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Based on staff interviews, facility document review, and patient record review, the facility failed to have an effective governing body to ensure that the facility provided Nursing Services to ensure patient safety; provided safe and effective Pharmaceutical Services, provided a comprehensive Infection Control program and to ensure that Discharge Planning is conducted for each patient. For these reasons, the Condition of Governing Body was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:


1. Reference A 0263 QAPI. Based on staff interviews, facility document review, and patient record review, the facility failed to have an effective Quality Assurance Performance Improvement Program, (QAPI); to ensure that the facility provided Nursing Services to ensure patient safety, provided safe and effective Pharmaceutical Services, provided a comprehensive Infection Control program and to ensure that Discharge Planning is conducted for each patient.. For these reasons, the Condition for QAPI was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

2. Reference A 0385 Nursing Services. Based on staff interviews, facility document review and patient record review, the facility failed to have an effective governing body to ensure that the facility provided Nursing Supervision to meet the patient's needs, developed and implemented Comprehensive Interdisciplinary Care Plans, provided medication according to the physician's orders and to report medication errors. Based of these findings this Condition of Participation is not met.
3. Reference A 0490 Pharmacy Services. Based on staff interviews and facility document review, the facility failed to ensure that medication profiles are performed and medication orders are reviewed by a licensed pharmacist before being administered to the patient. The facility failed to develop and implement pharmacy policy and procedures. The facility failed to exercise control of entry of non-pharmacy staff into the pharmacy when pharmacy staff is not present.

4. Reference A 0747 Infection Control Program. Based on observation, staff interviews and facility document review, the facility failed to ensure development and implementation of a comprehensive Infection Control Program and to ensure that the Hospital Leadership incorporated the Infection Control Program into the facility's Quality Assessment and Performance Improvement Program resulting in this Condition of Participation is not met.
5. Reference A 0799 Discharge Planning. Based on observation, staff interviews and facility document review, the facility failed to provide initial and ongoing Discharge Planning, post hospital discharge services, supervision of the Discharge Panning process, discharge education to patients, provide a list of outpatient providers for patients requiring post hospitalization services, and to provide accurate transfer information. Based on these findings the Condition of Participation for Discharge Planning is not met.

Based on staff interviews, facility document review, and patient record review, the facility failed to have an effective Quality Assurance Performance Improvement Program, (QAPI); to ensure that the facility provided Nursing Services to ensure patient safety, provided safe and effective Pharmaceutical Services, provided a comprehensive Infection Control program and to ensure that Discharge Planning is conducted for each patient.. For these reasons, the Condition for QAPI was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:

1. Reference A 0385 Nursing Services. Based on staff interviews, facility document review, and patient record review, the facility failed to provide Nursing Supervision to meet the patient's needs, failed to develop and implement Comprehensive Interdisciplinary Care Plans, failed to provide medications according to the physician's orders and to report medication errors. Based of these findings this Condition of Participation is not met. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.
2. Reference A 0490 Pharmacy Services. Based on staff interviews and facility document review, the facility failed to ensure that medication profiles are performed and medication orders are reviewed by a licensed pharmacist before being administered to the patient. The facility failed to develop and implement pharmacy policy and procedures. The facility failed to exercise control of entry of non-pharmacy staff into the pharmacy when pharmacy staff is not present.

3. Reference A 0747 Infection Control Program. Based on observation, staff interviews and facility document review, the facility failed to ensure development and implementation of a comprehensive Infection Control Program and to ensure that the Hospital Leadership incorporated the Infection Control Program into the facility's Quality Assessment and Performance Improvement Program resulting in this Condition of Participation is not met.

4. Reference A 0799 Discharge Planning. Based on observation, staff interviews and facility document review, the facility failed to provide initial and ongoing Discharge Planning, post hospital discharge services, supervision of the Discharge Panning process, discharge education to patients, provide a list of outpatient providers for patients requiring post hospitalization services, and to provide accurate transfer information. Based on these findings the Condition of Participation for Discharge Planning is not met.

Based on staff interviews, facility document review, and patient record review, the facility failed to provide Nursing Supervision to meet the patient's needs, failed to develop and implement Comprehensive Interdisciplinary Care Plans, failed to provide medications according to the physician's orders and to report medication errors. Based of these findings this Condition of Participation is not met. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.
Findings:
1. Based on observation and interview, the facility failed to provide appropriate nursing supervision during the procedure for blood glucose testing for 1 (Patient #2) of 1 patient sampled. The facility failed to provide nursing supervision regarding a transfer for 1 (Patient #6) of the 1 patient sampled. The facility failed to provide appropriate nursing supervision to insure appropriate treatment and medication administration for 3 (Patient #6, 21 and 22) of the 23 sampled. (Refer to Standard A 0395)

2. Based on interviews and facility record reviews, the facility failed to provide a comprehensive Interdisciplinary (IDT) Care Plan including care planning information regarding diagnosis and condition for 4( Patients #1, #6, #7, and 12) of the 24 sampled patients. (Refer to Standard A 0396)

3. Based on staff interview and facility record review, the facility failed to provide medications and medical treatments according to the physician's orders for 3 (Patient #6, 21 and 22) of the 24 Patient's sampled. The facility failed to appropriately and accurately provide written physician's orders and transcription of physician's orders for 1 (Patient #6) of the 1 sampled.
The facility failed to appropriately dispense and mix drugs for the population served on the medical surgical unit. (Refer to Standard A 0405)

4. Based on staff interview and facility record review, the facility failed to ensure a reporting and monitoring procedure for errors or omissions in the administration of drugs. (Refer to Standard A 0410)

Based on observation, staff interviews and facility document review, the facility failed to ensure development and implementation of a comprehensive Infection Control Program and failed to ensure that the Hospital Leadership incorporated the Infection Control in the facility's Quality Assessment and Performance Improvement Program (QAPI) resulting in this Condition of Participation not being met. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:
1. Based on observation, staff interview and facility record review, the facility failed to develop an infection control program which investigates, reports, and prevents infections for staff, community visitors, and patient populations. The facility failed to provide a program to monitor, measure, and evaluate infection control interventions and implementations. The facility failed to maintain infection control practices in the kitchen and food preparation areas to prevent the potential for food borne illness. (Refer to Standard A 0749)

2. Based on staff interviews, patient care observations, environmental observations, and facility document review, the Governing Body failed to ensure that the facility has an active Infection Control Program which provides data to the Quality Assessment and Performance Improvement, (QAPI), program for review and the development of actions plans for correction of infection control concerns.

Based on observation, staff interviews and facility document review, the facility failed to provide initial and ongoing Discharge Planning, post hospital discharge services, supervision of the Discharge Panning process, discharge education to patients, provision of a list of outpatient providers for patients requiring post hospitalization services, and accurate transfer information. Based of these findings the Condition of Participation for Discharge Planning is not met.These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.
Findings:

1) Based on staff interviews and facility record review, the facility failed to provide appropriate initial and ongoing assessments for discharge needs for the inpatient population served at the facility including 5 (Patient # 2, 6, 12, 18 and 23) of the 24 Patient's sampled. (Refer to Standard A 800)

2) Based on staff interviews and record review, the facility failed to evaluate the patients entering the hospital as an inpatient for post-hospital discharge services for 2 (Patient #2 and 12) of the 24 Patient's sampled. (Refer to Standard A 0806)

3) Based on staff interview and record review, the facility failed to ensure the delegated personnel developed and supervised the discharge planning for 3 (Patient # 2, 6 and 12) of the 24 sampled. (Refer to Standard A 0817)

4) Based on staff interview and record review, the facility failed to provide initial implementation of discharge planning including the provisions for post-hospital services and education of patients and caregivers for 6 (Patient #2, 6, 12, 18, 20 and 23) of the 24 Patient's sampled. (Refer to Standard A 0820)

5) Based on staff interviews and facility record review, the facility failed to provide the following for inpatient discharge patients requiring post hospital care services since 08/16/2013: a list of services such as Home Health Agencies (HHA) or Skilled Nursing Facilities (SNF) that are available in the service area of the patient as appropriate (i), provide patients the availability of managed care organizations (ii), documentation of the list that was provided to the patient or representative (iii). The facility failed to provide these services . (Refer to Standard A 0823)

6) Based on staff interview and record review, the facility failed to provide accurate information regarding patient transfer for 1 (Patient # 6) of the 1 Patient sampled. (Refer to Standard A 0837)

Based on observation and interview, the facility failed to provide appropriate nursing supervision during the procedure for blood glucose testing for 1 (Patient #2) of the 1 patient sampled.
The facility failed to provide nursing supervision regarding a transfer for 1 (Patient #6) of the 1 patient sampled. The facility failed to provide appropriate nursing supervision to ensure appropriate treatment and medication administration for 3 (Patient #6, 21, and 22) of the 24 sampled.

Findings include:


1. At 11:25 a.m. on 08/20/2013, a blood glucose test was observed. The nurse's aide was observed removing a blood glucose device from the medical supply drawer at the nursing station. The aide proceeded to enter the room for Patient #2. The nurse aide explained the procedure to Patient #2. The nurse aide donned gloves and performed the procedure. The aide was observed removing the gloves and discarding the used supplies appropriately. The aide then placed the testing device in the case and replaced the device into the drawer. The aide did not conduct hand hygiene prior to or after the procedure.

The nurse aide was interviewed at this time and she agreed she did not wash her hands before or after the procedure, stating "No I did not." The nurse then explained the blood glucose testing device was for multiple patient use. The nurse explained to the aide the device should have been cleaned before returning the device to the case and drawer. The nurse explained to the aide the device should be wiped down with either an alcohol swab or a germicidal/bactericidal and viralcide wipe. The nurse aide was then observed using the sani-wipe type cloth to clean the device. The aide wiped the device and immediately replaced the device in the case and returned it to the drawer. The Infection Control Designee was called to the nursing station. The review of the blood glucose testing device observation was explained to the designee. The designee explained the facility had recently just obtained these devices and the devices "were not for multi-patient use." The designee commented the facility was using the device manufacturer's manual for the policy and procedure for care and cleaning. The designee removed a binder from a cupboard in the nurse station. The binder contained the manual for the device used previously. The designee stated "This is for the old device; the manual for the new one is not in here." The designee agreed the staff did not have the current information for the appropriate use and cleaning for the Contour device. The designee stated "I can put a policy and procedure for this."
2. An interview with Staff Nurse 1 was initiated on 08/21/2013 at 1:15 p.m. The nurse commented Patient (Pt.) # 6 was transferred to Shands Hospital.

The transfer record was originally dated 08/19/2013. This date has a line drawn through the date. Under the crossed out (lined) date was an entry "08/20/2013". The record contains a physician order dated 08/20/2013 for transfer. The nursing notes dated 08/19/2013 at 7:00 a.m. contain "Report give to AM (morning) shift. Pt still pending transfer to Shands"

The transfer documents include facility forms "Transfer Record" and "Physician Transfer Authorization". The "Physician Transfer Authorization" was signed by the physician on 08/18/2013. Section 4 -E. of the form is checked, Name of Accepting M.D. is blank (without entry). The "Facility" field on the document contains a handwritten entry "Shands Hospital Gainesville Florida". The facility "Transfer Record" was originally dated 08/19/2013. This date has a line drawn through the date; under the crossed out (lined) date was an entry "08/20/2013". The receiving hospital is documented with a hand written entry "Shands Gainesville " Accepting Physician is blank (without entry). The "Consent" section of the transfer record contains "I agree to transfer to: Shands Gainesville (hand written entry) and is signed by the patient. The document does not contain a date or time the document was signed by the patient. The physician order dated 08/20/2013 states: "transfer pt (patient) to NFRMC (North Florida Regional Medical Center).

A review of the facility Policy and Procedure MS10245 dated 08/1/2013 includes a Procedure Guideline number 8.1 "There must be a physician order for transfer of a patient from Regional General Hospital-Williston to another facility." Number 9.2 guideline "Transfer Arrangements" contains instructions for transfer including "The transferring physician will notify the physician at the receiving facility and obtain the physician consent to transfer. Regional General Hospital - Williston personnel must receive confirmation from the receiving facility that the patient has been accepted."
Section number 5 "The physician's orders for the specific mode of transportation, as appropriate to the patient's medical condition, will be obtained. Except as stated in #2 above, Regional General Hospital- Williston personnel will arrange for transportation as ordered."

