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Based on medical record review, facility document review and staff interview, the facility failed to ensure and promote patient rights (A0015), failed to ensure the implementation of a Quality Assessment and Program Improvement (QAPI) for surgical services (A0263), failed to provide nursing services that meet the patient's needs (A0385), failed to ensure the implementation of a infection control program for the surgical program (A0747), failed to appoint a chief executive officer (A0057) and failed to ensure the quality and safety of outside services (A0084).

Findings:

1. Reference A0015:
Based on staff interviews and record review, the facility failed for 3 of 6 patients to ensure and promote the patient rights to formulate advanced directives and to receive care in a safe environment.

2. Reference A0263:
Based on observation, interview, and record review, it was determined that the facility failed to ensure the scope of Quality Assessment and Program Improvement (QAPI) included outpatient surgery, (A 0264), the facility failed to include the outpatient surgical program in the facility wide QAPI, (A 0265), the facility failed to measure, analyze and track quality indicators, ((0267), the facility failed to monitor the effectiveness and safety of the surgical program, (A 0275), and the governing body failed to ensure that a quality improvement (QI) program was defined, implemented and maintained that included surgical services (A 0310).

3. Reference A0385:
Based on record review, the facility failed for 2 of 6 patients (#5 and #6)to ensure that patient centered care plans are developed and implemented and that 1 of 6 patients received physician ordered medications.

4. Reference A0747:
Based on observation, interview, and record review, it was determined that the facility failed to ensure that the designated infection control officer was qualified to monitor a hospital-wide infection program (A-0749), and that the Chief Executive Officer, Medical Staff and Director of Nursing implemented a functioning surgical infection control program as part of the hospital-wide Quality Improvement Quality Assurance program (A-0756).

5. Reference A0940:
Based on record review and interview, the facility Chief Executive, Medical staff and Director of Nursing failed to ensure that the a infection control program was a part of the surgical services.

6. Reference A0057
Based on staff interview and facility document review, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital as required.

7. Reference A0084
Based on facility record review, observation and staff interivew, the facility failed to ensure a mechanism to evaluate the quality of the sterilization of surgical instruments by an outside service.

Based on staff interviews and record review, the facility failed for 3 of 6 patients to ensure and promote the patient rights to formulate advanced directives and to receive care in a safe environment.
Findings:

1. Reference A0132:
Based on record review, the facility failed to have evidence of making available to 3 (#3, #5, and #6) of 6 patients, advance directives or the right to formulate their personal advance directives.

2. Reference A 0144:
Based on staff interviews, facility document review and medical record review, the facility failed for 2 of 6 patients(#5 and #6) to provide a safe patient care environment and the facility failed to ensure adequate monitoring of the infection control practices and quality practices.

Based on observation, interview, and record review, it was determined that the facility failed to ensure the scope of Quality Assessment and Program Improvement (QAPI) included outpatient surgery, (A 0264), the facility failed to include the outpatient surgical program in the facility wide QAPI, (A 0265), the facility failed to measure, analyze and track quality indicators, ((0267), the facility failed to monitor the effectiveness and safety of the surgical program, (A 0275), and the governing body failed to ensure that a quality improvement (QI) program is defined, implemented and maintained (A 0310). For this reason the Condition for QAPI was found to be out of compliance at the time of the survey.

Findings:

1. Reference A 0264:

Based on facility document review and staff interview, the facility failed to include the surgical program into the hospital wide Quality Improvement Program (IP).

2. Reference A 0265:

Based on facility documentation and staff interviews, the facility failed to develop and measure quality indicators for the surgical program that reflect patient outcomes.

3. Reference A 0267:

Based on facility document review and staff interview, the facility failed to ensure that the facility measured, analyzed and tracked quality indicators for the surgical program.

4. Reference A 0275:

Based on facility document review and interview the facility failed to ensure that indicators reflecting effectiveness and safety of the surgical program.

5. Reference A 310:

Based on facility record review and staff interview, the Governing Body failed to ensure an ongoing quality improvement (QI), program that is defined, implemented, and maintained.

