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Based on medical record review, staff interview, and review of policies and procedures, the facility failed to obtain advance directive information from 2 of 24 sample patients (#2, #9) reviewed for advance directives. An additional 2 of the 24 sample patients (#23, #24) indicated they did not have advance directives, but there was no evidence the facility provided them with information. The findings were:

1. According to the medical record, patient #2 indicated s/he had a living will as an advance directive. However, this information was not in the record. Further review showed no evidence the facility tried to obtain a copy of the living will. On 9/22/11 at 9:55 AM HIC #1 verified the facility did not have a copy of the patient's living will, and, after reviewing the record, she stated there was no evidence the physician or else anyone had discussed the issue with the patient.

2. Medical record review showed patient #9 had advance directives, but they were not present in the record. On 9/22/11 at 9:55 AM HIC #1 confirmed the directive was not in the hospital's record, but she stated it might be in the patient's nursing home record. However, she acknowledged the hospital did not have access to that record.

3. Review of the medical record for patients #23 and #24 revealed they did not have advanced healthcare directives. This review also revealed no additional information regarding how to obtain an advanced directive was provided for the two patients.

Review of the facility's policy and procedure, "Advance Medical Directives/Living Wills", last revised 1/27/10, showed only that HIM was responsible for "retention of all advance directives in the patient's hospital and/or clinic medical record." It failed to address who was responsible for requesting/obtaining a copy of the directive.



27095

Based on staff interview and review of credentialing files, and policies and procedures, the facility failed to have a credentialing services agreement with a qualified entity for credentialing for 14 of 14 physicians (#1, #2, #3, #4, #5, #6, #7, #8 #9, #10, #11, #12, #13, #14) and 3 of 3 (#15, #16, #17) certified registered nurse anesthetist (CRNA) whose files were reviewed. The findings were;

Review of the policies and procedures for the facility's credentialing process and credentialing files for physicians #1 through #14 and CRNAs #15, #16, #17 revealed the credentialing process that resulted in approval for these professionals did not include the services of another qualified entity. Interview with the administrative assistant on 9/21/11 at 11:55 AM revealed she was responsible for ensuring staff credentials, privileges, and licenses were current. She stated the current credentialing process required review and approval by the medical board and governing body, but did not include an agreement or involvement with another qualified entity.

Based on observation and staff interview, the facility failed to perform electrical safety checks on 4 of 4 new items of equipment prior to placing the items in patient care areas. The facility further failed to clean 1 of 1 convection ovens in the kitchen. The findings were:

1. Observation while touring the ED on 9/19/11 at 3:45 PM revealed 2 patient warmers (Arizant Bear Hugger) and a blood/fluid warmer (Arizant Ranger). A third patient warmer was subsequently observed while touring the OR on 9/21/11 at 11:25 AM. The CNO stated in interview on 9/19/11 at 4:10 PM that the observed equipment was newly acquired at the facility. She stated a case of hypothermia at the facility prompted the acquisition of the warmers and their placement in the ED and OR. The CNO further stated her staff were training on the equipment and once trained the warmers would be available for patient care.

Interview with the maintenance director on 9/21/11 at 2:15 PM revealed the general policy that all newly acquired equipment is subject to an electrical safety check prior to placement in patient care areas; he acknowledged the new warmers had not been tested and "...probably slipped through the cracks..."

2. The kitchen and food preparation areas were toured on 9/21/11 at 3:40 PM; while on tour a convention oven was observed. The exterior surfaces of the oven were dirty with dried food splatter, crumbs, and dust. Observing the back of the oven showed an accumulation of dust around the fan motor housings and air intakes.

The dietary manager stated while on tour she maintained a cleaning scheduled for all the equipment in the kitchen, but acknowledged the exterior of the convention oven did not appear to have been cleaned as scheduled.

