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Based on medical record review, staff interview, and observation; the facility failed to ensure all patients receive care in a safe environment. This affected Patient 19 and had the potential to affect all patients admitted to the facility's telemetry unit. The facility had a capacity for 115 beds and a census of 77 on 06/01/10. There were 17 patients on the telemetry unit on 06/02/10, including Patients 21 and 22. Staff M, N, O, P and Z were interviewed. On 06/02/10 a determination of immediate jeopardy (IJ) was made. Administrative staff were notified of the determination the same day and that based on observations on the telemetry unit, interview of staff who work on the telemetry unit, and medical review for patient #19. The facility took immediate action and the IJ was removed on 06/04/10 at 3:30 PM, prior to exit.

Based on medical record review, policy review, and staff interview; the facility also failed to follow their policies on wound care and fall precautions to prevent the wounds from worsening and patient injury from falls. This affected 3 of 66 medical records reviewed (Patients 27, 54, and 64).

The Condition of Participation of Nursing Services was also found to be not in compliance at the substantial allegation survey completed on 11/25/09.

Findings Include:

The medical record for Patient 19 was reviewed on 06/02/10. The patient was admitted to the facility on 05/04/10 with a diagnosis of Dehydration and Respiratory Distress. The medical record contained documentation in the nurses notes that the patient was on telemetry during his/her entire hospital stay. The admission orders on 05/04/10 at 11:00 PM contained orders for telemetry, bedrest, fall precautions, and do not resuscitate care and comfort (DNR CC). The patient was found by nursing half off the bed without respirations. The patient was put on a monitor and noted to be in asystole (absence of electrical activity of the heart), his/her pupils fixed and dilated, and no lung sounds or heart beat was able to be auscultated (heard). The patient was pronounced dead at 1:40 AM.

In an interview on 06/02/10 at 11:15 AM, Staff N stated Patient 19's death was investigated. All staff working on the unit the night of the patient's death were interviewed on 05/11/10. The investigation showed the patient was on telemetry at the time of his/her death and at some undetermined point the leads came off the patient and the facility was unable to determine for how long or what event lead to the patient being found partially out of bed. The telemetry alarm for leads being dislodged is a low audio alert. No one was assigned to watch the telemetry monitors on 05/11/10. Staff N further stated that it was possible the patient had been there for some time before found by staff making rounds. Staff N also stated no new measures or changes have been implemented yet, just an increased awareness by staff on the telemetry unit to keep a closer eye on the monitors as much as possible.

Staff Z was interviewed via phone on 06/04/10 at 9:24 AM. Staff Z stated on the night in question, he/she and several other staff were assisting a patient who required several staff to reposition. When finished assisting with this patient, Staff Z began making patient rounds. Staff Z saw two nurses at the nursing station. Staff Z found Patient 19 with his/her head caught between the bedrail and the mattress with his/her face into the mattress, arms on the bed, and the rest of the patient on the floor. Staff Z called for help and freed the patient's head from the bedrail. Staff Z supported the patient's upper body until additional staff arrived and assisted in placing the patient back into bed. Nursing staff took over upon arrival. Staff Z stated he/she had responded to Patient 19's call bell almost exactly one hour prior to finding the patient unresponsive.

During observation of the telemetry unit on 6/02/10 at 1:20 PM there were 17 patients in the telemetry unit on second floor. Observation during this time revealed a low sounding alarm of Patient 22's monitor. The monitor read ventricular tachycardia which is a lethal heart rhythm. The surveyor had questioned this rhythm and was told by Staff O that the patient had had artifact ( inaccurate readings caused by patient movement all day.) The surveyor then told Staff M that the patient's monitor did not identify artifact, but did show a brief period of ventricular tachycardia. The surveyor then requested that staff O check the patient.

During an interview with Staff M a low sounding alarm was heard for Patient 21. Staff M did not respond to the alarm. The surveyor then notified Staff M that the monitor identified the rhythm was ventricular tachycardia. When patient 21 was identified the surveyor went to observe the patient before staff did.

Interview of Staff P on 6/2/10 at 1:45 PM revealed the telemetry monitor's audio was set at 100 percent volume. When the surveyor requested a reading of the volume of the monitors, Staff P found the settings of the volumes to be from 50 to 80 percent and not 100 percent. Staff P stated that "someone must have changed the settings".


