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Based on a review of the facility's credentialed files, governing board bylaws, medical staff bylaws, policies and procedures, and staff interviews it was determined that the facility failed to ensure ongoing medical staff professional peer evaluations.

Findings were:

A review of credentialed files (#1, #2, #3, #4, and #6) revealed no evidence of peer reviews for five (5) of six (6) files.

A review of the governing board bylaws revealed that the board appoints the recruitment of the medical staff and ensures the compliance with the medical staff bylaws rules and regulations and the credentialing process of the facility. The board ensures compliance with performance improvement efforts in monitoring physicians through peer review, FPPE (Focused Professional Peer Evaluation), OPPE (Ongoing Professional Peer Evaluation), and hospital-wide in the performance improvement committee which is a medical staff committee.

A review of medical staff bylaws revealed that the responsibilities of the medical staff are to account to the Board for the patient care processes and outcomes rendered by all Members, Residents, Interns, and Allied Health Professionals authorized to practice in the facility through the following:

--A procedure in place for monitoring patient care practices, including intake, assessment, treatment plans, treatment plan reviews, and restraint and seclusion;
--Analysis of patient care processes and outcomes through a valid and reliable quality management program consistent with the requirements of the Joint Commission and CMS (Center for Medicaid and Medicare Services).
--A procedure to ensure that each Member and Allied Health Professional provides services within the scope of individual Clinical Privileges granted.

Review of the facility's policy entitled FPPE/OPPE, no policy number, no date, revealed that the policy would define, determine, maintain, evaluate and verify the general competencies, experience and physical ability of existing and new practitioners to provide care, treatment, and services to patients. The policy further revealed that the OPPE (Ongoing Professional Practice Evaluation), is defined as the documented review and summary of ongoing data collected for the purpose of assessing a practitioner's clinical competence to perform quality/safe patient care services in all areas of general competencies. The policy revealed that FPPE (Focused Professional Practice Evaluation) is defined as the establishment of current privilege/procedure-specific competence when performing requested privileges for new practitioners or to address concerns regarding a practitioner's ability to provide safe, high-quality patient care or to address competency concerns identified through the OPPE process.

During an interview on 08/28/18 at 2:45 p.m. in the conference room with the CNO (#1) and the credentialing file specialist, it was acknowledged that five (5) out of six (6) credentialed files did not contain any peer review documentation.

Based on a review of the facility's policies and procedures, facility logs, staff interview, and medical record review, the facility failed to monitor the patient's (#1, #6, #11, #3, #19 ) blood pressure for five (5) of twenty (20) patients reviewed.

Findings

A review of the facility policy, no number, "Vital Signs," effective date February 2018, revealed that an order for vital signs should be interpreted as including temperature, pulse, respirations, and blood pressure. Oxygen saturation would be recorded as appropriate. A further review revealed that the registered nurse (RN) would assess a patient's vital signs as ordered by the physician, and the vital signs would be documented on a flow sheet and placed in the patient's medical record.

A review of the medical record revealed a Medical Doctor (MD) order dated 08/22/18 at 11:40 p.m. for Patient #6 to have vital signs assessed and recorded four (4) times per day while awake.

A review of the Vital Signs Record dated 08/26/18 revealed that Patient #6 had vital signs assessed and documented at 8:00 a.m. and 11:00 a.m.

A review of the medical record revealed a Medical Doctor (MD) order dated 04/19/18 at 7:00 a.m. for Patient #1 to have vital signs assessed and recorded daily.

A review of the Vital Signs Record dated 04/18/18 through 04/24/18 revealed that Patient #1 had no vital signs documented on 04/21/18.

A review of the medical record revealed a Medical Doctor (MD) order dated 08/25/18 for Patient #11 to have vital signs assessed and recorded four (4) times per day while awake.

A review of the Vital Signs Record dated 08/26/18 revealed that Patient #11 had no vital signs documented at 7:40 a.m. and 4:00 p.m.

A review of the medical record revealed a Medical Doctor (MD) order dated 06/11/18 at 10:00 p.m. for Patient #3 to have vital signs assessed and recorded four (4) times per day while awake.

A review of the Vital Signs Record dated 06/11/18 through 06/15/18 revealed that on 06/14/18 Patient #6 had vital signs assessed and documented at 8:00 a.m. and 11:00 a.m.

A review of the medical record revealed a Medical Doctor (MD) order dated 06/02/18 at 10:54 p.m. for Patient #19 to have vital signs assessed and recorded four (4) times per day.

