HospitalInspections.org

Based on interviews and review of the governing board committee meeting minutes, the provider failed to ensure:
*A total annual program review and evaluation of the facility and their services they provided had occurred.
*A comprehensive facility wide Quality Assurance Performance Improvement program (QAPI) that ensured all departments and services had developed and implemented a system/process improvement plan.
*A comprehensive infection control program was implemented under the direction of a fully trained infection control (IC) officer.
*Four of eleven departments [maintenance, housekeeping, pharmacy, and nursing] had completed an annual review of their policies and procedures.
*Medication security had occurred in two of two emergency department rooms.
*Nutritional assessments had been completed on swingbed patients by one of one registered dietician (RD).
*Substantial compliance was maintained with previously cited regulatory deficiencies (C272 and C333).
Findings include:

1. The hospital failed to develop a process to ensure a periodic review of their total program had occurred annually. They had been previously cited on 1/22/15 for regulatory deficiency C333.

Refer to C331, finding 1.

2. The hospital failed to ensure a QAPI program was developed to encompass all hospital departments and services including nursing services, social services, activities, environmental, dietary services, contracted vendors, emergency department, pharmacy department, rehabilitation department, diagnostic services, laboratory services, outpatient services, and swing bed in developing and implementing a system/process improvement plan.

Refer to C336.

3. The hospital failed to ensure registered nurse (RN) B had the appropriate training and guidelines to follow to fulfill her roll as the IC officer, program development reviewer, and QAPI director.

Refer to C270, C278, C330, C331, and C336.

4. The hospital failed to ensure the maintenance, housekeeping, pharmacy, and nursing services departments had completed an annual review of their policies and procedures. C272 had been previously cited during the 1/22/15 survey.

Refer to C272.

5. The hospital failed to ensure a process was in place for the security of medications and the accountability of narcotics had occurred in emergency rooms one and two.

Refer to C276.

6. The hospital failed to ensure the RD had completed nutritional assessments on four reviewed swingbed patients.

Refer to C401.

35237




32332

Based on observation, interview, and policy review, the provider failed to:
*Develop a comprehensive infection control (IC) program for identifying, trending, tracking, and investigating infections.
*Have a method to monitor and track communicable diseases for employees.
*Review and update infection control policies.
*Ensure:
-The IC nurse had received the education necessary for directing a comprehensive infection control program.
Findings include:

1. Interview on 4/17/18 at 2:00 p.m. with IC nurse B revealed:
*She had accepted the role of IC nurse in October 2017.
*The director of patient care services had done been the IC nurse before she had taken over.
-The infection trending and tracking data he had given her had been from 2007.
*She:
-Was unable to locate more recent trending, tracking, and investigating of infections.
-Had no infection control background other than her role as a floor nurse.
-Planned to enroll in an infection preventionist program but had not yet enrolled.
-Was given permission to enlist services of an IC consultant to provide recommendations.
*There was no IC committee nor IC meetings.
*There was no infection prevention and control policy.
*The director of nursing (DON) was responsible for employee health concerns.
*Infection information:
-Had been gathered to comply with the Hospital Improvement Innovation Network (HINN) in order to receive payment.
-The HINN information:
--Had not been investigated for infection prevention, control, or education to staff.
--Was not part of the Quality Assurance review.
-She gave the above information to the director of patient care services.
-She did not know what the director did with that information.

Continued interview with IC nurse B revealed:
*The IC consultant had visited on 2/8/18. She:
-Provided a number of recommendations.
-Identified the provider's current IC policies were outdated and had not reflected the current practices in the hospital.
-Recommended updating the policies.
-Recommended regular environmental infection control rounds.
*Since the 2/8/18 consultant meeting:
-The IC nurse had developed an infection prevention and control policy and updated three other IC policies.
-Those policies had not yet been presented to the governing board for approval.

Interview on 4/18/18 at 8:30 a.m. with the DON revealed:
*She:-Was responsible for the employee health program.
-Had not maintained a log of employee communicable diseases.
-Confirmed:
--The provider did not have an infection control program in place for identifying, trending, tracking, and investigating infections.
--She had received HINN reports from the IC nurse, but no infection trending/tracking or investigating had been completed.
--The information was not getting to the governing board.
--The previous administrator had not allowed the staff to talk to the governing board.
*The laboratory (lab):
-Had previously been assessing and tracking/trending infections.
-Stopped the infection assessments about one or two years ago.

Interview on 4/18/18 at 9:10 a.m. director of patient care services F regarding infection control confirmed:
*He had been responsible for the infection control program until the IC nurse had taken over in October 2017.
*The provider did not have an infection control program in place for identifying, trending, tracking, and investigating infections.
*He had not made infection control "top priority."
*There was no IC committee nor IC meetings.
*Staff had discussions regarding infection control, but nothing had been documented.
*He had provided all the previous IC material to the IC nurse when she had started.
*Some trending/tracking had been done by the lab.
-He would locate and provide that lab information.
*He was not aware the IC policies had not been reviewed or signed.

Interview on 4/18/18 at 2:00 p.m. with lab director/manager D revealed he was not aware of the lab personnel assessing and tracking/trending infections.

