HospitalInspections.org

Cross refer to:

A0057

Cross refer to:

A0621

Cross refer to:

A0701
A0726

Cross refer to:

A0748

Based on a review of documentation, review of clinical records, interviews with staff and a tour of the facility, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital. Failure to do so increases the risk of patient harm.

Findings were:

Facility policy titled "Surgical Consents" states, in part:

"POLICY:
It is the policy of Stamford Memorial Hospital to obtain informed consent for operative and other invasive procedures. The physician must explain the proposed procedure and its associated risks, possible complications, benefits and alternative options to the patient prior to the procedure. Patients must then sign an informed Surgical Consent form to evidence that they have been informed and wish to proceed with the procedure. The surgeon, dentist, podiatrist will witness and sign the consent form also."

Facility policy titled "Anesthesia Service Policy" states, in part:

PROCEDURE
"6. The anesthesia record is completed by the anesthetist and is inclusive for the intra-operative and post-operative assessments ...The anesthetist will sign and date the document; and if the provider of anesthesia is a CRNA, the physician, dentist or podiatrist will co-sign the document."

During the review of clinical records for 4 surgical patients (patients #13, #14, #15 and #16), the following was noted:

-4 of 4 surgical consents lacked the signature of the surgeon or dentist.

-1 of 4 anesthesia records (patient #15) was not co-signed by the physician, dentist or podiatrist.

Facility policy titled "Purchasing and Storage" states, in part:

"A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
Refrigerated perishable foods: 33 to 40 degrees (Fahrenheit)
Frozen Foods: -10 to 0 degrees (Fahrenheit)"

Facility policy titled "Sanitation - Dishwashing" states, in part:

"To properly was(sic) dishes with the dish machine:...Make sure that wash-water temperature is at least 125 degrees F for 52 seconds, and rinse water is at least 125 degrees F for 25 seconds...Water Temperatures and chlorine levels will be checked the first load after each meal to ensure the machine is functioning correctly. These level(sic) will be recorded."

During a tour of the facility on 4-8-15, the following was noted:

-A document titled "Equipment Temperature Log" hung from one of the kitchen's refrigerators. In an interview with staff #19, staff #19 indicated that the document was for recording the temperatures of the kitchen refrigerators and freezers. The document contained no acceptable temperature range for either the refrigerators or the freezers. In an interview with staff #19 on 4-8-15 at 1:44 pm, staff #19 was asked to state the acceptable temperature range for the refrigerators. Staff #19 replied "33 to 37 degrees." When asked to state the acceptable temperature range for the freezers, staff #19 replied "-5 to 7 or 8 degrees." In an interview with staff #20 on 4-8-15 at 1:47 pm, staff #20 was asked to state the acceptable temperature range for the refrigerators. Staff #20 replied "36 to 40 degrees." When asked to state the acceptable temperature range for the freezers, staff #20 replied "-8 to about 5 degrees." In an interview with staff #21 on 4-8-15 at 3:11 pm, staff #21 was asked to state the acceptable temperature range for the refrigerators. Staff #21 replied "25 to 35 degrees." When asked to state the acceptable temperature range for the freezers, staff #21 replied "-10 to -5 degrees." 2 of 7 temperatures recorded thus far for the month of April were out of range for one of the freezers, and 5 of 7 temperatures recorded thus far for the month of April were out of range for a 2nd freezer. Lack of knowledge of acceptable temperature ranges for food storage can lead to spoiled food and food-borne illnesses.

-A document titled "Dishmachine Log" was provided to the surveyor by staff #19. The log contained boxes for the documentation of the wash & rinse cycle water temperatures as well as the chlorine concentration. Different columns were present for breakfast, lunch and dinner uses of the dishwashing machine. Review of the document revealed that, for the breakfast wash cycle, the water temperature was below 125 degrees Fahrenheit for 6 of the 8 days recorded. For the breakfast rinse cycle, the water temperature was below 125 degrees for 2 of the 8 days recorded. For the lunch wash cycle, the water temperature was below 125 degrees for 6 of the 7 days measured.

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.

