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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of NFPA 101 2000 edition of the Life Safety Code chapters for an existing healthcare occupancy.

The findings include:

K18: The facility did not provide corridor separation doors that had positive-latching hardware.
K46: The facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure.
K50: The facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K62: The facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25.
K76: The facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling. .
K147: Electrical system did not meet the minimum regulations for NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of NFPA 101 2000 edition of the Life Safety Code chapters for an existing healthcare occupancy.

The findings include:

K18: The facility did not provide corridor separation doors that had positive-latching hardware.
K46: The facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure.
K50: The facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K62: The facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25.
K76: The facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling. .
K147: Electrical system did not meet the minimum regulations for NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on record review and interview the facility failed to ensure policies and procedures for the provision of clinical services are reviewed by medical staff and are current, relevant and based on accepted standards of practice. In 7 of 12 services reviewed (Surgery, Discharge Planning, Nursing, OPO, ED, Central Services and Swing Bed) policies were not reviewed per policy. This deficiency has the potential to affect all 6 patients receiving care at the hospital at the time of the survey.

Findings include:

Review of hospital policy; "Policies and Procedures" dated 04/02/2015 states; "By the end of 2013 all Policies and Procedures will be online and accessible for employees." in addition it states; "Annually, each department will be assigned a month to review and update their Policy and Procedures".

A review of facility policies and a list of facility policies revealed that policies and procedures were not consistently reviewed, amended or revised on a regular basis. The list of policies revealed approximately 60% of the facility's policies are in draft form, under review or waiting to be approved.

Per interview with DON C on 03/01/2016 at 11:00 AM a policy for sexual abuse victims was requested and ED staff provided a policy from 1985. C stated that there should be a more recent policy which she was unable to locate in the database.

Per interview with RN H on 03/01/2016 at 3:45 PM when requesting policies H stated they were not accessible because they were under review.

Per interview with CNO B on 03/02/2016 at 3:00 PM all policies are in the process of being transferred to an electronic format.

During an interview on 3/1/2016 at 9:45 AM, CNO B stated all the facility policies include a "revision date" and a "review date." Per B, the review date indicates the date the policy is due for review or the date the policy had been reviewed. CNO B stated the date "doesn't change if the policy hadn't been reviewed" on the due date. CNO B confirmed that it cannot be determined with any certainty that a policy had been actually reviewed on the date listed on the policy.

Based on observation, record review and interview the hospital failed to ensure medications, biologicals and perishable supplies were monitored and secure in 3 of 10 (ED, cardiac rehabilitation and rehabilitation clinic) areas observed and pharmacy staff failed to have prescribed medications available for 1 of 6 inpatients (Patient #5). This deficiency has potentially contributed to poor pain control for the affected patient (Patient #5) This deficient practice had the potential to affect all 6 patients served by the hospital at the time of the survey.

Findings include:

Observations in the ED;

During a tour of the ED with DON C on 03/01/16 at 10:45 AM, the following observations were made;

In exam room #5:

Expired hemoccult specimen cards dated 02/2013, seracult specimen cards dated 05/2008, gauze sponges dated 06/2015 and a needle dated 12/2015. All these supplies were stored in the exam table drawer.

In exam room #6:

3 outdated vaccutubes (for the drawing of blood) with expiration dates of 02/2016, were observed in a wall cabinet, a PAP (cervical smear) test kit with an expiration date of 11/2014 and a Benzoin swab stick (for cleaning skin) with an expiration date of 01/2010. Per interview with C at the time of the observation, these supplies could be inadvertently used by staff.


During a tour of the Loyal Clinic with CEO L on 03/01/16 at 09:15 AM, the following observation was made;

2 opened multidose bottles of Dexamethasone 4mg/ml with expiration dates of 01/01/2016 in the locked medication cabinet.

During a tour of the Cardiac rehab department with CEO L on 03/01/16 at 11:45 AM, the following observations were made;

The crash cart containing medications and supplies was found unlocked and the department was open with no staff present. CEO L agreed at the time of the observation that anyone could wander in.

The hospital had no policies governing the monitoring of outdated medications and supplies or the security of medications.



