HospitalInspections.org

Based on observation, interview and record review, the Board of Managers (Board, governing body) failed to ensure oversight of the Sleep Study Program provided through contract and failed to ensure that 16 of 16 contracted patient care services were included in the facility's Quality Assessment/Performance Improvement (QAPI) Program. These failures increased the potential for sub-standard care to be provided by contracted services for all patients admitted to the facility. The Sleep Study Program performed approximately 14 procedures per month or 172 annually. The facility census was 14.

Findings included:

1. Record review of the facility's contracted services list showed 16 agreements for direct patient care services to be provided for the facility's patients including interpreter services; laboratory; mobile magnetic resonance imaging (MRI, uses strong magnetic fields and radio waves to form images of the body); occupational, speech and physical therapy; pharmacy; and sleep studies.

2. During concurrent observation and interview on 03/18/15 at 10:25 AM, Staff K, Manager of Respiratory Therapy (RT) Services, stated that Sleep Study Services were provided in the basement of a medical building adjacent to the facility. Observation of the sleep study area showed two sleep study rooms with monitoring equipment and supplies.

3. Record review showed a Sleep Study policy and procedure manual approved by a clinical manager and medical director responsible for the services that were not employees or on staff at the facility.

During an interview on 03/18/15 at 10:45 AM, Staff E, Chief Nursing Officer (CNO)/ Chief Operation Officer (COO), stated that the facility had a contract to bill for services provided by the Sleep Study Services but had never provided clinical oversight for the program.

During a concurrent interview on 03/18/15 at 1:05 PM, the listed Sleep Services Medical Director stated that he had submitted the policies and procedures for Sleep Services to Staff NN, Director of Surgical Services and previous manager of Outpatient Clinics to be approved. The Sleep Studies Clinical Manager stated that he had never been asked to submit quality data to the facility.

During an interview on 03/18/15 at 1:20 PM, Staff NN stated that he had not received the Sleep Study Services policies and procedures for facility approval and that he had no oversight for the sleep study program.

During an interview on 03/16/15 at 2:00 PM, Staff A, Quality Risk Manager, stated that not all contracted services submitted data for the QAPI program.

During a telephone interview on 03/18/15 at 3:05 PM, Staff OO, Chairman of the Board, stated that the QAPI Program had recently been discussed and the Board recognized that the Program was incomplete. He stated that the QAPI plan had not been submitted to the Board.










32281









27727

Based on interview, record review and policy review, the facility failed to ensure that care plans were modified to include goals and interventions related to restraint (any manual method, physical or mechanical device that immobilizes or reduces the ability of an individual to move his/her arms, legs or body freely) for one current patient (#2) and three discharged patients (#16, #45 and #46) of four patients whose records were reviewed for manual holds (restraint). This had the potential to affect all patients who were restrained by failing to ensure that the patients' physical and psychological needs were met and to potentially prevent future restraint use. The facility census was 14.

Findings included:

1. Record review of the policy titled, "Use of Seclusion and Restraint Protocol," dated 02/2015, showed the following directive:
- The Plan of Care will be updated by the nurse in the event of a seclusion or restraint episode.
- The Plan of Care will reflect that the event occurred and the nurse should identify the associated treatment goals, objectives, and interventions for the patient.
- The Plan of Care will be updated every time a seclusion or restraint episode occurred.

2. Record review of current Patient #2's physician order for manual hold and nursing care plan showed one episode of a manual hold on 02/28/15 with no modifications made in the nursing care plan.

3. Record review of discharged Patient #16's physician order for manual hold and nursing care plan showed one episode of a manual hold on 01/19/15 with no modifications in the nursing care plan.

4. Record review of discharged Patient #45's physician order for manual hold and nursing care plan showed two episodes of a manual hold dated 01/30/15 and 02/01/15 with no modifications in the nursing care plan.

5. Record review of discharged Patient #46's physician order for manual hold and nursing care plan showed one episode of a manual hold on 02/18/15 with no modifications in the nursing care plan.

During an interview on 03/19/15 at 10:35 AM, Staff G, Registered Nurse (RN), Department Manager, stated that the nurses should have updated the plan of care for the patients.

Based on interview, record review and policy review the facility failed to ensure completion of a face-to-face (medical and behavioral) evaluation for one current patient (#2) and three discharged patients (#16, #45 and #46) of four patients whose records were reviewed for manual holds (any manual method, physical or mechanical device that immobilizes or reduces the ability of an individual to move his/her arms, legs or body freely). This deficient practice had the potential to delay behavioral and/or medical treatment that may have been required for restrained patients. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Restraint and Seclusion Use (All Ages)", revised 01/2015, showed that a physician must document a face-to-face assessment of the patient within one hour of initiation of physical restraints. The purpose of the face-to-face assessment was to work with the patient and staff to identify ways to help the patient regain control, make necessary revisions to the individual's treatment plan, and if necessary, provide a new written order.

