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Based on observation, interview and policy review, the facility failed to ensure Emergency Department (ED) staff maintained two of two emergency carts (crash carts) located in the ED. This failure increased the potential for patients presenting to the ED with emergencies to receive substandard care. The ED average daily census was approximately 14 patients (5,000 visits per year). The facility census was 10.

Findings included:

1. Record review of the facility policy titled, "Crash Cart Emergency Supplies," revised 02/07, showed:
- Nursing staff will maintain emergency carts containing appropriate drugs to meet patient needs in emergency and/or life threatening situations.
- Pharmacy staff checks and restocks the emergency cart every weekday morning and after each use.
- Pharmacy staff locks the emergency cart after it is restocked.
- The emergency cart will be made functional soon after use.

2. Observation in the ED on 08/11/14 at 1:45 PM showed the pediatric emergency cart in Trauma Room #1 and the adult emergency cart in Trauma Room #2 were unlocked.

3. During an interview on 08/11/14 at approximately 1:45 PM, Staff B, Chief Nursing Officer (CNO), stated that:
- The pediatric emergency cart in Trauma Room #1 was never locked.
- The emergency cart in Trauma Room #2 had been opened for an emergency that morning.
- The emergency cart in Trauma Room #2 needed to be restocked with medications before being locked again.

4. Observation in the ED on 08/12/14 at 8:30 AM showed the emergency cart in Trauma Room #2 was unlocked.

During an interview on 08/12/14 at approximately 8:40 AM, Staff K, Registered Nurse (RN), stated that the emergency cart in Trauma #2 had not been used since the morning of 08/11/14.

5. During interviews on 08/12/14 at approximately 8:50 AM and on 08/14/14 at 10:50 AM, Staff S, Pharmacy Director, stated that:
- The pediatric emergency cart in Trauma Room #1 was never locked after stocking medications and that it should be to ensure the appropriate medications were maintained.
- The facility policy was emergency carts were to be made functional soon after use.
- The ED staff did not notify the Pharmacy regarding the emergency cart in Trauma Room #2 being used on the morning of 08/11/14 or his staff would have restocked it immediately after that.
- The emergency cart in Trauma Room #2 was not restocked until the morning of 08/12/14.
- Pharmacy staff needed to communicate better with nursing when the emergency cart was used so they could restock medications timely.
- When the Pharmacy was closed, the nursing supervisor should restock the used emergency cart.

6. During an interview on 08/14/15 at 11:35 AM, Staff B, CNO, stated that her expectation was the ED nurses would notify the Pharmacy or the nursing supervisor immediately after the emergency cart was used to restock medications in it. She stated that the emergency cart should always be ready for emergency care of patients.

Based on observation, interview and record review, the facility failed to ensure fresh water supply resources in janitor sinks with hose bibs (hose attached to a water fixture outlet) remained free of potential contamination from infectious waste and failed to ensure all critical care Respiratory equipment including ventilators were tested annually by a qualified contractor. These deficient practices had the potential to cause contaminated water to backflow into the clean water supply and may cause non functioning Respiratory department equipment, including ventilators, to be used for patients with breathing problems. The facility census was 10.

Findings included:

1. Observation on 08/11/14 at 2:15 PM showed no backflow protection on a sink fixture in a janitor's closet (Room 133) to prevent contaminated water from being sucked out of the basin and into the sanitary water supply when the water valve was shut off. A hose attached to the spout of the sink fixture extended to the bottom of the sink and rested on the drain sieve. Without (backflow) protection, any water remaining in the basin when the valve was turned off could be pulled up the hose by the suction created and contaminate the freshwater tanks and plumbing system. In the unlikely event of a drain stoppage or plug, the water level in the deep basin sink could potentially cause a cross connection between the fresh resources and dirty water in the basin of the sink.

During an interview on 08/11/14 at 2:15 PM, Staff C, Maintenance Supervisor confirmed the finding and stated that he had not noticed this sink needed backflow protection. He stated that he did not have a specific policy for checking for backflow protection and prevention measures on deep basin sinks.

2. Record review of the facility's policy titled, "Respiratory Care Preventative Maintenance," reviewed 04/05, showed direction for staff to ensure all critical care Respiratory equipment including ventilators be tested annually by a contractor. The purpose of the annual test was early detection for potential maintenance problems, proper care and routine maintenance.

3. During an interview on 08/12/14 at 10:25 AM, Staff P, Director of the Respiratory Department, stated that:
- The facility ventilators were tested in 05/24/13 and 07/14/14 (14 months between checks).
- The contractor was not able to perform the annual check in 05/14.
- Staff P did not want to spend the extra departmental money to hire a second contractor to perform the annual check as directed by the facility policy.


16215

Based on interview and record review, the Medical Director failed to ensure medical staff oversight, in conjunction with a Nurse Practitioner (NP), in the development, execution and periodic review of the written policies governing furnished services. This deficient practice affected all patients in the facility and placed patients at risk for substandard care. The facility census was 10.

Findings included:

1. Record review of the facility document titled, "Medical Staff Bylaws," dated 02/14, showed medical staff shall coordinate and provide a forum for discussion of Hospital and Medical Staff policy and practice.

2. During an interview on 08/13/14 at 10:30 AM, Staff TT, Doctor of Osteopathy (DO), Chief of Staff, stated that he did not know if patient care policies were periodically reviewed by a physician. He stated that the medical staff representation on the Quality Management Board (QMB) was a NP. He stated there was not a physician appointed to the QMB.

During an interview on 08/13/14 at 2:45 PM, Staff A, Director of Quality, stated that:
- All departments submitted their new, revised and reviewed policies through the QMB for review and approval.
- There was no physician on the QMB;
- The QMB only forwarded new policies to the Medical Staff and Governing Board for review and approval.
- There was no physician review of the revised/reviewed policies.

Based on interview and record review, the facility failed to ensure physicians reviewed and signed the medical records of patients cared for by the Advance Practice Registered Nurse (APRN, nurse practitioners) in one record (#2) of two current patient records and two records (#45, #50) of fifteen discharged patient records reviewed. This deficient practice had the potential to adversely affect the safety and quality of care provided to patients who received care by APRNs. The facility employed three APRN. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations", dated 02/14, showed:
- The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient.
- All entries in the medical record shall be accurately dated, timed and authenticated (signed).
- All orders shall be entered into CPOE (Computerized Physician Order Entry) of the EMR (Electronic Medical Record) or in writing, dated, timed and authenticated the next time the prescribing practitioner provides care to the patient, or documents information in the patient's medical record, OR within forty-eight hours, whichever is earliest.

2. During an interview on 08/14/14 at 9:05 AM, Staff SS, MD, Collaborative Practice Physician (a physician who has signed a written agreement with an APRN to be available for collaboration at all times either in person or electronically), stated that the APRN could not admit patients. Staff SS stated that only the attending physician had admission privileges. Staff SS stated that it was the facility's policy that all orders by the APRN should be co-signed by the attending physician the day they were initiated or at the latest the following day.

3. Record review of the History and Physical (H&P) Note for current Patient #2 showed she was admitted to the facility on 07/28/14. Record review of the Physician Orders showed the following orders entered by the APRN, not signed by the attending physician:
- On 07/29/14 there were two Protocol orders (a set of predetermined criteria that define a course of action for effective management of common patient care problems), two telephone orders (TO), one verbal order (VO) and a CPOE.
- On 07/30/14 there was one computer generated order;
- On 08/01/14 there were two TO;
- On 08/02/14 there were three CPOE and four VO;
- On 08/03/14 there was one TO;
- On 08/04/14 there was one CPOE order;
- On 08/05/14 there were three TO, four CPOE orders;
- On 08/06/14 there was one CPOE order; and
- On 08/08/14 there was one CPOE order.

During an interview on 08/13/14 at 9:05 AM, Staff SS, MD, stated that he rounded daily with the APRN and that he did not know why the orders were not signed off.

