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Based on observation, interview and document review, the facility failed to maintain the nourishment refrigerator on the medical/surgical unit at an identified acceptable temperature range, failed to dispose of outdated nourishments and failed to maintain separation between food items and medical supplies resulting in the potential for contamination of both food and supplies and poor patient outcomes for the six current (6) inpatients. Findings include:

On 09/16/2014 at approximately 0845, observation on the medical surgical unit revealed a supply room that contained both medical supplies and nourishments items. On the front of the nourishment refrigerator was a document titled "Temperature Control Storage Manual Tracking Log, September 2014." The document contained a "Temperature range: 36-40 degrees Fahrenheit." The document was noted to contain two areas for staff documentation of refrigerator temperatures, twice daily. According to staff E (Director of Nursing), who was present during the document review, she stated, "The temperatures are checked on the midnight shift by nursing and then on the day shift by dietary." The document review revealed that on September 11 th, 12 th, 14 th and 15 th the refrigerator temperatures for both the nursing and dietary staff checks were documented at 34 degrees, below the facility's identified range of 36-40 degrees. A second document located on the refrigerator titled "Temperature Controlled Storage Manual Tracking Log" reads, "If temperature is out of range, the following steps must be taken: 1. Check appliance to verify: a. Temperature gauge is set within appropriate range for contents, b. Appliance is plugged into an outlet, c. Door to appliance seals properly when closed. 2. After checking the appliance: a. Leave the appliance undisturbed for sixty (60 minutes), then, b. Re-check temperature; c. Document this information in the Action Taken section below." The nourishment refrigerator was also noted to contain only one item (identified by staff E as cottage cheese) that contained a date of 9/14. When staff E was queried as to if the date was the date when the item was placed into the refrigerator or an expiration date, staff E stated, "I am not really sure, I will need to get back to you on that."
Further review of the supply room, revealed that in a small area that contained cupboards with nourishment items such as cereal, crackers and drinking cups that the cupboards also contained medical supplies such as boxes of gloves, containers of hand sanitizer and tubes of antifungal cream.

On 09/16/2014 at 0900, during an interview with staff E, she confirmed the that the refrigerator temperatures were out of range on the dates identified. When queried about the the steps that should be taken if the refrigerator was out of range, she stated, "Staff should recheck it, and document it and if it is still out of range they should be notifying maintenance." When queried about supplies and nourishment being stored together, staff E replied, "We can separate them."

On 09/16/2014 at 1400, staff E came to the conference room and stated, "The date on items in the refrigerator is the expiration date, so yes, the cottage cheese was outdated and should have been taken out on the 14 th (of September)."

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 9/16/14, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the below listed K-tags on the CMS-2567 dated 9/16/14 for Life Safety Code survey findings.

K-0050
K-0147

Based on observation, interview, and document review, the facility failed to ensure that the injection port on the intravenous (IV) tubing was cleaned before attaching a second syringe, and that IV lines were dated when it's use was initiated resulting in the risk for patient harm for six inpatients. Findings include:

On 09/18/2014 at approximately 0930 during observation in the special procedure room, staff P failed to clean the injection port between the first and second IV push medications. The sequence of two IV push medications was repeated for a total of 4 times between 0930 and 0950 on 9/18/14, staff P failed to clean the injection port between the first and second IV push medications all four times.

On 09/18/2014 at 0955 staff E was asked if this was the policy, staff E stated, "staff P should have cleaned the injection port before giving the second IV push medication."

On 09/18/2014 at approximately 1300 during review of the facilities reference book titled, " Nursing Interventions and Clinical Skills" "Elsevier Mosby copyright 2012", chapter 23 pages 568 through 570 outline, "Administration of Parenteral Medications." Beginning on page 569, "8. b. (1) Clean injection port...with antiseptic swab (2) Insert syringe.....through injection port....(5) Remove syringe...(6) Clean injection port ....with antiseptic swab (7) Insert syringe though injection port...(9) withdraw syringe (10) clean injection port with antiseptic swab. (11) attach syringe..."


