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Based on the Life Safety Code Validation survey, completed on April 22, 2014, the Condition of Physical Environment is not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey (B4OE21).

Based on document review and interview the facility failed to provide a written response to a complaint/grievance for one of one patient listed in the facility's complaint log and in the survey sample. (Patient #30)

The findings included:

Review of Patient #30's electronic medical record (EMR) was conducted at 1:56 p.m. on April 15, 2014. Patient #30 was admitted to the facility on January 23, 2014 and expired on March 13, 2014.

Review of the Case management entry dated February 3, 2014 documented Patient #30's family voiced concerns related to nursing and respiratory care provided to the patient.

An interview was conducted on April 16, 2014 at 3:44 p.m., with Staff 2 and Staff #5. Staff #2 reviewed the facility's documents with the surveyor. The documentation revealed Patient #30's family had delivered a written letter to the person identified in a complaint. Staff #2 reported a meeting had been set up with Patient #30's family member, but he/she canceled related to being in "an accident." Staff #2 stated, "By March 8, 2014 [Name of Patient #30's family member] had decided to remove the patient from "the vent and let [him/her] die at home. We tried to gently direct [Name of Patient #30's family member] that it was not likely [Patient #30's name] would be able to travel home." Staff #2 and the surveyor reviewed the complaint log. The facility documented in their complaint log that Patient #30's family's complaint had been resolved. Although documented as resolved, the facility had not met with Patient #30's family related to the written concerns presented to facility staff on February 19, 2014. The surveyor requested to review the complaint investigation and resolution letter sent to Patient #30's family member. Staff #2 stated, "I didn't see this as a grievance and I didn't send a letter."

An interview was conducted on April 17, 2014 at 2:28 p.m., with Staff #3. Staff #3 verified receipt of the written complaint from Patient #30's family. Staff #3 reported the investigation and notification of the complaint results were generally handled by Staff #2.


Review of the facility's policy titled "Patient Complaint and Grievance Process" read in part: "Patient Complaint: Grievance: Any expression of dissatisfaction (written or verbal) related to an occurrence within [Name of the facility], which is of such severity that it is not able to be resolved to the satisfaction of the complainant at a department level by the staff present. Complaints that require further investigation, further action for resolution, or are postponed for later resolution are considered grievances ... 6. A written complaint is always considered a grievance ... 12. [The name of the facility]... A written response is sent to the complainant upon resolution of the grievance ... [sic.]"

Based on clinical record reviews, document reviews and interviews, the facility failed to have consent/authorization for treatment signed at admission for 6 of 31 sampled patients (Patient #7, 14, 21, 26, 27 and 31).

The findings include:

1. On 04/15/2014, a review of Patient #7's electronic medical record (EMR) revealed the patient had been admitted to the facility on 04/08/2014 with decubitus ulcer, hip. Patient #7's "Consent to Treat" form was signed by the patient on 04/09/2014 at 3:00 p.m. The record failed to contain evidence the consent was signed at admission.

2. On 04/15/2014, a review of Patient #14 EMR revealed the patient had been admitted to the facility on 03/07/2014 with acute respiratory failure. Patient #14's "Consent to Treat" form was signed by the patient on 03/10/2014 at 10:30 a.m. The record failed to contain evidence the consent was signed at admission.

3. On 04/15/2014, a review of Patient #21 EMR revealed the patient had been admitted to the facility on 04/08/2014 with acute respiratory failure. Patient #21's "Consent to Treat" form was signed by the patient on 04/09/2014 at 2:50 p.m. The record failed to contain evidence the consent was signed at admission.

On 04/15/2014 at 3:30 p.m., Staff #2 and Staff #3 were interviewed related to the agency's policy and procedure for the admission process. Both were asked to provide the survey team with a copy of the agency's policy regarding completing admission forms.

On 04/16/2014 at 8:00 a.m., Staff #2 provided the survey team with a copy of the agency's Policy and Procedure titled "Patient Admission Process." The policy read in part: "Patient admissions are based upon documented consent, accurate billing and payment information and completed timely. The procedures help ensure that the appropriate legal representative is identified, consent for the admission is obtained; patient information is collected and entered correctly into the HMS system......Ensure that all fields are completed on admission documents and that the documents are signed by the patient/representative upon admission and notify supervisor when signatures cannot be obtained."

