HospitalInspections.org

Preceptor: 18560
Based on observation, interview, and policy review, the provider failed to ensure:
*Five of five laryngoscope blades (used to guide a breathing tube down the throat and into the airway) used in the emergency room (ER) were stored in a sanitary manner.
*Two of two outdated chest tube insertion trays (used in an emergency for a collapsed lung) were available for patient use.
Findings include:

1. Observation on 11/19/13 at 8:20 a.m. in the ER revealed:
*There were five laryngoscope blades placed in a white plastic basket.
*The blades were unprotected from contamination.

Interview immediately following the above observation with the director of nursing (DON) revealed:
*She thought the blades did not have to be sterilized.
*When the blades had been used they had been sent to central supply to be cleaned and then returned to the basket on top of the crash cart.
*She was unsure as to what chemical had been used to clean and disinfect the laryngoscope blades.

2. Observation on 11/19/13 at 9:55 a.m. in the ER revealed there were two chest tube insertion trays in the cupboard with an expiration date of 10/20/12.

Interview immediately following the above observation with the DON revealed the nursing staff were supposed to check for outdated supplies and remove the supplies from patient use.

Review of the provider's 9/16/09 Inventory and/or Removal of Dated Medications/Supplies policy revealed:
*The policy was to ensure all outdated medication and medical supplies were removed from unit inventory prior to expiration.
*The DON, department supervisor, or designee would have been responsible for checking for expiration dates.
*Inventory would have been checked on the last seven days of every month.

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*The emergency room (ER) crash cart's (medications and supplies were stored in the cart for emergencies) top drawer was appropriately secured.
*Expired multi-dose insulin vials had been removed from one of one pharmacy refrigerator.
*Expired insulin in one of one glucometer tray was removed and not readily available for patient use.
*Medications in three of three storage areas in the surgical suite (operating room [OR] supply cabinet, OR storage closet, and central supply storage closet) were not outdated.
Findings include:

1. Observation on 11/19/13 at 8:40 a.m. in the ER revealed a crash cart with the top drawer opened. The medication in the top drawer was accessible and not secured.

Interview immediately following the above observation with the director of nursing (DON) revealed the crash cart drawers are locked unless the cart was in use.

2a. Observation on 11/19/13 at 9:00 a.m. in the pharmacy refrigerator revealed the following opened vials of insulin and the expiration dates:
*Levemir 11/2/13.
*Lantis 11/2/13.
*Novolog 11/10/13.
*Humalin 11/10/13.

b. Observation on 11/19/13 at 9:10 a.m. in the pharmacy revealed a glucometer tray (used for obtaining blood sugars) had Humalin regular insulin with a 11/17/13 expiration date.

c. Interview immediately following the above observations with the DON revealed the insulins were expired and should have been removed from the refrigerator and the glucometer tray.

3a. Observation on 11/19/13 at 1:30 p.m. of the supply cupboard in the central supply sterilization room revealed two pediatric/infant lumbar puncture trays with a February 2013 expiration date.

b. Observation on 11/19/13 at 2:30 p.m. of the OR storage closet revealed the following expired supplies:
*A package of blood fluid warming tubing with a October 2013 expiration date.
*An epidural anesthesia tray with a August 2013 expiration date.
*A bottle of calibration gas mixture with a June 2013 expiration date.

c. Observation on 11/19/13 at 2:45 p.m. of the OR supply cabinet revealed four 20 milliliter vials of 2 percent Lidocaine with a 11/1/13 expiration date.

d. Interview on 11/19/13 at 3:00 p.m. with the surgery director revealed she tried to check on a monthly basis for expired supplies.

4. Review of the provider's 9/16/09 Inventory and/or Removal of Dated Medical Medications/Supplies revealed:
*It was the policy to ensure that all outdated medication and medical supplies were removed from unit inventory prior to expiration.
*The DON, department supervisor, or designee would have been responsible for checking for expiration dates.







18560



30170



22452

Preceptor: 15036
Based on observation, interview, and policy review, the provider failed to ensure:
*A process had been developed and implemented to monitor surgical site infections for one of one surgical suite.
*Patient care technician (PCT) C followed the manufacturer's disinfection instructions for one of one whirlpool tub.
*Aseptic technique was followed by the physical therapist for one of one sampled patient's (33) dressing change.
*Hand hygiene protocols were following by one of one surgery director and one of one physician (F) after coming in contact with contaminated items or performing patient care tasks in the surgical suite.
*Contaminated endoscopic scope was not hand carried from the procedure room by one of one surgery director to the decontamination room after one of one sampled patient's (13) urology procedure.
*Surgical scrub attire was worn by one of one physician (F) upon entering the procedure room for one of one sampled patient's (13) urology procedure.
*Outside shipping containers were not used to store medical supplies in four of four surgical suite storage areas (operating room [OR], procedure room, central supply, and the OR storage closet).
*The glucometer had been disinfected by registered nurse (RN) A after one of one sampled patient's (3) fingerstick blood glucose.
*Documentation time for high-level disinfection of ultrasound probes was documented by the radiology director in one of one radiology department.
Findings include:

1. Review on 11/20/13 at 10:30 a.m. of RN D's 2010 through 2013 infection control surveillance and monitoring information revealed no documentation regarding:
*Investigation summary of hospital acquired infections.
*Surgical site infections.

