HospitalInspections.org

Based on interview, record review, and Revised Statutes of Missouri (RSMo) review, the facility failed to:
- Ensure staff met facility job description requirements of certification in basic life support (BLS, basic life saving measures) for two staff (BB and CC) of 12 employed staff reviewed.
- Document job-specific orientation was completed for four staff (I, P, V, and CC) of 12 employed staff reviewed.
- Document licensure expiration dates for two staff (I and DD) of 12 employed staff reviewed.

These failures had the potential to affect the care and outcome of all patients. The facility census was 14.

Findings included:

1. Review on 01/09/19, of the employee files for Staff BB, Pharmacy Technician, and Staff CC, LPN, showed that their BLS certifications had expired; however, both staff continued to work full-time at the facility.

During an interview on 01/09/19 at 1:30 PM, Staff Z, Human Resources Director, stated that all employees were required to have BLS certification, however, the facility did not have a policy or procedure in place for BLS requirements.

During an interview on 01/09/19 at 3:30 PM, Staff V, Registered Nurse (RN), Infection Control Nurse and Cardiopulmonary Resuscitation (CPR, part of BLS) Coordinator, stated that the facility did not have a policy or procedure in place for BLS requirements. Staff V further stated the facility did not have a policy or procedure in place that addressed employee discipline for BLS certification non-compliance.

2. Review on 01/09/19, of the employee files for Staff P, RN, Surgical Services Coordinator; Staff V, RN, Infection Control Nurse; Staff CC, LPN; and Staff I, LPN, showed that job-specific orientation was not completed.

3. Review on 01/09/19, of the facility's undated job descriptions titled, "Licensed Practical Nurse (LPN)," and "Certified Nursing Assistant (CNA)," showed that a current Missouri LPN license or current LPN license from a compact state was required, and successful completion of a course for Certified Nursing Assistant was required.

Review on 01/09/19, of the employee files for Staff I, LPN, and Staff DD, CNA, showed that the LPN licensure expiration date and the active CNA certification were not documented.

During an interview on 01/09/19 at 1:30 PM, Staff Z, Human Resources Director, stated that CNA certifications were verified upon hire (or when certification is obtained after hire), however, the facility did not verify CNA certifications again. Staff Z further stated the facility required all nursing assistants to be certified.

The process showed that the facility did not appropriately meet applicable standards for licensure, certification, registration or employment, required for Critical Access Hospital (CAH) personnel.

Based on observation, interview, record review, and policy review, the facility failed to:
- Ensure that the healthcare services are furnished in accordance with appropriate written policies that were consistent with applicable state law. (C-271)
- Ensure that staff followed infection control policies and infection prevention standards, which included that all intravenous (IV, in the vein) catheter (flexible tube inserted into the body) sites and IV tubing were properly labeled and dated for three patients (#8, #13, and #15). (C-278)
- Follow the standard of practice and provide consistent cardiac (heart) monitoring for five patients (#10, #12, #13, #15, and #16) who were monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm) (C-294).
- Follow the standard of practice and make notification to physician of patient change of condition and obtain treatment orders if indicated for one patient (#6) (C-294).
- Complete event documentaton and monitoring post patient event for one patient (#10) (C-294).
- Implement a care plan specific to the care needs of four patients (#6, #10, #11, and #14) (C-298).

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

Refer to the 2567 for additional information.

Based on interview, the facility failed to establish and maintain written policies and procedures directing Nursing Services, Medical Records, Personnel, and the Organizational Structure. This included missing policies, as well as policies that were in place but with no clear direction. This practice failed to provide clear direction for nursing, medical records, and personnel staff, as well as the overall organizational structure, and had the potential to affect the safety and welfare of all patients receiving care at this facility. The facility census was 14.

Findings included:

1. Even though requested, the facility failed to provide the following policies:
- Code Blue (emergency situation where a patient's heart or breathing stop, and staff quickly respond with a process specific to restoring the heartbeat or breathing);
- Telemetry (monitoring of the electrical impulses of a person's heart rate that provides a real time measurement of a patient's cardiac rhythm);
- Care Plans;
- Medical Record Authentication (written policies and procedures to substantiate medical records are genuine);
- Basic Life Support (BLS, basic life saving techniques) Certification Requirements and Consequences for Non-Compliance for All Staff;
- Periodic Review of All Staff for Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care);
- Periodic Review of Certified Nursing Assistant (CNA) Active Certifications; and
- Reporting Changes in Ownership, Operating Officials, and Medical Director to the State agency.