3. An interview was conducted with the Respiratory Therapist (RT) on 08/19/2013 at 12:45 p.m. The respiratory therapist explained she works day shift usually 8:00 a.m. - 5:00 p.m. Monday -Friday. The RT explained she is the manager of the department and stated: "I am the only Respiratory Therapist in the hospital." The RT explained the continuum of care for respiratory therapy treatments. The RT explained she checks each patient record in the morning on arrival to the hospital. Then checks and documents the physician orders for each patient and new admission to the floor. The RT states "I see who has what every day." The RT explained she reviews the Medication Administration Record (MAR) to insure the treatments were administered during the night. The RT explained on each Monday she personally reviews the MARs to insure accuracy of administration and transfer of the physician orders to the MAR. The RT explained the nurses are delegated to provide respiratory drug and treatment administration to the patients when she is not working. The RT was asked the procedure for reporting an error in the treatment administration. The RT explained she would verify the error and gather information then" report the occurrence to the CNO (Chief Nursing Officer)". The Risk Management Designee was interviewed at 4:45 p.m. on 08/19/2013. The Risk designee commented the incident logs were in the conference room, but she did not recall any incident reports for medications.

A review of facility Incident /Occurrence forms was conducted on 04/20/2013. These reports did not indicate errors in medication/drug administration and omissions. An interview with the CNO was conducted at 4:00 p.m. The CNO stated "Yes, I know there have been errors with respiratory treatments because I was involved with the follow up." The CNO commented she would check on this and return. At 4:16 p.m. the CNO returned with facility documents including personnel records. The CNO explained the facility completes a "Medication Occurrence Report". This Medication Occurrence Report was completed for Patient # 21 & 22. The CNO explained these were not included in the facility incident reporting system. A review of the Medication Occurrence Report for Patient #21 was conducted. The occurrence dates "08/1 & 08/2 2013" and the medication involved was "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the occurrences happened on the medical surgical floor, on the night shift on 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient, but did not cause patient harm."

The record for Patient #22 was reviewed at 4:25 p.m. The "Medication Occurrence Report" revealed the occurrence dates "08/1 & 08/2 2013 " and the medication involved was " Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the occurrences occurred on the medical surgical floor, on the night shift on 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

Each "Medication Occurrence Report" included 2 dates 08/01 and 08/02/2013. The RT, during an interview on 08/21/2013, verified these were for both error dates on 08/2/2013, indicating a lapse in time for reporting the 08/01/2013 error of omission for the respiratory treatments. The RT verified she completed the reports by stating: "Yes, I completed the reports and notified the Nursing Supervisor."

A review of the MAR for Patient # 21 revealed the inhalation administration of "Albuterol Atrovent dual neb every 8 hours" was blank (without entry) for the 2200 (10:00 p.m.) on 08/01/2013 and the 0600 (6:00 a.m.) doses.

The MAR review for Patient #22 included nurse initials the "duo neb (Albuterol Atrovent) q8 hours (every 8 hours)" was administered on 08/2/2013 at 10:00 p.m. and 6:00 a.m.

The Risk Manager (RM) designee was interviewed and commented these omission were not included as incidents. The RM designee commented the RT treatment processes has not been identified as a quality indicator for Quality Assurance Performance Improvement (QAPI). The CNO then commented the nurse was counseled and is on a human resource termination track. The CNO commented there is a concern regarding the incident and medical errors reporting and the follow up for QAPI indicators and identification.

4. A medication pass was conducted for Patient #6 on 08/20/2013 at 10:08 a.m. The record was requested post medication pass for review. At approximately 9:45 a.m. on 08/21/2013, the medical record was reviewed. The medication review and physician order review revealed discrepancies regarding physician pain medication orders and the Medication Administration Record (MAR). The following physician orders for pain medications were in the medical record presented at time of survey:
08/17/2013 at 2145 (9:45 p.m.)- Dilaudid 0.5 mg IV q4h (Every 4 hours) PRN (as needed) - telephone order
08/18/13 at 0045 (12:45 a.m.) Tylenol 500 mg po (by mouth) q 6 hours (every 6 hours) PRN HA (headache), D/C (discontinue) Morphine 2 mg (milligrams) IV- order noted at 0050 (12:50 a.m.)
08/19/13 at 1240 (12:40 p.m.) Percocet 5/325 q6 hrs (every 6 hours) PRN pain -Verbal order
08/19/13 at 2230 (10:30 p.m.) Give Percocet 5/325 mg po q4h PRN pain (frequency changed) -telephone order
MAR document contains:Tylenol 500 mg po q6 hr PRN - the HA for headache not included- Administered twice on 08/19/13- 0500 (5:00 a.m.) and 1130 (1130 a.m.).
Morphine - MS (morphine sulfate) 1 mg 1 q2 h PRN pain- Administered 08/17/13 -2000 (8:00 p.m.), 08/18/13- 1500 (3:00 p.m.) 08/18/13 2200 (10:00 p.m.). A review of the medical record revealed no orders written for morphine 1 milligram or 2 milligrams. There is a physician order to D/C morphine 2 mg on 8/18/13.
Percocet 5/325 mg po q 6 hrs PRN pain - Administered 08/19/13/at 1300 (1:00 p.m.), 08/19/13 at 1920 (7:20 p.m.), 08/20/13 at 2410 (Could indicate Military time for 12:10 a.m. 0010 would indicate 12:10 a.m. or 12:10 p.m.), 08/20/13 at 0350 (3:50 a.m.), and 08/20/13 at 1035 (10:35 a.m.). There is no entry on the MAR indicating the frequency change to every 4 hours as per the physician order dated 08/19/13 at 10:30 p.m.

The CNO was asked to review the record findings. The CNO confirmed the findings at 4:40 p.m. on 08/21/2013 stating: "You are right; I do not see the orders. "

Based on interviews and facility record reviews, the facility failed to provide a comprehensive Interdisciplinary (IDT) Care Plan including care planning information regarding diagnosis and condition for 4 ( Patient #1, #6, #7, and #12) of the 24 sampled patients.


Findings include:
1. An interview with the CNO (Chief Nursing Officer) was conducted at 12:00 noon on 08/21/2013. The CNO stated "Most are not using the IDT care Plan appropriately." The CNO commented the main concentration up to survey was dedicated to the Emergency Department (ED) to insure the proper administration of care in that department. The CNO explained the (ED) is much improved so that will allow time to concentration on nursing intervention and care applications. The CNO explained the nursing staff was informally trained regarding nursing care plans and the facility form entitled "Interdisciplinary Plan of Care". The CNO presented a sign in sheet for an in-service to the clinical staff entitled "How to Complete Forms". The training was completed from 08/1-08/07/13.

2. A review of the IDT plan of care for Patient #2 was conducted. Patient #2 has a history of diabetes and wounds, with previous toe amputations due to the disease. The IDT plan of care was reviewed and the skin breakdown problem was not addressed. The patient is currently receiving wound care and dressing changes at the facility.

3. A review of the IDT plan of care for Patient #6 was conducted. Patient #6 has a history of pain. The IDT plan of care was reviewed and the pain problem is identified, but is incomplete. The patient outcome criteria is not identified.

4. A review of the IDT plan of care for Patient #12 was reviewed. Patient #12 has a history of cardiac deficits and was admitted with hypertension. The IDT care plan identifies Fluid Balance, Circulation, and Safety problems. The plan of care does not include Activity intolerance which address the Heart Rate, Rhythm and BP (Blood pressure) or Neurological, which are stroke indicators.

Based on staff interview and facility record review the facility failed to provide medications and medical treatments according to the physician orders for 3 (Patient #6, 21 and 22) of the 24 Patient's sampled. The facility failed to appropriately and accurately provide written physician orders and transcription of physician orders for 1 (Patient #6) of the 1 sampled.
The facility failed to appropriately dispense and mix drugs for the population served on the medical surgical unit.

Findings include:
1. An interview was conducted with the Respiratory Therapist (RT) on 08/19/2013 at 12:45 p.m. The respiratory therapist explained she works day shift usually 8:00 a.m. - 5:00 p.m. Monday -Friday. The RT explained she is the manager of the department and stated "I am the only Respiratory Therapist in the hospital." The RT explained the continuum of care for respiratory therapy treatments. The RT explained she checks each patient record in the morning on arrival to the hospital. Then checks and documents the physician orders for each patient and new admission to the floor. The RT states "I see who has what every day." The RT explained she reviews the Medication Administration Record (MAR) to insure the treatments were administered during the night. The RT explained on each Monday she personally reviews the MARs to ensure accuracy of administration and transfer of the physician orders to the MAR. The RT explained the nurses are delegated to provide respiratory drug and treatment administration to the patients when she is not working. The RT was asked the procedure for reporting an error in the treatment administration. The RT explained she would verify the error and gather information then" report the occurrence to the CNO (Chief Nursing Officer)".

The Risk Management Designee was interviewed at 4:45 p.m. on 08/19/2013. The Risk designee commented the incident logs were in the conference room, but she did not recall any incident reports for medications.

A review of facility Incident /Occurrence forms was conducted on 08/20/2013. These reports did not indicate errors in medication/drug administration and omissions.

An interview with the CNO was conducted at 4:00 p.m. The CNO stated "Yes, I know there have been errors with respiratory treatments because I was involved with the follow up." The CNO commented she would check on this and return. At 4:16 p.m. the CNO returned with facility documents including personnel records. The CNO explained the facility completes a "Medication Occurrence Report". This Medication Occurrence Report was completed for Patient # 21 & 22. The CNO explained these were not included in the facility incident reporting system.

A review of the Medication Occurrence Report for Patient #21. The occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the omissions occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

The record for Patient #22 was reviewed at 4:25 p.m. The "Medication Occurrence Report" revealed the occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the occurrences occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

Each "Medication Occurrence Report " included 2 dates 08/01 and 08/02/2013. The RT, during an interview on 08/21/2013, verified these were for both error dates on 08/2/2013, indicating a lapse in time for reporting the 08/01/2013 error of omission for the respiratory treatments. The RT verified she completed the reports by stating "Yes, I completed the reports and notified the Nursing Supervisor."

A review of the MAR for Patient # 21 revealed the inhalation administration of "Albuterol Atrovent dual neb every 8 hours" was blank (without entry) for the 2200 (10:00 p.m.) on 08/01/2013 and the 0600 (6:00 a.m.) doses.

The MAR review for Patient #22 included nurse initials the "duo neb (Albuterol Atrovent) q8 hours (every 8 hours)" was administered on 08/2/2013 at 10:00 p.m. and 6:00 a.m.

The Risk Manager (RM) designee was interviewed and commented these omission were not included as incidents. The RM designee commented the RT treatment processes has not been identified as a quality indicator for Quality Assurance Performance Improvement (QAPI). The CNO then commented the nurse was counseled and is on a human resource termination track. The CNO commented there is a concern regarding the incident and medical errors reporting and the follow up for QAPI indicators and identification.

2. A medication pass was conducted for Patient #6 on 04/20/2013 at 10:08 a.m. The record was requested post medication pass for review. At approximately 9:45 a.m. on 08/21/2013, the medical record was reviewed. The medication review and physician order review revealed discrepancies regarding physician pain medication orders and the Medication Administration Record (MAR). The following physician orders for pain medications were in the medical record present at time of survey:
08/17/2013 at 2145 (9:45 p.m.)- Dilaudid 0.5 mg IV q4h (Every 4 hours) PRN (as needed) - telephone order
08/18/13 at 0045 (12:45 a.m.) Tylenol 500 mg po (by mouth) q 6 hours (every 6 hours) PRN HA (headache), D/C (discontinue) Morphine 2 mg (milligrams) IV- order noted at 0050 (12:50 a.m.)
08/19/13 at 1240 (12:40 p.m.) Percocet 5/325 q6 hrs (every 6 hours) PRN pain -Verbal order
08/19/13 at 2230 (10:30 p.m.) Give Percocet 5/325 mg po q4h PRN pain (frequency changed) -telephone order
MAR document contains:Tylenol 500 mg po q6 hr PRN - the HA for headache not included- Administered twice on 08/19/13- 0500 (5:00 a.m.) and 1130 (1130 a.m.).
Morphine - MS (morphine sulfate) 1 mg 1 q2 h PRN pain- Administered 08/17/13 -2000 (8:00 p.m.), 08/18/13- 1500 (3:00 p.m.) 08/18/13 2200 (10:00 p.m.). A review of the medical record revealed no orders written for morphine 1 milligram or 2 milligrams. There is a physician order to D/C morphine 2 mg on 8/18/13.
Percocet 5/325 mg po q 6 hrs PRN pain - Administered 08/19/13/at 1300 (1:00 p.m.), 08/19/13 at 1920 (7:20 p.m.), 08/20/13 at 2410 (Could indicate Military time for 12:10 a.m. 0010 would indicate 12:10 a.m. or 12:10 p.m.), 08/20/13 at 0350 (3:50 a.m.), and 08/20/13 at 1035 (10:35 a.m.). There is no entry on the MAR indicating the frequency change to every 4 hours as per the physician order dated 08/19/13 at 10:30 p.m.

