HospitalInspections.org

Based on observation, review of policy and procedure and interview with staff, it was determined contracted staff failed to follow their policy for total chlorine testing. This did affect Patient Identifier # 12 and had the potential to negatively affect all patients requiring inpatient dialysis.

Findings include:

Policy: Ultra-Low Total Chlorine Test Strips

It is the policy of ... to accurately determine the levels of total chlorine in water, ensuring that it is within safe limits for use.

Procedure:

2. Collect a fresh 100 ml (milliliters) sample of water ...

3. Remove one test strip from its foil package and dip it in the sample for 20 seconds...

4. Remove the strip and shake once, briskly, to remove excess water.

5. Wait 20 seconds for the test strip color to develop...

6. Compare color matching...

********

1. PI # 12 was admitted to the facility on 9/11/17 with diagnoses including Altered Mental Status and End Stage Renal Disease.

An observation of care was conducted on 9/12/17 at 2:55 PM to observe Employee Identifier (EI) # 5, Registered Nurse Acute Dialysis to provide PI # 12 a dialysis treatment as ordered per the physician.

EI # 5 prepared the dialysis machine, collected the 100 ml sample of water to test the total chlorine, removed the RPC Ultra-Low (Trademark) strip from the package and dipped it in the sample for 20 seconds. EI # 5 then removed the strip and left the room and stated, "I need to get my clipboard because it has my strip that I compare this strip to on it". When EI # 5 returned to the room the surveyor ask EI # 5 when the results should be read and EI # 5 stated, "Immediately."

EI # 5 failed to follow the facility policy for total chlorine testing.

An interview was conducted on 9/14/17 at 1:30 PM with EI # 1, Chief Nursing Officer, who verified the aforementioned findings.

Based on review of facility policy, medical records, observations and interviews, it was determined the facility failed to ensure:

1. The plans of care were initiated and updated with realistic goals and treatments according to the facility policy.

2. The plan of care was followed for individual, group and activity therapies.

3. Nursing services evaluated patient problems and interventions each shift.

4. A policy was developed for the evaluation of patient problems and interventions.

5. Group therapies were completed according to the plan of care.

This affected 2 of 2 patient records reviewed for care plans, including Patient Identifier (PI) # 2, PI # 3 and has the potential to affect all patients served.

Findings include:

Facility policy: Treatment Team Meetings
Effective date: 1/1/2007
Date reviewed/revised: 5/14; 6/17

Policy:

Each patient's individual treatment plan shall be continuously reviewed, evaluated and updated during the course of the patient's hospitalization. The treatment team will meet weekly for each pt (patient). Treatment team meetings will be held on Monday, Wednesday, and Friday. Each patient's plan of care will be reviewed and/or revised to reflect the patient's current status.

Admission date will determine which day the treatment plan is initiated, and reviewed. Treatment plan should be initiated within 24 hr (hours) of patient's admission, and reviewed within the next week on Monday, Wednesday or Friday.

Purpose: To individualize current treatment plans.

Procedure:

The multidisciplinary treatment team, led by the patient's attending physician will formally update the treatment plan weekly at the treatment team meeting. The Case Manager, Treatment Nurse, Social Worker, Recreational Therapist and Psychiatrist are required to be in attendance at each meeting...

Each treatment plan review meeting must be documented in the medical record by the Case Manager/Social Worker...

The review of the treatment plan will include:
Evaluation of the patient's progress towards meeting the existing objectives. All problems identified must be reviewed.

Treatment team recommendations that include effectiveness of current interventions, specific interventions that will assist the patient in meeting the objectives, and treatment plan revisions that are necessary...

Each member of the treatment team in attendance shall sign the Treatment Plan Review Form...

On 9/12/17, the surveyor questioned geri-psychiatric staff about patient group activities/meetings and was informed patient groups are at 9:00 AM and 2:00 PM.

On 9/12/17 at 2:30 PM, the surveyor observed Employee Identifier (EI) # 8, Activities Coordinator enter the geri-psych unit and began gathering patients for BINGO. At that time, PI # 3 was taken in a geri-chair and PI # 2 ambulated to the Activities Room for BINGO.

1. PI # 2 was admitted to the facility on 9/2/17 with Schizoaffective Disorder, Bipolar type.

Review of the Interdisciplinary Treatment Plan Data Base dated 9/2/17 revealed no documentation the psychiatrist was in attendance or signature.

Review of the Treatment plan dated 9/2/17 revealed the interventions to meet the short term goals included the following: Community Meeting daily times (X) 10 days, Medications Group 3 X week (wk), Group Psychotherapy 3 X wk X 10 days, Spirituality Group 2 X wk X 10 days, Leisure/recreation Group 3 X wk X 10 days and Reminiscence Group.

