HospitalInspections.org

Based on observation, interview and document review it was determined that the facility staff failed to ensure that equipment and supplies used for emergency procedures were available for use.

The findings included:

1. The anesthesia cart, which was located inside the OR (operating room) contained supplies commonly used by the person administering anesthesia. Access to the cart was limited to only the pharmacist and the person administering anesthesia (Employee #23).

Observation of the contents of the anesthesia cart on 3/2/15 revealed the following supplies to be out of date: spinal trays used for anesthesia- expiration date 12/14, LMA (laryngeal mask airway) used for airway control- expiration date 1/12/14, IV catheters routinely used for access to patients bloodstream by insertion into a vein- expiration dates 1/13 and 2/13, IV start kits- expiration date 11/13, alcohol disinfectant caps -expiration date 10/14. The expiration dates were confirmed by Staff #3 and Staff #22. These supplies were removed from the cart by Staff #3 who stated that he/she would ensure that the person who administers anesthesia (Staff #23) would be notified that these supplies needed replacing.

During a phone interview with Staff #23 he/she stated that he/she did all the restocking for the cart and restocked supplies as needed. When asked how often he/she was required to initiate an IV site while in the OR, he/she replied that it was "not very often only when the nurses have trouble".

The facility had no schedule for restocking therefore the surveyor (nor staff) could not ascertain how many patients would have been potentially affected by the expired supplies, as there was no way to know when the supplies were last stocked.

2. Two AED's (automated external defibrillator, used for emergency treatment of life-threatening cardiac arrhythmia) inventory #02636 and # 02582 which were owned and maintained by the facility and located in the outpatient physical therapy department, were found to have expired electrode pads stored with the AED. The expiration dates were 9/15/14 and 1/28/14 respectively. The AED's last scheduled maintenance was November 2014.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the concerns with the administrative staff #1, 4, 11, 13 and #15.

This Condition of Participation was not met based on observation, staff interview and facility document review, the facility staff failed to ensure the physical plant environment was maintained in a safe operating condition which involved the dishmachine, and failed to maintain humidity control in anesthetizing locations to provide adequate levels for patient health and safety.

The findings included:

1. On 2/27/15 at 9:20 a.m., the surveyor observed the dishwasher in the kitchen was not functioning properly resulting in inadequate sanitization of the dishes which were used for both patients and staff. This observation resulted in a finding of IMMEDIATE JEOPARDY on 2/27/15 at 10:27 a.m. after consultation with the State Agency. On 2/27/15 at 10:30 a.m. the facility Staff #1 and 11 were notified of the Immediate Jeopardy situation and a plan of removal was requested. On 2/27/15 at 12:55 p.m., the survey team received the facility plan of removal which documented the following:

Virginia Federal/State Surveyor found chemical/heater dishwasher appearing to not function properly. Strip did not meet minimum required ppm (parts per million) to show that dishwasher was appropriately sanitizing dishes, when tested by the surveyor. (Name of equipment contractor) provided maintenance and tested machine on February 12, 2015 and all results were in compliance.
Immediate jeopardy plan of correction for the dishwasher:
1. Upon meeting with the surveyors, discontinue use of the dishwasher.
2. Instituted use of disposable dishes/utensils for staff and patient meals until (name), our contractor has verified the dishwasher is operating properly and employees have shown competencies.
3. Training and education will be completed by March 2, 2015.
4. Immediate call to internal maintenance.
5. Immediate action taken to notify vendor (name). They instructed CFO (Chief Financial Officer) on how to prime machine and how it is not a heated unit and that the heat comes form the hot water heater. It is to reach 120 degrees.
6. The manufacturer manual was given to the surveyors.
7. The proper process was not followed by BCH (Bath Community Hospital) employee at the time of inspection by surveyor.
8. (Name of Staff # 15) (CFO) went to kitchen to test dishwasher. Using proper process, it tested appropriately using the test strip instructions. The results were well above 50 parts per million.
9. (Name of Staff #15) will provide the proper training on the use of sanitizing/dishwasher to staff on shift February 27, 2015 with documented return demonstration 2/27/15. Interim Dietary Manager is to ensure completion of training of other staff members by March 2, 1035. Sanitation must be completed prior to each use.
10. Log for sanitization test will be implemented immediately.

Correction for 3 (three) compartment sink:
1. Documentation log will be implemented with education to all dietary employees completed by March 2, 2015 with documented return demonstration. Process to be implemented prior to each use.
2. Immediate repair of leak of pipe going to sink was initiated on 2/27/15 at 11:00 a.m.

The surveyor returned to the kitchen at 12:05 p.m., however the repeat testing performed by Staff #15 demonstrated the dishwasher was still not functioning properly and the facility stated that disposable dishes and utensils would be utilized until the vendor had serviced the machine and all staff had been educated and demonstrated competency by March 2, 2015.
The survey team accepted the plan of removal on 2/27/15 at 1:15 p.m.

2. The facility staff also failed to maintain humidity control in anesthetizing locations to provide adequate levels for patient health and safety and failed to ensure that essential equipment located in the operating room was maintained according to the manufacturer's instructions for use (IFU).

Please refer to C0222 and C0226 for further information.

Based on observation, staff interview and facility document review, the facility staff failed to ensure the physical plant environment was maintained in a safe operating condition. The facility dishwasher was not functioning to properly sanitize the dishes and utensils which were being used for patient and staff meals and failed to ensure that essential equipment located in the operating room was maintained according to the manufacturer's instructions for use (IFU). Also, the facility failed to ensure the AED's (automated external defibrillators) in the facility were maintained in safe operating condition.

The failure of the dishwasher to properly sanitize the dishes was identified as Immediate Jeopardy.

The findings included:

1. On 2/27/15 at 9:20 a.m., while inspecting the kitchen area, the surveyor inquired if the dishwasher used heat or chemical or both to sanitize the dishes. Staff # 17 stated , it was "both, chemical and heat". The surveyor asked Staff #17 to run the dishwasher and demonstrate how the checks were done to ensure the dishwasher was functioning properly and sanitizing the dishes. Staff # 17 began to run the machine and stated, "We were told we have to run it three or four times before it gets to temperature." The surveyor observed as Staff #17 ran the dishwasher four times through its cycle. On the next cycle, (fifth run) the surveyor observed the temperature to reach 90 (ninety) degrees for the wash cycle and 100 (one hundred) degrees for the rinse cycle. The surveyor again inquired what the temperature should be for the machine. Staff #17 stated, "It should reach 120 (one hundred twenty) degrees. The local Health Inspector wants it at 120." The surveyor asked Staff #17 to check the chemical sanitization of the machine. Staff #17 took a test strip and placed it in the water in the bottom of the dishwasher tank. The strip was observed for 10 (ten) seconds, as required by the test strip labeling, and there was no observable change, indicating no chemical was present. Staff #17 obtained a new strip and tested the water again. There was no evidence of chemical detected. The surveyor then asked Staff #17 to please repeat the testing after running the machine again with a dish inside and the strip on the plate. Staff #17 ran the machine through the cycle with the test strip inside on the plate and there was no change in the test strip indicating there was no chemical present. Staff #17 then checked the chemical dispenser and stated, "This may be the problem, it is almost out of chemical." Staff #17 proceeded to change the chemical container and ran the machine through the cycle three more times to ensure the chemical was flowing into the machine. The surveyor could observe chemical flowing through the tubing. Staff #17 then tested the machine again by dipping the test strip in the water in the tank inside the machine and the test strip showed no change, indicating no chemical present. At that time the surveyor asked Staff #17 to contact maintenance and administration and inform them of the problem. The surveyor also observed the drain pipe under the three compartment sink had a large plastic container under the elbow to the rinse sink which was almost full of water. Staff #17 stated, "The pipe has a leak and they told me to put a bucket underneath it until they could fix it." The surveyor also asked Staff #17 to review the chemical testing logs for the dishwasher and the three compartment sink. Staff #17 stated, "We do not have any logs. We do not do testing on the dishwasher or the sink..." The surveyor inquired if the dishes or utensils were treated any differently for patients who were on isolation. Staff #17 stated, "No, all the dishes are treated the same." Staff # 12 arrived and stated the machine had a booster placed for the temperature. After running the machine several more times the temperature was observed at 112 for the wash cycle and 116 for the rinse cycle. Staff #12 stated he/she was not familiar with the testing of the chemicals but there should be a manual that explained how that was to be done. Staff #17 stopped the machine in mid-cycle and again checked the water with a new strip and the strip showed no evidence of any chemical. The surveyor asked Staff #17 and #12 to contact administration and inform them of the issue with the dishwasher. Staff #12 stated he/she would also contact (contractor) for service.

On 2/27/15 the survey team met at 9:45 a.m. and reviewed the findings related to the dishwasher/kitchen. Based on team review, the State Agency was consulted at 9:52 a.m. and at 10:27 a.m. the State Agency agreed with the surveyors findings of IMMEDIATE JEOPARDY . On 2/27/15 at 10:30 a.m. the facility Staff #1 and 11 were notified of the Immediate Jeopardy situation and a plan of removal was requested. Staff #15 stated the facility "...used to keep a log for the sink and dishwasher but do not keep one anymore. We haven't used a log for two years..." The survey team discussed with the facility the concern also of two current inpatients who were on contact isolation, one for c-difficile diarrhea* and the other for VRE** (vancomycin resistant enterococcus) and the lack of sanitation of the dishes and utensils for the entire facility including all patients and staff who chose to eat the meals prepared in the kitchen.

The surveyor was provided with the "Installation and Operation Manual- (Brand name or dishwasher) Series Door Type, Chemical Sanitizing single and Dual rack Dishmachines- August 8 2011 (Revision S) from (vendor name)" Page 2 evidenced "Temperatures: Wash (minimum) 120 (degrees) F (Fahrenheit) and Rinse (minimum) 120 (degrees) F (Fahrenheit)." Page 25 documented, "...By following the operating and cleaning instructions in this manual, you should get the most efficient results from your machine. As a reminder, here are some steps to take to ensure that you are using the dishmachine in the away it was designed to work: 1. Ensure that the water temperatures match those listed on the machine data plate...8. Ensure that all chemicals being ejected into the machine have been verified as being at the correct concentrations..."

The facility Policy and Procedure "Isolation Policy: Standard and Transmission-Based Precautions -Reviewed August 2014" evidenced: Special Consideration Items: Isolation food trays-All trays are considered contaminated and are treated the same. Trash is disposed of in the patients room and the tray, dishes, and utensils are placed in a container bin for transport to the dietary department or the dirty utility room...Contact Precautions: Contact or touch is the most common and most significant mode of transmission of infectious agents. Patients in Contact Precautions include those infected or colonized with *Clostridium difficile (c-diff), rotavirus, or other organisms deemed significant by Infection control. Contact transmission can occur by directly touching the patient, though contact with the patient's environment, or by using contaminated gloves or equipment..."

On 2/27/15 at 12:55 p.m., the survey team received the facility plan of removal which documented the following:

Virginia Federal/State Surveyor found chemical/heater dishwasher appearing to not function properly. Strip did not meet minimum required ppm (parts per million) to show that dishwasher was appropriately sanitizing dishes, when tested by the surveyor. (Name of equipment contractor) provided maintenance and tested machine on February 12, 2015 and all results were in compliance.
Immediate jeopardy plan of correction for the dishwasher:
1. Upon meeting with the surveyors, discontinue use of the dishwasher.
2. Instituted use of disposable dishes/utensils for staff and patient meals until (name), our contractor has verified the dishwasher is operating properly and employees have shown competencies.
3. Training and education will be completed by March 2, 2015.
4. Immediate call to internal maintenance.
5. Immediate action taken to notify vendor (name). They instructed CFO (Chief Financial Officer) on how to prime machine and how it is not a heated unit and that the heat comes form the hot water heater. It is to reach 120 degrees.
6. The manufacturer manual was given to the surveyors.
7. The proper process was not followed by BCH (Bath Community Hospital) employee at the time of inspection by surveyor.
8. (Name of Staff # 15) (CFO) went to kitchen to test dishwasher. Using proper process, it tested appropriately using the test strip instructions. The results were well above 50 parts per million.
9. (Name of Staff #15) will provide the proper training on the use of sanitizing/dishwasher to staff on shift February 27, 2015 with documented return demonstration 2/27/15. Interim Dietary Manager is to ensure completion of training of other staff members by March 2, 1035. Sanitation must be completed prior to each use.
10. Log for sanitization test will be implemented immediately.

Correction for 3 (three) compartment sink:
1. Documentation log will be implemented with education to all dietary employees completed by March 2, 2015 with documented return demonstration. Process to be implemented prior to each use.
2. Immediate repair of leak of pipe going to sink was initiated on 2/27/15 at 11:00 a.m.

The surveyor returned to the kitchen at 12:05 p.m., however the repeat testing performed by Staff #15 demonstrated the dishwasher was still not functioning properly and the facility stated that disposable dishes and utensils would be utilized until the vendor had serviced the machine and all staff had been educated and demonstrated competency by March 2, 2015.

The survey team accepted the plan of removal on 2/27/15 at 1:15 p.m.

*Clostridium difficile (C. difficile) is a bacterium that causes inflammation of the colon, known as colitis. People who have other illnesses or conditions requiring prolonged use of antibiotics, and the elderly, are at greater risk of acquiring this disease. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. Clostridium difficile can live for long periods on surfaces. (www.cdc.com/cdifficile accessed 3/10/15 at 1:44 p.m.)
**Enteroccocci are bacteria that are normally present in the human intestines and in the female genital tract and are often found in the environment. These bacteria can sometimes cause infections. Vancomycin is an antibiotic that is used to treat some drug-resistant infections caused by enterococci. In some instances, enterococci have become resistant to this drug and thus are called vancomycin-resistant enterococci (VRE). Most VRE infections occur in hospitals. VRE is often passed from person to person by the contaminated hands of caregivers. VRE can get onto a caregiver's hands after they have contact with other people with VRE or after contact with contaminated surfaces. VRE can also be spread directly to people after they touch surfaces that are contaminated with VRE. VRE is not spread through the air by coughing or sneezing. (www.cdc.com/vre accessed 3/10/15 at 2:17 p.m.)
On 2/27/15 at 4:45 p.m., the survey team met with Staff # 1, 11, 4, and 15 and discussed the concerns. Staff #1 stated disposable dishes and utensils would be utilized until March 2, 2015 when staff were educated and demonstrated competency and (the Vendor/Contractor) had serviced the machine.


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2. During a tour of the OR (operating room) on 2/25/15 with Staff #3, the surveyor asked to review the OR temperature and humidity log. Staff #3 directed the surveyor to a document on the wall entitled "OPERATING ROOM TEMPERATURE AND HUMIDITY LOG". This document provided areas to document date, temperature, humidity, signature and an area for comments. Surveyor review of the document revealed humidity levels ranging from 19-54% documented for the time period of 1/29/14 to 2/24/15. The facility does not provide surgical services daily and as directed in facility policy entitled "TEMPERATURE and HUMIDITY MONITORING POLICY" the humidity and temperature levels were recorded only on days the OR was in use. Also noted in the aforementioned policy the statement, "Humidity in the OR should be between 20-60%." Staff #3 was asked if he/she was aware of any waiver or variance the facility may have obtained and/or documented related to the humidity levels in the OR. He/She (the employee) was not aware of any waiver. During the entrance interview on 2/24/15 and again on 3/2/15, the CEO was asked if the facility had been granted any waivers or variances related to the OR humidity levels the CEO replied that he/she was not aware of any variance or waiver.