Based on observation, staff interview, and review of policies and procedures, the facilty failed to secure medications in 2 of 2 emergency crash carts examined for contents. The findings were:

On 9/20/11 at 10:10 AM the crash cart by the nurses' station was observed to be unlocked. Ten 10 milliliter (ml) syringes of normal saline and four 1000 ml bags and one 500 ml bag of IV solutions were stored in the unlocked drawers. Observation of the crash cart in the emergency department on 9/21/11 at 3:15 PM revealed it also contained five unsecured 10 ml syringes of normal saline and four 1000 ml bags of IV solutions. On 9/20/11 at 10:55 AM pharmacist #1 stated medications were to be locked, and on 9/22/11 at 7:50 AM the DON stated she was unaware the IV solutions were not secure. According to the facility's 6/7/11 policy and procedure, "Pharmacy Security," medications "shall be kept in locked storage or be inaccessible to unauthorized individuals."

21849

Based on observation, staff interview, and nationally recognized standards, the facility failed to monitor and maintain records of the temperature and humidity in 1 of 1 OR suites. The findings were:

The facility's OR room was toured with the surgery supervisor on 9/21/11 at 11:20 AM. While on tour, the supervisor was asked to show the survey team records for monitoring the temperature and humidity in the OR. The supervisor stated the OR staff did not maintain environmental records; instead she thought this task was performed by the maintenance director.

The maintenance director stated in interview on 9/21/11 at 4:20 PM that he monitored temperatures with an application on his computer. He demonstrated a system that tracked temperatures in the heating, ventilation, and air conditioning (HVAC) system at selected points, but was not able to show the specific temperature in the OR nor did he have the ability to monitor humidity in the OR. A follow-up interview with the surgical supervisor on 9/21/11 at 3:20 PM confirmed the lack of any other records to show temperature and humidity in the OR.

The Association of PeriOperative Registered Nurses (AORN), Perioperative Standards and Practices, 2010 edition, endorses a requirement to monitor temperatures and humidity levels in OR suites and further provides recommend ranges for temperature and humidity in OR and sterile processing areas. During an interview on 9/21/11 at 2:25 PM, the surgical supervisor stated that the facility adopted AORN standards for its surgical environment and practices.

Review of utilization documents on 9/22/11 at 9:25 AM showed the facility performed 41 surgical procedures in the last 12 months.

Based on review of policies and procedures and staff interview, the facility failed to develop polices that include a description of the services provided. The findings were:

Interview with the CEO on 9/22/11 at 10 AM revealed the facility's services were described in the policy entitled, "Scope of Services", revised 2008. The CEO also stated the policy needed to be revised because it did not reflect the current services. A review of this policy revealed it described services that were no longer provided, and it failed to include all of the current services.

Based on observation, staff interview, and review of manufacturer's product label information, infection control policies and procedures, and nationally recognized standards for infection prevention, the facility failed to ensure staff disinfected 2 of 2 flexible endoscopes and 1 of 1 glucometers as specified by the equipment manufacturers. The facility further failed to monitor non-direct care staff for compliance with infection control policies and procedures. In addition the facility's infection surveillance process failed to monitor outpatients with active infections receiving IV antibiotics in inpatient care areas. The findings were:

A. The endoscopy reprocessing area was toured with the surgical supervisor on 9/21/11 at 11:35 AM; while on tour the surgical supervisor stated she was also responsible for reprocessing endoscopy equipment. The following deficiencies were discovered in the reprocessing area:

1. On 9/21/11 at 11:30 AM, two flexible channel brushes were observed hanging from a sink faucet in the reprocessing room; the surgical supervisor stated in interview on 9/21/11 at 11:40 AM that she reused these channel brushes to clean flexible endoscopes. When asked to show the survey team an unused channel brush, the supervisor removed a new brush from a drawer, it was labeled by the manufacturer as "single use only." The supervisor stated at this time she was not aware the brushes were single-use.

On 9/21/11 the manufacturer's instructions for cleaning and disinfecting endoscopes were reviewed, the instructions include a specific warning against reusing single-use channel brushes to ensure proper cleaning and avoid potential damage to the endoscope.

2. The supervisor stated on 9/21/11 at 11:50 AM that she used a chemical disinfectant, Cidex-OPA, to disinfect endoscopy equipment; she further stated she used a test strip to verify the OPA concentration in the disinfectant solution. Review of the package insert for the test strips showed the manufacturer required that unused test strips be discarded 90 days after the container was first opened. There was no evidence on the container to show when it was first opened, nor was there documentation of a modified expiration date to reflect the 90-day open container stability.

