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Based on observation, interview, and record review, the hospital failed to ensure patient care and health information management services were provided in accordance with State laws and regulations as evidenced by:


1. Failure to comply with California Code of Regulations (CCR), Title 22, Sections 70707, 70707.1, 70707.3 and 70707.4 by failing to ensure that for each patient undergoing surgical sterilization, prior to commencing surgery, the surgeon had obtained and properly documented informed consent for sterilization using a special state form. (Patient 5)

2. Failure to comply with CCR, Title 22, Sections 70223 (d) by failing to ensure that for five of six sampled surgical patients undergoing surgery, prior to commencing surgery, the anesthetist or the surgeon had verified a qualified medical history and physical examination, appropriate screening tests and informed consent were properly documented and in the patients' medical record. (Patients 1-5)

3. Failure to obtain California Department of Public Health, Licensing and Certification (CDPH L&C) approval to use an alternate method for the supervision of medical records service.

These failures had the potential for unsafe patient care.

Findings:

1. On 4/9/13, Patient 5's record was reviewed. Patient 5 was admitted to the hospital on 6/15/12 and underwent an outpatient surgical sterilization procedure. This type of surgery requires a special consent form that must be completed in accordance with California Code of Regulations (CCR), Title 22, Sections 70707, 70707.1, 70707.3 and 70707.4.

Section 70707.4(c)(1-4) read, "The physician performing sterilization, or an alternate physician shall certify, by signing the Consent Form, that:
(1) The physician or alternate physician, shortly before the performance of sterilization, advised the individual to be sterilized that federal benefits shall not be withheld or withdrawn because of a decision to be sterilized.
(2) The physician or an alternate physician explained orally the requirements for informed consent as set forth on the Consent form.
(3) To the best of the physician's or alternate physician's knowledge or belief, the individual to be sterilized appeared to knowingly and voluntarily consent to be sterilized.
(4) At least 30 days have passed between the date of the individual's signature on the Consent form and the date upon which the sterilization was performed..."

The consent form in Patient 5's medical record was not completed in accordance with section 70707.4(c). The physician did sign the form, but failed to provide any information other than his signature in the "Physician's Statement" section. Without the additional information that was intended to be filled into the empty form spaces, the physician's signature does not certify that Patient 5 received the necessary information required by this section of the regulation.

On 4/9/13 at 3:30 pm, the Surgical Coordinator reviewed Patient 5's record and acknowledged that the consent was not complete.




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2. Section 70223(d) of CCR, Title 22 requires that "prior to commencing surgery the person responsible for administering anesthesia, or the surgeon if a general anesthetic is not to be administered, shall verify ... ascertain that a record of the following appears in the patient's medical record: (1) An interval medical history and physical examination performed and recorded within the previous 24 hours. (2) Appropriate screening tests, based on the needs of the patient, accomplished and recorded within 72 hours prior to surgery. (3) An informed consent, in writing, for the contemplated surgical procedure."

For five of 28 records reviewed (Patients 1, 2, 3, 4 & 5) the records lack evidence that the anesthetist and/or surgeon had ensured the records contained all of these documents before the surgical procedure. Each of these five records lack one or more of the three required documents. (Refer to C320 and C322 for completed details for each patient.)



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3. California Code of Regulations Title 22 Section 70747(b) stipulates: "The medical records service shall be under the supervision of a registered records administrator or accredited records technician...." (Note: these titles are now known as a registered health information administrator/technician.)

Health Information Management Staff D, the director of the medical records service, stated during an interview on 4/9/13 at 2:35 pm, that she does not have one of these above-stated credentials; therefore the facility had contracted with a credentialed person since 1996. The agreement with this consultant was reviewed on 4/10/13. The facility was unable to produce a letter of approval from CDPH L&C to allow for the use of a consultant to supervise the medical records service. This fact was confirmed during an interview with Chief Operating Officer on 4/10/13 at 2:05 pm.

Based on observation and interview, the facility failed to ensure that the clinical laboratory (lab) was kept in a clean and orderly fashion. This failure has the potential to result in inaccurate tests, contamination of supplies, and the cross-contamination which could cause infection.

Findings:

On 4/10/13 at 2 pm, the lab was toured. The patient draw (front) area had a sink, under which was stored blood draw supplies. Sinks can easily leak and go undetected. which could result in a contamination of patient care supplies.

The middle room and back room of the lab were cluttered with lab supplies and paperwork. Several windows were open, allowing dust from nearby fields to enter. There was a thick layer of dust over the countertops and shelves.

Boxes of lab supplies were stored on the floor in both the middle and back rooms of the lab.

The refrigerator holding lab supplies and media for cultures was not clean. Dirt and spills were evident on the flat surfaces and the shelves had rusted areas. Rust erodes the cleanable surface allowing for contamination and is unable to be sanitized.

On 4/11/13 at 9 am, Lab Manager (LM) toured the lab and reviewed the above findings. LM acknowledged the lab was disorganized, cluttered, and unsanitary. LM confirmed that there was no program for cleaning the lab.

On 4/10/13 at 4:15 pm, the Chief Operating Officer (COO) toured the lab and reviewed the above findings. COO stated he was aware of problems with the lab and had recently (within the last 2 weeks) hired a new person for the LM position. COO acknowledged the above findings of a disorganized and unsanitary lab environment.

Based on food storage observations, dietary staff interview, and document review, the hospital failed to ensure: 1) the required food supplies planned for use in a disaster were adequate to meet the hospital developed plan; and 2) the facility failed to ensure the existing emergency plan for the provision of food during a disaster included appropriate food recommendations for patients prescribed puree diets. Failure to ensure a planned, comprehensive, disaster menu would put medically frail patients at risk in the event of a disaster that required the hospital to shelter in place.

Findings:

1. During review of disaster meal planning on 4/8/13 beginning at 2:05 pm, it was noted that the plan was for 199 patients and staff for three days. A random comparison of the hospital developed inventory and available food supplies revealed there was inadequate supplies of canned tuna and nonfat dried milk. It was noted that the hospital was to have six- five pound bags of nonfat dried milk on hand and there was only four bags present. The plan did not state how much inventory of the other food items there was supposed to be at the hospital. There were four pouches and 10- six ounce cans of tuna which would be enough for 59 serving. The plan was for a one day menu to be repeated for three days. Therefore, they needed approximately 597 servings for the three days. In a concurrent interview with the Dietary Service Manager (DSM), she stated she was not sure how much inventory was needed for the disaster plan but she thought her par level should be what was needed for a disaster.

2. On 4/8/13, at 2:05 pm, during an inspection of the disaster food supply, it was noted that peanut butter was planned to be served to patients prescribed puree diets, each day at breakfast, for three days.

Review of the diet manual for the dysphagia puree (Level 1) diet indicated under additional guidelines for the puree diet to avoid peanut butter unless part of a complete pureed recipe that is easy to swallow. There was no recipe in the disaster plan for any peanut butter.

On 4/10/13 at approximately 11:30 am, an interview was conducted with the Registered Dietitian (RD). The RD stated she thought peanut butter would be okay but would need to be applesauce consistency. The surveyor informed the RD of what was in the hospital diet manual.

Based on document review and staff interview, the governing body (Board of Directors) failed to ensure that the medical staff Bylaws, Rules and Regulations and Administrative Policies were implemented so as to ensure that quality health care was provided in a safe manner. This failure permitted the hospital to operate without functional safeguards designed to ensure quality health care in a safe environment, and could contribute to patient harm.

Findings:

The facility's Medical Staff Rules under Section 7.3-4 (c) read as follows, "The hospital maintains a pharmaceutical formulary regularly reviewed and approved by the medical staff. Additions and deletions to the formulary are approved by the medical staff through the P&T (Pharmacy and Therapeutics) Committee. Physicians are expected to utilize formulary products whenever possible." It read as follows under Appendix 4H, "Duties of the Pharmacy and Therapeutics Committee shall be to develop, implement and monitor professional policies regarding evaluation, selection, and procurement of drugs comprising the hospital formulary."

A review of the hospital formulary disclosed that it did not contain Zofran (used for nausea and vomiting), a medication that was observed given to Patient 6 on 4/9/13. According to the formulary Droperidol was available for use. This was a medication that the FDA had issued a "Black Box Warning" (use with extreme caution).

During an interview on 4/11/13 at 10:30 am, the Pharmacy Nurse (Pharm Nurse) stated that she was part of the P&T Committee but did not know how long it had been since the entire formulary had been reviewed. She confirmed that Droperidol had been pulled from hospital stock about two years ago and stated that Zofran had been used at the facility for about a year. The Pharm Nurse confirmed that the formulary had not been updated to add Zofran and delete Droperidol from their list of medications.

Based on staff interview and document review, the hospital had not established a committee that included both physicians and Allied Health Practitioners (AHP) (physician assistant, nurse practitioner, or clinical nurse specialists) in order to develop, execute or periodically review written policies governing the services furnished in the hospital.

Findings:

On 4/8/13 the hospital was asked for the minutes of the Inter-Disciplinary Practices Committee (IDPC) or any other similar meetings where physicians and AHP had met to develop, consider or review hospital policies. Initially the hospital could not document any IDPC meetings. On 4/9/13 at 12:30 pm in a meeting with the Chief Executive Officer (CEO), the Chief Operations Officer (COO), the Chief of the Medical Staff (COS, Chief of Staff) and another Medical Staff Member (MSM7), those present acknowledged that the hospital had not, within in the past several years, had joint meetings of AHP & MS members where policies were reviewed or considered.

