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Based on review of departmental policy and procedure manuals and interviews with staff, the facility failed to review the policy and procedure departmental manuals annually and perform blood glucose quality control monitoring. This had the potential to affect all patients served in this facility.

Findings include:

Facility Policy:
Title: Blood Glucose Monitoring
Reference # 2154
(no date)

"...Purpose:
...Quality control assessment shall be completed daily and recorded...
Quality control shall include calibration and quality control check...
When the quality control check falls outside of the expected range, the monitoring device should be cleaned and the test repeated. If values continue to be out of range, the monitoring device shall be replaced..."


During the survey departmental policy manuals to include Radiology, Emergency Department, Dietary Department, Laboratory, Nursing Services and Pharmacy were reviewed. There was no documentation of an annual review.

An interview with Employee Identifier # 1, the Director of Operations, on 2/12/14 at 8:40 AM confirmed no annual policy review was completed.



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During a tour of the nursing unit on 2/12/14 at 8:20 AM, a True Balance capillary blood glucose monitor was observed. The surveyor asked to review the facility quality control log for the True Balance monitor. Employee Identifier (EI) # 6, Licensed Practical Nurse, reported glucometer controls were not being performed.

In an interview conducted 2/12/14 at 8:25 AM, EI # 2, Director of Nursing, confirmed there was no documentation daily glucose monitor controls were performed.

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

Findings include:

During a tour of the Emergency Department (ED) on 2/11/14 at 10:30 AM it was noted the hospital did not have the toll free State Hot Line number posted for patients in the front hospital lobby and emergency entrance waiting area to voice grievances.

An interview with Employee Identifier #1, Director of Operations on 2/12/14 at 1:00 P.M. confirmed the above.

Based on review of medical records, interview and emergency room records it was determined the facility failed to:

1. Document patient specific advance directives and decisions about their advance directives

2. Document education to the patients regarding the right to develop an advance directive.

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


Findings include:

The surveyor reviewed inpatient medical records and emergency room records. The hospital consent form which is signed by patients or family for both inpatient admission and emergency room care has an acknowledgement that the patient was provided Advanced Directive information if desired.

There was no documentation if the patient was asked if they had an Advanced Directive. There was no documentation of an attempt to obtain an Advanced Directive for the staff to be knowledgeable in services the patient wished to have or not have provided while in the facility.

An interview with Employee Identifier #1, Director of Operations on 2/12/14 at 10:00 AM confirmed the above.

Based on the recertification survey conducted on 2/13/2014 and an interview, the facility failed to have an organized, hospital-wide and documented system of quality assessment and performance improvement program. This had the potential to affect all patients served by the facility.

Findings include:

The surveyor requested to see the hospital's Quality Assurance and Performance Improvement (QAPI) program documentation.

An interview was conducted on 2/13/14 at 10:00 AM, with Employee Identifier (EI) # 3, Quality and Risk Manager, staff responsible for the hospital QAPI program. EI # 3 verified the facility does not have an on going hospital-wide quality improvement program.


Refer to A 273 for additional findings.

Based on facility policy and interview, it was determined the facility failed to follow it's policy, perform quality assurance activities to ensure improvement in patient care and evaluate the program effectiveness. This had the potential to affect all patient's served.

Facility Policy:
Title: Continuous Quality Improvement (CQI) Plan
(no date)

" 1. Purpose...to continue evaluating quality and appropriateness of care and clinical performance...
Goals:
...e. To provide documentation...of an ongoing CQI program that includes effective mechanisms for reviewing and evaluating patient care and for appropriate response to finding.

...Necessary Component for Departmental Evaluation...

5. Documentation that reasonably substantiates the effectiveness of the overall program to enhance patient care...

Responsibilities in CQI

1. Governing Body and Chief Executive Officer

...the Governing Body and Administration has approved this CQI plan to be reviewed and revised...to objectively and systematically monitor and evaluate the quality and appropriateness...

5. Evaluation of the CQI Program
...At least annually the plan shall be reviewed, and revised if necessary by the CQI Committee...
The CQI Coordinator will be responsible for preparing a report for annual reappraisal using source documentation..."


An interview was conducted 2/13/14 at 10:10 AM with Employee Identifier (EI) # 3, Quality and Risk Manager. EI # 3 presented the facility Quality Assurance documentation. Review of the 2012 and 2013 documentation failed to include hospital wide integration of data assessment, measurement, tracking and analysis.

There was no evidence the governing board had received the report of annual reappraisal documentation.

On 2/13/14 at 10:50 AM, EI # 1, Director of Operations confirmed staff failed to comply with facility policy for completion of continuous quality improvement activities.

Based on review of personnel files, nursing standard of practice and interview the facility failed to ensure the licensed nursing staff were competent in providing nursing services and had a job description confirming their duties to perform.

In addition this Condition of Participation is not met as evidenced by
failure of the Nursing Service department to:

1. Perform and document patient/caregiver education and notify the physician of changes in a patient's condition. Refer to A 392.

2. Ensure 1 of 3 patients on sliding scale insulin and 2 of 8 patients received their medication as ordered. Refer to A 405

3. Follow the policy for blood transfusions and notify the physician of an elevated temperature. Refer to A 409

4. Reconcile medication orders on admission to swing beds:

a. Document appropriately on the Medication Administration Record (MAR) of self-administered medications

b. Assess accuracy and safe administration of home medications

c. Document an order from the physician allowing self-administration of medications. Refer to A 412

Findings include:

Alabama Board of Nursing Chapter 610-x-6
Standards of Practice

610-x-6-.03 Conduct and Accountability. The registered nurse and the licensed practical nurse shall:

" (1) Have knowledge and understanding of the laws and rules regulating nursing...
(4) Be responsible and accountable for the quality of nursing care delivered to patients based on and limited to scope of education, demonstrated competence and nursing experience.
(5) Be responsible for monitoring and evaluating the quality of patient care delivered by personnel under the individual nurse's supervision..."


Employee Identifier (EI) # 1, the Director of Operations, date of hire 12/2012 per EI # 1. The personnel file failed to have a signed job description provided to the surveyor 2/12/14. The personnel file also failed to include a skills competency.


Employee Identifier # 2, the Director of Nursing, date of hire 8/4/11 failed to have a signed job description in her personnel file provided to the surveyor 2/12/14. The personnel file also failed to include a skills competency review list for nursing.


