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Based on facility tours and staff interviews, the facility failed to maintain a safe environment to protect the health and safety of patients.
This failure contributed to the potential for patient injury due to improperly stored supplies and the use of expired supplies during patient procedures.

FINDINGS:

1. The facility failed to ensure oxygen tanks were secured.
a) On 05/15/13 at 10:00 a.m., a tour of the facility's Extended Care Unit (ECU) was conducted with the facility's Director of Nursing (DON). During the tour, an ECU storage room was viewed and contained 5 oxygen tanks that were standing upright on the floor and not secured in any fashion.
b) During the tour, an interview was conducted with the facility's DON. The DON stated that s/he had educated staff multiple times on the importance of securing oxygen tanks and that it was his/her expectation that oxygen tanks would be secured at all times.
2. The facility failed to ensure that supplies used during patient procedures were not expired.
a) On 05/14/13 at 10:0 a.m., a tour of the facility's Emergency Department (ED) was conducted with the facility's Director of Nursing (DON).
Shelving units in the ED were viewed and contained 4 culture swabs with manufacturer's expiration dates of 04/2013 and 2 containers of ultrasound gel with manufacturer's expiration dates of 01/2013 and 11/2012. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
The ED's refrigerator was viewed and contained 3 cauterization tools with manufacturer's expiration dates of 05/2009. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
During the tour, the ED's rapid sequence intubation kit was viewed and contained 2 packets of lubricating jelly with manufacturer's expiration dates of 04/2009 and 1 packet of lubricating jelly with a manufacturer's expiration date of 08/2008. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
b) On 05/15/13 at 10:00 a.m., a tour of the facility's Extended Care Unit (ECU) was conducted with the facility's DON.
The ECU's automated external defibrillator (AED) was viewed. The AED's battery's manufacturer's expiration date was listed as 02/2013. The facility's Director of Nursing (DON) verified the manufacturer's expiration date and immediately removed the item.
The ECU's storage room contained 2 specimen swabs with a manufacturer's expiration date of 06/2012 and 2 specimen swabs with a manufacturer's expiration date of 03/2012. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
During the tour, the ECU's crash cart was viewed and contained 3 twenty-two gage intravenous (IV) catheters with manufacturer's expiration dates of 04/2013, 2 fourteen gage IV catheters with manufacturer's expiration dates of 03/2012, 1 sixteen gage IV catheter with a manufacturer's expiration date of 02/2012, 1 eighteen gage IV catheter with a manufacturer's expiration date of 01/2013, and 4 laboratory specimen tubes with manufacturer's expiration dates of 04/2013. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
c) On 05/15/13 at 10:30 a.m., the facility's Physical Therapy unit was toured with the facility's DON.
The cupboards in the Physical Therapy area were viewed and contained 2 tubes of massage lotion with manufacturer's expiration dates of 04/2012 and 2 one liter bottles of sterile water with manufacturer's expiration dates of 03/2004 and 04/2004. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
A respiratory therapy storage closet was located in the Physical Therapy area and contained 2 cans of carbon dioxide with manufacturer's expiration dates of 05/2002 and 08/2000. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
d) On 05/15/13 at 11:00 a.m., a tour of the facility's Surgical Suite was conducted with the facility's Operating Room (OR) Manager and the facility's DON.
During the tour, the facility's OR crash cart was viewed and contained the following expired items: 15 eighteen gage IV catheters with manufacturer's expiration dates of 02/2013, 2 arterial blood gas kits with manufacturer's expiration dates of 12/2012, 1 carbon dioxide monitor with a manufacturer's expiration date of 02/2013, 2 five hundred milliliter bags of 5% Dextrose with an expiration date of 02/2013, and 2 one liter bags of Normal Saline with manufacturer's expiration dates of 03/2013. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
During the tour, the facility's OR Manager stated the crash cart had been checked for expired supplies within the last two weeks.
During the tour of the OR, the sterile storage room was viewed and contained several pieces of cauterization equipment with manufacturer's expiration dates of 04/2011 and several pieces of scope equipment with manufacturer's expiration dates of 04/2012. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
e) On 05/15/13 at 12:00 p.m., an interview was conducted with the facility's DON. S/he stated it was her expectation that expired equipment would not be stored or available in patient care areas.

Based on observations, staff interviews and review facility documents, the facility failed to ensure that contracted services furnished the agreed upon services.

This failure led to preventative maintenance not being performed on multiple types of equipment used for patient care.

FINDINGS:

1. The facility did not ensure that preventative maintenace was performed on its equipment.

a) On 05/14/13 at 11:00 a.m., a tour of several facility departments was conducted with the facility's Director of Nursing (DON).

In the Emergency Department the following items were viewed: a Bipap machine that contained no sticker documenting that preventative maintenance had been performed, and a Bair Hugger that was documented as having had preventative maintenance performed in 07/2010. The facility's DON verified these findings.

In the Radiology department, an ultrasound machine was viewed and contained no sticker documenting that preventative maintenance had been performed. The facility's DON verified these findings.

b) On 05/15/13 at 8:30 a.m., a tour of several other facility departments was conducted with the facility's DON.

In the facility's Extended Care Unit (ECU), a Hoyer lift, used for lifting patients, was viewed and contained no documentation of preventative maintenance having been performed. The facility's DON verified these findings.

In the Pre-Operative area of the surgical suite, an anesthesia monitor was viewed and contained a sticker that documented preventative maintenance had last been performed in 04/2012. The facility's DON verified these findings.

In the Operating Room, a machine used for cauterizing procedures contained no documentation of having had preventative maintenance performed.

In the Post Anesthesia Care Unit (PACU) area of the surgical suite, a Bair Hugger machine was viewed and contained a sticker that documented preventative maintenance had last been performed in 04/2011. The facility's DON verified these findings.


c) On 05/16/13 at 1:00 p.m., the facility's policy,"Equipment Management Plan", was reviewed. the policy stated,"All equipment in the equipment program shall be evaluated by (company name), or the individual name." The facility's DON verified this was the current policy.

Based on observations, interviews, and document review, the facility failed to ensure that medications and supplies available for patient use were appropriately stored.

This failure created the potential for negative patient outcomes by the facility having expired medications and supplies readily available for staff to use in providing patient care.

Findings:

1. The facility did not follow manufacturer's specifications when warming intravenous fluid.

a) Observations were conducted on 05/13/13 at 11:01 a.m. of the facility's Emergency Department with the facility's Chief Nursing Officer (CNO). A warming cabinet in the department contained 2 bottles of sterile water that were labeled 4/4/13 and 4/23/13. There were also 2 bags of lactated ringer intravenous solution that were labeled 3/23/13 and 4/29/13. Additionally there was one bag of normal saline intravenous solution that was labeled 5/22/13. The CNO stated that staff were expected to label the solutions with the date the fluids were placed into the warmer and that fluids were not to remain in the warmer longer than 14 days. S/he stated that the bag of normal saline was not labeled properly. S/he removed each of the identified fluids and solutions and discarded them.

b) During the above observation, it was noted that there was a record of the temperature of the cabinet being monitored. However, the document stated that temperatures were not to exceed 104 degrees Fahrenheit. On 05/01/13, 05/04/13, and 05/09/13 had temperatures recorded of 105 degrees Fahrenheit without documentation of follow-up action. Additionally, the temperature currently read 105 degrees Fahrenheit. These observations were confirmed with the CNO and the Emergency Department Nurse present at the time of the observations.

2. The facility did not discard expired medications.

a) Observations were conducted on 05/15/13 at 10:18 a.m. of the facility's post anesthesia cart unit with the facility's Chief Nursing Officer (CNO). The emergency cart contained a 1000 ml bag of saline that had a manufacturer's expiration date of 05/01/13. Additionally, there was a bag of 5% dextrose solution for the use when a heparin drip infusion was needed that had a manufacturer's expiration date of 02/01/13.

b) An interview was conducted with the facility's CNO during the above observation. S/he stated that expired medications should be discarded before the manufacturer's expiration date. S/he confirmed the above findings of expired items.

c) On 05/15/13 at 10:30 a.m., the facility's Physical Therapy unit was toured with the facility's CNO. The cupboards in the Physical Therapy area were viewed and contained 2 one liter bottles of sterile water with manufacturer's expiration dates of 03/2004 and 04/2004, and 20 vials of steroids with manufacturer's expiration dates of 01/2013. The facility's CNO verified the manufacturer's expiration dates and immediately removed the items. A respiratory therapy storage closet was located in the Physical Therapy area and contained 2 cans of carbon dioxide with manufacturer's expiration dates of 05/2002 and 08/2000. The facility's CNO verified the manufacturer's expiration dates and immediately removed the items.

