HospitalInspections.org

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Based on observations and interview the facility failed to ensure Emergency room supplies and medications located in one of two emergency supply carts, one of one pediatric supply carts, one of one supply rooms, one of one Broselow bags, and one of two anaphylaxis (a severe, potentially life-threatening allergic reaction) boxes did not exceed the manufacturer's safe use date. This deficient practice has the potential to cause compromised medications and unsafe supplies to be used during the care and treatment of emergent patients.

Findings include:

- Emergency Department Emergency Supply Cart observed on 5/22/2017 at 12:00 PM revealed one 500 milliliter bag of 0.9% Sodium Chloride (a medication used to increase fluids in the body) with an expiration date of 4/2017

- Pediatric Emergency Supply Cart observed on 5/22/2017 at 12:35 PM revealed the following:

1. One Endotracheal Tube guide (a device used to assist placement of an endotracheal tube (a tube placed in the windpipe to assist with breathing)) with an expiration date of 9/2016.
2. Two packets of EZ lubricating Jelly with expiration dates of 4/2016 and 7/2016.
3. One intravenous (IV) start kit (a kit containing a tourniquet, tape, and a clear adhesive bandage used to secure the IV catheter) with an expiration date of 10/2016
4. One 20-gage IV needle with an expiration date of 2/2017.
5. One 18- age IV needle with an expiration date of 10/2016.

- Broselow Bag located in the hallway between Emergency Room #1 and 2 observed on 5/22/2017 a 12:40 PM revealed the following expired pediatric supplies:

1. Seven packets of EZ lubricating Jelly with expiration dates of 2/2016.
2. Seven Endotracheal Tube guide (a device used to assist placement of an endotracheal tube (a tube placed in the windpipe to assist with breathing)) with an expiration date of 9/2016.
3. Five 18-gage IV needles with expiration dates of 10/2016, 9/2016, and 4/2016.
4. Four 20-gage IV needles with expiration dates of 9/2016, 8/2016, and 4/2016.
5. Three 22-gage IV needles with expiration dates of 10/2016 and 7/2016.
6. Seven intravenous (IV) start kit (a kit containing a tourniquet, tape, and a clear adhesive bandage used to secure the IV catheter) with an expiration date of 2/2017

- Supply rooms lower Cabinets observed on 5/22/2017 at 12:40 PM revealed the following:

1. Two 3000 milliliter bags of Sodium Chloride (a medication used to increase fluids in the body) with an expiration date of 2/2017.
2. Two Laryngeal masks size 4 with an expiration date of 10/2016
3. One 1000 milliliter bag of Aminosyn (a medication used to replace amino acids in the body)

- Anaphylaxis Box observed on 5/22/2017 at 2:00 PM revealed two intravenous (IV) start kit (a kit containing a tourniquet, tape, and a clear adhesive bandage used to secure the IV catheter) with an expiration date of 10/2016

Administrative Staff A interviewed on 5/22/2017 at 12:45 PM indicated they have a group of people that are responsible for monthly inventories and acknowledged they must have missed inventorying the Broselow Bag.

Pharmacy Nurse Staff M interviewed on 5/22/2017 at 4:15 PM indicated the 1000-milliliter bag of Aminosyn is on backorder and they were not aware they could not keep it until a replacement was available.

Policy titled "Purchasing Policy and Procedure" reviewed on 5/23/2017 at 10:00 AM directed " ...Manufacturers guarantee the sterility from their pre-packaged sterile products as long as the package is undamaged and the date of expiration has not lapsed ...and ...Staff will check the expiration dates on all supplies as per the chart below on a monthly basis ..."

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Based on observations, staff interview, and policy review, the CAH failed to ensure all supplies are maintained to safely meet patients' needs for the day-to-day operations for one of one Nursery and one of one Physical Therapy rooms. The deficient practice of the failure of the facility to dispose of expired supplies places all patients at risk for receiving ineffective supplies resulting in inappropriate care and testing results.

Findings include:

Physical Therapy (PT) Department treatment room observed on 5/22//2017 at 3:00 PM revealed the following outdated supplies:

1) One of four packages of TENS unit pads outdated 7/2016.
Interview with Physical Therapy Assistant Staff N on 5/22/2017 at 3:05 PM acknowledged the supplies were expired and should have been disposed. S/he stated the supplies were all purchased by the hospital and the department uses "a lot of them" during a week so "I am totally surprised they would be outdated especially by that much."

Nursery observed on 5/22/2017 at 1:00 PM revealed the following outdated supplies:

1) Two Stem Cell (biological cells that can divide and produce more stem cells) Collection kits for both cord blood and cord tissue outdated 10/2016 and 4/2013.

Interview with Staff RN J on 5/22/2017 at 1:20 PM acknowledged the outdated supplies.

Policy "Purchasing Policy & Procedure" directs " ...Shelf Life: Manufactures guarantee the sterility for their pre-packaged sterile products as long as the package is undamaged and the date of expiration has not lapsed. Staff will check the expiration dates on all supplies as per the chart below on a monthly basis ... ...Nursery responsible party is nursing." Physical Therapy is not noted for supply checks.


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Based on observation and policy review, the Critical Access Hospital (CAH) failed to follow facility policies when administering biologicals in one of one observations (RN Staff O). Failure to administer medications and biologicals as set forth in policy places all patients at risk of potential life threatening reactions.

Findings include:

RN Staff O observed on 5/23/2017 at 9:05 AM admitting out-patient #31 for the administration of 2 units packed red blood cells (PRBCs). RN Staff O performed the admission process and started an intravenous site (IV) on patient #31. RN Staff O obtained the first unit of PRBC from the blood bank, carried it to the medication room, attached the tubing to the blood unit, took the blood to the patient's room and confirmed the patient's identity using the patient name band and the blood component label. Staff RN O connected the blood tubing to the patients IV site and started the infusion. Following the first 15 minutes of the blood infusion, Staff RN O called Staff RN J to patient #31's room and asked Staff RN J to confirm the patient's identity and correct unit of blood. Staff RN J confirmed both and charted the confirmation.

RN Staff O and RN Staff J interviewed on 5/23/2017 at 10:00 AM, both nursing staff confirmed per policy, blood is to be checked before it is started infusing and that step was initially missed. Staff RN O stated she/he had given multiple transfusions and the normal policy is to perform the patient identification and appropriate blood component with another nursing staff member prior to starting the transfusion not after it has been started.

Policy "Nursing Guidelines for Blood Administration" directs " ...At the bedside correctly identify the patient and the product. Validate the patient's name and hospital number on the compatibility form with the patient's identification on the wrist band ... ...Ask the patient to identify them self ... ...Sign the compatibility record. This must be done by two professionals. Professionals who sign are validating the correct blood product is being administered to the correct patient ..."

