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Based on document review and staff interview, the facility failed to demonstrate quality monitor indicators for 3 of 11 contracted services.

Findings:

1. Document review of the hospital quality monitor indicators on October 5, 2011 at 1pm indicated three contracted services were not included in the monitor: Housekeeping; Rehab Services; and Mobile Services.

2. Interview with Employee #A2 and Employee #8 on October 5, 2011 at 1pm verified these findings.

Based on review of policies and procedures, patient records, and staff interview, nursing services failed to ensure blood transfusions were administered in accordance with approved policies and procedures for 6 of 8 patient records reviewed.

Findings included:

1. Review of policies and procedures on 10-5-11 between 11:10 AM and 11:30 AM revealed a policy/procedure titled: Blood, Blood Products, Derivatives Administration", policy number: "PCS B-8", last revised "10/09", which read: "Packed cells/blood..never exceed 4 hours from the time the bag is taken out of the validated cooler..." and "Blood transfusion must must initiated within thirty minutes from the time the bag is removed from the validated cooler..." and "Assess vitals (T,P, and B/P) within 1 hour prior to administration and sign record." and "Reassess vitals (T,P, B/P)...fifteen minutes after "start time" (plus or minus 5 minutes is acceptable)..."

2. Review of patient records on 10-5-11 between 12:15 PM and 2:35 PM revealed the following:
a. Patient #L1 was admitted on 7-6-11 and discharged on 7-8-11. The patient received 2 units of leukoreduced packed red blood cells (LR PRBC). The first transfusion was initiated on 7-7-11 at "1130 AM" and the second transfusion was initiated at "1325" on the same date. The time each unit was removed from the validated cooler was not documented, therefore the surveyor was unable to determine if the transfusions were initiated with 30 minutes from the time the blood was removed from the cooler and if the blood was out of the validated cooler no more than 4 hours, as required by approved policies and procedures.
b. Patient #L2 was admitted on 9-12-11 and discharged on 9-13-11. The patient received 2 units of LR PRBC's. The first transfusion was initiated on 9-13-11 at "0140" and fifteen minute vital signs were taken at "0140", the same time the transfusion was initiated. The second transfusion was started at "0520" on the same date. The time each unit was removed from the validated cooler was not documented, therefore the surveyor was unable to determine if the transfusions were initiated with 30 minutes from the time the blood was removed from the cooler and if the blood was out of the validated cooler no more than 4 hours, as required by approved policies and procedures.
c. Patient #L4 was admitted on 6-8-11 and discharged on 6-8-11. The patient received 2 units of LR PRBC's on 6-8-11. The first transfusion was initiated at "1359" and the second transfusion was initiated at "1406". The time each unit was removed from the validated cooler was not documented, therefore the surveyor was unable to determine if the transfusions were initiated with 30 minutes for the time the blood was removed from the cooler and if the blood was out of the validated cooler no more than 4 hours, as required by approved policies and procedures.
d. Patient #L5 was admitted on 5-13-11 and discharged on 5-16-11. The patient received 2 units of LR PRBC's. The first transfusion was initiated on 5-14-11 at "1045" and the second transfusion was initiated on 5-15-11 at "0045". The time each unit was removed from the validated cooler was not documented, therefore the surveyor was unable to determine if the transfusions were initiated with 30 minutes for the time the blood was removed from the cooler and if the blood was out of the validated cooler no more than 4 hours, as required by approved policies and procedures.
e. Patient #L7 was admitted on 3-29-11 and discharged on 4-7-11. The patient received one unit of LR PRBC's on 3-30-11, which was initiated at "1712". The time the unit was removed from the validated cooler was not documented, therefore the surveyor was unable to determine if the transfusion was initiated with 30 minutes for the time the blood was removed from the cooler and if the blood was out of the validated cooler no more than 4 hours, as required by approved policies and procedures.
f. Patient #L8 was admitted on 9-22-11 and discharged on 9-26-11. The patient received one unit of LR PRBC's on 9-25-11, which was initiated at "1738." The time the unit was removed from the validated cooler was not documented, therefore the surveyor was unable to determine if the transfusion was initiated with 30 minutes for the time the blood was removed from the cooler and if the blood was out of the validated cooler no more than 4 hours, as required by approved policies and procedures.

3. In interview on 10-5-11 between 1:20 PM and 2:35 PM, Staff Member #L11 acknowledged the above findings and conveyed the facility did not document the time units of blood were removed from the validated coolers.

