HospitalInspections.org

Based on review of the employee personnel files, interview, and facility policy, it was determined the facility failed to follow their policy for Annual Evaluations and failed to complete competency skills on personnel.

This had the potential to negatively affect all patients served by the facility.


Findings include

Policy: Employee Performance Review

Policy Effective Date: 01/01/13

Purpose:

To outline the hospital's performance review procedure. The annual evaluation review date is the anniversary date of when the employee started in their current position.

Policy:

" It is the policy of Mizell Memorial Hospital to have supervisors conduct performance reviews on each of their employees. The purpose of the review is to provide an opportunity for the supervisor and the employee to discuss the employee's job performance. This process provides an opportunity for both parties to:

1. Review past performance in the position
2. To set future goals
3. To clarify expectations, and
4. To identify needed development goals.

Procedure:

The organization has two required employee performance reviews:

2. Anniversary Evaluations-This review is:

a) To set new goals for the coming year
b) To identify strengths and weaknesses and
c) To set new performance expectations.

Requirement:

Supervisors are required to complete annual evaluations on their staff members on or before the employee's anniversary or review date...".


Review of employee personnel files on 7/10/15 at 10:30 AM revealed the following:

1. 4 of 30 files reviewed failed to include annual evaluations

2. 9 of 30 files reviewed failed to include competency skills.

An interview conducted 7/10/15 at 1:00 PM with Employee Identifier (EI) # 22, Human Resource Director confirmed the above findings. EI # 22 stated competencies are conducted upon hire and annually.

Based on review of facility policy and procedure, medical records (MR) and interview, it was determined the facility failed to ensure care of patients requiring the use of restraints was provided according to facility policy. This affected 2 of 2 patients reviewed with restraints and did affect MR's # 13 and # 14. This had the potential to affect all patients requiring restraints.

Findings include:

Policy Reference # 9180
Subject: Restraint and Seclusion
Effective: 3/7/2010

Policy:
"...Restraint...may only be imposed to ensure immediate physical safety the patient...and must be discontinued at the earliest possible time...

Definitions:
Physical Restraint is any method, physical or mechanical device, material or equipment attached...to the patient's body...that restricts freedom of movement...

Scope:
...applies whenever...restraints are used...in all hospital settings.

Purpose:
To establish guidelines and procedures for the use of restraints...or protective devices with the goal of protecting the patient...

Orders for Restraint:
Written or verbal orders for initial and continuing use of restraint are time limited.
...ordered by the physician...accepted by nurses...
All patients will have a comprehensive assessment performed prior to the application or restraints...
Restraint ORDERS MAY NEVER BE WRITTEN AS A STANDING ORDER OR PRN (as needed)...

The use of a restraint must be in accordance...with safe and appropriate techniques; ended at the earliest possible time.

Medical/Surgical Physician Order:

A physician's order must be obtained for medical restraints and must specify the reason...and type of restraint. Restraint orders shall be renewed every 24 hours. Orders for the use of restraint...must never be written as standing order or on an as needed basis (PRN)...PRN orders are not permitted.

...Patients in medical restraints shall be observed/assessed at interval not greater than 2 hours...Assessment to include circulation, hydration needs, elimination needs, level of distress and agitation, mental status, cognitive functioning, skin integrity, nutritional needs, range of motion as indicated.

Changing position and releasing soft restraints will be done at a minimum of every 2 hours...

Restraint documentation:

...All assessments and monitoring of the patient

Document the time the restraint is released and the response of patients to release..."


1. MR # 13 was admitted to the facility 4/21/15 with diagnoses including Chronic Pulmonary Disease and Respiratory Failure.

Review of a physician's order dated 4/21/15 at 1:15 AM revealed the following: " Soft restraints OK if needed".

The 4/21/15 physician's order was written "as needed" for restraint use, a standing order and did not meet the facility restraint policy requirements.

Record review revealed the restraints were applied in the Emergency Room on 4/21/15 at 1:00 AM.

Review of the 4/12/15 and 4/22/15 nursing notes revealed 1 documented entry, 4/21/15 at 11:44 AM, and included "released rest (restraint) temp (temporarily) for communication with family and rescued".

There was no additional nursing documentation soft restraints were released a minimum of every 2 hours as per policy.

Review of the nursing progress notes from 4/21/15 from 9:15 PM through 4/22/15 at 2:00 AM revealed only the following restraint flowsheet documentation: circulation check, color/temp (temperature) and provide care every 2 hours.

There was no documentation regarding MR # 13's elimination needs, level of distress and agitation, mental status, cognitive functioning or skin integrity.

Record review revealed at 8:15 AM on 4/22/15 the patient was extubated.

Record review failed to include documentation of the time and date restraints were removed or assessment of the patient's response per policy.

2. MR # 14 was admitted to the facility 10/9/14 with diagnoses including Brain Stem Cerebrovascular Accident and Diabetes.

Record review revealed the patient was in surgery, returned to the intensive care unit 10/17/15 at 3:00 PM on the ventilator with soft restraints in place.

Record review of the 10/17/15 3:00 PM nurse documentation failed to include a comprehensive assessment was performed and documented as per policy. There was no documentation a comprehensive assessment was performed in surgery prior to restraint application.

On 7/9/15 at 2:40 PM written questions to the above reviews were submitted to Employee Identifier # 8, Chief Executive Officer. Written responses received on 7/10/15 at 7:30 AM verified the aforementioned findings.

Based on review of facility policies and procedures, quality assurance documentation and staff interviews, it was determined the facility failed to ensure all departments collected, monitored and evaluated quality improvement data to improve patient care per facility policy. This affected the Radiology department and Senior Behavioral Care Unit (SBCU) and had the potential to affect all patients served by the facility.

