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Based on observation, staff interview and review of records on 07/26/21, the Lakeview Specialty Hospital, Waterford, failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K211 - Means of Egress - General
2. K222 - Egress Doors
3. K345 - Fire Alarm System Testing and Maintenance
4. K915 - Electrical Systems - Essential Electrical System Categories

The cumulative effect of environment deficiencies results in the hospital's inability to ensure a safe environment for the patients.

Based on record review and interview the facility failed to ensure patient complaints/grievances are thoroughly investigated and addressed in a timely manner in 1 of 3 patient (Pt) complaints/grievances reviewed (Pt #6) in a total sample of 3 records reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Grievances, Complaints, and Advocacy Services--Hospital" last reviewed 9/20 revealed the following:
1. Patients and their representatives have the right to file grievances/complaints and or seek advocacy services.
2. A complaint that cannot be resolved at the time of complaint becomes a grievance. "At the time of complaint" is generally defined as within the shift that the complaint is made or within a timeframe acceptable to the patient or patient representative.
3. The original grievance and complaint form is forwarded to the Patient Family Representative.
4. The Patient Family Representative must review the grievance with the patient/representative within two business days of the grievance being made.
5. The Patient Family Representative or designee must investigate and resolve the patient's grievance within a reasonable period generally defined as seven days. (facility) must attempt to resolve all grievances as soon as possible.

Review of policy and procedure titled, "Conducting Internal Investigations" last revised 06/16 revealed the following:
1. The President and/or Quality Director and/or CNO (Chief Nursing Officer) will commence and/or oversee investigations on all compliance-related matters within 24 hours following notification of an event indicating a matter warranting investigation.
2. The hospital directors may delegate the investigation responsibilities but will retain ultimate supervision and responsibility for all compliance investigations. Information gathering and statements will be started by the department manager/supervisor immediately upon discovery of a compliance issue warranting investigation.
3. The investigation may include but is not limited to:
a. Reviewing and preserving documents related to the matter;
b. Interviewing appropriate individuals using the Witness Statement Form;
c. Reviewing policies and procedures applicable to the matter;
d. Collaborating with Human Resources as needed.
4. If a significant compliance violation is found, the Program Administrator will develop and implement a corrective action plan in consultation with the President and/or Quality Director and/or CNO...
5. All investigation methods and findings pursuant to the investigation must be documented using the Investigative Report Format. Copies of supporting documents should be attached to all reports.

Review of the complaint/grievance log revealed Director of Business Development P discussed Pt #6's complaints with CNO (Chief Nursing Officer) A and Administrator C on 07/13/2021 and reported Pt #6's complaints to Quality Coordinator Q and Intern R on 07/22/21. Review of the complaint log revealed on 07/12/21 Pt #6 called Director P with concerns of waiting 2 1/2 hours for dinner and was "very upset" about this situation. Pt #6 was also "worried about having another stroke" due to elevated blood pressure and indicated to Director P that his/her blood pressure was 172/110 (normal 120/80). Per complaint, Pt #6 stated his/her medications were changed and this has been a problem. Per review of the complaint log, Director P also reported that Pt #6 expressed concerns about the way Pt #6 was treated by nursing staff and CNAs (Certified Nursing Assistant). The complaint also revealed that Pt #6's mother called on 07/13/21 at 7:00 pm and was "extremely concerned and emotional about what was happening at (facility) regarding her son's blood pressure." Per complaint documentation, Pt #6 was sent out to acute care hospital on 07/13/21 at 8:55 pm via 911 for "uncontrolled hypertension and per patient request." Complaint documentation revealed that on 7/14/21 Director P spoke with ICU (Intensive Care Unit) nurse at acute care facility and indicated that Pt #6 was admitted to the Neuro ICU for a brain bleed.

Review of meeting notes revealed Director P, Quality Coordinator Q, and Intern R met on 07/22/21 (no time) to discuss Pt #6's complaint of elevated blood pressure concerns (10 days after Pt #6 contacted Director P with concerns). CNO A, Administrator C, and Compliance Director B were not listed as present for the meeting.

