HospitalInspections.org

Based on review of the Quality Assurance and Performance Improvement (QAPI) plan and interview, it was determined the facility failed to ensure all hospital services participated in QAPI. This affected medical records services, and maintenance services, and had the potential to affect all patients served.

Findings include:

Greene County Health System (GCHS) QAPI Plan
Date: None

Purpose:

Greene County Hospital QAPI plan provides guidance for overall quality improvement.

Services GCHS Provides To Patients:

QAPI activities are integrated across all the care and service areas of GCHS. Each area has a representative on the Quality committee...

A review of the facility QAPI program was conducted on 8/9/23 at 4:40 PM with Employee Identifier (EI) # 6, Director of Quality and Infection Control. During the review, the surveyor asked for all hospital department QAPI documentation.

There was no documentation from the medical records department or the maintenance department.

EI # 6 confirmed during the interview on 8/9/23 at 4:40 PM there was no documentation of participation in the hospital's QAPI program for medical records or maintenance services.

Based on review of Medical Records (MR), facility policy and procedures, and interviews with staff it was determined the facility failed to ensure an initial assessment for the need of PRN (as needed) medication and/or a follow up assessment was documented after the PRN medication was administered.

This affected five of 19 Self Recovery Detoxification MR's reviewed that received PRN medications including PI # 2, PI # 9, PI # 12, PI # 6, and PI # 1, and had the potential to negatively affect all patients cared for in this facility.

Findings include:

Hospital Policy: Pain Assessment
Department: Hospital/ED
Revision Dates: 9/22

Policy:

The Greene County Hospital (GCH) recognizes a hospitalized person's right to pain relief and supports a multidisciplinary approach to pain assessment and management. Pain assessment, pain management, and safe opioid use are organizational priorities ...

Procedure:

An assigned Registered Nurse obtains a pain assessment upon admission and when pain is reported ... Pain shall be reassessed with new reports of pain ...

Each completed pain assessment should include the initial pain assessment, an offered pain intervention, and a one-hour follow-up pain assessment ...

Hospital Policy/Procedure Title: Charting
Department: Detox (detoxification) Unit
Effective Date: 8/23

Purpose:

... During detox, charting by the license staff will include summary of assessment ...any PRN medication ...resolution of problems ...

1. PI # 2 was admitted to the hospital's Self Recovery Detox Unit on 8/7/23 with diagnoses of Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the Patient Progress Notes (PPN) dated 8/7/23 at 6:33 PM revealed PI # 2 received PRN medications as follows:

a. Vistaril 50 mg (milligrams) tab (tablet) orally.

b. Loratadine (Claritin) 10 mg tab by mouth.

c. Methocarbamol 750 mg tab by mouth.

d. Ondansetron (Zofran) 4 mg tab by mouth.

e. Loperamide HCL (Hydrochloric Acid) 2 mg Cap (Capsule) by mouth.

Further review of the PPN revealed there was no initial assessment documentation of the patient's need for PRN medications and no follow up assessment documented for resolution of problems.

Review of the PPN dated 8/7/23 at 11:45 PM revealed PI #2 received PRN medications as follows:

a. Vistaril 50 mg tab orally.

b. Ibuprofen (Motrin) 600 mg tab by mouth.

Further review of the PPN revealed no documentation of a follow up assessment for resolution of problems.

Review of the PPN dated 8/9/23 at 8:35 AM revealed PI # 2 received PRN medications as follows:

a. Methocarbamol 750 mg tab by mouth.

b. Ibuprofen (Motrin) 600 mg tab by mouth.

Further review of the PPN revealed no documentation of the patient's need of PRN medications and no follow up assessment for resolution of problems.

An interview was conducted on 8/10/23 at 4:00 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed the staff failed to document the patient's need for PRN medications and failed to assess for resolution of the problems as directed in the facility policy.

2. PI # 9 was admitted to the hospital's Self Recovery Detox Unit on 6/30/23 with diagnoses of Withdrawal, Rehabilitation Protocols and Medication Management.

Review of the PPN dated 7/4/23 at 2:00 PM revealed PI # 9 received the following PRN medications:

a. Loperamide 2 mg cap oral.

b. Ondansetron (Zofran) 4 mg oral.

Further review of the PPN revealed no documentation of the patient's need of PRN medications and no follow up assessment for resolution of problems.

An interview was conducted on 8/10/23 at 3:18 PM with EI # 1, who confirmed the staff failed to to document the patient's need for PRN medication and failed to assess for resolution of the problem as directed in the facility policy.

3. PI # 12 was admitted to the hospital's Self Recovery Detox Unit on 6/10/23 with the diagnoses of Withdrawal, Rehabilitation Protocols and Medication Management.

Review of the PPN dated 6/11/23 at 1:00 PM revealed PI # 12 received PRN medication as follows:

a. Ondansetron (Zofran) 4 mg oral tab.

b. Ibuprofen 600 mg oral tab.

Further review of the PPN revealed no documentation of the patient's need of PRN medications and no follow up assessment for resolution of problems.

An interview was conducted on 8/10/23 at 3:31 PM with EI # 1, who confirmed the staff failed to to document the patient's need for PRN medication and failed to assess for resolution of the problem as directed in the facility policy.


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4. PI # 6 was admitted to the Self Recovery Detox Unit on 6/26/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management, and discharged on 7/5/23.

