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Based on staff interviews, review of the facility's policies and procedures and review of the facility's surveillance video, the facility staff failed to ensure there was a policy/procedure for assessing, treating and referring (when appropriate) a medical emergency. The facility did not have an emergency department but had the potential for random people to approach the facility for emergency care.

On March 2, 2012 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (security guard). The unknown male told the security guard he wanted to kill himself and needed help.

The Findings Include:

There is one main entrance door for 2 hospitals in the same building. This facility and a second hospital for rehabilitation. The Administrator of this facility stated, "The Protection Officer serves both entities and the nursing supervisor is only used in an emergent situation or to get supplies that we don't have. If we use her she documents the amount of time she assisted us and we are billed for that time from the rehabilitation center."

On March 2, 2012 at 0135 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (PO). A review of the PO's documentation of the incident revealed the following:
The unknown male told the PO he (the unknown male) wanted to kill himself and needed help. The PO documented the following: he informed the unknown male the hospital "was not the facility". The unknown male sat on a bench outside the main entrance door and refused to leave the property unless the local authorities were called.

During an interview with the PO on 3/15/12 he stated, "I called the police. He (the unknown male) started flicking a lighter and I informed him he could not smoke on hospital property. Two (2) people came out of the building to smoke a cigarette and I walked away from the gentleman. When I returned which was seconds later the gentleman had set his jacket on fire. I stomped the fire out with my foot because there was no fire extinguisher nearby and I didn't have any gloves. The nearest fire extinguisher was inside the building and in the truck. I called the police a second time to tell them we needed an ambulance also. The police finally came and the gentleman was taken to the hospital. I notified the supervisor of the incident after the gentleman left."

The distance of the fire extinguishers was assessed by 3 environment/maintenance hospital employees who determined the fire extinguisher was approximately 52 from the door of the main entrance and approximately 60 feet from the bench which was outside the door of the main entrance. The Director of Safety and Protection estimated the truck was 60 feet from the entrance.

The nursing supervisor (for second hospital in same building) was interviewed on 3/15/12 and stated, "I didn't know there was a person at the front door until after the police had taken him away. I sent (name of Administrator for second hospital) an email regarding what I knew of the incident." The email was reviewed in another survey.

The 2 nurses (employees of second hospital) who walked out of the building were interviewed on 3/16/12 at 6:45 A.M.

Interviewee #12 stated, "(Name of PO) and a man sitting on the bench were outside when we exited the building. (Name of PO) walked up to us and said the gentleman appeared to be mentally unstable and the police have been called. (Name of PO) said he had not search the man and did not know if he had any type of weapon and to stay put. We were about 6 feet from the driveway by two trees and could not see anything."

Interviewee #13 stated, "As we came out the front entrance (name of PO) was standing and talking to someone on the bench. I asked if it was ok for us to come out and he said yes. (Name of PO) walked up to us where we were smoking and said the gentleman said he was going to kill himself and he had called 911. (Name of PO) walked back toward the man and we heard him say "Oh! No!" He (PO) then came back to us and told us the man had sat himself on fire but that he was ok. I could not see him (the unknown man); I guess he was still on the bench. (Name of PO) told us to not come in until the police arrived. We could not see the front of the building because a bush blocked our view."

On 3/13/12 the Director of Clinical Services (DCS) and the Administrator were asked for their policy pertaining to emergent care. The Nurse Manager stated, "We do not have a specific policy regarding the need for emergent care only these. The DCS provided the following policies

Criminal Activity and subject: Police Assistance # 800.005 with a Last Revision Date of 09/2007.

The policy was reviewed and the following is noted: "If the facts and situation warrants, the Protection Officer shall contact (911 if necessary) the local law enforcement when confronted with the following:
Threats to persons or property
Armed and unarmed assaults
Breaking and entering of any RHS facility
Breach of Peace, Fights, unruly crowd or individuals
Indecent exposure
Intoxicated persons, Mentally disturbed person or persons under the influence of drugs
Sexual Assaults (rape or molestation, etc.,)
Larceny to facility, patient, employee or visitor
Threatening, Harassing or Obscene phone calls
Robbery or homicide
Any strange, suspicious or unusual circumstance or person.

Protection Officers shall exhaust all means of providing assistance to maintain or restore the preservation of the peace and to prevent further destruction of property until the police arrive.

Once it has been established that any incident as outlined above has occurred, Officers shall notify:
1. Protection Supervisor
2. The Protection Supervisor shall contact the Protection Manager or Director, Safety & Protection Management...All detentions, inquires and contacts that result in a police response shall be documented in the log book and a QCCR written with complete details on the matter..."

and

Category: Safety Management, Subject: Personnel and Visitor Safety policy # 198-802.146

"...Visitor Injuries: When an incident involving an visitor occurs in the facility or on the facility grounds, the first person at the scene is responsible for the following: A. Assist the visitor, B. Notify the Director of Nursing, the Nurse Manager for the Nursing Supervisor for assistance C. If the visitor is unresponsive, immediate assistance is needed. EMS should be called if indicated....

