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Based on interview and record review, the facility failed to develop departmental policies for the laboratory. Specifically, the facility failed to show evidence of specific departmental policies for the laboratory, and instead utilized only manufacturers' directions for use instructions, and used protocols from another laboratory for obtaining, packaging, and transporting laboratory samples that would be sent off-site for evaluation. This practice had the potential to affect any patient receiving services from the laboratory.

Findings Include:

During a tour of the Laboratory Department on 02/04/19 at 3:00 PM, Staff G, Laboratory Director, produced protocols for testing equipment recommended by the equipment manufacturers'. She produced a protocol for an outside laboratory for obtaining, packaging, and transporting lab samples. Staff G did not produce policies and procedures developed for the operation of the Laboratory Department, specific to this hospital's lab and stated that she did not have a lab policy and procedure book.

In an interview on 02/05/19 at 8:54 AM, Staff D, Administrator stated that she was unable to locate any lab policies. She stated lab policies and procedures had not been identified in the quality improvement meetings. Staff D stated she relied on the department leaders to bring her the policies and procedures when they were due, and she would bring them to the Governing Body.

During an interview on 02/05/19 at 10:45 AM, Staff D, the Administrator, stated that the expectation would be for the department to have a policy and procedure on everything that happened in the lab. She stated the lab did have protocols for running equipment (manufacturers' instructions) and for samples to be sent to an outside lab.


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Based on interview and record review, the facility failed to review and update the departmental radiology and laundry policies and procedures. Specifically, the policies for the Radiology Department had not be reviewed since 2008, with few exceptions. The Laundry Department policies and procedures had not been reviewed and updated since 2008. This practice had the potential to adversely affect any patient receiving services in the facility.

Findings Include:

1. During a tour of the Radiology Department on 02/04/19 between 3:23 PM and 4:00 PM, Staff G, Radiology Department Director, stated that the policies for the Computed Tomography (CT) scanner were updated when the CT scanner was acquired last fall, but other departmental policies were last updated, "A long time ago." A review of the facility's Radiological Departmental policies showed the CT scanner policies were up to date. The most recent update for other departmental policies was 2008.

During an interview on 02/04/19 at 10:55 AM, Staff D, Administrator, stated that the prior Director of the Radiology Department (Staff G) was trying to retire, and had largely left the control of the department to the traveling Certified Radiology Technicians. The traveling Technicians were required to revise the policy because the facility had acquired a new CT machine, which the former Director of the department was not certified to operate.

In an interview on 02/05/19 at 10:45 AM, Staff D, the Administrator stated that the Radiology Department obtained the current x-ray machine in 2008, and stated she felt the departmental policies had last been reviewed and updated at that time. Staff D stated in August of 2018, the department acquired a CT machine, and the policies relating to that machine were developed. Staff D stated a review of policies and procedures for the Radiological Department had not been identified in the quality improvement program.

2. During an interview and tour of the Laundry Department on 02/04/19 at 1:00 PM, Staff A, Laundry Supervisor stated that the Infection Control Preventionist had taken the Laundry Policies, so the policies could be reviewed and updated.

In an interview on 02/04/19 at 1:55 PM, Staff B, the Infection Control Preventionist, stated that she had been asked to go through the policies to review infection control and had not had enough time to review the policies. She stated that the last review for the policies and procedures in the laundry department was 06/29/2016. Staff B stated that the Laundry policies had not be identified as an improvement project in the quality meetings.

