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Based on interview and record review the facility failed to ensure staff who performed inpatient special diet teaching were licensed, registered dietitians (RDs) in the State. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Review of the Missouri Revised Statutes RSMO 2004 Chapter 324.001. Sections 324.200 to 324.225 showed the following:
-Sections 324.200 to 324.225 shall be known and may be cited as the "Dietitian Practice Act".
-As used in sections 324.200 to 324.225, the following terms shall mean:
-(3) "Dietetics practice", the application of principles derived from integrating knowledge of food, nutrition, biochemistry, physiology, management, and behavioral and social science to achieve and maintain the health of people by providing nutrition assessment and nutrition care services. The primary function of dietetic practice is the provision of nutrition care services that shall include, but not limited to:
(c) Providing nutrition counseling or education in health and disease;
(f) Engaged in medical nutritional therapy as defined in subdivision* (8) of this section;
(4) "Dietitian", one engaged in dietetic practice as defined in subdivision* (3) of this section;
(7) "Licensed dietitian", a person who is licensed pursuant to the provisions of sections 324.200 to 324.225 to engage in the practice of dietetics or medical nutrition therapy;
(8) "Medical nutrition therapy", nutritional diagnostic, therapy, and counseling services which are furnished by a registered dietitian;
(9) "Registered dietitian", a person who:
(a) Has completed a minimum of a baccalaureate degree granted by a United States regionally accredited college or university or foreign equivalent;
(c) Successfully completed the registration examination for dietitians.

2. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated the following:
-The facility employed a registered dietitian (RD) as a consultant who came on site twice a month for four hours per visit;
-If a physician ordered a nutrition consult for a patient or ordered special diet teaching and the RD was not on site, the patient would not be provided diet teaching by the RD;
-Many patients could be discharged without nutritional assessment, consultation and/or diet teaching done by the RD;
-Staff F stated she thought the nursing staff performed diet teaching;

3. During an interview on 03/12/13 at 11:50 AM Staff O, Charge Nurse stated the following:
-She usually worked weekends;
-She had been working at the facility for about eight months;
-She provided diet teaching to every in-patient prior to discharge;
-She printed special diet information from the computer;
-She did not know if the special diet information from the computer matched the information in the facility diet manual;
-She had not called the facility RD for a patient consult, diet teaching or nutrition assessment in the last six months.

4. Record review of Staff O's personnel file showed she was licensed in the state as a registered nurse and not a registered dietitian (did not have credentials to provide nutrition assessment, nutrition counseling and /or teaching).

Based on interview, policy review and record review the facility failed to ensure that patient care was provided by or in accordance with the orders of a practitioner granted privileges to provide or order care and in accordance with State law. The facility had expired professional licensure on file for three (Staff U, W and X) of five physician's credentialing records reviewed. This had the potential to affect all patients seeking care in the facility. The facility census was three.

Findings included:

1. Record review of the facility's Medical Staff By-laws dated 03/07, Article III, 3.2-1 Basic Qualifications for Medical Staff Membership showed the requirement for a current valid license issued by the State of Missouri to practice medicine.

2. Record review of medical staff credentialing records showed an expired professional license on file for:
-Staff U, Chief of Staff; expired 01/13
-Staff W, Medical Director for Radiology; expired 01/13
-Staff X, Pathologist, expired 01/13

3. During an interview on 03/12/13 at 11:25 AM, Staff A, Supervisor of Health Information Management, (HIM) stated that she was not aware the professional licenses on file had expired for Staff U, Staff W, and Staff X.

4. During an interview on 03/12/13 at 11:25 AM, Staff B, Director of HIM, stated that she was not aware the professional licenses on file had expired for Staff U, Staff W, and Staff X.

Based on interview and record review the facility failed to ensure physician oversight and documentation of consultation and physician signature on orders for two of two Emergency Room (ED) patients (#14, #15) cared for by the Advanced Practice Nurse (APN.)
This had the potential to affect all patients seeking care at the facility. The facility census was three.

Findings included:

1. Review of the Collaborative Practice Agreement between Staff U, Doctor of Osteopathy (DO), Chief of Staff and Staff Y, APN, dated 01/02/12, showed physician consultation would be obtained for all patients seen in the ED by an APN and a notation of the consult, including the physician's name must be made in the chart.

2. Review of the Application for Privileges: Nurse Practitioner (another term for APN), by Staff Y, signed 01/16/12 by Staff U and Staff Y, showed all orders written by the APN must be co-signed by the supervising physician.

3. Record review of discharged Patient #14's medical record showed the patient was seen in the ED on 12/05/12 at 3:59 PM, by Staff Y, APN, for symptoms of an upper respiratory infection and a history of cardiac murmur. Staff Y assessed Patient #14 and wrote laboratory orders. The patient was transferred by helicopter transport to a higher level of care. Record review on 03/12/13 showed there was no physician consultation noted in the medical record and orders written by Staff Y were not co-signed by the physician.

4. Record review of discharged Patient #15's medical chart showed the patient was seen in the ED on 03/08/13 at 6:30 PM, by Staff Y, APN, with a complaint of mental status changes and bilateral (both) leg pain from the hips to feet. Staff Y assessed Patient #15 and the patient was transferred by private vehicle to a higher level of care. Record review on 03/13/13 showed there was no physician consultation noted in the medical record and orders written by Staff Y were not co-signed by the physician.









18018

Based on interview, record review and policy review the facility failed to ensure critical lab values were reported and documented according to policy for four of six discharged patients (#12, #13, #14, #15). This had the potential to affect all patients seeking care in the facility. The facility census was three.

