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Based on observation and staff interview, the facility failed to properly post notification signs regarding the absence of a Medical Doctor (MD) or Doctor of Osteopathy (DO) in 1 of 1 emergency rooms. Findings include:

On 8/26/13 at approximately 3:15 p.m., the surveyor observed the facility entrances and the emergency department. Posting of the required notice was neither posted in the emergency room nor in other prominent location within the facility.?

During an interview on 8/26/13 at 3:30 p.m., staff member A, the DON, verified that no signs had been posted to notify patients that a MD or DO was not available in the facility 24 hours a day, seven days a week.


? Federal Regulations read as follows;
Individual notices are not required in the CAH's dedicated emergency department (DED) (as that term is defined in 42 CFR 489.24(b)), but the DED must post a notice conspicuously, in a place or places likely to be noticed by all individuals entering the dedicated emergency department. The posted notice must state that the CAH does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition, as defined in 42 CFR 489.24(b

Based on observation and staff interview, facility staff failed to maintain patient care supplies at an acceptable level of safety and quality in 1 of 1 emergency rooms. Findings include:

On 8/27/13, beginning at 10:00 a.m., the surveyor observed the following expired patient care supplies available for use in the emergency room :

- six BREAS Exhalation ports with the manufacturer's expiration date of 1/2013.
- one open 4-oz. tube of Allegiance lubricating jelly with the manufacturer's expiration date of 2/2011.
- two Medpro Vacuflow 23-gauge blood collection sets with the manufacturer's expiration date of 10/2011.
- one open Kendall 1/2-inch-by-5-yard sterile plain packing strip; the bottle was not labeled with an opened on date.
- one open 8-oz. bottle of Hibiclens antimicrobial scrub solution with the manufacturer's expiration date of 6/2013.
- two 18-gauge-by-3-1/2 inch spinal needles with the manufacturer's expiration date of 7/2009.

The surveyor observed three packages of facility sterilized instruments that had the following problems:

- one emergency room tracheostomy hook, the sterilization verification indicator on the outside of the package had not completely changed color indicating that the sterilization process did not reach the appropriate temperature and for the proper duration of time. The package did not include an internal sterilization verification card that would document completion of the sterilization process.
- one package of sterile probes. Examination of the instruments revealed rust and pitting on the surface of the probes creating a surface that would be difficult to sterilize.
- one nasal pack tray that did not contain the internal sterilization verification card that would document completion of the sterilization process.

During an interview on 8/27/13 at 12:05 p.m., staff member A, the DON, verified the expiration dates of the identified supplies and the condition of the packages of sterilized instruments.

Based on observations and staff interview, the facility staff failed to maintain 1 of 2 bathing areas and the hallways of the building in a clean and orderly manner. Findings include:

During observations of the bathing facilities, across the hallway from room 19 on 8/27/13 beginning at 7:15 a.m., the surveyor noted the following problems:

- The area around the tub had multiple stained areas on the tile floor.
- Paint had been chipped off the heater cover on the right side of the tub. The area which lacked paint was approximately 3 inches by 1-1/2 inches and was covered with rust.
- Two unfilled holes in the wall above the heater cover.
-The vents in the heater cover on the left side of the tub were covered with rust spots and accumulated dust and debris.
- The linoleum floor around the tub had an uneven build-up of wax and dirt.
- The base cove molding in the bath area had pulled away from the walls.
- The corner molding on the wall between the toilet area and the shower was cracked. The tiles were cracked and missing.
- The storage area of the room had scarred and cracked linoleum on the floor.
- The shelves in the area were missing paint and had areas of rust on the shelves.
- There were areas along the hallway between the nurses' station and the emergency entrance where the base cove molding had separated from the wall, which created uncleanable surfaces.

During an interview on 8/27/13 beginning at 5:00 p.m., staff member A, the DON, stated that she was unaware of the maintenance issues in the bath area.

Based on document review and staff interview, the facility failed to ensure that the facility medical director met all responsibilities that included oversight of care provided to 7 (#s 3, 4, 5, 6, 7, 8, and 9) of 9 reviewed acute care patients in the facility. Findings include:

1. During the review of clinical records on 8/27/13 and 8/28/13 the surveyor noted that the medical director had not documented bi-monthly oversight visits to the facility, to ensure adequate medical direction for the facility.