Based on observation, interview, and record review, the facility failed to implement infection control prevention practices by not providing the proper PPE (personal protective equipment) in the laundry room, potentially adversely affecting all staff who sort laundry; and failed to provide proper PPE to be used during provision of care for one (Patient 1) of one patients placed on contact precautions, potentially adversely affecting all patients and staff by spread of infectious organisms: and failed to don required PPE while providing care for one (Patient 1) of one patients placed on contact precautions, potentially adversely affecting all patients and staff by spread of infectious organisms; failed to keep linens covered during distribution on the floor, potentially affecting all patients receiving linens from the linen cart, potentially adversely affecting all patients using hospital linens by spread of infectious organisms; and failed to exercise proper infection prevention measures during medication administration for two patients (Patient 22 and Patient 23) of two medication administrations observed, potentially adversely affecting all patients receiving medication by spread of infectious organisms. Specifically, the facility failed to provide goggles or a face mask to be used by staff while sorting laundry: failed to have protective gowns available at the patients room, to be used when providing care for Patient 1: failed to don proper PPE when cares were provided to Patient 1: left linens uncovered in a distribution cart in the hall: and staff touched medications with their bare hands when setting up medications to be administered to Patients 22 and 23. These practices had the potential to adversely affect all patients receiving services in the facility.

Findings Include:

1. During a tour of the Laundry Department on 02/04/19 at 1:00 PM, Staff A, Laundry Supervisor could not locate goggles or a face shield to be worn while sorting laundry and stated she did not use goggles when sorting laundry. She stated she had given the Laundry policy and procedure book to the Infection Control Preventionist.

In an interview on 02/04/19 at 1:55 PM, Staff B, Infection Control Preventionist, stated that she did not realize the laundry department lacked goggles or a face shield to use when sorting laundry. She stated the laundry staff should wear proper PPE when sorting laundry. Staff B reviewed the policy for sorting laundry and stated that the policy did not cover wearing goggles, but later provided a policy that indicated "masks" should be worn during sorting of laundry.

Review of the facility's policy, "Infection Control Laundry Department," revised 03/2009, showed, In the laundry, Handwashing facilities and protective barriers (gown, gloves, and masks) should be made available to personnel who sort laundry.

2. During an observation on 02/04/19 at 9:18 AM, a Contact Precautions notification was taped to Patients 1's door outside of her room. The notification instructed all doctors and staff to don a barrier gown and gloves before entering the room. On the bedside table outside of the room was large vinyl powder free gloves and a bottle of Purell antibacterial hand sanitizer. No other PPE (gowns) was found available on the bedside table, or found in the immediate area of Patient 1's room.

During an interview on 02/04/19 at 11:33 AM, Staff C, one of the two Directors of Nursing (DON) stated that she thought Staff B, the Infection Control Program officer, may have changed the contact precaution requirement for Patient 1, and that the change may be the reason there was no barrier gowns available on the bedside table outside of Patient 1's room. She stated the expectation was that staff would follow contact precautions when indicated.

During an interview on 02/05/19 at 10:00 AM, Staff C, the Infection Control Preventionist, stated that the expectation would be that staff would don the appropriate PPE when working with Patient 1.

3. During an observation on 02/05/19 at 1:10 PM, Staff F, Registered Nurse (RN) was observed in Patient 1's room. She did not have on a gown or gloves. A gown and gloves were observed to be available on the bedside table located outside of Patient 1's room. Staff F was touching the intravenous (IV) pump, pole, and tubing. A Unit of blood was observed to be hanging on the pole.

During an interview on 02/05/19 at 1:10 PM, Staff F, RN, stated that she had been messing with the IV pump and pole while she was waiting for the tubing to flush. She stated, "I was just messing with the tubing, that's why I didn't wear the gown and gloves. I should have put the gloves on, but I didn't touch her (Patient 1.)

During an interview on 02/05/19 at 1:45 PM, Staff C, DON, stated, "I think the intention was for the staff to wear gown and gloves. I think that is what (Name of Infection Control Preventionist) intended. I don't know why we have a problem with isolation here. We have been trained and trained."

Review of a facility's notification titled, "Contact Precautions," observed on the door of Patient 1's room throughout the survey, showed, Everyone Must: Clean hands when entering and leaving room. Doctors and Staff Must: Gown and Glove at door.

