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Based on interview and review of the Emergency Room (ER) nursing schedule, the ER patient log and clinical records, it was determined the facility failed to ensure a Registered Nurse (RN) evaluated the emergency nursing care needs for 24 ( #s 6, 13, 21-25, 28, 30, 32-36, 39-42, 44, and 47-50) of 45 (#6-50) sampled ER patients on 02/04/11,02/07/11, 02/08/11, 02/09/11, 02/10/11, 02/11/11, 02/14/11 and 02/21/11. The failure to have a RN triage and evaluate the patient needs placed them at risk for harm. The failed practice affected the 24 ER patients and any other patients whose ER triage and evaluation was performed by a Licensed Practical Nurse (LPN). Findings follow:

A. During the ER tour and interview on 02/23/11 at 1020, the Director of Nursing (DON) stated "We try but we do not always have a RN back here (ER)."
B. Review of Nursing policy and procedure (effective date September 2006) stated a "RN will triage all persons presenting to the ER on arrival."
C. Review of the facility nursing schedule from 01/20/11 to 02/22/11 revealed five shifts, 02/04/11 7 am-7 pm, 02/06/11 midnight to 0700, 02/07/11 7 pm-7am, 02/13/11 7 pm-7 am, and 02/21/11 7 pm-7 am when a RN was not assigned to the ER.
D. The ER log was reviewed from 01/20/11 to 02/22/11 for selection of the patient sample. Review of the ER clinical records for Patient #s 6, 13, 21-25, 28, 30, 32-36, 40-42, 44, and 47-50 revealed the assessment was performed by a LPN and Patient #39 had no ER nursing triage or evaluation.
E. The above clinical record findings were confirmed by the DON on 02/25/11 from 0855 until 1005.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to maintaining penetrations of smoke barrier walls and corridor walls were not sealed with a fire rated material. Failure to properly seal penetrations of smoke barrier walls had the potential to affect the health and safety of patients, visitors, and staff because a compromised smoke barrier wall allows the passage of fire and smoke from one side of the smoke barrier to the other. The failed practice had the potential to affect eight of eight patients on census on 02/23/11 and all staff and visitors.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to inspection of fire and smoke dampers. Failure to inspect fire and smoke dampers prevented the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect eight of eight patients on census on 02/23/11 and all staff and visitors.

See CMS 2567 K17, K25, and K67.

Based on Emergency Room (ER) Nursing schedules, ER log, clinical records and interview, it was determined the Governing Body failed to ensure a Registered Nurse (RN) evaluated the emergency nursing care needs for 24 ( #s 6, 13, 21-25, 28, 30, 32-36, 39-42, 44, and 47-50) of 45 (#6-50) sampled ER patients on 02/04/11,02/07/11, 02/08/11, 02/09/11, 02/10/11, 02/11/11, 02/14/11 and 02/21/11. The failure to have a RN triage and evaluate the patient needs placed them at risk for harm. The failed practice affected the 24 ER patients and any other patients whose ER triage and evaluation was performed by a Licensed Practical Nurse (LPN). See C0200 for details.

Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use on four (Emergency Department, Medical/Surgical Unit, Surgery and Recovery Room) of four nursing areas. The potential existed for the average daily census of 4.2 inpatients, 10.6 Emergency Department patients, and the average monthly census of 5.2 Surgery patients to receive outdated medications. Findings follow:

A. A tour of the four nursing areas of the facility was conducted on 02/23/11 between 0925 and 1110. The following outdated medications were observed available for patient use if ordered by a physician:

Emergency Department
1) Three Naloxone Hydrochloride Injectables expired 02/23/11;
2) Two Erythromycin Ophthalmic Ointments expired 01/11;
3) Two Calcium Chloride 10% Injectables expired 02/01/11;
4) Three Isuprel 1 milligram (mg) Intravenous expired 01/01/11;
5) Three Procainamide 1 gram (gm)/10 milliliter (ml) Injectables expired 02/01/11;
6) One Adenosine 12 mg/4 ml Injectable expired 11/10;
7) Two Lopressor 5 mg/5 ml Injectable expired 01/11;
8) Thirty-four Hydrocodone Bitartrate 5 mg/Acetaminophen 500 mg expired 02/01/11;
9) One Nitropress 50 mg/2 ml expired 11/01/10;
10) One Lactated Ringers 1000 ml intravenous solution expired 01/11;
11) One Acetaminophen Oral Suspension 160 mg/5 ml expired 11/10;
12) Two Prefilled Heplock Flush 5 mg expired 06/25/09; and
13) One Normal Saline 10 mg Injectable expired 07/10.
Medical/Surgical Unit
1) Four Sodium Chloride 0.9% Injectable expired 11/01/10; and
2) Three Procainamide 1 gm/10 ml Injectable expired 02/01/11.
Surgery
3) Two Procainamide 1 gm/10 ml expired 02/01/11.
Recovery Room
2) Two Procainamide 1 gm/10 ml expired 02/01/11; and
3) Two Succinylcholine 200 mg/10 ml expired 02/01/11.

