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Based on staff interviews and document reviews, The facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The facility failed to develop, implement and maintain an effective, on-going, hospital-wide, data-driven quality assessment and performance improvement program (AO263); The facility failed to ensure radiological services were integrated into the hospital-wide quality assessment and performance improvement program (AO528); and failed to ensure infection control was consistently integrated into the hospital-wide quality assessment and performance improvement program (AO747).

The cumlative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on interview and document review, the facility failed to develop a policy regarding reporting deaths associated with the use of restraints and seclusion to the Centers for Medicare and Medicaid Services.

Findings include:

On 07/02/10 at 1:20PM, Employee #1 and Employee #4 indicated the facility did not have a policy or a protocol regarding the reporting to the Centers for Medicare and Medicaid Services (CMS) any deaths associated with the use of restraints and seclusion.

Employee #1 indicated the facility had a policy to report the death to the state Sentinel Events Registry and The Joint Commission.

A review of the facility policy for "Situation Response Policy" approved on 03/17/10 and the "Sentinel Event for Joint Accredited Facilities Policy" approved on 03/24/10, lacked documented evidence regarding the reporting process for patient deaths related to restraints to CMS.

Based on interview and documentation review, the facility failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program (QAPI), that reflected the complexity of the hospital's organization and services involving all hospital departments and contracted services. The following processes were not in place:
CFR 482.21(a)(1) Tag A-0265 Program Scope.
CFR 482.21(a)(2) Tag A-0267 Tracking of Quality Indicators.
CFR 482.21(b)(3) Tag A-0277 Frequency and detail of data specified by governing body.
CFR 482.21(d)(1) Tag A-0291 Hospital must conduct performance improvement projects.
CFR 482.21(d)(3) Tag A-0300 Document what projects are being conducted.
CFR 482.21(d)(3) Tag A-0301 Reasons for projects conducted.
CFR 482.21(e)(5) Tag A-0317 Determination of the number of projects is determined annually.

The cumulative effect of these systemic practices resulted in the failure to deliver statutory mandated care to patients.

Based on document review and interview, the facility failed to have an ongoing quality assessment and performance improvement (QAPI) program that showed measurable improvement in indicators for which there was evidence that it would improve health outcomes.

Findings include:

Review of the minutes for the QAPI meetings for March 2010, April 2010 and May 2010 lacked data measuring improvements in quality indicators. The method for gathering data and tracking data was inconsistent and lacked documentation of measurable improvements in health outcomes.

On 6/30/10, in the morning, Employee #1 indicated that not all data was brought to the QAPI and any improvements or outcomes were given verbally by department heads. This was confirmed in the QAPI meetings minutes for March 2010, April 2010, and May 2010.

Based on interview and document review, the facility failed to measure, analyze and track quality indicators, including adverse patient events and other aspects of performance that assess processes of care for all hospital services and operations.

Findings include:

The facility's QAPI program did not track quality indicators on an ongoing basis. Review of the last 3 months minutes of the hospital's QAPI meetings showed no documented evidence of ongoing tracking of quality indicators. Facility wide audits from each department were not tracked in the facility's QAPI program.

On 6/30/10 in the morning, Employee #1 indicated that not all data was brought to the QAPI and any improvements or outcomes were given verbally by the department heads.



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Employee #5 indicated that blood gas testing was not brought to the hospital-wide Quality Assessment meetings due to consistent 100% compliance with the calling of critical values to physicians, the quality indicator used by the department and evaluated by Utilization Management Committee.

Based on interview and document review, the facility failed to ensure the frequency and detail of data collection was specified by the hospital's governing body.

Findings include:

The facility's governing body bylaws did not specify the frequency and or detail of data collection for the QAPI program.

On the morning of 6/30/10, Employee #1 indicated that there was no specification by the governing body for the frequency of data or detail of data collected for the QAPI program.

Based on document review and interview, the facility failed to track performance to ensure that improvements are sustained.