Based on document review, policy and procedure review, medical record review, and staff interview, the facility failed to ensure a properly executed informed consent form was in the patient's chart as required per facility policy and procedure for 11 of 22 (N2, N3, N4, N8, N13, N15-N17, and N19-N21) closed patient medical records reviewed.

Findings:
1. Review of Medical Staff Rules and Regulations on 10/5/11 at 11:00 AM, indicated on pg. 12, point 18., "All clinical entries shall be dated, timed and authenticated..."

2. Policy titled, "Consent to Operation and Anesthesia Services" reviewed on 10/5/11 at 10:34 AM, indicated on pg. 1, under Procedure section, points 1.D. & E., "All blanks on the consent form must be filled in. If the item is not-applicable, place N/A in the blank and/or draw lines to fill in the blank...The patient must sign the consent before he receives a sedative or mind-altering medication..."

3. Policy titled, "Surgical Consent" reviewed on 10/5/11 at 10:39 AM, indicated on pg. 1, under Procedure section, point 4., "Each patient will be provided with informed consent."

4. Review of closed patient medical records on 10/4/11 at 2:51 PM, indicated:
a. N2 had a Consent for Operative or Diagnostic Procedures dated 4/20/11, but was lacking physician signature and time for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable."
b. N3 had a Consent for Operative or Diagnostic Procedures dated 8/4/11 and:
i. time of patient's authentication was lacking;
ii. physician authentication was timed at 11:40 AM for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable";
iii. according to the Anesthesia Record, anesthesia administration started at 11:37 AM, which is prior to the physician explanation of risks and benefits statement.
c. N4 Operative Report dated 7/1/11, indicated patient underwent IV sedation and lacked a properly executed informed consent form.
d. N8 had a Consent for Operative or Diagnostic Procedures dated 4/6/11 and:
i. physician authentication was timed at 11:00 AM for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable";
ii. according to the Pre-Op Nursing Admission dated 4/6/11, Versed 2 mg and Fentanyl 100 mcg, both IVP (intravenous push), were administered at 10:46 AM, which is prior to the physician explanation of risks and benefits statement;
iii. according to the Operative Record, anesthesia administration started at 10:47 AM, which is prior to the physician explanation of risks and benefits statement.
e. N13 Operative Report dated 9/29/11, indicated patient underwent General anesthesia and Consent for Operative or Diagnostic Procedures:
i. was dated 9/30/11;
ii. lacked a physician signature and time for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable".
f. N15 had a Consent for Operative or Diagnostic Procedures dated 3/22/11 and:
i. physician authentication was timed at 9:00 AM for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable";
ii. according to the Pre-Op Nursing Admission dated 3/22/11, Versed 2 mg and Fentanyl 100 mcg, both IVP (intravenous push), were administered at 8:56 AM, which is prior to the physician explanation of risks and benefits statement;
iii. according to the Operative Record, anesthesia administration started at 9:00 AM, which is the same time of the physician explanation of risks and benefits statement.
g. N16 had a Consent for Operative or Diagnostic Procedures dated 4/6/11 and:
i. physician authentication was timed at 2:30 PM for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable";
ii. according to the Operative Record, anesthesia administration started at 2:21 PM, which is prior to the physician explanation of risks and benefits statement.
h. N17 Operative Report dated 4/29/11, indicated patient underwent General anesthesia and Consent for Operative or Diagnostic Procedures lacked a time of physician signature for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable".
i. N19 had a Consent for Operative or Diagnostic Procedures dated 8/31/11 and:
i. physician authentication was timed at 6:00 AM for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable";
ii. according to the Operative Record, anesthesia administration started at 5:59 AM, which is prior to the physician explanation of risks and benefits statement.
j. N20 had a Consent for Operative or Diagnostic Procedures dated 5/18/11 and:
i. physician authentication was timed at 10:00 AM for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable";
ii. according to the Pre-Op Nursing Admission dated 5/18/11, Versed 2 mg and Fentanyl 100 mcg, both IVP (intravenous push), were administered at 9:55 AM and 9:57 AM, respectively, which is the same time of the physician explanation of risks and benefits statement;
iii. according to the Operative Record, anesthesia administration started at 10:00 AM, which is prior to the physician explanation of risks and benefits statement.
k. N21 Operative Record dated 6/13/11, indicated patient underwent General anesthesia and Consent for Operative or Diagnostic Procedures lacked a time of physician signature for the statement: "I have explained the specific indications, alternatives, risks, benefits and complications of the operation or procedure, as well as the possible need for alternatives, risks and benefits of transfusion therapy, if applicable".

5. Personnel P14 was interviewed on 10/5/11 at approximately 9:10 AM, and confirmed the above-mentioned closed patient medical records lacked properly executed informed consent forms according to facility policy and procedure.

