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A. Based on interview, document review, and policy review, the provider failed to:
*Develop and implement a hospital wide comprehensive infection control program.
*Provide appropriate training for the infection control coordinator (ICC).
Findings include:

1. Interview on 5/4/16 at 8:30 a.m. with the ICC and the director of nursing consultant regarding the infection control program revealed they:
*Had no method of surveillance of infections of patients or employees.
*Had no process for tracking and trending of infections in the facility.
*Had not tracked surgical site infections and were unsure how to do so.
*Were made aware of one surgical site infection one week ago.
*Had not performed competencies on staff regarding infection control practices in the facility.
*Had no audits documented having been performed prior to the survey by the ICC.
*Had plans to begin audits in the future.
*Agreed the ICC needed additional training. She had two and one-half days shadowing another ICC in the approximately one and one-half years she had been in her position.
*Agreed the infection control program was not able to accurately monitor infections to resolution in the facility.
*Agreed there would be no way of knowing if there were:
-A large number of infections by employees, patients, and devices.
-Various types of infection without using data to analyze them.
-Surgical site infections and the root of those infections.
*Agreed the infection control program needed to report surveillance data to the quality assurance committee and the leadership committee.

Review of the provider's 2016 Infection Prevention Plan document revealed:
*Its purpose was to provide a safe environment for patients and employees.
*Its ongoing monitoring and reporting was to ensure it met state and federal regulations and standards.
*The ICC qualifications were:
-"Willingness to obtain proficiency in microbiology, asepsis, disinfection/sterilization, adult education, employee health practices, infectious diseases and epidemiology."
-"Obtains current ongoing education in infection prevention to ensure program is current."
-"Job description for role is maintained and updated as needed."
-"Competency within the role is assessed annually."
*Priority services of the infection prevention program were:
-Surveillance data was to be reviewed daily to prevent the spread of infection.
-The infection prevention committee was responsible for ensuring compliance.
*That plan had an attached agenda for audits they were planning on implementing in the future.

Interview on 5/4/16 at 2:00 p.m. with the surgery supervisor revealed she was unsure how to perform surveillance on surgical site infections.

Review of the provider's 2004 Establishing Infection Control policy revealed:
*Its purpose was to establish written infection control policies and review or revise those policies every two years or as needed.
*Department heads were to have devised written policies with the ICC covering prevention, surveillance, and control of infection.
*Administrative standard operating procedures were to have been developed by infection control per request of the infection control committee for practices, procedures, and illnesses of significant risk for transmission of disease or illness.
*Policies and procedures were to be researched using current published references and literature review.
*The infection control committee was to have scheduled a review of all policies every two years or as needed.
*The last review/revised date listed on that policy was 2009.



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B. Based on observation, interview, and manufacturer's guidelines review, the provider failed to clean and disinfect one of one whirlpool tub as recommended. Findings include:

1. Observation on 5/3/16 at 9:45 a.m. of certified nursing assistant (CNA) C (a temporary assistant) cleaning a whirlpool tub after giving a tub bath revealed she:
*Placed the tub chair into the tub and closed the door.
*Turned the selector knob to disinfectant.
*Filled the tub well to just over the top of the foot well.
*Added shampoo/soap from the tub selector to a Johnny mop (short-handled scrubbing tool) and began scrubbing all surfaces of the tub, and the top and back of the chair. She dipped the mop into the disinfectant as she scrubbed. She did not remove the chair seat to clean under the seat.
*Scrubbed the gel seat cushion.
*Turned on the spray jets to clean the jets.
*Stated she would leave the disinfectant on the tub surfaces for ten minutes.
*Emptied the tub.
*Turned the selector knob to tub cleaner and sprayed the tub and seat down using the cleaner through the shower head.
*Opened the tub door and allowed the tub to dry.

Review of the provider's undated Apollo Bath Cleaning Process and Bath Disinfecting process attached to the wall of the bathing room revealed the tub and chair cleaning process:
*Place the chair in the tub and close the door.
*Turn the blower on.
*Turn the selector knob to tub cleaner.
*Lift the seat bottom off chair.
*Use the cleaning solution to scrub the tub, chair, and underneath the bottom.
*Open the drain and turn the blower on.
*Turn the selector knob to rinse and control knob to on.
*When clear water comes out of all outlets turn the control button off.
*Leave the blower on for sixty seconds to force water out of the air lines.
*Use the shower wand to rinse the tub and chair.

