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Based on interview, record review and Revised Statutes of Missouri (RSMo) review, the facility failed to:
- Document that an inquiry was made to the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) for two employed staff (QQ and SS) of eight employed staff reviewed, to ensure they were not on the list prior to providing patient care.
- Document that a request was made for a criminal background check for one employed staff (SS) of eight employed staff reviewed for background checks, prior to providing patient care.
- Document that a request was made for criminal background checks and document that inquiries were made to the EDL for eight contracted staff (EE, FF, GG, HH, II, JJ, KK and LL) of eight contracted staff reviewed, prior to providing patient care.
- Ensure staff met facility job description requirements of certification in basis life support (BLS) for three staff (H, QQ, and RR) of eight staff reviewed. These failures had the potential to affect the care and outcomes of all patients. The facility census was eight.

Findings included:

1. Review of RSMo 192.2495, showed that prior to allowing any person who has been hired full-time, part-time, temporary or through contract to have contact with any patient, a request would be made for a criminal background check as well as an inquiry made to the department of health and senior services, whether the person is listed on the EDL.

Review on 11/05/18 of the employee file for Staff QQ, Licensed Practical Nurse (LPN), showed that no background check was conducted prior to or during employment.

2. Review on 11/05/18 of the employee file for Staff SS, LPN, showed that no EDL or no background check was conducted at any time prior to or during employment.

3. Review on 11/05/18 of a list of contracted employees which included the following Physicians: Staff EE, Staff FF, Staff GG, Staff HH, Staff II, Staff JJ, Staff KK and Staff LL, showed that no EDL or background checks were conducted prior to or during contracted employment.

During an interview on 11/08/18, at approximately 2:00 PM, Staff M, Human Resources (HR) Director, stated that the facility's practice was to conduct pre-employment checks to include background checks and EDL on all employees, and that the EDL check would be conducted each quarter thereafter on all staff. Staff M also stated that no background checks or EDL checks were currently being completed on any of the contracted staff.

4. Review on 11/05/18 of the facilities undated job descriptions titled, "Job Description for Registered Nurse," "Job Description for Licensed Practical Nurse," and "Job description for Certified Nurse Assistant," showed all licensed nurses and Certified Nurse Assistants (CNAs) were required to maintain a current Basic Life Support (BLS) certification.

Review on 11/05/18 of employee files for Staff H, CNA; Staff RR, Registered Nurse (RN) and Staff QQ, LPN, showed their BLS certification had expired, but continued to work for the following:
- Staff H a total of 83 shifts;
- Staff RR a total of 48 shifts; and
- Staff QQ a total of 13 shifts.

During an interview on 11/08/18, at approximately 3:00 PM, Staff J, Chief Nursing Officer (CNO), stated that it was the facility's policy and practice to ensure BLS certification was maintained and current on all certified and licensed nursing staff. Staff J also stated that she expected all licensed nurses and CNAs to be current on their BLS certification when they worked.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure five crash carts (mobile cart which contains emergency medical supplies and medications) of six crash carts observed, were secured and monitored in a manner to maintain emergency supplies and/or medications (C-202).
- Ensure storage areas which contained patient supplies were secured in a manner to prevent unauthorized access for two patient care areas (Emergency Department and Medical Unit) of two patient care storage areas observed (C-202).
- Ensure outdated supplies and medications were removed from potential patient use from storage areas on two units (Emergency Department and Medical Unit) of two unit storage areas reviewed (C-202). These failures had the potential to allow unauthorized access to emergency supplies and medications, as well as allow expired supplies and/or medications to be used during patient care, and could affect all patients. The facility census was eight.

The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.618 COP: Emergency Services.

Refer to the 2567 for additional information.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure five crash carts (mobile cart which contains emergency medical supplies and medications) of six crash carts observed, were secured and monitored in a manner to maintain emergency supplies and/or medications.
- Ensure storage areas which contained patient supplies were secured in a manner to prevent unauthorized access for two patient care areas (Emergency Department and Medical Unit) of two patient care storage areas observed.
- Ensure outdated supplies and medications were removed from potential patient use from storage areas on two units (Emergency Department and Medical Unit) of two unit storage areas reviewed. These failures had the potential to allow unauthorized access to emergency supplies and medications, as well as allow expired supplies and/or medications to be used during patient care, and could affect all patients. The facility census was eight.

Findings included:

1. Review of the facility's policy titled, "Crash Cart Maintenance," revised 02/14/18, showed the following:
- Checking the crash cart includes verifying an intact lock for any areas not inventoried in detail.
- Locks on the crash cart shall be of such a type as provides evidence of entry to the drawer/storage area and demonstrates anti-tampering security for drugs and supplies.
- The Charge Nurse of each shift is responsible for ensuring the crash carts are checked and equipment is tested every shift and after each use.
- This task may be delegated to the Emergency Department (ED) Nurse.

Review of the facility's undated ED checklist showed that the Registered Nurse (RN), Licensed Practical Nurse (LPN), and the Certified Nursing Assistant (CNA) were responsible for the checklist. The checklist included that the crash carts were clean, checked and locked, and the contents were inspected for outdates on the first day of each month.

Observation on 11/05/18 at 2:20 PM in the ED, showed the adult crash cart was locked with purple plastic locks, and on top of the crash cart was approximately five purple plastic locks used to relock the crash cart if the crash cart was opened.

Observation on 11/05/18 at 2:30 PM in the ED, showed the pediatric crash cart was locked with purple plastic locks, and on top of the crash cart was approximately three purple plastic locks used to relock the crash cart if the crash cart was opened.

Observation on 11/05/18 at 2:30 PM in the Medical Unit, showed the crash cart was locked with purple plastic locks, and on top of the crash cart was one purple plastic lock used to relock the crash cart if the crash cart was opened.

