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Based on record review and interview, the facility failed to ensure that all patients were informed of their rights, in advance of furnishing patient care for 20 of 20 patients reviewed (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20).


Findings included:


Record review on 03/25/15, of the facility's Patient Rights and Responsibilities form, last revised April 18, 2003, and last reviewed July 2008, revealed twenty rights and responsibilities for patients.


Record review on 03/25/15, of Patient medical records (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20) revealed no evidence or documentation of the Patient's receiving a copy of their Patient Rights and Responsibilities form.


Interview on 03/24/15, at 4:45 PM, with the Centralized Scheduling Coordinator and the Outpatient Admitting Coordinator confirmed they did not give a copy of the Patient Rights and Responsibilities form to inpatients and/or outpatients.


During an interview on 03/25/15, at 4:40 PM, with the Main Hospital Admitting Admission Representative A confirmed patients were not provided with information specific to the Patient Rights and Responsibilities form. Admission Representative A stated Patients were only provided the Notice of Privacy Practices (effective 09/23/13) and the Right to Receive Visitors for "Rights" upon admission. Admission Representative A further stated this information was only provided if they had never been a patient at the facility before, or if it had been over a year from their last visit; otherwise the facility would not necessarily ensure the patient signed the notice of privacy practices acknowledgment.


21863

Based on record reviews and interviews, the facility's governing body failed to develop, implement and maintain evidence of an effective, ongoing, hospital-wide, data driven quality assessment and performance (QAPI) program. Specifically,

1.) The facility failed to follow its policy and procedure regarding quality assessment and performance improvement (QAPI) activities by failing to ensure that all services and departments provided in the hospital were included in the hospital wide QAPI program. Review of the 2014/2015 program data documentation revealed the following hospital departments were not evaluated or included in the hospital wide QAPI program: telemedicine utilized in geropsychiatric services, wound care provided through the therapy department, respiratory therapy, materials management, pharmacy, plant operations, security, the swing bed program, human resources, staff development, and risk management.

Refer to A0273

2.) The facility failed to document how it identified problems and implemented a performance improvement project in the area of infection control. Review of the program data for the 2014/2015 year did not reveal documentation of how the facility decided on an ongoing performance improvement activity in infection control, implemented the activity, measured the activity's success, and tracked performance to ensure the improvements are sustained.

Refer to A0283


The cumulative effects of these deficient practices resulted in the facility's inability to meet the Condition of QAPI which could affect the overall patients' health and safety.

Based on record reviews and interviews, the facility failed to follow its policy and procedure regarding quality assessment and performance improvement (QAPI) activities.


Findings included:


Record review on 03/24/15, of Score Care Completion Policy and Procedure under the Quality Management Department, last revised February 25, 2005, revealed but was not limited to the following:


"Each department measuring or tracking for performance improvement will provide this information in the format of a Score Card. The individual departmental criteria for monitoring will be decided upon through collaboration with the department head and the quality management department. The quality management department will supply copies of departmental score cards to the medical staff office for distribution to the appropriate Medical Staff Committee members for review. The Operational Board will be provided reports, compiled from the above, regarding housewide performance in the same score card format."



Record review of QAPI documentation made available by the facility from 03/24/15, to 03/25/15, revealed no 2014/2015 program data documentation from the following hospital departments: telemedicine utilized in geropsychiatric services, wound care provided through the therapy department, respiratory therapy, materials management, pharmacy, plant operations, security, the swing bed program, human resources, staff development, and risk management.


Interview on 03/24/15, with Quality Management Administrative Staff A revealed the Director of Quality Management went on leave at the end of February 2015 and was not accessible at this time. She stated that if there is information on these departments, it is in her computer and not accessible to anyone but her. She confirmed that Score Cards are not completed for all departments. She stated all departments work together but there is "nothing cut and dried on how it all ties together."


During an interview on 03/24/15, at 12:15 PM, with the facility's Chief Nursing Officer (CNO) stated the facility had an "Action Plan to implement a Quality Improvement, QAPI; with targeted measures."


Interview on 03/24/15, at 3:00 PM, with Quality Management (QM) Administrative Staff A revealed there were no quality management meeting minutes available specific to QAPI because it was "one of those things we are working on" and currently "falls under other committees."

