HospitalInspections.org

Based on the Life Safety Code Deficiencies cited during the survey of June 4, 2015 it was determined that the Condition of Physical Environment was not met . The findings included:

K015- Due to penetrations on the wall to the south stair tower;
K025- Due to penetrations in the smoke barrier wall to the nursing wing;
K029 - Due to various penetrations in hazardous areas;
K056 - Failure to have sprinkler protection in the walkin cooler and freezer;
K064 - Due to improper mounting a fire extinguisher;
K069- Due to failure to tag the pull station for the hod extinguishing system and failure to document on the tag for the system the most recent service;
K130 - Due to the failure to store oxygen tanks and acetylene tanks secure and in areas where the tanks were not safely stored; and
K147- Failure to provide ground fault receptacles at three locations proximal to a water source.

Based on a review of policy, procedure, and 10 patient records, patients #1, 2, 4, 6, 7, 8, and 9 received no important message related to their right to contest discharge.

An onsite survey reveals the patient information folder contained a printed form titled, " Important Medicare Part D Information to Share with You. " Another printed form stated, " Welcome to ' Medicare & You ' 2015. " On review of records, a check sheet for various information given to the patient is found which included the Part D information but no Important Message (IM) information. No information or policy was found which revealed evidence that an IM was given to any patient.

Interview with the Director of Case Management on June 10, 2015 at 11 am revealed that she was not aware of the Important Message (IM) requirement. Consequently, no patient who was of an age or status to receive the IM did receive one. Therefore, the hospital failed to meet this requirement for patient rights.

Based on a review of hospital policy, it is determined that the hospital failed to 1) differentiate between a complaint and a grievance, and therefore cannot address grievance level issues and comply with regulatory requirements; and 2) failed to inform patients of who to contact in order to file a grievance; nor 3) was there any evidence that the hospital governing body approved, took responsibility, or delegated grievance resolution duties to a Grievance Committee.

Review of the facility policy " Patient Relations Program " (policy 3000 revised 08/13) revealed in part, " Each patient needs to be aware of the patient advocate and the procedure for making a complaint. Social Service employees are designated patient advocates. " The role of the Patient Advocate in part, is to " 2. Provide Bill of Rights handbook, if applicable, " and " 3. Explain how to make a formal complaint (policy 662). Review of policy 662, revealed a title, " Patient Abuse/Patient Complaint. " This policy failed to cover the scope of possible patient grievances. Further review of the Patient Bill of Rights revealed no statement of, or direction regarding how a patient may file a grievance with the facility.

Based on review of these policies and the patient handbook information, it was revealed that the hospital failed to differentiate between a complaint and a grievance, and failed to identify and define the scope of a grievance. Further, according to policy and the patient handbook, the only way a patient would know how to file a complaint or formal abuse complaint would be by talking to the Patient Advocate.

Where patients and others involved with the patient interests should have information available at all times on how to submit a grievance, these policies and the patient handbook lack the information needed to file a grievance.

Review of the " Patient Relations Program " revealed no statement that the Governing Body approved of, took responsibility for, or delegated the responsibility of the grievance processes to a Grievance Committee.

Therefore, the hospital failed to meet regulatory requirements for; 1) establishing a grievance processes, 2) informing patients and others involved with the patient interests how to file grievance level issues, and 3) demonstrating that the governing body had any involvement in the grievance process.

Based on a review of policies and 10 patient records, it is revealed that 1) the hospital failed to inform the patient that they may identify a " Support " person; 2) the hospital failed to inform patients that they could consent to or limit visitors as they or their support person designates; and 3) the hospital failed to state that they do not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.

Review of hospital " General Information " in the Patient Booklet revealed in part, " ...In the Specialty Hospital unit, the patient ' s will be spending most of their day in rehabilitation and will not be available for visitation. With that in mind, our visitation hours in our Long Term Acute Care Hospital are 8:00 AM to 8:00 PM. " No other information is given about the rights of patients regarding visitors which fails to meet regulatory requirements.

Based on an interview with the Infection Preventionist and a tour of the main laundry area, it is revealed that laundry for 5 of 5 unit patients is commingled and washed in cold water which presents an infection control issue for those patients.

Interview with the Infection Preventionist on June 11, 2015 at approximately 9:15 am revealed that the facility has no policy for cleaning personal laundry, but that a hospital industrial machine reaches temperatures of 160 degrees and is used to clean patient laundry that is not identified as infectious. This is done as a convenience for patients.

During survey, it was identified that none of the patients currently admitted had infectious processes which would require special handling. However, observation of the industrial machine being used to wash clothing for those 5 admitted patients was observed to be washing at a temperature of 69 degrees.

Interview with the director of Maintenance at 9:30 am revealed that the industrial washing machine has never gotten to temperatures of 160 degrees, and that patient clothing some years ago was done in the washing machines on the unit which had heat boosters installed to raise the water temperatures to 160 degrees. At the time of survey, unit based washing machines were only in use to wash patient bibs.

The knowledge that patient clothing was being commingled to be washed in cold water was unknown to the Infection Preventionist who otherwise had expansive infection prevention surveillance practices. However, based on the fact that this was not identified, this regulatory requirement was not met. Prior to the close of survey, it was revealed that the hospital will for now, send all patient clothing out for cleaning until another solution is found to the problem.