Review of the facility's undated policy titled "Contact Precautions," showed, Gloves should be worn when entering the room and while providing care for a patient. A gown should be worn when entering the room if it is anticipated that clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room or if the patient is incontinent or wound drainage is not contained by a dressing.

4. During an observation on 02/04/19 at 8:41 AM, a rolling two rack cart with a stack of clothing protectors, three mattress protector pads, one gown, and a stack of wash cloths was in the hall outside of room 118. The linens on the rack did not have a protective covering and were left exposed to the surroundings.

During an observation on 02/04/19 at 10:13 AM, the linen in the linen cart were covered with bath towels. At 9:26 AM the linens on the linen cart did not have a protective covering and were left exposed to the surroundings.

In an interview on 02/05/19 at 10:00 AM, Staff B, could not locate a linen transportation policy, and said, "I know our policy, since I worked here since the eighties. I know our policy is to keep it (linen) covered."

Review of the facility's policy, "Handling of Clean Linens," dated 02/04/19, showed, Linen is kept covered in a cart during distribution in the hall way.


5. On 02/06/19 at 8:35 AM, observation of medication administration for swing bed patients 22 and 23, Licensed Practical Nurse (LPN) J sanitized her hands, took the keys out of her pocket and opened the cart, opened a drawer and removed blister packs of medications. LPN J proceeded to remove the medication out of the blister packs into her hands prior to putting them in the mediation cup. Multiple times during the medication set up LPN J opened additional cart drawers and removed several inhalers and additional medication that was in a separate container. LPN J did not sanitize hands after touching the keys, touching additional medications or opening additional drawers on the cart.

Interview on 02/06/19 at 8:52 LPN J reflected that she always removes the medications with her bare hands because she has sanitized her hands prior to setting up medications.

Interview on 02/06/19 at 9:00 the Infection Preventionist Registered Nurse, B stated that staff should not touch medications with their bare hands if they are touching other surfaces.

A policy was requested on 02/06/19. RN B stated there was not a policy specific to hand hygiene and handling medications with bare hands.


In an interview on 02/05/19 at 10:00 AM, Staff B, Infection Control Preventionist (ICP,) stated that she had not reviewed the laundry policies for update. She stated the expectation for contact precautions would be that the staff would gown and glove when they entered the room to provide services to Patient 1. She did not know whey there was no gowns available outside of Patient 1's door yesterday.

Review of the facility's undated policy titled, "Infection Control Laundry Department," showed, In the laundry, handwashing facilities and protective barriers (gowns, gloves, and masks) should be made available to personnel who sort laundry.

Review of the facility's policy titled, "Handling of Clean Linens," dated 2-4-19, showed, Linen is kept covered in a cart during distribution in the hallway.

Based on observation, interview, and record review, the facility failed to ensure call lights were within the reach of five (Patient 2, Patient 6, Patient 7, Patient 9, and Patient 10) of five patients observed not having easy access to call bells, with which to call for assistance. Specifically, the call bells used to call for assistance were out of reach of the patients. This practice had the potential to increase the risk for injury of all patients who would need to request assistance.

Findings Include:

1. Review of the electronic medical record showed that Patient 2 was admitted to the hospital on 02/03/19 with diagnoses of chronic obstructive pulmonary disease, hypoxia and shortness of breath.

During an observation and interview on 02/04/19 at 9:09 AM, Patient was seated in a recliner chair in his room. The call bell was hung from the wall away from the patient. Patient 2 did not know where the call bell was located but thought he may be able to walk the three feet over to his bed to find the bed bell to call for a nurse. Patient 2 appeared short of breath and stated that he had been hospitalized for pneumonia.

2. Review of the electronic medical record showed that Patient 6 was originally admitted to the facility on 08/08/12 with diagnosis of Alzheimer's dementia.

During an observation on 02/04/19 at 10:28 AM, Patient 6 was sleeping in her bed, in her room. There was no call light available in the area where Patient 6's bed was located.

