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Based on record review and interview, the facility failed to ensure a registered nurse (RN) assessed a patient's needs accurately and timely and notified the physician of changes in condition for 1 of 33 sampled patients (Patient #13).

Findings include:

Patient #13 was admitted to the facility on 12/25/11 with diagnoses including fractured femur following a fall in prison.

The nurse's notes dated 12/26/11 at 18:56 (6:56 PM), documented "Pt (patient) has had emesis times two, the last one was projectile. Will be passed on to noc (night) nurse. Pt has IV (Intravenous) fluids running for hydration and guards are aware not to feed pt."

There was no documented evidence the physician was notified of Patient #13's vomiting.

On 12/27/11 at 10:15 AM, Patient #13 was transported to the OR (Operating Room) and had an ORIF (Open Reduction and Internal Fixation) of his left hip.

Following the procedure, documentation by the anesthiologist at 1:30 PM, indicated when Patient #13 was transferred from the OR fracture table to his bed, the patient vomited and the LMA (Laryngeal Mask Airway) was filled with approximately 100 cc (cubic centimeters) of black liquid. The physician removed the LMA and intubated the patient.

A consultation was done immediately by Dr (name) while the patient was still in the OR. The physician's history documented "...The patient did have history of coffee-ground emesis yesterday per jail personnel..."

A second consultation done on 12/27/11, by Dr (name) documented, "...during extubation with LMA, the patient vomited and aspirated. The vomitus looked like coffee-ground emesis..." The physician assessment documented - Aspiration pneumonia, status post bronchoscopy of coffee ground emesis; Questionable gastrointestinal bleed/hematamesis.

On 1/5/11, in the afternoon, the Unit Manager (Employee #31) confirmed there was no documented evidence the physician was notified regarding Patient #13's emesis on 12/26/11, and added the RN should have notified the physician at that time.

Based on observation, interview, record review, and document review, the facility failed to ensure medication for 2 of 33 sampled patients (Patient #9, #15) was documented as administered per the physician's orders.

Findings include:

Patient #9

Patient #9 was admitted 12/28/11 with diagnoses including pneumonia, atrial fibrillation, esophageal cancer, cardiomyopathy, and congestive heart failure.

On 1/5/12 at 3:45 PM the Interim Chief Nursing Officer (Employee #2) verified the nasal gastrostomy tube (NGT) was placed on 12/31/11 at 12:00 PM and the physician ordered on 12/30/11 at 17:44 (5:44 PM), "Keep pt (patient) NPO (nothing by mouth)".

The Medication Administration Record (MAR) throughout the dates of 12/31/11 through 1/6/12 indicated the following medications were to be given orally:
-Aspirin EC (Enterocoated) 325 mg (milligram) = 1 tab (tablet), with breakfast (Start date 12/28/11).
-Digoxin 125 mcg (micrograms) = 1 tab (Start date 12/29/11).
-Guaifenesin 200 mg = 10 ml (milliliters); 2 times a day (Start date 12/30/11).
-Carvedilol, 12.5 mg = 1 tab, 2 times a day with meals (Start date 12/30/11).
-Acetaminophen 650 mg = 2 tabs; PO or PR (per rectum), PRN (as needed) temperature greater than or equal to 101 F (Fahrenheit) max (maximum) 3 gm (grams) APAP (Acetaminophen) / Day (Start date 12/28/11).
-Nitroglycerin 0.4 mg = 1 tab, for chest pain, may repeat after 5 minutes (Start date 12/30/11).
-Magnesium Hydroxide, 30 ml = 30 ml, as needed by mouth (Start date 12/31/11).

There were no dosage instructions for the above medications to be administered via g-tube.

On 1/5/12 in the afternoon, Patient #9's chart was reviewed with the (Nurse) Education Manager (Employee #5), who verified there was no documented evidence the patient's medications were administered via g-tube and not orally. The IMC (Intermediate Care) Charge Nurse indicated the MAR dosage route was an error, and the patient's medications were actually administered via g-tube as ordered by the physician since the placement of the g-tube on 12/31/11.