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Based on observation, staff interview, and document review the facility failed to ensure a backflow prevention system is in place at the point of water connection for one of one prep sinks located in the kitchen. This deficient practice has the potential to allow dirty water to reenter the sink contaminating items being prepared in the skin.

Findings include:

- Kitchen observed on 5/23/2017 at 8:50 AM revealed a prep sink without evidence of a backflow preventer or an air gap.

Maintenance Staff C interviewed on 5/23/207 at 9:50 AM acknowledged the kitchens prep skink does not have an air gap or a backflow preventer.

Policy review on 5/23/2017 at 10:00 AM revealed the facility failed to develop a policy requiring a backflow prevention system on the kitchens prep sink.

The FDA Food Code 2009 read in part: 5-202.13 Backflow Prevention, Air Gap.
An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

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Based on observation, staff interview and document review the facility failed to ensure airflow equipment was tested and ready for use for one of one isolation rooms (Room #11). This deficient practice has the potential to expose hospital patients to airborne illnesses, which could lead to a worsening of condition or death.


Findings include:


- Room #11 observed on 5/22/2017 at 11:30 AM revealed an empty room with an ancillary room connected. No evidence of isolation airflow equipment was observed.

Administrative Staff A interviewed on 5/22/2017 at 11:30 AM confirmed Room #11 is the isolation room.

Maintenance Staff C interviewed on 5/23/2017 at 4:10 PM indicated the airflow equipment is stored and they have not used it in more than a year. Staff C confirmed they have not tested the equipment since its previous use and have not provided any training to ensure other staff members knew how to install it.

Licensed Practical Nurse Staff H interviewed on 5/23/2017 at 3:35 PM indicated they did not remember the last time the airflow equipment was used for the isolation room and acknowledged they do not know how to install or operate it and is unaware if they have had any training on the equipment's use.

Policy titled "Infection Prevention Guidelines for TB Patients" reviewed on 5/23/2017 at 8:00 PM directed " ...Patients presenting with signs/symptoms of TB will be separated from other patients and triaged in ER 1 until such time as the isolation room can be equipped with the appropriate airflow equipment ... and ... The patient will be moved to room 11 once the appropriate airflow equipment is installed and operational ..."

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Based on observation, staff interview, and policy review the facility failed to ensure the medication refrigerator located between Emergency Rooms 1 and 2 was locked. This deficient practice has the potential to allow unauthorized access to harmful or fatal medication. The facility failed to ensure all outdated medications were unavailable for use in one of one medication rooms. These deficient practices have the potential of unauthorized access to medications and to expose patients to unsafe, ineffective medications resulting in inadequate results.

Findings include:

Medication refrigerator observed on 5/22/2017 at 11:40 AM revealed it to be unlocked with the following medications available for unauthorized access:

1. Seven 2 milligram vials of Lorazepam (a medication used to treat seizures and anxiety)
2. One 100 unit vial of Humalin Insulin
3. Two 5 milliliter vials of Diltiazem (a medication used to treat high blood pressure)
4. One 10 milliliter vial of Succinylcholine (a medication used to relax muscles during surgery or other medical procedures)
5. Four 2 milliliter vials Bicillin (an antibiotic)
6. Two 10 milliliter vials of Cerebyx (used to treat seizures)
7. Three packages of 0.5 milliliters of Racepinephrine (used to treat breathing difficulties associated with asthma)
8. One 2 milliliter vial of Famotidine (a medication used to treat conditions that cause excess stomach acid)

Assistant Director of Nursing Staff G interviewed on 5/22/2017 at 2:05 PM verified the medication refrigerator should always be locked.

Policy titled "Storage of Medications at Nursing Stations or Patient Care Areas" reviewed on 5/23/2017 at 10:00 AM directed " ...Drugs shall be kept in locked storage when unattended and shall be inaccessible to unauthorized individuals ..."

Nursing Unit Medication room observed on 5/22/2017 at 4:00 PM revealed the following undated and outdated medications:

1. 1, 100units/milliliter vial of Humalin Insulin, open, undated
2. 1, 100units/milliliter vial of Humalin N Insulin, open, undated
3. 1, 1000 milliliter bag of Amniosyn 3.5% (electrolyte replacement), outdated 9/2016, marked not to be disposed of due to drug on backorder
4. 1, 25gm/50milliliter injection of Dextrose 50% (glucose) outdated 4/2017

RN Staff J interviewed on 5/22/2017 at 4:10 PM acknowledged the outdated and undated items and removed them from inventory.

Policy titled "Medication and Solution Storage" directs " ...All ,multi-dose vials for injection (i.e., lidocaine 1%), must be dated when opened and discarded after 30 days ... ...Refrigerated insulins must be dated when opened and discarded after 28 days ... ...Place open and discard dates on solution bottles."

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Based on observation, staff interview, and document review the facility failed to ensure staff preformed hand hygiene during five of six observed patient care activities Staff M, Staff T, unidentified physical therapy assistant (PTA), Staff O, and Staff J). The facility failed to monitor and maintain appropriate temperature and humidity ranges in the operating room (OR) and sterile supply storage area, and the sterile reprocessing room. The facility failed to ensure sterile supplies were stored in a low traffic area with restricted access. The facility failed to ensure the Sterile Reprocessing room had restricted access and ensure proper attire is worn when traveling into the clean area. The facility failed to ensure sterile supplies were not stored where they were exposed to possible water damage in one of two obstetrical rooms. The facility failed to ensure staff and visitors donned proper attire before entering a restricted OR area for one of one observation. The facility failed to ensure staff were informed of the cleaning products dwell (time a cleaning product needs to be wet to ensure disinfection occurs) during one of two staff interviews. The facility failed to ensure blood products were properly prepared during one of one blood administration observation. The facility failed to document water changes for the hydrocollator. These deficient practices have the potential to expose patients to harmful bacterial and infectious diseases.

