Chippenham Hospital

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to provide services necessary to two (2) of two (2) dialysis patients in the survey sample. (Patient #4 and Patient #13).

The findings included:

The clinical record for patient #4 contained documentation that the patient was admitted on [DATE]. Prior to the rehabilitation admission, Patient #4 received dialysis on 6/20/2021 as a hospital inpatient.

A physician order was entered on 6/22/2021 at 1:35 p.m. for hemodialysis.

A nephrology progress note on 6/23/2021 documented that the pt [patient] didn't get hd [hemodialysis] as ordered yesterday. According to the note, Patient #4 denied having shortness of breath, chest pain, no worsening edema, and was making some urine. The plan documented by the physician said spoke with [name of dialysis provider] and the hemodialysis must be done today and order is in...again.

A physician order was entered on 6/23/2021 at 9:54 a.m. for hemodialysis.

A nephrology progress note on 6/24/2021 documented that hd attempted but failed b/c [because] cath [catheter] not working and that staff didn't come back yet. The patient denied shortness of breath, chest pain, no worsening edema, and was making some urine.

A nephrology progress note on 6/25/2021 documented that Patient #4 still had no hemodialysis. The note documented that the patient has sob [shortness of breath] overnight req [required] oxygen. The physician discussed with nursing and documented that the patient had no worsening edema and was making some urine. The physician's plan stated no hd [hemodialysis] again, need to do it today to see if cath [catheter] working and if not fix it asap [as soon as possible], had oxygen req [required] overnight which is new, rehab [rehabilitiation] nursing told me that HWS said they would be at bedside this am, I have asked admin [administration] to call me asap.

Based on the clinical record review for Patient #4, hemodialysis was performed on 6/20/2021 and not again until 6/25/2021.

The clinical record for Patient #13 was reviewed and contained documentation that the patient receives outpatient dialysis Monday, Wednesday, and Friday. An order was entered for hemodialysis on 8/28/2021. A nephrology progress note on 8/29/2021 documented that Patient #13 didn ' t get uf [ultrafiltration] last night ...no hd [hemodialysis] done last night as ordered ...no acute need to run ...will run in am unless clinically [Patient #13] changes .... A nursing note on 8/29/2021 documented that Patient #13 signed consent for dialysis, but no dialysis was done. Physician order was entered but not stat [immediately], no dialysis was done. An addendum to the nursing note documented a dialysis nurse contacted at 9:23 a.m. to ask about seeing patient for dialysis; per dialysis nurse, cannot see patient as [nurse] is the only nurse and has multiple patients for dialysis today. The nursing supervisor was notified. A dialysis nurse called back and informed staff that a nurse will be by later to run patient. The clinical record for Patient #13 documented that hemodialysis treatment was administered on 8/30/2021.

An interview was conducted on 9/1/2021 with SM #9. SM #9 confirmed the findings in the medical record and acknowledged patient #4's missed dialysis treatments.

The concern was discussed with SM #2 and SM #9 on 9/1/2021 and again at the exit conference on 9/2/2021.

A facility policy titled, Dialysis Scope of Service, was reviewed and read in part: ...The scope of services is defined as services provided for patients with chronic and acute renal failure within the hospital setting...Hemodialysis is a contracted service by [name of contracted group]...The Hemodialysis Unit is operational six days a week, Monday through Saturday 7:00 a.m. - 5:30 p.m. A Hemodialysis RN is on-call for emergency dialysis when the department is closed...The Divisional Director and market Manager for the contracted Hemodialysis service, has 24 hour responsibility for the overall leadership and direction of the unit and will partner with the facility dialysis liaison and Medical Director or Chief Medical Officer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and document review, it was determined the hospital failed to maintain a well-organized nursing service to provide quality care to patients. Specifically, the hospital's nursing staff failed to appropriately document skin assessment findings, failed to ensure nursing assessment findings were communicated to the physician, and failed to obtain physician orders for wound care in one (1) of eight (8) clinical records reviewed in the survey sample. Clinical record # 2.

Findings:

Eight (8) clinical records were reviewed in the hospital on 04/27-28/21 with the Assistant Director of Advanced Clinicals and the Director of Informatics assisting in the navigation of the electronic record.

The clinical record for patient #2 contained documentation that the patient was admitted on [DATE]. Nursing documentation from 10/06-10/19/20 indicated the patient had no skin breakdown other than the patient's surgical incision site. Nursing documentation on 10/20/20, 10/21/20, 10/22/20, 10/23/20, and 10/24/20 indicated the patient had developed a pressure injury related to moisture and friction on the patient's posterior sacrum. The nursing documentation indicated nurses were dressing the wound with mepilex (a foam dressing). The clinical record contained no documentation of the wound's characteristics to include stage of pressure ulcer, measurements of the wound, appearance of the wound bed, edges and surrounding, presence or absence of drainage, pain, and/or response to treatment. The clinical record contained no documentation of a wound care consult, that the physician was notified of the hospital acquired pressure ulcer, or orders for wound care.

An interview was conducted with a nurse on 04/28/21 at 10:30 AM who had cared for patient #2. The nurse could not recall patient #2 or the condition of the patient's skin. The nurse stated that the expectation for any newly acquired wound would be for the nurse to place a wound care consult. The nurse stated this could be done anytime at the nurses discretion without physician notification. The nurse acknowledged there should be a physician's order in the chart for all wound care performed.

Interviews were conducted with the Quality Director throughout the morning of 04/28/21. The Quality Director confirmed a wound care consult should be initiated with a new hospital acquired wound. The Director of Quality confirmed the clinical record for patient #2 failed to contain wound care orders or a wound care consult.

The surveyors requested a policy related to wound documentation, the Director of Quality stated the hospital did not have a policy other than the policy, Skin Care Policy/Protocol. The surveyors were provided a copy of this policy that did not address wound documentation. The policy did, however state the following, Placement of 0.9% normal saline moistened dressing to open areas is appropriate. Dry gauze dressing is appropriate to areas of eschar. Any other types of dressing to be applied require a physician's order.

The administrative staff acknowledged the above noted findings during the exit conference on 04/28/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and document review, it was determined the hospital staff failed to ensure it discharged the patient with all necessary medical information pertaining to the patient's current course of illness and treatment to the appropriate post-acute care service providers and suppliers responsible for the patient's follow up care. Specifically, the hospital staff failed to include information about a patient's wound and wound care orders in the discharge instructions to the patient and home health agency responsible for the patient's follow up care in one (1) of eight (8) clinical records reviewed in the survey sample. Clinical record #2.

Findings:

Eight (8) clinical records were reviewed in the hospital on 04/27-28/21 with the Assistant Director of Advanced Clinicals and the Director of Informatics assisting in the navigation of the electronic record.

1The clinical record for patient #2 contained documentation that the patient was admitted on [DATE]. Nursing documentation from 10/06-10/19/20 indicated the patient had no skin breakdown other than the patient's surgical incision site. Nursing documentation on 10/20/20, 10/21/20, 10/22/20, 10/23/20, and 10/24/20 indicated the patient had developed a pressure injury related to moisture and friction on the patient's posterior sacrum. The nursing documentation indicated nurses were dressing the wound with mepilex (a foam dressing). The clinical record contained no documentation of the wound's characteristics to include stage of pressure ulcer, measurements of the wound, appearance of the wound bed, edges and surrounding, presence or absence of drainage, pain, and/or response to treatment. The clinical record contained no documentation of a wound care consult, that the physician was notified of the hospital acquired pressure ulcer, or orders for wound care.

The patient's discharge summary and discharge instructions were reviewed and contained no evidence of documentation of the patient's wound or orders for wound care. The case management notes for the patient indicated that the patient was to receive home health services after discharge from the hospital. The case management documentation failed to include any information about the patient having a wound or wound care orders to treat the patient's wound. The clinical record failed to contain documentation that the patient or caregiver was informed of how to treat the wound upon discharge from the hospital.

An interview was conducted with a nurse on 04/28/21 at 10:30 AM who had cared for patient #2. The nurse could not recall patient #2 or the condition of the patient's skin. The nurse stated that all orders for wound care should be on the discharge instructions and the nurse discharging the patient should review them with the patient or caregiver at the time of discharge.

The administrative staff acknowledged the above noted findings during the exit conference on 04/28/21.

Based on clinical record review, staff interview and facility policy/procedure review, the facility staff failed to ensure restraints were implemented per physician's orders for two (2) of four (4) records reviewed for the use of restraints. Patient # 1 and Patient #2.

For both patients, the staff were documenting the use of a restraint, for which there was no physician's order.

The findings included:

Patient #1 had a physician's order for the use of soft restraints, all extremities on 2/26/2020. According to documentation of monitoring the patient was documented as having bedrails and soft- all extremities. Every two hour monitoring evidenced the patient was in the soft restraints as well as bedrails.

Patient #2 had a physician's order for soft BUE (bilateral upper extremities) on 3/6/2020. According to monitoring documentation in the clinical record the staff had documented the patient was not only in the soft BUE restraints, but also had bedrails under restraint devices.

The facility policy and procedure Seclusion, Restraints and Restraint Alternatives was reviewed and evidenced, in part: ...5. Order for restraint or seclusion...a. An order for restraint or seclusion must be obtained from a LIP (Licensed Independent Practitioner)/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release...7b..A RN (Registered Nurse) will assess the patient at least every two (2) hours...

During the chart reviews with Staff Member #12 on 3/11/2020 between 9:45 a.m. and 10:45 a.m., the surveyor discussed the findings.

On 3/12/2020 at 12:15 p.m. the findings were again discussed with Staff Members #1 (Vice President of Quality), Staff Member #2 (Chief Medical Officer), Staff Member # 33 (Peer review Coordinator), Staff Member # 32 (Quality), Staff Member # 3 (Director of Risk and Patient Safety), Staff Member # 31 (Chief Nursing Officer), and Staff Member #30 (Assistant Chief Nursing Officer).

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to ensure an effective and safe discharge plan was implemented for one (1) of three (3) patients (Patient #18). Due to the severity of the deficiency, the facility failed to substantially comply with this condition.

See tag A-0802

Based on clinical record reviews, staff interview and document review, it was determined the facility staff failed to ensure one (1) of three (3) patient's (Patient #18) discharge plan was reassessed after the original discharge planning evaluation was completed.

The findings include:

Patient #18's initial discharge plan evaluation reflected that home health services was a need. The discharge plan did not reveal any evidence that home health services were no longer a need nor that home health services were initiated for Patient #18 post-discharge. Review of the Case Management Note dated 2/18/19 at 1510 (3:10 p.m.) evidenced a Case Manager (Staff Member #23) spoke with Patient #18 who was confused and unable to provide reliable information. SM #23 asked Patient #18 about an individual's name that was listed on Patient #18's facesheet. Patient #18 stated that individual was not involved. SM#23 documented that an attempt was made to contact the individual listed on the facesheet, but the phone was out of service. SM #23 further documented that per a previous note in Patient #18's chart, Patient #18 had no other durable medical equipment other than home oxygen. SM#23 documented a discharge planning evaluation that was completed for Patient #18. Home health was identified as a need and inadequate housing was identified as a discharge barrier. On 2/27/19 1314 (1:14 p.m.) a case management note evidenced that Staff Member #23 was notified by bedside registered nurse that physical therapy advised Patient #18 needs a rehabilitation setting. It was further evidenced in the note that Patient #18 refused to consider rehabilitation and has no other residence at this time.

The clinical record revealed documentation that Patient #18's capacity to make medical decisions were questionable and that pursuing guardianship was recommended. The discharge plan did not reveal any evidence that guardianship was in pursuit or that any action was taken in regards to Patient #18's incapacity to make medical decisions. A 2/21/19 clinical note documented at 0931 (9:31 a.m.) evidenced in part: ...dispo (disposition) Patient #18 is unsafe for discharge due to Patient #18's mental status which may be chronic. We have no family or MPOA (Medical Power of Attorney) at this time. A Psychiatric consultation note on 3/4/19 at 1608 (4:08 p.m.) evidenced in part, Poor attention, likely delusional themes and does not have clear understanding of medical issue and risk benefits of treatment plan. Cognitive impairment {sic} with atrophy on CT (computed tomography) head. IMO (in my opinion), Patient #18 currently lacks capacity to make medical decision {sic}. On 3/5/19 at 1219 (12:19 p.m.), a case management note evidenced that Case Manager, (Staff Member #24) documented that Patient #18 was seen by pysch on 3/4/19 and they say Patient #18 is not competent to make decisions cm (case management) has not been able to locate patients {sic} family. Patient #18 needs guardianship placement. cm {sic} following. On 3/6/19 at 1633 (4:33 p.m.), a clinical note evidenced in part, Disposition CRM to help with placement. Needs guardianship, has no capacity to make medicinal decision {sic}.

The clinical record also revealed documentation that Patient #18 was supplemented with oxygen via a nasal cannula during the hospitalization . The discharge plan instructions revealed that Patient #18 was dependent on supplemental oxygen; however, the discharge plan did not reveal any evidence that supplemental oxygen was arranged for Patient #18 upon discharge. A clinical note on 2/18/19 at 0914 (9:14 a.m.) evidenced that Patient #18 leaves {sic} alone and gets help from friends. Patient #18 could not say names but remembers address.

