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Based on record review and interview, the facility failed to establish a process that correctly distinguished between complaints and grievances for two of five patient grievances reviewed, and the facility failed to send written grievance responses as required. The facility census was 20.

1. Record review of the facility's document titled, "Patient Grievance Process," provided to patients upon admission showed the following:
- The patient has the right to file a grievance related to the quality of care, premature discharge, and billing at any time during his/her hospital stay and after discharge.
- All grievances receive immediate priority and must be investigated with efforts made toward resolution within 7 days.
- Follow up on grievances with the patient will be by written notification of the grievance process and determination within 7 days of the grievance submission.
- If the grievance cannot be resolved within 7 days due to further investigation being required, or evaluation of a corrective action, the patient shall be notified in writing of the expected date of grievance resolution.

2. Review of complaint/grievance investigations and responses on 03/17/11 at 12:00 Noon, showed the following:
- A written complaint was received 12/13/10 concerning care in the Emergency Department (ED) on 12/12/10. There is a notation that Staff P, ED Director, contacted the patient and stated that an investigation would be conducted, but there was no evidence of the investigation or any outcome. There was no evidence that a letter was sent to the patient or any other means of communication with the patient regarding the complaint as of 03/17/11.
- A complaint was received 12/14/10 by phone regarding a charge for ED services. Staff P, ED Director, contacted the patient by phone. During the conversation, the patient stated he/she would sue the facility, so the conversation was ended. There was no evidence of investigation into the complaint, no letter was sent to the patient, and no further attempts were made to contact the patient.

3. During an interview on 03/17/11 at 11:00 AM, Staff B, Quality Management (QI) Director, made the following statements:
- If the complaint is received while a patient is still hospitalized, it is considered a complaint and a written response is not given. The timeframe necessary to formulate a response is not considered.
- If the complaint is received after a patient has gone home, it is considered a grievance - but if it is received via phone call, a letter is not sent. The patient is contacted by phone and the response to the complaint is conveyed by phone.
- If a complainant mentions anything about fraud or a potential lawsuit, it is referred to the facility's lawyer for a response, and the complaint is not addressed through the complaint/grievance process.

Based on record review and interview, the facility failed to ensure that the governing body either maintained responsibility for the grievance process or delegated this responsibility in writing to a committee. The facility census was 20.

Findings included:

1. Record review of the facility's policy titled, "Patient Grievance Process," revised 11/08, showed a list of types of grievances and who they should be directed to, including phone numbers. The policy did not reference either the Governing Body or a Grievance Committee in regard to oversight of the complaint/grievance process.

2. Review of the Quality Assurance Meeting Minutes for January, February and March, 2011 showed the following:
- There was no mention that complaints/grievances were reviewed by the committee for thoroughness of investigation, timeliness of response, or quality of care.
- There was no mention of complaints/grievances at all for both January and February.
- The March meeting minutes referenced "Complaint Review" and stated that one chart was presented and reviewed, and stated "no issues were identified." The minutes did not indicate why this case was reviewed when others weren't.

3. During an interview on 03/17/11 at 11:20 PM, Staff B, Quality Management Director, stated the Governing Body did not review or make recommendations concerning complaints and grievances. Staff B stated the Quality Assurance Committee reviews complaints and grievances and makes recommendations regarding them, but oversight had not been officially delegated by the Governing Body.

Based on record review and interview, the facility failed to provide written grievance resolution within a reasonable timeframe to patients and/or families filing a complaint/grievance for three of five grievances reviewed. The facility census was 20.

Findings Included:

1. Record review of the facility's policy titled, "Patient Grievance Process," revised 11/08 showed the following:
- All grievances will receive immediate priority and must be investigated with efforts made toward resolution within seven days. Upon the grievance resolution or within seven days, the patient shall receive written notification of the grievance process and determination.
- If the grievance cannot be resolved within seven days due to further investigation being required or evaluation of a corrective action, the patient shall be notified in writing the expected date of grievance resolution. (Not to exceed 30 days.) All attempts will be made to resolve all grievances as soon as possible.

2. Review of grievance investigations and responses on 03/17/11 at 12:00 Noon, showed the following:
- A complaint was received 12/13/10 concerning care in the ED on 12/12/10. The patient complained that the ED physician refused to give him/her pain medication due to "drug seeking behavior." There was a notation that Staff P, ED Director, contacted the patient and stated that an investigation would be conducted.
- There was no evidence that an investigation was conducted within seven days, and no evidence that the patient was informed of the results of complaint investigation via written or other form of communication as of 03/17/11.
- A complaint was received 12/14/10 regarding the co-pay for ED services. Staff P, ED Director, contacted the patient by phone for more information. During the conversation, the patient stated he/she would sue the facility, and the conversation was ended.
- There was no evidence that an investigation was conducted within seven days as required by facility policy;
- There was no evidence that a letter was sent to the patient informing him/her that the matter was being referred for investigation and response; and
- There was no evidence that any further attempts were made to contact the patient as of 03/17/11.
- A complaint was received 03/03/11 concerning care in the ED. A letter was sent to the patient on 03/08/11 promising that the matter would be investigated.
- There was no evidence that an investigation was conducted within seven days as required by facility policy, and no evidence that the patient was informed of the results of complaint investigation via written or other form of communication as of 03/17/11.

