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Based on interview and record review the facility failed to ensure the Dietary department manager met the continuing education requirements to maintain professional certification to be qualified for her position. This deficient practice had the potential to affect food service sanitation and safety for all patients, staff and volunteers. The facility census was six.

Findings included:

1. Record review of the Association of Nutrition and Foodservice Professional's (the credentialing organization for Certified Dietary Managers) web site showed food service management professionals who complete the Certified Dietary Manager's course work and take the examination (examination established in 1985) were then required to earn 45 hours of continuing education (CE) every three years. At least five of the continuing education hours must be in sanitation and food safety.

2. Record review of a certificate of completion dated 1993 showed Staff D, Dietary Department Manager, completed course work and passed the examination to be a Certified Dietary Manager.

3. During an interview on 12/02/13 at 2:52 PM, Staff D stated that she had never attended any continuing education to earn CE hours to maintain certification because she did not know it was a requirement.

Based on observation, interview, record and policy review, the facility failed to ensure three of three Crash Carts, (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment at the site of medical/surgical emergency for life support protocols to potentially save a person's life):
- Could only be opened by authorized staff;
- The plastic secure locks were kept in a secure location in the Emergency Department (ED), the medical/surgical unit and the Outpatient Clinic; and
- The plastic secure locks were numbered and/or used sequentially.
This had the potential to allow drugs, biological's and equipment to be diverted. The facility census was six.
Findings included:
1. Record review of the facility's policy titled, "Crash Cart Check" reviewed 10/12, showed the following direction for staff:
- Crash cart is to be checked each shift that patient care is provided to verify it is locked.
- If the cart is open, you must verify that all items on the cart are actually present and are in useable condition.
- After verifying cart and defibrillator (a device the provides a therapeutic dose of electrical energy to the heart to restore normal function) function, document on the crash cart checklist located on the cart.
2. Observation on 12/03/13 at 12:00 PM of the Crash Cart in the hall of the Medical/Surgical Unit - East Wing showed a cart with a numbered plastic lock which was used to secure the drugs and supplies in the cart. The replacement plastic locks were kept in the Crash Cart drawer.
3. During an interview on 12/02/13 at 2:30 PM, Staff G, Relief Shift Supervisor, stated that the extra locks were kept in the Crash Cart. She stated that the locks were ordered from Central Supply and came to the floor in a plastic bag with numerous locks. She stated that there was not a system to monitor which locks were used or in what numbered order.
4. Observation on 12/03/13 at 3:55 PM, of the ED Crash Cart located in the Trauma room of the ED showed a red plastic key with a number that locked the Crash Cart. When the Crash Cart was opened it showed a key ring with 43 red plastic keys resting on the top drawer of the Crash Cart. The key ring with the red plastic keys was available to anyone that opened the Crash Cart.
5. During an interview on 12/03/13 at 3:55 PM, Staff C, RN, ED Manager, stated that:
- When staff opened the Crash Cart they are to document the date, time and reason why the Crash Cart was opened.
- Staff are to replace the red plastic key with a new one from the key ring located on the top drawer of the Crash Cart after it has been opened.
- The red plastic keys were not monitored, so if staff did not document when or why the Crash Cart was opened there would be no explanation why the key was replaced.

After Staff C reviewed the CODE BLUE CARTS checklist that staff documented when the Crash Cart was opened, Staff C stated that staff were not consistent in documenting why they opened the Crash Cart. Staff C stated that there was no way to know why staff opened the Crash Cart if they do not document the reason why. She stated that there was no way to monitor it since the keys were available to any staff or person that opened the Crash Cart.
6. Observation on 12/05/13 at 9:40 AM showed a Crash Cart in the Out Patient department which had a green plastic lock to secure the drugs and supplies in the cart.
7. During an interview on 12/05/13 at 9:50 AM, Staff V, Out-Patient Director, stated that she was aware of the problems that had occurred on other units with the numbered secure locks kept in the Carts. She stated that the numbered locks were kept in her office.
8. Observation on 12/05/13 at 10:00 AM showed a plastic bag with numerous green plastic numbered locks on the Directors desk. The printed information on the plastic bag showed there were originally 100 locks in the bag. The door to her office was unlocked which would allow anyone passing by to have access to the locks and therefore potential access to the drugs.




