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Based on observation, interview, and record review the facility failed to ensure medications stored in 1 of 3 crash carts in the Emergency Department were accounted for.
This deficient practice had the likelihood to cause harm to all patients admitted to the Emergency Department.
Findings include:
During an observation on 12/08/2014 at 1:35 p.m. the following was found in an open pediatric tray on the main medication crash cart:
*The crash cart had a plastic seal on it, but the pediatric medication tray in the inside was not sealed.
*There was an inventory sheet inside the pediatric tray which listed the following medications;
Atropine, Dextrose 50%, Dopamine 400 milligrams, Epinephrine 1mg, Heparin 25,000 units, Lidocaine 2g , (grams), Lidocaine 2%, and Sodium Bicarbonate 8.4 %.
*There were other medications in the tray which were not listed such as:
Adenosine, Terbutadine, Naloxone, Calcium chloride injectable's, Verapamil, Heparin 5000 units, Lasix 20 mg and 0.9% Sodium chloride.
During an interview on 12/08/2014 after 1:35 p.m., Staff #2 confirmed the observations.

Review of the undated policy titled "Pharmaceutical Services Policy and Procedure" revealed the following:
Emergency drugs area maintained in designated areas of the hospital. Emergency drugs are secured with devices allowing immediate access. Emergency drugs area replaced as soon as possible after notifications of use or detection of broken seals. See Emergency Crash cart contents in floor stock contents.
A. Emergency supplies are sealed with breakable plastic seals.
1. Upon need of emergency supplies staff shall break the seal and enter the supply area. (i.e. crash cart, etc.)
2. After completing patient service, the nursing staff shall restock all supplies used from any emergency stock area from the pharmacy and log on the after hours pharmacy entry log.
3. The emergency supply area shall then be sealed using breakable seals by the nursing staff on duty.
4. In the event that an emergency supply area is found unsealed the staff should then inventory the supplies and reseal the area.

Based on observation and interview the facility failed to:
A. secure the trash and waste. The facility's trash was not covered and made available for pillaging by rodents, birds and other animals.
Refer to tag C0223
B. dispose of two expired, one gallon containers of CIDEX (a high level disinfectant)
Refer to tag C0224
C. clean and maintain 2 of 2 utility rooms and a medication room. Employees were exposed to unsanitary conditions by frequenting the trash containers filled with municipal solid waste.
Refer to tag C0225

Based on observation and interview the facility failed to secure the hospital's waste/trash. Two of two trash containers containing municipal solid waste were observed with the covers open.
During a tour of the facility on 12/8/2014 with staff #20, two trash containers for municipal solid waste were observed with the covers open to the environment, making them accessible for pillaging by rodents, birds and other animals.
An interview with staff #20 at the time of the tour confirmed the two trash container's covers were open.
An interview was held with staff #1 and staff #2 on 12/09/2014. Staff #1 and staff #2 confirmed the two trash container's covers were open.

Based on observation and interview the facility failed to dispose 2 of 2, one gallon, expired, containers of CIDEX. The two one gallon containers of CIDEX (a high level disinfectant) were being stored in the Emergency Room's Dirty Utility Room.
During a tour of the facility on 12/8/2014 with staff #20, two, expired, one gallon containers of CIDEX were observed being stored in the Emergency Room's Dirty Utility room. The expired product was available to staff for use.
An interview with staff #20 at the time of the tour confirmed the CIDEX was expired. The product expired in the year of 2012.
An interview was held with staff #1 and staff #2 on 12/09/2014. Staff #1 and staff #2 confirmed the CIDEX was expired. The product expired in the year of 2012.

Based on observation and interview the facility failed to clean and maintain 2 of 2 utility rooms and a medication room. Employees were exposed to unsanitary conditions by frequenting the trash containers filled with municipal solid waste.
During a tour of the facility on 12/8/2014 with staff #2 the Utility Room located in the Emergency Room (ER) was observed to be dirty and un-kept. The floors were stained and un-swept. Obvious dirt and trash was scattered on the floor. The sink was stained and had patient care instruments lying in and around the sink. Two, expired, one gallon containers of CIDEX were observed being stored on the edge of the sink. Upon exiting the utility room, staff #2 used the word "nasty" to describe the room.
The tour continued to a Utility Room located in a hallway joining the ER and the Medical Inpatient Unit. The room contained a hot water heater that was covered in dust. The room contained mops, mop bucket, two bags filled with clothes along with other clutter. The floors were dirty and stained with obvious dirt and dust covering everything in the room.
The tour of the Medication Room located near the Nurses Station revealed the floor was stained and un-kept.

