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Based on observation, interview, record review, and policy review, the facility failed to:
- Ensure a safe environment when facility staff failed to follow policies related to elopement, Dr. Strong Code and Suicidal Patient Precautions for one of one current psychiatric patient (#16) and two of two discharged (eloped) psychiatric patients (#30 and #29) reviewed (A 0144);
- Ensure a safe environment when current patient (#16) was allowed to stay in her personal clothing while an inpatient after being admitted for attempted suicide and on suicide precautions (A 0144);
- Ensure a safe environment when discharged (eloped) patient (#30) was allowed to elope from the Intensive Care Unit (ICU) after she was admitted for a attempted suicide and a 96 hour psychiatric hold was issued by a Judge (A 0144);
- Ensure a safe environment when discharged (eloped) patient (#29) was allowed to elope from the Emergency Department (ED) where he was brought after attempted suicide when he jumped from a moving car (A 0144);

These failures had the potential to affect all patients in the facility when policies and procedures in place to protect patients were not put into effect and when judicial hold orders were not followed.
The facility census was 10.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient Rights resulting in a condition of Immediate Jeopardy (IJ).

As of 08/24/17, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ when the following were implemented:
- Revision of and education on policies related to sitters, suicidal precautions, care of behavioral health patients in the ED, behavioral health assessments, elopement, restraints, and involuntary commitment.
- Mock simulation drills will be performed on elopements and competency evaluated prior to each coworker starting their next shift.
- Security was initiated for continuous coverage of the facility.
- Drills will continue on each shift until compliance and then weekly and then monthly.
- Real time monitoring will commence immediately on staff involved in 1:1 elopement/suicidal precautions.
- Elopement assessments were revised and staff educated.

Based on interview, record review, and policy review, the facility failed to ensure that staff delivered the second Important Message (IM) From Medicare (a government notice provided to the patient to inform them of their discharge appeal rights) and ensure it was signed, dated, and placed in the patient's medical record within 48 hours prior to discharge for four discharged patients (#22, #23, #24, and #25) of four discharged Medicare patients' medical records reviewed. The facility also failed to provide an IM form to all Medicare eligible patients with the appropriate name and phone number for the agency that assists with the appeal for one current patient (#5) of one current patient record reviewed, and four discharged patients (#22, #23, #24, and #25) of four discharged patient records reviewed. These failures had the potential to affect all Medicare patients' ability to be informed of their right to appeal discharge. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Important Message From Medicare," dated 01/2014, showed:
-The facility will follow the requirements found in the May 2007 Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections concerning the Important Message from Medicare.
-All Medicare Beneficiaries registered as inpatients will be given a copy of the IM form CMS-R-193.
-During the registration process, the clerk will give the beneficiary (patient) a copy of the IM and request the patient to read and sign the form.
-When discharge seemed likely within one to two days, the Social Worker or Case Manager should deliver the follow-up notice, so that the patient has adequate time to appeal, if desired.

Record review of Patient #22's discharged medical record showed the patient received Medicare benefits, and was admitted to the facility on 04/25/17 and discharged on 05/02/17. There was no evidence of an IM provided prior to discharge.

Record review of discharged Patient #23's discharged medical record showed the patient received Medicare benefits, and was admitted to the facility on 05/04/17 and discharged on 05/08/17. There was no evidence of an IM provided prior to discharge.

Record review of discharged Patient #24's discharged medical record showed the patient received Medicare benefits, and was admitted to the facility on 05/19/17 and discharged on 05/22/17. There was no evidence of an IM provided prior to discharge.

Record review of discharged Patient #25's discharged medical record showed the patient received Medicare benefits, and was admitted to the facility on 05/11/17 and discharged on 05/17/17. There was no evidence of an IM provided prior to discharge.

During an interview on 08/23/17 at 3:01 PM, Staff T, Case Manager, stated that registration staff were responsible for the IM letters given to the patient.

Record review of Patient #5's current medical record showed an IM dated 08/19/17, and the signed form showed the incorrect name of the appeal agency, and the phone number listed on the form was not in service.

Record review of Patient #22, #23, #24, and #25's discharged medical records all contained admission IM letters that showed the incorrect name of the appeal agency, and the phone number listed on the form was not in service.

