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Based on record review and interview, facility staff failed to offer advance directives information to 2 of 2 surgical inpatient records (Patient #18, Patient #24) out of a total of 20 medical records reviewed.

Findings include:

Facility policy "Advance Care Planning/Directive" dated 1/16 states: "All adult patients will have an advanced care planning assessment by nursing staff. ...During the nursing admission process the advance directive status will be evaluated and advance directive record initiated. ...2) If no advance directive, does the patient want more information? When patient requests more information, the booklet or handout will be provided. ...Documentation: RN, social worker and advance directive facilitator will document all information and discussions pertaining to advance directive on the advance directive record (i.e. info given, refusal of info, changes in advance directive, obtaining DNR [do not resuscitate] orders)."

Patient #18 was admitted to the hospital through the surgical department on 1/2/2017 for a right total knee arthroplasty. Patient #18's medical record, reviewed on 1/18/2017 at 12:50 PM, includes an initial interview dated 1/2/2017 that states: "Advance Care Planning: Patient does not have an Advance Directive." The documentation does not include information about whether or not the patient was offered or requested advance directive information.

Patient #24 was admitted to the hospital through the surgical department on 11/14/2016 for a left total knee arthroplasty. Patient #24's medical record, reviewed on 1/18/2017 at 1:20 PM, includes an initial interview dated 11/14/2016 that states: "Advance Care Planning: Patient does not have an Advance Directive." The documentation does not include information about whether or not the patient was offered or requested advance directive information.

During an interview on 1/17/2017 at 2:45 PM, Spiritual Care Coordinator K stated patients are "asked upon admission if they have [Advance Directives] or not, if they don't they are asked if they would like to receive information. If yes, they are assigned to an Advance Care Planning facilitator."

The above findings were shared with Spiritual Care Coordinator K on 1/19/2017 at 8:55 AM. K stated "we need to clarify whose responsibility it is to ask if patients want more information" when patients are admitted through the surgical department. Spiritual Care Coordinator K went on to say, "it needs to be documented in the medical record."

Based on observation, staff interviews, and review of maintenance records between January 17 and January 19, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients


Findings include:

The facility was found to contain the following deficiencies.

K 161 Building Construction type
K 223 Doors with Self-Closingd DevisesMeans of egress requirements
K 254 Corridor Access
K 293 Exit Signage
K 311 Verical Openings Enclosure
K 321 Hazardous Areas
K 323 Anesthetizing Locations
K 351 Sprinklers Installation
K 353 Sprinklers Maintenace & Testing
K 372 Subdivision of Building Space Smoke Barrier
K 374 Subdivision of Building Space Smoke Barrier
K 920 Electrical Equipment Power Cords and Extensions

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, the facility failed to ensure bed bath warmer modules were operating correctly by not maintaining temperature logs of 2 of 2 warmers.

Findings include:

During a 1/17/2017 observation at 8:40 AM, the Emergency Department and the Medical Unit each had a SAGE Warmer for prepackaged bed bath products. Neither of these had temperature logs and the facility was unable to produce the logs or policy regarding maintenance for these modules.

During a 1/17/2017 interview at 8:40 AM with Staff F, it was stated "the warmer temperature is pre-set by the company, if it errors, the slot will show in red light and we notify the company." Staff F also stated "unsure how we would know if there is a malfunction with the module and the temperatures are off."

During a 1/19/2017 interview beginning 9:00 AM with Staff BB, it was stated "there are no temperature logs, but it is correct to say that we do not know if it malfunctions as the modules do not alarm. We did not think of implementing logs."

Based on observation, interview, and record review dietary staff failed to monitor refrigerator and/or freezer temperatures per facility policy in 1 of 1 Dietary department reviewed. Failure to follow policy and monitor refrigeration/freezing of food products has the ability to affect all patients serviced at this facility, including the 16.6 (averaged) patients present during the course of the survey.

Findings include:

Per interview with Director of Dietary Services T on 1/17/2017 at 10:00 AM regarding who is responsible for monitoring the temperatures of refrigerators and freezers in the facility, Director T stated that kitchen staff are responsible for checking and logging these throughout the building at the required time periods.

