25283 Based on review of medical records, policy review and staff interview it was determined the facility failed to ensure the consent for surgery was completed indicating informed consent was obtained for one (#1) of thirty patient records sampled. Findings included: Review of the medical record for patient #1 revealed the patient presented to the Emergency Department on 04/23/17 after a fall. Documents provided by the Adult Living Facility indicated patient #1 had a Health Care Surrogate (HCS) and list contact names and phone numbers. Review of the admitting physician's History and Physical dated 04/24/17 at 4:37 a.m. revealed a history of dementia and psychiatric illness. The note stated the patient was a poor historian and had expressive aphasia. Orthopedic Surgeon consultation note dated 04/24/17 at 7:25 a.m. noted the patient's history included Dementia and psychiatric illness. Orthopedic surgeon documentation, approximately 1 hour and 33 minutes later, dated 04/24/2017 at 8:58 a.m. stated the surgical treatment options were discussed with the patient, the patient voiced understanding and agreed to surgery. There was no documentation in the medical record that indicated the surgery was emergent. Facility policy titled Informed Consent dated 01/24/17 indicated a signed consent will be obtained from every competent adult or person authorized to sign for a minor or incompetent adult for major and minor surgery that involves entry into the body. If the patient has not been declared incompetent, but there is serious question as to their competency, the physician must initiate measures for legal declaration of incompetence in order to proceed and that will be documented in the chart. The policy states attempts will be made to notify the family and secure a consent. Review of the medical record included a consent for surgery form dated 04/24/17 at 6:45 a.m. The form listed the patient's name, the surgeon's name and the procedure to be performed. There was no signature from the patient or the Health Care Surrogate consenting to the surgery. On the line for the patient's signature were hand written words, unable to sign. There was no documentation on the consent form or in the medical record indicating why the patient or the patient's Health Care Surrogate did not sign the consent form. There was no documentation in the medical record an attempt was made to contact the patient's Health Care Surrogate to obtain consent for surgery or to provide the designated individual the information required to make informed decisions about the patient's care. There was no documentation in the medical record regarding the competency status for patient #1. The medical record revealed the patient had surgery on 04/24/17 at 8:58 a.m. without a signed consent form. An interview with the Nurse Leader on 04/26/17 at 12:00 p.m. confirmed the above findings.

31166 Based on observation and interview it was determined the facility failed to protect patients [past and present] personal and protected health information for greater than 530 past and present patients. Findings included: On 04/26/2017 at 7:47 a.m. the conference room assigned by facility for surveyors to conduct the validation survey was unlocked on arrival. All documents containing patients' personal and PHI [protected health information] had been moved, rearranged and placed in different folders. The [NAME] President of Quality and Patient Safety was immediately notified. She stated she was not sure what happened and had heard a children's community meeting had been held in the room. The surveyor requested the facility investigate due to the personal and PHI breach of the following information: 1. List containing current Inpatient census of fifty-four [54] patient names admitted , unit and diagnosis 2. The restraint death record log with eight [8] patient names 3. The Surgery Schedule log with two-hundred sixty-one [261] patient names, date of procedure, and procedure to be performed. 4. The list of Returns to OR [operating room] with one hundred fifty-six [156] patient names, date and procedure 5. The list of patients who received blood/blood products containing eleven [11] patient names, number of infusions and type of blood product administered and date of administration. 6. The list of surgical patients with positive wound cultures with fifteen [15] patient names 7. The facility's emergency room Transfer Out log for 2017 included ninety-five [95] patient names, reason for transfer, where they were transferred and the Transfer In log for 2017 included twenty-five [25] patient names and reason for transfer. 8. The first quarter EMTALA [emergency medical treatment and labor act] log contained patient names, time seen, reason for seeking emergency care, too numerous to count. 9. The confidential Peer Review Committee Minutes for January, February and March 2017 containing multiple patients too numerous to count. 10. The facility Grievance logs for year 2015 to 2017 containing patient names too numerous to count. On 04/27/2017 a request for information on the breech investigation throughout the day was made. The [NAME] President of Quality and Patient Safety stated they were working on it. No information was received to confirm an investigation, report of breach or action plan was being conducted.

31166 Based on record review and staff interview it was determined the facility failed to ensure safety of patients during investigation of an allegation of sexual misconduct made against a member of the facility's personnel. Findings included: A review of the facility's log of sexual abuse/misconduct revealed an allegation of sexual abuse/misconduct was reported in April 2016. A patient in the BHU [behavioral health unit] complained a staff member rubbed up against her and exposed himself to her. A review of the alleged sexual misconduct investigation revealed. The alleged incident happened on 04/20/2016. Review of facility documents revealed the staff member alleged of the sexual misconduct was moved from the BHU to the ARU [Addiction Recovery Unit] while the facility conducted an investigation. The staff member was assigned and continued to work in patient care areas providing direct patient care. Documentation revealed the staff member alleged of the sexual misconduct continued to work in patient care areas and returned to the BHU on 04/23/2016. The patient involved in the alleged incident was not discharged from the BHU until 04/29/2016. Review of an email dated 04/26/2016 from the [NAME] President of Quality and Patient Safety to the Executive staff stated I received a call this morning they [DCF] are closing the case with no substantiation. Interview with the [NAME] President of Quality and Patient Safety and the Director of Human Resources on 04/27/2017 at 9:10 a.m. revealed the above findings were confirmed. There was no explanation why the staff member remained in patient care activities while the allegation of sexual misconduct was investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31166 Based on medical record reviews and staff interviews it was determined the facility failed to ensure medical staff rules and regulations were followed for three [#3, #4, #14] of thirty sampled patient records and the policy for verbal and telephone order verification was followed for two [#11, #15] of thirty sampled patient records. Findings included: 1. Medical Staff Rules and Regulations Page 6 of 22 [regarding discharge summary] Item #19 The patient's medical record shall be complete within thirty days following discharge, including progress notes, final diagnosis and clinical resume. A review of patient # 3's medical record documented the patient was admitted on [DATE] and discharged home on 12/06/2016. A review of the discharge summary showed the summary was dictated on 03/09/2017 and authenticated by the physician on 03/10/2017, three months and four days after discharge. A review of patient # 4's medical record documented the patient was admitted on [DATE] and discharged home on 03/13/17. A detailed review of the medical record on 04/27/17 for patient # 4, with the director of surgical services, showed no documentation of a discharge summary, 45 days after discharge. A review of patient #14's medical record documented the patient was admitted on [DATE] and discharged home on 03/12/2017. A detailed review of the medical record on 04/26/2017 for patient #14, with the director of clinical care, showed no documentation of a discharge summary, 44 days after discharge. 2. Facility policy titled Verbal and Telephone Order Verification approved by the quality council and medical executive committee on 03/2017, stated on page 1 item B: Documentation of verbal and or telephone orders shall include (but not limited to) the following elements: Date and Time of the order for treatment or medication, .on page 2 item C. Standard verbal and or telephone orders are to be signed by the Prescriber within forty-eight hours. Hazardous orders must be signed within twenty-four hours (for example: Chemotherapy, Investigational Drugs, DNR [do not resuscitate], CMO [comfort measures only], Restraints). A review of patient #11's medical record documented a telephone order received on 04/19/2017 at 9:00 a.m. for hemodialysis. A detailed review on 04/26/2017 with the director of critical care confirmed the order was not verified/validated or signed by the ordering physician within the forty-eight hour time frame specified in the facility policy. A review of patient #15's medical record documented a telephone order for restraints received on 11/24/2016 at 2:10 a.m. A detailed review of the order on 04/26/2017 with the director of critical care showed the physician evaluation, signature, date and time section was left blank. A continued review documented a telephone order for restraints received on 11/25/2016 at 2:00 a.m. A detailed review of the order on 04/26/2017 with the director of critical care showed the physician evaluation, date and time section was left blank. An interview with the director of critical care confirmed she was unable to determine if the order was verified/validated within twenty-four hours per policy. A continued review of medical record documented a physician signed order for restraints on 11/26/2016. It showed the time of restraint order left blank. A detailed review of the order on 04/26/2017 with the director of critical care showed the section of the order for clinical justification was blank, time limit was blank, criteria for release was blank, physician evaluation was blank and time the order was signed by the physician was blank. An interview with the director of critical care on 04/26/2017 at 3:00 p.m. confirmed the above findings.

