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Based on medical record review, interview and policy and procedure review the facility failed to protect and promote each patient's rights. Findings include:

1. Facility failed to complete the resolution process of grievances logged. See tag A 123
2. Facility failed to ensure that the patient has the rights to refuse treatment. See tag A 131
3. Facility failed to ensure that patients are free from all forms of abuse or harassment. See tag A 145
4. Facility failed to ensure that restraint orders are signed by a physician in a timely manner, per policy. See tag A 168
5. Facility failed to ensure that restraints were not being ordered PRN (as needed). See tag A 169
6. Facility failed to ensure that each order for restraints be renewed per hospital policy. See tag A 173

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based on review of complaint/grievance reports, interview and policy and procedure review the facility failed to ensure that the patient received written notice of its decision in regards to the resolution of the grievance in 4 out of 6 (#25, #26, #27, #30) patient grievance reports reviewed. Findings include:

During review of grievance reports on 10/16/12 at approximately 1000 it was found that in patients grievances #25, #26, #27, and #30 there was no official written notice from the facility of its decision in regards to the resolution.
During an interview with Staff C on 10/16/12 at approximately 1400, when asked if there were any letters sent to these patients in regards to their grievances, she replied, "No".
During review on 10-17-12 at approximately 1000 of the policy and procedure titled, "Complaint and Grievance Process", it states, "The Director of Quality Management, along with the CEO, will prepare a written response to the patient's grievance. The written response is required whether or not a meeting was held to discuss the investigation with the patient".

Based on medical record review and grievance review the facility failed to ensure that a patient has the right to be involved in treatment, including the refusal of such treatment in 1 out of 1 (#28) medical records reviewed. Findings include:
During review of the medical record and grievance for patient #28 on 10/16/12 at approximately 1000 it was found that the patient had refused to have his Dobbhoff Tube replaced after it came out unexpectedly. In the grievance, the patient had told his wife that the "nurse" placed the tube back in even after the patient had told him "no" that he didn't want it back in. The "nurse" explained that he didn't realize the patient was saying no and he received reeducation on patient's ability to refuse treatment.

Based on patient grievance review, interview and policy and procedure review the facility failed to ensure that the patients had the right to be free from all forms of abuse in 5 out of 6 (#25, #26, #27, #28, #30) patient grievances. Findings include:
During patient #25 grievance review on 10/16/12 at approximately 1000 it was found that the patient had made the allegation of being treated intentionally cruel by being left on the toilet for an extended period of time, while the nurse visualized her crying on the toilet, left for approximately 2 hours according to grievance. The facility failed to follow its grievance policy to investigate and respond to the patient in writing in regards to the alleged abuse and the findings of the investigation.
During patient #26 grievance review on 10/16/12 at approximately 1000 it was found that the patient had made the allegation of being talked to "very rude" by the "nurse" and the "nurse moving walker roughly". The facility failed to follow its grievance policy to investigate and respond to the patient in writing in regards to the alleged abuse and the findings of the investigation.
During patient #27 grievance review on 10/16/12 at approximately 1000 it was found that the patient had made the allegation of being verbally abused by the clinical nurses assistant when patient asked for help to get off the bedpan. The facility failed to follow its grievance policy to investigate and respond to the patient in writing in regards to the alleged abuse and the findings of the investigation.
During patient #28 grievance review on 10/16/12 at approximately 1000 it was found that the patient had made the allegation of being physically abused by the "nurse" putting hands over the patient's mouth while inserting a tube. Patient didn't want tube placed, but nurse placed it in without regards to patients wish.
During patient #30 grievance review on 10/16/12 at approximately 1000 it was found that the patient's family had made the allegation that the patient was being treated with neglect. The patient was being left in the chair longer than the 2 hours that was ordered for her to be up, from approximately 0530-0900, the family was worried that the nurse didn't know how long the patient was up in the chair. The facility failed to follow its grievance policy to investigate and respond to the patient in writing in regards to the alleged abuse and the findings of the investigation.
During an interview with Staff C on 10/16/12 at approximately 1400, she agreed that the grievances were not being completed appropriately and thoroughly.
During policy and procedure review on 10/17/12 at approximately 0900 it was found in the policy titled, "Abuse, Neglect", it states under #5, protection of patients, "Any allegation of abuse or neglect by an employee must result in removal of the patient from potential of further abuse. Any employee involved in such an accusation, will be suspended with pay and instructed not to come to the hospital, until the investigation is completed and the matter resolved".