28273

On 09/16/2014 at approximately 0930, observations on the medical/surgical unit revealed that the intravenous tubings (IV) and IV insertion sites for patients #12 and #13 lacked dates as to when the IV's were started and when the IV tubing was first put up.
Patient #12 was noted to have one primary bag of normal saline IV solution hanging and two secondary bags (antibiotic piggy backs-Ceftazidime and Vancomycin). All three of the bags had IV tubing hanging from them that lacked dates of initiation.
Patient #13 was noted to have one primary bag of normal saline IV solution hanging and one secondary bag (antibiotic piggy back-Gentamicin) that lacked a date designation of initiation.

On 09/16/2014 at 1000, when staff H (Registered Nurse) was queried as to if they are supposed to date the IV insertion site and tubing when initiated, she stated, "they are." When staff H was queried if she could locate dates on the tubings and insertion sites for patients #12 and #13, she stated, "I did not see any."

On 09/18/2014 at 0900, request was made for the policy regarding dating IV tubing and IV insertion sites, staff A, (Chief Nursing Officer) stated, "I asked staff E (Director of Nursing) for the policy and she stated, 'We use a reference book called 'Nursing Interventions & Clinical Skills.'"

On 09/18/2014 at approximately 1100 during review of the facility's reference book titled, "Nursing Interventions & Clinical Skills, Elsevier Mosby copyright 2012," revealed in chapter 28 page 665 "Step 23, Label IV dressing, including date, time,catheter gauge size and length, and nurse's initials." Chapter 28 also contains an area on page 672 that read, "3. Changing infusion tubing: Determine when new infusion set is needed (e. g., according to agency policy, after contamination, or after puncture of infusion tubing). Rationale: Changing of continuous infusion and intermittent infusion tubing at recommended times reduces bloodstream infection."

On 09/18/2014 at 1130, when staff A was queried if she was aware that the reference book referred them back to facility policy for when IV insertion sites and IV tubing required changing, she stated, "No I was not aware of that."

Based on document review and interview, the facility failed to ensure that 1 of 1 current swing bed inpatients (#11) and 3 of 3 discharged patients (#14, #15, #16) admitted into swing bed status were provided with an activity assessment and opportunities for activities, resulting in the potential for unidentified and unmet patient needs for all 4 swing bed patients reviewed. Findings include:

On 09/16/2014 at approximately 1500, medical record review for patient #11 revealed that they were admitted to the facility in swing bed status on 09/08/2014. At the time of the record review, staff H (Registered Nurse) was unable to locate an activity assessment for patient #11. When staff H was queried about who's responsibility it was to complete an activity assessment on the patient, staff H stated, "We share the activity staff with the RNC (rehabilitation nursing center). They would be the ones to do it" Staff H was also unable to locate any documentation in either the electronic medical record or the hard chart copy for patient #11 regarding any visits/communications between activity staff and patient #11 during any of the eight (8) days that the patient had been at the facility. When staff H was queried as to how staff know that they need to complete an assessment on a swing bed patient, staff H stated, "When a patient is admitted into the swing bed status an e-mail goes out to the Dietary, Social Worker and Activity departments informing then of the admission."

On 09/17/2014 at approximately 1130, during an interview with staff J (Activity Assistant), when queried about the lack of an assessment for patient #11, staff J stated, "I take full responsibility for not completing the assessment." When queried if she had made any contact with the patient since they were admitted, staff J stated, "No, I was not aware that a swing bed patient was here." When queried about an e-mail going out to their department, staff J replied, "There are three of us in the department, I guess I just thought that it was already done by one of the other staff." Staff J also produced a document titled, "Assessment Recreation Therapy-Community Hospitals" that contained areas for identifying the patient's interest. Staff J stated, "This is what should have been filled out on the patient."

On 09/18/2014 at approximately 0900, during review and interview regarding closed medical records with staff H, she confirmed that the three (3) closed medical records for patients #14, #15 and #16, that were admitted into swing bed status, lacked evidence of activity assessments or documentation of any activities being provided to the patients during their stay.

