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Based on interview, record review and policy review, the facility failed to correctly identify three patients (#46, #47, and #48) of five patient complaints as grievances. This failure had the potential to inadequately resolve problems identified and affect all patients admitted to the facility. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Patient Complaint/Grievance Process," dated 06/2015, showed that:
- All grievances must be investigated towards resolution.
- A complaint was a patient or family concern which is immediately resolved and the patient or family is satisfied with the actions taken, examples included room change, noise control, etc.
- A grievance was a formal written or verbal complaint that was made to the facility by the patient or representative regarding the patient's care. A grievance could not be resolved at the time of the complaint, was postponed or referred to other staff for later resolution, or it required investigation, and/or further actions for resolution.

2. During an interview on 08/25/15 at 3:35 PM, Staff II, Director of Quality and Risk Management, stated that she had heard differences of opinions of whether a complaint was identified as a complaint or a grievance. During a concurrent record review of the facility policy and the complaint log, Staff II acknowledged that three entries (for Patients #46, #47, and #48) listed on the complaint log, should have been identified as grievances. The entries showed the following:
- A complaint dated 05/10/15 showed an Emergency Room (ER) physician was allegedly rude to Patient #46.
- A complaint dated 05/13/15 showed an alleged problem with ER wait time for Patient #47.
- A complaint dated 06/18/15, showed another alleged problem related to ER wait time for Patient #48.
The complaint log had documentation that the complaints were forwarded to the Emergency Department (ED) Director, the ED Director contacted the complainant, and information was forwarded to the ED Medical Director for follow up.

Based on interview and record review, and policy review, the facility failed to respond by letter per their policy to three patients (#46, #47, and #48) of five patients that filed grievances or had grievances filed on their behalf. This had the potential to cause a complainant to have unanswered questions/concerns about the care of the patient. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Patient Complaint/Grievance Process," dated 06/2015, showed that all grievances must be investigated towards resolution and the patient received written notification of the grievance process and determination within seven days.

During an interview on 08/27/15 at 11:00 AM with Staff II, Director of Quality and Risk Management, and a concurrent record review of documentation located in the form titled, "Complaint Log," she acknowledged that:
- The complainant for Patient #46 should have received a letter for a complaint of an emergency room (ER) physician's rudeness, and did not.
- The complainant for Patient #47 should have received a letter for a complaint of ER wait time, and did not.
- The complainant for Patient #48 should have received a letter for a complaint of ER wait time, and did not.
Staff II stated the letters were not sent because they were initially identified incorrectly as complaints instead of grievances.

Based on interview and record review the facility failed to ensure the Quality Assessment Performance Improvement program (QAPI) involved all patient care areas in collecting data and collecting measurable data toward indicators for analysis and trending for improvement for one department (Medical-Surgical) of 17 reviewed. This failure increased the potential for inconsistent, unsafe, and ineffective care for all medical-surgical patients. The facility census was 11.

Findings included:

1. Record review of the facility's document titled, "Performance Improvement Plan," dated 05/2015, showed the facility assured that the improvement process was organization wide, monitoring, assessing, and evaluating the quality and appropriateness of patient care, patient safety, and practices and clinical performance to resolve identified problems and improve performance. Data would be collected to determine whether design specifications for new processes were met and for the level of performance and stability of existing processes.

2. Record review of the Medical-Surgical QAPI Plan and data collection for indicators noted in the plan for the year of 2015 showed:
- No data was collected at all for the months of February, April, and May of 2015.
- The plan showed to collect data for compliance of a completed form and appropriate documentation of immunizations by nursing staff. No data was collected.
- Pain was to be assessed every shift per a one to 10 scale and documentation of non-verbal signs and symptoms by nursing. No data was collected.
- The plan showed to collect data for compliance with medication verification. No data was collected.
- The plan was to collect data for fall assessments completed every three days or when patient's status changed, placement of yellow arm bands and alert signage and the appropriate documentation by nursing staff. No data collected.

During an interview on 08/26/15 at 9:00 AM Staff II, Quality Director, stated that she expected the data to be collected according to the plan. She had failed to ensure this occurred due to recent changes in the Medical-Surgical department management.

During an interview on 08/27/15 at 8:40 AM, Staff L, Chief Nursing Officer (CNO), stated that she accepted responsibility for the QAPI not completed appropriately in the Medical-Surgical department due to a priority to hire nurses for this area.

During an interview on 08/27/15 at 10:00 AM, Staff E, Medical-Surgical, Intensive Care Unit (ICU), Director, stated that he was promoted to this position in March and his first priority was to hire nurses to staff the department. He stated that he was aware that the data collected failed to correlate with his QAPI plan, but had not changed the data collected yet.

