HospitalInspections.org

Based on records reviewed and interviews the Condition of Participation for Governing Body was not met.

Findings include:

1. The Hospital failed to protect and promote patient's rights and provide care in a safe setting.

See A-115, A-116, A-117, A-131, A-144, A-160, A-164, A-168, A-194 and A-196


2. The Hospital failed to develop an effective, ongoing, Hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that reflected the complexity of the Hospital's organization and services including utilization review and Pest Control.

See A-263 and A-297

3. The Governing Body failed to ensure the Hospital: (a) conducted utilization review (UF) on Medicare and Medicaid eligible patients; (b) members of the Utilization Review Committee (URC) did not review patients for whom they were professionally involved with in their care by participating in the development or execution of that patient's treatment plan; and (c) performed periodic reviews of each current inpatient receiving hospital services during a continuous period of extended duration.

See A-0652, A-654, A-656, A-657, A-658

4. The Governing Body failed to ensure standards of infection control were met by all staff in all patient areas.

See A-747 and A-749.

5. The Hospital staff failed to have written policies and procedures for discharge planning process that applies to all patients which included the screening; evaluation of the post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one; development of a discharge plan if indicated by the evaluation or at the request of the patient's physician, and initiation of the implementation of the discharge plan prior to the discharge of an inpatient.

See A-799, A-806, A-810, A-812, A-821.

6. The Hospital failed to meet the Condition of Participation for Surgical Services. Surgical Services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered.

See A-940, A-951, A952, A-956 and A-957.

Based on observations, record reviews, and interviews, it was determined the Hospital failed to protect and promote patient's rights.

Findings include:

1. The Hospital failed to separately and independently inform all patients of their rights.

See A-0116 and A-0117.

2. The Hospital failed to ensure that an authorized representative, as allowed by State law, signed informed consent for the administration of antipsychotics medications and failed to provide sufficient equipment to ensure patient's privacy would be maintained in the outpatient rehabilitation area.

See A-0131, A-0143.

3. The Hospital failed to demonstrate adequate safety interventions to prevent possible future elopement attempts by a patient after he/she eloped from Hospital Campus #1 in July 2016, and was not located by Hospital staff for approximately 7 hours.

See A-0164.

4. The Hospital failed to ensure that the use of chemical restraints was assessed as essential for the patient's safety and administered following an established plan.

See A-0160.

5. The Hospital failed to ensure that all staff were provided with appropriate training and able to demonstrate competency in the application of restraints.

See A-0194 and A-0196.

Based on observation, documentation review, and interview, the Hospital failed to develop an effective, ongoing, Hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that reflected the complexity of the Hospital's organization and services including utilization review and Pest Control.

Finding include:

1. Based on observation, record review and staff interview, the Hospital failed to have a performance improvement project addressing pest control including mice infestation.

During the Hospital survey on 2/14-2/21/17 it was identified that the Hospital was experiencing an infestation of mice.

The Surveyor's observations were provided to the Director of Nutrition Service, who said that there had been an increase in sighting of mice since the demolition/construction of the main dining room on the first floor starting in February 2017. The Director indicated that the food service department maintained a log of mice sightings that is checked by the Pest Control Technician when they visit the Hospital. Currently the Pest Control Company treats the main kitchen 2 times a week since the beginning of February. Prior to that, the Pest Control Company treated the main kitchen 1 time a week.

Interview with the Director of Housekeeping on 2/21/17 at 9:00 A.M., said that information about pest/mice was only discussed within the Housekeeping Department and information was not brought forward to QAPI (Quality Assurance Performance Improvement).

(see A-0297)

2. Based on records reviewed, interviews and review of the Hospital's QAPI Meeting Minutes, the Hospital failed to identify process improvement projects for the Condition of Utilization Review (UR).

Surveyors interviewed members of the UR Committee which included: Case Manager of the Medical Acute Care Unit (MACU), Vice President (VP) of Finance, Physician #1, Associate Chief Nursing Officer (ACNO), and the VP of Quality and Quality Affairs, at 11:08 A.M. on 2/21/2017. Physician #1 said he was always involved in medical reviews of his patients and no other clinicians reviewed the services provided to his patients. Physician #1 said clinicians did not conduct periodic reviews of patients for whom they were not professionally involved. This was not consistent with the Hospital's Utilization Review Plan.

The VP of Quality and Regulatory Compliance provided the Surveyor, at 3:35 P.M. on 2/21/2017, with QAPI Meeting Minutes, dated 2/26/2015 and 1/19/2016. The minutes indicated the topic of UR was reviewed at these two meetings. The QAPI Meeting Minutes gave no indication of any periodic review of services provided to Medicare and Medicaid eligible patients. There were no other meeting minutes or documents provided to the Surveyor to indicate UR of professional services was conducted for patients who were Medicare and Medicaid eligible and no indication the Hospital had conducted any periodic reviews of current inpatients by clinicians not professionally involved in a patient's care. This was not consistent with the Hospital's Utilization Review Plan. (See A-0652)












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Based on records reviewed and interviews, the Condition of Utilization Review (UR) is not met as the Hospital failed to: (a) conduct utilization review (UR) on Medicare and Medicaid eligible patients; (b) ensure the members of the Utilization Review Committee (UR) did not review patients for whom they were professionally involved with in their care by participating in the development or execution of that patient's treatment plan; and (c) failed to make periodic reviews of each current inpatient receiving hospital services during a continuous period of extended duration. Findings include:

a. The Hospital failed to conduct UR on Medicare and Medicaid eligible patients.

The Hospital's Utilization Review Plan, dated April 2013, indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care, Physicians and non-physicians shall not review patients to whom they have provided health care services or cases in which they have a significant involvement or financial interest. The Utilization Review Committee (URC) is charged with the following functions: To establish and implement a program of concurrent review of admissions and continued stay of all patients, in accordance with applicable statutes, regulations and/or requirements (Medicare, Medicaid third party payers). All patients are reviewed concurrently for appropriateness of level of care and use of facility services. Review continues as long as it is determined, on the basis of specific screening criteria, that further stay is medically necessary and appropriate.

Surveyors interviewed members of the Utilization Review Committee (URC), which included The Case Manager of the Medical Acute Care Unit (MACU), Vice President (VP) of Reimbursements and Contracting, Physician #1, Assistant Chief Nursing Officer (ACNO), VP of Quality and Regulatory Affairs, at 11:08 A.M. on 2/21/2017. The URC members said UR was conducted only for patients on the MACU, a 40 bed unit, and not for patients on any of the other hospital units which were considered long term care units (415 beds) where the patients resided and did not require discharge management or a length of stay review and therefore UR was not required. The UR Committee Members said UR was defined for short stay patients which would only include the MACU. This was not consistent with the Hospital's Utilization Review Plan.

The URC Members said UR meetings were held weekly on the MACU, monthly and bi-monthly. The VP of Reimbursements and Contracting said the bi-monthly meetings were held to globally review UR from a financial perspective.

Surveyors interviewed the President of the Hospital and VP of Quality and Regulatory Affairs at 2:36 p.m. on 2/21/2017. The VP of Quality and Regulatory Affairs said the Hospital's UR process focused on discharges and did not apply to patients on the long term care units. The President said the Hospital did not have sufficient medical staff to do UR by clinicians not professionally involved in a patient's care. This was not consistent with the Hospital's Utilization Review Plan.

The President said that the Hospital had work to do on the UR process.

b. The Hospital failed to ensure the members of the UR Committee did not review patients whose care they were professionally involved with or by participating in the development or execution of that patient's treatment plan.

The Surveyors interviewed members of the UR Committee which included: Case Manager of the MACU, VP of Reimbursements and Contracting , Physician #1, ACNO, VP of Quality and Quality Affairs at 11:08 A.M. on 2/21/2017. The Physician #1 said he was always involved in medical reviews of his patients and no other clinicians reviewed the services provided to his patients. Physician #1 said clinicians did not conduct periodic reviews of patients for whom they were not professionally involved. This was not consistent with the Hospital's Utilization Review Plan.

The VP of Quality and Regulatory Compliance provided the Surveyor, at 3:35 P.M. on 2/21/2017, with Quality Assurance and Performance Improvement (QAPI) Meeting Minutes, dated 2/26/2015 and 1/19/2016. The minutes indicated the topic of UR was reviewed at these two meetings. The QAPI Meeting Minutes gave no indication of any periodic review of services provided to Medicare and Medicaid eligible patients. There were no other meeting minutes or documents provided to the Surveyor to indicate UR of professional services were conducted for patients who were Medicare and Medicaid eligible and no indication the Hospital had conducted any periodic reviews of current inpatients by clinicians not professionally involved in a patient's care. This was not consistent with the Hospital's Utilization Review Plan.

c. The Hospital failed to make periodic reviews of each current inpatient receiving hospital services during a continuous period of extended duration.

Surveyors interviewed members of the URC, which included The Case Manager of the Medical Acute Care Unit (MACU), VP of Reimbursements and Contracting, Physician #1, ACNO, VP of Quality and Regulatory Affairs, at 11:08 A.M. on 2/21/2017. The URC members said UR was conducted only for patients on the MACU and not for patients on any of the other hospital units.

The Surveyor interviewed the President and Chief Medical Officer (CMO) at 4:26 P.M. 2/21/2017. The CMO said the Hospital conducted medical review of patients. The CMO showed the Surveyor 2 medical reviews, one review conducted in 2014 and one review conducted 6/2015. The CMO was unable to provide any further indication of any periodic reviews of patient services by clinicians not professionally involved in a patient's care. This was not consistent with the Hospital's Utilization Review Plan.

The Hospital failed to consistently meet infection control standards for five patients (Patients #13, #27, #38, #54 and #60), in a total sample of 63 patients, related to compliance with the pneumonia prevention protocol, asepsis, hand hygiene, cleaning, disinfection and sanitation, pet fish, food sanitation, pest control and use of personal protective equipment. Noncompliance with kitchen sanitation had the potential to affect every patient in the hospital.

Please see A-749.

Based on observation, interview and record review, the Hospital staff failed to have written policies and procedures for discharge planning process that applies to all patients which included the screening; evaluation of the post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one; development of a discharge plan if indicated by the evaluation or at the request of the patient's physician, and initiation of the implementation of the discharge plan prior to the discharge of an inpatient. Findings include:

The Hospital's Discharge Process policy, revised 10/29/15, indicated that: "It is the responsibility of the Unit's Interdisciplinary Teams to evaluate thoroughly the resident's/patient's and family's readiness to transition from Post Acute Care Services or a Long term Care Unit, in order to assist them in formulating a plan which is in the resident's/patient's best interest and ensures continuity of care."

During interview with the Senior Community Life Leader at 10:08 A.M. on 02/21/17, she said her staff did not have a specific discharge planning process, except that outlined in the policy provided to the Surveyor. The Senior Community Life Leader said the provided policy was for the Medical Acute Care Unit (MACU) and Rehabilitation Services Unit (RSU; a distinct skilled nursing facility area of Hospital Campus #1), but that it had been "adopted" by her staff on the units designated for long-term care, as they only averaged 2 or 3 discharges a year. The Senior Community Life Leader said discharge evaluations were not completed on patients unless there was a plan at the time of the patient's admission for discharge to another setting. The Senior Community Life Leader said that if the patient was admitted for long-term care, no discharge evaluations were completed, as the plan was for those patients to stay in the Hospital.

During interview with Nurse #3 at 10:47 A.M. on 02/14/17, she said there were no discharges from her floor, except for in the case of death, as the patients were considered long-term care residents.

During interview with Nurse #4 at 11:16 A.M. on 02/14/17, he said he rarely had discharges from his floor, for any reason other than death, as the patients were considered long-term care residents.

During interview with Nurse #16 at 12:57 P.M. on 02/17/17, she said they did not have discharges from her floor, except for in the case of death, as the patients were admitted for long-term care.

During interview with the Clinical Operations Manager at 7:55 A.M. on 2/15/17, she said there was no formal discharge planning for the patients who resided on South West. The Clinical Operations Manager said it was very rare that any of the patients were discharged.



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2. While at Hospital Campus #2, and during interview on 2/14/17 at 12:00 P.M., Nurse #12 (identified herself as being the Charge Nurse) said that there was no discharge planning/evaluation process completed on any of the "residents" located on the 2 North, 2 Northeast and 2 Northwest Units. Nurse #12 said that all patients residing on these 3 units/neighborhoods reside in Hospital Campus #2 as Long Term Care residents, and live here. Nurse #12 said that it is "unheard" of for discharge evaluations and or planning to take place on any of the residents, as the resident's plan is to live in this Hospital. Nurse #12 said that Hospital Campus #2 does not accept patients with Medicare benefits as the care at this Hospital is "Custodial in nature, and Medicare does not cover Custodial care."

During interview on 2/16/17 at 11:00 A.M., Nurse #18 said that there is no discharge planning or evaluations completed for any residents living on the 3 South units as these units are considered Long Term Care residents.

During interview on 2/16/17 at 11:05 A.M., Patient #63 said that he/she has been at this "corporation" since 3/2015. Patient #63 said that it was his/her understanding this was not a hospital, but a place where he/she would live, like that of a Nursing Home.

See A-806, A-812, A-812 and A-821.

Based on observation, interview and record review, the Hospital failed to meet the Condition of Participation for Surgical Services. Surgical Services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. Findings include:


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The Hospital failed to disclose that surgery was performed in the Dental Suites located at Hospital Campus #1 and Hospital Campus #2.

During an entrance conference on 2/14/17 at 9:20 A.M., between the Surveyors and the Administrative staff for Hospital Campus #1 and Hospital Campus #2, the Surveyors were told by the President that the services offered at this location (Hospital Campus #1), and a second location (Hospital Campus #2) did not include surgical services.

During a tour, observation and interview on 2/21/17 at 11:00 A.M., on the last day of the survey, of the Dental Suite #1 with Dental Assistant (DA) #1, the Surveyor was told that Hospital Campus #1 provided oral surgery on in-patients.

During interview on 2/21/17 at 2:38 P.M., the President of both hospital campuses said that the Hospital is affiliated with a larger hospital, and that the oral surgeons from that hospital have privileges to perform oral surgery at Hospital Campus #1 and Hospital Campus #2, and that this has been in existence for 20 years or so.

1. The Hospital staff failed to ensure that policies were developed for the Dental Inpatient suites and designed to assure the appropriate cleaning and disinfection of critical items used in oral surgery to prevent cross contamination and transmission of infection.

2. The Hospital failed to complete a medical history and physical examination prior to oral surgery for dental extractions for 2 of 2 oral surgery patients (#36 and #37).

3. The Hospital staff failed to ensure that emergency equipment, such as a resuscitator, defibrillator and tracheotomy set were available to the operating room (dental) suites

4. The Hospital staff failed to ensure that there was adequate provisions for immediate post-operative care of dental patients.

Based on observation, record reviews and interviews, the Hospital (composed of 2 locations, Hospital Campus #1 and Hospital Campus #2) failed to separately and independently inform all patients of their rights.

