HospitalInspections.org

Based on review of policy, observation and interview, it was determined the facility failed to ensure medication rooms were locked per policy in three of three (Medical Surgical, Emergency Department and Labor and Delivery) medication rooms toured on 02/26/18. By not keeping the medication rooms locked when unattended, the facility could not assure the safety, integrity or efficacy of the uncontrolled medications, supplies and emergency kits. The failed practice had the potential to affect all patients that were admitted into the facility. Findings follow:
A. Record review of the facility's policy titled, "Medication Security," showed medication rooms are to be locked when unattended.
B. During a tour of the facility on 02/26/18 from 1:00 PM until 2:10 PM observation showed the medication rooms in the Medical Surgical and Labor and Delivery Units to be unlocked. On 02/27/18 at 2:57 PM observation showed the Emergency Department's medication room was unlocked.
C. During an interview on 02/26/18 at 2:10 PM, the Director of Pharmacy verified the medication rooms in the Medical Surgical and Labor and Delivery units were unlocked.
During an interview on 02/27/18 at 2:57 PM, LPN #1 (Licensed Practical Nurse) verified the medication room was unlocked.

Based on observation it was determined the facility failed to maintain the building physical structure, environment and equipment in a state of good repair in two (Room 4105 and Room 4118) of two patient rooms observed. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for an infection control issue presented by the observed conditions. Findings follow:

A. During a tour of the facility on 02/26/18 at 1:05 PM, observation showed:
1) Cracking and chipping in the walls just above the trim behind the toilet in the bathroom of Room 4105.
2) Wallpaper pulling off of the walls around the toilet in the bathroom of room 4118.
B. In an interview conducted on 02/27/18 at 10:30 AM the Director of Maintenance verified the areas were in need of repairs.

Referenced Code: 42 CFR 485.623(c)(1)

Based on review of the Fire Drill Log and interview, it was determined there was no evidence six (first quarter - first and second shifts, third quarter - first and second shifts, and fourth quarter - first and second shifts) of eight (first, second, third, and fourth quarters - first and second shifts) required fire drills from January 1, 2017 to December 31, 2017 were performed. Failure to perform required fire drills prevented the facility from ensuring staff were trained and prepared to respond to fire emergencies with required procedures in a prompt and orderly manner to protect patients from fire and smoke. Findings follow:

A. Review of the fire drill documentation provided in the Fire and Safety Manual on 02/27/18 at 9:00 AM showed there was no evidence of a fire drill for:
1) The first quarter, first shift of 2017;
2) The first quarter, second shift of 2017;
3) The third quarter, first shift of 2017;
4) The third quarter second shift of 2017;
5) The fourth quarter, first shift of 2017;
6) The fourth quarter, second shift of 2017.
B. In an interview on 02/27/18 at 1:30 PM, the Director of Maintenance verified there was no further fire drill evidence available for review.
C. See K712.

Life Safety Code NFPA 101, 2012 Edition, Section 19.7.1.6

Based on review of Medical Staff Bylaws, Physician Credential files, and interview, it was determined the facility failed to obtain evidence of current competence (per bylaws) for two (#3 and #6) of nine (#1-#9) Physicians that were Credentialed or Re-Credentialed. By not checking for evidence of current competence, the facility could not guarantee the patients would receive care from a competent physician. The failed practice had the likelihood to affect all patients that were treated at the facility. Findings follow:
A. Review of Medical Staff Bylaws showed evidence of current competence must be submitted in order to apply or re-apply for appointment.
B. Review of Physician Credential files on 02/27/18 showed Physician #3 and #6 did not have evidence of current competence.
C. During an interview on 02/28/18 at 10:05 AM, the Chief Nursing Officer verified the Physicians did not have evidence of current competence.

