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Based on observation, interview and policy review the facility failed to ensure expired or opened supplies were unavailable for patient use. This failure could potentially affect all patients resulting in adverse or delayed treatment. The facility census was 15.

Findings included:

1. Record review of the facility policy titled, "Stock Rotation/Expiration Dates" revised 03/2011 showed no system for checking for expired supplies in patient areas.

2. Observation on 01/28/14 at 1:50 PM in the Emergency Department (ED) exam room #5 showed one wet prep vial with expired date of 01/13 and one Sepp antiseptic 10% providone (the brand name for antiseptic containing iodine used in first aid for minor cuts, abrasions and blisters) with the expired date of 12/08.

3. During an interview on 01/28/14 at 1:20 PM, Staff S, ED Director, stated that the purchasing department was responsible for restocking of any supplies that would have been charged to the patient and that the ED nursing staff was to check inventory of non-chargeable supplies and check for outdates on a weekly basis.

4. Observation on 01/29/14 at 12:35 PM in the cabinets of the Out Patient Clinic showed the following open or outdated supplies:
-Three partial bottles of Hydrogen Peroxide (a liquid known for its' bleaching properties).
-Approximately 75 Silver Nitrate Applicators (ridged wooden stick with 75% silver nitrate and 25% potassium nitrate on cotton tip) no date when opened.
-One test tube for Chlamydia (a sexually transmitted infection) expired 09/01/08.
-Three culture swabs expired 12/12.
-Three culture swabs expired 09/13.
-One pink top tube (used for drawing blood for blood bank) expired 08/13.
-Two yellow top tubes (used for drawing blood cultures) expired 03/13.
-One red and gray top tube (used for drawing blood for chemistries) expired 11/13.

5. During an interview on 01/29/14 at 12:50 PM, Staff EE, Director of the Out Patient Clinic, stated that all supplies were supposed to be for one time use and then thrown away. She stated that she was not aware the supplies were in the cabinets and did not know that some of them were expired. She stated that the staff checked for expirations before they used the supplies or tubes but there was not a formal system for checking for outdates on a scheduled basis.

6. Observation on 01/29/30 at 3:00 PM in a cabinet of the outer room of the lab (where patients have their blood drawn) showed the following expired supplies were two blue top tubes (used to collect clotting factors) expired 10/13 and three pink top tubes 08/13.

7. Observation on 01/29/30 at 3:15 PM in an unlocked drawer of the lab showed the following expired supplies of 100 Pink top tubes expired 07/12.

8. During an interview on 01/29/14 at 3:20 PM, Staff GG, Director of Laboratory, stated that the pink top tubes in that drawer were not used for blood draws. She stated that there was not a system nor documentation for expired supplies.

9. During an interview on 1/29/14 at 3:25 PM, Staff RR, Laboratory Technician, stated that the 100 pink top tubes were for drawing blood samples for the Blood Bank.


















32280

Based on observation, interview and policy review, the facility failed to ensure expired or compromised supplies were not available on the Crash Carts (a set of trays/drawers/shelves on wheels used in dispensing emergency medications/equipment to potentially save someone's life) for patient use and that emergency equipment was maintained. This had the potential to expose all patients to a negative outcome in an emergency situation. The facility census was 15.

Findings included:

1. Record review of the facility policy titled, "Checking of the Crash Cart", reviewed and revised on 10/09, showed:
-All crash carts will be locked with a red "Padlock Seal".
-The Seals will be obtained from pharmacy.
-Crash Carts will be checked every third Friday for quantity and after all emergencies when the cart is opened.
-Medications will be checked by Pharmacy every six months for outdated medications.
Checking of the Defibrillator (a machine used to shock the heart and restore the normal rate and rhythm):
-The defibrillator will be tested every 24 hours and a test strip will be run.
-A monitor strip will be run and placed into the crash cart notebook in the appropriate section.
-The nurse checking the defibrillator will document on the form provided, in the crash cart notebook, that the monitor was tested.

Record review of the undated facility policy titled, "Outside Pharmacy Medication Storage Areas" showed that all these areas shall be locked and accessible only to authorized personnel. It also stated that the pharmacy department will inspect these areas monthly and make appropriate recommendations.

2. Observation on 01/28/14 at 1:50 PM showed the following outdated supplies in the Pediatric (pertaining to infants, children and adolescents) crash cart located in the Emergency Department (ED):
-11 Pro-Vent Arterial Blood sampling kits (used for blood draws to check for the oxygen content of the blood) with expiration dates ranging from 06/2006 to 05/2013;
-Four Westmed 3cc syringes 23 gauge with Heparin (to prevent clotting of the blood) with expiration dates ranging from 07/2008 to 11/2011;
-One adult/child CO2 detector (a device to measure the amount of carbon dioxide in exhaled air) expiration date 11/2012.

3. During an interview on 01/29/14 at 10:30 AM, Staff Y, Director of Respiratory Therapy (RT), stated that when RT staff responded to an emergency code situation that they brought their own supplies, specifically the arterial blood sampling kits. Staff Y also stated that there was the possibility of RT supplies being utilized from the crash cart drawers and if the supplies were expired, it could jeopardize the safety and positive outcome for the patient.

4. During an interview on 01/28/14 at 1:20 PM, Staff S, Director of the ED, stated that the ED nursing staff were responsible for checking the supplies in the crash cart and that pharmacy was responsible for the medications in the crash cart.