The facility policy titled, "Refrigeration of Dietary Food Stored Outside the Dining Services Department," dated 6/16, was reviewed on 1/17/2017 at 4:03 PM. The policy states in part, "Frequency of monitoring (checking the temperature) is daily with manual graphing on a log sheet when food is stored in the refrigerator and freezer."

A review of the temperature logs for the months of October, November, and December 2016 and through January 18, 2017 for 10 refrigerators and/or freezers in the kitchen area, and 4 refrigerators and/or freezers from nursing units was completed on 1/18/2017 at 11:45 AM with Director of Dietary Services T. It was noted that several of the refrigerators in the kitchen have "In" and "Out" logs. Director T clarified that "In" is the beginning of the day and "Out" is the end of the day. Director T confirmed the following findings:
Kitchen area:
Sunshine Cafe refrigerator In log missing 3 entries, Out log missing 72 entries.
Room Service freezer missing 5 entries.
Beverage walk in refrigerator In logs missing 2 entries, Out logs missing 3 entries.
Walk in freezer In logs missing 2 entries, Out logs missing 3 entries.
Produce walk in refrigerator In logs missing 3 entries.
Air Screen refrigerator missing 4 entries.
Prep station refrigerator missing 6 entries and has one that appears to be scribbled out and is unreadable.
Cook's refrigerator In logs missing 8 entries, Out logs missing 7 entries.
Undercounter freezer on the food service line missing 4 entries
Blast chiller refrigerator missing 2 entries.

Nursing Units (October-December 2016):
Intensive Care unit refrigerator missing 1 entry (there was a period of 29 days where no log was kept due to no refrigerator to monitor).
Emergency Room refrigerator missing 33 entries (freezer logs not provided).
Multicare Center (Medical/Surgical floor) refrigerator missing 3 entries, freezer missing 1 entry.
Birth Center refrigerator missing 5 entries, freezer missing 4 entries.

Based on observation, staff interviews, and review of maintenance records between January 17 and January 19, 2017, the facility failed to construct, install and maintain the building systems to ensure life safety to patients


Findings include:

The facility was found to contain the following deficiencies.

K 161 Building Construction type
K 223 Doors with Self-Closingd DevisesMeans of egress requirements
K 254 Corridor Access
K 293 Exit Signage
K 311 Verical Openings Enclosure
K 321 Hazardous Areas
K 323 Anesthetizing Locations
K 351 Sprinklers Installation
K 353 Sprinklers Maintenace & Testing
K 372 Subdivision of Building Space Smoke Barrier
K 374 Subdivision of Building Space Smoke Barrier
K 920 Electrical Equipment Power Cords and Extensions

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview, staff at this facility failed to review policies on an annual basis in 1 of 1 policy review regarding policies. Failure to review policies annually has the potential to affect all patients at this facility including the 16.6 (averaged) patients per day on the dates of the survey.

Findings include:

In an interview with Director of Health Information Management L on 1/17/2017 at 2:03 PM regarding the medical records department and responsibility/review of policies for medical records, Director L stated that review of policies is "ongoing" and added, "For sure every other year. Two years is what our requirements are."

The facility's policy titled, "Policies, Procedures and Forms Development," dated 1/16, was reviewed on 1/17/2017 at 2:40 PM. The policy states in part, "Due to our triennial (3 year) [accrediting organization name] clock of reviewing and revising documents, dates are kept on the document in order from oldest date to most recent date. Date(s) three years old and older can be deleted as each document is updated and a reviewed or revised date is added."

In an interview with Quality Director Q on 1/17/2017 at 4:35 PM, Director Q stated that not all policies are reviewed annually. Only those that affect patient care are. Director Q stated that policies such as personnel, budget and those that do not affect patient care are reviewed every 3 years.

In an interview on 1/18/2017 at 10:10 AM with President O and Chief Operating Officer P regarding the policy review and how this facility completes this, President O reaffirmed what Director Q stated on 1/17/2017 and added, "My guess is the every 3 year review is from [accrediting organization]."