On 3/11/20 at 1:25 p.m. an interview was conducted with the Director of Case Management (Staff Member #22). The surveyor asked if the original discharge planning evaluation required amendment during the course of the hospital stay, how is this accomplished? Per Staff Member #22, the case management notes would reflect any new patient needs and/or changes to the original evaluation. In regards to obtaining guardianship for a patient, Staff Member #22 stated, There are multiple steps in the process. Two (2) physicians must document the patient's inability to make decisions. The case manager must exhaust a family search which can sometimes include contacting a law office for assistance. The process takes approximately one (1) month. The surveyor asked how a patient can designate a representative to contact on their behalf during the hospitalization . Staff Member #22 responded, If a patient designates a representative, case management will free text that information in the narrative notes. In regards to the patient's discharge needs, Staff Member #22 stated, Case managers are responsible for determining needs, i.e. oxygen in the home, etc. Staff Member #22 was not familiar with Patient #18; however, when the surveyor asked Staff Member #22 if there was a patient who Staff Member #22 had experienced difficulty contacting the family and on the day of discharge an unidentified individual shows up at the facility identifying themselves as the patient's adult child, how would Staff Member #22 handle the situation. Staff Member #22 stated, I would assess the interaction between the patient and this person. I would inform this person that we have been trying to locate the patient's family but have had difficulty. I would then ask this person where have they been and how did they know the patient was being discharged .

On the date of discharge, 3/11/19, Patient #18 was documented as being sent home with an adult child. There was no documentation found in the clinical record of any successful contact and/or location of an adult child for Patient #18, there was no follow-up documentation from discharge planning as to who the individual was, or where Patient #18 would be going after discharge.

Contained in the discharge instructions was a note indicating that one of Patient #18's medical problems was supplemental oxygen dependence. The brief discharge note dated 3/11/19 documented vital signs that were taken the morning of discharge and indicated Patient #18 was on two (2) liters of oxygen via a nasal cannula. There was no evidence contained in the clinical record that any follow-up was conducted as to whether Patient #18 still required supplemental oxygen, or how it would have been delivered to the patient, as there was no residential address or DME (Durable Medical Equipment) request or evaluation.

The survey team discussed the concerns regarding the discharge with the facility Administration on 3/12/20 at 12:00 p.m.

The facility policy/procedure Discharge Planning in the Continuation of Care was reviewed and evidenced, in part: ...All patients are screened to determine discharge planning needs. Discharge planning involves the patient, the family, the practitioner primarily responsible for the patient or the physician consultant, nursing case management/social work professionals, and other appropriate staff ....discharge planning focuses on meeting patients' health care needs after discharge ...

The facility policy Utilization Management Plan documented, in part: ...The process of discharge planning begins prior to or at admission for all patients. A discharge evaluation is performed by case management on patients identified as needing discharge planning ...the Case Manager works with the Attending physician, the patient, the patient's family and appropriate hospital departments to ensure continuity of care post discharge ....The Case Manager assesses discharge planning in a timely manner and prior to discharge and initiates discharge planning of nursing home or rehabilitation placement, durable medical equipment, home health care. Hospice, transportation, or other discharge needs are identified. Discharge planning activities include provisions for request of services required to improve or maintain health status post discharge.

Review of the facility policy Discharge of Patients revealed, in part: C. Discharge Planning shall begin at the time pf admission and is an ongoing process of determining patient/family needs to provide continuity of care ...Review discharge instructions with the patient/significant other ...note time of discharge/mode of discharge/accompanied by whom ...

Based on interviews and review of documents, it was determined hospital staff failed to administer drugs in accordance with the orders of the practitioner for two (2) of four (4) patients included in the sample with orders for alcohol detoxification. (Patient #11 and Patient #14)

The findings include:

Patient #11 was admitted to the hospital's detox unit on 04/09/19 with assessment to include acute depression and alcohol detoxification. Patient #11's electronic health record (EHR) was reviewed on 8/21/19 with the assistance of Staff Member (SM) #11 a navigator provided by the hospital.

An order was placed on 4/8/19 at 12:20 PM for CIWA-Ar (Clinical Institute Withdrawal Assessment from Alcohol) monitoring. The order reads as follows: CIWA, Monitor QID and with every PRN med dose. The hospital's QID (four times daily) administration times are 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. A review of the EHR for Patient #11 revealed CIWA-Ar scores documented on 4/8/19 at 12:08 PM , at 13:42 PM and at 19:02 PM. and CIWA-Ar scores documented on 4/9/19 at 10:00 AM. Nursing documentation on 4/9/19 at 14:36 PM reads in part as follows: Pt reports good sleep, good appetite. Denies all s/sx withdrawal. At 14:58 nursing documentation reads: Pt received 10 mg IM Geodon at 11:23 for agitation. Attempted to leave unit at approximately 1145 - Code Atlas called. Pt received 2mg po Ativan at noon. (directly conflicting with the documentation at 14:36). Documentation by nursing from 3:02 thru 3:17 PM details Patient #11 becoming increasingly agitated and confused which required notification of the physician. An emergency medical treatment order was obtained and Patient #11 was transferred to a medical unit at 5:44 PM.

Patient #14 was admitted to the hospital's detox unit on 04/23/19 with assessment to include alcohol dependency and withdrawal and hypertension. Patient #14's electronic health record (EHR) was reviewed on 8/21/19 with the assistance of Staff Member (SM) #11 a navigator provided by the hospital.

An order was placed on 4/23/19 at 9:58 AM for CIWA-Ar (Clinical Institute Withdrawal Assessment from Alcohol) monitoring. The order reads as follows: CIWA, Monitor QID and with every PRN med dose. The hospital's QID (four times daily) administration times are 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. A review of the EHR for Patient #14 revealed CIWA-Ar scores documented on 4/23/19 at 8:32 AM , at 10:13 PM and CIWA-Ar scores documented on 4/24/19 at 11:00 AM. Nursing documentation on 4/24/19 at 5:18 AM reads in part as follows: At approximately 0500, PT reported seeing people in his room that were not there and was talking to people that were not there. BP, Temp and RR stable. Pt's HR elevated at 118. Called (physician) to report changes including hx of seizures and DT's. New orders given will continue to monitor patient. A PRN medication was given at 5:17 AM. The EHR failed to provide evidence of a completed CIWA-Ar assessment related to the administration of the PRN medication. Physician documentation on 4/24/19 reads in part as follows: pt medical condition deteriorated since admission - has tachycardia, patellar fx not displaced and sig alcohol withdrawal with DTs, after discussion with medical team - plan to transfer pt to medical telemetry for evaluation and tx. ct alcohol detox per protocol.

Staff Member #12 (RN Charge Nurse) was interviewed on 8/21/19 related to the above concerns. After review of the EHR with SM #12, he/she agreed that it looked like the CIWA protocol was not followed. He/she stated that it appeared the nurse may have documented on the patients but failed to document completion of CIWA assessments.

EHR review for Patient #11 and #14 found both records contained orders for PRN medications but lacked the guidance for how nursing staff should use the CIWA-Ar score in determining the medication that should be given.

The surveyor asked to be provided with the education that nurses were given on the use of the CIWA-Ar protocol. The surveyor was provided with a printed presentation that contains a table which details the frequency of CIWA-Ar scoring based on the last score. For example if the last CIWA-Ar score was 5-10, the next assessment would be in four hours. The conflicts between education and orders resulted in nursing staff having vague guidelines at best.

A review of transfers out of the behavioral health units which included the alcohol abuse treatment unit, revealed fifty-five (55) transfers with seventeen (17)of those transfers having complicated withdrawal listed as the signs and symptoms. The surveyor reviewed four (4) of seventeen (17) records and found nursing orders related to the CIWA-Ar protocol were not followed in two (2) of four (4) records reviewed.

The hospital staff's failure to monitor and record CIWA-Ar assessments and/or provide medications based on the CIWA-Ra assessment was discussed with Staff Member (SM) #11 during record review and with the management team prior to exit on 8/23/19. No further information was provided to the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and document review, it was determined hospital staff failed to:

a) verify protection from airborne illness in negative pressure rooms, and;

b) provide a clean and sanitary environment in the behavioral health unit.

The findings are:

a) As part of reviewing infection control in the hospital, the surveyor reviewed the current list of patients who were on isolation precautions. Information provided to the surveyor on 8/22/19 detailed twenty-nine (29) patients were under isolation precautions. Patient #20 was noted to be on Airborne precautions. Patient #20 was admitted on [DATE] with severe sepsis secondary to pneumonia. The physician ordered a sputum culture to rule out tuberculosis and the patient was placed on airborne precautions. The surveyor asked to be provided the quality control testing for the isolation room of Patient #20 relating to air exchanges or negative pressure. On 8/22/19 at 3:20 PM, the surveyor discussed with Staff Member (SM) #18 the Infection Preventionist, how the process for monitoring the negative pressure rooms should work. He/she stated when a nurse documents that a patient is placed on airborne precautions, the nursing supervisor is notified and the engineering office receives notification via printer indicating quality control testing is required. The surveyor then reviewed the spooled reports (notification to the engineering office of any patient placed on airborne precautions) and learned a notification had not occurred since 7/3/19. The surveyor requested that a check be completed for any patient placed on airborne precautions and/or in the negative pressure rooms. (The hospital has 18 negative pressure rooms.) The surveyor was provided with documentation of negative pressure checks for C325-A (the only patient currently in a negative pressure room, Patient #20) that was conducted that day with no problems noted. SM #5, informed the surveyor that IT (information technology) had investigated to determine what may have caused the failure in the system and found the problem had occurred after a software upgrade that had failed to trigger the system to notify engineering of the admission of a patient to an isolation room.

A review of hospital policy Tuberculosis Exposure Plan last revised 1/2017 reads in part as follows: IV, B . e. Negative pressure differentials and air exchanges should be verified annually to ensure that the isolation room air distribution system is properly functioning, The negative pressure should be monitored daily and recorded when in use. Hospital staff failed to provide evidence that the aforementioned practice is followed.

The issue was discussed with SM # 5, SM #18 and SM #9 upon discovery and discussed with the management team prior to exit on 8/23/19. No further information was provided to the surveyor.

b) During a tour of 2 North on 08/22/19, (unit for the most acutely ill behavioral health patients monitored every 5 minutes) the surveyor noted scraps of paper on the floor and what appeared to be debris or dust/dirt. Patient rooms do not have private bathrooms on this unit. Bathrooms are locked for safety, requiring the patients to request use of the bathroom. There was a room containing a toilet designated for males and a room with a toilet for females, both of the bathrooms were noted to have damp areas on the floors which may or may not have been urine. Spots were seen on both toilets that appeared to be from a liquid that had dried, the surveyor was unable to determine if the spots were from urine. There was a notable odor to the bathrooms. A room containing one shower was located along the same wall as the rooms for the toilets. The surveyor asked what the cleaning schedule was for the toilets and shower. The surveyor was informed the unit was cleaned daily by Environmental Services workers and room were always cleaned when a patient was discharged . A review of schedules for environmental service workers confirmed the units were scheduled for cleaning at least once a day. The surveyor was told the nurses try to clean the showers between patients. The surveyor was shown a spray bottle marked Oxivir with no concentration or instructions for use marked on the bottle. It was determined through interviews that nurses were not aware of what the wet time (time needed for the product to kill bacteria, fungi, etc.) was for the product.

The above findings were discussed with SM # 3, SM #5 and SM #9 upon discovery and with the management team prior to exit. No further information was provided to the surveyor.

Based on a review of clinical records, facility documents and interviews, it was determined the facility's LIPs (Licensed Independent Practitioners) failed to ensure restraint orders were correctly identified as addressing violent behaviors, and therefore failed to ensure the restraint orders were renewed as required every four (4) hours, for one (1) of four (4) adult patients (Patient #7).

The findings were:

A review of Patient #7's clinical record took place on 03/13/19 at 10:15 a.m., with the Director of Advanced Clinicals (RN-registered nurse) assisting in navigating the EHR (electronic health record). That review identified the following documentation:

+ The registered nurse (RN) documented a summary of patient behaviors and care given, during the 7 a.m. to 7 p.m. shift, on 01/25/19 at 6:38 p.m. That documentation included, in part, the following: Shift note: patient very combative and non compliant today. patient [sic] placed in 4 point restraints today @ 1330 [1:30 p.m.] following yelling, frequent attempts to throw [him/her]self out of bed by rolling over onto stomach and throwing legs out of the bed and attempting to hit and kick nursing staff.

+ The physician documented a restraint order on 01/25/19 at 13:29 [1:29 p.m.]. That order listed the Level of restraint as Non-violent and the device as Waist and Soft all extremities. The order included Non-violent Restraint Time Limit 24 hours.

The surveyor reviewed the facility policy titled, Seclusion, Restraints and Restraint Alternatives (PolicyStat ID: 48) with the most recent revision date of 06/2018. That policy included a requirement that Orders for restraint or seclusion [for the management of violent of self-destructive behavior] must not exceed..Four (4) hours for adults, aged 18 years or older. That requirement was on page 3 of 16 of the policy, under the heading of Order for Restraint with Violent or Self-Destructive Behavior.

