HospitalInspections.org

Based on document review and interview the facility failed to ensure the Medicare IM (important message) form was presented and signed within the appropriate time frame, per the facility policy, for 4 of 10 records reviewed, Patients #2, #8, #9 and #10.

Findings Include:
1. Review of the Financial Policies and Procedure Manual, section 2.0, Patient Admissions, page number 7 indicated in section 2.6 Admission Documents, that a) Required Inpatient Forms included the "Important Message from Medicare/Champus...", and on page 8. in section c); Explanation of additional forms required for Medicare patients: Inpatients - An Important Message from Medicare/Champus - This form shall be given to the patient within 2 calendar days of admission and be signed by the patient/representative. Follow-up copy of the form signed at admission shall be given to the patient within 2 calendar days of discharge...it is the responsibility of the DQM (director of quality management)/Admissions clerk to ensure that this information is accurate...".

2. Review of medical records indicated:
A. Patient #2 was a current 72 year old patient admitted 12/5/16 who lacked a signature on the Medicare IM form in the chart.
B. Patient #8 was an 89 year old admitted on 11/16/16 and discharged on 12/9/16 who lacked a Medicare IM form signed prior to discharge.
C. Patient #9 was a 70 year old admitted on 11/3/16 and discharged on 11/25/16 who lacked a signed Medicare IM form at admission or at discharge.
D. Patient #10 was a 67 year old admitted 11/10/16 and discharged 11/29/16 who lacked a date and time on the signed Medicare IM form to be able to determine if it was for the time of admission or discharge.

3. At 4:25 PM on 12/20/16 and 9:15 AM on 12/21/16, interview with staff member #51, a nurse manager, confirmed that documentation related to the Medicare IM was missing for patients #2, #8, #9 and #10, as listed in 2. above and not per facility policy.

4. At 3:00 PM on 12/20/16, 10:30 AM, 11:00 AM and 1:00 PM on 12/21/16, interview with the CCO (chief clinical officer), staff member #50, confirmed that the unit secretary is responsible for getting admission documents signed, except for the consent for admission and treatment forms and the Medicare IM form, in which RNs are responsible for getting these signatures at the time of admission.

Based on document review and interview the facility failed to ensure that in its written notice to a complainant that the steps taken to investigate a grievance and the results of that investigation were clear for 1 of 1 grievance related to patient #7.

Findings Include:
1. Review of the facility policy Patient Complaint/Grievance Process, policy number H-ML 04-008 PRO, last approved/released 6/2016 indicated: under section 5. "DQM (director of quality management) Responsibilities", in item i.: "Once an action has been taken: i. Assure the complaining party is aware of the investigation results and actions taken. ii. If it is a grievance, face to face (preferred) or verbal contact should be made with the complainant to discuss the investigation and action taken before the written response (CEO [chief executive officer] letter) is sent...l. Send the final CEO letter as soon as: i. the (sic) investigation is completed and the issue resolved, or ii. it (sic) is determined resolution is not achievable...7. CEO obligations...d. Responding to Grievances...i. Call the complainant to discuss the results of the investigation and the actions taken to resolve the grievance. ii. Ask the complainant if they consider the matter resolved...".

2. Review of complaints and grievances indicated one had been filed by the family of patient #7 verbally on 11/7/16 and in writing on 11/11/16 with a letter dated 11/10/16 from the CEO that read:
A. "I am writing to thank you for sharing your concerns with us regarding your admission and first few days here in the hospital. We welcome your feedback as a valuable tool for improving the patient experience at [this facility]."
B. "We understand that your room when transferred here from [an acute care hospital] was not prepared as you expected and did not have all of the DME items that you use. Further one of your medications was not available and your room had a plumbing and a call light problem. We agree that if this happened as you reported it, this is not the type of experience we would want for you."
C. "Please let me assure you that we take this information seriously and respond responsibly. As you know your [family] called me immediately Sunday afternoon, the day you were admitted and again Monday morning, [named] CCO and I met with you frequently to make certain that all of your concerns are being addressed. [named] our Patient Advocate has also been involved with any follow up. As you know all of the issues expressed were timely addressed and resolved and no longer a concern we continue to monitor to ensure that your remaining days here in [facility] are satisfactory and pleasant."
D. "Again we apologize for the experience you had, and we are serious about maintaining the improvements your feedback has initiated. Having taken this action, we are considering this matter closed at this time Thank you for allowing us to provide medical care for you at [this facility]."
E. "Thank you again for your feedback. Please be assured it will benefit all of those who depend on our services."

