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Based on observations, policy review, and staff interviews, the facility failed to ensure that patient care supplies and equipment were maintained to ensure an acceptable level of safety and quality for all patients seen in the hospital. Findings include:


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1. On 8/15/11 at 2:00 p.m., the following outdated supplies were found in the Emergency Room and were available for patient use:
-Two BD (Brand name) safety glide Insulin syringes U-100, 1/2 mL, 29 Gauge, 1/2 inch, with a manufacturer's expiration date of 6/2010;
-One BD safety glide TB syringe, 1 mL, 27 Gauge, 1/2 inch, with a manufacturer's expiration date of 8/2010;
-Two Sterile Irrigation trays with a manufacturer's expiration date of 5/2011;
-One Yankauer suction set up with a manufacturer's expiration date of 7/2010;
-One Irrigation syringe with a use by date of 9/2010;
-One Bardex I.C. (Brand name) Anti-Infective Foley catheter with a use by date of 12/2010;
-Four Endotracheal tubes, 3.0 mm, uncuffed with a manufacturer's expiration date of 3/2011;
-Two Tracheal tubes, 6.0 mm, profile soft-seal cuff, clear, with a manufacturer's expiration date of 1/2009;
-Two Bard Infant Cath kits with a use by date of 11/2010; and
-Nuprep Skin Gel with a manufacturer's expiration date of 3/1/2010.

In the eye kit the following concerns were identified:
-A foreign body remover with a manufacturer's expiration date of 8/7/2009;
-Three expired sterile cotton applicators. One cotton applicator had a manufacturer's expiration date of 3/1/2010, one had a manufacturer's expiration date of 6/1/2007, and one had a manufacturer's expiration date of 12/1/2008; and
-Two tongue depressors that had a manufacturer's expiration date of 9/1/2010.

The following patient equipment which was available for use, lacked verification of required maintenance in the ER:
-A patient monitoring machine;
-A pulse oximetry machine;
-Three electric beds;
-Two examination lights; and an
-Ultra-violet examination light for the eyes.

2. On 8/15/11 at 3:00 p.m., the following outdated supplies were found in the OR and were available for patient use:
-One Tegaderm transparent dressing, 4 inch by 4 3/4 inch with a manufacturer's expiration date of 4/2011;
-Three Con Med Hand controlled with Blade Electrode, button switch, Safety Holister and 10 foot cable with a manufacturer's expiration date of 7/2010;
-Two Cricothyrotomy Catheter Sets with a manufacturer's expiration date of 4/1/09;
-Twelve Tongue depressors with a manufacturer's expiration date of 8/1/2010;
-Two 22 gauge IV Catheters with a manufacturer's expiration date of 11/1/2010;
-A Tracheal Tube with a manufacturer's expiration date of 10/1/99; and
-The examination light above the OR table lacked verification of required maintenance.

3. On 8/15/11 at 3:35 p.m., the following outdated supplies were found in the ER observation room and were available for patient use:
-One BD Vacutainer K2 EDTA 5.4 mg lab tube with a manufacturer's expiration date of 6/2010; and
-One BD Vacutainer serum lab tube with a manufacturer's expiration date of 8/2010.

The following patient equipment lacked maintenance verification in the ER observation room:
-An examination light lacked verification of required maintenance; and
-The ultrasound machine lacked verification of required maintenance.

