HospitalInspections.org

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a sanitary environment in the Emergency Department (ED).

Findings include:

Review on April 4, 2017, of the facility's "Environmental Services" policy, last revised April 28, 2015, revealed "Policy: The Environmental Services Department staff will clean all areas of the Emergency Department on a daily basis and as needed. ..."

Review on April 4, 2017, of the facility's form provided and identified by EMP4 as the housekeeping cleaning schedule for the ED revealed no requirement for cleaning of the top of cabinets and over bed light fixtures.

Interview with EMP4 on April 4, 2017, at approximately 9:15 AM confirmed the housekeeping cleaning schedule for the ED contained no requirement for cleaning of the top of cabinets and over bed light fixtures.

Observation on April 4, 2017, of the facility's ED revealed a layer of dust measuring approximately a quarter in size when gathered together on the over bed light fixture. There was a layer of dust measuring approximately a quarter in size when gathered together on the top bar of the over bed light and on the adjustable joint mechanism of the light in patient rooms 1, 2, 3 and 4.

Interview with EMP2 and EMP4 on April 4, 2017, at approximately 9:20 AM confirmed the layer of dust measuring approximately a quarter in size when gathered together on the over bed light fixture and on the top bar of the over bed light and on the adjustable joint mechanism of the light in patient rooms 1, 2, 3 and 4. EMP2 and EMP4 confirmed the layer of dust on the top of the wall mounted cabinet in patient rooms 1, 2, 3 and 4. EMP2 and EMP4 revealed the dust on the over bed lights and wall mounted cabinets would be seen in all ED patient rooms. EMP2 confirmed the dust on the over bed lights pose a concern regarding potential infection if a piece would fall into a patient's open wound.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure proper storage of food for six of six months reviewed (March 2016, April 2016, May 2016, June 2016, July 2016 and August 2016).

Findings include:

Review on April 3, 2017, of the facility policy "Infection Prevention and Control NS-4001," last reviewed November 1, 2013, revealed "Purpose: To prevent and control contamination and the spread of infection within the department and the hospital. Policy: Nutritional Services staff shall follow all appropriate infection prevention and control measures for all food service. Responsibilities: Nutritional Services Director shall: ... Stores frozen food at or below 0 degrees F. ...Control of the System: Preventative and corrective maintenance shall be documented. ... Records of proper temperatures for all refrigerators and freezing equipment shall be maintained. ... "

Review on April 4, 2017, of facility policy "Temperatures of Refrigerators and Freezers NS-7111," last reviewed November 1, 2013, revealed "Policy: Temperatures shall be recorded and kept on file of all refrigerators and freezers. ... Freezer temperatures shall be zero (0) degrees F or colder. ... At any time any refrigerator or freezer is not within the acceptable range, it must be reported to Plant Management immediately."

Review on April 4, 2017, of the facility form "Refrigerator/Freezer Temperature Check Sheet Nutritional Services Department," no review date, revealed spaces for staff to document Location, Month and Year. There were columns labeled Date, Temperature, Refrigerator, Freezer, Any Corrective Action Taken/Explain/Temperature Reassessed, Staff Signature to document findings.

Review on April 4, 2017, of the Refrigerator/Freezer Temperature Check Sheets for March 2016 through August 2016, revealed 25 incidents of temperatures over zero degrees Fahrenheit (F) in March 2016, 60 incidents of temperatures over zero degrees F in April 2016, 61 incidents of temperatures over zero degrees F in May 2016, 60 incidents of temperatures over zero degrees F in June 2016, 61 incidents of temperatures over zero degrees F in July 2016 and 22 incidents of temperatures over zero degrees F in August 2016 in the walk-in freezer.

Additional review of the Refrigerator/Freezer Temperature Check Sheets for March 2016 through August 2016, revealed no documentation the facility's Plant Management was notified of the elevated freezer temperatures.

Review of facility provided documentation revealed the walk-in freezer was serviced by an outside contractor on February 29, 2016, and June 14, 2016.

Interview with EMP7 at 11:30 AM on April 7, 2017, confirmed the freezer temperature were to be maintained at zero degrees F or below, and the freezer temperatures were out of range 25 times in March 2016, 60 times in April 2016, 61 times in May 2016, 60 times in June 2016, 61 times in July 2016 and 22 times in August 2016. EMP7 confirmed there was no documentation the facility's Plant Management was notified of the elevated freezer temperatures.

