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Based on medical record review, staff interview, and review of policies and procedures, the facility failed to obtain and/or implement advance directives for 3 of 20 sample patients (#2, #4, #9) with those directives in place. The findings were:

1. Medical record review showed patient #2 was admitted to swing bed status on 11/8/11 and unexpectedly passed away on 11/9/11. Review of the physician's 11/9/11 discharge summary showed the patient was improving and, on the morning of 11/9/11, the patient "began to eat [breakfast] at about 8:10 a.m...was found dead at 8:25 a.m." According to the "Advanced Directives, Living Will and/or Healthcare POA Status" form included in the medical record, the patient had a durable power of attorney (DPOA) that did not go into effect until the patient's supervising physician determined the patient lacked the capacity to make health decisions. At that time the patient's agent was authorized to make decisions according to the patient's "Durable Power Of Attorney for Health Care and Health Care Directive" and "in accordance with my other wishes to the extent known to my agent." In addition, the DPOA authorized any of the health care providers to "disclose and release my complete health records...to my agent."
Review of the admission orders showed the physician wrote "DNR" (do not resuscitate) when the patient was admitted to swing bed status from acute care. However, there was no evidence this was the patient's wish; nor was there evidence the physician discussed the matter with the patient's power of attorney (POA). Furthermore, there was no evidence the POA had been notified by the supervising physician that the patient lacked the mental capacity to make health care decisions. On 11/15/11 at 2 PM the CNO confirmed the DNR order and lack of documentation that the POA had been notified. The CNO stated the patient was not DNR while in acute care. During an interview on 11/16/11 at 11:52 AM, the physician who wrote the DNR order stated "...someone..." on staff told her the patient was DNR in the past so she wrote the order based on that comment.
According to the facility's policy and procedure entitled "Advance Directives", last revised 8/19/08, the attending physician "will incorporate the provisions of the advance directive into the patient medical treatment plan."

2. According to Policy #AC184, "Advance Directives", the employee processing the admission will ask the patient for a copy of the advance directive, which will become a permanent part of the patient's medical record. The policy also stated the attending physician will incorporate the provisions of the advance directive into the patient's medical treatment plan.
Review of the 11/2/11 facility form entitled "Advanced Directives, Living Will and/or Healthcare POA Status" for patient #4 revealed staff indicated the patient had previously established his/her advance directive wishes. Interview with the DON on 11/14/11 at 3:15 PM revealed staff failed to obtain a copy of the advance directives for this patient. She further stated as soon as staff were aware of the existing advanced directive, they should have done the necessary follow up to obtain a copy and placed it in the patient's medical record. Review of the medical record for the patient showed that as of 11/17/11, a copy of his/her advance directives had not be placed in the medical record. Further review showed the provisions of the patient's advanced directives had not been incorporated into his/her medical treatment plan in accordance with the facility's policy.

3. Review of the facility's "Advanced Directives, Living Will and/or Healthcare POA Status" showed a copy of the directive for patient #9 had been placed in the active medical record. However, detailed review of the acute care record showed it was lacking. On 11/15/11 at 2 PM the CNO confirmed the directive was not in the record. She stated staff probably moved the directive to the swing bed record instead of copying it and leaving the original on the acute care record as was correct.

Based on review of personnel files and staff interview, the facility failed to ensure current licensure by the State of Wyoming for prescribing controlled substances for 1 of 5 physicians (physician #1). The findings were:

Review of personnel records on 11/16/11 at 2:48 PM revealed the Wyoming Controlled Substance Registration for physician #1 had expired on 6/30/11. Interview with the CNO on 11/17/11 at 8:48 AM revealed she spoke with the physician who confirmed the license had expired; therefore, the physician was not currently licensed to prescribe controlled substances in the State of Wyoming.

Based on staff interview and review of policies and procedures, staff credentialing files, and the "Medical Staff Bylaws and Rules & Regulations," the facility failed to have a credentialing services agreement with a qualified entity for credentialing for 5 of 5 physicians (#1, #2, #3, #4, #5) and 2 of 2 (#6, #7) physician extenders whose files were reviewed. The findings were:

Review of the policies and procedures for the facility's initial and reappraisal credentialing processes and credentialing files for physicians #1 through #5 and physician extenders #6 and #7 revealed the credentialing processes that resulted in approval for these professionals did not include the services of another qualified entity as required.
Interview with the clinic manager on 11/15/11 at 11:55 AM revealed she was responsible for ensuring staff credentialing, privileging, and licenses were current. She stated she had only had this duty since October 2011 and was unaware the credentialing process required review and approval by both the medical board and governing body. Review of the "Medical Staff Bylaws and Rules & Regulations" confirmed there was no agreement or involvement with another qualified entity.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure all medications were appropriately secured in 1 of 1 emergency departments. The findings were:

Observation of the emergency department on 11/14/11 at 3:12 PM revealed medications were stored in unsecured locations as follows:
a. Eleven 10 ml syringes containing normal saline (NS) were located in the intravenous tray sitting on a counter;
b. Ten 10 ml syringes containing NS were in an open drawer;
c. Three thoracentesis kits containing Lidocaine were stocked on an open shelf;
d. A bottle of Tetracaine was in the open tote container used to hold equipment for eye injuries.
During the observation, RN #10 acknowledged that all the medications should have been secured as staff were not in the emergency department at all times. According to the facility's policy and procedure, "Drug Storage," revised 6/1/08, "Non schedule drugs will be stored inside locked cabinets that are designated as drug storage only...Non scheduled drugs which are stocked in the ER will be stored in a locked cabinet..."

Based on observation and staff interview, the facility failed to provide a clean and safe environment in 1 of 1 laundry rooms and in 1 of 1 patient bathing rooms. The findings were:

Observation on 11/15/11 at 1:48 PM revealed the following concerns:
a. The small area (approximately 3 feet by 3 feet) behind the clothes dryer in the laundry room was accessed by the main corridor door to allow servicing of the dryer. However, the area was littered with an inch build-up of lint. An operational 220 volt electrical outlet located on the wall serviced the dryer.
b. The wall in the patients' bathing room shower area had two "L" shaped metal brackets that jutted 3 inchs out into the room. They were attached to the wall approximately 5 feet off the floor directly over a patient shower bench and presented a safety hazard to patients.
c. Interview with the facility operations manager at the time of the observations confirmed the above findings.

Based on review of minutes from meetings of the governing body, staff interview, and review of the "Medical Staff Bylaws and Rules & Regulations," the governing body failed to ensure health care services were provided in a safe, effective manner (C241 and C270). In addition, the governing body failed to ensure policies and procedures for health care services and quality assurance indicators were implemented, reviewed, evaluated, or revised (C271, C276, C277, C280, C281, C293, C297, C298, and C397). The cumulative effects of these failures resulted in the determination that the condition of participation related to organizational structure was not met.