Findings include:

The facility QAPI program did not track performance improvement initiatives consistently. On 6/30/10 in the morning, Employee #1 indicated that data was taken to the Executive Committee, but not consistently brought to the QAPI meetings. The three months QAPI meeting minutes for March 2010, April 2010 and May 2010 did not document ongoing tracking of performance improvement initiatives to ensure improvements were sustained. The Executive Committee was supposed to report its findings to the QAPI committee according to Employee #1. The Executive Committee meeting minutes also lacked consistent tracking of performance improvement initiatives upon review.

Based on interview and document review, the facility failed to document what quality improvement projects were being conducted.

Findings include:

There was no documented evidence as to what specific quality improvement projects had been identified and conducted for the past year. On the morning of 6/30/10, Employee #1 indicated that projects were initiated in the Executive Committee as the need arose to quickly fix any issues.

Review of the Executive Committee minutes revealed yearly projects are not identified and tracked consistently and brought to the QAPI meetings.

Based on interview and document review, the facility failed to document which quality improvement projects are being conducted and the reasons for conducting these projects.

Findings include:

There was no documented evidence what quality improvement projects have been identified and conducted for the past year and the reasons for conducting these projects. On 6/30/10 in the morning, Employee #1 indicated that not all data was brought to the QAPI and any improvements or outcomes were given verbally by the department heads.

Based on document review, the facility failed to determine the number of distinct improvement projects was conducted annually.

Findings include:

There was no documented evidence that the facility's QAPI program had conducted distinct improvement projects annually. No projects were identified by the QAPI or governing body bylaws for the current year.

Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 32 sampled patients (Patient #23).

Findings include:

Patient #23 was admitted on 06/25/10. The initial physician admission orders dated 06/25/10, documented an order for physical therapy and occupational therapy screening, evaluation, and treatment.

The record lacked documented evidence of physical therapy and occupational therapy evaluations. Staff indicated nursing would need to complete a communication form indicating physical therapy and occupational therapy evaluations were ordered and sent to the therapy department to complete the evaluations. The record lacked documentation of the communication form.

Based on interview and record review, the facility failed to ensure a care plan was developed and updated identifying the patient's current problems and needs for 4 of 32 sampled patients (Patients #6, #23, #30, #32).

Findings include:

1. Patient #6 was admitted on 06/28/10 with diagnoses including chronic obstructive pulmonary disease.

The History and Physical dated 06/29/10 documented, "...Currently, the patient still feels short of breath, overall improved since admission, but still not back to the baseline...Continue steroids, short course of doxycycline, nebulizer, and wean oxygen as tolerated..."

The Interdisciplinary Plan of Care dated 06/28/10 documented the admitting diagnosis of COPD (chronic obstructive pulmonary disease). The plan of care did not identify "Altered Respiratory Status" as a patient problem. The plan of care was updated on 06/29/10 and 06/30/10.

On 07/01/10 at 10:00AM, Employee #4 indicated the patient problem "Altered Respiratory Status" should have been identified on the plan of care for the patient.

2. Patient #23 was admitted on 06/25/20 with diagnoses including chronic obstructive pulmonary disease.

The Interdisciplinary Plan of Care was initiated on 06/25/10 and did not identify "Altered Respiratory Status" as a patient problem.

3. Patient #30 was admitted on 05/15/10.

A review of the record revealed the patient was receiving respiratory treatments and was on oxygen therapy.

The Interdisciplinary Plan of Care was initiated on 05/15/10, with an admitting diagnoses of pneumonia and cerebrovascular accident. The initial plan of care did not identify "Altered Respiratory Status" as a patient problem.

The plan of care identified the patient had MRSA (Methicillin Resistant Staphylococcus aureus) in the nares on 05/15/10 and "Potential Actual Infection" was identified as a patient problem.

The plan of care was not updated when the patient was placed into contact isolation for positive Clostridium difficile infection on 06/30/10.

On 07/01/10 in the afternoon, Employee #4 indicated the plan of care should have been updated when there was a change in the patient's condition or a problem had been resolved, ideally weekly, and at least monthly.

4. Patient #32 was admitted on 06/29/10 with diagnoses including chronic obstructive pulmonary disease and emphysema.

The physician's order dated 06/29/10, documented the patient was on albuterol nebulizer treatments four times a day and as needed and oxygen to keep oxygen saturations equal to or greater than 92 percent.

