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Based on record review and interview, staff at this facility failed to ensure that Medicare eligible patients are provided the Medicare discharge appeal rights information within 48 hours of admission and/or discharge in 3 out of 5 out of a total of 20 medical records reviewed (Patient #14, 15 and 18.) Staff at this facility also failed to inquire about Advanced Directives for 2 out of 7 patients admitted for inpatient status (Patient #18 and 19.)

Findings include:

Per interview on 1/8/2017 at 2:40 PM with Discharge Planning Coordinator, Registered Nurse V, Nurse V stated that the Medicare Discharge Appeal Notice (also known as the Important Message from Medicare) is given to patients within 48 hours of admission to sign and date, and within 48 hours of discharge to sign and date. On this form the front side is signed on or close to admission and the back side is signed on or close to discharge.

Medicare Discharge Appeal Notice:
Patient #14's closed medical record was reviewed on 1/10/2018 at 7:15 AM accompanied by Medical/Surgical Nurse Manager U who confirmed the following findings: Patient #14, 71 years old, was admitted to the facility on 3/11/2017 and discharged on 3/13/2017, then readmitted on 3/26/2017 and discharged on 3/29/2017. For the admission of 3/11/2017, on the front and back side of the form an unidentified person wrote in, "Patient unable to sign POA [power of attorney] not present." There were no dates and it is unknown who wrote this statement.

For Patient #14's admission of 3/26/2017, there was only one side of the Medicare Discharge Appeal form scanned in to the computer. There was no evidence that the back side of the form was signed.

Patient #15's (88 years old) closed medical record was reviewed on 1/10/2018 at 7:55 AM accompanied by Nurse Manager U who confirmed the following findings: For Patient #15's inpatient episode of 4/1/2017-4/6/2017 there was no signed Medicare Discharge Appeal form prior to discharge.

Patient #18's open medical record was reviewed on 1/10/2018 at 10:00 AM accompanied by Nurse Manager U who confirmed the following finding: Patient #18, 66 years old, was admitted on 1/8/2018. The Medicare Discharge Appeal notice was signed but not dated or timed.

Advanced Directives:
Patient #18's open medical record was reviewed on 1/10/2018 at 10:00 AM accompanied by Nurse Manager U who confirmed the following finding: Patient #18 was admitted on 1/8/2018. Nursing did not address Advanced Directive status on admission. Per interview with Nurse U on 1/10/2018 at 10:13 AM regarding advanced directives being addressed, Nurse U stated, "No it was not addressed."

Patient #19's open medical record was reviewed on 1/10/2018 at 10:16 AM accompanied by Nurse Manager U who confirmed the following finding: Patient #19 was admitted on 1/8/2018. Nursing did not address Advanced Directive status on admission.

The facility's policy titled, "Advance Directives," dated 10/26/2017, was reviewed on 1/10/2018 at 10:50 AM. The policy states in part, "Inquire about Advance Directives. During the admission process, the persons outlined in #2 below [reference to nursing in the hospital and social work in the nursing home] will ask the patient whether he/she has completed an advance directive."

Per interview with Director of Nursing B on 1/10/2018 at 11:00 AM regarding a policy for the Medicare Discharge Appeal form, Director B stated, "There is no policy, only the form."

Based on observation, record reviews and staff interviews the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0133 - Multiple Occupancies-Construction Type
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0372 - Subdivision of Building Space

Based on observation, record review and interview, the facility failed to ensure equipment used for patient treatments is routinely inspected for safety, in 6 of 6 Hi-lo tables, in 2 of 5 ultrasound warmers, in 1 of 1 treatment chair, in 1 of 1 iontophoresis (an electrical stimulator) and in 1 of 1 Dynometer (to measure hand grip strength).

Findings include:

Review of facility policy titled Inventory and Inspection of New Equipment, revised 1/17, revealed under 2. "After receipt of any new equipment, but prior to installation, it must be inspected..."

Per observation on 1/9/18 at 11:50 AM in the wound care room, the Hi-Lo table has no inspection sticker, the ultrasound warmer has no inspection sticker and the treatment chair had an inspection date of 5/14/13. This deficiency was confirmed on 1/9/18 at 11:45 AM with Director of Nursing B, who agreed there should be annual inspections of the equipment.

On 1/9/18 between 1:15 PM and 2:15 PM the following was observed in the Physical Therapy Department:
Exam Room 1 had a Hi-lo table with an illegible inspection date.
Exam Room 2 had a Hi-lo table with no inspection sticker
Exam Room 3 had a Hi-lo table with an inspection sticker dated 2001
Exam Room 4 had a Hi-lo table with an inspection sticker dated 2006
Pediatric Room had a Hi-lo table with no inspection sticker.
The ultra sound warmer in the main gym had an inspection sticker dated 2015.
The iontophoresis unit has not inspection sticker and the Dynometer has no inspection sticker.

