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Based on observation, interview, review of clinical record, staff schedule and posted memos from 03/09-03/11/15, it was determined the Governing Body failed to effectively discharge it's oversight responsibilities to assure quality health care was provided in a safe environment for 3 of 3 patients (#4, #7 and #8) with orders for telemetry.

Observation on 03/09/15 and 03/10/15 revealed the telemetry transmission for Patient #4, #7 and #8 was not continuously monitored by trained and qualified staff and it could not be assured any unusual pattern, rate or potentially lethal arrhythmia would be identified to allow prompt intervention. The failed practice created an Immediate jeopardy to the health and safety of Patients #4, #7 and #8 and would affect all patients admitted with orders for telemetry. See CMS A-0385

Based on policy review and interview, it was determined the Facility failed to ensure the policy regarding abuse of a patient by a staff member had a provision as to a timeframe for an investigation and failed to have a provision as to how the patient would be protected during the investigation. The failed practice did not allow the Facility to be knowledgeable, proactive and timely in responding to allegations of patient abuse by staff and could affect any patient alleging abuse. Findings follow:

A. Review of policy provided titled "Internal Abuse" contained no guidance as to a timeframe for investigation of an abuse allegation and contained no provision as to how the patient would be protected during that investigation.

B. During an interview on 03/11/15 at 1020, the Chief Nursing Officer confirmed the abuse policy did not contain the required elements.

Based on QA (Quality Assurance) Meeting Minutes review for April 2014 through January 2015 and interview, it was determined the Facility failed to ensure laundry contracted services was included in the QA Program. The failed practice did not ensure the Governing Board was responsible for all aspects of the Facility and created the potential to affect any patient utilizing contracted services. Findings follow:

A. Review of QA Meeting Minutes for April 2014 through January 2015 revealed laundry services were not included in the QA Program.

B. During an interview on 03/11/15 at 0925, the Director of Quality Improvement confirmed there was no QA for Laundry Services.

Based on observation, interview, review of clinical records, staff schedule, policy and procedures and posted memos, it was determined the Facility failed to assure 3 of 3 patients (#4, #7 and #8) on telemetry were monitored in order to identify unusual patterns, rate or potentially lethal arrhythmias. Failure to monitor telemetry would not allow potentially lethal arrhythmias to be identified and prompt treatment to be provided. The failed practice created an Immediate Jeopardy to the health and safety of patient #4, #7 and #8 and would affect all patients admitted with orders for telemetry. The findings were:

A. Continuous observation by Surveyor#1 on 03/09/15 from 1508-1520 of the telemetry monitor at the nursing station revealed no staff was present at the nurses station.

Continuous observation by Surveyor #1 on 03/09/15 from 1531-1542 of the telemetry monitor at the nursing station revealed no staff was present at the nurses' station.

Continuous observation by Surveyor #1 on 03/09/15 from 1542-1545 of the telemetry monitor at the nursing station revealed no staff was present at the nurses station.

Continuous observation by Surveyor #1 on 03/10/15 from 0721-0744 of the telemetry monitor at the nursing station revealed no staff was present at the nurses station.

B. On 03/09/15 at 1525, RN #5 stated by interview the patients on telemetry were monitored via the telemetry transmission to the screen at the nursing station, "the one in the ICU is broken". RN #5 was asked who monitored the telemetry and she stated "The nurses at the nurse's station watch it."

On 03/10/15 from 0755-0758, RN #6 was asked by Surveyor how telemetry patients were monitored. RN #6 stated, "We check the printer first thing in the morning and then about every hour, which I haven't done yet this morning. We print off the strips a couple of times per shift, usually at the beginning of the shift." RN #6 proceeded to the printer located in the ICU. The ICU did not have patients. RN #6 picked up two pieces of paper from the printer and reviewed with Surveyor. RN#6 stated, "I guess they forgot to pick these up." The pages were titled "All strips report" for telemetry. The report for Patient #7 was printed on 03/09/15 at 0150; for Patient #8 the report was printed on 03/09/15 at 0656 with a system event stamp for "Asystole" auto generated by the system. RN#6 was asked by Surveyor how they would know if someone had seen the telemetry printout. RN#6 stated, "they usually initial the page, at least that's what we are supposed to do." RN #6 confirmed the date and times of the reports removed from the telemetry strip printer and that there was no signature or initials on the telemetry report.