On 04/16/2014 at 3:55 p.m., Staff #17 was interviewed related to the findings found in the clinical record reviews. Staff #17 acknowledged the "Consent to Treat" will be given to the patient or power of attorney (POA) by the Clinical Liaison prior to admission or a verbal consent to treat will be obtained via phone call to the patient or POA prior to arrival to the hospital and witnessed by two (2) persons. If a patient is unable to sign due to mental/medical status a note should be documented in the patient's record and a reason the patient's representative or POA was late signing the required forms. Staff #17 acknowledged there is no evidence contained in the records regarding the consents not being signed at admission.



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4. Review of Patient #26's Electronic medical record (EMR) and paper medical record was conducted at 10:10 a.m. on April 16, 2014. Patient #26 was admitted to the facility on January 31, 2014 and discharged from the facility on February 09, 2014. The review did not revealed admission consents, informed consents, consent for treatment, rights, or other admission documents. Patient #26's EMR documented the patient was alert, oriented and capable of signing his/her admission documents at the time of admission.

An interview was conducted on April 16, 2014 at approximately 10:28 a.m., with Staff #5. Staff #5 review Patient #26's medical records with the surveyor. Staff #5 verified Patient #26's closed discharge chart did not contain admission documents and consents. Staff #5 acknowledged the patient's EMR did not have scanned copies of the patient's admission consents and documentation of rights. Staff #5 stated, "I'll check with HIM (Health Information Management) to see if there is a thinned chart." A second request for additional information was made at approximately 9:46 a.m. on April 17, 2014. The facility did not provide the surveyor with additional information prior to the survey exit on April 17, 2014.

5. Review of Patient #27's EMR and paper medical record was conducted on April 16, 2014 at 11:58 a.m., with Staff #5. Patient #27's EMR documented the patient had been admitted to the facility on January 03, 2014 and discharged on February 12, 2014. Review of the admission documents, consents for treatment, informed consents, and rights were signed by the patient and dated January 06, 2014. Patient #27's EMR documented the patient was alert, oriented and capable of signing his/her admission documents at the time of admission.

An interview was conducted on April 16, 2014 at approximately 12:02 p.m., with Staff #5. Staff #5 review Patient #27's medical records with the surveyor. Staff #5 verified that Patient #27 had signed his/her admission documents three days after admission to the facility. Staff #5 stated, "If a patient comes in after hours the nursing staff is to notify the supervisor. Generally the admission paperwork is signed at the time of admission but on occasion later." Staff #5 acknowledged the facility had provided treatment without the patient's consent for treatment and without the patient signing the necessary paperwork at the time of admission.

6. An interview was conducted on April 15, 2014 at approximately 10:37 a.m., Patient #31. Patient #31 informed the surveyor his/her admission paperwork had not been signed at the time of admission. Patient #31 stated, "I came in on Friday and I didn't sign my consents until Monday. So, I was not provided a copy of my patient's rights until Monday."

A review of Patient #31's EMR was conducted at approximately 11:00 a.m. on April 15, 2014. Patient #31's EMR did not contain scanned copies of his/her admission documents, consent for treatment, or documentation of rights receipt. Patient #31's EMR documented the patient's admission to the facility as being April 11, 2014. Patient #31's EMR documented the patient was alert, oriented and capable of signing his/her admission documents at the time of admission.

An interview was conducted on April 15, 2014 at approximately 11:18 a.m., with Staff #5. Staff #5 reported paper documents were kept in a separate paper file. Staff #5 and the surveyor reviewed Patient #31's paper medical record on the unit. The review revealed Patient #31 had signed his/her admission consents and admission documents on Monday April 14, 2014, which was three (3) days after his/her actual admission to the facility.

Based on document review and interview the facility failed to document on a consistent basis the reason for restraints for one of one patient's that was in restraints and in the survey sample, (Patient #30).

The findings included:

Review of Patient #30's electronic medical record (EMR) was conducted at 1:56 p.m. on April 15, 2014. Patient #30 was admitted to the facility on January 23, 2014 and expired on March 13, 2014. Review of Patient #30's EMR and paper medical record revealed "Restraint Order and Flow Record: Medical" sheets dated from February 1, 2014 through February 11, 2014 and February 15, 2014 to February 17, 2014. Review of Patient #30's "Restraint Order and Flow Record: Medical" sheets revealed on:

February 2, 2014- The patient was in bilateral "Soft limb" restraints and Day shift- did not document the "Precipitating/Continued Reason for Restraints" and any "Comfort" interventions provided to Patient #30.

February 3, 2013-The patient was in bilateral "Soft limb" restraints and Day shift- did not document the "Comfort" interventions provided to Patient #30. The Night shift failed to document "Precipitating/Continued Reason for Restraints."

