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Based on medical record review, review of performance improvement data, review of facility incident reports, and staff interview, the facility failed to ensure interventions were designed to improve data identified as an area needing improvement (A283), failed to ensure contracted services and discharge planning were incorporated into the facility quality improvement program (A308), and failed to ensure the medical record where staff failed to notify a physician of a change in a patient's condition that did not respond to an ordered treatment was reviewed (A286). These systemic practices had the potential to affect all 58 patients receiving care in this facility.

Based on observations, medical record review, facility policy review, and staff interview, the facility failed to ensure nursing staff evaluated the nursing care needs for each patient in relation to assessing for fall prevention, pain management, and physician notification with a change in condition that did not respond to an ordered treatment. (A 392) The cumulative effect of these systemic practices affected three patients and had the potential to affect all 58 patients receiving care at the facility.

Based on observation, interview, and record review, the facility failed to ensure two hour barriers separating buildings had rated doors and were free of penetrations, to ensure each corridor door with self-closing hardware self-closed the doors, to ensure construction protecting shafts and other vertical openings are free of penetrations, to ensure each smoke tight barrier was smoke tight and free of penetrations, to ensure each rated barrier was free of penetrations, to maintain protective construction around hazardous areas, to provide emergency lighting in accordance with section 7.9, to ensure each path of egress was appropriately marked with an exit sign, to have supervisory personnel instructed on how to implement a fire drill, to ensure each sprinkler head was kept clean and free of obstructions within 18 inches of it, and to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. (A 709) This has the potential to affect all patients and visitors to the facility.

Based on review of contracted services, staff interview, and review of the facility quality improvement dashboard, the facility failed to incorporate contracted services into the quality improvement program to ensure problems with contracted services were identified.

Findings include:

The service contracts for the facility were reviewed on 05/23/16 at 8:30 AM. Contracts reviewed included contracts such as physician services agreement, ambulance transportation agreement, and dialysis clinic agreement.

Review of the facility's performance improvement indicator data for 2015 and year to date 2016 revealed no indicators for contracted services.

The meeting minutes for the Governing Body from February 25, 2015 to March 30, 2016 were reviewed on 05/19/16 at 2:00 PM. The meeting minutes did not reference the contracted services of the facility.

Staff S, Manager of Quality Improvement, was interviewed on 05/23/16 at 9:30 AM and was asked to provide documentation of the integration of contracted services into the quality improvement program. No documentation was provided at the time of exit.

Based on medical record review, observations, staff interview, and review of the policy regarding fall prevention, the facility failed to ensure patients received care in a safe setting with regard to correct fall precautions being initiated for patients. This affected three (Patient #1, #3, and #31) of 30 records reviewed and had the potential to affect all 58 patients in the facility.

Findings include:

Review of the facility policy titled "Fall Prevention", policy # Drake-NSG-20060921800035201 reveals that all patients will have a fall risk sign posted on the door frame, with the appropriate bed number on the sign.


1. The 3North unit was toured on 05/17/16 at approximately 09:30 AM. Stars were noted along the door frames outside of each room with a patient. Staff H revealed one star designated a low fall risk, two stars, a medium risk, and three stars, a high risk for a fall. The door frame outside of room 310 was noted not to have any stars. A request was made regarding the patient's fall risk designation. Staff stated the patient was a high fall risk.

The medical record of Patient #31, the patient in room 310, was reviewed on 05/19/16. Patient #31 was admitted to the facility on 05/16/16 at 03:10 PM after jumping from the second story window at another facility. The patient sustained multiple fractures. A sitter was noted to be at the bedside of the patient on admission as required by facility policy. A fall risk assessment was completed at 3:35 PM. Twenty-five points were issued for having a history of falling, fifteen points for having a secondary diagnosis, twenty points for IV (intravenous) therapy, and fifteen points for the patient's mental status. The fall risk assessment was 75 points making the patient a high risk for a fall. It was further noted the fall risk sign was displayed on the outside of the patient's door.

2. During the tour, two stars was observed on the door frame of room 319 revealing the patient was a medium risk for a fall.

