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Based on observation, staff interviews, and review of maintenance records between January 27 and January 30, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 33: enclosures around exit stairs with openings to unoccupied rooms;
K 34: exit access was obstructed and not readily accessible at all times;
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and travel was not interruption at stairs that go below the level of exit discharge;
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 67: heating and ventilation components were not in compliance with NFPA 90A;
K 73: obstructed egress path;
K 74: lacking information on burning characteristics on draperies and curtains;
K 75: improper storage of trash and soiled linens;
K 76: improper distance between oxygen storage and combustibles;
K 130: improper alarms for the emergency generator, improper distance between bulk oxygen tank and combustibles; and
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observations and staff interview (Staff C) in 2 of 7 department tours (OR and Radiology), the facility failed to maintain an environment for the safety of patients, staff and visitors. This deficiency potentially affects all Pts treated at this facility including the 14 patients (averaged) during the course of the survey.

Findings include:

Per tour of the Surgical Area on 1/28/2014 at 9:15 AM accompanied by Surgery Manager C noted the following:

* Tape and Velcro over the window in OR 1
* Tape over window in OR 2
* Multiple scrapes and gouges in the walls of the OR corridor hallways on both sides
* Missing paint and hole in wall in the "dirty utility room"
* Nursing/physician desk area with chipped missing laminate
* Water stain in ceiling tiles and scrapes and gouges in the walls of the "clean equipment room"

The above findings were noted by Surgery Manager C at the time of discovery. In an interview Surgery Manager C agrees the above findings are non-washable surfaces and are in need of repair.


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A tour of the Radiology Department was conducted on 1/28/2014 at 1:10 p.m. accompanied by Quality Mgr A and Imaging Services Mgr M who confirmed these findings at the time of discovery:

*In the GE room (abbreviation set by facility to identify the room from the brand of equipment in it) there was a significant are of porous surface on the floor and holes in the wall from a remodeling project 3 weeks prior the tour.

*In the Dell room there are multiple missing tiles on the floor. There is no work order to repair them and they have been like that since October.

The condition of these surfaces render them un-cleanable for microorganisms.

Based on observation, staff interviews, and review of maintenance records between January 27 and January 30, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 33: enclosures around exit stairs with openings to unoccupied rooms;
K 34: exit access was obstructed and not readily accessible at all times;
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and travel was not interruption at stairs that go below the level of exit discharge;
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 67: heating and ventilation components were not in compliance with NFPA 90A;
K 73: obstructed egress path;
K 74: lacking information on burning characteristics on draperies and curtains;
K 75: improper storage of trash and soiled linens;
K 76: improper distance between oxygen storage and combustibles;
K 130: improper alarms for the emergency generator, improper distance between bulk oxygen tank and combustibles; and
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and 1 of 1 Staff interview (Staff O), this facility failed to ensure the integrity of the contents of 1 of 2 emergency carts that contain medications, needles, and syringes in 1 of 2 rooms used for trauma patients in the ED. Failure to maintain the integrity of emergency carts has the potential to affect all patients in the ED, including the 3 patients present at the time of the tour.

Findings include:

A tour of the ED was conducted on 1/28/2014 at 10:27 a.m. accompanied by Quality Mgr A and ED Supv O. It was noted that in 1 of 2 rooms used for trauma patients where emergency carts were being kept, the emergency cart was not in view of staff and had a break away lock. Without the cart being under the supervision of staff with its current locking device, the assurance of not tampering the medications, needles, and syringes could not be guaranteed.

In an interview with Supv O during the time of the tour, Supv O stated that the cart is not visible at all times to staff and could be moved.

Based on 4 out of 9 department observations (OR, Laboratory, Sterile Processing, and Radiology) and staff performing patient care and other duties (Staff D, E, F, J, K, and T), P&P reviews, AORN standards of practice (SOP), and interviews with staff (Staff C, X, Y) this facility failed to ensure there is a comprehensive infection control program to monitor, prevent and control potential infections. This deficiency potentially affects all patients treated at this facility including the 14 (averaged) during the course of the survey.

Findings include:

Per AORN SOP for Inpatient and Ambulatory Setting 2013 edition, under Surgical Attire, III.c.2. The surgical gown back should be considered unsterile. The back of the gown cannot be constantly monitored. VII. Sterile fields should be constantly monitored, it should be monitored continuously.

