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Based on observation and interview, the Critical Access Hospital (CAH) failed to have portable suction machines (emergency equipment) on 2 of the 2 Inpatient units, the 2nd floor, Medical Surgical/Critical Care Unit/Pediatric Service, and on the Maternity Unit. In addition, the Hospital failed to have functional masks on the ambu bags for emergency resuscitation in 2 of the 5 Satellites, the Aquatic Therapy Program and the Outpatient Physical Therapy Rehabilitation. Findings include:

1. During tour on 3/10/14 at 10:30 A.M. of the 2nd floor, with the Unit Manager (UM) of the Medical Surgical Unit, the Adult and Pediatric Code Carts were evaluated for life saving equipment. Surveyor #1 observed there were no portable suction machines by or on these emergency carts.

During an interview on 3/10/14 at 10:31 A.M., Licensed Practical Nurse (LPN) #1 identified herself as one of the nurses who checks these carts. Upon inquiry LPN #1 said there were no portable suction machines on the emergency carts, only wall mounted suction in the patients' rooms. LPN #1 said that a portable suction machine was kept in the closet in the basement, two floors down. The UM of the Medical Surgical Unit, said that there were no portable suction machines on the Inpatient units..

During an interview on 3/11/14 at 7:30 A.M. with the Director of Regulatory Compliance, she said that there were no portable suction machines on the Inpatient units.

2. During tour of the Outpatient Physical Therapy Rehabilitation Satellite with Physical Therapist (PT) #1, on 3/11/14 at 8:10 A.M., a review of how they handled patient emergencies was conducted. Surveyor #1 observed the face mask on the ambu bag to be yellow and partially deflated (an indication it was old and would inadequately maintain a seal for ventilating a patient in an emergency). PT #1 said, "It (referring to the mask) is too old to be effective.

3. During tour on 3/11/14 at 10:30 A.M. of the Aquatic Therapy Program Satellite with the Administrative Director of Rehabilitation, a review of the emergency equipment by the pool was conducted. Surveyor #1 observed the mask for the ambu bag to be completely deflated, rendering it non-functional.

Based on review of the Governing Body (GB) meeting minutes, document review, and staff interview, the Critical Access Hospital's (CAH) Governing Body failed to ensure its organizational structure was maintained. Findings include:

1. During interview on 3/11/14 at 1:30 P.M., the Executive Vice President said that the Board of Trustees was the Hospital's Governing Body at the CAH and was responsible for the CAH's oversight and total operation.

Please refer to C241.

2. The Governing Body (GB) failed to ensure that the staff followed infection control policies and standards of practice related to medication administration, hand hygiene, and use of personal protective equipment (PPE).

Please refer to C270 and C278.

3. The GB failed to ensure that all staff had adequate immunity and/or vaccination status for the prevention of communicable diseases.

Please refer to C270 and C278.

4. The GB failed to ensure that all CAH patients were under the care of a practitioner who was under the supervision of a member of the medical staff.

Please refer to C241.

5. The GB failed to ensure the Pharmacy maintained oversight of the Outpatient Internal Medicine Satellite related to medication administration and storage practices (e.g. multi-dose vials and sample medications). The CAH failed to ensure that all drugs and biologicals were stored in a manner to prevent access and administration by unauthorized individuals, including unlicensed assistive personnel (UAPs). Additionally, The GB failed to maintain a safe environment in Pharmacy for the preparation of sterile products.
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Please refer to C276 and C297.

6. The GB failed to ensure their policies and procedures were reviewed or revised annually.

Please refer to C241 and C280.

7. The GB failed to ensure emergency equipment was in good repair (e.g. ambu bags) in the Satellites and that emergency equipment was available on the Inpatient Units on the code carts (e.g. portable suction machines), in case of an emergency.

Please refer to C204, C241 and C270.

Based on observations, staff interviews, and review of the Critical Access Hospital's (CAH) policies and procedures, the Governing Body failed to ensure that CAH policies were implemented and monitored related to: Pharmacy oversight of medication storage in the Outpatient Internal Medicine Satellite, infection control, proper supervision of allied health professionals, and patient rights. Findings include:

1. During interview on 3/11/14 at 1:30 P.M., the Executive Vice President said that the Board of Trustees was the Hospital's Governing Body at the CAH and was responsible for the CAH's oversight and total operation.

Review of the Board of Trustees current job description, on 3/12/14, indicated the following: "Principal Responsibilities. To ensure consistent, high quality care and/or services across the system... To establish system-wide policies... To ensure that the organization meets regulatory ... requirements."

2. Observations in Suite 1A of the Outpatient Internal Medicine Satellite at 9:00 A.M. on 3/12/14, indicated one large, four tiered, locked metal cabinet in the room labeled "Multipurpose Room." During the observation Medical Assistant (MA) #1 said that the cabinet contained sample medications. Upon Surveyor request, MA #1 unlocked and opened the cabinet, revealing multiple boxes of sample medications that included the following:

Crestor (lowers cholesterol), Benicar (lowers blood pressure), Celebrex (for arthritis), Januvia (for diabetes), Ularic (for gout), Welchol (lowers cholesterol), Advair (for asthma), Insulin (for diabetes), and Flovent Inhaler (for asthma). Vaccines included Pneumovax and Influenza. Multi-dose vials of Insulin and Tuberculin Skin Test were also stored in Suite 1A of the Outpatient Internal Medicine Satellite.

During interview on 3/12/14 at 10:30 A.M., the Director of Quality said that CAH policy required monthly Pharmacy rounds to occur at the Outpatient Internal Medicine Satellite.
During interview on 3/12/14 at 11:00 A.M., the Director of the Pharmacy said that he was aware that sample medications were stored in the Internal Medicine Satellite. However, he was unaware of the numbers and types of samples maintained in the Satellite. Additionally, the Director of Pharmacy said that he had not conducted any Pharmacy rounds at the Satellite since it was licensed by the Department of Public health (DPH), on 7/9/12.

3. Continued observations on 3/12/14 at 9:15 A.M., indicated that an area outside the room labeled Multipurpose Room, contained a counter, cabinets and two refrigerators. Refrigerator #1 was located on the countertop. MA #1 said Refrigerator #1 was used to store laboratory specimens that were obtained from patients (e.g. throat cultures, urine). Refrigerator #2 was stored on the floor, directly underneath the laboratory refrigerator (Refrigerator #1). MA #1 said medications including vaccines and insulin, were stored in Refrigerator #2.

MA #1 said that when she removed the vaccines from Refrigerator #2, for patient administration, she temporarily placed the vaccines on the counter while assembling needed supplies. Additionally, MA #1 said she used the counter to label patients' sample medications and laboratory specimens. The counter was the same counter used to store Refrigerator #1, in which laboratory specimens were stored. This practice created a risk for cross-contamination of patients' medications and vaccines.