No material was provided to this surveyor on request to director of patient care services F on 4/18/18 at 9:10 a.m. and at 2:20 p.m. for information on assessing and tracking/trending infections from the lab.

Interview on 4/18/18 at 4:15 p.m. with IC nurse B revealed:*Infection control policies:
-Were either outdated or non-existent.
-Had not been reviewed or updated with current hospital practices.
*She was unable to locate the requested infection control policies for:
-Infection prevention and control.
-Infection control meetings.
-Employee health services.
-An infection control job description.

Refer to C278 findings 1, 2, 3, 4, 5, 6, and 7 for further infection control information.

Based on interview and policy manual review, the provider failed to ensure policies were reviewed annually for 4 of 11 departments (maintenance, housekeeping, pharmacy, and nursing). Findings include:

1. Review of the pharmacy department's policy and procedure manual revealed it had been reviewed on 2/11/15 and 10/25/17 by the medical staff chairman. It had not been reviewed in 2016.

Interview on 4/18/18 at 11:25 a.m. with director of pharmacy services E confirmed the policy manual had not been reviewed annually.

2. Interview and record review on 4/18/18 at 2:15 p.m. of the maintenance and housekeeping policy and procedure manuals with director of quality assurance/infection control/utilization review B revealed:
*There was no documentation to support they had been reviewed annually or when the last review had been done.
*Review of the policies indicated several were many years old.
-The most recent updates appeared to have been in March 2015.
*She confirmed all policies should have been reviewed annually.




32355

3. Review of the dietary department's policy and procedure manual revealed it had last been reviewed on 1/2/15 by the dietary manager (DM), registered dietician, and administrator.
-There was no documentatioin to support the medical staff chairman had reviewed and approved those policies.

Interview on 4/17/18 at 1:45 p.m. with DM L revealed she:
*Confirmed the policy manual had not been reviewed annually.
*Had not been aware:
-Those policies should have been reviewed every year.
-That concern had been identified by the prior survey team during their last recertification on 1/22/15.
*Agreed as a department director she should have been made aware of that concern.




32332

4. Refer to C270, finding 1 regarding the provider's failure to ensure infection control policies had been developed, reviewed, and updated.

Surveyor: 32355
5. Interview on 4/19/18 at 3:15 p.m. with interim co-administrator J revealed:
*She was not aware:
-The policies and procedures for each of the above departments had not been updated annually.
-That had been a concern identified by the previous survey team on 1/22/15.
*To her knowledge there was no process in place for reviewing policy and procedure manuals annually.

Based on observation, interview, record review, and policy review, the provider failed to ensure processes had been in place for: *The accountability of narcotic medications stored in two of two emergency rooms.
*The security of medications in two of two emergency rooms by periodically changing the access combinations and codes of the medication storage areas.
Findings include:

1. Observation on 4/16/18 at 5:00 p.m. of emergency room 1 revealed medications had been stored in:
*A wheeled crash cart with a key pad access to unlock it.
*Two upper cabinets with combination locks on them.
*Inside one of those upper cabinets was a lock box with a key pad access to it.

2. Observation and interview on 4/17/18 at 8:50 a.m. of emergency room 2 with the director of nursing revealed:*Medications were stored the same way in both the emergency rooms.
*Both had wheeled crash carts with key pads to unlock them.
*Both had two upper cupboards with combination locks on them.
*Inside the upper cabinet was a separate lock box with a key pad access.
-That lock box stored narcotic medications.
*The outside of the cupboard had a list of what medications were stored inside of it.
*She unlocked the upper cupboard and lock box using the combination and key pad code.
*Medications inside the lock box included:-Demerol.
-Diazepam.
-Hydromorphone.
-Two different doses of morphine.
-Midazolam.
-Fentanyl.
--There were two carpjects or vials of each of those medications.
*There was no process in place to monitor the accountability of those medications.
-She thought the pharmacist checked the narcotics in those lock boxes but was unsure of how often.
*The crash carts were checked by the night shift nurses.
-They checked for out-dated medications but had not checked for quantities of medications.
*She agreed all nurses and the pharmacist knew the combinations and key pad codes.
-They could have accessed those medications at anytime.
*If a medication was used for a patient it would have been logged as ordered and been able to be tracked.
*If a medication was taken or diverted it would have been difficult to track it, since they had no process for checking them routinely.
*There was no process in place to change the combinations or codes for the cabinets or key pad locks.
-She agreed those should have been changed periodically for security purposes.
*She confirmed narcotics were high risk medication for diversion or mis-use.

Observation, interview, and record review, on 4/17/18 at 2:30 p.m. with director of pharmacy services E in emergency room 2 revealed:*She agreed all medications including narcotics should have been securely stored.
*She was not aware of the combination or key pad codes for the medication storage areas being changed on a routine basis.
-She agreed they should have been changed periodically for security since all nurses knew the codes.
*The list of the narcotic medications and what was in the lock box indicated:
-Two vials of Fentanyl were not mentioned on the list and should have been.-There should have been two vials or carpujets of each narcotic medication.
*She stated she had not updated the master list for the Fentanyl and should have.
-The Fentanyl count was correct.
*She only checked those lock boxes and medication counts monthly and as needed.
*There was no process in place to check those narcotic medications and their accountabilities in-between her monthly checks.
-It would have been difficult to identify if and when a medication was missing with their current process.
*She agreed the narcotic medications should have been checked more frequently than monthly due to amount of staff who had access to them.
*Narcotic medications were considered medications at high risk for diversion or mis-use.
-There should have had processes implemented to ensure their accountability.