The Interdisciplinary Plan of Care dated 06/29/10 documented an admitting diagnosis of chronic obstructive pulmonary disease. The plan of care did not identify "Altered Respiratory Status" as a patient problem.

Based on interview, the facility failed to ensure oversight of the fingerstick blood glucose testing in the hospital.

Findings include:

1. Employee #4 stated there was not adequate oversight and direction of the fingerstick blood glucose testing in the facility.

2. Employee #8 confirmed that the annual competency assessment for nurses did not include glucose meter testing.

Based on interview, record review and document review, the facility failed to ensure verbal orders were authenticated by the physician within 48 hours for 3 of 32 sampled patients (Patients #23, #24, #30).

Findings include:

1. A review of Patient #23's record revealed the following verbal orders were not authenticated by the physician:

- 06/25/10 "Patient to be given SVN (small volume nebulizer) treatments as follows: 1. UD (unit dose) Albuterol four times a day and PRN (as needed); 2. UD Atrovent four times a day; 3. 0.5 mg (milligrams) Pulmicort two times per day; oxygen to be given to maintain SpO2 (oxygen saturation) equal to or greater than 92 percent as per RT (Respiratory Therapy) protocol."
- 06/25/10 "Accu check (blood sugar test) AC/HS (before meals and bed time) with RISS (regular insulin sliding scale) per facility protocol."
- 06/26/10 "EKG (electrocardiogram) STAT (now); Kayexalate 60 grams by now times one now; repeat K (potassium) at 1900 (7:00PM) STAT."

2. A review of Patient #24's record revealed the following verbal orders were not authenticated by the physician:

- 06/08/10 "Place patient back on previous settings: AC (assist control) 8, Vt (tidal volume) 750, Peep 5, FiO2 (oxygen concentration) 35% at night. Resume weaning in AM (morning). Start on CPAP (continuous positive airway pressure) 5, PS (pressure support) 6, then place patient on...as tolerated per v.o. Dr. (name)."
- 06/09/10 "Famotidine 20 mg IV (intravenous) Q (every) 12 hours start now; send CBC (complete blood count), BMP (basic metabolic panel), PT (prothrombin time) & PT INR (international ionized ratio); D/C (discontinue) Fragmin; notify Dr. (name) of lab results."
- 06/09/10 "Place patient on SVN while on...as follows: 1. UD Albuterol every 4 hours and PRN; 2. UD Atrovent every 4 hours; 3. .5 mg Pulmicort two times a day; 4. Keeps SpO2 greater than or equal to 92% per RT protocol."
- 06/09/10 "Nutrition increase free water flush to 250 mL (milliliter) Q 4 hours via PEG (percutaneous endoscopic gastrostomy)."
- 06/09/10 " Place patient back on previous settings (AC 8, Vt 750, FiO2 35%, Peep +5, at night resume...FiO2 35% in AM/24 hours as to verbal order Dr. (name)."
- 06/10/10 "Continue...at 35%. ABG (arterial blood gas) in AM, place back on vent, if patient does not tolerate with previous vent settings on A/C."
- 06/12/10 "Discontinue vent."
- 06/12/10 "ABG on 35%...per RT protocol."
- 06/12/10 "Discontinue MDI's (meter dose inhalers), continue with UD Albuterol every four hours and PRN, UD Atrovent every four hours. Pulmicort 0.5 mg BID (twice a day) per RT protocol."
- 06/14/10 "Vancomycin 1.5 gram IV Q24 hours; draw Vancomycin trough 30 minute prior to 06/16 dose, pharmacy order."
- 06/14/10 "Speaking valve as tolerated Speech therapy to evaluate per RT protocol."
- 06/15/10 "1. Keep patient on red cap tonight; 2. ABG on AM."
- 06/16/10 "Give Vancomycin 1 gram IV x 1 dose as ordered then continue vancomycin 1.5 gram IV Q24 - 1st tomorrow. Change Vancomycin trough to 30 minutes prior to 06/19 dose per dosing protocol."
- 06/16/10 "Neck AP-LAT (anteroposterior-lateral) views for trach placement - STAT."
- 06/16/10 "Patient to be decannulated per v.o. (verbal order) Dr. (name). Trach care every shift per RT protocol."
- 06/17/10 "Diet clarification order, per ST (Speech Therapy): 1. Clear liquid diet; 2. 1:1 assist; 3. HOB (head of bed) upright as possible for all po (by mouth); 4. Aspiration precautions.
- 06/21/10 "Clarification of SVN Colistin 75 mg (milligrams) orders BID x (times) 14 days - start date 06/06/10."
- 06/23/10 "Continue Vancomycin at 1.5 gram IVPB (intravenous piggy back) Q 24 H (hours) (at 11:00); Vancomycin trough level on 06/29. 30 minutes prior to dose (if still on Vancomycin) per pharmacy dosing protocol."

