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03284


Based on observation, staff and patient interview, review of cleaning schedules, review of policy and procedures, it was determined, the hospital failed to ensure the hospital provides a sanitary environment to avoid sources and transmission of infections. This could affect the hospital's total census of 26 patients.

Findings include:

Based on observations, staff and patient interviews, review of the hospital's policy and procedures related to the cleaning of a patient room after discharge and review of the host hospital's housekeeping log, the acute long term care hospital failed to provide a sanitary environment for patients. This affected four ( Rooms 1548, 1551, 1556 and 1557) of 17 rooms observed. This could affect the hospital's total patient census of 26.


The hospital failed to ensure the infection control officer followed their system for control of infections. Refer to A749, 482.42 (a)(1), Infection Control Officer Responsibilities.

Based on review of the hospital complaint/grievance logs, hospital Patient/Family Complaint/Grievance Reports and staff interview the hospital failed to provide a written notice of the hospital's decision containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for eight (Patients # 6, #7, #9, #12, #13, #14, #15 and #16 ) of thirteen patients who had filed a grievance with the hospital. The patient sample size was sixteen patients whose medical records were reviewed. The hospital census was twenty-six.
Finding Include:
Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #6 revealed the patient's father complained to the hospital on 4/21/09, the patient was lying in bowel movement for one hour and the aide was aware and stated that he/she would be right back. The hospital documentation indicated that the aide knew the patient needed to be cleaned up, but was instructed to get vital signs. The hospital lacked evidence the patient/family of Patient #6 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #7 revealed Patient #7 complained to the hospital on 7/15/09 he/she had been waiting for an hour, since 3:55 PM, to have their compression boot put back on. Staff J documented that he/she answered the light at 4:55 PM and informed the Staff H, Staff G and Staff I to respond to the call light and thereafter the 3 staff arrived to put the patient's boot on. The hospital lacked evidence the patient/family of Patient #7 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #9 revealed Patient #9 complained to the hospital on 10/2/09. The patient called 3 times for pain medication. Staff K stated she tried to call the nurse three times however the nurse did not answer. The hospital lacked evidence the patient/family of Patient # 9 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #12 revealed Patient #12 complained to the hospital on 11/9/09 the patient waited so long for the bed pan the patient became incontinent. Staff M stated the patient had to wait 15 to 20 minutes. The hospital lacked evidence the patient/family of Patient #12 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #13 revealed Patient #13 complained to the hospital on 11/12/09 the patient pushed the call light and waited over an half an hour for assistance with positioning. The nurse apologized to the patient and caregivers. The hospital lacked evidence the patient/family of Patient #13 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #14 revealed Patient #14 complained to the hospital on 11/26/09 that the patient was wet from not getting the call light answered in a timely manner. Staff G stated she did not have a phone for part of the shift. The patient was told to call for the charge nurse if she has to wait longer than 15 minutes. Again on 12/6/09 the patient complained regarding the call light not being answered. The patient further states this has been happening since 11/25/09. The hospital lacked evidence the patient/family of Patient #14 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient for either of these complaints/grievances.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #15 revealed the patient complained an aide would not help him use the urinal. The hospital lacked evidence the patient/family of Patient #15 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

Review of the hospital Patient/Family Complaint/Grievance Report completed on 02/19/10 for Patient #16 revealed Patient #16 complained he/she had been left lying in a wet bed. The hospital lacked evidence the patient/family of Patient #16 had been provided with a written notice of the hospital's decision and actions taken on behalf of the patient as a result of this complaint.

The above findings were shared on interview with Staff C, Staff D and Staff E at 02/19/10 at 3:30 PM. On 02/22/10 at 10:45 AM an interview was held with Staff N. He/she stated, at that time, identification had been noted of the complaint/grievance process and "we need conclusion statements filled out at the end of the complaints we did."

Based on review of the hospital's Patient/Family Complaint/Grievance Reports, review of the hospital's policy and procedure related to call light response process and staff and patient interviews, the hospital failed to ensure the there was a plan in place for the ongoing monitoring of staff response to the patients' call lights that would ensure the patients' did not have to wait extended periods of time to have their call lights answered. This affected nine (Patient #3, #5, #6, #7, #8, #9, #12, #13 and #14) of thirteen patients whose hospital Patient/Family Complaint/Grievance Reports were reviewed, two of two patients interviewed, and one of one family member interviewed. The patient sample size was sixteen patients whose medical records were reviewed. The hospital census was twenty-six.