The sink contained a wire mesh strainer over the sink drain. The wire mesh strainer was covered with a black slimy substance. The wire mesh strainer had the appearance of not being cleaned for a long period of time. When the wire mesh strainer was removed from the sink's drain, the sink's drain was found covered with a black slimy substance.
On the counter next to the sink was a mortise and pestle used for crushing pills. The pestle was wrapped in a cloth tape that was stained and worn. The tape prevented the pestle from being cleaned and disinfected. The mortise contained fragments of white dust, what appeared to be pill remains. The mortise had not been cleaned.
The counters and cabinets were cluttered and un-kept. Visible dust was evident to sight and touch on top of the cabinets.

An observation was made of a cart that contained both dirty and clean sharps containers (a container that is filled with used medical needles and syringes). The dirty containers were touching the clean container, thereby contaminating the clean containers.

During a tour of the facility on 12/8/2014 with staff #20, two trash containers for municipal solid waste were observed with the covers open to the environment, making them accessible for pillaging by rodents, birds, and other animals.
On the ground in front of the two trash containers was a large puddle of liquid waste. The amount of liquid waste was so large and concentrated it was running down the drive way. Staff #20 revealed the liquid waste was a result of the trash truck compacting the trash, and as the trash was compacted, the liquid waste would drain onto the ground.
Hospital staff was observed walking through the liquid waste to put trash into the dumpster (trash bin). The staff would have to squeeze between the two trash containers thereby contaminating their clothes and shoes.
An interview with staff #20 at the time of the tour confirmed the above findings. When asked if the facility limited the number of employees exposed to the trash containers and liquid waste. Staff #20 replied no, due to the lack of housekeeping employees, each department took care of their own trash.

An interview was held with staff #1 and staff #2 on 12/09/2014. Staff #1 and Staff #2 confirmed the above findings.

Based on observation, interview and record review the faciilty failed to:

A. provide evidence the Quality Assurance Program was monitoring for infections.


Refer to tag C0278 for additional information.


B. provide evidence the Quality Assurance Program (QAPI) was monitoring for infections. The facility was unable to provide evidence lab cultures were being review for effectiveness of drug therapy.


Refer to tag C0338 for additional information.




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C. ensure sufficient number of Registered nurses to provide supervision and provide patient care on 2 of 2 units (Emergency Department and Medical Surgical).

Refer to tag C0296 for additional information.


D. ensure 5 of 5 patients received accurate assessments, continual monitoring and timely interventions in the Emergency Department (Patient #s' 1, 3, 7, 11, and 14.)

Refer to tag C0298 for additional information.


E. ensure 5 of 5 patients records were complete and accurate in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)


Refer to tag C0302 for additional information.


F. ensure 2 of 2 patients in swing bed status received activities as needed (Patient #s' 19 and 20).


Refer to tag C0385 for additional information.


G. ensure 2 of 2 patients in swing bed status received nutritional assessments as needed (Patient #s' 19 and 20).


Refer to tag C0388 and CO401 for additional information.



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H. evaluate, review, or revise the policy and procedures yearly.


Refer to tag C0334 for additional information.


I. have an effective quality assurance program to evaluate the quality, and appropriateness of the diagnosis, treatment furnished in the CAH, and of the treatment outcomes.


Refer to tag C0336 for additional information.


J. have an effective QAPI program, for patient care services, affecting patient health and safety. The facility failed to provide evidence of QAPI monitoring for infections.


Refer to tag C0337 for additional information.

Based on document review and interview the facility failed to provide evidence the Quality Assurance Program was monitoring for infections.
A review of the document titled Performance Improvement Plan, Department: Infection Control revealed Key department processes require routine monitoring in order to ensure effective and safe care to those served. Infection control issues will be reviewed monthly and summarized and reported quarterly to the Infection Control Committee. Significant findings and trends will be monitored:
Healthcare associated infections (HAIs)
Device-related infections
Antibiotics-resistant organisms
HAI TB
Other communicable diseases
Employee health trends
An interview with staff #2 revealed Infection Control was not monitoring antibiotics-resistant organisms, healthcare associated infections (HAIs) or employee health trends. Staffs #2 revealed Influenza and pneumococcal vaccine were not offered for elderly patients.



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During an observation on 12/08/2014 after 1:15 p.m. the following was found in the ED:
*The outside of the lab cart had a buildup of dust and inside of the drawers were soiled with particles. The base at the back of the cart was covered with spider webs.
* In the trauma room was a suction set up stored on top of a crash cart. Both the setup and cart were covered with a layer of dust and the base of the cart was covered with spider webs.
Inside a supply cabinet was 2 mini bore extension sets which expired November 2014 and a glass evacuated container which expired October 2014.
*During an observation of the physical therapy room on 12/08/2014 after 3:50 p.m., a hydrocoillator was found. The inside walls of the equipment had a buildup of brown substance and was rusted. The wire racks holding the heating packs inside the equipment had a build-up of brown substance.







