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Based on record review and interview, the facility failed to inform all in-patients and out-patients of their right to formulate advance directives for 6 (#s 3, 10, 20, 21, 22, and 26); and inform in writing all in-patients, surgical patients, and patients who receive anesthesia services notice the facility had no continuous (24 hours/7 days) medical doctor or doctor of osteopathy coverage for 11(# 3, 10, 16, 19, 20, 21, 22, 23, 27, 28 and 29) of 36 sampled patients. Findings include:

RIGHT TO FORMULATE ADVANCE DIRECTIVES:

1. Patient #26 was re-certified for out-patient physical therapy on 6/2/16.

On 7/19/16 at 4 p.m., staff member B was given a written request for copies of patient #26's admission forms and consents for his current out patient physical therapy services. Patient #26 signed a document titled, Conditions of Admission, on 6/2/16, which reflected a lack of information on a patient's rights to formulate advanced directives.

2. Patient #22 was admitted on 3/19/16 to medical/surgical in-patient services.

3. Patient #20 was admitted on 4/15/16 to medical/surgical in-patient services.

4. Patient #21 was admitted on 4/2/16 to medical/surgical in-patient services.

5. Patient #10 was admitted on 6/6/16 to medical/surgical in-patient services.

6. Patient #3 was admitted on 7/16/16 to medical/surgical in-patient services.

On 7/19/16 at 4 p.m., staff member B was given a written request for evidence the facility provided patients #s 3, 10, 20, 21, 22 information on their right to formulate advanced directives. No documentation regarding advanced directives was received.

Review of the facility's policy on Advanced Directives reflected written materials on the Patient's Self-Determination Act would be provided to all adult patients who were admitted as in-patients.

Review of the facility's Nursing and Swing Bed Patient's Bill of Rights reflected patients have the right to make end-of-life decisions that would be honored.

During an interview on 7/21/16 at 3:15 p.m., staff member A stated his understanding of the patient's right to formulate advance directives were for Swing Bed patients, not all in-patients and out-patients.

RIGHT TO BE INFORMED OF NO MD/DO 24/7:

1. Patient #27 received a surgery on 1/20/16.

2. Patient #29 received a surgery on 3/23/16.

3. Patient #28 received a surgery on 6/1/16.

4. Patient #23 was admitted on 3/2/16 to medical/surgical in-patient services.

5. Patient #22 was admitted on 3/19/16 to medical/surgical in-patient services.

6. Patient #16 was admitted on 3/28/16 to medical/surgical in-patient services.

7. Patient #20 was admitted on 4/15/16 to medical/surgical in-patient services.

8. Patient #21 was admitted on 4/2/16 to medical/surgical in-patient services.

9. Patient #19 was admitted on 5/7/16 to medical/surgical in-patient services.

10. Patient #10 was admitted on 6/6/16 to medical/surgical in-patient services.

11. Patient #3 was admitted on 7/16/16 to medical/surgical in-patient services.

On 7/20/16 at 4:00 p.m., staff member B was given a written request for evidence the facility provided patients #s 3, 10, 16, 19, 20, 21, 22, 23, 27, 28 and 29 notice of no continuous medical doctor or doctor of osteopathy coverage. No documentation of notices were received.

During the exit conference on 7/21/16 at 4:00 p.m., staff member O stated the facility had previously considered including the patient notification of no continuous medical doctor or doctor of osteopathy coverage, on the Conditions of Admission form, but could not recall why it had not been included.

Based on record review and interview, the facility failed to maintain a record keeping system to ensure medical licensure determination was current for their appointed staff, which had the potential to affect all patients who received services from an unlicensed medical professional. Findings include:

A review of the facility's credentialing files reflected a lack of current license determination:

-Non-staff members' LL, NN, and OO medical & DEA licenses were not current.
-Non-staff members' CC, DD, EE, FF, HH, II, MM, PP, QQ, and TT medical licenses were not current.
-Non-staff member JJ had no medical license on file.
-Non-staff member RR had no current DEA license on file.
-Non-staff member SS had no DEA license on file.

During an interview on 7/21/16 at 3:15 p.m., staff member A stated licensing questions needed to be discussed with staff member P. An interview was requested with staff member P, but was not obtained prior to the exit conference.

During the exit conference, staff members A, B, O, P, and Q were advised that additional information could be faxed to the State Agency for consideration, by the morning on 7/25/16. The facility faxed copies of current medical and DEA licenses.

