HospitalInspections.org

Based on a review of medical records (MR), facility documentation, and interview with staff(EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the "Important Message from Medicare (IM)" for four of four Medicare medical records reviewed (MR4, MR6, MR9, and MR10).

Findings include:

A review of facility policies revealed there was no policy to address the "Important Message from Medicare (IMM)."

A review on May 21, 2015, of MR4, MR6, MR9, and MR10 revealed a second copy of the Important Message from Medicare was not in the medical record prior to discharge.

An interview conducted on May 21, 2015 at 10:35 with EMP1 confirmed the medical records did not have the second copy of the "Important Message From Medicare."

Based on review of facility documents, medical records, and interview with staff (EMP), it determined that the facility failed to have a system in place to ensure that a patient's physician was contacted as soon as possible after the patient was admitted for five of five medical records reviewed (MR4, MR5, MR6, MR7, and MR8).

Findings include:

A review on May 21, 2015, of facility policy "Family Notification Form" last reviewed April 2013 revealed the policy did not address notification of the patient's own physician as soon as possible after the patient was admitted.

A review on May 21, 2015, of MR4, MR5, MR6, MR7, and MR8 revealed no documentation that the patient's physician was notified as soon possible after the patient was admitted to the hospital.

An interview conducted on May 21, 2015, at 2:30 PM with EMP1 confirmed that MR4, MR5, MR6, MR7, and MR8 did not contain documentation that the facility asked the patient if the patient wanted their physician to be contacted. Further interview with EMP1 confirmed that the policy did not address notification to the physician.

Based on review of policy, facility documents and interview with staff (EMP) it was determined the facility failed to include Quality Assurance Performance Improvement activities for all contracted services related to clinical care of patients.

Findings include:

A review on May 20, 2015, of the Wernersville State Hospital Policy/Procedure Manual " Performance Improvement Program " last revised January 13, 2013, revealed " .. The Performance Improvement Program is designed to objectively and systematically measure, assess, and improve the performance of the hospital ' s divisional services ... and outcomes related to patient care ... "

A review on May 20, 2015, of the Wernersville State Hospital Dashboard Report for the period April 2014 to May 2015 failed to identify that the facility monitored the following contracted services: Mobile radiology services, audiology, speech and language therapy and optometry.

An interview on May 22, 2015, at 9:00 AM with EMP2 confirmed mobile radiology, audiology, speech and language therapy and optometry services were not monitored through the hospital Performance Improvement Program.

Based on review of medical record (MR) and interview with staff (EMP), it was determined the facility failed to develop a treatment plan for self-administration of medications for one MR reviewed (MR25).

Findings include:

A review on May 21, 2015, of MR25 revealed the record did not contain a treatment plan for self-administration of medications.

An interview conducted on May 21, 2015, at 12:40 PM with EMP4 confirmed that MR25 did not contain a treatment plan for self-administration of medications.

Based on review of facility policy, medical record (MR), and interview with staff (EMP), it was determined the facility failed to document education provided to the patient regarding the safe and accurate administration of medications and failed to have a current order to self-administer medications for the one MR reviewed (MR25).

Findings:
A review on May 21, 2015, of Wernersville State Hospital policy " Self Medication Program, "last revised November 2014 revealed " ... II. PURPOSE ... The self-medication administration is a pre-discharge step and should not be continued for more than 60 days without Treatment Team re-evaluation. ... IV. CONSUMER ELIGIBILITY ... C. The consumer must first complete an education phase prior to being permitted to administer his/her own medication. ... V. PROCEDURE TO BEGIN SELF-MEDICATION TEACHING ... D. The nurse will give the consumer a medication pre-test prior to any teaching to assess the consumer ' s knowledge based on their current medication regimen, and write a note in the Progress Note section of the consumer ' s medical record documenting that the medication pre-test had been done as well as the outcome. ... F. The nurse will document each educational session and the consumer ' s response to teaching in a Progress Note. ... IV. PROCEDURE TO BEGIN SELF-MEDICATION ADMINISTRATION ... B. In transcribing the physician ' s order on the Medication Administration Record, write the date and " Self -Medication " in red ink along the top. On the last page of the routine Medication Administration Record transcribe "The medication nurse has observed the consumer taking and ingesting medication from the correct compartment of medication dispenser" and place an N, D, and E to signify each shift. ... "
A review on May 21, 2015, of Wernersville State Hospital Pharmacy-Procedure, Section No. 2049- " Self-Medication Policy " , last revised March 2011 revealed, " ... POLICY STATEMENT: In compliance with legal aspects and under specific medical conditions, certain consumers will be involved in a self-medication program in preparation for leaving the hospital. The self-administration is a pre-discharge step and should not be continued for more than 60 days without treatment team re-evaluation. ... "
A review on May 21, 2015, of MR25 revealed an original "Physician's Order" signed and dated July 2, 2014, for: "1) Self Med Program; 2) Send Med Minder." Further review of MR1 revealed no documentation that the patient was educated about the safe and accurate administration of medications, no documentation of a current order to self-administer medications, and no re-evaluation by the treatment team for continuation of self-administration of medications every 60 days.
An interview conducted on May 21, 2015, at 12:40 PM with EMP4 confirmed that MR25 failed to contain documentation that the patient was educated about self-administration of medications, no documentation of a current order to self-administer medications, and no documentation that the treatment team re-evaluated the patient for continuation of self-administration of medications every 60 days.