MA #1 said she provided the sample medications for and administered the vaccines to, the Satellite's patients.

4. According to 244.CMR 4.0, a nurse practicing in an advanced role [i.e., Certified Nurse Midwife (CNM)], must be under the supervision of a physician who reviews and provides direction for the nurse's prescriptive practice at least every three months, or delegates to another fully licensed, qualified physician such direction and review. And a nurse practicing in an institution may not practice in an expanded role until a physician is designated who shall provide such medical direction as is customarily accepted in the specialty area.

Review of CNM #1's credential file on 3/12/14, indicated that the file lacked documentation of physician oversight, including review of CNM #1's prescriptive practice at least every three months. Upon Surveyor request on 3/12/14 at 10:30 A.M., documentation of CNM's physician supervision was not provided.

The Governing Body failed to ensure that all CAH patients were under the care of a practitioner who was under the supervision of a member of the medical staff.

Please refer to C297.


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5. Review of the policies and procedures for case management, social services, patient rights, patient advocacy, skilled nursing beds and services, patient health information and confidentiality, HIPAA Privacy Rule, and medical records, the CAH's governing body failed to implement and monitor these policies to ensure they were administered. See also C-280.

For example:

a. Review of the Policy and Procedures for the Protection of Record Information revealed no policy and procedure review since 11/2001, and no policies or procedures developed by the Critical Access Hospital (CAH) for safeguarding record information from loss or destruction, for the removal and storage of records from the CAH, or the retention time and retrieval of records.

During interview on 3/11/14 at 2:50 P.M., the Director of Medical Records said that the policies for Protection and Record Information had not been reviewed as required. Additionally, the Director of Medical Records said that no policies and procedures had been developed for: the safeguarding of record information from loss and destruction; the removal and storage of medical records; and/or the retention time and retrieval of records by the CAH.

b. Review of the Policy and Procedures for the Verification of Authorized Individual Procedures (HIPAA Privacy Rule), indicated no policy and procedure review since 4/2007. Review of the Policy and Procedures for Release of Patient Health Information and Confidentiality, indicated no policy and procedure review annually since 4/15/10.

During interview on 3/11/14 at 4:10 P.M., the Director of Regulatory Compliance said that the policies for Verification of Authorized Individual Procedures and Patient Health Information and Confidentiality had not been reviewed, as required.

Please refer to C280.

c. Review of medical records, patient and staff interviews on 3/10/14 and 3/11/14 indicated that the CAH failed to inform 1 of 21 sampled Inpatients (#1) in writing and obtain patient's acknowledgement prior to admission and/or after admission about the Program for Skilled Level of Care, Understanding of Change in Status and Rights.

Please refer to C361.

d. Medical record review and patient and staff interviews on 3/10/14, indicated that the CAH failed to ensure that 1 of 21 sampled Inpatients (#1) had the right to formulate advance directives and to have hospital staff and practitioners who provided care in the hospital comply with these directives.

Please refer to C362.



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6. The CAH failed to ensure emergency equipment was in good repair (e.g., ambu bags) in 2 of 5 Satellites and that emergency equipment was available on the Inpatient Units on the code carts (e.g., portable suction machines), in case of an emergency.

Please refer to C204 and C270.

Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) failed to implement and maintain the provision of services for infection control practice, pharmacy oversight, and medication preparation, storage and administration. Findings include:

1. The CAH failed to ensure that the staff followed infection control policies and standards of practice related to medication administration, hand hygiene, and use of personal protective equipment (PPE).

Please refer to C276 and C278.

2. The CAH failed to ensure patient care equipment and supplies were stored and maintained in a clean and sanitary manner.

Please refer to C278.

3. The CAH failed to ensure proper administration of medications related to multi-dose vials and sample medications. The CAH failed to ensure sterile medications were prepared in a safe environment.

Please refer to C276 and C278.

4. The CAH failed to ensure Pharmacy maintained oversight of the Outpatient Internal Medicine Satellite related to medication practices.

Please refer to C276 and C278.

5. The CAH failed to ensure that all drugs and biologicals were stored in a manner to prevent access by unauthorized individuals (unlicensed assistive personnel-UAPs).

Please refer to C276 and C297.

6. The CAH failed to ensure that staff had adequate immunity or vaccination status for the prevention of communicable disease.

Please refer to C278.

7. The CAH failed to review and/or revise policies and procedures annually.

Please refer to C280.

Based on observations and staff interviews, the Critical Access Hospital (CAH), failed to ensure that the drug storage area in the Internal Medicine Satellite was administered in accordance with CAH policy and accepted professional standards of practice. In addition, the Pharmacy failed to ensure that sterile products were prepared and labeled in a suitable environment by appropriately trained and qualified staff. Findings include:

1. During interview subsequent to survey, at 11:00 A.M. on 3/27/14, the Director of Infection Control said that CAH policy prohibited staff from preparing medications from multi-dose vials in the patient treatment area and then using the same vial of medication for additional patients. The Director of Infection Control said that in the event a medication, in a multi-dose vial, was brought to a patient's bedside, the medication needed to be used for only that patient, and the remainder of medication discarded.

2a. According to Centers for Disease Control and Prevention (CDC) Infection Control (IC) Practices, multi-dose vials of medications brought to the patient area, must be used for that patient only and then discarded.

b. According to 244 CMR (Code of Massachusetts Regulations) 3.0, Unlicensed Assistive Personnel (UAP), may not administer medications.

Please refer to C297.

3a. Observations in Suite 1A of the Outpatient Internal Medicine Satellite at 9:00 A. M. on 3/12/14 indicated medications including multiple sample medications, vaccines, and insulin were stored in Suite 1A of the Satellite.

During the observation, Medical Assistant (MA) #1 said she maintained key access to the medication storage areas, provided the sample medications for and administered medications to the Satellite's patients. MA #1 said that all the medications were single dose except for the vials of Insulin, Influenza Vaccine, and Tuberculosis (TB) Skin Test. MA #1 said these medications were in multiple dose vials.

During the observation, Surveyor #2 asked MA #1 how she prepared the medications in the multi-dose vials for administration to patients. MA #1 said that upon physician's order, she brought the multi-dose vials of medications into the Examination Room, where she prepared and administered the medication to patients. MA #1 also said that she then returned the multi-dose vials to the medication refrigerator and used the now contaminated, multi-dose vials of medications for future patients.

MA #1 failed to employ CAH policy and CDC Standards to avoid cross-contamination during medication preparation and administration. CAH policy and CDC Standards required multi-dose vials of medications to be prepared for patient administration in clean area, away from the patient area.

b. Observations in Suite 1B of the Outpatient Internal Medicine Satellite at 10:30 A. M. on 3/13/14 indicated medications were also stored in Suite 1B of the Satellite. Two boxes of the medication Eligard (for management of advanced prostate cancer) were observed in the medication refrigerator. Sample medications were also observed in a locked metal cabinet in the corridor. MA #3 (an UAP), said that the medications were administered by the patients' physicians. However, the MA said she maintained the keys to the medication refrigerator and the sample medications cabinet. MA #3 also said she maintained the sample medication log.