On 4/10/13 the Medical Staff Coordinator (MSC: Admin Staff A) presented minutes showing that a meeting of a IDPC had occurred once in 2012 and once in 2011, however neither meeting contained the full complement of members required by Medical Staff Rules - Page 44, Rule 4.1, Appendix 4F - "Interdisciplinary Practice Committee," and CCR, Title 22, Section 70706. Specifically, there were no AHP or nursing staff members present. Nor did either of those meetings address hospital policies or procedures.

Based on staff interview and document review, the hospital failed to ensure that its physicians and allied health practitioners (AHP) participated together in periodically reviewing patients' health records and documenting that such reviews had taken place. This resulted in inadequate documentation of the midlevel practitioners' supervision. Inadequate supervision could lead to poor medical outcomes.

Findings:

On 4/8/13 the hospital was asked to provide documentation that physicians and the midlevel practitioners (physician assistants and/or nurse practitioners) were periodically meeting together to review patients' health records.

On 4/9/13 at 12:30 pm, in a meeting with the Chief Executive Officer (CEO), the Chief Operations Officer (COO), the Chief of the Medical Staff (COS, Chief of Staff) and another Medical Staff Member (MSM7) there was consensus that the hospital and clinic did not currently have a formal system in place to assure that at least five percent (5%) of the medical records for care provided by the Physician Assistant (PA) had been reviewed.

California law: Business and Professions Code 3502 (c)(2) requires that "The supervising physician shall review, countersign, and date a sample consisting of, at a minimum 5 percent of the medical records of patients treated by the physician assistant." The two Medical Staff (MS) members and two administrative officers acknowledged that the hospital did not currently have documentation of such a review. They asserted the Physician Assistant (PA-1) was actively supervised in the clinic on a daily basis and that they had maintained documentation of the supervision. However, they did not have a protocol to assure at least 5% of charts were jointly reviewed and signed by the physician and that a record of that review had been documented.

Based on observation, interview, and record review, the hospital failed to ensure that the provision of services was done in a safe manner, as evidenced by:

1. Failure to ensure the emergency department and clinic policies were developed and reviewed annually. (Refer to C 272)

2. Failure to ensure that a pharmacist was able to perform first dose medication review. (Refer to C 276, item 1)

3. Failure to ensure that the contents of the emergency drug supply located in the radiology department were check daily for security and expired medications. (Refer to C 276, item 2)

4. Failure to ensure that infection control policies were followed. (Refer to C 278, items 1-5)

5. Failure to ensure safe food handling practices. (Refer to C 279, item 4)

6. Failure to ensure the nutritional needs of the patients were met. (Refer to C 279, items 2,3,5 and 6)

7. Failure to to have physician's orders for nutritional supplements. (Refer to C 279, item 5)

8. Failure to to address the dietary educational needs of a diabetic patient. (Refer to C 279, item 7)

9. Failure to have a contract for services provided by an outside transcription service. (Refer to 285)

10. Failure to maintain a complete list of all services provided by contracts, arrangements or agreements, and have the scope and nature of the contracted services listed. (Refer to C 291)

11. Failure to meet the patients nursing needs. (Refer to C 294, items 1, 3, 4, 5 and 6)

12. Failure to properly document verbal physicians' orders. (Refer to C 294, item 2)

13. Failure to review all nursing staff at least annually for competency. (Refer to C 295)

13. Failure to accurately administer medications. (Refer to C 297, items 1-5)

14. Failure to provide care plans specific to the patient problems, planned outcomes, and interventions. (Refer to C 298 items 1-5)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of services were in compliance with the statutorily mandated Condition of Participation: Provision of Services.

Based on interview and record review, the hospital failed to ensure that emergency department and clinic policies were developed and reviewed annually; and that there was a clinic policy that directed clinic staff how to intervene in case of a medical emergency. This failure had the potential to result in unsafe care.

Findings:

The facility policy, "Policy and Procedure/Forms Writing," last reviewed 3/2012, indicated that the Department Manager was responsible for the annual review of their Policy and Procedure (P&P) Manual. The policy further indicated that policies would be forwarded to the Policy Committee followed by the Medical Staff Committee, then forwarded to the Board of Directors for final approval.

1. A review of the Emergency Department (ED) P&P Manual disclosed a cover sheet that listed an approval date of 4/13/10 for the Chief Nursing Officer (CNO), Chief Executive Officer (CEO), ED Director, and Chief of Staff, and an approval date of 6/22/10, for the Chair of the Governing Board.

During an interview on 4/9/13 at 4:50 pm, the CNO confirmed the above dates and stated that the ED P&P Manual was out of date.

2 a. A review of the Clinic P&P Manual disclosed a cover sheet that listed an approval date of 4/27/11 for the CNO, CEO, Medical Director, and Chief of Staff, and an approval date of 5/18/11, for the Chair of the Governing Board.

During an interview on 4/11/13 at 10:40 am, the CNO confirmed the above dates and that the Clinic P&P Manual was out of date.

b. During an interview on 4/9/13 at 2:10 pm, Licensed Vocational Nurse (LVN) 1 stated that in case of an emergency such as a respiratory arrest, clinic staff would begin CPR and call 911.

A policy regarding medical emergencies for the clinic was requested from the CNO. During an interview on 4/10/13 at 4:50 pm, the CNO confirmed there was no such policy.

Based on observation, interview, and record review, the facility failed to ensure that a pharmacist was able to perform first dose review for one of 28 sampled patients, and that emergency drugs were checked for security and expiration dates in the radiology department. These failures had the potential for unsafe medication administration and lack of appropriate medication availability in the event of an emergency.

Findings:

1. On 4/8/13 at 8 am, Nurse Manager (NM) 1 was asked how the pharmacist provides first dose review to check for drug allergies, interactions, duplications, and appropriateness of drug, dose, route, and diagnosis. NM 1 stated that all medication orders are faxed to the pharmacist for review and the pharmacist calls back to the nursing station for any concerns. The pharmacist provides a report if problems are identified. It is assumed, by the absence of a report, that the medication(s) have been reviewed by the pharmacist and that it is safe to administer the medication(s) to the patient.

On 4/8/13, Patient 28's record was reviewed. Patient 28 was admitted on 4/5/13 with diagnoses that included chest pain and lung disease. Patient 28's record indicated that two new medications (Septra - antibiotic, and Isosorbide mononitrate - chest pain medication) were ordered, and one medication (Kayexalate- removes excess potassium from blood) was discontinued on 4/8/13. Patient 28's record did not contain evidence that these physician's orders were faxed to the pharmacist on 4/8/13.

On 4/8/13 at 8 am, NM 1 reviewed the above orders and acknowledged that the pharmacist was not informed of Patient 28's medication changes above, and therefore could not conduct a first dose review for patient safety.

2. On 4/11/13 at 8:10 am, during a tour of the Radiology department, an emergency drug box was observed. Hanging on the cupboard where the drug box was located, was a Crash Cart Check Sheet log that indicated the emergency drug box was to be checked daily to ensure that there were no expired medications and the lock was secure. The log showed that the emergency drug box had been checked twice since 1/24/13, (two out of 75 days or 3 percent compliance.)

During a concurrent interview, the Radiology Manager (RM) acknowledged that the emergency drug box was to be checked daily and that this had not been done.

Based on observation, interviews, and document review, the facility did not develop an effective system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by failure to ensure:

1. That the hospital's policy for changing one of 28 sampled patient's gown without interrupting the flow of intravenous (IV) fluids was followed (Patient 6);

2. That the hospital's policy for cleaning the autoclave matched the protocol that was followed in the clinic;

3. That annual infection control in-services were given to all nursing staff as required;

4. That the urinary catheter collection bag (a urine drainage system consisting of a sterile tube that is placed in the bladder and remains there to continually drain urine into a collection bag) for one of 28 sampled patients was kept off the floor (Patient 6);

5. That the hospital's policy regarding annual TB (tuberculosis) skin tests was followed for four of nine sampled staff ;

6. That there was adequate disinfection of the x-ray table and that disinfectant wipes were readily available for staff use.

The failure to implement an effective infection control system could result in serious infections for patients and staff.

Findings:

1. A review of Patient 6's record disclosed that she was admitted to the facility on 4/7/13 with a diagnosis of dehydration due to vomiting and diarrhea. There was a physician's order for intravenous (IV) fluids at 125 milliliters (ml) per hour.

Upon entering Patient 6's room with Registered Nurse (RN) 1 on 4/9/13 at 7:25 am, it was observed that the IV was not infusing. IV fluids were restarted by RN 1 at 8:50 am. At 9:50 am, RN 1 stated that the IV had been discontinued by another nurse.

During an interview on 4/9/13 at 10:45 am, Nurse Manager (NM) 1 stated that she had stopped Patient 6's IV shortly after 7 am. NM 1 explained that Patient 6 had vomited everywhere so she had disconnected the IV to remove Patient 6's gown.

A review of the hospital's policy titled, "IV Therapy - Changing Gown With Infusion," effective 9/18/06, read as follows, "It is the policy to provide a uniform method of removal and replacement of gowns safely and without interruption of flow of IV solutions." Two of the rationales listed in the policy included, "Prevents interference with flow of solution," and "Prevents the spread of microorganisms."

2. On 4/9/13 at 2:10 pm, a visit was made to the off campus clinic. A written protocol for cleaning instruments and the autoclave was posted on the wall. During a concurrent interview, Medical Assistant (MA) 1 confirmed that they followed this protocol.

