HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure that nursing services reflected nationally accepted standards of practice as evidenced by:

A. The facility failed to protect telemetry patients from potential harm when:

1) The nursing staff failed to adequately monitor telemetry patients according to a standard of practice (no facility policy or procedure).

2) The facility failed to ensure that nursing staff were trained and understood how to use the facility's telemetry monitoring system. This included setting of parameters, alarm sound levels, the monitoring of telemetry patients when they were off the unit, and to recognize the alarm for when a battery was low in the patient's wireless unit.

3) Nursing staff who had assigned telemetry patients were not giving any type of "hand-off" communication when leaving the unit.

4) Nursing staff were not consistently documenting telemetry use and conditions identified by telemetry monitoring in patient records.

5) Nursing staff assigned to telemetry patients were not trained in Advanced Cardiovascular Life Support (ACLS). Refer to A397

These failures represented an Immediate Jeopardy (IJ). On 07/08/2014 at 4:50 PM, an IJ was declared regarding telemetry services. The hospital's leadership staff (acting Chief Executive Office and Acting Director of Nursing (ADON)) was notified of the IJ situation. An acceptable corrective action plan was received and approved; the IJ was abated on 7/09/2014 at 1:02 PM.

B. The facility failed to ensure that nursing staff developed and kept current interdisciplinary nursing care plans. Refer to A396

These failures put patients at risk for adverse outcomes. The cumulative effect of these system problems resulted on the inability of the hospital to comply with the mandated Condition of Participation for Nursing Services.

2. Patient #22 was admitted to the facility on 07/07/2014 with diagnoses that included vomiting and stomach pain. The History and Physical dated 07/07/2014 indicated the patient had been a "heavy drinker." At admission (07/07/2014 at 5:51 PM), the Patient's Physician ordered him/her to have telemetry monitoring.

A review of the Interdisciplinary care plans revealed no care plan addressing telemetry monitoring.

During an interview on 07/09/2014 at 11:10 AM, the ADON stated she would expect all nursing required documentation to address telemetry monitoring (this would include care plans).

3. Patient #19 was admitted to the facility 07/06/2014 at 8:05 PM with diagnoses that included right flank pain, back pain, right upper quadrant pain, blood in urine, chills, and dizziness. The History and Physical dated 07/06/2014 (7:59 PM) mentioned the patient had chest pain when lifting heavy objects or when moving into a seated position in bed.

Patient #19's Physician ordered telemetry monitoring on 07/06/2014 at 7:23 PM.

A review of the Interdisciplinary care plans revealed no care plan addressing telemetry monitoring.

During an interview on 07/09/2014 at 11:10 AM, the ADON stated she would expect all nursing required documentation to address telemetry monitoring (this would include care plans).

4. Patient #21 was admitted to the facility on 07/04/2014 at 2:23 AM with diagnoses that included shortness of breath and painful respirations associated with a headache. The patient's diagnoses also included end stage renal disease that required dialysis, diabetes, and high blood pressure. The History and Physical dated 07/04/2014 at 1:54 AM revealed under the cardiovascular section that the patient complained of having chest pain with coughing and peripheral edema.

An Inpatient Nursing Adult Admission assessment was completed on 07/04/2014 at 3:35 AM. The documentation indicated that Patient #21 had a history of heart disease, congestive heart failure, and peripheral vascular disease. A review of the Interdisciplinary care plans revealed no care plan addressing telemetry monitoring.

During an interview on 07/09/2014 at 11:10 AM, the ADON stated she would expect all nursing required documentation to address telemetry monitoring (this would include care plans).





26031


Based on interview and record review the hospital failed to ensure the nursing staff develops, and keeps current, a nursing care plan for 4 of 30 sampled inpatients (sample patient #6, #19, #21, and #22). Failing to generate an individualized nursing care plan could potentially contribute to not meeting all of the patient's needs.