Based on a review of clinical records and an interview with staff, all records did not contain a properly executed inform consent form for surgeries performed by the medical staff.

Findings were:

During the review of clinical records for 4 surgical patients (patients #13, #14, #15 and #16), the following was noted:

-4 of 4 surgical consents lacked the signature of the surgeon or dentist.

-1 of 4 surgical consents (patient #14) was incorrect, as the procedure(s) performed were not the procedure(s) for which consent was given. Surgical services were provided by physician #2. The surgical consent stated the procedure(s) to be "Dental Restoration and Dental Extractions." Medical reference site www.webmd.com defines "dental restorations" as "various ways your dentist can REPLACE missing teeth or REPAIR missing parts of the tooth surface." The operative states "Perio scale & root pln, 4+ per quad(rant): LL, LR, UL & UR." Medical reference site www.webmd.com defines "root planing and scaling" as "cleaning between the gums and the teeth down to the roots", not a procedure involving restoration or extraction. In an interview with staff #16 on the afternoon of 4-8-15, staff #16 stated that physician #2 uses pre-printed surgical consent forms and that "Dental Restoration and Dental Extractions" are listed as the procedure to be performed on all consent forms used by physician #2.

Facility policy titled "Surgical Consents" states, in part:

"POLICY:
It is the policy of Stamford Memorial Hospital to obtain informed consent for operative and other invasive procedures. The physician must explain the proposed procedure and its associated risks, possible complications, benefits and alternative options to the patient prior to the procedure. Patients must then sign an informed Surgical Consent form to evidence that they have been informed and wish to proceed with the procedure. The surgeon, dentist, podiatrist will witness and sign the consent form also."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.

Based on observation, interviews and a tour of the facility, the facility failed to employ a qualified dietitian that observed and adhered to professional standards of practice regarding food storage and sanitation. Failure to adhere to these professional standards compromises patient safety and increases the likelihood of infections caused by improper sanitation and improper food storage.
Findings were:

During a tour of the facility on 4-8-15, the following was noted:

-In the facility kitchen, the linoleum tile floor of the dry-goods pantry was chipped in several places, with individual tiles no longer glued to the floor. With breaks in the seal of the floor, the floor cannot be adequately cleaned and can harbor bacteria.

-A live insect, wasp-like in appearance, was noted on the vent directly above the cooktop. Insects in the facility can carry disease as well as sting or bite patients.

-7 ceramic tiles were missing from the wall area above the refrigerated walk-in, preventing the area from being properly cleaned.

-A document titled "Equipment Temperature Log" hung from one of the kitchen's refrigerators. In an interview with staff #19, staff #19 indicated that the document was for recording the temperatures of the kitchen refrigerators and freezers. The document contained no acceptable temperature range for either the refrigerators or the freezers. In an interview with staff #19 on 4-8-15 at 1:44 pm, staff #19 was asked to state the acceptable temperature range for the refrigerators. Staff #19 replied "33 to 37 degrees." When asked to state the acceptable temperature range for the freezers, staff #19 replied "-5 to 7 or 8 degrees." In an interview with staff #20 on 4-8-15 at 1:47 pm, staff #20 was asked to state the acceptable temperature range for the refrigerators. Staff #20 replied "36 to 40 degrees." When asked to state the acceptable temperature range for the freezers, staff #20 replied "-8 to about 5 degrees." In an interview with staff #21 on 4-8-15 at 3:11 pm, staff #21 was asked to state the acceptable temperature range for the refrigerators. Staff #21 replied "25 to 35 degrees." When asked to state the acceptable temperature range for the freezers, staff #21 replied "-10 to -5 degrees." 2 of 7 temperatures recorded thus far for the month of April were out of range for one of the freezers, and 5 of 7 temperatures recorded thus far for the month of April were out of range for a 2nd freezer. Lack of knowledge of acceptable temperature ranges for food storage can lead to spoiled food and food-borne illnesses.