2. The clinical records of 16 emergency room patients were reviewed. None of the emergency room records contained evidence that the physician review of care had occurred.

3. The clinical records of 3 acute care patients required physician oversight, and which was absent from the medical record.

a. Patient #1 was admitted to the facility 8/24/13 with diagnoses including status post fall and hip fracture.
b. Patient #2 was admitted to the facility on 8/26/13 with the diagnosis of hypotension.
c. Patient #3 was admitted to the facility 11/25/12 with the diagnosis congestive heart failure.

4. The clinical record of 6 acute care patients lacked documentation of physician review of the case, or signature for review of care and orders written by the physician's assistant.

a. Patient #4 was admitted to the facility 9/15/12 with complaints of fever, cough and possible pneumonia. The record did not include documentation of MD/DO review of the case, or signature for review of care and orders written by the physician's assistant.
b. Patient #5 was admitted to the facility 12/30/12 with diagnoses of diabetes mellitus, infected knee, and diabetic ketoacidosis. The record did not include documentation of MD/DO review of the case, or signature for review of care and orders written by the physician's assistant.
c. Patient #6 was admitted to the facility 2/15/13 with diagnoses of chronic alcohol abuse, confusion, and altered mental status. She was discharged on 2/16/13. The record revealed that the medical director had reviewed and signed the record on 7/1/13, 4 and 1/2 months after discharge.
d. Patient #7 was admitted to the facility 5/23/13 with diagnoses of osteoporosis, fractured ankle, and hypertension. She was discharged on 5/29/13. The record revealed that the medical director had reviewed and signed the record on 7/1/13, 33 days after discharge.
e. Patient #8 was admitted to the facility 7/26/13 with diagnoses of breast cancer, atrial fibrillation, and excessive anticoagulation. She was discharged 7/29/13. As of 8/28/13, the record lacked documentation of MD/DO review of the record or evaluation of the care provided by the physician's assistant.
f. Patient #9 was admitted to the facility 6/12/12 with shortness of breath. The patient was discharged on 6/14/12. The medical director signed the review of the record on 7/19/12.

During an interview on 8/27/13 at 5:00 p.m., staff member A, the DON, stated that the physician medical director came to the facility on a monthly basis and attended the medical staff meetings. She was not aware that the director had not been completed his oversight of the other providers on staff.

Based on document review and staff interviews, the facility failed to ensure that the physician periodically reviewed and signed the records for 6 (#s 3, 4, 5, 6, 7, and 8) of 9 acute care patients and 13 ( #s 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32) of 13 emergency room patients. Findings include:

1. Patient #3 was admitted to the facility 11/25/12 with the diagnosis congestive heart failure. required physician oversight, and which was absent from the medical record.

2. The clinical record of 6 acute care patients lacked documentation of physician review of the case, or signature for review of care and orders written by the physician's assistant.

a. Patient #4 was admitted to the facility 9/15/12 with complaints of fever, cough and possible pneumonia. The record did not include documentation of MD/DO review of the case, or signature for review of care and orders written by the physician's assistant.
b. Patient #5 was admitted to the facility 12/30/12 with diagnoses of diabetes mellitus, infected knee, and diabetic ketoacidosis. The record did not include documentation of MD/DO review of the case, or signature for review of care and orders written by the physician's assistant.
c. Patient #6 was admitted to the facility 2/15/13 with diagnoses of chronic alcohol abuse, confusion, and altered mental status. She was discharged on 2/16/13. The record revealed that the medical director had reviewed and signed the record on 7/1/13, 4 and 1/2 months after discharge.
d. Patient #7 was admitted to the facility 5/23/13 with diagnoses of osteoporosis, fractured ankle, and hypertension. She was discharged on 5/29/13. The record revealed that the medical director had reviewed and signed the record on 7/1/13, 33 days after discharge.
e. Patient #8 was admitted to the facility 7/26/13 with diagnoses of breast cancer, atrial fibrillation, and excessive anticoagulation. She was discharged 7/29/13. As of 8/28/13, the record lacked documentation of MD/DO review of the record or evaluation of the care provided by the physician's assistant.

