HospitalInspections.org

Based on review of records and interview, the hospital failed to:

have a nursing matrix staffing grid for the Emergency Department(ED).

have emergency services integrated into the Quality Assessment Performance Improvement (QAPI).

establish an advisory group that included a physician and mid-level practitioner for the purpose of annually reviewing patient care services policies and recommending changes as necessary.



Review of the nursing policy and procedure "Patient Staffing Guidelines last revised 11/2009 and reviewed on 5/2009", revealed the policy had a Medical -Surgical matrix for nursing staff. There was no nursing matrix for Emergency Department.

An interview with staff # 2 was conducted on 7/25/18 at 10:35 PM. Staff #2 confirmed that policy "Patient Staffing Guidelines" has not been reviewed for many years. Staff #2 stated it is a process they are working on but currently there is no updated and approved nursing staffing policy and procedure.

Review of the facility's QAPI revealed the facility had been tracking numbers in the ED but had not followed through with that data. There were no active PI projects.

An interview was conducted with staff #2 on 7/25/18 concerning the excessive number of "left without being seen" and patients leaving AMA after long wait times. Staff #2 stated they have been doing call backs for that population but they have been picked at random and was sparse. Staff #2 stated they have not been following in QAPI nor had a PI process to follow but she had a plan in place to start 100% call backs in August.


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During a review of policies and procedures, it was noted that many policies had review dates greater than a year old.

Review of the Medical Executive Committee meeting minutes and Governing Body meeting minutes for 2018 did not include information on annual review of policies.

An interview was conducted with Staff #3. Staff #3 confirmed there was not a process or committee for the purpose of reviewing and revising existing policies. Staff #3 advised that as new policies were needed or a need to update an existing policy was identified, then the new policy or changed policy would be sent through the Medical Executive Committee and through the Governing Body for approval.

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

A. maintain the facility's physical plant and did not have a written plan for improvements as of 7/24/2018.

This deficient practice had the likelihood to effect all patients of the facility.

On the morning of 7/24/2018 during the tour of the outside of the hospital building and grounds the following was identified:

1. The building had a flat or near flat roof and water down spouts were observed with black discoloration from rain water drainage that had grown mold. All down spouts were observed in this condition.

2. At the rear of the building at the outpatient entry point, crumbling concrete around flower beds, near the entrance of the building was observed. The crumbling concrete ledges were seat level and potentially could cause injury should a patient family choose to sit on the ledge while smoking or conducting a telephone call.

3. Air conditioning (AC) window units were observed in windows to provide interior AC. The units were observed with heavy dusts, dirt and cob web build up. This covering of debris would cause the window units to unnecessarily struggle to provide cool air on the inside of the building.


On the afternoon of 7/23/2018, a tour of the interior of the facility revealed the following:

1. Pharmacy

The pharmacy was observed to have large sections of plaster and wall paper that had become dislodged and was hanging down from both corners of the inside of the exterior wall of the room.

Between these two sections of falling plaster/wall paper was a centrally positioned window. An AC unit had been placed in the lower section of the window. A 1 inch space between the window casing and the lower portion of the unit ran from one side of the window to the other. The space allowed insects, dirt and hot air to enter the pharmacy.

The door which separated the medication storage room from an office/work room was observed with the door knob and dead bolt severely damaged. The door knob and dead bolt were observed dangling within the door frame. The room could no longer be secured.



2. Central Supply

The storage room which was being utilized for clean/sterile supplies was observed with the interior of the outside wall (concrete) crumbling. The staff had draped white cloth across two walls in an effort to protect the supplies from contamination of the concrete dust and particle matter. The ceiling had visible water damage and had begun to crumble and fall onto the upper cabinet surface. The light fixtures did not have covers over them and were positioned at angles in such a way as to block the water sprinklers in the ceiling, in the case of a fire.

3. Ceiling tiles

Wide spread water damage was observed on ceiling tiles through out the facility. Hallways, patient rooms, office spaces, storage rooms, lab, and radiology departments respectively.

4. Wide spread wall damage was seen. Holes in the plaster/concrete walls were observed. Some holes were the result of removing conduit 1.5 inches in diameter and not filling the resulting open space in the wall. Some holes were the results of electrical outlets being moved or damaged leaving an open space in the wall. Some areas were much larger and were where pipes may have required repair and a portion of the support wall had been removed, or where the pipes entered or exited the building via the wall. Some of these areas were between walls and were large enough to allow a rodent, snake or larger pest to obtain entry into the building. Some smaller holes simply looked as if a small object had punctured the wall and had been left.

Interview with the plant operations manager indicated some parts of the building were 70 years old and the crumbling concrete did not adhere to repair products. The plant operations manager implied building repair was over whelming.

5. Wide spread observation of fluorescent lights without covers.

6. The housekeeping staff removed facility trash via an outside door. Immediately adjacent to the exit door, pipes were observed ascending from near the floor into the ceiling. The pipe closest to the door way was observed with damaged insulation from staff hitting the insulation when taking the carts in and out the door. The damage exposed the insulation approximately 4 feet. The exposed insulation placed the staff at risk of contamination or injury.

The wall where the pipe entered the building from the outside had exposed surfaces no longer retaining paint and space around the pipe where insects or rodents might enter the building.



B. provide a system for ensuring patient use equipment was kept in operating condition in 2 of 2 areas of equipment use, Medical record storage and Physical Therapy/Rehabilitation.


Refer to C 0222


C. properly dispose of trash.

Refer to C 0223


D. store housekeeping supplies, drugs and biological's appropriately that were observed 7/23 and 7/24/2018.

Refer to C 0224

E. maintain records of documentation as evidence of having conducted one fire drill per shift per quarter for two quarters January, February,March (1st quarter) April , May, June (2nd quarter).

Refer to C 0232

F. ensure timely completion of 8 of 13 medical record entries by mid-level practitioners and periodically monitor prescriptive documentation provided by Registered Nurse Practitioners within the facility for four (4) months April, May, June, July of 2018.

Refer to C 0260

G. participate in the periodic review of 8 of 13 patient medical records and failed to insure timely completion of medical record entries for four (4) months, April, May, June, July of 2018.

Refer to C 0264




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H. keep hallways throughout the hospital cleared of clutter. During a tour of the hospital on 7-23-2018, all main hallways were observed to have furniture, equipment, and cabinets stored in them. Cabinets were found to be obstructing access to shutoff valves.

Refer to C 0225

Based on observation, document review and interview, the facility failed to provide a system for insuring patient use equipment was kept in operating condition in 2 of 2 areas of equipment use, Medical record storage and Physical Therapy/Rehabilitation.

This deficient practice had the likelihood to effect all patients of the facility.

1. Medical Record storage

On 7/25/2018, a tour of the on campus outside storage building used to house patient medical records revealed an A-B-C fire extinguisher with a tag indicating the most recent inspection by the fire prevention company that insures adequate charge for fire extinguishers, was 2011. This was confirmed by the office staff #8.

Interview with the Plant Operation Director indicated he was not aware of the expired fire extinguisher in the Medical Records storage building outside.

Review of the Facility policy for Fire extinguishers is found below, copied as written.

"MAINT'ENANCE DEPARTMENT
POLICY AND PROCEDURE NUMBER: MNT L 5
SUBJECT: FIRE EXTINGUISHERS PURPOSE:
D A T E : _ 5 / 9 5 _ REVTEWED:_6/96, 1/99.4/01 REVISED:
PURPOSE:
To assure that all fire extinguishing equipment with in the Hospital will function if needed , as
designed.
POLICY:
1. A licensed fire extinguisher company shall be constructed (Sic) to perform yearly inspections and test all of the fire extinguishing equipment within the Hospital.
2. Maintenance shall inspect each fire extinguisher on a monthly schedule and so indicate on the extinguisher report sheet.
PROCEDURE:
1. The Maintenance and Operation Manager shall initiate on a yearly basis, a purchase
requisition for a service contract with a licensed fire extinguisher contractor to inspect and service each fire extinguisher and fire protection system within the Hospital .
2. The records from the contractor shall be on file in the Maintenance Department office for
review and inspection.
3. The Hospital Administrator personnel shall inspect each fire extinguisher on a monthly
schedule according to the following:
a. The extinguisher shall be in its designated place.
b. Access to or visibility of, the extinguisher shall not be obstructed.
c. The operating instructions on the extinguisher name plate shall be legible and face
outward.
d. Any seals or tamper identifications that are broken or missing shall be replaced.
e. Any obvious physical damage, corrosion, leakage, or clogged nozzles, shall be noted,
f. Pressure gauge readings when not in operable range shall be noted".



2. Physical Therapy/ outpatient rehab.

On 7/24/2018, a tour of the Physical Therapy/Rehab department revealed a Hydroculator (a metal container which holds heated water and clay packs used to provide heat pack therapy to patients). The hydroculator was observed placed on an over bed table against the back wall of a cluttered closet. The closet held patient use incontinent pads stacked on an over bed table in front of the Hydroculator. A Christmas decoration was hanging off another piece of equipment near the end of the closet, a wheel chair not in use, and a second stack of incontinent pads was seen.

Interview with the Physical Therapist (PT) for the day, staff #20, indicated the Hydroculator was not in use because the clay packs had burst inside the Hydroculator, however, the Hydroculator light was red indicating it was plugged into electricity. The PT moved the over bed table which held the incontinent pads so she could turn the unit off. She further indicated the unit didn't have "much water in it to heat".

The PT was asked if there were plans to replace the clay packs and clean the Hydroculator for patient. She replied, "I really don't know because we don't use it much to start with".

The facility administrator was questioned regarding plans for use of the Hydroculator. He was aware it was not in functional use but was told by the PT they didn't use it much. There was no plan to replace the unit. He was not aware the unit was stored in the cluttered closet while plugged in without water in the unit.

A review of the facility's policy is found below, COPIED asten.

