HospitalInspections.org

Based on interview and record review, the facility failed to provide notice of the right to formulate an advance directive for 6 (#s 6, 7, 9, 23, 25, and 26) of 29 sampled patients. This deficient practice had the potential for the facility to provide life-sustaining treatments against the patient's wishes. Findings include:

Record review of patient #25's medical record showed an inpatient admission date of 12/11/22. No notification of advance directives was present in the medical record.

Record review of patient #7's medical record showed an inpatient admission date of 12/30/22. No notification of advance directives was present in the medical record.

Record review of patient #6's medical record showed an inpatient admission date of 1/3/23. No notification of advance directives was present in the medical record.

Record review of patient #9's medical record showed an inpatient admission date of 1/6/23. No notification of advance directives was present in the medical record.

Record review of patient #26's medical record showed an inpatient admission date of 2/24/23. No notification of advance directives was present in the medical record.

Record review of patient #23's medical record showed an inpatient admission date of 4/5/23. No notification of advance directives was present in the medical record.

During an interview on 6/21/23 at 10:53 a.m., staff member B said she was not aware of all the information required for the inpatient chart. Staff member B said all the inpatient information was located in the inpatient chart and if the information was missing, the facility did not have the information.

Based on interview and record review, the facility failed to ensure the process for developing, implementing, and periodically reviewing patient care policies included the participation of the nurse practitioners and physician assistants, who were members of the medical staff. The deficient practice had the potential to affect patients receiving care in the facility. Findings include:

During an interview on 6/20/23 at 2:40 p.m., staff member B stated she was responsible for ensuring facility policies were reviewed and updated as necessary. Staff member B stated there was no established process for including the medical providers in the development of patient care policies.

Review of the facility's policy binders, which contained all the facility's policies, failed to show documentation of medical provider involvement on many of the policies contained in the policy binders.

During an interview on 6/22/23 at 9:44 a.m., staff member M stated she was a traveling NP and not aware of facility policies and procedures.

Staff member L was the only medical provider who worked full-time for the facility, and who took the majority of the on-call shifts for the emergency department. She was not available for interview.

Based on interview and record review, the facility failed to have a process which ensured a Doctor of Medicine or Osteopathy signed the records of all inpatients cared for by nurse practitioners or physician assistants for 7 (#s 6, 7, 9, 23, 24, 25, and 26) of 8 sampled patients. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. Findings include:

During an interview on 6/21/23 at 12:15 p.m., staff member D stated he was responsible for the medical oversight of the nurse practitioners and physician assistants. Staff member D stated he reviewed both inpatient and outpatient records but did not always remember to sign the medical records which were reviewed.

Staff member E, who was responsible for providing the necessary records for physician review and signature, was not available for interview.

Review of the following medical records failed to show documentation of a signature by the physician who reviewed the record:

- Patient #25, admitted 12/11/22, discharged 12/12/22,
- Patient #7, admitted 12/30/22, discharged 1/7/23,
- Patient #6, admitted 1/3/23, discharged 1/7/23,
- Patient #9, admitted 1/6/23, discharged 1/8/23,
- Patient #24, admitted 1/21/23, discharged 2/23/23,
- Patient #26, admitted 2/24/23, discharged 2/26/23. and
- Patient #23, admitted 4/5/23, discharged 4/8/23.

Based on interview and record review, the facility failed to ensure nurse practitioners and physician assistants notified a Doctor of Medicine or Osteopathy when an inpatient admission occurred for 7 (#s 6, 7, 9, 23, 24, 25, and 26) of 8 sampled patients. This deficient practice had the potential to affect the quality of care for inpatients admitted to the facility. Findings include:

During an interview on 6/21/23 at 12:15 p.m., staff member D stated he was responsible for the medical oversight of the nurse practitioners and physician assistants. Staff member D stated he was not always notified when the nurse practitioners or physician assistants admitted patients to inpatient status in the hospital. Staff member D stated he believed this was because he would have disagreed with the admission.

Staff member E, who was responsible for providing the necessary records for physician review and signature, was not available for interview.

Review of the following medical records failed to show the non-physician practitioner notified the physician, who provided medical oversight, of the admission to inpatient status:

- Patient #25, admitted 12/11/22, discharged 12/12/22,
- Patient #7, admitted 12/30/22, discharged 1/7/23,
- Patient #6, admitted 1/3/23, discharged 1/7/23,
- Patient #9, admitted 1/6/23, discharged 1/8/23,
- Patient #24, admitted 1/21/23, discharged 2/23/23,
- Patient #26, admitted 2/24/23, discharged 2/26/23, and
- Patient #23, admitted 4/5/23, discharged 4/8/23.