A review of the clinic's policy titled, "Autoclave cleaning," last reviewed 1/31/11, was compared to the protocol posted at the clinic. The following step was included in the clinic's approved policy but not included in the protocol posted on the clinic wall, "Wipe the inside of the autoclave with mild soapy distilled water and a washcloth several times."

3. On 4/11/13 at 9 am, one of seven employee files reviewed failed to have documentation of annual infection control in-services. During a concurrent interview, the Director of Staff Development (DSD) confirmed that annual infection control in-services were required of all nursing staff. DSD was unable to locate documentation that RN 2 had completed the required in-services.

The facility policy, "Nursing License Files," last revised on 2/10/09, read as follows,"It is the responsibility of Nursing Administration to have on file in each employee's file . . . The list includes but is not limited to the following, annual in-services."

4. During the initial tour on 4/8/13 at 1:50 pm, Patient 6 was noted to have a urinary catheter collection bag lying on the floor.

During an interview on 4/8/13 at 1:55 pm, RN 1 confirmed that the bag was on the floor and stated it should be hanging on the side of the bed.

5. A review of the hospital's policy titled, "TB Test," last revised in 1/2010, read as follows, "All employees are required to have a TB skin test annually. All new hires are required to have a second TB skin test."

a. On 4/10/13, two of seven employee files reviewed failed to have annual TB skin tests. Licensed Vocational Nurse (LVN) 1 had last received a TB skin test on 8/31/11. Certified Nursing Assistant (CNA) 1 had last received a TB skin test on 11/11/11.

During an interview on 4/10/13 at 2:35 pm, the Director of Human Resources (DHR) confirmed that these were the most recent TB test for LVN 1 and CNA 1. DHR stated that TB tests were given every two years for hospital employees.

During an interview on 4/10/13 at 2:40 pm, the Infection Control Nurse (ICN) stated their policy was to perform the TB tests every two years but they were changing it to require annual TB tests. ICN was not aware that the hospital's current policy already required annual TB tests.



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b. On 4/11/13, the RM's employee file was reviewed. RM's file contained a TB test done on 2/23/12.

On 4/11/13 at 11:15 am, the DHR reviewed RM's file and confirmed that the 2/23/12 test was the most current test and was greater than one year old.

c. On 4/11/13, employee files were reviewed. The Laboratory Manager (LM) was hired on 2/15/13. LM's file contained a TB (tuberculosis) test, dated 2/14/13, but did not contain a second TB test as required by policy for new hires.

On 4/11/13 at 11 am, the DHR reviewed LM's file and confirmed that LM was aware that he needed to obtain a second test but had failed to do so.

6 a. On 4/11/13 at 8:10 am, during a tour of the Radiology unit, the Radiology Manager (RM) was asked how the x-ray table was prepared between patients. RM replied that they used a Sani-wipe (disinfectant cloths) between each patient. When asked to describe how long the Sani-wipe solution should remain on the x-ray table, she was unable to recall how long the surface should remain wet.

b. There were no Sani-wipe containers visible in the x-ray room. When asked where the Sani-wipes were kept, RM reached in, past several large items, and pulled the Sani-wipe container from the back of a deep cupboard. When asked to show a wipe, it was noted that the container had not been opened, and the protective plastic seal was still intact. When asked if this was convenient for use, RM replied that she wasn't sure, adding that the Sani-wipes should be out available for use.

The Centers for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, dated 6/6/03, listed under the heading, "Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas," that facilities should, "Select EPA-registered disinfectants, if available, and use them in accordance with the manufacturer's instructions." There was no reliable evidence that disinfectant wipes were readily available and used appropriately.

Based on observations, staff interview, medical record review and dietary document review, the hospital failed to ensure: 1) safe food handling practices as evidenced by retention of expired foods; 2) the hospital menu was being followed for two patients (Patient 28 and 29); 3) regular and therapeutic menus met the nutritional components to meet the current national standards including the RDA (Recommended Dietary Allowances) and the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council; 4) the facility failed to ensure the existing disaster plan for the provision of food during a disaster included appropriate food recommendations for patients prescribed puree diets; 5) lack of timely assessment for Patient 11; 6) diets provided by the kitchen were ordered by the physician (Patient 11); 7) nutrition supplements were prescribed by the physician for three patients (Patient 11, 16, 19); and 8) the education needs were assessed or addressed for one patient (Patient 18). Failure to ensure comprehensive dietetic services systems may put patients at risk for foodborne illness. Lack of accurate and effective clinical nutrition care may result in a complete lack of, or delay in medical nutrition therapy. Lack of timely and effective nutrition interventions may result poor dietary intake, weight loss and malnutrition, further compromising patients' medical status.

Findings:

Food Service

1. On 4/8/13 at 2:05 pm, during an inspection of the disaster food supply, it was noted that peanut butter was planned to be served to patients prescribed puree diets, each day at breakfast, for three days.

Review of the diet manual for the dysphagia puree (Level 1) diet indicated, under additional guidelines for the puree diet, to avoid peanut butter unless part of a complete pureed recipe that is easy to swallow. There was no recipe in the disaster plan for peanut butter.

On 4/10/13 at approximately 11:30 am, an interview was conducted with the Registered Dietitian (RD). The RD stated she thought peanut butter would be okay but would need to be applesauce consistency. The surveyor then informed the RD of what was in the hospital diet manual.

2. On 4/9/13 at approximately 11:15 am, an observation of the lunch tray line was conducted. The following items were to be served for the low fat at diet: honey mustard chicken, mashed potatoes with chicken gravy, and mixed vegetables. The following items were to be served to for a 2,000 milligrams (mg) Sodium diet: salt free baked chicken, mashed potatoes with salt free chicken gravy, and vegetables.

On 4/9/13 at approximately 11:40 am, sampled patient (Patient 28) was on a cardiac diet (2,000 mg Sodium, low fat and low cholesterol) and was served honey mustard chicken, mashed potatoes and gravy and vegetables. Another non-sampled patient (Patient 29) was on a low fat diet and was served baked chicken, mashed potatoes and gravy, and vegetables. The Dietary Service Manager (DSM) told the cook to switch out the honey mustard chicken with the baked chicken on Patient 29's tray.

On 4/10/13 at 10:50 am, an interview was conducted with the DSM. The DSM stated if someone is on a cardiac diet they should have received what was listed under the 2,000 mg Sodium diet since that is most restrictive. The DSM stated she was not aware the wrong food items went to the two patients on those diets. The DSM stated, I must have told the dietary staff incorrectly during the lunch tray line.

3. On 4/8/13 at approximately 2:00 pm, an interview was conducted with the RD regarding the nutrient analysis of the menu. The RD stated there was no micro-nutrient analysis of the menus at this time. The RD stated she was planning to, but has not yet, purchase a software program to do this. The RD stated she wanted to know what all the different Recommended Dietary Allowances (RDAs) were for all the nutrients so she would know what to analyze. The RD stated the macro-nutrients were analyzed.

Review of the diet manual for the regular diet, indicated "the regular diet is a well balanced diet created to provide 100% of the USRDI as defined by the National Research Council." It indicated the diet provided consists of a minimum of 2000-2200 calories, approximately 70-95 grams of protein.

Review of the hospital's policy and procedure titled," Menu Planning," dated 2005, indicated the nutritional needs of residents will be met in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (which are adjusted for age, gender, activity level and disability) through nourishing, well-balanced diets.

On 4/10/13 at approximately 12:00 pm, an interview was conducted with the DSM and the RD. The RD stated the menus are from Sysco and the Diet Manual was purchased through Becky Dorner so what is listed as the macro-nutrients (calories, protein, etc) is not necessarily what is being provided by the menus. The RD acknowledged they do not have any analysis of all the different diets, food item and menus, and what they provide.

4. On 4/8/13 at approximately 1:40 pm, two- eight ounce cartons of egg beaters were observed in one of the reach-in refrigerators with a manufacturer's expiration date of 3/31/13.

On 4/9/13 at 10:30 am, an interview was conducted with the DSM. The DSM stated they use the manufacturer's date as the expiration date, and based on that the egg beaters should be thrown out a week ago, on their expiration date 3/31/13.

Nutrition Care

5 a. On 4/9/13 at 7:15 am, the breakfast tray for Patient 11 was observed. The tray contained a four ounce mightyshake (nutrition supplement), house made milkshake, two fried eggs, toast, juice and a hot beverage.


Review of Patient 11's medical record was conducted. Patient 11 was admitted to a swing bed on 4/3/13 with diagnoses that included end stage congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of the physician's orders dated 4/3/13 indicated the diet was patient selective. Review of the physician's orders dated 4/8/13 indicated the diet was changed to mechanical soft. Review of the hospital's policy and procedure, "Diets Available on Menu," dated 2005, indicated there was no diet available that was called patient selective.

RD noted on Patient 11's Nutritional Screening & Data Collection Form, dated 4/3/13, that additional nutrients were needed to meet the patient's estimated nutritional needs. To accomplish this the RD directed staff to fortify Patient 11's diet and send a house product three times a day. Review of the Acute Nutritional Intervention Follow-ups, dated 4/5/13 by the RD, and 4/7/13 by the dietary student, indicated the diet progressed from clear liquid to selective and then changed to mechanical soft. The RD stated the plan of care change was to fortify the diet and to send the house product (nutrition supplement) three times a day with meals.

On 4/9/13 Patient 1's diet cardex, a tracking system the kitchen uses for all the patients to make sure they get certain food items at each meal, had Ensure (nutrition supplement) written in pencil under breakfast, lunch and dinner.