The failure of the facility staff to ensure restraint orders for Patient #7 were correctly identified as addressing 'violent' behaviors and subsequently resulting in the restraint orders not being renewed within the required time limit, was discussed during the record review with the aforementioned navigator as well as the facility's Vice President (VP) of Quality and Compliance. The VP of Quality and Compliance acknowledged the aforementioned nursing documentation (for Patient #7), described violent or self-destructive behaviors. The VP of Quality and Compliance also acknowledged the physician's orders for (Patient #7's) restraints failed to correctly identify the restraints as used to manage violent or self-destructive behaviors.

The surveyor met with the The VP of Quality and Compliance on 03/13/19 at 4:40 p.m., for a review of the Quality Program's oversight of proper use of restraints. The VP of Quality and Compliance stated that restraints were often challenging, however the quality oversight had not identified trends or issues regarding accurate identification of restraints used for the management of violent or self destructive behaviors.

Based on a review of clinical records, facility documents and interviews, it was determined the facility's staff failed to provide a face to face assessment addressing the required elements of evaluation, within one (1) hour of initiation of restraints used to address violent or self-destructive behaviors, for one (1) of four (4) adult patients (Patient #7).

The findings were:

A review of Patient #7's clinical record took place on 03/13/19 at 10:15 a.m., with the Director of Advanced Clinicals (RN-registered nurse) assisting in navigating the EHR (electronic health record). That review identified the following documentation:

+ The registered nurse (RN) documented a summary of patient behaviors and care given, during the 7 a.m. to 7 p.m. shift, on 01/25/19 at 6:38 p.m. That documentation included, in part, the following: Shift note: patient very combative and non compliant today. patient [sic] placed in 4 point restraints today @ 1330 [1:30 p.m.] following yelling, frequent attempts to throw [him/her]self out of bed by rolling over onto stomach and throwing legs out of the bed and attempting to hit and kick nursing staff.

+ The physician documented a restraint order on 01/25/19 at 13:29 [1:29 p.m.]. That order listed the Level of restraint as Non-violent and the device as Waist and Soft all extremities.

+ The record failed to contain evidence the restraints were accurately identified as used to address the aforementioned and documented violent/self-destructive behaviors. The record failed to contain evidence the patient received the required face-to-face evaluation within 1 hour of the initiation of the intervention (restraints), to evaluate the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion.

The surveyor reviewed the facility policy titled, Seclusion, Restraints and Restraint Alternatives (PolicyStat ID: 48) with the most recent revision date of 06/2018. That policy included, in part, the following information/requirements on page 4 and 5 of 16, under the heading of Face-to-face assessment by a Physician or LIP [Licensed Independent Practitioner.

A face-to-face assessment by a physician or LIP, RN or physician assistant [PA] with demonstrated competence, must be done within one (1) hour of restraint or seclusion initiation...to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

At the time of the face-to-face assessment, the LIP/physician/RN/PA will:

1. Work with staff and patient to identify ways to help the patient regain control

2. Evaluate the patient's immediate situation

3. Evaluate the patient's reaction to the intervention

4. Evaluate the patient's medical and behavioral condition

5. Evaluate the need to continue or terminate the restraint or seclusion

6. Revise the plan of care, treatment and services as needed.

The failure of the facility staff to ensure restraint orders for Patient #7 were correctly identified as addressing documented violent and self-destructive behaviors, and the subsequent failure to perform the required one (1) hour face to face evaluation/assessment, was discussed during the record review with the aforementioned navigator as well as the facility's Vice President (VP) of Quality and Compliance. The VP of Quality and Compliance acknowledged the aforementioned nursing documentation (for Patient #7), described violent or self-destructive behaviors. The navigator (Director of Advanced Clinicals) acknowledged there was no evidence the required one (1) hour face to face assessment/evaluation was performed.

Based on interviews and review of clinical records it was determined hospital staff failed to complete a written modification to the patient's plan of care after implementing the use of restraints for two (2) of five (5) patients included in the sample who had been restrained. (Patients #3 and #5)

The findings include:

1. Clinical records were reviewed with the assistance of a navigator provided by the hospital. Review of the clinical record for Patient #3 provided evidence of the application of soft bilateral upper extremity restraints on 5/31/18. Restraints were discontinued on 6/2/18. The plan of care for Patient #3 did not contain any reference to restraint use or any modification to the care plan. Patient #3 was interviewed on 6/5/18 and was not restrained at the time of the interview and stated that he/she did not remember being placed in restraints.

2. Review of the clinical record for Patient #5 provided evidence of the application of soft all extremity restraints on 5/27/18. Restraints were discontinued on 6/1/18. The plan of care for Patient #5 did not contain any reference to restraint use or any modification to the care plan.

Hospital Policy Seclusion, Restraints and Restraint Alternatives reads in part as follows: 10. Care of the Patient/Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. 12. Documentation Requirements: The medical record contains documentation of: l. Modifications to the plan of care.

The above findings were discussed with the management team at the time of discovery and again prior to exit on 6/13/18. No further evidence was provided to the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and review of documents it was determined hospital staff failed to administer medications in accordance with the orders of the practitioner for 3 of 14 sampled patients. (Patient #2, Patient #3, and Patient #6)

The findings include:

1. Review of clinical records identified the failure of nursing staff to follow the CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) protocol as written by the physician. The following information related to the implementation of the CIWA Protocol was provided to the survey team by Staff Member (SM) #3: Complete the CIWA-Ar now and then follow protocol. For scores less than 8 a CIWA assessment should be done every 4 hours. For a score of 8-15 a CIWA assessment should be done every 2 hours. For CIWA scores greater than 15 an assessment should be done every hour. If the CIWA-Ar scores are less than 8 for 3 consecutive readings, change to every 8 hours assessments then, if CIWA-Ar scores are less than 8 for 3 consecutive readings, change to every 12 hour assessments, if CIWA-Ar scores are less than 8 for 2 consecutive readings, notify the physician for discontinuation.

The CIWA-Ar score is used to determine the initiation of symptom triggered dosing ordered by the physician. For Patient #3 and Patient #6 the physician had ordered lorazepam (a benzodiazepine sometimes used for the treatment of acute alcohol withdrawal) 2mg every two (2) hours as needed for a CIWA-Ar score of 8-15, and lorazepam 4mg every two (2) hours as needed for a CIWA-Ar score greater than or equal to 15.

a. Patient #3 was admitted on [DATE] for assistance with alcohol detoxification. Patient #3's electronic health record (EHR) was reviewed with the assistance of a navigator provided by the hospital.

An order was placed on 5/23/18 for CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) protocol. Review of Patient #3's clinical record and staff adherence to CIWA-Ar protocol from 5/23/2018 to 6/5/2018 revealed the failure of nursing staff to follow the CIWA-AR protocol as written by the physician including but not limited to failure to complete CIWA-Ar assessments, failure to administer medication as ordered based on the assessment and administration of the wrong dose of medication based on the CIWA-Ar assessment.

b. Patient #6 was admitted on [DATE] for alcohol withdrawal and dependence. Patient #6's electronic health record (EHR) was reviewed with the assistance of a navigator provided by the hospital. An order was placed on 6/4/2018 for CIWA-Ar protocol. Review of Patient #6's clinical record and staff adherence to CIWA-Ar protocol from 6/04/2018 to 6/07/2018 revealed the failure of nursing staff to follow the CIWA-Ar protocol as written by the physician including but not limited to failure to complete CIWA-Ar assessments, failure to administer medication as ordered based on the assessment and administration of the wrong dose of medication based on the CIWA-Ar assessment.

Because the CIWA-Ar score (determined by assessment of the patient) determines the amount of medication to be administered and the timing of the next assessment, when an assessment is not completed per protocol it is impossible to determine exactly how many assessments and resulting medication administrations may have been missed.

The failure of nursing staff to follow CIWA-Ar protocol as ordered by the physician was supported by an observation on 6/07/2018 at 2:24 p.m.. The surveyor had the opportunity to observe medication being administered to Patient #6. Patient #6 was given 2mg of lorazepam orally by Staff Member (SM) #12. The surveyor asked SM #12 if the medication was part of the CIWA protocol and if so what the assessment score was. SM # 12 stated that he/she had not entered the assessment in the record yet but that it was a nine. When asked what the previous assessment was, SM #12 stated that it was also a nine, but that he/she had not given the patient medication because the patient was doing so good. SM #12 was asked if he/she had obtained a physicians order to deviate from the protocol and he/she replied no but that he/she had used nursing judgement to make that decision. SM #12 was asked if there was a nursing note to document the basis for that decision and he/she replied no.

On 6/07/2018 an interview was conducted with SM #4 (the director of the unit where the observation took place) at 3:00 p.m.. SM #4 was asked what he/she would expect of nursing staff related to the implementation of the CIWA-Ar protocol. SM #4 stated the expectation would be for the staff to follow orders as written unless an order had been obtained from the physician to do otherwise.

Hospital policy Adult Alcohol Withdrawal Policy and Procedure last revised 12/2015 reads in part as follows: Procedure: C. Frequency of vital signs and CIWA-Ar assessments will be determined by the nurse using the CIWA-Ar score based on the attached Alcohol Withdrawal Protocol Order Sheet (Appendix A) and CIWA-Ar Score Sheet (Appendix B) D: Doses will be administered by the nurse based on the calculated CIWA-Ar score by utilizing the attached Alcohol Withdrawal Protocol Order Sheet (Appendix A) and CIWA-Ar Score Sheet (Appendix B) (Appendix A and B have been incorporated into the electronic health record order sets and are no longer hard copy).

The hospital staff's failure to monitor and record CIWA-Ar assessments and/or provide medications based on the CIWA-Ra assessment was discussed with the management team when discovered, at end of day meetings and prior to exit on 6/13/2018. No further information was provided to the survey team.

2. Patient #2 was not provided as needed pain medications, as ordered.

Patient #2's medication orders included an order for oxycodone 5 mg tablet every four hours as needed for pain rated as a 1 - 5. This order's start date and time was 2/9/18 at 9:37 a.m.; this order's stop date and time was 2/16/18 at 9:38 a.m.

Review of clinical information provided to the surveyor by Staff Member (SM) #1 (the Quality Manager) and SM #3 (the VP of Quality/Compliance) indicted:

- On 2/12/18 at 9:54 a.m., Patient #2's pain was assessed as a '3'; no medication was documented as being provided. At 11:16 a.m., on the same day, Patient #2's pain was assessed as a '5' and oxycodone 5 mg was provided. At 11:45 a.m., Patient #2's pain was reassessed and was documented as still being a '5'; no addition pain interventions were documented.

- On 2/13/18 at 8:00 a.m., Patient #2's pain was assessed as a '4'; no medication was documented as being provided. At 9:32 a.m., on the same day, Patient #2's pain was assessed as a '5' and oxycodone 5 mg was provided. At 10:00 a.m., Patient #2's pain was reassessed and was documented as being a '4'; no additional pain interventions were documented.

The following statement was found in a facility policy and procedure entitled Pain Management (last revised - 4/16):

- All patients experiencing pain will have an individualized pain management plan.

- Reassessment - All patients will have their pain reassessed after any pharmacologic and/or non-pharmacologic intervention and at regular intervals in accordance with the Assessment/Reassessment Policy. Reassessment of pain will include: ... C. Additional interventions as indicated ...

Patient #2's clinical record included specific medications ordered to address pain but no individualized pain management plan was found by or provided to the survey team. The aforementioned reassessments of the patient's pain failed to identify if additional interventions were desired by the patient.

On 6/12/18 at 4:00 p.m., the failure of facility staff members to administer Patient #2's as needed pain medications as ordered and the failure of facility staff to develop a pain management plan to include acceptable pain levels for Patient #2 was discussed during a survey team meeting with SM #1 and SM #3; no additional information related to this issue was provided to the survey team prior to exit.

This is a complaint deficiency.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure operating rooms (ORs) were cleaned between patients/procedures according to the facility's written policy and procedure.

The findings include:

The facility staff failed to use a hospital-approved germicide when mopping an operating room (OR) floor between patients/procedures.

On 2/12/18, the surveyor observed facility staff members cleaning an operating room between patients/procedures; the facility's Quality Manager (Staff Member (SM) #1) was present for this observation. The surveyor was shown what cleaning agents were used during the cleaning observations. Two cleaning agents (Agent A and Agent B) where identified, by facility staff members, as being mixed together and used to mop the OR between patients/procedures. On the morning of 2/13/18, the surveyor and SM #1 confirmed with OR staff that the two cleaning agents identified on the previous day were the correct agents used when mopping the OR floors between patients/procedures. Neither of the two agents identified were labeled as 'germicidal'. The surveyor asked SM #1 for evidence of what hospital-approved germicide was to be used for mopping the floors between OR cases/procedures.

On 6/13/18 at 1:00 p.m., SM #1 provided the surveyor with product information for another cleaning agent (Agent C); this agent's information indicated it was a 'disinfectant cleaner and deodorant'. SM #1 stated that Agent C should have been used to mop the floor between patients. SM #1 reported Agent A and Agent B have been replaced with Agent C in the supply area for the OR cleaning supplies.

SM #1 provided the survey team with a policy entitled Sanitation, Operating Room (last revised - 1/15); SM #1 reported this policy addressed the cleaning of operating rooms between procedures (turnover cleaning). This policy included the following statement: The floor will be mopped using a hospital-approved germicide.