During an interview on 01/09/19 at 1:50 PM, Staff J, Registered Nurse (RN), Acute Care Services Director, stated that some of the Nursing Services policies were left broad intentionally and did not provide clear direction for staff. She stated that there was not a Code Blue policy, but just a list of standing orders and that this was intentional so that the facility would not have to change it every time the Advanced Cardiac Life Support (ACLS, specific lifesaving measures taken by certified health professionals when a patient's heartbeat or breathing stops) protocol changed.

During an interview on 01/09/19 at 10:40 AM, Staff A, RN, Chief Nursing Officer (CNO), stated that the facility was aware that they had missing and incomplete policies and that their system of policy management and maintenance needed attention.

2. During an interview on 01/09/19 at 1:30 PM, Staff Z, Human Resources Director, stated that all staff are required to have BLS certification. Staff Z further stated that the facility did not have a policy in place that addressed this requirement, nor did the facility have a policy in place that addressed staff discipline or potential consequences for non-compliance.

During an interview on 01/09/19 at 3:30 PM, Staff V, RN, Infection Control Nurse and Cardiopulmonary Resuscitation (CPR, part of BLS) Coordinator, stated the facility did not have a policy in place that addressed the BLS certification requirement for all staff, nor did the facility have a policy in place that addressed staff discipline or potential consequences for non-compliance.

During an interview on 01/09/19 at 1:30 PM, Staff Z, Human Resources Director, stated that new employees were screened for EDL placement upon hire, however, verifications were not conducted periodically after hire. Staff Z further stated the facility did not have a policy in place that addressed the frequency in which EDLs were verified.

During an interview on 01/09/19 at 1:30 PM, Staff Z, Human Resources Director, stated that active CNA certifications were verified for new employees upon hire (or when certification was obtained after hire); however, certifications were not conducted again annually nor periodically. Staff Z further stated the facility did not have a policy in place that addressed the frequency in which CNA certifications were verified.

3. During an interview on 01/09/19 at 8:40 AM, Staff U, Medical Records Director, stated the facility did not have a policy in place that addressed medical records authentication.

4. During an interview on 01/09/19 at 3:45 PM, Staff A, CNO, stated that the facility did not have policies in place that addressed reporting changes in ownership, operating officials, nor medical director to the State agency.





39841






40710

Based on observation, interview and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Ensure that nursing staff did not have food and drinks in patient care areas.
- Ensure that all intravenous (IV, in the vein) catheter (flexible tube inserted into the body) sites and IV tubing were properly labeled and dated for three patients (#8, #13, and #15) out of four reviewed.
- Ensure that housekeeping properly maintained and disposed of sharps containers (tamper-proof plastic containers, where used medical instruments or supplies which are high risk for puncturing the skin, and are a hazard for spreading disease or infection, are disposed of) in patient care areas.
- Ensure that all patient opened food and drink items were properly labeled and dated in the nourishment refrigerator on the Acute Care Unit.

These failed practices had the potential to expose all patients, visitors, and staff to cross-contamination (the movement of germs or bacteria from one surface or person to another) and increased the potential to spread infection. The facility census was 14.

Findings Included:

1. Review of the facility's undated policy titled, "Infection Control: Nutritional Services," showed that food stored in opened original containers would be covered and dated.

Observation on 01/07/19 at 3:30 PM, on the Acute Care Unit, showed an open and partially used container of 2% milk in the nourishment refrigerator that was not labeled or dated.

During an interview on 01/07/19 at 3:22 PM, Staff I, Licensed Practical Nurse (LPN), stated that all food and drinks stored in the nourishment refrigerator must be labeled with a patient identification label, the date it was opened and the expiration date.

2. Review of the facility's policy titled, "Intravenous Infusion," revised 03/26/14, showed direction for staff to apply a transparent (see-through) dressing over the IV insertion site, and to label the site with the date, time, catheter size, and the nurse's initials.

