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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.623 Physical Plant and Environment was out of compliance.

C-0926 MAINTENANCE There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. Based on observations, interviews and document review, the facility failed to ensure humidity ranges were maintained within acceptable ranges set forth by national standards of practice and facility policy in two of two surgical procedure rooms observed.

Based on observations, interviews and document review, the facility failed to ensure humidity ranges were maintained within acceptable ranges set forth by national standards of practice and facility policy in two of two surgical procedure rooms observed.

Findings include:

Facility policies:

The Environment Control of the Peri-operative Setting policy read, relative humidity should be maintained between 20-60% within the perioperative area. This includes the OR and endoscopy. Low humidity increases the risk of electrostatic charges which can pose a fire hazard in an oxygen rich environment with frequent use of flammable agents. Low humidity also increases the potential for dust which are known to carry microbes.

References:

The AORN Perioperative Nursing: Scope and Standards of Practice article (2021) read, the operating room is a room within a facility or unit that is equipped for the performance of operative or other invasive procedures. Construction and design guidelines specify how the operating room must be built and is important for maintaining the sterile environment and preventing infection.

According to www.aorn.org, AORN Design and Maintenance of the Surgical Suite, (2022) , the recommended humidity range in an operating room is 20% to 60%. Each facility should determine acceptable ranges for humidity in accordance with regulatory and accrediting agencies and local regulations.

1. The facility failed to ensure humidity levels within the facility were maintained within the acceptable ranges required by policies and national standards of care.

a. Facility observations on 4/18/22 at 11:30 a.m. revealed the humidity gauge in the OR suite read 16% humidity, and in the endoscopy suite read 16% humidity.

b. Facility daily humidity logs were reviewed and revealed from 10/5/21 to 11/24/21 the humidity was documented at 17% in the operating room and the endoscopy suite each day. From 12/1/21 to 4/20/22 the humidity was documented at 16% in the operating room and the endoscopy suite each day.

The humidity levels documented in the daily humidity logs were below the levels recommended from facility policy and national standards which list acceptable ranges between 20% to 60%.

c. On 04/20/2022 at 8:44 a.m., an interview was conducted with Registered Nurse (RN) #18. RN #18 stated she did not know what the required humidity range was or the importance of maintaining humidity levels within required ranges in procedure rooms.

d. On 4/20/22 at 10:03 a.m., an interview was conducted with operating room (OR) Director #4. Director #4 stated she believed the humidity levels in the procedure rooms was to be less than 60%. Director #4 stated there was a risk of the integrity of patient care supplies if the humidity was out of range. Director #4 was unable to state if staff had been educated on the required humidity range levels. Director #4 stated the facility followed AORN guidelines for guidance in the surgical area.

e. On 4/21/22 at 2:00 p.m., a second interview was conducted with Director #4. Director #4 stated she had found an additional humidity gauge in the patient procedure rooms, which read 23% humidity. Director #4 stated maintenance had the ability to see the humidity level but did not record it. Director #4 stated she had been documenting the humidity level from a moveable humidity gauge located in the operating room and endoscopy room, which always read 16%.

f. On 4/21/22 at 10:42 a.m., an interview was conducted with the Infection Preventionist (IP) #5. IP #5 stated low humidity in a patient procedure room was a fire risk. IP #5 stated high humidity in a patient procedure room was an infection risk. IP #5 stated out of range humidity levels in patient procedure areas had been addressed in the past. IP #5 stated the humidity log was to be documented daily and a work order was to be placed if the humidity was out of range.

Based on the manner and the degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.627 Organizational Structure was out of compliance.

C-0962 Governing Body or Responsible Individual. The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. Based on observations, interviews and document review, the facility's governing body failed to ensure patients who presented to the emergency department (ED) for suicidal ideation and/or suicide attempt were monitored and observed one to one (one staff member observing one patient) in order to ensure patient safety in four of four medical records reviewed where patients presented with suicidal ideation. (Patients #19, #20, #22, and #24).

Based on observations, interviews and document review, the facility's governing body failed to ensure patients who presented to the emergency department (ED) for suicidal ideation and/or suicide attempt were monitored and observed one to one (one staff member observing one patient) in order to ensure patient safety in four of four medical records reviewed where patients presented with suicidal ideation. (Patients #19, #20, #22, and #24).

Findings include:

Facility policy:

The Suicide Risk Assessment policy read, the purpose is to describe the process for assessing for risk and developing a plan of care for patients with suicidal/self-harm/harm of others ideation. The policy defines the following: One to one observation is when one competent observer is assigned to one patient and is within the line of sight of the patient with no physical barrier in the same room. The proximity is determined by the provider, registered nurse or qualified mental health professional. A competent healthcare provider is an individual who has completed a facility based competency assessment related to core elements required to monitor a patient under self-harm precautions. A suicidal patient is defined as a patient who presents to the hospital and expresses intent to harm self or has a positive screening for suicide.

The procedure for assessing suicide risk is as follows: At a minimum a RN will screen all patients during the triage process using the Columbia Suicide Severity Rating Scale (C-SSRS, an assessment used to determine a patient's suicide risk). The screening should be conducted as soon as the patient's condition permits. If the patient shows signs of being a self harm risk through the C-SSRS screening, the nursing staff will place the patient on one to one observation with a competent healthcare member. The suicide screening should be a part of the triage documentation process. The constant observation flowsheet will be used to document observation of the patient.

Facility documents:

The Patient Rights document included in the patients' admissions packet read, a patient has the right to personal privacy and to receive care in a safe setting.

The facility Bylaws of the Board of Trustees read, the purpose of the governing body shall be to operate and maintain a hospital which requires patients to receive care. The board shall have the powers to establish, maintain, and operate public hospitals providing health and personal care services. The Joint Conference Committee is composed of the executive committee of the board and the medical staff. The hospital administrator shall be an ex-officio member with voting privileges. The committee acts in an advisory capacity to the Governing Body on matters of hospital policy and practice, especially those pertaining to efficient patient care.

The Chief Executive Officer (CEO) job description read, the CEO reports to the Board of directors and provides overall leadership and coordinates activities of all aspects of the district's facilities.

