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Based on review of facility policy, observations, and interviews it was determined, the biomedical staff failed to perform preventive maintenance (PM) per policy. This had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy
Subject: Biomedical Engineering Services Policies & Procedures Manual
Revision Date: 3/29/18

1.5 Planned Maintenance:
Planned Maintenance events are scheduled procedures performed on clinical devices that are in the BES (Biomedical Engineering Services) Clinical Equipment Management Program. Standardized terms for planned maintenance activities consist of Preventive Maintenance and Safety Inspections...

All Planned Maintenance require updating the Planned Maintenance inspection sticker (annual color change) which will include the Date (month/Year) of the inspection, the inspector's Initials and a reinspect date (month/year) that is the PM work order due date plus the devices' PM Frequency, i.e. if PM work order due date is January, and the PM frequency is 6 months, the Reinspect date is July of the same year...

1.5.2 Planned Maintenance Intervals:
Planned maintenance is scheduled by department and/or equipment type at intervals..."

1. A tour of the Respiratory Department was conducted on 6/26/18 at 2:10 PM with Employee Identifier (EI) # 5, Certified Respiratory Therapist. The surveyor asked EI # 5 how often was equipment inspected. EI # 5 response was, "Annually."

The surveyor observed the 2 room humidifiers labeled with the sticker "Next PM due Jan 2017"

In an interview conducted on 6/28/18 at 8:30 AM with EI # 5 confirmed all electrical equipment had not been inspected annually.



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2. A tour of the Emergency Department was conducted on 6/27/18 at 8:40 AM with EI # 9, Emergency Room Director. The surveyor observed the following:

Exam rooms # 1, # 2, # 3, # 4, # 5, and # 6:

Gentec Adult continuous Vacuum regulators had no documented PM performed.

Exam rooms # 2 and # 5:

There was no documented PM on the Cardiac and Vital Sign Monitor.

Triage Room:

The patient scale and a Mindray blood pressure machine PM stickers had a next due PM date documented as January 2018.

An interview was conducted on 6/27/18 at 9:34 AM with EI # 9. The surveyor asked EI # 9 how often should the equipment in the Emergency Department have PM performed and documented? EI # 9 stated, annually. EI # 9 confirmed the above findings.

Based on review of medical records, policies and procedures, and interviews the facility failed to ensure:

1. The physician completed a History and Physical on all patients per facility policy.

2. The physician signed, dated and timed all orders per facility policy.

This affected 4 of 20 medical records (MR) reviewed including Patient Identfier (PI) # 15, # 1, # 6 and # 7 and had the potential to negatively affect all patients served by the facility.

Findings include:

Title: Section I. Admission and Discharge:

"... Section II. Medical Records

Choctaw General Hospital utilizes an electronic medical record (EMR) system. All information relating to a patient's admission to or encounter at Choctaw General Hospital will be entered exclusively into the electronic medical record. All entries into the medical record shall be legible. All information shall be placed into the record either by dictation/ transcription or by direct, typed entry. Handwritten notes are not acceptable unless the entire EMR system is offline.

A. Complete Medical Record: The attending practitioner shall be responsible for the preparation of a complete medical record for each patient ... The medical record shall contain at least the following:

... 3. The record and findings of the patient's assessment, including but not limited to the medical history of the patient and the report of a relevant physical examination...

13. Each medication ordered or prescribed for any inpatient...

C. History and Physical: A history and physical must be performed by a practitioner who has been granted privileges to do so within 30 days prior to, or within 24 hours after, inpatient admission or registration ... inpatient history and physical examination must be validated and countersigned by a licensed independent practitioner with appropriate privileges unless State and Federal (including Medicare/Medicaid) laws/regulations allow the Allied health professional to sign solely and bill for the history and physical. For all admissions the medical record shall show evidence that a complete history and physical examination has been placed in the electronic medical record within 24 hours of admission. This report shall include a medical history of the patient and the current physical assessment...