18018

Based on interview and policy review, the facility failed to follow established policies related to reporting adverse drug reactions (ADR) that occurred in the facility to the Food and Drug Administration (FDA/Med-Watch Program-the FDA's reporting system for an adverse or sentential event-an unexpected or unanticipated outcome, death, or serious physical or psychological injury, or the risk thereof). The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Adverse Drug Reactions" reviewed 01/13, showed the following direction:
- An ADR is any reaction to a drug that is unexpected, unintended, undesirable and occurs at doses normally used for prophylaxis (measures to maintain health and prevent the spread of disease), diagnosis, or therapy.
- Once the ADR has been identified, a pharmacist will investigate the incident and offer any information to nursing or to the physician that may be pertinent.
- The ADR will be reviewed by the Pharmacy and Therapeutics Committee and if determined necessary, a copy of the report will be sent to the Hospital Reporting Program of the Federal Food and Drug Administration.

2. During an interview on 12/05/13 at 11:35 AM, Staff BB, Pharmacist, stated that:
- When he received a report that a patient had experienced an ADR he does an investigation.
- After he had finished the investigation, he filled out a report on the facility's Medication Error-Adverse Drug Event Report Form.
- He gave the completed form to the facility's Clinical Nursing Officer/Risk Manager and she informed the FDA/Med Watch Program of the ADR.

3. During an interview on 12/05/13 at 11:35 AM, Staff B, Clinical Nursing Officer/Risk Manager, Register Nurse (RN), stated that she did not report the facility's ADR to the FDA/Med Watch Program because she thought the pharmacist reported them. Staff B stated that she did not know that Staff BB did not report the ADR to the FDA/Med Watch Program.

Based on interview and policy review, the facility failed to ensure the Infection Control Preventionalist (ICP) performed facility-wide surveillance to monitor infection control issues throughout the facility and failed to maintain a log with staff illnesses. This had the potential to affect staff, contractors, patients and visitors while at the hospital. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Infection Prevention Program" revised 11/11, showed the following direction:
- Surveillance: The following areas are the foundation of the surveillance program:
- Acute Care;
- Outpatient Services;
- Emergency Care;
- Surgery;
- Employee Health and Safety.
- Risk Identification and Prioritization:
- Surveillance: Total house surveillance is performed to ensure the safety of our patients, guests and staff.
- Methods and Standards of Surveillance: Program design-although there is no single method of surveillance design or implementation, sound epidemiological principals are the foundation of the program. Surveillance programs should include:
- Methods to determine, measure, and compare data related to disease and associated risks so that appropriate interventions can be planned and implemented.
- Detailed procedures concerning the collection of data. Consistency of the surveillance effort over time will maintain the accuracy and sensitivity of the data collection.
-Baseline data collection; baseline data provides the foundation for the other uses of surveillance. Baselines can be used to search for mechanisms to reduce infection rates and to determine if those measures produce the desired outcome.

2. During an interview on 12/04/13 at 2:55 PM, Staff Z, Registered Nurse (RN) ICP, stated that he did not have documented data related to surveillance for all departments throughout the facility. Staff Z stated that he did not perform surveillance in housekeeping, dietary or laundry and that he did not track staff illnesses or document them in a log.

Based on observation, interview and record review the facility failed to ensure:
- The menus used for patient meal service were approved (signed) by a Registered Dietitian.
- The Dietary department policies and procedures were approved (signed) by the Chief Executive Officer or designee.
- The approved diet manual was current and available to nursing personnel as reference information.
- Temperatures of hot foods served to patients were hot enough to prevent food borne illness.
- Foods used for patient consumption were stored in a sanitary manner and separate from non-food items.
These deficient practices had the potential to affect the therapeutic accuracy of diets served and food service sanitation and safety for all patients. The facility census was six.