The CNO was asked to review the record findings. The CNO confirmed the findings at 4:40 p.m. on 08/21/2013 stating "You are right; I do not see the orders. "
3. An interview with the CNO was conducted on 08/21/2013 at 12:00 noon. The CNO commented on the administration of drugs and medications. The CNO commented she was aware of the nursing staff "profiling and dispensing" the medications administered on the nursing floor. She continued to state "We have no stop gap for safety." The CNO continued there is not an appropriate mechanism for the pharmacist to provide the profiling (assuring there are no side effects or contraindications for the drugs ordered). The nurses obtain orders and are to fax to the pharmacist for profiling if the pharmacist is not in the building. The CNO commented the hiring of the Pharmacy technician will be a great asset to the facility and will assist to alleviate these problems. The Pharmacy Technician was hired last week according to the CNO. The CNO provided documentation of start date for the Pharmacy Technician. The CNO explained the nurse on the floor has access to the pharmacy 24/7 currently. The nurses are to remove the medications from the pharmacy as ordered and sign out the medication. The pharmacist then reviews these sign out sheets and reconciles the medication usage.
The CNO also stated "RNs (Registered Nurses) are mixing IV drugs at the cart (medication Cart)." The CNO explained the medication hood previously working was not available currently. This was confirmed with the observation of the medication pass for Patient #6. The Nurse was observed mixing Solumedrol for IV administration at the medication cart. The CNO commented this practice will change with the Pharmacist and the Pharmacy Tech (technician) on board. The CNO commented the Pharmacist is in negotiation with the hospital for full time employment. The CNO explained the Pharmacist is hired on a consultant basis currently.

Based on staff interview and facility record review the facility failed to ensure a reporting and monitoring procedure for errors or omissions in the administration of drugs.

Findings include:

1. An interview was conducted with the Respiratory Therapist (RT) on 08/19/2013 at 12:45 p.m. The respiratory therapist explained she works day shift usually 8:00 a.m. - 5:00 p.m. Monday -Friday. The RT explained she is the manager of the department and stated "I am the only Respiratory Therapist in the hospital." The RT explained the continuum of care for respiratory therapy treatments. The RT explained she checks each patient record in the morning on arrival to the hospital. Then checks and documents the physician orders for each patient and new admission to the floor. The RT states "I see who has what every day." The RT explained she reviews the Medication Administration Record (MAR) to insure the treatments were administered during the night. The RT explained on each Monday she personally reviews the MARs to ensure accuracy of administration and transfer of the physician orders to the MAR. The RT explained the nurses are delegated to provide respiratory drug and treatment administration to the patients when she is not working. The RT was asked the procedure for reporting an error in the treatment administration. The RT explained she would verify the error and gather information then" report the occurrence to the CNO (Chief Nursing Officer)".

The Risk Management Designee was interviewed at 4:45 p.m. on 08/19/2013. The Risk designee commented the incident logs were in the conference room, but she did not recall any incident reports for medications.

A review of facility Incident /Occurrence forms was conducted on 08/20/2013. These reports did not indicate errors in medication/drug administration and omissions.

An interview with the CNO was conducted at 4:00 p.m. The CNO stated "Yes, I know there have been errors with respiratory treatments because I was involved with the follow up." The CNO commented she would check on this and return. At 4:16 p.m. the CNO returned with facility documents including personnel records. The CNO explained the facility completes a "Medication Occurrence Report". This Medication Occurrence Report was completed for Patient # 21 & 22. The CNO explained these were not included in the facility incident reporting system.

A review of the Medication Occurrence Report for Patient #21. The occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the omissions occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

The record for Patient #22 was reviewed at 4:25 p.m. The "Medication Occurrence Report" revealed the occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the occurrences occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

Each "Medication Occurrence Report " included 2 dates 08/01 and 08/02/2013. The RT, during an interview on 08/21/2013, verified these were for both error dates on 08/2/2013, indicating a lapse in time for reporting the 08/01/2013 error of omission for the respiratory treatments. The RT verified she completed the reports by stating "Yes, I completed the reports and notified the Nursing Supervisor."

A review of the MAR for Patient # 21 revealed the inhalation administration of "Albuterol Atrovent dual neb every 8 hours" was blank (without entry) for the 2200 (10:00 p.m.) on 08/01/2013 and the 0600 (6:00 a.m.) doses.

The MAR review for Patient #22 included nurse initials the "duo neb (Albuterol Atrovent) q8 hours (every 8 hours)" was administered on 08/2/2013 at 10:00 p.m. and 6:00 a.m.

The Risk Manager (RM) designee was interviewed and commented these omission were not included as incidents. The RM designee commented the RT treatment processes has not been identified as a quality indicator for Quality Assurance Performance Improvement (QAPI). The CNO then commented the nurse was counseled and is on a human resource termination track. The CNO commented there is a concern regarding the incident and medical errors reporting and the follow up for QAPI indicators and identification.


2. A medication pass was conducted for Patient #6 on 04/20/2013 at 10:08 a.m. The record was requested post medication pass for review. At approximately 9:45 a.m. on 08/21/2013, the medical record was reviewed. The medication review and physician order review revealed discrepancies regarding physician pain medication orders and the Medication Administration Record (MAR). The following physician orders for pain medications were in the medical record present at time of survey:
08/17/2013 at 2145 (9:45 p.m.)- Dilaudid 0.5 mg IV q4h (Every 4 hours) PRN (as needed) - telephone order
08/18/13 at 0045 (12:45 a.m.) Tylenol 500 mg po (by mouth) q 6 hours (every 6 hours) PRN HA (headache), D/C (discontinue) Morphine 2 mg (milligrams) IV- order noted at 0050 (12:50 a.m.)
08/19/13 at 1240 (12:40 p.m.) Percocet 5/325 q6 hrs (every 6 hours) PRN pain -Verbal order
08/19/13 at 2230 (10:30 p.m.) Give Percocet 5/325 mg po q4h PRN pain (frequency changed) -telephone order
MAR document contains:Tylenol 500 mg po q6 hr PRN - the HA for headache not included- Administered twice on 08/19/13- 0500 (5:00 a.m.) and 1130 (1130 a.m.).
Morphine - MS (morphine sulfate) 1 mg 1 q2 h PRN pain- Administered 08/17/13 -2000 (8:00 p.m.), 08/18/13- 1500 (3:00 p.m.) 08/18/13 2200 (10:00 p.m.). A review of the medical record revealed no orders written for morphine 1 milligram or 2 milligrams. There is a physician order to D/C morphine 2 mg on 8/18/13.
Percocet 5/325 mg po q 6 hrs PRN pain - Administered 08/19/13/at 1300 (1:00 p.m.), 08/19/13 at 1920 (7:20 p.m.), 08/20/13 at 2410 (Could indicate Military time for 12:10 a.m. 0010 would indicate 12:10 a.m. or 12:10 p.m.), 08/20/13 at 0350 (3:50 a.m.), and 08/20/13 at 1035 (10:35 a.m.). There is no entry on the MAR indicating the frequency change to every 4 hours as per the physician order dated 08/19/13 at 10:30 p.m.

The CNO was asked to review the record findings. The CNO confirmed the findings at 4:40 p.m. on 08/21/2013 stating "You are right; I do not see the orders. "

Based on staff interviews and facility document review, the facility failed to ensure that medications profiles are performed and medication orders are reviewed by a licensed pharmacist before being administered to the patient. The facility failed to develop and implement pharmacy policy and procedures. The facility failed to exercise control of entry of non-pharmacy staff into the pharmacy when pharmacy staff is not present.

Findings

1 .Reference A0491 Based on staff interviews and facility document review, the facility failed to ensure the safe and appropriate uses of medications for all inpatients .Failure to development and implement pharmacy policy and procedures places patients at risk of not receiving safe and effective medications.

2. Reference A0492 Based on staff interview and record review, the pharmacist failed to ensure that medication profiles are developed and that medication orders are reviewed prior to dispensing and administration on all inpatients.

3. Reference A0500 Based on staff interview and observation, the facility failed to ensure that medications have are adequately controlled and distributed to provide for patient safety.

4. Reference A0504 Based on staff interviews and facility record review, the facility failed to ensure that only authorized personnel have access to the pharmacy.

5. Reference A0506 Based on staff interviews and facility record review, the facility failed to ensure that only authorized personnel have access to the pharmacy when the pharmacist is not in the facility.

Based on staff interviews and facility document review, the facility failed to ensure the safe and appropriate uses of medications for all inpatients. Failure to development and implement pharmacy policy and procedures places patients at risk of not receiving safe and effective medications.

Findings:

Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the pharmacy is currently operating without the guidance of written and approved policy and procedures. The Director of Pharmacy stated that she is working on new policy and procedures, but does not know when the will be completed and approved. When asked how she knows how to perform her functions as a director she stated that she applies the same principles as she does at CVS in Crystal River where she is employed as s full-time manager. The Director of Pharmacy stated that she also was the consultant Pharmacist for 2 ambulatory surgery centers in Citrus county.

Interview with the inpatient Registered Nurse (RN) on 08/01/2011 at 8:15 AM revealed when asked what do you do when you have a new admission and the pharmacist is not in the facility the nurse stated the following: E-mail the physician orders to the pharmacist; take the medication orders and write them on the Medication Administration Record, (MAR). I would then go to the pharmacy and sign them out and give them to the patient. If any medications could not be found in the pharmacy, I would ask the patient if they had their medications with them or could someone bring them in. Asked if the pharmacist reviewed the orders prior to administration, the nurse stated "no" sometimes she will E-mail back, but "I never wait before giving the medications." When asked how she knows if the medications ordered are safe to administer, she stated that she can look them up. When asked if there were any pharmacy policy and procedures to guide her, she stated "no".

Based on staff interview and record review, the pharmacist failed to ensure that medication profiles are developed and that medication orders are reviewed prior to dispensing and administration on all inpatients.

Findings:

1. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the pharmacy is currently operating without the guidance of written and approved policy and procedures. The Director of Pharmacy stated that she is working on new policy and procedures, but does not know when the will be completed and approved. When asked how she knows how to perform her functions as a director, she stated that he applies the same principles as she does at CVS in Crystal River where she is employed as a full-time manager. The Director of Pharmacy stated that she also was the consultant Pharmacist for 2 ambulatory surgery centers in Citrus county.


2. Interview with the inpatient Registered Nurse (RN) on 08/01/2011 at 8:15 AM revealed when asked what do you do when you have a new admission and the pharmacist is not in the facility the nurse stated the following: E-mail the physician orders to the pharmacist; take the medication orders and write them on the Medication Administration Record, (MAR). I would then go to the pharmacy and sign them out and give them to the patient. If any medications could not be found in the pharmacy, I would ask the patient if they had their medications with them or could someone bring them in. Asked if the pharmacist reviewed the orders prior to administration, the nurse stated "no" sometimes she will E-mail back, but "I never wait before giving the medications." When asked how she knows if the medications ordered are safe to administer, she stated that she can look them up. When asked if there were any pharmacy policy and procedures to guide her, she stated "no".

3. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy was conducted. When asked if she develops a medication profile on all inpatients receiving medications, she stated that she updated the profiles when she was last in the facility. She stated that she comes in when she was not working at CVS. She stated that she works two days a week, splitting time working at home 4 hours and at the facility for 12 hours.

4. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the floor nurse had a key to the pharmacy and, when needed, could come in the pharmacy and obtain medications for the patients. The nurse is to sign out any medications taken from the pharmacy. When asked if the sign out sheet were reviewed and compared to the patient records, she stated that they were not, but that would be one of the functions of the newly hired pharmacy technician. When asked if there was a system in place to determine if medications were missing from the inventory, she stated that unless it is very obvious or high cost medications, she could not tell if medications were missing from the pharmacy. When asked if there was a policy and procedure for pharmacy staff removing medication from the pharmacy she stated that she did not know of one.

5. Observation on 08/20/2013 at 9:50 AM revealed that Registered Nurse (RN) 1 entered the pharmacy twice during the interview with the contracted pharmacist. Both times, the nurse went to the shelves where medications are kept and removed several medications form the boxes they are stored in. At that time, the medications removed were checked against the label on the box. None of the medications were signed out. Interview with RN 1 on 08/20/2013 at 10:15 AM revealed that she did not sign out the medications and she stated that she would mark the medication billing form and return the form to the pharmacy so that the hospital could bill for the medication.