3. Interview on 4/17/18 at 2:50 p.m. with registered nurse N regarding the emergency rooms medication storage revealed:*She confirmed the above findings.
*All nurses and the pharmacist had access to those medications at anytime.
*Narcotic medications were high risk medications and should have been accounted for with access limited.
*She was not aware of the combination or key pad codes being changed on a routine basis.

Review of the provider's 10/25/17 Pharmacy Policy and Procedure manual revealed:*Pharmacist responsibilities included:
-"Dispense all narcotic drugs, barbiturates, alcohol, and other restricted or controlled drugs and maintain the required records related thereto."
-"Establish procedures for access to the Hospital Pharmacy stock of drugs including procedures for emergency situations."
-"Inspect ALL drug storage and medication areas monthly."*For narcotics:
-"All narcotics (CII-V) will be secured in a locked cabinet and a perpetual inventory maintained."-"The pharmacist and the director of nursing will have keys to access the narcotic cabinet."
*There was no mention of:
-How the medications were monitored for accountability.
-A process for changing the combinations or codes of the medication storage areas or how often that should have occurred.

Review of the provider's undated Medications Stocked in ER and OP policy from the nursing policy and procedure manuals revealed:*"Medications will be stocked in a locked cupboard of the ER and Procedure Rooms. Controlled medications will be kept in the safe within the locked cupboard. A list of medications and the quantities of each will be posted inside the cupboard with the medications. Medications will be replaced by the nurse after each use. Medications will be checked monthly for outdates by the nursing staff."*There was no mention of:
-How the medications were montitored for accountability.
-A process for changing the combinations or codes for the medications storage areas or how often that should have occurred.

32355




35237

Based on observation, interview, and policy review, the provider failed to ensure:
*Four of four clean patient care commodes had been stored in clean storage areas.
*Patient care items (three meal lap trays and two vinyl bolsters) for two of two patient care closets had been stored off the floor.
*Cardboard boxes containing patient care items had been stored off the floor in one of one clean utility room.
*Cleaning solutions used by dietary staff for kitchen disinfection had been tested for effectiveness.
*Linen delivered to the scope room had remained covered during the delivery.
*Housekeeping staff had knowledge of contact times required for use of disinfectant chemicals according to manufacturer's recommendations.
*Sanitary storage of supplies in two of two laboratory blood drawing rooms.
*Appropriate hand washing had been done by one of one laboratory technician (tech) (O) and one of three registered nurses (RN) (P) during patients' (8 and 38) care.
Findings include:

Surveyor: 32332
1a. Observation on 4/16/18 at 4:15 p.m., and further observations on 4/17/18 at 8:15 a.m., and on 4/18/18 at 7:45 a.m. of the acute care area revealed two patient item closets across from the nurses station with the following:
*The smaller closet contained a blue vinyl bolster cushion resting on the floor.
*The larger closet contained three meal lap trays and two blue vinyl bolsters resting on the floor.

b. Observation on 4/16/18 at 4:18 p.m. of the soiled utility room revealed four patient commodes stored directly across from a hopper used for cleaning soiled items.

c. Observation on 4/16/18 at 4:25 p.m. of an unmarked room across from emergency room 1 revealed three cardboard boxes placed directly on the floor. Those boxes contained:
*Disposable gowns.
*Splint material for patient use.
*A plaster roll immobilizer for patient use.

d. Observation on 4/16/18 at 4:30 p.m. of the storage room across from the pharmacy revealed a cardboard box placed directly on the floor containing telemetry equipment.

e. Interview on 4/18/18 at 1:55 p.m. with director of environmental services G regarding the above observations confirmed:
*The unmarked room was a clean utility room.
*Patient care equipment should not have been stored on the floor.
*The commodes in the soiled utility room had been cleaned.
*Clean patient equipment should not have been stored in a soiled room.
*The boxes should not have been stored directly of the floor.

Surveyor: 32355
2a. Observation on 4/17/18 at 8:20 a.m. of the dishwashing area in the kitchen revealed:
*A clipboard hanging on a wall with two sheets of paper attached to it.
-Those sheets of paper had been used to document the temperature and chlorine levels of the dishwasher.
-April 2018 was handwritten on both of the sheets with AM on one and PM on the other.
*On the sheet of paper labeled:
-April 2018 AM there were three out of seventeen days with no documentation to support the temperature and chlorine levels of the dishwasher had been checked.
-April 2018 PM revealed the same documentation as the AM sheet of paper.

Interview on 4/17/18 at 8:23 a.m. with dietary aide T revealed she:
*Confirmed the above observation.
*Confirmed the dietary staff should have been checking the temperature and chlorine level of the dishwasher each shift.
*Agreed if there was no documentation it would have been considered not done.
*Stated "That's our policy to check the temperature and chlorine level every shift."