Findings included:

1. Record review of the facilities policy titled, "Reporting Critical Patient Values" dated 09/28/00 showed direction for the following actions when a critical lab value was obtained:
-Document the actions taken on the log, requisition and the patient report forms and initial all notations.
-Record on the report, the time, date and person notified.

2. Record review of discharged Patient #15's medical record showed he was seen in the Emergency Department (ED) on 03/08/13, with mental status changes. Review of labs for 03/08/13, showed a critical high value Creatine Kinase (CK, used to detect inflammation of the muscles or serious muscle damage). There was no documentation present for time, date and person notified or initials of lab personnel.

3. Record review of discharged Patient #12's medical record showed she was admitted through the ED on 12/09/12, with pneumonia. Review of labs for 12/10/12, showed a critical high value for BNP (brain natriuretic peptide test, used to check for heart failure). There was no documentation present for time, date and person notified or initials of lab personnel.

4. Record review of discharged Patient #13's medical record showed she was seen in the ED on 11/29/12, following a fall and head injury. Review of labs for 11/29/12, showed a critical high value for Partial Thromboplastin Time (PTT, determines if blood thinning therapy is effective). There was a notation on the report that PTT could not be run. There was no documentation present for time, date and person notified or initials of lab personnel.

5. Record review of discharged Patient #14's medical record showed she was seen in the ED on 12/05/12, for symptoms of upper respiratory infection. Review of labs for 12/05/12, showed critical low value Hemoglobin and Hematocrit (H&H, the two major tests for anemia). There was no documentation present for time, date and person notified or initials of lab personnel.

6. During an interview on 03/11/13 at 3:30 PM, Staff M, Laboratory Manager, stated that the lab had a policy on reporting of critical values. Staff M stated that the lab kept a log of all tests run and made a notation on the log if it was a critical value. Staff M stated that all critical values were reported to the physician directly or a Registered Nurse if it was an in-house patient and the tech makes a notation on the lab report who was notified, date, time and initials the notation. Staff M was not aware lab staff were not following the critical values policy and there was no quality monitoring of critical value reporting.

Based on observation, record review and interview, the facility failed to maintain an active infection control program, an on-going committee, and conduct regular infection control meetings to ensure the facility had an effective operational system for identifying, reporting, investigating and controlling infections and communicable diseases of patients, visitors, contracted staff, volunteers and personnel. The facility census was three. This had the potential to affect patients and staff.

Findings included:

1. During an interview on 03/11/13 at 3:05 PM Staff F, Director of Dietary stated the following:
-She was not a member of the facility Infection Control Committee or the Infection Control program;
-The facility Infection Control Nurse had never been in the facility kitchen to observe and monitor practices or provide in-service education regarding sanitation or infection control related to food service.

2. Observation on 03/12/13 at 11:28 AM showed Staff AA, Cook assembled foods for the patient tray service; coughed into the air without shielding into the crook of her arm then, performed hand hygiene.

3. Record review of the facility's Infection Control Book on 03/12/13 at 2:05 PM, showed the last documented infection control meetings were conducted in 2008.

4. During an interview on 03/12/13 at 2:05 PM, Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO) stated that she had been the CNO for the facility since April 2012. The CNO stated the following information:
-The facility's Infection Control Officer (ICO) quit October 2012.
-She stated that she assumed the responsibility of the ICO when the other staff member left in October 2012.
-She stated that the infection control committee is just now being re-instated this month.
-She stated that she did not know when the facility stopped having an active infection control committee.
-She stated that from April 2012 to October 2012 the previous ICO did not have any infection control meetings.
-She stated that she did not have an infection control plan in place as of 03/12/13 at 2:20 PM.
-She stated that she did not teach infection control practices to staff, for example, coughing into the crook of your elbow.



16215

Based on observation, interview and record review the facility failed to ensure the following:
-The Dietary Director was a certified Dietary Manager;
-The Consultant Dietitian made sufficient visits to the facility to ensure the nutritional needs of the patients were met;
-The facility menus used for patient meal service were analyzed for nutrient content (protein, fat, carbohydrate, vitamins, minerals, calories);
-The Consultant Dietitian failed to provide comprehensive nutritional assessments within twenty-four hours of a patient being identified at nutritional risk;
-The Director of Dietary failed to provide appropriate in-service training to Dietary department staff regarding pertinent topics including food sanitation and safety and diet therapy;
-The Consultant Dietitian failed to provide complete regular and special diet menus for dietary staff to serve foods to patients;
-Staff failed to ensure the facility diet manual was approved by the medical staff for use with patients;
-The Dietary Director failed to ensure foods, supplies used in patient meal service and cases of documents were stored at least six inches above floor level to facilitate sweeping and mopping. These deficient practices had the potential to affect all patients. The facility census was three.

Findings included:

1. Record review of an undated copy of the facility's "Nutritional Services Director's Job Description/Evaluation" showed a qualification for the position was a graduate of an approved dietetic assistant's (dietary managers) program and be eligible to join the Dietary Manager's Association or be a member.

2. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated the following:
-She was a certified dietary manager student;
-She had just finished the sixth or seventh lesson;
-She had "a long way to go" [before completing her certified dietary manager's course].

3. During an interview on 03/12/13 at 11:15 AM Staff G, Consultant Dietitian confirmed Staff F was only in the first few lessons in the Certified Dietary Manager's course.