1. The facility's CEO, who was appointed by the governing board, failed to ensure policies and procedures regarding the assessment and treatment of suicidal patients were followed.

a. A review of four medical records where patients presented with suicidal ideation (SI) was completed.

i. On 4/3/22 at 8:10 p.m., Patient #19 presented to the emergency department with SI and a plan to harm himself. At 8:15 p.m., an ED psychiatric assessment was completed by a Registered Nurse (RN) #10. The assessment read Patient #19 was displaying constant SI and had a clear and lethal suicide plan. Further review of the record indicated one to one observation was not implemented for the patient and there was no documentation of the constant observation flowsheet.

ii. On 4/2/22 at 10:06 p.m., Patient #20 was brought in by law enforcement with the chief complaint of suicidal ideation. At 10:06 p.m., an ED psychiatric assessment was completed by RN #10. The assessment read Patient #20 had suicidal ideation and discussed detailed plans for suicide. Further review of the record indicated a one to one observation was not implemented and there was no documentation of the constant observation flowsheet.

iii. Similar findings were discovered in Patient #22 and #24's medical records.

b. On 4/21/22 at 7:09 a.m., an interview was conducted with registered nurse (RN) #11. RN #11 stated she had been an ED RN at the facility for a year. RN #11 stated when a patient presented with SI, all items would be removed from the room which could harm the patient. RN #11 stated patients were monitored by the nurse, who would check on the patient frequently and check vital signs every 30 minutes. She additionally explained the window of the room was kept open for staff to observe the patient.

RN #11 was provided the suicide risk assessment policy and procedure for review which read, a patient showing signs of being a self harm risk was to be on a one to one level of observation. RN #11 stated she was unaware of the policy and had not seen it before.

i. On 4/21/22 at 9:10 a.m., an observation was conducted by the Emergency Department. The exam room where staff stated SI patients were placed was within view from the nurses station. However, upon the observation it was noted the patient's bed could not be observed from the nurses station.

c. On 4/21/22 at 8:52 a.m., an interview was conducted with RN #10. RN #10 stated he had worked in the facility's ED for seven months. RN #10 stated when a patient presented with SI, the patient was monitored every 30 minutes by the emergency medical technician (EMT). RN #10 stated it was important for patients with SI to be monitored for safety to ensure the patient did not harm themselves. RN #10 stated he had never implemented a one to one observation for a suicidal patient at the facility. He further explained there were only two staff members working in the ED at night, so if the ED was full and there were five patients, there was a potential for an SI patient to not be continuously monitored.

d. On 4/21/22 at 12:42 p.m., an interview was conducted with the Director of Nursing (Director) #12. Director #12 stated she oversaw the medical-surgical unit and the emergency department. Director #12 stated when a patient presented with SI and was not violent, the patient would be placed in an exam room with all the equipment removed. She further explained every 15-30 minutes a staff member would check on the patient. Director #12 stated if a patient presenting with SI was not monitored, there was a risk the patient could harm or kill themselves.

Review of medical records and interviews with staff were in contrast to the facility policy which read if a patient screened positive for suicide, a one to one observation with a competent observer was to be implemented to ensure patient safety.

e. On 4/21/22 at 1:30 p.m., an interview was conducted with Chief Executive Officer (CEO) #13 and Chief Medical Officer (CMO) #14. CEO #13 and CMO #14 both stated they attended Governing body meetings and were involved in the oversight of the facility. CEO #13 explained she was given ultimate responsibility for the facility's functions as the CEO. CEO #13 stated it was important for staff to follow policies and procedures because the policies and procedures were based on national guidelines for patient safety.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.635 Provision of Services was out of compliance.

C-1006 The CAH's health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. Based on observations and interviews, the facility failed to ensure glucometer (a device used to measure blood sugar levels) test strips and testing solution were taken out of use when expired in one of one observations of the glucometer in the emergency department.

C-1016 Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. Based on observations, interviews and document review, the facility failed to ensure medications were stored, secured and administered according to facility policy. Specifically, the facility failed to ensure medications were stored securely to prevent unauthorized access. In addition, the facility failed to implement policies, processes and procedures for prescribed medications and controlled substances to ensure patient safety in two of two observations of a medication cart in the swing bed unit.

C-1049 All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. Based on observations, interviews and document review, the facility failed to ensure facility policies and national standards and guidelines were followed to ensure the patient's identity for 11 of 11 swing bed patients.

Based on observations and interviews, the facility failed to ensure glucometer (a device used to measure blood sugar levels) test strips and testing solution were taken out of use when expired in one of one observations of the glucometer in the emergency department.

Findings include:

References:

The Nova Statstrip Glucose Hospital Meter Test Strips instructions for use read, the expiration date is printed on the vial of test strips. Once opened, the StatStrip Glucose Hospital Meter Test Strips are stable when stored as indicated for up to six months or until the expiration date, whichever may come first. General precautions: do not use the test strip if the expiration date has passed, for this may cause inaccurate results. Storage and handling read, the test strips are stable for 24 months from the date of manufacture. The expiration date is printed on each vial. Reasons for out-of-range control result: the test strip may have expired. Check the expiration date on the test strip vial. Additionally, the control solution may have expired. Check the expiration date on the control solution vial. Control solution is good for only three months after opening.

The Nova StatStrip Glucose Control Solution instructions for use read, the expiration date is printed on the control vials. Once opened, solutions stored as indicated will be stable for up to three months or until the expiration date, whichever comes first. Use only for three months after first opening. When you open a new vial of control solution, count forward three months and write that date on the label of the control solution vial. Discard any remaining solution after the date you have written on the vial. Expected results: an out of range result may be caused by the following: one of the controlled solutions may have expired, or the test strips may have expired. Check the expiration date on the control solution vial or test strip vial. Control solution is good for only three months after opening.

1. The facility failed to date patient glucometer test strips and control bottles for glucometer testing in the emergency department (ED) with the date they expired to ensure accurate glucose results.

a. On 4/18/22 at 11:46 a.m., an observation of the glucometer in the ED was conducted. During the observation, the test strips showed no indication on when they had been opened or when they expired. According to the strip IFUs, the strips were stable for six months after opening. There was no date written to show when the strips were opened to indicate their stability.

In addition, there was no date indicating when the control solution bottles were opened or when they expired. This was in contrast with the manufacturer's instructions for use which instructed users to write the date three months after opening on the label of the control solution vial.

b. On 4/21/22 at 7:09 a.m., an interview with Registered Nurse (RN) #11 was conducted. RN #11 stated the nurses were responsible to complete quality control checks on the glucometer once per day and once per night. RN #11 stated it was important to complete quality control checks to ensure the results were accurate. RN #11 stated she was not sure when the bottles expired, but the opened bottles should have been dated.

Based on observations, interviews and document review, the facility failed to ensure medications were stored, secured and administered according to facility policy. Specifically, the facility failed to ensure medications were stored securely to prevent unauthorized access in one of one surgical areas observed. In addition, the facility failed to implement policies, processes and procedures for prescribed medications and controlled substances to ensure patient safety in two of two observations of a medication cart in the swing bed unit. (Cross-Reference C-0336)

Findings include:

Facility policies:

The Medication Storage Areas policy read, drugs shall be stored in the appropriate drug storage areas. Drugs shall be secured with a security lock and accessible to designated staff only.

