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Based on observation and staff interview, it was determined the CAH failed to ensure outdated drugs and/or biologicals were not available for use in patent care areas. This has the potential to affect 100% of the patients serviced by the CAH.
Findings include:

1. During a tour of the CAH, conducted 9/25/12 thru 9/26/12, the following were observed. In the fluid warming cabinet, 2 liters of NS- expired 9/14/12 and 1 liter LR- expired 9/24/12. 2 Avagard expired 7/12, one over each surgical scrub sink.

2. During a staff interview, conducted with the Surgery Manager on 9/26/12 at 2:00 PM, it was verbalized that expired drugs and/or biologicals are expected to be removed from the area daily.

A. Based on a review of CAH IC program (meeting minutes and tracking log), a review of CAH QAPI meeting minutes, and staff interview, it was determined the CAH failed to ensure its IC program accurately tracked and reported infection surveillance in a timely manner. This has the potential to affect 100% of the patients serviced by the CAH.
Findings include:

1. The IC Committee and the QI Council meeting minutes for May 2011 thru 2012 and the IC logs for April 2011 thru Sept 2012 were reviewed on 9/26/2012. When asked why the infection results in the IC Meeting minutes did not correspond with the infection results in the QI Council minutes or with the IC log, the IC nurse verbalized that "I report them even if they have not been worked up yet. There was one Asymptomatic UTI in February 2012. The work up on it was done April 12, 2012. There was one UTI in "late Spring"; however, I have not done the work up yet. There was one Surgical Site Infection (SSI) that came in last month; however, I have not done the work up yet." When asked what prevented the completion of timely work ups, it was verbalized that "I just don't have time."

2. Example of incongruence of IC log, IC Committee meeting minutes, and QI Council meeting minutes:
The 1st quarter of 2011 (April thru June) indicated 5 HAIs (4 C- Difficile and 1 UTI). The IC meeting minutes for July 2011 indicated "This past quarter- Pneumonia and UTI were noted as the top two infections..." The subsequent QI Council meeting minutes for September 2011 indicated "We have had some Foley associated UTIs... will be providing additional information after reviewing all cases." There was no ongoing communication related to the Pneumonia or C-Difficile results.

3. Example of incongruence of IC log, IC Committee meeting minutes, and QI Council meeting minutes:
The fiscal year ending (April 2011 thru March 2012) IC log indicated 9 HAIs (5 C-Difficile and 4 UTIs). The SSI result was "zero." The IC minutes results and/or findings did not correspond to these results. The QI Council minutes dated May 17, 2011 indicated "SSI- there were three cases..." The QI Council minutes dated May 29, 2012 indicated "Data not available for this report..."

4. During a staff interview, conducted with the IC nurse, the CEO, the CNO, and the Staff Development Coordinator on 9/26/12 at 12:15 PM, it was verbalized by the IC nurse that "Sometimes I report an infection that I'm working on and then I find out it doesn't meet the criteria. I'm not sure why these don't follow one another." 1. It was further verbalized by the IC nurse in explaining the processes and results of the IC program in conjunction with the QAPI program. When asked what the process is for monitoring and reporting infections it was verbalized "I get the report from various places like nursing, the physicians, and laboratory. Once I get them, they go on my log to work up and verify whether or not it meets the standards of an HAI. I report these to the IC Committee and then to the QI Council. We had a QI Subcommittee for less than a year, but this is no longer meeting."

B. Based on observation, a review of Hydrocollator cleaning/ temperature logs, a review of CAH policy, and staff interview, it was determined in 2 of 2 Hydrocollators in use, the CAH failed to ensure its Hydrocollators were maintained at the required temperature and cleaned per CAH policy.
Findings include:

1. During a tour of the CAH, conducted 9/26/12 at 2:00 PM with the PT Manager, 2 Hydrocollators were observed, one in the PT Department (#1) and one on the Medical Surgical floor rehabilitation room (#2). The Hydrocollator cleaning/ temperature logs for 2012 were reviewed and the following findings were observed. Hydrocollator #1: 19 of 37 weeks failed to indicate cleaning of Hydrocollator #1. 5 of 37 weeks failed to indicate a temperature. 32 of 32 temperatures recorded ranged 140-145 degrees, all below 170 degrees. Hydrocollator #2: There was no documentation to indicate cleaning of Hydrocollator #2. 12 of 37 weeks failed to indicate a temperature. 25 of 25 temperatures recorded ranged 130 to 135 degrees, all below 170 degrees.