Findings Include:

On 7/10/2014 both the paper and electronic medical records for sample patient #6 were reviewed with a licensed nurse (LN6). The patient was admitted on 06/25/2014 with diagnoses that included general weakness and end of life care. Some of his/her other diagnoses included hypertension, diabetes mellitus with peripheral vascular disease, end-stage renal disease and had suffered an old stroke and required assistance with mobility and transfers. The record also reflected a history of chronic skin ulcers to the left lower extremity. On that same date a nursing history and physical exam were completed. The nursing assessment also identified all the aforementioned and included that assistance was needed with bed mobility. The nursing documentation reflected patient #6 had a Stage II pressure ulcer to the coccyx (tail bone) area. The nurse concurred that based on the patient's history, limited mobility and past pressure ulcer history a Braden Skin Assessment should have been initiated. Additionally, the LN reviewed all current nursing care plans and acknowledged an individualized pressure ulcer nursing care plan should have been initiated for patient #6.

Based on observation, interview, and record review, the facility failed to protect telemetry (continuous heart monitoring-cardiac electrodes are connected to a portable transmission device that transmits the patient's heart rhythm to a distant monitor) patients from potential harm when:

1) The facility failed to ensure that nursing staff were trained and understood how to use the facility's telemetry monitoring system. This included setting of parameters, alarm sound levels, the monitoring of telemetry patients when patients were off the unit, and to recognize the alarm for a low battery in the patient's transmission device,

2) the nursing staff failed to adequately monitor and treat telemetry patients according to a standard of practice (no facility policy or procedure),

3) Nursing staff who had assigned telemetry patients were not giving any type of "hand-off" communication when leaving the unit,

4) Nursing staff were not consistently documenting telemetry use and conditions identified by telemetry monitoring in patient records, and

5) Nursing staff assigned to telemetry patients were not trained in Advanced Cardiovascular Life Support (ACLS-enhanced training in treating adult victims of cardiac arrest or other cardiopulmonary emergencies).

On 07/08/2014 at 4:50 PM, an Immediate Jeopardy (IJ) was declared regarding telemetry services. The hospital ' s leadership staff (acting Chief Executive Office and Acting Director of Nursing) was notified of the IJ situation. An acceptable corrective action plan was received and approved; the IJ was abated on 7/09/2014 at 1:02 PM.

Findings Include:

1. Observations were made of the Acute Care Unit (ACU) on 07/07/2014 at 12:30 PM. During this time period there was no staff in the nurse's station. Two other observations (1:55 PM and 2:30 PM) on the same day also revealed no staff in the ACU nursing station. The telemetry monitor that displayed the heart rhythms for the telemetry patients was located in the nurse's station. On 07/07/2014 at the above times there appeared to be four patients being monitored via the telemetry system. During the 2:30 PM observations there was no heart rhythm displayed for one of the telemetry patients and no alarm was sounding.

On 07/07/2014 at approximately 2:00 PM, License Nurse (LN) 1 indicated that when the alarm sounded it could be heard throughout the unit and the nursing staff relied on hearing the alarm to alert them of an issue with a telemetry patient.

On 07/08/2014 at 11:50 AM, there was no staff observed in the nurse's station. There was one patient (Patient #22) being monitored via the telemetry monitoring system.

On 07/08/2014 at approximately 1:50 PM, LN 1 and the Acting Director of Nursing (ADON) were asked by this surveyor to demonstrate the telemetry monitoring system's alarm. It was noted by this surveyor that there was no heart rhythm being transmitted to the monitor at this time. The screen only indicated the patient's name and room number. LN 1 again indicated that the alarm sound could be heard throughout the nursing unit. The two nurses looked through the menu bar and numerous other locations within the system's software but were unable to test the alarm sound levels.

During this time, the telemetry patient's (Patient #22) heart rhythm was still not being displayed on the monitor. The ADON directed LN 2 to go check the patient because there was no heart rhythm being displayed. LN 2 came back to the nurse's station and indicated the battery in the transmission device needed to be changed. When LN 2 placed a new battery in the transmitting device the patient's heart rhythm began to be displayed on the monitor. The ADON indicated there should have been an alarm or visual sign on the monitor indicating the battery needed to be changed.

The ADON and LN 1 explained that the telemetry monitoring system also had the capability to monitor a patient when they were in Radiology or the Emergency Department (located downstairs from the ACU). LN 1 explained that a nurse would accompany the patient and if a cardiac issue was identified by the telemetry system another nurse on the ACU would notify the accompanying nurse via telephone of the cardiac issue.

The ADON and LN 1 continued to explore the system's software to demonstrate how loud the alarm sounded. Another LN on the unit went to the patient's room and removed a cardiac electrode. This caused an alarm to sound a "beep" tone, which was only loud enough to be heard at the nurse's station. Both the ADON and LN 1 agreed that the alarm was not loud enough to be heard outside of the nursing station. The ADON indicated there was a way to make the alarm louder; however, the nursing staff was unable to demonstrate how to achieve louder alarms.