During an interview on 11/05/18 at 2:35 PM, Staff I, RN, Medical Unit Charge Nurse, stated that extra locks were kept on top of the crash cart for use when a drawer was opened. If they needed more locks, they retrieved them from the pharmacy.

The unsecured plastic locks had the potential to allow access to the medications and supplies in the crash cart without accountability. This rendered the medications and supplies unsecured.

During an interview on 11/05/18 at 2:47 PM, Staff E, RN, verified that the crash carts with the additional locks stored on the top, could allow unauthorized access to the crash cart.

Observation on 11/06/18 at 11:00 AM in the Radiology Computerized Tomography (CT, x-ray testing that produces images of the body using those x-rays and a computer) room, showed documentation that the crash cart had been checked on 11/06/18 at 7:00 AM. The lock numbers written on the crash cart check sheet showed the following:
- Drawer locked #1: 3928342 (number documented which should reflect the same number on the lock);
- Drawer locked #2: 3683321;
- Drawer locked #3: 4178408;
- Drawer locked #4: 3928306; and
- Drawer locked #5: 4178490.

Observation on 11/06/18 at 11:05 AM in the Radiology CT room, showed the following lock numbers on the crash cart:
- Drawer #1: 4178476;
- Drawer #2: 4178477;
- Drawer #3: 4178534;
- Drawer #4: 4178581; and
- Drawer #5: 4178554.

During an interview on 11/06/18 at 11:10 AM, Staff X, Imaging Director, stated that she did not know why the lock numbers were not accurately written on the crash cart check sheet. Staff X stated that her department did not check the crash cart, and believed it was the responsibility of the ED staff. Staff X added that there had not been an emergency in the department since the 7:00 AM check that required the crash cart to be opened (this indicated that the documented lock numbers should have been the same numbers on the crash cart locks).

Observation on 11/07/18 at 3:00 PM in the surgery pre-procedure area, showed a crash cart with five purple tagged drawers. The crash cart check sheet was completed for 11/07/18. There were no tag numbers written on the crash cart check sheet for any dates in November (this indicated that the locks had not been verified for integrity of the contents).

During an interview on 11/07/18 at 3:05 PM, Staff S, Surgical Services Director, stated that because the crash cart was located and kept in a locked room, she felt it was not necessary for staff to write the lock numbers down since only the surgical services staff had access to it.

2. Observation on 11/05/18 at 2:55 PM in the ED main storage area, showed a door with no lock to secure the storage area. The main storage area contained an suture cart (cart that contains items used to close or repair a wound) which contained items such as cautery pens (medical supply with a heated metal tip, used to control bleeding), Lidocaine (medication used to numb tissue or control heart rhythm/rate abnormalities), skin staplers (stapler used on skin to close a wound) and sterile (without germs) wound dressing supplies.

Observation on 11/05/18 at approximately 2:30 PM, showed the Medical Unit supply room (contains sterile items used in patient care, as well as needles and syringes) door was unsecured, with no locking device that prevented unauthorized access.

During an interview on 11/05/18 at 2:40 PM, Staff M, Human Resources (HR) Director, stated that the facility was aware that the supply room was unsecured.

During an interview on 11/07/18 at 2:00 PM, Staff J, Chief Nursing Officer (CNO), stated that the extra locks for the crash carts should not be stored on top of the crash carts, and storage areas should be secured to prevent unauthorized access.

3. Review of the facility's policy titled, "Inventory Control and Supply distribution," revised 11/13/17, showed no verbiage that directed staff to remove items which were outdated.

Observation on 11/05/18 at 2:20 PM of the ED adult crash cart, showed a combitube (tube provides an airway for artificial breathing when someone cannot breathe on their own) with an expiration date of 02/2017.

Observation on 11/05/18 at 2:45 PM in an ED storage area, showed the following expired medications and supplies:
- Chest decompression set (emergency supplies used after trauma to the chest) with an expiration date of 09/2018;
- Two blood collection tubes with expiration dates of 06/2018;
- Two, 1000 milliliter normal saline bottles (used for cleansing wounds) with expiration dates of 10/2018; and
- Seven, four ounce bottles of Betadine (wound cleanser) with expiration dates of 09/2018.

Observation on 11/05/18 at 2:55 PM in the ED main storage area, showed a suture cart with the following expired medications and supplies:
- Six, four ounce bottles of Betadine with expiration dates of 09/2018;
- Two plain gauze packing (placed inside a wound for absorption and healing) with expiration dates of 07/2018;
- Idoform (containing iodine, disinfectant agent) gauze packing with an expiration date of 07/2018;
- Four cautery pens with an expiration date of 03/2017;
- An opened Lidocaine vial with no open date or expiration date; and
- Eight skin staplers with expiration dates of 08/2018.

Observation on 11/05/18 at 3:10 PM, in the ED medication area, showed two pink blood collection tubes with an expiration date of 06/2018.

During an interview on 11/05/18 at 2:35 PM, Staff C, ED Director, stated that it was her expectation that staff followed the check list and removed all expired items from potential use on patients.

Observation on 11/05/18 at 2:30 PM in the Medical Unit, showed a crash cart with the following expired medications and supplies:
- Epinephrine (used to treat allergic reactions or increase the heart rate) vial with an expiration date of 10/2015;
- Benadryl (used to treat allergies and itching) vial with an expiration date of 11/2015;
- Dexamethasone (steroid, used to treat inflammation), two vials, with expiration dates of 07/2015;
- Solucortef (anti-inflammatory) vial with an expiration date of 07/2016;
- Small bottle of normal saline, with an expiration date of 11/2015; and
- Chest decompression set with an expiration date of 07/2017.

During an interview on 11/07/18 at 2:00 PM, Staff J, Chief Nursing Officer (CNO), stated that it was the responsibility of all nursing staff to check for expired supplies and remove the items from patient use.






