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Based on the Life Safety Code deficiencies observed during a tour of the main hospital and the satellite hospital located at Washington Adventist Hospital , it was determined that the hospital was not in compliance with the Condition of Physical Environment of the Medicare Conditions of Participation for Acute and General Hospitals as evidenced by:

K-015 Failure seal holes and gaps in ceilings and walls and failing to insure the integrity and/or proper flame spread range ratings;

K018 - Failure to insure that a corridor door latched;

K 029 - Failure to maintain smoke barrier doors closed allowing the doors to be propped open by wedges;

K 046- Failure to maintain all emergency lights in operable condition;

K050- Failure to have fire drills at random times on the night shift;

K062- Failure to maintain the sprinkler system in optimal condition;

K069 - Failure to maintain the filters over the cooking area in the kitchen clean and in good repair;

K071 - Failure to maintain the linen chute doors in a manner that prevents a possible fire hazard;

K034 - Failure to maintain stairs free of storage in the main hospital; and

K147 - Failure to employ only GFCI outlets in areas proximal to water.

Based on medical record review and staff interviews, it was determined that the nursing staff failed to notify the nutrition department when nursing confirmed that a client had a 61 pound weight loss.
Resident # 7 has multiple diagnoses including but not limited to status post CABG and Coronary Artery Disease. Upon admission to the hospital on 10/31/13, the client ' s weight was documented at 313.6 pounds on the wheelchair scale. On 11/4/13, the nurse confirmed that the client ' s weight was 251.9 pounds on the standing scale. This indicates a 61.7 pound weight loss since admission (5 days). Review of the consult book revealed that the nursing staff failed to notify the dietitian regarding this significant weight loss on the day it occurred. The dietitian was not made aware of the weight discrepancy until surveyor intervention on 11/6/13. A delay in notifying the dietitian when a client experiences a significant weight loss may have a negative impact on the client including further weight loss and/or dehydration.

Based on medical record review and resident and staff interviews, it was determined that the facility staff failed to monitor and document exactly how many milliliters of fluid was provided and consumed by one client with a physician order to increase po (by mouth) fluids and a second client with a physician order to encourage po fluids. In both cases, the nutrition department was not notified about either physician order regarding fluid consumption of a client. The findings include:
Resident # 8 has multiple diagnoses including but not limited to a CVA, diabetes and abdominal wound as a result of a motor vehicle accident. Medical record review revealed a physician order on 11/4/13 to " Increase po fluids " . Review of the " Patient Treatment Record " and interview with the charge nurse revealed that the nursing staff do not document the amount of fluids provided and consumed by the client. The nursing staff only initial every 12 hours on the treatment record beside " push po fluids " . The nursing staff failed to notify the nutrition department of the physician order to increase po fluids. As a result, the nursing staff cannot properly ensure that the resident is receiving and consuming adequate fluids.
Resident # 9 has multiple diagnoses including but not limited to CVA, hypertension and hypernatremia (elevated blood sodium levels). Review of the closed medical record revealed a physician order on 9/23/13 to " Encourage Po Fluids " (nectar thickened). Review of the " Patient Treatment Record " revealed nursing staff failed to document the amount of fluids provided and consumed by the client. According to facility policy staff are to initial every 12 hours beside the order. Initials are not documented on 7p -7a shift on 9/24/13. In addition, the " Patient Treatment Record " included " Encourage hydration " dated 9/16/13. On 9/24/13, initials are not documented on the 7p-7a shift. Again the nutrition department was not informed of these physician orders related to fluid consumption. As a result, the nursing staff cannot properly calculate the amount of fluid consumed by the client.

Based on interviews, and review of hospital #1's policy for the handling of patient medications which are non-formulary and which need to be utilized during admission, it is revealed that staff practices are not consistent with hospital policy.

Hospital #1 (H1) is part of a hospital system. The main campus of H1 is situated next to one of the system hospitals (H2), and the hospital satellite (H1S) is situated inside one of the system hospitals (H3).

Hospital policy "Medications brought to the Hospital by Patients" (reviewed 7/31/2012) states in part, "During the hours when the (hospital #1) pharmacy is closed, and the (patient) medication must be given prior to reopening the following day, the nurse will bring the medication and the copy of the physician's order to (H2) and ask a pharmacist to review the order and identify the medication."

Interview with the Charge RN at H1S on 11/5/13 at approximately 9:30 am revealed the process for the use of patients' own medications after close of pharmacy when those medications are not found in the hospital formulary. The RN stated that the physician writes an order for the patient to use their own medication. The Pharmacist of H3 then examines the medication for expiration, identification of the medication, and places a small round sticker onto the medication bottle with the pharmacist initials and date. This is consistent with hospital policy.

However, the RN went on to state that the pharmacy generates labels which are sent to the nursing unit, and which the RN applies to the patient's bottle of the medication. The label contains a bar-code, the patient name, and other patient demographics in addition to the original script. The original pharmacy label is not removed from the bottle.

Based on this information, staff practices are not consistent with the policy and is not a generally accepted standard of practice.

Based on review of 19 medical records, policies and procedures, and staff interviews, the hospital failed to ensure that 2 medical records were complete as required by the Federal regulation and as evidenced by:

In 2 of 19 medical record reviews patient #1 and patient #6 the Interdisciplinary Team Conference Note has a section called discharge planning with blocks in front of different resources. The staff after discussing the patient's care needs can check off the block and there is a section for comments. On the two patients medical records this area was blank. There was no indication that the patient had no needs at this time or the decision was still pending based on the patient evaluation. It is during the team meeting that these discharge plans are discussed and should be documented in this area but the area was left blank.