Review of the dishwasher temperature and chlorine level checking logs from 2/1/18 through 3/1/18 revealed:
*No documentation to support the staff had checked the temperature and chlorine level for:
-February 2018:
--The AM shift four out of the twenty-eight days.
--The PM shift twelve out of twenty-eight days.
-March 2018:
--The AM shift three out of thirty-one days.
--The PM shift ten out of thirty-one days.

b. Continued observation on 4/17/18 at 8:30 a.m. of the kitchen revealed:
*A bucket next to the three compartment sink filled three-fourths full of a whitish/gray colored liquid.
-That bucket contained one wet cloth.

Interview on 4/17/18 at the time of the above interview with dietary manager L revealed:
*She confirmed the bucket contained a quaternary (quat) sanitizing solution and was used to clean all the kitchen surfaces.
-That solution had been changed between shifts.
*The sanitizer was distributed from a dispenser above the three compartment sink.
-The dispenser had been automatically set for the correct dispensing amount.
-The sanitizer was then mixed with a bucket of hot water.
*She:
-Was not aware they should have tested the sanitizing solution for the correct parts-per-million (ppm).
-Stated:
--"Ecolab comes every month to check it and make sure it is set for the correct ppm."
--"We just assume it is the correct level."
-Had found some Hydrion QT-40 quat test strips in the cupboard next to the three compartment sink.
*The test strip roll had:
-No expiration date on it.
-Been discolored in random areas.
*She took a piece of the test strip and submerged it into the sanitizing solution.
-That test strip had not changed color to support there was any sanitizing solution in the bucket.
*She agreed they should have been periodically checking the ppm of the solution to ensure proper sanitation had occurred.

Continued interview revealed she:
*Confirmed the dietary staff were to have been checking the temperature and chlorine levels for the dishwasher each shift.
*Agreed if there was no documentation it would have been considered not done.
-Had not completed any audits of those logs.
*She had no policies or procedures for checking the:
-Temperature and chlorine levels of the dishwasher.
-Sanitizing solution to ensure it had been the correct ppm.

3. Observation and interview on 4/17/18 at 9:05 a.m. of the laundry service area with laundry aide M revealed:
*By the clothes dryer there had been a cart with a large metal basket attached to it.
-That metal basket had several large openings on all four sides and on the bottom of it.
*The laundry aide would have used that cart to deliver clean linens to the procedure room.
-That procedure room was used for patients to have colonoscopes and cystoscopes.
*The procedure room was located in another part of the building and had required her to go through separate hallways to get there.
*She:
-Would not have covered those clean linens during the delivery process to ensure cleanliness was maintained.
-Was aware that process was not sanitary and had created the potential for contamination of those clean linens.
-Stated "I think you can buy a liner to place inside of these baskets."
-Had not discussed those concerns with her supervisor.

Interview on 4/18/18 at 9:00 a.m. with director of environmental services G revealed he:
*Was not aware the laundry staff had been delivering clean linens to the procedure room in an unsanitary manner.
*Confirmed the process above was not sanitary and had created the potential for contamination of those clean linens.
*Stated:
-"I know there are liners you can put in those baskets to make sure they stay clean."
-"They can cover the top of the linens with a sheet or something."

Surveyor: 35237
4. Observation and interview on 4/17/18 at 8:20 a.m. with housekeeping staff Q and R outside emergency room two regarding room cleaning revealed:
*Housekeeper R was training housekeeper Q how to clean and disinfect patient rooms and surfaces.
*They used the following products:
-Quat 25L spray.
-Cavicide wipes.
-Room Service Total Release spray.
*Neither staff knew how long those products needed to be on the surfaces to effectively disinfect.
-They stated probably about thirty seconds.
*They agreed they should have known the instructions for use for the products they were using to ensure appropriate disinfection had been done.

Further interview and review of the product labels with housekeeper R in the housekeeping storage room revealed:
*The Quat 25L disinfectant should have had a contact time of ten minutes to be effective.
*The Cavicide stated it should have remained visibly wet for three minutes.
*The Room Service Total Release stated it should have remained wet for ten minutes.
*She confirmed they were not aware of those times, and they should have been.
*Ten minutes was a long time, and she was not sure the products stayed wet for that length of time.

Interview on 4/18/18 at 8:10 a.m. with housekeeper R, housekeeper/maintenance person S, and director of environmental services G regarding the above disinfectants revealed:
*Housekeeping/maintenance staff S thought ten minutes should cover almost every product they used for disinfection.
*The director stated most disinfectants were effective in three minutes.
*They all agreed the products should have been used according to their labels and instructions for use.
*Staff using those products should have known the length of time for product effectiveness to ensure appropriate disinfection had occurred.

