HospitalInspections.org

Based on the review of the facility's 2018 Quality Assurance/Performance Improvement Plan (QAPI) and interview, it was determined the facility failed to ensure the QAPI Committee was hospital-wide. This had the potential to affect all patients served by this facility.

Findings include:

Facility's 2018 Quality Assurance/Performance Improvement Plan

Purpose

To provide the patients of J. Paul Jones Hospital with the highest quality patient care within the capabilities of the hospital. This Quality Assurance / Performance Improvement Program promotes the mission of J. Paul Jones Hospital by establishing a formal, organizational-wide system to continually monitor and evaluate quality of care, appropriateness of care and clinical performance improvement found in the patient care process.

Quality Assurance Performance Improvement Committee

...The PI Committee shall meet monthly and maintain a record of its proceedings and shall report actions and recommendations to the Medical Staff and Administration.

Assessment and Analysis

...All departments will select and measure their quality of performance. The Performance Improvement Committee will serve in a support relationship to the efforts of all the departments. Communication of information shall be accomplished through reports and logs on a monthly basis.

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1. During tour of the Pharmacy Department on 5/2/18 at 7:07 AM with Employee Identifier (EI) # 16, Director Pharmacy and EI # 2, Director of Nursing (DON), the surveyor asked EI # 16, "What were the QAPI indicators for pharmacy"? EI # 16 and # 2 stated there were no PI indicators for Pharmacy.

Review of the QAPI committee meeting minutes on 5/3/18 at 10:00 AM for January, February and March 2018 revealed no documentation of QAPI indicators reported by the Pharmacy or Swing bed Unit.

During an interview on 5/3/18 at 11:15 AM with EI # 2, the surveyor asked EI # 2 if Pharmacy or the Swing bed Unit were participating in the facility QAPI and the response was no.

Based on review of medical records (MR) and interviews, it was determined the facility failed to ensure:

1. A policy was developed for the evaluation of patient problems and interventions.

2. The staff developed and updated a care plan with goals and treatments.

This affected 10 of 10 inpatient records reviewed for care plans, including Patient Identifiers (PI) # 11, PI # 12, # 13, # 14, # 15, # 16, # 17, # 18, # 19, # 20 and had the potential to affect all patients served.

Findings include:

Review of PI # 11, PI # 12, # 13, # 14, # 15, # 16, # 17, # 18, # 19 and # 20's MR revealed no documentation of a care plan.

The surveyor's requested a list of policies to review on 5/2/18 which included the Nursing Care Plan.

On 5/3/18 at 9:30 AM Employee Identifier # 2, Director of Nursing, stated the facility did not have a nursing care plan policy. EI # 2 further stated that the facility did not develop nursing care plans.

Based on medical record (MR) review, observation and interview, the hospital failed to assure administration of all patients ordered medications per physician orders for 2 of 10 inpatient medical records (MR) reviewed. This affected Patient Identifier (PI) # 11, # 13, and had the potential to affect all patients served by the hospital.

Findings include:

1. PI # 11 was admitted to the swing bed unit of the facility on 2/12/18 with diagnoses of Decline in function/level of mobility.

Review of the Physician's Orders revealed an order dated 2/12/18 for, "Hydralazine 25 milligrams (mgs) three times a day".

Review of the 02/16/18 Medication/IV (Intravenous) Solution charge sheet and Nursing Note revealed the following:

1:15 PM: Hydralazine - held due to blood pressure of 117/77.

8:00 PM: Hydralazine - not administered.

Review of 02/18/18 Medication/IV Solution charge sheet revealed the following:

2:00 PM: Hydralazine - not administered, "out of med" (medications) documented.

10:00 PM: Hydralazine - administered.

There was no documentation why the Hydralazine was not administered as directed per the physician's orders and no documentation the physician was notified.


Review of the MR revealed a Physician's Orders dated 2/13/18, for "Ambien 10 milligrams (mgs) at bedtime as needed for sleep".