Employee Identifier # 5, the Emergency Nurse, date of hire 10/18/11 failed to have a signed job description in his personnel file provided to the surveyor 2/12/14. The personnel file also failed to include a skills competency checklist for nursing signed and dated by the employee.


When the surveyor requested job descriptions on the employees a book was provided with the job descriptions for the different types of employment positions, there was no signed job descriptions in the book to demonstrate staff were aware of their job duties.



Refer to A 392, A 405, A 409 and A 412 for findings.




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EI # 11, the Nurse Assistant, date of hire 1/31/06, failed to have a signed job description in her personnel file provided to the surveyor 2/12/14. The personnel file also failed to include a skills competency checklist for nurse aide signed and dated by the employee.

EI # 12, Registered Nurse, Part-time, date of hire 8/3/13, failed to have a signed job description in her personnel file provided to the surveyor 2/12/14. The personnel file also failed to include a skills competency checklist for nursing signed and dated by the employee.

During an interview conducted 2/13/14 at 10:50 AM with Employee Identifier # 1, the Director of Operations, confirmed the above documentation was not provided.

Based on medical record (MR) reviews and interview, it was determined staff failed to perform and document patient/caregiver education and notify the physician of changes in a patient's condition. This affected MR # 4, 1 of 1 patient with a wound and MR # 5, 1 of 8 MR's reviewed. This had the potential to affect all patient's served.

1. MR # 4 was admitted 1/23/14 with diagnoses including Acute Cellulitis Left Great Toe and Diabetes Mellitus.

Review of the 1/23/14 physician admit order included wound care Left First Digit Ulcer. Review of the patient's medication administration record included wound care orders with Santyl to the left great toe twice daily.

MR review revealed the patient was discharged 1/26/14. The patient was to follow up at a wound clinic, 1/28/14 at 8:00 AM, 2 days later.

There was no documentation the patient or caregiver was educated to care for the wound until the scheduled wound clinic appointment.

An interview, conducted 2/13/14 at 9:18 AM with Employee Identifier (EI) # 2, the Director of Nursing, confirmed there was no documented wound care education to the patient or caregiver upon hospital discharge.


2. MR # 5 was admitted 7/8/13 with diagnoses including Fall with Bilateral Hip Injury.

MR review revealed 7/11/13 1:38 AM documentation the patient's blood pressure was 67/48. There was no documentation the physician was notified of the low blood pressure.

There was no documentation staff re-assessed the patient's blood pressure following the 67/48 reading.

Documentation review revealed on 7/11/13 at 4:45 AM the patient was found unresponsive, no spontaneous respirations, no palpable pulses. CPR (cardiopulmonary resuscitation) was started, the physician notified the patient was being coded and the monitor showing asystole.

Documentation revealed all resuscitation measures were discontinued at 4:55 AM.

An interview was conducted on 2/13/14 at 9:19 AM with EI # 2, who confirmed the above findings.

Based on review of medical records and interviews, it was determined staff failed to ensure 1 of 3 patients on sliding scale insulin and 2 of 8 patients received their medication as ordered . This affected Medical Record (MR) # 1 and # 5 and had the potential to affect all patients served by this facility.


Findings include:


1. MR # 1 was admitted to the facility 1/24/14 with diagnoses of Pyelonephritis, Diabetes Mellitus Type II, Urinary Tract Infection and Obesity.

The admission orders included, " Lantus 40 units QHS (every hour of sleep), Regular Insulin Sliding Scale Protocol # 1. Routine Sliding scale, fingerstick bedside blood glucose are to be done before meals and at bedtime if tolerating PO ( by mouth intake).
Blood glucose 151-200 = 3 units
Blood glucose 201-250 = 4 units
Blood glucose 251-300 = 6 units
Blood glucose 301-350 = 8 units. "

The recorded blood glucose 1/24/14 at 9:00 PM = 205, there was no documentation the patient received Regular insulin.

The recorded blood glucose 1/25/14 at 9:00 PM = 330, there was no documentation the patient received Regular insulin.

The recorded blood glucose 1/26/14 at 9:00 PM = 247, there was no documentation the patient received Regular insulin.

The nursing staff failed to administer the Regular insulin as ordered per sliding scale.

In an interview with Employee Identifier # 2, the Director of Nursing on 2/13/14 at 11:00 AM confirmed the nurse did not follow the order for sliding scale insulin.




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2. MR # 5 was admitted 7/8/13 with diagnoses including Fall with Bilateral Hip Injury.

MR review revealed 7/8/13 physician orders for q (every) day Vasotec, Atenolol, Detrol and Clonidine administration. Review of the patient's medication record administration record revealed the 7/10/13, 9:00 AM Vasotec and Atenolol doses were "held". The 7/9/13 and 7/10/13 9:00 AM Detrol doses were "NA" (not available).

Review of the 2012 Pharmacy Services Formulary medication list did not contain Detrol.

An interview was conducted on 2/13/14 at 9:19 AM with EI # 2, who confirmed staff failed to notify the physician medications were not administered as ordered.

Based on review of medical records, policy and procedures and interview it was determined in 1 of 1 blood transfusions administered the facility failed to follow there policy and failed to notify the physician of an elevated temperature. This affected Medical Record (MR) # 6 and had the potential to affect all patients served by this facility.

Findings include:

Policy # 2108: Blood/Blood Components-Transfusion (no date on the policy)

Policy:

" It is the policy of Hill Hospital to have a uniform method of transfusing blood products...
Vital signs shall be taken prior to infusion, 15 minutes after infusion begins and 30 minutes after completion of infusion, then 30 minutes and hourly thereafter..."

Procedure:

" Obtain baseline vital signs. report abnormal to physician..."

Medical Record Findings:

1. MR # 6 was admitted to the facility 1/23/14 with a diagnoses of Chronic Microcyticanemia, Lymphocytic Leukemia and Bronchitis.

The physician's orders dated 1/23/14 included type and crossmatch for 4 units of PRBC's (Packed Red Blood Cells) and administer. The patient also had orders for Ampicillin 1 GM (gram) IV (intravenous) every 8 hours, Isolation precautions if available due to Chronic Lymphocyctic Leukemia and Neutropenia, Diflucan 200 mg(milligrams) by mouth everyday (QD) and Gentamycin 20 mg IV QD.