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Based on interview and record review, the facility failed to ensure policies were developed with the advice of a physician and a non-physician practitioner. The deficient practice had the potential to affect patients receiving care in the facility. Findings include:

During an interview on 6/20/23 at 2:40 p.m., staff member B stated she was responsible for ensuring facility policies were reviewed and updated as necessary. Staff member B stated there was not currently a process for including the medical providers in the development of patient care policies.

During an interview on 6/21/23 at 12:15 p.m., staff member D stated he had been at the facility for at least five years and had never been involved in policy development.

Review of the facility's policy binders, which contained all of the facility's policies, failed to show documentation of medical provider involvement with regard to policy development.

Staff member L was the only medical provider who worked full-time for the facility, and she was not available for interview.

Based on interview and record review, the facility failed to ensure a care plan was initiated and current for each inpatient admission for 3 (#s 6, 7, and 9) of 8 sampled patients. Findings include:

Record review of patient #7's medical record with an inpatient admission date of 12/30/22, showed an admission diagnosis of urosepsis. No care plan was present in the medical record.

Record review of patient #6's medical record with an inpatient admission date of 1/3/23, showed an admission diagnosis of bilateral lower lobe pneumonia. No care plan was present in the medical record.

Record review of patient #9's medical record with an inpatient admission date of 1/6/23, showed an admission diagnosis of septic pneumonia. No care plan was present in the medical record.

During an interview on 6/21/23 at 10:53 a.m., staff member B said she was not aware of all the information required for the inpatient chart. Staff member B said all of the inpatient information was located in the inpatient chart and if the information was missing, the facility did not have the information.

Based on interview and record review, the facility failed to document a discharge summary from an inpatient stay, and include it in the medical records for 7 (#s 6, 7, 9, 23, 24, 25, and 26) of 8 sampled patients. Findings include:

1. Record review of patient #25's medical record showed an inpatient admission date of 12/22/22. No discharge summary was present in the medical record.

2. Record review of patient #7's medical record showed an inpatient admission date of 12/30/22. No discharge summary was present in the medical record.

3. Record review of patient #6's medical record showed an inpatient admission date of 1/3/23. No discharge summary was present in the medical record.

4. Record review of patient #9's medical record showed an inpatient admission date of 1/6/23. No discharge summary was present in the medical record.

5. Record review of patient #24's medical record showed an inpatient admission date of 1/21/23. No discharge summary was present in the medical record.

6. Record review of patient #26's medical record showed an inpatient admission date of 2/24/23. No discharge summary was present in the medical record.

7. Record review of patient #23's medical record showed an inpatient admission date of 4/5/23. No discharge summary was present in the medical record.

During an interview on 6/21/23 at 10:53 a.m., staff member B said she was not aware of all the information required for the inpatient chart. Staff member B said all the inpatient information was located in the inpatient chart and if the information was missing, the facility did not have the information.

During an interview on 6/21/23 at 1:28 p.m., staff member A said the board had approved the facility to purchase an electronic medical record because things were being missed in the patient charting. The new electronic medical record would be the check and balance for the charts being complete. Staff member A said administration was aware of missing items in the patient charts.

Record review of a facility document, "Procedure-Medical Records Chart Completion," not dated, showed:

" ...5. The attending physician, physician assistant, or nurse practitioner shall be held responsible for the preparation of a complete medical record within ten (10) days after the patient has been discharged from the Facility. This record shall include admission date, complaint, personal history, family history, history of present illness, physical examination, special reports such as consultations, clinical laboratory, x-rays, and others, provisional diagnosis, medical or surgical treatment, operative report, pathologic findings, progress notes, final diagnosis, condition on discharge, summary or discharge note, follow-up and autopsy report when available.

CAH Discharge Summary must include the following elements:

a. Reason for admission
b. Pertinent physical and laboratory findings;
c. Course and treatment of patient while in the Facility
d. Patient's condition on discharge, including final diagnosis recorded in full;
e. Instructions for further care or treatment, including referrals and medications. ..." [sic]

Based on interview and record review, the facility failed to ensure a history and physical exam was documented in the medical record for inpatient admissions; and failed to ensure a medical doctor co-signed and assumed full responsibility for the history and physical, when a patient was admitted by a mid-level practitioner for 3 (#s 6, 7, and 9) of 8 sampled patients. Findings include:

1. Record review of patient #7's medical record showed an inpatient admission date of 1/6/23. A history and physical examination was not present in the medical record.

