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Based on record review, policy review, and interview, the facility failed to have verbal orders signed within 48 hours for 3 of 20 patients ( #8, 9, 11) per facility policy.

Findings include:

Patient #8

Patient #8 was admitted on 1/21/16, with diagnosis of pneumonia. The nurse entered orders for Humulin (Regular) Insulin, 7 units, as a "written" and not as a "verbal order." This was a computer order entry error and was never seen or signed by the physician.

Patient # 9

Patient #9 was admitted on 1/22/16, with diagnosis of chest pain. The nurse entered orders for Synthroid 50 mcgs (micrograms) daily, Furosemide 40 mg (milligrams) daily and Lisinopril 20 mg daily as a "written" and not as a "verbal order." This was a computer order entry error and was never seen or signed by the physician.

Patient #11

Patient #11 was admitted on 2/11/16, with diagnosis of pneumonia. The nurse entered orders for normal saline continuous intravenous infusion as a "written" and not as a "verbal order." This was a computer order entry error and was never seen or signed by the physician.

On 3/29/16, at approximately 11:00 AM, the Director of Nurses was interviewed regarding verbal orders. She stated, "The nurses failed to enter the orders correctly as verbal orders."

Review of the facility policy, "Verbal Orders," revealed the following; " Procedure: The prescribing practitioner signs or initials the verbal order within the time frames consistent with Federal and State law or regulation (within forty-eight (48) hours). The content of verbal orders should be clearly communicated. The entire verbal orders should be repeated back to the prescriber. This will be documented by writing, "repeated back, read back, echo or similar wording" to the order."

Based on observation, policy review, and interview, the facility failed to meet infection control standards for transporting of soiled instruments, processing instruments, and ensuring that biological controls were documented.

Findings include:

On 3/29/16 at approximately 10:15 AM, observations were conducted in the sterile processing room. The following was observed:

1. The Metricide being used as an enzymatic cleanser had an expiration date of 4/2015. A second open bottle of Metricide had an expiration date of 11/2011.
2. Review of the biological controls for the sterilizer revealed no results were recorded for 8/29/15 and 11/1/15.
3. A patient food refrigerator was located in the clean area. Review of the temperature log revealed no temperatures were recorded from 3/25/16 - 3/27/16.
4. Review of the policy posted in the processing room revealed the following for cleaning and disinfecting of intubation equipment: "Wipe blade handle with PH7Q, Oxyvir wipe of bleach." The Director of Nurses was interviewed and reported the handles were wiped clean with the enzymatic cleaner, Metricide.

On 3/29/16, at approximately 10:00 AM, the Director of Nurses was interviewed regarding transport of soiled instruments from the Emergency Department to the processing area. The Director of Nurses reported the nurses transported the soiled instruments with gloved hands. The Director of Nurses confirmed the staff did not use a covered container for transport of the soiled instruments through the hall to the processing area.

Review of the facility policy, "Infection Prevention and Control Plan," with a revision date of 8/15, revealed the following under goals:

"Limiting the transmission of infections associated with procedures. Ensuring policies and procedures follow current infection control guidelines and recommendations.
Limiting the transmission of infections associated with the use of medical equipment, devices and supplies. Examples include cleaning, disinfection, and sterilization of equipment, sterile supplies, single-use devices."

Based on record review, policy review and interview, the facility failed to complete nutritional assessments for 9 of 20 patients. (Patient #1, #2, #4,#6,#7,#8, #10, #11).

Findings include:

Patient #1

Patient #1 was admitted to the facility on 1/7/16, with the diagnosis of pneumonia. Review of the patient's record revealed his admission weight was 114 pounds. There was a nursing nutritional screening completed. The dietician completed her assessment on 2/24/16, six weeks after the patient was discharged. Review of the dietician's assessment revealed the patient's ideal body weight was 148 pounds, and the patient's body mass index was 17.8, underweight.

Patient #2

Patient #2 was admitted to the facility on 1/29/16, with the diagnosis of diabetic ketoacidosis. The patient was discharged on 1/31/16. Review of the patient's record failed to reveal a nutritional assessment.

Patient #4

Patient #4 was admitted to the facility on 3/8/16, with the diagnosis of chest pain. The patient was discharged on 3/12/16. Review of the patient's record revealed the nursing nutritional screening was completed. There was no nutritional assessment completed by the dietician.

On 3/29/16, the Director of Nurses was interviewed and confirmed the nutritional assessments were not completed by the dietician as required by policy.

Patient #6

Patient #6 was admitted to the facility on 1/13/16, with diagnosis of chest pain. The patient was discharged on 1/18/16 to the Skilled Nursing Facility (SNF). Review of the patient's record revealed the nursing nutritional screening was completed. There was no nutritional assessment completed by the dietician until 2/24/16.