During an interview on 02/04/19 at 11:52 AM, Staff N, Licensed Practical Nurse (LPN), stated, "I don't know that a call light can reach (Patient 6.)" She stated the two other patients in the room had call lights, but the facility just didn't have a call light cord that was long enough to reach Patient 6." She stated, "She (Patient 6) doesn't communicate and does not use of her hands." Staff N stated, "she did not know if Patient 6 had ever been assessed for the possible use of another type of call system."

Review of Patient 6's "Care Plan" dated 01/01/19, showed, Answer all call lights in a timely manner.

3. Review of the electronic medical record showed that Patient 7 was readmitted to Intermediate Swing Bed status on 01/14/19 with diagnoses of pulmonary mycobacterial infection and Parkinson's disease.

During an observation on 02/04/19 at 8:45 AM, Patient 7 was in her bed in her room. The call light was more than four feet away from the resident and was attached to the wall. Patient was asking for help and was hard to understand.

During an observation on 02/04/19 at 9:03 AM, Patient 7 had been laid flat in the bed with both upper and both lower bed rails raised. The call light hung on the wall out of Patient 7's reach.

During an observation on 02/04/19 at 11:33 AM, Patient 7 sat in a recliner chair in her room. The call bell sat on the bed top more than five feet from the resident. During the observation Staff K, Certified Nurses Assistant (CNA) entered the room and placed the call light near Patient 7. She stated that she had moved the bell when she helped Patient 7 with her lunch.

Review of Patient 7's "Care Plan" dated 01/14/19 showed, Answer all call lights in a timely manner.

4. Review of the electronic medical record showed that Patient 9 was admitted to Intermediate Swing Bed status 09/10/18 with diagnoses of cerebral meningioma status post resection and left side hemiparesis (paralysis).

During an observation on 02/04/19 at 8:52 AM, Patient 9 was seated in a chair in his room. The call bell was on the bedside stand, out of reach of Patient 9. Patient 9 stated that he did not know how he would call for help if he needed help.

Review of Patient 9's "Care Plan" showed, Keep frequently used items within patients' reach: call light.

5. Review of the electronic medical record showed Patient 10 was admitted to the Intermediate Swing Bed status on 09/27/17 with diagnosis of Alzheimer's disease.

During an observation on 02/04/19 at 8:57 AM, Patient 10 was asleep in his bed with three bed rails in the up position. The call bell hung on the wall about five feet from the resident. The resident could not reach the call light from the bed.

Review of Patient 10's "Care Plan" showed, Answer all call lights in a timely manner.

Review of the facility's policy titled, "Call Lights," last updated 08/05/15, did not address assessing the patients' need for or ability to utilize a call light system, and did not address care planning for a patient who may not be able to effectively operate a standard call bell.

During an interview on 02/06/19 at 10:01 AM, Staff C and E, both Directors of Nursing (DONs), stated that the facility had not trained the staff on the use of call lights. They stated that the expectation would be for the call lights to be placed close to the patients for their use. Staff C and E confirmed that they had not assessed Patient 6 for the possible use of an alternative call system.

Based on observation, interview, and policy review, the facility failed to safely administer medication to one (Patient 8) of one patient who was observed to have medications left in the room, unattended by the nurse. Specifically, medications were left in Patient 8's room by the nurse for the patient to self-administer, and Patient 8 had not been approved to administer her own medications. This practice had the potential to increase the safety risk for patients allowed to self-administer medications who had not been assessed and approved to self-administer their own medications.

Findings Include:

Review of the electronic medical record showed, Patient 8 was an Intermediate Swing Bed Patient, readmitted to the facility 01/14/19.

During an observation and interview with Patient 8 on 02/04/19 at 11:33 AM, five medication pills sat on a napkin on a meal tray, on the bedside table, while Patient 8 was eating lunch. Patient 8 stated that she was "capable of taking her own pills." Patient 8 stated that the nurse had brought the pills to her and placed them on the napkin on her meal tray.