4. Record review of discharged Patient #45's admission orders showed the patient was admitted on 06/19/14 by a nurse practitioner and without the signature of an attending physician. Further review of the patient's Discharge Summary dated 06/26/14 showed the nurse practitioner signed the document, again without the signature of a physician.

5. Record review of discharged Patient #50's admission orders showed the patient was admitted on 04/24/14 by a nurse practitioner without the signature of an attending physician.




















16215

Based on observations, interviews, record and policy reviews, the facility failed to ensure that:
-The facility's policies and procedures (P/P) were developed and/or reviewed at least annually with the advice of physicians.
-The facility's drugs and biologicals were kept in a locked room or container to prevent access by unauthorized individuals.
-Outdated or otherwise unusable drugs and biologicals were not available for patient use.
-The facility had a process to report adverse drug reactions (ADR) to the Federal MedWatch program (the FDA's reporting system for an adverse event-an unexpected or unanticipated outcome, death, or serious physical or psychological injury, or the risk thereof).
-The facility's Infection Control Program (ICP) had a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients, staff, contracted staff and volunteers.
-Staff followed the policy for hand hygiene when providing patient care.
-The facility had a mechanism in place to evaluate the effectiveness of the ICP and to provide corrective action when needed.
-The ICP was hospital-wide and program-specific and implemented correctly.
-The Infection Control Officer (ICO) had the authority and indications to obtain microbiological (the branch of biology that deals with microorganisms and their effects on other living organisms) cultures from patients.
-The ICP had employee health policies in place related to infectious diseases and when infected or ill staff, contracted staff and volunteers should not provide patient care and/or not report to work.
-The ICP included a definition for nosocomial (hospital acquired infections) infections and communicable diseases.
-Facility P/P were reviewed annually in all patient care areas.
- Laryngoscope blades (equipment used to insert a breathing tube in the mouth and throat) were properly disinfected and packaged in one cart of two emergency carts observed in the Emergency Department (ED).
- All equipment used in the Sleep Lab was properly cleaned, sterilized and stored in a manner to maintain sterility before patient use.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services.
The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Based on interview and policy review, the facility failed to have a member from the medical staff to participate in and have input into the development and/or review of patient care policies and procedures utilized throughout the facility by staff. This had the potential to adversely affect the quality and consistency of all patient care provided to patients. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's Swing Bed Policy and Procedure (P/P) Manual and the facility's Infection Control P/P Manual showed that a member of the medical staff did not participate and/or have input in the development and/or review of patient care and procedures.

During an interview on 08/14/14 at 11:45 AM, Staff B, Registered Nurse, Chief Nursing Officer, stated that the facility did not have any P/P committee meeting minutes and medical staff was only involved with the development and revision of the Pharmacy department's P/P and not with other patient care department P/P.

Based on observation, interview, and policy review, the facility failed to ensure medications were stored securely on two nursing units (Ambulatory Surgery and Medical Surgical) out of two nursing units observed. The facility also failed to remove outdated and/or unusable drugs so they were not available for patient use. These failures increased the potential for medications to be tampered with, potentially reducing their availability and effectiveness for patients, and/or to be diverted for abuse by patients, visitors, and staff. The facility performed approximately 50 surgical cases per month. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility policy titled, "Storage of Medications," reviewed 11/13, showed all medications on the nursing units will be stored in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts.

2. Observation in the Ambulatory Surgery Department on 08/12/14 at 10:30 AM showed:
- The medication room opened onto the hallway close to patient care rooms.
-The medication room door was open and the room was unoccupied.
- A movable cabinet containing stock medications was on the counter in the medication room and had no lock on it.
- A refrigerator containing stock medications, including anesthesia medications, was in the medication room and had no lock on it.

3. During an interview on 08/12/14 at approximately 10:30 AM, Staff U, Surgery Supervisor, stated that the medication room door was left open during work hours and the stock medication cabinet and refrigerator had no locks on them.

4. Observation in the Ambulatory Surgery Department on 08/12/14 at approximately 1:00 PM and 3:00 PM showed the medication door continued open.

5. Observations throughout the survey from 08/11/14 to 08/14/14 showed that the Medical Surgical nursing unit's medication room did not have a door or other means to secure the medications, biologicals and supplies from unauthorized entry.

6. Record review of the facility's policy titled, "Storage of Medications" reviewed 11/13 directed staff that no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with our established procedures governing the destruction of medication.

7. Observation on 08/11/14 at 2:45 PM, of the Medical Surgical nursing unit's medication room showed the following outdated medications/biologicals:
-Five 1000 ml (milliliters) bags of 5% Dextrose (sugar) solution with expiration date: 04/13.
-Four bags of Clinimix (nutritional therapy administered by intravenous-through a vein) with expiration date: 02/14.
-All four bags of Clinimix had a white powdery substance on the outside covering.

During an interview on 08/11/14 at 2:45 PM, Staff A, Director of Quality, stated that the above medications were outdated and that the four bags of Clinimix contained a white powdery substance on the outside covering.

8. During interview on 08/14/14 at 1:42 PM, Staff S, Director of Pharmacy, stated that he expected staff to remove outdated medications from patient care areas. Staff S stated that he expected staff to follow the Pharmacy department's policy and procedures.










18018

Based on interview, the facility failed to have in place, an established policy related to reporting adverse drug reactions (ADR) that occurred, in the facility, to the Food and Drug Administration (FDA) MedWatch Program (the FDA's reporting system for an adverse event, which is an unexpected or unanticipated outcome, death, or serious physical or psychological injury, or the risk thereof). This had the potential to affect all patients that received medication therapy throughout the facility. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.
Findings included:

During an interview on 08/13/14 at 11:05 AM, Staff S, Director of Pharmacy, stated that to his knowledge the facility did not have a process or policy to report ADR that occurred in the facility to the FDA MedWatch program.

Based on observations, interviews, record and policy reviews, the facility failed to ensure that:
-Staff followed the facility's Hand Hygiene policy while providing care for five (#2, #5, #6, #7, and #53) out of five patients.
-Staff followed the facility's policy for catheter (tube placed into the bladder to drain urine) irrigation (solution instilled into the catheter tube to remove an obstruction in the bladder so urine can pass) for one (#7) out of one current patient observed.
-Staff followed the facility's policy for PICC (catheter inserted into a vein for prolonged therapy) line dressing care for one (#2) out of one current patient observed.
-The facility's Infection Control Program (ICP) included a definition for nosocomial (hospital acquired infections) infections and communicable diseases.
-The ICP had a system for identifying, reporting, investigating and controlling infections and communicable diseases of staff, contracted staff and volunteers.
-The IC Policies and Procedures (P/P) was current, updated and that nurses, physicians, contracted staff and volunteers followed the facility's hand hygiene policy when providing patient care.
-The facility had a mechanism in place to evaluate the effectiveness of the ICP and to provide corrective action when needed.
-The ICP was hospital-wide (including the contracted Sleep Laboratory), program-specific and implemented correctly.
-The IC Officer (ICO) had the authority and indications to obtain microbiological (the branch of biology that deals with microorganisms and their effects on other living organisms) cultures from patients.
-The ICP had employee health policies in place related to infectious diseases and when infected or ill staff, contracted staff and volunteers should not provide patient care and/or not report to work.
- Laryngoscope blades (equipment used to insert a breathing tube in the mouth and throat) were properly disinfected and packaged in one cart of two emergency carts observed in the Emergency Department (ED).
- All equipment used in the Sleep Laboratory was properly cleaned, sterilized and stored in a manner to maintain sterility before patient use.
These failed practices increased the potential for spreading infections and increasing the risk of hospital acquired infection exposure to patients, staff, contracted staff, volunteers and anyone seeking care at the hospital. The census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.
Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," revised 09/09, showed direction for facility staff:
-Wash with soap and water when hands are visibly soiled.
-If hands are not visibly soiled, an alcohol-based hand rub may be used to decontaminate hands.
-Decontaminate hands at the following times:
-Before gloving;
-After glove removal;
-Before and after each patient contact and;
-After handling contaminated objects.