Findings include:

- Pharmacy Staff RN M observed on 5/22/2017 at 2:00 PM at the nursing unit revealed them performing paper work at the nursing station and then entering patient room #12 without performing hand hygiene. S/he left the patient room at approximately 1:25 PM without performing hand hygiene and returned to the nursing station.
- Radiology staff T observed on 5/22/2017 at 2:25 PM revealed them at the nursing unit entering patient room #12 with a wheel chair without performing hand hygiene.
- Unidentified PTA Staff observed on 5/22/2017 at 2:30 PM at the nursing unit revealed them leaving patient room #15 with lift belts over her/his shoulder. Unknown PTA staff did not perform hand hygiene when leaving the patient room.
- RN Staff O observed on 5/23/2017 at 9:05 AM revealed them in patient room #11 admitting Patient #31 for blood transfusion. RN Staff O donned gloves without performing hand hygiene, filled out paper work at the bedside, prepared the patient for an intravenous needle insertion (IV), and inserted the IV. Staff RN O removed the needle, moved patient care equipment to the opposite of the bed, and restarted the IV in the opposite arm. S/he disposed of the contaminated items, removed the gloves, took paperwork to the nursing station, entered the medication room and washed her/his hands.
- RN Staff O observed on 5/23/2017 at 9:40 AM in patient room #11 revealed them connecting blood to Patient #31 with gloves on. RN Staff O reached into her/his pocket, removed a set of keys and handed them to RN Staff J. RN Staff J put the keys into her/his pocket, performed hand hygiene, and left the room. RN Staff O continued charting on the computer, took Patient #31 vital signs, performed lung assessment, and adjusted the blood flow rate. RN Staff O then removed her/his gloves and performed hand hygiene.

RN Staff O interviewed on 5/23/2017 at 9:45 AM acknowledged that she did not appropriately perform hand hygiene. "I was just a little nervous having you there watching."

RN Staff O and RN Staff J interviewed on 5/23/2017 confirmed that they handed contaminated items back and forth because hand hygiene was not performed at all times.

Policy "Hand Hygiene" directs " ...When to wash hands in patient care settings: Before direct contact with any patient, before a clean/aseptic procedure, after body fluid exposure, after patient contact, after contact with patient surroundings ..."

ER Night Shift Checklist reviewed on 5/23/2017 revealed the OR temperature parameters are 60-66 degrees Fahrenheit and the humidity between 50-60%. The log revealed the following information:

1. 12/5/2016- 12/16/2016 staff documented humidity below 50%
2. 12/12/2016 staff documented temperature at 50 degrees Fahrenheit
3. 12/13/2016 staff documented temperature at 48.5 degrees Fahrenheit
4. 12/17/2016 staff failed to document temperature or humidity
5. 12/18/2016 - 12/19/2017 staff documented humidity below 50%
6. 12/20/2016 - 12-12/23/2017 staff failed to document temperature or humidity
7. 12/24/2016 - 1/8/2017 staff documented humidity below 50%
8. 12/24/2016 staff documented temperature at 59.4 degrees Fahrenheit
9. 1/9/2017 staff failed to document temperature or humidity
10. 1/10/2017 - 1/22/2017 staff documented humidity below 50%
11. 1/23/2017 staff failed to document temperature or humidity
12. 1/24/2017 - 1/25/2017 staff documented humidity below 50%
13. 1/26/2017 staff failed to document temperature or humidity
14. 1/27/2017 - 2/23/2017 staff documented humidity below 50%
15. 2/24/2017 - 2/25/2017 staff failed to document temperature or humidity
16. 2/26/2017 - 3/26/2017 staff documented humidity below 50%
17. 3/27/2017 staff failed to document temperature or humidity
18. 3/28/2017 - 3/7/2017 staff documented humidity below 50%
19. 4/17/2017 staff documented humidity below 50%
20. 4/20/2017 staff documented humidity below 50%
21. 4/23/2017 - 5/5/2017 staff documented humidity below 50%
22. 5/12/2017 staff documented humidity below 50%
23. 5/20/2017- 5/23/2017 staff documented humidity below 50%

Administrator Staff A interviewed on 5/23/2017 at 4:50 PM acknowledged the missing documentation and confirmed the temperature and humidity ranges documented did not fall between the parameters indicated on the log. Staff A indicated they were very concerned there was no documentation that anyone was notified of the discrepancies.

Assistant Director of Nursing Staff G interviewed on 5/24/2017 at 9:45 AM indicated the night shift nurses take these recordings and they are not sure if they are reported to anyone. Staff G indicated they follow The Association of Perioperative Nurses (AORN) guidelines.

Policy titled Temperature and Humidity Policy" reviewed on 5/24/2107 at 4:00 PM directed " ... Temperature in the Surgical Suite is kept at 60 to 73 degrees Fahrenheit and humidity is to be kept at 30% to 60% to decrease free floating particle matter to keep possible contamination at a minimum ..."

The Association of Perioperative Registered Nurses (AORN) website on May 25, 2016 stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 75 [degrees] F . . . The recommended humidity range in an operating room is between 20% [percent] to 60% based on addendum d to ANSI (American National Standards Institute)/ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers)/ASHE (American Society for Healthcare Engineering) Standard 170-2008. Each

- Sterile supply room observed on 5/23/2017 at 9:00 AM revealed an unsecured room containing nonsterile and sterile supplies stored in cabinets together. The room lacked evidence the temperature and humidity are documented and maintained.

Assistant Director of Nursing Staff G interviewed on 5/24/2017 at 9:45 AM confirmed temperatures and humidity are not monitored in the supply room and the central reprocessing room.

Policy titled "Central Supply" reviewed on 5/24/2017 at 4:00 PM directed " ...Appropriate storage conditions * Limited access to storage area and/or closed cabinets * Clean supplies should be stored separately from sterile supplies * Area must be clean, dry, dust and lint free * Temperature of area should be 65-72 degrees F (18-22 degrees C) * Relative humidity between 35 and 50% ..."

A review of AORN Perioperative Standards and Recommended Practices, 2013 edition - Sterilization: Recommendation XV revealed in part: Sterilized items should have limited exposure to moisture and humidity to decrease the potential contamination of the sterilized items. Factors that contribute to contamination include air movement, humidity, temperature, location of storage, presence of vermin, whether shelving is open or closed, and properties of the packaging material. Sterile packages should be stored under environmental controlled conditions. Sterile items should not be stored under sinks or in other locations where they can become wet. Open shelving may be used if they are located in a secure, environmental controlled clean area.

- Sterile reprocessing room observed on 5/24/2017 at 9:15 AM revealed the room contained a fluid warmer on the designated clean area. Assistant Director of Nursing (ADON) Staff G wearing home laundered scrub bottoms and a t-shirt crossed the red and white tapeline into the clean area without donning proper attire.

ADON Staff G interviewed on 5/24/2017 at 9:15 AM indicated the room is accessible to all staff members with knowledge of the keypad code. Staff G confirmed staff not wearing proper attire enter the room and cross into the clean area to retrieve warmed IV fluids.
Policy review on 5/24/2017 revealed the facility failed to develop a policy restricting traffic in the sterile reprocessing room and requiring proper personal protective equipment.

- Observation in the labor and delivery room (LDR) on 5/22/2017 at 12:30 PM revealed a wooden cabinet with sterile delivery instruments and supplies stored. The cabinet back revealed a hole approximately 36" wide and 42" long. The wall behind the hole revealed an opening that did not go through the wall. Piping with a shut off valve was exposed. Behind the wall was a bathroom.