The inability of the facility to produce documentation of the facility's election to use the categorical waiver allowing CAHs (critical access hospitals) to maintain relative humidity in OR's at 20% or greater, results in the facility being required to maintain RH (relative humidity) levels in the OR at 35% or greater. As noted above this requirement was not met for twenty (20) of twenty-eight (28) days when the OR was in use and no documentation of any corrective action by the facility was provided to the surveyor.

In conducting a random check of the equipment located in the OR, specifically the instructions for use (IFUs) for equipment in relation to the relative humidity level, it was determined that at least one piece of equipment (the Electrosurgical Unit), had listed under "NORMAL USE & ENVIRONMENTAL RESTRICTIONS" the following statement "Relative Humidity 30% to 75%". For sixteen (16) of twenty-eight (28) days with relative humidity documented the RH was below 30% in the operating room and would be outside of the manufacturer's instructions and/or environmental restrictions for this equipment.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.


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3. An interview with Staff Person #12 and Contracted Staff Persons # 20 and #21, a representative of the agency contracted to perform the facility's equipment maintenance, was conducted by the Medical Facility's Inspectors (MFI's) on at 1:00 PM, During the interview, Staff Person #21 stated that "three of the AED's were given to the hospital by the community and because they are used by the doctor and Nurse Practitioner they often have them off site, and it is sometimes hard to get the maintenance done on those on time. A decision was made to remove those three AED's from the hospital's inventory so that it would not cause problems with compliance."

During the exit conference on 3/9/2015 at 3:15 PM, a discussion was held with Staff Persons # 1,# 4, #11,# 13, and #15 regarding the facility's responsibility to provide preventative maintenance in order to maintain all patient care equipment utilized in provision of patient care services in safe operating condition.

Based on observations by two (2) Medical Facilities Inspectors (MFI's) during a tour of the facility's emergency department on 2/24/2015 between 11:00 AM-11:30 AM, the facility failed to ensure that all supplies and equipment were stored properly.

The findings included:

1. The MFI's observed four (4) boxes of non-sterile gloves stored under the sink in the trauma room.
2. The MFI's observed five (5) boxes of non-sterile gloves, a container of disinfectant, and 3 white plastic body/morgue bags under the sink on the left when entering the exam room located beside the trauma room.
3. The observations made by the MFI's were shared with Staff Person # 4 at the time of discovery.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on observation, interview and document review it was determined that facility staff failed to maintain humidity control in anesthetizing locations to provide adequate levels for patient health and safety.

The findings include:

During an observation of the OR (operating room) on 2/25/15 with Staff #3, the surveyor asked to review the OR temperature and humidity log. Staff #3 directed the surveyor to a document on the wall entitled "OPERATING ROOM TEMPERATURE AND HUMIDITY LOG". This document provided areas to document date, temperature, humidity, signature and an area for comments. Review of the document revealed humidity levels ranging from 19-54% documented for the time period of 1/29/14 to 2/24/15. The facility does not provide surgical services daily. As directed in facility policy entitled "TEMPERATURE and HUMIDITY MONITORING POLICY" the humidity and temperature levels were recorded only on days the OR was in use. Of the 28 (twenty-eight) dates with documentation it was noted that on twenty (twenty) of those dates the humidity level in the OR was below 35% with one day recorded at 19%. Staff #3 was asked what he/she would do if the temperature and/or humidity levels were out of range. He/she replied that maintenance would be contacted. The OR "TEMPERATURE AND HUMIDITY LOG" contained no documentation of any contact with maintenance or any corrective action. Staff #3 was asked if he/she was aware of any waiver or variance the facility may have obtained related to the humidity levels in the OR, he/she (Staff #3) was not aware of any waiver being obtained. The facility CEO was also asked if the facility had been granted any waivers or variances during the entrance interview on 2/24/15.

On 3/2/15 during a meeting with Staff #12 the facility's maintenance manager, the question of whether the facility had any waiver or variance in place concerning the humidity level in the OR. Staff #12 stated that he/she had no knowledge of any and suggested the surveyor ask Staff #3. Staff #12 was asked what he/she would do if notified of any humidity and/or temperature levels that were outside of the guidelines, he/she replied that the manufacturer of the air/ventilation system would be contacted. When Staff #12 was asked how it was determined what the humidity level should be in the OR, he/she said that it was just what the system runs.

The inability of the facility to produce documentation of the facility's election to use the categorical waiver allowing CAHs (critical access hospitals) to maintain relative humidity in OR's at 20% or greater, resulted in the facility being required to maintain RH (relative humidity) levels in the OR at 35% or greater. As noted above this requirement was not met for 20 of 28 days when the OR was in use and no documentation of any corrective action was provided to the surveyor.

On 3/2/15 in the afternoon, facility CEO was again asked about the election to use a variance or waiver related to the RH in the OR, he/she stated that he/she had no knowledge of this.


On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

This Condition is not met due to the systematic nature of the standard level deficient practices related to the implementation of policies and procedures and practices regarding:

Emergency Services as cited in:
485.618 (b)(2) C0204- Equipment and Supplies

PHYSICAL PLANT as cited in:
485.623(b) C0222- Maintenance
485.623(b)(4) C0225- Premises clean and orderly
485.226(b)(5) C0226-Proper ventilation/light/temperature

PROVISION OF SERVICES as cited in:
485.635(a)(3)(iv) C0276- Storage, handling, dispensation and administration of drugs and biologicals.
485.635(a)(3)(vi) C0278- Patient Care Policies- Infection Control
485.635(a)(3)(vii) C0279 - Meeting Nutritional Needs
485.635(b)(4) C0284 - Emergency Procedures
485.635(c)(4)(ii) C0292 - Contractor Services comply with CoPs and standards
485.635(d),(d)(1) C0294- Nursing Services
485.635(d)(3) C0297 - Drugs in accordance with written and signed orders, acceptable standards of practice and Fed/State law.


CLINICAL RECORD requirements as cited in:
485.638(a) C0301-Maintained in accordance with Policies and Procedures
485.638(a)(2) C0302-Legible, complete, accurately documented, readily accessible, systematically organized.
485.638(a)(4)(iii) C0306- Information necessary to monitor patients condition and progress
485.638(a)(4)(iv) C0307-Dated signatures of orders

SURGICAL SERVICES as cited in:
485.639- C0320 -Surgical Services

PERIODIC EVALUATION as cited in:
485.641(b) C0336 - Quality Assurance

SPECIAL REQUIREMENTS FOR CAH (SWING BEDS) as cited in:
485.645 C0350- Special Requirements
485.645(d)(3) C)384- Staff Treatment of Residents
485.645(d)(4) C0385-Activities
485.645(d)(6) C0395-Comprehensive Care Plans
485.645(d)(6) C0397- Professional Standards of Quality
485.645(d)(9) C0400-Nutrition

Based on observations, clinical record review, staff interview, facility document review and the survey findings, it was determined the Governing Body failed to ensure the quality and services provided by the facility was monitored and implemented.

The findings included:

During the validation survey conducted 2/24 through 2/27 and 3/2 through 3/4 and 3/9/15, the survey team identified multiple areas of deficient practice throughout the facility areas.

On 3/9/15 at 1:00 p.m., Staff #11 stated, "We have had a huge turnover here in administration and there has been a disassociation of the board and the staff...for a year I have been trying to tell them the documentation is lacking and that it affects patient care..."

The survey team inquired as to how the facility was overseeing and reporting to the Governing Body. Staff #11 stated, "We have had a disassociation with the board that needs to be resolved..."

On 3/9/15 at 3:30 p.m., the survey team discussed the multiple concerns regarding the survey findings including the Immediate Jeopardy in the kitchen with Staff #1, 4, 11, 13, and #15.

This Condition is not met due to the systematic nature of the standard level deficient practices related to the implementation of policies and procedures and practices regarding PROVISION OF SERVICES as cited in:

485.635(a)(3)(iv) C0276- Storage, handling, dispensation and administration of drugs and biologicals.
485.635(a)(3)(vi) C0278- Patient Care Policies- Infection Control
485.635(a)(3)(vii) C0279 - Meeting Nutritional Needs
485.635(c)(4)(ii) C0292 - Contractor Services comply with CoPs and standards
485.635(d),(d)(1) C0294- Nursing Services
485.635(d)(3) C0297 - Drugs in accordance with written and signed orders, acceptable standards of practice and Fed/State law.

Based on observations made by the Medical Facility Inspector (MFI) while touring the physical plant, as well as staff and patient interviews, the facility failed to ensure that the rules for the storage, handling, dispensation and administration of drugs was followed for 2 (two) of 23 (twenty-three) Patients of the survey sample, Patient #6 and Patient #22, and that outdated medications were not available for use.

The findings included:

1. While touring the physical plant on 2/25/2015 at 9:45 AM, the MFI observed an unlabeled container of over-the-counter (Brand name) Ointment and an unlabeled bottle of "Rx only" (prescription only) Betamethasone Valerate lotion 1% in the bathroom on a shelf over the sink in the room of Patient #6. Patient #6 was admitted as an observation patient on 2/18/2015. During an interview, Patient #6 stated to the MFI, "That's my medicine from home, I'll take it with me when I go, it's for my eczema". Staff Person #7 was interviewed regarding storage and use of a patient's own medications from home and stated, "Patient's can bring medications from home, we keep them in our medication cart in their drawer and put their name on it. If the pharmacist is here, they take care of labeling the medication and adding it to the EMAR (electronic medication administration record); if the pharmacist is not in the hospital, the nurse checks the Facts and Comparison on the computer then puts the patients name on it and adds it to the EMAR." These findings were discussed with Staff Person #4 at the time of discovery.

The facility's policy and procedure for "Use of Patient's Own Medications- Revised 2/2014" was reviewed by the MFI, and was as follows: 1. It is prohibited for patients to use their own medication or for the nurse to administer a patient's own medication, prescription, over the counter drugs as well as vitamins and herbal products during a hospital stay. (see exception.) 2. Exceptions: A. A patient may continue to take her own birth control pills and his/her own eye drops, or multi dose container medications, (examples include eye drops, inhalers, ear drops). The nurse will insure (sic) that pt/family is aware and able to self administer the medications and will ensure that patient/family is correctly taking these medications. If there are medicines that are not on the hospital formulary, and the physician desires to continue those medications here, he will need to write a specific order for this to occur. These medications will not be stored in patient's room. B. Another exception could be if the patient is observation status. If the physician writes an order, patient may use own medications from home. C. A physician's order must be written in the chart for a patient to take his own med (medication). D. The medication will be sent to pharmacy for identification and visually inspect its integrity. If the pharmacy is closed, the physician or nursing personnel must identify the medication, using the Facts and Comparison's online identification product and inspect its integrity. Nursing must document in the MedAct that this has been completed for each medication to be used. E. The product must be labeled appropriately and within a good use date, and clean. F. The medication may be stored in the pharmacy and prepared in unit dose formulation for dispensing or located in the medication cart in the specific patient's drawer. If the medication is a bulk item, it will be stored in the medication cart with the rest of the medications for each patient. G. If this is after hours, the medication once identified by the physician or nurse, can be stored in the medication cart with the patient's other medications. Pharmacy will retrieve once open and unit dose the supply if needed. H. If a patient or family member brings in a patient's medication(s) upon admission to the hospital, the medications will be sent back home with the family member. BCH (abbreviation for the hospital) will not store a patient's home medications on a routine basis. I. If it is necessary to store these medications, the nurse will document all medications, counting narcotics if any, and store in the secured medication room. The patient will acknowledge the list and sign where indicated. The medications will be given back to family or patient upon discharge. If any of the medication(s) have been discontinued during the patient's stay, this will be brought to the attention of the patient or family member upon discharge. J. In some cases, patients may administer their own medications, such as insulin pumps and other specialty medications.

Patient #6's medical record was reviewed and lacked documentation that he/she had been assessed as being able to self administer medications or that the medications were being used correctly. There was no physician order for the medications observed in Patient #6's room, the medications were not labeled with Patient #6's name, and the medications were not listed on the 5 day M.A.R.(medication administration record) from 2/18/15 00:00 to 2/22/15 24:00 or the M.A.R. dated 2/23/15 00:00 to 2/25/2015 24:00. These findings were discussed with Staff Person #4 at the time of the discovery.

2. While conducting an audit of the facility's medication room, 2 MFI's observed a yellow envelope labeled with Patient #22's name which contained medications brought to the hospital with the patient on admission on 2/12/2015. Patient #22, no longer a patient, was transferred to a higher level of care on 2/18/2015. Per the facility's policy and procedure, the medications should have been returned to the family or patient upon discharge from the hospital. The observation was discussed with Staff Person #4 upon discovery. Further observation of the facility's medication room and medication refrigerator on 2/25/2015 at 10:45 AM, revealed an open box of Brovana 15 mcg (micrograms)/2 ml (milliliters) nebulizers containing an open foil pouch with one dose for Patient #22, date of admission 2/12/2015. The box had a pharmacy sticker stating "Do not use after 2/17/2015. Patient #22 was transferred to a higher level of care on 2/18/2015. This observation was discussed with Staff Person #4 upon discovery.

3. While conducting an audit of the facility's medication room on 2/25/15 at 10:45 a.m., the MFI's observed multiple single use packets of "EZ lubricating jelly" which expired in 12/2014, a single 10 cc (cubic centimeter) saline flush which had been removed from the protective plastic covering, a needle which had been removed from the protective packaging, a blue top tube used for blood collection which expired 11/2014, and 3 expired SST (serum separator tubes) used for blood collection which expired 1/2015. Staff Person #4 was made aware at the time the items were discovered.


On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on observation, staff interview and facility document review, the facility staff failed to ensure proper infection control policies and guidelines were followed for 3 (three) of 23 (twenty-three) patients of the survey sample, Patient #4, #5 and #6. Also, the facility did not follow guidelines for proper kitchen sanitation regarding the monitoring of the dishwasher and sink for correct temperature/chemical sanitation. This resulted in a finding if Immediate Jeopardy (IJ). (Please see C0220 and C0222 for further information regarding the specifics of the IJ finding.) Also, the facility staff failed to (a) implement a cleaning schedule as recommended by manufacturer for equipment used in outpatient physical therapy and (b) separate clean from dirty supplies used for patient care.

The findings included:

1. On 2/25/15 at 8:44 a.m. the surveyor observed a pile of sheets and towels on the floor at the inside entrance to room for Patient #5. Upon further observation, Staff # 31, who was in the room, came to the pile of linens and picked them up off the floor holding them against his/her body and underneath his/her chin. Staff #31 was observed to place the linens in a container marked "soiled" linen.

The facility policy and procedure for "Bedmaking" evidenced: (in part) "Place soiled linen in laundry bag...Avoid contamination of your uniform by handling dirty linen away from your body..."