Review of Patient 8's, "Medication Administration Record) (MAR) dated 02/04/2019 showed that the nurse had signed off as having administered six medications at 11:44 AM on 02/04/2019. Patient 8 had received six medication pills: Acetaminophen Oral 1,000 milligram (mg), Antioxidant A/C/E/Selenium Oral 1 cap, Glucosamine Oral 1 mg, Multivitamins Oral Tablet 1 tab, Omega 3 Fatty Acids-Fish Oil 360 mg-1,200 mg 1 cap, and Plavix Oral 75 mg.

During an interview with on 02/06/19 at 9:00 AM, Staff E, Director of Nursing (DON), stated that the expectation of the facility was that no medication would be left for the patient to self-administer. She stated that if a patient requested to administer their own medications, a physician's order would need to be obtained before this would be allowed. She stated that Patient 8 did not have an order to self-administer her own medications.

Review of the facility's document titled, "Medication Procurement and Administration Intermediate Swing Bed," last updated 08/01/2018, showed, No residents medication are to be left on the residents' tray, table or stand to be taken at a later time.

Based on interview, policy review and record review, Quality Management Plan review, and review of quality data, the facility failed to meet the Conditions of Participation at §485.641, by failing to meet the standards at C-0331, C-0334, and C-0336. Specifically, the facility failed to make actionable the Quality Management Plan developed by the facility and failed to review and revise the plan to assure effectiveness of the plan; and, the facility failed to assure the review and revision of the policies and procedures. This practice had the potential to adversely affect all patients receiving services at the facility.

Findings Include:


The facility failed to conduct an annual evaluation of the Quality Management Plan. Specifically, the Quality Management Plan, last approved by the Board President on 06/27/18, included a requirement for an annual review of the Quality Management Plan. The facility did not conduct the review. This practice had the potential to affect all patients receiving services in the facility. For details refer to C-0331.

The facility failed to evaluate, review and/or revise the policies and procedures for the Radiology Department, The Laundry Department, and the Laboratory Department. Specifically, most of the Radiology Department Policies and Procedures had not been updated since 2008, the Laundry Department policies had not been updated since 2016, and the facility was unable to produce the facility specific policies and procedures that guided the Laboratory Department. This practice had the potential to adversely affect any patient receiving services at the facility. For details refer to C-0334.

The facility failed to implement a comprehensive QAPI (Quality Assurance Performance Improvement) program when they did not identify specific improvement needs, develop improvement plans, implement corrective plans, and monitor corrective plans for improvement and sustainability. Specifically, the facility did not fully implement the facility designed "Quality Improvement Program," and did not reassess the "Quality Improvement Program" for effectiveness on a periodic basis. This practice has the potential to adversely affect the quality of care for all patients receiving services in the facility. For details refer to C-0336.

Based on interview and record review, the facility failed to conduct an annual evaluation of the Quality Management Plan. Specifically, the Quality Management Plan, last approved by the Board President on 06/27/18, included a requirement for an annual review of the Quality Management Plan. The facility did not conduct this review. This practice had the potential to affect all patients receiving services in the facility.

Finding Include:

Review of the facility's, "Quality Management Plan," approved 06/27/18, showed, The Performance Improvement Program and Plan will be reviewed for overall effectiveness of monitoring, evaluation, problem-solving and performance improvement activities on an annual basis. An assessment of each participating department and team will be conducted, as well as an appraisal of accomplishments of the program as a whole. Revisions in the program will be made as necessary to promote continued growth and identification of opportunities to improve services and operations.

Review of the facility's policy titled, "Quality Improvement Program," last reviewed 7/2015, showed, The Medical Staff and Hospital Governing Board will review the Quality Improvement Program at least annually to evaluate the Program for effectiveness and achievement of objectives and goals.

