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482.13 Condition of Participation: Patient's Rights is NOT MET.

Based on medical record reviews, staff interviews, personnel record review and review of facility policy and procedures, the facility did not ensure each patient's right to be free from restraints for convenience of staff, to receive care in a safe setting, have restraints used only if ordered by the physician and to have all restraints used monitored to ensure ongoing safety. The total census of the two hospital locations was 54 on 02/08/10. Please see findings at A144, A154, A167 and A168.

482.23 Condition of Participation: Nursing Services is NOT MET.

Based on observation, medical record review, and staff interview; the facility failed to ensure registered nurses supervised and evaluated the nursing care of each patient during their stay at the facility. This includes a total of 8 staff, including one physician and 16 patients. This includes not ensuring that all staff and visitors followed infection control measures posted outside patient rooms and appropriate hand washing, and that items taken into isolation rooms were properly disinfected or disposed when brought out of patient rooms. This affected Staff E, J, K, L, M, N, O and S, Patients 11,12, 18, 20, 22, 23 and 27 and patient families. The facility failed to ensure all patients with diet orders had documentation of receiving all meal trays and portions consumed. This affected Patients 6, 8, 10, and 13. The facility failed to ensure all patients were weighed and the weights recorded in the medical record per the physician's order. This affected Patients 5, 6, 8, 11, 12, and 13. The facility failed to ensure all patients with limited bed mobility were turned and repositioned at least every two hours to prevent skin breakdown. This affected Patients 8, 9, 10, 12,13, 15, 17, 18, 19, 20, and 21. Prompt incontinence care was not provided to Patient 8 on 02/08/10. Nursing staff failed to follow a physician order for intravenous Lasix ordered for Patient 9, tube feeding orders for Patient 9 and treatment of fungal dermatitis for Patient 5. Per interviews with patients, family and review of patient satisfaction surveys, call lights were not answered in a timely manner. Avoidable falls were sustained by Patients 7 and 9 and Patient 4 did not have the falls risk assessment ordered by the physician completed. Patient 13 did not have a nursing assessment completed for 9 hours after admission. The initial nursing assessment establishes the patient's baseline and must be completed in a timely manner. The facility failed to ensure Patient 6 was assisted to get out of bed during the 33 day stay in this facility. A total of 27 patients were observed and 16 patient records reviewed in the two hospital locations with a combined census of 54 on 02/08/10.


Please see A 395 RN Supervision of Nursing Care 482.23(b)(3).

Based on medical record review and staff interview, the facility failed to ensure all patients and/or next of kin were notified of the facility's policies including rights, responsibilities, and the right to file a complaint or grievance and the procedure to do so. This affected two of sixteen medical records reviewed (Patients 10 and 11). Census at the time of the survey was
33 at the Fairhill Location and 21 at the Cleveland location.

Findings include:

The medical record for Patient 10 was reviewed on 02/11/10. The patient was admitted to the facility on 02/05/10. The medical record contained diagnoses of acute pancreatitis and dementia. The medical record lacked documentation of patient or family education and orientation to the facility policies, including rights and responsibilities and the facility's grievance process. This finding was verified by Staff E on 02/11/10 at 11:20 AM.

The medical record for Patient 11 was reviewed on 02/11/10 and 02/12/10. The patient was admitted to the facility on 01/06/10. The patient had diagnoses of bacteremia, post operative infection, epilepsy, dysphagia, and mental retardation. The medical record lacked documentation of patient or family education and orientation to the facility policies, including rights and responsibilities and the facility's grievance process. This finding was verified by Staff B on 02/12/10 at 10:36 AM.

Based on medical record review and staff interview, family members appointed by Patients 5, 7 and 13 were not informed of a change in patient status and plan of care. Changes in medical status necessitated a transfer to an acute care hospital for Patient 7 and Patient 13 and a transfer to the special care unit on 3rd floor from the 2nd floor of the long term acute care hospital after a Code Blue was called for Patient 5. There were 33 patients in the Fairhill location with a capacity of 68 during the onsite survey of 02/08/10-02/12/10. Census at the Cleveland facility was 21 with a capacity for 51. A total of 16 patient records were reviewed.

Findings include:

Per medical record review on 02/10/10, Patient 5 was admitted to the Fairhill hospital location on 11/04/09 with respiratory failure, post mitral valve replacement, mitral valve endocarditis, renal failure, ventilator associated pneumonia, chronic obstructive pulmonary disease, hypertension, type 2 diabetes mellitus, congestive heart failure with 25% ejection fraction, dysphagia with percutaneous gastrostomy tube, Parkinson's Disease, severe protein calorie malnutrition and atrial fibrillation. The patient was transferred to a tertiary hospital on 01/06/10 with post traumatic pulmonary insufficiency. Per review of nurses notes written on 12/16/09 at 11:15 AM, " Code blue called. Patient transferred to special care unit bed 3." No documentation was found that the patient's physician or family were notified of the change in Patient 5's medical status or room transfer. This was confirmed on 02/10/10 in the afternoon by Staff Q, the registered nurse responsibile for tracking all code blues in the facility.

Per medical record review on 02/10/10, Patient 7 was admitted to the facility on 01/15/10 with diagnoses including renal failure, diabetes mellitus, history of trans-ischemic attack, hypertension, osteoarthritis and legal blindness. An occupational therapy assessment completed on 01/16/10 stated the patient required moderate assistance with toileting. This assessment stated Patient 7 was at risk for falls. Per an e-mail entry on 01/30/10 at 3:13 AM, Patient 7 was found between 1:00 AM-2:00 AM on 01/23/10 sitting on the floor with her/his back against the wall. The patient denied injury even though he/she fell on buttocks. Per nursing e-mail from Staff P to Staff E, the quality manager at the Fairhill location, earlier in the shift, Staff P had been aware that Patient 7 had been going back and forth to the bathroom with diarrhea. Staff P had told Patient 7 not to walk with bare feet and gave Patient 7 footies with non-skid surface to put on. When Patient 7 was found lying face down on the floor later in the shift, at approximately 2:30 AM on 01/23/10, Staff P noted that she told Patient 7 that she/he slipped because the footies were on wrong. At the time of the second fall feces were found on the bottom of the footies, night gown and various areas of the floor per nurses note on 01/23/10. Patient 7 was placed in a sitting position with assistance of three personnel and vital signs and neurological assessments were completed. A small enlarged area on the right lateral side of head was observed and the house officer was notified. Per house officer note written at 2:45 AM on 01/23/10, Patient 7 had a large knot on the back of the head and the systolic blood pressure immediately after the fall was 70. The house officer's plan was to send Patient 7 to a tertiary hospital for a CT of the head. Per a nursing entry written on 01/23/10 at 9:09 AM, " Unable to contact listed relative due to telephone number is out-of-state." This was confirmed by Staff B on 02/10/10 at 3:50 PM.

Per interview with Staff E on 02/11/10 in the afternoon, the patient did not return to the facility after the transfer.

The medical record for Patient 13 was reviewed on 02/12/10. The medical record contained documentation the patient was sent out to the hospital on 12/29/09 and admitted to an acute care hospital for emesis, abdominal distention and a possible ileus. The medical record lacked documentation the family and next of kin was notified of the transfer to the acute care hospital. This was verified by Staff B on 02/12/10 at 12:10 PM.

This deficiency substantiates an allegation contained in Complaint OH00053544.

Based on medical record review and staff interview, the hospital failed to ensure Patient 7's right to receive care in a safe setting. At the time of the onsite complaint investigation from 02//08/10, the Fairhill location had a census of 33 with a capacity of 68. A total of 16 medical records were reviewed.

