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Based on observations and staff interviews, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality in the emergency room, and laboratory area. Findings include:

1. On 6/18/12 at 3:50 p.m., during the review of the emergency room the surveyors observed the following expired patient care supplies:
-8 BD Insyte Autoguard 24 gauge intravenous catheters with the manufacturer's expiration date of 2/2012;
-14 BD Insyte Autoguard 16 gauge intravenous catheters with the manufacturer's expiration date of 2/2012;
-1 BD Insyte Autoguard 16 gauge intravenous catheter with the manufacturer's expiration date of 2/2010;
-1 BD Insyte Autoguard 14 gauge intravenous catheter with the manufacturer's expiration date of 2/2011;
-6 Robertazzi nasopharyngeal airways with the manufacturer's expiration date of 4/2012;
-2 Robertazzi nasopharyngeal airways with the manufacturer's expiration date of 1/2012.

On 6/18/12 at 3:50 p.m., staff member C, the DON, stated central supply staff check one area of the ER for expired supplies once a week.

2. On 6/20/12 at 9:40 a.m., during the review of the laboratory area the surveyor observed the following expired patient care supplies:
-68 light blue top vacutainers with the manufacturer's expiration date of 4/2012;
-3 dark blue top vacutainers with the manufacturer's expiration date of 2/2012;
-4 packages of Luer adapters with the manufacturer's expiration date of 6/2011; and
-1 thin prep PAP test container with the manufacturer's expiration date of 10/13/2011.

On 6/20/12 at 9:40 a.m., staff member G, the laboratory manager, stated the staff checks for outdates once a month or before using the supplies.

Based on observations and staff interviews, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals are not available for patient use.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

On 6/18/12 at 3:50 p.m., during the review of the emergency room, the surveyor observed the following expired medications:
-1 multi-dose vial of Xylocaine with an open date of 4/24/12. The vial was 25 days past the 30 day expiration date.
-1 povidone-iodine prep pad with the manufacturer's expiration date of 1/2012.

Staff member C, the DON stated the staff nurses check for outdated medications once a month.

Based on clinical record review and staff interview, the facility failed to develop and keep current the care plans for 5 (#s 2, 3, 9, 21, and 22) of sampled patients. Findings included:

On 6/21/12 starting at 8:25 a.m., the surveyor reviewed electronic medical records for patient #s 2, 3, 9, 21, and 22. The surveyor noted the electronic medical records lacked care plans for the above patients. The DON stated the electronic medical record program did not have a care plan application. The facility stopped doing care plans of patients requiring acute, observation, and swing bed skilled patients the end of February 2012.

Based on record review, facility policy review, and staff interview, the facility failed to collaborate with the OPO to involve family in the decision of organ donation for 3 (#s 10, 11, and 14) of 46 patients reviewed. Findings include:

1. On 6/20/12 at 3:00 p.m., the facility provided the surveyors with the Organ, Tissue and Eye Donation policy. The following was noted under the heading Procedure, Charge RN or designee, "1. All deaths and imminent deaths in the Emergency Room and CAH/Swing, regardless of age or medical/social history, will be reported to the RN in charge. It is his/her responsibility to assure that the Donor Referral Line is contacted.
2. The RN in charge or designee will call the Life Center Northwest Donor Referral Line prior to the family approach to evaluate medical suitability for donation, regardless of age or medical/social history...4. Document outcomes of the referral call, medical suitability and request (if applicable) on the Organ Donor Inquiry/Funeral Home form..."

2. Patient #14 was a 70 year-old female admitted to swing bed status on 5/23/12 and passed away on 5/24/12. The licensed nurse signed in the space designated for the name of the person completing the Donor Inquiry/Funeral Home Form on the Organ Donor side on 5/24/12. The staff member also marked "No" and wrote "Kidney Disease" for "Is the Patient a Candidate for Organ/Tissue Donation as determined by the procurement coordinator?" The document lacked the name of the procurement coordinator and the referral number to indicate the procurement facility was notified.

On 6/21/12 at 10:00 a.m., staff member C, the DON, stated she had called the Organ donation agency about patient #14. The organ donation agency had no record of the facility calling them for patient #14.

On 6/20/12 at 4:30 p.m., staff member C, the DON stated, she was not aware of organ procurement education for the facility nursing staff. The DON stated she had been at the facility for 2 years and had never had organ procurement education. Staff member G stated organ procurement education was not part of orientation or annual training.


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3. Patient #10 was a 70 year-old male admitted to swing bed status on 8/24/11 and died on 8/28/11. The licensed nurse signed in the space designated for the name of the person completing the Organ Donor Inquiry/Funeral Home form on the Donor Inquiry side on 8/28/11. The Donor Inquiry side of the form was otherwise blank. There was no evidence in the medical record that the OPO had been contacted when this patient died.

4. Patient #11 was an 85 year-old female admitted to swing bed status on 11/10/11 and died on 11/17/11. The licensed nurse signed in the space designated for the name of the person completing the Organ Donor Inquiry/Funeral Home form on the Donor Inquiry side on 11/17/11. The Donor Inquiry side of the form was otherwise blank. There was no evidence in the medical record that the OPO had been contacted when this patient died.

5. During the evening meeting with administration on 6/19/12 at 4:30 p.m., staff member A, medical records supervisor, stated the Organ Donor Inquiry/Funeral Home form for both patient #s 10 and 11 were not filled out.

