CMS-Henrico-Doctors-Hospital

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Based on interviews and document review, it was determined the facility staff failed to utilize a restraint in accordance with the patient's plan of care by not having an active restraint order for one (1) out of three (3) patients (Patient #3, #8, and #9) on 10/20/21 and 10/25/21.

The findings included:

The surveyor received facility policy titled, Restraints/Seclusion, Patient (with last revised date of 12/20) on 12/25/21 at 12:55 pm by Staff Member #1.

Under the Order for Restraint with Non-Violent or Non-Self-Destructive Behavior section, the policy reads, Renewal restraint order: If reassessment indicates an ongoing need for restraint, a renewal restraint order must be entered into the medical record within 24 hours of the initial restraint order. Subsequent renewal orders will be entered for each calendar day by the physician or other licensed practitioner, authorized by State law to order restraints.

The surveyor reviewed the restraint documentation record of Patient #8 on 10/26/21 at 11:53 am. Record review revealed Patient #8 was ordered a Posey enclosure non-violent restraint on 10/19/21 at 6:45 pm by the following physician (Staff Member # 28). The order shows that the restraint was ordered as getting out of bed would cause an extreme injury risk for Patient #8.

Note: the H&P provider note authored by Staff Member #28 on 10/19/21 at 12:15 pm indicates Patient #8 was a nonverbal autistic and mentally challenged young adult who was unable to listen to instructions and was a safety risk.

The restraint order was set to last twenty-four (24) hours, and was set to expire the next day on 10/20/21.

The surveyor was unable to find renewed orders for the Posey restraint enclosure for 10/20/21, as well as for 10/25/21, despite Patient #8 still having the restraint as evidenced by clinical documentation in the medical record confirming the restraint was still being used on both days.

At the end of day on 10/26/21, the surveyor confirmed with Staff Member #9 that Patient #8 continued to have the Posey restraint enclosure despite having renewed restraint orders on 10/20/21 and 10/25/21 by the physician, per policy.

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Based on interviews and document review, it was determined the facility staff failed to monitor the non-violent restrained patient by not performing the required two-hour assessment criteria for one (1) out of three (3) patients (Patient #3, #8, and #9).

The findings included:

The surveyor received facility policy titled, Restraints/Seclusion, Patient (with last revised date of 12/20) on 12/25/21 at 12:55 pm by Staff Member #1.

Under Monitoring the Patient in Restraints or Seclusion section of Page 4, the policy states, An RN will assess the patient at least every two hours. The assessment will include where appropriate:

1. Signs of injury associated with restraint, including circulation of affected extremities

2. Respiratory and cardiac status

3. Psychological status, including level of distress or agitation, mental status and cognitive functioning

4. Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met

5. Hydration/nutritional needs are being met

6. Hygiene, toileting/elimination needs are being met

7. The patient's rights, dignity, and safety are maintained

8. Patient's understanding of reasons for restraint and criteria for release from restraint

9. Consideration of less restrictive alternatives to restraint.

The surveyor reviewed the restraint documentation record of Patient #8 on 10/26/21 at 11:53 am. Record review revealed Patient #8 was ordered a Posey enclosure as a non-violent restraint on 10/19/21 at 6:45 pm by the following physician (Staff Member # 28). The order shows that the restraint was ordered as getting out of bed would cause an extreme injury risk for Patient #8.

Note: the H&P provider note authored by Staff Member #28 on 10/19/21 at 12:15 pm indicates Patient #8 was a nonverbal autistic and mentally challenged young adult who was unable to listen to instructions and was a safety risk.

During medical record review with Staff Member #9, the surveyor observed that the required two (2)-hour restraint monitoring section was entirely incomplete on the following occasions: 10/20/21 between 10:45 am through 8:00 pm, 10/21/21 between 9:30 am through 3:00 pm, and 10/22/21 between 2:00 pm through 8:00 pm.

The surveyor confirmed with Staff Member #9 and through clinical record that Patient #9 was under the Posey enclosure restraint during throughout these aforementioned periods.

At the end of day on 10/26/21, Staff Member #9 confirmed that the two (2) hour restraint monitoring documentation was not performed per policy for Patient #8 on the three (3) occasions.

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

Based on staff interview, clinical record review, and facility documentation review, it was determined the facility staff failed to monitor per facility policy, two (2) of three (3) patients in the survey sample (Patient #6 and Patient #7) who received blood transfusions.

The findings included:

On 10/26/21 at 2:05 p.m. Patient #6's electronic clinical record was reviewed with the Director of Quality (Staff #8). The review revealed Patient #6 was admitted to the facility on [DATE] with abdominal pain and rectal bleeding and was discharged on [DATE].

A review of physician's orders revealed on 10/8/21 1 unit of red blood cells (RBC) was ordered due to a low hemoglobin level of 6.6. Documentation showed the blood transfusion began on 10/8/21 at 1550 (3:50 p.m.) and ended on 10/8/21 at 1747 (5:47 p.m.).

Pre-transfusion vital signs were documented on 10/8/21 at 1504 (3:04 p.m.) however there were no vital signs documented during or at the time the transfusion was completed. Staff #8 identified a scanned blood transfusion slip within the electronic medical record and no vital signs were documented on the slip either.

On 10/26/21 at 3:00 p.m. a telephone interview was conducted with the Laboratory Manager (Staff #19). Staff #19 stated she was unable to see vitals on her end.

Facility policy titled Blood and Blood Products, Administration of with a revised date of 4/2020 included:

...E. 4. Monitor patient according to policy guidelines:

a. Vital signs will be obtained prior to starting the transfusion, after 15 minutes, and at the termination of the transfusion...

Staff #8 confirmed the vital signs should have been obtained pre transfusion, after 15 minutes and at the end of the transfusion. The administrative team was informed of the finding during exit conference on 10/27/21.

On 10/26/21 at 2:30 p.m. Patient #7's electronic clinical record was reviewed with the Director of Quality (Staff #8). The review revealed Patient #7 was admitted to the facility on [DATE] with abdominal pain and GI bleed and was discharged on [DATE].

A review of physician's orders revealed on 10/14/21 1 unit of red blood cells (RBC) was ordered due to a low hemoglobin level of 6.0. Documentation showed the blood transfusion began on 10/14/21 at 1837 (6:37 p.m.) and ended on 10/14/21 at 2209 (10:09 p.m.).

Pre-transfusion vital signs were documented on 10/14/21 at 1830 (6:30 p.m.) and at 1852 (6:52 p.m.), however there were no vital signs documented at the time the transfusion was completed.

Facility policy titled Blood and Blood Products, Administration of with a revised date of 4/2020 included:

...E. 4. Monitor patient according to policy guidelines:

a. Vital signs will be obtained prior to starting the transfusion, after 15 minutes, and at the termination of the transfusion...

Staff #8 confirmed the vital signs should have been obtained pre transfusion, after 15 minutes and at the end of the transfusion. The administrative team was informed of the finding during exit conference on 10/27/21.

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Based on interviews and document review, it was determined the facility staff failed to perform a safe discharge in ensuring the appropriate provision and transmission of patient information by not notifying the post-hospital facility that a patient was sent to be admitted for (1) out of three (3) patients (Patient #1, #10, and #11).

The findings included:

The surveyor reviewed the clinical record of Patient #1 on 10/26/21 at 11:53 am. Record review revealed Patient #1 was sent to the facility Emergency Department (ED) via EMS from a psychiatric assisted living facility (ALF) on 10/23/21. On 10/27/21, orders were made to discharge to Patient #1 back to the previous ALF.

The progress notes reveal ED staff arranged for Hospital to Home private transportation services to take Patient #1 back to the psychiatric ALF on 10/27/21. The surveyor was unable to find any documentation pertaining to notifying the ALF of the plan for Patient #1 to be discharged back.

Staff Member #9 contacted the ED Nurse Manager (Staff Member #26) who confirmed they did not contact the ALF, nor could provide any ED staff who did contact the facility regarding the discharge plan.

Both Staff Member #9 and Staff Member #29 (Director of Case Management) confirmed at this time that there was no documentation in the clinical record of Patient #1 that the facility staff had called a report to the ALF that the patient was being dropped off at the facility.

The surveyor received facility policy titled, Discharge Planning and the Continuum of Care (with last revised date of 01/19) on 12/25/21 at 12:55 pm by Staff Member #1.

Under Discharge Planning and Communication section, the policy reads, Appropriate information will be shared with other providers to ensure continuity of care in a timely manner. The information will be shared in a report (verbal and/or written) to the next provider of care.

The surveyor interviewed the Chief Medical Officer of the Emergency Department (Staff Member #30) on 10/27/21 at 2:10 pm. Staff Member #30 stated that it is the expectation for a staff member, such as a nurse, case manager, or provider to provide a report regarding the discharge plan to a facility post-discharge.

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Based on staff interview and review of facility documents, it was determined that facility staff failed to ensure that the facility's complaint and grievance policy was followed related to the written response grievance resolution process for thirty-four (34) out of one hundred and eighty-one (181) reported grievances.

Findings included:

A review of the facility's complaint and grievance log for the time period from 7/1/19 through 1/21/2020 revealed one hundred and eighty-one (181) reported grievances. Nine (9) of the grievances on the log which had not been documented as resolved were still within the 21 day response timeframe. Fifty-eight (58) of the remaining grievances on the log did not have a documented resolution date which fell within the 21 day timeframe. Of the aforementioned fifty-eight (58) grievances which had not been resolved within 21 days, twenty-four (24) were related to billing issues. Thirty-four (34) grievances which were not related to billing issues fell outside the 21 day timeframe for resolution, as described in the facility's policy and procedure.

Staff Member (SM) #1, Patient Safety Director, was interviewed on 1/28/2020 at 9:00 a.m., and the surveyor held a discussion related to the number of grievances which had exceeded the 21 day resolution timeframe, as specified in the facility's complaint and grievance policy. SM #1 replied that the facility has realized that grievances are not always closed within 21 days as specified in the policy, but that the investigations are robust, and physicians sometimes also review, depending on what needs to be reviewed. SM #1 also added that billing information doesn't drop for six (6) weeks, so those complaints can not be resolved in the specified time frame. SM #1 told the surveyor that staff communicates with the complainant throughout the process, and do our best to document that communication.

The surveyor randomly selected a grievance from the log and walked through it with SM #1. SM #1 was able to demonstrate that, although the grievance was not resolved within the 21 day timeframe, there was documentation of communication with the complainant throughout the facility's investigative process. SM #1 told the surveyor that that they review all letters before they go out to complainants, and that SM #31, Patient Advocate, talks with the family and or patients, and that SM #1 bridges the gap.

Concerns related to the grievance policy time frame expectation not being met with a large number of cases on the grievance log were discussed with SM #1 as noted above, and with SM #7, Vice President of Quality, on 1/30/2020 at approximately 2:30 p.m.

The facility's complaint and grievance policy, last revised 10/17/17, was reviewed and included the following information, in part, related to the grievance resolution process: ...2. Upon receipt of a grievance, the Patient Advocate shall confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven (7) days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient. A representative of the administrative staff will oversee and assist with the resolution process as needed. Medical staff leadership may be involved as needed to resolve physician delivery of care issues. 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....

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Based on interviews and document review, it was determined the facility staff failed to ensure a patient having restraints and/or seclusion utilized for violent behaviors was evaluated within the required time limits for one (1) of four (4) patients sampled for restraint review (Patient 9). Two (2) of the four (4) sampled patients had restraints implemented due to violent behaviors.

The findings include:

Patient #9's clinical documentation failed to provide evidence of the face-to-face assessment being completed within one (1) hour of the initiation of restraints and/or seclusion for violent behaviors. It was also identified that the facility's written policy and procedure incorrectly provided guidance to indicate a face-to-face was not required within the 1-hour time frame if the restraints and/or seclusion was discontinued prior to the completion of the 1-hour face-to-face assessment.

The following nursing documentation was dated 7/10/17 at 9:21 but the content of the documentation detailed events earlier the same day (prior to the initiation of restraints and seclusion): ... (he/she) INITIALLY REFUSED TO COOPERATE WITH THE SKIN ASSESSMENT AND SAFETY SEARCH BUT FINALLY DID WITH MUCH ENCOURAGMENT AND SARCASM [sic]. (he/she) THEN STARTED TO BANG (his/her) HAND ON WINDOW AND SAID (he/she) WOULD MAKE (his/her) HANDS BLOODY. (He/She) THEN SAID (he/she) WOULD JUST FIND SOMETHINGIN THE BATHROOM TO HURT OR HANG (himself/herself) ...

Patient #9's clinical documentation included the following nursing documentation dated 7/10/17 at 8:53AM: Upon arrival to the unit, patient was noted to be increasingly agitated with staff and attempting to elope. Patient walked into the seclusion room, without hands-on interventions. CPI De-Escalation techniques (orientation, reassurance, offering of food/beverage) used to help de-escalate patient. At 0710, seclusion room door was locked to prevent patient from eloping and harming staff. Haldol 5 mg IM, Ativan 2 MG IM, and Benadryl 50 mg IM order [sic] and seclusion order obtained from (doctor's name omitted). This writer maintained constant observation of patient. Patient begin [sic] to head bang and door was unlocked at 0720. (RN name omitted) administered IM medications for patient. Patient accepted medication willingly. At this time, patient noted to still be agitated, stating <> [sic] and requested to leave. This writer contacted (name omitted) at (agency initials omitted) to have patient evaluated for TDO ...

The following medication orders were found in Patient #9's clinical documentation: (1) on 7/10/17 at 6:59AM an order for Bendaryl 50mg IM (intramuscular injection) as a one-time dose; (2) on 7/10/17 at 6:59AM an order for Ativan 2mg IM as a one-time dose; and (3) on 7/10/17 at 6:59 Haldol 5mg IM as a one-time dose. Patient #9's clinical record also included orders for Seclusion documented as being entered on 7/10/17 at 7:25AM; this seclusion order was for the events documented in the aforementioned nursing documentation.

Patient #9's clinical documentation indicated on 7/10/17 the patient was placed in seclusion at 7:10AM and removed from seclusion at 7:20AM.

Documentation was not found in Patient #9's clinical record to indicate the 1-hour face-to-face assessment had been completed.

The following information was found in a facility policy and procedure provided to the survey team after the entrance conference; this policy and procedure was entitled Restraints, Patient (with an effective date and a last review date of 02/2016): Face-to-face assessment by a Physician or LIP: 1. Face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardized 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: a. Work with staff and patient to identify ways to help the patient regain control b. Evaluate the patient's immediate situation c. Evaluate the patient's reaction to the intervention d. Evaluate the patient's medical and behavioral condition e. Evaluate the need to continue or terminate the restraint or seclusion f. Revise the plan of care, treatment and services as needed Note: A telephone call or telemedicine methodology does not constitute face-to-face assessment. 2. When the 1-hour face-to-face is performed by a RN or physician assistant with demonstrated competence, the following must occur: a. The RN or physician assistant with demonstrated competence must consult the attending physician or LIP who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. (As soon as possible is to be as soon as the attending physician is able to be reached by phone or in-person.) A consultation that is not conducted prior to renewal of the order would not be consistent with the requirement as soon as possible. b. The consultation should include, at a minimum, a discussion of the findings of the 1-hour face-to-face evaluation, the need for other treatments, and the need to continue or discontinue the use of restraint or seclusion. c. If a patient who is restrained or secluded for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the face-to-face assessment, the physician must still see the patient face-to-face to perform the assessment within 24 hours.

The following information was found in APPENDIX D: DEFINITIONS of the aforementioned

Restraints, Patient policy and procedure. This is part of the definition for Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition is considered a restraint. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. A mediation that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint ...

On 7/19/17 at 1:50PM, Staff Member (SM) #7 (a registered nurse (RN)) was interviewed with the facility's Quality Manager present. SM #7 was the RN that was responsible for the completion of 1-hour face-to-face assessment for the medications as restraints and seclusion utilized for Patient #9 on the morning of 7/10/17. SM #7 reported that he/she did see Patient #7 after the medications was administered and the patient was removed from seclusion. SM #7 acknowledged no assessment was documented and the physician wasn't contacted because the medications changed the behaviors so (the patient) didn't need to be in seclusion.

On 7/20/17 at 9:25 during a survey team meeting with the facility's Vice-President of Quality and Risk, Chief Executive Officer (CEO), Quality Manager, and Chief Nursing Office (CNO), the failure of the facility staff to ensure a 1-hour face-to-face assessment was completed and documented, after Patient #9 was administered medication and placed in seclusion for 10 minutes on the morning of 7/10/17, in response to patient behaviors, was discussed.

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Based on observations, interviews and findings during a complaint investigation, it was determined the chief executive officer failed to ensure written process and procedures were in place for tracking patient remains placed in the facility's Morgue and maintaining the Morgue unit.

The findings included:

The surveyors entered the facility on 02/27/2017 at 10:15 a.m. and after a brief introduction with Staff Member #1 a tour was requested of the facility's Morgue.

While walking to the Morgue, Staff Member #1 explained the facility's Morgue was a built in refrigeration unit located on the first floor in a hallway, which had access to the loading dock. Staff Member #1 and the surveyors arrived at the Morgue unit by 10:28 a.m. on 02/27/2017. Staff Member #1 then placed a call for access to the Morgue refrigeration unit. At 10:36 a.m. on 02/27/2017 Staff Members #4 and #5 arrived with the key to the Morgue unit. Staff Member #5 opened the Morgue unit to reveal one black body bag with remains.

During the observation, Staff Member #6 arrived at approximately 10:38 a.m., and explained the Morgue unit was under his/her department's responsibility. The surveyor requested the past eighteen (18) months of temperature logs for the Morgue unit. Staff Member #6 explained his/her department did not keep documented temperature logs for the Morgue unit. Staff Member #6 stated, When my personnel performs rounds they glance at the gauge and if it is alright, they move on. The surveyor inquired how Staff Member #6's staff would know if the Morgue unit was working at the right temperature. Staff Member #6 reported if the unit was running, it was at the right temperature. The surveyor requested a list of patients' remains stored in the Morgue unit with their disposition and documented maintenance service performed on the Morgue unit for the past three years.

At 10:41 a.m. on 02/27/2017 Staff Member #5 presented a document titled Funeral Home-August [no year designated] to the surveyors. Staff Member #4 stated We started a process in August (2016). Staff Member #4 reported the document listed the names of the deceased patients with the date the body was placed in the Morgue unit and which funeral home picked up the bodies. The document listed three (3) bodies for the month of August 2016, one (1) body for October 2016 and one (1) body for January 2017. Staff Member #4 could not offer the reason the log was started or if the log was complete. Staff Member #4 verified the form only listed one date, which Staff Member #4 reported was the date the body was placed in the Morgue unit. The surveyor inquired regarding determination when the bodies were picked up by the funeral home. Staff Member #4 stated, In order to determine the date the body was released to the funeral home you would have to look at each patient's death record.

An entrance conference and interview was conducted on 02/27/2017 at 11:50 a.m., with Staff Members #1, #2, and #3. The surveyors discussed the findings and requested the policies, procedures, and the previously requested list of all remains held in the facility's Morgue for the past three (3) years as well as any remains held longer than one (1) year.

An interview was conducted on 02/27/2017 at 2:02 p.m., with Staff Member #6 and Staff Members #1 and #2 were present. Staff Member #6 presented two (2) service invoices for service performed on the Body Cooler by an outside vendor. Staff member #6 reviewed the vendor documents with the surveyor. One invoice documented the bodies within the Morgue unit needed to be removed. The surveyor requested information related to the bodies that were removed, where the bodies went and if they returned to the facility's Morgue unit once it had been repaired. The documents presented by Staff Member #6 were difficult to read and the surveyor requested legible copies. Staff Member #6 reported he/she would have to contact the service vendor to email their copy of the original invoices. Staff Member #6 reported if any other service had been performed by facility's maintenance staff on the Morgue unit, it had not been documented.

Staff Member #6 presented legible copies at 2:31 p.m. on 02/27/2017. Review of the outside vendor's Service Work Order dated 9/18/2016 [Sunday] read: Evap (evaporator) coil block of ice. Unit running after condenser water restarted. Waiting for bodies to be removed. Send tech (technician) Monday morning [Sic]. The second invoice was dated 09/19/2016 read in part: Located leak Liquid valve not back seating & (and) valve stem Packing ^ (increase) packing & add dress fitting ... Pull vacuum & recharge. Set water valve ... Install Temp (temperature) control to maintain temp in box [Sic].

On 02/27/2017 Staff Member #2 presented a list of patients who had died at the facility for the past three (3) years. Staff Member #2 reported the list would also contain patients that died on hospice service. Staff Member #2 explained that a hospice service rented space within the facility and utilized the facility's Morgue unit. Staff Member #2 reported if the patient died while on that hospice service the facility would not have a death record, since the hospice nurse would be completing the form and it would be part of the hospice service's medical record. Staff Members #1 and #2 verified the facility did not have a system to determine if or when a deceased hospice patient's remains were picked up from the facility's Morgue unit since the date for pick-up was only listed on the death record. The surveyors picked a sample from the deceased patients list provided and the Funeral Home-August document.

