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Based on policy review, record review, observation and interview the facility failed to:
-ensure medications are kept in a locked, secured area to prevent unauthorized access;
-inspect and remove expired, mislabeled, or unusable medications;
-properly label medications;
-report medication errors according to their policy;
-maintain a clean environment;
-properly store medications;
-ensure staff followed guidelines to prevent the risk of transmission of organisms;
-properly handle infectious waste;
-ensure patients received photographic documentation of wounds according to facility policy;
-ensure telephone/verbal orders were dated, timed and signed within 48 hours;
-document time of physician orders;
-ensure medications were administered timely;
-identify the patient before administering medications;
-follow manufacturer guidelines for administering a subcutaneous injection;
-administer the correct dosage of medications;
-ensure staff transcribed medication orders correctly;
-have currently signed orders for Sliding Scale Insulin; and
-identify and/or update the nursing care plans.

The facility census was 13.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with the Condition of Participation: Provision of Services.

Based on interview the facility failed to have a group of professionals develop and/or review facility policies. This had the potential to affect all patients. The facility census was 13.

Findings included:

In an interview on 8/6/10 at 9:05 AM, Staff D, Administrator said the facility had not used a group of individuals including a physician, nurse practitioner and someone other than facility staff to develop and/or review policies in at least two years.

Based on facility policy review, record review, observation, and interview, the facility failed to:
- Ensure medications are kept in a locked, secured area to prevent unauthorized access;
- Inspect and remove expired, mislabeled, or unusable medications; and
- Properly label medications.
These failures had the potential to affect all patients in the facility. The facility census was 13.

Findings included:

1. Observations showed:
- On 8/3/10 at 2:45 PM 20 pre-filled syringes of Normal Saline (salt water for injection) in an unlocked wall mounted holder located in the hallway, across from the nurses' station.
- On 8/4/10 at 10:15 AM 20 pre-filled syringes of Normal Saline (salt water for injection) in an unlocked wall mounted holder located in the hallway, across from the nurses' station.
- On 8/5/10 at 2:45 PM six pre-filled syringes of Normal Saline in an unlocked bin on the crash cart outside of a procedure room in out-patient services.
- On 8/5/10 at 2:50 PM four medications in an unlocked refrigerator in the surgical suite recovery room.
- On 8/3/10 at 3:45 PM a bottle of Miralax (a stool softener and laxative for constipation) and approximately 8 Dulcolax (laxative) tablets in an unlocked cabinet in a Outpatient/Urgent Care examination room.
- On 8/5/10 at 3:30 PM multiple bottles of Marcaine 0.5% (an injectable anesthetic) in several procedure carts within the Radiology Department.

Interviews revealed:
- On 8/4/10 at 11:10 AM, Staff E, Chief Nursing Officer stated Normal Saline is considered a drug and should be locked in the medication room.
- On 8/4/10 at 2:50 PM, Staff W, Nurse Director of Surgery stated the medications in the Recovery Room refrigerator are for the crash cart and there should be a lock on the refrigerator.

2. Review of the facility policy titled, "Outdated Medications", revised 8/6/08, gave the following directions (in part):
- "Medication storage areas will be checked monthly by the pharmacy staff for outdated medication."
- "Medication found to be outdated will be pulled from area, returned to pharmacy and placed in the outdated medication area."

Observations showed:
- On 8/3/10 at 3:20 PM in the medical/surgical medication room, the following expired medications:
- Fleet enema for Children (used to treat constipation or clean the bowel), expired 03/09;
- Isopropyl alcohol (disinfectant used externally), one bottle, opened 06/28/06, expired 07/08;
- Tincture Benzoin (solution used on skin to help tape adhere), expired 12/09;
- LoSo Bowel Prep (used to induce a bowel movement), expired 11/09.

- On 8/5/10 at 3:30 PM in the Radiology Department a bottle of Marcaine 0.5% with an expiration date of 11/09.

Interviews revealed:
- Staff E, Chief Nursing Officer, confirmed the above medications and biologicals were expired and should have been removed from the medication room.
- Staff S, Director of Radiology, confirmed the Marcaine was expired and should be removed.

During an interview on 8/5/10 from 8:30 AM to 11:30 AM, Staff U, Pharmacist said there is no inspection or inventory of medication storage areas within the facility except for the Pyxis [Medstation], crash carts (mobile cart used for emergency life-saving equipment and medications), and the narcotic box in the surgical suite.

3. Review on 8/4/10 at 10:28 AM of Patient #8's medical record revealed a physician order written 7/28/10 for ranolazine [Ranexa]" (used to treat chest pain) 500 mg (milligram) po (by mouth) every 12 hours.

Observation on 08/04/10 at 8:45 AM showed Staff J, L.P.N. (Licensed Practical Nurse) removed one tablet from an envelope with a hand-written label of "Ranexa 50 mg tabs" and administered it to Patient #8.

In an interview on 8/4/10 at 11:30 AM, Staff B, R.N., (Registered Nurse) stated the medication in the envelope labeled "Ranexa 50mg" was identical to medication in a bottle labeled "Ranexa 500 mg" and said "CVT 500" was stamped into both pills, indicating it was the same medication. Nurse B said the envelope used for Patient #8's medication administration was labeled wrong.