Based on review of policy, review of manufacturer's recommendations, observation, and interview, it was determined the facility failed to follow manufacturer's recommendations for length of storage and temperature in two of two (Labor and Delivery and Surgical Services) fluid warmers observed. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility. Findings follow:

A. Review of the facility's policy titled, "Floor Stock," revised 06/12, showed direction for facility staff to follow manufacturer's recommendations for storage.
B. Review of the manufacturer's recommendations showed large volume intravenous solutions could be warmed to temperatures not exceeding 104 degrees Fahrenheit, and for a period of time no longer than 14 days.
C. During a tour of the facility on 02/26/18 from 1:00 PM to 2:10 PM observation showed the following:
1) Labor and Delivery - 9- 1000 ml (milliliter) bags of 0.9% Sodium Chloride for injection made by Baxter stored at 100 degrees Fahrenheit that were not dated to indicate when they needed to be removed;
2) Surgical Services - 2- 1000 ml bags of 0.9% Sodium Chloride for injection made by Baxter stored at 110 degrees Fahrenheit (too high) and dated on the day they are placed in the warmer, and was told by the Surgery Director they keep them for 28 days (too long).
D. During an interview on 02/26/18 at 1:45 PM, with the Pharmacy Director verified the manufacturer's recommendations and that the facility was not following them.

Based on review of policy, IV Admixture competencies, and interview, it was determined the facility failed to ensure the aseptic manipulations of sterile products portion (media fill test) of the annual re-certification of Intravenous (IV) Admixture technique for all personnel (Pharmacists #1 and #2, and Pharmacy Technicians #1-3) trained to compound medications in the CAI (Compounding Aseptic Isolator) (per policy). By not evaluating the competencies of the personnel, the facility could not assure the sterility of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the CAI. Findings follow:
A. Review of the facility's policy titled, "Sterile Compounding- Staff Competency," revised 06/12, showed there should be an aseptic manipulations of sterile products (media fill test) assessment as part of their competencies.
B. Review of Pharmacy staff competencies showed no media fill testing had been done.
C. During an interview on 01/26/18 at 3:18 PM, the Director of Pharmacy verified they were not performing media fill tests as part of the annual compounding competencies.

Based on observation, review of policy, and interview, it was determined the facility failed to secure medications in that two of two (Cart #1 and #2) Respiratory Therapy rolling computer carts had unsecured medications. By not securing medications, the Facility could not assure they were not available to non-licensed personnel. The failed practice had the likelihood to affect all patients receiving Respiratory Therapy medications. Findings follow:

A. Review of the facility policy titled "Medication Safety," showed all medication in the facility was to be kept in a secure area and locked so it was not accessible to unlicensed personnel.
B. On 02/27/18 at 2:21 PM observation showed the following items on the carts, which were plugged into a wall outside of Respiratory Therapy, in a public hall across from the vending machines:
1) Rolling computer Cart #1 had the following solutions for nebulization in a basket, open and unsecured:
a) 14 - Budesonide 0.5 mg (milligram)/ 2 ml (milliliter);
b) 9 - Albuterol 2.5 mg/3 ml;
c) 4 - Ipratropium 0.5 mg/ ampule;
d) 4 - Levalbuterol 1.25 mg/ 3 ml;
e) 7 - Xopenex 1.25 mg / 3ml;
f) 1 - Sterile water for inhalation 500 ml; and
g) 4 - Ipratropium / Albuterol 0.5 mg/ 3 mg.
2) Rolling computer Cart #2 had the following solutions for nebulization in a basket, open and unsecured;
a) 9 - Levalbuterol 1.25 mg/ 3 ml;
b) 9 - Albuterol 2.5 mg/3 ml;
c) 7 - Ipratropium 0.5 mg/ ampule;
d) 10 - Ipratropium / Albuterol 0.5 mg/ 3 mg; and
e) 1 - Budesonide 0.5 mg / 2ml.
C. During an interview on 02/27/18 at 2:34 PM, Respiratory Therapist #1 verified the medications on the carts were not being secured to prevent unauthorized access to them.