Findings include:

Per medical record review on 02/10/10, Patient 7 was admitted to the facility on 01/15/10 with diagnoses including renal failure, diabetes mellitus, history of trans-ischemic attack, hypertension, osteoarthritis and legal blindness. An occupational therapy assessment completed on 01/16/10 stated the patient required moderate assistance with toileting. This assessment stated Patient 7 was at risk for falls. Per an e-mail entry on 01/30/10 at 3:13 AM, Patient 7 was found between 1:00 AM-2:00 AM on 01/23/10 sitting on the floor with her/his back against the wall. The patient denied injury even though he/she fell on buttocks. Per nursing e-mail from Staff P to Staff E, the quality manager at the Fairhill location, earlier in the shift, Staff P had been aware that Patient 7 had been going back and forth to the bathroom with diarrhea. Staff P had told Patient 7 not to walk with bare feet and gave Patient 7 footies with non-skid surface to put on. When Patient 7 was found lying face down on the floor later in the shift, at approximately 2:30 AM on 01/23/10, Staff P noted that she told Patient 7 that she/he slipped because the footies were on wrong. At the time of the second fall feces were found on the bottom of the footies, night gown and various areas of the floor per nurses note on 01/23/10. After this fall, Patient 7 was placed in a sitting position with assistance of three personnel and vital signs and neurological assessments were completed. A small enlarged area on the right lateral side of head was observed and the house office was notified. Per house officer note written at 2:45 AM on 01/23/10, Patient 7 had a large knot on the back of the head and the systolic blood pressure immediately after the fall was 70. The house officer's plan was to send Patient 7 to a tertiary hospital for a CT of the head. This was confirmed by Staff B on 02/10/10 at 3:50 PM.

Per interview with Staff E on 02/11/10 in the afternoon, the patient did not return to the facility after the transfer. No explanation was provided relating to why a bedside commode had not been provided to Patient 7, as prior to the morning of 01/23/10, the occupational therapy assessment indicated Patient 7 was at risk for falls and required assistance to walk from the bed to the bathroom. As recently as 01/19/10, according to physical therapy progress notes, Patient 7 had required hand held assistance to walk 5 feet in the room. On 01/21/10 per the physical therapy assistant (PTA) note, the patient began therapy but couldn't tolerate it. Per physical therapy progress note on 01/22/10, the patient reported pain and felt sick after minimal therapy and needed assistance from the caregiver to transfer from the wheelchair to the bed. No explanation was provided as to what had caused the diarrhea or any intervention taken as a result of the ongoing diarrhea which was at the root of why Patient 7 made multiple trips to the bathroom on 01/23/10. No explanation was provided as to why the nurse provided Patient 7 with footies to wear rather than educating Patient 7 on the need to put her/his call light on to wait for assistance to walk to the bathroom. This was confirmed on 02/11/10 in the afternoon by Staff E.

Based on personnel record, medical record review and staff interview, Staff R failed to ensure Patient 14's right to be free from physical restraint imposed as a means of convenience. A total of three patient medical records were reviewed with physical restraints of the sixteen sampled records. Census in the Fairhill location was 33 on 02/08/10 and 21 at the Cleveland location on 02/08/10.

Findings include:

Based on personnel record review on 02/11/10, Staff R, a state tested nursing assistant, was disciplined with a written warning on 11/28/09 for an incident relating to the restraining of both lower limbs of Patient 14 when there was no physician order to do so. The date of the incident is unknown as there was no information found in Patient 14's medical record regarding this incident per medical record review on 02/12/10. This was verified by Staff B on 02/12/10 in the afternoon.

Per review of the employee performance improvement form (11/28/09) on 02/11/10, "Staff R" was assigned as a sitter for Patient 14. During that time, the patient was found to be in four point restraints which were not ordered and applied by "Staff R". The charge nurse admonished "Staff R" and the restraints were removed but later one leg was restrained. Several times during the night "Staff R" was found to be on the computer at the nurse's station and to turn the volume down on the television when he was in the room. The Patient (14) removed dressings to their wounds while "Staff R" was to watch the patient". This personnel form also stated Staff R has had this concern previously discussed when he was placed in corrective action for being on the computer outside the patient's room when assigned to be a sitter on another case. The form further states, the expected level of performance is "To perform the duties of a sitter which is to watch the patient to prevent them from doing harm to themselves or others. The above action is patient abandonment and restraining a patient without an order to do so from the RN or a physician order." As confirmed by Staff D, the facility chief executive officer on 02/12/10 in the morning, there is no record of further monitoring of Staff R and Staff R remains a full time employee as of 02/12/10. Staff D also confirmed she had not been informed of this incident prior to the surveyor's review of Staff R's personnel record on 02/11/10.

Based on policy review, medical record review, and staff interview; the facility failed to ensure all restrained patients were monitored per the facility policy. This affected three of three restraint records reviewed (Patients 14, 15, and 16). Census in this long term acute care hospital location was 33 at the Fairhill location on 02/08/10 and 21 at the Cleveland location on 02/08/10.

Findings include:

The Use of Physical or Chemical Restraints policy was reviewed on 02/12/10. The policy stated the use of restraints requires a physician order and restraint orders must be renewed each calendar day. The policy stated the use of restraints must be continuously re-evaluated. Restraint observation and care provided (to include fluids offered, mental status, assistance with toileting needs, circulation and skin integrity of the restrained limb) was to be documented at a minimum of every two hours. The need to continue the use of restraints and the discontinuance of the restraint was to be documented as well. The policy also stated seclusion, four point restraints and vest restraints were not to used at this facility.

The medical record for Patient 14 was reviewed on 02/12/10. The medical record contained an order at 3:45 PM on 11/28/09 for bilateral soft wrist restraints to be applied as the patient was pulling on tubes and lines and disturbing medical equipment. The order for bilateral soft wrist restraints was renewed on 11/29/09 at 6:00 PM. The medical record contained an order for bilateral mitts to be placed on 12/05/09 at 11:55 AM. The medical record contained continued orders for the bilateral mitts on 12/06/09, 12/07/09, and 12/08/09 and an order for soft wrist restraints on 12/09/09. The medical record lacked documentation of the two hour restraint assessments from 11/28/09 at 10:02 PM to 8:00 AM on 11/29/09 and after 10:00 AM on 11/29/09. The medical record lacked documentation of the two hour restraint assessments on 12/05/09 from 5:23 PM to 8:00 PM, after 12:05 PM on 12/06/09, 12/07/09, 12/08/09, and 12/09/09. The medical record lacked documentation of the discontinuance of the use of restraints on this patient for the above mentioned dates. These findings were verified by Staff B on 02/12/10 at 3:53 PM.

The medical record for Patient 15 was reviewed on 02/12/10. The medical record contained an order at 10:45 PM for bilateral wrist restraints. The medical record contained orders for bilateral wrist restraints on 01/24/10 to 02/01/10, two orders on 02/03/10, and 02/05/10-02/07/10. The medical record lacked restraint orders on 01/23/10 and 02/02/10. The paper medical record contained a green sticker restraint order for 02/04/10 that was blank. The medical record contained documentation that restraints were used on the patient on 01/23/10, 02/02/10, and 02/04/10. The medical record lacked documentation of restraint reassessments every two hours on 01/23/10, 01/24/10, 01/30/10, 01/31/10, and 02/10/10 to 02/08/10. The medical record lacked documentation of restraint usage or reassessment from 01/25/10 to 01/29/10. The medical record documented restraints were discontinued on 02/08/10 at 11:56 AM. These findings were verified by Staff B on 02/12/10 at 5:07 PM.

The medical record for Patient 16 was reviewed on 02/12/10. The medical record contained an order at 4:30 PM on 12/16/09 to apply a soft wrist restraint to the left wrist. The medical record contained daily renewal orders for the left wrist restraint from 12/17/09 to 12/20/09. On 12/22/09 at 2:40 AM, an order was received to apply bilateral wrist restraints. On 12/24/09 at 3:55 AM, an order was written to apply bilateral wrist restraints, with a renewal order on 12/25/09, 12/27/09, and 12/28/09. The medical record lacked orders for restraints on 12/21/09 and 12/23/09. The green restraint order sticker in the physician's orders section of the paper medical record dated 12/26/09 at 7:30 AM stated no restraint ordered. The medical record lacked documentation of restraint reassessment every two hours on 12/16/09, 12/17/09, 12/18/09, 12/19/09, 12/20/09, 12/21/09, 12/22/09, 12/24/09, 12/26/09 12/27/09, and 12/28/09. The nurses notes on 12/22/09 at 6:37 PM stated restraint off. The medical record documented restraint usage on 12/21/09 and 12/26/09 even though the record lacked a physician's order. The medical record lacked documentation on 12/28/09 as to when the restraint was discontinued. This was verified by Staff B on 02/12/10 at 4:30 PM.

