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Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure medications were securely stored in 2 of 3 storage areas. The findings were:

Observation of the emergency department on 10/12/10 at 1:45 PM with the DON and RN #2 revealed unsecured IV cardiac medications, 3 vials of Lidocaine (1 in each pneumothorax kit), vials of Lidocaine for inserting chest tubes, several bottles of Pedialyte, and numerous IV solutions. Both the DON and RN #2 verified that the medications were unsecured. During an interview on 10/13/10 at 1 PM, the pharmacy technician stated intravenous solutions were ordered by, and stored in,the materials management department. Tour of the materials management department at that time showed numerous bags of various IV solutions were stored on shelves in the room. The room was locked, but materials management personnel had keys to the area. According to the facility's policy and procedure entitled "Medication Storage" (PH 1231), last reviewed 2/2010: "All drugs and biologicals must be kept in a locked room or container...behind one lock at a minimum...Medications outside of Pharmacy will be stored in the Pyxis, medication cart or in the cabinet in the locked med room...Access...is only by legally authorized personnel."

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure staff followed policies and procedures related to medication storage, expired medications, and medication errors. The findings were:

1. Refer to C224 for details related to the failure to store medications in accordance with policy number PH1231.

2. The following problems related to the storage of expired medications were noted:

Observation of the emergency department on 10/12/10 at 1:45 PM with the DON and RN #1 revealed the following expired medications stored in a manner that made them available for patient use:
a. Two bottles of ethyl chloride spray mist, expired 1/2007.
b. Four packages of Povidone iodine, each containing 3 swab sticks, expired 10/2007.
c. One vial of Lidocaine, expired 8/2010
d. Three 500 ml bags of normal saline, expired 9/2010.
e. Two 500 milliliter (ml) bags of normal saline, expired 2/1/10.
f. Three bottles of Betadine solution, which expired 9/2009, and three bottles of hydrogen peroxide that expired at the end of November 2009.
Both the DON and RN #2 confirmed the medications were available for patient use. In addition, observation in the medication room with RN #2 on 10/14/10 at 12:30 PM showed a tube of Formulation R, which expired on 6/2010. The RN confirmed it was available for patient use. Review of the facility's policy and procedure entitled "Outdated Drugs" Number PH 1221, last reviewed on 8/2010, showed "...all outdated drugs..." were to be removed "...from patient care areas on or before their expiration date."

3. Identified concerns related to failure to report medication errors:

Observation on 10/12/10 showed LPN #4 prepared and administered medications to patients #3, #21, and #22. While preparing the medications for patient #21 at 7:40 AM, the LPN stated she would not be administering Citracal as ordered as they were "out of" it. Medication reconciliation showed patients #3 and #22 also had Citracal ordered, but it was not administered them that morning either. According to the facility's policy and procedure entitled, "Medication Errors," Number PH 1234, last reviewed on 8/2009, these omissions constituted medication errors that should have been reported on the medication error worksheet. Interview with the risk manager on 10/13/10 at 2:55 revealed the errors had not been reported.

21849

Based on observation, staff interview, and review of policies, procedures, and manufacturer's instructions, the facility failed to maintain effective systems for monitoring and enforcing compliance with infection control standards. The effect of these failures were evident in 4 areas:
1. The facility failed to monitor expiration dates and replenish hand hygiene product in 4 of 10 randomly inspected dispensers used by staff and visitors.
2. The facility failed to monitor staff compliance with quality control procedures to ensure the proper operation of a steam autoclave; 7 packages of instruments were autoclaved without biological controls.
3. The facility failed to clean and disinfect a whole blood glucose testing device ("glucometer") after patient use during 1 of 1 observation.
4. The facility failed to enforce infection control standards prohibiting food and drink in areas with a risk for potentially infectious material for 2 of 3 observation days in the swing bed unit.