6. Review of the "CONTRACT FOR SERVICES" dated 02/20/2013 revealed under "Contractor agrees to perform the following services for Hospital:" -"Perform all functions that a Director of Pharmacy would perform at a facility of similar size and similar location. Contractor acknowledges that the hospital is currently undergoing a turnaround and faces numerous challenges. She undertakes to assist management in ensuring that the nursing care provided meets or exceeds the highest standards of pharmacy care. In addition Contractor will also perform work assigned by the hospital management form time to time. Contractor will perform the services as mutual agreed upon with Hospital Management."

Review of the contract does not provide any specific duties guidelines as related to developing and maintaining patient medication profiles or reviewing medications orders prior to administration of the medications.

7. An interview was conducted with the Respiratory Therapist (RT) on 08/19/2013 at 12:45 p.m. The respiratory therapist explained she works day shift usually 8:00 a.m. - 5:00 p.m. Monday -Friday. The RT explained she is the manager of the department and stated "I am the only Respiratory Therapist in the hospital." The RT explained the continuum of care for respiratory therapy treatments. The RT explained she checks each patient record in the morning on arrival to the hospital. Then checks and documents the physician orders for each patient and new admission to the floor. The RT states "I see who has what every day." The RT explained she reviews the Medication Administration Record (MAR) to insure the treatments were administered during the night. The RT explained on each Monday she personally reviews the MARs to ensure accuracy of administration and transfer of the physician orders to the MAR. The RT explained the nurses are delegated to provide respiratory drug and treatment administration to the patients when she is not working. The RT was asked the procedure for reporting an error in the treatment administration. The RT explained she would verify the error and gather information then" report the occurrence to the CNO (Chief Nursing Officer)".

The Risk Management Designee was interviewed at 4:45 p.m. on 08/19/2013. The Risk designee commented the incident logs were in the conference room, but she did not recall any incident reports for medications.

A review of facility Incident /Occurrence forms was conducted on 08/20/2013. These reports did not indicate errors in medication/drug administration and omissions.

An interview with the CNO was conducted at 4:00 p.m. The CNO stated "Yes, I know there have been errors with respiratory treatments because I was involved with the follow up." The CNO commented she would check on this and return. At 4:16 p.m. the CNO returned with facility documents including personnel records. The CNO explained the facility completes a "Medication Occurrence Report". This Medication Occurrence Report was completed for Patient # 21 & 22. The CNO explained these were not included in the facility incident reporting system.

A review of the Medication Occurrence Report for Patient #21. The occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the omissions occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

The record for Patient #22 was reviewed at 4:25 p.m. The "Medication Occurrence Report" revealed the occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the occurrences occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

Each "Medication Occurrence Report " included 2 dates 08/01 and 08/02/2013. The RT, during an interview on 08/21/2013, verified these were for both error dates on 08/2/2013, indicating a lapse in time for reporting the 08/01/2013 error of omission for the respiratory treatments. The RT verified she completed the reports by stating "Yes, I completed the reports and notified the Nursing Supervisor."

A review of the MAR for Patient # 21 revealed the inhalation administration of "Albuterol Atrovent dual neb every 8 hours" was blank (without entry) for the 2200 (10:00 p.m.) on 08/01/2013 and the 0600 (6:00 a.m.) doses.

The MAR review for Patient #22 included nurse initials the "duo neb (Albuterol Atrovent) q8 hours (every 8 hours)" was administered on 08/2/2013 at 10:00 p.m. and 6:00 a.m.

The Risk Manager (RM) designee was interviewed and commented these omission were not included as incidents. The RM designee commented the RT treatment processes has not been identified as a quality indicator for Quality Assurance Performance Improvement (QAPI). The CNO then commented the nurse was counseled and is on a human resource termination track. The CNO commented there is a concern regarding the incident and medical errors reporting and the follow up for QAPI indicators and identification.

Interview with the contracted pharmacist on 08/21/2013 at 10:30 AM revealed that she was not aware of any Respiratory medications not administered and was not involved in the investigation.

8. An interview with the CNO was conducted on 08/21/2013 at 12:00 noon. The CNO commented on the administration of drugs and medications. The CNO commented she was aware of the nursing staff "profiling and dispensing" the medications administered on the nursing floor. She continued to state "We have no stop gap for safety." The CNO continued there is not an appropriate mechanism for the pharmacist to provide the profiling (assuring there are no side effects or contraindications for the drugs ordered). The nurses obtain orders and are to fax to the pharmacist for profiling if the pharmacist is not in the building. The CNO commented the hiring of the Pharmacy technician will be a great asset to the facility and will assist to alleviate these problems. The Pharmacy Technician was hired last week according to the CNO. The CNO provided documentation of start date for the Pharmacy Technician. The CNO explained the nurse on the floor has access to the pharmacy 24/7 currently. The nurses are to remove the medications from the pharmacy as ordered and sign out the medication. The pharmacist then reviews these sign out sheets and reconciles the medication usage.
The CNO also stated "RN's are mixing IV drugs at the cart (medication Cart)." The CNO explained the medication hood previously working was not available currently. This was confirmed with the observation of the medication pass for Patient #6. The Nurse was observed mixing Solumedrol for IV administration at the medication cart. The CNO commented this practice will change with the Pharmacist and the Pharmacy Tech (technician) on board.
The CNO commented the Pharmacist is in negotiation with the hospital for full time employment. The CNO explained the Pharmacist is hired on a consultant basis currently.

Based on staff interview and observation the facility failed to ensure that medications have are adequately controlled and distributed to provide for patient safety.

Findings:

1. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the pharmacy is currently operating without the guidance of written and approved policy and procedures. The Director of Pharmacy stated that she is working on new policy and procedures but does not know when the will be completed and approved. When asked how she knows how to perform her functions as a director she stated that she applies the same principles as she does at CVS in Crystal River where she is employed as a full-time manager. The Director of Pharmacy stated that she also was the consultant Pharmacist for 2 ambulatory surgery centers in Citrus county.

2. Interview with the inpatient Registered Nurse (RN) on 08/01/2011 at 8:15 AM revealed when asked what do you do when you have a new admission and the pharmacist is not in the facility the nurse stated the following: E-mail the physician orders to the pharmacist, take the medication orders and write them on the Medication Administration Record, (MAR). I would then go to the pharmacy and sign them out and give them to the patient. If any medications could not be found in the pharmacy, I would ask the patient if they had their medications with them or could someone bring them in. When asked if the pharmacist reviewed the orders prior to administration, the nurse stated "no" sometimes she will E-mail back, but that "I never wait before giving the medications." When asked how she knows if the medications ordered are safe to administer, she stated that she can look them up. When asked if there were any pharmacy policy and procedures to guide her, she stated "no."


3. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the pharmacy is currently operating without the guidance of written and approved policy and procedures. The Director of Pharmacy stated that she is working on new policy and procedures, but does not know when they will be completed and approved. When asked if she develops a medication profile on all inpatients receiving medications, she stated that she updated the profile when she was in the facility. She stated that she would come in when she was not working at CVS. She stated that she worked two days a week, splitting time working at home 4 hours and at the facility for 12 hours.

4. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the floor nurse had a key to the pharmacy and when needed could come in the pharmacy and obtain medications for the patients. The nurse is to sign out any medications taken from the pharmacy. When asked if the sign out sheet were reviewed and compared to the patient records, she stated that they were not, but that would be one of the functions of the newly hired pharmacy technician. When asked if there was a system in place to determine if medications were missing from the inventory, she stated that unless it is very obvious or high cost medications, she could not tell if medications were missing from the pharmacy. When asked if there was a policy and procedure for non- pharmacy staff removing medication from the pharmacy she stated that she did not know of one.

5. Observation on 08/20/2013 at 9:50 AM revealed that Registered Nurse (RN) 1 entered the pharmacy twice during the interview with the contracted pharmacist. Both times, the nurse went to the shelves where medications are kept and removed several medications from the boxes they are stored in. At this time, the medications removed were checked against the label on the box. None of the medications were signed out. Interview with the RN 1 on 08/20/2013 at 10:15 AM revealed that she did not sign out the medications and she stated that she would mark the medication billing form and return the form to the pharmacy so that the hospital could bill for the medication.


6. Review of the "CONTRACT FOR SERVICES" dated 02/20/2013 revealed under "Contractor agrees to perform the following services for Hospital:" "Perform all functions that a Director of Pharmacy would perform at a facility of similar size and similar location. Contractor acknowledges that the hospital is currently undergoing a turnaround and faces numerous challenges. She undertakes to assist management in ensuring that the nursing care provided meets or exceeds the highest standards of pharmacy care. In addition Contractor will also perform work assigned by the hospital management form time to time. Contractor will perform the services as mutual agreed upon with Hospital Management."

Review of the contract does not provide any specific duties guidelines as related to developing and maintaining patient medication profiles or reviewing medications orders prior to administration of the medications.

7. An interview was conducted with the Respiratory Therapist (RT) on 08/19/2013 at 12:45 p.m. The respiratory therapist explained she works day shift usually 8:00 a.m. - 5:00 p.m. Monday -Friday. The RT explained she is the manager of the department and stated "I am the only Respiratory Therapist in the hospital." The RT explained the continuum of care for respiratory therapy treatments. The RT explained she checks each patient record in the morning on arrival to the hospital. Then checks and documents the physician orders for each patient and new admission to the floor. The RT states "I see who has what every day." The RT explained she reviews the Medication Administration Record (MAR) to insure the treatments were administered during the night. The RT explained on each Monday she personally reviews the MARs to ensure accuracy of administration and transfer of the physician orders to the MAR. The RT explained the nurses are delegated to provide respiratory drug and treatment administration to the patients when she is not working. The RT was asked the procedure for reporting an error in the treatment administration. The RT explained she would verify the error and gather information then" report the occurrence to the CNO (Chief Nursing Officer)".

The Risk Management Designee was interviewed at 4:45 p.m. on 08/19/2013. The Risk designee commented the incident logs were in the conference room, but she did not recall any incident reports for medications.

A review of facility Incident /Occurrence forms was conducted on 08/20/2013. These reports did not indicate errors in medication/drug administration and omissions.

An interview with the CNO was conducted at 4:00 p.m. The CNO stated "Yes, I know there have been errors with respiratory treatments because I was involved with the follow up." The CNO commented she would check on this and return. At 4:16 p.m. the CNO returned with facility documents including personnel records. The CNO explained the facility completes a "Medication Occurrence Report". This Medication Occurrence Report was completed for Patient # 21 & 22. The CNO explained these were not included in the facility incident reporting system.

A review of the Medication Occurrence Report for Patient #21. The occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the omissions occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

The record for Patient #22 was reviewed at 4:25 p.m. The "Medication Occurrence Report" revealed the occurrence dates "08/1 & 08/2 2013 " The medication involved "Duoneb Inh (Duoneb- medication Inh- inhaler). The documentation reveals the occurrences occurred on the medical surgical floor, on the night shift. On 08/1/2013 at 2200 (10:00 p.m.) and 08/2/2013 at 0600 (6:00 a.m.). The form was completed by the RT on 08/2/2013. The "Problem Code" is identified as "Omission". The "Outcome Codes" was identified as "An error occurred the reached the patient but did not cause patient harm."

Each "Medication Occurrence Report " included 2 dates 08/01 and 08/02/2013. The RT, during an interview on 08/21/2013, verified these were for both error dates on 08/2/2013, indicating a lapse in time for reporting the 08/01/2013 error of omission for the respiratory treatments. The RT verified she completed the reports by stating "Yes, I completed the reports and notified the Nursing Supervisor."

A review of the MAR for Patient # 21 revealed the inhalation administration of "Albuterol Atrovent dual neb every 8 hours" was blank (without entry) for the 2200 (10:00 p.m.) on 08/01/2013 and the 0600 (6:00 a.m.) doses.

The MAR review for Patient #22 included nurse initials the "duo neb (Albuterol Atrovent) q8 hours (every 8 hours)" was administered on 08/2/2013 at 10:00 p.m. and 6:00 a.m.

The Risk Manager (RM) designee was interviewed and commented these omission were not included as incidents. The RM designee commented the RT treatment processes has not been identified as a quality indicator for Quality Assurance Performance Improvement (QAPI). The CNO then commented the nurse was counseled and is on a human resource termination track. The CNO commented there is a concern regarding the incident and medical errors reporting and the follow up for QAPI indicators and identification.

Interview with the contracted pharmacist on 08/21/2013 at 10:30 AM revealed that she was not aware of any Respiratory medications not administered and was not involved in the investigation.