RN Staff J interviewed on 5/22/2017 at 12:30 PM acknowledged the presence of the hole.
Maintenance Staff C interviewed on 5/22/2017 acknowledged the hole and was unaware it was present. S/he confirmed it would be repaired immediately.

- ADON Staff G observed on 5/24/2107 at 10:00 AM revealed them entering the OR wearing home laundered scrub bottoms, a t-shirt, bouffant, and shoe covers. Staff G provided a bouffant and shoe covers for two surveyors and allowed entry into the sterile OR suite.

ADON Staff G interviewed on 5/24/2017 at 10:15 AM indicated they store surgical scrubs for staff and wear them for surgical days.

Policy titled "Attire in the Operating room" reviewed on 5/24/2107 at 4:00 PM directed " ...All reusable attire should be laundered in a health care accredited laundry facility approved and monitored by the hospital..."

- ADON Staff G interviewed on 5/24/2017 at 5/24/2017 at 10:05 AM indicted they perform terminal cleaning in the OR. Staff G revealed they do not know what the required dwell time for their chemical cleaner in the OR is.

ECOLAB 20 Neutral Disinfectant Cleaner label reviewed on 5/24/2017 at 4:30 PM directed " ...Let solution remain on surface for a minimum of 10 minutes. Rinse or allow to air dry.

- OR room observed on 5/24/2017 at 10:00 AM revealed an open container with used laparoscopic (a modern surgical technique in which operations are performed far from their location through small incisions) surgical equipment in a container.

ADON Staff G interviewed on 5/24/2017 at 10:15 AM confirmed the laparoscopic equipment located in the open container was used on a previous surgical procedure and was waiting for the company to pick them up for reprocessing. Staff G confirmed the room had been terminally cleaned without removing these items and other procedures could take place with these items remaining in the room.

Policy review on 5/24/2017 revealed the facility failed to provide a policy directing staff to ensure removal of all used surgical equipment requiring reprocessing after the surgical procedure is completed.

- RN Staff O observed on 5/23/2017 at 9:15 AM revealed wearing gloves and carrying 1 unit of blood from the laboratory to the nurse medication room at the nursing station. RN Staff O hung the blood from a hook on the wall and inserted blood administration tubing into the bag, priming (removing the air) from the tubing. RN Staff O took the blood from the nursing station to Patient #31 room and connected it to Patient #31.

RN Staff O stated, "We have always connected and primed the tubing in the medication room. I'm not sure why we do it that way."

Review of the "Infection Control Plan" directs " ...Adequate and realistic environmental control is a necessary part of an overall program for the control of infections. There must be adequate facilities, personnel, and procedures for disinfection and sterilization ... ...Some areas that require specific policies and methods include: ...Adequate aseptic techniques, examples, hand hygiene before and after patient contact ... ...Regular in-services training programs to acquaint and update employees of the why and how of infection control, Provisions for an appropriate clean environment, Established , written policies for closed urinary catheter care, intravenous catheter care, antiseptic solutions and use, etc. ..."

- PTA Staff N observed in Physical Therapy (PT) room on 5/22/2017 at 3:00 PM revealed them applying treatment pads from the hydrocollator (thermostatically controlled water bath for placing cloth heating pads) on unknown patient.

PTA Staff N interviewed on 5/22/2017 at 3:00 PM acknowledged the pads were from the hydrocollator and maintenance was responsible for monitoring the hydro collator temperatures and that PTA Staff N was not sure when the water was changed for the hydrocollator.

PTA staff failed to provide documentation of water changes and no policy directing water changes was available.

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Based on record review, interview, and policy review, the critical access hospital (CAH) failed to document a history and physical, medication review, failure to document a dismissal summary, and failure to complete a nursing care plan in 2 of 2 out-patient medical records reviewed (Patient #11 and Patient #12). Failure to provide all of the appropriate documentation put hospital staff at risk of insufficient knowledge resulting in unsafe care and places all out-patients at risk of receiving unsafe, inappropriate care.

Findings include:

- Review of out-patient #11's closed medical record on 5/22/2017 at 2:30 pm revealed the patient, 91 years old, diagnosed with peripheral artery disease (PAD) (narrowing of the arteries, mostly in the legs) receives intravenous (IV) antibiotics and wound dressing changes daily from 11/5/2016 through 11/30/2016. The medical record lacked evidence of a history and physical, medication review, nursing care plan, and dismissal summary.

- Review of out-patient #12's closed medical record on 5/22/2017 at 3:00 PM revealed the patient, 1 year old, diagnosed with respiratory syncytial virus (RSV) (respiratory virus causing elevated temperature, cough, and difficulty breathing). Patient #12 was admitted to CAH as an out-patient for a chest x-ray and albuterol breathing treatment o 12/29/2016. The medical record lacked evidence of a history and physical, medication review, nursing care plan, and dismissal summary.

Interview with ADON RN Staff G on 5/23/2017 at 10:30 am confirmed the out-patient medical records do not have history and physicals, care plans, dismissal summaries or medication records.

The CAH was unable to provide a charting policy for out-patients.

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Based on interview and record review Osborne County Memorial Hospital (CAH) failed to ensure care plans were completed in 5 of 30 records reviewed (patients # 3, 5, 7, 28 and 29). A nursing care plan must be developed and kept current for each patient at the CAH from admission to discharge or transfer. Failure of the CAH to ensure a nursing care plan is completed for every patient at the CAH puts all patients at risk for receiving care, medications and treatments unrelated to their diagnosis, unmet treatment and discharge goals and inappropriate physiological and physiological care.

Findings Include:

- Record review on 5/23/17 and 5/24/17 revealed the CAH nursing staff failed to develop a nursing care plan for patients # 3, 5, 7, 28 and 29 throughout their stay at the CAH.

Director of Nursing (DON) Staff B and Registered Nurse (RN) Staff K interviewed on 5/24/17 at 10:19 AM verified the records for patients # 3, 5, 7, 28 and 29 failed to provide documentation of a nursing care plan.

Policy and Procedure review on 5/24/17 revealed policy "Care Planning" states ...It is the policy of Osborne County Memorial Hospital to provide an individualized, interdisciplinary Plan of Care for all patients ...within eight hours of admission all patients shall have a Plan of Care generated by the RN ...any direct admission or post-operative admission that is expected to be an "observation" patient will have assessments and revision of Plan of Care within one hour of arrival on the Medical Surgical Unit ...the transfer of patients between levels of nursing care shall require a revision of the Plan of Care as appropriate to that level of care.