2. The CAH policy titled "Hot Pack Procedure" (reviewed 7/12) was reviewed on 9/26/12. It indicated "Hydrocollator units... cleaned every week and refilled with fresh water utilizing a thermostatic control to maintain a constant temperature... 170 degrees."

3. During a staff interview, conducted with the PT on 9/26/12 at 2:00 PM, it was verbalized that the temperature is expected to be monitored weekly and the Hydrocollators are to be cleaned every two weeks. During a staff interview, conducted with the OT Manager on 9/26/12 at 4:00 PM, it was verbalized that the temperature and cleaning of the Hydrocollators are expected to be documented weekly versus every two weeks.

A. Based on CAH policy review, a review of the 3 sink tub log, and staff interview, it was determined that the CAH failed to ensure the Dietary Department followed all the policy and procedures related to the sanitation of its pots and pans. This has the potential to affect 100% of the patients serviced by the CAH dietary services.
Findings include:

1. The CAH policy titled, "Infection Control Food Service" with a review date of 3/07, was reviewed. It indicated under "Pot and Pan Washing: 3... The solution shall contain at least 200 PPM (parts per million) of available chlorine as hypochlorite, and be at least 75 degrees Fahrenheit... 7. Sanitation water will be tested daily and recorded on log."

2. During a tour of the Dietary Department, conducted on 9/26/12 at 10:45 AM, the log for the 3 tub sink (pots and pans sink) was reviewed. There was no documentation to indicate the sanitizer solution strength and temperature were tested daily and recorded. The following are examples where the sanitizer solution strength was not tested. Between 12/15/11 and 12/31/11, there were 7 instances. In Jan 2012 there were 11 instances. In June 2012 there were 18 instances. There was no documentation on any of the logs to indicate the temperature of the sanitizer water was maintained at 75 degrees Fahrenheit.

3. During an interview with the Dietary Manager, conducted on 9/26/12 at 11:00 AM, it was verbalized that the Dietary staff were expected to record the strength of the sanitizer on a daily basis and the Dietary Department does not close for any day during the year. It was also verbalized that the Dietary Manager was not aware that the sanitizer solution was to be at 75 degrees Fahrenheit.

B. Based on a review of CAH policy, observation, and staff interview, it was determined the CAH failed to ensure all dietary food items were properly labeled after being opened, in accordance with its policy. This has the potential to affect 100% of the patients and visitors serviced by the CAH dietary services.
Findings include:

1. The CAH policy titled "Infection Control Food Service" with a review date of 3/07 was reviewed. It indicated under "Storage: 6. All food and supplies shall be clearly labeled. Food shall be dated and covered except during periods of preparation."

2. During a tour of the Dietary Department, conducted on 9/26/12 at 10:15 AM, it was observed that in the cook's line freezer, there were numerous opened food items that were not properly labeled. This included, but was not limited to, hash browns, waffles, individual sized pizzas, frozen peas, and french fries.

3. During an interview with the Dietary Manager, conducted on 9/26/12 at 10:45 AM, it was verbalized that the unlabeled items in the cook's line freezer were expected to be labeled when the items were opened.

A. Based on medical record review and staff interview, it was determined in 3 of 20 (Pts #3, #15, #16) medical records reviewed, the CAH failed to ensure incomplete and/or unclear physician orders for care were clarified to include all aspects needed to provide care to the patient being served.
Findings include:

1. The medical record of Pt #3 was reviewed on 9/26/12. Pt #3 was admitted as an inpatient to the CAH on 9/4/12 with the diagnoses Acute Mental Status Change, Hypotension, Hypoxemia, and Renal Failure. On 9/4/12 at 4:45 PM, there was a physician order "Give 500 ml bolus then increase IV to 150 ml/hour." It failed to indicate what type of IV fluid to give for the bolus or the fluid to run at 150 ml/hour. On 9/4/12 at 6:50 PM, there was a physician order "Change IV to D5NS." It failed to indicate what the rate was to be. There was no documentation to indicate the RN contacted the physician to clarify the orders.