K. Orders for Treatment:

... All verbal orders shall be entered, dated and timed by an appropriately authorized person... The person receiving the order shall read back the order to the practitioner to validate accuracy in transcribing. The responsible practitioner shall authenticate such orders by their signature with date and time in accordance with Section II (Y): Timeliness of Completion of Records..."

Facility Policy and Procedure
Subject: Verbal and Telephone Orders
Revision Date: 3/20/18

"Purpose
To improve communication among caregivers when receiving verbal or telephone orders...

The orders must be written clearly, legibly, and completely...the verbal order shall be authenticated within fifteen (15) days following the entry of the order, by the responsible practitioner/ physician by signing legibly with time and date..."

******

1. PI # 15 was admitted to the facility on 5/7/18 with a diagnosis including Generalized Weakness.

Review of PI # 15's MR on 6/27/18 revealed the following Physician's Orders:

1. Ensure 1 can BID (2 times a day), to help meet nutritional needs until appetite improves, dated 5/8/18.

2. Ativan 1 mg (milligram), one PO (by mouth), BID, PRN (as needed) for mild agitation, dated 5/10/18.

3. Ativan 1 mg, IM (intramuscular), BID, PRN for severe agitation dated 5/10/18.

The Registered Nurse (RN) signed, dated, and timed the verbal orders on 5/8/18 and 5/10/18. The physician failed to authenticate the verbal orders by documenting his/her signature, date, and time on the above orders per facility policy.

An interview was conducted on 6/28/18 at 1:49 PM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the above findings.

2. PI # 1 was admitted to the facility on 5/8/18 with a diagnosis including Diabetic Ketoacidosis.

Review of PI # 1's MR on 6/27/18 revealed a Physician's Restraint / Seclusion Orders dated 5/8/18 at 8:20 PM by the RN. The physician failed to authenticate PI # 1's restraint / seclusion order by not documenting the date and time on the order per facility policy.

An interview was conducted on 6/28/18 at 1:58 PM with EI # 1, who confirmed the physician should have documented the date and time on the restraint / seclusion form.

3. PI # 6 was admitted to the hospital on 6/25/18 with a diagnosis including Dehydration.

Review of PI # 6's MR on 6/27/18 revealed a dictated History and Physical (H & P) dated 6/25/18. The physician left blank spaces for his/her signature, date, and time on PI # 6's history and physical. The physician failed to authenticate PI # 6's H & P by not documenting his/her signature, date, and time per facility policy. Further review revealed the physician failed to complete the H & P examination within 24 hours of admission per facility policy.

Review of PI # 6's MR revealed a Physician's Order to transfer PI # 6 to another healthcare facility. The RN signed, dated, and timed the verbal order on 6/26/18. The physician failed to authenticate the transfer order by documenting the date and time on order per facility policy.

An interview was conducted on 6/28/18 at 1:55 PM with EI # 1, who confirmed the above findings.



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4. PI # 7 was admitted to the swing-bed unit on 5/25/18 with diagnoses including Chronic Diabetes Mellitus Left Foot Ulcer.

Review of the MR conducted on 6/27/18 revealed the H & P was completed by the physician on 6/1/18 (7 days) after admission to the swing bed unit.

Further review of the above mentioned H & P revealed no documentation the patient had a Peripherally Inserted Central Catheter (PICC) on admission to the facility.

The physician failed to perform and document a complete H & P within 24 hours of being admitted to the facility.

In an interview conducted with EI # 2, Swing Bed Coordinator, on 6/27/18 at 4:10 PM, the above findings were confirmed.

5. During a tour of the medical record department conducted on 6/27/18 at 9:30 AM with EI # 3, Medical Records Director, the surveyor observed a folder of physician's orders that were not completed per policy.

The folder contained physician's orders that were signed and there was no date or time documented when the physician signed the orders.

Further review of the folder revealed physician verbal orders that were written for the dates of 11/8/17 to 4/26/18 and signed by the physician. There was no date and time documented the physician signed the verbal orders.

In an interview conducted on 6/28/18 at 8:30 AM, EI # 3 confirmed the above findings.

Based on the review of facility policies, observations, and interviews it was determined the staff failed to ensure:

a) All medications were locked in the Respiratory Department.

b) All medication vials were labeled with the date opened in the Rehabilitation Department.