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* During a tour with staff #1 on 12/08/14 the medical supply room was full of cardboard shipping boxes. The shipping boxes were on the floor and sitting next to clean supplies. The shipping boxes had the likelihood of exposing the clean supplies to contaminates.

Interview with staff #1 during tour on 12/8/2014 confirmed the shipping boxes were in the clean supply room and on the floor.

Based on observation, interview, and record review the facility failed to ensure a sufficient number of Registered Nurses (RN) to provide supervision and patient care on 2 of 2 units the Emergency Department (ED) and Medical Surgical(MS).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:
During an interview on 12/08/2014 after 2:15 p.m. Staff #3 reported they try to have 3 RN's in the facility, but that does not always happen. When they do not have 3 RN's they get an extra Licensed Vocational Nurse (LVN) to help out. Staff #3 reported she got to work today at 5:45 a.m. and was the only staff working the ED. Staff #3 reported having approximately 11 patients come through the ED so far today. After 1:00 p.m. an LVN came in to help her today.
During an interview on 12/08/2014 at 3:10 p.m., Staff #5 reported since the last time the staffing is somewhat better. She reported they have one RN in the ED. There was one RN, one LVN, and one tech on the medical/surgical unit. They were planning to have RN positions to cover 11:00 a.m.-11:00 p.m. and 12:00 p.m.-12 midnight. Someday's they have someone come in during that timeframe, but it is sporadic. There was two LVN's there today, but one was an orientee who just started. Staff #5 reported this morning she went over to help Staff #13 in the ED to start an IV, but that was the only time today. She had to leave the LVN's and tech on the Medical -Surgical unit alone. There was no way she could go back and help the ED nurse because she had 4 admits on the medical-surgical unit and was up to 7 patients now.
During an observation on 12/09/2014 at 11:30 a.m., Staff #5 left the nurses station on the Medical -Surgical side. She reported she had to go and help in the ED to triage two patients. Staff #21 (LVN) was left on the Medical-Surgical unit without RN supervision.
During an interview on 12/10/2014 at 9:15 a.m., Staff #8 (Staffing coordinator) reported she was working as much as she could to cover the openings (in the schedule). They were having a hard time getting nurses to fill the positions (11:00 a.m.-11:00 p.m.) The new hires they do have were not ready for the ED because they were not ACLS certified. There was only one time where there was one RN for the entire facility, but it was only for 2 hours.
Review of the Census reports for December 2014 revealed there were patients on the medical surgical unit every day during from 12/01-08/2014. The patient census ranged from 4-10. The average daily census in the ED during this timeframe was from 11-27 patients.
Review of December 2014 timesheets for the Emergency Department and Medical Surgical unit revealed the following:
*6:00 a.m.-6:00 p.m. shift
2 RN's and 1 LVN, 4 out of 8 days
1 RN and 1 LVN, 1 out of 8 days
*6:00 p.m.-6:00 a.m.
2 RN's and 1 LVN 6 out of 8 days;
1 RN and 1 LVN 1 out of 8 days;
And 1 RN, 1 out of 8 days.
During an interview on 12/10/2014 after 10:45 a.m., Staff #1 confirmed the staffing numbers. Staff #1 provided a written statement dated 12/10/2014 of steps she had taken to improve the staffing numbers. On 11/28/2014 she met with the system CNO (chief nursing officer) to try for staff assistance and again on 12/09/2014 and no one was available.
Review of a facility policy named "Staffing" dated 07/2002 revealed the following:
There must be a registered nurse available to the unit at all times....
I. A. A professional registered nurse must complete/do the assignment of nursing care on each nursing unit or in each nursing department. The assignment must be based on the following:
3. Approved staffing patterns and /or patient classifications data regarding acuity, census, and staffing policies.
Review of the staffing grid for the Medical unit dated November 2014 revealed the following:
A census of 1-10 called for 2 nurses (RN/LVN) for both day and night shift.

