HospitalInspections.org

Based on document review and interview the facility failed to ensure licensure of all staff in accordance with applicable Federal, State, and local laws and regulations for 1 of 3 licensed personnel reviewed. Findings include:

Review of Michigan Department of Community Health online license verification document noted that staff LPN F's nursing license expired 3/31/2010. The finding was confirmed with staff A, the Director of Human Resources. Staff A stated that it was; " ...noticed the license had expired (on 7/21/10) and the staff member told she was not able to work until the license was renewed."

The facility failed to maintain a clean, safe and properly functioning physical environment.

Findings Include;

During the facility tour on 7/20/2010 with the facilities engineer the following observations were made;

1. In the Exam Room 104 the pipes underneath the sink were not properly sealed and the hot water valve was leaking.

2. In the OR Clean Supply Room patient care items were observed stored in the cabinet underneath the sink.

3. In the CSR the sink base cabinet was severely rusted and holes were observed in the bottom and back of the cabinet.

4. The pipes under the sink at the Nurse's Station were not properly sealed.

5. In Radiology the sink base cabinet was severely rusted and holes were observed in the bottom and back of the cabinet.

6. In the Shower Room located on the patient floor the shower lacked an emergency nurse call pull station.

Based on observation and interview the facility failed to ensure current and accurate records were kept of the receipt and disposition of all outdated scheduled drugs. Findings include:

During a tour of the pharmacy department on 7/21/2010 at 1200 hrs, outdated scheduled medications were observed in a large box on a shelf within the medication storage room. Inquiry was made with the pharmacy technician B as to the number of each outdated scheduled drug in the box. Pharmacy technician B replied that there was no documented counts of expired scheduled medications. The findings were verified during a telephone interview with the pharmacy manager E on 7/22/2010 at 0945 hrs.

Based on document review and interview the facility failed to ensure the director of dietary services was involved in a CAH-wide quality assurance program. Findings include:

Review of both the facility's Infection Control Committee meetings dated 5/17/2010 and 12/29/2009, and the Board of Directors meeting minutes dated 4/21/2010, noted no documented participation of dietary services in the facility wide QA program. During an interview with the facility Nursing Services Manager on 7/21/2010 at 1330 hrs, it was confirmed that dietary services had not integrated food and dietetic services into the CAH-wide QA and Infection Control Programs.

Based on records reviewed, policies reviewed, and interview the facility failed to ensure that rehabilitation services were provided in accordance with an individualized plan of treatment for 2 of 2 records receiving physical therapy services. Findings include:

**The agency's policy entitled; "Implementation of Physical Therapy into Plan of Care"(sic), specifies the physical therapist will; "Perform an initial evaluation of the patient including objective data on functional limitations", then develop a plan of treatment that reflects; "Realistic goals (that)will be written in measurable terms.", and the written plan will cover at a minimum; "....(what) Procedures and modalities (will) be applied,...."

MR #12: The patient's start of care date was 7/9/10 with diagnoses that included; a ruptured right biceps tendon. The initial Physical Therapy Assessment dated 7/9/10 noted a pain rating scale was included on the assessment that defined a measurable pain rating sytem that included; "...Numerical pain rating scale where 0 represents no pain and 10 represents the worst pain imaginable." The documented patient response was; "Patient stated that pain in her right arm and elbow is severe"(sic). During an interview with staff Physical Therapist C, it was related that the patient was unable to express the pain in quantifiable terms due to the patient's age. There was no documentation detailing the clinical circumstance at the time of the evaluation.
Also, the goals identified on the evaluation were as follows; "1) No pain, 2) Reduce Swelling, 3) Improve range, 4) Improve Strength, 5) Restore lost function"(sic). The identified goals failed to be written in measurable terms.
Also, there was no documented (physical therapy) procedures and modalities that were to be applied in the patient's treatment for the physicians review.

MR #13: The patient's start of care date was 7/21/10 with diagnoses that included; right plantar fascitis. The goals identified on the evaluation were as follows; 1) Normal Range, 2) No pain, 3) Improve function, 4) Develop a supportive home program. The identified goals failed to be written in measurable terms.
Also, there was no documented (physical therapy) procedures and modalities that were to be applied in the patient's treatment for the physicians review.