3. None of the 13 emergency room records contained documentation of the physician oversight of patient care provided by the physician's assistant or nurse practitioner on duty. Review of other records indicated that from approximately January 1, 2013 through June 30, 2013, there were no signatures indicating physician review had been completed..

a. Patient #20 was brought to the emergency room on 7/14/12 with complaints of flu like symptoms. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

b. Patient #21 came to the emergency room on 7/28/12 with a gunshot wound to the head. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

c. Patient #22 came to the emergency room on 8/6/12 with complaints of jaw pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

d. Patient #23 was brought to the emergency room on 9/1/12 for treatment of a scalp laceration. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

e. Patient #24 was brought to the emergency room on 9/30/12 with complaints of lethargy and fever. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

f. Patient #25 came to the emergency room with complaints of a syncopal episode, low back pain and chronic obstructive pulmonary disease. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

g. Patient #26 came to the emergency room on 12/1/12 in active labor. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

h. Patient #27 was brought to the emergency room on 12/13/12 status post motor vehicle accident. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

i. Patient #28 came to the emergency room 1/1/13 with complaints of jaw pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

j. Patient #29 came to the emergency room on 3/8/13 with complaints of chest pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

k. Patient #30 came to the emergency room on 4/20/13 with complaints of chest pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

l. Patient #31 was brought to the emergency room on 5/11/13 with cold like symptoms. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

m. Patient #32 came to the emergency room on 6/28/13 with complaints of shortness of breath. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

During an interview on 8/27/13 at 5:00 p.m., staff member A, the DON, stated that the physician medical director came to the facility on a monthly basis and attended the medical staff meetings. She was not aware that the director had not been completing his responsibilities for oversight of the other providers on staff.

During an interview on 8/28/13 at 9:20 a.m., staff member P, the medical records designee, stated that the medical director was supposed to come every month and sign charts.

Based on document review and staff interviews, the facility failed to ensure that the physician periodically reviewed and signed the records for 13 ( #s 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32) of 13 emergency room patients. Findings include:

None of the 13 emergency room records contained documentation of the physician oversight of patient care provided by the physician's assistant or nurse practitioner on duty. Review of other records indicated that from approximately January 1, 2013 through June 30, 2013, there were no signatures indicating physician review had been completed..

1. Patient #20 was brought to the emergency room on 7/14/12 with complaints of flu like symptoms. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

2. Patient #21 came to the emergency room on 7/28/12 with a gunshot wound to the head. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

3. Patient #22 came to the emergency room on 8/6/12 with complaints of jaw pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

4. Patient #23 was brought to the emergency room on 9/1/12 for treatment of a scalp laceration. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

5. Patient #24 was brought to the emergency room on 9/30/12 with complaints of lethargy and fever. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

6. Patient #25 came to the emergency room with complaints of a syncopal episode, low back pain and chronic obstructive pulmonary disease. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

7. Patient #26 came to the emergency room on 12/1/12 in active labor. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

8. Patient #27 was brought to the emergency room on 12/13/12 status post motor vehicle accident. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

9. Patient #28 came to the emergency room 1/1/13 with complaints of jaw pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

10. Patient #29 came to the emergency room on 3/8/13 with complaints of chest pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

11. Patient #30 came to the emergency room on 4/20/13 with complaints of chest pain. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

12. Patient #31 was brought to the emergency room on 5/11/13 with cold like symptoms. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

13. Patient #32 came to the emergency room on 6/28/13 with complaints of shortness of breath. The record did not include a signature, initials, or a note indicating that the record had been reviewed by the MD/DO.

During an interview on 8/27/13 at 5:00 p.m., staff member A, the DON, stated that the physician medical director came to the facility on a monthly basis and attended the medical staff meetings.

During an interview with staff member P, the Medical records designee, on 8/28/13 at 9:20 a.m., staff member P stated that the medical director was supposed to come every month and sign charts.

Based on observation and staff interview, facility staff failed to ensure that outdated/unusable medications were not available for administration to patients in 1 of 1 emergency rooms. Findings include:

During observation of the emergency room on 8/27/13, beginning at approximately 10:00 a.m., the surveyor noted the following expired or unusable medications in these locations in the emergency room;

Crash Cart;
- two 50 gram tubes of Actichar solution with the manufacturer's expiration date of 1/2013.
- one open partially used bottle of Nitroglycerine 0.4 mg. sublingual tablets. The bottle was not marked with the date that the bottle was opened.
- four 500 mg. bottles of Aminophylline solution for intravenous injection with the manufacturer's expiration date of 6/13.

