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Based on observation, review of policies/procedures, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure outdated medications and supplies were not available for patient use in the Radiology, Cardiac Rehabilitation, Respiratory, Laboratory and Nursing Departments and medications were secured when stored in the Physical Therapy Department.. The CAH reported a census of 10 current patients.

Failure to remove outdated medications for patient care areas could potentially result in patients receiving outdated and ineffective medications.

Findings include:

1. Observation during the Radiology Department tour on 1/12/10 at 3:00 PM revealed (1) 1900 ml (milliliter) sulfate suspension expired 4/10/08 and (9) 240 ml barium omnipaque solutions expired 10/12/08 stored in a cupboard in a room between the 2 x-ray rooms.

An interview on 1/12/10 at 3:00 PM the Director of Radiology acknowledged the expired supplies.

2. Observation during the Cardiac Rehabilitation tour on 1/12/10 at 1:55 PM revealed the crash cart contained (4) 18 ga (gauge) intravenous (IV) needles expired 5/09, (3) 20 ga IV needles expired 8/09, (1) 20 ga IV needle expired 10/09 and (1) 22 ga IV needle expired 9/09.

An interview on 1/12/10 at 1:55 PM the Director of Cardiac Rehab acknowledged the outdated supplies.

3. Observation during the Respiratory Therapy Department tour on 1/12/10 at 1:35 PM revealed (1) xopenex 0.5 ml inhalation medication expired 10/09, (1) xopenex 0.5 ml inhalation medication expired 12/09, (12) albuterol sulfate 3 ml doses- inhalation medication expired 12/09, 3 yellow top and 9 blue top vacutainers used to obtain blood expired 12/09 stored in a cupboard in the supply room.

An interview on 1/12/10 at 1:35 PM the Director of Respiratory acknowledged the outdated medications and supplies.

4. Observation during the Laboratory Department tour on 1/12/10 at 9:45 AM revealed (1) BBL culture swab expired 12/09 stored in the blood draw room and (10) BBL culture swabs expired 12/09 stored in the supply room.

An interview on 1/12/10 at 9:45 AM, the Director of Laboratory acknowledged the outdated supplies.

5. Observation during the Nursing Unit tour on 1/11/10 at 1:05 PM revealed 10 gastroccult test slides expired 12/09 stored in the clean utility room.

An interview on 1/11/10 at 1:05 PM with the Acute Care Manager acknowledged the outdated supplies.

6. Observation during the Physical Therapy Department tour on 1/12/10 at 2:00 PM revealed a 10 ml vial of dexamethasone medication stored, unsecured in a drawer across from a file cabinet in the physical therapy office.

An interview on 1/12/10 at 2:00 PM the Doctor of Physical Therapy stated the dexamethasone was stored in the file cabinet at night when staff leave work for the night. The file cabinet does not have a lock and cannot be locked.

Review of the hospital policy/ procedure Storage of Drugs and Biologicals revised 5/08 revealed all drugs and biologicals are appropriately secured and stored.

Review of the hospital policy/ procedure Medication Area Inspection revised 5/07 revealed the pharmacy department under the direction of the pharmacist will inspect departmental areas to ensure all drugs and biologicals at GCMC are stored appropriately, secure from unauthorized access and maintained according to manufacturer's recommendations.

I. Based on policy review, document review, and staff interviews, the facility failed to ensure that a system is in place for identifying, reporting, investigation, and controlling infections and communicable diseases among personnel that provide services in the hospital for 6 of 19 staff and 10 of 14 volunteers (Staff K, L, M, N, O, P and Volunteers Q, R, S, T, U, V, W, X, Y, and Z).

The hospital reported a census of 10 inpatients.

The facility must have a system in place to identify individuals who could transmit an infectious disease to other staff or patients. In order to identify the individuals who may be at risk for transmitting an infectious disease, the facility must ensure all persons who work/volunteer at the facility have a Tuberculosis (TB) status on file.

Failure to perform the TB testing could result in a person working or volunteering at the facility with a communicable disease, which could be passed to other staff or patients.

Findings included:

1. Review of the CAH policy "Employee Health Policy" revised 7/09 stated the following:
a. "Purpose: The purpose of the employee health program is to pre-screen employees for communicable disease and potential health problems, provide needed Tuberculin Skin Test (TSTs)..."
b. "Policy: ...employees will receive a TST every four (4) years..."

