Lakeview Hospital

Based on interview and record review, it was determined that the hospital failed to promote and protect each patients' rights.

On 3/21/19, a finding of Immediate Jeopardy (IJ) was identified in the area of Patient Rights. The hospital was notified of this finding on 3/21/19, at 10:41 AM. The Hospital submitted an IJ removal/abatement plan on 3/21/19, at 2:17 PM, alleging removal of the IJ as of 3/21/19, at 2:15 PM. The plan was accepted and the hospital was notified at 2:45 PM on 3/21/19. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 3/21/19, but at 7:00 PM rather than 2:15 as they had alleged. The hospital was notified of the IJ removal at 7:05 PM on 3/21/19.

Findings include:

1. The hospital did not provide patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency. (Refer to tag A-115)

2. The hospital did not provide patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency. (Refer to tag A-118)

3. The hospital did not obtain an informed consent to treat for 3 of 30 sampled patients. Specifically, the hospital did not obtain written or verbal consent to treat for patients who were incapacitated or otherwise unable to consent to treatment upon admission. (Refer to tag A-131)

4. The hospital failed to ensure each patient was free from all forms of abuse or harassment. Specifically, for 1 of 30 sampled patients an allegation of sexual abuse was not investigated until the next morning and the patient was not afforded sufficient protection to ensure the incident would not happen again.

(Refer to tag A-145)

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

Based on observation, interview, and record review it was determined the hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment. Specifically, for 1 of 30 sampled patients an allegation of sexual abuse was not investigated until the next morning and the patient was not afforded sufficient protection to ensure the incident would not happen again. (Patient identifier: 16.)

On 3/21/19 a finding of Immediate Jeopardy (IJ) was identified in the area of Patient Rights. The hospital was notified of this finding on 3/21/19 at 10:41 AM. The Hospital submitted an IJ removal/abatement plan on 3/21/19 at 2:17 PM alleging removal as of 3/21/19 at 2:15 PM. The plan was accepted and the hospital was notified at 2:45 PM on 3/21/19. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 3/21/19, at 7:00 PM, based on the steps the hospital had taken. The hospital was notified of this finding at 7:05 PM on 3/21/19.

Findings include:

Patient 16 was admitted on [DATE] with suicidal ideation.

1. A review of patient 16's electronic medical record was completed on 3/26/19.

On 3/7/19 at 3:06 AM, registered nurse (RN) 1 entered the following note in patient 16's electronic medical record, ...During her assessment she mentioned how she felt that another pt (patient) was watching her from the hallway. She rated her mood moderate...About 45 min (minutes) later she ran up to me in distress and said that this other pt had been in her room and walked u pto (sic) her bed and possibly touched her. She became extremely agitated and distrustful. She began saying she wanted to be discharged and that she didn't feel safe. There was no evidence to support that another pt was in her room. She started to pound on the door and demand to leave and that she would be filling (sic) a law suit. I was able to calm her eventually but it took a couple hours. She eventually fell asleep. Will continue to monitor. Note: No further information regarding this incident was placed in patient 16's electronic medical record by RN 1.

On 3/7/19 at 10:12 AM, RN 2 entered the following note in patient 16's electronic medical record, At approximately 0835 (8:35 AM) patient brought concern to this writer about another male patient entering her room last night. Escalated this issue to unit director at approximately 0845. Police notified.

Additionally, when hospital staff contacted her husband after her discharge he informed staff, She is struggling ... We would like to see the video ... (name of patient 16) is concerned she may not know exactly what happened because she had been given a sleeping pill that night.

2. On 3/19/19 the survey team reviewed the hospital incident log, and found one incident recorded on 3/7/19 by RN 2, no incident was found to be reported by RN 1. The survey team requested this incident report to review.

The incident report submitted by RN 2 on 3/7/19 at 10:32 AM revealed that on 3/6/19 at 10:00 PM an event occurred. RN 2 documented the following, Pt alerted RN at0835 (sic), an uninvited male patient came into her room last night and 'touched my butt'. She states she told night shift, but was not satisfied with their response. Now asked me about speaking with the director or 'Security Director' today. She said 'A guard came and walked the halls for just 20 minutes, that's it, then no one'. Pt stated she does not feel safe. I notified unit director and unit manager of situation immediately following her request at 0845 this morning.

The incident report also included a note from the behavioral health unit director (BHUD) placed in the incident report on 3/7/19 at 11:01 AM and revealed the following, I was notified of this incident upon arrival to the unit at approximately 0700 (7:00 AM). I immediately alreated (sic) the other staff about the incident and ensured that a staff member was stationed in the hallway at all time (sic). I reviewed video footage from 1800-2300 (6:00 PM to 11:00 PM). Upon review of video footage I did witness a male patient enter (name of patient 16)'s room at approximately 2238 (10:38 PM), he was in her room for approximately 35 seconds at which point I saw him exit the room quickly followed by (name of patient 16) approximately 3 seconds later. She alerted nursing staff of the incident, they followed up with her, ensured that the q(every)15 minute checks were completed and documented on time and allowed patient to keep her door shut after the incident. I interviewed the patient at approximately 0830 with the safety director. During her interview she stated ' I was given medicine to help me sleep and went to sleep at approximately 2130 (9:30 PM), around 1030 I felt a brushing sensation on my leg, I awoke and thought I saw a short overweight black male quickly leaving my room. It felt like he just touched my thigh and butt. I quickly went to the nursing station and told staff.' She stated during the interview that she would like to (sic) police contacted and that she wanted to press charges. PD (police department) was contacted and arrived to the unit at approximately 1000, they took statements from (name of patient 16) and the male suspect. They stated that there was not enough evidence to charge anyone with a crime at this time...Both patient are being assessed at this time 1100 3/7/2019 by their MD's (medical doctors) to decide appropriate level of monitoring and placement. A staff member will be stationed in the hallway at all times while male suspect is on the unit.

Lastly, the incident report included a note from the patient safety and risk manger (PSRM) dated 3/7/19 at 3:45 PM which read, The male patient who entered (name of patient 16)'s room was discharged today and (name of patient 16) will be discharged later today. This was discussed with facility CNO (chief nursing officer) and CEO (chief executive officer), and will now be a police matter for any further investigation and follow up.