During an interview on 08/24/17 at 10:30 AM, Staff T, confirmed that they had been using the forms that showed an incorrect agency for discharge appeals, but that they were not aware this was an old form.

During a concurrent interview on 08/24/17 at 2:18 PM, Staff T and Staff AA, Registration Manager, stated that they were not previously aware of the problems with the IM not being completed prior to discharge by registration staff, nor the incorrect agency on the form.

Based on observation, interview, record review, and policy review, the facility failed to:
-Ensure a safe environment when facility staff failed to follow policies related to elopement, Dr. Strong Code and Suicidal Patient Precautions for one of one current psychiatric patient (#16) and two of two discharged (eloped) psychiatric patients (#30 and #29) reviewed (A 0144);
-Ensure a safe environment when current patient (#16) was allowed to stay in her personal clothing while an inpatient after being admitted for attempted suicide and on suicide precautions (A 0144);
-Ensure a safe environment when discharged (eloped) patient (#30) was allowed to elope from the Intensive Care Unit (ICU) after she was admitted for a attempted suicide and a 96 hour psychiatric hold was issued by a Judge (A 0144);
-Ensure a safe environment when discharged (eloped) patient (#29) was allowed to elope from the Emergency Department (ED) where he was brought after attempted suicide when he jumped from a moving car (A 0144);

These failures had the potential to affect all patients in the facility when policies and procedures in place to protect patients were not put into effect and when judicial hold orders were not followed.
The facility census was 10.

Findings included:

2. Record review of the facility policy titled, "Security (Doctor Strong)," dated 04/03/15, showed direction that staff should:
-Call a Dr. Strong Code when help was needed to control a violent or potentially violent individual.
-Dial 70 and page Dr. Strong to department (name) stat (immediately), repeat the message three times.
-Call the local police department on weekends and after normal working hours.

Record review of the facility policy titled, "Suicidal Patient Precautions," dated 12/2014, showed direction that staff should:
-Maintain visual contact of the patient at all times, if visual contact was obscured the patient must be a direct 1:1 at all times.
-Remove all patient belongings and place patient in a gown.
-Not allow the patient to leave their room unless accompanied by a staff member.

Record review of the facility policy titled, "Elopement- Adult Patient," dated 12/2014, showed direction that staff should:
-Not attempt to chase the patient down the stairs or through hallways;
-Notify the Nursing Supervisor for assistance;
-Notify the physician;
-Attempt to talk the patient into returning; and
-Call a Dr. Strong.

Record review of Patient #16's History and Physical (H&P) showed that she was a 13 year old female who presented to the ED via ambulance at 8:48 PM on 08/22/17 after she took an overdose of medication. She had a history of attempted suicide, and had multiple cuts on body from cutting. She has a past medical history of depression, anxiety, post traumatic stress disorder (PTSD), and substance abuse. She was admitted to the medical floor on one to one nursing supervision, suicide precautions with diagnosis of depression and undetermined intent overdose. She was to remain on the medical floor until transfer to psychiatric inpatient treatment facility was arranged.

Observation on 08/23/17 at 10:15 AM, in Patient #16's room, showed Patient #16 had not been placed in a gown and was wearing her own personal clothing.

During an interview on 08/23/17 at 10:17 AM, Staff N, Maintenance, stated the following:
-He normally functions as a maintenance worker, he was cross trained to be one on one (staff member must see the patient at all times) with patients.
-He was unsure if the patients should be in their own personal clothing.
-If a patient tried to elope (unauthorized leave from the facility without proper discharge), he did not have the authority to prevent them from leaving.

During an interview on 08/23/17 at 10:40 AM, Staff P, Registered Nurse (RN), stated that patient #16 should have been changed into a gown in the ED prior to admission to the floor.