The facility's policy (Medication Administration, current effective date 12/11) indicated as follows:
"2.G. Medication orders must include:
1. Drug
2. Dosage
3. Route
4. Frequency
5. Date Ordered
6. Time Ordered
7. Signature of Authorized Person
8. Patient's name on physician order form before sending to Pharmacy.
E. Medication Orders
1. General Information
a. Pharmacy Department assumes primary responsibility for clarification or proper conversion in instances where a medication order is written in other than the metric quantities.
c. The most current medication dosage takes precedence over any previous order. The prior order is discontinued. This excludes one time orders.
4. Hold or NPO
b. 'NPO except medications' order is written, medications are administered as ordered.
c. 'NPO' all oral medications are held unless ordered otherwise by the Licensed Independent Practitioner. Note: If patient has an NG or G-tube the pharmacist may amend order to specify NG/GT route.
G. Checking and Administration
1. At the beginning of each 24 hours, the nurse responsible for administering medication verifies the Medication Administration Record with the previous MAR. Any discrepancies are checked against the physician's original order. The MAR is signed as verified...
2. Obtain medication(s) for one patient at a time.
3. Verify for accuracy: drug, dose, time, patient, and route...."



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Patient #15

Patient #15 entered the facility on 1/5/11. Patient #15 was scheduled for an outpatient surgical procedureon 1/5/12, to remove a sebaceous cyst on his back.

Patient #15's Pre-Operative (Pre-Op) Admission Orders dated 12/8/11, documented to start an intravenous (IV) with normal saline.

On 1/5/11 in the morning, Patient #15 was in the preoperative area. Patient #15 had an IV to his left hand which was connected to a 1000 ml (milliliter) bag of Isolytes.

Patient #15's Outpatient Pre-Op/Procedure Admission form dated 1/5/12, documented:

- " ...0650 (6:50 AM) 100 ml Isolyte started L (left hand ... "

On 1/5/12 in the morning, the Director of Pre-Operative/Post-Operative Services confirmed the wrong IV solution was started for Patient #15.

Based on observation, interview, and document review, the facility failed to ensure patient medical records were inaccessible to unauthorized persons.

Findings include:

On 1/4/12, 1/5/12, and 1/6/12, 1 of 2 doors to the Medical Records Department was unlocked and was accessible to the general public. (Although there was a posted sign indicating, "Staff Only" on the door, there was no impediment to accessing the areas in which medical records were stored.)

On 1/5/12 at 9:30 AM, there were 2 staff members located in work stations at the entry to the office (where the door opens into). One of these staff members was interviewed and indicated as follows:
-She and 1 other employee work at the work station at the entry to the office during the hours of 7:00 AM until 5:00 PM daily on Monday through Friday of each week.
-On Saturday and Sunday of each week there are 2 other employees working at this station during the hours of 7:00 AM until 5:00 PM.
-The security coded lock of the entry door are released daily at 5:00 AM, and "generally" locked again at approximately 6:00 PM.
-Various types of staff members of the facility are allowed access to patient medical records, including (but not limited to) physicians, physician assistants, nurse case managers, and social workers.
-Persons who are non-hospital staff members are also allowed access to patient medical records, including (but not limited to) social workers and other staff members from the Health Department located across the street from the facility.

On 1/5/12 at 11:00 AM, the Interim Operations Manger of Health Information Services (Employee #32) was interviewed, and indicated as follows:
-The reason the coded lock is released at 5:00 AM daily is for continuity and ease of access to patient medical records by hospital staff.
-There are staff available in different stations throughout the various rooms of the Medical Records Department between the hours of 5:00 AM through 11:30 PM. However, there are no staff available specifically stationed near the entry door between the hours of 5:00 AM and 7:00 AM 7 days a week who are able to screen persons coming into the office to review patient medical records.

The policy regarding HIM (Authorized Access to HIM Department, effective date 8/06, revised 1/09) indicated the following:

"I. Purpose: To maintain confidentiality and assure that only those individuals authorized have access to the Health Information Management Department.
II. Policy Guideline: It is the policy of the Health Information Management Department to strictly maintain the confidentiality and security of the numeric codes and/or keys used to gain access to the secured areas of the department."

