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Based on patient record reviews, staff interviews, and review of the hospital's policy and procedures, the hospital failed to ensure the patient's Plan of Care (POC) had measurable goals and had individualized interventions for fifteen of thirty patient records reviewed. (Patient 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 29)

The findings are:

Patient 29
On 12/17/2019 at 9:00 AM, review of the closed record for Patient 29's POC revealed the patient's POC had no specific times when the patient's problems were identified or when the interventions were completed. Patient 29 was admitted with tube feedings for a Halo Procedure. The patient's POC was customized to reflect the Halo procedure and the Halo traction. Under the problem for nutrition, clear liquids was crossed out and the nurse wrote tube feedings only. There were no additional problems, goals, or interventions for nutritional needs documented. On 12/18/2019 at 9:30 AM, the Chief Nursing Officer (CNO) verified the findings and stated, "..... these are corporate forms. This is what we are using for now. We hope to get the module for Cerner to allow care plans to be computerized."

Policy and Procedure
On 12/18/2019 at 9:45 AM, the hospital's policy specific to the POC, reads, "The care, treatment, and rehabilitation planning process is designed to ensure that care is appropriate to the patient's specific needs and the severity level of his or her disease. Because of each patient's unique needs (including those needs dictated by the patient's age and developmental level), expectations and characteristics, the care planning process is designed to identify and incorporate such needs to ensure individuated and appropriate plan."







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Patient 12
On 12/17/2019 at 10:20 AM, review of the closed chart for Patient #12 revealed the patient's POC was not an individualized patient specific plan with measurable goals to document outcomes. The patient's POC was a preprinted, standardized form for "Surgical with Cast, LE(Lower Extremity)". The findings were verified by Clinical Document Improvement/Utilization Management (CDI/UM) on 12/17/2019 at 10:20 AM.

Patient 13
On 12/17/2019 at 10:47 AM, review of the closed chart for Patient 13 revealed the patient's POC was not an individualized patient specific plan with measurable goals to document outcomes. The patient's POC was a preprinted standardized form for "Spinal Fusion, Posterior". The findings were verified by CDI/UM on 12/17/2019 at 10:47 AM.

Patient 14
On 12/17/2019 at 11:30 AM, review of the closed chart for Patient 14 revealed the patient's POC was not an individualized patient specific plan with measurable goals to document outcomes. The patient's POC was a preprinted standardized form for "Surgical with Dressing-Right Knee Fusion". The findings were verified by CDI/UM on 12/17/2019 at 11:30 AM.

Patient 15
On 12/17/2019 at 11:12 AM, review of the closed chart for Patient 15 revealed the patient's POC was not an individualized patient specific plan with measurable goals to document outcomes. The patient's POC was a preprinted standardized form for "Spinal Fusion, Posterior". The findings were verified by CDI/UM on 12/17/2019 at 11:12 AM.




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Patient 6
On 12/17/2019 at 11:04 AM, review of the closed chart for Patient 6 revealed the patient's POC had outcomes listed that were not measurable or had no outcomes listed. The interventions listed were comfort, Intravenous (IV) site, and voiding instead of specific actions to reach the goal. The findings were verified by the CNO at 9:40 AM on 12/18/2019.

Patient 7
On 12/17/2019 at 11:59 AM, review of the closed chart for Patient 7 revealed the patient's POC had one diagnosis of nutrition with the intervention of nothing by mouth (NPO) and the goal retching/vomiting/none. There was no diagnosis or intervention for nausea or vomiting. There was no goal for the patient's NPO status. The findings were verified by the CNO at 9:40 AM on 12/18/2019.

Patient 8
On 12/17/2019 at 1:36 PM, review of closed chart for Patient 8 revealed the patient's POC had outcomes listed that were not measurable or had no outcomes listed. The interventions listed were skin and Foley instead of specific actions to reach the goal. The findings were verified by the CNO at 9:40 AM on 12/18/2019.

Patient 9
On 12/17/2019 at 1:53 PM, review of the closed chart for Patient 9 revealed the patient's POC had outcomes listed that were not measurable or had no outcomes listed. The interventions listed were Foley, skin, and comfort instead of specific actions to reach the goal. The findings were verified by the CNO at 9:40 AM on 12/18/2019.

Patient 10
On 12/17/2019 at 1:59 PM, review of the closed chart for Patient 10 revealed the patient's POC had outcomes that were not measurable or had no outcomes listed. The interventions listed were Foley, skin, and comfort instead of specific actions to reach the goal. The findings were verified by the CNO at 9:40 AM on 12/18/2019.


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Patient 16
On 12/17/19 at 8:30 AM, review of the closed chart for Patient 16 revealed the patient was admitted 7/8/19 for Irrigation and Debridement of bilateral knees. The care plan was preprinted and titled "Wound with Surgical Management". The patient's care plan had no nursing diagnosis, interventions, or measurable goals for the patient.