3. During an interview on 03/17/11 at 11:00 AM, Staff B, Quality Management Director, made the following statements:
- If a complaint was received while a patient was still hospitalized, it was considered a complaint and a written response was not given. The timeframe necessary to investigate and formulate a response was not considered.
- If a complaint was received after a patient had gone home, it was considered a grievance.
- If it was received via phone call, a letter was not sent. The patient was contacted by phone and the response to the complaint was conveyed.
- If it was received via email, a written response was sent via email.
- If it was received by mail, a written response was sent.
- If a complainant mentioned anything about fraud or a potential lawsuit, it was referred to the facility's lawyer for a response, and the complaint was not addressed through the complaint/grievance process.

Based on record review and interview, the facility failed to provide written response to two of five grievances reviewed, and the facility failed to accurately inform the grievant of the steps taken on behalf of the patient during investigation and the results of the investigation for one of three complainants who received written response. The facility census was 20.

Findings Included:

1. Record review of the facility's policy titled, "Patient Grievance Process," revised 11/08 showed the following:
- All grievances will receive immediate priority and must be investigated with efforts made toward resolution within 7 days. Upon the grievance resolution or within 7 days, the patient shall receive written notification of the grievance process and determination. This notification shall include:
- The name of the Grievance Representative;
- The steps taken to investigate and resolve the grievance;
- The final result of the grievance; and
- The date of grievance completion.
- If the grievance cannot be resolved within 7 days due to further investigation being required or evaluation of a corrective action, the patient shall be notified in writing the expected date of grievance resolution. (Not to exceed 30 days.) All attempts will be made to resolve all grievances as soon as possible.

2. Review of grievance investigations and responses on 03/17/11 at 12:00 Noon, showed the following:
- A complaint was received 12/13/10 concerning care in the ED on 12/12/10. The patient complained that the ED physician refused to give him/her pain medication due to "drug seeking behavior." There was a notation that Staff P, ED Director, contacted the patient and stated that an investigation would be conducted. There was no evidence that the patient was informed of the results of complaint investigation via written or other form of communication as of 03/17/11.
- A complaint was received 12/14/10 regarding the co-pay for ED services. Staff P, ED Director, contacted the patient by phone for more information. During the conversation, the patient stated he/she would sue the facility, and the conversation was ended.
- There was no evidence that a letter was sent to the patient informing him/her that the matter was being referred for investigation and response, and no evidence that any further attempts were made to contact the patient as of 03/17/11.
- A complaint was received 03/03/11 concerning care in the ED. A letter was sent to the patient on 03/08/11 promising that the matter would be investigated. There was no evidence that the patient was informed of the results of complaint investigation via written or other form of communication as of 03/17/11.

3. During an interview on 03/17/11 at 11:00 AM, Staff B, Quality Management (QI) Director, made the following statements:
- If a complaint was received while a patient was still hospitalized, it was considered a complaint and a written response was not given. The timeframe necessary to investigate and formulate a response was not considered.
- If a complaint was received after a patient had gone home, it was considered a grievance.
- If it was received via phone call, a letter was not sent. The patient was contacted by phone and the response to the complaint was conveyed.
- If it was received via email, a written response was sent via email.
- If it was received by mail, a written response was sent.
- If a complainant mentioned anything about fraud or a potential lawsuit, it was referred to the facility's lawyer for a response, and the complaint was not addressed through the complaint/grievance process.

Based on record review and interview, the facility failed to assure safe protection of residents and patients by failing to check the Missouri Disqualification List (EDL) upon the new hire of employees and at least annually. The facility census was 20.

Findings included:

Record review of employee files showed Employee Disqualification Lists checks had not been done periodically.

During an interview on 03/17/11 at 11:30 AM, Staff A, Chief Nursing Officer, stated that EDL checks were done at hire only. Staff A stated it was not facility practice to do EDL checks periodically.

Based on record review and interview, the facility failed to:
- Assure that there was an effective, ongoing, hospital-wide quality assurance and performance improvement program that showed measurable improvement in indicators for which there was evidence that it would improve safety and/or health outcomes;
- Formally establish quality improvement objectives with data collection methodology and measurable outcomes that would reflect program effectiveness;
- Measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assessed processes of care, hospital service and operations until such time as performance improvement was achieved and sustained; and
- Effectively train, monitor and provide guidance to staff charged with quality and performance improvement data collection. The facility census was 20.

Findings included:

1. Review of the Organizational Performance Improvement Plan, revised 03/2011, showed the following:
- With authority delegated by the Governing Body, the medical staff strives to improve and assure the provision of quality patient care through the monitoring, assessment and evaluation of performance measurement and outcome.
- The Medical Executive Committee delegates the oversight responsibility for performance improvement activity monitoring, assessment and evaluation of patient care services provided throughout the facility to the Medical Records, Utilization, and Quality Assurance/Performance Improvement Committee.

2. Record review during the survey process showed that quality improvement (QI) activities throughout the facility varied in scope and success.
A. The Maintenance department had no QI processes in place and did not submit data to the Quality Management Director.
- During an interview on 03/15/11 at 11:00 AM, Staff KK, Director of Plant Operations, stated he/she does not have any QI processes in place and does not currently submit data to the Quality Management Director. However, Staff KK stated he/she had been developing checklists, performing preventive maintenance rounds, and met regularly with administration to give progress reports.