39562




40710

Based on observation, interview, and record review, the facility failed to:
- Ensure that staff followed the facility's policy and the infection prevention standards for the United States Pharmacopoeia (USP) for compounded sterile preparations (C-276).
- Ensure that staff followed infection control policies and infection prevention standards. (C-278)
- Ensure one Pharmacist (Staff CC) of two Pharmacists reviewed, had approved, specific privileges as directed by the hospital's Medical Staff Bylaws (C-292).
- Ensure two off-site services (nearby pharmacies) of two off-site services reviewed, had approved, specific privileges as directed by the hospital's Medical Staff Bylaws (C-292).
- Follow the standard of practice and provide consistent cardiac (heart) monitoring for two patients (#6 and #7) of two patients observed, who were being monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm) (C-294).
- Properly secure the indwelling urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) tubing for two patients (#6 and #10) of two patients who had indwelling urinary catheters (C-294).
- Assess pain level per use of a numeric or visual pain rating scale for as needed (PRN) medications prior to administration for three patients (#8, #10, and #11) of four patients reviewed (C-294).
- Follow the facility medication administration policy and assess patient's response to as needed on three patients (#8, #10, and #11) of four patients reviewed (C-294).
- Implement a care plan for chronic pain, skin integrity, indwelling urinary catheter, and fall risk for four patients (#6, #8, #10 and #11) of eight patients reviewed (C-298).


The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.635 Condition of Participation.


Refer to the 2567 for additional information.

Based on observation, interview, record review and review of the United States Pharmacopoeia (USP) Chapter 797 for compounded sterile preparations (CSPs, medications or solutions that are mixed in a way to prevent contamination), the facility failed to ensure that staff followed the facility's policy and the infection prevention standards when they failed to:
- Ensure the work areas (buffer area) were kept uncluttered and free from particle-generating (potential contaminants) materials.
- Document and clean the buffer area on days that medications were compounded.
- Document and clean the primary engineering controls (PEC, a device that provides an environment for compounding medications) daily, and/or before processing CSP.
- Have a documented growth media (test to ensure proper cleaning technique) sampling.
- Have a documented proper garbing/procedure (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test (test to ensure staff who process CSPs are able to prevent contamination of the CSP).
- Have a written record or log that demonstrates that the CSP is performed properly.

These failed practices had the potential to increase the risk of cross contamination in CSPs that may result in patient harm and/or death. The facility performs approximately 20 CSPs per month. The facility census was eight.

Findings included:

1. Review of the USP, Chapter 797, dated 2013, showed that:
- For non-hazardous preparations, if the buffer area was not physically divided by walls, the buffer area must rely on a line of demarcation (physical line that separates one area from another).
- Particle shedding objects (pencils, corrugated cardboard, paper, and cotton items) are prohibited in the buffer area.
- The buffer area floors should be cleaned daily, walls monthly, ceilings monthly, storage shelving monthly and documented on a cleaning log.
- Sampling plans that included surface disinfection sampling (growth media requirements) performed on a periodic basis, at a minimum, every six months.
- Low risk compounding required proper garbing/procedures (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test.
- Documented easily accessible written record or log that demonstrates that the CSP is performed properly.

Review of the facility's policy titled, "Preparation and Compounding of Intravenous (IV, in the vein) Solutions and Sterile (without contamination) Products in Accordance with USP 797 and USP 795," revised 03/05/18, showed that the intent herein is to present general operational guidelines that will aid in the use of the isolator to provide a sterile positive pressure work environment for the compounding of non-hazardous drugs. Regulatory and recommended guidelines, published by USP, American Society of Hospital Pharmacists (ASH) and state boards must be observed.

2. Observation on 11/06/18 at 10:45 PM showed the following:
- A barrier isolator (PEC) within the pharmacy, without a line of demarcation.
- In the PEC were 10 packaged syringes (particle shedding material), 10 packaged needle hubs (particle shedding material) and a stack of open four by four gauze pads (particle shedding material).
- No documented written record or log that demonstrates that the CSP was performed properly.

3. During an interview on 11/06/18 at 10:50 AM, Staff O, Pharmacist, stated that he:
- Did approximately 20 CSPs per month;
- Did not have a log of the CSPs that were performed;
- Was unaware of the USP 797 regulation;
- Did not garb when he performed CSPs;
- Did not have documented growth media sampling;
- Did not have a documented successful glove fingertip test;
- Did not have a cleaning log for the buffer area or the barrier isolator; and
- Acknowledged the particle shedding material within the barrier isolator.


39562

Based on observation, interview, record review and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Maintain the cleanliness of 22 laryngoscope blades (equipment that allowed visualization of the vocal cords while a breathing tube was placed) out of 22 observed and stored in crash carts (mobile cart which contains emergency medical supplies and medications) located in the Emergency Department (ED) and the Medical Unit.
- Ensure items which were not disposable, and intended for use on multiple patients, were properly packaged to maintain sterile conditions in two crash carts of two crash carts reviewed.
- Perform hand hygiene before and after glove use, after touching inanimate objects (non-living objects, such as keyboards, tables, etc.), and between patient tasks for two patients (#8 and #9) of two patients observed.
- Ensure that blood glucose (sugar) control vials, test strips and multi-use medication were timed and dated when opened.
- Ensure that the temperature of food items prepared in the kitchen was recorded each day.
- Ensure that expired food was not used for patient/staff consumption.
- Ensure the name of the food item, the date the item was made or package opened, and staff initials was placed on food packages in the kitchen freezers, refrigerators, dry storage area and food prep area.
- Ensure opened refrigerated food was dated to provide notice of when to discard in the patient nourishment refrigerator on the Medical Unit.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was eight.

