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Based on observation, document review and interview, the Critical Access Hospital (CAH) failed to post signs regarding the patient's right to receive emergency medical care at each entrance. This deficient practice has the potential to result in all individuals entering the Emergency Department (ED) or waiting for treatment to be unaware of their rights


Findings included:


- Review of a map of the CAH building confirmed two entrances that might be used by patients seeking emergency care or waiting for examination or treatment. The two entrances are the ambulance entrance and the main hospital entrance.

Ambulance entrance observed on 4/24/2017 at 11:00 AM revealed an entry without signs posted regarding the patients right to receive emergency medical care.


Director of Nursing Staff A interviewed on 4/24/2017 at 11:00 AM confirmed the CAH failed to post the required information at each emergency entrance.

Based on observations and interview the facility failed to ensure Emergency room supplies and medications did not exceed the manufacturer's safe use date. This deficient practice has the potential to cause compromised medications and unsafe supplies to be used during the care and treatment of emergent patients.

Findings include:


- Emergency Department Rolling Supply Cart observed on 4/24/2017 at 11:20 AM revealed the following:

1. Eight Povidone-iodine SwabSticks (swabs used to clean the skin) with and expiration date of 7/2013
2. Nine Prolene 6.0 sutures with an expiration date of 1/2017
3. Six Ethilon 5.0 sutures with an expiration date of 1/2017


- Emergency Supply Cart observed on 4/24/2017 at 11:35 AM revealed the following:

1. One 10 milliliter vial Lidocaine 2% (medication used to numb the skin) with an expiration date of 5/2016
2. Seven 20 milliliter syringes of Saline Flush with an expiration date of 2/2017
3. One 250 milliliter bag of Sodium Chloride (a medication used to increase fluids in the body with an expiration date of 3/2017
4. One 100 milligram syringe of Lovenox (medication used to reduce the risk of blood clots) with an expiration date of 3/2017
5. One EZ-Stabilizer (device used to secure an Intraosseous (in the bone) needle) with an expiration date of 9/2016
6. Intraosseous needle 4mm 15guage with an expiration date of 2/2017
7. Two Chlora-Prep Swabsticks (swabs used to clean the skin) with expiration dates of 8/2016 and 12/2016
8. Five Clave Connectors with an expiration date of 11/2015
9. Three Stylet's sizes small, medium, and large with expiration dates of 11/2016, 2/2017, and 3/2016
10. Two LMA (device used to manage an airway in an emergent situation) with expiration dates of 1/28/2017 and 2/28/2017


- Pediatric Emergency Supply Cart observed on 4/24/2017 at 12:00 PM revealed the following:

1. Three Clave Connectors with an expiration date of 11/2015
2. Three LMA (device used to manage an airway in an emergent situation) with expiration dates of 1/28/2017, 2/28/2017, and 9/28/2015
3. Three 18guage IV needles with an expiration of 1/2017
4. Six Safety blood collection sets with an expiration date of 2/2017
5. Five bandages with an expiration date of 2/2014
6. Endotracheal tube (a tube placed in the windpipe to assist with breathing) size 7.5 with an expiration date of 3/2014, size 8.0 with an expiration date of 2/2017
7. Three Stylet's sizes small, medium, and large with expiration dates of 11/2016, 2/2017, and 3/2016

- Lower Cabinets observed on 4/24/2017 at 12:10 PM revealed the following:

1. Two Rape Kits with an expiration date of 2/2017

- Upper Cabinets observed on 4/24/2017 at 12:15 PM revealed the following:

1. One Bacti-Swab (red topped swab used to collect a specimen) with an expiration date of 3/5/2017
2. One Bacti-Swab (blue topped swab used to collect a specimen) with an expiration date of 2/13/2017
3. Monojet Safety Syringe 1 milliliter Eight with an expiration date of 4/2016, Four with and expiration date of 9/2015, Four with an expiration date of 2/2014
4. Three Povidone-iodine SwabSticks (swabs used to clean the skin) with and expiration date of 11/2016
5. Three Chlora-Prep Swabsticks (swabs used to clean the skin) with expiration dates of 7/2015 and 12/2014
6. Three 10 milliliter vials of Marcaine 0.25% with an expiration date of 4/1/2017
7. One bottle of Nitrostat 0.4milligrams (a medication used to treat patients with chest pain) with an expiration date of 10/2016


Director of Nursing Staff A interviewed on 4/24/2017 at 12:30 PM indicated medications and supplies were inventoried monthly and stated "(RN Staff C) must have just forgotten to throw out the expired supplies".