"MAINTENANCE DEPARTMENT
POLICY AND PROCEDURE NUMBER: MNT 1.14
DATED: 5/95
REVIEWED: 10/96,1/99,4/01
REVISED: 2/97
SUB.IECT: PREVENTIVE M AINTENANCE (EQUIPMENT)
POLICY:
It is the policy o:r this Maintenance Department to work with Administration and Environment of Care Committee to establish a Preventive Maintenance Program for all equipment. It is
imperative to have a good preventive program to keep all equipment in safe working order and to offset the time any such equipment may maffunction.
PROCEDURE:
A Bio-Med Service Specialists will clean all internal parts of equipment, also calibrate and adjust equipment as is specified in the Equipment Manual . or as deemed necessary for the continue safe operation of al 1 equipment.
B. All external parts shall be cleaned by department responsible for use of equipment.
C. Records of inspections, maintenance, or recommendations shall be maintained by
Maintenance and appropriate written reports distributed to individual departments concerned.
D. Information regarding each item of equipment shall be kept in Maintenance. Operator's
instruction booklets will be kept in the department the equipment is being used in.
E. All new electrical equipment shall be evaluated and tested by the Maintenance Department
prior to its use.
F. Testing intervals shall be consistent with the manufacturer's recommendations; standards
promulgated by recognized technical organizations and frequency of use. In no case shall the
testing of patient electrical equipment exceed six (6) months.
G. Department Supervisors will notify Maintenance Department by requisition of any
malfunctions".

Based on observation and interview the faclity failed to properly dispose of trash.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On 7/24/2018, observation revealed dumpster was left open with the lid resting on the back of the dumpster. There was no containment fence to reduce or inhibit scavenging by people or animals.

This was confirmed by the Plant Operations Director, Staff #9.

Based on observation and interview the facility failed to have a preventative maintenance program to ensure housekeeping supplies, drugs and biological's were appropriately stored in 2 of 2 areas (housekeeping and pharmacy) observed.

This deficient practice had the likelihood to effect all patient and staff of the facility.


Finding included.

On 7/23/2018 during the initial tour of the interior of the building, the following areas were observed with improperly stored content.

1. Store room across from the pharmacy.

The store room across from the pharmacy was being utilized to store intravenous solutions for mixture and intravenous emergency treatment drugs. The Registered Pharmacist stated the door was locked at the end of each work day. This statement was witnessed by three (3) surveyors.

Examination of the door revealed it had no locking mechanism. The store room was not capable of being locked. The room had direct access from the hallway.


2. House keeping closet on the East hallway.

Upon entering the housekeeping closet on the East hallway. Clean and dirty supplies were stored in the same area. Biohazard boxes which were full of biohazard waste, were observed stored in close proximity to the housekeeping carts which, if cross contaminated, traveled throughout the building. Clean paper towels were stored in unlocked cabinets above the biohazard boxes.

The florescent lights in the ceiling did not have a cover over it, protecting staff from glass breakage should one of the fluorescent bulbs shatter.

The room was sprinklered and a floor buffer pad and cardboard box were stored above the cabinet. The distance to the ceiling was less than 18 inches, which is required for full sprinkler coverage in case of a fire.

Based on observation and interview, the hospital failed to keep hallways throughout the hospital cleared of clutter.

Findings included:

During a tour of the hospital on 7-23-2018, all main hallways were observed to have furniture, equipment, and cabinets stored in them.

The oxygen and vacuum shut-offs for rooms 224, 226, 232, 234, 236, 244, and 246 were observed to have access obstructed by wall cabinets that were stacked up on the floor in front of them.

Interview with Staff #1 revealed that the hospital district had closed an office. Part of the clutter in the hallway was from furniture and equipment from the closed office and part was from renovations in process.

Based on record review and interview, the facility failed to maintain records of documentation as evidence of having conducted one fire drill per shift per quarter for two quarters - January, February,March (1st quarter) April , May, June (2nd quarter).

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On the afternoon of 7/24/2018, interview with the plant operations manager, staff #9, confirmed he was behind on conducting fire drills. He confirmed most staff worked three 8 hour shifts but some staff worked "mid-shifts and partial shifts".

Review of the documentation of fire drills conducted since January 2018 revealed three (3) drills had been conducted. Fire drills were documented as conducted on the following dates and shifts:

1/15/2018 1:00 PM shift identified 1st shift (7:00 AM - 3:00 PM)
2/08/2018 7:04 AM shift identified as 2nd (sic) (7:00 AM - 3:00 PM) The location identified was not within the licensure of the facility. (clinic)
4/10/2018 11:30 am 1st shift (7:00 AM - 3:00 PM)

The facility had not conducted a second or third shift fire drill in two quarters and had not conducted a mid shift fire drill at all.

On 1/15/2018 a problem was identified and documented on the fire drill report. No other "after drills" remarks were documented.

Based on record review, document review, and interview the facility's Governing Body failed to ensure that Medical Staff Rules, Regulations, and Bylaws were enforced for the timely completion of 8 of 13 (#8, #10, #12, #13, #14, #15, #16 and #17) medical record entries by mid-level practitioners and periodic monitor of prescriptive documentation provided by Registered Nurse Practitioners within the facility from three (4) months April, May, June, July of 2018.

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On the morning of 7/26/2017 medical records (MR), for patient's (Pt/Pt's) #5 thorugh #17 were reviewed. This review provided evidence of History and Physical (H&P) reports that had been initiated but not fully completed, as well as H&P's dated/signed greater than 24 hours after the patient had visited the emergency department (ED) and/ or admitted to the hospital. The incomplete documentation was submitted by the Registered Nurse Practitioner (RNP) who initially treated the patient. Within each H&P was/should have been, the RNP's prescriptive planning for treatment of the Pt.


RNP #39

Pt #10 was seen in the ED on 4/27/2018 for acute diverticulitis. The H&P was completed, signed and entered into the pt's MR on 5/28/2018, thirty (30) days after being treated in the ED.

The H&P was co-signed by the physician over sight on 6/1/2018, thirty-two (32) days after being treated in the ED.


Pt #12, was seen in the ED on 6/21/2018. On the date of the MR review, 7/26/2018 the H&P was found to be incomplete and without signature of the RNP #39. The H&P was 36 days and counting incomplete and unavailable for the MR.

The H&P was not completed by the physician oversight or co-signed by the MD oversight.


Pt #13 was seen in the ED on 6/21/2018 and admitted to inpatient services. Pt #13 was discharged on 6/27/2018. The H&P was incomplete without History of Presenting Illness, No review of systems. The document was not signed as of 7/26/2018 by the author (RNP #39), thirty (30) days past the 24 hours requirement.

The H&P was not signed by the RNP's Physician oversight, indicating his unawareness of the H&P omission.


Pt #14 was treated in the facility 6/3/2018. The H&P was completed, signed and entered into the MR on 7/10/208, thirty-seven (37) days outside the 24 hours time line.

The Vice Medical Director co-signed the document 7/14/2018, 42 days outside the 24 hour timeline.


Pt #15 was treated in the ED on 6/3/2018. Review of the H&P present in the electronic medical record (EMR) did not have the electronic signature of the author, RNP #39,
fifty-three (53) days outside the 24 hour requirement.

The H&P had not been co-signed or completed by the physician over sight as of 7/26/2018, this indicated his unawareness the H&P was outstanding.


Pt #17 was treated in the ED on 4/6/2018. The H&P was transcribed and signed 5/15/2018 by the RNP, #39, yhirty-nine (39) days past the 24 hour requirement for the H&P to be completed and on the pt's MR.


The physician oversight, staff #27, had co-signed the H&P 5/17/2018, forty-one (41) days late.



RNP #30

Pt #8 was seen in the ED after a ground level fall, on 6/2/2018. The H&P was completed, signed and entered into the pt's MR on 6/27/2018. The record was signed 23 days after the 24 hour requirement.

The Physician oversight for this RNP co-signed the H&P 7 days later on 7/4/2018.


Pt #16 was treated in the ED on 5/9/2018. The H&P had been transcribe but had not been signed by the author RNP #30 as of 7/26/2018. The MR was 81 days outside the 24 hour requirement to be completed.

The physician oversight for this RNP, physician #27, had not co-signed the H&P. Indicating his unawareness of the delay in the H&P's availability in the MR.

Although the Medical Director co-signed the RNP H&P's, the lack of corrective action indicated he was unaware of the gross delay in completion of H&P in the patient's MR. He simply electronically co-signed the document without reviewing the document and time line in which the document was created.

On 7/25/2018 an interview with the MR Director, staff #19 confirmed she was aware of the consistent delay in timely completion of H&P's from RNP #39. She further indicated she had provided the Medical Director the H&P information and asked for help to get the documentation completed in the 24 hour time frame. She indicated she had reminded the Medical Director of the Medical Staff guideline indicating suspension with continued inability of a practitioner to comply with the MR guidelines, but nothing had happened.

On 7/26/2018 an discussion with the Medical Director, physician #27 occurred. He was again made aware of the deficit of compliance by RNP #39 in timeliness of the H&P for pt's she treated. He was also made aware of the occasional lateness of signature on H&P by RNP #30.

The Medical Director confirmed he would address this issue with the RNP's.

On 7/26/2018 a review of the facility's Medical Staff Bylaws, "Section 4.08 General requirements of Clinical Staff Membership", was as follows:

"Section 4.08 General requirements of Clinical Staff Membership. In order to obtain or maintain membership on the Clinical Staff and in order to be granted clinical privileges as a member of the clinical staff, applicants must demonstrate:
...

(c) Appropriate Management of Medical Records. Preparing in legible and accurate form, completing within prescribed timelines and maintaining the confidentiality of medical records for all patients to whom the Member provides care in LDRMC facilities in accordance with applicable policies of LDRMC. This shall include, but is not limited to, performing histories and physicals and completing all necessary documentation as required by LDRMC Policy HIM 9.3 which is incorporated herein by reference.

i. A medical history and physical examination shall be completed no more than thirty (30) days before or twenty-four (24) hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia
services. The medical history and physical examination must be completed
and documented by a physician, an oral and maxillofacial surgeon, dentist,
podiatrist, or other qualified licensed individual in accordance with State
law and Medical Center policy.

ii. An updated examination of the patient, including any changes in the patient's condition, be completed and documented within twenty-four (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination is completed within thirty (30) days before admission or registration. The updated examination of the patient, including any changes m the patient's condition, must be completed and documented by a physician, an oral and maxillofacial surgeon, dentist, podiatrist, or other qualified licensed individual in accordance with State law and Medical Center policy."



