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Based on interview and record review, the hospital failed to ensure that the patient representatives of 5 of 20 sampled patients were involved in care planning and treatment decisions (Patients 8, 12, 13, 15, and 17.)

Findings:

1. Patient 8 was admitted to the acute care unit from 10/21/11 to 10/27/11.

Review of the medical record revealed the form "Admission: Acute Care Unit." This documented that, upon admission, Patient 8 was informed of his rights. However, the form also documented that the patient had only "partial understanding" of his rights.

During an interview on 12/6/11, hospital staff were unable to provide documentation that Patient 8's representative was notified of the right to be involved in care planning and treatment decisions during the admission to the acute unit.

2. Patient 12 was admitted to the acute care unit from 10/15/11 to 10/18/11.

Review of the medical record revealed the form, "Admission: Acute Care Unit." This documented that Patient 12 was unable to comprehend his rights.

During an interview on 12/6/11, hospital staff were unable to provide documentation that Patient 12's representative was notified of the right to be involved in care planning and treatment decisions during the admission to the acute unit, other than a phone message notifying her of the patient's admission.

3. Patient 15 was admitted to the acute care unit from 10/15/11 to 10/21/11.

Review of the medical record revealed the form, "Admission: Acute Care Unit." This documented that Patient 15 was unable to comprehend his rights.

During an interview on 12/6/11, hospital staff were unable to provide documentation that Patient 15's representative was notified of the right to be involved in care planning and treatment decisions during the admission to the acute unit, other than a phone message notifying her of the patient's admission.

4. Patient 17 was admitted to the acute care unit from 10/18/11 to 11/3/11.

Review of the medical record revealed the form, "Admission: Acute Care Unit." This documented that, upon admission, Patient 17 was informed of his rights. However, the form also documented that the patient was unable to comprehend his rights and that an attempt to contact the patient's family on the date of admission was unsuccessful. There was no documentation that the further attempts had been made to contact the patient's family.

During an interview on 12/6/11, hospital staff were unable to provide documentation that Patient 17's representative was notified of the right to be involved in care planning and treatment decisions during the admission to the acute unit.





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5. Patient 13 was admitted to the acute care unit from 9/12/11 to 9/14/11.

Review of the medical record revealed the form, "Admission: Acute Care Unit." This documented that Patient 1 was unable to comprehend his rights. She had a family member who was listed as her conservator, however the section of the admission sheet that would indicate the conservator was notified of her right to make decisions about Patient 13's care during treatment in the acute unit was blank.

During an interview on 12/6/11 at 1:00 PM, hospital staff were unable to provide any documented evidence that Patient 13's representative was notified of the right to be involved in care planning and treatment decisions during the admission to the acute unit, other than a phone message notifying her of the patient's admission.

Based on interview and record review, the hospital failed to ensure that a current nursing care plan for pressure ulcers was developed for 1 of 20 sampled patients (Patient 17.)

Findings:

Patient 17 was admitted to the acute care unit on 10/18/11 with diagnoses that included dehydration, emesis, and Stage II pressure ulcer.

On 12/6/11, the nursing care plan was not found in the medical record. Staff stated it was in the computer and provided a printout. There was no plan of care for the pressure ulcer or prevention of further skin breakdown.

Based on interview and record review, the hospital failed to implement its procedure for ensuring that employees who had separated from employment no longer had access to patient information and medical records.

Findings:

Computer access records were reviewed for three employees who had separated from employment in the previous three months. Two of the three employees had not had their computer access terminated and still would be able to access patient medical records and information systems.

During an interview on 12/7/11 at 9:20 AM, clinical records staff stated that she is the one to remove the computer access of separated employees, that she used to receive a list of separated employees monthly from the personnel department, but that she had not received a list for about five months.

During an interview on 12/7/11 at 9:55 AM, personnel department staff stated she used to send the report to clinical records monthly but had not done so for a few months.

Based on observation, record review, and interview, the facility failed to ensure that the acute unit had a current therapeutic diet manual approved by the dietitian and medical staff.

Findings:

During observation of the unit on 12/8/11 at 10 AM, it was observed that the unit did not have a current therapeutic diet manual approved by the dietitian and medical staff. The most current diet manual was not readily available to all medical, nursing, and food service personnel. The copy of the diet manual being used in the unit was dated 3/10/09 while the latest/most current version of the diet manual was dated 4/29/11.

In an interview with the Unit Supervisor (US) on 12/8/11 at 10:30 AM, she acknowledged that the copy of the diet manual available in the unit was not the current one ( dated 4/29/11). The US was not able to give an explanation why the unit did not have the current copy of the diet manual.

Based on observation and interview, the facility failed ensure a safe environment was maintained when it failed to ensure that all smoke alarms were fully operational.

Findings:

During the initial tour on 12/5/11, it was observed that the individual patient rooms each had two smoke alarms that were powered by individual 9 volt batteries. Smoke alarms in patient rooms 4018 and 4026 were periodically making a beeping sound; an indication of a low charge in their batteries. In patient room 4025, one of the alarms was missing from its wall mount.

That same day at approximately 11:15 AM, unit supervisory staff acknowledged she was aware of the situation and had notified plant operations.

Based on observation and interview, the hospital failed to ensure that patient care items were stored in a safe and sanitary manner.

Findings:

During the initial tour of the acute care unit on 12/5/11, boxes of patient care items were observed stored on the floor in storage room 4015.

During an interview at the time, unit staff confirmed the items should not have been on the floor.

Based on observation, record review, and interview, the facility failed to ensure that the Speech Therapist/Pathologist had current ongoing required training.

Findings:

During review of personnel files of on 12/7/11 at 9 AM, it was verified that the unit's Speech Therapist/Pathologist did not have current annual training on Cardiopulmonary Resuscitation (CPR), Infection Control, Emergency Preparedness, Fire Safety, Abuse Prevention, Sexual Harassment/Equal Employment Opportunity (EEO), Adaptive Training and Restrictive Intervention (ATARI), and Health Insurance Portability and Accountability Act (HIPAA).

In an interview with the facility's Standard Compliance Coordinator (SCC) on 12/7/11 at 1 PM, he acknowledged that the Speech Therapist/Pathologist did not have the above-mentioned current required annual training classes per the facility's Staff Development Procedures and Guidelines.