Findings include:

Mizzell Memorial Hospital
Plan for Improving Organization Performance 2015

I. Purpose and Scope

This plan is designed to provide the framework for ensuring the involvement of the entire organization into the philosophy of continuously improving the organization's performance...

Objectives

C. Provide a basis for determining priorities and setting criteria for performance-improvement activities...
E. Improve patient care process and outcomes through continually monitoring and evaluating the quality and appropriateness of patient care. clinical performance and other patient related processes...

Departments will set up Quality Indicators to measure overall quality and assure improvements are pursued in their respective departments. These will include quality control activities...designed to measure improvements...

Quality Updates are provided for the board of Directors quarterly and more often as needed..."

SBCU Policy No. 14.001
Subject: Performance Improvement Plan

Policy:
A. Performance Improvement Plan for the psychiatric unit describes the quality monitoring evaluation process...integrated into the hospital-wide program and approved by the hospital.
C. Monitoring and reporting occur ...no less than monthly...
D....include monitoring activities of high risk, high volume, or problem prone activities..."

SBCU Policy No. 14.002
Subject: Performance Improvement Communication Process

Policy:

Performance improvement information is reviewed and communicated on a monthly basis. This process is documented in monthly committee meetings...and integrated into the hospital wide-process.

Procedure:
A. A written report reflecting activities of the committee include: conclusions, recommendations and ongoing status evaluation...provided to the hospital PI (performance improvement) committee.


During a 7/9/15 10:30 AM tour of the Radiology Department, Employee Identifier (EI) # 24, Radiology Department Manager presented the surveyor documentation of 2014 Radiology Quality Indicators including Patient Safety, Utilization and Satisfaction indicators.

The surveyor requested 2015 data monitoring documentation. EI # 24 reported no 2015 data had been collected, monitored or evaluated.

In a 7/10/15 8:40 AM interview with EI # 7, Chief Quality Improvement Officer (CQI), EI # 7 was unable to provide documentation the Radiology department had collected and reported any 2015 Performance Improvement data.


During an interview on 7/9/15 at 1:30 PM with EI # 3, SBCU Manager, the surveyor reviewed SBCU quality improvement activities, which was chart audit documentation provided by EI # 3.

There were no identified quality improvement indicators for the SBCU department presented to the surveyor.

There was no evidence the chart audit documentation was used for quality improvement activities or that audit information had been quantified and presented to the PI committee.

In a 7/10/15 8:40 AM interview with EI # 7, it was confirmed SBCU had not submitted monthly quality improvement documentation as required per facility policy.

Based on review of medical record (MR), facility policies and procedures and interview, it was determined the facility failed to ensure the staff followed their own policies for wound care and failed to complete care plan for the care of patients requiring wound care.

This affected 3 of 3 patients with wounds, MR # 21, # 20, and # 22 and had the potential to negatively affect all patients requiring wound care.

Findings include:

Subject: Dressing Change-Surgical


"...Pick up all soiled dressings and hold them in dominate hand, hold red plastic bag, open with opposite hand and pull bag down over hand and soiled dressings, being careful not to touch edges of the top of the bag.

Wash hands.

Cleansing the Incision Area:

Put on sterile gloves.
Cleanse the incision and surrounding skin per physician's orders
Cleanse the incision with sterile swabs soaked in normal saline or a solution prescribed by the patient's physician.
Cleanse the incision outward: clean from top to bottom using the swab only once. Discard swabs as appropriate. Remove gloves. Wash hands.

Application and completion of dressing:
...Put on sterile gloves..."

Policy Reference # 4002
Subject: Hand Hygiene-CDC (Centers for Disease Control) Guidelines
Revised: 08/16/12

Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.

"Policy:
All personnel will use the hand-hygiene techniques, as set forth...The CDC has recommended guidelines on..use of non-antibacterial soap and water...or an alcohol-based hand rub.
...Before each patient encounter...Before applying gloves...after removing gloves...

Procedure:
...Work lather around fingernails, top of hands...Rinse...under running water...Dry hands with clean paper towel and discard. Turn off faucets with paper towel and discard..."


Policy: Wound Care Protocols

The facility will use Wound Care Protocols that have been approved by Medical Staff. When a wound is identified, the attending physician will be notified. The applicable Wound Care Protocol will be implemented, unless the physician declines and gives other orders.

"...B. Stage II Pressure Ulcer...Definitation...

1. Cleanse wound with "3M Wound Cleanser"

2. Apply "3M No Sting Barrier Film" #. Cover wound with (choose type needed):

1. Non Draining to Minimal Drainage-3M Tegaderm Transparent Film Dressing

2. Minimal to Moderate Drainage-3M Tegaderm Hydrocolloid Dressing

3. Moderate to Heavy Drainage- 3M Tegaderm Foam Dressing...

4. Change every 3 days and "as needed"...

C. Stage III-IV Pressure Ulcer ...Definition...

1. Cleanse wound with "3M Wound Cleanser"

2. Apply "3M No Sting Barrier Film"

3. Fill wound with (choose type needed):

1. Non Draining to Minimal Drainage-3M Tegaderm Hydrogel Wound Filler

2. Moderate to Heavy Drainage- 3M Tegaderm Alginate Dressing....."



1. MR # 21 was admitted to the facility 12/03/14 with diagnosis of Cellulitis of the right leg.

On 12/04/14 at 4:05 PM, the following wound care was documented:" Dressing change to right foot. Wound #1 6 cm(centimeters) by 5 cm with 1 cm tunneling to 30% of border... area cleaned with NS (normal saline) and wet to dry dressing applied, ABD (abdominal pad) , Kerlix and ace bandage, Wound #2, 4 by 4 cm 0.25 cm deep ...cleaned with NS and wet to dry dressing applied, ABD (abdominal pad) , Kerlix and ace bandage".