There were no provisions in the facility's policy regarding the hours in which the doors to the Medical Records Department were to be secured and to whom access to patient medical records was allowed.

Based on record review, interview and policy review, the facility's nurses failed to document the waste associated with the administration of as needed pain medication for 1 unsampled patient (Patient #34).

Findings include:

Patient #34

On 1/2/12, Patient #34 was admitted with diagnoses of pneumonia and depression.

On 1/3/12 at 3:10 PM, a physician ordered intravenous Dilaudid 1 milligram (mg) every 3 hours as needed.

On 1/3/12 at 3:43 PM, the pharmacy's delivery signature receipt indicated someone signed for a 2 mg ampule of Dilaudid.

On 1/3/12 at 3:55 PM, a nurse documented an administration of 1 mg of intravenous Dilaudid. The nurse failed to document 1 mg of Dilaudid waste on the medication administration record or elsewhere within the patient's record.

On 1/5/12 at 10:27 AM, a nurse signed out a 2 mg vial of Dilaudid from the Pyxis at location 4TM2. The all station events report received from the pharmacist showed the nurse failed to document Dilaudid waste. The corresponding medication administration record lacked documentation of the Dilaudid dose administered.

The nurses were unavailable for interviews.

On 1/6/12 in the afternoon, Employee #2 indicated nurses should document waste of unused controlled drugs.

According to the facility's policy Controlled Drugs: Administration, last revised 7/09, "...the disposition of a portion of a controlled drug remaining in an ampule, vial, or syringe must be documented. Documentation of wastage or destruction shall be on the next available line of the administration record or in a designated column or area of the record. A licensed person must witness and cosign for all wastage and destruction..."

Based on interview and document review, the laboratory failed to make provision in writing for the reporting of tissue specimen results.

Findings include:

There was no documented evidence of a policy and procedure including written instructions concerning the disposition of final patient tissue specimen
results.

On 1/6/12, Employee #24, Employee #25, Employee #26, and Employee #23 confirmed there were no written instructions concerning the disposition of final patient tissue specimen results.

This STANDARD was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that 1 ice machine was connected to the sewer drain in a manner which would prevent contamination of its potable water supply. The UPC requires an air gap or air break on this drain line. This cross connection increased the risk of illness from the possible consumption of contaminated drinking water. All residents and staff could possibly be affected.

Findings include:

NRS 444.350 1. Any construction, alteration or change in the use of a building or other structure in this State must be in compliance with the Uniform Plumbing Code (UPC) of the International Association of Plumbing and Mechanical Officials in the form most recently adopted by that Association, unless the State Public Works Board posts a notice of disapproval of any amendment to the Code pursuant to subsection 5.
Uniform Plumbing Code (1997 edition), 801.2 Establishments engaged in the storage, preparation, selling, serving, processing, or other handling of food and beverage involving the following equipment which requires drainage shall provide indirect waste piping for refrigerators, refrigerator coils, freezers, walk-in coolers, iceboxes, ice making machines....

On 1/4/12, the ice machine in the clean utility room on 2 South, was observed to be directly connected to the building's wastewater drain.

On 1/4/12 the Director of Facilities (Employee #21) verified there was no indirect waste piping in the drain from the ice machine.

Based on observation, interview, and policy review, the facility failed to ensure safe and appropriate storage of sterile supplies and infection control practices were maintained for isolation precautions.

Findings include:

1. On 1/6/12 at 8:45 AM, a Cardiac procedure was being performed in the Catheterization lab (laboratory) Room #2. Along with the Cardiologist and Anesthesiologist, there were 4 other staff members and 1 medical supply representative assisting with the procedure. At one end of the room was 1 blue plastic lined linen container with linen inside the bin. The medical supply representative used the top of the bin as a table, placing approximately 10 to 12 packages on the top of the cover. Also placed on the top of the blue bin were keys and an opened box of gloves. During the entire procedure no one had access to the bin due to the supplies being stored on top of the bin. There was also linen on the floor next to the bin. Out of the 10 to 12 packages that were on top of the bin approximately 5 to 6 packages were used during the procedure. The medical supply representative also placed packaged medical supplies on the floor between 2 red plastic lined containers used for trash. Some of the packaged supplies that were on the floor were also used for the procedure.