2. Record review of current Patient #2's physical restraint documentation dated 02/28/15 showed the patient was placed in a manual hold. The physician failed to complete a one hour face-to-face assessment per policy and failed to identify patient needs.

3. Record review of discharged Patient #16's physical restraint documentation dated 01/19/15 showed the patient was placed in a manual hold. The physician failed to complete a one hour face-to-face assessment per policy and failed to identify patient needs.

During an interview on 03/19/15 at 10:10 AM, Staff K, Registered Nurse (RN), stated that there was no one hour face-to-face for this patient.

4. Record review of discharged Patient #45's physical restraint documentation dated 01/30/15 and 02/01/15 showed the patient was placed in a manual hold on each date. The physician failed to complete a one hour face-to-face assessment for each restraint episode and failed to identify patient needs.

During an interview on 03/19/15 at 10:20 AM, Staff K, RN, stated that there was no one hour face-to-face documented for this patient. Staff K stated that the patient should have been reassessed after the restraint application.

5. Record review of discharged Patient #46's physical restraint documentation dated 02/18/15 showed the patient was placed in a manual hold. The physician failed to complete a one hour face-to-face assessment per policy and failed to identify patient needs.

During an interview on 03/19/15 at 11:20 AM, Staff G, RN, Department Manager, stated that there was no one hour face-to-face documented for this patient.

Based on interview, record review and policy review the facility failed to have systemic practices in place for the Quality Assessment Performance Improvement (QAPI) Program. The facility failed to:
- Provide evidence that each quality indicator selected was related to improved health outcomes for 16 of 16 departments of the facility (refer to A-0273).
- Analyze the collected data for 16 of 16 departments (refer to A-0273).
- Provide evidence that the quality indicator data was collected and was compared for measurable improvement for improved health outcomes (refer to A-0273).
- Provide evidence that 16 of 16 patient care services were monitored for performance improvement opportunities (refer to A-0273).
- Provide the Governing Body the QAPI Program for approval (refer to A-308).
- Provide evidence that improvement activities focused on areas of high risk, high volume or problem prone areas for 16 of 16 departments (refer to A-0283).
- Identify and reduce medical errors (refer to A-286).
- Ensure projects were implemented within the scope and complexity of the facility's services (refer to A-0297).
- Ensure the program was proportional to the scope and complexity of the hospitals services and contracted clinical services (refer to A-308).
- Ensure the Chief Executive Officer (CEO) was responsible and accountable to have a facility-wide Quality Assessment Performance Improvement (QAPI) Program in place (refer to A-309)

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at Condition of Participation: Quality Assessment and Performance Improvement Program. The facility census was 14.

Based on interview and record review the facility failed to ensure that the Quality Assessment Performance Improvement (QAPI) Program met the following requirements:
- That each quality indicator selected was related to improved health outcomes for 16 of 16 departments.
- The collected data was analyzed for all departments.
- That 16 of 16 contracted clinical services provided QAPI data to the facility.
These had the potential to negatively affect all patients' health and quality of care for the services provided. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Quality Improvement Process," reviewed 09/2012 showed direction to measure identified goals and objectives by statistical monitoring, comparison monitoring, physical assessment, or systematic assessment.

2. Record review of the facility's QAPI Plan titled, "Performance Improvement " dated 2015, showed a list of quality improvement activities which had been submitted. Three department examples are:

Pharmacy selected:
-Order entry fixes to safeguard against errors.
-Education on CPOE (Computerized Provider Order Entry). (This is not related to improved health outcomes.)
-Update Total Parenteral Nutrition (TPN) protocol/ Total Parenteral Alimentation (TPA) protocol (the act of providing nutrition administered by means other than through the digestive tract, as by intramuscular or intravenous injection, when a patient can not take nourishment by mouth)
-Vaccine storage compliance with CDC (Centers for Disease Control and Prevention) guidelines.
-Mock medication tracers (a method to identify unrecognized medication management and safety issues).
-Continue patient medication education at discharge.

Dietary selected:
-Monitor food cost monthly. (This is not related to improved health outcomes.)
-Food allergy documentation audit monthly.
-Food temperature monitoring- check for completeness monthly.
-Ongoing temperature check dishwasher/fridge/freezers.
-Healthy food promotions in café. (This is not related to patient improved health outcomes.)
-Education on healthy nutrition.

Housekeeping selected:
-Monitor alcohol gel (used for hand cleansing) use in dispensers.
-Cooperate with disaster drills. (This is not related to improved health outcomes.)
-Maintain floors and carpets; Monitor patient room cleanliness.
-Updates to department equipment. (This is not related to improved health outcomes.)

During an interview on 03/16/15 at 2:00 PM, Staff A, Quality Risk Manager, stated that the list reflected a summary of the plans which had been submitted from some but not all departments for 2015. She stated that she could not provide evidence that facility-wide data had been collected, analyzed or tracked. She could not provide evidence that data was presented to the Governing Board. She stated that she sent the summary list to the Performance Improvement Committee.