5. Observation on 4/17/18 at 9:55 a.m. in laboratory blood draw room one with laboratory tech O during patient 38's blood draw revealed:
*Multiple laboratory tubes were held in an opened plastic storage unit to the right of the handwashing sink.
-They were only a few inches from the sink and could have been contaminated during handwashing.
*Cardboard boxes containing laboratory supplies were stored on the counter directly in front of the sink.
-They were only a few inches from it and could have been contaminated during handwashing.
*A shelf above the counter contained partially used paper tape, tourniquets, and a container of opened, unprotected, two-inch by two-inch gauze pads.
*She got supplies from the shelf above the counter and set them directly on the counter next to the sink.
-Those supplies included a tourniquet, gauze pads, a needle, and syringe.
*She washed her hands for three to five seconds, shook her hands against the sides of the sink, turned off the faucet with her bare hands, and then got paper towels to dry them.
*She put on a pair of gloves.
*With her gloved hands she pushed a previously used butterfly needle device into the sharp's container.
-The device had been partially hanging out of it.
*With those contaminated gloves still on she got her supplies off the counter by the sink and moved them toward the patient.
*She set the gauze pads directly onto the arm rest of the chair and placed the tourniquet on the patient's left upper arm.
*She proceeded to draw the patient's blood and put the contaminated gauze onto his blood draw site, and secured it with paper tape.
*She then moved back to the sink area and got three laboratory tubes from the storage unit next to the sink.
-She filled those tubes with the patient's blood sample.
*After the tubes were filled she placed stickers on each of them.
-She then got a pen from the top shelf to write on each tube.
*When she was done she removed her contaminated gloves, washed her hands for approximately five seconds, shut off the faucet with her bare hands, and then dried her hands with paper towels.
*She left the blood draw room with the tubes and went back to the laboratory.

Interview following that observation with laboratory tech O in the laboratory revealed:
*The above observation was her usual practice.
*The supplies in that blood draw room were always stored that way.
*She agreed supplies being used for patient care should have been kept free of potential contamination.
*She agreed drawing a patient's blood should have been a clean and sanitary process.
*She confirmed she had not washed her hands properly for infection control.
*She had not set barriers down on the counter or arm rest of the chair and could not have been sure they had been cleaned properly prior to that blood draw.
-Those areas would have been considered contaminated.
*She confirmed anything setting in close proximity to the hand washing sink could have been contaminated.
*Disinfectant wipes were available in the room for cleaning surfaces, but she had not used those before or after the patient's blood draw.
*Both blood draw rooms were used for patients.

Observation on 4/18/18 at 10:45 a.m. of blood draw room two revealed:
*There was no handwashing sink available in that room.
*In a drawer of a cart there were:
-Partial rolls of paper tape.
-Multiple opened, unprotected, two-inch by two-inch gauze pads stored inside of a cardboard alcohol preparation pad box and laying directly in the drawer.

Interview on 4/18/18 at 11:00 a.m. with director of laboratory D regarding the blood draw rooms and the observation of the laboratory tech above revealed:
*He confirmed the storage of supplies in the blood draw rooms was not sanitary.
*Staff should have washed their hands appropriately and for at least twenty seconds.
*Staff drawing blood should have maintained clean and sanitary conditions and used supplies that were not potentially contaminated.
*Both blood draw rooms were used for patients.
*He stated he had ordered a new storage unit for the laboratory tubes, but he could not say when it was ordered or give supporting documentation for that.
*He was aware blood draw room two had no handwashing sink.
-He confirmed staff would have had to leave the room to wash their hands.
*Drawing a patient's blood could have resulted in bloodborne contamination, and a handwashing sink should have been readily available.

6. Observation on 4/18/18 at 3:55 p.m. of registered nurse (RN) P during patient 8's emergency room evaluation revealed:
*RN P inserted an intravenous (IV) access site into the patient's right forearm.
*After securing the patient's IV access she removed her soiled gloves.
*After removing her gloves she washed her hands for approximately three seconds, dried her hands, and then went to the computer to chart.

Interview on 4/18/18 at 11:30 a.m. with RN P in follow-up to the above observation revealed:
*She agreed she had not washed her hands appropriately.
*She should have washed them for at least twenty seconds.

7. Interview on 4/18/18 at 8:50 a.m. with the director of nursing regarding infection control revealed:
*Handwashing should have been completed for at least twenty seconds.
*Appropriate handwashing included the appropriate length of time and not re-contaminating hands by touching the sink or faucet handles.
*Their hand washing policy was not complete or accurate and needed to be updated.
*Storage of patient use supplies including the items in the laboratory blood draw rooms should have been stored properly to keep them free from potential contamination.
-Items should not have been stored in close proximity to the sink to prevent potential contamination.

Interview on 4/18/18 at 9:05 a.m. with director of quality assurance/infection control/utilization review B regarding infection control revealed:
*Handwashing should have been done appropriately by all staff.
*She had done random handwashing audits and was aware some staff were not doing it properly.
-That was an ongoing education item.
*The current hand washing policy was not complete or accurate.
-It had not even mentioned the use of hand sanitizer.
*All their infection control policies needed to be updated or written.
*There was no policy addressing storage of patient care supplies and one-time use items such as gauze pads.
*She was aware of infection control concerns in the blood draw rooms, but those had not been corrected yet.
*She confirmed the storage of supplies in close proximity to the sink were not stored properly to keep them free from potential contamination.
*The new unit for laboratory tubes had not been ordered yet as the director of laboratory services had indicated.
*An infection control consultant had been to the facility in February 2018 and made several recommendations including for the storage of supplies in the blood draw rooms.
-Those recommendations had not been followed-up on yet and should have been.