3. Record review of Patient #30's ED Record showed that she was a 39 year old female who presented to the ED via ambulance at 2:09 AM on 07/03/17 after she took an overdose of medication in an attempt to kill herself. The patient was intubated (placed a tube in throat) and put on a ventilator (machine that breathes for patient). The patient was placed on a continuous infusion (constant flow into the vein) of a sedation medication (to keep patient asleep and calm) and admitted to the ICU at 6:30 AM.
-At 9:30 AM the sedation medication was stopped;
-At 10:10 AM the patient was extubated (tube removed from throat, ventilator stopped);
-At 10:10 AM Staff L, RN (Registered Nurse Chief Nursing Officer (CNO)) confirmed with the patient that she tried to harm herself when she took the pills;
-At 10:45 AM Staff E, Social Worker, began process to place patient into a psychiatric facility;
-At 3:00 PM Staff E updated patient on placement process and patient advised her that she would be fine and wanted to go home, she had a 10 year old daughter that she needed to take care of;
-At 3:17 PM patient advised Staff L, RN, that she wanted to leave;
-At 4:05 PM the patient again advised Staff L that she wanted to leave, Staff L left voicemail message with a Judge to discuss a court ordered hold;
-At 4:41 PM Staff L documented that patient belongings were returned to patient in order to facilitate registration and that the Judge had issued a court order for psychiatric commitment (96 hour hold);
-At 5:09 PM Staff L documented that patient declined to return personal belongings for lockup;
-At 5:34 PM Staff L documented that a significant other arrived to visit with patient;
-At 5:46 PM Staff L documented that patient eloped from unit with significant other wearing hospital gown and flip flops. The social worker, nurse practitioner and police were notified.

Document review of, "Application to Court for 96 Hour Detention, Evaluation and Treatment," showed that it was signed by a Judge on 07/03/17 to hold Patient #30 to transfer for psychiatric evaluation and treatment.

During an interview on 08/23/17 at 3:10 PM Staff L, RN, CNO, stated that:
-She had been called into staff on 07/03/17 due to a sick call.
-She was on 1:1 care for Patient #30 because she was intubated and suicidal.
-Patient #30 was calm most of the day after she was extubated.
-Patient #30 became increasingly agitated as the afternoon continued and stated that she needed to leave to take care of her daughter.
-She was intimidated by Patient #30's significant other because of his size and demeanor, but he had not threatened her.
-Neither the patient nor her significant other spoke to her as they walked by on the way out.
-She knew the Judge had ordered the 96 hour hold.
-She did not think that she had the right to stop the patient.
-She did not call a Dr. Strong Code but did call the police soon after the patient left.

During an interview on 08/24/17 at 1:30 PM Staff E stated that she had attempted to place Patient #30 into psychiatric facility throughout the day on 07/03/17. The patient had been calm and cooperative for most of the day, but then became agitated in the afternoon because she had a 10 year old daughter that she cared for. Staff E stated that she submitted the application for a 96 hour hold to the Judge and about 5 PM, she received confirmation that the Judge had signed the application. She did not think she was on the unit when the patient actually left but was notified shortly after that. She did not "hotline" (report to a specific phone number) the situation (a suicidal psychiatric patient that eloped to take care of a child) to Child Protective Services because she believed the child was safe.

During a telephone interview on 08/24/17 at 2:40 PM Staff II, Nurse Practitioner (NP), stated that she covered Patient
#30 in the ICU that day. Staff II stated that she had several interactions with the patient during the day and the patient was cooperative and calm. Staff II stated the she did not know the patient became agitated or wanted to leave until after the patient had left.

4. Record review of Patient #29's ED visit showed that he was a 24 year old male who presented to the ED at 7:27 PM on 06/28/17 after he jumped out of a moving vehicle in order to hurt himself. Staff LL, Triage RN noted that the patient was clearly in pain but refused to answer any additional questions.

Record review of Staff S, ED Physician, documentation showed:
-The patient was profoundly uncooperative;
-The patient had multiple abrasions and left ankle was swollen;
-The patient was adamantly opposed to blood tests or tetanus shot (injection to prevent disease commonly called lockjaw that can occur with skin breaks);
-The patient was opposed to a mental health evaluation;
-Because of the suicidal gesture they (the ED) must pursue a psychiatric assessment;
-The patient, rather abruptly, ran from the ED;
-They were without measures or resources to detain him involuntarily;
-They notified the local police department to locate, detain, and bring him to a safe environment for a mental health evaluation;
-The patient disposition was eloped from the ED, with a diagnosis of attempted suicide and ankle sprain with hip abrasions.