8. A medication pass was conducted for Patient #6 on 04/20/2013 at 10:08 a.m. The record was requested post medication pass for review. At approximately 9:45 a.m. on 08/21/2013, the medical record was reviewed. The medication review and physician order review revealed discrepancies regarding physician pain medication orders and the Medication Administration Record (MAR). The following physician orders for pain medications were in the medical record present at time of survey:
08/17/2013 at 2145 (9:45 p.m.)- Dilaudid 0.5 mg IV q4h (Every 4 hours) PRN (as needed) - telephone order
08/18/13 at 0045 (12:45 a.m.) Tylenol 500 mg po (by mouth) q 6 hours (every 6 hours) PRN HA (headache), D/C (discontinue) Morphine 2 mg (milligrams) IV- order noted at 0050 (12:50 a.m.)
08/19/13 at 1240 (12:40 p.m.) Percocet 5/325 q6 hrs (every 6 hours) PRN pain -Verbal order
08/19/13 at 2230 (10:30 p.m.) Give Percocet 5/325 mg po q4h PRN pain (frequency changed) -telephone order
MAR document contains:Tylenol 500 mg po q6 hr PRN - the HA for headache not included- Administered twice on 08/19/13- 0500 (5:00 a.m.) and 1130 (1130 a.m.).
Morphine - MS (morphine sulfate) 1 mg 1 q2 h PRN pain- Administered 08/17/13 -2000 (8:00 p.m.), 08/18/13- 1500 (3:00 p.m.) 08/18/13 2200 (10:00 p.m.). A review of the medical record revealed no orders written for morphine 1 milligram or 2 milligrams. There is a physician order to D/C morphine 2 mg on 8/18/13.
Percocet 5/325 mg po q 6 hrs PRN pain - Administered 08/19/13/at 1300 (1:00 p.m.), 08/19/13 at 1920 (7:20 p.m.), 08/20/13 at 2410 (Could indicate Military time for 12:10 a.m. 0010 would indicate 12:10 a.m. or 12:10 p.m.), 08/20/13 at 0350 (3:50 a.m.), and 08/20/13 at 1035 (10:35 a.m.). There is no entry on the MAR indicating the frequency change to every 4 hours as per the physician order dated 08/19/13 at 10:30 p.m.

The CNO was asked to review the record findings. The CNO confirmed the findings at 4:40 p.m. on 08/21/2013 stating "You are right; I do not see the orders. "
9. An interview with the CNO was conducted on 08/21/2012 at 12:00 noon. The CNO commented on the administration of drugs and medications. The CNO commented she was aware of the nursing staff "profiling and dispensing" the medications administered on the nursing floor. She continued to state "We have no stop gap for safety." The CNO continued there is not an appropriate mechanism for the pharmacist to provide the profiling (assuring there are no side effects or contraindications for the drugs ordered). The nurses obtain orders and are to fax to the pharmacist for profiling if the pharmacist is not in the building. The CNO commented the hiring of the Pharmacy technician will be a great asset to the facility and will assist to alleviate these problems. The Pharmacy Technician was hired last week according to the CNO. The CNO provided documentation of start date for the Pharmacy Technician. The CNO explained the nurse on the floor has access to the pharmacy 24/7 currently. The nurses are to remove the medications from the pharmacy as ordered and sign out the medication. The pharmacist then reviews these sign out sheets and reconciles the medication usage.
The CNO also stated "RN's are mixing IV drugs at the cart (medication Cart)." The CNO explained the medication hood previously working was not available currently. This was confirmed with the observation of the medication pass for Patient #6. The Nurse was observed mixing Solumedrol for IV administration at the medication cart. The CNO commented this practice will change with the Pharmacist and the Pharmacy Tech (technician) on board.
The CNO commented the Pharmacist is in negotiation with the hospital for full time employment. The CNO explained the Pharmacist is hired on a consultant basis currently.
The facility failed to prepare and monitor medication administration as ordered by the physician.

Based on staff interviews and facility record review, the facility failed to ensure that only authorized personnel have access to the pharmacy.

Findings:

1. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the pharmacy is currently operating without the guidance of written and approved policy and procedures. The Director of Pharmacy stated that she is working on new policy and procedures,but does not know when the will be completed and approved. When asked how she knows how to perform her functions as a director she stated that he applies the same principles as she does at CVS in Crystal River where she is employed as a full-time manager. The Director of Pharmacy stated that she also was the consultant Pharmacist for 2 ambulatory surgery centers in Citrus county.

2. Interview with the inpatient Registered Nurse (RN) on 08/01/2011 at 8:15 AM revealed when asked what do you do when you have a new admission and the pharmacist is not in the facility the nurse stated the following: E-mail the physician orders to the pharmacist, take the medication orders and write them on the Medication Administration Record, (MAR). I would then go to the pharmacy and sign them out and give them to the patient. If any medications could not be found in the pharmacy, I would ask the patient if they had their medications with them or could someone bring them in. When asked if the pharmacist reviewed the orders prior to administration, the nurse stated "no" sometimes she will E-mail back, but that "I never wait before giving the medications." When asked how she knows if the medications ordered are safe to administer, she stated that she can look them up. When asked if there were any pharmacy policy and procedures to guide her, she stated "no."


3. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the floor nurse had a key to the pharmacy and when needed could come in pharmacy and obtain medications for the patients. The nurse is to sign out any medications taken from the pharmacy. When asked if the sign out sheet were reviewed and compared to the patient records, she stated that they were not, but that would be one of the functions of the newly hired pharmacy technician. When asked if there was a system in place to determine if medications were missing from the inventory, she stated that unless it is very obvious or high cost medications, she could not tell if medications were missing from the pharmacy. When asked if there was a policy and procedure for non- pharmacy staff removing medication from the pharmacy she stated that he did not know of one.

4. Observation on 08/20/2013 at 9:50 AM revealed that RN 1 entered the pharmacy twice during the interview with the contracted pharmacist. Both times, the nurse went to the shelves where medications are kept and removed several medications form the boxes they are stored in. At this time, the medications removed were checked against the label on the box. None of the medications were signed out. Interview with the RN 1 on 08/20/2013 at 10:15 AM revealed that she did not sign out the medications and she stated that she would mark the medication billing form and return the form to the pharmacy so that the hospital could bill for the medication.

5. An interview with the CNO was conducted on 08/21/2012 at 12:00 noon. The CNO commented on the administration of drugs and medications. The CNO commented she was aware of the nursing staff "profiling and dispensing" the medications administered on the nursing floor. She continued to state "We have no stop gap for safety." The CNO continued there is not an appropriate mechanism for the pharmacist to provide the profiling (assuring there are no side effects or contraindications for the drugs ordered). The nurses obtain orders and are to fax to the pharmacist for profiling if the pharmacist is not in the building. The CNO commented the hiring of the Pharmacy technician will be a great asset to the facility and will assist to alleviate these problems. The Pharmacy Technician was hired last week according to the CNO. The CNO provided documentation of start date for the Pharmacy Technician. The CNO explained the nurse on the floor has access to the pharmacy 24/7 currently. The nurses are to remove the medications from the pharmacy as ordered and sign out the medication. The pharmacist then reviews these sign out sheets and reconciles the medication usage.
The CNO also stated "RN's are mixing IV drugs at the cart (medication Cart)." The CNO explained the medication hood previously working was not available currently. This was confirmed with the observation of the medication pass for Patient #6. The Nurse was observed mixing Solumedrol for IV administration at the medication cart. The CNO commented this practice will change with the Pharmacist and the Pharmacy Tech (technician) on board.
The CNO commented the Pharmacist is in negotiation with the hospital for full time employment. The CNO explained the Pharmacist is hired on a consultant basis currently.

6. Observation on 08/21/2013 at 8:00 AM revealed that staff nurse 1 revealed that she had her medication cart propping the pharmacy door open while she was obtaining the medications for her morning medication pass for all her patients. When asked about the practice of propping the door and stocking the cart with medications, she stated it was easier that going in the pharmacy to for each patient.

Based on staff interviews and facility record review the facility failed to ensure that only authorized personnel have access to the pharmacy when the pharmacist is not in the facility.

Findings:

1. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the pharmacy is currently operating without the guidance of written and approved policy and procedures. The Director of Pharmacy stated that she is working on new policy and procedures,but does not know when the will be completed and approved. When asked how she knows how to perform her functions as a director she stated that he applies the same principles as she does at CVS in Crystal River where she is employed as a full-time manager. The Director of Pharmacy stated that she also was the consultant Pharmacist for 2 ambulatory surgery centers in Citrus county.

2. Interview with the inpatient Registered Nurse (RN) on 08/01/2011 at 8:15 AM revealed when asked what do you do when you have a new admission and the pharmacist is not in the facility the nurse stated the following: E-mail the physician orders to the pharmacist, take the medication orders and write them on the Medication Administration Record, (MAR). I would then go to the pharmacy and sign them out and give them to the patient. If any medications could not be found in the pharmacy, I would ask the patient if they had their medications with them or could someone bring them in. When asked if the pharmacist reviewed the orders prior to administration, the nurse stated "no" sometimes she will E-mail back, but that "I never wait before giving the medications." When asked how she knows if the medications ordered are safe to administer, she stated that she can look them up. When asked if there were any pharmacy policy and procedures to guide her, she stated "no."


3. Interview on 08/20/2013 at 9:50 AM of the contacted Director of Pharmacy revealed that the floor nurse had a key to the pharmacy and when needed could come in pharmacy and obtain medications for the patients. The nurse is to sign out any medications taken from the pharmacy. When asked if the sign out sheet were reviewed and compared to the patient records, she stated that they were not, but that would be one of the functions of the newly hired pharmacy technician. When asked if there was a system in place to determine if medications were missing from the inventory, she stated that unless it is very obvious or high cost medications, she could not tell if medications were missing from the pharmacy. When asked if there was a policy and procedure for non- pharmacy staff removing medication from the pharmacy she stated that he did not know of one.

4. Observation on 08/20/2013 at 9:50 AM revealed that RN 1 entered the pharmacy twice during the interview with the contracted pharmacist. Both times, the nurse went to the shelves where medications are kept and removed several medications form the boxes they are stored in. At this time, the medications removed were checked against the label on the box. None of the medications were signed out. Interview with the RN 1 on 08/20/2013 at 10:15 AM revealed that she did not sign out the medications and she stated that she would mark the medication billing form and return the form to the pharmacy so that the hospital could bill for the medication.

5. An interview with the CNO was conducted on 08/21/2012 at 12:00 noon. The CNO commented on the administration of drugs and medications. The CNO commented she was aware of the nursing staff "profiling and dispensing" the medications administered on the nursing floor. She continued to state "We have no stop gap for safety." The CNO continued there is not an appropriate mechanism for the pharmacist to provide the profiling (assuring there are no side effects or contraindications for the drugs ordered). The nurses obtain orders and are to fax to the pharmacist for profiling if the pharmacist is not in the building. The CNO commented the hiring of the Pharmacy technician will be a great asset to the facility and will assist to alleviate these problems. The Pharmacy Technician was hired last week according to the CNO. The CNO provided documentation of start date for the Pharmacy Technician. The CNO explained the nurse on the floor has access to the pharmacy 24/7 currently. The nurses are to remove the medications from the pharmacy as ordered and sign out the medication. The pharmacist then reviews these sign out sheets and reconciles the medication usage.
The CNO also stated "RN's are mixing IV drugs at the cart (medication Cart)." The CNO explained the medication hood previously working was not available currently. This was confirmed with the observation of the medication pass for Patient #6. The Nurse was observed mixing Solumedrol for IV administration at the medication cart. The CNO commented this practice will change with the Pharmacist and the Pharmacy Tech (technician) on board.
The CNO commented the Pharmacist is in negotiation with the hospital for full time employment. The CNO explained the Pharmacist is hired on a consultant basis currently.

6. Observation on 08/21/2013 at 8:00 AM revealed that staff nurse 1 revealed that she had her medication cart propping the pharmacy door open while she was obtaining the medications for her morning medication pass for all her patients. When asked about the practice of propping the door and stocking the cart with medications, she stated it was easier that going in the pharmacy to for each patient.

7. Interview with staff nurse 1 revealed that the facility has two sets of keys for the medication cart so that when two nurses are on duty at the same time both could have their own key. She stated that when only one nurse is on the second set of keys are locked in the cart. When asked what is to prevent a nurse from having a copy of the second set made without anyone knowing, she stated "nothing."

Based on observation, staff interview, and facility record review, the facility failed to develop an infection control program which investigates, reports, and prevents infections for staff, community visitors and patient populations. The facility failed to provide a program to monitor, measure and evaluate infection control interventions and implementations. The facility failed to maintain infection control practices in the kitchen and food preparation areas to prevent the potential for food borne illness.