B. The Nutrition Care, Respiratory, Pharmacy, Health Information Management (HIM), Emergency, Surgery, Utilization Review, and Outpatient Departments developed projects to monitor for each month of the year and collected data as requested by the Quality Management Director and Quality Assurance Committee, but lacked knowledge of the purpose of this activity. For each month of the year, one or two quality indicators were measured, the data was reported, and then that project was abandoned as the department moved on to a new area of focus - whether or not the desired outcome marker had been met.
- During an interview on 03/15/11 at 11:09 AM, Staff JJ, Registered Dietitian, stated he/she participated in hospital-wide Quality Assurance and prepared a report in the manner the Quality Management Director instructed. Staff JJ stated he/she continued to monitor projects that did not meet the stated goal, but only reported on those once per year.
- During an interview on 03/15/11 at 11:10 AM, Staff HH, Food Service Director, stated he/she monitored items such as temperatures of food and equipments monthly, but did not monitor items to report to hospital-wide quality.
- During an interview on 03/15/11 at 2:40 PM, Staff II, Director of Respiratory, stated he/she participated in hospital-wide Quality Assurance and prepared a report in the manner the Quality Management Director instructed. Staff II stated he/she continued to monitor projects that did not meet goal, but only reported on those once per year.
- During an interview on 03/15/11 at 2:50 PM, Staff T, Pharmacy Director, stated he/she participated in hospital-wide Quality Assurance data collection, and prepared his/her report in the manner the Quality Management Director instructed. Staff T stated he/she continued to monitor projects that did not meet goal, but only reported on those once per year. Staff T stated he/she reviewed any Incident Reports related to medications or pharmacy operations, but did not review reports regarding medication errors. Those reports are reviewed by Staff F, Pharmacy Tech, who co-chairs the Medication Error Prevention Committee.
- During an interview on 03/17/11 at 8:55 AM, Staff GG, Director of HIM, stated he/she participated in hospital-wide Quality Assurance and prepared a report in the manner the Quality Management Director instructed. Staff GG stated he/she continued to monitor projects that did not meet goal, but only reported on those once per year.
- During an interview on 03/16/11 at 9:40 AM, Staff P, Director of the ED, stated that the department participated in the hospital-wide Quality Assurance program and prepared a report in the manner the Quality Management Director instructed. Projects which did not meet their projected goals were only reported one time per year.
- During an interview on 03/17/11 at 10:00 AM, Staff D, Director of Surgery, stated that he/she did the same as the other departments for QI and collected data on several different identified projects each month.
- During an interview on 03/17/11 at 10:20 AM, Staff Y, Medical Office Complex Manager, stated QI activities for the two surgeons in that clinic were blended with QI activities for the Rural Health Center in the same location. Staff Y stated data was collected on each indicator for one month, according to the calendar of projects.
- During an interview on 03/16/11 at 2:51 PM, Staff EE, Utilization Review, stated that he/she collected data on observation admissions and one day stays for QI purposes, but did not have documentation to show on-going measurable progress in meeting stated goals. He/she stated that an end of year report was made to the Quality Management Director.

C. The Social Services department measured indicators for which there was no room for improvement, and collected data that represented utilization rates rather than being focused on improving patient safety, quality of care or health outcomes.
- During an interview on 03/16/11 at 10:10 AM, Staff G, Social Worker, stated QI data was collected on a monthly basis and forwarded to the Quality Management Director for inclusion in reports. Staff G stated an issue he/she had identified for QI involved communication between the nursing units, the patient's physician, and the Social Services department - however this topic was not part of the approved QI activities for the department.
- Record review of the Social Services Department QI data for calendar year 2010 showed a list of QI projects with two projects listed for each month of the year. The Department reached 100% compliance for nearly every project. A list of the projects approved for calendar year 2011 included projects that assessed utilization rates (e.g., # of home health referrals, # of durable medical equipment referrals).

3. During an interview on 03/16/11 at 10:10 AM, Staff B, Quality Management Director, stated that the 2011 Quality Management Projects for all Departments within the facility were approved by the QI Committee and then the list was submitted to the Board of Directors. Staff B stated the Governing Body was provided with the QI information, but the Governing Body did not provide feedback or guidance.

Based on record review and interview, the facility failed to document measurable progress achievements on quality improvement (QI) projects in the Nutrition Care, Health Information Management, Respiratory, Emergency, Surgery, and Utilization Review Departments. The facility census was 20.

Findings included:

1. Record review showed the Nutrition Care Department developed projects to monitor, but failed to show documentation of on-going measurable progress achieved on meaningful projects. The projects did not always meet the stated goal, did not always show that action was taken to achieve the stated goal, and did not carry a project into the next reporting period if they did not meet their stated goal. Documentation showed a new project was initiated each month.

During an interview on 03/15/11 at 11:09 AM, Staff JJ, Registered Dietitian, stated he/she participated in hospital-wide Quality Assurance and prepared a report in the manner the Quality Management Director instructed. Staff JJ stated he/she continued to monitor projects that did not meet the stated goal, but only reported on those once per year.

During an interview on 03/15/11 at 11:10 AM, Staff HH, Food Service Director, stated he/she monitored items such as temperatures of food and equipment monthly, but did not monitor items to report to hospital-wide quality.

2. Record review showed the Health Information Management (HIM) Department developed projects to monitor, but failed to show documentation of on-going measurable progress achieved on projects. The projects did not always meet the stated goal, did not always show that staff evaluated what action should be taken to achieve the stated goal, and did not show when actions taken.