On 07/08/2014 at approximately 3:30 PM, LN 1 and LN 2 were asked about the training they had received on the telemetry monitoring system. LN 2 indicated she had been trained on the system when she came to the facility, which was about a year ago. LN 1 indicated that the system was approximately 6 years old and she had been trained on the system when it was installed. Both nurses acknowledged there had not been any recent training or competencies.

On 07/09/2014 at 11:10 AM, the ADON offered additional information regarding the monitoring of patients when they left the ACU. The ADON revealed that she had forgotten that the telemetry system had portable monitors so when a patient left the ACU the nursing staff could use the portable monitors to continue to monitor the telemetry patient.

On 07/09/2014 a copy of the manufacture's "Directions for use" (Acuity and Mobile Acuity LT Central Monitoring System) was obtained for review. The manufacturer's instructions under "General information" (page 2) section indicated the following, "...Staff training in the operation of the Acuity System and the patient monitoring devices connected to it is essential for optimal use."

Manufacturer's warnings (page 4) included the following, "...close physical surveillance and clinical interpretation of cardiac data must still be an integral part of every patient's care...Ensure that Acuity System patients are kept under close surveillance, especially patients prone to arrhythmia events."

The manufacturer's instructions under the "Summary of Acuity System alarm and alert levels" (page 94) had a table that summarized the systems alarms. The information indicated that there was a lethal arrhythmia alarm tone that sounds with four loud beeps followed by a pause; a high-level alarm tone that sounds with three loud beeps followed by a pause; a medium-level alarm tone that sounds with one loud beep and one softer beep followed by a pause; and a low-level alarm tone that sounds with three spaced, soft beeps followed by a pause.

On page 3, under "General Warnings and cautions" the instructions indicate the following warning, "Ensure that the volume level on your computer is not set too low or is not set to mute as this may cause you to miss audible alarms generated from the Acuity System."

The nursing staff was unable to demonstrate knowledge of the telemetry monitoring system. The nursing staff relied on hearing the alarms to alert them to an issue with the telemetry patient, however, the alarms' sound levels were not loud enough to ensure that nursing staff could hear the alarm in the event a patient had a cardiac issue.

2. On 07/08/2014 at approximately 3:55 PM, the ADON was asked to provide a copy of the facility's policy and procedures regarding telemetry services. The ADON revealed that she had identified a problem with the telemetry services back in April 2014. She indicated the facility did not have a current policy and procedure for telemetry services; therefore, there was no established standard of practice for the nursing staff to follow.

On 07/09/2014 a copy of the manufacture's "Directions for use" (Acuity and Mobile Acuity LT Central Monitoring System) was obtained for review. The manufacturer's instructions under "General information" (page 2) section indicated the following, "The Acuity System and distributed monitoring devices are prescription devices to be used by authorized health care professionals using standard institutional procedures and good clinical guidelines for patient monitoring."

The facility failure of not having a policy and procedure regarding telemetry services resulted in the nursing staff not having a standard of practice (and procedures) to follow.

3. On 07/08/2014 at approximately 3:30 PM, three nurses on the ACU were asked about the care and monitoring of telemetry patients. LN 2 indicated that she did not specifically report to the other nurses about telemetry patients when she left the unit or went on break. The other nurses did not provide any additional information about the reporting off process of telemetry patients.

The facility's "Hand-off Communications" policy and procedure dated 07/20/2011 indicated that "'Hand-off' communications will take place whenever there is a change in the patient's caregivers. Caregivers includes all clinical staff and providers" and includes "when a nurse leaves the unit for a period of time."

The policy indicated that the communication should include "patient information regarding care, treatment and services-situations...Patient's current condition...interventions...What problems might be anticipated...What to watch for in the next interval of care."

4. During an interview on 07/08/2014 at approximately 3:30 PM, the ADON indicated that she would expect nursing staff to give a report of their assigned patients before leaving the unit or going on a break. This failure placed telemetry patients at risk of not being monitored adequately when the assigned nurse went on break or left the unit.

a. Patient #22 was admitted to the facility on 07/07/2014 with diagnoses that included vomiting and stomach pain. The History and Physical dated 07/07/2014 indicated the patient had been a "heavy drinker." At admission (07/07/2014 at 5:51 PM), the Patient's Physician ordered him/her to have telemetry monitoring.

