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Based on policy review, interview and record review the facility failed to ensure each patient and/or patient's representative was offered the opportunity to establish an advance directive for one patient (#95) of 18 patients records reviewed for advance directives. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

Review of the facility policy titled Advance Directives last revised 2/08 showed in part the following:
-In accordance with the Health Center's mission and values, as well as the Patient Self-Determination Act, patients are encouraged to make their own decisions to accept or refuse medical or surgical treatments. Patients are encouraged to document their wishes as clearly and specifically as possible to direct others in making decisions about medical care should he/she is unable to do so.
-Although it is preferable to have an Advance Directive prior to admission, St. Mary's Health Center provides staff assistance for completion of the documents.
-All out patients will be given the Your Life Your Decisions brochure at the time of registration.

Record review of current behavioral health outpatient Patient #95's admission history and physical showed the patient entered the outpatient program 8/02/09 for group therapy.

Record review of the patient's initial assessment form showed staff failed to offer assistance to Patient #95 when the patient indicated he/she does not have an advance directive.

Based on observation, interview and record review facility staff failed to ensure patients and visitors were provided full disclosure of video monitoring and recording by ninety-six cameras located in various locations including the Emergency Department, fifth floor Anti-partum Unit, Labor and Delivery entrance and the Behavioral Health Unit. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

For the St Mary's campus.

1. Record review of the facility admission packet booklet titled Welcome to SSM St Mary's Health Center, directed the following:
-On pages five and six stated in part, As a patient, you are a key member of your Health Care Team and have the right to have privacy and confidentiality when you are receiving care and take part in decisions about blocking visitors, mail, or phone calls as needed for your privacy, care and safety.
-On page fifteen Your safety and Security, Confidentiality, in part, directed Your privacy and confidentiality are important to us. Your name will be listed in our patient information database and given to callers at their request. At any time during your hospitalization, you can notify your nurses that you would like your stay to remain confidential.

2. Observation on 02/22/10 at 2:52 P.M. in the alcove outside the closed doors of the Labor and Delivery Unit revealed a ceiling mounted video device.

During an interview on 02/22/10 at 2:52 P.M. the Director of Labor and Delivery and Mother/Baby Unit, Staff F stated the following:
-Had been in position for three years.
-The ceiling mounted video camera was operational and in use now.
-Did not know if the video was recorded anywhere.
-Did not recall any signage informing anyone of possible video monitoring and/or possible videotaping.

Observation on 02/22/10 at 2:59 P.M. revealed a ceiling mounted video device in a corner over the Anti-partum Unit.

During an interview on 02/22/10 at 3:05 P.M. the Director the Anti-partum Unit, Staff G stated there was no signage posted informing anyone they may be video monitored or video recorded.

Observation on 02/23/10 at 1:40 P.M. at the facility East Entrance, revealed a sliding glass window opening into the Security Office and anyone standing at the window had full view of at least three video monitors of multi-framed images of various locations in the facility.

During an interview on 02/23/10 at 1:40 P.M. Director of Nursing Operations, Staff GG stated the following:
-Monday through Friday the East entrance was used for all the outpatient endoscopy patients and their families.
-The East entrance was also the entrance used for any facility visitor who had used valet parking options.
-The East entrance was the only entrance into the facility after 8:00 P.M. through 6:00 A.M.
-So all persons entering the building between 8:00 P.M. and 6:00 A.M. came through the East entrance and could stop at the sliding glass window of the Security office.

During an interview on 02/23/10 at 1:50 P.M. the Director of Security, Staff FF and Security Officer, Staff XX stated the following:
-Security Officer, Staff XX had been in position for fourteen years.
-The facility had ninety-six video cameras throughout the facility.
-There were "dozens" of video cameras on the fifth floor (location of the Women Units, Mother/Baby, labor and Delivery, Anti-partum)
-There was a video camera recording the entrance of the labor and Delivery area.
-There was a video camera in the Women's evaluation unit from the elevator.
-The video cameras provided real time viewing of the areas.
-The video system recorded and automatically retained images for forty days.
-Any images could be retrieved and recorded for permanent retention.
-All video images were viewed on five monitors in the Security station.
-One Security staff was assigned to watch the video monitors at all times.

Observation on 02/23/10 at 2:00 P.M. revealed one of the monitors with an image of a female patient, being transported in a bed out of an area identified by Security staff as the Labor and Delivery unit. Further observation on 02/23/10 at 2:00 P.M. revealed multiple patients and visitors in and around circular nurse's desk, identified by Security staff as the Emergency Department area.

During an interview on 02/23/10 at approximately 2:10 P.M. the Director of the Emergency Department, Staff NNN stated the department had two ceiling mounted video cameras and there was no posted signage informing patients and visitors of video monitoring or video recording.




19957

Observation on 2/24/10 at 11:00 A.M. showed a monitor in the nurses' station of the behavioral health unit, monitoring two seclusion rooms. One screen on the monitor showed an image of a male patient restrained on a bed in one of the seclusion rooms.
During an interview on 2/24/10 at 11:05 A.M. the team leader, Staff PPP said there are no signs posted on the unit to inform patients or visitors that they may be monitored.

Based on observation, interview and record review facility staff failed to establish and maintain systematic, proactive policies and procedure for prevention against infant abduction attempts on the Women's and Baby Unit and failed to provide a safe environment for all patients, staff, and visitors by ensuring staff maintain one emergency crash cart on the St. Mary's campus that is used during life-threatening events. The hospital census was 305 patients at the St Mary's campus (seventeen infants in the St Mary's newborn nursery) and 147 patients at the Cardinal Glennon campus.

Findings included:

For the St Mary's campus.

1. Record review of the facility policy titled ID Security Badges, reviewed 10/07 directed, in part, the following:
-All personnel having contact with babies will provide proper identification before transporting babies.
-The identification will be the employees ID badge and/or a temporary infant security badge with a picture ID.
-Temporary security badges were issued by the Charge Nurse or the Nursery nurse.
-Temporary security badges could be issued to pediatric medical residents (a physician in training), nursing instructors and nursing students.

Record review of the facility policy titled Infant Safety on Mother/Baby Unit, revised 10/08 directed in part, the following:
-Parents were instructed in identification of staff each time the infant was taken from the mother's room.
-Parents were instructed on other steps to ensure the infant's safety.
-Parents were instructed to read their bracelet number to the staff bringing the infant to them.
-Parents were instructed to require the nurse taking the infant to show facility and unit specific identification.
-The policy failed to direct proactive steps for staff to take to avoid situations that might foster increased chance of abduction attempts.

Record review of the facility Infant Security Measures and Patient/Family Education on Reporting Concerns dated 06/09 directed the patient to authenticate and attests to receipt of an explanation and an understanding of the following:
-Never give the infant to anyone not wearing proper identification.
-Always ask for identification of any staff handling the infant.
-Never leave the infant unattended or walk in the hallway with the infant in arms.
-The infant must remain on the unit until discharge.
-The policy failed to direct proactive steps for staff to take to avoid situations that might foster increased chance of abduction attempts.

Record review of the facility Infant Abduction Plan revised 08/09 directed staff on procedural steps to take after a reported abduction however did not contain any proactive measure as prevention.

