HospitalInspections.org

Based on observations, record reviews and interviews the facility failed to:
-Ensure each patient and/or patient's representative in the emergency department (ED) was offered the opportunity to establish an advance directive. This had the potential to affect all patients seen in the ED. (A0132)
-Provide a safe environment for 26 of 26 patients on the Resolutions Unit (Behavioral Health) by allowing:
Non-suicide- resistant shower water control knobs in three of three patient shower rooms
Non-suicide-resistant sink plumbing in two of three patient shower rooms
Non-suicide-resistant handicap grab bars attached to toilets in 27 of 27 bathrooms
Plastic bags throughout the unit
Exposed broken light bulb in one patient room
Exposed and removable metal screws in light fixtures in 19 of 27 rooms
Accessible electrical cords in one of three shower rooms
Unsecured soap and detergent in three of three laundry alcoves
The configuration of these water control knobs, toilets, sinks and handicap bars creates a looping hazard for all patients on the unit. The presence of plastic bags, removal metal screws, a broken light bulb and soap and detergent create hazards for patients at risk for suicide. (A0144)
-Provide storage of confidential patient information in a manner to prevent unauthorized access for patients. This had the potential to affect all patients in the facility. (A0147)
-Have a policy documenting the training requirements for physicians in the use of restraint or seclusion. (A0176)
The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with CFR 482.13, Condition of Participation: Patient Rights

Based on record review and interview, the facility failed to ensure each patient and/or patient's representative in the emergency department (ED) was offered the opportunity to establish an advance directive. This had the potential to affect all patients seen in the ED. The facility census was 45. The emergency department averages 930 patient visits per month.

Findings included:

Review on 9/14/10 of the facility patient rights given to patients or their representative showed in part, "The patient/family has the right to participate in the development of the patient's plan of care. Within this process the patient has a right to the following:
-Make informed decisions regarding his/her care
-Being informed of his/her health status
-Being able to consent to or refuse treatment.
A patient has a right to formulate Advance Directives and expect health care providers to comply with these directives."

Record review of the admitting information for current Patients #61 and #62 showed both patients entered the ED for treatment on 9/14/10. The review showed no documentation of staff asking Patient #61 or #62 if they had an advanced directive or if they wanted information concerning an advanced directive.

During an interview on 9/14/10 at 10:30 AM, Staff C said that the staff don't ask the patients or their representatives if they have an advanced directive unless they are admitted to the facility or unless the need arises.

During an interview on 9/15/10 at 3:10 PM, Staff E, Clinical Quality Coordinator said the ED clerks only ask about advanced directives when patients are admitted. Staff E said staff should ask every patient.

Based on observation and interview the facility failed to provide a safe environment for 26 of 26 patients on the Resolutions Unit (Behavioral Health) by allowing:
- Non-suicide- resistant shower water control knobs in three of three patient shower rooms
- Non-suicide-resistant sink plumbing in two of three patient shower rooms
- Non-suicide-resistant handicap grab bars attached to toilets in 27 of 27 bathrooms
plastic bags throughout the unit
- Exposed broken light bulb in one patient room
- Exposed and removable metal screws in light fixtures in 19 of 27 rooms
accessible electrical cords in one of three shower rooms
- Unsecured soap and detergent in three of three laundry alcoves
The configuration of these water control knobs, toilets, sinks and handicap bars creates a looping hazard for all patients on the unit. The presence of plastic bags, removal metal screws, a broken light bulb and soap and detergent create hazards for patients at risk for suicide. The unit census was 26 and the facility census was 45.

Findings included:

Observation on 9/14/10 on the adolescent area of the unit showed the following patient safety issues:
- The shower room has a regular shower water control knob, which protrudes from the wall approximately two inches. The room also contains a large whirlpool tub with electrical cords accessible to patients.
- The laundry alcove has plastic bags sitting in a bin on the floor, along with soap and detergent available to patients.
- Plastic bags in trash containers in an interview room accessible to patients.
- Rooms 252, 253, 254, 255, 256, 257, 259 and 260 have exposed removable metal screws in the ceiling light fixtures.
- Room 258 has a broken exposed light bulb in the bathroom ceiling.
- The dining room has exposed removal metal screws in the dining area and the attached bathroom.
- All patient toilets have handicap grab bars attached to the toilets. Items can be looped over the handicap grab bars.

Observation on 9/14/10 on the adult area of the unit showed the following patient safety issues:
- There are two showers in the shower room. Both showers have regular shower water control knobs and facets, which protrude from the wall approximately two inches. A sink in the shower room has exposed plumbing.
- The laundry alcove has plastic bags located in an unlocked drawer and has soap and detergent available to patients.
- Rooms 273, 274, 275, 276, 277, 278, 279, 280, 281, 283 and 284 have exposed removable metal screws in the ceiling light fixtures.
- All patient toilets have handicap grab bars attached to the toilets. Items can be looped over the handicap grab bars.

Observation on 9/14/10 on the geriatric area of the unit showed the following patient safety issues:
- The shower room has a regular shower water control knob, which protrudes from the wall approximately two inches. Plastic bags are stored in the shower room. A sink in the shower room has exposed plumbing.
- The laundry alcove has plastic bags, soap and detergent, which are available to patients.
- An unlocked storage closet located in the hallway contains plastic bags.
- All patient toilets have handicap grab bars attached to the toilets. Items can be looped over the handicap grab bars.

Observation showed all patient rooms are unlocked and patients have access to their rooms and bathrooms without monitoring by staff.

During an interview on 9/14/10 at approximately 10:00 AM, Staff H, Behavioral Health Program Director said that patients with suicidal ideations are admitted to all three areas of the Resolutions unit. Staff H said that patients on the adolescent and adult units are allowed to use the shower rooms without direct observation by staff. Patients on the geriatric unit may be assisted by staff if needed while using the shower room.

Based on observation and interview, the facility failed to provide storage of confidential patient information in a manner to prevent unauthorized access for patients. This had the potential to affect all patients in the facility. The facility census was 45.

Findings included:

1. Facility policy #1-9, dated 6/2007 "Policy/Procedure, Patients Rights" states in part at #8, "The patient has the right to confidentiality of his or her health care provided and medical record".

2. Observations in Patient #14's room on 9/14/10 at 3:05 PM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

3. Observations in Patient #12's room on 9/14/10 at 3:15 PM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

4. Observations in Patient #13's room on 9/15/10 at 9:20 AM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

5. Observations in Patient #12's room on 9/14/10 at 3:15 PM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

6. Observations in Patient #11's room on 9/15/10 at 4:00 PM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.



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7. Observation on 9/14/10 at 10:15 AM showed a clipboard attached to the foot of Patient #1's bed. The clipboard held an Intake/Output sheet and a charge sheet which contained the patient name, age, date of birth and medical record number.

8. Observations in Patient #21's room on 9/15/10 at 9:15 AM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

9. Observations in Patient #14's room on 9/15/10 at 9:35 AM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

10. Observations in Patient #20's room on 9/15/10 at 9:45 AM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

11. Observations in Patient #19's room on 9/15/10 at 10:05 AM showed an Intake/Output sheet and a charge sheet on the back of the patient's door which contained the patient name, age, date of birth and medical record number.

Based on policy review and interview the facility failed to have a policy documenting the training requirements for physicians in the use of restraint or seclusion. The facility census was 45.

Findings included:

Review of facility restraint policy 3-23, revised 6/2010, showed in section C "Physicians do not have to be trained in restraining or secluding patients. Physicians who order restraints or seclusions or examine patients in restraints or seclusion shall have a working knowledge of the restraints and seclusion policy."

The facility provided no policy on the training requirements of physicians.

During an interview on 9/16/10 at approximately 4:00 PM, Staff F, Patient Staff Education, said that there is no policy on the training requirements of physicians.

Based upon record review and interview, the facility failed to ensure that there is an effective, ongoing, hospital-wide quality assurance/performance improvement program, responsible to the Governing Body of the hospital, which would lead to reduced medical errors and improved patient care. This applies to all patient services. The facility census was 45.

The severity and cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

See related citations at A0264, A0273, A0285 and A0309.

Based upon record review and interview, the facility failed to:
- assure that there was an effective, ongoing, hospital-wide quality assurance and performance improvement program that showed measurable improvement in indicators for which there is evidence that it would improve health outcomes;
- identify and reduce medical errors; and
- measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.
This applied to all patient services. The facility census was 45.

Findings included:

1. The facility failed to produce documented evidence of an effective hospital-wide program for Quality Assessment and Performance Improvement.