In addition, based on interview and review of patient orders, it was determined that pre-printed admission order forms reveal an area to indicate code status which was left blank.
The hospital paper admission order form revealed a check-box area just under the diagnosis portion on which the physician documents the patient's code status. Review of medical records for patients #2, 3, 4, and 5 revealed this area to be blank. The interview with the Chief Medical Officer revealed that unless other instructions are given, the electronic portion of the medical record defaults to full code status. However by policy and procedure the admission orders must indicate a code status. For patients #2, 3, 4, and 5, the hospital failed to indicate a code status and therefore the medical record is incomplete.

Based on a lunch meal observation, review of diet spread sheets and menus and staff interviews, it was determined that clients with a physician order for a pureed diet are not provided pureed bread. It was also determined that the facility staff failed to provide the correct portion size of ratatouille to 2 clients during the lunch meal observation. The findings include:
During a lunch meal observation on 11/5/13, surveyor observed bread was served to clients on a regular diet; however, bread was not offered or provided to clients with a physician order for a pureed diet. The spread sheet failed to include pureed bread and the kitchen did not have a recipe for it either. Interview of the food service manager confirmed pureed bread is not being served.
The surveyor also observed the food service worker serve ratatouille to 2 clients with a 3 ounce scoop. The surveyor reviewed the facility spread sheet and noted that the correct portion size of ratatouille is 4 ounces, a larger amount. The surveyor notified the food service manager of this concern. After surveyor intervention, a 4 ounce scoop was used to serve the ratatouille. The 2 clients that were served a smaller amount of ratatouille were given a replacement with the proper size.

Based on observations made on November 5-6 2013 during tours of the main hospital and the satellite hospital that prepared its meals and of the remote hospital within hospital and its kitchen the following maintenance concerns were noted:
1. In the main hospital's kitchen, the spray nozzle for the rinse device for the dishwasher extended below the flood rim of the waste sink due to a worn spring and the wash drain bay of the three compartment sink extended into the floor drain and the drain for the ice machine extended about ? inch into floor drain which has the potential to contaminate clean water or surfaces in the event of a back up. .
2. In main kitchen located at Shady Grove Adventist Hospital, the ice machine and both hand sinks at the cook line had drains that extend into the floor sinks. They were copper, so they did not " slip " into the drain.
3. On initial tour at 10:00 AM, in the Washington Adventist Hospital kitchen , it was observed that:
? For the main steam table, the cook had placed wet towels on the entire top of the surface surrounding the steam table food pans. When the surveyor inquired about why, she was told by supervisory staff that the cook does that daily to keep the steam table clean. There was no sanitizer on the towels and they were put there daily between meals. After surveyor intervention, the towels were removed.
? The can opener and stand by the cook line were observed to be excessively soiled.
? The tops of the ovens, etc. under the cook line were greasy and dusty. One large cooking utensil was stored on top of the oven.
? There was a greasy three door fryer under the hood that was inoperable.
? The Victory warming cabinet gasket was held on the unit with 4 pieces of duct tape. The bracket that the gasket is normally attached to was missing.
? There was a water fountain near the hand sink closest to the entrance that was inoperable and had the cover removed, exposing the motor and wiring. I was told that the unit power " was probably " shut off.
? The floor in the dishwashing area was damaged, excessively soiled and there was a water leak, coming from the dishwasher.
? Two hood filters were damaged (louvers missing/ tilted) and the hood filters were very greasy.
? Many old , dried up mouse droppings were observed on the floor in the dry storage room, primarily at the wall floor juncture. Review of the pest records showed that there had been a problem last spring but nothing currently. The facility failed to provide adequate cleaning of the floors along the wall floor juncture.
? At the loading dock, there was a ? inch gap across the bottom of the door leading outside as well as a gap between the two loading dock doors.

During tours of the unit at the Washington Adventist Hospital unit, the surveyor observed 7 empty, 5 full tanks of oxygen in the Clean Utility Room but there was no Oxygen storage sign on the door.

Based on tour of the Washington Adventist Hospital kitchen it was observed the hospital's installation of monitoring thermometer in its kitchen equipment was incorrect and therefore provided possible inaccurate readings as evidence by:

1. Review of the Staff refrigeration unit R 1 on temperature log it was noted that the thermometer read 45 degrees F, however, the thermometer was installed on compressor where air flow from condenser makes the reading inaccurate. Even though it is a designated staff refrigerator, it is located right in a food preparation area and contained foods meant for patients-beverages and health shakes.

2. The exterior thermometer for the walk-in referred to as hot cook during the survey was at 47 degrees, internal thermometer was tied to the cooling fan, so the accuracy of the temperature was questionable .
3. The exterior thermometer on the cold production walk-in was observed at 50 degrees F. The internal thermometer was at 33 degrees F, but due to the location of the interior thermometer on the compressor fan, the accuracy of the temperature could not be ascertained by the surveyor.

Based on observation and staff interviews, it was determined that the nursing supervisor failed to notify the infection control nurse when a nursing aide was not feeling well in order to ensure clearance to work and safety. The findings include the following:
On 11/5/13, during a lunch meal observation, surveyor observed employee wearing a yellow face mask while feeding a client in the main dining room. The surveyor immediately asked the unit manager why this employee was wearing a mask. The unit manager was not aware that the employee was wearing a face mask nor the reason for it. After surveyor intervention, it was discovered that the employee was not feeling well with cold symptoms and a sore throat. Interview with the infection control nurse the next day revealed that she had not been informed of the situation and never cleared the ill employee to work per facility policy.