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Based on observation, interview and record review, the facility failed to meet the Condition of Participation (COP) for Nursing Services by failing to :

1. Supervise and evaluate nursing care of patients requiring gastrostomy tube, indwelling catheter, pressure ulcer and pain management (Refer to A 0395).

2. Ensure the nursing staff developed care plan that addressed patient needs such as isolation precaution, oxygen use, indwelling catheter, and gastrostomy tube feeding ( Refer to A 0396).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the nursing services met the needs of the patients.

Based on observation, interview and record review, it was determined that the facility did not meet the Condition of Participation (COP) for Medical Record Services by failing to :

1. Ensure the physician progress notes were dated and timed (Refer to A450).

2. Ensure all orders, including verbal orders were dated, timed and authenticated promptly by the ordering practitioner (Refer to A454).

3. Ensure the physicians authenticated prescribed verbal orders within forty eight hours (Refer to A457).

4. Ensure the medical history and physical examination was completed and documented not more than 30 days before or 24 hours after admission. Also the Psychiatric History and Mental Status Examination did not contain vital and necessary information for diagnosis and planning of care (Refer to A458).

5. Ensure a properly executed informed consent for surgical procedures (Refer to A466).

6. Ensure the discharge summaries were completed within 30 days following discharge (Refer to A469).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the medical records services met the needs of the patients.

Based on observation, interview and records review, the facility failed to meet the Condition of Participation for Physical Environment as follows:

The facility did not maintained the physical plant in such a manner that the safety and well being of patients was assured. ( Refer to A701)

The facility failed to maintain the premises in a clean/sanitary and in good repair at all times. (Refer to A724)

The facility failed to maintain room finish and frame spread rating of Class A or Class B at all times (Refer to K 015)

The facility failed to maintain the sealed construction for the corridor walls. (Refer to K 017)

The facility failed to maintain the corridor doors in a condition to resist the passage of smoke, free of obstructions to closing and with a means suitable for keeping the door closed. (Refer to K 018)

The facility failed to ensure two magnetically held doors automatically closed upon activation of the fire alarm system. (Refer to K 021)

The facility failed to maintain construction of smoke barriers wall in a condition to provide at least an one hour fire resistance rating. (Refer to K 025)

The facility failed to ensure one cross-corridor smoke barrier door closed. (Refer to K 027)

The facility failed to provide an 3/4 hour fire rated construction for the Mammography Room, an hazardous area. (Refer to K 029)

The facility failed to provide a stairway with protection aganist fire or smoke from other parts of the building. (Refer to K 033)

The facility failed to maintain the smoke compartment corridor and fire exit access clear of all non-essential equipment at all times. (Refer to K 039)

The facility failed to provide documented evidence fire drills were held at least quarterly on each shift to ensure all personnel were drilled not less than once in each 3-month period and under varying conditions. (Refer to K 050)

The facility failed to ensure the fire alarm system provided effective warning of fire in any and all parts of the building. (Refer to K 051)

The facility failed to ensure that the Fire Alarm Panel back up source of power, batteries, were always kept in optimal condition. (Refer to K 052)

The facility failed to ensure a sprinkler system water supply shut off control valve was supervised to sound and display at least a local alarm when closed. (Refer to K 061)

The facility failed to provide ashtrays of safe design where smoking was permitted. (Refer to K 066)

The facility failed to ensure and provide documentation that the fourth floor dining room draperies were in compliance with the provision of NFPA 13 and NFPA 701. (Refer to K 074)

The facility failed to ensure that soiled linen and trash collection receptacles were held in a room protected as a hazardous area. (Refer to K 075)

The facility failed to ensure canopies exceeding 4 feet in width were sprinklered or constructed of noncombustible or limited combustible material. (Refer to K 130)

The facility failed to develop an approved policy and procedure regarding the fire alarm system out of service for more than 4 hours in a 24-hour period. In the event of an inoperable fire alarm system, approved policies and procedures relating to the protection of the facility, along with implementation, would help in the prevention and/or management of a fire emergency. (Refer to K 155)

The facility failed to ensure the activation of the smoke detectors at elevator lobbies of one of three elevators, that had a travel distance greater than 25 feet, failed to recall the elevator car to the designted level, and activation of the smoke detector at the elevator lobby of the designated level, failed to return the car to an alternate level. (Refer to K 160)

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the Physical Environment met the needs of the patients.

Based on observation, interview and record review, the facility failed to meet the Condition of Participation (CoP) for Infection Control by failing to :

1. Ensure the infection control officer implement policies and procedures for patients on contact isolation when staff members failed to wear personal protective device during provision of care( Refer to A 0748).

2. Ensure the infection control officer implement infection control policy on handwashing after provision of care, opened,undated and expired drugs/medication/supply, unlabeled respiratory and gastrostomy supplies, procedure in providing perineal care and handling of medication with contaminated pair of gloves (Refer to A 0749).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the infection control service was met.

Based on observation, interview and record review, the facility staff failed to ensure a patient was provided personal privacy during provision of care by a physician.

Findings:

On June 29, 2010, at approximately 11 a.m., during the initial tour of the emergency room (ER) with the administrative nursing staff, Patient 1 was observed sitting in a chair by the hallway. The physician was interviewing the patient amidst the staff and visitors that were passing by and overhearing the conversation. The patient and the physician were talking about the patient's psychotic episodes and outburst which were audible to the hospital staff such as security guard, sitter, nurses and visitors.

A review of the medical record revealed the patient was brought to the ER for a medical clearance. The patient had been experiencing agitation and hallucination for three days. The patient was admitted to the psychiatric unit of the hospital later that day.

During a concurrent interview with the administrative nursing staff, she stated that the physician should have taken the patient to the triage room which was not occupied at that time to provide the patient with personal privacy during the examination.

Based on observation, interview, and record review, the facility failed to ensure that 3 of 22 sampled patients (Patients 2, 4 and 6), received the care based on their needs while at the facility. Patient 2, who was unresponsive and totally dependent on staff for the performance of her activities of daily living was observed with thick white material in the oral cavity. Patient 4, who was assessed as having self-care deficit due to pain was observed with long fingernails and with black material underneath the nails. Patient 6, who was assessed as unable to care for himself was admitted to the behavioral unit without medical clearance as stipulated by the facility Admission Criteria on Mental Health Unit.