2. The medical record of Pt #15 was reviewed on 9/27/12. Pt #15 was admitted to Outpatient services on 8/21/12 with the diagnosis Adenocarcinoma of Lung and is currently receiving Outpatient IV Chemotherapy. On 8/21/12 and 9/11/12, the physician orders failed to indicate the frequency as to which the Chemotherapy medications were to be administered. There was no documentation to indicate the RN contacted the physician to clarify the orders.

3. The medical record of Pt #16 was reviewed on 9/27/12. Pt #16 was admitted to Outpatient services on 8/7/12 with the diagnosis Osteomyelitis and is currently receiving Outpatient IV antibiotics via a vascular access device (VAD). There was no physician order to indicate the type of VAD, the use of the VAD, the type and amount of flushes to be used, the type of dressing, and cap changes. There was no documentation to indicate the RN contacted the physician to clarify the orders.

4. During a staff interview, conducted with the Staff Development Coordinator and the CNO on 9/27/12 at 2:00 PM, it was confirmed that all orders should include name of drug (IV fluid), rate/dose, frequency, dressing(s), cap changes, and any other information needed to administer the care to the patient.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 3 (Pts #3, #17) medical records reviewed, in which the patient had an IV access greater than 72 hours, the CAH failed to ensure IV sites were changed every 72 hours, as per CAH policy.
Findings include:

1. The CAH policy titled "Peripheral Intravenous Therapy" (reviewed 7/12) was reviewed on 9/26/12. It indicated "Policy: 3. All peripheral intravenous sites and tubing will be changed at least every 72 hours..."

2. The medical record of Pt #3 was reviewed on 9/26/12. Pt #3 was admitted an inpatient to the CAH on 9/4/12 with the diagnoses Acute Mental Status Change, Hypotension, Hypoxemia, and Renal Failure and was discharged on 9/8/12. Nursing documentation indicated Pt #3's IV site was started on 9/4/12. There was no documentation to indicate the IV site was changed every 72 hours, as per CAH policy.

3. The medical record of Pt #17 was reviewed on 9/27/12. It indicated Pt #17 was admitted on 3/8/12 with diagnoses of Chest Pain and Acute Febrile Episode. Documentation indicated a peripheral IV was started on 3/6/12 (while in observation status). There was no documentation that indicated the IV site was changed between 3/10 and 3/15/12 (which exceeded the 72 hour time limit).

4. During a staff interview, conducted with the Staff Development Coordinator and the CNO on 9/27/12 at 2:00 PM, it was confirmed that IV sites were to be changed every 72 hours unless the physician ordered otherwise.

A. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 7 (Pts #8, #9) medical records reviewed, in which the patient underwent a surgical procedure, there was no documentation of the physician's signature and date that the patient received an explanation of the procedure.
Findings include:

1. The CAH policy and procedure titled, "Informed Consent For Treatment" with a Review Date of 6/11, was reviewed. It indicated under, "Procedure: PHYSICIAN DECLARATION: (DONE PRIOR TO PROCEDURE) 1. It is the physician's duty to obtain the informed consent from each patient for each procedure. To satisfy this duty, the physician must disclose information in each of the following areas: patient's diagnosis, patient's prognosis, proposed treatment, risks and benefits associated with proposed treatment, a well as limitations, alternative treatment (risks and benefits explained), risks of forgoing treatment, should the patient refuse treatment, names of all physicians or practitioners involved in the procedure. The patient's questions are answered at this time. The physician then signs and dates the "Physician Declaration" for the procedure to be performed. 2. MEDICAL AND/OR SURGICAL TREATMENT: a) Consents for treatment are signed by a person qualified to give consent. An informed consent is obtained prior to the following types of procedures: surgical or invasive, all procedures where anesthesia is used...."