Patient 17
On 12/17/19 at 9:00 AM, review of the closed chart for Patient 17 revealed the patient was admitted 8/1/19 for Varus Derotational Osteotomy (VDRO). The care plan was titled "VDRO with Soft Tissue Releases". The patient's care plan had no nursing diagnosis, interventions, or measurable goals for the patient.

Patient 18
On 12/17/19 at 9:45 AM, the review of care plan for Closed Patient 18 revealed the patient was admitted 7/13/19 for right knee fusion. The care plan is titled Surgical with Dressing. The care plan is missing nursing diagnosis, interventions and measurable goals for the patient.

Patient 19
On 12/17/19 at 10:05 AM, the review of care plan for Closed Patient 19 revealed the patient was admitted 10/24/19 for Removal of external fixator and body cast applied. The care plan is titled Immobility. The care plan is missing nursing diagnosis, interventions and measurable goals for the patient.

Patient 20
On 12/17/19 at 10:20 AM, review of the closed chart for Patient 20 revealed the patient was admitted 10/8/19 for a Spinal Fusion, Posterior. The patient's care plan was titled "Spinal Fusion". The patient's care plan had no nursing diagnosis, interventions, or measurable goals for the patient.

On 12/18/2019 at 9:30 AM, the Chief Nursing Officer (CNO) verified the findings and stated, "..... these are corporate forms. This is what we are using for now. We hope to get the module for Cerner to allow care plans to be computerized."

Policy and Procedure
On 12/18/2019 at 9:45 AM, the hospital's policy specific to the POC, reads, "The care, treatment, and rehabilitation planning process is designed to ensure that care is appropriate to the patient's specific needs and the severity level of his or her disease. Because of each patient's unique needs (including those needs dictated by the patient's age and developmental level), expectations and characteristics, the care planning process is designed to identify and incorporate such needs to ensure individuated and appropriate plan."

Based on observations and interview, the hospital failed to provide instruction for safety to patients and visitors in two playground areas of the hospital campus.

The findings are:

On 12/16/2019, during a tour of the hospital campus from 1:00 PM to 2:45 PM with the Director of Engineering, observations revealed 2 large fiberglass animals which are not fenced and are part of the garden area. There was a sign near the entrance door to the playground that states, "Do not climb on the benches". There was no sign in the first-floor outdoor playground area to alert visitors and patients to refrain from climbing on or under the 2 large unsecured fiberglass animals. On 12/16/2019 at 1:30 PM and during an interview on 12/18/19 at 10:30 AM, the Director of Engineering verified the finding.

Based on observations, interviews, and a review of the hospital's policy, entitled, "Re-Service of Leftover Foods", the hospital failed to ensure one of one dietary managers was knowledgeable of how to calibrate a food thermometer; one of one dietitians and one of three dietary aides observed plating food wore the same gloves when to touching and plating foods potentially cross contaminating utensil handles and food; one cup of scrambled eggs was not labeled/dated in one of two stand up refrigerators; one pan of meat was not labeled/dated in the walk-in freezer; eight of fourteen light covers over the main kitchen prep area had a black substance and/or dead insects noted in the plastic covers; gas grill had a black substance built up on the side of the grill and on the table underneath; and the trash compactor had debris on the ground to the side of the compactor. The hospital failed to ensure Yankeur suction equipment was not removed its packaging prior to patient use in the post anesthesia care unit.


The findings included:

Observations in the kitchen on 12/16/19 at 1:30 PM revealed a stand up refrigerator that had a container of liquid/scrambled eggs that was not dated or labeled when prepared. Observations at 1:38 PM on 12/16/2019 of the walk in freezer revealed a pan of meat that was not dated or labeled. The findings were verified by the Dietary Manager at 1:32 PM and 1:39 PM. On 12/16/19 at 3:45 PM, review of the hospital's policy, entitled, "Re-Service of Leftover Foods" revealed information that leftover foods should be labeled/dated.

Observations on 12/16/19 at 1:40 PM revealed eight of fourteen light fixtures over the dietary prep area had a black substance and/or dead insects noted in the plastic covers. The gas grill had a buildup of a black substance on the side and on the table under the grill. During an interview on 12/17/19 at 12:00 PM, the Director of Engineering, who is responsible for the cleaning of the light covers, observed and verified the findings of the dirty light covers. The Director of Engineering reported environmental rounds are completed bi-annually and the cleaning of the light covers is done at that time, but She/he had no documentation of when the light covers had been cleaned. Observations of the gas grill revealed the table under the grill had been cleaned but the buildup of the black substance on the side of the grill was still there.

Observations on 12/16/2019 at 2:00 PM of the trash compactor revealed trash/debris on the ground on the sides of the trash compactor that included trash bags, cardboard, gloves, paper, and plastic cup lids. The findings were verified by the Dietary Manager at about 2:02 PM on 12/16/2019 who stated only kitchen staff use the trash compactor.