Interview at that time with RN D revealed:
*She monitored hospital acquired infections but had not conducted investigations for the causes of those infections.
*She should have been conducting investigations and documenting those investigations regarding hospital acquired infections.
*They had talked about monitoring surgical site infections in the nurse meetings but had not implemented a process to monitor for surgical site infections.
*She had never followed up with surgical patients and had never done any monitoring of surgical site infections.

Interview on 11/19/13 at 3:30 p.m. with the surgery director revealed she did not monitor surgical site infections. She did not have a process in place to monitor surgical site infections.

2. Observation and interview on 11/19/13 at 8:25 a.m. of PCT C disinfecting the whirlpool tub in the procedure unit revealed she:
*Put on a pair of gloves. She wore no protective covering over her clothing.
*Was unsure what disinfectant was used as maintenance took care of that.
*Was uncertain how far to fill the whirlpool tub with water. It depended how dirty it looked and the film that was left on the tub after it had been used. She usually let the disinfectant stay on the tub surfaces for two to three minutes. She filled the whirlpool tub one-half full.
*Used a brush that was on the top of the whirlpool tub to brush the interior of the tub and the front of the lift chair, and then rinsed the surfaces with water. She had not used the brush on the back of the lift chair. After she had used the brush on the tub and the chair she placed the brush back on the top of the whirlpool tub.
*Had not removed the gloves she had worn when cleaning the tub before she opened a cabinet to remove a canister of Clorox disinfectant wipes.
*Used the same Clorox wipe to wipe off the top of the soiled laundry cabinet, the top of a foot stool, and the seat of a chair used by the patient. She then used another Clorox wipe to wipe off the top of the sink counter.
*Did not wipe off the exterior of the whirlpool tub with a Clorox wipe.
*Was unsure what the contact time was after using the Clorox wipe. She stated she had not needed to wipe off the exterior of the tub, because housekeeping came in after she was done and wiped everything down again.
*Never worried about protecting her clothing while disinfecting the whirlpool as water never splashed up. She would only wear a gown if it was known the patient had methicillin resistant staphylococcus aureus (type of bacteria resistant to antibiotics) or any infection.
*Had never had any real training on disinfecting the whirlpool tub.
*Was told to look over the manufacturer's instruction manual. She did not know what had happened to the manual, as it was no longer in the procedure room. She had not seen the instruction manual for a couple years.
*Was unsure how long after she had completed her cleaning of the whirlpool tub and the procedure room that housekeeping cleaned the room.

Observation on 11/20/13 at 8:25 a.m. of PCT C disinfecting the whirlpool tub in the procedure room revealed she:
*Put on gloves.
*Followed the same procedure as on 11/19/13 for disinfecting the whirlpool tub.
*Removed a bag of soiled laundry from the soiled laundry cabinet and placed it on the floor. She stated she would remove that and the bag of garbage when she was done with the whirlpool tub and cleaning the procedure room.
*Used a Clorox wipe to wipe off the top of the foot stool.
*Opened a cabinet without changing gloves to get a new garbage bag.
*Used the same Clorox wipe to wipe off the rim inside the tub door, the top edges of the tub, and the seat of the arm chair used by the patient. She did not use the Clorox wipe again to clean off the exterior part of the whirlpool tub.
*Removed her gloves and washed her hands at the sink. She used her bare hands to shut off the faucet.
*Placed the contaminated orange plastic card that had been on the top of the whirlpool tub back on the sink counter. A Clorox wipe had not been used to wipe off the card.
*Stated she had completed her cleaning of the procedure room.
*Had not used a Clorox wipe on the sink counter or on the top of the soiled laundry cabinet. She told the surveyor she would come back and wipe them down.

Interview on 11/20/13 at 8:45 a.m. with the physical therapist (PT) regarding the above revealed he:
*Had done a whirlpool on patient 33 for a non-healing leg wound prior to the disinfection of the whirlpool tub on 11/19/13 and on 11/20/13.
*Placed a small orange plastic card on the top of the whirlpool tub after he was done with the whirlpool and dressing change for the patient. The orange card was a way of letting the PCTs know the whirlpool tub needed to be disinfected.
*Was not responsible to supervise the PCTs when they disinfected the whirlpool tub. Nursing likely did that along with education on the disinfecting process.
*Was not aware of the contact time of the Clorox wipes. He agreed the back of the whirlpool lift chair and the outside of the tub should have been wiped down.
*Was unsure how long it was between when the PCT cleaned the whirlpool tub and the procedure room and when housekeeping cleaned the room.
*Stated at that time only patient 33 used the whirlpool tub. If there were other patients who used the whirlpool tub it could have been a probability the whirlpool tub and procedure room would have been used before housekeeping had done their cleaning.