Per interview with CNO A on 08/4/21 at 2:00 pm, CNO A stated she/he has no documented evidence of staff investigating Pt #6's complaint in regards to Pt #6's blood pressure concerns; including but not limited to, documentation of interviewing Pt #6 about his/her concerns and documentation of interviewing the nurses and physicians involved in Pt #6's treatment. CNO A stated he/she met with Administrator C in regards to Pt #6's complaints but does not have any documentation of what was discussed. CNO A stated he/she did not investigate Pt #6's concerns with how he/she was being treated by nursing staff and CNAs because Pt #6 was unable to tell CNO A specific names of staff. CNO A stated there is no documented evidence of staff addressing Pt #6's complaint of waiting 2 1/2 hours for dinner.

Per interview with Compliance Director B and CNO A on 08/04/21 at 2:00 pm, A and B were not aware of the "Investigative Report Format" to document investigation methods and findings as per the "Conducting Internal Investigations" policy. Per CNO A complaint/grievance investigations should be completed within 7 days as per policy.

Based on record review and interview the facility failed to ensure all patient's complaint/grievances are followed up with a written response documenting the results of the complaint/grievance investigation in 1 of 3 patient (Pt)complaint's/grievances reviewed (Pt #6) in a total sample of 3 records reviewed.

Findings Include:

Review of policy and procedure titled, 'Patient Grievances, Complaints, and Advocacy Services--Hospital" last revised 09/20 revealed the following:
1. The Patient Family Representative will ensure the grievance filed is resolved to the satisfaction of the person filing the grievance within 7 days.
2. In it's resolution of the grievance, the hospital must provide the patient with the written notice of its decision, the written notice must include:
a. Hospital Contact person.
b. Steps taken on behalf of the patient to investigate the grievance
c. Results of the grievance process
d. Date of the investigation completion
e. Additional patient rights if dissatisfied with resolution

Review of Pt #6's complaint/grievance documentation revealed on 07/12/21 (no time documented) Pt #6 called Business Director P with concerns of waiting 2 1/2 hours for dinner and was "very upset" about this situation; Pt #6 was also "worried about having another stroke" due to elevated blood pressure and indicated to Director P that his/her blood pressure was 172/110 (120/80 is normal). Per complaint, Pt #6 stated his/her medications were changed and this has been a problem. Per review of the complaint log, Director P also reported that Pt #6 expressed concerns about the way Pt #6 was treated by nursing staff and CNAs (Certified Nursing Assistant). The complaint also revealed that Pt #6's mother called on 07/13/21 at 7:00 pm and was "extremely concerned and emotional about what was happening at (facility) regarding her son's blood pressure." Per complaint documentation, Pt #6 was sent out to acute care hospital on 07/13/21 at 8:55 pm via 911 for "uncontrolled hypertension and per patient request." Complaint documentation revealed that on 7/14/21 Director P spoke with ICU (Intensive Care Unit) nurse at acute care facility and indicated that Pt #6 was admitted to the Neurology ICU for a brain bleed.

Per interview with CNO (Chief Nursing Officer) A on 08/04/21 at 2:00 pm, CNO A stated he/she reviewed Pt #6's medical records in regards to Pt #6's complaints of elevated blood pressure and felt the nurses did a good job documenting the events and communicating with the physician. CNO A stated a letter was not given to Pt #6 documenting steps taken to investigate the grievance. CNO A stated he/she did not follow up with Pt #6 to ensure the grievance filed was resolved to the satisfaction of the person filing the grievance as per policy.

Per interview with Pt #6 on 08/04/21 at 12:36 pm, Pt #6 had not heard back from staff in regards to the outcome/findings of the investigation into Pt #6's negative experience with some of the CNAs and nursing staff and the situation surrounding the management of his/her high blood pressure. Pt #6 stated that if it was not for his/her advocating to be sent out to an acute care hospital he/she probably would have not survived. Pt #6 stated he/she requested a meeting with leadership and physician to address his/her complaints but the meeting never happened.