5. Record review of the Out Patient "Cardiac Monitor/Defibrillator Checklist" (Defibrillator Discharges), dated 01/27/no year, showed the defibrillator checklist had been signed by a nurse as having been checked daily.

6. Observation on 01/29/14 at 1:30 PM showed Staff SS, Registered Nurse (RN), when asked to operate the defibrillator without it being plugged into the electricity was unable to do so because the back up battery was dead.

7. During an interview on 01/29/14 at 1:35 PM, Staff EE, Director of Out Patient, stated that the defibrillator was checked each morning but probably not unplugged when checked and that is what would show that the battery was dead. She confirmed that the battery should be in operating condition in case of a code (a respiratory or cardiac arrest) .

8. Observation on 01/27/14 at 10:30 AM in the nursing medication room showed a locked cabinet which was identified for emergency drugs. These drugs were:
-Nitroglcerin expired 04/12;
-Glucose tablets;
-Nalbuphine (used to treat pain);
-Ziac (a medication to treat high blood pressure);
-Diazapam a medication to treat anxiety, sleeplessness and alcohol withdrawal);
-Nitro a medication used to treat heart problem);
-Zidovudin used for treatment of Human Immuodeficiency Virus(which causes AIDS (Acquired Immunodeficiency Syndrome) expired 10/11;
Acetaminophen (a mild pain medication) opened with no date;
Also found in this cabinet were four prescription drugs in one patient's name:
-Crixivan (a medication used to treat HIV) expired 03/01;
-Epivl (a medication used to treat HIVexpired 07/1;.
-This patient had been discharged from the hospital in December of 2013.
-The prescription drug, Bisop/HCTZ (a medication to treat high blood pressure) was found in the locked emergency cabinet, for a second patient who had been admitted in August 2013,

9. During an interview on 01/27/14 at 10:45 AM, Staff D, House Supervisor, stated:
-The drugs in this cabinet were for emergencies such as code blues on the Med/Surg Unit.
-It took less time for the staff to remove the emergency medications from this cabinet than from the Pyxis (automated medication dispensing system).
-The nursing staff did not check this cabinet for expired medications; that would be done by pharmacy.
-The patient medications were kept in this locked cabinet and staff would call the discharged patient to come after them.

10. During an interview on 01/27/14 at 11:15 AM, Staff K, Pharmacist, stated that he was unaware that the cabinet was used by nursing for emergency medication. He stated that the Pyxis had been in place for about two years and was used for emergency medications. He stated that none of the medications found in this cabinet would be used for medical emergencies except for the Nitroglycerin.

11. Observation on 01/28/14 at 4:15 PM showed the Med/Surg Crash Cart with one sterile package of curved scissors which expired on 09/29/10 and one intubation tube which was partially open.

12. During an interview on 01/28/14 at 4:20 PM, Staff J, RN, stated that the responsibility for checking the supplies in the Crash Cart was nursing. She confirmed the expired scissors and the break in integrity of the intubation tube packaging.
























32280

Based on interview and record review the facility failed to ensure that physician orders designated patients were classified as either inpatient or observation status for two patients (#15 and #18) of five patients observed. This failure had the potential to affect all patients admitted to the facility and increased the risk of inappropriate admission classification including the appropriate length of stay. The facility census was 15.

Findings included:

1. Even though requested, the facility failed to provide a written policy on length of stay and inpatient and observation status and procedures.

2. During an interview on 01/29/14 at 8:45 AM, Staff U, Director of Medical Records, stated that the facility does not have a policy on length of stay or inpatient or observation status. Staff U stated that they just follow the regulations for Critical Access Hospitals.

3. Record review of Patient #15's medical record showed it did not contain an order indicating observation status. The patient census sheet obtained from the facility showed the patient was on observation status.

4. Record review of Patient #18's medical record showed it did not contain an order for observation status. The patient census sheet obtained from the facility showed the patient was on observation status.

5. During an interview on 01/29/14 at 9:05 AM, Staff V, Registered Nurse (RN), stated that the medical records did not contain an order for observation status but there should have been. Staff V also stated that she was aware of the observation status from the report she received at the beginning of her shift.

Based on document review and interview the facility failed to have in place a plan for the supply of potable (drinkable) water in case of a water outage. This deficient practice places all patients at risk of not having drinkable water and possibly being moved from the facility to another location. The facility census was 15.

Findings included:

1. Review of the facility emergency response plan, conducted on the morning of 01/29/14, showed the facility plan did not include an arrangement with an outside agency to supply the facility with potable water during a disruption of the water supply to the facility.

2. During an interview on 01/29/14 at 3:04 PM, Staff FF, Maintenance, stated the facility currently did not have an agreement with an outside agency to supply the facility with potable water if the water supply to the facility were to be disrupted.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that the facility policies and procedures were developed and reviewed/revised at least annually with the advice of a group of professional personnel;
- Ensure the rules for the storage, handling, dispensation, and administration of drugs and biological's were followed;
- Ensure that a pharmacist reviewed all medication orders for appropriateness before the first dose was administered to the patients admitted after pharmacy hours or on a Sunday;
- Ensure that infection control policies were followed for hand hygiene;
- Ensure that Dietary staff cleaned and maintained kitchen equipment in a sanitary manner, labeled open foods with date, and that the staff properly wore hair nets/caps to fully cover hair;
-Ensure the patients Plan of Care were individualized to meet their potential care needs and response to the interventions for those needs.
The facility census was 15.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with the Condition of Participation: Provision of Services.

