HospitalInspections.org

Based on review of departmental policy and procedure manuals and interviews with staff, the facility failed to:

1. Review the policy and procedure departmental manuals annually for the Emergency Department, Radiology and Physical Therapy.

2. Follow the policy for a psychosocial assessment by the social worker on the Behavioral Health unit within 72 hours of admission.

3. Follow the policy for a Psychiatric evaluation no later than 60 hours from the admission day on the Behavioral Health unit.

4. Follow the policy for Hepatitis B Immunization.

5. Follow the policy for Code Blue requiring all patient care service personnel maintaining a current CPR (cardiopulmonary resuscitation) card.

This had the potential to affect all patients served in this facility.


Findings include:


Policy Number 03.002 Elements of the Psychosocial Assessment

2.0 Policy: " Psychosocial Assessment will be completed within 72 hours of admission and include at least the required elements defined in this policy..."


Policy Number 03.002 Elements of the Psychiatric Evaluation

2.0 Policy:" Psychiatric Evaluations will be completed within 60 hours of admission and include at least the required elements defined in this policy..."

Policy: Hepatitis B Immunization Policy

It is the policy of Tombigbee Health Care Authority to offer the Hepatitis B vaccination at no cost to all employees who come in contact with blood and body fluids while doing their job.

Procedure:

1. The department manager must send any new employee, who comes in contact with blood and body fluids while performing their job duties to the Infection Control Coordinator.
2. The Infection Control Coordinator will provide the employee with information on the Hepatitis B vaccine and cautionary information.
3. Any consenting employee must sign a vaccine consent form.
4. Any employee declining the offered vaccine must sign a declination form.


Policy: Code Blue

Staff Requirements:
All Patient Care Services personnel must maintain a current CPR card.
Registered Nurses in the Emergency Department, Medical Intensive Care unit, Surgical and Maternal/Infant departments are required to be ACLS (Advanced-Cardiac-Life-Support) certified.

.....


During a tour of the Emergency Department 12/2/14 at 10:20 AM, the surveyor observed the policy and procedure manual on the shelf had last been reviewed in 2012 and the computerized policy and procedure book was dated as last reviewed 2013.

In an interview with Employee Identifier (EI) #13, the Director of the Emergency Department, at 10:40 AM on 12/2/14, she confirmed the date of the last review.

1. Medical Record (MR) # 20 was admitted to the Behavioral Health unit by court order 11/20/14 with a diagnosis of Schizophrenia.

A review of the medical record 12/3/14 at 8:40 AM revealed no psychiatric evaluation was documented in the medical record. The staff nurse, Employee Identifier (EI) # 20, on the unit reviewed the electronic medical record for the psychiatric evaluation 12/3/14 at 9:00 AM and confirmed no evaluation had been dictated.

A review of the medical record 12/3/14 at 8:40 AM revealed no psychosocial assessment was documented in the medical record. EI # 20 asked the Social Worker, EI # 12 for the evaluation and was told she had made numerous phone calls to family and they would not respond.

The surveyor requested documentation from EI # 12 regarding attempts to contact family and received a Psychosocial Assessment form dated 11/21/14. The top left corner of the form had hand written in the side, " Have left messages for patient's husband... and for patient's sister... but they have not returned calls."

On the right hand side of the form had hand written in the side, " Patient is refusing to answer any of this writer's questions."

There was no date or times of the attempted contacts or contact with the patient on the unit.

The rest of the form was blank.

2. MR # 19 was admitted to the Behavioral Health Unit 11/21/14 with diagnoses of Rule Out Delirium, History of Dementia, Rule Out Psychosis, Rule Out Bipolar Disorder with Psychosis and Behavioral Disturbances.

A review of the medical record 12/2/14 at 2:00 PM failed to have documentation of a psychosocial assessment. The surveyor requested the assessment from EI # 12, the Social Worker on 12/2/14 at 2:20 PM. EI # 12 stated that she had continued to work on the assessment and that was why she had not put a copy with the medical record. The treatment team book also did not have a copy of the assessment to work with the interdisciplinary treatment team toward patient's discharge and goals.

The lack of the psychosocial assessment negatively affects the treatment team's ability to address patient needs and plan for interventions and update goals.

In an interview 12/3/14 at 9:00 AM with EI # 11, the Director of Behavioral Health confirmed the social worker was not up to date on the psychosocial assessments. EI # 11 stated that they had arranged for EI # 12 to dictate the assessments but this had not been started.

.....

A review of personnel files 12/4/14 at 8:30 AM revealed 7 of 17 employee files reviewed failed to have proof of Hepatitis B vaccination or a declination form.

In an interview 12/4/14 at 9:00 AM, EI # 21, Administrative Assistant to Human resources confirmed they could not locate any further Hepatitis B forms.

....

A review of Patient Care Services personnel files 12/4/14 at 8:30 AM revealed 6 of 12 employee files reviewed failed to have proof of CPR.

In an interview 12/4/14 at 9:00 AM, EI # 21, Administrative Assistant to Human resources confirmed they did not have documentation of CPR.



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A tour of the Physical Therapy Department on 12/3/14 at 11:15 AM. The surveyor request to see the Departmental Policies and Procedures Manual. Review of the cover sheet revealed the Departmental Policies and Procedures were last reviewed on March 7, 2012.

An interview was conducted on 12/3/14 at 11:30 AM with EI # 18, Director of Physical Therapy. EI # 18 verified the above findings.

An interview was conducted with EI # 19, Director of Radiology on 12/3/14 at 1:15 PM. The surveyor asked if all staff in Radiology and Nuclear Medicine were CPR certified and the response was, " It is not required because the Emergency Department is just right next door."

On 12/3/14 at 1:30 PM the surveyor requested the Policy and Procedure Manual for the Radiology Department from EI # 19. Review of the cover sheet revealed the date the Radiology Departmental Policies and Procedures were last reviewed was February 2013.

An interview with EI # 19 conducted 12/3/14 at 1:40 PM verified the above findings.

Based on observations and an interview with administrative staff, it was determined the hospital failed to inform patients of their right to file a grievance with the State agency. This had the potential to affect all patients receiving services from the hospital.

Findings include:

During a tour of the Behavioral Health unit on 12/02/14 at 11:30 AM it was noted the Behavioral Health Unit in the hospital did not have the toll free State Hot Line number posted for patients in the hallway or on the Patient Rights provided to the patients admitted to Behavioral Health to voice grievances.

A copy of the Patient Rights form provided to the patients and families on admission was reviewed 12/3/14 at 9:30 AM and the toll free State Hot Line number was not included with the rights to call related to a grievance.