Interview on 11/20/13 at 9:00 a.m. with housekeeper E revealed:
*Two housekeeping staff were on duty Monday through Friday and one housekeeping staff person on weekends.
*The housekeeping priorities were the emergency room, cat scan room, and the x-ray room. They tried to get those rooms done by 7:00 a.m.
*It was not assigned but one of the two housekeepers would clean the procedure room before they went off duty at 2:30 p.m.
*They knew they needed to clean the room as the PCT would write it down on a white erase board at the nurses' desk.
*They would wipe down the foot stools, chairs, sink counter, cupboards, and the top of laundry cabinet with disinfectant wipes. They would mop the floor after that.
*They never did any cleaning of the whirlpool tub, and that included not wiping down the exterior of the tub.
*Their supervisor had told them they were not to do any cleaning of the whirlpool tub or the screens on any machines.

Interview on 11/20/13 at 9:15 a.m. with the director of nursing (DON) revealed:
*The instruction manual for the whirlpool tub should have been in the procedure room.
*Each PCT might have filled the tub a little different, but the instructions in the manual were specific.
*The cleaning/disinfecting instructions should have been posted in the procedure room.
*All surfaces should have been wiped down with the Clorox wipes including the back of the lift chair and the exterior surface of the whirlpool tub.
*She knew the housekeeping staff wiped down the surfaces and mopped the floor in the procedure room. She was unsure if they had done any cleaning of the whirlpool tub.
*She thought infection control nurse D had monitored some of the PCTs disinfecting the whirlpool tub.
*The PCT had not written on the white erase board for housekeeping to clean the procedure room on 11/20/13.
*She was not sure of the contact time of the Clorox wipes, but infection control nurse D would know.

Review of the provider's 9/25/12 Disinfecting the Whirlpool manufacturer's instructions revealed:
*"Press and hold the disinfect jets button located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub."
*"Using the long handled brush, thoroughly scrub all interior surfaces of the tub. Let disinfectant stay on the surface for 10 minutes."
*"Rinse the chair lift and the tub's interior surfaces thoroughly with the shower sprayer."

3. Observations on 11/19/13 at 8:10 a.m. and on 11/20/13 at 8:05 a.m. of patient 33's wound treatment revealed:
*He had just received a whirlpool for a left lower leg non-healing wound. The patient drained the tub water and used a towel to dry his leg including the wound area.
*He was assisted by the PT to remove his legs from the whirlpool tub.
*On 11/19/13 the PT put on a pair of sterile gloves without washing his hands or using hand sanitizer.
*The PT removed a package of guaze, an abdominal binder dressing (ABD) dressing, a roll of white tape, a tongue blade, a jar of Silvadene cream, and forceps from a tray sitting on the counter of the sink.
*The PT placed all the above supplies on a laundry cabinet without a barrier between the cabinet and the supplies.
*The PT put a clean towel on a foot stool and placed the patient's left leg on it. He used the forceps, removed exudate (drainage) from the wound, and wiped the ends on a gauze pad. He used a tongue blade to spread Silvadene cream on the left leg wound.
*The PT without changing gloves put a sterile ABD pad and gauze covering over the wound. The tape was put on the gauze covering to keep it intact.
*The PT placed the jar of Silvadene cream and the roll of tape back in the tray on the cupboard.
*The patient put on his shoes and socks after the wound was dressed.
*The patient was given no instructions on performing hand hygiene before he left the room.

Interview on 11/20/13 at 8:45 a.m. with the PT revealed:
*He tried to make the dressing change sterile, but sometimes it was not perfectly sterile.
*He thought they disinfected the top of the laundry cabinet everyday, but he should have placed a barrier between the top of the cabinet and the supplies.
*Hand hygiene should have been done prior to putting on sterile gloves, after removing soiled gloves, putting new ones on, and after removing gloves at the end of the dressing change.
*He had received training on wound dressing changes in PT school.
*He had followed the policy nursing had for wound dressing changes.

Interview on 11/20/13 at 9:15 a.m. with the DON revealed:
*Hand hygiene should always have been performed prior to doing wound dressing and putting on gloves, when removing soiled gloves to put new ones on, and after removing gloves after the dressing change.
*Nursing usually had done wound dressing changes. The physician had ordered the daily whirlpool and dressing change for patient 33 to be done by PT.
*She had no oversight over PT when they were doing wound dressing changes.