28028 Based on review of medical records and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to ensure care was provided according to physician orders for two (#11, #27) of thirty patients sampled. Findings included: 1. A review of patient #11's hemodialysis physician orders and dialysis treatment flow sheets documented a physician's order for Hemodialysis with a DFR (Dialysate Flow Rate) of 700. A review of the dialysis treatment flow sheet for 04/21/2017 revealed the DFR ran at 800 as set by the RN (Registered Nurse). A detailed review of the patient's medical record with the director of critical care on 04/26/2017 confirmed the above findings and stated there was no evidence of physician order to increase DFR. A review of patient #11's medication orders showed an order for Calcium Acetate 1334 mg [milligrams] by mouth three times a day. A review of the medication administration record documented the patient was administered the phosphate binder on the following dates and times: 04/19/2017 at 8:35 a.m. and 8:26 p.m. 04/20/2017 at 8:48 a.m.; 2:47 p.m. and 9:53 p.m. 04/21/2017 at 8:35 a.m.; 4:50 p.m. and 8:11 p.m. 04/22/2017 at 9:54 a.m.; 3:54 p.m. and 10:03 p.m. 04/23/2017 at 9:38 a.m. and 8:34 p.m. 04/24/2017 at 9:11 a.m. and 2:22 p.m. 04/25/2017 at 11:42 a.m. 04/26/2017 at 8:56 a.m. and 1:49 p.m. A review of the medication indications and usage using the 2017 Physician's Desk Reference 71st edition: www.pdr.net/ and Epocrates Online: https://online.epocrates.com documented calcium acetate, brand name PhosLo was to be given orally with food. An interview with the facility pharmacist on 04/26/2017 at 1:00 p.m. confirmed the medication was to be given with food to be effective. An interview with the director of critical care noted nurses were to know the medications they were giving as part of patient safety. An interview with the director of dietary services on 04/26/2016 at 2:00 p.m. revealed meal tray delivery to the unit the patient was on were Breakfast at 8:30 a.m.; Lunch at 12:30 p.m. and Dinner at 5:30 p.m. On 04/26/2017 at 3:00 p.m. a detailed review of the medication administration record with the director of critical care and the facility pharmacist confirmed the medication was not administered appropriately to be effective. 2. Review of the medical record for patient #27 revealed an order for hemodialysis three times per week on Monday, Wednesday, Friday. Review of the hemodialysis orders dated 4/10/2017 at 11:00 a.m. revealed no ordered rate for the DFR. Review of the hemodialysis treatment flowsheets revealed the RN ran the DFR at the following rates: 4/10/2017 DFR 800 4/12/2017 DFR 600 4/13/2017 DFR 700 4/15/2017 DFR 700 4/17/2017 DFR 700 4/19/2017 DFR 800 4/21/2017 DFR 700 4/24/2017 DFR 600 Interview and review of the record with the Director of Critical Care on 4/27/17 at 3:30 p.m. confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25283 Based on review of medical records and policy and staff interview it was determined the nursing staff failed to develop and keep current an individualized care plan for two (#1, #2) of thirty patients sampled. Findings included: 1. Review of the medical record for patient #1 revealed the patient was admitted on [DATE] with a right femoral neck fracture. Review of the Pain Assessment completed in the Emergency Department on 04/23/17 at 4:48 p.m. revealed a pain score of five out of ten (zero was no pain and a ten was the worst possible pain). Review of the History and Physical dated 04/23/17 at 4:59 by the Emergency Department physician revealed the patient complained of right hip pain. The history indicated the patient was cognitively impaired and had impaired communication. The admitting physician's History and Physical dated on 04/24/17 at 04:37 a.m. revealed patient #1 had pain in the right hip at the time of the assessment. On 4/23/17 an order was initiated for Morphine Sulfate, 2 milligrams (mg) intravenously every two hours as needed for pain. Review of the document Patient's Plan of Care created on 04/23/17 revealed the identified problems were Impaired Musculoskeletal Function, Impaired Physical Function and Impaired Neurological Function. There was no plan of care developed to address pain prior to or after surgery. 2. Review of the triage record for patient #2 revealed the patient presented to the emergency department on 04/17/17 at 6:27 a.m. for perforated appendicitis. At the time of triage, Patient #2 reported a pain score of ten out of ten (Zero was no pain and a ten was the worst possible pain). According to the Nursing Admission assessment dated [DATE] at 11:23 a.m. patient #2 complained of left lower quadrant abdominal pain. Review of the pain assessment documentation revealed Patient #2 continued to experience intermittent pain from the time of admission until 04/26/17 at 12:00 p.m. Review of the document Patient's Plan of Care created on 04/17/17 revealed the problems identified were Impaired Gastrointestinal Function, Impaired Skin Integrity and Knowledge Deficit. There was no plan of care developed to address pain from 04/17/17 to 04/26/17. Review of the facility policy titled Assessment-Reassessment dated 01/24/17 revealed the Registered Nurse will determine and set priorities on the patient's nursing care needs during the initial assessment phase. Upon completion of the initial assessment, an individualized, prioritized plan of care shall be developed in consultation with the patient/significant other. Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition. The plan of care shall be reviewed regularly in consultation with the patient/significant other and revised as patient's condition or diagnosis changes. An interview with the Nurse Leader on 04/26/17 at 12:00 p.m. confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28028 Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were timely administered and administered in accordance with orders for two (#27, #28 ) of thirty sampled patients. Findings included: Review of policy and procedure Medication Administration, effective date 5/24/16, under section, Procedure III Standard Medication Administration Times indicated timed medications ordered more than once a day will be given no more than one hour before or one hour after the scheduled time. 1. Patient #28 was admitted on [DATE] to the Intensive Care Unit with sepsis. Review of physician admission orders dated 4/8/17 at 8:00 p.m. included orders for Zosyn 2.75 grams every eight hour. Physician order dated 4/8/17 at 9:50 p.m. ordered Bactroban twice a day. Review of the Electronic Medication Administration Record noted the Zosyn was given on 4/8/17 at 10:32 p.m. and on 4/9/17 at 4:43 a.m. The medication was due at 6:00 a.m., approximately one hour and fifteen minutes later. There was no documentation as to why the medication was given earlier than one hour. Review of the Electronic Medication Administration Record revealed no evidence the Bactroban was administered. Interview with the Director of Critical Care during the record review on 4/27/17 indicated Bactroban had been faxed to the pharmacy but not placed on Electronic Medication Administration Record. The Director of Critical Care stated medications that are timed are given one hour before or one hour after the due time. Record review and interview with the Director of Critical Care on 4/27/17 at approximately 3:00 p.m. confirmed the above findings. 2. Review of the medical record for patient #27 revealed a physician order for Epogen 4000 units with each hemodialysis treatment. Review of the medical record revealed the patient received hemodialysis on 4/10/2017 beginning at 2:21 p.m. Review of the MAR (Medication Administration Record) dated 4/10/2017 revealed no evidence the Epogen was administered as ordered. Review of the medical record revealed the patient received hemodialysis on 4/12/2017 beginning at 11:45 a.m. Review of the physician orders revealed an order on 4/11/2017 to change the Epogen to 8000 units with each hemodialysis treatment. Review of the MAR dated 4/12/2017 revealed Epogen 8000 units was administered at 12:14 p.m. At 12:15 p.m. Epogen 4000 units was administered. Review of the MAR revealed the Epogen was administered once by the primary care nurse and also administered by the hemodialysis nurse. Review of a physician order indicated Zemplar 2 mcg (micrograms) was to be given with each hemodialysis treatment. Review of the medical record revealed the patient received hemodialysis on 4/10/2017 at 2:21 p.m. Review of the MAR dated 4/10/2017 revealed no evidence the Zemplar was administered as ordered. Review of the medical record revealed the patient received hemodialysis on 4/12/2017 beginning at 11:45 a.m. Review of the MAR dated 4/12/2017 revealed Zemplar was administered at 12:13 p.m. and at 12:15 p.m. Review of the MAR revealed the Zemplar was administered once by the primary care nurse and also administered by the hemodialysis nurse. Review of the MAR revealed on 4/15/2017 at 10:45 a.m. Albumin was administered to the patient by the hemodialysis nurse. Review of the physician orders revealed no evidence of an order to administer Albumin. On 4/21/2017 at 9:45 a.m. and 11:30 a.m. Albumin was administered to the patient by the hemodialysis nurse. Review of the physician orders revealed no evidence of an order to administer Albumin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31166 Based on record review and staff interviews it was determined the facility failed to keep accurate medical records for three (#4, #6, #14) of thirty sampled records. Findings included: On 04/26/2016 a review of Patient # 4's medical record revealed the patient was discharged on [DATE]. A detailed review showed no evidence of a physician discharge summary. On 04/27/17 a review of Patient #6's surgical record revealed the patient had a surgical procedure performed on 02/17/17. Review of nursing documentation revealed the surgery was performed in operating room [OR] #3. Review of the anesthesia record revealed the surgery was performed in OR #2. On 04/26/2017 a review of patient #14's medical record revealed the patient was discharged on [DATE]. A detailed review showed no evidence of a physician discharge summary. On 04/27/17 at approximately 2:25 p.m. an interview conducted with the Director of Critical Care and the Director of Surgical Services confirmed the above findings.