Director of Nursing Staff A interviewed on 4/24/2017 at 1:45 PM revealed the LMA's and endotracheal tubes were currently on order but they did not want to remove the expired ones until new ones arrived.


Policy titled "Discarded Medications" reviewed on 4/25/2017 at 9:45 PM directed " ...all medications shall be discarded according to manufacturer recommendations ...and ... Multi-dose vials are timed, dated and initialed upon initial needle puncture. All multi-dose vials shall be discarded within 24 hours of needle puncture or immediately upon expiration if sooner ..."


Policy review on 4/26/2017 at 11:00 AM revealed the facility failed to develop a policy directing staff to dispose of expired supplies.

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the hospital provided proper isolation and ventilation for patients requiring airborne precautions in one of one isolation rooms. This deficient practice has the potential to expose hospital patients to airborne illnesses, which could lead to a worsening of condition or death.

Findings include:


- Director of Nursing Staff A observed on 4/25/2017 at 1:00 PM attempting to set the negative pressure on the control monitor outside the isolation room (Room #6). A tissue test (a test where a tissue is placed under the crack in the door to determine if the system is working. If the tissue blows back toward the hallway the pressure in the room is positive or if the tissue is pulled into the room it is negatively pressured) was preformed to identify if the room was properly producing a negative pressure. The tissue was blown away from the door into the hallway indicating positive pressure.

Director of Nursing Staff A interviewed on 4/25/2017 at 1:00 PM revealed the negative pressure room should be checked monthly by the maintenance staff. Staff A indicated they have never used the isolation room.

Maintenance Staff D interviewed on 4/25/2017 at 1:10 PM indicated they do not test the negative pressure room and were not aware of their responsibility for testing that system.

Policy titled "TB Patient's Isolation Room" reviewed on 4/25/2017 at 1:30 PM directed " ... Maintenance Dept. will perform monthly checks to ensure proper working order of the Room Pressure Monitoring Device ..."

Based on observation and staff interview the facility failed to ensure all doors latched properly when tested and failed to ensure oxygen cylinders were stored in a secured manner. These deficient practices have the potential to place all patients and staff at risk for injury.

Findings include:

- Medical Gas storage room observed on 4/25/2017 at 12:30 PM revealed six empty oxygen cylinders standing upright on the floor unsecured.

Maintenance Staff D interviewed on 4/25/2017 at 12:30 PM acknowledged the unsecured oxygen cylinders were empty and should have been stored in a different area while waiting for removal.


- Exit door located between main entrance and hallway observed on 4/25/2017 at 12:40 PM revealed the door failed to latch when tested.

Maintenance Staff D interviewed on 4/25/2017 at 12:30 PM acknowledged the door did not latch properly and indicated they will need to adjust the closure mechanism on the door.

Policy titled "Oxygen Delivery" reviewed on 4/26/2017 at 1:45 PM directed "...Store oxygen cylinders upright and secured..."

Based on staff interview and policy review the facility failed to ensure nurse practitioners (NP) participated in periodic review of hospital policies for four of four departments (Emergency Department, Nursing Department, Swing Bed, and Pharmacy). This deficient practice has the potential to cause ineffective guidance for hospital staff, which could lead to poor patient outcomes.


Findings include:

- Review of policy review documentation on 4/26/2017 at 3:00 PM revealed the facility conducted a policy review between 9/21/2016 and 9/29/2016 and failed to ensure a Mid-Level (Nurse Practitioner) documented they reviewed hospital policies.

NP Staff Q interviewed on 4/26/2017 at 2:15 PM indicated Director of Nursing Staff A delivers a stack of policies to their desk for review and signature. Staff Q denied presence of formal meetings to review policies with mid-level providers. Staff Q indicated policies are also discussed at medical staff meetings. Staff Q indicates they feel comfortable initiating conversations with facility staff if they saw the need to revise or initiate a policy.

Policy review on 4/26/2017 at 2:00 PM revealed the facility failed to provide a policy directing Mid-level staff to participate in the review of hospital policies.

Based on medical record review, staff interview and policy review the facility failed to ensure nurse practitioners notified the physician of patient admissions for 4 of 20 patients reviewed (#'s 14, 16, 19, and 20). This deficient practice has the potential for patients to receive inadequate medical care, which could cause harm or death.