3. On 3/20/19 at 9:13 AM, an interview was conducted with the BHUD and hospital quality director (QD). The BHUD stated the incident involving patient 16 had been reviewed by him and was closed. The BHUD further stated his staff did everything they should have, including notifying him immediately. When asked when he was notified the BHUD stated at about 7 (AM) on 3/7/19. The BHUD stated he was aware that patient 16 reported the incident to the night shift staff on 3/6/19 and that staff continued to perform visual checks of each patient every 15 minutes and, kept someone in the hall most of the night to ensure nothing else happened. The BHUD stated the night shift staff should have completed an incident report and informed the next shift during report. The BHUD confirmed an incident report had not been completed by night shift staff. The BHUD further stated the night shift staff performed increased monitoring by, watching monitors which were at the nurses station but that they didn't do a great job documenting. The BHUD stated when a patient reported an allegation, as patient 16 had, the staff were to immediately contact him and ensure the patient was safe. The BHUD stated hospital security should also be informed. The BHUD stated because this incident happened on the night shift the house supervisor should have been notified of the incident. The BHUD stated he was not sure if the house supervisor or hospital security had been notified of the alleged incident on 3/6/19. The BHUD further stated they were having an in-service tonight to discuss incidents and what the expectations of the staff were. The BHUD stated he had not talked with RN 1, who was patient 16's nurse on the night of 3/6/19 yet. The QD stated she would find out if the house supervisor and/or security was informed of the incident.

4. On 3/20/19 at 10:14 AM, the QD provided the survey team with two incident reports from the hospital security regarding patient 16. The QD stated that when security was initially contacted, on 3/6/19, it was called in as man-power needed because patient 16 was agitated. The QD stated when security was notified it was a possible sexual assault a new incident report was completed. The QD further stated she had reviewed the house supervisor logs and could not find that they had been notified of the incident.

The incident reports were reviewed on 3/20/19.

The first incident report dated 3/6/19 at 10:38 PM revealed the following information, I was called by RN (name of RN 3) to the Adult Behavioral Unit at 2238 (10:38 PM) when a problematic patient was asking to review footage of her room ((407)). (Name of RN 3) asked be to do a walk through of the unit just to calm the patient down. When I arrived (name of RN 3) told me the patient was claiming that another male patient had entered her room, and left. I walked down the hall, and the patient approached me asking if I could help her get out of the unit so she could contact a lawyer. She accused the patient in the room across from her of entering her room while she was sleeping and wanted to review footage of her room. I told her I can't show her footage, but I could keep an eye on the cameras to make sure that didn't happen. The patient got angry with me that I didn't do as she asked, and stormed off down the hall. I went to the nurses station, and RN (name of RN) told me that it was her who had entered the patients room to do her regular Q-15's, and that she had already tried telling this to the patient but the patient wouldn't listen. We then heard the patient tapping on the glass on the doors entering the unit trying to get the Ortho(orthopedic)/Spine staff's attention. I approached her and told her she wasn't allowed past the red line and that she shouldn't be tapping the glass. She argued with me that security was useless since I wouldn't let her out, and started to change her story about what the other patient had done while in her room, now saying he was 'tapping her shoulder', even though this wasn't initially told to us. RN (name of RN) assured the patient that it was her who had entered the room and even showed her the Q-15 log. The patient wasn't happy, but eventually stormed off to her room. The nurses told me the patient was most likely trying to be manipulative in order to get herself out of the unit, and that reviewing camera footage probably wasn't needed. I left the adult BHU (behavioral health unit) when everything calmed down at 2315 (11:15 PM).

The second incident report dated 3/7/19 at 8:30 AM, revealed the following information, At approximately 0800 (8:00 AM) hours, I was notified by BHU Director (name of the BHU director) that an incident had occurred last night on adult psych. I responded to adult psych with security manager (name of security manager). While enroute to adult psych, I told (name of security manager) that security officer (name of security officer) had told me about the incident that occurred on adult psych last night where a female patient stated that a male patient had entered her room. I was informed that the patient was demanding to see security video footage and was making threats about suing the hospital. (Name of security officer) told me that they could not confirm that the male patient had entered her room. He told me that staff had showed the female patient the Q 15 report after the patient had demanded to see it.

...I spoke with (name of the BHUD and the PSRM) and they confirmed that the male patient had entered the female patient's room They said that the female patient wanted to report the incident to Bountiful police and press charges...Bountiful police officer (name of officer) arrived and interviewed the female patient in the conference room outside the adult psych unit.. The female patient said that she was sleeping and she was awaken (sic) when she felt something touch her on her upper thigh below her buttocks...She stated when she woke up, the patient from across the all in room 406 was in her room. She stated that he immediately ran out of her room and began walking the hallway like nothing had happened. She stated that she immediately reported the incident to staff and that security arrived on the floor. She stated that she was told by staff that nobody entered her room. She stated that security stayed on the floor for approximately 30 minutes and then left...

...The male patient from room 406 was also interviewed by officer (name of officer). He stated that he did not enter the female patient's room to his knowledge. He stated he is a paranoid schizophrenic and that he could have entered the room but that he didn't think he did... Officer (name of officer) stated that he did not have enough information to file any criminal charges and would file the report for informational purposes only...

... A plan was put in place to have hospital staff do a line of sight on the male patient until they can figure out what to do with both patients.

5. On 3/20/19 at 10:20 AM, the camera footage of the psychiatric unit hallway from 3/6/19 at 10:30 PM to 3/7/19 at 9:07 AM was reviewed with the security manager (SM) and QD. The following was observed:

a. At 10:31 PM, a male patient, patient 28, was observed to walk in front of the doorway to patient 16's room and look into her room for approximately 2 to 3 seconds. He was observed to look up and down the hallway multiple times prior to and after looking into patient 16's room.

b. At 10:35 PM, patient 28 was again observed outside patient 16's room looking up and down the hallway multiple times. Patient 28 then appeared to step just inside the doorway of patient 16's room for approximately 2-3 seconds and again walk away.

c. At 10:37 PM, patient 28 was observed to enter patient 16's room and remain in her room for 34 seconds. Patient 28 was then observed to quickly exit her room and enter the room directly across the hall. Per the QD, the room patient 28 entered was his assigned room. As soon as patient 28 entered the room across the hall, patient 16 was observed to quickly exit her room and walk towards the nurses station at the front of the unit. A nurse, RN 1 per interview with QD, was then observed to follow patient 16 back to her room. RN 1 was observed in patient 16's room for approximately 5-10 seconds, he then went back to the front nurses station.