3. A review of Patient #30's record revealed the following verbal orders were not authenticated by the physician:

- 06/02/10 "D/C Mucomyst SVN order per RT protocol."
- 06/02/10 "Change SVN tx (treatment) to as follows: 1. UD Albuterol three times a day and PRN; 2. UD Atrovent three times a day; 3. D/C oxygen per RT protocol."
- 06/17/10 "Zyvox 600 mg IV Q 12 H until further order by Dr. (name)."
- 06/20/10 "D/C oxygen per RT protocol."

On 06/30/10 at 11:50AM, Employee #5 indicated the "per RT protocol" was the same as a verbal order and the physician should sign the order within 24 hours.

The facility policy "Physician Orders - Telephone and Verbal" dated 03/2006, documented "...5. If the prescribing/attending physician is not expected to be in the facility within 48 hours to countersign the order, the original order sheet is completed and sent to the physician for signature..."

Based on interview and record review, the facility failed to ensure consents for treatment were signed by the patient or legal representative for 10 of 32 sampled patients (Patient #6, #8, #9, #14, #24, #26, #30, #10, #19, #20).

Findings include:

1. Patient #6 was admitted on 06/28/10. A review of the chart revealed the "Consent for Treatment" dated 06/28/10 lacked the patient's and facility representative's signature.

On 07/01/10 at 10:00AM, Employee #4 indicated the facility should obtain the patient or legal representative signature for consents on admission. If the patient was unable to sign the consent and legal representative was not available at the time of admission, nursing was responsible for obtaining the signed consent form.

2. Patient #24 was admitted on 05/22/10. A review of the chart revealed the "Consent for Treatment" dated 05/22/10 lacked the patient's and facility representative's signature.

3. Patient #30 was admitted on 05/15/10. A review of the chart revealed the "Consent for Treatment" dated 05/15/10 lacked the patient's and facility representative's signature.




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4. Patient #10 was admitted on 6/4/10. A review of the chart revealed a blank Consent for Treatment form, except for a date of 6/4/10 written on it. The form lacked signatures by the patient (or his/her legal representative), and by a facility representative.

5. Patient #19 was admitted on 5/26/10. A review of the chart revealed a blank Consent for Treatment form, except for a date of 5/26/10 written on it. The form lacked signatures by the patient (or his/her legal representative), and by a facility representative.

6. Patient #20 was admitted on 6/14/10. A review of the chart revealed a blank Consent for Treatment form, except for a date of 6/14/10 written on it. The form lacked signatures by the patient (or his/her legal representative), and by a facility representative.



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7. Patient #26 was admitted to the facility on 6/25/10. The patient's medical record contained a blank Consent for Treatment form not signed by the patient as of 6/30/2010.



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8. Patient #8 was originally admitted on 5/28/10 and readmitted on 6/15/10. A review of the chart revealed the "Consent for Treatment" dated 6/15/10, lacked the patient's and facility representative's signature.

9. Patient #9 was admitted on 6/27/10. A review of the chart revealed the "Consent for Treatment" was not dated and lacked the patient's and facility representative's signature.

10. Patient #14 was admitted on 6/19/10. A review of the chart revealed the "Consent for Treatment" was dated 6/20/10 with the statement "patient disoriented." There was no patient signature nor an attempt to contact the patient's son or other contact indicated on the "Patient Admission Record."