Review of the medical record revealed an untitled document dated 9/7/17 - 7 PM shift, which listed the patient's problems and interventions.

Review of the Treatment Plan Review dated 9/8/17 revealed no documentation the psychiatrist was in attendance and reviewed or signed the Treatment Plan Review.

Review of the medical record revealed an untitled document dated 9/11/17 - 7 PM shift, which listed the patient's problems and interventions.

The surveyor reviewed the patient's medical record on 9/12/17, which revealed (2) two Activity Group notes, (1) dated 9/5/17 and (1) dated 9/11/17.

The surveyor submitted a list of questions related to the untitled document with the patient's problems and interventions to EI # 1 questioning the purpose and frequency the document was to be completed. The surveyor also requested the policy related to the document.

On 9/14/17 at 9:50 AM, EI # 1 stated the purpose of the untitled documents was to evaluate the patient's progress toward meeting goals and the frequency of this evaluation was to be completed every shift. EI # 1 verified the facility did not have a policy related to the completion of evaluations of patient progress and interventions and the evaluations were not completed every shift. EI # 1 also verified care plans were not completed and updated according to facility policy.

On 9/14/17 at 10:50 AM, the surveyors asked EI # 2, Clinical Nurse Manager/Interim Director Geri-Psychiatric unit if there was a calendar of group activities because the surveyors did not see an activities calendar posted any where on the unit. EI # 2 stated she would talk with EI # 8 and get a copy.

On 9/14/17 at 11:00 AM, the surveyors entered EI # 8's office. At that time, the surveyors asked EI # 8 if there was a schedule of activities for the geri-psych patients. EI # 8 stated he had not completed a calendar for September. He also verified he did not have one for August either, but, thought he had one for July somewhere.

A second interview was conducted on 9/14/17 at 11:30 AM with EI # 8. During this interview, EI # 8 verified the activities groups should be 2 times a day. He stated he doesn't always get to have group in the afternoons and on weekends none of the groups are done as there is no one to do them.

2. PI # 3 was admitted to the geri-psychiatric unit of this facility on 8/22/17 with Major neurocognitive disorder with psychosis and behavioral disturbance and a history of chronic Schizophrenia.

Review of the Interdisciplinary Treatment Plan Data Base dated 8/22/17 was documented as having been signed by the psychiatrist on 9/4/17, which was 13 days after admission.

Further review of the Interdisciplinary Treatment Plan Data Base dated 8/22/17 revealed the patient had disorientation/confusion, impaired judgement and memory impairment. The patient's inventory of limitations included, "degree of insight, physical status, education/cognition and motivation..."

Review of the Treatment plan dated 8/22/17 revealed the goals included the following short term goals, "... Patient will initiate 2 daily contacts with peers by 8/29/17... Patient will complete/assist with daily grooming/hygiene by 8/29..."

Review of the Treatment plan dated 8/22/17 revealed the interventions to meet the above goals included the following, "... Group Psychotherapy 3 X a wk X 10 days, Exercise Group 4 X wk X 10 days, Spirituality Group 2 X wk X 10 days... Leisure/recreation Group 3 X wk X 10 days..."

Review of the Patient Care Notes dated 8/23/17 revealed the nurse documented, "pt (patient) up in geri chair at nurses desk, crying and talking to self, can not communicate why (he/she) is crying and unable to follow directions, rambling incoherent speech..."

Review of the medical record revealed an untitled document dated 8/24/17 - 7 PM shift, which listed the patient's problems and interventions. There was no documentation this document was completed for the 7 AM shift.

Review of the Patient Care Notes dated 8/25/17 at 11:56 AM, revealed the nurse documented, "... pt remains in bed, awake and alert, oriented to person only, rambling incoherent speech, cooperative..."

Review of the Patient Care Notes dated 8/25/17 at 4:45 PM, revealed the nurse documented, "... remains in bed, no change in neuro (neurological)... talks nonsensically, unable to follow conversation..."

Review of the Patient Care Notes dated 8/25/17 at 5:15 PM, revealed the nurse documented, "... continues to talk nonsensically, and... is unable to follow conversation with word salad..."

Review of the medical record revealed no documentation the evaluation of the patient's progress toward meeting goals was completed for the 7 AM shift on the following dates: 8/25/17, 8/26/17, 8/27/17, 8/28/17.

There was no documentation in the medical record of an evaluation of the patient's progress toward meeting goals for 8/29/17 both 7 AM and 7 PM shifts. There was no documentation the evaluation of the patient's progress toward meeting goals was completed for the 7 AM shift on 8/30/17 and 8/31/17. There was no documentation in the medical record of an evaluation of the patient's progress toward meeting goals for 9/1/17 both 7 AM and 7 PM shifts.