2. Review of the facility policy titled, "Emergency Crash Carts", revised 07/09, gave direction, in part, to include the following:
"Policy: Adult carts will be maintained and readily available in the Pharmacy and in patient care areas".
"Purpose: To ensure that emergency supplies and medications will be available for patients, visitors, or employees if needed for life saving medical emergencies."
"The cart has two separate expiration dates. One is for the medications ('Rx') and the second is for supply items ('Central') and is located on a white sticker on the front of the crash cart. These dates refer to the earliest expiration date of medications and supplies inside the crash cart. The individual who checks the cart should document the expiration dates for the corresponding day on the checklist. It is the responsibility of the person who checks the crash cart to notify Pharmacy or Central Services for replacement."
"The crash cart is 'ready for use' when the lock is intact and medications and supplies are not expired according to above.""Items on the outside of the cart are to be checked and are included in the daily check system. See attachment B for listing of items."
"If the cart is not sealed or the expiration date is due, the cart should be exchanged following the crash cart exchange process."
"Cart Exchange Process
1. The nurse or a designated individual will page the Pharmacy technician/student.
2. The Pharmacy technician/student will go to the floor, remove the medication trays from the cart and identify the patient that used the cart.
3. The technician/student will bring the medication trays to the Pharmacy Department and attach the patient label to the charge sheet.
4. Central Service will bring a clean cart from Pharmacy to the nursing division and take the used cart to Central Service 'dirty' area after the medication trays have been removed.
5. Pharmacy will refill the medication trays and place the charge sheet on the secretary's desk.
6. When receiving a used cart, Central Service will clean cart, restock and check for outdated supplies, and return the cart to Pharmacy.
7. Upon receiving the cart from Central Service, Pharmacy will insert the medication trays attach the plastic lock and place a sticker indicating the next item to expire and its expiration date. Carts will be stored in the safe until requested from a department."
Attachment B document showed "External Crash Cart Content List" to include suction equipment, ambu bag (for delivering breaths), sharps container (for disposal of used needles and syringes), oxygen tank, cardiac board (for placing under a person to create a hard surface), clipboard (holds CPR [cardiopulmonary resuscitation] record, and emergency cart supply list).


3. Record review of the facility Patient Census Listing revealed staff admitted Patient #9 on 02/21/10 with diagnosis of labor.

During an interview on 02/22/10 at approximately 2:40 P.M. the parent of Patient #9 stated the following:
-He/she was concerned about the security on the unit.
-He/she had come onto the unit to visit Patient #9 and approached staff at the nurse's desk.
-Parent of Patient #9 was not asked for identification.
-Parent of Patient #9 asked to be directed to a specific room number (thought to be Patient #9's room number).
-Parent of Patient #9 was not asked to provide a name of the patient whom he/she was visiting.
-Parent of patient #9 was directed to the room, went down the hall and entered the room.
-The parent of Patient #9 further stated he/she could have been anyone and also since patients were sometimes assigned different rooms after admission, there was no way for staff to know if the unidentified parent of Patient #9 was supposed to visit that particular patient in that particular room.
-There were a lot of people in the hall.
-They (the staff) had never seen me before and they let me in.

4. Observation on 02/22/10 at 2:52 P.M. revealed both door leading onto the Mother/Baby unit were opened with easy access to and from the public elevators.
Further observation revealed closed doors labeled Labor and Delivery just off the central nurse's desk.

During an interview on 02/22/10 at 2:52 P.M. the Director of Labor and Delivery and Mother/Baby Unit, Staff F stated the following:
-The Unit had 3200 babies per year.
-Security on the unit for protection of infants consisted of education of the patients.
-Education consisted of telling the patients not to surrender their infant to anyone without a specific type of facility badge.
-Arm banding with corresponding numbers (patient matched to infant's number).
-Four video cameras for recording.
-Doors at the ends of the corridors were alarmed.

5. During an interview on 02/25/10 at 11:45 A.M. the Director of Women's Service, Mother/Baby Unit and Labor and Delivery, Staff F stated the following:
-She felt the key to infant protection was education of the mother.
-She did not feel the facility policies placed all the responsibility for infant security on the mothers.
-She felt the facility responsibility was to ensure staff always wore the appropriate badges (even though badges could be reproduced/counterfeit).
-The Labor and Delivery Unit was a secured unit (locked doors) that required anyone to telephone and request to be "buzzed in".
-The Mother/Baby Unit (where mothers could have their infants in the room with them during the day) was not a locked unit because of the physical plant.
-If locked doors to the Mother/Baby Unit were to be installed then four rooms allocated to the unit would be outside the locked doors (the physical plant problem).
-There were no locked entry doors into the Anti-Partum unit either.
-A further deterrent would be increased staff vigilance of people walking in the halls.
-When the Director was told about the parent of Patient #9 not being challenged or stopped by staff at the desk, she stated that was a problem.
-If used, she felt electronic bracelets and arm banding caused staff to become too reliant on the system itself so, she was against use of electronic monitoring.
-Infant abduction drills were conducted only once a year.
-She and the staff had tried to consider every scenario to put into place for a future planned renovation of the units.
-Unit renovation was planned within the next six months.


27724

6. Observation on 02/24/10 at approximately 9:15 a.m. in the Cardiac Rehab (rehabilitation) department showed a crash cart (storage cart for equipment, supplies and medication used when a person's heart and/or breathing stops). Upon opening the crash cart with Registered Nurse and Clinical Support Nurse, staff AA, each drawer had plastic covering the contents and a date marked on the plastic. The dates marked on the plastic ranged from 10/09 to 01/11. The plastic over the contents in the bottom drawer was torn and no longer intact. On the front, outside of the cart was one white sticker indicating when the next medication expired.

During an interview on 02/24/10 at 9:00 a.m., staff AA stated that they currently had eight patients in the Cardiac Rehab department and that they average 30 patients a day.

During an interview on 02/24/10 at 9:20 a.m., staff AA stated that he/she had opened the crash cart this week to get oxygen tubing and had replaced the oxygen tubing and lock by getting those items from central supply. Staff AA stated that he/she was not sure if the dates marked on the individual drawers indicated the expiration date or the date the items were replaced. Staff AA stated the process for changing out the crash cart is that the entire cart goes to pharmacy for replacement.

During an interview on 02/24/10 at 9:20 a.m., Nursing Director, staff BB, stated that there should be two white stickers attached to the front of the crash cart with one indicating when medications were due to expire and the second sticker to indicate when supplies were due to expire. Staff BB confirmed that the supply sticker was missing.

7. Review of the document titled, "Crash Cart Checklist", found on the Cardiac Rehab crash cart showed the following items were found to be expired:
- Blood gas kit (laboratory kit used to draw blood and analyze), count of two, expired 10/09;
- Bio patch (antimicrobial dressing), expired 11/09;
- Electrode Diaph Accutacr (unknown what this product is for), count of three, expired 12/09;
- Stopcock, 4-way (used with IV [intravenous] tubing for administering medications and fluids through a vein), count of two, expired 12/09;
- Defibrillator pad (used to place on the patient to deliver electrical shock to the heart), count of two, expired 01/10.
This document showed a delivery date of the crash cart (to the department) of 04/29/09.

8. Review of the document titled, "Defibrillator and Crash Cart Checklist" on 02/24/10 showed that from 02/05/10 to 02/23/10 the crash cart was checked or that the department was closed. The columns marked "Expiration Dates", one column for supplies and one column for medications, were blank with no checkmarks or dates. Another column marked "Attachment B" was blank with no checkmarks.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed in the facility. Record review of two (Staff Z and Staff AAA) of ten personnel files revealed staff failed to document that the names of staff were compared against the EDL on hire. The hospital census was 305 patients at the St Mary's campus and 147 patients at the Cardinal Glennon campus.