Review of the provider's undated Changing a Wound Dressing policy revealed:
*"Preparation:
-Perform hand hygiene.
-Clean off over-bed table.
-Place sterile supplies on the over-bed table."
*"Remove gloves and perform hand hygiene thoroughly after the dressing change."

4. Observation on 11/19/13 at 11:44 a.m. of physician F revealed he:
*Entered the procedure room to perform a cystoscopy on patient 13.
*Entered the procedure room in his street clothes. He was wearing shoe covers, a hair net, and a ring on his finger.
*Was not observed washing his hands or using hand gel before entering the room or before putting on a sterile gown and sterile gloves.
*Performed no hand hygiene after removing his gloves after the procedure. He went to the charting room and was doing documentation in the patient's medical record.

Interview on 11/19/13 at 12:15 p.m. with the surgery director revealed the above physician should:
*Have changed into a scrub uniform prior to entering the procedure room.
*Have performed hand hygiene prior to putting on the sterile gloves and after he had removed the gloves at the end of the procedure.

Review of the provider's June 2012 Infection Control in the OR policy revealed:
*"Surgeons, anesthetists, and nursing personnel enter their respective dressing rooms to don cotton scrub suits, caps, and masks before entering the OR suites. Shoe covers are required for anyone who does not have shoes that stay in the hospital and in cases where blood may splash on shoes."
*"No jewelry other than pierced earring posts covered by a cap is worn by scrub personnel in the OR."
*"Good handwashing is maintained at all times."

Review of the provider's January 2013 Handwashing policy revealed:
*"Hands will be washed:
-When hands are visibly dirty or contaminated with any material or are visibly soiled with blood or other bodily fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
-If hands are not visibly soiled, staff may use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations.
-Alcohol-based hand rubs are to be used before invasive procedures such as wound care."
*"Change gloves during patient care if moving from a contaminated body site to a clean one."
*"Ring use should be kept to a minimum as they can impair the integrity of the gloves when worn."
*"Use towel to turn off faucet after washing hands."
*"Decontaminate hands:
-Before having direct contact with patients.
-After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings.
-After contact with inanimate (environmental) objects (including medical equipment) in the immediate vicinity of the patient.
-After removing gloves."

Review of the provider's August 2013 Infection Control Program Policy revealed:
*"All employees can and are expected to initiate the chain of activity designed to detect, prevent, and control the spread of infection."
*"The objectives of the infection control program include the following:
-Improve the quality of health care delivery through the identification, prevention, and control of healthcare acquired infections.
-To maintain surveillance of the healthcare facility infection potentials.
-Establish and communicate standards of infection control practices within each department in the hospital to reduce the incidence of health-care associated infections among patients and personnel.
-Maintain a system for the prevention of transmission of communicable disease between the hospital and the community.
-Develop, maintain, and evaluate on an ongoing basis, the effectiveness of the infection control activities within the hospital."



15036

5. Observation on 11/19/13 at 11:00 a.m. of patient 3's fingerstick blood sugar (FSBS) by RN A revealed:
*After the results of the test had been read and documented she put the contaminated glucometer in the community supply bin used for obtaining FSBS.
*She returned to the medication administration room and placed the community supply bin in the cabinet.
*She had not disinfected the glucometer or the community supply bin prior to storage.

Interview on 11/20/13 at 9:10 a.m. with the DON revealed:
*The contaminated glucometer should have been disinfected prior to placing it in the community supply bin and stored in the medication room.
*The glucometer should have been disinfected with a Clorox wipe or CaviWipe prior to storage.
*The provider did not have a policy for glucometer disinfection.
*The manufacturer's directions for cleaning should have been followed.

Interview with on 11/20/13 at 5:00 p.m. with RN A revealed:
*She had not disinfected the glucometer after she had obtained patient 3's FSBS.
*The glucometer was disinfected by staff at the end of the day.
*There might have been a potential for cross-contamination between patients if the glucometer was not disinfected properly.

Review of the manufacturer's directions for cleaning revealed the glucometer should have been cleaned with soap and water after use. The manufacturer's directions had not included how often.

Review of the Centers for Disease Prevention, May 2012 Infection Prevention During Glucose Monitoring and Insulin Injection Internet information revealed:
*"Whenever possible glucometers should not be shared.
*If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."

6. Review of the log book documentation completed for ultrasound probe high-level disinfection revealed:
*The staff had documented if the test strips had passed or failed in accordance to the manufacturer's directions.
*The soak time for the ultrasound probes had not been documented.

Review of the Cidex Plus manufacturer's directions for use revealed the soak time for high-level disinfection of instruments was twenty minutes.