The CAH failed to ensure that all drugs and biologicals were stored in a manner to prevent access by unauthorized individuals (UAPs), as persons without legal access to drugs or biologicals cannot have keys to medication storage rooms, carts, cabinets, or containers.

Whenever persons without legal access to the drugs or biologicals have unmonitored access to drugs or biologicals stored in an area, the CAH would not be considered as in compliance with the requirement to store all drugs and biologicals in a locked manner.

c. During interview on 3/12/14 at 10:30 A.M., the Director of Quality said that CAH policy required the Director of Pharmacy to inspect drug storage areas monthly. However, on 3/12/14 at 11:00 A.M., the Director of Pharmacy said he had not inspected the Outpatient Internal Medicine Satellite (to determine if medications were prepared and administered appropriately and stored in a manner that prevented unauthorized access), since the Satellite was licensed on 7/9/12.

d. Review of the CAH policy titled "Drug Samples-MM.03.01.EP4" on 3/13/14 indicated the following:

"General Statement: Drug samples are not to be left in any location of Fairview Hospital to it's clinics without proper processes set in place. Pharmacy will assist with the process."

"Specifics:
Samples must be received and put away by a registered individual....The log needs to contain the initials of the licensed practitioner giving the medications and education to the patient."

During interview on 3/12/14 at 9:00 A.M., MA #1 said that she completed the sampled medication label with the name of the patient, the date the sample was dispensed, the name, strength and dose of the medication, and instructions per the ordering physician. MA #1 said she then gave the sample medications to the patients.

MA #1 also said that she received the sample medications from the Drug Representatives and logged the medications into the tracking book. MA #1 said she maintained the sample medication log book.

During interview on 3/13/14 at 11:00 A.M., MA #3 said she received the sample medications from the Drug Representatives and logged the medications into the tracking book. MA #3 said she maintained the sample medication log book.

Review of the personnel files of MA #1 and MA #3 on 3/13/14, indicated that neither MA was licensed to administer or have access to medications.



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4. The Pharmacy failed to ensure that sterile products were prepared and labeled in a safe environment by appropriately trained and qualified personnel. During tour of the Pharmacy the following observations were made:

a. On 3/11/14 at 7:30 A.M., Surveyor #3 observed a horizontal laminar flow hood located in an alcove created within the bulk medication storage area, approximately a foot from shelving and commercially packaged pharmaceuticals. The area and environmental controls do not conform to standards for the compounding of sterile products (CSPs) in the United States Pharmacopeia (USP) Chapter 797, as the hood is not "in a segregated com¿pounding area restricted to sterile compounding ac¿tivities that minimize the risk of CSP contamination. "

b. On 3/11/14 at 8:35 A.M, Surveyor #3 observed Pharmacy Technician (PT) #1 preparing 3 ophthalmic solutions within a certified laminar flow hood in a confined congested area next to products and shelving. Washing and garbing was observed to occur within this congested area rather than within an ante-area as per USP Chapter 797. A congested area has the potential to lead to cross-contamination, an infection control issue.

c. On 3/11/14 at 8:45 A.M, Surveyor #3 observed Pharmacist (PH) #1 verify/check the compounding of the 3 ophthalmic solutions within the certified laminar flow hood.

d. During these observations neither PT #1 nor PH #1 documented their actions on the order form.

Based on observations, review of Infection Control (IC) Policies, and staff interviews, the Critical Access Hospital (CAH), failed to ensure that staff adhered to IC policies and IC Standards of Practice related to: hand hygiene, administration medications from multi-dose vials; proper surgical attire; inappropriate storage of supplies and cleaning of equipment, proper use of personal protective equipment (PPE-gloves); staff maintenance of required immunities; and annual review of IC Policies, for 1 of 21 Inpatients (#4) and 1 of 13 sampled Outpatients (#6). Findings include:

1. Observations in the Cardio-Respiratory Department on 3/10/14 at 1:00 P.M. indicated the following:

-The pulmonary function testing (PFT) machine had a basket attached to the leg of the machine. In the basket was stored multiple disposable filters, mouthpieces, and nose clips. The basket was uncovered.

-Surveyor #2 asked the Co-Director of the Cardio-Respiratory Department to demonstrate how he disinfected the pulmonary function testing machine after each patient use and the name of the product he used to disinfect the equipment.

-The Cardio-Respiratory Department Co-Director said he used PDI Disinfectant Wipes to disinfect the machine, tubing, and hand piece.

-Review of the PDI Disinfectant Wipes manufacturer's directions for use (MDFU) indicated that the surface being disinfected needed to remain visibly wet for two minutes, to ensure an effective bacteria kill time. The Co-Director of the Cardio-Respiratory Department said that he did not ensure that the surfaces disinfected with the PDI Wipes was visibly wet for two minutes.

-After wiping the equipment (machine, tubing and hand piece) for 20 seconds, the Co-Director of the Cardio-Respiratory Department placed the ineffectively disinfected handpiece with tubing on top of the disposable filters, mouthpieces, and nose clips that were to be used with future patients.

-The PFT machine tubing had rings with crevices between each ring, for the length of the tubing. The Co-Director said that he did not disinfect the crevices between each ring. He said that he just wiped off the tubing from end to end. The Co-Director said that it would take too much time to carefully clean each crevice on the tubing.

-Upon surveyor inquiry, the Co-Director of the Cardio-Respiratory Department indicated the PFT machine and tubing were not effectively disinfected and created a risk for cross-contamination of the disposable supplies from the ineffectively disinfected tubing and handpiece.

2. Observations in the Central Processing Department (CPD) on 3/10/13 at 1:30 P.M., indicated that Central Sterile Technician (CST) #1 was in the Decontamination Area of the CPD. CST #1 then left the Decontamination Area and entered the sterile processing side of CPD wearing the same surgical attire (scrub suit) worn in the Decontamination Area, creating a risk for cross-contamination.

During interview at the time of the observation, CST #1 said the sterile processing side of CPD was a restricted area and clean surgical attire was required to be worn in the sterile processing side of CPD. CST #1 also indicated that staff who worked in the Decontamination Area needed to change their scrub suits before entering the sterile processing side of CPD.

Review of the CAH policy titled "Dress Code for Central Services Personnel," not revised since 1/1996, was incomplete and did not address the required surgical attire or personal protective equipment, required in each area of CPD.

3. According to the Association of periOperative Registered Nurses (AORN), Recommended Practice II for Surgical Attire, "Clean surgical attire, including shoes, head covering, masks, and jackets should be worn in the semi-restricted and restricted areas of the surgical or invasive procedure setting.

