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Based on review of facility documentation, observation and staff interview (EMP), it was determined the facility failed to ensure there was a facility policy or procedure in place regarding written notification to inpatients and outpatients that no medical physician (MD) or physician of osteopathy (DO) was present in the facility at all times; the facility failed to provide written notification to inpatients and outpatients on admission that no MD or DO was present in the facility 24-hours a day, seven days a week; and, the facility failed to ensure signage was posted in the Emergency Department (ED) disclosing there was no MD or DO present in the facility 24-hours a day, seven days a week.

Findings include:

1) A request was made of EMP1 on May 22, 2019, for a facility policy or procedure regarding provision of a written notification to inpatients and outpatients that a medical physician (MD) or physician of osteopathy (DO) was not present in the facility at all times. No policy was provided.

Interview with EMP1 on May 22, 2019, at approximately 10:00 AM revealed the facility does not have a policy or procedure in place regarding provision of a written notification to inpatients and outpatients that a medical physician (MD) or physician of osteopathy (DO) was not present in the facility at all times.

2) Review on May 22, 2019, of the facility's Admission Packet, no review date, revealed no documentation written notification was provided to inpatients and outpatients on admission that an MD or DO was not present in the facility 24-hours a day, seven days a week.

A request was made of EMP1 on May 22, 2019, for the facility's notification to inpatients and outpatients on admission that an MD or DO was not present in the facility 24-hours a day, seven days a week. None was provided.

Interview with EMP1 on May 22, 2019, at approximately 10:00 AM revealed the facility does not have written notification to provide to inpatients and outpatients on admission that an MD or DO was not present in the facility 24-hours a day, seven days a week.

3) Observation on May 22, 2019, of the facility's ED revealed no posted signage disclosing there was an MD or DO was not present in the facility 24-hours a day, seven days a week.

Interview with EMP1 and EMP5 on May 22, 2019, at approximately 11:00 AM confirmed no signage was posted in the ED disclosing an MD or DO was not present in the facility 24-hours a day, seven days a week.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure a current and accurate inventory of expired controlled substances was maintained in the facility's pharmacy.

Findings include:

Review on May 22, 2019, of the facility's "Section 68.00 guidelines for the Destruction of Expired C-II Substances" policy, no current review date, revealed "Policy 1. The Pharmacy Department will maintain a perpetual inventory of expired controlled (C-II) Substances until such time of disposal. ..."

Observation on May 22, 2019, of the locked drawer identified by EMP6 and EMP7 as the locked expired controlled medication drawer revealed the following outdated controlled narcotic pain medications:
Fentanyl 100 mcg/hr (micrograms/hour) patch - six patches
Duragesic 75 mcg/hr patches - three patches
Methadone 10 mg (milligram) tablets - 100 tablets
Morphine Sulfate oral solution 100 mg/5 ml (milliliter) 20 mg/ml bottle open and partially used
Oxycontin 15 mg Extended Release tablets - 20 tablets
Oxycontin 20 mg Extended Release tablets - 40 tablets
Oxycontin 20 mg tablets - 81 tablets
Morphine Sulfate Extended Release 15 mg tablets - 140 tablets
Morphine 5 mg pre-filled syringes - five syringes

Interview with EMP7 on May 22, 2019, at approximately 9:35 AM confirmed these were expired controlled medications; these medications are considered C-II medications and these C-II medications are waiting for disposal through a registered third-party vendor.

Observation on May 22, 2019, of the pharmacy C-II substance destruction log revealed no documentation the above C-II medications were listed on this log.

Interview with EMP7 on May 22, 2019, at approximately 9:45 AM confirmed these controlled medications were not listed on the C-II medication log as required by facility policy.

Based on review of facility documentation, observation, the manufacturer's instruction for use and staff (EMP) interview, it was determined the facility failed to provide staff with an policy to ensure that reusable equipment was cleaned and reprocessed appropriately as evidenced by failure to date an opened bottle of [name of solution] Test Strips, failure to establish quality control procedures for [name of solution] Test Strips and failure to monitor the temperature and minimum recommended concentration (MRC) of [name of solution] (used for high-level disinfection) prior to each use.

