HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure one crash cart (mobile cart which contains emergency medical supplies and medications) of three crash carts observed, were monitored in a manner to maintain emergency supplies and/or medications.
- Ensure storage areas which contained patient supplies were secured in a manner to prevent unauthorized access for two patient care areas (Emergency Department [ED] and Medical Unit) of two patient care storage areas observed.
- Ensure outdated supplies and medications were removed from potential patient use from storage areas on one unit (ED) of two unit storage areas reviewed. These failures had the potential to allow unauthorized access to emergency supplies and medications, as well as allow expired supplies and/or medications to be used during patient care, and could affect all patients. The facility census was eight.

Findings included:

1. Review of the facility's policy titled, "Checking of the Crash Cart," revised 03/2014, showed the following:
- Nursing will check for outdated supplies the first week of every month.
- All crash carts contents will be set up identical.
- Charge nurse will check padlock seals for consistency at shift change and chart on the designated form in the black notebook in the medication room.
-Nursing will check the defibrillator (a device that activates a shock to the heart when indicated) every 24 hours.

Observation on 01/14/19 at 2:00 PM, the crash cart located on the Medical/Surgical unit showed the defibrillator checklist with no documentation on 12/13/18; 12/22/18; 12/24/18; 12/25/18; 12/29/18; 12/30/18; 01/04/19; and 01/10/19.

During an interview on 01/14/19 at 2:00 PM, Staff K, Registered Nurse (RN) stated that the crash cart defibrillator should be checked once per day.

During an interview on 01/14/19 at 2:04 PM, Staff B, Director of Nursing (DON) stated that the crash cart defibrillator should be checked once per day.

2. Review of the facility's policy titled, "Outside Pharmacy Medications Storage Areas," revised 06/2014, showed that these areas shall be locked and accessible only to authorized personnel.

Observation on 01/14/19 at 2:55 PM, in the ED main storage area, showed a door that was unsecured, with no locking device that prevented unauthorized access. The main storage area contained sterile items used in patient care, as well as needles, syringes, and Lidocaine (medication used to numb tissue or control heart rhythm/rate abnormalities.)

During an interview on 01/14/19 at 3:00 PM, Staff D, ED Supervisor, stated that the ED main storage area was unsecured and should be secured to prevent unauthorized access.

Observation on 01/14/19 at 2:10 PM, in the Medical/Surgical Unit work area there were two supply baskets with intravenous catheters (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and needles sitting on the counter. The two doors to the area were both open and that allowed for any person to enter the area.

During an interview on 01/16/19 at 9:48 AM, Staff B, DON stated that all supplies should be in a secured area on the Medical/Surgical unit.

During an interview on 01/16/19 at 9:45 PM, Staff B, Director of Nursing (DON), stated that the ED main storage area and the medical/surgical storage area should be secured to prevent unauthorized access.

3. Review of the facility's policy titled, "Daily Stock Rotation/Expired Dates," revised 03/2014, showed any product which has expiration dates which have passed shall be removed for the physical inventory.

Observation on 01/14/19 at 2:55 PM, in the ED main storage area, showed expired items available for patient use:
- One chest drain unit, expiration date of 01/06/18;
- One 4LPC tracheotomy tube, expiration date of 01/03/18; and
- One 8LPC tracheotomy tube, expiration date of 01/04/18.

Observation on 01/14/19 at 3:25 PM of the ED medication room, showed expired items available for patient use:
- Open bottle of fecal occult developer, date of 09/11/18;
- Open bottle of gastric occult developer, date of 09/11/18; and
- 20 mojet needles, expiration date of 02/2011.

Observation on 01/14/19 at 3:55 PM of the ED pediatrics crash cart showed four 20 gauge needles with expiration date of 07/2018 and three 22 gauge needles with expiration date of 07/2018.

During an interview on 01/14/19 at 4:00 PM, Staff D, ED Supervisor, acknowledge the expired supplies and stated that any multi use items should be discarded within 90 days. Staff D also stated that it was the responsibility of all nursing staff to check for expired supplies and remove the items from patient use.

During an interview on 01/16/19 at 9:45 AM, Staff B, Director of Nursing, stated that expired items should be removed from storage to prevent potential use on patients.




39840

Based on observation, interview, record review, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 the facility failed to:
- Provide care in a safe setting for one suicidal patient (#1) of one suicidal patient observed. (C-274)
- Ensure that staff followed the infection prevention standards for the USP for compounded sterile preparations. (C-276)
- Ensure that staff followed infection control policies and infection prevention standards. (C-278)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services. The facility census was eight.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 01/14/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 01/15/19, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- On 01/14/19 at 5:30 PM immediate implementation of direct observation for all suicidal and homicidal patients deemed unsafe was initiated.
- On coming night shift was contacted and educated.
- From 01/14/19 to 01/15/19 at 7:00 AM, staff in the ED were to notify the ED supervisor of any suicidal or homicidal patients presenting to the ED.
- Prior to working next shift, all staff will be required to do hands on education/training for direct observation care of the suicidal or homicidal patients deemed unsafe.
- All suicidal or homicidal or patients deemed unsafe will immediately be placed into direct observation care and a sitter will be assigned to the patient.
- A physician or RN will order direct observation care in EpowerDoc.
- A direct observation flowsheet will be developed that included a sitter that will document every 15 minutes on the flowsheet. RN documentation will include verification of the direct observation, ensure room safety, and hourly rounding with documentation.