2. Review of staff and volunteer personnel files, on 1/12/2010 revealed 6 of 19 staff and 10 of 14 volunteer files lacked evidence of the required TB test, either at the beginning of service, or a repeat TB test every four years.

3. During an interview on 1/13/10 at 9:00 AM, the Employee Health Nurse stated, "This is my fault, I was thinking the TB test were due in 2010, I see they were due in 2009. The employees/volunteers with TB test from 2005 would be over due". The Employee Health Nurse confirmed the Volunteers worked in various patient areas of the CAH.
The Employee Health Nurse confirmed the personnel health file of Staff K, L, M, N, O, P and Volunteers Q, R, S, T, U, V, W, X, Y, and Z) lacked evidence of a current TB status.


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II. Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a sanitary dietary environment and serve ready to eat foods in a sanitary manner.
The CAH reported a census of 10 patients.

Failure to maintain a clean Dietary environment and serve 'ready to eat' foods in a sanitary manner could result in the outbreak of a food borne illness.

Findings include:

I. An observation on 01/11/10 at 1:00 PM, during the initial tour of the Dietary Department, revealed an accumulation of carbon build up on the Vulcan Range drip tray and the back splash. The observation also noted dried on food spills, and food debris on the oven sides and outside of the oven doors.

A review of the procedure titled, "Cleaning of Equipment " review date of 05/09, lacked information for cleaning of the drip tray, and stated " ...Clean outside of ovens including controls... " A review of the "Daily Cleaning Checklist for January 2010" lacked initials by the 2nd cook for cleaning of the drip tray on 01/05/10.

During an interview on 01/11/10 at 1:00 PM, the Director of Nutrition Services verified the need for cleaning the range back splash, drip tray, oven front and sides, and the lack of documentation on the cleaning schedule for 01/05/10.

II. An observation on 01/11/10 at 5:25 PM, revealed Staff Q, the cook, wearing gloves and serving the evening meal. Staff Q contaminated her gloves when she left the serving area and touched various serving surfaces. Staff Q served the evening meal placing the biscuits by hand on the individual patients ' plates, therefore contaminating the ready to eat food with her contaminated gloves.

A review of the policy/procedure titled, "Infection Control-Hand Hygiene " revised date of 05/08, stated " ...Gloves should be worn during food prep. This is especially important when touching Ready-to-Eat foods. Hands should be washed following the above procedure when changing gloves for any reason... "

During an interview on 01/12/10 at 2:00 PM, the Director of Nutrition Services verified Staff Q contaminated the biscuits with her contaminated gloved hands. The Director of Nutrition Services stated tongs would have been appropriate to use for serving the biscuits.

Based on medical record review, hospital policy/procedure review and staff interviews the Critical Access Hospital (CAH) failed to ensure all physician orders were signed, dated and/or timed for 5 of 10 closed surgical records (11, 12, 13, 14 and 16) reviewed requiring a post anesthesia note. The CAH reported a census of 10 current patients.

Failure to sign, date and/or time physician orders could potentially interrupt continuity of care and transferability of changes in procedures and treatments for patients.

Findings include:

Record review of 10 closed surgical records revealed the Certified Registered Nurse Anestisist (CRNA) failed to date and/or time the post anesthesia note for Patients 11, 12, 13, 14 and 16.

Review of the Greene County Medical Center Medical Staff Bylaws approved 4/17/08 revealed all orders for drugs and biologicals, including telephone orders, must be legible, timed, dated and authenticated with the ordering practioner's signature.

An interview on 1/13/10 at 8:45 AM the Director of Surgery acknowledged the above surgical records were not signed, dated and/ or timed.

Based on observation, hospital policy/ procedure review and staff interview the Critical Access Hospital (CAH) failed to maintain patient record confidentiality by securing the patient medical records in the Radiology and Physical therapy Departments.The hospital reported a census of 10 current patients.

Failure to secure patient medical records could potentially cause harm to patients if the confidentiality of the patient records is not maintained.

Findings include:

Observation during the Radiology Department tour on 1/12/10 at 3:00 PM revealed an unlocked room in the back hallway containing patient x-ray files and personal information stored on shelves.

An interview on 1/12/10 at 3:00 PM with the Director of Radiology acknowledged the patient x-ray files and personal information stored unsecured in the room. Housekeeping staff have unsupervised access to the area for cleaning at night.