Based on record review and interview the facility staff failed to ensure that there was a physicians order for restraint every 24 hours in 4 of 5 restraint medical records reviewed (Patient #1,3,4,5) out of a total universe of 10 medical records.

Findings include:

The facility policy titled "Medical Restraint-Hospital" #14.260, last revised 01/21, revealed "RESTRAINT PROCEDURES: If use of restraint is necessary, a physician will order restraint prior to its application. Orders obtained in accordance with this policy to address a patient's medical care-related needs (safety) that are evidenced by non-violent or non-destructive behavior (non-behavioral restrain) are considered in full force and effect for up to one calendar day-which includes the day the order was obtained. For example, if a restraint is ordered on Monday the restraint ordered is current to the next calendar day (Tuesday)...-The Physician's order will reflect the specific intent for the restraint, the type of restraint, and the duration for its use, which will not exceed one calendar day...Ongoing assessment of the patient's well-being while in restraints is made hourly by the nurse. The nurse will document in the EMR (Electronic Medical Record) every two hours. Documentation will include: time, neurovascular check completed, skin integrity check, safety check, range of motion, re-assessment of restraint use, and alternative interventions."

Patient #1 was admitted to the facility on 2/11/2021 after a hospitalization following a motor vehicle accident (MVA). Patient #1 was diagnosed with a TBI (traumatic brain injury) secondary to MVA with neurocognitive (decreased mental function) deficits. Reviewed physician orders and clinical documentation from 7/3/2021-7/26/2021. On 18 out of 24 days (7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/23 & 7/25/2021) there was no physician order for restraints documented and there was nursing documentation of the restraint being in place and being checked every 2 hours.

Patient #3 was admitted to the facility on 6/25/2021 after a hospitalization following a fall. Patient #3 was diagnosed with a TBI due to a fall, status post right cranioplasty (surgical repair of a skull defect resulting from an injury). Reviewed physician orders and clinical documentation from 7/18/2021-7/26/2021. On 4 out of 9 days (7/18, 7/21, 7/23 and 7/26) there was no physician order for restraints documented and there was nursing documentation of the restraint being in place and being checked every 2 hours.

Patient #4 was admitted to the facility on 6/30/2021 after a hospitalization following a pedestrian versus MVA. Patient #4 was diagnosed with a TBI and subarachnoid hemorrhage (brain bleed). Reviewed physician orders and clinical documentation from 7/18/2021-7/23/2021. On 2 out of 9 days (7/20 and 7/23) there was no physician order for restraints documented and there was nursing documentation of the restraint being in place and being checked every 2 hours.

Patient #5 was admitted to the facility on 7/8/2021 after hospitalization for a motorcycle accident (MCA). Patient #5 was diagnosed with a TBI due MCA, status post cranioectomy for evacuation of a subdural hematoma (surgical removal of bleeding caused by trauma). Reviewed physician orders and clinical documentation from 7/18/2021-7/26/2021. On 1 out of 9 days (7/20) there was no physician order for restraints documented and there was nursing documentation of the restraint being in place and being checked every 2 hours.

During an interview on 7/28/2021 at 1:30 PM with CNO A, reviewed and confirmed that physician orders for restraints is missing for multiple dates. CNO A stated, "Since we have transitioned to our Electronic Health Record (EHR) in October of 2020 we have had problems with getting the physicians to put in the order for restraints."