Review of the Patient Care Notes dated 9/1/17 at 7:30 AM revealed the nurse documented, "... patient rambling nonsensically..." and at 9:30 AM the nurse documented, "... patient sitting up in bed and continues to ramble..."

There was no documentation in the medical record of an evaluation of the patient's progress toward meeting goals for 9/2/17 both 7 AM and 7 PM shifts.

Review of the Patient Care Notes dated 9/2/17 at 8:30 AM revealed the nurse documented, "... pt currently calm and cooperative, pt rambling..." and at 2:00 PM the nurse documented, "... pt occasionally singing out, speech loose, pt currently confused, calm, and cooperative..."

There was no documentation the evaluation of the patient's progress toward meeting goals was completed for the 7 AM shift on 9/3/17, 9/4/17 and 9/5/17.

Review of the Treatment Plan Review dated 9/5/17 revealed no documentation the psychiatrist was in attendance or signature.

Review of the Patient Care Notes dated 9/6/17 at 5:45 PM revealed the nurse documented, "... pt in geri-chair in activity room crying out sounding like a baby or cat. When spoken to (he/she) begins to ramble..."

There was no documentation the evaluation of the patient's progress toward meeting goals was completed for the 7 AM shift on 9/6/17 and 9/5/17.

Review of the Special Observation List dated 9/8/17 revealed from 3:30 PM to 4:30 PM the patient's location was documented as being in the activity room, resting in the chair. There was no documentation of meaningful interaction with others or participation in an activity.

The above Treatment Plan interventions were not individualized for this patient's condition as the patient was mainly in bed or in a geri-chair and the patient was unable to initiate interactions with peers as the patient had rambling nonsensical speech and was oriented to self only.

There was no documentation in the medical record of an evaluation of the patient's progress toward meeting goals for 9/8/17, 9/9/17 and 9/10/17 both 7 AM and 7 PM shifts. There was no documentation the evaluation of the patient's progress toward meeting goals was completed for the 7 AM shift on 9/11/17.

Review of 18 of 18 Special Observation Lists dated 8/23/17 to 9/11/17 revealed no documentation the patient had any interactions with peers or visitors. The majority of the patient's location codes were in the patient's room. The patient was documented as having been sitting in a chair at the nursing station. There was no documentation of meaningful interaction with others during those times. The patient was also documented as having been in the dining room eating with no meaningful interaction with others during that time.

A review of the medical record revealed no documentation of individual, group and activity therapies.

An interview was conducted on 9/14/17 at 9:40 AM with EI # 1, who verified the above findings.

Based on review of medical records ( MR), facility policy and interviews with the staff, it was determined the facility failed to ensure the staff provided interventions to relieve pain and failed to provide follow up in a timely manner after an intervention was provided. This affected 1 of 23 MR's reviewed, including Patient Identifier (PI) # 20 and had the potential to negatively affect all patients served by the facility.

Findings include:

Title: Pain Assessment and Reassessment

Policy:
Respect and support the patient's right to optimal pain assessment and management. Pain is assessed for all patients. The organization will also address the appropriateness and effectiveness of the pain management...

Procedure:
It is the responsibility of all clinical staff to screen all patients for the presence or absence of pain...
If the screening assessment reveals pain is present in the patient, it is the responsibility of the nursing staff to conduct an in depth clinical assessment of the pain, including the intensity and quality, character, frequency, location and duration of pain.

It is the responsibility of the nursing staff to perform periodic assessments of the patient for the determination of pain, relief from pain, and responses to treatment.

Document:
...Any use of analgesics.
Include other pain interventions
The effectiveness of all interventions and any side effects or adverse reactions.
Reassessment should be done with each assessment, after intervention, change in caregiver or with status of patient.

1. PI # 20 was admitted to the facility on 2/2/17 with an admitting diagnosis of Metabolic Acidosis and Dehydration.

Review of the Registered Nurse (RN) documentation on 2/11/17 at 8:45 AM revealed the patient complained of pain to the abdomen and rated the pain a 10 on a scale of 0 being no pain and 10 the worst imaginable pain. Further review revealed the nurse documented he/she provided emotional support and repositioned the patient. There was no documentation the patient was medicated for pain control.

Review of the RN documentation on 2/11/17 at 9:00 AM revealed the patient continues to complain of pain rating the pain a 10 and the patient had increased restlessness. Further review revealed the patient was provided with emotional support and was repositioned for comfort.

Review of the RN assessment on 2/11/17 at 11:55 AM revealed 3 hours and 10 minutes after the patient's first initial complaint of pain the patient was medicated for pain. Review of the RN documentation revealed the nurse failed to document what medication was given to the patient for pain and there was no documentation of a follow up after medication was given.

An interview was conducted on 9/14/17 at 11:10 AM with Employee Identifier # 1, Chief Nursing Officer, who confirmed the patient should have been medicated and a follow up within 30 minutes should have been conducted to reassess pain level and the nurse should have documented everything in the nursing note.