4. Review of the facility's policy titled "Patient Nutritional Assessment" revised 04/25/12 showed the following direction:
-The Dietary Director completed a Dietary Assessment for each patient;
-The Dietary Director and/or the Consulting Dietitian will actively and continually assess patient nutritional status:
-The assessment will include but is not limited to the following: type of diet served, checking for conformance with the physician's order; patient's dietary habits, including food preferences; tolerance to foods served; ability to feed self, noting total or partial assist; ability to chew food served; weight on admission;
-Documentation of pertinent findings will be reflected in the initial assessment and addressed in the Dietary Progress Notes:
-Problem identification. Utilizing the collected data, Dietary will identify and document nutrition problems. This process will be ongoing;
-Goals/Outcome Criteria. Dietary will document on the Care Plan appropriate outcome criteria for each nutritional problem identified.

5. Review of the facility's policy titled "Diet Consult Education" revised 04/25/12 showed the following direction for facility staff, the Nutrition Services Director (Director of Dietary) and/or the Consultant Dietitian present modified diet instruction and/or dietetic counseling to the patient and or family of a patient upon physician request.

6. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated the following:
-She was not a dietitian;
-The facility employed a Consultant Dietitian;
-The Consultant Dietitian visited the facility twice a month;
-A physician ordered nutrition consult for an in-patient was usually answered by the dietitian after the patient was discharged.

7. Record review of the Consultant Dietitian's visit reports, provided by Staff F on 03/11/13 showed the Consultant Dietitian was on site twice a month (every fourteen days) for four hours each time.

8. During an interview on 03/12/13 at approximately 9:00 AM Staff Z, Chief Financial Officer stated that the average length of stay for regular hospital patients was 3.3 days and the average length of stay for patients in Swing Bed (a Medicare program in which the bed the patient occupied can be paid for as an acute patient or as a long term care resident) status was 9.48 days.

9. During an interview on 03/12/13 at 11:45 AM Staff F stated that she did not review any information in the patient medical records and she did not record any information in the patient medical records (as directed in facility policy).

10. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated she had no knowledge of a nutrient analysis of the current menus served to patients and if there was one, the Consultant Dietitian would have it.

11. During an interview on 03/12/13 at 11:15 AM Staff G, Consultant Dietitian stated she had not developed and maintained a nutrient analysis (a calculation of protein, carbohydrate, fat, vitamins, minerals, calorie content) of menus served to patients.

12. Review of the facility menus showed the following:
-A twelve day cycle menu of only lunch and suppers (no breakfasts listed):
-Diets for regular, no added salt diet (unknown salt content), soft diet, pureed diet, high protein (unknown protein content), and limited concentrated sweets diet (unknown calorie or concentrated sweets content);
-In the margin of each page a notation for "1800 calorie diet, same as regular; allow four carbs (carbohydrates)" but no explanation of what foods were "carbs";
-In the margin of each page a notation for "2000 calorie diet, same as regular; allow five carbs" but again no explanation of what foods were "carbs".

13. Review of the facility's policy titled "Diet Consult Education" revised 04/25/12 showed the following direction for facility staff, the Nutrition Services Director (Director of Dietary) and/or the Consultant Dietitian present modified diet instruction and/or dietetic counseling to the patient and or family of a patient upon physician request.

14. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated the following:
-She does not perform nutrition assessments;
-The facility employed a contracted Consultant Dietitian;
-The Consultant Dietitian visited the facility twice a month (every fourteen days) for four hours each visit;
-If a physician ordered a dietary consult, the consult was usually not done until the dietitian's next visit (usually after the patient was discharged from the hospital).

15. During an interview on 03/12/13 at approximately 9:00 AM Staff Z, Chief Financial Officer stated the following:
-The average length of stay for regular hospital patients was 3.3 days;
-The average length of stay for patients in Swing Bed status was 9.48 days.

16. During an interview on 03/12/13 at 11:45 AM Staff F stated she did not review any information in the patient medical records and she did not record any information in the patient medical records.

17. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated the following:
-She had been in position since 04/12;
-She had not done any recent in-services for the dietary staff.

18. Record review of the last in-services provided for Dietary staff showed undated, records of two meetings including one titled "carbohydrate counting" and another titled "on work" without information on what was covered, who attended, length of the in-service or evaluation of the session.

19. During an interview on 03/12/13 at 11:15 AM Staff AA, Cook stated the following:
-She had been employed at the facility for approximately five years;
-She had not had any in-service training regarding food temperatures or any other topics regarding food sanitation or safety during that period.

20. During an interview on 03/11/13 at 2:45 PM Staff F, Director of Dietary stated the following:
-The facility Consultant Dietitian wrote the current set of menus used for patient meal service;
-The menus included regular (unrestricted) diet, soft diet, pureed diet, high protein diet, limited concentrated sweets diets;
-The menus included lunches and suppers but no breakfasts;
-Staff used the lunch and supper menus to serve meals however just served breakfast foods from memory.

21. Review of the current menu cycle provided during the survey by Staff F showed the Consultant Dietitian had provided the following:
-Only lunch and supper menus for the regular (unrestricted) diet:
-Only lunch and supper menus for some special diets (soft diet, pureed diet, high protein diet and limited concentrated sweets diets);
-She failed to provide written breakfast menus for the regular and any of the special diets.

22. During an interview on 03/12/13 at 11:15 AM Staff G, Consultant Dietitian confirmed she had failed to provide written breakfast menus for staff to use to serve foods on the regular diet and the special diets.

23. Review of the facility's policy titled "Missouri Diet Manual" revised 04/25/12 showed the following direction:
-The diet manual was used as a guide for ordering and following diets;
-The Diet Manual, 8th edition by Dorner and Associates was kept at the nurse's station and in the Dietary department:
-Additional {diet} references could be obtained from the Consultant Dietitian;
-These {the Diet Manual and the unidentified additional information from the Consultant Dietitian} were to be consulted when ordering and following modified diets.