Findings Include:

- Patient #14's medical record reviewed on 4/25/2017 at 2:00 PM revealed a Nurse Practitioner (NP) admitted the patient was on 12/2/2016 and discharged them on 12/4/2016 with a diagnosis of cellulitis (a skin infection). The medical record revealed the NP failed to notify the physician of the patient's admission.

-Patient #16's medical record reviewed on 4/25/2017 at 2:45 PM revealed a NP admitted the patient on 2/3/2016 and discharged them on 2/6/2016 with a diagnosis of cellulitis (a skin infection). The medical record revealed the NP or PA failed to notify the physician of the patient's admission.

-Patient #19's medical record reviewed on 4/26/2017 at 10:25 AM revealed the NP admitted the patient on 2/20/2016 and discharged them on 2/23/2016 with a diagnosis of pneumonia (an infection of the lung). The medical record revealed the NP failed to notify the physician of the patient's admission.

-Patient #20's medical record reviewed on 4/26/2017 at 11:15 AM revealed the NP admitted the patient on 1/11/2017 and discharged them on 1/12/2017 with a diagnosis of kidney stones . The medical record revealed the NP failed to notify the physician of the patient's admission.

Director of Nursing staff A interviewed on 4/25/2016 at 4:15 PM indicated a phone call is usually made to the physician; however, they (nurse practitioners) failed to document it in these medical records. Staff A revealed the facility did not have a policy for mid-level practitioners notifying a physician of a patient's admission.

Based on observation, interview, record review and policy review the facility failed to ensure compliance and requirements related to patient care was provided for drugs and biologicals stored and infection control. The facility failed to discard expired supplies, clean the glucometer according to manufactures guidelines and ensure the kitchen was clean, expired foods discarded and vents cleaned. Failure to ensure requirements related to patient care puts all patients at risk for receiving treatment with supplies that are unsafe and may not work as they are intended (see evidence Tag C0276). Failure to ensure a clean environment for food preparation and expired foods puts all patients at risk for food contaminated with bacteria, viruses, chemicals or poisonous metals resulting in potential food poisoning, illness and diseases (see evidence Tag C0278).

Based on observation, document review and staff interview the Critical Access Hospital (CAH) failed to ensure that outdated, mislabeled or otherwise unusable drugs are not available for patient use in one of one medication supply rooms, one of one pharmacy rooms, and one of one instrument cleaning rooms. This deficient practice may cause patients to receive ineffective medications or supplies which has the potential to cause harm to all patients.

Findings include:


Medication Supply Room observed on 4/24/2017 at 1234 PM revealed the following:
1. One vial of Humulin R (insulin) opened on 12/25/2016 and is available for use 126 days after opening

2. One Multi-dose vial of normal saline opened and used without a label indicating when it was opened

3. Two bottles of Readi-cat barium sulfate suspension (medication used to coat the inside of your esophagus, stomach, or intestines which allows them to be seen more clearly on a CT scan or other radiologic (x-ray) examination) with an expiration date of 12/2016

4. One package Ultrasite iv end cap with an expiration date of 2/2016

5. One package BD Q-style brand iv end cap with an expiration date of 2/2014

6. Fifteen packages of 1-milliliter syringes with needles one with an expiration date of 6/2015, two with an expiration date of 9/2015, and twelve with an expiration date of 4/2016.

7. Twelve Provodone Iodine swab sticks (medication used to clean the skin), one with an expiration date of 12/2012, one with an expiration date of 6/2014, one with an expiration date of 11/2014, four with an expiration date of 12/2016, and five with an expiration date of 9/2015.


- Pharmacy Room:

1. One rocker switch pencil (a medical device used in surgery to burn the skin or flesh with a heated instrument to stop bleeding or prevent the wound from being infected) with an expiration date of 5/2016

2. One disposable biopsy valve (a non-sterile item used to cover the opening to the biopsy/suction channel inlet gastrointestinal endoscopes) with an expiration date 9/2012

3. One Gastrointestinal Endoscope cleaning device (a device used to clean scopes used during a gastrointestinal procedure) expired.

4. One solution test strip container to test gastrointestinal scopes with an expiration date of 6/2016

5. One REM poly adhesive II electrode (an electrode use to monitor patient impedance levels (frequency of water and fluids passed through the body) with an expiration date of 1/2013.

6. One REM poly adhesive electrode for adults with an expiration date of 8/2015.


- Instrument Cleaning Room
1. One spray bottle of Hydrogen Peroxide Cleaner with an expiration date of 11/2016.



Pharmacy Tech Staff C Interviewed on 4/24/17 at 12:37 PM indicated the supplies in the pharmacy room were saved for reordering purposes. Staff C stated they know the items are not to be saved once expired and will discard them and write down the items and order numbers for future use.