Findings include:

According to the Hospital's Admissions Policies and Procedures (effective date 12/5/06), the Hospital had altered the admission criteria to their Long Term Care Hospital (LTCH) certified beds and subsequently failed to ensure Medicare beneficiaries received the "Important Message from Medicare about Your Rights" and ensured that all patients received comprehensive information about their Medicare benefits as it related to their admission to the hospital.

The Hospital is identified as an LTCH, which is a long term chronic hospital, and falls under the acute care hospital regulations from the Centers for Medicaid and Medicare services (CMS) for Medicare certification. The LTCH is expected to admit patients from acute care hospitals or within 60 days of discharge from an acute care hospital. The criteria for admission includes treating patients who may have more than one serious medical condition that may improve with time and care and who may return home. The patients generally are medically complex and require daily physician intervention to manage the care; and whose average length of stay is 25 days or more. In addition, the LTCH's must meet the requirements under CoP (Conditions of Participation) for acute Hospitals.

During observation and interviews at both Hospital Campuses (#1 and #2), the Staff frequently referred to the patients as "residents" and discussed their care as custodial and/or Long Term Care (LTC). The exception was when staff discussed the patients who resided on the MACU (Medical Acute Care Unit) that was located in Hospital Campus #1.

During the Surveyor's review of compliance, it was determined that the Hospital had modified the admission criteria. The Hospital indicated that they followed the admission criteria for their LTCH patients being admitted to the MACU, as outlined by the National Associations of Long Term Care Hospital (NALTH). Review of the information, provided by the Hospital, indicated that only a disclaimer from the NALTH was provided. The Hospital failed to clarify their admission criteria to the MACU, but did state that it met Medicare criteria. The Hospital admission staff stated that the MACU was the only unit on both Hospital campuses where they admitted Medicare patients despite the entire hospital being Medicare certified.

However, the Hospital did provided a complete policy and procedure for admission criteria for the LTC/custodial care patient that were being admitted to their LTCH certified hospital beds. The criteria was non-skilled and the application process included being placed on a waiting list (therefore, not admitted from an acute setting). The patients filling out the application signed a form notifying them that they did not qualify for Medicare (Part A for hospital stay). There was no indication that the patients applying for LTC and subsequently admitted were provided "An Important Message From Medicare." The rights of a Medicare beneficiary were clouded by Hospital procedures which centralized placement of patients admitted to the 2 Hospital campuses. The Hospital admitted all LTC patients to Hospital Campus #1 and Hospital Campus #2, but did not admit patients accessing their Medicare Part A to Hospital Campus #2. Patients accessing their Medicare Part A hospital care were only admitted to the MACU at Hospital Campus #1.

During the Survey process, several admission packets were requested and reviewed. The packets were obtained from Hospital Campus #1 and Hospital Campus #2. The admission packets indicated that Medicare beneficiaries were not consistently provided information about their Medicare rights and that the "Important Message from Medicare" was not identified as part of the process after admission.

During interviews with multiple Hospital staff at Hospital Campus #1 and Hospital Campus #2, held between 2/14/17 and 2/21/17, indicated that either independently and/or separately that Hospital staff did not consistently provide notices of Medicare information to all patients. In addition, staff reported that they thought that another discipline may be providing some part of the information required. However, after multiple interviews with Admissions, Social Service, and Financial support staff, all said that Medicare benefits were not offered to patients being admitted to the LTC units (which are hospital level certified beds).

The Hospital's Vice President of Finances said on 2/21/17 at 1:25 P.M., that admissions were centralized and that residents admitted to LTC did not use their Medicare benefit. She did not know who and if the "Important Message from Medicare " was provided.

The Surveyor interviewed the Director of Admissions at 11:30 A.M. on 2/15/17, the Risk Manager at 10:30 A.M. on 2/17/17, and the Finance Officer of both Hospital Campuses at 12:50 P.M. on 2/21/17. The Director of Admissions, the Risk Manager and the Finance Officer said, and a review of several admission application packets indicated, that some of the admission packets contained the information in regards to the "Important Message From Medicare," and some did not. However, there was no evidence that the information had been provided to all patients admitted to the Hospital, as evidenced by inconsistency in admission packets reviewed at both Hospital Campuses, staff lack of knowledge of who provided the notices (or what the notice was) and staff reporting no need to provide the Medicare notice to the "LTC residents" admitted to the Hospital LTC beds.

During record review of 5 of 5 patients (#47, #48, #49, #50 and #51) that had been admitted to the Memory Unit, located at Hospital Campus #2, none of the records indicated that these patients were provided the "Important Message from Medicare."

Patient #47 had been admitted to the Hospital on 2/1/17. Record review failed to indicate that Patient #47 was provided with the "Important Message from Medicare" and/or any other information in regards to Medicare benefits.

Patient #48 had been admitted on 12/11/14, record review indicated that a notice of non-coverage was signed after admission by the Health Care Agent on 2/13/14. There was no information pertaining to the "Important Message ..." in Patient #48's medical record.

Patient #49 had been initially admitted in 9/2015, with a recent acute hospitalization from 1/30/17 through 2/13/7, had no information indicating the Patient's right and notices in regards to his/her Medicare.

Following review of Patient #49's record, the Admission Staff at Hospital Campus #2 was interviewed at 10:30 A.M. on 2/16/17. The Admission Staff said that, "[Patient #49] lived on the long term care unit and Medicare was not utilized as a payer source."

Patient #50, admitted 4/4/16, had a signed letter notifying the patient of non-coverage of Medicare as he/she did not require inpatient hospital care (4/4/16). However, there was no evidence that the Hospital provided Patient #50 with the Important Medicare Message.

Patient #51, admitted 4/12/10, had a signed letter notifying the patient of non-coverage of Medicare as he/she did not require inpatient hospital care (4/12/10). However, there was no evidence the Hospital provided Patient #51 with the Important Medicare Message.

Based on interview and record review, the Hospital failed to ensure 1 patient (#63 ) was informed, when appropriate, of the patient's right, in advance of furnishing, then discontinuation of therapy/patient care whenever possible.

Findings include:

For Patient #63, Hospital Campus #2 staff failed to ensure Patient #63 had been informed of his/her right as a Medicare beneficiary, for services provided, such as pressure ulcer care, Physical/Occupation therapies (PT/OT), and when/if the Medicare coverage had ended.

Patient #63 was admitted to Hospital Campus #2 in 3/2015, from a Rehabilitation Facility, with diagnoses including diabetes mellitus, urinary retention requiring a chronic indwelling urinary catheter and cerebral vascular accident with left hemiparesis.

Review of the clinical record indicated that Patient #63 had been provided PT and/or OT services (4/2015 and 5/2015). However, Patient #63 had been ill with urinary tract infections (UTIs), and according to therapy notes, had refused therapy on 4/8, 4/9 and 5/4/15. There was no evidence documented in the clinical record that PT/OT services had begun and notice provided to Patient #63 that services would be covered under Medicare Part B, or when the services ended, as required.

During interview on 2/16/17 at 2:00 P.M., Occupational Therapist (OT) #1 who identified that she was the Director of Therapy at Hospital Campus #2, said that she was familiar with Patient #63, and that he/she had been on PT and OT, services covered under Medicare Part B. OT #1 said that she did not inform Patient #63 about the coverage when it began or when it ended, and was not sure who did, as was the Patient's right.

According to the clinical record, Patient #63 developed hospital-acquired pressure ulcers to the buttocks in 10/2016, and in 11/2016 a pressure ulcer to the right ischium. In addition, Physician and Nurse Practitioner progress notes dated 1/27/17, 2/3/17 and 2/15/17, indicated that Patient #63 developed "severe hypospadius" (abnormal urethral opening, normally located at the tip of the penis, and now located on the underside of the penis) as result of erosion from a chronic indwelling catheter, and recommendations from a urologist (1/22/17), the decision was made to re-locate the indwelling catheter by removing it from the penis and placing it into the lower abdomen (also known as a supra pubic catheter) in order to urinate (surgery scheduled for Friday, 2/17/17).

During interview on 2/16/17 at 11:00 A.M., Nurse #18 said that Patient #63 was admitted to the "Nursing Home" in 2015. Nurse #18 said that there was no discharge plan or evaluation for Patient #63 to go to a lower level of care as Patient #63 "lived here now."

Review of the clinical record indicated Patient #63 had requested therapy to walk better since being admitted to Hospital Campus #2 in 2015, had not walked, primarily used a wheelchair for mobility, and a referral was made for services.

During interview on 2/16/17 at 11:05 A.M., Patient #63 said that he/she lived in his/her own home, had been transferred to a Rehabilitation Center, then transferred to Hospital Campus #2 to live in 2015. Patient #63 said that he/she signed a paper on admission in 2015 indicating that Medicare did not pay for services in this "Nursing Home Corporation." Patient #63 said that he/she had to pay privately for his/her continued stay here and had recently sold his/her home. Patient #63 said that he recalled receiving therapy to use a walker, and indicated a walker nearby, but was never told that therapy services were covered by his/her Medicare or supplementary insurance. Patient #23 said that he/she paid privately for all services provided at the Nursing Home Corporation as agreed upon when he/she was admitted to the Hospital in 3/2015. Patient #63 said that he/she is having surgery to put the catheter into his/her abdomen on Friday (2/17/17), due to an "erosion" on the penis, caused by the catheter he/she has had for a few years.

Patient #63 said he/she was admitted to "Long Term Care" at Hospital Campus #2 as he/she could no longer stay in his/her home due to falls, and problems with his/her indwelling catheter he/she has had for a few years due strictures and other health reasons, such as multiple urinary tract infections. Patient #63 said that he/she signed a paper when he/she was admitted to the Hospital indicating that Medicare was not accepted at this Hospital for his/her stay. Patient #63 said that he/she has a supplemental insurance, which was used in conjunction with his/her Medicare benefit for hospitalizations. Patient #63 said that he/she requested therapy as he/she felt he/she was getting weaker in the legs, had more difficulty standing, as he/she just sat in the wheelchair and wanted to get stronger and walk like he/she used to.

Record review indicated that Patient #63 did sign and date (3/2015) a documented entitled: "Admission Notice: Notice of Non-Coverage for both Hospital Campus #1 and Hospital Campus #2. The document indicated the services that Patient #63 required were for "Ongoing management and therapeutic care for conditions(s) do not require inpatient hospital care. The notice indicated if "the patient" decided to enter the "hospital," "the patient" will be financially responsible for, "All customary charges for services rendered after receipt of the hospital notice," except those services for which the patient is eligible to receive payment under Part B.

Based on record review and interviews, the Hospital failed to ensure that an authorized representative, as allowed by State law, signed informed consent for the administration of antipsychotics medications for two incapacitated patients (Patient #23, #41), in a total sample of 63 patients.

Findings include:

Review of the Hospital's policies and procedures for Antipsychotic Medication Use dated 2/10/10, Section II, part A. Antipsychotic Medications and Valid Consent, indicated that a physician or nurse practitioner who wishes to prescribe an antipsychotic medication to a resident must obtain valid consent. When a resident lacks the capacity to make a decision about antipsychotic medication, the attending physician must document this in the resident's medical record. The attending physician should then inform the resident's legal health care agent of the determination of incapacity and discuss the recommendation for antipsychotic medication with the agent. If the health care agent agrees to proceed with antipsychotic medication treatment, this must be documented in the resident's medical record with the HSL (Hebrew Senior Life) Antipsychotic Consent Form.

"Situations may arise in which a newly admitted patient or resident who has been taking antipsychotic medication lacks decision-making capacity to give consent to continue this medication and the Health Care Agent cannot immediately be contacted. When the health care provider believes that abruptly discontinuing the antipsychotic medication could be harmful, temporarily continuing the medication until valid consent is obtained is justifiable. Consent should be ideally be obtained within 24 hours of admission."

1. Patient #23 was admitted to the Hospital in September 2016, with diagnoses that included dementia with behaviors and cognitive decline, chronic kidney disease, acute encephalopathy and weight loss. Patient #23 had been residing in an assisted living setting with his/her spouse and was admitted to the Hospital for long term care. The Health Care Proxy was activated.

Review of the Consent for Antipsychotic Medication(s), dated 10/3/16, obtained by the Nurse Practitioner for the medication, Haldol for oral administration, indicated the reasons for the use of drug documented as: dementia with agitation, elopement behaviors and accusations. The benefits expected were reduction of agitation.

Review of the signatures section indicated it was blank where the Health Care Agent was to sign for consent. Review of the additional page where the practitioner indicated the reason why the consent cannot be obtained on admission, dated 9/28/16, was "unable to contact" the Health Care Agent and they would continue to try and contact the person, was dated 9/28/16.

As of 2/15/17, during the survey period, Patient #23's consent was still not signed.

The Memory Unit Operations Leader [MUOL#16] was interviewed on 2/15/17 at 10:30 A.M. MUOL #16 provided Patient #23's consent form and said that the consent should have been signed within 24 hours of admission and noted that several months had passed (5 months) without the consent form being signed by the activated Health Care Proxy.

Review of Patient #23's Medication Administration Record [MAR] indicated that in addition to the scheduled dose of Haldol - 0.5 mg twice a day, prescribed 12/21/16 through 3/21/17, Patient #23 also received 0.5 mg daily PRN (as needed) by mouth for agitation, also prescribed 12/21/16 through 3/21/17.

Review of the Hospital's policies and procedures for Antipsychotic Medication Use dated 2/10/10, Section II, part D. Emergency and "PRN" Use of Antipsychotic Medications indicated that use of antipsychotic medications on a PRN basis is discouraged. The policy also indicated that the time course of improvement for psychotic symptoms in response to antipsychotic symptoms in response to antipsychotic's drugs is such that intermittent dosing is unlikely to be effective. If PRN antipsychotic medication is to be used, documentation of valid consent must be in the resident's medical record. Standing orders for PRN emergency use of antipsychotic medications are prohibited.

Review of Patient #23's medical record indicated there was no consent form signed for the PRN administration of the antipsychotic Haldol by the Health Care Proxy.


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2. Patient #41 was admitted to the Hospital in 4/2014. Diagnoses include Alzheimer's Disease with behaviors and Non-psychotic mental disorder due to organic brain damage (meningiomas/brain tumors). Hospital staff failed to ensure that Patient #41's representative was informed of his/her health status prior to the administration of intramuscular (IM) anti-psychotic medications.

Review of clinical record (Nurse's Note) indicated that on 9/21/14, at dinner time, Patient #41, "went to the kitchen counter and took a can of ensure (nutritional drink). (S)he was reprimanded by RA (resident assistant) that (s)he shouldn't take things which doesn't belong to her/him." The Nurse's Note indicated Patient #41 became aggressive and angry. After a few minutes, Patient #41 went back to the counter and grabbed a tray of desserts and "shoved" it on the counter. Security staff was called. Patient #41 became calmer and was pacing on the unit, followed by Security. The Physician was contacted who ordered 2.0 milligrams (mg.) of Haldol (antipsychotic medication) IM.