Based on interview and record review the facility failed to ensure the Quality Assessment Performance Improvement (QAPI) program included performance improvement projects (assessment conducted of a patient care problem through peer analysis, intervention, resolution of the problem, and follow-up.) This failure increased the potential risk of adverse events/errors and substandard care for all patients treated within the hospital. The facility census was 11.

Findings included:

1. Record review of the facility document titled, "Performance Improvement Plan," dated 05/2015, showed facility direction that a project or project(s) would be developed and implemented for inclusion in the organization wide performance improvement program at the facility. No performance improvement project(s) were documented in this plan.

2. During an interview on 08/26/15 at 1:00 PM, Staff II, Quality Director, stated that they had no performance improvement projects.

During an interview on 08/27/15 at 8:40 AM, Staff L, Chief Nursing Officer (CNO), stated that the facility worked on some performance improvement issues, but failed to set them up as projects.

During an interview on 08/24/15 at 1:36 PM, Staff F, Director of Dietary, stated that he did not have any QA projects for the department.

During an interview on 08/26/15 at approximately 3:00 PM, Staff G, Registered Dietitian, stated that the Dietary department did not have any QA projects.

Based on interview and record review the Governing Body failed to ensure:
- The Dietary department established and maintained a Quality Assurance Performance Improvement (QAPI) program to review the quality of food and nutrition services provided to patients.
- The Obstetric (OB, the branch of medicine that deals with woman's health before, during, and after childbirth) department established QAPI programs that focused on improvement of the quality of care provided to OB patients.
- That four of nine patient care contracted services were involved in the hospital wide QAPI.
These failures had the potential to allow unsafe food sanitation practices to be used for patient care; and increased the potential for adverse events and errors for all patients that were provided treatment. The facility census was 11.

Findings included:

1. Record review of the facility's document titled, "Performance Improvement Plan," dated 05/2015, showed direction for the Governing Body that:
- They were responsible for the quality of patient care provided.
- They provided resources and support systems for the performance improvement functions related to patient care and safety.
- It was their responsibility to evaluate the effectiveness of the performance improvement activities performed throughout the hospital and the organizational performance improvement program as a whole.

2. Record review of the Dietary department's undated policy titled, "Goals for Performance Improvement," showed the following directives:
- The goals of the Dietary department's performance improvement plan was to continually and systematically plan, design, measure, assess and improve performance of priority focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors;
- To achieve the goals, the Dietary department incorporated quality planning through a systematic method to work in the department and with other departments to improve patient care and to provide a method to assess and achieve optimal patient health outcomes; and
- The Scope of Care was described and included safe, sanitary patient meal service free of contamination; and an evaluation of patient satisfaction.

Record review of the Dietary department's undated policy titled, "Reporting - Quality Assurance (QA) Systematic Quality Review," showed directives for the Dietary department Manager to:
- Design and review all QA studies and data reviews conducted within the timeframe of the report;
- Identify problems, plan of action and follow up;
- Prepare the reports; and
- Send the reports to the QA Committee for review and submission to the Medical Executive Committee and the Governing Body.

3. During an interview on 08/24/15 at 1:36 PM, Staff F, Director of Dietary, stated that he collected information such as temperatures of the refrigeration equipment, and the dish washing machine but, did not have identified problems that would require temperature data collection. He further stated that he did not submit the temperature data to the QA Committee for review and submission to the Medical Staff Executive Committee or the Governing Body.

During an interview on 08/27/15 at 8:55 AM, Staff F stated that he attended QA Committee meetings where he discussed work done within the Dietary department and, he again confirmed he did not have any planned, defined studies for submission to the QA committee or any other staff.

4. Record review of the each departments QAPI plan showed that there was no plan for the OB Department.

During an interview on 08/26/15 at 9:00 AM Staff II, Quality Director, stated that the OB Department failed to have a QAPI plan with indicators to allow for collection, analysis, and trending of data.

During an interview on 08/27/15 at 9:24 AM Staff N, Director of OB and Nursery, stated that she just started in March of 2015 in this position and planned to revise the previous directors ideas and start a QAPI plan, but she had no official QAPI plan with indicators at this time.