During an interview on 03/18/15 at 1:05 PM, the Sleep Services Clinical Manager stated that he had never been asked to submit Quality Data for the contracted Sleep Study Services to the facility.

During an interview on 03/18/15 at 3:05 PM, Staff OO, Chairman of the Board, stated that he was aware that the elements needed for meeting the QAPI regulations were not met. He stated the QAPI plan had not been submitted to the Board.













32281

Based on interviews and record review the facility failed to collect Quality Assessment Performance Improvement (QAPI) data that focused on areas of high risk, high volume or problem prone areas for 16 of 16 departments. This had the potential to affect all patient' quality of care for the clinical services provided. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Quality Improvement Process," reviewed 09/2012, showed directives to collect and measure data by statistical monitoring, comparison monitoring, physical assessment, or systematic assessment.

2. Record review of the facility's QAPI Plan titled, "Performance Improvement" dated 2015, showed a list of quality improvement activities which had been submitted for departments. The list did not reflect that the quality indicators selected were related to high risk, high volume or problem prone outcome for patients.

3. Record review of the facility document titled, "Performance Improvement Evaluation 2014" showed an annual evaluation was performed to improve the quality of services and performance and increase the effectiveness of the organizational improvement program. The document listed seven questions related to submitted department plans.
These questions were not related to analysis of service and were not related to high risk, high volume or problem prone outcome for patients.

4. Record review of the facility's document titled, "Performance Improvement", dated 2015, showed the Respiratory Therapy Department had selected the following indicators to measure:
- Patient education; (This is not high risk, high volume or problem prone.)
- Code (a medical emergency, especially in a hospital, when a
patient's heart stops beating or his or her lungs stop functioning) review;
- Patient satisfaction; (This is not high risk, high volume or problem prone.)
- Update to equipment: EKG (monitor heart rate and rhythm); PFT(pulmonary function testing, measures lungs and breathing) and Et CO2 (measures the level of carbon dioxide in the air exhaled from the body);
- Cidex appropriate use/documentation, (chemical liquid that destroys bacteria, which are small living things that often cause disease)
- Facilitate staff education;
- Employee education;

During an interview and concurrent record review of the department document titled, "2015 Plan, Department Respiratory Therapy" on 03/17/15 at 9:50 AM, Staff H, Manager of Respiratory therapy stated that she had selected the following QAPI indicators for 2015:
- New equipment, EKG machine, PFT and Et CO2 monitor.
- Purchase some up to date education materials for patients to help with COPD (Chronic Obstructive Pulmonary Disease, difficulty breathing) readmissions.
- Keep all certifications up to date.
- Keep all patient satisfaction surveys high;
- Hand hygiene, (if required).
Staff H stated that:
-She chose QAPI indicators for her department by looking at the new services that were being added and determining the equipment she would need to support the services.
- She continued to monitor patient satisfaction even though her department's patient satisfaction scores had been at 100% in the past and that she hoped to get more surveys returned.
- She stated that she was not aware of selecting indicators based on improving patient outcomes or high risk, high volume, problem prone areas.

5. Record review of the facility's document titled, "Performance Improvement " dated 2015, showed the laboratory had chosen the following indicators for monitoring:
- Interface Microbiology reports to EMR (Electronic Medical Record); (This is not high risk, high volume or problem prone.)
- Staff education/update equipment;
- Blood culture contamination;
- Patient satisfaction; (This is not high risk, high volume or problem prone.)
- D-Stix (dipstick, a chemically sensitive strip of paper used to identify one or more constituents such as glucose or protein in urine) result validation;
- Quality Control (a procedure or set of procedures intended to ensure precision and accuracy of testing equipment) corrective action log;
- Blood utilization;
- Monitor specimen rejection with focus on hemolysis (breakdown of red blood cells);
- Critical results (outside the normal range), track time the result is available to be reported.

During an interview on 03/18/15 at 2:00 PM, Staff LL, Laboratory Director, stated that she chose the QAPI indicators the Laboratory Department would measure based on requirements or recommendations from the following organizations:
-CLIA (Clinical Laboratory Improvement Amendments, legislation that promulgated quality assurance practices in clinical labs) requirements;
- APIC ( Association for Professionals in Infection Control) recommendations;
- CDC (Center for Disease Control and Prevention);
- Joint Commission (nongovernmental agency that establishes guidelines for the operation of hospitals) recommendations:
- As well as reports from the Community Health Department.
She stated that she was not familiar with choosing QAPI indicators that improved patient outcomes or were based on high risk, high volume and problem prone areas.

During an interview on 03/16/15 at 2:00 PM, Staff A, Quality Risk Manager, stated that a facility wide analysis of quality improvement plans to improve patient care was not done and that not all indicators were chosen due to high risk, high volume and/or problem prone areas. She stated that the data collected was reported verbally to the Performance Improvement Committee but no monitoring of the care or formulating of action plans for improved patient care was done.