Based on record review and interview, the facility failed to ensure medical providers applicants had timely appointments and credentialing. Findings include:

A review of the facility's credentialing files reflected:

-Non-staff member KK and II were granted a temporary 120 day appointments on 7/2015. Their files reflected a lack of additional information after the temporary appointments.
-Non-staff member AA was granted a temporary 120 day appointment on 12/2015. Their files reflected a lack of additional information after the temporary appointment.
-Non-staff member AA and BB were granted a temporary 120 day appointment on 12/2015. The file reflected a lack of additional information after the temporary appointment.
-Non-staff member's CC, DD, EE, FF, GG, HH, and JJ files reflected a lack of information regarding appointment or credentialing.

During an interview on 7/21/16 at 3:15 p.m., staff member A stated staff member P could answer questions regarding appointment and credentialing. An interview was requested for staff member P, but unable to obtain prior to the exit conference.

During the exit conference on 7/21/16 at 3:45 p.m, staff members A, B, O, P, and Q were advised that additional information could be faxed to the State Agency for consideration, by the morning on 7/25/16. No additional appointment or credentialing information was received.

Based on observation, record review and interview, the facility failed to ensure a routine audit was completed for the crash cart supplies used in the surgical suite, which potentially could affect all surgical patients experiencing an adverse event requiring emergency supplies. Findings include:

During an observation on 7/20/16 at 3:00 p.m., the surgical suite's crash cart log had only one audit entry on 7/18/16 for July. No audits were logged for 7/1/16 - 7/17/16, or 7/19/16 - 7/20/16.

During an interview on 7/20/16 at 3:00 p.m. staff member D stated the staff were not routinely auditing the surgical suite's crash cart. Staff member D stated he knew that was a problem, and would be working to improve that system.

On 7/21/16 at 9:00 a.m., staff member B was given a written request for a policy and procedure for crash cart audits. No policy was received.

Based on record review and interview, the facility failed to ensure their pneumococcal vaccine policy reflected the most current CDC guidelines (CDC, Morbidity and Mortality Report, September 4, 2015), which had the potential to affect all patients medically eligible to receive the pneumococcal vaccine. Findings include:

During a review of the facility's infection control policies, the pneumococcal vaccine policy reflected a lack of information on the current CDC guidelines on the use of both the 13-Valent Pneumococcal Conjugate Vaccine and the 23-Valent Pneumococcal Polysaccharide Vaccine.

During the exit conference on 7/21/16 at 3:45 p.m., staff member O stated their pneumococcal vaccine policy was currently being reviewed. Staff member A and B were advised that additional information could be faxed to the State Agency for consideration, by the morning of 7/25/16. No pneumococcal vaccine policy was received.

Based on record review and interview the facility failed to ensure their nursing staff received the necessary training to provide safe and effective emergency and trauma services, which had the potential to affect all patients needing emergency services. Findings include:

Record review of the Nursing Department Description for Licensed Practical Nurse reflected required credentials included a current BLS, and PALS, and ACLS within 120 days of hire.

Record review of the Nursing Department Description for Registered Nurse reflected required credentials included a current BLS, and PALS, ACLS, and TNCC within six months of hire.

On 7/21/16 at 11:35 a.m., staff member Q was given a written request for evidence of current nursing credentials for the following employees:

-Staff member G's PALS.
-Staff member R's BLS.
-Staff member S's BLS, PALS, and TNCC.
-No documentation was provided.

During an interview on 7/19/16 at 1:10 p.m., staff member B stated the nurses who work with the in-patients also float to the emergency department. Staff member B stated she was working on a system to track the nurses credentialing requirements. Staff member B stated it can be difficult to find and send staff to required trainings.

Based on record review and interview, the facility failed to ensure a surgical consent was provided for 1 (#27) of 36 sampled patients. Findings include:

Patient #27 received surgery on 1/20/16.

On 7/20/16 at 4:00 p.m., staff member B was given a written request for patient #27's consent for surgery. No documentation of surgery consent (including risk and benefits) was received.

During the exit conference on 7/21/16 at 3:45 p.m., staff member A and B were informed additional information on patient #27's surgical consent could be faxed to the State Agency for consideration, by the morning of 7/25/16. No consent for surgery was received.

Based on record review and interview the facility failed to ensure a post-anesthesia evaluation was completed for 1 (# 29); and a qualified medical provider (MD/DO; a doctor of dental surgery or dental medicine; or a doctor of podiatric medicine) completed an evaluation immediately before the surgery to evaluate the risk of the procedure for 3 (#s 27, 28 and 29) of 3 surgical patients, out of 36 sampled patients. Findings include:

1.. Patient #29 had a surgery at the facility on 3/23/16.

