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A. Based on random observation, record review, and interview, the provider failed to ensure all essential patient care equipment in the facility was maintained in a safe operating condition. Biomedical testing could not be ensured or provided for all essential equipment. Findings include:

1. Random review on 12/28/10 of the biomedical testing labels in the operating suite (OS), emergency suite (ES), laboratory, x-ray suite, therapy suite, pharmacy, and the acute care/swing bed (ACSB) revealed testing dates could not be located on the equipment. Interview with environmental services supervisor (ESS) I at the time of the review confirmed that condition. He stated he thought the biomedical testing person used the bar code number for identification in a tracking system for the testing of each piece of equipment. A copy of the last biomedical test report was requested through ESS I, director of nursing (DON) C, and administrator D. None of the employees listed could retrieve a copy of the last biomedical testing report from the biomedical technician.

B. Based on observation and interview, the provider failed to monitor and log the safety of patient care equipment. The daily checklists for the crash carts located in three of three patient care areas (OS, ES, and ACSB) had not been performed on a daily basis. Findings include:

1. Review of the provider's daily checklists for monitoring the safety and integrity of equipment and medication on the crash carts located in the OS, ES, and ACSB, revealed the following:
* OS - The last two weeks was completely void and not checked.
* ES - The last nine months had twnety eight days void and not checked.

Interview with DON C at 4:00 p.m. on 12/27/10 confirmed the daily checklists from the ES had not been completed. Interview with registered nurse/quality assurance/infection control/safety officer B at 1:45 p.m. on 12/28/10 confirmed the daily checklists from the OS had not been completed for the past two weeks. She stated the OS director had left abruptly two weeks ago and the daily checklists had not been kept current.



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2. Observation on 12/28/10 at 9:00 a.m. revealed a crash cart located in the ACSB portion of the hospital. Review of the daily checklist on the top of the crash cart revealed multiple gaps in documentation for the daily checks of that crash cart.
*March 2010: Eight days when the crash cart had not been checked.
*April 2010: Twenty-two days when the crash cart had not been checked.
*May 2010: Nineteen days when the crash cart had not been checked.
*June 2010: One day when the crash cart had not been checked.
*July 2010: Three days when the crash cart had not been checked.
*August 2010: Nine days when the crash cart had not been checked.
*September 2010: Six days when the crash cart had not been checked.
*October 2010: Thirteen days when the crash cart had not been checked.
*November 2010: Eighteen days when the crash cart had not been checked.
*December 2010: Seven days when the crash cart had not been checked.

Items to have been checked on the crash carts included:
*The lock was secured for medications stored in the crash carts.
*The defibrillators were plugged in.
*The defibrillators had been tested.
*The suction machines had the tubing in place and were ready to be used.
*Adult and pediatric Ambu bags were present.
*The bulbs on the laryngoscopes had been checked every third night.

Interview at the above time with licensed practical nurse G revealed:*The crash cart had not been needed since he had started in October 2010.
*He was aware the night nurses were to have checked the crash carts each night.

Interview on 12/28/10 at 1:57 p.m. with DON C revealed the ACSB and ES crash carts were to be checked by the night nurses. He stated no specific nurse was assigned that task but was decided among the nurses on duty. He also stated there was no policy for checking the crash carts.

Based on observation, testing, and interview, the provider failed to maintain cleanable and durable surfaces for the walls in the soiled linen holding area of the laundry room and the cart storage area of the dining room. Those walls had gouges and holes in the gypsum board. Findings include:

1. Observation at 4:00 p.m. on 12/27/10 revealed the soiled linen holding area of the main laundry room had gouges and scrapes in the wall. Those scrapes and gouges were 12 inches to 24 inches long and dug into the chalk of the gypsum board (photos 5 and 6). Interview with environmental services supervisor (ESS) I at 2:00 p.m. on 12/28/10 confirmed the above findings. He stated he was aware of the damage to the wall by the linen carts but had not had time to repair the walls.