Findings include:

Review of the complaint/grievance log on 02/17/10 at 2:00 PM revealed multiple complaints from patient and family members dated 6/10/09 to the present related to call lights not being answered in a timely manner. These complaints include various complaints of nursing care with lack of timely responses to call lights and patients left incontinent for long periods of time.

Review of the hospital's Patient/Family Complaint/Grievance Reports for thirteen patients revealed the hospital has had complaints of call lights not being answered in a timely manner for greater than six months. Interviews conducted with patients and a family member of a patient during the survey indicated the problem with call lights not being answered in a timely manner nor according to the hospital policy continued to be a problem current at the time of the survey. According to the hospital's Patient/Family Complaint/Grievance Reports, the hospital was aware call lights were not being answered in the time frame defined by hospital policy and that this was a continuing problem.
Patient #3 was admitted to the hospital unit on 12/22/09 with Multi System Failure and non-ambulatory due to status post amputation of all toes on both feet. The patient had developed C-Diff (Clostridium Difficile) resulting in loose stools during the hospital stay. The hospital complaint/grievance for this patient was reviewed. Staff E stated on the patient complaint/grievance form dated 12/25/09 the patient complained "basically that he was unhappy with the response time from the aide and nurse assigned to him on the night shift of 12/24/09. He felt they were also unfair in expecting him to be more independent." The response by Staff E was "the aide and nurse who provided care on the night shift of 12/24/09 will not be reassigned to the patient if other options are available." On 12/30/09 the progress notes stated that Staff E contacted physical therapy to evaluate the patient's ability to perform peri-care after bowel movements while the patient is in bed. The Physical Therapy Staff spoke with the patient about staff concerns over the patient not assisting with peri-care. Patient complained of not being able to thoroughly complete the task with good hygiene, the patient had no access to running water from the bed and peri care had to be completed in the supine position. Physical Therapy staff felt the patient would require assistance with peri-care after bowel movement in bed. Physical Therapy spoke with the supervising Occupational Therapist for her recommendation. Occupational Therapy agreed the patient would require assistance with peri-care until bed rest restrictions were lifted. Physical Therapy staff relayed Occupational Therapy recommendations to the staff and Select CEO. The physician orders for bed rest restrictions were not discontinued until 1/13/10 at 0850.
Patient #5's family member submitted a complaint/grievance to the facility on 06/10/09, regarding the patient was left on the bed pan. The family member stated "at shift change, wife was on commode. Husband went to door twice to ask for assistance. Nurse said she would send in the aides. No aide arrived. An oncoming nurse after report came into the room. The husband had already placed the patient back in bed."

Patient #6's father complained to the hospital on 4/21/09, that the patient was lying in bowel movement for one hour and that the aide was aware. The aide stated that he/she would be right back. The hospital's documentation indicated that the aide knew the patient needed to be cleaned up, but was instructed to get vital signs.

Patient #7 complained to the hospital on 7/15/09, that he/she had been waiting for an hour since 3:55 PM to have the compression boot put back on. Staff J documented that he/she answered the light at 4:55 PM and informed Staff H, Staff G and Staff I to respond to the call light and thereafter the three staff members arrived to put the patient's boot on.

Patient #8's mother complained to the hospital on 9/1/09, " the patient was left on the bed pan for an hour and no nurse was seen for 4 hours". The documentation further indicated the staffing agency that supplied the nurse to the hospital was called regarding the family members complaint that the nurse had not been seen for 4 hours and had left the patient on the bed pan for an hour. The hospital wrote a letter to the patient's family apologizing for the issues that the patient experienced.

Patient #9 complained to the hospital on 10/2/09, the patient called three times for pain medication. Staff K stated she tried to call Staff L three times however, the nurse did not answer.

Patient #12 complained to the hospital on 11/9/09, the patient waited so long for the bed pan causing incontinence. Staff M stated the patient had to wait 15 to 20 minutes.

Patient #13 complained to the hospital on 11/12/09, the patient pushed the call light and waited over a half an hour for assistance with positioning. The nurse apologized to the patient and caregivers.

Patient #14 complained to the hospital on 11/26/09, the patient was wet from not getting the call light answered in a timely manner. Staff G stated she did not have a phone for part of the shift. Patient was told to call for a charge nurse if she has to wait longer than 15 minutes. Again on 12/6/09, the patient complained regarding the call light not being answered. The patient further stated this has been happening since 11/25/09.