The first unit of blood was administered 1/23/14 at 2245 (10:45 PM), the baseline vital signs were documented as, " Temperature 102.7 Fahrenheit, pulse 104, respirations 20 and blood pressure 109/59." The Blood Transfusion Chart Copy contains instructions next to the baseline vital sign section, " Notify MD (medical doctor) if temperature ^ ( greater than) 100 degrees or over".

A review of the nurses documentation failed to indicate the patient was not placed in isolation. The physician was not notified of the elevated temperature.

In an interview 2/13/14 at 8:25 AM with Employee Identifier # 1, the Director of Operations the above information was confirmed.

Based on review of medical records, policy and procedures and interview it was determined the facility failed to:

1. Reconcile medication orders on admission to swing beds

2. Document appropriately on the Medication Administration Record (MAR) of self-administered medications

3. Assess accuracy and safe administration of home medications

4. Document an order from the physician allowing self-administration of medications.

This affected Medical record # 2 and # 3, and had the potential to affect all patients served by this facility.


Findings include:

Policy # 3017 Medication Administration (no date)

Policy:

" Medications will be administered only upon the orders of physicians...who are members of the medical staff, are authorized members of the house staff or have been granted privileges to write such orders and under the guidelines of their respective scopes of practice. Administration will be by a physician, registered nurse, licensed practical nurse...

The following policies will govern administration of medications in this institution:

MAR will be compared with the physicians orders prior to preparation of any medication at least one time each shift. The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order and the medication product label...

No medication will be left at the patient's bedside except for the following: Nitroglycerin sublingual tablets...

The nurse administering the medication will stay with the patient until the medication is taken. If a medication has been opened and is refused by a patient it is to be destroyed. This also applies to medications held because of nurse discretion...

Medications from home that the patient brings to the hospital will be disposed of in two ways:
Sent home with an immediate relative,
Sent to the hospital pharmacy to be stored until the patient is discharged..."

Policy: Verbal and Written Orders-General (no date)

Policy:

" All orders of medication and treatment shall be written into the medical record of the patient and signed by the ordering licensed independent practitioner.

All orders for medications shall include the date and time of the order, the name of the drug, the dosage, the route, frequency of administration...

All orders that are a resumption or continuation of previous orders must be rewritten in their entirety by the prescribing licensed independent practitioner, or reconciliation form computed and signed...

The medication reconciliation shall serve as a medication order sheet when completed and signed by the physician."


Medical Record (MR) findings:

1. MR # 2 was admitted to the swing bed on 2/5/14 with diagnoses of Advanced Debility and Pylonephritis.

A review of the swing bed admission orders included, " Medical monitoring tests (labs, X-rays, blood sugars, etc... Continue medications as ordered..."

There was no medication reconciliation sheet attached to the orders.

In an interview 2/13/14 at 10:00 AM with Employee Identifier (EI) # 2, the Director of Nursing, stated that the medication reconciliation form was not completed.

2. MR # 3 was admitted to the swing bed on 2/8/14 with diagnoses of Diabetes Mellitus with Peripheral Neuropathy and decreased mobility, Old CVA (Cerebrovascular Accident), Advanced debility and Neurogenic Bladder.

A review of the swing bed admission orders included, " Medical monitoring tests (labs, X-rays, blood sugars, etc... blood sugars were circled."

There was no mention of medications, to continue medications as ordered or may use home medications. There was no medication reconciliation sheet attached to the orders.

A form titled Regular insulin sliding scale protocol was attached with a date of 2/8/14, this form was not marked or signed by a physician or nurse as a verbal order or a physician's order.

A review of the MAR dated 2/8/14, 2/9/14, 2/10/14 and 2/12/14 included the following medications:

Oxycontin 20 mg (milligrams) po (by mouth) TID (three times a day)-
on 2/8/14 the 9:00 AM dose had * (asterisk) in the slot, 3:00 PM dose was blank and the 9:00 PM dose had "ref " (refused) documented. The same information was on 2/9/14 and nothing was documented on 2/10/14 or 2/11/14.

Valium 2.5 mg po TID - on 2/8/14 the 9:00 AM dose was blank, 3:00 PM dose was blank and the 9:00 PM dose had "ref" documented. The information on 2/9/14- 9:00 AM dose had * (asterisk) in the slot, 3:00 PM blank and the 9:00 PM dose had "ref" documented. There was nothing documented on 2/10/14 or 2/11/14.

Celebrex 200 mg po qd (daily) - on 2/8/14 the 9:00 AM dose was blank, 2/9/14 the 9:00 AM dose had * (asterisk) and there was nothing documented on 2/10/14 or 2/11/14.

Lyrica 150 mg po BID (twice a day) - on 2/8/14 the 9:00 AM dose was blank and the 9:00 PM dose had " ref" documented. The information on 2/9/14 - 9:00 AM dose had * (asterisk) in the slot and 9:00 PM dose had " ref ". There was nothing documented on 2/10/14 or 2/11/14.

Simvastatin 40 mg po HS (hour of sleep)- 02/8/14 and 2/9/14 the 9:00 PM dose had " ref". There was nothing documented on 2/10/14 or 2/11/14.

Celexa 20 mg po qd- 2/8/14 dose at 9:00 AM was blank, 2/9/14 dose at 9:00 AM had * (asterisk) and there was nothing documented on 2/10/14 or 2/11/14.

The handwritten MAR page 1 of 4 documented * (asterisk)- not available, patient's own med (medication).

The handwritten MAR page 2 of 4 documented * (asterisk) and " ref" on medications with an explanation of * (asterisk) patient wife states she used his own meds.

The medication administration record failed to have a back side for the nurse to document if medications not administered and a reason if not given.

The nurses failed to document accurately on the MAR and failed to document discussion with the wife to ensure the medications were being given correctly and at the appropriate time.

In an interview with EI # 2, the Director of Nursing on 2/13/14 at 8:20 AM confirmed the nurse failed to document on the MAR accurately and there was no order for administering home medications or for the wife to administer them.

This condition of participation for Pharmaceutical Services is out of compliance based on observation, review of Quarterly Pharmacy and Therapeutics Committee meeting minutes, review of policy and procedures and review of Medication Administration records.

The facility failed to:

1. Store medications, keep the medication cart secured and manage medications according to policy. Refer to A491

2. Conduct Quarterly Pharmacy and Therapeutics Committee meetings. Refer to A 492

3. Ensure Compounded Sterile Preparations (CSP) medications were prepared and administered safely. Refer to A 501

4.Ensure all medications and biological's available for patients were not expired. The facility failed to ensure all multi-dose vials were labeled with the date opened. Refer to A 505

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


Refer to A 491, A 492, A 501 and A 505 for findings.