Findings include:

1. A tour of the facility was conducted on 08/19/2013 at 10:00 a.m. The tour included an equipment room and a medical supply room located next to the nurses' station. The medical supply room contained metal shelving units. The units were observed stacked with clean medical supplies such as gauze, and other wound dressings. On a lower shelf, a washcloth was observed in a wad like fashion with brown discoloration. A bottle of iodofoam gauze (used for wound packing) lot # 1100018662 was observed as previously open and expired on 06/2013. Staff Nurse #6 was interviewed and commented the wash cloth should not be there and would be removed. The nurse commented the iodofoam gauze should have been discarded after use.
The equipment storage room contained Intravenous (IV) poles (Metal pole used to hold IV pumps and IV solution bags). One pole was observed with a pump covered with a plastic bag. The IV pole with the covered pump was observed with rust like material on the legs of the pole. The bases of the legs were also observed with black/brown dirt like material. The floor was also noted with debris and dirt like substance. An interview with Staff Nurse #6 was conducted regarding the findings in the equipment storage room. The nurse stated "the pump covered would indicate that piece of equipment was clean." The nurse could not explain why clean and dirty equipment was observed in one storage area. The Biohazard room was observed with a plank of wood missing from the sink cabinet. A screw was observed exposed leaving a potential source for injury and infection. Room 101 was identified as an isolation precaution room. On the morning of 08/19/2013, an observation of Room 101 was conducted. The patient was observed ambulating in the hall and entered room 101. The patient stated this was his room and he was getting ready for discharge. At approximately 1:30 p.m., room 101 was observed being terminally cleaned. The bed was stripped of the bed linens. A staff member donned with PPE was cleaning the mattress. The mattress was observed with an area of approximately 24 inches wide by 32 inches long. The area was shedding the top layer of the mattress. The mattress outer edges were curling, frayed and shredding. The Infection Control Designee was notified of the mattress condition. The designee went to room 101 and examined the mattress. The designee commented she would retire that mattress and examine all mattresses in the building and could see the condition of the mattress was an infection control risk. On 08/20/2013, the a contractor of the facility presented a facility purchase order for 10 new mattresses. The contractor explained the facility ordered these and would retire old mattresses as needed.

2. A medication pass was conducted on 08/20/2013 at 10:10 a.m. During the medication pass, Staff Nurse #1 required an IV pump for an intravenous medication. The nurse was observed retrieving an IV pole with an IV pump covered in plastic. The nurse retrieved the IV pole from the storage area next to the nurses' station. The nurse stated "The plastic means this pump is clean and ready for use".

3. At 11:25 a.m. on 08/20/2013, a blood glucose test was observed. The nurse aide was observed removing a blood glucose device from the medical supply drawer at the nursing station. The aide proceeded to enter the room for Patient #2. The nurse aide explained the procedure to Patient #2. The nurse aide donned gloves and performed the procedure. The aide was observed removing the gloves and discarding the use supplies appropriately. The aide then placed the testing device in the case and replaced the device into the drawer. The aide did not conduct hand hygiene prior to or after the procedure.
The nurse aide was interviewed and she agreed she did not wash her hands before or after the procedure, stating "No I did not." The nurse then explained the blood glucose testing device was for multiple patient use. The nurse explained to the aide the device should have been cleaned before returning the device to the case and drawer. The nurse explained to the aide the device should be wiped down with either an alcohol swab or a germicidal/bactericidal and viralcide wipe. The nurse aide was then observed using the sani-wipe type cloth to clean the device. The aide wiped the device and immediately replaced the device in the case and returned it to the drawer. The Infection Control Designee was called to the nursing station. A review of the blood glucose testing device observation was explained to the designee. The designee explained the facility had recently just obtained these devices and the devices "were not for multi-patient use." The designee commented the facility was using the device manufacturer's manual for the policy and procedure for care and cleaning. The designee removed a binder from a cupboard in the nurses' station. The binder contained the manual for the device used previously. The designee stated "This is for the old device; the manual for the new one is not in here." The designee agreed the staff did not have the current information for the appropriate use and cleaning for the Contour device.

3. At 11:15 a.m. on 08/20/2013, the sink in the nurses' station was utilized. The sink area was found with a used discolored sponge on the ledge of the sink. The splash board behind the sink had expanded, separated from the facing and spread open exposing the layers of pressed wood. There was a coffee pot by the sink with cups open area up. These were located under the paper towel dispenser. An electrical cord was observed coming down from a hole in the ceiling. This was plugged in to an extension cord (surge protector type with multiple outlets) on top of the cupboards by the sink. The cord coming from the plugged in outlet was draped down the cupboard wall by the sink and plugged into the outlet to the right side of the sink. This cord is draped over the paper towel dispenser.

4. Over the area of the sink in the nurse station the air handling vent was observed with string like dust debris in the vent. The Infection Control designee was notified of the sink area and the air handling intake vent. The designee commented these infection control concerns would be "taken care of".

5. An interview with the Infection Control Designee and the Chief Nursing Officer was conducted on 08/20/2013 at 1:30 p.m. The Designee explained she was appointed to the position in November 2012. The designee explained the facility does not have an immunization program for the employees during flu season. The designee explained the facility had not had immunizations for approximately 5 years. The designee commented the facility did not have a formal immunization education program, but would be willing to initiate an educational program during the flu season. The designee commented each employee receives a PPD (Purified Protein Derivative-Tuberculosis test) prior to employment and annually thereafter.

A review of the surveillance records for the facility was conducted during the interview with the Designee and the CNO. The designee explained the list of infections is kept each month. The list includes various infections and numbers indicating occurrences for that month. The designee explained she does not track for ongoing trends specifically to hospital locales, wings, departments, or use patient days to measure infection rates. The designee explained she did not conduct infection control /infection prevention compliance surveillance to insure staff knowledge. The designee commented the program could use improvement regarding tracking, trending, surveillance, and evaluation of current the infection control program.

6. The interview with the CNO and the Infection Control Designee on 08/20/2013 at 1:30 p.m. included the management of communicable diseases. The designee explains the staff is aware to report any infections to her. The CNO agreed the staff is aware infections need to be reported to the designee. The record for Patient #24 was reviewed with the CNO and designee. . Patient #24 is a 5 year old female presented in the emergency department on 07/28/2013 with a raised itchy rash. The Patient was diagnosed with "Scabies".
The designee stated "I was not aware of that patient." The designee and the CNO agreed they did not know if the rooms or linens were appropriately cleaned after treatment of this patient. .

The CNO was interviewed on 08/21/2013 at 9:50 a.m. The CNO stated "The administration approved to hire an infection control nurse."

7. The findings in the food preparation and kitchen are as follows:08/19/2013 11:48 AM- Observation of the kitchen revealed on a counter two raw ground beef packages placed on top of a package of cheese, and a box of cucumbers. Behind the raw ground beef, to the left, revealed a cardboard box containing a packaged ham.
08/19/2013 11:49 AM- Interview with the Dietary Manager revealed the cooler was being repaired so the food was placed on the counter until the repair work was completed. The Dietary Manager stated he would place the raw ground meat and ham in the cooler as "The repairs are done."
08/19/2013 12:15 PM- Observation of the cooler revealed the ham no longer in the box, and two packages of raw ground beef on the metal shelf in the cooler. The temperature inside of the cooler registered at 68 degrees.
08/19/2013 12:15 PM- Interview with the Dietary Manager revealed verification of the cooler temperature at 68 degrees, and the storage of the ham and two packages of raw ground beef. The Dietary Manager stated the repair to the cooler had been recently completed, and it would take a little while for the cooler to cool down. The Dietary Manager stated he would remove the ham and ground beef, and place them in the freezer.
08/19/2013 12:45 PM- Interview with the Dietary Manager revealed the raw ham, and two packages of raw ground beef were delivered at approximately 8:30 AM to 9:00 AM. The ham and raw ground beef were placed on the counter due to the cooler being under repair. The cooler repairs were completed, and the ham and ground beef were removed from the counter at approximately 12:10 PM into the cooler. The cooler temperature was noted to be 68 degrees at 12:15 PM; the ham and ground beef were removed from the cooler and moved to the freezer.
08/19/2013 12:17 PM- Observation for the temperature of a cooked chicken breast revealed a temperature of 95 degrees.
08/19/2013 12:17 PM- Interview with the Dietary Manager and the Head Cook revealed verification of the temperature of the cooked breast of chicken at 95 degrees.
08/19/2013 2:50 PM- Observation of the area behind the ice machine revealed five large cockroaches, one lizard, and multiple small insects dead on a white paper substance.
08/19/2013 2:50 PM- Interview with the Dietary Manager revealed verification of the deceased insects on the white paper substance behind the ice machine.
08/19/2013 3:10 PM- Observation of the cooler revealed the cooler was empty.
08/19/2013 3:11 PM- Interview with the Head Cook revealed the cooler was in the process of being repaired.
08/20/2013 9:48 AM- Interview with the Head Cook revealed the temperature for the dish washing machine is taken every morning.
08/20/2013 9:48 AM- Review of the Dishwasher Temperature Log revealed temperatures being completed every morning with the results of 120 degrees for the wash and rinse cycles.
08/20/2013 9:57 AM- Observation of the Eco Lab label on the side of the dish washing machine in the kitchen revealed the wash and rinse cycles are to be at greater than 130 degrees.
08/20/2013 9:58 AM- Interview with the Dietary Manager verified per Eco Lab's recommendation on the dish washing machine the temperature is to be greater than 130 degrees. The Dietary Manager also revealed he was unaware of the temperature requirements.
08/20/2013 10:33 AM- Interview with the Dietary Manager revealed the chemical products provided for the dish washing machine are provided by Eco Lab. Eco Lab is the manufacturer of the dish washing machine. The Dietary Manager stated he doesn't know who owns the machine. He doesn't know if it is owned by Eco Lab or the hospital.
8. A review of the immunization and staff health concerns revealed the following:
08/21/2013 at 3:48 PM- Interview with employee #2 revealed there is no policy and procedure for staff immunizations for Purified Protein Derivative to determine exposure/infection with tuberculosis.
08/21/2013 at 3:52 PM- Interview with the Registered Nurse in the emergency department revealed the procedure for facility staff for testing of Protein Purified Derivative is: The staff member comes to the emergency department with the proper form provided from the human resources department. The emergency department administers the Purified Protein Derivative, and the staff member is to return to the emergency department within 48 to 72 hours to have the results read. The information of each staff member tested is kept in a book entitled Non-Emergent Screening.
08/21/2013 at 3:54 PM- Review of the Non-Emergent Screening book revealed no evidence of employee #9 having been administered Purified Protein Derivative for tuberculosis screening.
08/21/2013 at 3:54 PM- Review of the Non-Emergent Screening book revealed employee # 13 was administered with Purified Protein Derivative for tuberculosis screening on 08/01/2013.
08/23/2013 at 9:48 AM- Review of the Centers for Disease Control and Prevention web site revealed the Mantoux technique for screening of tuberculosis states the results are to be read within 48 to 72 hours.

Based on staff interviews and facility record review, the facility failed to provide appropriate initial and ongoing assessments for discharge needs for the inpatient population served at the facility including 5 (Patient # 2, 6, 12, 18 and 23) of the 24 Patient's sampled.

Findings include:
1. An interview with the Chief Nursing Officer (CNO) was conducted at 9:45 a.m. on 08/21/2013 regarding the facility discharge planning efforts. The CNO explained the facility does not have a Social Service Worker and continued to explain the discharge planning is delegated to the nurses. The CNO commented the main focus has been dedicated to the emergency department (ED) to insure the ED is meeting their emergency medical regulations. The CNO explained at "first guess " she could not be sure if the nurses are documenting "what they do" for discharge planning.

The CNO presented a facility form entitled "Nursing Admission Assessment /Interview " The CNO called it the "blue sheet". The CNO explained the blue sheet is used for discharge planning. The second page of the blue sheet contains a section entitled "Environmental and Self-Care Considerations/Educational /Discharge Planning." The CNO explained the nurses are expected to fill in each section and complete each entry. A review of the facility records for Patient # 2, 6 and 12 revealed the blue sheets were not complete. The CNO commented the Medical Record Department is delegated to insure the medical record for each patient is complete. The CNO explained the facility, at this time, does not have "checks and balances" as of yet and "all forms need in-services and will be included in the next implementation." The CNO commented she has in-serviced the nursing staff verbally, but has "nothing in writing" and there is no documentation of follow up to measure the effectiveness of these in services.

A review of the facility policy and procedures was conducted during the interview with the CNO. The Facility currently has the following policies: MS 10240- Transfer of Patient to another Unit: Revised 08/01/2013; MS10245- Transfer of Patient to Outside Facility: Revised 08/01/2013; MS10235- Transfer of Patient for diagnostic Procedure: Revised 08/01/2013
MS10065- Discharge of Patient: Revised 08/01/2013. The CNO denied knowledge of any additional policy and procedures for discharge, or discharge evaluation or planning tools used by the facility. The CNO stated "These are the only ones I know of."

