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Based on staff interviews, facility document review, and observations, the Governing
Body failed to ensure an effective Pharmaceutical Service program to ensure patient safety; and to ensure the accountability of the Governing Body for oversite of the Pharmaceutical Services. For these reasons, the Condition of Governing Body was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:

1 .Reference: A 0043: Based on interviews and record review the facility failed to ensure that medications profiles are performed and medication orders are reviewed by a licensed pharmacist before being administered to the patient. The facility failed to develop and implement pharmacy policy and procedures regarding patients at risk to receive safe and effective medications. The facility failed to ensure that dispensing of drugs and biological's must be under the supervision of a pharmacist.

Based on staff interviews, and facility document review, the Governing
Body failed to ensure an effective Pharmaceutical Service program to ensure patient safety; and to ensure the accountability of the Governing Body for oversite of the Pharmaceutical Services. For these reasons, the Condition of Governing Body was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:

During an interview on 01/10/17 at 1:30 PM, the pharmacist that was contracted with the pharmacy stated that she worked 2 days a week, and does not review the new orders for patients medications. When she was asked if she was a consultant pharmacist, she stated, "No I am not a consultant pharmacist, and do not have my consultant license."

During an interview on 01/11/2016 at 2:00 PM, the Medical Director stated that the last quarterly Pharmacy and Therapeutics committee meeting was not held because the former pharmacist had left. The Pharmacy and Therapeutics committee is monitoring the pharmacy systems and stated, he is not monitoring it and is not aware of the concerns identified during the recertification survey.

Review of the Pharmacy and Therapeutics Meeting Minutes revealed that the last date the committee met was on July 11, 2016

During an interview on 01/11/17 at 3:15 PM with the facility's contracted part time pharmacist, she was asked if she maintained pharmacy and accounting records pertaining to the requisitioning, dispensing of drugs and pharmaceutical supplies, and supervised and coordinated all the activities of pharmacy services. She stated, "I order all the medications needed for the pharmacy, stock the nurses medication room, but I do not keep a record of medications dispensed other than controlled medications."

During an interview on 01/11/2016 at 4:00 PM, the Director of Business Operation stated that based on incident/medication variance reports that medication errors are being reported to the Organization's Risk Manager. Asked if other data is being collected related to the pharmacy she stated that she was not sure what other data was collected and if reported

Based on staff interview, policy review and medical record review the facility failed for 14 ( patient # 10, and patients #17 thru # 29),of 30 records reviewed to ensure that all physician orders were signed, timed and dated.

Findings:

Review of the medical record for patient #10 revealed that physician orders written on 12/30/2016, 01/03/2017, 01/04/2017, and on 01/09/2017 were not timed by the physician when authenticated.

Review of the medical record for patient #17 revealed that physician orders written on 4 times on 09/07/2016, 09/14/2016, 09/20/2016, and on 09/21/2016 were not timed by the physician when authenticated. Review of the medical record revealed that a physician order written on 09/09/2016 and the Admission Protocol Physician orders were not signed by the physician.

Review of the medical record for patient #18 revealed that physician orders written on , and on 07/22/2016 and on 07/25/2016 were not timed by the physician when authenticated.

Review of the medical record for patient #19 revealed that physician two orders written on 12/28/2016 were not timed by the physician when authenticated.

Review of the medical record for patient #20 revealed that physician two orders written on 07/15/2016 and two orders written on 07/18/2016 were not timed by the physician when authenticated.

Review of the medical record for patient #21 revealed that physician two orders written on 10/16/2016 were not timed by the physician when authenticated.

Review of the medical record for patient #22 revealed that physician orders written on 09/22/2016 were not timed by the physician when authenticated. Review of the medical record revealed that a physician Admission Protocol Physician orders were not signed, dated or timed by the physician.

Review of the medical record for patient #23 revealed that physician 2 orders written on 10/31/2016, one written order was not timed by the physician when authenticated. Review of the medical record revealed that a physician Admission Protocol Physician orders were not signed, dated or timed by the physician.

Review of the medical record for patient #24 revealed that physician orders written on 07/08/2016, 07/11/2016 and 2 written order written on 07/12/2016 were not timed by the physician when authenticated. Review of the medical record revealed that a physician Admission Protocol Physician orders were not timed by the physician.

Review of the medical record for patient #25 revealed that physician orders written on 10/15/2016, two orders written on 10/16/2016, one order written on 10/17 and 10/18/2016 were not timed by the physician when authenticated.