During an interview on 4/9/13 at 10:05 am, the DSM stated that from 4/3/13 until 4/8/13 the kitchen was sending Ensure three times. The DSM stated the RD discontinued the Ensure on 4/8/13 and started house made milkshakes (ice cream and milk). The DSM stated she changed the diet cardex when she made a copy because it was not updated after the RD had seen the patient on 4/8/13. The DSM stated they will provide supplements when the RD recommends them and not when they receive a physician's order. The DSM stated when they received the diet order that stated patient selective they took that to mean it was a regular diet. Dietary staff asked the nurse for clarification but did not get a physician's order for the diet or the supplements. The physicians order was not specific on the diet to serve the patient. There was no documented evidence that nursing staff clarified the order requesting the physician to be specific. There was no documented evidence that there was a physician's order for the supplements.

b. Patient 19 was admitted to the facility on 3/15/13 with diagnoses that included right peri-rectal abscess. Review of the physician's orders, dated 3/15/13, indicated a no added salt diet. There was no other physician's diet orders in the medical record.

Review of Patient 19's Nutritional Risk Screening Form, dated 3/15/13, showed Patient 19 had food intakes less than 75% for three days, broken/missing teeth, likes soft foods and ground meats, and had poor appetite three days prior to admission.

Review of the Acute Nutritional Intervention Follow-Up, dated 3/18/13, indicated the plan of care change was a "grind diet with mightyshakes with meals three times a day."

Review of the care plan, dated 3/15/13, showed it was not updated on 3/18/13 with the RD intervention of the nutrition supplement and diet change.

On 4/10/13, at approximately 12:00 pm, the RD stated that she does not get a physician's order when she supplements or fortifies diets as an intervention. She documents the intervention and notifies the kitchen of the changes.

c. Patient 16 was admitted to the hospital on 9/7/12 with diagnoses that included dehydration, bladder cancer, and diabetes. Review of the physician's orders dated 9/7/12 indicated a low sodium, diabetic diet. There was no other physician's orders for the diet in the medical record.

Review of Patient 16's Nutritional Assessment and Care Planning, dated 9/12/12, showed an intervention of Nepro (nutrition supplement specific for patients with kidney problems) three times a day with meals. Review of the Acute Nutritional Intervention Follow-up, dated 9/12/12, showed the average total supplement was 50% of Glucerna (nutrition supplement specific for patients with diabetes) on tray.

Review of the care plan dated 9/7/12, showed it was not updated on 9/12/12 to include the RD intervention of Nepro as the nutrition supplement.

6. Review of the hospital's policy and procedure titled Nutritional Screening/Monitoring Forms, dated 11/06, revised 2012, directed that the Nutritional Risk Screening Form be completed on all acute and swing bed patients within eight hours of admission to acute care. The Nutritional Assessment and Nutritional Care Plan Form, for acute and swing bed patients, is then sent to the RD after the patient has been in the facility 24 hours, but before 48 hours. The Nutritional Data Collection and Intervention Follow-Up Form is to be completed by the DSM or Designee within 3-5 days of admission.

Patient 16 was admitted to the hospital on 9/7/12 with diagnoses that included dehydration, bladder cancer, and diabetes. Review of the physician's orders dated 9/7/12 indicated a low sodium, diabetic diet. Review of the Nutritional Risk Screening Form dated 9/7/12, showed Patient 16 had dehydration, food intakes less than 75% for three days, was visually malnourished, was a poor eater and had a poor appetite three days prior to admission.

Review of the Nutritional Assessment and Care Planning Form dated by the RD on 9/12/12, showed Patient 16 was at risk for nutritional depletion or malnutrition related to diabetes, CHF, renal failure, Stage II decubitus ulcer (localized injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as manifested by visually malnutrition, underweight, healing needed, low intakes, decreased appetite. The RD interventions were to obtain food preferences, cater to food requests, provide snacks offered by nursing, Nepro three times a day with meals, fortified diet, and soft foods with mashed potatoes, gravy and low sodium, diabetic diet.

Review of the Acute Nutritional Intervention Follow-Up dated 9/12/12, showed the average total meal intake was 50% and Patient 16 was taking 50% of Glucerna on tray. Patient 16 also had a new open area on his buttock this morning and no appetite. The RD indicated to see care plan for the plan of care change. Review of the Care Plan dated 9/7/12, showed the patient problem was alteration in nutrition related to inability to eat (circled on care plan) and nausea (written under "other"). The expected outcomes indicated patient will maintain at appropriate weight during hospital stay, patient will tolerate oral intake. The interventions/approach planned were to provide the ordered diet, maintain position of comfort during meals, administer medications as ordered, monitor oral intake and percent of meals eaten. The care plan showed it was resolved on 9/12/12. There were no outcomes or goals identified so it is unclear which ones were pertinent.

On 4/10/13 at 12:10 pm, an interview was conducted with the CNO. The CNO stated her expectation is that all assessments should be made within 24 hours. The CNO acknowledged that the RD assessment should have been more timely, sooner than 5 days after admission, for a nutritionally compromised patient.

7. Patient 18 was admitted to the facility on 8/17/12 with diagnoses that included poorly controlled diabetes and chronic kidney disease secondary to diabetes. Patient 18's history and physical, dated 8/17/12, noted that the patient had a past medical history of uncontrolled diabetes.

Patient 18's Nutritional Risk Screening Form, dated 8/17/12, noted that Patient 18 had uncontrolled diabetes.

The Nutritional Assessment and Care Plan Form, dated 8/20/12, showed Patient 18's glucose was 756 and on 8/20/12 was 265. Patient 18's height was 5'3" and 206 pounds. It showed Patient 18's number one problem was being at risk for nutritional depletion or malnutrition related to diabetes, rheumatoid arthritis, and chronic kidney disease as manifested by renal insufficiency, and high blood sugars. The RD intervention was the diet ordered of 1800 calorie, 1200 milliliters fluid restriction, 2,000 mg sodium. There was no mention of diet education or to refer the patient to the RD in an outpatient clinic after discharge.

Patient 18's Acute Patient Care Plan, dated 8/17/12, indicated the patient had a knowledge deficit but did not identify what the knowledge deficit was related to. The expected outcome/goal was for the patient/family to verbalize and/or demonstrate understanding of education during hospitalization, and the intervention circled indicated to document education related to each problem.

The Nursing Progress Record, dated 8/17/12, indicated patient education given was nutrition. There was no documentation in the progress record specific to the type of nutrition information/teaching that Patient 18 received, and/or if he understood the information.

On 4/10/13 at 10:30 am, an interview was conducted with the Nurse Manager (NM) 1. NM 1 stated nursing should document what education was given and what kind of understanding Patient 18 had. The NM 1 stated nursing should also notify the RD to educate Patient 18 on the diabetic diet and this should be care planned. NM 1 stated the care plan was not specific to state what the knowledge deficit was related to or what they educated on.

On 4/10/13 at 11:30 am, an interview was conducted with the RD. The RD stated she sees patients at the clinic and she has spoke with nursing to make more clinic referrals for diet education when appropriate. The RD was not able to speak to why she did not address Patient 18's diet education needs in her assessment.

Based on document review and staff interview, the facility failed to ensure that a properly executed agreement was in place for one of the two medical transcription services. This may result in unauthorized release of protected medical information.

Findings:

On 4/9/13, the facility provided a "proposal" for medical transcription and a one-page "service agreement" dated 6/2006 that was signed only by a representative of the hospital.

During an interview with Health Information Management Staff D on 4/10/13 at 10 am, she stated that this service transcribed for the clinic patient visits and that the service is located outside the United States.

The facility was unable to produce a final agreement signed by both the hospital and the transcription service. On 4/10/13 at 2:05 pm, the Chief Operating Officer confirmed that the facility did not have a properly executed agreement.

Based on staff interview and document review, the hospital failed to maintain a complete list of all services furnished under arrangements or agreements. The partial list that was kept did not detail the full nature and scope of the services provided by each of those contracts, arrangements, or agreements.

Findings:

On 4/8/13 the hospital was asked to provide their complete list of contracted services and a multi-page spreadsheet document was provided. Review of this spreadsheet, showed that the description listed for some contracted services was incomplete and lacked essential information. The list typically contained a description that was the same as the title of the written contract. For many of the contracts, the title did not contain enough information to clearly define the full nature and scope of the services being provided.

On 3/9/13 in an interview with the CEO, he acknowledged that the contract list did not contain the full scope and nature of services for each of the contracts. He stated that he had previously identified this flaw in the contract database, and he then outlined a detailed plan to improve the database so that it could be used in the hospital's Quality Assessment and Performance Improvement (QAPI) program.

Based on observation, interview, and record review, the facility failed to ensure that patients' needs were assessed and interventions completed to meet the needs for six of 28 sampled patients. (Patients 6, 11, 15, 20, 27 and 28)

1. Patient 6's intravenous (IV) fluids were temporarily stopped and not given as ordered by the physician.

2. Patient 15's physician orders contained a verbal order that did not comply with the hospital's policy for writing verbal orders.

3. Emergency Department (ED) patient was left alone without a call light or other method for calling for assistance. (Patient 27)

4. Patient 11 was not routinely shaved.

5. Patients 11 and 28 were not turned every two hours as directed by the care plan.

6. Patient 20 did not have an assessment prior to the provision of care.

These failures had the potential for patients' needs to go unattended and result in adverse health consequences including deterioration of health condition, dignity issues, pressure ulcers, and undetected health issues.

Findings:

1. A review of Patient 6's record disclosed that she was admitted on 4/7/13 with a diagnosis of dehydration due to vomiting and diarrhea. There was a physician's order for IV fluids at 125 milliliters (ml) per hour.