Review of the Medication/IV Solution charge sheet dated 2/17/18 revealed Ambien 2.5 mg half a tablet was administered at 9:00 PM.

Review of the Medication/IV Solution charge sheet dated 2/18/18 revealed Ambien 2.5 mg was administered at 8:00 PM.

Staff failed to administer 10mg of Ambien as directed per the physician's orders.

An interview was conducted on 5/3/18 at 12:21 PM with Employee Identifier (EI) # 2, Director of Nursing and EI # 3, Assistant Director of Nursing, who confirmed the above findings


2. PI # 13 was admitted to the facility on 4/30/18 with diagnosis of Altered Mental Status

Review of the Physician's Orders revealed order for Rocephin 1 gram (gm) IV every 24 hours dated 4/30/18.

Review of the Medication/IV Solution charge sheet dated 4/30/18 revealed Rocephin was administered at 3:00 PM for the initial dose.

Further review of the MR revealed on 5/1/18 Rocephin was administered at 11:00 AM, which was 20 hours and not 24 hours as directed per the physician's orders.

An interview was conducted on 5/3/18 at 12:18 PM with EI # 2 and EI # 3, who comfirmed the above findings.

Based on review of medical records (MR), Medical Staff Rules and Regulations, facility policy and interviews with administrative staff, it was determined the facility failed to ensure all orders were signed, dated and timed by the ordering physician for 8 of 10 inpatient records reviewed, including Patient Identifiers (PI) # 17, # 18, # 16, # 14, #19, # 11, # 12, and # 20, and had the potential to negatively affect all patients served by the facility.

Findings Include:

Excerpt From the Medical Staff Rules and Regulations
Revised: 9/13/16

4. General Conduct at Care

4.2 Physician Orders

4.2.1 All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if dictated to a Registered Nurse, to a Licensed Practical Nurse ...

4.2.2 Such orders shall be signed by the person ... within twenty-four hours.

4.2.3 Specific standing orders, when applicable to a given patient, shall be reproduced in detail on the Order Sheet of the patient's record, dated and signed by the staff member.

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Facility Policy:
The Chart and Charting
Reviewed: 1/3/18

"Physician's Orders:

1. Physician's orders should be checked and transcribed at earliest opportunity after being written.

2. ...The nurse's first initial, last name, title, date and time are to be written under the last order."

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1. PI # 17 was admitted to the facility on 12/12/17 with diagnoses including Syncope and Anemia, Severe.

Review of the 12/12/17 "Admit..." orders and "Anemia profile..." orders signed and dated by the physician revealed there was no documentation of the time the orders were written.

Review of the MR revealed five (5) telephone orders (TO) and/or verbal orders (VO) dated 12/13/17. There was no documentation of the date or time the physician signed the TO's or VO's.

An interview was conducted on 5/3/18 at 12:42 PM with EI # 2, Director of Nursing, who verified the aforementioned findings.

2. PI # 18 was admitted to the facility on 12/29/17 with a primary diagnosis of Gastrointestinal Bleed.

Review of the MR revealed admission VO's dated 12/29/17 at 11:10 AM. There was no date and time the physician signed the VO's.

Review of the MR revealed a VO dated 12/29/17 (after the admission orders), "LR (Lactated Ringers) 1 Liter Bolus ..." There was no documentation of the time the nurse received the VO and there was no date and time the physician signed the VO.

Review of the MR revealed a VO dated 12/29/17 at 4:22 PM. There was no date and time the physician signed the VO.

Review of the MR revealed a VO dated 12/29/17 at 6:10 PM. There was no date and time the physician signed the VO.

Review of the MR revealed written orders documented by the physician on 12/29/17, after the 6:10 PM orders. There was no documentation of the time the orders were written by the physician. There was no documentation written under the last order of the nurse who transcribed the order, date or time as directed per the facility policy.