3. At 1:50 PM on 12/21/16, interview with the CEO, staff member #52, confirmed that:
A. This staff member felt that the specifics of the investigation process and steps taken to investigate the complaint and its results were present in their letter to the patient.
B. It was not felt that they needed to give more detail than that which was written.
C. This staff member and others met with the family of patient #7 during their hospitalization in attempts to meet thier needs.

4. No documentation was provided related to staff member #52 stating that staff met with patient #7 and/or their family to resolve issues and meet their needs.

Based on document review and interview the facility failed to ensure that consents for admission and treatment were signed, per the facility policy, by 4 of 5 current patients or their representative, Patients #2, #3, #4 and #5.

Findings Include:
1. Review of the Financial Policies and Procedure Manual, (no approval date noted), section 2.0, Patient Admissions, page number 6 indicated in section 2.5 Patient Admission, section c) Completing Admission Forms that "...Ensure that all fields are completed on admission documents and that the documents are signed by the patient/representative upon admission. Notify Controller/designee when signatures cannot be obtained and document reason...a) After Hours Admission When Admissions Clerk/designee is not available, the Nursing supervisor/designee shall register the patient in Meditech through the After Hours Admission routine to create the Protouch registration and allow for immediate medical record documentation...".

2. Review of current patient medical records indicated:
A. Patient #2 was admitted on 12/5/16 and lacked a signed consent for admission and treatment.
B. Patient #3 was admitted on 10/4/16 and lacked a signed consent for admission and treatment.
C. Patient #4 was admitted on 12/15/16 and lacked a signed consent for admission and treatment.
D. Patient #5 was admitted 11/23/16 and had consents signed by the family but lacked a witness signature and a date or time of family authentication.

3. At 4:25 PM on 12/20/16 and 9:15 AM on 12/21/16, interview with staff member #51, a nurse manager, confirmed that documentation was lacking for consents for patients #2, #3, #4 and #5 as listed in 2. above.

4. At 3:00 PM on 12/20/16, 10:30 AM, 11:00 AM and 1:00 PM on 12/21/16, interview with the CCO (chief clinical officer), staff member #50, confirmed that the unit secretary is responsible for getting admission documents signed, except for the consent for admission and treatment forms and the Medicare IM form, in which RNs are responsible for getting these signatures at the time of admission.

Based on document review and interview the nursing executive failed to implement the facility staffing guidelines grid for portions of a three week period in November for the 5th and 6th floor nursng units.

Findings Include:
1. Review of the document "Staffing Guidelines", no policy number, dated 6/26/16 indicated that for the 5th floor 5 RNs (registered nurses) and 3 CNAs (certified nursing assistants) are to be scheduled on the day and night shift for 22 or more patients and for 22 or more patients on the 6th floor, there are to be 4 RNs and 3 CNAs scheduled on both shifts for 22 or more patients.

2. Review of the staffing for the 5th floor for the week of 11/6/16 to 11/12/16 indicated that on 11/9 and 11/11/6, there were only 2 CNAs with 22 patients present each day and on 11/9, 11/10, 11/11 and 11/12/16 there were only 2 nurse aides on the night shift with 22 patients present each day.

3. Review of the staffing for the 5th floor for the week of 11/20/16 to 11/26/16 indicated 11/23/16 had 23 patients with only 2 CNAs scheduled for both the day and night shift.