During an interview on 9/16/10 at 10:40 AM, Staff E, Clinical Quality Coordinator, said the facility made the decision to begin hospital-wide quality surveillance several weeks before the initiation of this survey.

2. Review of current quality monitoring revealed surveillance in various areas of the facility including tracking of medication errors, but there was no evidence of analysis and systematic performance improvement applications. Multiple areas of the facility had no quality improvement surveillance in place.

During an interview on 9/16/10 at 10:45 AM, Staff E produced a document titled, "Pemiscot Memorial Health Systems Organizational Performance Improvement Plan." Staff E said the plan was not in effect yet. The facility is not affiliated with a Quality Improvement Organization.

Based upon review of facility records and interview, the facility failed to:
- Incorporate quality indicator data including patient care data and other relevant data to monitor the effectiveness of services and quality of care;
- Identify opportunities for improvement and changes that would lead to improvement; and
- Develop an ongoing hospital-wide quality program, for which the Governing Body had specified the frequency and detail of data collected.
This applied to all patient services. The facility census was 45.

Findings included:

1. Review of current quality monitoring revealed surveillance in various areas of the facility including tracking of medication errors, but there was no evidence of analysis and systematic performance improvement applications. Multiple areas of the facility had no quality improvement surveillance in place.

2. During an interview on 9/16/10 at 10:45 AM, Staff E, Clinical Quality Coordinator, said the facility was not affiliated with a Quality Improvement Organization, and did not have a Quality Improvement Committee to assist in monitoring and evaluating the effectiveness of the program. Therefore, the quality improvement data was collected and distributed to administrative staff for review. The facility provided no evidence that quality improvement data was brought before the Governing Body or the Medical Staff.

Based on Quality Improvement document review and interview the facility failed to collect and analyze data related to high-risk or problem-prone areas to monitor the effectiveness and safety of services and quality of care provided in the emergency department. The facility census was 45.

Findings include:

1. Review of the emergency services quality improvement data revealed no data collection or monitoring of length of stay in the emergency department, physician response time, timeliness of diagnostic studies and appropriateness of treatment rendered in the emergency department.

During an interview on 9/14/10 at 9:30 a.m. Staff E Clinical Quality Coordinator said the emergency department looks at admission time to the ED and the time of triage but is not monitoring the actual length of stay in the ED. Staff E said staff review transfers but the ED Medical Director does not monitor the appropriateness of transfers out of the ED. Staff E said no data could be found for physician response time, timeliness of diagnostic studies or the appropriateness of treatment rendered.



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2. During an interview on 9/15/10 at 3:45 PM the manager of radiology stated that he/she does not know of any quality assurance information which is submitted to a committee or available for review by the governing body. The mammography technician does collect data but only submits that to the manager of the department and is subject to no further review.

During an interview on 9/15/10 at 3:37 PM the manager of radiology stated that the only two reports for any of the services provided by the department for which there were physicist reports on the equipment ensuring that it operated properly were for the nuclear medicine and mammography units.



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3. During an interview on 9/16/10 at 10:55 AM, Staff E, Clinical Quality Coordinator, said that the facility has an ICU/CCU Committee which meets quarterly. The purpose and scope of the committee was not disclosed. However, no quality improvement data was made available for review by surveyors or the Governing Body.

Based upon review of facility records and interviews, the facility failed to ensure that:
- The Governing Body, the Medical Staff, and the Administrative staff are responsible for the Quality Assessment/Performance Improvement Program;
- The program had clear definition, including ongoing program priorities for improving quality of care and patient safety;
- The program had adequate resources for reducing risk to patients; and
- All improvement actions are evaluated.
This applied to all patient services. The facility census was 45.

Findings included:

1. Review of facility documents revealed that the core administrative body failed to be responsible and involved in the Quality Improvement Program, that the current Quality Improvement Program failed to have hospital-wide design, and that the facility failed to have specific priority focus for improving patient safety so that all improvement actions were evaluated.

2. During an interview on 9/16/10 at 10:45 AM, Staff E, Clinical Quality Coordinator, said the facility was not affiliated with a Quality Improvement Organization, and did not have a Quality Improvement Committee to assist in monitoring and evaluating the effectiveness of the program. Therefore, the quality improvement data was collected and distributed to administrative staff for review. The facility provided no evidence that quality improvement data was brought before the Governing Body or the Medical Staff.

Based on record review and interview the facility failed to delineate or approve specific privileges for all members of the medical staff or to ensure that the granting of privileges is based on defined criteria and individuals requesting specific privileges are approved to provide only those specific services. The patient census was 45.

Findings included:

1. During an interview on 9/16/10 at 9:45 AM Staff X (administrator) and Staff Y (physician on staff) stated that they did not know of any core privileges or other definitions available for physicians with a specific specialty in the medical field which would define the basic privileges each physician was allowed to provide to patients. Only the privilege sheets completed by each physician would define this.

2. Review of "Article VII of Professional Staff" governing body bylaws under 7.2-C stated that the definition of the clinical privileges which may be appropriately granted within the institution and within each department are activities of the medical staff.

3. Review of the Medical staff bylaws and rules under Article V states that a practitioner providing clinical services at this hospital by virtue of medical staff membership or otherwise, may in connection with such practice, exercise only those clinical privileges specifically granted to him/her by the board. Privileges governing clinical practice are granted in accordance with prior and continuing education, training, experience, and demonstrated current competence and judgment as documented and verified in each practitioner's credential file. Under definitions it is stated that Medical Staff is defined as all practitioners who have been granted clinical privileges to attend patient in the hospital. Clinical Privileges are defined as the permission granted to a practitioner to render specific diagnostic, therapeutic, medical, dental or surgical services. Section 2.213 states that responsibilities of the medical staff are evaluating practitioner credentials for initial and continued membership in the medical staff organization and for the delineation of clinical privileges for each individual practitioner in the hospital.

4. Record review of the credentialing files for physicians indicated that physicians on the application marked an area that stated all clinical privileges be granted as applied for. This is the form that the medical staff and governing body indicate their approval on for appointment to staff and to practice clinical privileges.

5. Review of the privileges titled "Delineation of Privileges of Family Practice" for Physician #3 indicated that under clinical areas #9 was check marked to indicate pediatrics as the specialty.
There were no other privileges requested on the form dated 6/30/07 which included 83 specific privileges. On the last page of the application under the section "I request privileges in the following" pediatrics was marked. Neither the medical staff bylaws nor the privileging form defined the specific privileges this physician could provide to patients.

6. Review of the privileges, titled Delineation of Privileges of Medicine" requested by Physician #10 indicated #15 was marked indicating psychiatry. On the last page of the application (dated 12/20/07) a box was marked for "other" and psychiatry department was handwritten in. No other specific privileges were indicated under medicine which included four other areas of which none dealt with psychiatry specialties. Neither the medical staff bylaws nor the privileging form defined the specific privileges this physician could provide to patients.

7. Review of the application for Physician #2 on the last page indicated a section for "I request privileges in the following" and emergency, medicine, obstetrics/gynecology, surgery and a category of other for ENT and chest were marked.

The sheet for "Delineation of Privileges for Obstetrics and Gynecology" is blank for all sections including obstetrical surgical procedures, medical treatment during pregnancy and medical gynecological privileges. The form is dated 9/1/02. The sheet for "Delineation of Privileges of Family Practice" is blank for all areas including clinical areas and special procedures and treatment of disease entities. The sheet for "Delineation of Privileges of Medicine" is blank under the sections of clinical areas, special procedures, and biopsy and incision. The section for endoscopy and special studies has some areas requested. The sheet for "Delineation of Privileges of Emergency Medicine" and surgery has areas requested. Neither the medical staff bylaws nor the privileging form defined the specific privileges this physician could provide to patients for those areas the physician did not specifically request.

8. Review of the application and privileges for Staff Y (Physician) of radiology indicated privileges on a form where "Diagnostic Radiology" is handwritten on the privileges sheet as there is no section for this specialty when the sheet was signed in 1978 and there is a newer sheet dated 1998 for privileges for this physician.

9. Review of the specific privilege sheets that the facility maintains for physicians included Radiology (specific to each type of procedure or service), Anesthesia, Pathology, Obstetrics & Gynecology, Medicine, Family Practice, Emergency Medicine, Surgery, and Podiatry. There is no specialty for psychiatry or pediatrics which defines the privileges to be granted or requested.

Based on facility policy review, observation, record review, and interview, the facility failed to identify patients per facility policy before administering medications to one patient (#1) and ensure medications were administered as ordered by the physician for two patients (#20 and #19) of 11 patients observed during medication administration. The facility census was 45.