Review of the MR revealed a VO written 12/29/17, "Transfer to Spring Hill Memorial ..." There was no documentation of the time the nurse received the VO and there was no date and time the physician signed the VO.

Review of the MR revealed a VO written on 12/29/17 at 9:30 PM (last order in the MR), "Type Cross and transfuse 2 more units ..." There was no documentation the physician had signed the VO as directed per the Medical Staff Rules and Regulations.

An interview was conducted on 5/3/18 at 12:25 PM with EI # 2 who verified the aforementioned findings.



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3. PI # 16 was admitted to the facility on 7/28/17 with diagnoses of Infected Decubitus Ulcers.

Review of the Physician's Orders revealed admission order dated 7/28/17 written by the physician with no signature or time documented.

Review of the Physician's Orders revealed one (1) VO dated on 7/29/17 by Registered Nurse (RN). There was no date or time documented by the physician when VO was signed.

An interview was conducted on 5/3/18 at 12:39 PM with EI # 2 and EI # 3, Assistant Director of Nursing, who confirmed the above findings.


4. PI # 14 was admitted to the facility on 10/16/17 with diagnoses of Anemia, Lung Cancer, and weakness.

Review of the Physician's Orders revealed admission order dated 10/16/17 written by the physician with no time documented.

Review of the Physician's Orders revealed two (2) VO's, including lab order dated 10/17/17 and discharge order dated 10/17/17, by RN.

Further review of the VO's dated 10/17/17 by RN revealed there was no date or time documented by the physician when VO was signed.

An interview was conducted on 5/3/18 at 12:15 PM with EI # 2 and EI # 3, who confirmed the above findings.

5. PI # 19 was admitted to the facility on 2/6/18 with diagnoses of Urosepsis and Urinary Tract Infection (UTI).

Review of the Physician's Orders revealed four (4) VO's, including medication order dated 2/6/18 by RN, lab order dated 2/7/18 by Licensed Practical Nurse (LPN), medication and lab order dated 2/7/18 by LPN, and medication order dated 2/7/18 by LPN.

Further review of the VO's dated 2/6/18 and 2/7/18 revealed there was no date or time documented by the physician when VO was signed.

Review of the Physician's Orders revealed CBC order dated 2/7/18 written by the physician with no time documented.

An interview was conducted on 5/3/18 at 12:37 PM with EI # 2 and EI # 3, who confirmed the above findings.

6. PI # 11 was admitted to the swing bed unit of facility on 2/12/18 with diagnoses of Decline in function/level of mobility.

Review of the Physician's Orders revealed eight (8) VO's, including medication orders dated 2/12/18, 2/13/18, and 2/19/18 by RN, medication order dated 2/13/18 and 2/19/18 by LPN, lab order dated 2/14/18 by LPN, ultrasound order dated 2/14/18 by RN.

Further review of the VO's dated 2/12/18, 2/13/18, 2/14/18, and 2/19/18 revealed there was no date or time documented by the physician when VO was signed.

Review of the Physician's Orders revealed VO for Thyroid-stimulating hormone (TSH) and T4 (Thyroxine) Lab order dated 2/14/18 by RN.

Further review of VO dated 2/14/18 revealed there was no documentation of physician signature.

Review of the Physician's Orders revealed VO for diet change by RN dated 2/20/18.

Further review of VO dated 2/20/18 revealed there was no documentation of physician signature.

An interview was conducted on 5/3/18 at 12:21 PM with EI # 2 and EI # 3, who confirmed the above findings.



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7. PI # 12 was admitted to the facility on 4/28/18 with diagnoses including Acute Renal Failure, Failure To Thrive, Cough, and Weakness.

Review of the 4/28/18 "Admit..." orders signed by the physician revealed there was no documentation of the date and time the orders were written.

Review of the MR revealed four (4) TO and/or VO dated 4/28/18 and 4/29/18. There was no documentation of the date or time the physician signed the TO's or VO's.