2. Record review of patient #6's medical record showed an inpatient admission date of 1/3/23. A history and physical examination was not present in the medical record.

During an interview on 6/21/23 at 1:28 p.m., staff member A said the board had approved the facility to purchase an electronic medical record because things were being missed in the patient charting. The new electronic medical record will be the check and balance for the charts being complete. Staff member A said administration was aware of missing items in the patient charts.

Record review of a facility document, "Procedure-Medical Records Chart Completion," not dated, showed:

" ...2. A complete history and physical examination on CAH inpatients shall be performed within 24 hours after admission of the patient and signed by the attending physician, physician assistant, or nurse practitioner. ..."

3. Record review of patient #9's medical record showed an inpatient admission date of 1/6/23. A history and physical was performed by staff member K, but was not co-signed by staff member D.

During an interview on 6/21/23 at 12:28 p.m., staff member D said he did not co-sign anything in the patient's chart. Staff member D said he did monthly chart reviews and would document in the progress notes if there was an identified issue. Staff member D said he reviewed chart notes, medication, lab, and care plans for patients. A check list for record review was not provided to him by the facility.

Based on interview and record review, the facility failed to provide health information within the patients' medical record to monitor patient progress for 2 (#s 6 and 7) of 8 sampled patients. Findings include:

Record review of patient #7's medical record for inpatient admission, dated 12/30/22, showed the following information missing from the medical record:

a. Physician history and physical for acute illness;
b. Physician progress notes;
c. Lab results: no blood test results, no cultures, and no sensitivities to verify or monitor urosepsis.

Record review of patient #6's medical record for inpatient admission, dated 1/3/23, showed the following information missing from the medical record:

a. Physician history and physical for acute illness;
b. Physician progress notes.

During an interview on 6/21/23 at 1:28 p.m., staff member A said the facility was aware of missing information and missing documentation in medical records.

Record review of a facility document, "Procedure-Medical Records Chart Completion," not dated, showed:

" ...5. The attending physician, physician assistant, or nurse practitioner shall be held responsible for the preparation of a complete medical record within ten (10) days after the patient has been discharged from the Facility. This record shall include admission date, complaint, personal history, family history, history of present illness, physical examination, special reports such as consultations, clinical laboratory, x-rays, and others, provisional diagnosis, medical or surgical treatment, operative report, pathologic findings, progress notes, final diagnosis, condition on discharge, summary or discharge note, follow-up and autopsy report when available. ..." [sic]

Based on interview and record review, the facility failed to have a method for authenticating the signatures of individuals documenting in the medical record. Findings include:

During an interview on 6/19/23 at 1:20 p.m., staff member A stated the facility used a paper medical record and did not have a method for authenticating the signatures of staff and medical providers who documented in patient medical records. Staff member A stated she did not think the signature authentication list was necessary.

A request was made on 6/19/23 for the list of authenticated signatures; no documentation was received prior to the end of the survey.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control.

Based on observation, interview, and record review, the facility failed to:

-Ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. (See C1204)

-Ensure the facility maintained facility-wide infection prevention/control policies that were current and based on national standards. This deficient practice had the potential to affect all patients and staff within the facility. (See C1206)

-Ensure specific tracking and trending of infections were established for the Infection Prevention and Control Program; follow facility policy and ensure timely and routine cleaning, disinfection, and spore testing of the autoclave sterilizer used to sterilize patient care instruments; establish a clear delineation between clean and dirty areas for processing of instrumentation; identify a process for tracking of equipment sterilized by the autoclave in the event of an autoclave malfunction or indication of pathogen growth. These deficient practices had the potential to affect all patients receiving care within the facility. (See C1208)

-Ensure an antibiotic stewardship program was established and adhered to nationally recognized guidelines. This deficient practice had the potential to affect all patients receiving antibiotics unnecessarily. (See C1221)

-Ensure the facility had a system in place for active surveillance, prevention and control of all infections, to include antibiotic use. This deficient practice had the potential to affect both patients and staff within the facility. (C1225)

-Ensure the individual employed as the Infection Prevention and Control Specialist was qualified to develop and implement a facility-wide infection control, surveillance, and prevention program based on nationally recognized guidelines. This deficient practice had the potential to affect all patients and staff providing care within the facility. (See C1229)

