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Based on review of the medical record, observation, interview with staff, patients and their families and review of policy it was determined that the hospital failed to ensure safe care was provided to three current patients (Patients 8, 9 and 15) and three previous patients (Patients 31, 32, and 33) who had complained to the hospital and failed to ensure three of four patients (Patients 17, 18, and 19) had physician orders for restraints and were monitored according to the facility's policy for the use of restraints. The facility census was 25 at the time of the survey.

Findings include:

The facility failed to provide safe care to all patients. Please see A 144.

The facility failed to ensure orders were obtained for the use of restraints. Please see A 168.

The facility failed to ensure all restrained patients were monitored according to the facility's policy. Please see A 175.

Based on review of the medical records, interview with staff, policy review, and observation; it was determined that the Registered Nurse failed to ensure care to all patients was delivered as per physicians orders, hospital policy and acceptable standards of practice and the nurse failed to follow hospital policy and acceptable standards of practice in regards to medication administration. This practice was noted during 2 of the 2 medication administrations observed. The Registered Nurse also failed to supervise the patient care delivered by non licensed staff. This involved 11 of 25 patients (Patients 14, 16, 15, 21, 11, 12, 8, 20, 24, 25, and 26). The hospital census was 25.

Findings include:

The nurse failed to supervise the patient care delivered by non licensed staff. Please refer to A 395 for additional information.

The nurse failed to follow hospital policy and acceptable standards of practice in regards to medication administration. Please refer to A 404 for additonal information.

Based on interview and observation, the facility failed to ensure fire extinguisher placement, sprinkler system, smoke detectors, and corridor doors met the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 25 patients in the facility.

Findings include:

The fire extinguisher placement, sprinkler system, smoke detectors, and corridor doors did not meet the applicable life safety code provisions. Please see A 710.

Based on review of the medical record, interview with patients and their families and review of policy and procedures it was determined that the hospital failed to provide safe care to all patients. This involved 3 of 25 current patients and 3 previous patients that had complained to the hospital, Patients 8, 9, 15, 31, 32 and 33. The hospital census was 25.

Findings include:

An interview with the family of Patient 8 was conducted on 06/28/11 in regards to the care provided at the hospital. The family stated that Patient 8 was to be turned every 2 hours and never gets turned. They stated that when the call light was pressed it took a very long time for the staff to respond and when they did respond they asked what was needed and then didn't return for a longer period of time. The medical record of Patient 8 was reviewed on 06/28/11 and revealed that on 06/24/11 the patient was turned 6 times, on 06/25/11 the patient was turned 4 times, on 06/26/11 the patient was turned 3 times, on 06/27/11 the patient was turned 5 times, and on 06/28/11 at the time of the review at 12:55 PM there was no documentation that Patient 8 had been turned that day.

An interview was conducted with Patient 9 on 06/28/11 at 1:20 PM. Patient 9 was questioned about the care that he/she had received since admission to the hospital. Patient 9 stated that on the previous day he/she had turned the call light on for assistance up to the bedside commode and no one responded which resulted in his/her incontinence of urine while in bed. Patient 9 also stated that this AM he/she placed the call light and no one answered for over 55 minutes. Patient 9 stated at that time he/she had to urinate so badly they required the assistance of a visitor to get out of bed to the commode. A second interview was conducted on 06/29/11 at 2:00 PM. At this time Patient 9 became tearful and shared the further difficulties he/she had experienced with delay in staff response to the call light. Patient 9 stated it had been worse since our last discussion and that this morning he/she became upset with staff and complained when he/she waited for 45 minutes for someone to answer the call light so they could use the bedside commode. Patient 9 stated that he/she would push the call light and then it would be turned off outside the room. Patient 9 stated he/she would turn the call light on again and it would once again be turned off with his/her needs not being met. Patient 9 stated that after this occurred several times he/she got out of bed without assistance to the bedside commode.

An interview was conducted with the family of Patient 9 on 06/29/11 at 2:15 PM. Patient 9's family stated that a week ago the patient sat on the bedpan for over 45 minutes while the call light was on.