Open Storage shelves;
- one 1000 ml. bag of Lactated Ringers intravenous solution with the manufacturer's expiration date of 5/2013.
- one open partially used 30-ml. multi-dose vial of 1% Xylocaine with Epinehrine 1%. The vial was not marked with the date that it was first opened.

Nasal Tray;
- four foil packs of Triple Antibiotic ointment with a manufacturer's expiration date of 12/2012.

During an interview with staff member A, the DON, on 8/27/13 at 11:30 a.m., staff member A stated that nursing staff had just reviewed the medications and supplies in the emergency room but had missed the identified items.

Based on observations, facility staff failed to follow approved infection control guidelines during 1 of 2 medication passes and during the provision of care to 1 (# 35) swing bed resident. Findings include:

1. During observation of the medication pass on 8/28/13 beginning at 7:45 a.m., staff member C, a registered nurse, used an alcohol based hand sanitizer to clean her hands between patients/residents. After wetting her hands with the hand sanitizer and rubbing it in for approximately 15 seconds, staff member C wiped the remaining sanitizer off of her hands on her uniform top.?


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2. The surveyor observed staff members N and R provide perineal care to resident #35 on 8/27/13 at 4:10 p.m. Staff members N and R assisted resident #35 to the toilet via mechanical lift. Resident #35 urinated and had a bowel movement. Staff member N placed gloves on and provided perineal care. Staff member N then placed a clean incontinent product on resident #35 and pulled her pants up. Staff members R and N assisted resident #35 to sit in the wheelchair. Staff member N removed her gloves and placed them in the garbage and wheeled resident #35 to the lounge area to watch the television. Staff member N failed to wash or sanitize her hands upon removal of her gloves.

? http://www.cdc.gov/handwashing/

How do you use hand sanitizers?
? Apply the product to the palm of one hand.
? Rub your hands together.
Rub the product over all surfaces of your hands and fingers until your hands are dry.

Based on observations and staff interview, the facility failed to store food in a sanitary manner and failed to have a qualified dietician provide training and education to dietary staff. Findings include:

1. The surveyor observed the kitchen on 8/26/13 at 2:45 p.m. The surveyor observed the following in the refrigerator:

- 2 1/2 gallons of vitamin D milk with a use by date of 8/22/13. Staff member G stated the milk had been delivered to the facility on 8/8/13;
- an 11 oz. can of mandarin oranges with a use by date of 12/11.

The freezer in the kitchen had a large amount of ice buildup as the door seal gasket did not adhere tightly.

2. The refrigerator at the nursing station was observed on 8/26/13 at 3:00 p.m. The surveyor observed the following:

- two 5.3 oz. Activia greek yogurt with an expiration date 8/8/13;
- a 5.3 oz. Dannon oikos yogurt with an expiration date 1/22/13;
- a 16 oz. bottle Kraft classic ranch dressing with an expiration date of 4/11/13;
- a jar of apple butter with an expiration date 2012;
- a 16 oz. bottle Kraft thousand island dressing with an expiration date of 1/15/13;
- a 16 oz. bottle Kraft classic catalina dressing with an expiration date of 7/13/13;
- a 7.5 oz. bottle of Taco Bell mild restaurant sauce with an expiration date 7/3/13; and
- a 12 oz. bottle of Kraft tartar sauce with an expiration date 8/9/13.

Silver duct tape was holding the refrigerator shelf together and white nursing tape was holding a shelf together in the freezer.

3. The surveyor observed the main dining room on 8/26/13 at 4:00 p.m. The surveyor found the following items stored in the cabinets in the main dining room opened and not sealed:

- an 11 oz. box of Nilla Wafers;
- a 15.1 oz. box Ritz crackers;
- a 24 oz. box baking soda;
- a five pound bag of flour;
- a 15 oz. bag of pretzels;
- a 32 oz. box Aunt Jemima pancake mix;
- a 1.75 oz. box of ice cream cones;
- a four pound box ice cream salt; and
- a four pound box pickling salt.

4. During an interview with staff member H, the dietary manager, on 8/27/13 at 2:35 p.m., she stated the dietician had not provided any training or education other than the training handbook. She stated the education and training to the staff is provided by herself not the dietician.

