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Based on interview and record review the facility failed to have a group of professionals (the Policy and Procedures Committee) develop facility policies and procedures for the department of Quality Assurance. The facility census was 10.
Findings included:
1. Record review of the Policies and Procedures for Quality Assurance showed that they had not been developed by a group of professionals.
2. During an interview on 03/12/14 at 11:45 AM, Staff S, Director of Quality Assurance, stated that policies for Quality Assurance had not been developed as yet.




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Based on interview, record review and policy review, the facility failed to ensure staff developed and kept current individualized care plans based on the assessed needs of five (#1, #2, #3, #5, #6) of five patient care plans reviewed. These failures had the potential to deny all patients admitted to the facility nursing and medical care needed to meet their individual needs and promote optimal healing. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Nursing Care Plans," dated 02/14 showed the nursing care plan was based on the patient's nursing care needs, was consistent with medical care and developed based on appropriate nursing interventions and patient goals.

2. During an interview on 03/11/14 at 1:20 PM and concurrent review of the care plan for Patient #1, Staff E, Registered Nurse (RN), stated that Patient #1 was admitted to the facility for treatment and care related to her lower back and left leg pain. Staff E stated that comfort measures provided to Patient #1 included a continuous heating pad placed on her back, elevation of her left leg, placement of a pain patch, and "keeping her moving". Staff E stated that the care plan did not have planned interventions for any problems identified on the care plans and that the staff "just do what we (they) do" when needed.

3. Record review of Patient #1's care plan showed no care plan for the heating pad, or interventions that included pain medication, elevation of the left leg or frequency of ambulation and/activity.

4. Observation on 03/11/14 at 3:10 PM of the Medical Unit showed Patient #1 resting in bed with a heating pad on her back.

5. During an interview on 3/12/14 at 1:15 PM and concurrent care plan review for Patient #2, Staff F, RN, stated that Patient #2 was diabetic, not able to speak and express her needs, and required the head of the bed to be elevated 90 degrees while she was lying in bed due to risks of aspiration (choking). Staff F stated that the care plan did not include identified problems, patient goals or interventions related to diabetes, her inability to communicate verbally, and the risk of aspiration. She stated that if a care plan had not been developed for significant problems, patient care activities had the potential of not being performed or documented.

6. During an interview on 03/12/14 at 3:00 PM, Staff G, Certified Nurse Assistant (CNA), stated that Patient #3 had a heating pad on her bed to relieve back pain.

7. Review of Patient #3's care plan showed no care plan or interventions for the use of a heating pad.

8. During an interview on 03/11/14 at 1:45 PM, Staff F, stated that Patient #5 was alert and oriented, had a medical history significant for colon cancer, had a urinary tract infection (an infection in any part of the urinary system - kidneys, ureters, bladder, urethra) when he was admitted (now resolved) and was on sliding scale insulin dose injections two times daily.

9. Review of Patient #5's care plan showed an active problem for confusion and urinary tract infection. The care plans showed no interventions listed on any care plan for any problems identified.

10. During an interview on 03/11/14 at 1:40 PM, Staff H, RN, stated that Patient #6 was admitted to the facility for dehydration (a lack of water in the body), a urinary tract infection and distended abdomen. Staff H stated that Patient #6 received multiple medications and nursing interventions to produce a bowel movement and remove stool.

11. Review of Patient #6's care plan showed no care plan or planned interventions for abdominal distention or removal of stool.

12. During an interview on 03/12/14 at 9:00 AM, Staff B, Chief Nurse Officer (CNO), stated that staff developed a patient problem list only and the problem lists did not include individualized planned interventions based on the assessed needs of the individual patients. She stated that since the facility's last survey and plan of correction, they have focused on developing and monitoring problem lists only.


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Based on interviews the facility failed to provide a quality of care review of 10 percent (representative sample) of active and discharged medical records as part of the annual Periodic Evaluation and Quality Assurance
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. The facility census was 10.

Findings included:

1. During an interview on 03/11/14 at 2:00 PM, Staff C, Director of Case Management, stated that an annual quality of care review had not been completed.

2. During an interview on 03/12/14 at 2:00 PM, Staff S, Director of Quality Assurance, stated that 10 percent (representative sample) of active and discharged medical records had not been reviewed as a part of the annual evaluation.




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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. This failure had the potential to adversely affect the appropriate care of all patients in the facility. The facility census was 10.

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. During an interview on 03/11/14 at 2:00 PM, Staff S, Director of Quality Assurance, stated that the medical charts had been sent two weeks previously to another network facility for evaluation of treatment by facility physicians but had been returned without being evaluated due to the illness of the evaluator.







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