HospitalInspections.org

Based on staff interview, record review and policy and procedure review, the facility failed to ensure nursing care plans were completed on four (4) out of 10 medical records reviewed (Patient #1, #3, #14 and #19).

Findings Include:

Medical Record review for Patient #1, #3, #14, and #19 revealed no documented evidence of an admission or current nursing care plan.

During an interview on 11/07/19 at 1:55 p.m. the Director of Nurses (DON) confirmed that the patients did not have any care plans on the charts. The DON reported that she had looked multiple places and could not find one. The DON reported that she would expect all patients to have a nursing care plan.

A review of the facility's problem list and care plan procedure revealed that each patient should have a nursing care plan and that it should be kept up to date by the nurse.

A-0491 / §482.25(a)

Based on staff interview, documentation, and policy and procedure review, the facility failed to ensure medications were properly stored in correct temperature settings.

Findings Include:

Observation tour of Acute Care Nurse Medication Room on 11/05/19 at 2:00 p.m. confirmed numerous medications stored in medication refrigerator with no thermometer in refrigerator and no current refrigerator log. Medications observed during tour in medication refrigerator with no temperature log or thermometer: Infuvite, Levemir, Novolin 70/30, and Novolin N.

Interview on 11/05/19 at 2:00 p.m. with RN #1 confirmed refrigerator log not up to date and refrigerator has no thermometer. RN # 1 confirmed nurse responsible for checking refrigerator temperature daily.

Review on 11/05/19 at 2:25 p.m. of Facility Pharmacy Policy Section 09-04 (no policy number, no effective date and no revision date) "Temperatures" confirms " ... Refrigerator - A cold place in which the temperature is held between 2 C and S C (36F and 46F)".




§482.25(a)(1)

Based on staff interview, documentation, and policy and procedure review, the facility failed to ensure pharmacy and therapeutics committee meetings and staff training on pharmacy policies and procedures.

Findings Include:

Observation tour of pharmacy on 11/06/19 at 10:00 a.m. confirmed Registered Pharmacist present.

Interview with Registered Pharmacist on 11/06/19 at 10:00 a.m. confirmed no pharmacy and therapeutics committee in place for facility. Registered Pharmacist also confirmed no on-going staff education of written policy and procedures related to pharmaceutical services.

Review on 11/06/19 at 11:10 a.m. of Facility Policy Section 04-02 (no policy number, no effective date, and no revision date) "Medication Use" confirmed "Medical staff, nursing service, pharmacy, management and administrative staff, and other departments services and individuals shall participate and collaborate in medication use improvement activities." " ...Performing Medication Use Evaluation activities (e.g. in conjunction with the Pharmacy and Therapeutics Committee)." No documentation of Pharmacy and Therapeutics Committee meeting minutes presented on three (3) of three (3) survey days. No documentation of pharmacy staff policy and procedure in-services presented on three (3) of three (3) survey days.

A-0505 / §482.25(b)(3)

Based on staff interview, documentation, and policy and procedure review, the facility failed to ensure unusable drugs are not available for patient use.

Findings Include:

Observation tour of Medications Room on Acute Care during facility tour on 11/05/19 at 2:00 p.m., confirmed eight (8) multi-use vials and bottles of medications opened with no initials and date for the following medications: Clear Lax, A-Hist DM, Potassium Chloride, Polyethelene Glycol, Infurvite, Levemir, Novolin 70/30, and Novolin N.

Interview on 11/05/19 at 2:00 p.m. with RN #1, confirmed multi-use vials and bottles of medications opened with no initials and date for eight (8) medications. RN #1 confirmed nurse knowledge of proper labeling of multi-dose medications once opened. RN #1 could not explain reason for improper labeling of eight (8) opened medications.

Interview on 11/06/19 at 9:30 a.m. with Director of Nursing confirmed knowledge of multi-use vials and bottles of medications opened with no initials and date for eight (8) medications.

Review of Policy and Procedure on 11/06/19 at 10:00 a.m. "Guidelines for Use of Multiple-Dose Medication Vials (MDV)" (No policy number and no effective date or revision date) " ...6. All MDV shall be dated when open (Month, date, year). 7. All MDV shall be discarded after 30 days by notifying pharmacy that 30 days has lapsed and returning medication (MDV) to pharmacy."

Based on Interview, Document Review, Policy and Procedure review the facility failed to ensure posting of dietary menus.

Findings Include:

Interview on 11/07/19 at 1:30 p.m. with Director of Dietary confirmed no menu posted since 2018. Director of Dietary confirmed Consultant Registered Dietician visits monthly to evaluate Dietary services. Last Consultant evaluation visit October 22, 2019. Dietary Manager confirmed instruction by Consultant to use 2018 menus. Dietary manager confirmed menus written in refrigerator temperature log.