An interview with Employee Identifier #11, Director of the Behavioral Health unit 12/3/14 at 10:00 AM confirmed the above.

Based on the review of the facility's Performance Improvement Plan for 2014, Quality Meeting Minutes, and interview, it was determined the facility failed to ensure the Performance Improvement Committee:


A. Develop new interventions when old interventions were not effective. Refer to A 283

B. Identify areas that needed improvement. Refer to A 283

C. Adopted polices supporting a non-punitive approach to staff reporting of medical error, adverse events and situations the staff considered unsafe. Refer to A 286

D. Had a hospital-wide and documented system of quality assessment and performance improvement program. Refer to 308


This had the potential to negatively affect all patient served by this facility.

Based on the review of the facility's 2014 Performance Improvement Committee Minutes, the 2014 Performance Improvement Plan, Specifications Manual for National Hospitals Inpatient Quality Measures for 2014 and the Occurrence Report for 2014 and interview it was determined the facility's Performance Improvement Committee failed to:

A. Develop new interventions when old interventions were not effective.

B. Identify areas that needed improvement.

This had the potential to affect all patients served by this facility.

Findings include:

Facility's 2014 Performance Improvement Plan

Purpose:

This Performance Improvement (PI) Program promotes the mission of Bryan W. Whitfield Memorial Hospital by establishing a formal, organization-wide system to monitor and continuously improve patient outcomes and services.

The purpose of the PI Plan is to provide a written guideline for the Performance Improvement Program. This plan will be used by each employee of the organization to continually monitor and improve the processes they perform...

Administration:

Bryan W. Whitfield Memorial Hospital's administrative leaders are responsible for setting expectations, developing plans, and implementing procedures to assess and improve the quality of the organization's governance, management, clinical, and support process. Leadership shall fulfill these responsibilities by:

Setting priorities for the organization- wide performance improvement activities that are designed to improve patient outcomes...

Director of Professional Standards:

The Director of PI is responsible for :

Overseeing an ongoing, systematic process to track the evaluation of quality and appropriateness of care.

An interview was conducted with Employee Identifier (EI) # 1, Director of Professional Standards on 12/6/14 at 9:30 AM. The surveyor requested to see documentation on indicators for Quality Improvement the facility had developed. EI # 1 indicated one of the indicators was obtained from the Specifications Manual for National Hospitals Inpatient Quality Measures for 2014 for Pneumonia Antibiotic Consensus Recommendations.

Review of the Performance Improvement documentation for the indicator Pneumonia Antibiotic Consensus Recommendations for 2014 revealed the following:

January = 50 % failed
February = 100 % failed
March = 80 % failed
April = 50 % failed
May = 50 % failed
June = 33 % failed
July = 100 % failed
August = 100 % failed
September 50 % failed

Review of the Performance Improvement Committee Minutes dated March 11, 2014 revealed no documentation the above indicator was discussed or another action plan was developed due to 100% failure for February.

Review of the Performance Improvement Committee Minutes dated April 8, May 13, June 10, July 8, August 12, September 9, October 14 and November 13, 2014 revealed no documentation the above indicator was discussed or another action plan was developed.

An interview was conducted with EI # 1 on 12/6/14 at 9:30 AM. The surveyor asked what action plans were developed due to the failure of the indicator for Pneumonia Antibiotic Consensus Recommendations. The response was she would have to contact EI # 16, Director of the Pharmacy because EI # 1 was not sure.

Review of the 2014 Occurrence Report revealed an increase in falls:
August had 2 falls
September had 3 falls
October had 4 falls.

Review of the September 9, October 14 and November 13, 2014 Performance Improvement Committee Minutes revealed no documentation the above falls were reviewed nor was an action plan was developed to prevent falls.

An interview was conducted with EI # 1 on 12/6/14 at 10:15 AM. EI # 1 verified the above findings.

During an interview with EI # 1 on 12/6/14 at 10:10 AM the surveyor asked for any documentation the Performance Improvement Committee had on Causal Analyses the committee had investigated. EI # 1 stated one of the Causal Analyses they had investigated was Medication Near Miss. EI # 1 stated it was from the staff placing the wrong patients' stickers on physician orders. The surveyor asked what preventative actions had been developed, if the measures showed an improvement and if no improvement had been seen what other measures were put into place. EI # 1 stated she was not sure and would have to get with EI # 16. There was no documentation the Performance Improvement Committee documented the success or failures of their action plans.

Based on the review of the facility's policies and procedures and interviews, it was determined the facility failed to adopt polices supporting a non-punitive approach to staff reporting of medical error, adverse events and situations the staff considered unsafe. This had the potential to affect all patients served by this facility.

Findings include:

During a review of the facility's policies and procedures on 12/6/14 at 8:00 AM, the surveyor was unable to find a policy on a non-punitive approach to staff reporting of medical error (including near misses/close calls), adverse events and situations the staff considered unsafe.

An interview was conducted with Employee Identifier # 1, Director of Professional Standards on 12/6/14 at 9:30 AM. The surveyor requested the policy on a non-punitive approach to staff reporting of medical error (including near misses/close calls), adverse events and situations the staff considered unsafe. EI # 1 was unable to submit a policy.

Based on the review of the facility's 2014 Performance Improvement Committee Minutes and the 2014 Performance Improvement Plan and interview, it was determined the facility failed to ensure the Performance Improvement Committee was hospital-wide. This had the potential to affect all patients served by this facility.

Findings include:


Facility's 2014 Performance Improvement Plan

Purpose:

This Performance Improvement (PI) Program promotes the mission of Bryan W. Whitfield Memorial Hospital by establishing a formal, organization-wide system to monitor and continuously improve patient outcomes and services.

The purpose of the PI Plan is to provide a written guideline for the Performance Improvement Program. This plan will be used by each employee of the organization to continually monitor and improve the processes they perform...

Objectives:

The objectives of the PI Plan are as follows:

6. To define the integration of care services by requiring each department to identify their scope of service, to include what service they provide, to whom, how, and how others interact with them in providing the service.

Administration:

Bryan W. Whitfield Memorial Hospital's administrative leaders are responsible for setting expectations, developing plans, and implementing procedures to assess and improve the quality of the organization's governance, management, clinical, and support process. Leadership shall fulfill these responsibilities by:

Setting priorities for the organization- wide performance improvement activities that are designed to improve patient outcomes...

Review of the Performance Improvement Committee Minutes revealed not all departments were not involved in the Performance Improvement Committee as follows:

February 11, 2014 - Chief Executive Officer, Clinical & Community Services, Fiscal Services, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, Management Information Services, Medical Staff, and Human Resources.

March 11, 2014 - Chief Executive Officer (CEO), Clinical & Community Services, Fiscal Services, Laboratory, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, Information Services, Medical Staff, and Human Resources.