Review of the PPN dated 6/26/23, revealed the patient received PRN Ibuprofen 600 mg, by mouth at 6:29 PM. There was no documentation why the patient received the medication, or the effectiveness after administration.

Further review of the PPN dated 6/26/23, revealed the patient received PRN Clonidine 0.1 mg, by mouth, at 8:11 PM. There was no documentation why the patient received the medication, or the effectiveness after administration.

Review of the PPN dated 7/1/23 revealed PI # 6 received PRN Ibuprofen 600 mg, by mouth at 2:23 PM for complaints of a headache, rated 6 out of 10. There was no documentation of the effectiveness after administration.

Review of the PPN dated 7/2/23 revealed PI # 6 received PRN Ibuprofen 600 mg, by mouth at 4:48 PM. There was no documentation why the patient received the medication, or the effectiveness after administration.

An interview was conducted on 8/10/23 at 4:29 PM with EI # 1, who confirmed staff failed to document the reason PRN's were given, or the effectiveness after administration, per policy.

5. PI # 1 was admitted to the Self Recovery Detox Unit on 8/2/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the PPN dated 8/3/23 revealed the patient received the following PRN meds (medications) starting at 10:45 PM to 10:51 PM:

a. Vistaril 50 mg, cap, by mouth.

b. Methocarbamol 750 mg, tab, by mouth.

c. Ibuprofen 600 mg, tab, by mouth.

d. Mylanta 12 oz liquid, oral, dose 30 (ml).

There was no documentation why the PRN meds were given, and no follow up documentation of the effectiveness.

Review of the PPN dated 8/4/23 revealed the patient received the following PRN medications at 9:42 AM:

a. Methocarbamol 750 mg, tab, by mouth.

b. Ibuprofen 600 mg, tab, by mouth.

c. Mirapex 0.125 mg, pill, oral.

There was no documentation why the PRN meds were given, and no follow up documentation of the effectiveness.

Review of the PPN dated 8/4/23 at 7:30 PM revealed the patient received PRN Ondansetron 4 mg, tab, by mouth, for complaints of nausea. There was no documentation whether or not the patients nausea was alleviated.

Review of the PPN dated 8/4/23 revealed the patient received the following PRN medications starting at 10:38 PM to 10: 43 PM:

a. Omeprazole 40 mg capsule, by mouth.

b. Vistaril 50 mg, capsule, oral.

c. Methocarbamol 750 mg, tab, by mouth.

There was no documentation why the PRN meds were given, and no follow up documentation of the effectiveness.

Review of the PPN dated 8/5/23 revealed the patient received the following PRN medications starting at 8:30 PM to 8:31 pm:

a. Methocarbamol 750 mg, tab, by mouth.

b. Vistaril 50 mg, capsule, oral.

On 8/5/23 at 8:46 PM the RN documented the following, "Patient is up and about, requested Vistaril 50 mg and Robaxin 750 mg along with her/his Trazodone 50 mg(,) allmeds (all meds) given as requested."

There was no documentation why the PRN meds were given, and no follow up documentation of the effectiveness.

An interview was conducted on 8/10/23 at 3:08 PM with EI # 1, who confirmed staff failed to document the reason PRN medications were administered, and the effectiveness, per policy.

Based on review of medical records (MR), policies and procedures, and interviews, it was determined staff failed to ensure:

1. The Interdisciplinary Treatment (IDT) Plan was individualized for each patient, and updated with new problems and/or medical diagnoses.

2. A Nursing Care Plan was developed for a Swing Bed patient.

This affected 7 of 19 inpatient MR's reviewed, and did affect Patient Identifier (PI) # 6, PI # 13, PI # 1, PI # 17, PI # 8, PI # 11, PI # 15, and 1 of 1 Swing Bed records reviewed, including PI # 20, and had the potential to affect all patients admitted to the hospital.

Findings include:

Hospital policy: Standards of Care
Department: Self Recovery
Policy number: 54
Date effective: 08/2023

Purpose:

Patient Care and Quality

Procedure:

The patient can expect:

...2. To be assessed by an R.N. (Registered Nurse) within 24 hours of admission, with a nursing diagnosis and care plan initiated for all identified problems and needs.

...11. Individualized discharge planning to be initiated on admission and updated and revised throughout the patient's stay....

14. To have his/her master treatment plan reviewed, updated and/or revised weekly by the multidisciplinary treatment team...

Hospital policy: Standards of Practice
Department: Self Recovery
Policy number: 55
Date effective: 08/2023

Procedure:

Patient Care and Quality

...Nutrition:

1. Each patient will be assessed by the dietician to determine nutritional status, special needs or limitations.

2. Individual diet teaching will be given as needed by the dietician.

1. PI # 6 was admitted to the hospital on 6/26/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management, and discharged on 7/5/23.

Review of the Emergency Department (ED) Physician Medical Record, dated 6/26/23, revealed a diagnosis of UTI (Urinary Tract Infection).

Further review of the ED record dated 6/26/23 revealed the following documentation, "...blood pressure 181/108, Medical History ...Gout, ...no current medications..."

Review of the IDT Plan dated 6/28/23 revealed the SW (Social Worker) documented in the Problem List, "... Pt (patient) has medical concerns of high blood pressure and gout.