Based on observation, record review, policy review, and interview, the facility failed to provide care in a safe setting when the facility failed to:
- Ensure that one patient (#1) of one patient reviewed with a diagnosis of suicidal ideation (SI,Thought to harm self), was not placed in a psychiatric safe room (an exam room that was free of medical equipment or dangerous objects that the patient could use to harm himself or others).
- Ensure one patient (#1) of one patient reviewed in the Emergency Department (ED) with a diagnosis of SI was provided care in a safe setting, when there was no documented oversight in the Electronic Medical Record (EMR) by the attending Registered Nurse (RN), and the patient was left unsupervised with access to dangerous objects that the patient could use to harm himself or others.
- Ensure nursing staff had a clear understanding for implementing 1:1 (one on one) monitoring of patients and provided a psychiatric safe room.
These failures placed all patients with suicidal ideation in an unsafe environment and at risk for self-harm. This constitutes a condition of Immediate Jeopardy in which the health and safety of the patients were at risk. The facility census was eight.

Review of the facility's policy titled, "Psychiatric Evaluation Policy," revised 04/11/17, showed that:
- Ray County Memorial Hospital is a non-psychiatric receiving hospital.
- The ED physician shall evaluate the patient and determine the need for a psychiatric evaluation.
- If the patient is deemed in need of psychiatric treatment, the following criteria shall be assessed and documented:
- Vital signs times two and as needed;
- Observations of signs and symptoms of mental, emotional, behavioral or suspected substance abuse;
- Documentation of potential danger to self, staff or others; and
- Maintain patient safety.
The policy did not contain directives for staff to remove dangerous objects, a need for implementing 1:1 monitoring or a frequency of documenting assessments, interactions, interventions, and/or oversight for SI patients in a non-behavioral health safe area.

Review of Patient #1's ED medical record dated 01/14/19, showed that she was a 12 year old female, with no medical or psychiatric history, presented to the ED at 11:50 AM, with three centimeter reddened area to her left wrist that she did with a knife on 01/13/19. The patient stated that she had cut herself with a knife and told her mother she would like to do harm to herself. She was depressed because of her poor relationship with her father. The patient currently presents with depression and admits to SI with a plan to cut herself.

Observation on 01/14/19 at 2:00 PM, in the ED, showed Patient #1 in green paper scrubs with no staff providing 1:1 monitoring of the patient. Patient #1's room had the following dangerous objects that posed a safety risk:
- Plastic knife on the dinner tray (cutting or stabbing hazard);
- Patient #1's plastic personal belongings bag that contained shoes with shoelaces (asphyxiation/ligature hazard);
- Four boxes of exam gloves on the wall (unnecessary medical supplies);
- Plastic black trash bag liner (asphyxiation hazard);
- Plastic red bio-hazard bag liner (asphyxiation hazard);
- Unlocked cabinet with 10 plastic emesis bags (asphyxiation hazard);
- Unlocked cabinet with two unused plastic personal belongings bags (asphyxiation hazard);
- Unlocked cabinet with one plastic bag with oxygen tubing (asphyxiation hazard);
- Unlocked cabinet with two large plastic bags of stuffed animals (asphyxiation hazard);
- Unlocked cabinet with four boxes of exam gloves (unnecessary medical supplies);
- Unlocked cabinet with open box of alcohol pads (unnecessary medical supplies); and
- Unlocked cabinet with one large heavy unsecured metal bracket (weapon hazard).

During an interview on 01/14/19 at 2:05 PM, Patient #1's mother stated that:
- Patient #1 was in the ED because she was having ongoing SI for two months and attempted to cut herself with a knife.
- The patient had been waiting two hours for behavioral health to come in and assess her.
- There were no staff watching Patient #1 and had not seen staff for "awhile".
- She did leave Patient #1 alone in the room to go get food from the main lobby.
- No staff directed her not to leave Patient #1 alone.
- The suicidal attempt was new to her because Patient #1 never had any psychiatric issues before.

During an interview on 01/14/19 at 2:20 PM, Staff E, Registered Nurse (RN) stated that:
- She was the responsible nurse for Patient #1;
- She should have removed the dangerous objects from the room and locked the cabinets;
- The facility did not use one on one monitoring for SI patients.
- The facility did not use any documents that required 15 minute rounding on SI patients.
- She was unaware that the mother had left Patient #1 alone in the room.

Review of Patient #1's ED medical record dated 01/14/19, showed no documented assessments, interactions, interventions, and/or oversight for Patient #1's safety from 12:20 PM to discharge of 3:27 PM.

During an interview on 01/14/19 at 2:15 PM, Staff D, ED Supervisor acknowledge the dangerous objects in Patient #1's room and stated that the dangerous objects should have been removed and the cabinets locked. Staff D also stated that the facility did not use one on one monitoring or use 15 minute documentation on SI patients.

During an interview on 01/14/19 at 2:53 PM, Staff F, ED Physician, stated that:
- Patient #1 was a harm to herself;
- She had text messaged a friend that she was going to harm herself; and
- It was the responsibility of the facility to provide safety to Patient #1.

Review of the facility's ED new nurse checklist did not contain directives for staff to provide a safe environment, and/or oversight for SI patients that present to the ED.