Based on review of minutes from meetings of the governing body, staff interview, and review of the medical staff bylaws, the governing body failed to ensure the medical staff was accountable for the quality of care provided to patients. In addition, the governing body failed to ensure health care services were provided in a safe, effective manner. Finally, the governing body failed to ensure development of an effective, facility wide QAPI program and ensure policies and procedures for health care services were implemented, reviewed, evaluated, and revised as necessary. The findings were:

Review of the July, August, September, and October 2011 minutes from meetings of the Board of Governors showed no indication the board members were aware of any of the concerns identified during the recertification and complaint survey conducted from 11/14/11 through 11/17/11. The review showed no evidence the medical staff kept the board apprised of physician concerns or peer review activities, (C257, C270) According to the "Medical Staff Bylaws and Rules & Regulations", it was "the responsibility of the medical staff and the Board of Directors of the hospital to safeguard the interests of the public..." Additionally, the purpose of the organized medical staff was to "provide a means whereby issues concerning the medical staff and the hospital...may be discussed by the medical staff with the governing body and chief executive officer." In addition there was no evidence the board was aware of the care issues identified at C295 and C297.
Further review of the minutes showed the Board reviewed quality assurance indicators, but there was no follow-up with the departments. Refer to C331, C332, C333, C334, C336, C337, C338, C340, C341, and C342 for evidence related to quality assurance concerns. Finally, review of the policies and procedures revealed many had not been approved by the Board since 2008 (C271). Interview with the former chief financial officer, who attended every meeting, on 11/17/11 at 10:55 AM confirmed the board members did not discuss care issues.

Based on staff interview; review of peer review activities, minutes of medical staff meetings, and policies and procedures; and interview with the medical director, the facility failed to ensure physicians conducted adequate peer review activities and provided direction and supervision for hospital staff. The findings were:

Refer to C257 for details regarding this failure.

Based on staff interview; review of peer review activities, minutes of medical staff meetings, and policies and procedures; and interview with the medical director, the facility failed to ensure the medical staff conducted adequate peer review activities and provided direction and supervision of hospital staff. The findings were:

Review of minutes from medical staff meetings since November 2010 revealed six inpatient charts were sent out for peer review. Three patient charts were sent out in December 2010 and three in April 2011. A "Hospital Peer Review" form was filled out by the consultant physician after each record was reviewed. Each form had multiple comments, recommendations and suggestions. Further review of minutes from the general medical staff meetings failed to show if any of these comments, recommendations or suggestions were discussed or acted upon. In addition, meeting minutes also revealed executive (closed) sessions were held only in January, August and September 2011.
Review of facility policy HIM-021 "Peer Review" revised 7/31/08 revealed "peer review is to assist in assuring quality of care of our patients and efficiency of services rendered." The policy goes on to state that review of patient records "will be done on a regular monthly basis" by physicians in [network CAH].
On 11/16/11 at 9:50 AM interview with HIM clerk #1 and the CNO revealed specific criteria for selecting medical records for peer review was lacking. The clerk stated they just picked records of patients who had a "...difficult stay..." She did not keep a list of which records were selected. She further stated the records were sent to another facility for review, returned, and then the recommendations were sent to the medical staff for review. Finally, although hospital policies required peer review to be performed monthly, the clerk stated that, until the CEO recently requested two records be reviewed, a peer review had not been performed since April 2011. During the interview, both the clerk and the CNO stated, "The system is broken."
On 11/16/11 during an interview at 3:30 PM, the medical director stated she asked for a review of one of the records requested by the CEO. She acknowledged the reason for her request was a concern related to an ordered amount of an administered medication versus the amount the ordering physician dictated in his note. However, follow-up with the ordering physician was lacking.




20082

Based on observation, medical record review, staff interview, review of facility policies and procedures, and review of the QAPI program, the hospital failed to provide appropriate health care services for acute and swing bed patients (C271, C276, C277, C278, C280, C281, C293, C295, C297, and C298). In addition, the failure of the facility to ensure staff verified medication orders and administered medications appropriately (C297) resulted in a determination of immediate jeopardy on 11/16/11 at 2:27 PM. The hospital's action plan included immediate education of all professional staff currently working or scheduled to work during the next four shifts (two days) to include:
a. All orders to be transcribed with verification by two nurses; both to initial the MARs;
b. Each patient's MAR to be started with the same date and all recopied MARs to flow forward for the next seven days;
c. Questionable orders to be verified with the physician before being carried out. If the nurse is still uncomfortable giving the medication, s/he is to notify the CNO or nursing supervisor, notify the provider s/he cannot or does not wish to give the medication, and ask the provider if s/he would like to give it.
d. Completion of a medication error report if any error is made or discovered.
The action plan was accepted on 11/17/11 at 2:10 PM, and immediate jeopardy was abated at that time.

Based on medical record review, review of policies and procedures, and staff interview, the facility failed to ensure staff furnished care for 11 of 22 sample patients (#2, #4 #9, #10, #12, #13, #14, #15, #18, #19, #22) in accordance with the facility's written policies. The findings were:

Medical record reviews, staff interview, and review of policies and procedures revealed staff failed to adhere to facility policies and procedures while providing care for patients #2, #4, #9, #10, #12, #13, #14, #15, #18, #19, and #22. For details, refer to C151, C224, C276, C277, C280, C281, C295, C297, and C298.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure medications were administered as ordered, the physician was notified and subsequently verified or changed questionable orders, or that errors were reported appropriately. These failures affected 8 of 22 sample patients (#2, #4, #9, #10, #12, #14, #15, #18). In addition, the facility failed to ensure medications were properly secured in the emergency department and that expired medications were not available for patient use. The findings were:

1. Refer to C297 for evidence the facility failed to ensure medications were administered as ordered and that questionable orders were verified or changed.

2. Refer to C277 for details related to failure to report medication errors.

3. Refer to C224 for information related to failure to comply with the policy and procedure for medication storage in the emergency department.

4. According to the facility's policy and procedure "Labeling and management of outdated drugs" last revised 6/1/08, "All expired drugs will be removed from the shelf..." Failure to adhere to this policy and procedure was identified as follows:
a. Observation on 11/15/11 at 7:50 AM with RN#10 revealed the following expired medications were available for use:
1. An unopened vial of Procrit Epoetin Alfa, forty thousand units, was in the medication room labeled "expired September 2011."
2. An opened and partially consumed container of liquid labeled "10% cocaine/ sodium chloride mixed on 11/10/10" was in the medication cart. Interview with the RN at that time revealed staff did not know whether or not the mixture was "good."
b. Observation on 11/15/11 at 2:05 PM with LPN#1 revealed the following expired medications were available for use in the pharmacy medication storage room:
1. Twenty-five vials of 10% calcium gluconate, one hundred mg, labeled "expired October 2011."
2. Seventeen 5 mg prednisone pills labeled "expired September 2011."
At that time the LPN stated the outdated medications should have been removed from the storage shelves, and she had no explanation for why it had not been done.
















27095

Based on medical record review, staff interview, review of policies and procedures, and review of incident reports, the facility failed to ensure medication errors were identified and reported for 7 of 22 sample patients (#2, #4, #9, #12, #14, #15, #18). The findings were:

According to the facility's policy and procedure, "Medication Errors," last revised 9/9/08, the definition of an error included "Omission of medication." Further review of this policy and procedure showed staff were to report any errors immediately to the physician and to the CNO and pharmacy manager within 24 hours. In addition, staff were to document the error in the patient's medical record and complete an incident report. Failure to follow this policy and procedure was identified as follows:
a. Refer to C297 for detailed evidence related to medication errors for patients #2, #4, #9, #12, #14, #15, #18.
b. Review of the incident reports with the CNO on 11/17/11 at 9:25 AM showed only two medication errors had been reported for acute care since 1/1/11. The CNO confirmed that the medication errors identified by the survey team had not been identified by the previous CNO although medication errors was one of the QAPI indicators being tracked for nursing services.