There is no evidence in the clinical record that a behavior assessment was completed, nor was there any evidence that Patient #41's representative had been notified prior to the administration of the Haldol.

Review of a Nurse's Note dated 9/22/14 indicated Patient #41 was compliant with taking medications. The note also indicated Patient #41 became angry and "snatched peanut butter and jelly sandwich from staff". Patient #41 was seen by the Physician who ordered the antipsychotic medication Risperdone Consta 50 mg. IM now, and then 25 mg. every two weeks.

There was no evidence in the clinical record that Patient #41's representative consented to the administration of Risperdone or was informed of his/her behavior and that staff would be administering Risperdone IM on a regular basis to Patient #41.

During interview on 7/21/17 at 9:40 A.M., Patient #41's Physician said that he reviewed his/her clinical record and was unable to find evidence that Patient #41's representative consented to the IM administration of Haldol and Risperdone.

Based on observation, record review and interview, the Hospital failed to demonstrate adequate safety interventions to prevent possible future elopement attempts by one patient (Patient #36) from a total sample of 63 patients, after he/she eloped Hospital Campus #1 in July 2016, and was not located by Hospital staff for approximately 7 hours. In addition, the Hospital failed to ensure that a safe environment was maintained for 5 of 15 Country Kitchens observed at Campus #2 to ensure all patients are cared for in a safe setting.

Findings include:

1. Patient #36 was admitted to Hospital Campus #1 in March 2010 with diagnoses which included: dementia, insulin dependent diabetes, hypertension, and peripheral neuropathy (nerve damage, which often causes weakness, numbness and pain).

Observations of the floor/unit on which Patient #36 resided, on 02/17/174, indicated: a centrally located nursing unit, elevators, dining and sitting areas; a wanderguard (an alert system consisting of sensor(s) placed near exit(s), and a bracelet worn by an individual at risk for wandering or exiting the Hospital) sensors located adjacent to the elevator doors; that patient rooms were located in one of two distinct units, one on either side of the common areas, with a majority of the rooms not visible from any of the common areas; Patient #36's room was at the end of the hallway on one unit, directly across from a stairwell exit door, and not visible unless physically on the unit; a sign on the stairwell exit door across from Patient #36's room indicated that it was alarmed, but could be opened in 15 seconds; and, a security camera mounted to the ceiling above Patient #36's doorway, which appeared to be directed at the stairwell exit door.

Review of a Hospital incident report indicated that Patient #36 eloped from Hospital Campus #1 on 07/14/16 at approximately 6:01 A.M. The report indicated that Patient #36 was seen in a common area by nursing staff at 5:55 A.M., and that an alarm sounded for the exit door located near Patient #36's room. The report indicated that Patient #36 was seen on surveillance video exiting his/her floor, but was not seen on surveillance video exiting Hospital Campus #1. The report indicated that staff were unable to locate Patient #36 after a search of Hospital Campus #1.

Review of Progress notes, dated 07/14/16, indicated that Patient #36 was located in another town and returned to Hospital Campus #1 at 1:15 P.M. The notes indicated that Patient #36 reported he/she took the bus that stopped outside of Hospital Campus #1, and that someone cut his/her "bracelets" off after he/she left.

Review of the Progress Note, dated 07/17/16, indicated that Patient #36 reported he/she would elope from Hospital Campus #1 again, but would use a different exit from the floor.

Review of the Progress Notes, dated 07/18/16, indicated that at approximately 5:00 A.M., Patient #36 attempted to elope via an exit door. The notes indicated that Patient #36 reported planning his/her next elopement, and a "Lo-jack" bracelet was implemented.

Review of the Behavior Care Plans, dated 08/14/16 and 09/02/16, indicated that Patient #36 continued to attempt to open exit doors. The care plans did not include interventions to address the behavior

Review of the Patient Note, dated 10/19/16, indicated that Patient #36 told staff that a door on another floor was unalarmed.

Review of the Behavior Care Plans, dated 11/03/16, 12/18/16 and 01/20/17, indicated that Patient #36 continued to attempt to open exit doors. The care plans did not include interventions to address the behavior.

Review of the Elopement Care Plan indicated that it was dated 02/14/17, the start of survey.

During an interview with Nurse #16 at 12:57 P.M. on 02/17/17, she said the wanderguard system ceased elevator function only. Nurse #16 said Patient #36 looked like he/she could be a visitor to Hospital Campus #1, and was able to walk without assistance. Nurse #16 said that prior to Patient #36's elopement on 07/14/16, he/she had a wanderguard bracelet in place, which he/she had cut off multiple times. Nurse #16 said a "Lo-jack" bracelet was placed on Patient #36 afterwards, which would allow security and police to track Patient #36's location should he/she elope again. Nurse #16 said Patient #36 had not attempted to cut the "Lo-jack" bracelet off "yet", but figured it was just a matter of time before he/she did. Nurse #16 said that on 07/14/16, Patient #36 exited the floor via the stairwell door located across from his/her room. Nurse #16 confirmed that Patient #36's room at the time of survey and the room he/she resided in at the time of the elopement were the same. Nurse #16 said Patient #36 often sat and watched the local bus go by, and so knew the timing of when it stopped outside of Hospital Campus #1. Nurse #16 said Patient #36 also knew the timing of change of shift, which was about when he/she eloped on 07/14/16.

During an interview with Unit Secretary #1 at 12:44 P.M. on 02/17/17, she said that only the elevators were wanderguard secured, meaning they would not work if any patient with a wanderguard bracelet was close enough to the wanderguard sensors. Unit Secretary #1 said the stairwell exits were alarmed and were monitored with the use of security cameras. Unit Secretary #1 said the feed from the security cameras went to a monitor at the nursing station.

During an interview with Nurse #5 at 12:52 P.M. on 02/17/17, she said the stairwell exit doors were alarmed, but were not part of the wanderguard system, and were monitored via security cameras. Nurse #5 said the only exits from the floor on the wanderguard system were the elevators.

There was no documentation in the medical record at the time of survey that Hospital Campus #1 implemented adequate interventions to reduce the likelihood of future elopements by Patient #36.


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2. During the tour of the Country Kitchens on 2/15/17, the Surveyor observed that the Country Kitchens had an open floor plan and were easily accessible to the patients.

On 2/15/17, the Surveyor observed that the Country Kitchens on 3 North East, 2 North and 3 South had unlocked drawers that contained large, sharp chef knives with the blades exposed. Long term care residents including some residents with dementia resided on these units. The potential for injury existed because of the easy accessibility to the open kitchen areas.

During an interview with Dietitian during the tour, she indicated that keys are available in the Country Kitchens to lock the drawers that contained knives.

3. On 2/15/17, the Surveyor also observed that chemicals stored in the Country Kitchens were not always secured properly.

In the 3 South East and the 2 North Kitchens, chemicals such as detergent, sanitizer and all purpose cleaner were stored unlocked. Long term care residents including some residents with dementia resided on these units. The potential for injury existed because of the easy accessibility to the open kitchen areas.

During an interview on 2/16/17, the Executive Director said that chemical cabinets should be locked in the Country Kitchens.

Based on observations, record review, policy review and interview, the Hospital staff failed to determine when the use of an antipsychotic drug should be considered a chemical restraint and Hospital staff failed to prohibit the use of drugs or medications used to manage a behavior that was not a standard treatment for the patient's condition for two patients (#23 and #41), out of a total sample of 63 patients.

Findings include:

Review of the Hospital's policies and procedures for Antipsychotic Medication Use dated 2/10/10, Section I, Purpose: indicated that various medical and psychiatric disorders may give rise to psychotic symptoms. Psychotic symptoms may include delusions, hallucinations, or severely disorganized thinking- the symptoms may be transients or, as in the case of schizophrenia, chronic. Some residents with dementia may experience delusions and hallucinations during the course of their illness. Psychotic symptoms are often a source of distress for the resident who is experiencing them.
Section II B - Prescribing Antipsychotic Medications: Prescription practices for antipsychotic medications must be in compliance with the Federal Nursing Home Reform Act of 1987 regulations:

*Antipsychotic medications should be used only for residents who have been diagnosed with one or more of the following specific conditions: schizoaffective disorder, delusional disorder, mood disorder with psychotic features, acute psychotic episodes of brief reactive psychosis, schizophreniform disorder, atypical psychosis, Tourette Syndrome disorder, Huntington's disease, dementia or delirium (Hospital policy bold print) with associated psychotic and/or disruptive behaviors as described:

1. Symptoms must be persistent.
2. Preventable causes of the symptoms have been ruled out.
3. The symptoms pose a danger to self or others.
4. There is continuous yelling, screaming or pacing that interferes with functioning.
5. The resident experiences psychosis that causes distress or impairs functioning.

* Antipsychotic medication should NOT be prescribed to treat wandering, poor self-care, restlessness, memory impairment or anxiety.

1. Patient #23 was admitted to Hospital Campus #1 in September 2016 with diagnoses that included dementia with behaviors and cognitive decline, chronic kidney disease, acute encephalopathy and weight loss. Patient #23 had been residing in an assisted living setting with his/her spouse and was admitted to the Hospital for long term care. The Health Care Proxy was activated.

None of the above diagnoses meet the Hospital's criteria for diagnoses requiring an antipsychotic medication as outlined in the policy.

Review of Patient #23's Medication Administration Record [MAR] indicated that in addition to the scheduled dose of Haldol - 0.5 mg twice a day prescribed 12/21/16 through 3/21/17, Patient #23 also received 0.5 mg daily PRN (as needed) by mouth for agitation, also prescribed 12/21/16 through 3/21/17.

Review of Patient' #23's care plan for dementia with behavioral disturbances indicated the following:

*Exhibits one of more of the following behaviors at least once daily - wandering.
*Problem behaviors - exit seeking.
*Troubling behaviors - decreased frequency.
*Assess presence of these or other factors that may cause behavior problems - pain, fear.
*Assess for the presence of - chronic illness changes.
*Utilize - behavior mapping tool.
*Review - medication regimen.
*Problem behaviors, additional approaches - wanderguard.
*Problem behaviors care plan progress - continue plan.

None of the above behaviors outlined in Patient #23's care plan can be described as delirium or
as a hallucination.

Review of the nursing notes dated 9/30/17 at 7:25 A.M., indicated Patient #23 was "very agitated" and redirected with no effect. Attempted to administer PRN Haldol, but Patient #23 refused.

Review of the MAR dated 9/28/16, indicated that Patient #23 received 0.5 mg of PRN Haldol at 7:00 P.M. for restlessness and pacing.

Review of the MAR dated 10/1/16, indicated that Patient #23 received 0.5 mg of PRN Haldol at 4:40 P.M. for agitation [no details documented].

Review of the MAR dated 10/2/16, indicated that Patient #23 received 0.5 mg of PRN Haldol at 11:35 A.M. for being verbally abusive, pushing his/her walker against another patient, exit seeking behavior - asking anybody to open the elevator.

Review of the MAR dated 10/2/16, indicated Patient #23 received 0.5 mg of PRN Haldol at 7:35 P.M. for restlessness and agitation [no details documented. Trying to elope.

Review of the MAR dated 10/3/16, indicated Patient #23 received 0.5 mg of PRN Haldol at 12:40 P.M. for exit seeking.

Review of the MAR dated 10/5/16, indicated Patient #23 received 0.5 mg of PRN Haldol at 12:00 P.M. for intrusive, disruptive behavior.

Review of the MAR dated 10/10/16, indicated Patient #23 received 0.5 mg of PRN Haldol at 10:30 A.M. for intrusive, disruptive behavior.

Review of the MAR dated 10/12/16, indicated Patient #23 received 0.5 mg of PRN Haldol at 10:01 A.M. for being loud and intrusive, yelling at noisy patients, yelling at patients and for intrusive, disruptive behavior.

Review of the MAR dated 10/13/16, indicated that Patient #23 received 0.5 mg of PRN Haldol at 2:35 P.M. for being loud and intrusive, yelling at noisy patients.

Review of the MAR dated 10/16/16, indicated that Patient #23 received 0.5 mg of PRN Haldol at 12:19 P.M. for being restless and asking for scissors.

Review of the MAR dated 10/16/16 indicated that Patient #23 received 0.5 mg of PRN Haldol at 12:19 P.M. for restlessness and asking for scissors.

Review of Patient #23's MAR and the nursing notes from 10/16/16 through 2/14/17 indicated that no further PRN Haldol was administered.

None of the behaviors documented above were demonstrative of psychotic behaviors as outlined in the Hospital policy. In fact, behaviors such as wandering, restlessness, were specifically documented as reasons NOT to treat with an antipsychotic medication.

The Memory Unit Medication Nurse was interviewed on 2/16/17 at 11:30 A.M. The Medication Nurse said that Patient #23 was very agitated when he/she was first admitted and could no longer be maintained at the Assisted Living Center. The Medication Nurse said the PRN Haldol was ordered for use when Patient #23 was agitated and could not be re-directed. The Medication Nurse was asked by the Surveyor if Patient #23's diagnoses and behaviors met the criteria for using antipsychotic medications. The Medication Nurse said that Patient #23 had dementia with behaviors, so that was when they used antipsychotic medications.

The Medication Nurse's response was not consistent with the Hospital's policy on antipsychotic medication use.

2. Patient #41 was admitted to the Hospital in 4/2014. Diagnoses include Alzheimer's Disease with behaviors and Non-psychotic mental disorder due to organic brain damage (meningiomas/brain tumors). Hospital staff failed to ensure that Patient #41 was not chemically restrained when staff administered an imtramuscular doses of an anitpsychotic medication that was not medically necessary but was used for patient discipline or staff convenience.Findings include:

Review of clinical record (Nurse's Note) indicated that on 9/21/14, at dinner time, Patient #41, "went to the kitchen counter and took a can of ensure (nutritional drink). (S)he was reprimanded by RA (resident assistant) that (s)he shouldn't take things which doesn't belong to her/him." The Nurse's Note indicated Patient #41 became aggressive and angry. After a few minutes, Patient #41 went back to the counter and grabbed a tray of desserts and "shoved" it on the counter. Security staff was called. Patient #41 became calmer and was pacing on the unit, followed by Security. The Physician was contacted who ordered 2.0 milligrams (mg.) of Haldol (antipsychotic medication) IM.

There is no evidence in the clinical record that a behavior assessment was completed, nor was there any evidence that Patient #41's representative had been notified prior to the administration of the Haldol.

Review of a Nurse's Note dated 9/22/14 indicated Patient #41 was compliant with taking medications. The note also indicated Patient #41 became angry and "snatched peanut butter and jelly sandwich from staff". Patient #41 was seen by the Physician who ordered the antipsychotic medication Risperdone Consta 50 mg. IM now, and then 25 mg. every two weeks.

There was no evidence in the clinical record that Patient #41's representative consented to the administration of Risperdone or was informed of his/her behavior and that staff would be administering Risperdone IM on a regular basis to Patient #41.