Review of the medical record for patient #26 revealed that 3 physician orders written on 10/02/2016, and one order written on 10/05/2016 were not timed by the physician when authenticated. Review of the medical record revealed that a physician Admission Protocol Physician orders were not signed by the physician.

Review of the medical record for patient #27 revealed that two physician orders written on 01/03/2017, were not timed by the physician when authenticated.

Review of the medical record for patient #28 revealed that a physician Admission Protocol Physician orders written on 11/25/2016 were not signed by the physician.

Review of the medical record for patient #29 revealed that 3 physician orders written on 07/26/2016, and three orders written on 07/24/2016, 07/21/2017 and 07/18/2016 were not timed by the physician when authenticated. Review of the medical record revealed that a physician Admission Protocol Physician orders were not signed by the physician.

During an Interview on 01/10/2016 at 10:30 AM, the Director of Health Information stated that physician orders should be timed and signed. She stated that the omissions noted should have of been found when the record was processed on discharge.

Review of the Bylaws, Rules, and Regulations of the Medical Staff Organization under Article VIII Roles, Rules and Regulations, Physician and or Psychiatrist revealed that the "Maintain accurate, complete and appropriate consumer records, treatment plans and other required information."

Based on observation, interviews and record review, the facility failed to ensure that medications profiles are performed and medication orders are reviewed by a licensed pharmacist before being administered to the patient. The facility failed to develop and implement pharmacy policy and procedures regarding patients at risk to receive safe and effective medications. Failure to ensure that dispensing of drugs and biologicals must be under the supervision of a pharmacist with the documentation of the flow of pharmaceuticals from their entry into the hospital through dispensation/administration.


Findings

1 .Reference A 0491: Based on staff interviews the facility failed to ensure the safe and appropriate uses of medications for all inpatients, and the documentation of the flow of pharmaceuticals from their entry into the hospital through dispensation/administration. Failure to develop and implement pharmacy policy and procedures places patients at risk of not receiving safe and effective medications.

2. Reference A 0492: Based on interview and record review revealed that the facility failed to have a full time, part time, or consulting pharmacist responsible for developing, supervising, coordinating all the activities of the pharmacy services, to ensure that medication profiles are developed and that medication orders are reviewed prior to dispensing and administration of medications to all inpatients.

3. Reference A 0493: Based on observation and interview, revealed that the facility failed to ensure that quality pharmaceutical services, accurate and safe medication administration and to provide appropriate clinical services as well as the participation in continuous quality improvement programs that meet the needs of the patient population being served.

4. Reference A 0500: Based on staff interview and observation the facility failed to ensure that medications are adequately controlled and distributed to provide for patient safety.

5. Reference A 0501: Based on observation and interview, the facility failed to ensure that dispensing of drugs and biological's must be under the supervision of a pharmacist.

6. Reference A 0505: Based on observation, interview, and facility policy review it was determined that the facility failed to ensure insulin was properly labeled showing date opened, and also failed to ensure that insulin was discarded after the expiration dates. Failure to follow facility policy and procedure for insulin labeling and discarding of expired insulin has the potential for adverse effects to the residents.

Based on staff interviews and record review, the facility failed to ensure the safe and appropriate uses of medications for all inpatients, and the documentation of the flow of pharmaceuticals from their entry into the hospital through dispensation/administration. Failure to develop and implement pharmacy policy and procedures places patients at risk of not receiving safe and effective medications.

Findings:

During an interview on 11/11/17 at 4:00 PM, the Administrator was asked if the pharmacist had a job description or the written agreement for her responsibilities that clearly defined and included the development, supervision and coordination of all the activities of pharmacy services. The administrator stated they facility does not have a job description for the pharmacist and confirmed that there was not a job description in the contract from the pharmacy of her duties.

During an interview on 11/10/17 at 1:30 PM, with the pharmacist that was contracted with the pharmacy stated that she worked 2 days a week, and does not review the new orders for patients medications. When asked if she was a consultant pharmacist, she stated, "No I am not a consultant pharmacist, and do not have my consultant license."

During an interview on 01/11/17 at 3:15 PM, with the facility's contracted part time pharmacist stated if she maintained pharmacy and accounting records pertaining to the requisitioning, dispensing of drugs and pharmaceutical supplies, and supervised and coordinated of all the activities of pharmacy services. She stated, "I order all the medications needed for the pharmacy, stock the nurse's medication room, but I do not keep a record of medications dispensed other than controlled medications."