In an interview on 02/06/19 at 10:30 AM, Staff E and C, both Directors of Nursing, with Staff E also being the Quality Management Coordinator, stated that the Quality Management Program had not been evaluated on an annual basis, and that they could not provide any written documentation of an annual evaluation of the Quality Management Program.

Based on policy review and interview, the facility failed to evaluate, review and/or revise the polices and procedures for the Radiology Department, the Laundry Department, and the Laboratory Department. Specifically, most of the Radiology Department Policies and Procedures had not been updated since 2008, the Laundry Department policies had not been updated since 2016, and the facility was unable to produce the facility specific policies and procedures that guided the Laboratory Department. This practice had the potential to adversely affect any patient receiving services at the facility.

Findings Include:

In an interview on 02/05/19 at 8:54 AM, Staff D, Administrator stated that she was unable to locate any lab policies. She stated lab policies and procedures had not been identified in the quality improvement meetings. Staff D stated that the lack of updates for the policies in the Radiology department had not been identified for quality improvement. Staff D said she relied on the Department Directors to inform her of the status of policies and procedures in their department, and she then moved the policies on to the Governing Board. Refer to C-0271 and C-0272.

Review of the Radiology Department Policies and Procedures showed they were last updated in 2008, except for Computed Tomography policies and procedures.

In an interview on 02/05/19 at 10:45 AM, Staff D stated that the review of policies and procedures (all policies and procedures, although some departmental policies and procedures had been updated) updates had not been identified in the quality improvement program.

In an interview on 02/04/19 at 1:55 PM, Staff B, the Infection Control Preventionist, stated that the last review for the policies and procedures in the laundry department was 06/29/2016. Staff B stated the Laundry policies had not be identified as an improvement project in the quality meetings. Refer to C-0271 and C-0278.

Review of the Laundry Department's policies and procedures showed they were last updated in 2016.

Review of the facility's, "Quality Management Plan," last updated 06/27/18, did not directly address review and revision of the facility's policies and procedures.

Based on interview, record review, and policy review, the facility failed to implement a comprehensive Quality Assurance Performance Improvement (QAPI) program when they did not identify specific improvement needs, develop improvement plans, implement corrective plans, and monitor corrective plans for improvement and sustainability. Specifically, the facility did not fully implement the facility designed "Quality Improvement Program," and did not reassess the "Quality Improvement Program" for effectiveness on a periodic basis. This practice has the potential to adversely affect the quality of care for all patients receiving services in the facility.

Findings Include:

Review of the facility's policy titled, "Quality Improvement Program," last reviewed 7/2015, showed, Each department would implement a systemic method of problem identification by means of critical indicators. These written indicators will be identified, and routine data collection will be documented. Data collected by the Quality Improvement Coordinator will be assessed on a periodic basis and changes, if any, will be implemented in a joint effort to improve the quality of patient care.

Review of the facility's "Quality Management Plan," not signed or dated showed, The program ensures a systematic approach that continuously monitors, develops, and improves our health care delivery services, professional practices, and leadership, cultivating and The Quality Management Program focuses on the application of ongoing, planned systematic monitoring and evaluation of the quality of services delivered and operations by the Organization's team members. The methodology the organization had adopted is based on a variety of applications that all come together to assure optimal patient care activities and the ability to keep pace with the changing healthcare environment: Find a Process to Improve; Organize to Improve the Process; Clarify Current Knowledge of the Process; Identify the Desired Performance Outcome; Identify the Performance Gap between Current and Desired Outcomes; and, Selection of the Process Improvement activity Most Likely to Produce Desired Outcomes: Plan for Improvement; Act to Improve; Check for Desired and measurable Improvement; Enhance for Efficiency, Effectiveness and User-friendliness and The Performance Improvement Program and Plan will be reviewed for overall effectiveness of monitoring, evaluation, problem-solving and performance improvement activities on an annual basis. The Quality Management Plan detailed the various responsibilities of the Quality Improvement team members and departments.