During a telephone interview on 08/24/17 at 11:00 AM, Staff S stated that;
-Because the patient never actually stated to him that he was suicidal, would not cooperate with the examination and the significant other was not present to describe his behavior, the legal ground to hold him was tenuous.
-"I was not inclined to cause harm to him or myself to prevent him from leaving".
-This little ED does not have the resources to stop a patient that was running out.
-The patient was not placed on one on one observation because he could be seen from the nurse's station, he was not in a gown, he remained in his personal clothes.
-In his experience suicidal patients do not elope.
-The episode happened so quickly there was not time to call a "Dr. Strong" (overhead page to have staff gather rapidly in a safety/security situation). We did report it to the police by telephone, they did not come to the ED.

During an interview on 08/23/17 at 3:35 PM Staff C, Chief Executive Officer (CEO) stated that both of these elopements were reviewed after they occurred and it was determined that staff followed policy and there were no opportunities for improvement in either case.



37921

Based on observation, record review, policy review, and interviews, the facility failed to:
-Promptly identify and correct deficiencies in a timely manner of one patient (#14) of four patients who were being monitored by telemetry (continuous monitoring of the heart rate.)
-Follow the standard of practice related to telemetry monitoring on four patients (#5, #13, #14, and #32) of four telemetry patients observed.
-Implement proper assessments according to assessment protocol on alcohol withdrawal of one patient (#14) of two alcohol withdrawal patients reviewed, so that appropriate care/interventions could be instituted to protect the patient.
-Promptly identify and correct deficiencies in a timely manner of one patient (#18) of one patient reviewed who was at risk for aspiration (condition in which food, liquids, saliva was breathed into the airway).
-Implement proper seizure precautions and organized interventions according to facility's policy on two patients (#14 and #17) of two seizure precaution patients reviewed.
-Use appropriate transfer device according to the facility's policy to prevent one patient (#14), from a fall, of one patient reviewed.
-Perform hourly rounds/assessment according to the facility's policy on three patients (#15, #17, and #18) of seven patients reviewed.
-Provide patient hygiene timely according to facility's guidelines on three patients (#13, #14, #17) of three patients reviewed.
(Please refer to A 0395)

The cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Based on observation, record review, policy review, and interviews, the facility failed to:
- Promptly identify and correct deficiencies in a timely manner of one patient (#14) of four patients who were being monitored by telemetry.
- Follow the standard of practice related to telemetry monitoring on four patients (#5, #13, #14, and #32) of four telemetry patients observed.
- Implement proper assessments according to assessment protocol on alcohol withdrawal of one patient (#14) of two alcohol withdrawal patients reviewed, so that appropriate care/interventions could be instituted to protect the patient.
- Promptly identify and correct deficiencies in a timely manner of one patient (#18) of one patient reviewed who was at risk for aspiration.
- Implement proper seizure precautions and organized interventions according to facility's policy on two patients (#14 and #17) of two seizure precaution patients reviewed.
- Use appropriate transfer device according to the facility's policy to prevent one patient (#14), from a fall, of one patient reviewed.
- Perform hourly rounds/assessment according to the facility's policy on three patients (#15, #17, and #18) of seven patients reviewed.
- Provide patient hygiene timely according to facility's guidelines on three patients (#13, #14, #17) of three patients reviewed.
The facility census was 10

Findings included:

5. Even though requested, the facility failed to provide a telemetry monitoring policy that showed directives for staff to monitor patients on telemetry.

6. Record review of Patient #14's History and Physical (H&P) showed that she was a 55 year old female admitted under telemetry services for seizures related to voluntarily abstaining from alcohol.

Observation on 08/22/17 at 10:25 AM, on the medical floor, showed Staff K, Registered Nurse (RN) was within viewing distance of the telemetry monitors. The telemetry monitor showed that Patient #14's monitor was not picking up any heart rhythm. Staff L, CNO observed Patient #14 at bedside, she walked back toward Staff K, spoke with her, and then Staff K walked into the patient's room and reconnected the patient to telemetry. The patient was off the telemetry monitor for approximately eight minutes.

During an interview on 08/22/17 at 10:30 AM, Staff K stated that she did not respond because it happens all the time, there were no staff to watch the telemetry monitors.