4. On 8/15/11 at 3:40 p.m., the following outdated supplies were found in the procedure room located next to the ER observation room and were available for patient use:
-One box PDI (Brand name) Alcohol prep pads, size: large, 30 count, with a manufacturer's expiration date of 11/2008;
-One Hemoccult card, with a manufacturer's expiration date of 10/2006;
-Six Aventis alcohol swabs, with a manufacturer's expiration date of 2/2009;
-Four ZLB (Brand name) Behring alcohol swabs, with a manufacturer's expiration date of 3/2010;
-Two Medi-Choice, sterile cotton tipped applicators, with a manufacturer's expiration date of 3/2010;
-One BD Spinal needle, 25 Gauge, 3 1/2 inch, with a manufacturer's expiration date of 9/2010;
-Three jars of Formalin solution, 10%, Neutral Buffered, pH 7.0, with a manufacturer's expiration date of 2/2011;
-Four Biogel powder-free, surgical gloves with Biogel coating, size: 6 1/2, with a manufacturer's expiration date of 1/2007;
-Three Biogel gloves, size: 8, with a manufacturer's expiration date of 5/2006;
-One Nuprep Skin Gel tube, 4 ounces, with a manufacturer's expiration date of 10/2007;
-A Suction Catheter Mini Tray was open, not sealed, and lacked an expiration date;
-30 Povidone-Iodine Prep Pads with a manufacturer's expiration date of 4/1/2004;
-A Laryngeal Mask with a manufacturer's expiration date of 1/2009;
-Eight Four Way Stop Cocks with a manufacturer's expiration date of 11/2009;
-Twenty Olympus Biopsy valves, single use, with a manufacturer's expiration date of 8/2000;
-A radial jaw 4 large capacity with needle, with a manufacturer's expiration date of 8/2009;
-A Resolution Clip 155 cm with a manufacturer's expiration date of 5/2009;
-The tread mill stress test machine lacked verification of required maintenance; and
-Three examination lights lacked verification of required maintenance.

On 8/15/11 at 3: 30 p.m., staff member C, the manager of Bio-Medical, stated that if there were no stickers on patient equipment then maintenance checks were not completed. The surveyor asked for a log of maintenance on patient equipment and staff member C stated she had no way of monitoring or verifying if patient equipment was maintained timely and properly.

5. On 8/16/11 at 9:45 a.m., the following outdated supplies were found in the medication room and were available for patient use:
-Four Jelco-W Intravenous catheters, 24 Gauge, 5/8 inch, with a manufacturer's expiration date of 3/2011;
-One BD 60 mL syringe with Luer-lok tip, with a manufacturer's expiration date of 7/2010;
-One Bard Irrigation Syringe, 50 cc bulb type, with a manufacturer's expiration date of 8/2009; and
-One BD Vacutainer Lithium Heparin, 68 USP unit, lab tube, with a manufacturer's expiration date of 7/2009.

6. On 8/16/11 at 9:00 a.m., a tour of the therapy room was completed. The following concerns were identified:
-Hibiclens chlorhexidine gluconate Antiseptic with a manufacturer's expiration date of 8/2000;
-A bottle of Fluocinonide 0.05% with a manufacturer's expiration date of 2/1/11;
-A bottle of Hydrocortisone with a manufacturer's expiration date of 12/11/10; and
-A bottle of Dexamethasone Liquid with a manufacturer's expiration date of 6/7/08.

On 8/16/11 at 2:00 p.m., the policy and procedure titled Medical Equipment Preventive Maintenance Program was reviewed. Documented on the policy under the description of Procedure was the following:
" ...in collaboration with the director of Nursing, and in conjunction with personnel from appropriate ancillary departments, shall ensure that inspection and preventive maintenance is performed within manufacturer's recommended guidelines;....and
-Documented under Inspection, Maintenance and Removal from Service;
-....a permanent Medical equipment Preventive maintenance log. The log shall include the inspection schedule for each piece of equipment; indicate the date and the time of each inspection; inspection results; maintenance performed if applicable;...and the signature of the person performing the inspection; and
- it is recognized that certain maintenance and testing may be performed either by hospital staff members or outside contractors or services."

7. On 8/17/11 at 1:30 p.m., the following outdated supplies were found in Central Supply and were available for patient use:
-Seven KCI, VAC (Brand name), Y-connectors, with a manufacturer's expiration date of 4/2011;
-One box Hypodermic needle-pro device with needle, with a use by date of 12/2008;
-Two Portex Lumbar Puncture kits, Infant, 22 Gauge Quincke, with a use by date of 9/2007;
-Three 20 french Magna Port peg tubes, with a use by date of 11/2010; and
-Three Adult Lumbar Puncture kits, with a use by date of 11/2008.

In an interview with staff member C, the Central Supply Manager, on 8/17/11 at 2:00 p.m., she stated that she was aware of the outdated supplies stocked in the Central Supply room but stated those supplies were no longer used and that she hadn't removed them from the shelves yet.