-Ensure an antibiotic leadership team was in place to establish and implement a process to monitor and improve the use of antibiotics. This deficient practice had the potential to affect all patients in the facility. (See C1231)

-Ensure an antibiotic stewardship program was established and implemented in collaboration with the CAH's QAPI leadership. This deficient practice had the potential to affect all patients of the facility. (See C1244)

Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include:

During an interview on 6/21/23 at 3:00 p.m., staff member B said the governing body appointed staff member C to the Infection Preventionist position on 5/24/23. Staff member B said both staff members B and C were to receive training.

During an interview on 6/22/23 at 8:55 a.m., staff member A stated staff member C had been appointed as the Infection Preventionist, but had no training, and would not be able to answer questions regarding the program.

Record review of the facility's personnel file for staff member C did not show documentation of the staff member's education, training, certifications, and experience in infection control.

Based on interview and record review, the facility failed to maintain facility-wide infection prevention/control policies that were current and based on national standards. This deficient practice had the potential to affect all patients and staff within the facility. Findings include:

Record review of a facility document, "Infection Control- Transmission Based Precautions," [sic] not dated, showed:

" ...Droplet Precautions
- In addition to standard precautions, wear a surgical mask when within 3 feet (6 feet for smallpox) of persons known or suspected of having diseases spread by droplets (examples include influenza, pertussis, meningococcal diseases).

Airborne Precautions
...Put on a NIOSH-certified fit-tested N-95 respirator just before entry to an area of shared air space and wear at all times while in the area of shared air space. Remove and discard respirator just after exiting area. The respirator may be discarded in the regular trash unless contact precautions must also be followed. In this case, place the respirator in a plastic zip-loc bag, seal and then discard into the trash.

...Reference: ...cdc.gov (2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings) "

Record review of the facility's Infection Control Policy manual showed:

- 2023 Infection Control Tracking form for the facility was blank.
- Antibiotic stewardship policy did not contain professional references were being used for guidance. The policy was not dated or signed.
- Blood/body fluid spills policy had recommendations and references dated for 2012. It was not revised, approved, or signed.
- Terminal cleaning recommendations and references were dated for 2012.
- Hand washing guidelines and references were dated CDC 2012.
- No policies were found for COVID-19, outbreak, staff and patient testing, isolation, or vaccination of staff and patients.

During an interview on 6/22/23 at 8:55 a.m., staff member A stated staff member C had been appointed as the Infection Preventionist, but had no training, and would not be able to answer questions regarding the program.

During an interview on 6/22/23 at 9:47 a.m., staff member A said the facility worked with the medical director to manage residents that tested COVID positive. There were no policies created, and patients were handled as cases developed.

Based on observation, interview, and record review, the facility failed to ensure specific tracking and trending of infections were established for Infection Prevention and Control Program; failed to follow facility policy and ensure timely and routine cleaning, disinfection, and spore testing of the autoclave sterilizer used to sterilize patient care instruments; failed to establish clear delineation between the dirty and clean areas for processing instruments sterilized in the autoclave machine; and failed to establish a process for identifying equipment processed by the autoclave in the event of a sterilizer malfunction, or to indicate pathogen growth. The accumulative effects of these deficient practices had the potential to affect all patients receiving care within the facility. Findings include:

1. Tracking and Trending of Infections

Record review of the facility Infection Control Policy manual showed the facility infection control tracking sheet for 2023 was blank.

During an interview on 6/21/23 at 12:28 p.m., staff member D said the tracking and trending of infections or antibiotic usage was not brought to the medical staff. He was not aware of any infection tracking being done.

2. Autoclave Sterilizer

During an observation on 6/20/23 at 3:24 p.m., the table top autoclave was located in the clean storage room, sitting on a counter to the left of the sink. A towel was located on the counter to the left of the autoclave, and contained various pieces of instrumentation in preparation for sterilization. Several packages of instruments that had been sterilized were lying on the towel, next to the non-sterile instruments. The packages containing instruments, were dated, and had indicator tape on the exterior. No steam indicator for identification of sterilization success was contained in the packages. On top of the sterilizer was a container of glucose test strips. To the left of the sterilized and clean instruments, on the counter, were two walkie talkies and two coiled extension cords that were visibly soiled. The clean utility room contained a blanket/fluid warmer, nonsterile patient supplies, and various cardboard boxes containing supplies. The room also contained clean linen and soiled fall mats on a rolling cart.