Based on review of facility policy, observation, and interview with staff (EMP), it was determined that the Director of Dietetic Services failed to ensure safety practices for food handling were maintained in the kitchen.

Findings include:

A review on May 20, 2015, of facility policy "Policy and Procedure for Food Storage, " date issued January 1, 2014, revealed " Policy Statement: It is necessary to practice good storage techniques in order to prevent spoilage and contamination of food supplies. ... Procedure ... 5. All stored foods are properly labeled using a marking pencil. 6. Upon delivery, all perishable food deliveries received should be dated by the Ingredient Room employees. "

An observation on May 20, 2015, at 1:25 PM of the cook preparation area revealed a five gallon plastic Rubbermaid container of powdered milk, a five gallon plastic Rubbermaid container of white flour, a five gallon plastic Rubbermaid container of white sugar, a five gallon plastic Rubbermaid container of potato flakes, a five gallon plastic Rubbermaid container of oatmeal, three 111 ounce (oz.) cans of Red Gold tomato paste, four 7 pound (lb.) 2 oz. cans of Hunts tomato ketchup, one 7 lb. 3 oz. can of Hunts chili sauce, six 104 oz. cans of Furmano's marinara sauce, six 102 oz. cans of Furmano's diced tomatoes, four 105 oz. cans of yellow cling peaches, three 6 lb. 10 oz. cans of fruit mix and six 6 lb. 11 oz. cans of crushed pineapples that did not contain a received on or use by date.

An observation on May 20, 2015, at 1:30 PM of the dry supply storage area revealed an 18 oz. plastic container of granulated onion and a 30 oz. plastic container of granulated oregano that did not contain use by dates.

An observation on May 20, 2015, at 1:35 PM of a freezer in the dry supply storage area revealed five veggie chicken patties that were not in the original packaging and did not contain a received on or use by date. Further observation revealed 11 garden burgers and one 16 oz. bag of whipped topping that did not contain a received on or use by date.

An observation on May 20, 2015, at 1:45 PM of the dining room refrigerator revealed 12 fresh salads that did not contain a use by date. Further observation revealed 22 cups of fresh strawberries with whipped topping that were not covered and did not contain a use by date.

An observation on May 20, 2015, at 2:00 PM of the walk-in refrigerator revealed a bucket containing celery sticks did not contain a use by date.

An observation on May 20, 2015, at 2:05 PM of Room 139, another walk-in refrigerator revealed two 30 lb. boxes of fresh celery and a 30 lb. box of pre-sliced potatoes that did not contain a received on or use by date.

An observation on May 20, 2015, at 2:10 PM of the walk-in freezer revealed nine 5 lb. boxes of hamburger did not contain a received on or use by date.

An interview conducted on May 20, 2015, at 2:30PM with EMP3 confirmed that the facility failed to follow their policy for labeling the food items.

Based on review of facility policies, medical record (MR), and interview with staff (EMP), it was determined the facility did not properly implement the discharge plan, by failing to list the changes from the patient's pre-admission medications, for four of five medical records (MR) reviewed (MR5, MR7, MR8, and MR9).

Findings include:

A review on May 21, 2015, of MR5, MR7, MR8, and MR9 revealed the list of medications the patient should be taking after discharge did not contain clear indications of changes from the patient's pre-admission medications.

An interview conducted on May 21, 2015, at 11:30 AM with EMP1 confirmed the list of medications did not contain clear indications of changes from the patient's pre-admission medications.