Based on staff interview, and review of medical records, laboratory reports, hospital policies, and infection surveillance activities, the facility failed to maintain accurate and complete surveillance records for 2 of 5 sample patients (#13, #19) specifically reviewed for infection control concerns. The findings were:

Medical records for 5 patients identified with infections or antibiotic therapy were reviewed on 11/15/11 and 11/16/11. Laboratory reports and infection control logsheets were similarly reviewed to determine the accuracy and continuity of infection surveillance activities. The concomitant review of clinical and infection information revealed the following deficiencies:
a. Progress notes, physician orders, and laboratory reports in patient #13's medical record showed s/he received 5 antimicrobials (ciprofloxacin, Zosyn, vancomycin, Flagyl, Rocephin) in a 10 day period, January 5-14, 2011. Of these 5 antimicrobials, 3 were administered less than 48 hours before being discontinued; the discontinuance was attributed to antibiotic resistance in an Escherichia (E.) coli isolated from the patient's urine.
Review of the patient's laboratory results dated 1/8/11 showed a urine culture positive for a multi-drug resistant E. coli. The culture isolate demonstrated resistance to flouroquinolone, aminoglycosides, and selected penicillin and cephalosporin antibiotics.
Infection surveillance reports were reviewed on 11/16/11 at 3:40 PM with the infection control nurse. The January 2011 surveillance record reported that patient #13 received a single antibiotic, ciprofloxacin, and did not have any positive culture results. The infection control nurse stated in interview on 11/16/11 at 3:55 PM she received reports from the nursing staff and, in this case, the information was incomplete. The infection control nurse acknowledged the surveillance data for patient #13 was not an accurate and complete record of the patient's antibiotic therapy and culture results.
b. A physician's progress entry dated 1/24/11 for patient #19 noted the patient had "...MRSA [methicillin-resistant Staphylococcus aureus] positive Staph pneumonia..." Review of laboratory results and infection surveillance records for January 2011 failed to uncover any evidence to show the patient was culture positive for MRSA. A previous progress note, dated 1/16/11 and entered by a different physician, stated the patient was being treated prophylactic to cover the potential for resistant Staph infection. The 11/16/11 physician entry further stated there was no need to perform cultures.
The infection control nurse stated in interview on 11/16/11 at 4:40 PM she was not aware discrepant reports existed in the patient's record. She further stated she did not routinely review physician progress notes as part of the infection surveillance program; she expected this information to be reviewed by the nursing staff and reported to her as necessary. She acknowledged that in the case of patient #19 there was no report of a MRSA infection.

Crook County Medical Services District policy IC 005, Infection Control Program, revised and accepted 10/13/10, required staff to identify and monitor infections and antibiotic treatment among patients. Interview with the CNO on 11/16/11 at 5:15 PM revealed her expectation that nursing staff review provider notes and seek clarification from providers when questions or discrepancies exist.

Based on staff interview and review of policies and procedures, the facility failed to ensure health care policies were reviewed annually. The findings were:

On 11/17/11 at 8:15 AM the CNO stated that the health care policies had not been reviewed annually. Review of the policies confirmed some had not been reviewed in several years. Some examples are as follows:
a. Policy #PH0001 Hospital Pharmacy Services; revised 6/1/08
b. Policy #PH0002 Drug Storage; revised 6/1/08
c. Policy #AC198 Charting; revised 6/18/08
d. Policy #AC 184 Advance Directives; revised 8/19/08
e. Policy #AC219 Incident Reports; revised 8/25/08
f. Policy #AC161 Medication Errors; revised 9/9/08

Based on staff interview and review of the organizational structure and policies and procedures, the facility failed to develop and implement all the required elements for outpatient services. The findings were:

Review of the facility's organizational structure and policies and procedures revealed the lack of a single individual who directed the outpatient services, written policies and procedures defining the scope of rehabilitation services as approved by the medical staff, and required written qualifications and competences for rehabilitative staff as defined by the medical staff. Interview with the CNO on 11/15/11 at 3:45 PM revealed each department provided outpatient services, but no one individual was designated as responsible for outpatient services. Evidence of defined written policies and procedures, and evidence of written qualifications and competencies were requested by the surveyor, but not provided.

Based on staff interview and review of the QAPI program, the CEO failed to ensure that all contracted services provided data that enabled the hospital to comply with the condition of participation for periodic evaluation and quality assurance review. The findings were:

During an interview on 11/15/11 at 10 AM, the chairman of the quality assurance (QA) committee stated that the contracted services of occupation and physical therapies were not included in the QAPI program. In addition, on 11/15/11 at 10:35 AM the laboratory manager reported the contracted reference laboratory did not provide QA data for monitoring. At 2:15 PM on the same date, the radiology manager stated that the service contracted to over-read 100 percent of the radiology films did not provide QA data. Review of data collected for the QAPI program verified the statements.

Based on medical record review and interviews with visitors and staff, the facility failed to provide nursing services that met the needs of 4 of 22 sample patients (#4, #10, #18, #22) reviewed. The findings were:

1. Review of the medical record for patient #18 revealed the patient was admitted to the hospital on 7/27/11 from long term care; the admitting diagnoses included dementia and severe agitation. Interview with the social services director on 11/16/11 at 6:10 PM revealed the patient's extreme, agitated behavior started a few days prior to 7/27/11 after daily doses of Seroquel were added to his/her medication regime. Review of the nursing admission assessment showed the patient was confused and disoriented, required assistance with activities of daily living, did not have pressure ulcers, had a shuffling gait, and had no problems with urination. Review of the physician admission orders showed the following medications were ordered daily: Zyprexa 5 mg, Plavix 75 mg, Isosorbide mononitrate, Bystolic 5 mg, Seroquel XL 50 mg, Zoloft 50 mg and intravenous or intramuscular injections of Haldol 10 mg with Benadryl 25 mg every six hours as needed.
Review of the medication administration record showed the following medications were ordered and administered: On 7/27/11 Haldol and Benadryl prior to the 8 PM transfer to the hospital and again at 10:50 PM. On 7/28/11 Haldol and Benadryl at 1:45 AM and 9 PM. On 7/29/11 Haldol and Benadryl at 4:40 AM, 12:30 PM and 1 PM. On 7/29/11 Haldol and Benadryl at 8 PM. On 7/30/11 Haldol and Benadryl at 2 AM, 10:15 AM, and 6 PM. On 7/31/11 Haldol and Benadryl 8 AM. On 8/1/11 Haldol and Benadryl at 8 and 2 PM. On 8/2/11 Haldol and Benadryl at 8 AM and 2:20 PM. On 8/3/11 Haldol at 6 AM and 12 PM. On 8/5/11 Haldol 5 mg at 4 AM. On 8/6/11 Haldol 5 mg at 3:12 PM and 8:15 PM. On 8/7, 8/8, and 8/9/11 the patient received Haldol 5 mg at least once each day. According to the 7/27/11 to 8/9/31 nurses' notes and medication administration records, the Haldol injections were administered intravenously until 8/1/11 when the route of administration was changed to intramuscular.
Further review of the nurses' notes showed a urinary catheter was inserted on 7/30/11 at 10:20 AM due to urinary retention, and the patient developed a stage II pressure sore on the coccyx on 8/6/11. Review of the 8/5/11 nursing summary showed the patient's condition had declined and s/he required total care for all activities of daily living except feeding and that required assistance. Review of the 8/7/11 nurse's notes showed the patient continued to have periods of agitation, ambulated with "much difficulty", and later fell out of bed. The following concerns were identified regarding the care the patient received:
a. Interview with the patient's friend on 11/15/11 at 1:30 PM revealed his/her concern regarding the patient's progressive decline that increased at each visit. S/he stated s/he was concerned about the medications the patient received. The visitor also stated s/he had taken her concerns to the administrator, but no changes were made.
b. Review of the plan of care showed no interventions for monitoring psychotropic drug use, decline in activities of daily living, nutritional and hydration needs, urinary catheter care, and preventive skin care.
c. Review of the medical record and interview with the CNO on 11/17/11 at 1:45 PM, revealed no evidence of monitoring for the effects of psychotropic medication use and adverse effects (anticholinergic) of frequent benadryl use. The CNO further stated this monitoring should have been done.
d. Review of the medical record and interview with RN #6 on 11/16/11 at 5:35 PM revealed the necessary ongoing skin assessments, care and monitoring to prevent the development of the pressure sores were not implemented because as the patient got weaker and weaker, s/he was resistant to care and did not want to leave the recliner.
e. According to the medical record, a nutritional evaluation was completed by the dietary manager on 8/5/11, but an additional assessment of nutritional needs by a registered dietitian was not done. Review of the food consumption records showed sometimes the patient only ate a few bites; however, the records were incomplete and documentation for each meal was lacking.
f. Review of the manufacturer's packaged insert information for Haldol showed the following information was included in the warning: "Haldol injection is not approved for intravenous administration. If Haldol injection is administered intravenously, electrocardiogram monitor..." for changes in heart pattern and arrhthymias. Review of the medical record and interviews with RN #6 on 11/16/11 at 11:20 AM and with the CNO on 11/17/11 at 1:45 PM revealed staff failed to do this monitoring.
g. Interview with social worker and discharge planner on 11/16/11 at 6:10 PM revealed the patient was discharged from the hospital on 8/9/11 and returned to the long term care unit where s/he began to physically and mentally improve after the Haldol injections were discontinued.