A review was conducted on 02/28/2017 of the lease agreement between the facility and the hospice service. The lease agreement did not include the hospice service's use of the facility's Morgue unit. The lease agreement did not include information related to the actions to be taken by the hospice service staff whenever a hospice patient died at the facility.

On 02/28/2017 at 8:25 a.m., the surveyor reviewed Patient #8's electronic medical record (EMR) which included scanned paper documents with Staff Member #15. Patient #8's name was pulled from the facility's Funeral Home-August form the date associated with Patient #8 was 8/26/16. During the review of Patient #8's medical record, it was determined the patient died at the facility. The review revealed Patient #8's Death Report did not have documentation the funeral home had picked up the remains. The surveyor inquired if the body currently in the facility's Morgue unit belonged to Patient #8.

An interview was conducted on 02/28/2017 at 8:51 a.m., with Staff Members #1 and #2. Staff Member #2 provided the name of the patient's remains, which was currently in the Morgue unit. Staff Member #2 clarified the date on the Funeral Home-August form was the date the funeral home pick-up the body not the date the body had been placed in the Morgue unit. The surveyor informed Staff Members #1, #2, and #15 the name provided for the remains currently in the Morgue unit was not included on the list of patients that had died in the past three (3) year or the Funeral Home-August form. Staff Members #2 and #15 verified the patient had not been included. The identified patient was added to the survey sample and designated as Patient #10.

An interview was conducted on 02/28/2017 at 2:12 p.m., with Staff Members #1, #2, and #3. Staff Member #1 reported the facility did not have a means to track the remains of patients placed in the Morgue unit by the facility or the hospice service. Staff Member #1 reported the facility did not have a log or tracking documentation related to if the deceased patient's remains were picked up from here and transported to another one of our facilities during the repairs on the Morgue unit. We will only have when the funeral home picked the patient up on their death record. Staff Member #1 reported the facility did not have a means to determine which remains were removed when the Morgue unit was under repair, where the remains were transported, if families were notified of the transfer, or if the remains were returned to the facility.

An interview and document review was conducted on 03/01/2017 with Staff Member #1. Staff Member #1 reported he/she had contacted the manufacturer of the Morgue refrigeration unit. Staff Member #1 reported the manufacturer did not have an operation manual for the exact model of the facility's Morgue unit. Staff Member #1 reported the manufacturer had assured him/her the information being presented regarding the facility's Morgue unit's operation would be the same. Staff Member #1 reported the manufacturer's Maintenance Instructions only recommended but did not require annual inspection of the unit. Staff Member #1 did verify the manufacturer's Maintenance Instructions included cleaning the unit to eliminate organisms.

Review of the manufacturer's Maintenance Instructions read in part: 1. To protect the cabinet finish as well as the product, the refrigerator should be cleaned often using lukewarm water and a good fungicidal detergent to eliminate air borne low temperature growing organisms ... 3. The condensing unit is completely sealed and needs no oiling or other lubrication. However, the finned condensing unit through which air passes can become clogged with lint and other foreign substances in the air. The opening between the fins should be cleaned of lint every few months ... 4. An annual inspection of the mechanical refrigerating equipment by a competent serviceman is recommended, as a mechanic can frequently make adjustments, which prevent breakdown in the future ...

An interview was conducted on 03/01/2017 at 2:35 p.m., with Staff Member #11. Staff Members #1 and #2 were present during the interview. Staff Member #11 reported the cleaning of the Morgue unit was not directly his/her department's responsibility. Staff Member #1 reported related to the findings the facility recognized opportunity for change. Staff Member #1 reported the Morgue unit, had not previously been included on the facility's environment of care rounds but would be added. A request was made for the facility's policy related to cleaning the Morgue unit.

An interview was conducted on 03/01/2017 at 3:32 p.m., with Staff Members #1, #2, and #3. Staff Member #1 verified the lease agreement did not include how the hospice service would handle their deceased patient's remains. Staff Member #1 reported the facility had viewed the hospice service used of the facility's Morgue unit, like electrical or water services provided to a tenant.

An interview was conducted on 03/02/2017 with Staff Member #1. Staff Member #1 presented a policy titled Morgue Cleaning. Staff Member #1 reported the policy was primarily for facilities within their healthcare system that performed autopsies.

Review of the facility's policy titled Morgue Cleaning read in part: Purpose: To ensure systematic cleaning procedure. Responsible Persons: All Environmental Service Staff [EVS]. Policy: EVS: The morgue will be cleaned daily as needed and after autopsy ... The policy directed staff to clean the room including floors, window sills and walls. The policy was not specific to the cleaning of a refrigerated Morgue unit.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. Staff Member #6 presented documentation related to the facility's preventative maintenance program. Staff Member #6 presented the rating system utilized by the facility, which placed equipment on a semi-annual, annual, or no maintenance required schedule. Staff Member #6 presented documentation that the facility's Morgue unit had been placed on the no maintenance required status related to the mechanical functions. Staff Member #6 stated, The body holding unit did not need annual maintenance like oiling. The unit was built to just continuously run and it fell off the annual list. But an infection control score will be added, which will pull the unit back on an annual schedule.

An interview was conducted on 03/03/2017 at 10:29 a.m., with Staff Member #1. Staff Member #1 reported he/she became aware of an issue with the facility's Morgue unit around the Holidays (2016). Staff Member #1 stated, I received a complaint from the staff that worked in the two offices on the same hallway as the unit. The surveyor inquired related to the nature of the staff complaints. Staff Member #1 stated, It was about odor. Staff Member #1 stated, The hospice policies and procedure did not hold them accountable to provide information related to their deceased patients placed in our Morgue. Staff Member #1 reported the facility's policy and procedures did not emphasize the hospice service's accountability for documenting their patient remains with the facility or the removal of unclaimed remains from the facility's Morgue unit. Staff Member #1 reported due to the necessary filing with the court system the patient remains, were not removed until the beginning of February 2017.

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

Based on observations, interview, document review and as part of a complaint investigation, it was determined the facility staff failed to maintain completed death records for six (6) of twelve (12) deceased patients medical records reviewed. (Patients #8, #9, #10, #11, #21 and #22)

The findings included:

The surveyors entered the facility on 02/27/2017 at 10:15 a.m. and after a brief introduction with Staff Member #1 a tour was requested of the facility's Morgue.

While walking to the Morgue, Staff Member #1 explained the facility's Morgue was a built in refrigeration unit located on the first floor in a hallway, which had access to the loading dock. Staff Member #1 and the surveyors arrived at the Morgue unit by 10:28 a.m. on 02/27/2017. Staff Member #1 then placed a call for access to the Morgue refrigeration unit. At 10:36 a.m. on 02/27/2017 Staff Members #4 and #5 arrived with the key to the Morgue unit. Staff Member #5 opened the Morgue unit to reveal one black body bag with remains. The surveyor requested a list of patients' remains stored in the Morgue unit with their disposition and documented maintenance service performed on the Morgue unit for the past three years.

At 10:41 a.m. on 02/27/2017 Staff Member #5 presented a document titled Funeral Home-August [no year designated] to the surveyors. Staff Member #4 stated We started a process in August (2016). Staff Member #4 reported the document listed the names of the deceased patients with the date the body was placed in the Morgue unit and which funeral home picked up the bodies. The document listed three (3) bodies for the month of August 2016, one (1) body for October 2016 and one (1) body for January 2017. Staff Member #4 could not offer the reason the log was started or if the log was complete. Staff Member #4 verified the form only listed one date, which Staff Member #4 reported was the date the body was placed in the Morgue unit. The surveyor inquired regarding determination when the bodies were picked up by the funeral home. Staff Member #4 stated, In order to determine the date the body was released to the funeral home you would have to look at each patient's death record. On 02/27/2017 Staff Member #2 presented a list of patients who had died at the facility for the past three (3) years.

1. Review of Patient #8's electronic medical record (EMR), which included scanned paper documentation, was conducted on 02/28/2017 at 8:25 a.m., with Staff Member #3. Patient #8's EMR documented the patient's death occurred on 08/25/2016. The review revealed Patient #8's Death Report was signed by nursing staff only. Patient #8's Death Report did not have a physician's signature with time and date. Patient #8's Death Report did not list a funeral home and did not have documentation the patient's remains had been removed from the facility's Morgue. Staff Member #3 verified the findings.

2. Review of Patient #9's EMR was conducted on 02/28/2017 at 9:20 a.m., with Staff Member #3. Patient #9's EMR included scanned paper documentation. The initial review of Patient #9's EMR Staff Member #3 could not locate the patient's Death Report. Review of the physician's Discharge Summary for Patient #9 indicated the patient died on [DATE]. At 10:39 a.m. Staff Member #1 presented Patient #9's Death Report. Patient #9's Death Report was only signed by nursing staff and did not have a physician's signature with time and date. Patient #9's Death Report did not list a funeral home and did not have documentation the patient's remains had been removed from the facility's Morgue. Staff Member #3 verified the findings.

3. Review of Patient #10's EMR was conducted on 02/28/2017 at 12:24 p.m., with Staff Member #3. Patient #10's Emergency Department [ED] documentation indicated the patient died on [DATE]. Staff Member #1 identified the remains currently in the facility's Morgue as of 02/28/2017 belonged to Patient #10. Review of Patient #10's Death Report did not have documentation of the patient's Preliminary Cause of Death, Race, Marital Status, Valuables/Valuables Disposition, and Address. Patient #10's Death Report did not indicate notification or attempted notification of the patient's attending physician or family. Patient #10's Death Report was not signed, dated or timed by neither nursing staff nor a physician. Staff Member #3 verified the findings.

4. Review of Patient #11's EMR was conducted on 02/28/2017 at 12:37 p.m., with Staff Member #3. Patient #11's ED documentation indicated the patient died on [DATE]. Review of Patient #11's Death Report did not have nursing staff signature with date and time. Patient #11's Death Report did not have a signature with time and date to indicate the patient's remains were picked up or which facility staff released the patient's remains. Staff Member #3 verified the findings.

5. The electronic medical record (EMR) for Patient #21 was reviewed on 02/28/17 at 10:42 a.m. with Staff Member #2. Patient #21's death report revealed the physician pronounced Patient #21's death on 12/12/15 at 1:58 a.m. and electronically signed the form on 12/21/15 at 6:03 p.m. However, the Death Record for release of the remains revealed the actual time of death was 2:09 a.m. The surveyor was unable to locate in the EMR, any documentation of the funeral home person/persons responsible for signing the release of the deceased remains when removed from the facility. On 02/28/17, the surveyor requested further information regarding evidence of Patient #21's remains being released to a funeral home from Staff #2.

The surveyor, along with assistance from facility Staff Member #2, who was navigating the EMR, were unable to locate further documentation revealing the responsible party to whom Patient #21's remains were released to.

6. A review of Patient #22's EMR was conducted on 02/28/17 at 10:29 a.m. with Staff Member #2. Patient #22's death report revealed the physician pronounced Patient #22's death on 03/20/15 at 03:00 a.m. The surveyor was unable to locate in the EMR, any Death Record documentation showing evidence the funeral home person/persons responsible for signing the release of the deceased remains when removed from the facility. On 02/28/17, the surveyor requested further information regarding evidence of Patient #22's remains being released to a funeral home from Staff #2.

An interview was conducted with Staff Member #2 on 02/28/17. Staff Member #2 reported Patient #22's EMR did not have evidence Patient #22's remains were released to a funeral home, as it was not completed and it should have been.

On 02/28/17 at 4:15 p.m., the survey team reviewed the concerns of incomplete medical records with the Administrative Staff Members #1 (CEO), Staff Member #2 (Vice President of Quality), and Staff Member #3 (Chief Nursing Officer).

Show Text of Violation

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

Based on observations, interviews, and document review during a complaint investigation, it was determined the facility's food service director failed to ensure dietary services were managed in manner to prevent the potential spread of infectious agents related to pests and practices.

The findings included:

1. An unannounced observational tour was conducted as part of a complaint investigation within the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6. On arriving at the kitchen doorway the observation revealed Staff Member #12 leaving the kitchen and entering the hallway with two (2) uncovered half-size pans of fried chicken. Staff Member #12 entered into the facility's cafeteria side door. The surveyor inquired of Staff Member #6, a non-food handler, what was observed. Staff Member #6 reported although he/she did not work in the kitchen, [Staff Member #12's name] should not have left the kitchen with the food uncovered. The surveyor knocked on the cafeteria's side door to speak with Staff Member #12. Staff Member #12 immediately acknowledged he/she should not have left the kitchen with the food uncovered.

Staff Members #1 introduced the surveyors to Staff Member #10. The surveyors obtained hairnets and with Staff Member #10 assistance began the kitchen tour. The observation revealed the kitchen had drop in ceiling tiles within a metal grid over the majority of the kitchen area. The surveyors initially requested one (1) ladder but suggested a second ladder for the facility's staff to simultaneously view the space between the ceiling and the drop in ceiling tiles with the surveyor.

An observation conducted while walking to the kitchen's dry storage room revealed a door leading to the outside area (Ambulance side). The door had a gap at the bottom edge, which provided a route pests could enter.

An initial observation was conducted on 02/27/2017 at 10:53 a.m. with Staff Members #1, #6, and #10 in the kitchen's dry storage room. The observation revealed a beverage rack with three (3) observable cans of soda on the floor under the rack, the base of the rack had multiple layers of brownish crumbling material under the right side front leg. The wire shelving unit to the right of the beverage rack had two (2) bent cans of soda on the floor under the wire rack. On the floor under a third wire shelving unit that lined the wall of the room was a bottle of ensure, a green cup, two (2) plastic dinning bowls, and three (3) packages of eating utensils. Four (4) of the wire shelving unit had a plastic sheeting cover for the bottom shelf. The plastic sheeting on each shelf had a layer of grayish material, identified by Staff Member #10 as dust.

An initial observation was conducted on 02/27/2017 at 11:04 a.m. in the walk-in refrigerator with Staff Member #1 and #10. The observation revealed string beans had been spilled on the floor and an apple was clearly visible lying on the floor in the corner of the unit between two (2) wire shelving units. The walk-in refrigerator had a cart with two (2) trays of prepared food items in a red sauce partially covered with plastic wrap, the trays did not have an intact cover to prevent the introduction of contaminates. The observation revealed a lump of whitish substance, which appeared to be molding, on the floor under a food storage wire rack. Staff Member #10 identified the whitish lump as probably a zucchini that has been left on the floor too long.

An initial observation was conducted on 02/27/2017 at 11:09 a.m. in the walk-in freezer with Staff Members #1 and #10. The observation revealed broken frozen noodles scattered across the floor. The intact surface of the floor within the unit was worn off in multiple areas revealing rust and pitting. The floor did not have an intact surface which could be cleaned and disinfected.

An observation was conducted at 11:15 a.m. on 02/27/2017 with Staff Member #6 and the surveyor. Staff Member #6 and the surveyor utilized ladders to view the space between the Kitchen ceiling and the drop-in ceiling tiles. Since Staff Member #12 was in the process of preparing sandwiches; ceiling tiles outside of the food preparation area was chosen for inspection. The area was near the information board towards the back of the kitchen. The surveyor used a flashlight during the observation, which revealed approximately four (4) blacken rice-size droppings on the fifth (5th) from the wall drop-in ceiling tile and approximately three (3) blacken rice-size droppings on an adjacent drop-in ceiling tile. Staff Member #6 identified the blacken rice-size droppings as mouse droppings. Related to the findings a second location was selected by the surveyor at 11:21 a.m. on 02/27/2017. The area selected was center-oriented between the dishwashing area to the rear, above and to the front of Refrigerator #7. Staff Member #6 removed two drop-in ceiling tiles, with the aid of a flashlight the surveyor and Staff Member #6 observed an uncountable number of blacken droppings ranging in size from larger than a dried-grape to rice-size on the surface of the two ceiling tiles removed. Staff Member #6 verified the observation findings and identified the dropping to be more than just mouse dropping and possibly rat dropping.

Staff Member #6 and the surveyor moved up another level on the ladder and utilized the flashlight to observe a larger area of the space between the ceiling and the drop-in ceiling tiles. The surveyor was able to access an observable area of thirteen (13) ceiling tiles in length by eight (8) ceiling tiles across [each ceiling tile approximately twenty-four (24) inches by twenty-four (24) inches] the entire area had an innumerable spreading of rodent droppings of various sizes. The surveyor questioned Staff Member #6 regarding the extent of the rodent droppings and whether the contaminated area extended over the tray line and tray prep area. Staff Member #6 verified the findings and that the contaminated area was over the tray prep area and the tray line. The ceiling vents and light fixture components obstructed the view as to whether the rodent droppings were over the cooking area. Staff Member #6 informed Staff Members #1 and #13 of the findings.

At 11:26 a.m. on 02/27/2017 Staff Member #6 and Staff Member #13 moved the ladders and re-positioned them between Refrigerator #7 and the tray line preparation area. Staff Member #6 removed two (2) ceiling tiles to provide an observation area from above the tray line to above the cooking area [approximately twenty (20) ceiling tiles in length and thirteen (13) ceiling tiles across]. Staff Member #6 and the surveyor viewed the drop-in ceiling tiles with the aid of a flashlight. The drop-in ceiling tiles in this area were also covered with an incalculable amount of rodent droppings. These findings were verified by Staff Member #6. Staff Member #6 stated, We have to replace the entire ceiling (drop-in ceiling tiles).

Observations were conducted from 11:29 a.m. through 11:38 a.m. on 02/27/2017 with Staff Members #1, #6 #10, #13 and the surveyors. The surveyor questioned the reason for the torn plastic sticking up from the surface on the top shelf of the tray line. Staff Member #10 stated, That is the shipping plastic when the unit was brought in. Staff Member #10 could not provide the date the unit was delivered and stated, It's been a while. Staff Member #6 and the surveyor conducted observations of the top surface of Refrigerator #7. The observation revealed multiple layers of gray matter and a cluster of blacken rice-size material. Staff Member #6 identified the gray matter as dust and the blacken rice-size material as rodent droppings. Staff Member #6 and the surveyor observed the top of Refrigerator #5, which revealed the entire top of the refrigerator was covered with gray matter/dust.

An observation of the top of Refrigerator #4 revealed layers of dust and a cluster of mouse droppings as identified by Staff Member #6. An observation of the top of Refrigerator #8, located within the cooking area, revealed both dust and evidence of rodent activity. Staff Member #6 verified the findings. The surveyor asked Staff Member #10 for the cleaning schedule for the kitchen, including the appliances, and major equipment utilized during meal preparation. Staff Member #10 reported the kitchen staff was responsible for general cleaning of the kitchen on a daily and weekend schedule. Staff Member #10 reported an outside vendor also cleaned the kitchen. Staff Member #10 verified the facility staff and the outside vendor failed to clean the tops of the refrigerator units and failed to note or report rodent activity. The surveyor requested documentation of the pest control service for the past three (3) years and the last two (2) food inspection reports conducted in conjunction with the Health Department.

Review of the facility's Food Establishment Inspection Report for 19 [DATE] and 1 [DATE] did not have documentation included for the presence of Insects, rodents & animal... The surveyor reviewed two additional Food Establishment Inspection Report for 24 [DATE] and 9 Jun 2016 both documented line 36 Insects, rodents & animal not present as in compliance.

A partial review of the pest control service invoices was conducted on 03/01/2017. The review revealed three (3) continued repeated recommendations, which involved the kitchen and the adjacent cafeteria. The three (3) repeated recommendations were:

a. The need for a sweep for the dock plate door to exclude pest this recommendation was listed on the invoices for-11/2014, 1/21/15, 3/25/15, 4/7/15, 6/10/15, 7/15/15, 8/19/15, 10/28/15, 11/18/15, 12/29/15, 1/20/16 and then monthly throughout 2016 and 01/2017.

b. The needed repair of the laminate above the serving line- this recommendation was listed on the invoices for-11/2014, 12/17/14, 2/15/15, 9/30/15, 11/18/15, 12/16/15, 1/20/2016, 1/18/2017 and 2/15/2017.

c. The recommendation to pour water down drains (for common areas and the kitchen) to prevent traps from drying out and becoming harborages for pest and rodents- the recommendation was listed 11/2014, 112/10/14, 1/21/15, 2/11/15, on three (3) invoices for September 2015, two (2) invoices in October 2015, and 11/23/2016. Review of the pest control vendor invoices revealed one invoice dated 2014 related to placing rodent traps in the kitchen ceiling. The surveyor did not find recent pest control invoices (2016-2017), which documented inspection of the kitchen ceiling or the placement of rodent traps in the kitchen ceiling.