Findings included:

. Review of the facility's policy titled, "Chemical Sterilization or High Level Disinfection," revised 11/13/17, showed directives for staff to perform the following:
- Items which are not disposable, are intended for use on multiple patients, and cannot be autoclaved (sterilization through extreme heat temperatures), will be cleaned and disinfected/sterilized with a chemical disinfectant or cold sterilization solution after each use.
- Care must be taken not to contaminate the item; it is to be used in a sterile application.
- Store the disinfected item appropriately.

Review of the facility's policy titled, "Sterilization Procedure," revised 12/22/17, showed that all items to be sterilized for use as a sterile supply shall be contained in see through pouches or wrapped. Insert small, clean, dry items into pouches, where visualization of items is desired.

Observation on 11/05/18 at 2:30 PM inside the Medical Unit crash cart, showed 11 unpackaged laryngoscope blades lying inside a plastic non-sterile pouch.

Observation on 11/06/18 at 9:05 AM inside the Emergency Department (ED) room #1, showed 11 unpackaged laryngoscope blades lying inside a plastic non-sterile pouch.

During an interview on 11/06/18 at 2:35 PM, Staff U, Pulmonary Service Director, stated that respiratory was responsible for cleaning the reusable laryngoscope blades and verified that the laryngoscope blades were exposed to possible cross-contamination.

Observation on 11/05/18 at 2:20 PM in the Emergency Department (ED) adult crash cart, showed two unpackaged needle holders (surgical instrument used to hold needle for suturing) inside the cart.

Observation on 11/05/18 at 2:30 PM in the ED pediatric crash cart, showed two unpackaged forceps (medical instrument) in the cart.

During an interview on 11/05/18 at 2:35 PM, Staff C, ED Director, stated that the forceps and the needle holders should not be unpackaged in the crash carts.

2. Review of the facility's policy titled, "Handwashing," dated 12/07/15, showed directives for staff to perform hand hygiene:
- After situations during which contamination of hands is likely to occur, especially those involving contact with blood or body fluids, secretions, or excretions (even if hands were gloved);
- Before and after touching wounds; and
- After touching inanimate sources that are likely to be contaminated with microorganisms (bacteria, virus, or fungus).

Observation on 11/06/18 at 10:00 AM on the Medical Unit, showed Staff V, Registered Nurse (RN), prepared to change Patient #8's right thigh (upper portion of the leg) dressing and bilateral (both) knee dressings. During the dressing changes, Staff V:
- Used an open, undated bottle of normal saline (cleansing solution) to cleanse the patient's wounds;
- Changed his gloves eight times and failed to perform hand hygiene between the glove changes; and
- After he applied ointment and a dressing to the patient's left knee wound with his gloved hands, he touched the bed rail with his contaminated gloves.

During an interview on 11/06/18 at 10:10 AM, Staff V stated that he should have performed hand hygiene before and after glove changes, and that the bottle of normal saline used to clean the wounds should have been timed and dated after the bottle was opened.

Observation on 11/05/18 at approximately 2:30 PM, showed Staff K, RN, entered Patient #9's room to discontinue intravenous (IV, in the vein) solution. Without performing hand hygiene or donning gloves, Staff K disconnected the IV tubing from the patient #9's upper arm and exited the room without performing hand hygiene.

During an interview on 11/08/18 at 4:00 PM, Staff BB, Infection Control (IC) Director, stated that she expected hand hygiene to be performed before and after patient contact. She expected the practice of "foam in and foam out" to be practiced at all times, and for hand hygiene to be performed between all glove changes.

3. Review of the facility's policy titled, "Blood Glucose Monitoring," revised 03/20/17, showed the directive for staff to perform daily quality control checks (tests to ensure the monitor works properly) on the blood glucose monitors per the manufacturer's instruction.

Observation on 11/06/18 at 9:05 AM on the Medical Unit, showed two plastic containers, each which contained a blood glucose monitor, two test control vials, a container of test strips and other supplies. The test control vials and the test strips in each container were opened, but were not labeled with the open date or time. The test control vials and the test strips had written instructions to discard three months after they were opened.

During an interview on 11/06/18 at 9:10 AM, Staff L, Inpatient and Swing Bed Director, stated that her expectation of staff was to time and date the test control vials and test strips after they were opened.

Observation on 11/05/18 at 2:55 PM, in the ED main storage area, showed a suture cart (cart that contains supplies used to close a wound) with one Lidocaine vial (medication used to numb tissue or correct an abnormal heart rhythm) that was opened, but was not labeled with the open date or time.

During an interview on 11/05/18 at 2:56 PM, Staff J, Chief Nursing Officer (CNO), acknowledged the opened Lidocaine vial was not labeled with the open date or time, and stated that any open multi-use medication should be timed and dated after the medication was opened.

4. Review of the facility's policy titled, "Food Preparation - Food Temperatures," reviewed 07/05/18, showed that the cooks, under the supervision of the Director, regularly checks that the temperature of the food served to the patients is maintained at a safe and palatable temperature. Each day the cook records the temperatures of food items on the Food Temperatures sheet before and after patient food service.

Review of the facility's food temperature documentation for the month of September showed the following:
- 09/04/18: no food temperatures were obtained for breakfast and supper.
- 09/06/18: no food temperatures were obtained for breakfast and dinner.
- 09/10/18: no food temperatures were obtained for breakfast and dinner.
- Food temperatures were not documented 27 out of 30 days during the month of September.
- Breakfast temperatures were never documented as checked.

Review of the facility's food temperature documentation for the month of October showed the following:
- 10/01/18: no food temperatures were obtained for breakfast and dinner.
- 10/06/18: no food temperatures were obtained for breakfast and supper.
- 10/07/18: no food temperatures were obtained for breakfast.
- 10/10/18: no food temperatures were obtained for breakfast and supper.
- 10/13/18: no food temperatures were obtained for breakfast and supper.
- 10/25/18: no food temperatures were obtained for breakfast.
- 10/26/18: no food temperatures were obtained for breakfast.
- 10/27/18: no food temperatures were obtained for breakfast.
- 10/28/18: no food temperatures were obtained for breakfast.
- 10/29/18: no food temperatures were obtained for breakfast and supper.
- 10/31/18: no food temperatures were obtained for breakfast and supper.
- Food temperatures were not documented 20 out of 31 days during the month of October.
- Breakfast temperatures were never documented as checked.