February 4, 2014- The patient was in bilateral "Mitt" restraints. Both the Day shift and Night shift failed to document the "Precipitating/Continued Reason for Restraints."

February 5, 2014-The patient was in bilateral "Soft limb" restraints. The Day shift failed to indicate whether "Patient Specific Interventions" (treatments, diversional activities, comfort measures or "Other") were performed. Nursing failed to include in Patient #30's care plan whether the restraints were discontinued, continued, or "Other" outcomes.

February 6, 2014-The patient was in bilateral "Soft limb" restraints. The Night shift failed to document "Precipitating/Continued Reason for Restraints."

February 7, 2014-The patient was in bilateral "Soft limb" restraints. The Day shift failed to include in Patient #30's care plan whether the restraints were discontinued, continued, or "Other" outcomes.

February 8, 2014-The patient was in bilateral "Soft limb" restraints. The Night shift failed to include in Patient #30's care plan whether the restraints were discontinued, continued, or "Other" outcomes.

February 9, 2014-The patient was in bilateral "Soft limb" restraints. The Day shift and Night shift failed to indicate that staff provided "Comfort" measures for Patient #30.

February 10, 2014- The patient was in bilateral "Soft limb" restraints and Day shift did not document the performance of "Comfort" measures and restraints as part of the plan of care. The Night shift failed to document the Patient #30's "Precipitating/Continued Reason for Restraints."

February 11, 2014-The patient was in bilateral "Soft limb" restraints. The Night shift failed to indicate whether "Patient Specific Interventions" (treatments, diversional activities, comfort measures or "Other") were performed.

February 16, 2014-The patient was in bilateral "Soft limb" restraints. The Night shift failed to indicate whether staff provided "Comfort" measures for Patient #30.

February 17, 2014-The patient was in bilateral "Soft limb" restraints. The Night shift failed to document the Patient #30's "Precipitating/Continued Reason for Restraints." The Night shift failed to indicate whether "Patient Specific Interventions" (treatments, diversional activities, comfort measures or "Other") were performed. Nursing failed to include in Patient #30's care plan whether the restraints were discontinued, continued, or "Other" outcomes.

An interview was conducted at 2:46 p.m. on April 15, 2014 with Staff #5. Staff #2 and the surveyor review Patient #30's medical records. Staff #5 stated, "The restraint order and flow sheet forms are not complete."

Based on observations, document review and interview the facility failed to maintain a system to prevent the spread of infections with portable radiology equipment moved between three patient rooms (two patients were on contact precautions) without disinfecting the equipment between patients.

The findings included:

Observations conducted on the units from 9:55 a.m. to 10:25 a.m. on April 15, 2014 revealed Staff #15 moved portable radiology equipment between patients on "Contact Precautions" and non-precaution patients.

An observation conducted at 9:55 a.m. on April 15, 2014 revealed Staff #15 rolled the portable x-ray equipment into a room to perform a radiological image, the patient was on contact precautions. Staff #15 removed an imaging cassette enclosed in a plastic bag from the bin of the portable radiology equipment. Staff #15 placed the bagged cassette under the patient in contact with the patient's clothing and bed linens. Post the imaging procedure, Staff #15 removed the plastic bag from the imaging cassette and placed the cassette on the room floor by the door. After removing his/her personal protective equipment (PPE); Staff #15 picked-up the imaging cassette from the floor and placed it in the bin of the portable radiology equipment. Staff #15 did not wipe down the imaging cassette prior to placing it in the bin. Staff #15 did not disinfect the portable radiology equipment prior to entering the next room.

An observation conducted on April 15, 2014 at 10:05 a.m., Staff #15 entered the second room. The patient was also on "Contact Precautions." Using the same manner, Staff #15 retrieved a bagged cassette from the bin of the portable radiology equipment. Staff #15 utilized the imaging cassette, placing it in contact with the patient's clothing and bed linens. Once the imaging procedure was completed, Staff #15 removed the imaging cassette from the plastic bag and set the cassette on the floor near the door of the patient's room. After removing his/her personal protective equipment (PPE); Staff #15 picked-up the imaging cassette from the floor and placed it in the bin of the portable radiology equipment. Staff #15 did not wipe down the imaging cassette prior to placing it in the bin. Staff #15 did not disinfect the portable radiology equipment prior to entering the next room.