Based on record review and staff interview, the CAH failed to ensure that staff responsibilities were met. The Condition of Participation of Staffing and Staff Responsibilities was not met as evidenced by the following findings:

1. Failure to have patient health records reviewed and signed by a medical doctor. Refer to C259 and C260.

2. Failure to have mid-level practitioners participate with MD/DO in review of patient records. Refer to C264.

3. Failure to have the medical doctor notified when a patient was admitted to the hospital by a mid-level practitioner. Refer to C268.

Based on record review and staff interview, the Medical Doctor/Doctor of Osteopathy (MD/DO) failed to review patient records, medical orders, and medical care services for 10 (#s 1, 2, 3, 4, 5, 8, 9, 12, 14, and 16) of 24 sampled medical records. Findings include:

1. On 8/16/11 at 2:00 p.m., the clinical record for Patient #1 was reviewed. Patient #1 was admitted to the hospital on 12/13/10, with a diagnosis of congestive heart failure and was discharged on 12/17/10. The clinical record lacked documentation of an MD/DO review of orders and care provided.

2. On 8/17/11 at 8:00 a.m., the clinical record for Patient #2 was reviewed. Patient #2 was admitted to the facility on 10/13/10, with diagnoses of cellulitis, hypertension, A-Fib and DM type II. The patient was discharged on 10/17/10. The clinical record lacked documentation of an MD/DO review of orders and care provided.

3. On 8/17/11 at 8:00 a.m., the clinical record for Patient #3 was reviewed. Patient #3 was admitted to the facility on 1/31/11 with diagnoses of CVA, CAD, DJD, and dementia. Patient #3 died on 2/17/11. The clinical record lacked documentation of an MD/DO review of orders and care provided.

4. On 8/16/11 at 3:00 p.m., the clinical record for Patient #4 was reviewed. Patient #4 was admitted to the facility on 4/7/11 with a diagnosis of gallbladder w/o mention of cholecystitis and was discharged on 4/11/11. The clinical record lacked documentation of an MD/DO review of orders and care provided.

5. On 8/16/11 at 3:00 p.m., the clinical record for Patient #5 was reviewed. Patient #5 was admitted to the facility on 7/29/11 with diagnoses of lung cancer and COPD. Patient #5 was discharged on 7/31/11. The clinical record lacked documentation of an MD/DO review of orders and care provided.

6. On 8/17/11 at 8:00 a.m., the clinical record for Patient #9 was reviewed. Patient #9 was admitted to the facility on 7/16/11 with a diagnosis of cancer and was discharged on 7/18/11. The clinical record lacked documentation of an MD/DO review of orders and care provided.

7. On 8/17/11 at 8:30 a.m., the clinical record for Patient #12 was reviewed. Patient #12 was admitted to the facility on 12/2/10 with a diagnosis of aspiration pneumonia and died on 12/6/10. The clinical record lacked documentation of an MD/DO review of orders and care provided.

8. On 8/16/11 at 2:30 p.m., the clinical record for Patient #14 was reviewed. Patient #14 was treated and discharged from the ER on 5/24/11 for confusion. The clinical record lacked documentation of an MD/DO review of orders and care provided.

9. On 8/16/11 at 2:30 p.m., the clinical record for Patient #16 was reviewed. Patient #16 was treated and discharged from the ER on 7/19/11 for SOB and anxiety. The clinical record lacked documentation of an MD/DO review of orders and care provided.


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10. On 8/17/11 at 8:30 a.m., the clinical record for Patient #8 was reviewed. Patient #8 was admitted to the ER on 3/10/11 with a diagnosis of stroke symptoms with subsequent admission to the CAH. The clinical record lacked documentation of an MD/DO review of the Emergency Room report and the History and Physical.

On 8/17/11 at 1:45 p.m., during an interview, staff member A stated that the medical doctors have not reviewed patient medical records.

Based on record review and staff interview, the Medical Doctor/Doctor of Osteopathy failed to sign the patient records cared for by mid-level practitioners for 10 (#s 1, 2, 3, 4, 5, 8, 9, 12, 14, and 16) of 24 sampled medical records. Findings include:

1. On 8/16/11 at 2:00 p.m., the clinical record for Patient #1 was reviewed. Patient #1 was admitted to the hospital on 12/13/10 by a PA, with a diagnosis of congestive heart failure and was discharged on 12/17/10. The clinical record lacked documentation of an MD/DO review and signature.