34337



Review of facility policy "Pharmacy Hours/Staffing Plan" dated 8/29/2015 states: "There will be at least one assigned pharmacist in house at all times during pharmacy open hours and one assigned pharmacist on-call at all times during outside normal hours...Hours a pharmacist will be in-house are: Mondays from 0700-1630, Tuesdays through Fridays from 0800-1630, Saturday and Sunday by remote access only. After hour service is on an on-call basis by phone only...The on-call pharmacist is available for information purposes only."

Patient #5 was admitted on 2/29/2016 for left shoulder surgery. A fentanyl (IV pain medication) PCA (Patient Controlled Analgesia) pump was started post-operatively on 2/29/2016 at 7:20 PM. Per Patient #5's pain flowsheet, Patient #5 reported the following pain levels and received the following interventions: 2/29/2016 7:20 PM: pain level "9"--PCA pump started; 2/29/2016 8:50 PM: pain level "8"; 2/29/2016 9:20 PM: pain level "6"--80 mcg of fentanyl infused via PCA; 2/29/2016 10:20 PM: pain level "4"--95 mcg of fentanyl infused via PCA; 2/29/2016 11:20 PM: pain level "6". On 3/1/2016 at 12:26 AM, Patient #5 received oxycodone (oral pain medication). Patient #5's reported pain level on 3/1/2016 at 12:40 AM was "3" and had received a total dose of 125 mcg fentanyl via PCA.

Per Patient #5's medical record, on 3/1/2016 at 5:17 AM "PCA stopped due to no more medication in the hospital." On 3/1/2016 at 5:36 AM, Patient #5's pain level is rated "10." Per medication administration records, Patient #5 was administered 600 mg ibuprofen orally and 1 mg dilaudid (IV pain medication) at 5:36 AM. On 3/1/2016 at 7:55 AM, Patient #5 received oxycodone for a pain level of "10."

On 3/1/2016 at 8:20 AM, RN F reported to MD P that Patient #5's PCA "ran out overnight" and wouldn't be available until pharmacy comes in after 8:00 AM. At 11:45 AM Patient #5 asked RN F: "Are they going to make sure I have enough pain medicine for tonight? So I don't have to go through that again?"

During an interview on 3/1/2016 at 11:45 AM, DON C stated "I'm not sure if the PCA was set up and ran out or if it wasn't started at all...I know it [PCA syringe] needs to be compounded by pharmacy" but stated C wasn't clear what happened in this situation. DON C went on to state that poor pain control is "not acceptable" and "we should have medication for back up."

During an interview with RN O on 3/3/2016 at 2:15 PM, RN O stated "I didn't call the pharmacist" when the medication ran out. Per O, "we have an issue with that [running out of medications] sometimes. I told the oncoming nurse at change of shift...I would expect [oncoming RN] to call the pharmacist when they got in [at 8:00 AM] to get more medication."

Based on observation, record review and interview, the facility 1) failed to adhere to restricted traffic flow patterns in 2 of 2 restricted-access departments (Central Supply and Surgery) 2) failed to design a tracking system for the disinfection of endoscopes in 5 of 5 endoscopes used in the facility. These deficient practices had the potential to affect all 6 patients served by the hospital at the time of the survey.


Findings include:

1) Restricted-Access Departments

Review of facility policy "Central Services" revised 11/11/2014 states: "To assist in supporting collaboration...between the user (Surgical Services) and supplier (Central Service)...E. Environmental Control: 1. Traffic control and environmental monitoring follow essentially the same guidelines as those designed for the OR, including strict compliance with dress code and quality assurance programming."

Review of facility policy "Traffic Patterns in the Surgical Suite" revised 11/11/2014 states in part: "A. 1. The area within the surgical suite is divided into 3 zones: ...b. semi-restricted, where scrub attire is required according to operating room attire policy. Peripheral support areas include clean and sterile supply room, instrument room...Only authorized staff and patients are allowed in this semi-restricted area. c. Restricted area includes operating rooms, procedure rooms, and clean core area where sterile procedures are carried out...9. Supplies and equipment are stored as close to the point of use as possible to facilitate retrieval and in maintaining traffic patterns."

Review of facility policy "Attire in the Operating Room" revised 11/11/2014 states: "A. All staff entering semi-restricted and restricted areas of the surgical suite shall be in operating room attire...Operating room attire consists of standard reusable woven fabric or single-use nonevent scrubs and a surgical hat or hood...All head and facial hair is to be covered...Shoe covers shall be worn..."