Based on record review the facility failed for 2 of 6 patients (#5 and #6)to ensure that patient centered care plans are developed and implemented and that 1 of 6 patients received physician ordered medications.

1. Reference A 0396:

Based of record review, the facility failed for 2 of 5 (Patients #5 and #6) inpatient records to thoroughly complete and implement nursing care plans that included approaches to achieve patient centered goals.

2. Reference A 0404:

Based on staff interviews, facility document review and medical record review, the facility failed for 1 of 6 patients(#5) to provide physician ordered medications.

Based on observation, interview, record review, it was determined that the facility failed to ensure that the designated infection control officer was qualified to monitor a hospital-wide infection program (A-0749), and that the Chief Executive Officer, Medical Staff and Director of Nursing failed to maintain a functioning surgical infection control program as part of the hospital-wide Quality Improvement Quality Assurance program (A-0756).

Findings:


1. Reference A 0749:

Based on record review and interview, the facility failed to ensure that the infection control officer developed and implemented a surgical infection control program.

2. Reference A 0756:

Based on record review and interview, the facility Chief Executive, Medical staff and Director of Nursing failed to ensure that the hospital-wide infection control program was a part of the governing body or medical staff discussions.

Based on record review and interview, the facility Chief Executive, Medical staff and Director of Nursing failed to ensure that the a infection control program was a part of the surgical services.

Findings:

1. Interview with the Director of Nursing/Surgical Director on 05/25/2010 at 4:00 PM revealed that the she did not know the details of a ongoing infection control program specific to the surgical program and that she thought that the program was part of the overall hospital-wide infection control program. When asked specific questions about the sterilization status of surgical instruments she stated that she did not have any idea and that she would get the medical director to answer questions.

2. Review of the governing body minutes, quality improvement committee minutes and the medical staff meeting minutes failed to revealed that the surgical infection control was not a part of any discussions from January 2010 through May 26, 2010.

3. Interview with the infection control nurse on 05/26/2010 at 9:15 AM revealed that the facility does not have a surgical specific infection control plan. The nurse stated that if a surgical patient had an infection that she would either get a laboratory slip or that the surgeon would tell her. The nurse stated that the infection control program did not review any ongoing aspects of the program such as the cleaning/sterilization of equipment or the use of antibiotics.

Based on staff interview and facility document review, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital as required.

Findings:

Review of the Governing Body Minutes revealed that as of 03/01/2010 the facility did not have a Chief Executive Office, (CEO) that was appointed by the facility's Governing Body.

Interview on 05/25/2010 at 5:00 PM with the Director of Support Services revealed that the facility is administered by the leadership team that includes, the Director of Support Services, the Human Resources Director and the Business Office Manager. The Director of Support Services stated that the team has frequent telephone conversations with the former Chief Finical Officer and the owner.

Review of the Governing Body Minutes for 2010 did not reveal that the facility would be managed by the administrative team or that any recruitment activities to hire a CEO were in process.

Based on facility record review, observation and staff interview, the facility failed to ensure a mechanism to evaluate the quality of the sterilization of surgical instruments by an outside service.

Findings:

Observation on 05/25/2010 at 4:40 PM in the surgical suite revealed a desk out side of the functioning operating room that had five wrapped surgical trays stacked on it. Interview at the time of the observation with the physician revealed that the trays contained his personal instruments and that where sterilized at an ambulatory surgical center, (ASC), in Ocala, Florida for him. Review of the facility records did not reveal any documentation of the cleaning/sterilization of the trays. Interview with the director of support services on 05/25/2010 at 4:50PM revealed that he had taken the trays to the ASC and had brought them back to the hospital. When asked if the hospital had a contract or performed any QA on the packs, the director stated "no."

Based on record review, the facility failed to have evidence of making available to 3 (#3, #5, and #6) of 6 patients, advance directives or the right to formulate their personal advance directives.

Findings:

1. Review of the medical record for patient #3 revealed on the face sheet under Advanced Directive the letter Y, but did not contain the Advanced Directive Form, the Physician Code Status or indicate the in the medical record the patient's Do Not Resuscitate (DNR) status. Review of the medical record did not reveal evidence that the patient was offered or asked about advanced directives.