The medical record of Patient #3, the patient in room 319, was reviewed on 05/19/16. Patient #3 was admitted to the facility on 05/09/16 at 07:18 PM. The patient's fall risk assessment, completed at 09:51 PM, indicated the patient was a high fall risk as the assessment score was 45. It was confirmed with Staff G, the incorrect number of stars were displayed on the patient's door frame as the patient was a high fall risk, not a medium one.

3. Review of the medical record for Patient #1 revealed the patient was admitted to the facility on 05/17/16 with diagnoses of peritonitis and lupus. On 05/17/16 a fall risk assessment was completed and the patient was identified as a moderate fall risk, based upon the MORSE rating scale. The plan of care revealed that a moderate risk determines that the fall risk rating on the patient's door have 2 stars, to alert staff to the increased risk.


On 05/18/16 at 5:30 PM, the patient did not have fall risk signage on the door frame. This finding was confirmed by Staff G. Staff G then placed fall risk signage on the door frame with one star. Staff G confirmed the fall risk assessment rating was 35 and required signage with two stars, not one.

Based on record review, staff interview and review of policies the facility failed to ensure their policy was followed regarding the use of restraints. This affected one (Patient #21) of three patients reviewed for restraints. The census was 58.

Findings include:

Review of the facility policy titled Restraint and /or Seclusion: Non-Violent/Non Self- Destructive Behavior and Violent/ Self Destructive Behavior revised on 08/01/15 revealed orders for restraints must be renewed every 24 hours by the physician after assessing the patient for the continued need of the restraints.

Review of the medical record for Patient #21 on 05/23/16 revealed an admission date of 04/02/16 with diagnoses of respiratory failure, encephalopathy and adjustment disorder with anxiety.

Review of a physician's order dated 04/04/16 revealed the patient was placed in bilateral non-violent, soft restraints to the upper extremities for protection and medication device access. Further review of the physician progress notes reveal no assessment or mention of the bilateral upper extremity wrist restraints from 04/03/16 through 04/08/16 and 04/11/16 through 04/17/16.

These findings were verified with Staff E on 05/20/16 at 1:30 PM who states the physician should note their restraint assessment in the progress notes. After reviewing the progress notes from 04/03/16 through 04/08/16 and 04/11/16 through 04/17/16, Staff E verified the progress notes did not mention the use of or an assessment of the restraints.

Based on review of the facility's performance improvement data and staff interview, the facility failed to use data collected to identify opportunities for improvement. This had the potential to affect all 58 patients hospitalized in the facility.

Findings include:

The facility's quality performance improvement indicator data for 2015 and 2016, including two indicators within Nursing and Infection Prevention, was reviewed on 05/18/16 at 3:30 PM. The indicator within Nursing was as needed pain assessment compliance. The goal was to be greater than 90%. The compliance percentage for 2015 was 58.7% and so far for 2016, a lower percentage rate of 44%. This indicator was implemented on 01/01/14.

Staff S, the Manager of Quality Improvement, was interviewed on 05/18/16 at 3:45 PM and asked to provide documentation of any interventions designed to improve this data. Staff S revealed this information was given to the Director of Clinical Operations. There were no documented interventions that revealed the facility was addressing the need for improvement in this area.


Clostridium difficile rate per 10,000 patient days, an indicator under Infection Prevention, was also reviewed. The goal was 1.4 and data for 2015 and 2016 revealed the actual clostridium difficile rate per 10,000 patient days was 9.6 and 10.5. There were no interventions that revealed the facility was addressing the need for improvement in this area.

These findings were confirmed with Staff S on 05/19/16 at 9:30 AM.

Based on medical record review, review of personnel record , and staff interview, the facility failed to analyze results of a medical record review of a transferred patient who later expired at another facility. This affected one of two expired patients reviewed (Patient #8) and had the potential to affect the hospital's 58 patients.

Findings include:

Review of the medical record of Patient #8 revealed the patient was admitted from an outside hospital on 03/10/16 at 06:08 PM for management of congestive heart failure, dialysis, and wound care. The attending physician, on 03/10/16 ordered respiratory therapy to assess and treat the patient. An as needed order for nebulizer breathing treatments every six hours for wheezing or complaints of shortness of breath was also noted on the day of admission.