Interview on 11/21/13 at 7:40 a.m. with the director of radiology revealed she:
*Had not documented the ultrasound soak time in the Cidex Plus disinfectant.
*Had attended a seminar and misunderstood what should have been documented in the Cidex Plus log book.
*Stated ultrasound probes were soaked for eight minutes, but she was not sure.
*Stated after putting the ultrasound probes in the disinfectant she had done other tasks, and by the completion of those tasks more than eight minutes had passed, maybe twenty minutes.
*She thought the policy for ultrasound indicated a twenty minute soak for high-level disinfection.
*A review of the manufacturer's directions for use revealed the soak time for high-level disinfection should have been 20 minutes.




26180

7. Observation on 11/19/13 at 1:40 p.m. of RN B revealed she:
*Entered patient 28's room.
*Washed and dried her hands prior to:
-Starting a nebulizer treatment.
-After completing the nebulizer treatment and prior to putting gloves on to start a medication intravenously.
-After removing her gloves and prior to leaving the room.
*Washed and dried her hands each time using the following process:
-Scrubbed her hands using soap and water.
-Shut the water off after washing her hands with her bare hands.
-Dried her hands using a paper towel.

Interview at that time with RN B revealed she should not have turned the water off with her clean hands. She should have used a paper towel to turn the faucet off.

Review of the provider's January 2013 handwashing policy revealed the procedure for soap and water included: "When washing hands with soap and water, wet hands first with water, apply product and rub hands together for 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off faucet."

Based on interview, record review, policy review, and menu review, the provider failed to ensure:
*Nutritional screens were completed for acute care inpatients.
*The diet manual was current.
*Dietary department policy and procedures were appropriate and reviewed annually.
*Menus were analyzed and nutritionally adequate.
*Menus were reviewed annually by the registered dietitian (RD).
*A nutritional assessment was completed for one of six swing bed patients (15) reviewed.
Findings include:

1. Interview on 11/20/13 at 10:00 a.m. with the certified dietary manager (CDM) revealed:
*No nutritional screens had been completed on acute care patients.
*If she noticed a concern with an acute patient's nutritional status or eating habits she would have notified the RD.
*The diet manual used was a 2005 edition.
*She had several dietary service manuals.
*The dietary service manuals had not been reviewed annually.
*There had been no analysis of the menus to determine if they were nutritionally adequate.
*The RD had not reviewed the menus annually.

Review of the undated dietary service manuals revealed no policy or procedures related to frequency of meals served, diet ordering, patient tray delivery, or availability of diet manuals.

Review of the provider's menus from 11/19/13 through 11/25/13 revealed consistently inadequate amount of fruit servings, no nutritional analysis, and no menu review by the RD.



30170

2. Review of patient 15's medical record revealed:
*He had been admitted on 2/22/13.
*He had a total right knee replacement and was in swing bed services.
*He had a history of uncontrolled diabetes.
*There had been no nutritional assessment completed by the RD during his stay in the hospital from 2/22/13 to 3/8/13.

Interview on 11/21/13 at 8:30 a.m. with the CDM revealed:
*There was no policy and procedure in place for completing nutritional assessments on at risk patients.
*There had been no nutritional assessment completed on patient 15.
*There should have been a nutritional assessment completed by the RD.

Based on interview and policy manual review, the provider failed to ensure policy manuals were reviewed annually for four of four sampled departments (dietary, medical records, swing bed, and pharmacy) reviewed. Findings include:

1. Review of the dietary department's undated policy and procedure manual revealed no documented date when it had last been reviewed.

Interview on 11/20/13 at 10:00 a.m. with the certified dietary manager revealed she had several manuals related to dietary services. She confirmed there was no one specific dietary services policy manual. She stated dietary policy and procedures had not been reviewed annually.

2. Review of the medical records compliance manual revealed it had last been reviewed in 2009.

Interview on 11/20/13 at 9:30 a.m. with the health information director revealed she was aware her department's policy and procedure manual needed to be reviewed annually. She had recently had realized the manuals needed to be reviewed.


26180

3. Interview on 11/20/13 at 11:40 a.m. with the pharmacist revealed she had been working on the policies. They currently did not have complete updated policies for the Omnicell medication delivery system.

Interview on 11/21/13 at 10:00 a.m. with the director of nursing revealed the pharmacy and medication administration policies were not up-to-date.



30170

4. Review of the provider's swing bed policies and procedures revealed they had not been reviewed annually since 2008.

22452

Based on record review and interview, the provider failed to ensure six of six sampled patients (8, 9, 10, 11, 12, and 13) had a complete follow-up nursing assessment documented after a surgical procedure prior to their discharge home. Findings include:

1. Review of patient 8's medical record revealed:
*She had a laparoscopic colpectomy on 9/6/12.
*The 9/6/12 "post-op" notes revealed at 4:05 p.m. the patient had requested to stay past supper and be discharged after that. She was rating her pain a 3 out of 10 (1 being no pain and 10 being severe pain) at that time. Discharge instructions were documented as given to her at that time.
*There was no further nursing assessment documentation in the medical record regarding her pain, her vital signs (blood pressure, pulse, and respirations), or the appearance of her surgical dressing prior to her discharge.
*There was no documentation of the actual time she had been discharged home.