The findings were:

1. Regarding hand hygiene product:

a. Observation while touring the facility on 10/11/10, 10/12/10, and 10/13/10 showed the facility used wall-mounted hand hygiene gel dispensers in patient care locations and other high traffic areas. Of ten dispensers inspected, three were found to contain expired product and a fourth was empty.
(1) On 10/11/10 at 2:10 PM expired hand hygiene product was discovered in a clean utility room in the swing bed unit. According to the manufacturer's label information the product expired February 2010. Interview with RN #2 on 10/12/10 at 9:45 AM confirmed the product was expired and should have been replaced.
(2) On 10/12/10 at 3:30 PM expired hand gel was found in the laboratory phlebotomy room. The product was labeled with an expiration date of July 2009. Laboratory technician #5 was shown the product and she acknowledged it was expired and should have been replaced.
(3) On 10/13/10 at 10:14 AM expired hand hygiene product was found in the hallway adjacent to the physical plant maintenance shop. Examination of the manufacturer's label information showed the product expired in March 2006. At 11:20 AM the same day, an individual delivering laundry to the facility was observed to use the product before and after delivering clean linens.
(4) On 10/11/10 at 2:50 PM the hand gel dispenser located behind the nurses' station was found to be almost empty; the dispenser had to be pumped 4-5 times to dispense sufficient hand gel to cover both hands when applied according to the manufacturer's instruction for use. The following morning, 10/12/10 at 8:15 AM, the dispenser was found to be empty and continued observation on 10/12/10 from 8:40 AM to 11:25 AM showed the product was not replaced, even after 2 staff (LPN #4 and RN #3) attempted to use the dispenser and failed to get enough hand gel to cleanse their hands. LPN #4 was interviewed regarding the empty dispenser on 10/12/10 at 11:15 AM and she stated, "Housekeeping should be checking that [hand hygiene dispenser]; it's their job."

b. The infection control officer stated in interview on 10/12/10 at 11:45 AM that expired hand hygiene product should not be used in the hospital. She further stated housekeeping was responsible for monitoring potency dates and checking for empty dispensers.

2. Regarding compliance with autoclave controls:

a. Review of the facility's records of sterilization and autoclave controls showed a validation procedure involved checking a biological indicator (BI) and control was to be performed once a week. The infection control officer was present during the record review and acknowledged the BI procedure was required once a week, and the results of the procedure should be entered into the autoclave logbook.

b. Continued review revealed a lack of BI and control results for a 10-week period, from 6/22/10 to 9/6/10. When these documents were shown to the infection control officer, she acknowledged the lack of documentation "...probably meant controls weren't run..." She attributed the deficiency to a high turnover in personnel, but acknowledged proper controls should be completed before sterilizing instruments or other supplies. The sterilization log showed seven packages were autoclaved during the timeframe where documented controls were lacking.

3. Regarding glucometers:

On 10/12/10 at 11:45 AM, LPN #4 obtained a glucometer from a basket labeled "ECF [extended care facility]" and performed a blood glucose test on patient #23. After completing the test, the LPN returned the glucometer to the basket without cleaning it. At that time she confirmed she had not cleaned the glucometer; she further stated she had never cleaned it, nor was she aware it should be cleaned. Two glucometers were observed at the facility, one for the acute care unit and one for swing bed patients. The manufacturer's instructions were reviewed on 10/12/10 at 1:25 PM; these instructions sowed glucometers were to be cleaned after each use and three acceptable methods for cleaning the device were described.

4. Regarding compliance with food and drink policies:

a. Observation on 10/11/10 at 7:40 AM showed LPN #4 placed her coffee cup on the medical cart adjacent to the dining room in the swing bed unit. Over the next 23 minutes, she was observed to repeatedly drink from the cup while charting patient vital signs. She was observed to take vital signs of three nonsample patients, a process that involved patient contact. At no time during the observation did the LPN wash her hands or clean/disinfect the contact surface of the medication cart.

b. Observation on 10/14/10 from 12:45 PM to 1:27 PM showed LPN #10 repeatedly drank from a coffee cup she kept on the medical cart while charting patient information. During the 42-minute observation, the contact surface of the cart encountered patient charts, binders from other locations in the unit, and a cup used to administer medication to a resident. In one instance, patient #21 was observed to exit the dining room and remove a tissue from her pocket to wipe her nose; the patient then placed the same hand on the medical cart surface to steady her gait. The LPN returned to the cart, placed both hands on the horizontal contact surface, drank from her coffee cup, and returned her cup to the cart.

c. When interviewed on 10/14/10 at 1:30 PM, LPN #10 stated she should not have her coffee on the medication cart. The DON was present at the same interview and confirmed food and drink should not be on the medical cart or other areas where patient care was given. The infection control officer was interviewed 14 minutes later, at 1:44 PM and stated the observed practices violated facility policies that prohibited food and drink in areas at risk to contamination.