In this same interview, Chief Operating Officer P stated, "I guess indirectly personnel policies do affect patient care. So does budget if you think about it."

Based on observation, interview, and record review clinical staff failed to follow facility policy regarding hand hygiene and glove changing in 4 of 7 observations of patient care (Patients #3 (had 2 separate observations), 8, and 9.). Failure to follow policy and maintain an environment that controls potential infections has the ability to affect all patients serviced at this facility, including the 16.6 (averaged) patients present during the course of the survey.

Findings include:

1. An observation of patient care (administration of a nebulizer treatment) was conducted with Respiratory Therapist N and Patient #3 on 1/17/2017 at 3:00 PM. After applying gloves and touching Patient #3's intact skin during a lengthy attempt to check a pulse oximeter, once obtained Therapist N moved to the computer to document, handled the vital sign monitor, nebulizer machine and pole with the contaminated gloves.

During the treatment Therapist N's phone rang. N removed one glove, removed the phone from N's pocket and replaced it back in the pocket, then went to the bathroom to remove the other glove and did hand hygiene. The contaminated phone was put back in the pocket without being cleaned.

These findings were discussed per interview with Infection Preventionist Y on 1/19/2017 at 8:10 AM. Infection Preventionist Y stated that it would have been ideal for Therapist N to remove gloves and do hand hygiene after touching the patient. Infection Preventionist Y stated, "It's the gold standard and would have been the best thing to do...its a gray area."

Infection Preventionist Y also stated that every time staff takes hands off the computer they are to do hand hygiene, and ideally Therapist N should have removed both gloves and did hand hygiene before answering the phone. Y stated, "Now you have a dirty item in the pocket. The failsafe is to disinfect the phone after use."


2. During an observation on 1/17/2017 beginning at 2:40 PM, Staff I performed wound care for Patient #8 on the front of lower right leg. After completing wound debridement, Staff I removed gloves and reached into the supply cabinet, without performing hand hygiene, and obtained dressing supplies. Staff I then donned a new pair of gloves to dress the wound, without performing hand hygiene prior. During an interview with Staff Y on 1/19/2017 at 8:40 AM, it was stated "that is not acceptable, it should never have happened."

3. During an observation on 1/18/2017 beginning at 11:50 AM, Staff Z performed a foley catheter removal on Patient #9. After removal of catheter, Z did not remove gloves and readjusted Patient 9's head of bed and blankets. During an interview with Staff Y on 1/19/2017 at 8:40 AM, it was stated "that was very much a breech of infection control and should not have happened."

4. During an observation on 1/18/2017 beginning at 12:04 PM, Staff AA administered Patient #3's Tuberculin test. AA typed on computer keyboard then proceeded to observe and touch Patient 3's arms without first performing hand hygiene, went back to the computer and typed on the keyboard, then back to Patient #3 and administered the medication without performing hand hygiene. During an interview on 1/19/2017 at 8:40 AM with Staff Y, it was stated "it is in the policy and training that staff is to perform hand hygiene after using a computer keyboard.

Policy review of Hand Hygiene, on 1/19/2017 at 9:00 AM, states: "WHEN TO PERFORM HAND HYGIENE,: After removing gloves and any other type of persona protective equipment (PPEs [personal protective equipment]). After using a shared computer (touch screen or keyboard), Before and after direct contact with patients, After moving from a contaminated body site to a clean body site during patient care, even when gloves are worn, After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressing, even when gloves are worn and hands are not visibly soiled."






37421

Based on record review and interview, nursing staff at this facility failed to appropriately assess a surgical incision upon admission and throughout the patient's hospitalization in 1 of 1 patients (Patient #23) who was admitted with a recent surgical incision out of a total of 20 medical records reviewed. Failure to assess incisions/wounds has the potential to affect all patients served at this facility, including the 16.6 (averaged) patients present during the course of the survey.