The Pharmacy Services policy read, the facility will obtain services of a licensed pharmacist who establishes a system of records of receipts and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, determine that drug records are in order and that an account of controlled drugs is maintained and periodically reconciled. Pharmaceutical services will assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each patient.

The Controlled Substances-Missing policy read, the purpose is to establish a procedure which provides a system for investigating, reporting and tracking missing controlled substances. The pharmacist is responsible for maintaining controlled substances and tracking reports of missing controlled drugs. Nursing is responsible to report any missing controlled drugs.

The Controlled Substances-Control and Accountability policy read, the nurse will make a controlled substance record for each blister pack (pill pack) with the drug name, prescription number, quantity received, patient name, dosage and physician name. The controlled substance record will contain the information above and the date and time each medication dose was administered, the signature of the person who administered the medication and the quantity of the medication remaining.

References:

The Dantrolene sodium manufacturer's instructions for use (IFU) read, Dantrolene is classified as a direct-acting skeletal muscle relaxant. Dantrolene is indicated, along with appropriate supportive measures, for the management of hypermetabolism of skeletal muscle characteristic of malignant hyperthermia (MH) crises in patients of all ages. MH is a disorder which causes a fast rise in body temperature and severe muscle contractions when someone receives general anesthesia. Administration of Dantrolene results in muscle weakness i.e. decrease in grip strength, weakness of leg, lightheadedness and potential for hepatotoxicity (chemical driven liver damage).

Lorazepam manufacturer's instructions for use read, warning risk for abuse, misuse and addiction. Directions for use, Lorazepam tablets is indicated for the management of anxiety disorders or for the short-term relief from the symptoms of anxiety and anxiety associated with depressive symptoms.

1. The facility failed to ensure medications were stored securely and not available to unauthorized personnel.

a. On 4/18/22 at 11:30 a.m., the operating room (OR) #1 was observed. Upon observation, it was noted the MH cart drawer was unlocked and contained seven boxes of Dantrolene, each box containing six vials of the medication.

b. On 4/19/22 at 3:00 p.m., an interview was conducted with Operating Room (OR) Director #4. Director #4 stated she could not ensure the unsecured Dantrolene medication was not tampered with.

c. On 4/19/22 at 1:49 p.m., an interview was conducted with OR Registered Nurse (RN) #2. RN #2 stated housekeeping cleaned the pre-op and post anesthesia care unit (PACU) areas. RN #2 stated some staff outside of the OR had badge access into the main pre-op and PACU area. RN #2 stated there was a risk of storing unlocked medications. The risk was the medication could be moved, taken or tampered with. RN #2 stated medication inventory on the MH cart was completed at the end of the month, not daily.

d. On 4/19/22 at 1:40 p.m., an interview was conducted with OR Scrub Tech (Tech) #1. Tech #1 stated terminal cleans (thorough cleaning of an operating room after use) were done by OR staff, not housekeeping. Tech #1 stated OR suites were located behind a red line which was a restricted area and was locked at the end of the day. Tech #1 stated housekeeping cleaned the pre-op, PACU and office areas in the surgical department. This allowed housekeeping staff access to the surgical suite where the Dantrolene was stored.

e. On 4/19/22 at 2:10 p.m., an interview was conducted with RN #3. RN #3 stated the MH cart was checked at the end of the month. RN #3 stated if the MH cart was left unlocked there was a risk of unauthorized personnel having access to the Dantrolene.

2. The facility failed to implement policies, processes and procedures for the handling, dispensation, and administration of controlled substances to ensure patient safety. Specifically, prescription medications filled by retail community pharmacies (a pharmacy where prescription medications are filled or dispensed to the general public) were not verified and inventoried by a facility pharmacist before the medication was administered to the patient.

a. On 4/18/22 at 12:05 p.m., an observation was conducted of the medication cart in the swing bed unit and revealed the medications stored within the cart were prepared and filled by retail community pharmacies. The medications stored within the medication cart contained prescription labels. The prescription labels stated the name and address of the dispensing pharmacy, the date the prescription was filled, the name of the patient, the name, strength and dosage of the medication and the medication administration instructions.

At 12:22 p.m., Registered Nurse (RN) #19 was observed accessing the medication cart when she administered medication to Patient #7. RN #19 unlocked the controlled substance lockbox located within the medication cart to retrieve 1 mg of lorazepam (a medication used to treat anxiety) for Patient #7. RN #19 removed a medication blister pack (individually sealed tablets contained within a foil tamper-evident package) containing lorazepam 0.5 mg tablets for Patient #7.

The prescription label attached to the lorazepam 0.5 mg tablet blister pack read, one tablet three times daily for anxiety. RN #19 removed two 0.5 mg lorazepam tablets from the blister pack and proceeded to administer the medication to Patient #7. RN #19 did not scan the medication administered to Patient #7 into her medical record to track the medication administration.

b. On 4/19/22 at 11:05 a.m., a second observation of the medication cart was conducted and revealed Patient #7 had two prescriptions for lorazepam. Lorazepam 0.5 mg tablets lorazepam 1 mg tablets were both stored in the medication cart.

c. Patient #7's medical record review revealed on 4/15/22 the prescription for 0.5 mg tablets of lorazepam was discontinued by the physician and a new prescription for 1.0 mg tablets of lorazepam was placed.

The new prescription was filled at the retail pharmacy and delivered to the facility on 4/15/22. However, the 0.5 mg tablets of lorazepam discontinued were not removed from the medication cart and disposed of by facility staff once the 1.0 mg tablets of lorazepam were checked in and placed in the medication cart.

d. On 4/19/22 at 11:14 a.m., an interview was conducted with RN #19. RN #19 stated prescriptions written for swing bed patients were sent to retail community pharmacies to be filled. RN #19 stated the retail community pharmacy filled prescriptions for swing bed patients and had the medications delivered to the facility.

RN #19 stated controlled substances filled at retail community pharmacies were reviewed by two RNs before the medication was administered to the patient. RN #19 stated two RNs reviewed the controlled substances supplied from the retail community pharmacy and recorded the name of the medication, the dosage and strength of the medication, the quantity supplied by the retail community pharmacy and the date the medication was received. RN #19 stated this information was placed in the narcotics logbook located on the medication cart. RN #19 stated the RN used the quantity (count) of the controlled substance initially recorded when the medication was received from the retail pharmacy and then tracked the quantity administered to the patient within the narcotics logbook.

RN #19 stated medications supplied by retail community pharmacies were not verified or checked by a pharmacist when the medication was delivered to the facility. RN #19 stated retail pharmacy medications were not scanned into the medical record for the patient since the medication was not supplied by the facility.