On the afternoon of 6/13/18, the failure of the facility staff to clean the OR floors with the correct cleaning agent was discussed during a survey team meeting with the facility's Vice-President of Quality/Compliance and SM #1.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure a post-procedure note detailing an operation/procedure was immediately included in the patient's clinical record for three (3) of six (6) patients reviewed for operations/procedures (Patient #1, Patient #2, Patient #10).

The findings include:

Patient #1's clinical documentation was reviewed on 6/5/18 at 10:40 a.m. with Staff Member (SM) #1 (the Quality Manager). No immediately documented post-surgical note was found in the clinical record. Evidence of an immediately dictated operative report was found.

Patient #2's clinical documentation was reviewed on 6/5/18 and 6/6/18 with SM #1. No immediately documented post-surgical note was found in the clinical record. Evidence of an immediately dictated operative report was found.

Patient #10's clinical documentation was reviewed on 6/7/18 at 9:15 a.m. with SM #1. No immediately documented post-surgical note was found in the clinical record. Evidence of an immediately dictated operative report was found.

The following information was found in the facility's Rules and Regulations of the Medical Staff (dated 4/19/17): Operative reports and reports on other surgical procedures shall include a detailed account of the findings at surgery or at the time of the procedure as well as the details of the surgical technique or the procedure involved, the names of the surgeon and assistant, specimens removed, estimated blood loss, and post operative diagnosis. Operative and procedure reports shall be dictated immediately after surgery or other procedure. A written progress note is also to be entered which contains pertinent information. The reports are to be promptly signed by the surgeon or physician and made a part of the patient's current medical record.

On 6/12/18 at 4:00 p.m., the failure of facility staff members to ensure a post-surgical note was documented immediately after the aforementioned three (3) procedures was discussed during a survey team meeting with SM #1 and the facility's VP of Quality/Compliance (SM #3); SM #3 confirmed that the dictated operative report would not be immediately available in the patients' clinical records at the time of dictation.

Based on interview and document review it was determined nursing staff failed to obtain vital signs at the required intervals for two (2) of three (3) patients in the survey sample who were administered blood or blood products. (Patients #7 and #10)

The findings include:

The clinical records for Patient #7 and Patient #10 were reviewed with the assistance of a navigator provided by the facility (Staff Member (SM) # 13).

Patient #7 was administered two units of platelets (components of blood that help the clotting process) on January 18, 2018 with administration of the first unit beginning at 2:15 p.m. Review of the clinical record revealed nursing staff failed to obtain the patient's vital signs prior to the administration of blood products as defined by hospital policy. The absence of documented vital signs prior to administration of blood products was confirmed by SM #13.

Patient #10 was administered one unit of red blood cells on January 16, 2018 beginning at 12:51 p.m. and ending at 4:00 p.m. Review of the clinical record revealed nursing staff failed to obtain the patient's vital signs after completing the administration of blood products as defined by hospital policy. The absence of documented vital signs after the administration of blood products was confirmed by SM #13.

Hospital policy Blood & Blood Products, Administration Of revised 02/2014 contains the following, in part:

N. Patient Monitoring

1. RN/LPN remains with the patient for the first fifteen (15) minutes of the transfusion.

2. Vital signs: Blood Pressure, Temperature, Pulse, Respirations, Pulse Oximetry

a. At the initiation of transfusion

b. 15 minutes after the start of the transfusion

c. Completion of the transfusion

The failure of nursing staff to obtain vitals signs for patients receiving blood or blood products was confirmed by SM # 15 and shared with the management team prior to exit. No further information was provided to the survey team.

Based on interviews and document review, it was determined the facility staff failed to ensure a grievance by Patient #14's parent was addressed according to the facility's policies and procedures.

The findings include:

The facility staff failed to follow the facility's policies and procedures to address a grievance lodged by Patient #14's parent.

The complainant provided the survey team with copies of email communication between Patient #14's parent and the facility's Chief Medical Officer (CMO). This email communication discussed specific concerns with clinical documentation related to Patient #14. The email communication provided by the complainant indicated the CMO had requested clarifying information related to which clinical documentation was of concern to Patient #14's parent. This email communication also indicated Patient #14's parent wanted his/her concerns to be considered a formal complaint.

The facility's CMO was interviewed on 3/21/17 at 1:40PM. The CMO reported meeting with Patient #14's parents to discuss concerns. The CMO acknowledged concerns with the aforementioned clinical documentation was discussed. The CMO stated after the meeting he/she did receive email communication from Patient #14's parent with the documentation in question attached. The CMO was unable to provide the survey team with copies of this email communication. The CMO stated the meeting with Patient #14's parents was not documented.

The above referenced email was discussed with the facility's Chief Executive Officer (CEO) and the facility's Director of Risk Management (Staff Member (SM) #4) during a survey team meeting on 3/22/17 at 4:00PM. On 3/23/17 at 9:00AM, SM #4 reported that the facility's CMO was unable to find the email communication with Patient #14's parent.

The following information was found in the facility's policy and procedure entitled, 'Patient Complaint and Grievance' (approved 9/15 and last revised 11/10): Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS Conditions of Participation (COP), or a Medicare beneficiary billing complaint related to rights and limitation provided by 42 CFR 489. A written complaint is always considered a grievance ... A written complaint also includes those complaints received via electronic mail or facsimile. ... Whenever the patient or the patient's representative requests that their complaint be handled as a formal complaint or patient request a response from the hospital, then the complaint is a grievance and all the requirements apply.

The following information related to written notice of the grievance resolution to the complainant was found in the aforementioned facility policy and procedure:

- Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days.

- In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion.

The facility's grievance log was reviewed by the survey team on 3/21/17; neither Patient #14 nor the patient's parent was included on the grievance log. SM #4 was interviewed, on 3/21/17 at 1:08PM, related to a potential grievance/complaint related to Patient #14; SM #4 stated no complaint or grievance was found on the facility's log. On 3/21/17 at 2:20PM, SM #4 stated if he/she had been aware that this complaint was made after the patient was discharged then it would have been treated as a grievance.

This is a complaint deficiency.

Based on facility documents and clinical record reviews, the facility failed to obtain a current written restraint order for one (1) out of four (4) patients sampled for restraint review (Patient #3).

The findings include:

On 03/21/17 at 3:35 PM the surveyor reviewed Patient #3 clinical record. The surveyor was navigated through the clinical records by Staff Member (SM) #30. On 03/19/17 at 10:08 PM the physician (SM #31) wrote an order for non-violent bilateral upper soft wrist restraints. According to the clinical record the restraints were initiated at 3:05 AM, almost five (5) hours later. No documentation was noted in the clinical record as to why the restraints were not applied at the time the physician wrote the order.

On the morning of 03/21/17 an interview was conducted with SM #30. He/she stated that the nurse taking care of the patient was trying to prevent the patient from having restraints applied. SM #30 acknowledged the nurse should have gotten another order, prior to applying the restraints at a later time.

On 03/21/17 at 11:34 AM a Policy and Procedure Entitled, Seclusion, Restraints and Restraint Alternatives (last revised 12/2016) was reviewed and read in part as follows: An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. 1. An order for restraint or seclusion may not be written as a standing order, protocol or as a PRN or as needed order. 2. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews and document review it was determined that hospital staff failed to follow infection control guidelines including the use of appropriate personal protective equipment (PPE), performing appropriate hand hygiene and educating patients and/or family members related to infection control precautions. These practices affected 4 of 24 patients in the survey sample, Patients #17, #18, #24 and #13.

The findings include:

1. Patient #17 was placed on Enhanced Contact Precautions for Clostridium Difficile (a gram-positive bacillus normally found in the digestive tract and a common cause of antibiotic-associated diarrhea). Hospital policy Guideline for Patients with Clostridium Difficile directs that all patients who are diagnosed with or thought to have [DIAGNOSIS REDACTED] are placed in Enhanced Contact Precautions. Enhanced contact precautions require hand hygiene with soap and water, gown and gloves. A sign was on the room door designating the need for Enhanced Contact Precautions, but an isolation cart containing PPE supplies was not located nearby.

On 3/22/17 at 9:30 am Staff Member #14 (a registered nurse) was observed entering the room of Patient # 17 without donning PPE or performing hand hygiene. Staff Member #14 left the room without hand hygiene and went down the hall to obtain an isolation cart. Staff Member #14 re-entered the room donned a gown and gloves, gave medications to the patient and removed gloves. No hand hygiene was performed upon entering the room or with glove changes. After removing gown and gloves Staff Member #14 completed soap and water hand hygiene before leaving the room. A family member present in the room stated that hospital staff had not been wearing gowns before this. Patient #17 had been on Enhanced Contact Precautions since 3/19/17. Staff Member #18 the Infection Preventionist was present during the observations.

2. Patient #18 was on contact precautions requiring the use of gloves and gowns. On 3/22/17 at 1:20 pm, the surveyor observed Staff Member #13 (a physical therapist) to be standing at the bedside in front of the patient who was seated in a chair. Staff Member #13 was wearing gloves but no gown (a gown was hanging from the door of the room). A gait belt (used when ambulating a patient) was across Staff Member #13's right shoulder. Staff Member #13 removed his/her gloves, performed hand hygiene and left the room. There was a sign on the door designating contact precautions to be used for this patient. The surveyor asked Staff Member #13 what that would mean to him/her regarding the use of PPE. Staff Member #13 stated I should have put my gown on when I returned to the room Staff Member #13 was asked about the gait belt over his/her shoulder, he/she stated that it (the gait belt) was usually cleaned after leaving the patient's room. It was noted by the surveyor that by having the unclean gait belt across his/her shoulder Staff Member #13 was contaminating his/her scrubs. Staff Member #18 was present during the observation.

3. Patient # 24 was on standard precautions. On 3/22/17 at 1:40 pm an individual identified as a nursing student was observed leaving the room without performing hand hygiene. The nursing student retrieved supplies and returned to the patient's room entering without performing hand hygiene. Staff Member #17 (the nursing instructor) was asked what training the students received related to infection control at the hospital. Staff Member #17 stated the students received the same infection control training that hospital employee's get. Staff Member #17 stated he/she would expect the students to perform hand hygiene when entering and/or leaving a patients room. Staff Member #18 was present during the observation.

4. Patient #13's clinical documentation failed to include: (a) the placement of the isolation precaution signs and equipment and (b) patient and/or representative education related to the isolation precaution.

The following information was found in the facility policy and procedure entitled, Guideline for Isolation Precautions in Hospitals (approved and last revised on 1/2017) under the heading Contact Precautions: F. Communication 1. A Contact Precautions sign will be placed on the door to the patient's room and on the front of his/her chart. 2. The patient's isolation status must be updated in the electronic medical record. 3. The patient's isolation status must be communicated to all stall interacting with the patient.

The following information was found in the facility policy and procedure entitled, Guideline for Patients with Clostridium Difficile (approved and last revised on 1/2017):

- (Clostridium Difficile) is the most common cause of antibiotic-associated diarrhea (AAD).

- All patients who are diagnosed with or thought to have [DIAGNOSIS REDACTED] are placed in Enhanced Contact Precautions.

- A. Patients identified with diarrheal stools will be evaluated for placement in Enhanced Contacted Precautions. 1. The nursing staff will place an Enhanced Contact Precautions sign on the patient's room door, retrieve PPE, and place an order for an isolation box or cart in Meditech. ... 4. The patient will be education about Enhanced Contact Precautions, and a handout will be provided.

Patient #13 was admitted on [DATE]. An ADMINISTRATIVE DATA form for this admission indicated the patient was on contact isolation precautions.

Patient #13 was admitted on [DATE]. An ADMINISTRATIVE DATA form for this admission indicated the patient was on contact isolation precautions for CDIFF.

Patient #13's clinical records for the 8/6/16 and 8/25/16 admissions did not include documentation to indicate who placed the isolation precautions sign and equipment and /or when the sign and equipment was placed.

During an interview on 3/23/17 at 1:00PM, an assistant direction (Staff Member (SM) #1) acknowledged no documentation was found to indicate when the isolation precautions sign and equipment was placed. SM #1 also acknowledged no documentation was found to indicate the patient and/or family was educated about the isolation precautions. (The Vice-President of Quality (SM #24) was present during this interview.)

This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review it was determined the facility failed to document informed consent was obtained for two (2) of twelve (12) patients included in the survey sample. (Patients #10 and #12)

The findings included:

A review of Patient #10's electronic medical record (EMR) was conducted on 02/23/2017 at 8:45 a.m., with Staff Member #15. The review revealed Patient #10 was admitted to the facility on [DATE] with the diagnosis of Hemoptysis. Patient #10's EMR contained a scanned form titled Conditions of Admission that included provisions for Consent to Treatment, Consent to Treatment Using Telemedicine, Consent to Medication Not Yet FDA Approved and/or Medication prepackaged/Repackaged by Outsourcing or Compounding Pharmacy, HIV/Hepatitis B or C Testing, Consent to Photograph, Videotapes and Audio Recordings, Financial Agreement, Consent to Authorize Use of Email and Text for Patient Billing and Financial Obligations, and Acknowledgement (of reading form) and Acknowledgement of Notice of Patient Rights and Responsibilities. Patient #10's Conditions of Admission was signed by a physician's assistant only. Patient #10's Conditions of Admission did not have a second witness signature if the patient was not able to sign. Patient #10's Conditions of Admission form did not indicate whether the patient could sign his/her own form or not. Staff Member #15 verified the findings. Staff Member #15 reported the form should have at least been signed by a second witness if the patient could not sign. Staff Member #15 reported staff should have noted on the patient's signature line whether the patient could sign or not.