April 8, 2014 - Clinical & Community Services, Fiscal Services, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, Pharmacy, and Information Services.

May 13, 2014 - CEO, Fiscal Services, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, Clinical & Community Services, and Human Resources.

June 10, 2014 - Fiscal Services, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, Clinical & Community Services, Pharmacy, and Human Resources.

July 8, 2014 - CEO, Fiscal Services, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, Clinical & Community Services, Patient Care Services, Medical Staff, and Information Systems.

August 12, and September 9, 2014 - Fiscal Services

October 14, 2014 - Fiscal Services, Radiology, Physical Therapy, Security, Respiratory, Facility Operations, Environmental Services, and Clinical & Community Services.

November 13, 2014 - Fiscal Services.

An interview was conducted with Employee Identifier # 1, Director of Professional Services on 11/6/14 at 10:15 AM who verified the above findings.

Based on observation, American Journal of Nursing, Fundamentals of Nursing medication standard of preparation practice, and interviews, it was determined the facility's practice did not include filtered needles use when withdrawing medication from an ampule.

Findings include:

American Journal of Nursing
January 2001
Volume 101 Number 1
pages 75

Is it important to use filter needles when administering medication reconstituted from a powdered form or when withdrawing medication from a glass ampule?

Yes...filter needles prevent the inadvertent administration of small glass fragments when drawing up medication from a glass ampule..."


Fundamentals of Nursing
Potter-Perry 6th Edition 2005
pages 875

Preparing Injections

"...Equipment

Medication in an ampule
Syringe, needle and filter needle
Steps
6. A. Ampule preparation...

...4. Draw up medication quickly, using filter needle long enough to reach bottom of ampule...
11. Replace filter needle with needle for injection."


During a 12/2/14 at 1:15 PM observation of care in Operating Room , Employee Identifier (EI ) # 5, Certified Registered Nurse Anesthetist, prepared a syringe and needle, opened the medication ampule, withdrew medication from the ampule and administered the intravenous medication. EI # 5 did not use a filter needle.

An interview conducted 12/2/14 at 1:55 PM with EI # 5 confirmed a filter needle was not used to withdraw the medication from the ampule.

A telephone interview 12/5/14 at 10:00 AM with facility Pharmacist, EI # 16 confirmed filter needles are to be used with ampule medication preparation.






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During a tour of the Emergency Room (ER) 12/2/14 at 10:45 AM the surveyor asked EI # 13, ER Director, if the ER nurses used filtered needles after observing glass ampules on the shelf with the medications.

EI # 13 stated that they did not use filtered needles in the ER and did not have any filtered needles.

A telephone interview was conducted with EI # 1, the Director of Professional Standards 12/5/14 at 12:30 PM requesting a policy for the use of filtered needles.

In a response from EI # 1 12/5/14 at 1:52 PM confirmed, " Nursing does not use filtered needles and does not have a policy."

Based on observations and interview, it was determined the facility failed to ensure all medications were secured in the pre operative care unit. This had the potential to negatively affect patients receiving care from surgery services.

Findings include:

During a 12/2/14 at 1:40 PM tour of the pre operative treatment area including the nursing station and refreshment area, a small refrigerator was observed. Two vials of medication were observed on top of the refrigerator, one an unopened bottle of Aminophylline 500 milligram(mg) 25 mg/ milliliter (ml) and one open bottle of Labetalol Hydrochloride 200 mg/40 ml injectable. The 2 injectable medications were not stored in a cabinet or secured.

There was one Registered Nurse (RN) working in the pre operative care area on 12/2/14. The injectable medications were left unsecured when the RN was away from the nursing station.

During a 12/2/14 1:45 PM interview with Employee Identifier (EI) # 6, Pre-Operative Care RN, verified the above.

Based on observation, facility policy and procedure and interview, it was determined the facility failed to ensure:

a) all biologicals in patient treatment areas were not expired.

b) all biologicals in use were correctly labeled.

This had the potential to negatively affect patients receiving care from surgery services.

Findings include:

Facility Policy and Procedure
Title: Multi-Dose Vials
Revised 11/11

"...all multi-dose vials have the date initially used on the vial. Pharmacy will attach the multi-dose sticker to the vial prior to sending it to the floor. The yellow sticker will indicate the date the vial was opened.
For all multi-dose vials...the medication may be used for 28 days..."

During a 12/2/14 at 1:30 PM tour of the endoscope cleaning room, 23 Thin Prep pap test containers, expired 10/18/14, were found in a cabinet

During a 12/2/14 at 1:40 PM tour of the pre operative care nursing station, a small refrigerator was observed with one open bottle of Labetalol Hydrochloride 200 mg/40 ml injectable on top of the refrigerator. The Labetalol injectable did not have a yellow sticker on the bottle. The bottle was not labeled with the open date.

During a 12/2/14 1:45 PM interview with Employee Identifier (EI) # 6, Pre Operative Registered Nurse, the above was verified and bottle discarded.

During a 12/2/14 2:10 PM tour of the Endoscopy procedure suite, one bottle, 1/2 full of betadine, expiration date 2013 was observed. One 1000 milliliter bottle of sterile water that contained a blue color liquid was observed. The surveyor asked EI # 3, Nurse Manager Surgery Services, what the "bluish liquid" was ? EI # 3 reported that "Endozyme had been added to the sterile water." The sterile water bottle was not labeled to include Endozyme.

An interview with EI # 3 on 12/2/14 at 2:10 PM confirmed the findings.

Based on United States Health Public Food Code 2009 regulations, facility policies, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner and the dishmachine temperature was checked for each use.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.

...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...

Storing
4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.

(A) Except as specified in ¶ (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored:

(B) Clean equipment and utensils shall be stored as specified under ¶ (A) of this section and shall be stored:

(1) In a self-draining position that allows air drying; and

(2) Covered or inverted.

************

Facility Policy: Leftovers

Effective Date 1/1/99

Policy:

Leftovers are minimized through menu planning, forecasting/tally methods and evaluating menu item acceptance. Leftovers are used within 48 hours or by the next meal whenever possible...

************

Facility Policy: Food Storage
Revised 10/12/98

Unit personnel will store food and supplies properly upon receipt. Personnel storing food and supplies will be trained on correct storage procedures...

Procedure:

Refrigerator:
A. Discard leftovers not utilized within 48 hours.

Freezer:
A. Rotate stock and be sure all items are dated and labeled that have been removed from the original cases.

************

Facility Policy: Storage of Pots, Dishes, Flatware and Utensils

Policy:

Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means.