During an interview on 03/17/11 at 8:55 AM, Staff GG, Director of HIM, stated he/she participated in hospital-wide Quality Assurance and prepared a report in the manner the Quality Management Director instructed. Staff GG stated he/she continued to monitor projects that did not meet goal, but only reported on those once per year.

3. Record review showed the Respiratory Department developed projects to monitor, but failed to show documentation of on-going measurable progress achieved on projects. The projects did not always meet the stated goal, and documentation did not always show staff monitored those projects until he/she met stated goals.

During an interview on 03/15/11 at 2:40 PM, Staff II, Director of Respiratory, stated he/she participated in hospital-wide Quality Assurance and prepared a report in the manner the Quality Management Director instructed. Staff II stated he/she continued to monitor projects that did not meet goal, but only reported on those once per year.



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4. Record review showed the Emergency Department (ED), Surgical Department, Utilization Review Department developed projects to monitor for each month of the year and those projects did not always carry forward from month to month when stated goals were not achieved. Documentation failed to show on-going measurable progress, and did not always show that action was taken to achieve the goals projected.

During an interview on 03/16/11 at 9:40 AM, Staff P, Director of the ED, stated that the department participated in the hospital-wide Quality Assurance program and prepared a report in the manner the Quality Management Director instructed. Projects which did not meet their projected goals were only reported one time per year.

During an interview on 03/16/11 at 2:51 PM, Staff EE, Utilization Review, stated that he/she collected data on observation admissions and one day stays for QI purposes, but did not have documentation to show on-going measurable progress in meeting stated goals. He/she stated that an end of year report was made to the Quality Management Director.

During an interview on 03/17/11 at 10:00 AM, Staff D, Director of Surgery, stated that he/she did the same as the other departments for QI and collected data on several different identified projects each month.

Based on record review, observation, and interview, the facility failed to accurately document, assess, measure, stage and further describe a Stage II (partial thickness skin loss usually presenting as an abrasion, blister, or shallow crater) pressure ulcer for one (Patient #8) of three patients with pressure ulcers. The facility census was 20.

Findings included:

1. Record review of the facility's policy titled, "Wound/Skin Care," revised 05/2007, showed the following direction:
-Whenever a skin breakdown is identified, the Physician will be notified and the Standard Skin Care Protocols will be implemented.
-Physical Therapy will also be notified of the patient's skin breakdown.
-EZ graph is a measuring tool used during a skin assessment if skin breakdown has been identified.
-The skin breakdown will be measured initially and every 3 days using the EZ Graph measurement tool

2. Review of current Patient #8's medical record showed the following:
- History and Physical (H&P) showed the patient was admitted to the facility on 03/08/11 for acute hypoxic respiratory failure (insufficient oxygen for the body), systolic heart failure (the pumping action of the heart is weakened) and sepsis (bacterial infection which affects the entire body). Documentation under skin integrity showed intact skin with no breakdown noted and skin fragile and thin.
- Review of the Intensive Care Unit (ICU) Patient Progress Notes dated 03/08/11 at 2:25 AM, showed skin integrity to be intact with no breakdown noted with a laceration (no location was identified). Review of the patient's Braden score (patients who score 15-18 are considered at a low risk for skin breakdown) was assessed as a 17.
- Patient #8 transferred to the Medical/Surgical (Med/Surg) floor on 03/10/11. The Braden Score was assessed as an 18 at the time of transfer. Documentation dated 03/10/11 at 5:58 PM, stated there was redness noted to the left hip and a treatment was applied. There was no documentation that the staff notified the physician or physical therapy, implemented the Standard Skin Care Protocols, or described and documented the physical description of the wound or staged the wound - as required by policy.
- Patient #8's Braden Score was assessed as a 17 on 03/14/11. The score was not updated following skin breakdown of the left hip.
- There was no documentation throughout the patient's record of the facility policy for pressure sores being followed. There is no evidence that the wound was measured or staged.
- Discharge Planning documentation showed the patient would be discharged home with tegaderm (a transparent adhesive dressing) to left hip.

3. Observation on 03/15/11 at 2:46 PM, showed Patient #8 with an open area approximately the size of a dime on his/her left hip, covered by tegaderm (a clear adhesive dressing).

During an interview on 03/15/11 at 2:50 PM, Patient #8 stated that he/she did not have the pressure sore before entering the hospital.

4. During an interview on 03/15/11 at 3:15 PM, Staff H, past Director of Med/Surg, stated that upon review of the patient's record he/she confirmed there was no documentation of the staff notifying the physician or physical therapy, or of documentation by the staff according to the facility policy.

Based on record review, observation, and interview, the facility failed to have sufficient safeguards to ensure access to all information regarding patients was limited to those individuals designated by law, regulation and policy caring for the patients. The facility also failed to protect the records so that only those persons having a part in the patients' care could view the records when they were caring for patients. The facility census was 20.

Findings included:

1. Record review of the facility's policy titled, "Hours of Operation," dated 05/2009, showed the following:
-The Health Information Management (HIM) Department hours are from Monday through Friday 7:00 AM to 4:00 PM. Should an individual need to gain access to the department after hours, he or she must contact the Nursing Supervisor for assistance.
-The Health Information Management Department shall remain locked at all times.