Based on interview and record review the facility failed to ensure 5 of 5 patients received accurate assessments, continual monitoring, and timely interventions in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)
This deficient practice had the likelihood to cause harm in all patients:
Findings include:
Review of Emergency Department (ED) Triage report revealed Patient #1 was a 32 year old male who presented on 12/08/2014 at 2:29 p.m. and was triaged at 2:30 p.m. by nursing. There was documentation he presented with complaints of swelling down his throat and into his ear. Patient #1 had a blood pressure of 140/90 and a pain level of 8 out of 10 (0 indicating no pain and 10 being severe pain).
Review of the Physician Record revealed his assessment was at 2:20 p.m. (before presentation). Review of the Physician Record revealed Patient #1 had acute pain in maxilla/mandible-due to dental caries, abscess, and gingivitis. Documentation revealed the pain was resolved after septocaine (meaning septocaine/articaine is an anesthetic agent). Review of physician orders which were not timed by the physician or nursing revealed no orders for an anesthetic agent. There was no documentation of the time or amount of anesthetic agent administered.
There was no documentation of continued pain assessment, monitoring after an anesthetic agent, nor any other vital signs prior to discharge by nursing.
Review of a discharge summary on Patient #1 revealed they were timed for 2:44 p.m. and signed off by nursing at 3:14 p.m. There was no documented time of when the patient signed the form.
Review of an ED Triage Report dated 12/08/2014 revealed Patient #11 was a 4 year old female who presented at 12:33 p.m. because of being sent home from school with an elevated temperature of 102. Nursing documented the following vital signs: 99.5 degrees Fahrenheit temperature, 128 beat per minute pulse, and respirations of 14. There was no documentation of a blood pressure.
Review of the Emergency Physician Record dated 12/08/2014 revealed no documentation of the time the patient was screened by the physician.
Review of the record revealed Patient #11 was discharged at 2:08 p.m.
The initial set of vital signs was the only documented vital signs on the patient. There was no blood pressure documented on the record at all.
Review of an ED Triage report revealed Patient #7 was a 36 year old male who presented on 12/05/2014 at 5:03 p.m. with chest pain. Review of the triage assessment revealed no documented assessment of the pain level on presentation to the ED. The pain portion of the assessment was left blank. Patient #7 had a blood pressure of 147/97 on presentation.
Review of the ED Physician record dated 12/05/2014 revealed no documented time of when the physician performed his medical screening. According to the Physician record revealed Patient #7 had chest pain and it was at a level of 6.
Review of the physician orders revealed no date or time they were written. There was an order for Aspirin and Nitroglycerin written on the form. There was documentation after the Aspirin order of the time 7:42 p.m. (over 2 hours after presentation) indicating administration time. Behind the Nitroglycerin order revealed documentation of no chest pain, but there was no time documented.
Review of the daily focus assessment report dated 12/05/2014 revealed Patient #7 was discharged at 10:30 p.m. There was no documentation of a continued assessment of vital signs on the patient.
Review of an ED Triage report revealed Patient #3 was a 46 year old female who presented 11/16/2014 with coughing after receiving a flu shot. Review of the ED record revealed no time documented of when the patient received a medical screening.
Review of physician orders revealed they were not dated or timed. There were orders for respiratory treatments, antibiotic, and steroid medications on the sheet which did not include the frequency or route to administer.
Review of an ED Triage report dated 09/05/2014 revealed Patient #14 was a 54 year old female who presented on 09/05/2014 at 9:40 a.m. with chest pain. Patient #14 had an elevated blood pressure of 161/105 and a pain level of 10 out of 10 (1 lowest range of pain and 10 being the highest amount of pain). An Aspirin was administered at 9:58a.m. Nitroglycerin was administered at 9:58 a.m. and at 10:00 a.m. without any documentation of vital signs being recorded. The next documented blood pressure was at 1:56 p.m. and it was still 161/105.
The first documentation of an intravenous site being started was at 2:12 p.m.
During an interview on 12/10/2014 after 10:00 a.m., Staff #2 confirmed the problems with assessment in the emergency room charts.

Review of Nursing Policy and Procedures dated 09/2014 revealed the following:
Title:" Pain Assessment and Management"
A. Pain control is a patient's right. The patient experiencing pain will be appropriately assessed and interventions will be made within 30 minutes to provide pain relief.
C. The physicians will prescribe all medications and other pain management interventions and oversee the pain control/management of their patients.
E. Each patient will be initially assessed on admission, and thereafter as necessary, by nursing service staff for pain location, duration, onset, intensity, character, and any existing method used for pain control, the frequency of use of pain control and its effectiveness. Licensed nursing staff will, in addition to assessments, administer and initially evaluate the success of pain control/management measures. Once initiated, each patient should be reassessed after each medication dose and as needed concerning pain control/management. The physicians should be notified if pain control measures are ineffective. This will be documented in the patient's medical record.

Title: "Medications Administration in Emergency Room"
I. A. Medication may be given to a patient only upon the order of an individual with clinical privileges or of an authorized member of staff.
II. A. The ER (emergency room) sheet shall be maintained to reflect date, time, medication, dosage, frequency and route of administration as ordered by the physician as well as the initials and signature of that person administering medication.

