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Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the type of restraint used was the least restrictive intervention that was effective to protect the patient from harm. The facility failed to evaluate and identify the use of a seat belt to be a restraint for one (1) of six (6) sampled patients with restraints (Patient #27).

The findings include:

Review of the facility's policy titled "Use of Restraints and Protective Measures" effective April 2013, revealed the use of restraints should be based on an individualized patient assessment with the least restrictive device utilized.

Record review revealed Patient #27 was admitted by the facility on 04/23/13 with diagnoses which include Rehabilitation S/P Chronic Obstructive Pulmonary Disease and Coronary Artery Bypass Grafting. Further review revealed a seat belt was applied on 04/30/13; however there was no documented evidence that Patient #27 was assessed for the use of a seat belt or for the least restrictive device.

Interview with the Director of Nursing for Inpatient Rehabilitation, on 07/19/13 at 5:10 PM, revealed there was no documentation of Patient #27 being assessed for the use of a seat belt. Further interview revealed it was Physical Therapy's responsibility to assess and document the use of the seat belt.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure restraint orders were not written as a standing order or on an as needed basis (PRN). The facility failed to ensure restraints interventions were not discontinued and then re-started under the same order for one (2) of six (6) sampled patients that had restraint orders (Patient #6 and #25). Patient #6's and #25's restraints were removed for family visits and without direct staff supervision and reapplied without a new physician' order.

The findings include:

Review of the facility's policy titled "Use of Restraints and Protective Measures" effective 04/2013, revealed as needed (PRN) orders were not permitted and if a restraint was discontinued, a new physician's order should be obtained before reapplication.

Record review revealed the facility admitted Patient #6 on 07/03/13 with diagnoses which included Status Post (S/P) Acute Myocardial Infarction and S/P Acute Respiratory Failure. Further record review for Patient #6 revealed a soft waist restraint when in a wheelchair and four (4) side rails up when in bed were reordered and applied on 07/14/13. The record further revealed the spouse was at the bedside on 07/14/13 from 2:00 PM until 11:00 PM at which time the restraint was removed. Patient #6's record then revealed, on 07/15/13 at 12:00 AM, the patient was placed back in restraints without a new physician order being obtained.

Record review revealed the facility admitted Patient #25 on 04/02/13, with diagnoses which included Traumatic Brain Injury, S/P motor vehicle accident and Acute Respiratory Failure S/P trauma. Further record review for Patient #25, revealed restraints were applied on 04/09/13 and removed during various times of the day on 04/10/13, 04/16/13, 04/17/13, 04/18/13, 04/19/13, 04/20/13, 04/21/13 and 04/22/13 due family presents and then reapplied with no documented evidence of a new physician's order for restraints was obtained for any of the above dates.

Interview with LPN #1, on 07/19/13 at 6:25 PM, revealed she does initiate restraint applications. Further interview revealed she thought the facility's policy was to obtain an order from the physician to reapply restraints if they had been removed for reasons other than direct care by staff.

Interview with the Director of Nursing for Inpatient Rehabilitation, on 07/19/13 at 5:10 PM, revealed the facility's policy was not to permit PRN restraint orders and a new physician's order was necessary if the restraints were removed for family visits.

Based on interview, record review, and review of facility's policy, it was determined the facility failed to ensure the Attending Physician, who has over all responsibility and authority for the management and care of the Patient, was aware of the restraint intervention for three (3) of six (6) sampled patients with restraints (Patients #6, #7 and #25).

The findings include:

Review of the facility's policy titled, "Use of Restraints and Protective Measures", Effective date April 2013, section "Orders for Restraint Use", revealed the Attending Physician must be contacted as soon as possible (ASAP) of restraint or seclusion to inform him/her that the patient has been restrained or secluded. Per facility's policy ASAP means contacting the physician within one hour for non-violent, non-self-destructive behavior or immediately (within a few minutes) if the patient is exhibiting violent/self-destructive behaviors. Further review of the facility's policy revealed when the Attending Physician of record is unavailable, the responsibility will be delegated to another covering physician, who will then be considered the Attending Physician.

1. Record review revealed the facility admitted Patient #6 on 07/03/13 with diagnoses which included Status Post (S/P) Acute Myocardial Infarction and S/P Acute Respiratory Failure. Further record review revealed Patient #6 had a verbal order from an unidentifed Physician, on 07/09/13 at 12:30 PM, for a soft waist restraint when in a wheelchair and four (4) side rails up when in bed. Four (4) side rails up was applied on 07/09/13 at 1:00 PM. The record then revealed, on 07/10/13 at 6:00 AM, the Ordering Physician co-signed this order; however, there was no documentation the Attending Physician had been notified within the one (1) hour timeframe required per facility policy.