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

Findings include:

Facility Policy
Subject: Security of Staff and Medications
Policy No: 20-01
Effective Date: 3/15/18

Policy
"Security of the pharmacy and medication storage areas... Medications are secured so that unauthorized personnel can not obtain access (locked or under constant surveillance)...

Medications may be accessible only to authorized personnel..."

Facility Policy
Subject: Infection Control: Multiple- Dose Sterile Medications
Policy No: 21-06
Effective Date: 3/15/18

Policy
"Multiple-dose sterile medications (e.g. vials) shall be used ... using Centers for Disease Control (CDC) Safe Injection Practices...

Use of Multiple- Dose Vials

CDC...recommend use of a multiple dose vial for a single patient...and recommend that opened or punctured multiple dose vials be used for no more than 28 days...

The healthcare professional first puncturing the vial must place the beyond-use date on the vial..."
******

1. A tour of the Respiratory Department was conducted on 6/26/18 at 2:10 PM with Employee Identifier (EI) # 5, Certified Respiratory Therapist. The surveyor asked EI # 5 if there were any medications available for patient use in the Respiratory Department?

EI # 5's response, "We only have respiratory medications." The surveyor observed an unlocked cabinet that contained the medications including Albuterol Nebulizer's (nebs), Atrovent nebs, Zopenex, and Duoneb's.

At 2:40 PM the surveyor observed EI # 5 leave the respiratory department and the door was left open.

In an interview conducted on 6/28/18 at 8:30 AM, EI # 5 confirmed the medications were not in a locked cabinet.

2. An observation of the rehabilitation (rehab) unit was conducted on 6/27/18 at 11:55 AM with EI # 7, Physical Therapist.

The surveyor asked EI # 7, "Does the rehab unit have medications available for patient use?" EI # 7 obtained the key for lock box and upon opening the lock box revealed an open vial of Dexamethasone 20 milligrams (mg) / 5 milliliters (ml). The vial was not labeled with the date opened.

In an interview conducted on 6/28/18 at 9:40 AM, EI # 7 confirmed the above findings.

Based on the review of facility policies and procedures, observations, and interviews, it was determined the staff failed to ensure:

a) All refrigerated foods were labeled per policy.

b) All refrigerated foods were disposed of after 4 days.

c) All frozen foods were disposed of with in 6 months.

d) Food Temperature Logs were completed.

Findings include:

Facility Policy and Procedure
Subject: Food Temperatures
Effective Date: 11/29/2007

"Policy: All foods served to patients shall maintain palatable meal temperatures and be protected against contamination.

Procedure:...

2. All potentially hazardous food, when placed on display for services, shall be kept hot or cold as required...

3. Temperatures of food items are taken and recorded at the beginning of each meal service and every 2 hours if the food is displayed for greater than a 4 hour period.

4. Temperatures of food will be taken by shift supervisor and recorded..."

Facility Policy and Procedure
Subject: Food Service
Effective Date: 11/29/07

"Policy: Food served to patients is palatable, attractive, and at the proper temperature.

Procedure:...

1.d. If served hot, the holding temperature of such food shall be kept at 140 degrees Fahrenheit or above...

2. b. Leftovers must be stored in the refrigerator...and be utilized within a 4 day period..."
******

1. A tour of the dietary department was conducted on 6/26/18 at 11:05 AM with Employee Identifier (EI) # 4, Dietary Manager, and the surveyor observed the following:

Walk In Cooler

1- 30 gallon (gal) covered trash can labeled Tea 6/21/18. The surveyor asked EI # 4, how long food items should be stored before discarding. EI # 4 response was "5 days. We go though so much tea, we take it from here (the can) and put in other containers."

2- large (lg) plastic trays of cooked rice and labeled 6/27/18 (tomorrow's date). The surveyor asked EI # 4, about labeling food for a future date. EI # 4 response was, "I guess they mis-labeled it. It should have been labeled today."

1- gal container of hot sauce was not labeled with the date opened.

1- gal container of BBQ sauce was opened and not labeled.