d. From 10:38 PM to 10:43 PM, patient 16 was observed to be in and out of her room multiple times, as well as looking out from her doorway up and down the hall on multiple occasions.

e. At 10:43 PM, RN 1 was observed to walk back to patient 16's room with patient 16 from the front nurses station.

f. At 10:45 PM, a security officer was observed to enter the unit and begin walking the hall.

g. At 10:49 PM, RN 1 was observed to exit patient 16's room. Shortly, after patient 16 was observed to be talking with the security officer near the entrance of the unit. After talking with the officer, patient 16 was observed to be at the doors to the unit.

h. At 10:55 PM, patient 16 was observed to enter her room and the nurse is observed locking the door to her room. The QA director stated staff locked her door for her safety, but that she could exit anytime. The QA director further stated anyone entering patient 16's room would need a key to enter.

Note: Throughout this time patient 28 was observed to enter his room, leave his room, walk the halls, and then re-enter his room multiple times.

i. At 10:56 PM, patient 28 was observed to be talking with an aide, RN, and security officer in the hallway near the front nurses station.

j. At 10:57 PM, patient 16 was observed to exit her room and walk down the hallway to the area outside the front nurses station. The security officer and RN 1 are observed to be in the hallway outside of the front nurses station. Patient 28 is observed to be on the opposite side of the hall in the area outside of the front nurses station.

k. At 11:02 PM, patient 16 was observed to walk back to her room and enter her room.

l. At 11:03 PM, patient 28 was observed to walk back down to his room and enter his room.

m. At 11:08 PM, the security officer was observed to leave the unit.

Note: The security officer was on the unit for approximately 23 minutes.

n. At 11:09 PM, patient 28 was observed to exit his room and walk down the hall to the area outside of the front nurses station. No staff members were observed in the hallway. Patient 28 walked back to his room at 11:10 PM, again no staff were present in the hallway.

o. At 11:20 PM, during what appeared to be a 15 minute visual check of each patient, a nurse is observed to unlock patient 16's door and perform a visual check, the nurse did relock her door.

Note: Patient 16's door was locked for 25 minutes.

p. At 11:43 PM, during what appeared to be a 15 minute visual check of each patient, RN 3 was observed to unlock patient 16's door and perform a visual check, RN 3 was not observed to relock patient 16's door.

q. From 11:51 PM to 12:00 AM, a hospital technician stood in the hallway outside of the front nurses station.

r. At 11:57 PM, RN 1 was observed to enter patient 16's room without having to unlock the door.

s. At 12:03 AM, RN 1 was observed to exit patient 16's room without locking her door as he left.

t. At 12:04 AM, RN 1, RN 3, and the technician were observed to exit the nurses station at the front of the unit and go to the nurses station at the back of the unit.

At 10:55 AM, during the review of the camera footage, the BHUD entered the security office. The BHUD stated unit staff had locked patient 16's door to ensure her safety. When the surveyor informed the BHUD that per hospital camera footage patient 16's door had only been locked for 25 minutes he responded, O, really?.

At 10:56 AM, during the review of the camera footage the QD stated the hospital had actually not closed out the incident yet. The QD further stated, we have 60 days per the PSO (contract with the patient safety organization) to investigate. When the surveyor asked how during that 60 day review period they were protecting patients to ensure this did not happen again the BHUD stated he had talked with staff about the incident but could not provide evidence of this. The BHUD then stated he had talked to staff about reporting incidents to him immediately and more thorough assessments. When asked what was meant by more thorough assessments the BHUD stated, If they would have called me I would have come in and figured out an appropriate plan.

Note: When the BHUD was interviewed earlier in the day, he did not inform the surveyor that staff education had occurred. In fact he stated training would be completed tonight (3/20/19).

At 11:00 AM, the QD stated she had reviewed the house supervisor logs and could not find that they had been notified of the incident. The QD confirmed the house supervisor should have been informed of the incident on 3/6/19.

u. From 12:17 AM to 5:25 AM, approximately every 15 minutes staff were observed to perform visual checks of each patient. The QD confirmed during this time patient 16's door was not locked and staff were not observed to remain in the hallway. The QD stated staff were watching the monitors in the nurses station which gave them a visual of the hallway and each patient room. The QD confirmed this could not be verified because there were no cameras in either of the nurses station.

v. From 5:25 AM to 6:19 AM, unit staff were not observed to complete 15 minute visual checks on each patient. The QD and SM confirmed during this timeframe staff were not observed to complete visual rounds on each patient. The QD confirmed patient rounding should have been completed during this timeframe. The QD also confirmed staff were not observed to be stationed in the hallway to observe patients.

At 11:38 AM, the SM stated he was informed by his security officer who was on shift during the night of 3/6/19 that he had been called up to the psychiatric unit, but that he was called up for an agitated patient not a possible sexual assault.

w. At 7:20 AM, the BHUD was observed to enter the unit and talk with the day shift technician in the hallway.

x. At 7:32 AM, patient 16 was observed to exit her room and go down the hallway to the area outside of the front nurses station.

y. From 7:32 AM to 8:32 AM, patient 16 was observed to enter and exit her room on multiple occasions. Staff members were observed to be in the hallway at all times during this time. At 8:32 AM, patient 28 was observed in the hallway at the same time as patient 16. Patient 16 was observed to quickly walk past him.

z. At 8:33 AM, RN 2 was observed to enter patient 16's room.

aa. At 9:04 AM, the SM was observed to enter the unit.

bb. At 9:06 AM, the BHUD, the PSRM, and a security officer were observed to enter the unit.

cc. At 9:07 AM, the BHUD and the PSRM were observed to enter patient 16's room.