5. Record review of the facility's document titled, "Performance Improvement Plan," dated 05/2015 showed no QAPI plan for the following contracted services:
- Specialized lab services;
- Blood bank provider;
- Occupational therapy (therapy that works with the upper body); and
- Speech therapy (diagnose and treat language and swallowing disorders)

During an interview on 08/26/15 at 1:36 PM and 08/27/15 at 8:35 AM, Staff II confirmed that the facility failed to involve the four above mentioned contracted services in the hospital wide QAPI plan.

During an interview on 08/26/15 at 1:53 PM, Staff II stated that the Governing Body was not given the QAPI annual plan or the individual department indicators for review.

During an interview on 08/27/15 at 9:36 AM, Staff JJJ and Staff KKK, members of Governing Body, stated that they did not review QAPI for all the individual departments and contracted services and stated that they were ultimately responsible for all the hospital operations.



16215

Based on interview and record review the facility failed to ensure members of the Medical Staff, who were requesting reappointment, provided necessary evidence of professional education, a statement of their ability to perform the privileges requested; health status and supporting peer references of competence as direct by the facility Medical Staff Bylaws for seven (Staff BBB, CCC, DDD, EEE, FFF, GGG, and III) of eight credentialing files reviewed. This deficient practice had the potential to permit staff seeking reappointment, without documented evidence of education/training; review of health status and references from peers, to provide care to patients. The facility census was 11.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," dated 07/08/14 showed directives for staff seeking reappointment to the Medical Staff to provide documentation including:
- Any post-secondary school training (college), including the name of the institutions and the date attended, any degrees granted, course of study or program completed and for all post-graduate training, names of persons responsible for reviewing the applicant's performance.
- A statement as to whether the applicant's health status is such that the applicant is able to perform all procedures for which he or she has requested privileges, with or without accommodation, according to accepted standards of professional performance and without posing a direct threat to patients. and
- The names of at least three (3) medical or health care professionals in the applicants same profession or a member of the local county or regional medical society (for use as professional references) who have known the applicant for a minimum of two (2) years and who, through observation, have personal knowledge of his or her clinical ability, ethical character; the effect of his or her health status, if any, on the privileges sought; ability to work cooperatively with others, and who are willing to provide specific written comments on these matters upon request from the Medical Staff or Hospital. At least one (1) of such individuals must have had organizational responsibility for supervision of the applicant's performance.

2. Record review of the credentialing files for Staff BBB, CCC, DDD, EEE, FFF, GGG, and III showed each staff (all were reapplying for membership to the Medical Staff) failed to provide evidence of post secondary education; name of the institution; degree; name of the person who reviewed the applicant's performance; a statement regarding the applicant's ability to perform all procedures requested privileges; health status; and three medical or health care professionals in the applicants same profession who have personal knowledge of the applicant's clinical ability, ethical character; and ability to work cooperatively with others.

During interview on 08/27/15 from 9:00 AM through 10:50 AM, Staff WW, Medical Staff Coordinator, reviewed and confirmed that each of the seven, of eight credentialing files reviewed, failed to contain the required evidence of post secondary education documentation; the required statement of ability to perform the privileges requested and the three statements from peers confirming the applicant's clinical ability, ethical character, health status and ability to work with others.

Based on observations, interviews, record reviews and policy review, the facility failed to supervise and/or evaluate fall risk precautions to ensure that they were in place for three patients (#6, #7, and #9) of six patients identified as a high fall risk. These failures affect all patients admitted as a high fall risk, and had the potential to lead to an injurious fall in any department because of a fall risk identification/communication failure to all staff. The facility also failed to follow physician's orders to do a wound culture for one patient (#3) of three patients reviewed for orders. This failure had the potential to prolong treatment to an infection causing possible deterioration. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Patient Fall Prevention," revised 06/2015, showed:
- Nursing staff were to utilize a standardized assessment tool to determine a patient's risk for falls.
- The assessment tool identified patients in one of three risk classifications:
- High risk = score of 45 or higher.
- Moderate risk = score of 25-44.
- Low risk = score of 0-24.
- Patients identified as high risk for falls were to have a yellow sticker on their armband to assist in communication to all departments that the patient had been identified as a high/moderate risk for falls and extra safety precautions were to be taken.
- Patients identified as high risk were to have the high risk protocol implemented.
- High risk protocol listed that the patient's armband was to be checked every shift to maintain communication and identification of patients at risk for falls.
- Patients identified as high risk for falls were to remain on the fall prevention/reduction protocol for the duration of the hospitalization unless documented otherwise by a Registered Nurse (RN) or a physician.

2. Record review of the fall risk assessment in Patient #6's medical record showed a fall risk assessment score of 60. The high risk classification was marked to initiate fall protocol.