The facility failed to ensure adequate monitoring of telemetry patients, including Patient 19 who was found on the floor of his/her room on the telemetry unit non-responsive.
Please see A 392, 482.23(b); Staffing and Delivery of Care.

The facility failed to follow their policies on wound care and fall precautions to prevent wound worsening and patient injury.
Please see A 395, 482.23(b)(3); RN Supervision of Nursing Care.

Based on review of the medical records, staff interview and review of facility policies and procedures, the facility failed to provide an appropriate medical screening to all patients. This affected 5 out of the 8 patient records reviewed that were identified with suicidal ideation and/or overdose (Patients 29, 33, 34, 35, and 36).
Findings include:
Review of the medical record for Patient 29 revealed that the patient presented to the Emergency Department (ED) by way of the local fire department on 06/01/10 at 12:39 AM. The squad report stated that the patient's mother called 911 because the patient contacted her and stated that he/she took all his/her pills. When the fire department arrived on scene the patient denied any suicidal ideation. After arriving at the ED the patient still denied suicidal ideation but admitted to drinking 4 beers. Patient 29 was then evaluated by the physician at 1:05 AM and it was documented that the patient was a difficult historian and was upset situationally, but with no homicidal or suicidal ideation. At 3:29 AM the patient was reassessed by the nurse and confessed to taking 20 tablets of Stratera 25 mg (medication used for Attention deficit disorder), but gave no reason for the ingestion. Nursing staff contacted poison control for instruction and then monitored the patient for 4 hours per their recommendation. The patient was then discharged home without a psychiatric evaluation at 5:55 AM; however the patient was encouraged to follow up with a crisis team if needed and be seen at the local free clinic in two days.
Later that same day, at 8:19 AM, Patient 29 returned to the ED stating that she was released that morning from the ED and admitted at that time that he/she took all her medicines on Sunday night and that these medicines included; a narcotic anxiety medication, medication for attention deficit disorder, an aspirin based pain medication, a medication used for cough, and acetaminophen. There was no documented evidence of how much of each medication that the patient had ingested. During this return visit he/she was now complaining of feeling weak and shaky. The physician's documentation stated that he/she still continued to have intermittent thoughts of suicide. The patient was transferred to another acute medical center for further evaluation with a diagnosis of dizziness and once the patient was medically stable they would undergo a psychiatric evaluation.
Review of the medical record for Patient 33 revealed that the patient presented to the ED on 04/04/10 at 1:41 AM by way of the local fire department with an overdose. The squad report stated that the patient and witnesses confirmed that the patient took 6 muscle relaxers at 12:55 AM because he/she was having trouble sleeping and feeling depressed. Review of the nursing documentation stated that the patient took 6 tablets of Celexa 20mg (a medication used for depression) because he/she was having trouble sleeping and not because he/she wanted to hurt him/herself. The physician's documentation also stated that the patient had no suicidal intent and the patient was discharged home at 3:05 AM without a psychiatric evaluation.
Review of the medical record for Patient 34 revealed that the patient presented to the ED on 04/29/10 at 11:48 AM by his/her personal vehicle. During triage the patient stated that he/she had accidentally taken a whole week's worth of medications on Tuesday. The patient denied suicidal ideation and didn't remember even taking them or why he/she took them. The patient had a history of depression and schizophrenia. Review of the physician's assessment revealed that the patient stated that he/she was seen at a counselor's office that morning and they didn't feel he/she was suicidal or homicidal. There was no documentation that the physician contacted the counselor to verify these findings. The patient had been hearing voices and was cutting on him/herself for three weeks. The physician's documentation stated that the overdose was accidental with no suicidal intent. An interview with the patient's mother revealed that she felt the patient was "okay and not suicidal". The patient was discharged home without a psychiatric evaluation.
Review of the medical record for Patient 35 revealed that the patient presented to the ED on 04/08/10 at 9:45 PM by his/her personal vehicle. Patient 35 had a history of bipolar disorder and schizophrenia. During triage at 9:46 PM the patient stated that he/she had been out of his/her medications for two weeks and was currently living at a group home. The patient started walking from group home, couldn't remember where it was and was having paranoid thoughts and hearing voices. The patient also stated that he/she had a plan to use poison to commit suicide with either antifreeze or bleach, but had no means of purchasing either at that time. At 1:42 AM the physician's note read that they (facility) received a call back from the Crisis team and that earlier that day the patient was seen at another local hospital and evaluated by a counselor prior to coming to the ED. The patient was from a group home in Lorain Ohio and the Crisis team planned on sending a cab to get him around 7:00 AM and arrange bus transportation back to Lorain. On 04/09/10 at 7:15 AM, the patient left the ED by a cab without a psychiatric evaluation .
Review of the medical record for Patient 36 revealed that the patient presented to the ED on 05/12/10 at 12:52 PM by a personal vehicle with the patient's mother. The patient was Autistic and currently was homeless living with his/her mother in a local shelter. At triage the mother reported that the patient stated that he/she wanted to kill him/herself earlier that day. The patient denied feeling like he/she wanted to harm him/herself or others. The physician documented that the patient was positive for hostile and angry feelings and refused counseling or psychiatric treatment. At 4:54 PM the patient was discharged from the ED without a psychiatric evaluation and no information where the patient could follow up as needed.
The facility policy entitled "Suicide Risk Assessment and Interventions in an Acute Care Setting" was reviewed on 06/01/10. This policy stated that all patients receiving any treatment in any inpatient, outpatient or other practice setting with a diagnosis of an emotional or behavioral disorder will be screened for risk of suicide, regardless of assessment by an outside mental health agency. Then if a patient was identified to be at risk for suicide a referral would be made to a behavioral health professional.