Interview with EMP8 confirmed the freezer temperature was to be maintained at zero degrees F or below.

Based on observation and staff interview (EMP), it was determined the facility failed to ensure filled biohazard boxes were stored on pallets; failed to ensure a sanitary environment was maintained in the linen rooms; failed to ensure hair was covered in the food service department for three of five staff observed; failed to ensure dietary equipment was cleaned as per policy for two of nine pieces of equipment examined; failed to ensure dishwasher temperatures were within recommended range; and failed to ensure a sanitary environment in the walk-in refrigerator.

Findings include:

1) Review on April 3, 2017 of the facility policy "Hazardous Materials - Handling and Storage Facility Services - Maintenance policy," last reviewed November 18, 2013, revealed "Policy: The Facility Services Manager is responsible for ensuring that the correct procedures for labeling, handling, using and storing hazardous material is strictly adhered to by all hospital staff. ... Storage and Handling: Hazardous materials must be stored in clearly marked and strictly controlled safety storage areas. ... "

Review on April 5, 2017, of the facility policy "Hazardous Materials and Waste Management Plan Environmental Services," last reviewed December 1, 2013, revealed "Policy: Endless Mountains Health Systems will comply with generally accepted infection control practices, and with federal and state regulations for disposal of medical and non-medical waste. ... Objective: The objective of the Hazardous Materials and Waste Management Plan is to develop a system that addresses the identification, selection, handling, storage, use and disposal of hazardous materials and wastes. ... Goals: ... To provide adequate space and equipment for the safe handling and storage of hazardous materials and waste ... Policy: ... Biohazard and non-biohazard waste holding areas will be inspected regularly by the Facilities Services manager/designee. Any deficiencies found will be documented, and prompt action will be taken to address any handling, segregation, containment or storage issues. ... "

Observation on April 3, 2017, at 2:15 PM of the biohazard storage room revealed the following: There were five biohazard boxes stored directly on the floor. By the wall in the biohazard storage room, there were two biohazard boxes stored directly on the floor. Directly in front of these two biohazard boxes were three open and partially filled biohazard boxes stored directly on the floor.

Interview with EMP13 on April 3, 2017, at 2:15 PM, confirmed the observations in the biohazard storage room where the biohazard boxes were stored directly on the floor. EMP13 stated the biohazard boxes were to be stored on pallets.

2) A request was made on April 3, 2017 for a policy and procedure for emptying and cleaning the linen chute. No policy/procedure was provided.

Observation on April 3, 2107, at 1:35 PM, of the laundry chute room revealed approximately 12 soiled linen bags fell out of the laundry chute when the door was opened. The soiled linen bags fell onto the floor and approximately five of the soiled linen bags opened. The soiled linen went onto the floor. EMP4 and EMP13 donned gloves, picked up the closed linen bags, and placed them in the soiled linen cart in the room. EMP4 and EMP13 then picked up the soiled linen from the floor and placed the soiled linen in the open bags and a new soiled linen bag in the room. After the linen and linen bags were removed from the floor, EMP4 and EMP13 transported the full soiled linen cart to the soiled linen storage room. They returned to the laundry chute room with an empty cart, wearing the same gloves donned when they picked up the soiled linen. In moving from the laundry chute room to the soiled linen room, the door knobs were touched with the soiled gloves. EMP4 and EMP13 removed their gloves and cleansed their hands after returning to the laundry chute room and placing the empty cart by the wall.

Interview with EMP4 on April 3, 2017, at 1:50 PM, confirmed the observations above where the soiled linen fell out of the laundry shoot, opened and spilled onto the floor. EMP4 revealed the laundry chute was checked for soiled linen bags first thing each morning, in the afternoon, and on the evening shift. EMP4 was unaware of a policy and procedure for emptying and cleaning the laundry chute.

Interview with EMP13 on April 3, 2017, at 1:50 PM, confirmed the observations above where the soiled linen fell out of the laundry shoot, opened and spilled onto the floor.
EMP13 was unaware of a policy and procedure for emptying and cleaning the laundry chute.