2. The medical record of Pt #8 was reviewed on 9/25/12. It indicated Pt #8 was admitted to the CAH on 9/25/12 with a diagnosis of Open Wound. The document titled, "Consent for Medical/Surgical Treatment Physician Declaration and Patient Consent" was reviewed. The surgical procedure is listed as "wound closure." The next section states, "I certify that I have explained to the patient to the extent reasonable and consistent with currently acceptable standards of practice, the need for and nature of the procedure, the expected outcome, pertinent alternatives, risks/consequences and common complications. All the patient's questions were answered. I authorize information for informed consent for the type of anesthesia designated by me to be given by an anesthesia practitioner." The surgical procedure was performed on 9/25/12. There was neither a physician's signature nor a date/time on the informed consent as of 9/27/12.

3. The medical record or Pt #9 was reviewed on 9/25/12. It indicated Pt #9 was admitted to the CAH on 9/24/12 with diagnoses of Iron Deficiency Anemia and Weight Loss, Abdominal Pain. The document titled, "Consent for Medical/Surgical Treatment Physician Declaration and Patient Consent" was reviewed. The surgical procedure is listed as "Esophagogastroduodenoscopy" (EGD)." The next section states, "I certify that I have explained to the patient to the extent reasonable and consistent with currently acceptable standards of practice, the need for and nature of the procedure, the expected outcome, pertinent alternatives, risks/consequences and common complications. All the patient's questions were answered. I authorize information for informed consent for the type of anesthesia designated by me to be given by an anesthesia practitioner." The surgical procedure was performed on 9/25/12. There was neither a physician's signature nor a date/time on the informed consent as of 9/26/12.

4. During an interview with the CNO, conducted on 9/25/12 at 2:45 PM, it was verbalized that the informed consent is required prior to the performance of any surgical and/or invasive procedure.

B. Based on a review of the CAH Medical Staff Bylaws Rules/Regulations of Medical Record, medical record review, and staff interview, it was determined that in 1 of 7 (Pt #8) medical records reviewed in which the patient received a surgical procedure, the CAH failed to ensure a H&P was on the record prior to the surgical procedure.
Findings include:

1. The CAH Medical Staff Bylaws Rules/Regulations of Medical Record, dated 06/2011, was reviewed. It indicated under "Medical Records 1. ...A complete inpatient medical record also includes medical history including chief complaint, details of present illness, relevant past social and family histories (as appropriate to the age of the patient), an inventory of body systems, a statement of the conclusions or impressions drawn form (sic) the admission history and physician exam, and a statement of the course of action planned for the patient while in the hospital;..." And under "III. SURGICAL SERVICE (including Anesthesia and Recovery Room) 8. A history and physical examination must be completed (and on the chart) no longer than thirty (30) days prior to surgery...."

2. The medical record of Pt #8 was reviewed on 9/25/12. It indicated Pt #8 was admitted to the CAH on 9/25/12 with a diagnosis of Open Wound. A document titled, "HISTORY AND PHYSICAL", with a dictated date of 8/16/12 was reviewed. The dictated document did not contain the information as required by the CAH Rules/Regulations. The most recent H&P contained only information related to the abdominal wound of the patient. The only History and Physical that included the required information had a dictated date of 6/2/12, more than 30 days prior to the surgical procedure. Documentation indicated that Pt #8 had a surgical procedure of a wound closure performed on 9/25/12. There was no documentation of a History and Physical on the chart prior to the procedure.

3. During an interview with the DON, conducted on 9/27/12 at 3:30pm, it was verbalized that all surgical patients must have a current H&P on their chart prior to the performance of any surgery and that H&P must contain the required information.

C. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 4 of 11 (Pts #1, #3, #17, #19) Patient and/or Swing Bed medical records reviewed, the CAH failed to ensure its DVT/ PE Risk Assessment was completed as per its CAH policy.
Findings include:

1. The CAH policy titled "DVT/ PE Risk Assessment" (reviewed 7/11) was reviewed on 9/26/12. It indicated "Policy.... The assessment will be made by the physician upon admission to inpatient or swing..."

2. The medical record of Pt #1 was reviewed on 9/25/12. Pt #1 was admitted as an inpatient to the CAH on 9/6/12 with the diagnoses Metastatic Cancer of Colon and Generalized Weakness. The DVT/ PE Risk Assessment was blank.

3. The medical record of Pt #3 was reviewed on 9/26/12. Pt #3 was admitted as an inpatient to the CAH on 9/4/12 with the diagnoses Acute Mental Status Change, Hypotension, Hypoxemia, and Renal Failure. There was no documentation to indicate a DVT/ PE Risk Assessment was completed upon admission.