2. Review of the medial record for patient #5 revealed a Physician Code Assessment form that was signed by the physician, but was not completed including the date the physician signed the form. Review of the medical record revealed that the chart did not contain the Advanced Directive Information form and that the Cardex section for the Code status section was not completed.

3. Review of the medial record for patient #6 revealed a Physician Code Assessment form was not completed, that the chart did not contain the Advanced Directive Information form and that the Cardex section for the Code status section was not completed.

Based on staff interviews, facility document review and medical record review, the facility failed for 2 of 6 patients(#5 and #6) to provide a safe patient care environment and the ensure adequate monitoring of the infection control and quality practices.

Findings:

1. Review of the medical record for patient #5 revealed that the patient was admitted to the facility on 05/10/2010. Review of the medical record revealed that the at 2:20 PM admission orders were written that included lab work with the physician to be call with the results and to provide intravenous fluids to treat severe diarrhea resulting in dehydration. Additionally, the admission orders included "Resume home medications". Review of the medical revealed the patient has a medical history that includes cerebral palsy and a history of epilepsy. Review of the medical record revealed that the Admission Nursing Assessment was started 2:45 PM on 05/10/2010 and not completed until 05/11/2010 at 11:00 AM. Interview with the nurse that completed the admission assessment revealed that it was a busy day and that at the same time she was involved in transferring a patient to a different hospital for treatment for a fractured hip related to a fall within the facility.

Continued review of the medical record revealed that an admission nursing note was written at 3:30 PM. Review of the nursing note revealed "Patient admitted to the service of Dr. ( #1) (Direct admit). Has diagnosis of diarrhea, dehydration. V/S stable. Care given at bedside. Pt is nonverbal unable to answer question on admission sheet. Care giver helped."

Review of a physician order dated 05/10/2010 at 4:00 PM revealed the home medications that included "Dilantin infatab 50 mg 2 tabs po, (by mouth), BID, (twice a day) and Amantadine HCl 100 mg 1 tab BID." Review of the patient medication administration record revealed that the Dilantin was scheduled to be administered at 7:00 AM and at 5:00 PM

Interview with the patient's 7:00 AM- 7:00 PM nurse on 05/25/2010 at 1:30 AM revealed that the patient did not receive the 5:00 PM dose of Dilantin or Amantadine on 05/10/2010. When asked why, the nurse stated that the patient was having problems swallowing. Interview 05/27/2010 at 11:20 AM with the patient's Medical Case Manager representing The Agency for Persons with Disabilities revealed that the patient did not have a history of swallowing problems. The case manager stated that the patient was being seen by a Neurologist at the University of Florida for his/her neurology care.

Review of the 2010 Edition of the PDR Nurse's Drug Hand Book on page 313 revealed under Warnings/Precaution for Dilantin " Avoid abrupt discontinuation " and on page 965 for Amantadine " Do not d/c abruptly ... May increase seizure activity " .


Review of the medical record revealed a nursing note dated 05/10/2010 at 5:30 PM that stated "Unable to place Heplock X 2 persons. Message left for M.D. Lab having difficulty drawing blood also".

Interview with the physician #1 on 05/24/2010 at 10:30 AM revealed that the physician stated that he was notified at 8:00 PM and was not notified at 5:30 PM. During the interview physician #1 stated that if he/she had known that the IV was not started or the labs were not done he/she would have arranged for a line to be placed in the femoral vein by physician #2.

Review of the medical record did not reveal that physician #1 was called at 8:00 PM or any time after the 5:30 nursing note.

Review of the next nursing note dated 05/10/2010 written by the 7:00 PM-7:00 AM nurse but not timed written revealed " Pt in bed with head of bed up 45 degrees. Lung sound clear bilateral, bowel sounds hypo active, X 2 attempt to insert Hep Lock by ER No success, Notified Dr. #2 of need".