2. Observation on 08/11/14 at 2:35 PM showed:
-Staff J, Physician, and Staff K, Registered Nurse (RN), were in the ED triage room to provide care for Patient #6's nosebleed.
-Staff J and Staff K wore disposable gloves and both handled blood-stained gauze held to the patient's nose.
-Staff J left the room without removing his soiled gloves or performing hand hygiene, went to the supply room, and re-entered the triage room holding supplies in his gloved hands.
-Staff K removed her soiled gloves, left the room without performing hand hygiene, re-entered the room without performing hand hygiene, and put on a new pair of gloves.
-The patient was moved to an exam room where Staff J treated the nosebleed.
-Staff J left the exam room without removing his soiled gloves or performing hand hygiene and disposed of the soiled gloves in the wastebasket by the nursing station.

During an interview on 08/11/14 at approximately 3:00 PM, Staff K stated that facility policy was to perform hand hygiene before putting on and after taking off gloves. She stated that she failed to perform hand hygiene before putting on and after taking off gloves when she was providing care for Patient #6.

During an interview on 08/11/14 at approximately 3:15 PM, Staff J stated that he did not need to perform hand hygiene after removing gloves. He stated that the gloves protected him against acquiring disease.

During an interview on 08/13/14 at 10:30 AM, Staff TT, Chief of Staff, stated that his expectation was all physicians would follow the facility's hand hygiene policy and wash their hands. He stated that he expected physicians to wash their hands between patients and when entering or leaving a patient care room.

3. Observation on 08/12/14 at 9:05 AM, showed:
-Staff M, RN, entered Patient #7's room to discontinue an intravenous (IV-catheter placed in a vein so medication and/or fluids can be administered directly into a vein) line and to re-insert another IV line.
-Staff M put on non-sterile gloves, inserted the IV, removed the non-sterile gloves but did not perform hand hygiene after she removed the non-sterile gloves.
-Staff M then put on another pair of non-sterile gloves, removed the old IV from the patient's other arm, removed the non-sterile gloves but did not perform hand hygiene after she removed the non-sterile gloves.

Observation on 08/12/14 at 9:50 AM, showed Staff M, RN, entered Patient #7's room to administer medication. Staff M touched the patient's urostomy (a surgical procedure that diverts the normal flow of urine from the kidney's and ureters into a specially created opening where urine drains into a bag) tubing without gloves and failed to perform hand hygiene before she administered the medication.

4. Observation on 08/12/14 at approximately 2:00 PM showed:
-Patient #53 was in an Ambulatory Surgery treatment room to receive blood transfusion.
-Staff V, RN, entered the room and failed to perform hand hygiene before putting on gloves.
-Staff V touched the patient's wrist to look at her identification band.
-Staff V then removed her gloves and failed to perform hand hygiene upon leaving the room.

During an interview on 08/12/14 at approximately 2:15 PM, Staff V stated that she had gone down the hall after leaving Patient #53's room and washed her hands in the medication room.

5. During an interview on 08/12/14 at approximately 2:10 PM, Staff R, Surgery Supervisor, stated that nurses should perform hand hygiene before putting on gloves, after taking off gloves, and before and after patient contact.

6. Record review of the facility's policy titled, "Catheter Irrigation/Instilling Medication," reviewed 11/13, showed the following direction for facility staff:
-Wash hands and put on gloves.
-Disconnect catheter from drainage tube. Place the sterile protective cap over the end of the drainage tube or hold in non-dominant hand being careful not to contaminate tip of tubing.
-Put on sterile gloves after removing clean gloves.
-Upon completion of irrigation, remove the protective top from the drainage tube and wipe it with an antiseptic swab.
-Wipe the end of the catheter with an alcohol sponge, and connect the catheter to the drainage tube.
-Remove gloves and wash your hands.

7. Observation on 08/12/14 at 9:25 AM, showed Staff M, RN, entered Patient #7's room to irrigate his urostomy. After Staff M irrigated the patient's urostomy she re-connected the urostomy to the drainage tube without cleansing the end with an alcohol pad.

8. Record review of the facility's policy titled, "Redressing Care for PICC's," (a type of catheter inserted into a vein used for prolonged therapy) reviewed 09/09, showed the following direction for facility staff:
-Clean the insertion site and surrounding area using sterile technique.
-Clean the area around the insertion site with alcohol. Repeat three times and allow to dry.
-Then swabbing in a circular motion away from the insertion site, clean the area with betadine, repeat three times and allow to dry.
-Clean away the betadine with alcohol/acetone swabs. Do this again in a circular motion moving away from the insertion site.
-Apply occlusive dressing to be certain the entire site and extension tube is covered.

9. Observation on 08/12/14 at 2:50 PM, showed:
-Staff M, RN, entered Patient #2's room to change her PICC line dressing.
-Staff M put on non-sterile gloves and removed the old dressing.
-Staff M removed the old dressing and non-sterile gloves but failed to perform hand hygiene after she removed the non-sterile gloves.
-Staff M touched the area around the insertion site of the PICC line using her bare hand.
-Staff M then placed a pad under the patient's left arm and put on sterile gloves but failed to perform hand hygiene before she put on sterile gloves.
-Staff M cleansed the insertion site of the PICC line with a Chloraprep (a solution used to disinfect skin) stick.

10. Staff did not follow the facility's policy titled, "Redressing Care for PICC's," last reviewed 09/09 when staff failed to:
-Clean the area around the insertion site with alcohol. Repeat three times and allow to dry.
-Then swabbing in a circular motion away from the insertion site, clean the area with betadine, repeat three times and allow to dry.
-Clean away the betadine with alcohol/acetone swabs. Do this again in a circular motion moving away from the insertion site.

During an interview on 08/14/14 at 10:30 AM Staff B, RN, Chief Nursing Officer (CNO) stated that some of the Infection Control P/P's are not current and did not reflect current infection control standards, for example, the facility policy titled, "Redressing Care for PICC's," last reviewed 09/09, was not current because staff no longer used betadine when cleansing the insertion site.

11. During an interview on 08/14/14 at 10:30 AM, Staff XX, Registered Nurse (RN), Infection Control Officer (ICO), stated that he expected:
-Staff to follow the facility's Infection Control P/P.
-Facility staff, physicians, contracted staff and volunteers to follow the facility's hand hygiene policy.
-Staff to use either hand sanitizer or wash their hands with soap and water upon entry into a patient's room and after leaving.
-Staff to either use hand sanitizer or wash hands with soap and water before putting gloves on and after removing gloves.

12. Record review of the facility's Infection Control Program (ICP), Infection Control Log, and Infection Control Policy and Procedure (P/P) Manual showed that the Infection Control Officer (ICO) failed to ensure that:
-The ICP contained a definition for nosocomial (hospital acquired infections) infections or communicable diseases.
-The ICP contained a system to follow for identifying, reporting, investigating and controlling infections and communicable diseases of facility staff, contracted staff or volunteers.
-The Infection Control P/P Manual was reviewed and/or revised annually. The last documented review date of the manual was 10/17/12.
-Infection Control P/P were current and staff practiced current standards of infection control when caring for patients. For example, the current policy that staff used during a PICC line dressing change was last reviewed 09/09 and instructed staff to use betadine to cleanse the insertion site and is no longer the current practice staff followed.
-The ICP had a mechanism in place to evaluate the effectiveness of the program and a way that provided corrective action when needed. The last documented date the ICP had been reviewed for its effectiveness was 10/17/12.
-The ICP was hospital-wide and program-specific.
-The ICP or the Infection Control P/P Manual contained a statement that gave the ICO the authority and indication to obtain microbiological cultures from patients.
-The Infection Control P/P Manual had employee health policies in place related to infectious diseases and when infected or ill facility staff, contracted staff or volunteers should not provide patient care and/or report to work. The ICO did not have a system in place to monitor/track facility staff, contracted staff or volunteers when they called in or did not report to work due to infection or illness.