The disinfection process according to the above policy was to have continued after the cleaning process as follows:
*Place the tub chair in the tub and close the door.
*Turn the blower on.
*Turn selector knob to disinfect.
*Lift seat bottom of chair.
*Use disinfecting solution to scrub the tub, chair, and the underneath seat bottom.
*Leave wet for ten minutes then open the drain and turn the blower on.
*Turn the selector to rinse and control knob to on.
*Turn the control knob off when clear water comes out of all outlets.
*Leave the blower on for sixty seconds to force the water out of the air lines.
*Use the shower wand to rinse the tub and chair.

Interview on 5/4/16 at 8:30 a.m. with the ICC revealed she agreed:
*CNA C had not followed the manufacturer's guidelines for cleaning and disinfecting the tub and chair.
*She had disinfected the tub before cleaning it.
*She used a cleaner to rinse the tub.
*The provider used the manufacturer's guidelines for their policy on tub cleaning.

When asked in the above interview how the staff were trained on how to clean the tub the ICC stated:
*The nursing assistants trained new employees on the floor when they began working.
*There was no formal training on tub disinfection.

Based on observation, interview, and policy review, the provider failed to have a system to secure narcotic medication from unauthorized access in one of one operating room, one of one emergency room (ER), and one of one recycling room while awaiting disposal. Findings include:

1. Observation on 5/3/16 at 10:53 a.m. in the operating room revealed:
*The red sharps containers (bin for used needles and syringes) used by anesthesia to place used narcotic pain medication syringes in was not secured to the anesthesia cart.
-It was able to be removed at will from the cart.
*On the floor was a black sharps container.
-In that container were discarded vials of narcotic medication.
-That sharps container was not secured in any way.
*The operating room was not locked or secured from unauthorized access when not in use.

Interview on 5/3/16 at 1:45 p.m. with registered nurse (RN) A in the ER revealed:
*ER nursing staff disposed of used narcotic pain patches in the red wall mounted sharps containers.
*Those sharps containers were kept in a locked container mounted to the wall.
*Housekeeping staff replaced the container when it was full.
*The full container was taken by housekeeping staff down to the locked recycling room.
*The recycling room had an access door with a large window that opened immediately to the outside.

Observation and interview on 5/4/16 at 9:45 a.m. with the chief nursing officer and the pharmacist regarding the narcotic pain patch storage observations above revealed:
*They were unaware nursing staff were placing the narcotic pain patches in the sharps containers.
*Unlicensed personnel had access to the recycling room and the sharps containers.
*They agreed the potential for diversion was high given:
-The amount of staff that had access to the sharps containers and the recycling room.
-There was an unmonitored, unsecured exit door in the recycling room.
-There was no security for the narcotic medication in the recycling room.

Review of the provider's revised August 2015 Handling of Controlled Substances policy revealed:
*Used narcotic patches were to be flushed down the toilet and destroyed in the presence of a witness.
*There was no mention of diversion prevention.
*There was no mention of narcotic medication awaiting disposal or transport of narcotic medication or access to those medications.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of one sampled patient (3) received necessary rehabilitative services while a patient. Findings include:

1. Observation on 5/3/16 at 9:00 a.m. of patient 3 with registered nurse (RN) B revealed:
*She was alert and able to speak, but her speech was difficult to understand.
*She acknowledged she had pain and was sore in her abdomen.
-The RN reminded her she had a gastrostomy tube (feeding tube going into the stomach) placed the day before. She offered her some pain medication that the patient accepted.
*She was also given an oral medication in applesauce.
*She had difficulty swallowing the pill and requested more applesauce to get it down.
-Her daughter who was present said repeatedly, "Tuck your chin mom when you swallow."
*She was coughing large amounts of phlegm (mucous) and had a gag-like sound when she coughed.