Based on review of policy, observations and interviews, it was determined the staff failed to store medications, keep the medication cart secured and manage medications according to policy. This had the potential to affect all patient's served.


Facility Policy:
Title: Storage of Medications and Solutions in Patient Care Areas
Department: Medical Surgical Unit

Policy:
It is the responsibility of the Pharmacy to assure that all chemicals, drugs, medications...are sorted at the nursing stations in a manner to assure accuracy of administration...prevent degradation and allow accessibility to authorized personnel only.

Procedure:
" The Pharmacist shall make monthly inspections of all storage areas to assure compliance...
The drug carts of the patients are to be kept current (i.e., no drugs that are not currently in use should be stored on the unit)...
Lockable storage units or drug carts shall be provided for each storage area...
Floor stock items should not be overstocked...
Drugs shall be kept in locked storage when unattended and shall be inaccessible to unauthorized individuals...
The refrigerator temperature will be kept between 36 and 46 degrees Fahrenheit. Temperature should be checked daily...Discrepancies'...reported promptly...
Refrigerated insulin must be dated when opened and discarded after...30 days.
All multi-store pour bottles must be dated when opened...discarded in 6 months..."
Record open and discard dates on solution bottles.


Findings include:

On 2/11/14 at 10:25 AM, a tour of the radiology service department and interview with Employee Identifier (EI) # 8, Radiology Director was performed. A box of CT (computerized tomography) contrast medium that contained three bottles of Readi-Cat contrast agent was laying on the floor in the dark room.

During the tour, EI # 8 picked the box of CT contrast medium from the floor and placed the on the table in the dark room. The contrast medium
IV fluids were not stored in a manner to prevent contamination.


On 2/11/14 at 1:40 PM, a tour of hospital pharmacy services and interview with EI # 12, Pharmacy Director was conducted. A small refrigerator that contained medications was observed in the pharmacy. The surveyor asked to review the refrigerator temperature log monitor. EI # 12 reported the refrigerator temperature log documentation had not been completed.

Two boxes that contained IV (Intravenous) fluids was laying on the floor in the pharmacy supply room as observed during the pharmacy tour. The
IV fluids were not stored in a manner to prevent contamination.


During a tour of the IV Medication (Med) room 2/12/14 at 9:05 AM with EI # 7, Registered Nurse, four boxes of IV fluids were laying on the floor. The IV fluids were not properly stored.

During medication (med) pass observations on 2/12/14 at 9:10 AM, EI # 6, Licensed Practical Nurse performed med passes to 5 different patients. While standing in hallway on the Medical Surgical (Med Surg) unit, EI # 6 prepared medications stored in the nursing medication cart, entered each patients room and dispensed ordered medications.

The medication cart was left in the hallway, unattended and unlocked during the med passes. The surveyor was able to open individual patient med drawers while EI # 6 dispensed patient medications.

During an interview at 10:05 AM on 2/12/14, EI # 6 reported the medication cart would not lock.

During a tour of the Med Surg unit on 2/12/14 at 10:45 AM, a refrigerator located in the Intravenous (IV) drug room was observed. Review of the IV Room daily refrigerator log revealed numerous dates monitoring was not documented:
September 2013 monitoring not documented 14 of 30 days.
October 2013 monitoring not documented 17 of 31 days.
November 2013 monitoring not documented 13 of 30 days.
December 2013 monitoring not documented 18 of 31 days.
January 2014 monitoring not documented 15 days of 31 days.
February 2014 monitoring not documented 7 of 12 days.

An interview with EI # 2, the Director Of Nursing at 10:50 AM on 2/12/14 validated staff had not performed daily refrigerator temperature monitoring and medications were not stored properly.

Based on documentation review and interviews, it was determined staff failed to conduct Quarterly Pharmacy and Therapeutics Committee meetings. This had the potential to affect all patient's served.

Findings include:


On 2/11/14 at 1:40 PM, a tour of hospital pharmacy services and interview with Employee Identifier (EI) # 12, Pharmacy Director was performed.

EI # 12 reported to the surveyor the Pharmacy and Therapeutics Committee meets "quarterly". EI # 12 provided requested meeting and minutes documentation for 2012 and 2013. Review of the Pharmacy and Therapeutics Committee meetings documentation revealed meetings were conducted 5/31/12, 12/18/12 and 11/11/13.

Review of the 12/18/12 meeting minutes documentation revealed the next scheduled meeting was in January with Quarterly meetings to begin the second Thursday in February (2013).

The surveyor requested the facility policy for Pharmacy and Therapeutics from EI # 12 during the tour.

The Pharmacy and Therapeutics Committee meetings documentation failed to reveal quarterly meetings had been performed as reported by the EI # 12.

On 2/13/14 at 10:00 AM, a request was made to the Director of Operations, EI # 1 for the policy on Pharmacy and Therapeutics meetings. No policy was received.

Based on policy and documentation review, medical record, observation and interviews, it was determined staff failed to ensure Compounded Sterile Preparations (CSP) medications were prepared and administered safely. This had the potential to affect all patient's served.

Findings include:

Facility Policy:
Title: Immediate-use Medications Pharmacy Exception Policy
January 1, 2011

" Immediate-use medications are Compounded Sterile Preparations (CSP) to be prepared without the need of special facilities and practices...It is critical that products prepared by a nonpharmacist have a minimal margin for error (e.g.,single dose administration)..."

Two key criteria for this defined exemption are as follows:
A. Avoidance of touch contamination/sterile aseptic techniques/areas)
B. Administration within 1 hour..."


On 2/11/14 at 1:40 PM, an observation of the hospital pharmacy services and interview with Employee Identifier (EI) # 12, Pharmacy Director was performed.

During the 2/11/14 1:40 PM interview, EI # 12 reported the pharmacy did not have a laminar flow hood or other contamination control device for sterile preparation compound. EI # 12 reported the facility uses ready mixed drugs whenever possible. EI # 12 provided the surveyor the facility policy for Immediate-use medications (IUM). EI # 12 reported nursing staff perform medication preparation for the few medications that required compound preparation in the IV (Intravenous) drug room on the nursing unit.

EI # 12 reported he performed education to nursing staff on the Immediate-Use Pharmacy Exception Policy. There was no available documentation of this education. EI # 12 referred the surveyor to the Director Of Nursing, EI # 2. EI # 2 was also was unable to provide documentation of nursing education or competency for the use of IUM's.