The next nursing note dated 05/10/2010, no time written, revealed "Family and friends at bedside, pt has limited speech and uses hand jesters due to dx: history CP".

The next nursing note dated 05/10/2010, again no time written, revealed "Family came to nurses station and notified nursing staff of patient not responding, nursing staff went to room, unable to get V/S, (vital signs) or O2 saturation %, notified Dr. (#2)".

The next nursing note date 05/10/2010 at 9:05 AM revealed " Dr. (#2) at bedside, O2 via ambu applied. New orders to transfer pt to ER. Staff 1 LPN, (licensed practical nurse) and 2 PM, (paramedics) with Dr. (#2) transferred pt to ER. CPR started, see attached sheet"

The next nursing note dated 05/10/2010 at 9:52 revealed " Code Called. Dr. (#2) talked with family and friends of pat death".

Review of the medical record revealed that the last nursing note in the medical record was entered as " Late entry 9:15 PM " written on 05/11/2010 at 11:25 AM " Pt. drinking contrast in preparation for CT, (CAT Scan) of abdomen. Parents and care giver at bedside" .

Review of the Discharge Summary dictated on 05/20/2010 revealed under Course in Hospital " Through (his/her) course in the hospital, there was difficulty obtaining IV access and laboratory on the patient. At one point during the evening, (he/she) apparently aspirated and became hypoxic. (He/She) died of cardiac arrhythmia, I was not present: this was handled by nurses and by the emergency room physician. The patient's passing was declared dead by the emergency room " .

2. Review of the medical record for patient #6 revealed that the resident was admitted to the facility following a fall at home, hitting his/her head and while being transported to the emergency room experienced a grand mal seizure. The patient was treated and stabilized in the ER and admitted for treatment and monitoring of the new onset of seizures. The patient was admitted with the diagnosis of grand mal seizures and COPD. The admission orders included vital signs every 4 hours, neurological checks, Bed fast, bed side commode, dry sterile dressing to forehead change daily, Hep Lock, and 1800 cal regular diet. Admission medications included Atrovent nebulizer every four hours as needed, Dilantin 100 mg PO start 05/10,2010, Lortab 5 mg one every four hours as needed for pain, Colace 100 mg PO twice daily. Review of the medical record did not include a physician's order for full side rails, padded side rails or seizures precautions. Review of the patient's Fall Assessment form completed on 05/09/2010 by the 7:00 PM nurse revealed that the patient scored a fall risk of 11 indicating a high risk to experience a fall. Review of the form revealed that Precautions were initiated. Review of the fall precautions to be initiated included, bed in lowest position, transfer with assist of one, bedside table and personal belongings within reach at all times, fall risk symbol on door, call bell in reach at all times, non-skid shoes/slippers, remove clutter and excessive furniture from the room and hourly observation. Review of the Nursing Admission Assessment/Interview form dated 05/10/2010 at 0200 revealed that the admission assessment was completed 9 hours following the 5:00 PM 05/09/2010 admission to the unit. Review of the admission assessment revealed that prior to the admission the patient lived at home alone. The assessment revealed that the patient did not require any specialized equipment for ambulation and did not have impairments related to mobility. However, the section related to ambulation was not completed. Under the section Risk for Falls, the nurse checked yes and checked side rails up x 4, Call bell within reach, M.D. notified and that the family was unable to stay with the patient. Review of the physician progress notes and physician orders did not reveal that the physician was informed of the fall risk or that any orders were written for side rails or other interventions related to the patient elevated risk for falls. Review of the Nursing Flow Sheet for the 05/09/2010 revealed the patient as charted as confused and anxious. Review of the medical record for patient #6 revealed a nursing note dated 05/09/2010 at 12:00 Midnight " Pt continuing to climb out of bed, continue to redirect pt, will continue to monitor " . Review of a nursing note dated 05/10/2010 at 4:00 AM revealed " Pt in bed, confused attempt to notify family with no response, continue to redirect. Review of the next nursing note at 5:00 AM revealed ER supervisor and Director of Nursing and Dr. (#2) aware of alert and confused with pt " . Review of the next nursing note at 5:25 AM revealed Dr. #2 evaluated patient, and "Ativan 0.5 mg IM given per order " . Review of the next nursing noted at 5:35 AM revealed " Pt found on floor, ROM done, small skin tear noted on left elbow with x 2 assist pt back to bed, Dr. (#2) evaluated pt at this time " . The next nursing note at 5:45 AM revealed " Pt in bed, restraints applied per orders. At this time pt complaining of left hip pain, Dr. (#2) aware" . Review of the facility investigation into the fall with fracture and interview with the facility's Risk Manager on 05/25/2010 at 2:30 PM revealed that the patient had climbed out of bed when the nurse was in the process of getting the wrist restraints ordered by the physician. Review of the medical record, facility report and interview with the Risk Manager revealed that the patient was left unsupervised at the time the nurse was getting the wrist restraints.