A review of Nurse's Notes revealed no nursing documentation regarding the initiation of telemetry monitoring or any other documentation about the telemetry monitoring. A review of the Interdisciplinary care plans revealed no care plan addressing telemetry monitoring.

A Physician's order dated 07/08/2014 at 5:59 PM discontinued telemetry monitoring. There was no nursing documentation that telemetry monitoring had been discontinued.

b. Patient #19 was admitted to the facility 07/06/2014 at 8:05 PM with diagnoses that included right flank pain, back pain, right upper quadrant pain, blood in urine, chills, and dizziness. The History and Physical dated 07/06/2014 (7:59 PM) mentioned the patient had chest pain when lifting heavy objects or when moving into a seated position in bed.

Patient #19's Physician ordered telemetry monitoring on 07/06/2014 at 7:23 PM.

A review of Nurse's Notes revealed no nursing documentation regarding the initiation of telemetry monitoring or any other documentation regarding the telemetry monitoring. A review of the Interdisciplinary care plans revealed no care plan addressing telemetry monitoring.

A Physician's order dated 07/08/2014 at 9:00 AM discontinued telemetry monitoring. There was no nursing documentation indicating that telemetry monitoring had been discontinued.

c. Patient #21 was admitted to the facility on 07/04/2014 at 2:23 AM with diagnoses that included shortness of breath and painful respirations associated with a headache. The patient's diagnoses also included end stage renal disease that required dialysis, diabetes, and high blood pressure. The History and Physical dated 07/04/2014 at 1:54 AM revealed under the cardiovascular section that the patient complained of having chest pain with coughing and peripheral edema.

An Inpatient Nursing Adult Admission assessment was completed on 07/04/2014 at 3:35 AM. The documentation indicated that Patient #21 had a history of heart disease, congestive heart failure, and peripheral vascular disease. A review of Nurse's Notes revealed that nursing staff had not consistently documented on telemetry monitoring. There was no note indicating that telemetry had been initiated. A review of the Interdisciplinary care plans revealed no care plan addressing telemetry monitoring.

A Physician's order dated 07/08/2014 at 9:08 AM discontinued telemetry monitoring. There was no nursing documentation that telemetry monitoring had been discontinued.

During an interview on 07/09/2014 at 11:10 AM, the ADON stated she would expect shift documentation to address telemetry monitoring.
Refer to A396

5. During an interview on 07/08/2014 at 3:55 PM, the ADON stated that she had identified a problem with telemetry monitoring back in April 2014. She explained that one of the issues identified was that many nursing staff did not have current Advanced Cardiac Life Support (ACLS) training, which was required for nursing staff on the ACU.

A review of the training records for the nursing staff assigned to the ACU revealed that only four of the fourteen (4 of 14) nurses assigned to the ACU had current ACLS training. The ACU supervisor also did not have current ACLS training. No training information was received regarding the five contract LNs assigned to the unit.

On 07/09/2014 a copy of the manufacture's "Directions for use" (Acuity and Mobile Acuity LT Central Monitoring System) was obtained for review. The manufacturer's instructions under "General information" (page 2) section indicated the following, "The Acuity System and distributed monitoring devices are prescription devices to be used by authorized health care professionals using standard institutional procedures and good clinical practice guidelines for patient monitoring ...Users should be skilled ...with knowledge and experience to acquire and interpret patients' vital-signs data."

ACLS is a protocol for handling patients who are experiencing serious medical emergencies such as cardiac arrest. ACLS training refers to the skills and training necessary to use the protocol safely and properly. These guidelines are constantly changing, due to new information in the medical field, and frequent training is required for people after they are certified. The failure of not having nursing staff that had received this advanced training placed telemetry patients at risk for adverse outcomes.

Based on observation, interview and record review, the facility failed to:

1. Maintain completed medical records when eight of eleven sampled patients (Patient numbers 7, 8, 9, 10, 11, 18, 19, and 21) did not have all sections of the facility's Inpatient Consent forms completed.