The above deficiencies were confirmed in interview with Physical Therapy Manager KK on 1/9/18 between 1:15 PM and 2:15 PM, who agreed they all should have current inspections.

Per interview with Building Operations Manager C on 1/10/19 at 10:15 AM, equipment is to be inspected upon receipt and before patient use, but does not know manufacturer instructions on continued maintenance. Manager C does not have an Alternative Equipment Maintenance list.

Based on observation and interview the facility failed to ensure dirty items are not stored in treatment rooms, in 1 of 6 treatment rooms observed (Exam room 8).

Findings include:

Per observation on 1/9/18 at 1:35 PM, Exam Room 8 had a sheet covered dirty laundry bin along with a Hi-lo table. At 1:43 PM Physical Therapy Aide MM entered Exam Room 8 and exited carrying linens and placed them in a laundry bin in the corridor. Per interview with Aide MM, s/he removed the linens because it looked like the room had been used.

Per interview with Building Operations Manager C on 1/10/18 at 10:00 AM s/he agreed the dirty linen should be stored in a treatment room.

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0133 - Multiple Occupancies-Construction Type
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0372 - Subdivision of Building Space

Based on record review and interview the facility failed to ensure there are guidelines for midlevel staff to follow in the event a Medical Doctor is not available in an emergent situation, in 1 of 1 policy on medical staff guidelines.

Findings include:

Per interview on 1/8/18 at 9:40 AM with Emergency Room Manager E, Nurse Practitioners work in the Urgent Care area. Manager E said there is no policy in place with guidelines for the Nurse Practitioners to follow in emergent situations.

Review of facility policy titled Physician & Allied Health Professional Staff Class Guidelines, reviewed 12/2016, there were no guidelines for midlevel practitioners in the urgent care department.

Based on observation, record review, and interview, staff at this facility failed to maintain an environment free of potential contamination to patients and other staff by not adhering to infection prevention expectations of the facility and nationally recognized standards of practice in 7 out of 10 departments observed (Emergency Department, Obstetrical Department, Kitchen, Respiratory Therapy Department, Physical Therapy Department, Nuclear Medicine, Surgical and Decontamination area, Medical/Surgical Unit), 14 of 15 observed (H, N, O, P, Q, S, T, X, CC, DD, EE, FF, HH and LL) and 3 of 3 observations of care (Patient #1, 11 and 22).

The facility's policy titled, "Hand Hygiene," dated 7/27/17, was reviewed on 1/9/2018 at 2:58 PM. The policy reveals in part, "Alcohol-based hand sanitizer use is permitted, if hands are not visibly soiled. Decontamination of hands using an alcohol-based hand sanitizer to be done at the following times: 1. Before any direct contact with patient skin. 2. After you have touched a patient's intact skin, such as after taking a pulse, temperature, or blood pressure or moving a patient/resident...3. Before non-surgical insertion of any invasive device, such as as urinary catheters or IVs [intravenous]. 4. When you come in contact with inanimate objects in a patient's immediate vicinity, including medical equipment. 5. Before donning gloves and after removing gloves that are not visibly soiled...8. Before and during medication preparation and dispensing..."

The facility's policy titled, "Cleaning and Sterilizing Instruments," dated 10/17/17, was reviewed on 1/9/2018 at 2:47 PM. The policy reveals in part, "Surgical instruments and powered equipment should be cleansed and handled according to manufacturer's instructions."

The facility's policy titled, " Intravenous Therapy: Medication Administration," dated 12/2/16, was reviewed on 1/9/2018 at 3:00 PM. The policy reveals in part, "B. IV [intravenous] bolus injection...(6) Cleanse port with alcohol wipe."

The facility's policy titled, "Attire in the Surgery Department," dated 6/19/17, was reviewed on 1/9/2018 at 4:05 PM. The policy does not reflect the updated recommendation from the Association of peri-Operative Registered Nurses to ensure that ears are also covered with the surgical cap. Per interview with Peri-Operative Nurse Manager R on 1/9/2018 at 4:05 PM, Manager R stated R looked up the recommendation and did find that the ears should be covered.