Title: "ED Record Charting"
Purpose: To provide documentation of the Emergency Department patient from arrival to disposition.
1. Upon Patient's arrival to ED document the following:
D. Pain Level
E. Vital Signs

Based on interview and record review the facility failed to ensure 5 of 5 patients records were complete and accurate in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)
This deficient practice had the likelihood to cause harm in all patients:
Findings include:
Review of Emergency Department (ED) Triage report revealed patient #1 was a 32 year old male who presented on 12/08/2014 at 2:29 p.m. and was triaged at 2:30 p.m. by nursing. There was documentation he presented with complaints of swelling down his throat and into his ear. Patient #1 had a blood pressure of 140/90 and a pain level of 8 out of 10 (0 indicating no pain and 10 being severe pain).
Review of the Physician Record revealed his assessment was at 2:20 p.m. (before presentation). Review of the Physician Record revealed Patient #1 had acute pain in maxilla/mandible-due to dental caries, abscess, and gingivitis. Documentation revealed the pain was resolved after septocaine (meaning septocaine/articaine is an anesthetic agent). Review of physician orders which were not timed by the physician or nursing revealed no orders for an anesthetic agent. There was no documentation of the neither time or amount of anesthetic agent administered.
There was no documentation of continued pain assessment, monitoring after an anesthetic agent nor any other vital signs prior to discharge by nursing.
Review of a discharge summary on patient #1 revealed they were timed for 2:44 p.m. and signed off by nursing at 3:14 p.m. There was no documented time of when the patient signed the form.
Review of an ED Triage Report dated 12/08/2014 revealed patient #11 was a 4 year old female who presented at 12:33 p.m. because of being sent home from school with an elevated temperature of 102. Nursing documented the following vital signs: 99.5 degrees Fahrenheit temperature, 128 beat per minute pulse, and respirations of 14. There was no documentation of a blood pressure.
Review of the Emergency Physician Record dated 12/08/2014 revealed no documentation of the time the patient was screened by the physician.
Review of the record revealed Patient #11 was discharged at 2:08 p.m.
The initial set of vital signs was the only documented vital signs on the patient. There was no blood pressure documented on the record at all.
Review of an ED Triage report revealed patient #7 was a 36 year old male who presented on 12/05/2014 at 5:03 p.m. with chest pain. Review of the triage assessment revealed no documentation of an assessment of the pain level on presentation to the ED. The pain portion of the assessment was left blank. Patient #7 had a blood pressure of 147/97 on presentation.
Review of the ED Physician record dated 12/05/2014 revealed no documented time of when the physician performed his medical screening. According to the Physician record revealed Patient #7 had chest pain and it was at a level of 6.
Review of the physician orders revealed no date or time they were written. There was an order for Aspirin and Nitroglycerin written on the form. There was documentation after the Aspirin order of the time 7:42 p.m. (over 2 hours after presentation) indicating administration time. Behind the Nitroglycerin order revealed documentation of no chest pain, but there was no time documented.
Review of the daily focus assessment report dated 12/05/2014 revealed Patient #7 was discharged at 10:30 p.m. There was no documentation of a continued assessment of vital signs on the patient.

Review of an ED Triage report revealed Patient #3 was a 46 year old female who presented 11/16/2014 with coughing after receiving a flu shot. Review of the ED record revealed no time documented of when the patient received a medical screening.
Review of physician orders revealed they were not dated or timed. There were orders for respiratory treatments, antibiotic, and steroid medications on the sheet which did not include the frequency or route to administer.


Review of an ED Triage report dated 09/05/2014 revealed Patient #14 was a 54 year old female who presented on 09/05/2014 at 9:40 a.m. with chest pain. Patient #14 had an elevated blood pressure of 161/105 and a pain level of 10 out of 10 (1 lowest range of pain and 10 being the highest amount of pain). An Aspirin was administered at 9:58 a.m. Nitroglycerin was administered at 9:58 a.m. and at 10:00 a.m. without any documentation of vital signs being recorded. The next documented blood pressure was at 1:56 p.m. and it was still 161/105.
The first documentation of an intravenous site being started was at 2:12 p.m.
During an interview on 12/10/2014 after 10:00 a.m., Staff #2 confirmed the problems with assessment in the emergency room charts.
Review of Nursing Policy and Procedures dated 09/2014 revealed the following:
Title:" Pain Assessment and Management"
A. Pain control is a patient's right. The patient experiencing pain will be appropriately assessed and interventions will be made within 30 minutes to provide pain relief.
C. The physicians will prescribe all medications and other pain management interventions and oversee the pain control/management of their patients.
E. Each patient will be initially assessed on admission, and thereafter as necessary, by nursing service staff for pain location, duration, onset, intensity, character, and any existing method used for pain control, the frequency of use of pain control and its effectiveness. Licensed nursing staff will, in addition to assessments, administer and initially evaluate the success of pain control/management measures. Once initiated, each patient should be reassessed after each medication dose and as needed concerning pain control/management. The physicians should be notified if pain control measures are ineffective. This will be documented in the patient's medical record.

Title: "Medications Administration in Emergency Room"
I. A. Medication may be given to a patient only upon the order of an individual with clinical privileges or of an authorized member of staff.
II. A. The ER (emergency room) sheet shall be maintained to reflect date, time, medication, dosage, frequency and route of administration as ordered by the physician as well as the initials and signature of that person administering medication.