RN #6 Stated by interview on 03/10/15 at 1450 that alarms for the telemetry on the monitor at the nursing station were not audible to staff when in a patient room.

C. Clinical record review for Patient #4 revealed a 62 year old male. An EKG performed 03/06/15 at 1725 revealed "Sinus Tachycardia rate >99; Minimal ST depression". An order for telemetry was noted for 03/06/15 at 2055.

Clinical record review for Patient #7 revealed a physician order on 03/07/15 at 0847 for "Transfer to M-Surg (Medical/Surgical) with Telemetry".

Clinical record review for Patient #8 revealed an order for telemetry on 03/09/15 at 1259.

D. The Facility schedule was provided by the CNO for 03/01-03/28. On 03/09-03/10/15 document review revealed 20 of 20 Registered Nurse (RN) Staff and 1 of 1 Licensed Practical Nurse (LPN) scheduled on the employee roster for 03/01-03/28/15 and all had evidence of current ACLS (Advanced Cardiac Life Support).

E. A policy and procedure, revised 02/04/04 was provided 03/10/15 by the CNO for Med-Surg Telemetry which stated "Patients ordered per their physicians to have cardiac monitoring per telemetry will be assigned to a room on the Med/Surg or Senior Care Unit and their telemetry observed and documented per the Charge Nurse on the Med/Surg Unit each shift." The procedure stated "The EKG transmission from the telemetry units will be monitored per the Med/Surg nurse on duty. Should an unusual pattern or rate appear, or the alarm sound, a nurse on the Med/Surg will check with the patient immediately. If any concerns regarding the patient's status the Med/Surg Charge Nurse will proceed quickly to the patient's room and assess the status. Any abnormal arrhythmia noted in the patient's EKG patter, the Charge Nurse and?or the ICU nurse will notify the staff and/or the physician of this change. A rhythm strip will be run and placed on each telemetry patient's chart at the beginning of each shift per the Charge Nurse on the Med/Surg Unit." On 03/10/15 at 1545 the CNO confirmed this was the current policy for Telemetry.

F. On 03/09/15 an "Interoffice Memorandum" from the QI/CM Director was noted posted at the nursing station. The memorandum was dated 02/12/15 and stated: "Due to staff not being present at the desk around the clock, the Telemetry printer must be checked hourly. This will help us to determine if a patient on telemetry has had an arrhythmia that may not have been reported to the nurse by the patient. By checking the printer hourly, we will be able to provide needed care in a much timelier manner."

This was confirmed by the Director of QA/Case Management 03/10/15 at 1515.

G. After a written plan was received from the Facility on 03/11/15 at 1430, the Immediate Jeopardy was abated with the following plan: "Plan of Action to remove Immediate Jeopardy for lack of monitoring of telemetry patients. The standard and preferred monitoring and hand off of telemetry patients will be as follows: The qualified Charge Nurse assigned to monitor telemetry patients will hand off the monitoring responsibility to another qualified staff member if this staff member must leave the monitoring area. In the circumstance that there is no immediate access to another qualified staff member to hand off telemetry monitoring to, the action will be as follows: The assigned nurse will take the portable audio/video monitor from the nurses's station with her when leaving the monitoring area in order to visually monitor the telemetry from any location on the Med/Surg Unit. This portable unit will also provide the nurse audible monitoring of alarms from the telemetry system, but does not limit the nurse to only respond to alarms when away from the monitoring station. Current staff on duty has been educated on this process and has provided both verbal and demonstrated back through direct observation by the CNO (Chief Nursing Officer) that this process is understood. A memo and in-service to other applicable staff will be provided as shifts change until all appropriate staff have been educated and shown competency in utilizing this process beginning immediately."

On 03/09-03/10/15 document review revealed 20 of 20 Registered Nurse (RN) Staff and 1 of 1 Licensed Practical Nurse (LPN) scheduled on the employee roster for 03/01-03/28/15 had evidence of current ACLS (Advanced Cardiac Life Support). Observation on 03/11/15 at 1530 and 03/12/15 at 1220 revealed staff were absent from the nursing station but a RN with ACLS had the portable audio/video monitor with the telemetry screen visible and alarms were audible. Review of position descriptions revealed ACLS was not required for RN or LPN Staff.