2. Properly file and maintain the patient medical record.

Findings Include:

1. Patient numbers 7, 8, 9, 10, 11, 18, 19, and 21's medical records were reviewed. All three patient's Inpatient Consent forms (HS-860), "ADVANCED DIRECTIVES/PATIENT BILL OF RIGHTS" section were left blank. This section had three questions that asked if the patient had written "advanced directive for health care" (a document that indicates how a person wants medical decisions made should they become unable to do so themselves) and required the staff person filling out the form to mark either "Yes" or "No."

On 07/07/2014 at approximately 12:50 PM, LN 1 was asked about the Inpatient Consent form specifically the "Advanced Directive" section. LN 1 indicated that in the facility's Electronic Health Record (EHR) there was also a question about Advanced Directives. LN 1 stated that she did not think the "Advanced Directive" section on the Inpatient Consent form needed to be completed anymore. LN 1 added that if a patient wanted more information about Advanced Directives a Social Service referral was made in the EHR.

During an interview on 07/08/2014 at approximately 1:15 PM, the Acting Director of Nursing (ADON) and the Assistant DON both indicated that with the EHR the question does not need to be asked when the Inpatient Consent is being completed; however, the form without the Advanced Directives information was incomplete. The ADON further added that the facility needs to address the use of the form.


29935


2. During an interview on 7/9/2014 beginning at 2 P.M., the Medical Records staff conducted a tour through both the outpatient and inpatient department. Near the photocopy machines, paper boxes filled with medical records were stored directly on the floor stretching approximately 7 feet across the floor and 3 feet high. As the tour continued into the scanning area, open medical records were stored directly on the floor in stacks under tables. The staff stated "storage is an issue. We don't have enough space." As the tour continued into the inpatient chart review area, boxes of charts were stored from the floor to approximately 18 inches below the ceiling along the back wall of the room.

Upon review of the medical record policies there was no evidence of a policy or procedure for storage and retention of records. The staff indicated the "manual needed to be updated."




15977

Based on observation, interview and record review the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use. The use of outdated, unlabeled or mislabeled medications could potentially lead to an inadvertent compromise of the medication's sterility and potency.

Findings Include:

1. On 07/07/2014 the Surgical Department was toured with a licensed nurse (LN4). There are 3 operating rooms (OR) in the department. While inspecting OR #2 an undated 20 milliliter (ML) multidose vial of 1% Lidocain with Epinephrine (local anaesthetic agent) was found in the active supplies. During a concurrent interview with LN4 he reported if the vial were dated and initialed it could be used for approximately 28 days after opened but since it was undated and not initialed the shelf life of the product was in question. The facility policy: "Date Medications that have been opened for use in the Pine Ridge Health Care Facility" indicates "Date all opened medications" and "multi-dose injectable's vials are good for 28 days" unless otherwise indicated.

2. While making further observations multiple intravenous (IV) and irrigation solutions were identified in the blanket warmer between OR #1 and OR #2. All the solutions were dated except for three 500 ML bags of IV Normal Saline. The nurse acknowledged the solutions should have been dated because based on the manufactures recommendations the shelf life of the solutions was only good for 14 days at temperatures above a set temperature. The Hospira's manufacture's recommendations on IV and irrigation solutions states the solutions "temperature should not exceed 104 Fahrenheit ....and for a period no longer than two weeks."

3. The anesthesia medication carts were inspected on the same date in the presence of LN4 and with an anesthesia provider. Two 100ML bags Normal Saline of IV admixtures were identified in anesthesia medication cart #2. The solutions were ephedrine and phenylephrine 100mcg/ml in 100ml bags of Normal Saline. The anesthesia provider stated the IV admixtures were mixed on 06/15/2014 and the solutions would be good till 07/15/2014. LN4 was requested to call the Pharmacy Department and validate when the IV admixtures would expire. Based on pharmacy guidance, LN4 reported the aforementioned solutions should be used within 24 hours of being mixed. The facility policy: "Date Medications that have been opened for use in the Pine Ridge Health Care Facility" indicates "IV bags containing medications such as antibiotics must be used within 24 hours or discarded."

Based on interview and facility document review the hospital laboratory service failed to have a complete notification system in place to take appropriate action when notified that blood or blood components it received, or transfused, were identified as being at increased risk of transmitting Human Immunodeficiency Virus or Hepatitis C virus.