Based on observation, record review, and interview the facility failed to ensure a nurse provided medications in a timely manner in 1 of 5 patient (Pt) medical records reviewed (Pt #6) in a total sample of 10 records reviewed, failed to reassess and address hypertension in 1 of 5 medical records reviewed (Pt #6) in a total sample of 10 records reviewed, failed to perform pain reassessments after providing interventions in 2 of 5 medical records reviewed (Pt #7, 12) in a total sample of 10 records reviewed, failed to ensure Certified Nursing Assistants (CNA) monitor patients on Intensive Supervision in 1 of 2 Patients observed on Intensive Supervision (Pt #1) in a total sample of 10 records reviewed, and failed to provide interventions to prevent skin breakdown in 2 of 5 medical records reviewed (Pt #8, 12) in a total sample of 10 records reviewed.

Findings Include:

Review of the policy and procedure titled, "Standard Administration Times" last revised 03/20 revealed "Medications must be administered within 60 minutes of their scheduled administration time unless otherwise specified (60 minutes prior to or after the scheduled administration time)."

Review of Pt 6's History and Physical dated 06/11/21 at 5:24 pm revealed Pt #6 was admitted on 06/11/21 at 10:15 am for continued rehabilitation status post cerebral vascular accident with acute/subacute infarcts in brain bilaterally. Per History and Physical Pt #6 was diagnosed with right sided hemiplegia (paralysis of one side of the body), Seizures, Hypertension, and End Stage Renal Disease.

Review of Pt #6's Medication Administration record revealed the nurse administered the following medications more than 60 minutes after scheduled medication administration ordered time:
-08/01/21 Hydralazine (Blood Pressure 'BP' lowering medication) due at 2:00 pm, not given until 3:40 pm.
-07/31/21 Hydralazine due at 2:00 pm, not given until 3:13 pm
-07/29/21 Clonidine (BP lowering medication) due at 3:00 pm, not given until 4:53 pm.
-07/21/21 Clonidine due at 3:00 pm, not given until 4:19 pm.
-07/25/21 Hydralazine due at 2:00 pm, not given until 4:19 pm
-07/12/21 Renvela (phosphorus binder) due at 5:00 pm, not given until 7:32 pm
-07/12/21 Clonidine due at 3:00 pm, not given until 4:11 pm.

Review of Pt #6's Medication Administration record revealed there was no documented evidence of the nurse administering Pt #6 the following medications as per physician orders:
-07/28/21 Fosrenol (Phosphorus binder) due at 5:00 pm.
-07/28/21 Procrit (treats anemia) due at 5:00 pm.
-07/12/21 Lactase (lactose intolerance) due at 5:00 pm.
-07/12/21 Amlodipine (BP lowering medication) due at 4:05 pm.
-07/11/21 Amlodipine due at 12:10 pm.

Review of Pt #6's BP log revealed Pt #6's BP was 182/100 (120/80 normal) on 06/14/21 at 8:34 pm. Review of Pt #6's Medication Administration record revealed Pt #6 was given Carvedilol (BP lowering medication) at 8:34 pm. Per review of nursing progress notes dated 06/14/21, there was no evidence of a RN assessing Pt #6 for of signs and symptoms of hypertension and rechecking Pt #6's BP to ensure the medication intervention was effective.

Review of Pt #6's BP log revealed Pt #6's BP was 170/104 on 07/11/21 at 2:28 pm. Review of Pt #6's Medication Administration record revealed Pt #6 received Clonidine at 3:00 pm. Per review of nursing progress notes dated 07/11/21, there was no evidence of a RN assessing Pt #6 for signs and symptoms of hypertension and rechecking Pt #6's BP to ensure the medication intervention was effective.

Review of Pt #6's BP log revealed on 07/11/21 at 11:00 pm Pt #6's BP was 172/98. Review of Pt #6's Medication Administration record revealed Pt #6 received Amlodipine (BP lowering medication) on 07/11/21 at 11:00 pm. Per review of nursing progress notes dated 07/11/21, there was no evidence of a RN assessing Pt #6 for signs and symptoms of hypertension and rechecking Pt #6's BP to ensure the medication intervention was effective.

