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Based on observation, document review and interviews it was revealed the Executive Director failed to ensure the facility employs an adequate number of medical record personnel to ensure prompt completion, filing and accessible medical records. This failure has the potential to place all patients at risk for incomplete and damaged stored medical records.

Findings include:

1. An observation conducted of the medical records department on 01/14/20 at approximately 9:38 a.m. revealed multiple stacks of patient files piled waist high and stored on the floor and on chairs. The filing cabinets are full of medical records without any additional space for filing.

2. A review of the "Organizational Chart" revealed the employee working in medical records is designated as the "Director of Medical Records."

3. A review of the "Medical Records" job description, performance evaluation dated 12/22/17, states in part: "Assure that work/assignment areas are clean and records, files, etc. are properly stored ... Report all unsafe/hazardous conditions ...."

4. An interview with the Director of Medical Records was conducted on 01/13/20 at approximately 1:30 p.m. When asked if there is adequate staffing for medical records she stated in part: "I work full time for the skilled nursing facility and part time for the rehabilitation hospital." When asked what the expected time is to file patient records she stated in part: "It is expected for the orders to be signed and charts completed and filed within two (2) weeks."

5. An interview was conducted with the Director of Medical Records on 01/14/20 at approximately 9:38 a.m. When asked if she is able to adequately maintain patient medical record files she stated in part: "I am the only employee. I also get pulled to work the hospital units when they are short staffed."

6. An interview with the Director of Nursing and social worker #1 was conducted on 01/14/20 at approximately 3:00 p.m. When asked if the medical records department is staffed adequately to maintain patient medical records they stated in part: "The Director of Medical Records is a Licensed Practical Nurse and gets pulled to the unit to work and not able to complete the chart audits in a timely manner." When asked if she is the only employee in the medical records department, they concurred.

A. Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that three (3) of thirteen (13) inpatient medical records failed to have a discharge summary (patient #7, # 10 and #12). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of discharged medical records for the acute inpatient rehabilitation hospital revealed patient #7, #10 and #12 failed to have a discharge summary.

2. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "Discharge Summaries - All patient/residents records shall include a discharge summary."

3. An interview was conducted with the Director of Nursing (DON) on 01/13/20 at 2:10 p.m. When asked if she could find the discharge summaries for patient #7, #10 and #12 she stated, "No, there isn't any."

4. A telephone interview was conducted with the Medical Director of the Inpatient Rehabilitation Center on 01/15/20 at 9:20 a.m. When asked the expectation of a discharge summary being completed by the Nurse Practitioner or physicians he stated in part: "I expect them completed within thirty (30) days of the patient being discharged." When asked if they have a procedure to ensure the discharge summary is completed he stated in part: "I am told if there is no discharge summary or if charts need signed and then I contact the practitioners to have them sign them... I did not know this was a problem on the rehab side of the hospital. I've only been made aware of it on the skilled nursing facility of the hospital."

5. An interview was conducted with the administrator on 01/15/20 at approximately 9:40 a.m. He concurred with the above findings.

B. Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that two (2) of thirteen (13) inpatient medical records failed to have a signature by a practitioner for a telephone order (patient #7 and #10). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of the medical record for patient #7 revealed a telephone order given by physician #1 on 12/06/19 with no time noted that states, "Foley cath care every shift, empty foley & record amount every shift, change O2 tubing every Sunday 7-3, air mattress check function every shift." No physician signature noted. A second telephone order on 12/07/19 with no time noted given by physician #2 states, "Send to ER for evaluation." No physician signature noted.

2. Review of the medical record for patient #10 revealed a telephone order given by Nurse Practitioner #1 on 11/09/19 for the patient to be discharged to a funeral home. No Nurse practitioner signature noted.

3. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "A verbal order will include the date, time and full signature and title of the person to who the verbal order has been given and will be authenticated by the prescribing medical staff member at the next visit."

4. An interview was conducted with the DON on 01/13/20 at 2:10 p.m. When asked if she could find an order with the practitioner's signature on patient #7 and patient #10, she stated in part: "No" and concurred with the above findings.


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C. Based on observation, document review and interviews it was revealed the Executive Director failed to ensure the facility properly files, retains, makes accessible and protects medical records from exposure to water and damage in the medical records department. This failure has the potential to place all patients at risk for incomplete and damage of medical records.

Findings include:

1. An observation conducted on 01/14/20 at approximately 9:38 a.m. of the medical records department revealed multiple stacks of patient files piled waist high and stored on the floor and on chairs. The filing cabinets are full of medical records without any additional space for filing medical records.

2. A review of the "Medical Records" job description, performance evaluation dated 12/22/17, states in part: "Assure that work/assignment areas are clean and records, files, etc. are properly stored ... Report all unsafe/hazardous conditions ...."