31166 Based on record review and staff interview it was determined the facility failed to ensure medication orders were reviewed by the pharmacist for appropriateness of the drug, dose, frequency, route and method of administration for one [#11] of thirty records. Findings included: A review of patient #11's physician order revealed an order for Calcium Acetate [Trade name: PhosLo] 1334 mg [milligrams] by mouth three times daily. A review of patient #11's medication profile revealed the medication was reviewed by a pharmacist, however the need to administer the medication with food was not entered. During an interview with the facility's Director of Pharmacy on 04/26/2017 at approximately 1:30 p.m. he confirmed the medication was a phosphate binder that needed to be given with food to be effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31166 Based on observation and staff interview it was determined the facility failed to ensure routine and preventive maintenance, inspections, testing and repair activities were performed. Findings included: On 04/24/2017 at approximately 10:00 a.m. accompanied by the Life Safety Code surveyor and the Maintenance Director a tour of the facility was conducted on the 3rd Floor. It was noted: 1. Observation of 3-prong electrical beds with no documentation of preventative maintenance or electrical safety tests. 2. Observation and inspection of the 3rd floor revealed patient restrooms in rooms 333, 335, 363, 365, 361 and 387 revealed all exhaust vents not working and clogged with fuzzy lint. 3. Patient nutrition room's ice dispenser drain and tray covered in brown slimy substance. Observation of the 2nd floor revealed a locked Behavioral Health Unit [BHU] and an Adult Rehabilitation Unit [ARU]. It revealed: 1. Observation of the BHU revealed a clogged sink drain in the staff lounge with approximately 2 inches of greenish brown liquid confirmed by the Maintenance Director 2. Observation of the BHU showed fire extinguishers stored within locked cabinets. Interview of staff member [A] during the tour stated she did not have a key. An interview with the BHU charge nurse on 04/24/2017 stated all staff should have a key to the fire extinguishers. 3. Observation of patient room [ROOM NUMBER] revealed restroom exhaust vent not working and with fuzzy lint on grate covering. 4. Observation of the air conditioning unit in patient room [ROOM NUMBER] with copious amounts of brown sticky substance and fuzzy lint. Per the maintenance director, housekeeping did not have a key to the unit cabinet and stated maintenance checks, cleans and changes filters once per month and this one is due. 5. Observation of the BHU and ARU patient laundry rooms revealed dryer with copious amount of lint in the dryer vent behind the cleaning screen. Observation of the 1st floor revealed the Intensive Care Unit, Emergency Department, Laboratory Department, Pharmacy, Radiology and Dietary. It revealed: 1. Observation during tour of the Intensive Care Unit (ICU) on 4/27/17 at 12:30 p.m. with the Director of Critical Care revealed in the nourishment room next to the refrigerator a grape fruit size area of paint peeling down to the wood work. Interview with the Director of Critical Care during the observation indicated she had no knowledge of how it occurred or when it occurred. An interview with the maintenance director during the tours confirmed the above findings.