An interview was conducted on 5/3/18 at 12:16 PM with EI # 2, who verified the above findings.

8. PI # 20 was admitted to the facility on 10/26/17 with diagnoses including General Inpatient Hospice and Lung Cancer.

Review of the MR revealed three (3) VO dated 10/26/18, and 10/27/18. There was no documentation of the date or time the physician signed the VO's.

An interview was conducted on 5/3/18 at 12:43 PM with EI # 2, who verified the above findings

Based on review of medical records (MR), Medical Staff Rules and Regulations, and interview with administrative staff, it was determined the hospital failed to ensure all history and physicals (H & P's) were completed no more than 30 days before or 24 hours after admission or registration.

This affected 3 of 10 inpatient records reviewed, including Patient Identifier (PI) # 19, # 13, # 17, and had the potential to negatively affect all patients served by the hospital.

Findings include:

Excerpt From the Medical Staff Rules and Regulations
Revised: 9/13/16

3.0 Medical Records

3.2 Patient History and Physical

3.2.4 The medical history hall be completed within twenty-four (24) hours of admission.

3.3.4 When a patient is re-admitted within thirty (30) days for the same or a related problem, is medical record may be updated by an interval note describing any changes in his condition...

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1. PI # 19 was admitted to the facility on 2/6/18 with diagnosis of Urosepsis and Urinary Tract Infection (UTI).

Review of the H&P revealed it was not created or signed until 2/19/18 by the physician.

An interview was conducted on 5/3/18 at 12:37 PM with Employee Identifier (EI) # 2, Director of Nursing and EI # 3, Assistant Director of Nursing, who confirmed the above findings.

2. PI # 13 was admitted to the facility on 4/30/18 with diagnosis of Altered Mental Status.

Review of the MR on 5/3/18 revealed the physician had failed to document an H&P, which was 2 days after admission.

An interview was conducted on 5/3/18 at 12:18 PM with EI # 2 and EI # 3, who confirmed the above findings.



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3. PI # 17 was admitted to the facility on 12/12/17 with diagnoses including Syncope and Anemia, Severe.

Review of the MR revealed an H & P completed by the physician on 12/15/18, which was 3 days later. The physician failed to complete the H&P per the facility Medical Staff Rules and Regulations.

An interview was conducted on 5/3/18 at 12:42 PM with EI # 2 who verified the aforementioned findings.

Based on review of facility policy and procedure, observations, and interviews, it was determined the staff failed to store medications according to the facility policy. This had the potential to negatively affect all patients served by this facility.

Findings include:
Policy and Procedure Manual: Use Of Unit Refrigerators
Effective Date: 1/1/85

"Use Of Unit Refrigerators:

... Drugs requiring refrigeration are to be stored in the refrigerator designated for drug storage.... Medication refrigerators are not to be used for storage of food..."

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An observation tour on 5/1/18 at 12:40 PM in the Laboratory Services revealed a bottle of Glucose - Easyde X (times) 100 (used for glucose tolerance testing) stored inside of the staff refrigerator. The surveyor observed containers with staff food and beverages store with the above medication. The staff failed to follow the facility's policy and procedure for storing medications.

An interview was conducted on 5/3/18 at 1:01 PM with Employee Identifier # 4, Laboratory Manager, who confirmed the above findings.

Based on policy review and interview with Employee Identifier (EI) # 4, Laboratory Manager, it was determined the facility failed to ensure a system was in place to take appropriate action when notified that blood or blood components it received are at increased risk of transmitting Human Immunodeficiency virus (HIV) or Hepatitis C Virus (HCV).

This had the potential to negatively affect all patients receiving blood or blood products.

Review of the policy and procedure book on 5/1/18 at 1:00 PM revealed there was no policy or procedure available for identifying the correct procedure for dealing with Infectious Blood and Blood Products.

An interview conducted 5/3/18 at 1:01 PM with EI # 4 confirmed there was no policy.