An interview was conducted on 02/28/2017 at approximately 9:00 a.m., with Staff Member #10. Staff Member #10 reviewed an eight (8) page document related to kitchen staff and their area to clean with the surveyor. Staff Member #10 acknowledged although he/she had documented assignments for the kitchen staff his/her staff had not been monitored to ensure their assigned task was performed.

2. Observations were conducted on 03/02/2017 from 9:28 a.m. through 1:43 p.m. in the kitchen area to determine compliance with the Condition of Participation regarding food services. The tour was conducted in a manner to view equipment at the outer perimeter of the kitchen and then to work inward towards the cooking area.

Staff Member #10 reported the breakfast dishes had not been washed. Staff Member #10 started the dish washer unit the surveyor acknowledged that the unit made need to run through a couple of cycles prior to reaching the required temperature of 160 degrees Fahrenheit (F). Staff Member #10 ran the dish washer through five (5) cycles and the gauge for the wash temperature never reached 160 degrees F. Staff Members #2, #10 with the surveyors reviewed the dish washer temperature logs, which recorded the wash temperature for the past three months for the wash of each meal's dishes and equipment as exactly 160 F. Staff Member #10 stated, I guess it broke last night.

The facility staff did contact a service vendor regarding the dishwasher during the time of the survey. The temperature gauze was broken and once repaired, showed the water temperature to be 170 to 180 degrees.

The observation continued to the three (3) compartment sink area. Staff Member #10 informed the surveyors the white dishware turned upright positioned on a table was clean. The table was positioned next to a water heater. The top of the water heater and the top of the side panel were both covered with a thick layer of gray matter. Staff Member #10 identified the gray material as dust. A cart was positioned next to the table, which had stacked pans. Staff Member #10 informed the surveyors that all pans/pots were air dried prior to stacking. The observation revealed four (4) quarter-size pans had a greasy residue on outside of the pan, which was in direct contact with the inner surface of the pan stack upon it. Three (3) full-size pans were stacked together with wet inner surfaces. Staff Member #10 verbalized that wet pans stacked together provided a breeding medium for bacteria. Staff Member #10 reported the utility staff should have made sure the pans did not have greasy residue on their outer surfaces

An observation of the air gap for the ice machine revealed a concave funnel like metal device positioned over the floor drain. A copper tubing line ran from the back of the left side of the ice machine an ended in the metal device. The observation revealed liquid dripping from the center of the bottom of the ice machine. Staff Member #10 and the surveyor donned gloves to inspect the bottom of the ice machine by touch. The inspection revealed the liquid dripped/drained from bottom of the ice machine through a round opening and within that was a smaller opening. The smaller opening contained a brownish gelatin like substance. The surveyor inquired regarding the last cleaning of the drain/opening in the bottom of the ice machine. Staff Member #10 reported he/she had not been aware of the ice machine having an opening which needed to cleaned. Staff Member #10 verified the brownish gelatin like substance had been removed from the smaller drain opening.

The observations continued to the Breakfast Cereal storage area. The prep table had stored pans stacked together. Staff member #10 reported the pans were clean and ready for use. Staff Member #10 and the surveyor found two (2) half-size pans stacked together with wet inner surfaces.

A reach-in freezer located in the food prep area contained one (1) opened bag of peaches and one (1) opened bag of mixed berries, which were not sealed and did not have an opened date.

An observation of the pot rack in the cooking area revealed two (2) brazier pots were stacked with wet inner surfaces.

Observations conducted in walk-in freezer #2 revealed brownish-tan clumps on the floor. Staff Member #10 identified the material as sausage crumbles. Staff Member #10 reported the staff must have dropped it when preparing pizzas. In the next freezer one (1) box each of carrots and corn were opened with the inner plastic liner not covering the food product. Staff Member #10 stated, The box can be left open but the plastic should be covering the food to prevent contamination. In Freezer #1 two boxes was open with frozen cakes neither box had been covered to protect the cakes from contamination; three (3) lemon-poppy seed on one box and two (2) chocolate cakes in the second box . Staff Member #10 removed the two boxes and asked Staff Member #12 to place all of the cakes in one box and cover the box. Staff Member #10 reported that kitchen staff had received training regarding methods to reduce and prevent the contamination of food product and kitchen equipment. Staff Member #10 verified the surveyor findings.

Staff Member #10 reported the survey process revealed areas of opportunity for re-education of his/her staff.

An interview was conducted on 03/02/2016 at approximately 12:44 p.m., with Staff Member #10. The surveyor presented control binders and invoices and inquired regarding the recommended repairs to keep pest from entering the kitchen. Staff Member #10 stated, I don't receive those invoices. I didn't know about that information.

Show Text of Violation

Based on observations, interviews, complaint investigation, and document review, it was determined facility staff failed to ensure:

1. The facility's kitchen was maintained in a manner to prevent harborage of rodents and

2. The Morgue unit was maintained to prevent pervasive odors.

The findings included:

An unannounced observational tour as part of a complaint investigation was started in the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6. Staff Member #1 introduced the surveyors to Staff Member #10. The surveyors obtained hairnets and with Staff Member #10 assistance began the kitchen tour. The observation revealed the kitchen had drop-in ceiling tiles within a metal grid over the majority of the kitchen area. .

An observation conducted while walking to the kitchen's dry storage room revealed a door leading to the outside area. The door had a gap at the bottom edge, which provided a route for pests to enter the kitchen area.

An observation was conducted at 11:15 a.m. on 02/27/2017 with Staff Member #6 and the surveyor. Staff Member #6 and the surveyor utilized ladders to view the space between the Kitchen ceiling and the drop-in ceiling tiles. Since Staff Member #12 was in the process of preparing sandwiches; the initial selection of ceiling tiles for opening and inspection were outside of the food preparation area. The area initially chosen was near the information board towards the back of the kitchen. The surveyor used a flashlight during the observation, which revealed approximately four (4) blacken rice-size droppings on the fifth (5th) from the wall drop-in ceiling tile and approximately three (3) blacken rice-size droppings on an adjacent drop-in ceiling tile. Staff Member #6 identified the blacken rice-size droppings as mouse droppings. Related to the findings a second location was selected by the surveyor at 11:21 a.m. on 02/27/2017. The area selected was center-oriented between the dishwashing area to the rear, above and to the front of Refrigerator #7. Staff Member #6 removed two drop-in ceiling tiles, with the aid of a flashlight the surveyor and Staff Member #6 observed an uncountable number of blacken droppings ranging in size from larger than a dried-grape to rice-size on the surface of the two ceiling tiles removed. Staff Member #6 verified the observation findings and identified the dropping to be more than just mouse dropping and possibly rat dropping.

In the same area Staff Member #6 and the surveyor moved up another level on the ladder and utilized the flashlight to observe the larger area of the space between the ceiling and the drop-in ceiling tiles. The surveyor was able to view an area of thirteen (13) ceiling tiles in length by eight (8) ceiling tiles across [each ceiling tile was approximately twenty-four (24) inches by twenty-four (24) inches]; the entire area had an innumerable spreading of rodent droppings of various sizes. The surveyor questioned Staff Member #6 regarding the extent of the rodent droppings and whether the contaminated area extended over the tray line and tray prep area. Staff Member #6 verified the findings and that the contaminated area was over the tray prep area and the tray line. The ceiling vents and light fixture components obstructed the view as to whether the rodent droppings were over the cooking area. Staff Member #6 informed Staff Members #1 and #13 of the findings.

At 11:26 a.m. on 02/27/2017 Staff Member #6 and Staff Member #13 moved the ladders and re-positioned them with Refrigerator #7 at the rear and in front of the tray line preparation area. Staff Member #6 removed two (2) ceiling tiles to provide an observation area from above the tray line to above the cooking area [approximately twenty (20) ceiling tiles in length and thirteen (13) ceiling tiles across]. Staff Member #6 and the surveyor viewed the drop-in ceiling tiles with the aid of a flashlight. The drop-in ceiling tiles in this area were also covered with an incalculable amount of rodent droppings. These findings were verified by Staff Member #6. Staff Member #6 stated, We have to replace the entire ceiling (drop-in ceiling tiles).

Observations were conducted from 11:29 a.m. through 11:38 a.m. on 02/27/2017 with Staff Members #1, #6 #10, #13 and the surveyors. The surveyor questioned the reason for the torn plastic sticking up from the surface on the top shelf of the tray line. Staff Member #10 stated, That is the shipping plastic when the unit was brought in. Staff Member #10 could not provide the date the unit was delivered and simply stated, It's been a while. Staff Member #6 and the surveyor conducted observations of the top surface of Refrigerator #7. The observation revealed multiple layers of gray matter and a cluster of blacken rice-size material. Staff Member #6 identified the gray matter as dust and the blacken rice-size material as rodent droppings. Staff Member #6 and the surveyor observed the top of Refrigerator #5, which revealed the entire top of the refrigerator was covered with gray matter/dust. An observation of the top of Refrigerator #4 revealed layers of dust and a cluster of mouse droppings as identified by Staff Member #6. An observation of the top of Refrigerator #8, located within the cooking area, revealed both dust and evidence of rodent activity. Staff Member #6 verified the findings. The surveyor asked Staff Member #10 for the cleaning schedule for the kitchen, including the appliances, and major equipment utilized during meal preparation. Staff Member #10 reported the kitchen staff was responsible for general cleaning of the kitchen on a daily and weekend schedule. Staff Member #10 reported an outside vendor also cleaned the kitchen. Staff Member #10 verified the facility staff and the outside vendor failed to clean the tops of the refrigerator units and failed to note or report rodent activity. The surveyor requested documentation of the pest control service for the past three (3) years and the last two (2) food inspection reports conducted in conjunction with the Health Department.

A partial review of the pest control service invoices was conducted on 03/01/2017. The review revealed three (3) continued repeated recommendations, which involved the kitchen and the adjacent cafeteria. The three (3) repeated recommendations were:

a. The need for a sweep for the dock plate door to exclude pest this recommendation was listed on the invoices for-11/2014, 1/21/15, 3/25/15, 4/7/15, 6/10/15, 7/15/15, 8/19/15, 10/28/15, 11/18/15, 12/29/15, 1/20/16 and then monthly throughout 2016 and 01/2017.

b. The needed repair of the laminate above the serving line- this recommendation was listed on the invoices for-11/2014, 12/17/14, 2/15/15, 9/30/15, 11/18/15, 12/16/15, 1/20/2016, 1/18/2017 and 2/15/2017.

c. The recommendation to pour water down drains (for common areas and the kitchen) to prevent traps from drying out and becoming harborages for pest and rodents- the recommendation was listed 11/2014, 112/10/14, 1/21/15, 2/11/15, on three (3) invoices for September 2015, two (2) invoices in October 2015, and 11/23/2016. Review of the pest control vendor invoices revealed one invoice dated 2014 related to placing rodent traps in the kitchen ceiling.

An interview was conducted on 03/02/2016 at approximately 12:44 p.m., with Staff Member #10. The surveyor presented the pest control binders and invoices and inquired regarding the recommended repairs to keep pest from entering the kitchen. Staff Member #10 stated, I don't receive those invoices. I didn't know about that information.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. The surveyor inquired regarding which staff was responsible for overseeing and correcting the repeated recommendations documented by the pest control vendor. Staff Member #6 stated, What recommendations, one of my staff signs the electronic pad there isn't a printout given. The surveyor reviewed the binders with the pest control vendor's invoices with Staff Member #6. Staff Member #6 reported the pest control vendor places the invoice in the binder on their return visit. Staff Member #6 reported the facility staff did not monitor the binders; the invoices were kept in the binders for proof of pest control services. The surveyor inquired which of facility staff was responsible for inspecting for rodents and other pest. Staff Member #6 stated, All of us are. I think you saw my face when we looked in the ceiling, I was taken back. When I came down I said to [Staff Member #1's name] we have a problem.

Review of the facility's policy titled Environmental Services Infection Prevention Guidelines read in part: H. Pest Control 1. An effective pest control program will be maintain to forestall or prevent infestation and/or eliminate infestation should it develop. 2. A preventative maintenance and inspection program will be maintained throughout all constructed spaces and surrounding property ...

2. An observation was conducted as part of an complaint investigation of the facility's Morgue refrigeration unit on 02/27/2017 from 10:15 a.m. through 10:44 a.m., with Staff Member #1 with other staff members joining the observation. The Morgue unit's door had a built-in thermometer, which read 34 F (degrees Fahrenheit). At approximately 10:38 a.m. Staff Member #6 joined the observation and explained the Morgue unit was under his/her department's responsibility. The surveyor requested the past eighteen (18) months of temperature logs for the Morgue unit. Staff Member #6 explained his/her department did not keep documented temperature logs for the Morgue unit. Staff Member #6 stated, When my personnel performs rounds they glance at the gauge and if it is alright, they move on. The surveyor inquired how Staff Member #6's staff would know if the Morgue unit was working at the right temperature. Staff Member #6 reported if the unit was running, it was at the right temperature. The surveyor requested documented maintenance and service performed on the Morgue unit for the past three years.

An interview was conducted on 02/27/2017 at 2:02 p.m., with Staff Member #6 and Staff Members #1 and #2 were present. Staff Member #6 presented two (2) service invoices for service performed on the Body Cooler by an outside vendor. Staff member #6 reviewed the vendor documents with the surveyor. One invoice documented the bodies within the Morgue unit needed to be removed. The surveyor requested information related to the bodies that were removed, where the bodies went and if they returned to the facility's Morgue unit once it had been repaired. The documents presented by Staff Member #6 were difficult to read and the surveyor requested legible copies. Staff Member #6 reported he/she would have to contact the service vendor to email their copy of the original invoices. Staff Member #6 reported if any other service had been performed by facility's maintenance staff on the Morgue unit, it had not been documented.

Staff Member #6 presented legible copies at 2:31 p.m. on 02/27/2017. Review of the outside vendor's Service Work Order dated 9/18/2016 [Sunday] read: Evap (evaporator) coil block of ice. Unit running after condenser water restarted. Waiting for bodies to be removed. Send tech (technician) Monday morning [Sic]. The second invoice was dated 09/19/2016 read in part: Located leak Liquid valve not back seating & (and) valve stem Packing ^ (increase) packing & add dress fitting ... Pull vacuum & recharge. Set water valve ... Install Temp (temperature) control to maintain temp in box [Sic].

An interview was conducted on 03/01/2017 at 2:35 p.m., with Staff Member #11. Staff Members #1 and #2 were present during the interview. Staff Member #11 reported the cleaning of the Morgue unit was not directly his/her department's responsibility. Staff Member #1 reported related to the findings the facility recognized opportunity for change. Staff Member #1 reported the Morgue unit, had not previously been included on the facility's environment of care rounds but would be added.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. Staff Member #6 presented documentation related to the facility's preventative maintenance program. Staff Member #6 presented the rating system utilized by the facility, which placed equipment on a semi-annual, annual, or no maintenance required schedule. Staff Member #6 presented documentation that the facility's Morgue unit had been placed on the no maintenance required status related to the mechanical functions. Staff Member #6 stated, The body holding unit did not need annual maintenance like oiling. The unit was built to just continuously run and it fell off the annual list. But an infection control score will be added, which will pull the unit back on an annual schedule.

An interview was conducted on 03/03/2017 at 10:29 a.m., with Staff Member #1. Staff Member #1 reported he/she became aware of an issue with the facility's Morgue unit around the Holidays (2016). Staff Member #1 stated, I received a complaint from the staff that worked in the two offices on the same hallway as the unit. The surveyor inquired related to the nature of the staff complaints. Staff Member #1 stated, It was about odor. Staff Member #1 reported the odor was due to unclaimed remains. Staff Member #1 reported due to the necessity of filing documentation with the court system the patient remains were not removed until the beginning of February 2017.

Show Text of Violation

Based on observations, interviews and documents reviewed, it was determined the facility staff failed to implement a system to ensure staff practiced infection reducing behaviors as evidenced by:

1. Ensuring proper hand hygiene and handling blood glucose monitoring equipment in a manner to prevent the spread

of hospital acquired infection;

2. Failure to administer medication in an aseptic environment;

3. Failure to perform environmental cleaning after patient on contact isolation and before new patient contact;

4. Facility staff failed to ensure facility's structure is in good repair and operating condition as evidenced by one (1)

of three (3) walk-in refrigerator floors did not have an intact surface and could not be disinfected;

5. Failure to maintain a sanitary physical environment as no evidence of collaboration to implement measures to

develop, identify, investigate, and evaluate measures for pest control in the food service area; and

6. Failure to handle linens in a manner to prevent the spread of infectious agents.

The findings included:

1 A. On 02/28/17 at approximately 11:35 a.m., the following was observed with Staff Member #15 (Staff Educator) during use of a point of care device: Staff Member #16 performed hand hygiene and donned gloves to perform a blood glucose check on Patient #15 in room #505. Staff Member #16 placed all supplies including alcohol pad, gauze pads, box of finger stick lancet devices, glucometer strips container and glucometer on Patient #15's bedside table. Staff Member #16 cleaned the site with alcohol prior to finger stick for blood sample. The first drop of blood was wiped away with gauze pad and second drop was placed on strip in glucometer. The glucometer was then placed on the bedside table where the box of finger stick lancets and glucometer strips remained. Staff Member #16 stated, There are no wipes to clean the meter with, so I will need to get some. Staff Member #16 removed his/her gloves, picked up the contaminated glucometer, placed the glucometer strips container in the box of finger stick lancet devices and left Patient #15's room with no hand hygiene and a contaminated glucometer. Staff Member #16 was observed reaching into a box of gloves on the wall in the hall outside Room #509 to get another pair and no hand hygiene was performed. Staff Member #16 entered into the clean medication room, placed the contaminated glucometer on top of the box of finger stick lancets directly next to nine (9) individual staff drinking containers (some containing straws) neatly covered and sitting on a paper napkin covering the countertop. Staff Member #16 wiped the glucometer once with a sani-cloth, waited four (4) minutes for the contact time, placed the glucometer into the clean docking station, then removed gloves and performed hand hygiene. The container of glucometer strips were not cleaned and the box of finger stick lancets were returned to the clean supplies for other patient use after they had been in a patient's room and in contact with a contaminated glucometer.

An interview was conducted on 02/28/17 at the 5 East Nursing Station with Staff Member #14 (Nurse Manager) and Staff Member #15 in regard to observations of Staff Member #16 during patient care in room #505. Staff Member #15 revealed that the glucometers are used on multiple patients and the hospital policy for cleaning glucometers is directly from the manufactures guidelines. Staff Member #15 brought the concerns of the surveyor's observations to Staff Member #14, who said he/she would re-educate Staff Member #16 regarding proper hand hygiene and point of care cleaning procedures.

Staff Member #16 failed to perform hand hygiene when leaving a patient's room and prior to donning new gloves. The container of glucometer strips were not cleaned and the box of finger stick lancets were placed for other patient use after they had been in a patient's room and in contact with a contaminated glucometer. Staff Member #16 failed to clean the glucometer according to the facility policy and procedure and manufacture's guidelines.

A review of the policy titled, Whole Blood Glucose by Nova Statstrip read in part the following: Purpose: The Statstrip Glucose Hospital Meter System is intended for in-vitro diagnostic, multiple-patient use for the quantitative determination of glucose in capillary finger stick, venous whole blood, arterial whole blood, and neonate heel stick specimens. Patient Testing: Adhere to Standard Precautions and Infection Control guidelines. 24. The comment meter cleaned must be added to each patient result, follow the below cleaning procedure between each patient test...25. Dock the meter to allow results to transmit to meditech. Maintenance: Cleaning the exterior: The meter should never be immersed in cleaning agents...The meter's external surface should be cleaned and disinfected with a fresh bleach wipe from the EPA-approved list D. 1. Remove a fresh wipe from the canister and thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally and 3 times vertically avoiding the meter's bar code scanner and electrical connector. 2. Gently wipe the surface area of the test strip port making sure no fluid enters the port. 3. Ensure the meter surface stays wet for the appropriate time based on the specific cleaner being used at the facility.

2. Observations were conducted on 02/28/17 beginning at 11:44 a.m., with Staff Member #15 and Staff Member #17 during the administration of medication on the 5 East Unit room #506 for Patient #16 on Contact Precautions. Staff Member #17 placed the medications on a flat surface table in the designated clean area. Staff Member #17 performed hand hygiene prior to donning his/her personal protection equipment (PPE) and offering a gown and gloves to the surveyor. Staff Member #17 opened a small cabinet mobile work station within the patient's room and placed the medications on the wooden surface. The surveyor observed the mobile work station to be dirty with multiply visible white round marks and two (2) pieces of paper trash.