Further review of the IDT Plan dated 6/28/23 revealed a pre-filled/copied set of Goals, Objectives, Intervention Methods, and Long Term Goals. There was no documentation of high blood pressure, gout, or the UTI. There was no documentation of an assessment by the dietician to address diet needs related to gout.

Further review revealed the Intervention Method for Objective number five, "Learn about the Recovering Process" had a line drawn through it, and no documentation of what intervention method was used.

An interview was conducted on 8/10/23 at 4:29 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed the IDT Plan was not individualized or updated to reflect the patient's needs.

2. PI # 13 was admitted to the Self Recovery Detox Unit on 6/13/23 with a diagnosis of Withdrawal, Rehabilitation Protocols, and Medication Management. The patient left the hospital AMA (Against Medical Advice) on 6/17/23.

Review of the Interdisciplinary Treatment Plan dated 6/13/23, revealed the social worker documented , "...Pt has medical issue of painful bladder syndrome... has concerns of having STD's (Sexually Transmitted Disease), Hep (Hepatitis) A, Hep C..." There was no documentation these concerns were addressed in the treatment plan.

Further review of the IDT Plan dated 6/13/23 revealed a pre-filled/copied set of Goals, Objectives, Intervention Methods, and Long Term Goals. Further review revealed the Intervention Method for Objective number five, "Learn about the Recovering Process" had a line drawn through it, and no documentation of what intervention method was used.

An interview was conducted on 8/10/23 at 3:59 PM with EI # 1, who confirmed the IDT Plan was not individualized to meet the patient's needs.

3. PI # 1 was admitted to the Self Recovery Detox Unit on 8/2/23 with a diagnosis of Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the MR revealed no IDT Plan. The surveyor requested a copy of the Plan and none was provided.

An interview was conducted on 8/10/23 at 3:08 PM with EI # 1, who confirmed there was no documentation of an IDT Plan for PI # 1.

4. PI # 17 was admitted to the Self Recovery Detox Unit on 6/22/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management. The patient left the hospital AMA on 6/25/23.

Review of the Interdisciplinary Treatment Plan dated 6/22/23, revealed the social worker documented , "...Pt has medical concerns with medication" There was no further documentation this concern was addressed in the treatment plan.

Further review of the IDT Plan dated 6/22/23 revealed a pre-filled/copied set of Goals, Objectives, Intervention Methods, and Long Term Goals. The Intervention Method for Objective number five, "Learn about the Recovering Process" had a line drawn through it, and no documentation of what intervention method was used.

An interview was conducted on 8/10/23 at 4:31 PM with EI # 1, who confirmed the plan was not individualized to meet the patient's needs.

5. PI # 20 was admitted to Swing Bed status on 10/21/2020 with diagnoses including Cardiomyopathy and Left Sided Pleural Effusion.

During record review on 8/9/23 the surveyor requested the Nursing Care Plan for PI # 20. None was provided.

An interview was conducted on 8/10/23 at 4:45 PM with EI # 1, who confirmed there was no Nursing Care Plan developed for PI # 20.



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6. PI # 8 was admitted on 6/14/23 with a diagnoses including: Withdrawal; Rehabilitation Protocols; Medication Management.

Review of the IDT Plan dated 6/14/23 revealed a pre-filled/copied set of Goals, Objectives, Intervention Methods, and Long Term Goals.

Further review of the IDT Plan revealed the Intervention Method for Objective number five, "Learn about the Recovering Process" had a line drawn through it, and no documentation of what intervention method was used.

An interview was conducted on 8/10/23 at 3:23 PM with EI # 1, who confirmed the IDT was not individualized or updated to reflect the patient's needs.

7. PI # 11 was admitted on 6/7/23 with a diagnoses including: Withdrawal; Rehabilitation Protocols; Medication Management.

Review of the IDT Plan dated 6/8/23 revealed a pre-filled/copied set of Goals, Objectives, Intervention Methods, and Long Term Goals.

Further review of the IDT Plan revealed the Intervention Method for Objective number five, "Learn about the Recovering Process" had a line drawn through it, and no documentation of what intervention method was used.

An interview was conducted on 8/10/23 at 3:43 PM with EI # 1, who confirmed the IDT was not individualized or updated to reflect the patient's needs.

8. PI # 15 was admitted on 6/16/23 with a diagnoses including: Withdrawal; Rehabilitation Protocols; Medication Management.

Review of the IDT Plan dated 6/16/23 revealed a pre-filled/copied set of Goals, Objectives, Intervention Methods, and Long Term Goals.

Further review of the IDT Plan revealed the Intervention Method for Objective number five, "Learn about the Recovering Process" had a line drawn through it, and no documentation of what intervention method was used.

An interview was conducted on 8/10/23 at 3:40 PM with EI # 1, who confirmed the IDT was not individualized or updated to reflect the patient's needs.