Interview on 5/3/16 at 4:00 p.m. with the director of rehabilitation services revealed:
*She was a physical therapist.
*They also offered occupational therapy (OT), but they contracted with an agency for that service.
*They had a contracted speech therapist (ST), but she only provided outpatient services to the hospital.
*ST was not available to the patients in the hospital.

Interview on 5/4/16 at 10:00 a.m. with patient 3's daughter revealed:
*Her mom had been admitted on 4/29/16.
*She had noted her mom was more difficult to understand when she spoke, and she had increased difficulty swallowing.

Review of patient 3's 4/29/16 history and physical revealed:
*She had been brought into the emergency room complaining of left facial droop, and she was choking on her food at lunch that day.
*She was coughing.
*She was having speech difficulty.
*Her admission diagnoses included:
-Aspiration pneumonia (caused when food or saliva is breathed into the lungs).
-Cerebrovascular accident (stroke).
-Dysphagia (difficulty swallowing).

Interview on 5/4/16 at 8:30 a.m. with the chief nursing officer (CNO) regarding patient 3 revealed:
*They had a contract with a ST, but there were no ST services offered to inpatients.
*When they had a patient that needed ST they sent them to another facility that offered that service.
*If she got a referral for a patient who might need ST they would not admit them.
-They would have them go to a facility that provided ST.
*ST had not been offered to this patient, because it was not available.
*She was unsure if they had completed a swallow study on her or who would do that.
-She wondered if a dietitian would have done that.

Interview on 5/4/16 at 9:00 a.m. with the director of rehabilitation regarding patient 3 revealed:
*She had reviewed the history and physical completed by the physician on 4/29/16.
*She would have recommended ST if it had been available, but it was not.

Further interview on 5/4/16 at 2:30 p.m. with the CNO regarding patient 3 revealed:
*A swallow study had not been completed.
*Their dietitian did not do them.

Review of the provider's 4/24/12 ST contract revealed:
*ST obligations were: "To provide ST services to the Leasor to include consultation, evaluation, diagnosis, treatment, documentation by written progress notes, research, planning, instruction to Leasor personnel and review of Leasor's patient care policies for patients presented for ST services."
*"Compliance with local, state, and federal laws."

Review of the provider's 11/3/15 Bedside Swallow Evaluation/Dysphasia Evaluation revealed "Patients who present with symptoms of dysphagia will be evaluated by Speech Language Pathologist."

Based on patient care record review, interview, and Swing Bed Guide review, the provider failed to ensure four of five sampled swing bed patients (7, 23, 24, and 25) had an activity assessment completed by a qualified activity director. Findings include:

1. Review of patients 7, 23, 24, and 25's care records revealed there had not been an activity assessment completed nor was there evidence that individual and group activities had been planned for them.

Interview on 5/3/16 at 2:00 p.m. with the chief nursing officer revealed:
*They used the activity director at the adjoining skilled nursing facility (SNF) to oversee the activity program for patients in the swing bed program.
-She was a certified occupational therapy assistant (COTA) and qualified activity director.
*When a patient was admitted the nurses completed an activity screen on them.
-They had not done an assessment on the patients.
*She confirmed some of the swing bed patients had been there for over thirty days.
*They always posted the activity calendar for the nursing home on the wall of each hospital room, and patients could have attended those if they desired.

Interview on 5/4/16 at 9:30 a.m. with the above referenced COTA at the adjoining SNF revealed:
*She was the activity director at the nursing home.
*She had been in that position for about four years.
*She had no oversight of the activity program in the hospital.
*Once in awhile the nurses in the hospital asked her for activity supplies for a patient.
*She had recently been asked to see a patient who had been there for four to five weeks, because the nurses thought he was bored.
*She had no idea patients might be in the hospital that long and felt bad they might not have had any activity.
*Prior to her taking this position she had worked in therapy and recalled the activity director from the SNF coming into the hospital to see the patients.
*Doing activity assessments in the hospital and planning activities for those swing bed patients had never been part of her responsibility.

Review of the provider's 2011 A Guide for Swing Bed Patients revealed "The activity staff is responsible to develop plans for independent and group activities for you while you are a swing bed patient. This plan may include participation in activities at Winner Regional Healthcare Center which has scheduled activities 7 days a week, or independent activities in your hospital room."