Findings Include:

On 7/08/2014 the facility's laboratory service was inspected in the presence of the Laboratory Manager. Later on that same date the facility Blood Bank Look-Back Policy was reviewed. On 07/09/2014, during a concurrent interview and record review, the acting Laboratory Manager compared the regulatory requirements with the current policy and acknowledged the policy was not consistent with current regulatory requirements. The facility Look-Back Policy indicates "the FDA (Food and Drug Administration) requires that at least 3 documented attempts to notify the patient must be made within 8 weeks of receiving the look-back notice" whereas the regulatory requirement is for the facility to make reasonable attempts to give notification over a period of 12 weeks. On 07/10/2014 a revised facility Blood Bank Look-Back Policy was received.

Based on observation, interview, and record review, the hospital failed to ensure supplies and equipment must be maintained to ensure an acceptable level of safety and quality. The use of old supplies could potentially alter the outcome of test results or could impact the number of attempted therapeutic interventions since the integrity of the supplies is expired.

Findings Include:

1. On 07/07/2014 the Surgical Department was toured with a licensed nurse (LN4). There are 3 operating rooms (OR) in the department. While inspecting the ORs and the malignant hyperthermia cart, several sterile supplies were noted to be outdated/expired. The LN validated that the expired supplies consisted of:

- One container of Iodoform gauze packing that expired on 01/2014;

- One Laparoscopy pack that expired on 06/2014;

- Seven 22 gauge intravenous catheters that expired on 12/2013;

- Thirteen endotraheal tubes size 8.0 internal diameter that expired on 11/2013; and

- Nineteen blood specimen tubes of all different lab types that expired starting on 11/2013 to 6/2014.

2. On 07/07/2014 at approximately 1:50 PM, the Crash Cart on the Acute Care Unit was inspected with Licensed Nurse (LN) 1. A package of pediatric electrode pads were found to have been expired on 06/23/2014. LN 1 verified that the pads were expired.


29642


3. On 07/07/2014 at approximately 10:20 AM, a tour of the kitchen was conducted. During the tour freezers and refrigerators were inspected. The following food items were not labeled or appropriately sealed:

Refrigerator #2:

a. There was an opened bag of broccoli that had been taped shut. The bag was not labeled with a date indicating when the broccoli was initially opened

b. There was a small bowl of salsa that was covered with clear wrap. There was no date on the salsa indicating when it had been placed in the bowl.

c. There was an opened jar of Miracle Whip that did not have a date on it to indicate when it was opened.

d. There were two cardboard boxes that contained "Fresh-cut" vegetables. Neither box was dated.

e. There were four clear plastic boxes of strawberries. None of the boxes were dated.

Dietary Worker 1 stated that all food items that are opened should have a date on them to indicate when the item was opened. Dietary Worker 1 also indicated that the cardboard boxes should have had a date to indicate when they received the vegetables.

Refrigerator #4:

a. There was a package of Mozzarella cheese that was not sealed well and was not dated.

b. There was a package of Cheddar cheese that was not sealed and not dated.

A number of Dietary Workers in the area indicated that the cheese should have been sealed and dated.

c. There was 1/4 of a stick of butter placed on the refrigerator rack without being sealed or dated.

d. There was a box of cream cheese that was not dated.

Cook Station (in back corner):

a. Six of 29 bottles of assorted spice bottles had no open date on them.

b. A container of "Quick" oats were opened but not dated.

c. A container of "Old Fashion" oats were open but not dated

The findings were discussed with Dietary Worker 1. Dietary Worker 1 acknowledged that all food items should be sealed and dated after opening.

4. On 07/10/2014 at approximately 10:45 AM, the dishwasher was observed being used. A dietary worker was asked about the log. She indicated that the temperature should be checked each time the dishwasher was used.

A review of the log for July 2014 revealed that no readings were recorded on 07/07 or on 07/08. On 07/09/2014 there were no readings recorded for the breakfast dishes or lunch dishes. The dietary worker stated the person doing the dishes should have recorded the readings.

The facility's policy, "Dishwasher Operation and Daily Maintenance Competency" review date 03/2014 indicated the following, "When you are nearly done washing dishes, read the wash and rinse temperature readings on the thermometers on the top of the machine near the 'Power' button. Record these temperatures in the temperature log that is found on top of the machine."

5. On 07/10/2014 at approximately 10:55 AM, the Supervisor Dietary Worker (SDW) was asked about a cleaning schedule. The SDW indicated he scheduled staff who did all the cleaning. The SDW also indicated that he had Veteran workers who helped with the cleaning.

