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On the days of the Recertification Survey based on observations, record reviews, and interviews, the governing body failed to ensure that the Emergency Department (ED) had a patient call system in place, failed to ensure the hospital had an active Utilization Review process, and failed to provide a system with feedback to ensure a sanitary patient care environment which includes but is not limited to: the Emergency Department, Medical Surgical Unit , and Radiology Department.

The findings are:

Cross Reference to A701: The facility failed to maintain the overall hospital environment in a safe and sanitary manner to ensure the safety and well - being of patients in the dietary kitchen area, public hallways, Radiology Department, Emergency Department, Nurse Station, Medical Surgical Department, and Patient Rooms.

Cross Reference to A144: The Hospital's Emergency Department (ED) failed to ensure a safe environment for patient care in that the Emergency Department did not have a call system in place for patients

Cross Reference to 654: The Hospital failed to have a organized Utilization Review (UR) Committee that was functional and was composed of 2 physicians who carry out the UR Functions.

On the day of the Recertification Survey based on observation, hospital policy review, and staff interview, the Hospital's Emergency Department (ED) failed to ensure a safe environment for patient care in that the Emergency Department did not have a call system in place for patients.

The findings are:

On 1/25/2010 at 1300, observations of the Emergency Department (ED) with the Department Manager revealed that the decontamination shower room, two patient bathrooms, and 6 of 6 patient examination rooms failed to have a patient call system in place. The Department Manager verified that there was no patient call system available in the Emergency Department. During the tour, all curtains were drawn shut in all of the patient examination rooms and these patients were not visible to staff who were at the Nursing Station. Examination Room #6 had a bathroom without a call system and the patient room was not visible from the Nursing Station.

On 1/26/2010 at 0835, observation showed Registered Nurse (RN) #3 administer an injection to Patient #14, and then, when RN #3 left the patient's room, he/she drew the curtain closed. There was no available call system in the patient room so that the patient (#14) could summon assistance if needed. The finding was verified by RN #3 who reported that there were individual tap bells available at Nursing Station but none of the tap bells had been placed in the patient care areas.

Hospital policy on Clinical Alarms, effective date 1/12004, amended on 11/2006 and reviewed on 11/6/2009, reads, "Clinical Alarms are defined as any alarm that is intended to protect the patient receiving care or alert the staff that the patient is at increased risk and needs immediate assistance. There alarms include, but are not limited to, physiological monitor alarms, leg alarms, infusion pumps, ventilator alarms, panic or emergency buttons (bathroom) and nurse call systems."

On the days of the Recertification Survey based on interview and record review, the facility failed to ensure Registered Nurse (RN) supervision of the Licensed Practical Nurse's (LPN) documentation of patient assessments for 3 of 32 records reviewed (Patient #6, 7, and 8), following physician orders for 1 of 32 records reviewed (Patient #3, and the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient for six of six resident records reviewed in hospital swing beds. (Residents #1, 2, 3, 4, 5, and 6)

The findings include:

A clinical record review conducted on 1/27/10 at 1415 revealed Patient #6 was admitted to the facility on 12/4/09 and discharged 12/10/09 with the diagnosis of Pneumonia. On 12/4/09, the chart showed a physician order was written for "O2 (oxygen) 3 L(liters) min (minute) -1 by nasal cannula (NC)". On 12/9/09, an physician order was written to "change O2 to (PRN) as needed chest pain (CP) or shortness of breath (SOB)". There was no documentation of O2 administration on the hospital form, titled, "24 Hour Nursing Flow Sheet" on 12/4/09 during the 0700-1900 and 1900-0700 shifts. On 12/7/09, there was no documentation of O2 administration for the 0700-1900 and 1900-0700 shifts. The shift assessments were documented by an LPN and co-signed by the RN indicating supervision and/or confirmation of assessment findings.

A clinical record review conducted on 1/27/10 at 1515 revealed Patient #7 was admitted to the facility on 12/5/09 and discharged on 12/9/09 with the diagnosis of Syncope. On 12/5/09, a physician order was written for "O2 2 liters(L)/NC (nasal cannula)". On 12/8/09, a physician order was written "change O2 to prn (as needed) shortness of breath (SOB). There was no documentation of O2 administration on the hospital form, titled, "24 Hour Nursing Flow Sheet" on 12/5/09 during the 0700-1900 and 1900-0700 shifts. On 12/6/09, during the 1900-0700 shift, O2 was documented at 1 L, and the Nurse's Notes showed staff documented the patient was breathing without O2 on room air (RA). On 12/7/09, during the 0700-1900 and 1900-0700 shifts, there was no documentation of O2 administration, and the Nurse Notes showed the patient was breathing without O2 on RA. The assessments were documented by an LPN and co-signed by an RN indicating supervision and/or confirmation of assessment findings.

A clinical record review conducted on 1/27/10 at 1615 revealed Patient #8 was admitted to the facility for observation on 12/9/09 and discharged on 12/10/09 with the diagnosis of Transient Ischemic Attack versus Stroke. On 12/9/09, a physician order was written for "O2 via NC @ 2L +/-". There was no documentation of O2 administration on 12/9/09 and 12/10/09. The assessments were documented by an LPN and co-signed by an RN indicating supervision and/or confirmation of assessment findings. The findings were verified by the Chief Nursing Officer on 1/27/09 at 1645.




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On 1/26/2010 at 1230, a review of Patient #3's Medical Record showed a physician order for vital signs every 15 minutes until stable. Patient #3 was admitted with a diagnosis of pyelonephritis. Vital signs taken at 2000 on admission to Medical Surgical unit were recorded as: temperature 98.8, pulse 101, respirations 20, blood pressure 103/62 and oxygen saturation 97%.
Vital Signs were not obtained again until 2400 and were recorded as: temperature 97.8, pulse 78, respirations 18, blood pressure 84/56, oxygen saturation 99%.
Vital Signs were obtained at 0400 and staff recorded: temperature 97.4, pulse 77, respirations 20, blood pressure 91/61, and oxygen saturation 96%.
The Finding were verified with Registered Nurse (RN) #4 who reported that the first set of vital signs were stable, so vital sign assessment every 15 minute was unnecessary but acknowledged that the patient's pulse (101) at 2000 and blood pressure (84/56) at 2400 were not within normal range.

Review of hospital policy, Standards of Practice applicable to Nursing Services, amended on 10/05, and reviewed and approved by the Chief Executive Officer, Chief Nursing Officer and Director of Medical/Surgical Services on 11/6/2009, reads, "It is the policy of the Med/Surg (Medical / Surgical) Department of ... Community Hospital to utilize the American Nurses Association's standards of practice based on the nursing process. The emphasis is based on the process of assessment and problem identification. The standards are divided into the four phases of assessment, planning, implementation and evaluation."