Record review of the facility's daily census, dated 08/22/17, showed that four (#5, #13, #14, and #32) patients were admitted under telemetry services.

During an interview on 08/22/17 at 10:15 AM, in the telemetry monitoring area, Staff L, CNO, stated that there were times the telemetry on the patients were not monitored.

Observation and concurrent interview on 08/23/17 at 9:50 AM showed no staff within viewing area of the telemetry monitors. Staff L stated we have a lot to work on.

7. Record review of the facility's assessment protocol titled, "Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar, Clinical Institute Withdrawal Assessment for Alcohol scale)," showed directives for staff to perform assessments:
-Assess and rate each of the following criteria: nausea/vomiting, tremors, anxiety, agitation, paroxysmal sweats, orientation, tactile disturbances, auditory disturbances, visual disturbances, and headache;
-After rating each of the 10 criteria, total the score to achieve a CIWA-Ar score;
-If the CIWA-Ar score was higher or equal to eight, repeat assessments every one hour for eight hours;
-If stable, assessments every two hours for eight hours, then if stable, assessments every four hours;
-If at any time the CIWA-Ar score was higher or equal to eight, then assessments will repeat every one hour for eight hours; and
-Early interventions for CIWA-Ar score of eight or greater provides the best means to prevent the progression of withdrawal.

Record review of Patient #14's H&P showed that the patient was normally a heavy drinker, admitted to a beer a day and robust amounts of tequila. For 48 hours, the patient had voluntarily abstained from alcohol.

Record review of Patient #14's progress notes showed the following alcohol withdrawal assessments performed:
-On 08/21/17 at 11:12 AM, The CIWA-Ar score was eight;
-On 08/21/17 at 1:15 PM, The CIWA-Ar score was two; and
-On 08/21/17 at 3:15 PM, The CIWA-Ar score was two.

During a telephone interview on 08/23/17 at 4:00 PM, Staff MM, RN, stated that nurses are to follow the instructions on the alcohol withdrawal flowsheet. If the flowsheet instructed us to do one hour assessments, then we should perform one hour assessments.

During an interview on 08/23/17 at 10:20 AM, Staff S, Physician, stated that he expected the nursing staff to follow the alcohol withdrawal assessment protocol, and that the assessments and interventions delegate the treatment plan.

Even though the protocol directed the staff to reassess every one hour after a CIWA-Ar score of eight, the staff failed to perform one hour assessments, which had the potential to delay treatment.

8. Although requested, the facility was unable to provide a policy related to Aspiration Precautions.

9. Record review of Patient #18's medical record showed:
-72 year old female with admission on 08/22/17 for diagnoses of Sepsis (a serious infection where bacteria can be found throughout the body) and Pneumonia (lung infection caused by a virus or bacteria);
-Patient #18 resided in a nursing home, and was found with low oxygen saturations, increased secretions, and an increased temperature and was sent to the hospital for evaluation;
-Admission orders on 08/22/17 at 6:17 AM showed a nursing order for Aspiration Precautions;
-The patient was to have nothing by mouth (NPO) due to swallowing difficulties; and
-Speech therapy saw the patient on 08/22/17 at 11:17 AM, and the impression was that the patient was at increased risk for aspiration and nursing was informed.

Observations on 08/22/17 at 1:45 PM on the Medical/Surgical Unit showed:
-Staff K, Registered Nurse (RN), was standing in front of a supply cabinet;
-A visitor from Patient #18's room walked to the nurse's station and reported that the patient was choking;
-Staff F, RN, went to Patient #18's room, while Staff K continued to stand in front of a supply cabinet;
-Staff F assessed the patient and informed the family that Staff K was coming to suction the patient;
-Staff K asked for assistance from another RN to locate a Yankauer Suction tip (a firm plastic suction tip with a large opening designed to allow effective suction without damaging surrounding tissue); and
-Staff K found the Yankauer Suction tip, and was at the bedside at 1:49 PM to suction Patient #18.

During an interview on 08/22/17 at 3:50 PM, Staff K, stated:
-She was the nurse for Patient #18;
-The patient was not in any respiratory distress, and they just had a wet cough;
-There were orders for Aspiration Precautions for Patient #18;
-She had difficulty finding the Yankauer Suction tip; and
-They don't use them that often.