2. On 8/17/11 at 8:00 a.m., the clinical record for Patient #2 was reviewed. Patient #2 was admitted to the facility on 10/13/10 by a PA, with diagnoses of cellulitis, hypertension, A-fib and DM type II. The patient was discharged on 10/17/10 and the clinical record lacked documentation of an MD/DO review and signature.

3. On 8/17/11 at 8:00 a.m., the clinical record for Patient #3 was reviewed. Patient #3 was admitted to the facility on 1/31/11 by a PA, with diagnoses of CVA, CAD, DJD, and dementia. Patient #3 died on 2/17/11. The clinical record lacked documentation of an MD/DO review and signature.

4. On 8/16/11 at 3:00 p.m., the clinical record for Patient #4 was reviewed. Patient #4 was admitted to the facility on 4/7/11 by a PA, with a diagnosis of gallbladder w/o mention of cholecystitis and was discharged on 4/11/11. The clinical record lacked documentation of an MD/DO review and signature.

5. On 8/16/11 at 3:00 p.m., the clinical record for Patient #5 was reviewed. Patient #5 was admitted to the facility on 7/29/11 by a PA, with diagnoses of lung cancer and COPD. Patient #5 was discharged on 7/31/11. The clinical record lacked documentation of an MD/DO review and signature.

6. On 8/17/11 at 8:00 a.m., the clinical record for Patient #9 was reviewed. Patient #9 was admitted to the facility on 7/16/11 by a PA, with a diagnosis of cancer and was discharged on 7/18/11. The clinical record lacked documentation of an MD/DO review and signature.

7. On 8/17/11 at 8:30 a.m., the clinical record for Patient #12 was reviewed. Patient #12 was admitted to the facility on 12/2/10 by a PA, with a diagnosis of aspiration pneumonia and died on 12/6/10. The clinical record lacked documentation of an MD/DO review and signature.

8. On 8/16/11 at 2:30 p.m., the clinical record for Patient #14 was reviewed. Patient #14 was treated in the ER by a PA for confusion and was discharged on 5/24/11 by a PA. The clinical record lacked documentation of an MD/DO review and signature.

9. On 8/16/11 at 2:30 p.m., the clinical record for Patient #16 was reviewed. Patient #16 was treated by a PA and was discharged from the ER on 7/19/11 by a PA for SOB and anxiety. The clinical record lacked documentation of an MD/DO review and signature.


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10. On 8/17/11 at 8:30 a.m., the medical chart for Patient #8 was reviewed. Patient #8 was admitted to the ER on 3/10/11 by a PA, with a diagnosis of stroke symptoms with subsequent admission to the CAH. The medical record lacked documentation of an MD/DO review of the Emergency Room report and the History and Physical.

On 8/17/11 at 1:45 p.m., during an interview with staff member A, she stated that the medical doctors have not reviewed or signed patient medical records who were cared for by the mid-level practitioners.

Based on record review and staff interview the mid-levels failed to meet with the Medical Doctor/Doctor of Osteopathy to review the patient health records for 9 (#s 1, 2, 3, 4, 5, 9, 12, 14, and 16) of 24 sampled medical records. Findings include:

The policy and procedure titled Physician Assistant, Nurse Practitioner, & Clinical Nurse Specialist Responsibilities documented that a physician assistant, nurse practitioner or clinical nurse specialist were expected to "Participate with a doctor of medicine or osteopathy in periodic review of the patients' health records."

On 8/17/11 at 1:45 p.m., during an interview, staff member A stated that a review of the medical records cared for by mid-level practitioners had not been completed with a medical doctor.

See tags C259, C260, and C268.

Based on record reviews and staff interview the mid-level practitioners failed to notify the Medical Doctor/Doctor of Osteopathy when a patient was admitted to the hospital for 7 (#s 1, 2, 3, 4, 5, 9, and 12) of 24 sampled medical records. Findings include:

1. On 8/16/11 at 2:00 p.m., the clinical record for Patient #1 was reviewed. Patient #1 was admitted to the hospital on 12/13/10 by a PA, with a diagnosis of congestive heart failure and was discharged on 12/17/10. The clinical record lacked documentation that the MD/DO was notified of the admission.