Observation during the Physical Therapy Department tour on 1/12/10 at 2:00 PM revealed an unlocked file cabinet in the secretary's office containing patient medical records.

An interview on 1/12/10 at 2:00 PM the Director of Physical Therapy acknowledged the cabinet contained patient medical files. Staff do not lock the file cabinet when leaving work at night. Housekeeping staff clean the office unsupervised at night and would have access to the patient files.

Review of the hospital policy/ procedure Medical Record Security reviewed 3/06 revealed all medical records shall be housed in physically secure areas under the immediate control of the Health Information Management Director. Areas housing health information shall be restricted to authorized personnel. Medical records must be available and accessible at all times for patient care. When in use within the hospital, records shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals.

Based on medical record review, hospital policy/procedure review and staff interview the Critical Access Hospital (CAH) failed to complete a post anesthesia assessment after a surgical procedure for 2 of 10 closed records reviewed, (Patient 15 and 18) and 1 of 1 open record reviewed, (Patient 21). The hospital reported a current census of 10 patients.

Failure to complete a post anesthesia assessment could potentially interrupt continuity of care and transferability of changes in procedures and treatments for patients.

Findings include:

Medical record review for 2 of 10 closed patient records, (Patient 15 and 18) and 1 of 1 open patient records, (Patient 21) lacked documentation of a post anesthesia assessment.

Review of the Post Anesthesia Evaluation policy/ procedure revised 1/05 revealed an anesthesia provider provides post anesthesia follow up evaluation of the patient's response to anesthesia and for potential anesthetic complications, taking appropriate corrective actions and requesting consultation whenever indicated.

Interview on 1/13/10 at 8:45 AM the Director of Surgery acknowledged the above medical records lacked documentation of a post anesthesia assessment.

Based on policy review, document review, and staff interviews, the CAH hospital staff failed to document individual or group activities provided to skilled patients and ensure the plan of care included activity goals for 3 of 3 open (#26, 27 and 28) and 5 of 5 closed skilled records reviewed (#29, 30, 31, 32 and 33). The hospital reported a census of five skilled patients.

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient has the potential to impede the physical and psychological well being of each patient.

Findings included:

1. Review of Green County Medical Center Skilled Nursing Care Policy entitled "Patient Activities" approved 6/18/09 stated "the activities program is organized and staffed in a manner designed to meet the activity needs of the patients. A member of the staff is assigned the responsibility for developing, documenting, and maintaining the activities program. A sufficient number of support staff are available to meet the activity needs of the patients. Activities program staff participate in patient care management which includes the following:
a. Membership on the interdisciplinary team.
B. Assessment of each patient's activity needs.
C. Assistance in the development of an interdisciplinary plan of care for each patient.
D. Documentation in the patient record of the response to the activities program which also addresses significant changes in the patient;s response to the activities and reporting of these changes to nursing personnel.
E. Review and revisions, as necessary of these aspects of the interdisciplinary plan of care that pertain to the patient's activity program.

2. Review of the open medical record for Patient #26 admitted to the skilled unit on 1/5/10 revealed the activity assessment completed on 1/5/10 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 1/5/10 revealed no activity goal.

3. Review of the open medical record for Patient #27 admitted to the skilled unit on 12/18/09 revealed the activity assessment completed on 12/18/09 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 12/9/09 revealed no activity goal.

4. Review of the open medical record for Patient #28 admitted to the skilled unit on 1/8/10 revealed the activity assessment completed on 1/8/10 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 1/8/10 revealed no activity goal.

5. Review of the closed medical record for Patient #29 admitted to the skilled unit on 2/7/09 and discharged on 2/10/09 revealed the activity assessment completed on 2/9/09 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 2/8/09 revealed no activity goal.

6. Review of the closed medical record for Patient #30 admitted to the skilled unit on 5/11/09 and discharged on 5/18/09 revealed the activity assessment completed on 5/18/09 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 5/12/09 revealed no activity goal.

7. Review of the closed medical record for Patient #31 admitted to the skilled unit on 8/14/09 and discharged on 8/19/09 revealed the activity assessment completed on 8/15/09 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 8/14/09 revealed no activity goal.