Based on observation, staff interview, and review of medical records and manufacturers' label information, the facility failed to follow laboratory standards required by the Clinical Laboratory Amendment (CLIA). These failures were evident in 1 of 4 open sample patient records lacking complete laboratory reports and 4 of 9 randomly inspected laboratory items stored in the emergency department (ED) found to be expired. The findings were:

1. Medical record review of patient #1 revealed a piece of paper to which a small printout was taped; the printout showed the results of a urine screen performed on a semi-automated analyzer and was dated 9/28/10. The paper and printout failed to include information to show the name and location of the testing facility, reference values for comparing the patient's results, or evidence that clinically significant findings were confirmed by other test methods.

Registered nurse (RN) #2 stated in interview on 10/11/10 at 4:40 PM the urine screen was performed by another nurse, RN #3, who was known to go to the laboratory and "run the machines." Interview with RN #2 and the DON on 10/12/10 at 4:20 PM confirmed the RN did use laboratory instrumentation "on occasion" to test patient specimens and had performed the 9/28/10 testing in the facility's laboratory.

The laboratory manager acknowledged in interview on 10/12/10 at 9:12 AM the printout was from an analyzer in the laboratory. She further stated all patient test results were required by facility policy to be reported on a standard form that included location information, reference values, and confirmatory testing when appropriate. The manager was not able to find a copy of the 9/28/10 urine screen performed on patient #1, nor a physician's order for the test. When shown the results of the urine screen, the manager acknowledged results for nitrite ("positive") and leukocyte esterase ("small") would have triggered a microscopic examination to provided further information to the provider. The laboratory manager further stated nursing staff were not trained to operate instrumentation in the laboratory, nor were they assessed for technical proficiency with the analyzers.

The CLIA regulations are found in the Code of Federal Regulations, Title 42, Part 493. These regulations require all patient test reports to show the name and location of the testing facility and include reference ranges for reported values. Further, clinically significant findings discovered during a screening test should be referred for confirmation by alternative methods. The laboratory is also required to maintain a copy of all reported test results for a minimum of 2 years.

2. Observation and examination of ED supplies on 10/12/10 at 9:20 AM revealed the following laboratory sample collection items were expired:

a. Blood collection tubes containing lithium heparin gel, lot number 8339175, expiration December 2009.
b. Blood collection tubes for serum samples, lot number 9104191, expiration August 2010.
c. Culture tubes for transport, lot number 9227617, expiration March 2008.
d. Collection tube for endocervical and male urethral swab, lot number 564949A, expiration August 2010.

The laboratory manager stated in interview on 10/13/10 at 2:15 PM that expired products should not be used. She further stated the laboratory provided specimen collection items to the ED, but the ED staff was responsible for maintaining a current inventory.

Based on interview with staff and review of minutes from the quality assurance program, the administrator failed to ensure services contracted by the facility were involved in the quality assurance program. The findings were:

During an interview on 10/13/10 4 PM, the administrator confirmed he was responsible for the operation of the facility. He stated he was unaware that organizations contracted to provide patient services in the facility were required to participate in quality assurance. The administrator verified that laundry services, therapy services (physical, occupational, and speech therapy), and organ procurement services were all contracted, but did not submit quality assurance information. Refer to C330, C336, and C337 for details.

Based on observation, medical record review, staff interview, review of policies and procedures, and review of personnel files, the facility failed to ensure all nursing staff were evaluated and that they were aware of and followed facility policies and procedures. Interview with the DON on 10/12/10 at 1 PM revealed the facility frequently used contract nursing staff. The DON stated competency was determined by the agency employing the nurse. The DON further stated competency checks were not performed by the facility prior to patient contact. The DON reported the facility provided orientation based on the agency RN's "desires." She defined this as consisting of a few hours to completing a shift before being scheduled to work independently. Review of a contract RN's personnel file showed the skills checklist was a self-evaluation. There was no evidence these skills were demonstrated to the agency or to the facility before the RN took charge of patients. Refer to C296 for details related to inappropriate documentation, incomplete assessments, and lack of clarification of orders. See C297 for information related to medication errors and lack of appropriate standing orders and bowel protocol. See C298 for information regarding lack of care plans. In addition, nursing staff failed to report medication errors as required (C276), violated accepted infection control practices (C278), and performed laboratory tests without meeting necessary requirements (C282). These failures impacted nursing services' ability to meet the needs of 11 of 23 sample patients (#1, #2, #3, #4, #7, #10, #19, #20, #21, #22, #23.