The Respiratory Flowsheet revealed the patient received an as needed nebulizer breathing treatment at 3:49 AM on 03/17/16. The medical record lacked documentation of the reason the breathing treatment was given.

A Nursing Note at 5:43 AM on 03/17/16 noted the patient was "up in chair all night" and requested a breathing treatment for increased congestion.

There was documentation verifying the patient received the requested breathing treatment.

A note at 9:55 AM from a physical therapist revealed the patient declined services of the physical therapist because he/she had not slept well due to "being up all night coughing." It was further noted the patient declined occupational therapy at 11:01 AM for the same reason.

The medical record revealed a Nurse Practitioner examined the patient at 5:27 PM, more than 13 hours after the as needed breathing treatment was given. The Nurse Practitioner's note, not yet co-signed by an attending physician as required, revealed he/she ordered a portable chest X-ray at 6:02 PM. The chest X-ray revealed bilateral pleural effusions.

The medical record lacked documentation of any collaboration between the Nurse Practitioner and a physician about the patient's condition. A Nursing Note at 7:10 PM revealed the patient's family expressed concern about the patient's complaints of shortness of breath. Crackles and rubbing were noted in both lung fields at this time. Respiratory was again called for an as needed breathing treatment. The treatment was given at 7:36 PM. A note at 8:30 PM revealed the patient's family again, complained of the patient's "coughing for 2 days."

A Nursing Note at 8:56 PM revealed the patient had been up sitting in a chair the "entire day" complaining of having difficulty breathing.

The medical record lacked documentation a physician was called until 11:30 PM.

The physician's note revealed the patient was seen for complaints of shortness of breath. The physician acknowledged the chest X-ray results and noted the patient to be "quite anxious." The physician ordered Valium to reduce the patient's level of anxiety. The physician suggested waiting until the patient's hemodialysis the next morning for further treatment. The patient's family again, expressed concern and the decision was made to transfer the patient to a facility for acute care. The patient was transferred at 1:07 AM on 03/18/16. Aggressive resuscitative measures were taken, including intubation, the patient passed away at 10:01 AM.

The personnel record of the Nurse Practitioner was reviewed on 05/24/16 at 09:00 AM. The Nurse Practitioner, part of a physician group contracted by the hospital, was approved to care for patients by the Governing Body on 12/18/15 for the period of 12/21/15 to 11/30/17. The core privileges of the Nurse Practitioner revealed the nurse, "in collaboration with physicians" could provide and manage the care of individuals and groups with complex health problems. The standard care arrangement revealed criteria for referral to a physician included a patient whose condition is "unusual," who is not making satisfactory progress, or whose condition is unresponsive to the plan of care.

Staff H, a Nurse Practitioner, was interviewed on 05/24/16 at 03:05 PM. Staff H recalled Patient #8 as being "very sick." Staff F further revealed he/she had collaborated with a physician often about the patient's care. It was confirmed the medical record lacked documentation of any collaboration with a physician. Staff H also revealed he/she was initially required by his/her covering physician to have any progress notes or discharge summaries co-signed by a physician. When asked for the reason for the co-signature, Staff H stated: "I figured it was because I was new." Staff H further explained his/her covering physician informed him/her the requirement to have a physician co-sign progress notes was no longer required since April, leaving only discharge summaries needing to be co-signed by a physician. It was confirmed the progress note, written on 03/17/16 had never been co-signed.

Staff S, Manager of Quality Improvement, was interviewed on 05/24/16 at 11:30 AM and confirmed review of Patient #8's medical record and confirmed no formal review of the record from the governing body.

Based on staff interview, review of the quality improvement plan, and review of the facility's performance indicator data, the facility failed to incorporate contracted services and discharge planning into their quality improvement program to ensure problems in the areas were identified.

Findings include:

Staff B, the manager of Discharge Planning, was interviewed on 05/18/16 at approximately 2:15 PM. Staff B revealed discharge planning was built into the facility's quality improvement plan however, when asked for specific performance indicators related to discharge planning, Staff B was unable to provide any.