During an interview on 6/21/22 at 10:53 a.m., staff member B said the facility placed the clean instruments into the sterilization pouch. No indicators were placed in the pouch, and a piece of indicator tape was placed on the outside of the bag with a date. The facility did not place a load number on the bag or document what was contained in each load processed through the autoclave. Staff member B said tracking the instrumentation, if an infection was identified, would be difficult. The facility used the indicator on the bag and the tape to determine if the instrument had been sterilized. Staff member B said no biological spore testing was done on the autoclave to check for function. Staff member B said the facility did not have a log to record the loads. Staff member B said the autoclave does not have a schedule of regular cleaning. Staff member B said she sent the autoclave out for cleaning in November of 2021. Staff member B said the policy for the autoclave was outdated, from when she was a CNA, 9 to 10 years ago. A biomedical technician checked the autoclave for safety but not for function.

Record review of a facility document, "Autoclave", not dated, showed:

" ...Autoclave will be cleaned each day it is used.

...Bacteriologic Testing:

The purpose of this testing is to ensure continued sterility of products which have been processed.

...1. Place SPORDI Kilit Ampules in center of test pack, or in the load at the point most difficult to sterilize.
2. Place in autoclave and process
...3. Remove load from autoclave, Remove Kilit Ampule.
4. Record results of testing and place in table in autoclave room."

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was established and adhered to nationally recognized guidelines, including best practices for the use of antibiotics for 2 (#s 3 and 7) of 6 sampled patients. Findings include:

During an interview on 6/21/23 at 12:28 p.m., staff member D said the tracking and trending of infections and antibiotic usage was not brought to the medical staff. He was not aware of any infection tracking being done.

Record review of patient #7's medical record showed an admission on 12/30/22 for urosepsis. Patient #7 was placed on an antibiotic (cefepime) when no urine culture was documented in the medical record.

Review of patient #3's medical record showed a urinalysis on 6/17/23, with no culture, and the patient was ordered an antibiotic.

Record review of a facility policy, "Antibiotic Stewardship", not signed or dated, did not contain a reference as to what professional organization the facility was using for stewardship recommendations.

Based on interview and record review, the facility failed to ensure they had a system in place for active surveillance, prevention, and control of all infections to include antibiotic use. This deficient practice had the potential to affect both patients and staff within the facility. Findings include:

During an interview on 6/21/23 at 12:28 p.m., staff member D said that the tracking and trending of infections or antibiotic usage was not brought to the medical staff. He was not aware of any infection tracking being done. Staff member D said the board was knowledgeable to be effectively involved in the oversight of the CAH and what was required to provide medical care for patients. Staff member D said he had recommended the board be trained in the actual needs of the facility.

During an interview on 6/21/23 at 3:00 p.m., staff member B said the infection preventionist was not currently reviewing hospital acquired infections and the staff had not been educated on the tracking of infections. The staff had received training from an online provider for prevention of infections.

Record review of the facility Infection Control Policy manual showed the facility infection control tracking sheet for 2023 was blank.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was established and implemented in collaboration with the CAH's QAPI leadership. This deficient practice had the potential to affect all patients in the facility. Findings include:

During an interview on 6/19/23 at 3:45 p.m., staff member B stated, "I can tell you, there has not been a quality committee meeting in the last year." Staff member B was not able to identify any ongoing quality projects or data collection activities for the facility. Staff member B stated the first quality committee meeting was scheduled for 6/28/23.

During an interview on 6/21/23 at 12:28 p.m., staff member D said that the tracking and trending of infections or antibiotic usage was not brought to the medical staff. He was not aware of any infection tracking being done. Staff member D said the board is not aware of the need for a QA program.

A request was made on 6/19/23 for minutes from the QAPI Committee meetings for the past year; no documentation of minutes was received prior to the end of the survey.

Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist was qualified to develop and implement a facility-wide infection control, surveillance, and prevention program based on nationally recognized guidelines. This deficient practice had the potential to affect all patients and staff providing care within the facility. Findings include:

During an interview on 6/21/23 at 3:00 p.m., staff member B said the governing body appointed staff member C to the Infection Preventionist position on 5/24/23. Staff member B said both staff member B and C were to receive training and were working to update the facility's policies. Staff member B said the position of Infection Preventionist did not have a job description.