An observation conducted on April 15, 2014 at 10:15 a.m., Staff #15 entered the third room. This patient was not on "Contact Precautions." Using the same manner, Staff #15 retrieved a bagged cassette from the bin of the portable radiology equipment. Staff #15 utilized the imaging cassette, placing it in contact with the patient's clothing and bed linens. Once the imaging procedure was completed, Staff #15 removed the imaging cassette from the plastic bag and set the cassette on the floor near the door of the patient's room. After removing his/her personal protective equipment (PPE); Staff #15 picked-up the imaging cassette from the floor and placed it in the bin of the portable radiology equipment. Staff #15 did not wipe down the imaging cassette prior to placing it in the bin. Staff #15 did not disinfect the portable radiology equipment prior to entering the next room.

An interview was conducted on April 15, 2014 at approximately 10:25 a.m., with Staff #15. Staff #15 reported he/she wiped down the portable radiology equipment "At the start of my day. If I see something on it I wipe it down." Staff #15 acknowledged that infectious agent could be transferred without being visible to the eye. Staff #15 reported the bin in the portable radiology equipment did not have a designated clean and dirty section. Staff #15 agreed when an imaging cassette is picked-up from the floor they have come in contact with infectious agents. Staff #15 agreed by not disinfecting the imaging cassette prior to placing them in the bin the cassette would cross-contaminate the other imaging cassettes and/or the outer plastic bags. Staff #15 stated, "I'm transporting germs from one patient to the next." Staff #15 reported not being aware of the proper method or the facility's policy for disinfecting the portable radiology equipment between patients.

Review of the facility's policy titled "Cleaning/Disinfection of Reusable Equipment" read in part "Purpose: To provide clean and or disinfected patient care supplies, equipment, and environment in order to minimize the risk of hospital acquired infections through the use of such items ... Non-critical items can be decontaminated on the units where they are used ..."

Based on document review and interview the facility failed to provide evidence that written discharge instructions were provided for one of two discharged to home patients included in the survey sample. (Patient #28)

The findings included:

1. Review of Patient #28's Electronic medical record (EMR) and paper medical record was conducted at 9:40 a.m. on April 16, 2014. Patient #28 was admitted to the facility on January 07, 2014 and discharged home from the facility on January 30, 2014. The review did not reveal facility staff had provided the patient with written discharge instructions.

Review of the facility's policy titled "Discharge Planning" in part read "D. Provide patient and family/caregiver with discharge instruction sheet ... (All written instructions and prescriptions should be in layman's terms) ... E. Ask the patient and family/caregiver to verbalize understanding of the discharge instructions ... F. Have the patient and family/caregiver sign the discharge instruction sheet attesting to the receipt of the information. G. Sign and date the form, and give the original to the patient or responsible family/caregiver ..."

An interview was conducted on April 16, 2014 at approximately 9:58 a.m., with Staff #5. Staff #5 review Patient #28's medical records with the surveyor. Staff #5 verified that Patient #28's closed discharge chart did not contain evidence the patient had received written discharge instructions. Staff #5 stated, "They (the staff) are to review the discharge instructions, make a copy, have the patient or the representative sign the discharge instructions, and placed the signed copy in the medical record. I do not see one here." Staff #5 stated, "I'll check with HIM (Health Information Management) to see if there are any loose papers that have not been filed." A second request for additional information was made at approximately 9:46 a.m. on April 17, 2014. The facility did not provide the surveyor with additional information prior to the survey's exit on April 17, 2014.

Based on document reviews, clinical record reviews, and interviews it was determined the agency failed to ensure that patient care was provided according to the patient's plan of care for 7 of 31 clinical records in the survey sample (Patients #15, 19, 21, 22, 23, 24 and 31)

The findings include:

1. On 04/15/2014, a review of Patient #15's electronic medical record (EMR) revealed the patient had been admitted to the facility on 04/03/2014 with decubitus ulcer, lower back. The Plan of Care (POC) for Patient #15 revealed Occupational Therapy (OT) services ordered on 04/04/2014 for an evaluation and three (3) times a week to treat and evaluate. No OT services were conducted on the week beginning 04/04/2014. The week of 04/07/2014 - 04/12/2014, two (2) visits were documented as conducted on 04/07/2014 and 04/09/2014, when three (3) visits per week were ordered. The occupational therapist failed to follow the plan of care ordered by Patient #15's physician, and failed to alert Patient #15's physician of the need to alter the plan of care.