Review of the provider's undated Hand Washing Technique policy revealed:
*It was not detailed or specific.
*It had not mentioned:
-How long to wash hands.
-How to turn off the faucets without re-contaminating hands.
-When hand washing should have been completed.

32332




35237




32355

Based on interview, the provider failed to ensure:
*A comprehensive facility wide Quality Assurance Performance Improvement program (QAPI) that ensured all departments or patient care departments/services had developed and implemented a system/process improvement plan.
*Systems were implemented to achieve and maintain compliance for annual policy review and utilization review (UR).
*A total evaluation program was developed to review the services they had provided on an annual basis.
Findings include:

1. Interviews from 4/17/18 through 4/18/18 revealed a facility wide QAPI program had not been developed to ensure an effective process was in place to enhance and maintain the quality of care the patients received.

Refer to C336.

2. Interviews from 4/17/18 through 4/18/18 revealed the provider failed to ensure policies and UR had occurred on an annual basis.
-They had been previously cited on 1/22/15 for regulatory deficiency C272 and C333.

Refer to C272 and C331.

3. Interviews from 4/17/18 through 4/18/18 revealed the provider failed to develop a program to complete yearly reviews on all the services that had been provided.

Refer to C331.

There had not been any meeting minutes, policies, and guidelines to review for all the areas of concern identified above.

Based on interviews, the provider failed to ensure a periodic evaluation of its total program was done annually for three of three years ([2015, 2016, and 2017]. Findings included:

1. Review of the plan of correction dated 1/22/15 for the previous Department of Health survey revealed the provider should have developed and implemented a policy, process, and guidelines for evaluating the services they had provided and reported annually to the governing board.

Review of the January 2015 Statement of Deficiencies conducted by the South Dakota Department of Health revealed the facility had failed to maintain their compliance with the following deficiency that had been cited: C333.

2. Interview on 4/17/18 at 1:30 p.m. with director of patient services F regarding utilization review [IR] revealed he:
*Had referred the surveyor to the director of infection control [IC], quality assurance [QA], and utilization review [UR] B to discuss any concerns regarding those committees and meetings.
*Had not been aware of a UR committee.
*Was aware of the deficiency from the past recertification survey in January 2015 regarding UR.
*Stated:
-"I'm not sure what you mean, but I don't think we have one."
-"We don't have a specific team or committee to review the systems/services we have and identify any concerns as a whole."
-"Each department looks at any concerns they have separately but not to determine if there is a problem system wide for any identifying concerns."
*Had not been aware all departments were not reviewing their policies annually.
*Stated "Yes they should be."

3. Interview on 4/17/18 at 2:45 p.m. with director of IFC, QAPI, and UR B revealed she:
*Confirmed there was not a UR committee and was unsure what that all involved.
*Was not aware that UR was a part of her job description and duties.
*Stated:
-"I review open and closed charts for nursing purposes only and have been since the last survey on 1/22/15.
-"But I review nothing on the facility as a whole, and there is not a committee does a review of the facility as a whole."
-"I'm not even sure what that entails."
-"Anything I do is for the nursing department and all that information is given to [director of patient care services name]."
-"I don't know what [name] does with that information."

4. Interview on 4/18/18 at 10:55 a.m. with the medical director revealed he:
*Was not aware there should have been both an UR committee developed to ensure a full review had been completed on all the services/resources they offered as a facility.
*Stated "Our old administrator kept saying everything was just fine, and we believed him."

5. Interview on 4/18/18 at 3:00 p.m. with the interim co-administrator I revealed she had not been aware of the concern with UR identified above.

35237




32332




32355

Based on interview and record review, the provider failed to ensure a comprehensive facility wide quality assurance performance improvement (QAPI) program to include all departments or patient care departments/services had developed and implemented a system/process improvement plans. Findings include:

1. Interview on 4/17/18 at 1:30 p.m. with director of patient services F regarding QAPI revealed he:
*Had referred the surveyor to the director of infection control (IFC), quality assurance (QA), and utilization review [UR] B to discuss any concerns regarding the committee and meetings.
*Stated:
-"We don't have a specific team or committee to review the systems/services we have and identify any concerns as a whole."
-"Each department looks at any concerns they have separately but not to determine if there is a problem system wide for any identifying concerns."
-"Each department does a performance improvement [PI] report for safety."
-"The departments don't attend any meetings for safety or quality."

Review of the January 2015 Statement of Deficiencies conducted by the South Dakota Department of Health revealed the facility had failed to maintain their compliance with the following deficiencies that had been cited that included: C272 and C333.