Interview of Staff R on 6/4/10 at 2:00 PM revealed a psychiatrist (staff KK) was available for consult in the emergency department.

This substantiates complaint OH00055626.

Based on review of medical records and staff interview and confirmation it was determined that the facility failed to ensure that patients had the right to be admitted to the hospital instead of being transferred. This affected 4 out of the 8 patient transfer records reviewed and involves Patients 56, 57, 58, and 59. The total amount of patients transferred from the Emergency Department in the past six months was 160.
Findings include:
Review of the medical record for Patient 56 revealed that the patient presented to the ED on 02/21/10 at 11:34 AM by personal vehicle. The patient had a history of chronic respiratory disease, hypertension and gastric ulcers. The patient was triaged as a level 2 semi-urgent and complained of a productive cough and pain above the stomach. Review of the physician's documentation dated 02/21/10 at 3:52 PM revealed that the plan of care was discussed with the patient; that the patient is aware that his/her insurance is not accepted here; and he/she will have to go to another acute care hospital. The patient's registration documentation revealed that the patient's insurance coverage is through Caresource. The Physician Certificate for Transfer lists the benefits for the patient's transfer as insurance will be accepted and the risks for transfer as motor vehicle accident and the risk that the patient's condition may worsen during transport. Review of nursing documentation revealed that the reason for transport to another acute care hospital was "payor directed"; the patient was transferred by squad at 4:25 PM with a cardiac monitor and oxygen.
Review of the medical record for Patient 57 revealed that the patient presented to the ED on 12/31/09 at 5:59 AM by way of the local emergency squad. Patient 57 had a history of seizure disorder and diabetes. The patient was transported to the ED due to an episode in which he/she passed out and fell. During the ED visit the patient underwent imaging studies and an EKG. At 8:15 AM the physician documentated that his/her recommendation was to admit the patient into the hospital due to the episode in which the patient passed out. At 8:36 AM nursing documentation stated that due to the patient's insurance the patient will be transferred to another acute care hospital. At 9:04 AM an addendum was written to the physician's notes which stated that after the chart was signed and locked, registration informed the physician that the patient's insurance will not cover admission to the hospital (Affinity Medical Center) and that he "must" be transferred to another acute care hospital. Further reveiw of the nursing documentation revealed that Patient 57's transfer was initiated as per "Payor Direction". At 8:41 AM the patient left the ED by squad, with an Intravenous line and a heart monitor, to be transferred to another acute care hospital. There was no documentation in the medical record that the patient consented to the transfer. Patient 57's insurance carrier was Buckeye Aged and Disabled insurance.
Review of the medical record for Patient 58 revealed that the patient presented to the ED on 12/21/09 at 3:48 AM by way of the local emergency squad. Patient 58 had a history of anxiety, arthritis, hypertension and stomach problems. At 3:41 AM Patient 58 stated that he/she fell on the way to the bathroom, felt dizzy and almost passed out. At the time of triage the patient experienced bleeding from the rectum and the nose. The Physicians Certificate of Transfer stated that the benefits of the patient to be transferred were the need for a gastroenterology consult (physician who specializes in diseases and conditions of the digestive system) and because the patient's insurance dictates. The risk for transfer to the patient was the potential to be involved in a motor vehicle accident during transport to the receiving hospital. A review of Patient 58's admission information revealed that the patient has Prime Time Health Plan. Review of nursing documentation revealed that at 6:45 AM Patient 58 was transferred to another acute care hospital for "Payor Directed". At 6:45 AM Patient 58 was transferred to another acute care hospital by squad with a cardiac monitor.
Review of the medical record for Patient 59 revealed the patient presented to the ED on 12/04/09 at 1:17 PM by personal vehicle with shortness of breath. Patient 59 had a history of chronic respiratory disease and diabetes. During the initial physician exam at 1:17 PM it was determined that the patient was in severe respiratory distress. Review of documentation written by the attending physician at 3:13 PM stated that after the patient was admitted, it was discovered that the patient's insurance was not accepted at AMC (Affinity Medical Center). A review of the registration data revealed that the patient had Medicaid HMO. The patient was given the option of transfer to one of two other acute care hospitals in the area. A review of the nursing documentation listed the reason for the transfer as "payor directed". The Physician Certificate of Transfer document listed the benefits for transfer as in-patient care and insurance and the risks for transfer was traffic. At 5:15 PM Patient 59 was transferred to another acute care hospital by squad with a cardiac monitor, oxygen and an intravenous line.
There was no documentation that the above patients had an opportunity to be admitted to the hospital instead of being transferred to another acute care hospital. This was confirmed with Staff JJ on 06/03/10 at 9:00 AM.

