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Based on medical record review, facility document review and staff interview revealed that the facility failed to ensure and promote patient rights (A0115), failed to ensure the implementation of a Quality Assessment and Program Improvement,(A0263), failed to provide nursing services that meet the patient's needs (A0385), failed to maintain a complete and accurate medical records for each patient, (0431), and failed to provide outpatient services, that meets the needs of the patients, (1076). For these reasons, the Condition of Participation for Governing Body has been found to be out of compliance.

Findings:

1. Reference A0115: Based on staff interviews and record review the facility failed to ensure and promote the patient rights to formulate advanced directives, failed to ensure the patients right to file a grievance and to have their privacy protected while receiving care. Failure to ensure and promote patient rights has the potential to reduce the patients' self-esteem and affect their psychosocial well-being.

2. Reference A0263: Based on observation, interview, and record review, it was determined that the facility failed to define the scope of Quality Assessment and Program Improvement (QAPI), (A 0264), the facility failed to set priorities for the QAPI program, (A 0285), the governing body failed to conduct performance improvement projects, (A0297), conduct projects annually, (A0298), failed to defined, implemented and maintained the QAPI program, (A 0310) failed to set priorities and evaluation actions taken by the QAPI program, (A0312) and establish expectations for safety, (A0314). For this reason the Condition for QAPI was found to be out of compliance at the time of the survey.

3. Reference A0385: Based on observation, medical record review and interview the facility failed to ensure that a Registered Nurse was immediately available to supervise a Licensed Professional Nurse during patient care for 12 nights during the month of June, 2010 (A 0392), the facility failed to ensure that 5 of 19 (#4, #12, #13, #14, and #15) in-patient medical records reviewed contained a nursing care plan (A0396), and the facility failed to ensure that Patient #11 received physician ordered medications (A0404). These findings resulted in the facility being out of compliance with the Condition of Participation under Nursing Services.

4. Reference A0431: Based on record review and interview, the facility failed to ensure they properly maintained the facility's medical records. This facility is out of compliance with the Condition of Participation under Medical Record Services as the facility was out of compliance with the standards under Form and Retention of Records (A 0438), Medical Record Services (A 0450), Content of Record (A 0458), and Discharge Summary (A 0466). Failure to maintain patients' records may result in the facility's inability to provide continuation of care.

5. Reference A1076: Based on record review and interview, the facility failed to have an integrated outpatient services department, with acceptable standards. This resulted in the Condition for Outpatient Services not to be met as the facility did not meet the standards under A1077 (Integration of outpatient services) and A 1079 (Outpatient Personnel). Failure to have an integrated outpatient services department may result in the outpatients' needs not being met.

Based on staff interviews and record review the facility failed to ensure and promote the patient rights to formulate advanced directives, failed to ensure the patients right to file a grievance and to have their privacy protected while receiving care. Failure to ensure and promote patient rights has the potential to reduce the patients' self-esteem and affect their psychosocial well-being.

Findings:

1. Reference A0118: Based on facility document review the facility failed to ensure that all patients were informed whom to contact to file a grievance. Failure to inform patients whom to contact to file a grievance places patients at risk of not having concerns addressed by the facility.

2. Reference A0119: Based on facility document review and staff interviews the Governing Body failed to ensure that patient grievances were reviewed and resolved. Failure to review and resolve patient grievances places patients at risk of not receiving appropriate care and services.

3. Reference A0120: Based on facility document review and staff interviews the Governing Body failed to ensure a mechanism for timely referral of patient grievances for review by the facility's Quality Improvement Committee. Failure for the review of patient grievances by the Quality Improvement Committee places patients at risk of not receiving appropriate care and services.

4. Reference A0121: Based on facility document review the facility failed to ensure that there were clearly explained procedures for patients regarding the process for submission of a grievance. Failure to have clear procedure for patients regarding how to submit a grievance places patients at risk of not having concerns addressed by the facility.

5. Reference A0122: Based on facility document review the facility failed to ensure that there were clearly explained procedures for patients regarding the process for submission of a grievance. Failure to have clear procedure for patients regarding how to submit a grievance places patients at risk of not having concerns addressed by the facility.

6. Reference A0123: Based on facility document review the facility failed to ensure that 4 of 4 complaints reviewed to provide each patient with a written notice that includes all required information. Failure to provide patients who file grievances with follow up a letter places patients at risk of not receiving appropriate care and services.

7. Reference A0131: Based on record review and interview, the facility failed to ensure that 6 out of 29 (#3, #4, #5, #11, #13, and # 29) patients had the to make an informed decision regarding care received. Failure to ensure that patients are provided the opportunity to consent to treatment may result in the patients' receiving treatment against their will.

8. Reference A0132: Based on record review and staff interview, the facility failed to ensure 9 of 24 (#3, #4, #5, #12, #13, #14, #15, #19, and #29) patients had documented advanced directives explained to them. Failure to explain advanced directives to all patients may result in the patient's desires to go unknown.

9. Reference A0142: Based on observation and interview, the facility failed to ensure the Emergency Room (ER) patients' right to privacy, while being triage. Failure to honor patients' rights may result in a decrease in the patients' self-esteem and psychosocial well-being.

Based on observation, interview, and record review, it was determined that the facility failed to define the scope of Quality Assessment and Program Improvement (QAPI), (A 0264), the facility failed to set priorities for the QAPI program, (A 0285), the governing body failed to conduct performance improvement projects, (A0297), conduct projects annually, (A0298), failed to defined, implemented and maintained the QAPI program, (A 0310) failed to set priorities and evaluation actions taken by the QAPI program, (A0312) and establish expectations for safety, (A0314). For this reason the Condition for QAPI was found to be out of compliance at the time of the survey.

Findings:

1. A0264: Based on facility document review and staff interviews the facility failed to define the scope of the Quality Assurance Performance Improvement (QAPI) program. Failure to define the scope of the QAPI program can result in not identifying opportunities for improvement.

2. A0285: Based on facility's document review and staff interviews the facility failed to set priorities for the Quality Assurance Performance Improvement (QAPI) program. Failure to set priorities for the QAPI program can result in not identifying opportunities for improvements in patient safety and quality of care.

3. A0297: Based on facility document review and staff interviews the facility failed to conduct performance improvement project as part of it's Quality Assurance Performance Improvement (QAPI) program. Failure to conduct performance improvement projects has the potential of the facility not identifying opportunities to improve the quality of care that patient receive and the safety of the environment that care is provided.

4. A0298: Based on facility document review and staff interviews the facility failed to establish the number of performance improvement projects to be conducted annually as part of it's Quality Assurance Performance Improvement (QAPI) program. Failure to conduct performance improvement projects has the potential of the facility not identifying opportunities to improve the quality of care that patient receive and the safety of the environment that care is provided.

5. A0310: Based on facility document review and staff interviews the Governing Body/Administration failed to define the scope of, ensure the implementation of, and the maintaining of the Quality Assurance Performance Improvement program, (QAPI). Failure of the Governing Body/Administration to oversee the QAPI program can result in not identifying opportunities for improvement.

6. A0312: Based on facility document review and staff interviews the governing body/administration failed to set priorities and evaluation actions taken by the Quality Assurance Performance Improvement (QAPI) program. Failure to set priorities for the QAPI program and evaluate the actions taken to improve quality can result in not improving patient safety and quality of care.

7. A0314: Based on facility document review and staff interviews the governing body/administration failed to establish expectations for safety. Failure to establish safety expectations has the potential of patient care not being provided in a safe environment.

Based on observation, medical record review and interview the facility failed to ensure that a Registered Nurse was immediately available to supervise a Licensed Professional Nurse during patient care for 12 nights during the month of June, 2010 (A 0392) and the facility failed to ensure that 5 of 19 (#4, #12, #13, #14, and #15) in-patient medical records reviewed contained a nursing care plan (A0396). These findings resulted in the facility being out of compliance with the Condition of Participation under Nursing Services.

