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Based on interview, it was determined that the facility did not ensure inspections were done by the local fire department. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of 19 patients on 02/09/15.

In an interview on 02/11/15 at 1045, the Respiratory Therapy Director, that was also responsible for Emergency Management, verified there was no documentation of fire department inspections available for review.

Based on interview, Infection Control Committee Meeting Minutes and policy and procedure review, it was determined the facility failed to ensure biological spore results were reported to the Infection Control Committee. Failure to report biological spore results did not allow the Infection Control Committee to provide guidance and direction in any corrective actions deemed necessary. The failed practice was likely to affect any patient whose care necessitated the use of sterilized equipment. Findings follow:

A. Review of the Infection Control Committee Meeting Minutes from 12/19/13 through 01/29/15 revealed no biological spore results were reported to the Infection Control Committee.
B. During an interview with the Infection Control Nurse at 0905 on 02/12/15, the findings in A were verified.


Based on interview, hand hygiene surveillance document review and policy and procedure review, it was determined the facility failed in that there was no evidence hand hygiene surveillance was performed monthly from 4/11 to 02/12/15. Failure to conduct hand washing surveillance did not allow the facility to be knowledgeable of the hand washing activities performed by staff and did not allow the facility to afford guidance and direction to prevent disease transmission by poor hand hygiene practices. The failed practice was likely to affect all patients receiving care in the facility. Findings follow:

A. During an interview with the Infection Control Nurse from 0900 to 0945 on 02/12/15, she stated the last documented hand washing surveillance was dated 04/11.
B. Review of the hand washing surveillance documents received from the Infection Control Nurse at 0935 on 02/12/15 revealed: "#2. Observe 5 Hand Hygiene Opportunities MONTHLY." There was no evidence hand hygiene was monitored since April of 2011.
C. Review of the facility policy and procedure titled Hand Hygiene received at 1000 on 02/10/15 revealed the following on page 3: "Reference CDC (Centers for Disease Control) Guideline for Hand Hygiene in Health-Care Setting. Review of the CDC Guideline for Hand Hygiene in Health-Care Setting revealed the following under Part II, Recommendations, page 33: 7.B. Monitor HCW ' s (health care worker ' s) adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance." Part III, Performance Indicators, Page 34, 1.A. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities by ward or by service. Provide feedback to personnel regarding their performance.
D. During an interview with the Infection Control Nurse from 0900 to 0945, she confirmed the findings of A and B.
E. During an interview with the Chief Nursing Officer at 1035 on 02/13/15, she confirmed the findings of A, B, and C.


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Based on policy review, Physician Credential File review, and interview, it was determined there was no evidence the facility had a means to identify and control infections in that 4 (#1-#3, #5, and #8) of 11 (#1-#11) Physicians did not have a current TB (tuberculin) skin test. The failed practice created the potential for an exposure to TB to go unnoticed and could affect any patient being treated by those physicians. Findings follow.

A. Review of policy titled "Tuberculosis Control Program" stated, "Medical Staff: Medical staff members (who do not have a history of positive PPD) have an annual PPD skin test ....(This same procedure applies to physician office staff personnel who make rounds in the hospital.)"
B. Review of Physician Credential Files revealed Physicians #1-#3, #5, and #8 did not have a current TB skin test.
C. During an interview on 02/12/15 at 1130, the Infection Control Nurse confirmed the physicians did not have current TB skin tests.

Based on observations, interviews and policy and procedure review, it was determined the facility failed to ensure telemetry monitors for 6 of 6 (#13 and #21-25) patients on telemetry were continuously monitored by nursing staff. Failure to continuously monitor telemetry placed patients at potential risk of arrhythmias not being addressed. The failed practice affected Patient #13 and Patients #21-25. Findings follow:

A. During an interview with the Chief Nursing Officer (CNO) at 1335 on 02/11/15, she stated there was no dedicated nursing staff observing the telemetry monitors located in each pod and in the Emergency Room (ER).
B. Observations during the ER tour at 1405 on 02/11/15 revealed 6 patients were on telemetry in the facility (one in the ER and five on the nursing unit).
C. During an interview with the ER Charge Nurse at 1409 on 02/11/15, she stated it was the nurse's responsibility to monitor the telemetry but no one was assigned to sit there and monitor it. The ER Charge Nurse stated the ER staff can see the nursing unit telemetry patient tracings but the nursing unit staff cannot see the ER telemetry patient tracings.
D. Review of the policy and procedure titled Telemetry/Cardiac Monitors revealed the following under Procedure: "...All nurses on the inpatient area and ER will be responsible for monitoring the patient's rhythms. If the ER nurse notices a change in the rhythm, that nurse will call the inpatient area to ensure that the rhythm has been documented and that the patient has been reassessed..."
E. During an interview with the ER Charge Nurse at 1409 on 02/11/15, she confirmed the findings at B and C.
F. During an interview with the CNO at 1030 on 02/13/15, she confirmed the findings of A and D.

Based on surgical privilege document review and interview, it was determined surgical privileges for 2 (#7 and #8) of 3 (#7, #8 and #12) surgeons available to the Operating Room staff were greater than 2 years old. Failure to ensure Operating Room staff had current surgical privileges available did not allow staff to be knowledgeable regarding what procedures each surgeon was credentialed to perform. The failed practice was likely to affect all patients undergoing procedures performed by Surgeons #7 and #8. Findings follow:

A. Review of the Operating Room binder containing current surgical privileges received from the Surgical Services Director at 1505 on 02/11/15 revealed the surgical privileges for Physician #7 was dated 01/27/2012 and Physician #8 was dated 07/31/12.
B. During the interview with the Surgical Services Director at 1505 on 02/11/15, she verified the findings in A.

Based on interview, it was determined there was no planned activities for swing bed patients. Failure to develop an activities calendar did not allow the swing bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice affected the one (#1) swing bed patient on 2/13/15. Findings follow:

A. During an interview with the Chief Nursing Officer (CNO) at 1030 on 02/12/15, she presented an activity calendar to which she stated the activities listed were those activities that Patient #1 participated in for that day. The CNO stated there was no developed planned activity calendar for swing bed patients.
B. During an interview with the Chief Nursing Officer at 1030 on 02/12/15 she verified the findings of A.


Based on clinical record review and interview, it was determined an activities assessment was not performed for one of one Swing Bed Patient (#1). Failure to conduct an assessment identifying the resident's individual activity interests did not allow the facility to ensure the mental and psychosocial well-being of each Swing Bed patient. The failed practice affected the one (#1) swing bed patient on 02/12/15. Findings follow:

A. Review of the Social Assessment dated 02/02/15 for Patient #1 revealed it did not contain any information identifying activities the patient was interested in or had previously participated in.
B. During an interview at 0955 on 02/13/15, the findings of A were verified by the Clinical Informatics Analyst.


Based on interview, it was determined the facility did not employ a qualified professional to direct the Swing Bed Activities Program. Failure to employ a qualified professional did not ensure the Swing Bed patients were receiving activities designed to meet the interests, physical, mental and psychosocial well-being of each patient. The failed practice affected the one (#1) Swing Bed patient on 02/12/15. Findings follow:

During an interview with the Chief Nursing Officer at 1045 on 02/13/15 she stated the Swing Bed Supervisor was a registered nurse and without any other credentials meeting the qualifications of the Swing Bed Activities Program.