Findings included:

1. Record review of the current facility menus used to serve patient meals showed the Registered Dietitian (RD) failed to sign them (signifying approval of the nutritional content of the menus).

2. During an interview on 12/02/13 at 3:08 PM, Staff D, Dietary Department Manager reviewed the menus and confirmed that the facility menus had not been approved (signed) by the RD.

3. Review of the facility Dietary department policy and procedure book showed the policies and procedures were signed by the Dietary Department Manager but not the Chief Executive Officer (CEO) or designee.

4. During an interview on 12/02/13 at 3:30 PM, Staff D stated that she had signed the department policies however, had not asked her supervisor (the Chief Financial Officer and designee for the CEO) to approve (sign) them.

5. During an interview on 12/02/13 at 3:15 PM, Staff D stated that the approved facility diet manual was the "Manual of Clinical Dietetics" from the American Dietetic Association (ADA) revised 2000 (thirteen years ago) and that the diet manual was maintained on the facility computer system.

6. Record review of the approval page showed that the "Manual of Clinical Dietetics" was last approved in 11/13 by staff including the RD and the Medical Staff president.

7. Record review of the Academy of Nutrition and Dietetics (AND) website showed the following:
- The ADA became the AND 01/12.
- "The Manual of Clinical Dietetics" was a hardcover textbook.
- The diet manual available through the AND was titled "The Nutrition Care Manual".
- "The Nutrition Care Manual" was available in an on-line version.

8. Observation and interview on 12/03/13 at 12:26 PM, on the patient unit showed:
-Staff I, Nurse Supervisor, searched on a book shelf for the diet manual and when she did not find it stated that she would get a copy from another area.
- Staff QQ, Certified Nurse Aide, also searched a book shelf in the nurse's station looking for a diet manual. She stated she did not know if the diet manual was on the facility computer.
- Staff RR, Unit Clerk, stated she had been employed with the facility a long time and did not know where the diet manual was located.

9. Record review of the United States Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2011 Food Code, Chapter 3-501.16 showed hot foods should be served at or above 135 degrees Fahrenheit.

10. Record review of the facility's policy titled "Temperatures" dated 12/11/12, directed Dietary department staff to serve hot foods on patient meal trays at or above 135 degrees Fahrenheit.

11. Observation on 12/03/13 at 12:35 PM on the patient unit showed Dietary department staff served a test meal tray with foods including:
- Baked chicken at 125 degrees Fahrenheit;
- Au gratin potatoes at 120 degrees Fahrenheit;
- Peas at 125 degrees Fahrenheit.

12. During an interview on 12/03/13 at 12:35 PM, Staff D, stated that the chicken, potatoes and peas should be served at or above 135 degrees Fahrenheit and the test tray temperatures did not meet temperature standards.

13. Record review of the USDHHS,PHS, FDA, 2011 Food Code, Chapter 3-305.11 Food Storage, (A) (2) directed staff to protect foods from contamination by storing food where they were not exposed to splash, dust, or other contamination.

14. Observation on 12/03/13 at 12:45 PM, on the patient unit showed the following:
- Staff stored foods and beverages in a refrigerator for patient use;
- The refrigerator had an eight inch by eleven inch sign on the door that directed "Patient Food Only";
- In the freezer section of the refrigerator, staff stored individual ice cream servings in a plastic shoe box with ice packs (routinely used on patients).

15. During an interview on 12/03/13 at 12:45 PM,
- Staff D stated that the ice packs should not be in the freezer with the foods for patient use.
- Staff R, Relief Nursing Supervisor, stated that the ice packs should not be stored in the patient food refrigerator.
- Staff I, Nursing Supervisor, stated that the ice cream and ice packs should not be stored together and that the ice cream should now be discarded.