The clincial record failed to show evidence of a clear plan and assessment to manage the dementia behaviors of this patient and staff instead chose to chemically restrain the patient for behaviors that could have been managed otherwise.

Based on records reviewed and interviews the Hospital failed to consistently adhere to their policy for use of alternatives before restraints were applied for 2 of 2 targeted patients (Patient #26 and Patient #34) requiring restraint use.

Findings include:

According to the Hospital Policy titled Restraint Policy, dated 5/13/14, the standard protocol ensured the utilization of alternatives to restraints prior to restraint application.

1. For Patient #26, a patient with a tracheotomy (a temporary or permanent opening in the neck), a feeding tube, and condom catheter urinary drainage device who had reportedly pulled out medical devices repeatedly.

The Surveyor interviewed the Nursing Director for the Medical Acute Care Unit (MACU) at 10:30 A.M. on 2/14/17. The Nursing Director for the Medical Acute Care Unit said Patient #26 required hand mitts each night at bedtime to prevent Patient #26 from pulling out medically necessary tubes. The Nursing Director for the Medical Acute Care Unit said Patient #26 did not require the mitts during the day because he was placed in a chair in the doorway of his/her bedroom and was observed by the Hospital Staff.

Patient #26's Medical Record indicated on 2/13/17, interventions that included redirection, pain assessment, medication, providing fluids and positioning were to be used as alternatives to restraint. However, these interventions were documented at 10:19 A.M. and the restraints were not applied until 10:00 P.M. that night.

Patient #26's Medical Record indicated on 2/14/17, interventions that included redirection, pain assessment, medication, providing fluids and positioning were to be used as alternatives to restraint. However, these interventions were documented at 1:44 P.M. and the restraints were not applied until 10:00 P.M. that night.

2. For Patient #34, a patient with a tracheotomy, a peripherally inserted central catheter (PICC) who had reportedly pulled out medical devices repeatedly.

The Nursing Director for the Medical Acute Care Unit said Patient #34 required hand mitts at all times to prevent Patient #34 from from pulling out medically necessary tubes.

Patient #34's Medical Record indicated his/her restraint's were checked according to policy every two hours, however, no documentation of alternatives to restraint were located in the medical record.

Based on records reviewed and interview, the Hospital failed to adhere to their policy and procedure for ordering restraints in 2 of 2 patients (Patient #26 and Patient #34) who staff physically restrained, in a total sample of 63 patients.

Findings include:

According to the Hospital Policy titled Restraint Policy, the provider must order any form of restraint, including the type of device, and the order must be renewed every 24 hours.

1. For Patient #26, a patient with a tracheotomy (a temporary or permanent opening in the neck), a feeding tube, and condom catheter urinary drainage device who had reportedly out pulled out medical devices repeatedly.

The Surveyor interviewed the Nursing Director for the Medical Acute Care Unit (MACU) at 10:30 A.M. on 2/14/17. The Nursing Director for the Medical Acute Care Unit said Patient #26 required hand mitts each night at bedtime to prevent Patient #26 from pulling out medically necessary tubes.

Patient #26's medical record indicated that during the week (2/7/17 through 2/14/17) the provider failed to order the mitt restraints on 2/8, 2/9, 2/10, 2/11 and 2/13/17. Patient #26 medical record indicated that the restraint was in place and the restraint check was performed and documented consistently during that time frame.

The Nursing Director for the Medical Acute Care Unit said orders for restraints were required every 24 hours.

2. For Patient #34, a patient with a tracheotomy, a peripherally inserted central catheter (PICC) who had reportedly pulled out medical devices repeatedly.

The Nursing Director for the Medical Acute Care Unit said Patient #34 required hand mitts at all times to prevent Patient #34 from from pulling out medically necessary tubes.

Patient #34's medical record indicated that during the week (2/7/17 through 2/14/17) the provider failed to order the mitt restraints on 2/9/17 and 2/11/17, as required despite Patient #34 being restrained on those days.

Based on observations and interviews, the Hospital (composed of 2 locations, Hospital Campus #1 and Hospital Campus #2) failed to ensure that staff were properly trained in the safe application of restraint devices.

Findings include:

The Hospital policy and procedures for Restraints indicated that the Hospital recognizes the use of physical restraints as an intervention for maintaining the patient's care and safety when other measures have been ineffective; the patient is unwilling or unable to follow instructions, medical care is compromised, and it essential to protect patients from harming themselves or others.

The policy indicated that staff are trained to perform initial and on-going assessment of the continued need for the restraint and the effectiveness of alternative measures to limit the use of restraints, to respect patient rights and dignity, and to protect the patient from risks associated with the non-use of restraints.

In addition, the policy and procedure indicated that it reports deaths in restraints according to the requirements and records restraints in an internal log.

The Hospital policy indicated that the scope of knowledge for use of restraints is extended to nursing staff, providers, therapy and social service. The policy outlines specifics for the use of restraints and staff competency in situations where clinical justification warrants application to prevent injury in their MACU (Medical Acute Care Unit) located on Hospital Campus #1. The policy subsequently defines restraints, use of restraints and procedure according to the regulatory requirements.

In addition, the Hospital's policy for restraints includes, restraint devices that may be considered medically appropriate and alternate strategies and techniques to assist in preventing restraint use.

During observations, staff interviews and review of patient records at the Hospital Campus #2, the consensus of the Staff including nursing, security and administration indicated that Hospital Campus #2 did not use any restraints and that the nursing staff, providers, therapy and social service staff were not properly trained in the safe implementation of restraint devices, because they did not use restraints.

During interview on 2/16/17 at 12:30 P.M., Security Staff #1 and #2, both said that they assisted in situations requiring restraints. They said they brought a bag to the intervention and that the bag contained restraints. Both Security Staff said that they did not actually apply the restraints, but focused on de-escalating the situation. The Security Staff said that nursing staff applied the restraints and that they may assist with a physical hold.

The 2 Security Staff said most of their education had been on de-escalating a situation and crisis intervention. They said that they had been trained in the past in application of restraints, but not recently. The Security staff said that the training had not included physical holds.

During interview with RN #20 on 2/16/17 at 12:45 P.M., she said that Hospital Campus #2 did not use restraints and that other than the Security Staff no one was trained on applying a restraint. RN #20 said that Security Staff would apply the restraint under the direction of a physician.

Further review of Hospital policy and interviews conducted on Hospital Campus #1 on 12/17/17 at 1:00 P.M., indicated that according to the Director of Professional Education, restraints are not used at either Hospital campus, with the exception of the MACU (located on Campus #1) for medically appropriate care. The Director said that the only staff trained in restraint application was Security Staff and the staff that worked in the MACU. She said that the Hospital had 1 person who was a certified trainer and that she trained them.

The Hospital provided a handout about Crisis Intervention, Reasons for Restraints and a list of staff that included security and nursing staff assigned to the MACU that had completed the online training of Restraint Safety Training. There was no indication of staff competency in applying restraints had been done or how often training had been done. The Staff Developer said that staff were to do the online restraint policy review yearly, but did not indicate how often staff were retrained in restraint application.

Further review and interviews with Hospital Administration failed to indicate that any staff, other than their Hospital statements, substantiated that either the Security Staff, the MACU staff, and Hospital Staff at Hospital Campuses #1 and #2 (including physicians) were trained in restraint application. The Surveyor requested this information, but it was not provided.

During discussion, the Staff Developer said that the only restraints the Hospital had in their buildings were hand mittens, however it was later discovered and observed that the Hospital utilized soft wrist restraints, vest restraints and chemical restraints. The Hospital was unable to provide evidence that staff at either Hospital Campuses had received formal training in the proper application, monitoring and use of these devices.

Based on observations and interviews, the Hospital (composed of 2 locations, Hospital Campus #1 and Hospital Campus #2) failed to ensure that all staff were provided with appropriate training and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for patients that may require restraint devices.

Findings include:

During record review and staff interview, the Hospital's (Campus #1 and Campus #2) staff said that the Hospital did not use restraints with the exception of the MACU (Medical Acute Care Unit) located on Hospital Campus #1. The Hospital said that restraints were used where clinical justification was required and other than this no restraints were used.

The Staff Developer said that Security and the nursing staff on the MACU received yearly review of restraints and that these specific staff were trained in the application of restraints.

Although, the Survey team was provided with a list of staff who had completed the online review of the Hospital's policy of restraints, no evidence was provided of training of staff of the actual application of restraints.

The Risk Manager said that the Hospital had a staff who was certified to train Hospital staff in restraints and said she would provide either an interview and/her certification, however this information and opportunity was not provided. The Security Staff said that most of their training had been in de-escalating the situation and that they did not apply restraints, however many of the nurses on both campuses said that security was responsible for the application of restraints.

The verbal information provided by the Hospital was not clear and subsequently the Hospital did not provide adequate evidence that all staff were provided with appropriate training.

Based on observation, record review and staff interview, the Hospital failed to have a performance improvement project addressing pest control, including mice infestation.

Findings include:

During the Hospital survey on 2/14-2/21/17, it was identified that the Hospital was experiencing an infestation of mice.

The Surveyor's observations were provided to the Director of Nutrition Service, who said that there had been an increase in sightings of mice since the demolition/construction of the main dining room on the first floor, starting in February 2017. The Director indicated that the food service department maintained a log of mice sightings that is checked by the Pest Control Technician when they visit the Hospital. Currently, the Pest Control Company treats the main kitchen 2 times a week since the beginning of February. Prior to that, the Pest Control Company treated the main kitchen 1 time a week.

Interview with the Director of Housekeeping on 2/15/17 at 10:00 A.M., said that he keeps a separate log for pest control monitoring for the building (excluding the main kitchen). The Director said that he received information via phone/email and documents the information on the Pest Control logs for the Pest Control technician to review when they come to treat the Hospital.

Review of the Pest Control Service Request Log dated 9/16-2/15/17 (5.5 months), indicated 107 citings of mice in patient care areas as well as pharmacy, locker rooms and administrative offices.

Interview with the Director of Housekeeping on 2/21/17 at 9:00 A.M., said that information about pest/mice was only discussed within the Housekeeping Department and information was not brought forward to QAPI (Quality Assurance Performance Improvement).


34494

Based on record review and interview, the Hospital failed to follow their policy/protocol in providing comprehensive care and treatment of a PICC (peripherally inserted central catheter) for one sampled patient (#18) in a total sample of 63 patients.

Findings include:

For Patient #18, the Hospital failed to perform dressing changes and to measure the external catheter length per Hospital policy/protocol for a PICC (peripherally inserted central catheter).

Patient #18 was admitted to the Hospital on 12/2016, with diagnoses including aspiration pneumonia, respiratory failure, tracheostomy, gastrostomy tube, septic shock and cerebral vascular accident.

Clinical record review indicated Patient #18 had a PICC line inserted at the Hospital on 12/27/16, to provide intravenous (IV) access for antibiotic and diuretic administration.

Review of the Hospital's policy/protocol in providing care and treatment for a PICC requires the dressing to be changed 24 hours after insertion/admission, then every seven days and as needed. Nursing staff are also required to obtain a baseline measurement of the external catheter length and then obtain measurements with each dressing change and document any catheter migration.

Further clinical record review indicated that nursing staff failed to perform the dressing change after the initial dressing change on 12/30/17. The nursing staff did not change the dressing until 1/10/17, which was 11 days after the initial dressing change (should have been changed on 1/6/17).

The clinical record indicated Patient #18 did not have any documentation from 12/31/16 through 1/9/17 to support the PICC dressing had been changed or measurement of the external catheter length had been performed, per the PICC line protocol.

On 2/15/17 at 11:30 A.M., Nurse #19 said that the nursing staff did not follow policy/protocol in providing care and treatment of a PICC catheter, by failing to perform dressing changes and measuring external catheter length.

Based on record review and interview, the Hospital staff failed to ensure an informed consent was completed prior to administering a blood transfusion for one patient (#8) in a total sample of 63 patients, in accordance with Hospital policy and procedure.

Findings include:

Review of the Hospital Policies and Procedures for Blood Component and Blood Product Administration (revised 8/15/16), the first requirement indicated that an informed consent be completed before administration of Blood/Blood Components. The policy directs that a Physician, Physician Assistant or Nurse Practitioner is responsible for obtaining the informed consent.

Medical record review indicated Patient #8 received Blood component transfusions on 10/25/16, 12/7/16 and 1/11/17.

Review of a Physicians progress note, dated 10/24/16, indicated 2 units of packed red blood cells were ordered for transfusion on 10/25/16. There was no indication in the progress note that the informed consent had been discussed with Patient #8, including the risks versus benefits and possible complications.

Review of the Consent for Transfusion of Blood Components located in Patient #8's medical record, indicated the form was signed and dated 10/24/16 by Patient #8, however, the Physician signature line had the abbreviation T.O. (telephone order). The Physician's last name was signed, and dated 10/24/16, by Nurse #8.

During interview with Nurse #9 on 2/15/17 at 11:00 A.M., she said that Nurse #8 had gotten a telephone order from the Physician to read the consent to Patient #8, then the Physician came in and signed it. Nurse #9 said the Physician did not date the consent when he signed it.

During interview with Nurse #17 on 2/15/17 at 11:05 A.M., she said that a medical provider discusses the Blood products information with the patient and then the patient makes an informed decision and the medical provider signs the form. Nurse #17 said that it should not be a telephone order.

During interview with Nurse #8 on 2/15/17 at 11:45 A.M., she said she signed the consent for Transfusion of Blood Components with Patient #8, and the Physician was not present at that time.

Based on observation and interview, the Hospital failed to ensure that only designated pharmacy and medical staff had after-hours access to the pharmacy, located at Hospital Campus #2.

Findings include:

The Surveyor observed the pharmacy at 12:00 P.M. on 2/15/17. All areas of the pharmacy were clean and patient-specific medication cards were housed in lockable medication carts.

The Surveyor interviewed Pharmacist #1 at 1:30 P.M. on 2/15/17. Pharmacist #1 said that Security Staff and Nursing Clinical Coordinators have after-hour access to the pharmacy at Hospital Campus #2 and its entire stock of drugs. Pharmacist #1 said that only designated pharmacists and medical staff are supposed to have access to the pharmacy, per Hospital policy.

Pharmacist #1 indicated that the Hospital does not have an on-call pharmacist to respond to after hours to obtain and dispense drugs from the pharmacy.

Based on record review and interview, the Hospital failed to ensure the members of the Utilization Review Committee (UR) did not review patients for whom they were professionally involved in the patient's care by participating in the development or execution of that patient's treatment plan. Findings include:

The Hospital's Utilization Review Plan, dated April 2013, indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care, Physicians and non-physicians shall not review patients to whom they have provided health care services or cases in which they have a significant involvement or financial interest. The Utilization Review Committee (URC) is charged with the following functions: To establish and implement a program of concurrent review of admissions and continued stay of all patients, in accordance with applicable statutes, regulations and/or requirements (Medicare, Medicaid third party payers). All patients are reviewed concurrently for appropriateness of level of care and use of facility services. Review continues as long as it is determined, on the basis of specific screening criteria, that further stay is medically necessary and appropriate.