Record review of the facility's personnel file for staff member C did not include documentation of the staff member's education, training, certifications, and experience in infection control.

Record review of a facility document, "Infection Control- Transmission Based Precautions," not dated, showed:

" ...Droplet Precautions
- In addition to standard precautions, wear a surgical mask when within 3 feet (6 feet for smallpox) of persons known or suspected of having diseases spread by droplets (examples include influenza, pertussis, meningococcal diseases).

Airborne Precautions

...Put on a NIOSH-certified fit-tested N-95 respirator just before entry to an area of shared air space and wear at all times while in the area of shared air space. Remove and discard respirator just after exiting area. The respirator may be discarded in the regular trash unless contact precautions must also be followed. In this case, place the respirator in a plastic zip bag, seal and then discard into the trash.

...Reference: ...cdc.gov (2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings) "

Record review of the facility Infection Control Policy manual showed:

- 2023 Infection Control Tracking form for the facility was blank.
- Antibiotic stewardship policy did not contain professional references being used for guidance. The policy was not dated or signed.
- Blood/body fluid spills policy had recommendations and references dated for 2012. It was not revised, approved, or signed.
- Terminal cleaning recommendations and references were dated for 2012.
- Hand washing guidelines and references were dated CDC 2012.
- No policies were found for COVID-19, outbreak, staff and patient testing, isolation or vaccination of staff and patients.

Based on interview and record review, the facility failed to ensure an antibiotic leadership team was in place to establish and implement a process to monitor and improve the use of antibiotics. This deficient practice had the potential to affect all patients in the facility. Findings include:

During an interview on 6/21/23 at 12:28 p.m., staff member D said that the tracking and trending of infections or antibiotic usage was not brought to the medical staff. He was not aware of any infection tracking being done.

During an interview on 6/21/23 at 3:00 p.m., staff member B said the governing body appointed staff member C to the infection Preventionist position on 5/24/23. Staff member B said both staff members B and C were to receive training and were working to update the facility policies. Staff member B said the position of Infection Preventionist did not have a job description.

Record review of the facility Infection Control Policy manual showed the facility infection control tracking sheet for 2023 was blank.

Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Quality Assessment and Performance Improvement.

Based on interview and record review, the facility failed to:

- Maintain an ongoing QAPI program. (See C1306)

- Maintain an ongoing QAPI program using objective measures to evaluate the facility's processes, functions, and services. (See C1309)

- Maintain an ongoing QAPI program which addressed indicators intended to improve patient outcomes, and the prevention or reduction of medical errors, adverse events, and facility-acquired conditions. (See C1311)

- Maintain an ongoing QAPI program which used the quality measures to analyze and track its performance. (See C1319)

Based on interview and record review, the facility failed to maintain an ongoing QAPI program. Findings include:

During an interview on 6/19/23 at 3:45 p.m., staff member B stated, "I can tell you, there has not been a quality committee meeting in the last year." Staff member B was not able to identify any ongoing quality projects or data collection activities for the facility. Staff member B stated the first quality committee meeting was scheduled for 6/28/23.

During an interview on 6/21/23 at 12:15 p.m., staff member D stated the facility had not presented any quality data to the medical staff and he had not attended a quality committee meeting in the past five years.

Review of the facility's document titled, "Quality Improvement Plan," not dated, showed the scope of the program was intended to incorporate all patient care services.

A request was made on 6/19/23 for the minutes of all quality committee meetings for the past year; No documentation was received prior to the end of the survey.

Based on interview and record review, the facility failed to maintain an ongoing QAPI program using objective measures to evaluate the facility's processes, functions, and services. Findings include:

During an interview on 6/19/23 at 3:45 p.m., staff member B stated, "I can tell you, there has not been a quality committee meeting in the last year." Staff member B was not able to identify any objective measures currently being used to evaluate the facility's processes and services. Staff member B stated the first quality committee meeting was scheduled for 6/28/23.

Review of the facility's document titled, "Quality Improvement Plan," not dated, showed it was the responsibility of the quality committee to provide a framework for a systematic approach to designing, measuring, assessing, and improving performance. The document failed to show objective measures were used, and there was no evaluation of the facility's performance.

A request was made on 6/19/23 for the minutes of all quality committee meetings for the past year; no documentation was received prior to the end of the survey.