Director of Nursing interviewed on 4/26/2016 at 11:00 AM indicated there is not a policy directing staff to discard expired supplies.

Policy titled "Discarded Medications" reviewed on 4/25/2017 at 9:45 PM directed " ...all medications shall be discarded according to manufacturer recommendations ...and ... Multi-dose vials are timed, dated and initialed upon initial needle puncture. All multi-dose vials shall be discarded within 24 hours of needle puncture or immediately upon expiration if sooner ..."

Based on observation, staff interview and document review the facility failed to ensure a system for identifying, reporting, investigating and controlling a sanitary environment in the facility kitchen. Failure to ensure a sanitary environment in the facility kitchen puts all staff, visitors and staff at risk for food contaminated with bacteria, viruses, chemicals or poisonous metals resulting in potential food poisoning, illness and diseases. The facility also failed to ensure cleaning of the glucometer (a medical device used to test blood sugars in a diabetic patient) according to manufacturer's guidelines in 1 of 1 glucometers. Failure to ensure appropriate cleaning of the glucometer puts all patients at risk for cross contamination of bacteria, viruses, and blood borne pathogens resulting in infection, illness and disease.

Findings include:

- Observation on 4/24/17 at 1:21 PM revealed the facility kitchen with the following findings:
- Lime build up covering the hot/cold handles to the dishwashing sink
- Lime build up on all sides of the dishwasher/sanitizer
- A knob missing to an exposed stem to turn on a burner to the gas stove
- 5 of 6 storage shelves with rust covering the entire surface (shelves were for pans, dish racks, serving trays, and plastic containers)
- Large rack for hanging pots and pans revealed visible dust on all pots and pans
- The window ledge behind the refrigerator and sink revealed thick dust and dead bugs
- The entire surface of the floor was dirty and sticky in areas
- The small sink on the east wall revealed buildup of dirt and two pools of dirty water sitting on each side
- The long black vent behind the oven and stove was rusty with cob webs
- The hood vent over the stove had rust on the bottom
- The heating/cooling vent above the three large refrigerators was rusty and dusty
- Water leaking from faucet handles over the dishwashing sink
- Exposed pipes in the pantry area visibly stained with brown stains, and above ceiling tile opening for pipes to run through visibly stained with brown stains. The pipes ran down the wall to the floor and were behind where large containers of dried goods were stored (flours and sugars) and the ceiling tiles were also brown stained.
- Front of the oven was visibly dirty.


- The facility kitchen revealed the following food items expired, not sealed and without dates the item was opened for:
- Three jello packages opened with no dates (raspberry, lemon and orange)
- One package of Carnation instant breakfast expired 3/1/17
- Beneprotein mix, 5 cans expired 12/27/16 (118 days ago)
- Pumpkin pie spice, 1 container opened with no date
- Corn chips opened on 10/19/16 (188 days ago)
- Graham cracker crust, the bag was marked 7/28
- Medium barley, one box marked 9/30
- Spices found on a shelf by the oven with opened shaker lids that were covered with spice and open to air particles and dust
- Garlic powder
- White pepper
- Black pepper
- Salt
- Onion powder
- Whole celery seed
- Cinnamon
- Paprika
- Shaker bottle of powdered sugar
- Shaker bottle of cherry jello
- Shaker bottle of cinnamon and sugar

Dietary Manager Staff E interviewed on 4/24/17 at 1:21 PM indicated the large hanging rack that held the pots and pans were dusty and they try to keep them clean. Staff E stated a work order was turned in to maintenance to have the vents cleaned. Staff E verified the findings and with no comment.

Maintenance Staff D interviewed on 4/24/17 at 2:25PM indicated they have no record of a written work order, but remembers a verbal requests given.

Dietician Staff L interviewed on 4/24/17 at 2:40 PM verified they come to the facility at least 1 time a month to review charts, progress notes, work with menus, looks for cleanliness and performs staff training. Staff L clarified the manual, and diets used and stated he/she would forward the power point slides from the staff trainings that were performed.

Chief Executive Officer Staff B interviewed on 4/26/17 at 1:47 PM stated they are aware of lack of cleanliness and care taken to keep a clean environment in the facility kitchen. Staff B stated this has been an ongoing issue that will strongly be addressed. Staff B stated he/she will be collaborating with Staff L and Staff E to resolve the issues.