Surveyors interviewed members of the UR Committee which included: Case Manager of the MACU, VP of Finance, Physician #1, ACNO, VP of Quality and Quality Affairs at 11:08 A.M. on 2/21/2017. The Physician #1 said he was always involved in medical reviews of his patients and no other clinicians reviewed the services provided to his patients. Physician #1 said clinicians did not conduct periodic reviews of patients for whom they were not professionally involved. This was not consistent with the Hospital's Utilization Review Plan.

Surveyors interviewed the President of the Hospital and VP of Quality and Regulatory Affairs at 2:36 P.M. on 2/21/2017. The VP of Quality and Regulatory Affairs said the Hospital's UR process focused on discharges and did not apply to patients on the long term care units. The President said the Hospital did not have sufficient medical staff to do UR by clinicians not professionally involved in a patient's care. This was not consistent with the Hospital's Utilization Review Plan.

See Findings in A 0652

Based on records reviewed and staff interviews, the hospital failed to determine the medical necessity of patient's admissions continued stays at the hospital for all Medicare and Medicaid eligible patients. Findings include:

The Hospital's Utilization Review Plan, dated April 2013, indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care, Physicians and non-physicians shall not review patients to whom they have provided health care services or cases in which they have a significant involvement or financial interest. The Utilization Review Committee (URC) is charged with the following functions: To establish and implement a program of concurrent review of admissions and continued stay of all patients, in accordance with applicable statutes, regulations and/or requirements (Medicare, Medicaid third party payers). All patients are reviewed concurrently for appropriateness of level of care and use of facility services. Review continues as long as it is determined, on the basis of specific screening criteria, that further stay is medically necessary and appropriate.

During a tour of 4 South Berger, on 2/21/2017, the Unit Manager (UM) told the Surveyor that in November 2014, the Hospital admitted 23 patients from a long term care nursing faclity that had closed, to this unit which the UM said was considered a long term care unit.

Three nonsampled patient records were reviewed (Nonsampled A, B and C). Admission notices in each record indicated there were notices of non-coverage that stated the patients "did not require inpatient hospital care" yet they were admitted to certified hospital beds. Admission progess notes by physicians on each patient indicated the patients did not require a higher level of care from the long term care nursing facility and the plan was for continued long term care.

Review of UR minutes indicated none of these patients were reviewed for medical necessity and appropriateness of admission or stay.

Surveyors interviewed members of the Utilization Review Committee (URC), which included The Case Manager of the Medical Acute Care Unit (MACU), Vice President (VP) of Reimbursements and Contracting, Physician #1, Assistant Chief Nursing Officer (ACNO), VP of Quality and Regulatory Affairs, at 11:08 A.M. on 2/21/2017. The URC members said UR was conducted only for patients on the MACU and not for patients on any of the other hospital units. The URC members said the other hospital units were long term care units where the patients resided and did not require discharge management or a length of stay review and therefore UR was not required. The UR Committee Members said UR was defined for short stay patients which would only include the MACU and not patients on any of the other hospital units. This was not consistent with the Hospital's Utilization Review Plan.

Surveyors interviewed the President of the Hospital and VP of Quality and Regulatory Affairs at 2:36 p.m. on 2/21/2017. The VP of Quality and Regulatory Affairs said the Hospital's UR process focused on discharges and did not apply to patients on the long term care units. This was not consistent with the Hospital's Utilization Review Plan which indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care.

Based on records reviewed and staff interviews, the hospital, which is a Prospective Payment System (PPS) excluded hospital, failed to make periodic reviews for each current inpatient receiving hospital services during a continuous period of extended duration. Findings include:

The Hospital's Utilization Review Plan, dated April 2013, indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care, Physicians and non-physicians shall not review patients to whom they have provided health care services or cases in which they have a significant involvement or financial interest. The Utilization Review Committee (URC) is charged with the following functions: To establish and implement a program of concurrent review of admissions and continued stay of all patients, in accordance with applicable statutes, regulations and/or requirements (Medicare, Medicaid third party payers). All patients are reviewed concurrently for appropriateness of level of care and use of facility services. Review continues as long as it is determined, on the basis of specific screening criteria, that further stay is medically necessary and appropriate.

Surveyors interviewed members of the Utilization Review Committee (URC), which included The Case Manager of the Medical Acute Care Unit (MACU), Vice President (VP) of Reimbursements and Contracting, Physician #1, Assistant Chief Nursing Officer (ACNO), VP of Quality and Regulatory Affairs, at 11:08 A.M. on 2/21/2017. The URC members said UR was conducted only for patients on the MACU and not for patients on any of the other hospital units. The URC members said the other hospital units were long term care units where the patients resided and did not require discharge management or a length of stay review and therefore they said UR was not required. The UR Committee Members said UR was defined for short stay patients which would only include the MACU and not patients on any of the other hospital units. This was not consistent with the Hospital's Utilization Review Plan.

Surveyors interviewed the President of the Hospital and VP of Quality and Regulatory Affairs at 2:36 p.m. on 2/21/2017. The VP of Quality and Regulatory Affairs said the Hospital's UR process focused on discharges and did not apply to patients on the long term care units. This was not consistent with the Hospital's Utilization Review Plan which indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care and All patients are reviewed concurrently for appropriateness of level of care and use of facility services.

See Findings in A 0652

Based on records reviewed and staff interviews, the Hospital failed to have the Utilization Review Committee (URC) review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services furnished to all Medicare and Medicaid eligible patients. Findings include:

The Hospital's Utilization Review Plan, dated April 2013, indicated: All patients admitted to the Hospital are subject to ongoing review to determine the medical necessity and appropriate level of care, Physicians and non-physicians shall not review patients to whom they have provided health care services or cases in which they have a significant involvement or financial interest. The Utilization Review Committee (URC) is charged with the following functions: To establish and implement a program of concurrent review of admissions and continued stay of all patients, in accordance with applicable statutes, regulations and/or requirements (Medicare, Medicaid third party payers). All patients are reviewed concurrently for appropriateness of level of care and use of facility services. Review continues as long as it is determined, on the basis of specific screening criteria, that further stay is medically necessary and appropriate.

Surveyors interviewed members of the Utilization Review Committee (URC), which included The Case Manager of the Medical Acute Care Unit (MACU), Vice President (VP) of Reimbursements and Contracting, Physician #1, Assistant Chief Nursing Officer (ACNO), VP of Quality and Regulatory Affairs, at 11:08 A.M. on 2/21/2017. The URC members said UR was conducted only for patients on the MACU and not for patients on any of the other hospital units. The URC members said the other hospital units were long term care units where the patients resided and did not require discharge management or a length of stay review and therefore UR was not required. The UR Committee Members said UR was defined for short stay patients which would only include the MACU. This was not consistent with the Hospital's Utilization Review Plan.

Surveyors interviewed the President of the Hospital and VP of Quality and Regulatory Affairs at 2:36 p.m. on 2/21/2017. The VP of Quality and Regulatory Affairs said the Hospital's UR process focused on discharges and did not apply to patients on the long term care units.

The VP of Quality and Regulatory Compliance provided the Surveyor, at 3:35 P.M. on 2/21/2017, with Quality Assurance and Performance Improvement (QAPI) Meeting Minutes, dated 2/26/2015 and 1/19/2016. The minutes indicated the topic of UR was reviewed at these two meetings. The QAPI Meeting Minutes gave no indication of any periodic review of services provided to Medicare and Medicaid eligible patients.

See Findings in A 0652

Based on observation and interview, the Hospital failed to consistently failed to maintain equipment and supplies in an acceptable level of safety and quality for 3 of 3 patient rooms, 2 of 5 country kitchens and the eye wash station located on the Medical Acute Care Unit (MACU). Findings include:

1. The Hospital failed to consistently maintain equipment free of dust and debris in 3 of 3 patient rooms (Patient #2 and Non-sampled Patients #1 and #2) and provide an accessible eye wash station on the Medical Acute Care Unit.

The Surveyor observed the MACU at 10:20 A.M. on 2/14/16.

A. For Patient #2, a ventilator-dependant patient with a tracheotomy (a temporary or permanent opening in the neck) and pneumonia, the fan was observed in his/her bedroom in use with debris and dust covering the fan blades.

B. For Non-sampled Patient #1, a ventilator-dependant patient with a tracheotomy and pneumonia, the fan was observed in his/her bedroom in use with debris and dust covering the fan blades.

C. For Non-sampled Patient #2, a patient with respiratory failure, the box fan was observed in his/her bedroom with debris and dust covering the fan blades.

When interviewed, The Director of Nursing on the unit said she would have the fans cleaned.

D. The eye wash station for the MACU was located in the patient shower area but was blocked by the weight chair and the hoyer lift rendering the station inaccessible for an employee or visitor who needed urgent access.


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2. The Hospital failed to secure cleaning supplies and store them in a manner as not to endanger patient safety in 2 of 5 country kitchens at Hospital Campus #1.

The Surveyor and the Director of Nutrition Services conducted an initial tour of the 5 Country Kitchens on 2/14/17 at 11:00 A.M. at Hospital Campus #1. The Country Kitchens are self contained kitchenettes where the food is delivered from the main kitchen in bulk and then meals are served directly to patients that reside on each of the units. All clean up, including dish washing, is completed by the dietary aid assigned to that Country Kitchen.

It was observed on 3 E and 1 Berger Country Kitchens that the cleaning supplies were stored under the sink. The doors of the cabinet were not secure and the cleaning supplies were easily accessible. The Country Kitchens are located in the unit dining rooms where patients gather, attend activities and eat meals.

Interview with the Director of Nutrition Services on 2/14/17 at 12:00 P.M. said that he was unaware of were the cleaning supplies were stored and acknowledged that the cleaning supplies were not secured in the cabinet and accessible to everyone, including the patients.

Based on observation, documentation review and interview, the Hospital failed to store food products appropriately and failed to monitor food temperatures consistently.

Findings include:

1. On 2/15/17, during a tour of the country kitchens with the Hospital Dietitian, raw shell eggs were stored above ready to eat foods in 4 of 15 country kitchens on the 3 North East, 3 North, 3 South and 1 South Kitchens. Raw foods such as shell eggs should be stored below ready to eat foods to avoid the potential for contamination.

2. In the 3 North and 3 North East Kitchens, boxes of cereal (cream of wheat) were stored opened in cabinets and were not wrapped or resealed to preserve freshness and prevent contamination. In the 3 North East Kitchen, condiments such as lemon spice and garlic powder were stored in sticky containers that were not dated. A sign in the kitchen read: "condiments expire 1 month from date of opening".

3. In the 3 North West Kitchen, stainless steel cleaner was stored with a George Forman Grille. In the 1 South West Kitchen, a cleaning product was stored with napkins. In the 3 North West Kitchen, plastic knives were stored with a cleaning brush and oven cleaner. In the 3 North East Kitchen, condiment containers were stored with detergent and
sanitizer in the cabinet under the sink. In 3 kitchens; 3 North East, 3 South and 2 North, sharp knives were stored in
unlocked drawers. In 3 South East and the 2 North Kitchen, chemicals such as detergent, sanitizer and all purpose cleaner were stored unlocked.

4. In 2 country kitchens, food temperature monitoring was not completed on the following dates: 2/3 and 2/7/17 in the 3 North East Kitchen and 2/2, 2/3 and 2/8/17 in the 3 North Kitchen. In addition, on 2/15/17 at breakfast on 3 North East Unit and on 2/16/17 at lunch on the 1 South Unit, staff failed to sanitize the food thermometer prior to checking food temperatures. The above observations were reviewed with the Dietitian.

Based on observation and interview, the Hospital failed to consistently meet infection control standards for five patients (Patient #13, #27, #38, #54 and #60) in a total sample of 63 patients, related to compliance with the pneumonia prevention protocol, asepsis, hand hygiene, cleaning, disinfection and sanitation, pet fish, food sanitation, pest control and use of personal protective equipment. Noncompliance with kitchen santiation had the potential to affect every patient in the hospital. Finding include:

1. According to the The Society for Healthcare Epidemiology of America (SHEA) publication of Infection Control and Hospital Epidemiology titled "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update" the Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients included the evidenced based practice to elevate the head of the bed to 30°- 45°.

For Patient #13, a ventilator-dependant patient with a tracheotomy (a temporary or permanent opening in the neck) respiratory failure and pneumonia, Patient #13's bed did not contain a measurement device to establish the reading of the head of the bed angle.

The Surveyor interviewed Registered Nurse (RN) #1 who was caring for Patient #13 at 11:00 A.M. on 2/14/17. RN #1 said there were a few beds on the Medical Acute Care Unit (MACU) that did not have an installed angle reader and she was taught to judge the angle by looking.

The Surveyor interviewed Respiratory Therapist (RT) #1 who was on duty in the MACU at 11:10 A.M. on 2/14/17. RT #1 said there were beds on the MACU that did not have an angle reader and he said he was able to judge the angle because of repeated practice.


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2. For Patient #54, Hospital staff failed to ensure that a dressing change for a pressure ulcer was conducted using proper infection control practices.

Patient #54 was admitted to the Hospital in 9/2016. Diagnoses included dementia and pressure ulcer on left heel (unstagable).

Review of the Hospital policy, Hand Hygiene (reviewed 11/2015) included the following indications for hand hygiene:
- "Before entering a resident's/patient's room".
- "Before touching a resident/patient, even if gloves will be worn".
- "Before donning and after removing PPE (personal protective equipment - (gown, mask, gloves)".
- "Before exiting the resident's/patient's care area, after touching the resident, or immediate environment (bed, chair, table, door knob, personal belongings) or equipment".
- "After contact with blood, body fluids or excretions, wounds, or wound dressings".
- If your hands will be moving from a contaminated-body site to a clean-body site during care".

On 2/15/17 at 2:20 P.M., the Surveyor observed Nurse #6 and Resident Assistant (RA) #2 during a dressing change for a wound on Patient #54's left heel.

The Surveyor observed Patient #54 at 2:20 P.M. on 2/15/17 sitting in a wheelchair in the Patient's room. Patient #54 was wearing dirty, worn slipper socks on both feet. On a nightstand across from the bed, was Patient #54's pressure relieving boot (TruVue). Observation indicated the TruVue boot was dirty and ripped. The inside of the boot was dirty and had an old brownish stain.

Review of the clinical record indicated that Patient #54 had just finished a course of the antibiotic medication Bactrim for a heel wound infection. It was administered from 1/20/17 to 2/14/17 (a total of 26 days).

Nurse #6, without performing hand hygiene, donned clean gloves outside the patient's room and entered the room.