2. According to the history and physical dated 10/22/11, patient #10 was admitted for chest pain resulting from a fall that morning. Review of the 10/22/11 fall risk assessment showed the patient was at high risk for additional falls. Review of nursing documentation timed at 4 AM on 10/28/11 showed the patient was found face down on the floor with his/her legs entangled in the reliner. The notes documented that the patient was "carefully untangled from around foot of recliner, et [and] rolled to back. 2-man assist into bed...cont [continues] to be lethargic et unable to answer questions. Arouses to verbal stimuli briefly et [and] returns to sleep...mumbles that [s/he] fell, but no other words spoken...4 cm bruised, swollen bump noted to [left] forehead...abrasion above left eye. 0.5 cm laceration below [left] eye..." The following deficient practice was identified:
a. There was no evidence the patient was assessed and the extent of his/her injuries determined prior to being moved.
b. Despite the evidence of head injuries, neurological checks were not completed appropriately. They were obtained at 4 and 6 AM but "sleeping" was written in at 5 AM even though, according to the nursing notes at 5 AM, the patient was "Heard calling out et [and] moaning...appears more alert..." and was given a narcotic for complaints of chest pain. Review of the facility's policies and procedures entitled "Neurological Vital Signs" and "Altered Level of Consciousness Protocol" revealed neither addressed the frequency for performing neurological checks. On 11/16/11 at 6:10 PM the CNO confirmed the neurological checks should have been completed at 5 AM.
c. There was no documentation that the physician was immediately notified of the acute care patient's fall and subsequent injuries; therefore, no orders for treatment were obtained

3. According to the medical record, patient #22 was admitted to swing bed status on 10/21/11 for rehabilitation after surgical repair of a fractured hip. Review of the "Admission Nursing Assessment & History" revealed it was incomplete. The immunization status was blank, the skin assessment failed to describe the patient's incision, abrasions to the right hand and forearm were listed but not indicated on the physical outline, and the pain assessment was inaccurate as the patient's highest pain level of 6/10 (0 to 10 scale with 10 the worst pain) in the last 24 hours was neither continuous nor breakthrough pain, nor was it described as both. The nursing assessment completed on the afternoon or evening (PM was circled) of 10/21/11 documented that the patient's entire left heel was discolored and "purplish", but the skin was intact. The following concerns were noted:
a. Even though the patient's discolored left heel was documented on 10/21/11, there was no evidence treatment was initiated until 10/27/11, and on 10/28/11 the physical therapist recommended "Skin-Prep" applied to both heels twice daily. Review of the physician's progress note dated 10/31/11 showed "...will treat it like a pressure sore." No other orders were given.
b. Review of the MARs showed nursing applied "Skin-Prep" to both heels three times per day as a "nursing order" from 10/27/11 through 11/9/11.
c. Review of the "Pain Monitoring Flow Sheet" showed the patient was not always assessed before or after pain medication was administered. Although the patient was medicated from 10/22/11, monitoring was not initiated until 10/23/11 and was then performed only one of the three times the patient received a narcotic. Evidence of pain monitoring was lacking from 12:15 PM on 10/23/11 to 10/27/11 at 8:15 AM. During that time period, the patient was medicated ten times. Monitoring from 10/27 through the patient's discharge on 11/9/11 remained sporadic and did not coincide with all the times the patient was medicated. Furthermore, on 11/8/11 the patient's pain was documented as 4/10; the patient was medicated, but the untimed reassessment showed it was ineffective. However, no other treatment for pain relief was initiated.
d. During an interview on 11/16/11 at 5:10 PM, the social worker stated she had been informed by a family member that the patient had been in the facility for a week, but his/her dressing had not been changed. Detailed review of the nursing documentation provided no evidence the dressing on the patient's incision was removed and the incision assessed until 10/28/11.

4. Review of the medical record for patient #4 showed the 11/7/11 physician's orders included checking the patient's blood pressure four times daily and administering the following blood pressure medications; hydrochlorothiazide 25 mg daily, Norvasc 10 mg daily, and Coreg twice a day. On 11/9/11 the physician increased the dose of Coreg to 25 mg twice a day and ordered the pulse to be checked with the blood pressure four times a day. On 11/11 /11 an additional blood pressure medication, lisinopril 10 mg daily, was added to the patient's medication regime. On 11/12/11 the lisinopril was increased to 20 mg daily; then on 11/13/11 it was increased to 30 mg daily. However, a review of the vital signs documented in the medical record showed the patient's blood pressure and pulse were checked only one to three times a day on 11/8, 11/9, 11/11, 11/12, 11/13 and 11/14/11. Interview with RN #10 on 11/15/11 at 8:55 AM revealed staff failed to obtain the vital signs four times a day because this physician's order was not consistent with the usual routine for the unit which was to check the vital signs weekly.

5. On 11/16/11 at 3:00 PM the CNO stated staff were to perform a complete assessment on every acute care patient every shift (twice daily) and as needed. A complete assessment of every swing bed patient was to be conducted weekly and as needed. Care plans for both acute and swing bed patients were to be updated with every assessment.