Based of record review, the facility failed for 2 of 5 (Patients #5 and #6) inpatient records to thoroughly complete and implement nursing care plans that included approaches to achieve patient centered goals.

Findings:

1. Review of the medical record for patient #5 revealed that the patient was admitted on 05/10/2010 with the diagnosis of dehydration secondary to diarrhea. Review of the Review of the Interdisciplinary Plan of Care Form developed on 05/10/2010 revealed three problems identified, Fluid Balance, Education Needs, and Discharge Needs. Review of the Interdisciplinary Plan of Care Form revealed that the box identified as Date Identified and Priority Number only had the date listed, and that the priority/frequency problem to be addressed was not completed. Review of the problem Fluid Balance revealed a Goal of "Fluid Volume Adequate", and under Outcome Criteria none of the approaches were checked. Continued review of the medical record did not reveal any plan to achieve the identified goals.

2. Review of the medical record for patient #6 revealed that the resident was admitted to the facility following a fall at home, hitting his/her head and while being transported to the emergency room experienced a grand mal seizure. The patient was treated and stabilized in the ER and admitted treatment and monitoring of the new onset of seizures. The patient was admitted with the diagnosis of grand mal seizures and COPD. The admission orders included vital signs every 4 hours, neurological checks, Bed fast, bed side commode, dry sterile dressing to forehead change daily, Hep Lock, and 1800 cal regular diet. Admission medications included Atrovent nebulizer every four hours as needed, Dilantin 100 mg PO start 05/10,2010, Lortab 5 mg one every four hours as needed for pain, Colace 100 mg PO twice daily. Review of the medical record did not include a physician order for full side rails, padded side rails or seizures precautions. Review of the patient ' s Fall Assessment form completed on 05/09/2010 by the 7:00 PM nurse revealed that the patient scored a fall risk of 11 indicating a high risk to experience a fall. Review of the form revealed that Precautions were initiated. Review of the fall precautions to be initiated included, bed in lowest position, transfer with assist of one, bedside table and personal belongings within reach at all times, fall risk symbol on door, call bell in reach at all times, non-skid shoes/slippers, remove clutter and excessive furniture from the room and hourly observation. Review of the Nursing Admission Assessment/Interview form dated 05/10/2010 at 0200 revealed that the admission assessment was completed 9 hours following the 5:00 PM 05/09/2010 admission to the unit. Review of the admission assessment revealed that prior to the admission the patient lived at home alone. The assessment revealed that the patient did not require any specialized equipment for ambulation and did not have impairments related to mobility. The section related to ambulation was not completed. Under the section Risk for Falls, the nurse checked yes and checked side rails up x 4, Call bell within reach, M.D. notified and that the family was unable to stay with the patient. Review of the physician progress notes and physician orders did not reveal that the physician was informed of the fall risk and no orders for side rails or other interventions related to the patient elevated risk for falls were found. Review of the Nursing Flow Sheet for 05/09/2010 revealed the patient as charted as confused and anxious. Review of the medical record for patient #6 revealed a nursing note dated 05/09/2010 at 12:00 Midnight " Pt continuing to climb out of bed, continue to redirect pt, will continue to monitor " . Review of a nursing note dated 05/10/2010 at 4:00 AM revealed " Pt in bed, confused attempt to notify family with no response, continue to redirect. Review of the next nursing note at 5:00 AM revealed ER supervisor and Director of Nursing and Dr. (#2) aware of alert and confused with pt " . Review of the next nursing note at 5:25 AM revealed Dr. (#2) evaluated pat, Ativan 0.5 mg IM given per order " . Review of the next nursing noted at 5:35 AM revealed " Pt found on floor, ROM done, small skin tear noted on left elbow with x 2 assist pt back to bed, Dr. (#2) evaluated pt at this time " . The next nursing note at 5:45 AM revealed " Pt in bed, restraints applied per orders. At this time pt complaining of left hip pain, Dr. (#2) aware " . Review of the facility investigation into the fall with fracture and interview with the facility's Risk Manager on 05/25/2010 at 2:30 PM revealed that the patient had climbed out of bed when the nurse was in the process of getting the wrist restraints ordered by the physician. Review of the medical record, facility report and interview with the Risk Manager revealed that the patient was left unsupervised at the time the nurse was getting the wrist restraints.