24. Review of the copy of the Diet Manual maintained in the Dietary department showed staff failed to obtain any proof of approval by the medical staff.

25. During an interview on 03/11/13 at 2:45 PM Staff F, Director of Dietary stated the facility Diet Manual was not approved by the medical staff for use in ordering diets for inpatients.

26. Record review of the United States Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code, Chapter 3-305.11 (A) (3) directed that food should be stored at least six inches above the floor level.

27. Observation on 03/11/13 at 3:10 PM in the facility Dietary department dry foods storeroom showed staff stored the following:
-Various foods including juices on eight shelving units, each approximately one inch off the floor level;
-A full case of insulated bowls used on patient meal trays directly on the floor;
-A partial case of plastic knives and a case of plastic spoons that were used on patient meal trays directly on the floor;
-Multiple boxes of old forms and papers stored directly on the floor.

28. During an interview on 03/11/13 at 3:16 PM Staff F Director of Dietary stated she knew cases of foods and other patient tray service related articles should not be stored on the floor however, she had no other place to store those items.

Based on interview, policy review and record review the facility failed to ensure the Medical Director of Radiology had approved policies and procedures that assure acceptable standards of practice and approved standards of safety including the scope and complexity of radiological services offered. This had the potential to affect the safety of staff and the care and safety of all patients seeking radiological care from the facility. The facility census was three.

Findings included:

1. Record review of the Radiology Policy and Procedure Manual dated 04/19/12, showed no signature of approval by the Medical Director of Radiology.

2. During an interview on 03/12/13 at 10:10 AM, Staff I, Director of Radiology, stated that it was the policy of the facility that all policies and procedures for Radiology were reviewed annually and approved by the Board of Directors, Medical Staff and Medical Director of Radiology. Staff I stated that she could not show proof the Radiology Department Policy and Procedure manual had been reviewed and approved by the Medical Director of Radiology.

Based on interview, policy review and record review the facility governing body failed to take action to ensure services provided through agreement or arrangements were with a provider or supplier that participated in the Medicare Program for three of ten contracts reviewed. This had the potential to affect all patients seeking care at the facility. The facility census was three.

Findings included:

1. Record review on 03/13/2013, of an agreement between the facility and a contractor to provide ultrasound services dated 03/07/12, lacked evidence to ensure contractor participation in Medicare.

2. Record review on 03/13/13, of an agreement between the facility and a contractor to provide blood products dated 02/01/10, lacked evidence to ensure contractor participation in Medicare.

3. Record review on 03/13/13, of an agreement between the facility and a network facility dated 10/26/99, lacked evidence to ensure network facility participation in Medicare.

4. During an interview on 03/13/13 at 11:30 AM, Staff E, Administrative Assistant, stated that the facility did not have a policy related to contracts and services provided under agreement or arrangement.

Based on record review and interviews the facility failed to ensure a complete list of services provided under contract or agreement and failed to include the nature and scope of those contracted services for 98 of 98 contracts on the list. This deficient practice had the potential to place all staff and patients of the facility at risk. The facility census was three.

Findings included:

1. Review of the Contracts list for the facility showed 98 contracts or service agreements with the date the contract or service agreement was finalized. The list did not indicate the nature and scope of the services provided through the contracts.

2. During an interview on 03/11/13 at 3:00 PM, Staff M, Laboratory Manager, stated that the laboratory had an agreement for the Laboratory Medical Director, Staff V, and for reference lab services. Staff M stated that she did not have a copy of the contract.

3. During an interview on 03/13/13 at 11:00 AM, Staff I, Director of Radiology, stated that Radiology had an agreement for annual radiation testing and the provision of services for the facility Radiation Safety Officer. Staff I stated she did not have a copy of the agreement and had not seen the agreement.

4. During an interview on 03/13/13 at 11:30 AM, Staff E, Administrative Assistant, stated that:
- The facility could not find a written contract or service agreement with the laboratory contractor. The laboratory contractor was not included on the facility contracts list;
- The facility could not find a written contract or service agreement with the radiation safety contractor. The radiation safety contractor service agreement was not included on the facility contracts list;
-The reference lab services contractor's service agreement dated 06/24/11 was not included on the facility contract list.

Based on record and policy review, the facility failed to follow their policy when staff failed to incorporate a nursing care plan that addressed all patient needs that included measurable goals, individualized interventions and timetables for two patients (#2 and #9) out of two current in-patients reviewed. The facility census was three (two in-patient and one swing-bed patient). This had the potential to affect all patients that required a care plan.

Findings included:

1. Record review of the facility's policy titled, "Nursing Standards of Patient Care" reviewed 03/13 showed the following direction for staff:
-Each patient will receive nursing care/interventions in an effective manner given the current standard of care with evidence base practice, in order to achieve the desired/projected outcome for the patient. Each patient will:
-Be assessed for biophysical, psychosocial, environmental, cultural, spiritual, developmental, self-care, nutritional risk, education, abuse/neglect risk, and discharge care needs/state.
-Be provided nursing care based on the needs/diagnosis identified through use of assessment data.
-Have a plan of care that prescribes individualized interventions to attain expected outcomes and reflects recognized standards of care and evidence-base practice as well as respects patient's rights.
-Have his/her needs/state reassessed and the plan of care evaluated and revised based on assessment data and evidence-base practice.
-Each patient will have nursing care/interventions available to meet his/her needs. Each patient (and/or family, as appropriate) will receive:
A. Individualized care/interventions based on identified needs.
B. Age appropriate nursing care/interventions.
C. Education in respect to patient's health care needs/state.
D. Nursing care/interventions designed to meet the patient's/family's actual and potential post-discharge care needs.
E. Nursing care/interventions designed to promote hygiene, comfort, and or pain control.
F. Nursing care/interventions designed to maintain or improve nutritional status.
G. Nursing care/interventions designed to maintain a clean environment, promote infection control, and prevent nosocomial infections (an infection acquired in a hospital.)
-Each patient will receive nursing care/interventions in an effective manner, given the current evidence based practice guidelines, in order to achieve the desired/projected outcome for the patient.