2. On 8/17/11 at 8:00 a.m., the clinical record for Patient #2 was reviewed. Patient #2 was admitted to the facility on 10/13/10 by a PA, with diagnoses of cellulitis, hypertension, A-Fib and DM type II. The patient was discharged on 10/17/10. The clinical record lacked documentation that the MD/DO was notified of the admission.

3. On 8/17/11 at 8:00 a.m., the clinical record for Patient #3 was reviewed. Patient #3 was admitted to the facility on 1/31/11 by a PA, with diagnoses of CVA, CAD, DJD, and dementia. Patient #3 died on 2/17/11. The clinical record lacked documentation that the MD/DO was notified of the admission.

4. On 8/16/11 at 3:00 p.m., the clinical record for Patient #4 was reviewed. Patient #4 was admitted to the facility on 4/7/11 by a PA, with a diagnosis of gallbladder w/o mention of cholecystitis and was discharged on 4/11/11. The clinical record lacked documentation that the MD/DO was notified of the admission.

5. On 8/16/11 at 3:00 p.m., the clinical record for Patient #5 was reviewed. Patient #5 was admitted to the facility on 7/29/11 by a PA, with diagnoses of lung cancer and COPD. Patient #5 was discharged on 7/31/11. The clinical record lacked documentation that the MD/DO was notified of the admission.

6. On 8/17/11 at 8:00 a.m., the clinical record for Patient #9 was reviewed. Patient #9 was admitted to the facility on 7/16/11 by a PA, with a diagnosis of cancer and was discharged on 7/18/11. The clinical record lacked documentation that the MD/DO was notified of the admission.

7. On 8/17/11 at 8:30 a.m., the clinical record for Patient #12 was reviewed. Patient #12 was admitted to the facility on 12/2/10 by a PA, with a diagnosis of aspiration pneumonia and died on 12/6/10. The clinical record lacked documentation that the MD/DO was notified of the admission.

On 8/17/11 at 1:45 p.m., during an interview, staff member A stated that the medical doctors have not reviewed any patient medical records. Staff member A stated that the hospital "expects the medical doctors to monitor a patient that was admitted to the hospital."

Based on observations, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs were not available for patient use. Findings include:

1. On 8/15/11 at 12:30 p.m., the following concern was identified in the adult crash cart in the Emergency Room:
-One tube of Nitro-Bid nitroglycerin ointment USP, 2%, 30 grams with a manufacturer's expiration date of 2/2011.

2. On 8/15/11 at 3:00 p.m., the following concern was identified in the Operating room:
-One bottle of Betadine solution, topical antiseptic bactericide, 16 ounces, with a manufacturer's expiration date of 12/2008.

3. On 8/16/11 at 9:45 a.m., the following concern was identified in the medication room:
-Four bags of 5% Dextrose and 0.45% Sodium Chloride Injection USP, 1000 mL, with a manufacturer's expiration date of 5/2011.

Based on record review, and staff interview the facility failed to ensure that all entries in the medical record were authenticated by the physician and/or mid-level practitioners, which included signature, date, and time of the entry, for 16 (#s 1, 2, 3, 4, 5, 6, 7, 8, 11, 13, 14, 15, 16, 19, 20, and 21) of 24 medical charts reviewed. Findings include:

1. Patient #1 was admitted to the facility on 12/13/10. The following entries were not authenticated:
-The Interdisciplinary Patient Discharge Planning record was not signed, timed or dated; and
-The Conditions of Admission form lacked a time of signature.

2. Patient #3 was admitted to the facility on 11/1/10. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature;
-The Physician's Progress Notes lacked a time of documentation on 12/20/10, and 11/28/10.

3. Patient #4 was admitted to the facility on 4/7/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature; and
-The ER Physician Record lacked a date and time of signature.

4. Patient #5 was admitted to the facility on 7/29/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature;
-The ER Physician Record lacked a signature, date, and time;
-The ER Provider Orders lacked a signature, date, and time; and
-The Instructions For Post Hospital Care lacked a signature, date, and time.

5. Patient #6 was admitted to the facility on 6/3/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature;
-The ER Physician Record lacked a date and time of signature;
-The Physician Progress Notes on 6/6/11 and 6/7/11 lacked a time and signature; and
-The Discharge Planning Record lacked a time of signature.