37588 Based on review of facility policy, observation and staff interview it was determined the facility failed to follow the infection control policies related artificial nails, nail polish and nail length. Findings included: On 04/25/17 at 9:00 a.m. review of the facility surgical services policy titled OR-Scrub Technique, revised 02/14/17 revealed the following: keep fingernails trimmed neatly and short .fingernail polish should not be worn .no artificial nails of any type allowed. Review of a human resources policy titled Professional Dress Standards revealed artificial nails may not be worn by employees providing direct patient care, in food services, environmental services or sterile processing. Review of an infection control policy titled Hand Hygiene, effective 01/16/16 revealed a house wide clinical policy indicating no artificial nails are allowed. Review of an infection control policy titled OSHA Bloodborne Pathogen Exposure Control Plan effective 01/11/16 revealed a house wide policy requiring nails to be short enough to allow thorough cleaning under nails and to avoid damage to gloves .artificial nails or tips on employees providing direct patient care is not permitted since these can become colonized with microorganisms that cannot be removed by routine hand washing. The Association of peri-Operative Registered Nurses (AORN) recommended the following: Fingernail tips should be no longer than 2 mm (millimeters) (0.08 inch). Studies found fingernails at a length shorter than 2 mm were less likely to harbor bacteria when compared to nails longer than 2 mm. (Guideline for hand hygiene. In: Guidelines for Preoperative Practice. Denver, CO: AORN, Inc.) On 04/25/17 at approximately 9:55 a.m. a tour was conducted, accompanied by the Director or Surgical Services, of the Sterile Processing and Peri-operative Departments. During the tour of the Operating Room the RN Supervisor was observed wearing finger nail polish with an approximate length of 5 mm. An interview conducted with the RN supervisor revealed she performed direct patient care. The nails were not artificial. Additionally, the RN supervisor stated scrub techs cannot wear artificial nails, but the Registered Nurses (RNs) can. At approximately 11:00 a.m. a tour was conducted of the Sterile Processing Department (SPD) where the sole Sterile Processing Technician was observed wearing artificial nails with an approximate length of 10 mm. The SPD technician stated she performed all of the functions related to the sterile processing of surgical instruments for the facility. Additionally, the SPD technician stated she was aware the policy for her position did not allow wearing of artificial nails. On 04/25/7 at approximately 11:07 a.m. the Director of Surgical Services confirmed the above findings with the OR RN Supervisor and Sterile Processing Technician nails.

11553 Based on record review, review of policy and procedure and staff interviews it was determined the facility failed to ensure a patient's right to chose a home health agency for post hospitalization care per facility policy was maintained for one (#19) of thirty records reviewed. Findings included: Review of patient #19's record with the Nurse Director of the Behavioral Health Unit (BHU) and the Nurse Manager of the BHU on 4/24/17 and 4/25/17 noted the patient was admitted to the BHU on 4/15/17. Review of the admission assessment and physician progress notes, nursing documentation and case management notes from the date of admission to 4/23/17 did not reveal evidence the patient was receiving home health care prior to admission. Patient interview on 4/24/17 at 2:25 p.m. revealed the patient was going home that day with home health care. The patient stated no choice of a home health agency was provided. The patient stated the physician ordered the prior home health care agency. Review of physician orders dated 4/24/17, no time, indicated to discharge home with home health agency A. Review of case management documentation dated 4/24/17 indicated home health care agency A was contacted for in home assessment. Interview with the Nurse Director of the BHU and Nurse Manager of the BHU on 4/26/17 at 2:26 p.m. revealed no documentation of a choice list for home health agencies being provided to the patient or prior information related to home health agency A could be located. Review of policy and procedure Discharge Planning issued 3/3/17, no number, under policy 2b. indicated the evaluation of the patient's post discharge needs is identified in the first stage of discharge planning. Number 13 indicated a list of home health agencies available to the patient will be presented for a patient's choice.

37588 Based on review of facility policy, review of documents and staff interview it was determined the facility failed to follow the policy related to terminal cleaning and disinfection of the surgical department operating rooms for 18 of 90 days reviewed. Findings included: On 04/25/17 at approximately 11:10 a.m. review of the facility surgical services policy titled Cleaning Sanitation Surgical Procedure Areas, revised 02/02/17, revealed the objective of the policy was to re-establish a clean safe environment after each surgical procedure .cleaning procedures done within the Surgical Suite will be according to the Association Of periOperative Registered Nurses (AORN) recommend guidelines. Further review of the policy revealed terminal cleaning will be performed at the conclusion of the day's schedule, operating rooms, scrub/utility areas, corridors, furnishings and equipment should be terminally cleaned .mechanical friction and a hospital-approved disinfectant/detergent are used to clean equipment and areas that should include: 1) Surgical lights and tracks, 2) Fixed and ceiling mounted equipment 3) All furniture, including wheels and casters 4) Handles of cabinets and push plates 5) Face plated of vents 6) Horizontal surfaces (e.g. tops of counters & fixed shelving) 7) Entire floor 8) Kick buckets 9) Scrub sinks On 04/25/17 at approximately 10:30 a.m. review of the facility documents for the months of February, March, and April 2017 titled with the following: Team Member: By initialing the following spaces, you are indicating that the suite has been terminally cleaned and disinfected to AORN and Joint Commission Standards .Manager/Supervisor: By providing your signature, you are indicating cleaning has been in compliance. Further review of the document revealed multiple days in this three month period that did not have staff or Manager/Supervisor initials indicating the OR suite had been terminally cleaned. On the following dates the facility performed surgical procedures and terminal cleaning was not performed: 02/20/17-Review of the surgical log revealed surgical procedures were performed in OR #2 and #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #2 and #6. 02/22/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3. 02/26/17-Review of the surgical log revealed surgical procedures were performed in OR #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #4. 03/03/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1. 03/07/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3. 03/19/17-Review of the surgical log revealed surgical procedures were performed in OR #1 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1 and #4. 03/20/17 - Review of the surgical log revealed surgical procedures were performed in OR #6 and #7. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6 and #7. 03/24/17-Review of the surgical log revealed surgical procedures were performed in OR #3 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3 and #4. 03/25/17-Review of the surgical log revealed surgical procedures were performed in OR #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6. 03/29/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3. 04/02/17-Review of the surgical log revealed surgical procedures were performed in OR #2. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #2. 04/04/17-Review of the surgical log revealed surgical procedures were performed in OR #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6. 04/08/17-Review of the surgical log revealed surgical procedures were performed in OR #1 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1 and #4. 04/09/17 - Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1. 04/13/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1. 04/15/17-Review of the surgical log revealed surgical procedures were performed in OR #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #4. 04/16/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1. 04/21/17-Review of the surgical log revealed surgical procedures were performed in OR #1, #2 and #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1, #2 and #3. On 04/25/17 at 10:25 a.m. an interview conducted with the Director of Surgical Services and the Director of Environmental Services confirmed the above findings.