Medical record review revealed 2 patients were receiving Lasix and Rocephin during the survey visit. Both medications required compounding by nursing staff.

On 2/13/14 at 9:15 AM, a new Airclean Systems laminar flow hood was sitting on an overbed table in the IV drug room. There was no proof of inspection on the new hood. There was no documentation the staff had been educated on use of the hood.

During a 2/13/14 10:00 AM interview with EI # 1, the Director of Operations validated the above findings.

Based on observation, CDC (Centers for Disease Control) safe practices for use of multi-dose vials, policy and procedures and interview with facility staff it was determined the facility failed to ensure all medications and biological's available for patients were not expired. The facility failed to ensure all multi-dose vials were labeled with the date opened. This had the potential to affect all patients served by this facility.

Findings include:

Policy: Infection Control (There was no date the policy was written or revised on the form.)

The Nursing Services Department recognizes the impact and responsibility of carrying out the practical aspects of infection control, as nurses are the only persons throughout the hospital who have direct contact with the patients 24-hours a day.

Medications/Intravenous (IV) Fluids:

" All parenteral and IV medications must be prepared using strict aseptic technique. Disinfect the counter area with an approved disinfectant prior to medication/IV solution preparation.

Mutidose vials will be used for the treatment of a single patient.

Multidose vials are to be dated when opened, stored appropriately and disposed of in 28 days or per manufacturers expiration date and/or pharmacy recommendations..."

CDC- Multi-dose vials- Safe Practices last updated 2/9/11

Questions about multi-dose vials:

4. When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United sates Pharmacopoeia (USP) General Chapter 797[16] recommends the following for multi-dose vials of sterile pharmaceuticals:
1. If a multi-dose has been opened or accessed (needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.


An observation was conducted in the Emergency Department(ED)on 2/11/14 at 10:00 AM. The surveyor observed the following expired drugs or unlabeled drugs and sterile supplies:


Drug Room:

Nubain multi-dose vial opened and no date when the vial was first accessed.

Exam Room #2:
1000 ml(milliter) bag of D 5 1/2 NS (Dextrose 5% with 1/2 Normal saline) expiration date 7/2013
1000 ml bag of NS (Normal saline) expiration date 11/2013

An observation was conducted in the IV (intravenous) medication room on 2/12/14 at 9:00 AM.

The surveyor observed the following expired drugs or unlabeled drugs and sterile supplies:

Tuberculin solution 1 ml vial dated as opened 8/3/13
Tuberculin solution 1 ml vial opened but not dated
Humulin R (regular) 3 ml vial opened but not dated
Novolin N (NPH) 10 ml vial opened but not dated.




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On 2/12/14 at 8:20 AM an observation of the nurses station was conducted. The following items were found in a top cabinet:
One 8 ounce can of Resource Thickner, open and dated 9/22/12.
One 15 ml Hemocult solution, expiration date 10/2012.
Accu check Aviva test strips, 1 bottle of 50, expired 11/30/2011.
True Test glucose strips, 1 bottle, expired 11/2013.
Accu check test strips, 1 bottle # 50, expired 9/30/2011.

The expired supplies were removed by the Director of Nursing, EI # 2 and Registered Nurse, EI # 7 during the tour.

During a tour of the IV (Intravenous) Medication (Med) room 2/12/14 at 9:05 AM with EI # 7, the following open, not dated medications, opened greater than 28 days or improperly stored medications were observed:
One 5 ounce (oz) bottle Green GI (Gastrointestinal) Cocktail, open not dated
One vial Azithromycin 500 milligram (mg), open not dated
One bottle Lantus 100 unit/ml (milliliter), opened, dated 7/22/13
One 10 ml bottle Novolin 70/30 100 units, date not legible
One 3 ml Lantus Solostar insulin pen, 100 units/ml, open, not dated
One 3 ml Levemir Flex insulin pen, 100 units/ml, open, not dated

On 2/12/14 at 9:25 AM during medication (med) pass with EI # 6 LPN, Licensed Practical Nurse, the following medications belonging to named discharged patients were identified in the medication cart:
Albuterol Sulfate 2 mg/5 ml, fill date 9/16/13.
1 bottle of Polyethylene Glycol 527 grams, fill date 12/3/13.
Amlodipine 10 mg, 7 tablets, fill date 11/13/13.
Pravastine 10 mg, 10 tablets, fill date 10/3/13
Proair 90 mcq (milliequivalent), 1 inhaler, fill date 9/27/13.
Sodium Bicarbonate 650 mg, 30 tablets, fill date 12/16/13

EI # 6 confirmed the medications should have been returned upon patient's discharge and removed from the med cart.

The following medications, found in the medication cart opened, not dated or expired:
1 bottle of Green GI cocktail,1 ounce, open, not dated
1 Combivent inhaler 20 mcq, open, not dated
1 16 ounce bottle Q-Tussin (sticky top), open, not dated
1 bottle of Acetaminophen 160 mg/ 5 ml, open, not dated (sticky top)
1 bottle Promethazine 6.25 mg/5 ml, expired 10/28/13 (sticky top)

An interview, conducted on 2/12/14 9:20 AM with EI # 6 verified the above medications were open, not dated and/or expired.

Based on review of facility policy and procedure and interview, it was determined radiation badges were not monitored according to facility policy. This had the potential to affect all patient's and staff.

Findings include:

Facility Policy:
Title: Radiation Protection Program:
Committee/Department Radiology
(no date)

" 1. Standard operating procedure will be reviewed by each radiology employee...
3. Film badge reports will be reviewed bi-monthly for any elevated exposures..."

During a tour of the radiology department on 2/11/14 at 10:20 AM, the surveyor met with Employee Identifier (EI) # 8, Radiology Department Director who provided the department policy manual, date last approved 6/18/07, and radiology badge inspection documentation.

Documentation review included a Radiation Exposure Summary Report for Calendar Year 2013. The document contained radiation exposure results reported for 4 individuals on 5/29/2013. EI # 8 was unable to produce additional radiation monitoring documentation.

An interview on 2/11/14 at 1:30 PM with EI # 8 confirmed current facility policy for radiation monitoring had not been followed.

Based on review of the Nutritional Consultant Services agreement and interview with the dietary manager it was determined the dietitian failed to visit the facility quarterly to ensure the patients nutritional needs were being met. This had the potential to affect all patients served in this facility.