13. During an interview on 08/14/14 at 10:30 AM Staff B, RN, Chief Nursing Officer (CNO) and Staff XX, RN, ICO, stated:
-Staff XX stated that he did not know if the medical executive board had approved the facility's ICP.
-Staff XX stated that neither the ICP nor the Infection Control P/P Manual had established procedures for implementing corrective actions and those corrective measures were not applied throughout the facility.
-Staff XX stated that the ICP was not included as part of the facility's employee health program.
-Staff XX stated that he did not make observations of contracted staff or volunteers related to infection control issues.
-Staff XX stated that he did not monitor when contracted staff or volunteers called-in or did not report to work.
-Staff B stated that she received reports of facility staff call-ins but did not pass the information on to Staff XX.
-Staff XX stated that the facility did not have documented evidence that the ICP or Infection Control P/P Manual had been reviewed and/or revised since 10/17/12.
-Staff XX stated that the ICP did not contain a definition for nosocomial (hospital acquired infections) infections and communicable disease.
-Staff XX stated that he did not have a method for obtaining reports of infections and communicable diseases for patients, facility staff, contracted staff or volunteers.
-Staff XX stated that he did not have a P/P giving the ICO the authority and indication for obtaining microbiological cultures from patients.
-Staff XX stated that the facility's Employee Health P/P did not include a policy related to infectious diseases and when infected/ill staff should not provide patient care and/or must not report to work that included all facility staff, contracted staff and volunteers.
-Staff XX and Staff B stated that the ICP did not have any current quality indicators or measures the facility was monitoring or following.
-Staff B stated that some of the Infection Control P/P's are not current and did not reflect current infection control standards.

14. Record review of the facility policy titled, "Crash Cart Emergency Supplies," revised 02/07, showed emergency cart supplies include laryngoscope with various blades.

Record review of the facility policy titled, "Infection Control of the Emergency Department," revised 01/07, showed directive for staff that soiled laryngoscope blades will be cleaned and sent to the Central Sterilization Department for processing.

Record review of the 2014 sterilization and packaging guidelines by the American Association of periOperative Nurses (AORN) showed laryngoscope blades require high level disinfection and individual sealed packaging to ensure continued sterility.

15. Observation on 08/11/14 at 1:45 PM showed the emergency cart in the Emergency Department (ED) Trauma Room #2 contained unpackaged laryngoscope blades.

During an interview on 08/11/14 at approximately 1:45 PM, Staff B, Chief Nursing Officer (CNO), stated that she was unaware that laryngoscope blades need to be disinfected and sealed in individual packages.

16. Record review of the Sleep Laboratory contractor's policy titled, "Infection Control," dated 11/11, directed that all equipment used in the Sleep Laboratory must be cleaned and sterilized prior to use.

Observation on 08/12/14 at 1:55 PM in the Sleep Laboratory showed staff stored five oxygen face masks and two lengths of plastic tubing on a metal clothing hanger suspended over the top of a closet door.

During an interview on 08/12/14 at 1:55 PM, Staff P, Director of Respiratory, stated he was not sure how the contract Sleep Laboratory staff would use the oxygen masks and felt hanging the oxygen masks and tubing over the door was not an appropriate method of storing patient care equipment.

During a telephone interview on 08/19/14 at 9:33 AM, Staff EEE, Sleep Laboratory Contractor, stated that he was unsure who was responsible for the equipment hanging on the door and stated that he felt hanging over the door was not a sterile method of storing cleaned equipment.

During a telephone interview on 08/20/14 at 3:12 PM, Staff EEE confirmed the oxygen masks and tubing belonged to the Sleep Laboratory contractor. After questioning his technician who had been to the facility recently, the oxygen masks and tubing were washed and left to dry by hanging over the door. Staff EEE confirmed that hanging the cleaned masks so that the masks came in contact with the door surface may cause cross contamination onto the mask from any unwanted substances that may be on the door.



31633




32281




16215

Based on interview and record review, the facility failed to ensure:
- The Dietary department policies and procedures, approved annually, accurately described procedures for staff to follow;
- The Respiratory department policies and procedures, approved annually, accurately described procedures for staff to follow;
- The Respiratory department's contracted Sleep Laboratory (Lab) operated with policies and procedures that were approved for use in patient care by the facility's Medical Staff and Governing Body.
- The Health Information Management (HIM) policies and procedures were reviewed annually.
- The Emergency Department (ED) policies and procedures were reviewed annually.
- The Swing Bed policies and procedures were reviewed annually.
- The Infection Control policies and procedures were reviewed annually.

These failures had the potential to permit unsafe, unapproved policies and procedures to be used in patient care. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care then Skilled Nursing care at the same facility, if needed) patients.

Findings included:

1. Record review of the Dietary department's policy and procedure manual showed the Chief Nursing Officer (CNO), the organizational supervisor of the Dietary department, approved the policies and procedures in 12/13.

2. During an interview on 08/13/14 at 10:00 AM, Staff Y, Director of Dietary, stated that some of the policies were not up to date (current).

3. Record review of the facility's policy titled, "Confirmation of Diet Orders," revised 12/06, directed Staff Y to confirm a patient diet order in the medical record.

4. During an interview on 08/13/14 at 10:00 AM, Staff Y stated that:
- The "Confirmation of Diet Order" policy was approved by the CNO in 12/13 with the rest of the Dietary policies and procedures.
- Staff Y did not follow the "Confirmation of Diet Order" policy as written anymore.
- Staff Y currently received patient diet orders through the computer.
- The Dietary department had received diet orders through the computer since approximately 10/31/13 (two months prior to the CNO's approval of the policy manual).

5. Record review of the facility's policy titled, "Enteral (by way of the gastrointestinal tract) Nutrition Formulary," (a list of the available liquid nutritional supplements) revised 05/08/08, showed the Dietary department offered seven specifically named liquid oral nutritional supplements.

6. During an interview on 08/13/14 at 10:00 AM, Staff Z, Registered Dietitian (RD), stated that:
- The policy was in the Dietary department policy and procedure manual and approved in 12/13.
- The facility no longer maintained a supply of many of the products listed in the policy.
- The "Enteral Nutrition Formulary" was not a current policy.

7. Record review of the Respiratory department's policy and procedure manual showed the policies and procedures were approved by the Medical Director and the Chief Executive (CEO) on 08/30/13.

Record review of the facility's policy titled, "Respiratory Care Infection Control Policy," reviewed 2012, showed direction for Respiratory department staff to categorize work related tasks according to possible exposure to infectious material like blood, blood products, body fluids (saliva) and/or tissue. The policy identified IPPB (Intermittent Positive Pressure Breathing, a lung expansion therapy used when a patient cannot breathe deeply enough to inflate the lung) as a procedure that could expose staff to infectious material.

During an interview on 08/13/14 at approximately 1:30 PM Staff P, Director of Respiratory, stated that:
- Respiratory staff no longer performed IPPB treatments.
- Many of the other procedures listed on the "Respiratory Care Infection Control Policy" were no longer performed by staff.
- The policy was not current even though the policy and procedure manual was approved on 08/30/13.

8. During an interview on 08/12/14 at 8:58 AM, Staff P stated that:
- The Sleep Lab was located in a building across the street from the facility.
- Respiratory department staff maintained a key to the Sleep Lab.
- Respiratory department staff maintained copies of Sleep Lab patient medical records.
- He had no knowledge of Sleep Lab policies and procedures.

9. Record review of the facility's Sleep Lab contractor's policies and procedures, revised 11/11, showed the policies were not approved (no approval signatures) by the contractor's own medical director or the clinical supervisor and further review showed the policies were not approved annually by Staff P, the facility medical staff or the CEO for use with facility patients.