3. The facility did not consistently monitor the temperature of refrigerators that medications were stored in.

a) Observations were conducted in the facility's pharmacy on 05/14/13 at 2:50 p.m. There was a log for the documentation of the refrigerator temperatures attached to the medication refrigerator. There had not been any entries since 05/10/13. Additionally, there were no entries on dates that fell on the weekend.

b. An interview was conducted with the facility's pharmacist at the time of the above observation. S/he stated that s/he was responsible for recording the temperature of the medication refrigerator. S/he stated that s/he had not documented the temperature of the refrigerator since 05/10/13. S/he additionally stated that the facility's staff did not check the temperature during the weekend and would have no knowledge if the temperature had not been maintained during the weekend.

Based on observations, staff interviews, and facility document review, the facility failed to ensure that the Operating Room (OR) humidity and temperature level was monitored and maintained at recommended levels.

This failure had the potential to result in increased risk of infection or surgical fire.

FINDINGS:

1. The facility's surgical department did not ensure and maintain a safe humidity level for patient care.

a) On 05/15/13 at 10:00 a.m., a tour of the facility's surgical department was conducted with the facility's OR Manager and the facility's Director of Nursing (DON).

In the Post Anesthesia Care Unit (PACU), the facility's OR temperature and humidity log was viewed. The log's last hand-written OR temperature and humidity reading was documented as March 10, 2013. The OR Manager stated the temperature and humidity log was to be done daily. The OR Manager could not find documentation that the OR temperature and humidity levels had been monitored since March 10, 2013.

In the Operating Room, there was a temperature and humidity measuring instrument, that recorded the humidity level as 20%, and the temperature as 71.2 degrees Fahrenheit. The facility's OR Manager verified these findings.

b) On 05/16/13 at 11:30 a.m., the facility's policy,"Ventilation and temperature control in the Operating Room", was reviewed. The policy stated,"The humidity in the OR is generally maintained between 45-55%. Humidity greater than 60% may cause condensation on cool surfaces, whereas humidity less than 45% may not suppress static electricity". The facility's OR Manager verified this was the current policy.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Organizational Structure. The governing body of the facility failed to ensure that all requirements related to the organizational structure of the facility and all other Conditions of Participation were met.

The facility failed to meet the following standards under the Condition of Organizational Structure:

Tag C 241 - Governing Body of Responsible Individuals:
The governing body of the facility failed to adequately determine, implement and monitor the policies governing the CAH's total operation and to ensure that those policies were administered so as to provide quality health care in a safe environment in multiple departments and functions of the facility and outpatient clinics.

Based on tours, observations, interviews, and review of facility documents, the governing body of the facility failed to adequately determine, implement and monitor the policies governing the CAH's total operation and to ensure that those policies were administered so as to provide quality health care in a safe environment in multiple departments and functions of the facility and outpatient clinics.

The failures created the potential for negative patient outcomes.

The findings were:

Reference Tag C 204 - Medical Equipment and Supplies: the facility failed to ensure that equipment and supplies commonly used in emergencies and patient care were available. Specifically, the facility failed to ensure that expired supplies were removed from patient care areas.

Reference Tag C 222- Maintenance: the facility failed to ensure that preventative maintenance was performed on all patient care equipment.

Reference Tag C 224 - Maintenance: the facility failed to ensure that drugs and biologicals available for patient use were appropriately stored. Specifically, the facility failed to store medications according to policy and failed to remove expired medications from patient care areas.

Reference Tag C 226 - Maintenance: the facility failed to ensure that proper temperature controls were maintained in all pharmaceutical medication storage refrigerators. Specifically, the pharmacy failed to maintain complete temperature tracking logs to ensure that appropriate refrigerator temperature levels were maintained for patient medications.

Reference Tag C 273- Patient Care Policies: the facility to have a policy in place that described ther services provided by the facility.

Reference Tag C 276 - Patient Care Policies - Safe Medication Storage: the facility failed to ensure that all medications were maintained and stored in accordance with accepted professional principle and their own policies and procedures. The facility failed to ensure that refrigerators for storage of medication were monitored for adequate temperature control. The failures created the potential for negative patient outcome.

Reference Tag C 278 - Patient Care Policies - Infection Control: the facility failed to have a system for identifying, reporting, investigating and controlling infections and communicable diseases of personnel. The facility was also in breach of procedures for infection control in the food and dietary services and the operating room environment.

Reference Tag C 280 - Patient Care Policies - Annual Provider Review of Policies: the hospital failed to have a process in place for annual policy review by a group of professional personnel that include one or more doctors of medicine or osteopathy, one or more physician assistants, nurse practitioners or clinical nurse specialist, if they are on staff, and at least one member who was not a member of the hospital staff.

Reference Tag C 283 - Direct Services - Radiology Services: the facility failed to ensure that preventative maintenance was performed on radiology equipment.

Reference Tag C 291 - Services by Agreement - Contract List: the facility failed to maintain a complete and accurate list of all services furnished under arrangements or agreements, including the nature and scope of the services provided.

Reference Tag C 292 - Services by Agreement - CEO Oversight: the Chief Executive Officer (CEO) of the facility failed to adequately manage the CAH's total operation and to ensure that the policies were administered so as to provide quality health care in a safe environment in multiple departments and functions of the facility and outpatient clinics. The failures created the potential for negative patient outcomes.

Reference Tag C 308 - Protection of Record Information: the hospital failed to have sufficient safeguards against loss, destruction or unauthorized use of retained patient records. The facility also failed to secure all records and radiology films.

Reference Tag C 333 - Periodic Evaluation: the facility failed to ensure that an evaluation was done at least once a year that included a review of a representative sample of both active and closed clinical records. The facility failed to ensure that members of the medical staff were involved in the annual review.

Reference Tag C 336 - Quality Assurance: the facility failed to ensure that it had an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

Reference Tag C 337 - Quality Assurance: the facility failed to ensure that all patient care services and other services affecting patient health and safety were evaluated.

Reference Tag C 342 - Quality Assurance: the facility failed to ensure that the facility's quality assurance program took appropriate remedial action to address deficiencies found through the department's quality assurance program. Specifically, when medication errors were discovered by the facility's medical record reviews, there was no documentation of remedial action to address the deficiencies found.

Reference Tag C 343 - Quality Assurance: the facility failed to ensure that the facility's quality assurance program documented the outcome of all remedial actions.

During the course of the survey, the team discovered that the facility had experienced multiple changes of CEO leadership in recent years while under a management agreement with an entity that provided the CEOs for the facility. In April 2013, the governing body hired the current CEO to manage the facility. Facility leadership staff were just beginning the process of implementing changes, based on the feedback received during the survey, when this survey team entered to conduct a validation survey.

Based on the manner and degree of deficiencies, the Facility failed to be in compliance with the Condition of Participation of Provision of Services. Specifically, the Facility failed to have policies in place that described the services provided by the facility, to ensure that facility policies were reviewed at least annually, that drugs were stored in a safe manner, and that there was effective infection control monitoring.

The Facility failed to meet the following Standards under the Condition of Participation of Services:

Tag C 273 Patient Care Policies
The Facility failed to have a policy in place that described the services provided by the facility.
Tag C 276
The Facility failed to ensure drugs and biologicals were stored, handled, and dispensed in a safe manner.

Tag C 278
The Facility failed to have a system for reporting, identifying, investigating, and controlling infections.

Tag C 280 Patient Care Policies
The Facility failed to ensure that facility policies were reviewed at least annually.

Based on interviews, facility document and policy reviews, the CAH failed to have a policy which described the services furnished directly by the CAH and those which were furnished through agreements or arrangements.

This failure contributed to the potential for the facility to provide services that did not meet the needs of the patient population.

FINDINGS:

1. The facility did not have a policy which described the services provided by the CAH and those provided under agreements or arrangements.

a) On 05/15/13, a review of the facility's policies and procedures revealed that the facility's policies did not include a policy which described the services furnished directly by the CAH and those provided under agreements or arrangements.

b) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated the facility did not currently have a policy which described the services provided directly by the CAH and those provided through agreements or arrangements.

Based on observations and interviews, the facility failed to maintain proper storage of drugs and biologicals.

This failure had the potential for expired or improperly stored medications to be administered to the facility's patients.