Findings:

Reference A0392: Based on record review and interview the facility failed to ensure that a Registered Nurse was immediately available to supervise a Licensed Professional Nurse during patient care for 12 (1, 4, 5, 6, 9, 10, 14, 15, 25, 26, 28 and 29) nights during the month of June, 2010. The facility failure to ensure that a Registered Nurse is available to supervise patient care may lead to a delay in care during an emergent situation.

Reference A0396: Based on medical record review and interview the facility failed to ensure that 5 of 19 (#4, #12, #13, #14,and #15) in-patient medical records reviewed contained a nursing care plan. The failure to develop care plans specifically designed for a patient's current status and level of functioning, with measurable goals, may prevent the patient from reaching his/her highest level of functioning.

Based on record review and interview, the facility failed to ensure they properly maintained the facility's medical records. This facility is out of compliance with the Condition of Participation under Medical Record Services as the facility was out of compliance with the standards under Form and Retention of Records (A 0438), Medical Record Services (A 0450), Content of Record (A 0458), Informed Consent(A 0466), Practitioners Orders (A0467), and Discharge Summary (A 0468). Failure to maintain patients' records may result in the facility's inability to provide continuation of care.

Findings:Reference A 0438: Based on record review and interview, the facility failed to promptly complete 3 of 24 (#2, #14, and #29) closed patients' records. Failure to promptly complete discharge patients' records may result in the facility being unaware of the care and services provided to the patients, in the event the patients return to the hospital.

Reference A 0450: Based on record review and interview, the facility failed to ensure that 4 of 5 Emergency Room (ER) patients (#22, #23, #24, and #25) had entries that were dated and timed. Failure to ensure all entries are time may result in the nurse not recalling last time patient was assessed.

Reference A 0458: Based on record review and interview, the facility failed to ensure that 8 of 24 (#6, #9, #10, #11, #12, #14, #15 and #29) in patients' records had a medical history and physical (H&P) completed within 24 hours of admission. Failure to have a completed H&P on the patients' records may result in the physicians and nurses being unaware of any medical history, which may be affected by this hospital admission.

Reference A 0466: Based on medical record review and interview the facility failed to obtain a properly executed informed consent prior to surgery for 2 of 5 ( #6 and #8) outpatient surgery patients scheduled for elective outpatient surgery. The facility failure to ensure that patients have properly executed informed consents may lead to the patient not being properly informed of their risks or benefits of the procedure prior to surgery.

Reference A 0467: Based on medical record review the facility failed to ensure that the contents of the medical record was available and complete for 2 of 5 ( #6 and #7) outpatient surgery patients scheduled for elective outpatient surgery. The facility failure to ensure that patients medical records were available and complete places the patients at risk for not receiving appropriate medical care in the event of an emergency.

Reference A 0468: Based on record review and interview, the facility failed to ensure that 2 of 24 patients' (#2 and #15) had a discharge summary indicating the outcome of hospitalization and disposition of care. Failure to maintain a complete record may result in the facility's inability to review the patient's past admission information, if the patient is readmitted into the facility.

Based on record review and interview, the facility failed to have an integrated outpatient services department, with acceptable standards. This resulted in the Condition for Outpatient Services not to be met as the facility did not meet the standards under A 1077 (Integration of outpatient services) and A 1079 (Outpatient Personnel). Failure to have an integrated outpatient services department may result in the outpatients' needs not being met.

Findings:

Reference A 1077: Based on record review and interview, the facility failed to have the outpatient services department integrated with the facility's inpatient services. Failure to have an integrated outpatient services department may result in the patients' needs not being met.

Reference A 1079: Based on record review and interview, the facility failed to follow their own policies and procedures (P&P) regarding appropriate professional personnel available for the facility's outpatient services. Failure to ensure appropriate professional personnel are available for outpatient services may result in inappropriate care and services to go undetected.

Based on facility document review the facility failed to ensure that all patients were informed whom to contact to file a grievance. Failure to inform patients whom to contact to file a grievance places patients at risk of not having concerns addressed by the facility.

Findings:

Review of the facility's policy and procedure titled "Customer Complaints" approval and last revised 9/16/1996 did not reveal how or to whom a patient could express a grievance. Continued review of the policy and procedure did not reveal how the facility staff was to inform the patients of their rights to file a grievance or how to document if the patient was informed of their rights to file a grievance.

Based on facility document review and staff interviews the Governing Body failed to ensure that patient grievances were reviewed and resolved. Failure to review and resolve patient grievances places patients at risk of not receiving appropriate care and services.

Findings:

Interview with the Risk Manager Designee on 06/29/2010 at 2:30 PM revealed that the facility does not maintain a patient grievance log. When asked for the grievances for all of 2010 the Risk Manager Designee provided four complaints from patients and a blank "Patient Complaint Form".

Review of the facility's policy and procedure titled "Customer Complaints", with an approval and last revised date of 9/16/1996, revealed that the Patient Complaint Form is to be completed as part of the policy and procedure for patient/customer complaints.

Interview with the Risk Manager Designee on 06/29/2010 at 2:30 PM revealed that the staff does not have to use the form if they don't want to.

Review of the Risk Management policy titled "Patient Grievance", last reviewed on 06/01/2010, revealed that the Purpose of the policy was to "To analyze and trend grievances to insure appropriate resolution and decrease potential for additional grievances of similar identified types". The Procedure for the policy contained the four following items:

1. A grievance can be reported to any employee.
2. The grievance will be reported to the responsible department manager, who will initiate an investigation of the grievance.
3. The resolution will be presented to the person making the grievance
4. Grievances will be reported to QI [Quality Improvement] monthly.

Review of the facility's policy and procedure titled "Customer Complaints," with the approval and last revised date of 9/16/1996, did not reveal how the patient grievance data would be collected and present to the Governing Body, QI or any facility committee for review and resolution.

Review of the patients' grievances received by the facility during 2010 revealed:

1. A letter from a patient dated 04/27/2010 that expressed a concern about the care they had received at the facility. Review of the file did not reveal that the facility had completed a customer complaint form or documented any follow-up after receiving the patient letter.

2. Review of a patient complaint received on 04/15/2010 relating to care the patient had received at the facility did not reveal that a customer complaint form was completed. The file did contain a follow-up letter that stated that the matter was referred to physician peer review and that the process was confidential. No other follow-up was documented in the file.

3. A phone call from a patient voicing a concern about care at the facility. Review of the file did not reveal that the facility had completed a customer complaint form or documented any follow-up after receiving the patient's call.

4. A note from a patient expressing a concern about care at the facility. Review of the file did not reveal that the facility had completed a customer complaint form or documented any follow-up after receiving the patient's note.

Review of the Governing Body Committee minutes for 2010 did not reveal that the Governing Body had reviewed the above patient concerns or that they ensured that the patient grievance process/policies were up to date and being implemented as established by the facility.

Based on facility document review and staff interviews the Governing Body failed to ensure a mechanism for timely referral of patient grievances for review by the facility's Quality Improvement Committee. Failure for the review of patient grievances by the Quality Improvement Committee places patients at risk of not receiving appropriate care and services.

Findings:

Interview with the Risk Manager Designee on 06/29/2010 at 2:30 PM revealed that the facility does not maintain a patient grievance log. When asked for the grievances for all of 2010 the Risk Manager Designee provided four complaints from patients and a blank "Patient Complaint Form".

Review of the facility's policy and procedure titled "Customer Complaints", with an approval and last revised date of 9/16/1996, revealed that the Patient Complaint Form is to be completed as part of the policy and procedure for patient/customer complaints.

Interview with the Risk Manager Designee on 06/29/2010 at 2:30 PM revealed that the staff does not have to use the form if they don't want to.

