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482.41 Condition of Physical Environment is NOT MET as evidenced by the failure of the facilities of 119 to be in compliance with the 2000 Existing Life Safety Code at the Gateway location and the 2000 New Life Safety Code at the Cleveland Fairhill location.

Findings include:

During a tour of both locations on 07/19/10-07/21/10 while accompanied by Staff K, it was observed that there was a failure to ensure all corridor doors had no impediment to closing (K18), failure to ensure smoke barriers are constructed to provide 30 minutes fire rating at the Gateway location and one hour at the Cleveland Fairhill location (K25), failure to ensure exit components are arranged to provide a continuous path of escape at the Gateway location (K33), failure to assure stairways used as exits are in accordance with regard to interior stair exits at the Gateway location (K34), provision of exit and directional signs (K47) and spacing of smoke detectors (K130). Please see A709 for more details.

Per interview with Patient 17 on 07/22/10 between 10:48 AM-11:45 AM, call light responses are slow and on 07/18/10, he/she waited for 50 minutes to be assisted back to bed from the bedside commode between 6:30 PM and 7:20 PM. Per interview, Patient 17 was uncomfortable and when the staff did not respond to her/his call light, the patient called a family member to call the facility to prompt removal of the patient from the bedside commode. Per Patient 17, his/her gown was not changed from 07/16/10-07/18/10 and the bedside commode is not emptied after each use. Per medical record review on 07/22/10, the patient is alert and oriented to person, place and time and requires an assist of one and was at a risk for falls. Per medical record review, the patient is receiving physical therapy and on 07/17/10, required assistance to use the bedside commode. Patient 17 reported that she/he had been told by a staff member on 07/18/10 that a patient complaint would be generated as a result of the patient's concerns, but as of 07/22/10, according to Staff C, the director of quality, at 11:48 AM, no compliant had been written up.

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The medical record review for Patient # 11 was completed on 07/22/10. This patient was admitted to the facility on 06/08/10 for diagnoses that included cerebral vascular accident, seizures and upper gastrointestinal bleed. Physician orders for restraints were started on 06/08/10 at 6:00 PM and continued until 06/15/10 at 4:42 PM. Restraint observation and care documentation was completed by nursing every two hours with the following exceptions. On 06/09/10 nursing failed to document from midnight to 06:00 AM, 06/10/10 nursing failed to document from 2:00 PM to 6:00 PM, 06/11/10 nursing failed to document from 8:00 AM to 12:00 noon, 06/12/10 nursing failed to document from 03:00 AM to 10:53 AM and 1:00 PM to 4:00 PM, 06/13/10 nursing failed to document from 8:00 PM to midnight and on 06/14/10 nursing failed to document from 08:00 AM to 12:00 noon. This finding was verified with Staff B who assisted the surveyor in electronic medical record review on 07/22/10 at 2:20 PM.

Based on medical record review, facility policy review and staff interview the facility failed to document according to the hospital's policy the observations of and the care provided to one (Patient #11) of five patients reviewed for whom restraints were used. The sample size was 19 patients. The census at the Fairhill location was 32 patients. The census at the Gateway location was 26 patients.

Findings include:

The medical record review for Patient #11 was completed on 07/22/10. This patient was admitted to the facility on 06/08/10 for diagnoses that included cerebral vascular accident, seizures and upper gastrointestinal bleed. Restraints were initiated, according to the physician's order, on 06/08/10 at 6:00 PM and continued until 06/15/10 at 4:42 PM.

Review of the nursing documentation revealed nursing failed to document the observations of and care provided to Patient #11 at varying times on six consecutive days as follows: from midnight to 06:00 AM on 06/09/10; from 2:00 PM to 6:00 PM on 06/10/10; from 8:00 AM to 12:00 noon on 06/11/10; from 03:00 AM to 10:53 AM and from 1:00 PM to 4:00 PM on 06/12/10; from 8:00 PM to midnight on 06/13/19; and from 08:00 AM to 12:00 noon on 06/14/10. This finding was verified by Staff B who assisted the surveyor in electronic medical record review on 07/22/10 at 2:20 PM.

The hospital's policy number H-PC 05-010 entitled " Use of Physical or Chemical Restraint" was reviewed on 07/22/10. In the section noted on page 6 of 16 entitled "Physical or Chemical Restraints: General Requirements" the policy required staff to document the observations of and the care provided to restrained patients at a minimum of every two hours.

