the dust is eliminated and allow it to dry before putting it back into the machine.
7. Disinfect your mask, tubing and humidifier after washing them by filling a sink with 1 part vinegar and 1 part water. Soak it in the sink for approximately 10 minutes. Rinse thoroughly by allowing the water to run through and over the equipment up to 3 minutes.
8. Allow the equipment to dry before reconnecting it to the machine.

Patient #8 was admitted to the facility in 10/2013 with diagnoses including acute respiratory deficiency, congestive heart failure, diabetes, alpha-1 antitrypsin deficiency and severe obstructive sleep apnea.

During interview at 8:35 A.M. on 11/6/13, the patient and his/her spouse said that the CPAP machine the patient was using belonged to the patient as the hospital had not provided a machine for the patient's use. Additionally the hospital staff had not cleaned the device since his/her admission to the facility.

During interview at 8:40 A.M. on 11/6/13 Respiratory Therapist #3 said that because the machine belonged to the patient, the respiratory department was only responsible for cleaning the filter, but not the hosing, the mask or the water container.

During interview at 8:45 A.M. on 11/6/13 Registered Nurse #5 said the machine had not been cleaned since the patient arrived over 3 weeks earlier

During interview at 8:50 A.M. on 11/6/13 the First Floor Unit Manager confirmed that the machine had not been properly maintained.

Although the hospital permitted the patient to use his/her machine from home, they made no arrangements to ensure the cleanliness of the device.

Based on observations, interviews, and review of the Hospital's policies/procedures, logs, and employee health records, the Hospital failed to consistently ensure an acceptable level of infection prevention practice.

Findings included:

1.) The Hospital failed to ensure that the high level disinfectant (a chemical cleaner that should destroy all microorganisms, except for bacterial spores) consistently complied with the manufacturer's directions for use to reprocess semi-critical items (items that contact mucous membranes or non-intact skin) in the Respiratory Department.

The following step in the use of the disinfectant was not performed in accordance with the manufacturer's instructions:

The Surveyor observed the Decontamination Room at 11:30 A.M. on 11/5/13. The Hospital was using a manual high-level disinfection process using an OPA product (ortho-phthalaldehyde) to reprocess the bronchoscope. The Respiratory Therapy (RT) Director described the disinfection process. The RT Director said, at the completion of the high level disinfectant soak, the channels of the bronchoscope were flushed with sterile water. According to the manufacturer's directions for use, the equipment must be totally immersed in a large volume of fresh/sterile water for at least one minute, and repeated immersions in fresh/sterile water for a total of three separate rinses to ensure removal of chemical residue.


2.) According to the CDC publication "Guidelines for Preventing Health Care Associated Pneumonia, 2003", in the absence of medical contraindication(s), elevate at an angle of 30-45 degrees the head of the bed of a patient at high risk for aspiration (e.g., a person receiving mechanically assisted ventilation and/or who has an enteral tube in place).

The Surveyor interviewed Respiratory Therapist #1 (RT #1) at 10:30 to 10:55 A.M. on 11/5/13. RT #1 said the position of the head of bed (HoB) was routinely checked on patient's receiving mechanical ventilation. The Surveyor asked RT #1 to demonstrate how the head of bed was measured. RT #1 could not locate the measuring device on non-sampled patient #1's (NS #1) bed that would be used to measure the HoB. RT #1 said not all beds had measuring devices and RT #1 would "estimate" the level of the head of the bed.

The Nurse Manager of the first floor was interviewed at 11:00 A.M. on 11/5/13. The Nurse manager said there was a device on NS #1's bed and was able to demonstrate the location of the device.

3.) The hospital failed to comply with industry standards for a respiratory protection program to comply with the Occupational Safety and Health Administration (OSHA) general industry standard.

According to OSHA regulations, employees using a particulate respirator (i.e. an N 95) are required to be fit tested (a procedure to ensure correct fit of an employee's respirator/mask) annually. A respirator/mask is used to protect the healthcare worker against diseases spread through the air, e.g., tuberculosis.