Review of the Risk Management policy titled "Patient Grievance", last reviewed on 06/01/2010, revealed that the Purpose of the policy was to "To analyze and trend grievances to insure appropriate resolution and decrease potential for additional grievances of similar identified types". The Procedure for the policy contained the four following items:

1. A grievance can be reported to any employee.
2. The grievance will be reported to the responsible department manager, who will initiate an investigation of the grievance.
3. The resolution will be presented to the person making the grievance
4. Grievances will be reported to QI [Quality Improvement] monthly.

Review of the facility's policy and procedure titled "Customer Complaints," with the approval and last revised date of 9/16/1996, did not reveal how the patient grievance data would be collected and present to the Governing Body, QI or any facility committee for review and resolution.

Based on facility document review the facility failed to ensure that there were clearly explained procedures for patients regarding the process for submission of a grievance. Failure to have clear procedure for patients regarding how to submit a grievance places patients at risk of not having concerns addressed by the facility.

Findings:

Review of the facility's policy and procedure titled "Customer Complaints," with an approval and last revised date of 9/16/1996, did not reveal how or to whom a patient could express a grievance. Continued review of the policy and procedure did not reveal how the facility staff was to inform the patients of their rights to file a grievance or how to document if the patient was informed of their rights to file a grievance.

Based on facility documentation review, the facility failed to ensure that specific time fames are established for the review and response to patient grievances. Failure to specify time frames for the facility's actions in addressing patient concerns has the potential of resulting in the patient not receiving needed care and services.

Findings:

Review of the facility's policy and procedure titled "Customer Complaints," with an approval and last revised date of 9/16/1996, did not reveal any time frames for the review and response for patient/customer complaints.

Review of the Risk Management policy titled "Patient Grievance" last reviewed 06/01/2010 revealed that the Purpose of the policy was to "To analyze and trend grievances to insure appropriate resolution and decrease potential for additional grievances of similar identified types". The Procedure for the policy contained the four following items:

1. A grievance can be reported to any employee.
2. The grievance will be reported to the responsible department manager, who will initiate an investigation of the grievance.
3. The resolution will be presented to the person making the grievance
4. Grievances will be reported to QI monthly.

Review of the two policies did not reveal any time frames for the review and response for patient/customer complaints.

Based on facility document review the facility failed to ensure that 4 of 4 complaints reviewed to provide each patient with a written notice that includes all required information. Failure to provide patients who file grievances with follow up a letter places patients at risk of not receiving appropriate care and services.

Findings:

Review of the facility's policy and procedure titled "Customer Complaints," with an approval and last revised date of 9/16/1996 did not reveal information regarding providing the complainant a letter indicating who to contact, steps taken on their behalf, the resolution of their grievance and the date of completion.

Review of the patients' grievances received by the facility during 2010 revealed:

1. A letter from a patient dated 04/27/2010 that expressed a concern about the care they had received at the facility. Review of the file did not reveal that the facility had completed a customer complaint form or documented any follow-up after receiving the patient letter.

2. Review of a patient complaint received on 04/15/2010 relating to care the patient had received at the facility did not reveal that a customer complaint form was completed. The file did contain a follow-up letter that stated that the matter was referred to physician peer review and that the process was confidential. No other follow-up was documented in the file.

3. A phone call from a patient voicing a concern about care at the facility. Review of the file did not reveal that the facility had completed a customer complaint form or documented any follow-up after receiving the patient's call.

4. A note from a patient expressing a concern about care at the facility. Review of the file did not reveal that the facility had completed a customer complaint form or documented any follow-up after receiving the patient's note.

Based on record review and interview, the facility failed to ensure that 6 out of 29 (#3, #4, #5, #11, #13, and # 29) patients had the right to make an informed decision regarding care received. Failure to ensure that patients are provided the opportunity to consent to treatment may result in the patients' receiving treatment against their will.

Findings:

(1 ) During medical record review for Patient #3, admitted 6/14/10 and discharged on 6/16/10, there was no signature on the "authorization for treatment form."

( 2) During medical record review for Patient #4, admitted 4/26/10 and discharged on 4/29/10, there was no signature on the "authorization for treatment form."

( 3) During medical record review for Patient #5, admitted 6/8/10 and discharged on 6/14/10, there was no signature on the "authorization for treatment form."

Interview with the Director of Nursing on 6/29/10 at 2:30 PM confirmed that the medical records for Patients #3, #4, and #5 did not contain the signatures on the facility's "authorization for treatment" form.(4) Review of patient #11's record revealed the patient had presented to the facility's Emergency Room (ER) on 06/13/10. Further review of the record reveal the patient's Emergency Room/Outpatient Record revealed the section entitled, "Authorization for treatment, guarantee of payment, assignment of insurance benefits." Review of this section failed to reveal the patient's signature.

(5) Review of patient #13's record revealed the patient had been admitted in to the facility on 04/21/10. Further review of this record failed to reveal a signed consent for treatment.

(6) Review of patient #29's record revealed the patient was admitted into the facility on 05/27/10. Further review of the patient's record revealed the Emergency Room/Outpatient Record had a section entitled, "Authorization for treatment, guarantee of payment, assignment of insurance benefits." Review of this section failed to reveal the patient's signature.

Interview with the Director of Nursing (DON) on 06/29/10 at 3:06 PM revealed she was unable to locate the signed documents for patient #11, #13, and #29.






26404

19678

Based on record review and staff interview, the facility failed to ensure 9 of 24 (#3, #4, #5, #12, #13, #14, #15, #19, and #29) patients had documented advanced directives explained to them. Failure to explain advanced directives to all patients may result in the patient's desires to go unknown.

Findings:

( 1) During medical record review for Patient #3 it was noted that the face sheet under "Advanced Directives" the letter "Y" was typed. Further review of the medical record revealed that there was no Advanced Directives form indicating that the patient was offered or informed about his or her advanced directives.

(2 ) During medical record review for Patient #4 it was noted that the face sheet under "Advanced Directives" was left blank. Further review of the medical record revealed that there was no Advanced Directives form indicating that the patient was offered or informed about his or her advanced directives.

( 3) During medical record review for Patient #5 it was noted that the face sheet under "Advanced Directives" the letter "N" was typed. Further review of the medical record revealed that there was no Advanced Directives form indicating that the patient was offered or informed about his or her advanced directives.

Interview with the Director of Nursing on 6/29/10 at 2:30 PM confirmed that the medical records for Patients #3, #4, and #5 did not contain the facility's "Advanced Directives" form.

(4) Review of patient #12's medical record revealed an, "Advanced Directive Information," sheet dated 06/07/10. Further review of this form revealed the question, "Advance Directive information has been given to the patient." This question was left unanswered. Further review of this patient's record revealed a document entitled, "Physician Code Assessment." Review of this form revealed that every patient was considered full code unless there was a Do Not Resuscitate (DNR) order has been written on the physician's orders. Further review of this documentation revealed a check next to the statement, "Addressing DNR code status on this admission is NOT deemed appropriate." This document was signed by the physician on 06/22/10.

(5) Review of patient #13's medical record failed to reveal an Advanced Directive Information. Further review of this patient's medical record revealed a signed "Physician Code Assessment" which also indicated that the addressing the DNR was not appropriate. This form was signed by the physician on 05/22/10.

(6) Review of patient #14's record revealed an, "Advanced Directive Information," sheet dated 06/07/10. Further review of this form revealed the question, "Advance Directive information has been given to the patient." This question was answered, "No". Further review of this patient's medical record revealed a signed "Physician Code Assessment" which also indicated that the addressing the DNR was not appropriate. This form was signed by the physician on 06/26/10.

(7) Review of patient #15's record revealed an "Advanced Directive Information," sheet dated 06/19/10. Further review failed to reveal that an Advanced Directive information had been given to the patient, as the question was not answered. Further review of this patient's medical record revealed a signed "Physician Code Assessment" which also indicated that the addressing the DNR was not appropriate. This form was signed by the physician on 06/26/10.