19969 Based on observation, record review and staff interview, the facility failed to fully sprinkler the MRI (Magnetic Resonance Imaging) Building an existing health care occupancy as required by NFPA 101, (2012), 19,3.5.3, 9.7.1.1 (1), NFPA 13 (2010), with the additional requirement provided in the CMS (Centers for Medicare and Medicaid Services) S&C (Survey and Certification) letter 11-05 LSC Revised 02.18.2011. Findings included: 1. On 04/25/2017, the second day of survey, observation from 9:00 a.m. to 11:30 a.m. accompanied by the Facilities Manager revealed a MRI Building physically attached to the main hospital by a covered walkway. Continuing observation upon entering the building revealed smoke detectors and available egress through front and rear exits. There were no sprinkler heads observed. Staff interview of the Facilities Manager concurrent with tour confirmed the MRI building was protected by the hospital fire alarm system, however, the building was not sprinklered. On 04/25/2017 staff interview of the Imaging Department Manager revealed some inpatients did receive MRI procedures in the MRI Building. A request was made for a listing of all inpatients billed for MRI procedures for the months of January and February, 2017. On 04/25/2017 record review of the listings provided by the Imaging Department Manager of inpatients receiving MRI procedures revealed 29 inpatients in January, 2017 and 37 inpatients in February, 2017. On 04/25/2017 record review of NFPA 101 (2012) 19.1.3.1 Multiple occupancies revealed in section (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation. Record review of S&C-11-05-LSC REVISED 02.18.2011, revealed CMS does not consider the number of patients in determining if a provider is a hospital or a CAH; therefore, a CMS-certified hospital or CAH does not need to have four or more inpatients at all times in order to be classified as a Health Care Occupancy. Occupancy classification must be determined regardless of the number of patients served at a hospital's or CAH's component facility. Therefore, the facility does provide MRI procedures to hospital inpatients in the MRI Building and the MRI Building is a Health Care Occupancy and must meet existing health care requirements of NFPA 101, (2012), Chapter 19,3.5.3, 9.7.1.1 (1), as well as NFPA 13 (2010). NFPA 101, (2012), 19,3.5.3, 9.7.1.1 (1) NFPA 13 (2010) S&C-11-05-LSC REVISED 02.18.2011

19969 Based on observation and staff interview, the facility failed to maintain smoke barriers as required by NFPA (2012), 8.5.2.1, 8.5.2.2, 8.5.4.1, 8.4.4, and 4.6.12.5. Findings included: 1. On 04/24/2017 observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed penetration of smoke barriers (corridor walls above the suspended ceiling) and opening protectives (doors in means of egress of fire/smoke barriers). Examples of observed penetrations included: 2nd floor, Behavioral Health Unit, the means of egress corridor walls above the suspended ceiling penetrated by cables; means of egress corridor walls above the suspended ceiling at the IT (Information Technology) room with penetration by a cable; multiple penetrations through the suspended ceiling in the computer equipment room in which it was not possible, due to the fragility of the equipment, to determine whether the exterior walls to the compartment have been penetrated. Continuing observation revealed opening protectives (means of egress corridor doors) in which new door hardware had been installed and either the type of locking device or the wrong locking device had been installed resulting in 1/2 inch hole penetrations of the 1 1/2 inch substantial doors. Examples of observed penetrations included: the Nursing Station dictation room with 2 penetrations at the latching device and the third floor Wound Care Office 2 penetrations, 1/2 inch holes, at the latching device. Staff interview of the Facilities Manager concurrent with the tour acknowledged the penetrations above the suspended ceiling, in the IT room and in corridor doors. The facility is required to conduct an inspection of means of egress corridor walls above the suspended ceiling as well as opening protectives, means of egress corridor doors, identifying penetrations and the correction of the deficiencies by qualified personnel and maintaining documentation of the findings and outcomes for the authority having jurisdiction. NFPA (2012), 8.5.2.1, 8.5.2.2, 8.5.4.1, 8.4.4, 4.6.12.5

19969 Based on observation and staff interview, the facility failed to maintain water closet (bathroom) ventilation as required by NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8, and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Findings included: 1. On 04/24/2017, the first day of survey, observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed installed water closet ventilation units failed to operate upon testing by applying a piece of tissue paper to the face of the ventilation return resulting in the tissue falling from the return indicating no suction by the ventilation unit. Examples of the failed units include patient rooms 333, 363, 365, 387 and 219. The facility is required to conduct an inspection of all patient room water closet ventilation units determining the operation and if impaired to correct the deficiency and record the findings for review by the authority having jurisdiction. NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8 NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems

19969 Based on observation, record review and staff interview, the facility failed to maintain electrical safety as required by NFPA 101 (2012), 9.1.2, NFPA 70 (2011SB), Article 517 Health Care, NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8, 10.2.2.1.1, 6.4.4.1, and 6.4.4.1.2.1. Findings included: 1. On 04/24/2017 observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed in third floor patient rooms, electrical beds. Continuing observation when entering an empty patient room on the third floor and extracting the electric bed power cord from the duplex outlet revealed a three prong receptacle and the three prong power cord. Staff interview of the Facilities Manager, concurrent with tour, when asked whether all patient beds were three prong the response was yes. 2. On 04/25/2017 record review from 11:30 a.m. to 2:45 p.m. revealed no documentation of the testing of electrical beds with three prong power cords as required by NFPA 101 (2012), 9.1.2, NFPA 70 (2011SB), Article 517 Health Care, NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8 and 10.2.2.1.1. Staff interview of the Facilities Manager and assistant acknowledged there was no documentation of the testing of the patient beds. 3. On 04/25/2017 record review from 11:30 a.m. to 2:45 p.m. revealed no documentation of the annual inspection and periodic exercise of the main and feeder circuit breakers of the essential electrical system as required by NFPA 99 (2012) 6.4.4.1, Maintenance and Testing of Essential Electrical System and 6.4.4.1.2.1. Staff interview of the Facilities Manager and assistant confirmed there was no documentation of an annual inspection and periodic exercise of the main and feeder circuit breakers of the essential electrical system. NFPA 101 (2012), 9.1.2 NFPA 70 (2011SB), Article 517 Health Care NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8, 10.2.2.1.1, 6.4.4.1, 6.4.4.1.2.1

31098 Based on record review, policy review, and staff interview it was determined the facility failed to provide an appropriate screening examination that included ancillary services and failed to provide an appropriate transfer to 1 (#21) of 21 sampled patients. Please refer to A2406 and A2409.