3. An interview with the Director of Medical Records was conducted on 01/14/20 at approximately 9:38 a.m. When asked if she is able to adequately maintain patient medical record files she stated in part: "I am the only employee. I also get pulled to work the hospital units when they are short staffed." When asked if all the records filed and stored on the floor and chair were exposed to hazards of water and damage, she concurred.

4. An interview with the DON and social worker #1 was conducted on 01/14/20 at approximately 3:00 p.m. When asked if the medical records department is staffed adequately to maintain patient medical records they stated in part: "The Director of Medical Records is a Licensed Practical Nurse and gets pulled to the unit to work and not able to complete the chart audits in a timely manner." When asked if she is the only employee in the medical records department, they concurred.

A. Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that three (3) of thirteen (13) inpatient medical records failed to have a discharge summary (patient #7, # 10 and #12). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of discharged medical records for the acute inpatient rehabilitation hospital revealed patient #7, #10 and #12 failed to have a discharge summary.

2. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "Discharge Summaries - All patient/residents records shall include a discharge summary."

3. An interview was conducted with the Director of Nursing (DON) on 01/13/20 at 2:10 p.m. When asked if she could find the discharge summaries for patient #7, #10 and #12 she stated, "No, there isn't any."

4. A telephone interview was conducted with the Medical Director of the Inpatient Rehabilitation Center on 01/15/20 at 9:20 a.m. When asked the expectation of a discharge summary being completed by the Nurse Practitioner or physicians he stated in part: "I expect them completed within thirty days of the patient being discharged." When asked if they have a procedure to ensure the discharge summary is completed he stated in part: "I am told if there is no discharge summary or if charts need signed and then I contact the practitioners to have them sign them... I did not know this was a problem on the rehab side of the hospital. I've only been made aware of it on the skilled nursing facility of the hospital."

5. An interview was conducted with the administrator on 01/15/20 at approximately 9:40 a.m. He concurred with the above findings.

B. Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that two (2) of thirteen (13) inpatient medical records failed to have a a signature by a practitioner for a telephone order (patient #7 and #10). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of the medical record for patient #7 revealed a telephone order given by physician #1 on 12/06/19 with no time noted that states, "Foley cath care every shift, empty foley & record amount every shift, change O2 tubing every Sunday 7-3, air mattress check function every shift." No physician signature noted. A second telephone order on 12/07/19 with no time noted given by physician #2 states, "Send to ER for evaluation." No physician signature noted.

2. Review of the medical record for patient #10 revealed a telephone order given by Nurse Practitioner #1 on 11/09/19 for the patient to be discharged to a funeral home. No Nurse Practitioner signature noted.

3. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "A verbal order will include the date, time and full signature and title of the person to who the verbal order has been given and will be authenticated by the prescribing medical staff member at the next visit."

4. An interview was conducted with the DON on 01/13/20 at 2:10 p.m. When asked if she could find an order with the practitioner's signature on patient #7 and patient #10 she stated in part: "No" and concurred with the above findings.

Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that two (2) of thirteen (13) inpatient medical records failed to have a a signature by a practitioner for a telephone order (patient #7 and #10). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of the medical record for patient #7 revealed a telephone order given by physician #1 on 12/06/19 with no time noted that states, "Foley cath care every shift, empty foley & record amount every shift, change O2 tubing every Sunday 7-3, air mattress check function every shift." No physician signature noted. A second telephone order on 12/07/19 with no time noted given by physician #2 states, "Send to ER for evaluation." No physician signature noted.

2. Review of the medical record for patient #10 revealed a telephone order given by Nurse Practitioner #1 on 11/09/19 for the patient to be discharged to a funeral home. No Nurse Practitioner signature noted.

3. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "A verbal order will include the date, time and full signature and title of the person to who the verbal order has been given and will be authenticated by the prescribing medical staff member at the next visit."

4. An interview was conducted with the Director of Nursing on 01/13/20 at 2:10 p.m. When asked if she could find an order with the practitioner's signature on patient #7 and patient #10 she stated in part: "No" and concurred with the above findings.

Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that three (3) of thirteen (13) inpatient medical records failed to have a discharge summary (patient #7, # 10 and #12). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of discharged medical records for the acute inpatient rehabilitation hospital revealed patient #7, #10 and #12 failed to have a discharge summary.

2. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "Discharge Summaries - All patient/residents records shall include a discharge summary."

3. An interview was conducted with the Director of Nursing (DON) on 01/13/20 at 2:10 p.m. When asked if she could find the discharge summaries for patient #7, #10 and #12 she stated, "No, there isn't any."