(8) Review of patient #29's record failed to reveal an "Advanced Directive Information," sheet. Further review of this patient's medical record revealed a signed "Physician Code Assessment" which also indicated that the addressing the DNR was not appropriate. This form was signed by the physician on 06/26/10.

Interview with the hospital's physician on 06/29/10 at 2:19 PM revealed he checks off the not appropriate DNR question because the patient's condition is not bad enough to cause death. Further interview revealed he is not a surgeon so he would not discuss the risk of surgery with the patients. According to the physician, he never discusses DNRs with his patients. When asked if he would speak to a patient who presented gravely ill to the hospital, the physician stated that this type of patient would not be in the facility as he/she would have been transferred to another hospital.

(9) Review of the medical record for patient #19 revealed that the patient was admitted to the facility on 06/27/2010. Review of the Advanced Directive Information on 06/29/2010 revealed that the form only contained the patient's name, patient's number and date, 06/27/2010, the form was started. All the check boxes related to advanced directives was were left blank, therefore not indicating the patient's preference related to advanced directives.






26404

Based on observation and interview, the facility failed to ensure the Emergency Room (ER) patients' right to privacy, while being triage. Failure to honor patients' rights may result in a decrease in the patients' self-esteem and psychosocial well-being.

Findings: Observation of the ER on 06/28/10 at 10:15 AM with the Registered Nurse (RN) on duty revealed a room within the triage room that was separated by a door. The only way to enter this room was to go through the triage portion of the room.

Interview with the RN on 06/28/10 at 10:20 AM revealed that the room inside of the triage room was the admissions room for the ER. Further interview with the RN revealed, "Patient Confidentiality is very poor."

Based on facility document review and staff interviews the facility failed to conduct performance improvement project as part of it's Quality Assurance Performance Improvement (QAPI) program. Failure to conduct performance improvement projects has the potential of the facility not identifying opportunities to improve the quality of care that patient receive and the safety of the environment that care is provided.

Findings:

Review of the facility documentation did not reveal that the facility had a written QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the committee or governing body had reviewed or directed any performance improvement projects to be conducted.

Interview with the QA Director on 6/29/2010 at 3:00 PM revealed that neither the QAPI committee nor the Governing Body has directed that performance improvement projects are to be conducted or has established that number of projects that are to be conducted annually as part of the QAPI program.

Based on record review and interview the facility failed to ensure that a Registered Nurse was immediately available to supervise a Licensed Professional Nurse during patient care for 12 (1, 4, 5, 6, 9, 10, 14, 15, 25, 26, 28 and 29) nights during the month of June, 2010. The facility failure to ensure that a Registered Nurse is available to supervise patient care may lead to a delay in care during an emergent situation.

Findings:

During review of the staffing schedule for the month of June, 2010 it was revealed that on 6/1, 6/4, 6/5, 6/6, 6/9, 6/10, 6/14, 6/15, 6/25, 6/26, 6/28, and 6/29 there was only a Licensed Practical Nurse assigned on the medical-surgical unit and a Registered Nurse assigned in the emergency room.

Interview of the Director of Nursing (DON) on 6/30/10 at 1:15 PM revealed that during the day shift (7 AM- 7 PM), she is available to supervise the LPN assigned on the medical-surgical unit. She stated that on the night shift (7 PM- 7 AM), the RN assigned in the emergency room is available to supervise the LPN assigned on the medical-surgical unit. The DON stated that the facility is constantly advertising for nurses and uses agency provided nurses, but that the facility is in a rural area and it is hard to find staff.

Based on medical record review and interview the facility failed to ensure that 5 of 19 (#4, #12, #13, #14,and #15) in-patient medical records reviewed contained a nursing care plan. The failure to develop care plans specifically designed for a patient's current status and level of functioning, with measurable goals, may prevent the patient from reaching his/her highest level of functioning.

Findings:

(1) During medical record review for Patient #4 it was noted that the "Interdisciplinary Plan of Care" was left blank.

Interview of the Director of Nursing (DON) on 6/29/10 at 2:30 PM confirmed that a nursing care plan had not been developed for Patient #4.

(2) Review of patient #12's medical record revealed the patient was admitted into a swing bed on 06/10/10. Further review of the patient's record revealed the a Minimal Data Set (MDS) was completed on 06/13/10. Further review of this patient's record revealed the patient had a fall assessment completed on 06/08/10. Review of this fall assessment revealed the patient was scored a ten. According to the documentation, "A score of 10 or more indicates a high risk." Review of patient #12's record failed to reveal a care plan was created with the identified fall risk.

(3) Review of patient #13's medical record revealed the patient was admitted into a swing bed on 04/24/10. Further review of this patient's record revealed an MDS dated 04/26/10. Review of a fall assessment dated 04/21/10 revealed the patient scored a 7 on the assessment. Further review of the fall assessment revealed, "If patient does not meet a score of 10 but in the nurse's judgement the patient is at high risk, initiate fall protocol." According to this assessment the nurse did initiate the fall protocol. Review of patient #13's care plan dated 04/21/10 failed to reveal a care plan regarding patient safety or fall precautions.

Interview with the DON on 06/29/10 at 3:05 PM revealed no fall care plan had been initiated for patient #13.

(4) Review of patient #14's record revealed the patient was admitted into the facility on 05/29/10 and then admitted into a swing bed on 06/2/10. Further record review failed to reveal a care plan for patient #14.

Interview with the Director Of Nursing (DON) on 06/29/10 at 3:06 PM confirmed that patient #12's and #14's records did not contain care plans.
(5) Review of patient #15's record revealed the patient was admitted into the facility on 06/19/10 and into a swing bed on 06/22/10. Further record review revealed a MDS dated 06/23/10, but no care plan was found in patient #15's record.

Interview with the DON on 06/29/10 at 3:05 PM revealed that the facility had completed an MDS, but she was unable to locate a care plan in the medical record.

Review of the facility's swing bed policies and procedures (P&P) entitled, "Fall Precautions," revealed the policy was approved on 09/05/01. Further review of the P&P revealed, "For each patient considered to be at high risk for falls, nursing must complete a fall risk care plan."

Review of the swing bed P&P entitled, "Nursing Care Plan", revealed "The [Registered Nurse] will use data collected from the Nursing Assessment at the time of admission to construct a care plan."



26404

Based on record review and interview, the facility failed to promptly complete 3 of 24 (#2, #14, and #29) closed patients' records. Failure to promptly complete discharge patients' records may result in the facility being unaware of the care and services provided to the patients, in the event the patients return to the hospital.

Findings:

(1) During medical record review for Patient #2 it was revealed that the patient was admitted to the facility on 5/20/10 and discharged on 5/24/10. Continued medical record review revealed that there was no discharge summary provided by the physician in the medical record.

Interview with the Director of Nursing on 6/29/10 at 2:30 PM confirmed that there was no discharge summary in the medical record for Patient #2.

(2) Review of patient #14's record revealed the patient was admitted to the hospital on 05/29/10. Further review of the patient's record revealed the physician dictated the patient's Health and Physical (H&P) on 05/30/10, but it was not transcribed until 06/02/10. Further review of patient #14's H&P revealed the physician signed it on 06/26/10. According to patient #14's record, he/she had been discharged from the facility on 06/05/10.

(3) Review of patient #29's record revealed the patient was admitted in to the facility on 05/27/10. Further review of the patient's record revealed the patient had been discharged from the facility on 05/29/10. Further review of the facility's record revealed the patient's H&P was dictated on 06/16/10 and transcribed on 06/18/10.

Interview with the Director of Nursing on 06/29/10 at 3:06 PM revealed the hospital's physician was behind in his dictations and completion of his patients' records.


26404

Based on record review and interview, the facility failed to ensure that 4 of 5 Emergency Room (ER) patients (#22, #23, #24, and #25) had entries that were dated and timed. Failure to ensure all entries are time may result in the nurse not recalling last time patient was assessed.