Per interview with 5 of 9 patients at the Fairhill location between 07/20/10 and 07/22/10, complaints were heard from Patients 1, 16, 17, 18 and 19. These complaints were regarding a lack of care and delayed call light responses.

Per interview with Patient 1 on 07/20/10 between 4:07 PM-4:29 PM, call light responses range from 10-30 minutes with response time longer after 7:00 PM. Per medical record review on 07/21/10, this patient is alert and oriented to person, place and time. Patient 1 reported to the surveyor that he/she waited over 30 minutes for the call light to be answered on 07/18/10, that he/she walked to the bathroom without assistance even though a falls risk completed on admission and on 07/21/10 as at risk for falls and requires an assist of one. Per observation, each patient has a visible clock in direct view of the patient. These findings were verified on 07/21/10 by Staff D at 2:50 PM.

Per interview with Patient 16 on 07/20/10 between 4:30 PM-4:55 PM, this alert and oriented patient admitted on 06/08/10 told the surveyor of long waits for call light response after 7:00 PM and on one occasion he/she waited two hours to be assisted off the bedside commode after 12 midnight. Assessed to be at risk for falls throughout the hospitalization, Patient 16 required assistance from the commode to the bed. These findings were verified on 07/20/10 by Staff D at 3:00 PM.

Per interview with Patient 17 on 07/22/10 between 10:48 AM-11:45 AM, call light responses are slow and on 07/18/10, he/she waited for 50 minutes to be assisted back to bed from the bedside commode between 6:30 PM and 7:20 PM. Per interview, Patient 17 was uncomfortable and when the staff did not respond to her/his call light, the patient called a family member to call the facility to prompt removal of the patient from the bedside commode. Per Patient 17, his/her gown was not changed from 07/16/10-07/18/10 and the bedside commode is not emptied after each use. Patient 17 reported that she/he had been told by a staff member on 07/18/10 that a patient complaint would be generated as a result of the patient's concerns, but as of 07/22/10, according to Staff C, the director of quality, no compliant had been written up.





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The medical record review for Patient 2 was conducted on 07/19/10. Patient #2 was admitted to the facility on 07/16/10 with respiratory distress, chronic lung disease, sepsis and shock. On admission Patient #2 was noted to have a Stage II pressure ulcer, which means that he/she has a wound which affects the two outermost layers of skin. This pressure ulcer is located on her coccyx (tail bone) area. Review of the nursing documentation since admission revealed there was no evidence that Patient #2 had been turned.

The facility policy on prevention of skin breakdown was reviewed on 07/23/10. This policy states that staff is required to turn the patient when they are unable to turn themselves, every two hours regardless of the type of bed surface. There is no documentation that the facility followed their policy.

This was confirmed with Staff D on 07/19/10 at 3:50 PM.


An interview was conducted with Patient 18 and family on 07/22/10 at 1:05 PM. Patient 18 complained that care in the facility is very slow. Patient 18 stated that he/she had a colostomy placed prior to admission. The colostomy leaks around the seal that is adhered to the skin and the exterior dressing becomes very saturated and leaks on the bed linens. At Patient 18 ' s request the site to his/her left abdomen was observed by this surveyor and noted to be saturated and leaking. Patient 18 stated that he/she pushes the call light when care is needed then staff answer the call light and ensure him/her that they will return. Patient 18 stated that often it takes 2 hours for staff to return to his/her room to provide the assistance that was originally requested.

This was confirmed with Staff C on 07/22/10 at 5:23 PM.


An interview was conducted with Patient 19 on 07/22/10 at 1:25 PM. Patient 19 was admitted to the facility 3 weeks ago and voiced multiple complaints regarding the care received. Patient 19 stated that it is a big hassle to get any ice water unless you ask for it, and that the water currently in the pitcher at the bedside was left from yesterday. Patient 19 also stated that staff does not bring anything unless you request it. Patient 19 discussed two separate incidents that happened recently in which he/she placed the call light on for assistance up to the bedside commode to have a bowel movement. One hour later no one had come to assist him/her up to the bedside commode which resulted in an episode of incontinence in the bed. Patient 19 also shared that on one occasion he/she had requested the staff empty the bedside commode following two bowel movements that had remained in the commode all morning. After the request was made the staff did empty the commode at lunchtime.

A review of the medical record was completed on 07/22/10 and revealed that Patient 19 is to have assistance with toileting on the bedside commode and be offered toileting every two hours. There was no documentation to support that this was being followed.

This was confirmed with Staff C on 07/22/10 at 5:23 PM.