Per interview on 1/28/2014 at 9:00 AM with Surgery Manager C, the facility follows AORN SOPs.

Per review on 1/28/14 at 11:10 AM the facility P&P titled "Hand Hygiene Guideline" dated 6/13 states "1: Hand hygiene must be used before and after patient contact; after contact with environmental surface; object and equipment in patients immediate vicinity; after handling contaminated materials; before and after glove use; anytime hands are visibly soiled; before eating, drinking, smoking, or using the toilet; after coughing or sneezing; before work shift begins and after work shift is complete for non patient care areas."

Per review on 1/28/14 at 11:00 AM the facility P&P titled "Surgery Department" it states "12. Sterile gowns should be considered sterile only in front from chest to the level of the sterile field and he sleeves should be considered sterile from two inches above the elbow to the cuff. 22. Sterile persons should observe the following: a. They should stay near the sterile tables if waiting for the procedure to start. b. Stay in the room - corridor is considered a contaminated area."

Per interview on 1/29/2014 at 9:00 AM with IP X, hand hygiene should be performed before and after patient contact, before putting on gloves and after removing gloves, and after touching contaminated objects per facility policy.


Examples in OR:
On 1/28/14 at 9:05 AM observed ST D during Pt # 1's procedure, while sterile gowned and gloved turn, away from the open instrument table allowing the back of the sterile gown to brush the edge of the sterile table. Surgery Manager C confirmed at the time of observation that STs should not turn their back to the sterile field.

On 1/28/14 at 9:10 AM observed ST D while in sterile gloves and gown leave the OR and proceed into the sub-sterile room to retrieve items from the flash sterilizer, then return to the sterile field in the OR. Per interview with Surg Manager C at 11:00 AM this is the regular practice for ST to retrieve the sterile items from the sub-sterile room and stated "our policy does state not to leave the room when sterile."

On 1/28/13 at 8:55 AM observed FA E touch the trash bin and move it closer to the instrument table then proceed to assist in the set up of opening and handing over sterile equipment to ST D without the benefit of hand hygiene after touching a contaminated object. Surgery Manager C confirmed at the time of observation that FA E should have performed hand hygiene after touching the trash bin.


Examples in the lab:
Per interview on 1/29/14 at 9:30 AM with IP X, the facility's policy titled "Medical Equipment Cleaning" was reviewed. The policy states "all non-critical medical equipment is cleaned thoroughly with hospital approved disinfectant after patient uses."

Per interview with Lab Manager Y on 1/28/2014 at 3:30 PM, lab draw chairs (chairs used to obtain blood samples) are cleaned by house keeping daily. Per interview with IP X on 1/29/14 at 9:15 AM lab draw chairs should be cleaned after each patient use.


Examples in sterile processing:
On 1/28/2014 at 1:00 PM received a copy of the manufactures instructions for enzymatic spray that is usually used for instrument cleaning from Surgery Manager C, titled "Ruhof Pepzyme - Enzymatic Foam Spray." It states "Begins breaking down bio-burden before instruments reach decontam" and further reads "spray directly on soiled instruments and scopes immediately after use. Allow foam to stay on instruments and scopes until ready for cleaning." Surg Manager C acknowledged they have been using this product incorrectly and should not be relying on this product for the cleaning of the instruments.

Per interview with Surgery (Surg) Manager C on 1/28/14 at 1:00 PM this facility does not have a policy specific to surgical instrument decontamination and cleaning.

Per review on 1/28/14 at 1:15 PM accompanied by Surg Manager C, the manufactures instructions for the washer/disinfector used at this facility states under 4.3.1 General Loading Guidelines "The nature of the item to be processed can require additional actions such as dismantling for separate processing, manual pre-cleaning of difficult surfaces, etc., prior to the item being processed in the washer/disinfector."

Per interview with IP X on 1/29/14 at 9:30 AM the cleaning and decontamination is covered under the policy titled "Medical Equipment Cleaning" dated 6/13. It states "All reusable, non-disposable critical items are cleaned in the department of use with enzymatic cleaner and transported to Sterile Processing in a covered container for reprocessing. Refer to Sterilization and Sterility Assurance policies. It further reads " Enzymatic cleaner instructions: For Pre-soak, dilute 1 fluid ounce per gallon of water; Soak a minimum of 2 to 5 minutes; If reusable brushes are used they should be cleaned and disinfected or sterilized regularly; after soaking, rinse thoroughly or transfer to the next cleaning operation, such as manual cleaning, automated washing equipment - washer/disinfector."