FINDINGS:

1. The facility did not follow current standards of practice for multiple dose vials.

a) A position paper from the Association of Professionals in Infection Control and Epidemiology (APIC) titled, "Safe Injection, Infusion and Medication Vial Practices in Healthcare" published July 30th, 2009 stated the following, in pertinent parts:
"The transmission of bloodborne viruses and other microbial pathogens to patients during routine healthcare procedures continues to occur due to unsafe and improper injection, infusion and medication vial practices being used by healthcare professionals within various clinical settings throughout the United States ...
APIC strongly supports adherence to the following safe injection, infusion and medication vial practices ...
Vials
?Always follow the manufacturer's instructions for storage and use...
?Discard single-dose vials after use. Never use them again for another patient.
?If a multidose vial must be used, it should be used for a single patient whenever
possible. The risk of transmission posed by inappropriate handling of multi-dose vials has been clearly demonstrated and mandates a practice of one vial per one patient whenever possible. Infection transmission risk is reduced when multi-dose vials are dedicated to a single patient...
?Dispose of opened multidose medication vials 28 days after opening, unless specified otherwise by the manufacturer, or sooner if sterility is questioned or compromised..."

b) The facility's policy "Medication and Solution Storage" stated that "All multidose vials for injection (i.e. Lovenox), must be dated and initialed when opened and discarded after 28 days."

c) On 05/15/13 at 10:30 a.m., a tour of the facility's surgical area was conducted with the facility's Director of Nursing (DON) and Operating Room (OR) Manager. A multiple dose vial of Lidocaine was noted on a shelf in the OR with a handwritten date of 03/28/13, indicating when it expired. The OR Manager confirmed the finding and the DON discarded the vial.

2. The facility stored IV fluids in warmers for improper periods of time.

a) On 05/14/13 at 9:30 a.m., a tour of the facility's Emergency Department (ED) was conducted with the facility's Director of Nursing (DON) and an ED staff nurse. During the tour, the facility's ED fluid warmer was viewed and contained 2 one liter bottles of sterile water with hand-written dates of 04/04/13 and 04/23/13 and 2 one liter bags of intravenous (IV) fluid with handwritten dates of 03/23/13 and 04/29/13. The ED staff nurse stated it was policy to not keep fluids in the warmer for longer than two weeks and immediately removed the bottles of sterile water and bags of IV fluid.

The ED fluid warmer contained a hand-written log that documented the daily temperature of the warmer and a note that stated the maximum temperature for storing intravenous fluids should be 104 degrees Fahrenheit. The temperature for 05/01/13, 05/04/13, and 05/09/13 listed the temperature as 105 degrees Fahrenheit. The ED staff nurse verified these findings and stated that s/he was unaware of anything that had been done to ensure the fluid warmer did not reach temperatures above 104 degrees Fahrenheit.

b) On 05/16/13 at 10:00 a.m., the facility's policy,"Storage and warming of IV Fluids and Irrigations Fluids", was reviewed. The policy stated,"Solutions for injection and irrigation in PVC and CR3 plastic flexible containers, in their overwraps, may be warmed to a temperature not to exceed 40 degrees Celsius (104 degrees Fahrenheit) unless otherwise specified on the label", and, "Fluids in both the above containers will be warmed for no longer than 14 days". The facility's DON verified this was the current policy.

3. The facility did not ensure expired medications were removed from patient care areas.

a) On 05/15/13 at 10:30 a.m., the facility's Physical Therapy unit was toured with the facility's DON.
The cupboards in the Physical Therapy area were viewed and contained 2 one liter bottles of sterile water with manufacturer's expiration dates of 03/2004 and 04/2004, and 20 vials of steroids with manufacturer's expiration dates of 01/2013. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.
A respiratory therapy storage closet was located in the Physical Therapy area and contained 2 cans of carbon dioxide with manufacturer's expiration dates of 05/2002 and 08/2000. The facility's Director of Nursing (DON) verified the manufacturer's expiration dates and immediately removed the items.

b) During the tour of the Physical Therapy area, an interview was conducted with the DON. The DON stated it was his/her expectation that expired medications would be discarded and not stored in patient care areas.

Based on observations, facility document review, and staff interviews, the facility failed to ensure that facility practices were performed in a manner that would prevent communicable diseases.

This failure contributed to patients and staff being exposed to potentially infectious agents.

FINDINGS:

1. The facility routinely used flash sterilization to clean sterile instruments.

a) On 05/15/13 at 10:00 a.m., a tour of the facility's surgical area was conducted with the facility's Operating Room (OR) Manager. During the tour, the OR manager stated that the facility routinely used flash sterilization during patient procedures. The OR manager stated s/he was aware flash sterilization was to be used only during emergency situations, but that the facility routinely performed flash sterilization for "expediency".

b) On 05/16/13 at 12:00 p.m., the facility's policy, "Flash Sterilization," was reviewed. The policy stated,"Flash autoclaving of surgical instruments should only be done in the instance of emergency situation and/or when there is insufficient time to sterilize an item by the preferred prepackaged method and/or manufacturer's recommendation". The facility's OR Manager verified this was the current policy.

c) On 05/16/13 at 1:15 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that it was his her expectation that flash sterilization would not be routinely used in the OR.

2. The facility did not ensure that cleaning solutions were properly diluted to ensure effective cleaning and disinfection of equipment used during patient procedures.

a) On 05/15/13 at 10:00 a.m., the facility's sterile instrument cleaning area was viewed and an interview was conducted with the Operating Room (OR) Manager. The OR Manager stated s/he cleaned the surgical instruments in a cleaning solution that s/he mixed prior to putting them in the washer. The OR Manager stated that s/he mixed "three pumps" of the cleaning solution, labeled,"Metrizyme," in an unknown amount of water that s/he estimated was the "right amount" by "looking at old water marks" in the sink. S/he stated there was no marking on the sink to indicate how many gallons it could hold. The OR Manager then read the manufacturer's instructions on the "Metrizyme" bottle to the surveyor, which stated,"to add 4 pumps (1 ounce) of Metrizyme to 1 gallon of water". The facility's OR manager was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the sink.

b) On 05/16/13 at 11:30 p.m., the facility's OR Manager was asked to provide the surveyors with the facility policy regarding disinfecting of sterile instruments. The OR Manager stated the facility currently did not have a policy regarding the cleaning of sterile instruments, except for flash sterilization.

3. The facility did not ensure that endoscopes were stored in a fashion to protect them from potential contaminates.

a) On 05/15/13 at 10:00 a.m., a tour of the facility's surgical area was conducted with the facility's OR Manager and the facility's Director of Nursing (DON). During the tour, the facility's endoscope storage area was viewed and an interview was conducted with the OR Manager. The endoscopes were viewed hanging in the sterile instrument room. The endoscopes were not contained in a closet or covered in any fashion that would protect them from dust or debris. The OR Manager stated that the endoscopes were always stored in this manner as the facility did not have another area to store them.

b) On 05/16/13 at 12:30 p.m., the facility's policy "High Level Disinfection of Endoscopes", was reviewed. The policy stated,"Store endoscopes in a manner which will protect the endoscope". The facility's OR Manager verified this was the current policy

4. The facility performed dry dusting and sweeping in patient care areas.

a) On 05/15/13 at 11:00 a. m., the facility's OR janitor's closet was viewed. The closet contained a broom and dustpan. The facility's OR Manager stated the housekeepers used this broom for "sweeping".

b) On 05/16/13 at 12:00 p.m., the facility's policy, "Cleaning-Surgery Department", was viewed. The policy stated,"Damp dust all flat surfaces and overhead lights every morning prior to the first surgical procedure". The policy made no mention of sweeping the OR. The facility's OR Manager verified this was the current policy.

5. The facility failed to ensure that patient care items were not stored on the floor.

a) On 05/14/13 at 2:30 p.m., a tour of the facility's pharmacy was conducted with the facility pharmacist. Two cardboard boxes containing intravenous fluid were viewed on the pharmacy floor. The pharmacist stated s/he kept these boxes on the floor as there was not ample shelf storage.

b) On 05/15/13 at 10:00 a.m., a tour of the facility's Extended Care Unit (ECU) was conducted with the facility's Director of Nursing (DON) and the medication room was viewed. On the floor of the medication room, a cardboard box containing feeding pump tubing and a plastic box containing intravenous fluid were viewed. The DON stated it was his/her expectation that patient care items would not be stored on the floor.

c) On 05/15/13 at 11:00 a.m., a tour of the facility's surgical suite was conducted with the facility's DON and the Operating Room (OR) Manager. A box of suction tubing was viewed in a cardboard box on the floor of the shower in endoscope procedure room.

d) On 05/15/13 at 11:15 a.m., an interview was conducted with the facility's DON. The DON stated it was his/her expectation that patient care items would not be stored on the floor.

6. The facility failed to ensure patient linens were protected from potential contaminates.

a) On 05/14/13 at 3:12 p.m., a tour of the facility's linen storage area for the Extended Care Unit (ECU) was conducted with the facility's Nurse Educator. The linens were stored in a room that contained an open window and a door that was open to the common hallway. The linen was contained on shelving that could be covered with a fabric cover, but the cover was not in use. The facility's Nurse Educator stated the door and window to this room were frequently kept open and the linens were not kept covered. The Nurse Educator immediately covered the linens.

b) On 05/15/13 at 10:30 a.m., the ECU's linen storage area was again viewed with the facility's DON. The window and door to the room were both open and the linens were uncovered. The DON immediately covered the linens.