On 2/25/15 at 11:55 a.m. Staff # 5 was observed to walk down the hallway carrying a lunch tray. Staff #5 was observed to enter the room of Patient #5 whose door was clearly marked with signage that the patient was on contact isolation and contained a rack over the door for gowns, gloves, and masks (PPE- personal protective equipment). Staff #5 did not don any PPE but entered the room and was observed through the open door to go to the bedside of Patient #5 and place the tray on the overbed table. Staff #5 was observed to move items off the overbed table, without gloves or other PPE. Staff #5 was observed to move a washbasin, tissues and a plastic cup. Staff #5 walked over to the other side of the bed and adjusted the pillow of Patient #5, then came out of the room. On the way out of the room, Staff #5 was observed to rub his/her hands with hand sanitizer. Staff #5 then walked to the storage room door and pressed in the entrance code and entered the storage room. He/She immediately came back out carrying a package of yellow isolation gowns and proceeded to Patient #5's room and after opening the package of gowns, placed the gowns in the slot in the rack on the door. Staff #5 was then observed to don the yellow gown and gloves and re-enter Patient #5's room and began to assist the patient with the lunch meal.


Review of the clinical record for Patient #5 revealed the patient was admitted on on 2/21/15. On 2/23/15, Patient #8 had a positive c-difficile test result after experiencing diarrhea.
(Clostridium difficile (C. difficile) is a bacterium that causes inflammation of the colon, known as colitis. People who have other illnesses or conditions requiring prolonged use of antibiotics, and the elderly, are at greater risk of acquiring this disease. The bacteria are found in the feces. People can become infected if they touch items or surfaces that are contaminated with feces and then touch their mouth or mucous membranes. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. Clostridium difficile can live for long periods on surfaces. www.cdc.com/cdifficile accessed 3/10/15 at 1:44 p.m.)
The facility Policy and Procedure "Isolation Policy: Standard and Transmission-Based Precautions -Reviewed August 2014" evidenced: Contact Precautions: Contact or touch is the most common and most significant mode of transmission of infectious agents. Patients in Contact Precautions include those infected or colonized with Clostridium difficile (c-diff), rotavirus, or other organisms deemed significant by Infection control. Contact transmission can occur by directly touching the patient, though contact with the patient's environment, or by using contaminated gloves or equipment...Healthcare workers caring for patients in Contact Precautions must: Out on gloves before entering the room. Put on a disposable gown prior to entering the patient's room when direct contact with the patient or the patient's environment is anticipated. Remove and discard gloves and clean hands before leaving the patient's room or in a semiprivate room before leaving the patients immediate vicinity...Organisms Requiring Transmission-Based Precautions: C-difficile: Precautions- Contact. Duration of Precautions: Until diarrhea resolves. Comment: Hand hygiene with soap and water not alcohol gel."

On 2/25/15 at 4:00 p.m., Staff # 1, 4, and 11 were made aware of the observations.
2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. For the 1/30/15 admission, Patient #4 was "discharged" from the swing bed and admitted into the acute inpatient status due to a diagnosis of flu. Rapid Flu A/B testing ordered 1/30/15 revealed a positive result. The surveyor was unable to locate any physician order for the patient to be placed on isolation status until 2/3/15 when an order for "Isolation Droplet" was obtained.
On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative Staff #1, 4, 11, and 13, and 15.


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3. During observation of outpatient physical therapy department on 3/4/15, it was noted that two (2) Hydrocollator Heating Units were in use. These units have an immersion type heating element which maintains heated water in which pads are immersed. The unit is designed to provide a ready supply of heated pads to be used in therapy.

When the physical therapy director (Staff # 14) was asked to provide the log documenting the cleaning of the Hydrocollator units, he/she stated that there was no record kept of the cleanings but that it was completed frequently. Review of the user manual for the unit revealed the following statement "The tank should also be drained, cleaned and inspected at minimum intervals of every two weeks." Staff #14 stated that a log would be obtained and records would be kept of cleaning from this point forward.

4. During observation of supplies used to administer Dexamethasone (a medication used to treat inflammatory conditions), an open 5ml syringe with a blunt fill needle was noted to be stored with unopened supplies. This 5ml syringe was not labeled but appeared to have been stored there for some time as the dosage lines on the syringe were beginning to fade. This finding was confirmed with Employee #14 who immediately removed the syringe and disposed of it.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.


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5. On 2/25/2015 at 9:45 AM, while interviewing Patient #6, the MFI observed a heparin lock used for intermittent IV ( intravenous) drug administration in his/her lower right forearm which was covered by a clear dressing. The dressing was not dated and did not include the patient's name, the signature of the person who inserted the access, or the date and time of placement. Patient #6, date of admission 2/18/2015, was alert and oriented, and a good historian of the hospital stay, during the interview, when asked when the IV (intravenous) access had been placed, stated "they put that in when I came in, it's been there since last Wednesday. It doesn't hurt so they left it in". Staff Person #8 was interviewed on 2/25/2015 at 10:15 AM regarding the hospital policy for IV access and stated "We change IV's every 3 days, but if they are patent and no problems like redness or pain, we get a leave order, especially for patients who are hard sticks. We write the date and initials on the dressing when accessed". The medical record for Patient #6 did not include an order to leave the IV access for more than 3 days. The findings were discussed with Staff Person #4 on 2/25/2015 between 1:00 PM and 2:00 PM.

The facility's policy and procedure titled Needleless IV System revised 9/2014 addressed IV sites in the following way: "IV sites are to be changed every 72 hours, a Physicians order must be obtained to extend the 72 hours. IV tubing is to be changed every 72 hours. IV sites and tubing are to be labeled with patient's name, date, time, nurses signature. IV sites and tubing should be changed if any question of infiltration, redness or contamination.".

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on observation, staff interview, facility document and policy review, the facility staff failed to ensure guidelines for acceptable kitchen sanitation were developed/followed resulting in a finding of IMMEDIATE JEOPARDY on 2/27/15 at 10:27 a.m. after consultation with the State Agency.

The findings included:

On 2/27/15 at 9:20 a.m., the surveyor toured/inspected the facility kitchen. The surveyor inquired if the dishwasher used heat or chemical or both to sanitize the dishes. Staff # 17 stated it "was both, chemical and heat". The surveyor asked Staff #17 to run the dishwasher and demonstrate how the checks were done to ensure the dishwasher was functioning properly and sanitizing the dishes. Staff # 17 began to run the machine and stated, "We were told we have to run it three or four times before it gets to temperature." The surveyor observed as Staff #17 ran the dishwasher four times through its cycle. On the next cycle, (fifth run) the surveyor observed the temperature to reach only 90 (ninety) degrees for the wash cycle and 100 (one hundred) degrees for the rinse cycle. The surveyor again inquired what the temperature should be for the machine. Staff #17 stated, "It should reach 120 (one hundred twenty) degrees. The local Health Inspector wants it at 120." The surveyor asked Staff #17 to check the chemical sanitization of the machine. Staff #17 took a test strip and placed it in the water in the bottom of the dishwasher tank. The strip was observed for 10 (ten) seconds, as required by the test strip labeling, and there was no observable change, indicating no chemical was present. Staff #17 obtained a new strip and tested the water again. There was no evidence of chemical detected. The surveyor then asked Staff #17 to please repeat the testing after running the machine again with a dish inside and the strip on the plate. Staff #17 ran the machine through the cycle with the test strip inside on the plate and there was no change in the test strip indicating there was no chemical present. Staff #17 then checked the chemical dispenser and stated, "This may be the problem, it is almost out of chemical." Staff #17 proceeded to change the chemical container and ran the machine through the cycle three more times to ensure the chemical was flowing into the machine. The surveyor could observe chemical flowing through the tubing. Staff #17 then tested the machine again by dipping the test strip in the water in the tank inside the machine and the test strip showed no change, indicating no chemical present. At that time the surveyor asked Staff #17 to contact maintenance and administration and inform them of the problem. The surveyor also observed the drain pipe under the three compartment sink had a large plastic container under the elbow to the rinse sink which was almost full of water. Staff #17 stated the "Pipe has a leak and they told me to put a bucket underneath it until they could fix it." The surveyor also asked staff #17 to review the chemical testing logs for the dishwasher and the three compartment sink. Staff #17 stated, "We do not have any logs. We do not do testing on the dishwasher or the sink..." The surveyor inquired if the dishes or utensils were treated any differently for patients who were on isolation. Staff #17 stated, "No, all the dishes are treated the same." Staff # 12 arrived and stated the machine had a booster placed for the temperature. After running the machine several more times the temperature was observed at 112 for the wash cycle and 116 for the rinse cycle. Staff #12 stated he/she was not familiar with the testing of the chemicals but there should be a manual that explained how that was to be done. Staff #17 stopped the machine in mid-cycle and again checked the water with a new strip and the strip showed no evidence of any chemical. The surveyor asked Staff #17 and #12 to contact administration and inform them of the issue with the dishwasher. Staff #17 stated he/she would also contact (contractor) for service.

On 2/27/15 the survey team met at 9:45 a.m. to discuss the above findings. Based on team review, the State Agency was consulted at 9:52 a.m. and at 10:27 a.m. the State Agency agreed with the surveyors findings of IMMEDIATE JEOPARDY . On 2/27/15 at 10:30 a.m. the facility Staff #1 and 11 were notified of the Immediate Jeopardy situation and a plan of removal was requested. The survey team discussed with the facility the concern also of two current inpatients who were on contact isolation, one for c-difficile diarrhea and the other for VRE (vancomycin resistant enterococcus) and the lack of sanitation of the dishes and utensils for the entire facility including all patients and staff who chose to eat the meals prepared in the kitchen. (Please refer to C0222 for further information).

The surveyor reviewed a document "Dietary Dishwasher/Pot & Pan Sink Temperature Log. This document was to record the wash cycle temperature, rinse cycle temperature, pot and pan sink and test strip results for each use (breakfast, lunch and dinner). On 2/27/15 at 10:30 a.m., Staff #15 stated the facility "...used to keep a log for the sink and dishwasher but do not keep one anymore. We haven't used a log for two years..."

The surveyor requested the facility policy and procedures for use of the three compartment sink and kitchen sanitation on 3/4/15. On 3/9/15 the surveyor reviewed the policy "Emergency Dishwashing" this was the policy given to the surveyor for the use of the three compartment sink. The policy did not describe the daily use of the sink or chemical testing only "Fill sink #3 with hot water and sanitizing agent per product instructions..." The facility policy "Food and Nutrition Services- Sanitation Program" evidenced: Purpose: To maintain a clean, safe, and effective environment of care, and to prevent the transmission of disease-carrying organisms. Policy: The Food and Nutrition Services Department maintains a sanitation program. Procedure: 1) The Certified Dietary Manager monitors sanitizing schedules and procedures. Equipment, walls and floors and storage areas are routinely cleaned with the appropriate sanitizing compounds. 2) Reference local and state sanitation requirements to be in compliance. 3) A copy of the Sanitation Schedule is posted in the kitchen." This was the complete policy.

During the interview with Staff # 11 regarding the Quality Assurance program for the facility on 3/9/15 at 1:00 p.m., Staff #11 stated the Dietary Consultant does a "monthly checklist and report'. The surveyor requested to inspect the previous three months of these "reports" submitted by the Consultant. On 3/9/15 at 3:00 p.m., Staff #11 stated, "Here is the form that he/she is supposed to complete, but after contacting the (director) he/she (consultant) has not been doing them. The (director) stated he/she (the consultant) will start doing these immediately." The document "Consultant Dietitian Monthly Report Checklist" contained a specific area for the monitoring of "dishroom sanitation" which included "procedures ensure dishes and utensils are clean & sanitized" and "wash temp is >140 (greater than) & rinse temp is >180 degrees and recorded..." This document was dated 12/12/2010.

The findings and concerns were discussed with facility administration on 2/27/15 at 4:45 p.m., and further discussion was held on 3/9/15 at 3:15 p.m.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on a review of Staff Person # 29's personnel record, the facility's policy and procedure for activities and activity assessment, the facility failed to ensure that the staff person contracted as director of activities enabled the CAH (critical access hospital) to comply with all applicable conditions of participation and standards for the contracted services.

Findings included:

1. The MFI reviewed the facility's swing bed activity policy and procedure, last reviewed August 2010, which states "It is the policy of (the facility) to provide an on going monthly program of activities which meets the needs of the patients, is part of the care planning process and is directed by an activity coordinator that works with hospital staff and the community in developing the program". Seven (7) patients whose records were reviewed revealed multiple issues, including Interdisciplinary Team Meeting (IDT) documents had not been completed for the activities section, initial interviews which did not include an activity assessment, the activity calendars did not include times that programs were offered, there was no documentation that scheduled activities had been offered to patients, or that scheduled activities had been refused. The facility's activity policy and procedures stated "Documentation for activities. The activity coordinator will complete for each resident an activity assessment, care plan complete with identification of needs, measurable patient oriented goals and detailed approaches and progress notes that indicate progress toward the goal indicated in the care plan. Daily progress notes will also be written to indicate involvement and response toward the care plan goal. The activity director will attend the interdisciplinary care plan meeting helping to orient the other participants as to the need for and value of activities.". Records reviewed did not include daily progress notes by the activity director. Nor evidence the activity director or representative was attending the Interdisciplinary Team Meetings.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the clinical record contained information that was accurately documented for 2 (two) of 23 (twenty-three) patients of the survey sample. Patient # 12 and #4.

The findings included:

1. The clinical record for Patient #12 was reviewed on 3/4/15. Patient #12 was admitted to swing bed status on 1/15/15 from acute inpatient care. The "Nurse's Note" on 1/15/15 documented, "...duoderm (hydrocolloid dressing) to left and right buttock areas. Pt (patient) c/o (complained of) pain in bottom- repositioned on side with pillow behind pt (patient)..." The surveyor, along with assistance from facility staff (Staff # 4 and 13) who were navigating the electronic medical record, were unable to locate any descriptive assessment or documentation of measurements of the wounds. The physician's "History and Physical" dated 1/15/15 documented "Sacral decubitus ulcer...daily wound care..." And on 1/16/15 there was a physician's order for "wound care". Neither the surveyor or the staff navigator was able to locate in the electronic medical record, any specific physician's orders for wound care, no wound measurements or description, and the care plan was not individualized for the patient's skin condition and care of same. The "care plan" documented: assess location/extent of impairment, monitor appearance/character of skin, follow procedures for wound drainage, maintain aseptic tech/w (technique with) dressing change, follow protocol for tx (treatment of decubitus) and Maintain nutritional support" There was no documentation of the assessment of the skin and there was no order for a consult with the facility dietitian due to Patient #12's impaired skin integrity. No pictures of the wound was found in the clinical record.

There was documentation on 1/18/15 in the "Nurse's Notes" of: "...stage 2 decubitus ulcer to bilateral buttocks..."