6. Patient #11 was cared for in the ER on 3/24/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature;
-The ER Provider Orders lacked a date and time of signature; and
-The Authorization For Release of Protected Health Information form lacked a signature, date, and time.

7. Patient #13 was cared for in the ER on 7/25/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature;
-The ER Physician Record lacked a date and time of signature;
-The Provider Orders for ED Chest Pain lacked a date and time of signature;
-The Initial Observation Orders lacked a date and time of signature;
-The Discharge Planning Record lacked a time of signature; and
-The Venous Thromboembolism Prophylaxis Orders lacked a time of signature.

8. Patient #14 was cared for in the ER on 5/24/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature;
-The ER Physician Record lacked a date and time of signature;
-The Head Injuries Care Plan lacked a time of implementation; and
-The Admission Assessment/Discharge Planning/Nutrition Screening form lacked a signature, time, and date.

9. Patient #15 was cared for in the ER on 7/28/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature; and
-The ER Physician Record lacked a date and time of signature.

10. Patient #16 was cared for in the ER on 7/19/11. The following entries were not authenticated:
-The Conditions of Admission form lacked a time of signature; and
-The ER Physician Record lacked a date and time of signature.

11. Resident #19 was admitted to a swing bed on 4/15/11. The following entries were not authenticated:
-The H&P was not available in the chart;
-The Physician Orders for July 2011 lacked a signature, time, and date;
-The Provider's Progress Note on 8/2/11 lacked a time of signature;
-The Physician's Progress Note on 6/6/11 lacked a time of signature;
-The Nursing Assessment lacked a date, time, and signature;
-The Informed Consent/Use of Side rails was not completed, and lacked a time, date, and signature;
-The side rail assessment lacked a signature, date, and time; and
-The Admission Assessment/Discharge Planning/Nutrition Screening Form lacked a signature and time.

12. Resident #20 was admitted to a swing bed on 5/10/11. The following entries were not authenticated:
-The Physician's Progress Note lacked a date and time of signature;
-The Physician Orders for May 2011 and July 2011 lacked a signature, time, and date;
-The Physician Order Sheet Admit Status 5/19/11 and 8/10/11 entries lacked a time of signature;
-The Physician's Progress Notes dated 5/19/11 lacked a signature;
-The Admission Assessment/Discharge Planning/Nutrition Screening Form lacked a signature and time;
-The side rail assessment lacked a signature, date, and time;
-The Risk for Entrapment Assessment form lacked a signature, date, and time;
-The Side Rail Assessment form was not completed, and lacked a signature, time, and date;
-The Social Service Admission Sheet lacked a signature and time; and
-The Admission/Financial Agreement form lacked a signature.

On 8/16/11 at 1:45 p.m., staff member A stated that all entries in the medical records should be dated, timed and signed.


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13. Patient #2 was admitted to the facility on 10/13/10. The following entries were not authenticated:
-The Venous Thromboembolism (VTE) Prophylaxis Order lacked a time;
-Admission Nursing Assessment lacked a time;
-Discharge orders lacked a time; and
-Instructions for Post Hospital Care lacked a time.

14. Patient #7 was admitted to the facility on 6/30/11. The following entries were not authenticated:
-The Emergency Department Provider Orders lacked a date and time of when they were signed;
-a Physician Progress Note dated 7/3/11 lacked a time; and
-Instructions for Post Hospital Care lacked a time for the nurse and a date and time for the patient.

15. Resident #8 was admitted to the facility on 9/1/09. The following entries were not authenticated:
-A Physician's order written on 6/16/11 at 8:30 a.m., lacked a signature.

16. Resident #21 was admitted to the facility on 4/9/11. The following entries were not authenticated:
-On 7/12/11 two Consents to Blood Transfusion were signed by the patient, both lacked a time that they were signed by the patient; and
-an Inter-facility Transfer Authorization form lacked a time the receiving physician accepted the transfer and lacked a time from the transferring physician at the bottom of the form.

Based on observations and staff interviews, the facility failed to safeguard medical charts against unauthorized use. Findings include:

On 8/15/11 at 10:30 a.m., the door to the therapy room was observed to be open. There were multiple visitors walking past the open door which exposed the therapy room. The door was observed to be open the entire day.