Review of the facility's document titled, "Patients by Final Impression," dated 07/01/18 through 01/15/19, showed the facility admitted 25 patients with a diagnosis of SI.

During an interview on 01/15/19 at 8:00 AM, Staff L, Licensed Practical Nurse (LPN), stated that she had worked for the facility for 10 years and did not use one on one monitoring for SI patients and/or was required to document every 15 minutes for safety.

During an interview on 01/14/19 at 5:30 PM, Staff B, Director of Nursing, stated that the facility did not have a plan in place to provide one on one monitoring, documentation, or to provide safety to patients that were suicidal/homicidal or danger to self or others.

Based on observation, interview, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 for compounded sterile preparations (CSPs, medications or solutions that are prepared in a way to prevent contamination), the facility failed to ensure that staff followed the infection prevention standards when they failed to:
- Document and clean the buffer area (sterile zone in the pharmacy where CSPs are prepared) on days that medications were compounded;
- Have a documented growth media (test to ensure proper cleaning technique) sampling;
- Have a documented proper garbing/procedure (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test (test to ensure staff who process CSPs were able to prevent contamination of the CSP); and
- Have a written record or log that demonstrates that the CSP was performed properly.
These failed practices had the potential to increase the risk of cross contamination in CSPs that may result in patient harm and/or death. The facility performs approximately 60 CSPs per month. The facility census was eight.

Findings included:

Review of the USP, Chapter 797, dated 2013, showed that:
- The buffer area floors should be cleaned daily, and walls, ceilings and storage shelving cleaned monthly, and documented on a cleaning log;
- Sampling plans that included surface disinfection sampling (growth media requirements) should be performed on a periodic basis, at a minimum of every six months;
- Low risk compounding required proper garbing/procedures (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test; and
- A documented log or written record that the CSP was performed properly, should be easily accessible.

Review of the facility's policy titled, "Sterile (without contamination) Compounding Standard Operating Procedures," dated 04/2013, showed no general operational guidelines for the disinfection of the buffer area that followed the recommended guidelines by USP Chapter 797.

Observation on 01/15/19 at 2:30 PM showed the following:
- A barrier isolator (provides a physical barrier for compounding CSPs) within the pharmacy;
- No log that demonstrated when the buffer area was cleaned;
- No log that demonstrated a successful glove fingertip test; and
- No documented written record or log that demonstrated that the CSPs were performed properly.

During an interview on 01/15/19 at 3:00 PM, Staff N, Director of Pharmacy, stated that he:
- Performed approximately three CSPs per day, about five days a week;
- Had no log of the CSPs that were performed;
- Had no documented growth media sampling;
- Had no documented successful glove fingertip test available;
- Had no cleaning log for the buffer area or the barrier isolator; and
- Was unaware that sampling plans were to have been performed at a minimum of every six months and documented.

Based on observation, interview, policy review, and review of the United States Department of Health and Human Services Food Code (USDA Food Code), the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Perform hand hygiene (by using soap and water or a waterless hand sanitizer or foam) before they entered the patient's room and after inanimate objects (non-living objects, such as keyboards, tables, etc.) were touched; then medications were immediately administered for two patients (#4 and #5) of three patients observed;
- Ensure cleanliness of the Workstation on Wheels (WOWs, computer and supplies on wheels) for three patients (#4, #5 and #6) of three patients observed;
- Maintain the cleanliness of 9 laryngoscope blades (equipment that allowed visualization of the vocal cords while a breathing tube was placed) out of 9 observed and stored in crash carts (mobile cart which contains emergency medical supplies and medications) located in the Emergency Department (ED.)
- Ensure items which were not disposable, and intended for use on multiple patients, were properly packaged to maintain sterile conditions in one patient care area (ED) of two patient care areas reviewed.
- Date and time intravenous catheter sites (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) for three patients (#3, #5 and #7) of three patients observed;
- Ensure foods were labeled and dated with an acquisition date, expiration date, and removed from patient consumption after expiration date.
- Ensure that the dietary staff labeled with a date to be consumed ready-to-eat foods that have been prepared onsite or commercially prepared and opened for refrigerated, frozen food, and dry storage areas.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was eight.

Findings included:

1. Review of the facility's policy titled, "Hand Hygiene," dated 2017, showed:
- Foam in and foam out of the patient rooms would be demonstrated by all health care medical staff in patient care areas;
- All staff that had direct patient care would decontaminate their hands before they had direct contact with patients and afterwards;
- All staff would decontaminate their hands after contact with inanimate objects in the immediate vicinity of the patient;
- All staff would decontaminate hands before medication preparation; and
- That gloves were to be changed when moved from a contaminated body site or equipment and/or surroundings, to a clean body site or equipment and/or surroundings.

Observation on 01/15/19 at 8:47 AM showed Staff L, Licensed Practical Nurse (LPN), failed to:
- "Foam in" before she entered Patient #5's room;
- Perform hand hygiene before she prepared and administered oral medications; and
- Perform hand hygiene after she touched the WOW and before she administered a subcutaneous (SQ, situated or applied under the skin with a needle) medication into Patient #5's abdomen.

Observaion on 01/15/19 at 9:00 AM showed Staff L, LPN, failed to "foam in" before she entered Patient #4's room. Staff L did not perform hand hygiene after she touched the WOW and her phone and then immediately prepared and administered Patient #4's oral medication.

