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Based on medical record review, policy review, observations and staff interview, the facility failed to ensure nursing performed the fall risk assessment per policy and failed to communicate the patient's elevated temperature to the physician. (A 395) and failed to ensure the care plan identified the patient as a high fall risk with interventions for fall prevention. (A 396) The facility also failed to ensure an agency registered nurse followed the current facility policy requiring staff to wear personal protective equipment (A 398). The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patient's nursing needs would be met.

Based on review of the facility bylaws, interview and review of the facility's policy and procedure it was determined the facility failed to ensure the bylaws were reviewed and revised annually per policy. This had the potential to affect all 47 patients.

Findings include:

Review of the hospital's medical staff bylaws revealed they were last reviewed by the medical staff on 03/28/13 and by the governing body on 04/19/13.

Review of the facility policy titled, Governing Board, dated 06/16, revealed the governing body and medical staff bylaws were to be reviewed annually.

Interview with Staff A on 04/05/17 at approximately 12:00 PM revealed the hospital bylaws should be reviewed annually.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure nursing performed the fall risk assessment per policy for Patient #19 and Patient #20 and failed to communicate an elevated temperature to thephysician for Patient #23. A total of thirty one medical records were reviewed. The active census was 47.

Findings include:

According to the policy staff are instructed to re-evaluate patients identified at risk for falls once a week. Review of the Falls Prevention Policy H-PC 03-008 ( Release date 06/2016) states patients are screened for fall risk upon admission and at established intervals thereafter during the patient's length of stay. At the time the fall risk screen is completed, appropriate fall intervention precautions are initiated. A score equal to or greater than 10 revealed the patient is at risk for falls. Those patient's identified at risk for falls will have additional interventions added to their plan of care in an effort to prevent falls. At risk fall interventions may include, but are not limited to use of a falls risk sign/device to communicate the risk to all caregivers (Falling leaves, Falling Stars, bracelets, etc.), use of a reminder to call for help sign posted in the patient's room to remind the patient to call for assistance and use of bed/chair alarms. The fall risk will be re-evaluated weekly.

1. Patient #19 was admitted to the facility on 02/22/17 at 9:00 PM with diagnoses that included sepsis and encephalopathy.The physician's History and Physical also revealed the patient had a history of falls at home. The registered nurse's admission assessment on 02/23/17 at 12:15 AM included a fall risk assessment with a score of a five for mental status change, a two for physical status, a zero for sensory status, and the maximum score of a ten for fall history, for a total score of 17, documenting the patient was a high risk for a fall.

The next fall risk assessment was noted at 12:15 PM on 03/06/17, 11 days after the initial fall risk assessment. This assessment noted a score of a 0 was given for fall history, overall total of 10, still revealing the patient was a high risk for a fall.

The next fall risk assessment was documented on 03/10/17 at 11:00 PM that noted a score of 0 for fall history and overall score at this time was a 9.

The next fall risk assessment was 03/23/17 at 8:00 PM. The total score revealed a high risk for fall, however the history of a fall remained a 0 and did not address the patient's history of falls at home.

A Nursing Note revealed the rapid response team was called at 10:03 AM on 03/25/17 as the patient fell out of bed and was found with his knee to heel still in the bed. The CT revealed no acute injury.

A fall risk assessment was performed by a registered nurse after the fall at 10:21 AM on 03/25/17. The patient received a total score of a 9 with a 0 for his/her fall history.

Staff B, the Nurse Manager, was interviewed on 04/06/17 at 3:15 PM. According to Staff B, re-evaluations of patients identified at risk for falls should occur every Thursday. It was confirmed the medical record lacked documentation of the weekly re-evaluations. Staff B also revealed that the patient should have received a score of a 10 for fall history due to the patient's documented history of falls prior to admission.

2. Review of Patient #20's medical record on 04/07/17 revealed an admission date of 02/03/17 with diagnoses that included diabetes mellitus II and end stage renal disease. Further review of the medical record revealed on 02/03/17 a fall risk assessment was completed and the patient scored 19, documenting the patient was a high risk for a fall.
No other fall risk assessments were completed during the hospital stay. The patient expired on 02/23/17.

Interview with Staff I on 04/07/17 at approximately 11:40 AM revealed fall risks assessments are required to be completed weekly. Staff I verified at that time that a fall risk assessment was completed on 02/03/17 and no other fall risk assessment was completed.