1- 5 pound (lb) container of sour cream was opened and not labeled.

Walk In Freezer

The following plastic ziplock bags were not labeled with contents or the date opened:
1- package (pkg) of breaded mushrooms
1- pkg of corn nuggets

The following plastic containers were not disposed of per policy.
1- gal meat sauce with the date of 9/18/17.
1- gal chicken pot pie with the date of 12/5/17.
2- small bowls labeled Corn Chowder with the date of 3/10/18.

Prep Refrigerator

3- gal size Ziplock plastic bags of French Toast not labeled with contents or date opened.

2- gal size Ziplock plastic bags of English Muffins.

The surveyor asked EI # 4, "When was the French Toast and English Muffins removed from the freezer and placed in the refrigerator?" EI # 4 ask the dietary staff, and their response was, 'I think yesterday'.

The dietary staff failed to store, label, and date food per policy.

During the tour of the dietary department on 6/26/18 at 11:05 AM, a review of the Food Temperature Logs for May and June was conducted and revealed staff failed to document the time each of the food temperatures were taken from May 1- June 30.

The dietary staff failed to complete Food Temperature Log documentation per policy.

In an interview conducted on 6/26/18 at 3:10 PM, EI # 4 confirmed the above findings.

2. On 6/27/18 at 10:40 AM the surveyor returned to dietary department and observed in the walk in cooler:

1- 5 lb container of sour cream opened and not labeled with the date opened.

1- gal plastic container with the labeled "Soup 12/17/17" (greater than 6 months old)

In an interview conducted on 6/27/18 at 11:45 AM with EI # 4, confirmed the staff failed to use or discard food with in 6 months, and prepare and labeled foods per policy.

Based on the review of policies and procedures, medical records (MR), observations and interviews with administrative staff, it was determined the nurse failed to:

1. Assess and measure wounds and surgical sites per policy.

2. Ensure complete physician orders were obtained for wound and Peripheral Inserted Central Catheter (PICC) care.

3. Document how wound and PICC line care was performed.

4. Perform hand hygiene and infection control practices per policy.

This affected 1 of 1 records reviewed with a PICC line and 2 of 2 records with wounds. This affected Patient Identifier (PI) # 7 and # 8, had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy and Procedure
Subject: Handwashing and Hand Hygiene
Revised Date: 3/20/18

"Outcome:

To prevent the direct or indirect spread of organisms...

2. Handwashing must be done before and after each procedure in patient care and after handling contaminate material and equipment...

5. Dry hands and arms with paper towel. Turn off faucet with the same towel. The faucet is considered contaminated...

Hand Hygiene/ Use of Hand Degermers...

f. Wash their hands after removing gloves."

Facility Policy and Procedure
Subject: Isolation Precautions
Revision Date: 9/20/17

Purpose or Scope: Early recognition and precautions in place.

Procedure: Standard precautions are the foundation of all precautions to prevent transmission of infectious agents...

Contact Precautions: ... known or suspected to be infected or colonized ... that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces...

2) Gloves and Handwashing:... During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (... wound drainage). Remove gloves... wash hands...

5) Patient-Care Equipment... If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient..."

Facility Policy and Procedure
Subject: PICC Lines
Revised Date: 5/16/18

Purpose:

"The purpose of this policy is to offer direction...

Care of PICC (Dressing Change): Change after initial 24 hours then every 3 days.

Supplies: Surgical dressing kit, Sterile Gloves,...

10. Clean insertion site in a circular motion starting at insertion and working outward with Chloraprep (do not use alcohol).
11. Allow the area to dry
12. Cover area with a sterile transparent dressing...
16. Document response to procedure, care of line, and condition of site..."

Facility Policy and Procedure
Subject: Pressure Ulcer Prevention/ Intervention
Revised Date: 5/16/18

Scope: All patients

General Assessments, Documentation, Consultations, and Discharge Planning
- The RN (Registered Nurse) assesses and evaluates the patient for alteration in skin integrity and circulatory impairments on admission and every shift...