Surveyor: 26180
2a. Interview on 4/17/18 at 9:00 a.m. with the occupational therapist revealed:
*They did not really have any quality measures they were working on in the rehabilitation (rehab) department.
*They did complete chart audits for completion.
-But they had no data on that.
*The director of patient care took care of that.

b. Interview on 4/17/18 at 11:00 a.m. with the director of patient care revealed:
*The rehab department monitored things like their medical records.
*They did not compile any data on their monitoring.
*He felt they were doing things for their quality assurance.
-But there was nothing documented.
*When asked how they could monitor progress or process improvement without documented data.
-He concurred they could not.

c. A review of the rehab department's medical record documentation revealed:
*They completed reviews of medical records to make sure they were thoroughly completed.
*They only checked yes or no.
-Yes meant it was complete; no meant it was not complete. .
--There was no indication of what exactly had not been completed.
*There was no documented quantitative data that was being collected.

Surveyor: 32355
3. Interview on 4/17/18 at 1:40 p.m. with dietary manager (DM) L revealed she:
*Had:
-Not attended any quality or safety meetings.
-Completed temperature audits on all the refrigerators and submitted that information to the compliance officer (CO) quarterly.
*Was not sure who attended the quality or safety meetings and what was reviewed at those meetings.
*Had completed an inspection of the kitchen on 5/15/17 and identified several areas of concern.
-Those areas of concerns identified on that report had been: cleanliness, food hygiene, new staff, pest control, cracks in the flooring, and electrical safety.
*Stated:
-"I took my concerns to the [CO A name] and was told my concerns were not measurable and that I needed to find something else to monitor."
-"I recognized a concern with frig temping and submitted that."
-"I don't attend her meetings and am not informed what is discussed."
-"We just do self-auditing of those other areas to make sure we are in compliance."
*Had met the goal for refrigerator temperatures for the last two quarters.
*Stated "I've never been told to stop checking them and if there is something else I should be working on."
*Had attended a meeting every week for department heads.
*Stated:
-"If you review the department head meetings all we discuss is when everyone is going to be here or gone."
-"We don't discuss or review any real concerns from each department."

Review of the department head meetings from 10/3/17 through 4/10/18 confirmed the interview with DM L.

Surveyor: 32332
4. Interview on 4/17/18 at 2:00 p.m. with director of IFC, QAPI, and UR B regarding QAPI revealed infection information:
*Had been gathered to comply with the Hospital Improvement Innovation Network (HINN) in order to receive payment.
*The HINN information:
-Had not been investigated for infection prevention, control, or education to staff.
-She gave the above information to the director of patient care services.
-She did not know what the director did with that information.
-Was not part of the Quality Assurance review.

Interview on 4/17/18 at 5:00 p.m. with director of IFC, QAPI, and UR B revealed:
*She was responsible for QA.
*Safety/compliance officer A was responsible for compliance.
*The medical director was not involved with QA.
*There was no QA program set up prior to her stepping into the position.
*She did not review quality.
*She did not have guidelines for QA.
*The HINN reporting was done to receive payment.
*Her performance improvement had been auditing hand washing.

Interview on 4/18/18 at 8:20 a.m. with director of IFC, QAPI, and UR B regarding the HINN infection information revealed, "I did not know what QA encompassed, so I didn't do more than submit it to the state."

Surveyor: 35237
5. Interview on 4/18/18 at 10:35 a.m. with the director of radiology services regarding QAPI revealed she:
*Was not part of the quality committee and had not attended quality meetings.
*Submitted PI forms to compliance officer A quarterly along with an end of the year summary.
*Had several areas identified with data collection on her PI plan.

6. Interview on 4/18/18 at 11:00 a.m. with the director of laboratory services regarding QAPI revealed he:
*Had started working there in October 2017.
*Had not attended any quality meetings.
*Submitted performance improvement data forms to compliance officer A quarterly.
*Was unsure who all participated in the quality meetings.

7. Interview on 4/18/18 at 11:25 a.m. with the director of pharmacy services regarding QAPI revealed she:
*Had not attended quality meetings.
-She was not invited to them.
*Submitted PI data forms to compliance officer A quarterly along with an end of the year summary.
*For 2017 she had worked on undocumented narcotic wasting that had been continued from 2016.
-She planned to continue that PI 2018 and start a new PI for antibiotic stewardship.

Surveyor: 32355
8. Interview on 4/17/18 at 2:45 p.m. with director of IFC, QAPI, and UR B revealed she:
*Stated:
-"I review open and closed charts for nursing purposes only and have been since the last survey in January 2015.
-"But I review nothing on the facility as a whole and there is not a committee does a review of the facility as a whole."
-"I'm not even sure what that entails."
-"Anything I do is for the nursing department and all that information is given to [director of patient care services name]."
-"I don't know what [name] does with that information."
*Confirmed the interview with DM L regarding the department head meetings.
*Had referred the surveyor to CO A to review the QAPI and PI meetings and the information obtained from those meetings.

Interview on 4/17/18 at 4:00 p.m. with CO A revealed she:
*Had been the director for PI.
*Had not been sure what QAPI was or what it all involved.
*Stated:
-"I am not about patient safety I review only safety for the staff."
-"You say quality, I don't know what that means."
-"I am not a medical person, so I have no idea what they review or look at."
-"You say quality, I say performance improvement."
-"I don't know what was on our last survey or what compliance concerns we should be looking at."
*Had not been aware of any quarterly review to ensure:
-Patient safety for reduction of medical errors.
-Improvement actions were evaluated.
-Patient safety improvement actions had been evaluated.
-Adequate resources were allocated for reducing risk to patients.
*Stated "I don't know anything about what quality is or what it should involve, again I am not a medical person, and I have no idea what that is."