Patient #4 was interviewed on 02/18/10 at 11:45 AM. He/she stated a concern regarding staff response to call lights. He/she stated response to call lights is based on the nurse/aide assigned and sometimes the response is up to more than 30 minutes before the patients' needs are met.

Patient #18 was interviewed on 02/18/10 at 9:00 AM. He/she stated a concern regarding staff response to call lights. He/she stated the response to call lights "depends on what they are doing, He/she has to wait sometimes more than 30 minutes. The girls don't like cleaning up. "

A family member of a current patient approached the surveyor on 02/19/10 at 8:30 AM. The family member stated he/she was concerned regarding the patient's needs not being met for "long periods of time for staff to respond to call lights".

The hospital policy and procedure for "call light response process" was reviewed on 02/17/10 at 2:00 PM. This policy stated-answer call light before 4th ring; ask patient what they need; call appropriate discipline; if tied up, ask how long until they can respond; call other team member if necessary; acceptable time frame (i.e.<15 minutes for toileting), call charge nurse if staff unable to go within 15 minutes; let patient know a staff member is coming and when able follow-up with staff or patient to verify someone respond.

The above findings were shared on interview with Staff C, Staff D and Staff E at 02/19/10 at 3:30 PM. On 02/22/10 at 10:45 AM an interview was held with Staff N. He/she stated at that time identification had been noted of the complaint/grievance process and "we need conclusion statements filled out at the end of the complaints we did." He further stated he feels the staff follow up, however, there is no documented evidence of any system in place to minimize call light response time ongoing monitoring of call lights response to ensure patients' needs are met in a timely manner. The Quality Assurance/Improvement requested at the time of the survey regarding these matters was not available for review.

This deficiency substantiates Complaint Number OH00050373



03161

03161

Based on observations, staff and patient interviews, review of the hospital's policy and procedures related to the cleaning of a patient room after discharge and review of the host hospital's housekeeping log, the acute long term care hospital failed to provide a sanitary environment for patients. This affected four ( Rooms 1548, 1551, 1556 and 1557) of 17 rooms observed. This could affect the hospital's total census of 26 patients.

Findings include:

During a tour of the hospital, on 02/17/2010, during the morning hours, three hospital rooms (Room 1557, Room 1551, Room 1548) were identified by Staff C as being ready for occupancy. Staff C was present at all times during the tour. Staff E was intermittently present during the tour.

Observation of Room 1557, during the tour of the hospital on 02/17/2010 at 10:00 AM, revealed the room was unoccupied. Patient #4, who had, according to Staff C, a diagnosis of Clostridium Difficile (C-Diff) (which was verified by review of the clinical record completed on the afternoon of 02/17/2010), had been transferred out of Room 1557 earlier in the morning of 02/17/2010.

C-Diff is a gram positive spore forming anaerobic (can live without free oxygen) bacillus. The toxins of C-Diff attack the intestinal wall and if left untreated, may cause intestinal ulcerations. C- Diff is highly contagious and a person can become infected with direct contact with the fecal matter of an infected person. Even touching a microscopic specimen of this organism can be infectious. C-Diff can live on a countertop or flat surface for several days. The Centers for Disease Control (CDC) has strict guidenlines for the disinfection of a hospital room that has been occupied by a patient infected with C-Diff.

Further observation of Room 1557 revealed the surface of the bedside table had a build-up of a sticky substance. Staff C was asked to open the three drawers of the beside table. Inside the drawers, which had no handle pulls, was a heavy build up of a dried brownish-gray substance and dust and debris. The following items were identified inside the drawers: three (3) open urostomy bags, three (3) urostomy stoma appliance, a used hair brush with grayish hair between the bristles, an open tube of moisturizing cream, an open container of a body wash, an open bottle of mouth wash, two (2) open bottles of moisturizing lotion, a personal get well card to Patient #1(who had been discharged a week prior, on 2/10/2010), four (4) mouth swabs, an oral care kit, Tegaderm, (skin barrier) twelve (12) Q-tips, two (2) pairs of scissors, three (3) hemostats, three (3) sheets, two (2) pillow cases, four (4) blue disposable bed pads, part of a newspaper dated 1/21/2010, four (4) four by four gauze dressings, one (1) two by two gauze dressing, five (5) rolls of used surgical paper tape, two (2) pairs of ostomy scissors, a can of no-sting barrier film, a container of saline and an open tube of stoma adhesive which had a sticky grayish substance on the outside of tube. The over- bed table was streaked with a sticky grayish substance and in need of cleaning. The inside storage area of the over-bed table had a clear dry substance. The dirty bedside table and the dirty over-bed table, as noted above, were moved to Room 1557 from Room 1556 at the time of the transfer of Patient #4 from Room 1557 to Room 1556. The last time Room 1556 had been cleaned, according to the environmental 's system log, was on 02/10/2010, a week prior to 02/17/2010. The items noted in the bedside table belonged to Patient #1 and had not been removed when the room was cleaned on 02/10/2010.