21307

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status-post right hip fracture with repair, and anemia status-post transfusion. Physician orders dated 1/18/10 included activity level per PT (physical therapy) and OT (occupational therapy), low salt diet, and intake and output every shift. An initial nursing admission assessment was not completed at the time of swing bed admission on 1/18/10.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. On 1/19/10, physician orders included standing order protocol, diet as tolerated with one can of Boost twice daily (resident weight eighty-five pounds), PT evaluation for gait strengthening, and up as tolerated. A nursing admission assessment was not completed at the time of the swing bed admission on 1/18/10. The "24 Hour Nursing Flow Sheet" dated 1/23/10 failed to address sleeping patterns during the night shift.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. Physician admission orders included walk with assistance, PT/OT, 1800 calorie ADA (American Diabetes Association) with Glucerna one can three times daily, and vital signs every shift. An initial nursing admission assessment was not completed at the time of the swing bed admission on 12/11/09.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. Admission orders dated 10/17/09 included up as desired, and 1000 cubic centimeter (cc.) free water fluid restriction, and low cholesterol mechanical diet. An initial nursing admission assessment was not completed at the time of the swing bed admission on 10/17/09.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. The physician orders included physical therapy for strengthening, mechanical soft diet with 1500 milliliters (ml.) fluid restriction, and keep skin clean and dry. A nursing admission assessment was not completed at the time of the swing bed admission on 8/28/09.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old admitted on 8/24/09 with a diagnosis of status/post total right hip replacement. Physician orders dated 8/24/09 included activity level per physical therapy, regular diet, intake and output every shift, and change dressing to right hip as needed. Physician orders dated 8/25/09 included "Physical therapy -post op right hip replacement twice daily, and discontinue oxygen- pulse oximeter every shift, notify if less than 90%". The "Standing Order Protocol" form was not placed on the resident's medical record and therefore was not signed by the physician. There was no order for the initiation of oxygen. An initial nursing admission assessment was not completed upon admission on 1/18/10. Nursing notes on 8/24/09 at 1955 showed staff documented that oxygen was infusing at 2 liters per minutes per nasal cannula. The "Graphic Record" dated 8/25/09 showed staff failed to document intake and output on the 7 PM to 7 AM shift. On 1/27/10 at 0945, the findings were reviewed with Registered Nurse #1 who stated that upon admission as a swing bed resident from acute care status, an initial nursing assessment should be completed.

Review of hospital Policy #70.6022, "Requirements for Swing-Bed Patients", amended 10/05, reads, "... Procedure: ... 3. A Nursing Assessment shall be completed on all patients within twenty- four (24) hours of admission ...".

Review of hospital Policy# 70.6022, "Admission Assessment", amended 9/05, reads, "Policy: The Admission Assessment Form is to begin within 1 (one) hour of admission with the physical, social and psychosocial elements completed within 8 (eight) hours and the entire assessment completed in 24 (twenty-four) hours for the medical/surgical patient ... ".

On the days of the Re-certification survey, based on interview, record reviews, and review of policy and procedure, the hospital failed to ensure that nursing staff developed and kept current a nursing care plan for each patient for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair, and anemia status post transfusion. Physician orders dated 1/18/10 included activity level per PT (physical therapy) and OT (occupational therapy), low salt diet, intake and output every shift. A nursing admission assessment was not completed upon admission on 1/18/10. Nursing care plans included: Pain Management that was initiated by nursing on 1/13/10 upon acute inpatient admission; Inpatient Physical Therapy Intervention that was initiated by nursing on 1/20/10; Age Specific Physical, Motor/Sensory, Cognitive and Psychosocial Needs for the Elderly Patient that was initiated on 1/13/10 upon acute inpatient admission; and Fall Prone that was initiated by nursing on 1/14/10 during acute inpatient admission. Care plans included expected outcomes, interventions, and a section for staff to document the date that interventions were completed. It was not indicated on the nursing care plan for pain management that the intervention for PT/OT and social work consults had been completed as documented on the therapy evaluation forms dated 1/18/10 and on the progress notes documented by the social worker on 1/19/10.

On 1/25/10 at 1430, review of Resident #2's open medical record revealed the eighty-two year old was admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. On 1/19/10, physician orders included standing order protocol, diet as tolerated with one can of Boost twice daily (resident weight eighty-five pounds), PT evaluation for gait strengthening, and up as tolerated. A nursing admission assessment was not completed upon admission on 1/18/10. Nursing care plans included: Inpatient Physical Therapy Intervention initiated by nursing on 1/19/10, but did not identify who initiated the care plan, if the problem was actual or potential, what the problem was related to, and did not address specific outcomes or standards of care; Fall Prone initiated by nursing on 1/14/10 during acute inpatient admission; Age Specific Physical, Motor/Sensory, Cognitive and Psychosocial Needs for the Elderly Patient initiated on 1/14/10 upon acute inpatient admission with disciplines responsible for the interventions not identified. There was no plan of care to address the stasis ulcer and dressing changes to the resident's leg.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. Physician admission orders included walk with assistance, PT/OT, 1800 calorie ADA (American Diabetes Association) with Glucerna one can three times daily, and vital signs every shift. A nursing admission assessment was not completed upon admission on 12/11/09. Nursing care plans included: Fall Prone initiated by nursing on 12/2/09 during acute inpatient admission; Age Specific Physical, Motor/Sensory, Cognitive and Psychosocial Needs for the Elderly Patient initiated on 12/2/09 upon acute inpatient admission, but did not identify disciplines responsible for the interventions. There was no plan of care to address problems related to anemia to include nursing interventions and goals.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. Admission orders dated 10/17/09 included up as desired, and 1000 cubic centimeters (cc.) free water fluid restriction, low cholesterol mechanical diet. Physician orders dated 10/18/09 included "Please make sure sitting up when eating/ drinking and eat slowly". A nursing admission assessment was not completed upon admission on 10/17/09. Nursing care plans included Inpatient Physical Therapy Intervention initiated by nursing upon acute admission on 10/17/09, but did not address if nursing interventions were applicable or not applicable; Age Specific Physical, Motor/Sensory, Cognitive and Psychosocial Needs for the Elderly Patient initiated on 10/15/09 during acute inpatient admission, but did not address if any of the nutritional interventions were applicable to the resident and also failed to identify which nursing interventions were applicable to the resident; and an Injury care plan initiated by nursing on 10/15/09 during acute inpatient admission, and identified a nursing intervention to orient the patient to surroundings every two hours, but there was no supporting documentation of the intervention was found in the resident record. It was not indicated on the care plan for pain management that the intervention for PT/OT and social work consults had been completed as documented on the therapy evaluation forms dated 1/18/10, and on the progress notes documented by the social worker on 1/19/10.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. The physician orders included physical therapy for strengthening, mechanical soft diet with 1500 milliliters (ml.) fluid restriction, and to keep skin clean and dry. A nursing admission assessment was not completed upon admission on 8/28/09. Nursing care plans included "Alteration in Comfort" initiated by the nurse on 8/19/09 during the acute inpatient hospitalization did not identify the outcomes; "Age Specific Physical, Motor/Sensory, Cognitive and Psychosocial Needs" for the Elderly Patient (over 80 years) initiated on 8/19/09 during the acute inpatient hospitalization, but did not specify disciplines responsible for the interventions and specific outcomes were not identified; "Cardiac Status initiated on 8/19/09 during the acute inpatient hospitalization did not identify specific outcomes; "Injury" care plan initiated on 8/19/09 during the acute hospitalization did not identify actual or potential problems and specific interventions were not addressed pertaining to the resident.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with a diagnosis of status/post total right hip replacement. Physician orders dated 8/24/09 included activity level per physical therapy, regular diet, intake and output every shift, change dressing to right hip as needed, and standing orders per protocol. There was no plan of care in the residents's record as confirmed by the Director of Medical Records on 1/27/09 at 0945. In an interview on 2/27/09 at 0945, the findings were reviewed with Registered Nurse #1 who stated that a new nursing care plan should be developed for residents changing from acute inpatient hospitalization to swing bed status.