Review of Patient #12's EMR was conducted on 02/23/2017 with Staff Members #3 and #15. Patient #12's EMR documented the patient was admitted to the facility on [DATE] for Respiratory Failure. The review revealed a Consent to Invasive Diagnostic/Therapeutic Procedures/Treatments form. The consent form was signed by two (2) nursing staff with the explanation the patient's spouse had provided telephone consent for the patient's procedure Bronchoscopy. The form's Doctor Attestation which read: I attest to having explained the anticipated benefits, material risks, and alternative methods of treatment of the above -identified procure/treatment (s) with the patient or the patient's representative [Sic] was blank. The form did not include the required physician's signature, date and time. Staff Member #15 navigated multiple sections of Patient #12's active EMR and paper medical record. Review of the Bedside Procedure Note did not provide documentation that the risk and benefits had been explained to Patient #12's spouse. Staff Member #15 verified the informed consent should have been signed dated and timed by the physician performing the procedure. Staff Member #15 verified Patient #12's Medical records did not have documentation the procedure had been explained including the risks and benefits to the patient or the patient's spouse.

Review of the facility's policy titled Consent (Informed)- Written Confirmation read in part: B. Informed consent[:] Informed Consent is the agreement by the patient to the proposed procedure, treatment, or course of treatment after he/she has achieved a reasonable understanding of its risks and benefits, and the risks and benefits of alternative procedures or no treatment ... D. Written Confirmation of the Process [:] The practitioner who has been granted privileges to perform the procedure, should make a timed and dated notation in the patient's medical record documenting the discussion and summarizing the content prior to performing the procedure ... Administrative Considerations: ... D Telephone Consent: When the patient's surrogate decision-maker is not able to come to the hospital to sign the consent form consent may be obtained by the doctor via telephone. Two witnesses should verify the procedure with the party on the telephone and document the conversation on the consent form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review it was determined nursing staff failed to obtain a physician's order after placing a patient in restraints for one (1) of four (4) restraint patients included in the survey sample. (Patient #12)

The findings included:

Review of Patient #12's EMR was conducted on 02/23/2017 with Staff Members #3 and #15. Patient #12's EMR documented the patient was admitted to the facility on [DATE] for Respiratory Failure. Patient #12's EMR documented the patient was placed in soft bilateral upper extremity (UE) restraints from 02/04/2017 through 02/20/2017. Review Patient #12's EMR revealed nursing staff discontinued Patient #12's restraints at 12:30 p.m. on 02/06/2017. Review of Patient #12's EMR documented nursing staff reapplied soft bilateral upper extremity restraints at 1700 (5:00 p.m.) on 02/06/2017. Staff Member #3 navigated Patient #12's EMR and with the surveyor reviewed Patient #12's active paper medical record.

An interview was conducted on 02/23/2017 at 3:47 p.m., with Staff Member #3. Staff Member #3 reported the renewal order covering 02/06/17 stopped when staff removed the restraints at 12:30 p.m. on 02/06/2017. Staff Member #3 reported a new order; an initial twenty-four hour restraint order should have been obtained from the physician when the restraints were started later on 2/6/17.

Review of the facility's policy titled Seclusion, Restraints, and Restraint Alternatives read in part: 5. Order for Restraints or Seclusion ... a. 2. If a patient was recently released from restraints or seclusion, and exhibits behaviors that can only be handled through the reapplication of restraints or seclusion, a new order is required ...

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review it was determined the facility staff failed to document the required two (2) hour assessments for non-violent restraints for two (2) of four (4) restrained patients included in the survey sample (Patients #7 and #12)

The findings included:

An interview was conducted on 02/22/2017 at 8:59 a.m., with Staff Member #3. Staff Member #3 reported the facility's policy for assessment and reassessment of non-violent restrained patients was every two hours.

1. A review of Patient #7's electronic Medical record (EMR) was conducted on 02/22/2017 at 9:11 a.m., with Staff Member #3. Patient #7's EMR documented the patient was placed in soft upper extremity (UE) restraints from 01/12/2017 through 02/16/2017. Review Patient #7's EMR revealed nursing staff failed to provide proof of assessments for the following dates and times:

01/16/2017 at 1800 (6:00 p.m.); 01/17/2017 at 1600 (4:00 p.m.) and 1800 (6:00 p.m.); 01/19/2017 an eight hour gap from midnight to 0800 (8:00 a.m.); 01/23/2017 at 1800; 01/29/2017 did not have a 0600 (6:00 a.m.), 1530 (3:30 p.m.), 1730 (5:30 p.m.); 01/30/2017 at 0000 (12:00 a.m.); 01/31/2017 at 0600 (6:00 a.m.); 02/02/2017 at 0400 (4:00 a.m.) and 0600 (6:00 a.m.); and on 02/08/2017 at 0600 (6:00 a.m.). Staff Member #3 verified the findings.

An interview was conducted during the EMR review on 02/22/2017 at 11:07 a.m., with Staff Member #3. Staff Member #3 navigated Patient #7's EMR. Staff Member #3 reported he/she could not find evidence of completed restraint assessments for the dates and times as listed above. Staff Member #3 reported Patient #7's EMR did not provide evidence nursing staff had removed Patient 7's restraints on the listed dates and times. Staff Member #3 stated, If the restraints were removed new physician's orders should have been obtained.

2. Review of Patient #12's EMR was conducted on 02/23/2017 with Staff Members #3 and #15. Patient #12's EMR documented the patient was admitted to the facility on [DATE] for Respiratory Failure. Patient #12's EMR documented the patient was placed in soft upper extremity (UE) restraints from 02/04/2017 through 02/20/2017. Review Patient #12's EMR revealed nursing staff failed to provide proof of assessments for the following dates and times: 02/06/ 2017 at 6:00 a.m. and on 02/11/2017 at Midnight and 0200 (2:00 a.m.). Staff Member #3 navigated Patient #12's EMR and at 3:47 p.m. verified nursing staff had failed to document restraint assessments at the above times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, clinical record review, and review of facility documents, it was determined the facility staff failed to ensure a care plan was developed regarding the self-administration of medications for one (1) of one (1) patients of the survey sample who had a medication available for self administration, Patient #4.

The findings included:

Patient #4 was admitted on [DATE] with diagnoses that included, but were not limited to: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Rheumatoid Arthritis and Osteoporosis.

Review of the clinical record for Patient #4 revealed an order for Xeljanz 5mg (milligrams) po (by mouth) twice a day, Patient's own medication (Xeljanz is used to treat adults with moderately to severely active rheumatoid arthritis per www.drugs.com).

On 2/22/17 at 10:30 a.m., the surveyor discussed the self administration of medications and home medications' with Staff Member # 7. Staff Member #7, at that time, stated, No patient is allowed to self administer medications. Any medications brought from home must be sent to the pharmacy and they are checked and a bar code is applied. The medications are locked up and the nurse administers the medications to the patients. Patients cannot keep medications in their room and they can't self administer. The nurse administers all medications to the patient... During the review of the clinical record, the surveyor asked Staff #7 to locate documentation regarding the pharmacy review of the medication that Patient #4 had brought from home. Staff #7 stated, It does not look as though Pharmacy has addressed (Patient #4's) home medications.

Further review of the clinical record for Patient #4 revealed that for the documentation for the administration of the Xeljanz from 2/18 through 2/23/17, the medication was documented as not administered- taken.

On 2/23/17 at 2:30 p.m., the surveyor interviewed Staff Member # 3 regarding a patient's ability to self administer medications and the facility policy and procedure regarding the same. Staff Member #3 stated, It depends on what the medication is whether the patient can self administer...some patients may have medications that they self-administer based on what it is- like an insulin pump or something. The surveyor requested a copy of the facility policy and procedure regarding the self administration of medications.

On 2/24/17 at 9:20 a.m., the surveyor inquired as to the reason the Xeljanz was documented as not administered-taken by the nurse in the patient's medication administration record, as whether the patient was receiving the medication or not. Staff Member #3 stated, After speaking with the Nursing Director and the nurse on the unit, that is one med he/she (Patient #4) will not let us take. He/she would not let us take it to the pharmacy and he/she takes it him/herself. That is why it is documented that way because the nurse can't document something they do not administer, but the patient is taking it him/herself.

Further review of the clinical record for Patient #4 revealed no care plan information regarding the self administration of medications, nor any nurses notes regarding the same. There was no evidence the physician was aware the patient had refused to allow staff to take the personal medications and was self administering it, and whether the patient had been assessed as being capable of self administration of medications. There was no documentation that the Pharmacy had reviewed the medication and/or spoken with Patient #4 regarding the use of the medication and the self-administration. There was no documentation found in the clinical record that Patient #4 had refused to allow the staff to take possession of the medication.

A review of the concerns were discussed with the facility administrative Staff Members # 1, 2, 3, 25 and 26 on 2/24/17 at 1:00 p.m.

Based on interviews and facility document review, it was determined hospital staff failed to ensure nursing assignments were made in accordance with patient needs and the competency and qualifications of nursing staff by a) failing to evaluate performance annually for 4 of 9 registered nurses' and b) failing to ensure documentation of orientation for 2 of 9 registered nurses' whose personnel files were selected for review.

The findings include:

Personnel files were reviewed on 2/23/2016 and 2/24/2016 with the assistance of Staff Members #22, 23, and 24. Review of personnel files #1, 5, 8 and 13 (all registered nurses) failed to provide evidence of annual performance evaluations. Staff Member #24 stated that completed evaluations are turned into HR (human resources), the evaluations are then sent to a vendor to be scanned into the employee file, he/she was unable to find documentation of evaluations for the calendar year 2015 for the aforementioned personnel. Review of hospital policy Performance Evaluation reads in part,...Employees should receive a formal performance evaluation, at a minimum, on an annual basis.

Personnel files #4 and #5 failed to provide evidence of a completed initial competency assessment for a critical care registered nurse. Core competencies not documented include but are not limited to the following: ability to care for trauma patient, ability to care for cardiac patient, admissions, discharges and transfers, safety and emergency procedures, tracheostomy care and neurological care. Personnel files #4 and #5 were identified as belonging to registered nurses who work in critical care areas of the hospital and have been employed for at least a year. Staff Member #23 stated that he/she would have expected the core competencies to have been completed or marked as not applicable.

The missing evaluations and core competencies were discussed with Staff Members #23 and #24 on 2/24/17. No further information was provided to the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, clinical record review, staff interview and facility document review, it was determined the facility staff failed to ensure patients were supervised during the administration of medications, Patient # 4.

Patient #4 was observed talking his/her medications without supervision from the nurse.

The findings included:

Patient #4 was admitted on [DATE] with diagnoses that included, but were not limited to: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Rheumatoid Arthritis and Osteoporosis.

On 2/23/17 at 9:40 a.m., the surveyor went to Patient #4's room, escorted by Staff Member # 3 in order to interview the patient. After receiving permission, the surveyor entered the room (Staff Member #3 waited outside the door) and observed Patient #4 to be alone, sitting on the side of the bed, holding a paper souffle cup from which he/she was retrieving pills and placing them in his/her mouth. The surveyor explained the purpose of the visit and requested permission to interview him/her. Patient #4 stated, Yes, I will talk with you, after I am finished taking my medications. There was no nurse present in the room at the time. The surveyor inquired as to the medications the patient was taking and he/she stated, I am just getting around to taking my morning medications. I wanted to eat something so I didn't take them until now. The surveyor inquired as to the patient self-administering medications. Patient #4 stated, The nurse gives me all my medications...

On 2/22/17 at 10:30 a.m., the surveyor discussed the self administration of medications and home medications' with Staff Member # 7. Staff Member #7, at that time, stated, No patient is allowed to self administer medications. Any medications brought from home must be sent to the pharmacy and they are checked and a bar code is applied. The medications are locked up and the nurse administers the medications to the patients. Patients cannot keep medications in their room and they can't self administer. The nurse administers all medications to the patient...

Further review of the clinical record for Patient #4 revealed no physicians order regarding the patient self-administering medications. There was no care plan information regarding the self administration of medications, nor any nurses notes regarding the same.

Review of the facility policy Adult Medication Administration revealed, in part: ... A. Prescribing...8. Medications should not be left at the patient's bedside...G. Administration...1d. Explain to the patient what medications they are being given, their intended use, and what reaction, if any, they should expect and/or report. e. Administer the medication...k. No mediations will be left at the bedside for self administration. In the event that a medication is to be self-administered, the nurse caring for the patient will supply the medication at the appropriate time...