6. On 3/20/19 at 4:40 PM, an interview was conducted with RN 3. RN 3 confirmed she was working on the BHU on the night of 3/6/19. RN 3 stated that patient 16 came out of her room and said a patient, patient 28, came into her room. RN 3 stated that she did not remember patient 28 being around the patient 16's room. RN 3 stated the patient 28 usually hung out around the nurses' station and she did not remember him leaving his usual spot. RN 3 stated that she told patient 16 she would not let it happen again and I'd keep her safe. Then patient 16 told RN 3 that she was touched by patient 28. RN 3 stated she asked what patient 16 meant by that and stated, you know touched me. RN 3 again stated she informed patient 16 she would not let that happen and she would keep her safe. RN 3 stated that they kept patient 16 safe by completing 15 minute checks and watched patient 28 closely. RN 3 stated security talked to patient 16. RN 3 stated that patient 16 thought security was going to be there all night be he could not do that because he was the only security officer on that night. RN 3 was not positive if patient 16 reported to security that she had been touched. RN 3 stated that patient 16 mostly talked to RN 1. Security filed a report but RN 3 did not know if RN 1 had filed one.

On 3/20/19 at approximately 4:40 PM, an interview was conducted with RN 2. RN 2 confirmed she worked the day shift on 3/7/19. RN 2 stated patient 16 came to her when she woke up around 8:30 AM, and was very upset and distressed. RN 2 stated patient 16 did not make a lot of sense because she was so upset, but stated that a large black shadow entered her room and touched her butt. RN 2 stated she told her supervisor and that her supervisor was reviewing the tapes at that time. RN 2 stated that patient 16 stated that she may have had a sleep pill that night so it was all fuzzy to her.

7. Patient 28 was admitted on [DATE]

A review of patient 28's medical record was completed on 2/26/19.

On 3/7/19 at 3:06 AM, RN 1 entered the following note in patient 28's electronic medical record, Pt has been walking the hallway most of the evening. He was watched carefully as he had a history of wandering into others rooms. But no behavior like that was seen...His interaction with another pt in which he was accused of going into her room did add uneeded (sic) stress to him. But he handled it well. He was concerned about legal issues if he were 'targeted' by these problems and if he would be in legal trouble. I alleviated his concerns and he went to slee (sic) well...

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

Based on interview and record review it was determined that the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice. Specifically, for 5 of 10 sampled patients the hospital did not ensure patient reassessments, including pain reassessments were documented, and that medication reconciliations were completed or lists of home medications were obtained. (Patient Identifiers: 1, 3, 5, 6, and 7.)

Findings include:

1. Patient 6 sought treatment in the emergency department (ED) on 4/21/2020 at 6:00 AM, for dizziness and multiple falls related to the dizziness.

On 8/4/2020 at 12:13 PM, a telephone interview was conducted with patient 6. Patient 6 stated she did not receive appropriate care at Lakeview Hospital. Patient 6 stated she had experienced, a lot of pain while at Lakeview Hospital and that her pain was not controlled while in the ED, and she was discharged to a local skilled nursing facility in pain. Patient 6 further stated Lakeview Hospital did not appropriately reconcile her medications which caused the skilled nursing facility to receive an incorrect medication list and to give her incorrect medications. Patient 6 further stated she was, put in the back room, and did not receive assistance when needed, including meals while at Lakeview Hospital.

A review of patient 6's medical record was completed on 8/5/2020.

a. Nursing documentation revealed that Hydromorphone (an opioid given for severe pain) 0.5 milligrams (mg) was given intravenously at 7:30 AM, due to a headache with a pain rating of 8 out of 10.

No follow up documentation from nursing staff could be found to indicate the effectiveness of the administered pain medication was assessed.

A physical therapy (PT) evaluation was completed on 4/21/2020 from 8:57 AM to 9:27 AM. The PT documented that patient 6 had a pain score of 5 out of 10 in her neck, left shoulder, and right eye. The PT also documented that medication was an alleviating factor.

An occupational therapy (OT) evaluation was completed on 4/21/2020 from 10:35 AM to 10:55 AM. The OT documented that patient 6 had a pain score of 4 out of 10 in her head.

Nursing documentation revealed that Ibuprofen 600 mg was given by mouth at 12:30 PM, due to a pain rating of 7 out of 10.

No follow up documentation from any ED staff could be found to indicate the effectiveness of the administered pain medication.

b. Patient 6 discharged from the ED on 4/21/2020 at 6:10 PM to a local skilled nursing facility. No reassessment of any kind was documented after 12:30 PM by the nursing staff prior to patient 6's discharge. Due to the lack of documentation between 12:30 PM and 6:10 PM on 4/21/2020 the survey team could not determine if patient 6's needs were adequately addressed by hospital staff.

Note: The physician documented patient 6 discharged on [DATE] at 3:55 PM. On 8/4/2020 at 3:22 PM, the director of quality (DoQ) confirmed patient 6 did not discharge from the ED until 6:10 PM.

The hospital's Documenting the Provision of Care policy was reviewed and revealed the following information:

REASSESSMENT FOLLOWING MSE (medical screening exam):

...Level (2)/ Emergent will be documented at a minimum of hourly and more frequently if condition warrants.

Level (3)/Urgent will be performed and documented every 2-4 hours as condition dictates ...

Note: Nursing documentation indicated patient 6 was a Priority: 3 and should have had reassessments performed and documented every 2 to 4 hours.

On 8/4/2020 at 3:22 PM, the director of quality (DoQ) confirmed patient 6 did not have any reassessments after 12:30 PM on 4/21/2020, or follow up to pain medication administration documented in her medical record.

c. Patient 6 called in a grievance to the hospital on [DATE] relating to the lack of care she felt she received at the hospital. A letter was sent to patient 6 on 5/1/2020 with the following documented, ...Your medical records were reviewed and the staff involved in your care were interviewed. In evaluating your case, it became evident that a breakdown in communication did occur that resulted in a less than complete medication reconciliation. The care provided during your stay looked to be appropriate and necessary...Please know that your concerns have been addressed with our staff and that as a result of your experience we will be modifying our standard med rec (reconciliation) process in the ED...

On 8/4/2020 at 10:34 AM, a telephone interview was conducted with the DoQ. The DoQ stated a previous employee completed the investigation called in by patient 6, but that she would speak to it the best she could. The DoQ stated ED nursing staff were supposed to complete a medication reconciliation prior to a patient being transferred from the ED to a skilled nursing facility or to the hospital floor. The DoQ stated a medication reconciliation had not been documented by nursing staff for patient 6. The DoQ stated the ED manager had re-educated ED staff during their huddles but that they did not keep specific documentation on what was discussed in the huddles. The DoQ stated she would follow up with ED staff to see if any of them could remember this patient and could talk to the surveyor about patient 6 stay in the ED on 4/21/2020.