Based on policy review, medical record review, personnel record review and staff interview; the facility failed to ensure orders were obtained prior to applying all restraints and for all restraints used. This affected three of three restraint records reviewed (Patients 14, 15 and 16). A total of 16 medical records were reviewed at both hospital locations. Census on 02/08/10 at Fairhill was 33 and 21 at the Cleveland location on 02/08/10.

Findings include:

The Use of Physical or Chemical Restraints policy was reviewed on 02/12/10. The policy stated the use of restraints requires a physician order and restraint orders must be renewed each calendar day. The policy stated the use of restraints must be continuously re-evaluated. Restraint observation and care provided (to include fluids offered, mental status, assistance with toileting needs, circulation and skin integrity of the restrained limb) was to be documented at a minimum of every two hours. The need to continue the use of restraints and the discontinuance of the restraint was to be documented as well.

The medical record for Patient 15 was reviewed on 02/12/10. The medical record lacked restraint orders on 01/23/10 and 02/02/10. The paper medical record contained a green sticker restraint order for 02/04/10 that was blank. The medical record contained documentation that restraints were used on the patient on 01/23/10, 02/02/10, and 02/04/10. These findings were verified by Staff B on 02/12/10 at 5:07 PM.

The medical record for Patient 16 was reviewed on 02/12/10. The medical record lacked orders for restraints on 12/21/09 The green restraint order sticker in the physician's orders section of the paper medical record dated 12/26/09 at 7:30 AM stated no restraint ordered. The medical record documented restraint usage on 12/21/09 and 12/26/09 even though the record lacked a physician's order. This was verified by Staff B on 02/12/10 at 4:30 PM.

Based on personnel record review on 02/11/10, Staff R, a state tested nursing assistant, was disciplined with a written warning on 11/28/09 for an incident relating to the restraining of both lower limbs of Patient 14 when there was no physician order to do so. (The date of the incident is unknown as there was no information found in Patient 14's medical record regarding this incident). Per review of the employee performance improvement form (11/28/09) on 02/11/10, "Staff R" was assigned as a sitter for Patient 14. During that time, the patient was found to be in four point restraints which were not ordered and applied by "Staff R". The charge nurse admonished "Staff R" and the restraints were removed but later one leg was restrained with no physician order to do so.

Staff D, the facility chief executive officer, confirmed she had not been informed of this incident prior to the surveyor's review of Staff R's personnel record on 02/11/10 per interview the morning of 02/12/10.

Based on observation, medical record review, and staff interview; the facility failed to ensure registered nurses supervised and evaluated the nursing care of each patient during their stay at the facility. This includes not ensuring that all staff and visitors followed infection control measures posted outside patient rooms and appropriate hand washing, and that items taken into isolation rooms were properly disinfected or disposed when brought out of patient rooms. This affected Staff J, K, L, M, N, O and S and Patients 11,12, 18, 20, 22, 23 and 27. The facility failed to ensure all patients with diet orders had documentation of receiving all meal trays and portions consumed. This affected Patients 6, 8, 10, and 13. The facility failed to ensure all patients were weighed and the weights recorded in the medical record per the physicians order. This affected Patients 5, 6, 8, 11, 12, and 13. The facility failed to ensure all patients with limited bed mobility were turned and repositioned at least every two hours to prevent skin breakdown. This affected Patients 8, 9, 10, 12,13, 15, 17, 18, 19, 20, and 21. Prompt incontinence care was not provided to Patient 8 on 02/08/10. Nursing staff failed to follow a physician order for intravenous Lasix ordered for Patient 9, tube feeding orders for Patient 9 and treatment of fungal dermatitis for Patient 5. Per interviews with patients, family and review of patient satisfaction surveys, call lights were not answered in a timely manner. Avoidable falls were sustained by Patients 7 and 9 and Patient 9 did not have the falls risk assessment ordered by the physician completed. Patient 13 did not have a nursing assessment completed for 9 hours after admission. The initial nursing assessment establishes the patient's baseline and must be completed in a timely manner. The facility failed to ensure Patient 6 was assisted to get out of bed during the 33 day stay in this facility. A total of 27 patients were observed and 16 patient records reviewed in the two hospital locations with a combined census of 54 on 02/08/10.

Findings include:

In an interview on 02/09/10 at 10:30 AM, Staff G stated only three patients (Patients 22, 24, and 25) were able to turn and reposition themselves without assistance. All other patients required assistance to turn and reposition every two hours.

Observations were made on the second floor long term acute care hospital unit on 02/09/10 from 9:52 AM through 2:55 PM. Patients 17, 18, 15, 19, and 21 were observed lying on their backs at 9:52 AM, 11:41 AM, 1:30 PM, and 2:55 PM. Patients 20 and 10 were observed lying on their backs at 11:41 AM, 1:30 PM, and 2:55 PM. These patients did not appear to have been turned or repositioned.

Per review of Patient 9's medical record on 02/10/10, the patient was admitted on 12/11/09 at 2:34 PM with diagnoses including deconditioning status post cardiac surgery. An initial nursing assessment revealed Patient 9 was mobile with assistance and required a two person assist with pericare. The medical record was silent to evidence of turning and repositioning of this patient from 12/11/09 at 2:34 PM-12/12/09 at approximately 3:45 PM when the last nursing entry was written prior to Patient 9's transfer to a tertiary hospital with shortness of breath. This was confirmed on 02/10/10 by Staff B, the director of quality management.

At 10:56 PM on 02/09/10, a family member was observed in Patient 22's room without wearing any personal protective equipment (PPE). Signs posted on the wall outside Patient 22's room was observed to state the patient was in droplet precautions and contact precautions and listed the required PPE to wear in the patient's room. This family member was then observed to leave Patient 22's room greet, hug and kiss the cheek of Patient 26 in the hallway, then return to Patient 22's room, all without hand hygiene or wearing PPE. It was then observed that the family member of Patient 26 returned the patient to his/her room. Posted on the wall outside Patient 26's room was a sign identifying this patient on contact precautions, with the list of PPE to be worn in the room. The family member of Patient 26 was not observed to wear PPE or perform hand hygiene.

At 11:00 AM on 02/09/10,Staff J was observed to answer the call light for Patient 22. Staff J donned the appropriate PPE, assisted Patient 22, removed the PPE, washed his/her hands, then left the room carrying the patient's breakfast tray, without wearing gloves. Patient 22 was in contact and droplet precautions.

On 02/09/10 from 11:05 to 11:25 AM, Staff K was observed to change the dressing to Patient 22's back. Patient 22 was noted to be in contact and droplet precautions. Staff K donned the appropriate PPE upon entering the room. Staff K removed the dressing, removed his/her gloves, and reached out and touched the patient's arm and name band to verify his/her identification without wearing gloves. Without performing hand hygiene, Staff K put on a new pair of gloves and proceeded to clean the wound. Without changing gloves, Staff K packed the wound with normal saline moistened gauze and covered the gauze with a pre-taped dressing. Staff K, while wearing the same pair of gloves, reached under the neck of his/her protective gown, removed a green marker that was attached to his/her name badge, wrote the date and time on the new dressing, reached back under the protective gown, and reattached the green marker to his/her name badge. Staff K was not observed to clean the green marker prior to re-attaching it to his/her name badge. Staff K then removed all PPE and washed his/her hands prior to leaving the room. The bedside table, that Staff K had taken into Patient 22's room prior to the dressing change, was pushed out into the hall by Staff K as he/she was leaving the room. A dietary worker was observed to walk up to this bedside table and lean against it while talking to Patient 22. Staff K was not observed to clean the bedside table or inform the dietary worker that the bedside tray table needed to be cleaned as it had just been removed from an isolation room.

On 02/09/10 at 11:44 AM, Staff L was observed in Patient 11's room leaning on the bed's side rail talking to the patient and the patients' family member. Patient 11 was observed to be in contact precautions per the sign posted outside the patient's room. Staff L and the family member were not observed to be wearing PPE.

On 02/09/10 at 11:49 AM, Patient 23 was observed to be in droplet and contact precautions per the sign posted outside the patient's room. Family and visitors were noted in Patient 23's room without wearing PPE.

On 02/09/10 at 2:58 PM, Staff M was observed examining Patient 20 without wearing PPE. Signs posted outside Patient 20's room stated this patient was in contact and droplet precautions.