Based on medical record review, staff interview, and observation; the facility failed to ensure all patients received care in a safe environment. This affected Patient 19, 21, and 22 and had the potential to affect all patients admitted to the facility's telemetry unit. The facility had a capacity for 115 beds and a census of 77 on 06/01/10. There were 17 patients on the telemetry unit on 06/02/10, including Patients 21 and 22. Staff M, N, O, P and Z were interviewed.

Findings include:

The medical record for Patient 19 was reviewed on 06/02/10. The patient was admitted to the facility on 05/04/10 with a diagnosis of Dehydration and Respiratory Distress. The medical record contained documentation on the nurses notes that the patient was on telemetry during his/her entire hospital stay. The admission orders on 05/04/10 at 11:00 PM contained orders for telemetry, bedrest, fall precautions, and do not resuscitate care and comfort (DNR CC). The medical record contained a DNR CC form signed by the patient on 03/16/10. A physician progress note dated 05/11/10 at 1:55 AM, stated a code blue was called and the patient had no pulse or respirations upon arrival in the patient's room. The patient was found by nursing half off the bed without respirations. The patient was put on a monitor and noted to be in asystole (absence of electrical activity of the heart), his/her pupils fixed and dilated, and no lung sounds or heart beat was able to be auscultated (heard). The patient was pronounced dead at 1:40 AM.

In an interview on 06/02/10 at 11:15 AM, Staff N stated Patient 19's death was investigated. All staff working on the unit the night of the patient's death were interviewed on 05/11/10. The investigation showed the patient was on telemetry at the time of his/her death and at some undetermined point the leads came off the patient and the facility was unable to determine for how long or what event lead to the patient being found partially out of bed. The telemetry alarm for leads being dislodged is a low audio alert. No one was assigned to watch the telemetry monitors on 05/11/10. Staff N further stated that it was possible the patient had been there for some time before found by staff making rounds. There were five registered nurses and two aides caring for 26 patients that shift. A patient was being admitted to the floor and most of the staff were assisting an obese patient at the other end of the floor immediately prior to Patient 19 being found unresponsive and not breathing. A root cause analysis was completed and found adequate staffing, the two upper side rails were up, and the patient was restless that evening. Staff N also stated that once a patient was taken off a monitor, the data deletes and there is no record of how long Patient 19 was off the telemetry monitor or what cardiac events may have occurred. Staff N also stated no new measures or changes have been implemented yet, just an increased awareness by staff on the telemetry unit to keep a closer eye on the monitors as much as possible.