Findings:

1. On June 30, 2010, at approximately 1:45 p.m., during the medication pass observation, Patient 2 was observed lying in bed, with the head of bed elevated. The patient had gastrostomy tube (GT) feeding of Novasource Renal infusing at 35 cubic centimeters (cc) /hour. There was thick, white material observed in the patient's oral cavity.

A review of the clinical record revealed the patient was admitted to the facility on May 29, 2010, with diagnoses that included septic shock, acute respiratory failure and metabolic encephalopathy secondary to hypoxemia.

The admission patient assessment indicated the patient was unresponsive, non-verbal and totally dependent on staff for the performance of her activities of daily living.

2. On June 30, 2010, at approximately 10 a.m., during provision of care observation Patient 4 was observed lying in bed with an indwelling catheter in place.

Patient 4 was observed with long fingernails and with black material underneath the nails. According to the admission record, Patient 4 was admitted to the facility on June 29, 2010, with diagnoses that included hyperglycemia and hypertension. The admitting assessment documented the patient had weakness on lower body strength, contractures and decreased mobility. The patient was further assessed as having self-care deficit due to pain.

During a concurrent interview with RN 4, she stated that she would have someone provide the nail/oral care to the patients right away.

3. A review of the medical record for Patient 6 revealed the patient was involuntarily admitted to the facility on May 13, 2010, with diagnosis of Psychosis. The patient was agitated, aggressive, yelling, disruptive and striking out at facility staff. The patient was placed on a 72 hour hold due to being danger to others and gravely disabled.

The patient was initially seen in the emergency room and the disposition was to admit to medical-surgical unit. However, the patient was admitted to the behavioral unit at the Hawthorne Campus. There was no medical clearance found in the medical record for this patient prior to transfer to the behavioral unit.

The initial nursing admission assessment in the behavioral unit documented the patient was unable to care for self, requiring assistance of staff to eat, change clothing and do hygiene care. The patient used wheelchair to ambulate and needed constant redirection. The patient was wearing a foam helmet to protect from hitting head to the wall or furniture. The patient has a Ventriculo-Peritoneal (VP) shunt status post brain surgery and has seizure disorder.

A review of the facility's policy on Admission Criteria on Mental Health Unit stipulated patients admitted to the unit must be able to perform, activities of daily living (eating, dressing, bathing, etc) and participate in the program. Also stipulated all patients admitted from an emergency room, transferred from within the hospital or from another facility will be medically cleared and medically stable prior to acceptance.

On July 2, 2010, at approximately 9:30 a.m., during an interview with the chief executive officer (CEO), she acknowledged the patient should not have been admitted to the behavioral unit due to his medical condition. The patient should have been in the medical surgical unit provided with a sitter.

Based on observation, interview and record review, the facility staff failed to ensure that a registered nurse evaluated the care of each patient under their supervision upon admission and on an on going basis for 4 of 22 sampled patients (Patients 2, 3, 4 and 5). For Patient 2, the facility failed to follow the physician's order for the gastrostomy tube feeding. For Patient 3, who had a stage 3 pressure ulcer over the sacral area had no wound treatment order, had an order for a low air loss mattress that was not carried out and had an indwelling catheter with no physician's order. For Patient 4, the facility failed to implement pain management plan of care. For Patient 5, who had an indwelling catheter had no physician's order for the indwelling catheter, had no assessment for continued use and evaluation of the urine output in accordance with the plan of care.


Findings:

1. On June 30, 2010, at approximately 2 p.m., during the tour of the unit, with RN 6, Patient 2 was observed lying in bed with gastrostomy tube feeding on. The tube feeding was Novasource-Renal 1000 ml bottle, hang on June 28, 2010, infusing at 35 cc/hr.

A review of the physician's order dated June 24, 2010, documented Renal Resource at 50 cc /hour. Shortly, after checking the physician's order, the patient's feeding pump was rechecked and it was found to be infusing at 30 cc /hour.

During a concurrent interview with RN 6, she stated she changed the rate of the feeding pump to 30 cc/hr. When further asked why, RN 6 was unable to respond.

2. On June 30, 2010, at approximately 10 a.m., during the tour of the unit, Patient 3 was observed lying in a regular bed with an indwelling catheter in place. The indwelling catheter was draining 350 cubic centimeters (cc) of cloudy, amber-colored urine. The patient was also noted to have bandage on both feet.

During a concurrent interview with RN 3, she was unable to state why the patient had an indwelling catheter nor was there a written evidence to indicate the patient was assessed for the use of an indwelling catheter. There was no written documentation to indicate the physician ordered an indwelling catheter for Patient 3.

Further review of the clinical record revealed the following:
a. Patient 3 was admitted to the facility on June 29, 2010, with diagnoses that included non-healing wound on the sacral area, deep vein thrombosis and status post trans- urethral resection of the prostrate. The patient was admitted from a skilled nursing facility.
b. A physician's order on admission for low air loss mattress which was not carried out.
c. The admission skin/ pressure ulcer assessment documentation indicated a stage 3 pressure ulcer on sacral area which measures 3.5 cm by 3.1 cm by 0.4 cm and stage 2 pressure ulcers on the right and left heels which measure 3.2 cm by 2.5 cm by 0.2 cm and 2.0 cm by 1.2 cm.
However, the clinical record failed to show written documentation for a wound care treatment order.
3. On June 30, 2010, at approximately 9:05 a.m., during the medication pass observation, Patient 4 was observed lying in bed. When RN 4 started to touch the patient's left leg, he started to groan and verbalized the level of pain was 10.

According to the admission record, Patient 4 was admitted to the facility on June 29, 2010, with diagnoses that included hyperglycemia, end stage renal disease and hypertension.

The admitting assessment indicated the patient was assessed as having sharp pain on both legs, 4 on scale of 0-10, acceptable level of pain was 2, movement makes it worst and rest makes it better.