Interview on 4/17/18 at 5:00 p.m. with director of IFC, QAPI, and UR B revealed she:
*Confirmed CO A had been involved with safety but was not sure what that all entailed.
*Stated "I know everyone reports to her, but I have no idea what is done with that information."
*Confirmed she was:
-The director of QAPI, and there had been no formal committee developed or meetings in place to ensure compliance was maintained by all departments to ensure quality of care was delivered to all patients.
*Stated:
-"There are no formal reports for any committee to review."
-"Each department reviews their concerns within their department."
-"I think we need some guidance here."
*Confirmed all components of the hospital should have been incorporated into a committee and reviewed at a minimum of quarterly to ensure compliance for the patients' safety and well-being.
*Stated "There were wasn't programs set-up prior to my stepping in, so I didn't and don't have any guidelines to follow."
*Had no policies or procedures to follow for the implementation of an effective QAPI program.

Interview on 4/18/18 at 9:00 a.m. with the director of nursing (DON) revealed she:
*Confirmed there was no formal QAPI committee established to ensure all components of the hospital had been reviewed on a regular basis.
*Agreed that was an important committee and should have been established a long time ago.
*Had been aware of the results from the past recertification survey on January 2015.
*Had not been aware policies throughout the facility were not being updated annually and agreed they should be.
*Confirmed the department head meetings had not involved important concerns from each area and should have.
*Was not sure what CO A was reviewing in PI meetings.
*Stated:
-"I know we all turn in reports to her, and I have no idea what she does with my fall information or our medical errors."
-"Our leadership has not been good for sometime now, and we have been going through a lot of turmoil."
-"We just need to start stepping up to the plate."
*Agreed with such breakdown from administration they had created the potential for poor quality of care to have occurred.

Interview on 4/18/18 at 9:10 a.m. with the director of patient care services revealed he stated:
*"I don't have a concern about the quality, we are just missing putting all the pieces together."
*"I was not aware all the departments were not reviewing their policies annually, and yes they should be."

Interview on 4/18/18 at 10:55 a.m. with the medical director revealed he:
*Had not been aware of all the concerns and breakdown within the administration identified above.
*Agreed he should have been informed to ensure the patients received consistent and quality of care.
*Stated "As the medical director I want to know what's going on."
*Had not been receiving any department head meeting minutes for over a year.
*Stated "They were pretty bland anyway and didn't discuss much in the way of concerns."
-He agreed they should have been.
*Was not aware there should have been a QAPI developed to ensure a full review had been completed on all the services/resources they offered as a facility.
*Stated "Our old administrator kept saying everything was just fine, and we believed him."

Interview on 4/18/18 at 3:00 p.m. with the interim co-administrator I revealed she:
*Had not been aware of all the concerns identified above.
*Stated:
-"I was the assistant not the executive assistant."
-"I had been asked to type up things, but that was all."
-"Our previous administrator did not share things or make sure we were aware of any concerns."
-"I was not made aware of what all of our deficiencies from the past survey entailed and should have."
*Agreed there was a significant breakdown in communication in the administrative department as identified above.
-That breakdown had created the potential for patient quality of care to have been compromised along with safety risks.

Based on record review, interview, policy review, the provider failed to ensure four of four sampled swing bed patients (3, 5, 8, and 10) had a nutritional assessment completed by a registered dietitian (RD). Findings include:

Surveyor: 35625
1. Review of patient 3's electronic medical record (EMR) revealed:
*He had been admitted to swing bed on 4/14/18.
*The physician had ordered a low sodium diet with a two gram limitation.
*There was no documented nutritional assessment by the RD.

Surveyor: 26180
2. Review of patient 5's EMR revealed:
*She had been admitted to a swing bed on 1/5/18.
*The physician had ordered a low residual bland diet with small portions..
*There was no documented nutritional assessment by the RD.

3. Review of patient 8's EMR revealed she:
*Had been a patient in the swing bed from 3/21/18 through 4/3/18.
*Had a 1500 constant carbohydrate diet ordered by the physician.
There was no documented nutritional assessment by the RD.

4. Review of patient 10's EMR revealed he:
*Had been admitted on 2/7/18 and was discharged on 2/16/18.
*The physician had ordered a high calorie diet with a health shot protein beverage.
*There was no documented nutritional assessment by the RD.

5. Interview on 4/17/18 at 2:50 p.m. with the RD revealed:
*The nurses usually communicated with her on hospital admissions by sending her some basic information about the patient.
*Within forty-eight hours it was expected she would have completed the nutritional assessment.
*She confirmed there was not a documented nutritional assessment on the above residents.

Surveyor: 35625
Review of the provider's undated Nutritional Assessment and Screening policy revealed: "A qualified and knowledgeable person will do assessment on every patient and swingbed patient....If completed nutritional assessment tool indicated high-risk form will be faxed to RD LN [registered dietitian, licensed nutritionist]. This will be done within the first 24 hours of admission."