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Based on interview and record review the facility failed to ensure that a current contract with a network hospital was maintained and that the network hospital provided review functions for at least credentialing and quality assurance. This affects all patients in a census of five.
Findings included:
1. Review of a letter attached to a contract from the network hospital, dated 01/24/2006, and stated that attached was an original signed affiliation agreement. Paragraph #7 of the terms stated that the agreement shall be for a period of one year from the date of execution by the parties. Following this initial term the agreement shall be renewed for another year only upon the mutual written agreement of both the (network hospital) and affiliate.
The agreement had expired as of the date of survey and no current contract was available.
2. During an interview on 08/25/10 at 2:00 p.m. the administrator stated a copy of a visit from the network hospital dated December 2007 was a previous visit, and a representative from the network hospital had been at the facility more recently. The network hospital in communications had stated that they were currently reviewing contracts with affiliated hospitals.
A copy of a visit from the network hospital, dated 05/13/10, revealed that a medical records review and walk through survey had been done at that time.
The facility did not have in place a current contract for credentialing and quality assurance with at least one hospital that is a member of the network, a quality improvement organization (QIO), or other qualified entity. The review for quality assurance is to include medical record review which was provided by the network hospital.

Based on observation and interview, the facility failed to monitor and remove expired or outdated supplies from patient care areas in the Emergency Department (ED), Radiology, and Laboratory. This had the potential to affect all in-patients and any out-patients using Emergency services, Radiology services, and/or Laboratory services. The hospital census was five.

1. Observation on 08/23/10 at 1:30 p.m. showed the following supplies located in the ED triage area respiratory supply cabinet were expired:
-eight Arterial Blood Gas (AGB) kits (a needle and syringe used to draw blood and measure the acid and base balance of the body), Lot #K125972 expired 02/05;
-three ABG kits, Lot #K519494, expired 06/06;
-seven Yankauers (a sterile plastic tube used to suction secretions, etc. from a patient during emergency or routine care), Lot #0405052, expired 05/09;
-one Yankauer, Lot #9906302, expired 06/04;
-two Yankauers, Lot #0009253, expired 09/05.

2. During an interview on 08/23/10 at 1:30 p.m., Staff K, Director of Patient Care stated it is the responsibility of the respiratory staff to monitor and remove supplies from the respiratory supply cabinet in the ED.

3. Observation on 08/23/10 at 2:30 p.m. showed the following supplies located in ED Bay 1 were expired:
- four Endotracheal tubes (ETT) (a tube passed through the mouth and into the lungs to assist a patient with poor/no breathing), Lot #05GE30, expired 06/10.

4. Observation on 8/23/10 at 2:33 p.m. showed the following supplies located in the ED hall cabinet were expired:
-22 sterile gauze sponges eight inches by four inches, Lot #40295600, expired 01/09.

5. Observation on 08/23/10 at 2:45 p.m. showed the following sutures (needle and thread used to close wounds, also known as stitches) located in ED Bay 3 were expired:
-one 6-0 ethilon, Lot #TDE772, expired 01/09;
-five 6-0 vicryl, Lot #UMZ046, expired 07/10;
-seven 6-0 ethilon, Lot #BH9329, expired 01/95;
-one 6-0 vicryl, Lot #HM9179, expired 07/00;
-one 6-0 ethilon, Lot #SJH914, expired 07/08;
-11 intravenous catheters (IV) (a needle and plastic tube inserted through the skin and into a vein to administer medication or fluids) 22 gauge (size of the needle and catheter), Lot #7201628, expired 07/10.

6. During an interview on 08/23/10 at 2:45, Staff K, stated the ED nurses are responsible for removing expired or outdated supplies from the ED.

7. Observation on 08/23/10 at 2:50 p.m. showed the following supplies located in the Radiology Department were expired:
-one IV catheter, 18 gauge, Lot #3550K53, expired 12/03;
-one IV catheter, 20 gauge, Lot #3011O35, expired 09/04;
-eight IV catheters, 20 gauge, Lot #3010K84, expired 10/03;
-one IV catheter, 18 gauge, Lot #0680K52, expired 03/03;
-four IV catheters, 18 gauge, Lot #MO1EO96-07, expired 05/04.

8. During an interview on 08/23/10 at 2:50 p.m. Staff K stated the Radiology staff were responsible for removing expired or outdated supplies from the Radiology Department.