The interdisciplinary plan of care developed on admission addressed pain and the intervention was pain management. However, review of the medication administration record (MAR) on admission failed to show written documentation to indicate the registered nurse provided medication and/or non-medication intervention to address the patient's pain.

During concurrent interview with RN 5, while reviewing the clinical record concurred the patient's pain should have been further evaluated and addressed for Patient 4.

4. On June 30, 2010, at approximately 8:15 a.m., during the medication pass observation, Patient 5 was observed lying in bed with an indwelling catheter in place. The indwelling catheter was draining 220 cc of cloudy, yellow colored urine with sediments.

A review of the admission record revealed that the patient was admitted to the facility of June 21, 2010, with diagnoses that included urosepsis, hyperglycemia, diabetes mellitus and altered mental status. There was no physician order for the use of an indwelling catheter nor was there an assessment for the continued or discontinued use of the indwelling catheter for Patient 5.

The admission assessment documented the patient was admitted with an indwelling catheter. A care plan was developed on admission that addressed the use of an indwelling catheter and one of the interventions was to assess for signs and symptoms of infection such as cloudiness, sediments in the urine. The daily patient assessment on June 30, 2010, at 7 a.m., documented the indwelling catheter was draining, however the sediments and cloudiness of the urine was not identified and assessed.

Based on interview and record review, the facility failed to ensure the nursing staff developed a nursing care plan for 5 of 22 sampled patients (Patients 2, 11, 12, 14, and 15).

Findings:

1. A review of Patient 11's Admission Sheet disclosed the patient was admitted to the facility on June 1, 2010, with diagnosis of foot ulcer.

During the initial tour of the Telemetry Unit on June 29, 2010 at 11:20 a.m., with Employee 1 and Employee 2, the patient's room was observed with a posted sign "Contact precaution" by the door. According to Employee 2, the patient was in the room with MRSA (Methicillin resistant staphylococcus aureus) contact isolation.

An interview with Employee 2 on June 29, 2010 at 12:05 p.m., as well as a review of the nursing plan of care, revealed no documented evidence that a registered nurse had developed a nursing care plan for contact isolation.

2. A review of Patient 12's Admission Sheet disclosed the patient was admitted to the facility on June 23, 2010 with diagnosis of cellulitis.

During the initial tour of the Telemetry Unit on June 29, 2010 at 11:30 a.m., with Employee 1 and Employee 2, the patient's room was observed with a posted sign "Contact precaution" by the door. According to Employee 2, the patient was in the room with MRSA contact isolation.

An interview with Employee 2 on June 29, 2010 at 11:58 a.m., as well as a review of the nursing plan of care, revealed no documented evidence that a registered nurse had developed a nursing care plan for contact isolation.

3. A review of Patient 14's Admission Sheet disclosed the patient was admitted to the facility on June 15, 2010, with diagnosis of psychosis.

During the initial tour of the Gero-Psych Unit on June 30, 2010 at 10:15 a.m., with Employee 1 and Employee 3, the patient's room was observed with a posted sign "Contact precaution" by the door. According to Employee 3, the patient was in the room with MRSA contact isolation and was on hemodialysis treatment.

During an interview with Employee 3 on June 30, 2010 at 11:05 a.m., as well as a review of the nursing plan of care, revealed no documented evidence that a registered nurse had developed a nursing care plan for contact isolation and hemodialysis.

4. A review of Patient 15's Admission Sheet disclosed the patient was admitted to the facility on June 5, 2010 with diagnosis of bipolar disorder.

During the initial tour with Employee 1 and Employee 3 in the Gero-Psych Unit on June 30, 2010 at 10:20 a.m., the patient's room was observed with a posted sign "Contact precaution" by the door. According to Employee 3, the patient was in the room with MRSA contact isolation.

During an interview with Employee 3 on June 30, 2010 at 2:17 p.m., as well as a review of the nursing plan of care, revealed no documented evidence that a registered nurse had developed a nursing care plan for contact isolation and hemodialysis.




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5. On June 29, 2010, at approximately 1:45 p.m., during the tour of the unit with administrative nursing staff, Patient 2 was observed lying in bed. The patient had an indwelling catheter draining 500 cc of dark amber colored urine with sediment. The patient was on gastrostomy tube feeding Renal Novasource infusing at 35 cc/hour which was hung of June 28, 2010, at 11 p.m. The patient was on Venti mask of 30% oxygen.

During a concurrent interview with administrative nursing staff , while reviewing the patient's clinical record, failed to show documentation that care plans were developed to address concerns such as indwelling catheter, gastrostomy tube feeding and the use of oxygen via Venti mask.

Based on record reviews and staff interviews, the facility failed to ensure the physician progress notes were timed for 2 patients (Patient 11 and 15).

Finding:
1. A review of Patient 11's clinical record revealed the patient was admitted to the facility on June 1, 2010. However, the physician progress dated June 22, 26, 27, and 28, 2010 were not timed.

In addition, the physician's telephone orders dated June 2, 23 and 27, 2010, were countersigned but not dated and timed by the physician.

2. A review of Patient 15's clinical record revealed the patient was admitted to the facility on June 5, 2010. However, the physician progress notes dated June 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, and 29, 2010 were not timed.

During an interview with Employee 1 on June 29, 2010 at 12:05 p.m. she stated the physician progress notes should have been timed.

Based on interview and record, the facility staff failed to ensure all orders, including verbal orders, for 7 patients ( Patient 11, 12, 13, 14, 15, 19, 20) were dated, timed, and authenticated promptly by the ordering practitioner.

Findings:

1. A review of Patient 11's clinical record revealed the patient was admitted to the facility on June 1, 2010.

However, a review of the physician's orders received on 6/2/10 at 8:40 a.m., 6/23/10 at 6:30 p.m. and 6/27/10 at 6 p.m., revealed the telephone orders were not dated, timed, and authenticated promptly by the ordering practitioner.

2. A review of Patient 12's clinical record revealed the patient was admitted to the facility on June 23, 2010.

However, a review of the physician's orders received on 6/25/10 at 7:50 p.m., revealed the telephone order was not dated, timed, and authenticated promptly by the ordering practitioner.