A review of the concerns were discussed with the facility administrative Staff Members # 1, 2, 3, 25 and 26 on 2/24/17 at 1:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review it was determined nursing staff failed to perform vitals at the required intervals for three (3) of four (4) patients in the survey sample for blood administration. (Patients #7 and #10 and #11)

The findings included:

1. A review of Patient #7's electronic Medical record (EMR) was conducted on 02/22/2017 at 9:11 a.m., with Staff Member #3. Patient #7 was admitted to the facility on [DATE]; after being brought in by emergency medical transport. Patient #7 was scheduled for surgical intervention related to bezoar (indigestible material) caused by ingested cigarette butts. Patient #7 had an exploratory laparoscopy performed on 01/11/2017. Review of Patient #7's inpatient EMR documented the patient received blood transfusions on 01/11/2017, 01/13/2017, 01/17/2017 and 01/20/2017. Review of the blood transfusion documentation revealed nursing staff failed to perform the vital signs at the end of the transfusion on 01/13/2017, 01/17/2017 and 01/20/2017. Staff Member #3 navigated Patient #3's EMR to locate vitals documented in other areas of the patient's EMR. Staff Member #3 reported the nursing staff failed to follow the facility's policy and best practices.

2. A review of Patient #10's EMR was conducted on 02/23/2017 at 8:45 a.m., with Staff Member #15. The review revealed Patient #10 was admitted to the facility on [DATE] with the diagnosis of Hemoptysis. Staff Member 15 reported the EMR system used by the facility is a data entry system until the patient is discharged . Staff Member #15 reported when the patient's final medical record is compiled information may be kicked out or placed in another area.

Review of Patient #10's EMR revealed the physician had ordered two (2) separately timed units of red blood cells (RBC) for 11/01/2016; one (1) unit of platelets on 11/02/2016; seven (7) units of fresh frozen plasma (FFP) on each of the following dates: 11/03/2016. 11/04/2016 and 11/06/2016. Staff Member #15 reported if more than one (1) unit of FFP was ordered the blood bank generally pooled together and infused as one unit. The RBC unit transfused at 2125 (9:25 p.m.) on 11/01/2016 did not have a complete set of ending vital signs. The platelet transfusion on 11/02/2016 did not have the first fifteen minute and ending sets of vital signs. For the seven (7) units of FFP transfused on 11/03/2016 the nursing staff failed to enter a complete ending set of vital signs. On 11/04/2016 nursing staff failed to document a complete set of ending vital signs.

Staff Member #15 navigated Patient #10's EMR to determine if nursing staff had documented portions of the vital signs in other areas of the patient's EMR. Staff Member #15 verified the vital signs were missing as noted above. Staff Member #15 reported Patient #10's EMR did not provide documentation complete vital signs were performed as required. Staff Member #15 reported if nursing staff failed to click the right drop down box; the vital sign would not appear on the document related to the blood transfusion.

3. A review of Patient #11's EMR was conducted on 02/23/2017 at 9:11 a.m., with Staff Member #3. Patient #11's EMR documented the patient was admitted related to Liver Failure and gastrointestinal bleeding (GI Bleed). Patient #11's EMR revealed the following physician ordered blood products:

RBC (Red Blood Cells) - 12/17/2016 at 9:20 a.m., 3:41 p.m., and 3:54 p.m.; 12/19/2016 at 6:24 a.m.

Platelets - 12/17/2016 at 12:20 p.m., 12/18/2016 at 1:20 a.m., 12/19/2016 at 6:24 a.m., and 12/20/2016 at 4:40 p.m.

Fresh Frozen Plasma (FFP) - 12/17/2016 at 12:21 p.m.

Staff Member #3 navigated multiple sections of Patient #11's EMR to locate documentation of the required pre-transfusion, fifteen minutes after starting transfusion and ending set of assessment vital signs. The review revealed nursing staff failed to have assessment of the end vital signs for Platelets administered on 12/17/2016 at 1:07 .p.m., 3:00 p.m.; 12/19/2016 at 9:32 a.m. The review revealed nursing staff failed to have assessment of the fifteen minutes after starting transfusion and ending vital signs for: Platelets administered on 12/18/2016 at 0:59 a.m. and 12/20/2016 at 5:15 p.m. The review revealed nursing staff failed to perform an ending assessment of vital signs for RBC administered on 12/17/2016 at 7:28 p.m. and on 12/19/2016 at 7:01 a.m. The findings were verified by Staff Member #3.

Review of the facility's policy titled Blood & (and) Blood Products, Administration of read in part: N. Patient Monitoring 1. RN/LPN (Registered Nurse/Licensed Practical Nurse) remains with the patient for the first fifteen (15) minutes of the transfusion 2. Vital signs: Blood Pressure, Temperature, Pulse, Respirations, Pulse Oximetry [:] a. at the initiation of transfusion b. 15 minutes after the start of the transfusion c. Completion of the transfusion ... Q. Click 'Document' to enter 1st 15 min set of vital signs ... S. 'End' enter the time and date, volume amount defaults but may be edited, enter 'Additional Fluid Volume' T. Click 'Document' to enter Ending set of vital signs ... [Sic]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure that policies and procedures were developed for the self-administration of medications for one (1) of one (1) patient in the survey sample who had medications in the room available for self administration, Patient #4.

During a tour of the facility numerous medications were observed in Patient #4's room. Patient #4 was also self administering a medication which staff had stated the patient refused to give to staff.

The findings included:

Patient #4 was admitted on [DATE] with diagnoses that included, but were not limited to: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Rheumatoid Arthritis and Osteoporosis.

During a tour of the facility on 2/21/17 at 2:00 p.m., the surveyor observed the following medications sitting out on the windowsill of Patient#4's room: Fluticasone nasal spray (open container)(Fluticasone nasal spray is used to relieve sneezing, runny, stuffy, or itchy nose and itchy, watery eyes caused by hay fever or other allergies [caused by an allergy to pollen, mold, dust, or pets]), Ventolin inhaler, in open packaging, (VENTOLIN HFA is used to treat or prevent bronchospasm), Spiriva inhaler , in an opened packaging, (Spiriva HANDIHALER is used for maintenance treatment of bronchospasm), Alkaseltzer heartburn relief gummies (over the counter medication in an opened container), and Nasal decongestant spray (over the counter medication in an opened packaging).

Also the surveyor observed a bottle of Xylocaine 1% 200mg/20 mg (two-hundred milligrams per twenty milliliters) bottle (small amount of medication remaining in the bottle) sitting on the patient's sink and a syringe containing sodium chloride (3 milliliter syringe) attached to a t-connector extension tube lying also in the window sill. (Medication information obtained from 2014 Drug Nursing Handbook Springhouse Corporation).

Review of the clinical record for Patient #4 revealed a physicians order for the Fluticasone and Spiriva, however there was no order for the medication to be left in the patient's room or self-administered. There was no order for the Ventolin Handihaler, however the patient did have an order for Ventolin which was administered via a jet nebulizer by respiratory therapy. There was no physician's order for the Alkaseltzer gummies, or the nasal decongestant spray. Further review of the clinical record for Patient #4 revealed an order for Xeljanz 5mg (five milligrams) po (by mouth) twice a day, Patient's own medication (Xeljanz is used to treat adults with moderately to severely active rheumatoid arthritis per www.drugs.com).

On 2/22/17 at 10:30 a.m., the surveyor discussed the self administration of medications and home medications' with Staff Member #7. Staff Member #7, at that time, stated, No patient is allowed to self administer medications. Any medications brought from home must be sent to the pharmacy and they are checked and a bar code is applied. The medications are locked up and the nurse administers the medications to the patients. Patients cannot keep medications in their room and they can't self administer. The nurse administers all medications to the patient...

Further review of the clinical record for Patient #4 revealed that for the documentation for the administration of the Xeljanz from 2/18 through 2/23/17, the medication was documented as not administered- taken.

On 2/23/17 at 2:30 p.m., the surveyor interviewed Staff Member # 3 regarding a patient's ability to self administer medications and the facility policy and procedure regarding the same. Staff Member #3 stated, It depends on what the medication is whether the patient can self administer...some patients may have medications that they self-administer based on what it is- like an insulin pump or something. The surveyor requested a copy of the facility policy and procedure regarding the self administration of medications. At that time the surveyor discussed with Staff Member #3 the observations regarding the medications in the room of Patient #4.

On 2/24/17 at 8:40 a.m., the surveyor again discussed self administration of medications with Staff Member #3 and requested the facility policy and procedure. Staff Member #3 stated, The medications are at the physicians' discretion... The surveyor requested a list of medications that patients were permitted to self administer based on the physician's discretion. Staff Member #3 stated, There is no specific list, It is at the physicians discretion, and no policy reflects this. The other medicines in the room, the Xylocaine and syringe were left over from a procedure the patient had... At 9:20 a.m., the surveyor inquired as to the reason the Xeljanz was documented as not administered-taken by the nurse in the patient's medication administration record, as whether the patient was receiving the medication or not. Staff Member #3 stated, After speaking with the Nursing Director and the nurse on the unit, that is one med he/she will not let us take. He/she would not let us take it to the pharmacy and he/she takes it him/herself. That is why it is documented that way because the nurse can't document something they do not administer, but the patient is taking it him/herself.

Further review of the clinical record for Patient #4 revealed no physician orders regarding the patient self-administering medications. There was no care plan information regarding the self administration of medications, nor any nurses notes regarding the same. There was no evidence the physician was aware the patient had the medications and was self administering it, and whether the patient had been assessed as being capable of self administration of medications.

The facility policy and procedure Patient's Personal Medications was reviewed and evidenced, in part: ...Policy Statement: Medications brought to the hospital by a patient should not be given except by written order of the physician. Medications brought into the hospital by the patient are not administered unless they have been identified by a pharmacist and are in an appropriately labeled (label applied by the pharmacy or manufacturer original label) container...Procedure: When a patient brings personal medications to the hospital at the time of admission, one of the following occurs: A. The medication is identified by the nurse for medication reconciliation, and then sent home with a family member or are giver within 24 hours after admission. B. If home medication must be kept in the facility, the following procedure will be followed: ...D. A prescriber may order the patient may use(sic) his/her home medication(s) under the following conditions: 1. The Pharmacy and Therapeutics Committee classifies the medication as non-formulary and no suitable formulary option is acceptable to the prescribing licensed independent practitioner. 2. The pharmacy cannot obtain the formulary medication...E. If the above criteria are met in section D for a patient to use home medications, the pharmacist will enter and dispense the medication as follows: 1. Verify the integrity of the product using qualified drug information reference...2. Enter the medication on the MAR to generate a bar coded label as most appropriate...3. Label the medication without occluding the original dispensing or identifying label...4. Dispense appropriately labeled medication in its original container to the nursing unit...F. The Pharmacist will NOT identify and label the medications in the following situations: 1....or the integrity of the medication cannot be determined- the drug will be withheld from the patient and the prescribing physician contacted for an alternative medication therapy...2. Note that opened multiple dose containers such as liquids, inhalers, creams, ointments, ect. CANNOT be verified as the labeled ingredient...

A review of the concerns were discussed with the facility administrative Staff Members # 1, 2, 3, 25 and 26 on 2/24/17 at 1:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure that policies and procedures were followed for the self-administration of medications for one (1) of one (1) patient of the survey sample who had a medication (non-formulary) brought from home and was self administering the medication. Patient #4.

Patient #4 was self administering a medication which staff had stated the patient refused to give to staff.

The findings included:

Patient #4 was admitted on [DATE] with diagnoses that included, but were not limited to: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Rheumatoid Arthritis and Osteoporosis.

Review of the clinical record for Patient #4 revealed an order for Xeljanz 5mg (five milligrams) po (by mouth) twice a day, Patient's own medication (Xeljanz is used to treat adults with moderately to severely active rheumatoid arthritis per www.drugs.com).

On 2/22/17 at 10:30 a.m., the surveyor discussed the self administration of medications and home medications' with Staff Member # 7. Staff Member #7, at that time, stated, No patient is allowed to self administer medications. Any medications brought from home must be sent to the pharmacy and they are checked and a bar code is applied. The medications are locked up and the nurse administers the medications to the patients. Patients cannot keep medications in their room and they can't self administer. The nurse administers all medications to the patient... During the review of the clinical record, the surveyor asked Staff #7 to locate documentation regarding the pharmacy review of the medication that Patient #4 had brought from home. Staff #7 stated, It does not look as though Pharmacy has addressed (Patient #4's) home medications.

Further review of the clinical record for Patient #4 revealed that for the documentation for the administration of the Xeljanz from 2/18 through 2/23/17, the medication was documented as not administered- taken.

On 2/23/17 at 2:30 p.m., the surveyor interviewed Staff Member #3 regarding a patient's ability to self administer medications and the facility policy and procedure regarding the same. Staff Member #3 stated, It depends on what the medication is whether the patient can self administer...some patients may have medications that they self-administer based on what it is- like an insulin pump or something. The surveyor requested a copy of the facility policy and procedure regarding the self administration of medications. At that time the surveyor discussed with Staff Member #3 the observations regarding the medications in the room of Patient #4.

On 2/24/17 at 8:40 a.m., the surveyor again discussed self administration of medications with Staff Member #3 and requested the facility policy and procedure. Staff Member #3 stated, The medications are at the physicians discretion... The surveyor requested a list of medications that patients were permitted to self administer based on the physicians discretion. Staff Member #3 stated, There is no specific list, It is at the physicians discretion, and no policy reflects this. At 9:20 a.m., the surveyor inquired as to the reason the Xeljanz was documented as not administered-taken by the nurse in the patient's medication administration record, as whether the patient was receiving the medication or not. Staff Member #3 stated, After speaking with the Nursing Director and the nurse on the unit, that is one med he/she (Patient #4) will not let us take. He/she would not let us take it to the pharmacy and he/she takes it him/herself. That is why it is documented that way because the nurse can't document something they do not administer, but the patient is taking it him/herself....that medication is a non-formulary medication...