9. Observation on 08/24/10 at 9:35 a.m. showed the following supplies located in the Laboratory Department phlebotomy station were expired:
-one clear blood tube (used to collect blood), Lot #9149942, expired 06/10;
-one blue top blood tube, Lot #368381, expired 01/10;
-one pink top pediatric blood tube, Lot #9044564, expired 07/10;
-one anaerobic blood culture bottle (used to collect blood to test for the presence of bacteria), Lot #9267233, expired 07/31/10.

10. During an interview on 08/24/10 at 9:35 a.m. Staff S, phlebotomist, stated that he/she was responsible for removing expired or outdated supplies from the Laboratory phlebotomy area.

11. During an interview on 08/25/10 at 2:30 p.m., Staff K, stated there was no hospital policy regarding the monitoring and removal of expired or outdated supplies.

Based on observation and interview, the facility failed to ensure medications in the Emergency Department (ED) were secured to prevent unauthorized access. This had the potential to allow anyone entering or within the hospital unauthorized access to the medications. The facility census was five.
Findings included:
1. Observation on 08/23/10 at 1:25 p.m. showed the Emergency Department contained no patients or staff. The main entrance to the Emergency Department is unlocked. A second Emergency Department entrance is through a door which is propped open. The door is located off of a main corridor for radiology and laboratory studies. A third entrance is through an unlocked "dirty utility" room door, which was located immediately next to the second entrance. The Emergency Department stores medications in drawers with a see-through Plexiglas top. The drawers are closed with breakaway locks, which are easily broken by pulling the drawer open.
2. During an interview on 08/23/10 at 1:25 p.m., Staff K, Director of patient care stated the ED is left unattended when there are no patients in the ED. Staff K added the nurses who provide care to ED patients are also assigned patients on the floor, and those staff are located on the floor when the ED is empty.
3. Observation on 08/23/10 at 3:40 p.m. showed this surveyor along with another surveyor entered the unattended ED and examined the medication drawers. The medications would have been easily accessed by pulling on the drawer, breaking the breakaway lock, and removing the medications.

Based on observation, interview and record review the facility failed to ensure the staff follow the facility hand hygiene policy and accepted standards of practice when staff did not cleanse their hands when entering or leaving a patient's room or between glove changes and did not wear a pair of gloves when starting an intravenous (IV) lock for four (Patient's #1, #2, #3 and #5) of five patients observed. The facility census was five on the day of entrance.

Findings included:

1. Review of Infection Control Policy Section 18, policy #18.3, titled "Handwashing Technique", with a date of 12/13/96 and revised 01/10/07 showed handwashing is practiced to reduce contamination of the hands and to eliminate the spread of organisms and should be completed at the following time:
-during the performance of normal duties (II.B.2);
-before and after any procedures (II.B.10);
-before and after contact with a patient or his environment, or with articles that come in direct contact with the patient (II.B.11);
-after contact with ...body fluids, secretions, or excretions, or in other situations during which microbial contamination of the hands occurs (II.B.12);

2. Observation on 08/23/10 at 1:46 p.m. revealed Staff A, Licensed Practical Nurse (LPN), entered the room of Patient #2 and did not cleanse his/her hands before administering oral Tylenol (a medication used to relieve mild to moderate pain) to the patient. Staff A then donned a pair of non sterile gloves and administered eye drops to the patient.

3. Observation on 08/23/10 at 1:55 p.m. revealed Staff B, Registered Nurse (RN), entered the room of Patient #1 and paced a stethoscope (a medical instrument used to listen for sounds inside the body) and otoscope (a medical instrument consisting of a magnifying lens and light used to look into the ears) on the bedside table. Staff B then left the patient's room and returned with a patient identification band which she placed on the patients left wrist. Staff B auscultated (listened) the patient's lungs and abdominal sounds and placed the stethoscope on the bedside table. Staff B then used the otoscope light to assess the patient's pupils. The otoscope was then placed on the bedside table on top of the stethoscope. Staff B then palpated (felt) the patients left foot and picked up the stethoscope and otoscope. Gloves were not worn during auscultation or palpation of the patient's foot. No hand cleansing was done when entering or leaving the room. No hand cleansing was done between tasks. The stethoscope was not cleansed before or after auscultation.