2. Record review of current Patient #2's medical chart showed she was admitted to the facility on 03/08/13 with complaints of right flank pain, left upper abdominal pain, nausea and vomiting.

Record review of the patient's History and Physical (H&P) dated 03/13/13, showed the following information:
-Chief Complaint: Severe right flank pain, right and left upper abdominal pain and hematuria (blood in the urine).
-Past Medical History: The patient has a longstanding history of renal calculi (kidney stones) with insufficient ureters (tubes which propel urine from the kidneys to the urinary bladder). The patient reports that she is to have her ureters replaced.
-Lab and X-Ray: Computerized tomography (CT scan, cross-sectional images of the bones and soft tissues inside the body) shows that the patient does have renal stones. Urinalysis shows blood.

Record review of the patient's Physician's Orders Sheet (POS) showed the following orders:
-On 03/07/13 CT with renal stone protocol.
-On 03/07/13 add fiber to diet.
-On 03/08/13 Valium (medication used to treat seizures) 5 milligrams (mg) to 10 mg intravenous (IV) times one (once) for seizure activity.
The patient was admitted from observation status to acute care status on 03/08/13.

Record review of the Patient Treatment/Care Plan dated 03/08/13 showed the following:
-It did not address the need to monitor and strain the patient's urine for the presence of kidney stones and/or blood.
-It did not address the need to add fiber to the patient's diet due to complaints of constipation.
-It did not address the need to implement seizure precautions related to the patient's history of seizure activity.

3. Record review of current Patient #9's medical chart showed she was admitted to the facility on 03/11/13 with complaints of orthostatic hypotension (sudden fall in blood pressure when standing up).

Record review of the patient's H&P dated 03/12/13 showed the following information:
-Chief Complaint: Orthostatic hypotension
-History of Present Illness: The patient is a 78-year-old resident at a residential care facility (RCF). She was having lunch and when she stood up to walk back to her room, got dizzy, fell down and now complains of slight disorientation.
-Past Medical History: Orthostatic hypotension and a history of falls.

Record review of the patient's POS showed the following orders:
-On 03/11/13 routine orthostatic vital signs (blood pressure taken in lying position, then sitting position and then standing position), oxygen at two liters per nasal cannula.
-On 03/12/13 telemetry (monitoring of cardiac rhythm and transmission of signal from one electronic unit to another) monitoring due to syncope (fainting) and add snacks between meals.

Record review of the Patient Treatment/Care Plan dated 03/11/13 showed the following:
-It did not address the need to monitor cardiac function per telemetry.
-It did not address the need to add snacks between meals.
-It did not address the patient's need to have orthostatic vital signs monitored.
-It did not address the patient's need for oxygen use.

4. During an interview on 03/12/13 at 1:20 PM, Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO), stated that she expected staff to individualize the Patient Treatment/Care Plan to include and reflect a patient's diagnosis, needs, care and treatments. Staff D stated that she expected staff to update the Patient Treatment/Care Plan with any changes the patient might experience. Staff D stated that Patient Treatment/Care Plan should be individualized and specific.

5. During an interview on 03/13/13 at 10:10 AM, Staff J, RN, Day Charge Nurse stated that the Patient Treatment/Care Plan should be individualized based on patient assessment and diagnosis.

Based on interview and record review the facility failed to ensure three of three current patients (#1, #2 and #9) and eight of twelve (#4, #5, #6, #7, #10, #12, #14 and #15) discharged patient medical records contained dated, signed entries (orders, progress notes, lab requisitions) by all physicians and health care professionals involved in the care of the patient. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Record review of the facility Medical Staff Rules and Regulations, revised 03/07 showed the following:
-Article VII Medical Records, 7.1 Contents of Medical Records, D 11 showed all inpatient medical records shall contain signed and dated progress notes made by the Medical Staff which gives a pertinent chronological report of the patient's course in the Hospital and reflect any change in condition and the results of treatment.
-Article VII Medical Records, 7.3 General Requirements. All clinical entries in the patient's medical record shall be entered in the patient's medical record in a timely manner, legible, dated, authenticated, and recorded in ink, typewritten or electronically recorded.

2. During an interview on 03/11/13 at 1:20 PM Staff A, Supervisor of Health Information Management (HIM) stated the following:
-She audited patient medical records for dated and timed signatures on all documentation;
-The HIM medical record audits showed staff who document in the medical records frequently failed to date and time their signatures;
-Physicians frequently failed to date and time their orders and progress notes;
-She would like all entries to be dated, timed and signed;
-The HIM department used the Medical Staff Rules and Regulations for direction on dates, times and signatures.

3. Record review of current Patient #1's medical chart showed she was admitted to the facility on 03/03/13 with complaints of right sided pneumonia and hypoxia (oxygen deprivation).

Record review on 03/13/13 at 2:30 PM of the patient's Physician's Order Sheet (POS) showed the following:
-On 03/03/13 the physician failed to sign or date four orders.
-On 03/07/13 the physician failed to sign or date one order.
-The patient was admitted to Swing Bed services on 03/03/13. The physician failed to sign or date the Swing Bed General Admitting Orders.

4. Record review of current Patient #2's medical chart showed she was admitted to the facility on 03/08/13 for complaints of left upper abdominal pain, right flank pain, nausea and vomiting.