Procedure:

Dish Handlers, Trayline Area Employees
1. Air dry pots, dishes, flatware, and utensils before storage, or store in a self-draining position.

************

Facility Policy: Dishmachine Temperatures
Effective Date: 1/1/99

Procedure:

1. During each period of use, records wash and final rinse temperatures on the Dishmachine Temperature Record Form.

A tour of the Dietary Department was conducted on 12/2/14 at 10:10 AM with the Employee Identifier (EI) # 22, Dietary Manager. The surveyor observed the following:

In the cooler :

A bag of cooked biscuits and french toast (identified by EI # 22) - no label of contents or date
A pack of bread - not dated
A pan of melted cheese and a pan of ketchup, which was identified by EI # 22 - no label of contents or date
A pan of ketchup, which was identified by EI # 22 - no label of contents and dated 11/20/14
2 pans of ready to cook macaroni and cheese dated 11/28/14
A tub of tomato paste, which was identified by EI # 22 - no label of the contents nor a date
A pan of roast beef, which was identified by EI # 22, with no label and was dated 11/15/14
A white tub of chicken with no date
A pan of roast beef, which was identified by EI # 22, with no label of contents or a date
Opened bags of Roast Beef, Turkey, Bacon Bits and Fajita Chicken with no date
Packages of Beef patties and Carrots were opened and no date
Packages of Rolls already open and no date
Plain bag of hush puppies, which was identified by EI # 22, opened with no label of contents or date
Opened bag of corn not labeled or dated
Tub of Cool Whip opened and not dated
A 3 pound block of cream cheese partially used and no date

An interview was conducted with EI # 22 on 12/2/14 at 11:00 AM who verified the food in the cooler should be labeled and dated.

During a tour of the dietary department on 12/2/14 at 10:00 AM and 2:00 PM the surveyor noted rectangular pans which were wet, stacked upon each other setting on the shelf.

An interview was conducted with EI # 22 at 2:05 PM who verified the pans were to be aired dry before nesting and not wet.

Review of the Dishmachine Temperature Record from 9/11/14 to 11/10/14 revealed no documentation the temperatures were checked as follows:

9/11/14 - Evening Readings
9/14/14 - Evening Readings
9/20 and 21/14 - Morning or Midday Readings
9/25/14 - Midday Readings
10/4/14 - Midday Readings
10/10/14 - Evening Readings
10/12/14 - Morning and Midday Readings
10/15/14 - Evening Readings
10/17 and 18/14 - Midday Readings
10/19/14 - Morning and Midday Readings
10/20/14 Evening Readings
10/31/14 - Morning, Midday and Evening Readings
11/6/14 - Midday Readings

An interview was conducted wit EI # 22 on 12/3/14 at 12:00 PM, who verified the above findings.

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility:

1. Be constructed, arranged and maintained as required by the LSC.

2. Maintain preventive maintenance on the equipment in the hospital.

3. Ensure patient care areas were maintained, furniture in patient care areas was maintained and in good repair.

4. Ensure bathrooms available to the public were clean with fixtures in working order.

5. Ensure refrigerator temperatures were monitored and results documented in the pre operative care unit.

This had the potential to affect all patients, staff and visitors served by the facility.


Findings include:

Refer to Life Safety Code survey report and A 701 and A 726 for findings.

Based on observations and interview it was determined the facility failed to:

1. Maintain preventive maintenance (PM) on the equipment in the hospital.

2. Ensure patient care areas were maintained, furniture in patient care areas was maintained and in good repair.

3. Ensure bathrooms available to the public were clean with fixtures in working order.

This had the potential to affect all patients served.

Findings include:

After arriving at the facility 12/2/14 at 9:30 AM, the surveyors were shown to the public bathroom off of the front lobby to use during the onsite visit.

The surveyors observed on entry to the bathroom at 12/2/14 9:35 AM an odor present. The double sink failed to have a soap dispenser at the first sink and the second sink left water standing with floating debris in the water when used for hand hygiene.
The soap dispenser by the first sink was broken and unable to hold soap.
The light switch by the first sink had water damage around the outlet and was discolored.
The surveyors notified the Director of Professional Standards, Employee Identifier (EI) # 1 on each day of the survey (12/2/14, 12/3/14 and 12/4/14) of the continued standing water and problems in the bathroom off of the lobby.


A tour of the Emergency department was conducted by the surveyor 12/2/14 at 10:20 AM with EI # 13, the Director of the Emergency Department. The surveyor noted multiple pieces of equipment in the 9 bed emergency room with no preventive maintenance stickers or stickers dated from 2011 and 2012. The most current preventive maintenance sticker was dated March of 2013.

In an interview with EI #13 at 10:40 AM on 12/2/14, she confirmed with the Preventive Maintenance man, EI # 14, that he had gotten behind and if it did not have a preventive maintenance sticker on the equipment it had not been checked.

A tour of the Behavioral Health unit was conducted by the surveyor 12/2/14 at 11:15 AM with EI # 15, the Clinical Coordinator. This is a 10 bed unit with all semi-private rooms.

The shower heads in the patient rooms (# 225, 224, 223, 222, 221) extended from the shower in a curved fashion long enough to allow a hanging hazard in all of the rooms except the shower to the Seclusion room, which was flush to the shower wall.

The air conditioner units were pulled away from the walls and loose in the room # 225 and the Seclusion room.

The day room where patients sit, do activities, watch television and gather had brown chairs single and a double chair sitting around the walls of the room, 2 of the chairs observed had towels laid in the bottom of the chairs. All of the chairs in the room had splits in the cushions of the bottoms and several arms were also split open with stuffing visible. A hole was observed in the wall approximately 2 inches in diameter. When asked how the hole came to be in the wall EI # 15 stated a chair probably hit the wall.

The surveyor observed electrical wires behind the patient beds with the cords tied up to shorten the exposed length. EI # 15 stated that they tried to keep the beds pushed up against the walls where they would not be exposed for the patients to be able to see them.

In an interview with EI # 15 on 12/2/14 at 11:45 AM confirmed the above observations on the Behavioral Health unit.





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A tour of the Laboratory department was conducted by the surveyor 12/3/14 at 9:40 AM with EI # 4, Administrative Director of Laboratory Services. The surveyor noted multiple pieces of equipment in the 2 room lab department with no preventive maintenance stickers, stickers dated 2013, illegible stickers, and 3 preventive maintenance stickers dated March 2015.

In an 12/3/14 9:55 AM interview with EI # 4 the above findings were confirmed.



17650

A tour of the Medical Intensive Care Unit (MICU) was conducted by the surveyor 12/2/14 at 11:30 AM with EI # 17, Charge Nurse of MICU. The surveyor noted multiple pieces of equipment in MICU 2, 3 and 4 with no preventive maintenance stickers or stickers dated with the due date of the next PM as 2012 and 2013.