Based on interviews and document review, the facility failed to ensure that contracted radiologic and peripherally inserted central catheter (PICC) placement services were integrated into the hospital-wide quality assessment and performance improvement (QAPI) program.

Findings include:

Employee #5 stated that X-ray services were not integrated into the hospital-wide Quality Assessment program, but the number of procedures performed was reported to Utilization Management Committee. Employee #4 confirmed the nurses performing PICC placement did not attend hospital orientation and the hospital did not verify their qualifications and training.



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The facility's last three QAPI meeting minutes for March 2010, April 2010 and May 2010 did not have any documented evidence that Radiologic services was incorporated into the QAPI program.

Based on interview and document review, the facility failed to ensure that the radiology services were supervised by a radiologist.

Findings include:

The contracts for X-ray and ultrasound services did not include radiology director services for the hospital. The chief financial officer of the contracted radiologic services stated in a phone interview that the supervising physician of Portable X-ray of Southern Nevada and Vision Medical Imaging was not the director of radiology services for the hospital.

Based on document review and observation of testing materials, the facility did not ensure that laboratory services were adequately provided.

Findings include:

1. An inspection of glucose meters and corresponding test supplies on the units revealed that control bottles were not marked when they were opened as required by the manufacturer on Units 100, 200, 300, and the Observation Unit. Expired controls were found on the Observation Unit. Test strips not matching the calibration strips were found in two baskets on the 200 Unit.

2. An inspection of glucose meter control logs revealed that acceptable control ranges were not listed on the control logs of the 100 and Observation Units. No lot numbers for the high control or the test strips were indicated on the quality control (QC) log on the 400 Unit. No glucose meter QC logs could be located besides the logs currently being used on the units, which included data from June 2010, except for five QC log sheets which appeared to represent data from January 30, 2005 through June 5, 2005.

Based on a review of the hospital protocol and interview, the laboratory tests available in the case of an emergency were not delineated.

Findings include:

Employee #5 confirmed that the undated Rapid Response/Code Blue/Chest Pain Policy did not clarify the "STAT labs" available in an emergency.

Based on an interview with Employee #5, visits to each unit and a review of hospital rapid response protocol, a comprehensive list of the laboratory tests provided by the hospital did not exist.

Findings include:

Employee #5 confirmed that a detailed list of each of the laboratory tests provided on a routine and stat basis by the hospital was not available.

Based on a review of hospital policy, the medical staff and a pathologist did not determine which specimens required a macroscopic examination and which tissues required both macroscopic and microscopic examinations.

Findings include:

The Tissue Specimen Collection and Reporting policy, revised 12/08, did not contain a list of the tissue specimens requiring macroscopic examination and those requiring both macroscopic and microscopic examination, which had been determined by the medical staff and a pathologist.

Based on observation, document review, policy review, and interview, the facility failed to ensure: 1) mechanisms were in place to assure the dishmachine was working properly and dispensing an adequate amount of sanitizer; 2) foods were date marked according to facility policy; and 3) each food service employee received a systematic orientation upon hire and a performance evaluation at the end of the probationary period per facility policy.

Findings include:

1. An initial tour of the kitchen on 6/29/10 at 8:20 AM revealed no sanitizer was being dispensed into the low-temperature dish machine. According to manufacturer's instructions, the concentration of a chlorine-based sanitizer used for low-temperature dish machines should be 50 - 100 ppm (parts per million). Upon inspection of the dish machine, it was determined there was a hole in one of the connecting tubes, and the sanitizer had not been primed. Employee #12 acknowledged the audits to check the accuracy of the dish machine's sanitizer concentration and daily logs had not been routinely conducted. According to the facility's "Safe Employee Work Practices" policy, dated 3/2006, "The Nutrition Director/designee is responsible for instructing employees in the proper use and maintenance of equipment. The Nutrition Director notified the maintenance department of any safety hazards or equipment breakdowns."