RA #2 and Nurse #6 assisted the Patient #54 into bed for the dressing change. Nurse #6 placed a clean towel on the bed and then assisted RA #2 to reposition Patient #54's left foot and leg. Then, without performing hand hygiene, and donning clean gloves, Nurse #6 gathered dressing supplies and dumped them all onto the towel which was now contaminated due to repositioning Patient #54 with the heel and legs on the towel.

The Surveyor observed that Patient #54 did not have a dressing on the heel wound. Nurse #6 said that Patient #54 removes the dressing on occasion. The wound measured 1.5 x 1.5 centimeters (cm.) and was approximately 2.0 cm. deep.

The Surveyor observed Nurse #6 and RA #2 repeatedly touching Patient #54's wound by running their contaminated gloved hands over the wound again and again. There was no hand washing or changing gloves per policy. The left heel and ankle were very dry and flaky.

Using the same gloves, Nurse #6 reached into her pocket and retrieved scissors. Nurse #6 did not clean the scissors, before cutting about a two inch piece of Packing Strip from the sterile bottle of packing. Nurse #6 placed the contaminated scissors back into her pocket. After pouring a small amount of full-strength Betadine (antiseptic solution) into a medication cup, she placed the Packing Strip into the Betadine to soak.

Using the same gloves and no hand hygiene, Nurse #6 sprayed wound cleanser into the wound, and dried the area with gauze. Again, using the same contaminated gloves, Nurse #6 then removed the strip from the medication cup and began to pack the wound. The strip fell onto the towel. Nurse #6 picked it up from the contaminated surface and placed the contaminated strip into the pressure ulcer wound. The wound was covered with a protective dressing. Nurse #6 then gathered up all the contaminated gauze, the Packing Strip bottle, the Betadine and the Wound cleanser in one hand and disposed of the gauze, then placed the supplies back on the Treatment Cart.

Without performing hand hygiene, and donning clean gloves, Nurse #6 put the same dirty, worn slipper socks on Patient #54, then proceeded to put the ripped, dirty TruVue boot back on him/her. The Surveyor asked Nurse #6 why she did not get clean socks and ask someone about a clean boot. Nurse #6 said she didn't know, but would ask someone. The Surveyor observed that Nurse #6 did not wash her hands and changed gloves at all during the treatment, contaminating everything she used.



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3. For Dental Suites, located in Hospital Campus #1 and Hospital Campus #2, Dental staff failed to ensure brushes used to remove debris (tissue and blood) from dental instruments used for oral surgery and for other dental procedures, had been cleaned between use, or at the end of the day. In addition, Dental staff failed to ensure clean instruments had been rinsed under a faucet in a clean sink area.

During a tour on 2/21/17 at 11:00 A.M. of the Dental Suite/Laboratory, located in Hospital Campus #1 with Dental Assistant (DA) #1, the Surveyor observed a dirty sink area with 2 brushes stored partially on the edge of a dirty sink and counter. The bristles to the two brushes were worn and had wooden-type, discolored handles. DA #1 said that the brushes were not disinfected between each use, when used to brush debris from oral surgery dental instruments (such as blood and tissues), and dental instruments used for teeth cleaning. DA #1 said there was no policy she was aware of for disinfection processes used for dental care/oral surgery provided for inpatients and outpatients.

DA #1 said that after the dental instruments were brushed, rinsed and soaked, that the instruments were placed into an ultrasonic machine with a solution for a more thorough cleaning. DA #1 said that the cleaned instruments were then rinsed under the faucet in the dirty sink. DA #1 said that there was no clean sink area in the Dental Laboratory area where dental instruments were disinfected, prior to processing. Rinsing clean dental instruments in a dirty sink increases the risk of cross-contamination to the clean instruments.

During a later interview on 2/21/17 at 4:00 P.M., the Director for Infection Control said that there was no policy for disinfection of dental instruments, but the Hospital used Centers for Prevention Disease Control (CDC) guidelines for sterilization processes.


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4. On 2/15/17 at 8:35 A.M., during the medication pass, Licensed Practical Nurse (LPN) #2 was in the process of administering medications. There was a wall mounted fan that was laden with dust. LPN #2 said she was hot and proceeded to turn on the fan. The dust from the fan began to blow on and around the medication cart. LPN #2 continued to prepare medications which included a needle and syringe for insulin administration without turning off the fan and ensuring a clean area to prepare medications.

5. For Patient #38, the Hospital failed to ensure there were policies and procedures in place to properly care for four fish in a manner that would decrease the possibility of water borne infection.

The recommendations of Centers for Disease Control (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following:
Guidelines for Environmental Infection Control in Health-Care Facilities
Controlling the Spread of Waterborne Microorganisms
*Avoid placing decorative fountains and fish tanks in patient-care areas.

On 2/17/17 at 11:45 P.M., during a medication pass in Patient #38's room, revealed 3 containers, 1 clear container with a yellow cover, filled with water containing 1 fish, a second clear container with a pink cover, filled with water containing 2 fish and a third container without a cover, containing 1 fish. Each container had a build up of beige like substances at the bottom of each container.

During interview on 2/17/17 at 2:10 P.M., Registered Nurse #7 said that the staff are aware that Patient #38 had the fish and that he/she took care of them him/herself. RN #7 said that he believes Patient #38 cleans the fish containers two times a week but couldn't be sure how or when the cleaning takes place. The Surveyor asked RN #7 when the fish containers were last cleaned and he said he wasn't sure, that there was no record keeping for this. RN #7 said he thought Patient #38 had 3 fish and was not aware that there were actually 4 fish in his/her bedroom. RN #7 there was not a specific policy for patients to have fish as pets.

During interview on 2/21/17 at 12:10 P.M., Infection Preventionist #1 said that the Infection Control Department had no awareness that Patient #38 had fish in his/her room and there was no Hospital policy or procedure in regard to patients having fish as pets.


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6. On 2/14/17 at 10:00 A.M., the Surveyor conducted an initial sanitation tour of the main kitchen on Hospital Campus #1 with the Director of Nutrition Services and a Dietary Supervisor #1 for the kitchen.

During the tour, dietary staff were observed completing the dish and pot cleaning procedure after the breakfast meal. The dietary staff were observed utilizing the pot washing machine. The Surveyor asked the supervisor if the staff document the pot washing machine temperatures to ensure that the pots and pans were sanitized properly, and the Supervisor replied no.

Next the Surveyor observed the staff completing the dish washing procedure at the dish washing machine. The Surveyor checked the temperature gauges for the wash and final rinse cycle and both were adequate in temperature. The Surveyor asked Supervisor #1 if the dietary staff document the temperatures of the wash and rinse cycle to ensure that the dishes (dishware, silverware, glassware and trays) were sanitized properly. Supervisor #1 said that a Kitchen Supervisor has the responsibility of recording the wash and final rinse temperatures of the dish washing machine but no one records the temperatures of the pot machine.

Review of the Dish Machine Temperature Log for January 2017, indicated there were several blanks on the log including: 28 of 31 breakfast meals had no documented temperatures, 10 of 31 lunch meals had no documented temperatures and dinner was complete.

Review of the February 2017, Dish Machine Temperature Log for the main kitchen indicated 9 of 32 meals had no documented evidence that dish washing machine temperatures were monitored for the cleaning process after a meal.

The Surveyor and the Director of Nutrition Services then conducted tours of the 5 Country Kitchens. The Country Kitchens are self contained kitchenettes were meals are served directly to patients that reside on each of the units and all clean up, including dish washing, is completed in each Country Kitchen.

The Dish Machine Temperature Logs for February 2017 for all 5 Country Kitchens were reviewed by the Surveyor and the Director of Nutrition Service on 2/15/17 with the following results:
1 Berger- All temperatures were recorded for the wash and rinse cycle, however the recorded final rinse temperatures were all below 180 degrees Fahrenheit.
5 Berger- 6 of 43 meals were left blank
3 East-1 of 43 meals left blank
3 West-13 of 43 meals left blank
5 East-8 of 43 meals left blank

It was also noted that from 2/14/17- 2/21/17, the Hospital was experiencing a flu/upper Respiratory outbreak and there were 3 units that had been quarantine (5 E, 3 E, 3 NW) during survey.

Review of the Hospital reporting system on 2/23/17, indicated that the Hospital had experienced several outbreaks between 12/15- current including:
-12/17/15 GI illness for 11 cases
-3/7/16 norovirus on 5 Berger
-2/16/17 Flu/Upper Respiratory 9 positive cases

7. On 2/14/17 at 12:00 P.M., the Surveyor observed the food service staff serving the noon meal from the tray line in the main kitchen. The Surveyor asked if temperatures were taken prior to the start of the tray line, and Supervisor #1 said yes. Review of the Food Temperature Log indicated that all foods had a corresponding temperature with the exception of the puree foods. The Surveyor asked the chef to take temperatures of puree food to ensure proper temperature. Upon completing the task of obtaining food temperatures the Chef wiped the thermometer with a paper towel and did not sanitize the thermometers.

On 2/15/17 during the noon meal (12:00 P.M.) on 5 E in the Country Kitchen the Surveyor observed Diet Aid #1 (DA#1) obtaining food temperatures prior to service, however DA#1 did not sanitize the thermometer after use.

On 2/16/17 at 9:00 A.M., Diet Aid #1 (DA #1), who was scheduled in the 5 E Country Kitchen consistently 5 days a week, was interviewed. The Surveyor asked DA #1 how he/she cleaned and sanitized the thermometers after use. DA #1 said that he/she rinses the thermometer off with hot water then she wipes it off with paper towel.

On 2/16/17 at 9:15 A.M., Diet Aid #2 (DA #2), who was consistently scheduled on the Berger 1 Country Kitchen, was interviewed. The Surveyor asked how DA #2 cleaned and sanitized the thermometer after use. DA #2 said he/she used a paper towel to wipe off the thermometer.

The Director of Nutrition Services was interviewed on 2/21/17 at 10:30 A.M. and said that there is no system in place to ensure that all dietary staff have been trained and utilized the proper procedure to wash and sanitized all food thermometers after use, including the main kitchen and all 5 Country Kitchens. The Director also said that there is no Policy and Procedure in place to ensure that food thermometers are sanitized adequately to reduce the spread of food borne illness.

8. On 2/14/17 at 1:00 P.M., the tour of the Country Kitchens continued with the Supervisor. During the tour the Surveyor observed on 1 Berger Country Kitchen mice dropping in the two lower corner cabinets where kitchen equipment was stored. The cabinet under the sink, where chemicals were stored, also had numerous mice droppings.

Mice can carry Hantavirus. The virus is found in their urine and feces, but it does not make the animal sick. It is believed that humans can get sick with this virus if they breathe in contaminated dust from mice nests or droppings.

The Surveyor's observations were provided to the Director of Nutrition Service who said that there had been an increase in sighting of mice since the demolition/construction of the main dining room on the first floor starting in February 2017. The Director indicated that the food service department maintained a log of mice sighting that is checked by the Pest Control Technician when they visit the Hospital. Currently the Pest Control Company treats the main kitchen 2 times a week since the beginning of February. Prior to that, the Pest Control Company treated the main kitchen 1 time a week.

Interview with the Director of Housekeeping on 2/15/17 at 10:00 A.M., said that he keeps a separate log for pest control monitoring for the building (excluding the main kitchen). The Director said that he receives information via phone/ email and documents the information on the Pest Control logs for the Pest Control technician to review when they come to treat the Hospital.

Review of the Pest Control Service Request Log dated 9/16- 2/15/17 (5.5 months), indicated 107 sightings of mice in patient care areas as well as pharmacy, locker rooms and administrative offices.

Review of the "Concern Resolution Report" indicated that families had been reporting mice sightings to the Hospital utilizing the grievance process. Review of the grievance log indicated the following:

-8/19/16 a family member called the Department of Public Health and reported mice running in and out of a patient's room leaving excrement (droppings).

-9/27/16 a family member called the Hospital to complain about a mouse jumping out of her family member's trash can earlier that day. The family member said that the patient was very upset and would not be able to sleep unless there was a trap in place. The staff member, who was to follow up about the complaint, documented in the grievance log that housekeeping was paged but said that there were no more traps at the Hospital and he had to go to CVS to buy more.

-12/27/16 a patient complained that he/she took it upon themselves to kill a mouse in their room. The nurse entered the room to find the patient attempting to kill the mouse with a grabber. The mouse stopped moving and a nurse came and flushed it down the toilet.

On 2/21/17 at 9:00 A.M., the Surveyor met with the Pest Control Technician, Director of Housekeeping and The Director of Support Service. The Technician said that he visits the Hospital twice a week since the beginning of February and 1 time a week prior to that. He said that he checks the Pest Control logs and puts out traps and bait. The Surveyor asked the Technician what was his plan with the increase of sighting of mice and he said put out more traps. They was no indication that the Hospital was addressing how the mice may be entering the building/units or ensuring that food sources were not accessible to the mice on patient units.

The Director of Supportive Services said that he sent an email on 10/20/16 to the Director of Nurses addressing "Mouse Facts" including elimination of food sources. A second email was generated by the Director of Supportive Services advising staff the potential for increase mice activity due to construction. Despite the 2 emails, the mice activity continue to grow.

The Surveyor asked the Director of Housekeeping if this information about pest/mice activity was brought forward to QAPI (Quality Assurance Performance Improvement) and he said no.

9. For Patient #27, the Hospital failed to initiate Contact Plus Precaution as per the Hospital policy, when Patient #27 was suspected of having Clostridium difficile (C-diff) infection.

Review of the Infection Control Policy and Procedure for Clostridium difficile (C-diff) infection dated 7/2015, indicated that any patient/resident with C-diff (suspected or diagnosed) should be placed on Contract Plus Precautions in addition to Standard Precautions. The policy also indicated that strict hand hygiene protocols should be implemented with the emphasis on washing hands with soap and water due to the presence of spores. The staff should also wear gowns if substantial contact with stool in the courses of care or with contaminated environmental services as well as not sharing personal care equipment i.e. stethoscopes.

Patient #27 was admitted to the Hospital in 3/2012 with diagnoses that included aphasia secondarily to CVA (Cerebral Vascular Accident) hemiplegia, hypertension, atrial fibrillation, diabetes, glaucoma, hyperlipidemia, apnea and dependent for activities of daily living including personal care.

Review of the Nurse Practitioner's (NP) documentation dated 10/13/16 at 9:30 A.M. indicated that Patient #27 was experiencing occasional loose stools most days, even without the use of laxatives. The NP documented that she questioned the tube feeding formula but would check the stool for C-diff infection.

Review of the nutrition note dated 10/13/16, indicated the Dietitian documented that Patient #27 was receiving Jevity 1.5 at 60 ml per hour for 16 hours per day with 1250 ml water flush per day. The Dietitian also documented that staff reported an increase in the number of liquid stools.

Review of the nurse's notes dated 10/13/16, indicated that Patient #27 had a tube feeding formula and water flush change and would continue to assess and treat as ordered.

On 10/18/16, the dietitian documented that Patient #27 continued to have frequent loose stools and that Patient #27 may benefit from a GI (Gastroenterologist) consult.