During an interview on 08/24/15 at 3:20 PM, Staff E, RN, Director of Medical Surgical unit, stated that the current process for patients identified as high fall risks was for the patient to wear a yellow gown, yellow socks, a yellow sticker placed onto their armbands and a laminated fall precautions sign was to be clipped on the outside of their doorway. Staff E stated that Patient #6's sign was placed backwards because Physical Therapy must have evaluated him and lowered his score. Staff E also stated that the patient was alert and oriented and this was why he was not wearing a yellow gown (contrary to the policy).

Observation on 08/24/15 at 1:45 PM showed Patient #6 dressed in a green hospital gown with his armband free of any stickers. The doorway to his room showed a laminated fall precautions sign that was turned around backwards that inhibited staff and/or visitors to know that he was on fall precautions.

3. Observation and concurrent interview on 08/24/15 at 2:10 PM showed Patient #7 dressed in a green patient gown with his armband free of any stickers. There was no fall precaution sign on the doorway. The patient's daughter stated that the patient was blind and was brought to the facility because of increased confusion.

Record review of the History and Physical (H&P) in Patient #7's medical record showed he was admitted to the facility on 08/23/15 for difficulty breathing and behavior change with a decline in his mental status.

Record review of the patients fall risk assessment showed a score of 85. The high risk classification was marked to initiate the fall protocol.

4. Observation and concurrent interview on 08/24/15 at 3:00 PM showed Patient #9 dressed in a green patient gown with her armband free of any stickers. There was no laminated fall precaution sign on the doorway. The patient stated she had passed out and had fallen earlier that day in her garden.

Record review of the H&P in Patient #9's medical record showed she was admitted to the facility on 08/24/15 due to syncope (partial or complete loss of consciousness with interruption of awareness or oneself and ones surroundings) and weakness.

Record review of the fall risk assessment showed a score of 60. The high risk classification was marked to initiate the fall protocol.

During an interview on 08/25/15 at 3:55 PM, Staff Z, RN, stated that Patient #9 should have been on fall precautions upon admission due to the fact that the patient had fallen prior to admission. Staff Z also stated that the patient was very confused on admission. She stated that a yellow gown and socks and a fall precautions sign should have been initiated upon admission.

5. During an interview on 08/25/15 at 10:30 AM, Staff U, LPN, stated that if a patient was a high fall risk they would have more frequent checks by nursing staff, wear a yellow gown and yellow socks and have a fall precautions sign on their doorway. She stated that they didn't have as many yellow gowns as they did the regular green ones so they didn't always have the yellow ones to use.

6. During an interview on 8/26/15 at approximately 9:20 AM, Staff L, Chief Nursing Officer (CNO), stated that she expected the RNs to supervise the LPNs and Certified Nurse Assistants to ensure nursing practices and patient cares were appropriately completed.

7. Record review of the facility's policy titled, "Nursing Notation/Verification of Physician's Orders," revised 06/2015, directed RNs and LPNs to check for new orders frequently throughout the shift. Once orders were entered and verified, another RN/LPN will re-verify the accuracy of the orders.

8. Record review of Patient #3's H&P dated 08/19/2015, showed he was admitted on that date with multiple fractures, one of which was in his left lower leg requiring an external fixator (a device that holds the bones in place by way of pins through the skin at various intervals into the bones-breaks in the skin can potentially lead to infections by way of an opening for bacteria to enter).

Record review, on 08/25/15, of Patient #3's Physician's orders dated 08/19/15, showed a signed order for nursing to obtain a wound culture of the left leg (the skin openings around the pins).

During an interview on 08/25/15 at 9:42 AM, Staff E, Director of Medical Surgical unit stated the culture results were still pending.

During an interview, and concurrent record review on 08/25/15 (six days after the order was written) at 10:47 AM, Staff U, LPN responsible for Patient #3, stated that, according to the record, the culture had never been obtained by nursing. Staff U stated that the nurse responsible for the patient when the order was written was responsible to either obtain the culture, or pass the need to obtain it on to the oncoming nurse. Staff U stated it was definitely a nurses responsibility, and she had no knowledge of the continued need for a culture via her report on this date.

During an interview on 08/26/15 at 9:27 AM, Staff MMM, RN stated that the culture had been obtained on 08/25/15 (after surveyor inquiry) and the results were now pending.



