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Based on observations made during the Life Safety Code survey on July 19 , 2011 it was determined that the Condition of Participation for the Physical Environment was not met. See Life Safety Code 2567 for deficiencies.

Based on a review of 17 closed records, it is determined that four (4) of the closed records lacked evidence that Important Message (IM) notifications had been provided as evidenced by the following:

Closed record for patient # 39, a 70 year old female, revealed only an admission IM.

Closed records for patient #42, an 84-year-old male who would have received one IM.

Patient # 43 ,a 65-year-old male, lacked two IMs.

Patient # 44, an 80 year-old male, who would have received two IMs, revealed neither admission nor discharge IMs.

Based on medical record review and staff interview, it was determined that the facility failed to obtain family member consent prior to local and intravenous sedation and a surgical procedure for a patient declared incapable to make medical decisions by two physicians for 1 of 29 open patient records reviewed.
On 7/20/11, review of medical record # 29 revealed that two physicians completed Certificates of Patient Incapacity to Make an Informed Decision Regarding Medical Treatment on 5/24/11. The facility staff failed to obtain the patient's son (family member) consent for the insertion of a dialysis shunt and local and intravenous sedation for the procedure on 5/26/11. The physician instead had the patient who was declared incapable to make informed medical decisions by 2 physicians two days earlier, sign both of the consents. Medical record review revealed that the family member had previously declined to agree to dialysis treatment for the patient. On 7/20/11, interview with the Quality Improvement Nurse regarding this issue failed to reveal any documentation indicating that the patient was capable of making medical decisions on 5/26/11.