On 07/19/10 at 3:35 PM the family member of Patient 4 was observed entering the room carrying the personal protective equipment (PPE) into the room without donning prior to entry. Patient 4 is currently in contact and droplet isolation for MRSA (methicillin resistant staphylococcus aureus) which is a bacterium that causes infections in various parts of the body. Contact and droplet (respirator) isolation precautions require the donning of a gown, mask and gloves to enter the room. The family member was observed standing next to the bed and talking to Patient 4 and then stopped to don a gown. There was no observed intervention from staff or reeducation completed with this family member at the time of this observation. This was confirmed with Staff T on 07/23/10 at 11:25 AM.

On 07/20/10 at 10:15 AM Staff U was observed entering the room of Patient 5. Staff U wore no PPE (personal protective equipment) while in Patient 5 ' s room. Patient 5 is currently in contact isolation for two kinds of multi drug resistant organisms. Staff U, a physician, was observed without a gown or gloves examining Patient 5. Staff U also removed his/her stethoscope from their pocket to assist in the examination and then replaced the stethoscope prior to when he/she left the room. Staff U was observed by Staff X without the proper PPE on. There was no observed intervention between the Staff X and Staff U during the time of the exam conducted on Patient 5. This was confirmed with Staff W on 07/20/10 at 10:40 AM.

Review of the facility policy was conducted on 07/23/10 at 1:00 PM revealed that if the patient is on contact precautions all staff and visitors will don gloves and a gown prior to entering the room. If the patient is on droplet precautions a mask will be worn.

Based on observation, patient interview, staff interview, medical record review and hospital policy review the hospital failed to ensure the registered nurse's assignment of patient care met the individual needs of five (Patients 1, 16, 17, 18 and 19) of nine patients interviewed at the Fairhill location, and one (Patient 2) of 19 sampled patients. The census at the Fairhill location was 32 patients. The census at the Gateway location was 26 patients.

Findings include:

An interview was conducted with Patient 1 on 07/20/10 between 4:07 PM-4:29 PM. The patient stated call light responses ranged from 10-30 minutes and response time was longer after 7:00 PM. Review of the medical record on 07/21/10, revealed this patient was alert and oriented to person, place and time. Patient 1 stated that he/she had waited over 30 minutes for the call light to be answered on 07/18/10. He/she had then walked to the bathroom without assistance even though a falls risk assessment completed on admission and a reassessment on 07/21/10, revealed the patient was at risk for falls and required the assistance of one person for ambulation. Per observation, on 07/20/10, the patient had a clock in his/her room in direct view of the patient. These findings were verified on 07/21/10 by Staff D at 2:50 PM.

An interview was conducted with Patient 16 on 07/20/10 between 4:30 PM-4:55 PM. The alert and oriented patient who was admitted on 06/08/10, told the surveyor of long waits for call light response after 7:00 PM. The patient said, on one occasion, he/she had waited two hours to be assisted off the bedside commode after 12 midnight. The medical record was reviewed on 07/21/10 and revealed the patient had been assessed to be at risk for falls throughout the hospitalization. Patient 16 required assistance for ambulation/transfer from the commode to the bed. These findings were verified on 07/20/10 by Staff D at 3:00 PM.

An interview was conducted with Patient 17 on 07/22/10 between 10:48 AM-11:45 AM. The patient stated call light responses were slow. The patient said on 07/18/10, he/she waited for 50 minutes to be assisted back to bed from the bedside commode between 6:30 PM and 7:20 PM. Patient 17 stated he/she was uncomfortable on the bedside commode and when the staff did not respond to her/his call light, the patient called a family member to ask the family member to call the facility to assist the patient from the bedside commode. Patient 17 stated his/her gown was not changed from 07/16/10-07/18/10 and the bedside commode is not emptied after each use. Patient 17 reported that she/he had been told by a staff member on 07/18/10, that a patient complaint would be generated as a result of his/her concerns, but as of 07/22/10, according to Staff C, no complaint had been written up.

The medical record review for Patient 2 was conducted on 07/19/10. Patient #2 was admitted to the facility on 07/16/10 with respiratory distress, chronic lung disease, sepsis and shock. On admission Patient #2 was noted to have a Stage II pressure ulcer, (a wound which affects the two outermost layers of skin). The patient was unable to turn self. The pressure ulcer was located on his/her coccyx (tail bone) area. Review of the nursing documentation since admission revealed the record lacked evidence that Patient #2 had been turned.

The facility policy, number H-WC-01-001 entitled "Wound Prevention" was reviewed on 07/23/10 and revealed, under the Procedure section at 2A on page 1 of 3, staff are required to turn the patient, when the patient is unable to turn self, every two hours regardless of the type of bed surface.