Findings included:

1. Review of the facility policy titled, "Uniform Drug Administration Policy," gave the following direction (in part):
- In all areas of the Hospital the patient is identified before a dose of medication is administered. The person administering the medication identifies the patient by asking the patient his/her name and checking the identification bracelet prior to administration of medications.

Review of the facility policy titled, "Medication Administration," last revised 6/2007, gave the following direction (in part):
- Medications administered greater than one hour prior to or after scheduled time shall be considered late or early.

2. Observation on 9/14/10 at 10:15 AM showed Staff A, LPN (Licensed Practical Nurse) administer Flagyl (an antibiotic) 500 mg (milligrams) po (by mouth) to Patient #1. Patient #1 was dozing, and was not wearing a patient identification armband. Staff A spoke to the patient, then administered the medication.

During an interview on 9/14/10 at 10:20 AM, Staff A said he/she looked at the clipboard attached to the foot of Patient #1's bed to identify that this was the correct patient. The clipboard at the foot of the bed contained an Intake/Output sheet and a charge sheet which contained the patient name, age, date of birth and medical record number.

Review of Patient #1's medical record on 9/16/10 at 9:00 AM showed a form titled, Treatments" dated 9/15/10. On the line "Check armband q (every) shift," a checkmark was placed in the 10:00 AM column indicating the patient was wearing an armband.

3. Observation on 9/15/10 at 9:45 AM showed Staff Q, RN (Registered Nurse) administer the following medications to Patient #20:
- Flomax (used to treat the symptoms of enlarged prostate) 0.4 mg po (by mouth)
- Protonix (used to treat gastro esophageal reflux disease) 40 mg IV (intravenous)

Review of the MAR (Medication Administration Record) on 9/16/10 at 9:15 AM showed these medications were scheduled to be given at 9:00 AM.

4. Observation on 9/15/10 at 10:15 AM showed Staff Q, RN administered the following medications to Patient # 19:
- Indur (used to treat chest pain) 30 mg, 2 tabs po
- ASA (aspirin) 325 mg po
- Plavix (used to prevent strokes and heart attacks) 75 mg po
- Lopressor (used to treat high blood pressure) 50 mg po
- Claritin (used to treat allergies) 10 mg po
- Levothyroid (used to treat thyroid problems) 75 mcg (micrograms) po
- Ciprofloxacin (antibiotic) 400 mg IV

Review of the MAR on 9/16/10 at 9:20 AM showed these medications were scheduled to be given at 9:00 AM. The above medications were initialed as being given at 10:00 A.M. rather than the time they were actually administered, 10:15 A.M. with the exception of Ciprofloxacin, which was not charted as being administered.

Based on policy review, record review and interview the facility failed to obtain physician's orders that contained all necessary information to administer medication for two patients (#4 and #5) of five records reviewed for medication administration. The facility census was 45.

Findings Included:

Review of the undated facility policy, "Prescribing/Ordering General Practices" showed the policy statement is "The hospital will develop, implement and maintain policies and procedures to support prescribing and ordering of drugs that ensure the safe, clear and legal use of drugs." The policy showed (in part) orders for "as needed" or "PRN" medications shall specify the indication(s) for use and be specific for dose and dosage frequency.

Open record review on 9/14/10 showed Patient #4 entered the facility 9/11/10 for treatment of behavioral problems. Review of the physician's orders showed the following orders dated 9/11/10 at 4:05 PM:
Tylenol 650mg (milligrams, unit of measure) po (by mouth) q4 hours (every four hours) PRN (as needed)
Ativan (used to treat anxiety) 2mg q4 hours IM/po (injected or by mouth) PRN
Haldol (used to treat hallucinations, delusions and unusual behavior) 5mg q4 hours IM/po PRN
The physician's orders do not specify the indication for use for the above medications.

Open record review on 9/14/10 showed Patient #5 entered the facility 9/03/10 for treatment of Bipolar Disorder (mood swings) with a medical diagnosis including asthma. Review of the physician's orders showed the following orders dated 9/03/10 at 6:20 PM:
Tramadol (a pain reliever) 50mg po q6 hours PRN
Salbutamol HFA (used to treat asthma) 2 puffs 4 x day (four times a day) PRN
The physician's orders do not specify the indication for use for the above medications.

During an interview on 9/14/10 at 4:55 PM, Staff D, Director of Pharmacy, said that all orders for a PRN medication should include the reason the medication is ordered. Staff D said that he/she fills these PRN medication orders without clarifying the orders with the physicians.

Based upon observation and interview, the facility failed to protect the patient identification information for medical records. This applied to all in patients and outpatients. The current census was 45.

Finding included:

Observation during the tour of the Medical Record Department on 9/14/10 at 2:00 PM showed both doors to the Mail Room on the 2nd Floor were propped open to the hallway passage. In the mail room, a large trash receptacle bin (on wheels) was found to be unlocked and full of discarded pages of medical records, which included patient names and dates of birth and other medical information from medical record entries.

During interview on 9/14/10 at 2:00 PM, Staff K, Director of Medical Records, stated that the Housekeeping personnel sometimes have to empty the shred bin receptacles because they get overloaded. When the shred bin papers are collected, they would be dumped into the receptacle in the Mail Room until the contracted company for shredding comes to manage the work.

Based on review of the facility's medical staff rules and regulations, facility policy review, and record review, the facility failed to ensure physicians telephone orders are authenticated within 24 hours for four patients (#4, #5, #3 and #1) of 60 records reviewed for verbal order authentication. The facility census was 45.

Findings included:

1. Review of the Medical Staff Rules and Regulations, revised June 2004, showed (in part) on page 2 section 4, "Orders dictated over the telephone shall be signed by the person whom dictated with the name of the physician per his/her own name. The next day the physician shall sign such orders."

Review of the facility policy titled, "Verbal and/or Telephone Physician's Orders," last reviewed 9/2007, showed the following (in part):
- Verbal and telephone orders shall be signed by the prescribing practitioner within twenty-four (24) hours.

2. Open record review showed Patient #4 entered the facility on 9/11/10 for treatment of behavioral problems. Review on 9/14/10 of physician's order dated 9/11/10 at 7:20 PM showed a telephone order for Levaquin (used to treat infection) 750mg (milligrams, unit of measure) po (by mouth) for 5 days. The order was not signed by the physician.

3. Open record review showed Patient #5 entered the facility 9/03/10 for treatment of bipolar disorder (mood swings).
- Review on 9/14/10 of a physician telephone order dated 9/10/10 at 8:35 PM showed an order for Motrin (used to treat pain) 800 mg po, three times a day prn (as needed) and Docusate NA (used to treat constipation) 100 mg. po, two times a day prn. The telephone order was not signed by the physician.
- Review on 9/14/10 of a physician order dated 9/11/10 at 8:20 PM showed an order for Robitussin DM (used to treat cough/congestion) 10 ml (milliliters, unit of measure) every six hours prn. The order was not signed by the physician.
- Review on 9/14/10 of a telephone order dated 9/06/10 at 10:05 AM to change Depakote ER 250mg 4xday (four times a day) to Depakote ER 500 mg 2xday (two times a day). The physician's signature was not timed or dated.
-A telephone order dated 9/06/10 at 2:35 PM for Claritin (used to treat allergies) 10mg po daily. The physician's signature was not timed or dated.

4. Open record review showed patient #3 entered the facility on 9/07/10 for treatment of hallucinations and delusions.
- Review of the physician's orders on 9/14/10 showed the following:
Admission telephone orders dated 9/07/10 at 3:45 PM for:
Geodon (for treatment of hallucinations/delusions) 40 mg po daily at 6:00 PM
Cymbalta (used to treat depression) 30 mg po, three times daily
Alprazolam (used to treat anxiety and panic attacks) 0.5 mg po, two times daily
Atendol (used to treat high blood pressure) 50/25 po, two times daily
The physician's signature for the above orders was not dated or timed.


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5. Review of the medical record for current Patient #1 on 09/14/10 at 11:00 AM showed the following (in part):
- A telephone order dated 9/9/10 at 8:30 AM:
- "Tylenol (analgesic) 1000 mg (milligrams) po (by mouth) now, and QID (four times daily) prn (as needed) for fever more than 100.5
- Chest x-ray
- Sputum for culture
- Urine for culture
- Blood culture
- Zosyn (antibiotic) 3.375 gm (gram) IV now and q (every) 6 hrs (hours)
- Flagyl (antibiotic) 500 mg now and q 8 hrs"
There was no physician signature to authenticate the order.
- A telephone order dated 9/10/10 at 9:40 AM for "Physical therapy eval (evaluation) and treat."
The order was signed by the physician but was not dated or timed.