10. During an interview on 08/11/14 at 1:24 PM, Staff N, Health Information Management (HIM) Supervisor, stated the department policies and procedures were last reviewed on 08/11/12 and were not routinely reviewed and approved annually.

11. Record review of the ED policy and procedure manual showed the last documented review date was was 03/17/12.

During an interview on 08/11/14 at approximately 2:00 PM, Staff B, RN, CNO, stated that she thought the ED policies and procedures had been reviewed since 03/17/12 but did not provide more recent review documentation.

12. Record review of the facility's Swing Bed policy and procedure manual showed the last documented review date was 04/17/13.

During an interview on 08/13/14 at 3:08 PM, Staff B, RN, CNO, stated that the facility's Swing Bed policy and procedure manual had not been reviewed and/or revised since 04/13.

13. Record review of the facility's Infection Control policy and procedure manual showed the last documented review date was 10/17/12.

During an interview on 08/14/14 at 11:00 AM, Staff XX, RN, Infection Control Officer, stated that the facility's Infection Control policies and procedures had not been reviewed and/or revised since 10/17/12.







18018






























31633

Based on interview and record review, the facility failed to initiate a contract (written agreement) with one of one reference laboratory regularly
used to provide services to its patients. The facility failed to include the nature and scope of services for 360 of 360 contracts on two lists of facility contracts reviewed. These failures increased the potential for patient care services by arrangement to be inappropriately utilized and reviewed. The facility census was 10.

Findings included:

1. During an interview on 08/12/14 at 9:15 AM, Staff T, Laboratory Manager, stated that the facility laboratory had an arrangement with an outside reference laboratory to provide services to facility patients. She stated that she was unaware if there was a written contract between the facility and the reference laboratory.

2. Record review of a list of 251 general contracts with other providers and vendors showed no contract between the facility and the outside reference laboratory. Further record review of that list and another list of 109 facility contracts with physicians showed none of the contract entries included the nature and scope of services provided.

3. During an interview on 08/14/14 at approximately 10:00 AM, Staff YY, Administrative Secretary, stated that:
- She maintained the contract lists.
- There was no contract between the facility and the outside reference laboratory.
- She was unaware that the lists were to include the nature and scope of the services provided in each contract.

Based on interviews, record and policy review, the facility failed to follow their Nursing Care Plan policy when staff failed to incorporate a nursing care plan that addressed all patient needs that included measurable goals, interventions and time tables for three (#1,#7, #8) out of three patients reviewed. This failure had the potential to deny all patients admitted to the facility care based on their individual needs. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Nursing Care Plan" revised 09/10, showed direction for facility staff:
-To establish a uniform guide for establishing individualized patient nursing care plans.
-The plan is updated and revised periodically based on evaluation of patient progress/achievement of goals.
-Based on review and analysis of data collection/assessment, determine patient's actual or potential nursing needs/problems/concerns. Include educational needs and discharge planning.
-Establish a patient-centered goal for each nursing diagnosis.
-This is what the nurse and patient/family expect to achieve as a desired outcome of nursing care.
-Each should be concise and measurable and individualized.
-Select interventions designed to achieve the established goal.

2. Record review of Patient #1's Face Sheet showed she was admitted to the facility on 08/06/14 with complaint of a gait abnormality (deviation from normal walking).

Record review of the patient's History & Physical (H&P) dated 08/09/14, showed the patient had weight loss, palpitations (feelings of having rapid, fluttering or pounding heart), an unstable gait (a problem with walking in a coordinated manner while maintaining postural control), recent falls, dizziness and lightheadedness, depression, and lung cancer.

Record review of the patient's Admission Assessment Inquiry dated 08/11/14 showed staff documented the patient had:
- Weakness of her extremities, unsteady gait, dizziness, and required a walker and staff assistance to ambulate;
- Urgency (a sudden, compelling urge to urinate) and Stress Incontinence (inability to control the urge to urinate); and
- Decreased appetite and was eating poorly.

Record review of the patient's orders dated 08/06/14 at 2:23 PM showed an order to place the patient on Fall Precautions (safety measures to avoid injuries and falls).

Record review of the patient's Plan of Care dated 08/06/14 at 2:47 PM showed staff did not include fall risk, risk for nutritional compromise, and risk for skin breakdown due to incontinence in her Plan of Care.

3. Record review of Patient #7's Face Sheet showed he was admitted to the facility on 08/10/14 with complaints of abdominal pain and difficulty urinating.

Record review of the patient's H&P dated 08/10/14 showed that his urine was red like blood. The patient has chronic kidney failure and cancer of the prostate glands. The plan was to admit the patient and treat him accordingly.

Record review of the patient's Admission Assessment Inquiry dated 08/10/14 showed staff documented that he had a urostomy (a surgical procedure that diverts the normal flow of urine from the kidney's and ureters into a specially created opening where urine drains into a bag) with approximately five milliliters (ml) of red urine in drainage bag. Patient had bloody drainage from his penis.

Record review of the patient's orders dated 08/10/14 at 8:00 PM, showed staff documented to irrigate (procedure to remove obstruction, for example, blood clots from a urinary/urostomy catheter) the patient's urostomy prn (as needed).

Record review of the patient's Plan of Care dated 08/10/14 showed staff did not include the patient's urostomy in his Plan of Care.

4. Record review of Patient #8's Face Sheet showed she was admitted to the facility on 08/11/14 with complaints of a fall.

Record review of the patient's H&P dated 08/12/14 showed the patient was admitted due to a fall. The patient had failure to thrive and changes in her urinalysis indicating she had a urinary tract infection (UTI- is an infection that affects part of the urinary tract system).

Record review of the patient's Admission Assessment Inquiry dated 08/11/14 showed staff documented that the patient experienced urinary retention (inability to empty the bladder) and a Foley catheter (tube inserted into the bladder to drain urine) was inserted by staff.

Record review of the patient's orders dated 08/11/14 at 1:36 PM, showed an order was written to maintain Foley catheter.

Record review of the patient's Plan of Care dated 08/11/14 showed staff did not include the patient's Foley catheter or her failure to thrive in her Plan of Care.

5. During an interview on 08/12/14 at 10:30 AM, Staff M, Registered Nurse (RN), stated that since the facility began using the electronic health record (EHR) in 2012, she had never seen a completed care plan with goals and interventions. Staff M stated that since using the EHR she had never seen or did not know how to view or print a patient's completed care plan that included problems, goals and interventions.

During an interview on 08/12/14 at 1:20 PM, Staff BB, RN, stated that patient care plans did not have one screen that showed the problems, goals and interventions. Staff BB stated that the interventions will "pop" up on the EHR periodically throughout the day. Staff BB stated that patient care plans were based on assessment and problems the patient was admitted with. Staff BB stated that she had never added a care plan for a patient that was not prompted by the computer from the admission assessment that was patient specific. Staff BB stated that she had never added to the care plan, for example, when a new problem occurred with the patient she did not update or add the new problem.

During an interview on 08/13/14 at 8:38 AM and 3:40 PM, Staff B, RN, Chief Nursing Officer (CNO), stated that she would expect to see a care plan for Foley catheters if a patient had one while admitted to the facility. Staff B stated that she expected staff to follow the facility's policy and procedures. Staff B stated that she expected patient care plans to reflect current problems the patient had.

During an interview on 08/13/14 at 2:00 PM, Staff FF, RN, stated that nursing staff did not see on patients' EHR care plans that included goals and interventions.



32281

Based on interview and record review, the facility failed to ensure informed consent was properly documented in the medical record prior to surgical procedure for six patients (#17, #20, #23, #31, #35, #37) of 23 patients receiving ophthalmic (having to do with the eyes) surgery. This failure increased the potential that informed consent was not obtained prior to surgery for all patients receiving surgical procedures. The facility census was 10. The facility performed approximately 50 surgical cases per month.