Record review on 03/13/12 at 2:30 PM of the patient's POS showed the following:
-On 03/07/13 the physician failed to sign or date one verbal order.
-On 03/08/13 the physician failed to sign or date the admission orders.
-On 03/08/13 the physician failed to sign or date Medication Reconciliation Orders.

5. Record review of current Patient #9's medical chart showed she was admitted to the facility on 03/11/13 for complaints of orthostatic hypotension (dizzy spells).

Record review on 03/13/13 at 2:30 PM of the patient's POS showed the following:
-On 03/11/13 the physician signed one telephone order but failed to date his signature.
-On 03/11/13 staff the physician failed to date when he signed the order.
-On 03/11/13 the physician failed to sign or date Medication Reconciliation Medication orders.

6. Record review of discharged Swing Bed Patient #4's Discharge Summary showed the physician signed the document on 02/13/13 but failed to date and time his signature.

7. Record review of discharged Patient #5's medical record showed the following:
-An admission history and physical (H&P) showed staff admitted the patient on 12/10/12. The physician signed the H&P but failed to date and time his signature.
-A Discharge Summary showed the patient was discharged on 12/14/12, the physician signed the document but failed to date and time his signature.
-A physician's verbal order dated 12/14/12, was signed but the physician failed to date and time his signature.

8. Record review of discharged Patient #6's medical record showed the following:
-An admission H&P showed staff admitted the patient on 10/12/12. The physician signed the H&P but failed to date and time his signature.
-A Discharge Summary showed the patient was discharged on 10/19/12. The physician signed the document but failed to date and time the signature.
-Physician progress notes dated 10/12/12 through 10/19/12 were signed and dated but untimed.
-Verbal orders dated 10/12/12 and on 10/19/12 were signed but not dated and timed.

9. Record review of discharged Patient #7's admission H&P showed staff admitted the patient on 02/24/13. The physician signed the H&P but failed to date and time his signature.

10. Record review of discharged Patient #10's medical record showed she was admitted to the facility after being seen in the Emergency Department (ED) on 02/01/13, with mental status changes. Record review of the physician orders showed the following:
-On 02/01/13 at 7:35 AM, Physical Therapy (PT) staff wrote an order and the physician failed to date and time when he signed the order.
-On 02/01/13 at 10:00 AM, staff wrote a verbal order from the Advanced Practice Nurse (APN). The APN failed to date and time when she signed the order and the physician failed to date and time when he co-signed the order.
-On 02/01/13 at 12:20 PM, the APN wrote an order and the physician failed to date and time when he co-signed the order.
-On 02/01/13 at 12:30 PM, staff wrote a verbal order from the APN. The APN failed to date and time when she signed the order and the physician failed to date and time when he co-signed the order.

11. Record review of discharged Patient #12's medical record showed she was admitted to the facility after being seen in the ED on 12/09/12, with a diagnosis of pneumonia. Record review of the physician orders showed the following:
-On 12/13/12 at 5:55 AM, a standing order was written by staff. The APN failed to date and time when she signed the order and the physician failed to date and time when he co-signed the order.
-On 12/13/12 at 8:10 AM, two orders were written by the APN, and the physician failed to date and time when he co-signed the orders.
-On 12/14/12 an order was written by staff, not timed and the physician failed to date and time when he signed the orders.

12. Record review of discharged Patient #14's medical record showed the patient was seen in the ED on 12/05/12 at 3:59 PM by Staff Y, APN. Record review of the physician orders showed the following:
-On 12/05/12 at 3:50 PM, three orders were written by the APN and not signed off by the physician.
-On 12/05/12 at 4:05 PM two orders were written by staff and not signed off by the physician.
-On 12/05/12 at 4:10 PM an order was written by staff and not signed off by the physician.

13. Record review of discharged Patient #15's medical record showed the patient was seen in the ED on 03/08/13 at 6:00 PM, by Staff Y, APN. Record review of the physician orders showed on 03/18/13 at 6:16 PM an order written by staff was signed off by the APN but not timed. The order was not signed off by the physician

14. During an interview on 03/12/13 at 1:20 PM, Staff A, Supervisor of Health Information Management, stated that she expected physicians to date and sign all entries in patients' medical records.



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Based on observation and interview the facility Health Information Management (HIM) department failed to ensure patient medical records were maintained to protect against loss, destruction and/or unauthorized access and use. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three.

Findings included:

1. Observation on 03/11/13 at 2:05 PM in the Health Information Management (HIM) medical records room showed six to seven floor to ceiling, open metal file shelving units filled with paper patient medical records.

2. During an interview on 03/11/13 at 2:05 PM Staff A, Supervisor, HIM stated the following:
-The open shelving contained paper medical records of the most currently treated patients;
-HIM staff routinely worked and occupied the file room Monday through Friday from 8:00 AM through 4:30 or 5:00 PM;
-The main door to the medical records file room was locked during non-business hours;
-Staff could access the file room with a key;
-One staff who was routinely assigned to access the file room was a Housekeeping staff who cleaned the medical records file room at approximately 4:00 AM daily;
-The Housekeeping staff person could potentially access, destroy or discard any patient medical record stored on the open shelving while in the medical records file room.

Based on interview, policy review and record review the facility failed to take action to ensure services provided through agreement or arrangements were evaluated for quality of care for five of ten contracts reviewed. This had the potential to affect all patients seeking care at the facility. The facility census was three.

Findings included:

1. Record review on 03/13/13 of the agreement between the facility and an imaging service to provide ultrasound dated 03/07/12, showed no evidence of evaluation of services and no Quality Assurance (QA) activities.