Based on observation, interview, review of clinical records, staff schedule, policy and procedures and posted memos, it was determined the Facility failed to assure 3 of 3 patients (#4, #7 and #8) on telemetry were monitored in order to identify unusual patterns, rate, or potentially lethal arrhythmias. Failure to monitor telemetry transmission results would not allow potentially lethal arrhythmias to be identified and prompt treatment to be provided. The failed practice created an Immediate Jeopardy to the health and safety of patient #4, #7 and #8 and would affect all patients admitted with orders for telemetry. See CMS A-0385

Based on review of policy, review of clinical records and interview, it was determined the Facility failed to assure nursing staff followed physician orders for 2 (#11 and #17) of 10 (#11-20) surgical patients. Failure to follow physician orders did not assure patients received medications determined appropriate by their physician and was likely to affect all patients in the Facility. Findings follow:
A. Review of policy titled Medication Policies stated, "All drugs, both legend and non-legend, are to be administered to patients only upon the written authorization of a physician with clinical privileges, or after verbal order to a licensed person."
B. Review of clinical record for Patient #17 revealed a Post-Op (Operative) order for Morphine 3-4 mg (milligram) IV (Intravenous) every ___ (missing frequency)hours prn (as needed) for pain, dated 02/17/15. Review of Post Anesthesia Recovery Record revealed Demerol 12.5mg was given IV push on 02/17/15 at 1000. No evidence of an order for Post-Op Demerol.
C. Review of clinical record for Patient #11 revealed a Post-Op order for Hydrocodone/Acetaminophen 5/325 mg one tablet po (by mouth) every ___ (missing frequency) hours prn for pain, dated 02/26/15. Review of Post Anesthesia Recovery Record revealed Hydrocodone 5/325 mg two tablets given at 1315. No evidence of an order for Post-Op Hydrocodone 5/325 mg two tablets.
D. During an interview on 03/13/15 at 0950, the Operating Room Nurse Supervisor verified the the findings in B and C.

Based on review of Medical Staff Rules and Regulations, review of surgical clinical records and interview, it was determined the facility failed to ensure physician's completed their orders for the frequency of medication administration in 4 (Patients #11, 17, 19 and 20) of 10 (#11-20) surgical patients. By not completing the orders, the nurses were not aware of the treatment determined appropriate by the patient's physician and had the likelihood to affect all patients in the facility. Findings follow:
A. Review of Medical Staff Rules and Regulations stated "The physician must order drugs by name, dose, route, and frequency of administration."
B. Review of surgical clinical records revealed the following incomplete orders:
1) Patient #11: Hydrocodone/Acetaminophen 5/325 mg (milligram) (Lortab) one tablet po (by mouth) every ___(missing frequency) hours prn (as needed) for pain;
2) Patient #17: Morphine 3-4 mg IV every __ (missing frequency) hours prn pain;
3) Patient #19: Hydrocodone / Acetaminophen 5/325 mg (Lortab) one tablet po every ___(missing frequency) hours prn for mild pain; and
4) Patient #20: Hydrocodone / Acetaminophen 5/325 mg (Lortab) one tablet po every ___(missing frequency) hours prn for mild pain.
C. During an interview on 03/13/15 at 0950, the Operating Room Nurse Supervisor verified the incomplete orders.

Based on review of policies, review of clinical records and interview, it was determined the facility failed to ensure patients' responses to PRN (as needed) medications were documented (per policy) in 5 (#1, #3, #5, #6 and #10) of 10 (#1-10) in-patient records. By not documenting a patient's response to PRN medications, physicians and other health care providers were not fully informed of the patient's condition in order to help them make decisions on the provision of care to the patients. The failed practice had the likelihood to affect all patients who receive PRN medications. Findings follow: The bottom line for outcome is really not being able to determine if pain medications were effective in relief of pain symptoms.