Findings include:

Review on May 23, 2019, of facility policy "The proper cleaning, disinfection, and sterilization of endoscopes by OR personnel", last revised by the facility March 5, 2015, revealed "...a. Manual high level disinfection i. Completely immerse the scope and all removable parts in [name of solution] ii. Flush disinfection into all channels. Make sure that all channels are filled with [name of solution] and that no air pockets remain. b. Complete microbial destruction cannot occur unless all surfaces are in complete contact with [name of solution]. Visual confirmation cannot be confirmed so purge until steady flow of solution is observed (FDA,2009) i. Cover the soaking basin with a tight fitting lid and soak for 25 minutes ii. Purge all channels completely with air before removing the scope from [name of solution] iii. Rinse the scope and flush all channels with water..."

Review on May 23, 2019, of package insert (manufacturer's instructions for use) for [name of solution] Test Strips revealed "...It is recommended that the disinfectant be tested before each disinfection cycle to ensure the ortho-phthaladehyde is above the MRC...Customer Storage...Test strips are good for 6 months once opened. The date opened should be written on the test strip bottle...Quality Control...Implementing routine use of control solutions will increase user proficiency, minimize procedural errors and protect against the inadvertent use of outdated product or product that is deteriorated due to improper storage or handling. Each facility should establish its own Quality Control procedures...Warnings and Precautions...The [name of solution] sample to be tested must be between 68-81*F [20-27*C] ..."

An opened bottle of [name of solution] Test Strips with no documentation of the date opened was observed during a tour of the Endoscopy reprocessing room on May 23, 2019, at 11:00 AM. Review of the facility's monitoring log on May 23, 2019, at approximately 11:05 AM, revealed no quality testing of [name of solution] Test Strips had been completed. Further review of the monitoring log revealed monitoring of the temperature and MRC of the solution was not completed prior to each use.

Interview with EMP12 on May 23, 2019, at approximately 11:05 AM, confirmed the facility does not have a policy to date [name of solution] Test Strips upon opening, to establish quality control procedures for [name of solution] Test Strips, and to monitor the temperature and MRC of [name of solution] prior to each use.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure staff working in the dietary department had all hair restrained; the facility failed to ensure staff working in the dietary department washed their hands after touching hair; and, the facility failed to ensure dietary staff performed food temperatures on all foods on the tray line to ensure the foods were at a proper temperature for patient consumption.

Findings include:

1) Review on May 21, 2019, of the facility's "Infection Control Guidelines" policy, last revised March 2019, revealed "... 5. No hair is permitted to be exposed in long strands at the side of the face. 6. Shoulder length hair must be restrained with caps and nets. 7. Caps, hairnets to caps and hairnets must be worn at all times all hair fully covered at all times - especially during food preparations serving food, and dishroom [sic] work. ..."

Observation on May 21, 2019, at approximately 11:30 AM revealed EMP8, EMP9 and EMP10 with hair extending out from under the hair net.

Interview with EMP9 on May 21, 2019, at the time of the observations confirmed EMP8, EMP9 and EMP10's hair extended out from under their hair net.

2) Review on May 21, 2019, of the facility's "Infection Control Guidelines" policy, last revised March 2019, revealed "...11. Continual hand washing is mandatory! = meal and coffee breaks smoking, handling of soiled equipment, raw meat, personal habits, etc. ..."

Observation of EMP8 on May 21, 2019, revealed this employee, with gloved hands, taking food temperatures, stop and tuck loose hair under the hair net and return to taking food temperatures. EMP8 did not remove the gloves, perform hand washing and put on a clean pair of gloves.

Interview with EMP8 on May 21, 2019, at the time of the observation confirmed this employee, with gloved hands, took food temperatures, stop and tucked loose hair under the hair net and returned to taking food temperatures and this employee did not remove the gloves, perform hand washing and put on a clean pair of gloves.

3) Review on May 21, 2019, of the facility's "Documenting Food Temperatures" policy, last revised August 27, 2018, revealed "Policy Statement Food temperatures of food are taken to eliminate the potential for foodborne illness from improper temperature control of food. ... Procedure: Food temperatures will be taken on prepared food items served in the dietary department. Food temperatures taken will be recorded on the time/temperature food preparation log. A sanitized thermometer will be used to check the temperature in the thickest part of the food. Barnes Kasson utilizes the time without temperature control as the public health control up to a maximum of 4 hours: 1. The food shall have an initial temperature of 41*F or less when removed from cold holding temperature control. 2. The food shall have an initial temperature of 135*F or greater when removed from hot holding temperature control. 3. Food shall not be served and discarded within 4 hours from the point in time when the food is removed from temperature control. Total time between 41*F and 135*F must not exceed 4 hours."