Further review of the clinical record for Patient #4 revealed no care plan information regarding the self administration of medications, nor any nurses notes regarding the same. There was no evidence the physician was aware the patient had refused to allow staff to take the personal medications and was self administering it, and whether the patient had been assessed as being capable of self administration of medications. There was no documentation that the Pharmacy had reviewed the medication and/or spoken with Patient #4 regarding the use of the medication and the self-administration. There was no documentation found in the clinical record that Patient #4 had refused to allow the staff to take possession of the medication.

Review of the facility policy Adult Medication Administration revealed the following, in part: ... A. Prescribing :...9. Medications brought to the hospital by a patient should not be given except by written order of the physician. Drugs brought into the hospital by the patient are not administered unless they have been identified by Pharmacy and are in an adequately labeled (label applied by a pharmacy or manufacture's original label) container. All medications taken by the patient including patients own meds, are recorded on wither the MAR (medication Administration Record) or eMAR (electronic medication administration record)...F. Procedure:...1 d. Patients own medications should be reviewed by pharmacy prior to administration only after the order is written by the physician...G. Administration:...k. No medications will be left at the bedside for self administration. In the event that a medication is to be self-administered, the nurse caring for the patient will supply the medication at the appropriate time...

The facility policy and procedure Patient's Personal Medications was reviewed and evidenced, in part: ...Policy Statement: Medications brought to the hospital by a patient should not be given except by written order of the physician. Medications brought into the hospital by the patient are not administered unless they have been identified by a pharmacist and are in an appropriately labeled (label applied by the pharmacy or manufacturer original label) container...Procedure: When a patient brings personal medications to the hospital at the time of admission, one of the following occurs: A. The medication is identified by the nurse for medication reconciliation, and then sent home with a family member or are giver within 24 hours after admission. B. If home medication must be kept in the facility, the following procedure will be followed: ...D. A prescriber may order the patient may use(sic) his/her home medication(s) under the following conditions: 1. The Pharmacy and Therapeutics Committee classifies the medication as non-formulary and no suitable formulary option is acceptable to the prescribing licensed independent practitioner. 2. The pharmacy cannot obtain the formulary medication...E. If the above criteria are met in section D for a patient to use home medications, the pharmacist will enter and dispense the medication as follows: 1. Verify the integrity of the product using qualified drug information reference...2. Enter the medication on the MAR to generate a bar coded label as most appropriate...3. Label the medication without occluding the original dispensing or identifying label...4. Dispense appropriately labeled medication in its original container to the nursing unit...F. The Pharmacist will NOT identify and label the medications in the following situations: 1....or the integrity of the medication cannot be determined- the drug will be withheld from the patient and the prescribing physician contacted for an alternative medication therapy...2. Note that opened multiple dose containers such as liquids, inhalers, creams, ointments, ect. CANNOT be verified as the labeled ingredient...

A review of the concerns were discussed with the facility administrative Staff Members # 1, 2, 3, 25 and 26 on 2/24/17 at 1:00 p.m.

3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review it was determined facility staff failed to ensure an accurate and complete medical record was maintained for two (2) of twelve (12) patient's medical records reviewed as part of the survey sample. (Patients #7 and #9)

The findings included:

A review of Patient #7's electronic Medical record (EMR) was conducted on 02/22/2017 at 9:11 a.m., with Staff Member #3. Patient #7's EMR documented he/she was admitted to the facility on [DATE]; after being brought in by emergency medical transport. The review revealed Patient #7 was scheduled for surgical intervention related to bezoar caused by ingested cigarette butts. Patient #7 had an exploratory laparoscopy perform on 01/11/2017. Review of Patient #7's inpatient EMR for this admission revealed a scanned form titled Outpatient: Endoscopy Physicians order form. The form was signed by a physician. The form read in part The following medications are administered under the direct supervision of physician. Under this subheading there were two handwritten notations 5 mg (milligram) Midazolam IV (intravenous) and 50 mcg (microgram) Fentanyl IV. The form did not have a date and time documented at either entered medication or anywhere on the form. Two additional medications were handwritten on the form under the section Additional Orders: Levaquin and Flagyl [dose and route not legible for both medications] these mediations were not dated or timed. Staff Member #3 navigated reviewed Patient #7's EMR for clarification and reported the form appeared to be a part of the patient's 01/11/2017 admission. Staff Member #3 verified the findings. Staff Member #3 reported the physician should have timed and dated the medications

According to the online medical dictionary.com; A bezoar is a ball of swallowed foreign material most often composed of hair or fiber. It collects in the stomach and fails to pass through the intestines.

A review of Patient #9's EMR was conducted on 02/23/2017 at approximately 8:29 a.m., with Staff Member #15. Patient #9s EMR documented he/she was admitted to the facility on [DATE] for Mood Disorder. Patient #9's EMR contained a Patient Rights and Responsibilities for behavioral health service was signed by the patient, his/her parent, and facility staff. On Patient's #9's Patient Rights and Responsibilities form the line designated for Time for all three signatures were blank. Staff Member #15 verified the Patient Rights and Responsibilities form signatures should have been timed. Staff Member #15 reported he/she was not sure the facility had a specific policy related signing, dating, and timing general forms. Staff Member #15 reported if the form has a line for time then it should have been filled in.

No policy was provided prior to exit on 02/24/2017.

Based on observations, staff interviews, personnel record review and review of the facilities policies and procedures, it was determined facility staff failed to ensure appropriate use of PPE (personal protective equipment including gowns, gloves, masks and eye protection devices), that isolation techniques were followed, and that staff followed the facility's policy and procedure for discharge cleaning of an isolation room. Also the facility staff failed to ensure annual tuberculosis screening questionnaires were completed for 4 of 14 staff members whose personnel records were reviewed. (Personnel Records #1, 4, 5 and 12.)

Findings include:

1. A tour of the hospital was conducted by the surveyors on 2/21/17 between 1:15 PM and 2:30 PM; the following observations were made:

At 1:30 PM, the surveyor noted a sign for Enhanced contact precautions posted outside Room #20 on the CVICU (Cardio-vascular intensive care unit) stepdown unit. The sign included instructions that hand hygiene, gown, and gloves were mandatory before entering the room. Staff Member #3, who was accompanying the surveyors on the tour was asked what Enhanced Contact precautions meant, and he/she stated it's used for C-diff, when soap and water must be used for handwashing.

A surveyor observed a staff member in Room #20, identified as a Nurse Practitioner (NP) by Staff Member #3. The NP was wearing an isolation gown; however, it was not tied, and was gaping open leaving the clothes beneath the gown exposed. The NP removed his/her gown, washed hands with soap and water, then walked across the room from the sink, past the bottom of the patient's bed, to throw away paper towels into the trash. The NP then exited the room rubbing clothing against the curtains on the way out the door.

At 1:35 PM, a surveyor observed Staff Member #27, an RN (registered nurse) touch the curtains covering the glass doors of the room with contaminated gloved hands several times while providing care to the patient. Staff Member #27 pushed back the curtains with gloved hands while trying to get the attention of another staff member. Staff Member #28 retrieved supplies requested by Staff Member #27, went to Room #20, touched the curtain with ungloved hands, reached inside the room past the curtain with ungloved hands, and without sanitizing hands before or after, placed supplies on a table inside the door.

At 1:40 PM, a surveyor observed housekeeping staff touch the privacy curtain in front of the glass door of

Room #20 with ungloved hand, without sanitizing or washing his/her hands, turned to the housekeeping cart, and pushed the cart down the hall to another room.

Staff Member #27 removed his/her PPE gown, but left his/her gloves on. Wearing dirty gloves, Staff Member #27 pushed the EKG machine through the curtains, stopping just outside the door, and wiped off only the top of the EKG (electro-cardiogram) machine used for the patient in Room #20. While still wearing the same gloves,

Staff Member #27 pushed the machine to a storage area where it was available for use on another patient. Staff Member #27 went back into the room, removed gloves, washed hands; there were no paper towels in the room with which to dry his/her hands, then exited the room, again brushing his/her scrubs against the curtain covering the door to room #20.

The surveyor requested the facility's policy related to isolation precautions, and was given the policy and procedure titled Guideline for Isolation Precautions in Hospitals. The policy did not include Enhanced Contact Precautions; however, it included the following information regarding contact precautions: Contact precautions are designed to reduce the risk of transmission of epistemologically important microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patient-care activities that require physical contact.......Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment..... Under gloves and hand hygiene the policy states ...3. Remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent; 4. After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments. Under the heading C. Gown: ...3. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environment. Under E. Patient Care equipment: 2. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient.

2. While standing in the hallway of a unit interviewing Staff Member #6, the Director for that unit, the surveyor observed housekeeping staff cleaning the room of a patient who had been discharged , and who had been on contact isolation. A housekeeper entered the room wearing gown and gloves, and put trash into one large bag. Another housekeeping staff member went into the room without PPE, taking trash in ungloved hands, placed it into a cart with other trash, and pushed the cart down the hallway. The staff member was not observed washing or sanitizing his/her hands. The trash bag was clear plastic bag, not a hazardous waste bag, and did not indicate that it came from an isolation room.

The housekeeping staff who was cleaning the room removed a dust mop from the cleaning cart outside the door, carried it into the room, swept the dust/trash on the floor out into the hallway, sweeping it into a pan, and placed into the trash. The dust mop was then placed back onto the cleaning cart.

The facility's policy and procedure titled Cleaning Facility states in part : D. Isolation discharge cleaning

1. Employees shall wear appropriate protective clothing according to sinage posted on the patient's door. These rooms will be serviced last using newly mixed cleaning solution, new mop head, and cleaning cloth. Sanitize all equipment prior to usage and then follow the Seven-Step Cleaning Procedure. Remove cubicle curtains and shower curtain. Place in a blue linen bag at the patient room door for removal to soiled linen area. Remove linen by following Infection Control Guidelines. Wash all walls using hospital approved disinfectant. Follow the Regulated Medical Waste Disposal methods. Sanitize all equipment using a hospital-approve disinfectant....

The concerns were discussed with staff on 2/24/16 between 11:00 AM and 11:30 AM.

3. Personnel records of 14 staff members were reviewed on 2/23/17 and 2/24/17 with the assistance of Staff Member #22, 23 and 24. Review of Personnel Records #1, 4, 5 and 12 failed to provide evidence of an annual Tuberculosis Screening Questionnaire.

Upon discovering the missing screenings, a staff member assisting the survey team contacted the Occupational Health Department, the surveyor was told that if it (the screening) was not in the employee file, then it was not current. The surveyor was told that previous practice had been to obtain the screenings when fit testing was done for respirators but had been changed to the employees hire date in order to increase compliance.

The surveyor was later provided with Tuberculosis Screening Questionnaires for Personnel Records #1, 4, 5 and 12 on 2/24/17. The documents were dated 2/24/17.

Based on observation and interview the hospital failed to inform the patients of their rights for two of five patients (Patient #31 and Patient #33).

The findings included:

Five patient interviews (Patient #31, #32, #33, #34, and #35) were conducted on April 15, 2014 and April 16, 2014. Two (Patient #31 and #33) of the five patients interviewed indicated they had not received information relating to patient rights.

Patient #31 was interviewed on April 15, 2014 at 2:00 pm. Patient #31 was admitted through the emergency room . Patient #31 reported he/she did not recall receiving any information on patient rights. Patient #31 reported he/she received no Patient Guide Booklet (patient rights information and patient relations information on pages 12-15) or admission packet paperwork. Patient #31 reported he/she did not receive a Patient Relations Letter (letter which informs a patient how to make a complaint/grievance).

Patient #33 was interviewed on April 15, 2014 at 2:20 pm. Patient #33 reported he/she received no Patient Guide Booklet, brochure (additional information relating to patients and Patient Relations), or a Patient Relations Letter upon admission.

Staff #1 and Staff #6 were interviewed multiple times during the survey. Staff #6 reported again on April 16, 2014 at approximately 11:40 am each patient receives a letter upon admission with Patient Relations Information. This letter contains the contact number of the hospital's Patient Relations Department and the contact information of the Complaint Unit of the Office of Licensure and Certification. A copy of this letter was provided to the survey members. Staff #6 reported this letter is generated each time a patient is registered. Staff #6 reported each patient receives a Patient Guide Hospital Booklet at admission. A copy of the Patient Guide Hospital Booklet was provided to the surveyors. Patient Advocacy Information is found on pages 12-15. This information includes patient rights and the contact information for Patient Relations and the Complaint Unit of the Office of Licensure and Certification (OLC). Staff #6 provided a brochure which patients receive at admission which contains information relating to patients while hospitalized and how to contact Patient Relations. No patients interviewed had this additional brochure.

Staff #23 was interviewed on April 16, 2014 at 10:40 am. Staff #23 reported he/she gives the patient rights information and the Patient Relations letter when the patient is admitted .

Staff #22 was interviewed on April 16, 2014 at 10:45 am. Staff #22 reported he/she gives the patient admission packet (includes Patient Guide Booklet and brochure) and Patient Relations letter to the patient during registration. Informs the patient it is a resource. Reported patient rights is part of the packet if admitted but he/she does not go over the rights with the patient.