During an interview on 01/15/19 at 9:20 AM, Staff L, LPN, stated that she did not normally use foam before she entered a patient's room; that hand hygiene should have been performed before she applied gloves or provided care to the patients after she touched inanimate objects in the patient rooms.

2. Although requested, the facility failed to provide a policy regarding the disinfection of the WOWs.

Observation on 01/15/19 at 8:47 AM showed Staff L, LPN did not disinfect the WOW before she entered Patient #5's room and the WOW was not disinfected after she left the patient's room.

Observaion on 01/15/19 at 9:00 AM showed Staff L, LPN did not disinfect the WOW before she entered Patient #4's room and the WOW was not disinfected after she left the patient's room.

During an interview on 01/15/19 at 9:20 AM, Staff L, LPN, stated that the WOWs were cleaned when her shift started but not before or after they had been in patient rooms. Staff L also stated that she was unsure if any other shift cleaned the WOWs and was unaware of any policy that instructed staff what to do.

Observation on 01/15/19 at 10:20 AM showed Staff K, Registered Nurse (RN), did not disinfect the WOW before she entered Patient #6's room and the WOW was not disinfected after she left the patient's room.

During an interview on 01/15/19 at 10:30 AM, Staff K, RN, stated that it was not normal practice for the WOWs to be cleaned between patients.

3. Review of the facility's policy titled, "Processing of Instrument and Procedure Trays ," revised 08/23/18, showed that after placement into sonic washer, remove instruments from sonic washer, dry instrument prior to packaging.

Observation on 01/14/19 at 3:55 PM of the ED pediatrics crash cart showed three unpackaged laryngoscope blades and one unpackaged forceps (medical instrument) lying inside the crash cart.

Observation on 01/14/19 at 3:50 PM of the ED adult crash cart showed six unpackaged laryngoscope blades lying inside the crash cart.

Observation on 01/14/19 at 2:55 PM in the ED main storage area, showed two reusable dental mirrors unpackaged lying in a tray.

During an interview on 01/14/19 at 4:00 PM, Staff D, ED Supervisor, stated that every crash cart in the facility has open laryngoscope blades lying inside of the crash carts.

During an interview on 01/16/19 at 9:25 AM, Staff O, Infection Control Nurse,stated that any reusable instruments should be packaged to prevent possible cross-contamination.

4. Review of the facility policy titled, "IV Therapy", dated 06/11/2018 directed staff to change the IV dressing every 72 hours.

Observation on 01/14/19 at 2:26 PM, showed Patient #3's IV dressing (cover to protect and keep the IV catheter insertion site clean and hold in place) was not dated or timed.

Observation on 01/14/19 at 3:00 PM, showed Patient #5's IV dressing was not dated or timed.

Observation on 01/14/19 at 2:45 PM, there was no date or time on the IV dressing for Patient #7.

During an interview on 01/14/19 at 3:40 PM, Staff K, RN stated that the IV dressings were good for seven days.

During an interview on 01/16/19 at 9:48 AM, Staff B, DON stated that IV dressings should have been dated and timed.

During an interview on 01/15/19 at 2:00 PM, Staff O, Infection Control Nurse, stated that:
- Staff was expected to foam in and foam out of patient rooms each time;
- Hand hygiene was to be performed prior to direct patient care and prior to medications that were administered;
- Hand hygiene was to be performed after inanimate objects were touched;
- There was not a policy that instructed the staff on how the WOWs were to be cleaned or the frequency they were to be cleaned;
- It was expected that the WOWs should have been cleaned at the start of each shift, before the WOW was used as a table for medication administration; when staff exited a patient room and when staff entered a patient room;
- WOWs were never to go into an isolation (confines those known or suspected to be infected with a disease that can be easily passed on to others to prevent further infections) room.

5. Review of the "USDA Food Code," updated on 09/09/16, stated that a food shall be discarded if the food was not consumed before the expiration date and if it was in a container or package which does not bear a date.

6. Review of the "ServSafe essentials" (7th edition), showed that:
- Ready-to-eat foods that have been prepared onsite or commercially prepared and opened must be labeled with used by date to be consumed.
- All food will be labeled with received by dates and used by dates from manufacturer if in original container.
- If foods were removed from original containers or open, the product will be appropriately labeled and dated.

7. Review of the facility's policy titled, "Food Storage and Prevention of Contamination," revised 01/2017, showed that all items were marked with a received date, and when opened, and opened date was marked. All food was stored in a manner that will best preserve its freshness and wholesomeness.

8. Review of the facility's infection control meeting minutes, dated 07/11/18 showed that there was an investigation regarding a reported concern of a food borne illness in the facility. There were seven patients and two staff members that had symptoms. The investigation did not find a substantial amount of evidence to support a connection.

Observation on 01/14/19 at 2:30 PM, the patient refrigerator on the Medical/Surgical unit showed:
- Two orange juice with expiration dates of 10/03/18 and 12/15/18;
- Two apple juice with expiration dates of 11/07/18;
- One yogurt with an expiration date of 01/11/19;
- Two pudding with an expiration date of 12/20/18;
- One applesauce and one cottage cheese dated 01/13;
- 41 applesauce dated 01/14;
- Three gelatin bowls dated 01/10;
- Three gelatin bowls labeled toss 15; and
- One pitcher of orange juice dated 01/11/19.