Based on interview and record review the facility failed to have a group of professionals develop and/or review facility policies and procedures. This had the potential to adversely affect the quality and consistency of all patient care in the facility. The facility census was 15.

Findings included:

1. Record review of the facility's policies and procedures for the departments of Nursing, Radiology, Pharmacy and Quality Assurance contained only the signature of the Director of the Departments.

2. During an interview on 01/28/14 at 1:00 PM, Staff H, Quality Assurance, stated that the facility did not have a Policy and Procedure Committee. She stated that the Departmental Directors were responsible to review/revise the policies and procedures for their particular department.

3. In an interview on 01/28/14 at 1:30 PM, Staff A, Director of Nursing, stated that she reviewed/revised and approved the nursing policy and procedures. She stated that there was not a professional group that participated in development, revision or approval and was not aware that the committee should include one or more doctors of medicine or osteopathy, one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff and at least one member that is not a member of the facility medical staff. She stated she knew which one of the physician's would be willing to be a member of such a committee.

4. During an interview on 01/30/14 at 12:45 PM, Staff B, Administrator, stated that the facility did not have a Policy and Procedure Committee. He stated that the department heads were responsible for developing policies. He stated that some policies were made with board involvement and then they were approved and some policies were made with just department heads. He also stated that after some policies were developed a representative from Human Resources approved them and if they were patient care policies the Director of Nursing would approve them.





32280

Based on interview, record review and policy review the facility failed to:
- Ensure that a pharmacist reviewed patient medication profiles and physician's medication orders prior to administration of the first dose of medication for those patients admitted to the facility after pharmacy hours or on Sunday's;
- Ensure two of three Crash Carts, (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment at the site of medical/surgical emergencies for life saving protocols) were secure and did not contain expired medications or supplies;
- Ensure that Crash Cart locks were kept in a secure location in the Medical/Surgical (Med/Surg) Unit;
- Ensure that plastic secure locks were secure;
- Ensure that only pharmacists had access to controlled substances in the pharmacy.
- Ensure that pharmacy has an inspection and inventory managements system that ensures that outdated, mislabeled, or otherwise unusable drugs and biological's are not available for patient use. This deficient practice had the potential to cause medication errors, drug interactions and drug diversion that could adversely affect all patients in the facility. The facility census was 15.

Findings included:

1. Record review of the undated facility policy titled, "MEDICATION PROFILE", showed:
- The patient profile will be reviewed by the pharmacist upon receiving a new medication order.
-The pharmacist shall review the prescriber's order or a direct copy prior to the Administration of the initial dose.
-In an emergency or when the pharmacist is unavailable the order shall be reviewed within seventy two hours.

2. During an interview on 01/29/14 at 8:40 AM, Staff K, Pharmacist, stated that he and the Director of Pharmacy staggered hours Monday through Saturday. He stated that they are on call and would come in if there were an emergency but for the most part if a patient is admitted after hours on Saturday or on a Sunday that he would review the physician's order on Monday morning. He stated that the medication would be given to the patient without the physician's order being reviewed by a pharmacist.

3. During an interview on 01/30/14 at 9:10 AM, Staff Z, Pharmacist, Director of Pharmacy, confirmed that physician's orders were not reviewed prior to administering the first dose to patients admitted when the pharmacy was closed.

4. Record review of the undated facility policy titled," OUTSIDE PHARMACY MEDICATION STORAGE AREAS", showed that all refrigerated medication shall be locked and accessible only to authorized personnel and that these areas shall be locked and accessible only to authorized personnel.

5. During an interview on 01/29/14 at 11:00 AM, Staff BB, Pharmacy Technician (PT), stated that a key to the refrigerated narcotics in the pharmacy was in the unlocked drawer of the cabinet in the main room. She stated that they occasionally retrieved narcotics from the refrigerator using that key.

6. During a concurrent interview, Staff Z, Director of Pharmacy, stated that PT's should not access any narcotics and he was not aware the PT used that key; although he was aware the key was in the unlocked drawer.

7. Observation on 01/27/14 at 10:30 AM in the nursing medication room showed a locked cabinet which was identified for emergency drugs. These drugs were:
-Nitroglycerin expired 04/12;
-Glucose tablets;
-Nalbuphine (used to treat pain);
-Ziac (a medication to treat high blood pressure);
-Diazapam a medication to treat anxiety, sleeplessness and alcohol withdrawal);
-Nitro a medication used to treat heart problem);
-Zidovudin used for treatment of Human Immunodeficiency Virus(which causes AIDS (Acquired Immunodeficiency Syndrome) expired 10/11;
Acetaminophen (a mild pain medication) opened with no date;
Also found in this cabinet were four prescription drugs in one patient's name:
-Crixivan (a medication used to treat HIV) expired 03/01;
-Epivl (a medication used to treat HIV expired 07/01;.
-This patient had been discharged from the hospital in December of 2013.
-The prescription drug, Bisop/HCTZ (a medication to treat high blood pressure) was found in the locked emergency cabinet, a second patient who had been admitted in August 2013,

8. During an interview on 01/27/14 at 10:45 AM, Staff D, House Supervisor, stated:
-The drugs in this cabinet were for emergencies such as code blues (a respiratory or cardiac arrest) on the Med/Surg Unit.
-It took less time for the staff to remove the emergency medications from this cabinet than from the Pyxis (automated medication dispensing system).
-The nursing staff did not check this cabinet for expired medications; that would be done by pharmacy.
-The patient medications were kept in this locked cabinet and staff would call the discharged patient to come after them.