Upon entering Patient 6's room with Registered Nurse (RN) 1 on 4/9/13 at 7:25 am, it was observed that the IV was not infusing. IV fluids were restarted by RN 1 at 8:50 am. At 9:50 am, RN 1 stated that the IV had been discontinued by another nurse.

During an interview on 4/9/13 at 10:45 am, Nurse Manager (NM) 1 stated that she had stopped Patient 6's IV shortly after 7 am. NM 1 explained that Patient 6 had vomited everywhere so she had disconnected the IV to change Patient 6's gown and did not restart it. Patient 6's IV fluids were disconnected for approximately 1 hour and 45 minutes. During this time Patient 6 continued to have diarrhea.

A review of the hospital's policy titled, "IV Therapy - Changing Gown With Infusion," effective 9/18/06, read as follows, "It is the policy to provide a uniform method of removal and replacement of gowns safely and without interruption of flow of IV solutions." One of the rationales listed in the policy included, "Prevents interference with flow of solution."

2. A concurrent record review of Patient 15's record and interview was conducted on 4/10/13 at 1 pm with NM 1. The ED record contained orders for Patient 15 that included two medication orders that were not in the physician's handwriting, without the date, the nurse's signature or either verbal or telephone order written beside it.

NM 1 confirmed that these orders had been written by the nurse without her signature or any indication of whether it was a verbal or telephone order. She confirmed that the nurse should have written either verbal or telephone order, with the time she received the order and her signature.

A hospital ED policy titled, "Telephone, Verbal and Written Orders for Medication," last revised in 11/2007, read as follows, "all verbal and/or telephone orders for medications shall include the following criteria: date and time the order is prescribed verbally or via telephone, the name of the individual prescribing the drug and his/her licensure (i.e., MD), and the name and level of licensure of the individual receiving and documenting the order."

3. During the initial tour of the ED on 4/8/11 at 1:25 pm, Patient 27 was observed lying on a gurney and connected to a heart monitor. A review of the ED log disclosed that he had come to the ED with a complaint of chest pain. There was no staff member present in the room or the other ED rooms at this time.

During a concurrent interview, Patient 27 stated he had not been given a call light to use if he needed help.




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4. On 4/8/13 at 2 pm, Patient 11 was observed to be unshaven. Hair growth on his face was approximately 1/2 inch long. Patient 11's family member was at his bedside and acknowledged that he had not been shaven most days since his admission. Patient 11 stated he would like a shave every day and denied refusing the offer of a shave.

On 4/8/13 at 2:10 pm, Certified Nurse Assistant (CNA) 1 stated she planned on shaving him later that day.

On 4/9/13 at 7:15 am, Patient 11 was observed and had not been shaven, having still approximately 1/2 inch of hair growth on his face. On 4/11/13 at 11:15 am, Patient 11 was again unshaven.

On 4/11/13, a review of Patient 11's records, showed that he was admitted on 4/3/13. Patient 11's records showed that he was shaved on 4/9/13, one day of an eight day stay (13 percent). Patient 11's record did not indicate he had refused a shave.

On 4/10/13 at 3:30 pm, NM 1 was asked if she was aware that Patient 11 had not been shaved and she stated she had not seen him for several days.

On 4/9/13, the facility policy, titled, "Shaving Male Patient," dated 9/06, read, "Patients admitted to the hospital who shave daily will be offered a shave."

5a. On 4/8/13 at 2 pm, Patient 11's family member stated Patient 11 had a reddened bottom.

On 4/8/13, Patient 11's record was reviewed. Patient 11 was admitted on 4/3/13 with heart failure and lung disease. Patient 11's record contained a care plan for alterations in skin integrity which indicated that Patient 11 was to be repositioned every two hours and as needed. Patient 11's record did not contain evidence that his position was changed every two hours.

b. On 4/8/13, Patient 28's record was reviewed. Patient 28 was admitted with lung disease. Patient 28's record contained a care plan for alterations in skin integrity which indicated that Patient 28 was to be repositioned every two hours and as needed. Patient 28's record did not contain evidence that his position was changed every two hours.

On 4/9/13 at 7:10 am, NM 1 reviewed Patient 11 and 28's records and acknowledged that Patient 11 and 28's record did not have a nursing record that demonstrated they were turned every two hours as directed by their care plans.

6. On 4/9/13 at 2:30 pm, Patient 20's record was reviewed with RN 1. Patient 20 was seen daily for wound care to a surgical site. Patient 20's record did not contain a nursing assessment of Patient 20 or his wound. RN 1 confirmed that the record did not contain an assessment.

Based on interview and record review, the facility did not ensure that all nursing staff were evaluated for competencies in the area in which they worked or complete performance evaluations at least annually as required by its policy for five of seven employees. This had the potential to result in poorly trained staff and poor patient outcome.

Findings:

A facility policy, titled "Staff Qualifications and Competency," effective 9/2007, indicated that staff would be tested for competency annually following their 90 day probation period. A facility policy, titled "Performance Evaluations," effective 9/2007, indicated that performance evaluations would be conducted on an annual basis and were generally conducted concurrently or after the staff's competency assessment.

Seven employee files were reviewed with the Director of Human Resources (DHR) on 4/10/13 at 2:35 pm. The following issues were identified:

1. Nurse Manager 1's last Medical/Surgical competencies were completed on 1/2012, last Emergency Department (ED) competencies and Performance Evaluation were done on 2/27/12.

2. Registered Nurse (RN) 2's last ED competencies were completed on 1/12/12.

3. RN 3's last competencies for Outpatient Surgery and Performance Evaluation were completed on 2/25/12, Medical/Surgical competencies were completed on 2/20/12, and ED competencies were completed on 1/12/12.

4. Licensed Vocational Nurse 1's last clinic competencies and performance evaluation were completed on 2/28/12.

5. Certified Nursing Assistant (CNA) 1's last performance evaluation and CNA competencies were completed on 2/20/12.

During a concurrent interview, DHR confirmed the above dates for each employee and that they exceeded 12 months.

Based on observation, interview, and record review, the hospital failed to ensure the accurate administration of medications for four of 28 patients according to physician's orders and accepted standards of practice.(Patient 3, 5, 6, and 11)

1. The facility did not utilize accurate medication technique according to physician's orders for one of two patients during a medication administration observation. (Patient 6)

2. The facility did not administer all medications as ordered to one of 28 sampled patients. (Patient 11)

3. One of 28 sampled patients received a protective skin care ointment without an order. (Patient 11)

4. Narcotic orders were added by a nurse to previously written physician orders which had already been signed by the physician and noted by the nurse for one of 28 sampled patients. (Patient 5)

5. Post-operative narcotic orders were not clarified, not given as ordered, given in an amount that exceeded the maximum dosage, and given by a route not ordered by the physician for one of 28 patients. (Patient 3)

This resulted or had the potential to result in an increase in medication side effects for Patient 6, and resulted in the omission of a medication for Patient 11, lack of physician supervision of medications for Patients 3, 5, and 11 which could result in adverse health consequences.

Findings:

1. During a medication administration observation on 4/9/13 at 7:25 am, Registered Nurse (RN) 1 poured Potassium Solution (an electrolyte) 20 millequivalents (meq) into a plastic medication cup, then gave it to Patient 6 who drank it. RN 1 did not mix the medication with juice or dilute this medication prior to administration.

A review of the physician's order disclosed an order for Potassium 20 meq, three times per day in juice.

Lexi-Comp's Geriatric Dosage Handbook reads as follows under Nursing Implications, "oral liquid potassium supplements should be diluted (2-6 parts diluent) with water or juice during administration."

2. A facility policy titled, "Patient Medication Reconciliation, last revised in 11/2007, read as follows, "A method of reviewing all medication that a patient was taking prior to admission to the hospital on one form, displaying when the medication was last taken, and for the physician to determine what to continue while in the hospital . . . The Medication Reconciliation Form will be completed as soon as is convenient after admission to the hospital. . . The physician will review the completed form and mark yes for all medications to continue."

A review of Patient 11's record disclosed that he was admitted on 3/30/13 with diagnoses that included lung disease and heart failure. A medication reconciliation form was completed and included the medications Patient 11 took at home. This form was signed by Patient 11's physician on 3/30/13 at 11:30 pm. One of the medications that Patient 11 was to continue to receive while in the hospital was Losartan (used to treat high blood pressure) 25 milligrams daily. This medication had not been transcribed onto Patient 11's medication administration record (MAR) and there was no record that he had received this medication from 3/30/13 through 4/3/13.

During a concurrent record review and interview on 4/9/13 at 9:30 am, the Chief Nursing Officer (CNO) said, per policy the medication reconciliation form, with yes next to the medication, is an order when signed by the physician. The CNO stated that this medication was not added to the Patient 11's MAR so the medication was not given. She also stated that the chart check had not been done by the nurse.

An undated facility policy titled, "Physician Order Review - Responsibility of RN For Verification," read as follows, "Each RN will be responsible to ensure that the physician's orders for each patient have been carried out as ordered. RNs are responsible for verifying orders. A signature and classification must accompany review of all orders written and transcribed by the previous shift as evidence of procedure completion."



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3. On 4/8/13, Patient 11's record was reviewed. Patient 11 was admitted on 4/3/13 with heart failure and lung disease. Patient 11' record indicated he had developed a reddened coccyx (bottom) on 4/7/13 as noted in the nursing progress record. The 4/7/13 notes further indicate that a protective skin care ointment was applied on 4/7 and 4/8/13. However, Patient 11's physician did not order this protective skin care ointment until 4/9/13.