Interview on 03/25/15, at 12:00 PM, with the facility Risk Manager( who was being discharged as a patient from the facility on this date) revealed that all contracted services including pharmacy, laboratory, environment of care services, telemedicine, and cable services are computerized. She confirmed that these services are not currently being evaluated. She confirmed that the Director of Quality Management does not hold QAPI meetings and are no separate QAPI minutes were available for review.

Based on record review and interviews, the facility failed to document how it identified problems and implemented a performance improvement project in the area of infection control.


Findings included:


Record review of available Quality Assessment and Performance (QAPI) data for the 2014/2015 year did not reveal documentation of how the facility decided on an ongoing performance improvement activity in infection control , implemented the activity, measured the activity's success, and tracked performance to ensure the improvements are sustained.


Interview on 03/24/15, at 11:45 AM, with the Infection Control Coordinator revealed that one of the facilities's performance improvement activities was the documentation of urinary tract infections associated with the use of Foley catheters. She stated this information is communicated to the physicians but there is no documentation available on this process. She confirmed that the goal of 95 % had been consistently met for over a year but this was still considered an ongoing performance improvement activity. She confirmed there was no documentation on why this was originally chosen as a performance improvement project and why it continues as a performance improvement project.

Based on record review and interview, the facility failed to ensure medical records were promptly completed within thirty (30) days after a patients discharge; in accordance with the facility's policy which designated delinquent records were 14 days following discharge for 2 of 10 discharged patients reviewed (Patient's #2 and #7).

Patient #2 had been discharged from the facility over 30 days and Patient #7 over 100 days; and the medical records were incomplete and delinquent requiring physician signatures on the following: telephone orders, discharge summaries, and a history and physical (H&P)'s.

This deficient practice could affect the authenticity and integrity of Patients medical records; specifically those records requiring authentication by physician signature.


Findings included:

Review of the facility's Medical Staff By Laws approved 09/26/13, and Medical Staff Rules and Regulations approved 05/23/13, revealed the following: "C. 1. D. Medical records become delinquent 14 days following discharge (including signatures)." Further review revealed deficiency notices would be provided to the physicians and Medical Records Director and if records were not completed by the following Monday, then suspension would take effect.


Patient #2

Record review on 03/25/15 of Patient #2 revealed he was discharged from the facility on 02/04/15 (49 days ago). The following Physician orders and reports had not been signed or authenticated by a physician for Patient #2:

Physician #7's Telephone Order (TO) dated 01/31/15, for Ativan administration.
Physician #7's Discharge Summary dated 02/04/15. Further review of the electronic report revealed the following, "This document is considered preliminary until signed."
Physician #7's History and Physical (H&P) dated 01/02/15.



Patient #7

Record review on 03/25/15, of Patient #7's records revealed she was discharged from the facility on 12/11/14 (over 100 days ago). Patient #7's Discharge summary dated 12/11/14 had not been signed by Physician #21. The electronic report revealed the following, "This document is considered preliminary until signed."



Further review of the facility's Medical Staff By Laws and Rules and Regulations revealed the following, "E. Medical Orders: Verbal or telephone orders relating to cases involving restrain, narcotics, or high risk drug therapy must be signed within 48 hours from time of order. All verbal or telephone orders must be signed prior to the Patients' chart being completed and filed."


During an interview on 03/25/15, at 10:25 AM, with the Director of Education who assisted with the verification of records, confirmed the Patients Discharged records were incomplete and delinquent for Patients #2 and #7 requiring physician signatures for the telephone order, discharge summaries, and an H&P.


During an interview on 03/25/15, at 3:00 PM, with the Quality Management Administrative Staff confirmed the delinquent records for Patient's #2 and #7 and further provided acknowledgment that Physician #7 had 110 Delinquent Medical Records/Charts for the month of March 2015.


Record review of the March Total Delinquent Medical Records revealed the facility had a total of 950 records identified as delinquent. Further review revealed Physician #7 had 110 Total charts (at 11.58%) and Physician #21 had 3 Total charts.

Based on record review and interview, the facility failed to ensure that all patient medical record entries were completed and authenticated in writing or electronic form by the person responsible for providing the information or services performed, consistent with hospital policies and procedures for 2 of 10 discharged patients (Patient's #2 and #7) reviewed, and 1 of 10 current inpatient records reviewed (Patient #11).