An interview was conducted on 12/3/14 at 11:45 AM with EI # 17, who verified the above findings.

A tour of the Physical Therapy Department was conducted on 12/3/14 at 9:50 AM with EI # 18, Director of Physical Therapy. The surveyor noted 3 Solaris Estem Dynatrons with no sticker indicating the date of the last PM and 1 dated October 2008. The surveyor also noted no sticker on the Hydrocollator or the paraffin bath machine.

An interview was conducted on 12/3/14 at 10:00 AM with EI # 18, who verified the above findings.

A tour of the Radiology Department was conducted on 12/3/14 at 1:00 PM with EI # 19, Director of Radiology. The surveyor noted an ultrasound machine with a PM sticker dated August 2011.

An interview was conducted on 12/3/14 at 1:15 AM with EI # 19, who verified the above findings.

Based on observations, facility policy, temperature log documentation and interviews, it was determined the facility failed to ensure refrigerator temperatures were monitored and results documented in the pre operative care unit and laboratory department. This had the potential to negatively affect all patients treated at the facility.

Findings include:

Policy Number: VI.A.5
Health Services and Dining Services
11/12/98

" Procedure...

12. All refrigerators and freezers will have temperature logs maintained..."

Policy and Procedures
Blood Bank Refrigerator and Freezer
No Date

"Blood Bank Refrigerator Alarm Check
...Place one thermometer on the highest shelf containing blood and one of the lowest shelf. The temperatures will need to bee recorded every 4 hours..."

During a 12/2/14 at 1:00 PM tour of the pre-operative care unit, a small refrigerator labeled "patient nourishments" was observed.

Review of the 2014 temperature logs revealed missing temperature documentation on the following dates:

2/4/14, 2/7/`4 and 2/27/14.
3/5/14, 3/6/14, 3/7/14, 3/10/14, 3/13/14, 3/15/14, 3/16/14, 3/22/14, 3/23/14 and 3/27/14.
4/9/14, 4/10/14, 4/11/14, 4/15/14, 4/16/14 and 4/30/14.
5/7/14, 5/8/14, 5/13/14, 5/29/14.
6/12/14, 6/17/14, 6/18/14, 6/19/14, 6/23/14, 6/25/14 and 6/26/14.
7/22/14, 7/23/14 and 7/30/14.
9/3/14, 9/4/14, 9/10/14, 9/11/14, 9/12/14, 9/16/14 and 9/30/14.
10/8/14, 10/9/14 and 10/22/14.
11/3/14, 11/4/14, 11/5/14, 11/13/14, 11/14/14, 11/19/14, 11/21/14 and 11/24/14.

An interview conducted 12/4/14 at 11:50 AM with Employee Identifier (EI) # 3, Nurse Manager, Surgical Services confirmed the above.

A tour of the Laboratory department was conducted by the surveyor 12/3/14 at 9:40 AM with EI # 4, Administrative Director of Laboratory Services.

During an 12/3/14 10:00 AM interview regarding management of the facility blood supply, EI # 4 reported mechanical problems with the blood bank refrigerator fan that began 11/27/14.

Review of the facility documentation revealed between 11/27/14 2:00 PM and 12/2/14 at 12:00 PM, only 1 temperature every 4 hours was documented for the blood bank refrigerator. The facility failed to monitor and document refrigerator temperature readings for the highest and lowest shelf between 11/27/14 2:00 PM and 12/2/14 at 12:00 PM.

In an 12/3/14 10:05 AM interview with EI # 4 the above findings were confirmed.

Based on observations, review of facility policies and procedures, manufacturer's directions for use and interviews, it was determined the staff failed to:

a) follow and perform hand hygiene per facility policy.

b) follow the manufacturer's directions for Enzymatic-Dual Enzyme use and Tincture of Green Soap.

c) follow the facility policy for equipment cleaning for endoscope and surgical instruments.

This had the potential to negatively affect all patients served in the facility and staff.

Findings include:

Facility Policy and Procedure
Title: Hand Hygiene
Date 11/2013

Policy:
A. Objective:
"...purpose...to outline indications for and methods of hand hygiene for personnel in a patient care setting...All staff will adhere to this policy to reduce the transmission of microorganisms to patients and other personnel.

...Procedure
A. Hand Hygiene Indications:

1. Hand hygiene with either waterless hand sanitizer or soap and water is required:
Upon entering and leaving a patient room
Between patient contacts if more than one patient is on a room...
Before donning and after removing gloves
Before handling an invasive device (regardless of whether or not gloves are used)
After contact with body fluids or excretions, mucous membranes...or wound dressings...

C. Routine Hand Hygiene Techniques

...2. Handwashing with soap and water...It can be accomplished in the following manner:
a. Wet hands with water
b. Apply soap...
f. Use a dry paper towel to turn off faucets to avoid contamination..."


V. Mueller Instrument Enzymatic-Dual Enzyme cleaner
Directions for use on bottle: Use 1 to 2 ounces per gallon of water.

Tincture of Green Soap
Directions for use on bottle: Use 1 cup per 1 gallon of water.


During a 12/2/14 10:15 AM pre operative care observation with Employee Identifier (EI) # 6, Registered Nurse, an intravenous (IV) access site initiation was performed.

EI # 3 donned clean gloves, prepped the site with alcohol, inserted an IV catheter, removed and discarded the gloves. EI # 3 did not perform hand hygiene after glove removal.

EI # 3 donned clean gloves, applied tape to the IV catheter site, gathered and discarded the supplies. EI # 3 removed and discarded the gloves. EI # 3 did not perform hand hygiene after glove removal.

EI # 3 donned clean gloves, hooked the IV fluids to an tubing extension set, removed and discarded the gloves. EI # 3 did not perform hand hygiene after glove removal.

EI # 3 retrieved the patient's record, exited the patient room to the pre operative nurse station and began to document on the computer.
EI # 3 did not perform hand hygiene prior to leaving the patient's room.

EI # 3 failed to perform hand hygiene as per facility policy.

An observation of surgical instruments cleaning on 12/2/14 at 2:50 PM with EI # 8, Scrub tech was performed. EI # 8 had prepared a sink and instrument cleaning solution had been added. The surveyor asked EI # 8 what cleaning solution was used? EI # 8 reported Tincture of Green Soap or instrument Enzymatic could be used for surgical instrument cleaning. EI # 8 reported "4-5 squirts" was added to the water in the sink. EI # 8 reported he/she was "unsure" of the amount of water in the sink. EI # 8 did not know the amount or equivalent a "squirt of Enzymatic-Dual Enzyme cleaner". EI # 8 reported he/she wants to make sure "it has plenty of suds".