During an interview on 01/11/17 at 3:30 PM, with 2 Nursing House Supervisors, Staff #A and #B were asked what they would do when they have a question for a pharmacist, they both stated, they really don't have a pharmacist to speak to, and one of the House Supervisors, Staff #A stated if we have a question, we write it down for the pharmacist who comes in on Mondays and Wednesdays.

Observation on 01/11/17 at 11:04 AM on the Male Unit medication room with the Charge Nurse, Staff #C revealed that multiple bottles of pharmaceutical medication samples were in the medication cabinet including Cardizem ER 120 mg., Effexor 37.5 mg., and Effexor 75 mg.

Review of the facility's Policy and Procedure titled "Cart exchange and Profile Reconciliation" revealed the following: The purpose of this procedure is to document and provide the practices and steps the pharmacy personnel are to perform to provide the most effective utilization of resources and exchanging the consumer's carts and consumer profile reconciliation. Consumer profile reconciliation shall be conducted weekly to ensure accuracy between the Medication Administration Record (MAR) and Pharmacy Profiles. Discrepancies shall be compared to the original Doctor's Orders for verification.
Having the pharmacist present during the cassette exchange and profile reconciliation process provides nursing personnel with an opportunity to receive direct, clinical support from pharmacy personnel, to provide clinical in-service to the nursing staff personnel who are actually responsible for administering the drug therapy to the consumer, and to encourage positive rapport between nursing and the pharmacist.

Based on interview and record review revealed that the facility failed to have a full time, part time, or consulting pharmacist responsible for developing, supervising, coordinating all the activities of the pharmacy services, to ensure that medication profiles are developed and that medication orders are reviewed prior to dispensing and administration medications to all inpatients.

Findings:

1. Observation on 01/10/17 at 4:15 PM with the Administrator and the Director of Nursing revealed that there was a Pharmacy License posted for the facility, but not a Pharmacist License posted in the Pharmacy.

2. During an interview on 11/11/17 at 4:00 PM, the Administrator was asked if the pharmacist had a job description or the written agreement for her responsibilities that clearly defined and included the development, supervision and coordination of all the activities of pharmacy services. The administrator stated the facility does not have a job description for the pharmacist and confirmed that there was not a job description in the contract from the pharmacy of her duties.

During an interview on 11/10/17 at 1:30 PM, with the pharmacist that was contracted with the pharmacy stated that she worked 2 days a week, and does not review the new orders for patients medications. When asked if she was a consultant pharmacist, she stated, "No I am not a consultant pharmacist, and do not have my consultant license."

During an interview on 01/11/17 at 3:15 PM, with the facility's contracted part time pharmacist, she was asked if she maintained pharmacy and accounting records pertaining to the requisitioning, dispensing of drugs and pharmaceutical supplies, and supervised and coordinated of all the activities of pharmacy services. She stated, "I order all the medications needed for the pharmacy, stock the nurses medication room, but I do not keep a record of medications dispensed other than controlled medications."

During an interview on 01/11/17 at 3:30 PM, with 2 Nursing House Supervisors, Staff #A and #B, when they were asked what they would do when they have a question for a pharmacist, they both stated that they really don't have a pharmacist to speak to, and one of the House Supervisors, Staff #A stated if we have a question, we write it down for the pharmacist who comes in on Mondays and Wednesdays.

3. Review of the facility's Policy and Procedure titled "Cart exchange and Profile Reconciliation" revealed the following: The purpose of this procedure is to document and provide the practices and steps the pharmacy personnel are to perform to provide the most effective utilization of resources and exchanging the consumer's carts and consumer profile reconciliation. Consumer profile reconciliation shall be conducted weekly to ensure accuracy between the Medication Administration Record (MAR) and Pharmacy Profiles. Discrepancies shall be compared to the original Doctor's Orders for verification.
Having the pharmacist present during the cassette exchange and profile reconciliation process provides nursing personnel with an opportunity to receive direct, clinical support from pharmacy personnel, to provide clinical in-service to the nursing staff personnel who are actually responsible for administering the drug therapy to the consumer, and to encourage positive rapport between nursing and the pharmacist.

Based on observation and interviews the facility failed to ensure that quality pharmaceutical services, accurate and safe medication administration and to provide appropriate clinical services as well as the participation in continuous quality improvement programs that meet the needs of the patient population being served.

Findings:

During an interview on 11/11/17 at 4:00 PM, the Administrator was asked if the pharmacist had a job description or the written agreement for her responsibilities that clearly defined and included the development, supervision and coordination of all the activities of pharmacy services. He stated they facility does not have a job description for her and confirmed that there was not a job description in the contract from the pharmacy of her duties.