3) Review on April 3, 2017, of facility policy "Infection Prevention and Control NS-4001," last reviewed November 1, 2013, revealed "Purpose: To prevent and control contamination and the spread of infection within the department and the hospital. Policy: Nutritional Services staff shall follow all appropriate infection prevention and control measures for all food service. Responsibilities: Nutritional Services Director shall: Ensure clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards. ... Stores frozen food at or below 0 degrees F. ... Infection Prevention and Control Practices: ... All equipment shall be thoroughly cleaned after each use. ... Staff: Employees shall be expected to keep themselves clean, bathe daily, wear clean uniforms at all times, have clean hair (covered with a hair net), keep beards and mustaches close-cropped, keep hands clean and fingernails short and clean .... Equipment: ... Dishwasher: ... Shall maintain a final sanitation rinse of 180 degrees F and wash water of 165 degrees F [Fahrenheit] or higher. ... Refrigeration: Shall be kept in clean and sanitary condition through regular cleaning. ... Shall be used for food and food products only. ... Control of the System: Preventative and corrective maintenance shall be documented. ... Records of proper temperatures for all refrigerators and freezing equipment shall be maintained. ..."

Observation at 11:10 AM on April 3, 2017, in the food preparation area, revealed EMP7, EMP9 and EMP11 with all hair not covered by a hairnet.

Interview at 11:30 AM with EMP7 confirmed EMP7, EMP9 and EMP11 did not have all hair covered by a hairnet. EMP7 confirmed the facility policy required the employee's hair be covered with a hairnet.

4) Observation at 11:15 AM on April 3, 2017, revealed splatters of grease on the backsplash of the stove and brown grease covering the inside of the convection oven doors.

Interview with EMP8 at 11:15 AM on April 3, 2017, confirmed the splatters of grease on the backsplash of the stove and brown grease covering the inside of the convection oven doors.

5) Review at 11:30 AM on April 7, 2017, of "Cleaning Schedule -Nutritional Services" for January 2017, revealed no documentation the steamer, convection oven, refrigerator, or oven were cleaned weekly as per facility policy. Documentation for daily cleaning of the food cart was missing for 19 days, the coffee pot for 18 days, the microwave oven for 19 days, the stove top for 17 days and the toaster for 17 days.

Review on April 7, 2017, of "Cleaning Schedule -Nutritional Services" for February 2017, revealed no documentation the steamer, convection oven, refrigerator, or oven were cleaned weekly as per facility policy. Documentation for daily cleaning of the food cart was missing for 25 days, the coffee pot for 22 days, the microwave oven for 20 days, the stove top for 18 days and the toaster for 23 days.

Review on April 7, 2017, of "Cleaning Schedule -Nutritional Services" for March 2017, revealed no documentation the steamer was cleaned for 16 of 31 days. There was no documentation the convection oven, refrigerator, or oven were cleaned weekly as per facility policy. Documentation for daily cleaning of the food cart was missing for 7 days, the coffee pot for 7 days, the microwave oven for 6 days, the stove top for 14 days and the toaster for 8 days

Review on April 7, 2017, of "Cleaning Schedule -Nutritional Services" for April 2017, revealed no documentation the stove top was cleaned on April 1, 2017 and April 2, 2017.

Interview with EMP7 at 11:30 AM on April 3, 2017, confirmed there was no documentation the dietary equipment was cleaned as per the facility policy in January, February, March and April 2017.

6) Review at 11:30 AM on April 7, 2017, of the "Dishwasher Temperature Check Sheet" for May 2016, revealed 31 days when the wash temperature of the dishwasher was below 165 degrees F and two days when the final rinse temperature of the dishwasher was below 180 degrees F. There was no documentation maintenance was notified of the low temperature readings.

Review at 11:30 AM on April 7, 2017, of the "Dishwasher Temperature Check Sheet" for October 2016, revealed 31 days when the wash temperature of the dishwasher was below 165 degrees F and three days when the final rinse temperature of the dishwasher was below 180 degrees F. There was no documentation maintenance was notified of the low temperature readings.

Review at 11:30 AM on April 7, 2017, of the "Dishwasher Temperature Check Sheet" for November 2016, revealed 30 days when the wash temperature of the dishwasher was below 165 degrees F and two days when the final rinse temperature of the dishwasher was below 180 degrees F. There was no documentation maintenance was notified of the low temperature readings.

Review at 11:30 AM on April 7, 2017, of the "Dishwasher Temperature Check Sheet" for January 2017, revealed 30 days when the wash temperature of the dishwasher was below 165 degrees F and five days when the final rinse temperature of the dishwasher was below 180 degrees F. There was no documentation maintenance was notified of the low temperature readings.