-A document titled "Dishmachine Log" was provided to the surveyor by staff #19. The log contained boxes for the documentation of the wash & rinse cycle water temperatures as well as the chlorine concentration. Different columns were present for breakfast, lunch and dinner uses of the dishwashing machine. Review of the document revealed that, for the breakfast wash cycle, the water temperature was below 125 degrees Fahrenheit for 6 of the 8 days recorded. For the breakfast rinse cycle, the water temperature was below 125 degrees for 2 of the 8 days recorded. For the lunch wash cycle, the water temperature was below 125 degrees for 6 of the 7 days measured. Improperly washed and sanitized dishes can spread illness among employees and patients.

Facility policy titled "Purchasing and Storage" states, in part:

"A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
Refrigerated perishable foods: 33 to 40 degrees (Fahrenheit)
Frozen Foods: -10 to 0 degrees (Fahrenheit)"

Facility policy titled "Sanitation - Dishwashing" states, in part:

"To properly was(sic) dishes with the dish machine:...Make sure that wash-water temperature is at least 125 degrees F for 52 seconds, and rinse water is at least 125 degrees F for 25 seconds...Water Temperatures and chlorine levels will be checked the first load after each meal to ensure the machine is functioning correctly. These level(sic) will be recorded."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.

Based on a review of documentation, review of clinical records, interviews with staff and a tour of the facility, the condition of the physical plant and the overall hospital environment were not maintained in such a manner that the safety and well-being of patients was assured.

Findings were:

Facility policy titled "Purchasing and Storage" states, in part:

"A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
Refrigerated perishable foods: 33 to 40 degrees (Fahrenheit)
Frozen Foods: -10 to 0 degrees (Fahrenheit)"

Facility policy titled "Sanitation - Dishwashing" states, in part:

"To properly was(sic) dishes with the dish machine:...Make sure that wash-water temperature is at least 125 degrees F for 52 seconds, and rinse water is at least 125 degrees F for 25 seconds...Water Temperatures and chlorine levels will be checked the first load after each meal to ensure the machine is functioning correctly. These level(sic) will be recorded."

During a tour of the facility on 4-8-15, the following was noted:

-In the patient hallway between rooms 51 and 51A, an area of sealed wall covering measuring approximately 12 ft in length had peeled back from the lower section of the wall, exposing crumbling drywall plaster. A breach in the sealed wall covering prevented the surface from being properly cleaned and could service as an entry point for insects and other vermin.

-In the womens' bathroom near the physical therapy department, the surface of the two walls forming the corner nearest the toilet were cracked and bubbling, exposing crumbling drywall plaster. A bubbling appearance could indicate prior water damage and prevents the surface from being properly cleaned.

-The male and female restrooms in the physical therapy area were not equipped with safety call systems. Lack of a safety call system prevents the patient from summoning help in case of a fall or other emergency.

-In the facility kitchen, the linoleum tile floor of the dry-goods pantry was chipped in several places, with individual tiles no longer glued to the floor. With breaks in the seal of the floor, the floor cannot be adequately cleaned and can harbor bacteria.

-A live insect, wasp-like in appearance, was noted on the vent directly above the cooktop. Insects in the facility can carry disease as well as sting or bite patients.

-7 ceramic tiles were missing from the wall area above the refrigerated walk-in, preventing the area from being properly cleaned.

-A document titled "Equipment Temperature Log" hung from one of the kitchen's refrigerators. In an interview with staff #19, staff #19 indicated that the document was for recording the temperatures of the kitchen refrigerators and freezers. The document contained no acceptable temperature range for either the refrigerators or the freezers. In an interview with staff #19 on 4-8-15 at 1:44 pm, staff #19 was asked to state the acceptable temperature range for the refrigerators. Staff #19 replied "33 to 37 degrees." When asked to state the acceptable temperature range for the freezers, staff #19 replied "-5 to 7 or 8 degrees." In an interview with staff #20 on 4-8-15 at 1:47 pm, staff #20 was asked to state the acceptable temperature range for the refrigerators. Staff #20 replied "36 to 40 degrees." When asked to state the acceptable temperature range for the freezers, staff #20 replied "-8 to about 5 degrees." In an interview with staff #21 on 4-8-15 at 3:11 pm, staff #21 was asked to state the acceptable temperature range for the refrigerators. Staff #21 replied "25 to 35 degrees." When asked to state the acceptable temperature range for the freezers, staff #21 replied "-10 to -5 degrees." 2 of 7 temperatures recorded thus far for the month of April were out of range for one of the freezers, and 5 of 7 temperatures recorded thus far for the month of April were out of range for a 2nd freezer. Lack of knowledge of acceptable temperature ranges for food storage can lead to spoiled food and food-borne illnesses.