The facility policy and procedure "Wound Care" was reviewed. This document was a one page document which evidenced Routine Orders for Wound Care: 1. A wound care assessment is to be completed on all patients admitted to the Med/Surg (Medical Surgical) floor. 2. Photographs of all wounds are to be taken after a consent form has been completed by the patient or patients representative. Stage 1: 1. Cover and protect (keep contaminants off, protect from friction) 2. Add moisture to epidermis. Products: 1. Moisturizers-Aloe Vesta Skin Cream or Zinc Oxide. 2. Lubricating spray/ointment-Granulex spray. 3. Transparent adhesive dressing-Tegaderm or op-site. (These films will help decrease friction, provide semi-permeable sterile but moist environment, and enable autolysis.) Procedure: Notify Physician for plan of care for wound treatment and document in CSPI Nursing Assessment Flow Sheet."

The Policy and Procedure for "Decubitus Ulcer Prevention" was reviewed and evidenced it had not been updated to reflect the National Pressure Ulcer Advisory Panel Guidelines for staging since 2003 (last update for NPUAP 2007) even though the policy documented a review date of May 2014.

When interviewed further regarding the lack or wound care orders, incomplete policy, lack of individualized care plan and out of date decubitus staging protocols on staff #4 stated, 3/4/15 at 1:25 p.m. "Well we go by Lippincott for things not covered in our policies..."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. According to documentation on 12/28/14, Patient #4 had an order for "Wound Care" from the physician. The surveyor was unable to locate any specific orders, or order clarification for the "wound care" order. On 3/3/15 at 12:45 p.m., Staff #4 stated he/she was unable to locate in the clinical record any orders for specific wound care for Patient #4. There was no individualized wound care- care plan for Patient #4 found in the clinical record.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on clinical record review and staff interview, the facility staff failed to ensure verbal/telephone orders for medications were signed timely by the physician for 8 (eight) of 23 (twenty-three) patients of the survey sample. Patient #4, 5, 12, 15, 19, 3, 8, and 6.

The findings included:

1. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. On 12/29/15 the patient complained of pain and a verbal/telephone order was received for "Hydrocodone/Apap 5/325 (schedule II narcotic pain reliever) one PO (by mouth) PRN (as needed) Q6h (every six hours)". According to documentation in the electronic medical record the status of the order was "signed: pending", indicating as of the date the chart was reviewed by the surveyor (3/3/15) the order had not been signed by the physician. Patient #4 also had a verbal/telephone order for Xanax(an anti-anxiety medication) 0.5 mg (milligrams) PO (by mouth) BID (twice a day) PRN (as needed) which was ordered on 12/31/15, but was not signed until 1/25/15. Another verbal/telephone Xanax order was documented on 1/1/15 and not signed until 1/23/15. Patient #4 had Morphine (schedule II narcotic pain reliever) 2mg IVP (intravenous push) ordered (verbal/telephone order) on 1/3/15 that was not signed until 1/23/15 an Oxycodone (schedule II narcotic pain reliever) 5mg Q4h (every four hours) PRN (as needed) which was ordered 1/4/15 and not signed until 1/23/15.

2. Patient #5's clinical record was reviewed on 3/2/15 and revealed the patient was admitted 2/21/15 (acute inpatient). On 2/21/15 a telephone/verbal order was received for Tylenol 650mg Q6h PRN PO (every six hours as needed by mouth) for temperature or pain and was not signed until 2/24/15.


3. The clinical record review on 3/2/15 for Patient #12 revealed the patient was admitted on 1/9/15 (acute inpatient) through 1/15/15 and then to swing bed status on 1/15/15 through 1/21/15. On 1/9/15 an verbal/telephone order was received for Tylenol 325mg (milligrams) 650mg (milligrams) PO (by mouth) Q6H PRN (every six hours as needed. The order was not signed by the physician until 1/23/15. On 1/11/15 a verbal/telephone order for Lasix (a diuretic) 40mg IVP (Intravenous push) was received. The order was not signed until 1/23/15. On 1/17/15 Patient #12 received a verbal/telephone order from the physician for Heparin (anticoagulant-blood thinner) 5000 units/ml (units per milliliter) sub-q (subcutaneous injection) BID (twice daily). The order was not signed until 1/25/15. Also on 1/17/15, Ondansetron (Zofran- an anitemetic) was ordered (verbal/telephone) to be administered 4mg PO (four milligram by mouth) PRN Q6H (as needed every six hours). This order was not signed until 1/25/15.

4. Patient #15's clinical record was reviewed on 3/4/15 and revealed the patient was admitted on 2/2/15 to swing bed status (transfer from another acute care hospital). Patient # 15 had a verbal/telephone order on 2/3/15 for Metoprolol Tartrate ( Lopressor-antihypertensive) 25mg (milligrams) 12.5mg (milligrams) PO (by mouth) BID (twice a day). The order was not signed by the physician until 2/7/15. On 2/19/15 a verbal/telephone order was entered for Furosemide (Lasix-diuretic) 40mg X1 (administer one time) PO (by mouth). The order was not signed until 3/4/15.

5. The clinical record for Patient #19 was reviewed on 3/4/15 and revealed the following medication orders which were not signed timely:
12/23/14 phone order Lorazepam (antianxiety agent) 2mg/ml (milligrams per milliliter) injection 1ml ( one milliliter) IVP (Intravenous push) X1 (one time) not signed until 1/23/15.
12/23/14 phone order for Lorazepam 0,25mg (milligrams) IVP X1 not signed until 1/23/15.
12/14/14 verbal order for Santyl (a debrieding ointment) 250U/GM ( two hundred fifty units per gram) 1 (one) APP (application) daily TOP (topically) not signed until 1/23/15
12/24/14 verbal order for Bacitracin oint (ointment) 0.9gm (grams) UD (unit dose) 1 (one) APP daily to R (right) shin daily with dressing change not signed until 1/23/15
12/24/14 verbal order for Anucort HC (hydrocortisone- anti-inflammatory) 25mg SUPP (suppository) 1 (one) suppository rectally BID (twice a day) not signed until 1/23/15
12/14/14 phone order for Metronidazole (antibiotic medication) IVPB (intravenous piggy back) 500mg /100ml (five hundred milligrams per one hundred milliliters) Q6H (every six hours) not signed until 1/23/15
12/24/14 phone order for Vancomycon 125mg capsule PO (orally-by mouth) QID (four times a day) not signed until 1/23/15
12/12/14 verbal order for Lovenox (a blood thinning agent) 30mg (milligrams) sub-q (subcutaneous injection) Q24H (every 24 hours).

Review of the "Rules and Regulations of the Medical Staff and its Allied Health Practitioner Staff" which was dated as being reviewed January 2014, revealed: PATIENT CARE/ORDERS - 1. ...Verbal/Telephone orders- All orders for treatment must be in writing or electronic with the exception of the following situations: A. If provided by telephone to a registered nurse or licensed practical nurse and signed by the ordering physician within 24 (twenty-four) hours. B. If given to a professional member of the following departments and signed by the ordering physician within 24 hours: Laboratory, Respiratory Care, Radiology, Rehabilitation Services, Pharmacy, Registered Dietitian. All verbal/telephone orders must be verified. The staff member who received the verbal order must read the complete order back to the physician for verification and the physician must verbally confirm that the order is correct, and must sign and verify the order within 24 hours...."

The facility Policy and Procedure "Orders for Patient Care- Effective Date August 2014" revealed: "...Signing, Dating and Timing of orders for Patient Care- All orders shall be reviewed, verified and signed by the provider within 72 hours (seventy-two) of generation. These orders will be signed via e-signature in the electronic medical record, which allows for automatic date and time stamping. If orders are hand signed, they must be dated and timed..."

On 2/26/15 at 3:40 p.m., the survey team discussed the discrepancy between the Medical Staff Rules and the facility policy and procedure and requested clarification. Staff # 11 stated the policy was for 72 hours, but that the facility recently had discussed the need for the 24 hour signing.

On 2/27/15 at 4:05 p.m., the survey team discussed with Staff 1, 11 and #4, how information or recommendations for policy/procedures would go from the medical staff to the facility and vice versa. Staff #1 stated the information would be given to the DON (Director of Nursing) from the Medical Staff and then taken to the CIC (Continuous Improvement Committee- QA) for review and approval and then put into policy and them out for staff education.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns regarding the signing of verbal/telephone orders with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 10:30 a.m., Staff #7 was interviewed regarding the signing of verbal and telephone orders. Staff #7 stated, "If we receive a verbal or telephone order, it must be read back to the physician for verification and the physician has to sign it within 24 hours..."


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6. During a review of Patient #3's medical record, the MFI noted a phone order dated 12/28/2014 for Haloperidol (Haldol) 0.5 mg, directions take 1 (one) B.I.D. (twice daily) P.O. (by mouth) PRN (as needed) with a "pending" signature. Based on an interview with Staff Person #13, "pending" means the order was not signed. Also Patient #3's medical record contained a verbal order dated 12/24/2014 for Nystatin/ZNO/HC (Greers Goo) 30 GM (grams), directions 1 application P.R.N. topically to affected area. The order was documented as signed on 1/25/2015, more than one month after written, and 6 (six) days after Patient #3 was discharged.

7. During a review of Patient #8's medical record, the MFI noted a phone order dated 2/22/2015 for Ondansetron (Zofran) 4 mg (milligrams)/2 ml (milliliters), directions 4 mg IVP (Intravenous push) P.R.N. every 6 hours for nausea/vomiting with a "pending" signature. Based on an interview with Staff Person #13, "pending" means the order was not signed.
The MFI also noted a phone order dated 2/22/2015 for Ondansetron (Zofran) 4 mg ODT tablet for nausea/vomiting, directions 4 mg P.O. every 6 hours P.R.N. with a "pending" signature. Based on an interview with Staff Person #13, "pending" means the order was not signed.

8. During a review of Patient #6's medical record, the MFI noted phone orders dated 2/18/2015 for Guaifenesin S/F (Robitussin) 100 mg/5 ml, directions 5 ml P.O. every 6 hours for cough/congestion, and Temazepam (Restoril) 15 mg, directions 15 mg P.R.N. at bedtime for insomnia with a "pending" signature. Based on an interview with Staff Person #13, "pending" means the order was not signed. Patient #6's medical record also contained phone orders dated 2/20/2015 for Amlodipine (Norvasc) 10 mg, directions take 10 mg daily and Zolpidem (Ambien) 5 mg, directions, take 5 mg P.R.N. bedtime for insomnia with a "pending" signature. Based on an interview with Staff Person #13, "pending" means the order was not signed.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

This CONDITION IS NOT MET as evidenced by: Based on the systematic nature of the standard level deficient practices related to the implementation of policies and procedures and auditing practices regarding Clinical Record Requirements as cited in:

485.638(a) C0301 Maintained in accordance with Policies and Procedures
485.638(a)(2) C0302 Legible, complete, accurately documented, readily accessible, systematically organized.
485.638(a)(4)(iii) C0306 Information necessary to monitor patients condition and progress
485.638(a)(4)(iv) C0307 Dated signatures of orders

Based on staff interviews and a review of 23 (twenty-three) patient records by 3 (three) Medical Facility Inspectors (MFI's) between 2/24/2015 and 3/9/2015, the facility failed to ensure that verbal orders were signed/signed promptly, that the facility had a clear policy and procedure regarding time frame for signing verbal orders, and that patients admitted to a swing bed from the facility's acute care hospital contained discharge and admission orders, discharge summaries, or admission history and physicals for 10 (ten) of 23 (twenty-three) patient records, Patient #6, 20, 8, 18, 3, 5, 7, 4, 15, and 19.

Findings include:
1. Review of Patient #6's record by the MFI on 3/2/2015 revealed 3 verbal orders dated 2/19/2015 which were "pending" for signatures. Per an interview with Staff Person # 13, "pending" means that the orders have not yet been signed by the physician.

2. Review of Patient #20's record by the MFI on 3/4/2015 revealed 3 progress notes which had not been dated by the physician. Patient #20 was admitted to a swing bed on 1/17/2015, and was transferred to a higher level of care on 1/27/2015.

3. Review of Patient #8's record revealed 1 verbal order dated 2/17/2015, 1 verbal order dated 2/22/2015, 2 phone orders dated 2/22/2015, and 2 verbal orders dated 2/24/2015 which were "pending" for signatures. Per an interview with Staff Person # 13, "pending" means that the orders have not yet been signed by the physician.

4. The MFI reviewed the medical record for Patient #18, date of admission to acute care on 1/24/2015, on 3/4/2015. The history and physical for acute care admission dated 1/24/2015 was not signed by the physician until 2/26/2015. Further review revealed, Patient #18 was admitted to a swing bed from the acute care unit on 1/27/2015 and discharged back home on 2/5/2015, The IDT (Interdisciplinary team) meeting note dated 1/28/2015 was blank except for the discharge planning note by Staff Person #37 and the "other disciplines" section which had been marked to include discharge planning, dietary, pharmacy, activities, infection control, and family. The MFI reviewed the facility's policy for the Multi-disciplinary Team on 3/4/2015 revealing that the "Disciplines participating on this team include nursing, physical therapy, respiratory therapy, dietary, pharmacy, infection control, activities, social work, physician and patient/family. Each discipline is to share their individualized care plans including problems identified, measurable goals, and interventions. The Multi-disciplinary team is held weekly weekly to discuss patients' progress and discharge plans. Discharge planning of patient focuses on areas of current available support, prior level of functioning, expectation of current level of functioning, identification of social needs, medical equipment needs, and follow up health care.". The policy was last reviewed and revised May 2014. Weekly progress, including goals, by nursing, respiratory therapy, physical therapy, dietary, activities, pharmacy, family, and "other discipline" for Patient #18 were not completed.

5. The MFI reviewed Patient #3's medical record and noted 4 (four) physician orders written 1/1/2015 but not signed until 1/23/2015, 4 days after Patient #3 had been discharged from a swing bed. An order written 12/24/2014 was signed 1/25/2015, 6 (six) days after discharge. An order written 1/2/2015 was signed 1/23/2015. When staff were interviewed regarding the facility's policy and procedure for physician signatures of verbal and telephone orders, there was confusion as to whether orders were to be signed within 24 (twenty-four) or 72 (seventy-two) hours after receipt of the order.

6. A review of Patient #3's medical record by the MFI revealed that he/she was admitted to acute care on 12/24/2014, then stopped receiving acute care services and began receiving swing bed services on 1/1/2015. The admission date in the discharge summary from acute care to swing bed was identified as 12/26/2014; however, documentation on the acute care admission H&P and the acute care daily assessment recorded the admission date as 12/24/2014. Patient #3 was discharged from the facility's acute care services on 1/1/2015 and admitted to a swing bed in that facility; there was no documentation of a history and physical (H&P) prior to the swing bed admission. When Patient #3 was moved to a swing bed on 1/1/2015, the following physician orders were documented in the discharge summary: "New medications: 1. Unasyn 1.5 G (grams) IV (intravenous) daily, 2. Haldol 0.5 mg (milligrams) P.O. (by mouth) B.I.D. (twice daily) PRN (as needed) agitation, medication stopped Levaquin, home medications continued, diet: continue ADA (American Diabetic Association), and Activity: bedrest". Orders written during the acute care stay in the facility were left active upon Patient #3's admission to a swing bed, new orders were not written for the swing bed admission.