The supervisor stated on 9/21/11 at 11:55 AM that she was not aware the test strips expired 90 days after opening. She acknowledged she did not monitor the date these container were first opened. She further stated she was not sure when the current container of test strips was first opened.

3. When asked by a surveyor on 9/21/11 at 12:05 PM, the supervisor stated she did not maintain records or logs to track the use and disinfection of individual endoscopes each time they were used in a procedure. Current practices for endoscopy and reprocessing of endoscopy equipment as stated in the "Multi-society guideline for reprocessing flexible gastrointestinal endoscopes, 2003" and the CDC's "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" recommend records be maintained to track the use and disinfection of individual endoscopes as an infection control measure.

4. Review of utilization documents on 9/22/11 at 9:25 AM showed the facility performed 55 endoscopy procedures in the last 12 months.

B. Certified nurse assistant (CNA) #1 was observed on 9/20/11 at 11:10 as she preformed a finger-stick glucose test on patient #2. The following deficiencies were identified from the observation:

1. The CNA completed the test procedure without wearing gloves, to include handling the blood-loaded reagent test strip in her fingers. After completing the test procedure, she cleaned the glucometer by wiping it with a disposable disinfecting wipe (Sani-Cloth, PDI, Inc.); the total contact time of the disinfecting wipe on the glucometer was 58 seconds.

2. Review of the product label information on the disposable wipes container showed the manufacturer's statement that the disinfectant properties of the product required a minimum of 5 minutes wet contact time. Telephone interview with a technical representative for the manufacturer on 9/22/11 at 7:10 AM confirmed the minimum wet contact time was 5 minutes; the representative stated the disinfecting properties of the product were not reliable if the contact time was less than 5 minutes.

3. Interview with the CNA on 9/20/11 at 11:10 AM following revealed she had not received instructions about wearing gloves for glucose testing, nor how to effectively clean the glucometer.

4. On 9/21/11 at 2:20 PM the glucometer kit was inspected. Among the items in the kit were 6 individually-wrapped disinfectant wipes, each outer wrap was stamped with the expiration date "05/2011." Interview with RN #1 on 9/21/11 at 2:30 PM revealed that some of the nursing staff preferred to use the individually-wrapped disinfectant wipes to clean the glucometer after each use, as opposed to using the Sani-Cloth wipes. She further stated she was not aware the product had expired.

C. On 9/19/11 at 4:30 PM housekeeper #1 was observed in the administrative area of the facility. She was seen to clean several high-touch environmental surfaces with a dampened cloth. On top of her cleaning cart was a bottle of soda and an open bag of candy. At 4:35 PM she was observed to dip her cleaning cloth into a small plastic container on top of her cart; one edge of the cloth was seen to drag across the top of her soda bottle.

At 4:40 PM and again at 4:47 PM the housekeeper removed the cap from her soda bottle and took a drink; at the 4:40 PM observation she removed the glove from her right hand, but left both gloves on at the 4:47 PM observation.

The housekeeper stated in interview on 9/19/11 at 4:55 PM the plastic container on her cart contained a chemical disinfectant solution. She further stated she was not aware if facility policies restricted food and drink from her cleaning cart, but voiced her opinion that "...it might not be such a good idea" [to have food and drink on the cart]. The CNO joined the interview at 4:59 PM and stated food and drink were not allowed in work areas where patient care was given or if there were safety issues, such as exposure to infectious or potentially hazards materials.

Interview with the infection control nurse on 9/21/11 at 3:40 PM revealed a systematic process for monitoring infection prevention compliance among the facility's nursing staff. However, compliance monitoring techniques were not used to assess infection control practices among the hospital's non-nursing staff.

D. Infection surveillance activities where reviewed with the infection control nurse on 9/21/11 at 3:05 PM. These documents established a process of monitoring infections and antibiotic usage among inpatients, but failed to show evidence outpatients being treated in inpatient care areas were similarly monitored.