Review of the physician's orders revealed there were no wound care orders and no documentation the physician was contacted for orders.

Written questions were provided to Employee Identifier # 9 Registered Nurse, Emergency Room (ER) and Intensive Care Unit (ICU) Manager on 7/9/15 at 3:00 PM. A written response was given to the surveyor 7/10/15 at 8:30 AM confirming there were no orders for wound care.

2. EI # 1, Intensive Care Nurse (ICN) performed surgical wound care to MR # 22 on 7/9/15 at 1:30 PM. MR # 22 had a post operative right hip replacement. Observation of the procedure was as follows: EI # 1 washed hands with soap and water, dried with paper towel, disposed the paper towel in the trash and turned the water off with bare clean hands. After donning gloves, the soiled dressing was removed and disposed of. EI # 1 removed soiled gloves and washed hands, dried with paper towel, disposed the paper towel in the trash and turned the water off with bare clean hands. EI # 1 donned gloved, opened alcohol preps times 2 and cleansed the incision back and forth down sutures and around the outside of the sutures with 1 alcohol prep, then used the other prep to complete the cleansing process. Clean dressing was applied.

Review of the physician's orders dated 7/6/15 revealed the only orders for wound care was as follows: "Reinforce dressing as needed."

An interview was conducted with EI # 9, Manager of ICU and ER, on 7/9/15 at 3:00 PM, who confirmed the facility policy for hand hygiene and surgical wound care was not followed. EI # 9 confirmed there were no other orders for wound care.

3. MR # 20 was admitted to the facility 3/3/15 with orders including "daily decubitus care per protocol" at 2:45 PM.

Review of the skilled nurse (SN) documentation dated 3/3/15 at 4:20 PM revealed the following "wound care performed per protocol".
There was no documentation of the cleansing agent, or type of dressing applied. There was no written protocol included with the physicians orders or on the patients plan of care.

Review of the SN documentation dated 3/5/15 revealed a Stage III pressure ulcer 2.5 centimeters (cm) circumference by 0.25 cm depth. "Hydrocolloid dressing in place."

Written questions were provided 7/9/15 at 3:30 PM to EI # 9, with written response provided to surveyor by EI # 9 on 7/10/15 at 7:30 AM. Written response confirmed the facility failed to include a wound protocol in the patient's care plan and the SN failed to document wound care by the facility wound care protocol.

Based on medical record review, interview and documentation it was determined the facility failed to ensure:

1. All animal bites were reported to the County Health Officer as deemed by the Alabama State Board of Health/ Division of Disease Control in 2 of 5
ER (Emergency Room) charts reviewed with animal bites.

2. Condition of the patient was documented upon discharge in 10 of 25 ER charts reviewed.

3. The Senior Behavioral Care Unit (SBCU) documented and provided ordered and needed care according to facility policy and procedure for 2 of 5 records reviewed. This did affect MR's # 6 and # 8 and had the potential to affect all patients served by the SBCU.


Findings include:

Policy: Animal Bites-Standard of Care
Department: Emergency
Effective: 4/2013

"...Report all bites to County Health Department (refer to policy on reporting animal bites)
Notify Police Department or County Sheriff of animal bite..."

SBCU Policy No. 05.002
Subject: Treatment Planning Process

2.0 Policy

"A. Each patient admitted to the program has an individualized written treatment plan...based on interdisciplinary clinical assessments...continuous and dynamic, beginning at...admission...through discharge.
C. Treatment planning is structured...identified patient problems are resolved via goal specific goal oriented treatment interventions. Continued care needs are identified as part of the treatment planning process.
D. Key elements essential to all stages of treatment planning include...:
2. Short term goals are written in observable and measurable terms

Treatment Planning Process
D. Interdisciplinary Team Meeting

The initial treatment team meeting...no later than 3 days after admission...the Interdisciplinary Treatment Plan is reviewed and revised. Each team member is responsible for having completed their assessment and to present a summary in the team meeting. The treatment team meetings are directed by the Attending Psychiatrist. The Social Worker or Case Manager services as Treatment Plan Coordinator and is responsible for ensuring ...the appropriate documentation is entered on the treatment plan...

Procedure for Completing Interdisciplinary Treatment Plan

D. The AXIS 1 through V are taken from the psychiatric evaluation.

N. Document the date the long-or short term goals have been resolved. In addition, date and document all changes or additions to the goals or problems.

P. Define specific interventions which compromise the treatment that will be utilized to help patient achieve short-and-long term goals...

R. Each time the plan is revised, enter date...indicate this and note any revisions in the appropriate area (goals, objectives, treatment, etc)...

Interventions

"1. Interventions are discipline specific
2...are specific...concise and clearly written...
3....list the frequency, the action/focus..."


1. Review of 2 of 5 ER records with animal bites revealed there was no documentation the County Health Department or the Police Department/Sheriff's office was notified. This affected Emergency Room (ER) record # 13, # 14, and had the potential to negatively affect all patients served by the facility with animal bites.

2. Review of 25 ER records revealed 10 did not contain documentation of the condition of the patient upon discharge.

This affected ER record # 1, # 2, # 8, # 9, # 14, # 15, # 18, # 20, # 22, and # 25 and had the potential to negatively affect all patients served by the facility.