Findings included:

For the St Mary's campus.

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also quarterly checks of all existing staff against the quarterly updated EDL to ensure no staff were on the EDL.

2. Record review of Staff Z's personnel file revealed Staff Z had been employed in the facility since 02/08/10, had EDL verification documented on 02/25/10 but, had not had any verification on hire that he/she was not on the EDL.

Record review of Staff AAA's personnel file revealed Staff AAA had been employed in the facility since 02/08/10, had EDL verification documented on 02/25/10 but, had not had any verification on hire that he/she was not on the EDL.


3. During an interview on 02/25/10 at 9:39 AM Human Resources Specialist, Staff YY stated the facility routinely performed EDL verification on a quarterly on current staff however, the facility failed to ensure clear documentation of EDL verification on hire for all staff.

Based on observation and interview, the facility failed to ensure patient medical information was secured to prevent unauthorized access for patients in Cardiovascular Recovery, 2 East, Cardiac Rehab and the Electroconvulsive Therapy (ECT) treatment room for 11 of 11 patients who received ECT at the St. Mary's campus. This failure has the potential to affect all patients at the St. Mary's campus. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of the facility policy titled, "Patient Rights and Responsibilities", reviewed 02/06, gave direction, in part, to include the following:
"As a patient you are a key member of your Health Care Team and have the right to:"
"Have privacy and confidentiality when you are receiving care."

Review of the facility's patient handout titled, "Patient Rights and Responsibilities", revised 12/08, gave direction, in part, to include the following:
"As a patient you are a key member of your Health Care Team and have the right to:"
"Have privacy and confidentiality when you are receiving care."

2. Observation on 02/22/10 at 2:30 p.m. in the CVR (Cardiovascular Recovery) unit in the public hallway showed a wire cart carrying supplies. On top of the supplies were several sheets of paper with patient names and personal information easily read by anyone in the hallway.

During an interview on 02/22/10 at 2:30 p.m., Registered Nurse Team Leader, staff O, stated those sheets of paper belonged to the respiratory therapist who was in an adjacent room.

3. Observation on 02/23/10 at 10:10 a.m. on 2 East (orthopedics, short stay surgery) in a common area room showed a clipboard sitting on a countertop. Attached to the clipboard was a list of six patients showing name, room, and diagnosis. Sitting in the room was one male.

During an interview on 02/23/10 at 10:10 a.m., Registered Nurse Team Leader, staff P, stated that the male sitting in the room was a visitor and that the room was used for group physical therapy. Staff P stated that the clipboard belonged to a physical therapist and had the list of patients that person was to see that day and agreed that it shouldn't have been left in public view.

4. Observation on 02/23/10 at 10:20 a.m. in Patient #21's room showed a wall-mounted computer, used by staff for documenting patient care, with Patient #21's record on the monitor and viewable by anyone who walked into the patient's room. There was no one in the room other than the patient. While this surveyor was interviewing Patient #21, a staff member walked into the room, identified themselves as someone from occupational therapy, and left the room. The patient record was still viewable on the computer monitor.

5. Observation on 02/24/10 from 9:00 a.m. to 10:15 a.m. in the Cardiac Rehab (rehabilitation) department showed several patient records sitting on top of a counter. During this surveyor's observations, several patients walked up to the counter to sign in to the department or ask questions of staff. Also noted was that this counter was not always attended by staff.

During an interview on 02/24/10 at 9:30 a.m., Registered Nurse and Clinical Support Nurse, staff AA, stated that they need the records out so staff can refer to the records. Staff AA stated that unless the patients can read upside down, it's not a problem. At the time of my arrival, 9:00 a.m., staff AA stated that they had eight patients.



19957

Observation on 2/23/10 showed an ECT treatment room across from the behavioral health in-patient nurses' station. Lying on a table were 11 medical records containing patient information which included a face sheet, consent for ECT (a treatment for severe major depression w here seizures are electrically induced in anesthetized patients for a therapeutic effect) and patient labels with names, birthdates and other patient information. Lying on a desk was a notebook with information regarding numerous patients (too numerous to count) who had received ECT over the course of a year or more.

During an interview on 2/23/10 at 10:25 AM team leader Staff PPP said the medical records belong to patients receiving outpatient ECT. Staff PPP said the housekeeping department has access to the locked room at any time in order to clean.

Staff PPP said patient identifier information should be locked up and secured.

Based on policy review, record review and interview, the facility failed to care plan restraint use for one patient (#96) of six restraint records reviewed. The facility census was 305 patients at the St Mary's campus and 147 patients at the Cardinal Glennon campus.

Findings included:

Review of facility policy "Restraint Utilization Violent, Self Destructive" showed in part the following:
-Patient will be protected from harm in the least restrictive environment possible with the intent to prevent, reduce and work to eliminate the use of restraints
-Patient will be restrained only when necessary to provide and promote safety and when the least restrictive interventions have been determined to be ineffective
-The patient will be placed in restraints based on identified individual needs with consideration of the impact on the individual's rights and well-being
-The patient will be able to continue his/her care and participate in the care process
-The plan of care will be modified to include restraint and seclusion interventions, responses and actions
-Documentation will include the care plan

Record review on 2/23/10 showed current Patient #96 entered the facility 2/21/10 for treatment of bipolar disorder (episodes of manic and depressive moods and behaviors). Review of the nurses' notes dated 2/22/10 at 7:15 PM showed Patient #96 became physically aggressive toward staff. Staff physically held Patient #96 and placed the patient in a seclusion room in four point restraints (restraint of both arms and legs).

Review of the patient's care plan on 2/23/10 showed no documentation of restraint use.

During an interview on 2/23/10 at 3:05 PM, Team Leader Staff PPP said staff failed to care plan the restraint use for Patient #96.

Based on policy review, record review and interview the facility failed to obtain a physician's order for a physical hold restraint for one patient (#96) of six restraint records reviewed. The facility census was 305 patients at the St Mary's campus and 147 patients at the Cardinal Glennon campus.

Findings included:

Review of facility policy Restraint Utilization Violent, Self Destructive showed in part the following:
-Patient will be protected from harm in the least restrictive environment possible with the intent to prevent, reduce and work to eliminate the use of restraints
-Patient will be restrained only when necessary to provide and promote safety and when the least restrictive interventions have been determined to be ineffective
-The patient will be placed in restraints based on identified individual needs with consideration of the impact on the individual's rights and well-being

Appendix A of the policy showed in part:
-Restraint is any manual method or physical/mechanical device, material or equipment that is attached to or adjacent to the patient's body that (s)he cannot easily remove, restricts freedom of movement or normal access to one's body, is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his/her legal representative has consented, is not indicated to treat the patient's medical condition or symptoms, or does not promote the patient's independent functioning.
-A therapeutic hold is used in place of physical restraint when the patient becomes physically out of control and it is necessary for the staff to aid in regaining control of emotions and behavior. The staff holds the patient for a short period (usually 5 to 10 minutes), until the impulsive upsurge has passed and the patient has better control.