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Based on interview, record and document review Osborne County Memorial Hospital failed to ensure a completed History and Physical (H&P) documented in the record for 1 of 30 records reviewed (patient # 30). The facility failed to ensure a physician signature on the H&P within appropriate time frames after admission for 3 of 30 records reviewed (patients # 23, 26 and 27). The facility failed to ensure a physician signature on the discharge summary within appropriate time frames after discharge for 3 of 30 records reviewed (patients # 23, 25 and 28). Failure to ensure an H&P is part of the patient's record and physicians authenticating H&Ps and Discharge Summaries within appropriate time frames puts all patients at risk for receiving care that is unsafe and inaccurate resulting in harm and poor outcomes.

Findings include:

- Record review on 5/24/17 revealed the inpatient record for patient #30 failed to have evidence of an H&P completed by Staff W.

- Record review on 5/23/17 revealed inpatient record for patient # 23 admitted 10/30/16 failed to be authenticated by Staff W within 48 hours after admission. The physician authenticated the H&P on 12/14/16, 45 days after admission.

- Record review on 5/23/17 revealed inpatient record for patient # 26 admitted 2/4/17 failed to be authenticate by Staff W within 48 hours after admission. The physician authenticated the H&P on 2/11/17, 7 days after admission.

- Record review on 5/24/17 revealed inpatient record for patient # 27 admitted 2/21/17 failed to be authenticated by Staff W within 48 hours after admission. The physician authenticated the H&P on 2/24/17, 3 days after admission.

- Record review on 5/23/17 revealed inpatient record for patient # 23 discharged 11/2/16 failed to be authenticated by Staff W within 30 days after discharge. The physician authenticated the Discharge Summary on 11/29/16, 14 days after discharge per the facility policy (stated at end of tag), and 27 days after discharge per Federal requirements.

- Record review on 5/23/17 revealed inpatient/death record for patient # 24 discharged/date of death on 10/26/16 failed to be authenticated by Staff W within 30 days after discharge. The physician authenticated the Discharge Summary 2/24/17, 111 days after discharge.

- Record review on 5/24/17 revealed inpatient record for patient # 28 discharged on 4/5/17 failed to be authenticated by Staff W within 14 days after discharge per the facility policy and 15 days after discharge per Federal requirements.

Medical Record Manager Staff R interviewed on 5/24/17 at 2:51 PM, verified medical record for patient #30 failed to show evidence of an H&P, medical records for patient's #23, 26 and 27 failed to be authenticated by the physician within 48 hours of admission, and medical records for patient's #23, 25, and 28 failed to be authenticated by the physician with the facilities policy and procedure of 14 days following a patients discharge. It was verified Staff W failed to authenticate all 6 charts found to be lacking timely authentification for H&Ps and Discharge summaries, and for the missing H&P.

- Document review on 5/24/17 revealed document "Osborne County Memorial Hospital Medical Staff Constitution, Bylaws, Rules and Regulations" states ...a complete history and physical examination will be performed and recorded within 24 hours after admission.

- Document review on 5/24/17 revealed document "Osborne County Memorial Hospital Medical Staff Constitution, Bylaws, Rules and Regulations" states ...the attending practitioner must complete and sign the record within 14 days following the patient's discharge. Health Information Management staff will be responsible for tracking requirements for chart completion and reporting status to the appropriate Medical Staff Member. Administration shall notify the Chief of Staff of Staff of consistent non-compliance of this requirement. Reprimand by Medical Staff may include suspension or admitting privileges. Three suspensions of admitting privileges within a 12 month period shall be sufficient cause for permanent suspension from the hospital.

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Based on interview, record and document review Osborne County Memorial Hospital (CAH) failed to ensure the History and Physical (H&P) for 1 of 30 records reviewed (patient # 28) was authenticated by the physician. A physician must sign and assume full responsibility for the H&P. Failure of the physician to authenticate the H&P puts all patients at risk for receiving care based on inaccurate medical information and causing unsafe and harmful outcomes.

Findings Include:

- Record review on 5/24/17 revealed patient # 28's record lacked a physician signature authenticating the H&P. Patient # 28 was admitted on 4/3/17, the physician failed to authenticate the H&P within the last 51 days.

Medical Records Director Staff R interviewed on 5/24/17 at 9:10 AM, stated after dictation from whoever performs the H&P it goes to transcription offsite and then back for signature. It may have a lag time.

- Document review on 5/24/17 revealed document "Osborne County Memorial Hospital Medical Staff Constitution, Bylaws, Rules and Regulations" stated ...in part: ...a complete history and physical examination will be performed and recorded within 24 hours after admission.

- Document review on 5/24/17 revealed document "Osborne County Memorial Hospital Medical Staff Constitution, Bylaws, Rules and Regulations" states ...The attending practitioner must complete and sign the record within 14 days following the patient's discharge.

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Based on observation, staff interview, and document review the facility failed to monitor and maintain appropriate temperature and humidity ranges in the operating room (OR) and sterile supply area, and the central reprocessing room. The facility failed to ensure sterile supplies were stored in a low traffic area with restricted access. The facility failed to ensure the Sterile Reprocessing room had restricted access and failed to ensure staff members wear proper attire when traveling into the clean area. The facility failed to ensure staff and visitors donned proper attire before entering a restricted area for one of one observation. The facility failed to ensure staff were informed of the cleaning products dwell (time a cleaning product needs to be wet to ensure disinfection occurs) during one of two staff interviews. The facility failed to ensure all materials used in prior surgeries were removed at the conclusion of the procedure. The facility failed to provide evidence the Steam Sterilizer was maintained daily and weekly according to manufacturer's directions. The cumulative effect of this systemic failure has the potential to cause exposure to bacteria or other infectious materials for all patients receiving surgical services.

Findings include:

ER Night Shift Checklist reviewed on 5/23/2017 revealed the OR temperature parameters are 60-66 degrees Fahrenheit and the humidity between 50-60%. The log revealed the following information:

1. 12/5/2016- 12/16/2016 staff documented humidity below 30%
2. 12/12/2016 staff documented temperature at 50 degrees Fahrenheit
3. 12/13/2016 staff documented temperature at 48.5 degrees Fahrenheit
4. 12/17/2016 staff failed to document temperature or humidity
5. 12/18/2016 - 12/19/2017 staff documented humidity below 30%
6. 12/20/2016 - 12-12/23/2017 staff failed to document temperature or humidity
7. 12/26/2016 - 1/8/2017 staff documented humidity below 30%
8. 12/24/2016 staff documented temperature at 59.4 degrees Fahrenheit
9. 1/9/2017 staff failed to document temperature or humidity
10. 1/10/2017 - 1/22/2017 staff documented humidity below 30%
11. 1/23/2017 staff failed to document temperature or humidity
12. 1/24/2017 - 1/25/2017 staff documented humidity below 30%
13. 1/26/2017 staff failed to document temperature or humidity
14. 1/27/2017 - 2/19/2017 staff documented humidity below 30%
15. 2/22/2017 - 2/23/2017 staff documented humidity below 30%
16. 2/24/2017 - 2/25/2017 staff failed to document temperature or humidity
17. 2/26/2017 - 3/23/2017 staff documented humidity below 30%
18. 3/27/2017 staff failed to document temperature or humidity
19. 3/28/2017 - 4/7/2017 staff documented humidity below 30%
20. 4/23/2017 - 4/24/2017 staff documented humidity below 30%
21. 4/26/2017 staff documented humidity below 30%
22. 5/4/2017 - 5/6/2017 staff documented humidity below 30%
23. 5/21/2017 staff documented humidity below 30%

Administrator Staff A interviewed on 5/23/2017 at 4:50 PM acknowledged the missing documentation and confirmed the temperature and humidity ranges documented did not fall between the parameters indicated on the log. Staff A indicated they were very concerned there was no documentation that anyone was notified of the discrepancies.

Assistant Director of Nursing (ADON) Staff G interviewed on 5/24/2017 at 9:45 AM indicated the night shift nurses take these recordings and they are not sure if they are reported to anyone. Staff G indicated they follow The Association of Perioperative Nurses (AORN) guidelines and have recently acquired the AORN book.

Policy titled Temperature and Humidity Policy" reviewed on 5/24/2107 at 4:00 PM directed " ... Temperature in the Surgical Suite is kept at 60 to 73 degrees Fahrenheit and humidity is to be kept at 30% to 60% to decrease free floating particle matter to keep possible contamination at a minimum ..."

The Association of Perioperative Registered Nurses (AORN) website on May 25, 2016 stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 75 [degrees] F . . . The recommended humidity range in an operating room is between 20% [percent] to 60% based on addendum d to ANSI (American National Standards Institute)/ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers)/ASHE (American Society for Healthcare Engineering) Standard 170-2008.

- Sterile supply room observed on 5/23/2017 at 9:00 AM revealed an unsecured room containing nonsterile and sterile supplies stored in cabinets together. The room lacked evidence the temperature and humidity are documented and maintained.

ADON Staff G interviewed on 5/24/2017 at 9:45 AM confirmed temperatures and humidity are not monitored in the supply room and the Sterile Reprocessing room.

Policy titled "Central Supply" reviewed on 5/24/2017 at 4:00 PM directed " ...Appropriate storage conditions * Limited access to storage area and/or closed cabinets * Clean supplies should be stored separately from sterile supplies * Area must be clean, dry, dust and lint free * Temperature of area should be 65-72 degrees F (18-22 degrees C) * Relative humidity between 35 and 50% ..."

A review of AORN Perioperative Standards and Recommended Practices, 2013 edition - Sterilization: Recommendation XV revealed in part: Sterilized items should have limited exposure to moisture and humidity to decrease the potential contamination of the sterilized items. Factors that contribute to contamination include air movement, humidity, temperature, location of storage, presence of vermin, whether shelving is open or closed, and properties of the packaging material. Sterile packages should be stored under environmental controlled conditions. Sterile items should not be stored under sinks or in other locations where they can become wet. Open shelving may be used if they are located in a secure, environmental controlled clean area.

- Sterile reprocessing room observed on 5/24/2017 at 9:15 AM revealed the room contained a fluid warmer on the designated clean area. Assistant Director of Nursing (ADON) Staff G wearing home laundered scrub bottoms and a t-shirt crossed the red and white tape line into the clean area without donning proper attire.

ADON Staff G interviewed on 5/24/2017 at 9:15 AM indicated the room is accessible to all staff members with knowledge of the keypad code. Staff G confirmed staff not wearing proper attire enter the room and cross into the clean area to retrieve warmed IV fluids.

Policy review on 5/24/2017 revealed the facility failed to develop a policy restricting traffic in the sterile reprocessing room and requiring proper personal protective equipment.

- ADON Staff G observed on 5/24/2107 at 10:00 AM revealed them entering the OR wearing home laundered scrub bottoms, a t-shirt, bouffant, and shoe covers. Staff G provided a bouffant and shoe covers for two surveyors and allowed entry into the sterile OR suite.

ADON Staff G interviewed on 5/24/2017 at 10:15 AM indicated they require the surgical staff to wear the surgical scrubs they have available for surgical days.

Policy titled "Attire in the Operating room" reviewed on 5/24/2107 at 4:00 PM directed " ...All reusable attire should be laundered in a health care accredited laundry facility approved and monitored by the hospital..."

- ADON Staff G interviewed on 5/24/2017 at 5/24/2017 at 10:05 AM indicted they perform terminal cleaning in the OR. Staff G revealed they do not know what the required dwell time for their chemical cleaner in the OR.

ECOLAB 20 Neutral Disinfectant Cleaner label reviewed on 5/24/2017 at 4:30 PM directed " ...Let solution remain on surface for a minimum of 10 minutes. Rinse or allow to air dry.

- OR room observed on 5/24/2017 at 10:00 AM revealed an open container with used laparoscopic (a modern surgical technique in which operations are performed far from their location through small incisions) surgical equipment stored inside.

ADON Staff G interviewed on 5/24/2017 at 10:15 AM confirmed the laparoscopic equipment located in the open container was used on a previous surgical procedure and was waiting for the company to pick them up for reprocessing. Staff G confirmed the room had been terminally cleaned without removing these items and other procedures could take place with these items remaining in the room.

Policy review on 5/24/2017 revealed the facility failed to provide a policy directing staff to ensure removal of all used surgical equipment requiring reprocessing after the surgical procedure is completed.

- ADON Staff G interviewed on 5/24/2017 at 10:30 AM indicated they do not have a log or documentation to provide evidence the manufactures routine maintenance schedule was followed for the Getinge Steam Sterilizer.

Getinge Steam Sterilizer manufacturer's handbook reviewed on 5/24/2017 at 1:00 PM directed " ...The customer is responsible for routine maintenance items at the intervals specified. Routine Maintenance Schedule Daily: Reviewing the Cycle Printouts, Cleaning the sediment Screens. Weekly: Cleaning the exterior surfaces, cleaning the chamber interior, cleaning the Accessories, Cleaning the Door Gaskets, Cleaning and Testing the UPS (optional Equipment) ..."