On 02/10/10 at 12:11 PM, observations were made in the patient kitchen on the second floor long term acute care hospital unit with Staff E. A plastic grocery type bag containing a plastic covered food container and a foil wrapped item was observed in the patient refrigerator. Staff E removed the bag and its contents from the refrigerator and it was observed the first name and room number for Patient 22 was written on the plastic bag. Staff E stated this refrigerator was to contain only food for patients and any food items placed in the refrigerator must contain the name and room number of the patient. When asked why a bag with food items from a patient in isolation precautions was in the refrigerator, Staff E stated he/she did not know the answer. Staff E then took these food containers and plastic bag to Staff I to inquire further. Staff I stated that patients in isolation could have food from the patient refrigerator, but once it was taken into the room it was to be disposed. Staff I took the food items to find out who had placed them in the refrigerator. At 12:11 PM, Staff I stated the plastic container of food and the foil wrapped item had been in Patient 22's room and had been thrown away. Staff I would have dietary sanitize the refrigerator and had spoken to the staff to remind them not to put anything from an isolation room in the refrigerator.

On 02/12/10 at 8:50 AM, Staff O was observed at the bedside of Patient 18 without wearing PPE within three feet of the patient. Signs posted above the bed and on the door from the hallway stated the patient was in droplet and contact precautions. These precautions requires staff to don a disposable gown and mask when within three feet of the patient.

On 02/10/10 at 9:50 AM, Staff N was observed to give medications to Patient 12. Patient 12 was in contact precautions and received all medications per gastrostomy tube. Staff N was observed to wear the required PPE while in the patient's room. Staff N was observed to remove the stethoscope from around his/her neck and shoulders and from under the protective gown while wearing gloves, and listen to the patient's abdomen to check placement of the gastrostomy tube prior to giving medications. Staff N was then observed to return the stethoscope to around his/her neck and shoulders without cleaning or disinfecting the stethoscope and gave the patient his/her medications. Staff N was observed to clean and disinfect the stethoscope after leaving the patient's room and after contaminating his/her neck and top.

On 02/08/10 at 5:52 PM, the surveyor and Staff E observed Staff S, a licensed practical nurse beside the head of the Patient 27's bed, and Patient 27's family member was seated within three feet of Patient 27. Neither were wearing PPE. A sign on the door to the hallway into the patient's room reflected the patient was in droplet precautions and when within three feet of the patient, a mask and disposable gown and gloves are to be worn. Upon leaving Patient 27's room, the surveyor asked Staff S why he/she and the patient's visitor did not have PPE on and Staff S responded, "I guess I should have" and then re-entered Patient 27's room to address the need for PPE with the visitor.

The medical record for Patient 8 was reviewed on 02/10/10 and 02/12/10. Patient 8 was admitted to the facility on 02/02/10 at 3:40 PM. The medical record contained diagnoses of acute respiratory failure, diabetes, kidney failure, a history of cancer to the stomach and colon, and a history of protein calorie malnutrition. The patient had a diet ordered. The medical record documented the patient refused breakfast on 02/07/10 and 02/09/10; and recorded the portion of lunch eaten on 02/09/10 and snacks eaten on 02/09/10 and 02/10/10. The medical record lacked any additional documentation of meals offered or consumed from 02/02/10 through 02/10/10. The medical record for Patient 8 contained orders on 02/03/10, 02/05/10, and 02/08/10 for obtaining the patient's weight before and after dialysis. The dialysis flowsheets for 02/03/10, 02/05/10, and 02/08/10 were reviewed and lacked documentation of weights. The physical therapy evaluation on 02/03/10 and the occupational therapy evaluation on 02/04/10 documented Patient 8 required minimal assistance from one person to move in bed. The nursing admission assessment on 02/02/10 lacked documentation regarding a skin assessment. The nurses note on 02/03/10 at 2:41 AM, documented a Braden scale of 15 (low risk of skin breakdown) and skin not intact, but lacked details regarding the skin breakdown. On 02/03/10 at 12:00 PM, the nurses notes contained documentation of an open denuded area under the patient's left breast (0.3 centimeters(cm) by 4.5 cm by 0.1 cm) and a purple area behind the one ear (0.5 cm by 0.5 cm) where the oxygen tubing presses against the ear. At 1:08 PM on 02/03/10, the nurses notes documented blanchable erythema to the right and left buttocks. On 02/04/10 at 4:00 PM, impaired skin integrity was added to the care plan with instructions to assist the patient to turn and reposition in bed every two hours. On 02/12/10 at 2:00 PM, the nurses notes documented the patient's buttocks remain intact with blanchable erythema. On 02/12/10 at 4:25 PM, the nurses notes listed the Braden scale to be 14, moderate risk. Review of the nurses notes revealed a lack of documentation the patient was turned and repositioned from admission on 02/02/10 through 02/04/10 at 3:04 PM. The medical record lacked documentation the patient was turned and repositioned every two hours on 02/04/10, 02/05/10, 02/06/10, 02/07/10, 02/08/10, and 02/09/10. These findings were verified by Staff E on 02/10/10 from 3:30 PM to 4:36 PM and Staff B on 02/12/10 at 5:45 PM. Per observation and interview with Patient 8 on 02/08/10 at 6:10 PM, the patient was receiving dialysis provided by a contracted company, whose staff member, a patient care technician, was seated at the entrance of the room in a chair. During an interview with Patient 8, she/he told the surveyor he/she had been incontinent of diarrhea at least 30 minutes earlier and had been told by a staff member whose identity is unknown, that she could not be turned to be cleaned up while on dialysis. When the patient care technician, Staff HH was interviewed at 6:13 PM, she denied that the patient could not be turned while on dialysis and confirmed she had made staff aware of the need to clean Patient 8 at least 30 minutes earlier and had been told the staff were passing supper trays. Per observation on 02/08/10 at 6:17 PM, Staff AA, a registered nurse entered the room to begin cleaning the patient and was joined by a nursing assistant, Staff II. When Patient 8 was turned to the side, greenish diarrhea which had developed a liquid ring on the cotton underpad was observed. Per medical record review on 02/12/10, the patient's stool was positive for Clostridium Difficile. These interviews and observations were witness by Staff E, the facility's director of quality on 02/08/10.

Per nursing notes and entries made by nursing assistants, Patient 6's dietary intake was not documented on a consistent basis. Patient 6 was admitted to the facility on 12/18/09 with post operative wound infection, parastomal hernia, renal insufficiency, diabetes mellitus, malnutrition, physical deconditioning, bladder and prostate cancer, left shoulder arthroplasty. Per initial nursing assessment on 12/18/09 Patient 6 was 69 inches tall and weighed 204.8 pounds. Per review of a laboratory report dated 12/19/09, the patient's prealbumin ( an indication of protein stores) was 14.3 with a reference of 20-40 mg/L. On 12/21/09 total protein was 5.6 with a reference of 6.4-8.2 gm/dL and albumin was 1.6 with reference values of 3.4-5.0 gm/dL. Per dietary assessment on 12/21/09, Patient 6's overall estimated Kcal/day need was 2100-2600 Kcalories with a daily protein need of 75-112 grams. An order for mechanical soft diet was considered appropriate for the patient and the patient was identified as being at high nutritional risk. Even though weights were physician ordered weekly, the next recorded weight was on 01/10/10 when it was 175.6 pounds, a loss of 29 pounds in three weeks. Review of dietary intake included in the medical record under vital signs and intake and output, indicated there was no documented record of dietary intake on 12/24/09, for lunch and dinner on 12/25/09, none for 12/26/09-breakfast on 12/29/09, none for 12/31/09-01/02/10, none for 01/04/10 and none from 01/05/10 at lunch through 01/21/10 except an entry on 01/12/10 at breakfast that he/she had refused the alternate meal and consumption of 25 % of the meal at lunch. These findings were verified by Staff B on 02/11/10 in the afternoon while Staff B assisted the surveyor in review of the computerized medical record. Per interview with Staff BB, the facility's medical director, on 02/12/10 at 5:06 PM, a contributing factor to Patient 6's decline was his/her nutritional status. The decline included a dehiscence of an abdominal wound on 01/21/10 necessitating transfer back to the tertiary hospital from which he/she came.