On 09/18/2014 at 0930, review of the facility's policy titled, "Activities Assessment, Policy 21.4.1.45, Revised/Reviewed Date: January 2008, Purpose: To ensure assessment of all residents to determine their cognitive, physical, psychosocial and spiritual needs following state and federal guidelines. Responsibility/Scope: It is the responsibility of the Activity Director/or designee. Procedure: 1. Upon completion of the Activity and History Assessment, a hand written, initial assessment shall be written and placed in the activity progress notes."

Based on document review and interview, the facility failed to develop a comprehensive care plan for
1 of 1 current swing bed inpatient (#11) and 3 of 3 (#15, #16, #17 ) discharged swing bed patients, resulting in the potential for unidentified and unmet patient needs for all 4 swing bed patients reviewed. Findings include:

On 09/16/2014 at approximately 1500, a medical record review for patient #11 revealed that they were admitted to the facility in swing bed status on 09/08/2014 for rehabilitation post lumbar laminectomy. At the time of the record review, staff H (Registered Nurse) was able to produce two documents regarding care planning for patient #11. In the electronic medical record, staff H produced a document titled, "Adult Interdisciplinary Plan of Care and in the patient's hard chart was a pre-printed plan of care titled, "Laminectomy-Adult, Interdisciplinary." The two plans of care identified, "Problems/Complications, Outcomes and Interventions/Activities" but did not identify timeframes for evaluation of the interventions or outcomes. When staff H was queried regarding frequency for evaluating the interventions and outcomes identified in the plan of care, she stated, "All plans of care are supposed to be updated every shift."Per staff H, the facility has two 12-hour shifts per day. When queried if that is for swing bed patients, staff H stated, to my knowledge it is for everyone." A review of the two care plans for patient #11 revealed that the the "Adult Interdisciplinary Plan of Care" had been charted on once on 09/09/2014 and once on 09/10/2014. Review of the "Plan of Care- Laminectomy-Adult, Interdisciplinary" that identified three "Problems/Complications" #1. "Impaired Physical Mobility R/T (related/to) Neuromuscular impairment had been charted on only one shift on 09/09, 09/10, 09/11, 09/12, 09/14 and 09/15. The same documentation was noted for #2. "Problem/Complication -Risk for Peripheral Neurovascular Dysfunction R/T spinal injury." Problem #3. "Risk for urinary retention R/T Spinal Surgery contained staff charting for a single shift on 09/09, 09/12, 09/13, 09/14 and 09/15."

On 09/16/2014 at 1515, staff H confirmed the findings and stated, "they should have been documented on every shift."

On 09/18/2014 at approximately 0900, during review of closed medical records with staff H, she confirmed that the three (3) closed medical records for patients #14, #15 and #16, who were admitted into swing bed status, all lacked documentation of updates to the plans of care every shift.

On 09/18/2014 at 1015, review of the facility's policy titled, "Plan of Care, Reference #14092, Effective Date: 06/17/2014," revealed that the policy does not make reference regarding how frequently the staff are to update the plan of care. Staff A (Chief Nursing Officer) confirmed the lack of staff direction in the policy and stated, "We have some work to do on this." When staff A was queried further about timeframes for reaching the desired patient outcomes or reassessment of outcomes and interventions regarding the plans of care, she stated, "They don't have any."

Based on document review and interview, the facility failed to either maintain an agreement or have a Dentist on staff to provide dental services for swing bed patients resulting in the potential for poor patient outcomes for the 1 of 1 (#11) current swing bed inpatient. Findings include:

On 09/18/2014 at approximately 1100, review of documents provided by the facility listing services provided either directly by the facility or by agreement/arrangement, lacked information regarding Dental services.

On 09/18/2014 at 1115, during an interview with staff A (Chief Nursing Officer) when queried if the facility had a Dentist on staff or if they have an agreement with a Dentist, staff A stated, "We do not."