On 7/20/16 at 4:00 p.m., staff member B was given a written request for patient #29's post-anesthesia evaluation. No documentation was provided.

During the exit conference on 7/21/16 at 3:45 p.m., staff member A and B were informed additional information on patient #29's post-anesthesia evaluation could be faxed to the State Agency for consideration, by the morning of 7/25/16. No post-anesthesia evaluation was received.

2. On 7/20/16 at 4:00 p.m., staff member B was given a written request for patient #s 27, #28, and #29's qualified provider examination immediately prior to his surgery. No documentation was received.

On 7/21/16 at 9:00 a.m., staff member B was given a written request for a policy and procedure for the qualified practitioner to provide an evaluation immediately before the surgery, to evaluate the risk of the procedure. No policy was provided.

During the exit conference on 7/21/16 at 4:00 p.m., staff member O stated the regulatory language for the "qualified provider" was easily misunderstood, as the definition was referenced to another section in the regulations.

Based on record review and interviews, the facility failed to show evidence their staff received background checks before being hired. Additionally, the facility failed to show evidence their staff had been educated in abuse and neglect, which had the potential to affect all patients at the facility who require abuse prevention, and identification, interventions, and state reporting as potential or actual abuse victims. Findings include:

-A review of the facilities personnel files for five of the staff had no evidence that a background check had been done or the Abuse Registry checked when the staff was hired to work at the facility.

During an interview on 7/20/16 at 4:30 p.m., staff member I stated that she knew the nursing homes required a background check of their employees but that it is not a requirement of the CAH. Staff member I stated the new staff go through orientation and receive education on the Abuse Policy and Procedure.

There was no evidence the background check was done when checking the license. There was no evidence for the non-licensed personnel that a background check was done.

-During an interview on 7/21/16 at 1:00 p.m., staff member T stated in the time he has been at the facility that he has never had abuse training.

During an interview on 7/21/16 at 2:00 p.m., staff member G stated that in the time she had been at the facility she has never had education on abuse.

During an interview on 7/21/16 at 2:20 p.m., staff member M stated that he had no abuse training recently. He could not remember if he got information during his orientation.

A review of the facility's orientation packet showed there was no copy of the abuse policy and procedure.

A review of the personnel files showed the files lacked any confirmation the staff received the abuse policy and procedure, or read it.



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During an interview on 7/18/16 at 2:25 p.m., staff member C stated she had worked at the facility for 35 years. Staff member C could not recall any facility training on abuse and neglect.

During an interview on 7/19/16 at 1:10 p.m., staff member B stated the nursing staff who worked with the medical/surgical in-patients had not received training on abuse and neglect.

During an interview on 7/20/16 at 10:05 a.m., staff member F stated he had never been trained at the facility on abuse and neglect.

During an interview on 7/21/16 at 9:50 a.m., staff member H stated she missed her scheduled new hire orientation, but to date had not been oriented on abuse or neglect.

During an interview on 7/21/16 at 10:10 a.m., staff member E stated she had worked at the facility for more than 25 years and could not recall ever being oriented on abuse or neglect.

During the exit interview on 7/21/16 at 3:45 p.m., staff member A stated that he thought just looking up the license would be good enough for a background check.

Based on observations, interviews and record review, the facility failed to list a qualified person who could set up activity programs for the swing bed patients for 2 (#s 1, and 2) of 36 sampled patients. Findings include:

1. Patient #1 was admitted to the facility on 7/7/16 to swing bed status with a diagnosis of failure to thrive.

During an observation on 7/18/16 at 4:30 p.m., Patient #1 was in her room, in her bed watching television.

During an interview on 7/18/16 at 4:30 p.m., Patient #1 stated she does not remember any one talking to her about activities. Patient #1 stated that it was okay, because she doesn't have a desire for activities; she is just happy with watching television.

2. Patient #2 was admitted to the facility in swing bed status on 7/14/16.

During an observation on 7/18/16 at 4:55 p.m., patient #2 was walking with a walker from the bathroom, around the bed to the chair. Patient #2 took two rest periods as she was going around the bed. Patient #2 sat in her chair and proceeded in eat her supper.

During an interview on 7/19/16 at 7:30 a.m., patient #2 stated she could not remember if the facility talked to her about activities when she was admitted.

During an interview on 7/21/19 at 10:00 a.m., staff member B stated the facility did not have a activity director or an equivalent. The nurses were to offer activities and then chart the activity.