Based on observation, review of manufacturer's recommendations, and interview, it was determined the facility failed to follow manufacturer's recommendations for temperature storage for floor stock enemas in one (Labor and Delivery) of one warmer that had enemas in it. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that received the enemas in the facility. Findings follow:

A. Review of manufacturer's recommendations on the packaging showed the enemas were to be stored at 59-86 degrees Fahrenheit.
B. During a tour of the facility on 02/26/18 from 1:00 PM to 2:10 PM, observation revealed 5 enemas stored in the warmer at 100 degrees Fahrenheit.
C. During an interview on 02/26/18 at 1:31 PM, the Director of Pharmacy verified the facility was not following the manufacturer's recommendations for storing the enemas.

Based on observation, manufacturer's recommendation and interview, it was determined the facility failed to follow manufacturer's recommendation for one of one bottle of 0.9 % Sodium Chloride for irrigation. By not following manufacturer's recommendation the facility could not assure its safety and efficacy if used once opened and not discarded. The failed practice had the likelihood to affect all patients admitted to this unit. Findings follow:

A. Review of the manufacturer's recommendations showed the packaging stated this solution is sterile and once opened, the facility was to discard any unused portion.
B. During a tour of the facility on 02/26/18 from 1:00 PM until 2:10 PM, observation showed a 1000 ml (milliliter) bottle of sterile 0.9% Sodium Chloride for Irrigation, with a "Medication Added" label attached. The label showed this container contained 200 ml of Betadine and 800 ml of 0.9 Sodium Chloride. It was mixed on 01/29/18. It was stored in the warmer and available for patient use.
C. During an interview on 02/26/18 at 1:35 PM, the Pharmacy Director verified the Sodium Chloride for Irrigation had been mixed, labeled and stored for future use, and not discarded after initial use.

Based on policy and procedure review, review of the outside company work reports, and interview, it was determined the facility failed to manage and prevent the outbreak of communicable infections in that the facility failed to follow their policy and procedure for checking the negative pressure of three of three (Room #5, Emergency Rooms (ER) #4 and #5) airborne isolation rooms. Failure to perform air flow checks for negative pressure rooms monthly when unoccupied and daily when occupied did not allow the facility to be knowledgeable and assure the negative pressure rooms were working correctly prior to patients being placed in the rooms. The failed practice had the potential to affect any patient placed in the rooms, visitors and staff members working in the rooms. Findings follow:

A. Review of the policy and procedure received from the Infection Control Nurse at 8:30 AM on 02/28/18 showed airborne isolation rooms were to be checked by maintenance daily when occupied and monthly when not occupied.
B. Review of the outside company work reports received from the Interim Director of Maintenance showed the airborne isolation rooms were checked on 11/30/17, 06/09/17, 12/23/16, 06/15/16 and 12/03/15.
C. During an interview with the Interim Director of Maintenance and the Infection Control Nurse at 12:50 PM on 2/28/18 the Interim Director of Maintenance stated an outside company checks the four isolation rooms every six months.

Based on review of the Arkansas Department of Health Mandatory Reportable Diseases List and Instructions and interview, it was determined the facility failed to prevent, identify, and manage infections in that it was not using the most current list of reportable diseases. Failure to utilize the most current list did not ensure the facility was aware of all diseases required to be reported, and had the potential to allow communicable diseases to go unreported and untreated. The failed practice had the potential to affect all staff and patients in the facility. Findings follow:

A. Review of the Arkansas Department of Health Mandatory Reportable Diseases List and Instructions received from the Infection Control Nurse at 1:55 PM on 02/28/18 showed a date of 09/01/2014.
B. Review of the current Arkansas Department of Health Mandatory Reportable Diseases List and Instructions showed a date of 12/01/16.