4. The medical record of Pt #17 was reviewed on 9/27/12. It indicated Pt #17 was admitted on 3/8/12 with diagnoses of Chest Pain and Acute Febrile Episode. There was no documentation that indicated a DVT/ PE Risk Assessment was completed by the physician per policy and procedure.

5. The medical record of Pt #19 was reviewed on 9/27/12. It indicated Pt #19 was admitted on 9/1/12 with diagnoses of Dehydration and Nausea. There was no documentation to indicate that the physician performed a DVT/ PE Risk Assessment upon admission as per its policy.

6. During a staff interview, conducted with the Staff Development Coordinator and the CNO on 9/27/12 at 2:00 PM, it was confirmed that the physician is to complete the DVT/ PE Risk Assessment upon admission to inpatient status.

A. Based on a review of CAH policies, medical record review, and staff interview, it was determined in 2 of 5 (Pts #1, #16) medical records reviewed, in which the patient received IV therapy, the CAH failed to ensure IV and vascular access device (VAD) documentation included all pertinent information necessary to monitor the patients care.
Findings include:

1. The CAH policy titled "Central Venous Line Insertion Management" (reviewed 5/12) and the policy titled "Peripheral Intravenous Therapy" (reviewed 7/12) were reviewed on 9/27/12. Each indicated "Maintenance:..." The Central Venous Line Insertion Management policy further indicated the tegaderm dressing and caps were to be changed every 7 days. During a staff interview, conducted with the Staff Development Coordinator and the CNO on 9/27/12 at 2:00 PM, it was verbalized that the accessing of VADs, initiating of peripheral IVs, changing IV and VAD dressings, changing of VAD caps, the type/ amount/ dosage of flushes, and various other aspects related to IV/ VAD care are all expected to be documented in the corresponding "Intervention" or other related screens of the computer documentation.

2. The medical record of Pt #1 was reviewed on 9/25/12. Pt #1 was admitted to the CAH on 9/6/12 with the diagnoses Metastatic Cancer of Colon and Generalized Weakness and received IV therapy via a VAD. On 9/6/12 at 4:00 PM, nursing documentation indicated "Port accessed..." There was no documentation to indicate what type of VAD, how it was accessed (type and size of needle used), patient tolerance, solution used to flush it, blood return, or the type of dressing used (gauze or tegaderm).

3. The medical record of Pt #16 was reviewed on 9/27/12. Pt #16 was admitted to Outpatient services with the diagnosis Osteomyelitis and is currently receiving Outpatient IV antibiotics which started August 7, 2012. There was no documentation to indicate what type of VAD, solution(s) used to flush it, and blood return. There was no documentation to indicate the caps were changed every 7 days, as per CAH policy. There was no documentation to indicate the type of dressing to be used and no documentation to indicate when, or if, the dressings were changed.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 3 (Pts #17, #18) medical records reviewed, in which the patients received wound care, the CAH failed to ensure weekly wound documentation was completed, as per CAH policy.
Findings include:

1. The CAH policy titled, "Assessment of Systems" with a review date of 6/12, was reviewed. It indicated under, "G. Integumentary System: Rashes, scars, bruises, blisters, moles, warts, tumors, growths, boils, ulcers, decubitus (NOTE LOCATION AND DESCRIPTION). All wounds are photographed on admission (or when they appear) and a description is entered into the medical record. Wounds are reassessed with photograph and measurements every Wednesday ("Wound Wednesday")".

2. The medical record of Pt #17 was reviewed on 9/27/12. It indicated Pt #17 was admitted on 3/8/12 with diagnoses of Chest Pain and Acute Febrile Episode. Documentation indicated Pt #17 had a diabetic ulcer on a toe. There was no documentation that indicated the wound was photographed on admission or that the measurements of the wound was taken every Wednesday, per policy

3. The medical record of Pt #18 was reviewed on 9/27/12. It indicated Pt #18 was admitted on 9/1/12 with a diagnosis of Infected Diabetic Foot Ulcer. There was no documentation that indicated the wound was photographed on admission or that measurements of the wound were taken every Wednesday.

