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Based on observation, interview, record review, review of service invoices, and review of the facility's performance maintenance policy, it was determined the facility failed to ensure that all patient care equipment was maintained in safe operating condition. Observation revealed the facility utilized two (2) portable water treatment machines (machines that treat the water used for Hemodialysis to ensure the water is safe) for Hemodialysis. The machines required Preventative Maintenance (PM) every year; however, the facility had not conducted PM on the portable water treatment machines since February 2016.

Based on observation, interview, record review, review of service invoices, and review of the facility's performance maintenance policy, it was determined the facility failed to conduct Performance Maintenance (PM) on the portable water treatment machines (machines that filter the water before the water can be used for hemodialysis) used for Renal Hemodialysis (a process of purifying or removing toxins from the blood of a person whose kidneys are not working normally) to ensure the machines were in safe operating condition. Observation revealed the facility had two (2) portable water treatment machines in use for Hemodialysis. Review of the manufacturer's recommendations revealed the water treatment machines required annual PM; however, a review of the service invoices for the portable water treatment machines revealed PM had not been completed since February 2016, approximately two (2) years ago.

The findings include:

Review of the facility's policy titled "Performance Maintenance," undated, revealed all equipment specified as biomedical equipment would be inventoried and checked on a regular basis. According to the policy, frequency of inspection would be determined by the type, accessibility, and manufacturer's recommendations. Review of the manufacturer's guidelines revealed Performance Maintenance should be completed on an annual basis.

A review of service invoices for the portable water treatment machines revealed PM had not been conducted since 02/05/16.

Review of a facility roster revealed from 02/05/17 through 02/12/18, the facility had dialyzed eighteen (18) patients using the portable water treatment machines that had not received PM. Further observation on 02/14/18 revealed the facility utilized the portable water treatment machines.

Interview with Biomedical Equipment Contractor #1 on 02/14/18 at 2:30 PM, confirmed the last scheduled PM completed on the portable water treatment machines was on 02/05/16. The contractor stated the company stopped servicing the machines at that time and had not conducted any further PM.

Interview with Biomedical Equipment Contractor #2 on 02/12/18 at 12:25 PM, revealed they were contracted to perform PM on the portable water treatment machines; however, they had not been contacted to conduct the service and PM had not been provided.

Interview with the Director of Dialysis on 02/15/18 at 11:55 AM, also confirmed that there was no documented evidence that PM had been completed on the two (2) portable water treatment machines used for Hemodialysis at the facility. The Director of Dialysis further stated that the water treatment machines received service for necessary repairs in June and July of 2017; however, PM was not completed at that time.

Based on observation, interview, record review, and review of facility policy, it was determined that the facility failed to supervise and evaluate the nursing care for one (1) of fifteen (15) sampled patients (Patient #7). Patient #7 was admitted to the facility with a diagnosis of Hemicraniectomy (surgical removal of a portion of the skull) and was assessed to be at high risk for falls. Upon admission Patient #7's physician ordered a therapy evaluation to obtain a protective helmet for the patient due to a history of frequent falls. However, the facility failed to obtain protective head gear to prevent injury. According to Patient #7's medical record, the patient continued to be at risk for falls and got out of bed/chair unassisted, with no evidence the patient had any protective head gear.

Based on observation, interview, record review, and review of facility policy, it was determined that the facility failed to supervise and evaluate the nursing care for one (1) of fifteen (15) sampled patients (Patient #7). On 02/01/18, Patient #7 was admitted to the facility and was assessed to be at high risk for falls. Patient #7's physician ordered a Therapy evaluation to obtain a protective helmet due to a history of surgical removal of a portion of the patient's skull. However, the facility failed to obtain protective gear for the patient's head.

The findings include:

Review of the facility's policy titled "Fall Assessment and Prevention," dated December 2017, revealed the facility would assess each patient's fall risk and take action to address any identified risk.

Review of the medical record for Patient #7 revealed the facility admitted the patient on 02/01/18 with diagnoses that included status post acute hospitalization related to a right Hemicraniectomy (surgical removal of a portion of the skull) with a skin flap, status post acute hospitalization with fever and aspiration, and a history of frequent falls.

Review of Patient #7's Nursing Admission Assessment dated 02/01/18 at 9:00 AM revealed Patient #7 was assessed to be at high risk for falls and scored a 90 on the Morse Fall risk assessment (a score of 45 or greater indicates a high fall risk).