Staff D confirmed, on 07/19/10 at 3:50 PM, staff had not followed the hospital policy related to turning the patient.


An interview was conducted with Patient 18 and family on 07/22/10 at 1:05 PM. Patient 18 complained that care in the facility is very slow. Patient 18 stated that he/she had a colostomy placed prior to admission. The colostomy leaks around the seal that is adhered to the skin and the exterior dressing becomes saturated and leaks onto the bed linens. At Patient 18 ' s request the site to his/her left abdomen was observed by this surveyor and the exterior dressing was noted to be saturated and leaking. Patient 18 stated that he/she pushes the call light when care is needed. The staff answers the call light and assures him/her that they will return. Patient 18 stated often it takes 2 hours for staff to return to his/her room to provide the assistance that was originally requested. This finding was confirmed with Staff C on 07/22/10 at 5:23 PM.


An interview was conducted with Patient 19 on 07/22/10 at 1:25 PM. Patient 19 was admitted to the facility 3 weeks ago and voiced multiple complaints regarding the care received. Patient 19 stated that it is a big hassle to get any ice water and that the water currently in the pitcher at the bedside was left from yesterday. Patient 19 stated that staff does not bring anything unless you request it. Patient 19 discussed two separate incidents that happened recently in which he/she placed the call light on for assistance up to the bedside commode to have a bowel movement. One hour later no one had come to assist him/her up to the bedside commode. This lack of assistance resulted in an episode of bowel incontinence in the bed. Patient 19 also shared that on one occasion he/she had requested the staff empty the bedside commode following two bowel movements in the morning. The staff emptied the commode at lunchtime.

A review of the medical record was completed on 07/22/10 and revealed that Patient 19 is to have assistance with toileting on the bedside commode and to be offered toileting every two hours. The record lacked evidence to support the care as planned was being followed. This finding was confirmed with Staff C on 07/22/10 at 5:23 PM.

Based on review of the medical record, interview and confirmation with staff, review of policies and procedures it was determined the facility failed to ensure that the staff documented accurate information in the medical record. This was found in 1 out of 19 medical records, Patient 15. The current census at the Fairhill location is 32.

Findings include:

The medical record review was conducted on 07/22/10. Patient 15 was admitted on 07/20/10 from the subacute facility nursing area located on the first floor of the building where the hospital is located with an increase of shortness of breath. The medical admission orders were completed on 07/20/10 at 3:50 PM. The admitting diagnosis was listed as acute myocardial infarction (heart attack), respiratory and chronic obstructive pulmonary disease. This admitting order was not signed by the registered nurse and was documented as a RBTO " read back telephone order " . At an unknown date and time these admission orders were authenticated by Staff U, the patient's physician. An interview was conducted on 07/22/10 at 10:40 AM with Staff U. This interview revealed that at no time did he/she give the diagnosis of acute myocardial infarction over the telephone as an admitting diagnosis for Patient 15.

An interview conducted with Staff V revealed that he/she took the order from Staff U over the telephone and read back the order for accuracy but might have found the diagnosis from Patient 15 ' s subacute facility record. A review of the subacute chart for Patient 15 was conducted by Staff W. Staff W reported that he/she could find no evidence of documentation in the long term care medical record that indicated a diagnosis of acute myocardial infarction.

This was confirmed with Staff W on 07/22/10 at 2:00PM.

Based on review of medical record department data report and interview with Staff G, the medical records of 30 of 59 patients discharged in the month of June 2010 had not been completed within 30 days.

Findings include:

Per interview with Staff C on 07/22/10 at 3:30 PM, the Fairhill facility currently has 30 delinquent medical records. An average of 59 patients were discharged. A medical record statistics form presented to the surveyor on 07/22/10 at 3:33 PM revealed a 50% medical record delinquency rate for June 2010 and a 42% delinquency rate for the month of May 2010.

Based on facility observations staff interview and verification the following life safety code deficiencies were addressed at the long term acute care hospital. The long term acute care hospital at the Gateway location had a capacity of 51 beds with a census of 26 patients at the time of the survey. The long term acute care hospital at the Fairhill location had capacity of 68 beds with a census of 32 patients at the time of the survey.

Please see the Life Safety Code deficiency report for more specifics.