The next documented nurse's note was dated 10/18/16, that indicated that Patient #27 had 2 watery stools and a stool sample was collected and sent to the lab. On 10/20/16 at 1:08 A.M., the nurse documented that she received a call from the labs at 10:30 P.M. (10/19/16) indicating that Patient #27's results detected C-diff in the stool sample. The MD was contacted and a new order for Contact Plus Precautions and an antibiotic were initiated.

Review of the CNA documentation for Patient #27's daily bowel movements (BM) indicated that between 10/11- 10/20/16, Patient #27 experienced 2-3 soft, loose or watery BMs daily.

On 10/20/16, the NP documented that Patient #27 experienced 3- 4 loose stools a day. The NP documented that there were previous concerns about a stool back on 6/16 but staff were unable to collect a stool sample, but found to have C-diff in a current stool sample. The NP documented the plan to continue with antibiotic and waiting for infection disease MD consult.

Review of the Infectious Disease MD consult dated 10/20/16 at 14:35 P.M., indicated that Patient #27 had loose stool that were thought to be from the G tube feedings, however the G tube feeding formula and rate were changed and the diarrhea appeared to have worsened. Patient #27's stool was checked and was positive for C-diff. The plan was to treat with antibiotics (Flagyl) and if symptoms fail to improve recommend change to Vancomycin.

On 10/31/16, the Dietitian documented that Patient #27 was diagnosed with C-diff with the initiation of an antibiotic and the number of loose stools have declined.

Nurse #16 was interviewed on 2/15/17 at 2:00 P.M. and indicated that she was not the unit manager at the time of Patient #27's infection, however reviewed the Hospital policy with the surveyor and said that Patient #27 should have been placed on Contact Plus Precautions on 10/13/16, and not waited 6 days while attempting to collect a stool sample.

Infection Control Preventionist #2 was interviewed on 2/16/17 at 2:00 P.M., and said that staff can only collect watery stool samples to culture for C-diff, but did acknowledge that there were no nurses notes between 10/13-10/18/16 that indicated if staff were unable to collect a stool sample or the consistency of Patient #27's stool.


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10. On 2/15/17 at 8:30 A.M. the Surveyor conducted an initial sanitation tour of the Country Kitchens and the Main Kitchen on Hospital Campus #2 with the Dietitian.

During the tour, raw shell eggs were stored above ready to eat foods in 4 of the 15 Country Kitchens (the 3 North, 3 North East, 3 South and 1 South Kitchens). Raw foods such as shell eggs should be stored below ready to eat foods to avoid the potential for cross contamination.

Boxes of hot cereal (cream of wheat) were not stored properly in the 3 North and 3 North East Kitchens. The packages were not wrapped or resealed to preserve freshness and prevent contamination. Condiments such as Lemon Spice and Garlic Powder were stored in sticky opened and undated containers in the 3 North East Kitchen. A sign in the kitchen read: "condiments expire 1 month from date of opening".

Chemicals and cleaners were not always stored properly to avoid the potential for contamination in 3 Country Kitchens. In the 1 South West Kitchen, a cleaning product was stored with napkins. In the 3 North West Kitchen, plastic knives were stored with a cleaning brush and oven cleaner. In the 3 North East Kitchen, 3 condiment containers were stored with dish detergent in the cabinet under the sink.

11. On 2/15/17. during the initial tour, the Surveyor asked if temperatures were taken prior to the start of the meal service in each Country Kitchen. The Dietitian said yes. Review of the Food Temperature Logs indicated that food temperature monitoring was not done on the following dates: on 2/3/17 and 2/7/17, in the 3 North East Kitchen. Food temperatures were not done on 2/2/17, 2/3/17 and 2/8/17, in the 3 North Kitchen.

On 2/15/17, at breakfast, the Surveyor observed that staff did not sanitize the food thermometer before and after checking food temperatures. In the 3 North East Kitchen, staff rinsed the food thermometer under running water before and after checking a food temperature. On 2/16/17 at lunch in the 1 South Kitchen, the server did not sanitize the food thermometer before and after checking the food temperatures on the steamtable.


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12. For Patient # 60, the hospital failed to follow proper infection control standards as related to preparing and utilizing a clean dressing field while conducting a dressing change.

On 2/16/2017, at 10:50 A.M., a dressing change observation took place on the 3 south unit within Campus #2. The nurse prepared a set up of the clean dressing field on the top of a mobile metal treatment cart. After the field was prepared, a housekeeper then rolled the dirty cleaning cart directly past and alongside the dressing field. After this occurred, the housekeeper then pulled out the mop from the bucket of dirty mop water just used to clean the Patient #60's bathroom floor.

Neither the nursing supervisor, who was assisting the staff nurse, nor the staff nurse, made any attempt to provide a clean field for the dressing material . Surveyor intervened and the staff then discarded the field cover and any bottles or stock material that was unopened and contaminated by the dirty housekeeping cart as well as the dirty water from the mop bucket.

Based on record review and interview, the Hospital failed to ensure that 20 patients (#3, #7, #15, #17, #20, #40, #41, #42, #43, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54 and #63), in a total sample of 63, the hospital failed to conduct a discharge planning evaluation upon admission, as required.


1. For Patient #42, Hospital Campus #2 staff failed to ensure a discharge plan had been completed and included documentation of a discharge evaluation, related to the likelihood of his/her capacity for self-care or of the possibility of Patient #42 being cared for in the environment from which he/she entered the Hospital.

Patient #42 was admitted to Hospital Campus #2 in 10/2011 from home. Patient #42's diagnoses included Obsessive Compulsive Disorder (OCD), delusional and anxiety disorders.

Record review revealed there was no discharge plan or discharge evaluation documented in the clinical record.

During interview on 2/14/17 at 12:00 P.M., Nurse #12 said that 2 North, Northeast and Northwest Units, located at Hospital Campus #2, was considered Long Term Care (LTC). Nurse #12 said that the combined 3 units were considered "neighborhoods," where Resident Assistants (RAs) and nurses provide custodial care, such as bathing, washing, grooming, meal preparation, and medication administration for "residents". Nurse #12 said that Patient #42 lived by him/herself at home, wanted to come live here because Patient #42 had a family member living here, liked it, and thought over time, that Patient #42's condition may worsen to a point where he/she could no longer live at home, and wanted to live here. Nurse #12 said that, per Patient #42's request, Patient #42 was admitted to LTC (although not considered LTC/Skilled Nursing Facility, but a hospital). Nurse #12 said that Patient #42 was primarily independent, kept to him/herself a lot, and had some manageable behaviors. Nurse #12 said that there was no discharge plan or discharge evaluation completed/documented. She said that discharge planning/evaluations were literally "unheard of", as residents come here to live, either by choice, or due to a decline in a condition, requiring LTC placement.

Please refer to A-812.

2. For Patient #43, Hospital Campus #2 staff failed to ensure a discharge plan was documented or discharge evaluation was completed/documented.

Patient #43 was admitted to Hospital Campus #2 in 3/2015. Patient #43's diagnoses included Cerebral Vascular Accident (CVA), right hemiparesis, dementia, contractures, had a feeding tube for all nutrition, was non-ambulatory, and required 24 hour nursing care. According to the clinical record, Patient #43 was admitted to Hospital Campus #2 for Long Term Care.

Record review revealed there was no discharge plan or discharge evaluation completed or documented to indicate alternate options, if any, with a potential for discharge.

During interview on 2/14/17 at 12:30 P.M., Nurse #12 said that there would be no discharge plan or evaluation completed/documented for this "resident" who was long term care (despite living in a hospital setting).

3. For Patient #45, Hospital Campus #2 staff failed to ensure a discharge plan was documented or discharge evaluation was completed/documented, as required for hospitalized patients.

Patient #45 was transferred from Hospital Campus #1 to Hospital Campus #2 in 3/2016 with diagnoses including heart failure, atrial fibrillation, severe asthma and chronic Clostridium Difficile infection requiring on-going antibiotic therapy.

According to a Physician's history and physical (H&P) note, dated 3/11/16, Patient #45 came to live at Hospital Campus #2, had lived in another state, and was admitted to Hospital Campus #2 for LTC due to the inability to live in a less supportive setting.

Further review indicated that there was no documented discharge plan or discharge evaluation completed/documented for Patient #45.

4. For Patient #46, Hospital Campus #2 staff failed to ensure a discharge plan was documented or discharge evaluation completed/documented, as required for a patient admitted into this Hospital center.

Patient #46 was admitted to Hospital Campus #2 in 9/2014 with diagnoses including weight loss, anxiety, hypertension, impaired cognition, irritable colon, urinary incontinence and functional quadriplegia.

Review of Patient #46's H&P, dated 9/23/14, indicated he/she was admitted to LTC from the community.

During interview on 2/15/16 at 2:30 P.M., Nurse #12 said that Patient #46 was here for LTC, required custodial care and used continuous Oxygen via a nasal cannula. Nurse #12 said that there would be no discharge plan or discharge evaluation completed/documented for Patient #46 as the plan was for the "resident" to live here.

5. For Patient #63, Hospital Campus #2 staff failed to ensure a discharge plan was documented or discharge evaluation completed/documented, as required for a Hospital center.

Review of Patient #63's clinical record revealed there was no discharge plan or discharge evaluation completed/documented.

While at Hospital Campus #2, and during interview on 2/16/17 at 11:00 A.M., Nurse #18 (identified she was the Charge Nurse for the South Neighborhood Units) and that there was no discharge planning/evaluation process completed or documented on any of the "residents" located on the 3 South, Southeast or Southwest Units. Nurse #18 said that all patients residing on these 3 units/neighborhoods reside as long term care residents, and live here (despite the facility/units were considered hospital beds). Nurse #18 said that discharge evaluations would not be documented and/or discharge planning completed on any of the patients. Nurse #18 said that Patient #63 came here from a Rehabilitation Facility to live here.

During interview on 2/16/17 at 11:05 A.M., Patient #63 said that he/she lived at home by him/herself with services from private duty nursing care staff for management of his/her catheter. Patient #63 said that he used to walk, using a cane sometimes, had a few falls, ended up going to a Rehabilitation Facility, and then eventually ended up here. Patient #63 said that his/her house recently was sold, and unfortunately it was no longer an option to return back to that setting, and had resigned him/herself to living in the long term care "corporation." Patient #63 said that he/she had been on a waiting list to come here, and that discharge planning had never been discussed while here, as he/she was told this long term care "corporation" is where he/she had to live. Patient #63 said that at this point, all of his/her belongings had been sold by a person he/she had appointed to manage outside affairs, as well as his/her house, and there was nothing left but a few mementos he/she pointed out around the room.

Please refer to A-812.


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6. Patient #41 was admitted to the Hospital in 4/2014, with diagnoses of dementia with aggressive behaviors.

Review of the Admission Note indicated that Patient #41 was being admitted for long term care. Hospital staff failed to ensure there was a discharge planning evaluation completed by the Hospital.

7. Patient #52 was admitted to the Hospital in 4/2014. Review of the Admission History and Physical (H&P) indicated the reason for admission was Long Term Care.

8. Patient #53 was admitted to the Hospital in 6/2016 with diagnoses including Parkinson's Disease and dementia.

Review of the Admission H&P indicated Patient #53 was admitted for Long Term Care due to dementia.

9. Patient #54 was admitted to the Hospital in 9/2016 with diagnoses of Parkinson's Disease and dementia with behaviors.

Review of the Admission H&P indicated Patient #54 was admitted to the Hospital for Long Term Care due to functional/cognitive deficits.

During interview on 10:30 A.M., Nurse #11 said the Hospital does not do any Patient discharge evaluations because this is a nursing home and this will be their home until they pass away.


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10. During record review of 5 patients (#47, #48, #49, #50 and #51) that had been admitted to the Memory Unit, located at Hospital Campus #2, none of the records indicated that the Hospital staff ensured that there was a discharge planning evaluation completed for each patient. For example:

a. Patient #47 had been admitted on 2/1/17, record review failed to indicate that the Patient was evaluated for discharge planning.

b. Patient #48 had been admitted on 12/11/14, record review failed to indicate that staff evaluated him/her for discharge planning.

c. Patient #49 had been initially admitted in 9/2015, with a recent acute hospitalization from 1/30/17 through 2/13/7, record review failed to indicate that staff evaluated him/her for discharge planning.

d. Patient #50, admitted 4/4/16, record review failed to indicate that staff evaluated him/her for discharge planning.

e. Patient #51, admitted 4/12/10, record review failed to indicate that staff evaluated him/her for discharge planning.

During interview on 2/15/17 9:30 A.M., Social Worker # 1 (Hospital Campus #2) and RN # 11 (Memory Unit) said the Hospital does not do any patient discharge evaluations because this is a nursing home and this will be their home until they pass away.


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11. Patient #3 had been admitted on 3/23/16, and clinical record review failed to indicate that he/she was evaluated for discharge planning.

12. Patient #15 had been admitted on 12/21/16, and clinical record review failed to indicate that staff evaluated him/her for discharge planning.

13. Patient #20 had been admitted on 3/16/2009, and clinical record review failed to indicate that the Patient was evaluated for discharge planning.

On 2/15/17 at 11:00 A.M., RN #8 said that the above referenced patients would not be evaluated for discharge because they are here for long term care and will stay here until they expire/die.


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14. Patient #7 was admitted to the Hospital in 6/2016, with diagnoses which included Alzheimer's dementia, seizure disorder and cancer of the prostate.

Review of the Clinical record indicated that Patient #7 was transferred from the Hospital's skilled nursing facility to the Berenson 4 West unit in 6/2016. The Admission Social Worker (SW) note indicated that SW will assist and support "resident" as he/she adjusts to life at Berenson 4. There was no evidence of discharge planning within the clinical record.

During interview on 2/14/17 at 12:10 P.M., Registered Nurse (RN) #8 said that they call the patients on all the units "residents" because this is now their home and they are here for long term care services. She said they would only leave if they were not happy here, but some of our residents have been here for 20 years. She said there was no plan for discharge for Patient #7.

15. Patient #17 was admitted to the Hospital in 1/2013, with diagnoses which included Alzheimer's Dementia with behavioral disturbances.

There was no evidence of discharge planning within the clinical record.

During interview on 2/16/17 at 1:15 P.M., SW #1 said that Patient #17 has been on Berenson 5 West since 2013. She said the only reason he/she would be discharged is if the family requested this. She also said that Berenson 5 West is a long term care/medical unit and we don't do discharge planning for these "residents."

16. Patient #40 was admitted to the Hospital in 4/2016, with diagnoses which included diabetes, atrial fibrillation and cerebral embolism.

There was no evidence of discharge planning within the clinical record.

During interview on 2/21/17 at 2:00 P.M., RN #7 said that Patient #40 was transferred to Berenson 5 East from an assisted living facility because he/she was getting harder to manage. RN #7 said that the only way he/she would be discharged from Berenson 5 East would be if the family wasn't happy with the care in this Hospital.