Per medical record review on 02/10/10, Patient 5 was admitted to the facility on 11/04/09 with diagnoses including respiratory failure, post mitral valve replacement with mitral valve endocarditis, diabetes mellitus , renal failure and severe protein calorie malnutrition and percutaneous enteral gastrostomy tube. Per review of physician order written 11/05/09, the patient was to be weighed daily. Specific dialysis orders written by a nephrologist directed staff to weigh before and after each dialysis treatment. When weights were reviewed in the medical record including the vital signs and intake and output documents and the dialysis treatment flow records, weights were not found as ordered. No weights were recorded for 11/12/09, 11/15/09, 11/18/09, 11/20/09, 11/22/09, 11/23/09, 11/25/09-11/29/09, 12/01/09, 12/05/09, 12/06/09, 12/08/09, 12/10/09, 12/12/09-12/15/09, 12/17/09, 12/19/09 and 12/20/09, 12/22/09 , 12/24/09-12/30/09, 01/02/10, 01/03/10 -01/07/10. Additionally, no post dialysis weights were recorded for 11/05/09, 11/07/09, 11/12/09, 11/19/09, 11/21/09, 11/24/09, 12/07/09, and 12/26/09. Per record review on those days, weights were either not recorded or a scale was not available. On 11/24/09 Patient 5's predialysis weight was recorded by a facility registered nurse as 149.4 kilograms or 329.37 pounds and the post was documented as 68.8 kilograms. This patient was admitted to the hospital with a weight of 172.62 pounds and the last post dialysis weight recorded prior to the patient's transfer to a tertiary hospital on 01/06/10 was obtained on 12/28/09 when it was 152.90 pounds. On tube feedings throughout the patient's stay as the primary nutritional source, the lack of weights contributed to the complexity of meeting the patient's needs and contributed to an avoidable weight loss as confirmed by Staff B on 02/10/10 at 4:35 PM. by Staff B.

The medical record for Patient 10 was reviewed on 02/11/10. The patient was admitted to the facility on 02/05/10. The medical record contained diagnoses of acute pancreatitis and dementia. The dietician documented in a dietary note on 02/08/10 at 1239 that the patient had a mechanical soft diet ordered with no documentation of meal intakes in the medical record. The dietary note also stated the patient was on total parenteral nutrition (TPN) and was only meeting 43% of calorie needs and 60% of protein needs. On 02/10/10 the nurses notes stated the patient refused breakfast. The medical record lacked documentation of any other meals offered or consumed from 02/02/10 to 02/11/10. The nursing admission assessment on 02/05/10 at 1844 noted skin intact, a Braden score of 16 (low risk for skin breakdown), limited mobility, bedfast, and unintentional weight loss. The nurses notes on 02/06/10 at 2:43 AM documented skin intact, a Braden score of 14 (moderate risk), bedfast, and very limited mobility. On 02/08/10 at 2:21 AM and 7:30 AM, the nurses notes stated the patient's skin was not intact, but lacked further information regarding the skin breakdown. The physical therapy and occupational therapy evaluations on 02/08/10 noted the patient had decreased bed mobility and required assistance to change position. The weekly wound assessment completed on 02/08/10 at 3:53 PM documented an intact surgical incision and a Stage 1 pressure ulcer to the left lateral foot below the fifth toe (2.2 cm by 1.5 cm) that was non-blanchable. The medical record lacked documentation the patient was turned and repositioned every two hours from admission on 02/05/10 through 02/08/10 at 12:00 PM. The medical record lacked documentation the patient was turned and repositioned every two hours on 02/08/10, 02/09/10, 02/10/10, and 02/11/10. These findings were verified by Staff E on 02/11/10 from 9:00 AM to 11:20 AM.

The medical record for Patient 11 was reviewed on 02/11/10 and 02/12/10. The patient was admitted to the facility on 01/06/10. The patient had diagnoses of bacteremia, post operative infection, epilepsy, dysphagia, and mental retardation. The medical record noted the patient was receiving Jevity continuously through a feeding tube. The medical record contained orders for weekly weights. On admission on 01/06/10 the medical record noted a weight of 136.80 pounds. The medical record noted a weight of 138.09 pounds on 01/10/10. The computerized medical record lacked documentation of any additional weights from 01/10/10 through 02/12/10. A paper listing of all patients and weights recorded weekly was reviewed on 02/12/10 and revealed a weight loss of greater than ten pounds during this hospital stay. The paper list documented weights of 129.6 pounds on 01/11/10, 127 pounds on 01/15/10, 135.2 pounds on 01/21/10 and 128 pounds on 02/07/10. The medical record lacked documentation of the weight loss and actions taken. These findings were verified by Staff E and G on 02/11/10 from 11:20 AM to 12:09 PM and Staff B on 02/12/10 from 10:00 AM to 10:36 AM.

The medical record for Patient 12 was reviewed on 02/11/10 and 02/12/10. The patient was admitted to the facility on 12/17/09. The medical record contained diagnoses of pressure ulcers, osteomyelitis, encephalopathy, and protein calorie malnutrition. The medical record noted the patient was receiving nothing by mouth and total parenteral nutrition (TPN) at admission. The medical record documented the patient had a gastrostomy tube placed on 01/11/10. The TPN was discontinued and the patient started receiving Promote continuously through the feeding tube on 01/13/10. Review of the admission orders in the paper chart on 12/17/09 revealed an order for weekly weights. Review of the computerized orders revealed an order for daily weights on 12/18/09 at 6:00 AM. Review of the medical record revealed weights were recorded at least weekly and sometimes daily from admission to 01/13/10 and from 01/31/10 to 02/08/10. The medical record lacked documentation of weights from 01/13/10 to 01/31/10. The patient's weight on admission on 12/17/09 was 209.1 pounds. The patient's weight on 01/13/10 was 215.2 pounds. The patient's weight on 01/31/10 was 194.08 pounds. A weight loss of 21.12 pounds, which occurred at the time the patient was changed from TPN to tube feeds. The patient's weight on 02/08/10 was 191.4 pounds. The nursing admission assessment on 12/17/09 at 6:35 PM documented four pressure ulcers and a Braden scale of 13 (moderate risk). The nurses note on 12/18/09 at 12:00 AM noted a Braden score of 12 (high risk). The weekly wound assessment completed on 12/18/09 at 11:00 AM identified five pressure ulcers and two callous' on the left foot. The medical record lacked documentation of turning and repositioning from admission on 12/17/09 through 12/21/09 at 4:48 PM. The medical record lacked documentation the patient was turned and repositioned every two hours from 12/22/09 through 01/20/10. The medical record lacked documentation the patient was turned and repositioned after 01/20/10 at 2:40 PM. to 02/12/10. These findings were verified with Staff E on 02/12/10 from 8:45 AM to 10:00 AM.

The medical record for Patient 13 was reviewed on 02/12/10. The patient was admitted to the facility on 11/24/09. The medical record contained diagnoses of abdominal pain, post operative infection, septicemia, peritoneal abscess, and gastritis. Review of the medical record revealed an order for a mechanical soft diet on 11/24/09 through 11/28/09. The medical record documented meal intake on 11/26/09 for breakfast, lunch, and dinner. The medical record lacked documentation of any other meals offered or consumed from 11/24/09 to 11/28/09. The patient was admitted to an acute care hospital from 11/28/09 to 12/04/09. When the patient was readmitted to this facility, the patient was to receive nothing by mouth, but receive TPN (total parenteral nutrition) and then subsequently tube feedings. On 02/03/10 at 3:44 PM, a nectar thickened pureed diet was ordered with orders for assistance with meals. The medical record contained documentation of breakfast intake on 02/10/10, dinner intake on 02/11/10, and that breakfast was refused on 02/12/10. The medical record lacked documentation of any other meals offered or consumed from 02/03/10 to 02/12/10. The admission orders on 11/24/09 contained an order for weekly weights. The medical record lacked documentation of weight from 11/24/09 to 11/28/09, from 12/04/09 to 12/20/09, from 01/01/10 to 01/17/10, from 01/17/10 to 01/31/10, and 01/31/10 through 02/12/10. The first documented weight for Patient 13 was 131.2 pounds on 12/20/09. The most recent weight documented for this patient was 119.8 pounds on 01/31/10, a weight loss of 11.4 pounds. These findings were verified with Staff B on 02/12/10 from 10:36 AM to 12:10 PM.