On 8/4/2020 at 3:55 PM, the DoQ indicated that after speaking with the ED director and staff that none remembered patient 6 and would not able to answer the survey team's questions about her stay.

2. A review of patient 3's medical record conducted on 8/4/2020, revealed the following:

Patient 3 was admitted on [DATE] at 7:39 AM. She voluntarily went to the ED with symptoms of dizziness and weakness. It was documented that she reported these symptoms had been occurring for the last 2 days. She later admitted to taking about 10 pills that belonged to her mother with the intent to fall asleep and not wake up. It was documented that she did not know what kind of pills they were but thought they were muscle relaxers.

a. At 8:00 AM, suicide precautions were implemented which included a reassessment of the patient every fifteen minutes to assess for safety.

Fifteen minute checks were documented in her medical record from 8:00 AM through 11:15 AM. The patient remained in the ED until 2:21 PM, at which time she was transferred to the behavioral health unit for inpatient care related to suicidal intent.

There was no documented evidence that the fifteen minute checks had been discontinued by the physician or that the checks had been conducted between the hours of 11:30 AM and 2:21 PM when she was transferred out of the ED.

b. In a psychiatric evaluation note dated 8/3/2020 at 9:41 AM, it was documented that the patient had been prescribed antidepressant medications two years prior, but had stopped taking them due to the side effects.

In a document titled Certificate for Emergency Commitment it was documented by a physician, Stopped medications and Overdose attempt.

There was no documented evidence in the medical record that the ED staff had completed a medication reconciliation or assessment of home medications the patient may have been taking.

3. A review of patient 7's medical record conducted on 8/4/2020, revealed the following:

Patient 7 was admitted on [DATE] at 5:19 PM. She was transferred via ambulance from a skilled nursing facility where she was recovering from abdominal surgery. It was documented the patient had a tumor removed from her abdomen in early April. The exact date of surgery was not documented in her medical record.

a. Upon admit it was documented that the patient reported she did not have any pain. In an initial physician note dated 4/25/2020 at 5:23 PM, it was documented that the patient denied abdominal pain.

In a re-evaluation physician note dated 4/25/2020, (the note was not timed), it was documented that the physician, was able to express a fair amount of purulence with minimal pressure. There was no documentation as to how the patient tolerated the procedure. Furthermore, there was no documented pain assessment conducted after the procedure or for the remainder of her stay in the ED.

b. In a physician note dated 4/25/2020 at 5:23 PM, it was documented the patient was being treated for a urinary tract infection with Cipro and Macrobid (antibiotics). There was no other documentation about these medications, including dosage, frequency, or duration. Furthermore, there was no documented evidence in the medical record that the ED staff had completed a medication reconciliation or assessment of home medications the patient may have been taking.

4. Patient 1 was admitted to the facility's ED on 8/3/2020, with a diagnosis of right arm laceration.

On 8/3/2020, patient 1's medical record was reviewed and revealed the following:

a. On 8/3/2020 at 8:30 AM, the nurse performed an assessment and documented a pain scale of 5 out 10. No treatments were documented to address the patient's pain. There was also no reassessment of the patient's pain before discharge.

b. Patient 1's medical record also revealed no documentation of home medications.

On 8/3/2020 at 9:30 AM, the patient was given 500 milligrams of the antibiotic Cephalexin. Because the patient's home medications were not documented there is no way of knowing whether there was a potential drug interaction with the antibiotic and the medications the patient may be on.

5. Patient 5 was admitted to the facility's ED on 5/8/2020, with the primary diagnosis listed as headache. Secondary diagnoses were unspecified fall, striking against or struck by other objects, and laceration without foreign body to scalp.

Patient 5's medical record was reviewed on 8/4/2020, and revealed the following:

a. On 5/8/2020 at 1:14 PM, the nurse performed an assessment of the patient's pain. The patient rated her pain an 8 out 10. No treatments were documented to address the patient's head pain. There was also no reassessment of the patient's pain before discharge.

On 8/4/2020 at 1:42 PM, the facility's DoQ was interviewed. She was asked whether patient 5 should have been reassessed for pain. She stated that the patient's pain should have been reassessed before the patient was discharged , and that it looked like the, bare minimum was charted on that patient.

On 8/5/2020 at 1:21 PM, an interview was conducted with patient 5. She stated that when she was at Lakeview ED, on a scale of 1 to 10, her pain was a 9 and that they had not addressed her pain. She stated that when she discharged she was in the same amount of pain.

b. Patient 5's medical record also revealed no documentation of the patient's home medication.

On 8/4/2020, the facility's policy labeled Documenting the Provisions of Care was reviewed. Under the ED section it was documented that a detailed assessment should include medications and treatments prior to arrival.

On 8/4/2020 at 1:42 PM, an interview was conducted with the DoQ. She stated that a detailed assessment should be done on every patient, and the physician should have documented on their assessment the patient's home medications as well.

Based on interview and review of emergency department medical records, it was determined that the hospital did not comply with the provider agreement as defined in 42 CFR 489.24(b), to comply with 42 CFR 489.24.

Findings include:

1. The hospital failed to maintain a central log of each individual who came to the emergency department seeking assistance. (Refer to tag A-2405)

2. The hospital failed to provide an appropriate medical screening examination. (Refer to tag A-2406)

Based on interview and record review it was determined that the hospital failed to maintain a central log of each individual who came to the emergency department seeking assistance. Specifically, 1 of 21 sample patients who came to the ED seeking assistance was not placed on the hospital's central log. (Patient identifier 21.)

Findings include:

A complaint was called in regarding patient 21 and the lack of care she received, when she was brought to the hospital's ED on 10/16/19.

1. On 10/23/19 the central log for the date the allegation occurred was reviewed and the patient's name was not found. The central log was reviewed for the days immediately prior to and after the date provided by the complainant. The hospital's electronic medical record system was also accessed and the patient's name was placed in the search bar, the patient's name was not found.

2. After interviews with hospital staff, a local police officer, and a family member of patient 21 were completed, it was determined patient 21's family had sought treatment for patient 21 at the hospital's ED on 10/16/19. (Refer to tag A-2406).