Review of a Physical Therapy (PT) Evaluation dated 02/01/18 revealed Patient #7 demonstrated an unsteady gait with poor balance and was an "impulsive fall risk."

Review of Patient #7's History and Physical dated 02/01/18 revealed the patient had a history of frequent falls. The physician's plan was to consult Occupational Therapy for helmet protection due to a history of frequent falls. Review of physician orders dated 02/01/18 at 9:58 AM revealed an order for an Occupational Therapy evaluation that stated, "Order helmet for head."

Review of the Occupational Therapy (OT) Evaluation dated 02/01/18 revealed the OT evaluated Patient #7 and documented that the patient had a helmet at home but did not have one at the facility. Further review of the recommendations made by OT revealed the OT recommended discontinuing OT services after the evaluation and documented no plan to obtain a helmet for the patient.

Further review of the Physical Therapy treatment notes dated 02/02/18 through 02/12/18 revealed Patient #7 continued to be a fall risk and was noted to have a "scissoring patterned" gait, poor balance, and "assistance needed for all functional mobility and activity." However, there was no evidence the facility obtained a helmet to protect the patient's head from injury should a fall occur.

Review of nursing notes dated 02/09/18 at 6:28 AM, 01/10/18 at 8:00 PM, and 02/11/18 at 8:00 AM, revealed Patient #7 got up unassisted, with no evidence the resident had protective head gear. On 02/09/18, staff found Patient #7 out of bed at the sink drinking water without staff assistance. On 02/10/18, the patient was sitting on the side of the bed and attempted to stand to go to the restroom. Further review of the nursing notes revealed on 02/11/18, Patient #7 jumped out of a geri-chair while staff were transporting the patient down the hallway.

Observation of Patient #7 on 02/12/18 at 12:45 PM revealed a Certified Nursing Assistant (CNA) was transferring Patient #7 without a protective helmet in place.

Interview with the Director of Physical Therapy on 02/13/18 at 3:16 PM revealed Patient #7 required a helmet for safety due to a previous head injury resulting in the surgical removal of a portion of the patient's skull.

Interview with Registered Nurse (RN) #2 on 02/13/18 at 10:42 AM revealed she was aware Patient #7 required a helmet to prevent head trauma. RN #2 stated the facility had attempted to obtain the patient's helmet from home but had been unsuccessful. However, there was no evidence any further action was taken to protect the resident from head trauma.

Interview with the Director of Nursing (DON) on 02/15/18 at 11:45 AM, revealed the facility was attempting to obtain Patient #7's protective helmet from home, but did not believe the unavailability of a helmet placed the resident at risk for injury.

Interview with the Medical Director on 02/15/18 at 11:30 AM, revealed the physician ordered an OT evaluation for Patient #7 for the purpose of obtaining a protective helmet for the patient. However, the physician stated that he conducted no follow-up to ensure the equipment was obtained. The physician stated that once OT was ordered, OT developed their own plan of care, and he had no further involvement.

Based on interviews, record reviews, and review of facility policies it was determined the facility failed to follow their policy and procedure when prescribing Schedule II medications (drugs that are considered controlled substances are divided into five schedules based on whether they have a currently accepted medical use in treatment, their relative abuse potential, and likelihood of causing dependence when abused) for two (2) of fifteen (15) sampled patients (Patient #1 and Patient #2).

The findings include:

Review of the facility policy titled "Automatic Stop Orders," revised 12/19/17, revealed controlled substances would have an automatic stop date after thirty (30) days.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 12/04/17 with diagnoses that included Spina Bifida, Paraplegia, and Sacral Decubitus. Review of Patient #1's physician orders for 12/13/17 revealed an order for Hydrocodone/Acetaminophen 7.5 mg/325 mg one tablet every six (6) hours. The order was written for 12/13/17 to 12/13/18, a period of 365 days.

Review of the medical record for Patient #2 revealed the facility admitted the patient on 01/19/18 with diagnoses that included Debilitation, status post acute hospitalization for pneumonia/sepsis, respiratory failure, and Stage 5 renal failure and dialysis. Review of the physician orders for the patient for 02/01/18 revealed an order for Hydrocodone/Acetaminophen 5 mg/325 mg one tablet every eight (8) hours. The order was written from 02/01/18 to 02/01/19, a period of 365 days.