4. A telephone interview was conducted with the Medical Director of the Inpatient Rehabilitation Center on 01/15/20 at 9:20 a.m. When asked the expectation of a discharge summary being completed by the Nurse Practitioner or physicians he stated in part: "I expect them completed within thirty days of the patient being discharged." When asked if they have a procedure to ensure the discharge summary is completed he stated in part: "I am told if there is no discharge summary or if charts need signed and then I contact the practitioners to have them sign them... I did not know this was a problem on the rehab side of the hospital. I've only been made aware of it on the skilled nursing facility of the hospital."

5. An interview was conducted with the administrator on 01/15/20 at approximately 9:40 a.m. He concurred with the above findings.

B. Based on review of medical records, medical staff by-laws and rules and regulations and staff interviews it was determined that two (2) of thirteen (13) inpatient medical records failed to have a a signature by a practitioner for a telephone order (patient #7 and #10). This failure has the potential for all patients to have an incomplete medical record.

Findings include:

1. Review of the medical record for patient #7 revealed a telephone order given by physician #1 on 12/06/19 with no time noted that states, "Foley cath care every shift, empty foley & record amount every shift, change O2 tubing every Sunday 7-3, air mattress check function every shift." No physician signature noted. A second telephone order on 12 07/19 with no time noted given by physician #2 states, "Send to ER for evaluation." No physician signature noted.

2. Review of the medical record for patient #10 revealed a telephone order given by Nurse Practitioner #1 on 11/09/19 for the patient to be discharged to a funeral home. No Nurse Practitioner signature noted.

3. Review of the medical staff by-laws and rules and regulations, with an approval date of 03/27/13, states in part: "A verbal order will include the date, time, full signature and title of the person to who the verbal order has been given and will be authenticated by the prescribing medical staff member at the next visit."

4. An interview was conducted with the DON on 01/13/20 at 2:10 p.m. When asked if she could find an order with the practitioner's signature on patient #7 and patient #10 she stated in part: "No," and concurred with the above findings.

Based on record review and staff interviews it was revealed the facility failed to conduct maintenance and testing on the facility's essential electric system in accordance with National Fire Protection Association (NFPA) 110. The facility's census was seven (7).

Findings include:

1. Facility document review on 01/13/20 at approximately 3:00 p.m. revealed no documentation of a annual fuel quality test for the generator.

2. An interview on 01/14/20 at approximately 2:15 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.

Based on observation and staff interviews it was revealed the facility failed to maintain smoke and fire barrier doors in accordance with the National Fire Protection Association (NFPA)101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was seven (7).

Findings include:

1. An observation on 01/14/20 at approximately 2:05 p.m. revealed a set of ninety (90) minute rated corridor doors missing floor strike plates by the lobby.

2. An interview on 01/14/20 at approximately 4:00 p.m. with the Director of Plant Operations verified these findings. The findings were were also acknowledged by the administrator at the exit interview on 01/14/20.

Based on record review and staff interviews it was revealed the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with NFPA 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was seven (7).

Findings include:

1. Record review on 01/13/20 at approximately 3:00 p.m. revealed fire drills recorded during the second shift of the first quarter at 4:02 p.m. and the second shift of the second quarter at 4:50 p.m., which were held within one (1) hour of each other.

2. Record review on 01/13/20 at approximately 3:00 p.m. revealed fire drills recorded during the third shift of the first quarter at 5:53 a.m. and the third shift of the second quarter at 5:30 a.m., which were held within one (1) hour of each other.

3. Record review on 01/13/20 at approximately 3:00 p.m. revealed that the facility failed to record any fire drills for the fourth quarter of 2019.

4. An interview on 01/14/20 at approximately 2:15 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.

Based on observation and staff interviews it was revealed the facility failed to maintain electrical equipment testing and maintenance in accordance with National Fire Protection Association (NFPA) 101 and 99. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was seven (7).

Findings include:

1. A facility tour on 01/14/20 at 1:46 p.m. revealed no evidence of the physical integrity, resistance, leakage current and tough current tests for fixed and portable patient-care related electrical equipment (PCREE) for the patient beds.

2. An interview on 01/14/20 at approximately 2:15 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.

A. Based on observation, documentation review and interviews it was determined the Infection Control Director (ICD) failed to ensure facility staff follow infection control policies to clean and disinfect the patient shower room, patient room #404, the patient dining area and remove expired food and staff food from the patient's refrigerator to avoid sources of infection on the Acute Rehabilitation Unit. This failure has the potential to place all patients at risk for infection.

Findings include:

1. An observation conducted on 01/13/20 at approximately 11:15 a.m. revealed the patient's shower room had debris build-up in the drain, black and white substance build-up in the corner of the entrance into the standing shower and yellow substance on the floor at the entrance of the chair shower area.