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28722

Based on facility policy review, record review, observation and interview, the facility failed to report medication errors according to their policy for two patients (#8 and #15) of six patients observed during medication pass. The facility census was 13.

Findings included:

1. Review of the facility policy titled, "Event Report Guidelines and Procedure," revised 8/08, gave the following direction (in part):
"PROCEDURE:
- 1. The hospital employee with the knowledge of the event is responsible for completing the report form.
- 2. Complete an Event Report Form for any of the following events or conditions which:
- A. May result, has resulted or could have resulted in an injury to a patient or visitor.
- B. Reflects a variation from customary hospital policy, procedure or practices that adversely affect patient care.
- 5. Document in the patient's record only a factual description of the occurrence, what was done for the patient, and who was notified. DO NOT make reference to the Event Report in the patient's chart."
"- MEDICATION RELATED EVENT REPORTS: If an Event Report is completed due to a medication error, or near-miss a Medication Error Report Form should be completed. If an adverse reaction to a medication is noted, complete the Event Report and an Adverse Drug Reaction Form. Place the appropriate form and the Event Form in the Director of Nursing's mailbox."

2. Review of the medical record on 8/4/10 at 10:15 AM for Patient #8 revealed a physician order, written 7/28/10, for Potassium 40 mEq daily.

Observations on 8/4/10 at 9:07 AM, showed Staff J, L.P.N., administered Potassium Chloride 10 mEq (milliequivelents) to Patient #8.

During an interview on 8/6/10 at 11:10 AM, Staff E, Director of Nursing, confirmed that there were no Event Reports submitted for Patient #8's medication error on 8/4/10.

3. Review of the medical record on 8/4/10 at 10:00 AM for Patient #15 revealed a physician order written 8/3/10 for Propranolol 80 mg.

Observation on 8/4/10 at 9:58 AM, showed Staff J, L.P.N., administered Propranolol 40 mg to Patient #15.

Review of the medical record on 8/4/10 1:00 PM revealed no documentation in the nursing notes to indicate the attending physician was informed of the incident.

During an interview on 8/6/10 at 11:10 AM, Staff E, Director of Nursing, confirmed that there were no Event Reports submitted for Patient #15's medication error on 8/4/10.

Based on facility policy review, observation, record review and interview, the facility failed to:
- maintain a clean environment;
- properly store medications;
- ensure staff followed guidelines to prevent the risk of transmission of organisms for two patients (#12 and #13); and
- properly handle infectious waste.

These failures had the potential to affect all patients, staff, and visitors in the facility. The facility census was 13.

Findings included:

1. Observation on 8/3/10 at 2:45 PM showed the crash cart (mobile cart used for emergency life-saving equipment and medications) in the medical/surgical unit. The cart and equipment stored on top and sides of the cart were covered in dust. Staff E, Director of Nursing, confirmed that the cart needed cleaned.

Observation on 8/5/10 at 11:30 AM, during a tour of the Pharmacy showed the floor had small bits of paper and smudges of a dark colored substance.

Observation on 8/6/10 at 10:15 AM, during a tour of the Laboratory Department showed numerous black spots that appeared to be mold covering the air vent above the microbiology workstation.

During an interview on 8/6/10 at 10:20 AM, Staff T, Lab Technician, said mold has the potential to release spores which would contaminate laboratory specimens. The air vent covering was reported to the Maintenance Department, but had not yet been replaced.

2. Observation on 8/3/10 at 3:20 PM showed a corrugated box containing pre-filled syringes of Normal Saline (solution used for injecting into a patient) sitting directly on the floor in the medical/surgical medication room.

During an interview, Staff E, Director of Nursing, stated that the boxes should not be stored on the floor.

3. Review of a document provided by the facility titled, "Donning PPE (Personal Protective Equipment), gave the following direction (in part):
"Gown
Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back.
Fasten in back at neck and waist."

Review of a document provided by the facility titled, "Removing PPE (Personal Protective Equipment), gave the following direction (in part):"Gloves
Outside of gloves are contaminated."

Review of the facility policy titled, "Medication Administration", reviewed/revised 04/10, gave the following direction (in part):
"Pill splitter/crusher will be cleaned before and after each use."

Review of Patient #12's medical record revealed he/she was admitted on 8/3/10 with MRSA (Methicillin-Resistant Staphylococcus Aureus [infection resistant to antibiotics]), which requires isolation precautions.

Observation on 8/4/10 at approximately 9:30 AM showed Staff P, Respiratory Therapist administering a breathing treatment to Patient #12. Staff P's isolation gown was not tied at the waist, which allowed the ties of the gown and his/her personal clothing to come in contact with the patient's bed. After surveyor entered the room, Staff P tied the gown at the waist. Staff P used his/her gloved hands to reach inside the isolation gown to remove something from their pocket two times. One of these times, Staff P removed a pulse oximeter (small instrument to measure the patient's oxygen saturation) and placed it on the patient without cleaning. Staff P touched his/her hair several times with their gloved hands and returned those gloved hands to direct patient contact.