Based on policy review and interview with Employee Identifier (EI) # 4, Laboratory Manager, it was determined the facility failed to ensure:

1. A lookback system was in place for staff to appropriately quarantine infectious blood and blood components.

2. A lookback system was in place to notify and counsel recipients that may have received infectious blood and blood components.

This had the potential to negatively affect all patients receiving blood or blood components.

Findings include:

Review of the policy and procedure book on 5/1/18 at 1:00 PM revealed there was no policy or procedure available for identifying the correct procedure for dealing with infectious blood and/or quarantine infectious blood products.

An interview conducted 5/3/18 at 1:01 PM with EI # 4 confirmed there was no policy. EI # 4 stated, "I do not have a policy to quarantine blood product."

Based on observations and interviews, it was determined the hospital failed to ensure:

a) Food was stored in a safe and sanitary manner.

b) The dishwashing machine temperature was checked during each use.

This had the potential to negatively affect all patients.

Findings include:

Manufacturer Instruction label on dishwashing machine:

Jackson Product Company
Model 10AB Serial # 44992M
Wash temperature 150 degrees - 165 degree Fahrenheit
Final Rinse temperature 180 degree - 195 degree Fahrenheit...

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1. A tour of the Dietary Department was conducted on 5/2/18 at 11:35 AM with Employee Identifier (EI) # 5, Dietary Manager and EI # 6, Dietary. The surveyor observed the following:

In the Refrigerator:

6 - Borden Vitamin D Milk 236 ml (milliliter) expired 5/1/18. The staff failed to discard expired milk.

In the storage room:

2 - Open packets of McCormick Chili Mild Seasoning mix. The staff failed to store dry goods in a manner to prevent rodent/pest contamination.

In an interview was conducted on 5/3/18 at 9:45 AM with EI # 5, who verified the expired milk should have been discarded and the dry goods should be stored to prevent contamination. The surveyor requested a policy on food storage. There was no policy provided.

2. During the observation of dishwashing conducted on 5/2/18 at 12:47 PM the surveyor noted the temperature gauge remained at zero during the entire process.

The surveyor asked EI # 6, "How do you check the dishwashing machine temperature to ensure the manufacturer's temperature range has been reached?" EI # 6 stated, I didn't know I had to check the temperature when using the dishwasher. The staff failed to ensure the dishwasher reached the manufacturer's temperature range of 150 degrees - 165 degrees.

An interview was conducted on 3/22/18 at 10:30 AM with EI # 5, who verified the above findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on review of facility policy, Daily Refrigerator Temperature Monitor Log and interviews it was determined the facility failed to ensure equipment was monitored to maintain safety of patients and staff. This had the potential to affect all patients and staff.

Findings include:

Daily Refrigerator Temperature Monitor

Medication Refrigerator

Instructions: Each day, record the temperature (in Degrees Fahrenheit) by placing a dot in the box ...

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Use of Unit Refrigerators
Reviewed: 1/3/18

...All refrigerators are required to have thermometers and maintain a temperature of 44 (degrees).

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1. During a tour of the Emergency Department (ED) on 5/1/18 at 12:40 PM the surveyor asked Employee Identifier (EI) # 3, Assistant Director of Nursing (ADON), "Where are the medications for the ED kept?" EI # 3 stated, "All medications for the nursing units (including ED) are located in one area, which is in the main nursing unit of the hospital". (Medications were stored in a "medication refrigerator" in the main nursing unit in close proximity to the ED).

Review of the Daily Refrigerator Temperature Monitor Log revealed there was no documentation on 3/2/18, 3/3/18, 3/4/18, 3/8/18, 3/16/18, 3/17/18, 3/24/18, 3/25/18, 3/26/18, 3/31/18, 4/1/18, 4/4/18, 4/14/18, 4/15/18, 4/16/18, 4/17/18, 4/18/18, 4/27/18, 4/28/18 and 4/29/18 of a daily temperature as directed.