Based on review of Medical Staff Rules and Regulations, record review and interview, the facility failed to ensure the physician completed the history and physical within 24 hours of admission for two patients (#3 and #4) and the facility failed to ensure the physician completed the history and physical prior to a surgical procedure for two patient (#32 and #1) of nine records reviewed for history and physicals. The facility census was 45.

Findings included:

1. Review of the Medical Staff Rules and Regulations, revised June 2004, showed in part on page 4 section 12, "A complete history and physical (H&P) examination shall be written or dictated within seven (7) days prior to admission or within twenty four (24) hours after admission of the patient."

2. Open record review for Patient #3 on 9/14/10 showed the patient entered the facility 9/07/10 for treatment of psychosis (hallucinations/delusions). The physician dictated the history and physical 9/10/10.

3. Open record review for Patient #4 on 9/14/10 showed the patient entered the facility 9/11/10 for treatment of mental retardation with behavioral issues. No history and physical was noted in the record.

During an interview on 9/14/10 at 3:00 PM Staff H, psychiatric unit program director, confirmed there was no history and physical on Patient #4 record.



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4. Record review for Patient #32, admitted 8/17-21/10 for childbirth via caesarian section, showed that the History and Physical was dictated by the physician on 8/17/10. On the physician order sheet, the pre-operative physician orders were written at 5:20 AM, and the post-operative physician orders were written at 6:20 AM.

During interview on 9/16/10 at 3:00 PM, Staff K, Director of Medical Records, stated that the transcriptionist service begins the day at 8:00 AM every morning, Mondays through Fridays. There are no offsite (typing of medical record notes at a location other than the facility campus) transcription services. Staff K confirmed that this History and Physical would not have been on typed and on the chart before the surgery had begun for this patient.



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5. Review of Patient #1's medical record on 9/14/10 at 11:05 AM showed a form titled, "History and Physical Examination," dated 8/23/10 with a hand written history. The form was signed by the physician, but the signature was not dated or timed. It is not possible to determine if the physician has signed within the required time frame, if the date and time of the signature are lacking.

Based upon record review and interview, the physicians failed to date and time signatures for discharge summaries of fifteen (#38, 39, 43, 44, 46, 42, 32, 37, 50, 51, 62, 56, 57, 48, 49) of fifteen cases reviewed for discharge summaries that had been due for signatures. The current census was 45.

Finding included:

1. During interview on 9/14/10 at 2:00 PM, Staff K, Director of Medical Records, stated that the facility policy, given in the Medical Staff Bylaws, required the physicians to complete and sign the discharge summaries of patients' records within fifteen days of discharge. There is no expectation of the signatures to be dated and timed for signing. During this interview, Staff K stated, "We are happy to get signatures."

2. Record review for these discharged patients showed the following:
-Patient #38, admitted 7/27-8/13/10 to Surgical Acute Care had physician signature for discharge summary transcribed 7/27/10; but lacked date and time of physician signature.

-Patient #39, admitted 7/27-8/12/10 to Medical Acute Care had physician signature for discharge summary transcribed 8/16/10; but lacked date and time of physician signature.

- Patient #43, admitted 8/03-7/10 to Medical Acute Care had physician signature for discharge summary transcribed 8/7/10; but lacked date and time of physician signature.

- Patient #44, admitted 8/29-31/10 for Medical Observation had physician signature for discharge summary transcribed 8/31/10; but lacked date and time of physician signature.

-Patient #46, admitted as an outpatient 8/1-2/10 had no discharge summary.

-Patient #42, admitted 8/9-14/10 for childbirth, had physician signature for discharge summary transcribed 8/31/10; but lacked date and time of physician signature.

-Patient #32, admitted 8/17-21/10 for childbirth had physician signature for discharge summary transcribed 8/ 26/10; but lacked date and time of physician signature.

-Patient #37, admitted 8/23-25/10 to Medical Acute Care, had physician signature for discharge summary transcribed 9/3/10; but lacked date and time of physician signature.

-Patient #50, admitted 6/22-7/13/10 to Medical Intensive Care, had physician signature for discharge summary transcribed 7/16/10; but lacked date and time of physician signature.

- Patient #51, admitted 10/1/09-2/09 for childbirth had physician signature for discharge summary transcribed 10/5/09; but lacked date and time of physician signature.

-Patient #62, admitted 8/23-27/10 for childbirth had physician signature for discharge summary transcribed 8/31/10; but lacked date and time of physician signature.

-Patient #56, admitted 8/25-26/10 for childbirth physician signature for discharge summary transcribed 8/26/10; but lacked date and time of physician signature.

- Patient #57, admitted 8/07-24/10 to Medical Acute Care had physician signature for discharge summary transcribed 9/3/10; but lacked date and time of physician signature.

- Patient #48, admitted 6/3-9/10 to Medical Intensive Care had physician signature for discharge summary transcribed 6/0/10; but lacked date and time of physician signature.

-Patient #49, admitted 6/17-17/10 to Medical Acute Care had physician signature for discharge summary transcribed 6/18/10; but lacked date and time of physician signature.

It is not possible to determine if the physician has signed within the required time frame, if the date and time of the signature are lacking.

Based on facility policy review, observation and interview, the facility failed to ensure that medications were stored at the proper temperature. This had the potential to affect all patients. The facility census was 45.

Findings included:

1. Review of the facility policy titled, "Unit Inspection," gave the following direction (in part):
- Drugs shall be stored at appropriate temperatures.

Review of the facility policy titled, "Refrigerated Drug Storage" gave the following direction (in part):
- POLICY: All refrigerated drug storage areas will be inspected daily to ensure compliance with drug storage standards.
- PROCEDURE: In the event of variance from normal temperature range, the Pharmacist will be consulted immediately to determine the disposition of drugs.

2. Observation on 9/14/10 at 10:15 AM in the Intensive Care Unit showed a small refrigerator in the locked medication room. The freezer compartment of the refrigerator was covered with a layer of one-inch thick ice. Several medications, including insulin (used to treat diabetes), were stored within the refrigerator.

3. Review of the temperature log showed the following:
9/1/10 - 39
9/2/10 - 30
9/3/10 - No temperature recorded
9/4/10 - No temperature recorded
9/5/10 - No temperature recorded
9/6/10 - 39
9/7/10 - 37
9/8/10 - No temperature recorded
9/9/10 - 39
9/10/10 - 32
9/11/10 - No temperature recorded
9/12/10 - No temperature recorded
9/13/10 - 39
9/14/10 - 39

Instructions at the bottom of the page give the following directions:
- Daily record temperature and initial.
- Proper temperature range for refrigerator is 36-46?F (2-8?C).
- If temperature is outside of range for two days contact the pharmacy department regarding proper disposition of medications.

4. During an interview on 9/14/10 at 10:20 AM, Staff B, RN (Registered Nurse) Charge Nurse said, "The temperatures aren't being recorded like they should be. I don't know why."

During an interview on 9/16/10 at 9:30 AM, Staff T, Pharmacy Technician said, "No one has notified of the Pharmacy that temperature recordings are outside the correct range."

5. Observation on 9/14/10 at 10:45 AM showed a multi-dose vial of Levemir Insulin (used to treat diabetes) and a multi-dose vial of Humalog Insulin (used to treat diabetes) were stored on a countertop near the Intensive Care Unit nursing station. The medications were not refrigerated.

During an interview on 9/14/10 at 2:15 PM, Staff D, Pharmacy Director, said, "Refrigerator temperatures are supposed to be checked daily. We have a lot of trouble getting employees to do this."

Based on observation and interview, the facility failed to provide patient safety and reduce risk of adverse events with regard to administering high risk medications for one patient (#1) of one patients observed receiving high risk medications. The facility census was 45.

Findings included:

Observation on 9/14/10 at 10:40 AM showed Staff B, LPN (Licensed Practical Nurse) prepared an insulin (used to treat diabetes) injection for Patient #1. Staff B did not have a second nurse check the dosage before administering insulin to Patient #1.

During an interview on 9/14/10 at 2:25 PM, Staff D, Pharmacy Director, said, "The facility does not have a policy for high risk medication administration."

Based upon record review and interview, the facility failed to have signed and timed written orders for Sliding Scale Insulin for three (Patients #39, 14, and 45) of three patients reviewed for sliding scale insulin. The facility census was 45.