12450

Based on interview, record review and policy review the facility failed to identify pertinent, current health problems in the care plan for four patients (#3, #6, #10,
#25) of seven patients' care plans reviewed. This failure could potentially lead to the lack of care interventions to meet established goals and/or address/solve the problems. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Patient Care Plan/Problem List," Revised 08/2009, directed staff to do the following:
- Each patient will have an individualized care plan.
- The Registered Nurse (RN) or Licensed Practical Nurse (LPN) shall add problems throughout the patient's hospitalization as identified during the assessment.
- The RN/LPN shall address the patient's care plan each shift.

2. Record review of Patient #3's History and Physical (H & P) dated 08/19/2015, showed he was admitted on that date with multiple fractures, one of which was in his left lower leg requiring an external fixator (a device that holds the bones in place by way of pins into the bones, through the skin at various intervals). The patient also had multiple abrasions and bruises related to a motorcycle accident (breaks in the skin can potentially lead to infections by way of an opening for bacteria to enter).

Record review, on 08/25/15, of the patient's care plan dated 08/19/15, showed staff failed to identify actual altered skin integrity and/or the potential for infection related to the altered skin integrity.

During an interview on 08/25/15 at 10:25 AM, Staff E, Manager for the Medical Surgical unit, stated that a potential for infection should be addressed in the patient's care plan, and confirmed it was not.

3. Record review of Patient #6's H & P dated 08/24/15, showed he was admitted on 08/23/15 for complaints of abdominal pain, pneumonia and a history of diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar.)

Record review on 08/24/15 of the patient's care plan dated 08/24/15, showed staff failed to identify potential problems related to the pneumonia and unstable glucose (blood sugar) level.

During an interview on 08/24/15 at 3:20 PM, Staff E, Manager for the Medical Surgical unit, stated that his pneumonia and unstable blood sugar should be addressed in the patient's care plan, and confirmed that it was not.

4. Record review of Patient #25's medical record showed:
- The patient had a history of Hypertension (elevated blood pressure) as documented on the history sheet from the physician's office.
- The patient took a blood pressure medication twice a day per the admission record.
- The patient had a pre and post-operative diagnosis of preeclampsia (a condition that occurs during pregnancy that often caused elevated blood pressure, retention of fluid, and protein in the urine). The patient also underwent a Cesarean Section (C-Section, a surgical procedure to deliver the baby from the patient's abdomen). This information was documented on the Operative Report.
- The care plan showed no documentation of a plan of care for Hypertension or incision care.

During an interview on 08/25/15 at 3:25 PM Staff N, Director of Obstetric (OB, branch of medicine related to care of women before, during, and after delivery) and Nursery, stated that staff failed to document a care plan for hypertension and skin integrity.

5. Record review of Patient #10's H & P dated 08/21/15, showed she was admitted on that date with altered mental status (a condition that may include confusion, loss of memory, and poor judgment), weakness, and decreasing level of consciousness (The normal state of being awake and able to understand what is happening around you is diminishing or lessening).

Record review of the patient's admission nursing fall assessment showed the patient was at moderate risk of falls.

Record review of the patient's care plan on 08/24/15, showed staff failed to identify a problem for altered mental status to include the patient's risk of falls and develop interventions to prevent falls.

During an interview on 08/24/15 at 3:15 PM, Staff J, Registered Nurse (RN), stated that she did not realize that altered mental status was not added to the problem list and care planned and it should have been included.

During an interview on 08/27/15 at 12:45 PM, Staff M, RN Staff Educator, stated that the patient should have had a fall prevention plan in the care plan for her moderate risk of falls

During an interview on 08/27/15 at 9:30 AM, Staff L, Chief Nursing Officer (CNO), stated that there should have been fall prevention planning with interventions for patients that had fall risk.





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32280

Based on observation, interview and policy review the facility failed to ensure medications were not accessible to unauthorized personnel, patients and/or visitors for one patient (#3) of three patients observed for medications, and for one of two trauma rooms in the Emergency Department (ED). These failures could potentially lead to a diversion and/or harmful ingestion of non-prescribed medications to any patient, personnel, or visitor. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Storage of Medications and Supplies in the Nursing Units," revised 04/2011, directed staff to keep all drugs locked when unattended, inaccessible to unauthorized individuals.

2. Observation on 08/25/15 at 10:30 AM, showed the following:
- A 1/2 ounce tube of Bacitracin ointment (antibiotic) on a shelf in Patient #3's room.
- A tube of Mupirocin ointment (antibiotic) on the same shelf in Patient #3's room.
- No staff were attending to these medications, and they were accessible to anyone passing the patient's room.