2. Observation at 4:45 p.m. on 12/27/10 revealed a cart storage area in the dining room by the kitchen. The two walls in that area had three areas that were damaged. Those areas included:
* A large chip from the plaster on the corner that measured about two inches by five inches (photo 3).
* A large gouge and hole in the wall that measured about three feet long, three inches wide, and one half inch deep in areas (photo 1).
* A large hole the size of a baseball that had broke through the gypsum board (photo 2).

Interview with ESS I at 4:30 p.m. on 12/18/10 confirmed the above findings. He stated he was aware of the damage to the wall but had not had time to repair the walls.

Based on observation, interview, and record review, the provider failed;
*To monitor and record temperature and humidity levels in the operating room (OR).
*Record temperature and humidity on five of six surgical patients' (18, 19, 20, 22, and 23) records.
Findings include:

1. Observation at 10:35 a.m. on 12/28/10 of the OR revealed neither a temperature gauge nor a hygrometer (meter to measure humidity) could be located in the room. Interview with registered nurse B at the time of the observation confirmed that finding. She revealed she was not aware of any gauges or meters to monitor temperature or humidity. She further revealed she was not aware if temperature and humidity were logged on the patients' chart.

Interview with environmental services supervisor (ESS) I at 1:45 p.m. on that same day revealed he was not aware of any gauges or meters to monitor the temperature or humidity in the OR. He stated he could monitor the temperature and humidity of any area from his computer. The ESS stated he was not aware the room itself must have a monitor to ensure the OR met the parameters for infection control guidelines.




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2. Review of five of six surgical patients' (18, 19, 20, 22, and 23) records revealed there was no documentation in those records that noted the temperature and humidity of the operating room during those patients' invasive surgical procedures.

Based on observation, record review, and interview, the provider failed to ensure:
*All take-home medications dispensed from the emergency suite (ES) had been labeled with an expiration date.
*Intravenous (IV) solutions in two of two warming cabinets [ES and operating room (OR)] had been stored according to the manufacturer's specifications.
Findings include:

1. Observation on 12/28/10 at 10:00 a.m. of medications labeled for physician dispensing from the ES revealed:
*All oral solid medications were placed in vials and labeled with directions for the physician to complete when the medication was dispensed to the patient.
*Most oral solid medications were packaged in individual unit-dose packages labeled with an expiration date and placed inside the vials.
*Some of the oral solid medications were placed inside the vials without unit-dose packaging. Those vials were not labeled with the expiration date of the medication inside.
*All vials were wrapped in a paper prescription to have been completed by the physician. That paper had a hand-written expiration date of the medication.

Interview at the above time with director of pharmacy F revealed:
*The hand-written expiration date on the paper prescription wrapper was so the pharmacy staff could observe for outdated medications.
*The paper prescription was not dispensed to the patient along with the medication vial.
*For those vials of medications without unit-dose packaging there would be no way the patient could determine the expiration date of the medication once it left the ES.

2. Observation on 12/28/10 at 10:00 a.m. of a warming cabinet in the ES revealed it contained 16 bags of IV solutions. The temperature reading of the unit was 105 degrees Fahrenheit (F). Observation of the IV solution bags revealed none had been labeled with the date they had been placed in the warming unit or a date when they should have been removed from the unit. One of the bags had a manufacturer's assigned expiration date of October 2010.

Interview at the above time with director of pharmacy F revealed the pharmacy service did not place the IV solutions in the warming cabinet. He stated he was not aware if the provider had a policy for warming solutions.

Interview on 12/29/10 at 10:00 a.m. with administrator D revealed she was not aware if the provider had a policy for warming IV solutions.

Review of the provider's index of policies revealed a policy for warming IV solutions could not be found.

Review of a letter from the manufacturer for IV solutions and irrigation fluids dated 12/19/08 revealed:
*Solutions of large volume IVs could have been warmed in their plastic overpouches to temperatures not to exceed 104 degrees F and maintained for a period no longer than 14 days.
*Irrigation solutions could have been warmed to temperatures not to exceed 150 degrees F and maintained for a period no longer than 72 hours or to temperatures not to exceed 113 degrees F and maintained for a period of 14 days.
*The IV and irrigation solutions could have been removed from the warmer once the maximum number of days was reached and used until the manufacturer's expiration date. The solutions could not be warmed more than once.
*After removal from the warming cabinet the IV and irrigation solutions should have been identified as having been placed in the warming cabinet.