4. During a staff interview with the SDC, conducted on 9/27/12 at 1:15 PM, it was verbalized that all wounds are measured and documented every Wednesday.

A. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 11 (Pts #1, #3) medical records reviewed, in which verbal and/or telephone orders were utilized, the CAH failed to ensure verbal/telephone orders were signed in accordance with its policy.
Findings include:

1. The CAH policy titled "Verbal/ Telephone Orders" (reviewed 4/12) was reviewed on 9/25/12. It indicated "Policy: 1. Verbal orders are to be used sparingly and signed as soon as possible by the ordering physician. 2. Telephone orders should be signed by the ordering physician... within 48 hours."

2. The medical record of Pt #1 was reviewed on 9/25/12. Pt #1 was admitted to the CAH on 9/6/12 with the diagnoses Metastatic Cancer of Colon and Generalized Weakness and was discharged on 9/11/12. As of 9/27/12 at 2:00 PM, 7 physician orders (3 verbal and 4 telephone), which had not been signed by the physician.

3. The medical record of Pt #3 was reviewed on 9/26/12. Pt #3 was admitted to the CAH on 9/4/12 with the diagnoses Acute Mental Status Change, Hypotension, Hypoxemia, and Renal Failure and was discharged 9/8/12. As of 9/27/12 at 2:00 PM, there were 6 physician orders (1 verbal and 5 telephone) which had not been signed by the physician.

4. During a staff interview, conducted with the Staff Development Coordinator and the CNO on 9/27/12 at 2:00 PM, it was confirmed that verbal orders are to be used sparingly and signed as soon as possible and telephone orders are to be signed within 48 hours.

B. Based on medical record review and staff interview, it was determined in 4 of 20 (Pts #3, #7 #15, #16) medical records reviewed, the CAH failed to ensure documentation was timed and dated to indicate chronology of care provided.
Findings include:

1. The medical record of Pt #3 was reviewed 9/26/12. Pt #3 presented to the ED on 9/4/12 with the Chief Complaint of Mental Status Change. There was no documentation to indicate the time the MSE was completed.

2. The medical record of Pt #7 was reviewed on 9/26/12. Pt #7 was admitted to the CAH on 7/25/12 with the diagnosis Gallstones and underwent a Laparoscopic Cholecystectomy that day. The update of the H&P failed to indicate the time as to when it was updated.

3. The medical record of Pt #15 was reviewed on 9/27/12. Pt #15 was admitted to Outpatient services with the diagnosis of Adenocarcinoma of Lung and is currently receiving Outpatient IV Chemotherapy which started 8/21/12. The monthly Health Summary failed to indicate the date and time as to when it was completed.

4. The medical record of Pt #16 was reviewed on 9/27/12. Pt #16 was admitted to Outpatient services with the diagnosis Osteomyelitis and is currently receiving Outpatient IV antibiotics which started August 7, 2012. The monthly Health Summary failed to indicate the date and time as to when it was completed.

5. During a staff interview, conducted with the Staff Development Coordinator and the CNO on 9/27/12 at 2:00 PM, it was confirmed that all documentation was to be dated and timed to ensure the chronology of care can be tracked.

Based on a review of policy and procedure, medical record review and staff interview, it was determined that in 1 of 7 (Pt. #18) medical records reviewed in which the patient underwent a surgical procedure, the CAH failed to ensure there was a post-anesthetic evaluation completed.
Findings include:

1. The policy and procedure titled, "Responsibility Of Anesthesia Care - CRNA" was reviewed. It indicated under, "Management of Anesthesia: E. ... A post-operative note will be done on all patients to include level of consciousness, stability of vital signs and absence of complications."

2. The medical record of Pt. #18 was reviewed on 9/27/12. It indicated Pt #18 was admitted on 9/1/12 with a diagnosis of Infected Diabetic Foot Ulcer. The wound was surgically debrided on 9/4/12 under monitored anesthesia care/ IV sedation. There was no documentation that a post-anesthesia evaluation was performed prior to the discharge of Pt. #18 from the CAH.

3. During an interview with the Director of Surgery, conducted on 9/27/12 at 2:45PM, it was verbalized that all the post-operative patients are to have a post-operative note by Anesthesia.