3. Patient #23 was admitted to the Intensive Care Unit on 12/11/16 at 5:15 PM with diagnosis of encephalopathy. The patient was noted to be a full code. The patient's temperature on admission was within normal limits at 97.6 degrees Fahrenheit. At 4:00 PM on 12/26/16 the patient's temperature was elevated at 101.8 degrees Fahrenheit. A Nursing Note at 4:52 PM revealed the nurse called the physician leaving a message on a recorder stating the patient's elevated temperature. A Nursing Note at 4:55 AM revealed the physician was called again but there was no answer. The patient's temperature remained elevated at 101.8 at 12:00 AM. The medical record lacked documentation the physician was informed of the patient's elevated temperature.

Staff B was interviewed on 04/07/17 at 4:15 PM and confirmed this finding.






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Based on observation, medical record review, and staff interview, and policy review it was determined the facility failed to ensure the care plan identified the patient as a high fall risk with interventions for fall prevention. This affected five patients of thirty one medical records reviewed. (Patient #21, #22, #2, #19 and #31) A total of thirty one medical records were reviewed. The active census was 47.

Findings include:

Review of the Falls Prevention Policy H-PC 03-008 ( Release date 06/2016) states patients are screened for fall risk upon admission and at established intervals thereafter during the patient's length of stay. At the time the fall risk screen is completed, appropriate fall intervention precautions are initiated. A score equal to or greater than 10 indicates the patient is at risk for falls. Those patient's identified at risk for falls will have additional interventions added to their plan of care in an effort to prevent falls. At risk fall interventions may include, but are not limited to use of a falls risk sign/device to communicate the risk to all caregivers (Falling leaves, Falling Stars, bracelets, etc.), use of a reminder to call for help sign posted in the patient's room to remind the patient to call for assistance and use of bed/chair alarms. The fall risk will be re-evaluated weekly.

1. Review of the medical record for Patient #21 revealed the patient was admitted on 03/22/17 status post cardiac arrest and multi-organ failure. A fall risk screening was completed on 03/23/17 at 1:10 AM with a score of 21, high risk for a fall. The care plan failed to identify the patient was a high risk for falls.

Although the daily nursing documentation beginning 03/31/17 revealed interventions including fall signage, ID band, and a bed alarm being utilized, observation of a respiratory treatment for Patient #21 on 04/04/17 at 11:00 AM revealed none of the documented interventions in the nursing notes were in place.

2. Review of the medical record for Patient #22 revealed the patient was admitted to the facility on 02/27/17 with diagnosis of neurosarcoidosis. The falls risk assessment dated 03/23/17 identified a fall risk score of 12, high risk for a fall. The care plan failed to identify the patient was a high risk for falls.

Review of daily nursing notes revealed interventions in place to include an ID band and posted sign, however, observation of a respiratory treatment for Patient #22 on 04/04/17 at 11:22 AM revealed none of the documented interventions in the nursing notes were in place.

3. Review of the medical record for Patient #2 revealed the patient was admitted to the facility on 03/22/17 following a subarachnoid hemorrhage secondary to a motor vehicle accident. The nursing admission assessment identified a fall risk score of 13, high risk for a fall.

Patient #2 fell on 03/26/17 with no injuries noted.

The care plan lacked interventions prior to the patient's fall on 03/26/17.

This finding was confirmed with Staff B on 04/04/17 at 2:34 PM.

4. Patient #19 was admitted to the facility on 02/22/17 at 9:00 PM with diagnoses that included sepsis and encephalopathy. The nurse's admission assessment on 02/23/17 at 12:15 AM identified a fall risk score of 17, high risk for a fall.

The care plan lacked interventions prior to the patient's fall on 03/25/17.

This finding was confirmed with Staff B on 04/06/17 at 5:30 PM.

5. Review of the medical record for Patient #31 revealed the patient was admitted on 02/25/17 for diagnosis of respiratory failure.The medical record revealed a fall risk assessment was completed on 02/25/17 with a score of 14, high risk for a fall.

Patient #31's care plan failed to identify the patient was a high risk for falls and/or interventions.

This finding was confirmed with Staff B on 04/07/17 at 4:45 PM.