Findings include:

The facility policy titled, "Assessment/Reassessment Policy for MCC [multicare center]," dated 5/16, was reviewed on 1/19/2017 at 8:25 AM. The policy states in part, "All admissions to Mulitcare Center will have:...A complete Initial Physical Assessment, within 8-hours of admission to the unit."

Patient #23's closed medical record was reviewed on 1/18/2017 at 3:25 PM accompanied by Assistant Director R who confirmed the following:

Patient #23 was admitted to the facility on 12/6/2016 with a urinary tract infection and sepsis (diffuse infection in the blood stream). Patient #23 had a previous amputation of the 5th toe on the left foot on 11/30/2016 at an alternate facility for gangrene (a condition that happens when body tissue dies, caused by a decreased supply of blood due to injury, illness, and/or infection). Patient #23 was discharged from this facility on 12/9/2016 to a skilled nursing facility.

Upon admission on 12/6/2016 there was no nursing assessment of the surgical incision site of the left foot. The initial nursing database indicates, "Dressing dry and intact."

There is no indication throughout Patient #23's hospitalization that the surgical incision was assessed by nursing other than stating, "dressing dry and intact". There are no orders from the physician to address the surgical site. There is no documentation in progress notes from the physician or nursing regarding the surgical wound.

Per interview with Assistant Director R on 1/18/2017 at 3:40 PM regarding the lack of documentation and assessments of the left foot surgical wound, Assistant Director R stated that there should be some sort of documentation addressing this wound and there is not.

Based on record review and interview, nursing staff at this facility failed to develop nursing care plans that are individualized and/or address the needs of the patient in 10 out of 14 out of a total of 20 medical records reviewed (Patients #3, 18, 19, 20, 21, 22, 23, 24, 27, and 28).

Findings include:

Facility policy "Assessment/Reassessment Nursing Policy" dated 5/2016 states: "The patient plan of care is developed by nursing in collaboration with other disciplines or agencies, based on existing plan of care, medical orders and patient needs. ...Plan of care revisions shall be completed and documented according to changing patient needs. Nursing interventions shall be based on the patient needs, their plan of care and/or patient reassessments. Documentation: nursing interventions and patient responses will be documented according to unit protocol."

Patient #19's closed Swing Bed medical record was reviewed on 1/18/2017 at 12:41 PM accompanied by Assistant Administrator R who confirmed the following: Patient #19 was admitted to Swing Bed on 10/14/2016 for strengthening needs after being admitted to acute care for frequent falls with multiple abrasions and cellulitis (inflammation of the tissues).

Patient #19's goal for skin integrity is, "skin remains intact, non erythematous [red]."


Per interview with Assistant Director R on 1/18/2016 at 1:06 PM regarding patient care plans, Assistant Director R stated that nursing staff follow the practitioner orders and standing orders that are on the MedAct (patient plan of care generated by inputting physician orders) and nurses are supposed to put at least 2 problems related to the patient's needs and goals for those problems.


Patient #20's closed Swing Bed medical record was reviewed on 1/18/2017 at 1:45 PM accompanied by Assistant Administrator R who confirmed the following: Patient #20 was admitted to Swing Bed on 12/1/2016 for strengthening needs after receiving a cardiac pacemaker.

Patient #20's goal for skin integrity is, "skin remains intact, non erythematous."


Patient #21's closed medical record was reviewed on 1/18/2017 at 2:12 PM accompanied by Assistant Administrator R who confirmed the following: Patient #21 was admitted to the medical floor on 10/7/2016 with symptoms of a potential stroke.

Patient #21's goal for skin integrity is, "skin remains intact, non erythematous."


Patient #22's closed medical record was reviewed on 1/18/2017 at 2:35 PM accompanied by Assistant Administrator R who confirmed the following: Patient #22 was admitted to the medical floor on 11/4/2016 with weakness, falls, and anemia.

Patient #22's goal for skin integrity is, "skin remains intact, non erythematous."