Based on medical record review, staff interview, review of policies and procedures, and review of the QAPI program, the hospital failed to
ensure staff administered medications appropriately for 7 of 22 sample patients (#2, #4, #9, #12, #14, #15, #18). In addition, staff failed to verify questionable medication orders prior to administration for patient #10. The effect of these failures resulted in an immediate jeopardy situation due to the increased risk to patient health and safety. The findings were:

1. Review of the medical record showed patient #9 was admitted to acute care on 11/2/11. According to the admission orders, staff were to administer Clindamycin (antibiotic) 900 mg IV every 8 hours (three times a day), Ancef (antibiotic) 1.5 grams IV every 8 hours, and Valium (antianxiety) 5 mg IV or orally every 6 hours (four times a day), routinely. The physician also ordered wound care, a Nicotine patch 21 mEq daily, and D5 1/2 NS (5% Dextrose and 1/2 strength normal saline) with 20 mEq of potassium IV at 120 ml per hour (8.3 hours infusion time). The orders were written at 4:53 PM on 11/2/11. At 11 PM that night, the physician changed the order for the IV fluids to 1/2 NS with 20 mEq of potassium to run at 120 ml per hour. However, he ordered this to start after the D5 1/2 NS was completed. The physician ordered Megace 20 ml daily on 11/3/11 at 12:04 PM. On 11/5/11 at 2:33 PM the physician ordered Valium to be decreased to 2.5 mg twice daily for 2 days and then discontinued. On 11/6/11 the physician ordered D5 1/2 NS with 4 grams of Magnesium IV at 90 ml per hour with telemetry in place during the infusion. Review of the November 2011 MARs identified the following deficient practices:
a. There was no evidence the patient received Clindamycin and Ancef as ordered. According to the MARs, the patient received two doses of both medications on 11/3 instead of three doses as ordered.
b. Valium was not administered on 11/2/11 and was given twice on 11/3/11 instead of every 6 hours as ordered. In addition, on 11/3/11 initials and times were circled or scratched out at 8 AM and 2 PM so it was not possible to determine if the medication was administered at those times.
c. Documentation indicated the IV of D5 1/2 NS with 20 mEq of potassium was started at 6 PM on 11/2/11. The completion time for an IV to run at 120 ml per hour would have been at 2:20 AM. Instead, the next bag of IV solution was started at 5 AM on 11/3/11, indicating the first bag took eleven hours to complete. Documentation as to why this discrepancy occurred was not present in the record.
d. The Megace ordered daily on 11/3/11 at 12:04 PM was not initiated until 11/4/11. There was no documentation that the physician authorized starting the medication the next day.
e. The 11/5/11 order to decrease Valium to 2.5 mg for 2 days was transcribed onto the MAR to be administered for 3 days. However, there was no evidence staff administered the medication correctly for the 2 days it was given as the 8 AM dose on 11/5/11 was circled as not administered; no explanation for this discrepancy was documented.
f. The Nicotine patch was not initialed as administered on 11/6/11.
g. Detailed review of the MARs and nursing documentation showed no evidence 4 grams of Magnesium in D5 1/2 NS was ever infused as ordered on 11/6/11. Nor was there evidence the order was cancelled.
h. Wound care was implemented with "barrier cream" to the buttocks, but the "barrier cream" was never identified so there was no way to determine if it was appropriate.
On 11/15/11 at 2:00 PM the CNO reviewed the MARs and confirmed these medication errors.

2. Medical record review showed 3 year old patient #14 was admitted on 1/6/11 after being seen in the emergency department. Orders in the emergency department at 8:40 AM on 1/6/11 included an IV of NS with potassium chloride (KCl) 20mEq and 1/2 ampule of bicarbonate per liter to run at 200 ml per hour for 2 hours. The second IV order on 1/6/11 at 3:45 PM was for 1/2 NS with 20 mEq KCl and 1/2 ampule adult bicarbonate per liter to run at 200 ml per hour for 2 hours and then finish the bag at 60 ml per hour. Orders after admission at 6:20 PM on 1/6/11 included Tylenol 15 mg per kilogram every 6 hours, scheduled, and an IV of 1/2 NS with 20 mEq KCL per liter to run at 60 ml per hour. An order dated 1/7/11 at 10:14 AM was for 1000 ml of 1/2 NS with 20 mEq KCL and one ampule adult bicarbonate. The following deficient practices were identified:
a. Even though the first order for IV fluids was written by the physician at 8:40 AM, documentation indicated the bag was hung at 8:00 AM. Although the order did not specify whether adult or infant bicarbonate was to be infused, the nurse documented she added the infant type. There was no verbal order written by the nurse for the medications she administered, and there was no evidence she questioned the physician regarding the type of bicarbonate to be used before adding it.
b. The second IV order written at 3:45 PM specified that adult bicarbonate be infused. However, the nurse documented she noted the order at 1:10 PM, but started the IV at 12:30 PM. Again, there was no evidence a verbal order was obtained prior to 3:45 PM.
c. The second IV at 200 ml per hour for 2 hours should have been completed at 2:30 PM if started at 12:30 PM as documented. However, the IV was not slowed to continue at 60 ml per hour until 3:30 PM.
d. There was no evidence the IV ordered on 1/7/11 was ever infused; no order to cancel it was found.
e. Tylenol was not administered every 6 hours as ordered; the noon and midnight doses were circled as not given. Review of the documentation showed no rationale for not administering the medication.

3. Review of the July 2011 MAR and 7/6/11 nurse's notes for patient #15 showed RN #6 administered Haldol 5 mg intravenously on 7/6/11 at 3 PM. Review of the medial record for this patient showed no physician's order for the administration of the medication. Interview with the DON on 11/16/11 at 11 AM confirmed the lack of a physician's order. Although the medication box was clearly labeled "For intramuscular use only," review of the manufacturer's packaged insert information for Haldol showed the product recommendations included the following warning: "Haldol injection is not approved for intravenous administration. If Haldol injection is administered intravenously, electrocardiogram monitor..." for changes in heart pattern and arrhthymias. Review of the medical record revealed no evidence of monitoring or nursing assessments for changes in heart patterns or arrhthymias. During an interview on 11/16/11 at 11:20 AM, RN #6 confirmed she administered the medication, but she did not remember the circumstances regarding administering the medication without a physician's order. She stated she was not aware of the need for post injection monitoring; therefore, she had not done this after administering the intravenous Haldol.

4. Review of the medical record revealed patient #18 was admitted to swing bed status in the hospital on 7/27/11; the admitting diagnoses included dementia and severe agitation. Review of the physician's admission orders showed medications included intravenous or intramuscular injections of Haldol 10 mg with Benadryl 25 mg every six hours as needed. Review of the MAR showed the patient received IV Haldol eleven times before the route was changed to intramuscular on 8/1/11. Interview with the pharmacy manager on 11/17 /11 at 10:02 AM revealed the only type of Haldol the facility stocked was that with the box labeled for intramuscular use only.

5. Review of the medical record for patient #4 showed his/her diagnosis included diabetes mellitus and the physician ordered daily insulin doses and blood glucose testing four times daily. Further review of this medical record revealed the following documentation:
a. On 11/9/11 the physician ordered three scheduled Humalog insulin injections in addition to the sliding scale insulin doses.
b. On 11/11/11 the three times a day dose of Humalog insulin was increased from two units to three units at mealtimes.
c. On 11/10/11 the blood glucose levels were 144, 228, 149 and 199. On 11/11/11 the blood glucose levels were 141, 167, 162 and 247. On 11/12 to 11/13/11 the blood glucose levels ranged from 142 to 212.
d. Review of the documentation in the MAR showed insulin was administered as ordered every day except 11/11/11. The documentation on the MAR for the 5 PM scheduled insulin on 11/11/11 was circled and left blank. At that time the glucose level was 162. The next time the glucose level was checked, it was 247 (the highest level recorded from 11/10/11 to 11/13/11).
During an interview on 11/16/11 at 11:35 AM, RN #6 stated she provided care for the patient on 11/11/11, but she could not remember whether or not she administered the 5 PM scheduled dose of insulin. She also confirmed the 5 PM dose was circled, and she stated that usually meant she did not administer the medication.