Based on observations made during a tour, facility policy review, and staff interview, the facility failed to ensure non-employee nursing personnel adhered to the current facility policy for transmission-based precautions. This had the potential to affect all patients cared for by non-employee nursing personnel.

Findings include:

The Medical Surgical unit was toured on 04/03/17 at approximately 10:30 AM. Yellow signage on the door of room number 2030 revealed anyone entering the room should be wearing a gown and gloves as the patient was in contact isolation. There was also a small yellow sign to the right of the door that read "contact isolation." A staff member was observed caring for the patient in room 2030. Although the staff member was wearing disposable gloves, he/she was not wearing a disposable gown. Staff D, the Education Coordinator, present during the tour, identified this staff member as an agency registered nurse. Staff D asked the agency nurse to put on his/her gown and the agency nurse stated: "There weren't anymore gowns in the cart."

The facility policy titled Transmission-Based Precautions was reviewed on 04/03/17 at 03:00 PM. According to the policy contact precautions is a method designed to reduce the risk of transmission of microorganisms by direct or indirect contact. Contact precautions are used for patients with known or suspected infections. Contact precautions include hand hygiene, gloves, gowns, and masks. The policy instructed staff to don a gown whenever clothing may have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient.

The medical record of Patient #4, the patient in room number 2030, was reviewed. The patient was admitted to the facility on 03/23/17 for sepsis secondary to MRSA bacteremia. It was further noted that the patient had MRSA in a wound. He/She was placed in contact isolation at the time of admission.

Staff I, the Infection Control Practitioner, was interviewed on 04/04/17 at 02:30 PM. It was confirmed that the agency nurse should have been wearing a disposable gown to care for the patient.

Based on observation, staff interview, and review of policy and procedure the facility failed to maintain the privacy and confidentiality of patient health information. This affected one (Patient #31) of thirty one medical records reviewed. The active census was 47.

Findings include:

Review of the Safeguards: Paper Documents Containing Protected Health Information Privacy and Security Policy 25 states paper documents containing personal health information will be maintained in a manner that maintains privacy. All reasonable safeguards will be taken to reduce the potential for unauthorized acquisition, access, use or disclosure of personal health information.


On 04/06/17 at 10:00 AM observation of a terminal clean by an environmental service aide was conducted in room 2048 on the medical surgical unit. The patient was discharged and left a hospital bag that contained personal hospital items and paperwork. During the terminal clean the environmental service aide placed the hospital bag in a larger bag to be discarded with regular trash. The hospital bag was requested to be removed from the trash bag to identify the paperwork. The bag was retrieved and included the patient's admission facesheet which included demographics, admission agreement, patients rights and responsibilities, anatomical gift by living donor form, advance directives form, notice of privacy practices, medicare payer questionnaire, and valuables statement. All documents were signed /dated by the patient on 03/02/17 at 1:00 PM.

Staff G stated in an interview on 04/06/17 at 10:22 AM he/she didn't know patient health information was in the hospital bag. Staff B was observing at this time and confirmed personal health information was discarded in the regular trash. Staff B proceeded to discard the paperwork in the shred bin in the nurses station.

Based on observation, staff interview, and policy review it was determined the facility failed to ensure all dosimetry badges were monitored for radiation exposure. This affected one badge of twenty one badges monitored on the quarterly report. The active census was 47.

Findings include:

Review of the Radiology Department Radiation Protection Program Policy and Procedure ( Reviewed 2016) states personnel monitoring devices must be left in the designated storage area when not in use. Personnel monitoring devices are not to be taken home. Employees caught tampering with badges will face disciplinary action.

Tour of the radiology department on 04/04/17 at 3:45 PM identified the dosimetry badges stored within the department. Staff D stated the badges are sent off site monthly to the manufacturer and/or vendor for testing/monitoring of radiation exposure and a quarterly report is generated. A random dosimetry badge was pulled from the storage area to identify if all badges were being monitored for radiation exposure per the quarterly report. The first badge pulled failed to be included on the quarterly radiation dosimetry report.

Staff D stated in an interview on 04/05/17 at 9:52 AM the staff member took the dosimetry badge offsite and he/she will start the disciplinary process as per policy. Staff D confirmed with the vendor the employee had no monthly monitoring of the dosimetry badge for the quarterly report dated 01/30/17.