Based on review of medical records (MR), hospital policies and procedures, and interviews, it was determined the hospital failed to ensure:

1. Medical Records department staff was knowledgeable regarding their own policies and procedures.

2. All MR's were accounted for and maintained in a secure location.

3. Staff had the ability to retrieve records when requested.

4. Medical Records department participated in the hospital wide Quality Assessment Performance Improvement program.

4. Physician's orders were signed and dated per policy.

5. General Admission Orders (standing orders) for the Self Recovery Unit were signed and dated by the physician.

Refer to A 432, A 454, A 457

Based on review of policies and interviews with staff, it was determined the hospital failed to ensure staff was knowledgeable of their own policies regarding the requirements of the Medical Records (MR) department, including:

1. Timeframe for completion of records.

2. All medical records were accounted for and maintained in a secure location.

3. The ability to retrieve records when requested.

4. Ensuring the medical record was completed after discharge.

5. Ability to code and index records.

6. Compiling data and participating in Quality Assurance activities.

This deficient practice had the potential to affect all patients served by the hospital.

Findings include:

Hospital policy: Accuracy and Timeliness of Medical Record Documentation and Whiteboard Validation
Policy number: None listed
Date Written: 01/01/2014

Purpose:

To define general guidelines for documentation of accurate, timely and complete medical records...

Policy:

1. A complete, legible and accurate paper and/or electronic medical record will be maintained for every individual who is evaluated or treated...

2. Medical record entries must be completed in real time. Records not completed within 24 hours of discharge are considered delinquent.

3. The following time frames shall be followed when documenting the patient's medical record:

...Discharge Summary
A concise discharge summary shall be documented within 10 days post discharge...

7. A weekly count of all incomplete and delinquent charts will be generated on Monday of each week. The report will include an account of the number of total deficiencies... The report will be distributed to Hospital Administration, Quality Assurance and the Clinical Department Heads. Individual physicians and nurses will receive notification of specific deficiencies requiring their attention...

An interview was conducted on 8/8/23 at 3:30 PM with Employee Identifier (EI) # 3, Medical Records Manager. EI # 3 stated she/he had been in this position for one and a half years. EI # 3 confirmed medical records were maintained both electronically and in paper form.

During the interview, the surveyor asked EI # 3, "What is the policy or timeframe for the completion of the medical record?" EI # 3 responded, "I don't think we have one." EI # 3 further stated she was unaware of how the electronic records were backed up or saved, and unaware of an ability to code or index records for retrieval of medical information.

EI # 3 further stated she/he did not keep up with the percentage of incomplete records, and when asked does the department participate in the hospital's Quality Assurance Performance Improvement committee or activities, EI # 3 responded, "Not that I am aware of."

During reviews of MR's on 8/3/23, four discharged patients' physical records were
unable to be located. The physical record included items such as the consent forms, Physician Admission Standing Orders, Interdisciplinary Team Treatment Plans, original EKG's (Electrocardiograms), and daily group activity documentation. The four missing patient records had been discharged in June. EI # 3, Medical Records Manager reported to the surveyors the records could not be located. On 8/4/23, the missing records were discovered on the Self Recovery Unit, and brought to the surveyors for review. The discharged patient records had been in the left in the department for two months.

An interview was conducted on 8/4/23 at 4:29 PM with EI # 1, Chief Nursing Officer, who confirmed the records should have been in the Medical Records department, and staff failed to follow the policies for the MR department.

Based on review of medical records (MR), hospital policies and procedures, and interviews, it was determined the hospital failed to ensure physician's orders were signed per policy.

This deficient practice affected 2 of 19 inpatient records reviewed, including Patient Identifier (PI) # 13, PI # 19, and 1 of 1 Swing Bed record reviewed, including PI # 20, and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital policy: Accuracy and Timeliness of Medical Record Documentation and Whiteboard Validation
Policy number: None listed
Date Written: 01/01/2014

Purpose:

To define general guidelines for documentation of accurate, timely and complete medical records...

Policy:

1. A complete, legible and accurate paper and/or electronic medical record will be maintained for every individual who is evaluated or treated...

2. Medical record entries must be completed in real time. Records not completed within 24 hours of discharge are considered delinquent.

...Verbal Orders
Verbal orders shall be authenticated daily by the ordering Physician.

Hospital policy: GCH (Greene County Hospital) Medical Records Policy and Procedures
Policy number: None listed
Date: None listed

...Completion, Timeliness and Authentication of Medical Records

...All Medical Records entries are to be dated, the time entered, and signed.

1. PI # 13 was admitted to the Self Recovery and Detox Unit on 6/13/23 with diagnosed including Withdrawal, Rehabilitation Protocols, and Medication Management. The patient left Against Medical Advice on 6/17/23.

Review of the physician's orders dated 6/14/23 at 1:25 PM revealed a phone order for Urinalysis, Clean Catch. The signature line read "Pending." The physician failed to sign the phone order, daily, per policy.

An interview was conducted on 8/10/23 at 3:59 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed the physician had not authenticated the order, 54 days post discharge. Per policy, records not completed within 24 hours of discharge are considered delinquent.

2. PI # 19 was admitted to the hospital on 5/31/23 with diagnoses including Acute Renal Failure and Dehydration, and discharged on 6/2/23.

Review of the MR revealed the following verbal orders by the physician:

a. EKG was written on 5/31/23 at 8:45 PM. The physician's signature is labeled as "Pending."

b. Chest 2V (Xray two views) was written on 5/31/23 at 8:45 PM. The physician's signature is labeled as "Pending."

c. Zofran 8 mg, SL (sublingual), PRN (as needed) Q6H (every six hours) was written on 5/31/23 at 11:20 PM. The physician's signature is labeled as "Pending."