3. On 10/24/19 an interview was conducted with the hospital's chief nursing officer (CNO). The CNO confirmed patient 21 should have been placed on the hospital's central log.

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

Based on interview and record review it was determined that the hospital failed to provide an appropriate medical screening examination for one sample patient to determine if an emergency medical condition existed. Twenty medical records were reviewed, however, none of the 20 medical records included the complaint patient because the hospital failed to list the patient on the central log, evaluate the patient, or create a medical record for the patient, therefore there was no record to review. (Patient identifier 21.)

Findings include:

A complaint was received regarding patient 21 and the lack of care she received, when she was brought to the hospital's Emergency Department (ED) on 10/16/19. The complainant indicated the local police were also involved.

1. On 10/23/19, the central log for the date the allegation occurred was reviewed and the patient's name was not found. The central log was reviewed for the days immediately prior to and after the date provided by the complainant. The hospital's electronic medical record system was also accessed and the patient's name was placed in the search bar - the patient's name was not found.

No medical record review could be conducted because the hospital had no record of the patient ever coming to the hospital

2. On 10/23/19, at 10:51 AM, the hospital quality assurance (QA) manager was interviewed and informed survey staff that, if police were called to the ED, security would have an incident report.

The hospital's security incident log, for October 2019, was reviewed. This revealed one incident on 10/16/19 (the date which the complainant alleged patient 21 was turned away from the ED.) No names of any of individuals who were present in the ED during the incident, besides the hospital's security officer, were on the report.

The security incident report, from 10/16/19, revealed the security officer received a call, ...to come to the waiting room of the emergency department. Upon arriving there was a (sic) two ladies and two men in the waiting room. They were trying to hold down what seemed to be a very intoxicated female in the chair. They said she needed to be admitted and they could not handle her anymore. She was compliant as I talked to her and stated all she wanted to do was go home. About 1915 (7:15 PM) or so 3 Bountiful Police Officers showed (sic) to talk with the family. After about 45 minutes of talking with the female and the family separately they stated they had no reason to pink sheet (an emergency application for involuntary commitment without certification form completed by a peace officer or Mental Health Officer requesting temporary commitment of a person) her or keep her. They left the hospital about 2000 (8:00 PM). The family remained and tried to talk the female into self admitting herself (sic) into the hospital for observation and to get some help they believed she needed. The scene was calm when I got a call to go to another floor. I told the PBX operator to call if there were any further issues.

On 10/23/19 at 11:49 AM, a review and interview of the 10/16/19 incident, in the hospital ED, was completed with the hospital's security manager and the security officer who responded. The security officer who responded to the incident stated he was called to the ED on 10/16/19 to help with an intoxicated lady. The security officer stated, when he arrived at the ED, a woman was being physically held down by her mother in the ED waiting area. The officer stated the woman being held down was brought to the ED by her mother, her husband, and her husband's father. The officer stated he talked with the woman's husband who stated they did not know what else to do and that the woman had torn up their home. The officer stated he talked with the woman being held down, and that she was calm and informed him she just wanted to go home. The officer stated he talked with the admitting people and they told him that we can't help her unless she self admits. The officer stated that, by the time the local police arrived and they took the intoxicated woman into the consultation room, they talked to patient 21 for about 40 minutes, maybe close to an hour. The officer stated the police officers told him there was nothing they could do and that he got a call to another floor and by the time he made it back to the ED they had left.

Interviews were conducted with patient 21's mother and the local police officer who were both present during the incident above and both confirmed this incident was with the patient named in the complaint, patient 21.

3. On 10/23/19 at 10:59 AM, a telephone interview was conducted with the mother of patient 21 to ask if she was present when her daughter was brought to the ED on 10/16/19. Patient 21's mother confirmed she was present and that she, her daughter's husband and her daughter's, husband's father, brought patient 21 to the ED. Patient 21's mother stated she entered the ED and told the clerk that they needed assistance getting her daughter into the ED from her car. Patient 21's mother stated she had parked her car right outside the sliding glass doors. Patient 21's mother stated the ED clerk informed her they could not help bring her daughter into the ED from the car. Patient 21's mother stated her daughter's husband and her husband's father had to physically bring her daughter into the ED. Patient 21's mother stated she told the ED clerk that they had brought her daughter in to the ED because she had threatened to jump off of her balcony and that she wanted to go back to her lord god. Patient 21's mother further stated her daughter had broken glass all over her house and that she had children in the house. Patient 21's mother stated the ED clerk stated they could not help her daughter and that she should call the police who may be able to help. Patient 21's mother stated she called 911 on her cell phone and that initially two police officers arrived, with a third arriving shortly after the first two. Patient 21's mother stated the police officers took her daughter to a room just to the side of the clerk's desk and talked with her separately. Patient 21's mother stated they told the police officers of her daughter's threat to kill herself and even showed the officers pictures of the house. Patient 21's mother stated the police officers then told her that they could not see any reason to keep her daughter, and they turned us loose. Patient 21's mother further sated the next day her daughter stated, She was going to OD (overdose) and she was going to sleep and her lord god. Patient 21's mother stated that 911 was called and the police took her daughter to another hospital where she was admitted to their psychiatric unit for five days. Patient 21's mother then stated, We were not treated like we were at a medical facility. I mean if anyone even examined her they would have known things were out of whack. Patient 21's mother further stated, I am so upset that we came to the emergency department and got absolutely no help. I mean we could have had a death. We had an absolute crisis on our hands and got absolutely no help at Lakeview emergency room . Patient 21's mother confirmed no medical personnel from the hospital saw her daughter while they were in the ED.

4. On 10/23/19 at 2:48 PM, an interview was conducted with the ED registrar who was working on 10/16/19. Also present during the interview were the hospital's chief nursing officer (CNO), QA manger, and the registrar's supervisor. The registrar stated the patient's mother walked in to the ED and stated she needed help out front to get her daughter inside. The registrar stated she asked the mother what the issue was and she stated, She has been drinking and is having SI (suicidal ideation) issues, but that she did not want to come into the ED. The registrar stated she told the mother that unfortunately we can't force them to be seen if they are over 18. The registrar stated she called one of the registered nurses (RN's) to confirm what she had told the mother was correct and the RN told the registrar, There is nothing we can do, we can't force them to be seen. The registrar stated she told the mother the RN confirmed they could not force her daughter to be seen, but that she could call security, who also could not force her in, and at the same time she saw the husband bear hugging and carrying the patient into the ED. The registrar stated she did inform the mother she could call the police. The registrar stated the police arrived shortly after the patient had been carried into the ED. The registrar confirmed no medical personnel from the hospital saw the patient. The hospital CNO stated she talked with the ED manager and confirmed with him that the hospital staff could not force anyone into the ED unless the police stated to. The CNO further stated the ED manager told her, You can't go out and screen in the lobby.