Patient #2 was discharged from the facility over 30 days and Patient #7 over 100 days; and the medical records were incomplete and delinquent requiring physician signatures on the following: telephone orders, discharge summaries, and a history and physical (H&P)'s. Patient #11's Admission Physician Medication Verbal Orders and Medication Reconciliation had not been signed since his admission on 03/19/15.

This deficient practice could affect the authenticity and integrity of Patients medical records; specifically those records requiring authentication by physician signature.



Findings included:


Review of the facility's Medical Staff By Laws approved 09/26/13, and Medical Staff Rules and Regulations approved 05/23/13, revealed the following: "C. 1. D. Medical records become delinquent 14 days following discharge (including signatures). 9. All clinical entries in the Patient's medical record shall be accurately dated, timed and authenticated." Further review revealed deficiency notices would be provided to the physicians and Medical Records Director and if records were not completed by the following Monday, then suspension would take effect.


Further review of the facility's Medical Staff By Laws and Rules and Regulations revealed the following, "E. Medical Orders: Verbal or telephone orders relating to cases involving restrain, narcotics, or high risk drug therapy must be signed within 48 hours from time of order. All verbal or telephone orders must be signed prior to the Patients' chart being completed and filed."


Patient #2

Record review on 03/25/15, of Patient #2 revealed he was discharged from the facility on 02/04/15 (49 days ago). The following Physician orders and reports had not been signed or authenticated by a physician for Patient #2:

Physician #7's Telephone Order (TO) dated 01/31/15 for Ativan administration.
Physician #7's Discharge Summary dated 02/04/15. Further review of the electronic report revealed the following, "This document is considered preliminary until signed."
Physician #7's History and Physical (H&P) dated 01/02/15.


Patient #7

Record review on 03/25/15, of Patient #7's records revealed she was discharged from the facility on 12/11/14 (over 100 days ago). Patient #7's Discharge summary dated 12/11/14, had not been signed by Physician #21. The electronic report revealed the following, "This document is considered preliminary until signed."


Patient #11

Record review on 03/25/15, of Patient #11's records revealed he was admitted to the facility on 03/19/15. Patient #11's Verbal ordered Medications and Inpatient Medication Reconciliation Orders dated 03/19/15, by Physician #7 revealed a physician had not signed or authenticated the verbal physician admission orders for medications administered.


During an interview on 03/25/15, at 10:25 AM, with the Director of Education who assisted with the verification of records, confirmed the Patients Discharged records were incomplete and delinquent for Patients #2 and #7 requiring physician signatures for the telephone order, discharge summaries, and an H&P.


During an interview on 03/25/15, at 2:00 PM, with the facility's Director of Nursing on the Medical Surgical floor 4 confirmed that Patient #11's verbal ordered Medications and Inpatient Medication Reconciliation Orders dated 03/19/15, had not been signed or authenticated by a physician as of this date.


During an interview on 03/25/15, at 3:00 PM, with the Quality Management Administrative Staff confirmed the delinquent records for Patient's #2 and #7 and further provided acknowledgment that Physician #7 had 110 Delinquent Medical Records/Charts for the month of March 2015.


Record review of the March Total Delinquent Medical Records revealed the facility had a total of 950 records identified as delinquent. Further review revealed Physician #7 had 110 Total charts (at 11.58%) and Physician #21 had 3 Total charts.

Based on record review and interview, the facility failed to ensure all orders, including verbal and telephone orders were authenticated promptly by the ordering practitioner or by another practitioner who was responsible for the care of the Patient in accordance with State law, Hospital policies, and medical staff by laws, rules, and regulations for 1 of 1 discharged patients (#2) reviewed, and 1 of 10 current inpatient records reviewed (Patient #11).


This deficient practice could affect the authenticity and accuracy of Patients verbal and telephone orders taken and transcribed by others that require authentication by physician signature.


Findings included:


Review of the facility's Medical Staff By Laws approved 09/26/13, and Medical Staff Rules and Regulations approved 05/23/13, revealed the following: , "E. Medical Orders: Verbal or telephone orders relating to cases involving restrain, narcotics, or high risk drug therapy must be signed within 48 hours from time of order. All verbal or telephone orders must be signed prior to the Patients' chart being completed and filed."