-A document titled "Dishmachine Log" was provided to the surveyor by staff #19. The log contained boxes for the documentation of the wash & rinse cycle water temperatures as well as the chlorine concentration. Different columns were present for breakfast, lunch and dinner uses of the dishwashing machine. Review of the document revealed that, for the breakfast wash cycle, the water temperature was below 125 degrees Fahrenheit for 6 of the 8 days recorded. For the breakfast rinse cycle, the water temperature was below 125 degrees for 2 of the 8 days recorded. For the lunch wash cycle, the water temperature was below 125 degrees for 6 of the 7 days measured.

-During a tour of the patient care unit, an area of ceiling tile measuring approximately 1' by 1' located above the room's air cooling and heating unit contained a large stain that appeared to be a water stain. Dust was noted on the high, horizontal surfaces of the room. Several gouges were present in the sheetrock behind the head of the bed, exposing the drywall plaster. Water stained ceiling tiles can indicate a past or current water leak and can grow and harbor mold and mildew. Dust can contain and carry bacteria. Exposed drywall plaster cannot be properly cleaned, allowing bacteria to be harbored.

-In the ER patient waiting room, 3 completely stained (with what appeared to be a water stain) ceiling tiles were noted. Large, uncovered openings, measuring approximately 24" by 3", led into the ceiling crawl space above 2 of the 3 air vents. Water-stained ceiling tiles can indicate a past or current water leak and can grow and harbor mold and mildew. Openings into the ceiling crawl space can allow the entry of insects and other vermin.

-In ER #1, dead bugs were noted on 2 of the room's 6 light fixtures. Insects can carry and transmit disease. Laminate had bubbled around the room's sink fixtures, exposing the plywood beneath the laminate and preventing proper cleaning as well as encouraging the growth of bacteria, mold and mildew.

-The double doors leading into the ER hallway from the ambulance bay did not fit snugly against the threshold and daylight could be seen through the space. Doors leading to the outside that do not properly seal allow dust, dirt and insects to enter the building, posing an infection hazard.

-In the operating room dirty workroom, the laminate had bubbled around the room's sink and sink fixtures, exposing the plywood beneath the laminate and preventing proper cleaning as well as encouraging the growth of bacteria, mold and mildew.

-In the operating room, dust was noted on high, horizontal surfaces, including the overhead lamps. Dust carries bacteria, which can cause infection.

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.

Based on a review of documentation, a tour of the facility and interviews with staff, there was not proper temperature control in the food preparation area.

Findings were:

During a tour of the facility on 4-8-15, the following was noted:

-A document titled "Equipment Temperature Log" hung from one of the kitchen's refrigerators. In an interview with staff #19, staff #19 indicated that the document was for recording the temperatures of the kitchen refrigerators and freezers. The document contained no acceptable temperature range for either the refrigerators or the freezers. In an interview with staff #19 on 4-8-15 at 1:44 pm, staff #19 was asked to state the acceptable temperature range for the refrigerators. Staff #19 replied "33 to 37 degrees." When asked to state the acceptable temperature range for the freezers, staff #19 replied "-5 to 7 or 8 degrees." In an interview with staff #20 on 4-8-15 at 1:47 pm, staff #20 was asked to state the acceptable temperature range for the refrigerators. Staff #20 replied "36 to 40 degrees." When asked to state the acceptable temperature range for the freezers, staff #20 replied "-8 to about 5 degrees." In an interview with staff #21 on 4-8-15 at 3:11 pm, staff #21 was asked to state the acceptable temperature range for the refrigerators. Staff #21 replied "25 to 35 degrees." When asked to state the acceptable temperature range for the freezers, staff #21 replied "-10 to -5 degrees." 2 of 7 temperatures recorded thus far for the month of April were out of range for one of the freezers, and 5 of 7 temperatures recorded thus far for the month of April were out of range for a 2nd freezer. Lack of knowledge of acceptable temperature ranges for food storage can lead to spoiled food and food-borne illnesses.