Record review of Patient #3's medication orders on 08/25/15, and concurrent interview with Staff U, Licensed Practical Nurse, at 10:47 AM, showed the following:
- There was an order for an antibiotic ointment called Mupirocin.
- There was no order for an antibiotic ointment called Bacitracin.
- There was no order for either antibiotic ointment to be self-administered by Patient #3.
- Staff U stated that the ointments should not have been in the patient's room, that the physician should be notified of the ointment without an order, and family notified and educated about medications in the patient's room.

3. Observation in the ED and concurrent interview on 08/25/15 at 2:20 PM showed the following:
- Medications stored in a cabinet in an unoccupied/unsupervised trauma room included-
a. Atropine (reduces secretions)
b. Sodium Bicarb (a bodily fluid replacement [electrolyte])
c. Dextrose 50 (fluid replacement and caloric supplement)
d. Adenosine (used to get heart back into normal rhythm)
e. Epinephrine (used to get heart back into normal rhythm, and to treat medication allergies)
f. Lidocaine injectable (used to get heart back into normal rhythm)
g. Nitroglycerin (treats heart pain)
h. Diprovan (used as an anesthesia)
i. Dobutamine (makes heart pump harder)
J. Heparin (a blood thinner)
k. Activase (a blood thinner)
- Staff A, ED Director, stated that the key to this cabinet was kept in the neighboring unlocked cabinet on a hook. This same key opened a refrigerator in the trauma room that contained two vials of Diltiazem (used for high blood pressure) 125 milligrams (mg)/25 milliliters (ml); two vials of Diltiazem 25 mg/5 ml; two vials of Succinylcholine (a skeletal muscle relaxant) 200 mg/10 ml; and two vials of Rocuronium Bromide (used as an anesthesia) 50 mg/15 ml.
- Staff A stated that they did it this way so the nurses had easy access to the medications, without having to retrieve the key from another room/source. Staff A stated she realized the possible implications of the unsupervised, accessible medications.

Based on observation, interview and record review facility staff failed to ensure an approved, current therapeutic diet manual was available to nursing staff on the Medical/Surgical unit to use as a diet reference. This deficient practice had the potential to permit staff to serve patients on therapeutic diets inappropriate or unapproved foods. The total facility census was 11. The therapeutic diet census was four.

Findings included:

1. Record review of the facility's undated policy titled, "Therapeutic Diets," showed the facility used the American Dietetic Association (now called the Academy of Nutrition and Dietetics) Nutrition Care Manual as a guide for prescribed diets and the Nutrition Care Manual was on the facility computer system.

During an interview on 08/24/15 at 1:36 PM, Staff F, Director of Dietary stated that the Nutrition Care Manual was available on the facility computers available at the nurse's station.

2. Observation and concurrent interview on 08/2515 at 11:40 AM on the Medical/Surgical unit showed Staff Z, Team Leader, Registered Nurse (RN):
- Retrieved a loose leaf notebook from a bookshelf in the nurse's station;
- She stated that the (retrieved) notebook was the facility diet manual; and
- She confirmed that the loose leaf notebook did not contain any evidence that it was the approved facility diet manual; that it was approved by the medical staff for use with the patients; or that it contained current diet information (it was not dated).

During an interview on 08/26/15 at approximately 3:00 PM, Staff G, Registered Dietitian, confirmed the following:
- The approved facility diet manual was on the computer system;
- The loose leaf notebook on the Medical/Surgical unit was a paper copy of some of the diets; and
- It did not contain proof that it was part of the approved, current therapeutic diet manual.

Based on observation, interview, and policy review the facility failed to ensure that staff followed infection control policies and standards when they failed to:
- Perform hand hygiene (wash hands with soap and water or use hand sanitizer) after removal of gloves and touching patient equipment for two patients (#3 and #16) of two patients observed.
- Perform hand hygiene after removal of gloves and prior to putting on sterile gloves when manipulating a central venous access device (a catheter placed into a large vein in the neck, chest or groin for administration of medication or fluids or to obtain blood samples) for one patient (#18) of one patient observed;
- Maintain the cleanliness of laryngoscope blades (equipment used to insert a breathing tube into the mouth and throat) stored in three areas (Obstetric [OB, care of a mom and baby throughout the delivery process] Department, Operating Room #1 [OR, where surgical procedures were performed], and OR crash cart [cart where emergency supplies are kept]) of three areas observed.
- Maintain the cleanliness of the OR table mattresses in two OR rooms (#1 and #2) of two observed.
These deficient practices had the potential to increase the risk of cross contamination and placed all patients, visitors, and staff at risk for infection. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 01/2013, showed staff directives to perform hand hygiene:
- Before direct contact with a patient;
- After direct contact with a patient's skin;
- After staff had contact with body fluids, wounds, or broken skin;
- After staff touched equipment or furniture near a patient;
- Before staff put on or removed gloves; and
- When staff moved from dirty to clean.