Association of periOperative Registered Nurses Guidelines for PeriOperative Practice
Recommendation III Published online January 2017, III.a. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn. [2: Moderate Evidence]

Per interview with periOoperative Nurse Manager R on 1/9/2018 at 8:02 AM regarding standards of practice followed in the Surgical department, Manager R stated, "AORN [Association of peri-Operative Registered Nurses] and AAMI [Association for the Advancement of Medical Instrumentation]."

Per interview with Infection Preventionist, Registered Nurse BB on 1/9/2018 at 3:16 PM regarding Standards of Practice for infection control in the facility, Nurse BB stated the following standards are followed, "APIC [Association of Professionals in Infection Control and Epidemiology], CDC [Centers for Disease Control], AORN, AAMI, and WHO [World Health Organization] for the 5 points of hand hygiene."

Nurse BB also stated that BB does not go in to the Surgical Suite to do infection prevention audits. Nurse BB stated that BB relies on the Operating Room staff to do that.

Observation in the Emergency Department:

The following was observed on 1/8/18 between 10:00 AM and 10:30 AM in the Emergency Department:
When preparing to start an Intravenous (IV) line for Patient #1, Nurse H donned gloves, obtained supplies, removed the cover of a small trash bin on the IV cart and proceeded to open the supply packets without the benefit of changing glove and performing hand hygiene. Once Nurse H cleaned the needle site with alcohol, Nurse H touched the site and inserted the needle without recleaning the site.

The above observation was discussed in interview with Director of Nursing B on 1/10/18 at 11:00 AM who confirmed gloves should have been changed after touching the trash bin.

Observations in the Obstetrical Unit:

Review of facility policy titled Infection Control: Food Preparation, Storage and Serving revealed under #12 "...All foods taken from an open box will be tabled and dated individually prior to leaving the kitchen."

On 1/8/18 at 11:15 AM the following items were observed in the Obstetrical Unit kitchen:
13 packages of instant cocoa out of original packaging with no expiration date.
7 packages of instant cream of wheat out of original packaging with no expiration date.
1 package of oatmeal out of original packaging with no expiration date.
1 -8 ounce carton of skim milk was open in the refrigerator.
1 condiment bottle labeled chocolate syrup with no date, and syrup dripping down the outside.

These findings were confirmed in interview with Obstetrical Manager F at time of discovery on 1/8/18 at 11:15 AM.

Observations in the kitchen:

Review of facility policy titled Infection Control: Personal Hygiene revealed under #6 "...Hair caps or nets must be worn at all times..."

Review of facility policy titled Infection Control: Food Preparation, Storage and Serving revealed under #12 "...All foods taken from an open box will be tabled and dated individually prior to leaving the kitchen."

The following was observed in the Kitchen on 1/8/18 between 11:30 AM and 12:30 PM:
At 11:40 AM Dietary Aides DD, EE and FF had hair outside of their hair nets and/or bonnets. This deficiency was confirmed in interview at time of discovery with Dietary Manager G, who added all hair should be contained in hair net or bonnet.
At 12:10 PM Cook CC rinsed his/her hands in the sink next to the food prep table, walked across the room to the handwashing sink and obtained paper towels to dry his/her hands.
At 12:30 PM there were 18 packets of instant Cream of wheat and 5 packets of instant Oatmeal, out of original packaging with no expiration dates. This was confirmed in interview with Dietary Manager G at time of discovery, who was unaware the items should be dated when removed from the original packaging.
At 12:40 PM while observing dish washing, the dish washer was observed to not reach the 160 degree heat during the wash cycle, that is the benchmark on the log. The first tray observed revealed the wash temperature reached 135 degrees, the second tray observed revealed the wash temperature reached 147 degrees and the third tray wash temperature was 153 degree. The three trays were not run through the washer once the temperature rose to the required temperature. Per interview with Dishwasher J, s/he does not check the temperature for each wash cycle, and waits until the fourth or fifth tray to look to document the wash temperature.

Per interview with Dietary Manager G on 1/8/18 at 12:50 PM the washer temperatures should reach 150 degrees for the wash cycle and trays should be sent through the washer until the water reached that temperature.

Observations in Respiratory Therapy Department:

Review of the Oxivir manufacturer's instruction revealed "All surfaces must remain wet for one-minute..." There are no instructions to dilute Oxivir for cleaning

On 1/9/18 at 10:30 AM Respiratory Therapist HH was observed cleaning after performing a Pulmonary Function Test ( PFT) to measure lung capacity on Patient #21. Therapist HH poured Oxivir into a basin and filled it with water, placing the handle and pneumotach (that attached to the disposable mouthpiece) into the solution for one minute. Therapist HH removed the items from the solution and set them on a paper towel to dry. Therapist HH took a spray bottle of Oxiver, sprayed the solution onto a washcloth and wiped down the PFT machine, the surfaces were not wet upon application of the Oxiver for the one minute contact time.