A review of the Vital Signs Record dated 06/02/18 through 06/11/18 revealed that on 06/05/18, 06/07/18, and 06/09/18 Patient #19 had vital signs assessed three ((3) times in a twenty-four (24) hour period. On 06/10/18, the patient's vital signs were assessed two (2) times in a twenty-four period.

During an interview with the Chief Nursing Officer (Employee #1) on 08/28/18 at 1:45 p.m. in the Conference Room, the Chief Nursing Officer (CNO) stated that it was his/her expectation of the nursing staff to assess and record the patient's vital signs as ordered by the MD. The CNO added that vital signs and MD orders are part of the nursing orientation process and annual competencies check-off.

Based on observation, review of records, and interviews, the facility failed maintain a clean environment in the kitchen area in such a manner that ensues the safety and well-being of patients.

A review of the facility's policy and procedures for "Storage Procedure", no date listed, revealed that the facility shall remove any expired products from storage and properly dispose product. The policy further listed that flour and sugar were to be stored in portable bins with tight fitting covers and labeled, and dry goods shall be placed in plastic containers with tight fitting lids after they are opened. The policy listed the containers shall be labeled with product and date, and products should be checked periodically for insects. The policy further provided that frozen foods must be properly covered.

During the tour of the kitchen's refrigerator on 8/27/18 at 2:10 p.m., the following were observed:
-2 (two) cartons of soy milk with an expiration date of 8/22/18,
-1 (one) container of ham base with no expiration date or dates of applicable use on its container, -1 (one) bag of Ricotta cheese with an expiration date of 6/30/18,
-2 (two) rotted, brown colored lemons covered in white matter in a box of lemons.

During an interview on 8/27/18 at 2:15 p.m. in the kitchen walk-in refrigerator with the Food Service co-managers, the Food Service managers were unable to provide any information regarding the applicable food use of the Ricotta cheese, and ham base. The food service managers further stated that they would find out from their food service provider the expiration dates of the aforementioned items. No further information was provided to identify the expiration dates of the aforementioned items.

During the tour of the kitchen's freezer on 8/27/18 at 2:20 p.m., 1 (one) bag of peas inside a cardboard box and 1 (one) bag of carrots inside a cardboard box were found opened and unsealed.

During an interview on 8/27/18 at 2:25 p.m. in the kitchen walk-in freezer with the Food Service co-managers, the Food Service managers acknowledged the unopened bags of frozen vegetables. The Food Service managers further stated that staff members may have forgotten to seal the bags of frozen vegetables.

During the tour of the kitchen's dry storage area on 8/27/18 at 2:40 p.m., the following were observed:
-1 (one) jar of Maraschino cherries with no expiration date(s) of applicable use on its container, 1 -1 (one) plastic bottle of mayonnaise with no expiration date,
-unidentified black, oblong shaped droppings in on top of 1 (one) can of gelatin
-unidentified black, oblong shaped droppings in a box with 5 bags of expired sugar free whipped topping (expiration date of 4/17/17),
-A rodent trap in proximity of the gelatin can in the dry storage area.

The following were found unsealed and open to the elements;
-1 (one) bag of grits,
-1 (one) bag of flour,
-1 (one) large bag of bread crumbs,
-2 (two) boxes of cornstarch.

During an interview on 8/27/18 at 2:45 p.m. with the Food Service co-managers, the Food Service co-managers acknowledged the unidentified black droppings in oblong shapes and stated that the facility did not have a rodent issue at the time of survey, but that the rodent trap was a preventive measure. In addition, the Food Service co-managers stated that the facility's maintenance recently completed above the ceiling tiles and that may be the reason of the observed droppings. The Food Service managers stated that the sugar free whipped topping was not in patient or retail use. The Food Service managers further acknowledged the unopened dry goods and stated that staff members may have forgotten to close and secure the dry goods after use. The Food Service managers were not able to determine the expiration date of the jar of Maraschino cherries and plastic bottle of mayonnaise.

Also observed during a tour of the dishwashing area of the kitchen on 8/27/18 at 3:00 p.m., a floor fan with multiple layers of dark, gray dust on the fan blades and cover, circulating air in the direction where clean food preparation and storage equipment pass through after wash cycles. At the time of the observation the Food Service co-managers acknowledged the finding and stated that the fan was needed because of the extreme heat in that area of the kitchen.