Observation on 8/4/10 at approximately 9:40 AM showed Staff I, L.P.N. (Licensed Practical Nurse) administer medications to Patient #12. A sign on Patient #12's entrance door showed that he/she was in reverse isolation. Staff I stated that anyone entering the room was to wear a protective gown, mask, and gloves. During the medication administration through the patient's J-tube (tube inserted through abdomen into the intestines for administering liquid food and medications), Staff I reached around to the inside of his/her gown and pulled a roll of tape out of their pocket. Staff I used the tape to secure the connection of the J-tube. Staff I removed tape from his/her pocket two times, returning the tape both times to their pocket after use. Staff I requested a pill crusher (tool used for crushing medications) be brought to the patient's room and another staff member handed this to Staff I. The pill crusher was used for crushing Patient #12's medications and afterwards the pill crusher was returned to the medical surgical unit's medication room without cleaning before or after use on Patient #12. During an interview, Staff I confirmed that the pill crusher was not cleaned.

Observation on 8/4/10 at approximately 10:45 AM showed Staff Q, C.N.A. (Certified Nurse Assistant) giving Patient #12 a bath. Staff Q did not have the isolation gown tied at the waist.

Observation on 8/4/10 at approximately 10:50 AM showed Staff I, L.P.N. administer medications to Patient #12, who was in reverse isolation. Staff I was unable to remove the tape around the connection of the J-tube so removed one of his/her gloves and proceeded to remove the tape with the ungloved hand and administer medications without hand hygiene or replacing the glove.

During an interview on 8/4/10 at 3:05 PM, Staff R, Infection Control Nurse, stated that the facility did not have a policy on "Reverse Isolation". Staff R confirmed that the isolation gown s should be tied at the waist. Staff R stated that an isolation patient is supposed to have dedicated equipment, or any equipment that goes in and out of the patient's room is to be cleaned in-between use. Staff R stated that gloves are to be worn while providing direct patient care to an isolation patient or if touching anything in the patient's environment. Staff R stated that if a staff member needs to get anything out of their pocket while wearing PPE (Personal Protective Equipment), they should remove their soiled glove, perform hand hygiene, remove the item from their pocket and then that item should be dedicated to that patient.

Observation on 8/4/10 at 11:15 AM showed Staff I, L.P.N. wore gloves to administer medication to Patient #13. Staff I continued to wear the same gloves to remove a dressing from Patient #13's right heel. Staff I reached into his/her pocket to obtain scissors. Staff I used the scissors to remove the dressing. Staff I changed gloves (without washing/using gel to clean hands) and cleaned the wound to the right heel. Staff I changed gloves (without washing/using gel to clean hands) and applied ointment and a dressing to the wound. Staff I placed the used scissors back in his/her pocket without disinfecting them.

In an interview on 8/4/10 at 11:40 AM, Staff I L.P.N. said it is facility policy to wash or use gel to clean hands after removing gloves. Staff I said he/she should have cleaned his/her hands when changing gloves during the wound care and should have cleaned the scissors before putting them back in his/her pocket.

4. Review of untitled written materials provided to this surveyor showed under Section 4.4.2.4., "All sharps are considered regulated medical waste, but these are to be placed in red, rigid, sharps disposal containers located in each patient room and in various patient areas throughout the hospital."

Observation of the Microbiology area of the Laboratory on 8/5/10 at 3:15 PM, showed approximately 15 blood slides laying on a countertop. Additional blood slides were observed in a small cardboard box on the countertop.

During an interview on 8/6/10 at 10:15 AM, Staff T, Lab Technician, said slides should be disposed of in a sharps container, but the practice is to keep the slides for several days so that specimens can be rechecked. According to Staff T, slides are usually stored in a "slide box," but the box is missing.



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28722

Based on record review and interview the facility failed to ensure one acute patient (#12) and two swing bed patients (#13 and #8) of nine sampled current patients received photographic documentation of wounds according to facility policy. The facility census was 13.

Findings included:

1. Review of the facility policy titled "Wound Photography" last revised 3/10 gave the following direction (in part):
"Policy:
When patients are admitted to the hospital with ulcerated cellulitis, pressure ulcers, diabetic ulcers, or problematic surgical or traumatic wounds a picture should be taken upon admission, every Tuesday, when there is a change in wound status and on discharge."

Review of the facility policy titled, "Photography," revised 5/08, gave the following direction (in part):
- "It is the policy of WCMH (Washington County Memorial Hospital) that a photograph shall be taken of all wounds, decubitus ulcers, and other skin issues on admission or during hospitalization if one should develop. Photographs should be repeated weekly, with any changes in wound status, and upon discharge."

2. Review on 8/4/10 at 8:50 AM of Patient #12's acute medical record revealed the patient was admitted on 8/3/10.

Review of Patient #12's Nursing Admission Summary revealed:
Pressure Sore Risk Identified-yes
Pressure Sore Identified-yes
Photos taken-no

The body diagram indicated an excoriated area over the coccyx.

Review of the Decubitus Wound Care Physician Orders revealed an order on 8/3/10 for Stage I (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved) Pressure Ulcer Present Standard Care.

Patient #12's medical record had no wound photographs.

In an interview on 8/4/10 at 9:05 AM, Staff E Chief Nursing Officer said photographs should be taken on admission of any skin areas of concern. Staff E confirmed there were no photographs in the chart or on the camera to be printed for Patient #12.

3. Review on 8/4/10 at 9:15 AM of Patient #13's swing bed medical record revealed the patient was admitted on 7/19/10.

Review of Patient #13's Physician Orders revealed an order on 8/1/10 for Bactrim (wound ointment) to wound on right heel two times a day and dress with 4X4 and wrap.