Review of the facility's November food temperature documentation on 11/06/18 at 3:00 PM, showed the following:
- 11/01/18: no food temperatures for breakfast and supper.
- 11/02/18: no documentation of food temperatures at any meal.
- 11/03/18: no food temperatures for breakfast.
- 11/04/18: no food temperatures for breakfast and dinner.
- 11/05/18: no food temperature for breakfast.
- 11/06/18: no food temperature for breakfast.

During an interview on 11/07/18 at 11:55 AM, Staff QQ, Assistant Dietary Manager, stated that staff tried to test temperatures at every meal; but forgot to write them down.

During an interview on 11/07/18 at 12:15 PM, Staff AA, Dietary Director, stated that she expected staff to check the temperature of the food every day, at every meal and to document the temperature on the food temperature log sheet.

5. Review of the facility's nutritional services policy titled, "Storing," revised 01/04/18, showed that the delivery date is marked on each item of canned goods as it is placed on the shelf. All food stored in refrigerators are kept covered, dated and labeled.

Observation on 11/06/18 at 2:30 PM in the dietary dry storage room showed the following:
- Two packages of powdered sugar free jello with no expiration date.
- An uncovered box of pepper packets with no expiration date.
- An uncovered box of salt packets with no expiration date.
- Two packages of blueberry muffin mix with no date of expiration.
- Two jars of peanut butter that expired in 2015.
- Containers of parsley, popcorn and salt with no expiration date.

Observation on 11/06/18 at 2:45 PM in the dietary walk in refrigerator showed two trays of cookies with no label and date of when they were made, and 64 sticks of margarine with no date of expiration.

Observation on 11/06/18 at 2:55 PM in the dietary reach in refrigerator located in the kitchen, showed celery and green peppers with no date or label.

Observation on 11/06/18 at 3:00 PM in the dietary walk in freezer showed the following:
- A container of blueberries with no date or label.
- A bag of rice krispie treats with no date or label.
- A bag of waffles with no date or label.
- A chocolate cake with no date or label.
- Two chicken breasts in a bag with freezer burn with no date or label.
- A pan of manicotti with no date or label.
- A box of cookies with no date or label.
- A package of pickle loaf with an expiration of 2016.
- A package of bologna with an expiration of 08/2108.

Observation on 11/06/18 at 3:15 PM in the kitchen food preparation area showed a container of peanut butter that expired on 06/2017 and a plastic container of margarine that was not labeled or dated.

Observation on 11/05/18 at 2:40 PM on the Medical Unit storage room, which housed a small refrigerator for storing patient snacks, showed a container of milk that had been opened that was not labeled or dated.

During an interview on 11/06/18 at 3:30 PM, Staff AA, Dietary Director, stated that she was responsible for checking for expired foods and she needed to do a better job. Her expectation of staff was to label and date all foods that were stored in the dry storage area, kitchen, refrigerators and freezers.






37921




40710

Based on interview and record review, the facility failed to ensure one Pharmacist (CC) of two Pharmacist reviewed had approved, specific privileges as directed by their Medical Staff Bylaws. The facility also failed to have two off-site services (near-by Hospital Pharmacies) of two off-site services reviewed, had approved, specific privileges as directed by their Medical Staff Bylaws. This failure could allow an unqualified Pharmacist to provide substandard care to all patients that received Pharmaceutical services. The facility census was eight.

Findings Included:

1. Review of the facility's Medical Staff Bylaws, dated 05/21/12, showed that no person, including those with a contract of employment with the hospital, may admit or provide any health care services to patients in the hospital unless he or she is a medical staff member or has been granted clinical privileges in accordance with the procedures set forth in these Medical Staff Bylaws. Qualifications for membership that apply, or holds medical staff
appointment, must at the time of application, initial appointment and continuously thereafter:
- Hold a current valid license issued by the State of Missouri.
- If appropriate, have a current, valid drug Enforcement Agency (DEA) and Bureau of Narcotics and Dangerous Drugs (BNDD) registration.
- Have professional liability insurance of such kind, in such amount, and underwritten by such insurers as required or approved from time to time by the Board of Directors.

During an interview on 11/06/18 at 10:30 AM, Staff O, Pharmacist, stated that:
- He was the only Pharmacist employed at the facility.
- In his absence, Pharmacist CC, from a local unaffiliated near-by Pharmacy would provide pharmacological services within the facility.
- After 11:00 PM, and on weekends, staff were instructed to call near-by facilities that would answer questions concerning pharmaceutical therapy.
- There were no contracts between the hospital and Pharmacist CC or the near-by facilities, to provide pharmaceutical therapy within the hospital.

Review of the facility's Pharmacy Director Job Description, dated 04/30/18, showed that if the director cannot be contacted, two near-by facility pharmacies have agreed to answer questions concerning pharmaceutical therapy. The telephone numbers to both pharmacies is available at both nurse's stations.

2. Even though requested, the facility failed to show a written agreement with the near-by pharmacies that showed appointment/approval by the Board of Directors and written guidelines for the performance of specified services developed and with input by the Medical Staff and/or Board of Directors.

Review of the facility's time sheet for employees, dated 10/09/18, showed that Pharmacist CC worked six hours on 10/09/18.

Even though requested, the facility failed to show a written agreement that showed Pharmacist CC's appointment/approval that demonstrated to the satisfaction of the medical staff and the Board of Directors that she met all of the qualifications and requirements.