4. The 6th floor census for the week of 11/6/16 to 11/12/16 had a census of 23 each day. The day shift staffing lacked the required number of aides on 11/7/16, 11/8/16 and 11/9/16 when only 2 were staffed, with the guidelines indicating 3 were to be scheduled.

5. The week of 11/13/16 to 11/19/16 for the 6th floor indicated the census was 22 or 23 all week. The night shift on 11/16/16, 11/17/16, and 11/18/16 had only 2 nurse aides scheduled when the guidelines indicated that 3 were to be staffed for that census number.

6. The week of 11/20/16 to 11/26/16 for the 6th floor indicated there was a census of 22 to 24 patients. The day shifts on 11/22/16 and 11/23/16 had only 2 nurse aides with the census on the 22nd being 23 and on the 23rd being 24 patients so that 3 nurse aides were required. The night shifts on 11/20/16 and 11/24/16 had only 2 nurse aides with the 20th having 22 patients and the 23rd having 24 patients and both shifts requiring 3 nurse aides, per the staffing guidelines document.

7. At 1:00 PM on 12/21/16, interview with the CCO (chief clinical officer), staff member #50, confirmed that the acuity of patients is also considered when staffing the 5th and 6th floor nursing units, and not just the staffing grid. The facility "may cut back on the number of aides" with a lower acuity of patients "for budgetary reasons".

Based on document review, observation and interview, the facility failed to ensure that a infection control practices, in relation to a clean facility, were maintained in one patient room that was reported to be ready for a patient admission, room 5203, and related to hallway ceiling lights, a portable vital signs monitor and a supply room and the infection control committee failed to ensure there was an active and effective implementation of requirements for standard/contact precautions for staff entering 3 patient rooms on the 5th floor in which patients were noted to be on contact precautions, rooms 5201, 5220 and 5221, and two rooms on the 6th floor, rooms 6207 and 6218.

Findings Include:
1. Review of the policy Terminal Cleaning of a Patient Room, policy number HD: H-HC 02-011, last approved 5/2015, indicated under "Rationale": "Patient rooms are thoroughly cleaned and disinfected following termination of occupancy by transfer or discharge...Terminal cleaning is completed before another patient is admitted or transferred to that room...Terminal cleaning of a patient room includes window sills, furniture, bed, bathroom (toilet, handrail, sink, shower/tub, and bathroom fixtures), inside bedside drawers and over-bed drawer, light switches, door handles, floor, etc.." Under Procedure on page 3 indicated cleaning staff was to: "...6. Remove disposable items, placing them in a plastic bag to be discarded, empty trash including biohazard trash, and remove from room...8..a. Dust and wipe down all ceilings and walls...d. Be sure to wipe/dust everything shoulder high and above...".

2. At 11:55 AM on 12/20/16, the 5th floor nursing unit was toured in the company of staff member #50, the CCO (chief clinical officer) and the following was observed:
A. Room 5203 was reported to have been cleaned and ready for the next patient with the following issues noted:
a. There was dust and debris noted on the floor as one entered the room and in corners of the room where housekeeping had failed to mop the floor sufficiently.
b. There was a dried splash noted on the ceiling above the bed (approx. 12 inches in diameter) and dark stains observed in the crevices between several ceiling tiles.
c. There was an accumulation of dust on the top of a wall mounted cork/communication board.
d. There was trash present in a receptacle which included IV bags and tubing.
e. One of the two call lights in this private room did not work.
f. The louvered wall mounted air vent on the wall behind the bathroom toilet had an accumulation of dust present.
g. The toilet had a leak when flushed, with water spraying out from a joint/gasket.
h. Wall tile were protruding and not flush on the wall behind the toilet.
B. At 1:20 PM on 12/20/16, it was noted that the drop down ceiling lights in the hallway outside rooms 5220 and 5221 had bugs present with one having 12+ present.