On 1/28/2014 at 10:30 AM accompanied by Surg Manager C, observed CST F place a tray of soiled surgical instruments inside the hopper (a wall mounted sink with a spigot and a spray arm that flushes like a toilet) with only one side submerged under water. CST F sprayed instruments using the spray arm and brushed any remaining bioburden with a stainless steel brush above the waterline of the hopper. CST F stated at the time of the observation "we usually spray the instruments with an enzymatic cleaner but we are out." CST F than proceeded to place instruments into the automated washer/disinfector. When asked if they do an pre-soak with enzymatic cleaner prior to placing instruments into washer/disinfector CST F stated "No we just use the spray."



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Examples of patient care:
An observation of medication administration by RN J to Pt. #25 was conducted on 1/28/2014 at 7:45 a.m. After obtaining medications, RN J entered Pt. #25's room to administer oral medications and failed to perform hand hygiene upon entry to the room.
An observation of a procedure by MD K in the newborn nursery was conducted on 1/28/2014 at 9:15 a.m. accompanied by Mgr A. MD K was attempting to snip the tissue that secures the tongue to the base of the mouth (frenulum snip) of a newborn when MD K threw the scissors across the room onto a counter stating, "That is defective, it's too dull, it won't cut," thereby contaminating the counter and its contents that came in contact with the contaminated instrument.
An observation of a dressing change by RN T on Pt. #3 was conducted on 1/29/2014 at 8:25 a.m. Pt. #3 had a hip replacement and had a hemovac drain in to relieve fluid at the surgical site. After washing hands and putting on gloves, RN T removed a dirty dressing from a puncture site on the hip, then removed the drain and removed one glove on the right hand to wrap around the removed end of the drain tube, then proceeded to remove two more dressings and open and apply new dressings all with the same gloves thereby contaminating everything touched by those gloves after the removal of the dirty dressings.
Mgr A was informed of these findings on 1/29/2014 at 9:00 a.m. and stated the gloves should have been removed and hands washed after the removal of the old dressings and before new dressings were applied.
In an interview with IP X on 1/29/2014 at 9:23 a.m. there is no double glove policy that X is aware of. Staff are not taught to wear double gloves and not change gloves and wash hands after the removal of dressings.
The facility policy titled, "Sterile Technique for Dressing Changes P&P," dated 2/13 was reviewed on 1/29/2014 at 12:25 p.m. The policy states in part, "Put on Non-sterile gloves. Gently remove old dressing. Place the soiled dressings in the appropriate plastic trash bag. Remove your gloves and dispose of them in trash bag. Wash your hands. Open all dressings with clean hands. Wash your hands."
The observed procedure was not sterile, rather clean technique, however the expectation was to remove soiled gloves, wash hands, and apply clean gloves after removing the old dressings (see above interview with Mgr A).

Examples in Radiology:
A tour of the Radiology Department was conducted on 1/28/2014 at 1:10 p.m. accompanied by Quality Mgr A and Imaging Services Mgr M, who confirmed this finding at the time of discovery. It was noted that the mattress used in the ultrasound room, which is covered with a vinyl material, had many cracks and missing sections of vinyl which would not allow for appropriate disinfection between patients.

During this same tour accompanied by Quality Mgr A and CT Tech L, in a small utility room in the radiology department a cleaning station for vaginal ultrasound probes that uses Cidex (cleaning chemical) was placed on the wall. In cabinet in this same room was a stock of oral contrast for CT scans and an employee water bottle, books and binders with papers. This does not demonstrate a separation of clean and dirty.

In an interview with IP X on 1/29/2014 at 9:07 a.m. regarding this cleaning station and its location, IP X stated that Radiology was instructed to make the room where the US probe cleaning station is a "dirty" room by the IP about a year ago."




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Examples in OR:
A tour of the OR was conducted on 1/29/2014 at 8:40 AM accompanied by staff G (Pant Operations Manager), staff H (Construction Liason) and staff I (Construction Supervisior). It was observed that the air flow from the dirty sterilization room was in to the cleaner hallway i.e. from the clean area into the dirty area. To prevent contamination, the air should go from clean to dirty.