Review of hospital Policy # 21.9290, "Discharge Planning", amended 11/06, read, " ... Upon admission to the hospital, a nursing admission interview and assessment is done on all patients regardless of pay source. Included in the initial assessment is a list of triggers that assist the nurse in anticipating discharge needs of the patient. Any needs or problems identified should be referred to the Case Management Department for evaluation. The Nursing Staff should take an active role in Discharge Planning as they communicate with the patient and family on a one to one basis throughout the hospital stay...Discharge planning is an interdisciplinary hospital wide process insuring continuity of care and insuring that maintenance of high quality care is available tot he patient's post hospitalization....".

Review of hospital Policy, "Care Plans", amended 11/2009, read, "Policy: A Registered Nurse plans each patient's nursing care based on identified nursing diagnosis and/or patient care needs ... Care plans s are initiated on admission and upgraded every shift ... ".

On the days of the Recertification Survey based on interview and record review, the facility failed to ensure the prescribed administration of Oxygen (O2) ordered by the physician for 2 of 31 clinical records reviewed. (Patient #7 and 8)

The findings include:

A clinical record review conducted on 1/27/10 at 1515 revealed Patient #7 was admitted to the facility on 12/5/09 and discharged on 12/9/09 with the diagnosis of Syncope. On 12/5/09, an order was written for "O2 2 liters (L)/NC (nasal cannula)" and on 12/8/09, an order was written "change O2 to prn (as needed) shortness of breath (SOB)". There was no documentation of O2 administration on the hospital form, titled, "24 Hour Nursing Flow Sheet" on 12/5/09 during the 0700-1900 and 1900-0700 shift. On 12/6/09, during the 1900-0700 shift, O2 was documented at 1L, and the Nurse's Notes showed staff documented the patient was breathing without O2 on room air (RA). On 12/7/09, during the 0700-1900 and 1900-0700 shifts, there was no documentation of O2 administration, and the Nurse's Notes showed staff documented the patient was breathing without O2 on RA.

A clinical record review conducted on 1/27/10 at 1615 revealed Patient #8 was admitted to the facility for observation on 12/9/09 and discharged on 12/10/09 with the diagnosis of Transient Ischemic Attack versus Stroke. On 12/9/09, an order was written for "O2 via NC @ 2L +/-". There was no documentation of O2 administration on 12/9/09 and 12/10/09.
The findings were verified by the Chief Nursing Officer on 1/27/09 at 1645.

On the days of the Re-certification survey, based on interview, record reviews and review of policy and procedure, the hospital failed to ensure that all medical record entries were legible and complete for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair, and anemia status post transfusion. On 1/19/10, the physician wrote an order for "Standing order protocol". The "Standing Order Protocol" form was not placed on the resident's medical record and therefore was not signed by the physician. A nursing admission assessment was not completed upon admission on 1/18/10. There was no documentation in the chart pertaining to patient rights or advanced directives. A section on the bottom of the physical therapy and occupational therapy evaluation form indicating the physician's recommendation regarding the treatment plan had not been completed and there was no verbal order in the chart from the physician agreeing with the treatment plan for physical therapy and occupational therapy.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old was admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. On 1/19/10, physician orders included standing order protocol, diet as tolerated with one can of Boost twice daily (resident weight eighty-five pounds), PT evaluation for gait strengthening, and up as tolerated. The "Standing Order Protocol" form was not placed on the resident's medical record, and therefore, was not signed by the physician. A section on the bottom of the physical therapy and occupational therapy evaluation form indicating the physician's recommendation regarding the treatment plan had not been completed, and there was no verbal order in the chart from the physician agreeing with the treatment plan for physical therapy and occupational therapy. A nursing admission assessment was not completed upon admission on 1/18/10. The "24 Hour Nursing Flow Sheet" dated 1/23/10 failed to address sleeping patterns during the night shift.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. Physician admission orders included walk with assistance, PT/OT, 1800 calorie ADA (American Diabetes Association) with Glucerna one can three times daily, and vital signs every shift. A nursing admission assessment was not completed upon admission on 12/11/09.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. Admission orders dated 10/17/09 included up as desired, and 1000 cubic centimeters (cc.) free water fluid restriction, and low cholesterol mechanical diet. A nursing admission assessment was not completed upon admission on 10/17/09.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. The physician orders included physical therapy for strengthening, mechanical soft diet with 1500 milliliters (ml.) fluid restriction, keep skin clean and dry, and standing orders. The "Standing Order Protocol" form was not placed on the resident's medical record, and therefore, was not signed by the physician. A nursing admission assessment was not completed upon admission on 8/28/09.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with diagnosis of status/post total right hip replacement. Physician orders dated 8/24/09 included activity level per physical therapy, regular diet, intake and output every shift, change dressing to right hip as needed, and standing orders per protocol. Physician orders dated 8/25/09 included "Physical therapy -post op right hip replacement twice daily, and discontinue oxygen- pulse oximeter every shift, notify if less than 90%". The "Standing Order Protocol" form was not placed on the resident's medical record, and therefore, was not signed by the physician. There was no order for the initiation of oxygen. A nursing admission assessment was not completed upon admission on 1/18/10. Nursing notes on 8/24/09 at 1955 showed staff documented that oxygen was infusing at 2 liters per minutes per nasal cannula. There was no plan of care in the residents's record as confirmed by the Director of Medical Records on 1/27/09 at 0945.
The findings were reviewed and confirmed in an interview with Registered Nurse #1 on 2/27/09 at 0945.