32281

Based on interview and record review the facility failed to ensure an ongoing Quality Assurance and Performance Improvement Program was implemented to identify and reduce medical errors. This had the potential to negatively impact the safety of all patients. The facility census was 14.

Findings included:

1. Record review of the facility's QAPI Plan titled, "Performance Improvement " dated
2015, showed the following Performance Indicators chosen by Pharmacy:
-Order entry (electronic entry of physician orders) fixes to safeguard against errors.
-Update Total Parenteral Nutrition (TPN) protocol/ Total Parenteral Alimentation (TPA) protocol (the act of providing nutrition administered by means other than through the digestive tract, as by intramuscular or intravenous injection, when a patient can not take nourishment by mouth)
-Vaccine storage compliance with CDC (Centers for Disease Control) guidelines.
-Mock medication tracers (a method to identify unrecognized medication management compliance and patient safety issues).
-Continue patient medication education at discharge.

2. During an interview on 03/18/15 at 1:30 PM, Staff Y, Pharmacist, stated that:
- He received a written report regarding medication errors that was filled out by staff when the error occurred;
- He looked at the report to determine who made the error and the type of error that was made;
- He sent the written report to Risk management to hand log the error; and
- To his knowledge there was not a current process to measure or trend medication errors.


32281

Based on record review and interview the facility failed to ensure any department conducted an annual Quality Assurance and Performance Improvement (QAPI) Project regarding their service and/or operation. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Quality Improvement Process," dated 09/2002 showed direction to identify projects of an important function for Quality Improvement.

2. Record review of the facility's QAPI Plan titled, "Performance Improvement" dated 2015, showed a list of quality improvement activities which had been submitted. There were no projects indicated on the list.

During an interview on 03/16/15 at 2:00 PM, Staff A, Quality Risk Manager, stated that the list reflected a summary of the plans which had been submitted. She stated that she could not provide evidence that projects were implemented.

Based on record review and interview the Governing Board failed to ensure the facility-wide Quality Assurance and Performance Improvement (QAPI) Program was proportional to the scope and complexity of the hospital's services and contracted clinical services. This had the potential to effect all patients' health and quality of services provided. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled "Quality Improvement Process," dated 09/2012, showed direction to develop a plan which should govern the improvement program and should identify important aspects of care and services as goals and objectives of the plan.

2. During a telephone interview on 03/18/15 at 3:05 PM, Staff OO, Chairman of the Board, stated that the QAPI Program had recently been discussed and the Board recognized that the Program was incomplete. He stated that the QAPI plan had not been submitted to the Board.

Based on interview and record review the Chief Executive Officer (CEO) failed to ensure an on-going Quality Assurance and Performance Improvement (QAPI) Program for quality improvement and patient safety, which included the reduction of medical errors, was defined, implemented and maintained. The failure to establish and maintain an effective facility-wide QAPI Program had the potential to affect all patients' health outcomes and the quality of care. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Quality Improvement Process," reviewed 09/2012 showed the hospital advisory board shall review the results and effectiveness of the quality assurance and improvement activities and recommend action as warranted.

Record review of the facility document, "Performance Improvement," dated 09/2012 showed no evidence that the facility had developed, implemented and maintained an effective, ongoing, facility-wide data driven, quality assessment and performance improvement program.

2. During an interview on 03/18/15 at 4:17 PM, Staff F, CEO, stated that he was aware of the Boards' responsibility to oversee the QAPI Program. He stated the QAPI Program had not been submitted to the Board. He stated that he understood the plan was not data driven and facility-wide.

Based on observation, interview and policy review the facility failed to ensure the medical record system was organized in order to ensure prompt completion and filing of medical records for four records (#16, #23, #39, #40) of ten discharged patients' records reviewed. This failed practice resulted in incomplete medical records and had the potential to negatively affect the continuity of care for patients re-admitted to the facility. The facility census was 14.

Findings included:

1. Record review of the facility's undated job description titled,"Health Information Management (HIM) Director," showed the following responsibilities: Establishes and enforces medical record policies and procedures necessary for effective and efficient processes and maintains appropriate staffing to ensure prompt completion, filing/scanning and retrieval of medical records.

2. Record review of the facility's policy titled, "Medical Record Department Functions," dated 12/2014, showed the functions of the Medical Record Department included to transcribe and file in a timely manner and maintain the medical record, which is a complete case history or written report, pertaining to each patient.

3. During record review on 03/17/15 at 1:15 PM Staff D, HIM Director was requested to provide a copy of three patients' (#39, #40, #41) Discharge Summaries and seven patients' (#16, #21, #22, #23, #42, #43, #44) complete medical record.

On 03/17/15 at 3:30 PM Staff D returned the request list for patients' records with written notations that four records (#16, #23, #39, #40) of ten patients' records requested had not contained a Discharge Summary.