Per medical record review with the assistance of Staff B on 02/10/10, Patient 9 was admitted to the facility on 12/11/09 at 2:34 PM with physician orders written at 4:45 PM. Those orders included intravenous Lasix 40 milligrams at 9:00 AM and 2:00 PM with no parameters to hold this medication. A tube feeding order was included for Resource or its' equivalent at 45 milliliters per hour with a water flush to the percutaneous enteral gastrostomy tube of 250 milliters every 8 hours. Strict intake and output was ordered every four hours. Patient 9's condition upon admission was "guarded". Per medical record review on 02/10/10 in the medication, Lasix was not given on 12/12/09 at 9:00 AM as Staff T determined with a blood pressure of 99/62 and pulse of 58, the blood pressure was too low to administer the Lasix. There is no documented evidence Staff T notified the patient's physician that the physician order had not been implemented. Per vital signs review on 12/11/09 and 12/12/09, the patient's systolic blood pressure ranged from 135-99. At 10:03 AM on 12/12/09, Patient 9's blood pressure was documented at 110/69 by Staff T, but the Lasix was not administered until 3:30 PM on 12/12/09 when the patient's oxygen saturation was recorded at 92% when it had been between 95-100% previously. Patient 9 was transferred to a tertiary hospital at approximately 5:17 PM on 12/12/09 with rapid shallow breaths with the use of accessory muscles. These findings were verified on 02/12/10 at 10:50 AM that Staff T should have administered Patient 9's Lasix on 12/12/09 at 9:00 AM.


Per Patient 9's medical record review, on 02/10/10 the patient was admitted with a physician order for nothing by mouth and tube feeding at 45 milliliters per hour at 4:45 PM on 12/11/09. The nasogastric tube was in place upon transfer from the tertiary hospital on 12/11/09. Medical record review revealed the tube feeding was not started until approximately 8:30 PM so Patient 9 did not receive any nutrition from 2:34 PM - 8:30 PM. On 12/12/09 laboratory values for total protein was 6.1 with 6.4-8.2 gm/dL as recommended and albumin of 1.5 with a therapeutic value of 3.4-5.0 gm/dL as recommended. These findings were verified by Staff B on 02/11/10 in the afternoon.

Call lights were not answered in a timely manner per review of patient satisfaction surveys, Patient 11's family members and Patients 7 and 8. Per interview with Patient 8 on 02/08/10 at 6:13 PM, she told the surveyor she had been waiting for over 30 minutes to be cleaned of diarrhea. This was confirmed by Staff HH, the patient care technician assisting with the patient's dialysis.

Per review of a patient complaint on 02/11/10, filed by Patient 7 relating to an incident which occurred on 01/23/10 when Patient 7 fell in the room while he/she was a patient in the facility. Patient 7 stated he/she had put her/his light on because she/he had diarrhea and needed to go to the bathroom. No one came, she/he called out and still no one came. He/She went to the bathroom alone and slid on the floor due to diarrhea and hit his/her head. Patient 7 was transferred to a tertiary hospital emergency room for a CT of the head.

Per review of 28 patient satisfaction surveys from 01/10/10, 11 rated the response to call lights as "poor". Response 516062 dated 01/24/10 said it took 20 minutes for a call light to be answered. Response 515908 dated 01/26/10 remarked it took 30 minutes to answer call lights. Response 516351 on 02/09/10 stated the call light was put on to get a pain pill. The nurse turned the call light off and did not bring the pain pill.

Per interview on 02/08/10 with three of Patient 11's family members at 6:37 PM, Patient 11 who is non-verbal and unable to use the call light, has waited up to one hour to be cleaned of bowel incontinence after a family member put on the call light in Patient 11's room. Family is typically in the room visiting from 9:30 AM-8:00 PM daily and told the surveyor the patient is turned "sometimes". Per medical record review on 02/11/10, Patient 11 is unable to turn himself/herself and depends on staff for repositioning. These concerns were shared with Staff E who was present during the interview with this family.

The medical record for Patient 13 was reviewed on 02/12/10. The medical record listed an admission time of 2:20 PM on 11/24/09. At 3:10 PM on 11/24/09 the physician was called to verify the admission orders. The nursing admission assessment was not completed until 11:15 PM on 11/25/09. This was verified by Staff B on 02/12/10 at 12:10 PM.

Per medical record review on 02/12/10, Patient 6 was admitted on 12/18/09 with post operative wound infection, parastomal hernia, renal insufficiency, diabetes mellitus, malnutrition, physical deconditioning, bladder and prostate cancer and left shoulder arthroplasty. Per the occupational therapy evaluation completed on 12/21/09, Patient 6 required maximum assistance with bathing and dressing and moderate assistance with grooming. Documentation in the nurses notes/vital signs/intake and output note reflected assistance with bathing was provided on 12/21/09, 12/25/09, 12/31/09, 01/01/10,01/05/10, 01/17/10, 01/18/10 and 01/21/10. Per nursing entry on 01/13/10, the patient refused to be cleaned by staff and refuses to comply with directions. The nursing assistant entry stated, "Nurse aware." No further intervention was documented or what the status of the patient's hygiene was between 01/05/10-01/17/10 when no bathing assistance was documented. These findings were confirmed on 02/12/10 at 3:15 PM by Staff B.

An avoidable fall occurred with injury to Patient 7 on 01/23/10 per medical record review. Review of patient complaints revealed filing of a complaint with the facility by Patient 7 after staff failed to answer her/his call light for assistance to the bathroom. Per the complaint information, Patient 7 was experiencing diarrhea and sustained an unwitnessed fall on the way to the bathroom when he/she slipped on diarrhea which was on the floor. Review of Patient 7's medical record revealed a diagnosis of legal blindness and an occupational therapy evaluation dated 01/16/10 which assessed Patient 7 to need moderate assistance with toileting. These findings were confirmed on 02/10/10 by Staff B at 3:50 PM.

An avoidable fall was experienced by Patient 9 on 12/12/09 at 6:35 AM per review of Patient 9's medical record on 02/11/10. Patient 9 was admitted on 12/11/09 at 2:34 PM and the attending physician, Staff M, completed a history and physical examination at 5:00 PM. Information included in this examination included "post operative atrial fibrillation". Staff M documented that "Coumadin, an anti-coagulant was not considered in view of his ? fall risk." A nursing assessment completed on 12/11/09 at 4:46 PM by Staff T revealed the patient to be mobile with assistance with no falls risk assessment found in the nursing assessment. Nursing entries in the medical record on 12/11/09 at 10:36 PM described Patient 9 as "confused". A nursing note dated 12/12/09 at 9:38 AM included, "Found by nurse on knees along side of bed. Returned to bed with three assists. VSS. Denied pain. Exhibited ability to MAE WNL. Reoriented to time and place. Patient cleansed of observable loose brown stool. Foley catheter intact. No observable injuries noted at the time of assessment." These findings were confirmed on 02/11/10 in the afternoon by Staff B.

Per review of Patient 6's medical record on 02/10/10-02/12/10, a physician order had been written on 12/18/09 at 5:30 PM for the patient's activity level to be "up with assistance". Documentation in the medical record revealed nursing staff assisted Patient 6 to be up in the chair once during the 33 day st

Based on observations and staff interviews, the facility did not ensure that a system was in place for the identification and reporting of infections in order to prevent the spread of known infections. This relates to patients in contact or droplet isolation. Eight patients were affected, 11, 12, 18, 20, 22, 23, 26 and 27. Patient families, one physician (Staff M) and eight staff members were included, Staff E, I, J, K, L, N, O and S. Total patient census on 02/08/10 in the Fairhill location where all the following examples were observed, was 33.

Findings include:

At 10:56 PM on 02/09/10, a family member was observed in Patient 22's room without wearing any personal protective equipment (PPE). Signs posted on the wall outside Patient 22's room was observed to state the patient was in droplet precautions and contact precautions and listed the required PPE to wear in the patient's room. This family member was then observed to leave Patient 22's room greet, hug and kiss the cheek of Patient 26 in the hallway, then return to Patient 22's room, all without hand hygiene or wearing PPE. It was then observed that the family member of Patient 26 returned the patient to his/her room. Posted on the wall outside Patient 26's room was a sign identifying this patient on contact precautions, with the list of PPE to be worn in the room. The family member of Patient 26 was not observed to wear PPE or perform hand hygiene.