A review of the facility's policy, "Destruction of Organisms (Cleaning)" review date 03/2014 revealed the following, "Deep Cleaning: all areas within the dietary department must be deep cleaned at least on a monthly basis. These deep cleaning chores are to be listed and assigned by the Dietary Supervisor every month... Daily and Weekly cleaning duties will also be listed and the person working in that particular are[a] will be responsible for not only doing the cleaning, but will also be responsible for recording that they have done it by initialing the duty sheet." The policy further indicated that the areas for monthly deep cleaning were floors, counters, drawers, sinks, cooler, reach in coolers, steam table, cold deck, dishwasher, hood, all small appliances, meat slicer, stove, convention ovens, cabinet steamer, tilt skillet, steam jacketed kettle, walls, supply bins and barrels, bulk ice machine, and cafeteria.

On 07/11/2014 at approximately 8:00 AM, attempted to interview SDW regarding the documentation (duty sheets). It was reported that the SDW would be coming in late. Supervisory Engineer was asked about the "duty sheets" and a copy was requested. The "duty sheets" were not proved.

There was no documentation indicating that the listed equipment had been cleaned monthly as the facility's policy directed.

Based on interview and document review the facility failed to ensure staff members who had the potential for exposure to Tuberculosis(TB) were screened upon hire and annually thereafter. The facility also failed to ensure staff was trained in appropriate techniques for cleaning and disinfecting the physical environment when an employee was not trained regarding the proper use of cleaning and disinfecting agents for the mobile van.

Findings Include:

1. A review of direct care giver employee health files were reviewed on 7/10/2014 beginning at 10 AM. A total of eleven files were reviewed for health screening and immunizations. Two of eleven files had documentation of employees testing positive for Tuberculosis (TB) in March of 2005 and December 2006. There was no evidence of follow up for appropriate treatment, or yearly follow up for identification of signs and symptoms that may be related to TB. Eight of the eleven files had no evidence of completion of verification of immunization status. These files included two contracted staff who began caring for patients on May 20, 2014.

After an interview with the Employee Health Nurse who also serves as the Infection Control Nurse, these findings were confirmed in writing.

Review of the hospital policy titled 'Employee Health Program' revised 3/2013 identified the Employee Health Nurse to "Initiate and maintain employee health records on all hospital employees...and assures compliance regarding immunizations, updating immunizations annually, copy of immunizations...The policy listed under TB skin test that "TST converters (employees who test positive for TB) will be referred to the TB chest clinic:the ICN will send the employee for a chest x-ray, reactors will fill out an annual health questionnaire."


29642


2. On 07/09/2014 at approximately 3:15 PM, a tour of the mobile van was conducted. During the tour, Employee 1 was asked about the cleaning of the mobile van. Employee 1 was unable to give specifics about the cleaning and disinfectant agents used on the mobile van. Employee 1 indicated he had never received training regarding cleaning and disinfectant agents. The Supervisory Engineer was present during the interview and she confirmed that Employee 1 had not received this training.

The facility's housekeeping department policy entitled "Infection Control" with a review date of 02/14/2014 indicated that "All new employees shall be given an orientation training program in cleaning procedures."

Based on interview and record review the facility failed to ensure the discharge plan was included in the medical record for 6 of 30 sampled patients (sample patients 1-6). Failure to include the discharge plan in the medical record has the potential to lead to fragmented care, duplication of services and may contribute to increased readmissions.

Findings Include:

1. On 07/10/2014 the paper and electronic medical records of sample patients 1-6 from the Acute Care Unit were reviewed with licensed nurse (LN) #3. The LN concurred that based on the record review none of the paper or electronic medical records contained discharge assessments, discharge plans or discharged nursing care plans. The LN reported all of the inpatients are discussed in a daily multidisciplinary meeting that takes into consideration the discharge needs of each individual patient. Among other things, the patient's discharge needs are discussed and actions are taken, if indicated, by members of the multidisciplinary team to meet the needs of the patients before discharge.