An interview conducted 7/9/15 at 9:30 AM with Employee Identifier # 9, Director of Emergency Room and Intensive Care Unit confirmed the above findings.



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3. MR # 6 was admitted to the SBCU on 4/9/15 with diagnoses including Bipolar, Type I, Depressed Phase and Generalized Anxiety.

Review of the Initial Interdisciplinary Treatment Plan completed between 4/9/15 and 4/12/15 did not include documentation of MR # 16's AXIS 1 through V Psychiatric diagnoses.

Review of the Initial Interdisciplinary Treatment Plan revealed Activity Therapy ordered 5 times a week for 30 minutes. Review of the record revealed documentation of 1 activity therapy group performed 4/14/15. There was no documentation why the therapy was not performed as ordered.

Review of the Physican Admitting Orders included weight on admission and "Sunday".

Review of the 4/11/15 8:30 AM Nursing Progress note documentation revealed MR # 6 reported a fall. There was no post fall assessment by the Registered Nurse. There was no documentation the physician was notified. There was no incident report documentation completed.

Review of the Nursing Progress Note documentation failed to include the patients weight on Sunday 4/12/15.

Review of the 4/15/15 Interdisciplinary Treatment Plan Review failed to include documentation of MR # 6's progress toward short term goals (improved/unchanged/revised/resolved) for problems 1 and 2, depressive symptoms and fall risk.

There was no documentation of how or if the plan was revised or if the goal was accomplished.

The 4/15/15 Treatment Team documentation failed to identify MR # 6's continued care needs in the treatment planning process.

During an interview on 7/9/15 at 12:40 PM with EI # 3, SBCU Manager, the findings above were confirmed.

4. MR # 8 was admitted to the SBCU on 6/10/15 with diagnoses including Alzheimer's Disease, Status Post Cerebrovascular Accident and Diabetes Mellitus.

Review of the Initial Interdisciplinary Treatment Plan completed between 6/10/15 and 6/12/15 did not include documentation of MR # 8's AXIS 1 through V Psychiatric diagnoses.

Review of the 6/10/15 Initial Interdisciplinary Treatment Plan Physician intervention documentation failed to include a physician assessment frequency, monitoring/educating regarding treatment benefit/risks or other interventions. The physician focused interventions was left blank.

Review of the medical record failed to include physician progress notes during the 6/10/15 to 6/18/15 SBCU stay.

Record review revealed a dietary consult order dated 6/11/15. There was no dietary consult performed and documented.

Review of the 6/17/15 Interdisciplinary Treatment Plan Review revealed documentation of MR # 8's progress toward short term goals for problem 1, psychotic behaviors was unchanged and revised. There was no documentation of the revised interventions or goals for problem 1.

Review of the 6/17/15 Interdisciplinary Treatment Plan Review revealed documentation of MR # 8's progress toward short term goals for problem 2, fall risk was left blank. There was no documentation of MR # 8's progress towards the short term fall goal as improved/unchanged and revised/resolved, all were left blank. There was no documentation of revised interventions or goals for problem 2.


Review of the 6/17/15 Interdisciplinary Treatment Plan Review revealed documentation of MR # 8's progress toward short term goals for problem 3, Diabetes was unchanged and revised. There was no documentation of the revised interventions or goals for problem 3.

During an interview on 7/9/15 at 1:10 PM with EI # 3, the aforementioned findings were confirmed.

Based on review of facility policy and procedure, medical records and staff interview, it was determined the facility failed to:

1. Complete Psychiatric Evaluations as per facility policy.

This affected MR # 6, 1 of 5 Senior Behavioral Care Unit (SBCU) records reviewed. This had the potential to negatively affect all patients served by the SCBU.

2. Ensure all History and Physicals and Discharge Summary's included a time and date the physician signed the documents.

This affected 14 of 17 records reviewed.


SBCU Policy No. 03.003

Subject: Elements of the Psychiatric Evaluation

Policy

"Psychiatric Evaluation will be completed and placed on the patients' chart within...60 hours hours per CMS (Centers for Medicare/Medicaid Services)..."

1. MR # 6 was admitted to the SBCU on 4/9/15 with diagnoses including Bipolar, Type I, Depressed Phase and Generalized Anxiety.

Review of the Psychiatrist Evaluation revealed a 4/12/15 dictation date and a 4/13/15 transcription date. The physician signature did not include documentation of the date reviewed/completed.

There was no evidence the psychiatric evaluation was completed within 60 hours per facility policy.

In an interview on 7/9/15 at 12:40 PM with EI # 3, SBCU Manager, the finding above was confirmed.







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Review of medical records revealed 14 of 17 records did not include a date and time of the physician's signature documented on the History and Physical as well as the Discharge Summary. This included MR # 1, 2, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, and 22.

An interview conducted 7/10/15 at 10:30 AM with EI # 5, Chief Financial Officer, verified there was no date and time of the physician's signature on the aforementioned documents.

Based on review facility policy and procedure, Medical Records (MR) and interviews with the staff, it was determined the facility failed to ensure all physician orders and MR forms had the patient information and were signed, timed and dated when the order was written or the form was completed. This did affect 3 of 14 inpatient records, MR # 12, MR # 19 and MR's # 14 and 1 of 5 Senior Behavioral Care Unit (SBCU) records reviewed and did affect MR #16. This had the potential to negatively affect all patients served by the facility

SBCU Policy No. 02.204

Subject: Admission Orders

"1.0 Purpose: To ensure that a patient is admitted to the program the physician's orders will be complete and include all of the required elements...

Procedure:

A. Admitting Orders
1. The written order to admit is given by a licensed physician...

2. Telephone order require the co-signature of the physician...no later than 48 hours. Orders are always signed with name, credential, date, and time..."

