Every finding on record at Hospice of the Western Reserve, Inc

Based on observations and staff interviews, the facility failed to ensure the delayed egress doors were being maintained per NFPA 101-2012 Edition, Sections 7.2.1.6.1.1. This could affect all patients receiving services in the Ames Family Hospice House inpatient unit. The census was 22. Findings include: --- Observation during a test of the fire alarm on 11/03/22 at 11:38 A.M. revealed several doors with a delayed locking mechanism that was connected to the fire alarm did not unlock when the fire alarm was activated. All doors opened when a key entry was entered. Those doors were: -The two exit doors located in the Great Room with exit signs beside them. -The exit door that was designated as a means of egress by room 158. -The double doors that lead to the back dock. An interview with Staff B verified the finding at the time of the discovery.

Based on medical record review, review of the admission packet and staff interview, the agency failed to provide written patient rights and responsibilities for 20 of 20 patients reviewed (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20). This could affect all patients receiving services from the agency. The agency census was 873. Findings include: --- Review of the medical records for Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20 revealed education was provided on patient rights and responsibilities. However, the medical records were silent for verification written patient rights and responsibilities were provided. Interview on 11/01/22 at 12:01 P.M. with Staff A revealed the agency did not provide a copy of written patient rights and responsibilities unless requested by the patient or family. Staff A stated the agency provided an admission packet, which referred patients and families to a website where rights and responsibilities could be viewed. Review of the undated admission packet confirmed written patient rights and responsibilities were not included and patients and families were directed to the agency's website to access patient rights and responsibilities.

Based on observation and staff interview, the agency failed to ensure the delayed egress doors were being maintained (K222).

Based on observation and staff interview, the agency failed to meet the requirements for NFPA 101-2012 Edition, Chapter 19 Existing Healthcare. This had the potential to affect all patients receiving services in the inpatient unit. The inpatient unit census was 22. Findings include: --- - K222 - the facility failed to ensure the delayed egress doors were being maintained.