Findings:

Review of patient #22's record revealed the patient presented to this facility's ER on 05/31/10 at 20:00 (8:00 PM). Further review of this record revealed the, "Triage/ER Flow Sheet." Review of this sheet revealed a documentation section with five entries. The entries indicated the triage assessment, the patient being placed in a treatment room, the patient being seeing by the physician, diagnostic studies completed, sutures completed by the physician and the wound being cleaned and dress, All of these entries were initialed by the nurse, but the documentation fail to indicate the dates and times these entries were made.

Review of patient #23's record revealed the patient presented to the ER on 06/06/10 at 18:23 (6:23 PM). Further review of this patient's record revealed the, "Triage/ER Flow Sheet." Review of this flow sheet revealed the documentation section indicates the patient was triaged at 18:23, the temperature was obtained at 19:25 (7:25 PM), and the patient's full vital signs were obtained at 19:45 (7:45 PM). The next nine entries are not dated or timed. According to these entries, there was a change in shift and the nurse obtained orders for laboratory testing and X-rays. Further review of the entries without dates and times revealed the patient was to be transferred to another hospital, the receiving hospital accepted the patient, a heplock 22 gauge was established, the patient's record was copied and provided to the ambulance staff who were transporting the patient to the receiving hospital.

Review of patient #24's record revealed the patient presented to the ER on 06/15/10 at 13:39 (1:39 PM). Review of the patient's, "Triage/ER Flow Sheet," revealed the documentation section had three entries that were not dated or timed. Further review of this section revealed the patient was evaluated by the physician, the area cleansed and evaluated, dressing and splints applied, and the patient was transferred to another facility. The document page is signed by the nurse at the bottom of the page and each of the entries are initialed.

Review of patient #25's record revealed the patient presented to the ER on 06/27/10 at 11:10 AM. Review of the patient's, "Triage/ER Flow Sheet" revealed the patient was triaged at 11:10 AM and vital signs were obtained and laboratory test completed at 12:15 PM. The next entry stated that the patient was transferred to another hospital by ambulance. This entry was neither dated nor timed. The last entry was written by someone other that the nurse who made the first two entries. The bottom of the page was signed by the nurse who wrote the last entry.

Interview with the Director of Nursing (DON) on 06/29/10 at 2:55 PM revealed that she could not determine the time the entries were made. Further interview with the DON revealed that patient #23's and #25's entries were completed by the same nurse. According to the DON, patient #23's last entries were completed after there was a change in shift.

Based on record review and interview, the facility failed to ensure that 8 of 24 (#6, #9, #10, #11, #12, #14, #15 and #29) in patients' records had a medical history and physical (H&P) completed within 24 hours of admission. Failure to have a completed H&P on the patients' records may result in the physicians and nurses being unaware of any medical history, which may be affected by this hospital admission.

Findings:

(1) During facility record review it was revealed that patient #6 was listed on the operating room register on 4/26/10 for a colonoscopy. Review of the patient's medical record revealed that there was no history and physical provided by the physician/surgeon.

(2) During medical record review for Patient #9 it was revealed that the patient was admitted to outpatient surgery for a colonoscopy on 1/18/10. Further medical record review revealed that there was no history and physical provided by the physician/surgeon in the medical record.

(3) During medical record review for Patient #10 it was revealed that the patient was admitted to outpatient surgery for a colonoscopy on 3/12/10. Further medical record review revealed that there was no history and physical provided by the physician/surgeon in the medical record.

Interview of the Director of Nursing on 6/29/10 at 2:30 PM confirmed that there was no history and physical for Patients #6, #9, and #10.
(4) Review of patient #11's record revealed that the patient was admitted in to the facility on 06/13/10 and discharged on 06/20/10. Further review of this patient's record failed to reveal the patient's H&P. Review of the front of this patient's record revealed a, "Deficiency Slip," with the physician's name, with an audit date of 06/21/10. Further review of this slip revealed a check mark in the missing column for "History & Physical Exam".

(5) Review of patient #12's record revealed the patient was admitted into the facility on 06/07/10 and discharged on 06/11/10. Further review of this record revealed a typed, "Personal History & Physical Examination," document. Review of the last page of this report revealed it had been dictated on 06/21/10 at transcribed on 06/22/10.

(6) Review of patient #14's record revealed the patient was admitted in to the facility on 05/29/10 and discharged on 06/05/10. Further review of this record revealed a typed, "Personal History & Physical Examination, " document. Review of the last page of this report revealed it had been dictated on 05/30/10, but it was not transcribed until 06/02/10. The document was signed on 06/26/10.

(7) Review of patient #15's record revealed the patient was admitted into the facility on 06/19/10 and discharged on 06/23/10. According to patient #15's record, he/she was admitted into a swing bed on 06/22/10. Further record review revealed a, "Swing Bed Admission/Rollover Checklist." Review of this check list revealed a check next to, "H&P (copy)." Further record review failed to reveal an H&P copy in the record.

(8) Review of patient #29's record revealed the patient was admitted in to the facility on 05/27/10 and discharged on 05/29/10. Further review of this record revealed a typed, "Personal History & Physical Examination, " document. Review of the last page of this report revealed it had been dictated on 06/16/10 and transcribed on 06/1810. The physician signed this document on 06/26/10.

Interview with the Director of Nursing on 06/29/10 at 3:06 PM revealed she was unable to obtain patient #11's, #12's, #14's, #15, and #29's H&Ps. Further interview with the DON revealed the hospital's physician is behind in his documentation.


26404

Based on medical record review and interview the facility failed to obtain a properly executed informed consent prior to surgery for 2 of 5 ( #6 and #8) outpatient surgery patients scheduled for elective outpatient surgery. The facility failure to ensure that patients have properly executed informed consents may lead to the patient not being properly informed of their risks or benefits of the procedure prior to surgery.

Findings:

(1) During facility record review it was revealed that Patient #6 was listed on the operating room register on 4/26/10 for a colonoscopy. Review of the patient's medical record revealed that there was no consent for the procedure.

(2) During medical record review for patient #8 it was revealed that the patient had a colonoscopy on 3/8/10. The patient signed the consent for surgery, the nurse witnessed the signature, but the surgeon did not sign the consent acknowledging that informed consent had been explained to the patient.

Interview with the Director of Nursing on 6/29/10 at 2:30 PM stated that she would look for the rest of the chart for Patient #6. She confirmed that there was no surgeon signature for Patient #8.

Review of the facility policy titled "Consent for Surgical and Medical Procedures page 3 section B.2. stated that the "physician's signature evidences that the physician/dentis has informed the patient or Legal Representative of the benefits, risk and alternatives of the proposed procedure."

No other information was provided to the surveyor prior to exit of the facility on 6/30/10 at 4:30 PM, regarding patient #6's consent form.

Based on medical record review the facility failed to ensure that the contents of the medical record was available and complete for 2 of 5 ( #6 and #7) outpatient surgery patients scheduled for elective outpatient surgery. The facility failure to ensure that patients medical records were available and complete places the patients at risk for not receiving appropriate medical care in the event of an emergency.


Findings:

(1) During facility record review it was revealed that patient #6 was listed on the operating room register on 4/26/10 for a colonoscopy. Review of the patient's medical record revealed that there was no consent for the procedure, no record of the procedure or pre-operative assessment by the circulating nurse, no anesthesia record and no history and physical provided by the physician.

(2) During facility record review for patient #7 it was revealed that the patient was listed on the outpatient/emergency room log as being admitted for an outpatient colonoscopy on 5/10/10, but was not listed on the operating room register. Review of the patient's medical record revealed that there was no signature on the anesthesia record and no signature on the progress notes with documentation that sedation medications were given.