Based on review of 42 CFR (Code of Federal Regulations) 412.25, Medicare Benefit Policy - Chapter 2 - Inpatient Psychiatric Hospital (IPF) Services, Medicare General Information - Eligibility and Entitlement Chapter 4, medical records and interview with facility staff, it was determined the facility failed ensure patients admitted to the Prospective Payment System (PPS) excluded Psychiatric unit were certified and recertified for admission regardless of the patient's payor source.

This affected 2 of 2 records reviewed of patients admitted to the PPS excluded Psychiatric unit, including Patient Identifier (PI) #s 2, PI # 3 and had the potential to affect all patients admitted to the PPS Psychiatric unit.

Findings include:

1. 42 CFR 412.25 Excluded hospital units: Common requirements.

(a) Basis for exclusion. In order to be excluded from the prospective payment systems as specified in 412.1(a)(1) and be paid under the inpatient psychiatric facility prospective payment system as specified in 412.1(a)(2) or the inpatient rehabilitation facility prospective payment system as specified in 412.1(a)(3), a psychiatric or rehabilitation unit must meet the following requirements.

(1) Be part of an institution that: (i) Has in effect an agreement under part 489 of this chapter to participate as a hospital;

(ii) Is not excluded in its entirety from the prospective payment systems; and (iii) Has enough beds that are not excluded from the prospective payment systems to permit the provision of adequate cost information, as required by 413.24(c) of this chapter.

(2) Have written admission criteria that are applied uniformly to both Medicare and non-Medicare patients.


2. Medicare Benefit Policy - Chapter 2

20 - Admission Requirements

For all IPFs, according to 42 CFR (Code of Federal Regulations) 412.27 (a) and 42 CFR 482.61, distinct part psychiatric units of acute care hospitals and CAHs (Critical Access Hospitals) are required to admit only those patients whose admission to the unit is required for active treatment, of an intensity that can be provided appropriately only in an inpatient hospital setting, of a psychiatric principal diagnosis that is listed in the Fourth Edition, Text Revision of the American Psychiatric Association's Diagnostic and Statistical Manual, or in Chapter Five of the International Classification of Diseases, applicable to the service date. Psychiatric hospitals are required to be primarily engaged in providing, by or under the supervision of a psychiatrist, psychiatric services for the diagnosis and treatment of mentally ill persons, according to 42 CFR 412.23(a)...

... 30.2.1- Certification and Recertification Requirements

30.2.1.1 - Certification
The certification that a physician must provide with respect to IPF services is required to include a statement that the services furnished can reasonably be expected to improve the patient's condition or for diagnostic study. The certification is required at the time of admission or as soon thereafter that is reasonable and practical...

30.2.1.2 - Recertification

If the patient continues to require active inpatient psychiatric treatment, then a physician must recertify as of the 12th day of hospitalization (with subsequent recertifications required at intervals established by the IPF's Utilization Review committee on a case-by-case basis, but no less than every 30 days) that the services were and continue to be required for treatment that could reasonably be expected to improve the patient's condition, or for diagnostic study, and that the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel. In addition, the hospital records should show that services furnished were intensive treatment services, admission or related services, or equivalent services...


3. Medicare General Information - Eligibility and Entitlement Chapter 4

10.9 - Inpatient Psychiatric Facility Services Certification and Recertification

The requirements for physician certification and recertification for inpatient psychiatric facility services are similar to the requirements for certification and recertification for inpatient hospital services. However, there is an additional certification requirement. In accordance with 42 CFR 424.14, all IPFs (distinct part units of acute care hospitals, CAHs, and psychiatric hospitals) are required to meet the following certification and recertification requirements.

At the time of admission or as soon thereafter as is reasonable and practicable, a physician (the admitting physician or a medical staff member with knowledge of the case) must certify the medical necessity for inpatient psychiatric hospital services. The first recertification is required as of the 12th day of hospitalization. Subsequent recertifications will be required at intervals established by the hospital's utilization review committee (on a case-by-case basis), but no less frequently than every 30 days.

There is also a difference in the content of the certification and recertification statements. The required physician's statement should certify that the inpatient psychiatric facility admission was medically necessary for either (1) treatment which could reasonably be expected to improve the patient's condition, or (2) diagnostic study.

The physician's recertification should state:
1. That inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either:
a. Treatment which could reasonably be expected to improve the patient's condition;
b. Diagnostic study;

2. The hospital records indicated that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services, and

3. Effective July 1, 2006, physicians will also be required to include a statement recertifying that the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel.