An interview was conducted on 5/1/18 at 1:30 PM with EI # 3 and EI # 2, Director of Nursing, who verified the aforementioned findings.

Based on Occupational Safety and Health Administration (OSHA), Center for Disease Control (CDC), Procedural Chart for Use With the BacT/Alert (registered trademark of BioMerieux) Adult Blood Culture Collection Kit, observations and interviews, it was determined the facility staff failed to:

1. Store laboratory (lab) supplies/test reagents separately from lab specimens to prevent contamination.

2. Obtain blood cultures per manufacturer's instructions

This did affect an unsampled patient and had the potential to affect all patients.

Findings include:

OSHA
Subject: Most Frequently Asked Questions Concerning the Bloodborne Pathogens Standard
Standard Number: 1910.1030
Corrected Date: 11/01/2011

" ... Methods of Control
Universal Precautions
Q (question) 15. What is meant by the term Universal Precautions?
A (answer) 15. Universal Precautions is OSHA's required method of control to protect employees from exposure to all human blood and other potentially infectious materials (OPIM). The term, "Universal Precautions," refers to a concept of bloodborne disease control which requires that all human blood and certain human body fluids be treated as if known to be infectious for HIV, HBV or other bloodborne pathogens.

Q16. Can Body Substance Isolation (BSI) be adopted in place of Universal Precautions?
A16. Yes. Body Substance Isolation is a control method that defines all body fluids and substances as infectious. BSI incorporates not only the fluids and materials covered by the standard but expands coverage to include all body substances. BSI is an acceptable alternative to Universal Precautions, provided facilities utilizing BSI adhere to all other provisions of the standard ..."

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Center for Disease Control (CDC)
Date: November 11, 2005 / 54(RR13); 1-25

Subject: Good Laboratory Practices for Waived Testing Sites

"Survey Findings from Testing Sites Holding a Certificate of Waiver under the Clinical Laboratory Improvement Amendments of 1988 and Recommendations for Promoting Quality Testing ...

Recommended Good Laboratory Practices ...

The OSHA Bloodborne Pathogens Standard applies to sites where workers have potential occupational exposure to blood and infectious materials (25). The requirements for compliance with this standard include, but are not limited to:

... Use of Universal Precautions, an approach to infection control in which all human blood and certain human body fluids are treated as if known to be infectious for HIV, hepatitis B virus, hepatitis C virus, and other bloodborne pathogens. Universal Precautions is one component of Standard Precautions, a broader approach designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals ...

Safety training for handling blood, exposure to bloodborne pathogens, and other infectious materials ..."

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Title: Procedural Chart for Use With the BacT/Alert (registered trademark of BioMerieux) Adult Blood Culture Collection Kit

... 2. Remove protective flip top overcap. Note: The septum is not serile and must be disinfected.

3. Cleanse the septum with 70 % (percent) alcohol...

7. Place adapter cap on the Aerobic... culture bottle septum and press down to penetrate and obtain blood flow. Hold the adapter cap down on the bottle...

8. Using the fill indicator line on the label, obtain 8-10 ml of blood. Move the adapter cap from the aerobic bottle to the Anaerobic... bottle and continue the collection..."

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1. During a tour of the Laboratory Services conducted on 5/1/18 at 12:50 PM with Employee Identifier (EI) # 5, Laboratory (lab) Manager. The surveyor observed the contracted outside lab vendor staff picking up lab specimens from a refrigerator labeled as Labcorp. The surveyor also observed the following supplies stored inside of the refrigerator:

Hemochron (an A1C calibrator [used for test that measures the level of hemoglobin]).

The surveyor asked EI # 5, "Should clean supplies be stored separate from collected specimens?" EI # 5 stated they can be stored together. The staff failed to treat lab specimens as if they were infectious per CDC Good Laboratory Practices.

In an interview conducted on 5/3/18 at 1:01 PM, EI # 5 confirmed the above findings.