Next to the blue plastic lined container was a red plastic lined container. Throughout the procedure the container was continuously filled with paper trash, medical supplies that were used during the procedure, and used gloves. By the end of the procedure the container became full and overflowed with trash. At the end of the procedure the staff did not attempt to change the plastic bag when the container was overflowing with trash. Some staff members were attempting to compact the trash by using their hands to push the trash further into the plastic. During the procedure the top of the container top was propped up with tape, but by the end of the procedure staff members were opening the top of the container with bare hands and also used gloves. The foot pedal to prop up the cover was barely used.

Next to the red plastic lined container were the medical supplies that were on the floor leaning against the wall. Next to the packaged medical supplies was another red plastic lined container used for trash. The container was placed directly underneath a computer screen that was secured to the wall. The red plastic lined container was also being used as a table top. The foot pedal to prop the container was barely used and staff were opening the lid with bare hands and gloved hands throughout the entire procedure. Also, a clear plastic bag was placed on the floor. When packaged supplies were used for the procedure the opened empty package would be placed into the clear plastic bag on the floor. A staff member would then pick up the plastic bag from the floor and place it on top of the trash lid (red container that was placed under the computer screen) and scan the empty packages. A large black binder was also being placed on top of the trash lid, where staff members would flip the pages of the binder to scan bar codes.

After the procedure a technician was cleaning his area. The technician attempted to use the red trash container properly by using the foot pedal to open the top. The technician had difficulty opening the container due to the large black binder on top. The technician hesitated to touch the binder but used his index finger to secure the binder so it would not fall off the lid.

On 1/6/12 at 11:35 AM, the Director of Infection Control confirmed it was an inappropriate practice to use trash bin lids as table tops, placing medical supplies on top of soiled linen containers, placing medical supplies on the floor, compacting trash by pushing trash down with gloved hands, not using the foot pedal to open lids, and using bare hands and gloved hands to open trash containers.


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2. During the initial tour of the 2 North unit, Room #217 and Room #221 were noted to have Isolation carts outside the doorway and a sign which indicated Isolation. There was no sign indicating the type of Isolation the patients were on, which would indicate the appropriate precautions to be taken.

The Charge Nurse (Employee #30) indicated both patients were on Contact Isolation for wounds.

On 1/6/11 in the morning, the Director of Infection Control verbalized the type of Isolation should be posted for all patients on Isolation precautions.

The facility's policy (Isolation Guidelines, current effective date 12/11) indicated signage was required for isolation precautions, and delineated 3 categories of transmission based precautions: Airborne Precautions, Contact Precautions, and Droplet Precautions.

Based on record review and interview, the facility utilized the services of an unlicensed referral agency to place 4 unsampled patients in dependent care homes (Patient #35, #36, #37, and #38).

Findings include:

On 1/6/12 in the afternoon, the Licensed Social Worker (Employee #20) provided a municipal business license and business card for the referral agent the facility used to place discharged patients in homes for dependent care. A state database check revealed the referral agent was unlicensed as a referral agent for placing dependent persons in dependent care homes.

On 1/6/12 in the afternoon, the Director of Case Management (Employee #19) provided a list of 4 patients discharged within the last 4 months (Unsampled Patient #35, #36, #37, and #38), for whom the facility used the referral agent for placement after discharge. A disposition location of the patients revealed each patient was placed in a licensed home for dependent care.

There was documented evidence of social services notes written by Employee #34 for each patient, which referred to conversations with individuals about placing each of the above patients in homes for dependent care.

The facility's employees expressed a lack of awareness for the requirement of using a licensed referral agent pursuant to Nevada Revised Statute 449.0305 when utilizing a referral agent to find placements for dependent patients.

Based on interview and record review, the facility failed to maintain proper communication with the outpatient clinic (Patient #22, #21).

Findings include:

The hospital had an outpatient clinic located across the hospital parking lot in a separate building from the hospital. The department was a hyperbaric and wound healing center. The center had 78 active patients on file.