3. A review of Patient 13's clinical record revealed the patient was admitted to the facility on June 13, 2010.

However, a review of the physician's orders received on 6/19/10 at 9:30 a.m., 6/20/10 at 3 p.m., 6/20/10 at 5:50 p.m., 6/20/10 at 6:30 p.m., 6/21/10 at 10:45 a.m., 6/21/10 at 2:56 p.m., 6/22/10 at 9:45 a.m., and 6/27/10 at 9:10 a.m., revealed the telephone orders were not dated, timed, and authenticated promptly by the ordering practitioner.

4. A review of Patient 14's clinical record revealed the patient was admitted to the facility on June 15, 2010.

However, a review of the physician's orders received on 6/16/10 at 2 p.m., 6/16/10 at 11 a.m., 6/22/10 at 1:30 p.m., and 6/22/10 at 3:30 p.m., revealed the telephone orders were not dated, timed, and authenticated promptly by the ordering practitioner.

5. A review of Patient 15's clinical record revealed the patient was admitted to the facility on June 5, 2010.

However, a review of the physician's orders received on 6/6/10 at 3:45 p.m., 6/6/10 at 6:40 p.m., 6/8/10 at 2:50 p.m., 6/8/10 at 4 p.m., 6/19/10 at 3 p.m., and 6/20/10 at 3 p.m., revealed the telephone orders were not dated, timed, and authenticated promptly by the ordering practitioner.

6. A review of Patient 19's clinical record revealed the patient was admitted to the facility on May 22, 2009 and expired on May 28, 2009.

However, a review of the physician's orders received on 5/23/09 at 9 a.m., revealed the telephone order was not dated, timed, and authenticated promptly by the ordering practitioner.

7. A review of Patient 20's clinical record revealed the patient was admitted to the facility on March 14, 2010 and was discharged on March 26, 2010.

However, a review of the physician's orders received on 3/14/10 at 9:50 a.m., revealed the telephone order was not dated, timed, and authenticated promptly by the ordering practitioner.

During an interview with Employee 1 on July 1, 2010 at 3 p.m., she stated all telephone orders should be dated, timed, and authenticated promptly by the ordering practitioner.

Based on record review and interview, the facility failed to ensure the physicians authenticated prescribed verbal orders within forty eight hours for 7 of 22 patients (Patient 11, 12, 13, 14, 15, 19, and 20).

Findings:

1. A review of Patient 11's clinical record revealed the patient was admitted to the facility on June 1, 2010.

However, a review of the physician's orders received on 6/2/10 at 8:40 a.m. and 6/23/10 at 6:30 p.m., revealed the telephone orders were not authenticated promptly by the ordering practitioner as of June 29, 2010.

2. A review of Patient 12's clinical record revealed the patient was admitted to the facility on June 23, 2010.

However, a review of the physician's orders received on 6/25/10 at 7:50 p.m., revealed the telephone order was not authenticated by the ordering practitioner as of June 29, 2010.

3. A review of Patient 13's clinical record revealed the patient was admitted to the facility on June 13, 2010.

However, a review of the physician's orders received on 6/19/10 at 9:30 a.m., 6/20/10 at 3 p.m., 6/20/10 at 5:50 p.m., 6/20/10 at 6:30 p.m. 6/21/10 at 10:45 a.m., 6/21/10 at 2:56 p.m., 6/22/10 at 9:45 a.m. and 6/27/10 at 9:10 a.m., revealed the telephone orders were not authenticated promptly by the ordering practitioner as of June 29, 2010.

4. A review of Patient 14's clinical record revealed the patient was admitted to the facility on June 15, 2010.

However, a review of the physician's orders received on 6/16/10 at 2 p.m., 6/16/10 at 11 a.m., 6/22/10 at 1:30 p.m. and 6/22/10 at 3:30 p.m., revealed the telephone orders were not authenticated by the ordering practitioner as of June 30, 2010.

5. A review of Patient 15's clinical record revealed the patient was admitted to the facility on June 5, 2010.

However, a review of the physician's orders received on 6/6/10 at 3:45 p.m., 6/6/10 at 6:40 p.m., 6/8/10 at 2:50 p.m., 6/8/10 at 4 p.m., 6/19/10 at 3 p.m. and 6/20/10 at 3 p.m., revealed the telephone orders were not authenticated by the ordering practitioner as of June 30, 2010.

6. A review of Patient 19's clinical record revealed the patient was admitted to the facility on May 22, 2009 and expired on May 28, 2009.

However, a review of the physician's orders received on 5/23/09 at 9 a.m., revealed the telephone order was not authenticated by the ordering practitioner as of July 2, 2010.


7. A review of Patient 20's clinical record revealed the patient was admitted to the facility on March 14, 2010. The patient was discharged on March 26, 2010.

However, a review of the physician's orders received on 3/14/10 at 9:50 a.m., revealed the telephone order was not dated, timed, and authenticated promptly by the ordering practitioner as of July 2, 2010.


During an interview on June 30, 2010 at 11:05 a.m. and July 2, 2010 at 11:30 a.m., Employee 1 stated verbal orders for Patient 11, 12, 13, 14, 15, 19, and 20 were not authenticated within 48 hours.

Based on record review and interview, the facility failed to ensure the medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission for 5 of 22 patients (Patient 6, 21, 16, 17 and 20). For Patients 6 and 21, there was no written documentation of a History and Physical examination performed. In addition, the physician failed to ensure that the Psychiatric History and Mental Status Examination for 4 of 22 sampled patients (Patient 6, 7, 21 and 22) contained vital and necessary information for diagnosis and planning of care.

Findings:

1. Patient 6 was involuntarily admitted to the facility on May 13, 2010,with diagnosis of Psychosis. The patient is a resident of a skilled nursing facility. The patient was agitated, aggressive, yelling , disruptive and striking out at facility staff. The Initial Psychiatric Evaluation was performed on May 13, 2010. The medical record failed to show written evidence to indicate a history and physical was done.