Interview with EMP7 at 11:30 AM on April 3, 2017, confirmed the dishwasher wash and final rinse temperatures were below the required temperatures in May 2016, October 2016, November 2016 and January 2017. EMP7 confirmed there was no documentation maintenance was notified of the low temperature readings.

7) Observation at 11:20 AM on April 3, 2017, of the walk-in refrigerator in the food service department revealed three employee lunch bags stored with patient food.

Interview with EMP7 at 11:20 AM on April 3, 2017, confirmed the lunch bags belonged to food service employees.

Interview at 9:20 AM on April 5, 2017, with EMP8 confirmed it was not appropriate for employee lunch bags to be stored with patient food in the walk-in cooler.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure staff used approved abbreviations when documenting in the Emergency Department (ED) patient medical record for three of 10 medical records reviewed (MR44, MR45 and MR46), failed to ensure patient medical records were stored in a manner to prevent damage from fire and water in the Medical Records Department, and failed to ensure medical records were completed within 30 days of discharge for 91 of 103 applicable medical records reviewed (MR47 through MR136).

Findings include:

1) Review on April 4, 2017, of the facility's Medical Records Department Policy and Procedure Abbreviation List, dated March 28, 2017, revealed no documentation that "ntf" was an approved abbreviation.

Review of MR44, MR45 and MR46 on April 4, 2017, revealed EMP17 used the abbreviation "ntf" when documenting in the nurse's notes.

Interview with EMP2 on April 4, 2017, at approximately 11:30 AM confirmed EMP17 used the abbreviation "ntf" when documenting in MR44, MR45 and MR46's medical record. EMP2 confirmed "nft" was not an approved hospital abbreviation.

2) Review on April 4, 2017, of the facility's "Storage and Retrieval Systems" policy, no review date, revealed "Comprehensive and Centralized System A comprehensive, centralized system for the storage and retrieval of medical records, from creation through destruction, shall be established and maintained as a major function of the medical records department. ... Safeguard records and documents from tampering, loss, and inadvertent destruction ... Storage Space Specifications Storage space shall be selected and maintained to protect records from unauthorized access, loss, and inadvertent destruction. Therefore, storage space shall be selected to meet the following specifications: Adequate lighting Protection against fire, including sprinkler system Freedom from potential hazards, such as flooding or damage from broken water pipes ..."

Observation on April 4, 2017, of the facility's Medical Records Department revealed 15 metal shelving units. There were 7 shelves on each unit which were open and did not have closing doors. Each shelf was full of patient medical records. There were 2 water sprinklers for the facility's fire suppression system above these shelving units.

Interview with EMP6 on April 4, 2017, at approximately 1:30 PM confirmed the open shelving units with open shelves with no closing doors, the shelves were full of patient medical records and the 2 water sprinklers for the facility's fire suppression system above these shelving units. EMP6 confirmed these patient medical records were not protected from potential fire and water damage.

3) Review on April 4, 2017, of the facility's "Physician Requirements For Patient Medical Records" policy, no review date, revealed "Policy- It is the policy of Endless Mountains Health Systems to provide a medical record of the patient that is a timely, authentic, and legible description of the patient's clinical condition and hospital course. Scope - Health Information Management and Administration Objective - To define physician requirements for the medical record. Procedure - General Requirements All entries must be timed, dated and authenticated. Records shall be completed and authenticated within 30 days following patient discharge. Records will be considered complete when all dictated reports are transcribed and all entries authenticated. Final diagnosis and complications must be recorded without abbreviations or symbols. ..."

Review on April 4, 2017, of the facility's "Bylaws Rules and Regulations Of The Medical Staff," last revised June 2016, revealed "... Article VII. Corrective Action ... Section 3. Automatic Suspension a. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically after warning of delinquency for failure to complete medical records within 30 days of a patient's discharge. This type of suspension will not require notification to the National Practitioner Data Bank. Ordinarily, the medical record librarian should notify a practitioner of his disciplinary status, with copies of the notice to the Chairman of medical records committee, Chairman of the Executive Committee and the Chief Executive Officer. The practitioner may be permitted 48-72 hours in which to complete the delinquent record. If the Chairman of the Executive Committee does not intercede on his behalf within the stated time span, the delinquent practitioner's admitting privileges must be suspended by the Chief Executive Officer. b. Action by the State Board of Medical Examiners revoking or suspending a practitioner's license, shall automatically suspend all of his hospital privileges. c. It shall be the duty of the President of the Medical Staff to cooperate with the Chief Executive Officer in enforcing all automatic suspensions.