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3. Observation on 12/28/10 at 10:30 a.m. revealed a warming cabinet in the OR. It contained eight bags of IV solutions and four bottles of irrigation solutions. The temperature reading on the unit was 109 degrees F. The temperature reading of the IV solutions within the unit was 109 F. Review of the IV solutions and irrigations solutions revealed none had been labeled with the date they had been placed in the warming unit or a date when they should have been removed from the unit. Interview with director of nursing C and registered nurse B at the time of the observation revealed they were not aware there was a temperature limit and calendar limit for warming solutions.

Based on record review, interview, and policy review, the provider failed to ensure reports of medication errors or adverse drug reactions had been prepared for two of two sampled patients (14 and 31) with potential medication error or adverse drug reaction. Findings include:

1. Review of patient 14's medical record revealed:
*She had been admitted on 12/10/08.
*On 12/10/08 the physician had ordered intravenous (IV) normal saline (NS) with 40 milliequivalents (mEq) potassium chloride (KCl) to run at 100 milliliters (ml)/hour. There were no additional physician orders to change the flow rate until 12/12/08 when the physician ordered NS to run at 125 ml/hour.
*Nurse's notes on 12/11/08 documented:
- 6:25 a.m., IV of NS with 40 mEq KCl running at 100 ml/hour.
- 11:30 a.m., NS running at 25 ml/hour.
- 5:00 p.m., NS running at 25 ml/hour.
- 6:40 p.m., IV of NS with 40 mEq KCl running at 25 ml/hour, but no order was found to change rate from 100 ml/hour to 25 ml/hour.
*Nurse's notes on 12/12/08 documented:
- 7:00 a.m., NS with 40 mEq KCl running at 25 ml/hour.
- 10:00 a.m. IV changed to NS running at 125 ml/hour.
*There was no documentation in the nurse's notes, physician's orders, or physician progress notes to show the physician had been notified the flow rate of the NS with 40 mEq KCl had been changed from 100 ml/hour to 25 ml/hour.
*There was no documentation in the nurse's notes, physician's orders, or physician progress notes to explain why the flow rate had changed.
*There was no documentation in the nurse's notes, physician's orders, or physician progress notes to show that a medication error report had been completed.

Interview on 12/28/10 at 4:30 p.m. with director of nursing (DON) C revealed:
*When the different flow rate for the NS with 40 mEq KCl was noticed it should have been verified with patient 14's physician.
*If the flow rate had been changed there should have been a physician's order in patient 14's record to do so.
*If there was no physician's order to change the flow rate, a medication error report should have been completed.

Interview on 12/29/10 at 11:15 a.m. with registered nurse (RN) B revealed:
*One of her duties was to act as the quality assurance/performance improvement coordinator.
*She did not have a file of the medication error reports from December 2008. Those reports might not have been transferred from the old hospital location to the new hospital location.
*She was one of the nurses involved with the care of patient 14 but could not remember the details of the case.
*Completion of a medication error report form would not have been documented in the nurse's notes.

Interview on 12/29/10 at 11:30 a.m. with administrator D revealed:
*DON C had a file of the medication error reports for December 2008.
*There was no documentation of a medication error on 12/11/08.

Review of the provider's 3/3/05 policy for medication errors revealed:
*A medication error was defined as any preventable event that may have caused or led to inappropriate medication use or patient harm while the medication was in the control of the health care professional.
*The policy was that medication errors should have been handled in such a way to preserve as much safety to the patient as possible and to afford immediate correction with adequate documentation as to the cause of the error.
*All staff were expected to report medication and treatment errors by completing a medication error report.
*The physician was to have been notified immediately, the patient monitored for adverse effects, and documentation made in the nurse's notes.




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2. Review of patient 31's closed medical record revealed:
*She had been admitted on 8/19/10 and discharged on 8/22/10.
*She had diagnoses that included cellulitis to her lower legs from poison ivy contact.
*She had no allergies listed on her admission record.

