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Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evidenced by the hospital failing to include the House Keeping Department in the hospital's QAPI program.

On 04/04/2019 at 10:30 a.m., a review of the hospital's QAPI program and quarterly meetings and minutes for 2018 failed to reveal the House Keeping Department was included in the QAPI program.

During an interview on 04/04/2019 at 10:45 a.m., S2Quality confirmed the House Keeping Department was not included in the QAPI program for all four quarters of 2018.

Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered as ordered by the physician and according to acceptable standards of practice for patient records reviewed for 2 (#1, #5) of 10 medical records reviewed for medication administration from a total sample of 30 patient records.

Findings:

Patient #1
Review of Patient #1's medical record revealed an order for sliding scale insulin as follows:
Humulin R 100u/ml
150 - 200 2u
201 - 250 4u
251 - 300 6u
301 - 350 8u
351 - 400 10u
Call MD over 400

Review of Patient #1's medical record revealed documentation on 3/31/19 at 4:15 p.m. of a blood glucose of 199. Further review revealed no documentation of insulin having been given or an explanation as to why it had not been given.

In an interview on 4/1/19 at 1:30 p.m. with S1DON, she verified 2 units of insulin should have been given for a blood glucose of 199.


Review of Patient #1's medical record revealed an order for Clonidine 0.2 mg q 8 hours for systolic blood pressure greater than 100.

Review of Patient #1's vital signs revealed the following blood pressures documented with no documentation that clonidine had been administered:
3/30/19 at 3:22 a.m. - 171/101
3/30/19 at 7:00 p.m. - 182/107
4/1/19 at 7:25 a.m. - 190/110

In an interview on 4/1/19 at 1:52 a.m. with S1DON, she verified Clonidine should have been given for the above referenced blood pressures or documentation as to why it had not been given.

Patient #5
Review of Patient #5's physician's orders revealed an order dated 10/16/19 at 9:31 a.m. for Levophed 1mg/ml dose 4mg at 33.8 ml/hr. Comments: Titrate per MD. Follow Crash Cart Infusion Chart. Further review revealed no specific orders on the frequency or dosage to titrate the infusion.

Review of the Crash Cart Infusion Chart for Levophed revealed no time intervals for titration or dose to be titrated.

Review of Patient #5's nurse's notes revealed the Levophed infusion had been titrated as follows:
10/16/19
2:07 a.m. - 7mcg/min
3:21 a.m. - 9mcg/min
10:45 a.m. - 7mcg/min
11:45 a.m. - 5mcg/min
12:19 p.m. - 3mcg/min
1:45 p.m. - 2mcg/min
2:39 p.m. - 1mcg/min
6:15 p.m. - discontinued

In an interview on 4/1/19 at 3:19 p.m. with S1DON, she said the RNs were supposed to be calling the physicians for titration orders but she could not locate orders for titration or documentation of discussions with a physician for titration in Patient #5's medical record. She also verified the Crash Cart Infusion Chart had no guidelines for titrating the Levophed infusion and there was no hospital protocol for titrating.

Based on observation and interview, the hospital failed to ensure medical records were stored in locations where they are protected from fire and water damage by 1) having medical records stored on top of filing cabinets underneath a sprinkler head in the mammography storage room; and 2) storing medical records on open metal shelves in the medical records room under sprinkler heads.
Findings:

1) On 04/02/19 at 2:00 p.m., observation of the mammography storage room revealed approximately 30 medical records sitting on top of a filing cabinet underneath a sprinkler head.

An interview at this time with S4Radiology Director confirmed the records would not be protected from water damage or fire.

2) On 04/04/19 at 10:10 a.m., observation n the medical records room with S7HIM Manager revealed hundreds of patient charts stored on open metal shelves. Sprinkler heads were observed above the shelves. Observation revealed S8Medical Records Clerk was scanning patient records in this room.

At that time, interview with S8Medical Records Clerk revealed approximately 600 medical records were stored on the shelves, but had not been scanned into the computer. S8 further revealed that these patient records dated from 2009-2014. When asked if the records were protected from water if the sprinklers were activated, he stated no.




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Based on observation and interview, the hospital failed to ensure that outdated and unusable drugs were not available for patient use by storing expired medications in the operating room drug storage area with other medications available for patient use.
Findings:

On 04/03/19 at 10:15 a.m., observation of Operating Room #1 revealed the following medications were stored with other medications available for patient use:
4 vials of Lidocaine 2%, 20mg/ml - 3 expired in November 2018 and 1 expired in June 2108;
4 vials of Sensorcaine 0.5%, 50 ml - expired in February 2019.