Review on April 4, 2017, of the delinquent medical record list provided by EMP6 revealed there were 91 delinquent records greater than 30 days of patient discharge. The following physicians had medical records greater than 30 days post discharge that required completion of information: CF4 had 4 medical records; CF10 had 77 medical records; and OTH1 had 9 medical records. EMP6 provided documentation that CF4, CF10 and OTH1 were notified of their delinquent medical records; that copies of these notices went to the Chairman of medical records committee, Chairman of the Executive Committee and the Chief Executive Officer.

Interview with EMP6 on April 4, 2017, at approximately 2:00 PM confirmed CF4, CF10 and OTH1 had patient medical records greater than 30 days post discharge that required completion of information. EMP6 confirmed the facility did not follow their established policy or the Bylaws Rules and Regulations Of The Medical Staff regarding medical staff with delinquent medical records. EMP6 revealed CF4, CF10 and OTH1's admitting privileges were not suspended.

Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed failed to ensure annual performance reviews were completed for four of 24 personnel files (PF10, PF11, PF19 and PF22).

Findings include:

Review on April 5, 2017, of the facility's "Personnel Policy and Procedure Subject - Performance Evaluation," last reviewed December 7, 2016, revealed "Policy ... 5. Performance evaluations will be given during the month of September. ... Procedure 1. Evaluation forms will be distributed by August 31 of each year to Department Heads/Supervisors by the Human Resources Department. ... 5. If an evaluation is not received by the Human Resources Department by October 1, the Director of Human Resources will notify the Administrative Director of evaluations not received. The Administrative Director will notify the Department Head/Supervisor that evaluations must be received no later than October 15. 6. If the evaluation is not received by October 15, the Director of Human Resources will notify the Administrative Director to schedule a conference with the Department Head/Supervisor responsible for the evaluation and progressive discipline will begin."

Review on April 4, 2017, at approximately 10:00 AM, revealed PF10 was hired October 29, 2007, and was currently employed at the facility. There was no documentation of performance evaluations for 2015 or 2016.

Review on April 4, 2017, at approximately 10:00 AM, revealed PF11 was hired April 14, 1981, and was currently employed at the facility. There was no documentation of performance evaluations for 2015 or 2016.

Review on April 4, 2017, at approximately 10:00 AM, revealed PF19 was hired July 23, 2014, and was currently employed at the facility. There was no documentation of performance evaluations for 2015 or 2016.

Review on April 4, 2017, at approximately 10:00 AM, revealed PF22 was hired October 15, 2012, and was currently employed at the facility. There was no documentation of performance evaluations for 2015 or 2016.

Interview with EMP9, on April 5, 2017, at 10:45 AM, confirmed there were no performance evaluations for 2015 and 2016 for PF10, PF11, PF19 and PF22.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Materials Management and Maintenance policies and procedures were reviewed annually.

Findings include:

1) Review on April 3, 2017 of the facility documentation revealed the statement "The Policies and procedures in Materials Management have been reviewed and revised as necessary." The last review date was December 10, 2015.

Interview with EMP12 on April 3, 2017, at 11:50 AM, confirmed the Policies and Procedures in Materials Management were last reviewed December 10, 2015. EMP12 revealed the policies and procedures were updated as needed.

2) Review on April 3, 2017, of the facility documentation revealed a sheet stating "Facility Services - Maintenance Policy and Procedure Manual Review." The last review date was November 27, 2013. These policies and procedures included the housekeeping, laundry and maintenance services.

Interview with EMP13 on April 3, 2017, at approximately 3:00 PM, confirmed the Facility Services - Maintenance Policy and Procedure Manual was last reviewed November 27, 2013. EMP13 revealed the policies and procedures for housekeeping, laundry and maintenance services were updated as needed.

Interview with EMP1 on April 4, 2017, at 10:35 AM, confirmed the facility's policies and procedures were to be reviewed annually.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure quality improvement was completed on all contracted services provided to the facility.