-A document titled "Dishmachine Log" was provided to the surveyor by staff #19. The log contained boxes for the documentation of the wash & rinse cycle water temperatures as well as the chlorine concentration. Different columns were present for breakfast, lunch and dinner uses of the dishwashing machine. Review of the document revealed that, for the breakfast wash cycle, the water temperature was below 125 degrees Fahrenheit for 6 of the 8 days recorded. For the breakfast rinse cycle, the water temperature was below 125 degrees for 2 of the 8 days recorded. For the lunch wash cycle, the water temperature was below 125 degrees for 6 of the 7 days measured. Failure to properly wash and sanitize dishes can increase the risk of illness for patients and staff.

Facility policy titled "Purchasing and Storage" states, in part:

"A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
Refrigerated perishable foods: 33 to 40 degrees (Fahrenheit)
Frozen Foods: -10 to 0 degrees (Fahrenheit)"

Facility policy titled "Sanitation - Dishwashing" states, in part:

"To properly was(sic) dishes with the dish machine:...Make sure that wash-water temperature is at least 125 degrees F for 52 seconds, and rinse water is at least 125 degrees F for 25 seconds...Water Temperatures and chlorine levels will be checked the first load after each meal to ensure the machine is functioning correctly. These level(sic) will be recorded."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.

Based on observation, interviews, a review of documentation and a tour of the facility, the infection control officer failed to develop and implement adequate policies governing control of infections and communicable diseases. Failure to develop and implement adequate policies increases the likelihood of disease and illness within the facility.
Facility policy titled "Purchasing and Storage" states, in part:

"A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
Refrigerated perishable foods: 33 to 40 degrees (Fahrenheit)
Frozen Foods: -10 to 0 degrees (Fahrenheit)"

Facility policy titled "Sanitation - Dishwashing" states, in part:

"To properly was(sic) dishes with the dish machine:...Make sure that wash-water temperature is at least 125 degrees F for 52 seconds, and rinse water is at least 125 degrees F for 25 seconds...Water Temperatures and chlorine levels will be checked the first load after each meal to ensure the machine is functioning correctly. These level(sic) will be recorded."

During a tour of the facility on 4-8-15, the following was noted:

-In the patient hallway between rooms 51 and 51A, an area of sealed wall covering measuring approximately 12 ft in length had peeled back from the lower section of the wall, exposing crumbling drywall plaster. A breach in the sealed wall covering prevented the surface from being properly cleaned and could service as an entry point for insects and other vermin.

-In the womens' bathroom near the physical therapy department, the surface of the two walls forming the corner nearest the toilet were cracked and bubbling, exposing crumbling drywall plaster. A bubbling appearance could indicate prior water damage and prevents the surface from being properly cleaned.

-In the facility kitchen, the linoleum tile floor of the dry-goods pantry was chipped in several places, with individual tiles no longer glued to the floor. With breaks in the seal of the floor, the floor cannot be adequately cleaned and can harbor bacteria.

-A live insect, wasp-like in appearance, was noted on the vent directly above the cooktop. Insects in the facility can carry disease as well as sting or bite patients.

-7 ceramic tiles were missing from the wall area above the refrigerated walk-in, preventing the area from being properly cleaned.