Observation on 01/15/19 at 9:00 AM, in the pastry dry storage room, located in the kitchen, showed the following:
- Four rice crispy bags, removed from original container, with no used by date.
- Four cornflake bags, removed from original container, with no used by date.
- One bag of coco powder, removed form original container, with no used by date.
- One open bag of bowtie pasta noodles with no use by date.

Observation on 01/15/19 at 9:10 AM, in the dry storage area, located in the kitchen, showed the following:
- 10 unpackaged bottles of Hershey syrup with no received by date or used by date.
- Four, one gallon of tomato coloring with no received by date or used by date.
- Two opened boxes of white cheese cake mix with no used by date.
.
Observation on 01/15/19 at 9:20 AM, in the pastry leftover refrigerator, located in the kitchen, showed the following:
- One pan of four prepared sweet potatoes, open to air, with no use by date.
- One pan of 25 bake potatoes, open to air, with no use by date.
- Five prepared spice cakes with no prepared date or use by date.
- Four prepared vanilla pudding with no prepared date or use by date.
- Four prepared chocolate pudding with no prepared date or used by date.
- Three prepared fruit pies with no prepared date or used by date.

Observation on 01/15/19 at 9:25 AM, in the pastry refrigerator, located in the kitchen, showed the following:
- Nine prepared ham salads with no prepared date or used by date.
- Seven prepared tuna salads with no prepared date or used by date.
- One open glass of ensure with no prepared date or used by date.
- 20 prepared salads with no prepared date or used by date.

Observation on 01/15/19 at 9:30 AM, in the walk in refrigerator, located in the kitchen showed the following:
- One open box of cheese with no received date or used by date.
- One prepared fruit cocktail with no used by date.
- Three blocks of cheese with no used by date.

Observation on 01/15/19 at 9:35 AM, in the walk in refrigerator freezer, located in the kitchen, showed the following:
- Three open bags of fish sticks with no used by date.
- Two pork chops, open to air with visible freezer burn, with no used by date.
- One bag of corn dogs, removed from original container, with no used by date.
- One box of hamburgers, open to air with visible freezer burn, with no used by date.
- One box of blackberries, open to air with visible freezer burn, with no used by date

During an interview on 01/14/19 at 3:05 PM, Staff T, Dietary Aide stated that:
- She stocked the patient refrigerator, rotated the items, and checked the dates.
- The applesauce was good for seven days.
- The pitcher of orange juice was made in the kitchen and was usually good for seven days; and
- The date on the gelatin was the date it was made.

During an interview on 01/14/19 at 2:30 PM, Staff K, Registered Nurse (RN) stated that the kitchen staff stocked the patient refrigerator and checked for outdates, and she was not sure how long the applesauce and cottage cheese dated 01/13 could have been used.

During an interview on 01/16/19 at 9:48 AM, Staff B, RN Director of Nursing (DON) stated that kitchen staff were responsible for checking the outdates and there should not have been any expired food in the refrigerator.

During an interview on 01/15/19 at 9:40 AM, Staff I, Director of Dietary, stated that all staff were Safe Serve certified and were to label and date all foods that were stored in the dry storage area, kitchen, refrigerators and freezers. She was unaware that all foods were to be labeled with used by date. Staff I also stated that foods should be covered at all times.

During an interview on 01/16/19 at 9:25 AM, Staff O, Infection Control Nurse,stated that staff were confused on the dietary labels whether the date on the foods were the preparation date or the used by date. The dietary labels should be universal or staff to understand. Foods that were expired should be removed from service of the patient and all foods should be labeled with used by date.








39840

.



37921

Based on interview, record review, and review of the Medical Staff Rules and Regulations, the facility failed to ensure each patient medical record contained a dated and authenticated history and physical (H&P), placed in the medical record within 24 hours of admission for one patient (#4) of six patient medical records reviewed for presence of an admission H&P. The failure to maintain timely documentation had the potential to cause miscommunication regarding patient care between the admitting physician and other health care professionals who contributed to the patient's care. The facility census was eight.

Findings included:

Review of the "Medical Staff Rules and Regulations," dated 01/2016, showed that a medical H&P examination must be completed and documented no more than 30 days before or 24 hours after admission and placed in the patient's medical record within 24 hours after admission.

Review on 01/15/19 at 9:30 AM of Patient #4's medical record showed, the patient was admitted to the facility on 12/19/18 and had no documented H&P (27 days after the patient was admitted to the facility).

During an interview on 01/15/19 at 9:50 AM, Staff B, Director of Nursing (DON), stated that an H&P should have been completed and placed in a patient's medical record within 24 hours after they were admitted.

During a phone interview on 01/16/19 at 9:10 AM, Staff F, Medical Doctor (MD), stated that he thought if a patient came from another facility with an H&P, another H&P did not need to be completed.