5. On 10/23/19 at 3:46 PM, an interview was conducted with the hospital CNO and QA manger. The CNO confirmed no medical personnel approached the woman discussed in the 10/16/19 security incident report.

6. On 10/23/19 at 4:14 PM, a telephone interview was conducted with the local police officer who responded to the incident in the ED on 10/16/19. The officer stated he arrived at Lakeview hospital's ED waiting room, where patient 21 had been brought by her husband, mother, and her husband's father. The officer stated patient 21's family brought her in to the ED for a, mental eval. The officer stated, when he arrived, patient 21 was in the ED's consultation room and family stated she had told them that she wants to return home to her heavenly father and her god. The officer stated patient 21's husband did show him a video of patient 21 breaking things in the house. The officer stated he spoke with patient 21 in the consultation room and that she stated she did not want to hurt herself and she did not want to die. The officer stated he informed patient 21's husband and mother that our part is done. The officer stated, when he left the hospital, patient 21 was still in the consultation room in the ED. The officer stated he did not see a medical professional speak with patient 21 while he was at the hospital.

The police report correlating with the hospital security incident, dated 10/16/19, was reviewed. The report, dated 10/16/19 at 7:12 PM, revealed the officer responded to Lakeview hospital's ED at the request of patient 21's husband who had taken his wife to the ED for a mental evaluation, and that he was, requesting officers pink sheet patient 21. The report also revealed, ...(name of patient 21's husband) said (name of patient 21) did not want to be there but they felt she needed assistance ...on Monday night, (name of patient 21) broke items in their residence. (Name of patient 21's husband) did show me a video of the damage he took with his cell phone. (The name of patient 21's husband) said he believes (name of patient 21) is suicidal and (name of patient 21) said she wants to return to her 'Lord God'.

I (police officer) made contact with (name of patient 21). (Name of patient 21) said she and her husband are in the process of getting divorced. (Name of patient 21) said she did break a few items in her house and the items were hers. (Name of patient 21) said no one else was home when she broke the items. (Name of patient 21) said she did not want to be here at Lakeview and her family forced her into the van at her residence in (name of local city) and dragged her into the hospital.

I (police officer) told (name of patient 21) her family was concerned about her well being and that she was making threats of suicide. I (police officer) asked (name of patient 21) is (sic) she wanted to die, (name of patient 21) said no. I (police officer) asked (name of patient 21) if she wanted to hurt anyone and (name of patient 21) said no. (Name of patient 21) said she does not want to die and does not want to hurt anyone. (Name of patient 21) said she has three children that need her and she wants to be there for them. (Name of patient 21) said she does use medication for anxiety and for depression. (Name of patient 21) said she wanted to go home and sleep. I (police officer) asked (name of patient 21) if she wanted to be seen by a doctor as her family was requesting. (Name of patient 21) said she did not want to be seen and she felt fine.

...(Name of patient 21's husband) said he did not want to get her into trouble but wanted her to get help. I (police officer) informed (name of patient 21's husband) that (name of patient 21) provided me with no indication that she would self harm herself or to others based on this information, no further action would be taken ...

7. On 10/23/19 at 4:20 PM, an interview was conducted with the hospital CNO and QA manager. The CNO stated she had contacted corporate and they informed her that the hospital should have screened the patient who came into the ED on 10/16/19.

8. On 10/24/19, a review of the medical record from the hospital where Patient 21 was admitted on [DATE] at 1:11 PM, due to an overdose, was completed.

Note: Patient 21 overdosed less than 24 hours after being turned away from Lakeview hospital on [DATE].

9. A review of the admitting hospital's emergency room physician documentation, dated 10/17/19 at 1:36 PM, revealed the following:

Patient 21, ...presents (sic) emergency department with suicidal ideation and following a (sic) overdose. Patient overdosed on lorazepam and Ambien as well as alcohol. She had been texting with her mother who ultimately called police who then found the patient laying in her bed at home. Patient was conscious but did report multiple times that she wanted to go to sleep without waking up ... The physician noted the crisis team was alerted and arrived to evaluate patient 21. The crisis worker informed the physician that patient 21 had made multiple statements to family members that she wants to simply go 'home' and by this she means to heaven. The crisis worker also informed the physician that patient 21's husband, ...found his children at home with her intoxicated multiple times with broken glass throughout the house. He did attempt to find help earlier this week but was told there was little if (sic) they were able to do via police.

10. A review of the admitting hospital's crisis worker's (CW) behavioral health notes, dated 10/17/19, revealed the following:

(Name of patient 21) was not the most accurate reported and CW had to talk to husband to get the most accurate information. (Name of patient 21) would answer questions but was very guarded. (Name of patient 21) is a heavy alcoholic and with her OD she is currently a danger to herself and her 2 kids at home. (Name of patient 21) is also going through marital problems with husband saying they may get divorced and although (name of patient 21) denies feeling suicidal, she overdosed and reported to her husband that she wants to go to bed and never wake up. CW staffed with Dr. (name of physician) and CW agree that (name of patient 21) needs immediate inpatient stabilization for her and her children's sake. The notes also revealed, (name of patient 21) is currently a danger to her self (sic) and her kids ...

11. A review of the admitting hospital's nursing documentation, dated 10/17/19, revealed the following:

...Pt (patient) lives with her husband and three children 12yr (years), 8yr, 8mos (months). Pt reports that she intentionally took an unknown quantity of her prescribed Ambien 10mg (milligrams) and Ativan 2mg. pt stated she wanted 'go to sleep and not wake up.' Husband reports that she has been heavily drinking daily and making suicidal statements at home lately ...

Based on interview and record review, it was determined that the hospital did not provide patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency.

Findings include:

On 3/19/19, review of the admission packet and paperwork was completed.

There was no documented evidence that the hospital had provided patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency.