Observation on 01/08/19 at 10:47 AM, showed that Patient #13's IV insertion site was not dated, timed, or initialed.

Observation on 01/08/19 at 10:47 AM, showed that Patient #15's IV insertion site was not dated, timed, or initialed.

Observation on 01/08/19 at 10:55 AM, showed that Patient #8's IV tubing was not dated and timed.

During an interview on 01/08/19 at 10:50 AM, Staff M, RN, stated that each IV insertion site should have a label with the date and time the IV was started, gauge (size) of IV catheter and initials, and that IV tubing should be dated and timed.

3. Even though requested, the facility failed to provide an infection control policy related to food and drink in the nurses' station.

Observation on 01/07/19 at 2:35 PM, showed that there were multiple open drinks at the nurses' station in the inpatient acute care area.

Observation on 01/08/19 at 9:30 AM, showed there were two drinks (a soda and a water) at the nurses' station in the Emergency Department (ED).

4. Even though requested, the facility failed to provide an infection control policy related to sharps containers.

Observation on 01/07/19 at 4:10 PM, showed that the sharps containers in the medication room and several patient care rooms were over 3/4 full in the inpatient acute care area.

5. Even though requested, the facility failed to provide an infection control policy related to hand hygiene and glove use.

Observation on 01/07/19 at 10:00 AM, showed Staff DD, Certified Nursing Assistant (CNA), provided personal care to Patient #50. During the patient's care, Staff DD failed to change gloves and perform hand hygiene after the patient's bed bath and perineal care (peri-care, cleansing the genitals and anal area) were provided, and before lotion was applied.

During an interview on 1/09/19 at 11:11 AM, Staff V, RN, Infection Control Nurse, stated that:
- There should not be any nursing staff food or drink at the nurses' stations.
- All IV tubing should be dated and labeled.
- All sharps containers should be emptied once they become 3/4 full.
- Gloves should be changed and hand hygiene performed any time staff move from dirty (area considered to be soiled or contain large amounts of germs) to clean (area considered to be clean, although not considered free of germs).
- Patient food and drink items stored in open containers should be dated and labeled.






40710




39089

Based on observation, interview, record review and policy review, the facility failed to:
- Provide consistent telemetry monitoring (monitoring of the electrical impulses of a person's heart, that provides a real time measurement of a patient's heart rate and rhythm, which is done through a computer monitor located in a centralized area that is not in the same location as the patient) for five patients (#10, #12, #13, #15 and #16) of five patients monitored on telemetry in the inpatient Acute Care Unit.
- Complete a reassessment and notify the physician of a patient's change in condition that had the potential to need a prescribed treatment for one patient (#6) of four patients' assessments reviewed.
- Complete an event report (formal documentation of an event that was unexpected or negatively impacted the outcome of patient care, reviewed by administration to prevent reoccurrence) for one patient (#10) of one sentinel event (actual events that could or did cause patient harm) reviewed. These failures had the potential to affect the care and outcomes of all patients, as well as affect the facility's ability to review and investigate events that could impact patient care, to prevent their reoccurrence. The facility census was 14.

Findings included:

1. Even though requested, the facility failed to provide a policy related to telemetry monitoring.

Observation on 01/07/19 at 3:15 PM, showed that Staff FF, Unit Secretary, walked around the nurses' station of the Acute Care Unit, answered phones, and assisted other staff with computer issues, while she monitored Patients #10, #12, #13, #15 and #16, who were on telemetry.

Observation on 01/07/19 at 4:15 PM, showed Staff FF walked away from the telemetry monitor screen without notifying or alerting other staff that she stepped away.

Observation on 01/08/19 at 9:38 AM, showed Staff FF walked away from the telemetry monitor screen, and failed to notify or alert other staff that she stepped away. The monitor screen was left unattended until Staff FF returned at 9:52 AM.

Observation on 01/08/19 at 09:48 AM, showed Staff FF answered the phone, then walked away from the telemetry monitor screen.

Observation on 01/08/19 at 11:05 AM, showed Staff FF walked away from the telemetry monitor screen and exited the nurses' station. During 10-minutes of observation, Staff FF answered several phone calls, worked on the printer, and assisted a nurse with computer documentation. Staff FF failed to consistently visualize the telemetry monitor screen as she was frequently pulled away and distracted.