7. The facility did not ensure items used for serving food were properly stored.

a) On 05/14/13 at 1:45 p.m., a tour of the facility's kitchen was conducted with the facility's Nurse Educator and a dietary staff member. During the tour, scoops were viewed in containers of corn meal, sugar, and corn bread mix.

b) During the tour, the facility's dietary staff member was interviewed. The staff member stated that these scoops were routinely stored in the containers.

8. The facility's dietary department did not ensure all food items were properly labeled.

a) On 05/14/13 at 1:45 p.m., a tour of the facility's kitchen was conducted with the facility's Nurse Educator and a dietary staff member.

A rolling tray in the kitchen contained 3 large plates of cookies with no expiration dates. The facility's dietary staff member stated the cookies were not labeled because they had been baked that day and all the staff members knew this.

On a shelving unit, a large clear plastic container was labeled, "Elbow Roni" with no expiration date, and contained a brown powdery substance. The dietary staff member could not find any other labeling on the container besides the one stating, "Elbow Roni". The dietary staff member stated the container was mislabeled and s/he believed the brown, powdery substance in the container to be, "gluten free flour".

On another shelving unit, a clear plastic container containing a white powdery substance labeled, "Baking Only", was viewed. The clear plastic container did not contain an expiration date or a label to indicate the contents of the container. The dietary staff worker stated that s/he believed the white powdery substance to be sugar.

b) During the tour, the facility's dietary staff member was interviewed. The facility's dietary staff member was unable to state how s/he could positively identify food items or their expiration dates if they were not labeled.

9. The facility's dietary department did not ensure expired items were not provided for patient and staff consumption.

a) On 05/14/13 at 1:45 p.m., a tour of the facility's kitchen was conducted with the facility's Nurse Educator and a dietary staff member and numerous expired and unlabeled items were viewed.

In the facility's kitchen freezers, the following expired and unlabeled items were viewed: 2 packets of green chile with hand-written dates of 03/11/13, 1 clear Tupperware container labeled as "spicy gravy", with no expiration date, 1 saran wrapped package of sliced salami with no expiration date, 1 bag of frozen catfish with no expiration date, and 1 box of lettuce with slimy black leaves.

The dietary staff worker verified that the listed items were unlabeled and expired, and viewed the lettuce and stated,"It looks like its going bad, but we'll clean it and take the black stuff off".

In the facility's dry storage area the following expired and unlabeled items were viewed: 1 container of pasta with a manufacturer's expiration date of 05/01/08, 9 boxes of gelatin mix with manufacturer's expiration dates of 2010 and 2011, 11 containers of pudding mix with manufacturers' expiration dates of 11/03/12, 4 containers of bread crumb mix with a manufacturer's expiration date of 04/11/13, 2 boxes of nutritional supplements with manufacturers' expiration dates of 11/18/12 and 01/22/13, and 1 container of lima beans with a handwritten expiration date of 10/28/12.

The dietary staff worker verified that the listed items were expired.

b) On 05/15/13 at 9:00 a.m., the facility's dietary manager spoke with the surveyors and stated it was his/her expectation that all food would be properly labeled and that expired items would not be used or served to patients or staff.

c) On 05/16/13 at 1:45 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated it was his/her expectation that expired food would not be served and that it would be discarded.

Based on interviews and review of facility documents, the facility failed to evaluate, review, and revise facility health care policies.

This failure had the potential for the facility policies to be inconsistent with current facility practices.

FINDINGS:

1. The facility did not perform annual evaluations of its policies.

a) On 05/15/13 at 9:00 a.m., numerous facility policies were reviewed, including, "Medical Records Retention", "Medical Record Gudelines for Physicians", and "Record Confidentiality", all of which had not been evaluated or revised since 2008. Multiple other policies had not been evaluated or revised since 2009 and 2010.

b) On 05/15/13 at 4:25 p.m, an interview was conducted with the facility's Director of Nursing (DON). The DON stated s/he was aware that many facility policies had not been revised for several years and that the facility was currently working to evaluate and update its policies.

d) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that many policies had not been updated or evaluated for several years and that the facility was currently working to update its policies.

Based on observations, facility policy review, and staff interviews, the facility failed to ensure that radiological procedures were performed in a manner that protected both staff and patients.

This failure contributed to patients and staff being exposed to harmful radiation and potential infectious agents.

FINDINGS:

1. The facility did not ensure preventative maintenance was performed on radiology equipment.

a) On 05/14/13 at 11:00 a.m., the facility's radiology department was toured with the facility's Director of Nursing (DON) and a radiology technician. An ultrasound machine was viewed and contained no sticker documenting that preventative maintenance had been performed. The facility's DON verified these findings.

b) On 05/16/13 at 1:00 p.m., the facility's policy,"Equipment Management Plan", was reviewed. the policy stated,"All equipment in the equipment program shall be evaluated by (company name)." The facility's DON verified this was the current policy.

2. The facility stored patient care items below the sink in the radiology area.

a) On 05/14/13 at 11:00 a.m., the facility's radiology department was toured with the facility's Director of Nursing (DON) and a radiology technician. A triangular pillow was viewed in a cabinet below the sink in the ultrasound room. The facility's radiology tech stated that this pillow was used during patient procedures.

b) The facility's DON stated that it was his/her expectation that no items would be kept below sinks.

3. The facility failed to ensure that staff members properly stored their dosimetry badges.

a) On 05/14/13 at 11:00 a.m., the facility's radiology department was toured with the facility's Director of Nursing (DON) and a radiology technician. The radiology technician stated that there were four staff members in the department and that all staff members were required to wear dosimetry badges when working in the department. The radiology technician was unable to locate the dosimetry badges for the two staff members who were not working that day. The radiology technician stated that staff members were not allowed to take dosimetry badges home or remove them from the unit when not in use.

b) On 05/15/13 at 3:30 p.m., the facility's policy, "Radiation Safety for Radiology Personnel and Patients", was reviewed. The policy stated,"All radiology personnel who may be exposed to ionizing radiation must wear monitoring devices to track amount of radiation received." The facility's DON verified this was the current policy.

Based on facility document reviews and staff interviews, the facility failed to create and maintain a current list of contracted services.
This failure created the potential for services to be performed without contractual oversight, and for services to be performed outside the contracted service's scope of practice.

FINDINGS:

1. The facility failed to maintain a current list of contracted services.

a) On 05/13/13 at 3:00 p.m., a review of the facility's document that listed contracted services was conducted. The document listed only four contracted services and contained no documentation regarding the scope or services provided by those services.

b) On 05/16/13 at 10:00 a.m., an interview was conducted with the facility's Director of Nursing (DON) in regards to the list of contracted services. The DON stated that the list of contracted services was incomplete and verified there was no documentation regarding scope and services of the contracted services.

Based on observations, staff interviews and review facility documents, the facility failed to ensure there was an individual or committee in place that evaluated contracted services.

This failure led to contracted services not being evaluated and contracted services not being performed.

FINDINGS:

1. The facility did not ensure that it had an individual or committee in charge of evaluating contracted services.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's contracted services had been evaluated.

b) On 05/15/13 at 4:25 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated the facility did not have an individual or committee that evaluated contracted services and that the facility's current list of contracted services was incomplete.

c) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility had not conducted an evaluation of contracted services.

d) Reference Tag C 222 - Maintenance: the facility failed to it had effective maintenance plans in place. Specifically, the facility failed to ensure preventative maintenance was performed on facility equipment.

Based on observations, staff interviews and review facility documents, the facility failed to ensure that contracted services furnished the agreed upon services.

This failure led to contracted services not being evaluated and contracted services not being performed.

FINDINGS:

1. The facility did not ensure that contracted services provided the agreed upon services.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's contracted services had been evaluated to ensure they were providing the agreed upon services.

b) On 05/15/13 at 8:30 a.m., a tour of the facility was conducted with the facility's Director of Nursing (DON). During the tour, it was noted that multiple pieces of equipment were overdue for preventative maintenance, which was provided by a contracted service. The DON stated it was his/her expectation that all contracted services would be provided on time and in accordance with the contracts.

c) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility had not conducted an evaluation of contracted services to ensure the companies provided the agreed upon services.

d) Reference Tag C 222 - Maintenance: the facility failed to it had effective maintenance plans in place. Specifically, the facility failed to ensure preventative maintenance was performed on facility equipment.