Per interview with Assistant Director R on 1/18/2017 at 3:02 PM regarding individualizing patient goals to reflect the needs of the patients, and the discovery that all 4 of the patients reviewed have the same exact goal but different problems, Assistant Director R stated, "So they are not making them patient specific." Assistant Director R stated that staff are able to go in to the goal and change it to make it specific to the patient.


Patient #23's closed medical record was reviewed on 1/18/2017 at 3:25 PM accompanied by Assistant Director R who confirmed the following:

Patient #23 was admitted to the facility on 12/6/2016 with a urinary tract infection and sepsis (diffuse infection in the blood stream). Patient #23 had a previous amputation of the 5th toe on the left foot on 11/30/2016 at an alternate facility for gangrene (a condition that happens when body tissue dies, caused by a decreased supply of blood due to injury, illness, and/or infection).

There is no nursing care plan, problems or goals addressing any of Patient #23's needs.


Patient #28's closed medical record was reviewed on 1/19/2017 at 8:34 AM. Patient #28 was admitted to the medical floor on 11/22/2016 with an infection in the right foot and Type I Diabetes. Patient #28 has no problems or goals that reflect Diabetes.

Per interview with Assistant Director R on 1/19/2017 at 8:40 AM regarding Patient #28's nursing care plan, Assistant Director R stated, "Yes, Diabetes should be on there."


34337


Per medical record review on 1/18/2017 at 12:50 PM, Patient #18 was admitted to the facility on 1/2/2017 following right total knee arthroplasty. Patient #18's care plan includes a problem for impaired physical mobility. The problem is documented as "addressed" on 1/5/2017 but there are no goals or interventions associated with the problem. Patient #18's care plan includes a problem for activity intolerance related to pain with a goal of "return to baseline activity." Baseline activity is not identified for the patient. There is no documentation of Patient #18's progress toward goals or resolution of the goals at the time of discharge on 1/5/2017.

These findings were shared with Vice President of Clinical Care G on 1/18/2017 at 4:05 PM. During an interview on 1/18/2017 at 4:05 PM, G stated the goal does not appear to be individualized to Patient #18 as Patient #18 was admitted for knee surgery and would not likely return to baseline (pre-surgery) activity levels by discharge.

Per medical record review on 1/18/2017 at 1:20 PM, Patient #24 was admitted to the facility on 11/14/2016 following left total knee arthroplasty. Patient #24's care plan includes problems for acute pain and risk for impaired tissue integrity. Goals state: "skin remains intact, non erythematous" for the problem of risk for impaired tissue integrity and "subjective report of pain using appropriate pain scale" and "desired relief/control of pain achieved" for the problem of pain. The goals are not individualized or specific to the patient. There is no documentation of Patient #24's progress toward the goals or resolution of the goals at the time of discharge on 11/18/2016.

Findings for Patient #18 and Patient #24 were shared with Director H at the time of the review. H stated "we don't document a summation of the plan of care when the patient leaves." When asked how progress toward goals is documented, H stated staff are expected to address the problems every shift and that should be indicated by a note stating "addressed."

Per medical record review on 1/18/2017 at 3:25 PM, Patient #3 was admitted to the hospital on 1/5/2017 with shortness of breath. Patient #3's care plan includes a problem of acute confusion with a goal of "mental status returns to baseline" and a problem of activity intolerance with a goal of "reports decreasing dyspnea during activity or exercise." The goals are not specific and measurable as written. The care plan does not include interventions designed to facilitate the patient meeting the goal. There is no documentation of Patient #3's progress toward the goals.

Per medical record review on 1/18/2017 at 3:40 PM, Patient #27 was admitted to the hospital on 1/15/2017 with generalized weakness and falls at home. Patient #27's care plan includes a problem of risk for falls with a goal of no falls. On 1/18/2017 Patient #27 was diagnosed with pneumonia. There are no nursing problems, goals or interventions related to Patient #27's impaired mobility and/or activity intolerance. These findings were shared at the time of the review with Director H. When asked if Patient #27 would be considered high risk for pneumonia, in part due to impaired mobility, H stated "yes." When asked what interventions staff had been using to help mitigate Patient #27's risk for pneumonia, H had no response.