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7. Patient #5's clinical record was reviewed on 3/2/15. On 2/23/15 the patient had a verbal physician's order to "Change to acute care for treatment of c-diff" which, on 3/2/15 (at the time of the chart review by the surveyor) was listed as "pending" meaning the order had not yet been signed by the physician. Further review revealed a "phone order" on 2/22/15 for "Clostridium Diff toxin (lab test) which on 3/2/15 was still in the clinical record as "pending". A verbal order entered 2/26/15 for A "chest single view (chest x-ray)" was still "pending" the physicians signature on 3/2/15.

8. Patient #7's clinical record was reviewed on 3/2/15. Patient #7 had a physician's verbal order for "MRSA (Methacillin resistant staphylococcus aureus) Screen Protocol" ordered on 1/8/15. The order was not signed until 1/23/15. There was also an order on the same date for a "VRE (vancomycin resistant enterococcus) Screen" which was not signed until 1/23/15. A verbal order for "Discontinue Foley (indwelling catheter)" was documented on 1/8/15 but was not signed until 1/23/15. Further review of the clinical record for Patient #7 revealed the patient was initially admitted on 1/5/15 as acute inpatient and on 1/8/15 was admitted to swing bed status. There was no discharge summary from the acute inpatient bed, and no History and Physician documented for the admission to the swing bed. Review of physicians orders for Patient #7 revealed "1/8/15: Continue all Nursing orders, Continue all Pharmacy orders, Continue all Dietary orders, Continue all Therapy orders..."

9. Patient # 4's clinical record was reviewed 3/3/15 and revealed the following orders which were not signed timely: 12/30/15 Discontinue Telemetry- "pending" as of the date the chart was reviewed. 1/1/15- CBC (complete blood count) signed 1/23/15, 1/1/15 BMP (Basic Metabolic Panel) signed 1/23/15. Further review of the clinical record for Patient #4 revealed the following: Patient #4 was admitted to acute inpatient status on 12/8/14. The Patient was discharged from acute inpatient and admitted to swing bed status on 12/13/14. On 12/20/14, Patient #4 was discharged from the swing bed and admitted to acute inpatient status. On 1/1/15, Patient #4 was discharged from acute inpatient status and admitted to swing bed status. On 1/30/15 Patient #4 was again discharged from swing bed status and admitted to acute inpatient status and discharged from the facility on 2/6/15. Review of the clinical record revealed the following: No Admission History and Physician for the swing bed admission on 12/13/15. There was no discharge summary for the acute inpatient discharge on 1/1/15, and no admission History and Physician for the swing bed admission on 1/1/15.

10. Patient #15 was admitted to the facility for acute inpatient care on 2/2/15 and then discharged from acute inpatient and admitted to swing bed status on 2/7/15. For the 2/7/15 admission to the swing bed status, there were no admission orders for Patient #15, only " Admit to Swing bed: Continue all Nursing Orders, Continue all Physical therapy orders, Continue all Diet orders, Continue all Pharmacy orders". No specific orders for the admission were written/documented.


11. Patient #19's clinical record was reviewed on 3/4/15. The following orders were not signed timely by the physician:
12/24/14- verbal order DNR (do not resuscitate) not signed until 1/23/15
12/24/14- phone order Contact isolation for c-diff- not signed until 1/23/15
12/15/15 - verbal order discontinue telemetry not signed until 1/23/15

Review of the "Rules and Regulations of the Medical Staff and its Allied Health Practitioner Staff" which was dated as being reviewed January 2014, revealed: PATIENT CARE/ORDERS - 1. ...Verbal/Telephone orders- All orders for treatment must be in writing or electronic with the exception of the following situations: A. If provided by telephone to a registered nurse or licensed practical nurse and signed by the ordering physician within 24 (twenty-four) hours. B. If given to a professional member of the following departments and signed by the ordering physician within 24 hours: Laboratory, Respiratory Care, Radiology, Rehabilitation Services, Pharmacy, Registered Dietitian. All verbal/telephone orders must be verified. The staff member who received the verbal order must read the complete order back to the physician for verification and the physician must verbally confirm that the order is correct, and must sign and verify the order within 24 hours...."

The facility Policy and Procedure "Orders for Patient Care- Effective Date August 2014" revealed: "...Signing, Dating and Timing of orders for Patient Care- All orders shall be reviewed, verified and signed by the provider within 72 hours (seventy-two) of generation. These orders will be signed via e-signature in the electronic medical record, which allows for automatic date and time stamping. If orders are hand signed, they must be dated and timed..."

On 2/26/15 at 3:40 p.m., the survey team discussed the discrepancy between the Medical Staff Rules and the facility policy and procedure and requested clarification. Staff # 11 stated the policy was for 72 hours, but that the facility recently had discussed the need for the 24 hour signing.

On 2/27/15 at 4:05 p.m., the survey team discussed with Staff 1, 11 and #4, how information or recommendations for policy/procedures would go from the medical staff to the facility and vice versa. Staff #1 stated the information would be given to the DON (Director of Nursing) from the Medical Staff and then taken to the CIC (Continuous Improvement Committee- QA) for review and approval and then put into policy and them out for staff education.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns regarding the signing of verbal/telephone orders with the administrative staff #1, 4, 11, and 13, and 15.

Staff who were interviewed during the survey were unclear regarding the timeframe for signing of the orders. On 3/9/15 at 10:30 a.m., Staff #7 was interviewed regarding the signing of verbal and telephone orders. Staff #7 stated, "If we receive a verbal or telephone order, it must be read back to the physician for verification and the physician has to sign it within 24 hours..."

On 3/9/15 at 3:10 p.m., the survey team discussed the findings with administrative staff #1, 4, 11, 13, and 15.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the clinical record contained information that was complete and accurately documented for 5 (five) of 23 (twenty-three) patients of the survey sample. Patient # 12, 4, 7, 6, and 3.


The findings included:

1. The clinical record for Patient #12 was reviewed on 3/4/15. Patient #12 was admitted to swing bed status on 1/15/15 from acute inpatient care. The "Nurse's Note" on 1/15/15 documented, "...duoderm (hydrocolloid dressing) to left and right buttock areas. Pt (patient) c/o (complained of) pain in bottom- repositioned on side with pillow behind pt (patient)..." The surveyor, along with assistance from facility staff (Staff # 4 and 13) who were navigating the electronic medical record, were unable to locate any descriptive assessment or documentation of measurements of the wounds. The physician's "History and Physical" dated 1/15/15 documented "Sacral decubitus ulcer...daily wound care..." And on 1/16/15 there was a physician's order for "wound care". Neither the surveyor or the staff navigator was able to locate in the electronic medical record any specific physician's orders for wound care, no wound measurements or description, and the care plan was not individualized for the patient's skin condition and care of same. The "care plan" documented: assess location/extent of impairment, monitor appearance/character of skin, follow procedures for wound drainage, maintain aseptic tech/w (technique with) dressing change, follow protocol for tx (treatment of decubitus) and Maintain nutritional support" There was no documentation of the assessment of the skin and there was no order for a consult with the facility dietitian due to Patient #12's impaired skin integrity. No pictures of the wound was found in the clinical record.

There was documentation on 1/18/15 in the "Nurse's Notes" of: "...stage 2 decubitus ulcer to bilateral buttocks..."

The facility policy and procedure "Wound Care" was reviewed. This document was a one page document which evidenced Routine Orders for Wound Care: 1. A wound care assessment is to be completed on all patients admitted to the Med/Surg (Medical Surgical) floor. 2. Photographs of all wounds are to be taken after a consent form has been completed by the patient or patients representative. Stage 1: 1. Cover and protect (keep contaminants off, protect from friction) 2. Add moisture to epidermis. Products: 1. Moisturizers-Aloe Vesta Skin Cream or Zinc Oxide. 2. Lubricating spray/ointment-Granulex spray. 3. Transparent adhesive dressing-Tegaderm or op-site. (These films will help decrease friction, provide semi-permeable sterile but moist environment, and enable autolysis.) Procedure: Notify Physician for plan of care for wound treatment and document in CSPI Nursing Assessment Flow Sheet."

The Policy and Procedure for "Decubitus Ulcer Prevention" was reviewed and evidenced it had not been updated to reflect the National Pressure Ulcer Advisory Panel Guidelines for staging since 2003 (last update for NPUAP 2007) even though the policy documented a review date of May 2014.

When interviewed further regarding the lack or wound care orders, incomplete policy, lack of individualized care plan and out of date decubitus staging protocols on staff #4 stated, 3/4/15 at 1:25 p.m. "Well we go by Lippincott for things not covered in our policies..."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. According to documentation on 12/28/14, Patient #4 had an order for "Wound Care" from the physician. The surveyor was unable to locate any specific orders, or order clarification for the "wound care" order. On 3/3/15 at 12:45 p.m., Staff #4 stated he/she was unable to locate in the clinical record any orders for specific wound care for Patient #4. There was no individualized wound care- care plan for Patient #4 found in the clinical record.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

3. Patient # 7 was initially admitted on 1/5/15 as acute inpatient and on 1/8/15 was admitted to swing bed status. Patient #7's record was reviewed on 3/2/15 and revealed the admission weight was 138.13. On 02/3/13 the patient had a "Nutrition Assessment" from the dietitian which documented the weight as 128.3 which was a 10 (ten) pound loss. On 2/26/15, the weight for Patient #7 was documented as 121.6 (17 lb loss) and on 3/2/15, the weight was at 123.3 (a 2 pound gain- 15 pound loss since admission). The assessment of the dietitian evidenced: "... per RN (registered Nurse) MD (physician) wants to try Prostat (protein supplement) if pt (patient) does not tolerate, recommend trying thickened carnation instant breakfast tid (three times a day w/ (with) meals may also try ensure pudding. Malnutrition risk r/t (related to) adv (advanced) age patient w/ (with) complex medical issues and intake supplementation like ensure pudding..Follow-Up 2/10/15: pt (patient) eating well (staff feeds) for added protein recommend thickened CIB (carnation instant breakfast) w/ (with) meals ensure pudding if prostat is not tolerated...."

The surveyor was unable to locate any orders for the carnation instant breakfast or ensure pudding which was recommended by the dietitian. Review of the "meal intake" documentation for Patient #7 revealed inconsistent documentation of the patient's intake as follows:
1/5/15- no breakfast intake was documented
1/6/15- no dinner intake was documented
1/7/15- no dinner intake was documented
1/9/15- no lunch intake was documented
1/10/15 - no lunch or dinner intake was documented
1/12/15- no dinner intake was documented
1/13/15- no breakfast intake was documented
1/18/15 no breakfast or lunch intake was documented
1/21/15- no breakfast intake was documented
1/22/15- no breakfast intake was documented
1/25/15- no lunch intake was documented
2/1/15- no lunch intake was documented
2/7/15- no lunch intake was documented
2/11/15- no dinner intake was documented
2/17/15- no lunch intake was documented
2/19/15- no lunch intake was documented
2/20/15- no dinner intake was documented

The surveyor was unable to locate a care plan for Patient #7 which addressed the nutritional needs/potential for malnutrition on the clinical record. Staff #4 stated on 3/2/15 at 1:40 p.m., that, "(Patient #4) was given the carnation instant breakfast and the ensure pudding by the staff but he/she stopped taking is, so the staff stopped giving it to him/her (Patient #7)." Staff #4 was unable to locate an order for or documentation of the carnation instant breakfast or the ensure pudding.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m. the survey team discussed the concerns with Staff #1, 4, 11, 13 and 15.



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4. Patient #6 was admitted to the facility on 2/18/2015 for observation, and at that time, based on documentation in the medical record and an interview with Patient #6, an IV (intravenous) access was placed in the right arm. During an interview of Patient #6 on 2/25/2015, the MFI observed an IV access for intermittent drug infusion (a saline lock) in the patient's right arm. Patient #6 told the MFI that the IV access had not been moved since the original placement which was documented in the record as being the right arm. The clear dressing over the access was not labeled with the date and time of placement or initials or signature of the person who placed the access. Review of the medical record for Patient #6 revealed documentation on 2/18, 2/19, and 2/20/2015 that the IV access was in the right arm. At 8:35 AM on 2/21/2015 the access was documented as being in the left arm. At 2155 (9:55 PM) on 2/21/2015 the site was documented as being in the right arm. On 2/22/2015 at 11:26 AM the site was documented in the left arm, at 1952 (7:52 PM) on 2/22/2015 documented as being in the right arm. On 2/23/2014 at 10:20 AM site was documented in left arm; on 2/23/2015 at 2025 (8:25 PM) site was documented in the right arm; on 2/24/2015 at 10:10 AM and 1930 (7:30 PM), the site was documented in left arm; on 2/25/15 at 8:301 AM site was documented in the left arm; on 2/25/2015 at 2330 (11:30 PM) site was documented in right arm #22 gauge, and on 2/26/2015 the site was documented at 8:00 AM as being in right arm #20 gauge.

5. The MFI reviewed the medical record for Patient #3, admitted to acute care on 12/24/2014, with a diagnosis of ulcer of the lower limb. The admission history and physical (H&P) includes documentation under "exam" of a "L (left) leg wound with wound vac" and a "R (right) 5 x 4 ulceration with clean base no evidence of infection, no discharge". There is documentation in the 12/24/2014 nurses note of a dressing change to the right leg ulcer described as a stage IV (4) wound, and on 12/25/2014 that "wound vac in place to left lower extremity. Dressing clean dry and intact to right lower extremity.". There are no physician orders for wound care documented in the record until 12/30/2014, 6 (six) days after admitted to acute care. When Patient #3 was moved to a swing bed on 1/1/2015, the following physician orders were documented in the discharge summary: "New medications: 1. Unasyn 1.5 G(grams) IV (intravenous) daily, 2. Haldol 0.5 mg (milligrams) P.O. (by mouth) B.I.D. (twice daily) PRN (as needed) agitation, medication stopped Levaquin, home medications continued, diet: continue ADA (American Diabetic Association), and Activity: bedrest". Orders written during the acute care stay in the facility were left active upon Patient #3's admission to a swing bed, new orders were not written for the swing bed admission.


On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m. the survey team discussed the concerns with Staff #1, 4, 11, 13 and 15.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure the medical records of 3 (three) of 23 (twenty-three) patients of the survey sample were promptly completed and contained all the information necessary to monitor the patient's condition along with the patients response to the treatments, interventions and care for Patient #'s 12, 4, and 3.


The findings included:

1. The clinical record for Patient #12 was reviewed on 3/4/15. Patient #12 was admitted to swing bed status on 1/15/15 from acute inpatient care. The "Nurse's Note" on 1/15/15 documented, "...duoderm (hydrocolloid dressing) to left and right buttock areas. Pt (patient) c/o (complained of) pain in bottom- repositioned on side with pillow behind pt (patient)..." The surveyor, along with assistance from facility staff (Staff # 4 and 13) who were navigating the electronic medical record, were unable to locate any descriptive assessment or documentation of measurements of the wounds. The physician's "History and Physical" dated 1/15/15 documented "Sacral decubitus ulcer...daily wound care..." And on 1/16/15 there was a physician's order for "wound care". Neither the surveyor or the staff navigator was able to locate in the electronic medical record any specific physician's orders for wound care, no wound measurements or description, and the care plan was not individualized for the patient's skin condition and care of same. The "care plan" documented: assess location/extent of impairment, monitor appearance/character of skin, follow procedures for wound drainage, maintain aseptic tech/w (technique with) dressing change, follow protocol for tx (treatment of decubitus) and Maintain nutritional support" There was no documentation of the assessment of the skin and there was no order for a consult with the facility dietitian due to Patient #12's impaired skin integrity. No pictures of the wound was found in the clinical record.