Based on observation, staff interview, and medical record review, the facility failed to ensure 3 of 20 sample patients (#2, #4, #19) reviewed for provision of care were appropriately evaluated by an RN to determine care needs. The findings.

1. Review of the medical record showed patient #19 was admitted on 6/9/10 and passed away on 6/10/10 at 4:30 PM. Further review showed the last entry made by nursing was at 6 AM on 6/10/10. Detailed review of the entire record revealed no evidence an RN evaluated the patient or provided care from 6 AM until his/her death at 4:30 PM, a time period of 10.5 hours. In addition, the mortician's receipt was lacking. RN #2 reviewed the record on 10/14/10 at 1:15 PM and confirmed the lack of documentation indicating whether or not the patient was assessed or that appropriate care was provided. She also confirmed lack of the mortician's receipt.

2. Observation on 10/11/10 at 1:25 PM showed patient #2 had a Stage II pressure ulcer on the right buttock. The wound was approximately 0.5 centimeters in diameter and was covered with yellow slough. According to nursing documentation, the wound was first discovered on 9/7/10 and was described as a "...pea sized open area..." The next documentation was dated 9/30/10 and indicated "...some slight swelling & inflammation about the site..." A nursing note dated 10/3/10 documented the wound "...appears to be decreased in size..." The note dated 10/11/10 indicated a new dressing was applied to the wound. Measurements and an accurate assessment and description of the appearance of the wound were not included in any documentation. Nor was it possible to determine the effectiveness of the prescribed treatment from the information included in the record.
Review of physician orders dated 10/10/10 showed an order for TED (anti-embolytic) hose at 20 millimeters (mm) mercury. Review of an unopened package of TED hose showed they did not exert pressure calculated in mm of mercury. Despite this fact, there was no evidence of any attempt to clarify the order.
On 10/14/10 at 8:07 AM, RN #2 confirmed the lack of specific assessment information describing the pressure ulcer. She also stated the order for TED hose should have been clarified and confirmed that it was not.

3. According to an assessment completed on 8/31/10, patient #4 suffered from daily joint pain. Detailed review of the record failed to reveal a comprehensive evaluation of the patient's pain. After reviewing the medical record on 10/14/10 at 1 PM, RN #2 confirmed an evaluation was lacking.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure medications were administered as ordered and in accordance with accepted standards of practice for 6 of 23 sample patients (#2, #3, #4, #18, #21, 22). The findings were:

1. Observation on 10/12/10 showed LPN #4 prepared and administered medications to patients #3, #21, and #22. While preparing the medications for patient #21 at 7:40 AM, the LPN stated she would not be administering Citracal as ordered as the facility was "out of" the medication. Reconciliation of the administered medications with physician orders showed patients #3 and #22 also had Citracal ordered, but it was not administered to these patients either that morning. These three errors of omission resulted in an error rate of 21.4 %. Reconciliation also showed neither of the three patients received the same medication at 8 PM on 10/9 and 10/10/10.

2. Review of the medication administration record (MAR) for patient #18 showed a physician order for a combined calcium and vitamin D (Citracal+D) supplement to be given twice daily, once in the morning and once at bedtime. Further review revealed the evening doses were not given on 7/2/10 and 7/3/10 and were noted as "not available" by the medication nurse. The morning doses were given as ordered on both days.

3. Medical record review showed patients #2 and #4 had the same standing orders and bowel protocol in place. Further review of those signed physician orders showed several medications lacked the dose, route of administration, and frequency of administration. At 8 AM on 10/14/10 RN #2 verified the described information was lacking. According to Smith, Duell, and Martin in "Clinical Nursing Skills Basic to Advanced Skills," 2008, correct medication orders include the "...dosage..., route of administration..., and frequency...to be given."


21849

Based on medical record review and staff interview, the facility failed to ensure appropriate care plans were developed and/or that specific interventions were delineated for 5 of 20 sample patients (#2, #7, #10, #19, #20). The findings were:

The following concerns were identified related to development and implementation of care plans:
a. The care plan was blank for patient #10.
b. Patient #2 lacked measurable goals related to pressure ulcers.
c. Specified intervention were not identified on the generic care plans used for patients #7, #19, and #20.
Interviews with RN #2 on 10/14/10 at 8:07 AM and 1 PM confirmed the aforementioned findings.

