HospitalInspections.org

30553

Based on observation, review of facility policy, and interview, the facility failed to ensure safe storage of cleaning supplies.

The findings included:

Observation on May 21, 2013, at 9:20 a.m., in the CT (computed tomography) scanner room, revealed one can of wasp spray, one can of CT screen cleaner, one can of Pledge (cleaning product to remove dust), stored in a cabinet with patient care supplies (IV tubing).

Review of facility policy, # 131665, Storage of Cleaning Supplies, dated August 2011, revealed "...establish a proper storage area for all equipment..."

Interview with the Radiology technician, on May 21, 2013, at 9:20 a.m., in the CT room, confirmed the cleaning supplies were stored in the cabinet with patient care supplies.

Interview with the Director of Clinical Services, on May 21, 2013, at 11:30 a.m., in the conference room, confirmed the cleaning supplies were stored with patient care supplies and the facility policy was not followed.

Based on policy review and interview, the facility failed to provide provisions for long term residents to perform work for the facility, if the resident desires to work and the need for work is included in the plan of care.

The findings included:

Review of facility policy titled: Patient Work, SN-DT-17000-0013-GL, last revised July 2011, revealed, "Given this is a short stay hospital based program it is anticipated that patient's would not perform any services for the hospital on a voluntary or paid basis."

Interview with the Clinical Coordinator, in the facility's conference room, on May 21, 2013, at 10:00 a.m., confirmed the facility did not have a policy related to long term care resident's right to work at the facility, if the resident desired and if the need for work was included in the resident's plan of care.

Based on medical record review, review of facility policy and interview, the facility failed to develop a comprehensive care plan for six patients (#3, #4, #5, #6, #9, #10).

The findings included:

Medical record review revealed Patient #3 was admitted to the facility on May 16, 2013, with diagnoses including Alzheimer's disease, Dementia with behavior disturbance, Hypertension, and Coronary Artery Disease.

Medical record review of the Admission Nursing Assessment, dated May 16, 2013, revealed the patient was admitted with pressure ulcers to the right and left heels.

Medical record review of the Interdisciplinary Plan of Care, dated May 16, 2013, revealed no interventions related to the patient's pressure ulcers.

Interview on May 20, 2013, at 1:45 p.m., with Registered Nurse (RN) #1 and the Director of Clinical Services, in the nurse's station, confirmed the patients care plan did not reflect the patients pressure ulcers to the heels and the pressure ulcers were present on admission.

Medical record review revealed Patient #4 was admitted to the facility on May 13, 2013, with diagnoses including Pneumonia and Deconditioning, and admitted to a Swing Bed status.

Medical record review of a physicians History and Physical, dated May 13, 2013, revealed, "...patient is currently too weak to get out of bed, so it seems advantageous to go ahead and admit...to swing bed status here and see if...can get...up and about and at least be able to participate a little more in...self care...will continue antibiotics...activity will be per physical therapy..."

Medical record review of the Interdisciplinary Care Plan, dated May 13, 2013, revealed no interventions related to the patient's physical therapy.

Interview with Registered Nurse (RN) #1 on May 20, 2013, at 1:55 p.m., in the nurse's station, confirmed no interventions documented in the care plan related to physical therapy.

Interview with the physical therapist on May 20, 2013, at 2:00 p.m., in the nurse's station, revealed "...is very weak but is improving...remains short of breath...see the patient twice a week and have began conditioning exercises..."

Interview with the Director of Clinical Services on May 20, 2013, at 2:05 p.m., in the nurse's station, confirmed the comprehensive care plan did not address the patient's physical therapy interventions for deconditioning.

Medical record review revealed Patient #5 was admitted to the facility on October 26, 2012, with diagnoses of Endocarditis. Further review of the medical record revealed a physician's order for, "Isolation Percautions" dated October 30, 2012, and an order to "DC (discontinue) Isolation" dated November 14, 2012.

Review of Patient #5's care plan revealed no interventions related to the patient being on Isolation Precautions.

Interview with RN #1, in the Health Information Office (HIM), on May 21, 2013, at 11:30 a.m., confirmed the patient's Isolation Percautions were not addressed in the care plan.


Medical record review revealed Patient #6 was admitted to the facility on November 30, 2012, with diagnoses which included Diabetes. Further review of the medical record revealed a physician's order, dated November 30, 2012, for "Accuchecks (finger sticks to test blood sugar level) four times a day".

Review of Patient #6's care plan revealed no interventions related to the patient's diabetes or the accuchecks four times a day.

Interview with RN #1, in the HIM office, on May 21, 2013, at 11:45 p.m., confirmed the patient's diabetes and accuchecks were not addressed in the care plan.


Medical record review revealed Patient #9 was admitted to the facility on February 12, 2013, with diagnoses of Right Sided Heart Failure and Pulmonary Hypertension. Further review of the medical record revealed a physician's order for "Accuchecks and Sliding Scale Insulin (Insulin dosages adjusted to blood sugar levels) AC and HS (before meals and at bed time)", dated February 12, 2013.

Review of Patient #9's care plan revealed no interventions regarding the patient's accuchecks or sliding scale insulin.

Interview with RN #1, in the HIM office, on May 21, 2013, at 11:55 am, confirmed there were no interventions documented in the care plan regarding the patient's accuchecks and sliding scale insulin.

Medical record review revealed Patient #10 was admitted to the facility on February 9, 2013, with diagnoses of Deconditioning, Depressed Mood, and Diabetes. Further review of the medical record revealed physician's orders, dated February 14, 2013, for Accuchecks and Sliding scale insulin before meals and at bedtime.

Further review of the medical record revealed no intervention documented on the care plan regarding the patient's Accuchecks and sliding scale insulin.

Interview with RN #1, in the HIM office, on May 21, 2013, at 12:15 p.m. confirmed there were no interventions, in the care plan, related to Patient #10's Accuchecks and sliding scale insulin.

Review of facility policy, #136860, Comprehensive Care Plan, revealed "...a comprehensive care plan for each patient will be initiated by nursing on the admitting shift and added to by other shifts as care planning issues are identified with a team update at least on a weekly basis...the facility must develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet patient's medical, nursing and psychosocial needs that are identified in the comprehensive assessment...a new or updated Comprehensive care plan will be reviewed, prepared and developed by an interdisciplinary team..."