There were no measuring instruments used to ensure to correct amount of cleaner and water was used for surgical instrument cleaning.

During an observation of endoscope cleaning on 12/3/14 at 8:40 AM with EI # 7, Scrub technician (tech), with gloved hands, placed the endoscope in the sink with cleaning solution. EI # 7, with gloves (dirty after endoscope contact) opened a drawer and retrieved the endoscope channel plugs. EI # 7 failed to remove gloves and perform hand hygiene before contact with the clean drawer surface.

EI # 7, wearing the same gloves, then placed the endoscope and channel plugs into the plastic bin with Wavicide disinfectant.

EI # 7, with "dirty" gloves still on, opened a drawer, retrieved a bottle of Chlorox spray, sprayed and wiped down the endoscope cart. EI # 7 then removed and discarded gown and gloves. EI # 7 did not perform hand hygiene after glove removal.

EI # 7 opened a drawer, retrieved a specimen bag, documented in the specimen log book, opened the drawer again and returned the log book. EI # 7 exited the endoscopy cleaning room.

At 10:00 on 12/3/14, EI # 7, while wearing gloves, completed the endoscope cleaning, removed the endoscope from the plastic bin and placed the endoscope in a sink with clean water. EI # 7 flushed all scope tubing channels with water and allowed the water to drain from the sink. EI # 7, wearing the dirty gloves, opened the cabinet drawer and obtained a bottle of alcohol. EI # 7 removed and discarded gloves. EI # 7 did not perform hand hygiene after glove removal and contaminated the drawer.

EI # 7 filled a cup with alcohol, then placed the endoscope buttons into the cup. EI # 7 donned clean gloves. EI # 7 did not perform hand hygiene before donning gloves.

EI # 7 attached a compressed air hose to the endoscope channels and removed gloves. EI # 7 did not perform hand hygiene after glove removal.

EI # 7 donned clean gloves, dried the endoscpe with a clean green towel, then removed the buttons from the cup, dried the buttons and placed them on the counter. EI # 7 removed and discarded his/her gown and gloves. EI # 7 did not perform hand hygiene before donning clean gloves.

EI # 7 replaced the plastic cover to the endoscope disinfectant bin, removed and discarded gloves. EI # 7 did not perform hand hygiene after glove removal.

EI # 7 donned clean gloves. EI # 7 failed to perform hand hygiene prior to donning clean gloves.

In a 12/3/14 10:20 AM interview with EI # 3, Nurse Manager, the above findings were confirmed.



18259

On 12/3/14 at 8:15 AM a medication pass was observed with EI # 23, Licensed Practical Nurse. EI # 23 entered Medical Record (MR) # 19's room on the Behavioral Health unit and opened Depakote Sprinkles to mix with yogurt. A piece of the paper came off and fell in the cup with the yogurt. EI # 23 reached in with her bare fingers and pulled the paper out of the cup and then proceeded to feed the yogurt to the patient.

The nurse failed to follow the policy for safe handling of medications and the facility failed to conduct active surveillance on staff in the facility to ensure hand washing and safe drug administration was maintained.

In an interview with EI # 23 on 12/3/14 at 8:25 AM, confirmed she reached in the cup with her fingers to retrieve the paper.



17650


An observation of wound care for MR # 29, was conducted on 12/3/14 at 10:00 AM with EI # 24, Physical Therapy Assistant (PTA). EI # 24 entered MR # 29's room and donned gloves without hand hygiene, unfastened MR # 29's diaper, changed gloves without hand hygiene, provided wound care to decubitus on coccyx, and removed gloves and left room without hand hygiene.

An observation of wound care for MR # 28, was conducted on 12/3/14 at 10:30 AM with EI # 18, Physical Therapy. EI # 18 washed hands, donned gloves, removed old dressing from abrasion on the right elbow, and changed gloves without hand hygiene.

An interview was conducted with EI # 1, Director of Professional Services on 12/3/14 at 2:00 PM, who verified the staff are to perform hand hygiene before and after gloves.

This Condition of Participation is not met as evidenced by:

Based on observations in the surgery department, Perioperative Standards and Recommendation Practices of AORN (Association of Operating Room Nurses), Centers for Medicare and Medicare Services (CMS) Survey and Certification (S & C) Memorandum 4/19/13, review of facility surgery policy and procedure manuals, medical records and interview, it was determined the facility failed to:

a) monitor and document temperature and humidity levels in the Operating Suites, Procedure rooms, Central Sterile Processing and Storage.

b) perform preventative maintenance on surgery equipment.

c) monitor and document Post Anesthesia Care Unit (PACU) patient temperatures per facility policy.


This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A951, A956 and A957 for findings.


Perioperative Standards and Recommendation Practices of AORN:

What are the recommended humidity ranges for an operating room?
Answer:
The recommended humidity range in an operating room is 20% to 60% based upon addendum d to ANSI (American National Standards Institute)/ASHRAE(American Society of Heating, Refrigerating, and Air-Conditioning Engineers) Standard 170-2008. Each facility should determine acceptable ranges for humidity in accordance with regulatory and accrediting agencies and local regulations. The center for Medicaid and Medicare systems has modified their requirements to allow for the 20% lower limit effective June 2013. Temperature and humidity should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system.

Resources
Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.
ANSI/ASHRAE/ Addendum d to Standard 170-2008: Ventilation of Health Care Facilities. 2010. www.ashrae.org/File%20Library/docLib/Public/20100714_ad170_2008_d.pdf. Accessed November 30, 2012.
Centers for Medicare & Medicaid Services. State Operations Manual Appendix A: Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Rev;84.2013;. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pd. Accessed July 15, 2013.
Updated July 18, 2013


What are the recommended temperature ranges for an operating room?
Answer:
The recommended temperature range in an operating room is between 68°F and 73°F (20°C to 23°C). Collaborate with infection prevention, and facility engineers when determining temperature ranges. Each facility should determine acceptable ranges for temperature in accordance with regulatory and accrediting agencies. The temperature should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system.
Resources
¿ Recommended practices for sterilization. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:513-540.

Updated January 28, 2013


Ref: S&C: 13-25-LSC (Life Safety Code) & ASC (Ambulatory Surgery Centers)
Date: 4/19/13

"Subject: Relative Humidity (RH)...Anesthetizing Locations Requirements...

Memorandum Summary

RH of equal to or greater than 20 Percent Permitted in Anaesthetizing Locations:...We are also recommending that RH not exceed 60 percent in these locations...
E. Ongoing Requirements: Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20 percent..."