2. Observation on 08/25/15 at 8:50 AM showed Staff U, Licensed Practical Nurse (LPN):
- Entered Patient #3's room for medication administration.
- Typed on the computer keyboard;
- Touched patient's armband;
- Touched the scanner and scanned medication packages then opened the medications into the medicine cup;
- Put on clean gloves and administered the medications to the patient;
- Hung an intravenous (within a vein, IV) medication bag onto the IV pole;
- Reached into her pocket with her gloved hand;
- Picked up and connected the medication bag to the IV tubing;
- Removed her gloves and taped the IV tubing to the patient's arm;
- Put on new gloves and administered an injection into the patient's abdomen.
Staff U failed to perform hand hygiene in between touching contaminated equipment and in between glove changes.

During an interview on 08/25/15 at 10:20 AM, Staff U, LPN, stated that she should have washed her hands with glove changes and before she gave the patient an injection. She said she failed to do this because she was nervous.

3. Observation on 08/25/15 at 8:45 AM showed Staff O, Registered Nurse (RN), with gloves on. She placed objects into a special container for sharps (needles and other sharp objects used for patient care), and removed her gloves. Staff O failed to perform hand hygiene after she removed her gloves.

During an interview on 08/25/15 at 8:55 AM Staff O stated that she should have performed hand hygiene immediately.

4. Observation on 08/25/15 at 10:36 AM showed Staff T, RN, in OR #2 with Patient #16. She removed her gloves and put on sterile gloves in preparation to insert a catheter. She failed to perform hand hygiene immediately after she removed her gloves.

During an interview on 08/25/15 at 10:45 AM, Staff T, stated that typically, she performed hand hygiene after she removed gloves.

Observation with concurrent interview on 08/25/15 at 10:40 AM showed Staff S, Certified Scrub Technician (CST), in OR #2 with patient #16. She removed gloves, hung catheter bag (holds urine as it comes out of the body) onto the OR table and put on another pair of gloves. Staff S failed to perform hand hygiene after she removed her gloves. She stated that she typically performed hand hygiene after she removed her gloves.

During an interview on 08/25/15 at 11:00 AM, Staff P, Director of Perioperative (care of patient pre, during , and post surgery) Services, stated that she expected her staff to immediately perform hand hygiene after they removed their gloves.

During an interview on 08/27/15 at 9:30 AM, Staff L, Chief Nursing Officer (CNO), stated that staff were expected to follow the facility's policies and procedures for hand hygiene and glove use.

5. Record review of the facility's policy titled, "Central Venous Access Devices," revised 09/2014, showed that one type of device was an implanted subcutaneous (under the skin) port (porta Cath, a surgically implanted infusion port placed in the subcutaneous pocket of the chest, arm, forearm, or abdominal wall and the catheter is inserted into a large vein and threaded into a larger vein that carries deoxygenated blood directly into the heart, used for long term IV therapy), and that complications associated with these types of devices were usually related to infection caused by contamination of the catheter from the skin of the patient or from the health care worker. (The policy failed to list the actual procedure guidelines for this type of device).

6. Observation on 08/25/15 at 10:55 AM, showed Staff E, RN, and Manager of the Medical Surgical unit, prepared to perform a porta Cath access and flush to Patient #18. Staff E prepared the room and put on clean gloves and wiped down the table with disinfectant wipes then he removed his gloves and left the room to get the patient. He brought the patient into the room and obtained the patients vital signs, proceeded to open sterile supplies and placed them onto the sterile field. He then put on the sterile gloves, cleaned the porta Cath site, placed the dirty ChloraPrep (trade name for a skin preparation used prior to surgery or invasive procedures to help reduce bacteria on the skin that may cause infection) applicator onto the sterile field, picked up the needle and inserted the needle into the patient's porta Cath and injected the flush. After flushing the port he removed the needle and his gloves and applied a band aid to the port site. He then wrote on some papers, obtained the patients vital signs, left the room and escorted the patient out of the room. Staff E did not perform hand hygiene at any time from when he cleaned the room until he dismissed the patient.

During an interview on 08/25/15 at 11:20 AM, Staff E, stated that he washed his hands before he began the procedure. He stated that he should have washed in between gloves changes. Staff E stated that he wasn't sure if he should have worn a mask for this procedure or not he would have to look at the policy to be sure and wasn't for sure if it was a sterile or clean procedure but stated that he used sterile gloves during these procedures. He stated that he personally performs two to three of these procedures per week on outpatients. (The facility had performed 62 porta Cath access procedures in the last seven months).