On 8/16/11 at 8:00 a.m., the door to the therapy room was still open and again there were visitors walking past the open door.

On 8/16/11 at 9:00 a.m., the therapy room was observed. There were two sets of bi-fold doors which were not locked. Behind the bi-fold doors were x-rays which contained patient information. The x-rays were not protected from disaster, loss, or unauthorized use.

The reception desk in the therapy department was unattended and contained 11 patient medical charts sitting on top of the desk. There were two unlocked file cabinets which contained patient medical charts. One cabinet was in the waiting room and the other cabinet was in the hallway across from the bathroom. The file cabinet across from the bathroom had a stack of patient medical charts sitting on top of the cabinet. The patients' active and non active medical charts were not protected from disaster, loss, or unauthorized use in the therapy department.

At this time, staff member A was asked when the therapy room was used and they said that it was only used on Mondays, Wednesdays, and Fridays or by appointment. The surveyor asked if the therapy room door was locked when it was not in use and staff member A stated no.

Based on document review and staff interviews, the facility failed to conduct or arrange for the required annual total program evaluation. Findings include:

The Conditions of Participation for Program Evaluation were not met in that;

The facility failed to complete or arrange for the required annual program evaluation to be completed for the years 2008, 2009, and 2010. Refer to C-0331.

Based on document review and staff interviews, the facility failed to carry out, or arrange for, an annual evaluation of the total CAH program. Findings include:

During the entrance conference with staff member F, the CFO, on 8/15/11 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility's most recent annual CAH program evaluation. The survey team reminded the CFO and DON of the request for the documentation of the annual program evaluation again at the end of day meeting on 8/16/11 that began at 3:30 p.m. The surveyor repeated the request to staff member F on 8/17/11 at approximately 8:30 a.m. The facility staff did not provide a copy of, or evidence of, the total program evaluation for the years 2008, 2009, and 2010 to the survey team at the time of the exit conference at 11:00 a.m. on 8/18/11.

On 8/16/11 at 3:00 p.m., the policy and procedure titled Annual Program Evaluation documented under the section titled PURPOSE was "To determine whether the utilization of services was appropriate. To determine whether established polices were followed. To determine whether any changes are needed in the programs or policies...; documented under the Procedure was "The program will be evaluated annually;
- The CEO and or the CFO will be available for interview and provide the annual review committee with financial and statistical reports...; and
- The total program review findings and recommendations must be documented in a written report and submitted to the CEO. The CEO and the staff must consider the findings of the evaluation and take corrective action if necessary."

On 8/17/11 at 3:40 p.m., staff member F confirmed that no total program evaluation had been completed.

Based on observations, record reviews, and staff interviews, the facility failed to assess for the use of restraints, obtain informed consents, obtain complete physician orders for the use of restraints, care plan the use of the restraints, and re-assess the continued use of restraints for 2 (#s 19, and 20) of 5 reviewed swing bed medical records. Findings include:

The facility restraint policy documented the following under Guidelines:
- "The application or use of a restraint, safety device or postural support is prohibited except to treat a resident/resident's medical symptoms and may not be imposed for the purpose of coercion, retaliation, discipline, or staff convenience;
- The use of a restraint was to be as a last resort and may only be used if the facility determines and documents that less restrictive measures have failed; and
-Restraints may not be used to permit staff to administer treatment to which the patient/resident has not consented."
The section on Procedure for Restraint Use documented the following:
-"RN assess and documents the need of the restraint;
-RN ensures that a less restrictive method has been attempted;
-The resident's care plan was to be modified;
-The family and resident were to be educated on the risk vs. benefits of a restraint prior to usage; and
-The medical provider was to write an order as soon as possible not to exceed 24 hours."

During the initial tour on 8/16/11 at 11:00 a.m., with the the Swing Bed Coordinator, staff member A, 1/2 bed rails were observed in the up position while resident #19 was asleep.

1. Resident #19 was admitted to swing bed status on 4/15/11 with diagnoses including renal failure, CHF, UTI and COPD. The medical record lacked the following required documentation:
- a consent for the use of the restraint;
- less restrictive intervention prior to the use of a restraint;
- an assessment prior to the use of a restraint;
- a complete physician's order that included a clinical medical symptom;
- re-assessing the use of the restraint after 24 hours; and
- obtaining new physician orders after 24 hours.
- The care plan was not updated to reflect the use of restraints.