10. Record review of the facility's policy titled, "Seizure Precautions and Support During a Seizure," revised 12/2014, showed directives for staff to perform seizure precautions:
- Prepare bed with padded side rails, with full side rails up;
- Place the bed in low position; and
- Equip the room with oxygen and suction setups.

Record review of Patient #14's H&P showed that she was admitted with a diagnosis of seizures. Her last seizure activity was at home, just prior to arrival.

Record review of Patient #17's H&P showed that he was admitted with a diagnosis of seizure disorder. His last seizure activity was at home, just prior to arrival.

Observation on 08/22/17 at 10:25 AM, in Patient #14's room, showed the patient sitting on the side of the bed, feet dangling, bed not in low position, and no padding on the side rails. There was no suction available in the room.

During an interview on 08/22/17 at 10:30 AM, Staff K, RN, stated that Patient #14 was on seizure precautions, and the patient must have removed the pads off of the side rails.

Observation on 08/23/17 at 10:05 AM, in Patient #17's room, showed no suction set up in the room.

During an interview on 08/23/17 at 9:00 AM, Staff Q, Respiratory Therapist, stated that if the patients required suction set up, it was the nurses responsibility.

11. Record review of the facility's policy titled, "Safe Patient Handling and Movement," revised 12/2014, showed the directives for staff was to use a gait/transfer belt when assisting a patient in transfer or walking.

Record review of Patient #14's H&P showed that she was a heavy alcohol drinker, for the past 48 hours had voluntarily abstained from alcohol and had two seizures, which resulted in a fall at home.

Record review of Patient #14's progress notes from 08/20/17 through 08/21/17 showed the following:
-On 08/20/17, at 7:45 PM, the patient was assessed as high risk for falls with intervention of placing falling star decal (a method of identifying patients at high risk for falls) on the patient's door.
-On 08/21/17 at 6:13 AM, the patient was assessed as very "groggy" with multiple prompts before the patient answered appropriately and speech was slurred.
-On 08/21/17 at 6:13 AM, the patient was very unsteady on her feet, was assisted to the commode.
-On 08/21/17 at 6:13 AM, the patient fell asleep on the commode and "slid" to the floor.
-On 08/21/17 at 6:13 AM, the patient was unable to stand without assist, taking three staff members to lift patient from the floor.

During a telephone interview on 08/23/17 at 4:00 PM, Staff MM, RN, stated the following:
-She was aware that Patient #14 was high risk for falls.
-She did not use a gait belt to transfer the patient; she grabbed the patient under her arm.
-She did not use a gait belt because she did not have time.

Even though the staff member had time to assess the physical and mental capabilities of the patient, the staff member failed to use the appropriate safety equipment during transfer and left the patient unattended that resulted in the patient falling.

12. Record review of the facility's policy titled, "Nursing Hourly Rounding P's +1," dated 04/04/16, showed the directive for staff to perform, for the safety of the patient, one hour rounds including assessment of pain, potty, position, and possessions.

Record review of Patient #15's hourly rounding flowsheet on 08/23/17 at 10:30 AM showed the following:
-7:00 AM, Staff rounded;
-8:05 AM, Staff rounded;
-9:00 AM, No staff rounded; and
-10:30 AM, No staff rounded.

Record review of Patient #17's hourly rounding flowsheet on 08/23/17 at 10:05 AM showed the following:
-7:00 AM, Staff rounded;
-8:00 AM, No staff rounded;
-9:00 AM, Staff rounded; and
-10:05 AM, No staff rounded.

Record review of Patient #18's hourly rounding flowsheet on 08/23/17 at 10:00 AM showed the following:
-7:00 AM, Staff rounded;
-8:00 AM, No staff rounded;
-9:00 AM, No staff rounded; and
-10:00 AM, No staff rounded.

Record review of the facility's ICU/Medical Telemetry staff meeting minutes, dated 07/20/17, showed that, "hourly rounding was more than simply poking your head in the room". The Staff were to address the "4P's" with the patient: pain, potty, position, and possessions.

During an interview on 08/23/17 at 10:45 AM, Staff O, Certified Nurse Assistant (CNA), stated that all staff regardless if they were a nurse or a CNA should perform hourly rounds. The staff should have signed the hourly rounding flowsheet.