The service contracts for the facility were reviewed on 05/23/16 at 8:30 AM. Contracts reviewed included contracts such as physician services agreement, ambulance transportation agreement, and dialysis clinic agreement. Review of the facility's performance improvement indicator data for 2015 and year to date 2016 revealed no indicators for contracted services.

The meeting minutes for the Governing Body from February 25, 2015 to March 30, 2016 were reviewed on 05/19/16 at 2:00 PM. The meeting minutes did not reference the contracted services of the facility or the facility at all.

Staff S, Manager of Quality Improvement, was interviewed on 05/23/16 at 9:30 AM and asked to provide documentation of the integration of contracted services into the quality improvement program. No documentation was provided at the time of exit.

These finding were confirmed with Staff S on 05/23/16 at 9:35 AM.

Based on medical record review, staff interview and review of the facility policy and procedures, the facility failed to ensure the physician was notified of a change in condition that did not respond to an ordered treatment as stated in their policy for one (Patient #8) of two expired patients reviewed. In addition, the facility failed to follow physicians' orders for (Patient #21) and failed to ensure that nursing staff followed policy and procedures regarding pain assessment for (Patient #12) and physician notification for (Patient #1) of 30 medical records reviewed. The facility census was 58.

Findings include:

Review of the facility policy titled, Changes in Patient Condition, reviewed on 11/12/13 revealed the nurse should, "always notify if the patient is symptomatic and does not respond to current treatments ordered." Further review of the policy reveals the physician should be notified for a change in condition based on the following parameters: temperature greater that 101 degrees, systolic blood pressure greater than 160 and diastolic blood pressure greater than 100 and lower than 60, heart rate greater than 150 and less than 50, respirations greater than 35 and lower than 8, pulse ox lower than 88% and a consistent score of 8 or above out of 10.

Review of the facility policy titled "Inter-Disciplinary Pain Management," (Drake-PC-200812-1201) revealed the staff is to assess the effectiveness of pain medication one to two hours after administering pain medication.

1. Review of the medical record of Patient #8 revealed the patient was admitted from an outside hospital on 03/10/16 at 6:08 PM for management of congestive heart failure, dialysis, and wound care. The attending physician, on 03/10/16 ordered respiratory therapy to assess and treat the patient. An as needed order for nebulizer breathing treatments every six hours for wheezing or complaints of shortness of breath was also noted on the day of admission.

The Respiratory Flowsheet revealed the patient received an as needed nebulizer breathing treatment at 3:49 AM on 03/17/16. The medical record lacked documentation of the reason the breathing treatment was given. A Nursing Note at 05:43 AM on 03/17/16 noted the patient was "up in chair all night" and requested a breathing treatment for increased congestion. However there was documentation verifying that the patient received the requested breathing treatment.

A note at 9:55 AM from a physical therapist revealed the patient declined services of the physical therapist because he/she had not slept well due to "being up all night coughing." It was further noted the patient declined occupational therapy at 11:01 AM for the same reason.

The medical record revealed a Nurse Practitioner examined the patient at 5:27 PM, more than 13 hours after the as needed breathing treatment was given. The Nurse Practitioner's note, not yet co-signed by an attending physician as required, revealed he/she ordered a portable chest X-ray at 6:02 PM. The chest X-ray revealed bilateral pleural effusions.

A Nursing Note at 7:10 PM revealed the patient's family expressed concern about the patient's complaints of shortness of breath. Crackles and rubbing were noted in both lung fields at this time. Respiratory was again called for an as needed breathing treatment. The treatment was given at 7:36 PM.

A note at 8:30 PM revealed the patient's family again, complained of the patient's "coughing for 2 days."

A Nursing Note at 8:56 PM revealed the patient had been up sitting in a chair the entire
day complaining of having difficulty breathing.

The medical record lacked documentation a physician was called until 11:30 PM.

The physician's note revealed the patient was seen for complaints of shortness of breath. It was further noted the physician acknowledged the chest X-ray results and also noted
the patient to be "quite anxious." The physician ordered Valium to reduce the patient's level of anxiety. It was also noted the physician suggested waiting until the patient's hemodialysis the next morning for further treatment.