According to AORN's Surgical Attire Recommendation III, "Surgical attire helps contain bacterial shedding and promotes environmental cleanliness. An individual sheds millions of skin squames (a cell or flake of skin) daily and five to 10% of skin squames carry bacteria."

-Observations in the Reprocessing Room of the Endoscopy Unit at 2:15 P.M. on 3/10/14, indicated that Registered Nurses (RN) #2 and #3, failed to wear proper surgical attire (a surgical hat) during high level disinfected (HLD) of endoscopes, providing a risk for cross-contamination of reprocessed equipment from shedded hair and/or skin squames.

Both RN #2 and RN #3 failed to adhere to AORN Recommended Practices for proper surgical attire, creating a risk for cross-contamination of endoscopes used for patients' invasive procedures.

4. For Outpatient #6, observations in the Endoscopy Unit, on 3/11/14 between 9:15 A.M. and 10:00 A.M., indicated the following breeches in IC practices:

a. Observation of the insertion of an intravenous (IV) line, at 9:15 A.M. on 3/11/14, indicated that after cleansing the IV site with an antiseptic, RN #7 waved her hand over the disinfected area, to air dry the IV insertion site.

During the observation, the Nursing Director of Maternal Newborn Services and the Endoscopy Unit, indicated that skin cleansed with an antiseptic should not be waved dry. The Nursing Director of Maternal Newborn Services and the Endoscopy Unit, confirmed that waving the air over disinfected skin may create air currents that contained bacteria and other contaminants, thereby contaminating the disinfected skin.

During interview on 3/11/14 at 4:00 P.M., the Director of Quality said that the CAH's IV policies were those of the Infusion Nurses Society. Review of Policies and Procedures for Infusion Nursing, 4th edition, on 3/11/14, read, "Cleanse insertion site with antiseptic solution: allow to dry completely." RN #7 did not allow the antiseptic to air dry, as required by CAH IV policies and procedures.

b. Review of the CAH's IV administration policy on 3/11/14, read, "Disinfect the Needleless connector with an antiseptic wipe, using friction and a scrubbing motion; allow to dry completely."
Observations in the Endoscopy Procedure Room between 10:00 A.M. and 10:15 A.M., on 3/11/14, indicated that Physician #2 administered IV sedation to Outpatient #6, three times between 10:00 A.M. and 10:15 A.M. Physician #2 failed to disinfect the needleless connector each time he accessed Outpatient #6's IV, as required.

During interview on 3/11/14 at 10:30 A.M., the Nursing Director of Maternal Newborn Services and the Endoscopy Unit said Physician #2 should have disinfected the needleless connector before administering Outpatient #6's IV sedation.

5. According to the Centers for Disease Control (CDC) and Prevention Standards for Hand Hygiene, staff are required to perform hand hygiene before donning and after removing gloves.

Observations in the Endoscopy Unit Decontamination Room on 3/11/14 at 10:30 A.M., indicated that Endoscopy Technician (ET) #1 failed to perform hand hygiene before donning gloves to clean the endoscope used with Outpatient #6.

Additionally, ET #1 failed to remove the contaminated gloves used to wash the endoscope, and perform hand hygiene before obtaining a clean chux (water resistant paper liner) to cover the washed endoscope for transport to the clean, reprocessing room.

During interview on 3/11/14 at 10:30 A.M., ET #1 said she should have performed hand hygiene before donning her gloves and she should have removed her gloves and performed hand hygiene before handling the clean chux.

6. According to CDC IC Standards of Practice for Medication Administration, multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use.

a. Observations in Suite 1A of the Outpatient Internal Medicine Satellite, on 3/12/14 at 9:00 A.M., indicated that multi-dose vials of vaccines and insulin were stored in the Outpatient Internal Medicine Satellite.

During interview, at the time of the observation, MA #1 said that she drew-up the medications from the multi-dose vials in the patient treatment area and administered the medications to the patients. MA #1 also said she then returned the multidose vials to the Medication refrigerator for use with other patients.

b. Upon request from Surveyor #2, MA #1 described how she disinfected patient equipment (the otoscope-used to examine patients' ears), between patients. MA #1 said she used PDI disinfectant wipes to disinfect the handle and earpiece of the otoscope. However, MA #1 said she had never removed the earpiece from the otoscope and disinfected the back and canal of the earpiece. This otoscope and earpiece was used with multiple patients.

c. Observations in Suite 1A of the Outpatient Internal Medicine Satellite, on 3/12/14 at 9:00 A.M., also indicated that a Laboratory specimen refrigerator was stored on the counter in the area designated for a patient nourishment station. MA #1 said she stored patient specimens (e.g., cultures, urine) in the refrigerator until they were collected by the CAH laboratory.

Under the counter, directly under the Laboratory refrigerator, the Medication refrigerator was stored. During interview in the Outpatient Internal Medicine Satellite on 3/13/14 at 11:15 A.M., the Director of Quality indicated that the close proximity of the Laboratory and Medication refrigerators, created a risk for cross-contamination of the injectable medications.



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7. On 3/10/14 at 11:25 A.M., Finger Stick (FS) blood glucose monitoring for Inpatient #4 was observed by Surveyor #1 on the Medical Surgical Unit, with Nursing Assistant (NA) #1.

NA #1 washed her hands in Patient #4's bathroom sink. After her hands were washed, she dried her hands, donned gloves and shut off the contaminated sink faucet with her clean gloved right hand, contaminating gloved right hand and creating a risk of cross contamination.

NA #1 then pierced Patient #4's finger with a lancet, while wearing the contaminated glove. Blood was obtained from the Patient's finger, and NA #1 put this blood on a test strip and inserted it into the glucometer. NA #1 removed her gloves but did not wash her hands, as required.

Without performing hand hygiene, NA #1 reached into her uniform pocket, obtained a piece of paper, and recorded the blood sugar reading thereby, contaminating her pocket, the paper and the pen. NA #1 then re-gloved without first performing hand hygiene, cleaned the glucometer with a Sani-Wipe (a disinfectant wipe), while wearing contaminated gloves.

During an interview on 3/10/14 at 11:27 A.M. with NA #1, Surveyor #1 discussed her observations. NA #1 said that she thought she might have shut it (referring to the faucet) off with her washed hand, and she should have washed her hands before donning gloves and right after obtaining the blood sugar reading.

8. During tour of the Outpatient Physical Therapy Rehabilitation Satellite, on 3/11/14 at 8:10 A.M. with Physical Therapist (PT) #1, the following were identified:

a. A review of the Hydrocullator Log for February and March 2014 indicated the cleaning and refilling of the hydrocullator was done every 20 to 30 days. According to the manufacturer's directions for use (MDFU), the cleaning of the hydrocullator should be done every 14 days. PT #1 said, "We can increase the frequency to every 14 days."

b. Surveyor #1 observed the Splint Form Pan (a water bath for heating thermoplastic material for making splints) contained a build up of sediment on the insides of the pan.