29935


2. On 7/10/2014 during a collaborative interview with the discharge planning team, the discharge planning process was reviewed. The team discussed the daily rounds that took place on the inpatient unit using a list of all inpatients and new admissions. The team would evaluate the individual patient needs with the charge nurse assigned. The charge nurse would verbally communicate the plan to the nursing staff caring for the patient. The team acknowledged discharge planning notes were not entered by the team in the medical record with the exception of a social service note upon consultation. When asked who had the responsibility of the discharge plan development and implementation, the reply was "Nursing."

During this collaborative interview, the team also discussed cases of patients no longer meeting criteria for hospitalization. Many patients, "approximately one per month" cannot be discharged due to homelessness, no help in the home, finances, and prolonged period for financial aid approval. The social worker stated she would enter a note under consult for these patients but no other discharge planning notes would be documented in the medical record by the interdisciplinary team.

Review of the policy titled 'Discharge Planning' dated 4.2011, revealed a list of responsibilities which included: "Work with patient, family and members of the healthcare team to coordinate services for care after discharge, provide short-term counseling related to the medical condition to aid patient and family in cooing with illnesses that are particularly traumatic because of their duration, severity, or effect on the patient's physical and psychological development, and to assist with situation requiring crisis intervention.... Coordinate all discharge planning needs and assist in making arrangements for services as soon as possible.... Document information regarding discharge planning and communicate findings to provider and staff..."

Based on interview and record review the hospital failed to ensure a post-anesthesia evaluation was written in accordance with hospital policies that reflected current standards of anesthesia care for 5 of 6 un-sampled closed surgical cases. Failing to complete and document assessments of: respiratory and cardiovascular function; mental status; temperature; nausea & vomiting; pain, and post operative hydration could potentially contribute to not identify post-anesthesia complications.

Findings Include:

On 07/10/2014 six random surgical cases that occurred between 07/01/2014 and 07/02/2014 were reviewed with LN7. During a concurrent interview with LN7 it was revealed that the post anesthesia assessment should be written on the Anesthesia Medical Record Form 517. The LN validated the written post-anesthesia evaluations in 5 of the 6 included comments such as:

1. "VSS, Little Bit pain, No N/V, no anesthe problems noted."
2. "tol Anesth well, no problems"
3. "tol Ansch well, no problems"
4. "tol Ansch well, no problems"5. "VSS no Anesth Problems noted"

During further interview with LN7 he validated after reading the post anesthesia records, he would have to presume there were no problems with the previously identified physiological systems since there was no documentation indicating that the assessment was completed.

On that same date the facility Post Operative Anesthesia Care policy was reviewed. The policy states "The anesthetist will document on the SF 517 record the discharge of the patient from the PACU when the patients condition is stable and the patient meets the PACU discharge criteria by the Aldrete Scoring system which include 6 parameters for discharge:(Activity, Respirations, Circulation, Pulse rate, Consciousness, O2 Saturation)." Additionally, "(a)t least one post anesthetic visit will be recorded on admission to PACU, a second not within 48 hours describing the presence or absence of anesthesia related complications...... Each post anesthesia visit will be documented on the post anesthesia evaluation form or the progress notes."

The Anesthesia Contract Statement of Work, which is in effect till 08/15/2014, stated "The contractor will ensure all anesthesia providers comply with the medical staff rules, regulations, and bylaws related to clinical practice as promulgated by the Clinical Director and the national Standards of Practice of this speciality." Additionally, the contract stated "Pre-operative and post-operative anesthesia evaluations will be made and properly recorded in the patient's medical record as required by the Center for Medicare and Medicaid Services(CMS)."

The "Practice Guidelines for Post-anesthetic Care: An Updated Report by the American Society of Anesthesiologist Task Force on Postanesthetic Care (February 2013)" is an update of recommendations originally published in 2002. While the American Society of Anesthesiologist (ASA) practice guidelines are not intended as standards or absolutes "They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility date." The purpose of the Guidelines is to improve postanesthetic care outcomes"....These Guidelines focus on the preoperative management of patients with the goal of reducing postoperative adverse events,"..."These Guidelines apply to patients of all ages who have just received general anesthesia, regional anesthesia, or moderate or deep sedation. The Guideline may need to be modified to meet the needs of the certain patient populations..." Based on the guidelines "Perioperative and postanesthetic management of the patient includes periodic assessment and monitoring of respiratory function, cardiovascular function, neuromuscular function, mental status, temperature, pain, nausea and vomiting, fluid assessment, urine output and voiding, and drainage and bleeding."