4. Observation on 08/23/10 at 2:10 p.m. revealed Respiratory Technician (RT) assist Patient #2 into the bathroom, RT pulled down the attends (adult diapers) the patient was wearing and then went to the bed and rearranged the bed clothes and moved the oxygen tubing which had been removed from the patient in order to go to the bathroom. RT then pushed the bedside table over. RT pulled up the attends of the patient and assisted the patient back into bed by lifting/guiding the patient's legs and covered the patient with the sheet and blanket. The RT then placed the oxygen cannula (a device used to deliver supplemental oxygen to a patient) back onto the patient. RT turned the light to the bathroom off and flushed the toilet and moved the bedside tray beside the patient's bed. No hand cleansing was observed when the RT entered the patient's room or between tasks. No gloves were worn when assisting the patient with his attends.

5. Observation on 08/23/10 at 2:20 p.m. revealed Staff A, LPN, entered Patient #3's room and administered an oral medication for pain. Staff A then moved the trash can and placed her hand on the patient's arm. No hand cleansing was observed when he/she entered the room and no hand cleansing was observed after moving the trash can and before touching the patient's arm.

6. Observation on 08/23/10 at 2:43 p.m. revealed Staff A, LPN, entered the Patient #1's room without cleansing his/her hands. The LPN then opened a sterile package of intravenous tubing and connected it to a bag of fluid. The LPN then left the room and returned with Staff B, RN, who examined the port to the patient's left arm peripherally inserted central catheter (PICC) [an in the vein access that can be used for a prolonged period of time] and flushed the port with normal saline; then connected the IV tubing to the flushed port. No gloves were worn for flushing the port. No cleansing of the port with alcohol was observed before connecting the IV tubing. Both LPN and RN left the room with no hand cleansing observed.

- An interview on 08/24/10 at 4:10 with Staff J, Infection Control Officer (ICO), stated the expectation would be that staff would cleanse their hands with soap and water or hand sanitizer before entering a patient's room and when leaving a patient's room and between glove changes. Also, the ICO stated she would expect staff to wear gloves when appropriate such as when flushing a port or connecting tubing to a port or when starting an IV.



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8. Observation on 08/23/10 at 3:00 p.m. showed Staff U, Outpatient Coordinator Registered Nurse (RN), change a dressing on Patient #5, who was receiving outpatient care. During the dressing change, Staff U removed gloves and failed to wash hands. Staff U then exited the outpatient room, answered a telephone, exited the outpatient area, return to the outpatient room, and put on gloves without washing hands. Staff U then completed the dressing change.
- During an interview on 08/23/10 at 3:00 p.m., Staff K, Director of Patient Care, stated staff should wash hands immediately before putting on gloves, and immediately after removing gloves when performing patient care.
9. Observation on 08/24/10 at 10:00 a.m. showed Staff D, RN, wore a glove on only one hand while he/she started an intravenous (IV) (inside the vein) catheter.
10. During an interview on 08/24/10 at 10:20 a.m., Staff K stated gloves should be worn on both hands when starting an IV catheter.

Based on interview and record review, the facility failed to ensure physician orders (verbal and telephone) were authenticated in accordance with hospital policy for 10 (Patient's #5, #9, #10, #15, #17, #22, #23, #24, #25 and #26) out of 15 medical records reviewed. The facility census was five.
Findings included:

1. Record review of Multidisciplinary Patient Care Services Department policy titled "Physician Orders", # 2.7, revised 10/14/09 showed the following:
-telephone orders must be signed by the ordering physician within 24 hours ...(page 1, II.B.2);
-verbal orders must be signed by the ordering physician within 24 hours ...(page 1, II.C.2)

2. During an interview on 08/25/10 at 11:25 p.m., Staff J, Health Information Management Nursing Director stated all verbal and telephone physician orders are to be signed within 24 hours.

3. Record review of Patient #5's closed chart revealed the following documents were not signed by the physician:
-physician order dated 08/18/10 at 9:45 a.m.;
-physician order dated 08/18/10 at 6:30 a.m.;
-physician order for Life Sustaining Treatment dated 08/18/10;
-physician order dated 08/19/10 at 10:00 a.m.;
-physician order dated 08/19/10 at 11:00 a.m.

4. Record review of Patient #9's closed chart revealed the following document was not signed by the physician:
-physician order for Life Sustaining Treatment dated 06/22/10.

5. Record review of Patient #17's closed chart revealed the following document was not signed within 24 hours;
-physician order for Life Sustaining Treatment dated 05/11/10 (signed by the physician on 07/11/10).

6. Record review of Patient #15's closed chart revealed the following documents were not signed by the physician:
-physician order dated 05/17/10 at 6:00 p.m.;
-physician order dated 05/18/10 at 1:30 p.m.