Staff Z was interviewed via phone on 06/04/10 at 9:24 AM. Staff Z stated on the night in question, he/she and several other staff were assisting a patient who required several staff to reposition. When finished assisting with this patient, Staff Z began making patient rounds. Staff Z saw two nurses at the nursing station. Staff Z found Patient 19 with his/her head caught between the bedrail and the mattress with his/her face into the mattress, arms on the bed, and the rest of the patient on the floor. Staff Z called for help and freed the patient's head from the bedrail. Staff Z supported the patient's upper body until additional staff arrived and assisted in placing the patient back into bed. Nursing staff took over upon arrival. Staff Z stated he/she had responded to Patient 19's call bell almost exactly one hour prior to finding the patient unresponsive.

Interview of two telemetry staff nurses (Staff O and M) revealed the telemetry had a history mechanism that recorded the patients readings from date of admission. This information was contradictory to the findings of the investigation by the facility.


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During observation of the telemetry unit on 6/02/10 at 1:20 PM there were 17 patients in the telemetry unit on second floor. Observation during this time revealed a low sounding alarm of Patient 22's monitor. The monitor read ventricular tachycardia which is a lethal heart rhythm. The surveyor had questioned this rhythm and was told by Staff O that the patient had had artifact ( inaccurate readings caused by patient movement all day.) The surveyor then told Staff M that the patient's monitor did not identify artifact, but did show a brief period of ventricular tachycardia. The surveyor then requested that staff O check the patient. Patient 22 was checked and his/her monitor leads were replaced.

During an interview with Staff M a low sounding alarm was heard for Patient 21. Staff M did not respond to the alarm. The surveyor then notified Staff M that the monitor identified the rhythm was ventricular tachycardia. When patient 21 was identified the surveyor went to observe the patient before staff did. The patient was not in distress at that time and was observed to be walking down the hall.

During the course of the observations on the telemetry unit on 06/02/10, Staff M and O was interviewed. Staff M stated that the charge nurse was responsible for the monitoring of the telemetry readings on the day shift. Staff O responded at this time that the charge nurse on duty was also responsible for supervising two licensed practical nurses and was hanging a blood transfusion. Staff M stated that there is no staff assigned to actually sit and watch the telemetry monitor readings. Staff O stated that staff tune out alarms after a while.

Staff M and O also stated on 6/02/10 that staff was needed to observe alarms at all times, due to staff all having various other assignments. Staff M showed the surveyors a staffing grid that called for a telemetry trained technician to be assigned to observe the telemetry monitors every day. According to Staff M this position had not been filled for at least a year.

Interview of Staff P on 6/2/10 at 1:45 PM revealed the telemetry monitor's audio was set at 100 percent volume. When the surveyor requested a reading of the volume of the monitors, Staff P found the settings of the volumes to be from 50 to 80 percent and not 100 percent. Staff P stated that "someone must have changed the settings".

This substantiates complaint OH00055626.

Based on medical record review, policy review, and staff interview; the facility failed to follow their policies on wound care and fall precautions to prevent wounds from declining and patient injury from falls. This affected 3 of 66 medical records reviewed (Patients 27, 54, and 64).

Findings include:

The medical record for Patient 54 was reviewed on 06/03/10. The record
lacked evidence of the wound measurements on admission. Review of the wound care
policy number PCS-40 revealed nursing will thoroughly document the wound
assessment immediately upon admission and at least every 7 days after discovery.
Documentation was to include a photo, measurement and description of the wound.
The progress note revealed the patient was admitted with a Stage II ulcer to the
right and left heel and the coccyx. Review of the wound status on 6/3/10, or
seven days after admission, did not have a photograph of the wound. The
nurse assessment dated 6/3/10, revealed the patient had Stage III heel wounds
bilaterally which had advanced from Stage II on admission. The nurse assessment dated 6/2/10 revealed the coccyx wound was staged at a level III six days after admission.
The surveyor was unable to determine if the size of the wound had increased from
admission due to the absence of measurement documentation on admission.