At 11:00 AM on 02/09/10, Staff J was observed to answer the call light for Patient 22. Staff J donned the appropriate PPE, assisted Patient 22, removed the PPE, washed his/her hands, then left the room carrying the patient's breakfast tray, without wearing gloves. Patient 22 was in contact and droplet precautions.

On 02/09/10 from 11:05 to 11:25 AM, Staff K was observed to change the dressing to Patient 22's back. Patient 22 was noted to be in contact and droplet precautions. Staff K donned the appropriate PPE upon entering the room. Staff K removed the dressing, removed his/her gloves, and reached out and touched the patient's arm and name band to verify his/her identification without wearing gloves. Without performing hand hygiene, Staff K put on a new pair of gloves and proceeded to clean the wound. Without changing gloves, Staff K packed the wound with normal saline moistened gauze and covered the gauze with a pre-taped dressing. Staff K, while wearing the same pair of gloves, reached under the neck of his/her protective gown, removed a green marker that was attached to his/her name badge, wrote the date and time on the new dressing, reached back under the protective gown, and reattached the green marker to his/her name badge. Staff K was not observed to clean the green marker prior to re-attaching it to his/her name badge. Staff K then removed all PPE and washed his/her hands prior to leaving the room. The bedside table, that Staff K had taken into Patient 22's room prior to the dressing change, was pushed out into the hall by Staff K as he/she was leaving the room. A dietary worker was observed to walk up to this bedside table and lean against it while talking to Patient 22. Staff K was not observed to clean the bedside table or inform the dietary worker that the bedside tray table needed to be cleaned as it had just been removed from an isolation room.

On 02/09/10 at 11:44 AM, Staff L was observed in Patient 11's room leaning on the bed's side rail talking to the patient and the patients' family member. Patient 11 was observed to be in contact precautions per the sign posted outside the patient's room. Staff L and the family member were not observed to be wearing PPE.

On 02/09/10 at 11:49 AM, Patient 23 was observed to be in droplet and contact precautions per the sign posted outside the patient's room. Family and visitors were noted in Patient 23's room without wearing PPE.

On 02/09/10 at 2:58 PM, Staff M was observed examining Patient 20 without wearing PPE. Signs posted outside Patient 20's room stated this patient was in contact and droplet precautions.

On 02/10/10 at 12:11 PM, observations were made in the patient kitchen on the second floor long term acute care hospital unit with Staff E. A plastic grocery type bag containing a plastic covered food container and a foil wrapped item was observed in the patient refrigerator. Staff E removed the bag and its contents from the refrigerator and it was observed the first name and room number for Patient 22 was written on the plastic bag. Staff E stated this refrigerator was to contain only food for patients and any food items placed in the refrigerator must contain the name and room number of the patient. When asked why a bag with food items from a patient in isolation precautions was in the refrigerator, Staff E stated he/she did not know the answer. Staff E then took these food containers and plastic bag to Staff I to inquire further. Staff I stated that patients in isolation could have food from the patient refrigerator, but once it was taken into the room it was to be disposed. Staff I took the food items to find out who had placed them in the refrigerator. At 12:11 PM, Staff I stated the plastic container of food and the foil wrapped item had been in Patient 22's room and had been thrown away. Staff I would have dietary sanitize the refrigerator and had spoken to the staff to remind them not to put anything from an isolation room in the refrigerator.

On 02/12/10 at 8:50 AM, Staff O was observed at the bedside of Patient 18 without wearing PPE while within three feet of the patient. Signs posted above the bed and on the door from the hallway stated the patient was in droplet and contact precautions. These precautions require staff to don a disposable gown and mask when within three feet of the patient.

On 02/10/10 at 9:50 AM, Staff N was observed to give medications to Patient 12. Patient 12 was in contact precautions and received all medications per gastrostomy tube. Staff N was observed to wear the required PPE while in the patient's room. Staff N was observed to remove the stethoscope from around his/her neck and shoulders and from under the protective gown while wearing gloves, and listen to the patient's abdomen to check placement of the gastrostomy tube prior to giving medications. Staff N was then observed to return the stethoscope to around his/her neck and shoulders without cleaning or disinfecting the stethoscope and gave the patient his/her medications. Staff N was observed to clean and disinfect the stethoscope after leaving the patient's room and after contaminating his/her neck and top.

On 02/08/10 at 5:52 PM, the surveyor and Staff E observed Staff S, a licensed practical nurse beside the head of the Patient 27's bed, and Patient 27's family member was seated within three feet of Patient 27. Neither were wearing PPE. A sign on the door to the hallway into the patient's room reflected the patient was in droplet precautions and when within three feet of the patient, a mask and disposable gown and gloves are to be worn. Upon leaving Patient 27's room, the surveyor asked Staff S why he/she and the patient's visitor did not have PPE on and Staff S responded, "I guess I should have" and then re-entered Patient 27's room to address the need for PPE with the visitor.

An interview with the infection control practitioner, staff cc, was conducted on 02/10/10 between 10:50 AM-11:20 AM revealed that PPE rounds are conducted during live rounds on a daily basis and the audits are not documented. Even though no trends were identified per review of facility acquired infections for 12/01/09-12/30/09, a total of 22 infections were determined to be facility acquired.

Based on medical record review and staff interview, the facility failed to ensure all patients receiving rehabilitation services received all treatments per physician's orders. This affected five of sixteen medical records reviewed (Patients 5, 6, 11, 12, and 13). Total census in both hospital locations on 02/08/10 was 54 with 33 at Fairhill and 21 at Cleveland.

Findings include:

The medical record for Patient 11 was reviewed on 02/11/10 and 02/12/10. The patient was admitted to the facility on 01/06/10. The patient had diagnoses of bacteremia, post operative infection, epilepsy, dysphagia, and mental retardation. The medical record contained orders on 01/15/10 for occupational therapy five times a week. The weeks of 01/17/10 and 01/24/10 lacked documentation of occupational therapy treatments. The medical record contained orders on 01/11/10 for speech therapy five times a week. The week of 01/24/10 only two speech therapy treatments were documented and the week of 01/31/10 only four speech therapy treatments were documented. These findings were verified by Staff E and G on 02/11/10 from 11:20 AM to 12:09 PM and Staff B on 02/12/10 from 10:00 AM to 10:36 AM.

The medical record for Patient 12 was reviewed on 02/11/10 and 02/12/10. The patient was admitted to the facility on 12/17/09. The medical record contained diagnoses of pressure ulcers, osteomyelitis, encephalopathy, and protein calorie malnutrition. The medical record contained orders on 12/21/09 for occupational therapy five times a week. The medical record contained documentation of occupational therapy treatments four times a week the weeks of 12/21/09 and 12/27/09. The medical record contained an occupational therapy treatment on 01/03/10 and then lacked documentation of occupational therapy treatments until 02/08/10 when the patient was re-evaluated. The medical record lacked documentation of any change in occupational therapy orders or discontinuation orders for occupational therapy. The medical record contained orders on 12/21/09 for physical therapy three times a week. The medical record contained only two physical therapy treatments the week of 01/03/10 and lacked documentation of any change in physical therapy orders for this week. These findings were verified with Staff E on 02/12/10 at 10:00 AM.

The medical record for Patient 13 was reviewed on 02/12/10. The patient was admitted to the facility on 11/24/09. The medical record contained diagnoses of Abdominal pain, post operative infection, septicemia, peritoneal abscess, and gastritis. The medical record contained orders on 11/27/09 for occupational therapy five times a week. The medical record contained only four occupational therapy treatments the weeks of 12/06/09, 12/20/09, and 01/10/10. The medical record contained only three occupational therapy treatments the weeks of 12/13/09 and 01/24/10. The medical record contained only two occupational therapy treatments the weeks of 01/03/10 and 01/17/10. The medical record lacked documentation of any occupational therapy treatments the week of 12/27/09. The medial record lacked documentation of any change in occupational therapy orders or discontinuation orders for occupational therapy. The medical record contained orders on 11/25/09 for physical therapy five times a week. The medical record contained only four physical therapy treatments the weeks of 12/13/09, 12/20/09, and 01/24/10. The medical record contained only three physical therapy treatments the weeks of 12/06/09, 01/03/10, and 01/31/10. The medical record contained only two physical therapy treatments the week of 12/27/09. The medical record lacked documentation of any physical therapy treatments the week of 01/17/10. The medical record lacked documentation of any change in physical therapy orders or discontinuation orders for physical therapy. The medical record contained an order on 12/22/10 for speech therapy five times a week. The medical record contained only two speech therapy treatments the weeks of 12/20/09 and 12/27/09. The medical record lacked documentation of any speech therapy treatments from 12/28/09 to 01/29/10. The medical record lacked documentation of any change in speech therapy orders or discontinuation orders for speech therapy from 12/22/09 to 01/29/10. These findings were verified with Staff B on 02/12/10 at 12:10 PM.