An interview was conducted on 8/10/23 at 3:33 PM with EI # 1, who confirmed the physician had not authenticated the orders, 69 days post discharge. Per policy, records not completed within 24 hours of discharge are considered delinquent.

3. PI # 20 was admitted to Swing Bed status on 10/21/20 with diagnoses including Cardiomyopathy and Left Sided Pleural Effusion. (PI # 20 was the most recent patient admitted to Swing Bed status). The patient expired on 10/26/20 due to Cardiac Arrest.

Review of the MR revealed admission orders written and signed by the physician. There was no date or time the orders were written, and there was no patient name or sticker containing patient information on the orders. The orders were "Noted" by the Registered Nurse (RN), but no date and time by the RN.

Further review of the MR revealed 8 Verbal Orders dated from 10/21/20 at 6:25 PM to 10/24/20 at 6:51 AM, entered electronically. The physician signature status was "Pending."

An interview was conducted on 8/10/23 at 4:45 PM with EI # 1, who confirmed the physician failed to authenticate the orders, daily, per policy. The patient was discharged greater than 2 years prior.

Based on review of medical records (MR), hospital policies and procedures, and interviews, it was determined the hospital failed to ensure the Self Recovery Unit Addictive Disease Program standing General Admission Orders (GAO) were signed and dated by the physician, per policy.

This deficient practice affected 16 of 19 Self Recovery records reviewed, including Patient Identifier (PI) # 6, PI # 13, PI # 1, PI # 17, PI # 14, PI # 2, PI # 9, PI # 10, PI # 12, PI # 8, PI # 11, PI # 15, PI # 5, PI # 3, PI # 7, and PI # 16, and had the potential to affect all patients admitted to this hospital.

Findings include:

Facility Policy: Medical Record Documentation and Validation
Department: Medical Detox Program
Revision Dates: 08/2023

Standing Admission Orders:
-Can be entered electronically by the admitting nurse or physician.
-The admitting physician will authenticate or validate daily unless an issue needs to be addressed sooner.
-The standing order template should be signed, dated, and timed by the nurse or physician who enters it into the EMR (Electronic Medical Record).
-If orders are entered by a nurse, the physician needs to sign, date, and time the orders within 24 hours of admission for order confirmation and authentication.

1. PI # 6 was admitted to the hospital on 6/26/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management and UTI (Urinary Tract Infection), and discharged on 7/5/23.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:29 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed the standing orders were not authenticated.

2. PI # 13 was admitted to the hospital on 6/13/23 with a diagnosis of Withdrawal, Rehabilitation Protocols, and Medication Management, and left AMA (Against Medical Advice) on 6/17/23.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:29 PM with EI # 1, who confirmed the standing orders were not authenticated.

3. PI # 1 was admitted to the hospital on 8/2/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 3:08 PM with EI # 1, who confirmed the standing orders were not authenticated.

4. PI # 17 was admitted to the hospital on 6/22/23 with diagnoses Withdrawal, Rehabilitation Protocols, and Medication Management, and left AMA on 6/25/23.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:31 PM with EI # 1, who confirmed the standing orders were not authenticated.

5. PI # 14 was admitted to the hospital on 6/13/23 with diagnoses Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 3:36 PM with EI # 1, who confirmed the standing orders were not authenticated.



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6. PI #2 was admitted to the hospital on 8/7/23 with diagnoses of Withdrawal, Rehabilitation Protocols and Medication Management.

Review of the Self Recovery Addictive Disease Program, General Admission Orders (GAO) dated 8/7/23 revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 4:00 PM with EI # 1, who confirmed the signature on the GAO was not authenticated per facility policy.

7. PI # 9 was admitted to the hospital on 6/30/23 with diagnoses of Withdrawal, Rehabilitation Protocols and Medication Management.

Review of the Self Recovery Addictive Disease Program, GAO dated 7/1/23 revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 3:18 PM with EI # 1, who confirmed the signature on the GAO was not authenticated per facility policy.

8. PI # 10 was admitted to the hospital on 6/7/23 with diagnoses of Withdrawal, Rehabilitation Protocols, Medication Management.

Review of the Self Recovery Addictive Disease Program, GAO revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 3:25 PM with EI # 1, who confirmed the signature on the GAO was not authenticated per facility policy.

9. PI # 12 was admitted to the hospital on 6/10/23 with diagnosis of Withdrawal, Rehabilitation Protocols and Medication Management.

Review of the Self Recovery Addictive Disease Program, GAO dated 6/10/23 revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 3:31 PM with EI # 1, who confirmed the signature on the GAO was not authenticated per facility policy.



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10. PI # 8 was admitted on 6/14/23 with a diagnoses including: Withdrawal; Rehabilitation Protocols; Medication Management.

Review of the GAO dated 6/14/23 revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 3:23 PM with EI # 1, who confirmed the standing orders were not authenticated.

11. PI # 11 was admitted on 6/7/23 with a diagnoses including: Withdrawal; Rehabilitation Protocols; Medication Management.

Review of the GAO revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 3:43 PM with EI # 1, who confirmed the standing orders were not authenticated.

12. PI # 15 was admitted on 6/16/23 with a diagnoses including: Withdrawal; Rehabilitation Protocols; Medication Management.

Review of the GAO dated 6/16/23 revealed a faded physician signature that appeared to have been on the form when copied with no date or time signifying when the orders were implemented.