2. Record review on 03/13/13 of the agreement between a blood bank and the facility dated 02/01/10, showed no evidence of evaluation of services and no QA activities.

3. Record review on 03/13/13 of the service agreement between a reference lab and the facility dated 05/19/11, showed no evidence of evaluation of services and no QA activities..

4. Record review on 03/13/13 of the agreement between a physician coverage group and the facility dated 01/01/12, showed no evidence of evaluation of services and no QA activities.

5. Record review on 03/13/13 of the agreement between a nurse staffing agency and the facility dated 01/01/12, showed no evidence of evaluation of services and no QA activities.

6. Record review of the facility quality report presented to the Board of Directors for the 4th Quarter 2012 showed no evidence of evaluation of services provided by contract or agreement and no QA activities for nine of ten contracts reviewed.

7. During an interview on 03/13/13 at 11:30 AM, Staff E, Administrative Assistant, stated that the facility did not have a policy for contracts and services provided under agreement or arrangement.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure the following:
-Individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed by the facility for nine staff (B, F, G, J, K, L, M, N and P) of nine staff reviewed.
-A request for a criminal background check (CBC) was done prior to allowing any person who had been hired to have contact with a patient or a Swing Bed (a Medicare program in which the bed the patient occupied can be paid for as an acute patient or as a long term care) resident for one staff (G) of one reviewed.
These deficient practices had the potential to affect all patients treated at the facility. The facility census was three (one was in Swing Bed status).

Findings included:

1. Review of the Missouri State Statutes showed the following:
-RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) to complete not only pre-employment EDL checks but also periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).
-RSMO 2003 Section 660.317 (3) (1) directed facilities licensed under Chapter 197 (hospitals) to request a criminal background check for any person who has been hired for a full-time, part-time or temporary position, prior to allowing the new hire to have contact with a patient or a resident.

2. Review of Staff B's personnel file showed Staff B:
-Was hired on a date prior to 01/05/00 (Staff B had been hired and re-hired in various positions and no clear hire date could be found);
-Had EDL verification on 07/13/11 however, the facility failed to check the EDL on a periodic basis thereafter.

3. Review of Staff F's personnel file showed Staff F:
-Was hired on 01/16/12;
-Had EDL verification on 01/20/12 however, the facility failed to check the EDL on a periodic basis thereafter.

4. Review of Staff G's personnel file showed Staff G:
-Was a contractor with no clear "hire" date or start date of the contract;
-The facility failed to check the EDL on hire/start of the contract and periodically thereafter;
-The facility failed to obtain a criminal background check on the contractor prior to contact with patients/residents.

5. Review of Staff J's personnel file showed Staff J:
-Was re-hired on 06/29/12;
-The facility checked the EDL on 11/22/10 for an earlier hire but none for the 06/29/12 hire date;
-The facility failed to check the EDL on a periodic basis on rehire and thereafter.

6. Review of Staff K's personnel file showed Staff K:
-Was hired on 07/30/99;
-Had an EDL check on 09/13/11;
-The facility failed to check the EDL on a periodic basis thereafter.

7. Review of Staff L's personnel file showed Staff L:
-Was hired 10/25/99;
-Had an EDL check on 09/13/11;
-The facility failed to check the EDL on a periodic basis thereafter.

8. Review of Staff M's personnel file showed Staff M:
-Was hired on 10/26/99;
-Had an EDL check on 09/13/11;
-The facility failed to check the EDL on a periodic basis thereafter.

9. Review of Staff N's personnel file showed Staff N:
-Was hired on 11/17/92;
-Had an EDL check on 09/13/11;
-The facility failed to check the EDL on a periodic basis thereafter.

10. Review of Staff P's personnel file showed Staff P:
-Was hired on 01/07/00;
-Had an EDL check on 09/13/11;
-The facility failed to check the EDL on a periodic basis thereafter.

11. During interviews on 03/12/13 at 3:00 PM and on 03/13/13 at 11:15 AM Staff E Administrative Assistant stated the following:
-She performed an EDL check for staff on hire;
-She was unaware of the requirement for periodic EDL checks;
-There was no facility policy directing periodic EDL checks;
-She was unaware of the requirement for criminal background checks;
-She did not have further information on Staff G's actual hire date (start of the contract), EDL checks or criminal background checks.

Based on record and policy review, the facility staff failed to follow their policy when staff failed to incorporate a nursing care plan that addressed all patient needs that included measurable goals, individualized interventions and timetables for one patient (#1) of one swing-bed patient reviewed (a Medicare program for patients who require medical care beyond acute care that is intended to treat rehabilitation conditions). This had the potential to affect all patients that required a care plan in the facility's swing-bed program. The facility census was three (two in-patient and one swing-bed).

Findings included:

1. Record review of the facility's policy titled, "Nursing Standards of Patient Care" reviewed 03/13 showed the following direction for staff:
-Each patient will receive nursing care/interventions in an effective manner given the current standard of care with evidence based practice, in order to achieve the desired/projected outcome for the patient. Nursing care will be provided by nursing staff that are competent to fulfill their assigned responsibilities. Each patient will:
-Be assessed for biophysical, psychosocial, environmental, cultural, spiritual, developmental, self-care, nutritional risk, education, abuse/neglect risk, and discharge care needs/state.
-Be provided nursing care based on the needs/diagnosis identified through use of assessment data.
-Have a plan of care that prescribes individualized interventions to attain expected outcomes and reflects recognized standards of care and evidence-base practice as well as respects patient's rights.
-Have his/her needs/state reassessed and the plan of care evaluated and revised based on assessment data and evidence-base practice.
-Each patient will have nursing care/interventions available to meet his/her needs. Each patient (and/or family, as appropriate) will receive:
A. Individualized care/interventions based on identified needs.
B. Age appropriate nursing care/interventions.
C. Education in respect to patient's health care needs/state.
D. Nursing care/interventions designed to meet the patient's/family's actual and potential post-discharge care needs.
E. Nursing care/interventions designed to promote hygiene, comfort, and or pain control.
F. Nursing care/interventions designed to maintain or improve nutritional status.
G. Nursing care/interventions designed to maintain a clean environment, promote infection control, and prevent nosocomial infections (infections acquired in the hospital).
-Each patient will receive nursing care/interventions in an effective manner, given the current evidence based guidelines, in order to achieve the desired/projected outcome for the patient.

