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Based on record review and interview the facility failed to ensure staff members were certified in accordance with applicable Federal, State and local laws and regulations. Specificially, the facility failed to ensure 4 out of 12 nursing staff maintained current CPR certification.

The failure to teach staff members providing direct patient care to recognize and care for breathing and cardiac emergencies have the potential to affect all patients admitted to the facility.

Findings include:

Review of Staff #11's Employee File revealed no current CPR certification.


Review of Staff #13's Employee File revealed no current CPR certification.


Review of Staff #14's Employee File revealed no current CPR certification.


Review of Staff #15's Employee File revealed no current CPR certification.


Interview on 02/20/2014 at 10:30 AM with Staff #8 revealed that Staff #11, #13, #14 and #15 did not have current CPR certification. Staff #8 stated that Staff #11, #13, #14 and #15 all should have current CPR certification.

Review of the facility's Job Description for Registered Nurses dated 02/01/1997 read, "Job qualifications for Registered Nurse is current CPR certification."

Review of the facility's Job Description for Licensed Vocational Nurses Policy dated 02/01/1997 read, "Job qualifications for Licensed Vocational Nurse is current CPR certification."

Interview on 02/20/2014 at 10:31 AM with Staff 8 revealed that Staff #11, #13, #14 and #15 work in the facility's Emergency Department.

Review of the facility's Cardiac Arrest Emergency Department Policy undated read, "All cardiac arrests within the Emergency Department will be treated according to the standards established by the American Heart Association. All Emergency Department staff will be CPR certified."

Based on observation, interview and record review the facility failed to provide a clean and orderly environment.

The failure to provide a clean and orderly environment has the potential to spread sources and transmission of infections and communicable diseases to all patients admitted to the facility.

Findings include:

Observation on 02/19/2014 at 9:40 AM in the facility's Emergency Room revealed 4 cracks that ran the full length of the Emergency Room floor.
Observation on 02/19/2014 at 10:00 AM in the facility's Small Emergency Room revealed a examining table with a mattress that had several pieces of its vinyl covering torn, exposing the padding underneath. Further observation of the patient bathroom in the Small Emergency Room revealed chipped paint and lots of rust on the metal door frame.
Observation on 02/19/2014 at 10:36 AM in the facility's Materials Management Room revealed several ceiling titles had yellow and brown stains on them. Further observation revealed that there were several broken pieces of ceiling title around the air condition vent.
Observation on 02/20/2014 at 11:30 AM in the facility's kitchen revealed a hole at the top of the wall under the air conditioner.
Interview on 02/20/14 at 11:31 AM with Staff #21 revealed that there should not be a hole in the wall in the facility's kitchen. Staff #21 revealed that she was not aware there was a hole in the wall in the facility's kitchen.
Review of the facility's Infection Control Policy undated read, "The facility will control the spread of infection within the hospital by maintaining a thoroughly clean and safe environment."

Based on a review of documentation, the governing body was not responsible for determining, implementing and monitoring policies governing the facility's total operation and for ensuring that those policies were administered so as to provide quality health care in a safe environment.

Findings were:

A facility document provided to the surveyors by the Chief Nursing Officer on 2-20-14 states that Registered Nurses at the facility are required to have current certification in BLS (Basic Life Support) and ACLS (Advanced Cardiac Life Support).

In a review of personnel files for 7 Registered Nurses (staff #5, #7, #8, #9, #10, #14 and #15), 3 of the 7 Registered Nurses (#10, #14 & #15) lacked current certification in ACLS.

Facility policy titled "Nurse Staffing Committee Policy" states, in part, "POLICY: 4. The Committee will meet at least quarterly and more frequently if desired. 7. The Committee will identify nurse-sensitive outcome measures and will use it to evaluate the effectiveness of the hospital's staffing plan."

A review of meeting minutes for 2013 revealed that only 3 of the required 4 meetings of the Nursing Advisory Committee were held:
· 3-7-13
· 10-2-13
· 11-6-13
No nurse-sensitive outcome measures were identified.
The above was confirmed in an interview with the Chief Executive Officer on 2-20-14.