During an interview on 08/26/15 at 9:45 AM, Staff E, and Staff M, RN, Staff Educator, both verified there was no procedure for staff to refer to when accessing a porta Cath in the nursing policies. Staff M stated that the policy for central venous access devices was revised in 2014 but apparently this procedure was omitted.

During an interview on 08/27/15 at 10:25 AM, Staff I, Infection Control Officer, stated that:
- A porta Cath flush was an aseptic technique (processes that maintain an environment that is free of harmful microorganisms and prevent the spread of infection).
- Staff E contaminated the aseptic area when he placed dirty items in the area.
- Staff E did not meet the facility's infection control standards during the procedure.

7. Record review of the facility's policy titled, "Processing Laryngoscope Blades," dated 05/2013, showed the staff directive to place laryngoscopes in a protective peel pouch after staff cleaned the laryngoscope.

8. Observation with concurrent interview on 08/24/15 at 2:00 PM showed three laryngoscope blades (for babies) not in individual peel packs and kept in a tackle box in the OB Department. Staff C, RN, stated that the staff took the tackle box to the OR for Cesarean Sections (C-Section, a surgical procedure used to deliver a baby through the mother's abdomen).

9. Observation with concurrent interview on 08/25/15 at 9:10 AM showed in OR #1 a plastic bag with three laryngoscope blades (for babies) not in individual peel packages. Staff P, Director of Perioperative Services, stated that the OB Department took care of these supplies and she was not aware they were not in individual peel packages.

10. Observation with concurrent interview on 08/25/15 at 9:20 AM showed four laryngoscope blades (for adults) not in peel packages and kept in the OR crash cart. Staff P stated that these were rarely used and she forgot to ensure they were individually wrapped.

During an interview on 08/25/15 at 11:00 AM, Staff P, stated that she expected laryngoscopes to be packaged in individual peel packs.

11. Record review of the facility's policy titled, "Housekeeping Procedures," dated 03/2013, showed staff directives for circulators (the nurses who plan and provide the care for the patient in surgery) and/or CSTs to clean the OR table mattress pads. There was no direction on how to remove adhesive from the mattress pads.

12. Observation with concurrent interview on 08/25/15 at 9:30 AM and 9:35 AM, showed in OR #1 and #2 mattress pads with multiple pen point adhesive areas. Staff P stated that she was not sure why there were areas of adhesive on the mattress.

13. Observation with concurrent interview on 08/24/15 at 2:15 PM showed:
- OB instruments in water on one side of a divided sink.
- Monitor belts (stretchy piece of material that hold monitors for baby heart beat and for contractions in place on the patient) sat in one side of a divided sink (not in water).
- Staff C, RN, stated that she cleaned the instruments by pouring some liquid detergent into the water in the sink and she cleaned the belts by sprinkling some detergent over the belts and then soak them in water. She did not measure the amount of the detergent or the water for the instruments or the belts.

14. Record review of the manufacture guidelines showed for the liquid detergent to use half an ounce of detergent to one gallon of water and for the powdered detergent to use two and a half tablespoons of detergent to one gallon of water.

During an interview on 08/27/15 at 8:20 AM, Staff L, stated that there was no facility policy that directed staff to follow manufacture guidelines for cleaning.

During an interview on 08/27/15 at 10:20 AM, Staff N, Director of OB and Nursery stated that there was a medicine cup to measure liquid detergent and a scoop to measure powdered detergent, but the sinks had not been marked for the appropriate amount of water.





















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Based on interview and policy review the facility failed to notify two of two Swing Bed (a status of admission that provides skilled care and receives a special reimbursement rate) patients (#3 and #8) of the cost of possible charges and/or services not covered by Medicare/Medicaid. This had the potential to mislead all Swing Bed patients of items covered by their insurance coverage. The facility Swing Bed census was two. The average monthly Swing Bed census was five.

Findings included:

1. Record review of the facility's policy titled, "Swing Bed Program," effective 08/15/01, showed a Swing Bed patient would be charged for beauty/barber shop services, personal toiletry items, routine physical examination, routine eye examination, dental services, private duty nurses and laundry. The policy failed to include the cost for these items and services.

2. During an interview on 08/25/15 at 2:40 PM, Staff EE, Swing Bed Coordinator, confirmed that the charges for items not covered by Medicare/Medicaid were not listed and/or provided to the patients.