Title: "ED Record Charting"
Purpose: To provide documentation of the Emergency Department patient from arrival to disposition.
1. Upon Patient's arrival to ED document the following:
D. Pain Level
E. Vital Signs

Based on interview, policy, and procedures the facility failed to evaluate, review, or revise the policy and procedures yearly.

Review of the policy and procedure books revealed no updated cover sheet with the last approved date, mention of review, or revise of policy and procedure. There was no evidence found of approved policy and procedures in the Governing Board (GB) minutes for 2014.

An interview with Staff #1 reported the current policy and procedures is on-line from corporate. Staff #1 revealed the GB meeting was canceled for the month of November and those policy and procedures have not been adopted by the GB for this facility.

Based on interviews, and review of the Quality Assurance and Performance Improvement (QAPI) records, the facility failed to have an effective quality assurance program to evaluate the quality, and appropriateness of the diagnosis, treatment furnished in the CAH, and of the treatment outcomes.
Review of the QAPI records revealed the ongoing monitoring and data collection for the following departments were in the range of 90-100%:
Admissions, Dietary, Environmental, Imaging, Infection Control, Lab, Maintenance, Medical records, Nursing, Pharmacy, Quality Assurance, Risk Management, and Safety.
Multiple goals were marked "met." The same problems and goals continued in each quarter reports for the year 2014.
Interview with Staff # 2 on 12/10/2014 reported the QAPI data has not been updated. The facility has been reviewing the same data each quarter for a couple of years. Staff # 2 reported she sends out the same questions for QAPI to each department to address and send back in. Staff # 2 reported seldom does anyone change the questions or addresses anything new.

Interview with the facility Administrator on 12/10/2014 confirmed the QAPI was not an effective program that addressed patient treatment, infection control, and treatment outcomes. The Administrator stated, "I guess I didn't realize the QAPI program was not updated and changing each quarter. I can now see where it is not working for us."

Based on interviews and review of the Quality Assurance and Performance Improvement (QAPI) records the facility failed to have an effective QAPI program, for patient care services, affecting patient health and safety. The facility failed to provide evidence of QAPI monitoring for infections.
Review of the Performance Improvement (PI) meeting held on 10/16/2014 the Infection Control Data was 100% for the following:
1. Inpatient diagnosis of communicable disease reported to health department.
2. Health associated infections.
3. Post discharge infections.
There were no goals for health associated infections and monitor and trend for post discharge infections.
An interview with staff #2 on 12/10/2014 revealed she did not have any plans to remove data from the PI plan, after 100% compliance, in a specific time frame. Staff #2 stated, "I have been working with the same data for about two years. When I tried to add new things to the QAPI program I was told to back off. I was being too mean."


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A review of the document titled Performance Improvement Plan, Department: Infection Control revealed Key department processes require routine monitoring in order to ensure effective and safe care to those served. Infection control issues will be reviewed monthly and summarized and reported quarterly to the Infection Control Committee. Significant findings and trends will be monitored:
Healthcare associated infections (HAIs)
Device-related infections
Antibiotics-resistant organisms
HAI TB
Other communicable diseases
Employee health trends
An interview with staff #2 revealed Infection Control was not monitoring antibiotic-resistant organisms, healthcare associated infections (HAIs), or employee health trends. Staff #2 revealed Influenza and pneumococcal vaccine were not offered for elderly patients.

Based on document review and interview the facility failed to provide evidence the Quality Assurance Program (QAPI) was monitoring for infections. The facility was unable to provide evidence lab cultures were being review for effectiveness of drug therapy.
A review of the document titled Performance Improvement Plan, Department: Infection Control revealed Key department processes require routine monitoring in order to ensure effective and safe care to those served. Infection control issues will be reviewed monthly and summarized and reported quarterly to the Infection Control Committee. Significant findings and trends will be monitored:
Healthcare associated infections (HAIs)
Device-related infections
Antibiotics-resistant organisms
HAI TB
Other communicable diseases
Employee health trends
An interview with staff #2 revealed Infection Control was not monitoring antibiotic-resistant organisms, healthcare associated infections (HAIs) or employee health trends. Staff #2 revealed lab cultures were not being monitored or reviewed for the effectiveness of antibiotics.