During record review and concurrent interview on 03/19/15 at 11:00 AM, Staff D presented the following documents:
- A Discharge Summary for Patient #16 dated completed on 02/27/15. Patient #16 was discharged on 02/11/15;
- A Discharge Summary for Patient #23 with no date of completion or physician signature. Patient #23 was discharged on 01/26/15;
- A Discharge Summary for Patient #39 dated completed on 02/17/15. Patient #39 was discharge on 01/07/15.
- A Discharge Summary for Patient #40 dated completed on 02/27/15. Patient #40 was discharged on 02/02/15.
Staff D stated that the Discharge Summary for Patient #23 had been typed by the physician's office staff and had been sent to the facility on 03/19/15 after she had requested it. She stated that the Discharge Summary for Patient #23 was not complete without being dated or signed by the authoring physician. She stated that the Discharge Summary for Patients #16, #39, and #40 had been dictated and signed by the physician but were not available previously because they had not been filed in the patients' medical records.

Based on observation and interview the facility failed to ensure the integrity, security and protection of all medical records by storing medical records in unlocked file storage in three locations (entrance to medical records, rehabilitation unit office, and a desk drawer in the speech pathologists office) of four locations observed. This failed practice placed medical records stored in these locations at risk for accessibility by unauthorized individuals. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Security of Medical Records," dated 12/2014, showed the patient's medical records shall be maintained to safeguard against loss, defacement, and tampering.

Record review of the facility's policy titled, "Medical Record Accessibility," dated 12/2014 showed:
- Medical records are under the surveillance of the Medical Record staff during working hours (Monday through Friday, 7:00 AM to 4:30 PM).
- Incomplete records for physician and nursing staff completion are housed in a file cabinet in the vestibule (room between the outer door and the interior of a building) of the Medical Records Department.
- Access to these records can be gained by keying the code numbers to the coded lock mounted on the door and entering the vestibule.

2. During concurrent observation and interview on 03/18/15 at 8:20 AM, showed an unlocked six drawer horizontal file cabinet in the entrance (vestibule) to the medical records department that contained approximately 30 medical records. Staff D, Health Information Management (HIM) Director, stated that the files were kept in the file cabinet so they were accessible to physicians after medical records working hours. She stated that the medical records vestibule was accessed either by using the coded lock on the door to the Medical Records Department or by entering the physician's lounge through the cafeteria and an unlocked door between the physician's lounge and the Medical Records vestibule. She stated that she did not know if the physicians' lounge was locked, who had access to the physician's lounge or when it was cleaned by housekeeping staff.

3. Observation of the physicians lounge on 03/18/15 at 8:30 AM showed the door from the physicians' lounge was locked on the vestibule side but could be opened from the lounge and the lounge was open to the cafeteria.

4. Observation of the Rehabilitation Building (a building adjacent to the hospital) on 03/18/15 at 8:45 AM showed the office of the Therapy (Physical and Occupational Therapy) Department was unlocked with no one in attendance. The room contained a five drawer file cabinet and a key was in the lock of the file cabinet. The file cabinet contained 12 patient records. Observation of the Speech Pathologists' (ST) office in the same building showed a desk drawer contained five current patient records with copies of the associated five discharge records from the facility. There was no lock on the desk drawer.

During concurrent interviews on 03/18/15 at 8:45 AM, Staff GG, ST, stated that the speech therapists kept patient records in an unlocked desk drawer in their office. Staff GG stated that she did not know when housekeeping cleaned the office but knew it was not during regular business hours when the therapists were working. Staff D, HIM Director, stated that she was not aware the patient records were kept in the Rehabilitation Department and that the records were not secured.

Based on interview, record review and policy review the facility failed to ensure all medical records were completed within 30 days of discharge for five (#21, #23, #39,#40, #41) of 10 discharged patient's records reviewed. This failed practice resulted in an incomplete medical record and impacted continuity of care and the safety and quality of care received by patients returning to the facility for care. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Completion of Medical Record," dated 12/2014, showed the following:
- Records of discharge patients shall be completed within thirty (30) days following discharge.
- A medical record shall be considered complete when the contents are assembled and authenticated.
- Complete record is defined as the transcription (a written or printed representation) of any dictated record content, authentication (signed by the author), and insertion into the medical record.
- All entries in the record must be timed, dated and authenticated and a method must be established to identify the authors of entries.

2. Record review of the medical record for Patient #21 showed he was discharged from the facility on 01/14/15. Review of the Discharge Summary showed it was dictated by the physician on 02/16/15 and transcribed on 02/17/15, 34 days following discharge.

3. Record review of the medical record for Patient #23 showed he was discharged from the facility on 01/26/15. Further review of the medical record showed no Discharge Summary. On 03/19/15 at 11:00 AM, a printed document was presented for inclusion in the medical record as the Discharge Summary. The document did not show a date of completion and had not been signed by the physician.