Finding included:

Reference to the Missouri Hospital Regulations at 19CSR30-20.021 for pharmacy requirements states, in part, "When medication therapy is based on a protocol or standing order and a specific medication order is not written, a signed copy of the protocol or of an abbreviated protocol containing the medication order parameters or of the standing order shall be placed in the medical record..."

Record reviews revealed the following:
-for Patient #39, currently admitted to the Swing Bed Program since 8/12/10, the Sliding Scale Insulin (a dosage of insulin determined by the result of blood sugar test) order was written on the physician order sheet of 8/12/10 at 8:12 AM. No parameters were indicated for the dosage of insulin in relation to the patient's blood sugar results. The physician's preference for the insulin scale was stamped on the Medicine Administration Record (MAR), but not on the order sheet. The orders lacked an appropriately signed order for this protocol process.

-for Patient #14, currently admitted to the acute service since 9/13/10 noted a physician order on 9/13/10 at 8:00 AM for Accuchecks QAC & QHS (blood sugar tests before each meal and at bedtime) with regular insulin to be given per the sliding scale insulin. No parameters were indicated for the dosage of insulin in relation to the patient's blood sugar results. The physician's preference for the insulin scale was stamped on the Medicine Administration Record (MAR), but not on the order sheet. The orders lacked an appropriately signed order for this protocol process.

-for Patient #45, a past admission to the acute service from 8/26-28/10 showed the physician order sheet of 8/26/10 to have Sliding Scale Insulin ordered. No parameters were indicated for the dosage of insulin in relation to the patient's blood sugar results. The physician's preference for the insulin scale was stamped on the Medicine Administration Record (MAR), but not on the order sheet. The orders lacked an appropriately signed order for this protocol process.

During interview on 9/16/10 at 4:00 PM, Staff U, Charge Nurse for the Intensive Care Unit, stated that the nursing staff would use the Sliding Scale parameters when the physician orders them or when Accuchecks are ordered.

Based on facility policy review, observation, and interview, the facility failed to ensure medications are kept in a locked, secured area to prevent unauthorized access. This had the potential to affect all patients and staff in the facility. The facility census was 45.

Findings included:

1. Review of the facility policy titled "Medication Security" gave the following direction (in part).
Procedure: All drugs, except those intended for crash cart used, will be stored in lockable containers or areas.

2. Observation on 9/14/10 at 9:55 AM in the Emergency Department (ED) showed an unlocked refrigerator with food, open bottles of amoxicillin (liquid antibiotic) and azithromycin (liquid antibiotic), as well as a prepackaged syringe of normal saline on top of the crash cart.

3. Interviews revealed:
-On 9/14/10 at 9:55 AM, Staff C, ED Registered Nurse, said the medications should not be in the refrigerator with the food and should be in the locked pyxis (medication dispensing machine) refrigerator. Staff C said the syringe of normal saline should not be out in the open.
-On 9/14/10 at 2:00 PM, Staff D, Pharmacist, said medication should not be in the refrigerator with food and all medications should be stored in a locked container or area.



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4. Observation on 9/14/10 at 9:55 AM showed the keys to the Intensive Care Unit medication room were laying in a box on a countertop accessible by visitors and unauthorized staff.

5. Observation on 9/16/10 at 8:35 AM showed the Intensive Care Unit medication room door standing open. A nurse aide was sitting at the nursing station looking into a patient room in the opposite direction of the medication room. The RN on duty was in a patient room. Inspection of the room showed that the refrigerator containing medications was unlocked.

Based on observation, facility policy review and interview, the facility failed to ensure all medications are properly labeled and failed to ensure expired medications were not available for patient use in the Intensive Care Unit. This had the potential to affect all patients. The facility census was 45.

Findings included:

1. Facility policy titled, "Labeling Standards," states in part, "All drug containers shall be labeled and drug labels must be clear, consistent, legible and in compliance with State and Federal Requirements."

Review of the facility policy titled, "Medication Administration," last revised 6/2007, showed the following (in part):
- Multi-dose vials may be used until they are empty unless 28 days after opening.

2. Observation of operating room #1 on 9/14/10 at 10:55 AM showed an anesthesia cart with a 20ml (milliliter) syringe with 17mls of milky liquid on top of the cart. No one was in the room at that time.

Staff G, Registered Nurse, Director of Surgery said at that time that anesthesia had been getting ready for the next case.

Staff D, Pharmacist said on 9/14/10 at 5:00 PM that if any medication is drawn up and not immediately used, it must be labeled.



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3. Observation on 9/14/10 at 10:45 AM showed a multi-dose vial of Levemir Insulin (used to treat diabetes) was stored on a countertop near the Intensive Care Unit nursing station. A hand-written date of "7/10" was written on the outside of the Levemir bottle indicated the bottle had been open longer than 28 days.

Based on facility policy review, observation, record review, and interview, the facility failed to follow their internal policy in regard to reporting medication errors for one (Patient #14) of eleven patients observed during medication administration. The facility census was 45.

Findings included:

1. Review of the facility policy titled, "Medication Administration," last revised 6/2007, showed the following (in part):
- Medication Errors: A variance Report will be prepared on all medication errors and delivered to the Pharmacy. The variance Report is not a part of the patient medical record.

2. Observation on 9/15/10 at 9:35 AM showed Staff Q, RN (Registered Nurse) administered Propafenone (used to treat abnormal heart rhythms) 150 mg (milligrams) one tablet po (by mouth) to Patient #14.

Review of Patient #14's medical record on 9/15/10 at 11:15 AM showed a physician's order for Propafenone 150 mg ? tablet TID (three times daily).

During an interview on 9/16/10 at 1:20 PM, Staff V, Interim Director of Nursing said that an occurrence report had not been received for this incident.

Based upon observation and interview, the facility failed to maintain safe environment for patients' food preparation and storage. This applied to all patients. The current facility census was 45.

Findings included:

1. Review of the facility policy titled, "Medications, Supplies, Special Equipment, Location and Storage," last revised 10/2006, showed the following (in part):
- Food Service personnel maintain a par level of dietary supplies. Dietary supplies are maintained in the nutritional center and refrigerator. Food Service checks and replaces needed items as required.

2. Observation during the kitchen tour on 9/14/10 at 9:30 AM noted the following:
- the walk-in cooler had the center section of the floor sealed with a white substance that protruded out the sides of the floor panel. This substance was not smooth or flush with the floor; and it could not be cleaned completely.
-the walk-in dairy refrigerator had the door standing unlatched and the temperature on the thermometer read 42 degrees Fahrenheit (F). In reference, the 1999 Food Code for Food Service Establishments in the State of Missouri states that the required temperature should be 41 degrees F, for safe holding of foods.
-floor tiles were chipped and missing portions near the stove and near the steam table.
-the carts used near the steam table had dirty wheels.
-cleaning rags were left on the edge of the carts, and not kept in a sanitizing solution.
-staff persons from other departments entered the kitchen, walked entirely into the food production area, and did not put on hair covering.

3. Observation, on 9/15/10 at 10:40 AM, of the patient food refrigerator on the 1st floor, for use of patient foods had the following:
-Banquet apple pie, no date of acquisition or expiration.
-Gaterade drink, open and half gone with a date of 2/8 and the name "Stiles".
-open Styrofoam cup with a napkin to cover, no date, label of contents or name of owner.
-7 cans of Suplena nutritional drink outdated July 1, 2010.
-Open bottle of Ranch Dressing, half gone, with no date of acquisition or date of expiration. It had the name, "Fran" written on it.
-Foil wrapped food with no label for contents or name of ownership and no date of acquisition or expiration.
-2 plastic containers with 'home food', with no label for contents or ownership or date of acquisition or expiration.
-2 dishes of fruit with no label for contents or name of ownership and no date of acquisition or expiration.
-1 large bottle of Aqua Fina liquid, half empty, with no label for name of ownership and no date of acquisition or expiration.

4. Observation of the patient food refrigerator on the 2nd Floor at 9:55 AM on 9/15/10 showed the following:
-2 sandwiches with meat and 2 slices of bread, with no label for contents or name of ownership and no date of acquisition or expiration.
-3 apples in plastic, no date of acquisition, stocking or expiration.
-a large plastic bag of cheese individually wrapped pieces, without date of acquisition or stocking (expiration date of 12/10).

5. During interview on 9/14/10 at 10:40 AM, the charge nurse, Staff U, stated regarding the cleaning of the refrigerator on the 1st Floor, "Would assume Dietary would clean".