Based on review of the medical records it was determined that patient #37 was kept in seclusion without justification, orders, or ongoing assessments as evidenced by:
Patient #37 is a 45-year-old female who on 3/31/2011, admitted from another hospital emergency department on a voluntary agreement with a diagnosis of Bipolar disorder and opiate dependence. Patient #37 reported feeling upset and suicidal, and that she attempted to overdose on pills. Patient #37 has a medical history of coronary heart disease, chronic obstructive pulmonary disease, gastroesophageal reflux disease, chronic back pain, and restless leg syndrome.
On admission of 3/31 at 1:30 pm, patient #37 was noted to be irritable. When the physician (MD) would not prescribe narcotics, she escalated to throwing a chair, resulting in a broken window. Patient #37 then threw a trash can, threatened to punch another window, and threatened the MD. Patient #37 was escorted to the seclusion room where she became combative with staff. A code Green was called, and she was placed in 4-point restraint on 3/31 at 1:30 pm. It is noted that when patient #37 became violent, she was certified as involuntary, and another placement was sought.
Orders for restraint appear in the record for 1:30, 5:30, and 9:30 pm. A nursing note written at 2:45 pm states "Restraints removed. Pt. remains in seclusion room with sitter." No new order for seclusion at 2:45 pm is found, nor is there behavioral information at 2:45 pm to justify seclusion for patient #37. PRN orders for restraint as cited in A-0169 for 5:30 pm and 9:30 pm were used to cover the seclusion, which required a new and unique order with all attending assessments such as the face to face. Visual observation documentation, done every 15 minutes, states only if the patient is awake or asleep and fails to document any behavioral information.
The RN hourly assessment for 2 and 3 pm are check boxes in which the RN checked "Unable to follow safety instructions," which does not meet the criteria for seclusion. At 6 pm, the nurse checked the box giving attribution to patient behaviors of "Marked agitation or combativeness which involves physically aggressive threatening behavior toward another individual. Violent or destructive." However, no progress note supports this attribution and the 15-minute flows for the entire 6 pm hour indicate patient #37 was asleep.
A nursing note of 5 pm states in part, "Pt. was sleeping in room 450 (seclusion room). Pt. has a sitter with her. Assessed pt. every two hours. No dift_?_ or complaint or distress noted. Pt. was up for her dinner and went back to sleep. Pt. still sleeping in room 450 ... "
A note of 8:34 pm states "Pt. was assessed at 2034 and V/S was taken T 98.2, P 74, R 20, BP 128/74. Pt very uncooperative. V/S taken, pt. is with sitter .... " Uncooperativeness is not criteria for seclusion.
A note of 3/31 at 2315 states "Pt. came out from the room to be assessed by the staff and V/S ( vital signs) taken. Pt. became agitated and went back to the room and closed the door. Pt was very uncooperative and refused her prn medication .... " No documentation is found to indicate that patient #37 remained violent or a danger to others or to herself. However, at 11:30 pm, she remained in seclusion even though seclusion/restraint documentation ends at 10 pm. Patient apparently slept in the seclusion room while still on 1:1.
A nursing note of 4/1 states "Sitter reported pt. went to BR (bathroom or bedroom) and upon returning to her room, refused to leave the door ajar to facilitate observation. Pt. pushed the sitter when she attempted to put the chair in the door to keep door open. Pt. is aggressive towards staff." Patient #37 was placed in 4-point bed restraint at 8:15 am.
A nursing note of 4/1 at 10:30 am states "Pt. reports that she understands why she was placed in restraint & is calm at this time. L (left) arm & leg removed." Patient #37 did not come out of restraints completely until 4 pm, though 15 minute observation notes show her as sleeping from 11:30 am until 4 pm. However, RN assessments for 8, and 10 am, then 12 noon, 2, and 4 pm indicates that patient #37 demonstrated:
1. Unable to follow safety instructions
2. Marked agitation or combativeness which involves aggressive threatening behavior toward another individual. Violent or destructive.
A note of 4/1 at 11 pm states in part, "Sleeping much of shift in room 450 (seclusion room) with the door open and a staff member observing her @ all times. Initially refused (angrily) vital signs and dinner. At 2 hr intervals she was assessed ... " From 4 pm until 11 pm, no documentation of two-hour assessments is found, nor are there any progress notes, though patient #37 remained in seclusion.
A nursing note of 4/2 at 2350 states in part, "Sitter with pt. on 1:1 c.o. (continuous observation) for safety at all times. Angry, poor impulse control with potential to act out, maintained in 450 (seclusion room) for maximum safety and observation. Pt. contracts for safety although ambivalence noted." The RN states that patient #37 was "Maintained" in the seclusion room, due to the "Potential to act out" indicating that patient #37 was not allowed to leave.
Further, patient #37 informed the RN of her plan for a safety contract. Safety contracts are not required for exit from restraint/seclusion. However, once patient #37 actually stated a safety contract, the RN subjectively notes "Ambivalence" from patient #37, suggesting she was still not released. At that time, patient #37 was in the seclusion room for a of total 31 hours.
Based on scant documentation, patient #37 had been in seclusion from 4/1 at 4 pm, without any justification, physician order, face to face, or other appropriate seclusion assessment or documentation. Additionally, no documentation is found indicating when patient #37 actually came out of seclusion until a note of 4/3 at 3 pm which states in part, "mixing in milieu." This indicates that patient #37 was possibly in seclusion for up to 47 hours.
The hospital failed to meet regulatory seclusion and patient rights requirements for justification and documentation of a seclusion event.

Based on review of two records where restraints were applied, it was determined that one patient #37 was secluded for 47 hours without orders to do so as evidenced by:

Patient #37 is a 45-year-old female who on 3/31/2011, admitted from another hospital emergency department on a voluntary agreement with a diagnosis of Bipolar disorder and opiate dependence. Patient #37 reported feeling upset and suicidal, and that she attempted to overdose on pills. Patient #37 has a medical history of coronary heart disease, chronic obstructive pulmonary disease, gastroesophageal reflux disease, chronic back pain, and restless leg syndrome.
On admission of 3/31 at 1:30 pm, patient #37 was noted to be irritable. When the MD would not prescribe narcotics, she escalated to throwing a chair, resulting in a broken window. Patient #37 then threw a trash can, threatened to punch another window, and had threatened the MD. Patient #37 was escorted to the seclusion room where she became combative with staff. A code Green was called, and she was placed in 4-point restraint on 3/31 at 1:30 pm. It is noted that when patient #37 became violent, she was certified as involuntary, and another placement was sought.
Orders for restraint appear in the record for 1:30, 5:30, and 9:30 pm. A nursing note of 2:45 pm states "Restraints removed. Pt. remains in seclusion room with sitter." No new order for seclusion at 2:45 pm is found, nor is there behavioral information at 2:45 pm to justify seclusion for patient #37. PRN orders for restraint (as cited in A-0169) for 5:30 pm and 9:30 pm were used to cover the seclusion, which required a new and unique order with all attending assessments such as the face to face. Visual observation documentation, done every 15 minutes, indicates only if the patient is awake or asleep, and gives no behavioral information.
Based on scant documentation, patient #37 remained in seclusion from 4/1 at 4 pm, without any justification, physician order, face to face, or other appropriate seclusion assessment or documentation. Additionally, no documentation is found indicating when patient #37 actually came out of seclusion until a note of 4/3 at 3 pm which states in part, "mixing in milieu." Without notes indicating otherwise patient #37 may have been in seclusion between 31 to 47 hours.
The hospital failed to provide physician orders for a secluded patient

Based on review of the the records for two patients it was determined that two restraint orders for patient #37 appear in the record 2 hours and 45 minutes, and 6 hours and 45 minutes after patient #37 was released from restraint as evidenced by:

Patient #37 is a 45-year-old female who on 3/31/2011, admitted from another hospital emergency department on a voluntary agreement with a diagnosis of Bipolar disorder and opiate dependence. Patient #37 reported feeling upset and suicidal, and that she attempted to overdose on pills. Patient #37 has a medical history of coronary heart disease, chronic obstructive pulmonary disease, gastroesophageal reflux disease, chronic back pain, and restless leg syndrome.
On admission of 3/31 at 1:30 pm, patient #37 was noted to be irritable. When the MD would not prescribe narcotics, she escalated to throwing a chair, resulting in a broken window. Patient #37 then threw a trash can, threatened to punch another window, and had threatened the MD. Patient #37 was escorted to the seclusion room where she became combative with staff. A code Green was called, and she was placed in 4-point restraint on 3/31 at 1:30 pm. Orders for restraints appear in the record for 1:30, 5:30, and 9:30 pm.
A nursing note of 2:45 pm states "Restraints removed. Pt. remains in seclusion room with sitter." No new order for seclusion as required is found. A 5:30 and 9:30 pm order are found which are unique to the restraints, had restraints continued at 4-hour intervals, indicating that the 5:30 and 9:30 pm orders were written prior to patient #37's seclusion initiation, and represent prn orders. Further non-real-time documentation, gave attribution (check marks) to "Restraint adjusted and maintained every hour" in the 2, 4, 6, and 8 pm blocks, though patient #37 was no longer in restraint as of 2:45 pm.
The hospital failed when they wrote prn restraint/seclusion orders not based in real-time assessment parameters.

Based on review of two restraint records, the restraint policy, and interviews, it is determined that patient # 36 was not released at the earliest possible time as evidenced by:

Patient #36 is a 31-year-old male, who presented to the emergency department (ED) on 1/23/11 at 6:30 pm via ambulance. Patient #36 was anxious, acutely confused, hearing voices, and feeling that people were following him. He reported feeling depressed and suicidal on 1/22. Patient #36 was noncompliant with medication for some time, following a remote inpatient admission. He was noted to have a negative toxicology, and was medically cleared. At 3:40 am due to a noted increase in disorganized thoughts, he was admitted to the behavioral health (BH) unit on a voluntary.
On the behavioral health unit, Patient #36 was assessed as having psychomotor retardation, and fell asleep during the psychiatric interview. Due to his obtunded state, the psychiatrist held all medications, and was to get a CAT scan to rule out trauma, and make contacts with family for further history.
On 1/24 at 11:50 pm, an RN note states in part, "Pt. pacing and agitated R/T (related to) rules and regulations of 4A. Pt. advised of mandatory lights out and the need to prepare to retire. Pt. refusing all direction and limits. Pt. #36 was offered prns X 5 which he refused. He was given IM medication, but erupted into breaking furniture in bedroom. A full code green was called, and pt subdued, but not (until) after breaking hanging pictures and assaulting staff. He was placed in 4-point restraints. House officer called r/t restraints and protocol." The RN notes him to be sleeping by 12:20 am. A telephone order for 12:10, 4, and 4:45 am appears in the record.
A hospitalist note of 1/25 at 1 am states "Pt evaluated for restraints. Pt agitated and is a risk to himself (broke chair & frame) and to others." At the time this note was written, patient #36 was asleep, which should have required a termination of restraint.
On 1/25 at 1:30 am, an RN note states "At 2355 the patient began to trash his room, broke the chair, the thermostat, and smoke detector. He pushed staff out of the way and tore pictures off the wall in the hallway and flung the pieces at staff. He threw himself at the front entrance. Code Green was called and patient was put in 4-point restraints hard-lock at 1:00 hrs. Pt. became quiet after restraints and soon after went to sleep. T 96.3, P 55, R 16, BP 100/52. Restraints were left on because of potential for violence. He slept off and on. Patient was monitored as per protocol. Urinal was offered to pt. several times and he declined. He took sips of water." The RN states that patient #36 stopped the violent behaviors, yet did not remove him from restraint due to a "potential" rather than actual threat of violence.
The hospital policy states that "Restraint/seclusion must be discontinued at the earliest possible time when the patient meets behavioral criteria." The policy cites examples of behavioral criteria as the patient's ability to "contract for safety, orientation to the environment, and cessation of verbal threats." While a discussion with the patient regarding appropriate behaviors is desirable, patients do not have to make a plan for safety or be oriented to the environment in order to come out of restraint or seclusion. Only cessation of actual violent behaviors or threats represents criteria for discontinuation.
An RN note of 1/25 at 7:30 am states "Patient sleeping. Left to sleep. All restraints in place due to patient ' s explosive violent disposition." This note indicates that patient #36 was left in restraint all night due to the nurse's subjective assessment that patient #36 had an explosive, violent disposition, and not on actual behavioral assessment parameters, which document that patient #36 was sleeping at the time of the note.
On 1/25 at 8 am, a nursing note states "Pt in 4-point restraints. Pt states he will be in physical control and declines need for further medications. Patient states he is in control and wishes to sleep. 97.7, 64, 18, 96/55. Pt ' s restraints removed ... "
Patient #36 remained in restraints for approximately 8 hours, despite documentation indicating that he was asleep ten minutes after restraints began, and had no further violent behaviors or threats.
Hospital Form 7-653 "Restraint & Seclusion Plan of Care" reveals an area for RN documentation of "Clinical Restraints Evaluated Every 2 Hours." In this area are three sections as follow:
1. Unable to follow safety instructions
2. Marked agitation or combativeness which involves aggressive threatening behavior toward another individual. Violent or destructive.
3. Self Injurious Behavior
The RN documented her initials in each of these three areas every two hours from 12 midnight through 6 am, attributing these behaviors to patient #36 during those time frames when he is largely documented by staff as asleep, and had no new violent behaviors. Actual documented behaviors indicate that patient #36 ceased his violence shortly after being placed in restraint. However, neither a physician or nurse considered taking patient out of restraint and instead, twice documented a "potential" for violence.
The hospital failed to release patient #36 at the earliest possible time, violating patient #36's patient rights.