This was in contrast to the Pharmacy Services policy which read, pharmaceutical services will assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each patient

e. On 04/20/2022 at 11:58 a.m., an interview was conducted with the Pharmacy Director (Director) #16. Director #16 stated pharmacists tracked the quantity and administration of medications dispensed from the internal pharmacy within the facility. Director #16 stated medications administered to swing bed patients were filled by retail community pharmacies. Director #16 stated medications supplied by retail community pharmacies were not verified, counted or tracked by the facility pharmacists if the medication was filled at a retail community pharmacy. Director #16 stated medications supplied by a retail community pharmacy were not scanned and could not be scanned when the RN administered the medication to a swing bed patient.

Director #16 stated the disposal of controlled substances supplied by retail community pharmacies was not monitored. Director #16 stated she was unable to ensure nursing staff disposed of controlled substances when prescriptions were discontinued or changed. Director #16 stated prescription medications and controlled substances supplied by retail community pharmacies were not reconciled to ensure the medication dosage and administration aligned with the physician's order. Director #16 stated there were no policies, processes, or procedures at the facility to ensure medications supplied from retail community pharmacies were dispensed, administered, tracked and reconciled.

The facility was unable to provide evidence of policies or processes related to the disposal of retail pharmacy medications.

f. On 4/20/22 at 8:34 a.m., an interview was conducted with the Director of Nursing (Director) #12. Director #12 stated prescription medications for swing bed patients were ordered from retail community pharmacies and once received at the facility the medications were checked in by a nurse. Director #12 stated controlled substances filled by retail community pharmacies were verified by two RNs as soon as the medication was delivered to the facility. Director #12 stated the quantity and dosage of the controlled substance were recorded and initialed by both RNs in the narcotics logbook.

Director #12 stated discontinued medications and controlled substances were removed from the medication cart and disposed of by staff. Director #12 stated the RN recorded the quantity of the controlled substance discarded in the narcotics logbook. Director #12 stated she did not perform medication audits for swing bed patients to ensure medications supplied by retail community pharmacies were administered correctly.

Director #12 stated she was unable to provide evidence nursing staff were educated on when and how to properly record and discard medications supplied by retail community pharmacies.

Based on observations, interviews and document review, the facility failed to ensure facility policies and national standards and guidelines were followed to ensure the patient's identity for 11 of 11 swing bed patients. (All patients admitted as swing bed patients) (Cross-Reference C0336, C1016)

Findings Include:

Facility Policies:

The Medication Administration policy read, medication incident reports are completed for wrong patient, wrong drug, wrong time, wrong dose, wrong route, omission, given without order, given with known allergy, prescribing error, missed medications, late administration of medication, and when medications are held for any reason outside of policy parameters.

The MS Patient Identification policy read, all patients admitted to the facility must receive a white identification bracelet. It is the policy of the facility to ensure all care delivered is established using national and local best practice standards.

The Patient Identification policy read, this policy is to ensure all hospital patients are wearing an identification armband at all times while being assessed or undergoing treatments and procedures within the hospital. This is to ensure patient safety at all times, provide mechanisms to verify correct patient identification, to reduce the risk of medication and treatment errors, and to ensure staff providing care is certain of the patients' identity. All clinical areas are to participate in this policy. At minimum, staff must check the patient name and patient date of birth. Patients who refuse to wear an armband will have refusal documented in the medical records.

The Medication Reconciliation and Administration policy read, medication administration will be the responsibility of the nursing staff. Administration of all medications will be given following five rights of drug administration.

Reference:

Lorazepam manufacturer's instructions for use read, warning risk for abuse, misuse and addiction. Directions for use, Lorazepam tablets is indicated for the management of anxiety disorders or for the short-term relief from the symptoms of anxiety and anxiety associated with depressive symptoms.

1. The facility failed to ensure a patient identification bracelet was worn to readily identify patients admitted to the swing bed unit. Specifically, a visual patient identifier was not present and verified when medications were administered to the patient.

a. Observations were conducted on the swing bed unit and revealed patients admitted as swing bed patients did not wear a patient identification armband. Examples include:

i. On 4/18/22 at 12:22 p.m., Registered Nurse (RN) #19 was observed administering medication to Patient #7. Patient #7 had a prescription for lorazepam (a medication used to relieve the symptoms of anxiety) and requested to receive the medication before she left the facility for an external appointment.

At 12:24 p.m., Patient #7 was seated in front of the nursing station when RN #19 approached Patient #7 to administer the requested dose of lorazepam. RN #19 placed the lorazepam tablets into a medication cup, asked Patient #7 to verify her name and administered the medication to Patient #7.

A patient identification armband was not observed to be present on Patient #7's wrists before the medication was administered. RN #19 did not review Patient #7's electronic health record (EHR) to verify the patient's information and medication dosage before the lorazepam was administered. Additionally, RN #19 did not obtain two patient identifiers before she administered the lorazepam to Patient #7.

ii. On 4/18/22 at 1:20 p.m., an interview was conducted with RN #19. RN #19 stated she oversaw Patient #7's care and was administered medications to Patient #7. RN #19 stated she verified Patient #7's name before the lorazepam was administered to the patient. RN #19 stated she manually entered the lorazepam dosage she gave to Patient #7 after the medication was administered.

RN #19 stated she had memorized each of the swing bed patients' names and the medications prescribed for the patient. RN #19 stated swing bed patients did not wear patient identification armbands and she did not verify the patient's identity or the medication dosage in the EHR before she administered medications to swing bed patients.

RN #19 stated the facility used the five rights of medication administration when medications were administered. RN #19 stated the five rights of medication administration were, the right patient, the right medication, the right dose, the right route and the right time. RN #19 stated the five rights of medication administration were used to prevent medication errors and adverse events (an event which caused, or has the potential to cause, unexpected or unwanted patient harm or injury).

iii. On 4/18/22 at 11:56 a.m., an observation was conducted of Patient #10 and his room. Observations revealed Patient #10 was observed seated in a recliner watching television while in his room. Patient # 10 wore a short-sleeved shirt and sat with his arms extended atop the armrests located on each side of the recliner.

A patient identification armband was not observed to be present on Patient #10's wrists.

iv. On 4/18/22 at 1:48 p.m., the patient in room #114 was interviewed. At the time of the interview, the wrists of the patient were observed. The patient did not have a patient identification armband on either wrist.

These observations were in contrast with facility policy. According to the Patient Identification policy all patients wore identification armbands at all times. Patient identification armbands were worn to ensure the patient's safety, to verify the patient's identity and to reduce the risk of medication and treatment errors. Additionally, staff must check the patient's name and the patient's date of birth before medications were administered and before treatments and procedures were performed.

b. Interviews with staff revealed patients admitted to the swing bed unit were not required to wear a patient identification armband or visual patient identifier.

i. On 4/18/22 at 12:53 a.m., an interview was conducted with RN #17. RN #17 stated patient identification bands were not worn by patients admitted to the swing bed unit of the facility. RN #17 stated patient identity was verified by accessing the electronic health record (EHR) for the patient. RN #17 stated the patients were asked their name and date of birth (DOB) and the information relayed from the patient was verified with the information in the patient's EHR.