On 3/19/19 at 4:00 PM, an interview was conducted with the chief nursing officer (CNO). The CNO stated that the information regarding filing a grievance with the state agency must have been missed when the patient rights and responsibilities pamphlet was printed.

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

Based on interview and record review, it was determined that the hospital did not obtain an informed consent to treat for 3 of 30 sampled patients. Specifically, the hospital did not obtain written or verbal consent to treat for patients who were incapacitated or otherwise unable to consent to treatment upon admission. (Patient identifiers: 4, 11, and 17.)

Findings include:

1. Patient 4 was admitted on [DATE], with an admitting diagnosis of urosepsis.

Patient 4's medical record was reviewed on 3/25/19. A review of the consent to treat revealed patient 4 was unable to sign the consent. The consent was signed by the admission person and co-signed by another staff member. No documentation could be located to indicate that a consent to treat had been completed by the patient or the patient's representative, prior to the patient being discharged from the hospital.

2. Patient 17 was admitted on [DATE], with an admitted diagnosis of an epidural abscess.

Patient 17's medical record was reviewed on 3/25/19. Patient 17's medical record was reviewed on 3/25/19. A review of the consent to treat revealed patient 4 was unable to sign the consent. The consent was signed by the admission person and co-signed by another staff member. No documentation could be located to indicate that a consent to treat had been completed by the patient or the patient's representative, prior to the patient being discharged from the hospital.

On 3/25/19, at 2:15 PM, an interview was conducted with the chief nursing officer (CNO). The CNO called the admission office and spoke with an admissions staff person to ask for clarification of what the hospital process was when a patient was unable to sign the consent to treat on admission. The staff person told her that if the patient cannot sign on admission they would have another staff person witness and sign the admission paperwork indicating that the patient was unable to sign. The staff person stated they did not follow up with the patient or the patient's representative to obtain a signed consent to treat.

During the interview, the CNO contacted the corporate person over the admissions department. The corporate person stated that if the patient was unable to sign the consent form upon admission, the admission staff were to go to the patient room at a later time and attempt to get a signed consent from the patient or the patient's representative. If the patient was still unable to sign the consent and there is no patient representative present, the admissions person was to contact the patient's representative by telephone and obtain a verbal consent to treat.

3. Patient 26 was admitted on [DATE], with an admitting diagnosis of shock.

Patient 26's medical record was reviewed on 3/26/19. No documentation could be located to indicate that a consent to treat had been completed by the patient or the patient's representative, prior to the patient being discharged from the hospital.

On 3/26/19 at 8:46 AM, an interview was conducted with the quality director (QD). The QD stated that the hospital was unable to locate the consent forms for patient 26.

Based on interview and record review it was determined that the Hospital did not ensure that certified registered nurse anesthetists (CRNAs) were under the supervision of the operating practitioner or an anesthesiologist who was immediately available.

Findings include:

On 3/20/19 at 8:15 AM, an interview was conducted with the chief nursing officer (CNO) concerning the hospital oversight and supervision of the CRNAs. The CNO stated that the hospital has anesthesiologists on call each day and most would be available to come in to assist within 5 minutes if there was a need.

The CNO stated that the hospital only used the CRNAs in labor and delivery. The CNO stated that the obstetrician would normally be the one to supervise the CRNA. The CNO further stated that the hospital did not have a policy or procedure concerning the supervision of the CRNAs nor did they have signed documentation to indicate that the physicians agreed to supervise the CRNAs and assist as necessary.

Based on observations made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain doors with self-closing devices in accordance with NFPA 19.2.2.2.8

This deficiency affected 1 of several smoke compartments.

Findings include:

1-During the facility tour it was observed that the women's services elevator machine room did have a self-closing device on the door but did not close to the full latching position and was not in accordance with 19.2.2.2.7, 19.2.2.2.8

Based upon observations made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5(18.3.2.1)

This deficiency affected several smoke compartments

Findings include:

1- During the facility tour it was observed that the women's services storage room near patient room 233 was observed to have a 3'x2' penetration that was not sealed, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1

2- During the facility tour it was observed that the PACU storage room was observed to have a 2'x2' penetration that was not sealed, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1

3- During the facility tour it was observed that the 3RD floor storage room was observed to have penetration's around a hvac duct, a sprinkler pipe and wire conduit that was not sealed at the time of this inspection, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1

4- During the facility tour it was observed that the 4th floor soiled utility room was observed to have a several penetration's that was not sealed, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1

Based upon observations/record review made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101, 9.7.5.

This deficiency affected several sprinkler heads.

Findings include:

1-During the facility tour it was observed that the sprinkler head in room 450 had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25

2--During the facility tour it was observed that the sprinkler head in room 447 had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25

3-During the facility tour it was observed that the sprinkler head in room 441 had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25

4-During the facility tour it was observed that the sprinkler heads in the therapy pool area had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25

5-During the facility tour it was observed that the sprinkler heads in the therapy pool change rooms had corrosion on the head of the sprinkler, Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation in accordance with NFPA 25

Based upon observations made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 13 of several GFIC outlets.

Findings include

1-During the facility tour it was observed that the outlet in the kitchen by the hand wash sink were not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

2- During the facility tour it was observed that the 2 outlet's in the east community class room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

3-During the facility tour it was observed that the outlet in the radiology control room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

4- During the facility tour it was observed that the outlet in the radiologist special control room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

5- During the facility tour it was observed that the outlet in the same day surgery by the nutrition sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

6- During the facility tour it was observed that the outlet in the same day surgery by the break room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

7- During the facility tour it was observed that the outlet in the same day surgery nurses station sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

8- During the facility tour it was observed that the outlet in the operating room 4&5 sub sterile sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

9- During the facility tour it was observed that the outlet in the women's services conference room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

10- During the facility tour it was observed that the outlet in the women's services kitchen sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

11- During the facility tour it was observed that the outlet in the medical surgical soiled utility room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

12- During the facility tour it was observed that the outlet in the 4th floor laundry room hopper sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

13- During the facility tour it was observed that the outlet in the hyperbaric lab room sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

Based upon made in the presence of the plant manager on 03-19-2019, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2.

This deficiency affected all smoke dampers.

Findings include:

1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper and not in accordance with NFPA 19.5.2.1, 9.2 and NFPA 72 Table 14.4.2.2