2. The initial tour of the kitchen revealed inconsistent date marking of potentially hazardous foods. In the walk-in refrigerator, there was an undated, opened container of cottage cheese and wrapped cold-cut sandwiches, on which was written, "use by 6/30/10." There was no indication as to when the sandwiches were made. In another refrigerator, there was a bag of cut ham with the date 6/24/10 written on it. The facility's "Food Safety in Receiving and Storage" policy, dated 3/2006, included the following guideline: "Potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 48 hours unless otherwise indicated." Employee #12 acknowledged the food service staff had not been in-serviced on updated date marking procedures.

3. Review of personnel files revealed food service employees were not receiving evaluations at the end of their probationary period (after 90 days). According to the facility's "Job Performance/Competency Evaluation" policy, dated 3/2006, "The Nutrition Director completes a performance evaluation as included in posted job description for Nutrition employees at the end of the probationary period...The original evaluation is placed in the employee's permanent personnel file after being signed and dated by both the Nutrition Director and employee." There was no evidence an Orientation checklist was completed, per facility policy, for each new food service employee, and this was confirmed by Employee #11. The "Orientation of Nutrition Personnel" policy, dated 3/2006, included the following procedures: "Newly hired Nutrition personnel receive both a general facility orientation and a departmental and position-specific orientation to establish clear expectations of the position. The orientation for Nutrition Personnel is conducted by the Nutrition Director, utilizing the Facility Nutrition Orientation Manual and Orientation Checklist contained in this manual...The signed orientation checklists and competencies are placed in the employee's personnel record prior to providing services unsupervised."

Based on observation, record review, policy review, and interview, the facility failed to ensure: 1) therapeutic and mechanically altered diets were prescribed by the attending physician; 2) the kitchen received all updated diet orders; 3) diet orders were transcribed onto the Medication Administration Record; and 4) patients were weighed weekly per facility policy for assessment of nutritional status. The records of 2 patients (Patients #10 and #19) exemplify the above, out of 32 sampled patients.

Findings include:

1. Patient #10 was admitted on 6/4/10, with diagnoses including multiple fractures, ventilator dependent respiratory failure, and tracheostomy status. The patient had a gastrostomy tube (g-tube) for nutrition and hydration.

On 6/11/10, a diet order was written by Employee #14 which read, "Increase TFs (tube feedings) to Fibersource HN @ 55 ml (milliliters) per hour - goal rate. Hold if TF residual is more than 200 ml. T.O. (telephone order) Dr. __." This order was not signed by the physician. In an interview with Employee #14 on 6/30/10, the employee acknowledged that writing T.O. on the note did not indicate that a verbal order was made; rather it was written in case the nursing staff wanted to clarify the order.

According to the facility's "Therapeutic Diets" policy, dated 3/2006, "Therapeutic and mechanically altered diets will be ordered by the physician and planned by the dietitian." The facility's "Physician Orders" policy, dated 7/2009, included the following procedures with regard to telephone/verbal orders: "Record the actual order received from the physician...Telephone/verbal orders are to be signed by the prescribing/attending physician within 48 hours...Transcribe the order onto the Medication Administration Record (MAR) or Treatment Record as appropriate..."

Review of Patient #10's record revealed that this diet order was not consistently followed, and had not been transcribed onto the MAR. On the 6/12/10 Daily Patient Care Record, a nurse wrote, "Pts residual greater than 100. TF on hold." On 6/26/10, a note read, "Fibersource HN infusing at 50 ml/hr..." The current TF order was an infusion rate of 55 ml per hour. In an interview with Employee #4 on 6/29/10 at 2:15 PM, the employee acknowledged that diet orders should be added to the MAR so that nursing staff could easily verify the order.

A review of Patient #10's Weight Document Form revealed an admission weight on 6/4/10 of 102 pounds (lbs). The next recorded weight, documented as using a bed scale, was 122.8 lbs on 6/23/10. On 6/28/10 the recorded weight was 123.2 lbs (bed scale). The requested re-weigh on 6/29/10 was 108.4 lbs (bed scale). Employee #15 was asked about the discrepancies in the weights. She explained that with the bed scale, 11.2 lbs needed to be deducted for the actual weight, which was taken into account when documenting the weights. The employee further indicated that the bed scale batteries may have been faulty.