- Document review on 4/26/17 revealed staff training provided by Dietician Staff L on 2/9/17 covered sanitation and food safety to include types of contamination and personal hygiene, 3/9/17 covered storing food and 4/13/17 covered preparing foods with clean utensils, work surfaces, supplies to prevent cross contamination.

- Document review on 4/26/17 revealed a dietary department daily, weekly and monthly cleaning schedule for early cook, early aid, late cook, late aid, kitchen staff and all staff. Review of a spread sheet for daily cleaning was provided with each area signed off as completed and initialed by the dietary personnel that completed the cleaning tasks. Review of the documentation reveals the areas were signed off as completed and the results of the observation revealed as noted above the findings of an unsanitary environment.

- Policy titled "Sanitation and Infection Control - Dry Goods Storage" reviewed on 4/25/17 directed "...All dry goods will be stored under safe and sanitary conditions to protect their quality and safety ...storage areas (cupboards, shelves, and pantries) must be clean and dry ...expiration dates must be checked on all perishable food and supplements ...food storage areas should be clean..."

- Policy titled "Sanitation and Infection Control - Cleaning Schedules" reviewed on 4/25/16 directed "...all staff is trained to use and understand the cleaning schedule ...the dietary manager will do a sanitation check of the kitchen on a regular basis using the sanitation check list ...the consulting dietician will check the cleanliness of the kitchen on the monthly visits ...the floor in the pantry and kitchen is to be swept and mopped at the end of the day or as needed..."

- Policy titled "Sanitation and Infection Control - Food Preparation and Equipment Practices" reviewed on 4/25/17 directed "...suitable utensils and surfaces that have been properly cleaned and sanitized to prevent cross-contamination will be used for food preparation activities ...work areas will be thoroughly cleaned with soap and water at the end of each work shift ...grease filters in overhead exhaust hood are cleaned with detergent to remove obvious grease on a regular basis. Twice a year, these will be thoroughly cleaned by the maintenance department..."


- Registered Nurse (RN) Staff I observed on 4/25/16 at 9:15 AM revealed them talking through the process of using a glucometer (a medical device used to test the blood sugar of a diabetic patient) as the facility did not have a diabetic patient. Staff I completed every step appropriately except when asked how to clean the glucometer and Staff I stated with an alcohol wipe. When asked if that is what the manufacturers guidelines recommend Staff I was not sure and then stated they were to use the bleach wipes. When asked where they were kept, there were none in the medication room (where the procedure was demonstrated), we followed Staff I to the housekeeping closet which failed to have any bleach wipes, we then followed Staff I to the clean room and a container of bleach wipes were located to clean the glucometer. Staff I was asked to locate the manufacturer's guidelines and asked Director of Nursing (DON) Staff A to locate them.

DON Staff A interviewed on 4/25/17 at 9:30 AM located the guidelines which stated the glucometer was to be cleaned with a Super Sani Cloth. Staff A stated the facility does not have Super Sani Cloths and he/she will get some immediately.

- Document review on 4/25/17 revealed the glucometer manufacturer's guidelines state ...only use Super Sani-Cloth to clean and disinfect the meter.

- Policy titled "Blood Glucose Machine" reviewed on 4/25/17 directed "...with hospital approved chemicals (preferred Sani-cloth): employees must clean and disinfect the flowing parts of the meter between patient uses: the area around slots and openings (do not get any moisture in the slots or openings), the meter display and the entire meter surface..."

Based on medical record review, policy review, and staff interview the Critical Access Hospital (CAH) failed to completely document necessary information on the certification of benefits vs risks of transfer form in order to ensure appropriate care for 3 of 11 patients (#'s 1, 4, and 5) transferred to another facility. This deficient practice has the potential to cause inappropriate care and resources to be available during patient transfers, which could cause a worsening of condition or death.

Findings include:


- Patient #1's medical record reviewed on 4/24/2017 at 1:00 PM revealed the patient was admitted on 3/15/2017 with a diagnosis of Shortness of Air and Rib fractures. The patient was transferred to Hospital BB for further care and treatment. The medical record revealed the provider failed to document the mode of transportation required for safe transport and the required personnel to accompany the patient on the certification of benefits vs risks of transfer form.


- Patient #4's medical record reviewed on 4/24/2017 at 1:00 PM revealed the patient was admitted on 12/14/2016 with a diagnosis of seizures. The patient was transferred to Hospital CC for further care and treatment. The medical record revealed the provider failed to document the mode of transportation required for safe transport, the required personnel to accompany the patient, failed to include their name as transferring physician, and failed to document the time and date transfer request was accepted on the certification of benefits vs risks of transfer form.