9. During an interview on 01/27/14 at 11:15 AM, Staff K, Pharmacist, stated that he was unaware that the cabinet had emergency medications in it. He stated that the Pyxis had been in place for about two years and was used for emergency medications.

10. Record review of the facility policy titled, "Checking of the Crash Cart", reviewed and revised on 10/09, showed:
-All crash carts will be locked with a red "Padlock Seal".
-The Seals will be obtained from pharmacy.
-Crash Carts will be checked every third Friday for quantity and after all emergencies when the cart is opened.
-Medications will be checked by Pharmacy every six months for outdated medications.

11. Concurrent observation on 01/27/14 at 10:30 AM, on the Med/Surg Unit showed a room which contained the medication area, IV supplies area and a nurse's snack area in between Nursing station #1 and Nursing station #2. The doors to this room were open. There was no lock available on either door.

Concurrent observation showed nursing, housekeeping and maintenance staff walking through this room. There were visitors in the halls throughout the observation with the potential of accessing this area.

12. Observation on 01/27/14 at 10:50 AM, in the Med/Surg area showed a Crash Cart with a red "Padlock Seal" securing the Cart. The 20 numbered replacement seals were on the top of the cart and available to anyone walking through the room.

13. During an interview on 01/27/14 at 11:00 AM, Staff D, House Supervisor, stated that the seals were supplied by pharmacy and kept on the top of the Crash Cart. She stated that the seal for the Crash Cart was replaced after a code or after the Cart had been opened. She stated that there was no particular order for the seals to be used and no documentation of the available numbers.

14. Observation on 01/29/14 at 10:05 AM showed the crash cart in the surgical suite with the bottom drawer open and the cart unlocked. The room was empty.

15. During an interview on 01/29/14 at 10:05 AM, Staff S, Registered Nurse (RN), stated that she left it open to replace some equipment that had been used.








27727

Based on observation, interview, record review and policy review the facility failed to:
-Follow their policy for hand hygiene (wash hands with hand sanitizer or with soap and water) for two patients (#12 and #14) of five patients observed;
-Follow their policy for hand hygiene in regards to inanimate objects (any medical equipment, supplies, linen contaminated-used, dirty dishes used by patients) and glove usage for two patients (#13 and #16) of five patients observed.
-Ensure that male urinal bottles (hand held plastic containers used to hold urine) were not placed on the bedside table in order to avoid cross contamination with clean surfaces for one patient (#13) of one patient observed. These failed practices increased the risk of infection and cross contamination and placed all patients and personnel at risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was 15.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," reviewed 05/11 showed the following:
-Hand hygiene is a critical component of patient and employee safety. It is the single most important strategy for preventing nosocomial infections.
-Effective hand hygiene removes transient microorganisms, dirt, and organic material from the hands and decreases the risk of cross contamination from patients, patient care equipment, and environment.
-The skin of patients and personnel can function as a reservoir of infectious agents. Appropriate hand hygiene practices will reduce the risk of cross contamination from patients, patient care equipment, and the environment.
-All staff, students and physicians must follow the hand hygiene policy.
-Clean hands before and after all patient care activities and after hand contaminating activities;
-Clean hands after contact with inanimate objects (any medical equipment, supplies, linen contaminated or used, dirty dishes used by patients or staff;
-Clean hands after removing gloves;
-Remove gloves after caring for a patient or touching potentially infectious materials such as linens, linen carts, IV poles, commodes, etc. and use an alcohol hand rub or soap and water to decontaminate your hands after removing gloves.
-Wearing gloves does not replace the need for hand hygiene.

2. Observation on 01/27/14 at 10:55 AM showed Staff C, Certified Nurse Assistant (CNA) failed to perform hand hygiene upon entering Patient #14's room. Staff C entered the room and immediately put on gloves.

3. Observation on 01/27/14 at 10:58 AM showed Staff C, CNA failed to perform hand hygiene upon entering Patient #12's room. Staff C entered the room and immediately put on gloves.

4. During an interview on 01/27/14 at 11:00 AM, Staff C, CNA stated that the policy for hand hygiene was to perform hand hygiene before and after applying gloves. She stated that she realized she didn't do hand hygiene either time when she entered the patients room and knows she should have.

5. Observation on 01/27/14 at 11:04 AM showed Staff OO, Registered Nurse (RN) enter Patient #13's room to assess his pain. The patient's empty urinal was lying on the bedside table where it could cross contaminate clean surfaces.

Observation on 01/27/14 at 2:00 PM showed Staff OO, RN, failed to do hand hygiene in between touching patient articles and medical equipment for Patient #13. Staff OO entered Patient #13's room with the computer on wheels (COW) and connected an intravenous (within the vein) bag of fluid with medication for administration. She then gathered trash from the patient's bedside table and charted on the COW. The patient's empty urinal was standing upright on his bedside table.

6. During an interview on 01/27/14 at 2:20 PM, Staff OO, RN stated that she didn't think hand hygiene was needed in between the tasks that she had performed because she didn't have gloves on and that it was all in the same room with the same patient. Staff OO stated that the COW was sanitized at the end of the day by housekeeping and sometimes during the day by staff. She stated that patient urinals should not be on the bedside tables but the patients were constantly placing them there.

7. Observation on 01/28/14 at 7:50 AM showed Staff OO, RN failed to do hand hygiene after glove usage and after touching inanimate objects, linens and food tray for Patient #16. Staff OO placed the computer on wheels (COW) into the patients' room and positioned it at the bedside. Staff OO prepared medications and put on gloves and administered a pain medication patch to the patient's left hip. She then removed the gloves, charted on the COW, and removed the patient's breakfast tray.