Based on medical record review, facility document review, and staff interview, the facility failed to maintain a record that included dated and timed signatures of the doctor of medicine or osteopathy on physician orders.

This failure led to staff being unaware of the date and time that orders were received and had the potential for services to not be provided by staff in a timely manner.

FINDINGS:

1. The facility failed to ensure that the physician orders were dated and timed in 4 (Sample Patients #7, 16, 17, and 20) out of 17 (Sample Patients #1, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20) Acute Care Unit (ACU) records reviewed.

a) On 05/16/13, a review of 17 ACU patient medical records was conducted and revealed that in 4 records the physician orders did not contain the date and time the orders were placed.

Sample Patient #7's medical record was reviewed and contained physician orders from 02/14/13 that contained a handwritten date that the orders were placed, but contained no documented time.

Sample Patient #16's medical record was reviewed and contained physician orders for Zofran 4 milligrams (mg) intravenously (IV) every 4 hours as needed for nausea, Rocephin 1 gram IV every 12 hours, and Zithromax 500 milligrams IV every day. The orders for these medications contained a physician signature, but no date or time.

Sample Patient #17's medical record was reviewed and contained physician admission orders that listed procedures to be performed and multiple medications to be administered to Sample Patient #17. The admission orders contained a physician signature, but no date or time.

Sample Patient #20's medical record was reviewed and contained physician orders for Protonix 40 milligrams IV every other day and Carafate 1 gram by mouth every other day. The physician orders contained a signature, but no date or time.

b) On 05/16/13 at 12:00 p.m., the facility's policy, "Medical Record Guidelines for Physicians", was reviewed. The policy stated,"All entries must be timed, dated, and authenticated". The facility's Director of Nursing (DON) verified this was the current policy.

Based on observations, interviews, and review of facility documents, the facility failed to ensure the confidentiality of medical record information by providing safeguards against loss and unauthorized use.

This failure had the potential to lead to unauthorized individuals accessing confidential records or for records to be lost.

FINDINGS:

1. The facility did not restrict access to medical records to those individuals with a need for access of medical records.

a) On 05/14/13 at 11:00 a.m., a tour of the facility's Radiology Department was conducted with the facility's Director of Nursing (DON). The Radiology Department had three large open shelving units that contained numerous patient radiology films. The Radiology Department was connected to the rest of the hospital by a hallway with no door and the shelving units in the Radiology Department contained no way to be locked or secured. The DON verified that these radiology films were not secure.

b) On 05/15/13 at 10:00 a.m., the surveyors and the facility's DON walked past the registration desk for the Radiology Department, which was unattended. On top of the registration desk, there was an envelope labeled as "mammography films". The facility's DON immediately removed the films and stated that it was his/her expectation that patient medical information would not be left unattended in public areas.

c) On 05/15/13 at 12:00 p.m., a tour of the facility's basement storage area was conducted with the facility's DON. The storage area contained numerous medical records from different departments in the facility and also numerous radiology films. All medical records and radiology films were contained on open shelving or in file cabinets without locks. The facility's DON verified this area could be accessed by numerous staff members.

c) On 05/15/13 at 3:30 p.m., the facility's policy, "Record Confidentiality", was reviewed. The policy stated,"Information known or contained in the patient's medical record shall be treated as confidential and will be released in appropriate circumstance only with the written consent of the patient or legal guardian". The facility's Director of Nursing (DON) verified this was the current policy.

Based on interviews and review of facility documents, the facility failed to ensure patient medical records were preserved for a minimum of 10 years.

This failure had the potential for medical records to be destroyed before being retained for 10 years.

FINDINGS:

1. The facility's policy did not ensure medical records were retained for a minimum of 10 years.

a) On 05/13/13 at 3:00 p.m., a review of the facility's policy,"Medical Record Retention", was conducted. The policy stated, "The patient records shall be preserved safely for a minimum of 7 years following the most recent dicharge date". The facility's Director of Nursing (DON) verified this was the current policy.

b) On 05/16/13 at 1:45 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The facility's CEO stated s/he was not familiar with the time frame for retaining patient medical records.

Based on the degree and manner of deficiencies, the Facility failed to be in compliance with the Condition of Participation of Surgical Services. Specifically, the Facility failed to ensure that surgical services were provided in a safe manner and that physician privileges were delineated.

This failure contributed to the risk of patient harm due to surgical instruments not being properly sterilized and physician privileges not being delineated.

FINDINGS:

1. The facility failed to ensure that instruments for surgery were properly sterilized following manufacturer's specifications and nationally recognized standards.

a) A review of the the 2011 Edition of the Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Setting by the Association of periOperative Registered Nurses (AORN) stated the following within "Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment," pages 441 and 442, in pertinent part: "Special precautions should be taken for reprocessing ophthalmic surgical instruments: Toxic anterior segment syndrome (TASS) can result from contaminants introduce into the eye during ophthalmic surgery. An incidence of TASS can cause serious damage to a patient ' s intraocular tissue and result in vision loss...Most case of TASS appear to result from inadequate instrument cleaning and sterilization...After manual or ultrasonic cleaning, instruments should be wiped with alcohol before preparation for sterilization. Wiping with alcohol disinfects the instruments and renders them safe to handle. After cleaning and disinfection, instruments contacting viscoelastic material should be inspected for residue under magnification...An adequate inventory of instruments should be provided to allow for thorough instrument cleaning and sterilization. An adequate inventory of instruments facilitates compliance with proper decontamination and sterilization processes. Adequate time should be provided for thorough instrument cleaning and sterilization. Time constraints may create a disincentive for personnel to adhere to decontamination procedures and may result in noncompliance."

b) On 05/15/13 at 10:00 a.m., a tour of the facility's surgical area was conducted with the facility's Operating Room (OR) Manager and the facility's Director of Nursing (DON). During the tour, the OR manager stated that the facility routinely used flash sterilization during patient procedures. The OR manager stated s/he was aware flash sterilization was to be used only during emergency situations, but that the facility routinely performed flash sterilization for "expediency".

c) On 05/16/13 at 12:00 p.m., the facility's policy, "Flash Sterilization," was reviewed. The policy stated,"Flash autoclaving of surgical instruments should only be done in the instance of emergency situation and/or when there is insufficient time to sterilize an item by the preferred prepackaged method and/or manufacturer's recommendation." The facility's OR Manager verified this was the current policy.

d) On 05/16/13 at 2:45 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that it was his her expectation that flash sterilization would not be routinely used in the OR.

2. The facility did not ensure that cleaning solutions were properly diluted to ensure effective cleaning and disinfection of equipment used during patient procedures.

a) On 05/15/13 at 10:00 a.m., the facility's sterile instrument cleaning area was viewed and an interview was conducted with the OR Manager. The OR Manager stated s/he cleaned the surgical instruments in a cleaning solution that s/he mixed prior to putting them in the washer. The OR Manager stated that s/he mixed "three pumps" of the cleaning solution, labeled,"Metrizyme," in an unknown amount of water that s/he estimated was the "right amount" by "looking at old water marks" in the sink. S/he stated there was no marking on the sink to indicate how many gallons it could hold. The OR Manager then read the manufacturer's instructions on the "Metrizyme" bottle to the surveyor, which stated,"to add 4 pumps (1 ounce) of Metrizyme to 1 gallon of water". The facility's OR manager was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the sink.

b) On 05/16/13 at 11:30 p.m., the facility's OR Manager was asked to provide the surveyors with the facility policy regarding disinfecting of sterile instruments. The OR Manager stated the facility currently did not have a policy regarding the cleaning of sterile instruments, except for flash sterilization.


3. The Facility failed to meet the following Standard under the Condition of Surgical Services:

Tag C 321 Designation of Qualified Practitioners
The Facility failed to ensure that physician's privileges were delineated to specify which procedures the physician could perform in the Operating Room.

Based on staff interviews and review of facility documents, the hospital failed to ensure that physician's privileges were delineated to specify which procedures the physician could perform.

This failure had the potential for physicians to perform procedures they were not authorized to perform in the facility.

FINDINGS:

1. The facility did not ensure that physician's privileges were delineated to specify which procedures they could perform.

a) On 05/15/13 at 1:00 p.m., a review of the physician credential files was conducted. No physician credential files contained delineation of privileges.

b) On 05/15/13 at 1:30 p.m., an interview was conducted with the facility's Director of Nursing's (DON) Administrative Assistant, who was in charge of maintaining the physician credential files. The Administrative Assistant stated that the physician files currently did not contain delineation of privileges.

c) On 05/16/13 at 1:15 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility currently did not have delineation of privileges on file for physicians.

Based on the degree and manner of deficiencies, the Facility failed to be in compliance with the Condition of Participation of Periodic Evaluation & Quality Assurance Review. Specifically, the Facility failed to ensure the facility implemented and maintained an effective quality program.