Based on a review of two restraint/seclusion patient records #36 and 37, policy, training and interviews, face to face documentation does not meet regulatory requirements as evidenced by:

On the hospital "Physician Restraint Form" a section for an " LIP/RN Evaluator: Behavioral Health Face to Face Evaluation within one hour of application" has a general statement which reads "I have personally examined this patient and have determined his/her suitability for restraint application/seclusion and validate the order(s) above. " This does not meet the regulatory requirements of the face to face, which asks for A through D of the regulation.

The hospital trains select nurses/LIPs to perform the face to face when a physician is not available. Training for the face to face appears appropriate, excepting restraint policy findings, which give examples of termination criteria such as safety contracts, and orientation to the environment, which do not of themselves, represent criteria for restraint/seclusion.

Patient #36 is a 31-year-old male, who presented to the emergency department (ED) on 1/23/11 at 6:30 pm via ambulance. Patient #36 was anxious, acutely confused, hearing voices, and feeling that people were following him. He reported feeling depressed and suicidal on 1/22. Patient #36 was noncompliant with medication for some time, following a remote inpatient admission. He was noted to have a negative toxicology, and was medically cleared. At 3:40 am due to a noted increase in disorganized thoughts, he was admitted to the behavioral health (BH) unit on a voluntary.

On the behavioral health unit, Patient #36 was assessed as having psychomotor retardation, and fell asleep during the psychiatric interview. Due to his obtunded state, the psychiatrist held all medications, and was to get a CAT scan to rule out trauma, and make contacts with family for further history.

On 1/24 at 11:50 pm, an RN note states in part, "Pt. pacing and agitated R/T (related to) rules and regulations of 4A. Pt. advised of mandatory lights out and the need to prepare to retire. Pt. refusing all direction and limits. Pt. #36 was offered prns X 5 which he refused. He was given IM medication, but " Erupted into breaking furniture in bedroom. A full code green was called, and pt subdued, but not after breaking hanging pictures and assaulting staff. He was placed in 4-point restraints. House officer called r/t restraints and protocol." The RN notes him to be sleeping by 12:20 am. A telephone order for 12:10 am appears in the record. A physician arrived on the unit to sign the restraint order, but neither the nurse or physician signed the area indicated for the face to face evaluator, nor did any progress note describe the all the elements of the face to face.

A hospitalist note of 1/25 at 1 am states "Pt evaluated for restraints. Pt agitated and is a risk to himself (broke chair & frame) and to others." At the time the note was written, patient #36 was asleep, which should have required a termination of restraint.

Patient #37 is a 45-year-old female who on 3/31/2011, admitted from another hospital emergency department on a voluntary agreement with a diagnosis of Bipolar disorder and opiate dependence. Patient #37 reported feeling upset and suicidal, and that she attempted to overdose on pills. Patient #37 has a medical history of coronary heart disease, chronic obstructive pulmonary disease, gastroesophageal reflux disease, chronic back pain, and restless leg syndrome.

On admission of 3/31 at 1:30 pm, patient #37 was noted to be irritable. When the MD would not prescribe narcotics, she escalated to throwing a chair, resulting in a broken window. Patient #37 then threw a trash can, threatened to punch another window, and had threatened the MD. Patient #37 was escorted to the seclusion room where she became combative with staff. A code Green was called, and she was placed in 4-point restraint on 3/31 at 1:30 pm, then was kept in seclusion at the termination of restraint without the benefit of another order for seclusion which would also have required a new face to face.

Patient #37 went into restraint again on 4/1 at 8:15 am, was released, according to documentation, at 4 pm, then remained seclusion without new orders.

The hospital failed to perform appropriate and complete face-to-face evaluations.

Based on review of the medical records of one patient who received a transfusion it was determined that transfusion documentation lacked appropriate information in support of safety measures per the standard of care, and outlined by hospital policy.