The complaint/grievance log was reviewed on 06/30/11 and included 3 complaints from patients and family in regards to the delay in staff response to call lights. On 03/17/11 a complaint was logged by the family of Patient 31. The family of Patient 31 stated the call light remained on for over 30 minutes due to the patient's need to use the bedpan. The staff did not respond which resulted in the patient's incontinence of stool. The family complained that once the staff came they appeared to be upset with the patient because he/she had been incontinent and needed help getting cleaned up.

A second complaint was filed on 03/17/11 by the family of Patient 32. The family complained that it took over 15 minutes for staff to respond to the call light when the patient required medication for pain.

The complaint/grievance log also included a complaint from Patient 33 which was filed on 04/20/11. Patient 33 complained that he/she was in need of suctioning and the call light was put on to notify staff of this need and 11 minutes later staff responded. The staff who responded was a nurse's aide and let the patient know a nurse would be notified. Five minutes later no staff had returned to the room to suction Patient 33 and the call light was turned back on and then staff responded and provided the treatment.

The complaint/grievance log reflected that for Patients 31, 32 and 33 these patients and family received a letter of apology from the hospital but there was no documentation to suggest that any education was done with the staff.

The policy Patient Rights and Responsibilities, was reviewed on 06/30/11. This policy detailed the rights of the patient and included the following:

"You have the right to expect personnel who care for you to be friendly, considerate, respectful and qualified through education and experience to perform the services for which they are responsible with the highest quality of of service."

"You have the right to receive the care necessary to help regain or maintain your maximum state of health and if necessary, cope with death".

"You have the right to be treated with consideration, respect and full recognition of dignity and individuality including privacy in treatment and in care for necessary personal and social needs".

The above findings were shared with Staff A and B on 06/28/11 at 4:15 PM.

Based on medical record review, observation, policy review, and staff interview the facility failed to ensure orders for restraint use were obtained for the use of restraints on three of four medical records reviewed with restraint usage (Patients 17, 18, and 19). The facility census was 25 at the time of the survey.

Findings include:

The medical record for Patient 17 was reviewed on 06/28/11. The patient was admitted to the facility on 05/27/11. The medical record contained an incomplete order for restraints that revealed only the date 06/29/11, time 6:00 AM, a nurse's signature, and the physician's signature. At 4:00 PM on 06/29/11, this surveyor observed a lap belt in place on Patient 17. The medical record contained documentation every two hours on 06/29/11 that a lap belt was in use. The medical record contained documentation the bilateral soft limb restraints were removed on 06/10/11 at 6:00 PM and reapplied at 7:30 PM without a new physician's order. This information was discussed with Staff A on 06/29/11 at 5:00 PM.

The medical record for Patient 18 was reviewed on 06/29/11 at 4:32 PM. The patient was admitted to the facility on 06/14/11. The medical record contained an order for a lapbelt restraint that was written by nursing at 6:00 AM, but lacked a physician signature or notation the restraint order was taken as a verbal order. The medical record lacked documentation of an order for restraint usage on 06/16/11, but contained documentation that the patient was restrained on this date. This information was discussed with Staff A on 06/29/11 at 5:00 PM.

The medical record for Patient 19 was reviewed on 06/30/11. The patient was admitted to the facility on 06/09/11. The medical record lacked documentation of an order for restraint usage on 06/19/11, but contained documentation the patient was restrained on this date. The medical record contained documentation on 06/10/11 that the bilateral wrist restraints were removed at 10:00 AM and reapplied at 2:00 PM with no new order obtained. The medical record contained documentation on 06/12/11 that the bilateral wrist restraints were removed at 9:30 AM and reapplied at 1:00 PM with no new order obtained. The medical record contained documentation on 06/13/11 that the bilateral wrist restraints were removed at 12:00 PM and reapplied at 6:00 PM with no new order obtained. This was discussed with Staff A on 06/30/11 at 9:30 AM.

The Restraint Use Policy was reviewed on 06/30/11. The policy stated a physician must order restraints and must reorder every 24 hours. The policy further stated if the restraint was removed for a trial period, a new order must be obtained to reapply the restraints.

Based on medical record review, observation, policy review, and staff interview; the facility failed to ensure all restrained patients were monitored according to the facility's policy for three of four medical records reviewed with restraint usage (Patients 17, 18, and 19). The facility census was 25 at the time of the survey.