2. Review of patient 9's medical record revealed:
*He had a right index finger wart removal on 12/6/12.
*There was no nursing assessment documentation regarding the appearance of the surgical incision site and if there was or was not a surgical incision dressing.
*There was no nursing assessment documentation regarding the circulation in the finger or the range of motion (movement) in the finger.
*He had been transferred to nursing floor status at 9:51 a.m. There was no further nursing assessment documentation after he was transferred to nursing floor status.
*There was documentation he had been discharged at 10:08 a.m.

3. Review of patient 10's medical record revealed:
*He had an excision of a lipoma on his neck on 2/21/13.
*There was documentation he had been transferred to nursing floor status at 10:40 a.m.
*There was documentation he had requested a surgical (lunch) tray at 10:45 a.m.
*There was no nursing assessment documentation of his vital signs or his tolerance of the lunch tray prior to his discharge.
*There was no documentation of his surgical incision site or if he had a surgical incision dressing.
*There was no documented nursing assessment for fifty minutes after being transferred to nursing floor status.
*He had been discharged at 11:50 a.m.

4. Review of patient 11's medical record revealed:
*He had a pilonidal cyst removal on 10/21/13.
*He was transferred to nursing floor status at 10:55 a.m.
*There was documentation at 11:00 a.m. he had received intravenous (IV) Toradol 30 milligrams
(pain medication) for a pain rating of 2-3 out of 10.
*At the time of discharge at 11:35 a.m. there was no further nursing assessment documentation of his surgical site, whether or not he had a dressing covering his surgical incision, no vital signs after returning to the nursing floor status, or his response to the IV Toradol that had been given for pain.

5. Review of patient 12's medical record revealed:
*He had a flexible gastroscopy and colonoscopy on 11/7/13.
*There was documentation he was transferred to nursing floor status at 11:00 a.m.
*There was no nursing assessment documentation of his vital signs after he had returned to the nursing floor.
*There was documentation he had been discharged at 11:51 a.m.

6. Review of patient 13's medical record revealed:
*She had a flexible cystoscopy on 11/19/13.
*There was documentation at 10:22 a.m. prior to the procedure her blood pressure was elevated at 180/63 and 172/64 (normal 120/60).
*There was no follow-up nursing assessment documentation of her blood pressure after the procedure had been completed at 10:53 a.m.
*There was documentation she had been discharged at 11:00 a.m.

7. Interview on 11/21/13 at 11:00 a.m. with the surgery director regarding the above patients revealed:
*There should have been nursing assessment documentation regarding vital signs, pain, appearance of surgical site incision, and whether or not the surgical wound was covered with a dressing.
*She was unable to locate the policy on requirements for nursing assessment documentation prior to discharge for same day procedures.

Based on observation, interview, and policy review, the provider failed to ensure one of three registered nurses (RN) (A) followed professional standards of medication administration during one of six patients (1) observed medication passes. Findings include:

1. Observation on 11/19/13 at 8:15 a.m. of RN A revealed she:
*Prepared to take medications to patient 1 in her room.
*Had taken the medications out of the Omnicell (medication cart) medication delivery system.
*Had a medication cup with multiple medications in it.
*Had taken all of the medications out of their individual package, so they were not identified by packaging.
*Identified each of the unpackaged pills except the last two which she was unable to identify.
*Went into patient 1's room with the list of medications and the medications in the medication cup.
*Said the patient's first name.
*Handed the patient the cup of medications.
*Had not informed the patient what each of the medications was.

Interview on 11/20/13 at 8:30 a.m. with the director of nursing revealed their policy regarding medication administration included:
*The nurse kept each individual medication in its package until the medication was given to the patient.
*The nurse identified each patient by looking at their arm band or saying the patient's name.
*The nurse would recite each medication when they opened each medication for the patient to ensure the patient knew what the medication was.
*She was unsure how long they had used the Omnicell medication delivery system.

Review of the provider's January 2012 Medications from Med Cart policy revealed the policy had not been updated since the conversion to the Omnicell medication delivery system.

Based on record review, interview, and policy review, the provider failed to ensure 1 of 11 sampled patients (18) had a care plan that addressed discharge planning needs. Findings include:

1. Review of patient 18's medical record revealed:
*She had been admitted on 11/14/13 for hepatic encephalopathy (liver impairment) due to alcohol abuse.
*She had been discharged on 11/18/13.

Review of patient 18's discharge summary revealed:
*She had been admitted with alcoholic cirrhosis (liver disease).
*Her ammonia level was over 200 (caused by liver failure).
-Normal level is less than 50.
-The level had returned to 59 during the course of her hospitalization.
*The physician had stated "I do not believe that she can reach normal levels, would like to keep the treatment as maximized as possible to keep her functioning as best possible. She is at high risk for readmission multiple times in the future for this same issue."
*It had not addressed any follow-up or referral for a chemical dependency program.

