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Based on interview, medical record review and policy review, the facility failed to ensure that patients have the right to receive care in a safe setting (A144) that resulted in a determination of immediate jeopardy; however, the facility took immediate and appropriate action and the immediate jeopardy was removed prior to exit. The facility failed to ensure patients have the right to be free from seclusion (A154). The cumulative effects of these systemic practices resulted in the facility's inability to ensure patients' needs would be met.

Based on review of policies, observations and interview, the facility failed to prevent elopement for one of ten patients (Patient #3) and failed to ensure a safe environment by failing to adhere to infection control practices for three of four patients. (Patient #1, #6 and #3) This had the potential to affect all patients receiving services from the facility. The census at the time of survey was 44.

Findings include:

1. Patient #3 was admitted to the facility on 05/24/16 with traumatic brain injury. Review of the Rehabilitation Nursing Admission Assessment revealed the 27 year old patient had a depressed right parietal skull fracture on 05/03/16. Patient #3 was in an acute care hospital from 05/03/16 and was transferred on 05/24/16 to a rehabilitation hospital. The assessment revealed patient had fair safety awareness. The safety interventions on the admission assessment on 05/24/16 revealed safety checks per safety assessment. The safety assessment revealed every two hour safety rounding per facility policy.

In an interview on 07/20/2016 at approximately 8:30 AM, Staff C stated it is the Facility's process to place all patients on Safety Observation Checks every two hours. The Facility had no policy in place prior to the survey for the Safety Observation Checks process.

Review of the nurses notes revealed on 05/29/16 at 3:40 PM a code brown (missing patient) was called after a staff member went to Patient #3's room and found the patient missing. The next note revealed Patient #3 was seen being wheeled back into the facility's parking lot by a friend. The nurses notes revealed staff met Patient #3 at the front of the facility, the patient was not harmed and was placed into the facility's NRU (Neuro Rehabilitation Unit), a locked unit.

On 07/19/16 at 4:10 PM, during an interview Staff G revealed staff met Patient #3 at the front of the facility. The supervisor also stated Patient #3 stated he/she was going down the road to his/her home.

Review of the plan of care for Patient #3 revealed a problem area of impaired safety awareness. The intervention was safety checks per safety assessment. Review of the Patient Safety Observation form for Patient #3 revealed on 05/29/16 no safety checks were done every two hours for the entire day.

Interview with administrative staff on 07/19/16 at 9:15 AM revealed Staff C received a call about Patient #3 leaving the facility and attempting to elope. Staff C revealed the patient had been telling staff he/she wanted to go outside. Staff was trying to keep him/her occupied. The patient was taken to his/her room. Staff went to check on the patient and he/she was not in his/her room. Staff C revealed the patient left the unit in his/her wheelchair, went up the elevator and out the front door. Staff C revealed the receptionist saw the patient go out the door but was not aware the patient was not to go out the door unaccompanied. Staff C revealed the patient went out to the front area of the building on the sidewalk close to the highway (four lane highway). Staff C revealed the facility had determined there was a 10 minute time period before a passerby brought the patient back and was met at the front of the facility by staff. Staff C also confirmed the facility had no assessment to identify patients at risk of elopement.


2. Review of the facility's policy titled "Hand Hygiene Guidelines-NPSG 7" (revised March 2015) was completed. The policy stated " Indications for hand washing and hand antisepsis are not limited to: decontaminate hands before having direct contact with a patient and decontaminate hands after removing gloves.