During an interview on 11/07/18 at 10:00 AM, Staff A, Chief Executive Officer (CEO), stated that Pharmacist CC and the near-by pharmacies did not have written contracts and guidelines for the performance of specified services. Staff A also stated that they should have been approved through the approval process.

Based on observation, interview, record review and policy review, the facility failed to:
- Follow the standard of practice and provide consistent cardiac (heart) monitoring for two patients (#6 and #7) of two patients who were monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm).
- Properly secure the indwelling urinary catheter tubing (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) on two patients (#6 and #10) of two patients who had indwelling urinary catheters.
- Assess pain level per use of a numeric or visual pain rating scale for as needed (PRN) medications prior to administration for three patients (#8, #10, and #11) of four patients reviewed.
- Follow the facility medication administration policy and assess patient's response to PRN pain medication within one hour after administration for three patients (#8, #10, and #11) of four patients reviewed. This had the potential to affect the outcomes of all patients, by providing sub-standard nursing care. The facility census was eight.

Findings included:

1. Review of the facility's policy titled, "Cardiac Monitoring," revised 03/08/17, showed that cardiac monitoring is performed based on the physician's order. Cardiac monitoring is used to continuously observe the heart's electrical activity in patients who may have a symptomatic arrhythmia (abnormal heart rhythm) or any cardiac abnormalities that may lead to life-threatening arrhythmias.

Review of the physician's orders and History and Physical (H&P) for Patient #6, dated 11/02/18, showed an order for cardiac monitor. Patient #6 was admitted to the Medical Unit with a diagnosis of Congestive Heart Failure (CHF, a condition in which the heart doesn't pump blood as well as it should). Her past medical history included a pacemaker (a small device that is placed in the chest to help control abnormal heart rhythms) insertion.

Review of the physician's orders and H&P for Patient #7, dated 11/05/18 showed an order for telemetry. Patient #7 was admitted to the Medical Unit with shortness of breath. He had a past medical history of high blood pressure, hyperlipidemia (high levels of fat in the blood) and cardiac catheterization (a procedure to examine how well the heart is working).

Observation on 11/05/18 at 2:00 PM and again at 3:00 PM, at the Medical Unit nurse's station, showed that Patient #6 and Patient #7's heart rhythms were displayed on the cardiac telemetry monitor. No staff were at the nurses' station monitoring the patients' heart rhythms.

During an interview on 11/05/18 at 3:05 PM, Staff J, Chief Nursing Officer (CNO), stated that her expectation of staff was that someone should watch the cardiac monitors at all times.

Observation on 11/05/18 at 3:30 PM, showed no staff at the Medical Unit nurse's station monitoring the patient's cardiac telemetry.

2. Review of facility's policy titled, "Urinary Catheters," revised 04/07/17, showed that indwelling catheters should be properly secured after insertion to prevent movement and urethral trauma.

Observation on 11/06/18 at approximately 4:00 PM, showed that both Patients #6 and #10, had indwelling urinary catheter in place with the catheter tubing dependent (to hang freely) and not properly secured.

Review of nurses note, dated 11/05/18, showed that Patient #6 had self-transferred from the bed to chair, and pulled the indwelling catheter out of her urethra (opening to the urinary tract) with the balloon (portion of the catheter which is inflated with a water solution, to keep the catheter inside the body) fully inflated. (This can cause significant trauma to the urinary tract).

During and interview on 11/08/18 at 3:00 PM, Staff J, CNO, stated that it was her expectation that all indwelling urinary catheters were properly secured after insertion, per policy, to prevent movement and urethral trauma .

3. Review of the facility's policy titled, "Medication Administration," revised 03/02/18, showed that when PRN medications were administered, documentation should include:
- Action taken (what medication was administered and dose);
- Date and time of administration;
- Nurses Initials;
- Patient's response to medication within one hour; and
- Nurse's initial and time response was noted.

Review of Patient #10's medical record showed that the patient was administered per os (PO, by mouth) PRN narcotic analgesic (strong and addictive drug) pain medication one time on 11/02/18, four times on 11/03/18, one time on 11/04/18, and one time on 11/05/18, without documentation of an assessment of pain level prior to administration, and without documentation of the patient's response to the medication within one hour after administration. Patient #10 was also administered Intravenous (IV, in the vein) PRN narcotic analgesic pain medication two times on 11/03/18, without documentation of an assessment of pain level prior to administration, per a numeric or visual pain scale, and without documentation of the patient's response to medication within one hour after administration.

Review of Patient #11's medical record showed that the patient was administered PO, PRN narcotic analgesic pain medication two times on 10/31/18, one time on 11/01/18, and one time on 11/05/18, without documentation of an assessment of pain level prior to administration, and without documentation of the patient's response to medication within one hour after administration.

Review of Patient #8's medical record showed that the patient was administered PO, PRN narcotic analgesic pain medication one time on 11/02/18, three times on 11/03/18, one time on 11/04/18, and one time on 11/05/18 without documentation of an assessment of pain level prior to administration, per a numeric or visual pain scale, and without documentation of the patient's response to medication within one hour after administration.

During and interview on 11/08/18 at 3:00 PM, Staff J, Chief Nursing Officer (CNO) stated that it is her expectation that all licensed staff perform an assessment, and document that patient's pain level, prior to administration of PRN medications used for pain control, and that licensed staff perform an assessment and document the patient's response to the medication within one hour after administration, as per policy.




39562

Based on record review and interview, the facility failed to implement a care plan for chronic pain, skin integrity, indwelling urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine), and/or fall risk for four patients (# 6, #8, #10, and #11) of eight patients reviewed. This failure had the potential to affect all patients admitted to the facility when individualized care needs were identified, but were not addressed in the Care Plan. The facility census was eight.