Review of Patient #13's Nursing Flow Sheet dated 8/3/10 revealed the patient had a skin area to the right heel.

Patient #13's medical record had no wound photo documentation from Tuesday 8/3/10.

In an interview on 8/4/10 at 10:10 AM, Staff I, Licensed Practical Nurse (L.P.N.) confirmed he/she had been assigned to Patients #12 and #13 on Tuesday 8/3/10. Staff I said wound photos are to be taken on Tuesdays. Staff I said he/she should have taken photos of Patient #12 and Patient #13's wounds yesterday but was tied up with another patient and did not have time. Staff I said he/she did not ask for help, but did pass it on the night nurse to take the photos.

4. Review of the medical record on 8/4/10 at 10:15 AM for swing bed Patient #8 revealed the patient was admitted to the facility on 7/28/10 for rehabilitation following a coronary artery bypass graft. Photos of Patient #8's surgical wound and bruises were taken upon admission. There were no wound photos taken 8/3/10.

During an interview on 8/4/10 at 10:28 AM, Staff J, L.P.N., said the weekly skin photographs were scheduled to be done on Tuesday 8/3/10, but were not done.


28722

Based on facility policy review, observation, record review and interview, the facility failed to:
- ensure telephone/verbal orders were dated, timed and signed within 48 hours for three patients (#8, #11, and #13);
- document time of physician orders for four patients (#7, #11, #12, and #13);
- ensure medications were administered timely for two patients (#12 and#15);
- identify the patient before administering medications for two patients( #8 and #15);
- follow manufacturer guidelines for administering a subcutaneous injection for one patient (#8);
- administer the correct dosage of medications for two patients (#8 and #15);
- ensure staff transcribed medication orders correctly for one patient (#15); and
- have currently signed orders for Sliding Scale Insulin for one patient (#13) of two patients receiving sliding scale insulin. A total of 26 medical records were reviewed and six patients were observed during medication administration.

The facility census was 13.

Findings included:

1. Review of the "Rules and Regulations of the Medical Staff" gave the following direction (in part):
"13. All orders for treatment shall be in writing and include both the doctor's signature and time of entry."

Review of the facility document titled, "Timely Entry Requirements", revised 7/30/08, gave the following direction (in part):
"Verbal orders are to be signed and dated by the physician within 48 hours after the verbal order has been given."

Review of the facility's policy titled, "Telephone/Verbal Orders", revised/reviewed 06/30/08, gave the following direction (in part):
"Telephone or verbal orders should be signed by the prescribing physician as soon as possible or within 48 hours."

2. Review of Patient #8's acute medical record on 8/3/10 revealed the following telephone order had not been signed by the physician.
- On 7/28/10 Albuterol (medication to dilate the airway) 0.83 mg (milligrams) Neb (nebulizer [inhaled medication]) tx (treatment) q (every) 4-6 hours prn (as needed).

Review of Patient #11's acute medical record revealed the following telephone/verbal orders were signed by the physician but not timed to indicate they were signed within 48 hours:
-On 8/2/10 Discontinue the oral Lasix, Discontinue CQ10 (nutritional supplement), cancel Fluorocortisone (steroid) 0.1 mg orally at bedtime

Review of Patient #13's swing bed medical record revealed in part the following telephone/verbal orders were signed by the physician but not timed to indicate they were signed within 48 hours:
-On 7/20/10 Insert Foley catheter, Dilaudid (pain medication) 1 mg IVP (intravenous push) every 6-8 hours as needed for pain
-On 7/22/10 Hydrocodone/Acetaminophen (pain medication) 5/325 one tablet orally every 6 hours as needed and monitor for lethargy, MOM (milk of magnesia) 30 milliliters orally one time, Discontinue Zofran (nausea medication) and start Phenergan (nausea medication) 25 mg IVPB (intravenous piggy back) every 6 hours as needed, Administer Fleets enema one time
-On 7/24/10 Phenergan 12.5 IVPB every 4-6 hours
-On 7/30/10 Zofran 4 mg IVP 45 minutes prior to breakfast, lunch and dinner
-On 8/1/10 Bactrim ointment to wound on right heel BID and dress with 4X4 gauze and wrap

3. Review of Patient #7's acute medical record revealed the following were written by a physician but not timed:
- On 8/3/10 Change Catapres (medication to lower blood pressure) to 0.1 mg (milligram) daily
Ativan (medication to reduce anxiety) to 0.5 mg 1 po (by mouth) q (every) 8 h (hours) prn (as needed)
- On 8/3/10 Prednisone (medication that helps prevent the body causing inflammation) to 20 mg 1 po q A.M.
- On 8/3/10 Type and cross for 2 units PRBC (Packed Red Blood Cells [blood transfusion]) give both and repeat H/H (Hemoglobin and Hematocrit [blood count]) and call to me."
- On 8/4/10 Increase Ativan to 1 mg tid (three times a day)
- On 8/4/10 Please have (physician) see pt (patient) to evaluate for GI (gastro-intestinal) source of blood loss.
- On 8/4/10 For blood sugar tests from finger stick > (greater than) 400 and < (less than) 500 give 20 units Novolog (insulin to lower blood sugar) and call MD (physician).
- On 8/4/10 Recheck CBC (Complete Blood Count [lab test to show basic blood cell components]), CMP [Comprehensive Metabolic Panel [lab test to show basic body functions]), CXR (Chest X-ray), BNP (Brain Natriuretic Peptide [lab test that measures the BNP hormone in the blood]) in A.M."