Based on observation, interview, record review, policy review and review of the Association of periOperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI), the facility failed to follow policies and guidelines for surgical services when they failed to:
- Ensure AAMI guidelines were followed in the Operating Room (OR) sterile processing room, when the cabinet edge had exposed particle board and the wooden desk was in the room.
- Ensure that laryngoscope (an instrument for examining the larynx (voice box), or for inserting a tube through it) blades were properly packaged and stored in the OR and in the crash cart.
- Ensure that supplies were not outdated.
- Ensure that the environment in the restricted area of the OR and in the OR were maintained by having cardboard (particle shedding products that can cause contamination) in the areas and wood dividers in the storage cabinets.
- Ensure that the OR floor was free of cuts and crevices that harbor bacteria.
- Ensure that flexible endoscopes were properly stored.
- Ensure that a History and Physical (H&P) was completed and documented in the medical record prior to the start of the procedure for three discharged patient records (#8, #12, and #14) of nine discharged patient records reviewed.
- Ensure that an informed consent was signed by the patient and physician prior to the start of the procedure for eight discharged patient record (#8, #9, #10, #12, #13, #14, #15, and #16) of nine discharged patient records reviewed.
- Ensure that the OR Register included the patient's age, preoperative diagnosis and postoperative diagnosis which were required elements.

These failed practices had the potential to compromise the safety and health of all patients undergoing procedures at the facility. The facility census was eight.

The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.639 Condition of Participation (COP): Surgical Services.

Findings included:
1. Review of the facility's policy titled, "Surgical Scope of Services," dated 12/2018 showed that the surgical department followed AORN and AAMI standards.

Observation on 01/15/19 at 9:10 AM in the sterile processing wrap room showed a corner of the countertop, where instruments were wrapped, was missing a piece of laminate and there was exposed particle board and a wooden desk with a laminate top pulled away from the surface.

During an interview on 01/15/19 at 9:10 AM, Staff V, Certified Surgical Technologist (CST) stated that:
- The corner of the countertop had been missing for a long time and she had informed maintenance.
- It was hard to clean the counter with the missing corner.
- She had asked that the wooden desk be removed many times and knew it should not be in the wrap room.

During an interview on 01/15/19 at 1:40 PM, Staff R, Registered Nurse (RN) Operating Room Supervisor stated that the wooden desk and the damaged countertop should not be in the sterile processing wrap room.

During an interview on 01/16/19 at 9:48 AM, Staff B, Director of Nursing (DON) stated that the wooden desk and the damaged countertop should not be in the sterile processing area.

2. Review of the 2018 AORN guidelines showed that laryngoscope blades should be stored in individual packages to prevent contamination.

Observation on 01/15/19 at 8:30 AM showed five laryngoscope blades in the OR crash cart that were not packaged.

Observation on 01/15/19 at 9:55 AM showed nine laryngoscope blades in the anesthesia machine drawer in the OR that were not packaged.

During an interview on 01/15/19 at 8:30 AM, Staff U, OR RN stated that the laryngoscope blades were cleaned after they were used and they have never been wrapped.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor stated that laryngoscope blades were cleaned after each use but not packaged.

During an interview on 01/16/19 at 9:25 AM, Staff O, Infection Control RN stated that laryngoscope blades should be packaged.

3. Review of the facility's document titled, "Checking supplies for outdates and par levels," dated 09/01/16 directed staff to check carts and to check the procedure room green cabinets and drawers monthly for outdates.

Observation on 01/15/19 at 8:30 AM in the procedure room cabinets and drawers showed:
- Two culture tubes expired 11/2018;
- One multi-lumen kit expired 07/31/2018;
- One box of #10 blades expired 03/2018;
- One specimen trap expired 06/2018; and
- One peel packed item dated 07/20/2016 expired 07/20/2017.

During an interview on 01/15/19 at 8:30 AM, Staff U, RN stated that she was not responsible for checking outdates and that the technologists were responsible.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor stated that supplies were checked for outdates once per month.

During an interview on 01/16/19 at 9:48 AM, Staff B, DON stated that no expired supplies were allowed.

During an interview on 01/16/19 at 9:25 AM, Staff O, Infection Control RN stated that she would not expect to see expired supplies and expired supplies should be removed and not used on any patient.

4. Review of the 2018 AORN guidelines showed that all surfaces should be durable, smooth and cleanable. Surfaces that are durable, smooth, and cleanable allow for ease of cleaning and assist in preventing buildup of dirt and debris in crevices. In the semi-restricted and restricted areas, absorbent material, such as exposed wood, should not be used.

Observation on 01/15/19 at 9:55 AM in the restricted area of the OR showed:
- Cardboard boxes on the supply cart;
- A storage cabinet with wooden boxes containing supplies with exposed wood around the edges;
- A cardboard box in the supply cabinet in the OR;
- A cardboard box containing a Christmas tree in the storage room; and
- Three plastic bags of stuffed animals sitting on the floor in the storage room.

During an interview on 01/15/19 at 9:55 AM, Staff U, RN and Staff V, CST both stated that there should be no cardboard or wooden boxes in the OR.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor stated that cardboard boxes should not be in the OR and there should not be wooden shelves in the sterile storage cabinet.

During an interview on 01/16/19 at 9:25 AM, Staff O, Infection Control RN stated that no cardboard was allowed in the OR; and no wooden shelves were allowed in the OR.

During an interview on 01/16/19 at 9:48 AM, Staff B, DON stated that there should be no cardboard in the OR and no stuffed animals in plastic bags in the OR.

5. Review of the 2018 AORN guidelines showed that the integrity of structural surfaces should be maintained, and surfaces should be repaired when damaged. Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning.

Observation on 01/15/19 at 9:55 AM of the OR floor showed multiple cuts on the surface.

During an interview on 01/16/19 at 8:00 AM, Staff R, OR Supervisor stated that the OR floor has been measured for replacement but needed board approval.