On 7/26/2018 a review of the facility's Medical Rules and Regulations, "Section 4. Medical Records", was as follows:

"Subsection 3.
A complete history and physical shall be written in all cases not more than seven days before or twenty-four (24) hours after admission of the patient.
(a) If the patient has been discharged less than seven (7) days, an interval note in the progress report will suffice, if the patient is readmitted
with the same diagnosis.

Subsection 4.
An incomplete medical record is considered delinquent thirty (30) days after
discharge. The H IM Director, or the Administrator, shall notify the delinquent member, and the penalty shall preclude admission of additional patients to the hospital, except in an emergency, and shall last until such time as ail delinquent charts are completed."

On 7/26/2018 a review of the facility's Medical Staff Rules and Regulations "section 20. Supervision of Mid-Level Personnel" did not identify the need for periodic review of the personnel to include their documentation or establish a protocol for when the periodic review would occur and what percentage of the Mid-Level Practitioner's documentation would be included. There was no requirement for actual review of services and documentation provided by the RNP.

On 7/26/2018 the MR policy and procedure (P&P), HIM 9.3 dated 2/25/02 and lasted reviewed 12/12, for completion of the medical record was reviewed.
The P&P indicated under "Procedure" 1. History and Physical examinations are documented in his of her medical record within 24 hours of admission. This time frame applies for weekends, holidays, and weekday admission. (The P&P does not separate ED admissions from in-patient admissions, therefore patients admitted for services should expect a current completed H&P on their MR within 24 hours after admission).

Review of the OCCUPATIONS CODE TITLE 3. HEALTH PROFESSIONS SUBTITLE B. PHYSICIANS CHAPTER 157. AUTHORITY OF PHYSICIAN TO DELEGATE CERTAIN MEDICAL ACTS SUBCHAPTER A. GENERAL PROVISIONS

(f) The periodic face-to-face meetings described by Subsection (e)(9)(B) must:(1) include:(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and(B) discussion of patient care improvement; and(2) be documented and occur:(A) except as provided by Paragraph (B):(i) at least monthly until the third anniversary of the date the agreement is executed; and(ii) at least quarterly after the third anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet; or(B) if during the seven years preceding the date the agreement is executed the advanced practice registered nurse for at least five years was in a practice that included the exercise of prescriptive authority with required physician supervision:(i) at least monthly until the first anniversary of the date the agreement is executed; and(ii) at least quarterly after the first anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet.(f-1) The periodic meetings described by Subsection (e)(9)(C) must:(1) include:(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and(B) discussion of patient care improvement;(2) be documented; and(3) take place at least once a month in a manner determined by the physician and the physician assistant.(g) The prescriptive authority agreement may include other provisions agreed to by the physician and advanced practice registered nurse or physician assistant.

The facilities physician staff had not established a supervisory oversight method or program to satisfy the requirement of physician oversight of advanced practice Registered Nurses or Physician Assistants.

Based on record review, document review, and interview the facility's Registered Nurse Practitioners failed to participate in the periodic review of patient medical records and failed to insure timely completion of medical record entries for four (4) months, April, May, June, July of 2018, #5 through #17 were reviewed (13 records), 8 of 13 medical records (#'s 8,10,11,12,13,14,15, and 16) were incomplete or were signed and timed outside of the facilities policy timeline.

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On the morning of 7/26/2017 medical records (MR), for patient's (Pt/Pt's) #5 thorugh #17 were reviewed. This review provided evidence of History and Physical (H&P) reports that had been initiated but not fully completed, as well as H&P's dated/signed greater than 24 hours after the patient had visited the emergency department (ED) and/ or admitted to the hospital. The incomplete documentation was submitted by the Registered Nurse Practitioner (RNP) who initially treated the patient. Within each H&P was/should have been, the RNP's prescriptive planning for treatment of the Pt.


RNP #39

Pt #10 was seen in the ED on 4/27/2018 for acute diverticulitis. The H&P was completed, signed and entered into the pt's MR on 5/28/2018. Thirty (30) days after being treated in the ED.

The H&P was co-signed by the physician over sight on 6/1/2018. Thirty-two (32) days after being treated in the ED.


Pt #12, was seen in the ED on 6/21/2018. On the date of the MR review, 7/26/2018 the H&P was found to be incomplete and without signature of the RNP #39. The H&P was 36 days and counting incomplete and unavailable for the MR.

The H&P was not completed by the physician oversight or co-signed by the MD oversight.


Pt #13 was seen in the ED on 6/21/2018 and admitted to inpatient services. Pt #13 was discharged on 6/27/2018. The H&P was incomplete without History of Presenting Illness, No review of systems. The document was not signed as 7/26/2018 by the author (RNP #39). Thirty (30) days past the 24 hours requirement.

The H&P was not signed by the RNP's Physician oversight, indicating his unawareness of the H&P omission.


Pt #14 was treated in the facility 6/3/2018. The H&P was completed, signed and entered into the MR on 7/10/208. Thirty-seven (37) days outside the 24 hours time line.

The Vice Medical Director co-signed the document 7/14/2018, 42 days outside the 24 hour timeline.


Pt #15 was treated in the ED on 6/3/2018. Review of the H&P present in the electronic medical record (EMR) did not have the electronic signature of the author, RNP #39.
Fifty-three (53) days outside the 24 hour requirement.

The H&P had not been co-signed or completed by the physician over sight as of 7/26/2018. this indicated his unawareness the H&P was outstanding.


Pt #17 was treated in the ED on 4/6/2018. The H&P was transcribed and signed 5/15/2018 by the RNP, #39. Thirty-nine (39) days past the 24 hour requirement for the H&P to be completed and on the pt's MR.


The physician oversight, staff #27, had co-signed the H&P 5/17/2018. Forty-one (41) days late.



RNP #30

Pt #8 was seen in the ED after a ground level fall, on 6/2/2018. The H&P was completed, signed and entered into the pt's MR on 6/27/2018. The record was signed 23 days after outside the 24 hour requirement.

The Physician oversight for this RNP co-signed the H&P 7 days later on 7/4/2018.


Pt #16 was treated in the ED on 5/9/2018. The H&P had been transcribe but had not been signed by the author RNP #30 as of 7/26/2018. The MR was 81 days outside the 24 hour requirement to be completed.

The physician oversight for this RNP, physician #27, had not co-signed the H&P. Indicating his unawareness of the delay in the H&P's availability in the MR.

Although the Medical Director co-signed the RNP H&P's, the lack of corrective action indicated he was unaware of the gross delay in completion of H&P in the patient's MR. He simply electronically co-signed the document without reviewing the document and time line in which the document was created.

On 7/25/2018 an interview with the MR Director, staff #19 confirmed she was aware of the consistent delay in timely completion of H&P's from RNP #39. She further indicated she had provided the Medical Director the H&P information and asked for help to get the documentation completed in the 24 hour time frame. She indicated she had reminded the Medical Director of the Medical Staff guideline indicating suspension with continued inability of a practitioner to comply with the MR guidelines, but nothing had happened.

On 7/26/2018 an discussion with the Medical Director, physician #27 occurred. He was again made aware of the deficit of compliance by RNP #39 in timeliness of the H&P for pt's she treated. He was also made aware of the occasional lateness of signature on H&P by RNP #30.

The Medical Director confirmed he would address this issue with the RNP's.


On 7/26/2018 a review of the facility's Medical Staff Rules and Regulations "section 20. Supervision of Mid-Level Personnel" did not identify the need for periodic review of the personnel to include their documentation or establish a protocol for when the periodic review would occur and what percentage of the Mid-Level Practitioner's documentation would be included. There was no requirement for actual review of services and documentation provided by the RNP.

On 7/26/2018 the MR policy and procedure (P&P), HIM 9.3 dated 2/25/02 and lasted reviewed 12/12, for completion of the medical record was reviewed.
The P&P indicated under "Procedure" 1. History and Physical examinations are documented in his of her medical record within 24 hours of admission. This time frame applies for weekends, holidays, and weekday admission. (The P&P does not separate ED admissions from in-patient admissions, therefore patients admitted for services should expect a current completed H&P on their MR within 24 hours after admission).

Review of the OCCUPATIONS CODE TITLE 3. HEALTH PROFESSIONS SUBTITLE B. PHYSICIANS CHAPTER 157. AUTHORITY OF PHYSICIAN TO DELEGATE CERTAIN MEDICAL ACTS SUBCHAPTER A. GENERAL PROVISIONS

(f) The periodic face-to-face meetings described by Subsection (e)(9)(B) must:(1) include:(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and(B) discussion of patient care improvement; and(2) be documented and occur:(A) except as provided by Paragraph (B):(i) at least monthly until the third anniversary of the date the agreement is executed; and(ii) at least quarterly after the third anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet; or(B) if during the seven years preceding the date the agreement is executed the advanced practice registered nurse for at least five years was in a practice that included the exercise of prescriptive authority with required physician supervision:(i) at least monthly until the first anniversary of the date the agreement is executed; and(ii) at least quarterly after the first anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet.(f-1) The periodic meetings described by Subsection (e)(9)(C) must:(1) include:(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and(B) discussion of patient care improvement;(2) be documented; and(3) take place at least once a month in a manner determined by the physician and the physician assistant.(g) The prescriptive authority agreement may include other provisions agreed to by the physician and advanced practice registered nurse or physician assistant.

The facility's physician staff had not established a supervisory oversight method or program to satisfy the requirement of physician oversight of advanced practice Registered Nurses or Physician Assistants.

