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Based on observation, staff interview, medical record review, and review of policies and procedures, it was determined the hospital failed to ensure wound orders were complete with a frequency, dressing changes were completed/documented as ordered, pain was managed appropriately, nursing staff verified nasogastric tube placement prior to administering instillations/irrigations, and dietary orders for meals were placed upon admissionand delivered. (A395) The cumulative effect of these systemic practices resulted in the facility's inability to ensure the safety of patients. This has the potential to affect all patients receiving services at the facility.

Based on schematic review, documentation review, observation, and interview the facility failed to ensure the identified fire rated smoke barriers were maintained, fire rating of vertical opens were maintained, self closing doors closed to latching position, hazardous area walls were maintained, hospital grade receptacles testing was completed and documented, the remote annunciator panel was located in a manned area, dampers were tested or functioning, and exit and directional signs were installed in accordance with NFPA 101. (A709) The cumulative effect of these systemic practices resulted in the facility's inability to ensure the safety of patients. This has the potential to affect all patients receiving services at the facility.

Based on medical record review, staff interview, and policy review it was determined the hospital failed to ensure wound orders were complete with a frequency, dressing changes were completed/documented as ordered, pain was managed appropriately, staff checked nasogastric tube placement prior to administering instillations/irrigations, and dietary orders for meals were placed upon admission and delivered. These findings affected four (Patient's #1, #3, #5 and #9) of thirty medical records reviewed. The active census was 61.


Findings include:


1. Review of Patient #3's medical record on 12/20/18 revealed an admission date of 12/16/18 for wound care with a diagnosis of stage four decubital ulcer to the coccyx and right ischium. Review of a physician's order dated 12/18/18 revealed an order to treat Patient #3's wounds by cleansing with normal saline, packing with clorpactin moistened gauze, cover with an ABD and secure with tape. There was no frequency included with the physician's order.

Review of the nursing wound care notes revealed on 12/18/18, wound care was documented for the coccyx once, but no care was documented for the ischium.


Interview on 12/20/18 at 2:00 PM with Staff I revealed the order is for two times a day and confirmed the nurse documented that care was provided once for the coccyx and not at all for the ischium on 12/18/18. Staff I also reviewed the medication administration for Patient #3 and confirmed the clorpactin was only documented as being pulled one time on 12/18/18.


2. Review of Patient #9's medical record revealed an admission date of 12/11/18 for post operative pelvic wound care with a diagnosis of end stage renal disease. Review of Patient #9's abdomen wound care order dated 12/11/18 revealed an order to cleanse, dry, apply moist gauze and secure with tape and a dry dressing twice a day.

Review of the medication administration record revealed the wound care order was entered for once a day.

Review of the wound care flowsheets revealed no wound care was documented on 12/13/18 or 12/19/18. In addition, from 12/11/18 through 12/18/18 wound care was documented as being provided once daily and on 12/15/18 and 12/16/18 the nurse documented that Silicone was used without an order.

This finding was verified with Staff I on 12/20/18 at 2:30 PM.

Interview on 12/20/18 at 2:30 PM with Staff F, the wound care nurse, revealed Patient #9's wound care order was supposed to be twice a day instead of once. Staff F stated, "I'm sorry it was supposed to be twice a day."

3. Review of Patient #5's medical record revealed an admission date of 12/15/18 with a diagnosis of endocarditis. Observation of medication administration on 12/18/18 at 9:44 AM with Staff E revealed the skilled nurse flushed Patient #5's nasogastric tube with water. At that time Staff E confirmed that he/she had not verified placement of the tube prior to administering the water. Staff E stated, "I flushed the nasogastric tube at 8:00 AM and we usually do it once a shift. " Staff D confirmed that placement was not obtained during the observation and prior to medication administration.


Review of the hospital policy titled, Gastric/Duodenal Tube last revised on 04/01/18 revealed staff must check tube positioning and patency prior to all instillations/ irrigations. For PEG and NG tubes aspirate gastric contents and notify the physician if gastric contents cannot be obtained.







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4. Review of Patient #1's medical record revealed an admission date of 11/01/18 at 12:53 PM. The pain assessment on admission at 1:32 PM revealed Patient #1's pain was a nine out of 10 at the surgical incision site of the abdomen. A physician order was received on 11/01/18 at 3:27 PM for Oxycodone five milligrams and was given at 3:38 PM.


Review of Patient #1's medical record revealed he/she was admitted with orders for Oxycodone (narcotic) five milligrams by mouth every six hours as needed; 11/02/18 Oxycodone was increased to 10 milligrams every six hours as needed; 11/08/18 Oxycodone was increased to 15 milligrams every four hours as needed due to ongoing complaints of abdominal pain from the surgical wound, and on 11/14/18 the Oxycodone was decreased to 10 milligrams every six hours as needed.


Further review of Patient #1's medical record revealed documented evidence the following times and dates Patient #1 was given Oxycodone without a pain reassessment as follows: 11/01/18 at 3:38 PM, and 8:48 PM, received five milligrams of Oxycodone (narcotic); 11/02/18 at 12:54 AM, and 6:46 AM received 10 milligrams of Oxycodone; 11/03/18 at 12:07 AM, and 8:23 PM received 15 milligrams of Oxycodone; 11/03/18 at 8:06 PM, and 12:30 PM received 15 milligrams of Oxycodone; 11/04/18 at 12:30 AM, 5:08 AM, and 10:09 AM received 15 milligrams of Oxycodone; 11/13/18 at 5:10 PM received 10 milligrams of Oxycodone; and on 11/14/18 at 7:55 AM received 10 milligrams of Oxycodone. For the dates of 11/01, 11/02, 11/04, 11/05, 11/06, 1113 and 11/14/18 there was no documented evidence the numeric rating scale (NRS) was used to indicate Patient #1s level of pain.