Based on observation during facility tour and staff interview it was determined the facility failed to meet the provisions of the Life Safety Code of the National Fire Prevention Association (NFPA). This had the potential to affect all those utilizing this facility. The facility census was 45 at the beginning of the survey.

Findings include:

K-353 Failed to ensure the sprinkler system was maintained

K-372 Failed to ensure the integrity of the one hour fire resistive smoke barrier

K-374 Failed to ensure the smoke barrier doors were functioning properly

Based on observations made during facility tour, policy review, and staff interview, the facility failed to ensure staff adhered to current infection control policies to prevent the spread of infections. This had the potential to affect all patients in the facility. The active census was 47.

Findings include:

1. The Medical Surgical and Intensive Care units were toured on 04/03/17 at approximately 10:30 AM. A staff member was noted to walk into Room #3004. A yellow sign was posted on the door that revealed gloves and a disposable gown must be worn when entering the patient room due to the patient being in contact isolation. The staff member went to the bedside of the patient and explained to the patient that he/she was going to perform an ordered test. Staff D, the Education Coordinator, present during the tour was asked if this staff member was required to wear personal protective equipment as the patient was in contact isolation. Staff D reported that the staff member should be wearing gloves and a disposable gown.

A sign on the door of Room #2012 on the Intensive Care unit also revealed that anyone entering the room should be wearing personal protective equipment. A visitor was observed sitting in a chair beside the patient's bed. The visitor was not wearing gloves or a disposable gown.

The facility policy titled Transmission-Based Precautions was reviewed on 04/03/17 at 3:00 PM. According to the policy contact precautions is a method designed to reduce the risk of transmission of microorganisms by direct or indirect contact. Contact precautions are used for patients with known or suspected infections. Contact precautions include hand hygiene, gloves, gowns, and masks. The policy instructed staff and visitors to wear gloves and don a gown whenever clothing may have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient.

Staff I was interviewed on 04/05/17 at 3:15 PM. It was confirmed that all staff and visitors entering both rooms should have been wearing both gloves and disposable gowns.

2. Observation during tour of the kitchen with Staff E on 04/04/17 at approximately 9:57 AM revealed the food preparation area freezer contained two opened undated frozen pizzas in a plastic bag, a bag containing seven opened undated breadsticks and 3 bags of opened undated packages of flat bread. Continued observation of the kitchen revealed the storage room freezer had no working thermometer with a package of opened, undated frozen sausage. Further observation revealed rice in a container with the scoop inside. In addition, a container of flour had the scoop inside with an open date of 10/02/16 and a discard date of 04/02/17.

These findings were verified at that time with Staff E, who stated scoops should not be stored in the containers with food and opened food items should be labeled with the date that the package was opened and the date of expiration. These findings were verified with Staff E who stated the freezer thermometer had not been working for "a couple of days".


Observation on 12/4/17 at 12:21 PM of the dietary tray line revealed dried brown substance with corn, peas, carrots and other unidentifiable crumbs under and flowing out into a drain under the food tray line preparation table. Staff E verified the finding at that time and stated that should not be on the floor because staff should mop daily.


Review of the dietary cleaning schedule log on 04/04/17 revealed the floor had not been mopped since 04/01/17.


Review of the hospital policy titled, Food and Supply storage dated 01/30/98 revealed the refrigerators and freezers should have one integral permanently affixed thermometer and one located inside the unit to measure the air temperature inside the warmest part of the freezer unit. In addition, the policy stated food products that are opened and not completely used and stored, should be labeled as to its contents and use by dates. The policy also states, scoops should not be stored in ingredient bins or containers.













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Based on staff interview and personnel file review it was determined the facility failed to ensure there was a director of respiratory services who was a doctor of medicine with responsibility for operation of the service.

Findings include:

Review of the organizational chart revealed Staff G was listed as the Director of Respiratory and Radiology departments.

Review of the Staff G's employee personnel file revealed a job description signed on 03/28/16 as the Respiratory Therapist Manager.

Staff M, the Assistant Administrator, stated on 04/07/17 at 4:40 PM the facility has a Medical Director for Respiratory and Critical Care, however, was unable to provide evidence the governing body had appointed this physician as the medical director and stated the personnel files were in Dallas, Texas.