Review of current Patient #11's acute medical record revealed the following orders were written by the physician but had not been timed:
-On 8/2/10 Chest X-ray in AM, increase Lasix (fluid pill) to 40 mg intravenous daily, increase KCL (potassium) 20 mg orally TID (three times a day)
-On 8/3/10 Niferex Forte (iron supplement) 150 mg orally BID (two times a day), BNP and BMP (basic metabolic panel) (lab test) in AM

Review of current Patient #12's acute medical record revealed the following orders were written by the physician but had not been timed:
-On 8/3/10 Sputum for C&S (culture and sensitivity), check BMP and CBC (complete blood count) in AM

Review of current Patient #13's swing bed medical record revealed the following orders were written by the physician but had not been timed:
-On 7/19/10 Swing bed Admission Orders

4. Review of the facility's policy titled, "Medication Administration", reviewed/revised 04/10, gave the following direction (in part):
"The five rights will be used prior to administering the drug. This includes: ...Right Time and Frequency."

Observation on 8/4/10 from 9:20 AM to 10:10 AM showed Staff I, L.P.N. (Licensed Practical Nurse), administer medications late to Patient #12. At 9:55 A.M., Staff I stated that he/she needed to get an applicator to administer Nystatin (medication for fungal infections). At 10:10 AM, Staff I stated that he/she still had to administer the Nystatin to Patient #12 as well as two other medications that hadn't arrived from pharmacy but needed to give medications to another patient first.

Observation on 8/4/10 at 10:40 AM showed Staff I administer the following medications to Patient #12 that were scheduled for 9:00 AM:
Nystatin 5 ml (milliliters) oral swish and swallow.
Multivitamin stresstab with zinc, 600 mg (milligrams), J-tube (tube inserted through abdomen into the intestines for administering liquid food and medications).
Bethanechol (medication to help with urination and bladder control), 25 mg, J-tube.

Observation on 8/4/10 at 9:58 AM showed Staff J, L.P.N., administered the following medications scheduled for 9:00 AM to Patient #15:
- Topiramate (anticonvulsant) 25 mg
- Propranolol (used to treat chest pain, high blood pressure and other heart conditions) 40 mg
- Risperidone (used to treat schizophrenia) 0.5 mg

During an interview on 8/4/10 at 10:15 AM, Staff E, Chief Nursing Officer, stated that medications are to be administered within 30 minutes before or 30 minutes after the scheduled administration time.

5. Review of the facility policy titled, "Drug Ordering and Administration," revised 1/10/08, gave the following direction (in part):
- "The nurse will identify the patient by asking his/her patient name and by checking the identification bracelet prior to the administration of medications."
- "The nurse will check for patient allergies by checking for an allergy bracelet and by asking the patient or family member about allergies prior to the administration of medication."

Observation on 8/4/10 from 8:45 AM to 10:00 AM showed Staff J, L.P.N., administered medications to two patients, Patient #8 and Patient #15. In both observations, Staff J did not ask the patient his/her name, and did not check the wristbands to confirm allergies and or identification.

6. Observation on 8/4/10 at 9:07 AM, showed Staff J, L.P.N., administered Enoxaparin (anticoagulant) 40 mg to Patient #8. Patient #8 was sitting in a chair at the bedside. Staff J expressed the air bubble from the prefilled syringe, injected the medication into the abdomen, and rubbed the site after withdrawing the needle.

Review of administration guidelines from Sanofi-Aventis () showed that the medication should be administered while the patient is lying down. To avoid loss of the drug, the manufacturer instructs users not to expel the air bubble, and further instructs users not to rub the injection site to minimize bruising.

7. Review of the medical record for Patient #8 revealed a physician order written 7/28/10 for Potassium 40 mEq daily.

Observation on 8/4/10 at 9:07 AM, showed Staff J, L.P.N., administered Potassium Chloride 10 mEq (milliequivelents) to Patient #8.

Review of the medical record for Patient #15 revealed a physician order written 8/3/10 for Propranolol 80 mg.

Observation on 8/4/10 at 9:58 AM, showed Staff J, L.P.N., administered Propranolol 40 mg to Patient #15.

8. Review of the facility policy titled, "Transcribing Physician Orders," revised 11/07, gave the following direction (in part):
- "MEDICATION ORDERS & MAR's: All medication orders shall be checked for accuracy and verified in the computer system by the RN (Registered Nurse). A second nurse will verify any medication order against the MAR (Medication Administration Record) for accuracy. Both nurses will sign off the medication orders."
- "NEW ADMISSIONS: Once the medication orders have been double checked, the RN will print out a Medication Administration Record (MAR). The MAR is then checked against the physician orders to verify accuracy. A second nurse will verify orders and co-sign the orders."