Findings include:

Review on April 5, 2017, of the facility's "Quality Improvement Plan," revealed "Endless Mountains Health Systems, through the Board of Directors, Medical Staff, and Chief Executive Office is dedicated to the provision of quality care to all of its patients. In order to ensure that quality care is provided, an ongoing Quality Improvement Process has been established. ...Purpose: The purpose of the Quality Improvement Plan for EMHS is to continually strive to improve services through establishing, implementing, monitoring, and documenting an ongoing Quality Assessment/Quality Improvement process. ...Authority and Accountability: . ... The Quality Improvement Committee This committee is a multidisciplinary group, which will meet quarterly, and more frequently as circumstances dictate. The QI committee will be responsible for the directing, monitoring and reviewing of all QI activities at Endless Mountains Health Systems. The committee will report directly to the CEO who will present the QI activities to the governing body. The members of the QIC are comprised of representatives of the administration, medical staff, nursing department, QI department, and ancillary services. The QI Committee will review the care provided by the medical staff, nursing and all ancillary services to include all health care practitioners employed or contracted by EMHS. ..."

Review on April 5, 2017, of the contractor list provided by EMP5 revealed a list of forty (40) contractors. The services include: waste management, fire protection, pest control, food service, linen, snow removal, medical gas, housekeeping, HVAC controls, transcription, laboratory, elevator maintenance, security/monitoring systems, respiratory equipment service, and kitchen equipment cleaning.

Interview on April 5, 2017, with EMP5 at approximately 9:05 AM confirmed the facility did not complete quality on all contracted services for 2016.

Review on April 5, 2017, of the Quality Meeting Minutes for 2016 revealed the contracted services were not reviewed by the Quality Improvement Committee.

Based on review of facility documents and staff interview (EMP), it was determined the Governing Body failed to assess the effectiveness of the performance improvement program for the 2015 calendar year.

Findings include:

Review on March 5, 2017, of the facility's "Quality Improvement Plan," revealed: Endless Mountains Health Systems, through the Board of Directors, Medical Staff, and Chief Executive Office is dedicated to the provision of quality care to all of its patients. In order to ensure that quality care is provided, an ongoing Quality Improvement Process has been established. ... Purpose: The purpose of the Quality Improvement Plan for EMHS is to continually strive to improve services through establishing, implementing, monitoring, and documenting an ongoing Quality Assessment/Quality Improvement process. ... Authority and Accountability: The Governing Body The Board of Directors has the ultimate responsibility and authority for the professional practices and the quality of care provided to its clients. The Board of Directors has jurisdiction over the Quality Improvement Process. They delegate the authority and accountability to the Chief Executive Officer. The Chief Executive Officer assumes responsibility for assuring that the quality assurance process is compatible with the requirements of third party payers, including Federal and state governments. The CEO will demonstrate to the Board of Directors that there is a well organized cross functioning review of such care. The CEO delegates authority and accountability for the operation and control of the QI process and the Quality Improvement Committee. The Quality Improvement Committee This committee is a multidisciplinary group, which will meet quarterly, and more frequently as circumstances dictate. The QI Committee will be responsible for the directing, monitoring, and reviewing of all QI activities at Endless Mountains Health Systems. The committee will report directly to the CEO who will present the QI activities to the governing body. ... The QI program will be evaluated annually to determine if the coordination and administration of the program is effective and efficient with improved patient care as a result. ..."

Review on March 5, 2017, of governing body meeting minutes from December 2015 to November 2016 revealed no documentation the governing body reviewed the effectiveness of the performance improvement program for the 2015 calendar year.

Interview on March 5, 2017, with EMP1 confirmed there was no documentation in the governing body meeting minutes of an annual overall assessment of the PI program for effectiveness and efficiency.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure swing bed patients had the right to choose their own personal physician in ten of ten swing bed medical records reviewed (MR34, MR35, MR36, MR37, MR38, MR39, MR40, MR41, MR42, MR43.)

Findings include:

Review on April 5, 2017, of the facility's "Swing Bed Statement of Patients Rights," dated last reviewed June 6, 2016, revealed the facility did not include that the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR34, MR35, MR36, MR37, MR38, MR39, MR40, MR41, MR42, and MR43 revealed the patients were admitted to the facility's swing bed program.