Patient #7 was observed on 9/20/11 at 9:45 AM receiving an IV in room #106 in the inpatient care area. Review of the patient's medical record on 9/21/11 at 1:15 PM showed s/he was receiving twice daily IV doses of Vancomycin and Gentamicin as an outpatient; these medications were ordered to treat post-operative complications related to peritonitis. Telephone interview with the servicing laboratory on 9/21/11 at 2:10 PM revealed Enterococcus faecalis was identified from a culture of the patient's perineal area.

Interview with the infection control nurse on 9/21/11 at 3:40 PM confirmed the facility's infection surveillance process was limited to inpatients and failed to routinely include outpatients receiving treatment in the inpatient care area. She confirmed patient #7 was not currently part of an ongoing surveillance program. She further acknowledged that infection, antibiotic therapy, and positive culture findings were criteria only monitored among inpatients.

Based on review of policies and procedures and staff interview, the facility failed to ensure provision of care policies were annually reviewed by professional personnel. The findings were:

Interview with the information services specialist on 9/20/11 at 3:55 PM revealed she used a database tracking system to notify administrative staff when departmental policies were due for annual review. She stated staff failed to consistently respond to the notifications and this resulted in overdue policy reviews. Review of the policy and procedure for blood glucose monitoring showed it was last reviewed and revised on 9/28/09. Review of the policies and procedures for scope of service showed it was last reviewed on 5/10/08.

Based on observation, staff interview, and review of manufacturer's product label information, the facility failed to properly monitor expiration dates for 2 of 2 vials of glucose quality control (QC) material. The findings were:

A glucometer was observed at the nurses' station on 9/21/11 at 2:20 PM. Interview with RN #1 at that time confirmed the device was routinely used to monitor whole blood glucose levels for patients. Included with the glucometer were two vials of QC material. The label information on the vials was reviewed in detail with the RN on 9/21/11 at 2:35 PM and it was noted the manufacturer assigned a 90-day open vial expiration date for the product. There was no documentation to show that facility staff tracked the expiration date of the QC material after opening.

The RN acknowledged in interview on 9/21/11 at 2:40 PM she was not aware the QC material had an open vial stability of 90 days. She further stated she did not know when the vials were first opened, as staff did not routinely record either the date a vial was opened or the lot number of the material in use.

Based on medical record review and staff interview, the facility failed to ensure medications were administered as ordered for 1 of 18 sample acute care in-patients (#1). The findings were:

Review of the medical record showed patient #1 was admitted for observation on 8/26/11 at 12:45 PM and then to acute in-patient status on 8/27/11 at 12:00 noon. Review of the physician's orders showed the patient was to receive Lipitor 20 mg at bedtime on 8/26/11. However, review of that medication administration record (MAR) showed the patient did not receive the medication as ordered. Review of the MAR for 8/27/11 showed the patient did not receive the ordered calcium carbonate, Advair Diskus inhaler, Lisinopril, Ocuvite, Fish oil, Protonix, Januvia, Detrol LA, zinc sulfate, or Arkansas Solution. The documentation indicated the patient was sleeping at 8 AM during the medication pass, but there was no evidence the medications were offered later. On 9/20/11 at 1 PM the CNO confirmed the lack of documentation and stated sleeping was not an acceptable reason for missing the routine medications. She acknowledged they should have been offered at a later time.

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to develop, implement, and revise care plans for 18 of 18 sample patients (#1, #4, #5, #6, #8, #9, #10, #11, #12, #13, #15, #16, #18, #19, #21, #22, #23, #24) admitted for acute care. The findings were:

Medical record review for acute care in-patients #1, #4, #5, #6, #8, #9, #10, #11, #12, #13, #15, #16, #18, #19, #21, #22, #23, #24 showed each had a generic care plan consisting of checked interventions to accomplish goals described under broad categories such as "Safety", "Skin Integrity/Breakdown/At Risk", "Cardiac", "Renal Failure", "IV Therapy", "Pain", etc. Regardless of each patient's reason for hospitalization, identified goals and interventions for each category were identical. However, the goals were not measurable, and many of the interventions were not individualized, specific, or revised as the patients' conditions changed. Examples were: therapeutic diets and supplements were not specified, assistive devices and ADL assistance were not identified, approaches to decrease inappropriate behaviors were not listed, and parameters for reporting blood sugar levels were not specified.
Review of the facility's policy and procedure, "Nursing Care Plans", Number 5.1.1.92, last revised 2/4/11, showed care plans should address "...immediate problems...indicate the nursing actions that will be taken to alleviate the problem(s) and...the health maintenance goals..." Continued review showed "Goals should be developed jointly, with the patient providing input to identify his or her expectations for recovery and health maintenance...New problems...will be added...as they arise...Standardized care plans...can be modified as needed...to address individual problems." On 9/19/11 while reviewing a record at 4:15 PM, the CNO confirmed that the care plans were not individualized or specific. She stated the care plans were used for both acute and swing bed patients.

Based on observation, medical record review, staff interview and review of policies and procedures, the facility failed to ensure medical records were complete and accurate (C302). Selected records in the closed sample also lacked properly executed consents for blood transfusions (C304). The facility further failed to safeguard the confidentiality of health information by restricting access to only those employees involved in patient care, quality assessment and utilization review, and health information management (C308). The cumulative effect of these deficiencies resulted in a determination the facility failed to meet the requirements for the condition of participation for clinical records.

Based on staff interview and review of medical records, laboratory transfusion logsheets, and nationally recognized standards for blood transfusions, the facility failed to ensure accurate and complete documentation of blood transfusions for 3 of 5 patients receiving blood products at the hospital. The findings were:

A sample of closed records was reviewed from 9/20/11 through 9/22/11; the sample was selected to include 5 patients having received pRBC transfusions as part of their treatment at the hospital. Of these 5 records, 3 were discovered to contain incomplete or inaccurate entries. The following discrepancies were found:

A. Patient #10 was noted to have 2 units of pRBCs transfused on 6/14/11. Laboratory records reviewed on 9/21/11 showed the unit of blood was released from the blood bank on 6/14/11 at 1:03 PM. According to the medical record, the transfusion was not started until 2:05 PM, a lapse of 62 minutes. The transfusion worksheet posted in the patients medical record failed to document the time the transfusion was completed and the volume of blood transfused. It was further noted that post-transfusion vital signs were entered in the medical record in pencil.

Review of the documentation in the blood bank transfusion logbook showed the release of a second unit of pRBCs for patient #10 on 6/14/11 at 5 PM. However, according to the medical record, the second transfusion was started at 3:49 PM the same day. The medical record also failed to include any post-transfusion vital signs, the time the transfusion was completed, the amount of blood transfused, or an assessment for a reaction to the transfusion. Review of the transfusion worksheet posted in the patient's record showed two RNs failed to complete a check of critical safety information prior to starting the second transfusion.

On 9/21/11 at 3:05 PM, HIC #1 confirmed the transfusion-related information was incomplete. She was further unable to account for the time discrepancies identified with the second unit of pRBCs transfused on 6/14/11.

MT #1 confirmed in interview on 9/21/11 at 2:35 PM that the first unit of pRBCs was released from the blood bank at 1:03 PM on 6/14/11; she was unaware there was a 62 minute delay in starting the transfusion based on medical record entries. She further stated transfusions should be started within 20 minutes of release from the blood bank. The technologist also confirmed the second unit of pRBCs was released from the blood bank at 5 PM on 6/14/11; she could not account for the time discrepancy in the medical record that documented the transfusion start time as 3:49 PM, a period 1 hour and 11 minutes prior to the time the unit was released from the laboratory.

Interview with the CNO on 9/21/11 at 2:10 PM revealed her expectation that nursing staff fully and accurately document all transfusion-related information in the medical record. She further stated that all nursing documentation was required to be completed in ink; pencil entries were not acceptable. The CNO acknowledged that the incomplete documentation, use of a pencil to record vital signs, and the discrepancies in times recorded by the nursing staff and laboratory were not previously detected by hospital staff. The CNO added that all blood components, patient identification, and unit label information must be reviewed by two RNs at the bedside prior to starting a transfusion.