- Patient #5's medical record reviewed on 4/24/2017 at 1:00 PM revealed the patient was admitted on 12/9/2016 with a diagnosis of 36 weeks pregnancy. The patient was transferred to Hospital BB for further care and treatment. The medical record revealed the provider failed to document the condition of the patient at time of transfer and the mode of transportation required for safe transport on the certification of benefits vs risks of transfer form.


Director of Nursing Staff A interviewed on 4/25/2017 at 5:00 PM acknowledged the certification of benefits vs risks of transfer form was not completed. Staff A indicated the information is in the medical record, but agreed the provider failed to complete the form appropriately.


Policy review on 4/26/2017 at 1:30 PM revealed the facility failed to develop a policy directing staff to ensure completeness of the certification of benefits vs risks of transfer form prior to transferring a patient to another facility.

Based on document review and staff interview, the facility failed to ensure orders were signed by a provider for 2 of 30 patients reviewed (patients #11 and #12). This deficient practice has the potential to cause incomplete patient information, which could decrease the quality and accuracy of future health care.

Findings include:

-Patient #11's medical record reviewed on 4/25/2017 at 12:45 PM revealed the patient was admitted on 4/12/2016 and discharged 4/15/2016 with a diagnosis of chronic obstructive pulmonary disease (COPD, a group of medical conditions used to describe deteriorating lung function). The medical record revealed the order for a urinalysis (microscopic testing of the urine), written on 4/12/2016 at 4:56 PM remained unsigned by a provider, 375 days after discharge.

-Patient #12's medical record reviewed on 4/25/2017 at 1:25 PM revealed the patient was admitted on 7/16/2016 and discharged 7/20/2016 with a diagnosis of fall with knee pain. The medical record revealed the order for OT (occupational therapy services), written on 7/18/2016 at 3:44 PM remained unsigned by a provider, 279 days after discharge.

Medical records staff F was interviewed on 4/26/2017 at 2:45 PM confirmed patient #11's urinalysis order and patient #12's order for OT was unsigned by a provider. Staff F revealed they review orders that need a signature every two weeks and report verbally to the provider. Staff F indicated if a provider failed to sign orders, s/he would inform their supervisor.

Policy titled "Medical Staff Bylaws reviewed on 4/26/2017 at 3:05 PM directed " ... A temporary suspension in the form of withdrawal of a practitioner's admitting privileges; effective until medical records are completed shall be imposed automatically after warning of delinquency for failure to complete ...the entire medical record within thirty days of a patient's discharge".

Based on observation and staff interview the Critical Access Hospital (CAH) failed to protect patient's medical records from destruction when stored in the annex of the CAH. This deficient practice has the potential to cause a loss of patient's medical information necessary for continuity of care.


Findings include:

- Medical Record Storage Area in the annex building observed on 4/25/2017 at 8:55 AM revealed 2 stacked boxes of patient's medical records stored in a locked area of a large storage room, with one box stored directly on the floor and 8 patient medical records in brown folders laying directly on the floor. Floor storage of medical records creates a potential for water damage or damage/destruction from bugs or rodents.

Medical Records Staff F interviewed on 4/25/2017 at 9:00 AM acknowledged the box and file folders of medical records stored directly on the floor. Staff F indicated they just had not had time to get them put away.

Policy review on 4/25/2017 at 2:00 PM revealed the facility failed to provide a policy directing staff to protect patient medical records from destruction.

Based on observation and staff interview the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee monitored all services that affect the health and safety patient care. The QAPI committee failed to ensure emergency department (ED) documentation was completed completely and accurately. Failure to review records for accuracy and completeness on ED transfer forms puts all patients at risk for receiving care that is inaccurate, unsafe, lacking continuity and has the potential for harm and poor outcomes. The QAPI committee failed to monitor the facilities kitchen and ensure cleanliness. Failure of the facility to ensure a sanitary environment in the facility kitchen puts all staff and patients at risk for exposure to bacteria and cross-contamination of pathogens that may cause illness and disease.


Findings include:

- Medical record review on 4/24/17 at 11:00 AM revealed 3 of 11 patients (Patient #'s 1, 4, and 5) that transferred from the facility failed to have a completed transfer form document in their medical record.


- The facilities kitchen observed on 4/24/17 at 1:21 PM revealed the facility failed to provide a sanitary environment. Logs in the kitchen revealed the staff is checking off they have cleaned the kitchen with evidence by observation it is not completed.