The Facility failed to meet the following Standards under the Condition of Surgical Services:

Tag C 0331 Periodic Evaluation
The Facility failed to carry out periodic evaluations of its total program.

Tag C 0332 Periodic Evaluation
The Facility failed to do an evaluation of the utilization of the facility's services.

Tag C 0333 Periodic Evaluation
The Facility failed to evaluate a sample of the facility's open and closed records.

Tag C 0334 Periodic Evaluation
The Facility failed to evaluate the facility's health care policies.

Tag C 0335 Periodic Evaluation
The Facility failed to ensure that the facility's utilization of services were appropriate.

Tag C 0336 Quality Assurance
The Facility failed to ensure the facility had an effective quality assurance program.

Tag C 0337 Quality Assurance
The Facility failed to ensure that all patient care services were evaluated.

Tag C 0342 Quality Assurance
The Facility failed to take appropriate remedial actions to address found deficiencies.

Tag C 0343 Quality Assurance
The Facility failed to document the outcome of remedial actions.

Based on interviews and review of facility documents, the facility failed to conduct periodic evaluations of its total program and services.

This failure had the potential for the facility's services to not meet the needs of its patient population.

FINDINGS:

1. The facility did not perform periodic evaluations of its total programs and services.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's program or services had been evaluated.

b) On 05/15/13 at 4:25 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated the facility had not performed periodic evaluations of its programs or services and did not conduct meetings to evaluate the facility.

c) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility had not conducted an evaluation of it programs or services.

Based on interviews and review of facility documents, the facility failed to conduct an annual evaluation of its services that addressed patient volume and volume of services provided.

This failure had the potential for the facility to be unaware of issues regarding patient volume and volume of services.

FINDINGS:

1. The facility did not perform annual evaluations of its services that addressed patient volume and provided services.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's program or services had been evaluated on annual basis, or that patient volume or volume of services had been addressed.

b) On 05/15/13 at 4:25 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated s/he was unaware if the facility performed annual evaluations of its services that addressed patient volume or volume of services provided.

c) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility had not conducted an annual evaluation of its services that addressed patient volume or volume of services provided.

Based on interviews and review of facility documents, the facility failed to conduct a review of active and closed patient medical records.

This failure had the potential for the facility to be unaware of issues related to documentation contained in patient medical records.

FINDINGS:

1. The facility did not perform a review of active and closed patient medical records.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents regarding quality were reviewed. The documents did not contain any documentation that the facility had performed a review of active and closed patient medical records.

b) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility had not conducted reviews of active and closed patient medical records.

Based on interviews and review of facility documents, the facility failed to evaluate, review, and revise facility health care policies.

This failure had the potential for the facility policies to be inconsistent with current facility practices.

FINDINGS:

1. The facility did not perform evaluations of its policies.

a) On 05/15/13 at 9:00 a.m., numerous facility policies were reviewed, including, "Medical Records Retention", "Medical Record Guidelines for Physicians", and "Record Confidentiality", all of which had not been evaluated or revised since 2008. Multiple other policies had not been evaluated or revised since 2009 and 2010.

b) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's policies had been evaluated, revised, or reviewed within the past year.

c) On 05/15/13 at 4:25 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated s/he was aware that many facility policies had not been revised for several years and that the facility was currently working to evaluate and update its policies.

d) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that many policies had not been updated or evaluated for several years and that the facility was currently working to update its policies.

Based on interviews and review of facility documents, the facility failed to conduct an evaluation to determine if its utilization of services was appropriate.

This failure had the potential for the facility to utilize services in a manner that resulted in patient/staff harm.

FINDINGS:

1. The facility did not perform annual evaluations of its utilization of services.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's utilization of services had been evaluated.

b) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility had not conducted an annual evaluations of its utilization of services.

Based on interviews and review of facility documents, the facility failed to implement an effective quality assurance program.

This failure had the potential for the facility to be unaware of ongoing facility issues regarding quality, resulting in potentially negative patient outcomes.

FINDINGS:

1. The facility did not have a quality assurance program.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents contained documentation of a quality plan, but no record of meeting minutes regarding quality issues.

b) On 05/15/13 at 4:25 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated the facility currently did not have a quality manager and that the facility did not conduct meetings "specifically regarding quality". The DON stated that issues regarding quality were addressed at staff meetings.

c) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility currently did not have a quality assurance program.

Based on interviews and review of facility documents, the facility failed to ensure that all patient care services and other services affecting patient health and safety were evaluated.

This failure had the potential for the facility to be unaware of issues regarding patient health and safety, resulting in negative patient outcomes.

FINDINGS:

1. The facility did not perform evaluations of its services affecting patient health and safety.

a) On 05/15/13 at 1:00 p.m., the facility's internal documents, including those regarding quality were reviewed. The documents did not contain any documentation that the facility's services affecting patient health and safety had been evaluated.

b) On 05/15/13 at 4:25 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated the facility did not have a quality assurance program in place at this time.

c) On 05/16/13 at 1:00 p.m., an interview was conducted with the facility's Chief Executive Officer (CEO). The CEO stated that the facility currently did not have a quality assurance program that addressed services affecting patient health and safety.

Based on interviews and review of facility documents, the facility failed to ensure that remedial actions were taken to correct deficiencies that occurred in the facility.

This failure had the potential for staff members to be unaware that they were performing actions in a way that was inconsistent with facility policies.

FINDINGS:

1. The facility did not ensure proper remedial actions were conducted when deficiencies were identified.

a) On 05/13/13 at 2:45 p.m., the facility's internal documents were reviewed and contained documentation of a Registered Nurse (RN) administering an inaccurate dosage of a controlled substance to a patient. The patient had to be treated for negative medical side effects that resulted from the inaccurate dosage of the administered medication.

b) On 05/15/13 at 2:00 p.m., a review of the facility's personnel files was conducted. The personnel file of the RN who had administered the inaccurate dosage of the controlled substance was reviewed. The personnel file contained no documentation of the incident being addressed with the RN and no documentation of remedial action being taken to the address the incident.

c) On 05/15/13 at 3:45 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated s/he was sure the incident had been addressed with the RN, but was unable to locate any documentation regarding the incident or any remedial action taken.

Based on interviews and review of facility documents, the facility failed to document the outcome of remedial action.

This failure had the potential for the facility to have no record that staff had been re-educated on issues regarding patient safety.

FINDINGS:

1. The facility did not ensure proper remedial actions were conducted and documented.

a) On 05/13/13 at 2:45 p.m., the facility's internal documents were reviewed and contained documentation of a Registered Nurse (RN) administering an inaccurate dosage of a controlled substance to a patient. The patient had to be treated for negative medical side effects that resulted from the inaccurate dosage of the administered medication.

b) On 05/15/13 at 2:00 p.m., a review of the facility's personnel files was conducted. The personnel file of the RN who had administered the inaccurate dosage of the controlled substance was reviewed. The personnel file contained no documentation of the incident being addressed with the RN and no documentation of remedial action being taken to the address the incident.

c) On 05/15/13 at 3:45 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON stated s/he was sure the incident had been addressed with the RN, but was unable to locate any documentation regarding the incident or any remedial action taken.

Based on facility document review and staff interview the facility failed to ensure that the facility had an agreement with an eye bank.

Findings:

1. The facility did not have a contract with an eye bank as required.

a) Upon entering the facility on 05/13/13, the facility was requested to provide a list of all contracts and agreements that the facility had.

b) A review of the list provided on 05/13/13 revealed that the list of services did not include an agreement with an eye bank.

c) Subsequent requests were made for an agreement between the hospital and an eye bank on 05/14/13 at 8:46 a.m. of the facility's Chief Executive Officer and on 05/16/13 at 11:39 a.m. of the facility's Chief Nursing Officer.

d) At the time of exit on 05/16/13 at 1:45 p.m. an agreement with an eye bank was not received.

Based on the manner and degree of deficiencies cited, the Facility failed to be in compliance with the Special Requirements for CAH Providers of Long-Term Care Services (Swing-Beds). The Facility failed to ensure the facility adhered to the special requirements for the provision of long-term care services (swing-bed services).

The Facility failed to meet the following Standards under the Special Requirements for CAH Providers of Long-Term Care Services:

Tag C 0388 - Resident Assessment:
The facility failed to ensure that the facility's staff conducted a comprehensive assessment that included the required elements reflected in this regulation after admission to the hospital's swing-bed program.

Tag C0389 - Resident Assessment - When Required:
The facility failed to ensure that the facility's staff conducted a comprehensive assessment within 14 calendar days after admission to the hospital's swing-bed program after prolonged hospitalization.