8. During an interview on 01/30/14 at 12:40 AM Staff II, Infection Control Officer stated that it was her expectation for staff to monitor patient care items such as urinals and for them not to be left on the patient's bedside tables.

Based on observation, interview, and policy review the facility failed to:
-Maintain clean kitchen food preparation and cleaning equipment;
-Follow policy for personal hygiene of dietary staff;
-Ensure cooking utensils were free of grease build up;
These failures had the potential for food borne illness for all patients, staff and visitors who ate foods prepared in the Dietary department kitchen. The facility census was 15.

Findings included:

1. Review of the facility's policy titled, "Dietary Services," issued on 06/13 showed the following:
-The Director of food service was responsible to provide safe food service for patients and employees.
-Provide for the proper receipt and storage of all food supplies;
-Ensure proper attire for food handlers including hair coverings;
-Ranges and grills should be cleaned daily.

2. Observation on 01/29/14 at 9:20 AM showed Staff TT cleaning the food serving line with a hair net on with bangs exposed, hanging down onto her forehead touching her eyebrows and a long ponytail hanging half way down her back.

3. During an interview on 01/29/14 at 9:30 AM Staff TT, Dietary staff, stated that per policy all kitchen staff were to wear hair nets or scrub caps and she pointed out that she was wearing a hair net today.

4. Observation on 01/29/14 at 9:50 AM in the kitchen's dry storage area showed a heating and air unit that ran parallel to the wall with thick lint covering the entire lower half of the unit. This unit was next to storage shelves that housed food products. Directly under the unit was duct work that was also heavily covered with lint.

5. Observation on 01/29/14 at 9:58 AM in the walk in refrigerator unit showed a package of cheese slices wrapped in cellophane with a strand of hair on top of the cellophane.

6. Observation on 01/29/14 10:10 AM of the kitchen's cooking and cleaning equipment showed the following:
-Thick lint above the on/off dials on the cooking stove;
-Thick lint on the shelf of a metal table the steam oven was located on top of;
-Thick lint with accumulations of food crumbs and grease residue on top of the dishwasher;
-Approximate 3"x4" rusted area with chips of rust flaking off on top of the booster heater located left of the dishwasher;
-Heavy grease residue/build up on the bottom and around the edges of two 10.5" cooking skillets.

7. During an interview on 01/29/14 at 11:15 AM Staff X, Director of Dietary, stated that she expects all kitchen staff to wear hair nets or scrub caps and that all hair should be covered. She stated that the kitchen area should be cleaned daily and that there should be no lint or food debris as was observed.

8. During an interview on 01/30/14 at 12:40 AM, Staff II, Infection Control Officer, stated that her expectations of the kitchen staff was to wear hair nets and that hair was to be completely covered to avoid contact with food items. She stated she hadn't noticed the staff with the bangs hanging onto forehead or the ponytail.

Based on interview, record review and policy review the facility failed to ensure that facility policies were updated and reviewed with input from a professional personnel group annually. There were outdated policies for administration; swing bed (a specific type of reimbursement for patients that needed a skilled service, such as therapy, but didn't need that level of care in a regular patient bed); infection control and nursing. The infection control department failed to have a correct policy that guided annual review. These failed processes increased the risk of improper care and placed all patients at risk for receiving inadequate care throughout the facility. The facility census was 15.

Findings included:

1. Record review of the facility policy titled, "Infection Control Policy Review," dated 1998 with no revision date showed the following:
-Infection Control policies and procedures, which are implemented for all services, are to be reviewed at least every two years.
-Revisions will be made more often if deemed necessary;
-The infection control nurse will meet with all departments to review policies related to infection control.
-Revisions will be submitted to the infection control committee for approval.

2. Record review of the facility's document titled, "Annual CAH [Critical Access Hospital] Program Evaluation" dated 11/01/11 - 10/31/12 showed the following:
POLICIES & PROCEDURES: Each department is to review and/or revise their policies yearly.

3. During an interview on 01/30/14 at 8:40 AM, Staff II, Infection Control Officer, stated that it was her responsibility to formulate infection control policies and that she reviewed the policies every two years on even years.

4. Record review of policies showed the following outdated policies related to patient care:
-One administration policy with an effective date of 08/05, and no review date;
-Three nursing service policies with no current review dates and effective dates of 04/05, 02/02 and 05/12;
-One swing bed policy with no review date and effective date of 07/06.

5. Record review of facility document titled "Infection Control Policy Manual Review Dates," showed review dates of every two years with the last review date of 11/12.

6. During an interview on 01/29/14 at 1:00 PM, Staff H, Director of Quality Assurance, stated that each department head reviews and approves their policies and procedures on an annual basis. She stated that there is no policy and procedures professional committee and she was not aware that it was required.

7. During an interview on 01/29/14 15 1:50 PM, Staff A, Director of Nursing, stated that she reviews the nursing policies and procedures on an annual basis but there is not a professional committee that reviews them.













27029

Based on interview, record review and policy review the facility failed to individualize care plans to ensure potential care needs and response to interventions are addressed for one (#12) of six patients reviewed and failed to implement interventions identified on the Plan of Care for one (#14) of six patients reviewed. This failure had the potential to deny all patients admitted to the facility care plan interventions needed to meet their needs. The facility census was 15.