31098 Based on record review, policy review and staff interview it was determined the facility failed to provide an appropriate screening examination to one (#21) of 21 sampled records. Findings included: The Emergency Provider Report dated 11/17/16 at 1:54 p.m. and signed by the Emergency physician included Patient #21 was 27 weeks pregnant and had been experiencing pain in her upper abdomen for the previous 2 days. The Physical Exam included the patient ' s vital signs were normal according the ambulance staff (EMS). The patient was not in acute distress. EMS reported no abnormal heart rhythm. The abdomen was described as gravid. There was no evidence of the physician's evaluation of the intensity of the patient's abdominal pain at the time she arrived nor at the time she departed. The record contained no evidence Patient #21 was offered diagnostic testing nor any treatment to relieve her pain before continuing in the same ambulance to the next hospital. The facility policy titled EMTALA-Screening and Stabilization, no policy number, effective 5/24/16 was reviewed on 11/28/16. The policy included documentation indicating the facility is required to provide an appropriate medical screening examination within the capability of the hospital's emergency services, including ancillary services routinely available to determine whether or not an Emergency Medical Condition (EMC) exists to any individual who requests services or presents in such a manner as a reasonable person would conclude an examination is necessary. An interview was conducted with the [NAME] President of Quality on 11/28/16 at approximately 10:00 a.m. She indicated she was present on 11/17/16 when the Director of Emergency Services called to say the department secretary observed a physician going out to examine a patient who was still in the ambulance. The [NAME] President of Quality and the Director of Emergency services determined from their interview with the ED physician that he had examined Patient #21 in the ambulance without bringing the patient into the facility and instructed the ambulance crew to take the patient to another hospital. She confirmed the above findings.

31098 Based on record review, policy review, and staff interview it was determined the facility failed to ensure one (#21) of 21 sampled patients was provided an appropriate transfer from the Emergency Department to another hospital. Findings included: The Emergency Provider Report dated 11/17/16 at 1:54 p.m. and signed by the Emergency physician included Patient #21 was 27 weeks pregnant and had been experiencing pain in her upper abdomen for the previous 2 days. The Physical Exam included the patient's vital signs were normal according the ambulance staff (EMS). The patient was not in acute distress. EMS reported no abnormal heart rhythm. The abdomen was described as gravid. The Emergency Provider Report included, Patient seen and examined in the ambulance bay and found to be medically cleared and stable to transfer to [another hospital]. Patient not in active labor but having abdominal pain for one day. My clinical reasoning is that this 3rd trimester patient with abdominal pain is not in labor but may start labor, so she should be at a facility with obstetrical and gynecologic services . There was no evidence the ED physician contacted the receiving facility at any time to ensure the receiving facility had the capability and capacity to accept the transfer of Patient #21. There was no evidence copies of the Provider Report, the only clinical information in the medical record, were sent to the receiving facility. The record did not include a Certificate of Transfer indicating the ED physician had provided Patient #21 with the information required for her to make an informed decision regarding her transfer, nor was there evidence the physician discussed the potential risks of transferring versus receiving treatment at this facility. The facility policy titled EMTALA-Transfer Policy, no policy number, effective 5/24/16 was reviewed on 11/28/16. The policy included documentation any transfer of an individual with an Emergency Medical Condition (EMC) must be initiated either by a written request for transfer or by a physician order with the appropriate physician certification as required under EMTALA. The policy required the physician to sign a certification that based upon the information available at the time of transfer the medical benefits of transfer outweighed the increased risks of the transfer, and the patient has been informed of the potential risks prior to making a decision. The policy indicated a transfer will be appropriate if the transferring hospital provided medical treatment within its capacity, the receiving hospital has available space and qualified personnel to provide appropriate treatment, and the transferring hospital sends the receiving hospital copies of all medical records related to the EMC. An interview was conducted with the [NAME] President of Quality on 11/28/16 at approximately 10:00 a.m. She indicated she was present on 11/17/16 when the Director of Emergency Services called to say the department secretary observed a physician going out to examine a patient who was still in the ambulance. The [NAME] President of Quality and the Director of Emergency services determined from their interview with the ED physician that he had examined Patient #21 in the ambulance without bringing the patient into the facility and instructed the ambulance crew to take the patient to another hospital. She confirmed the above findings.

31166 Based on medical record review, staff interview and review of on call coverage schedules, facility policy and procedures and transfer logs it was determined the facility failed to accept incoming appropriate transfers that were within the receiving facility's capabilities and capacity for two of (#22, #23) twenty-three patients sampled. Refer to findings in tag A-2411.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31166 Based on medical record review, staff interview and review of on call coverage schedules, facility policy and procedures and transfer logs it was determined the facility failed to accept incoming appropriate transfers that were within the receiving facility's capabilities and capacity for two of (#22, #23) twenty-three patients sampled. Findings include: An interview was conducted with the VP Quality/Patient Safety from [NAME] Community Hospital (the receiving facility -Facility A) on 12/17/2014 at 12:28 p.m. She stated on 11/29/2014 an ER (emergency room ) physician refused to accept transfers for two patients (#22, #23) from a transferring facility (Facility B- an acute care hospital). He stated had consulted with the GI (gastroenterologist) specialty physician on call. The GI physician stated facility B had GI coverage. Patient #22 was accepted at another facility. Patient #23 was accepted and transferred to another facility. The patients were refused for acceptance by the ER physician of facility A. Review of the medical record from Facility B for patient #22 revealed the patient presented to facility's B ED (Emergency Department) on 11/29/2014 for complaints of abdominal pain with nausea and vomiting for 6 days. This was the 3rd visit to the ED for the same symptoms. The patient had ongoing emesis despite medication and a plan to admit for intractable emesis. The physician documented no GI (gastroenterology) services were available with a transfer needed. Review of the form EMTALA/Memorandum of Transfer revealed the patient required care unavailable at facility A. Review of the medical record from Facility B for patient #23 revealed the patient presented to facility's B ED on 11/29/2014 for complaints of bloody sputum (hemoptysis) since 3:00 a.m. that day. Review of the ED physician documentation revealed the patient had a history of esophageal cancer. The patient would require admission for further evaluation. The ED physician documented they did not have GI on call and the hospitalist felt GI evaluation was needed. Review of the form EMTALA/Memorandum of Transfer revealed the patient required care unavailable at facility B. On 12/17/2014 at 12:28 p.m. an interview with the VP Quality/Safety and review of the call center log revealed on 11/29/2014 an ER (emergency room ) physician refused to accept a transfer for two patients (#22, #23) from facility B. He stated he had consulted with the GI specialty physician on call that stated facility B had GI coverage. Both patients were refused acceptance by facility A who had capacity and capability. The VP of Quality/Safety revealed only the AON (administrator on duty) had the authority to refuse a transfer per facility's A transfer policy and duty to accept. Review of the transfer logs for facility A revealed no evidence of patient #22 or #23 being accepted for transfer on 11/29/2014. Interview with the Nursing Director of Emergency Services on 12/17/2014 at 9:00 a.m. confirmed the patients (#22 and #23) were not on the transfer log dated 11/29/2014 due to the patients not being accepted for transfer. Review of the medical records for patient #22 and #23 and interviews with the VP Quality/Safety and the Nursing Director Emergency Services revealed both patients met the criteria for an individual with an Emergency Medical Condition that required specialized care for transfer by the ER physician of the Facility B to facility A. Review of Facility A's on call physician specialists Medicine Department On-Call Coverage Schedule for November 2014 revealed a Gastroenterologist was on call on 11/29/2014, the date of requested transfer but refused to accept patient #22 and #23. Review of the EMTALA - Transfer Policy dated 2/2014 with a purpose to establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an emergency medical condition (EMC), who requests or requires a transfer for further medical care and follow-up to a receiving as required by the Emergency Medical Treatment and Labor Act (EMTALA). The policy states that a hospital with specialized capabilities or facilities shall accept from a transferring facility an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. Under Section 3 - Authorization to Accept a Transfer, the policy states that, The Emergency Physician and the Hospital CEO or designee, such as the Administrator on Call (AOC) or the House Supervisor, are the ONLY individuals authorized to accept or refuse the transfer of an individual from another facility on behalf of the receiving hospital. Section 5 - Transfer Center Use, states that At the Emergency Physician's request, the Transfer Center must facilitate a discussion between the Emergency Physician and the on-call physician of the receiving facility. The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility

07459 Based on record review and interview the facility was not in compliance with 42 CFR ?489.24., the facility failed to examine or provide a medical screening exam for one patient (#21) and failed to comply with the regulations for transfer for two (#1 and #21)patients out of 21 patients reviewed. See A2406, A2407 and A2409.

07459 Based on Record Review and Interviews it was determined that the facility did not keep an accurate central log of individuals who come to the Emergency Department seeking emergency medical care for 1 out of 21 records reviewed #21. Findings Include: A review of the run report for the Hillsborough County Fire Rescue Service reveled that on on 2/23/2014 an Ambulance crew (R 38) responded to a private residence. They found a 2 year old infant in medical distress with a fever of 101.3 and a (Seal like bark) cough. They made arrangements to transport the resident and the mother wanted to go to the nearest Hospital. Patient was transported to Hospital #1. Upon arrival at the hospital the greeting ER nurse scolded the team of R 38, in front of the mother, and told them in a loud voice that Hospital #1 did not have an inpatient pediatric unit and asked why they brought the child to that facility. The crew of R38 were not told what bed to put the patient in only to pick an empty one by this RN. After waiting about 10 minutes in the room the mother became concerned that her child was not going to be seen and doubting the facilities desire to provide care for her child asked R 38 to transport the patient to another Hospital. During the tour of the emergency department on the morning of March 05, 2014 accompanied by an emergency department (ED) nurse and the VP of Quality Services and Risk management, an interview revealed that the normal practice for an Ambulance bring a patient to the ED was for a radio contact to be made between the two and the ED given the vital information on the patient being transported. If radio contact was not possible then the crews used a cell phone for contact. A review of the Run Report dated 2/23/2014 revealed that during the initial contact between the crew of R 38 and the RN that evening one of the crew members asked why they were not told not to bring the child to the ED when the Radio Call was made. A record review of patient #21 from Hospital #2 reveled that the patient did arrive at their facility at 23:55 and that patient #21 was provided a Medical Screening exam and that stabilizing medical care was provided. Pediatric patient was discharge to Home in the care of it's mother. The central log for the dates in question were reviewed and there was no entry for Resident # 21 on the central log. An Interview with the Interim Risk Manager on March 5, 2014 at approximately 11:30 a.m. revealed that the facility was aware of the incident but did not know the name of the patient and felt that since the crew of R 38 took the patient to another hospital that this patient was never a patient of Hospital # 1.

07459 Based on Record Review and Interviews it was determined that a medical screening examination was not performed on 1 out of 21 (#21) patient records reviewed. A medical record for patient # 21 did not exist at this facility as patient # 21 left the Emergency department before the Medical Screening Examination to seek health care elsewhere. Findings Include: Patient #21 arrived by ambulance at 23:17 on 2/23/2014 enroute the Ambulance Crew (R38) made Radio contact with Hospital #1 and let the hospital know the vital information on the pediatric patient they were transporting. The two year old patient had a fever of 101.3 and a (Seal like bark) cough. The Crew of R 38 brought patient #21 into the Emergency Department and were told by the greeting RN to put the patient anywhere so they took patient and mother to a room in the western cubical portion (fast track) of the Emergency Department. After waiting a period of time without being seen the mother became concerned and told the Ambulance crew she felt uncomfortable after the hostile greeting and wanted them to take patient #21 to another hospital. After contacting the Chief the ambulance crew placed patient # 21 back in the ambulance and transported mother and patient #21 to Hospital #2. An Interview with the Interim Risk Manager on March 5, 2014 at approximately 11:30 a.m. revealed that the facility was aware of the incident but did not know the name of the patient and felt that since the crew of R38 took the patient to another hospital that this patient was never a patient of Hospital #1. The interview confirmed that patient #21 was not entered on the hospital's log and that no record for patient #21 existed at hospital #1. Patient #21 was not triaged, nor was a Medical Screening Exam done by Hospital #1 to determine if a medical emergency existed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 07459 Based on Record Review and Interview it was determined that the facility did not provide emergency medial examination and treatment for 1 out of 21 records reviewed #21. Patient #21 arrived at the facility on 2/23/2014 at 22:55 and left the faciity on [DATE] at approximately 23:18, without being examined or treated by hospital staff. Findings Include: 1. Based on review of the ambulance run report, #0013769, signed 2/23/2014, it was determined that patient #21 was brought to the facility on [DATE] the patient was placed in a room in the fast track area and never examined by hospital personnel. After waiting some time in the room the pediatric patient's mother asked the ambulance crew to take the sick child to another hospital, which they did. 2. In an interview with the Risk Manager on 3/05/2014 at approximately 10:00 it was learned that the facility had done an internal investigation related to Patient #21 and the facility had self reported the incident to the Agency for Health Care Administration on February 27, 2014. It was also discovered based on this interview that the facility did not have any patient documentation on the resident and there was not an entry on the central log or a medical record of this visit available. The interview confirmed that patient #21 was not examined or treated while in the Emergency Department. 3. A review of investigation done by the interim Risk Manager revealed that it consisted of An interview with the nurse who spoke to the Ambulance Crew, an interview of the unit secretary, and interview of 3 other department staff. The investigation did not obtain the Ambulance Run Report or a medical record from the treating facility. The Interim Risk Manager confirmed that they did not even know the name for this patient. 4. Stabilizing medical treatment was not provided by hospital #1. Medical Records obtained from hospital #2 confirmed that hospital #2 did provide a medical screening examination and treatment for patient #21 later that evening.