Findings include:

The medical record for Patient 17 was reviewed on 06/28/11. The patient was admitted to the facility on 05/27/11. The medical record contained orders for restraint usage from 06/10/11 through 06/25/11. The medical record lacked documentation of restraint safety checks every two hours on 06/15/11, 06/18/11, and 06/19/11. The medical record lacked documentation of every two hour restraint safety checks on 06/10/11 from 2:00 AM until 8:00 AM, on 06/16/11 from 4:00 AM until 8:00 AM, on 06/22/11 from 6:00 PM until 10:00 PM, and on 06/23/11 from 4:00 PM until 8:00 PM. This information was discussed with Staff A on 06/29/11 at 5:00 PM.

The medical record for Patient 18 was reviewed on 06/29/11 at 4:32 PM. The patient was admitted to the facility on 06/14/11. The medical record contained orders for restraint usage on 06/14/11, 06/17/11 through 06/28/11. The medical record lacked documentation of every two hour restraint safety checks on 06/14/11, 06/25/11, and 06/28/11. The medical record lacked documentation of every two hour restraint safety checks on 06/26/11 from 4:00 PM until 8:00 PM. This information was discussed with Staff A on 06/29/11 at 5:00 PM.

The medical record for Patient 19 was reviewed on 06/30/11. The patient was admitted to the facility on 06/09/11. The medical record contained orders for restraint usage from 06/09/11 through 06/18/11 and 06/20/11 through 06/30/11. The medical record lacked documentation of restraint safety checks every two hours on 06/20/11 and 06/28/11. The medical record lacked documentation of every two hour restraint safety checks on 06/24/11 from 2:00 PM until 8:00 PM. This was discussed with Staff A on 06/30/11 at 9:30 AM.

The Restraint Use Policy was reviewed on 06/30/11. The policy stated the condition and needs of the patient must be reassessed and documented every two hours and as needed when the patient was restrained.

Based on review of the medical records, interview with staff, policy review, and observation; it was determined that the Registered Nurse failed to ensure care to all patients was delivered as per physicians orders, hospital policy and acceptable standards of practice. The Registered Nurse also failed to supervise the patient care delivered by non licensed staff. This involved 11 of 25 patients (Patients 14, 16, 15, 21, 11, 12, 8, 20, 24, 25, and 26). The hospital census was 25.

Findings include:

An observation was made on 06/27/11 at 12:15 PM. It was noted that a dirty soiled graduate was found on Patient 14's bedside table where he/she took their meals. This soiled graduate was located next to Patient 14's water glass that was being used by the patient. A staff interview was conducted with Staff G who verified the graduate had been used to empty and measure the stool out of Patient 14's colostomy.

The medical record for Patient 16 was reviewed on 06/29/11. Patient 16 was admitted on 06/20/11 with osteomyelitis (infection in the bone), non healing wounds and uncontrolled diabetes. On 06/27/11 at 1:05 PM the wound care of Patient 16 was observed. Patient 16 had three separate wounds located on the top and bottom of his/her left foot and one on the right foot that was between the 4th and 5th toes and ran from the top to the bottom of the foot. The wound care and dressing change was completed by Staff C, the Wound Care Nurse. During the observation Staff C was observed as he/she removed the dirty soiled dressing. Staff C never removed his/her gloves after handling the soiled dressing and cleansing each wound and did not was his/her hands. The same dirty gloves were used to apply an iodine based cream to each wound. Staff C used the same finger to apply this cream to each of the three wounds and then applied the clean dressing.

The medical record for Patient 15 was reviewed on 06/29/11. Patient 15 was admitted on 05/25/11 with active respiratory failure, pneumonia and a non healing surgical wound. Staff C was observed as he/she removed the soiled wound vac dressing to Patient 15's right abdomen. It was noted that Staff C never removed his/her dirty gloves or washed hands prior to the application of the clean wound vac dressing.

