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Based on observation, document review, and interview, the facility failed to ensure a clean and sanitary environment on 2 (1st floor and ground floor) of 2 patients care units to prevent the transmission of infectious diseases and hospital acquired infections. The infection control officer failed to report and document soiled and dirty areas during infection control rounds.

Refer to Tag A0749

Based on document review and interview, the facility failed to ensure the patient or the patients representative was informed of their rights in advance before providing or stopping care by signing the Important Message from Medicare (IM) within 2 days of admission in 4 (Patient #7, #8, #9, and #10) of 5 medical records reviewed.


This deficient practice had the likelihood to cause harm in all patients admitted to the facility.


Findings:


Patient #7

Patient #7 was a 60-year-old male admitted to the facility on 10/26/2020 at 9:29 PM.

A review of the Admission orders revealed Staff #11 gave a telephone order for admission on 10/26/2020 at 9:45 PM.

A review of the document titled "Important Message from Medicare" revealed Patient #7 signed the notice on 10/23/2020 at 10:25 AM.

That was 3 days prior to Patient #7 being admitted to the facility.


Patient #8

Patient #8 was an 81-year-old female admitted to the facility on 11/06/2020 at 5:05 PM.

A review of the Admission orders revealed Staff #12 gave a telephone order for admission on 11/6/2020 at 6:00 PM.

A review of the document titled "Important Message from Medicare" revealed the Power of Attorney for Patient #8 verbally signed the notice on 10/30/2020 at 2:54 PM.

That was 7 days prior to Patient #8 being admitted to the facility.


Patient #9

Patient #9 was a 62-year-old male admitted to the facility on 11/06/2020 at 11:02 PM.

A review of the Admission orders revealed Staff #12 gave a telephone order for admission on 11/6/2020 at 11:30 PM.

A review of the document titled "Important Message from Medicare" revealed Patient #9's spouse verbally signed the notice on 11/5/2020 at 10:05 AM.

That was 1 day prior to Patient #9 being admitted to the facility.


Patient #10

Patient #10 was a 66-year-old female admitted to the facility on 11/01/2020 at 10:50 PM.

A review of the Admission orders revealed Staff #11 gave a telephone order for admission on 11/1/2020 at 10:00 PM.

A review of the document titled "Important Message from Medicare" revealed Patient #10's spouse verbally signed the notice on 10/30/2020 at 10:03 AM.

That was 2 days prior to Patient #10 being admitted to the facility.


An interview was conducted with Staff #7 on 11/9/2020 after 11:00 AM. Staff #7 was asked if the Important Message from Medicare was being signed prior to a patient's admission. Staff #7 replied, "We have a policy that allows us to have consents signed 2 weeks prior to admission. Since the COVID precautions are in place we no longer go into patient's rooms to have them signed, we do verbal consents." Staff #7 was asked if the Administration Team went to other hospitals to have the consent forms signed. Staff #7 stated, "Yes we used to until COVID but now we just call on the telephone." Staff #7 was asked how she knew a patient was being admitted without an order by a physician. Staff #7 stated, "We go off the referral that we get from the referring facility. Sometimes we may not have a bed, or something may change with the patient, so they aren't actually admitted at the time of the referral." Staff #7 was asked if there was any documentation showing why the patient signed the IM letter prior to the full admission. Staff #7 said, "No we don't keep that information that is the transferring hospitals responsibility not ours."


Staff #2 and #7 confirmed the IM Letter was signed prior to patients being admitted to the facility.

Based on record review and interview, the facility failed to follow its own policy and procedure for an effective operation of the grievance process in 1 of 1(Patient #3) patient complaint reviewed.

Patient #3's wife complaint revealed, she had complained to the facility multiple times concerning the poor care her husband had received at the facility and felt that the excessive bills she had to pay due to their failure to give appropriate care was unacceptable.

Review of the complaints and grievance log revealed there was no complaint or grievance for patient #3.


An interview was conducted on 11-10-20 with Staff #1 he had presented a written complaint from Patient #3's wife on 4/30/20. Staff #1 was asked if a grievance was done on this complaint. Staff #1 stated he was just handling the financial issues of the complaint and assumed a grievance was done already. Staff #1 had no written evidence of his conversations with Patient #3's wife or responses.


An interview was conducted with Staff #2 on 11-10-20. Staff #2 stated that she did a root cause analysis (RCA) concerning the fall of Patient #3 on 11/21/19. Staff #2 stated that she did not do a grievance and properly respond back to the Patient #3's wife.