On 4/9/13 at 7:10 am, NM 1 reviewed Patient 11's record and acknowledged that a physician's order had not been obtained for the skin ointment given on 4/7 and 4/8/13.

4. On 4/9/13, Patient 5's record was reviewed. Patient 5 was admitted for surgery on 6/15/12. Patient 5's record contained a Medication Reconciliation form which indicated at the top that the patient had a sensitivity to Vicodin (pain medication) The form further indicated a physician order for Vicodin at discharge. Next to this order was a notation in a different handwriting than the physician that read, "SGS 0928 (9:28 am) cancel above. Percocet (for pain) 5/325 mg (milligrams) 1-2 orally every 4 hours as needed. Dispense 30 pills.

On 4/9/13 at 3:30 pm, the Surgical Coordinator (SC) reviewed Patient 5's record and acknowledged that this was a verbal order for a new medication that had not been properly recorded. Instead, the nurse amended an already signed physician order.

5. On 4/9/13, Patient 3's record was reviewed. Patient 3 was admitted on 11/30/12 for surgery. Patient 3's record contained an Anesthesia Form, dated 11/30/12 at 8 am, that had PACU (Post Anesthesia Care Unit - recovery room) orders for Demerol (a narcotic) 25 mg every 5 minutes as needed for pain, maximum dose 100 mg (no route of administration is noted on this order). The order was signed by the anesthesia provider. Patient 3's record further contained a physician's order form, dated 11/30/12 at 11:30 am, with an order for Demerol 25 mg IV (intravenous - via a vein) push every 30 minutes as needed for pain, signed by the surgeon. Patient 3's record indicated that she received Demerol as follows:
10:55 am 25 mg IV given by RN 4
11:05 am 25 mg IV given by RN 4 (10 minutes later)
11:35 am 25 mg IV given by RN 4 (30 minutes later)
12:00 pm 25 mg IV given by RN 5 (25 minutes later )
1:15 pm 25 mg IV given by RN 5 (75 minutes later)
1:35 pm 25 mg IM (intramuscular) given by RN 5 (20 minutes later)
Patient 3 received a total of 150 mg of Demerol.

On 4/9/13 at 3:15 pm, SC reviewed Patient 3's record. SC acknowledged that there should have been clarification of the two differing physician's orders for Demerol. SC further acknowledged that 100 mg maximum dose was exceeded and the IM route was never ordered.

On 4/11/13 at 11:20 pm, RN 5 stated she was unaware of the PACU orders for Demerol, limiting the dose to 100 mg and that she strictly used the surgeon's orders for Demerol to medicate Patient 3. RN 5 further stated that she had received a verbal order for the IM dose of Demerol at 1:35 pm, but had not recorded it.

Based on interview and record review, the hospital failed to ensure nursing care plans were developed and individualized for seven of 28 sampled patients.

1. Patient 6 did not have a care plan that addressed her admission diagnoses of dehydration, vomiting and diarrhea.

2. Patient 11, 16, 19, 26, and 28's care plans were not individualized.

3. Patient 20's did not have a care plan for his wound.

These failures had the potential for patients' needs to go unaddressed and result in adverse health consequences.

Findings:

A facility policy titled, "Care Planning," last revised 2012, read as follows, "Care, treatment and services are planned to ensure that they are appropriate to the patient's needs. Therefore, it is the policy of the hospital to provide an individualized, interdisciplinary plan of care for all patients that are appropriate to the patient's needs, strengths, limitation and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable."

1. A review of Patient 6's record disclosed that she was admitted from the Emergency Department to the medical unit for observation on 4/7/13 with a diagnosis of dehydration due to vomiting and diarrhea. Her status was later changed to a regular inpatient on 4/9/13. No care plan could be located in the record after Patient had been admitted for observation.

During a concurrent record review and interview on 4/10/13 at 8:05 am, Nurse Manager (NM) 1 stated that the ED care plan would have been used after Patient 6 was admitted for observation. This care plan was reviewed and NM 1 confirmed it did not contain any problems related to dehydration, vomiting or diarrhea or interventions that addressed those problems.
2 a. A review of Patient 26's record disclosed that he was admitted on 2/18/13, with diagnoses that included diabetes with very high blood sugars, vomiting, high blood pressure and a upper respiratory infection. His care plans were not individualized. Some problems were not specified as either an actual or a potential problem and some of the specific interventions were circled for some problems but not for others.

During a concurrent record review and interview on 4/9/13 at 3:50 pm, NM 1 confirmed the above and stated that the nurse should have circled whether Patient 26 had a potential problem or an actual problem.



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b. Patients 11 and 28's records were reviewed on 4/8/13. Patient 11 and 28's records had care plans that contained a preprinted care plan which had numbered categories of patient problems such as alterations in skin integrity, etc. Patient 11 and 28's care plans had admission date next to the circled number for each identified patient problem. The care plan did not indicate if the problem was actual or potential, which problems existed for each patient, and which goals and interventions were applicable for these patients.

3. On 4/9/13 at 2:30 pm, Patient 20's record was reviewed with Registered Nurse (RN) 1. Patient 20 was seen daily for wound care to a surgical site. Patient 20's record did not contain a nursing care plan for his wound care. RN 1 confirmed that the record did not contain a care plan.

On 4/9/13 at 2:30 pm, NM 1 reviewed Patient 11 and 28's records and acknowledged that their care plans were incomplete and were not individualized for each patient.

On 4/9/13 at 3:30 pm, the Surgical Coordinator reviewed Patient 20's record and acknowledged that there was no care plan.



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4. Review of Patient 16's medical record indicated he was admitted with diagnoses that include bladder cancer and dehydration. Review of the Nutritional Risk Screening Form dated 9/7/12, showed Patient 16 had dehydration, food intakes less than 75% for three days, visually malnourished, poor appetite three days prior to admission and was a poor eater.

Review of the Nutritional Assessment and Care Planning dated 9/12/12, showed an intervention of Nepro (nutrition supplement specific for patients with kidney problems) three times a day with meals. Review of the Acute Nutritional Intervention Follow-up dated 9/12/12, showed the average total supplement was 50% of Glucerna (Nutrition supplement specific for patients with diabetes) on tray.

Review of the care plan dated 9/7/12, showed that it was a preprinted care plan which had numbered categories of patient problems such as alterations in nutrition, etc. Patient 16's care plan had admission date next to the circled number for each identified patient problem. The care plan did not indicate if the problem was actual or potential, and which goals and interventions were applicable for these patient. The care plan was not updated to include the RD intervention of the nutrition supplement and there was no care plan to address his hydration needs since he came in with dehydration.

5. Review of Patient 19's medical record indicated he was admitted on 3/15/13 with diagnoses that included right peri-rectal abscess.
Review of the Nutritional Risk Screening Form dated 3/15/13, showed Patient 19 had food intakes less than 75% for three days, broken/missing teeth and likes soft foods and ground meats and had poor appetite three days prior to admission.

Review of the Acute Nutritional Intervention Follow-Up dated 3/18/13, indicated the plan of care change was a "grind diet with mightyshakes with meals three times a day."

Review of the care plan dated 3/15/13, showed that it was a preprinted care plan which had numbered categories of patient problems such as alterations in nutrition, etc. Patient 16's care plan had admission date next to the circled number for each identified patient problem. The care plan did not indicate if the problem was actual or potential, which problems existed for each patient, and which goals and interventions were applicable for these patient. The care plan was not updated to include the RD intervention of the nutrition supplement and diet change.

On 4/10/13 at 10:30 am, an interview was conducted with NM 1. NM 1 acknowledged the care plans were not specific to the patients.

Based on document and medical record review, and staff interview, the facility failed to ensure that the clinical records system was maintained in accordance with written policies and procedures (P & Ps). There were no safeguards in place for the use of electronic signatures by the medical staff; and two of two sampled personnel files of the Health Information Management department (HIMD) P & Ps were not reflective of current practices. These failures may result in appropriate procedures not being followed to protect and convey patient health information.

Findings:

1. The facility's practice was to have physicians/allied health staff electronically sign reports that have been dictated and transcribed, such as history and physicals, operative reports, emergency room visits, and discharge summaries. However, there was no system in place, or approved, by the governing body to ensure that the author is the only person who will use the computer key/code to authenticate/finalize the reports. Records 21, 22, 23, 24, and 25, reviewed on 4/11/13, contained electronically signed reports. This finding was confirmed by Staff HIM D on 4/11/13 at 10:30 am.

2. The HIMD P & P manual was reviewed on 4/10/13. The most recent approval page was signed in 7/2012 - 8/2012. Individual policies showed effective/revision dates from 2007-2010. Some of the policies were not reflective of current practice, such as #3003, Scope of Service, which stated that the transcription service was available on a 24-hour basis.

During an interview with Staff HIM D on 4/10/13 at 3:10 pm, she stated that the transcription service used by the clinic was only available weekdays from 8 am -5 pm. Policy #6073, Medical Record Content, stated that completion of records could be extended up to 30 days; however, the Medical Staff Bylaws, section 12.3-4 states that medical records are to be completed ... within 14 days of discharge. Also, the P & P manual contained a form, "Health Information Management Department Statement of Confidentiality." On 4/11/13 at 10:30 am, Staff HIMD stated that this form was no longer used.

3. The personnel files of two HIMD employees were reviewed on 4/10/13. The latest annual performance evaluation in HIMD Staff A's file was done in 9/2011.