The medical record for Patient 21 was reviewed on 06/29/11. Patient 21 was admitted on 04/28/11 with osteomyelitis and discitis of C4 and C5 (this is an infection and inflammation of the disc and is located in the neck). Patient 21 also had a wound to his/her sacrum. The wound care for Patient 21 was observed on 06/27/11. Staff C was observed as he/she applied a wound gel to the sacral wound with a gloved finger. With the same soiled gloves, Staff turned and grabbed the dry erase marker off of the dry erase board and labeled the dressing and then replaced the now contaminated marker.

The hospital policy, Guidelines for Hand Hygiene, was reviewed on 06/29/11. This policy stated that staff was" to decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings".

The medical record for Patient 11 was reviewed on 06/28/11. Patient 11 was admitted on 04/18/11 with respiratory failure and renal failure. Patient 11 was ordered to be on droplet precautions and placed in isolation related to a positive sputum culture that had shown that Patient 11 was infected with Acinetobacter (bacterium found in areas of the body such as the respiratory tract) and Pseudomonas (infectious bacteria). The hospital policy, Isolation Precautions, was reviewed on 06/29/11. The sign on Patient 11's door listed that the patient was on droplet precautions and advised staff and visitors to wear a gown, gloves and a mask. Staff D was observed on 06/28/11 to put on a gown and gloves and then walk to the patient's bedside. This RN Surveyor questioned the staff regarding the type of isolation Patient 11 was on and the protocols for the personal protective equipment that was to be worn. Staff C turned and reviewed the sign posted on the door and donned a mask to care for Patient 11. The personnel file of Staff D was reviewed on 06/30/11 and it was noted that he/she had been previously counseled for non adherence to isolation polices.

An observation was made of family members sitting at the bedside of Patient 12. Patient 12 was currently in isolation and was placed on droplet precautions. The two family members were noted to be wearing gloves and a gown but had their masks on but pulled down below their chins.

An interview with the family of Patient 8 was conducted on 06/28/11 in regards to the care provided at the hospital. The family stated that Patient 8 was to be turned every 2 hours and never gets turned. They stated that when the call light was pressed it took a very long time for the staff to respond and when they did respond they asked what was needed and then didn't return for a longer period of time. The medical record of Patient 8 was reviewed on 06/28/11 and revealed that on 06/24/11 the patient was turned 6 times, on 06/25/11 the patient was turned 4 times, on 06/26/11 the patient was turned 3 times, on 06/27/11 the patient was turned 5 times, and on 06/28/11 at the time of the review at 12:55 PM there was no documentation that Patient 8 had been turned that day.



The medical record for Patient 20 was reviewed on 06/30/11. The patient was admitted to the facility on 06/24/11. The medical record contained an order dated 06/24/11 to turn and repositioned the patient every two hours. The medical record lacked documentation the patient was turned every two hours from 06/24/11 through 06/30/11. The patient's Braden score (risk of developing skin breakdown) on admission was 13, moderate risk. This was discussed with Staff A on 06/30/11 at 11:00 AM.

The medical record for Patient 21 was reviewed on 06/30/11. The patient was admitted to the facility on 04/28/11. The medical record contained an order dated 04/28/11 to turn and repositioned the patient every two hours. The medical record lacked documentation the patient was turned every two hours from 04/28/11 through 06/30/11. The patient's Braden score on admission was 14, moderate risk. The patient had a reddened area on his/her sacral area (bottom) on admission on 04/28/11. This same area had a pressure sore measuring 3.96 cm (centimeters) by 4.37 cm by 1 cm on 06/27/11. On 06/30/11 at 10:27 AM, Staff H verified this patient had no open areas on his/her sacral area on admission. Both surveyors observed the dressing change to the sacrum during this survey. This was discussed with Staff A on 06/30/11 at 11:00 AM.

The medical record for Patient 24 was reviewed on 06/30/11. The patient was admitted to the facility on 06/15/11. The medical record lacked documentation the patient was turned every two hours from 06/15/11 through 06/30/11. The patient's Braden score on admission was 11, high risk. This was discussed with Staff A on 06/30/11 at 11:00 AM.

The medical record for Patient 25 was reviewed on 06/30/11. The patient was admitted to the facility on 06/13/11. The medical record contained an order dated 06/13/11 to turn and repositioned the patient every two hours. The medical record lacked documentation the patient was turned every two hours from 06/13/11 through 06/30/11. The patient's Braden score on admission was 17, low risk. This was discussed with Staff A on 06/30/11 at 11:00 AM.