Based on review of the Rules and Regulations for Critical Access Hospitals in Arkansas, 2016, water temperature logs, and interview, it was determined the facility failed to prevent infections in that it failed to ensure water used to launder the Operating Room (OR) uniforms was at or above 120 degrees Fahrenheit for 21 of 42 days. Failure to ensure the OR uniforms were laundered in water at or above 120 degrees Fahrenheit did not ensure the uniforms were clean and free of infective material. The failed practice had the potential to affect any patient whose care required services in the OR. Findings follow:

A. Review of the Rules and Regulations for Critical Access Hospitals in Arkansas, 2016, Table 9-2 showed the water temperature for laundry was not to be under 120 degrees Fahrenheit.
B. Review of the water temperature logs received from the Interim Director of Maintenance at 1:30 PM on 02/28/18 showed the facility begin checking the water temperature January 18, 2018.
C. Review of the above water temperature logs showed the facility's water temperature was not at or above 120 degrees Fahrenheit on 01/18/18, 01/23/18, 01/27/18 through 01/31/18, 02/02/18, 02/03/18, 02/05/18 through 02/09/18, 02/11/18, 02/12/18, 02/14/18, 02/17/18, 02/20/18, 02/25/18 and 02/26/18.
D. During an interview with the Interim Director of Maintenance at 1:35 PM on 02/28/18, he verified the findings in B and C.


31039

Based on observation, review of policy, and interview, the Infection Control Officer failed to identify the likelihood for infection control negative outcomes in that the facility failed to maintain therapy equipment in a manner that allowed thorough cleaning between patients in Rehabilitation for one of one quad canes (quad cane #1) and two of two walkers (walker #1 and #2) that had tape on them (not able to disinfect), in the Rehabilitation gym. By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, the facility could not assure a sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that received therapy services using the therapy equipment. Findings follow:

A. During a tour of Rehabilitation on 02/27/18, observation showed one cane and two walkers that had tape on them in the Rehabilitation gym.
B. Review of Rehabilitation Services policy titled, "Infection Prevention and Control," showed all walkers and canes are cleaned by wiping thoroughly with approved disinfectant solution between patients.
C. During an interview on 02/27/18 at 3:18 PM, the Director of Infection Control verified the equipment had tape on it.


38994

Based on observation and interview it was determined the facility failed to monitor and inspect their colonoscopes in that three of three were stored with the tip bent and touching the floor of the storage cabinet. Failure to ensure the colonoscopes were stored vertically with the tips not bent and not touching the bottom of the storage cabinet did not ensure that the colonoscopes were free from surface/airborne contamination and had the potential to affect any patient whose care required colonoscope use. Findings follow:

A. Observation during tour of the Operating Room #1 on 02/26/18 at 2:05 PM showed three of three colonoscopes stored with the tip of the scope bent and touching the bottom of the cabinet.
B. During interview with the Surgery Director on 02/26/18 at 2:05 PM the above findings were verified.


Based on observation and interview it was determined the Nuclear Medicine Room was dirty and not being routinely cleaned by the Environmental Services Department (EVS) and the Nuclear Medicine Technician (NMT) was scrambling eggs on a table top electric burner that was covered in dried food particles and dirt in preparation for Gastric Emptying Studies. The failed practice did not ensure a sanitary environment was provided for patients undergoing Nuclear Medicine Studies in this area and did not ensure that scrambled eggs were prepared in a sanitary environment prior to patient consumption. Findings follow:

A. Observation during tour of the Nuclear Medicine Department on 02/28/18 at 1:55 PM showed the floor was dirty with dirt piled up in the corners of the room, and a table top electric burner with dried food particles and dirt present.
B. During an interview with the Radiology Director on 02/28/18 at 1:55 PM he stated the Nuclear Medicine Room was only cleaned when the NMT called to have it cleaned and the table top electric burner was used by the NMT to prepare scrambled eggs for patient consumption prior to Gastric Emptying Studies.
C. During an interview with the Environmental Services Director on 02/28/18 at 3:00 PM she stated that the Nuclear Medicine Room was kept locked and that they did not have access to clean it on a routine basis. She further stated that it is only cleaned when requested by the NMT and that the EVS department had not been requested to clean it in quite some time.
D. The findings in A, B, and C were verified with the Chief Nursing Officer on 02/28/18 at 3:25 PM.