A. Review of policy titled "Charting Requirements for Nursing Units" stated "Charting is to include time, medication, dosage, route, site name and title of person administering medication. Patient's response will be charted; in nurses notes and on the back of the note in the prn section and pain sheet."
B. Review of Pharmacy policy titled "Administration of Drugs: Documentation of in Patient's Records" stated "Note the patient's response to PRN drugs."
C. Review of the policy titled "Patient Assessment and Reassessment Plan" stated "The nurse's notes and medication record will show appropriate documentation of pain medication and patient's response."
D. Patient #1: Review of clinical record and Medication Administration Record (MAR) from 02/06/15 to 02/13/15 revealed 30 doses of PRN medication administration with no evidence 17 had documentation of the patient's response. Findings were verified on 03/13/15 at 0955 by the CNO (Chief Nursing Officer).
E. Patient #3: Review of clinical record and MAR from 03/06/15 to 03/09/15 revealed 22 doses of PRN medication administration with no evidence 16 had documentation of the patient's response. Findings were verified on 03/13/15 at 0940 by CNO.
F. Patient #5: Review of clinical record and MAR from 03/03/15 to 03/12/15 revealed 39 doses of PRN medication administration with no evidence 32 had documentation of the patient's response. Findings were verified on 03/12/15 at 1315 by the Director of Quality Improvement/Case Management.
G. Patient #6: Review of clinical Record and MAR from 03/07/15 to 03/10/15 revealed 10 doses of PRN medication administration with no evidence 7 had documentation of the patient's response. Findings were verified on 03/13/15 at 1000 by CNO.
H. Patient #10: Review of clinical record and MAR from 02/23/15 to 02/25/15 revealed 4/4 doses of PRN medication administration did not have documentation of the patient's response. Findings were verified on 03/12/15 at 1345 by the Director of Quality Improvement/Case Management.

Based on clinical record review, review of Medical Staff Bylaws and interview, it was determined the facility failed to ensure Physician's standing orders were authenticated by the ordering practitioner for 4 (#12, #18-20) of 10 (#11-#20) surgical patients. By not authenticating orders, the facility could not ensure the care being provided was in accordance with the physician's plan of care. The failed practice had the likelihood to affect all patients who are admitted to the facility for procedures. Findings follow:
A. Clinical record review revealed the following orders that were not authenticated by the ordering practitioner:
1) Patient # 12's Admission Orders were not authenticated;
2) Patient # 12's Physician's Pre-Op (Operative) Antibiotic Order Form was not authenticated;
3) Patient # 18's Admission Orders were not authenticated;
4) Patient # 19's Admission Orders were not authenticated;
5) Patient # 19's Physician's Pre-Op Antibiotic Order Form was not authenticated;
6) Patient # 20's Admission Orders were not authenticated; and
7) Patient # 20's Physician's Pre-Op Antibiotic Order Form was not authenticated.
B. Review of Medical Staff Bylaws revealed "Standing orders shall be dated and signed by the practitioner and reproduced in detail on the order sheet of the patient's record."
C. During an interview on 03/13/15 at 0950, the Operating Room Nursing Supervisor verified the Physician's orders were not authenticated.

Based on review of clinical records, review of Medical Staff Rules and Regulations and interview, it was determined the facility failed to assure an assessment was completed to confirm the patient's condition had not changed since the History and Physical (H&P) was originally completed for 5 (#15, #17-20) of 10 (#11-#20) surgical patients. Failure to assure the patient's condition had not changed since the History and Physical was originally completed did not assure any changes in the patient's condition prior to surgery were taken into consideration and was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Review of the clinical record for Patients #11-#20 revealed the following:
1) Patient #15 had an H&P faxed to the facility on 02/13/15, and was admitted to the facility on 02/24/15 for a procedure. The clinical record failed to contain an assessment the patient's condition had not changed since the H&P was originally completed;
2) Patient #17 had an H&P faxed to the facility on 02/03/15, and was admitted to the facility on 02/17/15 for a procedure. The clinical record failed to contain an assessment the patient's condition had not changed since the H&P was originally completed;
3) Patient # 18 had an H&P faxed to the facility on 02/11/15, and had a procedure on 2/12/15. The clinical record failed to contain an assessment the patient's condition had not changed since the H&P was originally completed;
4) Patient #19 had an H&P faxed to the facility on 02/27/15, and was admitted to the facility on 03/04/15 for a procedure. The clinical record failed to contain an assessment the patient's condition had not changed since the H&P was originally completed; and
5) Patient #20 had an H&P faxed to the facility on 03/03/15, and was admitted to the facility on 03/06/15 for a procedure. The clinical record failed to contain an assessment the patient's condition had not changed since the H&P was originally completed;
B. Review of Medical Staff Rules and Regulations stated "A history and physical performed within thirty (30) days prior to hospital admission may be used, as long as the medical record contains durable, legible practitioner documentation that ...The patient's condition has not changed since the history and physical was originally completed."
C. During an interview on 03/13/15 at 0950, the Operating Room Nursing Supervisor verified the clinical records failed to contain an assessment that the patient's condition had not changed since the H&P was originally completed.