Based on document review and staff interviews, the facility chief executive officer failed to ensure that contracted dietitian services met all applicable conditions of participation and standards for the contracted services. Findings include:

During the review of contracts on 8/27/13, the surveyor selected the dietitian services contract for review. The contract had been in force since 4/1/2004 and was active indefinitely. The contract stipulated that the dietitian would provide monthly visits, consultations to patients and families, provide advice to the dietary supervisor, review and approve regular and therapeutic diets, and provide monthly inservice education and training to dietary personnel and dietary related inservices to other staff personnel as needed. The facility did not have a current dietary manual that had been reviewed and approved by the consulting dietitian.

Review of the contract books did not reveal evidence that the contract currently in force had been reviewed or evaluated for compliance with federal requirements for contract services.

During an interview with staff member H on 8/27/13 at 2:35 p.m., she stated the dietician had not provided any training or education other that the training handbook. She stated the education and training to the staff is provided by herself not the dietician.

During an interview with staff member F, the chief executive officer, on 8/28/13 at 4:45 p.m., staff member F stated that he reviewed the contracts for services annually. He stated that he would review each contract, remove any old or non-used contracts from the list and book. Staff member F stated that he had not been as thorough as possible and was not aware that there had been difficulties with the services provided by the contract dietitian. He did not document the annual review of the contracts in the annual program review documentation and report to the governing board.

Based on document review and staff interviews, the facility failed to ensure that clinical records for 9 (#s 1, through 9) of 9 reviewed acute care patients, and 13 (#s 20, through 32) of 13 emergency room patients included properly executed consent forms. Findings include:

During the review of clinical records on 8/27/13 and 8/28/13, the surveyor noted that none of the reviewed records included documentation of the time when consent for treatment was obtained by the patient or family member responsible. Review of the admission consent form in use by the facility revealed that the form did not include a space or tickler for the addition or documentation of the time when the consent was obtained.

During an interview with staff member A, the DON, on 8/27/13 at 5:00 p.m., staff member A stated that she was not aware that time of consents was not being documented on the consent forms.

Based on observation and staff interview, facility staff failed to ensure that the confidentiality and protection of radiological tests in 1 of 2 record storage areas. Findings include:

During observation of the radiology room on 8/27/13 beginning at approximately 9:55 a.m., the surveyor noted a cabinet in the locker room off the x-ray room that contained 4 shelves of processed radiology films. The cabinets did not lock. There were two doors into the room. One door opened into the x-ray room and was not equipped with a lock. The other door opened into the restroom from the main hallway. There was no external lock on that door.

During an interview with staff member E, the radiology technician, on 8/27/13 at 10:15 a.m., she stated that the films in the locker room area were older films that were awaiting destruction or storage. She stated that she was aware that there were no locks securing the old films.

Based on record reviews, observations, and staff interview the hospital failed to a complete a comprehensive assessment for restraints and failed to update the care plan for the use of restraints for 2 (#s 15 and 33) of 37 sampled swing bed residents. Findings include:

1. Resident #15 was admitted to the facility on 3/1/13 with diagnoses which included hypertension and Alzheimer's. The surveyor observed resident #15 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor documentation on the care plan for the lap buddy.

During an interview with staff member A, the DON, on 8/27/13 at 11:35 a.m., she stated resident #15 was able to remove her lap buddy. Resident #15 was not able to remove her lap buddy when staff member A asked her to do so on 8/27/13 at 11:40 a.m.

Staff member A further stated that the facility did not have a written policy and procedure for placement of a lap buddy on a resident.

2. Resident #33 was admitted to the facility on 7/15/10 with diagnoses which included depression and osteoporosis. The surveyor observed resident #33 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m. and on 8/28/13 at 7:40 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record lacked an assessment for the lap buddy or documentation on the care plan for the lap buddy.

During an interview with staff member A on 8/28/13 at 8:00 a.m., she stated resident #33 was able to remove her lap buddy. Resident #33 was not able to remove her lap buddy when staff member A asked her to do so on 8/28/13 at 8:00 a.m.