Findings Included:

1. Review of facility policy titled, "Nursing Care Plans," revised 02/28/17, showed that a care plan shall be initiated for each patient within 24-hours of admission, by the registered nurse (RN). Each care plan must be individualized for the patient by choosing options that are available for outcomes, indication and interventions. Review of the care plan shall be made by the caregiver every shift, and shall be documented in the Care Plan section of the Hospital information System (HIS, electronic health records system).

Review of Patient #6's medical record on 11/06/18, showed a physician's order for an indwelling urinary catheter on 11/02/18, but there was no individualized indwelling urinary catheter care plan.

Review of Patient #10's medical record on 11/06/18, showed a physician's order for an indwelling urinary catheter for palliative (pain) measures on 11/03/18, but there was no individualized indwelling urinary catheter care plan.

Review of Patient #8's medical record on 11/06/18, showed that the patient was a 97 year old female with a history of falls. A nurse's note, dated 11/06/18 showed that bed alarm was on. The patient's individualized care plan for at risk for falls did not list bed alarm as an intervention. Patient #8 was treated for wounds to bilateral (right and left) posterior (back side of) knees due to her recent use of Thrombo-Embolic Deterrent (TED) hose (long, tight fitting stockings that place mild static pressure on the legs to prevent blood from clotting), which caused pressure injury (skin wound or injury cause by constant pressure to the area) to the posterior knees, and had a dry dressing in place to her right hip, post-surgical site. Patient #8's medical record did not have an individualized skin integrity care plan.

Review of Patient #11's medical records on 11/06/18 showed that the was treated for chronic lower back pain (LBP) in which she rated six out of 10 on 11/01/18 in the physical therapy initial evaluation, and the patient needed (PRN) narcotic analgesic (strong and addictive drug) pain medication prescribed to help manage pain symptoms. Patient #11's medical record did not have individualized pain management care plan.

During an interview on 11/08/18 at 3:00 PM Staff J, Chief Nursing Officer (CNO), stated that it was her expectation that care plans be initiated within 24-hours of admission and upon change of condition and that each care plan was individualized to meet the specific needs of the patient.

Based on observation, interview, record review, policy review and review of the Association of periOperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI), the facility failed to:
- Ensure that the Sterile Processing Department (SPD, where contaminated surgical equipment and instruments were cleaned) staff followed manufacture's guidelines for enzymatic cleaner (cleaning agent) concentration when soaking contaminated surgical instruments, prior to sterilization (process that eliminates viruses and bacteria).
- Ensure AAMI guidelines were followed in the Operating Room (OR) decontamination (dirty) sterile processing room, when paper products (particle shedding products that can cause contamination) were left in the environment, and when a dirty, lint-producing towel was used to dry instruments.
- Perform appropriate hand hygiene and glove use while setting up a procedure table (table where instruments were placed in preparation for surgery or a hospital procedure).
- Ensure that tools used for esophageal dilation (a procedure that stretches a narrowed area of the swallowing tube in a person's body) were properly covered and stored.
- Ensure that a History and Physical (H&P) was completed and documented in the medical record prior to the start of the procedure for three discharged patient records (#14, #15, and #16) of four discharged patient records reviewed.
- Ensure that an informed consent was signed by the physician prior to the start of the procedure for one discharged patient record (#15) of four discharged patient records reviewed.
These failed practices had the potential to compromise the safety and health of all patients undergoing procedures at the facility. The facility performed 20-30 procedures per month. The facility census was eight.

The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.639 Condition of Participation (COP): Surgical Services.

Findings included:

1. Review of the facility's policy titled, "Sterilization Procedure," revised 12/22/17, showed that proper cleaning prior to sterilization is necessary to achieve sterilization of the processed item. To prepare soaking solution, mix according to solution label instructions.

During an interview on 11/08/18 at 9:00 AM, Staff S, Surgical Services Director, stated that the department followed the AORN and the AAMI guidelines.

2. Review of AAMI ST79:2017 guidelines showed that only clean, nonlinting cloths or instrument air should be used to dry instruments and containers. Cloths with lint can leave lint on instrumentation, and lint and airborne particles can carry microorganisms. Appropriate cleaning reduces the bioburden (the number of bacteria living on a surface that has not been sterilized).

Observation on 11/07/18 at 2:30 PM in the Sterile Processing Department dirty room showed the following:
- Two instruments lying on a linting (lint producing) white towel.
- The towel appeared dirty with areas of black discoloration.
- Paper (particle shedding) was hanging on the wall.
- Paper towel dispenser (particle shedding) was mounted on the wall.
- Metal pan that instruments laid in to be cleaned had white, hard water deposits inside the pan.

During an interview on 11/07/18 at 2:35 PM, Staff OO, Licensed Practical Nurse (LPN), stated that when she cleaned the operating room instruments, she did not measure the amount of water and detergent she put in the pan, and did not know what the proper measurements should be. Staff OO added that she was unaware that she should not use lint producing cloths, or that paper should not be in the room.

3. Review of the AORN Guidelines for Perioperative Practice, 2017 edition, showed the following:
- Personnel should wear clean gloves when handling processed flexible endoscopes (small tubular instrument with a camera, that is used to look deep into the body) and when transporting them to and from the storage cabinet.
- Wearing clean gloves may lessen contamination of processed flexible endoscopes by the hands of personnel.
- Studies related to storage of flexible endoscopes have confirmed endoscope contamination from the hands of personnel and environmental surfaces.
- Personnel working in the endoscopy suite must wear personal protective equipment (PPE, items such as gloves, gown and/or mask).

Observation on 11/08/18 at 9:00 AM showed that Staff OO, LPN, entered the sterile processing room, did not perform hand hygiene and picked up a clean endoscope with non-gloved hands. She then entered the procedure room, laid the endoscope on the covered procedure table and continued to set up the table and touched the endoscope with ungloved hands.