A review of the Policy and Procedure MS 10065 for" Discharge of Patient". The section identified as "Procedure Guidelines " Contains three listed planning for discharge elements: "1. Planning begins on admission-and continues throughout the hospital stay. 2. Patient and family teaching are a part of this preparation and are included in nursing care plan. 3. Social services and other staff are collaborated as appropriate."
The CNO was unable to present evidence or discharge planning documentation regarding those patients requiring high risk screening procedures. The CNO then commented there are other discharge forms used in the facility. The CNO presented a facility form entitled "Discharge Instructions", the CNO explained this is filled out at time of discharge. Another form entitled "Interdisciplinary Plan of Care" was presented. The "Interdisciplinary Plan of Care", according to the interview with the CNO, was reviewed as an in-service with the staff. The CNO explained the staff should know the area regarding discharge "must be filled out" and completed as part of the record. The section for discharge includes: "Discharge Needs " identified as a "Problem". The "Goal" section includes "Discharged to Safe Environment". The "Outcome Criteria" section includes " Patient discharged to: (insert check box) Appropriate post hospital care is arranged"

2. A review of the following records revealed the entries are either incomplete or blank (without entry): Patient # 2 (Incomplete), #6 (Incomplete), 12 (Blank), 18 (Blank), 20 (noted as a "Priority #3: Address prior to discharge") and 23 (Blank). The CNO commented during the 9:45 a.m. interview on 08/21/2013 that the "Nursing Admission Assessment /Interview" and discharge summary documents are the only facility mechanisms for discharge, discharge evaluation and discharge planning. The facility was not able to provide evidence of ongoing discharge planning or high risk evaluation for discharge planning. The CNO stated "I did not realize that discharge planning was so in depth." The CNO continued by commenting more time will be devoted to discharge planning in the future.

Based on staff interviews and record review, the facility failed to evaluate the patients entering the hospital as an inpatient for post-hospital discharge services for 2 (Patient #2 and 12) of the 23 Patient's sampled.

Findings include:

A review of the records for Patient #2 and #12 were conducted on 08/20/2013 at 1:15 p.m.

Review of Patient #2's record reveals the patient was admitted for care regarding a diabetic ulcer of the right foot. The Patient receives dressing changes to this wound daily. The patient record does not contain documentation for potential wound care, diabetic care or dietary care concerning discharge or discharge needs. Staff #1 was interviewed at approximately 1:25 p.m.. Staff #1 explained the discharge planning is completed after the physician writes the discharge order. The discharge vendors would be notified once the orders are completed.

A review of the record for Patient #12 reveals a physician progress note dated 08/21/2013 at 8:50 a.m. The physician documented "Pt (patient) has to go to Orlando this a.m. (morning) to be readmitted after her trip." The progress note includes: "Pt to take her BP (Blood Pressure) in 1 hour and call ER (Emergency room) re (regarding) need to take a Clonidine."
Review of the nurse's note dated 08/20/2013 at 10:03 a.m. states: "Pt discharged to home..."
The facility form entitled "Discharge Instructions" includes a written entry "follow up with Primary care physician Report back to ER for blood pressure check today."
The facility form entitled "Discharge Summary" includes a check mark indicating the Patient was discharge to Patient Home. Discharge Status indicates a Blood Pressure handwritten entry "168/100". The medical record does not include any follow up for re-admission or any potential re-admission instructions.

Based on staff interview and record review the facility failed to ensure the delegated personnel developed and supervise the discharge planning for 3 (Patient # 2, 6 and 12) of the 24 Patients sampled.

Findings include:

1. An interview with the Chief Nursing Officer (CNO) was conducted at 9:45 a.m. on 08/21/2013 regarding the facility discharge planning efforts. The CNO explained the facility does not have a Social Service Worker and continued to explain the discharge planning is delegated to the nurses. The CNO commented the main focus has been dedicated to the emergency department (ED) to insure the ED is meeting their emergency medical regulations. The CNO explained at "first guess " she could not be sure if the nurses are documenting "what they do" for discharge planning.

The CNO presented a facility form entitled "Nursing Admission Assessment /Interview " The CNO called it the "blue sheet". The CNO explained the blue sheet is used for discharge planning. The second page of the blue sheet contains a section entitled "Environmental and Self-Care Considerations/Educational /Discharge Planning." The CNO explained the nurses are expected to fill in each section and complete each entry. A review of the facility records for Patient # 2, 6 and 12 revealed the blue sheets were not complete. The CNO commented the Medical Record Department is delegated to insure the medical record for each patient is complete. The CNO explained the facility, at this time, does not have "checks and balances" as of yet and "all forms need in-services and will be included in the next implementation." The CNO commented she has in-serviced the nursing staff verbally, but has "nothing in writing" and there is no documentation of follow up to measure the effectiveness of these in services.

A review of the facility policy and procedures was conducted during the interview with the CNO. The Facility currently has the following policies: MS 10240- Transfer of Patient to another Unit: Revised 08/01/2013; MS10245- Transfer of Patient to Outside Facility: Revised 08/01/2013; MS10235- Transfer of Patient for diagnostic Procedure: Revised 08/01/2013
MS10065- Discharge of Patient: Revised 08/01/2013. The CNO denied knowledge of any additional policy and procedures for discharge, or discharge evaluation or planning tools used by the facility. The CNO stated "These are the only ones I know of."

A review of the following records revealed the entries are either incomplete or blank (without entry): Patient # 2 (Incomplete), #6 (Incomplete), 12 (Blank), 18 (Blank), 20 (noted as a "Priority #3: Address prior to discharge") and 23 (Blank). The CNO commented during the 9:45 a.m. interview on 08/21/2013 that the "Nursing Admission Assessment /Interview" and discharge summary documents are the only facility mechanisms for discharge, discharge evaluation and discharge planning. The facility was not able to provide evidence of ongoing discharge planning or high risk evaluation for discharge planning. The CNO stated "I did not realize that discharge planning was so in depth." The CNO continued by commenting more time will be devoted to discharge planning in the future.

2. A review of the records for Patient #2 and #12 were conducted on 08/20/2013 at 1:15 p.m.

Review of Patient #2's record reveals the patient was admitted for care regarding a diabetic ulcer of the right foot. The Patient receives dressing changes to this wound daily. The patient record does not contain documentation for potential wound care, diabetic care or dietary care concerning discharge or discharge needs. Staff #1 was interviewed at approximately 1:25 p.m.. Staff #1 explained the discharge planning is completed after the physician writes the discharge order. The discharge vendors would be notified once the orders are completed.

A review of the record for Patient #12 reveals a physician progress note dated 08/21/2013 at 8:50 a.m. The physician documented "Pt (patient) has to go to Orlando this a.m. (morning) to be readmitted after her trip." The progress note includes: "Pt to take her BP (Blood Pressure) in 1 hour and call ER (Emergency room) re (regarding) need to take a Clonidine."
Review of the nurse's note dated 08/20/2013 at 10:03 a.m. states: "Pt discharged to home..."
The facility form entitled "Discharge Instructions" includes a written entry "follow up with Primary care physician Report back to ER for blood pressure check today."
The facility form entitled "Discharge Summary" includes a check mark indicating the Patient was discharge to Patient Home. Discharge Status indicates a Blood Pressure handwritten entry "168/100". The medical record does not include any follow up for re-admission or any potential re-admission instructions.

Based on staff interview and record review the facility failed to provide an initial implementation of discharge planning including provisions for post-hospital services and educating patients and caregivers for 6 (Patient #2, 6, 12, 18, 20 and 23) of the 23 Patient's sampled.

Findings include:

1. A review of the Policy and Procedure MS 10065 for" Discharge of Patient". The section identified as "Procedure Guidelines " Contains three listed planning for discharge elements: "1. Planning begins on admission-and continues throughout the hospital stay. 2. Patient and family teaching are a part of this preparation and are included in nursing care plan. 3. Social services and other staff are collaborated as appropriate."
At 9:45 a.m. on 08/21/2013 during interview with the CNO, she was unable to present evidence or discharge planning documentation regarding those patients requiring high risk screening procedures. The CNO then commented there are other discharge forms used in the facility. The CNO presented a facility form entitled "Discharge Instructions", the CNO explained this is filled out at time of discharge. Another form entitled "Interdisciplinary Plan of Care" was presented. The "Interdisciplinary Plan of Care" according to the interview with the CNO was reviewed as an in-service with the staff. The CNO explained the staff should know the area regarding discharge "must be filled out" and completed as part of the medical record. The section for discharge includes: "Discharge Needs " identified as a "Problem". The "Goal" section includes "Discharged to Safe Environment". The "Outcome Criteria" section includes "Patient discharged to: (insert check box) Appropriate post hospital care is arranged"

At 10:15 a.m. a review of the following Patient records reveals the entries are either incomplete or blank (without entry): Patient # 2 (Incomplete), #6 (Incomplete), 12 (Blank), 18 (Blank), 20 (noted as a "Priority #3: Address prior to discharge") and 23 (Blank). The CNO commented at this time that the "Nursing Admission Assessment /Interview" and discharge summary documents are the only facility mechanisms for discharge, discharge evaluation and discharge planning. The facility was not able to provide evidence of ongoing discharge planning or high risk evaluation for discharge planning. The CNO stated "I did not realize that discharge planning was so in depth." The CNO continued by commenting more time will be devoted to discharge planning in the future.

2.An interview with Staff Nurse #1 was conducted on 08/21/2013 at 1:25 p.m. The nurse explained the discharge planning for patients was initiated with the writing of a physician order for discharge. The nurse explained once the physician order is written, the nursing staff would contact the appropriate vendor for post hospital care. When asked, the nurse explained the discharge planning was not specific, but the nurse would document the care the patient received on a daily basis in the nursing note. The nurse explained the facility uses the "blue sheet" for discharge planning. The nurse presented the facility form entitled "Nursing Admission Assessment / Interview" for Patient # 2. Review of the "Nursing Admission Assessment / Interview" revealed this patient has a history of diabetes and was admitted with a wound to the right foot. Staff Nurse #1 verified the "Nursing Admission Assessment / Interview" was incomplete by stating "I see what you are saying." The nurse then confirmed Patient #2 would receive discharge care with the physician discharge orders. The nurse commented any care needs for patients are noted in the nursing notes and commented the facility did not have any formal discharge planning.

Based on staff interviews and facility record review, the facility failed to provide the following for inpatient discharge patients requiring post hospital care services since 08/16/2013: a list of services such as Home Health Agencies (HHA) or Skilled Nursing Facilities (SNF) that are available in the service area of the patient as appropriate (i), provide patients the availability of managed care organizations (ii), documentation of the list that was provided to the patient or representative (iii). The facility failed to provide these services.

Findings include:

1. An interview with the Chief Nursing Officer (CNO) was initiated on 08/21/2013 at 9:45 a.m. The CNO presented a list of HHA, Durable Medical Equipment (DME), and Infusion companies. The CNO commented she had just put together a list of current providers the hospital was using. The list contained company names and telephone numbers. The CNO commented the patient population usually does not have insurance, but agreed the list did not include managed care indicators. The CNO explained the inpatient unit would have a notebook binder with brochures from each care service. The CNO stated "There is no formal documentation for this." The CNO continued to explain the concentration has been dedicated to the emergency room services and discharges planning for the inpatient units were in the beginning process of review. The CNO stated "We do not have the patient sign they received a list of providers." The CNO explained the floor would not have the list of service providers, but would have the note book of providers at the nursing station. The CNO explained the need to review the policy and procedures and that in-services for discharge and discharge planning was in process. The CNO denied documenting the in-services performed. The CNO denied the facility had any association with the listed providers.

2. At 1:15 p.m. on 08/21/2013, an interview with Staff Nurse 1 was initiated. The nurse explained the facility usually recommends one home health agency and 1 or 2 DME companies. The nurse denied having a list of providers to present the patients and denied having a notebook or binder for patient information brochures. The nurse stated "If it is for home health we recommend ____ (insert company name). The nurse then commented facility did not have any documentation confirming a patient who required post hospital services receives a list of providers.

Based on staff interviews and facility record review the facility failed to provide the following: a list of services such as Home Health Agencies (HHA) or Skilled Nursing Facilities (SNF) that are available in the service area of the patient as appropriate (i), provide patients the availability of managed care organizations (ii), and maintain documentation of the list that was provided to the patient or representative (iii). The facility failed to provide these services for inpatient discharge patients requiring post hospital care services.