The Surveyor reviewed the health records of 3 hospital employees on the respiratory protection team on 11/7/13. The health records indicated 3 of the 3 employees on the respiratory protection team had been fit tested since the start of survey on 11/5/13. The Chief Clinical Officer (CCO) was interviewed on 11/7/13 at approximately 11:00 A.M. The CCO said the Infection Preventionist (IP) kept the log with the annual Hospital's fit testing data. The CCO said the IP left employment at the Hospital abruptly two weeks prior to survey and the fit test log could not be located and the Hospital was unable to demonstrate compliance with the annual fit requirement.

Based on patient and staff interviews and record reviews, for three of fourteen patients reviewed from the Neurorehabilitative Units (NRU), (Patient #1, Patient #5 and Patient #7), the Hospital failed to ensure the discharge evaluations were reviewed and revised on a timely basis to avoid unnecessary delays in discharge.

During the entrance conference on 11/05/13 at 8:00 A.M., the Chief Executive Officer of the hospital said the Neurorehabilitative Units care for 41 patients and average 4 discharges a year.

The findings include:

1. The Corporate Discharge Planning Policy #H-ML 10-013 revised 08/2012 included the following:

5. The Case Manager will complete ongoing monitoring and evaluation of the appropriateness of the discharge plan. Appropriateness will be determined by:
- reassessment of medical condition
- review of current patient, family, physician, specialists, and ancillary staff
- criteria for appropriateness of current level of care
6. If current discharge plan is no longer appropriate, the Case Manager (or if applicable, Social Worker) will modify the plan as needed. Document modification in the progress notes.

2. During interview on 11/05/13 beginning at approximately 9:00 A.M., the Neurorehabilitative (NR) Program Director said case management/discharge planning for the Neurorehabilitative Units was provided by an occupational therapist. The Director said the NRU was not staffed with a social worker; but that the social workers from the medical units were available for consultation if needed.

3. On 11/05/13 at 11:30 A.M., a patient from the Neurorehabilitative Unit (Patient #1) requested to speak to the surveyor. The patient had some verbal limitations but was able to communicate his/her message. The patient said he/she had met the surveyor earlier in the morning. The patient said he/she lived on the Neurorehabilitative Unit and had been there about two years. The patient said he/she had earned privileges, was allowed to leave the unit and hospital, and ate in the cafe. The patient said he/she was improving and did not like being in the hospital and "there was nothing to do". The patient said he/she wants to leave but that no one talks about that.

Review of Patient #1's medical records on 11/05/13 P.M. revealed the patient was under the age of 65 and had been in the hospital for over two years. The patient had diagnoses of a cerebral vascular accident in 2009, a seizure disorder, a history of polysubstance abuse, a right visual field deficit and expressive and receptive aphasia. The September 2013 nursing summary indicated Patient #1 needed reminders to shower and was independent in all activities of daily living. The patient had achieved the highest level of independence (Level 10) in the NRU's system of privileges.

Further record review indicated the patient had an annual treatment review completed on 4/24/2013. The review noted the patient had maintained level 10 privileges throughout the previous twelve months. The review also noted an application had been submitted during the 2012 lottery for the habilitation program, but the patient had been found financially ineligible. The review noted the team felt the patient was a good candidate for supervised residential programing.

Review of the medical record progress notes on 11/05/13 revealed no further documentation regarding discharge planning since the 4/24/13 annual review. Review of the interdisciplinary team meeting minutes for 8/22/13, 9/19/13, 10/3/13 and 10/17/13 revealed no documentation regarding discharge planning.

The discharge planner (D.P.#1) was interviewed on 11/06/13 at 10:30 A.M. and said that limited options were available to individuals with head injuries for supervised residential programing. The discharge planner (D.P.#1) said he/she had appealed the patient's financial disqualification but had lost the appeal last year. The discharge planner (D.P.#1) said no review of the discharge plan had been completed on Patient #1 since 4/24/13. There was no evidence other options for post hospital care had been considered, attempted and/or determined inappropriate.