During observation in the central supply (CS) room on 3/1/2016 at 11:15 AM with Manager D and Surgical Tech E, Emergency Department (ED) staff opened a door to the CS room. Per Manager D, the ED is "right outside the CS room" and the "CS room is the ED storage room." Manager D stated ED staff wears hospital-issued scrubs, and "they have to put on cap and shoe covers" to enter. Surgical Tech E stated ED staff are "in and out throughout the day" to obtain supplies.

During an interview on 3/2/2016 at 11:50 AM, Infection Preventionist M stated keeping ED supplies in the CS room had been identified as a potential infection control risk "last summer." Per M, there are plans to move ED supplies out of the CS room, but "nothing has been done yet."

During observation of the surgery department on 2/29/2016 at 11:30 AM, the sterile corridor of the surgical suite (restricted area) contained an office space used for the anesthesia department. During an interview on 3/2/2016 at 11:50 AM with Infection Preventions M and Manager D, M and D stated that all persons entering the office in the sterile corridor "should wear proper attire." Per M and D, nursing staff from the inpatient unit will "sometimes" enter the corridor without proper attire (scrubs, cap, shoe coverings) to speak with staff in the office. M and D were unable to state why staff are not following policy for authorized personnel into restricted areas.

2) Endoscope Reprocessing

Facility policy "High-Level Disinfection of Endoscopes" revised 11/11/2016 states: "A. Endoscopes should be sterilized before each procedure...AC. All endoscopes shall be high-level disinfected between each use."

Association of Preoperative Registered Nurses (AORN) 2016 Guidelines for Preoperative Practice states in part: "A multidisciplinary team...should establish a policy to determine the maximum storage time that processed flexible endoscopes are considered safe to use without reprocessing...The multidisciplinary team should establish a policy for removing and reprocessing the endoscope before use if the maximum storage time has been exceeded."

During an interview with on 3/1/2016 at 10:50 AM, Manager D stated the facility follows AORN Guidelines. Per Manager D, the policy does not include a timeframe defining disinfection "before each procedure." Manager D stated the facility has 5 endoscopes in use and there is no system in place to track when the endoscopes are used or disinfected. Per D, there is no way to know how long an endoscope has been in storage prior to use.










34337

Based on observation, interview and record review, 1) dietary assessments were not completed according to recognized professional standards of practice. 7 out of 7 patients (#18, #19, #20, #21, #22, #23, #24) did not have in-person nutritional assessments completed and 2) food and equipment failed to be stored in a manner to prevent contamination from occurring. These deficient practices had the potential to affect all 6 patients served by the hospital at the time of the survey.

Findings include:

1) Assessments

On 2/29/2016, 11:58 AM, interview with Nutrition Services Quality Manager Q (NSQM-Q) revealed Register Dietitian N (RD-N) charting remotely (not in hospital) on patients. During interview on 3/1/2016, 8:10 AM, RD-N stated assessments are completed remotely.

On 3/1/2016, 9:50 AM, Lead Register Nurse (LRN) stated nursing completes nutritional risk screens on all patients. The nutritional risk screen is part of a flow chart process that will automatically trigger a referral when a nutrition assessment is needed by the registered dietitian.

On 3/1/2016, 10:59 AM, Registered Dietitian N (RD-N) provided list of referred patients (#18, #19, #20, #21, #22, #23, #24) that had nutrition assessments completed remotely. N stated N did not meet pt.s in person for any of the nutrition assessments.

On 3/2/2016, 8:31 AM - 11:50 AM, reviewed medical records for patients #18, #19, #20, #21, #22, #23 and #24. Nutrition related issues are as follows:
#18 - Congestive Heart Failure, Stage 3 Chronic Renal Disease, low albumin, appetite fair
#19 - Patient reports difficulty swallowing, poor appetite, weight loss greater than 5 pounds in past 3 months
#20 - Uncontrolled Type II Diabetes Mellitus, reports change in appetite
#21 - Patient noted had " pretty dramatic " weight loss, dehydration, repeated vomiting
#22 - Difficulty swallowing and chewing
#23 - Patient reports poor appetite and weight change
#24 - Hypokalemia, gastrointestinal losses, diarrhea following gastrointestinal surgery, poor appetite.

