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Based on observations on 12/14/11, compressed gas cylinders of oxygen are being stored outside of the oxygen store room in quantities greater than accepted by the CMS. In addition, the designated oxygen store room does not have adequate signage for the storage of oxygen.

Findings include:

CMS does allow 300 cubic feet of nonflammable gas to be stored outside of an oxygen storage room for each smoke compartment per Survey & Certification Letter (S&C) 07-010 issued on January 12, 2007. (See Attached.)

1.) During review of the facility on 12/14/11, there were three cases (12 units each) of compressed gas oxygen cylinders (E size containers) in storage at the Dining Room, Women's Restroom, and Television Room. All three of these rooms are part of one smoke compartment. Only one 12 unit rack of E sized compressed gas cylinders should be stored in this smoke compartment outside of an oxygen store room. Twelve E size compressed gas cylinders of oxygen is equal to 300 cubic feet of nonflammable gas.

2.) Secondly, the oxygen storage room in the facility is not adequately labeled to provide the minimum requirements for signage. In accordance with NFPA 99 Standard for Health Care Facilities, 1999 Edition, and Section 8-3.1.11.3 Signs; a precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on record reviews and staff interviews, the facility failed to ensure all entries by the health care professionals in the medical records were timed, dated, and signed for 6 (#s 1, 2, 3, 4, 5, and 6) of 6 records reviewed. Findings included.

1. Patient #1, a 107 year old female, was admitted to the facility swing bed program on June 29, 2009. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Nursing Monthly Summary for 1/11, 3/11, 4/11, and 5/11;
-Patient Rights;
-Agreement for Care;and
-The Elopement Risk Assessment lacked a date, time and signature.

2. Patient #2, a 74 year old female, was admitted to the facility swing bed program on August 8, 2009. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Discharge Planning;
-Nursing Admission Assessment;
-The Consent for Use and Disclosure for Treatment, Payment and Healthcare Operations;
-Social Service Assessment lacked date and time; and
-Monthly Nursing Summary for 7/11 ,8/11, and October 2011.

3. Patient #3, an 82 year old male, was admitted to the facility swing bed program on July 21, 2010. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Social Assessment lacked date, time, and signature;
-Consent for Treatment, Payment and Health Care Operations;
-Patient Rights;
-Discharge Planning;
-Nursing Admission Assessment;
-Elopement Risk Assessment; and
-Fall Risk Assessment.

4. Patient #4, a 75 year old male, was admitted to the facility swing bed program on March 24, 2011. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Consent for Treatment;
-Nursing Admission Summary;
-Patient Rights; and
-Monthly Nursing Summary for 11/11, 10/11, and September 2011.

5. Patient #5, an 86 year old female, was admitted to the facility swing bed program on December 7 2011. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Social Service Assessment lacked a signature, date, and time;
-Discharge Planning was blank and lacked a signature, date, and time;
-Consent for Treatment;
-Patient Rights;
-Fall Assessment;
-Elopement Risk Assessment; and
-Care Plan was blank and lacked a signature, date, and time.

6. Patient #6, a 91 year old female, was admitted to the facility swing bed program on May 20, 2010. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Discharge Planning;
-Social Service Assessment lacked a date and time;
-Consent for Treatment;
-Monthly Nursing Summary for 10/11;
-Quarterly Nursing Summary for 9/11;
-Fall Risk Assessment; and
-Elopement Risk Assessment.

On 12/14/11 at 11:10 a.m., the ADON and DON were interviewed regarding authentication of all entries in the medical records. The ADON stated that she was unaware that all entries needed to have a date, time, and signature. The DON stated she was not aware that entries other than nursing or physician entries needed to be dated and timed.

Based on record reviews and staff interviews, the facility failed to ensure all entries by the doctors and other health care professionals in the medical record were timed, dated, and signed for 6 (#s 1, 2, 3, 4, 5, and 6) of 6 records reviewed. Findings included:

1. Patient #1, a 107 year old female, was admitted to the facility swing bed program on June 29, 2009. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-History and Physical;
-Discharge Summary; and
-Physician Progress note dated May 26, 2011.

2. Patient #2, a 74 year old female, was admitted to the facility swing bed program on August 20, 2009. During record review on 12/14/11 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Discharge Summary; and
-History and Physical lacked time, date, and signature.

3. Patient #3, an 82 year old male, was admitted to the facility swing bed program on July 21, 2011. During record review on 12/14/11 at 10:00 a.m., it indicated that the following document lacked a time of when the signature was obtained:
-History and Physical.

4. Patient #4, a 75 year old male, was admitted to the facility swing bed program March 24, 2011. During record review on 12/14/10 at 10:00 a.m., it indicated that the following documents lacked a time of when the signature was obtained:
-Physician's Recapitulation Orders for 12/11 lacked a date or time;
-Monthly Physician Note dated 10/12/11; and
-History and Physical.

5. Patient #5, an 86 year old female, was admitted to the facility swing bed program on December 7, 2011. During record review on 12/14/10 at 10:00 a.m., it indicated that the following document lacked a time of when the signature was obtained:
-History and Physical.

6. Patient #6, a 91 year old female, was admitted to the facility swing bed program on May 20, 2010. During record review on 12/14/11 at 10:00 a.m., it indicated that the following document lacked a time of when the signature was obtained:
-History and Physical;

On 12/14/11 at 11:10 a.m., the ADON and DON were interviewed regarding authentication of all entries in the medical records. The ADON stated that she was unaware that all entries needed to have a date, time, and signature. The DON stated she was not aware that entries other than nursing or physician entries needed to be dated and timed.