In an interview on 02/06/19 at 10:30 AM, Staff C and E, both Directors of Nursing (DONs), and Staff E, the Quality Improvement Coordinator (QA), they stated that there were no current Quality Improvement Projects identified. They stated that clinical performance data was reviewed at the quality meetings, but the team had not identified any trends or specific areas for improvement. They stated, we try to identify, and trouble shoot problems. They stated problems are identified by supervisors in their day to day work. Staff E stated that she was unsure how to develop Quality Improvement projects. Staff E and C identified a poster-education on antibiotic stewardship that had been conducted by a staff member, but stated they had not determined a goal, process, or ways to monitor for effectiveness or sustainability of antibiotic stewardship. Staff E stated the Quality Improvement Program for the hospital had not been assessed on an annual basis for effectiveness.

In an interview on 02/06/19 at 10:30 AM, Staff C and E, both DONs, and Staff E, the QA, stated they had not identified ensuring patients had call lights in reach for use, or patient safety with the use of side rails as possible projects that may require performance improvement. Refer to C-0294 and C-0381.

Review of the 01/31/2019, 11/29/18, 10/25/18 meeting minutes showed the facility had identified several areas for improvement, and some actions were taken. Staff E stated that the facility did not have a process in place where priority improvement projects were identified, defined, planned, implemented, monitored, and evaluated for effectiveness.

During an interview on 02/05/19 at 9:34, Staff member B, Emergency Preparedness Coordinator stated that she was new to the position of Emergency Preparedness Coordinator and had not identified any performance improvement projects to be referred to the Quality Improvement Program. She stated that the annual assessment of the Emergency Preparedness Program had not been fully developed or conducted. Refer to E0004.

In an interview on 02/05/19 at 8:54 AM, Staff D, Administrator stated that she was unable to locate any lab policies. She stated lab policies and procedures had not been identified in the quality improvement meetings. Staff D stated that the lack of updates for the policies in the Radiology department had not been identified for quality improvement. For more details refer to C-0271 and C-0272.

In an interview on 02/05/19 at 10:45 AM, Staff D stated that the review of policies and procedures (all policies and procedures, although some departmental policies and procedures had been updated) updates had not been identified in the quality improvement program.

In an interview on 02/04/19 at 1:55 PM, Staff B, the Infection Control Preventionist, stated that she had been asked to go through the policies to review infection control and she had not had enough time to review the Laundry policies. She stated that the last review for the policies and procedures in the laundry department was 06/29/2016. Staff B stated the Laundry policies had not be identified as an improvement project in the quality meetings. Refer to C-0271 and C-278.

Based on observation, interview, and record review the facility failed to assess three patients (Patient 6, Patient 7, Patient 9) for safety when utilizing side rails, in the sample of 23 patients. Specifically, the patients were observed with three or four side rails up while in bed and the facility had not assessed the safety for the use of the side rails for each patient. This practice had the potential to increase the risk of injury for these three patients.

Findings include:

1. Review of the electronic medical record showed that Patient 6 was originally admitted to Intermediate Swing Bed status on 08/08/12 with diagnosis of Alzheimer's dementia.

During an observation on 02/04/19 at 10:28 AM, Patient 6 was sleeping in her bed, in her room. Both upper and lower bed rails were in the up position.

Review of Patient 6's electronic health record documented care needs for 02/04/19, showed, Risk Assessment- assistive device(s) in reach, bed in low position, brakes locked, call light in reach, non-skid socks on patient, room clear of obstructions, side rail up x [times] 4. Review of the "care plan" showed Patient 6 had problems with activity intolerance/mobility with impaired physical mobility, inability to transfer to bed, chair, toilet independently, poor balance/coordination, non-weight bearing/total care, generalized weakness; And, anxiety/mood/behaviors with history of anxiety/depression/sadness, dementia/cognitive impairment transfers, and ambulation; and used psychotropic medication, and had a history of falls. Review of the electronic medical record lacked evidence Patient 6 had been assessed for safety in the use of side rails.