Record review on 2/23/10 showed current Patient #96 entered the facility 2/21/10 for treatment of bipolar disorder (episodes of manic and depressive moods and behaviors). Review of the nurses' notes dated 2/22/10 at 7:15 PM showed Patient #96 became physically aggressive toward staff. Staff physically held Patient #96 took the patient to seclusion room and placed the patient in four point restraints (restraint of both arms and legs).

Review of the physician's order dated 2/22/10 at 7:15 PM showed an order for four point restraints, but no order for a physical hold.

During an interview on 2/23/10 at 3:05 PM, Team Leader Staff PPP said staff failed to obtain the restraint order for a physical hold for Patient #96.

Based on record review the facility failed to ensure that all orders for restraint indicated the type of restraint ordered. This affects two of six patients reviewed for restraint usage (#72 and 73). The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:
Review of the policy titled "Use of Protective Devices and Restraints" , last reviewed on 4/09, states in section 4.8 when the physician is ordering a restraint a valid order for restraint includes the following elements: 4.8.2, the intervention or type of restraint to be used.
1. Review on 2/23/10 of the patient record indicated that Patient #73 was in soft wrist restraints on 2/9/10. The restraint order sheet completed at that time does indicate the reason as a medical restraint, the section for type of restraint to be utilized is blank. None of the six options for type of restraint had been marked to indicate the type of restraint the physician was ordering.
2. Review on 2/23/10 of the patient record indicated Patient #72 was in soft wrist restraints on consecutive days. The restraint order sheets for the days of 2/19/10 and 2/20/10 indicate that a medical restraint had been ordered and the section for type of restraint to be utilized is blank. None of the six options for type of restraint had been marked to indicate the type of restraint the physician was ordering.

Based on record review and interview, the facility failed to ensure restraint related deaths reported to the Center for Medicare and Medicaid Services (CMS) are documented in the medical record for two patients (Patient #28 and #29) and failed to report one patient (Patient #31) restraint related death to CMS by the end of the next business day following the death. A total of seven records were reviewed for death that occurred within 24 hours of being restrained. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of a document provided by the facility on 02/23/10 at 3:10 p.m. showed a list of seven patients whose names had been reported to CMS due to death within 24 hours of being restrained.

2. Review of deceased Patient #28's medical record on 02/23/10 at 3:20 p.m. showed that he/she expired on 11/28/09. Further review of the record showed no entry by staff of notification to CMS of the patient's death within 24 hours of being restrained. This was confirmed by Registered Nurse, EPIC (computerized charting) Product Specialist, staff Y.

3. Review of deceased Patient #29's medical record on 02/23/10 at 3:25 p.m. showed that he/she expired on 11/19/09. Further review of the record showed no entry by staff of notification to CMS of the patient's death within 24 hours of being restrained. This was confirmed by staff Y.

4. Review of deceased Patient #31's medical record on 02/24/10 at 2:35 p.m. showed that he/she expired on 10/25/09 AT 5:50 a.m. Further review of the medical record showed that CMS was notified until 10/27/09 and no time was noted. The next business day to notify CMS was 10/26/09. This was confirmed by Regulatory Coordinator, staff LLL.

5. During an interview on 02/24/10 at approximately 2:45 p.m., staff LLL stated that they had a fax confirmation on Patient #29 showing the notification was made to CMS within 24 hours but confirmed that this information had not been included in the medical record.

Based on policy, record review, and interview, the facility failed to ensure four of nine patients (#3, #40, #42, & #43) found with skin breakdown were assessed by the wound nurse in a timely manner. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

Review of the policy titled "Wound Ostomy Continence/Wound Care Certified (WOC/WCC) Nurse Consultation" , dated as revised 10/09, states in the purpose of the policy in the Outcomes Statement in part as:
? To complete wound, ostomy and skin consultation per physician order
? Follow Skin Care Guidelines recommendation
? WOC/WCC Nurse or designee to work in collaboration with physician for developing individualized care
? To develop treatment plans of care that will achieve optimal patient outcomes
The process states in part the following:
? Each visit and plan of care documentation is located in the Care Plan and Progress Notes (skin and wound tab in EHR (Electronic Health Record) and is communicated to the primary nurse caring for the patient.
? Consults will be seen within 72 hours of initial consult
? Included in criteria for consults are : Stage 3, 4, or unstageable pressure ulcer
Review of medical record for current patient #3 showed an admission on 02/18/10 for a Gastrointestinal Hemorrhage. On admission patient #3 ' s medical record documents the presence of a 8 x 8 centimeter (cm) stage II (Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. ), partial thickness pressure sore. There is an order dated 02/18/10 requesting a consult from the wound care nurse. On the day of survey, 02/22/10 the wound nurse has not yet documented seeing patient #3. This is ninety-six (96) hours after the order was written.
Review of patient #3's medical record on 02/23/10 showed the wound nurse still has not assessed patient #3.
During an interview on 02/23/10 at 10:10 AM, Registered Nurse intensive care staff T said that he/she usually speaks with the wound care nurse regarding skin treatment for pressure sores, but the wound nurse does not always document in the patient ' s medical record.
Review of medical record for current patient #40 showed an admission on 02/08/10 for Vomiting. Skin documentation dated 02/16/10 showed a pressure sore to the coccyx area (tailbone) unstageable, measuring 1.5 cm. Skin documentation dated 02/20/10 showed a red left heel area, and right heel area measuring 4.4 x 3.8 cm pressure sore to the right heel. There is an order dated 02/16/10 requesting a consult from the wound care nurse. The wound care nurse did not see the patient until 02/22/10. This is one-hundred forty-four (144) hours after the order was written.
Review of medical record for current patient #42 showed an admission on 02/17/10 for Open Wound Knee, Leg, and Ankle (Non-healing and Non Surgical). Skin documentation dated 02/17/10 showed a left lower leg wound measuring 7 x 5 cm wide by 1 cm deep and unstageable. No order or request for a wound care nursing consult is found. Patient #42 has an unstageable wound, meeting the criteria for a wound care consult by the wound nurse.

Review of medical record for current patient #43 showed an admission on 02/19/10 for malaise and fatigue. Skin documentation dated 02/19/10 showed wounds (multiple) as follows:
Wound #1-right knee measuring 3.2cm x 1.2cm;
Wound #2- Left inner upper knee measuring 2.5cm x 1.2cm;
Wound #3-inner lower knee measuring 0.7cm x 0.7cm partial thickness; Wound #4-right upper hip measuring 6.5cm x 5cm;
Wound #6-left inner toe measuring 1.8cm x 1.7cm;
Wound #7-left inner foot measuring 1.7cm x 1.0cm; and
Wound #8-left hip not measured.
There is an order dated 02/19/10 requesting a consult from the wound care nurse. The wound care nurse did not see the patient until 02/23/10. This is ninety-six hours (96) hours after the order was written.

During an interview on 02/25/10 at 9:50 A.M. the registered wound care nurse staff OOO said that if he/she is not at the hospital the SWAT (special nursing unit designated skin nursing staff) nurses would usually speak with the floor nursing staff, but do not usually document in the patient's medical record. Staff OOO said that he/she was ill last week and did review the patient's pictures, however, did not document in any of the patient's medical records.