During an interview on 08/23/17 at 10:40 AM, Staff P, RN, stated that the staff should have signed the hourly rounding flowsheet.

13. Record review of the facility's guidelines, (Perry & Potter, pages 421-440 titled "Personal Hygiene and Bed Making), showed directives for staff to perform personal hygiene daily by washing hair and skin with warm water and soap to remove oil. Maintenance of personal hygiene was necessary for an individual's health, comfort, safety, and a sense of well-being.

During an interview on 08/22/17 at 10:15 AM, Patient #13 stated that he was admitted on 08/20/17 and had not received a bath for "two days" nor had any staff offered a bath.

Record review of Patient #13's medical record showed that he was admitted on 08/20/17, with diagnosis of alcoholism and that he was poorly groomed. As of 08/22/17, there was no documentation of Patient #13 receiving a bath.

During an interview on 08/22/17 at 9:40 PM, Patient #14 stated that she was admitted on 08/19/17, and had only received "one bath," and no staff had offered her another bath.

Record review of Patient #14's medical record showed that she was admitted on 08/19/17, with diagnosis of seizures related to alcohol withdrawal, and a history of a fall. As of 08/22/17, Patient #14 only received one bath documented on 08/21/17.

During an interview on 08/23/17 at 10:05 AM, Patient #17 stated that he had not received a bath in "three days," and no staff had offered a bath.

14. Record review of Patient #17's medical record showed that he was admitted on 08/21/17, with a diagnosis of seizure disorder, and history of falls, and documented that he would require assistance from caregivers.

During an interview on 08/22/17 at 10:30 AM, Staff K, RN, stated that patients don't get a bath every day, we are short staffed.

During an interview on 08/23/17 at 10:45 AM, Staff O, CNA, stated that patients should have a bath every day, we just don't have time to give the patients a bath.

During an interview on 08/23/17 at 9:00 AM, Staff P, RN, stated that patients should get a bath every day, we can't because of staffing.

15. Record review of the facilities staffing to patient ratio showed an average staff ratio of two nurses and one CNA, with no deviation between day and night shifts, to an average daily census of 7.5 patients.

During an interview on 08/24/17 at 4:00 PM, Staff L, CNO, stated that:
-Staffing was not the issue;
-Staff should have performed hourly rounding for patient safety; and
-Staff should have been watching the telemetry monitor and responded to the patient without being told.










36474

Based on observation, interview and policy review the facility failed to ensure that expired medications were removed from the Emergency Department (ED). Two injector syringes of Atropine (medication used during cardiac arrest [heart has stopped]) were expired in the Crash Cart (a cart that contained medications and supplies used when patients are critically ill). Also, two ammonia inhalants (medication used to wake a patient up quickly) were in a storage cart. This deficient practice placed all patients at risk to receive outdated, unusable drugs. The facility census was 10.

Findings included:

16. Record review of the facility policy titled, "Disposal of Expired and Unusable Medications," dated 10/1/16, showed:
-All expired and unusable medications should be disposed of or returned for credit if possible.
-Medications should be disposed of in a manner consistent with all local, state, and federal laws.
-All expired, damaged or contaminated medications will be removed from patient care areas.

Observation on 08/22/17 at 10:20 AM of the pediatric drawer in the Crash Cart of the ED, showed two injector syringes of Atropine with a hand written expiration date of 04/30/18 on the boxes. Upon further inspection, the manufacturer's expiration dates printed on the boxes were 08/01/17.

Observation on 08/22/17 at 10:40 AM of a storage cart in the ED showed two ammonia inhalants in a clear plastic box that was inside a clear bag. The clear bag had a sticker with a hand written expiration date of 04/2016. The clear box had a hand written expiration date of 05/2017.

During an interview on 08/22/17 at 10:55 AM, Staff G, Registered Nurse (RN), ED Manager, stated that expired medications should be removed from the area when they are beyond the expiration date and she was not sure why the hand written dates don't match the actual expiration dates.