Based on observation and interview, staff at this facility failed to maintain medical record confidentiality in 1 of 2 record storage areas observed. Failure to maintain medical record confidentiality has the potential to affect all patients receiving services at this facility, including the 16.6 (averaged) patients present on the dates of the survey.

Findings include:

An observation of Storage room 6 G10 was conducted on 1/17/2017 at 2:16 PM accompanied by Director of Health Information Management L and Safety Director E. There were numerous radiology log books, which included patient names and birthdates in large cabinets with sliding doors that were not secured.

Also observed were approximately 5 large bins (approximately 3 1/2 feet tall by 2 feet in diameter) full of x-rays and reports with visible patient information on them.

This storage room housed numerous beds and cribs and other medical equipment.

In an interview with Safety Director E at the time of the observation regarding who had access to this room, Director E stated, "Anyone can get in here."

The facility policy titled, "Security/Retention of Patient Information/Medical Records Policy," dated 1/17, was reviewed on 1/17/2017 at 4:05 PM. The policy states in part, "All confidential documents in paper form that are no longer needed, must be destroyed by placing them in the appropriate containers for destruction."

Based on observation, record review and interview, the facility staff failed to ensure surgical staff follow proper aseptic techniques in an effort to minimize risk to patients in 1 of 1 surgical departments observed (Surgical Services) and failed to document post-anesthesia evaluations in 4 of 4 patient records reviewed (Patient #18, Patient #24, Patient #25, Patient #26). This deficiency has the potential to affect all patients receiving surgical services at this facility.

Findings include:

Facility staff failed to document a post-anesthesia evaluation for 4 of 4 surgical patients. See tag C322.

Infection Control -- Medication Administration

Facility policy "Medication Procedure -- Part 1: Administration of Medications, Vaccinations and Reporting of Drug Events" dated 8/2016, states: "Medication vial septum and IV [intravenous] access port must be disinfected with alcohol pad and allowed to air dry before accessing."

On 1/18/2017 at 9:10 AM, Certified Registered Nurse Anesthetist V was observed accessing 4 different medication vials with a needle and syringe without disinfecting the septum of the vial with alcohol in preparation for use for Patient #4's surgery.

During an interview on 1/19/2017 at 8:15 AM, Infection Preventionist Y stated "They are expected to clean and disinfect that [medication vial septum]. That is our policy."

Infection Control -- Surgical Attire

Facility policy "Surgical asepsis: Surgical attire" dated 5/2016, states: "Put on a surgical head cover or hood and ensure that all hair and facial hair, including sideburns, are covered to prevent hair, dandruff, and microoganisms from falling onto the sterile field."

During observations in the surgical department on 1/18/2017 from 7:45 AM to 3:00 PM, male staff members were observed wearing skull caps in the operating rooms leaving hair exposed.

During an interview on 1/18/2017 at 11:30 AM, Surgical Services Director W stated "all hair should always be covered."

AORN [Association of periOperative Registered Nurses] Guidelines for Perioperative Practice, 2016 Edition, states: "Cell phones, tablets, and other personal communication or hand-held electronic equipment should be cleaned with a low-level disinfectant according to the manufacturer's instructions for use before and after being brought into the perioperative setting."

On 1/18/2017 at 8:05 AM, while assisting the set up of the sterile field in Operating Room #1 in preparation of Patient #4's surgery, Registered Nurse X was observed using a personal cell phone held in a carrying case along with credit cards and paper.

During an interview on 1/18/2017 at 11:30 AM, Surgical Services Director W stated the surgical staff use their personal cell phones in the surgical department in order to "communicate with each other." Per W, the facility does not have a policy directing the use of personal cell phones in the department but the facility follows AORN Guidelines for standards of care. Director W stated staff have not been educated to disinfect phones upon entering or exiting sterile or semi-sterile areas and stated it was not a common practice to disinfect phones used for personal use outside of the surgical department. When asked about the cell phone carrying case observed in Operating Room #1, W stated "I'm not sure how something like that could be disinfected."