Based upon interview and review of facility files, the contract service for dialysis failed to have complete evaluation for competency and background review for one (Employee JJJ) of one agency nurse for dialysis. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Finding included:

1. Review of the State of Missouri regulation, Missouri Revised Statutes, Chapter 660, Department of Social Services, Section 660.315, showed the regulation required licensed health care facilities to review each personnel file in comparison to the Employee Disqualification List in the State of Missouri, prior to health care contact with facility patients. 2. Review of the Missouri Revised Statutes, Chapter 335, Nurses, otherwise known as The Nurse Practice Act showed the requirement for Registered Nurses to be evaluated by personnel with equal or greater qualification(s). Licensed Practical Nurses (LPNs) have a lesser qualification than Registered Nurses.
3. Review of the facility personnel file for Employee JJJ, a Registered Nurse in the facility by way of contract for the specialty service of End Stage Renal Hemo-Dialysis, showed the personnel file to have had the nurse competency evaluation and review completed by another agency nurse, but of the status as a Licensed Practice Nurse.
Further review of this file showed the file lacking in professional check to assure that the RN had not been listed on the State of Missouri Employee Disqualification List (EDL) for past health care abusers.

4. This personnel file review was shared during interview with the Director of Human Resources, Employee YY on 2/24/10 at 4:05 p.m..

Based on facility policy review, record review, observation and interviews the facility failed to ensure medications were administered as ordered by the physician for two (Patient #82 and 83) of six patients observed during medication administration, and one (Patient #25) of 72 open chart reviews. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:
1. Review of facility policy titled, "Network Clinical Practice Policy - Medication Administration", effective date 01/10, showed the following (in part), "Medications should be given within 30 minutes before or after the scheduled time."
2. Review of the Medication Administration Record (MAR) for current Patient #82 dated 02/24/10 showed the following medications were ordered to be given at 9:00 a.m. but were not available for administration:
- Proventil (albuterol) Inhaler (helps open up the airways in lungs to make it easier to breathe), 2 Puffs 4 times daily;
- Atrovent (ipratropium) Inhaler (helps open up the airways in lungs to make it easier to breathe), 2 Puffs 4 times daily;
- Lithium Carbonate (used to treat the manic episodes of manic depression), 300 mg daily.

Review of the medical record for Patient #82 showed:
- The order for Proventil Inhaler was written 02/24/10 at 5:45 a.m.
- The order for Albuterol Inhaler was written 02/24/10 at 5:45 a.m.
- The order for Lithium was written 02/24/10 at 7:46 a.m.

During interview on 02/24/10 at 9:00 a.m., Registered Nurse (RN) BBB stated that the Pharmacy had not sent the newly ordered medications to the floor for administration yet. Staff BBB further stated it is the responsibility of the nurse to notify the Pharmacy that necessary medications are not available and request that they be sent, and that medications are usually available in the Pyxis within 15 minutes after new orders are verified by the Pharmacy.

During interview on 02/24/10 at 9:55 a.m., Staff Pharmacist CCC stated medications that are not routinely stocked in the Pyxis are brought to the nursing units approximately every 3 hours. Staff Pharmacist CCC did not have an explanation for why the missing medications had not been delivered to the nursing unit before the time they were to be administered, but stated the medications were received on the nursing unit at approximately 9:30 a.m.

During interview on 02/24/10 at 10:04 a.m. with Staff Pharmacist CCC and Staff Pharmacist EEE, both Pharmacists agreed that there is no automatic mechanism to alert the Pharmacy staff that medications are not available for administration and that they rely upon nursing staff to notify them of the medication absence.

Review of the Medication Administration Record (MAR) for Patient #82 at 11:00 a.m. 02/24/10 showed the following:
- Proventil (albuterol) Inhaler, 2 Puffs charted as given at 9:00 a.m.
- Atrovent (ipratropium) Inhaler, 2 Puffs charted as given at 9:00 a.m.
- Lithium Carbonate, 300 mg charted as given at 9:00 a.m.

During interview on 02/24/10 at approximately 11:15 a.m., Staff RN BBB stated the above listed medications were administered to Patient #82 at approximately 9:50 a.m. Staff RN BBB stated the system defaults to the time the medication was ordered to be given and enters that time when the medications are not scanned. It is up to the nurse to override the default and enter the correct time. RN BBB stated the medications listed above did not have a bar code to scan and he/she just forget to override and enter the correct time the medication was given.

Review of the Medication Administration Record (MAR) for current Patient #83 dated 02/24/10 showed Lidoderm (lidocaine) Patch 5% (local anesthetic used to relieve pain) was ordered to be given at 7:00 a.m. but was not available for administration.

During interview on 02/24/10 at 8:50 a.m., Staff RN BBB stated that the medication for Patient #83 was locked in a Pyxis that was currently broken down and they were waiting on the Pharmacy to repair the machine.

RN Staff BBB further stated it is the responsibility of the nurse to notify the Pharmacy that necessary medications are not available. Staff BBB sent an electronic message to the Pharmacy 02/24/10 at approximately 9:00 a.m. stating the medication was unavailable for administration due to the broken Pyxis.

Review of the Review of the Medication Administration Record (MAR) at 11:05 a.m. for current Patient #83 dated 02/24/10 showed Lidoderm Patch was administered at 9:57 a.m.

During interview on 02/24/10 at 10:04 a.m. with Staff Pharmacist CCC and Staff Pharmacist EEE, both Pharmacists agreed that there was no automatic mechanism to alert the Pharmacy staff that medications were not available for administration and that they relied upon nursing staff to notify them of the medication absence.

3. Review of the Medication Administration Record (MAR) for current Patient #25 dated 02/23/10 showed the following medications scheduled to be given at 9:00 a.m.:
- Asenapine (SAPHRIS) (used to treat the symptoms of schizophrenia and bi-polar disorder) 5 mg given at 9:52 a.m.
- Celecoxib (CELEBREX) (anti-inflammatory used to treat pain from inflammation) 200 mg given at 9:43 a.m.;
- Escitalogram (LEXAPRO) (antidepressant) 10 mg given at 9:43 a.m.
- Folic acid (FOLVITE) (vitamin) 1 mg given at 9:47 a.m.;
- Lisinopril (ZESTRIL) Used to treat high blood pressure and congestive heart failure) 20mg given at 9:45 a.m.;
- Vitamin B-1 (THIAMINE) (vitamin) 250 mg given at 9:48 a.m.

Based on observation, interview and record review staff failed to develop policies and procedures for appropriate handling and safe storage of patient home medications (brought into the facility by patients) confiscated, retained and stored by facility staff in the facility. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

For the St Mary's campus.

1. Record review of the facility Administrative Policy Manual policy titled Patient Valuables, reviewed 02/05 and provided during the survey, directed, in part, the following:
-It was the facility policy to have patients send money and other valuables home with their relatives.
-If it is impossible to send money and other valuables home the Nursing staff will call Security staff to pick up the valuables.
-Items to be included as valuables were cash, credit cards, bank cards, check books and jewelry.
-Bulky items such as suitcases, clothing were secured only if the patient were transferred to the Intensive Care Unit or the Cardiac Care Unit.
-All items were inventoried and itemized on the patient Valuable Receipt form signed by the patient or by Nursing staff if the patient was unable to sign the form.
-The policy does not direct Nursing staff or Security staff to confiscate patient medications and store them in the Security office lost and found room.

Record review of the facility Conditions of Admission Agreement form dated 06/19/08 directed in part, the following:
-Personal Property: I {the patient} have been informed and understand this facility will not be liable for any loss of my personal property unless it is inventoried and placed in a secured area maintained by this facility.