4. Review of Patient #5's medical records on 11/06/13 revealed the patient was under the age of 30 and had been in the hospital for over two years. The patient had a diagnosis of traumatic brain injury involving a right parietal skull fracture at 8 months of age, a mood disorder and a thought disorder.

Further record review revealed the patient had an annual treatment review conducted on 8/13/13. The review noted the patient had maintained level 10 (the highest level of independence in the NRU's system of privileges). The review noted the patient had been attending a technology appliance repair program located outside the hospital since March 2013. The review indicated the patient was ready for discharge to a residential treatment program but none were available due to budgetary constraints.

The Neurorehabilitative (NR) Program Nurse Manager (RN #1), was interviewed on 11/06/13 at 3:00 P.M. and said that the hospital transported Patient #5 to and from a community college program three days a week. RN#1 said the patient had done well and would soon graduate from the program.

Review of the medical record progress notes on 11/06/13 revealed no further documentation regarding discharge planning since the 8/13/13 annual review. Review of the interdisciplinary team meeting minutes for 8/22/13, 9/19/13, 10/3/13 and 10/17/13 revealed no documentation regarding discharge planning.

There was no documentation reflecting a review of the discharge plan nor consideration of other options had been completed on Patient #5 since 8/13/13.

5. The above findings were reviewed with the Chief Executive Officer (CEO) of the hospital on 11/07/13 at 4:30 P.M. The CEO said the hospital was concerned patients would fail without adequate discharge plans and there may not be an available bed to readmit them to. The CEO said the Case Managers should document discharge planning efforts, including barriers to discharge, on an ongoing basis.

Based on record review and staff interview, for eleven of twenty-one patients who died at the Kindred Northeast Hospital from 4/7/13 to 10/28/13, the Hospital failed to ensure that the Organ Procurement Organization (OPO) was notified timely when the death of a patient was imminent.

Findings include:

1. The Hospital policy and contract for organ and tissue donation included that the Hospital would make timely notification to the OPO as soon as it was anticipated that death was imminent or "as soon as possible (within 1 hour) after" a patient met the criteria for imminent death.

The Hospital could only produce a log of OPO notification between the dates of 4/7/13 to 10/28/13. The Hospital Chief Clinical Officer was unable to locate prior logs.

2. Per review of the Hospital patient discharge list, from 4/7/13 to 10/28/13, 21 patient deaths were noted at the Kindred Northeast Hospital's main campus in Stoughton.

Of the 21 deaths, the Hospital could not account for OPO notification for 3 patients: 1 on 6/20/13, 1 on 9/8/13 and 1 on 10/19/13.

3. For 8 non-sampled patients (Patient A, B, C, D, E, F, G and H) who died at the Kindred Northeast Hospital's main campus from 4/7/13 to 10/28/13, the Hospital failed to notify the OPO within 1 hour of death as per Hospital policy and OPO contract:

1. Patient A died on 5/8/13 at 5:00 P.M., the OPO was notified two hours later, at 7:00 P.M.
2. Patient B died on 6/29/13 at 9:00 P.M., the OPO was not notified until three days later, at 1:45 P.M. on 7/2/13.
3. Patient C died on 9/6/13 at 9:40 A.M., the OPO was notified over four hours later at 2:30 P.M.
4. Patient D died on 7/11/13 at 11:00 A.M., the OPO was notified 90 minutes later at 12:30 P.M.
5. Patient E died on 7/16/13 at 7:35 A.M., the OPO was notified two hours later at 9:35 A.M.
6. Patient F died on 8/23/13 at 7:38 P.M., the OPO was notified 78 minutes later at 9:00 P.M.
7. Patient G died on 8/16/13 at 6:45 P.M., the OPO was notified 1 3/4 hours later at 8:30 P.M.
8. Patient H died on 10/12/13 at 5:30 P.M., the OPO was notified 2 3/4 hours later at 8:20 P.M.

During interview on 11/8/13 at 10:30 A.M., the facility Chief Clinical Officer said that the facility did not notify OPO in a timely manner.