During a 12/2/14 2:45 PM tour of the surgery department, Employee Identifier (EI) # 3, Nurse Manager, Surgical Services was asked for the surgery department temperature and humidity monitoring documentation.

During a 12/2/14 2:50 PM interview with EI # 3, who confirmed the surgery department did not document temperature and humidity levels. The facility did not have a policy and procedure for temperature and humidity monitoring.

Based on observations in the surgery services department and interview, it was determined the facility failed to perform preventative maintenance on surgery equipment. This had the potential to affect all patients who received care in the surgery department.

Findings include:

A tour of the surgery services department was conducted by the surveyor 12/2/14 between 10:20 AM and 3:00 PM with Employee Identifier (EI) # 3, Nurse Manager, Surgery Services. The surveyor noted multiple pieces of equipment in the two operating room (OR) suites, one Endoscopy procedure room, the OR equipment storage room, the endoscopy cleaning room, Central Sterile, the Post Acute Anesthesia Unit and OR back hallway. The equipment had no preventive maintenance stickers or stickers dates ranged 2009 and 2013.

In a 12/2/14 3:00 PM interview with EI # 3 the above findings were confirmed.

Based on review of medical records (MR), facility policy and procedure and interview, it was determined the facility failed to monitor and document Post Anesthesia Care Unit (PACU) temperatures per facility policy. This did affect MR 's # 17 and # 18, 2 of 2 PACU records reviewed and had the potential to negatively affect all surgery patients treated in the facility.

Findings include:

Policy and Procedure
PACU
Title: Admission
Date: 8/2013

"...Monitor temperature upon arrival to the PACU, and each hour thereafter to avoid malignant hyperthermia...Over 100 degrees F (Fahrenheit) or under 95 degrees F is to be reported..."


1. MR # 17 was admitted to the facility 12/2/14 with a diagnosis of Biliary Colic and Cholethiasis and a Laproscopic Cholecystectomy was performed.

Review of the record revealed documentation the PACU assessment was performed at 8:50 AM, and vital signs documented at 8:55 AM. No temperature was documented.

At 9:00 AM, MR # 17's temperature was documented as 97.9 F (Fahrenheit).

The last PACU documentation entry was at 9:55 AM, and did not include temperature monitoring.

The Post Procedure record documentation was initiated at 10:00 AM by EI (Employee Identifier) # 6, Registered Nurse. At 10:05 AM vital signs were documented, but failed to include temperature documentation. There was no documentation MR # 17's temperature was monitored each hour.

MR # 17'S vitals signs were documented at 10:25 AM and lastly at 10:45 AM. There were no temperature's documented from 9:00 AM until MR # 17 discharge. There was no documentation the facility monitored MR # 17's temperatures each hour per policy.

2. MR # 18 was admitted to the facility 12/2/14 with a diagnosis of Symptomatic Cholethiasis and a Laproscopic Cholecystectomy was performed.

Review of the PACU documentation revealed MR # 18's temperature's at 1:40 PM was 98.4 F.

The last vital sign documented was at 3:25 PM. The documentation did not include MR # 18's temperature.

There was no documentation MR # 18's temperature was monitored hourly between 1:40 PM and 3:25 PM, a 1 hour 55 minute period.

The facility failed to follow its own policy and monitor and document temperatures each hour.

In a 12/3/14 11:35 AM interview with Employee Identifier # 3, Nurse Manager, Surgery Services, the above findings were confirmed.

Based on review of the Medical Records (MR) and interview, it was determined the facility failed to ensure the Physical Therapy Department followed the physician's order for wound care in 1 of 2 closed records reviewed with wounds. This affected MR # 31 and had the potential to affect all patients served by this facility with wounds.

Findings include:

1. MR # 31 was admitted to the facility on 1/10/14 with diagnoses including Gillian-Barre Syndrome, Methicillin Resistant Staphylococcus Aureus Infected Wounds, and Debridement of Wounds to Left Buttocks and Left Heel.

Review of the physician's order dated 1/10/14 at 3:15 PM revealed orders for Physical Therapy (PT)/Occupational Therapy (OT) to provide the following:

Xeroform dressing to left lower extremity daily

Wet to dry to sacral wound BID (twice a day) with Dakins solution/NS (normal saline) alternate.

Review of the Physical Therapy documentation revealed no documentation of a dressing change for:

1/11/14 - PM
1/12/14 - PM
1/13/14 - AM and PM
1/14/14 - AM and PM
1/15/14 - PM

Review of the Nurse Discharge Note revealed the patient was discharged home on 1/16/14 at 9:39 AM.

An interview was conducted with Employee Identifier # 9, Director of Nursing on 11/6/14 at 11:15 AM, who verified the above findings.

Based on review of medical records and interview it was determined the facility failed to complete a comprehensive assessment and establish a care plan to meet the needs identified for 2 of 2 patients residing in swing beds. This affected Medical Record (MR) # 27 and # 30 and had the potential to affect all patients served in the swing beds.


Findings include:


1. MR # 27 was admitted to the swing bed unit 11/28/14 with an admitting diagnosis of Fractured Femur, Open Reduction and Internal Fixation, other diagnoses included Hypertension and Diabetes Mellitus.

In an interview with Employee Identifier (EI) # 10, Coordinator of Swing Beds/ Social Services and Discharge Planner 12/4/14 at 9:30 AM, the surveyor asked for the comprehensive assessment and care plan developed on admission. EI # 10 stated that she did not know what I was referring too. EI # 10 printed off the admission assessment and the care plan which included the following generic problems:
1. Ineffective breathing pattern
2. Impaired skin integrity
3. Pain
4. High risk: Post -op complications
5. Self care deficit
6. High risk: Bleeding
7. High risk: Infection
8. Impaired skin integrity
9. Pressure Ulcers
10. Pain

The care plan did not include short term and/or long term goals and had no interventions documented.

The patient did not have a pressure ulcer according to the admission assessment.

The patient had not been on the swing bed unit long enough to have a treatment team meeting (team meets weekly) to discuss the patient needs, progress toward goals and interventions that might require change.

In an interview 12/4/14 at 10:30 AM with EI # 10, she confirmed the swing bed assessment and care plan did not address specific needs of the patient.


2. MR # 30 was admitted to the swing bed unit 10/7/14 with Chronic Debilitation associated with Chemotherapy and Chronic Lymphocyctic Leukemia/ Pancytopenia.

MR # 30 was hospitalized on the swing bed unit from 10/7/14 through 10/22/14 for a total of 16 days.

In an interview with Employee Identifier (EI) # 10, Coordinator of Swing Beds/ Social Services and Discharge Planner 12/4/14 at 9:30 AM the surveyor asked for the comprehensive assessment and care plan developed on admission and the interdisciplinary treatment team meeting documentation.

