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Based on record review the facility failed to insure all orders were dated and timed promptly by the ordering practitioner for seven (7) of thirty (30) sampled records. (# ' s 2, 3, 4, 6, 11, 22, and 23)

Findings:

Review of closed records on 04/07/2010 reflected that records 2, 3, 4, 6, and 11 failed to document the date and/or time when authenticated by the ordering practitioner.
Review of record #2 reflected that orders were not dated or timed including an order written on 11/06/2009.
Review of record #3 reflected that orders were not dated or timed including an order written on 02/13/2010.
Review of record #4 reflected that orders were not dated or timed including an order written on 02/01/2010.
Review of record #6 reflected that orders were not dated or timed including an order written on 02/03/2010.
Review of record #11 reflected that orders were not dated or timed including an order written on 09/22/2009.
Review of open records on 04/07/2010 (North Campus) reflected the following:
Patient #22 was admitted on 04/02/10 to the North Campus. The orders were not timed.
Patient #23 ' s record reflected an order was written on 03/31/2010 with no documented time or date.




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Based on record review the facility failed to insure all orders were authenticated by the ordering practitioner for three (3) of thirty (30) sampled records. (# ' s 2, 14, and 17)

Findings:

Review of closed records on 04/07/2010 reflected that records 2, 14, and 17 failed to document a physician ' s signature on all orders written.
Record #2 failed to document a physician ' s signature on an order written 11/06/2009.
Record #14 failed to document a physician ' s signature on an order written 03/09/2010.
Record #17 failed to document a physician ' s signature on an order written 11/02/2009.

Based on record review the facility failed to insure a discharge summary was documented for one (1) of twenty-one (21) sampled closed records. (#17)

Findings:

Review of closed records on 04/07/2010 reflected that record 17 failed to document a discharge summary for a patient discharged 03/02/2010.

Based on observation and interview, the facility failed to secure biologicals used for dialysis services in a secure room.

Findings:

North Campus
During tour of the facility on 4/6/2010 at approximately 10:30 a.m. room 8606 had the door closed. Upon entering the patient room, the surveyor observed 2 dialysis machines, and shelving unit containing dialysis solutions. The cabinet on the right side of the room contained 15,16,and 17 gauge needles. The was no lock present on the cabinet door.
Interview with the director of clinical services at the time revealed that the regular equipment storage room was under repair. She was not aware that the door should have been locked even though it was temporary.

Based on observation and interview the facility failed to insure supplies are stored in such a manner to ensure the protection against contamination.

Findings:

During tour of the facility (South) on 04/06/2010 between 9:15am and 10:30am; housekeeping supplies were observed in the dirty utility room of the south nursing unit, unused sharps containers were observed in the dirty utility room of the north nursing unit, and bedside phones were observed n the dirty utility room of the ICU.

Interview on 04/06/2010 at 10:30am with the administrator confirmed the inappropriate articles were in the dirty utility rooms.

Based on record review, observation, and interview the facility failed to insure policies related to aseptic and sterile surveillance were developed and implemented.
Evidence:
During tour of the Surgical Department (South Campus) on 04/06/2010 at 2:15pm sterile products were observed in the sterile supply room which had expiration dates which had expired. The products included sterile gloves with expiration dates of 09/09 and sterile sponges with expiration dates of 01/10.
Review of facility policies for Surgical Services failed to document a policy on monitoring of expiration dates of sterile products.
Interview with the nurse in charge of the Surgical Service on 04/06/2010 at 2:30pm confirmed the dates were outdated and that the facility did not have a specific policy on monitoring the expiration dates of sterile surgical products.

Based on observation, interview and record review, the facility failed to ensure that 1 of 9 active patients had a nutritional assessment completed timely (#22)

Findings:

Initial tour of the facility on 4/6/2010 at 9:50 a.m., observation of patient #22 revealed him/her in bed resting comfortably. The patient had his/her tracheostomy capped and was able to speak a few words, stating that s/he had been at the facility for a few days.
Review of the medical record revealed that the patient was admitted on 4/2/2010 with diagnoses including severe chronic obstructive pulmonary disease (COPD) and ventilator dependent respiratory failure. Further review revealed that the patient did not have a nutritional assessment present in the clinical record.

Review of the clinical services policy number A03-G for assessment and reassessment of patients issued 7/01/1995 and last revised on 09/01/99 documented scope of assessment performed by dietitian. nutrition screening initiated within 24 hours of admission. The nurse of dietitian conduct the nutrition screening found on the admission data base. Since a vast majority of patients are typically at significant nutritional risk. The dietitian assess all patients within 72 hours of admission

Interview with the director of clinical services on 4/7/10 at approximately 9 a.m. confirmed that the nutrition assessment had not been completed by the dietitian.

The contracted (as needed) dietitian completed the assessment on 4/7/10 and identified a low albumin level, history of significant weight loss to 90 pounds and gained 42 pounds back in the past year. The patient was 73 inches and weighed 132 pounds. The patient had been receiving nutrition via enteral feeding which had been discontinued. The request for physician order included Pulmocare 1 can at 2 pm and evening, and a multivitamin.