Based on interview and policy review, the facility failed to ensure that a Registered Nurse (RN) made patient care assignments based on the patients' needs. This had the potential to affect all patients treated at the facility. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Patient Assignments" revised 08/01, showed patient care assignments shall be made by the unit manager/supervisor each shift. Assignments must be made to reflect the consideration of the following:
- The patient's status.
- The environment which the nursing care is provided.
- The competence of the nursing staff member who is to provide the care.
- The degree of supervision required by and available to this person.

2. During an interview on 12/04/13 at 2:11 PM, Staff EE, Registered Nurse (RN), stated that RNs and Licensed Practical Nurses (LPNs) collaborated and discussed who was going to take what patient. Staff EE stated that the nursing manager/supervisor did not make out patient assignments for the staff nurses.

3. During an interview on 12/05/13 at 10:15 AM, Staff SS, LPN stated that:
- During shift report staff nurses decided what patients they want to care for.
- Staff reviewed patients' needs and divided the heavy load patients .
- Nursing managers/supervisors attended shift report but they did not assign patients to staff.

4. During an interview on 12/05/13 at 10:30 AM, Staff I, RN, Inpatient Team Manager, stated that:
- Nursing assignments were a team effort made by staff.
- Patient assignments were equally divided among staff.
- She did not make patient assignments for staff.
- She allowed staff to make the decision of what patients they wanted to care for.

5. During an interview on 12/05/13 at 10:45 AM, Staff AA, RN, Relief Supervisor stated that ultimately it was her responsibility to make patient assignments for staff. Staff AA stated that she would ask staff who was taking what patients during report but she did not assign patients to staff.

Based on observation, interviews, record and policy review, the facility failed to document assessment for one patient (#1) out of one patient reviewed that was admitted to the facility with a pressure ulcer (an area of skin that breaks down when something keeps rubbing or pressing against the skin). This had the potential to affect all patients admitted to the facility with pressure ulcers. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Wound Guidelines" revised 06/10, showed that assessment will include: Location, size in cm's (centimeters), depth, specifics of exudates (fluid that has oozed out of a tissue due to injury or inflammation), appearance of wound bed and condition of surrounding skin.

2. Record review of the patient's History and Physical (H&P) dated 12/02/13, showed Patient #1 was admitted on that date and had a deep sacral (a triangular-shaped bone at the bottom of the spine) pressure ulcer that was being treated with a wound VAC (a therapeutic technique that uses a sealed wound dressing connected to a vacuum pump to assist in healing wounds) at the nursing home.

3. Observation on 12/03/13 at approximately 10:15 AM, of the patient's sacral pressure ulcer showed a deep opened area approximately the size of a baseball that had reddened tissue around the opened area.

4. Record review of the patient's Initial Interview (Admission Nursing Assessment) dated 12/03/13 at 12:12 PM, showed staff documented that the patient had a wound/ulceration on sacrum, Stage 4 (a pressure ulcer that has become so deep that there is damage to the muscle and bone).
Staff did not document the size of the pressure ulcer in cm's, depth, exudate, appearance of wound bed or condition of surrounding skin.

5. Record review of the patient's Problems/Goals (Care Plan) dated 12/02/13 at 1:30 PM, showed staff did not include in the problem list the patient's alteration in skin integrity that included interventions and measurable timetables.

6. During interview on 12/04/13 at 10:15 AM, Staff I, Registered Nurse (RN), Inpatient Team Manager, stated that she would expect staff on admission to document measurements and describe a patient's wound in the medical record. Staff I stated that she would especially expect staff to document wound measurements and description of Stage 4 pressure ulcers. Staff I stated that she expected staff to follow the facility's policy and procedures.

Based on interview, record and policy review, the facility failed to incorporate a comprehensive care plan with measurable goals and timetables for two patients (#1 and #6) out of two patient's medical records reviewed for care plans. This had the potential to affect all patients admitted to the facility that needed a care plan. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Nursing Care Plans" revised 06/10, showed the following direction:
- The care plan will be initiated by the admitting Registered Nurse (RN) at the time of admission, or within 24 hours after admission.
- Realistic, measurable goals shall be mutually set with the patient and/or his/her significant other when possible.
- The care plan shall be reviewed each shift and revised as the needs change.
- These should include short-term goals and discharge goals.
- Set deadlines by which goals are to be achieved and problems solved.
- Identify specific nursing interventions to accomplish defined goals.
- Evaluate the effectiveness of nursing interventions in comparison with defined goals at the end of each shift.