On 3/2/2016, review of policy " Comprehensive Nutrition Assessment, " Revision Date 2/10/2016, states, " The facility will complete a comprehensive nutrition assessment for each individual that is screened for assessment. " Nutritional assessment is a systematic process of obtaining, verifying and interpreting data in order to make decisions about the nature and cause of nutrition-related problems. " Section " Components of a Comprehensive Assessment: " 1. Nutrition History, 2. General Appearance, 3. Height, 4. Weight, 5. Food and Fluid Intake, 6. Fluid Loss or Retention, 7. Altered Nutrient Intake, Absorption, and Utilization, 8. Diuretics, 9. Gastrointestinal (GI) Disorders, 10. Wounds and Other Health Impairments, 11. Chewing Abnormalities, 12. Functional Ability, 13. Medications



2) Storage

According to the 2013 Federal Food and Drug Administration Food Code, food items and equipment must be properly stored to prevent transmission of foodborne pathogens or contamination. Food-contact surfaces of equipment and utensils need protection from any accumulation of dust, dirt, food residue and other debris, by storing items in a clean, dry location to prevent exposure to splash, dust, or other contamination.

On 2/29/2016, 11:26 AM - 12:05 PM, toured kitchen with Nutrition Services Manager Q (NSM-Q) with the following concerns identified:
· In walk-in cooler was a roll in cart. On cart was a tray holding five dishes of pears uncovered. The sides of the cart have open slots and front and back of the cart does not have a door to protect food items from potential contamination. NSM-Q states the tray that is located several rows above the pears is the cover. Discussed how openings in cart exposes food to cross contamination.
· In the dry storage area are nine shelving racks. The bottom shelf of each rack was 2 ¾ inches above the floor. On the shelves were food items and paper products. The NSM-Q stated the bottom shelves are definitely too low.
· On the top of one shelf were three coffee pitchers not inverted and two coffee pitcher tops that were not covered.

On 3/2/2016 reviewed policy, "Food Storage" , revision date, 7/22/2015. In the section "Procedure," - line 11. - "Food is stored a minimum of 6 inches above the floor and 18 inches from the ceiling on clean racks or other clean surfaces, and is protected from splash, or other contamination." In the section "Procedure," -line 14, "Refrigerated Foods," bullet "f" states "All foods should be covered, labeled and dated."

Based on record review and interview, facility staff failed to ensure nursing staff is trained on 1) their role in organ procurement per policy for 2 of 3 patient deaths reviewed (Patient #12, Patient #13); 2) the use of restraint use in the facility. This deficient practice had the potential to affect all 6 patients served by the hospital at the time of the survey.

Findings include:

1) Patient Deaths and Organ Procurement

Review of facility policy "Organ/Tissue/Eye Donation" revised 5/6/2014 states in part: "A. Notify Statline, the triage center for organ, tissue and eye donation referrals at [phone number] for all impending/imminent deaths...and for all in-hospital deaths. See EMR E-Form: Mandatory Death Reporting Log...F. Document: (regardless of family's decision) 1. Conversation with family 2. Communication with the physician 3. Communication with the OPO/Tissue Bank/Eye Bank (EMR E-Form: Mandatory Death Reporting Log)"

Patient #12 died at the facility on 2/25/2015 at 9:20 PM. The Mandatory Death Reporting Log is not complete. The Mandatory Death Reporting Log does document the patient's medical suitability of donation or notification to the family of the patient's medical suitability to donate.

Patient #13 died at the facility on 4/23/2015 at 6:44 PM. Patient #13's medical record contains an eye donor operative report indicating donation. The Mandatory Death Reporting Log is not complete and does not document the patient's medical suitability of donation or the family's decision to donate.

These findings were confirmed with CNO B at the time of review on 3/1/2016 at 10:20 AM. Per interview at the time of review CNO B stated "I would expect the forms to be filled out completely."

During an interview with RN G on 3/1/2016 at 2:05 PM, RN G stated "We haven't had a death in awhile, I didn't know we had an electronic form for that."

During an interview with RN F on 3/2/2016 at 8:00 AM, RN F stated in the event of a death at the facility "we notify the coroner first, the coroner decides if they are a potential donor."

Per interview on 2/29/2016 at 2:35 PM, DON C stated it is the nurses role to "call the OPO [organ procurement organization]" and staff is "directed what to do by OPO."