Review of the policy and procedure "Complaint and Grievances" stated,

"ADMINISTRATION POLICY AND PROCEDURE

C06-A PAGE 2 OF 3

6. If a complaint cannot be resolved timely by the Hospital staff member, it will be considered a grievance.

7. CMS 482.13(a)(2), Interpretive guidelines, defines a patient grievance as follows. See Attachment A for a complete description and examples.
A patient grievance may be a formal or informal written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.

8. The Hospital staff member shall notify his/her supervisor. The complaint/ grievance form is then forwarded to the Hospital's Director of Quality Management. The Director of Quality Management shall enter the information into Lotus. The Director of Quality Management shall notify the CEO when a grievance has been received and logged in the Lotus Notes Grievance database.

9. The Director of Quality Management and/or Chief Nursing Officer will investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's CEO. The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint. If the grievance will not be resolved or the investigation completed within 7 days, the hospital shall inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow-up with a written response in a stated number of days.

10. Once the investigation has been completed, the findings of the investigation will be discussed with the Hospital's CEO.

11. It is suggested, but not required, that once the CEO and DQM and/or CNO have reviewed the findings of the investigation and actions taken (if any), they will attempt to schedule a face to face meeting with the patient or the patient representative to discuss the findings of the investigation, when possible. If a face to face meeting is not possible, the DQM, CNO and/or CEO will contact the patient or the patient representative, to discuss the investigation and actions taken (if any).

12. The DQM, along with the CEO, will prepare a written response to the patient's or patient representative's grievance. The written response is required whether or not a meeting was held to discuss the investigation with the patient or the patient's representative."

Based on record review and interview, the facility failed to:

A. ensure the Registered Nurse (RN) properly assessed patient care needs and the patient care assignments were properly carried out.

B. ensure the RN had clear communication and/or written care interventions completed by the nurse aide before documenting care in 1 of 1(patient #3) patient charts reviewed. The facility also failed to ensure the RN had supervised and gave clear assignments for who was on the "Turn Teams" in 184 out of 184 shifts.


A. Review of Patient #3's chart revealed he was a patient from 11-9-19 to 11-24-19. Patient #3 required full assistance for all activities of daily living (ADLs). ADL's describe fundamental skills that are required to independently care for oneself such as eating, bathing, brushing teeth, shaving and mobility.

Review of the nursing notes ADL's check dated from 11-10-19 to 11-24-19 revealed the following:

Review of the nursing notes in the chart for 11-11-19, 11-12-19, 11-13-19, 11-14-19 revealed only oral care and Foley care was given on both shifts. (Day shift is from 7AM to 7PM and Nights from 7PM to 7AM.) There was no documentation that the patient was given a bath, hair washed or shaved. There was no written documentation that he refused.

11-15-19
The nurses note documented the patient was given oral care and Foley care on the night shift only. No documentation that the patient refused.

11-16-19
No ADL's were documented performed. No documentation the patient refused.

11-17-19
Only oral care and Foley care provided on night shift. No documentation that patient refused.

11-18-19
Nurse documented that all care was provided by her on the day shift including a bath and shave. No care was documented on the night shift. This was the first time that the patient was documented in having a bath in 9 days.

11-19-19
Documentation was noted on both shifts for ADL's except hair wash and shave. No documentation that he refused. The patient had a fall and injury on that day.

11-20-19/11-21-19
No ADL's charted on day shift on Foley care on night shift. No documentation he refused.

11-22-19/11-23-19
Only oral care and Foley care for day shift. No documentation that he had refused care.

11-24-19
Patient was discharged.


An interview was conducted with Staff # 8 on 11-10-20. Staff #8 confirmed that the nursing assistants did not document care provided by them. The nurses' aides are performing the ADL's daily but have nowhere to document that information. There was a sheet the aides turn into the nurses but just address the vital signs and not the patient care or turn schedules. Staff #8 confirmed that the nurse just assumed the aide had done the ADL's and that the patients were turned at the proper time.



B. An interview was conducted with Staff #2 on 11-9-20. Staff #2 reported there is a "Turn Team" that is assigned for each unit daily. An apple sign was on the doors of all the patients that required to be turned in their bed every two hours. The team consist mostly of nursing aides but can also be nurses.

The team is supposed to turn the patients every two hours who require mobility assistance in the bed to prevent bed sores. Staff #2 stated that there were no assignments on the staffing sheets of who is supposed to be on the turn team daily. Staff #2 was unable to identify who was responsible for turning the patients.

Review of the Nursing Assignment Sheets form 11-1-19 to 11-31-19 and 9-1-20 thru 10-31-20 revealed there were no assignments for the turn teams. There was no way to prove who was responsible for turning the patients.