Based on observation it was determined the Facility failed to maintain the building physical structure, environment and equipment in a state of good repair. In three of seven areas the following was observed: damaged surfaces; use of a wall receptacle box as power strip; missing ceiling tiles; and a loose light fixture. The failed practice had the potential to affect all patients staff and visitors due to the potential for injury presented by the observed conditions. The Facility had a census of seven patients on 03/09/15. The findings follow:

A. On a tour of the Facility on 03/10/15 at 1210 with the Maintenance Director the following observations were made and verified:
1) In the Emergency Department, the laminate on the nurse station desk was chipped leaving exposed porous material and sharp edges exposed. A ceiling tile was missing in the ambulance entrance vestibule.
2) In the Surgery Department, the ceiling was cracked near the toilet room in the pre-operative and post-operative area. A ceiling tile was missing in the soiled utility room. A patient tray table had a loose metal plate. Three sections of the wall covering in the Post Anesthesia Care Unit were ripped with exposed porous wall material. In Operating Room 1, a time clock had been removed, with an open electrical box and wiring exposed. In Operating Room 2, a wall return air louver was loose. The electrical power cord to the autoclave was plugged into a metal wall receptacle box laying loose on a shelf and was used as a power strip to make available additonal electrical outlets for equipment in the area. This condition presented an electrical hazard because the receptacle box is only to be mounted within a wall.

B. On a tour of the Facility on 03/11/15 at 1300 with the Maintenance Director, the stucco covering of the generator wall enclosure was pulling away from the enclosure wall. A light mounted to the enclosure wall was hanging loose by electrical wires. The light fixture globe had green water with dead insects floating in it.

Based on observation, documentation review and interview, it was determined the Facility did not meet Life Safety Code requirements related to unobstructed means of egress, unsecured medical gas cylinders, fire damper inspections, posting of signage to prohibit smoking in medical gas enclosures, and annual generator load bank testing. The failed practices had the potential to affect all patients, staff, and visitors. See Tags K-72, K-77, K-104, K-141 and K-144.

Based on interview it could not be determined the Facility conducted scheduled preventative maintenance on building air handler equipment and exhaust fans due to a lack of inspection documentation, a written inventory of equipment that required preventative maintenance, and policy and procedures for preventative maintenance on the equipment. The failed practice had the potential to affect all patients, staff and visitors because the reliability of the equipment to provide ventilation for the building was not evaluated or verified. The Facility had a census of seven patients on 03/09/15. The findings follow:

In an interview on 03/11/15 at 1040 the Maintenance Director verified there was no documentation of preventative maintenance performed on building air handler or exhaust fans, no inventory list of equipment or written preventative maintenance procedures for the equipment available for review.

Based on observations and interviews, it was determined the facility failed to ensure the proper cleaning, disinfecting and maintenance of items utilized in the operating suite as well as the air quality of the operating suite. Failure to ensure equipment was cleaned, disinfected and that proper maintenance was performed had the potential to allow the development and spread of infections. The failed practice affected Patient #37 on 03/10/15 and was likely to affect all patients undergoing procedures in Operating Room #1 and #2. Findings follow:

A. During a tour of the operating suite at 0730 on 03/10/15 it was observed a white towel with tan spots on it, on the bottom of the cabinet which housed the clean scopes. The four scopes used for colonscopies were touching the towel on the floor of the cabinet and two of the four scopes were touching each other. During an interview with the Operating Room (OR) Nursing Supervisor at 0745 on 03/10/15, she verified the findings.