1. MR # 12 was admitted to the facility on 7/23/14 with an admitting diagnosis of Foot Ulcer/Infection.

Review of the MR revealed the physician progress notes dated 7/26/14, 7/28/14 and 7/29/14 did not contain any patient information including the patient's name and room number on the progress note and did not include a time the progress note was written.

Review of the DVT (Deep Vein Thrombosis) Assessment Form revealed the physician's signature and no documentation of a date or time form was completed.

Review of the Swing Bed Program Physician Admission Progress Note revealed no documentation of a date or time Progress Note was completed.

Review of the Swingbed Certification/Re-Certification form revealed no documentation of a date or time of physician's signature.

An interview conducted on 7/10/15 at 10:10 AM with Employee Identifier (EI) # 5, Chief Financial Officer (CFO), confirmed the above mentioned findings.

2. MR # 19 was admitted to the facility on 1/29/15 with an admitting diagnosis of Anemia.

Review of the MR revealed a dictated Short Stay Record by the physician with the physician's signature and no date and time of the signature.

Review of the MR revealed a physician order written on 1/30/15 and no time documented of when the order was written.

An interview conducted on 7/10/15 at 10:30 AM with EI # 5 confirmed the above mentioned findings.




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3. MR # 14 was admitted to the facility 10/9/14 with diagnoses including Brain Stem Cerebrovascular Accident and Diabetes.

Record review revealed a 10/18/15 3:30 PM and a 10/19/15 3:30 PM physician's restraint order for soft wrist/ankle restraint use.

There was documentation of the date and time the physician signed the 10/18/15 and 10/19/15 restraint orders.

On 7/9/15 at 2:40 PM written questions to the above review was submitted to EI # 8, Chief Executive Officer. Written responses, received on 7/10/15 at 7:30 AM, verified the aforementioned findings.

4. MR # 16 was admitted to the SBCU on 4/9/15 with diagnoses including Bipolar, Type I, Depressed Phase and Generalized Anxiety.

Review of the SBCU Physician Admission Orders did not include documentation of the date and time the physician signed the admitting orders.

Review of the 4/12/15 physician orders revealed a late entry for 4/11/14 at 9:40 PM for an ace wrap to right wrist for support.

There was no physician's signature on the 4/12/15 verbal order for the ace wrap.

During an interview on 7/9/15 at 12:40 PM with EI # 3, SBCU Manager, the findings above were confirmed.

Based on review of medical records (MR) and facility policy, it was determined the facility failed to ensure staff completed the discharge summary with all required elements and signed and dated as per facility policy. This did affect MR # 7, 1 of 3 Senior Behavioral Care Unit (SBCU)discharge records reviewed and had the potential to affect all SBCU patients discharged from the facility.

Findings include:

Policy No. 10/004
Psychiatric Discharge Summary

Policy
It is program policy that a comprehensive psychiatric discharge summary be completed by the attending psychiatrist within 30 days of the patients discharge or per medical Staff by-laws.

Procedure
A. Evidence of completion within 30 days of the patient's discharge by the attending physician or per hospital policy.
B. The following format is to be used by the psychiatrist in dictating the comprehensive discharge summary.

MR # 7 was admitted to the SBCU on 4/3/15 with diagnoses including Schizo-Affective Disorder, Bipolar.

MR # 7 was discharged on 4/14/15. Review of the physician's Discharge Summary revealed documentation the summary was dictated 5/24/15 and transcribed 5/26/15. This was greater than 30 days per facility policy.

In an interview on 7/9/15 at 12:00 PM with Employee Identifier # 3, SBCU Manager, the above finding was confirmed.

Based on observation and interviews, it was determined respiratory medications were not stored in a secure, locked area. This had the potential to negatively affect all patients served by the facility.

During a medication pass observation on 7/8/15 at 11:00 AM, Respiratory Therapist, (RT) Employee Identifier (EI) # 20, administered an inhalation treatment to an unsampled patient on the 3rd floor Medical Surgical unit.

The respiratory medications, kept on the 3rd floor Medical Surgical unit were stored in a small room in the hallway between the 3rd floor and Intensive Care unit entry door. The door, labeled "Dumb Waiter Room" was not locked. An inventory of the room revealed numerous aerosol medications including Xopenox, Duoneb, Acelylcysterine, Ipratropium Bromide, Budesonide and oxygen cylinders.

The facility failed to ensure all medications were stored in a locked, secure area.

In an interview with EI # 20 on 7/8/15 at 11:00 AM, EI # 20 reported pharmacy sends respiratory medications to the 3rd floor via the "Dumb Waiter". EI # 20 verified the door to the "Dumb Waiter" room was not locked.

Based on observations and interview the hospital failed to ensure outdated medications were not available for patient use. This had the potential to negatively affect all patients served by the facility.Findings Include:On 7/7/15 at 10:25 AM a tour of the Emergency Department was conducted with Employee Identifier (EI) # 8, Chief Executive Officer (CEO). During the tour the surveyor observed in the medication refrigerator 1 vial of Humalog Insulin, expiration date 8/14; 1 vial of Methylergomovine Maleate, 0.2 milligrams (mg) per 1 cubic centimeter (cc), expiration date 11/13; 4 vials of Pitocin 10 units per 1 milliliter (ml), expiration date 2/15; 3 Phenadoze suppositories, expiration date 2/15; Bicillin L-A 2 vials, expiration date 6/15.An interview with EI # 9, Emergency Room/ Intensive Care Director, confirmed the medications were expired.