On May 21, 2019, a random sample of dietary menus and Time / Temperature Food Preparation Logs were selected from January to April 2019.

Review on May 21, 2019, of the dinner menu for January 19, 2019, revealed the facility served cheese stuffed Weiner, yogurt, chocolate pudding, sherbet and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the dinner menu for February 1, 2019, revealed the facility served baked liver and onions, tapioca pudding, sherbet and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the lunch menu for February 7, 2019, revealed the facility served country baked chicken, yogurt, fresh fruit, cherry pie, sherbet and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the breakfast menu for February 9, 2019, revealed the facility served scrambled eggs, bacon and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the lunch menu for March 20, 2019, revealed the facility served yogurt, lemon pudding, sherbet and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the breakfast menu for March 29 and April 2, 2019, revealed the facility served oatmeal, cream of wheat, sausage patty and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the dinner menu for April 3, 2019, revealed the facility served roast pork and gravy, chef salad with turkey, ham and egg, yogurt, sherbet and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Review on May 21, 2019, of the dinner menu for April 12, 2019, revealed the facility served cubed beef steak, yogurt, sherbet and milk. There was no documentation dietary staff recorded the temperatures of these food items.

Interview with EMP9 on May 21, 2019, at approximately 2:00 PM confirmed dietary staff did not complete food temperatures on the above listed food items. EMP9 revealed dietary staff do not complete temperatures on all foods on the tray line at breakfast, lunch and dinner to ensure the foods are at a proper temperature for patient consumption.

Based on review of facility policies, credential files (CF), and staff interview (EMP) it was determined the facility failed to specify in the operating room practitioner's privileges supervision of the certified registered nurse anesthetist administering anesthesia for three of three operating room practitioner's credential files reviewed (CF5, CF9, CF15).

Findings include:

Review on May 24, 2019, of the facility, "Medical Staff of Barnes-Kasson County Hospital and Skilled Nursing Facility By-Laws Rules and Regulations," approved June 28, 2018, revealed "Preamble Recognizing that the Medical Staff is responsible for the quality of medical care in the hospital and must accept and assume this responsibility, subject to the ultimate authority of the Hospital Governing Body, and that the best interests of the patient are protected by concerted effort, the physicians practicing in Barnes-Kasson County Critical Access Hospital and Skilled Nursing Facility hereby organize themselves in conformity with the by-laws, rules and regulations hereinafter stated. ...29. The CRNA will function as a qualified anesthesia provider working under the medical direction of an Attending Physician in the department. He or she will practice within the scope and guidelines of professional training and certification, federal and state regulations, and hospital policy. ..."

Review on May 24, 2019, of CF5 revealed a request for privileges for general surgery dated May 25, 2018. The privileges did not include a request to supervise anesthesia administered by a certified registered nurse anesthetist.

Review on May 24, 2019, of CF9 revealed a request for privileges for ophthalmology dated May 17, 2018. The privileges did not include a request to supervise anesthesia administered by a certified registered nurse anesthetist.

Review on May 24, 2019, of CF15 revealed a request for privileges for orthopedics dated February 19, 2018. The privileges did not include a request to supervise anesthesia administered by a certified registered nurse anesthetist.

Interview on May 24, 2019, with EMP1 confirmed privileges for CF5, CF9, CF15 did not include a request to supervise anesthesia administered by a certified registered nurse anesthetist.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure all hospital departments, contracted services and services under arrangement were reflected in the Quality Improvement program.

Findings include:

Review on May 21, 2019, of the facility's "Performance Improvement Plan" last reviewed and revised April 1, 2019, revealed "... Scope The scope of the Performance Improvement Programs is organization wide. All departments and services of Barnes-Kasson Hospital ... are subject to involvement in the Performance Improvement Program. All departments and their staff are expected to be actively involved in that process, which may include participation on a team, collecting data, participating in data analysis, or implementing performance improvements. ..."