Based on observation of 1 of 1 food preparation area, P/P review, nationally recognized standards of practice, and 1 of 1 staff interview (Staff W), this facility failed to follow safety guidelines in the food preparation area. Failure to follow these safety guidelines has the potential to affect all patients receiving dietary services at this facility including the 14 patients (averaged) during the course of the survey.

Findings include:

According to the FDA food code from 2013, " Hair Restraints 2-402.11 Effectiveness.
(A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. "

The facility ' s policy titled, " Infection Prevention-Dress Code, " which is specific to the Food and Nutrition Services area and is dated 6/13, was reviewed 1/30/2014 at 8:00 a.m. The policy states in part, " All staff must have their hair restrained in a hairnet. A hat may be worn to restrain hair if the hair is very short. "

A tour of the area being used for preparation of patient food (kitchen in the attached clinic) while this facilities kitchen is being renovated was conducted on 1/27/2014 at 2:00 p.m. accompanied by Coord B. and Mgr Q (clinic employee).
Upon entry to the food preparation area, Mgr Q failed to provide hair cover for writer and Coord B until asked. Mgr Q and kitchen staff R, also a clinic employee, were noted to have hair only partially covered. Mgr Q wore a handkerchief style scarf and kitchen staff R wore a baseball style hat, both which left the hair in the back of the head uncovered. The hair was of sufficient length to not be contained by the hair coverings.
These findings were confirmed by Coord B at the time of discovery.

Per phone call with State of Wisconsin (the Department) dietician on 1/28/2014 at 3:12 p.m., the dietician stated that because the hospital patient ' s food is being prepared in the clinic ' s kitchen area, all employees in that area are expected to follow the guidelines for food safety that the hospital follows.

In an interview with Dietary Mgr W on 1/29/2014 at 11:00 a.m., Mgr W stated the hospital does follow the FDA food code as well as Wisconsin food code and ServSafe guidelines. Mgr W was informed of, and verbalized understanding of, the Department ' s dietician ' s phone conversation and outcome.

Based on MR review, Medical Staff R&Rs, and 1 of 1 staff interview (Staff AA ), this facility failed to ensure that telephone/verbal (TO/VO) orders are properly authenticated with signature, date, and time within a 48-hour period of being written in 3 out of 19 out of a total of 23 MRs reviewed (Pt.s #10, 13, and 18). Failure to have properly authenticated TO/VO has the potential to affect all patients receiving care in this facility, including the 14 (averaged) patients present during the course of the survey.

Findings include:

The Medical Staff R&Rs, dated March 23 2012, were reviewed on 1/27/2014 at 4:00 p.m. On page 13 of the R&R provided, section C, "GENERAL CONDUCT OF CARE," the R&R state in part, "All orders dictated over the telephone shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his or her own name. The responsible practitioner or his/her partner shall authenticate such orders within 48 hours."

In an interview with Medical Staff Coord AA on 1/28/2014 at 2:45 p.m., AA stated that this facility allows 48 hours for providers to sign off telephone orders."

A MR review on Pt. #10's closed death record was conducted on 1/29/2014 at 2:40 p.m. accompanied by Quality Mgr A who confirmed the finding. There is a VO dated 5/19/2013 that was not authenticated by the MD until 8/19/13, a time period of 3 months after it was written.

A MR review on Pt. #18's closed swing bed record was conducted on 1/30/2014 at 7:43 a.m. accompanied by Quality Mgr A who confirmed the finding. There is a VO dated 12/13/13 that is not authenticated by the MD.



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Pt #13's MR review on 1/29/2014 at 1:15 PM revealed There are TOs dated 10/20/13 at 6:00 PM, 10/29/13 at 9:15 PM, and 10/29/13 at 10:55 PM that are authenticated by the MD without a date and time. This is confirmed during the MR review with RN Supervisor U stating the MD should time the entry.

Based on MR review, and review of P&P in 3 of 19 out of a total of 23 MRs reviewed (Pts #13 and 14) this facility failed to ensure nursing CPs are individualized to Pts needs. This has the potential to affect all patients treated at the facility including the 14 patients (averaged) during the course of the survey.