Review of patient 18's plan of care revealed it had not addressed:
*Her alcoholism.
*Any discharge plans related to a referral to a chemical dependency program.

Interview on 11/20/13 at 11:00 a.m. with the social services designee regarding patient 18 revealed she:
*Had not received a referral for that patient from the physician.
*Agreed that her history of alcohol abuse should have been addressed upon discharge.
*Agreed the patient could have refused the referral, but there should have been a referral made. That had not been done.

Interview on 11/20/13 at 10:50 a.m. with the quality assurance/utilization review coordinator/registered nurse regarding patient 18 revealed she:
*Thought the patient's physician had talked to the patient about getting help for her alcoholism.
*Was unable to find any documentation of that discussion.

Based on record review, interview, and policy review, the provider failed to ensure 1 of 11 sampled patients (29) had a discharge summary. Findings include:

1. Review of patient 29's medical record revealed:
*She had been admitted on 2/12/13.
*She had been discharged on 2/14/13.
*The physician progress note dated 2/14/13 stated "Dismiss."

Interview and medical record review on 11/20/13 at 1:40 p.m. with the quality assurance and utilization review/registered nurse regarding patient 29 revealed:
*She had been discharged on 2/14/13.
*Her physician had not completed a discharge summary but had written "dismiss" when the patient was ready to be discharged.
*That physician had not always written a discharge summary.
*They did not have a policy that addressed discharge summaries other than to follow the requirements.

30170

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*One of five sampled swing bed patient's (16) discharge summary was signed, dated, and timed.
*One of six sampled surgical patient's (10) consent had been timed.
*One of six sampled surgical patient's (8) discharge instructions was timed.
*One of six sampled surgical patient's (11) history and physical was dated and timed.
Findings include:

1. Review of patient 16's medical record revealed:
*She had been admitted to swing bed services on 1/23/13.
*She had been discharged on 1/26/13.
*There was a discharge summary.
*The discharge summary had no signature, date, or time.

Interview on 11/21/13 at 8:15 a.m. with the health information director regarding the discharge summary for patient 16 revealed:
*She was unsure why the physician had not signed, dated, and timed the discharge summary.
*The physician had not used the electronic signature available and had preferred to hand write his signature on documents.
*There was not a policy and procedure in place for physicians to sign, date, and time the patient's documents in a timely manner when not using the electronic signature.

Review of the provider's October 2011 Medical Staff Bylaws revealed "A discharge summary shall be written or dictated on all medical records of patients hospitalized over 48 hours except for normal obstetrical deliveries, normal newborn infants and selected patients with problems of a minor nature. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible practioner."



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22452

2. Review of patient 10's medical record revealed:
*He was scheduled on 2/21/13 for a surgical procedure to remove a raised area on his neck.
*The consent form for the surgical procedure was dated 2/21/13 but had no time when the consent had been signed.

3. Review of patient 8's medical record revealed:
*She had a laparoscopic cholecystectomy on 9/6/12.
*The discharge instructions sent home with her were not dated or timed.

4. Review of patient 11's medical record revealed:
*He had a pilonidal cyst surgically removed on 10/21/13.
*The history and physical was not dated as to when it had been completed.

5. Interview on 11/21/13 at 11:00 a.m. with the director of surgery revealed "All the above documents should have been dated and timed when they had been completed."

22452

Based on observation, interview, and policy review, the provider failed to maintain the confidentiality of patient information in a procedure room for one of one sampled patient (33). Findings included:

1. Observation on 11/19/13 at 8:10 a.m. and on 11/20/13 at 8:24 a.m. in a procedure room revealed:
*Patient 33 received a whirlpool of his left leg due to a non-healing ulcer followed by a dressing change.
*A tray that contained a large jar of Silvadene cream and multiple guaze products used for the treatment was stored on the counter next to the sink.
*The tray remained on the counter after the patient had received his treatment until the next day when he came for his whirlpool treatment.
*The jar of Silvadene cream contained the patient's name and instructions for use of the cream.
*The door to the procedure room was left open during the day.

Interview on 11/20/13 at 8:45 a.m. with the physical therapist who was responsible for the daily whirlpool and dressing change for patient 33 confirmed the tray of supplies should have been put in a locked cupboard.

Review of the provider's undated Other Controls policy revealed "Reasonable efforts will be made to safeguard patient information without hindering the delivery of healthcare."

Based on record review and interview, the provider failed to ensure contracted pharmacy services was incorporated into the provider's quality assurance (QA) program. Findings include:

1. Interview on 11/20/13 at 11:40 a.m. with the pharmacist revealed she was unaware of any QA measures that had been completed. Pharmacy policies and procedures were not up-to-date.