RN #17 stated swing bed patients were not required to wear a patient identification armband. RN #17 then stated patients were at an increased risk for medication errors when identification armbands were not worn. RN #17 stated when the patient's identity was not verified prior to the administration of medications there was a risk for medication errors to occur. RN #17 stated the administration of medications not prescribed for the patient and the administration of an incorrect medication dosage were considered medication errors. RN #17 stated patients who received wrong and incorrect dosages of medication were at risk for allergic reactions, medication reactions and even patient death.

ii. On 4/18/22 at 4:20 p.m., an interview was conducted with the director of nursing (Director) #12. Director #12 stated swing bed patients did not have patient identification armbands or a visual patient identifier present on their person. Director #12 stated swing bed patients had been at the facility for an extended length of time and were not required to wear a patient identification armband.

iii. On 4/21/22 at 10:57 a.m., an interview was conducted with RN #23. RN #23 stated she had cared for swing bed patients at the facility who did not wear an identification armband and who were unable to state their names. RN #23 stated identification armbands were not required to be worn by swing bed patients and verification of the patient's identity was difficult with no patient identification armband.

Based on observations, interviews and document review, the facility failed to ensure infection prevention and control measures were implemented in order to maintain a clean and sanitary environment to avoid transmission of infection. Specifically, the facility failed to ensure a staff food and drink area was separate from the laboratory equipment and patient collected specimens in the lab.

Findings include:

Facility Policies:

The Infection Prevention and Control and Surveillance Program policy read, it is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement; provide a safe and sanitary environment; and to help prevent the development and transmission of disease and infection, in accordance with state and federal regulations, and national guidelines.

The Infection Control policy read, it is policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with state and federal regulations, and national guidelines.

Reference:

The Occupational Safety and Health Administration (OSHA) Exposure Control Plan for Blood Borne Pathogens read, eating and drinking are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or countertops where blood or other potentially infectious materials are present.

1. The facility failed to ensure staff food and drinks were separate from the laboratory equipment and specimens which contained blood and other bodily fluids.

a. On 4/18/22 at 12:08 p.m., observations were made of the laboratory department. The countertop contained a centrifuge (a machine with a rapidly rotating container that applies centrifugal force to its contents to separate fluids), sink, and a small microwave. A small desk was observed beside the microwave which contained a coffee maker. A small refrigerator was on the floor beside the coffee maker. A curtain separating the countertop and the desk was observed to be open.

i. On 4/19/21 at 8:10 a.m., a second observation was made of the laboratory department. Blood specimens as well as other body fluid specimens were noted in the lab area. The curtain separating the lab area and the food and drink area was observed to be open.

b. On 4/19/22 at 8:10 a.m., an interview was conducted with Lab Director (Director) #6. Director #6 stated the microwave, small refrigerator and coffee maker were placed in the lab area and when in use by an employee a curtain was to be pulled shut. Director #6 stated the food and drink area was used by employees for coffee and food for break times.

c. On 4/21/22 at 12:14 p.m., an interview was conducted with the Infection Preventionist (IP) #5. IP #5 stated the facility followed OSHA standards. IP #5 stated OSHA standards indicated the laboratory area, where blood, specimens and body fluid were present was to be separate from food areas. IP #5 stated a curtain was to be pulled closed as a barrier when the food area was used. IP #5 stated OSHA standards were used to determine a curtain made the food area separate from the lab area. IP #5 stated there was no risk of contamination to lab specimens but was unable to provide evidence to support this.

This was in contrast to facility provided guidelines referenced above, which read food and drink were not to be kept in refrigerators, freezers, shelves, cabinets or countertops where blood or other potentially infectious materials were present.

C-0330 - §485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review was out of compliance.

C-0336 The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. Based on interviews and document review, the facility failed to ensure the quality assurance performance improvement (QAPI) program defined individualized priorities to be implemented and maintained within the facility to reduce adverse events. Specifically, staff failed to ensure adverse events were reported, investigated, analyzed and tracked in order to identify contributing factors, implement preventive measures and corrective action and prevent recurrence for 40 of 43 adverse events reviewed.

C-0336 §485.641(b) Standard: Quality Assurance The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

Based on interviews and document review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program defined individualized priorities to be implemented and maintained within the facility to reduce adverse events. Specifically, staff failed to ensure adverse events were reported, investigated, analyzed and tracked in order to identify contributing factors, implement preventive measures and corrective action and prevent recurrence for 40 of 43 adverse events reviewed. (Cross-Reference C1016 and C1049)

Findings include:

Facility programs/plans:

The Quality Improvement (QI) Plan, effective 1/1/21, defines quality as "doing the right thing, for the right patient, at the right time". The Quality Improvement Program monitors the effectiveness and delivery of quality services to patients. The Quality Improvement Program will maintain and reflect ongoing: Monitoring and collection of data, problem prevention, identification, and data analysis. The identification, implementation, and evaluation of corrective actions. Measures to improve quality improvement.

The QI Plan is meant to maintain a comprehensive, effective system for evaluating the quality of care services provided to patients. Improvement of existing processes and functions by means of review, revision, re-write, implementation and evaluation for process effectiveness. The QI Program is designed to conduct Root-Cause-Analysis studies for high risk/high volume/problem prone situations, facilitate the systematic examination process for improvement of care/treatment/services and establish a systematic mechanism to quantify improvements and corrective actions implemented for the care/treatment/services of patients.

The quality improvement objectives at the facility will maintain patient safety, reduce medical errors, prevent undesirable effects, incorporate patient safety within facility programs and the facility to ensure patient care, treatment, and services are consistent with recognized professional standards and delivery of care. Safety impacts on patient care will be monitored, measured and analyzed and exchanged among the organization to ensure continual communication of implemented processes occur. The reporting of quality information among organization staff, senior leadership, directors/managers, medical staff, and the Governing Body will occur to ensure the achievement of results and review of processes to identify areas for process improvement. Facility leadership will ensure quality improvement objectives meet patient care requirements and are measurable.

Exchange and monitor performance and assess the impact on patient care. Ensure continual communication and reporting of quality information among organization staff, senior leadership, directors/managers, medical staff, and the Governing Body. Facility leadership will ensure quality improvement objectives meet care requirements and are measurable.