For convenience, the period covered by the physician's certification and recertification is referred to a period during which the patient was receiving active treatment. If the patient remains in the hospital but the period of "active treatment" ends (e.g. because the treatment cannot reasonably be expected to improve the patient's condition, or because intensive treatment services are not being furnished), program payment can no longer be made even though the patient had not exhausted his/her benefits. Where the period of "active treatment" ends, the physician is to indicated the ending date in making his recertification. If "active treatment" thereafter resumes, the physician should indicate, in making his recertification, the date on which it resumed...

Medical Record Review:

1. PI # 2 was admitted to the Geri-psychiatric unit of the facility on 9/2/17 with diagnosis of Schizoaffective disorder, Bipolar type.

Review of the medical record on 9/12/17 revealed no documentation the Initial Certification and Recertification was completed or signed by the psychiatrist.

An interview was conducted on 9/12/17 at 10:23 AM with Employee Identifier (EI) # 2, Clinical Nurse Supervisor/Interim Director of Geriatric Psychiatric unit, who verified the above findings.

2. PI # 3 was admitted to the Geri-psychiatric unit of the facility on 8/22/17 with diagnoses including Major neurocognitive disorder with psychosis and behavioral disturbance and a history of schizophrenia.

Review of the medical record on 9/12/17 revealed no documentation the Initial Certification and Recertification was completed or signed by the psychiatrist.

An interview was conducted on 9/12/17 at 10:23 AM with EI # 2, who verified the above findings.

Based on review of medical records and interview with staff, it was determined medical record documentation was not dated, incorrectly dated or incomplete for 2 of 2 patient records reviewed who were admitted to the geri-psychiatric unit. This affected Patient Identifier (PI) # 2, PI # 3 and has the potential to affect all psychiatric patient records.

Findings include:1. PI # 2 was admitted to the geri-psychiatric unit of this facility on 9/2/17 with Schizoaffective disorder, bipolar type on 9/2/17.

Review of the medical record revealed 3 Special Observation List, in which staff document observations every 15 minutes were undated.

Review of the medical record revealed (1) one Special Observation List was dated 9/1/17 (day before patient was admitted).

Review of the Special Observation List dated 9/3/17 revealed no documentation of the patient's location, behavior or intervention 5:45 AM to 6:45 AM.

An interview was conducted on 9/14/17 at 9:50 AM with Employee Identifier (EI) # 1, Chief Nursing Officer, who verified the above findings.

2. PI # 3 was admitted to the geri-psychiatric unit of this facility on 8/23/17 with Major neurocognitive disorder with psychosis and behavioral disturbance and a history of chronic Schizophrenia.

Review of the medical record revealed 3 Special Observation List, in which staff document observations every 15 minutes were undated.

Review of the Special Observation List dated 8/26/17 revealed no documentation of the patient's behavior or interventions at 5:00 PM, 5:15 PM and 5:45 PM.

Review of the Special Observation List dated 8/30/17 revealed no documentation of the patient's behavior or interventions at 10:00 AM.

The surveyor reviewed the Special Observation List dated 8/31/17, which the surveyor was unable to determine the patient's location and behaviors from 7:00 PM to 6:45 AM (9/1/17).

Review of the Special Observation List dated 9/6/17 revealed the staff person documented, "Outside" from 6:00 PM to 6:45 PM. There was no documentation of the patient's location, behavior or interventions.

An interview was conducted on 9/14/17 at 9:40 AM with EI # 1, who verified the above findings.

Based on observation and interview with Laboratory (Lab) staff, it was determined the Lab improperly stored personal food in the blood specimen storage refrigerator, and failed to dispose of outdated and opened supplies.

This has the potential to negatively affect all patients visiting this facility's laboratory.

Findings include:

1. During a tour of the Lab storage room on 9/12/17 at 1:28 PM, the following items were observed in the blood specimen storage refrigerator:

a. An employee's salad and unwrapped fork.
b. 2 bottles of water in the freezer of same refrigerator.

2. A tour of the Outpatient Lab Drawing Room was conducted on 9/12/17 at 1:50 PM. The following items were observed in the exam table drawer:

a. Purell Hand Sanitizer refill bag, one liter, expiration date October 2014.
b. (4) 60 cubic centimeters (cc) syringes out of sterile packaging.
c. (1) 60 cc irrigation syringe out of sterile packaging.

During an interview on 9/12/17 at 1:55 PM, with Employee Identifier (EI) # 13, Medical Technologist, the above findings were confirmed.

Based on a tour of the dietary area, The United States Public Health food Code 2013 regulations, facility policy and procedure, observations and interviews it was determined the Dietary Department failed to ensure the food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients served by the hospital.

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...

Title: Proper Labeling and Storage of Food Item
Revised date: 3/17

Policy:
...The following labels will be used in the Dietary Department to ensure the quality and safety of the food items: Dated Opened, Use First, Expiration Dates, Item Date Prepared.