Based on records reviewed and interviews, for 1 of 63 sampled patients, the Hospital failed to complete a discharge evaluation prior to Patient #1's discharge. Patient #1 was discharged from Hospital Campus #1 without any documented discharge evaluation.

Findings include:

The Hospital's Discharge Process policy, revised 10/29/15, indicated that it was, "the responsibility of the Unit's Interdisciplinary Teams to evaluate thoroughly the resident's/patient's and family's readiness to transition from Post Acute Care Services or a Long term Care Unit, in order to assist them in formulating a plan which is in the resident's/patient's best interest and ensures continuity of care." The policy did not indicate when the discharge evaluation would be completed.

During interview with the Senior Community Life Leader at 10:08 A.M. on 02/21/17, she said discharge evaluations were not completed on patients unless there was a plan at the time of the patient's admission for the patient to be discharged to another setting. The Senior Community Life Leader said that if the patient was admitted for long-term care, no discharge evaluations were completed as the plan was for those patients to stay in Hospital Campus #1.

Patient #1 was admitted to Hospital Campus #1 in January 2017, and discharged in January 2017.

Review of Patient #1's History and Physical, dated 1/11/17, indicated that he/she was admitted to Hospital Campus #1 for long-term care from an independent/supportive living residence.

Review of the Progress Note, dated 1/23/17, indicated that over the weekend, Patient #1 told staff that he/she wanted to return to his/her prior residence.

Review of the Progress Note, dated 1/26/17, indicated that Patient #1 was discharged to his/her prior residence.

There was no documentation in the medical record at the time of survey of any discharge evaluation for Patient #1.

Based on records reviewed and interviews, for 19 of 63 sampled patients (#1, 5, 6, 8, 16, 24, 25, 35, 36, 41, 42, 43, 45, 46, 52, 53, 54, 55, 63), the Hospital failed to include discharge planning evaluations in the patients' medical records. Staff interviews indicated that no discharge planning evaluations were completed on patients considered to be long-term care residents of the Hospital.

Findings include:

The Hospital's Discharge Process policy, revised 10/29/15, indicated that: "The specific information regarding the residents/patients [sic] individualized discharge plan is documented in the Medical Record."

1. Patient #1 was admitted to the Hospital in 1/2017, and discharged in 1/2017.

Patient #1's History and Physical (H&P), dated 1/11/17, indicated that he/she was admitted to Hospital Campus #1 for long-term care from an independent/supportive living residence.

Review of the Progress Note, dated 1/23/17, indicated that over the weekend, Patient #1 told staff that he/she wanted to return to his/her prior residence.

Review of the Progress Note, dated 1/26/17, indicated that Patient #1 was discharged to his/her prior residence.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #1.

2. Patient #5 was admitted to the Hospital in 11/2016, and discharged in 2/2017.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #5.

3. Patient #6 was admitted to the Hospital in 11/2016, and discharge in 12/2016.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #6.

4. Patient #8 was admitted to the Hospital in 4/2016.

Review of a Physician's note, dated 4/15/16, indicated Patient #8 was admitted to long term care from a skilled nursing facility.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #8.

5. Patient #16 was admitted to the Hospital in 10/2014.

During interview on 2/16/17 at 9:30 A.M. with Nurse #7, he said that there was no discharge planning for long-term care patients. Nurse #7 said that most of the patients were admitted for long-term placement.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #16.

6. For Patient #24 with dementia, pica and obesity, there was no documentation at the time of survey of any discharge planning activities in Patient #24's medical record or plan of care.

7. For Patient #25 with dementia and functional dependence, there was no documentation at the time of survey of any discharge planning activities in his/her medical record or plan of care.

8. Patient #35 was admitted to the Hospital in 3/2012.

During interview with Nurse #16 at 12:57 P.M. on 2/17/17, she said they did not have discharges from Patient #35's floor, except for in the case of death, as the patients were admitted for long-term care.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #35.

9. Patient #36 was admitted to Hospital Campus #1 in 3/2010.

Nurse #16 said they did not have discharges from Patient #36's floor, except for in the case of death, as the patients were admitted for long-term care.

There was no documentation in the medical record at the time of survey of a discharge evaluation for Patient #36.


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10. For Patients #41, #52, #53, #54 and #55, Hospital staff failed to ensure there was a discharge planning evaluation completed by staff.

During interview on 10:30 A.M., Nurse #11 said that there is no discharge care plan or discharge evaluation for any of the "residents" because this is a nursing home and this will be their home until they pass away.


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11. For Patient #42, Hospital Campus #2 staff failed to include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan.

Patient #42 was admitted to the Hospital Campus #2 in 10/2011. Patient #42's diagnoses included Obsessive Compulsive Disorder (OCD), delusional and anxiety disorders.

Record review revealed there was no discharge planning documented in the clinical record.

During interview on 2/14/17 at 12:00 P.M., Nurse #12 said that Hospital Campus #2 provided custodial care, such as bathing, washing, grooming, meal preparation, and medication administration. Nurse #12 said that discharge planning evaluations were "unheard of", and "residents" come here to live. There was no discharge plan for Patient #42.

12. For Patient #43, Hospital Campus #2 staff failed to include the discharge planning evaluation in his/her medical record for use in establishing an appropriate discharge plan.

Patient #43 was admitted to Hospital Campus #2 in 3/2015. Patient #43's diagnoses included Cerebral Vascular Accident (CVA), right hemiparesis, dementia, contractures, had a feeding tube for all nutrition and was non-ambulatory.

Record review indicated there was no discharge planning evaluation in the Patient #43's medical record for use in establishing an appropriate discharge plan.

During interview on 2/14/17 at 12:30 P.M., Nurse #12 said that there was no discharge plan or evaluation documented for this "resident". (despite being in a Hospital setting).

13. For Patient #45, Hospital Campus #2 staff failed to include the discharge planning evaluation in his/her medical record for use in establishing an appropriate discharge plan.

Patient #45 was admitted to Hospital Campus #2 in 3/2016, with diagnoses including heart failure, atrial fibrillation, severe asthma and chronic Clostridium Difficile infection requiring on-going antibiotic therapy.

According to a Physician's history and physical note, dated 3/11/16, indicated that Patient #45 was admitted at Hospital Campus #2 for Long Term Care.

Review of Progress notes indicated that Patient #45 went on vacations from the Hospital for 1 week ending 8/10/16 and again from 8/20 - 8/27/16.

Further review indicated that there was no documented discharge planning evaluation in Patient #45's medical record for use in establishing an appropriate discharge plan for Patient #45, a patient that the Physician agreed was able to leave the Hospital for vacations with a private aide.

14. For Patient #46, Hospital Campus #2 staff failed to include the discharge planning evaluation in his/her medical record for use in establishing an appropriate discharge plan.

Patient #46 was admitted to Hospital Campus #2 in 9/2014, with diagnoses including weight loss, anxiety, hypertension, impaired cognition, irritable colon, urinary incontinence and functional quadriplegia.

Review of the Patient's H&P, dated 9/23/14, indicated Patient #46 was admitted to long term care (despite that Hospital Campus #2 was licensed as a Hospital).

During interview on 2/15/16 at 2:30 P.M., Nurse #12 said that Patient #46 was here for LTC and required custodial care. Nurse #12 said that there was no discharge planning evaluation documented for Patient #46.

15. For Patient #63, Hospital Campus #2 staff failed to include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan.

Review of Patient #63's clinical record indicated there was no discharge planning evaluation in his/her medical record for use in establishing an appropriate discharge plan.

During interview on 2/16/17 at 11:00 A.M., Nurse #18 (identified as a Charge Nurse) said that there was no discharge planning evaluation documented in the clinical record for use in establishing an appropriate discharge plan for any of the "residents", as Hospital Campus #2 was a long-term care facility where residents come to live.

Based on records reviewed and interviews, for 2 of 63 sampled patients (Patient #1 and Patient #5), the Hospital failed to reassess the patients discharge prior to being discharged to a lesser level of care.

Findings include:

1. Patient #1 was admitted to Hospital Campus #1 in 1/2017, and discharged in 1/2017.

Review of Patient #1's History and Physical, dated 1/11/17, indicated that he/she was admitted to Hospital Campus #1 for long-term care from an independent/supportive living residence.

Review of the Progress Note, dated 01/23/17, indicated that over the weekend, Patient #1 told staff that he/she wanted to return to his/her prior residence.

Review of the Progress Note, dated 1/26/17, indicated that Patient #1 was discharged.

There was no documentation in the medical record at the time of survey of a discharge evaluation or reassessment for Patient #1.

2. Patient #5 was admitted to Hospital Campus #1 in 11/2016, and discharged in 2/2017.

Review of Patient #5's Discharge Planning care plan indicated that it was last updated 12 days prior to Patient #5's discharge.

There was no documentation in the medical record at the time of survey of a discharge reassessment for Patient #5 prior to his/her discharge to a skilled nursing facility level of care.

Based on observation and staff interviews, the Hospital staff failed to ensure that policies were developed for the Dental Inpatient suites and designed to assure the approparite cleaning and disinfection of critical items used in oral surgery to prevent cross contamination and transmission of infection.Findings include:

During observation in the Dental Suite/Laboratory areas, and interview with Dental Assistant (DA) #1 on 2/21/17 at 11:00 A.M., DA #1 walked the Surveyor through the process of the disinfection and processing of oral surgery dental instruments. DA #1 said that she was not aware of policies and procedures regarding cleaning and disinfecting of oral surgery dental instruments, but that she had worked as a Dental Assistant in the Dental Suite for 15 years, and described the processes she used as follows:

- Disinfects and processes instruments used for oral surgery (considered "critical" instruments, such as extraction forceps, scalpel blades, bone chisels and periodontal scalers) differently than those instruments used for non-surgical dental care.

- Talked through/demonstrating the processes she used to clean, soak, and sterilize oral surgery instruments.

- Identified 2 brushes stored on a Dirty Sink area. The bristles to the brushes were worn and the long, wooden-type handles were discolored. DA #1 said that she brushes the surgical instruments debris (friction) from the dental instruments, while rinsing under a stream of water in the dirty sink.

- Places the oral surgery instruments into a solution called "Barrier Milk", using 1 part of the Barrier Milk solution to 10 parts of distilled water, soaks the instruments in this solution for a period of time, then rinses the instruments under the faucet in the dirty sink (should be a clean sink), then places the surgical instruments into an ultrasonic machine/solution for approximately 15 minutes, removes, bags, places an indicator strip inside the bag, then places the bag with the instruments into the autoclave sterilizer.

Review of the Manufacturer's Directions for Use (MDFU) of the Barrier Milk solution indicated the solution was concentrated, and required dilution using 1 part solution to 6 parts bacteriostatic water. The surgical instruments would then be placed into the ultrasonic solution, then placed into a receptacle containing the Barrier Milk solution and the instruments would be soaked for 30-60 seconds.

The Surveyor asked DA #1 if there was a policy for using this particular solution, and why DA #1 did not follow the printed label instructions for the Barrier Milk, in accordance with the manufacturer's directions. DA #1 said that she was told how to dilute the Barrier Milk, and that the process and solution had been used by DA #1 to her recollection "since 2005".

During interview on 2/21/17 at 11:38 A.M. with the Administrative Director and DA #1, the Administrative Director said that there were policies and she would provide copies to the Surveyor later.

During interview on 2/21/17 at 2:38 P.M., the Director of Infection Control Program (DICP) said that the brushes stored on the dirty sink were worn and discarded immediately, after the Surveyor pointed out the condition and storage of the brushes. The DICP said that there was no policy for cleaning or disinfecting the brushes. In addition, the DICP said that she was not familiar with the Barrier Milk solution, and that the Dental Suite located in Hospital Campus #1 and Hospital Campus #2, followed the Centers for Disease Control and Prevention (CDC) guidelines, as the Hospital did not have specific policies for cleaning and disinfecting oral surgery dental instruments, or brushes used to clean debris from dental instruments (blood and tissue).

Based on record review the Hospital failed to complete a medical history and physical examination prior to oral surgery for dental extractions for 2 of 2 oral surgery patients (#36 and #37).
Findings include:

1. Review of the History and Physical indicated that it was dated for the day of Patient #36's admission to Hospital Campus #1 in 3/2010.

Review of the Dental Consult, dated 10/27/16, indicated that Patient #36 was seen for evaluation. The consult indicated that Patient #36 was to have a tooth extracted after medical clearance and consent had been obtained.

Review of the Dental Consult, dated 11/03/16, indicated that Patient #36 underwent a tooth extraction, which was sutured.

There was no documentation in the medical record that Patient #36 was evaluated for medical clearance prior to the procedure.


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2. Review of Patient #37's "Pre Procedure Medical Evaluation Department of Medicine Dental Clinic-Dental Surgery" form, indicated that it was signed by a Nurse Practitioner and dated as completed 9/7/16. This was done greater than 30 days prior to the patient's procedure date of 11/15/2016.

Review of a dental visit note, dated 11/15/16, indicated a dental extraction of a severely decayed tooth using Lidocaine 2% 1:100000 Epinephrine (local anesthetic) and curetted (curette a surgical instrument for scraping and removing material or tissue from an organ, cavity or surface) the socket (considered a surgical procedure).

Review of the dental record failed to reveal an updated History and physical completed on the day of the oral surgery or one completed within 30 days as required.

Based on observations and interviews with staff, the Hospital staff failed to ensure that emergency equipment, such as a resuscitator, defibrillator and tracheotomy set were available to the dental operating suites. Findings include:
A tour of the Dental Surgical area was conducted on 2/21/17 at 1: 30 P.M. by Surveyor #1 and #2 with Hospital staff. Surveyors observed that emergency/resuscitation equipment (Suction, oxygen, Automatic external defibrillor (AED), ambu bag) was not available to the dental surgical suite.

Staff said that if emergency equipment and staff qualified in advanced life saving skills were required, a call would be made to the Medical Acute Care Unit [MACU] and those staff would respond to the call and provide emergency care.

Surveyors also observed that there was no telephone or call bell system in the patient care areas to alert staff of an emergency. The Dental Hygienist said that one person, either the Hygienist or Dentist, would remain with the patient while one person left the room to go to the reception area and make the call to the MACU to summon the response team.

Based on record review and interviews, Hospital staff failed to ensure that there was adequate provisions for immediate post-operative care. Findings include:

1). A tour of the Dental Surgical area was conducted on 2/21/17. The Dental Hygienist was interviewed regarding services provided. The Dental Hygienist said that patients who have a tooth extraction or any type of surgical procedure performed are kept in the dental services area until any oral bleeding has stopped. Once staff have determined that bleeding has ceased, a 5x6 slip of paper titled, "Instructions Following Tooth Extractions" is sent back with the patient to the patient's room where he or she resides. The instructions include comfort measures, such as applying pressure to the site, ice packs, therapeutic rinses, pain control measures and to eat soft foods.

There was no evidence that the post-operative measures were incorporated into physician orders or the patient's care plan as the directions were given to the patient to implement, not nursing staff.