Review of patient 31's 8/19/10 physician's order revealed she was to receive "Ancef (antibiotic) 500 milligram (mg) IV now and then on q (every) 6h (six hours) schedule."

Review of patient 31's medication administration record revealed she had received Ancef 500 mg IV on the following dates and times:
*8/19/10 at 7:00 p.m.
*8/20/10 at 12:00 midnight.
*8/20/10 at 6:00 a.m.
*8/20/10 at 12:00 noon.
*8/20/10 at 6:00 p.m.
*8/21/10 at 12:00 midnight.
*8/21/10 at 6:00 a.m.

Review of patient 31's nurse's notes revealed on 8/20/10:
*7:00 a.m. She had raised red areas noted to her left axilla (armpit), front of her abdomen, her back, the upper part of her left leg, on the right side of her face near her mouth, and on her right hand.
*10:10 a.m. Triamcinolone cream was applied to all the red and raised areas.
*10:50 a.m. "Pt.(patient) itching skin and leaving scratch marks - mainly to right abdomen. Pt. given 12.5 mg of Benadryl."
*No further documentation of the red raised areas until 9:45 p.m. "Red raised rash noted to abdomen, back, thighs." "Getting worse, itches." "T-shirt off for comfort." "Triamcinolone cream applied."
*10:00 p.m. Benadryl 12.5 mg given.
Review of patient 31's nurse's notes on 8/21/10 revealed :
*5:25 a.m. "Pt. awake upon entering. States she is itching. 12.5 mg Benadryl given."
*8:00 a.m. "Rash noted ant/post trunk (back and abdomen), L (left) axilla."
*10:50 a.m. Saline lock intravenous access infiltrated. Saline lock discontinued.
*12:30 p.m. "Since develop allergy to Ancef, pt. received 5 cc (cubic centimeter) of Augmentin (antibiotic) denies itching."
*6:55 p.m. "Sm. (small) bumps - red on trunk, anterior and posterior thighs."

No further documentation was found in patient 31's nurse's notes.

Review of patient 31's physician's progress notes revealed an untimed 8/20/10 progress note. That note had no documentation present regarding the rash as described in the nurse's notes. An untimed 8/21/10 progress note revealed documentation of a patchy, blotchy, pruritic rash to the upper torso, especially to the back. "Prob. (probably) allergic rx (reaction) to IV Ancef."

Review of patient 31's physician's orders pages revealed:
*A verbal physician's order on 8/20/10 at 10:21 a.m. for Triamcinolone 0.1 percent cream to areas other than legs that were raised and red two times a day.
*An untimed physician's order on 8/21/10 to discontinue the IV antibiotics, start Augmentin 250 mg four times a day, and to record an allergy to Ancef. Those orders were noted by the nurse at 11:51 a.m.

Review of patient 31's discharge instruction sheet that was signed on 8/22/10 at 1:40 p.m. by the nurse and patient 31's responsible party revealed no documentation the allergy to Ancef had been communicated to patient 31's responsible party.

Interview on 12/29/10 at 1:00 p.m. with director of pharmacy F revealed:
*He was aware of patient 31's reaction.
*He was aware patient 31 had received six additional doses of Ancef after a rash had been documented.
*He had not completed an adverse drug reaction report.
*He did not track adverse drug reactions.
*A copy of all physician's orders were reviewed by the pharmacist.

Review of the provider's revised 8/3/10 adverse drug reaction reporting policy revealed:
*An adverse drug reaction was any response to a medication that was undesired.
*All adverse drug reactions and suspected drug reactions would be reported immediately to the physician by the patients' nurse.
*The drug reaction would be documented in the patients' medical record
*The adverse drug reaction form (ADR) would be initiated by a nurse, a pharmacist, or a physician.
*All adverse drug reactions and/or suspected drug reactions would be reported on the ADR form and would be reviewed by the Pharmacy and Therapeutics committee whose findings and actions would be noted.