Staff Member #17 gathered additional supplies to prepare Patient #16's medications. Staff Member #17 informed the surveyor that Patient #16 was on contact precautions for a history of Methicillin-resistant Staphylococcus aureus (MRSA). During the observation, Staff Member #17 was observed taking Patient #16's vital signs. Staff Member #17 opened the following single dose pill packages on the dirty mobile work station and placed into a pill cup for Patient #16: Oxybutynin 5 mg tab - one tab (antispasmodics that helps decrease muscle spasms of the bladder and the frequent urge to urinate), and Ferrous sulfate 25 mg tab - one tab (treat iron deficiency anemia). Staff Member #17 obtained two (2) thirty (30) cc (cubic centimeter) syringes from the patient's supplies, opened the packaging laying the contents on the contaminated mobile work station within the patient's space. Staff Member #17 used the thirty (30) cc syringe to add sterile water for diluent use to administer the Meropenem ( ultra-broad-spectrum antibiotic used to treat a wide variety of infections) and drew up a thirty (30) cc syringe to flush Patient #16's intravenous (IV) line once the Meropenem was administered. Staff Member #17 was not observed disinfecting the vial's rubber septum on the two (2) vials of sterile water or the vial of Meropenem before administering to Patient #16.

Staff Member #17 returned to the medication preparation area on the mobile work station and started to discard the empty single dose pill packages and empty vials. Staff Member #17 used the same contaminated gloves to enter information into Patient #16's electronic medical record via mobile work station within the patient's room. Staff Member #17 closed the mobile work station and did not wipe off the medication preparation area before or after use, and did not put down a protective barrier before opening the single pill packages or drawing up the Meropenem. Staff Member #17 removed his/her PPE within the designated clean area and utilized the hand sanitizer on the way out of the room.

An interview was conducted on 02/28/17 at the 5 East Nursing Station with Staff Member #14 and Staff Member #15 in regard to observations of Staff Member #17 during patient care in room #506. Staff Member #15 acknowledged the mobile work station was dirty and should have been cleaned before and after administering the patient's medications, and the rubber septum on the vials should have been disinfected before inserting the needle into them. Staff Member #15 reported nursing staff receive training related to infection control and these observations reveal breaches in infection control practices.

The surveyor requested the facility's policy for medication administration from Staff Member #15. Staff Member #15 presented the surveyor a policy titled Safe Use of Single and Multiple Dose Vials. The policy read in part the following: PROCEDURE: Single-use vials: A. Use of a SDV for a single patient during the course of a single procedure. The vials should be discarded after the single use. B. If a SDV must be entered more than once during a single procedure for a single patient to achieve safe and accurate titration of dosage, use a new needle and syringe for each entry...Multi-Dose Vials: ...D. Disinfect the vial's rubber septum before piercing by wiping (and using friction) with a sterile 70 percent isopropyl alcohol swab (or other approved antiseptic swab). Allow the septum to dry before inserting a needle.....

3. At 11:30 a.m. on 02/28/17, the surveyor observed a housekeeping staff member exiting room #508, a room which had a sign that the patient in that room was on contact precautions. Neither the mop head nor the mop water was changed before the housekeeping staff moved to clean the next room #509. The surveyor was actively involved observing a staff member perform a scheduled glucometer check before lunch arrived to the unit. After the completion of the glucometer check for Patient #15's blood sugar level, the surveyor proceeded to follow-up with the observation of the housekeeping staff member.

At 12:02 p.m. the surveyor observed a housekeeping staff member (Staff Member #18) cleaning room #519. Staff Member #18 was the same housekeeping staff member previously observed at 11:30 a.m. exiting room #508. Staff Member #18 was observed performing daily cleaning for room #519. After the daily cleaning of room #519 was completed, the surveyor inquired if Staff Member #18 was available for an interview outside of room #508, a contact isolation room. Staff Member #18 stated that would be fine and acknowledged he/she was covering 5 East Unit duties for a staff member that had to be off. Staff Member #18 verified he/she normally does the facility's floors and just fills in for staff as needed. The surveyor inquired when Staff Member #18 exits a contact isolation room after daily cleaning and enters into another patient room, are the mop heads/water changed. Staff Member #18 acknowledged that the cleaning process at the facility was to change the mop head and water every three (3) rooms. Staff Member #18 continued reporting that most of the environmental services' staff don't like using the string mop because it is too heavy, but will use the microfiber mops, which are changed after each room cleaning.

An interview was conducted on 03/01/17 at 2:51 p.m. in the conference room with the Director of Environmental Services (Staff Member #11). The facility administration staff were informed of the findings and a policy/procedure was requested. Housekeeping practices should minimize the potential for transmission of microorganisms, including proper methods to clean and disinfect equipment and environmental surfaces. Staff Member #11 stated, Everyone should have the same training, even the employees that fill in. Staff Member #11 verified he/she had only been in the director position for approximately six (6) weeks and currently some staff are using carts with ring mops (string mops) and the water is changed every three (3) patient rooms, and some staff are using the microfiber mops that get changed between each patient's room. Staff Member #11 stated, My goal is to make sure all staff have and implement the same microfiber system.

The policy titled Patient Room Daily Cleaning was received on 03/01/17 at 3:20 p.m. and read in part: Purpose: To ensure proper cleaning techniques for cleaning in patient rooms. PROCEDURE: 1. Protective gloves should be worn, along with other applicable personal protective equipment as needed.For [sic] 2. isolation rooms. Guidelines for the listed precautions and procedure EVS 303 will be followed. Hands will be washed before putting on gloves and after each glove change. Gloves will be changed between rooms and if torn or punctured. 3. Solution in mop bucket should be changed after every isolation room cleaning, if it appears to have visible dirt and as often as needed with a minimum change out of every three rooms. 4. Wet mop and dust mop heads should be changed after cleaning every isolation room cleaning, whenever they have visible dirt/soil and as often as needed with a minimum change out of every three rooms. 5. Separate cleaning cloths should be used in patient rooms and patient restrooms.....

4. An observation was conducted on 03/02/17 starting at 9:28 a.m. in the Food Service area. The observation revealed one (1) of three (3) walk-in refrigerator floors in Refrigerator #3 (Produce Box) having an exposed porous metal surface, with evidence of a previous smooth coating that had been worn, revealing a porous and non-intact surface. The surveyor conducted the observation in the presence of Staff Member #10 (Director of Dietary Services), Staff Member #31 and a second surveyor. The walk-in metal floor covered an area approximately eight (8) foot by six (6) foot. Staff Member #10 verified the findings.

During an interview with Staff Member #10, the survey team asked how the metal floors are cleaned. Staff Member #10 stated the floors are cleaned daily. Staff Member #10 confirmed the metal coating had worn off and the floor was back to a porous, non-intact metal surface. Staff Member #10 verified the floor's non-intact surfaces prevented it from being disinfected.

The survey team held a discussion of the observations and concerns with Staff Member #1 (CEO), Staff Member #2 (Vice President of Quality), Staff Member #3 (Chief Nursing Officer) on 03/02/17 during the end of the day meeting at 3:45 p.m.

5. The initial tour of the Food Service area was conducted on 02/27/17 at 10:53 a.m. with the presence of Staff Member #1 (CEO), Staff Member #2 (VP of Quality), Staff Member #6 (Director of Physical Plant), Staff Member #10 (Director of Dietary Service), and Staff Member #13. At 11:15 a.m., observations were conducted from two (2) ladders utilized by one (1) surveyor and Staff Member #6, opening and observing into the following drop ceiling areas: observations at 11:15 a.m. in the drop ceiling area by the Information Board and linen closet revealed mouse/rat feces located on the fifth ceiling panel from the wall. Observations at 11:21 a.m. in the drop ceiling area by Refrigerator #7 located in the center of the kitchen area looking toward the food prep area for an area of ceiling tiles covering eight (8) across and thirteen (13) long were covered in mouse/rat feces. Observations at 11:29 a.m. revealed mouse/rat feces on the top of Refrigerator #4. Observations at 11:32 a.m. revealed mouse/rat feces and chewed up rat debris on the top of Refrigerator #8 located across from the food prep area where food is prepared on the stove/grill. The facility administration staff were informed of the findings and a pest control policy/procedure was requested.

An interview was conducted with the Director of Infection Control (Staff Member #28) on 02/28/17 at 2:26 p.m. in the conference room. The surveyor asked Staff Member #28 what is the infection control officer's role in maintaining a sanitary physical environment related to pest control. Staff Member #28 stated, We (Infection Control) are not involved in pest control or scheduling the vendor. Unless we (Infection Control) observe rodents/pest or receive information that there is a pest problem, then we (Infection Control) are not involved. The surveyor asked Staff Member #28 if he/she was aware of a rodent problem in the Food Service area. Staff Member #28 stated, I was not aware of any problems. Staff Member #28 reported the infection control officer participates in conducting EOC rounds once a week in different areas of the hospital. The Food Service area is included in the rounds; however the EOC rounds are on a rotating schedule that include all areas of the hospital, each area gets observed at least twice a year. Staff Member #28 confirmed a food inspector from the Virginia Department of Health (VDH) are inspecting the Food Service area as required and completing reports on the findings. Staff Member #28 acknowledged the most recent project in pest control was developing a policy related to bed bugs due to the rise of cases in the community being brought into the facility. Staff Member #28 confirmed, The staff know to call us if there is a problem with bed bugs.

1 b. Glucometer techniques and hand hygiene observations:

An observation was conducted on 02/28/2017 from 11:38 through 112:05 p.m., with Staff Member #7. Staff Member #3 was present during the observation. Staff Member #7 performed a blood glucose check for Patient #20. Staff Member #7 laid the glucometer on the bed with the patient. After performing the glucose check Staff member #7 removed the test strip with blood from the glucometer with a gloved hand. Staff Member #7 other gloved hand to roll the glove with an enclosed used test strip from his/her hand and discard. Staff Member #7 used his/her ungloved hand to place the glucometer under his/her left arm pressing it against his/her body contaminating his/her uniform. Staff Member #7 removed his /her other glove and started to exit Patient #20's room. Staff Member #7 returned to the glove box in the patient's room, removed gloves without performing hand hygiene, and then performed hand hygiene on the way out of the patient's room. Staff Member #7 entered the area across from the automated medication dispensing system, placed the contaminated glucometer on a desk. Staff Member #7 donned the contaminated gloves and started a four minute process of cleaning the glucometer. Staff Member #7 reported the process was complete placed the glucometer in its docking unit. Staff Member #7 reviewed Patient #20's medication orders and prepared the patient's dose of insulin. Staff Member #7 did not disinfect the desk where the contaminated glucometer had been placed.

The observation with Staff Member #7 continued at approximately 11:59 a.m. Staff Member #7 administered the insulin to Patient #20. Staff Member #7 used the same gloves to enter data into the computer in the patient's room.

An observation was conducted on 03/01/2017 from 11:37 a.m. through 12:29 p.m., with Staff Member #32 during the cleaning of a discharged patient's room. Staff Members #3 and #11 observed the cleaning process from the doorway and hall. The observation revealed that Staff Member #32 changed his/her gloves three times without performing hand hygiene between glove changes. The observation revealed Staff Member #32 left the room to obtain linens to make the bed but did not perform hand hygiene on exiting the room. When Staff Member #32 returned to the room he/she did not perform hand hygiene after entering the room.

An interview was conducted on 03/01/2017 at 12:29 p.m., with Staff Member #3. Staff Member #3 reported Staff Member #32 failed to perform hand hygiene between three glove changes and failed to perform hand hygiene on exiting and entering the room.

6. An observation was conducted on 03/01/2017 from 11:37 a.m. through 12:29 p.m., with Staff Member #32 during the cleaning of a discharged patient's room. Staff Member #32 left the room to obtain linens to make the bed but did not perform hand hygiene on exiting the room. On entering the clean linen storage room Staff #32 failed to utilize the hand sanitizer. Staff member #32 retrieved the clean linens with contaminated hands. When Staff Member #32 returned to the room he/she did not perform hand hygiene after entering the room. Staff Member #32 placed the linens on the over the bed table. During the placement of the sheet on the bed, Staff Member #32 fanned the sheet in the air several times in an attempt to spread the sheet evenly on the bed.

An interview was conducted on 03/01/2017 at 12:29 p.m., with Staff Member #3. Staff Member #3 reported Staff Member #32 failed to correctly follow infection prevention process for gently unfolding the sheet on the bed. Staff member #3 reported it was not the facility's policy to fan the sheet in the air during the bed making task.

Review of the facility's policy titled Environmental Services Infection Prevention Guidelines read in part: B. Discharge and transfer bed cleaning ... 5. Hands will be washed after cleaning each bed and before handling clean linen ...

Show Text of Violation

Based on observations, interviews, and document review during a complaint investigation, it was determined the facility's food service department failed to meet the Condition of Participation requirements by evidence of rodent droppings, multiple areas that were dirty or not maintained in a sanitary manner and lack of repair work recommended by the pest control vendor.

The findings included:

An unannounced observational tour was conducted of the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6. Observations included a staff member leaving the kitchen area carrying food that was not covered. Observations also included multiple ceiling tiles in the kitchen area which had rodent droppings.

The surveyors noted a door in the kitchen's dry storage area. This door led to the outside and there was a gap at the bottom edge, large enough for pests to enter. A partial review of the pest control service invoices revealed that twenty-three service records (from 11/2014 - 1/2017) noted the need for a sweep for the dock plate door to exclude pest.

Other observations included food items and trash on the floor, grayish material - described by staff as dust, uncovered food in a refrigerator, rusting and pitting of the freezer floor, dust and rodent droppings on top of a refrigerator, and torn plastic on the tray line. Also, a broken temperature gauge on the dish washer was not repaired until a surveyor was observing the temperature of the dishwasher, and noted it did not reach the required temperature.

The pest control service records also showed a recommendation to repair the laminate above the serving line on seven (7) invoices between 11/2014 and 2/2017. This had not been repaired at the time of the survey. Pans washed at the three compartment sink were noted to be stacked when wet.

An interview was conducted on 02/28/2017 at approximately 9:00 a.m., with Staff Member #10. Staff Member #10 reviewed an eight (8) page document related to kitchen staff and their area to clean, with the surveyor. Staff Member #10 acknowledged although he/she had documented assignments for the kitchen staff his/her staff had not been monitored to ensure their assigned task was performed. A contracted service also had cleaning responsibilities in the kitchen area.

Please refer to A-0620 for additional information.

Show Text of Violation

Based on observations, interviews, complaint investigation, and document review, it was determined facility staff failed to ensure the Condition of Participation was met by failing to ensure

1. The facility's kitchen was maintained in a manner to prevent harborage of rodents and

2. The Morgue unit was maintained to prevent pervasive odors.

3. Annual fire safety inspections were conducted.

The findings included:

An unannounced observational tour as part of a complaint investigation was started in the facility's kitchen at 10:50 a.m. on 02/27/2017, with Staff Members #1 and #6

An observation conducted while walking to the kitchen's dry storage room revealed a door leading to the outside area. The door had a gap at the bottom edge, which provided a route for pests to enter the kitchen area.

A partial review of the pest control service invoices was conducted on 03/01/2017. The review revealed repeated recommendations, which involved the kitchen and the adjacent cafeteria. This included the need for a sweep for the dock plate door to exclude pest this recommendation was listed on the invoices for-11/2014, 1/21/15, 3/25/15, 4/7/15, 6/10/15, 7/15/15, 8/19/15, 10/28/15, 11/18/15, 12/29/15, 1/20/16 and then monthly throughout 2016 and 01/2017.

An observation was conducted at 11:15 a.m. on 02/27/2017 with Staff Member #6 and the surveyor. Staff Member #6 and the surveyor utilized ladders to view the space between the Kitchen ceiling and the drop-in ceiling tiles. Since Staff Member #12 was in the process of preparing sandwiches; the initial selection of ceiling tiles for opening and inspection were outside of the food preparation area. The area initially chosen was near the information board towards the back of the kitchen. The surveyor used a flashlight during the observation, which revealed approximately four (4) blacken rice-size droppings on the fifth (5th) from the wall drop-in ceiling tile and approximately three (3) blacken rice-size droppings on an adjacent drop-in ceiling tile. Staff Member #6 identified the blacken rice-size droppings as mouse droppings. Related to the findings a second location was selected by the surveyor at 11:21 a.m. on 02/27/2017. The area selected was center-oriented between the dishwashing area to the rear, above and to the front of Refrigerator #7. Staff Member #6 removed two drop-in ceiling tiles, with the aid of a flashlight the surveyor and Staff Member #6 observed an uncountable number of blacken droppings ranging in size from larger than a dried-grape to rice-size on the surface of the two ceiling tiles removed. Staff Member #6 verified the observation findings and identified the dropping to be more than just mouse dropping and possibly rat dropping.

In the same area Staff Member #6 and the surveyor moved up another level on the ladder and utilized the flashlight to observe the larger area of the space between the ceiling and the drop-in ceiling tiles. The surveyor was able to view an area of thirteen (13) ceiling tiles in length by eight (8) ceiling tiles across [each ceiling tile was approximately twenty-four (24) inches by twenty-four (24) inches]; the entire area had an innumerable spreading of rodent droppings of various sizes. Additional rodent droppings were also found in other areas of the kitchen.

Pest control invoices also revealed recommendations to pour water down drains (for common areas and the kitchen) to prevent traps from drying out and becoming harborages for pest and rodents- the recommendation was listed 11/2014, 112/10/14, 1/21/15, 2/11/15, on three (3) invoices for September 2015, two (2) invoices in October 2015, and 11/23/2016.

An interview was conducted on 03/02/2016 at approximately 12:44 p.m., with Staff Member #10. The surveyor presented the pest control binders and invoices and inquired regarding the recommended repairs to keep pest from entering the kitchen. Staff Member #10 stated, I don't receive those invoices. I didn't know about that information.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. The surveyor inquired regarding which staff was responsible for overseeing and correcting the repeated recommendations documented by the pest control vendor. Staff Member #6 stated, What recommendations, one of my staff signs the electronic pad there isn't a printout given. The surveyor reviewed the binders with the pest control vendor's invoices with Staff Member #6. Staff Member #6 reported the pest control vendor places the invoice in the binder on their return visit. Staff Member #6 reported the facility staff did not monitor the binders; the invoices were kept in the binders for proof of pest control services. The surveyor inquired which of facility staff was responsible for inspecting for rodents and other pest. Staff Member #6 stated, All of us are. I think you saw my face when we looked in the ceiling, I was taken back. When I came down I said to [Staff Member #1's name] we have a problem.

Review of the facility's policy titled Environmental Services Infection Prevention Guidelines read in part: H. Pest Control 1. An effective pest control program will be maintain to forestall or prevent infestation and/or eliminate infestation should it develop. 2. A preventative maintenance and inspection program will be maintained throughout all constructed spaces and surrounding property ...

2. An observation was conducted as part of a complaint investigation of the facility's Morgue refrigeration unit on 02/27/2017 from 10:15 a.m. through 10:44 a.m., with Staff Member #1 with other staff members joining the observation. The Morgue unit's door had a built-in thermometer, which read 34 F (degrees Fahrenheit). At approximately 10:38 a.m. Staff Member #6 joined the observation and explained the Morgue unit was under his/her department's responsibility. The surveyor requested the past eighteen (18) months of temperature logs for the Morgue unit. Staff Member #6 explained his/her department did not keep documented temperature logs for the Morgue unit. Staff Member #6 stated, When my personnel performs rounds they glance at the gauge and if it is alright, they move on. The surveyor inquired how Staff Member #6's staff would know if the Morgue unit was working at the right temperature. Staff Member #6 reported if the unit was running, it was at the right temperature. The surveyor requested documented maintenance and service performed on the Morgue unit for the past three years.

An interview was conducted on 02/27/2017 at 2:02 p.m., with Staff Member #6 and Staff Members #1 and #2 were present. Staff Member #6 presented two (2) service invoices for service performed on the Body Cooler by an outside vendor. Staff member #6 reviewed the vendor documents with the surveyor. One invoice documented the bodies within the Morgue unit needed to be removed. The surveyor requested information related to the bodies that were removed, where the bodies went and if they returned to the facility's Morgue unit once it had been repaired. The documents presented by Staff Member #6 were difficult to read and the surveyor requested legible copies. Staff Member #6 reported he/she would have to contact the service vendor to email their copy of the original invoices. Staff Member #6 reported if any other service had been performed by facility's maintenance staff on the Morgue unit, it had not been documented.

Staff Member #6 presented legible copies at 2:31 p.m. on 02/27/2017. Review of the outside vendor's Service Work Order dated 9/18/2016 [Sunday] read: Evap (evaporator) coil block of ice. Unit running after condenser water restarted. Waiting for bodies to be removed. Send tech (technician) Monday morning [Sic]. The second invoice was dated 09/19/2017 read in part: Located leak Liquid valve not back seating & (and) valve stem Packing ^ (increase) packing & add dress fitting ... Pull vacuum & recharge. Set water valve ... Install Temp (temperature) control to maintain temp in box [Sic].