During interview on 9/14/10 at 9:30 AM, the Food Services Manager, Staff L stated, "It's supposed to be a nursing job. But, we do it if it's really dirty when we stock the snack supplies."

6. Observation, on 9/15/10 at 10:40 AM, of the ice machine on the 1st Floor, provided for patient services, showed the water catch and drain tray to have accumulated black slimy substance around the edges and near the drain.



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7. Observation on 9/14/10 at 9:55 AM showed a large refrigerator in the Intensive Care Unit marked, "Staff Only." The following items were identified:
- Plastic sacks filled with crackers, with no label for contents or ownership or date of acquisition or expiration.
- Individual milk cartons, at least one expired January, 2010
- Multiple cans of nutritional supplement. At least one can of 1 Cal expired July, 2010.
- A sandwich wrapped in aluminum foil, with no label of ownership, date of acquisition or expiration.

During an interview on 9/14/10 at 10:00 AM, Staff B, RN (Registered Nurse) Charge Nurse said, "Patient snacks are kept in here, but it's really for staff use."

Based upon interview and review of facility records, the Food Service Manager failed to have required qualification. This applied to all patients. The current facility census was 45.

Findings included:

1. Reference to the Missouri State Hospital Regulations at 19.CSR.30-20 stated that the minimum requirement for Food Service Manager is the Certified Dietary Manager Certification.

2. Review of the Job Description for the Food Service Manager stated that the candidate "must be willing to take the Dietary Manager's Course."

3. During interview on 9/14/10 at 9:30 AM, Staff L, Food Service Manager, stated that he/she had begun the curriculum for the Dietary Managers' Certification, but had not completed the course.

4. Staff L stated that her/his responsibilities included:
-supervision of the Dietary staff
-evaluation of the Dietary staff, to include hiring, firing, and evaluation of staff performance
-scheduling the dietary staff
-representing the Dietary Department at Department Head Meetings, Quality Assurance Meeting, and interdepartmental activities
-approval of food service menus
-ordering and receiving of foods and supplies.

5. Review of Staff L's personnel file failed to show Certification of the Dietary Manager's Course.

Based upon record review and observation, the facility failed to have:
-accurate nutritional screening for two (#58, #39),
-complete nutritional assessment with interventions for two (#39 [two admissions]and #43)
-complete documentation for one (#59), of one patient receiving tube feeding by continuous feeding (100% of all patients receiving tube feedings),
-signature for the nutritional documentation for two (#48 and #55) of eight patients reviewed for Medical Nutrition Therapy, and
-participation by the Registered Dietitian in Swing Bed Program Plan of Care Meetings, for one (#39) of one patient reviewed in the Swing Bed Program.
-quality assurance for the nutritional screening and assessment care of the patients.
The facility census was 45.

Finding included:

1. Review of the facility policy, "Nutritional Screening and Monitoring" stated, in part, "If a patient triggers one or more of the Automatic trigger Diagnosis, the R.D. (Registered Dietitian) will complete a Nutrition Assessment within 48-72 hours of Admission, other patients will be assessed within 3-5 days".

2. Review of Patient #58, currently admitted since 9/14/10, showed the nursing admission assessment to indicate a recent thirty pound weight loss. The nutrition screen evaluation provided by nursing showed the nutrition screen to be negative for findings. No consult was sent to the Registered Licensed Dietitian, and no Medical Nutrition Therapy assessment had been initiated.

3. Record review of Patient #39, admitted 7/27-8/12/10 to the Medical Acute Care, showed the nursing admission assessment at admission to note a 20 pound weight loss within four weeks. The weight loss was not indicated on the nutritional screen form. The patient also had nutritional needs related to diabetes gastric bleeding and chronic obstructive lung disease. The Registered, Licensed Dietitian (RDLD) note of 8/12/10 was late at 16 days after admission and failed to include a plan of assessment and intervention. This note only noted abnormal labs, but did not indicate a nutritional concern for the abnormal blood levels. The RDLD's intervention was not included in the overall Plan of Care.

4. Patient #39 had also been admitted to the Swing Bed Program 8/12-22/10. The nutrition screen of 8/12/10 did not trigger a new referral; and the RDLD assessment was late at 10 days after the Swing Bed Admission. The Dietitian's interventions were not on the overall Plan of Care.

5. Record review of Patient #43, admitted 8/03-07/10, showed the nutrition screen to have referred to the dietitian for consult on 8/3/10. The medical record failed to show documented evidence of a nutritional consult and assessment for Patient #43.

6. Record review of Patient #59, currently admitted since 9/13/10, showed the patient was 35 year old receiving Jevity 1.5 at 20 cc/hour via a tube feeding system managed by an electric pump. The patient had intermittent nausea and vomiting; and the tube feeding was adjusted accordingly, sometimes put on hold for the time of nausea. The documentation failed to indicate a daily consumption of tube feeding for all days of the admission. The RDLD's notes of 9/13/10, stated, "Tube feeding off at present", and 9/14/10 stated, "Tube feeding running at 20cc (cubic centimeters) per hour," and indicated the amount of tube feeding ordered, but failed to assess the total estimated nutritional needs of the patient and state whether this feeding was adequate to meet the needs of the patient.

7. Record review of Patient #48, admitted from 6/3-9/10, showed the "Dietary Progress Note" of 6/7/10 to be a nutritional awareness of the patient's inability to eat per mouth. The note suggested the possibility of enteral (tube) feedings. The note failed to have a signature of the author.

8. Record review of Patient #55, admitted from 8/07-24/10 had a negative result for the nutritional screen at the time of admission. The "Dietary Progress Note", written on 8/23/10, 16 days after admission, stated a nutritional need of very low iron stores and that the patient disliked the hospital foods. The Dietary note failed to have a signature of the author.

9. During interview on 9/14/10 at 1:30 PM, Staff M, Registered, Licensed Dietitian, stated that there was no quality review or monitoring for the process of nutritional screening and assessment.

For the Swing Bed Program:
10. Record review for a Swing Bed admission as a closed record, Patient #39, for admission of 8/12-11/10, showed that the Registered Dietitian's assessment was not completed until the 10th day of the admission; and that the Registered Dietitian had not participated in the Care Plan Meeting for this patient. Patient #39 had nutritional needs of diabetes and Chronic Obstructive Lung Disease.

11. During interview on 9/16/10 at 10:00 AM, Staff R, Director of the Swing Bed Program, and Staff S, Activity Director and Social Service Designee, stated that the Care Plan meetings were held whenever everyone could get together. The meetings would include: Utilization Review, Social Service Designee - Activity Director, Nursing, Physical Therapy if involved in patient care and possibly the Registered Dietitian.

12. During interview on 9/14/10 at 1:30 PM, the Registered Dietitian, Staff M, stated that his/her attendance at the Swing Bed Care Plan Meeting is not possible because the meetings are usually held on Wednesday, and that is the day assigned for Nutrition Consult work at the area nursing home (a different provider account).

Based on observation, the facility failed to ensure that the condition of the physical plant was maintained as evidenced by all ceiling tiles remaining intact; tiles were not subject to water damage which would weaken the tiles and prevent them from preventing the passage of smoke above the ceiling; and air vents remained clean. The facility census was 45.

Findings included:

1. During observation of the critical care unit room 104 had one stained tile (evidence of water damage) and room 101 had two stained tiles. The main area of the unit had four stained tiles in the ceiling.

2. It was observed in the respiratory unit that there were at least six tiles in the ceiling with stains.

3. Observation on 9/15/10 revealed that in the main waiting area for the hospital there were three stained tiles. One of tiles surrounding a light in the area was protruding downward and appeared to be wet and a staff person who inspected the tile said that it was very wet.

4. It was observed in the radiology department that one tile near the entry to the computerized tomography (CT) scanner a two foot by six inch area of the tile was wet. Room #3 in the department had a missing tile which a staff person stated had been removed due to damage. In the radiology managers office there was observed to be three tiles with stains.

5. It was observed in the critical care unit that in room 104 the air duct was completely covered with dust or lint. In room 103 dust was observed on the ceiling tile next to the supply vent.

6. In the respiratory department there was observed to be a vent in the storage area completely covered by lint. In the janitor closet of the department the vent was completely covered by dust.

7. Observation on 9/14/10 of the ice machine drain tube near the outpatient surgery department revealed that the two tubes were connected directly to the drain trap of the sink nearby. One tube was from the drain tray (noted to have standing water in the tray) and one tube was from the ice supply reservoir.