2. Patient 7 was involuntarily admitted to the facility on May 13, 2010, with diagnosis of psychosis with suicidal ideation. The patient was transferred from a general acute care hospital. The patient was confused, anxious, pacing the hallway, paranoid, guarded and kept threatening to kill self. The Psychiatric History and Mental Status Examination and history and physical was performed on May 14, 2010.

3. Patient 21 was involuntarily admitted to the facility on June 26, 2010, with diagnosis of Paranoid Schizophrenia. The patient was agitated, delusional, paranoid, fighting with other in her apartment building and attacking son. The Psychiatric History and Mental Examination was done on June 29, 2010 (3 days later). The medical record failed to show written evidence to indicate a history and physical was done.

4. Patient 22 was admitted to the facility on November 13, 2009 , with diagnosis of Psychosis. The patient is a resident of a board and care facility. The patient was fighting with the residential care facility staff member because the patient believed he was being poisoned by the staff.
The Psychiatric History and Mental Examination and history and physical was performed on November 14, 2010.

Further review of the Psychiatric History and Mental Examination of Patients 6, 7, 21 and 22 revealed the domains/areas of clinical evaluations for example under the physical examination such as vital signs, neurological status including cranial nerves, skin with special attention to stigmata of trauma, history alcohol and substance abuse, etc. were not addressed.

For the history and physical examination, the following were examples of written documentation :
a. Physical examination section - under vital sign," there was no vital signs recorded in the chart."
b. Review of Systems section - under respiratory , "the patient denies shortness of breath and cough" and under central nervous system "the patient is agitated."

During a concurrent interview with the chief executive officer (CEO), she acknowledged the above findings and indicated it will be addressed with the medical staff.




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5. A review of Patient 16's Admission Sheet disclosed the patient was admitted to the facility on June 25, 2010 at 3:50 p.m., with diagnosis of psychosis.

However, a review of the clinical record revealed no documented evidence that the psychiatric history and evaluation was completed by the physician as of July 1, 2010, which was 6 days after the admission.

6. A review of Patient 17's Admission Sheet disclosed the patient was admitted to the facility on March 21, 2010 at 2:10 p.m., with diagnosis of psychosis.

However, a review of the clinical record disclosed the history and physical examination was not completed by the physician until March 23, 2009 at 7:34 p.m., which was 49 hours after the admission.

7. A review of Patient 20's Admission Sheet disclosed the patient was admitted to the facility on March 14, 2010, with diagnosis of psychosis.

However, a review of the clinical record disclosed the history and physical examination was not completed by the physician until May 26, 2010, which was 73 days after the admission.

During an interview with Employee 1 on July 1, 2010 at 2 p.m., she stated the history and physical examination, and psychiatric evaluation should be completed within 24 hours after admission.

According to the medical staff rules and regulations (page 15), the psychiatric history and physical examination shall be completed within 24 hours after the patient's admission or immediately before admission.

Based on observation, interview, and record review, the facility failed to ensure a properly executed informed consent for 2 surgical procedures for Patient 14.


Findings:

During the initial tour of the Gero-Psych Unit on June 30, 2010 at 10:15 a.m., with Employee 1 and Employee 3, Patient 14 was observed undergoing hemodialysis treatment. According to Employee 3, the patient had a Quinton catheter on right subclavian for hemodialysis.

A review of Patient 14's clinical record revealed the patient was admitted to the facility with diagnosis of psychosis, end stage of renal disease, congested heart failure, status post stroke on June 15, 2010. According to the medical consultation dictated June 16, 2010, the patient was alert, and oriented x 2.

A review of the "authorization for and consent" dated 6/30/10 at 9:15 a.m., for right arm angioplasty disclosed a telephone consent was obtained and was witnessed by 2 licensed nurses, however, there was no documented evidence that the physician had informed the patient's surrogate of the risk and benefit, and signed the informed consent.

An interview with Employee 3 on June 30, 2010 at 11:05 a.m., as well as a review of the entire clinical record revealed no documented evidence that the patient or his surrogate had been informed of the risks and benefits for the Quinton catheter placement.

Based on interview and record review, the facility failed to ensure the discharge summary was completed within 30 days following discharge for Patient 20.

Findings:


A review of Patient 20's clinical record revealed the patient was admitted to the facility on March 14, 2010. The patient was discharged on March 26, 2010.

However, a review of the clinical record disclosed the discharge summary was completed on May 9, 2010, which was 44 day after the discharge.

An interview with Employee 1 on July 2 at 11 a.m., revealed the discharge summary needs to be completed by the physician within 30 days.

Based on observation, interview and record review, the facility failed to meet the Condition of Participation (COP) for Pharmacy Services by failing to :

1. Ensure the facility's policy on Night Medication Locker in obtaining medication to meet the needs of the patient when pharmacy department is closed was followed (Refer to A491).

2. Ensure current and accurate records were kept of the receipt and distribution of all scheduled drugs (Refer to A494).

3. Ensure that all drugs and biologicals were kept in a secure area and the medication cart was locked at all times (Refer to A502).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the Pharmacy Services met the needs of the hospital.

Based on observation, interview and record review, the facility staff failed to follow the facility's policy on Night Medication Locker in obtaining medication that meet the needs of the the patient when pharmacy department is closed.

Findings:

On July 1, 2010, at approximately 1:50 p.m., during the initial tour with the Pharmacist of the Night Medication Locker Room located in the basement, the following was noted:

1. The medication refrigerator contents did not match the medication inventory list. For example :
Listed Actual
(2) Bacillin LA 1.2 Million (2) Bacillin LA 2.4 Million
(2) Cathflow (1) Cathflow
(10) Desmopressin (4) Desmopressin
(6) Hemabate 250 mcg (0) Hemabate

During concurrent interview with the Pharmacist, she stated the actual number of medications on the refrigerator and the list of refrigerated medication should be the same, but in this case it was not and was unable to give the reason for such.

2. The Night Locker Utilization Log revealed the following:

a. On June 25, 2010, at 11:12 p.m., two (2) Zofran 4 milligrams (mg) IV bag was taken out for a patient in room 301-C as a new order.
b. On June 26, 2010, at 2:10 a.m., two (2) Robitussin DM for an emergency room physician for not feeling well.
c. One (1) Amikacin 500 mg (250 mg/ml) was taken for pharmacy use. It was not dated.