Infection Control -- Surveillance

AORN Guidelines for Perioperative Practice, 2016 Edition, states: "Health care personnel should receive education, training, and competency validation on surgical hand hygiene products and procedures. ...Health care personnel should demonstrate proficiency in surgical hand hygiene practices and the use of surgical hand hygiene products periodically and when new products are introduced. Periodic performance monitoring should also take place. ...Hand hygiene practices should be measured to determine compliance."

During an interview on 1/17/2017 at 1:05 PM, Infection Preventionist Y stated surgical site infections were a focus area of improvement over the previous year. Per Y a number of interventions had been initiated to reduce the number of surgical site infections at the facility, none of which included hand hygiene or sterile technique auditing. Y stated there was no active hand hygiene surveillance being done in the surgical department.

During an interview on 1/18/2017 at 11:30 AM, Surgical Services Director W stated scrub techniques are addressed during new employee orientation but there was not a process in place to observe or audit for compliance with hand hygiene, scrub technique or sterile technique on a regular basis after the initial orientation.

On 1/19/2017 at 8:15 AM, when asked about the involvement of the Infection Preventionist in hand hygiene surveillance in the surgical department, Infection Preventionist Y stated "I have not gone in [the surgical department] in about 2 years."

Based on record review and interview, facility staff failed to document a post-anesthesia evaluation in 4 of 4 surgical patient records reviewed (Patient #18, Patient #24, Patient #25, Patient #26) out of a total of 20 medical records reviewed. This has the potential to affect all patients receiving anesthesia services at this facility.

Findings include:

Facility policy "Anesthesia Policy" dated 7/2016, states: "Post-Anesthesia Follow-up: The anesthetist is to follow-up with a visit the first day post-op and documents this visit on the postoperative record."

During an interview on 1/18/2017 at 11:05 AM, Anesthesia Director J stated "we see everybody" prior to discharge, "inpatients we will see the next day." J stated the post-anesthesia evaluation is documented in the post-operative section of the "Anesthesia Assessment" form.

Patient #18 underwent general anesthesia on 1/2/2017 for a right total knee arthroplasty from 10:55 AM to 1:25 PM. Patient #18's medical record includes an anesthesia record with post-op note that states: "Satisfactory except:" There is no documentation in the post-op evaluation section of the form. The note is signed and dated 1/2/2017, the note is not authenticated with a time.

Patient #24 underwent regional anesthesia on 11/24/2016 for a left total knee arthroplasty from 9:20 AM to 11:45 AM. Patient #24's medical record includes an anesthesia record with post-op note that states: "Satisfactory except:" There is no documentation in the post-op evaluation section of the form.

Patient #25 underwent general anesthesia on 12/15/2016 for a left lower extremity phlebectomy from 11:22 AM to 2:15 PM. Patient #25's medical record includes an anesthesia record with post-op note that states: "Satisfactory except:" There is no documentation in the post-op evaluation section of the form. The note is signed and dated 12/15/2016, the note is not authenticated with a time.

Patient #26 underwent general anesthesia on 12/27/2016 for a laparoscopic appendectomy from 2:00 PM to 2:50 PM. Patient #26's medical record includes an anesthesia record with post-op note that states: "Satisfactory except:" There is no documentation in the post-op evaluation section of the form.

The above findings were shared with Anesthesia Director J on 1/18/2017 at 2:35 PM. When asked what the post-anesthesia evaluation includes, J stated "we ask about memory, pain, sore throat, nausea. We look at the vitals." When asked about the documentation of the post-anesthesia evaluation, J stated "I can see how that is not enough to meet the regulations."

Based on record review and interview, staff at this facility failed to disclose, on a transfer/discharge notice, where a Swing Bed patient would be discharged to in 2 of 2 closed Swing Bed medical records reviewed (Patient #19 and 20). Failure to disclose discharge destination has the potential to affect all Swing Bed patients serviced by this facility (there were 0 present at the time of this survey).