7. Record review of patient #16's closed chart revealed the following documents were not signed by the physician:
-physician order for Life Sustaining Treatment dated 05/22/10;
-physician order dated 05/22/10 at 6:00 p.m.;
-physician order dated 05/22/10 at 7:30 p.m.;
-physician order dated 05/22/10 at 11:00 p.m.;
-physician order dated 05/22/10 at 11:30 p.m.



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8. Record review of Patient #22's Physician's Orders revealed in part the following information:
-On 05/10/10 at 8:13 p.m. a telephone order was not timed or dated by the physician
-On 05/09/10 at 4:00 p.m. a verbal order was not authenticated by the physician until 05/31/10 at 9:00 a.m.

9. Record review of Patient #23's Physician's Orders revealed in part the following information:
-On 05/27/10 at 11:55 p.m. a verbal order was not timed or dated by the physician.

10. Record review of Patient #24's Physician's Orders revealed in part the following information:
-On 07/26/10 at 1:50 p.m. a telephone order was not authenticated by the physician.
-On 07/27/10 at 11:45 p.m. a verbal order was not authenticated by the physician.
-On 08/02/10 at 9:30 a.m. a verbal order was not authenticated by the physician.

11. Record review of Patient #25's Physician's Orders revealed in part the following information:
-On 05/08/10 (no time) a verbal order was not authenticated by authenticated by the physician.

12. Record review of Patient #26's Physician's Orders revealed in part the following information:
-On 07/30/10 a Physician's Order for Life Sustaining Treatment was not authenticated by the physician.
-On 08/01/10 (no time) a verbal order was not authenticated by the physician.

Based on interview and record review, the facility failed to ensure nursing care plans were individualized and had measurable goals for two in-patients (Patient #1, #2 ) and 15 closed medical records (Patient # 5, #8, #7, #9, #10, #14, #17, #15, #18, #16, #19, #21, #23, #24, #25) out of 20 medical records reviewed. The facility census was five.
Findings included:
1. Record Review of Patient #5's closed chart revealed the nursing care plan was not individualized to the patient. According to the physician history and physical dated 08/17/10, the patient had a chief complaint of a right leg ulcer which cultured Methicillin-resistant Staphylococcus aureus (MRSA) (bacteria which does not respond to certain antibiotics) positive. The care plan dated 08/17/10 showed no goals or outcomes related to wound care or pain control.
2. Record review of Patient #8's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of pneumonia, asthma, or constipation.

3. Record review of Patient #7's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of obstructive chronic bronchitis with acute exacerbation (severe coughing and shortness of breath).

4. Record review of Patient #9's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of pneumonia.

5. Record review of Patient # 10's closed chart revealed the nursing care plan was not individualized to the patient. According to the physician history and physical dated 07/19/10, the patient had a chief complaint of swelling and redness of the right foreleg and chronically edematous. The care plan dated 07/18/10 through 07/20/10 showed no goals or outcomes related to wound care.

6. Record review of Patient #14's closed chart revealed the nursing care plan was not individualized to the patient. According to the surgical consent dated 05/13/10, the patient underwent an excision of a rectal fistula (tunneling wound from the inside of the rectum to the skin). The care plan dated 05/13/10 though 05/14/10 showed no goals or outcomes related to wound or fistula care.

7. Record review of Patient #17's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of confusion and altered mental status.

8. Record review of Patient #15's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of nausea and vomiting.

9. Record review of patient #18's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of acute pancreatitis (inflammation of the pancreas).

10. Record review of patient #16's closed chart revealed the nursing care plan showed no goals or outcomes related to the patient's diagnosis of lower leg joint effusion (fluid accumulation surrounding a joint).




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11. Record review of Patient #2's open medical record revealed the patient was admitted to the facility on 08/23/10 with a chief complaint of shortness of breath.
The History and Physical (H&P) dated 08/14/10 revealed in part the following information:
-Impressions: Urinary tract infection (UTI) [a bacterial infection of the bladder or kidneys]
The Generic Care Guide dated 08/23/10 revealed no goals or outcomes related to the urinary tract infection.

12, Record review of Patient #19's closed medical record revealed the patient was admitted to the facility on 06/13/10 with a chief complaint of shortness of breath and abdominal pain.
The H&P dated 05/03/10 revealed in part the following information:
Diagnosis of CHF (a condition in which the heart no longer pumps enough blood to the rest of the body)
- The Generic Care Guide dated 06/13/10 revealed no goals or outcomes related to the diagnosis of Congestive Heart Failure (CHF).