2. Record review of Patient #1's medical chart showed she was admitted to the facility on 12/02/13 with complaints of aspiration (when food or fluids are inhaled into the lungs) and Stage 4 pressure ulcer (a pressure ulcer that has became so deep that there is damage to the muscle and bone) ulcer.

3. Record review of the patient's Problems/Goals (Care Plan) dated 12/02/13, showed staff did not include aspiration or pressure ulcer in the patient's care plan.

4. During an interview on 12/04/13 at 10:15 AM, Staff I, Registered Nurse (RN), Inpatient Team Manager, stated that she would expect staff to care plan for the patient's skin wound. Staff I stated that a care plan for the patient's skin wound would be one of the first she would expect staff to initiate.

5. Record review of Patient #6's medical chart showed the patient was admitted to the facility on 11/26/13 with diagnosis of bowel obstruction (blockage of the intestines) after a previous abdominal surgery two weeks prior. Staff assessed and documented the patient as a fall risk with lower extremity weakness, ambulation with a walker and assist of staff.

6. Record review showed the patient was found on the floor of her room on 12/02/12. No updated care plan was found to reflect the fall or the increased interventions of a bed alarms, personal alarms or moving the patient closer to the nursing station. The care plan was not updated to reflect the decision of the physician to delay the patient's discharge on 12/02/13.

7. During an interview on 12/03/13 at 2:00 PM, Staff M, RN, stated that the care plans are to be reviewed each shift. Staff M stated that the care plan for the patient did not reflect an update for her recent fall or the change in discharge plans.

8. During an interview on 12/03/13 at 2:30 PM, Staff I, stated that the care plan for the patient had been documented as "reviewed" but that no updates to the care plan had been made. Staff I stated that the care plan should have been updated after the patient fell on 12/02/13 and updated after it was determined the patient would not be discharged on 12/02/13 as planned. Staff I stated that the care plan did not reflect the patient's individualized needs.





27727

Based on interview and record review facility staff failed to ensure all physician's verbal orders were signed within twenty-four hours in six (#6, #7, #10, #11, #12 and #14) of six patient medical records reviewed. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Medical Record Content", reviewed 04/13, showed that physician's verbal orders must be signed by the physician within twenty-four hours.

2. Record review of the facility's "Medical Staff Rules and Regulations Article VI, Orders, Paragraph 6.3-2, Documentation", revised 11/21/13 showed that all verbal orders shall ... be signed by the prescribing physician within twenty-four hours.

3. Record review of current Patient #6's physician's orders showed three verbal orders on 11/26/13 that were signed on 11/30/13.

4. During an interview on 12/03/13 at 2:30 PM, Staff E, Director of Health Information Management (HIM) stated that the three orders were not signed within the required twenty-four hours.

5. Record review of discharged Patient #7's physician's orders showed a verbal order on 10/03/13 that was signed on 10/15/13.

6. Record review of discharged Patient #10's physician's orders showed three verbal orders on 10/04/13 that were signed on 10/30/13 (first one); 11/20/13 (second one) and 10/08/13 (third one).

7. Record review of discharged Patient #11's physician's orders showed an order on 10/08/13 that was signed on 10/16/13.

8. Record review of discharged Patient #12's physician's orders showed an order on 09/24/13 that was signed on 10/02/13.

9. Record review of discharge Patient #14's physician's orders showed an order on 10/26/13 that was not signed.

10. During an interview on 12/03/13 at 2:25 PM, Staff E reviewed the discharged patient's physician's verbal orders for Patients #7, #10, #11, #12 and #14 and confirmed the physicians failed to sign the orders within the appropriate twenty-four hour time frame.