Review of hospital Policy, # 70.6022 "Charting", amended 10/05, read, "Purpose: To keep
an accurate record of what happens to the patient as an aid to the physician in treating of the patient ... ".

On the days of the Recertification Survey based on interview and record review, the Hospital failed to have a organized Utilization Review (UR) Committee that was functional and was composed of 2 physicians who carry out the UR Functions.

The findings are:

In an interview with the UR Director on 01/26/10 at 1330, the Director revealed that the physician who had been appointed to the UR committee had not attended any meetings or has not been available for UR review in a year. The Director reported that the committee has 3 attending physicians and 3 emergency physicians that act in advisory roles, and the committee meets quarterly without physicians.

On 01/26/10 at 1500, a review of Health Information Management/Utilization Review Meeting minutes dated October 30, 2008, reads, "...Dr. #2 was named our new physician advisor per medical staff. After discussion with Dr.---, he/she has agreed to continue as our advisor. 111. Department reported, a. Case Management: No issues...". On 01/26/10 at 1500, a review of Health Information Management/Utilization Review Meeting minutes dated January 27, 2009, reads, "... 111a. Case Management: No issues..". On 01/26/10 at 1500, a review of Health Information Management/Utilization Review Meeting minutes dated April 29,2009, reads, " ...111a. Case Management: No issues..".
On 01/26/10 at 1500, a review of Health Information Management/Utilization Review Meeting minutes dated July 28, 2009, reads, "... 11. Old/New Business: Due to Dr. #2 no longer being with the hospital, we will need to get a new physician advisor...111a. Case Management: No issues..". The October 2009 Health Information Management/Utilization Review Meeting minutes were not produced by the hospital for review.

On 01-27-10 at 0900 review of the Case Management Plan reads, "B. Meetings 1. Shall meet bi-monthly or more frequently as deemed necessary by the coordinator."
On 01/27/10 at 0800, a review of Medical Staff Meeting minutes dated November 10, 2009, reads, " V. New Business-...Ms--- announced that a new Chairman is needed for the Medical Record/Utilization Review (UR) Committee. Dr--- asked that Ms.---contact Dr. #2 to see if she/he plans to continue as chairman...".
During an interview with MD #1 on 01/28/10 at 0815, MD #1 revealed that that he/she was used on an advisory basis only. MD #1 reported that he/she was not part of a UR committee, does not attend UR committee meetings, and that most of her/his capacity comes down to documentation only.

On the days of the Recertification Survey based on observation, record reviews, and interviews, the facility failed to maintain the overall hospital environment in a safe and sanitary manner to ensure the safety and well - being of patients in the dietary kitchen area, public hallways, Radiology Department, Emergency Department, Nurse Station, Medical Surgical Department, and Patient Room.

The findings are:

During the tour of the Kitchen area on January 25, 2010 at 1400 with the Director of Support Services and the Kitchen Manager,observations revealed a dark black substance inside the Refrigerator #1 where food for the patients was stored. The Manager attempted to scrape the black substance from inside the refrigerator during the tour.

Observations of Cooler #1 revealed orange particles flaking off of the Cooler and the particles were also observed on the floor surrounding the Cooler.

Observations of the kitchen floor revealed areas located under the counters had a thick mixture of dust and grime, and doorway thresholds in the Kitchen had a grey black substance and old wax buildup present, The Kitchen Manager verified the wax buildup and grime on the kitchen floor.

The vent hood over the cooking stove had visible dust buildup. The Kitchen Manager stated that the hood cleaning was under contract. The Director of Support Services confirmed that there was a contract for cleaning this hood, and that it was last cleaned in November 2009 according to records. The Kitchen Manager verified that the vent hood appeared to be dusty but reported that cleaning of the vent hood was under the Support Services division.

Observation of the upper Patient Area on January 25, 2010 at 1600 revealed the area had gunite floors that were riddled with cracks The floors in this area (patient rooms and hallways) had wax buildup and had grey black grime. At the gunite/carpet border outside the Nursing station, the carpet was matted and frayed away from the rubber stripping. There was a chunk of dry wall on the floor with dry wall dust that had been knocked off the corner of the wall in the hall. Maintenance Technician #1 picked up the chunk of dry wall and threw it away.

The Oxi-Max 65 Oxygen Saturation Monitor located in Room 225 had no equipment sticker on it, and the facility had no record of the date that the Oxi-Max 65 monitor was services and calibrated.

Observation of Surgical Suite #1 revealed that the Surgical Suite had an area on the floor where the grout and tile had separated. Staff in the area stated that it had put in on a work order, but a work order could not be produced.

Observation of the Radiology showed the processor room was cluttered and very dusty. An open drain in the floor was used for disposal of liquids. The drain was heavily stained and dusty. The Director of Support Services verified that the area required cleaning.

Observations at the entrance to the hospital showed the grill of the air system was heavily encrusted with dust and was verified with the Director of Support Services.

Observations in the Emergency Department revealed the floors had a heavy wax build up with black - grey grime. Observations of a patient bathroom located in the Emergency Department had no handicap grab bar or call light installed.

During an interview on January 27, 1020 at 1100 with the Director of Support Services Division, which has responsibility for Engineering, Maintenance, Safety, Environmental Services/ Housekeeping, Food and Nutrition Services, Security, Information Systems and Materials Management, the findings were verified.

On 1/27/2010, review of Environmental Services policies (No.21.8100), reads, "...The Housekeeping Department shall maintain a clean, comfortable and sanitary environment for the patients, staff and visitors".
".... procedures, to "ensure acceptable standard for quality, and carrying out pertinent infection control procedures." A quality control initiative was described ".... inspection, analysis, action" to ascertain the "effectiveness of the plan." The final pages of this lengthy policy give the frequencies for which these cleaning procedures are to be followed for each specific area of the hospital. All of the hospital problem areas mentioned above (Kitchen, Hallways, Radiology, Emergency Department, Lobby) are listed as, "Daily" cleaning, except for Radiology which is six days per week. This includes "high dusting, dust mopping, wet mopping, damp wiping, trash and ashtrays."





28630

On 1/25/2010 at 1300, observations of the Emergency Department (ED) with the Department Manager revealed that the decontamination shower room, two patient bathrooms, and 6 of 6 patient examination rooms failed to have a patient call system in place. The Department Manager verified that there was no patient call system available in the Emergency Department. During the tour, all curtains were drawn shut in all of the patient examination rooms and these patients were not visible to staff who were at the Nursing Station. Examination Room #6 had a bathroom without a call system and the patient room was not visible from the Nursing Station.