Findings include:

Per review on 1/29/2014 at 3:00 PM of facility P&P titled "Nursing Care Plans" dated 1/13 states "1. Upon admission, the RN will complete the Admission Assessment in the EMR. The Admission Assessment will assist to create an individualized care plan. 2. Upon completion of the Admission Assessment, the RN will move to the Care Plan tab and create the care plan to include Daily Standards of Care, Patient Problem, Knowledge Deficit, and any other care plans pushed forward from the assessment (i.e. Level 1 Potential for injury)." The P&P goes on to state "6. Revisions to the care plan can be made at any point during the patient stay by the RN. New problems may be identified and goals/interventions may be revised, referred, discontinued, or added."

A MR review for Pt #13 was conducted on 1/29/2014 at 1:15 PM accompanied by RN supervisor U who confirmed these findings at the time of the MR review. Pt # 13 was admitted for a diagnosis of chest pain. Pt #13 has a history of diabetes and received blood glucose testing four times per day. The CP does not reflect any goals or interventions regarding diabetes or blood glucose testing.

A MR review for Pt #14 was conducted on 1/29/2014 at 1:25 PM accompanied by RN supervisor U who confirmed these findings at the time of the MR review. Pt # 14 was admitted for a diagnosis of bronchitis. Pt #14 has a history of diabetes and received blood glucose testing four times per day. The CP does not reflect any goals or interventions regarding diabetes or blood glucose testing.

Based on 2 of 2 transfer ED records (Pt. #2 and 6) out of a total of 23 MR reviews and 1 of 1 staff interviews (Staff A) this facility failed to maintain a MR that has a properly completed consent to transfer to a higher level acute facility. Failure to obtain properly completed consents has the potential to affect all patients receiving care in this facility including the 14 (averaged) patients present during the time of the survey.

Findings include:

A MR review was conducted on 1/28/2014 at 12:00 p.m. for Pt. #2 and on 1/29/2014 at 1:01 p.m. for Pt. #6 accompanied by Quality Mgr A who confirmed the findings at the time of the record reviews. Both of these patients were transferred to a higher level of acute care due to their conditions.

There are no risks listed on the transfer form or in the MDs documentation regarding what the risks are for either of these patients. Both patients had different diagnoses and were being transferred for different purposes.

In an interview with Mgr A during the time of the MR review for Pt. #2, Mgr A stated, "No, I don't see the risks either. I know they need to be documented."

Based on MR review, review of Medical Staff R&R, and interviews with 3 of 3 staff (B, N, and U), in 12 of 23 MRs reviewed the facility failed to ensure that 1. Pain assessments/reassessments were completed per expectation (Pt. #7, 11, 14, 15, 18, 19, and 23), 2. There were orders for medications and treatments (Pt. #4, 5, and 6), 3. There were properly completed and authenticated orders/forms (Pt. #4, 5, 8, 18, 19, and 20), and 4. That all patients have a completed H&P (Pt. #7). These failures have the potential to affect all Pts treated at this facility including the 14 patients (averaged) during the course of the survey.

Findings include:

The Medical Staff R&Rs, dated March 23 2012, were reviewed on 1/27/2014 at 4:00 p.m. The R&R state in part, "A complete admission history and physical examination shall be recorded within 24 hours of admission fro acute, respite, swing bed and observation patients....All records of discharged patients not otherwise specified above including signatures must be completed within 30 days of the discharge dates. Signatures not done by 30 days from discharge will be considered delinquent.....All orders for treatment shall be in writing....All clinical entries in the patient's medical record shall be accurately dated and authenticated. Authentication means to establish authorship by written signature, identifiable initials, or computer key."

In an interview with Nursing Services Mgr N on 1/28/2014 at 7:40 a.m. regarding RNs conducting pain assessments and reassessments, Mgr N stated that assessments are to be done every four hours and reassessments after medication intervention should be every 30 minutes to one hour.

In an interview with Nursing Supervisor U on 1/29/2014 at 8:00 a.m., Supv U stated that pain reassessments should be done within an hour regardless of the route of the medication.

Per MR review on 1/29/2014 at 1:25 PM accompanied by RN Supervisor U, Pt # 14 received Vicodin for pain on 12/8/2013 at 4:42 PM and did not have a follow up pain assessment documented until 10:11 PM.