Patient care and care processes are changed and improved through the utilization of the Plan, Act, Check, Enhance (PACE) cycle. PACE methodology: Plan: review and analyze processes to be improved and ensure immediate corrective and preventative action occurs to reduce the possibility of recurrence. Act: Development of an action plan to implement improved processes are implemented. Develop, update and adopt performance improvement measures to maintain ongoing performance standards. Check: collect and analyze data from the performance intervention and the effect of the process improvement. Enhance: perform an intervention and implement the new process if the performance indicator was met or modify the corrective action implemented and reevaluate the corrective action implemented.

Sentinel Events are defined as unexpected occurrences involving death or serious physical or psychological or risk thereof. "Or the risk thereof" pertains to any process or variation of process in which a recurrence of the event results in a significant or serious adverse outcome.

Facility policies:

The Incident Reporting/State Reportables policy effective 2/2/22 read, a reporting system and process are in place to help report events which were hazardous to patients, staff and visitors within the hospital. The reporting system and process will help to maintain a log of occurrence events and allow for continuous process improvement within the hospital.

An incident report is required to be completed for any occurrence in the hospital which threatens the safety and well-being of patients or visitors and for events resulting in injury to patients, visitors, or staff. Examples of reportable incidents/events: Not following hospital policies and procedures. Unanticipated patient and/or visitor injuries resulting from accidents or errors. Medication Errors. Lost or damaged patient or visitor personal property. Falls that occur for patients, visitors and staff and any incident/occurrence observed may contribute to assisting the hospital to avoid incidents and help the facility to continuously improve, adapt and maintain patient, visitor and staff safety.

The incident report should be initiated by the person or persons who were involved in or have discovered the adverse safety event. Incident reports should be completed within 24 hours of an incident or the discovery an incident. Information contained in the incident report must be based on facts.

Incident Reports will be entered by front-line staff and all staff will have access to the incident reporting system. Managers will receive notification of reports submitted by staff and managers complete the initial investigation of the event within 5 business days of when the event was reported. The risk management team and risk manager will review the event after the initial investigation review and within 15 days of when the event is reported. The final submission of the incident report will be performed by the risk manager. The risk management team may elect to perform a Root Cause Analysis based on their assessment of risk and the severity of the incident. Incidents will be monitored by the Risk Management team to look for trends and modes of process improvement (PI). Incident events trends will be reviewed quarterly at the Quality Meeting and in-depth analysis will occur once per year for incidents, complaints/grievances, patient outcomes and process improvement.

1. The facility failed to ensure staff reported adverse events in order to prevent recurrence.

a. Facility adverse events were reviewed in conjunction with patient medical records and revealed a lack of adverse event reporting by staff. Examples of adverse events not reported include:

i. Patient #3's medical record was reviewed. The Nursing Admission Assessment performed on 7/30/21 at 2:46 p.m. revealed Patient #3 wore dentures and the dentures were present when she was admitted to the facility.

Medical record review revealed on 9/25/21 at 7:33 p.m., a Nursing Note was entered by the Registered Nurse (RN) caring for Patient #3. The Nursing Note stated Patient #3's dentures were lost and without dentures Patient #3 experienced difficulty eating.

According to the Incident Reporting/State Reportables policy, adverse events were required to be completed by facility staff in the event of loss or damage of a patient's personal property.

The adverse event reporting log was reviewed and revealed staff did not complete an adverse event report when Patient #3's dentures were lost.

ii. Patient #5 was seen at the Emergency Department (ED) on 3/5/22 at 3:08 p.m. According to the initial patient assessment performed by the ED physician, Patient #5 was dehydrated (lack of a sufficient amount of water in the body), experienced weakness (decrease in muscle strength), fatigue (tiredness and a lack of energy), decreased appetite and had adventitious right-sided breath sounds (lung sounds that are abnormal). Additionally, Patient #5 had recently recovered from a surgical hip fracture repair, pneumonia (lung infection caused by germs, from bacteria and viruses) and coronavirus disease (COVID-19).

At 3:52 p.m. Patient #5 had an anterior-posterior (AP) chest radiograph (x-ray) performed. The result of the AP chest x-ray revealed Patient #5 had pneumonia, consistent with recovery from COVID-19 and bacterial pneumonia. At 7:27 p.m., Patient #5 was admitted to the acute inpatient unit.

On 3/7/2022, two days after Patient #5 was admitted to the facility, an order was placed for her to have a left rib unilateral x-ray (x-rays of only the left side of the ribs) performed. At 11:36 a.m., the x-ray results revealed Patient #5 had a rib fracture to her ninth left rib.

The results of the AP chest x-ray performed on 3/5/22, the day Patient #5 was admitted to the facility, did not indicate Patient #5 had a rib fracture.

A review of the nursing documentation entered into Patient #5's medical record revealed the patient had denied any pain on the left side of her body until 3/6/22 at 1:00 p.m., 22 hours after she was admitted to the facility. The nursing documentation entered at 1:00 p.m. on 3/6/22 stated Patient #5 reported pain in the upper quadrant of the left side of her body. On 3/7/22 at 6:22 a.m., nursing documentation revealed the patient experienced pain when turning.

According to the Incident Reporting/State Reportables policy, an incident report was required to be completed for any occurrence in the hospital which threatens the safety and well-being of patients or visitors and for events resulting in injury to patients, visitors, or staff.

The adverse event reporting log was reviewed and revealed staff did not complete an adverse event report when Patient #5's X-ray revealed a rib fracture two days after being admitted to the facility.

b. Leadership interviews revealed a lack of facility oversight and analysis of adverse events and lacked implementation of interventions to prevent reoccurrence.

i. On 4/26/22 at 2:55 p.m., the Director of Quality (Director) #24 was interviewed. Director #24 stated she oversaw the quality program, compliance and risk management. Director #24 stated her responsibilities included investigation, evaluation and tracking of adverse events. Director #24 stated she reviewed and investigated the adverse events and tracked and trended the adverse events reported at the facility.

Director #24 stated staff were required to complete adverse event reports for falls, medication and medical errors, suspected patient abuse and any patient harm event. Director #24 stated she reviewed and monitored adverse safety events at the facility. Director #24 stated staff completed adverse event reports to identify safety events which caused or could cause patient harm. Subsequently, she acknowledged, when staff did not complete adverse event reports, an investigation of the event would not occur.

Director # 24 stated adverse event reports were not completed by staff for Patient #3 and Patient #5. Director #24 stated the lack of incidents reported by staff resulted in potential harm to patients.

ii. On 4/26/22 at 2:53 p.m., an interview was conducted with CMO #14. CMO #14 stated an adverse event report should have been completed anytime patient dentures were lost or missing. CMO #14 stated an adverse event report was not completed when Patient #3's dentures went missing. CMO #14 stated there was no evidence an investigation, follow-up or mitigation was conducted to resolve the loss of Patient #3's dentures. CMO #14 stated Patient #3's dentures should have been replaced. CMO #14 stated staff were required to document what interventions were implemented for denture replacement and any dietary interventions required while Patient #3 was without dentures.