Interview with the Director of Nursing on 6/29/10 at 2:30 PM stated that she would look for the rest of the chart for Patient #6. She stated that no surgical procedures were performed at the facility after the entry on the operating room register on 4/26/10. When the surveyor showed the DON the medical record for Patient #7, no further information was provided as to why the procedure was not listed in the operating room register.

No other information was provided to the surveyor prior to exit of the facility on 6/30/10 at 4:30 PM.

Based on record review and interview, the facility failed to ensure that 2 of 24 patients' (#2 and #15) had a discharge summary indicating the outcome of hospitalization and disposition of care. Failure to maintain a complete record may result in the facility's inability to review the patient's past admission information, if the patient is readmitted into the facility.

Findings:

(1) During medical record review for Patient #2 it was revealed that the patient was admitted to the facility on 5/20/10 and discharged on 5/24/10. Continued medical record review revealed that there was no discharge summary provided by the physician in the medical record.

Interview with the Director of Nursing on 6/29/10 at 2:30 PM confirmed that there was no discharge summary in the medical record for Patient #2.


(2) Review of patient #15's record revealed the patient was admitted into the facility on 06/19/10 and discharged on 06/23/10. According to patient #15's record, he/she was admitted into a swing bed on 06/22/10. Further record review revealed a, "Swing Bed Admission/Rollover Checklist." Review of this check list failed to reveal that a discharge summary was required.

Interview with the Director of Nursing, while looking through this record, on 06/29/10 at 3:06 PM revealed she was unable to locate the patient's discharge summary. Further interview with the DON revealed the hospital's physician is behind in his documentation.



26404

Based on observation, facility record review and interview the facility failed to maintain instruments and equipment to ensure an acceptable level of safety and quality. The facility failure to ensure that instruments and equipment were properly maintained may lead to patient wound infections and hazardous conditions for staff and patients.

Findings:

During the tour of the operating room, recovery room and clean/dirty instrument rooms on 6/28/10 at 1:30 PM it was noted that there was an unsecured carbon dioxide cannister standing in the operating room suite. Tour of the dirty instrument processing room it was revealed that the scope buddy was last tested on 4/26/10. Review of the scope buddy manual beside the machine revealed that scope buddy should be tested prior to each use. Tour of the clean instrument processing revealed that there were 5 boxes of peel pack pouches which was outdated as of August, 2008.

Interview of the Director of Support Services, who was present during the tour, on 6/28/10 at 1:30 PM he immediately removed the unsecured carbon dioxide cannister. He stated that the facility had separate areas for clean and dirty instrument processing. He also stated that the facility was in the process of renovating another room for the dirty instrument processing. The Director of Support Services stated that an outside vendor serviced the Autoclave on 6/11/10 and that it was ready for use. He stated that he would provide the work order from that vendor. He stated that the scope buddy was used to process the colonoscopy scope.

On 6/30/10 at 2:45 PM another tour was conducted of the clean instrument processing area along with the maintenance director and the Director of Support Services. A counter draped in blue paper contained many individual packages of instruments. On the blue wrap a note was written that "2 cycles at 30 minutes each with 10 minute dry time, 282 pieces total, result satisfactory, no units discarded." "Expires 9/30/10" was written on all of the packages. On the adjacent counter there was a large covered container with green fluid labeled "Cidex soak activated 6/28/10." The empty "Cidex Plus" containers on the counter which had expired on April, 2010. The Director of Support Services immediately discarded the jugs but the container with the green fluid and the instruments were left in the processing room. He also stated that the facility needed to develop policies and procedures for cleaning, disinfection, and sterilizing instruments. At that time it was revealed that no record of the operating room lights being serviced could be found.

Interview with the maintenance director on 6/30/10 at 3:30 PM stated that he in-serviced the instrument technician hired by the facility. He also stated that the instruments are sterilized according to the Autoclave equipment manual recommendations which had a copyright date of 1965.

Review of the facility policy and procedure titled "Cleaning of Autoclaves/Generator Flushing" section B. 3. states that "routine autoclave checking/maintenance is done by the company on a quarterly basis, this is called preventative maintenance agreement inspection."

Review of the facility policy and procedure titled "Instrument Preparation and Handling Procedure" does not address high level disinfection of instruments (the use of glutaraldehyde) or specifications for loading the autoclave or recording the loads sterilized. The policy also does not address the biological monitoring of the effectiveness of the sterilizer.

Review of the Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 recommends specific procedures for disinfecting and sterilizing medical and surgical instruments to ensure that infectious pathogens are not transmitted to patients. The CDC guidelines recommends cleaning dirty instruments prior to the use of high level disinfectants. The guidelines also state that there should be procedures in place to for testing the high level disinfectant's effectiveness prior to each use. The guidelines also recommends that biological indicator tests are performed at least weekly to monitor the effectiveness of sterilizers against spore production. The guidelines state that the instruments should be placed loosely in the sterilizer so an not to impede the penetration of the sterilant. Also, the recommendation state that for each sterilization cycle specific information should be recorded that include the load contents, exposure parameters, operators name or initials and the results of the biological monitoring.

Based on medical record review and interview the facility failed to ensure that 3 of 5 outpatient surgical patients, (#6, #9,and # 10), had a current history and physical in the medical record prior to surgery. The facility's failure to ensure that a current medical history and physical examination were in the patient's chart prior to surgery places the patients at risk for not receiving appropriate medical care in the event of an emergency.

Findings:

(1 ) During facility record review it was revealed that Patient #6 was listed on the operating room register on 4/26/10 for a colonoscopy. Review of the patient's medical record revealed that their was no history and physical provided by the physician/surgeon.

( 2) During medical record review for Patient # 9 it was revealed that the patient was admitted to outpatient surgery for a colonoscopy on 1/18/10. Further medical record review revealed that there was no history and physical provided by the physician/surgeon in the medical record.

(3 ) During medical record review for Patient # 10 it was revealed that the patient was admitted to outpatient surgery for a colonoscopy on 3/12/10. Further medical record review revealed that there was no history and physical provided by the physician/surgeon in the medical record.

Interview of the Director of Nursing on 6/29/10 at 2:30 PM confirmed that there was no history and physical for Patients #6, #9, and #10.

Based on medical record review and interview the facility failed to ensure that physicians fully executed the informed consent by signing the consent forms for 2 (#6 and #8) of 5 sampled surgical patients. The facility failure to ensure that physicians' validate consent forms may lead to patients not receiving informed consent prior to surgery or procedures.

Findings:

(1) During facility record review it was revealed that Patient #6 was listed on the operating room register on 4/26/10 for a colonoscopy. Review of the patient's medical record revealed that there was no consent for the procedure.

(2) During medical record review for patient #8 it was revealed that the patient had a colonoscopy on 3/8/10. The patient signed the consent for surgery, the nurse witnessed the signature and but the surgeon did not sign the consent acknowledging that informed consent had been explained to the patient.

Interview with the Director of Nursing on 6/29/10 at 2:30 PM stated that she would look for the rest of the chart for Patient #6. She confirmed that there was no surgeon signature for Patient #8.

No other information was provided to the surveyor, regarding patient #6, prior to exit of the facility on 6/30/10 at 4:30 PM.

Based on clinical record review the facility failed to document information in the operating room register as required by regulation.

Findings:

Review of the operating room register revealed that the post operative diagnosis, age of the patient and total time of the operation were not listed on all patients logged in the register since the operating room re-opened on January 18, 2010. Review of the April 26, 2010 entry revealed that it did not contain the name of the anesthesia provider as well as the above listed information.

Based on record review and interview, the facility failed to have the outpatient services department integrated with the facility's inpatient services. Failure to have an integrated outpatient services department may result in the patients' needs not being met.
Findings:

Interview with the Admissions Clerk on 06/28/10 at 1:03 PM revealed the facility provides the following outpatient services: Outpatient laboratory tests and blood work, drug test for jobs, drug test for workers's compensation, X-rays as ordered by area physicians, CAT Scans as ordered by area physicians, ultra sounds as ordered by area physicians, and results of all test are faxed to the requesting physician.