Tag C0390 - Frequency of Assessments:
The facility failed to ensure that the facility's staff performed a comprehensive assessment within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition or not less often than once every 12 months while admitted to the hospital's swing-bed program.

Tag C0395 - Comprehensive Care Plans:
The facility failed to ensure that the facility's staff developed a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The facility failed to ensure that the care plans developed included the services that were to be furnished to attain or maintain the resident's highest practicable well-being.

Tag C0396 - Comprehensive Care Plans:
The facility failed to ensure that the facility's staff developed a comprehensive care plan for each resident that was prepared by an interdisciplinary team which included the attending physician, a registered nurse, other appropriate staff, and the resident or the resident's family or legal representative.

Tag C0398 - Services Provided:
The facility failed to ensure that services were provided by qualified persons. The facility failed to ensure that actions that required a registered nurse's judgment were conducted by a registered nurse or by someone that was delegated the task under the direction of a registered nurse.

Based on medical record review and staff interview the facility failed to ensure that the facility's staff conducted a comprehensive assessment that included the required elements reflected in this regulation after admission to the hospital's swing-bed program.

This failure had the potential to lead to patient needs and problems to go unnoticed and to not be addressed by the interdisciplinary team.

Findings:

1. The facility's staff did not perform a complete comprehensive assessment on two (Sample Patients #5 and #6) of 2 swing-bed patients whose records were reviewed.

a. A review of Sample Patient #5's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 03/30/13. The facility's staff had documented a partial assessment of the patient on a form titled "Admission Assessment and Interim Plan of Care" which served as the form to document the comprehensive assessment required by this regulation. The form was dated 03/30/13 and had many areas that were left blank including how the information was obtained (documentation of the patient's participation in assessment), pain assessment, and much of the initial discharge planning section. Additionally, there were 3 places on the 4 page form for a signature and title of the person completing the form. 2 of the signatures were missing.

The patient was transferred to the hospital's acute care program from 04/06/13 through 04/16/13 due to becoming lethargic and unresponsive. The patient returned to the hospital's swing-bed program on 04/17/13. The facility's staff had not conducted a comprehensive assessment upon the patient's readmission.

b. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) during the review of Sample Patient #5's medical record. S/he stated that the facility's staff was expected to complete all areas of the comprehensive assessment form and sign each area that asked for a signature. S/he confirmed that Sample Patient #5's assessment was incomplete. S/he stated that staff was expected to perform a comprehensive assessment of the patient after an acute hospitalization. S/he confirmed that the patient's record did not contain another assessment than the one originally performed upon the patient's initial admission into the facility's swing-bed program.

c. A review of Sample Patient #6's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 01/22/13. The facility's staff had documented a partial assessment of the patient on a form titled "Admission Assessment and Interim Plan of Care" which served as the form to document the comprehensive assessment required by this regulation. The form was dated 01/22/13 and had some areas that were left blank including how the information was obtained (documentation of the patient's participation in assessment), current medications, and the initial discharge planning section. Additionally, there were 3 places on the 4 page form for a signature and title of the person completing the form. All 3 of the signatures were missing.

The patient was transferred to another hospital's acute care program from 02/27/13 through 04/10/13 due to developing worsening abdominal pain and requiring surgery. The patient also required mechanical ventilatory support for his/her respirations during that hospitalization. The patient returned to the hospital's swing-bed program on 04/10/13. The facility's staff had not conducted a comprehensive assessment upon the patient's readmission.

d. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) during the review of Sample Patient #6's medical record. S/he stated that the facility's staff was expected to complete all areas of the comprehensive assessment form and sign each area that asked for a signature. S/he confirmed that Sample Patient #6's assessment was incomplete. S/he stated that staff was expected to perform a comprehensive assessment of the patient after an acute hospitalization. S/he confirmed that the patient's record did not contain another assessment than the one originally performed upon the patient's initial admission into the facility's swing-bed program.

Based on medical record review and staff interview the facility failed to ensure that the facility's staff conducted a comprehensive assessment within 14 calendar days after admission to the hospital's swing-bed program after prolonged hospitalization.

This failure had the potential to lead to patient needs and problems to go unnoticed and to not be addressed by the interdisciplinary team.

Findings:

1. The facility's staff did not perform a comprehensive assessment on two (Sample Patients #5 and #6) of 2 swing-bed patients whose records were reviewed after each patient was readmitted to the swing-bed program after acute hospitalizations with significant changes in the patients' health statuses.

a. A review of Sample Patient #5's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 03/30/13. The facility's staff had documented a partial assessment of the patient on a form titled "Admission Assessment and Interim Plan of Care" which served as the form to document the comprehensive assessment required by this regulation. The form was dated 03/30/13 and had many areas that were left blank including how the information was obtained (documentation of the patient's participation in assessment), pain assessment, and much of the initial discharge planning section. Additionally, there were 3 places on the 4 page form for a signature and title of the person completing the form. 2 of the signatures were missing.

The patient was transferred to the hospital's acute care program from 04/06/13 through 04/16/13 due to becoming lethargic and unresponsive. The patient returned to the hospital's swing-bed program on 04/17/13. The facility's staff had not conducted a comprehensive assessment upon the patient's readmission.

b. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) during the review of Sample Patient #5's medical record. S/he stated that the facility's staff was expected to complete all areas of the comprehensive assessment form and sign each area that asked for a signature. S/he confirmed that Sample Patient #5's assessment was incomplete. S/he stated that staff was expected to perform a comprehensive assessment of the patient after an acute hospitalization. S/he confirmed that the patient's record did not contain another assessment than the one originally performed upon the patient's initial admission into the facility's swing-bed program.

c. A review of Sample Patient #6's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 01/22/13. The facility's staff had documented a partial assessment of the patient on a form titled "Admission Assessment and Interim Plan of Care" which served as the form to document the comprehensive assessment required by this regulation. The form was dated 01/22/13 and had some areas that were left blank including how the information was obtained (documentation of the patient's participation in assessment), current medications, and the initial discharge planning section. Additionally, there were 3 places on the 4 page form for a signature and title of the person completing the form. All 3 of the signatures were missing.

The patient was transferred to another hospital's acute care program from 02/27/13 through 04/10/13 due to developing worsening abdominal pain and requiring surgery. The patient also required mechanical ventilatory support for his/her respirations during that hospitalization. The patient returned to the hospital's swing-bed program on 04/10/13. The facility's staff had not conducted a comprehensive assessment upon the patient's readmission.

d. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) during the review of Sample Patient #6's medical record. S/he stated that the facility's staff was expected to complete all areas of the comprehensive assessment form and sign each area that asked for a signature. S/he confirmed that Sample Patient #6's assessment was incomplete. S/he stated that staff was expected to perform a comprehensive assessment of the patient after an acute hospitalization. S/he confirmed that the patient's record did not contain another assessment than the one originally performed upon the patient's initial admission into the facility's swing-bed program.

Based on medical record review and staff interview the facility failed to ensure that the facility's staff performed a comprehensive assessment within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition or not less often than once every 12 months while admitted to the hospital's swing-bed program.

This failure had the potential to lead to patient needs and problems to go unnoticed and to not be addressed by the interdisciplinary team.

Findings:

1. The facility's staff did not perform a comprehensive assessment on two (Sample Patients #5 and #6) of 2 swing-bed patients whose records were reviewed after each patient was readmitted to the swing-bed program after acute hospitalizations with significant changes in the patients' health statuses.

a. A review of Sample Patient #5's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 03/30/13. The facility's staff had documented a partial assessment of the patient on a form titled "Admission Assessment and Interim Plan of Care" which served as the form to document the comprehensive assessment required by this regulation. The form was dated 03/30/13 and had many areas that were left blank including how the information was obtained (documentation of the patient's participation in assessment), pain assessment, and much of the initial discharge planning section. Additionally, there were 3 places on the 4 page form for a signature and title of the person completing the form. 2 of the signatures were missing.

The patient was transferred to the hospital's acute care program from 04/06/13 through 04/16/13 due to becoming lethargic and unresponsive. The patient returned to the hospital's swing-bed program on 04/17/13. The facility's staff had not conducted a comprehensive assessment upon the patient's readmission.

b. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) during the review of Sample Patient #5's medical record. S/he stated that the facility's staff was expected to complete all areas of the comprehensive assessment form and sign each area that asked for a signature. S/he confirmed that Sample Patient #5's assessment was incomplete. S/he stated that staff was expected to perform a comprehensive assessment of the patient after an acute hospitalization. S/he confirmed that the patient's record did not contain another assessment than the one originally performed upon the patient's initial admission into the facility's swing-bed program.

c. A review of Sample Patient #6's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 01/22/13. The facility's staff had documented a partial assessment of the patient on a form titled "Admission Assessment and Interim Plan of Care" which served as the form to document the comprehensive assessment required by this regulation. The form was dated 01/22/13 and had some areas that were left blank including how the information was obtained (documentation of the patient's participation in assessment), current medications, and the initial discharge planning section. Additionally, there were 3 places on the 4 page form for a signature and title of the person completing the form. All 3 of the signatures were missing.