Record review of the facility's policy titled, "Health Data Integrity," dated 05/2009, showed the following:
-It is the policy of Texas County Memorial Hospital to protect the privacy of individual's identifiable health information.
-The Information Management Committee is responsible for the development of organizational standards, policies and procedures concerning timeliness, accuracy, security, privacy and confidentiality, access, integrity and uniformity of data of both paper and electronic records consistent with law or regulation.
- Security/Confidentiality of Information:
- To provide a balance between data sharing and data confidentiality, individuals/departments have been identified with specific policies/procedures outlining the access to, and need for, data and information.
- Health Information Management Department, Nursing personnel, Medical Staff and Clerical personnel will have access to all necessary patient information in the medical records.
- All other individuals, including ancillary personnel and administrative personnel, will have access to patient data and information on an "as needed" basis and restricted to level of authority.

2. Observation on 03/16/11 at 9:40 AM, showed the following:
-Patients' medical records were stored in a large room of the facility's basement and also in a locked storage shed in back of the hospital.
-The medical records contained personal information regarding the patients.
-Maintenance Staff could access these areas with a master key.

3. During an interview on 03/16/11 at 3:50 PM, Staff GG, HIM Director, made the following statements:
- The HIM Department and Business Office stored patient medical records in the facility's basement and in a storage shed in back of the facility.
- To his/her knowledge, only HIM staff and the Business Office staff had keys to the storage areas in the basement and the shed.
- The Maintenance Department might also have keys to the storage areas because they never asked for the HIM Department's keys to gain access to the storage areas.
- Maintenance probably had a Master key they used to gain access to the HIM Department because they (maintenance) cleaned the carpets during the night in the absence of HIM Staff.
- All Nursing Supervisors and Emergency Room Staff had access to the HIM Department so they could obtain medical records in the absence of the HIM Staff.

4. Observation on 03/15/11 at 2:50 PM, showed the following:
-Staff II, Director of Respiratory Department, kept outpatients' orders for treatment in folder within an unlocked desk drawer.
-Review of the orders showed that they contained the patient's name, date of birth, address, phone number, last 4 social security number and insurance information.

During an interview on 03/15/11 at 2:50 PM, Staff II stated she/he did not lock the drawer containing the orders. Staff II stated a Staff member broke the keys and they could no longer lock the cabinet. Staff II tried several Department keys until he/she found a key that locked the drawer.

Based on record review, observation, and interview, the facility failed to ensure medications were kept in a locked, secured area to prevent unauthorized access. This had the potential to affect all patients in the facility. The facility census was 20.

Findings included:

1. Record review of the facility's document titled, "Night Medication Cabinet - Obtaining Patient Medication after Pharmacy is Closed," reviewed 11/10, showed the following direction:
-The Night Cabinet is a source of drugs for inpatients in the absence of the Pharmacist.
-The Night Cabinet, ER (Emergency Room) Pyxis (an automated drug dispensing system),
-and Departmental medication Floor Stock shall be utilized to obtain patient medication when the Pharmacy is closed.

2. Observation on 03/15/11 at 10:15 AM, showed two packages marked "Gent-L-Tip Phosphate Enema" (used to treat constipation) were identified on the Central Supply/Purchasing cart in the Intensive Care Unit (ICU), which contained clean supplies for use in the ICU.

During an interview on 03/15/11 at 11:00 AM, Staff C, ICU Registered Nurse (RN), stated the ICU rarely gave enemas, but that these supplied were always kept on the supply cart.



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3. Observation on 03/15/11 at 9:00 AM, showed a large room next to the Medical/Surgical (Med/Surg) nursing station. One wall contained a locked storage cabinet where non-narcotic medications were kept. Following facility protocol, nursing staff could access the cabinet and obtain medications when physician orders were received after the pharmacy had closed. Inside the locked cabinet were multiple drawers marked with the name of a medication, and sealed shut with un-numbered red, plastic seal straps. Some of the drawers had been opened, which allowed access to those medications when the outer doors were unlocked. A bundle of approximately 20 replacement seals was also located within the cabinet.

During an interview on 03/15/11 at 9:15 AM Staff H, Past Med/Surg Director, stated that staff removed the un-numbered red, plastic tags and then removed the number of doses necessary to initiate the medication. He/she stated the multi-purpose room was used for storage of supplies, non narcotic drugs and as a break room for staff.

During an interview on 03/15/11 at 2:10 PM, Staff H, Past Med/Surg Director, stated that when a medication was needed after the pharmacy closed, the lock was broken and the number of doses necessary to initiate the medication was removed from the appropriate drawer. The nurse was then required to log what medication was removed on a log sheet contained within the cabinet. The following day, the pharmacist would check the physician order and fill the medication, and pharmacy techs would restock and seal the drawer. Staff H did not know why the locks were contained within the cabinet, and stated nurses were not supposed to reseal drawers after opening them. The absence of a lock alerted the pharmacy tech to check the drawer when they made their daily rounds.

4. During an interview on 03/15/11 at 2:30 PM, Staff F, Pharmacy Tech, stated the locks were kept within the storage cabinet for the convenience of the tech checking and restocking the cabinet. Staff F could not recall whether there had ever been an instance of medications being removed from stock that could not be reconciled with a physician order, but agreed that it would be possible for medications to be removed without detection if a lock were reapplied.