An interview was conducted on 03/01/2017 at 2:35 p.m., with Staff Member #11. Staff Members #1 and #2 were present during the interview. Staff Member #11 reported the cleaning of the Morgue unit was not directly his/her department's responsibility. Staff Member #1 reported related to the findings the facility recognized opportunity for change. Staff Member #1 reported the Morgue unit, had not previously been included on the facility's environment of care rounds but would be added.

An interview was conducted on 03/02/2017 at 1:11 p.m., with Staff Member #6. Staff Member #6 presented documentation related to the facility's preventative maintenance program. Staff Member #6 presented the rating system utilized by the facility, which placed equipment on a semi-annual, annual, or no maintenance required schedule. Staff Member #6 presented documentation that the facility's Morgue unit had been placed on the no maintenance required status related to the mechanical functions. Staff Member #6 stated, The body holding unit did not need annual maintenance like oiling. The unit was built to just continuously run and it fell off the annual list. But an infection control score will be added, which will pull the unit back on an annual schedule.

An interview was conducted on 03/03/2017 at 10:29 a.m., with Staff Member #1. Staff Member #1 reported he/she became aware of an issue with the facility's Morgue unit around the Holidays (2016). Staff Member #1 stated, I received a complaint from the staff that worked in the two offices on the same hallway as the unit. The surveyor inquired related to the nature of the staff complaints. Staff Member #1 stated, It was about odor. Staff Member #1 reported the odor was due to unclaimed remains. Staff Member #1 reported due to the necessity of filing documentation with the court system the patient remains were not removed until the beginning of February 2017.

3. When the surveyors asked to review the State or County Fire Marshall inspections, facility staff stated they were not sure of the last inspection, that it may have been in 2012 or 2013.

Please see A-0701 and A-0715 for additional information.

Show Text of Violation

Based on observations, interviews and documents reviews, it was determined the facility staff failed to ensure they followed their infection control plan by identifying, reporting, investigating and controlling potential areas and behaviors that could potentially result in an infection by:

A. Ensuring proper hand hygiene was followed during 8 of 10 observations;

B. Safe injection practices were followed during 1 of 2 observations;

C. Staff used personal protective equipment and used it appropriately 4 of 4 observations;

D. Staff appropriately cleaned the environment and equipment for 2 of 2 observations; Staff in areas where high level disinfection occurred had clean and appropriately ventilation for 1 of 1 area, and linen was appropriately stored and transported in 2 of 2 observations;

E. Appropriately perform care for indwelling catheters for 1 of 2 observations;

F. Appropriate attire was worn and changed in surgical and clean areas in 3 of 4 observations;

G. Staff followed infection control procedures during ventilator care;

H. Following established care and cleaning of point of care devices in 2 of 2 observations;

I. Appropriate precautions were followed when caring for a patient on isolation in 1 of 2 observations;

J. Staff followed infection control practices in surgical and clean areas

K. Food and drinks were stored or ingested in appropriate areas in 4 of 5 observations; and

L. Facility equipment was maintained to prevent the spread of infection between patients in 3 of 3 observations.

The findings include:

1. A. On 6/15/2015 and 06/16/2015 on CICU (cardiac intensive care unit), Patient rooms on PSU, GYN OR (gynecology operating room) and in L&D (labor and delivery) the following observations were made:

CICU on 6/15/15 at approximately 2:45 P.M. a central line was observed being placed; following the placement Staff #19 removed gloves, exited the room and went to nurses' station and began entering information on the computer without performing hand hygiene.

PSU on 6/15/15 at approximately 1 P.M. Staff #17 was observed caring for a patient on contact isolation. Staff #17 applied an ointment to the lower to mid thigh and sides of the knee and upper shin and calf area of Patient #3. Patient #3 had an abraised area on the knee where a scab was forming. Staff #17 applied the ointment, removed the glove of the right hand reached under the PPE (personal protective equipment (gown)) and pulled out the ID (identification badge), scanned the badge and returned it to under the PPE. Staff #17 never performed hand hygiene during this process.

GYN OR on 6/16/15 at approximately 11:25 A.M. while observing a surgical procedure Staff #53 removed bloody sponges from the waste receptacle for count, removed his/her gloves and picked up note paper and began documenting without performing hand hygiene. The same Staff member was observed holding a specimen collection container and collecting the specimen with no gloves on.

L&D on 6/16/15 at approximately 12:25 P.M. A Staff was observed removing bloody sponges to ensure count was correct. Gloves were removed and the Staff began to document without performing hand hygiene. Staff #29 acknowledged this was observed. Staff #2 was present during all the observations and acknowledged the observance of the same.

B. On 6/15/15 at approximately 3:40 P.M. Staff #21 was observed instilling a medication into an INT (intermittent needle therapy). Staff #21 did not clean the port site prior to instilling the medication.

C. PSU on 6/15/15 at approximately 1 P.M. Staff #17 was observed caring for a patient on contact isolation. Staff #17 applied an ointment to the lower to mid thigh and sides of the knee and upper shin and calf area of Patient #3. Patient #3 had an abraised area on the knee where a scab was forming. Staff #17 applied the ointment, removed the glove of the right hand reached under the PPE (personal protective equipment (gown)) and pulled out the ID (identification badge), scanned the badge and returned it to under the PPE. Staff #17 did not perform hand hygiene during this process.

An observation conducted on CICU on 6/15/15 at approximately 2:35 P.M. revealed Staff #19 and 20 walking down the hallway pushing a cart. Staff #19 and 20 were both wearing head coverings. Staff #19 had on a paper head covering and Staff #20 had on a cloth head cover. Staff #19 and 20 entered room #8 of CICU to perform a central line placement procedure. Staff #19 and 20 did not change their head covering or place a clean head covering over them prior to the initiation of the procedure.

On 6/16/15 between 9:15 and 10:50 A.M. in the GYN OR area 3 staff members were observed in room #3 wearing cloth head coverings with no disposable head covers over the cloth head covers. Also during this time observations were made in the Central Sterile area. On the clean side of Central Sterile 2 staff members were observed in cloth head covers with no disposable head covers over the cloth and one Staff in a floral scrub jacket that Staff #2 confirmed was not a part of the scrubs furnished by the facility.

In the L&D area where an observed C-Section was observed on 6/16/15 Staff #31 was observed making adjustment to the lights over the surgical table with bare hands after the light handle covers had been put in place. Staff #31 was also observed grabbing the sides of the light with bare hands at the same time.

D. CICU on 6/15/15 at approximately 2:45 P.M. a central line was observed being placed; following the placement Staff #20 was observed cleaning the handle used to move the portable ultra sound and the cable with the probe but did not clean the rest of the machine that was either touching or less than 4 inches from the patient's bedside. The instructions on the product used to clean the machine directed the user to keep the equipment wet for 4 minutes. The parts of the portable ultra sound that were cleaned was wet for approximately 1 minute.

On 6/15/15 at approximately 2:30 P.M. in SICU (surgical intensive care) Patient #4 was receiving plasmapheresis dialysis. The dialysis machine had tape residue and paint was chipped.

On 6/16/15 between 9:15 and 10:54 A.M. the Central Sterile area was observed. This area is where dirty surgical instruments are cleaned, processed and sterilized. In this area the eye wash sink had debris in the sink and the eye wash ports were uncovered. Under the eye wash station laying on the floor were folded towels and blanket that had dried water rings on them. The air vents and grills were visibly dusty. There were 3 Steris Washers 2 of which had a black and or brown substance flashing around the washers on one or both sides.

The area of Central Sterile was warmer than the corridors. In this area a concentrate enzymatic presoak and cleaner was used on surgical instruments. The label on the cleaner documents Use adequate ventilation to maintain levels below established exposure limits. Staff #25 wore a standard paper mask and face shield.

The clean linen storage are was observed on 6/17/15 at approximately 10:30 A.M. The clean linen storage contained approximately 20 linen bins and storage shelving units total. Approximately 7 of the bins were not covered and contained clean linen. Staff #33 stated, I am embarrassed for you to see this. I expected this to be near perfect.

F. CICU on 6/15/15 at approximately 2:35 P.M. Staff #19 and 20 were observed walking down the hallway pushing a cart. Staff #19 and 20 were both wearing head coverings. Staff #19 had on a paper head covering and Staff #20 had on a cloth head cover. Staff #19 and 20 entered room #8 of CICU to perform a central line placement procedure. Staff #19 and 20 did not change their head covering or place a clean head covering over them prior to the initiation of the procedure.

At approximately 2:45 P.M. the central line was observed being placed; following the placement Staff #19 removed gloves, exited the room and went to nurses' station and began entering information on the computer without performing hand hygiene.

I. PSU on 6/15/15 at approximately 1 P.M. Staff #17 was observed caring for a patient on contact isolation. Staff #17 applied an ointment to the lower to mid thigh and sides of the knee and upper shin and calf area of Patient #3. Patient #3 had an abraised area on the knee where a scab was forming. Staff #17 applied the ointment, removed the glove of the right hand reached under the PPE (personal protective equipment (gown)) and pulled out the ID (identification badge), scanned the badge and returned it to under the PPE. Staff #17 did not perform hand hygiene during this process.

J. On 6/16/15 between 9:15 and 10:50 A.M. in the GYN OR area 3 staff members were observed in room #3 wearing cloth head coverings with no disposable head covers over the cloth head covers. Also during this time observations were made in the Central Sterile area. On the clean side of Central Sterile 2 staff members were observed in cloth head covers with no disposable head covers over the cloth and one Staff in a floral scrub jacket that Staff #2 confirmed was not a part of the scrubs furnished by the facility. By not changing attire the facility staff increased the risk of introducing infectious agents and cross contamination in the surgical and clean areas.

K. On 6/16/15 between 9:15 and 10:50 A.M. in the GYN OR area 2 Staff were observed walking down the hallways of the surgical area. One of these Staff Members was carrying an open drink and drinking it. The other Staff was carrying what appeared to be a sliced bagel. This Staff was eating on half of the bagel. Staff #24 attempted to redirect this Staff who was eating to the lounge. This Staff initially ignored the redirection.

L. Other observations made during the days of the survey were: Opened and accessed sterile equipment placed back in the anesthesia cart of GYN OR #2; tears in the surgical table; soiled wheel casters stored on top of clean/sterile paper wrapped surgical items; tears or chips in the floor of the OR; chips in numerous doors through out the GYN OR and chipped paint in the over head light in GYN OR #2.

On 6/16/15 at approximately 12:03 P.M. the area of Surgical L&D was observed. The area contained paper towels stacked causing remaining paper towels to be wetted. While Patient #8 was observed undergoing a C-Section there were 3 infant warmers in the room. One was to be used during the birth of Patient #8's baby. The remaining 2 infant warmers were uncovered and exposed. One infant warmer had a notebook open and laid across the bed of the warmer. Staff #29 stated, We have the additional warmers set up in case of an emergency. Also the floor of this room had cracks in the floor.

The floor of the GYN OR in the surgical corridor area had cracks or separations in the flooring where soil and or water had appeared to collect in areas.

The facility policy # 6 documents under Methods of Implementation and Control All employees will utilize standard precautions. Under sub-section Engineering Controls and Work Practices; In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious material, employees are not to eat, drink, apply cosmetics of handle contact lenses. Employee food and beverages are not to be kept in refrigerators or on counters where blood or other potentially infectious material is present. Under sub-section Personal Protective Equipment; All employees using PPE must observe the following precautions: Perform hand hygiene immediately or as soon as possible after removal of gloves or other PPE.

The facility also provided policy # 9 Surgical Attire. Under the section titled Procedure:

Sub-section A: #5 documents All surgical attire to include pant suits, hair coverings and cover jacket are to be laundered daily in an (Name of facility Company) accredited laundry.

B: #2 documents Disposable head coverings will be discarded after use. #3 documents Daily laundered fabric head covering may be worn with a disposable bouffant hair cover.

Sub-section H documents Protective barriers will be provided for all personnel #2 Gloves are changed and hand hygiene performed after each use and discarded in approved receptacles.

Sub section I documents Identification badges will be visible at eye level and be secure and clean. The use of lanyards is not recommended.

CDC's Healthcare-associated Infections - Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care Adhere to Standard Precautions

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect HCP and prevent HCP from spreading infections among patients. Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. Each of these elements of Standard Precautions are described in the sections that follow.

Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence. Further, at the facility level, an understanding of the specific procedures performed and typical patient interactions, as described above in Administrative Measures as part of policy and procedure development, will assure that necessary equipment is available.

2. A. During an observation of a central venous catheter dressing change conducted on 06/15/2015 and 06/17/2015, staff failed to perform hand hygiene between glove changes while performing patient care related to 2. C. and 2. F.

Ventilatory/Respiratory therapy care was observed on 06/17/2015, staff failed to perform hand hygiene between glove changes while performing patient care related to 2. C. and 2.G.

An interview was conducted 3:56 p.m. on 06/15/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

2. C. During an observation of a central venous catheter dressing change conducted on 06/15/2015 and 06/17/2015, staff failed to change gloves and perform hand hygiene before moving from a contaminated body site to a clean body site while performing patient care related to 2 F.

Ventilatory/Respiratory therapy care was observed on 06/17/2015, staff failed to change gloves and perform hand hygiene before moving from a contaminated body site to a clean body site while performing patient care related to 2. G.

An interview was conducted 3:56 p.m. on 06/15/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

2. F. An observation of a central venous catheter dressing change was conducted on 06/15/2015 at approximately 2:50 p.m. with Staff #36. Staff #36 performed hand hygiene, donned gloves and removed Patient #15's saturated right internal jugular (IJ) vein catheter dressing. Staff #36 failed to perform hand hygiene prior to donning sterile gloves to apply a new dressing.

An observation of a central venous catheter dressing change was conducted on 06/17/2015 at approximately 10:15 a.m. with Staff #46. Staff #46 performed hand hygiene, donned gloves and removed Patient #17's left Quinton catheter dressing. Staff #46 performed hand hygiene, donned sterile gloves, accessed port and cleaned, applied biopatch, removed gloves, failed to perform hand hygiene prior to donning gloves to apply a new dressing and write the date, time and initial of staff member applying the new dressing.

Review of the facility's policy titled Hand Hygiene, which read in part Policy: Hand hygiene is generally considered the most important single practice for preventing Healthcare- Associated Infections. The purpose of hand hygiene for routine patient care is to remove microbial contamination acquired by recent contact with infected or colonized patients or environmental sources. RESPONSIBLE PERSONS: A. All staff, volunteers, physicians, and contract employees. 3. Decontaminate hands a. Before having direct contact with patients. b. Before donning sterile gloves when inserting a central intravascular catheter. c. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical scrub. d. After contact with patient's intact skin .... e. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. f. If moving from a contaminated-body site to a clean-body site during patient care. g. After contact with inanimate objects .... h. After removing gloves.

An interview was conducted on 06/17/2015 at approximately 11:30 a.m., with Staff #2 and Staff #4. The surveyor informed Staff #2 and Staff #4 regarding the findings during observations. Staff #4 reported it is the facility's policy to do hand hygiene between all glove changes and this is what is expected of all staff.

2. G. An observation of ventilator/respiratory therapy care was conducted on 06/17/2015 at approximately 9:45 a.m. with Staff #49 Staff #49 performed hand hygiene, donned gloves and performed ventilator and respiratory care for Patient #15. Staff #49 removed gloves, did not perform hand hygiene, donned new gloves and logged into the computer to verify Patient #15's ventilator settings and proceeded to complete Patient #15's respiratory treatment. Staff failed to perform ventilator care/treatment in a manner to prevent the introduction of infectious agents and cross contaminants.

An interview was conducted on 06/17/2015 at approximately 11:30 a.m., with Staff #2 and Staff #4. The surveyor informed Staff #2 and Staff #4 regarding the findings during observations. Staff #4 reported it is the facility's policy to do hand hygiene between all glove changes and this is what is expected of all staff.

2. H. An observation was conducted on 06/17/2015 at approximately 10:45 a.m., during a blood glucose check on Patient #18. Staff #48 performed the glucose testing for Patient #18 wearing gloves and after completion of the testing, removed the strip with the blood sample from the glucometer with his/her gloved hands. Staff #48 then put on gloves to clean the glucometer with PDI Sani wipes. The surveyor informed Staff #48 regarding the findings during the observation and inquired if the glucometer was cleaned and disinfected according to manufacturer's instructions. Staff #48 stated, This is what I was taught.

The survey team held a discussion of the observations and concerns on 06/17/2015 at 11:50 a.m. with Staff #1, Staff #2, Staff #4, Staff #5 and Staff #7.

3 A. An observation on June 16, 2015 at 10:30 a.m., with Staff #12 revealed he/she failed to change gloves and perform hand hygiene between procedures for Patient #1. During the observation Staff #12 removed his/her gloves twice and failed to perform hand hygiene after glove removal. For further details see 3 E.

3 E. The following was observed during Foley catheter care on June 16, 2015 at 10:30 a.m.: Staff #12 performed hand hygiene and donned gloves to perform Foley catheter care on Patient #1. During Foley catheter care Patient #1 asked Staff #12 if he/she would clean [his/her] belly. Staff #12 cleaned Patient #1's abdomen and applied Nystatin powder without changing gloves and performing hand hygiene. Staff #12 opened and closed the Nystatin powder with a dirty gloved hand. Staff #12 placed the Nystatin powder into a plastic bag on top of a cart in the room and then opened a drawer with the same dirty gloved hand and placed Nystatin in the drawer. Staff #12 then opened another draw to get a linen bag for the dirty linen with the same dirty gloved hand. Staff #12 then removed dirty gloves and donned a second pair of gloves without performing hand hygiene. Staff #12 continued with Foley catheter care then removed gloves and donned a third pair of gloves without performing hand hygiene. After the procedures were complete Staff #12 removed gloves and performed hand hygiene before leaving the room. Staff #12 failed to follow proper hand hygiene during the Foley catheter care potentially placing the patient at higher risk for urinary tract infection.

3 H. The following was observed during use of a point of care devices on June 16, 2015 at 11:30 a.m.: Staff #13 performed hand hygiene and donned gloves to perform a blood glucose check on Patient #2. Staff #13 placed all supplies including alcohol pad, gauze pads, finger stick device, glucometer strips container and glucometer in the bed with Patient #2. Staff #13 cleaned the site with alcohol prior to perform the finger stick for the blood sample. The first drop of blood was wiped away with gauze pad and the second drop was placed on the strip in the glucometer. The glucometer was then placed on the counter of the sink where there was a roll of toilet paper and a urinal containing urine. Staff #13 wiped the glucometer once with a super sani-cloth then removed gloves and performed hand hygiene. The container of glucometer strips was not cleaned. Staff #13 failed to clean the glucometer according to the facility policy and procedure and manufacture's guidelines.

An interview with Staff #4 revealed that the glucometers are used on multiple patients and the hospital policy for cleaning glucometers is directly from the manufactures guidelines.

Hospital policy titled Whole Blood Glucose by NOVA STATstrip states The meter's external surface should be cleaned and disinfected with a fresh bleach wipe from the EPA-approved list D. 1. remove a fresh wipe from the canister and thoroughly wipe the surface of the meter (top, bottom, left, right sides) a minimum of 3 times horizontally and 3 times vertically avoiding there meter's bar code scanner and electrical connector.

The following ingredients are contained in the super sani-wipes according to Material Safety Data Sheet (MSDS): Isopropanol, benzyl-C 12-18 alkyldimethyl am ammonium chlorides, Quaternary ammonium compounds, C 12-18 alkyl (ethylphenyl, methyl, dimethyl, chlorides). The contact time listed is 2 minutes.

3. K. The following was observed during an interview on June 16, 2015:

On Unit 3 North there was a clear cup with an initial on the cup, containing a dark liquid observed on top of the counter at the nursing station and a clear cup with a logo containing a clear liquid on the desk beside the computers. Staff #16 was observed picking up the clear cup with the initial and drinking from it while standing at the nurses station.

On Unit 2 South Staff #15 was observed walking down the hall with a cup in hand. Staff #15 stopped at the nurses station and set the cup on the counter while talking with other staff members. Staff #15 picked up the cup and drank from it while continuing to walk down the hall.

4 D. An observation was conducted on June 16, 2015 from approximately 1:15 p.m. to 1:22 p.m., with Staff #3 and Staff #9. The observation was made while waiting to interview a patient as part of the discharge planning review. Staff #54 exited Room 221 carrying linens, observable bedspread and sheets, rolled together under his/her arms and against his/her uniform. Staff #9 asked Staff #54 to place the linens in a blue bag for transport. Staff #54 reported the linens were extras in [name of patient]'s room and there were no blue bags in the patient's room. Staff #54 continued to carry the contaminated linens across the nurses' station and down the hall to the soiled utility room. The surveyor questioned if the linens had been transported appropriately, Staff #9 stated, [He/she] should have transported the linens in a blue bag. Staff #9 reported the expectation would have been to leave the linens in the room and obtain a blue bag for transporting the linens.