Findings included:

1. Record review of the facility document titled, "Medical Staff Rules and Regulations," dated 02/14, showed these physician directives:
- All entries in the medical record shall be accurately dated, timed and authenticated.
- The performing practitioner was responsible for obtaining the patient's consent for surgical procedures.
- The informed consent must be documented in the patient's medical record.

2. Record review of ophthalmic surgery operative records showed Patients #17's, #20's, #23's, #31's, #35's and #37's signed consent forms dated 08/11/14 for each patient had no time entered.

3. During an interview on 08/13/14 at approximately 8:30 AM, Staff HH, Health Information Management (HIM) Transcriptionist, confirmed that the time was omitted from the 08/11/14 surgical consents for Patients #17, #20, #23, #31, #35, and #37. She agreed that without the time noted on the signed consent forms, there was no way to tell if consent was given by the patients prior to performing the procedures.

Based on interview and record review the facility staff failed to ensure:
- History and physicals (H&Ps) were documented (completed, dated, timed and signed) within 24 hours of admission in one (#1) of one current and four (#44, #48, #49, #52) of 11 discharged patient medical records reviewed.
- H&Ps were documented prior to surgery for one (#17) current and one (#16) discharged patient of four surgical records reviewed.
- Swing Bed H&Ps were either not updated or completed within seven days for one (#9) of three current patient records reviewed and for one (#41) of four discharged Swing Bed patient records reviewed.

These failures to maintain timely documentation had the potential to cause miscommunication regarding patient care between the admitting physician and other health care professionals who contributed to the patient's care. The facility performed approximately 50 surgical cases per month. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's undated policy titled, "Medical Records Content/Timeliness showed that a complete history and physical (H&P) must be documented within 24 hours of admission.

2. During an interview on 08/11/14 at 1: 24 PM Staff N, Supervisor, Health information Management (HIM) confirmed that patient admission H&P should be documented within 24 hours of admission.

3. Record review of current Patient #1's Admission Face Sheet showed the patient was admitted on 08/06/14 at 12:42 PM. The H&P was documented on 08/09/14, three days after admission.

4. Concurrent record review and interview with Staff N on 08/13/14 from at 8:40 AM to 9:55 AM and again from 1:20 PM to approximately 2:50 PM showed and Staff N confirmed the following:
- Patient #44, admitted on 06/27/14, had an H&P, completed, dated, timed and signed on 07/10/14.
- Patient #48, admitted on 05/12/14, had an H&P, completed, dated, timed and signed on 06/03/14.
- Patient #49, admitted on 04/23/14, had an H&P, completed, dated, timed and signed on 05/12/14.
- Patient #52, admitted on 05/20/14, had an H&P, completed, dated, timed and signed on 06/20/14.

5. Record review of the facility document titled, "Medical Staff Rules and Regulations," dated 02/14, showed the physician directive that the ambulatory surgical H&P shall be recorded no more than 30 days before (updated at the time of admission) or prior to the surgery.

6. Record review of the H&Ps for patients receiving procedures in the Ambulatory Surgery Department showed:
- Patient #16 had endoscopy (scope inserted into the body to diagnose disease) performed on 07/30/14.
- The handwritten H&P for Patient #16 was dated 07/30/14 with no time entered.
- Patient #17 had cataract (eye condition that decreases vision) removal performed on 08/11/14.
- The handwritten H&P for Patient #17 was dated 08/11/14 with no time entered.

During an interview on 08/13/14 at approximately 8:30 AM, Staff HH, HIM Transcriptionist, confirmed that the time was omitted from the handwritten H&Ps for Patient #16 and Patient #17. She further confirmed that without the time noted on the H&Ps, there was no way to tell if those were done by the physician prior to the procedure.

7. Record review of the facility's "Swing Bed Program Documentation Requirements" dated 4/13, showed that Medical Staff Documentation included: A H&P if admitted from acute care or ambulatory surgery may use existing Admission H&P with additional progress notes reflective of patient's/resident's current status. Otherwise, use same H&P format. This must be completed within seven days.

8. Record review of Patient #9's medical chart showed he was admitted to the facility as an acute care patient on 07/29/14 and admitted to the facility's Swing Bed Program on 08/01/14.

Record review of the patient's Progress Notes dated 08/02/14 showed that the physician did not update the acute care H&P or included in the Progress Note that the patient had been discharged from acute care status to the Swing Bed Program.

During an interview on 08/13/14 at 2:15 PM, Staff B, Registered Nurse (RN), Chief Nursing Officer (CNO) stated that Patient #9 did not have a H&P or Progress Note to date that tied his discharge from acute care services to admission to Swing Bed. Staff B stated that Swing Bed patients should either have an admission H&P from when they are discharged from acute care and admitted to Swing Bed status or a Progress Note stating that the patient had been discharged from acute care and admitted to Swing Bed services. Staff B stated that the H&P or the Progress Note should include the reason for the admission to Swing Bed services.

9. Record review of discharged Patient/Resident #41's Swing Bed admission face sheet showed admission 04/19/14 and the physician provided a H&P from an acute admission dated 04/16/14 without an additional progress note that the acute H&P was still accurate.

During an interview on 08/13/14 at 8:50 AM, Staff N, Supervisor, HIM confirmed that physicians were required to provide a progress note with an acute H&P that was used as a Swing Bed H&P.








18018




32281





































31633

Based on interviews, record and policy review, the facility failed to ensure staff obtained a physician's order prior to irrigating (instilling a solution into the bladder to remove an obstruction, so urine can drain out of the bladder) a urostomy (a surgical procedure that diverts the normal flow of urine from the kidney's and ureters into a specially created opening where urine drains into a bag) for one (#7) out of one current patient's Electronic Health Record (EHR) reviewed for irrigation orders. This failed practice had the potential to affect all patients needing bladder irrigation. The facility census was 10, which included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's policy titled, "Catheter Irrigation/Instilling Medications," last reviewed 11/13, showed that a licensed nurse may irrigate based on a physician's order.

2. Record review of Patient #7's History and Physical dated 08/10/14 showed that the patient was admitted to the facility with complaints of abdominal pain and his urine was completely red like blood.

Record review of the patient's Admission Assessment Inquiry dated 08/10/14 at 2:30 PM, showed staff documented that the patient had a urostomy with approximately 5 ml (milliliters) of red urine in drainage bag. Patient had bloody drainage from his penis. Attempted to irrigate the Foley (tube placed into the bladder to assist with draining urine) with sterile water, met resistance, and unable to withdraw urine.

Record review of the patient's orders dated 08/10/14 at 8:00 PM, showed an order to irrigate with Sodium Chloride irrigation solution-250 ml prn (as needed).

Staff documented that they irrigated the patient's urostomy five and a half hours before they received the physician order to perform the treatment.

3. During an interview and concurrent record review on 08/12/14 at 1:50 PM, Staff BB, Registered Nurse (RN), stated that staff needed a physician's order to irrigate a patient's Foley catheter. Staff BB reviewed Patient #7's EHR for the physician's order to irrigate his urostomy on 08/10/14. Staff BB stated that she could not find a physician's order to irrigate his urostomy in the EHR for 08/10/14.

During an interview on 08/12/14 at 2:10 PM, Staff B, RN, Chief Nursing Officer (CNO), stated staff would need a physician's order to irrigate a Foley catheter. Staff B stated that her expectation was for staff to receive a physician's order prior to irrigating a patient's Foley catheter.

During an interview on 08/12/14 at 2:10 PM, Staff M, RN, stated that a nurse would have to have a physician's order to irrigate a patient's Foley catheter.

Based on interview and record review facility staff failed to ensure patient medical records contained dated and/or timed physician's signatures on orders in two (#1, #2) of two current and eight (#14, #15, #16, #40, #46, #47, #48, #50) of 15 discharged patient medical records reviewed. This deficient practice had the potential to cause unintended, misunderstood physicians orders to be used in patient care. The facility performed approximately 50 surgical cases per month. The facility census was 10.