Observations in Physical Therapy:

Review of facility policy titled General Cleaning, dated 12/15/15, revealed "The treatment table, counter and carts will be cleaned with Oxivir Tb wipes between patients.

Review of facility policy titled Cidex OPA Cold Liquid Sterilization, 12/17/09, revealed "Tools removed from the cold sterilization tray for usage will be handled with the forceps, which are also soaked in the Cidex OPA in the upright stainless steel tube. The tools will be rinsed with sterile saline prior to use and dried with sterile gauze or a sterile towel. After use, debris will be manually cleaned from the tools using soap and water and the tools will be placed into the sterilization tray and submersed for a minimum of 12 minutes at room temperature..."

Per manufacturer instruction for use for Cidex OPA it states under A. High Level Disinfection 1. "Immerse device completely, filling all lumens and eliminating air pockets, in Cidex OPA Solution for a minimum of 12 minutes...Remove device from the solution and rinse thoroughly following the rinsing instructions below...B. Rinsing Instructions 1. Rinsing Procedure a). Manual Processing: Following removal from Cidex OPA Solution, thoroughly rinse the semi-critical medical device by immersing it completely in a large volume (e.g. 2 gallons) of water. Use sterile water unless potable water is acceptable...Keep the device totally immersed for a minimum of 1 minute in duration, unless a longer time is specified by the reusable device manufacturer...Remove the device and discard the rinse water...Repeat the procedure TWO (2) additional times, for a total of THREE (3) RINSES, with large volumes of fresh water to remove Cidex OPA solution residues.

On 1/9/18 between 1:40 PM and 1:50 PM Physical Therapy Aide LL cleaned the wound care room after treatment of Patient #22. Aide LL rinsed used instruments, including hinged scissors, in the sink and placed then in a narrow container filled with Cidex (cold disinfectant), the scissors were not in an open position to allow all surfaces to be exposed to the Cidex. When asked what was done with the instruments next, Aide LL said "Soak instruments in Cidex, they stay in there all the time, then are rinsed with saline before the next use. Aide LL added the Cidex is changed out every two weeks. In a follow up interview on 1/10/16 at 9:45 AM, Aide LL provided a 100 milliliter bottle of sterile water that s/he said is used to rinse the instruments before use, and then they are placed on a sterile ABD (thick dressing) to dry before use. Aide LL was observed to don gloves, wipe down the counter, removed gloves, donned new gloves to wipe down the treatment chair without performing hand hygiene. Aide LL repeatedly changed out gloves without performing hand hygiene. Patient #22's coat had been on the Hi-lo table in the room, the Hi-lo table was not cleaned.

Per interview with PeriOperative Nurse R on 1/10/18 at 10:00 AM, s/he confirmed the scissors should be open when soaking in Cidex, the rinsing should be 3 times with 2 gallons of sterile water, and the instruments should not be in the Cidex all the time. This was confirmed at time of observation with Physical Therapy Manager KK, who did not think the room was used for patient treatment.

Per tour of the Physical Therapy Department on 1/9/18 at 2:15 PM, there was a box of Bisquick expired 3/23/15 and Oatmeal expired 11/10/15 in the Occupational Therapy kitchen. This was confirmed in interview with Physical Therapy Manager KK on 1/9/18 at 2:15 PM.


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Observations in Nuclear Medicine:

On 1/8/2018 at 4:30 PM a tour of the Nuclear Medicine department was conducted with Radiology Manager M who confirmed the following observation: There was trash in the trash can and laundry in the hamper. Manager M confirmed that the last time the room was used was on 1/4/2018 and stated that there should not be trash and laundry left in the room.

Observations in the Surgical and Decontamination area:

Observations in Pre-operative unit:
The following observations took place on 1/9/2018:
At 7:40 AM Nurse N was observed to have 2 packages of intravenous cannulas in the pocket of Nurse N's scrub pants.
At 8:30 AM Nurse O was observed to have a cloth stethoscope cover over the stethoscope that was being carried around O's neck.