Per review of Pt #6's BP log, Pt #6's BP was 172/101 on 07/12/21 at 8:55 am. Review of Pt #6's Medication Administration record revealed at 8:55 am Pt #6 received Lisinopril, Carvedilol, and Clonidine to lower his/her BP. There was no evidence of staff rechecking Pt #6's BP until 3:19 pm (more than 6 hours later) at which time Pt #6's BP continued to be elevated at 170/100. Review of Pt #6's Medication Administration record revealed Pt #6 was given Clonidine at 4:11 pm. There was no evidence of staff rechecking Pt #6 BP until 8:27 pm (more than 4 1/2 hours later) at which time Pt #6 BP was still elevated at 170/100 and at 8:27 pm Pt #6 was given Clonidine, Lisinopril, and Carvedilol to lower BP. Nursing progress note dated 07/12/21 at 9:00 pm stated, "Writer checked patient BP manually was 180/110...Informed patient that I would come back at 2230 (10:30 pm) to recheck it, also that (Physicians) would talk to him tomorrow about this." Per review of the nursing progress notes dated 07/12/21, there was no evidence of a RN assessing Pt #6 for signs and symptoms of hypertension at the time of the elevated BP's and rechecking Pt #6's BP after interventions to assess if medication was effective.

Per interview with Chief Nursing Officer (CNO) A on 08/04/21 at 11:00 am, A stated that there is not a specific policy related to Hypertension and blood pressure assessments/reassessments, but if a patient's blood pressure is elevated and requires medication, CNO A would expect the RN to document an assessment of the patient and interventions provided. Per CNO A the BP should be rechecked 30 minutes after administering BP lowering medications. Per CNO A, RN's should be giving medications no later then 60 minutes after scheduled time and should document the reason a medication can not be given at scheduled time.

Review of policy and procedure titled, "Pain Management--Hospital" last revised 07/21 revealed the following:
1. At a minimum, an ongoing assessment will include the monitoring and recording of pain intensity every shift.
2. For patients with pain, reassessment of pain intensity will occur within one hour of intervention.
3. If the evaluation of the intervention indicates ineffective pain control, discussion with the physician and changes in the treatment plan should occur.

Review of Pt #7's medical record revealed Pt #7 was admitted on 02/11/21 at 3:07 pm for further rehabilitation status post having an intracerebral bleed. Review of Pt #7's pain scale assessments revealed on 02/27/21 at 12:24 pm Pt #7 had a pain rating of 10 (severe pain). Review of Pt #7's Medication Administration record revealed Pt 7's pain level was documented as a "10" and Oxycodone (pain medication) was documented as "Not given" "Given at an earlier time and is PRN (as needed)." Per review of the Medication Administration record there was no evidence of the RN giving Oxycodone earlier that day to manage Pt #7's pain. Review of Pt #7's Medication Administration record revealed no evidence of a pain intervention being provided to address Pt #7's pain rating of 10. Per review of Pt #7's pain scale documentation, Pt #7's pain rating of "10" on 02/27/21 at 12:24 pm was not reassessed by the RN until 02/28/21 at 4:45 am (more than 16 hours later) at which time Pt #7 continued to complain of pain, rating his/her pain at a "7".

Review of Pt #7's Medication Administration record revealed on 2/26/21 at 1:00 pm Pt #7 rated his/her pain level at a "5" and the RN administered Tramadol (Pain medication) at that time. Per review of the Medication Administration record, the RN did not reassess Pt #7's pain to ensure the intervention was effective until 6:38 pm (more than 5 hours later).

Review of Pt #12's History & Physical revealed Pt #12 was admitted on 5/17/21 for rehabilitation post motor vehicle accident resulting in spinal cord injury and traumatic brain injury. Review of Pt #12's Pain Medication Administration Record revealed the following:
On 06/21/21 at 9:00 pm Pt #12 received Oxycodone 10 mg PO (by mouth) for a pain rating of 6, the RN did not complete a pain reassessment until 12:48 am (3 hours & 48 minutes later).
On 06/22/21 at 8:54 pm Pt #12 received Oxycodone 10 mg PO for a pain rating of 6, the RN did not complete a pain reassessment until 10:14 pm (1 hour & 14 minutes later).
On 06/23/21 at 3:17 pm Pt #12 received Oxycodone 10 mg PO (by mouth) for a pain rating of 8, the RN did not complete a pain reassessment until 5:58 pm (2 hours & 45 minutes later).