Interview with Staff J on 12/20/18 at 4:03 PM revealed after the patient receives a pain medication the patient should be reassessed after one hour to determine the level of pain.

Review of the policy and procedure titled Pain Management Assessment and Intervention Protocol, Policy number P01-G, issue date: 12/01/00, last revised 04/01/18. On page (3 of 9) the policy revealed pain is assessed using the following scales: Numeric Rating Scale (NRS) 0-10 or the Critical Care Pain Observation Tool (CPOT) 0-8 (our adopted Behavior Pain Scale (BPS). All patients will be assessed for pain upon admission. If pain is indicated based on NRS or CPOT pain score, the patient will be assessed about every four hours, post- operatively, patients will be assessed for pain every two hours (while awake) for the first 24 hours. On page (5 of 9) revealed pain will be reassessed 30 to 60 minutes following a pain reduction intervention.

This finding was confirmed with the administrative staff prior to the exit conference on 12/20/18.

This finding substantiates substantial allegation number OH000101240.


5. Review of the policy and procedure titled Transcription/Notification of Diet Order, policy number FN-MS02, issue date: 06/21/02, revised 04/01/14 revealed active diet prescriptions are required for all patients to ensure meals are served in accordance with orders. The procedure was including the patient's admission diet prescription is ordered in the patient's medical record by the physician or practitioner responsible for the care of the patient, receipt of a written or transcribed order will be take as verification of the active order, meals from telephone or verbal communication of the diet prescription will not be served until above verification is received.

Review of Patient #1's medical record revealed he/she was admitted to the hospital on 11/01/8 at 12:53 PM. Patient #1's diet order was not placed until 11/01/18 at 6:10 PM for a therapeutic diet.

Interview with Staff J on 12/20/18 at 4:03 PM confirmed that Patient #1's diet order was entered at 6:10 PM and there is no documented evidence Patient #1 received a tray or was given anything to eat the day of admission.

Interview on 12/18/18 at 11:00 AM with Staff C revealed each unit has nourishment rooms with different food items for late admits. If staff calls and lets dietary know that they are expecting a patient, we will prepare a tray and place it in the refrigerator until the patient arrives. In addition, security has a key to the kitchen so staff can get in. The dietary manager stated the system is automated so when staff puts in a patient's dietary order it automatically adds them to the dietary census. They only time that a patient can be missed is if staff does not put the diet order in the system. The system alerts staff with an alert that states, "no diet assigned." Then dietary staff contacts the floor to get a diet order or something.

This finding was confirmed with the administrative staff prior to the exit conference on 12/20/18.

This finding substantiates substantial allegation number OH000101240.












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Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically Chapter 19 of the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association 101. This had the potential to affect all patients receiving services at the facility. The facility census was 61.


Findings include:

1. Please see K163 for findings related to the facility failing to ensure it's 2 hour fire rated walls constructed of wood were entirely covered with a noncombustible or limited-combustible material. .

2. Please see K223 for findings related to the facility failing to ensure doors located in fire rated walls were on self closing devices and closed to a latching position.

3. Please see K227 for findings related to the facility failing to maintain the fire rating of walls in exit passageways.

4. Please see K293 for findings related to the facility failing to ensure exit signage complied with NFPA 101.

5. Please see K311 for findings related to the facility failing to maintain the fire rating of vertical openings.

6. Please see K321 for findings related to the facility failing to ensure the identified hazardous areas ceilings and walls were smoke tight.

7. Please see K372 for findings related to the facility failing to ensure the fire rated smoke barriers were free of penetrations.

8. Please see K521 for findings related to the facility failing to ensure all fire/smoke dampers were tested and repaired when they failed testing.

9. Please see K914 for findings related to the facility failing to ensure hospital grade receptacle testing was completed.

10. Please see K916 for findings related to the facility failing to ensure the generator remote annunciator panels are located in a manned location.

Based on observation and staff interview it was determined staff failed to ensure internal food temperatures were obtained prior to serving trayline. In addition, dietary staff failed to ensure ice machines were clean. This had the potential to affect 26 patients who receive nutrition from dietary. The census was 61.


Findings include:


1. Observation of the kitchen on 12/18/18 at 11:15 AM revealed staff preparing trays and loading onto carts to be delivered to the hospital floors for patients. Review of the Patient Tray Line Temperature Log dated 12/18/18 revealed no cook temperature was recorded for breakfast or lunch and no hot holding temperature was recorded for lunch.

Interview at that time with Staff C revealed lunch cooking temperatures or hot holding temperatures were not recorded prior to serving patients on 12/18/18. Staff then began to obtain the temperatures for the food being held hot which they were already serving to patients.


2. Observation on 12/18/18 at 11:30 AM of the kitchen revealed a ice machine with black spots inside at the top of the bin. Interview with Staff C at that time revealed maintenance is in charge of cleaning the ice machines.

Staff C verified the black spots inside the ice machine and wiped the spots with a paper towel.