2. Review of the electronic medical record showed that Patient 7 was readmitted to Intermediate Swing Bed status on 01/14/19 with diagnoses of pulmonary mycobacterial infection and Parkinson's disease.

During an observation on 02/04/19 at 8:45 AM, Patient 7 was in her bed in her room. Both upper and lower side rails were in the up position.

During an observation on 02/04/19 at 9:03 AM, Patient 7 had been laid flat in the bed with both upper and both lower bed rails raised.

Review of Patient 7's electronic health record documented care needs, for 02/04/19, showed, Risk Assessment- bed in low position, brakes locked, call light in reach, room clear of obstructions, side rails up x 4. Review of the "care plan" showed that Patient 7 had a problem of activity intolerance/mobility with impaired physical mobility, inability to transfer to bed, chair, toilet independently, poor balance/coordination, generalized weakness; And, problems with anxiety/mood/behavior with a history of anxiety/depression/sadness, dementia/cognitive impairment, history of hallucinatory or delusional thinking, easily frustrated/ refuses care/worries needed assistance with transfers. Review of the electronic health record lacked evidence that Patient 7 had been assessed for safety in the use of side rails.

3. Review of the electronic medical record showed that Patient 9 was admitted to Intermediate Swing Bed status 09/10/18 with diagnoses of cerebral meningioma status post resection and left side hemiparesis (paralysis).

During an observation on 02/04/19 at 8:52 AM, Patient 9 was in bed lying on his back. Both upper bed rails and the left lower bed rail were raised, and the right side of the bed was up against the wall.

During an observation on 02/06/19 at 9:14 AM, Patient 9 was lying in his bed with the head of bed up approximately 40 degrees. Both upper and both lower bed rails were in the up position, and Patient 9 was sleeping. Review of the "care plan" showed that Patient 9 had problems with activity intolerance with generalized weakness, history of CVA [Cerebral Vascular Accident] and paralysis; And, a history of falls with presence of acute illness, visual/hearing difficulties, urinary or bowel incontinence, impaired physical mobility, diminished mental status, decreased lower extremity strength.

Review of the electronic medical record, "Care Meeting Note," dated 12/18/19, showed, Continues to have hallucinations on occasion.

Review of the electronic medical record lacked evidence Patient 9 had been assessed for safety of the use of side rails.

In an interview on 02/05/19 at 9:57 AM, staff E, one of two Directors of Nursing (DONs) stated, "We don't assess patients for side rails. We have been told we don't have to do that because we are a hospital."

Review of the facility's policy titled, "Restraint Policy and Procedures for Swing bed Patients," reviewed 8/9/15, showed, (Hospital) Intermediate Swing bed patients have the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience, and not required to treat the resident's medical symptoms And The Care Plan Team - will evaluate along with the physician and care plan accordingly for all residents - will assess the risk of decline at the time of initiation of the restraint- address reversal of any decline in health status - determine the intended use of any restraint used and document accordingly. And, Convenience-is any action taken by a facility to control resident behavior or maintain residents/patients with a lesser amount of effort by the facility and not in the resident's/patient's best interest.

During an interview on 02/06/19 at 10:01 AM, Staff C and E, both DONs, stated that the facility had not trained the staff on the use of side rails. They stated that historically the have not assessed patients for the use of side rails, and they thought of the side rails as a safety measure for the patient.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to annually update the EPP. This failure had the potential to affect all four current patients and the safety of potential patients receiving care in the facility.

Findings Include:

Review of the facility's EPP on 02/05/19 at 9:06 AM revealed that there was no documentation that the EPP had been reviewed annually.

In an interview on 02/05/19 at 10:30 AM, Staff B, who was responsible for the EPP, stated that there was no documentation of an annual program review or a policy available.