Per Interview with CNO A on 08/04/21 at 11:00 am, CNO A stated pain reassessments should be completed within a hour after the nursing intervention is provided.

Review of policy and procedure titled "Intensive Supervision--Hospital" last revised 04/21 revealed the following nursing responsibilities:
1. Responsible for ensuring an order is in place upon initiation and at the time of discontinuation. If intensive supervision is required and there is no order, the nurse shall contact the physician for an order.
2. Ongoing assessment of the need for intensive supervision.
3. Monitoring the patient in intensive supervision.
4. Supervising the sitter
The "Intensive Supervision" policy revealed, "The sitter will not leave the sitter role except to handoff the care of the patient to the care of a treating professional, when relieved for breaks/meals/end of shift by another sitter, as delegated by the nurse or physician responsible for the care of the patient." The "Sitter" is defined as the "Individual responsible for performing the intensive supervision of a patient under the supervision of the assigned nurse."

Review of History and Physical dated 02/11/21 at 4:00 pm, revealed Patient (Pt) #1 is wheel chair bound and non-ambulatory due to traumatic brain injury secondary to a motor vehicle accident. Per review of nursing assessment dated 07/25/21 at 5:27 am, Pt #1 "has generalized weakness, bilateral foot presses weak, Pt able to propel himself slowly in wheelchair using his feet." Review of Pt #1's medical record revealed a physician order for "IS (intensive supervision) at all times" dated 07/26/21.

Per interview with Chief Nursing Officer (CNO) A on 07/26/21 at 9:15 am, Pt #1 is on intensive supervision with a sitter at all times due to aggressive and impulsive behavior.

On 07/26/21 at 11:55 am observed Certified Nursing Assistant (CNA) E obtaining clean supplies from the supply room off the hallway. Per interview with CNA E at the time of the observation, when asked where Pt #1 was located CNA E stated that Pt #1 was in the bathroom on the toilet. Per observations at that time, the door to Pt #1's bathroom was closed.

On 07/26/21 at 12:15 pm observed CNA E cleaning up and gathering supplies while Pt #1 sat in the recreation room unattended, Pt #1 was not in view of CNA E.

Per interview with CNA E on 07/26/21 at 12:00 pm, when asked what a one to one is, CNA E responded, "When you're on a one to one you stick with him (Pt #1) you don't leave him." Per interview CNA E, he/she is usually the only staff member present on the third floor. Per E the nurse comes up from the second floor "a couple times a shift" to do Pt #1's assessments and give medications but is primarily located on the second floor.

Per interview with CNO A on 07/26/21 at 12:20 pm, A stated CNA E should not leave Pt #1 unattended and that Pt #1 should be in view of staff at all times as per the intensive supervision/one to one order.

Review of policy and procedure titled, "Prevention of Skin Breakdown" last reviewed 09/20 revealed the following:
1. Admitting nurse will perform "Skin Risk Assessment" (Braden scale) on every new patient during the admission process.
2. Nurse performing assessment will notify MD (Medical Doctor) of patient's risk level, or changes to patient's skin impairments.
3. MD will order preventative interventions appropriate for risk level.
4. For patients identified at being "High Risk" (score of 10-12) the following interventions are appropriate.
a. Increase the Frequency of turning
b. Maximize remobilization
c. Protect Heels
d. Manage Moisture
e. Manage nutrition
f. Manage Friction & Shear
5. For patient identified at being "Moderate Risk" (Score 13-14) the following intervention are appropriate.
a. Turning Schedule
b. Maximize remobilization
c. Protect Heels
d. Manage Moisture
e. Manage nutrition
f. Manage Friction & Shear

Review of the "Prevention of Skin Breakdown" policy revealed, "(facility) will assess all patients for risk of skin breakdown, on admission and routinely and implement appropriate interventions to prevent skin breakdown."