An interview was conducted on June 17, 2015 at 9:37 a.m. with Staff #9. Staff #9 verified the observation conducted on June 16, 2015 of Staff #54 improperly transporting the soiled linens. The surveyor requested a copy of the facility's policy for linen transport. Staff #9 reported that Staff #54 had not handled the linen per the facility's policy.

Review of the facility's policy titled Exposure Control Plan (ECP) for Bloodborne Pathogens revised 11/2014 read in part: Laundry: In accordance with Standard Precautions, all linens/laundry is considered contaminated. Contaminated linen should be handled as little as possible and with minimal agitation. Linen shall be bagged at the site of generation into plastic bags and closed to prevent leakage ...

4 K. An observation was conducted on June 16, 2015 from approximately 11:25 a.m. to 11:35 a.m., with Staff #3. The observation revealed a variety of staff drinks in at least eight locations within the nurses' station. The surveyor asked Staff #9 if staff could have opened cups with liquids or any drinks in the nurses' station. Staff #9 stated, Staff are not allowed to have opened drinks at their work station. Staff #9 collected the cups without lids and directed other nursing staff to remove the drinks from the area. One of three nurses commented I thought we could have drinks if the top was closed. Before the drinks could be collected, a drinking cup with a partially closed lid was knocked over by one of two staff charting. A request was made for the facility's policy.

Review of the facility's policy titled Exposure Control Plan (ECP) for Bloodborne Pathogens revised 11/2014 read in part:Engineering Controls and Work Practices: Engineering and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens ... In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious material, employees are not to eat, drink ... Employee food and beverages are not to be kept in refrigerators or on counters where blood or other potentially infectious material is present ...

An interview was conducted on June 17, 2015 at 9:30 a.m., with Staff #4. The surveyor clarified with Staff #4 that there was no other policy for food and drink in the nursing stations. Staff #4 reported the Exposure Control Plan (ECP) for Bloodborne Pathogens revised 11/2014 was the policy in place. The surveyor reviewed the policy with Staff #4 related to the indication that no food and drink should be in the nurses' station. Staff #4 stated, Potentially infectious specimens are brought into the nurses' stations, like urine cultures and other specimens. The nurses' station is an area where there is a potential for exposures to infectious materials. The surveyor shared the observation findings with Staff #4. Staff #4 reported there should be no beverages in the nurses' station whether opened or closed per policy.

Show Text of Violation

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

Based on staff interview and document review, it was determined the facility staff failed to ensure the discharge needs initial assessment/evaluation was performed for three of the five patients reviewed for discharge planning. (Patients #9, #11, and #12)

The findings included:

An interview and review of the facility's policy titled Discharge of Patients was conducted on June 15, 2015 at approximately 1:15 p.m., with Staff #3 and Staff #9. Staff #3 reported the facility had two pathways related to discharge planning. Staff #3 reported that case management might not be consulted for non-complicated patients that were generally independent. Staff #3 reported the discharge planning for non-complicated patients was handled by nursing staff. Staff #9 reported nursing and case management utilized the same policy related to discharge. The policy titled Discharge of Patients read in part: B. Discharge planning should begin at the time of admission and is an ongoing process of determining patient/family needs to provide continuity of care.

1. Patient #9 was admitted on [DATE] and discharged from the facility on May 16, 2015. His/her discharge plans included sternal wound care provided by a home health agency. Patient #9 was readmitted to the facility on on [DATE] for surgical exploration and debridement of his/her sternal wound. Review of the June 9, 2015 initial assessment by the Registered Nurse (RN) related to post discharge needs revealed the section had not been completed and was blank. [Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.]

An interview was conducted on June 16, 2015 at 9:08 a.m., with Staff #3 and Staff #9. Staff #9 verified Patient #9's initial assessment for post discharge needs had not been completed. Staff #3 reported the questions in the post discharge needs section of the initial nursing assessment can trigger the need to involve case management and other therapies.

2. Patient #11 was admitted to the facility for shortness of breath (SOB) on April 1, 2015 and discharged to a skilled nursing facility on April 3, 2015. Patient #11's initial assessment for Functional Screening by the RN indicated the patient had mobility deficits, but failed to indicate the area of deficit. Patient #11 was readmitted to the facility for shortness of breath on April 25, 2015 and discharged on [DATE].

An interview was conducted on June 16, 2015 at approximately 9:30 a.m., with Staff #3. Staff #3 acknowledged the above findings. Staff #3 reported the Functional Screening relates to treatment needs and post discharge needs.

3. Patient #12 was admitted on [DATE] for cellulitis involving his/her right foot and discharged from the facility on May 11, 2015. Review of the April 27, 2015 initial assessment by the RN related to post discharge needs had been left blank. Patient #12 was readmitted to the facility on on [DATE] for the surgical removal of gangrenous toes on his/her right foot. The readmission initial assessment dated [DATE], indicated Patient #12 did not have deficits in mobility. Although the RN documented in other areas of the readmission initial assessment that Patient #12 had decreased muscle coordination, a right foot wound, and unsteady gait. [Cellulitis is a skin infection that happens when bacteria spreads through the skin to deeper tissues.]

An interview was conducted on June 16, 2015 at approximately 11:00 a.m., with Staff #3 and Staff #9. Staff #9 verified the findings. Staff #9 reported if nursing staff documented on the fall assessment that the patient had deficits; those deficits should have been noted on the Functional Screening for treatment and discharge needs. Staff #3 and Staff #9 verified facility staff had failed to gather needed information on the initial discharge needs assessments for Patients #9, #11, and #12.

Show Text of Violation

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

Based on medical record review and interview the facility failed to ensure complete and appropriate care of an upper extremity injury for one of thirty two emergency department patients (Patient #10). Specifically, one of thirty two emergency department patients did not receive an x-ray which resulted in an undiagnosed fracture by the emergency department physician (Patient #10).

The findings included:

Thirty two electronic medical records were reviewed on March 9, 2015 and March 10, 2015. Patient #10's electronic medical record was reviewed beginning on March 9, 2015 at approximately 10:40 am. A copy of Patient #10 's medical record was requested on March 9, 2015 during the review. A copy of Patient #10 's medical record was received on March 9, 2015 at approximately 3:00 pm. The medical record of Patient #10 was reviewed for a second time on March 9, 2015 beginning at 5:30 pm.

Patient #10 was brought to the Emergency Department by rescue squad on January 14, 2015 at approximately 10:16 pm. The Emergency Services paramedic's documentation dated 01/14/2015 at 10:00 pm states arrived to find the patient (reference to Patient #10) sitting in a chair at the gym. The patient (reference to Patient #10) was throwing a dodge ball with his/her left continuously when he/she suffered significant pain in his/her left upper arm. Documentation by the paramedic states Patient #10 denied being struck by another person. Documentation by the paramedic indicates Patient #10 did not suffer any loss of consciousness (LOC) or fall. The paramedic's documentation states Patient #10 denied all pain except humeral pain just above his/her left elbow. Further documentation by the paramedic states no swelling or discoloration of the left upper extremity. The narrative note by the paramedic states Patient #10 complained of 2/10 pain in his/her arm while it was resting in his/her position of comfort (against the chest) however when he/she attempted to move his/her arm it increased the pain to 9/10. No notations by the paramedic indicated a change in the color, pulses, or sensation of Patient #10's left arm. Documentation on the Emergency Medical Services (EMS) Patient Care Report (page 1) states chief complaint fracture/dislocation.

Documented arrival time of Patient #10 to the emergency department on January 14, 2015 is 10:16 pm. Patient #10's triage was performed by Staff #11 at 10:18 pm on January 14, 2015. Documentation in the medical record of Patient #10 dated January 14, 2015 indicates the patient was seen by the emergency department physician at 10:22 pm. Documentation by Staff #11 states Patient #10 received a Triage Emergency Severity Index (ESI) of Level 3. According to the U. S. Department of Health and Human Service Agency for Healthcare Research and Quality Emergency the Emergency Severity Index (ESI) is a simple to use, five-level triage algorithm that categorizes emergency department patients by evaluating both patient acuity, and the resources needed. ESI levels 3, 4, and 5 are differentiated by the nurse's determination of how many resources are needed to make a patient disposition. Those patients who are expected to need two or more resources are designated as ESI level 3.

The triage policy for the facility was requested and received on March 10, 2015 at approximately 8:00 am. A review of the policy titled Triage indicates the facility classifies patients into five triage categories utilizing the Canadian CTAS system to assign acuity which includes resuscitation, emergent, urgent, less urgent, and non urgent. Of note the facility's electronic medical record lists triage priority scale under the ESI category documentation.

Staff #11 was interviewed on March 11, 2015 at 7:15 am. Staff #11 verified he/she was the triage nurse for Patient #10 and cared for Patient #10 while in the emergency department. Staff #11 stated a priority score of 3 means the doctor needs to see the patient within about ten minutes. Documentation by Staff #11 in Patient #10's electronic medical record states Patient #10 was alert and oriented times three. Documentation by Staff #11 in Patient #10's medical record states Patient #10's injury occurred 45 minutes ago and he/she was throwing a dodge ball and felt a pop in the left bicep. Further documentation dated January 14, 2015 at 10:24 pm by Staff #11 indicates Patient #10 was complaining of 4/10 pain in the left bicep area. Staff #11 documented a small knot was present and Patient #10 had limited range of motion due to pain. Notation was made by Staff #11 pertaining to the presence of positive pulses in Patient #10's left upper extremity. Documentation of a complete assessment of Patient #10 on January 14, 2015 by Staff #11 was found.

Staff #11 documented in the medical record of Patient #10 on January 14, 2015 at 10:24 pm under the Subjective Assessment Patient #10 stated he/she was playing dodge ball and went to throw the ball and felt a huge pop in the arm and it hurts to move it.

Documentation by Staff #11 in the electronic medical record of Patient #10 at 10:30 pm on January 14, 2015 under the Extremity Assessment notes the mechanism of injury as change of position/throwing ball. Further documentation states extremity discomfort and decreased range of motion. Documentation of skin changes, pulses, and sensation of the left upper extremity of Patient #10 by Staff #11 reveal no abnormalities. Documentation by Staff #11 indicates ice and elevation of Patient #10's arm was done per medical doctor (MD) order at 10:35 pm. Documentation by Staff #11 states a left sling and ice was applied per MD order at 10:47 pm. Documentation by Staff #11 at 10:47 pm on January 14, 2015 states Toradol 10 mg by mouth (po) and Oxycodone 5 mg/Tylenol 325 mg tablet po was administered to Patient #10 for pain. Toradol according to Drugs.com is a nonsteroidal anti-inflammatory drug (NSAIDS). It works by reducing hormones that cause inflammation and pain in the body. Oxycodone and Acetaminophen (Percocet) according to Drugs.com is a combination medicine used to relieve moderate to severe pain. Percocet is a narcotic.

Documentation in the electronic medical record of Patient #10 under HPI (history of present illness) on January 14, 2015 at 10:22 pm by Staff #19 states arm injury, patient with sudden onset of pain within the belly of the bicep while throwing during a dodge ball match. He/she felt and heard a pop at the onset of pain. No lump or swelling reported. Documentation by Staff #19 states mechanism of injury throwing a ball. Staff #19's documentation states Patient #10 reported a pain level of 4/10 in the left arm. Documentation by Staff #19 states pain exacerbated by flexion/extension at the elbow and movement of the bicep. Further documentation by Staff #19 states no numbness or tingling of Patient #10 ' s left upper extremity. Physical examination documentation by Staff #19 states under the category titled Arm/shoulder: tender to palpitation within the belly of the bicep. Limited flexion/extension at the elbow due to bicep pain. No palpable mass or deformity. No physical evidence of complete tendon rupture. Shoulder is normal. Documentation by Staff #19 indicates Patient #10's forearm/elbow, wrist, and hand were all normal. No documentation of a small knot noted (previously noted by Staff #11) on the left arm of Patient #10 by Staff #19.

Documentation on January 14, 2015 by Staff #19 indicates the medical orders for Patient #10 included ice, elevation, and a sling to the left arm. Medications ordered included Toradol 10 mg po and Percocet for pain. No entry was documented under the title Clinical Impression by Staff #19 on January 14, 2015. Documentation by Staff #19 on January 14, 2015 at 10:44 pm was found under Primary Impression which states biceps muscle tear.

No documentation was found in Patient #10's electronic medical record the patient had any radiology studies done on January 14, 2015.

Documentation by Staff #11 states Patient #10 was discharged at 11:03 pm with discharge instructions and two prescriptions (Toradol and Percocet) for pain. Documentation by Staff #11 indicates Patient #10 was advised to make an appointment to see orthopedics in 3 to 5 days. A copy of Patient #10's discharge instructions was reviewed on March 10, 2015 at approximately 3:00 pm. The discharge instructions were titled Strain.

Staff #11 was interviewed on March 10, 2015 at 7:15 am. Staff #11 verified during interview he/she felt a small knot on Patient #10 ' s left upper arm. Staff #11 stated Patient #10 was having trouble with flexion and extension of his/her left arm. When asked by the surveyor if a patient who fractures an arm will sometimes hear a popping sound Staff #11 stated yes, fractures will pop. Staff #11 stated not all patients with fractures will complain of a pop. Staff #11 confirmed that Patient #10 did not have any x-rays prior to discharge.

Staff #19 was interviewed by speaker phone in the presence of Staff #1 on March 10, 2015 at approximately 5:45 pm. Staff #19 verified he/she provided medical care to Patient #10 on January 14, 2015 in the Emergency Department at the facility named in the complaint. Staff #19 stated Patient #10 had sudden pain in the arm while throwing a ball and heard a pop. Staff #19 stated Patient #10 could move his/her arm and had full range of motion. Staff #19 stated he/she remembered Patient #10 had pain which was exacerbated with flexion/extension at the elbow. Staff #19 stated the bicep area was tender to palpitation. Staff #19 stated he/she thought the patient (reference to Patient #10) had a bicep muscle tear or strain. Staff #19 stated he/she treated Patient #10 conservatively but stressed the importance of following up with orthopedics. Staff #19 stated he/she thought about a fracture but Patient #10 was young and healthy and the mechanism of injury was throwing a ball. Staff #19 stated he/she is generally liberal with obtaining x-rays. Staff #19 verified he/she did not order an x-ray for Patient #10's injured arm on January 14, 2015 while in the emergency department.

Eight physician (including Staff #12 and Staff #19) credential files were reviewed on March 10, 2015 at approximately 9:15 am. All necessary documentation was available for review. All physician credentials were up to date.

Documentation in Patient #10's medical record dated January 19, 2015 from the follow-up visit to the orthopedic specialist was reviewed on March 10, 2015. The documentation by Staff #7 under the section titled Brief History states He/she (reference to Patient #10) was playing dodge ball a couple of days ago and he/she threw the dodge ball and felt a pop in his/her arm. He/she went to the hospital. No x-rays were taken. He/she was diagnosed with a biceps tendon tear and sent to me for follow up in a sling. Documentation of Patient #10's physical examination by Staff #7 states he/she has a notable amount of bruising over the medial side of the arm and the antecubital fossa (triangular cavity of the elbow that contains a tendon of the biceps, the median nerve, and the brachial artery). His/her arm is grossly swollen. Documentation by Staff #7 reveals x-rays were obtained of Patient #10's left arm during the orthopedic follow up office visit on January 19, 2015. Documentation by Staff #7 states x-rays including AP (anterior/posterior) and lateral of elbow as well as AP and lateral of the humeral (long bone in the arm) shaft were obtained. Documentation by Staff #7 states he/she has got a distal third humeral shaft spiral fracture with some displacement and slight varus (bent inward) angualtion. According to Orthopedics One.com humeral shaft fractures are defined as fractures in which the major fracture line occurs distal to the insertion of the pectoralis major (anterior chest muscle) and proximal to the supracondylar ridge (either of two ridges above the condyle of the humerus). The fracture is usually described as open or closed, by the location within the humeral shaft (proximal, middle, or distal third) and overall character of the fracture pattern (transverse, oblique, or spiral). According to Wheeless ' Textbook of Orthopedics torsion force will result in a spiral fracture. Documentation by Staff #7 indicates the treatments discussed with Patient #10 and his/her parents were Sarmiento bracing (a brace used to immobilize humeral shaft fractures) or open reduction and internal fixation (a type of surgery used to fix broken bones). Documentation by Staff #7 on January 19, 2015 indicated Patient #10 elected to have the open reduction and internal fixation (ORIF) because of the long bracing period of time. Further documentation by Staff #7 indicated the surgical procedure would be scheduled as soon as possible. Staff #7 stated he/she needs to ice this and use the compression sleeve as much as possible.

A copy of the electronic medical record of Patient #10 dated January 27, 2015 was received and reviewed on March 9, 2015. Documentation by Staff #7 indicates Patient #10 underwent surgery on January 27, 2015 for an Open Reduction Internal Fixation (ORIF) of the left humeral shaft fracture. Documentation by Staff #7 in the section titled Description of the Procedure states I placed 2 lag screws across the fracture securing the anatomic reduction. I slid a long Synthes (type of orthopedic trauma hardware) posterolateral locking plate, underneath the proximal radial nerve (large nerve in the arm). The radial nerve expansion was very broad across the posterior aspect of the humerus and almost parallel to the shaft of the bone, so that actually traversed quite a distance from proximal to distal along the humeral shaft. This caused me to use a much longer plate than I normally would with 3 cortical screws proximal to the fracture site and multiple cortical and locking screws distal to the fracture site.

Documentation by Staff #7 in Patient #10's electronic medical record indicates Patient #10 was discharged on [DATE]. Discharge plan documented by Staff #7 states he/she will be in a sling for comfort. Documentation by Staff #7 states Patient #10 will be in a compression sleeve to control edema and immediately begin range of motion exercises. Further documentation by Staff #7 states a follow up appointment for Patient #10 on Friday or Monday (no dates recorded) to put him/her on the edema (swelling) control sleeve and glove.

Staff #7 was interviewed via speaker phone on March 10, 2015 at approximately 10:45 am. Staff #1, Staff #6, Staff #3, and Staff #12 were present during the interview. Staff #7 confirmed he/she cared for Patient #10 during the follow up orthopedic visit on January 19, 2015. Staff #7 stated he/she remembered Patient #10 (called patient by name). Staff #7 stated Patient #10 had been to the emergency department (reference to facility named in the complaint) with an injury to the arm. Initially, Staff #7 stated the injury was sustained he/she thought playing baseball but later stated he/she remembered it was dodge ball. Staff #7 stated Patient #10 reported no x-rays were done while in the emergency department. Staff #7 stated Patient #10's left arm was very swollen and had a lot of bruising on January 19, 2015. Staff #7 stated he/she ordered x-rays (4 views) and a left humeral shaft fracture was found. Staff #7 stated this was a fracture that was missed. X-rays should have been taken. Staff #7 stated this type of injury is somewhat unusual but have seen a handful of these types of injuries. Staff #7 stated after being asked by the surveyor if x-rays were taken the night of the injury would the treatment be different for Patient #10. Staff #7 stated no the treatment would have been the same. No harm was done to the patient. No difference in the treatment but x-rays should have been taken. This was a misdiagnosis, thinking it was a bicep tear. A bicep tear would be an unusual injury for a patient of his/her age.

Staff #12 was interviewed on March 10, 2015 at approximately 10:25 am. Staff #12 confirmed he/she spoke with Patient #10 and explained why Staff #19 did not do an x-ray. Staff #12 confirmed he/she waived part of the bill. Staff #12 stated he/she spoke directly with Staff #19 after reviewing the medical record of Patient #10. Staff #12 stated it made more sense to him/her after speaking with Staff #19 pertaining to why no x-ray was taken. Staff #12 stated Patient #10 was a young healthy patient who had a non traumatic injury to the arm and although had pain had full range of motion. Staff #12 was asked by the surveyor if a torn bicep is a common injury in a 21 year old. Staff #12 stated it is not a common injury in a 21 year old. Staff #12 was asked by the surveyor about the significance of the popping Patient #10 described to the emergency department staff. Staff #12 stated popping is a common complaint with orthopedic injuries in general. Staff #12 stated popping can happen for a lot of reasons. Staff #12 stated the popping is more suspicious for a fracture. Staff #12 confirmed the emergency department has a Long Bone Fracture Protocol which is used for obvious fractures and pertains to pain management. A copy of the protocol was requested and reviewed on March 10, 2015. Staff #12 stated the decision to x-ray is determined by the physician based on physical examination, mechanism of injury, history, pain, and range of motion.

Documentation by Staff #12 to Staff #14 on February 27, 2015 pertaining to the complaint states he/she (reference to Patient #10) had no blunt trauma of any kind and full painless range of motion at every joint in the affected arm which lead to no imaging by the emergency department medical doctor.

According to the Mayo Clinic.com normal range of motion is defined as the full movement potential of a joint, usually its range of flexion and extension.