B. Interviews were conducted on 02/23/11 in which it was verified the medications were outdated and available for patient use. The Emergency Department Director and the Director of Nursing verified the medications were outdated and available for patient use in the Emergency Department between 0930 and 1010. Licensed Practical Nurse #1 verified the medications were outdated and available for patient use on the Medical/Surgical Nursing Unit at 1040. Registered Nurse #1 verified the medications were outdated and available for patient use in Surgery at 1045 and Recovery at 1110 respectively.

Based on observation, review of policies for infection control, employee report of illness, Negative Pressure Log, Tuberculosis Infection Control Plan, and interview, it was determined the facility failed to assure policies and processes were in place to prevent the potential spread of infection by staff; failed to monitor and evaluate staff for adherence to infection control policies and practices; and failed to monitor negative pressure of the AIIR (Airborne Infection Isolation Room) daily when occupied by a patient requiring airborne isolation. The failed practice increased the risk of infection at the facility and had the potential to affect eight of eight in patients on census 02/23/11, an average daily census of 4.2 inpatients, all employees and visitors.

A. On 02/25/11 at 1035, an interview was conducted with the Infection Control Nurse. The process for obtaining reports of infections and communicable disease on inpatients and employees were discussed. The facility form "Employee Illness Report" was provided to surveyor for review. The form included the instructions: "Employees are to fill out this form and submit to Department Head after each illness. Department Head will then route original to Infection Control and a copy to Human Resources." The form contained a "Type of Illness" category that stipulated "Check one." Categories included "Upper respiratory symptoms, Gastrointestinal symptoms, skin/subcutaneous infection, any illness with rash or fever, other infection not otherwise listed..." The form included the following, "Did you see a doctor or obtain a back to work permit? If you have been sick with an infectious illness and did not see a doctor for a permit to return to work, please notify the Infection Control Practitioner for clearance to return to work." Interview on 02/25/11 at 1035, the Infection Control Nurse stated, "I give them to the end of the pay period to complete the report. If I don't have it then, I contact their manager." Interview on 02/25/11 at 1045, the Infection Control Nurse confirmed there was no system in place for monitoring staff prior to return to work to assure no infectious illness was present.
B. A review of infection control policies was conducted on 02/24/11 and 02/25/11. The Infection Control Nurse stated by interview on 02/25/11 at 1045 there was no process in place to monitor staff adherence to facility infection control policies and practices.
C. The facility policy "Tuberculosis Infection Control Plan" was reviewed 02/25/11 and revealed "When in use for TB (Tuberculosis) isolation, the room will be monitored daily to ensure that negative pressure is maintained relative to the hallway and all surrounding areas. When not in use, the room will be monitored at least once monthly to assure that negative pressure capability is still present. A log will be kept of all monitor readings." Interview with the Infection Control Nurse and review of the "Negative Pressure Log" on 02/25/11 at 1130 revealed Room #11 was last occupied by a patient who required airborne isolation from 02/10/10 at 1230-02/25/10 at 0900. The Negative Pressure Log lacked documentation of daily negative pressure checks as required by facility policy 4 (02/13-02/14/10, and 02/20-02/21/10) of 16 (02/10-25/10) days it was occupied the patient. The Infection Control Nurse confirmed the findings by interview 02/25/11 at 1135 and stated "I am not here on the weekends to do the checks."

Based on review of policies and procedures for the Swing-Bed Program, closed record review, and interview, it was determined the facility failed to have patient activities directed by a qualified professional or by facility staff, designated as the activitiy director, who provided the service in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy. The potential existed for all patients admitted to the Swing-Bed program to have unmet activity needs. Findings follow:

A. Review of Closed Record #1 and #2 for Swing-Bed patients was conducted on 02/25/11. The clinical records provided did not include documentation of a comprehensive activities assessment designed to meet the interests and the physical, mental and psychosocial needs of each Swing-Bed patient.
B. Swingbed policies and procedures were reviewed on 02/25/11. In an interview with the Swingbed Coordinator on 02/25/11 at 1300, she was asked who was the person responsible for the Activities for the Swing bed patients. She stated "The nurse techs (technicians) provide activities and some of the nurses. I guess the person responsible would be the Director of Nursing, since the Director of Nursing before her was."
C. In an interview with the Director of Nursing on 02/25/11 at 1318, she was asked who was the person responsible for Activities for Swing-Bed patients. She stated "Well I guess it would be me" and confirmed the findings.