Patient #29 is an 85 year old female admitted to Laurel Regional Hospital with a diagnosis of Metabolic Disorder, Renal Failure, Hypokalemia, and Congestive Heart Failure. Based on review of the medical record it was determined that on May 9, 2011 orders were written for Patient # 29 to be transfused a unit of packed red blood cells. On further review of the medical record, specifically the blood transfusion form, it was determined that the unit of blood was not administered according to the hospital's internal protocol and standard patient safety practices.
According to the hospital's Protocol "Blood/Blood Components" pages 6-7 under Documentation. Tag, 5-254 the following items are to be completed for each blood component transfused; signature of two licensed professionals who verified identification of the patient and the blood/blood component, date and time the blood/blood component are initiated, date and time the blood/blood component is discontinued, vital signs at fifteen minutes and one hour after initiation of the transfusion, amount infused, presence or absence of adverse/transfusion reaction, post transfusion vital signs, and verification via check mark boxes as to whether or not a blood warmer was used, and if so what was the temperature/alarm check results and whether any reaction was suspected.
Based on review of Patient #29's blood transfusion form it was determined that the "Transfusion Tag" (form) for Unit # 536M91355 blood transfusion lacked the necessary documentation to complete the form as required by the hospital's protocol and standard safety practices.
On review of the form the following items were not completed: proper verification via signature by the transfusionist that the patient had been properly identified, that an inspection of the patient's wrist band had taken place, or that the unit label, number, and blood group had been checked. In addition the transfusion form lacked a signature for the person who received the unit of blood, date and time the blood was received, date and time the blood was initially started, date and time the transfusion was completed and by whom. The form also required but lacks verification via check mark that the entire unit had been given, whether a blood warmer had been used or if any reaction was suspected.

Based on a review of open and closed records, the following patient records failed to be complete with entries signed, dated and timed as evidenced by:
1. Patient #9 is a 63-year-old male who was in a motor vehicle accident, and suffered a traumatic brain injury. Documentation reveals that on 7/17/2010, separate telephone orders of Gabapentin 400 mg via G-tube BID x 30 days and Percocet 5/325 (?) tabs every 6 hours via G tube for pain until oxy IR is available. These orders were written but not signed by a physician.
2. Patient # 24 is an 86 year old male admitted to Laurel Regional Hospital on July 12, 2011 for Respiratory and Renal Failure. Review of the medical record indicates that an order written by the nurse on July 14, 2011 for a urine analysis does not indicate whether the order was given verbally or via telephone. The physician later signed the order but the order was not timed by the nurse or the physician.
On 7/16/11 an order to place the patient on a ventilator with specific settings was not timed by the physician when signed.
A telephone order written on July 16, 2011 to type and cross match the patient for two units of packed red blood cells had not been signed by the physician in the 48 hr time frame as required and remained unsigned as of July 20, 2011, the day of the survey.
A telephone order to remove a nasogastric tube, insert a new tube and then obtain a stat abdominal-ray lacked the date and time the order was received by the RN.
3. Patient #25 is an 89 year old female admitted on May 6, 2011 for a Small Bowel Obstruction. Review of the medical record indicates that a Physician progress note and a medication reconciliation form dated May 6, 2011 were not timed. The medication reconciliation form also lacked the printed name, date, and time of the clinician as the form requires.
4. Patient #40 is an 84-year-old female admitted on 4/20/2011 for altered mental status who was found to have a urinary tract infection on admission. Documentation reveals three electroencephalograms of 4/21, 4/26, and 5/3, not signed by a physician; a telephone order of 4/20 at 10:25 pm is not signed by a physician, and telephone orders of 4/26 at 1:15 and 8 pm are not signed by a physician.