During an interview on 11/10/17 at 1:30 PM, with the pharmacist that was contracted with the pharmacy, she stated that she worked 2 days a week, and does not review the new orders for patients medications. When asked if she was a consultant pharmacist, she stated, "No I am not a consultant pharmacist, and do not have my consultant license."

During an interview on 01/11/17 at 3:15 PM,with the facility's contracted part time pharmacist, she was asked if she maintained pharmacy and accounting records pertaining to the requisitioning, dispensing of drugs and pharmaceutical supplies, and supervised and coordinated of all the activities of pharmacy services. She stated, "I order all the medications needed for the pharmacy, stock the nurses medication room, but I do not keep a record of medications dispensed other than controlled medications."

During an interview on 01/11/17 at 3:30 PM, with 2 Nursing House Supervisors, Staff #A and #B, when they were asked what they would do when they have a question for a pharmacist, they both stated that they really don't have a pharmacist to speak to, and one of the House Supervisors, Staff #A stated if we have a question, we write it down for the pharmacist who comes in on Mondays and Wednesdays.

During an interview on 01/11/2016 at 2:00 PM, the medical director stated that that the last quarterly Pharmacy and Therapeutics committee meeting was not held because the former pharmacist had left. Ask if the Pharmacy and Therapeutics committee is monitoring the pharmacy systems. The medical director stated that he is not monitoring it and is not aware of the concerns identified during the recertification survey.

Review of the Pharmacy and Therapeutics Meeting Minutes revealed that the last date the committee met was on July 11, 2016

During an interview on 01/11/2016 at 4:00 PM, the Director of Business Operations on that based on incident/medication variance reports that medication errors are being reported to the Organization's risk manager. Asked if other data is being collected related to the pharmacy she was not sure.

3. Observation on 01/11/17 at 11:04 AM on the Male Unit medication room with the Charge Nurse, Staff #C revealed that multiple bottles pharmaceutical medication samples were in the medication cabinet including Cardizem ER 120 mg., Effexor 37.5 mg., and Effexor 75 mg.

4. Review of the facility's Policy and Procedure titled "Cart exchange and Profile Reconciliation" revealed the following: The purpose of this procedure is to document and provide the practices and steps the pharmacy personnel are to perform to provide the most effective utilization of resources and exchanging the consumer's carts and consumer profile reconciliation. Consumer profile reconciliation shall be conducted weekly to ensure accuracy between the Medication Administration Record (MAR) and Pharmacy Profiles. Discrepancies shall be compared to the original Doctor's Orders for verification.
Having the pharmacist present during the cassette exchange and profile reconciliation process provides nursing personnel with an opportunity to receive direct, clinical support from pharmacy personnel, to provide clinical in-service to the nursing staff personnel who are actually responsible for administering the drug therapy to the consumer, and to encourage positive rapport between nursing and the pharmacist.

Based on staff interview and observation, the facility failed to ensure that medications are adequately controlled and distributed to provide for patient safety.

Findings:

1. During an interview on 01/10/17 at 1:00 PM,of the contracted Pharmacist revealed that she did not develop medication profiles for inpatients, and medications are not being reviewed for appropriateness by a pharmacist before the first dose is dispensed. The contracted pharmacist stated that she stocks the medication rooms on the nursing units, will order the medications for the pharmacy, but does not profile of keep a record of medications dispersed or not used. Asked if the dispensing and administration of medication was delayed until she came in to restock the medication rooms on the units (male and female), she stated that the nurse would review the orders and go to the pharmacy, get the medications themselves and then give the medications as ordered. The contracted Pharmacist further revealed that the House Supervisor Nurse had a key to the pharmacy and when needed could come in pharmacy and obtain medications for the patients. The nurse is to sign out any medications taken from the pharmacy. When asked if the sign out sheet were reviewed and compared to the patient records she stated that they were not. When asked if there was a system in place to determine if medications were missing from the inventory she stated unless it is very obvious she could not tell if medications were missing from the pharmacy. When asked if there was a policy and procedure for pharmacy staff removing medication from the pharmacy she stated that she did not know of one.

2. Observation on 01/11/17 at 1:30 PM. Medications found on tour with the pharmacist revealed that the following medications were found on the Male and Female nursing unit medication rooms and medications found in the pharmacy were not secured.