Record review of the facility Nursing Policy and Procedure Manual dated 10/09, Patient Valuables directed nursing staff to refer to Administrative Policy Manual-Patient.

Record review of the facility form titled Valuables Inventory, dated 10/09 revealed the following:
-A sequentially numbered form.
-Identifying information blocks for the {patient} name, room number, patient number, date and time.
-A line for currency, change, checks, eighteen different credit cards by company name, jewelry listed by watches, necklaces, bracelets, rings, chains, earrings, eyeglasses, keys and "other item"
-A line for staff or patient signature.
-A line for Security staff signature.
-No lines, blocks to list medications of any type.

2. Observation on 02/23/10 at 1:38 P.M. in the Security Offices revealed a room designated as the "lost and found" with the following contents:
-Two large safes with in-the-door combination type locking mechanisms.
-Two open shelving units with randomly placed bags and boxes along two of the walls.
-Two cardboard boxes containing some sealed envelopes and some open envelopes.
-Some plastic grocery store bags (tied knots for closures) translucent enough to reveal multiple brown medication vials.
-Random luggage on the paper littered floor.
-Boxes of office supplies on the top shelves.

During an interview on 02/23/10 at 1:40 P.M. the Director of Security, Staff FF stated the following:
-He had been employed with the parent corporation that owned the facility for twenty four years.
-He had been Director of Security in the facility for eighteen months.
-The Security Offices housed the facility lost and found room and also used the same room to store patient valuables.
-The patient valuables were taken (by facility staff) from patients who were admitted to the facility, placed in bags and labeled with the patient's name.
-Patient valuables were items including but not limited to cash, jewelry, watches, luggage and other articles.
-Cash and jewelry were maintained in the safe.
-Medications and other valuables were stored in the envelopes and plastic grocery bags, some in the cardboard boxes and some on the open shelving.
-Some of the envelopes and plastic grocery bags had inventory forms attached and others did not.
-All patient medications that could not be sent home with a family member or friend were confiscated by nursing staff bagged and taken by Security staff and placed in the lost and found room.

3. During an interview on 02/25/10 at 10:36 A.M. the Director of Security, Staff FF stated the following:
-The lost and found items were placed on two or three open shelves just inside the door.
-The other items on the open shelving consisted of items secured from patients on admission.
-The general process included taking all valuables, including medications from patients on Behavioral Medicine Unit upon admission.
-Patient medications were classified as valuables.
-The process included taking all medications from all patients admitted to the facility so they could not self-medicate.
-In general, patient's families were instructed to take medications home upon admission however, occasionally a patient was admitted without family so their medications were confiscated.
-Outpatient surgical patients also surrendered all valuables including medications.
-The medications and other valuables were confiscated for safe keeping.
-Security staff placing patient valuables in the lost and found room should document all items on a Valuables Inventory form and document the transaction on a log with the corresponding number of the form, date, time and Security staff number.
-One of the cardboard boxes contained an estimated twenty envelopes.
-The second cardboard box contained nine sealed envelopes in it.
-Eleven plastic grocery bags of items were on the second shelf.
-Four plastic grocery bags were on the top shelf.
-One plastic grocery bag was on the bottom shelf.
-Medications were not logged in by name or number (Security only recorded the total number of vials and not the content or the name of the medication).
-He did not know if any controlled substances were in any of the envelopes or plastic grocery bags.
-If the patient valuables contained controlled substances or medications that required special temperature (refrigeration), humidity or handling, the Security staff would not be able to segregate those medications in a different area.
-Safety and security measures for the lost and found room included a ceiling mounted video camera in the corner of the room.
-There were no other procedures (other than video camera and log in system) to ensure security of any controlled substances that may be in any patient valuables.
-There was an incident, about eight or nine months ago during which one of the numbered Valuables Inventory forms was missing.
-Diversion of medication held in patient valuables, in the lost and found room could be done.

Observation on 02/25/10 at 10:36 A.M. revealed one plastic grocery bag held on open shelving, in the lost and found room, did not have an inventory form attached. Further observation revealed the plastic grocery bag contained thirteen medication vials of the following:
-Hydromorphone, a pain relief medication.
-Doxepin, an antidepressant medication.
-Fluticasone, an inhaler for breathing problems.
-Atrovent (box), a bronchodilator for breathing problems.
-Furosemide, a diuretic.
-Lyrica, a medication for nerve pain and used for epileptic seizures.
-Remeron, an antidepressant.
-Seroquel, an antipsychotic medication.
-Doxycycline, an antibiotic
-Lexapro (two vials), antidepressant medication.
-Meclizine, an antihistamine used for motion sickness, nausea, vomiting and dizziness.
-K-lor, a potassium supplement.

4. During an interview on 02/24/10 at 2:30 P.M. the Executive Director of Facility and Support Services (currently the Acting Director of Pharmacy), Staff DDD and Pharmacist, Staff HH stated the following:
-The facility did not have any policies and procedures directing Pharmacy involvement in the storage or handling of patient medications held in the facility.
-Since Pharmacists were not involved in the process they felt there was no need for a Pharmacy policy and procedure.
-Patient home medications were designated as patient valuables and handled by Security department therefore no Pharmacy involvement was required.

Based on observation, interview, and record review, the facility failed to follow policy and secure medications. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of the facility policy titled, "Pharmaceuticals: Storage", revised 05/00, gave direction, in part, to include the following:
"Medications will be stored in accordance with current standards."

Review of the facility policy titled, "Nursing Unit Inspections", revised 06/03, gave direction, in part, to include the following:
"Pharmacy Department personnel will inspect all drug storage areas in the health center."
"The Pharmacy personnel inspecting the drug storage areas will search for and remove from the storage area any outdated drugs, containers with worn, illegible or missing labels, or drugs which are inappropriately stored."

2. Observation on 02/24/10 at 9:30 a.m. in the Cardiac Rehab (rehabilitation) department showed the following medication stored in an unlocked and open file cabinet:
- Nitroglycerine (medication used for chest pain) 0.4 mg (milligrams) tablets, count two bottles;
- Glucose (sugar) tablets, count two containers.

During an interview on 02/24/10 at 9:30 a.m., Clinical Support Nurse, staff AA, stated that the file cabinet where these medications were stored is locked when staff not present.

3. Observation on 02/24/10 at approximately 10:00 a.m. in the Cardiac/Vascular department showed the following medications stored in an unlocked cabinet in a patient testing room. The room was unattended when we entered.
- Aminophylline (airway muscle relaxant) 10 ml (milliliters), count of two;
- Esmolol (used to control rapid heartbeats or abnormal heart rhythms) 10 ml;
- Verapamil (used to treat chest pain or abnormal heart rhythms) 5 mg;
- Lidocaine (used to treat abnormal heart rhythms) 5 ml;
- Atropine (used to increase heart rate) 10 ml;
- Albuterol inhaler (airway muscle relaxant) 200 inhalations;
- Atrovent inhaler (airway muscle relaxant) 200 inhalations;
- Nitroglycerine 0.4 mg tablets.

During an interview on 02/24/10 at approximately 10:00 a.m., cardiology nurse, staff DD, stated that the cabinet where these medications were stored is usually kept locked but confirmed that the cabinet was not locked when we entered the room.