Findings included:

1. Record review of the facility's policy titled, "Nursing Care Plans" dated 04/05 showed the following:
-A nursing care plan through the "problem list" will be implemented in the Point of Care computer system within 24 hours of admission.
-The nursing care plan will consist of patient goals, interventions and discharge planning.
-The nursing care plan will be reviewed each shift and documented within the patient progress notes.
-The nursing care plan will be updated as the patient's needs change and the plan will be implemented.

Record review of the facility's policy titled, "Fall Prevention" dated 02/02 showed the following:
-Every patient at time of admission will be assessed for fall risk.
-This will be done on the initial interview part of the admission;
-The Registered Nurse will reassess the patient's fall risk at least daily or when the patient's orientation/alertness deteriorates.
-Patients at risk for fall will have a green arm band placed on their wrist.

2. Record review of Patient #12's History and Physical (H&P) dated 01/26/14, showed the patient was admitted with right labial (part of the female genitalia) abscess/cellulitis (possible infection and swelling) and newly diagnosed diabetes mellitus Type II (a metabolic disorder that is characterized by high blood sugar that requires insulin administration). Further record review showed the patient had reported upon admission that she had occasionally fallen due to dizziness.

3. Record review on 01/27/14 of the Plan of Care for Patient #12 initiated on 01/26/14 showed no identified problem for risk of falls or any individualized interventions for risk for falls such as green arm band or signage on the doorway.

4. Record review on 01/27/14 of the H&P of Patient #14 showed the patient was admitted to the facility on 01/26/14 for chronic urinary tract infection, increased confusion and falls.

5. Record review of the Plan of Care for Patient #14 initiated on 01/26/14 showed no individualized interventions for high fall risk such as green arm band or signage on the doorway.

6. During an interview on 01/27/14 at 2:10 PM Staff OO, Registered Nurse (RN), stated that the policy for fall risk was to place falling star cutouts on the patient's doorway and that the patients would be identified with a "yellow" wrist band. Staff OO also confirmed that Patient #12 and Patient #14 did not have the identifying arm band or signage on the doorway indicating that they were at risk for falls.

Based on interviews and record reviews the facility failed to incorporate the following into the annual Periodic Evaluation and Quality Assurance Review:
-Review of at least 10 percent of both active and closed medical records;
-Have written criteria for review of the medical records;
-Annual review of departmental policies and procedures by an outside entity.
-Peer review of all physicians providing direct care to patients for appropriateness of diagnosis and treatment; and
-Ensure that all facility departments were represented in the facility-wide QAPI (Quality Assurance and Performance Improvement) Program.

The severity and cumulative effect of the deficient practices resulted in the facility being out of compliance with the requirements found for the Condition of Participation: Periodic Evaluation and Quality Assurance Review. The facility census was 15.

Based on interviews and record review the facility failed to provide a quality of care review for 10 percent (representative sample) of active and discharged medical records as part of the annual Periodic Evaluation and Quality Assurance (QA) Review. This had the potential to affect all patients in regard to the quality of care received and the potential to improve the quality of care for all patients. The facility census was 15.

Findings included:

1. Record review of the facility's document titled, "Annual CAH [Critical Access Hospital] Program Evaluation" dated 11/01/11 - 10/31/12 did not show evidence that a representative sample of patient medical records had been reviewed to assess Patient quality of care.

2. During a telephone interview on 02/03/14 at 9:35 AM, Staff U, Director of Medical Records, stated that there was no committee or designated person that provided for the annual periodic review of medical records for quality. She stated that she notified the facility departments and she reported the information they provided in the annual report. She stated that there was not an outside source or objective entity that provided for patient record review. She also stated that there is not a policy and procedure to guide staff through the necessary criteria for the periodic review.

Based on interview and record review the facility failed to ensure facility patient care policies were reviewed annually by a professional committee. This had the potential to affect all patients current care quality and failed to evaluate if policies and procedures could be changed or revised to improve the quality of care to patients. The facility census was 15.

Findings included:

1. Record review of the facility's document titled, "Annual CAH [Critical Access Hospital] Program Evaluation" dated 11/01/11 - 10/31/12 showed the following:
POLICIES & PROCEDURES: Each department is to review and/or revise their policies yearly.

2. During an interview on 01/29/14 at 1:00 PM, Staff H, Director of Quality Assurance, stated that each department head reviews and approves their policies and procedures on an annual basis. She stated that there is no policy and procedures professional committee and she was not aware that it was required.

3. During an interview on 01/29/14 15 1:50 PM, Staff A, Director of Nursing, stated that she reviews the nursing policies and procedures on an annual basis but there is not a professional committee that reviews them.

4. During a telephone interview on 02/03/14 at 9:35 AM, Staff U, Director of Medical Records, stated that there is no professional committee or designated person that performs the annual Periodic Review or Quality Assurance. She stated that the departments let her know that they have reviewed their policies and procedures and she reports that in the annual Periodic Review Summary.

Based on interview and record review the facility failed to incorporate Environmental Services into the facility-wide Quality Assurance (QA) Program. This had the potential to affect all patients regarding the quality of cleanliness and infection control prevention provided by housekeeping services. The facility census was 15.