Male nursing unit medication room.
Pharmaceutical sample bottles containing 7 tablets of the following medications:
Brintellix 5 milligram (mg.) sample bottle of 7 tablets
Pristig Extended Release (ER) 50 mg. sample bottle of 7 tablets
Vraylar 3 mg. sample bottle of 7 capsules

Female nursing unit medication room.
Pharmaceutical sample cards and bottles containing the following medications:
Strattera 18 mg., 25 mg., 40 mg., and 60 mg. capsules on a sample card-stating sample- not for sale
Vraylar 1.5 mg. sample bottle of 7 capsules
Invega 6 mg sample bottle of 30 tablets
Abilify 15 mg. tablets's on a sample card-stating sample- not for sale
Acyclovir 400 mg. of a stock bottle of 100 tablets
Amoxicillian 500 mg. of a stock bottle of 50 tablets

Pharmacy
Pharmaceutical sample bottles and a stock bottle containing the following medications were not secured in the pharmacy.
Invega 3 mg. 17 sample bottles of 30 tablets in each bottle
Invega 6 mg. 12 sample bottles of 30 tablets in each bottle
Invega 9 mg. 21 sample bottles of 30 tablets in each bottle
Artane 2 mg. of a stock bottle containing 100 tablets
Hydrclorthiazide 25 mg. of a stock bottle containing 100 tablets

During an interview on 01/10/17 at 2:00 PM, with the pharmacist while in the Pharmacy was asked where these pharmaceutical sample bottles of Invega 3 mg., 6 mg. and 9 mg. came from that were in this pharmacy, she replied, "the pharmacist before I started to work here, received them from the pharmaceutical sample bottles that are in the Patient Assistance Program locked storage room, which are for outpatient and new discharged patients."

During an interview on 01/10/17 at 3:00 PM,with the Risk Manager/Director of Business Operations stated that she supervised the Patient Assistance Program locked storage room, and that the previous pharmacist had a key at the time to this room and access at any time to these medications. She stated that these psychotropic medications in the Patient Assistance Program locked storage room, are for indigent and discharged patients, not for patients housed in this facility.

3. Observation on 01/11/17 at 11:04 AM on the Male Unit medication room with the Charge Nurse, Staff #C revealed that multiple bottles pharmaceutical medication samples were in the medication cabinet including Cardizem ER 120 mg., Effexor 37.5 mg., and Effexor 75 mg.

4. Review of the facility's Policy and Procedure for the Patient Assistance Program titled "Pharmaceutical Assistance Program revealed the following:
PURPOSE: To ensure maximum utilization of psychotropic drug samples and consumer assistance from Pharmaceutical companies for medications dispensed to this facility's consumers who are without prescription insurance coverage or the ability to pay for such medications.


5. Review of the "CONTRACT FOR SERVICES OF PHARMACIST" dated 08/24/2016 revealed under Responsibilities only "Provide duties as a Pharmacist". Review of the contract does not provide any specific duties guidelines as related to developing and maintaining patient medication profiles or reviewing medications orders prior to the administration of the medications.

Based on observation and interview, the facility failed to ensure that dispensing of drugs and biological's must be under the supervision of a pharmacist.

Findings;

During an observation on 01/211/17 at 1:30 PM, Medications found on tour with the pharmacist revealed that the following medications were found on the Male and Female nursing unit medication rooms, and in the Pharmacy and were not secured.

Male nursing unit medication room.
Pharmaceutical sample bottles containing 7 tablets of the following medications:
Brintellix 5 milligram (mg.) sample bottle of 7 tablets
Pristig Extended Release (ER) 50 mg. sample bottle of 7 tablets
Vraylar 3 mg. sample bottle of 7 capsules

Female nursing unit medication room.
Pharmaceutical sample cards and bottles containing the following medications:
Strattera 18 mg., 25 mg., 40 mg., and 60 mg. capsules on a sample card-stating sample- not for sale
Vraylar 1.5 mg. sample bottle of 7 capsules
Invega 6 mg sample bottle of 30 tablets
Abilify 15 mg. tablets's on a sample card-stating sample- not for sale
Acyclovir 400 mg. of a stock bottle of 100 tablets
Amoxicillian 500 mg. of a stock bottle of 50 tablets

Pharmacy
Pharmaceutical sample bottles and a stock bottle containing the following medications:
Invega 3 mg. 17 sample bottles of 30 tablets in each bottle
Invega 6 mg. 12 sample bottles of 30 tablets in each bottle
Invega 9 mg. 21 sample bottles of 30 tablets in each bottle
Artane 2 mg. of a stock bottle containing 100 tablets
Hydrclorthiazide 25 mg. of a stock bottle containing 100 tablets

During an interview on 01/10/17 at 2:00 PM,with the pharmacist while in the Pharmacy, she was asked where these pharmaceutical sample bottles of Invega 3 mg., 6 mg. and 9 mg. came from that were in this pharmacy, she replied, "the pharmacist I started to work here, received them from the pharmaceutical sample bottles that are in the Patient Assistance Program locked storage room, which are for outpatient and new discharged patient."