Findings include:

Agreement for Nutritional Consultant Services signed 10/3/2011

IV. Terms of Agreement

C. The dietitian agrees to make at least one visit per quarter of substantial length as needed by the facility and to make additional visits when requested.

During a tour of the kitchen 2/11/14 at 11:00 AM, the dietary manager, Employee Identifier (EI) # 4 was asked how often the dietitian visited. EI # 4 stated that she came every month.

The surveyor reviewed the dietitian consultant reports provided. The two reports were dated 1/31/13 and 11/8/13 .

EI # 4 stated she thought she had been to the facility more often than that, but she was always available by telephone.

An interview with Employee Identifier #1, Director of Operations on 2/12/14 at 3:00 PM confirmed the dietitian only came 2 times in 2013.

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Based on observation, review of Health Care Authority Board minutes and interview it was determined the facility failed to maintain and keep equipment in working order. This had the potential to affect all patients, staff and visitors served by the facility.


Findings include:

Refer to Life Safety Code violations.
Refer to A 701 for findings.

Based on observation, review of Health Care Authority Board minutes and interview it was determined the facility failed to maintain and keep equipment in working order. This had the potential to affect all patients, staff and visitors served by the facility.

Findings include:

On 2/11/14 at 11:00 AM the surveyor toured the dietary department with Employee Identifier (EI) # 4, the Dietary Manager. The surveyor observed the large stand up freezer and refrigerator were not working. The two compartment sink had no hot water to the sink and the faucet was taped over. The oven only heated at 500 degrees per EI # 4.

At 11:45 AM on 2/11/14 the surveyor observed the food being plated for the in house patients from the steam table. The first compartment on the left side of the steam table did not work, the other compartments were functional.

A review of the Health Care Authority Board minutes dated 2/19/13 confirmed the following needs:
" 2. Facility- roof replacement- need to execute contract
Food service- (freezer, oven, stove, dishwasher)- next purchase."

The Board was aware in February 2013 of the equipment in the dietary department not functioning properly.

In an interview with EI # 1, Director of Observation on 2/13/14 at 11:45 AM the above information was confirmed.




30952

On 2/11/14 at 1:40 PM, a tour of hospital pharmacy services and interview with Employee Identifier (EI) # 12, Pharmacy Director was conducted. A small refrigerator that contained medications was observed in the pharmacy. The surveyor observed the medication refrigerator in the pharmacy to contain an excessive amount of ice in the freezer compartment and was in need for defrosting.

During a tour of the nursing unit on 2/12/14 at 10:45 AM, a refrigerator located in the Intravenous (IV) drug room was observed. The surveyor observed an excessive amount of ice in the freezer compartment and in need of defrosting.

During a tour of the nursing floor on 2/13/14 at 9:40 AM, a patient beverage and snack refrigerator was observed to contain an excessive amount of ice in the freezer compartment and in need of defrosting.

In an interview 2/13/14 at 11:15 AM, EI # 1, the Director of Nursing confirmed the above observations.

This condition is not met based on observations, facility policy review and staff interview, it was determined the facility failed to ensure:

1. The Infection Control Nurse identified potentially hazardous events within the hospital.

2. An autoclave utilized for sterilizing instruments in the Emergency Department was used in a clean environment.

3. An organized and documented system of Infection Control practice was followed with surveillance and trending of infections.

4. Perform hand hygiene after contact with inanimate objects and prior to medication administration.

5. Sharp's containers were maintained safely.

6. Maintain equipment to prevent potential infection to patients and/or staff by use.

7. Utilize an autoclave to sterilize instruments for the Emergency department in a clean environment.

8. Empty sharps disposal containers at the fill line.


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

Findings include:

Refer to A 748 and A 749 for findings.

Based on review of infection control information provided and interview it was determined the infection control nurse failed to identify potential hazardous situations, educate staff and develop surveillance tools and monitor for infection control. This had the potential to affect all patients served by this facility.

Findings include:

On 2/12/14 the surveyor requested information from the Infection Control Committee and minutes from the Infection Control meetings.

On 2/12/14 at 4:05 PM, Employee Identifier(EI) # 2, the Director of Nursing provided two pages of minutes. The first page was dated 2/8/13 and the second page was dated 4/26/13 and included only a sign in sheet, no other information was attached.

In an interview 2/13/14 at 11:30 AM, with EI # 2, the Director of Nursing who was also in charge of Infection Control, she stated that infection control was way behind on the reports and the quarterly meeting. EI # 2 stated that there was no trending of infections and she did not have a surveillance tool.

In an interview with EI # 1, the Director of Operations on 2/13/14 at 12:05 PM, she confirmed they had been doing a lot of education on infection control and quality assurance and realized that it was a problem.

Based on observations, CDC guidelines for hand hygiene in health care settings; home diagnostics Quality Assurance/Quality Control Manual and interview it was determined the hospital failed to:

1. Maintain and clean equipment to prevent potential infection to patients and/or staff by use.

2. Utilize an autoclave to sterilize instruments for the Emergency department in a clean environment.

3. Empty sharps disposal containers at the fill line.

4. Perform hand hygiene after contact with inanimate objects and prior to medication administration.

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


www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

"...C. Decontaminate hands before having direct contact with patients
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."


www.homediagnostics.com
TRUEbalance Quality Assurance/Quality Control Manual
Section 7: Care and Storage of System
"...Caring for the TRUEbalance System
...Meter
Wipe Meter with a clean, lint-free cloth dampened with 10 % (percent) bleach and water or an approved OSHA (Occupational Health Safety Administration) approved disinfectant..."


Findings include:

On 2/11/14 at 10:00 AM the surveyor toured the Emergency Department and observed a dirty utility room with a hopper, IV (intravenous) poles pushed into the room and a small autoclave sitting on the counter. A bedside table pushed into the room had a blue surgical towel draped over it with multiple instruments laid out across the top.

The surveyor interviewed Employee Identifier (EI) # 5, the ER nurse,on 2/11/14 at 10:15 AM regarding the use of the autoclave. EI # 5 stated that the autoclave was not used that the instruments had been left there after being cleaned. They used mainly disposable instrument packages.