B. Observation of the Certified Registered Nurse Anesthetist (CRNA) at 0750 on 03/10/15 revealed she did not cleanse the septums of three of three single use vials (Versed, Diprovan and Zemuron) after removing the top and before drawing them up. During an interview with the CRNA at 1030 on 03/10/15, she verified she did not cleanse the top of a new medication vial before drawing the medication up in a syringe and administering it to Patient #37.

C. Observation of RN (registered nurse) #3 at 1015 on 03/11/15 revealed she removed a small brush hanging on the wall, used it to cleanse the inside of the arthroscope used on Patient #37 with Enzol and then hung it back on the wall. During an interview with the OR Nursing Supervisor at 0830 on 03/11/15, she verified the brush hanging on the wall should not have been used to clean the arthroscope as the cleanliness of it could not be assured; that a single use clean brush should be used every time.

D. During an interview with the Maintenance Director at 0910 on 03/11/5, he stated he had not checked the operating room air exchanges since 04/13 and there was no maintenance schedule for checking them. Review of the CDC (Centers for Disease Control) MMWR (Morbidity and Mortality Weekly Report) June 6, 2003 / 52(RR10); 1-42, revealed the following recommendations:
V. Infection-Control and Ventilation Requirements for Operating Rooms
A. Implement environmental infection-control and ventilation measures for operating rooms. 1. Maintain positive-pressure ventilation with respect to corridors and adjacent areas (1,114,115). Category IB, IC (AIA: Table 7.2) 2. Maintain >15 ACH, of which >3 ACH should be fresh air (1,116,117). Category IC (AIA: Table 7.2)

E. During an interview with the Maintenance Director at 0910 on 03/11/15, he stated he had not pressure checked the HEPA filters since 04/13 and there was no maintenance schedule for checking them. Review of the CDC (Centers for Disease Control) MMWR (Morbidity and Mortality Weekly Report) June 6, 2003 / 52(RR10); 1-42, revealed the following recommendations:
2. Monitor areas with special ventilation requirements (e.g., AII or PE) for ACH, filtration, and pressure differentials (1,7,8,10--26). Category IB, IC (AIA: 7.2.C7, 7.2.D6) a. Develop and implement a maintenance schedule for ACH, pressure differentials, and filtration efficiencies by using facility-specific data as part of the multidisciplinary risk assessment. Take into account the age and reliability of the system. b. Document these parameters, especially the pressure differentials.

F. Observations of the surgical services area at 0745 on 03/10/15 revealed a beige, metal cart with multiple pitted, rusted areas on top of the cart located in the pre-operative area. Sitting on top of the cart was the glucometer, IV (intravenous) start kits, syringes, gloves and other medical supplies. During a tour of the OR at 0850 on 03/11/15, in OR #1, five of five IV poles had bases with multiple areas of rust, two of two rolling stools had peeling paint on the bases, there was a hole in the wall adjacent to the OR corridor, and the OR table light had multiple pitted, rusted areas on the light and the arm. During an interview with the OR Nursing Supervisor at 0850 on 03/11/5 she verified the above. During an interview with the Maintenance Director at 0910 on 03/11/15 he also verified the findings above.







Based on observations and interviews it was determined the facility failed to follow its policy and procedure in that patients in contact isolation were not isolated. Failure to follow its policy and procedure had the potential to allow the spread of infection to other patients and visitors. The failed practice was likely to affect Patients #33-36 on 03/11/15. Findings follow:

A. Observations made in the Senior Care Unit at 0945 on 03/11/15 revealed Patients #31 and #32 wearing yellow isolation gowns sitting at a table in one corner of the Day Room. Patient #33, #34 and #35 were sitting in the Day Room as well. Patient #31 was ambulatory, hard to direct and required constant monitoring to keep her at the table. During an interview with RN #4 at 0950 on 03/11/15 she stated Patient #31 and #32 had VRE (Vancomycin Resistant Enterococcus) and were on contact precautions. RN #4 stated the table at which Patient #31 and #32 were sitting was the isolation corner of the room and because this was a psychiatric unit the patients had to be out of their rooms. The Senior Care Nurse Supervisor was gowned and gloved and took Patient #31 to her room. RN #4 stated it was the nurse ' s responsibility assigned to the isolation patients to come back and clean the table, chair and any other surfaces Patient #31 touched.