Findings included:

1. Record review of the facility's document titled, "Quality Assurance Plan" dated 04/13 showed the following:
- Hospital Departments/Services: Develops, implements, and evaluates the QA activities within each department.
- Development: Each department/service will develop a QA program for their specific department based upon their aspects of care.
- Prioritization: The department directors/managers have the responsibility for prioritizing monitors involving only services which they provide.
- Objective Assessment: Each department will be responsible for using clinically valid, written criteria to accomplish objective assessment.
- Reporting Schedule: Each department/service will submit a QA Monitoring/Evaluation form on a regular basis as determined by the annual monitoring schedule they submit at the beginning of the year. These scheduled monitoring will be done and submitted to the QA Coordinator the month they are due to go to the QA Committee.

2. During an interview on 01/28/14 at 1:00 PM, Staff H, Director of QA, stated that Environmental Services were not currently participating in the facility-wide QA Program. She stated that the department did not have a QA project, collect data or monitor patient services for quality outcomes or potential quality improvements.

Based on interview and record review the facility failed to have an eligible outside entity review the quality and appropriateness of the diagnosis, treatment or outcome of treatment provided by each physician who provided patient care services. The failure had the potential to adversely affect the appropriate care all patients in the facility. The facility census was 15.

Findings included:

1. Record review of the facility's document titled, "Quality Assurance Plan" dated 04/13, showed no evidence that physician peer review was integrated into the facility-wide Quality Assurance Plan or Program.

2. Record review of five Staff (JJ, KK, LL, MM and NN) Medical Doctors credentialing (credentialing and privileging are processes of formal recognition and attestation that a physician is both qualified and competent) records showed no Quality Assurance evaluation of clinical practice for the physicians currently providing direct patient care.

3. Record review of the facility's directory titled, "Medical Staff Roster" dated 03/13, showed 40 physicians with admitting privileges, 53 Consulting physicians and eight Emergency Department physicians.

4. During an interview on 01/28/14 at 1:00 PM, Staff H, Quality Assurance Director and Credentialing Coordinator, stated that physicians do not receive a peer review unless a review is necessary and precipitated by an adverse event. She stated that even then the review is not conducted by the network facility or by arrangement with an outside agency.

Based on interview and record review the facility failed to have an agreement with an Organ Procurement Organization (OPO) that met the following required criteria:
- Criteria for referral;
- Definition of "imminent death";
- Definition of "timely notification";
- Addresses the OPO's responsibility to determine medical suitability for organ donation;
- How the tissue and/or eye bank will be notified of potential donors;
- Provides for timely notification of death to the OPO;
- Permits the OPO, tissue bank and eye bank access to the facility's death record on a designated schedule;
- Includes that the facility is not required to perform credentialing reviews for, or grant privileges to, members of organ recovery teams as long as the OPO sends only qualified, trained individuals to perform organ recovery; and
- Describe the interventions the facility will utilize to maintain potential organ donor patients so that the patient organs remain viable.
This failure had the potential to affect all potential donors and/or families who had a desire to donate organ(s) and were not given the opportunity or prolong the emotional, physical and financial impact and caregiving needs of a potential donor recipient and their families. The facility census was 15.

Findings included:

1. Record review of the facility's policy and procedure titled, "Organ, Tissue and Eye Donation" dated 07/02, showed the following: The facility will refer deaths of all patients to the Midwest Transplant Referral Network (MTRN).The RN's [registered nurses] of the facility will no longer approach the families about organ donation. It will be the sole responsibility of the Midwest Transplant Network to obtain referrals.

2. Record review of the facility's document titled, "Monthly Death Register for 12/13" showed there had been 14 patients that had died in the facility during the year.

3. During an interview on 01/28/14 at 1:30 PM, Staff A, Director of Nursing (DON), stated that the only part facility staff had in organ, tissue and eye donation was to contact MTRN. She provided a Quality Assurance document dated 04/05/13 from the MTRN showing organ Referral Notification Analysis but could only provide the documentation from January, February and March of 2013. She later contacted the MTRN and provided the last 12 months of organ, tissue and eye donation reports showing the following data:
- Referral Notification Analysis of 14 reportable deaths, with 14 deaths reported to MTRN;
- Organ donors equaled 0;
- Tissue Donor Analysis: Eligible Tissue Donors equaled five, with one actual donor;
- Eye donors/donations were not included in the reports.
Staff A stated that there was no current contract or agreement with MTRN.

Findings included:

1. Record review of the facility's undated Swing Bed policy titled, "Activities Assessment," directed that the Activity Director (AD) provide activities which will be designed to reflect the interests and abilities of the patient.

Record review of the facility's undated Swing Bed policy titled, "Activity Assessment" directed that the activity calendar will list planned activities.

2. Record review of the facility's undated job description titled, "Occupational Therapy Procedures - Job Descriptions", showed the Occupational Therapist was also responsible for services for Activities Assessment for swing bed patients. And was to develop an activities program that included meaningful activities and goals for each patient Monday through Friday.

3. Record review of Patient #6's History and Physical (H & P) dated 01/23/14, showed the patient was admitted to the Swing Bed program on 01/25/14 with diagnoses of dizziness, weakness and shortness of breath.

4. Observation and concurrent interview on 01/27/14 at 2:00 PM, Patient #6 stated that she was unaware of any activity program.

5. Record review of Patient #6's Activity Assessment/Care Plan dated 01/27/14, showed the patient was alert and oriented. The assessment showed the patient enjoyed watching television (TV), movies, and word searches. (Staff failed to document any specific TV programs or movies.)

6. Record review of the patient's Daily Activity Note documentation showed one entry dated 01/28/14, "Patient wanted to be taken out of room for w/c [wheelchair] ride". Documentation also showed that the 28th was "Take-Out Tuesday" (patients were taken out of their rooms to the gift shop). This activity was not identified as a preferred activity by the patient. (Staff failed to document any specific, relevant activities provided for Patient #6).