Findings included;

One 07/19/10 through 07/22/10 observations were completed at locations of the long term acute care hospital. The locations were noted as the Gateway and Fairhill locations. The Gateway location was survey as an existing health care occupancy and the Fairhill location was surveyed as a new health care occupancy. The following life safety code deficencies were cited;

K18, which addressed the facility failure to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas had no impediment to the closing of the doors. The deficiency affected the Gateway location.

K25 which addressed the facility failure to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. and one hour fire rated walls in new health care occupancies. The Gateway and Fairhill locations were deficient in this requirement.

K33 which addressed the facility failure to ensure that exit components (such as stairways) were arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. The Gateway location was deficient in this requirement.

K34 which addressed the facility failure to ensure that stairways used as exits were in accordance with 7.2 with regard to interior stair exits should be arranged to open from the stair side at not less than every third floor. The Gateway location was deficient in this requirement.

K47 which addressed the facility failure to ensure that exit and directional signs were displayed in accordance with section 7.10 with continuous illumination. The deficient practice was observed at the Gateway location.

K130 which addressed the facility failure to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The deficient practice was observed at the Gateway and Fairhill locations.

Based on a tour of the kitchen on 07/20/10, review of dietary policies and procedures and staff interview, the kitchen at the Fairhill location is not maintained in a sanitary manner. This includes the flooring, walls, tray storage, dish storage, stove, hand washing areas and can opener. This facility has a capacity of 68 patients with a census of 32 on 07/19/10.

Findings include:

Per observation on 07/20/10 between 9:55 AM-10:40 AM while accompanied by Staff J and T, the following observations were made:

Pitting of the flooring was observed throughout the kitchen, especially near the two and three compartment sinks.

Build up of food on individual burners on the stove.

A metal container which stored patient food trays had a build up of rust on the sides which potentially could have been in contact with the trays.

A build up of dirt on the kitchen floor in corners and behind sinks.

Floor registers under the two and three compartment sinks were not clean.

Tile floor in the offices in the kitchen had an accumulation of dirt.

The large can opener affixed to the side of the prep table in the back of the kitchen revealed an accumulation of food debris. Per review of dietary policy, this can opener is to be cleaned after each use.

Wastebaskets were not located under hand wash sinks.

The wall behind the food prep table had spillage Staff J verified had been there for a while.

Serving bowls stored on an open rack were not dried before stacked.

All of these findings were observed by Staff J and Staff T.

On 07/19/10 at 3:35 PM the family member of Patient 4 was observed entering the room carrying the personal protective equipment (PPE) into the room without donning prior to entry. Patient 4 is currently in contact and droplet isolation for MRSA (methicillin resistant staphylococcus aureus) which is a bacterium that causes infections in various parts of the body. Contact and droplet (respirator) isolation precautions require the donning of a gown, mask and gloves to enter the room. The family member was observed standing next to the bed and talking to Patient 4 and then stopped to don a gown. There was no observed intervention from staff or reeducation completed with this family member at the time of this observation. This was confirmed with Staff C on 07/19/10 at 4:00 PM.

On 07/20/10 at 10:15 AM Staff U, a physician, was observed entering the room of Patient 5. Staff U wore no PPE (personal protective equipment) while in Patient 5 ' s room. Patient 5 is currently in contact isolation for two kinds of multi drug resistant organisms. Staff U was observed without a gown or gloves examining Patient 5. Staff U also removed his/her stethoscope from their pocket to assist in the examination and then replaced the stethoscope prior to when he/she left the room. Staff U was observed by Staff X without the proper PPE on. There was no observed intervention between Staff X and Staff U during the time of the exam conducted on Patient 5. This was confirmed with Staff W on 07/20/10 at 10:40 AM.

Review of the facility policy was conducted on 07/23/10 at revealed that if the patient is on contact precautions all staff and visitors will don gloves and a gown prior to entering the room. If the patient is on droplet precautions a mask will be worn.

Per medical record review on 07/20/10 and interview with Staff E, the respiratory therapist assigned to Patient 1 on 07/17/10 and 07/18/10 did not follow the medication order for Albuterol sulfate 2.5 milligrams per nebulizer every 4 hours as necessary for shortness of breath or wheezing. Documentation in the computerized medical record revealed doses of Albuterol were administered on 07/17/10 at 9:35 PM and 11:24 PM, at 4:20 AM and 5:25 AM and 9:26 PM and 10:29 PM on 07/18/10. Per interview with Staff E, the director of respiratory therapy, on 07/21/10 at 2:15 PM, the administration of all of repeated Albuterol doses were medication errors and the therapist should have notified the house officer or ordering physician if a more frequent dose was needed.