07459 Based on Record Review and Interview it was determined that the facility did not make appropriate transfer arrangements for two, (#1 and #21) of 21 records reviewed during this investigation. Findings Include: Patient #21 was in the Emergency Department of Hospital 1 on February 23, 2014 when the mother asked the ambulance crew, who brought the infant patient to the facility, to take them to another hospital. The Ambulance Crew agreed to do so and left the emergency department with the patient enroute to another facility. The risks benefits of this transfer were never explained to the mother. The facility did not make arrangements with another facility to care for the patient. An interview with the Interim Risk Manager on March 5, 2014 at approximately 11:30 a.m. revealed that the facility was aware of the incident but did not know the name of patient #21 and that no record other than her internal investigation existed of this encounter. Patient #1's record contained form called EMTALA/COBRA/Memorandum of Transfer dated 1/26/2014. This form was used by Hospital 1 to record the Risks and Benefits of a transfer to the patient from their facility to another. The form for Patient #1 was checked that the patient was stable and the reason for the transfer was to a Higher level of Care. Risks were only listed as MVA. The benefits portion of the form was blank. Patient #1 was transferred to hospital #3 for definitive medical care on . An interview with the VP of Quality/Risk management on 3/06/2014 at approximately 13:30 revealed that she had reviewed this form and was unsure why the patient was transferred. She agreed that because of this lack of understanding, that she did not know the benefits, to the patient, for the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28028 Based on medical record review, policy and procedure review, and staff interview it was determined the facility failed to ensure nursing staff provided interventions for a patient identified with pain for one (#2) of ten patients sampled; failed to assess the patient's pain level prior to providing pain medication and following administration of pain medication for one (#4) of ten patients sampled; and failed to ensure two (2) physician ordered consultations were completed for one (#2) of ten patients sampled. Findings include: 1. Review of the medical record for patient #2 revealed the patient was admitted to the facility on [DATE]. Review of nursing documentation revealed on 9/19/2013 at 3:12 p.m., the patient complained of back pain of 8 out of 10 with 10 being the worst possible pain. Review of the nursing documentation and MAR (Medication Administration Record) revealed the patient was medicated for pain at 7:01 p.m., approximately four (4) hours after complaining of pain. Review of the nursing documentation revealed no alternative interventions were offered or provided during those four hours. Interview with the Clinical Educator and Chief Nursing Officer on 11/26/2013 at approximately 2:30 p.m., confirmed the findings. 2. Review of the medical record for patient #4 revealed the patient was admitted to the facility on [DATE] status post a fall at home. Documentation revealed the patient sustained a fractured ankle requiring surgical repair. Review of the MAR revealed on 9/21/2013 at 9:57 p.m. Morphine 4 mg (milligrams) was administered IV (Intravenously). Review of the nursing documentation revealed no evidence the patient's pain level was assessed prior to administration of the Morphine. Review of the nursing documentation revealed no evidence the patient's pain level was assessed post administration of the Morphine. There was no documentation to reveal if the pain medication was effective. On 9/22/2013 at 3:38 a.m. Morphine 4 mg IV was administered. Review of the nursing documentation revealed no evidence of a pre or post pain level assessment. There was no documentation to reveal if the pain medication was effective for the patient's pain. Review of the facility, Pain Management, #PC 350, last approved 6/2012, states (II) Intervention, (D) re-evaluation occurs within 30 minutes to 1 hour following intervention, with documentation of the time; pain score, level of sedation, descriptors and/or non-verbal signs. Interview on 11/26/2013 at 11:30 am with the Clinical Educator confirmed the above findings. 3. Review of the medical record for patient #2 revealed the patient was admitted to the facility on [DATE]. Review of the physician orders revealed on 9/19/2013 at 6:15 am a pain management consultation was ordered. Review of nursing documentation on 9/19/2013 at 5:32 p.m., stated pain consultation not placed earlier, consult called by secretary. Review of the record revealed the consultation was not completed as ordered. The patient was discharged on [DATE]. Review of the physician orders revealed on 9/18/2013 at 7:00 p.m., a pulmonologist radiologist consultation was ordered. Review of the medical record revealed no evidence the consultation was completed. Interview with the Chief Nursing Officer on 11/26/2013 at approximately 2:30 p.m., confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28028 Based on medical record review, staff interview, and review of policy and procedure it was determined the facility failed to ensure the nursing staff kept current the nursing care plan and reviewed it daily for one (#2) of ten patients sampled. Findings include: Review of the medical record for patient #2 revealed the patient was admitted to the facility on [DATE] with a diagnosis of Pulmonary Embolus. Review of the patient's interdisciplinary plan of care revealed nursing identified knowledge deficit, discharge planning, safety, and pain as the focus areas. Review of the plan of care revealed no evidence nursing identified airway management/gas exchange as a focus area. The patient's admitting diagnosis was pulmonary embolus and documentation revealed the patient had abnormal breath sounds, complained of a cough, and chest discomfort. Review of the medical record revealed a pulmonologist evaluated the patient on 9/19/2013 and documented the patient had symptoms of gastroesophageal reflux disease, chronic obstructive pulmonary disease, and was a heavy smoker. Review of the patient's plan of care on 9/19/2013 and 9/20/2013 revealed no further documentation. Review of the facility policy, Assessment and Reassessment, last approved 11/2012, states the patient plan of care will be reviewed at least daily by an RN. Interview with the Clinical Educator and Chief Nursing Officer on 11/26/2013 at 2:30 p.m., confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28028 Based on medical record review and staff interview it was determined the facility failed to ensure nursing staff administered medication according to physician orders for one (#2) of ten patients sampled. Findings include: Review of the medical record for patient #2 revealed the patient was admitted on [DATE]. Review of the physician orders revealed on 9/19/2013 at 8:24 am an order for Solumedrol 30 mg (milligrams) IV (Intravenous) every 12 hours. Review of the MAR (Medication Administration Record) revealed the first dose of Solumedrol was administered on 9/19/2013 at 11:33 pm, approximately 15 hours after the physician order was written. Review of the record revealed no evidence or documentation to explain the delay in providing the medication. Interview with the Clinical Educator on 11/26/2013 at approximately 11:15 am confirmed the findings.