2. During an observation of care conducted on 5/2/18 at 10:00 AM with an unsampled patient the surveyor observed EI # 5, draw blood cultures.

EI # 5 removed the caps from 2 blood culture containers and placed an alcohol prep pad on top of each container. EI # 5 proceeded to inject 4 milliliters (ml) of blood from a syringe while the alcohol prep was on top of the blood culture container. EI # 5 removed the needle from the first blood culture container with the alcohol prep pad on the needle. EI # 5 then proceeded to inject 4 ml into the second blood culture container. The surveyor asked EI # 5, "Is that the proper way to collect the blood culture specimen?" EI # 5 stated, "Yes, this is how we have always collected our blood cultures." The staff failed to collect blood culture per manufacturer's instructions.

In an interview conducted on 5/3/18 at 1:01 PM, EI # 5 confirmed the above findings.

Based on review of the Swing Bed Employee Files and staff interviews, it was determined the facility failed to ensure the activity director met qualifications. This had the potential to negatively affect all patients admitted to the swing bed program.

Findings include:

On 5/2/18 at 9:30 AM an interview was conducted with Employee Identifier (EI) # 2, Director of Nursing, who also serves facility as activities director for swing bed. The surveyor asked EI # 2 about training for position as activities director. EI # 2 revealed that she did not have any prior experience in activities and had not received any training in activities.

Surveyor was given employee file of EI # 2 by facility for review on 5/3/18.

On review of EI # 2's employee file resume was found dated 7/2/96, just prior to employment with facility.

Review of resume found employment history of cashier, retail store manager, and nurse maid.

Further review of EI # 2 employee file revealed no evidence of experience with activities in a swing bed program.

Further review of employee file revealed there was no job description of Activities Director for swing bed program in employee file.

Based on review of medical records (MR) and interviews, it was determined the facility failed to ensure the staff developed and updated a care plan for improving physical, mental, and psychosocial functioning with goals and treatments. This affected 1 of 1 swing bed patient reviewed and had the potential to negatively affect all patients admitted to the swing bed unit.


Findings include:

1. PI # 11 was admitted to the swing bed unit of the facility on 2/12/18 with diagnoses of Decline in function/level of mobility.

Review of the MR revealed that there was no documentation of a plan of care that addressed the physical, mental, and psychosocial functioning.

On 5/2/18 at 9:30 AM an interview was conducted with Employee Identifier (EI) # 2, Director of Nursing, who stated that social services are provided by nursing staff.

On 5/3/18 at 9:30 AM EI # 2 stated that the facility did not develop nursing care plans.

Based on review of the Emergency Preparedness (EP) Program and interview with the agency staff, it was determined the facility failed to conduct training and testing on the EP program to its current and active staff members. This had the potential to negatively affect all patient served by this facility

Findings include:

Review of the EP program revealed no documentation of EP training to all current facility employees.

An 5/3/18 at 9:37 AM in an interview with Employee Identifier (EI) #2, Director of Nursing, and EI # 3, Assistant Director of Nursing, stated that the facility had not conducted training and testing on the hospital staff. The facility failed to provide documentation that the facility completed the following:

1. Initial and annual training for all new and existing staff, contracted or arrangement service providers, and/or volunteers.
2. Annual testing, evaluation, and demonstration of the staff's knowledge of emergency procedures.

Based on review of the Emergency Preparedness (EP) Program and interview with the agency staff, it was determined the facility failed to conduct training and testing on the EP program to its current and active staff members. This had the potential to negatively affect all patients served by this facility.

Findings include:

Review of the EP program revealed no documentation of EP training to all current facility employees.

On 5/3/18 at 9:37 AM in an interview with Employee Identifier (EI) # 2, Director of Nursing, and EI # 3, Assistant Director of Nursing, stated that the facility had not conducted training and testing on the hospital staff, contracted or arrangement services and/or volunteers.