Based on review of medical record policies, patient records, and staff interview, the dietetic services failed to ensure nutritional needs were met in accordance with the orders of the practitioner or practitioners responsible for the patient's care for 2 of 4 patient records reviewed.

Findings included:

1. Review of medical records policies on 10-5-11 between 12:05 PM and 12:15 PM revealed a policy titled: "Inpatient Medical Record Content", policy number "HIM-14", last revised "May 2009", which read: "Document accurately the course of treatment and results..." and "Clinical observations...documented in a timely manner..." and "The inpatient medical record shall document and contain...Nursing notes, nursing plan of care, medication records, and entries of other health care providers that contain pertinent, meaningful observations and information..."

2. Review of inpatient records on 10-5-11 between 11:30 AM and 11:55 AM revealed the following:
a. Patient #L9 was admitted on 10-4-11. The physician ordered a "Cardiac diet" at "1450". The patient's record did not contain the observation of how much the patient ate during dinner to indicate the physician's orders were followed, as required by the above mentioned approved policy.
b. Patient #L10 was admitted on 9-29-11. On "10-3-11", the dietician documented the following recommendations for the patient on the "Recommendation Form - Individual Resident Nutrition Recommendations/Response": "consider Boost Glucose Control with meals if pt. eats <= 75%...Needs ~2200 cals/day..." On "10-4-11" the patient's physician checked a box on the "Recommendation Form-Individual Resident Nutrition Recommendations/Response" form which read: "I agree with the recommendations". However, there was not a physician's order placed on the patient's chart for "Boost Glucose Control" or for a 2200 calorie diet. Nursing documentation from 10-1-11 to 10-4-11 indicated the patient received an "1800 ADA" diet and did not receive "Boost Glucose Control", even though the patient ate less than 75% of lunch and dinner on 10-2-11 and ate less than 75% of breakfast, lunch and dinner on 10-4-11.

3. In interview on 10-5-11 between 11:30 AM and 11:55 AM, Staff Member #L11 acknowledged the above findings.

Based on document review and staff interview, the facility failed to demonstrate assurance of patient safety by lack of preventive maintenance on 1 of 3 systems reviewed.

Findings:

1. Upon document review October 5, 2011 at 1:30pm, no PM (preventive maintenance) information was made available for review for the nurse call (code) system.

2. Upon interview with Employee # A11 at 1:30pm, staff indicated no preventive maintenance is completed for the nurse call (code) system.

3. No further documentation was presented prior to survey exit.

Based on document review and staff interview, the facility failed to show evidence of plan for emergency backup supply for fuel source.

Findings:

1. Upon document review on October 5, 2011 at 1:30pm, no documentation was made available to review related to plan for emergency sources for fuel supply.

2. Upon interview with Employee #A11 on October 5, 2011 at 1:30pm, staff indicated no plan for emergency fuel supply was available for review.

3. No further documentation was presented prior to time of survey exit.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure a transfer form was completed for 4 of 5 (N8, N9, N10 and N11) patients transferred to another acute care facility.

Findings:
1. Policy titled, "Acute Care Transfer Form" reviewed on 10/5/11 at 10:54 AM, indicated on pg. 1, under:
a. Purpose section, "The Acute Care Transfer Form will be completed for all transfers in order to provide the appropriate documentation required by federal law regarding any transfer out of [facility]."
b. Procedure section, point 1.c., "A new form is initiated with each transfer."

2. Policy titled, "Chart, Patient's Record" reviewed on 10/5/11 at 11:07 AM, indicated on pg. 1, under Procedure section, point 1.0, "Every patient admitted to the hospital has a record which is a complete and accurate history of the hospital stay."

3. Review of closed patient medical records on 10/4/11 at 2:51 PM, indicated:
a. N8 was transferred to another acute care facility on 4/6/11 and was lacking a completed Acute Care Transfer form.
b. N9 was transferred to another acute care facility on 6/14/11 and was lacking a completed Acute Care Transfer form. There was a different Transfer Form completed, but lacked: the accepting physician name, date/time notified; risks and benefits; provider certification; and mode of transport.
c. N10 was transferred to another acute care facility on 6/8/11 and was lacking a completed Acute Care Transfer form.
d. N11 was transferred to another acute care facility on 9/22/11 and was lacking a completed Acute Care Transfer form.

4. Personnel P14 was interviewed on 10/5/11 at approximately 9:10 AM, and confirmed the above-mentioned closed patient medical records lacked a completed transfer form according to facility policy and procedure.