Based on a lunch meal observation, interviews with food service staff, food service director (FSD), the dietitian and nursing staff, it was determined that the facility staff failed to: 1. utilize the proper measuring utensils that would ensure the appropriate portion size to meet the nutritional needs of the patients; 2. clarify the amount of milliliters of fluid restriction ordered by the physician and 3. meet the nutritional needs of 1 patient with a stage IV pressure sore for 5 days. The findings include:
1. The foodservice staff failed to utilize the proper measuring utensils that would ensure the appropriate portion size to meet the nutritional needs of the patients. Interview with the dietitian and food service manager and review of the diet list for Tuesday 7/19/11 revealed that the facility provides 1 patient a pureed diet and 5 patients a mechanical soft diet. A pureed diet is blended to the consistency of applesauce and used for patients with chewing and/or swallowing problems. A mechanical soft diet is used for patients with difficulty chewing regular food. Certain foods must be chopped or ground depending on the texture of the food and individual needs. On 7/19/11 at 11:30 a.m., the surveyor observed the lunch meal service. The food service worker served the following on the mechanical soft meal tray: #24 scoop (1 1/3 ounces) mashed potatoes and two 2 ounce scoops mechanical soft roast pork loin. The following was served on the pureed meal tray: 2 ounces pureed pork loin, 2 ounces pureed peas and #24 scoop (1 1/3 ounces) mashed potatoes. Interview with the FSD and dietitian and review of the master spread sheet at 11:35 a.m. confirmed that the correct portion sizes should have been 4 ounces (#8 scoop) mashed potatoes, 3 ounces mechanical soft roast pork loin, 4 ounces pureed roast pork loin and 4 ounces pureed peas. After surveyor intervention, the dietitian stated that the portion sizes would be corrected.
2. The nursing and dietary staff failed to clarify the amount of milliliters (ml) of fluid restriction ordered by the physician for 1 of 3 open medical records reviewed. On 7/19/11, review of medical record # 48 revealed on 7/18/11 at 3:30 p.m., the physician ordered a 1000 ml fluid restriction by mouth. As of 7/19/11 at 10:30 a.m., interview with the diet clerk and the dietitian confirmed that the kitchen was not notified about the specific milliliters of fluid restriction ordered by the physician the previous day. Interview with the unit nurse revealed that the nursing staff failed to document the specified amount of fluid restriction into the computer system. Review of the facility policy and interview with the dietitian confirmed that the patient should not be receiving any fluid on meal trays. One liter of fluid should be provided by nursing with medications only. On 7/19/11, Interview with the unit nurse confirmed that by 3 p.m. the patient received 480 ml of fluids with meals and 480 ml with medications therefore only allowing 40 ml of fluid for the rest of the day with medications. On 7/18/11, the dietitian completed a nutritional assessment and documented the 1 liter fluid restriction but she also failed to notify the diet clerk regarding the amount of physician ordered fluid restriction.
3. The facility staff failed to meet the nutritional needs of 1 patient with a stage IV pressure sore for 5 days. The dietitian failed to accurately calculate the amount of calories and protein provided to the same patient. On 7/20/11, review of medical record #17 revealed that the patient had a stage IV sacral pressure ulcer debrided at the hospital. The patient is gastrostomy tube (GT) dependent. A GT is a tube that is surgically inserted into the stomach which is used to provide nutrition, hydration and medications. On 7/16/11, the dietitian assessment stated that the patient ' s estimated needs are 2340 calories and 109 grams protein daily. She erroneously calculated that the patient ' s tube feeding of 55 ml/hour of Nepro for 20 hours provides 2371 calories and 107 grams of protein. She also recommended supplemental 500 mg of vitamin C and a renal multivitamin daily. The GT feeding actually provides 1976 calories and 89 grams of protein daily. This is deficient 354 calories and 20 grams of protein per day. On 7/19/11 at 11:06 a.m., 3 days later, the dietitian recognized her error and documented speaking with the nurse and making the following recommendations: Increase Nepro to 55 ml/hour for 24 hours to provide 2371 calories and 107 grams of protein daily, multivitamin daily and 500 mg of vitamin C daily for wound healing. As of 7/20/11 at 2:35 p.m., the physician had not been notified to discuss the dietitian's recommendations. During an interview, the dietitian stated that the change in the tube feeding rate should have happened right away especially because the patient had an extensive pressure ulcer. The surveyor also discussed these concerns with the unit nurse, clinical dietitian manager and the quality improvement nurse. After surveyor intervention, the next morning, the quality improvement nurse notified the surveyor that at 3:53 p.m. on 7/20/11, the physician ordered the following: Nepro 55 ml/hour for 24 hours, multivitamin 15 ml daily, vitamin C 500 ml daily and water flush 50 ml every 6 hours.