The three (3) occasions drug/medication was taken out of the night locker, the log failed to have a signature of the pharmacist to ascertain it was reviewed and verified by the pharmacist.

According to the facility's policy on Night Medication Locker stipulate the following :
1. Accurate, written documentation for medications removed from the night locker, in the absence of the pharmacist is required.
2. Within 24 hours, the pharmacist should verify the physician's order and correctness of medications removed from the night locker. Should any discrepancies occur, the pharmacist should investigate.
3. The pharmacy department should replenish the night locker on a daily basis.

Based on observation, interview, and record review, the facility failed to ensure current and accurate records were kept of the receipt and distribution of all scheduled drugs.

Findings:

During the tour of Unit I in the Hawthorne Campus of the facility on July 1, 2010 between 9:50 a.m. and 10:10 a.m., Employee 4 presented the evaluators with a list of accession of controlled medications by licensed nursing staff after pharmacy hours. There were 6 tablets of 5 mg abilify observed in the medication box. However, the medication box was labeled with "10 mg abilify (8)".

A review of the Night Locker Utilization Log disclosed one (1) tablet of 5 mg abilify had been removed by the licensed staff on 6/30/10 at 9 p.m. According to Employee 4, the actual count of abilify should be seven (7) tablets instead of six (6) tablets because he had only stocked seven (7) tablets of abilify. He admitted he had not stocked the right dosage and number of"abilify", based on the "List of medications stocked in Unit I for after pharmacy hours." A review of the aforementioned list disclosed Employee 4 should stock eight (8) tablets of 10 mg abilify.

Based on observation and interview, the facility staff failed to ensure that all drugs and biologicals were kept in a secure area and the medication cart was locked at all times.

Findings:

1. On June 30, 2010, at approximately 1:15 p.m., during the tour of the medication room on the 3rd floor-medical surgical unit with RN 5, the medication door was left ajar. There were two (2) medication carts that were found to be unlocked. One of the medication cart's locking mechanism was not working and needed repair.


During a concurrent interview with Environmental Services (EVS A), she stated she goes into the medication room at any time to clean the floor, dust the medication cart, collect the sharps container and collect the trash. She further stated that she knew the code to get into the medication room anytime.

On July 1, 2010, at approximately 9 a.m., during an interview, RN 5 stated the medication rooms on the different floors for the different units of the hospital were accessible not only to the licensed nursing staff but also to the non-licensed staff such as housekeeping and maintenance staff members. The security code to the medication room door was available to both licensed and non-licensed facility staff members.

2. On June 29, 2010, at approximately 11 a.m., during a tour of the emergency room, the following was noted:

a. The medication cart was found to be unlocked.
b. The medication refrigerator had accumulation of ice in the freezer and contained foods such as soda cans and ice-cream popsicle.
c. There was a medication Levimir (Insulin) opened and undated.
d. There were 2 empty portable oxygen tanks bedside the pediatric Crash Cart .

During a concurrent interview, the administrative nursing staff, stated the medication cart should always be locked when not in use, food should not be in the medication refrigerator and medication when initially opened should be dated and empty oxygen tank should be removed from patient areas more so beside the pediatric crash cart.

3. On June 30, 2010, at approximately 8:30 a.m., during medication pass observation, Patient 5 was observed lying in bed.

There was a container of Collagenase Ointment 15 gm labeled with patient's name on top of the bedside table. A review of the clinical record revealed that on June 23, 2010, the physician ordered cleanse occipital area with normal saline, pat dry, apply santyl ointment, then cover with dry sterile dressing daily. The medication administration record (MAR) dated June 29, 2010, documented that at 9 a.m., the patient received treatment of collagenase for his head wound by RN 7. A review of the nursing admission assessment dated June 21, 2010, documented the patient had a left wound on the head.

During concurrent interview with RN 7 she stated the medication should not be left at the bedside since the physician did not order such. The patient was sharing room with other patients.

Based on interview and record review, the facility failed to ensure that at least two of the members of the UR (Utilization Review) committee are doctors of medicine or osteopathy.

Findings:

An interview with Employee 5 on July 2, 2010 at 2:30 p.m., as well as a review of the UR minutes dated June 8, 2010, revealed there was only one doctor in the UR committee. According to Employee 5, there should be at least 2 doctors of medicine or osteopathy in the UR committee.

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Based on observation, interview and record review, the facility failed to maintain the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings:

During a tour of the facility on June 29, 2010, from 10:45 a.m.-11:45 a.m., and from 1:40 p.m.-3:42 p.m.,the following was observed:

ROOF:

1. There were 12 floor mats stored on the floor behind air handling unit #2. There was an aluminum pan measuring 10 feet x 2 feet stored along the wall. The surrounding area of the floor had an accumulation of dust and debris.

2. In the maintenance department, the alarm panel for the liquid oxygen had a busted bulb for the "on" button.

5th Floor

3. In the storeroom, there was a supply cart and a linen cart. The linen cart cover had a zipper which was not closed exposing the clean linens and the cover was torn.

4. In the clean/dirty utility room, the nurse call system panel on the wall had a detached cover. There were water stained ceiling tiles.

5. In Room 503, which was unoccupied, there was an extension cord taped to the floor and was running from the wall to the area of the floor between the two beds. The extension cord was plugged into a red wall socket. There was no equipment plugged into the extension cord.

6. Outside Room 506, on top of a chair in the hallway, there was a box of masks with some of the clean masks sticking out and the box was on top of a partially open plastic bag of clean gowns. The gowns were partially exposed.

During an interview on July 2, 2010, at 2:32 p.m., the infection control coordinator stated the masks and gowns should be inside an isolation cart or placed on the wall mounted dispensers.