Observations of the kitchen lunch service on 12/17/19 between 10:30 AM and 10:40 AM revealed Cook #1 temping food that was cooking in the oven. Cook #1 was asked by the surveyor to demonstrate how to ensure the thermometer was working properly. Cook #1 prepared a cup of ice water and placed the thermometer(s) in them. After about 5 minutes, (at 10:45 AM), the 3 thermometers were reading below 32 degrees Fahrenheit (F) which was not accurate since there was only a small amount of ice and more water with the ice floating to the top and the thermometer was resting on the bottom of the container. The thermometers read 20 degrees F, 22 degrees F, and 14 degrees F. The Dietary Manager took over from there, explaining that she/he opened 2 of the thermometers (brand new) that morning, and had calibrated all 3 of them. Upon further observation, the Dietary Manager was unable to get the thermometers calibrated correctly to 32 degrees F. The Dietary Manager did not add enough ice into the water and did not hold the thermometers properly in the ice water while calibrating them. When asked, the Dietary Manager stated that she/he did not think the hospital had a policy on how to calibrate the thermometer. The Dietary Manager was unable to provide documentation on training for dietary staff on how to ensure a thermometer was working properly by calibrating the thermometer.

Observations of the lunch tray line on 12/17/19 at 11:13 AM revealed Dietary Aide #1 plating food for staff and visitors. Wearing gloves, the Dietary Aide #1 picked up the grilled chicken (no utensil), placed the chicken on a cutting board, and used a knife to cut the chicken, touched the handle, and then placed the chicken on the salad and served it. Wearing the same gloves, Dietary Aide #1 picked up salad greens from a container without using a utensil and also touched the greens left in the bowl potentially cross contaminating the greens since he/she had not changed gloves. Dietary Aide #1 plated the greens into a carton, touched a knife handle, sliced an egg, and wearing the same gloves placed the egg over the salad greens. Wearing the same gloves, Dietary Aide #1 touched the tong handles and plated broccoli and mushrooms. Wearing the same gloves, she/he picked up cucumbers from a container without a utensil, touched a spoon handle to plate feta cheese, and then wearing the same gloves picked up dried cran-raisins without a utensil. Wearing the same gloves, Dietary Aide #1 picked up chicken, placed the chicken on a cutting board, and touched the knife handle to cut up the chicken. Dietary Aide #1 picked up the chopped chicken and placed the chicken in a cup of buffalo sauce, shook the cup, and then placed the chicken over the salad. Wearing the same gloves, Dietary Aide #1 used a plastic condiment cup to scoop up almonds from a container and touched the remaining almonds in the bowl. During an interview on 12/17/19 at 11:55 AM, Dietary Aide #1 verified the above observations.

Observations on 12/17/19 at 11:38 AM revealed the Dietitian plating food for a patient. The Dietitian, wearing gloves, picked up chicken tenders and plated the chicken. Then, the Dietitian wearing the same gloves opened the food warmer touching the door handle and removed a tray of french fries. Wearing the same gloves, the Dietitian picked up french fries and plated them. During an interview on 12/17/19 at 11:50 AM, the Dietitian was informed of the concern for potential cross contamination by touching handles/objects, and then wearing the same gloves to touch other food items.



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On 12/16/19 at 12:45 PM, observations during the tour of the Post Anesthesia Care Unit revealed four (4) opened Yankauers connected to suction canisters. The findings were verified by Manager 3 on 12/16/19 at 12:50 PM who stated, "They keep these connected in case they need one when a case comes out." Review of the manufacturer's packaging instructions for the Yankauer, reads, "Do not use if package is open or damaged".

Based on observations, review of the hospital's Operating Room (OR) register, and interviews, the hospital failed to show documentation that the hospital maintained an OR register with all required data such as total time of the operation, surgeon's assistant, name of anesthesia personnel, pre-operative and post-operative diagnosis, and the name of the scrub technician.

The findings are:

On 12/17/19 at 2:30 PM, review of the hospital's OR register revealed the following information was not documented: total time of the operation, surgeon's assistant, name of anesthesia personnel, pre-operative and post-operative diagnosis, and the name of the scrub technician.
On 12/17/19 at 2:45 PM, the findings were verified by Manager 3, who stated, "We make a copy of the posting forms. Anesthesia works a week at a time. The scrub technicians are listed at the bottom of the page."

Based on interview, the hospital failed to provide documentation that the Respiratory Therapy department is under the supervision of a physician who is designated as the Director of Respiratory Care.

The findings are:

On 12/18/2019, during an interview with the Operating Room (OR) Director and Respiratory Therapist (RT), they revealed the RT is under the oversight of the OR Director who is also a Registered Nurse (RN). On 12/18/2019 at 9:55 AM, in an interview with the Chief Nursing Officer (CNO), the CNO confirmed the RT reports directly to the OR Director. The hospital had no documentation or job description that showed the Director of Respiratory Care services is a physician and had no clear organization chart that showed lines of authority for inpatient respiratory services. The finding was verified by the CNO on 12/18/2019 at 9:55 AM.