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Based on document review and interview, the facility failed to assure that its patient care policies were developed with the advice of a group that included at least one doctor of medicine (MD) or osteopathy (DO) and one or more physician assistants, nurse practitioners or clinical nurse specialists for 4 patient care policies.
Findings:
1. Review of the policy/procedure Policy Management (effective date 2-14) failed to indicate a requirement or process assuring that at least one MD or DO participated with new patient care policy development and the policy/procedure failed to document any MD or DO participation with its development and/or approval. The policy/procedure failed to indicate, if applicable, the criteria for any policies not subject to the requirement.
2. During an interview on 2-04-14 at 1105 hours, staff A4 confirmed that the policy/procedure lacked a requirement or process to validate MD or DO participation with new patient care policy development and approval, lacked evidence of MD or DO participation with its development and lacked criteria (if applicable) for excluding any policies from the group development requirement.
3. The policy/procedure titled Policy Review Rehabilitation Department (effective 6-13) indicated the following: "The policies governing physical therapy, occupational therapy, speech therapy and diabetic education will be reviewed annually ...no annual physician review is required ...policies requiring physician input ...are discussed with the physician prior to implementing any new procedures ..." The policy/procedure failed to ensure documentation of participation by the medical director of rehabilitation services or another MD or DO for rehab services policy development and failed to indicate physician participation with its development and approval.

4. The policy/procedure Crash Cart Maintenance and Exchange (effective 11-13) and Code Blue Procedure, Roles and Responsibilities (effective 9-13) failed to document any MD or DO participation with its development and/or approval.
5. During an interview on 2-04-14 at 1045 hours, the Emergency Department (ED) director A14 indicated that a committee including chief nursing officer A2, chief operating officer A3, pharmacy director A11, medical surgical director A15, nursing educator A16, materials management manager A17, and respiratory therapy manager A18 were developing a standardized crash cart for use throughout the facility including the ED. The ED director A14 confirmed that the ED medical director or other physician was not participating with the crash cart standardization and policy development.

Based on document review and interview, the facility failed to assure that its patient care policies were reviewed at least annually by a group that included at least one doctor of medicine (MD) or osteopathy (DO) and one or more physician assistants, nurse practitioners or clinical nurse specialists for its rehabilitation (physical therapy, occupational therapy and speech therapy ) policies.

Findings:

1. The policy/procedure titled Policy Review Rehabilitation Department (effective 6-13) indicated the following: "The policies governing physical therapy, occupational therapy, speech therapy and diabetic education will be reviewed annually by the director of rehabilitation ...no annual physician review is necessary." The policy/procedure failed to ensure documentation of annual review by the medical director of rehabilitation services or another MD or DO and failed to validate physician participation with its development or annual review.

2. During an interview on 2-04-14 at 1100 hours, staff A4 confirmed that the rehabilitation services policy/procedure failed to require documentation of its policy/procedure review by its medical director or another MD or DO and confirmed that no documentation of an annual review by an MD or DO was available.

Based on policy and procedure review, manufacturer's recommendations, observation, and staff interview, the facility failed to ensure that no condition was created that might cause a hazard to patients related to glucometer test strips.

Findings1. review of the policy and procedure "Stat Strip Glucose Meter Patient Testing Care and Maintenance", policy number 385842, with a last "review/approved" date of 02/2013, indicated:
a. on page two under "General", it reads: "Important: Test Strips are stable until the expiration date on vial. Vials should be dated when first opened. Test strips are stable for 3 months after opening or until the expiration date on vial, whichever come first..."

2. at 2:05 PM on 2/4/14, review of the package insert for the Nova Stat Strips indicated under "storage and handling": "Expiration: The expiration date is printed on the vial of test strips. Once opened the StatStrip Test Strips are stable when stored as indicated for up to 180 days or until the expiration date, whichever comes first."

3. at 8:35 AM on 2/4/14, while on tour of the out patient/off site urgent care center in the company of staff member #61, the chief operations officer, and #74, the director of the urgent care center, it was observed in the nursing area that the glucometer test strips were not dated when opened, nor with an expiration date

4. interview with staff members #61 and #74 at 8:35 AM on 2/4/14 indicated it cannot be determined when the 180 day expiration date is on the test strips at the urgent care center since the strips were not dated when opened, or with a 180 day expiration date

5. at 11:30 AM on 2/4/14, while on tour of the Med/Surg area with staff member #61, the chief operations officer, and staff member #72, the nurse director of med/surg, it was observed that the glucometer test strips were dated as opened on 1/31/14 and dated with an expiration date of 2/28/14

6. interview with staff members # 61 and #72 at 11:30 AM on 2/4/14 indicated the test strips were incorrectly dated as the expiration date should have been 180 days, not 30 days

7. at 1:45 PM on 2/4/14, while on tour of the obstetrics department in the company of staff members #61, the chief operating officer, and #75, the RN director of obstetrics, it was observed that the glucometer test strips were dated when opened on 2/1/14 and dated with an expiration date of 3/1/14

8. interview with staff members #61 and #75 at 1:45 PM on 2/4/14 indicated the test strips are actually good for 180 days after opening, not 30 days

9. interview with the infection control preventionist, staff member #65, at 12:25 PM on 2/4/14, indicated:
a. the policy 385842, listed in 1. above, does not match the manufacturer's package insert recommendations for 180 day stability after opening
b. nursing staff are not following either the policy for 90 day (3 month) expiration, or 180 days, per the manufacturer
c. the urgent care center failed to follow the policy in dating the test strips at all after opening

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the nature and scope of services provided for 16 of 66 contracted services.

Findings:

1. The list of contracted services failed to indicate a description or scope of service for 3 of 3 listed emergency department services, 1 of 14 laboratory services, 2 of 13 pharmacy services, 5 of 12 radiology services, 2 of 14 rehabilitation services, 1 of 3 respiratory therapy services, and 2 of 7 surgical services.

2. During an interview on 2-04-14 at 1340 hours, the director of performance improvement A20 confirmed that the indicated services listed under the categories of laboratory, pharmacy, radiology, and rehabilitation lacked a description or nature and scope of services provided.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that the patient's physician participated with care planning and care conferences as part of the interdisciplinary team.

Findings:
1. review of the policy and procedure "Swing Bed Care Conference", policy number 533636, with a "review/approved" date of 08/2013, indicated:
a. under "Procedure", it reads: "...1. Conferences will be held on a mutually agreeable schedule for the Rehab Center staff, Nursing staff, Discharge Planner, and patient's significant others/family if indicated..."

2. review of two open swing bed patient medical records at 3:15 PM on 2/4/14, indicated:
a. pt. #5:
A. was admitted to swing bed status on 1/30/14
B. had a care conference on 2/3/14
C. lacked any documentation that the patient's physician participated in the development of the care plan and/or the care conference
b. pt. #6:
A. was admitted to swing bed status on 1/30/14
B. had a care conference on 2/3/14
C. had documentation in the minutes of the care conference that read: "...Dr. [named] notified of plan."

3. interview with staff member #72, the RN (registered nurse) manager/director of med/surg, at 3:30 PM on 2/4/14, indicated:
a. the physician never attends care conferences as they are so busy
b. physicians are involved in patient care decisions, but documentation does not show this
c. it was unknown that physician attendance was required at the care conferences
d. documentation is lacking that would indicate the attending physician is involved in care planning and care conferences
e. the facility policy does not include language to indicate the inclusion of physician participation in care conferences and planning