Review of the policy and procedure titled, "Patient Positioning--Hospital" last reviewed 07/21 revealed, "(facility) staff will provide positioning to patients who are unable to reposition themselves." Per policy, "Patients will be repositioned at least every 2 hours. This includes repositioning patients when they are in chair in addition to patients who are in bed."

Review of Pt #12's Physical Therapy Initial Evaluation dated 05/18/21 at 5:03 pm revealed, "Pt. presents with severe weakness, muscular extensor spasms in B UE (bilateral upper extremities) and LE (lower extremities), dep (dependent) in bed mobility and transfers, and impaired balance from spinal cord from MVA (motor vehicle accident)."

Per review of Pt #12's "Patient Rounding" logs dated 06/21/21 through 06/24/21, there was no evidence that staff repositioned Pt #12 every 2 hours to prevent skin break down as per "Patient Positioning" policy.

Review of Pt #8's medical record, Pt #8 was admitted on 06/16/21 at 1:31 pm with the diagnosis of anoxic brain injury. Review of Physical Therapy note dated 06/17/21 at 9:45 am, Pt #8 behavior was "comatose" and is a "maximum assist" with bed mobility. Review of "Nursing Admit Hx (history) & Assessment dated 06/16/21 at 6:42 pm, Pt #8's Braden scale is documented as "11" per policy this score puts Pt #8 at "High Risk" of skin break down.

Per review Pt #8's nursing shift assessments dated 07/04/21 at 1:18 pm (Braden Scale 14), 07/11/21 at 4:24 pm (Braden Scale 13), 07/18/21 at 11:47 am (Braden Scale 14), and 07/23/21 at 6:49 pm (Braden Scale 9), Pt #8 was at "Moderate" and "High" risk for skin breakdown as per policy. Per review of the above nursing shift assessments, there was no documented evidence of skin interventions being provided based on Pt #8's "High Risk" and "Moderate Risk" for skin breakdown.

Per review of Pt 8's "Patient Rounding" logs on 07/22/21, 07/23/21, 07/24/21 and 07/25/21, there was no evidence that Pt #8 was repositioned every 2 hours to prevent potential skin breakdown as per "Patient Positioning" policy.

Per Interview with CNO A on 08/04/21 at 11:00 am, staff should be documenting repositioning of patients every 2 hours on the "Patient Rounding" logs. Per CNO A, the RN should be providing skin interventions when patients are at risk for skin break down and evidence of these interventions should be documented in the patient's medical record.

Based on observation, staff interview and review of records on 07/26/21, the Lakeview Specialty Hospital, Waterford, failed to construct, install, and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

1. K211 - Means of Egress - General
2. K222 - Egress Doors
3. K345 - Fire Alarm System Testing and Maintenance
4. K915 - Electrical Systems - Essential Electrical System Categories

The cumulative effect of environment deficiencies results in the hospital's inability to ensure a safe environment for the patients.

Based on observations, interview, and record reviews the facility failed to ensure staff perform hand hygiene between glove changes, change gloves when going from a dirty task to clean task on same patient, disinfect and clean reusable supplies/equipment before returning to clean area, and failed to ensure trained staff are cleaning all patient rooms daily in 5 of 5 patient observations (Pt #1, 5, 8, 9, 11).

Findings include:

Review of policy and procedure titled, "Standard Precautions and Transmission-Based Precautions" last reviewed 02/20 revealed the following:
1. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
2. Remove gloves promptly after use and perform hand hygiene before touching non-contaminated items and environmental surfaces
3. Perform hand hygiene immediately after gloves are removed, between patient contacts, before and after entering the patient rooms, and between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
4. Supplies should be handled only with clean hands or clean gloves and should be stored in a drawer/cabinet.
5. Items used in a patients room should not be returned to clean supply areas.
6. Reusable medical devices or patient equipment should be disinfected after each use to reduce the risk of transmission of microorganisms to other patients.