Per MR review on 1/29/2014 at 3:10 PM accompanied by RN Supervisor U, Pt # 11 received Percocet for pain on 1/24/2014 at 6:58 PM and did not have a follow up pain assessment documented until 8:45 PM.

Per MR review on 1/29/2014 at 2:20 PM accompanied by RN Supervisor U, Pt # 15 received Dilaudid for pain on 1/21/2014 at 3:44 PM and did not have a follow up pain assessment documented until 5:37 PM. Also on 1/21/2014 Pt # 15 received Dilaudid for pain at 8:19 PM and did not have a follow up pain assessment until 9:41 PM.

Per interview with Quality Coordinator B on 1/29/2014 at 4:00 PM the facility does not have a general pain assessment policy.


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A MR review was conducted on Pt. #4's closed ED record on 1/29/14 at 12:26 p.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #4 came in to the ED on 11/14/13 with complaints of chest pressure. Nursing staff administered oxygen, and medications ("GI cocktail" and Zantac) however no MD order was found for these treatments. Pt. #4's discharge instructions do not have a time they were signed.

A MR review was conducted on Pt. #5's closed ED record on 1/29/14 at 12:51 p.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #5 came in to the ED on 12/4/13 with abdominal discomfort. Pt. #5 had an abdominal ultrasound completed however no MD order was found for this treatment. Pt. #5 left the ED against medical advice (AMA). There is no consent for treatment signed by the patient, or no AMA form completed.

A MR review was conducted on Pt. #6's closed ED record on 1/29/14 at 1:01 p.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #6 came in to the ED on 1/3/14 with blood pressure problems. The MD documented that the MD gave the medication Diltiazam however there is no MD order for this treatment.

A MR review was conducted on Pt. #7's closed swing bed record on 1/29/14 at 1:19 p.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #7 was admitted to swing bed status on 1/4/14, there is no H&P in the swing bed record. Random review of pain assessment/reassessment not being documented per expectation is as follows: On 1/4/14 at 4:35 p.m. received Tramadol, there is no pain score and no reassessment documented; On 1414 at 7:56 p.m. Hydromorphone was given, there is no pain score and no reassessment documented; On 1/5/14 at 12:08 a.m. received Tramadol, pain was reassessed at 1:34 a.m., 30 minutes past the 1 hour time frame.

A MR review was conducted on Pt. #8's closed death record on 1/29/14 at 2:10 p.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #8 was admitted on 1/26/2013 and passed away on 2/4/13. There are several progress notes (PNs) that are not co-signed by the MD reviewing a Physician Assistant within 30 days: PN written 2/2/13, not signed by MD until 3/22/13; PN written 2/3/13 not signed by the MD until 3/22/13; PN written 2/4/13 not signed by the MD until 3/22/13; PN written by the MD on 2/4/13 not signed until 4/2/13. There is no documentation in the MR, or on file with the nursing secretary, of the case number given by the OPO or the name of the OPO representative.

A MR review was conducted on Pt. #18's closed swing bed record on 1/30/14 at 7:43 a.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #18 has an MD order written on 12/16/13 that does not indicate the time it was written. Random review of pain assessment/reassessment not being documented per expectation is as follows: On 12/13/13 received Hydrocodone for pain level of 7 at 1:10 p.m., there is no reassessment; On 2/13/13 received Hydrocodone at 6:42 p.m., no pain level indicated, the reassessment is documented at 10:01 p.m., 3 hours and 20 minutes after medication; On 12/14/13 received Hydrocodone at 12:26 p.m., pain level of 0, no reassessment is documented; On 12/16/13 received Morphine at 5:49 a.m., pain is not rated, a reassessment is documented however pain is still not rated.

A MR review was conducted on Pt. #19's closed OB record on 1/30/14 at 8:18 a.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Pt. #19 was admitted on 12/30/13 for an emergency cesarean section (c-section). The H&P completed on 12/30/13 does not have a time it was completed, and cannot be verified chronologically that it was completed prior to the surgery. The discharge instructions are not dated or signed by the staff member completing them. Random review of pain assessment/reassessment not being documented per expectation is as follows: On 12/31/13 received Toradol at 8:55 a.m., no pain level indicated and pain is not documented as being reassessed until 2:00 p.m.; On 12/31/13 at 3:53 p.m. received Toradol, pain level not documented, pain not documented as being reassessed until 5:34 p.m.