An interview was conducted on 8/10/23 at 3:40 PM with EI # 1, who confirmed the standing orders were not authenticated.



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13. PI # 5 was admitted to the hospital on 6/19/23 with diagnoses of Withdrawal, Rehabilitation Protocols, and Medication Management, and discharged on 6/26/23.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:25 PM with EI # 1 who confirmed the standing orders were not authenticated.

14. PI # 3 was admitted to the hospital on 8/4/23 with diagnoses of Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:02 PM with EI # 1 who confirmed the standing orders were not authenticated.

15. PI # 7 was admitted to the hospital on 7/7/23 with diagnoses of Withdrawal, Rehabilitation Protocols, and Medication Management, and discharged on 7/11/23.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:20 PM with EI # 1 who confirmed the standing orders were not authenticated.

16. PI # 16 was admitted to the hospital on 6/20/23 with diagnoses of Withdrawal, Rehabilitation Protocols, and Medication Management, and discharged on 6/22/23.

Review of the MR revealed a copy of the GAO with no date or time signifying when the orders were implemented. The physician signature was faded and appeared to have been on the form when copied. Staff failed to ensure the physician signed, dated, and timed the orders.

An interview was conducted on 8/10/23 at 4:35 PM with EI # 1 who confirmed the standing orders were not authenticated.

Based on observations, policies and procedures, and interviews, it was determined the dietary director failed to ensure staff:

1. Followed policies and procedures for checking food temperatures.

2. Documented freezer and cooler temperatures per policy.

3. Cleaned the kitchen surfaces of dirt and grime.

4. Followed the policy and procedure for washing dishes in the 3 compartment sink.

This had the potential to affect all patients admitted to the hospital.

Findings include:

Facility Unit Refrigeration Equipment
Policy Number: None Listed
Date: None Listed

Policy: The facility ensures the quality and safety of refrigerated or frozen foods stored outside the food service area through accepted storage practices.

Procedure:
...3. The temperature (temp) is checked twice a day (early morning and as kitchen is closed) by a designated employee and documented on the Daily Temp Sheet.

Monitoring Food Temperatures

Policy: The temperature of TCS (Time and Temperature Control for Safety) cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41 F and below 135 F) for more than 6 hours.
Policy Number: FP.8.
Section: Food Production

Procedure:
1. TCS cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 F or higher.
2. The temperature of each potential hazardous food will be taken at the following times.
a. When the cooking process is completed...Food will be placed in hot holding equipment immediately after the cooking process is completed.
b. Hot food should not be placed on steam table earlier than 30 minutes prior to service.
c. Temperatures are checked immediately prior to service. If temperature is below 125 F, the food is reheated to 165 F for 15 seconds.
3. Cooking and holding temperatures should be recorded at each meal on the Daily Temp. Check Log. These logs should be maintained in a notebook in the serving area.

Policy: Manual Warewashing
Policy Number: SI.9.
Section: Sanitation and Infection Control
Originated: 09/04
Revised: 8/23

Policy: Food service pots and pans that cannot fit in a dish machine are cleaned and sanitized in a three-compartment sink.

Procedure:
...3. First compartment sink:
a. Fill the first sink with a cleaning solution. Water temperature should be 110 F.
b. Wash items in the first compartment sink using a brush, cloth, or nylon scrub pad to loosen the remaining soil.
c. Refill sink with water and cleaning solutions when water is dirty.
4. Second Compartment Sink
a. Fill the second sink with clean, clear water. (This is not necessary if items will be spray rinsed instead of being dipped.)
b. Immerse or spray rinse items in the second sink with clean, clear water.
c. Remove all traces of food and detergent.
d. Replace rinse water when it becomes cloudy and dirty.
5. Third Compartment Sink
a. Fill the third sink with water and sanitizer to the correct concentration.
b. Immerse items in the third sink. Chemical sanitizing is used. The sanitizer is mixed to the proper concentration of 100- (the remainder of the sentence is blank on the facility policy).
6. The concentration of the sanitizing solution is checked with an appropriate test kit when the sink is filled and again if the solution is used for an extended period of time.
...9. The employee using the three compartment sink documents temperature and concentration on the Daily Temp Sheet.

Food Storage, Labeling and Monitoring

Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures.

Procedure:
1. All food items must be labeled with the date they are received.
2. All food items that are not in their original containers must be labeled with the common name of the food and the date they are received.
3. Food, such as cake mixes, that are partially used: the remainder of item is to be stored in a Zip Lock bag or other closed container with the item name, date opened and use by date clearly noted on container.
...5. Suggested labeling includes:
a. Common Name
b. Date of preparation or Use By Date
...9. Monitoring storage temperatures
a. A thermometer is kept in all storage areas.
b. Temperatures in food storage units are monitored daily.
c. Documentation of time and temperature is recorded on the appropriate form...

1. Review of the Daily Temperature Check Logs from 7/1/23 to 8/8/23 (38 days)revealed the following which were not documented per hospital policy.

Temp checks of the storage areas were not routinely documented twice daily per policy. The storage areas include the:

Reach-in refrigerator
Walk-in cooler
Grab & Go area
Storage Freezer

There were 18 days where the temps of these areas were documented only once and nine days where there was no documentation.