Based on observation and interview, the facility failed to make the currently approved Diet Manual readily available and accessible to all medical and nursing personnel. The facility census was 20.

Findings included:

Observation on 03/15/11 at 11:15 PM, showed the facility had a hard copy of the approved Diet Manual at the Medical/Surgical (Med/Surg) nursing station, but did not have a hard copy in other nursing units within the facility.

During an interview on 03/15/11 at 10:45 AM, Staff JJ, Registered Dietitian, confirmed the Med/Surg nursing station had a printed copy of the current diet manual, but other nursing stations did not have a copy of the manual. Staff JJ stated only he/she had access to the manual on-line by using an access password, but no other employee had access unless he/she gave them the password.

Based on observation and interview, the facility failed to maintain walls and painted surfaces of patient rooms in a condition that presented a clean, safe, environment and adequately supported high quality patient care services in nine of 13 patient rooms located in the Medical/Surgical (Med/Surg) unit. The facility census was 20.

Findings included:

1. Observation from 03/15/11 at 9:00 PM through 03/17/11 at 1:00 PM, showed deep scrapes, gouges and torn wall paper on the lower 36 inches of the walls in an X-ray reading room and processing department. Damaged corners exposed glimpses of metal corner bead where plaster had fallen out.

2. Observation from 03/15/11 at 9:10 AM through 03/17/11 at 1:00 PM, showed large chips of paint peeled off or scraped from painted surfaces of door frames on the south wing, rooms 102-113. Paint was missing from entrance door frames of room 102, 107, and 109. Dried brown stains streaked down the wall cover surfaces on the east wall, between rooms 104 and 105. Scratched and peeled paint was missing from most of the door frame of the Med/Surg unit soiled utility room, exposing bare metal and other colors (white) of previous paint jobs.

3. Observation from 03/15/11 at 4:00 PM through 03/17/11 at 1:00 PM, showed large areas of paint peeled off or scraped from painted surfaces of entrance door frames to most of the rooms on the East wing, rooms 120-131. Most of the missing and chipped paint on south and east wings exposed bare metal and primer, or former painted surface of a different color. Wall paper in a shower room had a stained rub mark along the southeast wall, approximately two inches wide and 36 inches above the floor.

4. Observation on 03/15/11 at 11:00 AM, showed a broken and loose grill cover on a heat register in patient room 115 of the Obstetrics (OB) Department.

5. Observation on 03/15/11 at 1:15 PM, showed three gouged areas in the walls of a hallway outside OB department's nurse lounge.

6. Observation on 03/15/11 at 1:25 PM, showed a six inch diameter stain on a ceiling tile in the physician's lounge in the OB Department.

7. During an interview on 03/15/11 at 11:00 A.M., the Director of Plant Operations stated that maintenance has protective strips and coverings to apply to the wall and prevent further deterioration or damage. He stated that with current patient loads, any room renovation projects depend on how big of an area can be cordoned off. He stated it was difficult to put up plastic and control dust from saws and other tools without interfering with patient care. He stated that after renovation, some of the rooms in the original structure currently occupied by patients might be re-occupied as offices or limited equipment storage within code limitations for new construction. He stated that he makes monthly rounds through the hospital to check on obvious repairs and maintenance needs, however, he also relies on a computerized work order system he initiated shortly after taking over as Director. He stated he did not have any Quality Improvement (QI) processes in place and does not currently submit data to the Quality Management Director. He stated he has been working on developing checklists, preventive maintenance rounds and meets regularly with administration to give progress reports.

Based on record review and interview, the facility failed to establish formal policies, memorandums of agreements or contracted services for replenishment of fuel and water supplies in the event of prolonged severe weather or disaster situation that might potentially affect the hospital staff, visitors and patients. The facility census was 20.

Findings included:

1. Record review on 03/16/11 at 9:20 AM, showed no evidence of a formal policy for replenishment of fuel and water supplies to sustain the facility population and staff for a week or more in the event of a disaster situation, such as, fires, tornados, floods and earthquakes.

During an interview on 03/16/11 at 9:30 AM, Staff KK, Director of Plant Operations, stated he/she did not have a policy or any formal agreements with outside vendors for emergency resupply of essential fuels and water during a disaster situation. Staff KK stated that the fuel tanks for the two large generators are usually maintained at three quarters of a tank, which was considered sufficient for the most extended run times in the event of bad weather. Staff KK stated the same applied to re-supply of water. Staff KK stated the hospital stored a minimal supply of bottled water on site for emergencies, but would probably have to negotiate or purchase additional water from local stores if one could be found that still had water on hand after a disaster had been initiated.

Based on record review, observation, and interview, the facility failed to:
- Store food serving containers in a sanitary and safe manner;
- Remove outdated supplies from the facility stock; and
- Maintain refrigerator temperatures within an acceptable range to ensure medications did not deteriorate. The facility census was 20.

Findings Included:

1. Record review of the Food and Drug Administration (FDA) 2005 Food Code, Chapter 3-305.11 (A) (B) - Food Storage showed the following:
-(A) Except as specified in paragraph (B) and (C) of this section, food shall be protected from contamination by storing the food in a clean, dry location, where it is not exposed to splash, dust, or other contamination and at least 15 cm (6 inches) above the floor.
-(B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under Chapter 4-204.122.