Dust and debris was observed on the floor of the bathroom of Room 1557 which had been used by Patient #4. Two partially used rolls of toilet paper were observed to be positioned on the top of the toilet paper holder. The edges of the toliet paper were noted to be wet to dry. When questioned, regarding the toilet paper not properly positioned on the roller, Staff C stated for sanitary reasons the toilet paper should have been on the roller.

Staff A and Staff B were called to the unit by Staff E since the host hospital was responsible for housekeeping. Staff A and B stated that the unit has been having cleaning issues. They stated that staff on the unit generate (dispose of) trash onto the floor such as needle lugs, syringes, gloves, wrappers from disposable equipment, etc.

The trash can in the bathroom of Room 1557 was observed during the morning tour on 02/17/10, and contained trash and the linen cart in the bathroom contained dirty linen. The floor of the closet had a build up of dust and debris. There were twelve (12) used pillows stuffed into shelves in the closet. A large area, (the size of a football), was observed on two of the pillows to contain a dark brownish substance and long streaks of the same substance were noted. Staff A and B stated these pillows should have been sent to the laundry. All of the observations as noted above indicated Room 1557 had not been cleaned. Room 1557 was not ready for occupancy as had been previously stated by Staff C.

Interviews with Staff A and Staff B which occurred during the tour in the morning of 02/17/10, revealed the long term acute care hospital staff had failed to enter this room into the computer system for cleaning after the patient was transferred out of this room. Staff A and Staff B said a hospital wide system was in place for notifying the housekeeping department of the rooms which were in need of cleaning. Staff A further stated the long term acute care hospital staff have not been notifying the housekeeping department of the host hospital of transfers and/or if a patient had been in isolation. Staff A and Staff B stated the rooms of patients who had been in isolation require a more thorough cleaning.

Staff C confirmed, at this time, when patients were transferred from one room to another room or had been in isolation in the long term acute care hospital, staff had not notified the host hospital's housekeeping department. In addition, the log maintained by housekeeping, reviewed the morning of 02/18/2010, lacked information related to patient transfers from room to room within the long term acute care hospital or the fact the patients had been in isolation.

Room 1548, which Staff C had identified as ready for occupancy at the beginning of the tour on 02/17/10 was observed being damp mopped at 10:30 AM, however, after being mopped, a large brown substance the size of a nickle was observed on the floor and dust and debris was noted under the sink and bedside table. The room also contained areas of chipped paint; in the corner at the right lower wall and in the corner at left side lower wall by the sink. The wall by the window had an area of chipped paint measuring 6" by 9".

Room 1551, which Staff C had identified as ready for occupancy on 02/17/10, at the beginning of the tour, when observed at 11:00 AM revealed a large amount of dark brownish substance on top of the trash can lid. Dirty linen was present in the bathroom. The bedside table drawers and the over-bed table were in need of cleaning as evidenced by a sticky/tacky grayish substance noted on the drawer pulls. Dust and debris was noted in the drawers. There were streaks of a substance noted inside the storage area and on the table surface of the over-bed table.

The hallway observed on 02/17/2010 at 11:00 AM had a build up of dust and debris along the edges and large build up of dust and debris under the ice machine and refrigerator.

Patient #4, who had been transferred from room 1557 to Room 1556 and who was wheelchair bound and had bathroom privileges, stated during an interview on 02/18/10 at 10:00 AM, that he/she was admitted to Room 1557because it was handicap accessible.

The surveyors were informed by Staff A and Staff B during the afternoon of 02/18/2010, they were to meet with Staff E the next day, 2/19/10, to discuss the cleaning issues that were identified.

The above findings were shared during interview with Staff C, Staff D, and Staff E on 02/19/10 at 3:30 PM.

This deficiency substantiates Complaint Number OH00053309 OH00050373.