No backflow device or other method was noted to be on the lines which would prevent waste water draining from the ice machine or waste water from the sink drain from entering into the ice machine drains or the reservoir which contained the ice.



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8. Observation on 9/14/10 at 9:30 AM, revealed the Food Service Manager's office had two water damaged tiles, and water stained wallpaper.

9. Observation on 9/14/10 at 2:00PM revealed the Medical Records Department had two stained ceiling tiles at the back of the department over the electrical circuit box (dictation equipment), and two stained ceiling tiles near the entrance to the department by the copy machine and the first racks of medical records, putting medical records at risk for water damage.

10. Observation on 9/14/10 at 4:10 PM revealed the Rehabilitation Department gym had water stained ceiling tile near the window area, still wet.



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11. Observation on 9/15/10 at 8:50 AM showed multiple stained ceiling tiles inside Room 223. One appeared to have a black substance resembling mold visible on the tile.

Based on facility policy review, review of facility documentation of infection control activities, observation, and interview, the facility failed to:
- ensure staff performed adequate hand hygiene when entering patient rooms, after touching contaminated objects, and when changing gloves per the facility's policy for four patients (#21, #14, #20, and #19) observed during medication passes and two patients (#1, and #7) observed during nursing procedures;
- ensure equipment was cleaned and decontaminated between patient rooms;
- prevent the potential for transmission of infections and communicable diseases to facility staff; and
- ensure the Infection Control Practitioner conducted active surveillance to ensure staff compliance with hand hygiene and/or adherence to isolation precautions. This had the potential to affect all patients, visitors, and staff in the facility. The facility census was 45.

Findings included:

1. Review of facility policy titled "Hand Washing." Revised 5/2009, gave the following direction (in part):
- Hand washing and hand antisepsis is to be done when hands are visibly soiled or may have come in contact with blood or body fluids. In the absence of a true emergency, personnel should always wash their hands:
- Before and after having direct contact with patients, i.e., taking a pulse, blood pressure, or lifting; even if gloves were used.
- Before and after the use of all gloves, sterile and non-sterile, and protective equipment.
- After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood, or body fluids, excretions, or secretions.
- If hands are moved from a contaminated body site to a clean body site during patient care.
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. These sources include urine or secretion collections apparatuses.

2. Observation on 9/15/10 at 9:00 AM showed Staff Q, RN (Registered Nurse) administered medications to Patient #21 without performing hand hygiene before opening the medication packages and handling each pill as he/she dropped them into a medication cup and handed them to the patient.

Observation on 9/15/10 at 9:35 AM showed Staff Q, RN withdrew Furosemide (a diuretic) 40 mg (milligrams) into a syringe. Staff Q removed the needle from the filled syringe, then laid the syringe on a counter while preparing other medications. Staff Q transported the uncapped syringe to Patient #14's room, then laid the syringe on the bedside table. Staff Q did not perform hand hygiene before preparing the medication for injection, and did not perform hand hygiene before administering the medication intravenously (IV).

Observation on 9/15/10 at 9:45 AM showed Staff Q, RN withdrew Protonix (used to treat esophageal reflux disease) 40 mg into a syringe. Staff Q removed the needle from the filled syringe, then transported the uncapped syringe to Patient #20's room. Staff Q laid the syringe on the bedside table, then removed a prefilled syringe of normal saline from his/her uniform pocket. Staff Q used the normal saline to flush Patient #20's intravenous catheter, then administered the Protonix intravenously. Staff Q did not perform hand hygiene before preparing the medication for injection, and did not perform hand hygiene before administering the medication.

Observation on 9/15/10 at 10:05 AM showed Staff Q, RN administer medications to Patient #19. Staff Q did not perform hand hygiene before opening the medication packages and handling each pill before dropping them into a medication cup and administering orally to Patient #19.

During an interview on 9/16/10 at 10:50 AM, Staff F, Director of Patient/Staff Education said, "All staff should wash hands or do hand hygiene between patients. This is not an acceptable standard of practice." Staff F also said, "Transporting medication in an uncapped syringe and laying it down before administration is not an acceptable standard of practice." Staff F went on to say, "The nurse should remove the medications from the package without handling them. This is not an acceptable standard of practice."

3. Observation on 9/14/10 at 10:35 AM showed Staff A, LPN (Licensed Practical Nurse) obtained a blood glucose by fingerstick (a procedure to obtain a drop of blood for testing) on Patient #1. Staff A did not perform hand hygiene before applying gloves. Staff A placed the glucometer machine (used to obtain the blood glucose level) on Patient #1's bed while the test was performed. After completing the test and while still wearing gloves, Staff A gathered unused items from the patient's linens and placed them in his/her uniform pocket. Staff A removed the glove from the right hand and charted the fingerstick results on Patient #1's M.A.R. (Medication Administration Record) that was lying on Patient #1's linens. Staff A then removed the second glove and performed hand hygiene before picking up the glucometer machine from Patient #1's bed and leaving the room. Staff A did not disinfect the glucometer before placing it on a countertop near the nursing station and later placing it into the recharger.

4. Observation on 9/16/10 at 10:00 AM showed Staff U, RN performing hygiene for Patient #7's indwelling foley catheter (rubber tubing introduced into the bladder to provide for a continuous flow of urine from the bladder). Staff U did not perform hand hygiene before applying gloves and cleaning the patient's perineum around the catheter. Staff U changed gloves after cleansing the patient, but did not perform hand hygiene before donning a new pair of gloves and continuing with other aspects of patient care.

5. Observation on 9/14/10 at 9:45 AM showed an intravenous fluid pump stored in patient room 104. An instructional booklet was chained to the handle of the pump. The instructional booklet was visibly soiled, and the edges of the pages were curled and stiff.

During an interview on 9/14/10 at 9:50 AM, Staff B, RN Charge Nurse, said the booklet was intended to be a quick reference guide for staff.

Observation on 9/15/10 at 8:50 AM showed an intravenous fluid pump stored in patient room 223. An instructional booklet was chained to the handle of the pump. The instructional booklet was visibly soiled, and the edges of the pages were curled and stiff.

During an interview on 9/16/10 at 10:50 AM, Staff F, Director of Patient/Staff Education said, "Instruction booklets on IV pumps should have been removed by Central Supply or Nursing when they saw they were contaminated. This is not an acceptable standard of practice."

6. Observation on 9/15/10 at 8:50 AM showed a sharps container in the room of Patient #18 that was filled past the fill line (indicating need for replacement) and into the neck of the container. A used syringe, IV tubing and other items were protruding from the opening into the container, placing the patient, visitors, and staff at risk for accidental needle stick injury.

During an interview on 9/16/10 at 10:50 AM, Staff F, Director of Patient/Staff Education said, "The Infection Control Practitioner is responsible for checking sharps containers during 'nursing rounds.' Nursing should also be responsible to change them when they are full."



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7. Review of Infection Control policies and activities on 9/15/10 at 4:00 PM, showed no policy for surveillance to ensure staff comply with hand hygiene and/or adherence to isolation precautions, and no evidence that surveillance activities had been conducted.

Staff F, Acting Chief Nursing Officer, confirmed during an interview on 9/16/10 at 10:50 AM that there was no evidence that surveillance activities had been conducted.

Based on review of facility documentation of infection control activities, and interview, the facility failed to ensure the Infection Control Practitioner maintains a current log of patients with infections in the facility. This had the potential to affect all patients in the facility. The facility census was 45.

Findings included:

1. Review of Infection Control activities on 9/15/10 at 4:00 PM, showed no current log of patients with infections in the facility.

2. Staff F, Acting Chief Nursing Officer confirmed during an interview on 9/16/10 at 11:50 AM that no current log of patients with infections in the facility could be found.

Based on interviews and review of facility documentation of infection control activities, the facility failed to routinely conduct quality assurance activities for the infection control program. This has the potential to affect all patients in the facility. The facility census was 45.

Findings included:

1. Review of infection control quality assurance activities showed no data had been collected since 9/2009.

2. Staff F, Acting Chief Nursing Officer, confirmed during an interview on 9/16/10 at 10:50 AM that these were the most recent Infection Control quality assurance data collected.

3. Staff E, Registered Nurse, Clinical Quality Coordinator also confirmed during an interview on 9/16/10 at 1:00 PM that he/she had not received data from the Infection Control Practitioner since 9/2009.

Based upon record review, interview and policy review, the facility staff failed to have complete documentation for four (#48, #36,# 37, and #50) of five cases reviewed for Organ Procurement Organization (OPO) reporting. The facility census was 45.