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Based on interview and document review Obsorne County Memorial Hospital (CAH) failed to ensure compliance requirements related to Periodic Evaluation and Quality Assurance Review. The facility failed to: complete a periodic evaluation of its total program on an annual basis; provide utilization of services including the least number of patients served and volume of services; evaluate a sample of both active and closed clinical records; to review health care policies to ensure appropriate services; ensure policies are followed with changes made as needed and assess the appropriateness of the diagnosis and treatment furnished by physicians are evaluated (see further evidence at C-0331, C-0332, C-0333, C-0334, C-0335 and C-0340).

The cumulative effect of the hospital's failure to ensure annual review of the total program, utilization of patients served, clinical record review, policies are followed and changed as needed, appropriate services are provided, and evaluations of physician services puts all patients at risk for poor quality and unsafe care.

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Based on interview and record review Osborne County Memorial Hospital (CAH) failed to ensure an annual evaluation of its total program including the Quality Assurance and Performance Improvement Program (QAPI). Failure to ensure an annual review of its total program put all patients at risk for unsafe and poor quality care from each department in the CAH.

Findings include:

Quality Director Staff P interviewed on 5/23/17 at 10:00 AM verified a periodic evaluation of their entire program including QAPI was not completed in 2016.

Chief Executive Officer (CEO) Staff A interviewed on 5/23/17 at 11:30 AM,verified the QAPI program failed to be evaluated and reviewed for the 2016 year.

- Document review on 5/24/17 revealed "Quality Assurance and Improvement Program" states ...Quality Assurance Committee shall review and evaluate the QA/QI program annually for identification of components, which need to be instituted, altered or deleted and to recommend necessary changes if applicable.

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Based on interview and document review Osborne County Memorial Hospital (CAH) failed to ensure yearly program evaluation of all CAH services to include the number of patients served and the volume of services provided. Failure of the facility to evaluate CAH services, patients served and the volume of services puts all patients at risk for receiving care, nutrition, treatments and supportive services that are inadequate to the health and quality standards required.

Findings include:

Quality Director Staff P interviewed on 5/23/17 at 10:00 AM, verified the CAH failed to provide a yearly evaluation of the services provided to include the patients they serve and the volume of the services provided.

- Document review on 5/24/17 revealed "Quality Assurance and Improvement Program" states ...the Quality Assurance Committee shall review and evaluate the QA/QI program annually for identification of components, which need to be instituted, altered or deleted and to recommend necessary changes if applicable ...assign responsibility for monitoring and evaluation of activities ...delineate the scope of care provided by the organization ... identify the most important aspects of care provided and take action to improve care.

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Based on interview and documents review Osborne County Memorial Hospital failed to ensure review of both active and closed clinical records representing services furnished under the Quality Assessment and Improvement Program (QAPI). Failure to ensure review of active and closed clinical records under QAPI puts all patients at risk for not receiving quality, accurate and comprehensive care as chart reviews alert all staff to potential problems and issues to ensure quality of care is provided.

Findings Include:

Quality Director Staff P interviewed on 5/23/17 at 10:00 AM, verified the QAPI program fails to provide active and close chart reviews concerning the services provided.

- Document review on 5/24/17 revealed "Quality Assurance and Improvement Program" states ...The QA/QI program includes the following objectives: ...clinical and administrative staff monitor and evaluate the quality and appropriateness of patient care and clinical performance, resolve identified problems and report information to the governing body that the governing body needs to assist it in fulfilling its responsibilities for the quality of the patient care.

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Based on interview and document review Osborne County Memorial Hospital (CAH) failed to ensure the Quality Assurance and Performance Improvement (QAPI) program evaluated, reviewed and revised health care policies as part of the annual program evaluation. Failure of the CAH to evaluate, review and revise health care policies puts all patients at risk for receiving care that is unsafe and below the standard of care from each profession resulting in harm and poor outcomes.

Findings include:

Quality Director Staff P interviewed on 5/23/17 at 10:00 AM, verified the QAPI program lacks evidence to support evaluation, review and revision of policies for the CAH.

Chief Executive Officer Staff A interviewed on 5/24/17 at 3:40 PM, verified the QAPI program fails to provide oversight for policy and procedure reviews.

- Document review on 5/24/17 reveals "Quality Assurance and Improvement Program" states ...Quality and care shall be a joint interdisciplinary effort. QA/QI and Risk Management is the responsibility of all hospital personnel. Lines of collaboration and open communication channels shall be outlined and utilized (see organizational chart). All staff are made aware, by means of established policies and procedures that the public holds the hospital as a community service accountable for providing quality care.

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Based on interview and document review Osborne County Memorial Hospital (CAH) failed to ensure results from the annual Quality Assessment and Performance Improvement (QAPI) program evaluation for services and policies are added, deleted and/or revised to provide safe quality care for all patients served. Failure to ensure results from the annual program are evaluated puts all patients at risk for care that is unsafe and below the standard of care according to State and Federal guidelines.

Findings Include:

Quality Director Staff P interviewed on 5/23/17 at 10:00 AM, verified the QAPI program lacks evidence of results of the annual program evaluation implemented to provide safe, quality care to all patients served at the CAH. Staff P verified an annual evaluation of the QAPI program for 2016 failed to be completed.

Chief Executive Officer (CEO) Staff A interviewed on 5/23/17 at 11:30 AM, verified the QAPI program failed to be evaluated and reviewed for the 2016 year.

- Document review on 5/24/17 revealed "Quality Assurance and Improvement Program" states ...Quality Assurance Committee shall review and evaluate the QA/QI program annually for identification of components, which need to be instituted, altered or deleted and to recommend necessary changes if applicable.

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Based on interview and document review Osborne County Memorial Hospital (CAH) failed to ensure the quality and appropriateness of the diagnosis and treatment furnished by the physicians at the CAH was evaluated from an outside entity. Failure of the CAH to ensure an evaluation of the physician is performed by an outside entity puts all patients at risk for unsafe, poor quality of care that is below the standard of care according to State and Federal regulations.

Findings include:

Quality Director Staff P interviewed on 5/23/17 at 10:00 AM, stated s/he is not aware of who performs the evaluation of the physician at the CAH.

Chief Executive Officer, Staff A interviewed on 5/23/17 at 11:30 AM, stated at present only an internal review of the physician Staff V is performed. The CAH fails to ensure an outside entity provides an evaluation at this time.

- Document review on 5/24/17 reveals "Osborne County Memorial Hospital Constitution, Bylaws, Rules and Regulations" states ...any persons, group or entity which performs or assists in Risk Management, Peer Review, or Quality Review, including but not limited to persons, groups, or entities in and outside the Hospital which perform or assist in the peer review/risk management function specified in K.S.A. 65-4914 et seq., RRS neb. 24-12, 123:71-7903 are hereby designated peer review/risk management committees or officers whose conclusion, reports, records, findings and information shall be privileged as provided by Kansas and Nebraska law and their actions are to be immune from civil liability to the extent provided by Kansas and Nebraska law ...