Observations in the Endoscopy Suite:
The following observations took place on 1/9/2018:
At 8:20 AM Certified Registered Nurse Anesthetist P and Surgical Technician Q were observed to have their surgical caps tucked behind the ears, exposing the ears.
At 8:35 AM Anesthetist P attached a syringe containing Propofol (sedating agent) to Patient #11's intravenous luer lock port without cleaning the port first. Anesthetist P then removed the glove from the right hand and began documenting on paper without performing hand hygiene.
At 8:42 AM Anesthetist P used an Oxyvir wipe to clean up a spill of Propofol on the floor, discarded the wipe and the glove from the left hand, and without performing hand hygiene applied a new glove to the left hand to continue to support Patient #11's airway during the procedure.
At 8:55 AM Anesthetist P removed the glove from the left hand, did not perform hand hygiene, accessed the Omnicell (medication dispensing unit) for more Propofol, and applied another glove to the left hand without performing hand hygiene.
At 9:17 AM Anesthetist P removed the glove from the left hand, did not perform hand hygiene, entered the anesthesia cart for another intravenous bag, applied another glove to the left hand without performing hand hygiene.
At 9:26 AM Anesthetist P removed the glove from the left hand (end of procedure) and did not perform hand hygiene.
At 9:28 AM Technician Q removed gloves after the initial cleaning of the endoscope and applied new gloves to continue cleaning up supplies without performing hand hygiene.
At 9:29 AM, with the same gloves and personal protective equipment worn during assisting with the colonoscopy procedure, Nurse X began wiping down equipment (vital sign monitor and wires, nurse procedure cart, computer keyboard) before removing the gloves and performing hand hygiene.

Observations in Sterilization/Decontamination area:
The following observations took place on 1/9/2018:
At 9:35 AM, it was observed that there is no enclosure in the pass-through window between the contaminated side where dirty equipment is brought after procedures/surgeries. This large opening, which is approximately 2 1/2 feet wide by 3 feet high, is open between the dirty and clean side where clean instruments are taken from the washer, wrapped and placed in the sterilizer.

Per interview with Technician Q about this open area on 1/9/2018 at 9:35 AM, Technician Q stated, "I know Steris [sterilizer company] makes windows." Per interview with Peri-operative Manager R at 9:40 AM on 1/9/2018 regarding the open area, Manager R stated, "I was under the understanding that as long as airflow is ok, we don't need one."

At 9:40 AM, it was observed that the sink in the decontamination room is not measured/marked for content and there were no measuring devices for the enzymatic cleaner. Per interview with Technician Q on 1/9/2018 at 9:40 AM regarding the cleaning process, Technician Q stated, "I put in one squirt [of enzymatic cleaner] to a gallon of water...I know, we aren't measuring it and the sink is not marked." When asked how long instruments are being left to soak in the enzymatic cleaner, Technician Q stated, "As long as it takes. If I don't have a lot of instruments its a shorter time."

According to the directions for use on the Endozime AW Triple Plus enzymatic cleaner bottle in the decontamination room, the concentration is to be 1/2 ounce per 1 gallon of water, and soak time is listed as, "Soak for as little as 2 minutes."

Observations in the Operating Rooms:
The following observations took place on 1/9/2018:
At 10:00 AM a tour of Operating Rooms 1, 2, and 3 was conducted with Manager R. In Room 1, one air return vent was noted to have a fine coating of dust on the louvers. In Room 3, three vents were noted to have a fine coating of dust on the louvers. Per interview with Manager R on 1/9/2018 at 10:15 AM regarding terminal cleaning in the Operating Rooms, Manager R stated that cleaning of the vents is on the list but was not sure at the time how often they were to be done.

The above findings related to the Surgical Suite were discussed with and confirmed per interview with Manager R on 1/9/2018 at 10:20 AM. Manager R stated that supplies should not be kept in pockets and the cloth stethoscope cover is also not allowed.

The facility's Terminal Cleaning Check List, dated 5/12/16, was reviewed on 1/9/2018 at 4:05 PM. The check list reveals that vents in the operating rooms are currently to be cleaned once per month.

Observations on the Medical/Surgical floor:

The following observations took place on 1/9/2018:
At 11:30 AM, after touching Patient #1's intact skin, Nurse S entered the intravenous supply basket without performing hand hygiene and potentially contaminated the items Nurse S touched. Nurse S then applied gloves, cleansed the prospective intravenous site, opened the intravenous cannula package with gloved hands and attempted to start the intravenous.
At 11:52 AM Nurse S performed a finger stick on Patient #1 for a blood glucose test. After performing the test and handling the monitor with gloved hands, Nurse S removed gloves, performed hand hygiene, then handled the uncleaned monitor, placed it on the counter next to papers and the intravenous supply basket.
At 11:55 AM Laboratory Technician T was observed standing in the vestibule to Patient #1's room, did not perform hand hygiene and applied gloves.
At 12:00 PM without applying gloves, Nurse S handled the dirty glucose monitor again to clean it, thereby potential re-contaminating Nurse S's hands.