2. On 04/16/2014, a review of Patient #19's EMR revealed the patient had been admitted to the facility on 04/09/2014 with acute respiratory failure. The POC for Patient #19 revealed Physical Therapy (PT) services ordered on 04/10/2014 for an evaluation and five (5) times a week for balance and strengthening; OT services ordered on 04/11/2014 for an evaluation and five (5) times a week to evaluate and treat. The PT start of care date was 04/10/2014 with a PT evaluation. The week of 04/10/2014 - 04/12/2014, one (1) visit was documented when five (5) visits per week were ordered. The OT start of care date was 04/11/2014 with an OT evaluation. The week of 04/11/2014 - 04/12/2014, one (1) visit was documented when five (5) visits per week were ordered. Physical therapist and occupational therapist failed to follow the plan of care ordered by Patient #19's physician and failed to alert Patient #19's physician of the need to alter the plan of care.

3. On 04/16/2014, a review of Patient #21's EMR revealed the patient had been admitted to the facility on 04/08/2014 with acute respiratory failure. The POC for Patient #21 revealed PT services ordered on 04/09/2014 for an evaluation and five (5) times a week to evaluate and treat. The PT start of care date was 04/09/2014 with an evaluation. The week of 04/09/2014 - 04/12/2014, three (3) visits were documented as conducted on 04/09/2014, 04/10/2014 and 04/11/2014, when five (5) visits per week were ordered. The physical therapist failed to follow the plan of care ordered by Patient #21's physician, and failed to alert Patient #21's physician of the need to alter the plan of care.

4. On 04/16/2014, a review of Patient #23's EMR revealed the patient had been admitted to the facility on 03/28/2014 with ulcer, low limb. The POC for Patient #23 revealed PT services ordered on 03/31/2014 for an evaluation and three (3) times a week to evaluate and treat. The PT start of care date was 03/31/2014 with an evaluation. The week of 03/31/2014 - 04/05/2014, two (2) visits were documented as conducted on 03/31/2014 and 04/03/2014, when three (3) visits per week were ordered. The physical therapist failed to follow the plan of care ordered by Patient #23's physician, and failed to alert Patient #23's physician of the need to alter the plan of care.

The findings related to Patient #15, 19, 21 and 23's clinical record reviews were discussed with Staff #2 and Staff #4 on 04/17/2014 at approximately 9:45 a.m. Staff #4 stated there was an oversight by the agency and clarification was needed in the therapy orders and how they were written.


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5. Patient #22 (clinical record #22) was admitted to the facility on 04/08/14. Physical therapy services began on 04/09/14 with physical therapy services ordered five (5) times weekly. The week of 04/07/14 - 04/12/14, the physical therapist missed one (1) of five (5) visits ordered by the physician. The physical therapist failed to follow the plan of care ordered by Patient #22's physician, and failed to alert Patient #22's physician of the need to alter the plan of care.

6. Patient #24 (clinical record #24) was admitted to the facility on 04/01/14. Physical therapy services began on 04/02/14 with physical therapy services ordered five (5) times weekly. The week of 03/31/14 - 04/05/14, the physical therapist missed two (2) of five (5) visits ordered by the physician. The week of 04/07/14 - 04/12/14, the physical therapist missed two (2) of five (5) visits ordered by the physician. The physical therapist failed to follow the plan of care ordered by Patient #24's physician, and failed to alert Patient #24's physician of the need to alter the plan of care.

Staff #4 verified during the interview that physical therapy services were not provided as ordered for Patients #22 and #24. This interview occurred in the facility's conference room, on 04/17/14, at 09:45 a.m.



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7. An interview was conducted on April 15, 2014 at approximately 10:37 a.m., with Patient #31. Patient #31 informed the surveyor he/she had been admitted to the facility on Friday April 11, 2014. Patient #31 stated, "I was here all weekend and did nothing. They promised I would see a therapist on Sunday but nothing happened and no one came in to explain why I was not seen."

A review of Patient #31's EMR was conducted at approximately 11:00 a.m. on April 15, 2014. Patient #31's EMR contained physician's orders dated April 11, 2014 for admission and treatment. Included was a physician's order for Physical Therapy to evaluate and treat and weight bearing as tolerated. Patient #31's EMR documented the patient was alert, oriented and capable of understanding and following commands.

An interview was conducted on April 16, 2014 at 8:52 a.m., with Staff #4. Staff #4 reviewed the process for notifying the therapy department regarding physician orders for therapy. Staff #4 reviewed the therapy schedule with the surveyors. Staff #4 stated, "There was a physical therapist in house on April 13th (2014)." Staff #4 reported the therapist was qualified to perform evaluations." Staff #4 verified that Patient #31 had a physician's order for physical therapy and should have been seen Sunday April, 13, 2014.