All items when opened, prepared, or made in house shall have a label placed on the package or box as follows using the above labels:

Date Opened - this date will be placed on any and all items when an item is opened to be used for the first time. The label will be applied and the date the item was opened will be written on the label the day it is opened. This applies to all items used in the kitchen and Cafeteria area.

Use First - this label will be placed on all packages that have been opened and all the product was not used. This is to signify that this item should be used completely before opening another bag, box, or container of like item.

Expiration Date - All opened items or in house made items will have an expiration date label placed on the item if the original package does not have a printed expiration date on the package...

During a tour of the dietary department on 9/12/17 at 12:30 PM with Employee Identifier (EI) # 3, Dietary Manager, the surveyor observed in the dry storage area the following items:

1- full bin of animal cookies with no expiration date
1 - bin with 6 - 1 pound bags of Vanilla Wafers with no expiration date
1/2 - bin individually wrapped graham crackers with no expiration date
13 - 5.7 ounce packs of onion soup mix with no expiration dates
12 - 3.35 ounce packs of Ranch dressing with no expiration dates
12 - packs of potato flakes with no expiration dates
10 - 16 ounce packages of crumbled bacon bits with no expiration dates
1 - opened large bag of noodles with no open date and not sealed after opening
1 - 1/2 of a 5 pound bag macaroni opened with no open date
1 - 1/2 of a 5 pound bag of rice opened and no open date
1 - 12 of a 5 pound bag of noodles opened and no open date
8 - 12 ounce bottles of honey with no expiration dates
8 - 9 ounce packs of taco seasoning with no expiration dates
6 - cans of cranberry sauce with no expiration dates
2 - 1 gallon Cattlemen's BBQ sauce with no expiration date
1- 1/2 bag of Breaded Chicken in the freezer with no open date
Approximately 60 - 1 gallon cans of fruits and vegetables on the shelf with no expiration dates.

An interview was conducted on 9/12/17 at 1:30 PM with EI # 3 who confirmed the above mentioned findings and stated he/she never knew all the items need expiration dates.

Based on observations, review of the policies and procedures, Centers for Disease Control and Prevention (CDC) guidelines and interviews, it was determined the facility failed to ensure the staff followed infection control guidelines for hand hygiene, gloves and preparation of injectable medications. This did affect Patient Identifier (PI) # 11, # 12, # 15 and # 13 had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Hand Hygiene
Date Revised: 1/14

Policy:

Hand hygiene is considered the single most import procedure for preventing healthcare acquired infections.

Employees should wash their hands to prevent the spread of infections:

... Before and after direct patient contact
Before gloving
After removing gloves
... After contact with blood, body fluids, mucous membranes, non-intact skin, and wound dressing
... Before handling medication or food.

********

CDC Guideline for Hand Hygiene in Health-Care Settings
October 25, 2002 / 51(RR16);1-44

Gloving Policies

CDC has recommended that HCWs wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another... The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood.


CDC Injection Safety

Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections

Medication Preparation Questions

How should I draw up medications?
Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.

********

1. An observation was conducted on 9/12/17 at 10:50 AM to observe Employee Identifier (EI) # 4, Registered Nurse in Intensive Care Unit (ICU) administer Intravenous (IV) medication to Patient Identifier (PI) # 11. EI # 4 removed his/her gloves without performing hand hygiene as directed per the facility policy.

2. An observation was conducted on 9/12/17 at 2:55 PM to observe EI # 5, RN Acute Dialysis, prepare the dialysis machine for PI # 12. EI # 5, removed his/her gloves, placed the wadded gloves in his/her hands and left the room without performing hand hygiene as directed per the facility policy.

3. An observation was conducted on 9/13/17 at 8:36 AM to observe a Colonoscopy on PI # 15 in OR (Operating Room) # 4. EI # 7, Medical Doctor (MD), completed the procedure and removed his/her gloves without performing hand hygiene as directed per the facility policy.

An interview was conducted on 9/14/17 at 2:30 PM with Employee Identifier # 1, Chief Nursing Officer (CNO), who verified the aforementioned findings.



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4. An observation was conducted on 9/12/17 at 11:04 AM, to observe EI # 11, RN, perform wound care on PI # 13. EI # 11, RN, placed pad under the patient's bottom and folded patient's gown back. She then removed gloves and left the room to retrieve supplies, without performing hand hygiene. After cleaning the draining wound with soap and water, she removed the cover of the irrigation set, and placed it on the over bed table with her contaminated gloved hand. After packing the wound, she used a contaminated, gloved hand to set the bottle of packing gauze on the over bed table. Following the procedure, she removed her gloves and did not perform hand hygiene. She picked up contaminated packing gauze and placed it in the bath basin, and labeled irrigating solution with ungloved hands and no hand hygiene. EI # 11, RN failed to clean the over the bed table with any disinfectant.