Based on observations, record review, and staff interview, the facility failed to assess and update the plan of care for 2 (#s 15 and 33) of 37 sampled swing bed residents for the use of restraints. Findings include:

1. Resident #15 was admitted to the facility on 3/1/13 with diagnoses which included hypertension and Alzheimer's. The surveyor observed resident #15 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor documentation on the care plan for the lap buddy.

During an interview with staff member A, the DON, on 8/27/13 at 11:35 a.m., she stated resident #15 was able to remove her lap buddy. Resident #15 was not able to remove her lap buddy when staff member A asked her to do so on 8/27/13 at 11:40 a.m.

Staff member A further stated that the facility did not have a written policy and procedure for placement of a lap buddy on a resident.

2. Resident #33 was admitted to the facility on 7/15/10 with diagnoses which included depression and osteoporosis. The surveyor observed resident #33 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m. and on 8/28/13 at 7:40 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor documentation on the care plan for the lap buddy.

During an interview with staff member A on 8/28/13 at 8:00 a.m., she stated resident #33 was able to remove her lap buddy. Resident #33 was not able to remove her lap buddy when staff member A asked her to do so on 8/28/13 at 8:00 a.m.

Based on staff record review and staff interview, the facility failed to check the state nurse aide registry or licensing authorities prior to employment for 4 (#s J, K, L, and M ) of 6 staff employment records reviewed. Finding included:

1. The surveyor reviewed 6 staff member records on 8/28/13 at 3:45 p.m. The surveyor found 4 of the 6 lacked evidence of a screening prior to hire.

a. Staff member J had a hire date of 6/1/13;
b. staff member K had a hire date of 8/8/13;
c. staff member L had a hire date of 2/11/13; and
d. staff member M had a hire date of 10/17/12.

2. During an interview on 8/28/13 at 3:45 p.m., staff remember O verified that the screening for the 4 staff members above had not been completed.

Based on record review and staff interviews, the facility failed to ensure that a comprehensive nursing assessment for 2 (#s 15 and 33) of 37 residents was completed. Findings include:

1. Resident #15 was admitted to the facility on 3/1/13 with diagnoses which included hypertension and Alzheimer's. The surveyor observed resident #15 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor documentation on the care plan for the lap buddy.

During an interview with staff member A, the DON, on 8/27/13 at 11:35 a.m., she stated resident #15 was able to remove her lap buddy. Resident #15 was not able to remove her lap buddy when staff member A asked her to do so on 8/27/13 at 11:40 a.m.

Staff member A further stated that the facility did not have a written policy and procedure for placement of a lap buddy on a resident.

2. Resident #33 was admitted to the facility on 7/15/10 with diagnoses which included depression and osteoporosis. The surveyor observed resident #33 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m. and on 8/28/13 at 7:40 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor documentation on the care plan for the lap buddy.

During an interview with staff member A on 8/28/13 at 8:00 a.m., she stated resident #33 was able to remove her lap buddy. Resident #33 was not able to remove her lap buddy when staff member A asked her to do so on 8/28/13 at 8:00 a.m.

Based on clinical record review, policy review, and staff interview, the facility failed to develop a comprehensive care plan for the use of restraints for 2 (#s 15 and 33 ) of 37 sampled patients. Findings included:

1. Resident #15 was admitted to the facility on 3/1/13 with diagnoses which included hypertension and Alzheimer's. The surveyor observed resident #15 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor documentation on the care plan for the lap buddy.

During an interview with staff member A, the DON, on 8/27/13 at 11:35 a.m., she stated resident #15 was able to remove her lap buddy. Resident #15 was not able to remove her lap buddy when staff member A asked her to do so 8/27/13 at 11:40 a.m.

Staff member A further stated that the facility did not have a written policy and procedure for placement of a lap buddy on a resident.

2. Resident #33 was admitted to the facility on 7/15/10 with diagnoses which included depression and osteoporosis. The surveyor observed resident #33 to sit in her wheelchair with a lap buddy in place on 8/27/13 at 8:00 a.m. and 8/28/13 at 7:40 a.m.

The medical record was reviewed for an assessment of the lap buddy and the care plan. The medical record neither included an assessment for the lap buddy nor or documentation on the care plan for the lap buddy.

During an interview with staff member A on 8/28/13 at 8:00 a.m., she stated resident #33 was able to remove her lap buddy. Resident #33 was not able to remove her lap buddy when staff member A asked her to do so.