On 8/16/11 at 12:00 p.m., the surveyor interviewed a CNA, staff member M, regarding the use of bed rails. Staff member M stated that bed rails were used to keep residents in their bed especially at night. The surveyor asked if patient #19 could get out of bed independently and was told no. At this time, the surveyor observed patient #19 in bed with 1/2 side rails up on both sides of the bed and he was sleeping.

On 8/16/11 at 1:30 p.m., staff member A, was interviewed and stated bed rails were used for some residents. All the required documentation should be in the medical record prior to using restraints or bed rails.

On 8/16/11 at 1:30 p.m., the charge nurse on the swing bed unit stated that patient #19 has had bed rails since he had been admitted on 4/15/11.

2. Resident #20 was admitted to a swing bed on 5/10/11 with diagnoses including dementia, hypothyroidism, osteoarthritis and macular degeneration. The medical record lacked the following required documentation:
- a consent for the use of the restraint;
- a less restrictive intervention prior to the use of a restraint;
- an assessment prior to the use of a restraint;
- a complete physician's order, including a clinical medical symptom;
- re-assessing the use of the restraint after 24 hours;
- obtaining new physician orders after 24 hours; and
- the care plan did not reflect the use of the restraints.

Staff member M was interviewed at 12:00 p.m., and stated that patient #20 had a history of behaviors and using bed rails kept her in bed at night. At this time patient #20's bed was observed by the surveyor. The bed was alarmed and and had full bed rails.

Based on record review, policy review, and staff interview, the facility failed to develop a comprehensive care plan for 2 (#s 19 and 20) of 5 sampled swing bed patients. Findings include:

On 8/16/11 at 2:30 p.m., the policy and procedure titled Quality of Care for swing bed was reviewed. The following was documented under the section PURPOSE:
- "Each resident will receive and be provided with care and services to attain or maintain the highest practical physical, mental/and or psychosocial well being in accordance with the comprehensive assessment and plan of care.
POLICY:
- Upon Admission the process for developing a resident care plan will begin;
-These will be reviewed bi-annually and changes made as needed; and
-Changes will be made more often if resident condition changes, improves or deteriorates..."

The Policy and Procedure titled Nursing Assessments/Care Plan documented that "Comprehensive Care Plan: Nursing care planning starts upon admission....A nursing care plan is based on assessing the patient/resident's nursing needs and developing appropriate nursing intervention in response to those needs...the nursing care plan is part of the patient/resident's medical record and must comply with the requirements for patient/resident records."

1. Resident #19 was admitted to a swing bed on 4/15/11 with diagnoses including renal failure, COPD, CHF and UTI. Review of the active swing bed chart lacked a care plan.

2. Resident #20 was admitted to a swing bed on 5/10/11 with diagnoses of dementia and hypothyroidism. Review of the active swing bed chart lacked documentation of a care plan.

On 8/16/11 at 1:45 p.m., staff member A stated that all residents in a swing bed should have a care plan. The care plan coordinator was responsible for completing and updating the care plans.

On 8/16/11 at 2:00 p.m., staff member E, the care plan coordinator, was interviewed. Staff member E stated that she had not developed care plans for resident #19 and #20 because she thought the Care Area Assessments(CAAs) could be used as a care plan.

Based on record review, policy review, and staff interview, the facility failed to develop a comprehensive care plan timely for 2 (#s 19 and 20) of 5 sampled swing bed patients. Findings include:

1. Resident #19 was admitted to a swing bed on 4/15/11 with diagnoses including renal failure, COPD, CHF, and UTI. Review of the active swing bed chart lacked a care plan.

2. Resident #20 was admitted to a swing bed on 5/10/11 with diagnoses of dementia and hypothyroidism. Review of the active swing bed chart lacked documentation of a care plan.

On 8/16/11 at 1:45 p.m., staff member A stated that all residents in a swing bed should have a care plan.

On 8/16/11 at 2:00 p.m., staff member E, the care plan coordinator was interviewed. Staff member E stated that she had not developed care plans for resident #19 and #20.