The hospital surveillance video captured the above incident on video. The video was reviewed on 3/15/12 in the presence of the Director of Safety and Protection and Director of Regulatory Compliance and Nurse Manager for the second hospital. The video shows the door opening, the unknown man entering the building as the PO approached the door, the man being escorted out of the building without any hands being placed upon him. The man eventually sat on the bench. Police are called. 2 people (nurses, 1 registered nurse and 1 licensed practical nurse) exit the building without stopping. The PO re-enters the building for approximately 10 to 15 seconds. The PO then walks out of view of the camera for approximately 10 to 15 seconds returns and finds the unknown man in flames from his lap to his head. The PO repeatedly kicked the unknown man in the chest to extinguish the flames. The police are called a second time. Approximately 6 and 1/2 minutes pass before the police arrive. The 2 people re-enter the building while police are present.

There is no evidence the 2 staff who exited the building was asked by the PO to render assistance and there is no evidence the 2 staff offered assistance.

The Director of Safety and Protection (DSP) was interviewed on 3/15/12 regarding his investigation of the incident. The DSP stated, "He (unknown man) only threatened himself, he never threatened the PO or anyone or the building. He (the unknown man) never threatened the police or EMS. The only conversation PO reported with the 2 nurses was when they asked if it was safe to re-enter the building."

A copy of the DSP's investigation of the incident was provided by the DSP and provided the following information:

On 3/2/12 at approximately 1:30 A.M. an unidentified male knocked on the front door...The man asked for help and PO asked what kind of help. The man replied I'm going to kill myself. The man sat on the bench in front of the facility. PO began to question the man the man said two to three times "You better call CSB because I want to kill myself." PO called 911. As PO was observing the man 2 nurses exited the facility and walked toward the street. PO was monitoring the nurses, the man began to cry which was heard by PO and began to flicker a lighter. The PO called to the man and announced that smoking was not allowed on campus. The PO noticed the man had sat himself on fire. PO came the man's aid and put the fire out using his (the PO's) foot. EMS (911) was called a second time. As PO waited on the EMS he yelled out for assistance but the 2 nurses had left the area. The police arrived and a short time thereafter the ambulance arrived...

A review of the PO's personnel file was conducted during a previous survey on 3/14/12. The PO's personnel file did not indicate he had ever received training in assessing a person who is potentially suicidal. A copy of the facility's Behavioral Intervention Program was provided by the Nurse Manager on 3/15/12. The program was reviewed and there is no evidence in the training a PO received training to assess a potentially suicidal person.

The word hospital was on the building.

Based on record review, Patient interview, and staff interviews the facility staff failed to ensure that 1 patient of 1 patients under going invasive procedures, (Patient # 6) was free from all forms of abuse. (0145) Patient # 6 Doctor sutured a PICC Line without pain medication.

The Findings Include:


During general observations on the nursing unit the doctor stated loudly enough to be heard approximately 10 feet away from the nursing station while approaching two nurses standing in the hallway in front of the nursing station, "I am going to need a suture kit for room # (patients room #) so that I can suture the peg feeding tube (peripherally inserted endoscopic gastrostomy feeding tube) to secure it" visitors were also present in the hallway. The doctor then turned and proceeded into the doctor's charting and dictation room located across the hall from the nursing station.
Within a few minutes the doctor returned and stated in the hallway "The Patient does not have a peg tube, it is a PICC (Peripherally Inserted Central line Catheter) for antibiotic treatment for his infection, I would use my own tools, however, this Patient is under isolation for an infection so we will need disposable tools."

Upon discussion with Employee #9, present at the time, who stated, "the doctor is a medical examiner and keeps his own tools with him." It was undetermined if these tools were sterile or not. Employee # 9 stated, "We contract with the PICC insertion nursing group to do all of our PICC lines, but the PICC in (Patient name) Patient # 6 was done yesterday and the dressing change is due today. We have to secure the line some way because (patient name) Patient # 6 is severly allergic to "Stat Lock Tape" and other adhesives."

Employee #12 who was present for the procedure, stated "I was very concerned that the doctor used no pain medication before or during the procedure to give the patient generalized or localized relief from pain, even when the Patient asked about it."

A second Medical Facilities inspector interviewed Patient # 6 after the procedure who stated at interview "Yes I was concerned about the sutures without pain medication. I even asked the doctor about something for the pain, and he said I could not have anything because of my allergies. I am fearful of retaliation. I was in pain after the procedure, and had a bad night, but I don't know if it was because of the procedure."

Patient # 6 clinical record review revealed a 58 year old with a history of Spina Bifida since childhood, spinal cord surgery in the year 2000 with resultant paraplegia from the waist down, myelomeningocele, esophageal reflux disease, heart disease with paroxysmal supraventricular tachycardia, Diabetes type 2, right hip replacement, and a sacral decubitus ulcer stage 4 positive for osteomylitis and methycillin resistant stapholococcus aureus.
Patient # 6 is listed as having allergies to Iodine, Lasix, Pennicillin, and Latex.