Review of policy and procedure titled, "Cleaning Patient/Resident Room--Occupied" last reviewed 02/20 revealed, "All patient and resident rooms will be cleaned daily."

On 07/26/21 at 9:35 am observed Registered Nurse (RN) J perform medication administration for Patient (Pt) #5. RN J entered Pt 5's room placed a pill crusher on Pt #5's bedside table and proceeded to don gloves without performing hand hygiene. RN J then proceeded to crush Pt #5's medications using the pill crusher and administered the medication via Pt #5's Gastric Tube. RN J did not clean and disinfect the pill crusher before returning it back to the Medication room.

On 07/26/21 at 10:00 am observed RN K performing Pt #9's medication administration. RN K donned gloves and entered his/her pockets with gloved hands to obtain an alcohol wipe, RN K proceeded to give a subcutaneous injection into Pt #9's abdomen. RN K did not perform hand hygiene after removing gloves and did not remove gloves and and perform hand hygiene before obtaining clean supplies. Per observations, RN K donned gloves then went into pockets to retrieve scissors and placed the scissors on Pt #9's bedside table. RN K then administered medications via Pt #9's Gastric Tube and removed gloves without performing hand hygiene. RN K did not clean and disinfect the scissors after use and before returning to the Medication room.

On 07/26/21 at 10:37 am observed CNA (Certified Nursing Assistant) L and CNA M giving Pt #8 a bed bath. CNA M cleaned stool off Pt #8's buttocks and vaginal area during the bed bath and removed gloves x3 without performing hand hygiene between glove changes. CNA M removed gloves and obtained clean supplies from the cabinet x2 without performing hand hygiene after removing gloves and before obtaining clean supplies. Per observations, CNA L removed soiled sheets and helped place clean sheets under Pt #8; CNA L did not change gloves and perform hand hygiene after removing soiled sheets and before handling clean sheets to prevent cross contamination.

Per observations on 07/26/21 at 11:09 am RN N performing wound care on Pt #11. RN N removed the old wound dressing, removed gloves, then proceeded to obtain clean gloves from the glove box without first performing hand hygiene.

On 07/26/21 at 11:30 am during a tour of the 3rd floor, observed packaging material, food, and brown and red residue on the floor in an unused patient room. Per observations of the 3rd floor, the floors were sticky throughout the hallway and patient areas.

Per interview with CNA E on 07/26/21 at 11:52 am, Pt #1 is the only patient present on the 3rd floor and CNA E was assigned one to one Intensive Supervision of Pt #1. CNA E stated, "When you're on a one to one, you stick with them (patient), you don't leave." When asked who cleans the 3rd floor patient areas, CNA E responded, "I do." When asked if he/she has had training from housekeeping/environmental services on cleaning and disinfecting patient areas, CNA E responded "No."

Per interview with Chief Nursing Officer (CNO) A on 07/26/21 at 11:46 am, CNO A stated Housekeeping cleans the 3rd floor patient areas once per week. Per CNO A housekeeping is short staffed so they have not been cleaning the 3rd floor daily.

Per interview with Housekeeping Supervisor O on 07/26/21 at 12:40 pm, O stated that the housekeeping department is currently "staff challenged" and are short 4 full time housekeeping staff. O stated patient rooms should be cleaned daily. Per interview with Supervisor O it takes approximately 3 to 4 days of training per patient area to train staff on how and what to clean; O stated that CNA E is not trained in housekeeping. Per interview with O, housekeeping staff should be completing a daily patient room cleaning checklist as evidence of cleaning specific areas in the patient rooms (i.e. door knobs, light switches, window sills, phone). When asked if staff completed a cleaning checklist for the 3rd floor, O stated that he/she was unable to find a completed cleaning checklist.