The patient was transferred to another hospital's acute care program from 02/27/13 through 04/10/13 due to developing worsening abdominal pain and requiring surgery. The patient also required mechanical ventilatory support for his/her respirations during that hospitalization. The patient returned to the hospital's swing-bed program on 04/10/13. The facility's staff had not conducted a comprehensive assessment upon the patient's readmission.

d. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) during the review of Sample Patient #6's medical record. S/he stated that the facility's staff was expected to complete all areas of the comprehensive assessment form and sign each area that asked for a signature. S/he confirmed that Sample Patient #6's assessment was incomplete. S/he stated that staff was expected to perform a comprehensive assessment of the patient after an acute hospitalization. S/he confirmed that the patient's record did not contain another assessment than the one originally performed upon the patient's initial admission into the facility's swing-bed program.

2. The facility did not have a process in place to perform reassessments of patients at least every 12 months.

a. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) on 05/16/13 at 10:15 a.m. S/he stated that the facility did not have a process for completing the comprehensive assessment on a regular basis after admission if the patient remained in the hospital for more than 12 months. S/he stated that the majority of the facility's swing-bed patients were there on a long-term basis and usually stayed for over 12 months.

Based on medical record review and staff interview the facility failed to ensure that the facility's staff developed a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The facility failed to ensure that the care plans developed included the services that were to be furnished to attain or maintain the resident's highest practicable well-being.

This failure had the potential to lead to patient needs and problems to go untreated and unplanned and to not be addressed by the interdisciplinary team.

Findings:

1. The facility's staff did not develop a complete comprehensive care plan for two (Sample Patients #5 and #6) of 2 swing-bed patients whose records were reviewed.

a. A review of Sample Patient #5's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 03/30/13. The facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) who was an licensed practical nurse (LPN) had developed the patient's care plan on 03/30/13 which included 10 nursing diagnoses and a problem of "activities". Further review of the forms revealed that each were preprinted and did not include specific patient-specific objectives and did not include timetables. Additionally, many of the forms had blanks that were not filled in. The "activities" problem had listed "Independent, Dependent on staff, active participant, and passive participant" listed indicating that staff were to identify the patient's level of participation and dependency on staff which were not indicated by staff.

The patient was transferred to the hospital's acute care program from 04/06/13 through 04/16/13 due to becoming lethargic and unresponsive. The patient returned to the hospital's swing-bed program on 04/17/13. The patient's care plan was not updated until 04/29/13 and included the addition of "problems" of 8 medications and 1 "problem" of allergies/intolerance to foods. The "problems" for the 8 medications listed medications and dosages with the expected outcomes of each medication and side effects, precautions, and contraindications for each medication. There were no specifically identified goals or patient specific information for any of the 8 medications. The "problem" of "allergies/intolerance to foods" did not specify what allergies or intolerance existed, nor specific information that pertained to the patient in relation to allergies or intolerance to certain foods. Additionally, there was the addition of 2 problems of incontinence (both bladder and bowel). Neither plan included patient specific interventions, timetables or expected measurable outcomes specific to the patient.

b. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit during the review of Sample Patient #5's medical record. S/he stated that s/he had developed the patient's care plan independently. S/he stated that the facility did not have an interdisciplinary team develop the patient's care plan. S/he confirmed that the care plan did not include patient-specific measurable objective outcomes nor timetables.

c. A review of Sample Patient #6's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 01/22/13. The facility's Coordinator of the facility's Extended Care Unit who was an LPN had developed the patient's care plan on 01/29/13 which included 13 nursing diagnoses and a problem of "activities". Further review of the forms revealed that each were preprinted and did not include specific patient-specific objectives and did not include timetables. The "activities" problem had listed "Independent, Dependent on staff, active participant, and passive participant" listed indicating that staff were to identify the patient's level of participation and dependency on staff which were not indicated by staff. The patient's care plan also included the "problems" of 4 medications. The "problems" for the 4 medications listed medications and dosages with the expected outcomes of each medication and side effects, precautions, and contraindications for each medication. There were no specifically identified goals or patient specific information for any of the 4 medications.

The patient was transferred to another hospital's acute care program from 02/27/13 through 04/10/13 due to developing worsening abdominal pain and requiring surgery. The patient also required mechanical ventilatory support for his/her respirations during that hospitalization. The patient returned to the hospital's swing-bed program on 04/10/13. The patient's care plan was not updated until 04/29/13 and included the addition of 3 problems. The plans did not include timetables or expected measurable outcomes specific to the patient. The update on 04/29/13 also included the discontinuation of two of the medication "problems" as the patient did not return on those medications.

d. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit during the review of Sample Patient #6's medical record. S/he stated that s/he had developed the patient's care plan independently. S/he stated that the facility did not have an interdisciplinary team develop the patient's care plan. S/he confirmed that the care plan did not include patient-specific measurable objective outcomes nor timetables.

Based on medical record review and staff interview the facility failed to ensure that the facility's staff developed a comprehensive care plan for each resident that was prepared by an interdisciplinary team which included the attending physician, a registered nurse, other appropriate staff, and the resident or the resident's family or legal representative.

This failure had the potential to lead to patient needs and problems to go untreated and unplanned and to not be addressed by the interdisciplinary team. Additionally, the failure to include the resident or the resident's family/legal representative contributed to the patients' plans not being individualized to each patient.

Findings:

1. The facility's staff did not develop a complete comprehensive care plan for two (Sample Patients #5 and #6) of 2 swing-bed patients whose records were reviewed with an interdisciplinary team as required in this regulation.

a. A review of Sample Patient #5's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 03/30/13. The facility's Coordinator of the facility's Extended Care Unit (the name the facility had given to its swing-bed program) who was an licensed practical nurse (LPN) had developed the patient's care plan on 03/30/13 which included 10 nursing diagnoses and a problem of "activities".

b. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit during the review of Sample Patient #5's medical record. S/he stated that s/he had developed the patient's care plan independently. S/he stated that the facility did not have an interdisciplinary team develop the patient's care plan. S/he confirmed that the care plan did not include patient-specific measurable objective outcomes nor timetables.

c. A review of Sample Patient #6's medical record was conducted on 05/16/13. The patient was admitted to the hospital's swing-bed program on 01/22/13. The facility's Coordinator of the facility's Extended Care Unit who was an LPN had developed the patient's care plan on 01/29/13 which included 13 nursing diagnoses and a problem of "activities". The patient's care plan also included the "problems" of 4 medications.

d. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit during the review of Sample Patient #6's medical record. S/he stated that s/he had developed the patient's care plan independently. S/he stated that the facility did not have an interdisciplinary team develop the patient's care plan.

Based on medical record review and staff interview the facility failed to ensure that services were provided by qualified persons. The facility failed to ensure that actions that required a registered nurse's judgment were conducted by a registered nurse or by someone that was delegated the task under the direction of a registered nurse.

This failure created the potential for patient's needs to not be addressed adequately due to the lack of oversight.

Findings:

1. The facility had an LPN (licensed practical nurse) independently create care plans for patients. Additionally the facility did not have an RN (registered nurse) oversee assessments and other delegated functions performed by LPNs in the facility.

a. Cross Reference to C0395 - Comprehensive Care Plans, and C0396 - Comprehensive Care Plans for findings related to the facility's failure to ensure that an RN was involved in the care planning process for swing-bed patients.

b. A review of a document that was published by the Colorado Board of Nursing that was "developed for use in determining scope of practice" stated that LPNs could contribute to assessments, assist in identification of health care problems, contribute to establishing goals, and participate in planning a strategy of care. The document states that an RN was responsible for assessments, identification of health care problems, establishing goals, developing a written plan of care, and remaining responsible for all delegated acts in the implementation of the plan of care.

c. An interview was conducted with the facility's Coordinator of the facility's Extended Care Unit on 05/16/13 at 10:15 a.m. S/he stated that s/he developed the swing-bed patients' care plans independently. S/he stated that the facility had not had an interdisciplinary team develop the patient's care plan. S/he stated that s/he was not aware that as an LPN, s/he was not able to perform this task independently. S/he reviewed the above document from the Colorado Board of Nursing and confirmed that the document was clear that assessment and care planning were delegated functions and required oversight of an RN. S/he stated that the hospital did not currently have a method to document oversight by an RN of delegated tasks of assessment and care planning when it was performed by an LPN.