On 4/10/13 at 3:35 pm, HIMD Staff A stated that the evaluation was due in
1/2013 and was late, per the facility's policy #3012 Performance Evaluations, which states: "Performance evaluations are then conducted on an annual and as needed basis."

HIMD Staff D's file contained a job description that was incomplete, as it did not include her duties and responsibilities for a second position that was added in 8/2006. This finding was acknowledged by HIMD Staff D during the interview on 4/10/13 at 3:35 pm.

Based on medical record review and staff interview, the facility failed to ensure that records were accurate, complete, with patient identifiers, dates, and abbreviations explained, in eight of 28 sampled patient records. This may result in miscommunication among caregivers and pages of a record being misfiled which could negatively impact patient care.

Findings:

The following records were reviewed on 4/11/13, and the findings were confirmed with Health Information management (HIMD) Staff at 10:30 am:

1. Records fpr Patients 22, 24, and 25 contained forms that did not have titles, but were referred to as the vitals flowsheet and the nursing assessment. These forms did not contain a patient identifier, such as name and medical record number, on all pages.

2. The Nutritional Assessment and Care Plan in Patient 24's record was not dated when signed.

3. Patient 24's record contained the abbreviation "HCAP" in the physician's admission progress note. The meaning of this abbreviation was not the one listed in the 1991 reference book that Staff HIMD had. Staff HIMD further explained that the facility eliminated their "approved abbreviation list" several years ago and did not have a policy explaining how the meanings of abbreviations/symbols used in the medical record would be known to caregivers and other users of the record.



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4. On 4/9/13, surgical patients' records (Patients 2, 3, 4, 5, and 20) were reviewed. Patients 2 and 20 had history and physical (H&P) reports with dictation dates that were after the patients surgery. (For further information, see C 322) Patients 2, 3, 4, 5, and 20 had operative reports that indicated that they were dictated greater than 24 hours after surgery.

The facility's Medical Staff Rules and Regulations read at 7.2, item (f), "Operative reports shall be written or dictated immediately upon completion of the surgery. Any practitioner with un-dictated reports on the day of operation shall be notified of the deficiency by the medical records office; if this continues to be a problem, the chief of medical staff shall be notified."

On 4/9/13 at 4 pm, the Surgical Coordinator (SC) was interviewed regarding the lateness of the above dictations and she reported that the physician's dictated their operative reports immediately after each surgery. SC conferred with Administrative Staff A and found that the date, on H&Ps and operative reports, was actually the date the dictation was uploaded to the transcription service, and not the actual date and time of dictation. SC confirmed that the above records did not accurately convey the date and time of the dictations for surgical patients.

5. On 4/9/13, Patient 20's record was reviewed. Patient 20's record contained a verbal order, dated 4/6/13 at 5 pm, for wound care. This order was not signed by the physician.

On 4/10/13, the Medical Staff Rules and Regulations, under section 7.3-2, indicated that verbal orders were to be signed within 48 hours.

On 4/9/13 at 2:30 pm, SC confirmed the orders had not been signed by the physician, almost 72 hours later.

6. On 4/9/13, Patient 4's record was reviewed. Patient 4's record contained a form titled, "Outpatient Surgery Discharge Assessment," which was undated and did not included the time the patient was discharge.

On 4/9/13 at 3:10 pm, SC confirmed the above form did not include a date and time of Patient 4's discharge.

Based on medical record review and staff interview, the facility failed to ensure that all entries were authenticated by health care professionals in three of five patient records. (Patients 23, 24, and 25) This failure may result in not being able to identify the author of written entries.

Findings:

The following records were reviewed on 4/11/13, and the findings confirmed with Health Information Management Staff D on 4/11/13 at 10:35 am.

1. Patient 23's record contained an Outpatient Surgery Discharge Assessment that was not signed, nor was the author identified.

2. Patient 24's record contained a form (referred to as the vitals flowsheet) that contained initials, but not the full signature of the person who made the entries.

3. Patient 25's record contained an Initial Pain Assessment Form that was not signed, nor was the author of the entry identified.

Based on observation, interview, and record review, the facility failed to ensure that surgical procedures were conducted in a manner to assure patient safety for five of six sampled surgical patients, (Patients 1, 2, 3, 4 and 5) as evidenced by:
1. Failure to ensure that each patient undergoing a non-emergent surgical procedure had a complete history and physical conducted, in accordance with the hospital rules and acceptable standards of practice, and that the written document of the history and physical was placed in the medical record, prior to surgery.
2. Failure to count sponges during and after an abdominal surgery. (Patient 4)
3. Failure to accurately record urinary output for a postoperative patient. (Patient 4)
4. Failure to provide pre-operative teaching. (Patients 3, 4, and 5)
5. Failure to provide routine monitoring of the operating room (OR) suite temperature and humidity.

Failing to have a timely and proper medical history and physical examination conducted and recorded within 30 days prior to surgery, permitted the possibility that a patient could suffer harm as a result of an unrecognized pre-existing medical condition that may increase the risk of surgery or anesthesia during surgery.

Failing to count surgical sponges placed the patient a risk for the retention of a foreign object, and failing to provide pre-op teaching and post -op patient care, and the failure to monitor OR temperature and humidity had the potential for surgical patients to receive inadequate care that could result in infection and other adverse health consequences.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of services were in compliance with the statutorily mandated Condition of Participation: Surgical Services.

Findings:

1. On 3/9/13 the Medical Staff Bylaws and Medical Staff Rules (Rules) were reviewed, and the following requirements were noted:

In the Rules at page 90, Section 7.2 Medical Records Requirements states:
"(b) A complete admission history and physical examination shall be recorded within 24 hours of admission or immediately before in accordance with hospital policy and procedures by a doctor of medicine or osteopathy, or, for patients admitted only for oromaxillofacial surgery, by a oromaxillofacial surgeon, who has been granted such privileges by the Medical Staff. This requirement may be satisfied by a complete history and physical that has been performed within the 30 days prior to admission (the results of which are documented in the patient's medical record) so long as an examination for any changes in the patient's condition is completed and documented in the patient's medical record within 24 hours after admission.

"(c) This record shall include identification data; chief complaint; personal history; family history; history of present illness; should include pertinent findings resulting from an assessment of all of the systems of the body; physical examination; special reports such as consultations; clinical laboratory and radiology services and others; provisional diagnosis; medical or surgical treatment; operative report; pathological findings, progress notes."

"(d) When the history and physical examination are not recorded at the time of observation or potentially hazardous diagnostic procedure, the procedure shall be canceled, unless the attending practitioner states in writing that such delay would be detrimental to the patient."

Page 96 of the Rules, Section 7.3-6 Perioperative Services states:
"(a) ... A copy of a recent history and physical examination or note that the H&P has been completed shall be on the chart prior to the time scheduled for an operation unless the attending surgeon states in writing that a delay would constitute a hazard to the patient. A history and physical completed more than two weeks prior to the surgery shall have a note updating the interval period."

The medical records of 28 patients were reviewed during the survey and the following 4 surgical records (Patients 1, 2, 4 and 5) were observed to be lacking a complete pre-surgical H&P fulfilled all of the above referenced rules from the Medical Staff Rules.

On 4/9/13 at 11:30 these 4 records and others were concurrently reviewed with the CNO and she verified the four instances of incomplete pre-surgical documentation listed below.

1 a. Patients 1 was admitted to the hospital on 3/8/13 for an outpatient diagnostic and surgical procedure. The record contained a medical history and physical examination (H&P) that had been performed by the surgeon on 1/4/13, which was 63 days prior to the surgery. The record also contained an H&P dated 3/8/13, but not signed by the physician until 3/9/13. The record did not contain a note that the H&P has been completed and on the chart prior to the time of the surgical procedure.

b. Patients 2 was admitted to the hospital on 2/8/13 for an outpatient diagnostic and surgical procedure. The record contained an H&P that had been performed by the surgeon on 1/5/13, which was 34 days before the surgical procedure. The record also contained another H&P which had the date "2/8/13" at the top, however this second H&P documented it was dictated on 2/11/13 and it was signed by the surgeon on 3/9/13.

c. Patient 4 was admitted to the hospital on 12/14/12 for outpatient surgery. The record contains an H&P that had been performed by the surgeon on 11/9/12, which was 35 days prior to the surgery.

d. Patient 5 was admitted to the hospital on 6/15/12 for outpatient surgery. The record contains an unauthenticated H&P that had been performed by the surgeon on 4/20/12, which was 56 days prior to the surgery.



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2. On 4/9/13, Patient 4's record was reviewed. Patient 4 was admitted for surgery on 12/14/12. Patient 4's record contained a form titled, "Perioperative Record, " which had sections for surgical sponge and sharps counts to be verified by two personnel so a foreign object would not accidently be left in the patients' body. The sponge count portion of the above form was blank.

On 4/9/13, the facility policy, "Sponge Count," dated 4/2009, indicated that A sponge count and sharps count is necessary on all surgeries... They are counted in the O/R by both the scrub nurse and the circulating nurse before the beginning of the case...counted when starting to close the subcutaneous (lower level of the skin) tissue... The scrub and circulating nurse are the only individuals making the final count. Therefore, it is necessary that the names of the nurse making the final count are indicated on the permanent medical record of the patient... A needle, knife blade, and hypodermic needle count shall be completed in the same manner as the sponge count."

On 4/9/13 at 3:10 pm, the Surgical Coordinator (SC) reviewed Patient 4's record. SC acknowledged that the forms were completely blank in the section for counts demonstrating that these nurses did not routinely perform the required sponge and sharps counts.