3. Continued review of the medical record for patient #6 revealed that the patient was admitted to the facility following a fall at home with a minor head injury and new onset of seizures. Review of the nursing fall assessment completed on 05/09/2010 revealed that the patient was identified as a high risk for falls. Review of the Interdisciplinary Plan of Care Form developed on 05/09/2010 revealed three problems identified, Neurological, Needs, and Safety. Review of the Interdisciplinary Plan of Care Form revealed that the box identified as Date Identified and Priority Number only had the date listed, the priority/frequency problem to be addressed was not completed. Review of the problem identified as Safety revealed a Goal of "No injury" and and under Outcome Criteria none of the approaches were checked. The care plan did not reveal that the patient was identified as a high risk for falls and that a fall prevention plan has been developed.

Based on record review, the facility failed for 3 of 6 records (#5 and #6) to ensure that patient medical records were promptly and thoroughly completed.

Findings:

1. Review of the medical record for patient #3 revealed on the face sheet under Advanced Directive the letter Y but did not contain the Advanced Directive Form, the Physician Code Status or indicate the in the medical record the patient's Do Not Resuscitate (DNR) status. Review of the medical record did not reveal any evidence that the patient was offered or asked about advanced directives.

2. Review of the medial record for patient #5 revealed a Physician Code Assessment form that was signed by the physician, but was not completed including the date the physician signed the form. Review of the medical record revealed that the chart did not contain the Advanced Directive Information form and that the Cardex section for the Code status section was not completed.

3. Review of the medial record for patient #6 revealed a Physician Code Assessment form was not completed, that the chart did not contain the Advanced Directive Information form and that the Cardex section for the Code status section was not completed.

4. Review of the nursing note for patient #5 dated 05/10/2010 written by the 7:00 PM-7:00 AM nurse but not timed when written revealed " Pt in bed with head of bed up 45 degrees. Lung sound clear bilateral, bowel sounds hypo active, X 2 attempt to insert Hep Lock by ER No success, Notified Dr. (#2) of need".

The next nursing note dated 05/10/2010, no time written, revealed "Family and friends at bedside, pt has limited speech and uses hand jesters due to dx: history CP".

The next nursing note dated 05/10/2010, again no time written, revealed "Family came to nurses station and notified nursing staff of patient not responding, nursing staff went to room, unable to get V/S, (vital signs) or O2 saturation %, notified Dr. #2".

5. Review of the medical record for patient #5 revealed that the Admission Nursing Assessment was started 2:45 PM on 05/10/2010 and not completed until 05/11/2010 at 11:00 AM. Interview with the nurse that completed the admission assessment stated that it was a busy day and that at the same time she was involved in transferring a patient to a different hospital for treatment for a fractured hip related to a fall within the facility

6. Review of the Nursing Admission Assessment/Interview form for patient #6 dated 05/10/2010 at 0200 revealed that the admission assessment was completed 9 hours following the 5:00 PM 05/09/2010 admission to the unit.