Based on interview and record review, the facility failed to maintain an ongoing QAPI program which addressed indicators intended to improve patient outcomes, and the prevention or reduction of medical errors, adverse events, and facility-acquired conditions. Findings include:

During an interview on 6/19/23 at 3:45 p.m., staff member B stated, "I can tell you, there has not been a quality committee meeting in the last year." Staff member B stated the facility was not currently collecting any data for use by the quality committee. Staff member B stated the first quality committee meeting was scheduled for 6/28/23.

Review of the facility's document titled, "Quality Improvement Plan," not dated, showed one of the quality program goals was to identify indicators of quality related to outcomes of patient care.

A request was made on 6/19/23 for the minutes of all quality committee meetings for the past year; no documentation was received prior to the end of the survey.

A request was made on 6/19/23 for all incident/accident reports for the past year; no documentation was received prior to the end of the survey.

Based on interview and record review, the facility failed to maintain an ongoing QAPI program which used the quality measures to analyze and track its performance. Findings include:

During an interview on 6/19/23 at 3:45 p.m., staff member B stated, "I can tell you, there has not been a quality committee meeting in the last year." Staff member B stated the facility was not currently collecting any data for use by the quality committee. Staff member B stated the first quality committee meeting was scheduled for 6/28/23.

Review of the facility's document titled, "Quality Improvement Plan," not dated, showed one of the quality program goals was to identify indicators of quality related to outcomes of patient care.

A request was made on 6/19/23 for the minutes of all quality committee meetings for the past year; no documentation was received prior to the end of the survey.

A request was made on 6/19/23 for all incident/accident reports for the past year; no documentation was received prior to the end of the survey.

Based on interview and record review, the facility failed to provide documentation of discharge planning in the medical record for 3 (#s 6, 7, and 9) of 8 sampled patients. Findings include:

Record review of patient #7's medical record showed an inpatient admission date of 12/30/22 and a discharge date of 1/7/23. Discharge planning documentation was not present in the medical record.

Record review of patient #6's medical record showed an inpatient admission date of 1/3/23 and a discharge date of 1/7/23. Discharge planning documentation was not present in the medical record.

Record review of patient #9's medical record showed an inpatient admission date of 1/6/23 and a discharge date of 1/8/23. Discharge planning documentation was not present in the medical record.

During an interview on 6/21/23 at 10:53 a.m., staff member B said she was not aware of all the information required for the inpatient chart. Staff member B said all the inpatient information was located in the inpatient chart and if the information was missing, the facility did not have the information.

During an interview on 6/21/23 at 1:28 p.m., staff member A said the facility was aware of missing information and missing documentation on medical records.

Based on interview and record review, the facility failed to provide a written explanation of the patient's rights prior to a swing bed admission for 2 (#s 5 and 10) of 14 sampled patients. Findings include:

1. Record review of patient #5's medical record for a swing bed admission, dated 10/1/19, did not contain a signed copy of the patient's resident rights.

2. Record review of patient #10's medical record for a swing bed admission, dated 5/10/21, failed to show documentation of the provision of the notification of resident rights.

During an interview on 6/21/23 at 10:53 a.m., staff member B said she was unable to find a signed resident rights document on patient #5's medical record. She does not know what happened to miss the resident signing the document on admission.

Based on interview and record review, the facility failed to have documentation of evidence a thorough investigation had been completed for a Facility Reported Incident of verbal abuse and neglect of a patient from a staff member for 1 (#7) of 14 sampled swing bed patients. Findings include:

Review of a Facility Reported Incident to the State Survey Agency, dated 5/30/23, showed patient #7 had expressed concern to the staff about a staff member not turning her enough at night the week prior to the submitted event. Staff member B investigated the incident by viewing video, interviewing staff members and resident #7. The investigation found the allegations did occur and staff member J had been falsifying the records to show she was turning patient #7. Staff were instructed regarding the importance of turning and positioning resident #7. On 5/30/23, patient #7 reported staff member J was rough with turning and positioning, and was verbally abusive when providing care. Staff member J was sent home for the night and was terminated the next morning (5/31/23).

During an interview on 6/21/23 at 10:53 a.m., staff member B said, while investigating the incident, no patients were interviewed about other events that may have occurred involving staff member J. Staff member B said patient #7's care plan was not updated with interventions following the incident and patient #7 had not been evaluated for possible psychosocial harm following the event.

During an interview on 6/22/23 at 10:30 a.m., patient #7 said staff member J had not been turning her at night so she finally reported her, and staff member J became mean. Patient #7 said staff member J made her feel like she was doing something wrong by reporting her. Patient #7 said, "I am bound to my chair. I am not independent like my husband."