The patient's family again, expressed concern and the decision was made to transfer the patient to a facility for acute care. The patient was transferred at 1:07 AM on 03/18/16. Aggressive resuscitative measures, including intubation were taken. The patient expired at 10:01 AM.

Interview on 05/23/16 at 5:57 PM, Staff E verified that Patient #8 had been complaining of shortness of breath on 03/17/16 from 3:49 AM and the record did not reveal the physician was notified until 03/17/16 at approximately 11:38 PM.


Interview with the Staff A on 05/24/16 at 1:45 PM revealed although there is a facility policy for notifying the physician of abnormal vital signs, there is no facility policy that instructs staff to notify the physician for other abnormal symptoms such as bleeding, vomiting, or shortness of breath. Staff A verified there are currently no policies in place that instruct staff to notify a physician with abnormal symptoms other than abnormal vital signs.

Interview on 05/24/16 at 03:05 PM, Staff H, the Certified Nurse Practitioner(CNP) who assessed Patient #8 on 03/17/16, revealed the doctor would be contacted if a patient was unstable, a change in condition was noted or for anything out of a CNP's scope of practice. Staff H remembered Patient #8 being very sick. Staff H further revealed he/she had collaborated with a physician often about the patient's care. It was confirmed the medical record lacked documentation of any collaboration with a physician.

Interview with the Manager of Quality Improvement on 05/24/16 revealed the
medical record was initially reviewed by him/her on 03/24/16 but warranted no
further action.


2. Review of the medical record for Patient #21 on 05/23/16 revealed an admission date of 04/02/16 with diagnoses of acute respiratory failure, encephalopathy and adjustment disorder with anxiety. Review of a physician's order dated 04/04/16 revealed the patient was to receive an 125 milliliter (ML) water bolus every 4 hours through the patients' gastrostomy tube.

Further review of the medical record revealed the patient did not receive the 125 ml water bolus as ordered on 04/20/16 from 2:00 PM through 04/21/16 at 10:00 AM, 04/24/16 at 6:20 AM through 04/25/16 at 10:06 AM and 04/27/16 at 10:30 AM through 04/28/16 at 9:00 AM.

These findings were verified with Staff E on 05/23/16 at approximately 3:10 PM.




35979

3. Review of the medical record for Patient #1 revealed the patient was admitted to the facility on 05/17/16 with diagnoses that include peritonitis and management of dialysis and a history of lupus.

On 05/19/16 at 10:57 AM, the patient's blood pressure was 82/55 mmHg with a heart rate of 133 beats per minute. The medical record lacked documentation a physician was notified. At 2:37 PM, the vital sign flowsheet revealed the patient's blood pressure was 86/71 mmHg with a heart rate of 126 beats per minute. The medical record lacked documentation a physician was notified. At 8:29 PM the patient's blood pressure was 85/56 mmHg and his/her heart rate was 127 beats per minute. The patient's vital signs remained abnormal at 9:00 PM with a blood pressure of 85/69 mmHg and a heart rate of 130 beats per minute. The medical record lacked documentation a physician was notified. On 05/20/16, at 2:00 AM, the patients blood pressure remained low, at 89/55 mmHg and his/her heart rate remained elevated at 126 beats per minute. The patient's vital signs remained abnormal throughout the day and there was no evidence a physician was made aware.

Review of a Nursing Note on 05/20/16 at 10:49 PM, more than 24 hours after the patient's vital signs were noted to be outside of a normal range, revealed the patient was transferred to an acute care hospital via squad with mental status changes.

Review of the physician orders dated 05/17/16 revealed staff is to notify the physician if the patient's vital signs are outside of the following parameters: Systolic (top number) blood pressure less than 90 or heart rate greater than 120 beats per minute.

On 05/23/16 at 11:00 AM, Staff E confirmed a physician was not notified of the patients vital signs being outside of the parameters ordered by the physician.