During an interview with Occupational Therapist (OT) #1, Surveyor #1 asked for the cleaning log for the Splint Form Pan. OT #1 stated, "I clean it with a Sani-wipe as it needs cleaning, but not on a schedule. I fill the water pan as it decreases."

According to the MDFU, the Splint Form Pan should be refilled once a week and cleaned with a low abrasion, bleach free cleaner. The instructions state: "To remove hard water mineral build up, fill the pan with one gallon of distilled vinegar and three gallons of water after cleaning." There was no log to document the cleaning or water refill schedule, and vinegar has not been used to treat the sediment build up.

c. Surveyor #1 observed the Paraffin Bath on the counter in the OT's Office. The Paraffin Bath was used for heat therapy to patients' hands. Surveyor asked for the cleaning schedule for the bath and the paraffin wax changes. OT #1 did not have a log of when it was cleaned or when the paraffin wax was changed.

d. Surveyor #1 observed Physical Therapy Treatment Room #8. Two wedge cushions were stored in the 3 inch gap between the handwashing sink and the wall. A face/head cushion was stored on the opposite side of the sink. Storage of rehabilitation equipment on a sink counter created a potential for cross contamination from splashing water.

e. An open box of fabric softener sheets was stored directly on the floor of the laundry room.

f. A bag of hydrocollator covers were stored directly on the floor in the Storage Room.

9. During tour of the Satellite Wound Center on 3/13/14 at 10:15 A.M., in Examination Rooms #1, #2, #3, and #4, wound supplies were not stored in sealed containers. Sealed containers would prevent contamination with environmental hazards. In each Examination Room, there was a basin filled with 2 stacks of 4 by 4 gauze pads, which were uncovered, open unsealed sleeves of 2 by 2 gauze pads, cotton applicators and tongue blades.

During an interview with Registered Nurse (RN) #6, on 3/13/14 at 10:30 A.M., Surveyor #1 said, "In the 4 Examination Rooms, the gauze pads, cotton applicators and tongue blades for wound treatment were not closed to protect them from environmental contaminates. Is this your usual practice." RN #6 said, "Yes, it is."


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10. Review of the hospital's Occupational/Employee Health Program Policy indicated the following;

-To facilitate the placement and ensure the suitability of individuals according to their health and physical capabilities in work which they can perform with an acceptable degree of efficiency and without endangering their own health and safety, that of their fellow employees, or that of their patients.

-Before employment, all BHS (Berkshire Health Systems) employees are required to show proof of immunity through blood titer and/or documented vaccination to Measles (Rubeola), Mumps, German Measles (Rubella), Hepatitis B and Varicella (Chicken Pox). Proof of Tuberculosis (TB) skin test (TST) or blood assay is also required.

Review of health files for three current employees, and Certified Nurse Midwife (CNM) #1, indicated the files lacked documented evidence of immunity for communicable diseases as follows:

-Employee #29 had no documentation of TST or immunization against MMR (Measles, Mumps, Rubella) and Varicella;

-Employee #30 had no documentation of immunization against MMR and Varicella; and

-Employee #32 had no documentation of TST.

During an interview with the Director of Human Resources on 3/13/14 at 10:30 A.M., she said there was no evidence in the employees' files indicating they had been screened for communicable diseases before being employed, as required per the hospital policy.

Review of Certified Nurse Midwife (CNM) #1's credential file on 3/12/14 indicated the file lacked documentation of immunity to rubella, rubeola and TST. At the time of the review, Surveyor #2 asked the Medical Staff Coordinator to obtain documentation of CNM #1's immunity status. As of the last day of survey (3/13/14), documentation of CNM #1's immunity was not provided to Surveyor #2.

The Medical Staff Coordinator said that CNM #1 admitted and cared for mothers and susceptible newborn infants in the CAH's Maternal Newborn Service.

Based on documentation review and staff interviews, the Critical Access Hospital's (CAH's) professional personnel failed to review policies annually. Findings include:

1. Review of policies and procedures on 3/11/14, indicated the CAH failed to review the following policies for case management, social services, patient rights, patient advocacy, skilled nursing beds and services, patient health information and confidentiality, HIPAA Privacy Rule, and medical records annually as required.

Review of the Policy and Procedures for the Protection of Record Information revealed no review or revision of policies and procedures had been conducted since 11/2001. No policies or procedures had been developed by the CAH for safeguarding record information from loss or destruction, for who was allowed to remove medical records from the CAH, or for the retention of medical records.

During interview on 3/11/14 at 2:50 P.M., the Director of Medical Records said that the policies for Protection and Record Information had not been reviewed annually, and that there were no policies and procedures for the safeguarding of record information from loss and destruction or the retention of records by the CAH.

Review of the Policy and Procedures for the Verification of Authorized Individual Procedures (HIPAA Privacy Rule), indicated no policy and procedure review since 4/2007. Review of the Policy and Procedures for Release of Patient Health Information and Confidentiality, indicated no policy and procedure review annually since 4/15/10.

During interview on 3/11/14 at 4:15 P.M., the Director of Regulatory Compliance said that the policies for Verification of Authorized Individual Procedures and Patient Health Information and Confidentiality had not been reviewed annually.

Review of the Policies and Procedures Manual for Case Management and Social Services which included but were not limited to Patient Bill of Rights/Responsibilities, Social Service and Case Management responsibilities, performance appraisals, Patient Abuse/Neglect Prevention, Informed Consents, Discharge Planning and Responsibilities, Discharges from Acute Care to Skilled Nursing (Swing Beds), and Admission and Discharges from Skilled Nursing, indicated no policy and procedures review since 11/2001.

During interview on 3/12/14 at 9:30 A.M., the Director of Case Management said that the policies and procedures for Case Management and Social Services had not been reviewed annually. The Director said that policies and procedures were supposed to be reviewed every 3 years, not annually as required.


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2. On 3/13/14 at 12:20 P.M., Surveyor #4 conducted a random review of Emergency Department (ED) Policies with the ED Nurse Manager. The Policies did not indicate that a review and/or revision was conducted for all policies in 2013 or 2014.


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3. Review of nutrition policies/procedures indicated the following policies were not consistently reviewed and updated annually:

- The policy titled, Drug-Food Interaction: Prevention and Education, last reviewed/revised on 12/1/12.

- The policy titled, Nutrition Assessment and Documentation of Swing Patients, last reviewed/revised on 12/26/12.

- The policy titled, Nutrition and Food Service-Infection Control, last reviewed/revised 5/31/11.

During an interview with the Clinical Coordinator of Operation Better Start on 3/13/14 at 8:20 A.M., she said the nutritional policies provided to the surveyor did not have any further updates.

Additionally, review of personnel files indicated the following policies were not consistently reviewed and updated annually:

-The policy titled, BHSP (Berkshire Health System Policy) 132 Personal Appearance of Employees, was last reviewed/revised 04/27/12.