During an interview on 01/07/19 at 3:22 PM, Staff I, Licensed Practical Nurse (LPN), stated that:
- The Unit Secretary was responsible for monitoring all patients admitted to the Acute Care Unit with a telemetry order.
- The Unit Secretary was expected to notify nursing staff if there were any changes in a patient's heart rate, heart rhythm, or if the telemetry signal (wireless data transmission between the patient and computer monitor) was lost.
- The Unit Secretary was responsible for printing a telemetry strip (small recorded portion of the patient's heart rhythm) for each patient who was monitored by cardiac telemetry, and the telemetry strip was then placed into each patient's medical record.

During an interview on 01/09/19 at 10:37 AM, Staff A, Chief Nursing Officer (CNO), stated that:
- Telemetry was to be monitored by the Unit Secretary at all times.
- The Unit Secretary worked 12-hour shifts from 7:00 AM to 7:00 PM, and that overnight from 7:00 PM to 7:00 AM, the nurses on the unit monitored the telemetry.
- The Unit Secretary should notify another staff member if she was going to walk away, so that someone would watch the monitor screen.
- Her expectation was that the monitor screen was watched at all times.
- The facility had experienced an increase in patient's with telemetry orders.
- The facility had previously recognized there were problems with the telemetry monitoring process.

During an interview on 01/09/19 at 1:50 PM, Staff J, Acute Care Services Director, stated that she expected someone to monitor the telemetry screen 24-hours a day, seven days a week.

2. Review of facility's policy titled, "Assessment and Reassessment of the Acute Care Patient," dated 03/01/14, showed that each patient admitted to the Acute Care Unit shall receive a complete head-to-toe assessment by a qualified individual so that a plan of care can be developed to meet the needs of the patient. And, that any change in the patient's condition shall require an immediate reassessment with changes in the plan of care that reflect the change in condition.

During an interview on 01/07/19 at 3:15 PM, Patient #6 stated that she had bleeding hemorrhoids (a swollen vein or group of veins in the region of the anus) that caused her a great deal of discomfort and pain. Patient #6 stated that the nurses were aware of the hemorrhoids and were treating them with hemorrhoid cream. Patient #6 stated that she was thankful they were being treated with hemorrhoid cream, but did not feel the medication was very effective.

Record review on 01/07/19 at 4:30 PM, of Patient #6's assessments, nursing notes and physician orders, showed there were no reassessments that identified the hemorrhoids, no notification to the physician requesting treatment for hemorrhoids, and no physician's order to treat the hemorrhoids. Review of laboratory results dated 01/03/19, showed that Patient #6 had a lab result that tested positive for occult blood (blood in the feces that is not visibly apparent).

During an interview on 01/08/19 at 9:00 AM, Staff M, Registered Nurse (RN), stated that she was aware of the hemorrhoids and that blood had been observed in Patient #6's under garment pad. Staff M stated that the patient had had loose stools which caused excoriation (removal of the top layers of skin due to irritation) to the patient's buttocks, and that calmoseptine cream (a skin barrier ointment) was applied to the area, but no hemorrhoid cream was ordered. She was not aware of any physician notification related to the patient's hemorrhoids.

During an interview on 01/09/19 at 1:50 PM, Staff J, Acute Care Services Director, stated that it was her expectation that a reassessment be completed with any change of patient condition, and that the hemorrhoids should have been communicated to the physician and treated accordingly. She shared that the Acute Care census had been unusually high, more than they were used to, which could explain why the physician wasn't notified.

During an interview on 01/09/19 at 10:40 AM, Staff A, Chief Nursing Officer (CNO) stated that she expected changes in a patient's condition to be communicated to the physician, and that treatment should follow as warranted.

3. Review of the facility's policy titled, "Patient Safety Evaluation System," dated 10/01/18, directed staff that:
- They should initiate an event report whenever a patient safety event occurred, to include adverse (unexpected outcome related to healthcare) events, no-harm events, close calls, and hazardous conditions.
- Examples of reportable events included: medication errors, adverse reactions to medications or treatments, equipment malfunction/failure, patient falls, sudden deaths, and cardiac/respiratory arrest (when the heart or breathing ceases or stops) events.
- An event report should be completed immediately after an event.