On 7/8/15 at 8:45 AM a tour of the Surgical area was conducted. During the tour, the Anesthesia medication room was found to have 1- 15 cc Proparaccuine Hydrochloride Opthalmic Solution 0.5% expired 9/14,
4- Thrombin Topical 5,000 International Units expired 9/14, and 1 Tylenol suppository 650 mg expired 5/13.

An interview conducted 7/8/15 at 9:45 AM with EI # 2, Assistant Surgery Director confirmed the aforementioned supplies and medications were expired.

Based on facility policy, observation and interview, it was determined the facility failed to ensure dietary products were stored with proper labels and dated, expired products were removed from the shelves and food items in the refrigerator were stored properly. This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Stock Storage
Policy Date: 01/2011

Policy:

Food shall be stored on shelves in areas which provide the best preservation and be stored at a proper temperature for appropriate length of time.

Purpose:

To protect quality of food and to control costs.

Procedure:

1. Staple items to be stored in the storeroom on shelves with original label, or in a labeled container.

2. Older stock shall be rotated forward on shelves and new stock placed behind the older stock.

5. Supplies shall be stored as follows:
d. Thawed and thawing meat and poultry will be stored on the lowest possible shelves of the designated refrigerator location.

A tour of the Dietary Department was conducted on 7/8/15 at 11:00 AM with Employee Identifier # 13, Dietary Manager. During the tour the dry food storage was observed. While touring the dry food storage area it was observed that a large bag of pasta on the shelf was open and resealed with tape and no date of when the bag was opened. The surveyor observed 4 large boxes of gelatin containing 24 packs of gelatin to a box on the shelf. Three of the boxes of 24 packets expired 02/2014 and one box expired 09/2014.

A tour of the refrigerator revealed 2 containers of liquid not marked or dated. The dietary manager stated one was kool aide and the other was Ranch dressing. In the refrigerator were thawed breaded chicken breasts sitting above freshly made salads.

In the cooler area was a 8 pound 10 ounce bottle of Taco Sauce which was open and lacked the date it was opened.

A tour of the walk in freezer revealed according to the dietary manager a freshly made layer cake. The cake was not covered or dated and was sitting open on a shelf. When the surveyor entered the freezer on the right inside of the door, the first set of shelves by the door and on the floor were covered in ice approximately 1-2 inches thick. The dietary manager stated "the seal around the door needs to be replaced and it is letting air in the freezer causing the ice."

A tour of the 3 compartment sink area revealed a faucet on the wall with a garden hose attached. While walking past the hose the surveyor noticed the floor was wet and the hose was spraying continuous water from the faucet and at the nozzle area.

Review of the food temperature logs revealed on 6/24/15 no documentation of temperatures recorded for Breakfast or Lunch. The date was missing on the same log for the cafeteria food temperatures.

Review of the food temperature log dated 7/3/15 revealed no temperatures recorded for the supper food or for the cafeteria food.

An interview conducted 12:30 PM with EI # 13 confirmed the above mentioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served.

Findings include:

Refer to Life Safety Code violations.

Based on a tour of the facility, observations and interviews with the staff it was determined the facility failed to provide preventative maintance on all equipment in a timely manner and failed to replace expired supplies in multiple areas of the hospital. This had the potential to negatively affect all patients served by the facility.

Findings Include

1. A tour of the hospital was conducted on 7/7/15 and the hospital Laboratory was entered at 10:20 AM. During the tour, the surveyor observed 22 pediatric blood culture bottles with an expiration date of 2/15/15, 38 pediatric blood culture bottles with an expiration date of 5/31/15 and 16 needles with an expiration date of 9/2012.

An interview was conducted with Employee Identifier (EI) # 14, Phlebotomist, stated "we keep the expired needles but we do not use them
for blood draws." and confirmed the above mentioned findings.

2. A tour of the Medical Surgical Department was conducted on 7/7/15 at 11:40 AM with EI # 15, Medical/Surgical Manager. During the tour the surveyor entered a storage room and a Hoyer lift was being stored in the room. Observation of the preventive maintance sticker revealed the date of 10/23/1997. A lift scale was also in the room and observation of the preventive maintance sticker revealed a date of 10/2009.

An interview was conducted on 7/7/15 at 12:00 PM with EI # 15 who confirmed the above mentioned findings.

3. A tour of the ICU (Intensive Care Unit) was conducted on 7/7/15 at 12:15 PM with EI # 9, Emergency Room/ ICU manager.

During the tour the ICU crash cart was opened and inspected for expired medications and supplies. A Multi Lumen central line kit was found in the cart with an expiration date of 06/2015.

An interview was conducted with EI # 9 on 7/7/15 at 12:30 PM who confirmed the above mentioned findings.



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On 7/8/15 at 8:45 AM a tour of the Surgical area was conducted. Procedure Room # 5 contained 1 catheter tray expired 11/14, 1 drainage bag expired 11/14, and 1 multi lumen central catheter tray expired 1014.

The crash cart located near the procedure rooms contained 5 green top Vacuettes expired 12/14, 2 blue top Vacuettes expired 10/14 and 4 red top Vacuettes expired 1/15.

An interview conducted 7/8/15 at 9:30 AM with EI # 2, Assistant Surgery Director confirmed the aforementioned supplies and medications were expired.



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During a tour of the Outpatient Rehabilitation Unit on 7/7/15 at 2:30 PM, the surveyor observed 2 dime size holes in the vinyl cover of the therapy traction table.

The facility was unable to properly clean the traction table with holes in the cover.

The Elgin Pulley Exercise Machine did not have documentation preventive maintenance had been performed.