Based on record review and interview, the facility failed to ensure that the infection control officer developed and implemented a surgical infection control program.

Findings:

Interview with the infection control nurse on 05/26/2010 at 9:15 AM revealed that the facility does not have a surgical specific infection control plan. The nurse stated that if a surgical patient had an infection that she would either get a laboratory slip or that the surgeon would tell her. The nurse stated that the infection control program did not review any ongoing aspects of the program such as the cleaning/sterilization of equipment or the use of antibiotics.



Review of the facility's Quality Improvement Minutes did not reveal that the facility's review of surgical quality indicators. Review of the February meeting revealed that the committee only reviewed a report that "8 patient received surgery in January 2010, 7 EDG and 3 colonoscopies, CRNA is checking refrigerator daily and is 100 % compliant". Review of the Governing Body and Medical Staff Committee minutes for 2010 did not reveal that surgical services including it's Infection Control activities were reviewed.

Based on facility document review and staff interview, the facility failed to include the surgical program into the hospital wide Quality Improvement Program (QIP).

Findings:

Review of the facility's Quality Improvement Minutes did not reveal that the facility's review of surgical quality indicators. Review of the February meeting revealed the committee only reviewed a report that indicated "8 patient received surgery in January 2010, 7 EDG and 3 colonoscopies, CRNA is checking refrigerator daily and is 100 % compliant". Review of the Governing Body and Medical Staff Committee minutes for 2010 did not reveal that surgical services including its' Infection Control activities were reviewed.

Interview with the Infection Control Nurse on 05/26/2010 at 09:15 AM revealed that outpatient surgical services are not included in the QI program.

Based on facility documentation and staff interviews, the facility failed to develop and measure quality indicators for the surgical program that reflect patient outcomes.

Findings:

Review of the facility's quality improvement (QI) indicators did not reveal that the Surgical Program was included in the facility's QI program. Further review of the (QI) program also failed to reveal that indicators had been developed for the QI program or that patients' surgical outcomes were monitored.

Interview with the Director of Nursing/Surgical Director on 05/25/2010 at 04:00 PM revealed that the facility had not developed any outcome indicators for the surgical program.

Based on facility document review and staff interview, the facility failed to ensure that the facility measured, analyzed and tracked quality indicators for the surgical program.

Findings:

Review of the facility's quality improvement (QI) indicators failed to reveal that the Surgical Program was included in the facility's QI program and that indicators had been developed for the QI program that monitored patients' surgical outcomes.

Interview with the Director of Nursing/Surgical Director on 05/25/2010 at 4:00 PM revealed that the facility had not developed any outcome indicators for the surgical program.

Based on facility document review and interview, the facility failed to ensure that indicators reflecting effectiveness and safety of the outpatient surgical program were monitored.

Findings:

Review of the facility's quality improvement (QI) indicators failed to reveal documented evidence that the Surgical Program was included in the facility's QI program and that indicators were developed ane utilized that monitored the effectiveness and safety of the service for the QI program..

Interview with the Director of Nursing/Surgical Director on 05/25/2010 at 4:00 PM revealed that the facility had not developed any safety indicators for the surgical program.

Based on facility record review and staff interview, the Governing Body failed to ensure that the facility has a ongoing surgical program quality improvement (QI) program that is defined, implemented, and maintained.

Findings:

Review of the QI Committee, Governing Body Committee and Medical Staff Committee minutes for 2010 failed to reveal that the outpatient surgical program was incorporated into the facility wide QI program or that the safety, appropriateness and effectiveness of the outpatient surgical program was being monitored or evaluated.

Interview with the Director of Nursing/Surgical Director on 05/25/2009 at 4:00 PM revealed that the facility had not developed any outcome indicators for the surgical program.

Based on staff interview, and observations, the facility failed to provided the resources to maintain intermittent suction and sterilization of surgical equipment.

Findings:

1. Observation on 05/25/2010 at 4:10 PM of the equipment sterilization room located in the surgical suite revealed several small surgical instruments that were being prepared for sterilization. Observation of the sterilization room did not reveal any instruments that were packaged and ready for use.