2) Restraints

Review of policy "Restraints" states: "Revision dates: Not Approved Yet. Review dates: No review date." CNO B confirmed the facility does not currently have a policy in place for the use of restraints in the facility.

During an interview on 2/29/2016 at 2:35 PM, in regards to the process for restraint use in the facility, DON C stated "we have soft restraints and leather restraints but we haven't used [restraints] in years."

The facility's restraint use list showed that the facility hadn't used restraints on any patient in the last year.

During an interview with RN F on 3/2/2016 at 8:00 AM, RN F stated "we aren't allowed to use [restraints], we don't have any." RN F said F could not recall having received training on the use of restraints and was not aware of a restraint policy.

During an interview on 3/2/2016 at 8:35 AM, RN P stated "I haven't used [restraints]." Per RN P, P reviewed the restraint policy as part of orientation training.

Based on observation, record review and interview, facility staff failed to secure prescribed medication in 1 of 2 medication administrations observed (Patient #2). This deficient practice had the potential to affect all 6 patients served by the hospital at the time of the survey.


Findings include:

Review of facility policy "Medication Administration" reviewed 9/10/2015 states in part: "E. If any contamination of drug occurs. Properly waste the dose..."

On 3/1/2016 at 8:20 AM, RN F administered oral medications to Patient #5 in room 114. RN F dropped 1 medication (Senna, stool softener) on the floor. RN F left the patient's room without picking up the medication from the floor. RN F then went to the medication room at the nurse's station to obtain a new Senna tablet for Patient #5. When RN F returned to room 114 the pill was not on the floor.

During an interview with RN F on 3/1/2016 at 8:45 AM, RN F stated "I left it on the floor, OT [Occupational Therapy] gave it to me when I went back in the room."

This observation finding was confirmed with CNO B on 3/1/2016 at 9:45 AM. CNO B stated medications should not be left unattended.

Based on record review and interview the hospital failed to keep care plans current in 11 of 18 medical records reviewed requiring a nursing care plan (#1 through 10 &17) out of a total of 24 MR reviewed. This deficiency had the potential to affect all 6 patients being served by the hospital at the time of the survey.


Findings include:

Review of hospital policy "Care Plan Format for all Med/Surg Patients" dated 06/03/2014 states; "Care Planning is based on data collected from patient assessments with integration of those assessment findings in the care planning process." and "The plan of care shall be reviewed and updated daily, with revisions reflecting the reassessment of needs of the patient."


1. Per MR (medical record) review on 03/01/16 and 03/02/16 the nursing care plans found in the MR of patients #1, 2, 3, 4 and 17 did not contain nursing staff documentation reflecting progress towards goals

Per interview, with CNO B on 03/02/16 at 8:55 AM, the nursing care plans are developed from a computer system. Per B, assessments and evaluations should be linked to the nursing care plans and goals associated with them.

Per review of medical records problems associated with nursing care plan goals are listed as evaluated and verified but do not contain data supporting these conclusions.



34337


Facility policy "Care Plan Format For All Med/Surg Patients" review date 3/5/2014 states in part: "The plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family...The plan of care will be...revised as needed to meet the needs of the patient's changing condition."

Patient #5 was admitted as inpatient status post left total shoulder replacement on 2/29/2016. Per medical record review on 3/1/2016 at 1:50 PM with CNO B, Patient #5's care plan includes the following problems: Alteration in comfort r/t (related to) surgical pain; Risk for Infection r/t Break in Skin Integrity r/t Surgery. CNO B stated goals for the problems are autopopulated. The care plan documents that the problems have been "verified", "addressed" or "evaluated" during each shift. There is no indication what interventions were performed to facilitate the patient meeting goals.

Patient #6 was admitted as inpatient status post left total hip arthroplasty on 2/1/2016. Per medical record review on 3/1/2016 at 2:55 PM with CNO B, Patient #6's care plan includes the following problems: Alteration in comfort r/t surgical pain; Mobility: Physically impaired r/t Pain; Impaired Skin Integrity r/t Surgery. Patient #6 was discharged on 2/4/2016. There is no documentation as to the status of progress toward goals or goal resolution upon discharge.