The medical record for Patient 26 was reviewed on 06/30/11. The patient was admitted to the facility on 06/23/11. The medical record contained an order dated 06/23/11 to turn and repositioned the patient every two hours. The medical record lacked documentation the patient was turned every two hours from 06/23/11 through 06/30/11. The patient's Braden score on admission was 16, moderate risk. This was discussed with Staff A on 06/30/11 at 11:00 AM.

The Braden Scale - Instructions for Use policy was reviewed on 06/30/11. The policy stated all patients will receive an assessment to determine their Braden score on admission. If the patient's Braden score was low risk (17-23) the Conservative Pressure Ulcer Prevention Protocol would be initiated, which included turn and reposition the patient every two hours. If the patient's Braden score was moderate risk (12-16) or high risk (less than 11), the Conservative Pressure Ulcer Prevention Protocol would be initiated along with additional measures.



27700

Based on observation and interview, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 25 patients in the facility.
Findings include:

K018 of the life safety code requirements was found to not be met. On 06/29/11 the surveyors observed three corridor door that did not close completely because of infection control boxes found hung over the top of the door.

K062 and K064 of the life safety code requirements were found to not be met. The facility failed to provide evidence the automatic sprinkler system was inspected quarterly and tested annually. The facility failed to ensure two fire extinguishers were mounted in accordance with the National Fire Protection Association 10, chapter 4-3.2 and 1-6.10.

K130 of the life safety code requirements were found to not be met. On 06/29/11, the surveyors observed seven smoke detectors located too near air flow devices in violation of the requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1.

Based on observation and review of the hospital's policy and procedures it was determined that infection control officer failed to ensure that there was a system in place to detect non-adherence to the isolation and hand washing policies and procedures. This involved 2 of 2 physicians observed, Staff I and J. The hospital census was 25.

Findings include:

An on floor observation was conducted on 06/28/11 at 1:20 PM. During this observation it was noted that Staff I a physician entered a patient room who was on droplet isolation precautions without the proper personal protective equipment on as required by hospital policy. Per hospital policy, Isolation Precautions, the necessary protective equipment included a gown, mask and gloves.

A second on floor observation was conducted on 06/28/11 at 2:45 PM and included Staff J a physician who specializes in infection control. Staff J was observed first entering a room in which the patient was on contact isolation precautions. While in the room Staff J donned a pair of gloves but no gown as required by policy. Staff J removed the gloves and left the room without washing his/her hands. Staff J then went to a second patient's room in and also entered prior to donning a mask, gown and gloves required to enter a patient's room that was on droplet isolation precautions.

Based on observation of staff, interview with staff and review of the hospitals policy and procedure it was determined that the nurse failed to follow hospital policy and acceptable standards of practice in regards to medication administration. This practice was noted during 2 of the 2 medication administrations observed and involved Staff D and E. The hospital census was 25.

Findings include:

On floor observations were conducted on 06/28/11. During this observation two nurses were observed as they administered medications.

The medication pass with Staff D was observed on 06/28/11 at 9:15 AM. Staff D prepared the medications and administered them to Patient 11 without verifying the patient's identification. These medications included medication used to treat a heart condition, an injection of a blood thinner, vitamins, and a medication used for gastric reflux.

The medication pass with Staff E was observed on 06/28/11 at 9:45 AM. Staff E prepared the medication and administered them to Patient 23 without verifying the patient's identification. The medication was given intravenously and was a diuretic.

The policy, Medication Administration, was reviewed on 06/29/11. This policy stated that "The patient's armband shall match the patient identification and be checked prior to administration of medications. Staff will identify the patient using two hospital approved identifiers (Patient's name, date of birth and medical record number)". This policy was not followed by Staff D and E.

On 06/29/11 at 9:30 AM an interview was conducted with Staff F a pharmacist. During the interview Staff F shared that their have been medication errors involving the medication being administered to the wrong patient. The PNT (Pharmacy, Nutrition and Therapies) meeting minutes were reviewed for the previous seven months. It was noted that prior to the survey Staff D was counseled for administration of the wrong medications to the wrong patient.