2. Record review revealed the facility admitted Patient #7 on 07/12/13, with diagnosis which include Acute Right Ischemic Stroke, S/P Right Hemicraniectomy, Tracheostomy, Hypertension, and Left Hemiparesis and Neglect. Further record review for Patient #7, revealed restraints were applied on 07/12/13, at 3:00 PM, the order was signed by the Resident Physician; however there was no documented evidence the Attending Physician was notified of the restraint interventions.

3. Record review revealed the facility admitted Patient #25 on 04/02/13, with diagnoses which included Traumatic Brain Injury, S/P motor vehicle accident and Acute Respiratory Failure S/P trauma. Further record review for Patient #25, revealed restraints were applied on 04/09/13, at 10:45 PM, the order was signed by the Resident Physician; however there was no documented evidence the Attending Physician was notified of the restraint interventions.

Interview, on 07/19/13, at 6:50 PM, with the Director of Nursing for Inpatient Rehabilitation revealed there was no documented evidence that the Attending Physician was notified of the application of restraint intervention as per the facility policy for Patients #6, #7 and #25. Furthermore, she verified that none of the daily (07/12/13-07/19/13), restraint orders were signed by the Attending Physician, but were signed by the Resident Physician.

Based on interview, record review and review of facility policy and procedure, it was determined the facility failed to ensure nursing personnel assessed seven (7) of thirty (30) sampled patients (Patient's #1, #3, #4, #7, #8, #22, and #29), for pneumococcol vaccination history.

The findings include:

Review of the facility's policy titled "Charting Procedures", dated December 2012, section - Assessments C. revealed Pneumococcal Vaccination Nursing Assessment should be completed for every impatient admission.

1. Record review for Patient #1, revealed the patient was admitted to the facility on 07/06/13, with diagnosis which included Traumatic Brain Injury, trach and gastrostomy tube. Further review of the record revealed no admission nursing assessment was completed on pneumococcal vaccination history.

2. Record review for Patient #3, revealed the patient was admitted to the facility on 07/02/13, with diagnosis which included Traumatic Brain Injury, and gastrostomy tube. Further review of the record revealed no admission nursing assessment was completed on pneumococcal vaccination history.

3. Record review for Patient #4, revealed the patient was admitted to the facility on 05/20/13, with diagnosis which included respiratory failure and stroke with right sided hemiparesis. Further review of the record revealed no admission nursing assessment was completed on pneumococcal vaccination history.

4. Record review for Patient #7, revealed the patient was admitted to the facility on 07/12/13, with diagnosis which included stroke with right sided hemiparesis and gastrostomy tube. Further review of the record revealed no admission nursing assessment was completed on pneumococcal vaccination history.

5. Record review for Patient #8, revealed the patient was admitted to the facility on 07/09/13, with diagnosis which included stroke, congestive heart failure, diabetes and pacemaker. Further review of the record revealed no admission nursing assessment was completed on pneumococcal vaccination history.

6. Record review for Patient #22, revealed the patient was admitted to the facility on 02/28/13, with diagnosis which included chronic obstructive pulmonary disease. Further review of the record revealed no admission nursing assessment was completed on
pneumococcal vaccination history.

7. Record review for Patient #29, revealed the patient was admitted to the facility on 07/13/13, with diagnosis which included weakness and fatique. Further review of the record revealed no admission nursing assessment was completed on pneumococcal vaccination history.

An interview, on 07/19/13, at 6:50 PM, with the Director of Acute Rehab Nursing, revealed the admission nursing assessment for pneumococcal vaccination was not completed as per facility policy.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure all drugs and biologicals were administered in accordance with accepted standards of practice. The facility failed to ensure the patient's five rights were adhered to with the administration of medication for one (1) unsampled patient (Unsampled Patient A). The facility failed to ensure the right dose of medication was given to Unsampled Patient A during a medication pass.

The findings include:

Review of the facility's policy titled, "Medication Administration", updated August 2009, revealed the nurse should scan the medications to ensure the correct medication, route, dose and time.

Record review revealed Unsampled Patient A was admitted by the facility on 07/10/13 with a diagnosis of a Right Hip Fracture. Further review revealed a Physician's order for 324 milligram of Ferrous Sulfate (one tablet) to be given daily.

Observation of a medication pass, on 07/19/13 at 9:25 AM, revealed Registered Nurse (RN) #1 obtained 648 milligrams of Ferrous Sulfate (two tablets), placed medication into a medication cup then handed the cup to the patient. Medication administration observation was halted, RN #1 was made aware of the medication error prior to the patient taking the medications.