Findings include:

1. An interview with the Chief Nursing Officer (CNO) was initiated on 08/21/2013 at 9:45 a.m. The CNO presented a list of HHA, Durable Medical Equipment (DME), and Infusion companies. The CNO commented she had just put together a list of current providers the hospital was using. The list contained company names and telephone numbers. The CNO commented the patient population usually does not have insurance, but agreed the list did not include managed care indicators. The CNO explained the inpatient unit would have a notebook binder with brochures from each care service. The CNO stated "There is no formal documentation for this." The CNO continued to explain the concentration has been dedicated to the emergency room services and discharges planning for the inpatient units were in the beginning process of review. The CNO stated "We do not have the patient sign they received a list of providers." The CNO explained the floor would not have the list of service providers, but would have the note book of providers at the nursing station. The CNO explained the need to review the policy and procedures and that in-services for discharge and discharge planning was in process. The CNO denied documenting the in-services performed. The CNO denied the facility had any association with the listed providers.

2. At 1:15 p.m. on 08/21/2013, an interview with Staff Nurse 1 was initiated. The nurse explained the facility usually recommends one home health agency and 1 or 2 DME companies. The nurse denied having a list of providers to present the patients and denied having a notebook or binder for patient information brochures. The nurse stated "If it is for home health we recommend ____ (insert company name). The nurse then commented facility did not have any documentation confirming a patient who required post hospital services receives a list of providers.

Based on staff interviews, patient care observations, environmental observations and facility document review, the Governing Body failed to ensure that the facility has a active Infection Control Program which provides data to the Quality Assessment and Performance Improvement, (QAPI), program for review and the development of actions plans for correction of infection control concerns.

Findings:

1. A tour of the facility was conducted on 08/19/2013 at 10:00 a.m. The tour included an equipment room and a medical supply room located next to the nurses' station. The medical supply room contained metal shelving units. The units were observed stacked with clean medical supplies such as gauze, and other wound dressings. On a lower shelf, a washcloth was observed in a wad like fashion with brown discoloration. A bottle of iodofoam gauze (used for wound packing) lot # 1100018662 was observed as previously open and expired on 06/2013. Staff Nurse #6 was interviewed and commented the wash cloth should not be there and would be removed. The nurse commented the iodofoam gauze should have been discarded after use.
The equipment storage room contained Intravenous (IV) poles (Metal pole used to hold IV pumps and IV solution bags). One pole was observed with a pump covered with a plastic bag. The IV pole with the covered pump was observed with rust like material on the legs of the pole. The bases of the legs were also observed with black/brown dirt like material. The floor was also noted with debris and dirt like substance. An interview with Staff Nurse #6 was conducted regarding the findings in the equipment storage room. The nurse stated "the pump covered would indicate that piece of equipment was clean." The nurse could not explain why clean and dirty equipment was observed in one storage area. The Biohazard room was observed with a plank of wood missing from the sink cabinet. A screw was observed exposed leaving a potential source for injury and infection. Room 101 was identified as an isolation precaution room. On the morning of 08/19/2013, an observation of Room 101 was conducted. The patient was observed ambulating in the hall and entered room 101. The patient stated this was his room and he was getting ready for discharge. At approximately 1:30 p.m., room 101 was observed being terminally cleaned. The bed was stripped of the bed linens. A staff member donned with PPE was cleaning the mattress. The mattress was observed with an area of approximately 24 inches wide by 32 inches long. The area was shedding the top layer of the mattress. The mattress outer edges were curling, frayed and shredding. The Infection Control Designee was notified of the mattress condition. The designee went to room 101 and examined the mattress. The designee commented she would retire that mattress and examine all mattresses in the building and could see the condition of the mattress was an infection control risk. On 08/20/2013, the a contractor of the facility presented a facility purchase order for 10 new mattresses. The contractor explained the facility ordered these and would retire old mattresses as needed.

2. A medication pass was conducted on 08/20/2013 at 10:10 a.m. During the medication pass, Staff Nurse #1 required an IV pump for an intravenous medication. The nurse was observed retrieving an IV pole with an IV pump covered in plastic. The nurse retrieved the IV pole from the storage area next to the nurses' station. The nurse stated "The plastic means this pump is clean and ready for use".

3. At 11:25 a.m. on 08/20/2013, a blood glucose test was observed. The nurse aide was observed removing a blood glucose device from the medical supply drawer at the nursing station. The aide proceeded to enter the room for Patient #2. The nurse aide explained the procedure to Patient #2. The nurse aide donned gloves and performed the procedure. The aide was observed removing the gloves and discarding the use supplies appropriately. The aide then placed the testing device in the case and replaced the device into the drawer. The aide did not conduct hand hygiene prior to or after the procedure.
The nurse aide was interviewed and she agreed she did not wash her hands before or after the procedure, stating "No I did not." The nurse then explained the blood glucose testing device was for multiple patient use. The nurse explained to the aide the device should have been cleaned before returning the device to the case and drawer. The nurse explained to the aide the device should be wiped down with either an alcohol swab or a germicidal/bactericidal and viralcide wipe. The nurse aide was then observed using the sani-wipe type cloth to clean the device. The aide wiped the device and immediately replaced the device in the case and returned it to the drawer. The Infection Control Designee was called to the nursing station. A review of the blood glucose testing device observation was explained to the designee. The designee explained the facility had recently just obtained these devices and the devices "were not for multi-patient use." The designee commented the facility was using the device manufacturer's manual for the policy and procedure for care and cleaning. The designee removed a binder from a cupboard in the nurses' station. The binder contained the manual for the device used previously. The designee stated "This is for the old device; the manual for the new one is not in here." The designee agreed the staff did not have the current information for the appropriate use and cleaning for the Contour device.

3. At 11:15 a.m. on 08/20/2013, the sink in the nurses' station was utilized. The sink area was found with a used discolored sponge on the ledge of the sink. The splash board behind the sink had expanded, separated from the facing and spread open exposing the layers of pressed wood. There was a coffee pot by the sink with cups open area up. These were located under the paper towel dispenser. An electrical cord was observed coming down from a hole in the ceiling. This was plugged in to an extension cord (surge protector type with multiple outlets) on top of the cupboards by the sink. The cord coming from the plugged in outlet was draped down the cupboard wall by the sink and plugged into the outlet to the right side of the sink. This cord is draped over the paper towel dispenser.

4. Over the area of the sink in the nurse station the air handling vent was observed with string like dust debris in the vent. The Infection Control designee was notified of the sink area and the air handling intake vent. The designee commented these infection control concerns would be "taken care of".

5. An interview with the Infection Control Designee and the Chief Nursing Officer was conducted on 08/20/2013 at 1:30 p.m. The Designee explained she was appointed to the position in November 2012. The designee explained the facility does not have an immunization program for the employees during flu season. The designee explained the facility had not had immunizations for approximately 5 years. The designee commented the facility did not have a formal immunization education program, but would be willing to initiate an educational program during the flu season. The designee commented each employee receives a PPD (Purified Protein Derivative-Tuberculosis test) prior to employment and annually thereafter.

A review of the surveillance records for the facility was conducted during the interview with the Designee and the CNO. The designee explained the list of infections is kept each month. The list includes various infections and numbers indicating occurrences for that month. The designee explained she does not track for ongoing trends specifically to hospital locales, wings, departments, or use patient days to measure infection rates. The designee explained she did not conduct infection control /infection prevention compliance surveillance to insure staff knowledge. The designee commented the program could use improvement regarding tracking, trending, surveillance, and evaluation of current the infection control program.

6. The interview with the CNO and the Infection Control Designee on 08/20/2013 at 1:30 p.m. included the management of communicable diseases. The designee explains the staff is aware to report any infections to her. The CNO agreed the staff is aware infections need to be reported to the designee. The record for Patient #24 was reviewed with the CNO and designee. . Patient #24 is a 5 year old female presented in the emergency department on 07/28/2013 with a raised itchy rash. The Patient was diagnosed with "Scabies".
The designee stated "I was not aware of that patient." The designee and the CNO agreed they did not know if the rooms or linens were appropriately cleaned after treatment of this patient. .

The CNO was interviewed on 08/21/2013 at 9:50 a.m. The CNO stated "The administration approved to hire an infection control nurse."

7. The findings in the food preparation and kitchen are as follows:08/19/2013 11:48 AM- Observation of the kitchen revealed on a counter two raw ground beef packages placed on top of a package of cheese, and a box of cucumbers. Behind the raw ground beef, to the left, revealed a cardboard box containing a packaged ham.
08/19/2013 11:49 AM- Interview with the Dietary Manager revealed the cooler was being repaired so the food was placed on the counter until the repair work was completed. The Dietary Manager stated he would place the raw ground meat and ham in the cooler as "The repairs are done."
08/19/2013 12:15 PM- Observation of the cooler revealed the ham no longer in the box, and two packages of raw ground beef on the metal shelf in the cooler. The temperature inside of the cooler registered at 68 degrees.
08/19/2013 12:15 PM- Interview with the Dietary Manager revealed verification of the cooler temperature at 68 degrees, and the storage of the ham and two packages of raw ground beef. The Dietary Manager stated the repair to the cooler had been recently completed, and it would take a little while for the cooler to cool down. The Dietary Manager stated he would remove the ham and ground beef, and place them in the freezer.
08/19/2013 12:45 PM- Interview with the Dietary Manager revealed the raw ham, and two packages of raw ground beef were delivered at approximately 8:30 AM to 9:00 AM. The ham and raw ground beef were placed on the counter due to the cooler being under repair. The cooler repairs were completed, and the ham and ground beef were removed from the counter at approximately 12:10 PM into the cooler. The cooler temperature was noted to be 68 degrees at 12:15 PM; the ham and ground beef were removed from the cooler and moved to the freezer.
08/19/2013 12:17 PM- Observation for the temperature of a cooked chicken breast revealed a temperature of 95 degrees.
08/19/2013 12:17 PM- Interview with the Dietary Manager and the Head Cook revealed verification of the temperature of the cooked breast of chicken at 95 degrees.
08/19/2013 2:50 PM- Observation of the area behind the ice machine revealed five large cockroaches, one lizard, and multiple small insects dead on a white paper substance.
08/19/2013 2:50 PM- Interview with the Dietary Manager revealed verification of the deceased insects on the white paper substance behind the ice machine.
08/19/2013 3:10 PM- Observation of the cooler revealed the cooler was empty.
08/19/2013 3:11 PM- Interview with the Head Cook revealed the cooler was in the process of being repaired.
08/20/2013 9:48 AM- Interview with the Head Cook revealed the temperature for the dish washing machine is taken every morning.
08/20/2013 9:48 AM- Review of the Dishwasher Temperature Log revealed temperatures being completed every morning with the results of 120 degrees for the wash and rinse cycles.
08/20/2013 9:57 AM- Observation of the Eco Lab label on the side of the dish washing machine in the kitchen revealed the wash and rinse cycles are to be at greater than 130 degrees.
08/20/2013 9:58 AM- Interview with the Dietary Manager verified per Eco Lab's recommendation on the dish washing machine the temperature is to be greater than 130 degrees. The Dietary Manager also revealed he was unaware of the temperature requirements.
08/20/2013 10:33 AM- Interview with the Dietary Manager revealed the chemical products provided for the dish washing machine are provided by Eco Lab. Eco Lab is the manufacturer of the dish washing machine. The Dietary Manager stated he doesn't know who owns the machine. He doesn't know if it is owned by Eco Lab or the hospital.
8. A review of the immunization and staff health concerns revealed the following:
08/21/2013 at 3:48 PM- Interview with employee #2 revealed there is no policy and procedure for staff immunizations for Purified Protein Derivative to determine exposure/infection with tuberculosis.
08/21/2013 at 3:52 PM- Interview with the Registered Nurse in the emergency department revealed the procedure for facility staff for testing of Protein Purified Derivative is: The staff member comes to the emergency department with the proper form provided from the human resources department. The emergency department administers the Purified Protein Derivative, and the staff member is to return to the emergency department within 48 to 72 hours to have the results read. The information of each staff member tested is kept in a book entitled Non-Emergent Screening.
08/21/2013 at 3:54 PM- Review of the Non-Emergent Screening book revealed no evidence of employee #9 having been administered Purified Protein Derivative for tuberculosis screening.
08/21/2013 at 3:54 PM- Review of the Non-Emergent Screening book revealed employee # 13 was administered with Purified Protein Derivative for tuberculosis screening on 08/01/2013.
08/23/2013 at 9:48 AM- Review of the Centers for Disease Control and Prevention web site revealed the Mantoux technique for screening of tuberculosis states the results are to be read within 48 to 72 hours.
9. Review of the QAPI committee minutes for 2013 did not reveal any of the above findings reported or acted on by the committee.

10. Interview with the Infection Control Nurse on 08/21/3013 at 9:00 AM revealed that activities of the Infection Control Program are not reported to the QAPI committee.