On 1/26/2010 at 0835, observation showed Registered Nurse (RN) #3 administer an injection to Patient #14, and then, when RN #3 left the patient's room, he/she drew the curtain closed. There was no available call system in the patient room so that the patient (#14) could summon assistance if needed. The finding was verified by RN #3 who reported that there were individual tap bells available at Nursing Station but none of the tap bells had been placed in the patient care areas. The Hospital policy on Clinical Alarms, effective date 1/12004, amended on 11/2006 and reviewed on 11/6/2009, reads, "Clinical Alarms are defined as any alarm that is intended to protect the patient receiving care or alert the staff that the patient is at increased risk and needs immediate assistance. There alarms include, but are not limited to, physiological monitor alarms, leg alarms, infusion pumps, ventilator alarms, panic or emergency buttons (bathroom) and nurse call systems."

On 1/25/2010 at 1330, observations during a tour of medication room located in the Emergency Department (ED) showed a build-up of black grime around the faucet and sink ledge where patient medications were prepared, the floor had a heavy build up of wax and black grime around the edges. The findings were verified by the Department Manager.

Observation of the Emergency Department Examination Room #4 showed Examination Room #4 had a heavy build-up of wax and black grime around the edges. The Crash Cart's top had a layer of thick dust. The finding was verified by the ED Manager.

At 1415, Observations of ED Examination Room #5 showed a floor with a heavy build-up of wax and grey black grime around edges, and three thermal lunch bags were hanging on the wall with equipment such as a subclavian needle, jet insufflation and pericardiocentesis needles and the equipment had a thick layer of dust. Crash Cart #2 had a thick layer of dust on the top of the cart. Four sterile chest trays observed in an upper cabinet did not have an expiration date nor were wrapped in plastic to ensure sterility. The finding was verified by the Department Manager.

Observations of ED Examination Room #1 showed the room had a heavy wax build up with black grime. The finding was verified by Department Manager.

On 1/25/2010 at 1430, observations of ED Examination Room #6 revealed a floor in the exam room area and attached bathroom that had thick black grime substance on the floor, Stand alone eye examination equipment had a thick layer of dust on the tray and did not have a protective cover in place. The finding was verified by the Department Manager who reported that he/she had brought up the poor sanitary conditions in the Emergency Department at Department Head meetings without a resolution. A review of ED Performance Improvement Manual minutes showed no documentation of sanitation issues in the ED were discussed.

On 1/26/2009 at 1030, observations of the Second floor Medical /Surgical Unit 's Latex allergy cart showed the cart had a thick layer of dust on the top shelf and dirt particles in observed in the open shelf containers. The finding was verified by Registered Nurse (RN) #4.

Medical Surgical Patient Room #217 had a build up layer of grime on the bathroom floor. Shower in Hall A had a build up of black grime in the floor and stained ceiling tiles. The finding was verified by RN #4.


Hospital policy Description #9, Environmental Services, reviewed and approved on 11/6/2009 by the Chief Execution Officer, Chief Nursing Officer and the Director of Medical/Surgical Services, reads, "The Environmental Services Department is a service department with focus on sanitation of the facility. Housekeeping is responsible for ensuring that everyone works in a clean, safe environment. Environmental Services coordinates linen services to all units and provides frequent thorough cleaning of hospital interiors that is necessary to reduce pathogens. The goal of this department is to physically remove microorganisms from the various formats that might transmit to staff, visitors and patents". Description #13, reads, "Infection Control conducts hospital-wide surveillance of patients, employees, and environment. Policies and Procedures have been developed and approved by Medical Staff to assist in these activities. Infection Control collaborates with each department to develop unit/.department specific policies and procedures....".



27544

On 01/25/10 at 1315, a tour was conducted of the Radiology Department. Observation of the emergency box in the Computerized Axial Tomography (CAT) Scan Room revealed a plastic laryngoscope that would not light. Radiology Technician #1 confirmed that the batteries were not functioning. Review of facility policy and procedure, titled, Crash Cart Check, reads, " Action Directives:...d. Testing the equipment to ensure that it is working properly and that all parts are present and clean. This includes: -Ambu Bag. -Life Pac...- Suction Machine and Tubing...".

On 01/25/10 at 1345, observation of the Radiology Departments's Hot Room revealed the floor had a large amount of dust, particle debris, and discarded papers and wrappers. Under the counter where the emergency box and other boxes and containers were located, the area was cluttered and had a thick layer of dust and particle debris. When the emergency box was removed for inspection, a large amount of dust was observed on the emergency box. The counter in the hot room identified as the area where drugs and biologicals are prepared for patient use was dusty with a small amount of particle debris. Observation of the MRI Room revealed a treadmill that was covered with a large amount of dust and particle debris. A cart used for intravenous preparation of drugs was very dusty and had a residue buildup. Linen items were stored uncovered on top of the collimators. The MRI machine had a dust layer buildup.

On 01/25/10 at 1400, the Department Director confirmed that there were issues with housekeeping. The Director reported that Quality Assurance and Performance Improvement/Quality Improvement projects in the Nuclear Medicine Department were not identified to address the sanitation issue regarding the physical space and cleaning of the equipment.

Review of Centers for Disease Control (CDC) guidelines, titled, Environmental Cleaning, read, " Careful cleaning of patient rooms and medical equipment contribute substantially to the overall control of Methicillin-resistant staphylococcus aureus(MRA), Vancomycin-resistant enterococcus(VRE) transmission... D. thoroughly clean and disinfect environmental surfaces and medical equipment on a regular basis using EPA registered disinfectants and manufacturers directions...".








28552

The findings are:
On 01/25/10 at 1400, a tour of the operating room suite was conducted with the Operating Room Director. The following was observed : The laryngoscope blade cases were found with a sticky substance on the outside of each case. The case containing the straight blades, small handle was found to contain corroded batteries which had leaked to the outside of the handle.
On 01/26/10 at 0930 during a tour of the operating room with the Operating Room Director, the following was found: Observation of the Operating Room wall revealed grout was missing from the corners of the wall. The finding were verified by the Operating Room Director on 01/26/10.

On the days of the Recertification survey based on observations, interviews, and review of hospital policy and procedure, the hospital failed to ensure that the facility's equipment and supplies were maintained at an acceptable level of safety and quality.

The findings included:

On 1/25/10 at 1125, observations on the second floor included an ice machine with ice scoops in a holder on the side of the ice machine. An "Ice Scoop Washing Schedule" form was taped to the side of the ice machine. Documentation of washing of the scoop was noted for the following dates in January 2010: 2, 3, 7, 8, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, and 22. In an interview on 1/25/10 at 1335, the recently hired Dietary Manager stated that the ice scoops are taken to the kitchen three times a week and run through the dishwasher. The Dietary Manager was not aware of the "Ice Machine Scoop Washing Schedule" form for documentation.