Based on observation, document review, and interview the facility failed to ensure a clean and sanitary environment on 2 (1st floor and ground floor) of 2 patients care units to prevent the transmission of infectious diseases and hospital acquired infections. The infection control officer failed to report, and document soiled and dirty areas during infection control rounds.


A tour of the facility was conducted on 11-9-20 with Staff #1 and Staff # 2 at 10:40 am.

Physical Therapy Room

Card board boxes were found sitting on the floor full of medical supplies under the exercise table.

The equipment in the room was dusty and dirty.

The hand weights were soiled and sitting on a rack that was covered in dust and hair.

In the cabinet grooming appliance (hair dryer, combs, etc...) were found sitting in plastic buckets. The buckets were soiled with dust and hair.

Outside in the hallway, next to the physical therapy room, there was a patient hoist. Staff #1 stated it was usually stored there due to poor storage in the facility. The hoist was heavily soiled on the bottom with dirt, hair, and dust. The body of the lift was soiled with dust and dirt.


Central Bathing

The bathing room was also being used for storage of equipment. The room had floor mats stored against the wall, dynamaps, commode chairs, an open cart of medical supplies, toiletries, stacks of commode chair inserts. All the equipment was being used as clean but was visibly soiled with dust, dirt, mildew, and hair.

The floor of the room was soiled, and several broken tiles were found.

The shower chair was found to be heavily mildewed and torn. It was holding water in the pad of the seat. Under the pad, the plastic chair itself was heavily mildewed and all down the legs. A wedge cushion was found on the bottom of the shower floor and was pulled away from the floor. The cushion and the floor were found to be heavily mildewed. Trash was also found under the cushion.

The shower faucets had mildew growing around the faucets and the safety railing was broken.

Open plastic containers were found with toiletries in them that were heavily soiled with spilled soaps, unwrapped tooth brushes, trash bags, gloves, ropes, electrical cords, and packages of sterile wrap bandages. The containers were covered in dust and hair.


Patient Room Hallways on the 1st floor and Waiting Area

On the isolation room doors, there were isolation door caddies. These caddies hang from the outside of the patient room door and have plastic pockets for storage of (Personal Protection Equipment) PPE. It allows the nurse or visitor to put on PPE as needed before entering the room.

2 of 3 caddies viewed were missing items. The 1st caddy was missing gowns and the second was missing gloves.

In the waiting area was 5 chairs. One of the chairs were torn and exposing porous material. The chairs were dusty and had dried liquid spills and dried food crumbs on them.

An upright medication dispensing system was found. The outside of the cabinet, work top and key board was visibly soiled with dust. The inside of the cabinet where the mediation was stored was soiled with spilled medications. The pharmacist came and unlocked the cabinet and cleaned up the spilled medication. The pharmacist stated, it was the pharmacy staff's responsibility to keep the inside of the storage clean and stocked.

Two computer charting workstations on wheels (WOW's) were found in the hallway. Each station was heavily soiled with built up dirt, dust, and hair. Unopened syringes were found stuffed in a dirty holding container on the cart mixed with alcohol pads, black markers, trash, dust, and hair.

The baseboards going down the hallway were heavily soiled in dirt, dust, and hair.

A tilt table was found stored in the hallway. The table had vinyl on the top and it was torn all way down exposing the porous cushion underneath.

Door stops for hallway doors was recessed into the tile. The recessed area of door stop had an accumulation of dust, dirt, and debris in two of two doors.


Soiled Room

The soiled room was filled to capacity with trash and card board boxes to the ceiling. There were open trash cans exposed and old food trays with food on them. A food tray was sitting on top of a trash can. There was rolled up mattress uncovered sitting on the sink counter top and soiled fans. There was two E-cylinders sitting on the floor unsecured sitting next to the hamburger and fries.


Nutrition Room 1st floor.

This room is for preparing coffee, warming food, and storage of patient nutrition.

The microwave was found to be heavily soiled on the inside with dried liquids and food.

Drawers holding eating utensils was heavily soiled with food crumbs, dust, and hair.

Plastic bins holding condiments were found heavily soiled with debris from condiments, dust, and hair.

The metal rack holding the drinking water was rusted and heavily soiled with dirt and dust.

The cabinets holding the patient supplements (Ensure, Glucerna, Nepro) was soiled with dust and hair.

The coffee pot was sitting on a rolling cart with three drawers. The cart was heavily soiled with coffee spillage, dirt, crumbs, hair, and the wheels were rusted.

The patient refrigerator also had a freezer above. The top of the refrigerator was covered in a heavy dust. The inside of the refrigerator was dirty. There were old food crumbs, liquid spillage, dust, and hair build up. The freezer was also soiled with dust and paper trash.


