River Crest Hospital was found to be out of compliance with six conditions of Medicare participation. Inspectors with the Centers for Medicare and Medicaid Services (CMS) identified deficiencies related to the hospital’s governing body, patient rights, quality performance improvement, nursing services, food and dietetic services, and infection control.
According to CMS, the facility’s food service “created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death.” CMS found “there were risks observed with a likelihood for food borne illness to spread through utensils or dishware due to inadequate cleaning.” The unsanitary conditions were also found to extend to patient care units, including “medication rooms, patient rooms, bathrooms, laundry rooms, storage rooms and other areas affecting patient care.”
While CMS inspectors were touring the facility, a patient was heard saying that she wanted to tell them “how she had to call 911 and how they left her in the Seclusion room ‘with vomit on the floor.'” The facility was subsequently cited for failing to protect this patient’s rights. The patient had a history of stomach cancer and was admitted with a gastrointestinal disorder and significant stomach pain. The patient alleged that after she was placed in an observation room, the room became filthy from her vomiting but staff would neither clean the room nor let her leave it. This constituted an episode of seclusion without a physician’s order. After more than 16 hours the patient called 911 and was taken by ambulance to a nearby hospital where she was diagnosed with acute gastritis. When she returned to River Crest, she was returned to the observation room where she again spent the night. CMS inspectors verified that the room still had several patches of dried vomit and a vomit-covered hand towel stuck to the floor the following morning. The facility’s policy stated, “‘Restraint, seclusions or clinical time out shall not be used as punishment, for the convenience of staff, or as a substitute for effective treatment or rehabilitation.'”