Based on review of policy, medical records and interview it was determined the facility failed to ensure the nutritional needs of the patients were being met in four (#1, #3, #4 and #21) of five (#1-#4 and #21) patients in that they were not screened for nutritional risk in a timely matter, and/or not assessed by the Dietitian or Certified Dietary Manager per policy. By not assuring the screenings were done timely, the facility could not assure they were able to meet the patients' nutritional needs in time. The failed practice had the potential to affect all patients admitted into the facility. Findings follow:

A. Record review of the facility's policy titled, "Nutrition Screening and Assessment," revised on 9/30/16, showed direction for:
1) The initial nutrition risk screen is to be done by a nurse within 24 hours of admission.
2) If the initial screen triggers the patient is at risk, then a Registered Dietitian or Certified Dietary Manager has to perform a nutritional assessment within 72 hours after the referral was made.
B. Review of Patient #1's medical record showed they were admitted on 02/23/18, and their initial nutritional risk screen was performed on 2/23/18. They triggered the need for a nutritional assessment that should have been done by 02/26/18, but it was not done until 02/28/18.
C. Review of Patient #3's medical record showed they were admitted on 02/21/18, and their initial nutritional risk screen was performed on 02/21/18. They triggered the need for a nutritional assessment that was completed on 02/23/18. The recommendation of Registered Dietitian #1 was to follow up in 2-3 days, and there was no evidence of a follow up. The patient discharged 02/27/18.
D. Review of Patient #4's medical record showed they were admitted on 02/25/18, and did not receive an initial nutritional risk screen by a nurse.
E. Review of Patient #21's medical record showed this patient was admitted on 02/20/18, and their initial nutrition risk screen was done on 02/21/18. They triggered the need for a nutritional assessment that should have been done on 02/24/18, but was not done until 02/28/18.
F. During an interview on 03/01/18 at 3:41 PM, the Chief Nursing Officer verified the findings at B, C and D. During an interview on 03/01/18 at 3:45 PM, the Utilization Review and Compliance Officer verified the findings at E.

Based on clinical record review and interview it was determined a Registered Nurse failed to supervise and evaluate the nursing care in that one (#3) of one patient with Physician's orders to have been turned every 2 hours and as needed, was not turned every 2 hours as ordered. Failure to perform the turns as ordered did not ensure the patient's comfort and prevention of skin breakdown. The failed practice had the likelihood to affect all patients who needed these nursing services. Findings follow:

A. Review of Patient #3's clinical record revealed an admission date of 02/21/18, and a discharge date of 02/27/18. Review of physician's orders dated 02/24/18 showed orders for every 2 hour turns plus as needed with pillows for support. Review of the clinical record showed the only turns documented were 12/25 at 09:00 AM, 11:25 AM, 13:30 PM and 13:50 PM, and 12/26 at 09:55 AM and 11:59 AM.
B. During an interview on 03/01/18 at 1:09 PM, the Utilization Review and Compliance Officer verified the dates and times in A. were the only documented turns for Patient #3.


38994

Based on clinical record review and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that three (#2, #7, and #10) of ten (#1 - #10) patient's clinical records did not contain complete documentation of physician ordered daily weights. The failed practice did not give the physician the information necessary to make clinical decisions. The failed practice affected patients #2, #7 and #10. Findings follow:

A. Review of Patient #2's clinical record showed a physician's order for daily weights on 02/22/18 at 6:06 PM. The clinical record showed no documentation of daily weight on 02/23/18, 02/24/18, and 02/25/18.
B. Review of Patient #7's clinical record showed a physician's order for daily weights on 12/13/17 at 3:15 PM. The clinical record showed no documentation of daily weight on 12/14/17, 12/15/17 and 12/16/17.
C. Review of Patient #10's clinical record showed a physician's order for daily weights on 02/23/18 at 4:24 PM. The clinical record showed no documentation of daily weights on 02/24/18 and 02/25/18.
D. The above findings in A, B, and C were verified with the EMR (Electronic Medical Record) Coordinator on 03/01/18 at11:20 AM.