-A document titled "Equipment Temperature Log" hung from one of the kitchen's refrigerators. In an interview with staff #19, staff #19 indicated that the document was for recording the temperatures of the kitchen refrigerators and freezers. The document contained no acceptable temperature range for either the refrigerators or the freezers. In an interview with staff #19 on 4-8-15 at 1:44 pm, staff #19 was asked to state the acceptable temperature range for the refrigerators. Staff #19 replied "33 to 37 degrees." When asked to state the acceptable temperature range for the freezers, staff #19 replied "-5 to 7 or 8 degrees." In an interview with staff #20 on 4-8-15 at 1:47 pm, staff #20 was asked to state the acceptable temperature range for the refrigerators. Staff #20 replied "36 to 40 degrees." When asked to state the acceptable temperature range for the freezers, staff #20 replied "-8 to about 5 degrees." In an interview with staff #21 on 4-8-15 at 3:11 pm, staff #21 was asked to state the acceptable temperature range for the refrigerators. Staff #21 replied "25 to 35 degrees." When asked to state the acceptable temperature range for the freezers, staff #21 replied "-10 to -5 degrees." 2 of 7 temperatures recorded thus far for the month of April were out of range for one of the freezers, and 5 of 7 temperatures recorded thus far for the month of April were out of range for a 2nd freezer. Lack of knowledge of acceptable temperature ranges for food storage can lead to spoiled food and food-borne illnesses.

-A document titled "Dishmachine Log" was provided to the surveyor by staff #19. The log contained boxes for the documentation of the wash & rinse cycle water temperatures as well as the chlorine concentration. Different columns were present for breakfast, lunch and dinner uses of the dishwashing machine. Review of the document revealed that, for the breakfast wash cycle, the water temperature was below 125 degrees Fahrenheit for 6 of the 8 days recorded. For the breakfast rinse cycle, the water temperature was below 125 degrees for 2 of the 8 days recorded. For the lunch wash cycle, the water temperature was below 125 degrees for 6 of the 7 days measured.

-During a tour of the patient care unit, an area of ceiling tile measuring approximately 1' by 1' located above the room's air cooling and heating unit contained a large stain that appeared to be a water stain. Dust was noted on the high, horizontal surfaces of the room. Several gouges were present in the sheetrock behind the head of the bed, exposing the drywall plaster. Water stained ceiling tiles can indicate a past or current water leak and can grow and harbor mold and mildew. Dust can contain and carry bacteria. Exposed drywall plaster cannot be properly cleaned, allowing bacteria to be harbored.

-In the ER patient waiting room, 3 completely stained (with what appeared to be a water stain) ceiling tiles were noted. Large, uncovered openings, measuring approximately 24" by 3", led into the ceiling crawl space above 2 of the 3 air vents. Water-stained ceiling tiles can indicate a past or current water leak and can grow and harbor mold and mildew. Openings into the ceiling crawl space can allow the entry of insects and other vermin.

-In ER #1, dead bugs were noted on 2 of the room's 6 light fixtures. Insects can carry and transmit disease. Laminate had bubbled around the room's sink fixtures, exposing the plywood beneath the laminate and preventing proper cleaning as well as encouraging the growth of bacteria, mold and mildew.

-The double doors leading into the ER hallway from the ambulance bay did not fit snugly against the threshold and daylight could be seen through the space. Doors leading to the outside that do not properly seal allow dust, dirt and insects to enter the building, posing an infection hazard.

-In the operating room dirty workroom, the laminate had bubbled around the room's sink and sink fixtures, exposing the plywood beneath the laminate and preventing proper cleaning as well as encouraging the growth of bacteria, mold and mildew.

-In the operating room, dust was noted on high, horizontal surfaces, including the overhead lamps. Dust carries bacteria, which can cause infection.

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.

Based on a review of clinical records and interviews with staff, post-anesthesia assessments were not completed in accordance with current standards of anesthesia care to include a minimum of the assessment of respiratory function, including rate, airway patency and oxygen saturation; pulse rate, blood pressure, mental status, temperature, pain, nausea and vomiting and postoperative hydration.

Findings were:

During the review of clinical records for 4 surgical patients (patients #13, #14, #15 and #16), the following was noted:

-4 of 4 anesthesia records contained post-anesthesia assessment areas for only blood pressure, pulse, respirations, temperature and oxygen saturation following the surgical procedure. In interviews with staff #12, #16 and #18, the anesthetist would not be writing post-anesthesia assessment results anywhere else in the clinical record.

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the afternoon of 4-8-15 in the facility boardroom.