Patient #7 was admitted as inpatient status post right total knee replacement on 11/30/2015. Per medical record review on 3/1/2016 at 3:50 PM with CNO B, Patient #7's care plan includes the following problems: Alteration in comfort r/t surgical pain; Impaired Skin Integrity r/t Surgery; Impaired physical mobility r/t pain. Patient #7 was discharged on 12/3/2015. There is no documentation as to the status of progress toward goals or goal resolution upon discharge.

Patient #8 was admitted as inpatient status post drainage of abdominal wall abscess on 12/15/2015. Per medical record review on 3/2/2016 at 1:15 PM with CNO B, Patient #8's care plan includes the following problems: Alteration in comfort r/t pain; Skin Integrity--Actual Impairment. Patient #8 was discharged on 12/18/2015. There is no documentation as to the status of progress toward goals or goal resolution upon discharge.

Patient #9 was admitted as inpatient status post right total knee replacement on 2/29/2016. Per medical record review on 3/2/2016 at 12:55 PM with CNO B, the care plan does not include individualized goals or interventions.

Patient #10 was admitted as inpatient status post left total knee replacement on 2/29/2016. Per medical record review on 3/2/2016 at 1:00 PM with CNO B, Patient #10's care plan includes the following problems: Alteration in comfort r/t surgical pain; Risk for Infection r/t Break in Skin Integrity r/t Surgery; Impaired Physical Mobility r/t left knee replacement. The care plan documents that the problems have been "verified", "addressed", "reviewed" or "evaluated" during each shift. There is no indication what interventions were performed to facilitate the patient meeting goals.

During an interview on 3/1/2016 at 3:40 PM, RN H stated there is no documentation of the status or resolution of patient goals upon discharge.

During an interview on 3/2/2016 at 8:00 AM, RN F stated "goals autopopulate" and "we don't resolve them [the goals] at all." RN F confirmed there is no documentation in the care plan to indicate the patient's progress toward goals during the hospitalization.

During an interview on 3/2/2016 at 8:35 AM, RN P stated "we pick a diagnosis upon admission and it gives us interventions, we click on the care plan every shift and select address, review, evaluate or intervention."

Based on record review and interview the hospital failed to ensure discharge planning was initiated or provided per policy in 6 of 20 medical records (#1, 2, 4, 6, 7 and 8) requiring discharge planning out of a total universe of 24 records. This deficiency has the potential to affect 6 patients being served by the hospital at the time of survey.

Findings include:

Review of hospital policy; "Discharge Planning: Discharge of Hospital Patient" dated 06/16/2014 states; Discharge planning begins upon admission."

Per review of MR's #1, 2 and 4 there was no record of discharge planning being initiated upon admission. A flowsheet which is intended for the entry of information related to discharge needs was not completed in any of these medical records.

Per interview with CNO B on 03/02/2016 at 10:30 AM a discharge plan should be documented for all inpatients.

Patient #6 was admitted as inpatient status post left total hip arthroplasty on 2/1/2016 through 2/4/2016. Per medical record review on 3/1/2016 at 2:55 PM with CNO B, Patient #6 had not received a discharge planning screen to identify potential needs upon discharge.

Patient #7 was admitted as inpatient status post right total knee replacement on 11/30/2015 through 12/3/2015. Per medical record review on 3/1/2016 at 3:50 PM with CNO B, Patient #7 had not received a discharge planning screen to identify potential needs upon discharge.

Patient #8 was admitted as inpatient status post drainage of abdominal wall abscess on 12/15/2015 through 12/18/2015. Per medical record review on 3/2/2016 at 1:15 PM with CNO B, Patient #8 had not received a discharge planning screen to identify potential needs upon discharge.

Patient #17 was admitted to the hospital on 02/17/2016. Per interview on 3/2/2016 at 10:15 AM, Patient #17 stated "I'm supposed to go home on Friday (2 days), but haven't discussed the plan with anyone yet."

Based on record review and interview, facility staff failed to educate staff and have policies in place for the care and discharge of post-operative patients (#5, 9 and 10) in 1 of 1 Post-Anesthesia Care Units (PACU). Theis deficiency have the potential to affect all 12 patients receiving surgical and anesthesia services at the time of the survey.

Findings include:

Review of facility policy "Recovery Room Care and Guidelines" review date "No Review Date." CNO B stated on 2/29/2016 that the policy is in draft form and has not yet been approved.