Review of current Patient #15's medical record on 8/4/10 revealed a document titled, "Emergency Department Physician's Order," dated 8/3/10, listed the patient's current medications indicating they were to be continued, as follows:
- Risperdal [risperidone](used to treat schizophrenia) 0.5 mg po (by mouth) QD (every day)
- Wellbutrin [bupropion](antidepressant) 100 mg po BID (twice daily)
- Propranolol (used to treat chest pain, high blood pressure and other heart conditions) 80 mg po BID

Review of the M.A.R. dated 8/3/10 to 8/4/10 for current Patient #15, revealed:
- Risperdal [risperidone](0.5 mg tab, po, four times daily, not once daily, as ordered.
- Bupropion 75 mg tabs, po, two times daily, not 100 mg, as ordered.
- Propranolol 40 mg tabs, po, two times daily, not 80 mg, as ordered.

Review of the physician order dated 8/3/10 for Patient #15 revealed both the signatures of the Charge Nurse and the nurse verifying the M.A.R. per facility policy. However, the order was still transcribed incorrectly.

9. Review of the policy, "Transcribing Physician Orders" under Nursing policies, gave the following direction (in part):
- "Continuing Orders, Standing Orders & Protocols: In the event that a physician writes an order such as: continue home medications, administer "per protocol", or SSI {Sliding Scale Insulin} per admitting physician, the medications or protocol are to be written on the physicians order form in the like manner of a verbal order."

Review of Patient #13's swing bed medical record revealed an order for Sliding Scale Insulin Protocol per admitting physician. A copied page listed the amount of insulin to be given for a fasting blood sugar at levels ranging from 0 to 500, signed by the physician on 11/17/09.

During interview on 8/6/10 at 9:30 A.M., the Nurse responsible for the Swing Bed Program reviewed the order protocol and said, "This is used as the order."

During interview on 08/06/10 at 9:45 A.M., Staff Y, Medical Surgical Nurse Manager stated, "We pull this when the doctor orders finger sticks (test for blood sugar) before meals and HS (bedtime)".

During interview at the Exit Conference, Staff E, Director of Nurses stated he/she thought the physician had to sign the standing orders only once per year.


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28722

Based on policy review, record review and interview the facility failed to identify and/or update the nursing care plan for one acute patient (#12) and one swing bed patient (#13) of nine sampled current patients. The facility census was 13.

Findings included:

1. Review of the facility policy titled "Care Plan" dated Dec. 2002, gave the following direction (in part):
"Procedure:
-Analyze data and identify pertinent patient needs
-Prioritize and document pertinent patient problems/needs in the space provided on the Nursing flow sheet.
-Update at least daily to reflect current patient status and assessment
-Initiate the plan of care within 8 hours of admission, or by the end of your shift.
-Document interventions and care given to meet identified needs as well as the effectiveness of those interventions appropriately on the patient's flow sheet."

2. Review of the acute medical record revealed Patient #12 had been admitted to the facility on 8/3/10.

Review of Patient #12's Nursing Admission Summary dated 8/3/10 at 4:00 AM revealed:
Pressure Sore Risk Identified-Yes
Pressure Sores Identified-Yes
The body diagram indicated an excoriation area to the coccyx.

The Braden Scale for Prediction Pressure Sore Risk revealed a score of 14. (If patient scores below 16 initiate Skin Care Precaution Protocol.)

Review of the Nursing Flow Sheet dated 8/3/10 identified under Problem as: Impaired skin integrity related to intravascular access. The care plan area did not address or provided interventions for the patient's risk of impaired skin due to the identified pressure sore or the excoriated area to the coccyx as identified on admission.

In an interview on 8/4/10 at 9:05 AM, Staff Y Nurse Manager agreed Patient #12's care plan did not identify the patient's identified impaired skin issues.

3. Review of the swing bed medical record revealed Patient #13 had been admitted to the facility on 7/19/10.

Physician's order dated 8/1/10 revealed an order for Bactrim ointment to wound on right heel two times a day.

Nursing Flow Sheet dated 8/3/10 revealed under assessment of skin integrity -right heel. The problem area used for care planning under the skin section was blank.

In an interview on 8/4/10 at 9:05 AM, Staff Y Nurse Manager agreed Patient #13's flow sheet should have reflected impaired skin for the wound to the right heel under the care plan section.

Based on record review facility staff failed to ensure two current patients (#21 and #22) of two current outpatient ambulatory surgical medical records sampled and two closed patients (#16 and #17) of two closed surgical medical records sampled included a complete, properly executed consent form that included the type of anesthesia to be used. The facility census was 13.

Findings included:

1. Review of the Facility Policy titled "Purpose and Objectives" effective date 8/08 gave the following direction (in part):
"Responsibility:
-All entries in the record are to be dated, timed and authenticated after proper consent obtained.
-The medical record must be appropriately documented to meet the standards of licensing and surveying agencies, as well as the hospital Bylaws and Rules and Regulations."

2. Review of Patient #21's Consent for Operation, Anesthesia and Medical Services dated 8/5/10 revealed: I consent to the administration of such anesthetics as are considered advisable by my physician with the exception of (blank). The consent form did not include the type of anesthesia to be administered during the surgical procedure. The witnesses did not date or time their signatures on the consent.

3. Review of Patient #22's Consent for Operation, Anesthesia and Medical Services dated 8/5/10 revealed: I consent to the administration of such anesthetics as are considered advisable by my physician with the exception of (blank). The consent form did not include the type of anesthesia to be administered during the surgical procedure. The witnesses did not date or time their signatures on the consent.