An interview at this time with S12Surgery Director confirmed the expired medications should not be stored with medications available for patient use.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's chart for 2 (#9, #10) of 2 patient records reviewed who had hospital identified medication errors.
Findings:

Patient #9
Review of hospital incident reports and Patient #9's medical record revealed on 3/9/19 at 12:00 a.m. Norco 5mg had been given instead of the 10mg ordered. Further review revealed no documentation was in the medical record that the physician had been notified of the medication error.

Patient #10
Review of Patient #10's medical record revealed on 2/23/19 at 8:43 p.m. a whole Bactrim DS had been given instead of the ½ tablet that had been ordered. Further review revealed no documentation was in the medical record that a medication error had occurred or that the physician had been notified of the medication error.

In an interview on 4/2/19 at 9:38 a.m. with S2Quality, she verified the physician notification of a medication error and a notation of what had been administered in error should have been in medical record.

Based on observation, record review and interview, the hospital failed to ensure that all kitchen staff was competent in their respective duties as evidenced by failing to be aware of the correct concentration of sanitizer in the dishwasher.
Findings:

On 04/03/19 at 10:40 a.m., the surveyor requested S6Dietary Manager to check the sanitizer concentration in the dishwasher. S6Dietary Manager attempted several times using three different containers of test strips, but could not get any sanitizer to register. Observation of one of the chlorine test strip containers revealed an expiration date of 01/01/2017. When asked what concentration of sanitizer was required for adequate sanitation, S6Dietary Manager stated 75ppm. When asked how she knew that 75ppm was adequate sanitation, S6Dietary Manager stated that it has been that way since I started years ago. At that time, observation of the test strip containers revealed the labels had been wet and were brown and faded. The sample color chart for readings was very distorted.

Further observation of the test strip containers revealed different colors, indicating the different concentrations of sanitizer. The concentration readings were 0, 50, 100 and 250ppm. There was no color indicated for 75ppm. When S6Dietary Manager was asked how the staff would get a reading of 75ppm, she stated the color would be between the 50 and 100 reading. When asked if she could adequately see the color chart since it had gotten wet, she had no response. At this time, review of the dishwasher log with S6Dietary Manager revealed the sanitizer was checked once per day on the evening shift. Review of the logs for the past month revealed the staff was documenting 75ppm for the sanitizer concentration. The manufacturer's recommendations for sanitizer was requested at this time.

On 04/03/19 at 10:55 a.m., S5Registered Dietician entered the kitchen and confirmed that the dishwasher was a chemical (chlorine) sanitizer. She observed S6Dietary Manager attempting to use the test strips to check the sanitizer concentration. S5Registered Dietician stated that the sanitizer should be registering 75ppm but confirmed no sanitizer was registering. At this time, the manufacturer's recommendations for the sanitizer and dishwasher was requested.

On 04/03/19 at 10:58 a.m., interview with S9Cook revealed that she had checked the sanitizer on the dishwasher that morning. When asked if she documented this information, she stated yes and showed the dishwasher log to the surveyor. The log did not indicate that sanitizer was checked in the mornings. When asked what the sanitizer concentration was that morning, S9Cook stated "It turned brown".

On 04/03/19 at 11:30 a.m., interview with S5Registered Dietician revealed that she comes to the facility three times per week. When asked if she had ever observed the staff performing checks of the dishwasher sanitizer, she stated "Obviously not". She further stated that she thought the staff was using the wrong test trips.

As of exit on 04/04/19, the manufacturer's recommendations for sanitizer had not been provided to the surveyor.

Based on observation, record review and interview, the hosptial failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices as evidenced by the registered dietician failing to prepare and approve patient menus.
Findings:

On 04/03/19 at 11:10 a.m., observation in the kitchen revealed the lunch meal was prepared and on the steam table. At that time, the menu, as prepared and approved by S5Registered Dietician, was requested from S6Dietary Manager. S6Dietary Manager provided the surveyor with a piece of paper with handwriting on it stating the following:

Friday D - minestrone soup, chicken salad, pea salad
Sat L - pork chop, augratin
Sat D - chick dumpling, squash, cornbread
Sun L - spaghetti meatballs, calif blend
Sun D - chicken tortilla soup, turkey sandwich, pasta salad, beef pot pie, carrots, cornbread
Mon L - chicken strips, mashed potatoes
Mon D was left blank
Tues L - beef tips
Tues D was left blank
Wed L was left blank
Wed D was left blank
Thurs L was left blank

Further interview with S6Dietary Manager revealed that S5Registered Dietician writes the above menu down for the staff to follow. When asked if there were any other menus prepared by the dietician, including specialized diets, she stated no. She further stated that if a patient is on low sodium or diabetic diet, the staff know what to substitute. When asked how the kitchen staff knew what to prepare today for lunch since "Wednesday L (lunch)" was left blank, she had no explanation. When asked how the kitchen staff knows what to prepare for breakfast, since a breakfast menu was not written down for any day, she stated that the staff prepares the same breakfast every day.