4th Floor

7. The common area shower had tiles with molds.

8. In the storage room, a section of the wall had missing plaster.

9. In Room 406, the door frame and door had peeling paint.

10. In Room 409, in the restroom, the floor around the toilet was detached.

11. In the common area bathtub, the grab bar had no safety cover.

12. In the common area shower, the rubber threshold was detached.

13. In Room 415, there was peeling wall paint at the back of the beds.

14. In the seclusion room, in the restroom, the floor was detached around the toilet.

In the area near the bed, there was a hole in the wall measuring 6 inches in diameter. There was plaster debris on the floor. The bed had white stains.

The camera was located on the right upper corner of the room.

When viewing the room from the monitor located in the nurses' station, the camera was focused on the bed and the immediate area around the bed.

3rd Floor

15. In the nurses' station, the ceiling vent screen was thickly covered with dust.

16. In Room 302, the base coving was detached. There was a water stained ceiling tile. The restroom door had missing sections of the laminate.

17. In Room 305, there was a damaged section of the wall.

18. In the common area shower, the floor tiles had stains.

19. The clean linen room door had peeling paint.

20. In Room 311, there was a water stained ceiling tile.

21. In the common area bathtub, there was a sign "out of order." A housekeeping cart was stored inside.

During an interview on June 30 2010, at 9:25 a.m., the housekeeping supervisor stated the housekeeping cart should not have been stored in the bath tub room.

Radiology Department

22. There was a missing base coving and a detached base coving.

CAT Scan

23. There was a section of the wall with peeling paint.

Laboratory

24. In front of the refrigerator, there were 4 floor tiles with missing edges.

HAWTHORNE CAMPUS

During a tour of the facility on July 1, 2010, from, 9:50 a.m.-12:15 p.m., the following was observed:
Outer Patio

1. There was dust and debris on the floor. There were approximately 75-100 cigarette butts on the floor. There was no receptacle for the cigarette butts.

Outpatient Services

2. In the Partial Hospitalization Program (Outpatient Services), the male and female restroom used by the patients had no call system.

Patient Area

3. In Room 171- the window sill and blinds were thickly covered with dust.

4. In the common area shower room, the floor tiles had black stains.

5. In the shared restroom between room 123 and 124, the linoleum flooring was cracked.

6. In Room 125, in the restroom, the linoleum floor was cracked. The closet door for bed A had sections of the plywood sheet missing.

7. In Room 126, the window was dusty. The closet door for bed B was damaged.

8. In Room 127, the caulking around the toilet was missing.

9. In Room 128, the blinds were dirty.

10. In Room 145-the dining room, the table top had missing sections.

11. In the laundry room, the windows and blinds were dusty.

12. In the patio by Unit 2, the basketball net was ripped. There were cigarette butts on the floor. There was no receptacle for the cigarette butts.

The section of the door facing the patio was damaged.

13. In the south wing, the lower portions of the doors to the patient rooms were damaged.

14. The camera in the seclusion room was focused on the bed. The other areas of the room were not visible.

A review of the temperature and humidity log in the operating room and recovery room from January 2010 - June 2010, revealed the readings were not within range.

During an interview on June 30, 2010, at 9 a.m., the interim chief operating officer stated the facility had no documentation of a water analysis done. The facility had ice machines which was used for human consumption.




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HAWTHORNE CAMPUS

Kitchen

15. On July 7, 2010, at 12:35 p.m., the galvanized metal surfaces of the kitchen range hood and the back splash were spray painted. The surfaces were not smooth and easily cleanable. The spray painted surfaces were also not resistant to conditions that could adulterate food such as chipping, peeling, crazing, scratching and scoring.

16. There was an accumulation of dirt on the ceiling of the kitchen walk in refrigerator.

17. There was tape placed around the full length of the broken handle of the kitchen walk in refrigerator. The surface was not smooth and easily cleanable.

Based on observation, interview and record review, the hospital's dietary staff failed to ensure the kitchen was clean, sanitary and in good repair at all times for the safety and well-being of patients, personnel and visitors.

Findings:

On June 6, 2010, between 1 p.m. and 3:30 p.m., the evaluator conducted an inspection of the dietary department.

The evaluator inspected the dry storage area and observed missing sections of the wall base coving and wall damage. The evaluator also observed a large unsealed penetration around the food preparation sink waste water pipe and the walk-in refrigerator with a cracked wall coving that had separated from the wall.

On June 6, 2010, at 3:30 p.m., during an interview with the kitchen supervisor he stated that he would have the wall and wall coving serviced as soon as possible.

Based on interview and record review, the facility failed to ensure the infection control officer implemented policies and procedures for contact isolation for 2 patients (Patient 13 and 14).

Findings:

1. During the initial tour of the ICU (Intensive Care Unit) on June 29, 2010 at 2:05 p.m. with Employee 1, Patient 13's room was observed with a posted sign "Contact precaution" by the door. According to Employee 1, the patient was in the room with MRSA (methicillin resistant staphylococcus aureus) contact isolation.

On June 29, 2010 at 2:20 p.m., Employee 6 was observed entering the patient's room with a mask in his hand. Employee 6 started to wear his mask by the patient's bedside. During an interview with Employee 6, he admitted he should wear a mask before he entered Patient 13's room.

2. During the initial tour of the Gero-Psych Unit on June 30, 2010 at 10:15 a.m. with Employee 1, Patient 14's room was observed with a posted sign "Contact precaution" by the door. According to Employee 1, the patient was in the room with MRSA contact isolation.

On June 30, 2010 at 10:23 a.m., a hemodialysis (HD) nurse was observed providing hemodialysis treatment to the patient in the room without any personal protective device (PPE). During an interview with Employee 1, she stated that the HD nurse should have PPE as he entered Patient 14's room.

During an interview with Employee 7 on July 2, 2010 at 10 a.m., she stated Employee 6 should wear a mask as he entered the room standing within 3 feet from the patient. According to Employee 7, the HD nurse should wear gown and gloves.

According to the facility's policies and procedures for infection control, on page 53, "Donning PPE (personal protective device) upon room entry and discarding before exiting the patient room---."

Based on observation, interview and record review, the facility staff failed to ensure their infection control program designed to prevent and control infections was implemented.