4. Review of Patient #16's Consent for Operation, Anesthesia and Medical Services dated 7/26/10 revealed: I consent to the administration of such anesthetics as are considered advisable by my physician with the exception of (blank). The consent form did not include the type of anesthesia to be administered during the surgical procedure. The physician and the witnesses did not date or time their signatures on the consent.

5. Review of Patient #17's Consent for Operation, Anesthesia and Medical Services dated 7/12/10 revealed: I consent to the administration of such anesthetics as are considered advisable by my physician with the exception of (blank). The consent form did not include the type of anesthesia to be administered during the surgical procedure. The physician did not date or time his/her signature on the consent. The physician and the witnesses did not date or time their signatures on the consent.

Based on record review and interview, hospital staff failed to ensure physicians were credentialed for the surgical procedures performed for two discharged patients (#16 and #17) of two discharged surgical patients sampled. This had the potential to affect all patients seeking surgical services. The hospital census was 13.

Findings Included:

1. Review of the Facility Rules and Regulations of the Medical Staff last revised 10/05 revealed (in part): "#12 Any doctor desiring to perform surgery must submit a list of surgical procedures both major and minor, which is to be approved by the Active Medical Staff and Hospital Board of Trustees."

1. Review of Patient #16's discharged medical record revealed the patient had a left knee arthroscopy on 7/26/10 performed by Staff HH, Physician.

2. Review of Patient #17's discharged medical record revealed the patient had a carpal tunnel release/ulnar nerve release on 7/12/10 performed by Staff HH, Physician.

Review of Staff HH, physician's credentialing file revealed the physician had not requested privileges for arthroscopy or carpal tunnel release/ulnar nerve release when privileges were granted on 5/7/10.

During interview on 8/5/10 at 1:10 PM, Staff W, Nurse Director of Surgical Services stated he/she did not have a roster listing each physician's specific surgical privileges available in the surgical area to review when scheduling surgeries. Staff W stated each physician's surgical privileges was located in the administration office where credentialing is done.

During an interview on 8/6/10 at 10:50 AM, Staff E, Chief Nursing Officer confirmed Staff HH did not request privileges for the procedures performed.

Based on review of facility reports and interview, the facility failed to have an Annual Periodic Review, complete for the total number of acute admissions and review of a minimum of 10% of the fiscal year admissions. The facility census was 13.
Findings included:
Review of the facility document, "Annual Critical Access Hospital Program Evaluation, 2010" (for fiscal year ending 8/31/09, noted on pg 4 of 11) revealed the total number of patient days for admissions to the acute care program, the Swing Bed Program, and the Observation status. The report failed to include a number of actual admissions to the acute stay status, Swing Bed Program and observation status.
The report failed to include a report of a quality review for not less than 10% of active and closed patient records.
The report included a statement that facility administrative policies were reviewed, however, the policy manuals showed no documentation of review or update from the areas of: Food and Nutrition Services, Respiratory Therapy, Rehabilitation Therapy, Medical-Surgical Acute Care, Pharmacy, Emergency Room Departments Policies and Procedures. The Periodic Review notation regarding policy reviews stated, " Some of the policies were signed a long time ago (i.e. 1999). Each policy needs to be reviewed at least annually in order to ensure that it is continued applicability." (Actual wording of the report.)
During interview on 8/6/10 at 11:00 AM, Staff D, Administrator provided a summary sheet that had been faxed to the facility from the consultant who had provided the Periodic Program Evaluation for Fiscal Year 2009. Employee D stated, "He had all the data, but didn't put it all in the report."
Review of the summary sheet received by the facility on 8/10/10 revealed the summary did not include the total number of admission, the total number of patient care cases reviewed for quality of care, nor the report of the quality review or any changes made in response to those findings. The summary page stated in regards to facility policies, "The hospital has policies in place that guide the delivery of patient care services."

Based on review of facility documents and interview, the facility failed to have a quality of care review for 10% of patient admissions for the past fiscal year. The facility census was 13.
Findings included:
1. During interview on 8/5/10 at 1:00 P.M., Staff R, Director of Quality Management stated a quality review was completed for Emergency Room records and mortality review, and all readmissions within 30 days of previous discharge. The review process also included patients with reported medication errors, nosocomial infections and falls. The report was provided to the Director of Nursing, and Medical Staff. Any needed corrective action is the responsibility of the respective department heads. No particular total number of record reviews was planned.
2. Review of the facility Periodic Review titled, "Annual Critical Access Hospital Program Evaluation" fiscal year ending 8/31/09, revealed no report for patient case review, any remedial actions, or any monitoring for remedial actions.

Based on review of facility documents and interview, the facility failed to have an ongoing plan for Quality Assurance and Performance Improvement. The facility census was 13.
Finding included:
Review of the facility Quality Assurance program showed that the various department heads were scheduled to report to the Quality Assurance Committee on a quarterly basis. There was no overall plan for quality indicators to be monitored.
During interview on 8/5/10 at 1:00 P.M., Staff R, Director of Quality Management stated each department has standards that they want to meet. They pick areas for high volume, problem prone issues and focus on two areas in a year. He/she also stated that there hadn't been a plan in the recent past, since September, 2008.
During interview on 8/5/10 at 10:30 A.M., Staff EE. Director of Respiratory Therapy, stated the Respiratory Department was doing a study on 'turn-around times' (the time from the written order for consult until the patient was seen for the consult) Then the Director stated, "And anything else that comes up."