On 2/13/14 at 10:30 AM, EI # 1, Director of Operation observed in the ER with the surveyor the following:

1. A dirty utility room with an autoclave sitting on the counter top.

2. A metal pan in the sink with instruments waiting to be washed.

3. An overbed table with a green surgical towel laid out with instruments spread across the top.

4. Blue sleeve like packages to place the instruments in to place in the autoclave.

EI # 1 was asked if the autoclave was used to sterilize the instruments and she said that a staff member came in weekly to do a terminal cleaning on the instruments and then ran the autoclave to sterilize the instruments.

On 2/12/14 at 8:15 AM the surveyor observed an employee pushing a wheelchair down the hall with both arms of the wheelchair covered with white tape. The surveyor asked the employee why the arms were taped and she replied, " The plastic on the arms was loose and coming up and would scratch the patients." The surveyor asked where she was taking the wheelchair and she stated, " Back to the ER (emergency room)." The surveyor asked if it was used for the ER and she replied it was used wherever it was needed.

The white tape on the arms of the chair was discolored brown from repeated hands and arms that had been holding on to the chair. There was no way the chair could be cleaned with the tape attached to prevent potential infection being transferred between patients.

On 2/12/14 at 9:00 AM during a tour of the IV room, the surveyor observed a large (the size of a regular trash can) sharps container sitting on the floor filled to the top with overflow of needles on the floor beside and to the back of the container. This presented a potential infection control hazard for the nurses trying to prepare medications and intravenous fluids to dispose of the syringes and needles.

On 2/13/14 at 11:00 AM in an interview, EI # 1 confirmed the above information.



30952

During a 2/11/14 10:05 AM facility tour, the laboratory (lab) service department was observed to have a room equipped with a phlebotomy chair. Next to the phlebotomy chair was a red container with two opened vacutainer needles and bandaid packages. The red container did not have a top on it or a biohazard label. There were no lab personnel in the phlebotomy room at that time.

At 10:35 AM, EI # 9, Laboratory Director, arrived. A tour of the main lab room was performed. Upon entering the phlebotomy room, the open red container was now empty. EI # 9 reported the open red container was supposed to be used for trash only. EI # 9 placed a label for trash only, no sharps on the red container.

A 2/11/14 10:30 AM tour of the radiology department CT (computerized tomography) room was performed with EI # 10, radiology technician. EI # 10 reported the CT scan table was wiped down and linen changed after each patient. The surveyor to asked to see the cleaning solution used between patients.

EI # 10 took the surveyor into the Emergency Room. EI # 10 reported the CT table was cleaned with an unlabelled spray bottle that contained a clear liquid. EI # 10 reported the unlabelled spray bottle was Virex.

There was no label or documentation of the type solution in the spray bottle used to disinfect the CT table between patient use.

Observation of blood glucose monitoring for two patients by EI # 11, nurse assistant, was conducted 2/12/14 at 11:00 AM. EI # 11 performed the first capillary blood glucose test. EI # 11 placed trash in the garbage, lancet and strip in the sharps container, replaced the glucometer in the case, discarded the contaminated gloves and performed hand hygiene. EI # 11 entered the second patients room, donned gloves and performed the capillary blood glucose monitoring. EI # 11 disposed the trash to garbage can, lancet and glucometer strip to sharps container, replaced glucometer in the case, removed her contaminated gloves and performed hand hygiene.

EI # 11 failed to disinfect the glucometer between each patient use. During an 2/12/14 11:10 AM interview with EI # 11, it was confirmed the glucometer had not been cleaned between patients.

On 2/12/14 at 9:35 AM, a medication pass observation was performed with EI # 6, Licensed Practical Nurse. One oral medication was prepared in the hallway on the medication cart. EI # 6 entered the patient room (no hand sanitizer available at the door entry), verified patient's armband and administered the medication. EI # 6 failed to perform hand hygiene after medication preparation and prior to medication administration.

An interview following the medication pass with EI # 6 confirmed no hand sanitizer was available at the and room entry and no hand hygiene was performed after entering the patient room.

An observation of an Intravenous (IV) medication pass was performed on 2/12/14 at 1:48 PM with EI # 7, Registered Nurse. EI # 7 prepared the IV medication in the IV room, entered the patients room, verified the patient via armband and hung the medication. EI # 7 failed to perform hand hygiene prior to patient contact and IV medication administration.

Following the IV med pass, an interview with EI # 7 was conducted who confirmed room 208 did not have hand sanitizer at the door entry. EI # 7 failed to perform hand hygiene before administering the IV medication.

This condition is not met based on review of medical records and interview the facility failed to meet the needs of patients admitted to swing beds. The facility failed to provide:

1. Activities

2. Dental services if needed

3. Nutritional assessment

4. Patient rights to consent and Advanced Directives

5. Comprehensive assessment and plan of care to meet the individual needs of the patients and

6. Rehabilitative services as ordered.

Refer to A 1505, 1509, 1537, 1544 and 1548 for findings.
This had the potential to affect all patients served.

Based on review of medical records and interview it was determined the facility failed to complete a comprehensive assessment, nutritional assessment and establish a care plan to meet the needs identified for 2 of 2 patients residing in swing beds. This affected Medical Record (MR) # 2 and # 3 and had the potential to affect all patients served in the swing beds.

Findings include:

1. MR #2 was admitted to the swing bed on 2/5/14 with diagnoses of Advanced Debility and Pylonephritis.

A review of the medical record failed to contain documentation of a comprehensive assessment, nutritional assessment and a care plan.

In an interview 2/13/14 at 10:00 AM with Employee Identifier (EI) # 2, the Director of Nursing confirmed no assessment or care plan had been done on MR # 2.


2. MR # 3 was admitted to the swing bed on 2/8/14 with diagnoses of Diabetes Mellitus with Peripheral Neuropathy and decreased mobility, Old CVA (Cerebrovascular Accident), Advanced debility and Neurogenic Bladder.

A review of the medical record failed to contain documentation of a comprehensive assessment, nutritional assessment and a care plan.

In an interview 2/13/14 at 8:20 AM with EI #2, the Director of Nursing, she stated that a comprehensive assessment was completed. The assessment provided to the surveyor was completed 2/5/14 when the patient was admitted to the acute hospital, no comprehensive assessment or care plan was completed 2/8/14 for admission to the swing bed.

EI # 2 confirmed no assessment was completed or a care plan established for 2/8/14 when the patient was admitted to the swing bed.

Based on review of medical records and interview it was determined the facility failed to obtain consent for treatment and obtain/provide information to the patients on Advanced Directives admitted to swing beds in the facility. This affected Medical Record (MR) # 2 and # 3 and had the potential to affect all patients admitted to swing beds.