B. Medical record review showed patient #19 underwent a surgical procedure on 4/13/11. Following this procedure, the patient received two units of pRBCs. Review of the transfusion report dated 4/13/11 showed the first pRBC unit was started at 12:13 PM; vital signs were obtained and recorded prior to starting that unit. However, there was no documentation of post-transfusion vital signs, the volume of blood given, or whether the patient experienced a reaction. Nor was the blood tab number written on, or attached to, the transfusion report. On 9/22/11 at 11:28 AM, HIC #1 confirmed that the medical record was missing this information.

C. Transfusion related entries in patient #3's medical record documented the patient received 2 units of O negative pRBCs as an emergency uncrossmatched release from the blood bank on 5/17/11. However, the transfusion worksheet released by the laboratory to nursing service listed both units of pRBCs as "O positive." The discrepancy in blood type was not detected by either laboratory or nursing personnel, although the medical record showed both services signed the transfusion worksheet attesting to its accuracy.

Blood bank inventory and control logs were reviewed with MT #2 on 9/20/11 at 5:45 PM; these documents confirmed the units transfused to patient #3 were O negative. The technologist acknowledged an unresolved clerical error existed in the medical records.

D. The Standards for Blood Banks and Transfusion Services, 23rd edition, 2006, published by the American Association of Blood Banks, is a nationally recognized guideline for safeguarding patient safety and blood quality for transfusion events. These standards require transfusionists to verify all information matching the blood with the intended recipient, item by item, immediately prior to transfusion. These standards further require that the medical record include the name and donor number of the blood component, the date and time of transfusion, pre- and post-transfusion vital signs, amount transfused, identification of the transfusionist, and assessment for adverse events or reactions.

Based on staff interview and medical record review, the facility failed to ensure 5 of 5 patients (#3, #8, #10, #19, and #20) receiving blood components had properly executed blood transfusion consents in their medical records. The findings were:

A sample of open and closed medical records was reviewed on 9/19/11 through 9/22/11. Five patients (#3, #8, #10, #19, and #20) were noted to have received one or more units of pRBCs while at the facility. Of these 5 patients, 1 (#19) failed to have a blood transfusion consent in his/her medical record; the remaining 4 patients had consent forms that lacked both the date and time of consent (#3) or lacked the time of consent (#8, #10, and #20).

HIC #1 assisted surveyors on 9/22/11 at 9:20 AM to find a blood transfusion consent in patient #19's record; she was unable to find evidence of consent prior to transfusion in either electronic or paper records.

The CNO stated in interview on 9/22/11 at 9:30 AM the facility recently revised their consent process for transfusion to include a space for patients to date their signatures, but acknowledge the revised forms failed to include the time consent was given by a patient or patient's representative. She further stated all patient transfusion should have documented consent posted in the medical record.



21849

Based on observation, staff interview, and review of policies and procedures, the facility failed to limit access to medical records in 1 of 2 record storage areas. The findings were:

On 9/20/11 at 9:21 AM, maintenance staff were observed by a life safety code surveyor to enter a storage area in the radiology department. Subsequent investigation on 9/21/11 at 10:10 AM revealed the radiology storage room contained about 500 medical records on open shelving and in unsealed cardboard boxes, as well as four locked filing cabinets, x-ray film, radiology contrast media, a partial box of ceiling tiles, 6 air filters, and excess medical equipment.

Interview with the health information management (HIM) supervisor on 9/20/11 at 11:15 AM revealed the radiology storage area was used to archive medical records of deceased patients and medical records waiting offsite storage. She acknowledged access to this room was not limited to HIM staff.

On 9/20/11 at 1:45 PM the radiology supervisor was asked if she could access the storage room containing the medical records; she was able to unlock the door with a key kept by radiology staff. The supervisor stated she entered the store room to retrieve radiology supplies; she further stated the locked filing cabinets contained human resources records.