Interview with the Chief Pharmacist on 02/13/18 at 2:08 PM revealed it was facility practice for Schedule II narcotics to be ordered for a period of thirty (30) days at a time. The Pharmacist stated the pharmacy monitored medications monthly, but had not identified that Patient #1 and #2's medications did not have a 30-day stop date.

Interview with the Medical Director on 02/15/18 at 11:30 AM revealed that Nursing and Pharmacy should have identified that the Schedule II medications for Patients #1 and #2 did not have a stop date of 30 days.

Based on interviews, record reviews, and review of the facility policy, it was determined the facility failed to ensure a History and Physical was completed within twenty-four (24) hours of admission for one (1) of fifteen (15) sampled patients (Patient #2). Patient #2 did not have a History and Physical completed until three days after admission.

The findings include:

Review of the Medical Staff Bylaws, Rules and Regulations, undated, revealed a complete history and physical examination would, in all cases, be dictated or written within twenty-four (24) hours of the patient's admission.

Review of the facility's policy titled "Swing Bed Admission Criteria/Process," revised December 2017, revealed the admitting physician would complete a patient assessment and dictate a History and Physical within 24 hours of patient admission.

Review of the medical record for Patient #2 revealed the facility admitted the patient on 01/19/18 with diagnoses that included Debilitation, status post acute hospitalization for pneumonia/sepsis, respiratory failure, Stage 5 Renal Failure, and Dialysis. However, a review of Patient #2's History and Physical was not completed and dictated until 01/22/18 (three days after the resident was admitted).

Interview with the Medical Director on 02/15/18 at 11:30 AM, revealed he believed the Emergency Department (ED) physician's screening could be used as a History and Physical (H&P), and he did not complete a History and Physical within 24 hours if the ED physician had screened the patient.

Interview with the Health Information Manager (HIM) on 02/13/18 at 3:30 PM, revealed she could not track to ensure a History and Physical was completed until the patient was discharged and the medical record was closed. Continued interview with the HIM confirmed the Emergency Department (ED) screening did not suffice as a completed History and Physical.

Based on interviews, record review, and review of the facility's Medical Staff Rules and Regulations revealed the facility failed to ensure all physician orders were authenticated with the date and time of the physician's signature for four (4) of fifteen sampled patients (Patient #2, Patient #4, Patient #7 and Patient #8).

The findings include:

Review of the facility's Medical Staff Bylaws Rules and Regulations, undated, revealed all clinical entries in the patients' medical record shall be accurately dated and authenticated. The Medical Staff Bylaws did not address the need for the entries to be timed per the regulation.

1. Review of the medical record for Patient #2 revealed the facility admitted the patient on 01/19/18 with diagnoses that included Debilitation status post-acute hospitalization for pneumonia/sepsis, Respiratory failure, Stage 5 Renal Failure, and Dialysis. Review of Patient #2's physician orders from 02/02/18 through 02/06/18 revealed the Medical Director signed eleven (11) orders; however, he did not include the date or time the order was written.

2. Review of the medical record for Patient #4 revealed the facility admitted the patient on 12/27/17, with diagnoses that included right lower edema with cellulitis, Diabetes, and depression. Review of the physician orders dated 01/30/18, revealed the Medical Director signed the order, but failed to date or time with his signature.

3. Review of the medical record for Patient #7 revealed the facility admitted the patient on 02/01/18 with diagnoses that included status post right Hemicraniectomy with a skin flap, status post hospitalization for fever and aspiration, and a history of frequent falls. Review of Patient #7's physician orders for 02/01/18 and 02/02/18 revealed the Medical Director wrote six (6) orders for the patient. The Medical Director signed the orders, but had failed to include the date and time the order was written.

4. Review of the medical record for Patient #8 revealed the facility admitted the patient on 02/08/18, with diagnoses that included status post-acute hospitalization for Pneumonia, Chronic Kidney Failure, Chronic Respiratory Failure, and Immobility. Review of the physician orders for the patient revealed on 02/08/18 and 02/09/18, the Medical Director signed six (6) orders; however, the physician failed to date or time the order.

Interview with the Medical Director on 02/15/18 at 11:30 AM, revealed he always signed orders, and understood that he should also date and time the order, but sometimes failed to ensure the date and time was on each order.