4. During an interview on 02/24/10 at 11:40 a.m., Pharmacist, staff HH, stated pharmacy has a monthly inspection process for checking medications in areas where they don't have a PYXIS (automated medication dispenser), which would include Cardiac Rehab. Staff HH stated that pharmacy is not aware of medications being stored in Cardiac Rehab other than in the crash cart. Staff HH stated he/she doesn't believe medications are being stored in a cabinet in Cardiac/Vascular department.

5. During an interview on 02/24/10 at 1:35 p.m. Executive Director of Facilities and Support Services, staff KKK, and staff HH stated that no medications have been dispensed to Cardiac Rehab and Cardiac/Vascular departments and they are not sure how they got those medications. Staff HH stated inventories are being done but those medications were not found.

6. Review of three monthly inspection documents titled, "Medication Area Inspection Report" for the Cardiac Rehab department, dated for October, November, and December 2009, showed a checkmark under "Compliant" with the criteria of "Medication area access is secure".

7. Review of three monthly inspection documents titled, "Medication Area Inspection Report" for the Cardiac/Vascular department, dated for October, November, and December 2009, showed a checkmark under "Compliant" with the criteria of "Medication area access is secure".

Based on observation, interview, and record review, the facility failed to dispose of expired medications. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of the facility policy titled, "Pharmaceuticals: Storage", revised 05/00, gave direction, in part, to include the following:
"Medications will be stored in accordance with current standards."
"All medications will be stored according to manufacturers' guidelines or current literature."

Review of the facility policy titled, "Nursing Unit Inspections", revised 06/03, gave direction, in part, to include the following:
"Pharmacy Department personnel will inspect all drug storage areas in the health center."
"The Pharmacy personnel inspecting the drug storage areas will search for and remove from the storage area any outdated drugs, containers with worn, illegible or missing labels, or drugs which are inappropriately stored."

2. Observation on 02/24/10 at 9:30 a.m. in the Cardiac Rehab (rehabilitation) department showed the following expired medication:
- Nitroglycerine (medication used for chest pain) 0.4 mg (milligrams) tablets, bottle opened 10/05/09. Manufacturer guidelines on bottle stated that the medication expires three months after opening. (Expired 01/05/10).

During an interview on 02/24/10 at 9:30 a.m., Clinical Support Nurse, staff AA, confirmed that this medication had expired.

3. Observation on 02/24/10 at approximately 10:00 a.m. in the Cardiac/Vascular department showed the following expired medications:
- Aminophylline (airway muscle relaxant) 10 ml (milliliters), count of two, expired 10/09.

During an interview on 02/24/10 at approximately 10:00 a.m., cardiology nurse, staff DD, confirmed that these medications had expired.

4. During an interview on 02/24/10 at 11:40 a.m., Pharmacist, staff HH, stated pharmacy has a monthly inspection process for checking medications in areas where they don't have a PYXIS (automated medication dispenser), which would include Cardiac Rehab. Staff HH stated that pharmacy is not aware of medications being stored in Cardiac Rehab other than in the crash cart. Staff HH stated he/she doesn't believe medications are being stored in a cabinet in Cardiac/Vascular department.

5. During an interview on 02/24/10 at 1:35 p.m. Executive Director of Facilities and Support Services, staff KKK, and staff HH stated that no medications have been dispensed to Cardiac Rehab and Cardiac/Vascular departments and they are not sure how they got those medications. Staff HH stated inventories are being done but those medications were not found so were not checked for expiration.

6. Review of three monthly inspection documents titled, "Medication Area Inspection Report" for the Cardiac Rehab department, dated for October, November, and December 2009, showed a checkmark under "Compliant" with the criteria of "There are no expired or recalled medications in storage".

7. Review of three monthly inspection documents titled, "Medication Area Inspection Report" for the Cardiac/Vascular department, dated for October, November, and December 2009, showed a checkmark under "Compliant" with the criteria of "There are no expired or recalled medications in storage".

Based on facility policy review, record review, and interviews the facility failed to follow hospital policy to report medication errors for two patients (Patient #25, 83) given late medications. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of facility policy titled, "Network Clinical Practice Policy - Medication Administration", effective date 01/10, showed the following (in part), "Medications should be given within 30 minutes before or after the scheduled time."

2. Review of facility policy titled, "Occurrence Reporting," effective date 09/11/02, showed the following (in part):
- " It is the policy of SSM Health Care that all known occurrences not consistent with the routine operation of the entity or the routine care of a particular patient be reported to the entity's Risk Management Department using the SSMHC 'Confidential Occurrence Report' form within 24 hours of the occurrence."
- "Occurrences that must be reported include, but are not limited to: Medication occurrences."
- "Definition of 'Occurrence Report' - A formal, written report of a variance that has been standardized across SSMHC."
- "Definition of 'Medication Occurrences' - Any occurrence at any point in the medication process from the time a drug is ordered until the patient receives it, or fails to receive it."

3. Review of facility policy titled, "Medication Events (Errors, Reactions), revision date 02/09, showed the following (in part):
- "All medication events shall be reported in a timely manner. Medication events will include the following: Medication Errors, Adverse Drug Reactions, and Adverse Drug Events."
- Medication Errors:
- Omission error (failure to give an ordered dose);
- Wrong time error (ex. Medication ordered at HS but given in a.m.).
- Reporting of Medication Errors:
- All medication errors should be reported to the supervisor and/or risk Management via an Occurrence Report.
- When appropriate, notify other departments (e.g., pharmacy, Resp. Therapy, nursing) that were involved in making the error or who will be affected by the Error.
- Risk management will review all reported medication errors with pharmacy. All medication error will be reported to the Risk Management Committee and Significant errors will be reported to the P&T committee for follow-up Recommendation."

4. Review of the Review of the Medication Administration Record (MAR) for current Patient #25 dated 02/23/10 showed the following medications scheduled to be given at 9:00 a.m.:
- Asenapine (SAPHRIS) (used to treat the symptoms of schizophrenia and bi-polar disorder) 5 mg given at 9:52 a.m.;
- Celecoxib (CELEBREX) (anti-inflammatory used to treat pain from inflammation) 200 mg given at 9:43 a.m.;
- Escitalogram (LEXAPRO) (antidepressant) 10 mg given at 9:43 a.m.
- Folic acid (FOLVITE) (vitamin) 1 mg given at 9:47 a.m.;
- Lisinopril (ZESTRIL) Used to treat high blood pressure and congestive heart failure) 20mg given at 9:45 a.m.;
- Vitamin B-1 (THIAMINE) (vitamin) 250 mg given at 9:48 a.m.

5. Review of the Medication Administration Record (MAR) for current Patient #83 dated 02/24/10 at 11:05 a.m. showed the physician ordered Lidoderm (lidocaine) Patch 5% (local anesthetic used to relieve pain) to be given at 7:00 a.m. Lidoderm was not available for administration because of a broken Pyxis. The MAR showed staff administered the medication at 9:57 a.m.

During Interview on 02/24/10 at 11:20 a.m., Executive Director Staff L stated staff usually did not complete Incident Reports for late medications, because they still believed they had an hour before and after the medication "due" time.

During interview on 2/25/20 at approximately 11:30 a.m., Risk Manager Staff K stated no Occurrence Reports had been completed for Patients #25 or #83.