2. Record review of Patient #1's medical chart showed she was admitted to Swing-Bed services on 03/03/13 for complaints of right pneumonia and hypoxia (body is deprived of adequate oxygen supply).

Record review of the patient's History and Physical dated 03/03/13 showed that she presented to the emergency room from the nursing home with a chief complaint of temperature, respiratory distress, tachypnea (rapid breathing) and hypoxia. She has a history, unfortunately, of a severe stroke. She is not communicating. Her eyes are open. She doesn't obey simple commands, doesn't talk or answer questions.

Record review of the patient's Physician Orders dated 03/03/13 showed the following orders:
-Dietician to consult.
-Crush meds with applesauce and give honey thickened liquids.
-Use skin prep to the patient's left outer ankle, right inner heal, right buttock and around coccyx area two times a day until all are resolved.

Record review of the Patient Treatment/Care Plan dated 03/03/13 showed the Patient Treatment/Care Plan did not address:
-The need for the patient to have a dietary consult.
-The need for the patient to have her meds crushed in applesauce or to give honey thickened liquids.
-The skin issues the patient had on admission.

3. During an interview on 03/12/13 at 1:20 PM, Staff D, Registered Nurse (RN), Chief Nursing Officer (CNO), stated that she expected staff to individualize the Patient Treatment/Care Plan to include and reflect a patient's diagnosis, needs, care and treatment. Staff D stated that she expected staff to update the Patient Treatment/Care Plan with any changes the patient might experience. Staff D stated that Patient Treatment/Care Plan should be individualized and specific.

4. During an interview on 03/03/13 at 10:10 AM, Staff J, RN, Day Charge Nurse stated that the Patient Treatment/Care Plan should be individualized based on patient assessment and diagnosis.

Based on interview and record review the facility failed to ensure one (#1) of one Swing Bed residents received a comprehensive nutritional assessment to maintain or improve nutritional status. This deficient practice had the potential to affect all patients treated at the facility. The facility census was three with one of those in Swing Bed status (a Medicare program for patients who require medical care beyond acute care that is intended to treat rehabilitation conditions).

Findings included:

1. Review of the facility's policy titled "Patient Nutritional Assessment" revised 04/25/12 showed the following direction:
-The Dietary Director completes a Dietary Assessment for each patient;
-The Dietary Director and/or the Consulting Dietitian will actively and continually assess patient nutritional status:
-The assessment will include but is not limited to the following: type of diet served, checking for conformance with the physician's order; patient's dietary habits, including food preferences; tolerance to foods served; ability to feed self, noting total or partial assist; ability to chew food served; weight on admission;
-Documentation of pertinent findings will be reflected in the initial assessment and addressed in the Dietary Progress Notes:
-Problem identification. Utilizing the collected data, Dietary will identify and document nutrition problems. This process will be ongoing;
-Goals/Outcome Criteria. Dietary will document on the Care Plan appropriate outcome criteria for each nutritional problem identified.

Review of the facility's policy titled "Diet Consult Education" revised 04/25/12 showed the following direction for facility staff, the Nutrition Services Director {Director of Dietary} and/or the Consultant Dietitian present modified diet instruction and/or dietetic counseling to the patient and or family of a patient upon physician request.

2. Record review of Patient #1's medical chart showed she was admitted to the facility on 03/03/13 to Swing-Bed services with complaints of right sided pneumonia and hypoxia (body is deprived of adequate oxygen supply).

Record review of the patient's Daily Care Information dated 03/03/13 showed the following:
-Nutrition: Soft pureed [diet] and needs to be fed.
-Fluids: Honey thickened.
-Dietician to consult.

Record review of the patient's Physician Orders dated 03/03/13 at 9:30 AM, showed an order for the dietician to consult.

Record review of the patient's Nutrition Assessment dated 03/12/13 showed the patient did not have a nutritional assessment from 03/03/13 to 03/12/13, nine days after the order had been written.

3. During an interview on 03/11/13 at 2:25 PM Staff F, Director of Dietary stated the following:
-She does not perform nutrition assessments;
-The facility employed a contracted Consultant Dietitian;
-The Consultant Dietitian visited the facility twice a month for four hours each visit;
-If a physician ordered a nutrition assessment/dietary consult, the consult was usually not done until the dietitian's next visit (up to fourteen days later or usually after the patient was discharged from the hospital).

4. During an interview on 03/12/13 at approximately 9:00 AM Staff Z, Chief Financial Officer stated the average length of stay for regular hospital patients was 3.3 days and the average length of stay for patients in Swing Bed status was 9.48 days.

5. During an interview on 03/12/13 at 11:15 AM Staff G, Consultant Dietitian stated the following:
-She did not see every patient during their admissions;
-She only saw inpatients by consult from the physicians;
-If she were not on site when the consult was ordered, she would probably not see the patient until her next visit to the facility (up to fourteen days after the consult was ordered);
-She comes to the facility once every two weeks.







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