2. An observation conducted on 01/13/20 at approximately 11:15 a.m. revealed patient room #404 had broken tiles on the wall next to the toilet and a washcloth wedged into the top of the heater/air-conditioning unit located next to the bed.

3. An observation conducted on 01/13/20 at approximately 11:45 a.m. revealed the patient's dining room contained multiple boxes of Christmas decorations and a Christmas tree stacked in a corner, six (6) cloth chairs around the table, two (2) cloth sofas, two (2) patient lifts, one (1) patient scale and one (1) wheelchair which was stored next to the Christmas decorations.

4. An observation conducted on 01/13/20 at approximately 11:30 a.m. revealed the patient's refrigerator contained strawberry syrup that expired 11/12/19, lemon juice that expired 08/20/19, hot sauce that expired 09/15/19, ranch dressing that expired 07/19/19, grated parmesan cheese that expired 08/16/19 and hot sauce with no expiration date labeled with an employee's name. The refrigerator had a red substance laying on bottom under the crisper drawer.

5. A review of policy "Cleaning and Disinfection of Environmental Surfaces," revised 06/09, states in part: "Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities ... Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated."

6. A review of policy "Preventing Foodborne Illness-Food Handling," revised 07/2014, states in part: "Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. .... This facility recognizes that the critical factors implicated in foodborne illness are ... unsafe food sources."

7. A review of policy "Cleaning and Disinfection of Resident-Care Items and Equipment," revised 07/14, states in part: "Reusable resident care equipment will be decontaminated and/or sterilized between residents ..."

8. A review of the CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003)" states in part: "Cloth Furnishings ... minimizing the use of upholstered furniture and furnishings in any patient-care areas where immunosuppressed patients are located ... reduces the likelihood of disease."

9. An interview with the Director of Nursing (DON) was conducted on 01/13/20 at approximately 12:00 p.m. When asked if the above finding were not clean and an infection risk to patients, she concurred.

B. Based on observation, documentation review and interviews it was determined the ICD failed to ensure facility staff follow infection control policies to clean and disinfect the sink and cloth chairs to avoid sources of infection in the Acute Rehabilitation Services Department. This failure has the potential to place all patients at risk for infection.

Findings include:

1. An observation of the Physical Therapy Outpatient Department conducted on 01/14/20 at approximately 10:15 a.m. revealed the sink had white and green build-up on the faucet, white build-up around base of the faucet, a rusty drain plate and brown substance on the counter around the edge of the sink.

2. An observation conducted of the Physical Therapy Outpatient Department on 01/14/20 at approximately 10:15 a.m. revealed one (1) blue cloth stool was ripped open with foam protruding from the seat, one (1) blue cloth stool with a large brown stain in the center of the seat and one (1) red cloth chair.

3. A review of policy "Standard Precautions, Rehabilitation Services," revised 01/25/17, states in part: "Therapy equipment should be disinfected after patient use with a disinfectant wipe ... and/or as needed. ... Work and environmental surfaces must be disinfected with Environmental Protection Agency (EPA) approved disinfectant."

4. A review of the "CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003)" states in part: "Cloth Furnishings ... minimizing the use of upholstered furniture and furnishings in any patient-care areas where immunosuppressed patients are located ... reduces the likelihood of disease."

5. An interview with the Director of Rehabilitation Services (DRS) was conducted on 01/14/20 at approximately 10:45 a.m. When asked if the above areas were not clean and an infection risk to patients, she concurred.

C. Based on observation, documentation review and interviews it was determined the ICD failed to ensure facility staff follow infection control policies to clean the floor and clean and disinfect the hot pack covers to avoid sources of infection in the Outpatient Rehabilitation Services Department. This failure has the potential to place all patients at risk for infection.

Findings include:

1. An observation of the Occupational Therapy Outpatient Department conducted on 01/14/20 at approximately 10:45 a.m. revealed debris and cobwebs around a stack of weights and along the carpeted wall next to the supply closets.

2. An observation of the Occupational Therapy Outpatient Department conducted on 01/14/20 at approximately 10:45 a.m. revealed nine (9) hot pack covers hanging on a rack were stained with brown spots.

3. A review of policy "Standard Precautions, Rehabilitation Services," revised 01/25/17, states in part: "Therapy equipment should be disinfected after patient use with a disinfectant wipe ... and/or as needed. ... Work and environmental surfaces must be disinfected with EPA approved disinfectant."

4. An interview with the DRS was conducted on 01/14/20 at approximately 10:45 a.m. When asked if the above finding were not clean and an infection risk to patients, she concurred.