A. Based on observation and interview, the provider failed to install soap and paper towels at 24 of 24 handsinks in the patient bathrooms. Findings include:

1. Observation from 3:00 p.m. through 5:00 p.m. on 12/27/10 and again from 2:00 p.m. through 5:00 p.m. on 12/28/10 revealed 24 handsinks in 24 patient bathrooms did not have paper towel dispensers with single-service paper towels or soap dispensers. Interview with environmental services supervisor I at the time of the observations confirmed those findings. He stated he was not aware paper towel dispensers and soap dispensers had not been installed in those bathrooms.

B. Based on observation, interview, and policy review, the provider failed to maintain a sterile environment in the operating room. A sandwich bag filled with what appeared to be food was found in the bottom drawer of the anesthesia machine. Findings include:

1. Observation on 12/28/10 at 10:30 a.m. revealed a plastic sandwich bag half-filled with what appeared to be granola in the bottom drawer of the anesthesia machine cart in the operating room (photo 4). Interview with registered nurse (RN) B and director of nursing (DON) C at the time of the observation confirmed that finding. DON C revealed food was not allowed in the operating room and would talk to the certified registered nurse anesthetist.

Review of the infection control surgical services policy revealed no policy on food or drink in the operating room.



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C. Based on observation, record review, policy review, and interview, the provider failed to ensure appropriate instructions had been given to all staff and visitors for two of two patient rooms with isolation precautions. Findings include:

1. Observation on 12/27/10 from 3:30 p.m. through 5:00 p.m. revealed an unmarked cart by the door of room 109. That cart contained disposable gowns, gloves, and masks. No sign was noted on the door to direct visitors to the nurse's station.

Continued observation on 12/28/10 from 8:20 a.m. through 2:00 p.m. revealed an unmarked cart by the door of room 109. That cart contained disposable gowns, gloves, and masks. No sign was noted on the door to direct visitors to the nurse's station.

Interview on 12/28/10 at 2:30 p.m. with RN B revealed:
*The patient in room 109 had been on contact precautions for methicillin resistant staphylococcus aureus.
*She agreed the general public would not know what precautions to take before entering and exiting room 109.
*She had not thought of placement of a sign to direct visitors to the nurse's station before entering an isolation room.
*She stated they tried to keep "A close eye" before visitors entered any isolation room.

2. Observation on 12/29/10 at 8:10 a.m. revealed a cart that contained disposable gowns, gloves, and masks was by room 104. No sign was noted on the door that would have directed visitors to the nurse's station. A visitor was observed entering and exiting room 104 without having put on or taken off any personal protective equipment (gown or gloves).

Interview at the above time with DON C revealed the patient in room 104 had been placed on contact precautions when admitted on 12/28/10. He stated the patient was in isolation due to diarrhea and the result of testing for clostridium difficile was not back yet.

Review of the provider's revised 7/6/10 policy for posting and notification to indicate that a patient is on isolation revealed:
*Place the isolation cart outside the room door.
*Place instruction for precaution in the Cardex.
*Isolation signs were in the isolation folder in the file drawer.

Review of the provider's revised 7/6/10 contact precautions policy revealed no indication a sign was to be placed on the door of the room for instructions before entering.

Based on observation, testing, interview, and policy review, the provider failed to comply with the following proper food handling and hygienic practices:
* Communal tubs of butter and peanut butter were used for guest and staff use.
* Improper cooling of food.
* Improper handwashing and glove use.
Findings include:

1. Observation on 12/27/10 from 3:15 p.m. to 5:00 p.m. of the cafeteria and kitchen revealed:
* A communal tub of margarine spread and peanut butter sat on a table with a loaf of bread and a toaster in the dining room. Interview with dietary aide (DA) J at the time of the observation confirmed that finding. She stated that margarine, peanut butter, bread, and toaster were for the staff and guests to use. Observation at 4:25 p.m. on that same day revealed a child entered the dining room and took a swipe of the peanut butter with his finger and then left.
* A one gallon container of chili covered tight with aluminum foil, dated 12/27/10, was on the shelf in the reach-in cooler. That container of chili was warm to the touch. Testing of that container of chili revealed it tested at 87-101 degrees Fahrenheit (F). Interview with DA J at the time of the observation confirmed that finding. She stated that chili had been served at lunch and had been placed in the cooler at about 2:00 p.m. The time was now 4:50 p.m. DA J asked this surveyor if the chili should be discarded. She stated the chili was not going to be reserved to the patients but would be used as an alternative for staff and guests. This surveyor had the chili discarded at that time.
* DA J repeatedly donned new gloves without washing her hands upon re-entering the kitchen, beginning new tasks, unloading clean dishes, and serving a customer at the counter. Interview with DA J at the time of the observations revealed she liked to go over and above the rules and regulations and wore gloves all the time.