A Nutritional Progress Note, written on 6/23/10, included the following sentence: "No new weights." Four nursing staff were asked about the policy on weights, and they all indicated that weights were to be taken once a week. The staff confirmed that Patient #10 did not receive weekly weights per facility protocol. According to the facility's Nutrition Policies and Procedures manual, "Accurately measured heights and weights are essential for an appropriate nutritional assessment...For patients who cannot be weighed, a weekly upper mid-arm circumference can be obtained."

2. Patient #19 was admitted on 5/26/10, with diagnoses including pneumonia, severe malnutrition with cachexia, chronic obstructive pulmonary disease, and coronary artery disease. The patient was receiving both oral and parenteral nutrition.

Review of Patient #19's record revealed the following following order, dated 6/24/10, "Diet clarification order per MBS (modified barium swallow study); ground meats and puree with honey thick liquids; no thin liquids..." There was a note written by a nursing staff next to this order that read, "Notified dietary." There was no indication this updated diet order had been approved by the attending physician before it was implemented. An interview on 7/1/10 at 10:30 AM with the staff member who wrote the order confirmed that a verbal order was not made to the physician before the diet order was written and incorporated into the patient's meal plan.

Record review revealed Patient #19 had an admission weight of 118 lbs, and the next recorded weight was 126 lbs on 6/23/10. The Dietary Progress Notes section of the record included the following notes: 6/9/10 - "No new weights. Unable to adequately assess...Will place MD (medical doctor) request for weights weekly." 6/16/10 - "Awaiting new weight for proper assessment of TPN (total parenteral nutrition)." 6/25/10 - "Pt requesting something to eat - 'I'm so hungry'...To increase intake, will send texture-appropriate snacks, i.e. pudding, or yogurt between meals." This updated snack order was written on 6/25/10, and it read, "Nutrition eval done. Send snacks BID (twice a day) between meals (pt enjoys pudding/yogurt)." Review of the patient's computerized meal ticket information on 6/30/10 at 9:00 AM revealed this snack order had not been received by the kitchen. Both the dietary staff and the nursing staff acknowledged diet change communication orders were not always received by dietary staff, so that patient meal tickets could be updated.

Based on interview and document review, the facility failed to ensure the infection control program was consistently integrated into the hospital-wide quality assessment and performance improvement program.

Findings include:

Employee #8 indicated the facility received a monthly report from the contracted dialysis agency regarding the water analysis and maintenance of dialysis machines. The report documented the microbiology colony count, water colony count, limulus amebocyte lysate count, and the dialysate colony count. A review of the report faxed to the facility on 05/11/10, documented on 03/16/10 the dialysate colony count was four (the four was circled) for machine number G209-1004955. On 01/13/10, the dialysate colony count was 24 (the 24 was circled) for machine number D611-1004943.
On 06/30/10 at 2:30PM, Employee #4 and Employee #5 indicated the results were abnormal and the machines would need to be taken out of service, cleaned, and the colony count test repeated. Both employees verbalized there was no documented corrective action plan for the reports regarding the dialysis machines with the elevated colony counts.

Employee #5 indicated a verbal report would be provided to the Executive Committee regarding the infection control documentation received from the dialysis agency. The facility would review the reports for trends in the colony rates, problems with dialysis technicians, and problems with the equipment.

On 07/01/10 in the afternoon, Employee #7 and Employee #8 were unable to explain how the facility utilized the information provided in the infection control reports from the dialysis center and how the information was incorporated into the quality assessment performance improvement program. Both employees were unable to identify the normal ranges for the reverse osmosis colony count and the dialysate colony count. Both employees were unable to determine if the dialysate colony count of four and 24 were abnormal results which would require a corrective action plan.

A review of the Quality Assessment Performance Improvement meeting minutes revealed infection control was not consistently incorporated into the hospital-wide program. There were no identified performance improvement projects related to infection control. The data collected through the infection control committee was not analyzed to identify any performance improvement areas and there was no documentation related to on-going monitoring of the infection control program.

Based on interview and review of job descriptions for respiratory care staff, the qualifications of respiratory therapists were not specified by the medical staff.

Findings include:

Employee #5 confirmed that there was no evidence medical staff was included in the determination of the "Minimum Qualifications" listed in the respiratory therapists' position descriptions.