During an interview on 01/10/17 at 3:00 PM, the Risk Manager/Director of Business Operations stated that she supervised the Patient Assistance Program locked storage room, and that the previous pharmacist had a key at the time to this room and access at any time to these medications. She stated that these psychotropic medications in the Patient Assistance Program locked storage room, are for indigent and discharged patients, not for patients housed in this facility.

4. Observation on 01/11/17 at 11:04 AM on the Male Unit medication room with the Charge Nurse, Staff #C revealed that multiple bottles pharmaceutical medication samples were in the medication cabinet including Cardizem ER 120 mg., Effexor 37.5 mg., and Effexor 75 mg.


5. Review of the facility's Policy and Procedure titled "Cart exchange and Profile Reconciliation" revealed the following: The purpose of this procedure is to document and provide the practices and steps the pharmacy personnel are to perform to provide the most effective utilization of resources and exchanging the consumer's carts and consumer profile reconciliation. Consumer profile reconciliation shall be conducted weekly to ensure accuracy between the Medication Administration Record (MAR) and Pharmacy Profiles. Discrepancies shall be compared to the original Doctor's Orders for verification.
Having the pharmacist present during the cassette exchange and profile reconciliation process provides nursing personnel with an opportunity to receive direct, clinical support from pharmacy personnel, to provide clinical in-service to the nursing staff personnel who are actually responsible for administering the drug therapy to the consumer, and to encourage positive rapport between nursing and the pharmacist.

Based on observation, interview, and facility policy review it was determined that the facility failed to ensure insulin was properly labeled showing date opened, and also failed to ensure that insulin was discarded after the expiration dates.

Findings:

Observation on 01/09/17 at 10:05 AM of the medication room on the Female medical unit on revealed opened one bottle Humalog Mix 75/25 insulin, with the date of opening shows on the label as 10/29/17, greater than 30 days of opening.

During an interview at 10:15 AM on 01/09/17 with the nurse # C, on the Male medical unit confirmed the findings .


Observation on 01/09/17 at 10:25 AM of the medication room on the Male medical unit on revealed opened one bottle Novolin Mix 70/30 insulin and another bottle of Lantus 100 units/milliliter (ML) insulin, with no date of opening found on the label.

During an interview on 01/09/17 at 10:30 AM,10:30 AM on 01/09/17, staff D on the Male medical unit confirmed the findings.

During an interview on 01/10/17 at 1:35 PM, with the pharmacist stated Insulin is expired and should be discarded after 30 days of opening.

A Policy and Procedure for the expiration of insulin once opened and the dating of bottles of insulin was not provided. No further information on insulin was provided.

Based on staff interviews and document review, the facility failed to have a system in place to identify residents admitted with infections and patients receiving antibiotics for the treatment of infections.

Findings:

During an interview on 01/09/2017 at 11:00 AM,with the Director of Nursing/Infection stated that she did not monitor, collect data or present to any committee information relative to patient infections. The Director of Nursing/Infection stated that she was not aware of any processes in place that provided for the surveillance of hospital infections.

During an interview on 01/11/2017 at 3:00 PM, the Risk Manager stated that if a patients sent to the hospital related to an infection an incident report would be generated. If the Hospital wanted to track hospitalization related to infections they would ask the Lifestream Risk Manager to separate out the data. When asked for example if patients admitted to the geriatric unit with an urinary tract infections, that patient would not be identified and tracked by the hospital. When asked if there is a system to monitor the usage of antibiotics or laboratory cultures to identity potential or actual infections the risk manager stated the hospital does not monitor.

Review of the Bylaws, Rules, and Regulations of the Medical Staff Organization under Article III - Organization, C #5 revealed "Surveillance of Hospital Infections Potentials: Review of potential and cases and the promotion of preventive and corrective program designed to minimize the infection potentials."

Review of the policy titled " Infection Control Operational Procedure Policy" no date states that under A Purpose revealed "infections acquired in a facility or brought into a facility form the community are potential hazards for all patients having contact within the facility. This procedure establishes a mechanism of reporting, monitoring, evaluating, investigating and recommendation of measures designed to prevent, identify and control infections."