Documentation by the paramedic on January 14, 2015 stated Patient #10 had 9/10 pain when moving left arm. Documentation by Staff #11 on January 14, 2015 at 10:24 pm stated Patient #10's left arm had limited range of motion. Documentation by Staff #19 on January 14, 2015 at 10:22 pm states limited flexion/extension at the elbow due to bicep pain. Pain in the left arm exacerbated by flexion/extension at the elbow and movement of the bicep.

Show Text of Violation

Based on staff interview, facility document review, and in the course of complaint investigation, it was determined the facility staff failed to ensure an appropriate medical examination (MSE) was provided for one of 21 (twenty one) patients, Patient #21,who had been brought to the emergency department (ED) by a family member/significant other and requested assistance for the Patient. The family member/significant other came into the ED and stated the patient was out in the car and had been psychotic and was in need of help.

The findings included:

A self reported event was received by the RO (Regional Office) of 1/26/15 and forwarded to the SA (State Agency) for further investigation. According to the report, on 1/5/15, a male family member presented to the freestanding ED and approached the registration desk. The family member stated to the Registrar that he had a female patient in his vehicle who was psychotic and manic. He stated the patient had been this way for a week and her physician recommended she be taken to the ED. The family member questioned whether he could move his car to the ambulance entrance and escort the patient though that entrance. The family member indicated the patient became agitated in the presence of law enforcement and there were deputies present in the ED at that time. The Registrar stepped away from the desk and spoke with the ED physician who stated to the registrar the ED was not a psychiatric facility and to inform the family member of this fact. The registrar refused to do this, so the physician stated he/she would speak with the family. The ED physician entered the waiting area and spoke with the family member. The physician claimed he/she offered to see the patient but the family member declined and said he would take her to another facility. The patient was never entered into the ED logs. The patient left the ED without an appropriate MSE (Medical screening examination) and stabilizing treatment.

On 2/2/15 at 12:00 p.m., the survey team entered the facility in order to conduct the investigation of the reported event. A tour of the ED was conducted. Staff member #4 was interviewed concerning treatment of patients and EMTALA regulations and stated he/she was aware of the circumstances of the reported incident, when interviewed as to whether he/she had knowledge of any EMTALA violations at this facility. Staff #4 stated he/she had been informed about the incident on the day it occurred and had reported it to his/her supervisor. Staff #4 stated that, Every patient is treated here no matter what. We should not turn patients away or discourage them from receiving care...We do not know who the patient was. We did not get a name. The family member did not give that information and did not sign in...

On 2/2/15 at 1:50 p.m., Staff #5 was interviewed. Staff #5 stated he/she had been informed of the concern by one of his/her staff right after it happened. Staff #5 stated it was reported to the supervisor.

At 3:00 p.m. on 2/2/15, the surveyor interviewed Staff # 6, who was the registrar on duty at the time Patient #21 arrived to the ED. Staff #6 stated, A gentleman came in and said he had a female out in his car that had been psychotic for two weeks and he didn't know what to do with her, that her doctor said to bring her to the emergency room . He said she had a fear of law enforcement and there were two sheriffs in the ED at that time, so he wanted to know if he could bring her through the ambulance entrance. I went back to ask and there was no one at the nurses station except for (name of physician) and I asked him/her about it. He/she said that I should tell the gentleman that we were not a psychiatric facility and that he should take her (the patient) somewhere else. I told him I absolutely would do no such thing, that it was not right and also I could loose my job. He/she then said he/she would go out and talk with him. When I went back out the man was not there, but he came back in and said he had gone to the car and given her some medication to calm her so he could get her to come in. (Name of physician) came out and I heard him/her tell the gentleman that we were not a psych facility and that he should take her (the patient) somewhere else. The man told him/her that she (the patient) had been recently seen at (another hospital) and had been a patient there so (name of physician) told him he (the family member) should take her (the patient) back there. He (the physician) told the man he would be happy to see her (the patient) here but that it would take too much time because she would have to be transferred anyway and it would be easier if he(the family member) took her himself. There was another registrar present at that time. (Name of physician) then turned around and said. Are you ladies alright with that? I didn't say anything. I just looked at him/her because he/she knew I wasn't alright with it...I went to the charge nurse and told him/her what happened and he/she said it needed to be reported so he/she reported to his/her supervisor and I reported to mine...after this happened, and administration started asking questions, the doctor (name of physician) was still working and he/she would not speak to me or even look at me. It upset me because I was afraid he/she may retaliate...

On 2/2/15 at 3:20 p.m., the survey team was informed by Staff # 1 and 3 that the physician was no longer employed by the hospital. Staff #3 stated, This was brought to my attention by (Staff #1) because he/she had contacted the director of risk and then contacted me...I did not reach out to the registrar, but did reach out to (name of physician)...(name of physician) is no longer providing services for any of our facilities. The CMO (Chief Medical Officer) in conjunction with the CEO (Chief Executive Officer) made that decision...we will be doing education and haven't set a date for it yet but it will be in addition to the required annual EMTALA training. It will be done in forty-five days... Staff #3 also stated the other registrar who was present at the time the incident occurred was off on leave and not available, however the other registrar first sided with the doctor when interviewed, and then changed his/her story that he/she was not able to hear because the physician had his/her back to him/her...

At 4:00 p.m. on 2/2/15 the surveyors further interviewed Staff #4. Staff #4 stated, It was a (race) female with a history of bipolar having a severe manic episode. The gentleman who brought her was visibly upset and panicked. We had the police here for another patient who was agitated and because the nurses were tied up so (name of physician) went out and talked with the gentleman. After I was told what happened, I called (name of supervisor/director). I have been concerned that this would happen with this particular physician and I have voiced some concern regarding his/her attitude before this...my experience with (name of physician) was that I felt very frequently he/she would walk into a room and tell a patient reasons why they should be anywhere but here...I saw that happening a lot, but he/she never said he/she would not care for them and in fact, gave excellent care...but would say to staff, I am not a dermatologist etcetera, but I am happy to see him/her...

On 2/3/15 at 12:30 p.m., the surveyors inquired as to the corrective plan - removal measures outlined in the letter to CMS dated 1/26/15. Staff # 3 stated some of the removal measures had not been implemented as of yet. The surveyors inquired as to the status of each removal measure and were informed as follows:

A. The actions of the ED Physician were reported to the Peer review Committee for review...We just had Peer review on 1/28/15, but this was not discussed. It will be discussed at the 3/28/15 meeting...

B. The ED Physician was counseled...(This was completed according to evidence from the Medical Director and interview 2/3/15 12:50 p.m.)

C. (Initials of hospital) ED staff members at all of our campuses were educated on EMTALA requirements...This is not implemented yet. We are still working on the education part... (Physician re-education was documented by ED Medical Staff meeting January 22, and Med Exec meeting minutes January 21, 2015.)

D. (Initials of hospital) ED staff members were re-educated on procedures for escalating EMTALA questions to their supervisors. This is not completed yet...

E. (Initials of hospital) reviewed with ED staff members the response plan for patients that were outside the ED but on hospital property within 250 yards of the main building and present for en emergency medical condition. This is not completed yet...

Staff # 3 stated that she would be working on a plan of action for the above issues and it would be submitted by the end of March.

On 2/3/15 at 12:50 p.m., the surveyors interviewed the Medical Director (Staff # 7) for the facility. Staff #7 stated, I was informed the next day, I believe, and when I found out about it was the first time I spoke to (name of physician), however, we had many conversations about this...I did an EMTALA review with all of the physicians...they were either present in person or on the conference call...there is required annual training through (name of physician group) but secondary to this incident we bolstered the training...

The survey team reviewed a document dated 1/22/15, (Name of physician group) ED Meeting Minutes. This document evidenced EMTALA Review (presented by Staff #7) Detailed discussion of definitions and interpretation of law, focusing specifically on: EMTALA definition, EMTALA and ambulances, Central log, Emergency Medical Condition, Prudent layperson Observer, Hospital Property, Medical Screening Exam, Qualified Medical Personnel, and Comes to the Emergency Department. Case reviewed and group discussion of possible outcomes, options for management. Online EMTALA training for all providers required yearly.

The Medical Executive Committee meeting minutes for 1/21/15 were reviewed. The minutes documented, Ethics and Compliance Committee Update: (name of director) presented an update on EMTALA. It was noted: EMTALA REQUIREMENTS: Individuals must be evaluated and provided with medical support services and/or transfer arrangements that rare consistent with the capability of the institution and the well-being of the patient; Hospitals must have a list of physicians who are on-call to provide treatment necessary to stabilize an individual with an emergency medical condition; Hospital must have privileged physicians with skill sets to provide care that is consistent with the services it provides; Medical Executive Committee must review on-call schedule and make recommendations to CEO when formal changes are to be made or when legal or operational issues arise...

The facility policy on EMTALA was also reviewed. The policy stated, in part: EMTALA- Definitions and General Requirements: PURPOSE: To require, in conjunction with state-specific policies, that a hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department and requests such an examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) 42 U.S.C. Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists, regardless of the individuals ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care of hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made...

The policy Dealing with and Reporting Misconduct was reviewed and documented: We rely on you to report potential misconduct so that we may take corrective action and implement changes to prevent a similar violation from occurring...REPORTING CHANNELS: Your Supervisor, Human Resources Department, Facility Ethics and Compliance Officer, The Ethics Line...

Behavioral Health, Guidelines for Patient Care Management was reviewed and documented in part: Patients with emotional or behavioral disorders present with special needs. According to the scope of care and service (name of hospital) does provide inpatient and outpatient behavioral health treatment and care, Should a patient present to (name of facility) with a behavioral health disorder, processes will be implemented to facilitate patient safety, stabilize the patient and provide for a safe disposition...A. Emergency Department Guidelines: 1. Any patient, including patients with behavioral health (psychiatric) conditions who present to the Emergency Department or hospital grounds for treatment must be provided with an appropriate medical screening examination to determine of the patient is suffering from an emergency medical condition. triage is NOT the equivalent of a medical screening examination....

The survey team discussed the concerns related to the patient not being provided with an MSE or stabilizing treatment and that there was no identification of the patient for follow-up, on 2/3/15 at 3:00 p.m.

Show Text of Violation

Based on staff interview, facility document review, and in the course of a complaint investigations, it was determined the facility staff failed to ensure stabilizing treatment was provided for one of 21 (twenty one) patients, Patient #21, who was brought to the emergency department (ED) by a family member/significant other and requested assistance for the Patient. The family member/significant other came into the ED and stated the patient was out in the car and had been psychotic and was in need of help.

The findings included:

On 2/2/15 at 12:00 p.m., the survey team entered the facility in order to conduct the investigation of an event where a caregiver/patient reportedly arrived at the emergency department, requesting assistance. Reportedly a physician suggested the patient be taken to a different hospital, this was suggested prior to the patient being examined (medical screening exam) or stabilizing treatment provided.

A tour of the ED was conducted. Staff member #4 was interviewed concerning treatment of patients and EMTALA regulations and stated he/she was aware of the circumstances of the reported event, when interviewed as to whether he/she had knowledge of any EMTALA violations at this facility. Staff #4 stated he/she had been informed about the incident on the day it occurred and had reported it to his/her supervisor. Staff #4 stated that, Every patient is treated here no matter what. We should not turn patients away or discourage them from receiving care...We do not know who the patient was. We did not get a name. The family member did not give that information and did not sign in...

On 2/2/15 at 1:50 p.m., Staff #5 was interviewed. Staff #5 stated he/she had been informed of the concern by one of his/her staff right after it happened. Staff #5 stated it was reported to the supervisor.

At 3:00 p.m. on 2/2/15, the surveyor interviewed Staff # 6, who was the registrar on duty at the time of the incident. Staff #6 stated, A gentleman came in and said he had a female out in his car that had been psychotic for two weeks and he didn't know what to do with her, that her doctor said to bring her to the emergency room . He said she had a fear of law enforcement and there were two sheriffs in the ED at that time, so he wanted to know if he could bring her through the ambulance entrance. I went back to ask and there was no one at the nurses station except for (name of physician) and I asked him/her about it. He said that I should tell the gentleman that we were not a psychiatric facility and that he (the family member) should take her (the patient) somewhere else. I told him/her I absolutely would do no such thing, that it was not right and also I could loose my job. He/she (the physician) then said he/she would go out and talk with him. When I went back out the man was not there, but he came back in and said he had gone to the car and given her some medication to calm her so he could get her to come in. (Name of physician) came out and I heard him/her tell the gentleman that we were not a psych facility and that he should take her somewhere else. The man told him/her (the physician) that she (the patient) had been recently seen at (another hospital) and had been a patient there so (name of physician) told him (the family member) he should take her (the patient) back there. He/she (the physician) told the man he/she would be happy to see her (the patient) here but that it would take too much time because she would have to be transferred anyway and it would be easier if he (the family member) took her himself. There was another registrar present at that time. (Name of physician) then turned around and said, Are you ladies alright with that? I didn't say anything. I just looked at him/her because he/she knew I wasn't alright with it...I went to the charge nurse and told him/her what happened and he/she said it needed to be reported so she reported to her supervisor and I reported to mine...after this happened, and administration started asking questions, the doctor (name of physician) was still working and he/she would not speak to me or even look at me. It upset me because I was afraid he may retaliate...

On 2/2/15 at 3:20 p.m., the survey team was informed by Staff # 1 and 3 that the physician was no longer employed by the hospital.

At 4:00 p.m. on 2/2/15 the surveyors further interviewed Staff #4. Staff #4 stated, It was a white female with a history of bipolar having a severe manic episode. The gentleman who brought her was visibly upset and panicked. We had the police here for another patient who was agitated and because the nurses were tied up so (name of physician) went out and talked with the gentleman. After I was told what happened, I called (name of supervisor/director). I have been concerned that this would happen with this particular physician and I have voiced some concern regarding his attitude before this...my experience with (name of physician) was that I felt very frequently he/she would walk into a room and tell a patient reasons why they should be anywhere but here...I saw that happening a lot, but he/she never said he/she would not care for them and in fact, gave excellent care...but would say to staff, I am not a dermatologist etcetera, but I am happy to see him/.her...

On 2/3/15 at 12:30 p.m., the surveyors inquired as to the removal measures outlined in the letter to CMS (Centers for Medicare Medicaid Services) dated 1/26/15. Staff # 3 stated some of the removal measures had not been implemented as of yet.

Staff # 3 stated that she would be working on a plan of action for the above issues and it would be submitted by the end of March.

On 2/3/15 at 12:50 p.m., the surveyors interviewed the Medical Director (Staff # 7) for the facility. Staff #7 stated, I was informed the next day, I believe, and when I found out about it was the first time I spoke to (name of physician), however, we had many conversations about this...I did an EMTALA review with all of the physicians...they were either present in person or on the conference call...there is required annual training through (name of physicians group) but secondary to this incident we bolstered the training...

The Medical Executive Committee meeting minutes for 1/21/15 were reviewed. The minutes documented, Ethics and Compliance Committee Update: (name of director) presented an update on EMTALA. It was noted: EMTALA REQUIREMENTS: Individuals must be evaluated and provided with medical support services and/or transfer arrangements that rare consistent with the capability of the institution and the well-being of the patient; Hospitals must have a list of physicians who are on-call to provide treatment necessary to stabilize an individual with an emergency medical condition; Hospital must have privileged physicians with skill sets to provide care that is consistent with the services it provides; Medical Executive Committee must review on-call schedule and make recommendations to CEO when formal changes are to be made or when legal or operational issues arise...

The facility policy on EMTALA was also reviewed. The policy stated, in part: EMTALA- Definitions and General Requirements: PURPOSE: To require, in conjunction with state-specific policies, that a hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department and requests such an examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) 42 U.S.C. Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists, regardless of the individuals ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual requests emergency medical care of hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made...

The survey team discussed the concerns related to the patient not being provided with an MSE or stabilizing treatment and that there was no identification of the patient for follow-up on 2/3/15 at 3:00 p.m.

Show Text of Violation

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

Based on review of medical records, medical staff bylaws and interviews, it was determined that a patient who presented to the Emergent Department (ED) with an emergent situation left and went to another hospital for treatment when the on-call Orthopedic surgeon failed to come see the patient as required by this hospital's established Medical Staff Bylaws, Rules and Regulations 2013, (patient record #9).

The findings were:

1. The Medical Staff Bylaws, Rules and Regulations as revised 2013, were reviewed May 13, 2013 beginning at 3 PM, in the hospital's Administrative Conference room. A portion of those Bylaws read in part,

3. The following rules shall govern the conduct of physicians who are on-call to the Emergency Department at Henrico Doctors' Hospital:...

b. During the time the physician is scheduled to be on-call, the on-call physician or a qualified substituting physician shall be available for consultation within a reasonable period of time. While a reasonable timeframe is case/patient specific an initial response by telephone or in person, should not normally exceed 30 minutes. The on-call physician has the responsibility to secure the qualified alternate in the event that he/she is unavailable.

c. ...If the expertise of an on-call physician is needed, then the on-call physician would be obligated to provide care deemed necessary by the Emergency Department physician for completion of the medical screening exam.

2. Review of the patient's (#9) medical record revealed that on March 9, 2013 at 1703 (military time) a [AGE] year old male presented to the Emergency Department with complaints of Right hand index finger trauma. The patient was triaged (initially assessed) by a registered nurse (employee #7) which was also time stamped as 1703 and documented in the triage note, Subjective: Right hand index finger crush/injury with decreased sensation.

Objective: Alert & oriented, responding appropriately, follows commands skin warm dry, MAE (Mental alertness evaluation) x 4, no acute distress, bleeding controlled with pressure by patient.

The documentation also revealed that the patient's neurological, CV (cardiovascular), and respiratory status were all, WDP (within defined parameters). Pain was assessed using a numeric scale and on a scale of one (1) to ten (10) with one (1) being the least amount of pain, the patient was experiencing pain at a intensity of 5.

The triage note did not contain documentation of any visualization or assessment of the injured finger. The patient returned to the waiting room and was never assigned a bed in the Emergency Department, he remained in the waiting room the entire time except for the time spent in x-ray.

At 1717, the Physician's Assistant (PA ), employee #9, ordered an X-ray of the injured finger and that X-ray report read, Open fracture of the base of the distal phalanx of the second finger with slight distraction.

The Physician's Assistant (employee #9) documented a HPI- Extremity Inj Upper (History physical information- Upper Extremity Injury) which was time stamped as 3/9/13 1820 read in part,

HPI

Complaint: finger injury, The patient injured his finger, crushed his R index finger on some equipment. The R index finger is amputated, only hanging on by some skin. He is a XX (medical professional) and needs his finger repaired.

Source of history: patient ...

Review of Systems

Skin: laceration

Neuro: Reported numbness (to tip of R index finger), tingling (to tip pf R index finger)

Hand: Finger injury (amputation), type of finger injury (amputation R index finger), laceration, limited range of motion, neurologic deficit pre (present), vascular deficit present

Past Medical History Reports: none

Consultation #1 physician #4 (Hand Orthopod) who was not on-call

Call returned, He cannot come back in tonight. He says I can put a few loose stitches in the finger, and the patient can come back at 8:30 am tomorrow, and he will meet him here for repair. I can try to get someone else on-call.

Consultation: 2 (Orthopod on-call)

Call returned, physician #2 called back. I explained that the pt (patient) was a X (medical professional) and knows Dr. (another Ortho doctor). I told him he had an amputation to the right index finger, only hanging on by a thread. He said that I can take the finger off and flap the area, give him antibiotics and tetanus, and Dr (Ortho doctor) will see him next week. I told him again my concerns, and he repeated what he said initially.

Additional notes:

I (employee #9) spoke with physician #1 (Emergency Department doctor) about the issue. She said that he could be transferred to XX (another hospital) if he requests, otherwise we have called all of our contacts. I explained to the patient what the on-call doctor said. He (the patient) was very upset. I offered to give a digital block, but he declined. He wanted the doctor's name on-call and was going to leave and go somewhere else.

The patient left the Emergency Department at 1815.

The patient's electronic record was signed by the PA at 1842.

The supervising physician note read, The PA/NP's chart was reviewed. I agree with the assessment and care plan, and confirm the diagnosis. The note was electronically signed by physician #1

3. The hospital's Chief Medical Officer (physician. #5) was interviewed on May 14, 2013 beginning at 1155 in the Administrative Conference room. Physician #5 stated that he became aware of this incident on or about March 13, 2013 at which time he reviewed the patient's medical record and then proceeded to make phone calls. Physician #2 was called and asked about the situation. Physician #2 told the Chief Medical Officer (CFO) that he was not asked to come in and if they would have asked him to come he would have. The CFO said that they discussed the consequence of this incident and reviewed/re-educated on what should have occurred and specific aspects of the hospital's Bylaws in regard to on-call services. The CFO also said that he called the patient and listened to what the patient had to say. The conversation covered the incident, the patient's expectations, the hospital's expectations in providing quality care and that this incident would be investigated internally. The CFO then stated that at the end of the telephone conversation the patient seemed satisfied.