1) Review on May 21, 2019, of the Performance Improvement Committee reporting by department revealed the following hospital departments were not reflected in the committee reporting for Quality Improvement projects: Cardiac Rehabilitation, Physical therapy, Speech Therapy, Occupational therapy, Short Procedure Unit, Social Services, Materials Management, Environmental Services, Staff Development, infection Control, Intensive Care, Nuclear Medicine, Maintenance and Laundry.

Interview with EMP1 and EMP3 on May 22, 2019, at approximately 10:00 AM confirmed Cardiac Rehabilitation, Physical therapy, speech Therapy, Occupational therapy, Short Procedure Unit, Social Services, Materials Management, Environmental Services, Staff Development, infection Control, Intensive Care, Nuclear Medicine, Maintenance and Laundry were not reflected in the Performance Improvement Committee reporting for Quality Improvement projects.

2) Review on May 21, 2019, of the Performance Improvement Committee reporting for contracted services and services provided under arrangement revealed the following contracted services were not reflected in the committee reporting for Quality Improvement projects: clinical engineering services and linen services.

Interview with EMP1, EMP3, EMP13 and EMP14 on May 22, 2019, at approximately 10:15 AM confirmed clinical engineering services and linen services were not reflected in the Performance Improvement Committee reporting for Quality Improvement projects.

Based on review of facility documents and staff interview (EMP), it was determined the Quality Improvement department failed to review the results of the Incident Report log data regarding falls, medication errors and intravenous (IV) infiltrates and the facility failed to identify trends or patterns regarding patent falls, medication errors and IV infiltrates.

Findings include:

Review on May 21, 2019, of the facility's "Performance Improvement Plan" last reviewed and revised April 1, 2019, revealed "Introduction ... The aim is to ensure the care provided is safe, effective, patient-centered, timely, efficient and equitable. To that end, the organization as a whole will participate in systematic Performance Improvement efforts that will focus on areas that significantly impact critical clinical processes, clinical outcomes, key business results, facility core functions and the primary needs of patients ... Purpose ... This plan is for the use of all Barnes-Kasson staff to continually monitor and improve the processes they perform. The guiding principles of the plan are to identify and focus on functions that are important to the patients, residents and other customers, assess the performance with objective and relevant measures and defined data elements, involve all staff, pursue improvement continuously, and make determinations on quality and decisions on improvement strategies based on data. ...Objectives ... The objectives of this program are: To improve the quality of patient and resident care through assessment and evaluation of functions, processes and outcomes, utilizing identified measures of performance. To aggregate the results of measures of performance and to analyze the results using statistical tools and techniques to identify trends and patterns which do not meet standards, expectations, and/or desirable outcomes ...."

1) Review on May 21, 2019, of the facility provided Incident Report log for January 1 to May 21, 2019, revealed the facility had 10 falls, 12 medication errors and 14 IV infiltrates.

Interview with EMP1 and EMP3 on May 21, 2019, at approximately 1:30 PM confirmed there were had 10 falls, 12 medication errors and 14 IV infiltrates. EMP3 revealed this employee did not review the results of the Incident Report log data regarding falls, medication errors and IV infiltrates.

2) Review on May 21, 2019, of the facility's Performance Improvement Committee meeting minutes for January to May 2019, revealed no documentation the committee reviewed the results of the Incident Report log data regarding falls, medication errors and IV infiltrates.

Interview with EMP3 on May 21, 2019, at approximately 2:00 PM confirmed the Performance Improvement Committee did not reviewed the results of the Incident Report log data regarding falls, medication errors and IV infiltrates because these results were not reported to the committee.

3) A request was made of EMP3 on May 21, 2019, for the facility's trending or identified patterns regarding patent falls, medication errors and IV infiltrates. None was provided.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to complete a comprehensive initial interest survey assessing each patient's individual activity interests for eight of eight swing bed medical records reviewed (MR28, MR29, MR30, MR31, MR32, MR33, MR34 and MR35) and the facility failed to provide an ongoing activity program to meet the needs for eight of eight swing bed medical records reviewed (MR28, MR29, MR30, MR31, MR32, MR33, MR34 and MR35).