The medical record for Patient 64 was reviewed on 06/03/10. This patient was admitted to the hospital on 05/06/10 with a diagnosis of cerebral vascular accident with left-sided weakness. The nursing assessment at the time of admission revealed a stage I wound on the patient's coccyx area. According to documentation of the nursing assessment of the wound on 05/10/10 revealed it had advanced to a stage II. On 05/17/10 nursing documentation revealed the wound was excoriated and there was no staging noted at that time. A physician's order dated 05/18/10 at 14:05, noted by the registered nurse read, "please do not allow to sit up in chair for more than two hours at a time." The medical record lacked evidence this order was followed. The medical record lacked evidence the patient's physician was made aware of the patient's declining skin condition or that the hospital's wound care nurse was consulted about the patient's wound. Interview with Staff W and Staff V on 06/03/10 at 10:45 AM confirmed these findings.

Review of the medical record for patient 27 was completed on 06/04/10. This patient was admitted to the hospital on 04/14/10 with a diagnosis of acute renal failure. A fall risk assessment was completed on admission with a score of 16. According to hospital policy a fall risk assessment is to be completed by nursing every shift. A fall risk assessment score greater than 10 puts the patient in the "at risk" category and requires specific interventions be put in place. Nursing documentation revealed the patient sustained a fall on 04/22/10 at 2:30 PM. The fall risk assessment was not completed by the nurse on the evening shift following the fall. The fall risk assessment completed for the shifts on 04/23/10 failed to assign the five points for "fall during admission" to the patient's risk score. No fall risk assessment was completed for the day shift on 04/24/10. The patient was discharged from the hospital on 04/24/10 at 5:30 PM. This finding was verified with Staff R on 06/04/10 at 11:45 PM.

This substantiates complaint OH00055626.

Based on observation and interview of the medical record department, the facility failed to follow the hospital policies for medical records. The facility census was 77 patients.

Findings included:

Interview with Staff G on 06/01/10 revealed the current number of delinquent records (over 30 days) was 302. Staff R confirmed on 6/3/10 at 2:00 PM, no physicians were on suspension for the above delinquent records. The surveyor requested the policy for delinquent records and was presented the Health Information Management medical records policy number HIM 1.24 with an effective date of 5/2010, revealed the physician is responsible for completing the medical record within 30 days. Interview on 06/03/10 at 1:30 PM Staff G revealed this policy was being reviewed at corporate. Information was not provided as to which physician was delinquent and whether or not the physician was suspended. There were no further measures identified to ensure the medical records would be completed.

Based on observation and staff interview the facility failed to maintain the crash cart in a secure manner. The facility emergency department treated 13, 556 patient from December 2009 to May 2010.

Findings include:

Observation on 06/01/10 at 1:35 PM revealed the crash cart was unlocked in trauma room #2. This cart contained emergency medication in the event of a medical emergency. The emergency staff were to check the crash cart for security each shift. The sign off sheet for that shift had been signed as the crash cart being secure. This finding was confirmed by the staff W on 6/01/10 at 1:35 PM.

Based on findings from the Life Safety Code survey completed on 06/04/10, it was determined that the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. The hospital failed to ensure that the doors to the medical staff library latched into the door frame and failed to ensure that smoke detectors in various locations throughout the facility were located so that air flow would not affect operation of the detectors.

Findings include:

Building #1:

Please see K18 regarding failure to ensure that the two doors to the medical staff library latched into the door frames.

Please see K130 regarding failure to ensure that smoke detectors in various locations throughout the facility were located so that air flow would not affect operation of the detectors. All of the above smoke detectors were relocated to a distance greater than 36 inches from the nearest air diffusers before the survey exit on 6/4/10.

Based on observation of two surveyors and staff interview the facility failed to maintain clean equipment in the dietary department. The hospital census was 77.

Findings include:

Observation on 6/02/10 at 10:15 AM by two surveyors and staff K revealed a large mixer in the corner of the service room by the oven toaster had an electrical cord that was heavily soiled with dried food substances. A large meat slicer had a dried piece of meat on the underside of the cutting blade. A large cart holding boxes of utensils had a dust buildup on the lower shelf and lower shelf corners. In the fruit refrigerator there was a large unsealed bag of blueberries on a shelf. The dairy refrigerator had an ice buildup and was dripping water above shelves of butter and sour cream packets.

These findings were confirmed by staff K on 6/2/10 at 10:30 AM.