During an interview on 01/16/19 at 9:25 AM, Staff O, Infection Control RN stated that there should not be cuts in the OR floor.

During an interview on 01/16/19 at 9:48 AM, Staff B, DON stated that there should not be cuts in the OR floor.

6. Review of the 2018 AORN guidelines showed the flexible endoscopes should be situated in a secure location but not within the endoscopy procedure room and that flexible scopes should be hung vertically, without coiling and without touching the bottom of the cabinet.

Observation on 01/15/19 at 9:10 AM in the procedure room showed two flexible scopes hanging in a cabinet where the scopes were coiled.

During an interview on 01/15/19 at 9:10 AM, Staff V, CST stated that both of the flexible scopes should be hanging straight and she was not aware that the scopes could not be stored in the procedure room.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor stated that she was aware that scopes were to be hung straight and she was not aware that the scopes could not be stored in the procedure room.

7. Review of the facility's "Medical Staff Rules and Regulations," adopted 01/2016 showed:
- A complete history and physical examination would be recorded or the surgery would be deferred.
- Podiatric patients were to be admitted by a Physician member of the Medical Staff who shall be responsible for the pre-operative medical evaluation of the patient, care of any pre-existing or inter-current medical problems, and completion of the medical record planning discharge instructions.

Review of discharged Patient #8's medical record showed:
- No physical examination documented on the H&P for date of service 11/30/2018;
- A statement that read see consult; and
- A consult signed 12/05/2018 at 12:58 PM.

Review of discharged Patient #12's medical record showed the H&P signed by the Podiatrist.

Review of discharged Patient #14's medical record showed an H&P with no heart or lung assessment.

During an interview on 01/16/19 at 8:50 am, Staff R, OR Supervisor stated that a Podiatrist should not do H&P's according to the Bylaws.

During an interview on 01/16/19 at 9:48 AM, Staff B, DON stated that Podiatrist were not allowed to do H&P's, cosign anesthesia orders or cosign postoperative notes.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor stated that the circulating nurse was responsible for making sure the chart was complete prior to the surgery start.

8. Review of the 2018 AORN guidelines showed the following requirements of informed consent:
- The date and time the patient or the patient's legal representative signed the consent document;
- The date and time and the signature of the person who witnessed the patient or the patient's legal representative signing the informed consent document; and
- The signature of the responsible health care provider who executed the informed consent discussion with the patient or the patient's legal representative.

Review of the facility's policy titled, "Informed Consent," directed staff to obtain a patient signature on the consent form.

Review of the facility's "Medical Staff Rules and Regulations," adopted 01/2016 showed that a written, signed, informed consent shall be obtained by the operating surgeon prior to the operative procedure.

Review of discharged Patient #8's medical record showed no physician signature on the consent form and no time documented for the patient's signature on the consent form.

Review of discharged Patient #9's medical record showed no physician signature on the consent form.

Review of discharged Patient #10's medical record showed no patient signature and no physician signature on the consent form.

Review of discharged Patient #12's medical record showed no physician signature on the consent form.

Review of discharged Patient #13's medical record showed no physician signature on the consent form.

Review of discharged Patient #14's medical record showed no time documented on the witness signature on the consent form.

Review of discharged Patient #15's medical record showed no time documented on the consent form and no physician signature on the consent form.

Review of discharged Patient #16's medical record showed no physician signature on the consent form.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor stated that the circulating nurse was responsible for making sure the consent form was completed prior to the surgery start.

9. Review of the facility's policy titled, "Surgical Logbook," dated 09/01/2015 directed staff to record the following in the OR Register:
- Medical Record number;
- Patient name;
- Surgeon;
- Assistant surgeon, if present;
- Certified Registered Nurse Anesthetist (CRNA);
- Circulating and scrub nurse;
- Date of procedure;
- Operative or Invasive procedure;
- Surgery start and finish times;
- Type of anesthesia; and
- Inpatient or outpatient status.

Review of the facility's OR Register showed that there was no documentation of the patient's age, preoperative diagnosis or postoperative diagnosis.

During an interview on 01/15/19 at 1:40 PM, Staff R, OR Supervisor was not aware that the OR Register should contain the patient's age, preoperative diagnosis and postoperative diagnosis.

Based on interview, record review and policy review, the facility failed to incorporate five contracted services of 16 contracted services reviewed into their facility-wide Quality Assurance Performance Improvement (QAPI) Program. This resulted in the facility's failure to address ongoing problems or develop a plan to measure, assess and improve the quality of care provided by the services. This failure affects all patients receiving the contracted services in the facility. The facility census was eight.

Findings included:

Review of the facility's policy titled, "Quality Assurance Plan," revised 07/19/18, showed that:
- Each department/service will develop a quality assurance (QA) program for their specific department based upon their aspect of care.
- All patient care service contracts will be monitored to ensure compliance by the department providing that patient service.
- On an annual basis each department/service will be requested to submit a written report to the QA coordinator concerning the effectiveness of their QA program.

Review of the facility's list of contracted services provided, dated 01/15/19, showed the contracted services that were not included into their facility-wide QAPI program. The contracted services were:
- Physician Specialty Network (PSN) Rheumatology;
- PSN Immunotherapy;
- Digital Mammography Services (DMS);
- Shirkey's (outpatient speech therapy); and
- Coversa (sexual assault services.)