In an interview on 7/7/15 at 3:00 PM with EI # 18, Director of Rehabilitation Services, the above findings were confirmed.


During a 7/7/15 12:00 PM tour of the Senior Behavioral Care Unit with EI # 11, Registered Nurse, the following observations were made:

1 shower head with an extended cord approximately 3 feet long in the "Shower Room"

1 plastic electrical outlet not flush to the wall with exposed wires visible in the "Seclusion Room".

2 large wooden cabinets with sharp edges at the corners in the dining room and the nurse station.

2 pillows on the floor in the "Clean Linen" closet.

1 suction machine # 6105 on the Emergency cart with no preventive maintenance record.

3M defibrillator pads, 3 packets expired 12/14 on the Emergency cart.

2 non working flashlights above the Emergency cart.

2 laryngoscopes, unable to provide emergency light source for intubation were found on the Emergency cart.

EI # 11 present during the tour validated the above findings on 7/7/15 at 12:30 PM.

Based on observations, review of facility policy and interviews, it was determined staff failed to:

1. Perform hand hygiene according to facility policy. This affected MR # 3 and had the potential to affect all patients served by the facility and staff.

2. Perform annual Tuberculosis skin (TB) testing in 4 of 30 personnel files reviewed. This had the potential to negatively affect all patients served by the facility.

3. Perform Hepatitis B (Hep B) testing or produce a Hepatitis B declination in 2 of 30 personnel files reviewed. This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy Reference # 4002
Subject: Hand Hygiene-CDC (Centers for Disease Control) Guidelines
Revised: 08/16/12

Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.

"Policy:
All personnel will use the hand-hygiene techniques, as set forth...The CDC has recommended guidelines on..use of non-antibacterial soap and water...or an alcohol-based hand rub.
...Before each patient encounter...Before applying gloves...after removing gloves...

Procedure:
...Wet hands and soap to hands. Lather well (soap reduces surface tension enabling the removal of bacteria)...Wash hands thoroughly, using vigorous action for at least 15 seconds. Work lather around fingernails, top pf hands...Rinse...under running water...Dry hands with clean paper towel and discard. Turn off faucets with paper towel and discard..."

Policy: Employee Health Requirements

Revised Date: 01/15

Purpose:

To ensure the health and well-being of staff and patients through an effective employee health program.

Annual Requirements:

2. TB skin test- Must be administered annually unless employee can provide TB skin test documented from another facility or has had prior positive or allergic reaction to a skin test in the past in which case the employee will complete the TB questionnaire (as long as questionnaire answers are ok and chest X-ray is ok, employee is clear).

3. Hep B vaccination and/or titer- all employees are offered the Hep B vaccination series so they will need to do one of the following: provide documentation of the series and titer that indicates immunity, begin the series (or continue if have begun), if have already had series but have no documentation of titer have titer drawn, or sign to decline the series...


1. On 7/7/15 at 12:00 PM during medication passes on the Senior Behavioral Care Unit, Employee Identifier (EI) # 19, Licensed Practical Nurse performed hand hygiene using soap and water prior to and after medication dispensing. EI # 19 did not wash hands with soap and water for 15 seconds. EI # 19 turned off the faucet using wet hands.

EI # 19 failed to wash hands using soap and water for the required time and did not turn off the faucets with a paper towel.

An interview conducted with EI # 8, Chief Financial Officer on 7/10/15 at 2:30 PM verified staff failed to follow its facility hand hygiene policy.

2. An observation of care on 7/8/15 at 8:45 AM with EI # 12, Occupational Therapist was performed. EI # 12 performed hand hygiene at the sink 3 times. EI # 12 performed hand hygiene then turned off the faucet using wet hands.

EI # 12 failed to follow the facility policy for hand hygiene.

EI # 12 confirmed the above observations in an interview on 7/8/15 at 9:45 AM.

3. On 7/10/15 at 10:30 AM during review of personnel files, EI # 20, Respiratory Technician's current personnel file failed to include a completed Hep B consent/declination form.



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4. Observation of EI # 1, Intensive Care Unit (ICU) Registered Nurse (RN), was conducted 7/9/15 at 1:30 PM. EI # 1 washed hands with soap and water and failed to turn off faucet with towel, donned gloves, removed soiled dressing, removed gloves and without washing hands reapplied gloves.

An interview conducted 7/9/15 at 2:30 PM with the EI # 15, Registered Nurse, Medical Surgical Department Manager verified EI # 1 should have use the towel to turn off the faucet and sanitized hands between glove change.


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5. On 7/8/15 at 9:00 AM the surveyor entered the Medical Surgical area to observe a medication pass for 4 patients. During the second medication pass, EI # 10 donned clean gloves and split a tablet. After administering the medication, EI # 10 removed gloves. EI # 10 failed to sanitize hands prior to donning gloves and failed to sanitize hands after removing gloves.

During the third medication, EI # 10 donned clean gloves and prepared an injection for the patient. After giving the injection EI # 10 removed gloves. EI # 10 failed to sanitize hands prior to donning gloves and failed to sanitize hands after removing gloves.

An interview was conducted on 7/8/15 at 10:45 AM with EI # 15, Medical/Surgical Manager, who confirmed the above mentioned findings.

6. On 7/9/15 at 10:00 AM the surveyor observed a dirty patient room being cleaned by Environmental Services. EI # 16, Environmental Service employee, sanitized hands and donned clean gloves. EI # 16 began collecting the dirty linen and trash from the room, then removed the mattress and pillows from the bed.

EI # 16 removed gloves and donned clean gloves without sanitizing hands. EI # 16 sprayed the entire room with the spray. After waiting proper amount of time EI # 16 wiped entire room down with clean cloths.