Based on medical record review, interview and policy and procedure review the facility failed to ensure that orders for restraints were being obtained by a physician within a timely manner in 3 out of 3 (#6, #7, #15) restrained patients charts reviewed. Findings include:
During review of patient medical record #6 on 10/15/12 at approximately 1300 it was found that the patient was in bilateral mitt restraints. From 9/11/12 thru 10/13/12 there were 11 restraint orders not signed within 24 hours. There were 24 restraint orders received by verbal order by the nurse, a verbal order should only be taken upon initiation of restraints, the physician should be evaluating patient daily to write the order for continuation of restraints.
During review of patient medical record #7 on 10/15/12 at approximately 1300 it was found that the patient was in bilateral soft wrist restraints. From 9/28/12 thru 10/14/12 there were 9 restraint orders not signed within 24 hours. There were 10 restraint orders received by verbal order by the nurse, a verbal order should only be taken upon initiation of restraints, the physician should be evaluating patient daily to write the order for continuation of restraints.
During review of patient medical record #15 on 10/15/12 at approximately 1300 it was found that the patient was in bilateral mitt restraints. From 8/4/12 thru 8/10/12 there were 6 restraint orders not signed within 24 hours. There were 4 restraint orders received by verbal order by the nurse, a verbal order should only be taken upon initiation of restraints, the physician should be evaluating patient daily to write the order for continuation of restraints.
During an interview with Staff C on 10/16/12 at approximately 1400 she agreed that restraint orders are not being completed appropriately.
During policy and procedure review on 10/17/12 at approximately 1000 it was found in the policy titled, "Restraints and Seclusion", states, "A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical record on a daily bases when restraint use is clinically appropriate".

Based on medical record review and policy and procedure review the facility failed to ensure that orders for restraints were being obtained by a physician daily and not being used as PRN (as needed) orders in 1 out of 3 (#7) restrained patients charts reviewed. Findings include:
During medical record review on 10/15/12 at approximately 1300 it was found that in patient #7's medical record that restraint order sheets had been signed for 3 days in advance of the date of this survey (10/15/12). From 10/13/12-10/15/12 the orders were signed, dated and timed for 10/16/12 at 1035, which is a date one day following the review of this medical record on 10/15/12.
During policy and procedure review on 10/17/12 at approximately 1000 it was found in the policy titled, "Restraints and Seclusion", states, "The order for a restraint may never be written as a standing order or on an as needed basis (PRN)...".

Based on medical record review, interview and policy and procedure review the facility failed to ensure that orders for restraints were being obtained by a physician within a timely manner, daily in 3 out of 3 (#6, #7, #15) restrained patients charts reviewed. Findings include:
During review of patient medical record #6 on 10/15/12 at approximately 1300 it was found that the patient was in bilateral mitt restraints. From 9/11/12 thru 10/13/12 there were 11 restraint orders not signed within 24 hours. There were 24 restraint orders received by verbal order by the nurse, a verbal order should only be taken upon initiation of restraints, the physician should be evaluating patient daily to write the order for continuation of restraints.
During review of patient medical record #7 on 10/15/12 at approximately 1300 it was found that the patient was in bilateral soft wrist restraints. From 9/28/12 thru 10/14/12 there were 9 restraint orders not signed within 24 hours. There were 10 restraint orders received by verbal order by the nurse, a verbal order should only be taken upon initiation of restraints, the physician should be evaluating patient daily to write the order for continuation of restraints.
During review of patient medical record #15 on 10/15/12 at approximately 1300 it was found that the patient was in bilateral mitt restraints. From 8/4/12 thru 8/10/12 there were 6 restraint orders not signed within 24 hours. There were 4 restraint orders received by verbal order by the nurse, a verbal order should only be taken upon initiation of restraints, the physician should be evaluating patient daily to write the order for continuation of restraints.
During an interview with Staff C on 10/16/12 at approximately 1400 she agreed that restraint orders are not being completed appropriately.
During policy and procedure review on 10/17/12 at approximately 1000 it was found in the policy titled, "Restraints and Seclusion", states, "A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical record on a daily bases when restraint use is clinically appropriate".

Based on medical record review and interview the facility failed to ensure all orders were timed by the physician and/or physician assistant for 1 (#10) of 6 charts reviewed for complete orders, resulting in the potential for medical errors. Findings include:

Phone interview with patient #10's mother, on 10/17/12 at approximately 8:30 a.m., revealed that the patient's discharge did not go smoothly. The mother stated that the patient was discharged on 10/11/12, then the discharge was cancelled while in the patient was in the pharmacy retrieving out-patient medications. Review of patient #10's medical record revealed that there was an order on 10/11/12 "DC Home" and "Cancel" with no time documented for either entry on the same order block. Interview with Staff #B, on 10/17/12 at approximately 9:30 a.m., revealed that the patient's discharge was cancelled on 10/11/12, the time could not be verified. Further review of patient #10's medical record revealed that 2 of 9 orders were not timed by the physician/physician assistant.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated October 15, 2012 for Life Safety Code.