These findings were discussed with and confirmed per interview by Director of Nursing B on 1/9/2018 at 3:30 PM.

Based on record review and interview the facility failed to ensure there is a contract in place for use of a local pool for Aquatic Therapy, in 1 of 1 record (contract list).

Findings include:

Review of the list of contracts the facility provided, there is no contract between the facility and use of hotel pool.

Per interview with Physical Therapy Manger KK on 1/9/18 at 1:00 PM, the facility started Aquatic Therapy at a local hotel pool in December of 2017. Per Manager KK, there is no contract with the hotel, no monitoring of water quality and the pool is not restricted to patients during patient therapy sessions.

Based on record review and interview, nursing staff at this facility failed to reassess patients after administering pain medication according to facility expectation in 2 of 5 out of a total of 20 medical records reviewed (Patient #19 and 20).

Findings include:

Per interview with Medical/Surgical Nurse Manager U on 1/9/2018 at 10:30 AM regarding the pain management program at this facility, Manager U stated that nursing staff talk with patients about pain management and their goals then follow up with medication or non-pharmacological means as necessary. Following interventions for pain management staff are expected to perform reassessments for pain within 30 minutes for intravenous pain medication or within 60 minutes for oral pain medication.

Patient #19's open medical record was reviewed on 1/10/2018 at 10:16 AM accompanied by Nurse Manager U who confirmed the following findings: Patient #19 was admitted on 1/8/2018 with a blood clot in the leg. Patient #19 was medicated for pain on 1/8/2018 and 1/9/2018 and between those dates had 2 missed reassessments for pain management. Per interview with Manager U on 1/10/2018 at 10:20 AM, Manager U stated that the assessments were missed.

Patient #20's open medical record was reviewed on 1/10/2018 at 10:31 AM accompanied by Nurse Manager U who confirmed the following findings: Patient #20 was admitted on 1/6/2018 with Colitis (inflammation/infection in the colon). Patient #20 received intravenous Morphine (narcotic analgesic) on 4 occasions between 1/6/2018 at 4:00 PM and 1/7/2018 at 12:00 PM and received no reassessments for pain. Per interview with Manager U on 1/10/2018 at 10:40 PM, Manager U stated that there should be documented reassessments and there is not.

Per interview with Director of Nursing B on 1/10/2018 at 11:10 AM regarding a policy for pain management, Director B stated there is no policy that specifically addresses time frames for reassessment of pain after pain medication and provided the policy titled, "Pain Management Policy," dated 1/17, which reveals in part, "Reassessments will be performed post pain intervention...Pain assessments will be documented in the medical record."

Based on record review and interview, nursing staff at this facility failed to develop and/or update care plans that address the needs of the patients during their admission and/or at the time of discharge for 5 out of 9 out of a total of 20 medical records reviewed (Patient #14, 15, 17, 18, and 20).

Findings include:

Per interview with Medical/Surgical Nurse Manager U on 1/9/2018 at 10:30 AM, regarding nursing care plans Manager U stated, "They are based on nursing assessment and why the patient is here. They are started on admission and updated at the end of the shift. If any are resolved they should be resolving them and indicate if the goals are met, progressing, or not met...If on discharge a goals is not resolved, there should be a reason why it was not resolved."

Patient #14's closed medical record was reviewed on 1/10/2018 at 7:15 AM accompanied by Nurse Manager U who confirmed the following findings: Patient #14 was admitted to the facility on 3/11/2017 with Alzheimer's and a Sacral Wound, and discharged on 3/13/2017, then readmitted on 3/26/2017 with the same diagnoses, and discharged on 3/29/2017.

For the 3/11/2017 admission the nursing care plan has a skin integrity goal however it is not specific to the location of where Patient #14's pressure ulcer is or wound care following a surgical debridement of the ulcer on 3/10/2017. This goal was indicated to be not met when Patient #14 was discharged to a skilled nursing facility on 3/13/2017, however there is no documentation to indicate why the goal was not met.

For the 3/26/2017 admission, upon discharge to a skilled nursing facility again, Patient #14's skin integrity goal was documented as being resolved. Patient #14 left the facility on 3/29/2017 with a wound vacuum for the still present sacral wound. Per interview with Manager U on 1/10/2018 at 7:30 AM regarding the accuracy of this documentation, Manager U stated that the goal should not have been resolved, it should be not met and why.