During an interview on 2/29/2016 at 2:35 PM, DON C stated a gap in "recovery room training" had been identified previously and cross-training for the care of patients in PACU was completed "last week."

The education materials used in the training include the following: "Accurate body temps: ...Accurate temperatures are important...Length of stay in recovery: For right now, [CRNA] may suggest to you how long a patient should stay in recovery...It is ultimately your decision when to move the patient...Complications: ...Vitals should be taken every 5 minutes x 3 then every 15 minutes until they move out of recover 1 phase."

Patient #5 received surgical services for a left total shoulder replacement on 2/29/2016 under general anesthesia. Patient #5's Post-Anesthesia Care Record documents a full set of vitals, including temperature, upon arrival to the PACU at 7:10 PM. Another temperature is not obtained until 8:12 PM.

Patient #9 received surgical services for a right total knee replacement on 2/29/2016 under epidural/spinal anesthesia. Patient #9's Post-Anesthesia Care Record documents a full set of vitals, including temperature, upon arrival to the PACU at 12:32 PM. Another temperature is not obtained until 1:14 PM.

Patient #10 received surgical services for a left total knee replacement on 2/29/2016 under epidural/spinal anesthesia. Patient #10's Post-Anesthesia Care Record documents a full set of vitals, including temperature, upon arrival to the PACU at 9:12 AM. A partial set of vital signs are obtained at 9:17 AM and then again at 9:27 AM (more than 5 minutes later). Another temperature is not obtained.

During an interview with RN F on 3/2/2016 at 8:00 AM, RN F stated F works in the PACU and had received "no additional training" for the care of post-operative patients. Per F, F was not aware of any discharge criteria and "the CRNA sometimes tells us when the patient can go [discharged from PACU], but not always."

Based on observation, record review and interview, the facility failed to develop a comprehensive and effective system to identify, prevent and analyze adverse events related to patient care for 1 of 1 reportable incidents identified (medication errors). This has the potential to affect all patients receiving care at this facility.

Findings include:

Patient #5 was admitted on 2/29/2016 for left shoulder surgery. A fentanyl (IV pain medication) PCA (Patient Controlled Analgesia) pump was started post-operatively on 2/29/2016 at 7:20 PM.

Per Patient #5's medical record, on 3/1/2016 at 5:17 AM "PCA stopped due to no more medication in the hospital." On 3/1/2016 at 5:36 AM, Patient #5's pain level is rated "10."

On 3/1/2016 at 8:20 AM, RN F reported to MD P that Patient #5's PCA "ran out overnight" and wouldn't be available until pharmacy comes in after 8:00 AM. At 11:45 AM Patient #5 asked RN F: "Are they going to make sure I have enough pain medicine for tonight? So I don't have to go through that again?"

During an interview with RN O on 3/3/2016 at 2:15 PM, when asked if O had filled out an incident report about running out of medication, RN O stated "I didn't think of it." RN O stated "I think someone should be aware of it."

During an interview with DON C and CNO B on 3/2/2016 at 1:40 PM, "I think it [running out of a prescribed medication] is a reportable incident." CNO B confirmed the facility does not have a policy in place to guide staff as to what is considered reportable incidents.

Based on record review and interview the facility failed to provide an ongoing activities program for 3 of 3 swing bed patients (#4, 6 and #17) with a total universe of 24. This has the potential to affect all swing bed patients including the 1 swing bed patient present during this survey.

Findings include:

Review of hospital policy "Swing Bed Patient: Activity Plan" dated 11/12/2012 states; "Swing Bed patient will be provided with recreational activities as appropriate." and under policy objectives: "To maintain current and up-to-date records of patient program participation"

Per interview on 3/2/2016 at 10:15 AM, when asked about activity offerings, Patient #17 stated "I got a piece of paper with a list on it." Per #17, staff had come in "once" to offer the sheet of paper and there were no other offerings or activities that #17 was aware of. Pt. #17 was admitted on 02/17/2016.

Per review of medical records for pt.s #4 (Swing bed admission from 12/21/15 - 01/11/16), 6 (02/02 - 02/10/16) and 17 (admitted 02/17/16) documentation under "Swing Bed: Daily Assessment" was not complete for which daily activities were offered nor the outcome for those activities.

Per interview with CNO B on 03/02/2016 at 8:40 AM there is no documentation that activities are being offered on a daily basis.