Findings included:

1. Record review of the facility's "Medical Staff Rules and Regulations," dated 02/14 directed the following:
- A patient may only be admitted by a member of the medical staff with admission privileges.
- The admitting practitioner was responsible for preparation of a complete medical record for the patient including admitting orders.
- All medical record entries shall be accurately dated, timed and authenticated.
- All orders for treatment and diagnostic tests must be entered in Computerized Physician's Order Entry (CPOE) or written clearly, legibly and completely and signed by the physician responsible for them.

2. During an interview on 08/11/14 at 1:24 PM, Staff N, Supervisor of Health Information Management (HIM) department stated physician's were required to sign their orders and physicians were required to sign their telephone/verbal orders (TO/VOs) within 24 hours.

3. Record review of the Physician Orders for current Patient #1 showed the following orders not dated, timed or signed by a practitioner as of 08/11/14:
-On 07/29/14 there was a Protocol order (a set of predetermined criteria that define a course of action for effective management of common patient care problems) for PICC ( Peripherally Inserted Central Catheter, a thin, soft, flexible tube inserted into a vein) care and a Protocol order for application of an ointment.
- On 07/29/14 three TO/VOs;
- On 08/01/14 two TOs;
- On 08/02/14 five TOs;
- On 08/03/14 one TO; and
- On 08/05/14 four TOs.

4. Record review of the Physician Orders for current Patient #2 showed on 08/06/14 there were 18 TO from the physician not dated, timed and signed by the practitioner as of 08/11/14. The were 12 written orders for admission, signed by the practitioner and dated 09/06/14.

5. Concurrent record review and interview with Staff N, on 08/13/14 from at 8:40 AM to 9:55 AM and continued from 1:20 PM to approximately 2:50 PM showed and Staff N confirmed the following:
- Patient #40's physician signed three TO/VOs 10 and 11 days late.
- Patient #46's physician failed to sign CPOE admission orders and signed three TO/VOs each 15 days late.
- Patient #47's physician failed to sign CPOE admission orders and signed two TOs each 18 days late.
- Patient #48's physician failed to sign CPOE admission orders and six TOs 16 and 17 days late.
- Patient #50's physician signed two TOs 24 days late and the nurse practitioner signed five TOs 19 days late.

6. Record review of the physician orders for patients receiving procedures in the Ambulatory Surgery Department showed:
- Patient #14 had endoscopy (scope inserted into the body to diagnose disease) performed on 07/30/14.
- The physician orders for Patient #14 were dated 07/30/14 and had no time entered.
- Patient #15 had endoscopy performed on 07/30/14.
- The physician orders for Patient #15 were dated 07/30/14 and had no time entered.
- Patient #16 had endoscopy performed on 07/30/14.
- The physician orders for Patient #16 were dated 07/30/14 and had no time entered.

During an interview on 08/13/14 at approximately 8:30 AM, Staff HH, HIM Transcriptionist, confirmed that the time was omitted from the operative physician orders for Patients #14, #15 and #16.




31633






32281

Based on interview and record review, the facility failed to carry out a periodic review of the total program offered. This failure had the potential to affect the quality of care and safety of all patients accessing care at the facility. The facility census was 10.

Findings included:

1. Record review of the facility's "Performance Improvement Plan", updated 06/14, showed the facility would carry out its responsibilities for ongoing monitoring and evaluation of the quality and appropriateness of patient care activities and that at least annually a consultive review of the facility quality processes would be provided.

2. During an interview on 08/14/14 at 11:00 AM, Staff E, Chief Executive Officer (CEO), stated that the facility's annual review was financial based and not quality of programs. Staff E stated that the periodic review of quality initiatives and programs had not been accomplished for the past two years.

Based on interview and record review the facility failed to ensure the Infection Control Service, and two services provided through contractors; Reference Lab and Sleep Lab, were periodically evaluated for quality of care. This deficient practice had the potential to permit unapproved practices and policies to be used in patient care. The facility census was 10.

Findings included:

1. Record review of the facility's "Plan for Performance Improvement" showed:
- The objective of the plan was to provide a mechanism to assess the delivery of care throughout the organization;
- The Quality Management Board (QMB) had oversight for all aspects of improving organizational performance efforts throughout the organization;
- The quality assessment component was designed to systematically assess the care provided by all care providers and services.
- Department Managers was responsible for developing department specific Performance Improvement measures which allowed them to monitor and improve their most important functions.

2. During an interview on 08/12/14 at 9:00 AM, Staff A, Director of Quality stated that:
- All hospital departments were expected to develop quality improvement indicators annually, to be monitored monthly and reported to the QMB every three months.
- Infection Control measures were not reported to the QMB;
- Respiratory Services did not include their contracted Sleep Laboratory and the contracted laboratory services did not report quality monitors to the QMB.

3. During an interview on 08/14/14 at 11:43 AM, Staff B, Registered Nurse (RN), Chief Nursing Officer and Staff XX, RN, Infection Control Officer stated that the facility's Infection Control Program did not have any QA indicators or measures they were monitoring.

4. During an interview on 08/12/14 at 9:15 AM, Staff T, Laboratory Manager, stated that the laboratory had an arrangement with an outside reference laboratory to provide services to facility patients. She stated that she had never seen quality reports provided to the facility by the reference laboratory.

5. Record review of the facility's Sleep Lab contract agreement dated 09/01/12 showed the contractor agreed to participate in the facility quality assessment program.

6. Record review of the Respiratory department's current Quality Assessment (QA) studies showed staff did not include any projects involving the Sleep Lab contractor.

During an interview on 08/12/14 at 8:58 AM, Staff P, Director of Respiratory stated he did not include the Sleep Lab contractor in the departmental QA and he was not responsible for the work done in the Sleep Lab (even though he maintained a key to the sleep lab location and maintained copies of the medical records of facility patients who had undergone sleep lab studies).

During an interview on 08/12/14 at 1:00 PM Staff A, Director of Quality confirmed she expected the Respiratory department's QA to include a study of the Sleep Lab contractor's work.








18018




31633




32281

Based on record review and interview, the facility failed to ensure a physician evaluated the quality and appropriateness of care furnished by two Advanced Practice Registered Nurses (APRN) (Staff K and Staff CCC) of two files reviewed. This failed practice had the potential to place all patients treated in the facility by APRNs at risk for unsafe, ineffective care. The facility census was 10.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws" dated 02/14, showed:
- Applications for appointment, reappointment, clinical privileges and specified services for Recognized Medical Affiliates (APRN) shall be submitted and processed in the same manner as for Medical Staff membership and Clinical Privileges and Appointment.
- The reappointment application shall contain information necessary to maintain, as current, the Medical Staff file on the Staff member's healthcare related activities.
- The CEO or designee shall seek to collect or verify the additional information made available on each completed reappointment application and to collect any other materials or information deemed pertinent, including information regarding the Staff member's professional activities, performance and conduct in the Hospital.
- The Medical Executive Committee (MEC) shall review information regarding the performance and clinical competence of Medical Staff members and other Practitioners with clinical privileges.

2. Record review of the facility's "Performance Improvement Plan", dated 06/14, showed the medical staff provides effective mechanisms designed to monitor and evaluate the quality of patient care and the clinical performances of individuals with delineated clinical privileges. Physician specific data is aggregated and identified trends reported to MEC. Aggregate Physician specific data is reviewed by MEC at the time of re-credentialing of medical staff.

3. During an interview on 08/12/14 at 9:00 AM, Staff A, Director of Quality, stated that there was no report to the facility's Quality Management Board (QMB) regarding the quality of care provided by Affiliate medical staff members.

4. During record review of credentialing files and concurrent interview on 08/12/14 at 1:30 PM, Staff UU, Medical Staff Coordinator, stated that she did not receive any data supporting the quality or clinical practice evaluation for APRNs for reappointment packets. The reviewed credentials files did not contain any evidence of the evaluation of quality of care for Affiliate medical staff.