EI # 16 exited the room, removed gloves and obtained clean linen made the bed and placed clean hand towels. EI # 16 failed to sanitize hands after removing gloves and before obtaining clean linens.

An interview was conducted on 7/9/15 at 11:15 AM with EI # 17, Environmental Manager, who confirmed the above mentioned findings

7. On 7/8/15 at 11:30 AM the surveyor entered the Dietary area to observe plating of the patients food. The surveyor observed all employees had gloves on upon the surveyors arrival. Prior to the plating of food the hot food server was observed leaving his/her station with gloves on and went to another area of dietary, opened a drawer with the gloves on, obtained serving spoons and thongs. He/she returned to the hot food and placed spoons and thongs in the food. He/she did not remove gloves after touching a contaminated area or sanitize hands and don new gloves. He/she began to plate the hot food with the same gloves.

An interview was conducted on 7/8/15 at 12:30 PM with EI # 15, Dietary Manager, who confirmed the above mentioned findings.

Based on review of the Medical Records (MR), review of the Home Health and Hospice Choice Form provided to the surveyor and interviews it was determined the facility failed to provide a Home Health, Hospice and Skilled Nurse Facility (SNF) Choice Form to 2 of 6 discharge charts reviewed with referrals to either Home Health or Hospice. This affected MR # 10, MR # 20 and 2 of 3 discharge records reviewed from the Senior Behavioral Care Unit (SBCU), MR's # 7 and # 8. This had the potential to negatively affect all discharge patients with referrals to Home Health/ Hospice and SNF.

Findings include

Home Health and Hospice Choice Form

"Your physician may recommend home health or hospice after you leave the hospital. If your physician does order home health or hospice, you have the right to select an agency. Below is a listing of agencies who have contacted this facility requesting to be included as a choice for our patients...".

1. MR # 10 was admitted to the facility on 12/28/13 and transferred to the Swing Bed program on 1/3/14 with an admitting diagnosis of Altered Mental Status and Septicemia.

Review of the MR revealed the patient was discharged on 1/6/14 with discharge orders for Home Health.

Review of the MR revealed no documentation a Home Health or Hospice Choice Form was provided to the patient.

An interview conducted on 7/10/15 at 8:15 AM with EI # 5, Corporate Financial Officer (CFO), who confirmed the above mentioned findings.





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2. MR # 20 was admitted to the facility on 3/3/15 with diagnosis including Pressure Ulcer Stage III to low Back and Diabetes Mellitus.

Review of the MR revealed the patient was to be discharged on 3/5/15 to Hospice.

Review of the discharge documentation revealed there was no Hospice Choice Form provided to the patient or family.

An interview conducted 7/10/15 at 8:15 AM with EI # 5, CFO confirmed there was no choice form provided.




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3 MR # 7 was admitted to the Senior Behavioral Care Unit 4/3/15 with diagnoses including Schizoaffective Disorder, Unspecified.

Record review revealed MR # 7 was discharged 4/14/15 to a SNF.

Review of the MR revealed no documentation a Choice Form for SNF was provided to MR # 7 or the family.

An interview conducted 7/9/15 at 2:15 PM with EI # 3, Senior Behavioral Care Unit Manager, confirmed the finding above.

4. MR # 8 was admitted to the SBCU on 6/10/15 with diagnoses including Alzheimer's Disease, Status Post Cerebrovascular Accident and Diabetes Mellitus.

Record review revealed MR # 8 was discharged 6/18/15 with Hospice care.

Review of the discharge documentation revealed no Hospice Choice Form was provided to the patient or family.

An interview conducted 7/9/15 at 1:10 PM with EI # 3 confirmed no choice form for Hospice care was provided.

Based on observation and interview, it was determined the facility failed to document review and approval of all department policy and procedure manuals in the Respiratory Care Unit. This had the potential to affect all patients served by the facility.

On 7/8/15 at 1:45 PM, during a tour of the Respiratory Care unit, a review of the policy and procedure manuals was completed. There were no dates for review/revision/update by the Department Head and the Medical Director documented in any of the policy and procedure manuals in the Respiratory Care unit.

In an interview on 7/9/15 at 2:15 PM, Employee Identifier # 23, Certified Respiratory Technician confirmed the above findings.

Based on review of the Medical Records (MR), agency Swing Bed program and interviews with the staff it was determined the agency failed to ensure the activity director completed an activities calendar and documentation of activities on each swing bed patients. This affected 2 of 4 Swing Bed MR's reviewed. This affected MR # 11 and MR # 12 and had the potential to negatively affect all patients served by the facility.

1. MR # 11 was admitted to the Swing Bed program on 6/13/14 with an admitting diagnosis of Fractured Ribs and Decreased Mobility.

Review of the MR revealed as a swing bed patient the activity director is to complete an activity calendar for each patient and document all activities completed by the patients.

Review of the MR revealed no documentation of an activity calendar for the patient while on the Swing Bed program and no documentation of the activities completed by the patient.

An interview conducted on 7/10/15 at 8:25 AM with EI # 5, Chief Financial Officer (CFO) confirmed the above mentioned findings.

2. MR # 12 was admitted to the Swing Bed program at the facility on 7/29/14 with an admitting diagnosis of Foot Ulcer/Infections.

Review of the MR revealed as a swing bed patient the activity director is to complete an activity calendar for each patient and document all activities completed by the patients.

Review of the MR revealed no documentation of an activity calendar for the patient while on the Swing Bed program and no documentation of the activities completed by the patient.

An interview conducted on 7/10/15 at 10:10 AM with EI # 5 confirmed the above mentioned findings.