Based on review of facility documents and interview, the facility failed to provide contact information to the Swing Bed Program clients for advocacy agencies to include the Department of Health and Senior Services Hotline Number. The census for the Swing Bed Program was two. The total facility census was 13.
Findings included:
1. Review of the facility handout brochure, given to the residents at the time of their admission to the Swing Bed Program, showed the written information to be lacking the phone numbers for the Department of Health and Senior Services Hotline for concerns related to abuse and neglect of the elderly, or any address or contact process for this resource.
2. During interview on 8/4/10 at 1:30 P.M., Staff M, Director of the Swing Bed Program stated the admission review for the patients does not include information about the state agency hotline number. "It is not given at all."
3. During the times of the survey from 8/3-6/10, the facility was observed for any postings regarding the patients' right to call the state hotline agency. No such posting was available.

Based on review of facility records and interview, the facility failed to assure safe protection of residents and patients by failing to provide criminal background checks and check for the Missouri Disqualification List (EDL) upon the new hire of employees and intermittent (at least annual) check for the EDL review. This applied to all residents in the Swing Bed Program. The current Swing Bed census was 2; and the total facility census was 13.
Findings included:
1. Reference to Missouri Revised Statutes, Chapter 660, Department of Social Services, Section 660.317, revealed "Criminal background checks of employees, required when--persons with criminal history not to be hired, when, penalty--failure to disclose, penalty--improper hirings, penalty--definitions--rules to waive hiring restrictions." 660.317. 1.
2. Review of the personnel records for the following employees, revealed no review for the EDL list since the date of hire or since for the following:
-Staff M, Nurse Manager for the Swing Bed Program, hired 01/14/03
-Staff K, Food Service Manager, hired 01/25/02
-Staff E, Chief Nursing Officer, hired 09/03/02
-Staff R, Infection Control Nurse, hired 08/01/89
-Staff W, Nurse Manager of Surgical Services, hired 11/09/92
- Staff S, Radiology Director, hired 4/21/85
- Staff AA, Respiratory Therapy Manager, hired 1/26/98
- Staff JJ, Emergency Department Manager, hired 12/04/09
During interview on 8/6/10 at 10:30 A.M., Staff BB, Director of Human Resources, stated the facility had never done an EDL background check for anyone other than nursing personnel; and it had been quite a while since MHA (Missouri Hospital Association) had sent out a list.
During an interview on 8/6/10 at 10:50 AM, Staff E, Chief Nursing Officer stated he/she was checking the EDL online for nursing staff. Staff E said he/she had not checked for quite some time. Staff E said the EDL could not currently be accessed because his/her password had expired and the facility had applied for a new password.
3. Review of the personnel record for the Staff L, Registered, Licensed (contracted) dietitian, showed no criminal background check or EDL review since the date of the contract, newly revised (with previous contract for many years) on 1/4/10.
During interview on 8/6/10 at 11:45 A.M., Staff II, Administrative Assistant, stated that the facility does not do background checks on contract allied professionals and a call to the contract agency for the dietitian stated that they do not do it, either.


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Based on record review and interview, the facility failed to have daily activities for Swing Bed patients. This applied to two of two patients (#13, #8) in the Swing Bed Program. The facility census was 13.
Findings included:
During interview on 8/04/10 at 10:15 PM, Staff M, Nurse Manager of the Swing Bed Program stated the Activities component of the program was managed by the two Social Workers, one of whom is certified as an Activity Director in the State of Missouri. Employee M stated the Activities program does not keep a calendar of planned activities because the patients are generally a very short stay and it is impossible to know in advance what their preferences and needs would be. Employee M stated the Swing Bed patients do not come out of their rooms for meals, as all meals are served to the rooms. However, there is a small room for gathering, if the patients want to play cards or work a puzzle or something. On occasion, in good weather, they might go outside for a time, with a Certified Nursing Assistant.
During interview on 8/4/10 at 1:30 PM, Staff N, Social Worker on duty stated both Social Workers work together to manage the Activities for the Swing Bed patients. The goal is to provide what the patients like. They try to have activities three times per week.
Record review for Patient #13, currently admitted to the Swing Bed program since 7/19/10, showed no activity assessment and the activity documentation, kept in his/her room showed documentation only on 7/21, 7/27, 7/28 (hung humming bird feeder), 8/02, 8/03. Some notations were for family or friend visits, not facility provided activities.
Record review for Patient #8, currently admitted to the Swing Bed program since 7/28/10 showed no activity assessment and documentation only on 7/31, 8/3, 8/4.
During interview on 8/6/10 at 11:00 AM, Patient #13 stated that there were no special activities; and Patient #8 stated that he/she was pleased with care but was glad to be going home.

Based on review of the facility documents regarding the Swing Bed Program and interview, the facility failed to have a dentist on staff or available on a contract basis. The current Swing Bed census was two. The total facility census was 13.
Findings included:
Review of the Swing Bed Program on 8/4/10 at 1:30 PM, showed the Swing Bed Program Manual, Policies and Procedures to be lacking information regarding the consult to a dentist, if needed by a patient.
During interview on 8/4/10 at 1:30 PM, Staff M, Manager of the Swing Bed Program stated the policy was "pulled" when the prior dentist was no longer available. No other dentist had been arranged for a dental consult. Employee M confirmed this finding.