There was documentation on 1/18/15 in the "Nurse's Notes" of: "...stage 2 decubitus ulcer to bilateral buttocks..."

The facility policy and procedure "Wound Care" was reviewed. This document was a one page document which evidenced Routine Orders for Wound Care: 1. A wound care assessment is to be completed on all patients admitted to the Med/Surg (Medical Surgical) floor. 2. Photographs of all wounds are to be taken after a consent form has been completed by the patient or patients representative. Stage 1: 1. Cover and protect (keep contaminants off, protect from friction) 2. Add moisture to epidermis. Products: 1. Moisturizers-Aloe Vesta Skin Cream or Zinc Oxide. 2. Lubricating spray/ointment-Granulex spray. 3. Transparent adhesive dressing-Tegaderm or op-site. (These films will help decrease friction, provide semi-permeable sterile but moist environment, and enable autolysis.) Procedure: Notify Physician for plan of care for wound treatment and document in CSPI Nursing Assessment Flow Sheet."

The Policy and Procedure for "Decubitus Ulcer Prevention" was reviewed and evidenced it had not been updated to reflect the National Pressure Ulcer Advisory Panel Guidelines for staging since 2003 (last update for NPUAP 2007) even though the policy documented a review date of May 2014.

When interviewed further regarding the lack or wound care orders, incomplete policy, lack of individualized care plan and out of date decubitus staging protocols on staff #4 stated, 3/4/15 at 1:25 p.m. "Well we go by Lippincott for things not covered in our policies..."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. According to documentation on 12/28/14, Patient #4 had an order for "Wound Care" from the physician. The surveyor was unable to locate any specific orders, or order clarification for the "wound care" order. On 3/3/15 at 12:45 p.m., Staff #4 stated he/she was unable to locate in the clinical record any orders for specific wound care for Patient #4. There was no individualized wound care- care plan for Patient #4 found in the clinical record.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

3. The MFI reviewed the medical record for Patient #3, admitted to acute care on 12/24/2014, with a diagnosis of ulcer of the lower limb. The admission history and physical (H&P) includes documentation under "exam" of a "L (left) leg wound with wound vac" and a "R (right) 5 x 4 ulceration with clean base no evidence of infection, no discharge". There is documentation in the 12/24/2014 nurses note of a dressing change to the right leg ulcer described as a stage IV (4) wound, and on 12/25/2014 that "wound vac in place to left lower extremity. Dressing clean dry and intact to right lower extremity.". There are no physician orders for wound care documented in the record until 12/30/2014, 6 (six) days after admitted to acute care. When Patient #3 was moved to a swing bed on 1/1/2015, the following physician orders were documented in the discharge summary: "New medications: 1. Unasyn 1.5 G(grams) IV (intravenous) daily, 2. Haldol 0.5 mg (milligrams) P.O. (by mouth) B.I.D. (twice daily) PRN (as needed) agitation, medication stopped Levaquin, home medications continued, diet: continue ADA (American Diabetic Association), and Activity: bedrest". Orders written during the acute care stay in the facility were left active upon Patient #3's admission to a swing bed, new orders were not written for the swing bed admission.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m. the survey team discussed the concerns with Staff #1, 4, 11, 13 and 15.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure physician orders were signed in a timely manner for 8 (eight) of 23 (twenty-three) patients of the survey sample. Patient #'s 5, 7, 4, 19, 6, 20, 8, and 3.

The findings included:

1. Patient #5's clinical record was reviewed on 3/2/15. On 2/23/15 the patient had a verbal physician's order to "Change to acute care for treatment of c-diff" which, on 3/2/15 (at the time of the chart review by the surveyor) was listed as "pending" meaning the order had not yet been signed by the physician. Further review revealed a "phone order" on 2/22/15 for "Clostridium Diff toxin (lab test) which on 3/2/15 was still in the clinical record as "pending". A verbal order entered 2/26/15 for A "chest single view (chest x-ray)" was still "pending" the physicians signature on 3/2/15.

2. Patient #7's clinical record was reviewed on 3/2/15. Patient #7 had a physician's verbal order for "MRSA (Methacillin resistant staphylococcus aureus) Screen Protocol" ordered on 1/8/15. The order was not signed until 1/23/15. There was also an order on the same date for a "VRE (vancomycin resistant enterococcus) Screen" which was not signed until 1/23/15. A verbal order for "Discontinue Foley (indwelling catheter)" was documented on 1/8/15 but was not signed until 1/23/15.

3. Patient # 4's clinical record was reviewed 3/3/15 and revealed the following orders which were not signed timely: 12/30/15 Discontinue Telemetry- "pending" as of the date the chart was reviewed. 1/1/15- CBC (complete blood count) signed 1/23/15, 1/1/15 BMP (Basic Metabolic Panel) signed 1/23/15.

4. Patient #19's clinical record was reviewed on 3/4/15. The following orders were not singed timely by the physician:
12/24/14- verbal order DNR (do not resuscitate) not signed until 1/23/15
12/24/14- phone order Contact isolation for c-diff- not signed until 1/23/15
12/15/15 - verbal order discontinue telemetry not signed until 1/23/15

Review of the "Rules and Regulations of the Medical Staff and its Allied Health Practitioner Staff" which was dated as being reviewed January 2014, revealed: PATIENT CARE/ORDERS - 1. ...Verbal/Telephone orders- All orders for treatment must be in writing or electronic with the exception of the following situations: A. If provided by telephone to a registered nurse or licensed practical nurse and signed by the ordering physician within 24 (twenty-four) hours. B. If given to a professional member of the following departments and signed by the ordering physician within 24 hours: Laboratory, Respiratory Care, Radiology, Rehabilitation Services, Pharmacy, Registered Dietitian. All verbal/telephone orders must be verified. The staff member who received the verbal order must read the complete order back to the physician for verification and the physician must verbally confirm that the order is correct, and must sign and verify the order within 24 hours...."

The facility Policy and Procedure "Orders for Patient Care- Effective Date August 2014" revealed: "...Signing, Dating and Timing of orders for Patient Care- All orders shall be reviewed, verified and signed by the provider within 72 hours (seventy-two) of generation. These orders will be signed via e-signature in the electronic medical record, which allows for automatic date and time stamping. If orders are hand signed, they must be dated and timed..."

On 2/26/15 at 3:40 p.m., the survey team discussed the discrepancy between the Medical Staff Rules and the facility policy and procedure and requested clarification. Staff # 11 stated the policy was for 72 hours, but that the facility recently had discussed the need for the 24 hour signing.

On 2/27/15 at 4:05 p.m., the survey team discussed with Staff 1, 11 and #4, how information or recommendations for policy/procedures would go from the medical staff to the facility and vice versa. Staff #1 stated the information would be given to the DON (Director of Nursing) from the Medical Staff and then taken to the CIC (Continuous Improvement Committee- QA) for review and approval and then put into policy and them out for staff education.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns regarding the signing of verbal/telephone orders with the administrative staff #1, 4, 11, and 13, and 15.

Staff who were interviewed during the survey were unclear regarding the timeframe for signing of the orders. On 3/9/15 at 10:30 a.m., Staff #7 was interviewed regarding the signing of verbal and telephone orders. Staff #7 stated, "If we receive a verbal or telephone order, it must be read back to the physician for verification and the physician has to sign it within 24 hours..."


On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.


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5. Review of Patient #6's record by the MFI on 3/2/2015 revealed 3 verbal orders dated 2/19/2015 which were "pending" for signatures. Per an interview with Staff Person # 13, "pending" means that the orders have not yet been signed by the physician.

6. Review of Patient #20's record by the MFI on 3/4/2015 revealed 3 progress notes which had not been dated by the physician. Patient #20 was admitted to a swing bed on 1/17/2015, and was transferred to a higher level of care on 1/27/2015.

7. Review of Patient #8's record revealed 1 verbal order dated 2/17/2015, 1 verbal order dated 2/22/2015, 2 phone orders dated 2/22/2015, and 2 verbal orders dated 2/24/2015 which were "pending" for signatures. Per an interview with Staff Person # 13, "pending" means that the orders have not yet been signed by the physician.

8. Review of Patient #3's record revealed a verbal order dated 12/24/2014 for DNR (do not resuscitate) which was not signed by the physician until 1/23/2015, 4 (four) days after the patient was discharged from services. Staff who were interviewed were unclear as to whether the facility's policy and procedure regarding the required time frame for physician signature of verbal and telephone orders was 24 (twenty-four) or 72 (seventy-two) hours.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on the systemic nature of the findings related to surgical services it was determined that the facility staff failed to substantially comply with this condition of participation.

The findings include:

1. The facility staff failed to ensure that sterile supplies were stored in a manner that ensures sterility by monitoring the temperature and humidity of the sterile supply storage room in accordance with accepted standards of practice and the manufacturer's instructions for use concerning storage of sterile supplies.

During a tour of the sterile supply room on 2/25/15 with the OR (operating room) technician it was noted by the surveyor that the "Temperature and Humidity Log" revealed only documentation for 2/5/15. When the OR technician was questioned as to why there were no other dates documented, he/she stated that they had only "just started" recording this again, that "we used to do it all the time" and had just stopped at some point but was unable to say when or why.

Review of manufacturer's instructions for use for self-sealing sterilization pouches used by the facility in the sterilization process revealed the acceptable storage conditions to be a temperature between 40-95 degrees Fahrenheit and relative humidity between 10-90%. Manufacturer's instructions for use for the indicator tape for steam sterilization which is used by the facility in the sterilization process revealed best storage conditions would be less than 50% relative humidity and temperature between 59-86 degrees Fahrenheit.

Storage conditions for sterile supplies as recommended by AORN (Association of preoperative Registered Nurses) are for sterile items to be "..stored under environmentally controlled conditions, which means a temperature of approximately 75 degrees Fahrenheit, a maximum relative humidity of 70%..."

Review of facility's Policy and Procedure entitled "INFECTION CONTROL for CENTRAL STERILE" contains the following statement: "Events that could compromise an item's sterility may include, but are not limited to: Moisture exposure that leads to penetration of the packaging."

The lack of documentation of temperature and humidity levels for the sterile supply room, made it impossible for the surveyor or staff to determine that supplies were stored in a manner that would ensure continued sterility of supplies.

2. The facility staff failed to maintain humidity control in anesthetizing locations to provide adequate levels for patient health and safety.

During an observation of the OR (operating room) on 2/25/15 with Employee #3, the surveyor asked to review the OR temperature and humidity log. Employee #3 directed the surveyor to a document on the wall entitled "OPERATING ROOM TEMPERATURE AND HUMIDITY LOG". This document provided areas to document date, temperature, humidity, signature and an area for comments. Upon examining the document the surveyor noted humidity levels ranging from 19-54% documented for the time period of 1/29/14 to 2/24/15. The facility does not provide surgical services daily. As directed in facility policy entitled "TEMPERATURE and HUMIDITY MONITORING POLICY" the humidity and temperature levels were recorded only on days the OR was in use. Of the 28 (twenty-eight) dates with documentation it was noted that on 20 (twenty) of those dates the humidity level in the OR was below 35% with one day recorded at 19%. Employee #3 was asked what he/she would do if the temperature and/or humidity levels were out of range. He/she replied that maintenance would be contacted. The OR "TEMPERATURE AND HUMIDITY LOG" contained no documentation of any notification to facility maintenance personnel related to the humidity levels. Staff #3 was asked if he/she was aware of any waiver or variance the facility may have obtained related to the humidity levels in the OR, he/she (Staff #3) was not aware of any waiver being obtained. The facility CEO was also asked if the facility had been granted any waivers or variances during the entrance interview on 2/24/15.

On 3/2/15 during a meeting with Staff #12 the facility's maintenance manager, the question of whether the facility had any waiver or variance in place concerning the humidity level in the OR. Staff #12 stated that he/she had no knowledge of any waiver and suggested the surveyor ask Staff #3. Staff #12 was asked what he/she would do if notified of any humidity and/or temperature levels that were outside of the guidelines, he/she replied that the manufacturer of the air/ventilation system would be contacted. When Staff #12 was asked how it was determined what the humidity level should be in the OR, he/she said that it was just what the system runs.

The inability of the facility to produce documentation of the facility's election to use the categorical waiver allowing CAHs (critical access hospitals) to maintain relative humidity in OR's at 20% or greater, results in the facility being required to maintain RH (relative humidity) levels in the OR at 35% or greater. As noted above this requirement was not met for 20 of 28 days when the OR was in use and no documentation of any corrective action was provided to the surveyor.

On 3/2/15 in the afternoon, facility CEO was again asked about the election to use a variance or waiver related to the RH in the OR, he/she stated that he/she had no knowledge of any variance and/or waiver.

3. The facility staff failed to ensure that essential equipment located in the operating room was maintained according to the manufacturer's instructions for use (IFU).

In conducting a random check of the equipment located in the OR, specifically the instructions for use (IFU's) for equipment in relation to the relative humidity level, it was determined that at least one piece of equipment (the Electrosurgical Unit), had listed under "NORMAL USE & ENVIRONMENTAL RESTRICTIONS" the following statement "Relative Humidity 30% to 75%". For sixteen (16) of twenty-eight (28) days with relative humidity documented the RH was below 30% in the operating room and would be outside of the manufacturer's instructions and/or environmental restrictions for this equipment.

4. Observation of the contents of the anesthesia cart (which remains in the OR) on 3/2/15 revealed the following supplies to be out of date: spinal trays used for anesthesia, expiration date 12/14, LMA (laryngeal mask airway) used for airway control, expiration date 1/12/14, IV catheters routinely used for access to patients bloodstream by insertion into a vein expiration dates 1/13 and 2/13, IV start kits expiration date 11/13, alcohol disinfectant caps expiration date 10/14. The expiration dates were confirmed by Staff #3 and Staff #22. These supplies were removed from the cart by Staff #3 who stated that he/she would ensure that the person who administers anesthesia (Staff #23) was notified that these supplies needed replacing.

5. Review of the facility's OR log or register on 2/25/15 revealed the staff failed to document the age of the patient on the register/register. This omission was discussed with Staff #3 , who confirmed that the patient age was not listed on their log but could easily be added to the spreadsheet in the future.