Review on April 5, 2017, of MR34 revealed the patient was admitted to the swing bed unit on January 26, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR35 revealed the patient was admitted to the swing bed unit on February 5, 2017. MR35 revealed the patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR36 revealed the patient was admitted to the swing bed unit on March 9, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR37 revealed the patient was admitted to the swing bed unit on March 9, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR38 revealed the patient was admitted to the swing bed unit on March 10, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR39 revealed the patient was admitted to the swing bed unit on March 15, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR40 revealed the patient was admitted to the swing bed unit on March 16, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR41 revealed the patient was admitted to the facility's swing bed unit on March 17, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR42 revealed the patient was admitted to the facility's swing bed unit on October 19, 2016. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Review on April 5, 2017, of MR43 revealed the patient was admitted to the facility's swing bed unit on March 31, 2017. The patient signed the facility's "Swing Bed Statement of Patient Rights," and it did not include the patient had the right to choose a personal attending physician.

Interview on April 5, 2017, with EMP1 and EMP3 confirmed the facility's "Swing Bed Statement of Patient Rights" did not include that the patient had the right to choose a personal attending physician.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to document a discussion between the physician and the patient or the patient's family or responsible party regarding the DNR decision and order for four of 11 swing bed medical records reviewed (MR34, MR35, MR36 and MR37).

Findings include:

Review on April 5, 2017, of the facility's "Do Not Resuscitate (DNR)" policy, last reviewed March 21, 2017, revealed "Policy Objective - Endless Mountains Health Systems shall provide full resuscitative measures for patients in cardiopulmonary arrest unless the patient has previously expressed the desire not to have such treatment, and/or unless a Do Not Resuscitate (DNR) is written. Procedure - ... 2. Principles a. An adult with decision-making capacity possesses the right to refuse any medical or surgical intervention. b. A patient is judged to have decision-making capacity when he or she possesses the ability to understand the likely consequences of all reasonable options, and make a voluntary decision. c. A patient's decision to forgo CPR should only be made after a discussion of the benefits and burdens for this decision. d. In making medical recommendations for the patient, the physician's primary motivation is the best interest of the patient. In the case of a patient who lacks decision-making capacity, the attending physician should meet with the family members and seek concurrence. In the case of a person holding a durable power of attorney, this person will be included among those consulted, and in cases holds primary authority to consent to or authorize medical treatment. ... b. Documentation of the order The DNR order must be entered into the electronic health record [name of electronic health record system]; communicated to all care-givers, and documented in the progress notes. This documentation should briefly summarize the discussion held with the patient or the patient's family member(s). When a family member is used, a note documenting the patient's lack of capacity should also be present. ..."

Review of MR34 on April 5, 2017, revealed the patient was admitted to the facility's swing bed program on January 26, 2017. There was nursing and physician documentation that MR34 was awake, alert and oriented and able to make their own decisions. There was a physician order dated January 26, 2017, for Do Not Resuscitate (DNR) following a discussion with the patient's Power of Attorney. There was no documentation the physician discussed the DNR order with the patient.

Interview with EMP3 on April 5, 2017, at approximately 11:00 AM confirmed MR34 was admitted to the facility's swing bed program; there was nursing and physician documentation that MR34 was awake, alert and oriented and able to make own decisions; there was a physician order for DNR following a discussion with MR34's Power of Attorney; and there was no documentation the physician discussed the DNR order with the patient.

Review of MR35 on April 5, 2017, revealed the patient was admitted to the facility's swing bed program on February 5, 2017. There was nursing and physician documentation that the patient did not have decision-making capacity. There was a physician order dated February 5, 2017, for DNR. There was no documentation there was a discussion between the physician and the patient's family or responsible party regarding the DNR decision and order.

Interview with EMP3 on April 5, 2017, at approximately 11:15 AM confirmed MR35 was admitted to the facility's swing bed program; there was nursing and physician documentation that MR35 did not have decision-making capacity; and there was a physician order dated February 5, 2107, for DNR. EMP5 confirmed there was no documentation there was a discussion between the physician and the patient's family or responsible party regarding the DNR decision and order.

Review of MR36 and MR37 revealed these patients were admitted to the facility's swing bed program on March 9, 2017. There was nursing and physician documentation these patients were awake, alert and oriented and able to make their own decisions. There were physician orders dated March 9, 2017, for DNR in MR36 and MR37. There was no documentation in MR36 and MR37 that the physicians discussed the DNR status with the patients.