Multiple staff interviews were conducted April 15, 2014 and April 16, 2014. The following information was revealed during the interviews:

Staff #9- Staff #9 was interviewed on April 15, 2014 at approximately 1:45 pm. Staff #9 reported he/she was not sure of how a patient would make a formal hospital complaint. Staff #9 was not aware of the Complaint Unit of the Office of Licensure and Certification. Staff #9 was able to report how he/she would help the patient to initially solve the complaint.

Staff #10- Staff #10 was interviewed on April 15, 2014 at approximately 1:55 pm. Staff #10 reported he/she would help the patient resolve the complaint at the lowest level. Staff #10 reported he/she was not sure how the patient receives the patient rights. Staff #10 reported he/she does not go over patient rights with the patient. Staff #10 was not aware patients receive information on how to file a complaint or grievance.

Staff #11- Staff #11 was interviewed on April 15, 2014 at approximately 3:30 pm. Staff #11 stated patients do get the admission information. Staff #11 was not aware of the Patient Relations Information letter. Reported he/she has never seen the letter.

Staff #12- Staff #12 was interviewed on April 15, 2014 at approximately 3:45 pm. Staff #12 reported patients get the Patient Guide Booklet 75 percent of the time. Staff #12 reported he/she has never been inserviced on patient rights. Staff #12 reported he/she has not seen a letter titled Patient Relations Information with the admission information.

Staff #13- Staff #13 was interviewed on April 15, 2014 at approximately 4:00 pm. Staff #13 reported he/she would try to solve the complaint themselves and then go up the chain of command. Staff #13 reported he/she has never seen the Patient Relations Information letter. Staff #13 was unable to report how he/she would advise a patient to file a complaint to an agency outside of the hospital.

Staff #14- Staff #14 was interviewed on April 15, 2014 at approximately 4:10 pm. Staff #14 reported he/she has seen the Patient Relations Information letter come up with some patients.

Staff #15- Staff #15 was interviewed on April 15, 2014 at approximately 4:15 pm. Staff #15 reported he/she would try to resolve a complaint at the bedside and notify the director of the unit. Staff #15 reported he/she had no knowledge of the Patient Relations letter. Staff #15 reported the role of the Patient Advocate is for and with the patient.

Staff #16- Staff #16 was interviewed on April 15, 2014 at approximately 4:20 pm. Staff #16 reported he/she has never been inserviced on the admission packet information. Staff #16 reported any complaint response letters sent to a patient only have her phone contact information on them. Staff #16 reported he/she was not sure of the difference between a Patient Care Representative and a Patient Advocate.

Staff #18- Staff #18 was interviewed on April 15, 2014 at approximately 2:25 pm. Staff #18 reported when asked how to handle complaints he/she is sure there is a group of people that would take care of that but he/she is not sure who would take care of it. Staff #18 reported he/she would go to the case manager.

Staff #19- Staff #19 was interviewed on April 15, 2014 at approximately 2:25 pm. Staff #19 stated he/she would try to fix the problem or complaint first and then go up the chain of command. Staff #19 did not mention any outside resources a patient could use to file a complaint.

Staff #26- Staff #26 was interviewed on April 15, 2014 at approximately 2:30 pm. Staff #26 reported he/she would try to resolve the complaint and then go to the next person in the chain of command. Staff #26 did not mention any outside resources a patient could use to file a complaint.

Staff #27- Staff #27 was interviewed on April 16, 2014 at approximately 11:10 am. Staff #27 reported he/she would apologize to the patient and try to solve the problem at the bedside if the patient had a complaint. Staff #27 reported he/she would report the incident to Staff #21 if the patient was not satisfied. Staff #27 was aware patients receive the Patient Relations Information letter. Staff #27 reported he/she does not go over patient rights. Staff #27 reported he/she would use the language line if the patient was unable to understand the patient rights in English.

Staff #28- Staff #28 was interviewed on April 16, 2014 at 11:15 am. Staff #28 reported he/she would apologize to the patient if the patient had a complaint. Staff #28 stated he/she would try to resolve the complaint and inform Staff #21.

Staff #29- Staff #29 was interviewed on April 16, 2014 at 11:30 am. Staff #29 reported he/she would use the language line if the patient needed to be advised of patient rights in a language other than English. Staff #29 reported he/she does not go over patient rights upon admission. Staff #29 reported he/she was not aware of a Patient Relations Information letter. Staff #29 reported he/she was unaware a patient could contact an outside agency to file a formal hospital complaint.

Staff #1 was present at multiple staff interviews. Staff #1 and Staff #6 aware of the findings.

Based on interview and observation the facility failed to ensure information relating to patient grievances was received by two of five patients (Patient #31 and #33).

The findings included:

Five patient interviews (Patient #31, #32, #33, #34, and #36) were conducted on April 15, 2014 and April 16, 2014. The following information was found during the interviews:

Patient #31- Patient #31 was interviewed on April 15, 2014 at 2:00 pm. Patient #31 reported he/she was admitted through the emergency room . Patient #31 reported he/she received no Patient Guide Booklet or Patient Relations Information. Patient #31 reported he/she received no information on patient rights or how to file a complaint or grievance (information is provided in the Patient Guide Booklet pages 12-15).

Patient #32- Patient #32 was interviewed on April 15, 2014 at 2:15 pm. Patient #32 reported he/she received the Patient Guide Booklet. Patient #32 reported he/she did not receive the Patient Relations Information letter.

Patient #33- Patient #33 was interviewed on April 15, 2014 at 2:20 pm. Patient #33 reported he/she was admitted through the emergency room . Patient #33 reported he/she had received no Patient Guide Booklet or Patient Relations Information letter at admission.

Patient #34- Patient #34 was interviewed on April 16, 2014 at approximately 10:30 am. Patient #34 reports he/she loves the hospital and has been in the hospital for two weeks. Patient #34 reports he/she was admitted through the emergency department. Patient #34 initially reported he/she did not receive any information relating to the hospital upon admission. Patient #34 was asked if he/she had received a Patient Guide Booklet and a letter relating to the complaint/grievance process. Patient #34 reported he/she thought a booklet may have been given to him/her upon admission. Patient #34 reported the book was in the closet with his/her clothes. Patient #34 reported he/she is aware of his/her patient rights. Staff #21 was present and retrieved the hospital information book from the closet. No Patient Relations Information letter was found. Patient #34 reported he/she did not receive any letter relating to whom the patient could contact to file a grievance. Staff #21 was present during the interview.

Patient #36- Patient #36 was interviewed on April 16, 2014 at approximately 10:10 am. Patient #36 reports he/she was admitted through ambulatory surgery. Patient #36 reports he/she received the Patient Guide Booklet and the Patient Relations Information letter. Staff #30 was present during the interview.

Staff interviews were conducted on April 14, 2014 through April 16, 2014 relating to the grievance process. The results of these interviews are as follows:

Staff #1 and Staff #6 were interviewed multiple times during the survey. Staff #6 reported again on April 16, 2014 at approximately 11:40 am each patient receives a letter upon admission with Patient Relations Information. This letter contains the contact number of the hospital's Patient Relations Department and the contact information of the Complaint Unit of the Office of Licensure and Certification. A copy of this letter was provided to the survey team members. Staff #6 reported this letter is generated each time a patient is registered. Staff #6 reported each patient receives a Patient Guide Hospital Booklet at admission. A copy of the Patient Guide Hospital Booklet was provided to the surveyors. Patient Advocacy Information is found on pages 12-15. This information includes patient rights, contact information for Patient Relations and contact information for the Complaint Unit of the Office of Licensure and Certification (OLC). Staff #6 provided a copy of a brochure patients receive at admission. No patients interviewed had this additional brochure.

Based on observation and interview the facility failed to secure medications for one of two patients observed during a medication pass (Patient #35).

The findings included:

Two (Patient #35 and #36) medication passes were observed on April 16, 2014.

One (Patient #35) medication pass was observed on April 16, 2014 at approximately 10:15 am. Upon entering Patient #35's room two containers of prescription medications were observed on the counter top near the sink. The prescription medications were identified as eye drops and Mesalamine (medication used to treat ulcerative colitis) 500 milligrams. The medications had been brought from home. Staff #1, Staff #30, and Staff #21 were present during the medication pass. The hospital policy relating to the storage of home medications was requested and reviewed. Policy # Titled Patients Personal Medications states medications will be sent home with a family member or sent to the pharmacy. Medications from home can be taken with a physicians order after being identified by a pharmacist.

Staff #21 was interviewed on April 16, 2014 at approximately 11:40 am. Staff #21 verified the medications were present during the medication pass. Staff #21 reported he/she had seen the medications in the room earlier in the day and had requested them to be removed. Staff #21 verified the medications had been brought from home. Staff #21 verified with Staff #30 the medications had been removed from Patient #35's room. Staff #21 verified the medications would be sent to the pharmacy.

Based on observation and interview the facility failed to:

1. Properly perform cleaning/sanitizing techniques for one of one patient room (Staff #8).

2. Ensure staff follow appropriate use of personal protective equipment for two of thirty one staff (Staff #8 and Staff #31).

The findings included:

1. Staff #8 was observed performing a terminal cleaning (thorough cleaning and disinfection of isolation room) on April 15, 2014 at approximately 11:00 am. Staff #1 was observed donning gloves without performing any hand hygiene. Policy #7.05 titled Isolation Discharge Room Cleaning Procedure was reviewed on April 15, 2014. The policy states follow proper hand hygiene protocol after putting on appropriate personal protective equipment.

Staff #8 was observed approximately three (3) times leaving the isolation room gowned and gloved to go to the housekeeping cart outside the room in the hallway. Staff #8 reported when asked about leaving the room he/she is not suppose to leave the room gowned and gloved.

Staff #8 was observed washing the walls of the room. Staff #8 failed to wash the walls closest to the door to the hallway. Staff #8 failed to wipe down the light switch near the door to the hallway.

Staff #1 was present during the terminal cleaning. Staff #7 was present in the hallway directly outside the room being cleaned. Staff #1 made aware of the findings.

2. Unidentified Staff #31 was observed in the hallway outside the surgical conference room on the fourth floor at approximately 11:00 am on April 16, 2014. Staff #31 was observed passing the 4th (fourth) floor conference room with one hand gloved holding 2 (two) syringes. The other hand was ungloved. Staff #31 used ungloved hand to open the door and proceed down the stairs.

Staff #31 was observed by surveyor and Staff #6 at 11:10 am with both hands gloved and holding 2 syringes (not in a plastic bag). Staff #31 was observed opening the door to the stairs with the gloved hand. Staff #6 witnessed incident and stated gloves are not to be worn in the hallways unless transporting a patient that requires the use of gloves. Staff #6 attempted to find Staff #31 but was unable to locate. Staff #31 appeared to be carrying a specimen.

Based on staff interviews, review of the facility's written response to grievances, review of policy and procedures, and during the course of a complaint investigation it was determined the facility failed to provide the complainant with complete results of the grievance process, or a date the investigation will be completed. The grievance was filed on behalf of Patient #3.

The findings were:

The facility's Associate Chief Nursing Officer (ACNO), Continual Readiness Coordinator, Vice President of Quality and Compliance, and Associate Administrator for Complaints and Grievances were interviewed on 9/26/12 in the a.m. The administration staff explained the facility's grievance process and specifically discussed how the facility responded to the grievance placed on behalf of Patient #3. The facility sent the complainant two separate written responses approximately two months apart.

The surveyors reviewed the facility's initial response, a letter, which was sent by the facility's ACNO dated July 17, 2012. The letter was in response to a telephone call placed by the complainant. Within the facility's response letter, the ACNO lists the complainants concerns, During your conversation, you indicated you were displeased with this visit because you were concerned about our care and treatment of your father-in-law whom has advanced dementia. You voiced that you felt he was placed on medications he should not have been given and that the physicians ignored your requests regarding limitations of care and treatment. The response letter summarized Patient #3's hospital course and medications the patient received following the facility's review of the patient's medical record. No evidence of how the facility investigated the concern related to limitations of care and treatment was noted. There was no indication the investigation was to continue in order to answer those concerns. In an interview with the facility's Continual Readiness Coordinator on 9/27/12, she acknowledged the letter did not contain these elements. The facility's Associate Administrator for Complaints and Grievances was interviewed on 9/28/12 and she acknowledged the facility expected the letter from the ACNO to the complainant to be the end of communication related to this complaint until the facility received written communication from the complainant on 8/27/12. The facility considered that information from the complainant as an appeal to the facility's grievance response. The facility's Chief Executive Officer (CEO) then replied to the complainant's appeal via a letter dated September 11, 2012.

The facility's second response letter was reviewed on 9/27/12. Within this letter, written by the facility's CEO, the complainant's concerns were acknowledged and the letter indicated there had been an investigation launched. There was no mention of a date of completion for that investigation.

The facility's policy and procedure titled, Patient Complaint and Grievance was reviewed on 9/26/12. The policy's latest approved and revised date was 11/2010. The seven-page policy included a Grievance Resolution Process that read in part, 3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 days. And, 8. A grievance is considered resolved when the patient and/or patient representative are satisfied with the actions taken on their behalf. There may be situations where the organization has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance and the patient or the patient's representative remains unsatisfied with the actions taken by the organization. The patient may appeal this decision in writing to the hospital CEO.