2. Observation on 03/16/11 at 11:40 AM, showed the facility's staff stored paper goods in a storage room off from the seating area in the employees' dining room. The room contained boxes on shelves stacked to the ceiling in places and boxes stored under the metal shelves on the floor in the room. Observation showed one fire sprinkler visible in the center of the room, but no other sprinklers visible in the room because the boxes covered the ceiling space.

During an interview on 03/16/11 at 11:40 AM, Staff HH, Director of Food and Nutrition Services, stated he/she knew the boxes should not have been on the floor and should not have been stacked to the ceiling, but stated the facility ran out of room for storing the paper goods. Staff HH stated he/she would reorganize the room so that the boxes would not be on the floor and boxes would not reach the ceiling and cover the sprinkler heads.



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3. Observation on 03/15/11 at 10:10 AM, in the Intensive Care Unit (ICU) showed a wall cabinet which contained patient snack and nutritional supplements including the following:
- Two eight-ounce (oz.) cans Ensure Plus (protein shake, formulated to help a patient gain or maintain weight), expired 02/10;
- One eight-oz. can Ensure Plus, expired 01/10;
- One eight-oz. can Glucerna (nutritional supplement formulated for use with diabetic patients), expired 01/10; and
- One six-oz. bottle Cherry Enfalyte (designed to replace electrolytes and fluids - used with children) expired 01/10.

Observation on 03/15/11 at 10:23 PM, in the ICU showed a small refrigerator used for patient snacks which contained one eight-oz. can of Ensure, expired 12/10. The refrigerator also contained the lunch bag and lunch items for the nurse on duty.

During an interview on 03/15/11 at 10:25 AM, Staff B, Quality Management Director, stated the facility does not have a policy regarding nutritional supplements, but produced a document utilized by Dietary staff. Review of this document titled, "Weekly Nurse's Station Refrigerator Check," showed dietary staff were required to inspect the following when adding supplies to floor stock in ICU by checking that:
- Foods are within the allowed dates; and
- No other items are being stored in patient snack refrigerator except patient foods.

During an interview on 03/15/11 at 10:30 AM, Staff D, ICU Director, stated the facility did not have a policy addressing it, but confirmed staff should not place personal items in the refrigerators intended for patient foods.



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4. Observation on 03/15/11 at 9:00 AM, showed a refrigerator in a room next to the Medical/Surgical (Med/Surg) nursing station. The documentation of the temperature checks showed that the daily temperature checks fell out of the acceptable temperature range (32-46? F.) for17 days in January 2011; nine days in February 2011; and nine days out of 15 in March 2011. The documentation also showed the freezer temperature checks fell out of the acceptable temperature range (0-15? F.) for three days in January 2011; ten days in February 2011 and two out of 15 days in March 2011.

During an interview on 03/16/11 at 9:55 AM, Staff F, Pharmacy Tech, stated that a pharmacy tech records the temperature of the refrigerator and freezer in Med/Surg on a daily basis, and if the temperatures were out of range then they would complete a work order and submit it to the Maintenance Department. Staff F stated that they (the pharmacy techs who record the temperatures) didn't think anything about the refrigerator being too cold; just too hot because then some of the medications kept in the refrigerator would be unstable.

During an interview on 03/16/11 at 10:30 AM, Staff A, Chief Nursing Officer, stated that he/she had checked with maintenance and no work orders had been received by maintenance for the out of range refrigerator or freezer temperatures.

5. Observation on 03/16/11 at 2:00 PM, in the Laboratory showed a large, upright warmer containing intravenous (IV) fluids, among other items. The documented daily temperatures ranged from 105? - 123? F., for the months of January, February, and March of 2011. Documentation provided by the Laboratory Director stated IV solutions could be kept at 104? F., for four weeks without compromising the integrity of the IV fluids.

During an interview on 03/16/11 at 2:20 PM, Staff JJ, Director of the Laboratory, stated that the staff adjusted the temperature on the warmer in order to try to keep it within the optimal range, but since the door to the warmer was opened frequently during the day, it was difficult to maintain the optimal temperature.

6. Observation on 03/17/11 at 8:30 AM, in the Surgery Department showed a red cart with multiple drawers which contained the following outdated supplies:
- Controlled Radial Expansion Dilatation (a tube which is inserted to for the management of stone impaction in the pancreas) Lot 11639209, expired 03/10;
- Controlled Radial Expansion Dilatation Lot 11621670, expired 03/10;
- Controlled Radial Expansion Dilatation Lot 8317954, expired 01/08;
- Controlled Radial Expansion Dilatation Lot 12249118, expired 11/10;
- Controlled Radial Expansion Dilatation Lot 12249118, expired 11/10;
- Three Thermal Option II (an instrument which is used to access, diagnose and treat diseases of the digestive tract) Lot 180349, expired 06/05;
- Two Thermal Option II Lot 180349, expired 12/04;
- Three Cytology Brush (an instrument used to collect samples from the airways) Lot 175300, expired 05/05;
- Peel Away Introducer Set (a medical instrument which is used to insert a catheter) Lot 184167, expired 02/10;
- Peel Away Introducer Set Lot 174939, expired 07/09;
- Peel Away Introducer Set Lot 186966, expired 04/10;
- Peel Away Introducer Set Lot 184108, expired 02/10; and
- Peel Away Introducer Set Lot 186960, expired 04/10.