CMO #14 stated an adverse event report should have been completed when it was discovered Patient #5 had a new rib fracture and new onset of chest pain. CMO #14 stated an investigation for abuse was not performed when the rib fracture was discovered two days after Patient #5 was admitted to the facility. CMO #14 stated had staff completed an adverse event report for Patient #5 an investigation of the new rib fracture would have occurred.

CMO #14 stated staff failed to ensure adverse events report were completed for Patient #3 and Patient #5.

iii. On 4/20/22 at 3:15 p.m., Physician #15 was interviewed. Physician #15 stated on 3/7/22 he placed the order for Patient #5 to have a left rib unilateral x-ray performed. Physician #15 stated Patient #5 had left-sided rib pain after she was admitted and Patient #5's family reiterated the patient had new left-sided rib pain. Physician #15 stated the left rib unilateral x-ray revealed Patient #5 had a rib fracture to her ninth left rib. Physician #15 stated an adverse event report should have been completed when the rib fracture was discovered for Patient #5. Physician #15 stated he had not completed an adverse event report when the rib fracture was discovered.

iv. On 4/21/22 at 10:50 a.m., an interview was conducted with RN #25. RN #25 stated she was not aware of how to complete an adverse event report. RN #25 further stated she was not trained on how to complete an adverse event report. RN #25 stated she was instructed to initiate communication with the Director of Nursing (DON) #12 or the patient's physician if an adverse event occurred.

There was no evidence staff completed an adverse event report after the rib fracture to Patient #5's ninth left rib was discovered.

This was in contrast to facility policies. According to the Incident Reporting/State Reportables policy adverse safety events were reported for patients who were harmed or injured, when there was a suspicion of patient abuse and anytime the safety and wellbeing of a patient was threatened.

Furthermore, the QI Plan stated patient safety events were potential or actual adverse events resulting in harm or injury to a patient. Adverse events were required to be reported, investigated, reviewed and evaluated in order to prevent patient harm and to prevent adverse event recurrence.

2. The facility failed to ensure adverse event reports and patient safety processes were investigated, analyzed and tracked in order to identify contributing factors, implement preventive measures and prevent recurrence.

a. A review of adverse safety events from 4/1/21 through 4/28/22 revealed the facility failed to investigate adverse safety events and lacked implementation of preventive measures to reduce the risk of patient harm. Examples of adverse events not investigated included:

i. An adverse event was completed for Patient #10 on 1/26/22. Patient #10 had medicated cream used for chronic skin inflammation applied by two different nurses during the day. According to the medical record review, the medicated cream applied to Patient #10's skin had been discontinued when applied by nursing staff. Further review of the adverse event report revealed no evidence the facility investigated or implemented preventative measures to reduce and prevent a recurrence of the event.

ii. On 1/3/22 an adverse event was reported for Patient #29. The adverse event report stated the scanner used to scan medications was not used when medication was administered to Patient #29 and the wrong dose of medication was administered. A review of the adverse event report and the patient's medical record did not reveal which medication was administered incorrectly. Further review of the adverse event report revealed the facility had not investigated or implemented preventative measures to reduce and prevent the medication error from reoccurring.

iii. Patient #9 was administered 75 mg of Lyrica (a nerve pain medication) on 10/8/21. An adverse event was reported after the medication was administered to Patient #9. The adverse event report revealed Patient #9 was not prescribed Lyrica and the medication should not have been administered. Medical record review for Patient #9 confirmed Patient #9 had not been prescribed Lyrica. Further review of the adverse event report revealed no evidence the adverse event was investigated and preventative measures were implemented to prevent a recurrent adverse event.

iv. On 4/12/22 Patient #25 was administered 2.5 mg of Eliquis (a medication used to prevent blood clots from forming). According to the adverse event report, Patient #25 was not prescribed Eliquis and the medication had been prescribed for a different patient. Further review of the adverse event report revealed no evidence the facility investigated or implemented preventative measures to reduce and prevent a recurrence of the event.

An additional 36 adverse event reports were reviewed and revealed no evidence the facility investigated, reviewed, tracked and evaluated the adverse events to identify contributing factors and implement preventive actions.

There was no evidence the facility investigated, reviewed and evaluated the adverse events to identify contributing factors and implement preventive actions.

This was in contrast to the Incident Reporting/State Reportables policy which stated the initial investigation of adverse events will occur within five business days of the event occurring. A follow-up review of the adverse event will take place within 15 days of when the adverse event was reported. A final review of the adverse event will be performed by the risk manager and the risk management team to determine the need for a root cause analysis of the event. Adverse events will be monitored by the Risk Management team for trends and process improvements needed.

b. Interviews with staff revealed a lack of facility oversight and analysis of adverse events and the implementation of interventions to prevent reoccurrence.

ii. On 4/26/22 at 2:55 p.m., an interview was conducted with the Director of Quality (Director) #24. Director #24 stated there was a lack of adverse event investigations. Director #24 stated the facility was changing to a new adverse event reporting system on 5/1/22 and adverse events reported prior to the implementation of the new system had not been reviewed or investigated.

iii. On 4/26/22 at 2:33 p.m., an interview was conducted with Chief Medical Officer (CMO) #14. CMO #14 stated he was a Quality Officer and member of the Quality Improvement Committee. CMO #14 stated he performed medical record reviews to verify the QI performance indicators established at the facility were accomplished. CMO #14 stated he participated in the adverse event reviews conducted by Director #24.

CMO #14 stated adverse event reports were completed for situations that occurred outside the facility's normal scope of activity. CMO #14 stated when the safety of the patient was jeopardized and when patient harm occurred staff completed an adverse event report. CMO #14 stated adverse event reports assisted the facility to identify patient safety events, concerns and trends. CMO #14 stated staff were required to complete adverse event reports for the following types if adverse events: falls, medication errors, injury or harm of a patient, patient care concerns, suspicious actions or activities and when deviation of facility policies occurred.

CMO #14 stated he and Director #14 were working to implement a new adverse event reporting system throughout the facility. CMO #14 stated the old reporting system contained numerous adverse event reports which had not been reviewed, followed up on or investigated.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.645 Special Requirements for CAH Providers of Long-Term Care Services ("Swing-Beds") was out of compliance.

C-1624 §485.645(d)(7) Dental Services (§483.55(a)(2), (3), (4), and (5) and (b) of this chapter). §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. (a) Skilled nursing facilities. A facility- (2) May charge Medicare resident an additional amount for routine and emergency dental services; (3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; (4) Must if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and (5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. (b) Nursing facilities. The facility- (1) Must provide or obtain from an outside resource, in accordance with §483.70(g), the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; (4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and (5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Based on observations, interviews, and document review, the facility failed to promptly refer patients with lost or damaged dentures for dental services within three days of when the dentures were lost or damaged. Specifically, the facility failed to provide documentation of what was done to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay (Patient #3 and #8). (Cross-reference C0336).