Patient #2

Record review on 03/25/15, of Patient #2 revealed he was discharged from the facility on 02/04/15 (49 days ago). The Physician Telephone order (TO) dated 01/31/15, by Physician #7 for Ativan administration had not been signed or authenticated by a physician for Patient #2.


Patient #11

Record review on 03/25/15, of Patient #11's records revealed he was admitted to the facility on 03/19/15. Patient #11's Verbal ordered Medications and Inpatient Medication Reconciliation Orders dated 03/19/15, by Physician #7 revealed a physician had not signed or authenticated the verbal physician admission orders for medications administered.


During an interview on 03/25/15, at 10:25 AM, with the Director of Education who assisted with the verification of records, confirmed the Patients Discharged records were incomplete and delinquent for Patient #2 requiring Physician signatures.


During an interview on 03/25/15, at 2:00 PM, with the facility's Director of Nursing on the Medical Surgical floor 4 confirmed that Patient #11's verbal ordered Medications and Inpatient Medication Reconciliation Orders dated 03/19/15, had not been signed or authenticated by a physician as of this date.


During an interview on 03/25/15, at 3:00 PM, with the Quality Management Administrative Staff confirmed the delinquent records for Patient #2, and further provided acknowledgment that Physician #7 had 110 Delinquent Medical Records/Charts for the month of March 2015.


Record review of the March Total Delinquent Medical Records revealed the facility had a total of 950 records identified as delinquent. Further review revealed Physician #7 had 110 Total charts (at 11.58%) and Physician #21 had 3 Total charts.


Further review of the facility's Medical Staff By Laws and Rules and Regulations revealed the following, "C. 1. D. Medical records become delinquent 14 days following discharge (including signatures)." Further review revealed deficiency notices would be provided to the physicians and Medical Records Director and if records were not completed by the following Monday, then suspension would take effect.

Based on record reviews and interview, the facility failed to ensure that a medical history and physical (H & P) examination was completed by the Physician within 24 hours of admission in accordance with the facility's policy for 1 of 10 active Patient records reviewed (#14) that was currently hospitalized and admitted on 03/22/15.


This deficient practice could lead to a possible delay in the detection of health and safety issues.


Findings included:


Record review on 03/25/15, of Patient #14's medical chart revealed he was admitted to the facility on 03/22/15, and his H & P examination had not yet been completed or was evident in the active records; as of 3 days later.


Review of the facility's Medical Staff By Laws approved 09/26/13, and Medical Staff Rules and Regulations approved 05/23/13, revealed but was not limited to the following: "The history and physical examination shall be completed within 24 hours of admission."


Interview on 03/25/15, at 2:00 PM, with the facility's Director of Nursing on the Medical Surgical floor 4 confirmed that the history and physical had not been completed, or was evident in the active record for Patient #14 within the first 24 hours of admission and should have already been placed in the medical chart during this time.

Based on review of Laboratory services policies and confirmed during interview with staff this requirement was not met:

Findings:

a. During a review of Laboratory standard protocol and policies, a written description of laboratory services provided could not be found and evidence available that this written information was made available to the medical staff.


b. In an interview with staff # 4, laboratory services director, MT(ASCP) at 10:40 am on March 24, 2015, in the laboratory services department the staff member could not provide evidence that the laboratory policies did include a written description of laboratory services that is available to the medical staff.

Based on observations, interviews and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

1.) Medical Surgical Unit:

· Facility staff transferred un-bagged, infectious linen from the dirty linen cart to an uncovered transport container in the middle of the medical surgical patient care area. The keyless entry pad and entry door handle to the dirty utility room were contaminated with the staff's soiled gloves. The keyless entry pad and entry door handle were not sanitized after the transfer. Facility staff did not sanitize hands after biohazard linen transfer.

· Facility staff stored clean bandages and supplies in the cabinet of the dirty utility room.

2.) Wound Care Area:

· An infectious linen cart was in direct contact with a sterile supply cart within the wound care area.

· Soiled gloves were observed to be thrown on shelving and packages containing sterile wound vacuum foam.

· Three pairs of soiled surgical scissors used for sharp debridement were observed in the wound care sink.

3.) Whirlpool Area:

· Soiled surgical instruments used for sharp debridement were observed in a plastic container on the sink, half immersed in water.