Interview with dietary manager (DM) H at 8:15 a.m. on 12/28/10 revealed she was aware the chili had been discarded the night before. She stated both of her staff members were trained in Serv Safe and were aware of the proper cooling temperatures and techniques for food. She stated both staff were aware hot food must be cooled to 70 degrees F in two hours and 41 degrees F in and additional four hours. DM H was not aware the communal tubs of margarine and peanut butter could not be placed out for service by staff and guests. DM H also revealed she had trained her staff regarding handwashing and the proper use and application of gloves. She stated the dietary staff used the infection control policy for handwashing and proper application of gloves.

Review of the admissions policy and procedure book dated March 2010 revealed bread, butter, and peanut butter would be available 24 hours a day in the dining room for staff and guests. Review of the dietary leftovers policy and proper cooling of foods policy both dated June 2010 revealed the proper cooling methods of 70 degrees F in two hours and 41degrees F. in an additional four hours. Review of the infection control policy for handwashing dated July 2010 revealed there were no guidelines for handwashing in the dietary setting or any guidelines for the proper use and application of clean gloves.

Based upon record review and interview, the provider failed to ensure there was complete documentation of orders, interventions, and care provided for two of two sampled patients (14 and 31) with a potential medication error or adverse drug reaction. Findings include:

1. Review of documentation in patient 14's 12/11/08 nurse's notes revealed:
*At some time between 6:25 a.m. and 11:30 a.m. on 12/11/08 the flow rate of the patient's intravenous (IV) normal saline (NS) with 40 milliequivalents (mEq) potassium chloride (KCl) was changed from 100 milliliters (ml)/hour to 25 ml/hour.
*At 6:25 a.m. a registered nurse (RN) noted the IV of NS with 40 mEq KCl was running at 100 ml/hour.
*At 11:30 a.m. RN B noted NS was running at 25 ml/hour. There were no additional notes about the flow rate at that time.
*At 5:00 p.m. RN B noted NS was running at 25 ml/hour. There were no additional notes about the flow rate at that time.
*At 6:40 p.m. a different RN noted the IV of NS with 40 mEq KCl running at 25 ml/hour, but no order was found to change the flow rate from 100 ml/hour to 25 ml/hour. There were no additional notes about the flow rate at that time.

Review of patient 14's physician's orders and physician progress notes for 12/11/08 revealed:
*There was no documentation that indicated the physician had been notified of the change in the NS with 40 mEq KCl flow rate from 100 ml/hour to 25 ml/hour.
*There was no documentation to explain why the flow rate had changed.
*There was no documentation to indicate the physician had ordered a change in the flow rate.
*At 8:45 a.m. there was a progress note stating the decreased sodium and potassium were improved and IV fluids were to be continued.

Interview on 12/29/10 at 11:15 a.m. with RN B revealed:
*She was one of the nurses involved with the care of patient 14 but could not remember the details of the case.
*She would not have continued the flow rate of patient 14's IV at 25 ml/hour unless there had been a physician's order to do so.
*She could not tell by observing the record if the physician had changed the order and the change was not documented.

Refer to C277, finding 1.




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2. Review of patient 31's closed medical record revealed:
*She had been admitted on 8/19/10 and discharged on 8/22/10.
*She had diagnoses that included cellulitis to her lower legs from poison ivy contact.
*She had no allergies listed on her admission record.

Review of patient 31's 8/19/10 physician's order revealed she was to receive "Ancef (antibiotic) 500 milligram (mg) IV now then on q (every) 6h (six hours) schedule." That antibiotic was discontinued on 8/21/10 after patient 31 had received seven doses.