- The policy titled, BHSP 104 Corrective Actions-Effective, was last reviewed/revised 06/27/12.

During an interview with the Director of Human Resources on 3/13/14 at 1:10 P.M., she said these personnel policies were the most current and up to date policies that have been reviewed by administration and staff.


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4. Review of infection control (IC) and Post Anesthesia Care Unit (PACU), policies and procedures on 3/13/14, indicated the policies had not been consistently reviewed and/or revised annually, as required. For example:

- The policy titled, "High Level Disinfection of Ultrasound Probes" was documented as 'Original' and dated 3/12/12;
- The policy titled, "Radiology: Ultrasound Transducers-Care and Safety" was dated as last revised on 3/8/12;
- The policy titled, "Dress Code for Central Services Personnel" was dated as last revised 1/1996;
- The policy titled,"Drug Samples-MM.03.01.EP4" was dated as last reviewed on 4/6/10;
- The policy titled, "Multidose Vials-DA-217-MM.05.01.09" was dated as last revised on 6/20/10;
- The policy titled, PACU Admissions-PC.03.01.07.EPI, was dated as last revised on 10/31/09;
- The policy titled, "PACU Discharges", was dated as last revised in 12/2001; and
- The policy titled, "Discharge Criteria and Instructions for Surgical Day Care Patient - PC.04.01.01," was dated as last reviewed on 5/31/09.

Based on observations and staff interviews, the Critical Access Hospital (CAH) failed to ensure that medications were not administered by Unlicensed Assistive Personnel (UAP), and were administered in accordance with Centers for Disease Control and Prevention (CDC) Infection Control (IC) Standards, and Federal and State laws. Findings include:

According to Centers for Disease Control and Prevention (CDC) Infection Control (IC) Standards, multi-dose vials of medications, brought to the patient area, must be used for that patient only and then discarded.

According to 244 CMR (Code of Massachusetts Regulations) 3.0, related to Nurses delegation to Unlicensed Assistive Personnel (UAP), Nursing activities that may not be delegated to UAPs include the administration of medications. According to 244 CMR (Code of Massachusetts Regulations) 3.0, UAPs (Medical Assistants), may not administer or have access to medications.

Observations in the Outpatient Internal Medicine Satellite at 9:00 A.M. on 3/12/14, indicated medications, including multiple sample medications, vaccines, and insulin were stored in Suite 1A of the Satellite.

During the observation, Medical Assistant (MA) #1 said she maintained key access to the medication storage areas, provided the sample medications and administered medications to the Satellite's patients. MA #1 said that all the medications were single dose except for the vials of Insulin, Influenza Vaccine, and Tuberculosis (TB) Skin Test. MA #1 said these medications were in multiple dose vials. MA #1 said that she brought the multi-dose vials of medications into the Examination Rooms, where she prepared and administered the medications to the patients. MA #1 also said she returned the multi-dose vials to the medication refrigerator and used the now-contaminated vials of medications for future patients. MA #1 failed to use appropriate techniques to avoid cross-contamination during medication preparation and administration.

Review of MA #1's personnel file on 3/13/14, indicated that the file contained documentation that MA #1 was approved by the CAH to administer vaccines, insulin and TB skin tests, to patients, although prohibited by State Regulation.

During interview with the Director of Quality on 3/12/14 at 11:00 A.M. indicated the Director of Quality was unaware that UAPs (MAs) were not allowed to administer patient medications, or have access to medications, according to State law.

During interview subsequent to survey, at 11:00 A.M. on 3/27/14, the Director of Infection Control said that CAH policy prohibited staff from preparing medications from multi-dose vials in the patient treatment area, and then using the same vial of medication for additional patients. The Director of Infection Control said that a multi-dose vial brought to a patient's bedside, needed to be used for only that patient and the remainder of medication discarded.

Based on medical record reviews, the Critical Access Hospital (CAH) failed to ensure that all records were legible, complete, and accurately documented for 2 (#9, and #15) of 21 sampled Inpatients and 3 (#4, #7, and #8) of 13 sampled Outpatients. Findings include:

1. For Outpatient #4, medical record review on 3/11/14 of the Consent for Hyperbaric Oxygen Treatment indicated that the treating physician's signature was illegible.



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2. For Inpatient #9, (a newborn) the medical review on 3/10/14 indicated the following:

-The Hepatitis B vaccination declination lacked the signature, date and time of the newborn patient's parent(s);
-The declination for prophylactic eye care lacked the time and date of the parent(s)' signature.

3. For Outpatient #7, medical record review on 3/11/14, indicated that the medical record lacked a post-anesthesia evaluation. During interview on 3/11/14 at 11:15 A.M., RN #9 said that Outpatient #7 was discharged home before Physician #3 completed Outpatient #7's post-anesthesia evaluation.

4. For Outpatient #8, medical record review on 3/11/14, indicated that the examining practitioner's signature on the H&P was illegible. The H&P was dated 3/5/14. However, the medical record lacked an update to the H&P within 24 hours of surgery, as required.

5. For Inpatient #15, medical record review on 3/11/14, indicated that the H&P was dated 9/5/13. However, the medical record lacked a comprehensive H&P completed within 30 days or 24 hours of admission, as required.

Based on medical record review, patient and staff interviews, the Critical Access Hospital (CAH) failed to provide properly informed consents for 3 (#1, #8 and #15) of 21 sampled Inpatients and 5 (#4, #5, #6, #7, and #8) of 13 sampled Outpatients. Findings include:

1. For Inpatient #1, the CAH failed to inform the patient in writing and obtain patient consent prior to admission and/or after about the Program for Skilled Level of Care, Understanding of Change in Status and Rights, for the patient's Hospitalization and Treatment, and for the patient's Rights and Services.

Inpatient #1 was admitted to the CAH's Skilled Nursing Care (Swing Bed) in 3/2014.

During interview on 3/10/14 at 10:15 A.M., Patient #1 said that he/she was not given any written information by staff about the hospital admission process to a swing bed (skilled nursing care) unit, about his/her patient rights and consents for services and treatment, nor did staff discuss or put in writing his wishes to be discharged. The patient stated he/she had been admitted to the hospital against his/her wishes.

Medical record review on 3/10/14 at 11:00 A.M. indicated no evidence the patient had been informed about and given the opportunity to consent or refuse CAH admission, received notice of patient rights, notice of nursing/medical services, nor discharge planning.

During interviews with Case Manager #1 on 3/10/14 at 11:30 A.M. and with the Director of Case Management on 3/11/14 at 9:30 A.M., both said the patient was capable of signing consent forms, and that the CAH failed to provide any patient information and secure written consents before and/or after admission as to treatment agreements, patient rights, nursing/medical care planning, treatment services, or discharge planning.

Please refer to C361, C362, and C366.