· The biohazard trash can was wedged between a cabinet and the sink area, impeding the operation of the lid, making it inaccessible for staff use.

These deficient practices to provide a sanitary environment to avoid sources and transmission of infections and communicable disease could affect the health and safety of all patients and staff within the facility.


Findings included:


1.) Observation conducted on 3/24/15, at 12:30 p.m., of the facility's medical surgical unit with the Director of Medical Surgical Services, revealed Staff manually transferring un-bagged, infectious linen from a dirty utility cart, to an uncovered transport container. The infectious linen came into contact with the staff's uniform. Staff then removed a soiled plastic drop cloth from the dirty utility cart, wadded it up in their hands, and then transferred the soiled drop cloth to the soiled linen room, contaminating the keyless door entry pad and door entry handle with contaminated gloves. The keyless entry pad and door handle were not immediately sanitized after the transfer. Staff then proceeded down the hallway pushing the uncovered infectious linen transport cart without removing/ changing their gloves or washing their hands.


Interview with the Facility Director of Environmental services on 3/24/15, at 2:30 p.m., confirmed the Surveyor's observations and the facility's deficient practices regarding the potential for the transmission of infections and communicable diseases. Further interview revealed that infectious linen was to be contained in non-permeable bags, and handled/ transferred in the dirty utility room. He further stated that soiled laundry transport carts were to be covered before transport to the hospital ' s laundry facilities.

Continued Observation conducted on 3/24/15, at 1:15 pm, of the dirty utility room on the medical surgical unit revealed unopened boxes of gauze bandages and dressing supplies stored in the cabinet above the dirty utility sink.

Interview with the Facility Director of Medical Surgical services on 3/24/15, at 1:20 p.m., confirmed the Surveyor's observations, stating that staff were " hoarding supplies and they (staff) should not be doing that. "


Review of the facility's Infection Control policy for Linen (undated), area entitled: I Personnel Policies; Section E- Hand washing revealed: Personnel should wash hands after handling "contaminated" linens. Further review of the policy under the section entitled: III Equipment/ Supplies; Section B- Dirty Linen, revealed: Contaminated linen will be bagged and taken to the dirty work room and placed in the isolation linen container.


2.) Observations conducted on 3/24/15, at 4:30 pm, in the facility's Wound Care Area revealed the following:

· An infectious linen cart was in direct contact with a sterile supply cart within the wound care area.

· Soiled gloves were observed to be thrown on shelving and packages containing sterile wound vacuum foam.

· Three pairs of soiled surgical scissors used for sharp debridement were observed in the wound care sink.

In an interview conducted on 3/24/15, at 4:45 pm, the facility's Director of Rehabilitation Services confirmed the surveyor's observations, and the facility's deficient practice.

Record review of the Facility Policy/ and Procedure for Handling/ Cleaning, collection and transport of contaminated instruments for the Rehabilitation Services Department, dated 2/04/15, revealed in part the following:

- "Soak then scrub scissors in enzymatic detergent. Rinse then dry scissors."


3.) Observations conducted on 3/24/25, at 5:00 pm, of the facility's whirlpool area revealed the following:

· Soiled surgical instruments used for sharp debridement were observed in a plastic container on the sink, half immersed in water.

· The biohazard trash can was wedged between a cabinet and the sink area, impeding the operation of the lid, making it inaccessible for staff use.


In an interview conducted on 3/24/15, at 5:05 pm, the facility's Director of Rehabilitation Services confirmed the surveyor's observations, and the facility's deficient practice. Further interview revealed that staffs are to transport surgical instruments in enclosed containers to the sterilization area after use, and that surgical instruments were not be left "soaking" in the whirlpool/ wound care areas.


Record review of the Facility Policy/ and Procedure for Handling/ Cleaning, collection and transport of contaminated instruments for the Rehabilitation Services Department, dated 2/04/15, revealed in part the following:

- "Soiled instruments should be kept moist and soaked in a high level of disinfectant wexcide for 12 minutes, then scrub and brush dry ... ...Transportation for sterilization in secure hard sided containers ....Sterilize all instruments that are used for patient care."

During the Exit Conference on 3/25/15, the facility was given an opportunity to ask questions and provide additional information regarding the deficient practices identified during the survey process. No additional information was given at that time.