7. Record review of Patient #7's H & P dated 01/20/134, showed the patient was admitted to the Swing Bed program on 01/24/14 with a diagnosis of Urinary Tract Infection (an infection in the bladder or kidneys), Leukocytosis (an elevated white blood count usually indicating infection in the body and Bronchitis (inflammation of the membranes of the airways).

8. Observation and concurrent interview on 01/28/14 at 8:20 AM, Patient #7 stated that she was did not know of an activity program.

9. Record review of Patient #7's Activity Assessment/Care Plan dated 01/28/14, showed the patient had generalized weakness and functional decline. The patient enjoyed watching television (TV), movies, reading, word searches and cross words. (Staff failed to document any specific TV programs or movies.)

10. Record review of the patient's Daily Activity Note documentation showed two entries dated 01/24/14 where the staff had visited with patient and on 01/28/14 showed the patient was offered a magazine. Documentation also showed that the 27th was "Magazine Monday" The patient was not offered any other type of reading material. (Staff failed to document any specific, relevant activities provided for Patient #7).

11. Record review of Patient #8's H & P dated 01/23/14, showed the patient was admitted to the Swing Bed program on 01/20/43 for rehabilitation post abdominal aortic aneurysm (an artery which enlarges).

12. Observation and concurrent interview on 01/28/14 at 10:50 AM, showed Patient #8 did not respond when asked about interests in activities.

13. Record review of Patient #8's Activity Assessment dated 01/21/14, showed the patient was alert and oriented. The patient enjoyed watching television (TV) and movies. (Staff failed to document any specific TV programs or movies.)

14. Record review of the Daily Activity Notes documentation showed entries dated 01/22/14, 01/23/14 and 01/24/14. The documentation on 01/22/14 showed the patient was visiting with family. The documentation on 01/23/14 showed the patient requested a magazine to read and the documentation showed the patient was offered socialization. The documentation on 01/24/14 showed the patient was sleeping and family asked that she be allowed to sleep. (Staff failed to document any specific, relevant activities provided for Patient #8).

15. During an interview on 01/28/14 at 11:00 AM, Staff T, Registered Nurse (RN) stated the nursing staff did not necessarily know when activities would be offered unless told by the activities person.

16. During an interview on 01/28/14 at 1:00 PM, Staff DD, Activities Director, (AD), stated the following:
- She was contracted staff as the AD for the facility and spent approximately fifteen minutes daily per patient on the Swing Bed unit.
- She stated there was an activity calendar for the Swing Bed patients posted in the Therapy department [she is also contracted Occupational Therapy] but none were put in the patient charts.
- She confirmed that the activities were not individualize to each patient's interest. She confirmed that the activity program needed to be geared to the patient's assessed needs/abilities and to document participation and/or encouragement to attend.

Based on interview, record review and policy review, the facility failed to develop a comprehensive, individualized activity care plan for three (#6, #7, and #8) of three Swing Bed patients (a specific type of reimbursement for patients that need a skilled service, such as therapy, but did not need the level of care in a regular patient bed) reviewed. This failure had the potential to deny all patients admitted to the facility care plan interventions needed to meet their needs. The current Swing Bed census was three and the facility census was 15.

Findings included:

1. Record review of the facility's undated Swing Bed policy titled, "Swing Bed Procedures - Activity Assessment," gave the following direction:
-The care plan will be completed and placed in the Care Plan section of the patient's chart.
-It will address those activities that are appropriate for the patient's ability taking into account their medical condition.
-A weekly update will be documented on the Multidisciplinary Care Plan Review form in the Care Plan section.

2. Record review of Patient #6's History and Physical (H & P) dated 01/23/14, showed the patient was admitted to the Swing Bed program on 01/25/14 with diagnoses of dizziness, weakness and shortness of breath.

3. Record review of Patient #6's Activity Assessment/Care Plan dated 01/27/14, showed the patient was alert and oriented. The patient enjoyed watching television (TV), movies, and word searches. (Staff failed to document any specific TV programs or movies.)

4. Record review of the Comprehensive Care Plan showed no activity care plan.

5. Record review of Patient #7's H & P dated 01/20/134, showed the patient was admitted to the Swing Bed program on 01/24/14 with a diagnosis of Urinary Tract Infection (an infection in the bladder or kidneys), Leukocytosis (an elevated white blood count usually indicating infection in the body and Bronchitis (inflammation of the membranes of the airways).

6. Record review of Patient #7's Activity Assessment/Care Plan dated 01/28/14, showed the patient had generalized weakness and functional decline. The patient enjoyed watching television (TV), movies, reading, word searches and cross words. (Staff failed to document any specific TV programs or movies.)

Record review of The Comprehensive Care Plan showed no activity care plan.

7. Record review of Patient #8's H & P dated 01/23/14, showed the patient was admitted to the Swing Bed program on 01/20/43 for rehabilitation post abdominal aortic aneurysm (an artery which enlarges).

8. Record review of Patient #8's Activity Assessment dated 01/21/14, showed the patient was alert and oriented. The patient enjoyed watching television (TV) and movies. (Staff failed to document any specific TV programs or movies.)

Record review of the Comprehensive Care Plan showed no activities care plan.

9. During an interview on 01/28/14 at 1:00 PM, Staff DD, Activities Director, (AD), stated that there were no activity care plans in the Comprehensive Care Plans for Patients #6, #7 and #8.