B. During an interview with the Infection Control Nurse at 1055 on 03/11/15 she stated if Senior Care patients " wandered they did not need to be there (Senior Care). " The Infection Control Nurse stated her understanding from the Senior Care Management was Senior Care patients could not stay in their rooms; part of their treatment was group therapy and they must come out for that.

C. Observations at 1240 on 03/11/15 revealed Patients #31 and #32 in the Day Room at the corner table eating lunch. Patients #33-36 were observed to be sitting in the Day Room eating lunch as well. During an interview with the Senior Care Nurse Supervisor at this time she stated Patient #31 and #32 are her only patients. She stated once she got Patient #31 back to her room she had to come back and clean the table, chair, and handrails. Observations made in the Senior Care unit at 1420 on 03/11/15 revealed Patient #32 wearing a yellow gown at the corner table in the Day Room. Patient #35 was sitting in the Day Room as well.

D. An interview was conducted with the Infection Control Nurse and the Senior Care Nursing Supervisor at 1425 on 03/11/15. The Senior Care Nursing Supervisor stated the unit follows the hospital infection control policy. Review of the Infection Control policy titled " Senior Care " revealed the following: " Hospital Protocol will be adhered to in regard to infection control with the following additions: ... " Review of the policy titled " Detection and Management of VRE " received from the Infection Control nurse on 03/11/15 revealed under section V. ISOLATION PRECAUTIONS TO PREVENT PATIENT-TO-PATIENT TRANSMISSION the following:
1. Implement isolation promptly ...
3. Place patients in single room or cohort patients if more than one is positive for VRE ...
Under section VI. DISCONTINUING ISOLATION the following: Patients infected and/or colonized with VRE can be removed from isolation precautions when VRE negative results after finishing the decolonization protocol ...




30634

Based on observation, policy review, and interview, it was determined the facility failed to ensure food items in the walk in freezer were labeled and dated. The failed practice did not allow the facility knowledge as to which food items needed to be used first so as to ensure correct first-in first-out rotation and infection control processes. The failed practice created the potential to affect any patient in the facility receiving those food items. Findings follow.

A. Review of policy titled "Food Storage" stated, "Food stuffs and other perishable items will be dated with months and year of purchase on receipt from vendor. Vendor's delivery sticker with this information on them is acceptable. The oldest items will be used first."
B. During a tour of the kitchen on 03/11/15 at 0955, the following food items in the Walk-in Freezer were observed to not be labeled and dated:
1) Six of six bags Key West blend vegetables
2) Four of four bags broccoli
3) Five of five bags tater tots
4) Two of two bags Germany blend vegetables
5) Four of four bags garden blend vegetables
C. During an interview at the time of the tour, the Registered Dietitian confirmed the food items were not dated.




31039

Based on observation, review of policy and interview, the Facility failed to maintain therapy equipment in a manner that allowed thorough cleaning between patients in the rehabilitation gym. One (mat table #1) of two (mat table #1 and #2) had multiple tears along the entire perimeter (not able to sanitize) exposing the padding beneath and one of one shower floor had sticky non-slip tape/residue (not able to sanitize). By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, the Facility could not assure the sanitary environment when patients used those items. The failed practice had the likelihood to affect all patients that receive therapy services in the rehabilitation gym. Findings follow:

A. During a tour of the rehabilitation gym on 03/11/15 at 0840, observation revealed the following:
1) One mat table with multiple tears along the entire perimeter; and
2) Five strips of non-slip tape in the shower that was peeled back on the edges and the tape/residue remained on the shower floor.

B. Review of policy titled Equipment Cleaning and Care stated "All equipment used for patient care will be cleaned with STAT III after morning and afternoon sessions and/or following direct contact with a patient of questionable contamination".

C. During an interview on 03/11/15 at 0910, the Director of Rehabilitation verified multiple tears in the mat table and the sticky non-slip tape/residue on the shower floor.