Patient #15's closed medical record was reviewed on 1/10/2018 at 7:55 AM accompanied by Nurse Manager U who confirmed the following findings: Patient #15 was admitted to the facility on 3/17/2017-3/19/2017 for Chronic Obstructive Pulmonary Disease (disease of the lungs that affects the amount of oxygen/air perfused and causes respiratory distress) and Pneumonia. Patient #15 also had some cardiac issues with irregular heart rates in the emergency department and required cardiac medication to stabilize heart function. The nursing care plan for this admission does not have a goal for respiratory or cardiac function. Per interview with Manager U on 1/10/2018 at 8:00 AM, Manager U stated that the care plan should have addressed both.

Patient #17's closed Swing Bed record was reviewed on 1/10/2018 at 9:23 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #17 was admitted on 11/29/2017 for continued treatment needed for lower extremity cellulitis (inflammation of the tissues) and open wounds requiring on-going wound care. The nursing care plan does not address the wounds on the lower extremities or the wound care to be performed. Per interview with Manager U on 1/10/2018 at 9:30 AM, Manager U stated that the care plan should have addressed both.

Patient #18's open medical record was reviewed on 1/10/2018 at 10:00 AM accompanied by Nurse Manager U who confirmed the following finding: Patient #18 was admitted on 1/8/2018 with Right Lower Lobe Pneumonia. Patient #18 also has a history of alcohol dependence and was started on an alcohol withdrawal protocol after being assessed in the emergency department prior to admission. The nursing care plan does not address the alcohol withdrawal problem. Per interview with Manager U on 1/10/2018 at 10:10 AM, Manager U stated that the care plan should address the alcohol withdrawal. Manager U stated, "They are assessing for withdrawals."

Patient #20's open medical record was reviewed on 1/10/2018 at 10:31 AM accompanied by Nurse Manager U who confirmed the following findings: Patient #20 was admitted on 1/6/2018 with Colitis (inflammation/infection in the colon). The history and physical report from the physician identifies that Patient #20 had some active Gastrointestinal (GI) bleeding prior to hospital admission. The nursing care plan does not address the Colitis or the GI bleeding. Per interview with Manager U on 1/10/2018 at 10:40 AM, Manager U stated that the care plan should have addressed both.

The facility's policy titled, "Nursing/Interdisciplinary Plan of Care," dated 12/7/16, was reviewed on 1/10/2018 at 10:53 AM. The policy reveals in part, "Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patient's plan of care."

Based on record review and interview the facility failed to ensure all hospital services are tracked and trended with a measurable goal and plan to meet that goal in place, 1 of 1 Quality Improvement Schedule and 1 of 3 Quality Improvement Committee minutes reviewed (October 2017).

Findings include:


Review of the facility's Quality Improvement Schedule on 1/9/18 revealed there was no evidence of tracking and treading Organ Donations or Nuclear Medicine.

Review of the facility's October 2017 Quality Improvement Committee minutes revealed under Radiology, there was no documentation of Nuclear Medicine being discussed.

The above deficiencies were confirmed in interview with Quality R on 1/9/18 at 11:00 AM adding that Nuclear Medicine is discussed but not part of a Quality Plan.


26711

Per interview with Radiology Manager M on 1/8/2018 at 4:14 PM regarding Quality Improvement projects for the Nuclear Medicine Department, Manager M stated that Nuclear Medicine is a contracted service. The contracted service provides Manager M with quality data regarding the service on a quarterly basis. Manager M stated that M reviews the data for issues, and then stores the information in M's computer.

Manager M stated that the information for this contracted service is not forwarded to the Quality department for the over-all quality improvement plan for the facility because, "No one ever asked me for it."

Based on record review and interview, staff at this facility failed to ensure that all Swing Bed patients receive a notice of transfer or discharge in 2 of 2 Swing Bed medical records reviewed (Patient # 16 and 17).

Findings include:

Per interview with Discharge Planning Coordinator, Nurse V on 1/8/2018 at 1:50 PM regarding the Swing Bed transfer/discharge notice, Nurse V stated that the notice is given 48 hours prior to discharge.

Patient #16's closed Swing Bed record was reviewed on 1/10/2018 at 8:40 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #16 was admitted to Swing Bed on 10/4/2017 and discharged on 10/10/2017. There is no transfer/discharge notice in the medical record.

Per interview with Nurse V on 1/10/2018 at 8:52 AM regarding the transfer/discharge notice, Nurse V stated, "We don't always give the transfer/discharge notice to Swing Bed discharges. Only if they disagree with their discharge are they given the information and then it is put in the record."

Patient #17's closed Swing Bed record was reviewed on 1/10/2018 at 9:23 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #17 was admitted to Swing Bed on 11/29/2017 and discharged on 12/6/2017. There is no transfer/discharge notice in the medical record.