13, Record review of Patient #21's closed medical record revealed the patient was admitted to the facility on 05/03/10 with a chief complaint of left flank pain.
The Discharge Summary dated 08/06/10 revealed in part the diagnosis at time of discharge was 1. Left flank pain improved 2. Left distal ureteral calculi with hydronephrosis (an obstruction of the ureter [the tube which connects the kidney with the bladder] which distends and dilates the portion of the kidney known as the renal pelvis.
- The Generic Care Guide dated 06/13/10 revealed no goals or outcomes related to the diagnosis of .

14. Record review of Patient #23's closed medical record revealed the patient was admitted to the facility on 05/27/10 with a chief complaint of abdominal pain.
The H&P dated 05/27/10 revealed in part the following information:
Impressions: Ruptured Diverticulitis (a small bulging sac pushing outward from the colon wall which ruptures and becomes infected)
- The Gastro Intestinal (GI), Care Guide dated 05/27/10 revealed no goals or outcomes related to pain.

15. Record review of Patient #24's closed medical record revealed the patient was admitted to the facility on 07/26/10 with a chief complaint of wheezing and shortness of breath.
The H&P dated 07/26/10 revealed in part the following information:
Impressions: Bilateral pneumonia (an infection in both lungs)
- The Generic Care Guide dated 07/26/10 revealed no goals or outcomes related to the diagnosis of pneumonia.

16. Record review of Patient #25's closed medical record revealed the patient was admitted to the facility on 05/06/10 with a chief complaint of swollen feet.
Record review of the H&P dated 05/06/10 revealed in part the following information:
Impressions: CHF
Record review of the Progress note of 05/08/10 stated the patient's edema (swelling) may have been related to her being hypothyroid (a disease caused by insufficient production of thyroid hormones by the thyroid gland [a gland found in the neck below the "Adam's Apple").
- The Generic Care Guide dated 05/06/10 revealed no goals or outcomes related to the diagnosis of low thyroid or CHF.

17. An interview on 08/25/10 at 9:55 a.m. Director of Patient Care K stated there were no goals or outcomes listed on the Care Guides.

Based on observation, interview, and record review, the facility failed to secure patient medical records stored in the radiology department from unauthorized access. This had the potential to affect any patient who had radiology films or radiology interpretations stored in the Radiology Department. The facility census was five.
Findings included:
1. Record review of the Radiology policy in Section 5, #7, titled "Medical Records Requirements", dated 03/03/08 without revision stated the following element are included in typewritten reports:
-the patients identification (name, address, admission date, billing number, ...room/bed, birth date, age, ...and diagnosis (1.a.1);
-interpretation by the Radiologist (1.a.2).

2. Record review of the Health Information Management Services policy in Section 9, #6, titled "Access to Storage and Retrieval Areas", without approval date and without revision date, stated only authorized personnel shall be permitted direct access to the storage and retrieval areas so that proper safeguards against unauthorized use are maintained.

3. Observation on 08/23/10 at 2:50 p.m. showed immediately inside the radiology department main door were two areas that contained unsecured medical records. On the right was a sliding pocket door which did not lock, and on the left was a door propped open. Both areas contained radiology films and transcribed radiologist reports. The department was located off of a main corridor where patients pass to receive radiology and laboratory studies and outpatient medications and wound care. There were two staff members found exiting the radiology area where radiology films and reports are stored, leaving the department empty.

4. During an interview on 08/23/10 at 2:58 p.m., Staff T, Director of Radiology stated the Radiology department remains unlocked during business hours. The sliding door containing films and reports does not have a lock on it. The door on the left is Staff T's office, and remains open during business hours. Staff T also states the department is left unattended at times throughout the day.

5. Observation on 08/24/10 at 9:00 a.m. showed the door to the department was open and the Radiology Department was empty. Both storage areas for radiology films and reports were open and accessible.

Based on record review and interview the facility failed to include in their written Organ, Tissue, and Eye Procurement Policy a definition of "timely notification". The facility census was five.

Findings included:

1. Record review of the facility Organ, Tissue, and Eye Donation policy Section: 2 Policy 13 reviewed 10/13/08 revealed no definition of "timely notification".

2. An interview on 8/25/10 at 3:15 p.m. Director of Patient Care K after reviewing the policy stated there was no definition in the policy of "timely notification".