Findings include:

Review on May 23, 2019, of the facility's "Activities Program" policy, no review date, revealed "Policy: A swing bed activities interest survey will be performed on each client admitted under the status of swing bed. Procedure: The occupational therapist will perform the initial Interest Survey with each swing bed patient. The survey will then be available to activities personnel. The Interest Survey will be completed on the [name of electronic medical vendor] medical record system in the Electronic Forms tab and then selecting the OT [occupational] activities file. The information then to be provided on the survey when possible would be: 1. The patient's name and date of assessment. 2. The patient's mental status, ambulation status, communication, hearing and visual ability. 3. Resident's interests. The activities personnel will then derive activities from the survey for each patient. The activities personnel will record the activities attended on the log sheet and document a progress note as needed to reflect patient ' s participation or not. ..."

Review on May 23, 2019,of the Occupational therapy Swing Bed Activities Interest Survey revealed the following activities: Crafts - needlework, basis wood working, painting/drawing, knitting/crocheting, gardening, Games - cards, bingo, checkers, trivia/puzzles, other, Music - playing an instrument, group singing, radio/tapes, other, Entertainment - visitation, men/women's groups, movies, television, reminiscing Religious Activities - Bible Study, Religious Materials, notify pastor, other, Literary - library books, talking books, writing liters, newspapers / magazines / stories.

1) Review of MR28 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on May 14, 2019. Occupational Therapy assessed MR28's interests as visitation, television and newspaper.

Review of MR29 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on January 30, 2019, and discharged on February 8, 2019. Occupational Therapy assessed MR29's interests as visitation, television and newspaper.

Review of MR30 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on January 30, 2019. Occupational Therapy assessed MR30's interests as visitation, television and newspaper.

Review of MR31 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on May 14, 2019. Occupational Therapy assessed MR31's interests as visitation, television and newspaper.

Review of MR32 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on February 26, 2019, and discharged on March 14, 2019. Occupational Therapy assessed MR32's interests as visitation, television and newspaper.

Review of MR33 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on April 8, 2019, and discharged on April 22, 2019. Occupational Therapy assessed MR33's interests as visitation, television and newspaper.

Review of MR34 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on May 10, 2019. Occupational Therapy assessed MR34's interests as visitation, television and newspaper.

Review of MR35 on May 23, 2019, revealed the facility admitted this patient to the Swing Bed Program on April 25, 2019. Occupational Therapy assessed MR35's interests as visitation, television and newspaper.

Interview with EMP17 on May 24, 2019, at approximately 11:00 AM confirmed Occupational Therapy assessed MR28, MR29, MR30, MR31, MR32, MR33, MR34 and MR35's interests as visitation, television and newspaper. EMP17 revealed these patients ' interests were not assessed for all activities listed on the Occupational therapy Swing Bed Activities Interest Survey.

2) Review on May 23, 2019, of EMP16's work schedule revealed this employee works in the Activity Department on Tuesday, Wednesday and Thursday of each week.

Interview with EMP16 on May 23, 2019, confirmed this employee works in the Activity Department on Tuesday, Wednesday and Thursday of each week.

Review on May 23, 2019, of the facility's April and May 2019 Activity calendars revealed the following:
Sundays - Religious day
Mondays - Movie or Music day
Tuesdays - Craft or Trivia day
Wednesdays - Music, Trivia, or Art / Craft day
Thursdays - Art / Puzzle, Literature or Spa day
Fridays - Patient choice
Saturdays - Patient choice

Review on May 23, 2019, of MR28, MR29, MR30, MR31, MR32, MR33, MR34 and MR35 revealed these patients were admitted to the facility's Swing Bed program.

Review on May 23, 2019, of MR28, MR29, MR30, MR31, MR32, MR33, MR34 and MR35's Swing Bed Activity Log revealed no documentation activities were offered to these patients on Sunday, Monday, Friday and Saturday or that these patients refused to participate in activities while in the swing bed program.

Interview with EMP16 on May 23, 2019, confirmed MR28, MR29, MR30, MR31, MR32, MR33, MR34 and MR35 were admitted to the facility's Swing Bed Program; these patient's Swing Bed Activity Logs revealed no documentation activities were offered to these patients on Sunday, Monday, Friday and Saturday or that these patients refused to participate in activities while in the Swing Bed program.