Review of patient 31's nurse's notes revealed on 8/20/10:
*7:00 a.m. She had raised red areas noted to her left axilla (armpit), front of her abdomen, her back, the upper part of her left leg, on the right side of her face near her mouth, and on her right hand.
*10:10 a.m. Triamcinolone cream was applied to all the red and raised areas.
*10:50 a.m. "Pt.(patient) itching skin and leaving scratch marks - mainly to right abdomen. Pt. given 12.5 mg of Benadryl."
*No further documentation of the red raised areas until 9:45 p.m. "Red raised rash noted to abdomen, back, thighs." "Getting worse, itches." "T-shirt off for comfort." Triamcinolone cream applied."
*10:00 p.m. Benadryl 12.5 mg given.

Review of patient 31's nurse's notes revealed on 8/21/10:
*5:25 a.m. "Pt awake upon entering. States she is itching. 12.5 mg Benadryl given."
*8:00 a.m. "Rash noted ant/post trunk (back and abdomen), L (left) axilla."
*10:50 a.m. Saline lock intravenous access infiltrated. Saline lock discontinued.
*12:30 p.m. "Since develop allergy to Ancef, pt. received 5 cc (cubic centimeter) of Augmentin (antibiotic) denies itching."
*6:55 p.m. "Sm. (small) bumps - red on trunk, anterior and posterior thighs."
*No nurse's notes were found that indicated patient 31's physician had been notified of the rash that had developed after the start of the IV antibiotics.
*No nurse's notes were found that patient 31's responsible party had received information on the possible allergy to Ancef.

Interview on 12/29/10 at 11:30 a.m. with DON C revealed:*He agreed there was no documentation patient 31's physician had been notified of a rash.
*No information had been documented on patient 31's discharge instruction sheet of the allergy to Ancef.
*He agreed information on the notification of a suspected allergic reaction should have been documented.
*He agreed information on the physician determined allergy to Ancef should have been documented on the discharge instruction sheet.

Refer to C277, finding 2.

Based on record review and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, or times. A sample of 205 medical record entries revealed 161 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 45 telephone/verbal physicians' orders during review of medical records on all patient care areas revealed authentication of the order did not include a date for 14 and a time for 23.

2. Review of 62 written physicians' orders during review of medical records on all patient care areas revealed 1 was not signed, 7 were not dated, and 44 were not timed.

3. Review of 50 physicians' progress notes during review of medical records on all patient care areas revealed 39 were not timed.

4. Review of 23 miscellaneous forms regarding physician or staff contact with the patient during review of medical records on all patient care areas revealed 3 were not dated and 5 were not timed.

5. Review of 25 outpatient therapy progress notes revealed 25 were not timed and 16 were not signed.

6. Review of the provider's 6/15/00 policy on dating and authentication revealed all entries in the medical record should have been legible, timed and dated, and authenticated by the author of the entry. Authentication required written signature, initials, electronic signature, or rubber stamp.

Based on observation, activity coordinator position description review, and interview, the provider failed to ensure there was an effective activity program for four of four sampled swing bed patients (4, 5, 6, and 7). Findings include:

1. Interview on 12/28/10 at 3:00 p.m. with registered nurse/swing bed coordinator (RN/SBC) E revealed:
*The activities designee was physical therapist (PT) K.
*PT K coordinated all the activities for the swing bed patients.
*PT K did not have a consultant as she was qualified to coordinate activities for the swing bed patients.
*Was not aware a PT K was not qualified to act as the activities coordinator.
*There was no calender of activities.

Interview on 12/28/10 at 9:15 a.m. with swing bed patient 5 revealed she had been offered activities that included putting puzzles together, some type of craft activity, and eating her meals with others in the day room. She stated she had poor eyesight, so she would have been unable to put puzzles together or do the craft activity. She stated she would enjoy just visiting but mostly watched television.

Observation and interview on 12/29/10 at 3:00 p.m. with swing bed patient 4 revealed:
*He was seated at a table in the day room putting a puzzle together.
*He had been in isolation until one-half hour prior to that activity.
*He had been brought in some puzzles when he was isolated in his room but mostly watched television.