3. At 11:55 AM, 12:45 PM and 1:20 PM on 12/20/16 the CCO, staff member #50, confirmed that:
A. Room 5203 had a note on the door that it had been terminally cleaned and was ready for admission of the next patient.
B. Room 5203 was not cleaned as per facility policy and expectations and conditions were found to be as listed in 2. above.
C. At 12:45 PM, it was noted that the ceiling was being mopped (with a long handled tool) by housekeeping staff and the "splash/stain" was removable as were the black areas in the ceiling tile crevices.

4. At 1:25 PM on 12/20/16, the 6th floor nursing unit was toured in the company of staff member #50 and the following was observed:
A. The base unit of the B/P (blood pressure) monitor on wheels (in the hallway by the nursing station) was noted to be dirty and with a substance that resembled dried Betadine.
B. The supply room had dust present under the rolling supply carts as well as wrappers and shoe covers noted to be on the floor under the carts.

5. At 1:25 PM on 12/20/16, staff member #50 confirmed the conditions noted in 4. above.

6. At 12:15 PM and 1:50 PM on 12/20/16, interview with the contracted EVS (environmental services) director, staff member #53, confirmed that:
A. Ceilings are not on a cleaning schedule and are not washed with terminal cleaning. They are only washed "when requested", and it was unknown when the ceiling of 5203 had last been cleaned.
B. There is no log of cleaning for the drop down hallway ceiling lights, they are not on a "set schedule" for cleaning.
C. There is one staff member per day who cleans the "core area" of each floor. The supply room daily cleaning is considered part of the core cleaning.

7. At 12:50 PM on 12/21/16, interview with the infection control preventionist (ICP), staff member #61, confirmed that:
A. They have only been the ICP since October 2016.
B. They have not been following or checking up on the contracted EVS staff to be sure they are meeting the needs and requirements of the hospital in relation to infection control and cleanliness.

8. Review of the policy Transmission-Based Precautions, policy number H-IC 02-002 PRO, last approved 8/2016 indicated under Procedure: "...2. If an infection appears to be present the recommended appropriate transmission based precautions should be executed at that time... 4. Post the appropriate precaution signage visible outside patient room...". And on page 6 under section G. "Duration of isolation (sic) for Patients with Identified MDRO's (multi drug resistant organisms): a) Patient with positive cultures for MDRO typically remain in precautions for the duration of their present admission...".

9. While on tour of the 5th floor nursing unit at 11:55 AM on 12/20/16 in the company of the chief clinical officer, staff member #50, it was observed that:
A. Staff (a rehab tech, staff member #55) was in a posted contact isolation room (5201) with no gown on.
B. 2 staff members (1 nurse, staff member #59 and one respiratory therapist, staff member #54) were observed in an isolation room (5221) with no PPE (personal protective equipment) on.
C. 1 physician (staff member #58) was observed in an isolation room (5220) with no PPE on.

10. At 11:55 AM on 12/20/16, staff member #50 confirmed that the staff listed in 2. above were all in contact precaution rooms without the appropriate PPE.

11. While on tour of the 6th floor nursing unit in the company of staff member #50 at 1:25 PM on 12/20/16, it was observed that:
A. There was no contact precaution signage on the door to room 6207 but staff was wearing PPE to enter.
B. 1 dietary employee failed to sanitize their hands prior to gloving and gowning to deliver a meal tray to room 6218 which had a contact precautions sign on the door.

12. Review of the medical record for the patient in room 6207 indicated they had lab cultures that were positive for CRE.

13. At 4:25 PM on 12/20/16, interview with nurse manager, staff member #51, confirmed that patient #5 had CRE and should have had contact precautions signage posted on the door of their room.

14. At 12:50 PM on 12/21/16, interview with the infection control preventionist (ICP), staff member #61, confirmed that:
A. They have only been the ICP since October 2016.
B. They have not been monitoring the appropriateness of signage for patients on contact or other types of precautions.
C. Staff have not been tracked or observed for appropriateness of PPE when entering patient rooms of those in isolation/precautions.