Based on interview and record review the facility failed to ensure 2 of 2 patients in swing bed status received activities as needed (Patient #s' 19 and 20).
This deficient practice had the likelihood to cause harm in all patients.
Findings included:

Review of an admission assessment report revealed Patient #19 was admitted on 11/04/2014 with diagnoses which included urinary tract infection and aspiration pneumonia. Patient #19 was discharged on 11/11/2014.
Review of physician orders dated 10/15/2014 revealed Patient #20 was an 84 year old female admitted to the swing bed status with diagnoses that included urinary tract infection, altered mental status with severe dementia. Review of nursing assessment report revealed Patient #20 was discharged on 10/24/2014.
Review of the records revealed no documentation of an assessment addressing activity needs, activities provided, and the patient's response.
During an interview on 12/10/2014 after 10:00 a.m. Staff #2 confirmed she could not find an activity assessment or documentation on the patients. Staff #2 reported the activity director was only working three days a week in their facility.
During an interview on 12/10/2014 after 10:00 a.m., Staff #22 confirmed she was the activity director and that her documentation should be in the record. Staff #22 reported she did not keep a log or documentation of the activities that were provided. She also reported not being at work at the facility sometimes when patients are admitted.
Review of facility policies dated 09/2014 revealed the following:
Title: Activity Program
The Activities Director will plan and direct recreation programs for patients in the "Swing Bed Program" to effect improvement in their physical, mental, and social wellbeing. This will be done within 72 hours of admission.
4. Prepare activity care plan, stating the planned activity and the patient's response or nonresponse to this activity.

Based on interview and record review the facility failed to ensure the comprehensive assessment included activity pursuit and nutritional status in 2 of 2 patients in Swing bed status (Patient #s' 19 and 20).
This deficient practice had the likelihood to cause harm in all patients.
Findings included:
Nutrition
Review of an admission assessment report revealed Patient #19 was an 83 year old male admitted on 11/04/2014 with diagnoses which included urinary tract infection and aspiration pneumonia and was discharged on 11/11/2014.
Review of a care plan dated 11/04/2014 revealed an intervention to consider a clinical dietitian referral.
Review of a nutritional screen form dated 11/05/2014 revealed it was completed by the Staff #23 (dietary manager). The screen said the reason for the referral was difficulty chewing/swallowing, tube feeding, and new/uncontrolled diabetic. According to the screening the patient had a tube feeding order for the formula Periative at 30 cc per hour (formula for metabolically stressed patients). There was no documentation of the patient's height, usual weight, ideal weight range, and the follow-up section on the form was incomplete. There was no documentation of assessment of any current weight loss, calorie, protein, or fluid needs on this clinically compromised patient.
Review of laboratory results dated 11/04/2014 on Patient #19 revealed he had a low albumin level of 3.2 (reference ranges being 3.5-5.0) and the level had dropped on 11/10/2014 to 2.99 (albumin is one of the indicators to determine malnutrition).
Review of physician orders dated 10/15/2014 revealed Patient #20 was an 84 year old female admitted to the swing bed status with diagnoses which included urinary tract infection, altered mental status with severe dementia. Patient #20 had an order for NPO (nothing by mouth) status until more alert.
Review of a care plan dated 10/15/2014 revealed an intervention to consider a clinical dietitian referral whenever needed.
Review of a nutritional screen form dated 10/13/2014 (from a previous stay) revealed it was completed by the Staff #23 (dietary manager). The screening talked about the patient being on a mechanical soft diet and having risk of choking and weight loss. There was no screening for the visit which started 10/15/2014 and the NPO status. There was no documentation of the patient's height, usual weight, ideal weight range, documentation of assessment of any current weight loss, calorie, protein, or fluid needs on this clinically compromised patient.
Review of laboratory results dated 10/10/2014 on Patient #20 revealed she had a albumin level of 3.7 (reference ranges being 3.5-5.0) prior to admission to swing bed status and the level had dropped on 10/19/2014 to 2.8 (albumin is one of the indicators to determine malnutrition).
Review of a nursing assessment report revealed Patient #20 was discharged on 10/24/2014.
During an interview on 12/10/2014 after 10:00 a.m., Staff #23 confirmed there were no dietary assessments being done on the patients. Staff #23 reported she did not have the ability to perform detailed nutritional assessments. She reported not being able to get around to visit the patients like she wanted to.
During an interview on 12/10/2014 after 10:00 a.m. Staff #2 confirmed she could not find a nutritional assessment on the patient. Staff #2 reported the dietitian was not making regular visits.
Review of facility policies dated 09/2014 revealed the following:
Title "Nutritional Assessments"
Nutrition assessments are completed on patients when nutrition screening criteria are met during the initial nursing assessment, or as identified by the physician, or other healthcare professionals. Patients are assessed within 48 hours of referral. It listed it was the responsibility of the RN, LVN, Physician or Licensed Dietitian.
Title "Swing Bed Policy and Procedure"
The Dietary Manager will visit each "Swing Bed patient at least once a week to consult with them in regard to any personal preferences, quality and quantity of food received, or anything the patient may wish to discuss related to their diet.
Activity assessment
Review of an admission assessment report revealed Patient #19 was admitted on 11/04/2014 with diagnoses which included urinary tract infection and aspiration pneumonia and was discharged on 11/11/2014.
Review of physician orders dated 10/15/2014 revealed Patient #20 was an 84 year old female admitted to the swing bed status with diagnoses which included urinary tract infection, altered mental status with severe dementia. Review of nursing assessment report revealed Patient #20 was discharged on 10/24/2014.
Review of the records revealed no documentation of an assessment addressing activity needs, activities provided and the patient's response.
During an interview on 12/10/2014 after 10:00 a.m. Staff #2 confirmed she could not find an activity assessment or documentation on the patients. Staff #2 reported the activity director was only working three days a week in their facility.
During an interview on 12/10/2014 after 10:00 a.m., Staff #22 confirmed she was the activity director and that her documentation should be in the record. Staff #22 reported she did not keep a log or documentation of the activities that were provided. She also reported not being at work at the facility sometimes when patients are admitted.
Review of facility policies dated 09/2014 revealed the following:
Title: Activity Program
The Activities Director will plan and direct recreation programs for patients in the "Swing Bed Program" to effect improvement in their physical, mental and social wellbeing. This will be done within 72 hours of admission.
4. Prepare activity care plan, stating the planned activity and the patient's response or nonresponse to this activity.