On 1/5/11 in the afternoon, a sticker was noted on some active patient files. The Out-Patient Clinical Nurse Manager indicated the sticker was placed on the patient file to identify that the patient was positive for an infectious disease such as MRSA (methicillin-resistant Staphylococcus aureus). The surveyor requested a list of identified infectious patients. The Clinical Nurse Manager indicated she did not keep a list. The Clinical Nurse Manager was able to go through an active patient list and circle patients who were positive for some type of infectious disease. The surveyor randomly chose patients who were not circled by the Clinical Nurse Manager from the active list.

Patient #22

Patient #22 was an active patient since 3/30/11, and was being treated at the wound care clinic due to a left lower extremity ulcer. Wound culture reports completed on 8/17/11 indicated Patient #22 was positive for MRSA.

The Out-Patient Clinical Nurse Manager confirmed Patient #22 was positive for MRSA and was not identified through a sticker on her file as being positive for an infectious disease.

Patient #21

Patient #21 was an active patient since 11/3/10, and was being treated at the wound care clinic due to a right foot ulcer. Wound culture reports completed 8/3/11 and 5/4/11, indicated Patient #21 was positive for MRSA.

The Clinical Nurse Manager confirmed Patient #21 was positive for MRSA but was not identified with a sticker on the chart.

On 1/6/11, in the morning, the Director of Infection Control indicated the wound care outpatient clinic did not complete a hospital Opus alert computer program. The the Director of Infection Control indicated when a patient was positive for an infectious disease or has had a history of an infectious disease the Opus alert program would be completed so that the outpatient clinic staff and hospital staff would be aware of the patient's condition. The Director of Infection Control confirmed the wound clinic had not been completing the Opus program for any of their patients who were positive for an infectious disease and he indicated it should have been done.

Based on record review and interview, the facility failed to ensure physical therapy services were provided as ordered by the physician for 1 of 33 sampled patients (Patient #14).

Findings include:

Patient #14

Patient #14 was admitted 11/13/11 with diagnoses including intractable lower back pain, morbid obesity, and urinary retention.

Patient #14's physician orders dated 11/16/11 included an order for Physical Therapy (PT) to evaluate and treat the patient. The initial PT evaluation was completed on 11/18/11 with recommendations for Patient #14 to receive PT 3-5 times a week.

A physician order dated 11/29/11 indicated Patient #14 was to receive PT daily.

A physician order dated 12/20/11 indicated Patient #14 was to receive PT daily, three times a day.

A PT re-assessment was completed on 12/21/11 which included recommendations for Patient #14 to continue receiving PT 3-5 times per week.

The PT shift assessment notes documented Patient #14 did not receive PT services on 12/1/11, 12/4/11, 12/9/11 - 12/11/11, 12/18/11 - 12/20/11, 12/22/11, 12/24/11, 12/25/11, 1/1/12, and 1/2/12.

Documentation on the PT shift assessment notes indicated Patient #14 received PT 3 times on 12/28/11. There were no other days noted to have PT 3 times in one day since ordered by the physician on 12/20/11.

On 1/5/11, in the afternoon, Employee #22 revealed PT services were not done daily or 3 times a day, even when ordered by the physician. The recommendations made in the original PT evaluation would be followed. The recommendations for Patient #14 was 3 - 5 times a week, which was provided. The Employee added the PT would not communicate directly with the physician, but would expect the physician to review the therapist's recommendations regarding frequency of treatment and progress.

Based on interview and document review, the facility failed to specify the supervision requirements for respiratory department personnel.

Findings include:

There was no documented evidence of supervision requirements for the positions of Respiratory Therapist I, Respiratory Therapist II, and Respiratory Shift Supervisor.

On 1/5/12 Employee #27 was interviewed, and on 1/6/12 Employee #28 was interviewed. Both employees confirmed that the facility failed to specify in job descriptions, personnel competency forms, policy or other written format the supervision requirements for the performance of the duties of personnel classified as Respiratory Therapist I, Respiratory Therapist II, and Shift Supervisor, Respiratory.