EI # 10 stated that they talked every week especially with therapy but did not have a formal meeting and discuss the care plan and patient.

EI # 10 provided to the survey a swing bed sign in sheet dated 10/14/14 at 11:15 AM which was signed by the physical therapist, swing bed coordinator and a Registered Nurse (RN).

Attached to the sign in sheet was a form titled Weekly Interdisciplinary Team/ Skilled Nursing Care on which the RN had documented, " Feeds self, assists with self care, feet swollen, continues to move about...Progress/Issues/Needs Remaining: PT (Physical Therapy)."

There was no entry from Respiratory, Dietary, Activities in the areas on the from for documentation.

Physical Therapy documented, " Attached."

Occupational Therapy (OT) documented, " Attached."

The attachment was the PT plan of care and the OT plan of care.

EI # 10 provided for 10/21/14 interdisciplinary treatment team meeting documentation a Current Therapy caseload Report which had MR # 30 listed with the following written by MR # 30's name, " SBA ADLs (stand by assist activities of daily living) and SBA transfers."

There was no documentation 10/21/14 from nursing or any indication that the patient was ready to be discharged.

The swing bed unit failed to have documented interdisciplinary treatment team meetings to discuss the patient's needs, discharge planning and progress toward goals.

In an interview with EI # 10 on 12/4/14 at 10:30 AM she confirmed the treatment team meetings did not follow the rules for swing bed patients.

Based on interview and review of swing bed records the hospital failed to assure activity assessment and plan of care was developed for the patients and failed to follow through by providing activities to swing bed patients. This affected Medical Record (MR) # 27 and # 30, 2 of 2 swing bed records reviewed. This had the potential to affect all patients served in the swing bed unit.

Findings include:

1. MR # 27 was admitted to the swing bed unit 11/28/14 with an admitting diagnosis of Fractured Femur, Open Reduction and Internal Fixation, other diagnoses included Hypertension and Diabetes Mellitus.

The Activity Approval Sheet dated 11/29/14 documented:

" Long term goals:
Help patient to meet goals and needs and provide her with activities to meet leisure needs to better cope while admitted.

Short term goals:
Increase social interaction
Improve Moral and sense of well being
Sensory stimulation.

Plan and Goal:
Group activities: Provide as directed by patient.
Independent activities: Offer activities of interest.
Family Involvement: As desired or needed."

The Activity Progress note documented 11/28/14 at 1615 (4:15 PM), " Patient (Pt) activity assessment done. Pt is in a very pleasant mood."

11/29/14 at 1405 (2:05 PM), " Pt sitting up in bed. Left crossword and word search puzzles with her."

There was no further documentation of activity visits with the patient through 12/3/14.

There was no documentation of planned activities, offer of any group activities to increase social interaction as the activity therapist had documented in her goals. There was no documented and refused activities in the medical record.

The therapist had left the decision to the patient regarding group activity, activities of interest and the desire to involve the family.

In an interview with Employee Identifier (EI) # 10, Swing Bed/ Social Services Coordinator, 12/3/14 at 4:00 PM confirmed no specific activities were documented. EI # 10 stated that often patients did not wish to participate but it should be documented.

2. MR # 30 was admitted to the swing bed unit 10/7/14 with Chronic Debilitation associated with Chemotherapy and Chronic Lymphocyctic Leukemia/ Pancytopenia.

The Activity Approval Sheet dated 10/17/14 documented:

" Long term goals:
Help patient to meet goals and needs and provide her with activities to meet leisure needs to better cope while admitted.

Short term goals:
Increase social interaction.
Improve Moral and sense of well being.
Increase Physician (physical) Stamina and Tolerance.
Sensory stimulation.

Plan and Goal:
Group activities: Provide as directed by patient.
Independent activities: Offer activities of interest to pt as desired.
Family Involvement: As desired or needed."

The assessment was completed 7 days after admission.

The activity therapist documented 4 attempts to do therapy/activities with the patient:
" 10/10/14 at 1525 (3:25 PM) pt is not in room at this time to do activity assessment will reattempt tomorrow.
10/17/14 at 1615 (4:15 PM) (7 days later not tomorrow) pt assessment done, pt is very friendly, enjoyed talking and reminiscing about...
10/18/14 at 1433 (2:33 PM) pt lying in bed sleeping
10/20/14 at 1705 (5:05 PM) pt is sitting up on side of bed eating supper denies any need for activities this afternoon."


There was no documentation of planned activities, offer of any group activities to increase social interaction as the activity therapist had documented in her goals.

The therapist had left the decision to the patient regarding group activity, activities of interest and the desire to involve the family.

The activity program lacks consistent times to involve patients in group activities or individual activities, there is no activity calendar available or schedule for up coming activities.

In an interview with Employee Identifier (EI) # 10, Swing Bed/ Social Services Coordinator, 12/3/14 at 4:00 PM confirmed no specific activities were documented.

Based on review of medical records (MR) and interview it was determined the discharge planner failed to complete the discharge plan prior to discharge to ensure the patient's needs would be met post hospitalization.
This affected 1 of 1 discharged swing bed patient reviewed (MR # 30) and had the potential to affect all patients served by the swing bed unit.

Findings include:



1. MR # 30 was admitted to the swing bed unit 10/7/14 with Chronic Debilitation associated with Chemotherapy and Chronic Lymphocyctic Leukemia/ Pancytopenia.

MR # 30 was discharged 10/22/14, according to the physician's discharge summary, " Started on aggressive swing bed rehabilitation (rehab). He responded well, became much more mobile at the time of discharge and was doing better. Patient at time of discharge is stable and desires to go home early."

The Case Manager (CM)/ Social Services Discharge Summary documented, " 10/16/14 83 year old male lives with spouse. Admitted 10/7/14 for rehab. Plans to return home with spouse and hhc (home health care)."

The next entry was documented 12/3/14 at 12:10 PM, " 5 day MDS (Minimum Data Set) for 10/14/14."

The next entry was documented 12/3/14 at 12:12 PM, " 14 day MDS for 10/21/14. Patient states he is about ready to go home."

The next entry was documented 12/3/14 at 12:13 PM, " Patient decided to go home yesterday afternoon and was discharged. Patient told CM he did not want any services."

In an interview with Employee Identifier (EI) # 10, Coordinator for Swing Bed/ Social Services and Discharge Planner, on 12/4/14 at 10:30 AM confirmed the discharge plan was not completed timely and was completed after the surveyor asked for the discharge record. The patient was recieving home health when admitted to the swing bed unit but EI # 10 failed to document notification to follow up with the patient post discharge.