During an interview on 08/22/17 at 11:05 AM Staff M, Pharmacy Manager, stated that he hand wrote the expiration date on the Atropine medication and could not explain the discrepancy. Staff M stated that he just called the manufacturer of the ammonia inhalants and confirmed that the expiration date on that lot number was 05/2017. Staff M stated that he was not sure why the sticker on the bag stated the expiration date was 04/2016. Staff M stated that it was unacceptable to have medications available for use after the expiration date.

Based on record review, observation, and interview, the facility failed to ensure foods were labeled and dated with an acquisition date, safe used by date, and removed from patient consumption beyond the safe used by date. These deficient practices placed all patients at risk for unsanitary food service and cross contamination of food. The facility census was 10.

Findings included:

17. Record review of the facility's policy titled, "Food Storage," revised 03/2016, showed direction for facility dietary staff to ensure that all foods should be labeled, dated, and checked to assure that foods will be consumed by their safe used by dates, or discarded.

Record reviews of the facility's policy titled, "Accepting Food Deliveries," revised 03/2016, showed direction for facility dietary staff to label, date, and remove any foods not safe for consumption.

Observation on 08/24/17 at 10:25 AM, in the kitchen freezer, showed the following frozen food containers that were not labeled with the safe used by date or removed from storage when beyond safe used by date:
-One container of bone in pork chops, unlabeled, with no date of acquisition or safe used by date;
-Four containers of bacon bits, unlabeled, with no date of acquisition or safe used by date;
-Two chocolate pies, unlabeled, with no date of acquisition or safe used by date; and
-Two blueberry ring cakes, labeled, with safe used date of 06/22/17, not removed for consumption.

During an interview on 08/24/17 at 10:35 AM, Staff GG, Dietary Aid, stated that the container of bone in pork chops, bacon bits, and chocolate pies, should have been labeled. Staff GG also stated that the two blueberry ring cakes should have been removed and discarded.

During an interview on 08/24/17 at 10:40 AM, Staff FF, Director of Dietary, stated that:
-All frozen food containers should have been marked with the date of acquisition and safe used by date.
-Staff were checking the containers for safe use by dates, however, there were no record of quality measures to show the staff performed the task.
-Containers beyond the safe used by date should have been removed from the freezer and discarded.

Based on observation, interview and policy review, the facility failed to ensure staff removed outdated/expired supplies from the Emergency Department (ED) and ED crash cart (a cart that contained lifesaving medications and supplies used in emergencies), and also failed to keep supplies appropriately stored in the Medical Surgical Nursing Unit supply room. These failed practices to keep outdated/expired medications and equipment out of patient care areas, as well as properly store supplies, had the potential to pose a health risk to all patients seeking care and services in the facility. The facility census was 10.

Findings included:

18. Record review of the facility's policy titled, "Outdated Medical Supplies," revised 04/27/16 showed the following directives:
-Once a month Materials Management warehouse clerks and clinical staff will perform an expiration check on non-stock and par level supplies.
-Any expired or about to expire items will be pulled and sent to Materials management to be disposed of.

Observation on 08/22/17 at 10:20 AM of the ED Crash Cart showed one, 2.5 millimeter (mm, a unit of size), Endotracheal Tube (ET, a tube that is inserted through the mouth down into the trachea [windpipe] used to establish and maintain an open airway to assist with breathing) that had a manufacturer's expiration date of 05/2017.

Observation on 08/22/17 at 9:25 AM of the ED suture cart (cart that contained supplies for skin repair) showed two packages of 2.0 (size) black monofilament (type of suture) suture string that had a manufacturer's expiration date of 07/2017.

During an interview on 08/22/17 at 10:55 AM, Staff G, Registered Nurse (RN), ED Manager, stated that expired supplies should be removed from the area when they are beyond the expiration date and she was not sure why they had not been removed.

Observation on 08/22/17 at 1:42 PM showed a plastic bag filled with Chest Tube's (hollow drainage tube inserted into the chest in order to remove an abnormal collection of air or fluid from the space between the inner and outer lining of the lung) and Chest Tube drainage systems (plastic containers and tubing that connect to the chest tube to allow for the air and fluid to collect) placed on the floor of the Medical Surgical Nursing unit's supply room.

During an interview on 08/23/17 at 1:00 PM, Staff I, Infection Control Manager, stated that the supplies should not have been left on the floor, and should have been on a shelf in the storage room.



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