During an interview on 01/15/19 at 2:20 PM, Staff C, Director of Quality Assurance, acknowledged the five contracted services were not incorporated into their facility-wide QAPI Program. Staff C also stated that the departments that oversee the contracted services were responsible to ensure the effectiveness of the contracted services QA program and report it into their facility-wide QAPI program.

Based on Missouri State Statute review, policy review, record review, and interview, the facility failed to effectively screen all staff by comparing the names of staff on a periodic basis after hire against the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) of nine contracted Staff (P, Z, AA, BB, CC, DD, EE, FF, and GG) of nine contracted staff records reviewed to ensure that any staff on the EDL list were not employed in the facility. This failure had the potential to place all patients admitted to the facility at risk for their safety from abuse and neglect by staff members. The facility census was eight.

Findings included:

Review of RSMo 192.2495, showed that prior to allowing any person who has been hired full-time, part-time, temporary or through contract to have contact with any patient, a request would be made for a criminal background check as well as an inquiry made to the Department of Health and Senior Services, whether the person was listed on the EDL.

Review of the facility's policy titled, "Personnel Policy and Procedure Manual," revised 10/2009, showed that quarterly the Human Resource's staff will verify the EDL to insure that Ray County Memorial Hospital does not employ a person who has "knowingly" or "recklessly" abused or neglected a patient.

Review of the facility's undated contracted staff list showed Staff P, Registered Dietitian, was hired on 10/17/13 and the facility failed to check the EDL on a periodic basis to ensure Staff P had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff Z, Physician, was hired on 01/19/12 and the facility failed to check the EDL on a periodic basis to ensure Staff Z had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff AA, Physician, was hired on 07/19/18 and the facility failed to check the EDL on a periodic basis to ensure Staff AA had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff BB, Physician, was hired on 10/17/13 and the facility failed to check the EDL on a periodic basis to ensure Staff BB had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff CC, Physician, was hired on 11/19/15 and the facility failed to check the EDL on a periodic basis to ensure Staff CC had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff DD, Physician, was hired on 07/20/17 and the facility failed to check the EDL on a periodic basis to ensure Staff DD had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff EE, Physician, was hired on 10/16/03 and the facility failed to check the EDL on a periodic basis to ensure Staff EE had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff FF, Registered Dietitian, was hired on 07/18/02 and the facility failed to check the EDL on a periodic basis to ensure Staff FF had not been added on the EDL since hire.

Review of the facility's undated contracted staff list showed Staff GG, Physician, was hired in 1987 and the facility failed to check the EDL on a periodic basis to ensure Staff GG had not been added on the EDL since hire.

During an interview on 01/15/19 at 3:35 PM, Staff X, Director of Human Resources, stated that she was responsible to perform periodically checks of the names of current staff against the quarterly EDL updates. She did not include the contracted staff names against the EDL updates. She was under the impression that Staff C, Director of Quality Assurance, who was responsible for the contracted staff, performed the EDL checks on the contracted staff.

During an interview on 01/15/19 at 4:00 PM, Staff C, Director of Quality Assurance, stated that she was responsible for the contracted staff. She was disconnected from the EDL update program, and assumed that Staff X incorporated the contracted staff into her quarterly EDL updates. The facility had approximately 90 contracted staff currently working, and she realized that the periodically checks of the names of the contracted staff against the quarterly EDL updates had not been performed and should have.

Based on observation, interview and policy review, the facility failed to provide a comprehensive activity program for four Swing-bed patients (#3, #4, #5 and #17) of four Swing-bed patients reviewed. This had the potential to negatively impact the quality of life for the swing bed patient during their admission to the facility by failing to individualize activities to each patient's preference. The facility census was eight, with five of those in Swing-bed status (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility).

Findings included:

Review of the facility's policy titled, "Swing Bed Procedures - Activity Assessment," dated 03/12/14, showed:
- The facility will provide an ongoing program of activities for all swing bed patients based on the comprehensive assessment and the activities provided will be designed to reflect the interests and abilities of the patient.
- The Activity Director will assess the needs and abilities of the patient to participate and the plan developed will be specific and meaningful to the patient.
- The activity and goal will reflect the patient's interests and lifestyle that are enjoyable to the person, help the patient's self-esteem and dignity.

Observation on 01/14/19 at 2:26 PM showed Patients #3, 4, 5, and 18 did not have an activities calendar posted in their rooms.

During an interview on 1/14/19 at 2:32 PM, Patient #3 stated that she was unaware of an activities calendar and that activities were not specific to what interested her, it was whatever was offered at the time to everyone.

During an interview on 01/14/19 at 2:55 PM, Patient #4 stated that no calendar had been given or posted in her room. The patient's daughter stated that she was not aware of any scheduled activities based on her mother's interests and ability.

During an interview on 01/14/19 at 3:10 PM, Patient #5 stated that she did not have a calendar of activities and she had not participated in any activities that interested her. She also stated she was not sure if activities were offered to anyone.

During an interview on 01/15/19 at 11:44 AM, Staff M, Director of Rehabilitation, stated that:
- An activities calendar should have been in each Swing-bed patient room on the wall;
- Individual interests were a part of the comprehensive assessment upon admission, but not offered as an individual activity for that patient; and
- Activities were offered to all patients at a given time in a group and if a patient voiced they disliked an activity, another activity would have been offered, but not necessarily specific to their personal interests.