Based on record review and interview, this facility does not ensure that Swing Bed patients have the required information needed at the time of transfer or discharge. This deficiency has affected all Swing Bed patients admitted to this facility, including 2 of 2 Patients (Patient #16 and 17) whose closed Swing Bed records were reviewed.

Findings include:

The facility's notice that is given to Swing Bed patients upon transfer/discharge was reviewed on 1/8/2018 at 2:00 PM. The notice is a Medicare Notice of Non-Coverage form and does not include language that would inform the patient of the right to know the reason, effective date, or where they would be discharged or transferred should this occur.

The notice does not include information about the Long Term Care Ombudsman, or include information regarding who to contact for patients with developmental disabilities or mental illness.

These findings were discussed with and confirmed per interview by Discharge Planning Coordinator, Registered Nurse V, on 1/8/2018 at 2:00 PM.

Patient #16's closed Swing Bed record was reviewed on 1/10/2018 at 8:40 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #16 was admitted to Swing Bed on 10/4/2017 and discharged on 10/10/2017. There is no transfer/discharge notice in the medical record.

Patient #17's closed Swing Bed record was reviewed on 1/10/2018 at 9:23 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #17 was admitted to Swing Bed on 11/29/2017 and discharged on 12/6/2017. There is no transfer/discharge notice in the medical record.

Based on record review and interview, staff at this facility failed to do an activity assessment on all Swing Bed patients, and failed to maintain on-going documentation that Swing Bed patient's activity involvement was addressed during the Swing Bed admission in 2 of 2 Swing Bed records reviewed (Patient #16 and 17).

Findings include:

Per interview with Discharge Planning Coordinator, Nurse V on 1/8/2018 at 1:50 PM regarding the activity assessment for Swing Bed patients, Nurse V stated that Activity Coordinator JJ assesses all Swing Bed patients and then sees them weekly.

Patient #16's closed Swing Bed record was reviewed on 1/10/2018 at 8:40 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #16 was admitted to Swing Bed on 10/4/2017 and discharged on 10/10/2017. There is no activity assessment in the medical record. There is no documentation that either Coordinator JJ or nursing staff have addressed activities with Patient #16 during the Swing Bed admission. Per interview with Manager U on 1/10/2018 at 8:50 AM regarding documentation of on-going activity involvement, Manager U stated that it would be on a flowsheet in the medical record but that it has not been addressed.

Patient #17's closed Swing Bed record was reviewed on 1/10/2018 at 9:23 AM accompanied by Medical/Surgical Nurse Manager U and Nurse V who confirmed the following finding: Patient #17 was admitted to Swing Bed on 11/29/2017 and discharged on 12/6/2017. There is no activity assessment in the medical record. There is no documentation that either Coordinator JJ or nursing staff have addressed activities with Patient #17 during the Swing Bed admission.

Per interview with Nurse V and Coordinator JJ on 1/10/2018 at 9:45 AM regarding activity assessments, Coordinator JJ stated that JJ did not do an activity assessment on either Patient #16 or Patient #17. Nurse V stated, "It is an expectation that every Swing Bed patient have an activity assessment."

Per interview with Director of Nursing B on 1/10/2018 at 10:37 AM regarding re-assessment of Swing Bed patient's activity involvement, Director B stated, "There is no policy that specifically addresses Swing Bed patients and activities." Director B provided the facility policy titled, "Admission Assessment and Reassessment," dated 11/13/17, which revealed in part, "Reassessment of patient's needs is performed by the responsible RN [Registered Nurse] as warranted by the patient's condition."

Based on record review and interview, the facility failed to ensure patients are provided a copy of their rights upon admission, and the information is documented in the medical record in 11 of 11 inpatient records (1, 2, 7, 10, 14, 15, 16, 17, 18, 19 and 20) out of a total 20 medical records reviewed.

Findings include:

Per review of inpatient medical records on 1/9/18 between 2:00 PM and 3:15 PM and on 1/10/2018 between 7:15 AM and 11:00 AM the following inpatient medical records had no documentation the patients received a copy of their visitation rights: Patients 1, 2, 7, 10, 14, 15, 16, 17, 18, 19 and 20). These deficiencies were confirmed in interview with Informatics Technicians Z and AA on 1/9/18 between 2:00 PM and 3:15 PM, and Nurse Manager U, on 1/10/2018 between 7:15 AM and 11:00 AM.

Per interview with Director of Nursing on 1/10/18 at 8:00 AM she was unaware a copy of the rights should be given to the patients or documented in the record.