Finding included:

1. Review of facility contract with the OPO, dated February of 2007 and currently in effect, showed the expectation of the timeliness of the call to the OPO to be within one hour after the death of the patients.

2. Record review for Patient #48, admitted 6/9/10, showed the patient expired on 6/9/10 at 5:00 AM. A call to the OPO was documented and signed by the staff person calling, but the time of the call was not documented. It is not possible to know if the call was made within the one hour recommended limitation.

3. Record review for Patient #36, admitted 8/21/10, showed the patient expired on 8/21/10. The call to the OPO was documented, but failed to indicate the decision of the OPO regarding eligibility of the patient as a potential donor.

4. Record review for Patient #37, admitted 8/23/10, showed the patient expired on 8/25/10 at 3:00 PM. The OPO call was documented but did not have a date and time of the call.

5. Record review for Patient #50, showed the patient was admitted 6/22/10. The patient expired on 7/16/10. The OPO call was documented but lacked the signature of the person who called, and the time of the call.

6. During interview on 9/16/10 at 10:00 AM, Staff F, Nurse Manager responsible for the OPO program, stated the policy was newly revised and being re-educated.

Based on medical record review and interview, the facility failed to obtain a consent form prior to surgery which included the type of anesthesia to be used for six patients (#11, #16, #17, 22, #15, #30) out of seven surgery medical records reviewed; and failed to ensure staff completed and documented informed consent with date, time, and signature for one patient (#1) of seven surgery medical records reviewed. The facility census was 43.

Findings included:

1. Open medical record review conducted on 9/14/10 at 2:40 PM showed Patient #11 underwent an incision and drainage of the left gluteal (buttock) region on 9/14/10. The medical record contained a surgical consent for the type of surgery performed, but the consent did not include what type of anesthesia was to be used for that patient.

2. Closed medical record review conducted on 9/14/10 at 3:30 PM showed Patient #16 underwent an excisional debridement (surgical removal of tissue) of an infected left leg wound on 9/13/10. The medical record contained a surgical consent for the type of surgery performed, but the consent did not include what type of anesthesia was to be used for that patient.

3. Closed medical record review conducted on 9/15/10 at 2:40 PM showed Patient #17 underwent a colonoscopy (a colonoscopy is an exam used to detect changes or abnormalities in the large intestine (colon) and rectum. During a colonoscopy, a long, flexible tube (colonoscope) is inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the inside of the entire colon) on 9/13/10. The medical record contained a surgical consent for the type of surgery performed, but the consent did not include what type of anesthesia was to be used for that patient.

4. Closed medical record review conducted on 9/15/10 at 3:00 PM showed Patient #22 underwent a laparoscopic cholecystectomy (removal of the gallbladder) on 9/2/10. The medical record contained a surgical consent for the type of surgery performed, but the consent did not include what type of anesthesia was to be used for that patient.

5. Closed medical record review conducted on 9/15/10 at 3:15 PM showed Patient #15 underwent a rectocele (a rectocele occurs when the thin wall of fibrous tissue (fascia) separating the rectum from the vagina becomes weakened, allowing the front wall of the rectum to bulge into the vagina) repair on 8/25/10. The medical record contained a surgical consent for the type of surgery performed, but the consent did not include what type of anesthesia was to be used for that patient.

6. Closed medical record review conducted on 9/15/10 at 4:00 PM showed closed Patient #30 underwent a laparoscopic cholecystectomy and umbilical hernia (a protrusion of abdominal tissue or internal organs through the area around the belly button) repair on 6/11/10. The medical record contained a surgical consent for the type of surgery performed, but the consent did not include what type of anesthesia was to be used for that patient.

7. Staff G, Registered Nurse, Director of Surgery confirmed during an interview on 9/15/10 at 3:30 PM that the surgical consents did not specify what type of anesthesia would be used, but said at the time the consents are obtained the CRNA (Certified Registered Nurse Anesthetist) may not have known what type of anesthesia would be used until discussion with the physician performing the surgery.



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8. Open review of Patient #1's medical record on 9/14/10 at 11:05 AM showed the following:
- A form titled, "Authorization for Surgical Treatment or Other Medical Procedure," authorizing "Laparoscopic Cholecystectomy (removal of the gall bladder through a hollow tube inserted into the abdomen); Open Cholecystectomy (removal of the gall bladder through a larger 4-7 inch incision) if necessary. Possible operative Cholangiogram (an x-ray procedure during surgery to visualize bile ducts). Esophago-Gastro-Duodenoscopy (an examination of the lining of the esophagus, stomach, and upper duodenum with a small camera which is inserted down the throat)." The form does not indicate when the surgeon and/or anesthesiologist discussed the procedure and inherent risks so that the patient could arrive at an informed decision. The form was signed by the patient and was dated, but was not timed.
- A from titled, "Consent for Surgical Treatment and/or Other Medical Procedure," authorizes "Laparoscopic Cholecystectomy; Open Cholecystectomy if necessary. Possible operative Cholangiogram. Esophago-Gastro-Duodenoscopy." It also gives authorization for the surgeon to photograph the patient to "diagnose, treat and evaluate." The patient signed the form, but there is no date or time.

Based on medical record review and facility policy review the facility failed to follow facility policy to ensure post-operative anesthesia evaluations were completed on two inpatients (#11 and #16) and four outpatients (#17, #22, #15, and #30) out of two inpatient surgery records reviewed and four outpatient surgery records reviewed. The facility census was 45.

Findings included:

1. The facility titled, "Post Anesthesia Evaluation" revised 2/16/10, states (in part): A post-anesthesia evaluation will be made by anesthesia personnel in the form of a post-op visit conduced within 24 hours after surgery (unless the patient is discharged earlier) to determine any anesthesia complications. The time and date will be recorded by anesthesia personnel when the post-operative visit was made.

2. Open medical record review conducted on 9/14/10 at 2:40 PM showed Patient #11 underwent an incision and drainage of the left gluteal (buttock) region on 9/14/10. The medical record contained a post-operative anesthesia evaluation dated 9/14/10, which was not timed to show when the evaluation had been completed.

3. Closed medical record review conducted on 9/14/10 at 3:30 PM showed Patient #16 underwent an excisional debridement of an infected left leg wound on 9/13/10. The medical record contained a post-operative anesthesia evaluation dated 9/13/10, which was not timed to show when the evaluation had been completed.

4. Closed medical record review conducted on 9/15/10 at 2:40 PM showed Patient #17 underwent a colonoscopy (a colonoscopy is an exam used to detect changes or abnormalities in the large intestine (colon) and rectum. During a colonoscopy, a long, flexible tube (colonoscope) is inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the inside of the entire colon) on 9/13/10. The medical record contained a post-operative anesthesia evaluation dated 9/13/10, which was not timed to show when the evaluation had been completed.

5. Closed medical record review conducted on 9/15/10 at 3:00 PM showed Patient #22 underwent a laparoscopic cholecystectomy (removal of the gallbladder) on 9/2/10. The medical record contained a post-operative anesthesia evaluation dated 9/2/10, which was not timed to show when the evaluation had been completed.

6. Closed medical record review conducted on 9/15/10 at 3:15 PM showed Patient #15 underwent a rectocele (a rectocele occurs when the thin wall of fibrous tissue separating the rectum from the vagina becomes weakened, allowing the front wall of the rectum to bulge into the vagina) repair on 8/25/10. The medical record contained a post-operative anesthesia evaluation dated 8/25/10, which was not timed to show when the evaluation had been completed.

7. Closed medical record review conducted on 9/15/10 at 4:00 PM showed closed Patient #30 underwent a laparoscopic cholecystectomy and umbilical hernia repair on 6/11/10. The medical record contained a post-operative anesthesia evaluation dated 6/11/10, which was not timed to show when the evaluation had been completed.

Based upon observation and interview, the facility failed to protect the patient identification information for medical records. This applied to all in patients and outpatients. The current census was 45.

Finding included:

Observation during the tour of the Medical Record Department on 9/14/10 at 2:00 PM showed both doors to the Mail Room on the 2nd Floor were propped open to the hallway passage. In the mail room, a large trash receptacle bin (on wheels) was found to be unlocked and full of discarded pages of medical records, which included patient names and dates of birth and other medical information from medical record entries.

During interview on 9/14/10 at 2:00 PM, Staff K, Director of Medical Records, stated that the Housekeeping personnel sometimes have to empty the shred bin receptacles because they get overloaded. When the shred bin papers are collected, they would be dumped into the receptacle in the Mail Room until the contracted company for shredding comes to manage the work.