Based on observation, it was determined that facility staff failed to maintain the facility to ensure the safety of the patient as evidenced by:

On July 19 and 20, 2011 the surveyor accompanied by the General Manager and/or the Production and Catering Manager observed the following concerns in the Main Kitchen:

(1) The floors in the following areas were not clean: (a) Storage Room 3; (b) the Dry Storeroom; (c) under the preparation table; (d) the Tube Feeding Room; and (e) under the Traulsen 4-door refrigerator #5.

(2) The exhaust vents in the following rooms were not clean: (a) employees men's and ladies bathrooms; (b) truck washing area; and (c) janitor's closet.

(3) Two electrical junction boxes require covers: (a) above the entrance door in walk-in freezer #1 and under the counter below the Pepsi brand soda dispenser in the cafeteria.

(4) The grout of the floor tiles in the truck washing area is eroding and allows water to settle there. This provides a suitable area for fruit flies to breed.

(5) The wall corner guard is missing near the ice machine.

Additionally, on July 20, 2011 the surveyor accompanied by the General Manager and various unit managers observed the following environmental concerns in the critical care unit (a.) in the old medication room, there is an old unused refrigerator and the floor is dirty and the wall is in disrepair, (b.) In the new medication room, there is a pallet, (c) In Supply Room #364, the floor is dirty under the shelves, and (d.) In the Soiled Utility Room, the flushometer on the clinical sink leaks at the base.

Based on observation, it was determined that facility staff failed to maintain the equipment to ensure the safety of the patient as evidenced by:

On July 19 and 20, 2011 the surveyor accompanied by the General Manager and/or the Production and Catering Manager observed the following concerns in the Main Kitchen:

(1 ) The following food-contact surfaces were not clean: (a.) can opener blade; (b) the meat slicer (also a black cap which covers a hexagonal nut was missing as shown to the Production Manager); and (c) the underside of the vertical mixer.

(2) A non-food contact surface was not clean, the cabinet shelving under the vertical mixer.

(3) A shielded light bulb was not provided in the Traulsen brand refrigerator #5.

(4) Two large hoses equipped with mixing valves and temperatures gauges were installed on the wall in separate locations in the kitchen. It did not appear to the surveyor that they were equipped with a pressure-type backflow preventer. The maintenance staff person disagreed and was asked to supply literature supporting his claim that there was a check valve installed. If there is a check valve it must be a dual check valve.

(5) The maintenance staff person was questioned by the surveyor regarding what procedures were used to maintain the Follett brand ice machine in the main kitchen. The reply was that a contractor routinely does this but he was not sure of the exact procedure recommended by the ice machine manufacturer. This would apply to all machines throughout the facility.

(6.) On the dishmachine, the top for the vacuum breaker for the scrap trough was missing.

(7.) A nozzle end for the fire suppression system was missing, this may affect the suppression chemical stream.

Based on observation it was determined that facility staff failed to maintain the facility to ensure the proper temperatures for refrigeration and for dishwashing as evidenced by :

On July 19 and 20, 2011 the surveyor accompanied by the General Manager and/or the Production and Catering Manager observed the following concerns in the Main Kitchen:

1. The interior thermometers in the following refrigerator or freezer were not accurate: walk-in freezer #1 and walk-in refrigerator #3.

2. On the dishmachine, the final rinse temperature as measured by the gauge was reading in excess of 220 degrees Fahrenheit. To provide a satisfactory final rinse which is not steam, the temperature of the water must be maintained between 180 and 195 per the manufacturer and regulation. Adjustments were made and was brought down to the 200 to 210 range;