Procedure: Initial Assessment Upon Admission
-An initial skin assessment shall be performed by the Registered Nurse (RN) and documented on the Nursing Admission Database Form...
- Description of existing wounds...

Reassessments
- Every 12 hours and as needed (PRN)...

Wound Cleansing Solutions
- Cleansing optimizes wound healing and decreases potential for infection
- Use as ordered by the Physician...

Wound Measurements:
- Nurses shall perform initial assessments
- Length times width times depth is measured in centimeters (cm)...
- Recommendations are: perform weekly..."
*****

1. PI # 8 was admitted to the facility on 6/22/18 with diagnoses including Status/ Post (S/P) Right (Rt) Total Knee Replacement (TKR).

Review of the 6/22/18 Swing Bed Admission Orders revealed wound care/ incision care every 7 days. Clean with sterile saline and cover with silver dressing.

Review of the 6/22/18 nursing admission documentation and skin assessment revealed no documentation the surgical wound was assessed.

In an interview conducted on 6/27/18 at 4:10 PM with Employee Identifier (EI) # 2, Swing Bed Coordinator, the above findings were confirmed.

2. PI # 7 was admitted to the Swing Bed unit on 5/25/18 with diagnoses including Left Chronic Diabetic Mellitus (DM) Foot Ulcer.

Review of the 5/25/18 transferring hospital documentation revealed the patient had a PICC line placed on 5/24/18.

Review of the 5/25/18 admission physician orders revealed wound care orders to change wound VAC (vacuum assisted closure) every Tuesday and Friday.

Further review of the admission physician orders revealed no orders for the care of the PICC line.

Review of the 5/25/18 nursing admission documentation and skin assessment revealed no documentation the left foot wound or PICC line were assessed.

There was no documentation the staff contacted the physician for complete orders for the wound VAC and care of the PICC.

Review of the 5/26/18, 5/27/18, 5/28/18 nursing documentation revealed no documentation of assessments for the left foot wound or PICC.

During an observation of wound care conducted on 6/26/18 at 12:30 PM with EI # 6, Registered Nurse (RN), the surveyor observed contact precaution box on door.

EI # 6 performed hand hygiene, donned gown and 3 pair of gloves and entered PI # 7's room. EI # 6 removed papers from his/her uniform pocket, placed the papers beside the sink. EI # 6 cleaned the scissors with a Santi-Wipe and placed the cleaned scissors on the dirty papers.

EI # 6 then cut the the dirty kerlix and removed the dirty dressing and placed in the open red biohazard box in room.

EI # 6 with the same dirty gloves, opened the bottles of Hibiclens and Normal Saline (NS) and then cleaned the foot, and the wound bed. There was no barrier on the floor and the drainage went directly on the floor. EI # 6 then removed the top pair of gloves and donned clean gloves.

EI # 6 completed the wound care, removed the top pair of gloves, cleaned the scissors with a Santi-Wipe, placed scissors on the counter beside sink and wiped the table and floor with a Santi-Wipe.

EI # 6 removed all gloves, reached in pocket for pen and labeled the patient's wound dressing with bare hands. EI # 6 washed hands with soap and water, then removed the scissors from the sink and replaced scissors to her uniform pocket along with paper instructions.

In an interview conducted on 6/27/18 at 4:10 PM, EI # 1, Director of Nursing confirmed the staff failed to perform hand hygiene and follow infection control practices.

Based on review of medical record (MR), policies and procedures, and interview staff, it was determined the facility failed to:

a) Develop an organized activity program for Swing-Bed patients.

b) Develop and provide Swing-Bed patients an individualized activities care plan with goals.

This affected Patient Identifier (PI) # 7 and # 8, 2 of 2 Swing-Bed records reviewed. This had the potential to negatively affect all patients admitted to Swing-Beds.

The findings include:

Facility Policy and Procedure
Subject: Patient Activities
Revision Date: 4/1/18

"Policy:

The patient may meet with and participate in activities... The purpose of this policy is to provide a schedule of activities to accommodate the individual patient's needs and choices.

Procedure:
1. A patient will be provided a choice to participate in activities...
2. A planned, organized activity program will be developed specifically for each resident in the Swing-Bed program.