3. Patient 4's record contained a form titled, "Post Anesthesia Care Unit Record," which had a section for nurses to record fluids excreted by the body (output). The output section was further divided into categories for types of fluids and a area for the total output of each type of fluid to be totaled. This information is used to evaluate fluid balance. Patient 4's record had a time of 10 am and a check mark in the urine column on this form. There was no documentation in Patient 4's record as to the amount of urine that was excreted.

On 4/9/13 at 3:10 pm, the Surgical Coordinator (SC) reviewed Patient 4's record and acknowledged that the standard of practice is to document the amount of urine excreted. SC confirmed that Patient 4's fluid balance could not be adequately evaluated based on the documentation provided.

4. On 4/9/13, Patients 3, 4, and 5's records were reviewed. Patient 3, 4, and 5's records each contained a form titled, "Pre-operative Patient Teaching Sheet," which listed check-off elements for key processes that needed to be taught to patients prior to discharge. Not every element of this list would be applicable for every surgery. None of the above forms had any single element checked off. Instead, a line was drawn down the side and across the bottom of the list, the word "Noted" followed by the nurses name, date and time was written on the form. "Noted" is a term used in conjunction with physician's orders to let others know that the nurse has reviewed and implemented a set of physician's orders.

On 4/9/13 at 3:10 pm, SC was asked about the documentation of the pre-operative teaching of Patient 4. SC stated that she was responsible for performing the pre-operative teaching but did not document her teaching. She explained that "Noted" meant that the pre-operative nurse was "noting" that the pre-operative teaching was done.

When the fact that Patient 4's surgery would not require all the elements on the list was discussed with SC, she stated that the pre-operative nurse knows her very well and just knows that SC has done a through job of the pre-operative teaching. SC acknowledged that the appropriate documentation would be a check mark by each of the items that was actually taught to the patient by the nurse who actually performed the teaching, at the time of that teaching.

5. On 4/9/13 at 2:30 pm, during a tour of the OR, SC was asked to provide the temperature and humidity logs for the OR suite. SC produced humidity logs which measured the humidity every Friday but did not contain any corrective actions for when the humidity was below 20% humidity as outlined on their log. SC stated that surgery mostly occurred on Fridays but that surgery can also occur on Saturdays. SC confirmed that the humidity of the OR was not measured on the Saturdays in which surgery was performed.

SC stated there was thermometer in the OR, and no other way to evaluate and/or monitoring of the temperature of the OR. She stated that the temperature was controlled by an individual control on the wall.

SC acknowledged the above deficient practices and confirmed that the temperature and humidity were to be controlled at specific levels to prevent infections.

Based on record review and staff interview, for five of 28 reviewed records (Patients 1, 2, 3, 4 and 5), the hospital failed to ensure that:

1) Each patient undergoing a surgical procedure was examined by a qualified practitioner immediately before surgery, to evaluate the risk of the procedure to be performed; and

2) Each patient undergoing anesthesia for a surgical procedure, was examined by a qualified anesthetist, immediately before the procedure, to evaluate the risk of anesthesia.

These failures permitted the possibility that a patient could suffer harm as a result of unrecognized surgical or anesthesia risk.

Findings:

The medical records of 28 patients were reviewed during the survey and the following 5 records (Patients 1, 2, 3, 4 and 5) document a failure to ensure perioperative records are complete and in place as required by regulation and the Medical Staff Rules and Regulations.

On 4/9/13 at 11:30 am, these five records were concurrently reviewed with the Chief Nursing Officer (CNO) and she verified the findings listed below.

1. Patient 1 was admitted to the hospital on 3/8/13 for an outpatient diagnostic and surgical procedure. The record contained a medical history and physical (H&P) examination that had been performed by the surgeon on 3/8/13. However, the record did not contain documentation of an examination by the surgeon or other qualified practitioner within 24 hours, prior to the surgical procedure.

Patient 1 had anesthesia for the surgical procedure, and the record contained a "Pre-Anesthesia Evaluation" form, however the form lacked physical exam findings and did not comment on the risks of anesthesia.

2. Patient 2 was admitted to the hospital on 2/8/13 for an outpatient diagnostic and surgical procedure. The record contained a H&P that had been performed by the surgeon on 1/5/13, which was 34 days before the surgical procedure. There was a "Perioperative Physician Record" which contained a "24 Hour H&P Update" section which was marked with an X in the box adjacent to the text that read, "History & Physical greater than 24 hours, Patient has been re-evaluated and no changes from previous exam have occurred." However, the "Perioperative Physician Record" did not contain documentation of any physical exam findings and did not state that the risk(s) of the surgical procedure had been considered. Also in the record was a second H&P which had at the top, the date "2/8/13." However, this second H&P documented that it was dictated on 2/11/13 and signed by the surgeon on 3/9/13. There was no other documentation of a physical exam or surgical evaluation done within the 24 hours before the procedure.

Patient 2 had anesthesia for the surgical procedure, and the record contained a "Pre-Anesthesia Evaluation" form, however this form did not contain any physical exam findings, any pre-surgical diagnostic or laboratory study findings that would assist in evaluating this patient, who may have had some considerable risk factors consistent with the patient's age, history of heart disease and diabetes. The form did not comment on the risk of anesthesia for this patient.

3. Patient 3 was admitted to the hospital on 11/30/12 for outpatient surgery. The record contained an H&P that had been performed by the surgeon on 11/9/12 and three notes that indicated an update to the exam had been done earlier on the day of surgery.

Patient 3 had anesthesia for the surgery, but the "Pre-Anesthesia Evaluation" form did not contain any physical exam findings or any information about the risks of anesthesia.

4. Patient 4 was admitted to the hospital on 12/14/12 for outpatient surgery. The record contained an H&P that had been performed by the surgeon on 11/9/12, which was 35 days prior to the surgery. However, the record did not contain documentation of an examination by the surgeon or other qualified practitioner within 24 hours, prior to the surgical procedure.

Patient 4 had anesthesia for the surgery. The "Pre-Anesthesia Evaluation" form did not contain any physical exam findings or any information about the risks of anesthesia. The patient had a history of diabetes and hypertension but the chart did not contain a record that laboratory tests or other diagnostic studies had been obtained prior to surgery.

5. Patient 5 was admitted to the hospital on 6/15/12 for outpatient surgery. The record contained an unauthenticated H&P that had been performed by the surgeon on 4/20/12, which was 56 days prior to the surgery. However, the record did not contain documentation of an examination by the surgeon or other qualified practitioner within 24 hours, prior to the surgical procedure.

Patient 5 had anesthesia for the surgery, but the "Pre-Anesthesia Evaluation" form did not contain any physical exam findings or any information about the risks of anesthesia.

Based on interview, and facility document review, the facility failed to report quality indicators that included all radiology and laboratory (lab) services provided to patients. This resulted in an inability to effectively evaluate all services provided to patients and put patients at risk for poor outcomes.

Findings:

1 a. On 4/10/13, the facility policy, titled, "Organizational Performance Improvement Plan," last reviewed 5/2011, read under heading "Quality Control," - "Each department shall review their scope of service and goals and maintain quality control measures and quality control activities as appropriate. The substantive results of these activities shall be reported to the Quality Council at least quarterly."

On 4/11/13 at 8:10 am, the Radiology Manager (RM) was asked what quality control indicators does she monitor. RM stated that she had quality indicators for CT (an imaging unit) scan unit and the daily checking of the emergency drug box. When asked if these indicators were reported to the Quality Assurance and Performance Improvement Plan (QAPI), RM replied that these indicators were not reported to the Quality Department.

b. On 4/11/13 at 9 am, the Lab Manager (LM) was asked about the quality control measures performed in the lab. LM was able to demonstrate an active quality control program for various lab tests. When asked if the overall results of these tests were reported to the QAPI plan, LM replied that it had not been reported to the Quality Department.

On 4/11/13 at 9:30 am, the Director of Quality reviewed the above results, and acknowledged that the Radiology and Lab quality control indicators had not been reported to the QAPI Plan and hence did not have oversight by the governing body.

Based on document review and staff interview, the facility failed to have and implement written protocols designed to train and encourage the nursing staff to show discretion and sensitivity with respect to the circumstances, views, and beliefs of the families of potential donors. This failure had the potential to cause affected patients and families excess emotional distress.

Findings:

On 3/8/13 at the hospital was asked to provide the written protocol(s) and training records related to "Organ and Tissue Procurement" and no policies and procedures (P/P) were provided.

On 3/9/13 at 14:15 pm, the Chief Nursing Officer provided a single P/P and stated that the hospital did not have a specific protocol for sensitively training of the nursing staff. She also stated that to her knowledge, no such training had taken place in the past year. The single P/P titled "Organ and Tissue Donation - Nursing Staff Responsibilities" gave general guidelines about caring for patients near the end of their life, and specific details for preparing the documents related to organ and tissue procurement. However, the hospital had not done nursing staff sensitivity training and had no policies that directed the staff to be trained.

Based on interview and record review, the facility failed to ensure that the policy for patient rights had been updated to include visitation rights of patients. This failure had the potential for discrimination in regards to the patients' visitors and thus preventing patients from the proper support of their loved ones and visitors.

Findings:

On 4/10/13, the facility policy, titled, "Patient Rights and Responsibilities," dated 9/06, did not contain visitation rights language from CFR 485.635(a).

On 4/10/13 at 4:15 pm, the Chief Operating Officer (COO) reviewed the policy and the above CFR 485.635(a), and acknowledged that he was unaware of the regulations. COO confirmed the above facility policy had not been updated to reflect these regulations.