Based on observations, interviews, and document review, the facility failed to promptly refer patients with lost or damaged dentures for dental services within three days of when the dentures were lost or damaged. Specifically, the facility failed to provide documentation of what was done to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay in two of two medical records reviewed of patients with lost dentures (Patient #3 and #8). (Cross-reference C0336).

Findings include:

Facility policies:

The Dental Services policy read, ensure patients receive dental services, including routine dental services. If a referral does not occur within three business days, documentation of the facility's actions to ensure the patient could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

The Incident Reporting/State Reportable policy read, the facility shall provide a reporting system for occurrences that are potentially hazardous to patients. Any occurrence in the hospital that threatens the safety and well-being of patients or visitors, or which results in an injury to patients, visitors, or staff. Examples of Incidents include loss of damaged patient or visitor personal property.

1. The facility failed to ensure patients received dental services in accordance with the facility's policy.

a. A review of Patient #3's medical record revealed Patient #3 was placed under hospice care on 7/29/21 until the patient passed away on 12/21/21.

i. On 9/20/21 a nutritional assessment documented by a dietitian read, the patient's diet was a mechanical soft diet (when foods were blended, ground, or finely chopped to make it easier for a patient to chew and swallow).

ii. On 9/25/21 a nursing note read, patient continued to have moderate difficulty with meals related to loss of dentures and dietary textures need to be adjusted. There was no indication of what was to be done about the lost dentures.

iii. On 9/26/21 a nursing note read, the patient declined the use of her BiPAP (a type of device to help with breathing) due to her lost dentures.

iv. On 10/21/21 a nursing note read, the case management left a message with the dental clinic to set up an appointment. The call was placed one month after the dentures were noted to be missing.

v. On 10/22/21 a nursing note read, the patient did not have dentures and three mouth sores had developed; one to the lower gum line and two to the upper gum line.

vi. On 10/27/21 a case management note read, dentist appointment was scheduled to be on 11/2/21.

vii. On 12/6/21 a nursing note read, patient was taken to dentist appointment.

The care provided to Patient #3 was in contrast to the facility's policy which read, dental services should be provided within three business days. The facility was unable to provide documentation as to why there was a delay in the patient receiving dental services. Additionally, the facility was unable to provide documentation of a diet change after the patient lost her dentures.

b. A review of Patient #8's medical record revealed Patient #8 had been admitted since 8/5/21 to a swing bed.

i. On 2/8/22 an incident report was submitted which read, staff noted the patient's partial denture had a missing tooth and staff was unable to locate the missing tooth in the room.

ii. On 3/24/22 a nursing note read, Patient #8 was taken to a dental appointment. The dental appointment was 44 days after the partial denture was documented as missing.

The medical record review was in contrast to the facility's policy which read, dental services should be provided within three business days. The facility was unable to provide documentation as to what led to the delay in Patient #8 receiving dental services.

c. On 4/18/22 at 12:53 p.m., an interview was conducted with Registered Nurse (RN) #17. RN #17 stated dentures were important since patients depended on them for eating. She further explained if a patient lost their dentures, staff were to complete an incident report. RN #17 stated there were numerous risks to a patient if they lost their dentures. RN #17 stated the risks included patients developing mouth sores from trying to chew their food without dentures and a decrease in the patient's overall food consumption which could lead to inadvertent weight loss and frailty. She further explained due to the weight loss and frailty, patients could rapidly become weak, have an increased risk for falls, become depressed and could even result in the death of the patient.

d. On 4/18/22 at 1:20 p.m., an interview was conducted with Registered Nurse (RN) #19. RN #19 stated patients could not eat without their dentures or partials which could lead to an increased risk for the patient to stop eating. If a patient's dentures were lost, the patient's dietary order was to be changed to accommodate the patient's inability to chew food. RN #19 stated if a patient lost their dentures, there was a risk the patient would experience a failure to thrive and there was the potential for the patient to die from an overall decreased quality of life.

e. On 4/21/22 at 12:32 p.m., an interview was conducted with Medical Doctor (MD) #20. MD #20 stated Patient #3 did not need an extensive follow up with a nutritional consultation due to the patient's hospice status. He stated Patient #3 would need her diet order changed from a regular diet to a mechanical soft diet in order to address her loss of dentures and to maintain her comfort. MD #20 explained if a patient did not have dentures, it could affect the patient's weight and overall outcome. MD #20 stated he did not believe the loss of Patient #3's dentures accelerated the patient's outcome. MD #20 stated he used the mid-arm circumference measurements to measure weight loss for Patient #3 since she was too weak to obtain weights on a scale.

f. On 4/21/22 at 1:09 p.m., an interview was conducted with Case Manager (CM) #21. CM #21 stated her responsibilities included the arrangement of services for any patient in the facility. CM #21 stated she did not have a specific timeline to arrange patients' services but attempted to complete them the same day the need was known. CM #21 stated she received a verbal notification from either the physician and/or the nurse for any services a patient may need. She explained, if a patient needed dentures, she would arrange an appointment with dental services and did not need a physician's order to make the appointment. CM #21 explained hospice patients had their own hospice providers, nurses, therapists and social workers who handled the patient's care and arranged their needs.

g. On 4/26/22 at 12:32 p.m., an interview was conducted with Registered Dietitian (RD) #22. (RD) #22 stated a patient's nutritional evaluation was done by obtaining the patient's weight. RD #22 stated nursing staff weighed every patient. She further explained if a patient had lost weight, the patient's oral (PO) intake was evaluated. RD #22 additionally explained the patient was checked for any wounds or sores and the patient's laboratory results would be reviewed. RD #22 stated the facility used a mid-arm circumference measurement to measure malnutrition (when a person metabolizes muscle storage due to lack of nutrition to maintain muscles). However, RD #22 further explained the mid-arm circumference measurement was not a measurement she used to evaluate malnutrition. RD #22 stated if a patient lost their dentures, the patient's diet order should have been changed and speech therapy should have been involved to assess the patient for the risk of aspiration.

h. On 4/26/22 at 2:24 p.m., an interview was conducted with the Chief Medical Officer (CMO) #14. CMO #14 confirmed if a patient lost their dentures, an incident report should have been completed by staff. He explained the incident report would allow the facility to follow up with dental services in order to replace dentures in a timely manner.

CMO #14's interview was in contrast to Patient #3's care. An incident was not completed when Patient #3 lost her dentures in order to implement dental care services.