4. Record review of the medical record for Patient #39 showed he was discharged from the facility on 01/07/15. Review of the Discharge Summary showed it was dictated by the physician on 02/16/15 and transcribed on 02/17/15, 41 days after discharge

5. Record review of the medical record for Patient #40 showed the patient was discharged on 02/02/15. Further review showed no Discharge Summary as of 03/19/15.

6. Record review of the medical record for Patient #41 showed the patient was discharged on 02/16/15. Further record review showed no discharge summary as of 03/19/15.

During an interview on 03/16/15 at 1:45 PM, Staff D, Health Information Management (HIM) Director, stated that:
- Discharge summaries were to be completed within 30 days of patient discharge from the facility;
- Timely completion of Discharge Summaries was one of the QAPI (Quality Assurance Performance Improvement) indicators she had monitored for 2014 and continued for 2015;
- The Discharge Summary timely completion indicator had been carried over from 2014 due to continued non-compliance.
- The report for non-compliance with record completion was reported to the PI (Performance Improvement) Committee monthly and to the medical staff.

Based on observation, interview and record review the facility failed to ensure the therapeutic diet manual was available to nursing and dietary staff for use as a diet reference. This deficient practice had the potential to permit patients to be served unapproved therapeutic diets. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Diet Manual," reviewed 01/14/15, showed the approved therapeutic diet manual was maintained on the facility computer system and could be accessed by all nursing unit staff and by the Dietary department staff.

2. During an interview on 03/16/15 at 2:00 PM, Staff B, Registered Dietitian, confirmed that the facility diet manual was maintained on the facility computer system and was accessible by nursing staff and by Dietary department staff.

During an interview on 03/17/15 at 12:21 PM, on the psychiatry unit, Staff CC, Licensed Practical Nurse (LPN), stated she felt there was no facility diet manual and she could not tell where one would be kept.

3. During a concurrent observation and interview on 03/18/15 at 4:05 PM, on the medical/surgical unit, Staff S, Registered Nurse, stated that the diet manual was on the facility computer however, when asked to demonstrate access into the diet manual, she entered the name of a diet in the log in/password areas and could not successfully open the diet manual program.

During a concurrent observation and interview on 03/19/15 at 9:58 AM, in the facility kitchen, Staff HH, Cook, stated that:
- The diet manual was on the facility computer.
- She could not demonstrate access into it because the computer system was down.
- When the computer system was not working and Dietary department staff had to look up a special diet such as a renal diet (used for kidney disease), she had to wait until the computer department staff got the system working again.

Based on interview and record review the facility failed to ensure the Utilization Review (UR) Committee had at least two doctors of medicine or osteopathy appointed as members. This deficient practice had the potential to permit inappropriate or delayed review of Medicare, Medicaid or insurance company paid admissions to the facility. The facility census was 14.

Findings included:

1. Record review of the facility's undated UR Plan, provided during the survey, showed the following directives:
- The plan established a process for systematic review of the appropriateness of facility services provided to patients who were Medicaid or Medicare beneficiaries;
- The plan established a review process for identification of medical necessity for admission;
- The plan established a review process for the identification of the medical necessity of an extended stay (in the facility); and
- The plan identified that the UR committee membership was to consist of two physicians plus other appointed staff.

2. During an interview on 03/17/15 at 1:55 PM, Staff G, UR Coordinator, stated she had been the UR Coordinator and a member of the UR Committee for at least the last two years and in that period of time the UR Committee had not had two doctors as appointed members.

Based on observation and interview, the facility failed to maintain repairs to the building to prevent rainwater leaks through the roof into patient rooms and corridors on the 100, 200 and 300 units (three of three direct care wings), clean and soiled utility rooms, and the cafeteria. Wet, broken and stained ceiling tiles contradict staff attempts to maintain a clean environment and practice good infection control in patient living and patient treatment areas and directly impacts the health and well-being of the patient population. The facility census was 14.

Findings included:

1. Observation on 03/16/15 at 1:30 PM showed several ceiling tiles in the Ambulatory Surgical Unit were damaged with dark brown water stains the size of a dinner plate. Brown stains discolored the ceiling tiles of a semi-sterile area between the two operating rooms.

2. Observation on 3/16/15 at 1:40 PM showed a stained brown ceiling tile in the Emergency Room. During a concurrent interview Staff P, Registered Nurse (RN) stated that the ceiling leaked when it rained.

3. Observation on 03/16/15 at 2:30 PM in the medical-surgical 100 unit showed stained and damaged ceiling tiles in the corridor and patient rooms 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, and 117.

4. Observation on 03/16/15 at 2:55 PM in the 200 unit showed stained and damaged ceiling tiles in patient rooms 201, 203, 204, 205, 206, 207, 208, 210, 211, and 212. Wallpaper in the corridor was streaked and peeled from a water leak in the vicinity of rooms 208 and 210 and six corridor ceiling tiles were stained and one was missing. Dried water stains surrounded the air vent in the seclusion room. A ceiling tile in the corridor outside the seclusion room was stained. Stained tile and wall damage was observed in the Utilization Review office and in the center of the recreation room, just inside the security doors (south end) of the 200 corridor.