Based on review of records, observations, and interviews, the facility failed to:

A.
provide policy and procedure for three (3) of three (3) patient care areas (Medical Staff oversight of Registered Nurse Practitioners, Housekeeping and Nursing) of patient service from May through July 26, 2018.

Refer to C 0271

B.
establish an advisory group that contained a physician and mid-level practitioner for the purpose of annually reviewing patient care services policies and recommending changes as necessary. No evidence of a committee or advisory group was alleged or found. Hospital policies were not being reviewed by the Medical Staff on a periodic basis.

Refer to C 0272


C.
Ensure outdated medications were not accessible for patient use.

Ensure drugs and biological's were appropriately stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.

Ensure that a tracking system, on the movement of all scheduled drugs, from the point of entry into the hospital, to the point of departure either through administration to the patient, destruction or return to the manufacturer was being performed and followed.

Refer to C 0276

D.
maintain a sanitary environment necessary to ensure sources and transmission of diseases would be prevented in 6 out of 6 areas toured (Main Hallways, Central Supply Storage, Public Restroom, Ultrasound Examination Area, Pharmacy, and Patient Room 234).

Refer to C 0278

E.
maintain a list of services furnished under arrangement or agreement. The hospital CEO was not able to provide information on the contracts each department of the hospital managed and was unable to tell what services were being provided through agreement or arrangement.

Refer to C 0291

F.
provide oversight of all services provided under arrangement or agreement. Services provided under arrangement or agreement were not being evaluated to ensure services met the conditions of participation and standard requirements for a Critical Access Hospital.

Refer to C 0292

G.
Protect patients and staff from infectious communicable diseases in 1(#3) of 1 patient chart reviewed.

Provide a staffing matrix to determine the adequacy of staffing and to assess the delivery of care in 2 (medical surgical/swing and ED) of 2 nursing departments.

Develop, update, and maintain nursing policy and procedures.

Have current nursing competencies in 9 out of 9 (#2, 3, 6, 7, 8, 40, 41, 42, and 43) employee files reviewed.

Provide an active, ongoing review and analysis of the quality of nursing care through the Quality Assurance Performance Improvement (QAPI) program.

Refer to C 0294

H.
Assess and monitor the patient after the administration of a psychotropic drug used as a chemical restraint.

Have current policy and procedures on assessment/monitoring of patients receiving chemical restraints.

Properly identify and document a reason for administration of a chemical restraint.

Educate the patient /caregiver on the administration of a psychoactive medication in 2(23 and 4) of 2 patient charts reviewed.

Refer to C 0297

Based on observation, record review, and interview, the facility failed to provide policy and procedure for three (3) of three (3) patient care areas (Medical Staff oversight of Registered Nurse Practitioners, Housekeeping and Nursing) of patient service from May through July 26, 2018.

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


Physician oversight and review of Advanced Practice Registered Nurse, RNP

On the morning of 7/26/2017 medical records (MR), for patient's (Pt/Pt's) #5 thorugh #17 were reviewed. This review provided evidence of History and Physical (H&P) reports that had been initiated but not fully completed, as well as H&P's dated/signed greater than 24 hours after the patient had visited the emergency department (ED) and/ or admitted to the hospital. The incomplete documentation was submitted by the Registered Nurse Practitioner (RNP) who initially treated the patient. Within each H&P was/should have been, the RNP's prescriptive planning for treatment of the Pt.

On 7/25/2018 a MR review identified pt's #8, #10, #14, #15, #16 and #17 with H&P's that were entered, signed, and dated outside the 24 hour requirement for H&P to be complete.

Pt's #12 and #13 did not have a completed H&P in their MR.

The Medical Director co-signed for the RNP when the H&P was completed and entered into the MR. Therefore, he had the opportunity to review the documentation and become aware of the delay of completion for H&P. It was unclear at the time of the review if the Medical Director was aware of the 2 pt's without an H&P in their MR.

On 7/26/2018 an interview with the Medical Director indicated he was not aware of the two pt's with out a completed H&P in their MR.

On 7/26/2018 a review of the facility's Medical Staff Rules and Regulations "section 20. Supervision of Mid-Level Personnel" (RNP) did not identify the need for periodic review of the personnel to include their documentation or establish a protocol for when the periodic review would occur and what percentage of the Mid-Level Practitioner's documentation would be included. There was no requirement for actual review of services and documentation provided by the RNP.


Review of the OCCUPATIONS CODE TITLE 3. HEALTH PROFESSIONS SUBTITLE B. PHYSICIANS CHAPTER 157. AUTHORITY OF PHYSICIAN TO DELEGATE CERTAIN MEDICAL ACTS SUBCHAPTER A. GENERAL PROVISIONS

(f) The periodic face-to-face meetings described by Subsection (e)(9)(B) must:(1) include:(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and(B) discussion of patient care improvement; and(2) be documented and occur:(A) except as provided by Paragraph (B):(i) at least monthly until the third anniversary of the date the agreement is executed; and(ii) at least quarterly after the third anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet; or(B) if during the seven years preceding the date the agreement is executed the advanced practice registered nurse for at least five years was in a practice that included the exercise of prescriptive authority with required physician supervision:(i) at least monthly until the first anniversary of the date the agreement is executed; and(ii) at least quarterly after the first anniversary of the date the agreement is executed, with monthly meetings held between the quarterly meetings by means of a remote electronic communications system, including videoconferencing technology or the Internet.(f-1) The periodic meetings described by Subsection (e)(9)(C) must:(1) include:(A) the sharing of information relating to patient treatment and care, needed changes in patient care plans, and issues relating to referrals; and(B) discussion of patient care improvement;(2) be documented; and(3) take place at least once a month in a manner determined by the physician and the physician assistant.(g) The prescriptive authority agreement may include other provisions agreed to by the physician and advanced practice registered nurse or physician assistant.

The facility's physician staff had not established a supervisory oversight method or program to satisfy the requirement of physician oversight of advanced practice Registered Nurses or Physician Assistants.

Housekeeping Department.
A review of the housekeeping department P&P's identified no P&P which addressed the cleaning of air conditioning (AC) window units. This review was triggered by observation of 10 of 10 window units with a mixture of dirt, dust, cobwebs, dead insects and black organic matter growing on the AC window units. The units provided cool air to high clean work areas (lab, house keeping clean linen storage, pharmacy work room) and sterile work area (pharmacy hood area). Clean areas such as staff offices were also included in the observations.

Nursing Department
A MR review of pt #5 revealed she expired on 5/27/2018. The body was released to the funeral home without an order from the physician to do so.

Interview with the Chief Nursing Officer, Staff #2 and Chief Operating Officer, Staff #3 were questioned as to why there was no physician's order to release the body. They both replied "we don't have to". When the discussion continued and it was explained a physician's order is required for all actions that effect the chain of custody of the pt or the body of the pt they both replied "we never have".

The facility had no P&P to ensure the release of a deceased pt's body, left the facility with the knowledge and authority of the attending physician.

When the CNO and COO were asked who pronounced the pt dead they both replied the "Justice of the Peace" (JP). When asked why, with both Dr's and RN's, who are permitted to pronounce death in the facility, would a JP be called to perform the duty? The CNO and COO replied "We can't do it" (the RN). They explained the facility did not allow the RN to pronounce the death of a patient. Further discussion questioned if the ED physician is on the code team and the code is unsuccessful and the pt dies, why wouldn't the ED physician pronounce the death. The reply was, "we just always called the JP".

The facility did not have clear P&P to provide pronouncement of death within the hospital and maintain HIPPA privacy for the patient's family.

Based on review of records and interview, the hospital failed to establish an advisory group that contained a physician and mid-level practitioner for the purpose of annually reviewing patient care services policies and recommending changes as necessary.

Findings included:

During a review of policies and procedures, it was noted that many policies had review dates greater than a year old.

Review of the Medical Executive Committee meeting minutes and Governing Body meeting minutes for 2018 did not include information on annual review of policies.

An interview was conducted with Staff #3. Staff #3 confirmed there was not a process or committee for the purpose of reviewing and revising existing policies. Staff #3 advised that as new policies were needed or a need to update an existing policy was identified, then the new policy or changed policy would be sent through the Medical Executive Committee and through the Governing Body for approval.

Based on review, observation, and interviews, the Pharmacist failed to:

1.) Ensure outdated medications were not accessible for patient use.

2.) Ensure drugs and biological's were appropriately stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.

3.) Ensure that a tracking system, on the movement of all scheduled drugs, from the point of entry into the hospital, to the point of departure either through administration to the patient, destruction or return to the manufacturer was being performed and followed.




1.) In the main hallway a closet door was found to be unlocked. The closet had some medical supplies, paper products, a stool and three large card board boxes filled with expired or discarded medications.
The medications were prescribed and over the counter medications that had expired or the patient went home and medications were discontinued. The discarded medications were not secured and accessible to anyone walking in the hallway.

The pharmacist (staff #5) was aware the door was not locked and stated, "They are not narcotics. This is where the medications are kept that need to be discarded. The company comes and picks them up every 3 months." The medications were available for anyone to open the door and take them. The pharmacist was unable to tell me when the contracted company came last to pick up medications for disposal. The pharmacist had no list of these medications that needed to be discarded.

2.) Cardboard shipping boxes were observed on the cabinet shelves next to medication to be dispensed to patients, and stored on pallets on the floor. Cardboard shipping boxes can harbor pests and have the potential to come into contact with unknown toxic substances during the shipping process.

In the main pharmacy dispensing area, personal items such as a purse, water bottles, open lunch bag, and Styrofoam drink cup from a fast food restaurant was observed on a mobile workstation next to medication to be dispensed to patients. The Styrofoam fast food cup and personal items were directly in contact with the sterile hood, where sterile medication were mixed for patient use. Portable space heaters were observed to be stored on the floor next to medication to be dispensed to patients. Inside the trash can, next to medication to be dispensed to patients, was a tray with a dead spider on it and a can of WD-40.