Per medical record review on 02/10/10, Patient 5 was admitted to the facility on 11/04/09 with diagnoses including respiratory failure, post mitral valve replacement with mitral valve endocarditis, renal failure, ventilator acquired pneumonia, tracheostomy, chronic obstructive pulmonary disease, hypertension, diabetes mellitus type 2, congestive heart failure with 25 % ejection fraction, percutaneous enteral gastrostomy tube, dysphagia, Parkinson's Disease, severe protein calorie malnutrition and atrial fibrillation. The patient was discharged from the facility on 01/06/10 to a tertiary hospital. Occupational therapy assessed Patient 5 on 11/05/09 and recommended treatment five times per week for bed mobility, bathing, toileting and eating. Occupational therapy sessions were completed on 11/06/09, 11/09/09, 11/13/09 and 11/18/09. Per occupational therapy progress notes, Patient 5 refused therapy on 11/10/09. No explanation was documented for why therapy was not offered on 11/11/09, 11/12/09, 11/16/09, 11/17/09 or after 11/18/09 by occupational therapy. No discharge summary was found.

These findings were verified by Staff B on 02/11/10 in the afternoon. Speech therapy was ordered for Patient 5 and an initial evaluation was conducted on 11/05/09 with prognosis for increased communication as excellent. Per review of the speech therapy evaluation on 02/11/10, the recommended frequency for therapy was five times per week. Speech therapy sessions were documented on 11/06/09, 11/13/09, 11/16/09 and 11/20/09. No discharge summary was documented and no explanation was provided as to why Patient 5 was not provided speech therapy on 11/09/09, 11/10/09, 11/11/09, 11/12/09, 11/17/09, 11/17/09, 11/18/09, 11/19/09 or after 11/20/09. This was confirmed by Staff B on 02/11/10 in the afternoon.

Per medical record review on 02/12/10, Patient 6 was admitted to the facility on 12/18/09 with diagnoses including post operative wound infection, parastomal hernia, renal insufficiency, diabetes mellitus, malnutrition, physical deconditioning, bladder and prostate cancer with ileal conduit, gout and coronary artery disease and left shoulder arthroplasty. Physician orders at admission included evaluate and treat for physical and occupational therapies. An initial occupational therapy evaluation was completed on 12/19/09 and therapy was recommended five times per week for therapeutic exercise to one or more areas to develop strength, endurance, range of motion and flexibility. Patient 6's rehabilitation potential was described as "excellent." Per occupational therapy progress notes, six therapy sessions were conducted between 12/23/09-01/04/10, instead of the nine during that time frame including 12/21/09, 12/22/09 and 12/29/09 for which a note was not found. Additionally, no reason was given for why no further occupational therapy was offered between 01/04/10-01/21/10. No discharge summary was written as confirmed on 02/11/10 by Staff B in the afternoon. Patient 6 was transferred to a tertiary hospital on 01/21/10 per medical record review.

Per physical therapy evaluation and progress notes, an evaluation was completed on 12/21/09 at 2:45 PM which recommended physical therapy five times per week for endurance training, transfer mobility and bed mobility. Rehabilitation potential was documented as "good". Per progress notes dated 12/23/09 and 01/18/10 the patient was not seen due to a scheduling conflict. No reason was given for not receiving physical therapy on 01/15/10. No discharge summary was written to document the patient's accomplishment toward previously determined goals. The patient was transferred to a tertiary hospital on 01/21/10 with the last physical therapy session performed on 01/13/10. Patient refusals were documented for 01/14/10, 01/18/10, 01/19/10, 01/20/10 and 01/21/10. These findings were confirmed on 02/11/10 by Staff B in the afternoon.

This deficiency substantiates an allegation contained in Complaint OH00053544 and Complaint OH00053700.

Based on staff interview and medical record review, Patient 9 did not receive respiratory therapy services as ordered by medical staff including chest physiotherapy (CPT), incentive spirometry and Albuterol and Atrovent inhalers. A total of 16 patient medical records were reviewed in the Fairhill and Gateway hospital locations. Census on 02/08/10 at Fairhill was 33 and 21 on 02/08/10 at Cleveland.

Findings include:

Per medical record review, including physician orders and respiratory therapy documentation, Patient 9 was admitted to the facility on 12/11/09 at 4:45 PM as a transfer from a tertiary hospital. Diagnoses included deconditioning after aortic valve surgery, aortic stenosis, mitral regurgitation, coronary artery disease, cardiogenic shock, chronic renal insufficiency, carotid artery disease, erosive esophagitis, polymyalgia rheumatica, pleural effusion, gastroesophageal reflux disease, congestive heart failure, pancreatitis, pneumonia, transient ischemic attack, ascending aorta dilatation, hypertension, chronic obstructive pulmonary disease, swallowing difficulty and progressive effort intolerance. Orders written on 12/11/09 at 4:45 PM for this 87 year old included incentive spirometry every hour and chest physiotherapy every eight hours. On the discharge summary written by the attending physician at the long term acute care hospital dated 01/15/10, the physician wrote, " Looked ill at admission with tachypnea and rales bilaterally even though other vitals were normal. Patient looks like he has deteriorated after coming over and was discharged back to 'the tertiary hospital' for further management." Patient 9 was transferred back to the tertiary hospital on 12/12/09 at 5:17 PM, after an approximately 27 hours stay at this facility.

Respiratory therapy notes revealed incentive spirometry was documented as completed on 12/11/09 at 6:41 PM and the next time on 12/12/09 at 2:20 PM for Patient 9. Chest physiotherapy ordered for every eight hours was documented as delivered on 12/12/09 at 3:20 PM only. The documented reason the incentive spirometry was not done was "therapist unavailable." Per interview on 02/12/10 between 8:40 AM-9:15 AM with Staff FF, the respiratory therapist on duty on 12/12/09, revealed it isn't unusual that she documents therapist unavailable. While initially discussing Patient 9, Staff FF did not remember the patient until information relating to the patient's need to use a percussion vest was shared and then Staff FF recalled the patient and the patient's family and that Staff BB, the facility medical director, had come to see Patient 9 on 12/12/09. Staff FF also recalled she drew an arterial blood gas sample from the radial artery and the results "reflect a patient who clinically was in distress." Per laboratory report, the arterial blood gas was drawn on 12/12/09 at 3:15 PM and the result was a PO2 of 59 with 80-100 MHG being within normal limits. The value for PCO2 was 49 with 36-45 MMHG being within normal limits and the HCO3 value was 32.5 with normal limits being 22-26 meg/L. Additionally, prior to 12/12/09 at 2:20 PM, Patient 9's pulse oximetry measured between 96-100%. On 12/12/09 at 2:20 PM Patient 9's pulse oximetry measured 92% and at 4:06 PM on 12/12/09 the pulse oximetry measured 90%. Recommended level for pulse oximetry is 95-100%. This value measures the amount of hemoglobin sites with attached oxygen. When the PO2 and oxygen saturation remain below limits, there is evidence of hypoxemia. These findings were verified on 2/12/10 at 9:00 AM by Staff FF. Staff Y, the respiratory therapy director was present during the interview with Staff FF.

Respiratory medications ordered on 12/11/09 at 4:45 PM by the physician were Albuterol aerosol every four hours as needed and Atrovent aerosol every four hours as needed. Neither were given as respiratory therapy did not feel the medications were needed, according to an interview with Staff FF on 02/12/10 between 8:40 AM-9:15 AM. After the physician evaluated Patient 9 on 12/12/09 at 12:15 PM, both respiratory medications were prescribed every four hours. There is no documentation that these medications were administered prior to the patient's transfer to a tertiary hospital at 5:17 PM on 12/12/09.

This deficiency substantiates an allegation contained in Complaint OH00053545.