An area labeled "Final Cooking Temp/Time" on the log revealed only one entry for the 38 days reviewed. Per policy, food temperatures are to be checked immediately prior to service.

Cooking and holding temperatures of foods should be recorded at each meal per policy. On the daily log, there is an area for temps to be documented for breakfast, lunch, and dinner.

There were 20 days where no food temps were documented for breakfast.
There were 21 days where no food temps were documented for lunch.
There were ten days where no food temps were documented for dinner.
There were four days with no documentation.

The employee using the three compartment sink documents temperature of the water and concentration of the sanitizer on the Daily Temp Sheet, three times per day.

There were ten days with no documentation of temps or concentration.
There were 23 days with water temps and sanitizer concentration documented once.
There were three days with water temps and sanitizer concentration documented twice.

On 8/8/23 at 1:15 PM, the above findings were discussed with EI # 4, Dietary Manager, who confirmed staff failed to complete the temp logs per policy.



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2. A tour of the dietary department was conducted on 8/8/23 at 11:00 AM with EI # 4.

The following was observed:

a. Snack Room:

The refrigerator contained rusted shelves and crumbs. An opened paper packet of Carnation Breakfast powder was opened and in the plastic bin with ketchup packets. Also in the Snack Room an employee purse was observed on the food storage shelf.

b. Main Kitchen:

Approximately 10 small, hard shell bugs were observed on the floor next to the upright cooler. A black rolling cart contained crumbs and dirt particles. The stove had a dried white substance on the front door, and a large pile of dried black substance was on the floor beside the stove.

The steam table's bottom shelf was dirty with crumbs, dust particles, and small paper scraps.

The stationary can opener was dirty with a black grime, the microwave and plate warmer was sticky, inside and out.

A large baking tray was standing on the floor, leaning against the stove, and had a hard black substance around the edges. Six large baking trays were in the cabinet, and all 6 had hard black substance around the edges.

The counter tops along the back wall had cracked and missing laminate, with particle board showing.

The deep fryer was greasy on the outside, with grease looking liquid in puddles on the floor.

The baker's table bottom shelf was dirty with crumbs, plastic disposable lids, rust, and grime.

c. Walk in Freezer:

A box of frozen omelettes were opened and not secured closed, and unlabeled.

A frozen cheesecake was opened and unlabeled.

EI # 4, who was present on the tour, confirmed the above findings.

3. An observation of manual washing of cook ware was observed on 8/9/23 at 1:30 PM with EI # 7, dietary personnel.

The surveyor asked EI # 7 how much dish washing product she/he should put in the water? EI # 7 stated, "...I don't normally wash dishes. I just put a little in, and add some Clorox. EI # 7 failed to test the water. There was no rinse water added to the middle sink, and the third sink was being used to store cutting boards in a rack. EI # 7 did not utilize the third sink per policy.

EI # 7 confirmed she/he was unaware of the policy and procedure to clean the dishes.

An interview was conducted on 8/9/23 at 1:45 PM with EI # 4, who confirmed the dishes were not washed per policy.

Based on review of medical records (MR), hospital policy, and interview, it was determined the hospital failed to ensure the Registered Dietician performed dietary consults for all patients admitted to the Self Recovery Unit per policy.

This affected 19 of 19 Self Recovery unit MR's reviewed, including Patient Identifier (PI) # 6 who required special dietary instructions for Gout.

The deficient practice had the potential to affect all patients admitted to the hospital.

Findings include:

Hospital policy: Standards of Practice
Department: Self Recovery
Policy number: 55
Date effective: 08/2023

Procedure:

Patient Care and Quality

...Nutrition:

1. Each patient will be assessed by the dietician to determine nutritional status, special needs or limitations.

2. Individual diet teaching will be given as needed by the dietician.

During MR review of 19 patients admitted to the Self Recovery Unit, current and discharged, the surveyors observed no assessment provided by the dietician, per policy.

1. PI # 6 was admitted to the Self Recovery Unit on 6/26/23 with diagnoses including Withdrawal, Rehabilitation Protocols, and Medication Management.

Review of the Interdisciplinary Treatment (IDT) Plan dated 6/28/23 revealed the patient reported medical concerns including Gout.

There was no documentation of a consult with the dietician to determine/ identify foods that might trigger PI # 6's gout.

A phone interview was conducted on 8/8/23 at 2:19 PM with Employee Identifier (EI) # 9, Registered Dietician. EI # 9 stated she/he visited the hospital and connected long term care facility one time per month for approximately 4 hours. EI # 9 stated, "...it has been quite a while since consulting with a patient... I have worked with the detox unit in the past." EI # 9 further stated she/he had not been allowed in the kitchen area since the Covid pandemic was issued. EI # 9 confirmed no assessment had been conducted on the 19 records reviewed.

An interview was conducted on 08/10/23 at 4:29 PM with EI # 1, Chief Nursing Officer, who confirmed the IDT Plan was not individualized to meet the needs of the patient.

Based on medical record review (MR), facility policy and procedure, and interview, it was determined the facility failed to obtain physician ordered diets for patients admitted to the Self Recovery Detox (detoxification) Unit.