On observation on 05/25/2010 at 1:30 PM in the Emergency Room revealed a round container, (approximately 16 inches tall and 12 inched round) on the floor that was half full of dirty surgical instruments. Interview with the ER nurse during the observation revealed, when asked if there was enough clean instruments to meet the needs, "It's getting close".

2. Observation of the patient care areas in the facility did not reveal the capability of the staff to perform intermittent suction. Interview with the Director of Maintenance on 05/25/2010 at 10:35 AM revealed that the facility has two portable continuous suction machines. One is kept on the crash cart on the patient unit and one is kept in the maintenance office as a backup. The Director stated that the facility did not have intermittent suction.

Interview on 05/25/2010 at 2:00 PM with the ER Physician Assistant revealed that if a patient presented to the ER that needed intermittent suction the patient would have to be transferred to a different hospital.

Based on staff interviews, facility document review and medical record review, the facility failed for 1 of 6 patients(#5) to provide physician ordered medications.

Findings:

Review of the medical record for patient #5 revealed a physician order dated 05/10/2010 at 4:00 PM to resume the home medications that included "Dilantin Infatabs 50 mg 2 tabs po, (by mouth), BID, (twice a day) and Amantadine Hcl 100 mg 1 tab BID." Review of the patient medication administration record revealed that the Dilantin was scheduled to be administered at 7:00 AM and at 5:00 PM

Interview with the patient's 7:00 AM- 7:00 PM nurse on 05/25/2010 at 1:30 AM revealed that the patient did not receive the 5:00 PM dose of Dilantin or Amantadine on 05/10/2010. When asked why, the nurse stated that the patient was having problems swallowing. Interview 05/27/2010 at 11:20 AM with the patient's Medical Case Manager representing The Agency for Persons with Disabilities revealed that the patient did not have a history of swallowing problems. The case manager stated that the patient was being seen by a Neurologist at the University of Florida for his/her neurology care.

Review of the 2010 Edition of the PDR Nurse's Drug Hand Book on page 313 revealed under Warnings/Precaution for Dilantin " Avoid abrupt discontinuation " and on page 965 for Amantadine " Do not d/c abruptly ... May increase seizure activity " .

Based on record review and interview, the facility Chief Executive, Medical staff and Director of Nursing failed to ensure that the a surgical infection control program was a part of the governing body, Quality Assessment Quality Improvement committee or medical staff discussions.

Findings:

1. Interview with the Director of Nursing/Surgical Director on 05/25/2010 at 4:00 PM revealed that the she did not know the details of a ongoing infection control program specific to the surgical program and that she thought that the program was part of the overall hospital-wide infection control program. When asked specific questions about the sterilization status of surgical instruments she stated that she did not have any idea and that she would get the medical director to answer questions.

2. Review of the governing body minutes and the medical staff meeting minutes failed to revealed that the surgical infection control was not a part of any discussions from January 2010 through May 26, 2010.

3. Interview with the infection control nurse on 05/26/2010 at 9:15 AM revealed that the facility does not have a surgical specific infection control plan. The nurse stated that if a surgical patient had an infection that she would either get a laboratory slip or that the surgeon would tell her. The nurse stated that the infection control program did not review any ongoing aspects of the program such as the cleaning/sterilization of equipment or the use of antibiotics. When asked about trays being sent to Ocala for sterilization, she stated that she was not involved and did not have a process in place to monitor off site sterilization of surgical instruments.

4. Observation on 05/25/2010 at 4:40 PM in the surgical suite revealed a desk out side of the functioning operating room that had five wrapped surgical trays stacked on it. Interview with the medical director at the time of the observation revealed that the trays contained his personal instruments and that where sterilized at a ambulatory surgical center, (ASC), in Ocala, Florida for him. Review of the facility records did not reveal any documentation of the cleaning/sterilization of the trays. Interview with the director of support services revealed that he had taken the trays to ASC and had brought them back to the hospital. When asked if the hospital had a contract or performed any QA on the packs the director of support services stated "no".