Findings include:

In an interview on 1/17/2017 at 11:30 AM with the Director of Multicare Center (Medical/Surgical unit) H, Assistant Director R, and Nurse Case Manager M regarding the discharge/transfer notice to Swing Bed patients, Nurse Case Manager M stated that the current notice does not have a discharge/transfer destination on it.

Medical Record reviews on Patient #19 and 20's closed Swing Bed records on 1/18/2017 at 12:41 PM and 1:45 PM respectively, confirmed that the discharge/transfer notice did not have the destination on.

These findings were confirmed at the time of the medical record reviews by Assistant Administrator R who assisted with navigating the electronic medical record.

Based on record review and interview, staff at this facility failed to provide activity assessments for 2 of 2 Swing Bed patients (Patient #19 and 20). Failure to complete activity assessments for Swing Bed patients has the potential to affect all patients in Swing Bed status serviced by this facility (there were 0 present at the time of this survey).

Findings include:

In an interview on 1/17/2017 at 11:30 AM with the Director of Multicare Center (Medical/Surgical unit) H, Assistant Director R, and Nurse Case Manager M regarding the swing bed activity assessment, Director H stated, "Any staff member can do the activity assessment." Assistant Director R stated, "Each Swing Bed patient has a consult or activities."

In an interview on 1/18/2017 at 11:35 with Director H and Vice President of Clinical Care G regarding Swing Bed activity assessments, H and G disclosed that for approximately the past 3-4 months the activity director has not been getting electronic notices that there was a new swing bed patient to assess. Vice President G stated that as the Director, S would get a referral, do the assessment and set up the activities program for the patient.

Patient #19's closed Swing Bed medical record was reviewed on 1/18/2017 at 12:41 PM. Patient #19 was admitted to Swing Bed on 10/14/2016 for strengthening needs after being admitted to acute care for frequent falls with multiple abrasions and cellulitis (inflammation of the tissues). Patient #19 was discharged against medical advice on 10/21/2016.

There is no documented activity assessment for Patient #19.


Patient #20's closed Swing Bed medical record was reviewed on 1/18/2017 at 1:45 PM. Patient #20 was admitted to Swing Bed on 12/1/2016 for strengthening needs after receiving a cardiac pacemaker and discharged on 12/4/2016.

There is no documented activity assessment for Patient #20.

These findings were confirmed by Assistant Director R on 1/19/2017 at 8:25 AM after R conducted an independent review of Patient #19 and 20's electronic medical records to look for the assessment. Assistant Director R stated, "It was not done, it is not there."

On 1/19/2017 at 9:00 AM Activity Director S provided the facility policy titled, "Swing Bed Activity Department," dated 5/16. The policy states in part, "The activity department will also be notified of any new admissions on the swing bed referral form....Within 24 hours or on the next working day the Activity Director or Activity Aide Coordinator shall assess the patient's needs, interest, and ability to participate in the activity program..."

Based on record review and interview, staff at this facility failed to obtain a dental contract or agreement to provide services/make arrangements for Swing Bed patients in 1 of 1 Swing Bed program reviewed. Failure to provide for dental services has the potential to affect all Swing Bed patients serviced at this facility (there were 0 Swing Bed patients during the course of this survey).

Findings include:

A review of the "Swing Bed Patient's Bill of Rights/Responsibilities," dated 1/17, states in part, "Clinical Rights:...Be assisted with arranging routine or emergent dental care appointments and transportation..."

In an interview on 1/17/2017 at 11:30 AM with the Director of Multicare Center (Medical/Surgical unit) H, Assistant Director R, and Nurse Case Manager M regarding a contract or agreement with a dentist for Swing Bed patients, none of the staff present were aware if one was in place.

In an interview with Director of Health Information Management L (who also oversees Medical Staff bylaws) on 1/18/2017 at 9:15 AM, Director L stated that the facility does not have a Dentist on staff.

On 1/18/2017 at 11:35 AM Director H confirmed, through speaking with President O, that the facility does not have a contract/agreement for dental services for Swing Bed patients.