Based on medical record review and staff interview, the facility failed to maintain accurate information related to the health status of 6 of 20 sample patient records (#1, #2, #5, #7, #16, #19) reviewed. The findings were:

1. Review of the medical record showed patient #19 was admitted on 6/9/10 and passed away on 6/10/10 at 4:30 PM. Further review showed the last entry made by nursing was at 6 AM on 6/10/10. Review of the physician's discharge summary showed the patient expired at 4:30 PM that day. There was no mortician's receipt in the record. RN #2 reviewed the record on 10/14/10 at 1:15 PM and confirmed the lack of documentation and the missing mortician's receipt.

2. Observation on 10/11/10 at 1:25 PM showed patient #2 had a Stage II pressure ulcer on the right buttock. Review of nursing documentation dated 9/7/10, 9/30/10, 10/3/10, and 10/11/10 revealed measurements and an accurate assessment and descriptions of the appearance of the wound were not included in any documentation. On 10/14/10 at 8:07 AM, RN #2 confirmed the lack of specific assessment information.

3. Review of the medical records for patients #5, #7, #10, and #16 revealed advance directive information was not on any of these patients' records. After reviewing each of the records, beginning at 1:33 PM on 10/14/10, RN #2 confirmed the required information was missing.

4. A review of patient #1's medical record on 10/11/10 showed a continuing discrepancy with the patient's drug allergy status, as follows:
a. Monthly recapitulations of medication and treatments beginning 12/11/09 characterized the patient as "NKDA [no known drug allergies]". The 1/1/10 monthly summary had a hand written note listing "PCN [penicillin]" as a drug allergy; however, the the February and March 2010 recapitulations continued to show NKDA. Beginning April 2010 the monthly summaries list the patient as having an allergy to penicillin. The record lacked any evidence to clarify the patient's drug allergy status.
b. A medical history and physical examinations (H&P) completed 12/21/09 reported the patient as NKDA. A subsequent H&P listed PCN as a drug allergy, but a May 2010 clinic note continued to show the patient had no drug allergies. The drug allergy information on the admission order, signed 5/27/07, was blank. The patient's medical record folder was labeled "Drug Allergies: PCN."
c. RN#2 acknowledged in interview on 10/14/10 at 10:35 AM that the patient was allergic to PCN. Further, she verified there was no evidence this information was identified and clarified by nursing staff.


21849

Based on staff interview, review of policies and procedures, and review of the Safety, Compliance, Utilization Review, Risk, and Infection Control ("SCURRI" - acronym for the facility's quality assurance program) minutes, the facility failed to meet the requirements for this Condition of Participation. The facility failed to evaluate their total program on a yearly basis(C331). The facility failed to ensure an effective performance improvement program that evaluated all services (C336, C337). As the result of this system failure, the facility could not ensure quality services were provided for all patients. In addition, refer to C294, C296, C297, C298, C349, and C388 for information related assessment, documentation, and care issues identified during this survey.

Based on staff interview, review of minutes from the quality improvement program, and review of policies and procedures, the facility failed to ensure there was a yearly evaluation of the total QI program. The findings were:

According to the facility's policy and procedure entitled "Quality Improvement Program" last revised 6/14/06, the program was to be "reviewed annually to ensure the achievement of its objectives..." On 10/14/10 at 8:40 AM, the director of quality improvement stated the program was not evaluated yearly. Review of the minutes from the program meetings confirmed lack of a yearly evaluation.

Based on staff interview, review of minutes from the quality improvement meetings, and review of policies and procedures, the facility failed to establish an effective QI program. The findings were:

Interview with the director of the QI program (acronym "SCURRI" - Safety, Compliance, Utilization Review, Risk, and Infection Control) on 10/13/10 at 2 PM revealed the facility lacked a formally organized QI program where all departments and services reported data for analysis, developed benchmarks, identified and implemented interventions, and evaluated the results. The program director also stated, and interview with the department managers confirmed, that most of the departments had some kind of QI project. However, they did not all report to the SCURRI committee. The program director confirmed that contracted services did not report at all. Review of the minutes from the meetings confirmed that only those departments identified in the acronym "SCURRI" reported at the meeting. Other departments might attend the meetings, but they did not report on individual projects or evaluate the success of any interventions that were implemented.
According to the facility's policy and procedure titled "Quality Improvement Program" last revised 6/14/06, the facility "...is committed to continuous quality improvement by providing processes for improving the quality of patient care...data elements are to be collected and analyzed against predetermined indicators with identified thresholds or benchmarks...teams are formed to review and improve patient care and professional practices..." Elements to be selected for improvement were identified as high volume, high risk, problem prone, and high cost. Hospital-wide QI reports "...for both clinical and non-clinical quality reviews should be submitted...at least quarterly."