A MR review was conducted on Pt. #20's closed newborn record on 1/30/14 at 8:30 a.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. The discharge instructions are not signed or dated by the staff person completing them.

A MR review was conducted on Pt. #23's closed OB record on 1/30/14 at 9:10 a.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. Random review of pain assessment/reassessment not being documented per expectation is as follows: On 11/2/13 received Toradol at 3:55 a.m., no pain level is documented and pain is not documented as being reassessed until 11/3/13 at 7:24 p.m.; On 11/2/13 at 7:50 a.m. received Hydrocodone, no reassessment was documented until 7:25 p.m. and no pain scale is recorded. On 11/3/13 at 5:33 a.m. received Hydrocodone and pain reassessment is not documented until 7:25 p.m.

Based on observation, P&P review, and 1 of 1 staff interview (Staff M), this facility failed to ensure the confidentiality of numerous Radiology films (x-rays). Failure to ensure confidentiality of patient information has the potential to affect all patients receiving treatment at this facility, including the averaged 14 inpatients present during the survey.

Findings include:

The facility's policy titled, "Confidentiality," dated 7/09 was reviewed on 1/30/2014 at 7:45 a.m. The policy states in part that, "Confidential papers, reports, and computer printouts should be kept in a secure place."

An observation of a housekeeping storage room was made on 1/28/2014 at 10:45 accompanied by Construction Liaison H, Construction Supervisor I, and Plant Mgr G. It was noted that in this area where housekeeping staff store their large floor machines/buffers there were shelves upon shelves full of Radiology films that contained patient information such as name and date of birth in paper envelopes. In addition to the x-rays on the shelves there were two large blue bins, each half full of x-rays, that were not in envelopes.

These medical records are not secured in any manner and could be accessed by personnel not authorized to access them.

In an interview with Imaging Services Mgr M on 1/28/2014 at 1:10 p.m., Mgr M stated that M is aware of the area where the Radiology films are and understands that they are currently not secured against unauthorized access. Mgr M stated that the films in the blue bins were being readied for disposal.

Based on review of Quality program data and interviews with 4 of 4 staff (Staff A, B, M, and Z ), this facility failed to ensure all services affecting patient care are evaluated and included in the overall Quality plan for the facility. Failure to evaluate all services for quality of care has the potential to affect all patients receiving care in this facility. The average daily census during the survey was 14.

Findings include:

In an interview with Imaging Services Mgr M on 1/28/2014 at 1:10 p.m. regarding the contracted telemedicine service it was determined that this contracted service does do tracking and trending of QI data and Mgr M receives a quarterly report from them.

Mgr M does not, however submit this data to the QI Coord for inclusion in the overall QI program.

On 1/29/2014 at 10:21 a.m. an interview with Quality Mgr A and Quality Coord B was completed. When asked how contracted services were being monitored for quality, Coord B stated that the department Mgrs are responsible to monitor contracted services for quality.

In an interview with CEO Z on 1/28/2014 at 2:15 p.m. regarding Governing Body involvement to ensure contracted services are being provided in a safe and effective manner, CEO Z stated that the Governing Body has delegated this to the departments that use the contracted services to ensure that the services are safe.

Based on document review, MR review, and 1 of 3 staff interviews (Staff P), this facility failed to include all of the required contents for the discharge notice in the information provided to 2 of 2 swing bed patients (Pt. #7 and 18). Failure to provide all discharge information to swing bed patients has the potential to negatively affect all swing bed patients. There were 0 swing bed patients out of 14 (averaged) patients present during the course of the survey.

Findings include:

Review of the discharge information sheet given to swing bed patients was done on 1/28/2014 at 7:15 a.m. The form does not include where the patient will be transferred/discharged to, the name and contact information of the State long term care ombudsman, the contact information for the agency responsible for protecting developmentally disabled individuals, or the contact information for the agency responsible for protecting mentally ill individuals.

In an interview with SW P, Nursing Mgr N, and Quality Mgr A on 1/28/2014 at 1230, SW P confirmed that the discharge notice does not have all of the information on it.

MR reviews were done the closed swing bed records for Pt. #7 on 1/29/2014 at 1:19 p.m. and Pt. #18 on 1/30/2014 at 7:43 a.m. accompanied by Quality Mgr A who confirmed the findings at the time of the MR review. The required information is not present on the discharge form.