5. Observation on 03/17/15 at 8:45 AM in the 300 unit showed stained and damaged ceiling tiles in patient rooms 303, 307, 308, and 311. Observation showed water leaks stained seven suspended ceiling tiles in the 300 unit.

6. Observation on 03/16/15 at 3:00 PM in the cafeteria showed water stains on 30 ceiling tiles above the seating area and serving line where hot and cold foods were served at least twice a day. Five of the affected ceiling tiles were dark stained and bowed from being wet for extended periods of time. Several wastepaper baskets were arranged in a line below drain holes to catch the drips from holes that had been poked in the wet ceiling tiles.

7. Observation on 03/19/15 at 10:00 AM showed the cafeteria and serving line was closed due to water leaks and water on the floor.

During an interview on 03/16/15 at 2:00 PM Staff ZZ, Director of Maintenance, acknowledged the leaks. He stated that ceiling tiles damaged by leaks from rainwater could be observed all over the facility. He stated that everywhere there was a roof drain, the collars around the drains leaked and have caused water damage throughout the facility.



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Based on observations, interviews, record and policy reviews, the facility failed to ensure that:
- The Infection Control Program (ICP) included the identification, reporting, investigating and controlling infections and communicable diseases (disease transmitted from one person to another; also called contagious disease) of contracted staff and volunteers (Auxiliary).
- The ICP identified staff at risk for exposure to respiratory infections (infectious diseases involving the respiratory tract or breathing) and provided respiratory fit testing (a test protocol conducted to verify that a respirator/face mask is both comfortable and correctly fits the user) at regular intervals.
- Wall and floor surfaces of soiled utility rooms present smooth, non-porous surfaces where soils and spills may be efficiently removed and the area easily sanitized.
- Staff maintained patient mattress surfaces free from tears to allow proper cleaning for 12 of 22 mattresses observed.
These failures had the potential to place all patients, visitors and staff at risk for exposure to communicable diseases and infections. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "Infection Control Program", dated 11/2013 showed the mission of the Infection Control Program is to provide a safe environment and minimize the risk of infection to patients, personnel, and the public through comprehensive and multifaceted efforts. The ultimate goal from these efforts is to identify and reduce the risk of acquiring and transmitting infection. The goals and objectives were:
- To develop a consistent and reliable means of surveillance and documentation of healthcare associated infections by collecting accurate, valid and reliable data.
- To reduce the frequency and severity of healthcare associated infections (HAI, any infection acquired by a patient as a consequence of a healthcare intervention or which is acquired by a healthcare worker in the course of his or her duties) Surveillance through recognition and containment of infections and communicable diseases;
- Limiting unprotected exposure to pathogens (an agent that causes disease) throughout the hospital.

Record review of the facility's policy titled, "Healthcare Associate Infection Program," dated 04/2013, showed surveillance activities may include but not be limited to surveillance rounds which will include housekeeping activities and evaluation of any employee with an apparent infection or returning to work after an infectious condition.

2. During concurrent interviews on 03/18/15 at 2:00 PM, Staff RR, Employee Health Supervisor stated that:
- A communicable disease screening was performed for all new staff that included MMR (measles, an infectious viral disease causing fever and a red rash on the skin; mumps, a contagious and infectious viral disease causing swelling of the salivary glands in the face, and a risk of sterility in adult males; and Rubella, a highly contagious viral disease, spread through contact with discharges from the nose and throat of an infected person), Hepatitis B (a severe form of viral liver infection transmitted in infected blood), Tetanus (a bacterial disease marked by rigidity and spasms of the voluntary muscles) and tuberculosis (TB, a potentially serious infectious disease that mainly affects the lungs).
- The facility did not complete a health assessment or TB screening for contract staff or volunteers with patient contact.
- All staff was required to have an influenza vaccine annually and to wear a mask if they were unable to take the vaccine.
- The facility had not verified influenza vaccine or offered influenza vaccine for contract staff or volunteers.
Staff LL stated that the Infection Control (IC) Program did not include surveillance for infectious disease or monitoring of compliance with the IC Program policies and procedures for contract staff or for volunteers.

Staff LL, Infection Control Coordinator stated that the facility had not performed a risk assessment to determine staff at risk for exposure to respiratory infections. Staff RR, Employee Health Supervisor stated that the facility had not developed policies for screening staff for risk of exposure to respiratory infections or for providing respiratory fit testing at regular intervals.

During an interview on 03/19/15 at 10:30 AM, Staff TT, Volunteer, stated that there were 68 volunteers who took turns working in the gift shop and one of their duties was to go to the Outpatient waiting room to hand out magazines.