Based on record review and staff interview, the facility failed to maintain protocols and provide training to staff on the subject of organ donation and procurement at the facility. Findings include:

On 6/20/12 at 3:00 p.m., the facility provided the surveyors with the Organ, Tissue, and Eye Donation Policy and Procedure. The surveyor noted the following under the heading General Considerations, "...7. Pioneer Medical Center works cooperatively with the donation agencies in educating staff on donation issues..." The surveyor noted under the heading Procedure, it is the RN (Registered Nurse) in charge who is responsible to contact the Donor Referral Line.

On 6/20/12 at 4:30 p.m., staff member C, the DON stated, she was not aware of organ procurement education for the facility nursing staff. The DON stated she had been at the facility for 2 years and had never had organ procurement education. Staff member G, the QA and Infection Control Coordinator, stated organ procurement education was not part of orientation or annual training.

Based on review of policies and staff interviews, the facility failed to ensure the policy addressed the right of the patient to have access to their medical records within 24 hours of request. Findings include:


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1. The surveyor reviewed the facility policy and procedure titled Access of Individuals to Protected Health Information on 6/20/12 at 11:15 a.m. The policy and procedure had a date of 2/6/12. The following information was documented in the section titled Procedure:

... PMC will provide the individual with access to the protected health information within 30 days of the request for such access ...

2. During an interview with staff member A, Medical Records Supervisor, on 6/20/12 at 11:15 a.m., she stated the facility did not take 30 days to provide the patients with their medical record information. She stated a patient had come in that morning and wanted a copy of her medical record, and the facility provided the patient the copies of the record within two hours. She stated she would ensure the policy and procedure was changed.

During the evening meeting with the administration on 6/20/12 at 4:30 p.m., staff member B, the Administrator, stated the facility does not take 30 days for access to their medical records. He stated access is immediate for the patients and he would ensure the policy gets changed.

Based on record review and staff interviews, the facility failed to ensure that a comprehensive nursing assessment for 6 (#s 15, 16, 17, 18, 19, and 20) of 46 patients were completed. Findings include:

1. On 6/21/12 at 10:00 a.m., staff member C, the DON, stated the swing bed assessment was composed of only assessments for mood, memory, fall risk, pressure ulcers, and pain. The swing bed assessment did not contain all of the following components, and therefore the assessments were incomplete:
- Identification and demographic information;
- customary routine;
- cognitive patterns;
- communication;
- vision;
- mood and behavior pattern;
- psychosocial well-being;
- physical functioning and structural problems;
- continence;
- disease diagnoses and health conditions;
- dental and nutritional status;
- skin condition;
- activity pursuit;
- medications;
- special treatments and procedures;
- discharge potential;
- documentation of summary information regarding the additional assessment performed through the resident assessment protocols; and documentation of participation in assessment.

2. Resident #15 was admitted to swing bed status on 4/15/10. Resident #15 had assessments for mood, memory, fall risk, pressure ulcers, and pain. The medical record lacked all of the components for a complete comprehensive assessment.

3. Resident #16 was admitted to swing bed status on 5/7/12. Resident #16 did not have a complete comprehensive assessment in the medical record.


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4. Resident #17 was admitted to swing bed status on 5/7/12. Resident #17 did not have a complete comprehensive assessment in the medical record.

5. Resident #18 was admitted to swing bed status on 5/7/12. Resident #18 did not have a complete comprehensive assessment in the medical record.

6. Resident #19 was admitted to swing bed status on 1/4/12. Resident #19 did not have a complete comprehensive assessment in the medical record.

7. Resident #20 was admitted to swing bed status on 5/24/12. Resident #20 did not have a complete comprehensive assessment in the medical record.

Based on record review and staff interview, the facility failed to ensure that a complete comprehensive nursing assessment for 5 (#s 16, 17, 18, 19, and 20) of 46 swing bed residents was completed within 14 calendar days of admission. Findings include:

1. On 6/21/12 at 10:00 a.m., the DON stated the facility had not done a complete comprehensive assessment on resident #s 16, 17, 18, 19, and 20 after admitting the patients to swing bed status and continue to reside in the swing bed unit.

2. Resident #16 was admitted to swing bed status on 5/7/12. Resident #16 did not have a complete comprehensive assessment within 14 calendar days of admission.


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3. Resident #17 was admitted to swing bed status on 5/7/12. Resident #17 did not have a complete comprehensive assessment within 14 calendar days of admission.

4. Resident #18 was admitted to swing bed status on 5/7/12. Resident #18 did not have a complete comprehensive assessment within 14 calendar days of admission.

5. Resident #19 was admitted to swing bed status on 1/4/12. Resident #19 did not have a complete comprehensive assessment within 14 calendar days of admission.

6. Resident #20 was admitted to swing bed status on 5/24/12. Resident #20 did not have a complete comprehensive assessment within 14 calendar days of admission.

Based on observation and staff interview, the facility failed to adhere to professional standards for the medication pass for 5 (#s 16, 17, 18, 19, and 20) of 46 patients observed during the medication pass. Findings include:

On 6/20/12 starting at 8:15 a.m., the surveyor observed the morning medication pass to patient #'s 16, 17, 18, 19, and 20. Staff member I, an LPN (Licensed Practical Nurse), poured the patient's medication into a medication cup, took the medication cup to the patient, and assisted the patient to take the medication. Staff member I went back to the medication cart and started to set up the next patient's medications. Staff member I did not sign out the medications in the MAR for patient #s 16, 17, 18, 19, and 20 at the time the medications were administered for each patient.

On 6/20/12 at 9:10 a.m., staff member I stated she would sign out the patients' medications at noon or if she had some down time in between morning medication pass and the lunch medication pass.

On 6/20/12 at 4:30 p.m., during the evening meeting with the facility's administration, the DON stated the expectation of the facility was the nurse would sign the medication out after giving the patients their medications.