Based on interview and record review the facility failed to ensure 2 of 2 patients in swing bed status received nutritional assessments as needed (Patient #s' 19 and 20).
This deficient practice had the likelihood to cause harm in all patients.
Findings included:
Review of an admission assessment report revealed Patient #19 was an 83 year old male admitted on 11/04/2014 with diagnoses which included urinary tract infection and aspiration pneumonia and was discharged on 11/11/2014.
Review of a care plan dated 11/04/2014 revealed an intervention to consider a clinical dietitian referral.
Review of a nutritional screen form dated 11/05/2014 revealed it was completed by the Staff #23 (dietary manager). The screen said the reason for the referral was difficulty chewing/swallowing, tube feeding, and new/uncontrolled diabetic. According to the screening the patient had a tube feeding order for the formula Periative at 30 cc per hour (formula for metabolically stressed patients). There was no documentation of the patient's height, usual weight, ideal weight range, and the follow-up section on the form was incomplete. There was no documentation of assessment of any current weight loss, calorie, protein, or fluid needs on this clinically compromised patient.
Review of laboratory results dated 11/04/2014 on Patient #19 revealed he had a low albumin level of 3.2 (reference ranges being 3.5-5.0) and the level had dropped on 11/10/2014 to 2.99 (albumin is one of the indicators to determine malnutrition).
Review of physician orders dated 10/15/2014 revealed Patient #20 was an 84 year old female admitted to the swing bed status with diagnoses which included urinary tract infection, altered mental status with severe dementia. Patient #20 had an order for NPO (nothing by mouth) status until more alert.
Review of a care plan dated 10/15/2014 revealed an intervention to consider a clinical dietitian referral whenever needed.
Review of a nutritional screen form dated 10/13/2014 (from a previous stay) revealed it was completed by the Staff #23 (dietary manager). The screening talked about the patient being on a mechanical soft diet and having risk of choking and weight loss. There was no screening for the visit which started 10/15/2014 and the NPO status. There was no documentation of the patient's height, usual weight, and ideal weight range, documentation of assessment of any current weight loss, calorie, protein or fluid needs on this clinically compromised patient.
Review of laboratory results dated 10/10/2014 on Patient #20 revealed she had a albumin level of 3.7 (reference ranges being 3.5-5.0) prior to admission to swing bed status and the level had dropped on 10/19/2014 to 2.8 (albumin is one of the indicators to determine malnutrition).
Review of a nursing assessment report revealed Patient #20 was discharged on 10/24/2014.
During an interview on 12/10/2014 after 10:00 a.m., Staff #23 confirmed there were no dietary assessments being done on the patients. Staff #23 reported she did not have the ability to perform detailed nutritional assessments. She reported not being able to get around to visit the patients like she wanted to.
During an interview on 12/10/2014 after 10:00 a.m. Staff #2 confirmed she could not find a nutritional assessment on the patient. Staff #2 reported the dietitian was not making regular visits.
Review of facility policies dated 09/2014 revealed the following:
Title "Nutritional Assessments"
Nutrition assessments are completed on patients when nutrition screening criteria are met during the initial nursing assessment, or as identified by the physician, or other healthcare professionals. Patients are assessed within 48 hours of referral. It listed it was the responsibility of the RN, LVN, Physician or Licensed Dietitian.
Title "Swing Bed Policy and Procedure"
The Dietary Manager will visit each "Swing Bed patient at least once a week to consult with them in regard to any personal preferences, quality and quantity of food received, or anything the patient may wish to discuss related to their diet.