6. Surveyor review of operative reports on 2/25/15 for procedures performed on 2/25/15
failed to reveal documentation as to the type of anesthesia administered during the procedure for two (2) of two (2) reports reviewed. There were five (5) procedures performed on 2/25/15.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

This CONDITION IS NOT MET as evidenced by: Based on the systematic nature of the standard level deficient practices related to the implementation of policies and procedures, auditing and patient care practices regarding the Conditions of Participation as cited in:

485.623- Physical Plant/Maintenance
485.627- Organizational Structure
485.635-Provision of Services
485.638-Clinical Records
485.639- Surgical Services
485.645- Special Requirements for CAH (Swing Beds)

Based on clinical record review, staff interview, facility document review and the survey process, the facility staff failed to ensure an effective Quality Assurance Program was in place to evaluate the quality and services provided by the facility due to the multiple findings during the validation survey including Immediate Jeopardy.

The findings included:

During the validation survey conducted 2/24 through 2/27 and 3/2 through 3/4 and 3/9/15, the survey team identified multiple areas of deficient practice throughout the facility areas and Condition of Participation Requirements.

On 3/9/15 at 1:00 p.m., the survey team interviewed Staff #11 regarding the Quality Program. Staff #11 stated the charts wee audited by HIM (Health Information Management- Medical Records). Staff #11 stated, "The other review is done if we have a chart that needs to be sent out and I go through it, that is basically the only other review it gets..." Staff #11 further stated, "We have had a huge turnover here in administration and there has been a disassociation of the board and the staff...for a year I have been trying to tell them the documentation is lacking and that it affects patient care...as far as the physicians signing the orders we had to get a locum tenum and we failed miserably getting our scores back up regarding having the charts signed..."

The survey team inquired as to the responsibilities of the departments in maintaining their own quality program for each department and how they were overseeing and reporting to the Quality Committee and the Governing Body. Staff #11 stated, "We have had a disassociation with the board that needs to be resolved..."

On 3/9/15 at 3:30 p.m., the survey team discussed the multiple concerns regarding the survey findings including the Immediate Jeopardy in the kitchen with Staff #1, 4, 11, 13, and #15.

Based on clinical record review, staff interview and facility document review, the facility staff failed to meet the requirements for changing status from acute to swing bed services and due to the systematic nature of the standard level deficient practices related to the implementation of policies and procedures and practices for Special Regulations for Swing Beds the Condition is NOT met.

Patients were "admitted" to swing bed services without a discharge summary from the acute inpatient status , nor a History and Physical when admitted to the swing bed status. There were no "admission orders for the swing bed patients, just a "continue all previous orders" for the admission. This involved Patient #'s 7, 4, 15, and 3.

The findings included:

1. Patient # 7 was initially admitted on 1/5/15 as acute inpatient and on 1/8/15 was admitted to swing bed status. There was no discharge summary from the acute inpatient bed, and no History and Physical documented for the admission to the swing bed. Review of physicians orders for Patient #7 revealed "1/8/15: Continue all Nursing orders, Continue all Pharmacy orders, Continue all Dietary orders, Continue all Therapy orders..."

On 3/2/15 at 1:00 p.m., Staff # 4 stated, "We just talked about this the other day and I told them the patients records have to be treated as if they were going to another facility. There has to be a discharge summary, a discharge order, new orders for admission and a history and physical..."

2. Patient #4 was admitted to acute inpatient status on 12/8/14. The Patient was discharged from acute inpatient and admitted to swing bed status on 12/13/14. On 12/20/14, Patient #4 was discharged from the swing bed and admitted to acute inpatient status. On 1/1/15, Patient #4 was discharged from acute inpatient status and admitted to swing bed status. On 1/30/15 Patient #4 was again discharged from swing bed status and admitted to acute inpatient status and discharged from the facility on 2/6/15. Review of the clinical record revealed the following: No Admission History and Physician for the swing bed admission on 12/13/15. There was no discharge summary for the acute inpatient discharge on 1/1/15, and no admission History and Physician for the swing bed admission on 1/1/15.

3. Patient #15 was admitted to the facility for acute inpatient care on 2/2/15 and then discharged from acute inpatient and admitted to swing bed status on 2/7/15. For the 2/7/15 admission to the swing bed status, there were no admission orders for Patient #15, only " Admit to Swing bed: Continue all Nursing Orders, Continue all Physical therapy orders, Continue all Diet orders, Continue all Pharmacy orders". No specific orders for the admission were written/documented.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.


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4. Patient #3 was discharged from the facility's acute care services on 1/1/2015 and admitted to a swing bed in that facility; there was no documentation of a history and physical (H&P) prior to the swing bed admission. When Patient #3 was moved to a swing bed on 1/1/2015, the following physician orders were documented in the discharge summary: "New medications: 1. Unasyn 1.5 G (grams) IV (intravenous) daily, 2. Haldol 0.5 mg (milligrams) P.O. (by mouth) B.I.D. (twice daily) PRN (as needed) agitation, medication stopped Levaquin, home medications continued, diet: continue ADA (American Diabetic Association), and Activity: bedrest". Orders written during the acute care stay in the facility were left active upon Patient #3's admission to a swing bed, new orders were not written for the swing bed admission.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on a review of twelve (12) staff records between 2/26/2015 and 3/9/2015, the facility failed to ensure that a criminal record check was obtained for staff person # 29, date of hire 4/13/2001.

Findings include:

During a review of employee records on 2/26/2014, the Medical Facility Inspector (MFI) noted that a criminal record check had not been obtained for Staff Person #29.

The lack of a criminal record check for employee #29 was discussed with Staff Person # 11 on 2/26/2015 between 11:00 AM and 12:00 PM.


On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on observation, staff interview and facility document review, the facility staff failed to ensure the facility provided for an on-going program of activities designed to meet the interests of the patients for 7 (seven) of 9 (nine) swing-bed patient records reviewed. Patient #'s 7, 4, 23, 3, 8, 18, and 20. Based on a review of the facility's activities calendars for the months of December 2014 and January, February, and March 2015, the facility failed to ensure that residents were involved in an ongoing program of activities designed to reflect individual residents' interests and needs, that activities were offered at hours convenient to the residents, that activities occurred as planned, that comprehensive activity assessments were performed, that patients confined to their rooms were provided with suitable in-room activities, and that care plans addressed activities for patients.

The findings included:

1. Patient # 7 was initially admitted on 1/5/15 as acute inpatient and on 1/8/15 was admitted to swing bed status. Patient #7's record was reviewed on 3/2/15 and revealed documentation of the patient's activity participation. From 2/14/15 through 3/2/15 Patient #7 have "television" documented as the primary activity. On 2/17, 2/19, and 2/21/15 there was documentation of "socialization-company at BS (bedside)". On 2/21 and 2/22/15, "music" was documented. Review of the facility "Activity Calendar" revealed for the Month of February 2015: Room visits, fun facts, cornhole, crafts, Trivia, Popcorn and movie, walks, devotions, and sittersise were listed as activities which were rotated throughout the month daily. There was no documentation Patient #7 participated in any of these activities, not was there documentation the patient was invited and/or refused to attend nor that any alternative activities other than television were provided for the patient, as the patient was on "contact isolation". For the Month of March 2015, the activities through 3/2/15 were, Devotions and Range of Motion. There was no documentation Patient & was invited and/or refused to attend or that alternative activities were offered for Patient #7. Patient #7 did not have a care plan which reflected the Patients activity interests. There was no activity assessment present on the clinical record for Patient #7. The Activity calendar did not have any times or locations identified for the activities listed.

Staff #4 stated on 3/2/15 at 1:00 p.m., "If it is not on the 'Initial Interview' document, then it is not there..."

2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15.

Documentation in the clinical record during the swing bed admission revealed no activity care plan for Patient #4. The Activity Calendar for January 2015 revealed the following activities rotated throughout the month: Devotions, Dress in your favorite outfit from home, range of motion, TV and Conversation, Hallway walks, and movie/snack. There was no documentation that Patient #4 participated or was offered to attend/and or refused any of the planned activities on the calendar. Physical Therapy was documented an as activity on 1/12/15. The Activity calendar did not have any times or locations identified for any of the activities listed.


3. Patient # 23 was admitted 2/27/15. Review of the clinical record for Patient #2 revealed no activities assessment and no care plan which included activities. There was no documentation in the clinical record that Patient #23 participated in or was offered to participate in any activities.

According to the facility Policy: "Activity Assessment" the following was evidenced: "To provide for patient to be involved in activities of their choosing. Patients will be offered activities and be allowed to suggest activities of their liking, to enhance their daily lives. Procedures: 1. Using an approved activity's assessment form, all SNF bed patients will be assessed within seven days if their admission. 2. This will be placed on chart and documented in POC (plan of care). 3. Consideration will be given to patient's ability and desire, but all patients will be encouraged to participate in at least bedside activities of their liking (Reading letter writing, movies, ect.) 4. Patients will be informed of activities and encouraged to participate in those of interest. 5. A plan will be instituted on each patient with cooperation of staff, patient and family. One on one activities and group activities will be offered focusing on the capabilities of each patient. The patient's family and friends can be an integral part of patient's activities, with visits, phone calls, and letters. Documentation will be make in each Patient's chart. Each discipline is responsible to document when an activity is performed."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.


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4 . The activity calendars reviewed by the Medical Facility Inspector (MFI) listed multiple types of activities, some of which included movie/snack, TV and conversation, range of motion, hallway walks, trivia Thursday, dress in your favorite outfit from home, cornhole and sittersise. Activities documented for patients #3, #8, and #20, included TV, radio, PT (physical therapy), socializing,devotions, visitors, bed chair activities. The records lacked documentation that scheduled activities were offered or refused by patients.

The activity calendars did not include times; therefore, it could not be determined if activities were offered at hours convenient to the residents, for example, morning, afternoon, or evenings.

There was no documentation of a comprehensive activity assessment on the initial interview under "pertinent history" for Patient #8.

The facility policy and procedure for the multi-disciplinary team states "...Disciplines participating on this team include nursing, physical therapy, respiratory therapy, dietary, pharmacy, infection control, activities, social work, physician and patient/family. Each discipline is to share their individualized care plans including problems identified, measurable goals, and interventions. The activity portion of the Interdisciplinary Team Meeting document was not completed for Patient #3, Patient #8, Patient #18, and Patient #20.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.


On 3/9/15 at 3:15 p.m., the survey team again discussed the findings with the facility administrative staff #'s 1, 4, 11, 13 and 15.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to ensure a comprehensive, individualized care plan was developed and reviewed/revised for 5 (five) of 9 (nine) Swing bed Patient's of the survey sample. Patient #'s 12, 4, 7, 6, and 18.

The findings included:

1. The clinical record for Patient #12 was reviewed on 3/4/15. Patient #12 was admitted to swing bed status on 1/15/15 from acute inpatient care. The "Nurse's Note" on 1/15/15 documented, "...duoderm (hydrocolloid dressing) to left and right buttock areas. Pt (patient) c/o (complained of) pain in bottom- repositioned on side with pillow behind pt (patient)..." The surveyor, along with assistance from facility staff (Staff # 4 and 13) who were navigating the electronic medical record, were unable to locate any descriptive assessment or documentation of measurements of the wounds. The physician's "History and Physical" dated 1/15/15 documented "Sacral decubitus ulcer...daily wound care..." And on 1/16/15 there was a physician's order for "wound care". Neither the surveyor or the staff navigator was able to locate in the electronic medical record any specific physician's orders for wound care, no wound measurements or description, and the care plan was not individualized for the patient's skin condition and care of same. The "care plan" documented: assess location/extent of impairment, monitor appearance/character of skin, follow procedures for wound drainage, maintain aseptic tech/w (technique with) dressing change, follow protocol for tx (treatment of decubitus) and Maintain nutritional support" There was no documentation of the assessment of the skin and there was no order for a consult with the facility dietitian due to Patient #12's impaired skin integrity. No pictures of the wound was found in the clinical record. The care plan did not contain measurable objectives and timetables and the identification of steps taken to assist the resident to meet his/her objectives. There was no documentation found that the patient participated in the care plan, or the reason the patient was unable to participate.

There was documentation on 1/18/15 in the "Nurse's Notes" of: "...stage 2 decubitus ulcer to bilateral buttocks..."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. According to documentation on 12/28/14, Patient #4 had an order for "Wound Care" from the physician. The surveyor was unable to locate any specific orders, or order clarification for the "wound care" order. On 3/3/15 at 12:45 p.m., Staff #4 stated he/she was unable to locate in the clinical record any orders for specific wound care for Patient #4. There was no individualized wound care-care plan for Patient #4 found in the clinical record.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

3. Patient # 7 was initially admitted on 1/15/15 as acute inpatient and on 1/8/15 was admitted to swing bed status. Patient #7's record was reviewed on 3/2/15 and revealed the patient had a significant weight loss during the hospital stay (138.13 lbs to 123.6). The surveyor was unable to locate any care plan related to nutrition in the clinical record. There was documentation that Patient #4 had been evaluated by the dietitian on 2/3/15 with a follow-up note on 2/10/15, however no care plan for the weight loss was found in the care plan.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

The facility Policy and Procedure "Assessment, Care Planning, and Discharge Planning" was reviewed and evidenced: "E. Plan of Care: The results of the assessment are utilized to develop, review and revise the patient's plan of care...the comprehensive plan of care will identify patient problem areas. Additional components of the care plan will include measurable objectives/goals with a time frame for achievement, and the services interventions provided . The plan of care will be developed in the Multi-Team Meeting...The plan of care will be revised as needed with patient status changes, as new needs arise, and as needed..."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 10:30 a.m., Staff #7 stated, "The care plan is in the system and based on the assessment of the patient we can generate the care plan on this flow sheet under the assessment. Each shift should document on the care plan...Nutrition, Social Services and Physical therapy have their own care plans..."

On 3/9/15 at 2:40 p.m. the survey team discussed the concerns with Staff #1, 4, 11, 13 and 15.


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4. Patient #6's record was reviewed and the MFI and revealed that the stated goals listed on the care plan were not given a time frame; therefore, did not include measurable outcomes.

5. Patient #18's record was reviewed by the MFI and revealed that the stated goals listed on the care plan were not given a time frame; therefore, did not include measurable outcomes.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 2:40 p.m. the survey team discussed the concerns with Staff #1, 4, 11, 13 and 15.

Based on clinical record review, facility document review, and staff interview, the facility staff failed to ensure professional standards of quality were met for 5 (five) of 9 (nine) swing bed patients in regards to wound care, activities and patient monitoring. Patient #'s 12, 4, 6, 8, and 3.

The findings included:

1. The clinical record for Patient #12 was reviewed on 3/4/15. Patient #12 was admitted to swing bed status on 1/15/15 from acute inpatient care. The "Nurse's Note" on 1/15/15 documented, "...duoderm (hydrocolloid dressing) to left and right buttock areas. Pt (patient) c/o (complained of) pain in bottom- repositioned on side with pillow behind pt (patient)..." The surveyor, along with assistance from facility staff (Staff # 4 and 13) who were navigating the electronic medical record, were unable to locate any descriptive assessment or documentation of measurements of the wounds. The physician's "History and Physical" dated 1/15/15 documented "Sacral decubitus ulcer...daily wound care..." And on 1/16/15 there was a physician's order for "wound care". The surveyor nor the staff navigator was not able to locate in the electronic medical record any specific physician's orders for wound care, no wound measurements or description, and the care plan was not individualized for the patient's skin condition and care of same. The "care plan" documented: assess location/extent of impairment, monitor appearance/character of skin, follow procedures for wound drainage, maintain aseptic tech/w (technique with) dressing change, follow protocol for tx (treatment of decubitus) and Maintain nutritional support" There was no documentation of the assessment of the skin and there was no order for a consult with the facility dietitian due to Patient #12's impaired skin integrity. No pictures of the wound was found in the clinical record.