Based on clinical record review, policy and procedure review, and interview it was determined the facility failed to ensure its clinical records were complete and accurately documented in that 5 (#5, #6, #7, #8 and # 10) of 10 (#1 - #10) inpatient records had verbal orders not co-signed by the prescribing Physician within 24 hours, as per facility policy. Failure to follow facility policy did not ensure verbal orders were signed by the prescribing Physician and did not ensure staff had accurate and complete Physician orders. The failed practice affected patients # 5, #6, #7, #8 and #10. Findings follow:

A. Review of facility policy titled "Verbal and Written Orders" showed the provider shall co-sign the order within 24 hours.
B. Review of Patient #5's clinical record showed 15 verbal orders not signed by the Physician within 24 hours.
C. Review of Patient #6's clinical record showed 17 verbal orders not signed by the Physician within 24 hours.
D. Review of Patient #7's clinical record showed 21 verbal orders not signed by the Physician within 24 hours.
E. review of Patient #8's clinical record showed 12 verbal orders not signed by the Physician within 24 hours.
F. Review of Patient #10's clinical record showed 12 verbal orders not signed by the Physician within 24 hours.
G. During interview with the EMR (Electronic Medical Record) Coordinator on 03/01/18 at 4:00 PM the above findings in A, B, C, D, E, and F were verified.

Based on clinical record review, review of facility policy, and interview, it was determined the facility failed to obtain consent for treatment for five (#1, #5, #6, #19 and #20) of 21 (#1-21) patients and failed to obtain surgical/anesthesia consent for one (#3) of five (#3, #11-#14) surgical patients. Failure to obtain a signed consent for treatment, surgery and/or anesthesia did not afford the patient or their representative the opportunity to make informed decisions regarding his or her care. The failed practice had the likelihood to affect Patient #1, #3, #5, #6, #19 and #20. Findings follow:

A. Review of the facility's undated policy titled, "Medical Record Documentation," showed a signed general consent for treatment and care was to be signed by the patient or guardian and was to be in the record.
B. Review of the facility's untitled policy from Surgical Services showed surgery and anesthesia consents were to be obtained prior to surgery.
C. Review of Patient #1, #5, #6, #19 and #20's clinical records showed they did not contain the required consent for treatment. Review of Patient #3's clinical record showed it did not contain consent for surgery/anesthesia.
D. During an interview on 03/01/18 at 9:30 AM, the Medical Records Director confirmed the findings at C.

Based on clinical record review and interview, it was determined the facility failed to ensure verbal and telephone orders for two (Patient #1 and #2) of three (Patient #1-#3) patients in the inpatient geriatric-psychiatric unit were signed by the physician within 48 hours. The failed practice did not allow the facility to be in compliance with their procedure. The failed practice affected Patient #1 and #2. Findings follow:

A. Review of Patient #1's clinical record showed one of one physician's orders dated 02/24/18 and 15 of 17 physician's orders dated 02/25/18 unsigned. During an interview with the Program Manager at 10:16 AM on 02/01/18 the above was verified.
B. Review of Patient #2's clinical record showed three of three physician's orders dated 02/23/18 and nine of nine physician's orders dated 02/25/18 unsigned. During an interview with the Program Manager at 10:49 AM on 03/01/18 the above was verified.
C. During an interview with the Program Director at 9:15 AM on 03/02/18 she stated verbal/telephone orders on the geriatric-psychiatric unit were to be signed by the physician within 48 hours.