Review of the facility's Organization Chart approved on 06/18/10 revealed that the business office was under the Controller's responsibility. Further review of this chart revealed that the business office was responsible for the, "In/Out Patient Admissions." Further review of this organization chart failed to reveal anyone in charge of outpatient services. According to the Organization Chart, the Director of Support Services was responsible for the radiology and laboratory departments.

Interview with the Chief Executive Officer on 06/30/10 at 1:45 PM revealed that he had not seen Outpatient Services on the Organization Chart, when he recently reviewed it. Further interview confirmed that there were no bylaws written for outpatient services.

Interview with the Director of Nursing (DON) on 06/30/10 at 1:50 PM revealed that she had been the nurse responsible for the outpatient surgical procedures (colonoscopies) when the facility was providing that service, but that she is not responsible for the outpatient services.

Interview with the Director of Support Services on 06/30/10 at 2:00 PM revealed he was responsible for the laboratory and radiology department, so he would be the person responsible for the outpatient services department. Further interview with the Director of Support Services revealed he was not aware of the requirements regarding staffing and policies and procedures for outpatient services.

Interview with the radiology technician on 06/30/10 at 2:15 PM revealed the admissions clerk usually walks patients to radiology after registering. The radiologist stated that there was no nurse assigned to outpatient services and if a nurse is required to start an intravenous (IV), the patient is walked to the Emergency Room (ER) where the nurse on duty will start the IV. Further interview revealed that once the testing is completed, the patient is walked back to the ER where the nurse will evaluate the injections site, remove the IV and discharge the patient.

The radiologist provided an outpatient policy and procedure (P&P) which was not found in the facility's P&P manual. According to this P&P, it was last reviewed by the radiologist on 06/08/10. Review of this P&P revealed the objective of the P&P to be, "To verify the physician's radiology procedure order and to obtain legal consent prior to a radiology procedure." Further review of this P&P failed to reveal any of the information provided during the interview with the radiologist.

Interview with the person responsible for the laboratory (lab.) on 06/30/10 at 2:20 PM revealed that she has policies and procedures in her laboratory department that pertain to outpatient services, but it is part of the overall P&P for the laboratory. Further interview revealed there was no P&P specific to outpatient services.

Review of the P&P for laboratory revealed it was last reviewed on 05/09. Further review of this P&P revealed under the, "Verbal and Written Test Request, " that, "Verbal requests from the physician or any added test to specimen already obtained, the nurse must send a written or faxed order immediately." Further review of this section revealed, "Series or Standing orders are good for 28 days only and are only for specific test ordered for the particular diagnosis codes for those test." Review of page 6 of this P&P revealed the outpatient hours of Operation. Review of page 15 of this P&P revealed, "All outpatient critical values will be phoned to the physician or the nurse in charge of the clinic or office. On weekends where the office is closed, leave the result for the tech to call on Monday." Under the heading, "NCRH Blood Collection Guidelines revealed that for outpatient, "The technologist and phlebotomist will identify the outpatient by asking them to state their full name and state their birth date (day, month, and year) while comparing it to the outpatient face sheet sent to the lab. by the outpatient admitting clerk. Pediatric patients may be identified by their parent/guardian."

Review of the Outpatient Services P&P signed by the DON only on 07/28/09 revealed that the, "Patient will be seen by Phlebotomist, Radiology Department or Nursing staff." Further review of the P&P revealed, "Outpatient services will be supervised and monitored by DON and/or designated [Registered Nurse]."

Based on record review and interview, the facility failed to follow their own policies and procedures (P&P) regarding appropriate professional personnel available for the facility's outpatient services. Failure to ensure appropriate professional personnel are available for outpatient services may result in inappropriate care and services to go undetected.
Findings:

Review of the facility's Organization Chart approved on 06/18/10 revealed that the business office was under the Controller's responsibility. Further review of this chart revealed that the business office was responsible for the, "In/Out Patient Admissions." Further review of this organization chart failed to reveal anyone in charge of outpatient services. According to the Organization Chart, the Director of Support Services was responsible for the radiology and laboratory departments.

Interview with the Chief Executive Officer on 06/30/10 at 1:45 PM revealed that he had not seen Outpatient Services on the Organization Chart, when he recently reviewed it.

Interview with the Director of Nursing (DON) on 06/30/10 at 1:50 PM revealed that she had been the nurse responsible for the outpatient surgical procedures (colonoscopies) when the facility was providing that service, but that she is not responsible for the outpatient services.

Interview with the Director of Support Services on 06/30/10 at 2:00 PM revealed he was responsible for the laboratory and radiology department, so he would be the person responsible for the outpatient services department. Further interview with the Director of Support Services revealed he was not aware of the requirements regarding nurse staffing for outpatient services.

Interview with the radiology technician on 06/30/10 at 2:15 PM revealed the admissions clerk usually walks patients to radiology after registering. The radiologist stated that there was no nurse assigned to outpatient services and if a nurse is required to start an intravenous (IV), the patient is walked to the Emergency Room (ER) where the nurse on duty will start the IV. Further interview revealed that once the testing is completed, the patient is walked back to the ER where the nurse will evaluate the injections site, remove the IV and discharge the patient.

Review of the Outpatient Services P&P signed by the DON only on 07/28/09 revealed that the, "Patient will be seen by Phlebotomist, Radiology Department or Nursing staff." Further review of the P&P revealed, "Outpatient services will be supervised and monitored by DON and/or designated [Registered Nurse]."

Based on facility document review and staff interviews the facility failed to define the scope of the Quality Assurance Performance Improvement (QAPI) program. Failure to define the scope of the QAPI program can result in not identifying opportunities for improvement.

Findings:

Review of the facility documentation did not reveal that the facility had a written QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 did not reveal that a QAPI had been defined in witting or approved by the QAPI committee.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Based on facility's document review and staff interviews the facility failed to set priorities for the Quality Assurance Performance Improvement (QAPI) program. Failure to set priorities for the QAPI program can result in not identifying opportunities for improvements in patient safety and quality of care.

Findings:

Review of the facility's documentation did not reveal that the facility had a written QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the committee or governing body had established any priorities for improvement that will affect health outcomes, patient safety, and quality of care.

Based on facility document review and staff interviews the facility failed to establish the number of performance improvement projects to be conducted annually as part of it's Quality Assurance Performance Improvement (QAPI) program. Failure to conduct performance improvement projects has the potential of the facility not identifying opportunities to improve the quality of care that patient receive and the safety of the environment that care is provided.

Findings:

Review of the facility documentation did not reveal that the facility had a written QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the committee or governing body had reviewed or directed any performance improvement projects to be conducted.

Interview with the QA director on 6/29/2010 at 3:00 PM revealed that neither the QAPI committee nor the Governing Body has directed that performance improvement projects are to be conducted or has established that number of projects that are to be conducted annually as part of the QAPI program.

Based on facility document review and staff interviews the Governing Body/Administration failed to define the scope of, ensure the implementation of, and the maintaining of the Quality Assurance Performance Improvement program, (QAPI). Failure of the Governing Body/Administration to oversee the QAPI program can result in not identifying opportunities for improvement.

Findings:

Review of the facility documentation did not reveal that the facility has a written plan for the QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 did not reveal that a QAPI plan had been defined in witting or approved by the QAPI committee.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the committee or governing body had reviewed or directed any performance improvement projects to be conducted.

Interview with the QA Director on 6/29/2010 at 3:00 PM revealed that neither the QAPI committee nor the Governing Body has directed that performance improvement projects are to be conducted or has established that number of projects that are to be conducted annually as part of the QAPI program.

Based on facility document review and staff interviews the governing body/administration failed to set priorities and evaluation actions taken by the Quality Assurance Performance Improvement (QAPI) program. Failure to set priorities for the QAPI program and evaluate the actions taken to improve quality can result in not improving patient safety and quality of care.