On 04/03/19 at 11:20 a.m., an interview with S9Cook was conducted. When asked how she knew what to prepare for lunch that day, since there was no menu to follow, she stated that she prepares whats on hand. She further stated that the next time S5Registered Dietician comes to the hospital, she informs her and S5Registered Dietician writes it down.

On 04/03/19 at 11:30 a.m., an interview was conducted with S5Registered Dietician. The surveyor showed her the above handwritten menu and she stated that menu was for the staff meals. The surveyor asked her for a patient menu and she was unable to provide one.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety as evidenced by having non-functioning nurse call bells located on the side rails of 10 of 48 patient beds.
Findings:

On 04/03/19 at 10:00 a.m., observation of patient rooms a, b and c revealed a nurse call button on the bed side rail which did not function when activation was attempted.

An interview with S2Quality on 04/04/19 at 1:15 p.m. revealed that 10 patient beds in the facility had the visible non-functioning nurse call button features on the side rail. She confirmed that those rooms had call bells that were attached to cords plugged into the wall and clipped to the bed linens. She further confirmed that the non-functioning call bells on the side rails could cause confusion for a patient or family member who was attempting to call for assistance.

Based on observation and interview, the hospital failed to maintain a system for controlling infections and communicable diseases by failing to maintain a sanitary environment in: 1) patient rooms that were cleaned and ready for new admissions; 2) the outpatient laboratory room; 3) the emergency department triage and exam rooms; 4) the kitchen.
Findings:

1) On 04/02/19 at 10:00 a.m., observation of patient rooms that were cleaned and ready for new admissions revealed the following:
Room d - several strands of black hair were observed in the bathroom sink; a gerichair in the patient room had a hole in the seat approximately the size of a pencil eraser.
Room j - dried brown spills were observed in the bathroom sink; a brownish gray dried substance was noted on the sheet of the bed which had been made.

2) On 04/02/19 at 1:15 p.m., observation of the outpatient laboratory room revealed a chair that would be used by the patient during a venipuncture procedure had a tear in the edge of the seat.

On 04/04/19 at 1:45 p.m., an interview with S1DON confirmed the above patient rooms would need to be recleaned and the chairs would need repair.

3) On 04/03/2019 at 10:35 a.m., accompanied by S10RN, an observation of the emergency department revealed the following:

Room k - a thick layer of grime on the otoscope machine, the vitals machine and the patient's scale.
Room g - a thick layer of grime on the air mask bag unit and rips/tears to the vinyl covering of the chair, suction catheter kit expired 02/02/2019 and 11/2017, Sterile gloves #7 expired 2016-02, 2 petroleum gauze expired 2017-12.
Room i - rip/tear to the vinyl covering of the mattress, a thick layer of grime on the portable otoscope stand, grime on the portable vitals/heart monitor machine.
Room e - grime on the bed's mattress and frame, chair with rip/tears to the vinyl covering, grime on the otoscope stand and machine, defibrillator and crash cart with a thick layer of grime on the surfaces.
Room f - removing the bed-sheet revealed tape/heart monitor stuck to the bed's mattress.
Room h - rip/tear to the vinyl covering of the mattress, Epistaxis dressing expired 3/2018, Sterile gloves #6 expired 03/2019, 1x8" petroleum gauze expired 07/2017, 1 packet lubricating jelly expired 2018-11-01, 2 petroleum gauze 3x9" expired 08-2015.

During an interview on 04/03/2019 at 11:00, S10RN acknowledged the findings.

4) On 04/03/19 at 10:40 a.m., a tour of the kitchen was conducted. At that time, the surveyor requested S6Dietary Manager to check the sanitizer concentration in the dishwasher. S6Dietary Manager attempted several times using three different containers of test strips, but could not get any sanitizer to register. Observation of one of the chlorine test strip containers revealed an expiration date of 01/01/2017.

On 04/03/19 at 11:00 a.m., observation of the ceiling vents over the steam table revealed it was coated in grime and a thick build up of dust.






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