On 1/25/10 at 1350, observations of the clean patient room # 213 showed a phone jack outlet behind the bed that was pulled out from the wall, leaving an opening in the wall. The finding was confirmed with Registered Nurse (RN) #1.

On 1/25/10 at 1400, one pair of sterile vinyl exam gloves with an expiration date of 12/31/07 was found in the pediatric intubation kit, and two boxes of purple nitrite powder free exam gloves with an expiration date of 12/08 and 3/09 were found in the latex allergy cart.

Review of hospital Policy # 70.8415, "Care/Maintenance of Food Refrigerators, Freezers and Ice Machines", amended 10/08, reads, ".... B. Ice Machines/Ice Scoops/Ice Chests (Coolers): 1. Ice machines will remain closed except when retrieving ice for usage. The ice scoop will remain in the holder to facilitate better drainage, thus avoiding pooling of water. The handle will never come in contact with the ice. Ice scoops will be run through the dishwasher once per 24 (twenty-four) hours ...."

On the day of the Recertification Survey based on observation, staff interview, and hospital policy review, the Hospital failed to mitigate the risk of infection by ensuring that staff washed hands and gloved per Hospital policy and related to sanitary issues in all areas of the hospital.

The findings are:

On 1/25/2010 at 1322, Observation of Registered Nurse (RN) #2 showed RN #2 failed to wash his/her hands for a minimum of 15 seconds after performing patient care and prior to donning gloves to give injection. The finding was verified by RN #2.

Observation of Licensed Practical Nurse (LPN) #1 showed LPN #1 failed to don gloves prior to attaching an intravenous fluid bag to a patient's heparin lock per hospital policy. The finding was verified by LPN #1.

Hospital policy, Handwashing/Hand Hygiene, effective date 1/1993, last amended 1/2010, reads, "Policy: Section A. All employees are to wash their hands in situations including but not limited to 6. before donning and after removal of gloves" Section D. In addition to hand washing, personal protective equipment (PPE) must be used when actual or potential contact with blood/body fluids is anticipated."

Cross Reference to A701: The facility failed to maintain the overall hospital environment in a safe and sanitary manner to ensure the safety and well - being of patients in the dietary kitchen area, public hallways, Radiology Department, Emergency Department, Nurse Station, Medical Surgical Department, and Patient Room.





21307

On 1/26/10 at 0835, Licensed Practical Nurse (LPN) #1 was observed administering medications to the Resident in room # 211. Handwashing was performed for eight seconds after the medications were given to the resident. On 1/26/10 at 0848, LPN #1 administered medications to the resident in room # 212 without performing handwashing or sanitizing of the hands prior to the administration of the medications. On 1/27/10 at 1000, Registered Nurse #1 stated that handwashing should be performed for at least fifteen seconds. Hands should be washed before and after medications are administered.







28552

The findings are:
On 01/25/10 at 2:00pm a tour of the operating room suite was conducted with the Operating Room Director. The following was found:
The laryngoscope blade cases were found with a sticky substance on the outside of each case. The case containing the straight blades, small handle was found to contain corroded batteries which had leaked to the outside of the handle.

On 01/26/10 at 0930 during a tour of the operating room with the Operating Room Director, the following was found:
Observation of the Operating Room wall revealed grout was missing from the corners of the wall.

These finding were verified by the Operating Room Director on 01/26/10.

On the days of the Recertification survey based on interview, record reviews, and review of policy and procedure, the hospital failed to ensure the development of a discharge plan of care for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair, and anemia status post transfusion. Physician orders dated 1/18/10 included activity level per PT (physical therapy) and OT (occupational therapy), low salt diet, intake and output every shift. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old was admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. On 1/19/10 physician orders included standing order protocol, diet as tolerated with one can of Boost twice daily, PT evaluation for gait strengthening, and up as tolerated. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. Physician admission orders included walk with assistance, PT/OT, 1800 calorie ADA (American Diabetes Association) with Glucerna one can three times daily, and vital signs every shift. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. Admission orders dated 10/17/09 included up as desired, and 1000 cc. free water fluid restriction, low cholesterol mechanical diet. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. The physician orders included physical therapy for strengthening, mechanical soft diet with 1500 milliliters (ml.) fluid restriction, and keep skin clean and dry. There was no plan of care to address identified discharge needs.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with a diagnosis of status/post total right hip replacement. Physician orders dated 8/24/09 included activity level per physical therapy, regular diet, intake and output every shift, and change dressing to the right hip as needed. There was no plan of care in the residents's record as confirmed by the Director of Medical Records on 1/27/09 at 0945. The findings were reviewed and confirmed by RN #1 on 1/27/10 at 1000.

Review of hospital Policy # 21.9290, "Discharge Planning", amended 11/06, read, " ... Upon admission to the hospital, a nursing admission interview and assessment is done on all patients regardless of pay source. Included in the initial assessment is a list of triggers that assist the nurse in anticipating discharge needs of the patient. Any needs or problems identified should be referred to the Case Management Department for evaluation. The Nursing Staff should take an active role in Discharge Planning as they communicate with the patient and family on a one to one basis throughout the hospital stay...Discharge planning is an interdisciplinary hospital wide process insuring continuity of care and insuring that maintenance of high quality care is available tot he patient's post hospitalization....".

On the days of the Recertification survey based on interviews, record reviews, and review of polices and procedures, the facility hospital failed to ensure that specific swing bed requirements were met.

The findings included:

Cross reference A1508: The hospital failed to ensure that residents were informed of their rights and responsibilities prior to or upon admission, during their stay or when the hospital's rules changes for six of six resident records reviewed. (Resident's #1, 2, 3, 4, 5, and 6)

Cross reference A1510: The hospital failed to ensure that resident's were informed, in writing, of items and services that were not covered under Medicare or by the hospital's per diem rate for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

Cross reference A 1533: The facility failed to ensure the development and implementation of polices and procedures to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Cross reference A1537: The hospital failed to ensure the provision of an ongoing program of activities designed to meet the needs of the residents and directed by a qualified professional.

Cross reference to A1541: The hospital failed to ensure the development of a discharge plan of care for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

Cross reference A 1545: The hospital failed to ensure that rehabilitative services were provided under the written order of a physician for five of six resident records reviewed. (Residents #1, 2, 3, 4, and 5)

Cross reference A1548 : The hospital failed to ensure responsibility for the dental care needs of its residents.