Medications were found opened, and sitting on heavily soiled wooden shelves, and a wire rack close to the floor. There was no protective barrier between the soiled floor and the IV bags. The potassium chloride IV bags were soiled with dust. The medications were stored next to an open trash can that was full of food sacks and drinks.

The refrigerator held multiple medications. The inside was soiled with dirt and hair. Rust was also found on the inside door.

Two bags of 50 ml Sodium Chloride had expired on April the 1st 2018. A drawer was opened. Inside the drawer a soiled duster was found with towels and lock out clips for the crash carts.

Medications were sitting on vertical dusty wooden shelves. Some medications were mixed with papers, files, and plastic bags wadded among the medications. The floor under the shelves had dead bugs lying next to medications.

Dead bugs were found lying in containers that are used to hold medications on the shelves.

The air conditioning unit in the pharmacy was blowing in the main room, onto the medications, and preparation area. The facing was off of the unit and there was no filter. The air conditioning coils were exposed and covered in a heavy dust, dead bugs and mold. The vents of the unit were heavily mildewed and molded. The unit had large gaps on each side allowing the outside elements in. Daylight was easily seen on both sides of the unit. Bugs were coming in on both sides. The sheet rock and taping around the unit was torn and crumbling.

Open shipping boxes of IV solutions were found sitting on a heavily bug infested floor.

A floor mat found in the main pharmacy was heavily soiled with paper, dirt, hair, and dead bugs. The floor mat was lifted and the floor underneath the mat was extremely soiled and discolored.

Empty medication bottles used to fill prescriptions were found open and exposed. The bottles and lids were covered in a fine dust.

The drawers holding medications were soiled with dust, hair and bugs. 2 of 4 bottles of medications were found expired and in the drawer for use. The pharmacist stated those meds were ordered for employees but there was no labeling or proof provided that these medications were not available for patient use. The medications were Clarithromycin 500mg (antibiotic), Propranolol 40 mg (beta blocker), Lisinopril 10mg (ACE inhibitor) and Terbinafine 250 mg (antifungal). The Lisinopril 10mg (ACE inhibitor) expired in 2/2018, and Terbinafine 250 mg (antifungal) expired 9/2017.

A closet in the pharmacy area was found to be mixed with paper supplies, trash can liners, cardboard shipping boxes, notebooks and patient syringes.

Medications were stored on bottom shelves, underneath the main preparation area, less than 3 inches from the floor. The cabinet side had exposed particle board and the floor molding had come loose.

Open exposed vials of medications were sitting on a bottom shelf next to the heavily soiled floor. Under the cabinet was heavily inundated with large brown spiders and 20 or more spider egg sacks.

3.) In an unlocked closet across from the pharmacy the surveyor found multiple shipping boxes of Normal Saline, Dobutamine, and empty medication bottles. The boxes were stored on shelves and on the floor. The floor was heavily soiled with dust and dead bugs. The open medication boxes were dusty.

The surveyor found keys in a baggie on the top shelf. The keys were to the doors of the pharmacy. The surveyor was able to unlock the pharmacy doors.

An interview with staff #5 was conducted on 7/23/18. Staff #5 stated, "Oh I see you found my hiding spot (referring to keys). I keep an extra set up there because I'm always losing mine." Staff #5 was aware the closet was unlocked. Staff #5 stated, "Yes, it is unlocked now, but I lock that closet after hours." The closet door did not have a lock. Staff #5 was unable to provide the surveyor with a policy on securing drugs and biologicals.

4.) In the medication preparation room of the nurse's station, medication packets were found to be in the needle sharps container. Upon further investigation the packets were narcotic medications that had been wasted into the sharps container.

Review of the policy and procedure "Controlled Substance" dated May 31, 2017 stated, " If the controlled substance is not administered and it is not in its original packaging, the nurse must waste the controlled substance. The waste option is used on the automated dispensing machine. A second nurse/physician must witness the wasting of the controlled substance and co-sign in the automated dispensing system. The nurse must also document how the drug was wasted i.e, crush and flush, sink, sharps container."

An interview with Staff #43 was conducted on 7/24/18 at 2:00PM. Staff #43 was asked how she wasted narcotics. Staff #43 confirmed that she put the wasted pills and patches in the sharps container and liquids down the sink. Staff #43 was asked who was responsible for the sharps container. Staff #43 stated that she thought the housekeeper came and got them.

An interview was conducted with staff #2 and #5 on 7/24/18 concerning the disposal of narcotics. Staff #2 confirmed that housekeeping picks up the sharps containers and takes them to bio hazard area that is then picked up from a contracted company. Staff #5 confirmed the nursing staff was discarding narcotics into the sharps container. Staff #5 could not show that the narcotics had a chain of custody until it was safely destroyed. Staff # 5 confirmed she did not know what happened to the narcotics once they were picked up. The pharmacist failed to ensure a chain of custody was followed with the discarded narcotics.

An interview was conducted with Staff #7. Staff #7 stated that she was responsible for conducting environmental rounds, but had not done them since May 2018. Staff #7 stated she was relying on department heads to keep up with their areas. Staff #7 confirmed that a process or checklists for environmental rounds and reporting had not been developed for the department heads to use. No tracking method for environmental rounds had been established.

Based on observation, review of records, and interview, the facility failed to maintain a sanitary environment necessary to ensure sources and transmission of diseases would be prevented in 11 of 11 areas toured (Main Hallways, Central Supply Storage, Public Restroom #1 and #2, Ultrasound Examination Area, Pharmacy, Out Patient Area, Linen Room, Emergency Department, Patient Room 234 and 210)

A tour of the building was conducted on 7-23-2018. Findings included:


Main Hallway

The floor at the entry way into the facility was observed with heavy build up of dirt and dead insects at the interior threshold and corners of the hallway.

An outpatient physical therapy waiting area was observed in a main hallway of the hospital. A window was observed next to patient seating that had tape and tape residue on the window and adjacent wall. The window frame had chipped paint. These conditions prevent the window and wall from being properly cleaned. The window ledge was observed to be visibly dusty and dirty.


The wall and doorway for the outpatient physical therapy area was a temporary wall that did not fully reach the ceiling. The drywall was unfinished and the doorframe was made of unfinished wood with what appeared to be pencil marks placed for measuring during the construction of the wall. The unfinished wood and dry wall prevented the area from being properly cleaned, as it is porous. The wood frame, entrance door, drywall, and floor were all visibly soiled. An interview was conducted with Staff #2 and Staff #4 who confirmed the unfinished wall had been in place at least 2 years.

Ceiling tiles in the main hallway were stained from previous water leaks. The metal frame that held the ceiling tiles in place was rusted.

Central Supply Storage

Central supply storage area was observed to have paint and wall board material flaking off of the walls. Fabric sheets had been nailed to the wall in an effort to keep flaking material off of patient supplies. Not all areas of flaking paint and wallboard were covered, allowing matter to fall onto shelves and supplies. Ceiling tiles were visible with evidence of a mixture of past mold and water damage.

Medical supplies were found sitting next to shipping boxes. The floor was heavily soiled with dirt and dust. A fan was found sitting on the soiled floor and blowing up onto the medical supplies.

The florescent light fixtures had no lens covers and three of the bulbs were out.

Medical supplies were found sitting on wooden shelves that had exposed wood. The shelves were dusty and soiled. The wooden shelves were porous and unable to be cleaned properly.

A metal cart was found with medical supplies sitting on the bottom shelf. The supplies were dusty and dirty on top. The top of the cart and the handle was rusted.

The lock on the main door to the central supply room was covered in tape to keep it from locking. The tape was soiled and the room was left unsecured.


Public Restroom #1

A public women's restroom had a torn paper sign on the door indicating it was the women's restroom. Another sign was taped to the wall requesting that the ventilation fan not be turned off. A switch that looked like a light switch was underneath and taped in the up position. The door frame appeared to be made of metal. The paint was missing on parts of the door frame and the frame appeared to be rusted. Paint was missing off of the door. These conditions prevented the area from being properly cleaned. The door, door frame, and floor were visibly dirty. Inside of the restroom, a metal paper towel holder was rusted. The ceiling between the exhaust fan and light was visibly dirty. The wall corner by the toilet was cracked along the drywall portion of the wall and along the tile portion of the wall. These conditions prevented the restroom from being properly cleaned.


Patient Room 234

Patient room 234 was ready to receive a patient. This room was found to have visibly soiled floors around the windows, built-in closets, and built-in drawers. The furniture was observed to have a heavy build-up of dust on it. Signage with the room number on it were found to have tape and tape residue, preventing them from being adequately cleaned. The built-in drawers were made of unfinished wood and fiberboard on the inside. The inside was observed to be stained with dried liquid spills. Unfinished wood and fiberboard cannot be properly cleaned as it is porous and absorbs the dirt and bacteria. The bathroom of room 234 was missing the towel bar. The attaching hardware for the towel bar remained and exposed holes that opened to the interior inner wall. This allowed for insects and pests to be able to access the room. The bathroom sink was visibly soiled. A patient chair footrest was observed to be visibly soiled. Wall covering was observed to be peeling. This prevented the wall from being properly cleaned.

An interview was conducted with Staff #7. Staff #7 stated that she was responsible for conducting environmental rounds, but had not done them since May 2018. Staff #7 stated she was relying on department heads to keep up with their areas. Staff #7 confirmed that a process or checklists for environmental rounds and reporting had not been developed for the department heads to use. No tracking method for environmental rounds had been established.










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The woman's bathroom used for rehabilitation patients and general public was found to have plaster peeling from the walls and separating from the sheetrock and ceiling. The bathroom was found to have a cloth green and white couch that was heavily soiled with black stains.

The Main Hallway

The main hallway was found to have an exit door that was missing paint on the door and frame.
In the main hallway a door was opened, unlocked into a closet. The closet had some medical supplies, paper products, a stool and three large card board boxes filled with expired or discarded medications.
The medications were prescribed and over the counter medications that had expired or the patient went home and medications were discontinued.