Based on observation, record review, and staff interview, the Hospital failed to ensure that the Intubation Kits on the Code Carts were inspected, checked for completeness and functionality monthly, in accordance with the Hospital's Code Cart policy.

Findings included:

1. The surveyor observed the Code Cart designated for use by the outpatient Pulmonary Clinic in the event of a medical emergency, on 11/7/13 at 11:00 A.M.:

a. The Code Cart which included an Intubation Kit was locked in a closet adjacent to the hallway immediately outside the door of the clinic. Initially, (Physical Therapy Assistant #1) PTA#1 was able to open the door where the code cart was stored. However, after closing the door to the closet that housed the code cart, PTA #1 was unable to open the door after multiple attempts of turning the key to the left and right and pushing the door. The maintenance staff member responded to a call from PTA #1 to open the door to the closet that housed the emergency cart. After multiple unsuccessful attempts to open the door by PTA#1 and the Director of Respiratory Care, the maintenance staff member was able to open the door using his/her master key and forcefully pushing the door open. The maintenance staff member said that the lock was sticking and that he/she would take it apart and repair it.

b. The Intubation Kit contained various airway management equipment inside it, i.e. laryngoscope, endotracheal tubes, batteries, etc. According to the hospital Code Cart Checks Policy-for Nursing and Respiratory, "The Supervisor or Nurse Manager will check the code cart once a month." The date of the last check of the Intubation Kit was listed as 6/18/2012. The (Respiratory Therapy Director) R.T. Director was interviewed on 11/7/13 at 11:07 A.M. He/she said that the Intubation Kit had not been checked by a respiratory therapist since 6/18/12. The R.T. Director said that the Intubation Kit was supposed to be inspected monthly by the night shift R.T. to ensure that the kit was complete, the contents had not expired, and the equipment was functioning. The R.T. Director said that the respiratory therapist that worked nights should have checked the Intubation Kit monthly, per the hospital policy.

2. The Surveyor observed the Code Cart (Emergency Equipment) on the fourth floor NRU at 8:30 A.M. on 11/06/13. The Intubation Kit (Respiratory/Airway Emergency Management) was not locked as required in the facility policy.

Staff were unable to provide a list of equipment that was to be stocked in the Intubation Kit and there was no way to determine if the Intubation Kit included all emergency equipment that was to be available and accessible in an emergency.

There was no documentation on the check list that indicated when the Intubation Kit had last been checked. The check list indicated the Code Cart was not signed off as being checked on any dates in November. Nurse #2 reported that the Respiratory Department was responsible for checking the Intubation Kit.

3. The Surveyor observed the Code Cart (Emergency Equipment) on the second floor NRU at 8:50 A.M. on 11/06/13. The check list indicated that the Code Cart had been checked daily as required. There was no documentation on the check list that indicated when the Intubation Kit had last been checked. RN Unit Manager #2 reported that the Respiratory Department checked the Intubation Kit once a month and kept their own records.

The RT Director was interviewed on 11/06/13 at 9:10 A.M. and reported that the Respiratory Department did not check the Intubation Kits on the second and fourth floor NRU's.

4. The Surveyor observed the Code Cart (Emergency Equipment) on the first floor Medical Unit at 9:20 A.M. on 11/5/13. The Intubation Kit (contains Respiratory/Airway Emergency Equipment) check list indicated the equipment was not signed off as being checked in September 2013 (Code Cart #2), and October 2013 (Code Cart #1).

The Hospital CEO, Director of Nursing, and the Director of Risk Management were interviewed on 11/8/13 at 2:30 P.M. regarding the Respiratory Department's failure to inspect the Intubation Kits in accordance with the Hospital policy. The Hospital's administrative staff said that the Respiratory Department failed to follow the Hospital policy regarding monthly checks of the Intubation Kits, and omission to check the kits could be problematic if the intubation equipment were missing from the Intubation Kit, or, if the intubation equipment was found to be inoperable during a Code.