On the days of the Recertification survey based on interview, record reviews and review of hospital policy and procedure, the hospital failed to ensure that residents were informed of their rights and responsibilities prior to or upon admission, during their stay, or when the hospital's rules changes for six of six resident records reviewed. (Resident's #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair, and anemia status post transfusion. There was no documentation in the chart pertaining to patient rights or advanced directives.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old was admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. There was no documentation in the chart pertaining to patient rights or advanced directives.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. There was no documentation in the chart pertaining to patient rights or advanced directives.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. There was no documentation in the chart pertaining to patient rights or advanced directives.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. There was no documentation in the chart pertaining to patient rights or advanced directives.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with diagnosis of status/post total right hip replacement. There was no documentation in the chart pertaining to patient rights or advanced directives. The findings were reviewed and confirmed by the Director of Case Management on 1/27/10 at 0930.

Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, read " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... C. Standard: Federal regulations require a Medicare Swing-bed hospital to meet specific standards. Listed below are standards that this hospital strives to meet. 1. Patient Rights: Within the "Patients's Rights" section there is requirement by which this hospital plans to meet the rights of the patient...".

On the days of the Recertification survey based on interview and review of policies and procedures, the hospital failed to ensure that resident's were informed, in writing, of items and services that were not covered under Medicare or by the hospital's per diem rate for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair and anemia status post transfusion. There was no documentation in the chart pertaining to services, and charges for those services that are not covered under Medicare or by the or by the facility's per diem rate.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old was admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. There was no documentation in the chart pertaining to services, and charges for those services that are not covered under Medicare or by the or by the facility's per diem rate.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. There was no documentation in the chart pertaining to services, and charges for those services that are not covered under Medicare or by the or by the facility's per diem rate.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. There was no documentation in the chart pertaining to services, and charges for those services that are not covered under Medicare or by the or by the facility's per diem rate.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. There was no documentation in the chart pertaining to services, and charges for those services that are not covered under Medicare or by the or by the facility's per diem rate.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with a diagnosis of status/post total right hip replacement. There was no documentation in the chart pertaining to services, and charges for those services that are not covered under Medicare or by the facility's per diem rate.
The findings were reviewed and confirmed by Director of Case Management on 1/27/10 at 0930.

Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, read " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... "

Review of hospital Policy #70.6022, "Requirements for Swing-Bed Patients", amended 10/05, read, "Policy: ... B. Patients/ responsible parties will be informed when there are changes in services offered and charges for those services, including those not covered under the State Plan .... "

On the days of the Recertification survey based on interview and review of hospital policies and procedures, the facility failed to ensure the development and implementation of polices and procedures to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

The findings included:

On 1/27/10 at 0930, a review of the Swing Bed Policy and Procedure Manual revealed no policies and procedures related abuse and neglect of residents. In an interview on 1/27/10 at 0930, the Director of Case Management stated that the hospital had only recently started accepting swing bed residents again. The current policy and procedure manual was reviewed 1/4/10, but did not contain all of the policies and procedures for neglect and abuse.

On the days of the Recertification survey based on interview, record reviews, and review of hospital policy and procedure, the hospital failed to ensure the provision of an ongoing program of activities designed to meet the needs of the residents and directed by a qualified professional.

The findings included:

Review of the medical records for Residents #1, 2, 3, 4, 5, and 6 on the identified as swing bed residents revealed there was no activities assessment of all of the residents that also included no care planning to meet the swing bed patient needs. There was no activities calendars posted in resident rooms during observations on 1/26/10 and 1/27/10. On 1/27/10 at 0930, the Director of Case Management stated that the swing bed program did not have an activities director or an activities program.

Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, reads, " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... C. Standard: Federal regulations require a Medicare Swing-bed hospital to meet specific standards. Listed below are standards that this hospital strives to meet ... 5. Patient Activities: A qualified activities coordinator has been appointed to develop meaningful programs and activities designed to promote the physical, social, and mental well-being of Medicare patients. We have a staff member appointed to be the Activities Director...".

On the days of the Recertification survey based on interview, record reviews, and review of policy and procedure, the hospital failed to ensure the development of a discharge plan of care for six of six resident records reviewed. (Residents #1, 2, 3, 4, 5, and 6)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair, and anemia status post transfusion. Physician orders dated 1/18/10 included activity level per PT (physical therapy) and OT (occupational therapy), low salt diet, intake and output every shift. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old was admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. On 1/19/10 physician orders included standing order protocol, diet as tolerated with one can of Boost twice daily, PT evaluation for gait strengthening, and up as tolerated. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. Physician admission orders included walk with assistance, PT/OT, 1800 calorie ADA (American Diabetes Association) with Glucerna one can three times daily, and vital signs every shift. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia , seizure disorder, hiatal hernia and chronic anemia. Admission orders dated 10/17/09 included up as desired, and 1000 cc. free water fluid restriction, low cholesterol mechanical diet. A care plan pertaining to patient discharge needs, goals, and interventions as identified by the social worker was not documented.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. The physician orders included physical therapy for strengthening, mechanical soft diet with 1500 milliliters (ml.) fluid restriction, and keep skin clean and dry. There was no plan of care to address identified discharge needs.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with a diagnosis of status/post total right hip replacement. Physician orders dated 8/24/09 included activity level per physical therapy, regular diet, intake and output every shift, and change dressing to the right hip as needed. There was no plan of care in the residents's record as confirmed by the Director of Medical Records on 1/27/09 at 0945. The findings were reviewed and confirmed by RN #1 on 1/27/10 at 1000.

Review of hospital Policy # 21.9290, "Discharge Planning", amended 11/06, read, " ... Upon admission to the hospital, a nursing admission interview and assessment is done on all patients regardless of pay source. Included in the initial assessment is a list of triggers that assist the nurse in anticipating discharge needs of the patient. Any needs or problems identified should be referred to the Case Management Department for evaluation. The Nursing Staff should take an active role in Discharge Planning as they communicate with the patient and family on a one to one basis throughout the hospital stay...Discharge planning is an interdisciplinary hospital wide process insuring continuity of care and insuring that maintenance of high quality care is available tot he patient's post hospitalization....".

On the days of the Recertification survey based on interview, record reviews, and review of hospital policy and procedure, the hospital failed to ensure that rehabilitative services were provided under the written order of a physician for five of six resident records reviewed. (Residents #1, 2, 3, 4, and 5)

The findings included:

On 1/26/10 at 1550, a review of Resident #1's open medical record revealed the ninety year old was admitted on 1/18/10 with diagnoses of status post right hip fracture with repair, and anemia status post transfusion. Physician orders dated 1/18/10 included activity level per PT (physical therapy) and OT (occupational therapy), low salt diet, and intake and output every shift. Physical therapy and occupational therapy treatment plan and goals were documented on the therapy evaluation forms dated 1/18/10. A "Patient Care Conference" was documented on the progress notes dated 1/21/10 which included notes written by the dietician, respiratory therapy, social services, and pharmacy. There was no documentation by physical therapy or occupational therapy in the care conference notes. A section on the bottom of the therapy evaluation form indicating the physician's recommendation regarding the treatment plan had not been completed, and there was no verbal physican order in the chart from the physician agreeing with the treatment plan for physical therapy and occupational therapy. Occupational and physical therapy were being provided as recommended by the therapist at the time of their initial evaluation.