Chief Executive Officer, Staff B interviewed on 4/26/17 at 1:47 PM, stated they are aware of the lack of cleanliness and care taken to keep a clean environment in the facility kitchen. Staff B stated this has been an ongoing issue that will strongly be addressed. Staff B reviewed the cleaning logs for the last two months. It is noted the staff are checking the kitchen is being cleaned despite the visual observation that it was not. Staff B stated he/she will be collaborating with Staff L and Staff E to resolve the issues.

Infection Control Officer/Quality Assessment and Performance Improvement Staff K interviewed on 4/26/17 at 10:47 AM, indicated the Quality Assessment and Performance Improvement committee will expand to provide assessment and performance improvement measures to ensure a sanitary and healthy environment in the facility kitchen and completion of transfer forms in the ED, which is not currently being done.

Based on staff interview and document review the facility failed to provide documentation to Swing Bed Patients in the Patient Bill of Rights concerning Medicaid and Medicare benefits for 10 of 10 closed swing bed medical records reviewed (Patient #21- 30). Failure to inform residents of their Medicaid and Medicare benefits put all residents at risk for incurring charges for items and services not covered under their benefit and placing them in financial and emotional distress. The facility currently has no swing bed patients.

Findings include:

- Documentation review of the Swing Bed Patient Rights reveals the following rights failed to be disclosed to residents:

- The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of - (a) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (b) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each resident when changes are made to the items and services (6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including ay charges for services not covered under Medicare or by the facility's per diem rate.


Director of Nursing Staff A and CEO Staff B interviewed on 4/25/17 at 4:45 PM verified the Medicare and Medicaid rights for the Swing Bed residents failed to be included in the Patient Bill of Rights. The changes will be made. The facility fails to have a policy and procedure for Patient Rights.

Based on interview and document review the facility failed to provide documentation to Swing Bed Patients in the Patient Bill of Rights concerning the resident having the right to work at the facility for 10 of 10 closed swing bed medical records reviewed (Patient #21- 30). Failure to disclose the patient's right to work at the facility (i.e. doing housekeeping, laundry or preparing meals) puts all residents at risk for performing work they may want to refuse or working that is not documented as part of their care plan according to their medical abilities. The facility currently has no swing bed patients.

Findings include:

- Documentation review of the Swing Bed Patient Rights reveals the following rights failed to be disclosed to residents:
- Work ...The resident has the right to:
- (1) refuse to perform services for the facility;
- (2) perform services for the facility, if he or she chooses, when
- (i) the facility had documented the need or desire for work in the plan of care;
- (ii) the plan specifies the nature of the services performed and whether the services are voluntary or paid;
- (iii) Compensation for paid services is at or above prevailing rates; and
- (iv) The resident agrees to the work arrangement described in the plan of care

Director of Nursing Staff A and CEO Staff B interviewed on 4/25/17 at 4:45 PM verified Work for the Swing Bed residents failed to be included in the Patient Bill of Rights. The changes will be made. The facility fails to have a policy and procedure for Patient Rights.

Based on document review, record review, and staff interview the facility failed to include in their Swing Bed rights that the facility will provide patient notification of swing bed transfer 30 days prior to the transfer in 10 of 10 closed swing bed medical records reviewed (Patient #21- 30). Failure to provide notification puts all swing bed patients at risk of inappropriate transfer. The facility currently has no swing bed patients.

Findings include:

- Patient #21's medical record review revealed they were admitted to a swing bed on 4/25/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #22's medical record review revealed they were admitted to a swing bed on 4/25/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #23's medical record review revealed they were admitted to a swing bed on 1/3/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #24's medical record review revealed they were admitted to a swing bed on 11/14/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #25's medical record review revealed they were admitted to a swing bed on 1/20/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #26's medical record review revealed they were admitted to a swing bed on 1/26/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #27's medical record review revealed they were admitted to a swing bed on 1/31/2016 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #28's medical record review revealed they were admitted to a swing bed on 2/6/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #29's medical record review revealed they were admitted to a swing bed on 2/24/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #30's medical record review revealed they were admitted to a swing bed on 2/24/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

Director of Nursing Staff A interviewed on 2/25/2017 at 5:00 PM indicated they were unaware of a 30 day notification requirement prior to transfer.