6. According to the medical record, patient #2 was admitted to swing bed status on 11/8/11. Review of the admission orders showed the physician ordered Calcium 600 mg with Vit D to be administered twice daily. Review of the MAR showed the patient received all 8 AM medications on 11/9/11 except Calcium with Vitamin D. Review of the nursing notes showed no documentation as to why the medication was not given.

7. Review of the medical record for patient #12 showed s/he was an inpatient from 8/19 to 8/23/11. Further review showed an 8/20/11 physician's order for coumadin (a blood thinning medication) 3 mg to be administered daily. Review of the nurse's notes and MAR showed no evidence the medication was administered on 8/22/11.

8. Review of the physician's orders dated 10/24/11 at 11:44 showed he ordered Digoxin 0.75 mg orally twice daily for patient #10. According to the facility's reference, "Nursing 2011 Drug Handbook," by Wolters and Kluwer, the maximum initial dose of Digoxin for rapid digitalization is 0.4 to 0.6 mg orally or IV, followed by 0.1 to 0.3 mg every 6 to 8 hours. Although the ordered dose exceeded the maximum recommended amount, review of the MAR showed the medication was given at 8 PM that evening and at 8 AM on 10/25/11. Review of the nursing documentation showed no evidence the physician was questioned about the order. Review of the laboratory results completed on 10/26/11 showed the patient's digoxin level was critically high.

9. Review of the QAPI program with the CNO on 11/16/11 at 10 AM showed medication errors were one of the indicators being monitored. On 11/16/11 at 11:40 AM review with the CNO of the reported medication errors from January 2011 to 11/16/11 showed only two errors were identified and reported during the eleven month period. According to the facility's policy and procedure entitled "Medication Errors," last revised 9/9/08, errors were defined to include omissions; they were to be reported immediately to the physician and to the director of nursing and pharmacy manager within 24 hours, and staff were to complete an incident report.

The failure of the facility to ensure staff verified medication orders and administered medications appropriately resulted in a determination of immediate jeopardy on 11/16/11 at 2:27 PM. The hospital's action plan included immediate education of all professional staff currently working or scheduled to work during the next four shifts (two days) to include:
a. All orders to be transcribed with verification by two nurses; both to initial the MARs;
b. Each patient's MAR to be started with the same date and all recopied MARs to flow forward for the next seven days;
c. Questionable orders to be verified with the physician before being carried out. If the nurse is still uncomfortable giving the medication, s/he is to notify the CNO or nursing supervisor, notify the provider s/he cannot or does not wish to give the medication, and ask the provider if s/he would like to give it.
d. Completion of a medication error report if any error is made or discovered.
The action plan was accepted on 11/17/11 at 2:10 PM, and immediate jeopardy was abated at that time.




27095

Based on medical review, staff interview, and review of policies and procedures, the facility failed to develop, implement, and/or revise care plans for 3 of 22 sample acute care patients (#9, #10, #14). The findings were:

1. According to the history and physical dated 10/22/11, patient #10 was admitted for chest pain resulting from a fall that morning. Review of the 10/22/11 fall risk assessment showed the patient was at high risk for additional falls. Review of the undated care plan showed "Increased susceptibility to falling that may cause physical harm R/T [related to] history of fall." However, the only interventions the facility instituted were to have a call light in the patient's room, use appropriate (but unidentified) assistive devices, and use a "tab" alarm and bed alarm. The goal was to be free of injury throughout the hospital stay. The following concerns were noted:
a. Specific, individualized, interventions were not developed to address the patient's high risk for falls.
b. The plan was not revised after the patient was started on narcotics for pain control; due to the side effects, narcotics increased the risk of falls.
c. The initial care plan did not address confusion and was not revised when confusion was identified.
d. Safety when sleeping in a reclining chair versus the bed was not addressed.
Review of nursing documentation timed at 4 AM on 10/28/11 showed the patient was "found face down on the floor with his/her legs entangled in the reliner" chair and with bruising and a laceration to the face. There was no evidence the "tab" alarm had been utilized.

2. Review of the medical record showed patient #9 was admitted to acute care on 11/2/11. Review of the admission orders showed the physician ordered wound care but did not specify what was to be done. Review of the care plan showed the patient was at risk for increased damage to his/her skin but the interventions were to "keep area dry..., reposition, apply appropriate cream to area bilat [bilateral] buttocks..." The care plan failed to identify the area to keep dry, specify the frequency of repositioning, or identify the cream to be used.

3. Review of the medical record showed patient #14 was admitted on 1/6/11 for acute gastroenteritis with diarrhea and severe dehydration and discharged on 1/8/11. The three year old patient received IV fluids and was medicated for fever. Review of the entire medical record showed no evidence a care plan was ever developed.

4. After searching the policy and procedure manual on 11/17/11, at 1:40 PM that day RN #6 stated the facility had no policy and procedure for care plans; this was confirmed by the CNO at 1:41 PM. However, during a previous interview on 11/16/11 at 3:00 PM, the CNO stated care plans for both acute and swing bed patients were to be developed and updated with every assessment.

Based on staff interview and review of medical records, laboratory reports, and clinical documentation, the hospital failed to ensure medical records were maintained in a complete, accurate, and timely manner (C302, C304, and C307). Further, the facility lacked a process for identifying errors in medical records and implementing corrective actions (C297, C302, C333, C336, and C338). The cumulative impact of these systemic deficiencies was a determination that the hospital failed to meet the requirements of the condition for participation for medical records.

Based on staff interview and review of medical records and archived laboratory reports, the hospital failed to ensure 12 of 22 sample medical records (for patients #2, #4, #8, #9, #11 #12, #13, #14, #15, #18, #19, #20) were complete and accurate. Further, the hospital failed to implement a system to reliably detect medical record errors and initiate timely corrective actions. The findings were:

1. Medical record review revealed the following discrepancies:
a. Two closed records (patients #11 and #13) failed to contain accurate discharge summaries. The record for patient #11 included a transcribed summary identifying the patient by name, demographic data, and hospital record number. However, the dictated summary was not consistent with the patient's clinical course or admission timeline. Detailed review of the laboratory results cited in the discharge summary did closely match the clinical course of another individual, patient #13, admitted two weeks prior to patient #11. Review of patient #13's record failed to uncover a discharge summary for an inpatient stay lasting January 5-14, 2011.
b. A discrepancy was noted in the medical record for patient #19. A physician progress entry dated 1/17/11 noted the patient was placed on antibiotic therapy as a safeguard against possible Staphylococcus infection. The note further stated no cultures were necessary given the patient's condition.
A subsequent progress note, entered by a different provider and dated 1/24/11, summarized the patient's diagnosis as "...MRSA [methicillin-resistant Staphylococcus aureus] positive Staph pneumonia..." Review of the record failed to uncover any evidence the patient was ever cultured or otherwise reported with a MRSA positive infection. Review of microbiology reports on 11/18/11 at 5:20 PM with laboratory technician #1 failed to show evidence patient #19 had a positive culture report in January 2011. The laboratory technician also called the reference laboratory and laboratories at the two closest medical centers to determine if the patient was cultured at any of these facilities prior to his/her admission; there were no records of specimens received from patient #19 at these facilities.
c. The medical record for patient #20 failed to document vital signs during 4 of 4 blood transfusions performed on 10/16/11. Laboratory records showed emergency room staff ordered a total of 4 units of packed red blood cells (pRBC) be crossmatched for the patient. The first 2 units were released from the blood bank at 5:10 AM and 2 additional units were released at 7 AM. The medical record failed to include a record of vital signs for any of the 4 transfusion events.
On 11/19/11 at 2:45 PM the CNO provided a copy of the hospital's policy and procedures for administration of blood products. According to the policy statement, staff are required to monitor and record patient vital signs (blood pressure, heart rate, temperature, patency and appearance of the infusion site) for each transfusion event. Vital signs are to be recorded prior to starting the transfusion, every 15 minutes for a half hour, every 30 minutes for the next hour, and at hourly intervals for the remainder of the transfusion. A final set of vital signs are required one hour after the transfusion is completed. The CNO stated her expectation that all nursing staff comply with the requirements to monitor and record vital signs with every transfusion event.
d. The record for patient #8 contained health insurance and billing information for another patient.
e. Refer to C297 for inaccuracies in medication administration for patients #2, #4, #9, #12, #14, #15, and #18.

2. Health information management clerk #1 stated in interview on 11/19/11 at 2:40 PM that the health information management supervisor retired and the vacancy was unfilled. She further stated the current staff reviewed medical records as their workload permitted, but they were not always able to review records in a timely manner. She acknowledged the errors and inaccuracies cited.

Based on staff interview and review of medical records, the facility failed to ensure 3 of 3 sample patient records (#13, #20, and #21) involving blood transfusions had properly executed consents for transfusion. In addition, acknowledgements of privacy and information regarding emergency services were not timed or dated for sample patient #6. The findings were:

1. Of 3 medical records selected for review of blood transfusion documentation, all 3 (patients #13, #20, and #21) failed to include timed signatures to verify the patient's understanding of the transfusion procedure before it was initiated. These records were reviewed on 11/16/11 at 2:15 PM. Health information clerk #1 acknowledged in interview on 11/16/11 at 3:30 PM that consent forms should be signed and both the date and time annotated in the space provided on the consent form. She further stated it was the facility's policy to date and time signatures in the medical records.

2. Record review further showed that patient #6's signatures on the acknowledgements of privacy and information regarding emergency services were not dated or timed. Patient #6 had multiple visits to the emergency room and an inpatient admission within a 10 day period. It was not clear at what time or during which visit(s) the patient acknowledge the information contained on the privacy and emergency services forms.

Based on medical record review, staff interview and review of QAPI data, the facility failed to ensure dated signatures of various health care professionals for 6 of 22 sample patient records (#2, #9, #10, #14, #16, #22). The findings were:

Review of the following medical records showed signatures of various health care professionals were not dated:
a. The history and physical examination, the discharge summary, and the nursing assessments for patient #2.
b. The history and physical examination for patient #9 was transcribed on 11/4/11 and remained unsigned by 11/17/11. In addition, all the daily nursing assessments and the 1/8/11 discharge summary lacked dated signatures.
c. The 10/25/11 and 10/29/11 radiology interpretations for patient #10 were not signed, and the daily nursing assessments lacked dated signatures.
d. The history and physical examination and discharge summary for patient #14.
d. The discharge summary for patient #16.
e. The history and physical examination for patient #22 was dictated and transcribed on 10/21/11; it remained unsigned on 11/16/11.
The QA process for the HIM department was reviewed with HIM clerk #1 on 11/15/11 at 10 AM. The summarized data showed selected QA indicators, such as timely completion of history and physical examinations and dated/timed physician signatures, were consistently below the quality baseline established by the hospital. During the interview, the records clerk stated the low compliance rate was presented to the physicians at medical staff meetings. However, there was no documentation to show improvement of the quality indicators.

Based on staff interview and review of QAPI information, policies and procedures, medical staff bylaws, rules and regulations, and minutes from meetings of the medical staff and the governing body, the facility failed to conduct an annual evaluation of its total program that met the regulatory requirements (C332, C333, C334). In addition, the facility failed to develop, implement, evaluate, and revise an effective, facility wide QAPI program (C337, C338, C340, C342, C342). The cumulative effect of these failures resulted in the determination that the condition of participation for periodic review and quality assurance was not met.

Based on staff interview and review of QAPI information, policies and procedures, and "Medical Staff Bylaws and Rules & Regulations," the facility failed to conduct a yearly evaluation of their total program that included all required elements. The findings were:

a. Refer to C332 in regards to the facility's failure to perform an annual review of their total program to determine if the utilization of services was appropriate.
b. Refer to C333 in regard to the facility's falure to select a representative sample of open and closed records.
c. Refer to C334 in regard to the facility's failure to ensure all health care policies were reviewed annually.

Based on staff interview and review of QAPI data, the facility failed to conduct a yearly review of their total program to determine if the utilization of services was appropriate. The findings were:

During an interview on 11/15/11 at 10 AM, the CNO and HIM clerk #1 stated there had not been an evaluation of the total health care program during the past year. The clerk reported MR/UR (medical records/utilization review) review was not being routinely conducted as part of QAPI. She stated the determination of appropriateness of services was not always correct as there were times acute care patients should have been changed to swing bed status. Review of QAPI data verified the lack of an evaluation of the total health care program.

Based on staff interview and review of policies and procedures and minutes of the medical staff meetings, the facility failed to select a representative sample of both active and closed records for review and to conduct those reviews in a timely manner. The findings were:

During an interview on 11/16/11 at 9:50 AM, HIM clerk #1 stated the facility lacked formalized criteria for selecting medical records for review. She stated the only records she personally reviewed were those of patients with pneumonia, congestive heart failure, and heart attacks. Otherwise, HIM just picked records of patients who had a "...difficult stay." According to minutes from medical staff meetings for the past year, only six inpatient records were sent out for peer review, three in December 2010 and three in April 2011.
Review of facility policy HIM-021 "Peer Review" revised 7/31/08 revealed "peer review is to assist in assuring quality of care of our patients and efficiency of services rendered." The policy goes on to state patient records "will be done on a regular monthly basis."

Based on staff interview and review of policies and procedures, the facility failed to ensure all health care policies were reviewed yearly. The findings were:

During an interview on 11/15/11 at 10 AM, the CNO and HIM clerk #1 stated the facility's health care policies had not been reviewed yearly. Review of the policies confirmed the lack of an annual evaluation. Refer to C280 for evidence of specific policies that were not reviewed on an annual basis.

Based on staff interview, review of the QAPI program, and review of minutes from meetings of the Board of Governors, the facility failed to establish an effective, facility wide quality assurance program. The findings were:

a. Refer to C337 in regard to the facility's failure to evaluated all services effecting patent care.
b. Refer to C338 in regard to the facility's failure to effectively evaluate infection control information.
c. Refer to C340 in regard to the facility's failure to evaluate the quality and appropriateness of diagnosis and treatment provided by physicians.
d. Refer to C341 in regard to the facility's failure to provide evidence recommendations were evaluated and a corrective action plan developed during the peer review process.
e. Refer to C342 in regard to the facility's failure to take remedial action to address problems found through the QAPI process.