4. Review of the medical record for Patient #12 revealed an admission date of 4/29/16 and diagnoses of end stage renal disease and congestive heart failure. Review of the medical record revealed on 05/03/16 at 8:36 AM the patient complained of pain at "8" on a 0-10 scale. The nurse documented range of motion and medication as a pain control intervention. The medical record did not contain any documentation of pain medication administered at that time. On 05/03/16 at 6:28 PM, the patient complained of pain of a "7" on a 0-10 scale. The nurse documented pain medication being administered, but did not reassess the pain level to determine the effectiveness of the intervention. On 05/04/16 at 10:30 AM, the patient continued to complain of pain at "7" on a 0-10 scale. There were no interventions documented by the nurse and the pain was not reassessed. On 05/11/16 at 10:52 AM, the patient complained of pain of an "8" on a 0-10 scale. The nurse administered pain medication but did not reassess the pain to determine the effectiveness of the intervention. On 05/12/16 at 2:45 AM, the patient complained of pain at an "8" on a 0-10 scale. The nurse did not document any interventions for pain relief and did not reassess the pain level.

On 05/23/16 at 2:55 PM, the above findings were confirmed with Staff E.

Based on review of facility medical record statistics, facility policy review, and staff interview, the facility failed to ensure medical records were completed within 30 days of discharge. This affected 531 medical records reported delinquent from April, 2015 to April, 2016.

Findings include:

The facility's medical records statistics, including the delinquency report from 05/01/15 through 04/30/16, were reviewed on 05/18/16 at 02:00 PM. The monthly delinquency totals from May, 2015 through April, 2016 were as follows: 57, 53, 56, 66, 63, 72, 81, 44, 14, 8, 6, and 11. The average quarterly delinquency rate was 44 or 21.66 %. It was further noted the average monthly discharge rate was 204.33.

The facility policy titled Physician Suspension Process was reviewed on 05/18/16 at 04:00 PM. According to the policy a medical record not complete within 30 days of the patient's discharge is considered delinquent. It was further noted the physician receives a written notice that failure to complete delinquent records within 3 days will result in notification of the chief of staff and may lead to an entry in the physician's permanent credentialing file.

Staff I and Staff J, the Manager and Director of Health Information Management, were interviewed on 05/18/16. According to Staff I medical staff are sent a "friendly reminder" with incomplete records between 14 to 22 days. A second notice is sent to medical staff between 23 and 27 days. The third notice or the "final notice" is sent 30 days or after.

Staff I and J confirmed there was an average delinquency rate of 21.66%.

Based on observation, staff interview, and facility policy review, the facility failed to ensure outdated drugs and nutrition supplements would not be available for patient use. This had the potential to affect all 58 patients receiving care in the facility.

Findings include:

Review of the facility policy titled Storage of Clean, Dirty and Sterile Equipment and Supplies: Environmental Infection Control revealed the facility will ensure that no outdated medication and/or biologicals will be available for patient use.

Observation of the 3 North medical supply room on 05/17/16 at approximately 11:20 AM revealed four 1000 ml bags of Nutren 2.0 with an expiration date of 03/19/16.

This finding was verified at that time with Staff E.


On 05/17/16 at 11:20 AM during a tour of the clean storage area on the 3rd floor, three 250 ml containers of Replete with Fiber (a high protein nutrition supplement) were noted to be expired. One container was labeled with an expiration date of 10/20/15. The second bottle of Replete, a tube feeding, was labeled with an expiration date of 02/11/16. The last bottle was noted to have expired on 03/29/16.

These findings were confirmed by Staff E.




35979

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients and visitors to the facility.

Findings include:

K 11 Failed to ensure two hour barriers separating buildings had rated doors and were free of penetrations.
K18 Failed to ensure each corridor door with self-closing hardware self-closed the doors.
K 20 Failed to ensure construction protecting shafts and other vertical openings are free of penetrations.
K 23 Failed to ensure each smoke tight barrier was smoke tight and free of penetrations.
K 25 Failed to ensure each rated barrier was free of penetrations.
K 29 Failed to maintain protective construction around hazardous areas.
K 46 Failed to provide emergency lighting in accordance with section 7.9.
K147 Failed to ensure each path of egress was appropriately marked with an exit sign.
K 50 Failed to have supervisory personnel instructed on how to implement a fire drill.
K 62 Failed to ensure each sprinkler head was kept clean and free of obstructions within 18 inches of it.
K 67 Failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.