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2a. For Inpatient #8, medical record review on 3/10/14, the medical record lacked a specific consent for labor and delivery. The only consent found in Inpatient #8's medical record was the general CAH Consent to Hospital Admission and Medical Treatment. In addition, the consent for Anesthesia lacked the date and time of Inpatient #8's signature;

During interview on 3/10/14 at 2:30 P.M., Inpatient #8 said she was not informed of the risks and potential complications of labor and delivery when she signed the consent.

During interview on 3/10/14 at 2:45 P.M., Registered Nurse (RN) #1 said that the general consent was the only consent used for Maternal Newborn Services patients. RN #1 said the CAH did not maintain a specific consent for labor and delivery.

b. For Outpatient #5, medical record review on 3/11/14, indicated that the patient's surgical consent was signed by Outpatient #5 on 3/11/14 at 8:00 A.M. and by the surgeon on 3/11/14 at 8:15 A.M. In addition, the Anesthesia Consent lacked the date and time of the patient's and the witness' signatures.

During interview on 3/11/14, the Nursing Director of Surgery and Endoscopy said that the admitting nurses reviewed the scheduled procedure(s) with the patients, and then had the patients sign their consents. The surgeons then signed the consents when they visited the patients before surgery.

c. For Outpatient #6, medical record review on 3/11/14, indicated that the patient's surgical consent was obtained greater than 30 days prior to the 3/11/14 procedure.

During interview on 3/11/14 at 9:45 A.M., RN #3 said that Physician #2's office nurse (a Licensed Practical Nurse -LPN), reviewed the procedure prep, what will happen at the hospital, the surgeon's choice of anesthesia, and conducted a medication reconciliation with all patients. The Office LPN then signed the consent, had the patients sign the consents, and then Physician #2 signed the consents.

RN #3 then said that hospital policy required consents to be obtained within 30 days of the scheduled surgery or invasive procedure. RN #3 said that since the consent was outdated that she would get another consent, review the procedure with the patient again, have the patient sign the consent and then Physician #2 would sign the consent in the procedure room. RN #3 then reviewed the procedure with Outpatient #6 and had him/her sign the consent before Physician #2 was in the area. Physician #2 did not obtain the invasive procedure consent with the patient.

d. For Outpatient #7, medical record review on 3/11/14, indicated that the consent for the Patient's 3/11/14 procedure, was signed by the patient at 6:30 A.M. and by Physician #1 at 7:15 A.M. During interview at 11:00 A.M. on 3/11/14, RN #9, said that she obtained the Patient's consent. Physician #1 did not obtain the consent with Outpatient #7. In addition, the Anesthesia Consent lacked the date and time of the patient's and the witness' signatures.

e. For Outpatient #8, medical record on 3/11/14, indicated that the Patient signed the surgical consent on 2/27/14 at 9:15 A.M. and Physician #1 signed the consent on the day of surgery, 3/11/14, at 7:30 A.M. Physician #1 did not obtain the consent with Outpatient #8. In addition, the Anesthesia Consent lacked the date and time of the patient's and the witness' signatures.

f. For Inpatient #15, medical record review on 3/11/14, indicated that the medical record lacked a specific consent for labor and delivery. The only consent found in Inpatient #15's medical record was the general CAH Consent to Hospital Admission and Medical Treatment. In addition, the Anesthesia Consent lacked the date and time of the patient's and the witness' signatures.

Review of Physician #4's post delivery note, dated 3/10/14 at 7:05 P.M., indicated that Inpatient #15 suffered a second degree vaginal laceration during delivery.

During interview on 3/11/14 at 11:45 A.M., Inpatient #15 said she was not informed of the risks and potential complications of labor and delivery when she signed the Consent to Hospital Admission and Medical Treatment with the Admission Officer on 3/10/14.


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3. For Outpatient #4, medical record review on 3/11/14 of the Consent for Hyperbaric Oxygen Treatment indicated that the patient's signature and the treating physician's signature were not dated or timed.

Based on review of documentation and interviews, the Critical Access Hospital (CAH) failed to ensure that entries in the patient's medical record by the health care professional were dated, timed and authenticated, for 4 (#2, #17, #18, and #20) of 21 sampled Inpatient records and for 3 (#5, #8 and #10) of 13 sampled Outpatient records. Findings include:

1. Review of Inpatient #20's record indicated a surgical consent for an emergency appendectomy (secondary to acute appendicitis) was not properly executed.

The Surgeon signed the surgical consent but did not date or time this consent.

During an interview with the Director of Regulatory Compliance on 3/11/14 at 1:15 P.M., Surveyor #1 reviewed the surgical consent which was not timed or dated. She said, "It needed to be dated and timed by the Surgeon."


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2. For Outpatient #5, medical record review on 3/11/14, indicated that the history and physical (H&P) lacked the signature, date and time of the examining physician.

During interview on 3/11/14 at 10:00 A.M., Registered Nurse (RN) #7, acknowledged that the H&P was not signed by a licensed practitioner.

3. For Outpatient #8, medical record review on 3/11/14, indicated that the H&P lacked the date and time of the examining practitioner's signature.


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4. For Inpatient #2, who was admitted in 2/2014, medical record review of 3/10/14 indicated the patient's "Rehabilitation Communication Request" form Swing Bed Occupational Therapy and Physical Therapy was not signed and dated by the patient's Physician.

During interview on 3/10/14 at 3:20 P.M., Nurse #4 said the patient's Physician did not sign both the Occupational and Physical Therapy Treatment/Order as required.

5. For Inpatient #17, who was admitted in 10/2013 and discharged 11/2013, medical record review of 3/11/14 indicated:

1.) the patient's Pre-Operative Transfer Form was not dated by the Registered Nurse (RN), and
2.) the patient's "Rehabilitation Communication Request" form Swing Bed Physical Therapy was not signed and dated by the patient's Physician.

During interview on 3/12/14 at 9:15 A.M., the Director of Case Management said the RN should have dated the Pre-Operative Transfer Form, and the patient's Physician did not sign the Physical Therapy Treatment/Order as required.

6. For Inpatient Patient #18, who was admitted in 2/2014 and discharged in 2/2014, medical record review of 3/11/14 indicated the patient's "Rehabilitation Communication Request" form Swing Bed Occupational Therapy was not signed and dated by the patient's Physician.

During interview on 3/12/14 at 9:15 A.M., the Director of Case Management said the patient's Physician did not sign the Physical Therapy Treatment/Order as required.


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7. For Outpatient #10, medical record review on 3/11/14, indicated that the Cardiopulmonary Resuscitation Sheet did not have the authenticating signature of the physician.

Surveyor #4 interviewed the Nurse Manager of the Emergency Department at 7:40 A.M. on 3/13/14. The Nurse Manager said that the Cardiopulmonary Resuscitation Sheet, when signed by the physician, authenticated all medications and treatments administered to the patient during a cardiac arrest.