On 9/22/11 at 8:20 AM, facility policy number 3.1.4.21, Record Confidentiality, Security, Ownership, was reviewed. The policy required facility staff to safeguard the confidentiality of medical information and, further, to restrict access to HIM personnel and nursing personnel ("...Charge Nurse...") designated to access medical records at times the HIM department was not available.

Based on observation, staff interview, and review of policies and procedures and manufacturer's instructions, the facility failed to ensure flexible endoscopes were cleaned and reprocessed as required by the manufacturer (C278), failed to ensure medical equipment was checked for electrical safety prior to placement in the OR (C222), and failed to maintain records of temperature and humidity in the OR (C226). In addition the facility failed to determine the expiration dates of multiple boxes of chromic sutures; six of those boxes had expired but were available for use during surgeries. The cumulative effect of these deficiencies resulted in a determination that the facility failed to promote a safe surgical environment and, therefore, failed to meet the requirements for the condition of participation for surgical services.





21849

Based on medical record review, staff interview, and review of credentialing priveledges, the facility failed to develop policies and procedures that specified physicians could administer anesthesia, thus failing to meet the regulatory criteria for conducting post-anesthesia evaluations. This failure affected 1 of 3 surgical patients (#19) whose records were reviewed. The findings were:

Medical record review showed patient #19 underwent a surgical procedure on 4/13/11. Further review showed the surgeon conducted a post-anesthesia evaluation on 4/14/11. However, review of his credentialing priviledges showed the surgeon had not requested anesthesiology privileges. Multiple interviews with the administrative assistant from 9/22/11 through 9/29/11 revealed she was unable to find policies and procedures that specified physicians could administer anesthesia. Therefore, the post-anesthesia evaluation was not conducted by someone who met the regulatory criteria.

Based on review of the SB bill of rights, staff interview, and review of policies and procedures, the facility failed to guarantee swing bed residents the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This failure included all the rights itemized under the regulation. The findings were:

Review of the "Swing Bed Residents Notification of Rights" showed that not all the rights included within this requirement were addressed in the notice. The rights not included were:
a. The right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
b. The right to be free from interference, coercion, discrimination, or reprisal when exercising rights.
c. The right of a resident adjudged incompetent to have his/her rights exercised by a court appointed guardian.
d. The right to have a legal-surrogate exercise the rights of a resident not adjudged incompetent.
e. The right to be informed, both orally and in writing in a language understood by the resident, of all rights and rules and regulations governing conduct and responsibilities.
f. The right to be fully informed, in a language understood by the resident, of his/her total health status.
g. The right to access his/her own clinical record within 24 hours.
h. The right to purchase a copy of his/her record upon request and with two working day's advance notice.
Interview with the CNO on 9/22/11 at 8:05 AM confirmed the above itemized rights were not addressed in the notification. According to the facility's 01/11 policy and procedure, "SB Resident Rights", the purpose of the notification "is to ensure that all patients and their families or significant others are aware of the patient rights guaranteed them as a patient in this facility."

Based on review of the SB bill of rights, staff interview, and review of policies and procedures, the facility failed to ensure swing bed residents had the right to refuse treatment, participate in experimental research, and formulate an advance directive. The findings were:

Review of the "Swing Bed Residents Notification of Rights" showed the right to refuse treatment, participate in experimental research, and formulate an advance directive was not included in the notice. Interview with the CNO on 9/22/11 at 8:05 AM confirmed the right was not addressed in the notification. According to the facility's 01/11 policy and procedure, "SB Resident Rights", the purpose of the notification "is to ensure that all patients and their families or significant others are aware of the patient rights guaranteed them as a patient in this facility."

Based on review of the bill of rights for SB residents, staff interview, and review of policies and procedures, the facility failed to ensure swing bed residents had the right to be informed of items and services provided by the facility and paid for by Medicaid and those that the resident was expected to pay for personally. In addition, the bill of rights failed to provide for notification when changes occurred to those items and services. The findings were:

Review of the "Swing Bed Residents Notification of Rights" showed the right to be informed of items and services included in, and those not covered by, Medicaid benefits was not included in the notice. Additionally, the right to be informed of any changes to those benefits was not addressed. On 9/22/11 at 8:05 AM the CNO confirmed the rights were not included in the notification. According to the facility's 01/11 policy and procedure, "SB Resident Rights", the purpose of the notification "is to ensure that all patients...are aware of the patient rights guaranteed them as a patient in this facility."