Review of the provider's 2013 QA schedule for reporting revealed pharmacy was not part of that schedule.

Interview on 11/20/13 at 2:50 p.m. with the QA coordinator revealed:
*Pharmacy measures were not a part of the QA program.
*They had invited the pharmacist to participate in their program, but she had not done so yet.
*There were several areas pharmacy could review as part of the QA program.

Review of the provider's 2012 and 2013 QA meeting minutes revealed the pharmacy had not been a part of the QA program.

Review of the provider's 2013 governing board by-laws revealed "the QA committee shall study and evaluate policies, procedures, methods and techniques relating to patient care in view of making revisions in accordance with modern medical practice."

Based on observation, record review, interview, and policy review, the provider failed to ensure:
*Activity preferences and needs had been care planned for three of five sampled swing bed patients (14, 15, and 16).
*Appropriate documentation activities had been offered for four of five sampled patients (1, 14, 15, and 16).
*A scheduled activities calendar had been provided to swing bed patients.
Findings include:

1. Review of patient 1's medical record revealed:
*She had been admitted on 11/12/13.
*Her diagnoses had included:
-Chronic obstructive pulmonary (lung) disease.
-Hypertension.
-History of pneumonia.

Interview on 11/19/13 at 8:00 a.m. with patient 1 revealed she:
*Had been in the hospital for approximately a week.
*Was always short of breath.
*Had reading material her family had brought to the hospital.
*Had not been offered any activities from the staff.

Review of patient 1's 11/15/13 activity assessment revealed she liked:
*Cards.
*Reading and writing.
*Word games.
*Music.
*Pets.
*Computer.
*TV.

Review of patient 1's activity assessment dated 11/20/13 at 10:18 a.m. revealed:
*"In room activity: Offer activity visits.
*Other plan information: Will offer visits for social contact, encouragement, and discussion of feeling.
*Goal: Resident will accept visits within levels of comfort and tolerance 2 times weekly by discharge."
*There were no activities on her hospital care plan.
*There was no documentation of any activities that had been offered.

2. Review of patient 14's medical record revealed:
*She had been admitted on 9/13/13.
*She had been discharged on 9/23/13.
*On 9/16/13 her activity assessment had been completed.
*Her interests included:
-Cards.
-Jigsaw puzzles.
-Reading/writing.
-Word games.
-TV.
*There were no activities care planned or any documentation activities had been offered.

3. Review of patient 15's medical record revealed:
*He had been admitted on 2/22/13.
*He had been discharged on 3/8/13.
*On 2/26/13 his activity assessment had been completed.
*His interests had included:
-Walking.
-Reading/writing.
-TV.
*There were no activities care planned or any documentation activities had been offered.

4. Review of patient 16's medical record revealed:
*She had been admitted on 1/26/13.
*She had been discharged on 2/1/13.
*There was no documentation an activity assessment had been completed.

5. Interview on 11/20/13 at 2:30 p.m. with the social services/activity coordinator regarding swing bed patients revealed:
*The hours she worked as the activities coordinator varied because of her other job duties.
*She would usually go in and visit with the patient but had not always documented the visits.
*The activities had not always been done.
*The nursing assistants would at times perform some of the activities, but they had not been consistent.
*She agreed patients 14, 15, and 16 had not had activity care plans completed.
*There was no activities calendar available for swing bed patients.

Interview on 11/20/13 at 3:30 p.m. with the director of nursing regarding the activity program for swing bed patients revealed:
*The activities were not offered consistently.
*Care plans should have addressed the patients' activity preferences.
*Staff should have been educated on the importance of the activities program for swing bed patients.
*Policies and procedures had not been reviewed annually.

Review of the provider's undated Activities Policy and Procedure revealed:
*The purpose of the policy was to organize activities for all patients/residents for their mental and physical stimulation and seek methods of assisting each patient/resident as to his/her level of socialization orientation and integration while a patient/resident.
*The activity director would work with the director of nursing in developing programs and goals for the activities of the patients/residents. The activity director was responsible for all recreational activities.
*The activity program would have been directed by the activity director.
*The activity director worked with all the patients/residents by offering the following levels of contact:
-Week-day reality orientation groups.
-Programs.
*Reality orientation on a one-to-one level with each resident who was in need of it. The director of nursing would assist the activity director to have determined what level of group work or individual work was most beneficial for each patient/resident.
*On admission, emotional and social factor were considered in relation to medical and nursing requirements as part of the process of evaluation of a patients/residents needs and would determine whether the facility could offer appropriate care. An evaluation was done as soon as possible after admission and a plan was formulated and documented. The activity director made initial contact within the first two days following admission to inform residents of programs and to assist in the orientational problems that might have needed consideration by staff members. The activity director would see way of involvement for the patient/resident in the recreation program.