Based on observation and staff interviews, the Critical Access Hospital (CAH) failed to properly maintain medical records in a location that was protected from fire and water damage. Findings include:

Closed Record Maintenance:

Observation of the medical record room on the CAH Ground Floor, on 3/10/14 at 3:30 P.M. and on 3/11/14 at 2:30 P.M. with the Director of Medical Records, revealed multiple rows of closed medical records stored on metal cabinet shelves without these records being totally enclosed in a file cabinet. As a result, medical records were not stored to prevent their destruction from potential fire or water sprinkler damage. The Director said that the current storage of medical records did not provide effective protection of closed records if a fire occurred in the hospital when Administrative staff were unavailable (such as nights, weekends and holidays.)

:

Based on medical record review, patient and staff interviews, the Critical Access Hospital (CAH) failed to inform 1 of 21 sampled Inpatients (#1) in writing and obtain patient's acknowledgement prior to admission and/or after admission about the Program for Skilled Level of Care Understanding of Change in Status and Rights. Findings include:

Patient #1 was admitted to the CAH's Skilled Nursing Care (Swing Bed) in 3/2014.

During interview on 3/10/14 at 10:15 A.M., Patient #1 said that he/she was not given any written information by staff about the hospital admission process to a swing bed (skilled nursing), about his/her patient rights, nor the opportunity to acknowledge these rights and/or patient responsibilities. The patient stated he/she had been admitted to the hospital against his/her wishes.

Medical record review on 3/10/14 at 11:00 A.M. indicated no evidence the patient had been informed about and given the opportunity to acknowledge in writing before or after CAH admission, a notice of patient rights and responsibilities.

During interviews with Case Manager #1 on 3/10/14 at 11:30 A.M. and with the Director of Case Management on 3/11/14 at 9:30 A.M., both said the patient was capable of signing consent forms, and that the CAH failed to provide any patient information and secure written acknowledgement before and/or after admission as to patient rights and responsibilities.

Based on record review, patient and staff interviews, the Critical Access Hospital (CAH) failed to ensure that 1 of 21 sampled Inpatients (#1) had the right to formulate advance directives and to have hospital staff and practitioners who provided care in the hospital comply with these directives. Findings include:

Review of the Swing Bed policy indicated that patients had the individual's right under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment.

Inpatient #1 was admitted (from an acute care hospital to the skilled nursing unit (swing bed) in 3/2014.

During interview on 3/10/14 at 10:15 A.M., Inpatient #1 said that he/she was not given the opportunity by CAH staff or his/her Physician, either verbally or in writing, to formulate an Advance Medical Directive. The Patient said he/she wished to have a Do Not Resuscitate (DNR) status.

Record review on 3/10/14 at 11:00 A.M. indicated no evidence the patient had been allowed to formulate an Advanced Medical Directive. Physician orders, from the date of admission to 3/10/14, indicated the resident had a "Full Code" status.

During interviews with Case Manager #1 on 3/10/14 at 11:30 A.M. and with the Director of Case Management on 3/11/14 at 9:30 A.M., both said the patient was capable of signing an Advanced Medical Directive, and that the CAH failed to provide the patient with the right to refuse care as stipulated in a DNR directive.

Based on record review, patient and staff interviews, the Critical Access Hospital (CAH) failed to ensure that 1 of 21 sampled Inpatients (#1), had the right to participate in his/her care and treatment. Findings include:

Inpatient #1 was admitted (from an acute care hospital to the skilled nursing unit (swing bed) in 3/2014.

During interview on 3/10/14 at 10:15 A.M., Inpatient #1 said that he/she was not given any written information by staff about or participation in his/her level of care and services, before or after admission. The Patient stated he/she had been admitted to the hospital against his/her wishes.

Chart record review on 3/10/14 at 11:00 A.M. indicated no written evidence the Patient had been allowed to participate in the planning of his/her care. Almost all of the CAH's communication about care and treatment planning was confined to the patient's family members.

During interviews with Case Manager #1 on 3/10/14 at 11:30 A.M. and with the Director of Case Management on 3/11/14 at 9:30 A.M., both said the Patient was capable of participating in his/her treatment and care, and that the CAH failed to provide the Patient the opportunity to participate in his/her care and/or treatment changes.

Based on observation and interviews, the Critical Access Hospital (CAH) failed to protect the privacy and confidentiality of the patients' treated in the Aquatic Therapy Program.
Findings include:

Surveyor #4 interviewed the Director of Rehabilitation Services 10:00 A.M. on 3/11/14. The Director said that the Aquatic Therapy Program was conducted offsite at a local public swimming pool on Tuesdays and Thursdays from 8:00 A.M. to 9:00 A.M. The Director said that the CAH utilized 3 lanes of the pool while the public had access to the remaining 3 lanes, at the same time. The Director said that the pool was not closed to the public while the Aquatic Therapy Program was in progress creating a potential visual and auditory breach of patient confidentially. The public could see the patients who were receiving care and overhear staff discussions of patients' healthcare issues.

Based on observation, record review, resident and staff interviews, the Critical Access Hospital (CAH) failed to develop and keep a current nursing care plan for 1 of 21 sampled Inpatients (#1). Findings include:

Inpatient #1 was admitted (from an acute care hospital to the skilled nursing unit (swing bed) in 3/2014 with diagnoses that included Cerebrovascular Accident, depression and alcohol abuse.

Observation of the patient room, from the corridor on 3/10/14, from 10:05 A.M. to 10:20 A.M., indicated the Patient yelling and swearing loudly for nursing assistance.

During the initial portion of the interview on 3/10/14 at 10:15 A.M., Inpatient #1 continued to swear and yell that he/she wanted to leave the CAH and return home.

Record review on 3/10/14 at 10:45 A.M. indicated the resident had multiple episodes of swearing, yelling and refusing care. For example, the Patient used "foul language" and refused Physical Therapy treatment on 3/4/14 and 3/7/14. On 3/4/14, a nighttime nursing note indicated the Patient was "rude and belligerent," yelling and picking off a dressing. On 3/9/14 at 6:45 A.M., the Patient refused laboratory testing, and later, was arguing with a relative. On 3/9/14 the Nursing Note indicated the Patient was "non-compliant with using the call bell after getting up" without assistance.

Review of Inpatient #1's care plans on 3/10/14 at 10:55 A.M. indicated that care plans were initiated on 3/1/14. The care plans did not address the patient's anxiety and coping skills, verbal abuse behavior that could be heard by other patients and visitors, and patient resistance/refusal of care.

During interviews with Case Manager #1 on 3/10/14 at 11:30 A.M. and with the Director of Case Management on 3/11/14 at 9:30 A.M., both said that the Patient was not care planned for repeated documented and assessed episodes of anxiety, poor coping skills of yelling and swearing, and behavior identified as resistance/refusal of care.