During the investigation it was revealed that at the time of admission, the packet given to Patient # 6 and the Patient's spouse regarding conflict resolution and grievance/ complaints was inaccurate, specifically, name and address of the Surveying agency was wrong, and the facility administrator also had the "Advanced Beneficiary Notice" (form CMS-R-193) notated with the wrong phone number and address.

Based on observations made during the initial tour and interview with facility staff it was determined the organization failed to ensure confidentiality of patients clinical record information.

The findings were:

1. An initial tour of the clinical area was conducted on 3/12/12. At the front of the nurses station there was a countertop where clinical supplies and a clip board were sitting. This Inspector glanced down at the clip board and noted that it was the "Nursing Assignment Sheet 7:00 am - 7:00 pm." On this document was the following information;
Room #,
Admit Date,
Name (patient),
MD (doctor),
Diagnosis,
Iso (Isolation),
Code,
Dialysis, and lastly
Day Nurse (name of nurse assigned to each patient).

The above information was clearly visible for anyone to look at and included the information for ten (10) patients.

As the initial tour continued down the eastern hallway, a nurse (employee #9) was standing at a patient's room typing on the keyboard to a portable medication cart (on wheels) with a computer screen on the top. The employee (#9) left the cart and went into a patient's room that was across the hall and several doors away from the cart. Two (2) Inspectors walked over to the cart and observed the computer screen on the cart had a patient's name, diagnosis and demographic information up on the screen. The nurse left the cart unattended with the information on the screen for at least several minutes.

The above findings were presented to the Administrator and Director of Clinical Services during the daily summary report at the end of the day on 3/12/12. The Administrator stated, "Oh there is a cover sheet for that clipboard, they must have had it flipped back."


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2. During initial tour of the facility 3-12-2012, it was observed that on the nursing station ledge of the documentation desk, a document describing a PICC line (Peripherally Inserted Central Line Catheter) insertion for Patient # 6 was face up and available for anyone approaching the nursing station to view. There were visitors present at this time.

Based on observations, staff interviews and patient interviews the facility staff failed to ensure the environment was maintained in such a manner as to prevent potential injures.

The Findings Include:

During the initial tour of the facility on 3/12/12 a restroom was observed as you came around the corner from the elevator that did not have an emergency call bell. There was no specific labeling on the door designating it for staff only. The hand rails were observed in the hallway and several were found to be loose and with broken edges.

The Director of Clinical Services was asked if any of the patients ambulate and she stated, "Yes." One patient, Patient #2 was observed ambulating in hallways and outside.

Patient #2 was interviewed on 3/12/12 and stated, "I walk all over the place."

Based on observations and staff interviews the facility failed to ensure they followed their program for identifying and investigating potential problems in controlling infections and communicable diseases; as evidenced by dirty vents, dietary staff not wearing head coverings, no air gap for ice machine, torn mattress and chair coverings, unlabeled clean ventilator and BiPAP machine and patient personal tubing in regular trash can.

The Findings Include.

During the initial tour of the facility on 3/12/12 the following observations were made. The respiratory department had a ventilator and a BiPAP machine covered in plastic that could not be identified as having been cleaned and ready for patient use. Another ventilator was covered in plastic and labeled as needing PM (preventative maintenance). The respiratory therapist in the room stated, "We ran out of the tags we use to designate if some needs cleaned, is dirty or needs maintenance. I guess we could have just put a piece of paper on it (the machines) to let everyone know they were ready to use."

Also during the initial tour the keyboards attached to the moving documentation carts were observed to be dirty with debris.

The ice machine in the patient nutrition room failed to have an air gap. The drain tube was inserted into the drain below floor level. The Director of Plant Operations stated, "You are right there should be an air gap. I like for one to be about a half inch above the floor."

During the initial tour the ventilation system was observed outside the nutrition room. The vent had noticeable dust and debris hanging off it. On 3/13/12 the vents were observed in the dining area of the kitchen and had dust hanging off the vents and on the ceiling tiles immediately in front of the vents.

Observations of patient rooms were made on 3/12/12. Room 414 had a vinyl/leather chair with torn handles exposing porous surface. A mattress in room 418 was observed torn and had the inside of the mattress exposed. The Director of Clinical Services stated the person discharged from the room had been on isolation. The isolation trash can had been removed from the room. A nasal cannula and what appeared to be tubing from a Foley catheter were in the general trash can.

On 3/13/12 two male dietary attendants were observed serving food in the cafeteria and preparing food in the kitchen without head coverings. Also during this observation a vendor was observed entering the kitchen and food serving areas several times with no head covering. The Dietary Manager was asked if they prepare food for patients as well as staff and visitors and she said yes.

Hair coverings were not located at the door where the staff enter the kitchen but on a shelf where food is prepared. The dietary manager stated, "They (staff) have baseball caps and they should have them on, they don't like wearing them. The vendor is new."