The pharmacist (staff #5) was aware the door was not locked and stated, "They are not narcotics. This is where the medications are kept that need to be discarded. The company comes and picks them up every 3 months." The medications were available for anyone to open the door and take them. The pharmacist was unable to tell me when the contracted company came last to pick up medications for disposal.

Public bathroom #2

In the main hallway a set of women and men's bathrooms (identified as set #2) was found to have paint missing from the door and door frames. Tiles were missing from the floor and the floor was heavily soiled with dirt and dust.
Inside the men's bathroom, tiles were missing from the baseboard and wall leaving exposed sheet rock and broken tile. The urinal was missing and holes were in the wall. The florescent light fixtures had no lens covers and the bulbs were very dim.

The women's bathroom tiles were broken and missing from the wall.

Ultrasound Room

The ultrasound room had a stretcher bed sitting next to the ultrasound machine. The pillow was heavily soiled and did not have a pillow case. The fitted sheet on the bed was soiled with dust and dirt particles. Under the dirty fitted sheet, the mattress to the stretcher was heavily torn with large amounts of foam showing and soiled.

Multiple cords were running from the machine and bed along the floor. The cords were not secured.

The sonogram machine was found to be soiled with dust and hair.

The stretcher bed was sitting next to a window. The window blinds, windowsill, and window were covered in a heavy dust, dirt and hair.

In the area was a linen cart that had a laminated label taped over a dirty and rusted area on the soiled linen cart cover. The dirt and rust had transferred to the back of the laminated label.

The wall over and around a doorway, along with the door frame, was observed to be heavily soiled with what appeared to be a black mold/mildew.

A window air conditioning unit was observed to be heavily soiled with what appeared to be a mixture of mold/mildew, dust, and dirt. A white towel had been placed under the unit and was soiled with particles of this mixture from the air conditioning unit. The air conditioning unit filter was observed to be heavily covered in dust.

The ultra sound storage area was observed with 6 partially filled hand held bottles of ultra sound gel. All six (6) had some degree of dried gel and unidentified yellow crusted debris on the bottle tip. One (1) of the six were observed with a large amount of dried pink gel as well.

An interview with staff #23 (ultrasound tech) was conducted on 7/23/18. Staff #23 confirmed the ultrasound room was clean and ready for a patient. Staff #23 was asked if she was going to change the sheet and put on a pillow case. Staff #23 stated, "no." she was asked to show the surveyor how she would get ready for a new patient. Staff #23 placed a flat sheet over the uncovered pillow and dirty sheet. Staff #23 was asked why she would not change the linen each time. Staff #23 stated, "That just seems like a lot of trouble when I can just lay a sheet over it."

Outpatient Hallway

The main threshold from the outside to the inside out patient area was soiled with dust, dirt and bugs. The tile floors were broken and missing exposing concrete. The trash can outside the door was heavily soiled with mildew and mold.

Ceiling tiles were found to be heavily stained and wet. The air conditioning vents were dripping water.
The laboratory blood draw room was found to be soiled on the cabinets with dust and below the sink. The windowsill was found to be flaking paint, heavily soiled with dirt, and dead bugs.

The electrical panel in the outpatient area was in the main hallway. The panel was found to have keys hanging out of it and opened. The inside of the panel was not properly labeled.

The floor in the outpatient hallway had multiples holes. The tile was missing exposing the concrete. Inside the holes were dirt, paper clips, and unidentifiable objects.

The door and door frame to the radiology department was found to be missing paint and the laminate on the door was missing a large piece.

Inside a closet in the main hallway a fire extinguisher was found. The last date it was checked was July 2010.

Linen Room

Patient supplies, file cabinets, and paper supplies were found stored with the linen. The room was dusty and the floor was heavily soiled with dust, hair, and dead bugs.

Linen gowns were found uncovered on a bottom wire shelf. The shelf was not covered and there was no protective barrier between the linen and the soiled ground.

An air-condition window unit was found in the linen room. The unit was running and blowing on the uncovered linen. The unit was heavily soiled with dust and dirt. The vents of the unit had a significant amount of mold and mildew growing on the vent blades.

Closet across from the Pharmacy

In an unlocked closet the surveyor found multiple shipping boxes of Normal saline, Dobutamine, and empty medication bottles. The boxes were stored on shelves and on the floor. The floor was heavily soiled with dust and dead bugs. The open medication boxes were dusty.

The surveyor found keys in a baggie on the top shelf. The keys were to the doors of the pharmacy. The surveyor was able to unlock the pharmacy doors.

An interview with staff #5 was conducted on 7/23/18. Staff #5 stated, "Oh I see you found my hiding spot (referring to keys). I keep an extra set up there because I'm always losing mine." Staff #5 was aware the closet was unlocked. Staff #5 stated, "Yes, it is unlocked now, but I lock that closet after hours." The closet door did not have a lock.


Pharmacy

A pharmacy storage area was observed to have patient supplies for tube feeding patients and intravenous (IV - into a vein) medication delivery tubing stored with office supplies, decorations, expired medications and boxes of patient records. This storage practice provided for the opportunity to contaminate patient supplies.

In the main pharmacy dispensing area, personal items such as a purse, water bottles, open lunch bag, and Styrofoam drink cup from a fast food restaurant was observed on a mobile workstation next to medication to be dispensed to patients. The Styrofoam fast food cup and personal items were directly in contact with the sterile hood, where sterile medication were mixed for patient use. Portable space heaters were observed to be stored on the floor next to medication to be dispensed to patients. Inside the trash can, next to medication to be dispensed to patients, was a tray with a dead spider on it and a can of WD-40.

Review of the Material Safety Data Sheet for WD-40 showed that this is a petroleum based product. Oral ingestion may cause nausea, vomiting, and diarrhea. If swallowed, can enter the lungs and may cause chemical pneumonitis, severe lung damage and death.

Cardboard shipping boxes were observed on the cabinet shelves next to medication to be dispensed to patients, and stored on pallets on the floor. Cardboard shipping boxes can harbor pests and have the potential to come into contact with unknown toxic substances during the shipping process.

Ceiling tiles were observed with visible water damage and the plaster was observed at each corner of the outer most wall, hanging down several inches, having pulled away from the wall.

The threshold to the pharmacy was found to have cracked and missing floor tiles. The floor was heavily soiled with dirt, hair, and bugs.

Medications were found opened, and sitting on heavily soiled wooden shelves, and a wire rack close to the floor. There was protective barrier between the soiled floor and the IV bags. The potassium chloride IV bags were soiled with dust. The Medications were stored next to an open trash can that was full of food sacks and drinks.
Tile caulking around the sink area was missing exposing the materials behind the tile. The sink area was mildewed and dirty. The pipe under the sink was dripping onto sheets. The sheets were covered in mildew and mold. The wood shelf under the sink was wet and covered in mold.

The refrigerator held multiple medications. The inside was soiled with dirt and hair. Rust was also found on the inside door.

Two bags of 50 ml Sodium Chloride had expired on April the 1st 2018. A drawer was opened. Inside the drawer a soiled duster was found with towels and lock out clips for the crash carts.

Medications were sitting on vertical dusty wooden shelves. Some medications were mixed with papers, files, and plastic bags wadded among the medications. The floor under the shelves had dead bugs lying next to medications.
Dead bugs were found lying in containers that are used to hold medications on the shelves.

The air conditioning unit in the pharmacy was blowing in the main room, onto the medications, and preparation area. The facing was off of the unit and there was no filter. The air conditioning coils were exposed and covered in a heavy dust, dead bugs and mold. The vents of the unit were heavily mildewed and molded. The unit had large gaps on each side allowing the outside elements in. Daylight was easily seen on both sides of the unit. Bugs were coming in on both sides. The sheet rock and taping around the unit was torn and crumbling.

Open shipping boxes of IV solutions were found sitting on a heavily bug infested floor.

A floor mat found in the main pharmacy was heavily soiled with paper, dirt, hair, and dead bugs. The floor mat was lifted and the floor underneath the mat was extremely soiled and discolored.

Empty medication bottles used to fill prescriptions were found open and exposed. The bottles and lids were coved in a fine dust.

The drawers holding medications were soiled with dust, hair and bugs. 2 of 4 bottles of medications were found expired and in the drawer for use. The pharmacist stated those med's were ordered for employees. The medications were Clarithromycin 500mg (antibiotic), Propranolol 40 mg (beta blocker), Lisinopril 10mg (ACE inhibitor) and Terbinafine 250 mg (antifungal). The Lisinopril 10mg (ACE inhibitor) expired in 2/2018, and Terbinafine 250 mg (antifungal) expired 9/2017.

A closet in the pharmacy area was found to be mixed with paper supplies, trash can liners, cardboard shipping boxes, notebooks and patient syringes.

Medications were stored on bottom shelves, underneath the main preparation area, less than 3 inches from the floor. The cabinet side had exposed particle board and the floor molding had come loose.

Open exposed vials of medications were sitting on a bottom shelf next to the heavily soiled floor. Under the cabinet was heavily inundated with large brown spiders and 20 or more spider egg sacks.


Emergency Department


The Emergency Department (ED) Triage Room floor was missing approximately 5 inches of the vinyl floor in the threshold. The paint was chipped and missing on the door frame. The door was missing laminate that exposed particle board. The room was designated a terminally cleaned room and ready for a patient. The examination table was heavily soiled and the cover over the mattress was ripped and exposed. There was trash in the trash can and upon opening a soiled wooden drawer, patient supplies were found lying in the soiled drawer.

Patient Room # 210

Patient room #210 was confirmed by the nurse to be terminally cleaned and ready for a patient. The door frame was missing paint and soiled. The door was missing laminate that exposed particle board.

A metal bedside table on wheels was heavily rusted and unable to be cleaned properly.

The wooden drawers had patient supplies in them and trash mixed in. The glass on the window was broken and severely cracked.

A broken sign was for resuscitation was found lying up against the wall. Inside the closet weights, 3 plastic back boards, a full bottle of fluid absorbent for blood spills were found. The closet and contents was so heavily coated in dust and hair that the surveyor was able to write her initials.

