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Based on observation, document review and staff interview, it was determined the hospital failed to:

a. ensure all drugs and biologicals were stored in accordance with accepted professional principles and practices;

b. require the contracted pharmacist to annually review and revise as necessary, all drug room policies and procedures; and

c. failed to require the pharmacist to evaluate the competencies and job performance of the drug room supervisor.

Findings:

1. On the afternoon of 3/25/14, surveyors toured the radiology department and Computed Tomography (CT) unit with the radiology manager.

Surveyors observed twenty-two boxes of Optiray contrast 500 milliliters (mls) of ioversol injection 68%, twenty boxes of Optiray contrast 500 mls of ioversol 74%, and two normal saline flushes stored on an open metal storage rack unsecured.

2. On the afternoon of 03/25/14, the radiology manager stated, "The CT unit is left unlocked all day and when a patient needs a CT, radiology technicians will bring the patient out to the CT unit."

The radiology manager told surveyors that the CT unit used to have medications in the unit in case a patient had an allergic reaction to the contrast but with the CT unit unlocked they were concerned that anyone could take the medications.

The radiology manager was unaware that Optiray contrast media and normal saline were medications.

3. On the morning of 03/26/14, staff CC told surveyors that she looks at the Optiray contrast media on the metal rack and counts how many are there to make sure there is the proper amount. Staff CC was not able to tell surveyors how much Optiray contrast media ioversol injection 68% and ioversol injection 74% was to be kept in the CT unit.

Staff CC informed surveyors that the Optiray injectable contrast media and normal saline flushes comes from pharmacy and are stored on the open metal rack in the CT unit which is not always locked.
4. The drug room policies and procedures were no longer current and had not been reviewed and approved annually by the supervising pharmacist.
5. The personnel file for the drug room supervisor had no documentation of a current job description for the position and had no documentation the supervising pharmacist evaluated skills competencies for the drug room supervisor.

Based on document review and staff interview, it was determined the hospital failed to ensure medication errors and adverse drug reactions were sufficiently analyzed and possible corrective actions were identified and implemented.

Findings:

Meeting minutes were reviewed for documentation of medication errors and adverse drug reactions. The information reported in the quality meetings was limited to raw numbers of medication errors.

There was no documentation the medication errors were analyzed for root causes. There was no documentation possible corrective actions were identified and implemented.

There was no documentation Omnicell (the automated drug dispenser) reports were presented to the quality committee. There was no documentation of any actions taken in response to the Omnicell reports.

There were no reports of possible adverse drug reactions.

The findings were discussed with hospital leadership. No comment was made and no additional information was provided.

Based on personnel records review, infection control meeting minutes, policy and procedure review and staff interview, the hospital failed to:
a. designate an individual qualified through education, training and experience as an infection control officer
b. to have an active surveillance program that includes specific measures for prevention, early detection, control, education and investigation of infections and communicable diseases
Findings:
1. Surveyors reviewed the personnel record for the designated infection control officer. The personnel record contained no documentation of training or experience as an Infection control officer.
2. On the morning of 03/26/2014, surveyors asked the infection control officer if she had any training or experience as an infection control officer. She stated that she had not been to any classes but she received mentoring from other infection control officers at other hospitals. The personnel file contained no documentation of any mentoring.
3. On the morning of 03/25/2014, surveyors requested infection control policies and procedures, infection control log, infection control plan, infection control surveillance and monitoring activities, and infection control meeting minutes for the past 12 months.
4. Surveyors reviewed the infection control meeting minutes. The infection control meeting minutes contained no documentation of an active surveillance program to include measures for prevention, early detection, control, education and investigation of infections and communicable diseases of employees and patients.
5. On the morning of 03/26/2014, surveyors asked the infection control officer if she monitored infection control processes such as cleaning, in all departments of the hospital. She stated that she does not monitor the cleaning but all the department managers' reported to her.
6. On the morning of 03/26/2014, surveyors asked the infection control officer if she had a process for monitoring, investigating and reporting employee illness. She stated that she would not investigate an employee illness if it was one employee but if it was more than one employee with the same illness she would investigate. There was no documentation of any employee illnesses being investigated, monitored and reported.
7. A hospital policy on cleaning equipment documented, "...clean equipment will be covered with a plastic bag and tagged with a pink tag labeled clean ... "
8. On the afternoon of 03/26/2014, surveyors observed equipment such as wheelchairs and blood pressure machines stored in the Emergency Department uncovered in the clean storage area. Staff A was asked how she would know if the equipment was clean, she stated " I don't." Staff A stated that the staff was supposed to follow the policy and bag and label equipment after it is cleaned.

Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the contracted dietitian provided supervision of all nutritional aspects of patient care.

Findings:

1. At the time of survey, the hospital had no documentation the dietitian had full responsibility for all aspects of the clinical nutritional program. The hospital had not required the contracted dietitian to submit regular reports of all clinical activities performed.

2. There was no documentation to indicate the dietary manager was limited to non-clinical operations of the dietary department.
On 03/26/14, the dietary manager stated she was the clinical "go-between" for the nursing staff and the dietitian. At the time of the survey, the dietary manager did not have the qualifications to provide any clinical nutritional care. However, some clinical records documented the dietary manager performed nutritional assessments.

3. The nutritional assessment document used by the hospital staff did not collect all pertinent patient information. For example, the form did not allow for documentation of patient wounds or current infections.

4. The nutritional services policies and procedures had not been reviewed annually by the dietitian and revised as necessary.

5. There was no documentation the dietitian responded to the findings of the most recent health department kitchen inspection.

6. The hospital had no documentation the dietitian was a participating member of the infection control and quality assessment committees.

Based on document review and staff interview, it was determined the hospital failed to ensure all patient care policies and procedures were reviewed annually.

Findings:

During the survey, multiple departmental policy and procedure manuals were reviewed. There was no documentation the responsible professional, (i.e., pharmacist, dietitian, etc.,) reviewed and approved departmental policies and procedures annually.

Many policies in various areas were out of date and no longer reflected current practices.

The staff stated they were unaware of this requirement.

Based on document review and staff interview, it was determined the hospital failed to ensure all services provided by agreement or arrangement were evaluated for quality and adherence to acceptable standards of practice.

During the survey, it was determined that not all services provided by arrangement or agreement were evaluated. The hospital administrator verified this finding.

Based on document review and staff interview, it was determined the hospital failed to perform a comprehensive assessment and care plan for residents' activity needs for five (#11 - #15) of five clinical records reviewed. The five records were for patients currently in the hospital on swing bed status.

Findings:

On 03/26/14, five swing bed clinical records were reviewed. None of the records had documentation of a comprehensive assessment and the development of an activities care plan.

The records had no documentation activities were provided.

Staff I stated she could not explain why the swing bed patients did not have an activities assessment documented or why there were no activities documented in the clinical records.