There was documentation on 1/18/15 in the "Nurse's Notes" of: "...stage 2 decubitus ulcer to bilateral buttocks..."

The facility policy and procedure "Wound Care" was reviewed. This document was a one page document which evidenced Routine Orders for Wound Care: 1. A wound care assessment is to be completed on all patients admitted to the Med/Surg (Medical Surgical) floor. 2. Photographs of all wounds are to be taken after a consent form has been completed by the patient or patients representative. Stage 1: 1. Cover and protect (keep contaminants off, protect from friction) 2. Add moisture to epidermis. Products: 1. Moisturizers-Aloe Vesta Skin Cream or Zinc Oxide. 2. Lubricating spray/ointment-Granulex spray. 3. Transparent adhesive dressing-Tegaderm or op-site. (These films will help decrease friction, provide semi-permeable sterile but moist environment, and enable autolysis.) Procedure: Notify Physician for plan of care for wound treatment and document in CSPI Nursing Assessment Flow Sheet."

The Policy and Procedure for "Decubitus Ulcer Prevention" was reviewed and evidenced it had not been updated to reflect the National Pressure Ulcer Advisory Panel Guidelines for staging since 2003 (last update for NPUAP 2007) even though the policy documented a review date of May 2014.

"The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001." (http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/ accessed 3/17/15@6:23 p.m.).
When interviewed further regarding the lack or wound care orders, incomplete policy, lack of individualized care plan and out of date decubitus staging protocols on staff #4 stated, 3/4/15 at 1:25 p.m. "Well we go by Lippincott for things not covered in our policies..."

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

2. Review of the clinical record for Patient #4 revealed the Patient was admitted to the facility on 12/28/14 through 1/1/15 (acute inpatient) and then to swing bed status on 1/1/15 through 1/30/15, and then back to acute inpatient from 1/30/15 through 2/6/15. According to documentation on 12/28/14, Patient #4 had an order for "Wound Care" from the physician. The surveyor was unable to locate any specific orders, or order clarification for the "wound care" order. On 3/3/15 at 12:45 p.m., Staff #4 stated he/she was unable to locate in the clinical record any orders for specific wound care for Patient #4. There was no individualized wound care plan of care for Patient #4 found in the clinical record.

Further review of the clinical record revealed Patient #4 had a physicians order for "Digoxin (a medication used to treat irregular heart rhythms) 0.125 mg (milligrams) PO (by mouth) daily" and "Metoprolol ( a medication used to treat high blood pressure) 12.5 mg PO daily". The surveyor inquired as to the facility practice regarding the monitoring of the apical pulse for patients receiving these medications. On 3/3/15 at 12:45 p.m., Staff #4 stated, We use the standard form the pharmacy in the "facts and comparisons" and also the staff go by what is in the drug book on the unit..." The surveyor requested to examine the drug reference book that the staff currently have access to on the unit.

Review of the "Nursing 2015 Drug Handbook page 939 for "Metoprolol" revealed: "Nursing Considerations: Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute (beats per minute), withhold drug and call prescriber immediately..." For the medication "Digoxin" page 448: "Before giving drug,take apical-radial pulse for 1 (one minute), record and notify prescriber of significant changes or increase or decrease in pulse quality or deficit, irregular beats..." Staff #4 stated on 3/3/15 at 10:20 a.m., that he/she would expect staff to be "checking the apical pulse and documenting it."

The surveyor, with assistance from the facility record navigator, was unable to locate any documentation of an apical pulse being recorded before the administration of these medications in the clinical record for Patient #4.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 2:40 p.m. the survey team again discussed the concerns with Staff #1, 4, 11, 13 and 15.


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3. During a review of Patient #6's medical record, the Medical Facility Inspector (MFI) noted an order dated 2/18/2015 for Clonidine (Catapres) 0.1 mg tablet, directions give by mouth PRN (as needed) every 6 hours for SBP (systolic blood pressure) greater than 180 or DBP (diastolic blood pressure) greater than 110. The MFI also noted two orders dated 2/19/2015 to d/c (discontinue) telemetry and for routine vital signs. The MFI, with the assistance of Staff Person #13 navigated Patient #6's medical record but were unable to find documentation of vital signs being performed every 6 hours. Without every 6 hour monitoring of Patient #6's blood pressure, it would not have been possible for the nursing staff to determine whether or not a PRN administration of Clonidine was needed. Patient #6's medical record also revealed an order dated 2/18/2015 for Enalaprilat 1.25 mg (milligrams)/ml (milliliter) IVP (intravenous push) PRN (as needed) every 6 hours for SBP greater than 180 or DBP greater than 110. The MFI also noted two orders dated 2/19/2015 to d/c telemetry and for routine vital signs. The MFI, with the assistance of Staff Person #13 navigated Patient #6's medical record but were unable to find documentation of vital signs being performed every 6 hours. Without every 6 hour monitoring of Patient #6's blood pressure, it would not have been possible for the nursing staff to determine whether or not a PRN administration of Enalaprilat was needed.

4. During a review of the medical record for Patient #8, date of swing bed admission 2/12/2015, the MFI noted that the patient was started on Digoxin with a loading dose of 0.25 mg IVP (intravenous push) at 1436 (2:36 PM on 2/16/2015, He/she received Digoxin 0.125 mg p.o. (by mouth) daily after that for the remainder of the hospital stay, and was discharged home on Digoxin. Acceptable standards of practice for the administration of Digoxin include manually monitoring an apical pulse for one full minute prior to administration and to notify the physician if a pulse less than 60. Patient #8's vital signs were monitored routinely daily at 8:00 AM; based on an interview with Staff Person #4, staff use Welch Allen Vital sign machines to obtain routine vital signs. Digoxin was administered between 8:00 AM and 9:00 AM daily 2/17-2/24/2015. The EMAR ( electronic medication administration record) for Patient #8 was reviewed by the MFI on 3/3/2015, and lacked documentation that an apical pulse was obtained prior to administration of Digoxin, and there was no documentation of a pulse on the EMAR. During an interview with Staff Person #4 on 3/3/2015 at 1:00 PM regarding the facility's policy and procedure for administration of Digoxin, he/she stated "Expectation is that staff check apical pulse and document on the MAR assessment prior to administration of Digoxin".

5. During a review of Patient #3's medical record, the Medical Facility Inspector (MFI) noted an order dated 12/24/2014 for Clonidine (Catapres) 0.1 mg tablet, directions give by mouth PRN (as needed) every 6 hours for SBP (systolic blood pressure) greater than 180 or DBP (diastolic blood pressure) greater than 110. The MFI also noted an order dated 12/24/2014 for routine vital signs. The MFI, with the assistance of Staff Person #13 navigated Patient #6's medical record but were unable to find documentation of vital signs being performed every 6 hours. Without every 6 hour monitoring of Patient #3's blood pressure, it would not have been possible for the nursing staff to determine whether or not a PRN administration of Clonidine was needed.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 2:40 p.m. the survey team again discussed the concerns with Staff #1, 4, 11, 13 and 15.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure 5 (five) of 9 (nine) swing bed patients of the survey sample had their nutritional needs met. Patient #'s 7, 8, 20, 18, and 3.

The findings included:

1. Patient # 7 was initially admitted on 1/5/15 as acute inpatient and on 1/8/15 was admitted to swing bed status. Patient #7's record was reviewed on 3/2/15 and revealed the admission weight was 138.13. On 02/3/13 the patient had a "Nutrition Assessment" from the dietitian which documented the weight as 128.3 which was a 10 (ten) pound loss. On 2/26/15, the weight for Patient #7 was documented as 121.6 (17 lb loss) and on 3/2/15, the weight was at 123.3 (a 2 pound gain- 15 pound loss since admission). The assessment of the dietitian evidenced: NH (Nursing home) resident dementia NV (nausea vomiting) w/emesis (with vomiting) 2/1 now resolved, advanced dementia, UTI (urinary tract infection) 50% most meals noted to require thickened liquids now awaiting placement- per RN (registered Nurse) MD (physician) wants to try Prostat (protein supplement) if pt (patient) does not tolerate recommend trying thickened carnation instant breakfast tid (three times a day w/ (with) meals may also try ensure pudding. Malnutrition risk r/t (related to) adv (advanced) age patient w/ (with) complex medical issues and intake supplementation like ensure pudding...Monitoring/Evaluation: wts (weights) labs, intakes, diet adequacy vs (versus) supplementation, bowel function, skin integrity POC (plan of care)...Follow-Up 2/10/15: pt (patient) eating well (staff feeds) for added protein recommend thickened CIB (carnation instant breakfast) w/ (with) meals ensure pudding if prostat is not tolerated, weight is down this admit monitor BM (bowel movement) voids..."

Patient #7 had an order for "Prostat" (protein supplement) on 2/9/15 and the order was discontinued 2/13/15 due to "patient refusal". The surveyor was unable to locate any orders for the carnation instant breakfast or ensure pudding which was recommended by the dietitian. Review of the "meal intake" documentation for Patient #7 revealed inconsistent documentation of the patient's intake as follows:
1/5/15- no breakfast intake was documented
1/6/15- no dinner intake was documented
1/7/15- no dinner intake was documented
1/9/15- no lunch intake was documented
1/10/15 - no lunch or dinner intake was documented
1/12/15- no dinner intake was documented
1/13/15- no breakfast intake was documented
1/18/15 no breakfast or lunch intake was documented
1/21/15- no breakfast intake was documented
1/22/15- no breakfast intake was documented
1/25/15- no lunch intake was documented
2/1/15- no lunch intake was documented
2/7/15- no lunch intake was documented
2/11/15- no dinner intake was documented
2/17/15- no lunch intake was documented
2/19/15- no lunch intake was documented
2/20/15- no dinner intake was documented

The surveyor was unable to locate a care plan for Patient #7 which addressed the nutritional needs/potential for malnutrition on the clinical record. Staff #4 stated on 3/2/15 at 1:40 p.m., that, "(Patient #4) was given the carnation instant breakfast and the ensure pudding by the staff but he/she stopped taking is, so the staff stopped giving it to him/her (Patient #7)." Staff #4 was unable to locate an order for or documentation of the carnation instant breakfast or the ensure pudding.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 1:00 p.m. Staff #11 stated the dietitian had been doing a monthly report, and a checklist. The surveyor requested to review the report. At 2:15 p.m., Staff #11 stated, "He/She (dietitian) has not been doing them but will start doing them now..."



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2. A review of the swing bed record for Patient #8 by the MFI on 3/3/2015 revealed the reason for admission to be physical therapy (PT) for strengthening status post (s/p) GI (gastrointestinal) bleed with other diagnoses including anorexia, unintentional weight loss, hypomagnesia (decreased magnesium levels), Diabetes, depression, hypotension, and anxiety. The MFI noted an order by Staff Person # 19 for a forty-eight (48) hour calorie count, as well as a progress note by Staff Person #19 from 2/19/2015 documenting "Weight loss. Calorie count in progress.". Staff Person #13 and the MFI reviewed he medical record for Patient # 19; however, it lacked documentation of a 48 hour calorie count. When interviewed on 3/3/2015 between 1:30 PM and 2:00 PM, Staff Person #13 stated "The dietician only sees clients if consulted by the doctor or nursing based on dietary assessment, which was not completed for this patient".

3. A review of the swing bed record for Patient # 20 by the MFI on 3/4/2015 revealed that a nutritional assessment was not completed on the initial interview. Patient #20 was admitted to a swing bed with a diagnosis of DVT (deep vein thrombosis) status post (s/p) Coronary Artery Bypass Surgery (CABG). Patient #20 had several risk factors for malnutrition including increased nutritional needs associated with wound healing s/p CABG, and a medication regimen which included Lasix, a diuretic.The Interdisciplinary Team (IDT) meeting note dated 1/21/2015 included documentation by Staff Person #37 of an "inadequate diet, increased protein needs, d/c (discontinue) Juven (a nutritional drink to support tissue building to promote wound healing), add ensure, c/o (complains of) nausea, prefs (preferences) obtained, honor these....low alb (albumin, a protein in the blood used for tissue repair), edema bilateral lower edema...".

4. A review of the swing bed record for Patient #18 by the MFI on 3/4/2015 revealed that a nutritional assessment was not completed on the initial interview. Patient #18 was admitted to a swing bed after a stay in the facility's hospital; there was documentation in the hospital record that Patient #18 was seen by a dietician during that stay; however, there was no documentation that the patient was seen by the dietician after being admitted to a swing bed, and there was no documentation by a dietician on the IDT meeting note dated 1/21/2015 . Patient #18 was admitted to a swing bed with possible sepsis/weakness, and he/she had multiple risk factors for malnutrition, including dementia, depression, constipation, dysphasia (difficulty swallowing), and gastric reflux.

5. Patient #3 was an acute care admission to the hospital between 12/24/2014 through 1/1/2015 with diagnoses of ulcer of lower limb, right leg pain,chronic renal failure (CRF), type 2 diabetes, gout, hypothyroidism, and depression. Patient #3 was receiving home health services prior to the hospital admission, and had a wound vac due to a wound on the left leg prior to admission. On admission, there was documentation that Patient #3 had developed a 5 cm (centimeter) x 4 cm ulcer on the right leg. Documentation by the dietitian on 12/30/2015 includes "....poor intakes, sometimes takes Juven (a nutritional drink to support tissue building to promote wound healing), sometimes not, does drink his Ensures t.i.d. (three times daily) and sometimes asks for one...overall tolerating Ensures wt (weight) up slightly from admit noted, UTI (urinary tract infection) dx (diagnosis) wt fluct (fluctuation) noted per RN (registered nurse) constipation main issue and likely cause of low appetite/intakes recently, continues tolerating Ensure per RN...". Nutrition diagnosis includes documentation that Patient #3 has inadequate oral food/beverage intake, increased nutrient needs, and increased protein needs related to poor p.o. (by mouth) meals and fluids, wounds and UTI. The medical record for Patient #3 lacked documentation of percent of Ensure supplements consumed, or whether he/she accepted or refused supplements. Patient #3 was moved to a swing bed on 1/1/2015; the dietitian follow-up note dated 1/6/2015 documented "pt (patient) with decreased P.O. intakes per RN likely related to constipation issues now working to resolve this today, tolerating p.o. and Juven, overall blood glucose well controlled...p.o. had been good 50-100% meals now at 10% continue OBR (oral bowel routine) and current diet plan with oral supplements.". The swing bed record also lacked documentation of percent of supplements consumed, or whether Patient #3 refused or accepted supplements.

On 3/4/15 at 3:20 p.m., the survey team reviewed the concerns with the administrative staff #1, 4, 11, and 13, and 15.

On 3/9/15 at 3:15 p.m. the survey team again discussed the findings with administrative staff #1, 4, 11, 13 and 15.