Based on review of the SB residents' rights, staff interview, and review of policies and procedures, the facility failed to guarantee SB residents the right to refuse transfers or discharge unless necessary for the resident's welfare and the facility could not meet his/her needs, the resident's health had improved and services provided by the facility were no longer needed, the health and/or safety of others was endangered, the resident failed to pay for a stay in the facility, or the facility closed. The findings were:

Review of the "Swing Bed Residents Notification of Rights" showed it failed to include the right to refuse transfers or discharge unless necessary for the resident's welfare and his/her needs could not be met in the facility, the resident's health had improved and services provided by the facility were no longer needed, the health and/or safety of others was endangered, the resident failed to pay for a stay in the facility, or the facility closed. During an interview on 9/22/11 at 8:05 AM, the CNO verified that the right was not included in the notice. According to the facility's 01/11 policy and procedure, "SB Resident Rights", the purpose of the notification "is to ensure that all patients...are aware of the patient rights guaranteed them as a patient in this facility."

Based on staff interview and review of the transfer form, the facility failed to ensure staff were knowledgeable of the elements required to complete an appropriate discharge or transfer. The findings were:

During an interview on 9/22/11 at 8:05 AM the CNO stated the facility lacked an appropriate notice to provide to SB residents before discharge or transfer. The CNO further stated she was unaware of the requirement and of the required elements to be included in the notice. At 10:10 AM that day the CNO produced a copy of the transfer form and stated that it was the only form used when SB residents were transferred. Review of the form verified it lacked the required information necessary to complete an appropriate discharge or transfer.

Based on review of the bill of rights for SB residents, staff interview, and review of policies and procedures, the facility failed to guarantee SB residents the right to be free from physical or chemical restraints imposed for discipline or convenience. The findings were:

Review of the "Swing Bed Residents Notification of Rights" showed it did not address the right to be free from physical or chemical restraints imposed for discipline or convenience and not required to treat medical symptoms. Interview with the CNO on 9/22/11 at 8:05 AM confirmed the right to be free of restraints was missing. According to the facility's 01/11 policy and procedure, "SB Resident Rights", the purpose of the notification "is to ensure that all patients...are aware of the patient rights guaranteed them as a patient in this facility."

Based on review of the SB bill of rights, staff interview, and review of policies and procedures, the facility failed to ensure swing bed residents the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The findings were:

Review of the "Swing Bed Residents Notification of Rights" showed the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion was not addressed. On 9/22/11 at 8:05 AM the CNO confirmed the right was not included in the notice. Review of the facility's policy and procedure, "SB Resident Rights", last revised in 01/11, revealed the purpose of the notification "is to ensure that all patients...are aware of the patient rights guaranteed them as a patient in this facility."

Based on observation, medical record review, and staff interview, the facility failed to provide comprehensive assessments in various areas for 2 of 3 SB residents (#2, #17) who required those assessments. The findings were:

1. According to the admission sheet, resident #2 was admitted to swing bed status on 8/30/11, and an admission Minimum Data Set (MDS) assessment was completed on 9/12/11. Review of that MDS revealed the patient required comprehensive assessments for cognition, depression, activities of daily living, weight loss, pressure ulcers, and restorative care. Detailed review of the medical record showed comprehensive assessments were lacking.

2. According to the admission sheet, resident #17 was admitted to SB status on 7/25/11, and the admission MDS assessment was completed on 8/22/11. Review of that MDS revealed the patient required comprehensive assessments for behavioral symptoms, decline in activities of daily living and weight loss. Detailed review of the medical record showed comprehensive assessments were lacking.

3. While reviewing the SB record for resident #2 on 9/20/11 at 1:15 PM, the CNO stated the MDS was the only assessment used for SB residents. On 9/22/11 at 8:05 AM the CNO acknowledged she was unaware of the requirement for comprehensive assessments and care plans.