Based on interview and record review, the facility failed to provide social services to promote the patient's highest practice well-being for 1 (#29) of 14 sampled swing bed patients. Findings include:

During an interview on 6/22/23 at 10:15 a.m., patient #29 stated she wanted to move to another facility so she could walk outside. She stated staff remember B said she would assist her, but did not know what she could do. Patient #29 said there was not anyone at the facility to help her with a discharge plan, and no one to talk to. She stated she began to feel depressed, and told the nursing staff. She was taken off her antidepressant and did not know it. The nursing staff did get her back on the medication, and she felt better.

Record review of key personal showed staff member F was the social service director .

During an interview on 6/22/23 at 10:20 a.m., staff member F stated she did not know anything about social services, but did help the ombudsman talk with patients. She stated the facility had never had a social service staff member, and she had never documented anything in the medical records regarding social service interventions.

Review of the swing bed patients' medical records showed no social service documentation.

Based on interview and record review, the facility failed to have an effective and ongoing discharge plan for 1 (#29) of 14 sampled swing bed patients and had the potential to affect all patients wanting to discharge from the facility; and, failed to develop and implement a comprehensive fall prevention care plan for 2 (#s 27 and 28) of 14 sampled swing bed patients. Findings include:

1. During an interview on 6/22/23 at 10:15 a.m., patient #29 stated she wanted to move to an assisted living facility in another town, but did not have discharge assistance from the facility. She stated she needed someone to call the other facility and get a plan in place. The patient stated staff member B said she would help but was not sure what she could do. Patient #29 was attempting to call her son for help, but she said the call would not go through.

During an interview on 6/22/23 at 9:10 a.m., staff member A stated patient discharges were the responsibility of the charge nurse on duty. She stated the charge nurse worked with the Public Health department, and any other staff available to help with discharge. The care plan team discussed the discharge plan with the patient.

Review of patient #29's medical record did not show documentation of discharge planning.


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2. Review of a Facility Reported Incident submitted to the State Survey Agency, dated 11/5/22, showed patient #27 was found by staff on the floor, beside her bed. Staff heard patient #27 yelling for help. Patient #27 stated she had lost her balance and fell. Patient #27 was assessed and found to have a small bruise on her right wrist. No other injuries were reported.

Record review of patient #27's care plan showed a focus of Falls, initiated on 6/11/23. Patient #27's care plan interventions on falls included, "Review information on falls and attempt to determine cause of falls (if any). Record possible root causes. Alter/remove any potential cause if possible. Educate resident/family/caregivers as to causes."

3. Review of a Facility Reported Incident submitted to the State Survey Agency, dated 10/4/22, showed patient #28 had an unwitnessed fall in her room. The patient stated she had tripped over her feet and hit her head against the bathroom wall. Patient #28 was assessed and found to have no apparent injuries. She was instructed to use the call light for assistance and staff were informed of patient #28 being a fall risk. The report stated the care plan was updated on 10/6/22.

Review of a Facility Reported Incident submitted to the State Survey Agency, dated 11/10/22, showed patient #28 was found by staff on the floor, beside her bed. Patient #28 stated she fell out of bed and was unable to get up unassisted. Patient #28 was assessed and found to have no apparent injuries. She was again instructed to use the call light for assistance. The report states the care plan was updated to high fall risk with a goal of "do not fall."

Record review of patient #28's care plan, initiated 10/12/22, showed:

"Focus: Falls

...The resident is at risk for falls: unsteady transferring to/from chair/bed to standing position; walking; turning around when walking; on and off toilet; surface to surface transfers. Date Initiated 10/12/2022, Revision on: 11/20/2022

...Focus: ADL Functional/Rehabilitation Potential

...Bed Mobility: The resident is able to independently. Date Initiated: 10/12/2022, Revision on: 11/20/2022

...Toilet Use: The resident is able to independently. Date Initiated: 10/12/2022, Revision on: 11/20/2022

...Transfer: The resident is able to transfer/self. She walks/self throughout the facility. Uses FWW at times when she walks. Locomotion/self. Date initiated: 10/12/2022, Revision on: 11/20/2022. ..."

During an interview on 6/21/23 at 10:53 a.m., staff member B said she was unable to locate any investigation on the two requested facility reported events for patient #27 and patient #28. Staff member B said she did not think an investigation was done.