Findings include:


1. Medical Record (MR) #2 was admitted to the swing bed on 2/5/14 with diagnoses of Advanced Debility and Pylonephritis.


A review of the medical record failed to contain documentation of a consent for treatment or any information regarding Advanced Directives.



2. MR # 3 was admitted to the swing bed on 2/8/14 with diagnoses of Diabetes Mellitus with Peripheral Neuropathy and decreased mobility, Old CVA (Cerebrovascular Accident), Advanced debility and Neurogenic Bladder.


A review of the medical record failed to contain documentation of a consent for treatment or any information regarding Advanced Directives.


In an interview 2/13/14 at 10:00 AM with Employee Identifier # 2, the Director of Nursing confirmed there was no consent in the record because she thought the hospital record covered the swing beds also.

Based on interview and review of swing bed records the hospital failed to assure activities were provided to swing bed patients by a qualified person. This affected Medical Record (MR) # 2 and # 3 and had the potential to affect all patients served in the swing bed unit.

Findings include:

The surveyor reviewed two swing bed patient medical records while onsite.

1. MR #2 was admitted to the swing bed on 2/5/14 with diagnoses of Advanced Debility and Pylonephritis.

A review of the medical record failed to document any activities were provided from 2/5/14 through 2/13/14.

In an interview 2/13/14 at 10:00 AM with Employee Identifier (EI) # 2, the Director of Nursing, stated that the patient had not recieved activities.

2. MR # 3 was admitted to the swing bed on 2/8/14 with diagnoses of Diabetes Mellitus with Peripheral Neuropathy and decreased mobility, Old CVA (Cerebrovascular Accident), Advanced debility and Neurogenic Bladder.

A review of the medical record failed to document any activities were provided from 2/8/14 through 2/13/14.

In an interview 2/11/14 at 1:55 PM with EI # 1, Director of Operations, she stated they were looking at using an aide to handle the activities.

In an interview 2/13/14 at 11:15 AM with EI # 2, the Director of Nursing she stated they did not have a person in place yet to do activities.

Based on review of medical records and an interview the facility failed to document evaluation and treatment by physical therapy, speech therapy and occupational therapy as ordered. This affected Medical record (MR) # 2 and # 3. This had the potential to affect all patients on Swing Beds.

Findings include:


1. MR # 2 was admitted to the swing bed on 2/5/14 with diagnoses of Advanced Debility and Pylonephritis.

The admission orders included:

PT (physical therapy) to evaluate and then treat (no other info was selected on the order).

OT (occupational therapy) to evaluate and then treat once a day, 5 days a week (no further info was selected).

Speech Therapy (SLP) to evaluate and then treat (no other info was selected on the order).

The medical record in the facility had no visits documented by the PT, OT or SLP.

The surveyor requested any documentation of an evaluation or visits conducted on MR # 3 from 2/5/14 through 2/13/14.

On 2/13/14 the surveyor received the following documentation from PT:

A Plan of Treatment form dated as a start of care 2/5/14.
The plan was for PT evaluation
PT Re-evaluation
Therapeutic exercise
Gait training
Therapeutic activities.

The frequency on the Plan of Treatment was for PT to visit 5 times a week for 3 weeks.

There was no visits documented for 2/6/14, 2/7/14, 2/10/14, 2/11/14, 2/12/14 or 2/13/14 in the medical record or provided to the surveyor.

A Plan of Treatment form dated as a start of care 2/4/14.
The plan was for OT evaluation
OT Evaluation
Therapeutic exercise
Therapeutic activities
Self care training.

The frequency on the Plan of Treatment was for OT to visit 5 times a week for 3 weeks.

The OT plan of treatment was dated 2/4/14 and the patient was admitted to swing bed on 2/5/14.

There was no visits documented for 2/6/14, 2/7/14, 2/10/14, 2/11/14, 2/12/14 or 2/13/14 in the medical record or provided to the surveyor.

There was no documentation a speech therapist evaluated the patient while on swing bed.


2. MR # 3 was admitted to the swing bed on 2/8/14 with diagnoses of Diabetes Mellitus with Peripheral Neuropathy and decreased mobility, Old CVA (Cerebrovascular Accident), Advanced debility and Neurogenic Bladder.

The admission orders included:

PT to evaluate and then treat once a day, 5 days a week for the entire stay.

OT to evaluate and then treat once a day, 5 days a week for the entire stay.

The medical record in the facility had no documentation in the record from the PT or OT.

The surveyor requested any documentation of an evaluation or visits conducted on MR # 3 from 2/8/14 through 2/13/14.

On 2/13/14 the surveyor received the following documentation from PT:

A Plan of Treatment form dated as a start of care 2/8/14.
The plan was for PT evaluation
Therapeutic exercise
Gait training
Therapeutic activities.

The frequency on the Plan of Treatment was for PT to visit 5 times a week for 4 weeks.

There was no visits documented for 2/10/14, 2/11/14 or 2/12/14 in the medical record or provided to the surveyor.

On 2/13/14 the surveyor received the following documentation from OT:

A Plan of Treatment form dated as a start of care 2/10/14.
The plan was for OT evaluation
Therapeutic exercise
Therapeutic activities
Self care training.

The frequency on the Plan of Treatment was for OT to visit 5 times a week for 3 weeks.

There was no visits documented for 2/11/14 or 2/12/14 in the medical record or provided to the surveyor.

On 2/13/14 the surveyor received the following documentation from Speech Therapy (ST):

A Plan of Treatment form dated as a start of care 2/10/14.
The plan was for evaluation of speech, language, voice Treatment of speech, language, voice.

The frequency on the Plan of Treatment was for ST to visit 5 times a week for 12 weeks.

There was no order for speech therapy to evaluate or treat the patient.

There was no visits documented for 2/11/14 or 2/12/14 in the medical record or provided to the surveyor.

In an interview 2/13/14 at 8:20 AM, EI # 2, the Director of Nursing confirmed the above information.

Based on review of contracts and interview with administrative staff it was determined the facility failed to maintain a dentist on contract for provision of routine and emergency dental services to meet the needs of each swing bed resident which has the potential to impact all swing bed residents.

Findings include:

The surveyor requested a copy of the dental contract from hospital staff.

The facility had no dental contract to review.

An interview with Employee Identifier # 1, Director of Operation, on 2/12/14 at 1:30 PM revealed the facility had no dentist on staff or under contract.