Based on observation, outdated or otherwise unusable drugs were available for patient use.

Findings were:

During a tour of the facility on 2-19-14, the following outdated or unusable drugs were found:
· In the ER crash cart, 3 of 3 2-ml vials of Verapamil had expired 1-1-14 but were still available for patient use.
· In the ER crash carft, 1 of 1 50-ml vial of Lidocaine 1% had expired 2-1-14 but was still available for patient use.
· In the ER crash cart, 3 of 3 10-mg vials of Vecuronium had expired 1-1-14 but were still available for patient use.
· In the ER crash cart, 2 of 2 4-ml vials of Lasix had expired 2-1-14 but were still available for patient use.
· In the ER crash cart, 2 of 2 5-ml vials of Lidocaine 2% had expired 2-1-14 but were still available for patient use.
· In the ER crash cart, 2 of 2 24-guage intravenous needles had expired 12-13 but were still available for patient use.
· In the ER crash cart, 1 of 1 pediatric crycothyrotomy kit had expired 1-14 but was still available for patient use.
· In the ER crash cart, 1 of 1 adult crycothyrotomy kit had expired 1-14 but was still available for patient use.
· In the ER crash cart (pediatric section), 2 of 2 1-ml vials of Epinephrine had expired 1-14 but were still available for patient use.
· In ER Cabinet #2, 1 of 1 bottle of Maxitrol had expired 1-14 but was still available for patient use.
· In the patient care area nourishnment room, 2 of 2 8-oz cans of Beneprotein had expired 1-21-14 but were still available for patient use.
· In the service entrance janitor closet, 1 of 1 bottle of buffered emergency eyewash had expired 11-10 but was still available for use.

During a tour of the kitchen on 2-20-14, the following outdated or unusable drugs were found:
· In the kitchen area, 1 of 1 bottled of buffered emergency eyewash had expired 8-12 but was still available for use.
· In the dishwashing room, 1 of 1 bottled of buffered emergency eyewash had expired 8-12 but was still available for use.

The above was confirmed in an interview with the Chief Executive Officer on 2-20-14.

Based on record review and interview the facility failed to furnish an Activity Assessment in 1 of out 5 sampled Swing Bed resident's charts. Specifically, the facility failed to complete an activity assessment designed to ensure an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

This failure has the potential to affect all Swing Bed residents who require an ongoing program of activities that is designed to appeal to his or her interests and to enhance the resident's highest practicable level of physical, mental, and psychosocial well-being.

Findings include:

Review of Resident #17's chart revealed no Activity Assessment was completed. Further review of Resident #17's chart revealed that he was admitted to swing bed status on 11/15/2013 for left extremity pain with x-ray findings of lytic bone lesions in the femur. Further review of Resident #17's chart revealed he was discharged from swing bed status on 11/30/2013.

Interview on 02/20/2014 at 12:03 AM with Staff #8 revealed that a Activity Assessment was not completed on Resident #17. Staff #8 stated that since Resident #17 was a swing bed patient, an Activity Assessment should have been completed.

Review of the facility's Patient Activities Policy and Procedure undated read, "The purpose of an activities program is to create an environment that is as near to normal as possible, thereby encouraging persons in a facility to exercise their abilities. An activities program provides physical, intellectual, social, spiritual and emotional challenges much in the same way that everyday life in the community provides challenges. It provides these challenges in a planned, coordinated and structured manner and the activities provided are beneficial in overcoming specific problems. Within 72 hours of the patient's admission, the Patient Activities Coordinator will make an initial visit to the patient to determine the patient's interest and need, physician's recommendations etc. This applies to all patients, whether bedfast or ambulatory. The coordinator will then complete an Activities Assessment Form containing an activities plan for each individual patient. This plan will be discussed with the attending physician in order to identify limitations and modifications in the activities plan and to assure that the activities plan does not conflict with the prescribed medical plan of care. Upon approval of the attending physician activities may be instigated. The activities assessment form becomes a part of the patient's medical record and is used in completing the Nursing Care Plan. The Activities Plan for each patient is to be revised periodically to reflect interest and need. The plan must be revised at least every 14 days."