Facility Dietary Policy and Procedures were requested from Director of Nursing on three (3) of three (3) survey days. No Dietary Policy presented.

Review on 11/07/19 at 1:45 p.m. of evaluation dated October 30, 2019, by Consultant Registered Dietician confirmed " ...2. Menu posted ...". No further evaluations presented.

CONDITION: A-799 / §482.43(a)

Based on staff interview, medical record review, and policy and procedure review, the facility failed to ensure discharge planning evaluation assessment completed on three (3) of five (5) patient admissions reviewed.

FindingsInclude:

Interview on 11/06/19 at 4:30 p.m., with Social Services #1 confirmed no Discharge Planning Evaluation Assessment documentation for patient admissions between May 2019, and September 4, 2019. Social Services #1 confirmed understanding of facility policy requiring discharge planning evaluation assessment on all patient admissions. Social Services #1 also confirmed facility policy does not address circumstances where changes in patient condition would call for a discharge planning evaluation in patients not previously identified as needing one.

Review on 11/06/19at 4:45 p.m. of five (5) medical records, patient #1, #2, and #15, confirmed no documentation of completed Discharge Planning Evaluation Assessment in three (3) of five (5) medical records reviewed. No Discharge Planning Evaluation documentation presented for patient #1, #2, and #15.

Review on 11/06/19 at 4:45 p.m. of facility "Discharge Planning Policy" (no policy # or effective date or revised date) confirmed " ...The needs of the patient on discharge should be considered at the time the patient is admitted ...". Review of "Discharge Planning Policy" also confirmed " ...Effective discharge planning relies on accurate assessment on admission." Review of facility policy does not address circumstances where changes in patient condition would call for discharge planning evaluation in patients not previously identified as needing one.

A0812 / §482.43(b)(6)

Based on document review, staff interview, and policy and procedure review, the facility failed to ensure evaluation of possible needs of patients on discharge for three (3) of five (5) of patient medical records reviewed.

Findings Include:

Interview on 11/06/19 at 4:30 p.m., with Social Services #1 confirmed no Discharge Planning Evaluation Assessment documentation for patient #1, #2, and #15 possible needs of community based services, Home Health Agency, Skilled Nursing Facility, or evaluation of insurance coverage for post-hospitalization necessary services.

Review on 11/06/19 at 4:40 p.m. of five (5) medical records, patient #1, #2, and #15, confirmed no documentation of completed Discharge Planning Evaluation Assessment in three (3) of five (5) medical records reviewed. No Discharge Planning Evaluation documentation presented for patient #1, #2, and #15.

Review on 11/06/19 at 4:45 p.m. facility "Discharge Planning Policy" (no policy number or effective date or revised date) confirmed " ....Implementation is closely linked to planning. The nurse/case management shall liaise to coordinate implementing the discharge plan in collaboration with the patient, the patient's family, credentialed specialists and community agencies if required."

A-0843 / §482.43(e)

Based on document review, staff interview, and policy and procedure review, the facility failed to ensure reassessment of discharge planning process on an on-going basis.

Findings Include:

Interview on 11/06/19 at 4:30 p.m. with Social Services #1 confirmed no facility review of discharge planning process in an ongoing manner and facility tracking readmissions as part of discharge planning process to identify preventable readmissions and problems in discharge planning process.

Interview on 11/06/19 at 5:00 p.m. with Director of Nursing confirmed no knowledge of facility review of discharge planning process in an ongoing manner and facility tracking readmissions as part of discharge planning process to identify preventable readmissions and problems in discharge planning process.

Review on 11/06/19 at 4:45 p.m. of "Discharge Planning Policy" (no policy number or effective date or revision date) confirmed no readmission tracking policy for facility. No other facility policy on tracking readmissions was presented during three (3) of three (3) survey days.

A-0892 / §482.45(a)(5)
Based on interview, documentation, and policy and procedure review, the facility failed to ensure review of death records to improve identification of potential donors.

Findings Include:

Review of documents on 11/06/19 at 11:30 a.m. of Organ and Tissue Donation Cooperative Agreement and Tissue Donation records from Organ Procurement Organization confirmed monthly Tissue Donation Report January, 2018, through October, 2018. No further monthly documentation presented.

Interview on 11/06/19 at 11:45 a.m. with Director of Nursing confirmed Tissue Donation records from Organ Procurement thru October 2018. Records for November 2018, through October, 2018, requested from Director of Nursing on three (3) of three (3) survey days. No further reporting documentation presented.