The sheet on the stretcher was torn and had holes. The bed frame was soiled and rusted.

The bathroom floor was heavily soiled with dust and hair. The tile was broken and missing from the wall. The main pipe to the toilet was corroded with hard water build up and soiled where the pipe meets the bowl with old urine build up.

Based on interview, the facility failed to maintain a list of services furnished under arrangement or agreement.

Findings were as follows:

An interview was conducted with Staff #1 on 7-25-2018. A request for the list of contracted services had been requested on 7-23-2018 and had not been provided. Staff #1 stated there was not a list of contracted services. Staff #1 stated he did not know what contracts each department of the hospital managed and was unable to tell what services were being provided through agreement or arrangement.

Based on interview, the facility failed to provide oversight of all services provided under arrangement or agreement.

Findings were as follows:

Review of the Quality Monitoring program revealed that no quality data relating specifically to the quality of services provided under contract was being collected and reviewed.

An interview was conducted with Staff #1 on 7-25-2018. A request for the list of contracted services had been requested on 7-23-2018 and had not been provided. Staff #1 stated he did not know what contracts each department of the hospital managed and was unable to tell what services were being provided through agreement or arrangement.

Staff #1 confirmed that contracted services were not reviewed annually to ensure services provided met quality standards.

Staff #3 confirmed there were no quality monitors specific to contracted services.

Based on record review and interviews, Nursing failed to:

Protect patients and staff from infectious communicable diseases in 1(#3) of 1 patient chart reviewed.

Provide a staffing matrix to determine the adequacy of staffing and to assess the delivery of care in 2 (medical surgical/swing and ED) of 2 nursing departments.

Develop, update, and maintain nursing policy and procedures.

Have current nursing competencies in 9 out of 9 (#2, 3, 6, 7, 8, 40, 41, 42, and 43) employee files reviewed.

Provide an active, ongoing review and analysis of the quality of nursing care through the Quality Assurance Performance Improvement (QAPI) program.


1.) Review of the nursing policy and procedure "Patient Staffing Guidelines" last revised 11/2009 and reviewed on 5/2009, revealed the policy had a Medical -Surgical matrix for nursing staff. There was no nursing matrix for Emergency Department.

An interview with staff # 2 was conducted on 7/25/18 at 10:35 PM. Staff #2 confirmed that policy "Patient Staffing Guidelines" has not been reviewed for many years. Staff #2 stated it is a process they are working on but currently there is no updated and approved nursing staffing policy and procedure.

2.) Review of 9 (#2, 3, 6, 7, 8, 40, 41, 42, and 43) nursing personnel files revealed there was no current competencies in the files.

An interview with staff # 2 was conducted on 7/25/18. Staff #2 confirmed there was no current nursing competencies since 2016.

3.) A medication administration was observed for patient #3 on 7/24/18 at 2:00 PM. Staff # 43 unplugged the computer on wheels and rolled it into the medication room to prepare patient #1's medication. The patient had an order for IV Ampicillin. Staff # 43 pulled a 50 ml bottle of sterile water out of the patient Omnicell (Medication Dispensing Systems). The bottle had been opened and was dated, "opened 7/24/18". The bottle was clearly marked by the manufacturer "Single Dose Only." Staff # 43 was asked if she could reuse a bottle of sterile water that said "Single Dose Only? Is this a community bottle or does it belong to one patient?" Staff # 43 stated that she had called the pharmacist and she stated she could. Staff #43 confirmed the bottle was for any patient. Staff # 43 was not aware of what the policy and procedure said concerning reuse of a single dose vial.

Interview with staff # 5 was conducted on 7/25/18. Staff #5 confirmed the vials marked "Single Dose Only" should only be used once.

Review of the policy and procedure, " OMNICELL- Automated Dispensing Machines: Removed Medications, dated June 21 2017" revealed Multi-dose vials may be returned to the OMNICELL. The policy stated, "Always date the vial when first accessed. Return the vial under the same patient's name and change the expiration date which is 30 days henceforth." There was no policy found that addressed single dose vials.

Staff #43 continued to draw her sterile water from the single dose only vial and used it to reconstitute the ampicillin powder. Staff #43 gathered her IV kit and pushed the computer into the patient's room. Staff #43 gelled her hands and put on gloves. She performed the five rights and touched the patient's hands. Staff #43 used the wand on the computer to scan the patient's arm band. She administered the medication and charted in the computer. Staff #43 took off her gloves and gelled hands as she was leaving the room. She pushed the computer to the hallway. Staff #43 was asked why the patient was receiving antibiotics. Staff #43 stated the patient had a draining abscess in his groin area. There was no isolation sign on the patient's door nor was there any isolation procedures performed. Staff #43 was asked if the draining wound had been cultured and what type of infection the patient had. Staff #43 was not aware if cultures had been done. Staff #43 stated, "I didn't think about taking the computer in his room. I don't know what I should do about the computer now." Staff #43 confirmed the computer has been wheeled in and out of this patient's room for two days. Staff #43 did not have any training on isolation or infection control in her employee file. Staff #43 was not aware of what the policy and procedure said for placing a patient in isolation. Review of the patient's lab report showed positive for Staphylococcus Aureus.

Staff #2 was informed by the surveyor of patient # 3's diagnosis. Staff #2 stated the patient should have been placed in contact isolation when he was admitted 2 days ago.

Review of the facility's policy and procedure, "Isolation Policy" stated, "Patients with known or suspected communicable disease, colonization, or infection will be placed in isolation precautions appropriate for the communicable disease, colonization, or infection immediately upon the discovery or suspicion of the communicable disease, colonization, or infection, until the patient is found to be clear of the communicable disease, colonization, or infection."

There was no information on how the computer should be handled in an infected patients room or cleaning process.

Staff # 2 confirmed there was no policy and procedure to address the computer usage in an isolation room.
Review of the Quality Assurance Performance Improvement (QAPI) revealed there was no active Infection control or QAPI following isolation patients and infections. Staff #2 stated that chart checks are done daily however, patient #3 was not identified as a potential isolation patient, with IV antibiotics, and a draining wound.

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

Assess and monitor the patient after the administration of a psychotropic drug used as a chemical restraint.

Have current policy and procedures on assessment/monitoring of patients receiving chemical restraints.

Properly identify and document a reason for administration of a chemical restraint.

Educate the patient /caregiver on the administration of a psychoactive medication in 2(23 and 4) of 2 patient charts reviewed.

Review of patient #23's chart revealed the patient arrived to the facility ED with her mother on 7/20/18 at 12:00PM. Review of the Nursing ED Assessment note stated, "Chief complaint: "pt. audible hallucination will not sit saying she seen "all of us plotting against her" pt. asking for us to touch her hands so she can watch us. Stating the nurse has angry eyes." Affect and behavior: Anxious, irritable, restless, other: seeing "a baby" not here.

Review of the nursing assessment asked, "Is this a high risk situation where the patient is confused/Lethargic/disoriented/ or in severe pain/distress?" The nurse answered, "yes."

Review of the Physician notes dated 7/20/18 at 12:13PM stated, "History of present illness: The patient presents with psychiatric problem and agitation. The onset was today. The course/duration of symptoms is constant. Character of symptoms paranoid, active hallucinations. The degree of symptoms are severe. Self-injury none. The exacerbating factor is inpt here for 3 days for Etoh withdrawal, d/c yesterday. The relieving factor was none. Risk factors consist of as above. Mother states she has been with patient continually and no illicit drugs since d/c from here."

Review of the nurse's notes dated 7/20/18 at 12:28PM stated, "Came in with mom and a male, pt stated she does not want to be here. Pt moving around from one side of hall to next. Stated we were plotting against her. Pt will not allow me to assess her nor take V/S visual respirations are 22bpm. Mom is staying at bedside.

1427 (2:27PM) pt is in a psychotic state. Pt is unable to make full sentences but at this time she is using sign language. Mom and boyfriend is in room." There was no nursing documentation noted between 12:28PM and 2:30PM a 2-hour span. There was no documentation found on any nursing interventions performed to divert or alleviate the patient's symptoms before chemical restraint was given.

Review of medication orders dated 7/20/18 at 14:38 (2:39PM) revealed the physician ordered Haldol (psychotropic) 5 mg IM once NOW. There was no reason for the injection written on the order.

Review of the Medication Administration Record on 7/20/18 at 14:54 (2:54PM) revealed the medication Haldol 5 mg was given IM. There was no documentation if the patient was held to give the injection, if the patient was informed on the medication, or if the medication was effective.

Review of the nursing notes revealed there was no nursing assessment or vital signs after the administration of a psychotropic medication. Vital signs were documented 7/20/18 at 1855(6:55PM); a total of 4 hours later.
Review of the policy and procedure "Restraints" last revised on 10/15 revealed the policy defined a chemical restraint but there was no instruction on monitoring, assessing, or frequency of ongoing monitoring for a chemical restraint medication administration.

Review of the restraint log revealed there was no chemical restraints logged.

An interview with staff # 2 on 7/25/18 revealed the facility did not monitor the medication administration as a restraint. The facility had not been addressing the chemical restraints and staff #2 confirmed there had been no recent staff education concerning chemical restraints.



Review of patient #4's nursing assessment dated 3/29/18 at 22:47 (9:47PM) revealed he came to the ED with a chief complaint of "hearing voices and seeing demons. The voices are telling him to run into the highway." He was oriented to person and situation. His affect and behavior was, "appears depressed, combative, crying, impulsive, and self-injurious.

Review of the physician orders for patient #4 revealed he was ordered Haldol 5 mg IM on 3/29/18 at 2306 (11:06PM) and on 3/30/18 at 4:04AM. There was no reason stated on the orders for the medication. The medication was administered by the RN on 3/29/18 at 2330 (11:30PM) and 3/30/18 at 4:14AM. The patient was placed in bilateral wrist restraints at 2342 (11:42PM). There was no order found in the chart for a physical restraint. There was no documented reason in the nursing notes or physician notes on why the patient was receiving a chemical restraint. There was documentation of monitoring the patient in a physical restraint but no mention of the effects of the medication or effectiveness of the medication.