Based on observation, interview and policy and procedure review it was determined this condition was not met in that the facility failed to ensure the Surgery Department was locked and kept secure in a manner to ensure the surgery department was free from unauthorized persons. The failed practice did not ensure the surgery department was locked and secure from the unauthorized persons. Findings follow:

A. On 02/28/18 at 10:40 AM this Surveyor was able to enter the Surgical Department thru an unlocked door. Upon entering the Surgical Department it was found to be unoccupied, the anesthesia medication refrigerator was unlocked containing 3 succinylcholine and 5 rocuronium bromide medications. The unlocked door gave access to whomever may enter to both Operating Room #1, Operating Room #2, supplies, medications kept in the unlocked anesthesia refrigerator and the Surgical Department crash cart. A second door to the Surgery Department was also found unlocked, this door gave access to the Sterile Central Supply and the Surgical Department.
B. During interview with the Surgery Director on 02/25/18 at 2:44 PM she stated that all doors to the Surgery Department were locked at 2:00 PM each day or when all the cases were completed.
C. During Policy and Procedure review on 02/28/18 at 3:45 PM it was determined that the facility did not have a policy on Traffic Control in the operating room.
D. The above findings in A, B, and C were verified with the Surgery Director on 02/28/18 at 3:55 PM.

THIS IS A CONTINUING DEFICIENCY

Based on clinical record review and interview, it was determined this condition was not met in that the facility failed to ensure operative reports included the time of surgery for two (#10 and # 13) of four (#10 - #14) surgical patients. The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, and created the potential to affect any patient receiving an operation in the facility. Findings follow:

A. Review of the operative reports showed the time of surgery was not documented for Patients #10 and #13.

B. During interview with the Electronic Medical Records (EMR) Coordinator on 03/01/18 at 1:05 PM the above findings in A were verified.

Based on clinical record review, policy and procedure review and interview it was determined the facility failed to ensure History and Physicals were documented within 48 hours of admission and prior to surgery. The failed practice did not ensure that accurate and complete History and Physicals were documented within 48 hours of admission and prior to surgery and failed to ensure facility staff was knowledgeable and prepared to affect the appropriate care of patients. Findings follow:

A. Review of clinical records on 03/01/18 at 10:45 AM and 11:05 AM showed two (# 5 and # 7) of ten (#1-#10) inpatient clinical records with History and Physicals documented greater than 48 hours from the date of admission.
B. Review of clinical records on 03/01/18 at 2:10 PM showed one (#14) of four (#10-#14) surgery records had the History and Physical documented three days prior to surgery with no documented update the day of surgery.

C. Review of the facility policy and procedure on 02/28/18 at 10:15 AM showed for the general record "History and Physicals shall be in the patient's medical record within 48 hours of the patient's admission". Review of the facility policy and procedure on 02/28/18 at 1:45 PM showed for the Surgery Records "a History and Physical Examination on admission containing medical history and physical findings shall be documented by the attending physician on the patients' medical record prior to surgery".

D. The above findings in A, B, and C were verified with the EMR Coordinator on 03/01/18 at 3:45 PM.

Based on clinical record review, policy and procedure review and interview it was determined that two (#11 and # 13)of four (#10-#14) patients did not have post-operative anesthesia evaluations after surgery. Failure to complete a post-operative anesthesia evaluation did not ensure patients were recovered form anesthesia prior to discharge from the recovery area. The failed practice affected patients #11 and #13. Findings follow:

A. Review of the clinical record of Patients #11 and #13 showed no documentation of a post anesthesia evaluation.
B. Review of the facility's Surgery Records Policy showed "an anesthesia report, including preoperative evaluation and postoperative assessment shall be documented by the Anesthesiologist and/or Certified Registered Nurse Anesthetist (CRNA)".
C. During interview with the EMR Coordinator the above findings in A and B were verified on 03/01/18 at 12:55 PM.

Based on interview it was determined the activities calendar for swing bed patients had not been developed and placed on the Unit or in patient rooms. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice had the potential to affect any swing bed patient. Findings follow:

During an interview with the Utilization Review/HIPPA/Compliance Nurse at 8:30 AM on 03/01/18 she stated the facility did not develop an activities calendar for swing bed patients.