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Based on closed medical record review and document review, the Community Access Hospital (CAH) failed to ensure complete and inclusive verbal and written patient rights are presented to Swing Bed patients. Failure to communicate all patient rights in an understandable format denies patients the opportunity to know and act on those rights regarding their health care.

Findings Include:

Swing Bed Patient Rights and Responsibilities document presented to CAH swing bed patients, reviewed on 5/23/2017 at 1:00 PM, revealed the document does not inform swing bed patients of the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States and does not inform patients orally and in writing in a language the resident understands of his or her rights and rules and regulations governing resident conduct and responsibilities during the stay in the facility.

CEO Staff A interviewed on 5/23/2017 at 3:00 PM acknowledged the document lacked complete patient rights and the document would be reviewed for corrections.


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Based on personnel record review and policy review, the Community Access Hospital (CAH) failed to contact state registries to conduct back ground checks for all personnel providing direct care to swing bed patients in four of four nursing personnel files reviewed (Staff #B, #M, #H, #J). Failure to perform background checks on all personnel places all swing bed patients at increased risk of abuse, neglect, or mistreatment by previously documented personnel.

Findings Include:


- RN Staff #B employee file reviewed on 5/23/2017 at 9:30AM revealed no evidence of state registry or criminal background check.
- RN Staff #M employee file reviewed on 5/23/2017 at 9:40 AM revealed no evidence of state registry or criminal background check.
- LPN Staff #H employee file reviewed on 5/23/2017 at 10:00 AM revealed no evidence of state registry or criminal background check.
- RN Staff #J employee file reviewed on 5/23/2017 at 10:00 AM revealed no evidence of state registry or criminal background check.

CEO Staff A interviewed on 5/23/2017 at 3:00 PM acknowledged state registries have not been contacted for new personnel hired, but the practice has been changed in the last month and all new hires will be reviewed for histories of abuse, neglect, or mistreatment.


Policy review on 5/23/2017 at 10:45 AM revealed the CAH failed to develop a policy for criminal background and abuse checks.

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Based on record review and interview the critical access hospital (CAH) failed to ensure swing bed patients were provided activities according to their individual interests and needs including physical, mental, and social activities. Two of four swing bed medical records reviewed (Patient #3 and #4) failed to have documentation of activities specific to patient interests, abilities, and skills. Failure to provide activities and evaluate the outcomes in the patient plan of care for outcomes of the activities put all swing be patients at risk of not receiving all patient rights.


Findings include:


- Medical record review of Patient #3 on 5/24/2017 at 12:00 pm revealed no documentation of activities provided
- Medical record review of Patient #4 on 5/24/2017 at 12:45 pm revealed no documentation of activities provide

RN Staff K interviewed on 5/24/2017 at 2:00 PM acknowledged that the nursing staff are not involved in the activities of the swing bed patients and was unable to identify what the activity program consisted of. S/he was unsure where in the medical record activities are documented.

Document "Social Services and Patient Activities" reviewed on 5/24/2017 at 2:30 PM directs " ...The activities director or Social Services is responsible for the development and coordination of all patient activities. Activities will be conducted on a one to one basis ... ...Patients are not required to participate in activities if they do not desire. Patient activities will be logged in the computer under the patient's information."

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Based on record review and interview the critical access hospital (CAH) failed to ensure swing bed patients were provided medical social work access to meet mental and social needs. Two of two swing bed medical records reviewed (Patient #3 and #4) failed to have documentation of social service involvement and interventions specific to patient needs and concerns. Failure to provide social service access and evaluate the outcomes in the patient plan of care put all swing be patients at risk of not receiving all patient rights.


Findings include:


- Medical record review of Patient #3 on 5/24/2017 at 12:00 pm revealed no documentation of social service intervention
- Medical record review of Patient #4 on 5/24/2017 at 12:45 pm revealed no documentation of social service intervention

RN Staff K interviewed on 5/24/2017 at 2:00 PM acknowledged that a social worker is on staff at the facility, but was not working at the time. S/he confirmed the social worker is contacted by the nursing staff if a patient is identified as having a specific need, but "she usually visits with them about all of the patients every day."

Document "Social Services" reviewed on 5/24/2017 at 2:30 PM directs " ...Pertinent social data, including any personal and family problems which are related to the patient's illness are maintained in the medical record. Social services data is confidential and available only to the physician, or appropriate nursing staff, or other key personnel who are directly involved in the patient's care ... ...Functions of the service are: Identify needs of the swing bed patient, participate in the planning of patient care, meet the appropriate social needs of the patient ... ...maintain social service records."

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Based on record review and interview the critical access hospital (CAH) failed to ensure swing bed patients received a comprehensive assessment every 14 days to evaluate progress toward discharge. Closed medical record review revealed one of two swing bed patients (Patient #3) were hospitalized more than fourteen days without receiving a comprehensive assessment. Failure of the CAH to perform the assessment could cause a delay or untimely discharge of swing bed patients.


Findings include:


- Medical record review of Patient #3 on 5/24/2017 at 12:00 pm revealed the patient was admitted to the CAH swing bed on 5/5/2017 and dismissed on 5/24/2017. The medical record revealed no documentation of a comprehensive assessment 14 days after admission.

RN Staff K interviewed on 5/24/2017 at 2:00 PM lacked knowledge of necessary comprehensive assessments for swing bed patients and was stated s/he was unsure if they were ever performed and if they are, s/he stated the nursing staff don't document any differently.

Policy review on 5/24/2017 at 2:00 PM revealed facility failed to develop a policy for swing bed comprehensive assessments.

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Based on medical record review and staff interview, the critical access hospital (CAH) failed to ensure that one of two swing bed medical records (Patient #3) contained a current individualized nursing care plan. Failure of the CAH to include comprehensive care plans can result in not meeting the medical, mental, social, and physical needs of each swing bed patient and could result in delayed or inappropriate discharge.

Findings include:


- Medical record review of Patient #3 on 5/24/2017 at 12:00 pm revealed the patient was admitted to the CAH swing bed on 5/5/2017 and dismissed on 5/24/2017. The medical record revealed no documentation of a comprehensive care plan.

RN Staff K interviewed on 5/24/2017 at 2:00 PM voiced concern that a care plan was not developed and was unsure how it could have been missed.

Policy "Care Planning Process" directs ...RN is to develop plan of care to include physician and nursing specific approaches and observations based on the patient's problems and goals. Ancillary services will be included. Document total patient care on swing bed unit care plans ... ...Care plan meetings held weekly to ensure patient's needs are being met. All disciplines are to update care plans appropriately weekly for swing bed patients ..."

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