3. Observation on 03/16/15, at 2:10 PM showed a carpeted floor in Soiled Utility Room 102, where soiled bed linen and trash are temporarily held and soiled bedpans are emptied and washed out. The blue carpet was marked with wheel tracks and soiled with white lint and dark patches of unidentifiable residue. Carpeted floor surfaces require increased maintenance, frequency of cleaning and use with care. They are not conducive to keeping a sanitary environment because they do not present a smooth, non-porous surface where soils and spills may be efficiently removed and the area easily sanitized.

During an interview on 03/16/15 at 2:10 PM, Staff ZZ, Director of Maintenance, acknowledged the finding.

4. Observation on 03/16/15 at 2:40 PM showed dried blood on the right hand rail and bed frame and a tear approximately one/half inch long with tape residue on the mattress in bed #4 of the Emergency Room.

During a concurrent interview, Staff P, Registered Nurse (RN) stated that either the Emergency Room tech or the nurse would clean the mattress and bed after each patient. She stated that the mattress should have been removed from patient use.

5. Observation on 03/19/15 at 9:25 AM showed tears on both sides of bed mattresses in nine patient rooms #204, #205, #206, #208, #211, #306, #307, #309, and #311 of 19 mattresses in the rooms on the Behavioral Health Unit.

During an interview on 03/19/15 at 9:45 AM, Staff G, RN, Department Manager, stated that nursing should have reported the torn mattresses to the plant manager. Staff G stated that she could not find a policy or procedure for the responsibility of cleaning and reporting of mattresses.

6. Observation on 03/17/15 at 8:55 AM showed tears on both sides of two bed mattresses in patient rooms #110 and #111 on the medical surgical patient care unit.

During an interview on 05/19/15 at 8:45 AM, Staff E, Chief Operating Officer (COO)/Chief Nursing Officer (CNO), stated that when items were in need of repair or replacement, like torn mattresses, a report of the problem was generated on the electronic medical record (EMR) and ultimately a purchase order would be completed. Staff E stated he had not received any purchase orders for any mattresses.

Surveyor: Pritchard, Thomas L


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Based on record review and interview the Chief Executive Officer (CEO), Medical Staff and Director of Nursing Services failed to ensure that the hospital wide Quality Assessment and Performance Improvement (QAPI) for the Infection Control Program (ICP), addressed problems identified by the Infection Prevention and Control Annual Review and included evidence that the data collected was compared to performance benchmarks, identified which departments needed improvement and failed to implement sustainable interventions. The facility census was 14.

Findings included:

1. Record review of the facility's document titled, "2014 Infection Prevention and Control Annual Report," showed the following recommendations for 2015:
-Continue to monitor employee health, exposure risks and safer sharps devices;
-Develop an Antibiotic Stewardship program along with the pharmacy with the purpose to improve antibiotic usage;
-Incorporate environmental rounds (a check for cleanliness and adherence to infection control policies and procedures) into the Infection Control program;
-Stay current with the infection control regulations and conditions of participation through on-going education.

2. Record review of the facility's document titled, "ICP 2015 Performance Improvement Plan", undated, showed the focus on improvement was to stay current with national reporting rules. The plan showed the following improvement activities would be conducted for 2015:
- Continue with required reporting;
- Healthcare Associated Infections (HAI, infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting).
- MDRO's (Multidrug-resistant organisms, are bacteria that have become resistant to certain antibiotics);
-Hand hygiene surveillance; and
-Blood culture contamination rates.
The plan did not include established performance benchmarks or development and implementation of interventions to improve patient outcomes.

3. Record review of the facility's document titled, "Performance Improvement," dated 2015, showed the following QAPI indicators for the ICP for 2015:
- Hospital associated infections/ Personnel influenza vaccine;
- Monitor blood culture contamination rate;
- Monitor hand hygiene compliance; and
- Continue monitoring for HAI, MRSA (Methicillin, an antibiotic, resistant Staphylococcus aureus, a bacteria that causes infections in different parts of the body and more difficult to treat than most strains of staphylococcus aureus [aka staph] because it is resistant to some commonly used antibiotics), reportable diseases and isolation.

The facility Performance Improvement Plan did not include monitoring employee health, antibiotic stewardship or environmental rounding for IC.

During an interview on 03/18/15 at 2:00, Staff LL, Infection Control Coordinator, stated that
- There were no new indicators identified specific for Infection Control's 2015 QAPI;
- The IC Committee had discussed the need to incorporate Infection Control Surveillance beyond hand hygiene (the use of an alcohol based hand sanitizer or soap and water to clean hands) to include environmental rounds of the facility.
- Pharmacy had developed an antibiotic stewardship program but it was not a part of the IC QAPI plan.
- Environment rounds had not been implemented.
- The IC Committee prepared a report for the PI (Performance Improvement) Committee but did not receive feedback regarding the data submitted, improvements needed or necessary interventions.