4. The Vice President (VP) of Quality and Risk Management was interviewed multiple times during the onsite investigation. On May 14, 2013 beginning at 12 noon in the Administrative Conference room the VP of Quality and Risk stated that this incident has been discussed at the Peer Review committee meeting for surgery on April 24, 2013. The committee has requested that physician #2 respond in writing to the committee the circumstances surrounding this case. The incident is also being presented at the medical Peer Review Committee on May 22, 2013.

5. Interviews were attempted but unsuccessful with the Physician Assistant (employee #9), physician #2 and the complainant.

Show Text of Violation

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

Based on medical record review, Medical Staff Bylaws, Rules and Regulations 2013 and interview, it was determined the facility's Emergency Department failed to conduct an appropriate and accurate medical screening examination for one (1) of twenty (20) patients in the survey sample, medical record #9.

The findings were:

1. The Medical Staff Bylaws, Rules and Regulations as revised 2013 were reviewed May 13, 2013 in the hospital's Administrative Conference room. A portion of those Bylaws read in part,

3. The following rules shall govern the conduct of physicians who are on-call to the Emergency Department at Henrico Doctors' Hospital:...

b. During the time the physician is schedules to be on-call, the on-call physician or a qualified substituting physician shall be available for consultation within a reasonable period of time. While a reasonable timeframe is case/patient specific an initial response by telephone or in person, should not normally exceed 30 minutes. The on-call physician has the responsibility secure the qualified alternate in the event that he/she is unavailable.

c. The Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor. Such screening must be done within the facility's capabilities (including the use of ancillary services) and available personnel, including on-call physicians or physician's assistants. If the expertise of an on-call physician is needed, then the on-call physician would be obligated to provide care deemed necessary by the Emergency Department physician for completion of the medical screening exam.

2. Review of the patient's (#9) medical record revealed that on March 9, 2013 at 1703 (military time) a [AGE] year old male presented to the Emergency Department with complaints of Right hand index finger trauma. The patient was triaged by a registered nurse (employee #7) which was also time stamped as 17:03 and documented in the triage note, Subjective: Right hand index finger crush/injury with decreased sensation.

Objective: Alert & oriented, responding appropriately, follows commands skin warm dry, MAE (Mental alertness evaluation) x 4, no acute distress, bleeding controlled with pressure by patient.

The documentation also revealed that the patient's neurological, CV (cardiovascular), and respiratory status were all, WDP (within defined parameters). Pain was assessed using a numeric scale and on a scale of one (1) to ten (10) with one (1) being the least amount of pain, the patient was experiencing pain at a intensity of 5.

The triage note did not contain documentation of any visualization or assessment of the injured finger. The patient returned to the waiting room and was never assigned a bed in the Emergency Department, he remained in the waiting room the entire time except for the time spent in x-ray.

At 1717, a Physician's Assistant (employee #9) ordered an X-ray of the injured finger and that X-ray report read, Open fracture of the base of the distal phalanx of the second finger with slight distraction.

The Physician's Assistant (employee #9) documented a HPI- Extremity Inj Upper (History physical information- Upper Extremity Injury) which was time stamped as 3/9/13 1820 and read in part,

HPI

Complaint: finger injury, The patient injured his finger, crushed his R index finger on some equipment. The R index finger is amputated, only hanging on by some skin. He is a XX (medical professional) and needs his finger repaired.

Source of history: patient ...

Review of Systems

Skin: laceration

Neuro: Reported numbness (to tip pf R index finger), tingling (to tip pf R index finger)

Hand: Finger injury (amputation), type of finger injury (amputation R index finger), laceration, limited range of motion, neurologic deficit pre (present), vascular deficit present

Past Medical History Reports: none

Consultation #1 physician #4 (Hand Orthopod) who was not on-call

Call returned, He cannot come back in tonight. He says I can put a few loose stitches in the finger, and the patient can come back at 8:30 am tomorrow, and he will meet him here for repair. I can try to get someone else on-call.

Consultation: 2 (Orthopod on-call)

Call returned, physician #2 called back. I explained that the pt (patient was a X (medical professional) and knows Dr. (another Ortho doctor). I told him he had an amputation to the right index finger, only hanging on by a thread. He said that I can take the finger off and flap the area, give him antibiotics and tetanus, and Dr (another Ortho doctor) will see him next week. I told him again my concerns, and he repeated what he said initially.

Additional notes:

I (employee #9) spoke with physician #1 (Emergency Department doctor) about the issue. She said that he could be transferred to XX (another hospital) if he requests, otherwise we have called all of our contacts. I explained to the patient what the on-call doctor said. He (the patient) was very upset. I offered to give a digital block, but he declined. He wanted the doctor's name on-call and was going to leave and go somewhere else.

The patient left the Emergency Department at 1815.

The record failed to contain documented evidence that the injured index finger was assessed by the consulted on-call Orthopedic physician

3. When the patient left the hospital (#1), he went to hospital #2. Review of the medical record from the 2nd hospital reveals that the patient was arrived at hospital #2 on 3/9/13 at 1834 and was triaged (an initial assessment) beginning at 1841 by a registered nurse. Triage documentation read in part, Past medical History: cardiac stent (a plastic tube inside an artery in the heart to keep it open), MI (heart attack), HTN (high blood pressure) and high chol (high cholesterol), a fatty substance in the blood). The patient rated his pain level at a 6 on a scale of one (1) to ten (10). A detailed EMS (Emergency medical screening) was conducted and time stamped 3/9/13 1933.

Another X-ray of the finger was performed and revealed A near transection of the distal aspect of the second digit is noted with a horizontal fracture ... The remainder of the bones and soft tissue are otherwise intact and unremarkable.

A consult with a plastic surgeon was ordered and a portion of that documentation read, Right index finger with partial amputation of tip just proximal to nail, tissue intact on volar surface, tissue appears viable, sensation to sharp intact distally at tip, nail intact. Clean wounds with sterile saline (salt water) and chlorhexidine scrub (a liquid antiseptic that removes bacteria on the skin). Repaired skin with 4.0 nylon sutures. Splinted distal finger with metal splint.

The patient left the Emergency Department at 9:57 PM with prescriptions and discharge instructions.

Show Text of Violation

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

Based on clinical record review and interview, it was determined that the facility failed to have documented evidence in the clinical record that the facility provided and or offered stabilizing treatment to one (1) of one (1) patient's in the survey sample who had an emergent medical condition, refused the proposed treatment and left to seek care at another facility, patient #9.

The findings were:

Review of the patient's (#9) medical record in its entirety revealed that on March 9, 2013 at 1703 (military time) a [AGE] year old male presented to the Emergency Department with complaints of Right hand index finger trauma. The patient was triaged by a registered nurse (employee #7) which was also time stamped as 17:03 and documented in the triage note, Subjective: Right hand index finger crush/injury with decreased sensation.

Objective: .... Pain was assessed using a numeric scale and on a scale of one (1) to ten (10) with one (1) being the least amount of pain, the patient was experiencing pain at a intensity of 5.

The triage note did not contain documentation of any visualization or assessment of the injured finger. The patient returned to the waiting room and was never assigned a bed in the Emergency Department, he remained in the waiting room the entire time except for the time spent in x-ray.

At 1717, a Physician's Assistant (employee #9) ordered an X-ray of the injured finger and that X-ray report read, Open fracture of the base of the distal phalanx of the second finger with slight distraction.

The Physician's Assistant (employee #9) documented a HPI- Extremity Inj Upper (History physical information- Upper Extremity Injury) which was time stamped as 3/9/13 1820 and read in part,

HPI

Complaint: finger injury, The patient injured his finger, crushed his R index finger on some equipment. The R index finger is amputated, only hanging on by some skin. He is a XX (medical professional) and needs his finger repaired.

Source of history: patient ...

Review of Systems

Skin: laceration

Neuro: Reported numbness (to tip pf R index finger), tingling (to tip pf R index finger)

Hand: Finger injury (amputation), type of finger injury (amputation R index finger), laceration, limited range of motion, neurologic deficit pre (present), vascular deficit present

Past Medical History Reports: none.

Consultation: #2 (Orthopod on-call)

Call returned, physician #2 called back. I explained that the pt (patient was a X (medical professional) and knows Dr. (another Ortho doctor). I told him he had an amputation to the right index finger, only hanging on by a thread. He said that I can take the finger off and flap the area, give him antibiotics and tetanus, and Dr (another Ortho doctor) will see him next week. I told him again my concerns, and he repeated what he said initially.

Additional notes:

I (employee #9) spoke with physician #1 (Emergency Department doctor) about the issue. She said that he could be transferred to XX (another hospital) if he requests, otherwise we have called all of our contacts. I explained to the patient what the on-call doctor said. He (the patient) was very upset. I offered to give a digital block, but he declined. He wanted the doctor's name on-call and was going to leave and go somewhere else.

The patient left the Emergency Department at 1815.

The record failed to contain documented evidence that the patient was offered stabilizing treatment prior to the patient leaving the Emergency Department. The record also failed to contain any documentation of the injured index finger wound being cleansed, the dressing from home being removed and a clean dressing applied, antibiotics or a Tetanus Booster being offered or provided.

Show Text of Violation

Based on staff interview and in the course of a complaint investigation, it was determined the facility staff failed to comply with the special responsibilities of Medicare hospitals in emergency cases. The facility staff failed to provide evidence of an appropriate medical screening examination for the patient named in the complaint.

The findings include:

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint was seen in the ED on September 8, 2011.

The ambulance team that responded to a call related to the patient named in this complaint was interviewed by one Medical Facilities Inspector on September 22, 2011 at 9:15 a.m. The ambulance team responded to the scene which was on the sidewalk directly in front of the hospital named in the complaint (which will be referred to as the initial hospital). When the ambulance team arrived, two local police officers and two employees from the initial hospital were with the patient. One of the initial hospital employees was a security guard and one was with the engineering department. The first ambulance employee said when they arrived, the patient stated he didn't feel well and that he was sick. The patient requested going to the initial hospital but the police officers at the scene said the patient could not go there. The ambulance employee asked the patient his second choice and therefore transported him to that hospital (which will be referred to as the receiving hospital). The ambulance employee stated that he asked the security guard why the patient could not go to the initial hospital and the security guard response was that the patient could not go there. The second ambulance employee was interviewed by one MFI at 9:30 on September 22, 2011 and recalled the patient was sitting on the hospital property about 25 yards from the Emergency Department entrance when they arrived on the scene. The ambulance employee recalled the patient wanting to be seen at the initial hospital. When the MFI asked why the patient was transported to a hospital farther away, the ambulance employee recalled the police officer saying that someone told him (the officer) the patient wasn't allowed to go to the initial hospital. The second ambulance employee acknowledged he did not hear anyone say the patient could not be seen at the initial hospital, but that when he left the scene his impression was that the security guard had told the police officer the patient could be seen there.

Please refer to ?489.24(a) for additional information.

Show Text of Violation

Based on Emergency Department (ED) central log review, staff interviews, and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of an appropriate medical screening examination (MSE) for the patient named in the complaint.

The findings include:

On September 20, 2011 at 2:00 pm, following an entrance conference and tour of the ED, the facility's Vice President of Quality informed the Medical Facilities Inspectors (MFI) that on September 12, 2011 she received at call from another hospital's risk manager reporting a possible EMTALA violation that occurred on September 8, 2011. The risk manager indicated her hospital (referred to as the receiving hospital) received the patient named in this complaint on September 8, 2011 after an ambulance crew was informed the patient could not be seen at the hospital named in this complaint (referred to as the initial hospital). The Vice President of Quality (of the initial hospital) informed the MFIs that once she was presented with this information, she immediately began her own investigation and self-reported the incident to Office of Licensure and Certification. She provided an e-mail that the facility's Ethics and Compliance Officer sent to everyone at the initial hospital that read in part, While the main practical impact of EMTALA is in the ER and L&D, EMTALA compliance is actually the responsibility of every employee! Under EMTALA, the hospital has the responsibility to provide a medical screening examination (MSE) to any person who seeks emergency care or any person who is on our property and individual's appearance when observed suggest that the individual may need an exam to determine if an emergency medical condition exits. Our property is defined in the law as the entire hospital campus which is: 'The hospital's main building (sic) 'The physical area immediately next to the hospital's main building 'Other hospital area/structures located within 250 yards of the main building 'Parking lots, sidewalks and driveways (sic) As any hospital employee may encounter as (sic) person seeking care at our facility, please keep the EMTALA regulations in mind and assist the individual with obtaining care at our facility. Assist them in getting to the ER or someone who can provide an MSE, don't just give directions, assume they will get there or ignore them. When in doubt or if you need assistance contact your supervisor or the Nursing Supervisor. If you have any EMTALA questions contact (name, title and phone number of VP of Quality and name of ECO). The VP of Quality stated the facility had also reviewed their EMTALA policy and procedure and provided evidence of employee training.

As part of the complaint investigation, surveyors requested the Emergency Department (ED) Central Log. The ED Central Log contained no evidence the patient named in the complaint was seen in the ED on September 8, 2011.

The patient's record from the receiving hospital was obtained and reviewed on September 20, 2011. The record verified the patient was transported by ambulance from the scene in front of the initial hospital to the receiving facility's ED on September 8, 2011.

The ambulance team that responded to a call related to the patient named in this complaint was interviewed by one Medical Facilities Inspector on September 22, 2011 at 9:15 a.m. The ambulance team responded to the scene which was on the sidewalk directly in front of the hospital named in the complaint (which will be referred to as the initial hospital). When the ambulance team arrived, two local police officers and two employees from the initial hospital were with the patient. One of the initial hospital employees was a security guard and one was with the engineering department. The first ambulance employee said when they arrived, the patient stated he didn't feel well and that he was sick. The patient requested going to the initial hospital but the police officers at the scene said the patient could not go there. The ambulance employee asked the patient his second choice and therefore transported him to that hospital (which will be referred to as the receiving hospital). The ambulance employee stated that he asked the security guard why the patient could not go to the initial hospital and the security guard response was that the patient could not go there. The second ambulance employee was interviewed by one MFI at 9:30 a.m. on September 22, 2011 and recalled the patient was sitting on the hospital property about 25 yards from the Emergency Department entrance when they arrived on the scene. The ambulance employee recalled the patient wanting to be seen at the initial hospital. When the MFI asked why the patient was transported to a hospital farther away, the ambulance employee recalled the police officer saying that someone told him (the officer) the patient wasn't allowed to go to the initial hospital. The second ambulance employee acknowledged he did not hear anyone say the patient could not be seen at the initial hospital, but that when he left the scene his impression was that the security guard had told the police officer the patient could be seen there.

The ambulance's patient care report was reviewed on September 20, 2011. It documented the ambulance crew responded to a call involving the patient named in this complaint on September 8, 2011. The location's proper address was documented and found to be directly in front of the facility named in this report. The ambulance crew documented their primary impression as, Alcoholic Intoxication and within the narrative the crew wrote in part, Unknown the reason but (hospital named) Security informed (local police) that the pt (patient) was not allowed to go to (hospital named). The report documented no visible physical abnormalities or bleeding and included, Pt c/o (complained of) 'feeling sick.' Pt denied any CP (chest pain), SOB (shortness of breath), or Abd (abdominal) pains. Pt has ETOH (alcohol) on his breath and was uneasy on his feet. Pt denied any alcohol consumption today but states he has (sic) some last night. The report noted in part, Pt was able to stand and walk, w/(with) assistance, into the ambulance. Pt was secured to the stretcher. Pt was transported w/o (without) incident or change in condition to (receiving hospital) ER bed 10.

One of the two local police officers who responded to 911 call relating to a male lying outside of the facility named in this complaint was interviewed via phone by one Medical Facility's Inspector (MFI)on September 21, 2011 at 12:55 pm. The officer recalled responding to the location outside of the facility where a male was sitting or lying on the ground. The officer stated he didn't remember the exact words that were said, but recalled the male telling the officer that he had a medical condition and needed to go to the hospital. The officer said, I asked security, 'Do you guys want him?' and he said, 'No'. The officer recalled the ambulance crew asking why the patient was not going to the facility closest to their location and the police officer said he responded, They said they didn't want him. The police officer was unable to describe the security officer he spoke with at that time. When asked if he'd ever had this facility deny taking a patient in the past, the officer stated, I've worked this precinct for 12 years and I've never had a problem with (name of facility) or any hospital refusing a patient.

The other police officer who responded was not interviewed by the MFIs. He told the Office of Licensure and Certification's (OLC) Complaint Unit Supervisor he did not recall talking with anyone about where to send the male.

The security officer who responded to a dispatch regarding a man lying in front of the facility on the morning of September 8, 2011 was interviewed by one MFI on September 21, 2011. The security officer, the facility's Vice President of Quality, and one MFI walked outside the facility to reconstruct the security officer's experience on September 8, 2011. The security officer said after getting the call from dispatch there was a man down in front of the hospital, he and another employee walked down one street to the corner and looked down the adjacent street to see a man sitting on a short retaining wall, lying back on the grass in front of the hospital. The local police were present and talking with the man who was obviously intoxicated but not belligerent and had his pants down. The security officer told the MFI that although they walked toward the police, he knew that since the police were onsite, it was their investigation. After 3-5 minutes, the ambulance crew arrived and when the crew members approached the scene, the security officer returned to the hospital. He denied having a conversation with the officers saying, I thanked them for their service. They didn't ask me anything. The security officer acknowledged he was wearing a shirt that identified him as security as well as his badge. He did not recognize the ambulance crew or the police officers. When asked whether he knew why the man would not have been transported to his facility's ED, he said that when he left the scene, he did not know whether the man would be going to the hospital or going to jail for public intoxication.

The facility's engineering department employee who responded with the security guard was interviewed on September 22, 2011 by one MFI. He said when they arrived at the scene, the police department was already there. He described an old man that appeared drunk but said he did not get close enough to smell alcohol. He also stated, his pants were down. The employee said the ambulance arrived within 5 minutes of them reaching the scene. When asked if he could explain how the man ended up at another hospital rather than the initial hospital he said, I assumed the ambulance was going to take the patient around the block to our emergency department bay. He added, If I had heard the police department tell the ambulance guys you can't go to this hospital, I would have said 'why not?'. MFI asked the engineering employee if he heard anyone say that the patient could not come to their hospital and the employee said that although he could not make out every word, the only communication he saw between the security guard and police officers was when the security guard asked the officers if he could help them get the patient's pants back on.

The initial hospital's Director of Emergency Department was interviewed on September 20, 2011 at 3 p.m. She said the hospital's Associate Chief Nursing Officer informed her of a possible EMTALA violation and she verified the patient named in this complaint had never been registered in their ED on September 8, 2011. She informed the MFIs the patient was well known to the initial hospital's ED staff and then stated, It just sounds odd, he was here on the 5th, the 11th and the 13th. (of September 2011).

The Vice President of Quality stated on September 21, 2011 that her investigation revealed the patient had been seen in their ED over 50 times during the year of 2011 and at least twice since this incident. The MFI's verified the patient had been seen in the initial facility's ED on both September 11, 2011 and September 13, 2011 by reviewing the patient's ED records from both dates.

Respect us. Protect us. Pay us!

Henrico Doctors' Hospital

29 CMS Violations since 2011-09-22

Non Immediate Jeopardy Violations

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0166)

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0175)

Violation Name: BLOOD TRANSFUSIONS AND IV MEDICATIONS(A-0410)

Violation Name: DISCHARGE PLANNING- TRANSMISSION INFORMATION(A-0813)

Violation Name: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES(A-0122)

Violation Name: MEDICAL RECORD SERVICES(A-0450)

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0178)

Violation Name: CHIEF EXECUTIVE OFFICER(A-0057)

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0166)

Violation Name: FORM AND RETENTION OF RECORDS(A-0438)

Violation Name: DIRECTOR OF DIETARY SERVICES(A-0620)

Violation Name: MAINTENANCE OF PHYSICAL PLANT(A-0701)

Violation Name: REGULAR FIRE AND SAFETY INSPECTIONS(A-0715)

Violation Name: INFECTION CONTROL PROGRAM(A-0749)

Violation Name: FOOD AND DIETETIC SERVICES(A-0618)

Violation Name: PHYSICAL ENVIRONMENT(A-0700)

Violation Name: INFECTION PREVENTION CONTROL ABX STEWARDSHIP(A-0747)

Violation Name: INFECTION CONTROL PROGRAM(A-0749)

Violation Name: DISCHARGE PLANNING EVALUATION(A-0806)

Violation Name: IMPLEMENTATION OF A DISCHARGE PLAN(A-0820)

Violation Name: QUALIFIED EMERGENCY SERVICES PERSONNEL(A-1112)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: ON CALL PHYSICIANS(A-2404)

Violation Name: MEDICAL SCREENING EXAM(A-2406)

Violation Name: STABILIZING TREATMENT(A-2407)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: MEDICAL SCREENING EXAM(A-2406)