Based on staff interview and review of the QAPI program, the facility failed to evaluate all services affecting patient care, health, and safety. The findings were:

Interview with HIM clerk #1 and the CNO on 11/15/11 at 10:00 AM revealed contracted services were not included in the QAPI program. These services included physical and occupational therapy, the reference laboratory, and the contractor providing over-reads for all radiology films.
During an interview on 11/16/11 at 12:05 PM, physical therapist #1 revealed her company had a contract with the hospital to provide inpatient physical therapy. She also stated the physical therapy contracted services had never been involved or participated in the hospital's QAPI program.

The laboratory's quality assurance (QA) program was reviewed on 11/15/11 at 10:20 AM with laboratory technician #1. The documents showed the laboratory conducted quality assessment activities for its internal services, but failed to include any data or monitoring of its contracted reference laboratory. The technician stated in interview on 11/15/11 at 10:35 AM that the reference laboratory did not routinely provide any QA data for review and the laboratory did not actively monitor the quality of these contracted analytic services.
Review of QA program for the radiology department on 11/15/11 at 2:10 PM showed the department collected and reported information to the hospital QAPI committee related to the quality of its internal services. There was, however, no assessment of the quality of its contracted radiology services. Interview with radiology technician #1 on 11/15/11 at 2:15 PM confirmed the facility did not actively monitor the quality of x-ray reads or timeliness of services provided by the contracted radiologists. She further stated the contractor provided all definitive x-ray readings for the hospital.
Review of the Annual Contract Quality Review information showed the medical records department had a system for annually reviewing contracted services for the appropriateness of the services rendered and compliance with the existing terms of the contract. Further review showed the system was last implemented on 6/16/10 (seventeen months ago). Interview with HIM clerk #1 on 11/17/11 at 8 AM confirmed the quality review tool had not been implemented annually. The clerk also stated this review should be done at least annually to ensure the quality of the services provided by contracted individuals.




21849

Based on staff interview and review of policies, procedures, medical records, and infection surveillance activities, the facility failed to effectively evaluate information available to the infection control program on antibiotic therapy and culture reports. The findings were:

1. Review of infection control records on 11/15/11 and again on 11/16/11 revealed incomplete and inaccurate information on patient antibiotic therapy and culture reports. Although the infection program systematically reported monthly summaries of surveillance data, there was no evidence to show the program evaluated the accuracy of its reporting system or validated its data collection process. The following discrepancies were discovered:
a. As detailed in C278, the hospital infection control program failed to recognize incomplete antibiotic therapy entries for patient #13 and, further, failed to identify and monitor culture findings on the same patient. As described in C302, the patient's record lacked a discharge summary of significant clinical findings related to a urinary tract infection and antimicrobial therapy.
b. The infection control program failed to identify and resolve a discrepancy in the medical record of patient #19 that alleged the patient was positive for MRSA pneumonia. As detailed in C302 and C278, the hospital lacked a competent system for identifying potential inaccuracies in medical records and assessing their impact on infection surveillance activities.

2. The infection control nurse stated in interview on 11/16/11 at 3:45 PM that she received infection surveillance worksheets from the nursing staff; the information reported on these worksheets prompted her further investigation of infection concerns and antibiotic use. She acknowledged the existing data collection technique was incomplete in the instances cited with patients #13 and #19. The infection control nurse stated clinical records were not routinely audited to asses the accuracy and completeness of infection surveillance data.

3. Crook County Medical Services District policy IC 005, Infection Control Program, revised and accepted 10/13/10, required staff to identify and monitor infections and antibiotic treatment among patients.

Based on staff interview, review of policies and procedures, and review of peer review recommendations and the medical staff bylaws and rules and regulations, the facility failed to ensure the quality and appropriateness of diagnoses and treatments furnished by physicians were evaluated. The findings were:

Interview with the CNO and HIM clerk #1 on 11/16/11 at 9:50 AM revealed a physician from another hospital reviewed medical records to determine the appropriateness of the diagnoses and treatments provided by the facility's physicians. During the interview, the clerk stated that although the reviews were to be done monthly, she last sent records "several" months ago. According to the facility policy, HIM-021 "Peer Review," revised 7/31/08, patient records "will be done on a regular monthly basis." Although the facility had a system for peer review, perusal of minutes from the medical staff meetings for the past year revealed only six inpatient records had been sent for review, the last in April 2011. Both the CNO and the clerk stated, "The system is broken."

Based on staff interview, review of recommendations from peer review, and review of the minutes from the medical staff meetings, the facility was unable to provide evidence recommendations were evaluated and a corrective action plan developed for the QAPI program. This failure included 6 of 6 records evaluated during the peer review process. The findings were:

Interview with the CNO and HIM clerk #1 on 11/16/11 at 9:50 AM revealed a physician from another hospital reviewed medical records to determine the appropriateness of the diagnoses and treatments provided by the facility's physicians. The clerk stated HIM selected and sent the records for review and the results were sent to the medical staff for review at their meetings. The clerk stated no information related to corrective actions was included in the medical staff minutes or sent to the QAPI program.
Review of minutes from the medical staff meetings for the past year revealed only six inpatient records had been sent for review, three in December 2010 and three in April 2011. A "Hospital Peer Review" form was filled out by the consultant physician after each chart was reviewed. Each form had multiple comments, recommendations and suggestions. Review of minutes of the medical staff meetings failed to show if any of these comments, recommendations or suggestions were discussed or acted upon.

Based on staff interview, review of QAPI data, and review of minutes from meeting of the medical staff and governing body, the facility failed to take remedial action to address problems found through the QAPI process. The findings were:

The QA process for the HIM department was reviewed with HIM clerk #1 on 11/15/11 at 10 AM. The summarized data showed selected QA indicators, such as timely completion of history and physical examinations and dated/timed physician signatures, were consistently below the quality baseline established by the hospital. During the interview, the records clerk stated that the low compliance rate was presented to the physicians at medical staff meetings; however, there was no documentation to show improvement of the quality indicators. Review of the July, August, September, and October 2011 minutes from meetings of the governing body showed the board members reviewed data from the QAPI program. However, there was no evidence suggesting the board discussed any results, even when departments monitored the same indicators for years or reported they were dropping an indicator because the goal could not be met. Further, the facility was unable to produce evidence that remedial action was taken to address problems identified through the QAPI process.

Based on medical record review and staff interview, the facility failed to develop and revise care plans for 1 of 3 swing bed patients (#22) who required comprehensive care plans. The findings were:

Medical record review showed patient #22 was admitted to swing bed status on 10/21/11 for rehabilitative services after surgery for a fractured hip and discharged on 11/9/11. Review of the admission assessment showed the patient required assistance with activities of daily living, had a dressing covering an incision on the right hip, had a bruised left heel, and was at risk for falls. Review of the care plan identified the following concerns:
a. Although a self care deficit was identified, the interventions did not specify what how much assistance was required nor what assistive devices were needed.
b. There were no interventions developed to minimize falls.
c. The patient's bruised heel was identified on admission, but "skin-prep" was not initiated until 10/27/11. The care plan was undated so it was unknown when the other interventions related to pressure ulcer prevention were initiated.
d. Per the care plan, "skin-prep" was to be applied to the patient's heels daily. The plan had not been revised to reflect the application three times a day.
On 11/16/11 at 3 PM the CNO stated staff were to perform a complete assessment on every swing bed patient weekly and as needed and that care plans were to be updated with every assessment.





























27095