Interview with RN #1, on 07/19/13 at 3:25 PM, revealed she had scanned one tablet and opened two tablets. Further interview revealed the mechanism in place to reduce medication errors was to scan all medications prior to administration.

Interview with Unit Manager #1, on 07/19/13 at 3:34 PM, revealed the mechanism in place to reduce medication errors was scanning each medication prior to administration.

Based on observation, interview and review of facility policies, it was determined the facility failed to ensure 0.9 percent saline for irrigation, AccuChek control solution, and sterile water for injection that were available for patient use had not expired or were properly labeled.

The findings include:

Review of facility policy, "Labeling of Medications," policy number L-01, revision date 11/2012, revealed all medications from a multi-dose vial that were manipulated by nursing personnel would be dated at the time of manipulation.

Review of facility policy, "Glucose Testing Using AccuChek Inform," policy number AccuCheck, review date 02/28/13, revealed control solutions must be dated and initialed when first opened and were good for ninety (90) days after opening or until the expiration date printed on the label, whichever came first.

Observation of the General Rehab Unit's (GRU) medication room, on 07/16/13 at 3:14 PM, revealed two (2) AccuChek control solution bottles available for patient use, stored on the cabinet top, that were opened but had no opened date on the bottles. Further observation of the GRU, on 07/16/13 at 3:36 PM, revealed three (3) three thousand (3000) milliliter (ml) 0.9 percent saline bags, used for irrigation, with an expiration date of 04/2013 available for patient use in a cabinet in the medication room. Further observation of the facility on the Spinal Cord Unit (SCU), on 07/16/13 at 3:55 PM, revealed two (2) twenty (20) ml sterile water for injection vials opened with no opened date on the vials. These vials were available for patient use and were stored in a locked cabinet in the medication room.

Interview with RN #2, on 07/16/13 at 3:45 PM, revealed she knew the AccuChek control solution should be dated when opened and was good for ninety (90) days after opening. She further revealed it was all the staff's responsibility to make sure the solutions were dated when opened.

Interview with the Pharmacy Manager, on 07/18/13 at 11:30 AM, revealed pharmacy would have sent up the three (3) 3000 ml 0.9 percent saline bags for specific patients, and when the patients were discharged, the bags should have been returned to pharmacy by nursing personnel in a timely manner.

Interview with the Director of Nursing for Inpatient Rehabilitation, on 07/19/13 at 6:50 PM, revealed AccuChek control solution bottles and the multidose 20 ml sterile water for injection vials should have been dated when opened per facility policy. She further revealed it was nursing personnel's responsibility to check the locked cabinets for any expired medications and/or expired fluids used intravenously or for irrigation.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure that established policies and procedures were maintained for safe food handling practices. The facility failed to ensure opened food products were used or discarded by the use date. In addition, the facility failed to ensure the grill, gas stove and freezer were maintained utlizing sanitary conditions.

The findings include:

Review of the facility's policy titled, "Equipment Cleaning Procedures", dated 01/2013, revealed instructions for cleaning the grill and gas stove, but did not cover the drip pans or walk-in freezer or coolers. Review of the facility's policy titled "Sanitation and Storage", dated 01/2013, revealed no information for storage of opened food products.

Observation of the kitchen, on 07/17/13 at 10:50 AM, revealed a pan of tomato paste covered with plastic wrap, dated 07/15/13, sitting on a middle shelf of a cooler. Continued observation revealed the drip pans of the grill and gas stove had a build up of grease and food particles, the top of the grill had a build up of grease, and the freezer identified as #4 had an accumulation of dried food pactricles, and paper pieces on the floor under and between the shelves.

An interview with the Dietary Director, on 07/17/13 at 11:30 AM, revealed the pan of tomato paste should have been used or discarded on the 15th. Further interview at 1:55 PM, revealed all cleaning was to be done at least weekly per the cleaning schedule. She further stated the cooks did not use the grill much any more so it might have been overlooked.

Review of the weekly cleaning schedule for 07/08/13 through 07/14/13, revealed the drip pans, the large gas stove, and the walk in cooler and freezers were not listed on the cleaning schedule.

Observation of the #4 freezer with the Dietary Director, on 07/17/13, at 2:10 PM, revealed the freezer floor had an accumulation of dried food pactricles, and paper pieces still on the floor under and between the shelves. Interview at this time revealed that the freezer floor needed to be cleaned and she would get the cleaning schedule updated.