Based on record review and staff interviews, the facility failed to ensure that a comprehensive nursing assessment for 1 (# 4) of 6 swing bed residents was completed. Findings include:

Patient #4, a 75 year old male, was admitted to the facility swing bed program on 3/24/11 with diagnoses including peripheral neuropathy, peripheral vascular disease, chronic obstructive pulmonary disease, osteoarthritis, and back pain. During record review on 12/14/10 at 10:00 a.m., the admission nursing assessment dated 3/24/11 indicated that resident #4 had short term and long term memory problems. The nursing assessment did not indicate an assess was completed regarding the resident's smoking. There was no information if the resident was safe to smoke, oriented to where to smoke, and was able to self-administer his medications. The medical record lacked documentation that a direct observation or communication was completed with resident #4 to obtain information regarding smoking and self-administering medications.

On 12/14/11 at 9:30 a.m., the ADON stated that resident #4 was admitted after the facility was designated a non-smoking facility. The ADON stated the facility became non-smoking about a year ago. There was not an assessment completed regarding resident #4's ability to smoke. Resident #4 keeps his smoking supplies in his room. Staff does not monitor his supply or where he keeps the supply. Resident #4 does know where to smoke off campus and will sign himself out.

On 12/14/11 at 11:30 a.m., resident #4 stated that he knows he is suppose to smoke off the hospital property. Resident #4 stated he keeps his cigarettes and lighters in his night stand, and on his person. At this time, resident #4 opened his night stand drawer, and there were cigarettes and a lighter. In the night stand drawer the surveyor observed medications for a breathing treatment. Resident #4 stated that he was responsible for doing his own breathing treatment about every 4 hours. When the surveyor asked if the nursing staff checks on how often he does a breathing treatment, he stated no. Resident #4 stated "he does not write down when he completes a treatment."

On 12/14/11, at 11:30 a.m., the ADON stated that resident #4 does his breathing treatments and that there was no documentation completed by the nursing staff. There was not an assessment completed regarding his ability to safely and accurately self-administer his medications.

On 12/14/11 at 3:45 p.m., the DON stated that she was unaware that an assessment was to be completed for resident #4's ability to safely smoke and to self-administer medications.

Based on record reviews and staff interviews, the facility failed to develop a care plan for 2 (#s 4 and 5) of 6 sampled patients. Findings include:

1. Patient #5, an 86 year old female, was admitted to the facility swing bed program on 12/7/11 with diagnoses including dementia, anxiety disorder, depressive disorder, hypertension, and urinary tract infection. During record review on 12/14/10 at 10:00 a.m., the care plan was blank. The facility did not develop a care plan for patient #5.

On 12/14/11 at 3:45 p.m., the DON stated that a care plan should have been completed.

2. Patient #4, a 75 year old male, was admitted to the facility swing bed program on 3/24/11 with diagnoses including peripheral neuropathy, peripheral vascular disease, chronic obstructive pulmonary disease, osteoarthritis, and back pain. During record review on 12/14/10 at 10:00 a.m., the care plan did not address the following areas:
-ability to smoke independently;
-where the designated smoking area was located;
-interventions for monitoring his ability to smoke safely;
-where his cigarettes and lighters were stored;
-ability to self administer his medications; and
-interventions for monitoring his ability to administer his medications.

Review of the care plan developed on 3/24/11 indicated "administer medications as ordered to assist with breathing."

On 12/14/11 at 9:30 a.m., the ADON stated that resident #4 was admitted after the facility was designated a non-smoking facility.

On 12/14/11 at 11:30 a.m., the ADON stated that resident #4 does his breathing treatments and that there was no documentation by nursing staff.

On 12/14/11 at 3:45 p.m., the DON stated that a care plan should have been completed to address his smoking and self-administration of medications.

Based on clinical record review and staff interviews, the facility failed to ensure that medications ordered by the physician were given for 1 (#4) of 6 sampled residents. Findings include:

Patient #4, a 75 year old male, was admitted to the facility swing bed program on 3/24/11 with diagnoses including peripheral neuropathy, peripheral vascular disease, chronic obstructive pulmonary disease, osteoarthritis, and back pain. During record review on 12/14/10 at 10:00 a.m., the admission nursing assessment dated 3/24/11 indicated that resident #4 had short term and long term memory problems. The physician's orders were reviewed and lacked indication that resident #4 could self administer medications. The physician order dated 10/28/11 indicated Albuterol Neb (nebulizer) IH (inhaler) PRN (as needed) and Duoneb, IH QID ( four times a day). The active medical record lacked an assessment that he was able to self administer his medications and which medications. Review of the care plan developed on 3/24/11 indicated "administer medications as ordered to assist with breathing."

On 12/14/11 at 11:30 a.m., resident #4 stated that he was responsible for doing his own breathing treatments about every 4 hours. Resident #4 "was not sure which medication," the Albuterol or the Duoneb, "he was administering." In the night stand drawer, the surveyor observed medications for a breathing treatment. When the surveyor asked if the nursing staff check on how often he does a treatment, he stated no. Resident #4 stated "he does not write down when he completes a treatment."

On 12/14/11 at 11:30 a.m., the ADON stated that resident #4 does his breathing treatments and that documentation was not required of the nursing staff. The ADON was not sure what medications he was using for his breathing treatments.

On 12/14/11 at 3:45 p.m., the DON stated that she did not know what medications he was using for his breathing treatments.