Policy:

The Activity Program will be a multi-faceted and based on the assessment of each individual patient's needs, under the direct supervision of a qualified professional...

Procedure:

1. The Activities Director will complete an initial evaluation of the resident's activity needs and preferences. The activity plan (goals) will be documented on the Interdisciplinary Team Care Plan within seventy-two (72) hours of admission.

2. The Activities Program will be designed to:
a. Provide stimulation or solace.
b. Promote physical, cognitive, and emotional health.
c. Enhance the resident's physical and mental status.
d. Promote the resident's self-respect by providing activities that allow for self-expression, personal responsibility and choice.


7. The Activities Director will document in the medical record the following:
a. Activity Assessment.
b. Weekly review of each activity plan (located in the care plan).
c. Weekly progress notes.
d. Activities attendance record."
******

1. PI # 7 was admitted to the Swing Bed on 5/25/18 with diagnoses including Left Chronic Diabetic Mellitus (DM) Foot Ulcer.

Review of the MR was conducted on 6/27/18 at 4:00 PM with Employee Identifier (EI) # 2, Swing-Bed Coordinator. The surveyor requested documentation of PI # 7 individualized activities care plan and documentation of PI # 7's participation in the plan.

EI # 2 stated there was no documentation an individualized care plan had been developed for the patient admitted 34 days ago.

In an interview conducted on 6/27/18 at 4:30 PM, EI # 2 confirmed the above findings.

2. PI # 8 was admitted to the facility on 6/22/18 with diagnoses including Status/ Post (S/P) Right (Rt) Total Knee Replacement (TKR).

Review of the MR was conducted on 6/27/18 at 3:00 PM with EI # 2. The surveyor requested documentation of PI # 8 individualized activities care plan and documentation of PI # 8's participation in the plan.

EI # 2 stated there was no documentation an individualized care plan had been developed for the patient admitted 6 days ago.

In an interview conducted on 6/27/18 at 4:30 PM, EI # 2 confirmed the above findings.

Based on review of facility policies and procedures, temperature log sheets, observations, and interview it was determined, the rehabilitation staff failed to ensure:

a) Temperatures of the paraffin bath and hydrocollator were monitored and documented daily per policy.

b) The paraffin bath and hydrocollator were cleaned per policy.

This had the potential to negatively all patients served by the therapy department.

Findings include:

Facility Policy
Title: Cleaning Procedure for Paraffin Bath
Policy #: 6007
Revision Date: 10/1/15

Policy: The condition of the paraffin bath will be monitored closely and cleaned as necessary:

Procedure:...
2. ... Clean paraffin bath with 70% isopropyl alcohol or agency-approved cleaner...

...Temperature should rise to 113- 122 degree Fahrenheit (F); the temperature of the bath should be monitored daily (see Paraffin Bath Temperature Log)

3. Employee cleaning the paraffin bath should sign and dated the Paraffin Bath Cleansing Schedule."

Facility Policy
Title: Cleaning Procedure for Hydrocollator
Policy # 6006
Revision Date: 10/1/15

"Policy: The Hydrocollator unit will be cleaned every two weeks per manufacturer's recommendations....

10. Monitor temperature rise to 160 to 165 degrees F, the temperature of the Hydrocollator should be monitored on a daily basis (see Hydrocollator Temperature Log).

11. Employee cleaning the unit should sign and date the Hydrocollator Cleaning Schedule."

*****

During a observation of the rehabilitation (rehab) unit conducted on 6/27/18 at 11:55 AM with Employee Identifier (EI) # 7, Physical Therapist, the surveyor requested the temperature logs for freezer, Paraffin, and Hydrocollator.

Review of the Cold Pack Temperature Log Sheet, Paraffin Temperature and Cleaning Record, and the Hydrocollator Temperature and Cleaning Record revealed 19 of 19 temperatures were documented weekly from 2/16/18 to 6/22/18. There was no documentation when the equipment was cleaned.

In an interview conducted on 6/28/18 at 9:40 AM with EI # 7 confirmed the above findings.