Based on observation, interview, and record review, the facility failed to maintain patient blood testing supplies in safe condition for one blood sugar testing equipment of two observed. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of the facility's policy titled, "SureStep Whole Blood Glucose", written 03/09, gave direction, in part, to include the following:
"SureStepPro Test Strips
Date and initial when opening
Discard any unused portion 4 months after opening"

2. Observation on 02/24/10 at approximately 9:15 a.m. in the Cardiac Rehab (rehabilitation) unit showed a SureStep machine (device used for testing patient's blood sugar levels). The bottle of test strips was open and empty. There was no documentation on the bottle showing date it was opened or initials.

During an interview on 02/24/10 at approximately 9:15 a.m., Registered Nurse and Clinical Support Nurse, staff AA, stated he/she wasn't sure when the SureStep was last used.

During an interview on 02/24/10 at 10:30 a.m., Laboratory Tech in charge of point of care testing (including SureStep), staff EE, stated that the last patient to receive an SureStep test in Cardiac Rehab was on 02/15/10.

Review of the facility document titled, "Data Log Report" for Cardiac Rehab showed the last patient tested in Cardiac Rehab was on 02/15/10.

Review of another facility document titled, "Data Log Report" for Cardiac Rehab showed that the bottle of test strips found empty on 02/24/10 was the same bottle of test strips used for patient testing on 02/15/10.

Based on observation, interview and policy review, the facility failed to properly dispose of contaminated supplies and failed to maintain a clean and safe environment in one department of 15 patient care departments observed at St. Mary's campus. The hospital census was 305 at the St. Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

1. Review of the facility policy titled, "Blood Glucose Monitoring with Sure Step Pro/Flexx Bedside System", reviewed/revised 09/09, gave direction, in part, to include the following:
"Insert the test strip blood application side up ..."
"Remove the test strip and discard".

2. Observation on 02/24/10 at approximately 9:15 a.m. in the Cardiac Rehab (rehabilitation) unit showed a SureStep machine (device used for testing patient's blood sugar levels). The SureStep equipment and supplies were stored in the manufacturer's carrying case. When this surveyor lifted up one of the bottles of test solutions, used test strips were lying in the storage case. The used test strips appeared to have blood stains on them.

During an interview on 02/24/10 at approximately 9:15 a.m., Registered Nurse and Clinical Support Nurse, staff AA, agreed that the test strips found appeared to have been blood stained and should not have been left in the storage case.

3. Observation on 02/24/10 at 9:20 a.m. in the Cardiac Rehab unit showed an overhead mounted fan that was directed to blow air on patients who were on the treadmills and also blew air over the crash cart (storage cart for equipment, supplies and medication used when a patient's heart and/or breathing stops). The fan was covered with dark grey dust and clumps of dust were hanging from the fan.

During an interview on 02/24/10 at 9:20 a.m., staff AA and Nursing Director, staff BB, confirmed that the fan was very dusty and was blowing dust on patients.

4. Observation on 02/24/10 at 9:40 a.m. in the Cardiac Rehab unit showed a crash cart. The crash cart and equipment on top of the crash cart were covered in dust.

During an interview on 02/24/10 at 9:40 a.m., staff AA stated that environmental services (housekeeping) cleans the department. Staff BB stated that everyone is responsible for keeping the area clean.

During an interview on 02/25/10 at 9:25 a.m., Regulatory Coordinator, staff B, stated that environmental rounds are completed in all clinical areas two times a year.

During an interview on 02/25/10 at 10:10, Infection Control Coordinator, staff SSS, stated that the cleaning process includes high dusting (process of dusting everything above shoulder level). Staff SSS stated that environmental rounds are completed every two weeks with environmental services.

During an interview on 02/25/10 at 10:45, Regulatory Coordinator, staff A, stated that environmental rounds were not completed in Cardiac Rehab.




28722

Based on observation and interview, the facility failed to implement appropriate infection control policies and procedures to prevent the risk of transmission of organisms for one (Patient #82) of five current patients observed during medication administration. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

Observation on 02/24/10 at 9:15 a.m. showed Registered Nurse (RN) BBB preparing medications to administer to current Patient #82. After removing the appropriate medication from the Pyxis, RN BBB dropped the medication packet on the floor, then picked it up and placed it in a medication cup along with other medications, and failed to perform hand hygiene after handling the contaminated medication.

Observation on 02/24/10 at 9:24 a.m. showed Staff RN BBB unwrapped all medications packets and emptied them into the contaminated medicine cup, then administered meds from the cup to Patient#82.

During an interview on 02/25/10 at 10:15 a.m., Infection Control Coordinator Staff SSS stated that if a pill package is dropped on the floor, it should be cleaned, not put back into any container where meds will be placed and given to the patient.

Based upon record review and interview, the facility failed to make current policies and procedures available to staff on the Outpatient Behavioral Health Unit. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

Review of the Policy and Procedure binder for Outpatient Behavioral Health Services available for staff review on 02/23/10 at 9:10 a.m. showed the following:
- The policy cover sheet, signed by the Behavioral Services Director only, indicates "update will occur in April, 2007" .
- The majority of the written policies contained in the binder indicate last revision date was 06/07/2006.
- Seven policies listed on the Policy Index were missing from the binder.
- Fifteen policies were numbered differently from what was listed on the Policy Index.
- Many of the policies in the binder were not maintained in the order listed in the Policy Index.

An interview on 02/23/10 at 10:20 a.m. with Transitional Care Manager Staff J, Risk Manager Staff K, and Behavioral Health Executive Director Staff L showed the following:
- Policies and Procedures are maintained electronically for Behavioral Health Unit staff, but only the Unit Secretary and Staff J have access to these current policies. Staff can request a particular electronic policy be printed, if desired.
- Staff J stated the electronic policies all had an expiration date of 09/09/09.
- Hard copy binders of Behavioral Health policies as well as General Hospital policies are kept in Staff J's locked office. Staff have access to this area with a key.

Based on interview the facility failed to ensure the Behavioral Health outpatient department provided unit orientation to all staff for one of one staff member (Staff M) reviewed. The outpatient census was 52. The hospital census was 305 patients at the St Mary's campus and 147 at the Cardinal Glennon campus.

Findings included:

-During an interview on 2/23/10 at 3:30 PM, the manager of the Behavioral Health Transitional Care outpatient program, Staff J said therapist Staff M is relatively new to this facility. Manager J said that therapist Staff M usually works at one of their sister facilities and was pulled to help conduct groups in this outpatient program. Manager J said no unit specific orientation was given to therapist Staff M because the therapist received orientation at the sister facility. Manager Staff J said any orientation to this outpatient program is the responsibility of the clinical coordinator Staff N.

Staff J said there is no personnel record to review for unit specific orientation because the personnel record for therapist M is kept at the point of hire, not at this facility.

-During an interview on 2/23/10 at 9:35 AM therapist Staff M said that a sister facility is his/her home base and he/she has been conducting groups at this facility for two or three months. Staff M said he/she conducts groups in this facility twice a week. Staff M said the orientation he/she had at this facility is, "Kind of like on-going." Staff M said he/she had no formal orientation to this specific program prior to conducting groups for patients.
-During an interview on 2/23/10 at 10:10 AM the outpatient clinical coordinator Staff N said that therapist Staff M has been coming to this facility to conduct groups for about a month. Staff N said the therapist's home base is a sister facility and any orientation for the therapist would have been done at the point of hire, the sister facility; not at this facility. The clinical coordinator said, "We are similar programs."