Based on observation, policy review and staff interview, the facility failed to develop a system to maintain a sanitary hospital environment. This has the potential to affect all 58 patients receiving care in the facility.


Findings include:

The facility infection control policy titled Environmental Services was reviewed on 05/18/16 at 09:00 AM. According to the policy staff are instructed, under the category "cleaning methods," to wipe daily all horizontal surfaces including tables, beds, chairs, ledges, lights, and wall fixtures with a clean cloth dampened with a bleach wipe.


1. A 38 bed unit called 3 South was toured on 05/17/16 at 10:30 AM. According to Staff A patients with more severe respiratory disease processes, including patients on ventilators, are hospitalized on this unit. Room 324, an empty room ready for a patient, was observed. Large clumps of dust were noted to fall to the floor when sliding a hand along a shelf above the bed.

These facts were confirmed with Staff A on 05/18/16 at 09:15 AM.

2. On 05/17/16 at 11:20 AM, the microwave in the nutrition galley on 3 North contained dried food particles on the walls and ceiling of the microwave. This finding was confirmed by Staff E.

3. On 05/17/16 at 11:30 AM, a pill crusher was on the nurses station on 3 South. The pill crusher was coated with visible dirt on the edges and cracks. In the nutrition galley the microwave interior contained dried food particles on the walls and ceiling of the microwave. The drain grate on the counter area was sticky and had a collection of sticky liquid residue on the grate surface and in the drain tray. These findings were confirmed by Staff H.

4. On 05/17/16 at 12:00 PM during a tour on the 4 North unit, the refrigerator/freezer unit interior in the nutrition galley was warm and contained mold on all surfaces. Both compartments had a strong odor of mold and there was an accumulation of mold on the interior and exterior door seals. The digital temperature gauge located on the exterior of the unit did not show a temperature reading. These findings were confirmed with Staff A.

On 05/17/16 at 1:00 PM, Staff A stated that for some reason, the refrigerator/freezer unit was turned off. Staff A confirmed that the units have a digital temperature gauge that will transmit the temperature to the maintenance staff so that temperature variations can be investigated. Staff A did not know the reason the unit was not working or why the absence of a temperature reading was not investigated.




35979

Based on staff interview and review of policy and procedures the hospital failed to ensure reassessment of the discharge planning process included review of the readmissions. This has the potential to affect all 58 patients receiving care in the facility.


Findings include:

Review of the hospital's policy on Interdisciplinary Discharge Planning Process last reviewed on 11/2015 revealed the policy lacked evidence of reviewing readmissions as part of their reassessment of the discharge planning process.

Interview on 05/18/16 at approximately 2:15 PM with Staff B revealed she was unsure if the hospital reviews readmissions as part of their reassessment of the discharge planning process.

Interview on 05/19/16 at approximately 8:50 AM with Staff B revealed the hospital does not review readmissions as part of their reassessment of the discharge planning process.

Based on observation, staff interview and policy review, the facility failed to ensure there was a Director of Respiratory Care Services who was a Doctor of Medicine with responsibility for operation of the service. This has the potential to affect all 58 patients receiving care in the facility.


Findings include:


Staff D, the manager of Respiratory Services, was interviewed on 05/18/16 at 11:30 AM. Staff D revealed he/she had been manager of respiratory services for two years.

Staff D stated in interview it had been three to four years since there was an annual competency.

Staff D reported he/she directly reported to Staff A, Director of Clinical Operations.

Staff A, the Director of Clinical Operations, was interviewed on 05/19/16 at 11:00 AM. Staff A revealed he/she was trained as an advanced practice nurse with a master's of science in nursing.

It was confirmed with Staff A and Staff D there must be a Director of Respiratory Care services who is a Doctor of Medicine with the knowledge, experience and capabilities to supervise and administer the service properly.

Staff D was interviewed on 04/18/16 at 2:10 PM. revealed there was no director.