7. Observation on 03/17/11 at 9:37 AM, in the Surgery Department showed a large hinged box which was identified as "Pediatric Emergency Supplies." An inspection of the box showed four Trocar Thoracic Calibration (a rigid metal rod that is inserted into a tube which goes into the chest to drain fluid), had expired as of 08/28/02.

During an interview on 03/17/11 at 9:10 AM, Staff D, Director of Surgery, stated that these supplies were not used anymore and should have been thrown away. Staff D stated that the Emergency Department would respond to a pediatric emergency in surgery by bringing their crash cart, which had pediatric supplies on it. Staff D stated that the pediatric box was kept in surgery as a "back up" for pediatric emergencies.

During an interview on 03/17/11 at 1:30 AM, Staff A, Chief Nursing Officer, stated that the facility did not have a policy regarding the removal of outdated supplies.

Based on record review, observation, and interview the facility failed to ensure staff followed the facility's hand hygiene policy when staff did not cleanse their hands before and after having direct contact with a Patient (#26) and when staff did not cleanse their hands between glove changes for three (#7, #9, #13) of three patients. The facility census was 20.

Findings included:

1. Record review of the facility's policy titled "Hand washing," dated 04/05, showed the following direction:
- Healthcare workers should wash their hands with soap and water:
- When hands are visibly soiled (dirty); and
- When hands are visibly contaminated with blood or body fluids.
- Healthcare workers may use an alcohol-based hand sanitizer:
- Before having direct contact with a patient;
- After direct contact with a patient's skin;
- After having contact with body fluids, wounds, or broken skin;
- After touching equipment or furniture near patient; and
- After removing gloves.

2. Observation on 03/15/11 at 9:47 AM, showed Staff J, Director of Physical Therapy (PT), entered the room of Patient #7 to do wound dressings on a right foot wound, right and left buttock wounds, and an excoriation (reddened rash-like area) under the abdominal fold.

RIGHT FOOT WOUND:
- Staff J donned gloves and cleansed the right leg wound of Patient #7.
- Without changing gloves, he/she then picked up an Aquacel dressing (an absorbent dressing) and a Q-tip applicator from the bed side tray. Staff J applied the Aquacel to the wound bed and used the Q-tip to smooth it into place.
- He/she then placed a barrier dressing over the Aquacel dressing.
- Without changing gloves, he/she proceeded to pick up moisture barrier cream from the sink area and applied the barrier to the right leg.
- Staff J then removed the gloves and performed hand hygiene with soap and water.

ABDOMINAL FOLD:
- Staff J then applied gloves and cleansed the large, reddened, and damp abdominal fold of Patient #7.
- Without changing gloves, Staff J applied an unknown paste and Telfa (a dressing which doesn't stick to the skin) dressing to the area under the abdominal fold with his/her gloved hands.
- Staff J then removed the gloves and performed hand hygiene with soap and water.

RIGHT BUTTOCK WOUND:
- Staff J then applied gloves and removed a dressing from the right buttock of Patient #7 and cleansed bowel movement from the patient's skin.
-He/she removed the gloves and donned another pair of gloves. No hand hygiene was done between glove changes.
- Staff J then cleansed a small amount of blood from the wound bed using gauze dampened with sterile water.
- Without changing gloves, Staff J picked up non-sterile scissors from the bedside table, used them to cut a piece of Aquacel dressing, and applied the dressing to the wound bed.
- Staff J then applied Tegaderm dressing (a transparent adhesive dressing) over the Aquacel dressing.
- During this process, the scissors were dropped on the floor. Staff J picked them up and placed them on the patient's tray table.
- Staff J removed his/her gloves, left the patient's room, returned with a specimen cup.
- Staff J applied gloves and placed what he/she described as a "bone chip" from the foot wound into the container.

LEFT BUTTOCK WOUND:
- Without changing gloves, Staff J used the scissors that had been dropped on the floor to cut a piece of dressing for the left buttock wound, placed the scissors in his/her back pocket, and removed his/her gloves.
- Without performing hand hygiene, Staff J re-gloved and cleansed bowel movement from the patient's skin. The dressing on the right buttock became dislodged during the process of removing bowel movement.
- Without changing gloves, Staff J cleansed the right and left buttock wound areas and applied a dressing to both wounds; then assisted the certified nursing assistant to place a clean sheet under the patient.

3. Observation on 3/15/11 at 10:45 AM, showed Staff DD, Certified Nursing Assistant, CNA, provided Foley catheter (a tube which is placed in the bladder to drain urine) care to Patient #9, which involves cleansing the perineum at the point where the catheter enters the body. After completing catheter care, Staff DD removed his/her gloves and re-gloved without performing hand hygiene. Staff DD then proceeded to bathe the patient and apply lotion to the patient's body.

4. Observation on 03/16/11 at 9:20 AM, showed Staff Q, a Physician, entered the Emergency Department room of Patient # 26 without cleansing his/her hands. Staff Q assessed the patient's lung sounds using a stethoscope (a listening device), then left the room without performing hand hygiene. Staff Q then returned to the nurse's station where he/she picked up a medical record for review.

5. During an interview on 02/16/11 at 9:45 AM, Staff R, Infection Control/Risk Manager, stated the following:
- Staff should perform hand hygiene (cleansing their hands with soap and water or alcohol-based cleanser) before entering or leaving a patient's room;
- Staff should perform hand hygiene between glove changes; and
- Staff should apply a new pair of gloves between cleansing a wound and applying a clean dressing.