During an interview on 11/08/18 at 9:30 AM, Staff S, Director of Surgical Services, acknowledged that best practice would be for the staff to wear gloves when they handled endoscopes.

During an interview on 11/08/18 at 9:45 AM, Staff BB, Infection Control Director, stated that her expectation of the surgical services staff was to accurately measure the water and detergent to properly clean and disinfect instruments to prevent infection. Staff BB added that the surgical staff should always perform hand hygiene and wear gloves when setting up procedure tables and handling scopes that will be used in a patient procedure, to prevent cross contamination and infection.

4. Review of the AORN Guidelines for Perioperative Practice, 2017 edition, showed the following:
- Flexible endoscopes and endoscope accessories should be stored in a manner that minimizes contamination and protects the device or item from damage.
- Storage cabinets should have doors.
- Cabinets used for storage of flexible endoscopes and endoscope accessories should be located in a separate clean area close to, but not within, the endoscopy procedure room.
- Locating the storage cabinet outside of the procedure room helps prevent contamination of processed endoscopes.

Observation on 11/07/18 at 2:45 PM in the operating room/procedure room, showed a storage cart with no doors that contained a tray of esophageal dilators (tool used to widen a narrowed section of the esophagus, the tube that leads from the throat to the stomach).

During an interview on 11/07/18 at 2:40 PM, Staff OO, LPN, stated that the storage cart with the esophageal dilators stayed in the operating room/procedure room during all procedures. She was unaware that the esophageal dilators should be enclosed and stored outside of the procedure room area.

5. Review of the facility's "Preoperative Requirements," revised 04/12/17, showed the following information that should be present on the patient's medical record, prior to patient's transfer to the operating room suite:
- History and Physical (H&P) including the patient's general condition and anticipated operative procedure dated within 30 days of scheduled surgery.
- Statement from surgeon/physician acknowledging review of H&P, with the addition of any updates within 24 hours of scheduled surgery.
- Informed surgical consent, signed within 24 hours of scheduled surgery.

Review of the facility's policy titled, "Pre-operative Routine," revised 01/10/18, showed that the physician shall be responsible for obtaining and documenting informed consent for the anticipated surgical procedure. The physician shall complete a H&P as defined in the Medical Staff Rules and Regulations (if the H&P is greater than 48 hours, an update must be completed within 48 hours of the surgery, either by the primary care physician or by the surgeon).

Review of discharged Patient #14's Medical Record, showed that he had a colonoscopy (a procedure that looks inside the intestines with an endoscope) on 06/07/18. There was no H&P noted in the medical record.

Review of discharged Patient #15's Medical Record showed that he had a colonoscopy on 09/13/18. There was no H&P noted in the medical record. A consent form dated 09/13/18 was signed by the patient and witnessed by an LPN. There was no physician signature.

Review of discharged Patient #16's Medical Record showed that he had an Esophagogastroduodenoscopy (EGD, a procedure in which an endoscope is used to look inside the organs of the upper digestive tract) and a colonoscopy on 10/11/18. There was no H&P noted in the medical record.

During an interview on 11/07/18 at 2:05 PM, Staff S, Surgical Services Director, stated that she was aware that the physician needed to complete an H&P prior to the procedure. She stated that it was difficult to get the physician's to do this.

Based on observation, interview and record review the facility failed to have a designated person assigned as activities director with completion of a Missouri approved Activity Director Course, and failed to provide a comprehensive activity program for one swing bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patient (#9) of four swing bed patients reviewed. This failure to identify each residents interests had the potential to deny all swing bed residents the ability to reach their highest level of physical, mental and psychosocial well being. The facility census was eight, with four of those patients in swing bed status.

Findings included:

1. Review of the facilities policy titled, "Swing Bed: Activity Assessment, Planning, Implementation, and Documentation", dated 09/10/09 showed the following:
- Purpose is to establish a comprehensive program which provides benefits in all activities of daily living and to provide adequate supplies for these activities;
- To assure time development of an activity therapy plan;
- Activities will be provided to meet the special needs of the short-term skilled nursing patient;
- Activity Director or designated alternate is responsible for establishing an activity program for each swing bed patient based on Maslow's Hierarchy of Needs (five levels of physical and psychological needs); and
- Activity will be documented in the medical record and integrated into the patient's plan of care.

Review of the facility's undated job description titled, "Swing Bed Activity Director", showed a list of the preferred qualifications for this position:
- Formal training which will include high stool education or General Education Degree (GED);
- Completion of Missouri approved Activity Director Course;
- Previous experience in a health care setting; and
- Knowledge of medication terminology would be helpful.

Review of Patient #9's medical record showed that she was a 92 year old that was admitted to the facility swing-bed program on 11/02/18 for ongoing physical therapy and intravenous antibiotic therapy (IVAB, infusion of antibiotic through the vein) related to a weakness from status post cerebrovascular accident (CVA, also known as stroke, damage to the brain from interruption of its blood supply), and a urinary tract infection (UTI, infection of the urinary tract).

2. Review of Patient #9's activity documentation on 11/06/18 at 10:30 AM, revealed no initial comprehensive activity assessment completed. There were no activities documented as completed for this patient during the four days since her admission.

Review of Patient #9's care plan on 11/06/18 at 10:40 AM, revealed no activity entry.

During an interview on 11/06/18 at 9:54 AM, Staff M, Human Resource Director (HR), stated that the former activities director transitioned into a different role and that position had not since been filled with a designated activities director. Staff M also stated that they utilized therapy and nursing staff to cover activities.

During an interview on 11/08/18 at 3:00 PM, Staff J, Chief Nursing Officer (CNO), stated that the activities for the swing bed patients should be individualized and comprehensive to meet the patient's individual activity needs. Staff J also stated she questioned the current practice that allowed alternate staff to cover activities without a designated Activities Director, and agreed the activities assessments and the comprehensive plan should be formulated by an individual with formal activities training.