5. During an interview on 08/13/14 at 10:30 AM, Staff TT, Chief of Staff, stated that the MEC was responsible for monitoring and evaluating care through the credentialing process and included results of the facilities formal peer review (the evaluation of work by one or more people of similar competence to the producers of the work; peers) process. He stated that Affiliate medical staff members were not included in the physician peer review process. He stated that he was not aware of any data presented to the MEC regarding the evaluation of the quality of care or performance by Affiliate medical staff.

6. During an interview on 08/13/14 at 3:30 PM, Staff E, Chief Executive Officer (CEO), stated that there was not an official peer review process for Affiliate medical staff members. He stated that there was not a formal evaluation process or peer review for quality of care and no written documents on file from the collaborative practice physicians showing that the care had been evaluated.

Based on record review and interview the facility failed to train staff members on how to work with the Organ Procurement Organization (OPO, an organization responsible to evaluate and obtain human organs for transplantation.) This could potentially affect all patients who die at this facility, their family members, and individuals waiting for organ donation. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Organ, Tissue, and Eye Donation (the act of giving organ(s), tissue(s), or blood to someone else without compensation)", dated 11/13, showed the hospital-designated requestor (an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community in the methodology for approaching potential donor families and requesting organ donation) discusses the option of donation with the family at the appropriate time.
- Designated requestors are trained and certified by the OPO;
- Designated requestors must be recertified every year; and
- The OPO will provide requestor training, inform the hospital of the requestors who are certified and update the list as needed.

2. Record review of the Agreement between the OPO and facility dated 02/22/09 to remain in effect until terminated, showed:
- No Physician or member of the Hospital staff, including Hospital nursing staff, shall ask a patient or a patient's family to authorize donation, unless they have been trained as a designated requestor by the OPO.
- Physician and/or Hospital personnel may participate in a request for authorization for tissue donation when such personnel have participated in a training program and are determined to be a Designated Requestors, or such personnel are trained to make an introduction to the subject of tissue donation (known as bridge builder).
- The OPO will provide designated requestor training programs or programs designed to train hospital staff and physicians to serve as bridge builders.

3. During an interview on 08/13/14 at 3:40 PM, Staff B, Registered Nurse (RN), Chief Nursing Officer (CNO), stated that she had not requested any training from the OPO. She stated that staff had not had designated requestor training or any other training related to organ donation from the OPO in the last seven years.

Based on interviews, record and policy review, the facility failed to follow their Interdisciplinary Plan of Care policy when staff failed to incorporate a nursing care plan that addressed all patient needs that included measurable goals, individualized interventions and time tables for two (#2 and #7) of two Swing Bed patients reviewed. This failure had the potential to deny all patients admitted to the facility care based on their individual needs. The facility census was 10 that included four Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's policy titled, "Interdisciplinary Plan of Care," last reviewed 04/13, showed that:
-Each resident (patient) will have an interdisciplinary, individualized plan of care.
-The interdisciplinary plan of care includes at least:
-Resident needs;
-Goals that are realistic and measurable and;
-Approaches to meet identified goals, including care/services necessary to meet goals.
-The plan of care will be reviewed/revised as necessary to meet the resident individual needs.

2. Review of Patient #2's Face Sheet showed she was admitted to the facility on 07/28/14 for physical and occupational therapies as well as wound care following a Coronary Artery Bypass Graft (CABG, open heart surgery).

Record review of the patient's History & Physical (H&P) dated 08/01/14 showed the patient had seven open wounds on her right leg that required a wound VAC (a vacuum dressing to promote healing) for treatment and another wound on her upper left thigh. The patient had weakness in the right ankle that required an inflatable splint (air splint is used to immobilize a fracture using an inflatable support) for stability and prevent falling. The patient was being treated for COPD (Chronic Obstructive Pulmonary Disease, difficulty breathing).

Record review of the patient's Admission Assessment Inquiry dated 07/28/14 at 6:28 PM showed staff documented the patient had experienced weight loss, was eating poorly due to decreased appetite and was at medium risk for malnutrition. The patient required a walker and assistance for ambulation.

Record review of the Physician Orders showed orders dated 07/28/14 at 8:51 PM to maintain a Foley catheter, dressing change to the left groin wound daily, and Ensure liquid(dietary supplement) three times a day and orders dated 07/29/14 at 12:54 PM as protocols(a set of predetermined criteria that define a course of action for effective management of common patient care problems), for PICC (Percutaneous Inserted Central Catheter, a small flexible tube inserted into a vein for giving medications) Care and application of an ointment to a wound on the patient's buttocks (bottom).

Record review of the patient's Plan of Care dated 07/28/14 at 10:14 PM and not updated as of 08/11/14, showed staff did not include the risk for nutritional compromise, risk for impaired skin integrity, wound care, Foley catheter care, fall risk, PICC line care or risk for infection in the patient's Plan of Care.

3. Record review of Patient #7's Face Sheet showed he was admitted to the facility's Swing Bed Program on 08/01/14 for physical therapy (PT) status post cerebrovascular accident (CVA-stroke).

Record review of the patient's Acute H&P dated 08/05/14 showed the patient was admitted to the facility's Swing Bed program with a diagnosis of CVA. He will need PT.

Record review of the patient's Daily Assessment Inquiry dated 08/01/14 showed staff documented the patient had the following current activity interests/preferences:
-Reading;
-Writing;
-Magazines;
-Newspaper;
-Television;
-Puzzles;
-Visiting;
-Exercise and;
-Spiritual/religious.

Record review of the patient's Interdisciplinary Plan of Care (IPC) for activities dated 08/01/14 showed the following information:
-PROBLEM: Promote Activity and Participation.
-FREQUENCY: PRN (as needed).
-INTERVENTIONS:
-Provide referral as needed.
-Urge patient to do as much for self as possible.
-Work with family to set realistic goals for self care at home.
-Instruct patient on, assist with and have patient perform ADL (activities of daily living) activities.
The patient's IPC for activities did not address individualized goals, interventions or timetables and did not include the patient's current activity interests/preferences .

During an interview on 08/13/14 at 8:38 AM, Staff B, Registered Nurse (RN), Chief Nursing Officer (CNO) stated that Patient #7's IPC for activities was not individualized for him and did not have goals or interventions. Staff B stated that his activity plan of care was very "generic".

4. During an interview on 08/13/14 at 9:05 AM, Staff EE, Certified Occupational Therapist Assistant (COTA), Swing Bed Activity Director (Activity COTA) stated that:
-She did not know how nursing staff knew about a Swing Bed patients' IPC.
-The facility's electronic health record (EHR) did not allow her to individualize Swing Bed patients' activity IPC and she was not able to add to it to reflect patients' individual interest, likes or hobbies.
-The facility's EHR did not provide a place for her to document participation or refusal of activities.
-There was no way for her to track a patient's participation in activities when she was not working.
-The nursing staff had no way of knowing what Swing Bed patients' IPC for activities included because of their lack of ability to access it in the EHR.

During an interview on 08/13/14 at 2:00 PM, Staff FF, RN, stated that staff received communication from the Activity COTA but confirmed that nursing staff were not able to see Swing Bed patients' Activity IPC in the EHR with goals and interventions. Staff FF stated that if nursing staff did not receive verbal communication they had no way of knowing a patient's interventions or goals for activities by just looking at the EHR.

During an interview on 08/13/14 at 3:40 PM, Staff B, RN, CNO, stated that she expected for staff to follow the facility's policy and procedures. Staff B stated that a patient's IPC should reflect current patient problems.

During an interview on 08/14/14 at 9:10 AM, Staff BBB, Charge RN, stated that the activity plan of care for Swing Bed patients' do not show a patient's interest, goals or interventions. Staff BBB stated that she found out about Swing Bed patients' IPC for activities by talking to the Activity COTA or the patient.


























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