Findings:

1. On June 29, 2010, at approximately 11 a.m., during an observation tour of the emergency room, the following was noted:

a. RN 1 and RN 2 were observed after providing care to the patients proceeded to wash their hands. The licensed nurses were observed rubbing hands with liquid soap and rinsed their hands. The handwashing process lasted less than 10 minutes.

b. MD A was observed after examining Patient 1 proceeded to wash his hands. The physician was observed rubbing hands with liquid soap and rinsed his hands. The handwashing process lasted less than 10 minutes.

According to the facility's policy on Hand Hygiene stipulated that vigorously rub hands together for 10 to 15 seconds, generating friction on all surfaces of the hands and fingers.

During a concurrent interview with the administrative nursing staff, she stated that according to the facility's policy that it must be 10 to 15 seconds for handwashing.

2. On June 29 through July 2, 2010, from 9 a.m. through 4 p.m., during an observation tour in the different units, the following was observed:

a. In the emergency room, there was an opened and undated bottle of 0.9% of Sodium Chloride Irrigation, opened and undated bottle of Sterile Water, expired a bottle of Rubbing Alcohol and expired two (2) Defibrillator Pads.

b. In Room 314 B (shared room), the following was noted:

1) There were two (2) unlabeled wash basins and two (2) opened and undated bottles of 0.9 % Sodium Chloride and Sterile Water.

2) There was a complete breathing kit (mask, cannula) in an unlabeled bag hanging on the flow meter.

3) There was an irrigation syringe in a plastic bag dated June 27, 2010.

During a concurrent interview with the administrative nursing staff, she acknowledged the unlabeled wash basins that it would be difficult to ascertain which one belongs to which patient. She further stated, the wash basins should be labeled with at least the patient's name. The irrigation syringe should be discarded after 24 hours of use and the plastic bag that contained the breathing supplies should be labeled with at least patient's name.

3. On June 30, 2010, at approximately 10 a.m., during provision of care observation, Patient 3 was observed lying in bed with a fecal smell emanating from the bed. The patient had an indwelling catheter in place draining 350 cubic centimeters (cc) of cloudy, amber-colored urine. RN 3 checked the patient and found that he needed to be cleaned. The licensed nurse was observed to bring with her 5 pieces of wet face towels and hang 3 face towels by the bed rails and placed the 2 face towels by the side of patient. The patient was placed on the side-lying position and started to clean the buttocks using the wet towels placed by the side of the patient. The RN used the wet towels to finish the clean up of the patient's buttocks. During a concurrent interview with RN 3, she admitted that she should have used soap and water to cleanse the patient after bowel elimination. She further added that there was no available wash basin in the supply room that she could use for the patient.

The RN 3 was observed to have changed gloves and proceeded to perform treatment on a Stage III pressure ulcer on the buttock of the resident. She poured sodium chloride on the open wound and wiped the center of the wound and the surrounding area with the same gauze. The RN took another 4 by 4 gauze, cleanse the center of the wound then using the same gauze wiped the surrounding area. The RN repeated the procedure of using the same gauze when cleaning the wound from the center to the surrounding area when she cleansed the pressure ulcer on the left lateral ankle. During wound treatment and linen change RN 3 was assisted by LVN 1. The LVN with gloved hands lifted the indwelling catheter from the right side rail passed it over the patient in bed and handed it over to RN on the other side of the bed. Both licensed nursing staff members without changing gloves moved and touched the patient and placed new linen underneath the patient.

A review of the facility's policy on Perineal Care stipulated among others was to fill basin with warm water and wash and rinse the anal area to prevent skin breakdown of perineal area, itching, burning, odor and infections and for maintaining patient's comfort.

4. On June 30, 2010, at approximately 9:05 a.m., during the medication pass observation, RN 4 prepared the morning medications for Patient 4 in the medication room. The medications were taken to Patient 4's room for administration. The RN put on a pair of gloves and started to assess the patient's left foot. Without changing gloves the RN started to peel off the individual pills and placed them on the plastic cup and administered the medications to the patient.

On June 30, 2010, at 9:30 a.m., during an interview, with RN 4, she acknowledged that she should have washed her hands and don a new pair of gloves prior to touching the medications.

Based on observation and interview, the facility failed to ensure the call-in system was available to the operating room suites.

Findings:

During the tour of the operating room suites on June 30, 2010 between 8:45 a.m. and 10:25 a.m., all operating rooms were observed without a call-in system.

During a concurrent interview with Employee 7, she stated there was no call-in system in any of the operating room.

Based on observations, interview and record review, the facility staff failed to provide respiratory services in accordance with the physician's order for 3 of 22 sampled patients ( Patients 2, 8 and 9).

Findings:

On July 2, 2010, at approximately 9:40 a.m., during a tour of the intensive care unit, the following was observed:

1. Patient 8 was observed lying in bed and connected to a ventilator (Puritan Bennet 7200). The ventilator circuit/tubing and the Ballard were observed not labeled as to the date when it was last changed.

The ventilator settings were synchronized intermittent mandatory ventilation (SIMV) of 10, tidal volume (TV) of 500, fractionated inspired oxygen (FI02) of 30%, pressure support ventilation (PSV) of 10% and positive end expiratory pressure (PEEP) of 5.

A review of the patient's medical record revealed there was no documented evidence of a physician's order for the PEEP and PSV.

2. Patient 9 was observed lying in bed and connected to a ventilator (Puritan Bennet 7200). The ventilator settings were TV of 650, set rate of 12, FI02 of 30% and PEEP of 5.

The ventilator circuit/tubing and the Ballard were observed not labeled as to the date when it was last changed.

During a concurrent interview with the respiratory therapist A (RT) he stated that the Ballard should be changed every 72 hours and the ventilator circuit/tubing every 14 days. The RT concurred that it would be difficult to ascertain when the ventilator circuit/tubing and Ballard was applied and/or was last changed for Patients 8 and 9.

3. On June 29, 2010, at approximately 1:45 p.m., Patient 2 was observed lying in bed on a 30% oxygen with a Ventimask.

A review of the physician order dated June 21, 2010, revealed oxygen 50% with a Ventimask.

During a concurrent interview with RT B, he stated that if the oxygen need of the patient changes inform the physician and obtain a new order.