Review of the provider's activity coordinator position description signed by an occupational therapist on 7/18/03 revealed:
*The activity coordinator would ensure the coordination, development, implementation, and evaluation of the therapeutic activity program for all patients.
*Essential functions would have included:
**Assessment of each patient's needs for specialized activities.
**Develop and implement a care plan for each resident.
**Structure activities to encourage the patient to feel empowered.
**Provide balanced programs based on the patient's physical, social/emotional, and cognitive needs.
**Ensure the programs matched the patient's past and current needs.
**Supervise staff within the activity department.
**Interact with patients on a regular basis.
**Maintain all required records.

Review of an e-mail sent on 12/19/10 at 5:13 p.m. from administrator D revealed:
*Occupational therapist (OT) L was the activity coordinator and was the contact person for the PT K.
*OT L worked closely with PT K.

Based on record review, interview, and policy review, the provider failed to ensure four of four swing bed patients (4, 5, 6, and 7) had comprehensive care plans. Findings include:

1a. Review of swing bed patients 4, 5, 6, and 7's medical records revealed:
*Swing bed admission assessments with brief nursing diagnoses.
*Swing Bed Cardex's (nursing information sheets) with sections that included:
**Patient information: admission date and time, patient name, patient date of birth, physician name, age, room number, and code status.
**Diagnosis.
**Allergies.
**Emergency contact name and number.
**Intravenous access/therapy.
**Laboratory tests.
**X-rays.
**Appointments.
**Nurse communication.
**Therapies.
**Elimination: Last bowel movement and any appliances required.
**Intake.
**Nutrition: Diet and assistance required for eating.
**Activity: Weight bearing assistance, weight bearing restrictions, and assistive devices required.
**Privileges for activity: If patient is on bedrest or required assistance, and bathing.
**Vital signs: How often to be obtained.
**Equipment to be utilized.
**Dressing/grooming assistance required.
**Fall risk.
**Isolation requirements.
**Mouth care assistance.
**Skin: Wound/incision/pressure ulcer site.

b. Review of patient 4's Cardex revealed areas that had no documentation included:
*Elimination.
*Nutrition assistance required.
*Privileges for activity.
*Bathing.
*Equipment.
*Dressing/grooming.
*Fall risk.
*Isolation.
*Mouth care.
*Skin.
Further review of patient 4's medical record revealed he had methicillin resistant staphylococcus aureus in a wound on his foot and was on contact precautions.

c. Review of patient 5's Cardex revealed areas that had no documentation included:
*Elimination.
*Nutrition assistance required
*Bathing.
*Dressing/grooming.
*Fall risk.
*Mouth care.
*Skin.
Further review of patient 5's medical record revealed she had a wound to her upper left thigh.

d. Review of patient 6's Cardex revealed areas that had no documentation included:
*Nutrition assistance required.
*Privileges for activity.
*Bathing.
*Equipment.
*Dressing/grooming.
*Mouth care.
Further review patient 6's medical record revealed she was at high risk for falls. No interventions had been listed on the Cardex to prevent falls.

e. Review of patient 7's Cardex revealed areas that had no documentation included:
*Privileges for activity.
*Bathing.
*Dressing/grooming.
*Fall risk.
*Mouth care.

f. Interview on 12/29/10 at 9:30 a.m. with director of nursing C revealed:
*The initial nursing assessment nursing diagnoses and the Cardex were considered the plan of care.
*He agreed there had been no documentation of goals and interventions for patient's 4, 5, 6, and 7.
*He agreed the Cardex's for patients 4, 5, 6, and 7 were not complete in all areas.

Review of the provider's revised 10/25/10 care planning policy revealed:
*Within eight hours of admission all patients would have a written plan of care.
*The plan of care would be individualized based on the diagnosis and patient assessment.
*Other disciplines that consulted in the care of the patient would contribute to the plan as appropriate to the patient's diagnosis.
*The plan of care would be updated daily with revisions that reflected the reassessment of the needs of the patient.