Patient #7

Patient #7 was admitted to the facility on 1/16/16, with diagnosis of dehydration. The patient was discharged on 1/22/16 to the Skilled Nursing Facility (SNF). Review of the patient's record revealed the nursing nutritional assessment was completed. There was no nutritional assessment completed by dietician until 2/24/16.

Patient #8

Patient #8 was admitted to the facility on 1/21/16, with diagnosis of pneumonia. The patient was discharged on 1/24/16 to home. Review of the patient's record revealed the nursing nutritional assessment was completed. There was no nutritional assessment completed by dietician until 2/24/16.

Patient #10

Patient #10 was admitted to the facility on 2/2/16, with diagnosis of shortness of breath, Tachycardia. The patient was discharged to home on 2/4/16. Review of the patient's record revealed there was no nursing nutritional screen completed.

On 3/29/16, the Director of Nurses was interviewed and confirmed the nursing nutritional assessments were supposed to be completed on all patients.

Patient #11 was admitted to the facility on 2/11/16, with diagnosis of pneumonia. The patient was discharged on 2/13/16 to SNF. Review of the patient's record revealed there the nursing nutritional assessment was completed. There was no nutritional assessment completed by the dietician until until 3/29/16.

Based on record review, policy review, and interview, the facility failed to ensure care plans were initiated for 10 of 20 patients admitted to the facility (Patient #1, 2, 4, 5, 10, 11, 13, 14, and 15).

Findings include:

Patient #1

Patient #1 was admitted to the facility through the Emergency Department (ED) on 1/7/16, with the diagnosis of pneumonia. There was no care plan initiated during his stay. The patient was discharged on 1/10/16.

Patient #2

Patient #2 was admitted to the facility through the ED on 1/29/16, with the diagnosis of diabetic ketoacidosis. There was no care plan initiated. The patient was discharged on 1/31/16.

Patient #4

Patient #4 was admitted to the facility on 3/8/16, with the diagnosis of chest pain. There was no care plan initiated during his stay. The patient was discharged on 3/12/16.

Patient #5

Patient #5 was admitted to the facility on 3/15/16, with the diagnoses of spontaneous pneumothorax and end stage chronic obstructive pulmonary disease. No care plan was initiated during Patient #5's admission. The patient expired on 3/17/16.

Patient #13

Patient #13 was admitted to the facility on 2/13/16, with the diagnosis of right knee effusion. No care plan was initiated during Patient #13's admission. The patient was discharged on 2/17/16.

Patient #14

Patient #14 was admitted to the facility on 2/15/16, with diagnoses of hyperkalemia and disorientation. No care plan was initiated during the admission. The patient was discharged on 2/19/16.

Patient #15

Patient #15 was admitted to the facility on 2/23/16 with the diagnosis of pneumonia. No care plan was initiated during the admission. The patient was discharged on 2/25/16.

Patient #10 was admitted to the facility through the Emergency Department (ED) on 2/3/16, with the diagnosis of shortness of breath and tachycardia. There was no care plan initiated during the admission. The patient was discharged on 2/4/16.

Patient #11 was admitted to the facility through the Emergency Department(ED) on 2/11/16, with diagnosis of pneumonia. There was no care plan initiated during the admission. The patient was discharged to SNF on 2/13/16.

On 3/29/16, the Director of Nurses was interviewed and confirmed there were no care plans in the medical records of the patients listed. The Director of Nurses confirmed the facility policy was to initiate a care plan within 24 hours of admission.

Review of the facility policy, "Patient Care Plans," with an effective date of 2003, current revised date 1/12, revealed the following: "Care plans, electronic or paper, are initiated for all inpatient admissions within 24 hours of admission to the acute floor. Patient needs will be addressed including physical, emotional, and nutritional. Patient care plans will be kept in the medical chart, electronic or paper, under the tab marked "care plans."

Based on record review and interview, the facility failed to follow the physician's order for daily weights for 2 of 20 patients. (Patient #1 and #2)

Findings include:

Patient #1

Patient #1 was admitted to the facility on 1/7/16, with the diagnosis of pneumonia. Review of the patient's record revealed the patient had an order for daily weights. Review of the record failed to reveal the daily weights had been completed. The patient was discharged on 1/10/16, and was weighed on admission only.

Patient #2

Patient #2 was admitted to the facility on 1/29/16, with the diagnosis of diabetic ketoacidosis. Review of the patient's record revealed an order for daily weights. Review of the record failed to reveal daily weights had been done. The patient was discharged on 1/31/16, and was weighed on admission only.

On 3/29/16, the Director of Nurses was interviewed and confirmed the daily weights had not been completed as ordered.