An interview with staff # 2 on 7/25/18 confirmed the above findings. Staff #2 stated they had not been addressing the behavioral psychotropic medication administration as a restraint.

Based on observation, record review and interview, the facility failed to retain complete medical records, evidenced by incomplete Nursing assessments for 2 of 13 (#5 and #8) patient medical records reviewed, incomplete nursing care plans 13 of 13 (#5 thorugh #17), verbal orders not signed for 1 of 13 (#5) patients, admission staff process for complaint and grievance resolution (#5 through #17), Medical record staff coding accurately 1 of 13 patient (#11) whose MR was reviewed (Patient #5 thorugh #17).

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On 7/25/2018 a medical record (MR) review was conducted in the MR department under the supervision of the Health Information Management (HIM) Director. The electronic MR (EMR)review revealed the following incomplete patient admission assessments.

Pt #5 - the Registered Nurse (RN) failed to complete the safety screening tool identified within the EMR.
The RN failed to record the initial Blood pressure for the vitals signs record
The RN failed to document on the pt's plan of care (POC) other family members/persons who were involved.
The Nursing POC was initiated but no interventions were identified.
Pt #5's "Do not Resucitate" (DNR) was changed without cosignature of physician, or RN. Pt was listed as "Unable to Signs".
The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The medical provider failed to electronically sign 1 of 1 verbal orders.

Pt #6 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.

Pt #7 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.

Pt #8 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
Fall risk assessment completed but not acted upon in the POC. Pt #8 admitted for injuries resulting from recent fall.
The Nursing POC was initiated but no interventions were identified.
The H&P was not completed and signed withoin 24 hours.

Pt #9 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.

Pt #10 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.
History and physical (H&P) was incomplete as of 7/25/2018.

Pt #11 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.
MR staff coded Nephrolithiasis (implies surgical intervention) obtained from the ED physician working plan rather than the physician's final diagnosis for the patient.

Pt #12 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.
Admission staff initaled consents as witness rather than signing their legal name.
H&P was incomplete as of 7/25/2018

Pt #13, #14, #15, #16, and #17 - H&P was not completed in 24 hours.

All of the above findings were confirmed by the HIM Director.

Based on record review and interview, the facility failed to ensure complete and legible patient consents, completed by the patient registration staff in 4 of 13 records reviewed patients #5, #6, #9 and #12 of patients #5 through #17.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On 7/25/2018 a medical record review (MR) conducted in the MR department with the assistance of the Health Information Management (HIM) Director revealed illegible and incomplete MR

Admission staff were having patients (Pt/pt) sign admission consents and identifying themselves only with initials and date. The registration staff were failing to identify themselves with full signature date and time.

Pt #5's MR revealed the admission clerk indicated the "Pt was unable to sign" on the patient's admission consent form. The clerks signature was not legible and there was no co-signature confirming the patient was unable to sign.

Pt #6's MR revealed the admission clerk initialed the consent as the witness without signing a full legible signature.

Pt #9's MR revealed the "pt was unable to sign", a second person signed the consent without identification of who the person was. This unidentified person signed all the pt's consent documents.

Pt #12's MR revealed the stamped statement "Patient unable to sign" on the patient's admission consents. There was no explanation why the patient was unable to sign. The single witness had initialed the "Health Care Consent", the "Notice of Privacy Practice", the "Disclosure of Health Information for Treatment, Payment or Health Care Operations", "Patient Rights" and "Patient Notification of Data Collection". The date of 6/21/2018 was the only other staff documentation.

Interview with the HIM Director confirmed the admission staff had always initialed their admission documents. Would the initials be clear to anyone unfamiliar with who the staff member was she replied, "Probably not".

Review of the facility's policy "Medical Record Completion, Signature, 9.5" revealed,

"...Medical Record entries, shall be signed dated and timed upon completion."

Based on observation, record review and interview, the facility failed to retain complete medical records, that included dated signature of the physician or Registered Nurse Practitioners who worked directly under the supervision of the physician in 10 (#5, #6, #7, #10, #12, #13, #14, #15, #16, and #17) of 13 patient medical records reviewed.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On 7/25/2018, a medical record (MR) review was conducted in the MR department under the supervision of the Health Information Management (HIM) Director. The electronic MR (EMR)review revealed the following incomplete patient admission assessments.

Pt #5 - The medical provider failed to electronically sign, date, and time 1 of 1 verbal orders.

Pt #6 - The admission staff failed to document evidence that the process for complaint and grievance resolution was provided.
The Nursing POC was initiated but no interventions were identified.

Pt #7 - The H&P was not completed and signed, dated and timed within 24 hours.


Pt #10 - The History and physical (H&P) had not been completed, signed, dated or timed as of 7/25/2018.


Pt #12 -The H&P had not been completed, signed, dated and timed as of 7/25/2018.

Pt #13, #14, #15, #16, and #17 - The H&P had not been completed, signed, dated and timed in 24 hours.

All of the above findings were confirmed by the HIM Director.

Based on observation and interview, the hospital failed to:

A. store protected health information in a safe manner that prevented unauthorized disclosure in 1 department (Pharmacy) out of 7 departments toured.

B. employ appropriate after-hours access and tracking process to ensure that records could be located and had not been tampered with when patient medical records were removed from the medical records department after hours.

Findings included:

A.
A storage room off of a main hallway where guests and patients access services was observed to be unlocked. Inside the storage room, two unsecured cardboard file boxes were observed. The boxes, when the tops were removed, were observed to contain patient protected health records from 2017.

Interview with Staff #5 confirmed this was a pharmacy storage area and the patient records were for medications ordered. Staff #5 stated she left the door unlocked during the day.




28659

B.
The facility's procedure for after hours retrieval of medical records allowed the Charge nurse to enter the Medical Record (MR) department via a key which was kept on the nursing supervisors key ring. Any record that was removed from the MR department was recorded on a clip board which hung on the Wall inside the MR department. The required documentation included patient name, date of service, location (record was taken to) and check out date.

The process failed to include, when the record returned, was it intact and who returned it.

Interview with the Health Information Department director confirmed each morning they would review the clip board and begin the search to ensure the patient MR had returned to the department.

There was no process of control or corrective action if the MR failed to be returned to the department other than the MR staff attempting to locate it. The MR staff had no way of knowing where the MR had been placed, if it was not found in the MR department the following work day.

Based on review of records and interview, the facility failed to ensure that policies were reviewed annually as part of a quality evaluation of the hospital's total program.

Findings included:

During a review of policies and procedures, it was noted that many policies had review dates greater than a year old.

Review of the Medical Executive Committee meeting minutes and Governing Body meeting minutes for 2018 did not include information on annual review of policies.

An interview was conducted with Staff #3. Staff #3 confirmed there was not a process or committee for the purpose of reviewing and revising existing policies. Staff #3 advised that as new policies were needed or a need to update an existing policy was identified, then the new policy or changed policy would be sent through the Medical Executive Committee and through the Governing Body for approval.

Based on review of records and interview, the hospital failed to ensure all hospital departments and patient services provided through contract or arrangement were evaluated through the Quality Assurance Process Improvement (QAPI) program. Six departments and/or services (Laboratory, Respiratory, Dietary, Physical Therapy, Housekeeping, and Human Resources) reviewed did not have quality monitoring and evaluation measures out of 17 departments and/or services (Infection Control, Care Management, Emergency Department, Nursing Services, Business Office, Radiology, Laboratory, Maintenance, Medical Records, Medical Staff, Pharmacy, Information Technology, Respiratory, Dietary, Physical Therapy, Housekeeping, and Human Resources). Contracted services were not evaluated.

Findings included:

Review of the QAPI program revealed the hospital was voluntarily involved with three outside agencies that assist with quality data tracking. No quality measures were being tracked for 6 of the 17 departments and services reviewed. Review of the QAPI program revealed that no quality data relating specifically to the quality of services provided under contract was being collected and reviewed.

An interview was conducted with Staff #1 on 7-25-2018. A request for the list of contracted services had been requested on 7-23-2018 and had not been provided. Staff #1 stated he did not know what contracts each department of the hospital managed and was unable to tell what services were being provided through agreement or arrangement.

Staff #3 confirmed there were no quality monitors specific to contracted services. Staff #3 confirmed that not all departments and services were participating in QAPI.

Based on review and interview the facility failed to have a contract for the Activity Director. The facility failed to have the Activity Director involved in the Quality Assessment Performance Improvement (QAPI) process.

Review of the contracted services revealed the facility failed to have a contract with the contracted Activity Director (AD).

Interview with staff #1 and # 2 on 7/25/18 revealed there was no contract with the Activity Director. Staff #2 confirmed the AD was not participating in the QAPI process.

Based on document review and interview the facility failed to document the services of a Registered Dietician for three (3) months May, June and July of 2018.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.



On 7/25/2018 An interview with the Administrator confirmed the Registered Dietician had not provided a written report of her service to the facility for three months.

The services provided by the RD had not been evaluated by the Administrator, Quality Assessment Performance Improvement, or the Governing Body.

A review of the Contract for Registered Dietician's service to the facility required the RD provide a written document listing the services provided each month. Since the RD had not provided a written document for three months it was not clear if the facility actually retained a contracted Registered Dietician for patient services.

The services of a RD would ensure the patient nutritional status was evaluated by height (ht), weight (wt), protein, calorie, fluid and nutritional intake requirements for age, and body ht. and wt.

Review of the medical record for pt #7 revealed an under weight adult with an admission date of 5/30/2018. The physician ordered a daily weight be recorded and a nutritional consult. No RD consult was identified within the MR of pt #7.

On the morning of 7/24/2018 interview with the Food Services Supervisor, staff #10 confirmed the Registered Dietician (RD) had not been to the facility for three months or longer.