Based on interview, policy and record review, the facility failed to take to ensure services provided through agreement or arrangements (contracts) were evaluated for quality of care for one of five contracts reviewed. This deficient practice had the potential to affect all patients who received imaging services through the facility's contracted Nuclear Medicine Department. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Hospital Wide Performance Improvement", last reviewed 1/12, showed that "The activities of the Performance Improvement program shall apply to all departments, services and individuals within the hospital whose activities within the hospital have a direct or indirect impact on the quality of patient care." Further review showed the contracted nuclear medicine imaging services was not included under the Performance Improvement Scope of Services directory for all departments.

2. Record review of the agreement between the facility and the nuclear medicine imaging services company dated 03/01/10, showed no evidence of evaluation of services and no quality assessment or performance improvement activities.

3. Record review of the facility's document titled, "2013 Current PI (Performance Improvement) Reporting Schedule" showed no evidence that the contracted nuclear medicine imaging services company was evaluated for quality of service and that evaluation was reported to the Board of Directors. Further review of the quality report presented to the Board of Directors for the third Quarter 2013, showed no evidence of evaluation of nuclear medical services or any performance improvement/quality assessment activities.

4. During an interview on 12/04/13 at 10:50 AM, Staff B, Chief Nursing Officer, stated that:
- Prior to the last board meeting (November) no quality assessment information for nuclear medicine services had been submitted by the contracted imaging service.
- She had not received anything from the contracted imaging service since that date.
- The performance improvement/quality assessment activity information pertaining to nuclear medical services performed at the hospital had been compiled and submitted to the contracted service, but she had failed to notice that the contracted imaging service had not responded with any form of evaluation or tabulated result data to show how they were improving services to patients. She added, "we've not really had eyes on it."

Based on interview, record and policy review, the facility's Activity Director (AD) failed to:
- Provide activities which were individualized to the patient.
- Provide a care plan with measurable goals and timetables which addressed activities based on the patient's comprehensive assessment.
- Provide an activity calendar to the patient in a timely manner.
- Provide and/or post an activity calendar to the Medical/Surgical Unit for one patient (#6) of one Swing-bed record reviewed. The facility census was six with one of those in Swing-bed status (Swing-beds are a Medicare program in which a patient can receive acute care then if needed Skilled Nursing Home care).
Findings included:
1. Record review of the facility's policy titled, "Patient Activities Program - Swingbed" revised 01/12, showed direction for staff to personalize activities for each patient and provide as scheduling permits and condition allows and to have an Activity flow sheet present in each patient's chart.
2. Record review of Patient #6's medical record showed she was admitted to Swing-bed status on 11/26/13.
3. Record review of the undated Initial Activity Assessment showed the patient's current interests were cards, games, exercise, sports, music, reading, baking, walking, watching television, watching movies, and listening to the radio. The patient indicated she would prefer to participate either in the morning or afternoon and go to the dayroom. Documentation in the comments section showed the patient was not given an activity calendar because they had not yet been printed.
4. Record review of the patient's medical chart showed no Activity Flow Sheet was found in the patient's medical chart and no plan of care which included activities.
5. During an interview on 12/02/13 at 9:25 AM, Patient #6 stated that she did not remember anyone from Activities offering to provide her with activities and did not give her an activities calendar.
6. During an interview on 12/02/13 at 10:10 AM, Staff L, Activities Director, stated that she gave Swing Bed patients an activities calendar and a newsletter. She stated that she gave Patient #6 a December calendar and a newsletter earlier this morning. She stated that patients were taken to the Convalescent Center's dayroom for activities. She stated that she did not provide an Activities Calendar to the Medical/Surgical Unit; nor did she verbally inform the unit of upcoming activities.
7. During an interview on 12/03/13 at 12:35 PM, Staff M, Registered Nurse, on the Medical/Surgical unit stated that an activities calendar was not provided for posting. She stated that someone from activities would telephone the staff to let them know if they were planning to take a patient off the unit to go to an activity. She stated that if they didn't call; they would not know what activity was occurring.





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