During an interview on 9/14/17 at 9:40 AM, the above findings were reported to EI # 1, CNO.

5. An observation was conducted on 9/13/17 at 8:36 AM, to observe a colonoscopy on PI # 15. The procedure took place in Operating Room # 4. During the entire procedure, EI # 6, CRNA (Certified Registered Nurse Anesthetist), never wore gloves while touching the patient and administering anesthesia. The surveyor observed the CRNA draw up medication from 3 different vials. On 2 out of 3 vials used, he failed to clean the septum with alcohol before inserting the needle. The CRNA was observed performing hand hygiene one time during the entire procedure.

Following the procedure, at 8:59 AM, the surveyor observed EI # 6, CRNA, place the needle back on the syringe containing unused Propofol, and place it in his pocket. The surveyor observed the CRNA and RN dispose of the medication in the PACU (Post Anesthesia Care Unit).

Following the procedure, the surveyor observed EI # 12, Surgical Technologist, remove her gloves, then remove her contaminated disposable gown with ungloved hands and leave the room without performing hand hygiene.

During an interview on 9/13/17, at 10:00 AM, with EI # 6, CRNA, the above findings were confirmed. The CRNA stated, "I never wear gloves during a procedure, I can assess the patient better."

Based on review of facility policy and procedures, CDC guide lines, observations and interview with the staff it was determined the facility failed to ensure the staff followed the facility policy and procedure for proper hand washing and glove changes. This had the potential to negatively affect all patients served by the facility.

Facility Policy: Hand Hygiene
Date Revised: 1/14

Policy:

Hand hygiene is considered the single most import procedure for preventing healthcare acquired infections.

Employees should wash their hands to prevent the spread of infections:

... Before and after direct patient contact
Before gloving
After removing gloves
... After contact with blood, body fluids, mucous membranes, non-intact skin, and wound dressing
... Before handling medication or food.

CDC Guideline for Hand Hygiene in Health-Care Settings
October 25, 2002 / 51(RR16);1-44

Gloving Policies

CDC has recommended that HCWs (Health Care Workers) wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another... The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood.

Policy: Dress Code
Revised Date: 3/17

General Guidelines:

...Aprons will be worn at all times while on duty in the Kitchen or Serving Area. Aprons will be removed when leaving the above areas.

1. On 9/12/17 at 11:25 AM in the dietary area the preparation of food and plating was observed. During the preparation of the patients' lunch plates Employee Identifier (EI) # 9 was observed removing his/her gloves opened up the microwave and checked the food being warmed. After checking the food EI # 9 donned a clean pair of gloves without washing or sanitizing his/her hands.

EI # 14 was observed obtaining supplies with gloved hands for the process of plating of the food. EI # 14 removed gloves and donned a clean pair of gloves without washing or sanitizing hands.

EI # 9 placed a plate in the microwave with gloved hands, closed the microwave door and used the touch pad to start the microwave. EI # 8 then continued to plate food for the patients without removing his/her gloves and washing or sanitizing hands and donning a clean pair of gloves.

EI # 9 obtained pureed foods and placed them in the microwave with gloved hands, used the touch pad on the outside of the microwave to start the food. When the food was ready EI # 9 then removed the food from the microwave and opened each package and placed them on a plate all with the same gloves on. EI # 9 failed to remove gloves after touching the outside of the microwave, wash hands and don new gloves prior to removing the food from the microwave and placing on a plate.

After the completion of plating the plates were placed on a cart and EI # 14 exited the Dietary area with the cart and failed to remove his/her apron prior to exiting.

On 9/12/17 at 1:30 PM cleaning of the dishes and placing in dishwasher was observed by the surveyor. EI # 14 prepared the dishes by scraping all left over food off each plate. When complete EI # 14 removed gloves and donned clean gloves without washing or sanitizing hands. EI # 10 then donned gloves to assist with loading of the dishwasher and EI # 10 failed to wash or sanitize hands prior to donning clean gloves.

At approximately 1:45 PM, EI # 14 opened the dishwasher and removed a tray which became lodged in the dishwasher, removed gloves and dried hands on his/her apron and without washing or sanitizing hands donned a clean pair of gloves.

An interview was conducted on 9/14/17 at 11:00 AM with EI # 1, Chief Nursing Officer, confirmed the above mentioned findings.

2. On 9/13/17 at 8:50 AM the surveyor was on the Medical Surgical area on 3rd floor completing observations. The surveyor observed Respiratory Therapy performing a breathing treatment in a patient room. EI # 15, Respiratory Therapist, walked into the patient's room donned gloves and gave the patient a breathing treatment. EI # 15 failed to wash or sanitize hands prior to donning gloves.

An interview was conducted on 9/14/17 at 10:55 AM with EI # 1 who confirmed the above mentioned findings.