Based on observation, record review and staff interview, it was determined that nursing staff failed to adhere to professional standards during bolus feeding and medication administration via peg tube for 1 (#34) of 37 sampled swing bed residents and during transfers for 3 (#s 10, 35, and 1 unknown resident) of 3 observed transfers. Findings include:

1. Resident #34 was admitted to the facility on 3/28/12 with diagnoses including dementia, recent cerebral vascular accident with dysphasia, and multiple sclerosis. Resident #34 had a gastronomy tube placed 12/12/12 with physician orders including bolus tube feedings 5 times daily.

The surveyor observed staff member B provide a bolus feeding to resident #34, while she was in her room sitting in her recliner chair, on 8/27/13 at 12:10 p.m. Staff member B did not close the door to the room in order to provide privacy for resident #34. Staff member B stated "hopefully no one will come by." Staff member B, with her gloved hands, then pulled up resident #34's shirt to find the end of the tube, exposing her abdomen. Staff member B removed the cap off the end of the tube and checked the tube for residual by injecting air into the tube.

Staff member B then poured resident #34's bolus feeding into the tube and let it run per gravity. When the bolus feeding was finished, staff member B administered resident #34's medication mixed with water through the tube, and then flushed the tube with water. Staff member B then placed a cap on the end of the tube, and pulled resident #34's shirt down to cover her abdomen. Staff member B did not use a stethoscope at anytime during the administration of the tube feeding, water, or medication.?

2. The surveyor observed staff member B and an unknown CNA assist an unknown female resident to sit down in her wheelchair on 8/27/13 at 11:25 a.m. after ambulating. The wheelchair brakes were not in the locked position and the wheelchair moved backwards slightly when the resident sat down.

3. The surveyor observed staff member B assist resident #10 to stand from his wheelchair on 8/28/13 at 7:25 a.m. Staff member B did not have the wheelchair brakes in the locked position while assisting resident #10 to stand.?

4. The surveyor observed staff members K and Q transfer resident #34 on 8/28/13 at 9:35 a.m. Staff members K and Q placed resident #34 in a mechanical lift and transferred her from the bed to a Broda chair. The brakes were not in the locked position on the Broda chair when resident #34 was placed in the chair.?

?... 7. Using the catheter-tipped syringe, inject 20-30 cc of air while listening with a stethoscope...
The Lippincott manual of nursing practice (8th ed.). (2006). Philadelphia, PA: Lippincott.

?According to Sorrentino and Gorek, measures to maximize wheelchair safety included the use of non-skid footwear, positioning resident's feet on wheelchair footrests, and locking both brakes before the resident is transferred from the wheelchair.
Sorrentino, S.A. and Gorek, B. (2003). Long term care assistants (4th ed., pp. 147 and 155). St. Louis, Missouri: Mosby.

Based on observation and staff interview, the facility failed to properly post required EMTALA signage in 1 of 1 emergency room, 3 of 3 entrances, and 1 of 1 areas where patients would wait for treatment. Findings include:

On 8/26/13, beginning at 3:00 p.m., an initial walk through of the facility was completed. During the observation of the emergency room, the surveyor was unable to locate EMTALA signs. The surveyor went to the main entrance, emergency room entrance, and the corridor end doors within the facility and was unable to locate EMTALA postings. The surveyor returned to the emergency room door and noted a black and white 8-1/2-inch-by-11-inch mimeographed sign of EMTALA rights on a bulletin board immediately outside of the emergency room door. The sign was on a bulletin board placed 5 feet above floor level. The sign that was posted was not located in a place that was easily seen by patients or individuals waiting to be seen in the emergency room.

"Section 1866(a)(1)(N)(iii) of the Social Security Act requires the posting of signs which specify the rights of individuals with EMCs and women in labor.

To comply with the requirements hospital signage must at a minimum:
- Specify the rights of individuals with EMCs and women in labor who come to the emergency department for health care services;
- Indicate whether the facility participates in the Medicaid program;
- The wording of the sign(s) must be clear and in simple terms and language(s) that are understandable by the population served by the hospital; and
- The sign(s) must be posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area)."

During an interview with staff member A, the DON on 8/26/13 at 3:50 p.m., staff member A verified that the mimeographed sign was the only EMTALA sign posted in the building.