Based on observation and interview, it was determined the Facility failed to assure a roster that listed each practitioner's specific surgical privileges were available in the surgical suite and a list of any practitioner with suspended or restricted surgical privileges. The failed practice did not allow the OR staff to be knowledgeable regarding which surgical procedures the individual practitioner was credentialed to perform. The failed practice affected all patients who had a surgical procedure at the facility. The findings were:

A. Observation on tour of the OR on 03/10/15 did not reveal surgical privileges roster in the OR.

B. The Director of the OR confirmed there was not a roster of privileges of physicians or a list of suspended or restricted physician privileges in the OR suite on 03/11/15 at 0958.

Based on clinical record review, Medical Staff Bylaws review and interview, it was determined the Facility failed to ensure the time of the operation was included on the operative report for 10 of 11 (#5, #11, #12, and #14-#20) surgical patients, and failed to ensure 10 (#5, #11-#17, #19 and #20) of 11 (#5 and #11-#20) operative reports were signed by the physician according to the Medical Staff Bylaws. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Failure to sign the operative report did not indicate the physician had reviewed the operative report. Findings follow:

A. Review of Medical Staff Bylaws stated, "Medical records are reviewed to ensure: ...Operative reports dictated or written immediately after surgery (within six (6) hours) record the name of the primary surgeon, assistant(s), findings, technical procedures used, specimens removed, and post-operative diagnosis; and/or authenticated as soon as possible after surgery."

B. Review of clinical records revealed the time of the operation was not documented for 10 of 11 (#5, #11, #12, and #14-#20) surgical patients.

C. At the time of clinical record review on 03/12/15 and 03/13/15, the following operative reports were not signed by the physician:
1) Patient #5-had surgery on 03/03/15 and on 03/09/15
2) Patient #11-had surgery on 02/26/15
3) Patient #12-had surgery on 02/27/15
4) Patient #13-had surgery on 03/04/15
5) Patient #14-had surgery on 02/26/15
6) Patient #15-had surgery on 02/24/15
7) Patient #16-had surgery on 02/22/15
8) Patient #17-had surgery on 02/17/15
9) Patient #19-had surgery on 03/04/15
10) Patient #20 - had surgery on 03/06/15

D. During an interview on 03/13/15 at 0930, the Operating Room Nurse Supervisor confirmed there was no time of the operation and no signature of the physician on the operative report.

Based on clinical record review and interview, it was determined the Facility failed to assure there were orders for admission to swing-bed status for one of one patient (#1). It could not be assured the patient was to receive skilled nursing services without an order for admission to swing-bed status. The failed practice affected Patient #1 and had the potential to affect any patient admitted to swing-bed status. The findings were:

The Facility provided an inpatient admission register for "Skilled Care Admission" for the period 12/01/14 through 03/09/15 on 03/09/15. Patient #1 was the only name on the register.
Clinical record review on 03/13/15 revealed Patient #1 did not have orders to admit to swing-bed status and this was confirmed by Director of QI (Quality Improvement) on 03/13/15 at 1030.

Based on review of policies and procedures and interview, it was determined the Facility failed to have written policies and procedures for swing-bed patients to prevent mistreatment, neglect, abuse and misappropriation of property. Failure to have policies and procedures did not assure patients would be protected. The failed practice affected one of one patient (#1) on swing-bed at the time of the survey and had the potential to affect all patients admitted to swing-bed status. The findings were:

On 03/11/15 at 1500, it was determined by review of the Swing-bed Policy and Procedure Manual there was not a policy or procedure for prevention of mistreatment, neglect, abuse and misappropriation of property for Swing-bed patients. The Director of Quality was interviewed on 03/11/15 at 1500 and stated the policy was the hospital policy in the "Provision of Care section" and that there was no other policy for Swing-bed patients.

Based on review of policies and procedures and interview, it was determined the Facility failed to have a contract or arrangement with a dentist to provide Dental Services for Swing-bed patients if needed. The Facility could not assure dental care needs of a patient would be met in the event a dentist was needed for a Swing-bed patient. The failed practice affected one of one patient (#1) on Swing-bed at the time of the survey and had the potential to affect all patients admitted to Swing-bed status. The findings were:

On 03/11/15 at 1445, it was determined by review of the Swing-Bed Policy and Procedure Manual there was not a policy or procedure for obtaining Dental Services if needed for a Swing-bed Patient. The Director of Quality and the Director of Nursing confirmed on 03/12/15 at 0950 by interview that they did not have a current dental agreement or a dentist currently on staff to provide dental services if needed.