This deficient practice affected 14 of 19 records reviewed from the Self Recovery Unit, and did affect Patient Identifier (PI) # 3, PI # 16, PI # 6, PI 17, PI # 14, PI # 13, PI # 1, PI # 2, PI # 9, PI # 10, PI # 12, PI # 8, PI # 11, and PI # 15, and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Facility Policy: Diet and Supplement Orders
Policy Number: None
Revision Date: Nov 2017 - Mar 2018

Policy:

The resident's diet is prescribed by the attending physician...

Procedure:

1. The attending physician writes an order for regular or therapeutic diets and nutritional supplements to be served to each resident...

Review of 19 records from the inpatient Self Recovery Unit, revealed 14 records failed to contain documentation a patient diet was ordered by the physician.

An interview was conducted on 8/10/23 at 4:02 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there was no documentation of a physician ordered diet in the medical records.

Based on observation and interview, it was determined the hospital failed to ensure:

1. Preventive maintenance (PM) was conducted on electric patient beds.

2. Environmental risk assessments were documented.

3. The maintenance department participated in the hospital wide Quality Assessment Performance Improvement (QAPI) program.

This had the potential to affect all persons served by the hospital.

Findings include:

An observation of terminal room cleaning was conducted on 8/8/23 at 1:55 PM, in room 106.

The Stryker electronic bed was observed to have a built in feature to measure the patient's weight. There was no preventive maintenance sticker on the bed.

An interview was conducted on 8/10/23 at 9:19 AM with Employee Identifier (EI) # 5, Maintenance Director, who confirmed there was no PM performed on the 9 Stryker beds in the hospital. The patient equipment PM was conducted annually by a contracted company, which did not include the beds.

During the interview, the surveyor requested a copy of the most recent environmental risk assessment. EI # 5 stated, "I do a walk through two times a day for things like leaking tiles in the ceiling, no annual assessment." The surveyor asked EI # 5 if the department reported to or participated in the hospital wide QAPI program. EI # 5 stated, "No."

During the interview, EI # 5 confirmed there was no PM on the electric beds, no annual environmental risk assessment, and no participation in the QAPI program.

Based on review of the Swing Bed Policy and Procedure manual and interview, it was determined the hospital failed to develop policies and procedures to prohibit and prevent abuse of patients in Swing Bed status.

This had the potential to affect all patients admitted to Swing Bed status.

Findings include:

Review of the Swing Bed Policy and Procedure manual revealed no policy or procedure had been developed to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of property, as required.

An interview was conducted on 8/10/23 at 4:35 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there was no policy for prohibiting and preventing abuse and neglect of residents.

Based on review of the Swing Bed Policy and Procedure manual and interview, it was determined the hospital failed to develop policies and procedures regarding dental services for residents in Swing Bed status.

This had the potential to affect all patients admitted to Swing Bed status.

Findings include:

Review of the Swing Bed Policy and Procedure manual revealed no policy or procedure had been developed regarding dental services for residents.

An interview was conducted on 8/10/23 at 4:35 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there was no policy or procedure regarding dental services.

Based on review of Emergency Preparedness (EP) documentation and interview with staff, it was determined the facility failed to ensure their comprehensive EP Program was updated and reviewed Biennially (every 2 years) to comply with the State, Federal and local emergency preparedness requirements.

This had the potential to negatively affect all persons served by the facility.

Review of the facilities EP Plan and Program revealed the last update and review was dated 3/17/19.

An interview was conducted on 8/9/23 at 5:25 PM with Employee Identifier # 6, Registered Nurse, Quality Director/Infection Control, who confirmed the facilities EP Plan and Program was not updated and reviewed every two years as required.

Based on review of the facility's Emergency Preparedness (EP) policies and procedures, and interview with the facility staff, it was determined the facility failed to ensure policies and procedures had been updated and/or reviewed at least every two (2) years.

This had the potential to negatively affect all persons served by the facility.

Findings include:

On 8/9/23, Employee Identifier # 6, Registered Nurse, Quality Director/Infection Control, provided the surveyor with an EP Plan.

Review of the EP documentation provided to the surveyor revealed the policies and procedures for EP were last reviewed and updated on 3/17/19.

An interview was conducted on 8/9/23 at 5:25 PM with EI # 6, who confirmed the EP policies and procedures were not reviewed and updated at least every two years.

Based on review of the Employee Files, Job Descriptions, and interviews with staff, it was determined the facility failed to ensure all staff completed the Emergency Preparedness (EP) training initially and every two (2) years.

This affected three of three contracted Self Recovery Detox (Detoxification) Unit employees and had the potential to negatively affect the continuity of care to all patients at the facility.

Findings include:

1. Review of Employee Identifier (EI) # 10, Assistant Counselor/Addicition Technician employee's file revealed date of hire 1/8/21, no documentation of orientation to include EP and no documentation of completion of EP training every two years.

2. Review of EI # 11, Self Recovery Counselor employee's file revealed date of hire 3/7/23 with no documentation of orientation to include EP.

An interview was conducted on 8/10/23 at 5:00 PM with EI # 1, Chief Nursing Officer, who confirmed the facility failed to ensure the contracted employees received EP training initially and every two years.


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3. Review of EI # 8's, Certified Addiction Counselor (addiction tech) employee file revealed no hire date, and no documentation of orientation to include EP and no documentation of completion of EP training every two years.

An interview was conducted on 8/10/23 at 5:00 PM with EI # 1 who confirmed the facility failed to ensure the contracted employees received EP training initially and every two years.