Review of the facility's policy titled Cleaning of Shared Medical Equipment (revised March 2016) was completed. The policy stated "all shared patient care equipment is cleaned after each patient use according to manufacturer's instructions for use."

a. On 07/18/2016 at approximately 10:15 AM Staff E was observed performing wound care to the right inner calf of Patient #1. Staff E washed her hands, applied gloves and removed kling wrap by cutting it off with bandage scissors removed from her pocket. She placed the scissors on the bedside table and changed gloves with out cleaning her hands in between. Staff E cleansed the incision on the right inner thigh with normal saline solution. Staff E changed her gloves and washed her hands in between. Staff E placed the dressing supplies along with a new roll of tape on the Patient's bed. Staff E took a sterile Aquacel dressing (an anti-microbial dressing) and cut it to fit the incision with the same bandage scissors on the bedside table without first cleansing the scissors. Staff E applied an ABD pad over the Aquacel dressing and secured it by wrapping the wound with kerlix gauze and securing it with tape. After completion Staff E placed her dirty bandage scissors in her pocket along with the roll of tape. She then removed her gloves and washed her hands.


b. On 07/18/16 at 11:30 AM, Staff F was observed testing Patient #6's blood sugar with a blood glucose meter in the patient's room. Staff F was then observed taking the meter to another patient's room. Staff F was observed testing the blood sugar of Patient #7. On the door of Patient #7's room was a sign which revealed the patient was on contact precautions. After using the blood glucose meter, the staff member was observed putting the meter on the charger at the nurses station. Staff F confirmed he/she had not cleaned the meter after patient use.




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Based on observation and interview, the facility failed to ensure patients have the right to be free from seclusion. This affected 10 of 44 patients with the potential to affect twelve patients. The facility census was 44.

Findings include:


On 07/18/16 from 9:00 AM to 9:30 AM, a tour of the facility was conducted with Staff H. Rooms G1 through G12 were identified as the rooms on the locked unit. This unit was the facility's NRU (Neuro Rehabilitation Unit), a locked unit. Staff H revealed the door was locked and patients were unable to leave the unit. Family members were to press a button to notify the staff at the nurses station to allow the family member to leave or enter the unit. Review of the census revealed there were 10 patients on the unit and the unit had the capacity for twelve patients.

On 07/20/16 at 8:30 AM, Staff C revealed the facility had no written criteria for admission to the locked unit. Staff C revealed a physician's order was not obtained for a patient to be admitted to the locked unit. The facility also had no assessment to reveal the need for a patient to be on the locked unit.

On 07/20/16 at 2:45 PM, Staff A revealed none of the patients on the locked unit were at risk of elopement and none of the patients had a diagnosis of dementia. Staff A also confirmed the patients on this unit did not need to be on a locked unit.

Based on medical record review, policy review and interview, the facility failed to ensure the Registered Nurse (RN) met patient needs by failing to ensure patient safety observations were completed every two hours for ten of ten patients reviewed (Patients # 1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) and failed to ensure wound care was completed as ordered for Patient #4. This had the potential to affect all patients receiving services from the facility. The census was 44.

Findings include:

1. Review of the medical records for Patients # 1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 revealed all had Patient Safety Observation forms in the hard medical record. The record reviews further revealed all of these forms had inconsistent documentation of these checks being performed every two hours.

In an interview on 07/20/2016 at approximately 8:30 AM, Staff C stated it is the Facility's process to place all patients on Safety Observation Checks every two hours. The Facility had no policy in place prior to the survey for the Safety Observation Checks process.

Review of the facility policy titled "Wound Prevention , Care and Documentation" (revised March 2015) was completed. The policy stated " If the patient presents with a wound, altered skin integrity, document your initial daily, weekly and discharge findings in the medical record....assess the wound base, edges, exudate, surrounding skin and signs and symptoms of infection with each dressing change and document any changes in the medical record".

2. Review of the medical record for Patient #4 revealed the patient was admitted to the Facility on 06/07/2016 with an abdominal incision with three open areas. The record review further revealed a physician order, dated 06/07/2016, to cleanse abdominal wound with normal saline, apply wet to moist normal saline dressings and ABD pad daily. The record review further revealed no nursing documentation in the electronic record on 06/08/2016, 06/10/2016, 06/12/2016 and 06/13/2016 of wound care being completed.
In an interview on 07/19/2016 at 11:00 AM, Staff D confirmed these findings.