On 1/25/10 at 1430, a review of Resident #2's open medical record revealed the eighty-two year old admitted on 1/19/10 with diagnoses of status post fall, dehydration, osteoarthritis, and peripheral vascular disease with a large venous stasis ulcer on the right lower extremity. On 1/19/10, physician orders included diet as tolerated with one can of Boost twice daily (resident weight eighty-five pounds), PT evaluation for gait strengthening, and up as tolerated. The physical therapy evaluation, completed on 1/19/10 included a treatment plan with long term and short term goals. A section on the bottom of the therapy evaluation form indicating the physician's recommendation regarding the treatment plan had not been completed, and there was no verbal physician order in the chart from the physician agreeing with the treatment plan for physical therapy. The physical therapy "Inpatient Daily Progress Note" dated 1/20/10 was incomplete and failed to address subjective findings. The physical therapy "Inpatient Daily Progress Note" dated 1/22/10 was not signed and did not include the time of the therapy session.

On 1/26/10 at 1550, a review of Resident #3's closed medical record revealed the sixty-three year old was admitted on 12/11/09 with diagnoses of weakness with left knee inflammatory changes, diabetes mellitus and anemia. Physician admission orders included walk with assistance, PT/OT, 1800 calorie ADA (American Diabetes Association) with Glucerna one can three times daily, and vital signs every shift. The physical therapy evaluation completed on 12/11/09 included a treatment plan with long term and short term goals. A section on the bottom of the therapy evaluation form indicating the physician's recommendation regarding the treatment plan was signed by the physician on 12/18/09 after the resident's discharge. There was no verbal order in the chart from the physician agreeing with the treatment plan for physical therapy during the resident's swing bed stay. The physical therapy "Inpatient Daily Progress Note" dated 12/15/09 was incomplete and did not document the plan for continuation of therapy.

On 1/26/10 at 1430, a review of Resident #4's closed medical record revealed the eighty-one year old was admitted on 10/17/09 with diagnoses of delusional hyponatremia, seizure disorder, hiatal hernia and chronic anemia. Admission orders dated 10/17/09 included up as desired, 1000 cubic centimeters (cc.) free water fluid restriction, low cholesterol mechanical diet. An initial physical therapy evaluation was completed on 10/17/09 after transitioning from acute care to swing bed status but there was no order for a physical therapy consult in the resident's record.

On 1/26/10 at 1500, a review of Resident #5's closed medical record revealed the ninety-three year old was admitted on 8/28/09 with diagnoses of recent new onset of atrial fibrillation with congestive heart failure, chronic anemia, hyponatremia, and peptic ulcer disease. The physician orders included physical therapy for strengthening, mechanical soft diet with 1500 ml. fluid restriction, keep skin clean and dry, and standing orders. The physical therapy evaluation completed on 8/28/09 included a treatment plan with long term and short term goals. The treatment plan for frequency, days/week, read, "See above" but treatment frequency was not specified on the evaluation form. The resident was seen by the physical therapist on 8/28/09, 8/29/09, and 8/30/09. A section on the bottom of the therapy evaluation form indicating the physician's recommendation regarding the treatment plan was signed by the physician and dated 9/12/09. There was no verbal order in the chart from the physician agreeing with the treatment plan for physical therapy.

On 1/26/10 at 1705, a review of Resident #6's closed medical record revealed the eighty-one year old was admitted on 8/24/09 with a diagnosis of status/post total right hip replacement. Physician orders dated 8/24/09 included activity level per physical therapy, regular diet, intake and output every shift, change dressing to right hip as needed, and standing orders per protocol. The physical therapy evaluation completed on 8/24/09 recommended physical therapy visit frequency as daily for five days/week and as needed on weekends. There was no documentation on the form regarding discussion of the goals with the patient or family. "Inpatient Daily Progress Note" forms documented daily visits by physical therapy on 8/24/09, 8/25/09, 8/26/09, and 8/27/09. The findings were reviewed and confirmed with Registered Nurse # 1 on 1/27/10 at 0945.

Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, reads, " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... C. Standard: Federal regulations require a Medicare Swing-bed hospital to meet specific standards. Listed below are standards that this hospital strives to meet ... 2. Rehabilitative Service: The regulations require a Medicare Swing-bed hospital to meet specialized rehabilitative services, including physical therapy, occupational therapy ... ".

On the days of the Recertification survey based on interview and review of hospital contracts, the hospital failed to ensure responsibility for the dental care needs of its residents.

The findings included:

In an interview on 1/27/10 at 0930, the Director of Case Management reported that the hospital did not currently have a dentist available to meet the dental needs of its residents through a contract or on staff at the hospital.
Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, read " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... C. Standard: Federal regulations require a Medicare Swing-bed hospital to meet specific standards. Listed below are standards that this hospital strives to meet ... 3. Dental Services: A medicare Swing-bed hospital must make arrangements to provide dental services. The hospital should keep accurate records of dentists available in it community and assist patients in obtaining dental services .... ".

On the days of the Recertification survey based on interview and review of hospital contracts, the hospital failed to ensure responsibility for the dental care needs of its residents.

The findings included:

In an interview on 1/27/10 at 0930, the Director of Case Management reported that the hospital did not currently have a dentist available to meet the dental needs of its residents through a contract or on staff at the hospital.
Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, read " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... C. Standard: Federal regulations require a Medicare Swing-bed hospital to meet specific standards. Listed below are standards that this hospital strives to meet ... 3. Dental Services: A medicare Swing-bed hospital must make arrangements to provide dental services. The hospital should keep accurate records of dentists available in it community and assist patients in obtaining dental services .... ".

On the days of the Recertification survey based on interview and review of hospital contracts, the hospital failed to ensure responsibility for the dental care needs of its residents.

The findings included:

In an interview on 1/27/10 at 0930, the Director of Case Management reported that the hospital did not currently have a dentist available to meet the dental needs of its residents through a contract or on staff at the hospital.
Review of hospital Policy # 70.6022, "Medicare Restorative Care", amended 9/05, read " ... B. Medicare Requirements: To provide Swing-beds under the Medicare Program, a hospital must comply with all rules and regulations set forth by Medicare ... C. Standard: Federal regulations require a Medicare Swing-bed hospital to meet specific standards. Listed below are standards that this hospital strives to meet ... 3. Dental Services: A medicare Swing-bed hospital must make arrangements to provide dental services. The hospital should keep accurate records of dentists available in it community and assist patients in obtaining dental services .... ".