Pharmacy

Inside the pharmacy at the entry door a rusted file cabinet was found.

An open cabinet was found under a countertop work area. The cabinet was missing a door and the trash container was down there with trash in it. The cabinet shelf was missing laminate and porous wood fiber board was exposed. The cabinet was soiled with dirt and dust and could not be properly cleaned due to the exposed fiber board.


Clean Medical Supply Room

Inside the clean medical supply room 4 door caddies were hanging on the wall next to supplies. Inside the caddies were opened half full boxes of gloves, hair bonnets, shoe coverings, and gowns. There was no indication that these had been cleaned and were ready to dispense. Staff #1 nor Staff #2 could determine if the caddies were clean or dirty.


Patient Room 1084

The bed frame was found to be rusted in several spots under the mattress, the door frame was missing paint, the electrical plug had been pulled away from the wall.


Patient Hallway Ground Floor

Two computer charting workstations on wheels (WOW's) were found in the hallway. Each station was heavily soiled with built up dirt, dust, and hair.

The vinyl floor molding in the wall behind the WOW was found to be peeling off the wall and was unable to be cleaned properly.

A medication crusher was found sitting on the WOW in the hallway exposed. The crusher was soiled with dust and residue.

A metal dolly was found in the hallway with a mattress rolled up on it. There was no indication if the mattress was clean or dirty.


Clean Medical Supply Storage Room- Ground Floor

There was trash and debris found under the storage racks on the floor. There was dirty and soiled computer equipment found stored next to clean medical supplies; a WOW was found in the room, visibly soiled with dust, debris, and trash in the trash can. There was broken down IV extension poles sitting on the dirty and soiled floor.

Christmas decorations, door hangers for Christmas wreaths, 2 fly swatters, and a painting were all in the clean medical supply room. These items are unable to be cleaned properly to be placed with clean medical supplies.


Dialysis Room

A dialysis machine was hooked up to the sink but was not in cleaning mode. 7 dirty wet towels were laying on the floor underneath the tubing going from the sink to the machine.

Three cabinet doors were standing open above the sink with medical supplies in them. The shelves were dirty with dust and debris. The counter top next to the soiled and dirty sink had opened medical supplies, a drinking cup with a straw, notebooks, paper, and trash stored all over the counter tops.

Tubing to the machine and a disposable filter was found lying in an open and dirty cabinet.

An employee's personal back pack was found hanging on a supply cart filled with dialysis solutions.


Respiratory Therapy Room- Ground Floor

The room upon entry was small and full of portable ventilators that had plastic over them. There were two employee desks and a set of lockers for personal items in the same area. A smaller room to the side had a very narrow walking area to get around all the equipment and could be a fire hazard. One of the exit doors leading out of the room was blocked with equipment and boxes.

10 shipping boxes full of patient supplies were found in the second room sitting on the floor and on the counters. These supplies were sitting next to sink full of food debris and liquids. Staff # 9 confirmed the employees were "bad about dumping their food and drinks in the sink." An employee's food cooler (lunch container) was found sitting on the counter next to medical supplies.

Staff # 9 was asked how he knew the medical equipment was clean in the office and ante room area. He stated they would be covered in the plastic. A random ventilator was pulled from the group and the plastic removed. The ventilator was visibly soiled. There was uncovered tubing on the cart. There was dust and debris on the base of the cart, under the monitor screen and the bottom of the cart was covered in dirt and hair. A second ventilator was pulled with the same results.

2 EKG machines were in the office area and were not covered, sitting next to the ventilators. The EKG machines were visibly soiled with dust and debris.


Patient Nutrition Room -Ground Floor

The shelves holding water were rusted and dirty.

The microwave was heavily soiled with spilled liquids and food debris. The inside was rusted.

The refrigerator freezer was dirty on the inside with dirt and hair. The inside of the refrigerated section was soiled with spilled liquids, dust, hair, and food debris.


Storage Room

A storage room was found with shelves of wrapped mattresses. The walls had subway tiles going up to the ceiling. Multiple tiles were broken or missing. The tiles were very soiled with old spillage. The floor was dusty and had multiple paper debris.


Isolation Room

The isolation room had an air flow monitor outside the door. The monitor was in alarm mode and was not working properly.

An interview was conducted in the afternoon on 11-9-20 with Staff # 2 and #9 concerning infection control and environmental cleanliness. Staff #2 and #9 had been doing environmental rounding but stated that they were not looking for cleanliness as much as what needed to be repaired. Staff #2 stated the rounding form should be updated to assist in looking for environmental cleanliness.