Based on staff interview, review of the minutes for the QI program, and review of policies and procedures, the facility failed to implement a facility wide program that included contracted services. The findings were:

Interview with the director of the QI program on 10/13/10 at 2 PM revealed contracted patient care services were not involved in QI activities. She identified these services as laundry, organ procurement, and therapy, inclusive of physical, occupational, and speech therapies. Review of the minutes of the QI program confirmed these services were not included in the QI program. Interview with the administrator on 10/13/10 at 4 PM revealed he was unaware these services should be involved in the QI process. Review of the facility's policy and procedure related to quality improvement showed "Each department or service should focus on High Risk, High Volume/Cost and Problem Prone areas for improvement processes..."

21849

Based on staff interview and review of an established agreement with an organ procurement organization (OPO), the facility failed to ensure staff were trained and certified annually as required by the OPO. The facility further failed to approach the family of 1 of 3 hospital deaths (patient #19)to discuss potential organ donation. The findings were:

1. Reviewed of the facility's OPO agreement on 10/12/10 at 4:20 PM showed a requirement for one or more staff to be trained as designator requestors for organ donations and, further, these same individuals were required to recertify each year through a training program provided by the OPO. Review of the training records for OPO certification on 10/12/10 and again on 10/13/10 failed to show evidence of staff training since 2007.

Interview with the facility chief finance officer, who also administered contracts and agreements, on 10/13/10 at 9:40 AM confirmed training for designated requestors had not been completed in the last two years.

2. According to the physician's discharge summary signed on 6/11/10, patient #19 expired on 6/10/10. Review of the "Record of Death" form showed Donor Alliance, the organ procurement organization, was not contacted to determine eligibility for organ/tissue donation. On 10/14/10 at 1:15 PM RN #2 confirmed there was no evidence a contact had been made. The RN later stated she called the organization to see if the lack of documented contact was an oversight, but reported Donor Alliance had no information on the patient's death.

Based on staff interviews, the facility failed to ensure mail was delivered on Saturdays for 17 of 17 swing bed patients. The findings:

Interview with the DON and RN #2 on 10/12/10 at 10:53 AM revealed the facility did not provide mail delivery to swing bed patients on Saturdays. Both nurses acknowledged that mail was delivered to residents of the town on Saturdays. A subsequent interview on 10/14/10 at 1:50 PM with RN #6, who was in charge of the swing bed program, verified the lack of mail delivery on Saturdays.

Based on staff interview, the facility failed to ensure staff were knowledgeable of the required elements necessary to complete an appropriate discharge or transfer. The findings were:

During an interview on 10/14/10 at 1:50 PM, RN #6, who was in charge of the swing bed program, stated the facility lacked an appropriate notice to provide swing bed patients before discharge or transfer. The RN further stated she was unaware of the requirement or of the necessary elements to be included.

Based on observation, medical record review, staff interview, and review of job descriptions, the facility failed to provide accurate, comprehensive assessments for 4 of 4 swing bed patients (#1, #2, #3, #4). The findings were:

Observation on 10/11/10 at 1:25 PM showed patient #2 required extensive assistance with transfers, toileting, and dressing. Review of an MDS (Minimum Data Set) assessment, completed by an LPN in July 2010, indicated the patient was totally dependent on staff for these activities. Interview with the DON and RN #2 on 10/12/10 at 10:53 AM revealed the patient's condition was unchanged since his/her admission in April 2010. Both nurses confirmed the assessment was inaccurate.
Review of the assessments for patients #1, #3, and #4, completed by an LPN, revealed they were also coded incorrectly. During the aforementioned interview, the RNs stated other assessment formats had also resulted in inaccurate and/or incomplete data, so they returned to using the MDS form for assessing swing bed patients. However, there was no evidence of staff training in correct use of the form.Review of the facility's job description for LPNs revealed they could "...assist with assessments of the patient..." but could not independently complete assessments.