- Document titled "Patient Bill of Rights- Swing Bed Patients" reviewed on 4/24/2017 at 10:30 AM directed " ...in the event discharge or transfer becomes necessary, the patient has a right to sufficient preparation and orientation to ensure a safe transition from the facility and will be given at least 48 hours advance notice except in the case of emergency circumstances, the health and safety of other patients in the facility would be endangered, where patients health has improved sufficiently to allow an immediate discharge, or when the patients urgent medical needs require more immediate transfer ..."

Based on interview and document review the facility failed to provide documentation to Swing Bed Patients in the Patient Bill of Rights concerning contents of notice for transfer or discharge regarding the reason, effective date, location, right to appeal name and address of the State long term ombudsman, and information for the developmental disabilities and mentally ill protection and advocacy addresses and phone numbers for 10 of 10 closed swing bed medical records reviewed (Patient #21- 30). Failure of the facility to provide necessary information concerning transfer or discharge puts all residents at risk for unsafe care. The facility currently has no swing bed patients.

Findings include:

- Documentation review of the Swing Bed Patient Rights reveals the following rights failed to be disclosed to residents:
- Contents of Notice
- (i) The reasons for transfer or discharge
- (ii) The effective date of transfer or discharge
- (iii) The location to which the resident is transferred or discharged
- (iv) A statement that the resident has the right to appeal the action to the State
- (v) The name, address and telephone number of the State long term care ombudsman
- (vi) For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under part C of the Developmental Disabilities Assistance and Bill of Rights Act
- (vii) For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.


Director of Nursing Staff A and CEO Staff B interviewed on 4/25/17 at 4:45 PM verified the contents of notice for transfer and discharge rights for the Swing Bed residents failed to be included in the Patient Bill of Rights. The changes will be made. The facility fails to have a policy and procedure for Patient Rights.

Based on staff interview, medical record review, and policy review the facility failed to document evidence of patient participation in care plan meetings for 4 of 10 closed swing bed records reviewed (Patient's # 25, 26, 28, and 29). Failure to ensure the resident participates in care planning meetings put residents at risk for not ensuring patient rights are met related to their personal decisions and goals for their care.

Findings include:

- Patient # 25, 26, 28, and 29's medical record review on 4/25/17 revealed the facility failed to show documentation of patient or family participation in the hospital's care plan meetings.

Director of Nursing Staff A interviewed on 4/26/17 at 10:41 AM verified the missing documentation for residents # 25, 26, 28 and 29 in regards to participation in the care plan meetings. Staff A stated he/she personally talks with each resident prior to the care plan meetings that are held every Tuesday. Staff A stated he/she offers for the resident to attend and if they do not wish to come he/she relays the residents' needs and concerns to the team and then goes back to the resident to discuss the team input. Staff A clarified that if they did not document it, it was not done even though it was. Staff A stated he/she would ensure documentation of residents participating in care plan meetings is completed and accurate.

- Policy and Procedure review on 4/26/17 revealed policy "Utilization Review 1.3" states ...Rush Community Memorial Hospital's Utilization Review team meets every Tuesday at 13:00 with all care providers attending for a therapeutic conference of the patient's care. The family and patient are invited and encouraged to attend.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a nutritional assessment was completed for 2 of 20 sampled patients (patients #11 and #13). This deficient practice has the potential for patients to receive inadequate nutrition, which could cause further health deterioration and poor health outcomes.

Findings include:

-Patient #11's medical record reviewed on 4/25/2017 at 12:45 PM revealed the patient was admitted on 4/12/2016 and discharged 4/15/2016 with a diagnosis of chronic obstructive pulmonary disease (COPD, a group of medical conditions used to describe deteriorating lung function).The medical record lacked evidence of any nutritional assessment.

-Patient #13's medical record reviewed on 4/25/2017 at 1:40 PM revealed the patient was admitted on 10/31/2016 and discharged on 11/1/2016 with a diagnosis of syncope (fainting spell) and anemia (lacking of sufficient oxygen-carrying red blood cells in the bloodstream). The medical record revealed a nutrition assessment was completed by nursing with a score of '7'. The medical record lacked evidence of an assessment by the registered dietitian.

Director of nursing staff A interviewed on 4/26/17 at 10:56 AM indicated the Facility Dietician Staff L is faxed a form every day concerning the patients in the hospital and their dietary assessment. If a patient has a score of 3 or higher the dietician will fax back his/her recommendations to nursing who will follow up with the physician for a new diet order.

Policy titled Nutritional Screenings reviewed on 4/26/2017 at 2:30 PM directed " ... All patients will be screened to determine their level of nutritional risk, degree of nutritional care and monitoring within 24 hours of admission by a registered dietitian ..."