8. Review of the closed medical record for Patient #32 admitted to the skilled unit on 9/24/09 and discharged on 10/5/09 revealed no activity assessment and no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 9/24/09 revealed no activity goal.

9. Review of the closed medical record for Patient #33 admitted to the skilled unit on 7/24/09 and discharged on 8/7/09 revealed the activity assessment completed on 7/25/09 but no documentation in the Activity Progress Notes or Nursing Notes of individual or group activities provided. Review of the chart also revealed the Care Plan initiated on 7/24/09 revealed no activity goal.

10. During an interview on 1/12/10 at 9:30 AM the Director of Quality Management stated two Certified Nursing Assistants do the Initial Activity Assessment and the Activity Director from Long Term Care will review and cosigns the assessment. The Certified Nursing Assistants are to document activities offered to patients in the Activity Progress Notes or in the Nursing Notes of the skilled patients charts. Activity goals are not put on the patients care plan.
The Director of Quality Management acknowledged no documentation of activities on the Activity Progress Notes or Nursing Notes.

11. During an interview on 1/12/10 at 10:00 AM Staff K (Certified Nursing Assistant) stated activities are to be charted in the Nursing Notes or the Activity Progress Notes. Staff K also stated activity goals are not put on skilled patients care plans.

Based on policy review, record review and staff interview, the hospital failed to ensure that the plan of care developed by an interdisciplinary team included documentation of participation by the attending physician for 1 of 1 open (#27) and 5 of 5 closed swing bed medical records (#29, 30, 31, 32, and 33). The hospital reported a census of five skilled patients.

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient has the potential to impede the physical and psychological well being of each patient.

Findings included:

1. Review of Greene County Medical Center Skilled Nursing Care Policy entitled "Interdisciplinary Care Plans" approved 6/18/2009 stated "Each patient must have a documented plan using the nursing process from admission to discharge. Nursing care is goal directed and provided through the nursing process. Nursing goals are based on nurses assessments, are realistic, measurable, and consistent with the physician's prescribed therapy and if possible, are mutually set with the patient and/or his/her family. Documentation in the patient's chart reflects the implementation of the interdisciplinary plan of care."

2. Review of the open medical record and plan of care for Patient #27 admitted 12/18/09 to the swing level of care with a diagnoses of Anorexia Nervosa with Critical Weight Loss, Starvation, Multiple Skin Lesion on the Sacral and Rib Area revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 12/21/09 with reviews on 12/23/09, 12/28/09, 12/30/09 and 1/4/10.

3. Review of the closed medical record and plan of care for Patient #29 admitted 2/7/09 to the swing level of care with a diagnoses of Left Fibular Fracture, Dementia, Falls, Hypothyroidism, and Pernicious Anemia and discharged on 2/10/09 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 2/9/09.

4. Review of the closed medical record and plan of care for Patient #30 admitted 5/11/09 to the swing level of care with a diagnoses of Right Hip Joint Replacement, Hypertension, and Asthma and discharged on 6/3/09 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 5/14/09 with review on 5/18/09.

5. Review of the closed medical record and plan of care for Patient #31 admitted 8/14/09 to the swing level of care with diagnoses of Left Total Knee Replacement, Rheumatoid Arthritis, Hypertension, and Osteoporosis and discharged on 8/19/09 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 8/19/09.

6. Review of the closed medical record and plan of care for Patient #32 admitted 9/24/09 to the swing level of care with a diagnoses of Congestive Heart Failure with Transvenous Pacemaker, Diabetes Mellitus, Memory Loss, and Hyperlipidemia and discharged on 10/5/09 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 10/1/09 with review on 10/5/09.

7. Review of the closed medical record and plan of care for Patient #33 admitted 7/2/09 to the swing level of care with a diagnoses of Peripheral Vascular Disease, Post Right Knee Amputation, Ischemic Ulcers on the Left Ankle and Foot, Diabetes Mellitus, and Hypertension and discharged on 8/7/09 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 8/3/09 with review on 8/6/09

8. During an interview on 1/12/10 at 9:30 AM the Director of Quality Management acknowledged the Interdisciplinary Care Conferences lacked documentation of physician participation and signature of the Multi-Disciplinary Plan of Care. The Director of Quality Management stated "The Physician does not attend the Multi Disciplinary Plan of Care Meetings but I talk with the Physicians about any changes in the patient's condition every morning during patient rounds".