Based on observation, OR (Operating Room) Log Book, Temperature and Humidity Logs and interview with staff, it was determined the facility failed to ensure:

a) Refrigerators containing anesthesia medications were secured and locked in the Anesthesia Storage Room.

b) Temperature and Humidity Logs were monitored in the operating rooms on days procedures were performed.

Findings Include:

1. A tour of the Surgery Department was conducted by the surveyors on 9/13/17 at 9:15 AM with Employee Identifier (EI) # 6, the Certified Registered Nurse Anesthetist (CRNA). The surveyor's observed a room in the main hallway labeled, "Anesthesia Storage Room". The door to the storage room was unlocked.

Further observation of the Anesthesia Storage Room revealed an unlocked refrigerator containing 10 doses of Succinylcholine 200 mg (milligrams).

An interview was conducted on 9/13/17 at 9:20 AM with Employee Identifier (EI) # 6, the Certified Registered Nurse Anesthetist (CRNA), who confirmed the aforementioned findings.

2. A review of the OR Log Book and the Temperature and Humidity Logs were conducted by the surveyors on 9/13/17 at 3:30 PM for July and August 2017. There was no documentation the Temperature and Humidity was monitored on the following dates that procedures were performed:

July:
7/14/17: OR # 2
7/16/17: OR # 4
7/19/17: OR # 1, # 2, # 4
7/27/17: OR # 1, # 2
7/28/17: OR # 1, # 2

August:
8/1/17: OR # 2
8/13/17: OR # 2
8/19/17: OR # 1, # 2

An interview was conducted on 9/14/17 at 9:45 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO), who verified the aforementioned findings. EI # 1 stated staff should monitor the temperature and humidity daily when cases occur.

Based on review of facility policy, medical record and interviews, it was determined the facility failed to demonstrate evidence of an ongoing activities program with scheduled activities to promote quality of life for patient's admitted to the swing-bed program. This affected 1 of 1 swing bed patient record reviewed, including Patient Identifier (PI) # 22 and has the potential to affect all patient's admitted to the facility's swing-bed program.

Findings include:

Facility Policy: Swing Bed Program
Effective date: 6/1/2014

Purpose: Medical Center Barbour's Swing Bed Program is to provide rehab or extended medical stay to patients requiring care post the acute care admission.

Procedure:

Plan:

Any inpatient room may be used for swing bed care. Medical Center Barbour is licensed for five (5) swing beds. A swing bed admission is short term extended care stay covered by Medicare, some private/commercial insurances and in some cases, private pay...

Activities:

... Activity Plans and goals will be established to meet the needs and interest of the patient; to encourage self-care, to resume normal activities and to maintain an optimal level of psychosocial functioning...

An interview was conducted on 9/14/17 at 11:00 AM with Employee Identifier (EI) # 8, Activities Coordinator. When questioned about a schedule of activities for swing bed patients, EI # 8 stated he had not completed an activities calendar for swing bed patients for the months of August and September 2017.

An interview was conducted on 9/14/17 at 11:10 AM with PI # 22. When the surveyors asked the patient about recreational activities provided by the hospital. PI # 22 stated, "That's a great idea for them to provide activities for patients on swing bed. It gets really boring here staying for so long in a hospital. PI # 22 stated, "They have magazines on a bookcase/table."

A second interview was conducted on 9/14/17 at 11:30 AM with EI # 8. During this interview, the surveyors asked about the activities for swing bed patients. He stated that he finds out things the patient is interested in doing and "goes from there... If the patient likes to read, then we offer things for the patient to read." When questioned when this takes place, EI # 8 stated the nurses usually provide reading material for the patients.




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1. PI # 22 was admitted to the facility's swing-bed program on 9/3/17, with the diagnosis of Right Total Knee Arthroplasty.

Review of the medical record (MR) revealed an activities plan developed by EI # 8, Activities Coordinator, on 9/7/17 with the following Initial Treatment Plan: "...will encourage participation in activities 5 x/week (5 times per week), in order to increase motivation, socialization and physical functioning."

Further review of the MR revealed a Swing-Bed Care Plan developed by EI #11, RN (Registered Nurse), on 9/3/17, with the following intervention listed: "Activity offered BID (twice a day)."

A review of the MR revealed 17 documented "SB (Swing-Bed) Activity Offered" Patient Assessment Reports. 16 reports included Magazine, Television or Newspaper as the activity offered to the patient, with 3 of the 17 reports included offering "puzzles or games." One of 17 reports stated the patient is out of the room with physical therapy.

There was no documentation in the MR that EI # 8 participated in any activities with the patient, and failed to develop any plans to provide increased motivation, socialization, and physical functioning, as stated in his Initial Treatment Plan.

During an interview on 9/14/17 at 11:25 AM, with EI # 8, the above findings were confirmed.