During an interview on 01/08/19 at 9:45 AM, Staff M, RN, stated that:
- She was present when Patient #10 suffered respiratory arrest (cessation of breathing) on 01/07/19;
- She initiated a code blue (emergency situation where a patient's heart or breathing stopped, and staff quickly respond with a process specific to restoring the heartbeat or breathing); and
- She had been informed during change of shift report that Patient #10 had fallen during the night shift of 01/06/19 into 01/07/19.

Review of Patient #10's medical record showed that:
- She was a 43-year-old female admitted to the facility on 01/04/19 at 3:03 PM.
- Her admitting diagnosis included Altered Mental Status, Hepatic Encephalopathy (the loss of brain function related to a diseased liver, an organ in the stomach) with Hepatitis C (an infectious disease that primarily affects the liver), active Hepatitis B (severe form of hepatitis), and liver failure (when the liver stops functioning).
- She was confused and combative at times.
- She suffered a fall on 01/06/19 at 8:00 PM.
- She suffered witnessed Respiratory Arrest (cessation of breathing) on 01/07/19 at 2:35 PM, and subsequent code blue.
- She was ultimately intubated (insertion of a tube for artificial breathing) and transferred to an outside facility on 01/07/19 at 4:45 PM.

Although requested on 01/08/19, the facility was unable to produce an event report related to either Patient #10's fall or code blue.






39089




40710

Based on interview and record review and policy review, the facility failed to implement a care plan specific to the care needs of four patients (#6, #10, #11 and #14) of 14 patients' care plans reviewed. This failure had the potential to affect all patients admitted to the facility when individualized care needs were identified, but were not addressed in the care plan. The facility census was 14.

Findings Included:

1. During an interview on 01/09/18 at 1:50 PM, Staff J, Registered Nurse (RN), Acute Care Services Director, stated that a plan of care should be initiated within two hours of admission and updated with any change in patient condition. Staff J further stated the facility did not have a policy in place that directed staff on documentation requirements in the medical record specific to a patient's care plan.

Review of the facility's policy titled, "Assessment and Reassessment of the Acute Care Patient," revised 03/01/14, showed the following that upon completion of the initial admission assessment, an individualized care plan would be developed and that any change in the patient's condition required an immediate reassessment, and the care plan revised to reflect the change in condition.

Review of Patient #6's medical record showed that the patient was treated for chronic hip pain with as-needed narcotic medication (a drug that in moderate doses dulls the senses, relives pain, and induces profound sleep), and was treated with a skin barrier ointment for excoriation (removal of the top layers of skin due to irritation) to the patient's buttocks, and no care plan was in place for chronic (ongoing, greater than six months) pain or impaired (abnormal) skin integrity (describes the condition of skin).

Review of Patient #10's medical record showed that:
- On 01/04/19 at 3:30 PM, the 43-year-old female was admitted;
- On 01/05/19 at 1:45 AM, a care plan was initiated;
- On 01/06/19 at 8:00 PM, the patient suffered a fall; and
- The patient's care plan was not updated or revised after she fell.

Review of Patient #11's electronic medical record (EMR) on 01/07/19 at 3:30 PM, showed that a care plan was not initiated upon admission on 01/06/19 at 6:55 PM.

Review of Patient #14's medical record on 01/08/19 at 2:30 PM, showed that the patient was admitted on 01/07/19, with suspected clostridium difficile (C. diff a bacterium which infects the colon, causes diarrhea and is highly contagious) and was placed on contact isolation precautions (steps taken to isolate a patient and prevent the spread of infection or disease from one person to another) upon admission. C. diff was confirmed on 01/07/19. A care plan was not initiated for management of loose stools or contact isolation precautions.

During an interview on 01/08/19 at 10:40 AM, Staff A, Chief Nursing Officer (CNO), stated that an individualized care plan should be completed as close to admission as possible, and no later than two hours after admission. The CNO stated that she expected staff to have care plans completed for chronic pain, impaired skin integrity, management of loose stools, isolation precautions, fall risk, and that she expected care plans to be updated with any change of condition.





40710