Findings:

Review of the facility documentation did not reveal that the facility has a written plan for the QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 did not reveal that a QAPI plan had been defined in witting or approved by the QAPI committee.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the committee or governing body/administration had established any priorities for improvement that will affect health outcomes, patient safety, and quality of care.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the governing body/administration had reviewed or directed any performance improvement projects to be conducted.

Based on facility document review and staff interviews the governing body/administration failed to establish expectations for safety. Failure to establish safety expectations has the potential of patient care not being provided in a safe environment.

Findings:

Review of the facility documentation did not reveal that the facility had a written QAPI program.

Interview with the Quality Assurance (QA) Director on 6/29/2010 at 3:00 PM revealed that a written QA plan could not be found and that the facility did not have one.

Review of the QAPI committee minutes for 2009 and 2010 did not reveal that a QAIP program had safety expectations defined in witting or approved by the QAPI committee.

Review of the QAPI committee minutes for 2009 and 2010 revealed that the agenda called for individual departments to collect and report data on process indicators specific to each department. The minutes do not indicate any actions taken by the committee relating to the indicator data presented by the individual departments.

Review of the QAPI committee minutes for 2009 and 2010 did not indicate that the committee or governing body/administration had established clear expectations for patient safety.

Based on observation, facility record review and interview the chief executive officer, medical staff and the director of nursing failed to ensure that policies and procedures for maintaining instruments and equipment were developed to ensure an acceptable level of safety and quality for the patients. The failure to ensure that instruments and equipment were properly maintained may lead to patient wound infections and hazardous conditions for staff and patients.

Findings:

During the tour of the operating room, recovery room and clean/dirty instrument rooms on 6/28/10 at 1:30 PM it was noted that the operating room lights were due to be inspected on May, 2008. There was an unsecured carbon dioxide cannister standing in the operating room suite. Tour of the dirty instrument processing room revealed that the scope buddy was last tested on 4/26/10. Review of the scope buddy manual beside the machine revealed that scope buddy should be tested prior to each use. Tour of the clean instrument processing revealed that there were 5 boxes of peel pack pouches which were outdated as of August, 2008.

Interview of the Director of Support Services, who was present during the tour, on 6/28/10 at 1:30 PM it was revealed that the operating room lights were inspected recently and he would provide the information. He immediately removed the unsecured carbon dioxide cannister. He stated that the facility had separate areas for clean and dirty instrument processing. He also stated that the facility was in the process of renovating another room for the dirty instrument processing. The Director of Support Services stated that an outside vendor serviced the Autoclave on 6/11/10 and that it was ready for use. He stated that he would provide the work order from that vendor. He stated that the scope buddy was used to process the colonoscopy scope.

On 6/30/10 at 2:45 PM another tour was conducted of the clean instrument processing area along with the maintenance director and the Director of Support Services. A counter draped in blue paper contained many individual packages of instruments. On the blue wrap a note was written that "2 cycles at 30 minutes each with 10 minute dry time, 282 pieces total, result satisfactory, no units discarded." "Expires 9/30/10" was written on all of the packages. On the adjacent counter there was a large covered container with green fluid labeled "Cidex soak activated 6/28/10." The empty "Cidex Plus" containers on the counter expired April, 2010. The Director of Support Services immediately discarded the jugs but the container with the green fluid and the instruments were left in the processing room. He also stated that the facility needed to develop policies and procedures for cleaning, disinfection, and sterilizing instruments. At that time it was revealed that no record of the operating room lights being serviced could be found.

Interview with the maintenance director on 6/30/10 at 3:30 PM stated that when the outside vendor serviced the Autoclave he was in-serviced on the use of the machine. He stated that he in-serviced the instrument technician hired by the facility. He also stated that the dirty instruments were processed in the clean instrument processing room where the Autoclave is located. He also stated that the instruments are sterilized according to the Autoclave equipment manual recommendations which had a copyright date of 1965.

Review of the facility's policy and procedure titled "Cleaning of Autoclaves/Generator Flushing" section B. 3. states that "routine autoclave checking/maintenance is done by the company on a quarterly basis, this is called preventative maintenance agreement inspection."

Review of the facility's policy and procedure titled "Instrument Preparation and Handling Procedure" does not address high level disinfection of instruments (the use of glutaraldehyde) or specifications for loading the autoclave or recording the loads sterilized. The policy also does not address the biological monitoring of the effectiveness of the sterilizer.

Review of the Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 recommends specific procedures for disinfecting and sterilizing medical and surgical instruments to ensure that infectious pathogens are not transmitted to patients. The CDC guidelines recommends cleaning dirty instruments prior to the use of high level disinfectants. The guidelines also stated that there should be procedures in place to for testing the high level disinfectant's effectiveness prior to each use. The guidelines also recommends that biological indicator tests are performed at least weekly to monitor the effectiveness of sterilizers against spore production. The guidelines stated that the instruments should be placed loosely in the sterilizer so an not to impede the penetration of the sterilant. Also, the recommendation stated that for each sterilization cycle specific information should be recorded that include the load contents, exposure parameters, operators name or initials and the results of the biological monitoring.

Based on record review and interview, the facility failed to ensure five of five (#11, #12, #13, #14, and #15) swing bed patients received an ongoing activities program. Failure provide patients with an ongoing activities program may result in reducing the patients' self-esteem.

Findings:
Review of patient #11's record revealed the patient was admitted into a swing bed on 06/14/10.

Review of patient #12's medical record revealed the patient was admitted into a swing bed on 06/10/10.

Review of patient #13's record revealed the patient was admitted into a swing bed on 04/24/10.

Review of patient #14's record revealed the patient was admitted into a swing bed on 06/02/10.

Review of patient #15's record revealed the patient was admitted into a swing bed on 06/22/10.

Review of patients #11's - #15's medical records failed to reveal documented evidence of ongoing activities being conducted with each patient.

Review of the facility's policy and procedures entitled, "Activities Program For Swing Bed Patients, " dated 7/11/01 revealed that the facility was to have an Activities Director. Further review of this policy and procedure revealed, "Upon admission to a swing bed, the Activities Director will assess patient and develop an appropriate plan of care."

Interview with the Director of Nursing (DON) on 06/30/10 at 10:20 AM revealed that the facility does not have a contract with an activities person. The facility does contract with a local nursing home, but only for Occupational Therapy services.

Based on record review and interview, the facility failed to provide for 5 of 5 (#11, #12, #13, #14, and #15) swing bed patients with social services. Failure to provide social services to swing bed patients may result in their needs not being met once they have been discharged from the facility.

Findings:


Review of patient #11's record revealed the patient was admitted into a swing bed on 06/14/10.

Review of patient #12's medical record revealed the patient was admitted into a swing bed on 06/10/10.

Review of patient #13's record revealed the patient was admitted into a swing bed on 04/24/10.

Review of patient #14's record revealed the patient was admitted into a swing bed on 06/02/10.

Review of patient #15's record revealed the patient was admitted into a swing bed on 06/22/10.

Review of patients #11's - #15's medical records failed to reveal documented evidence of social services being provided to any of the patients.

Review of the facility's Policy and Procedures (P&P) entitled, "Swing Bed Scope Of Services," revealed it was approved on 07/11/01. Further review of this P&P failed to reveal that social services was one of the services provided to these patients.

Review of the facility's P&P entitled, "Swing Bed Scope of Services, " approved on 09/05/1996 revealed, "Social Services evaluates patient and family for social services and psychosocial needs."

Interview with the Director of Nursing (DON) on 06/29/10 at 3:06 PM revealed the facility did not have a contracted or full-time Social Worker.

Interview with the DON on 06/30/10 at 9:33 AM revealed that she had been unaware that the person providing services under the Journey's program was a Social Worker, who could have been providing those services to the swing bed patients.