Based on observation, interview and policy review the facility failed to implement and monitor infection control practices to reduce the risk for: infection and transmission of infectious agents among the twenty nine patients served by the facility. Findings include:

On 10/15/12 at approximately 1010, during facility tour found in the medication room, a hand hygiene sink that was cluttered within the splash contamination zone, with patient care supplies, a Physician Desk Reference (blocking access to disposable hand towels), a pill crusher and a biohazard spill kit with a manufacturers expiration date of 12/2011. This medication room contained the automated medication dispense machine/cabinet/refrigerator. Staff B was asked how the nurse could perform hand hygiene before dispensing medication, with the obstructed sink given that there was not any alcohol based hand sanitizer located in the room, to which Staff B replied, "it would be difficult".

On 10/15/12 at approximately 1015, during facility tour found in the pantry a patient food refrigerator that contained food stains and residual food debris, a freezer with a large brown stain, that was dried on, a microwave that had a large brown food stain on the bottom of the rotating glass, storage cabinets with residual food/liquid stains, and undersink storage of two opened cereal boxes. Staff B was asked about who was responsible for the maintenance and cleaning of the room to which he replied "I'm not sure I think that housekeeping is.... it (the pantry) needs some attention."

On 10/15/12 at approximately 1120 observed Staff H perform a blood glucose test, in a contact isolation room. Staff H performed the test and removed the glucometer (test machine) out of the contact isolation room without wiping it down. Staff H was asked what the policy was for cleaning the glucometer, to which she replied "we clean it once a day and sooner if it is visibly dirty". Staff H was asked whether the machine should be sanitized after removing from a contact isolation room, to which she replied "Oh, I forgot".

On 10/17/12 at approximately 1100, observed two respiratory therapy carts, containing respiratory therapy equipment and patient care (respiratory) medications. Both carts, one each on each side of the two unit corridors, had black stained tape holding together parts of the top surfaces of the carts. Staff O was asked how often these carts are cleaned and how the carts can be adequately sanitized with the layered black stained tape, to which he replied "I honestly don't know".

On 10/15/12 at approximately 1500, during a tour of the pharmacy area, revealed floor storage of medications marked "returns", the presence of two personal beverages and an apple in the pharmacy area where medication are compounded, stored and dispensed, two fans one facing the compounding hood and the other behind a computer screen, each fan contained visible dust, a cardboard box containing intravenous bags stored on the floor in front of the compounding hood, two unused vials of antibiotic and visible dust in the corners behind the hood, half-full needle-boxes (unmounted) stored on the floor in front of the compounding hood and visible and falling dust debris when a finger was swiped over the top of the compounding hood. Staff I was asked about the cleaning frequency of the pharmacy area, to which she replied that "we are cleaned daily, the hood is maintained every six months, and we are really tight for space here, so we don't have a lot of storage room". Staff I was asked whether she thought that the congestion on the floor allowed for thorough cleaning by the housekeeping staff to which she replied "no". Staff I was asked whether personal beverages and food are allowed in an area where medications are stored and dispensed to which she replied "no".

On 10/17/12 at approximately 1300 a review of facility policies revealed the following:
1). facility policy titled "IC VIII-1 Routine daily cleaning and disinfection" "undated" revealed the following:
All patient rooms, clinical support and ancillary areas will be cleaned daily...the clinical staff will be responsible for daily disinfection of equipment such as medication carts, wound care supply carts...".
2). facility policy titled "Policy IC VIII-10 General Sanitation" that was "undated" revealed "...Horizontal surfaces, work areas, hallways, service areas, and lounges shall be kept clean and uncluttered from unnecessary supplies, debris, or food..."
3). facility policy titled "IC VIII-4 Standard Precautions" "undated" revealed the following: .."work place" eating and drinking areas: Staff will not eat, drink, or apply cosmetics or lip balm in areas defined as the work place. The work place at Select Specialty Hospital is defined as the patient's room, care and treatment areas, lab specimen collection and storage areas, patient care areas, the laboratory, nurses' station and/or other areas where blood and other potentially infected material could contaminate the workplace...".
4). facility policy titled "IC VIII-4 Equipment Cleaning" "undated" revealed the following: : Whenever possible, there will be not shared equipment. Each patient will have their own thermometer, sphygmomanometer. If non-disposable cuffs are used, the cuff will be disinfected at discharge or transfer. When not possible (Weights, glucose monitoring, etc, certain respiratory equipment, etc) a sleeve device will be used or the equipment will be disinfected after use by the clinical staff, immediately after use...".