HospitalInspections.org

Based on interview and record review the facility governing body failed to ensure the Interim Physician Director of the Emergency Department was appointed to the facility Medical Staff with recommendations from the current medical staff members. The facility census was 48.

Findings included:

1. Review of the Medical Staff Bylaws, approved by the Governing Board, 10/07/11 showed the following:
-Definitions; paragraph 13. Physician means an individual with an M.D. [Doctor of Medicine] or D.O. [Doctor of Osteopathic Medicine] degree who is currently licensed to practice medicine in the State of Missouri.
-Article II, Membership; 2.1 Nature of Membership; No practitioner, including those in a administrative position by virtue of a contract or employment within the Hospital, shall admit or provide medical or health related services to patients in the Hospital unless they are members of the Medical Staff.
-Article II Hospital Employed or Contracted Members; Members who are employed or contracted by the Hospital to render services to it shall be subject to the Bylaws, Rules and Regulations and policies of the Medical Staff irrespective of whether the services rendered pursuant to such arrangement involve clearly clinical responsibilities, purely administrative responsibilities, or both clinical and administrative responsibilities.

2. During an interview on 10/31/12 from 9:30 AM through 11:20 AM Staff F, Medical Staff Coordinator stated the following:
-She maintained credentialing and privileging files on all members of the facility Medical Staff.
-The credentialing and privileging process involved recommendations and approvals by the physician department head, the physicians of the Medical Executive Committee and final approval of the appointment by the Governing Board.
-She did not have a credentialing file for Staff I, Interim Director of the Emergency Department (ED) because he was not a credentialed and privileged staff.
-Staff I was not licensed to practice medicine in the State.
-Staff I was contracted to perform administrative duties in the ED.

During an interview on 11/01/12 at 8:25 AM Staff BBB, Chief Executive Officer (CEO) confirmed he hired Staff I as a contractor to perform administrative duties in the ED. The CEO stated that Staff I:
-Was not licensed in the State,
-Was not a member of the facility Medical Staff.
-Did not undergo credentialing and privileging as outlined in the Medical Staff Bylaws [including recommendation by current members or the Medical Executive Committee of the medical staff].

Based on interview and record review the facility Governing Body failed to ensure the Chief Executive Officer (CEO) managed the operation of the facility to ensure:
-One contracted physician was credentialed, privileged and licensed as a physician in the state.
-Contractors providing direct patient care and services were systematically evaluated and that evaluation was incorporated into the quality assessment and performance improvement program (QAPI).
-The plan of correction from the most recent survey (08/22/12, during which problems with nursing care for patients with pressure ulcers were found) was followed to sustain an effective correction of cited deficiencies for one (Patient #6) of one patient . The facility census was 48.

Findings included:

1. Review of the Medical Staff Bylaws, approved by the Governing Board, dated 10/07/11 showed hospital employed or contracted members who are employed or contracted by the Hospital to render services to it shall be subject to the Bylaws, Rules and Regulations and policies of the Medical Staff irrespective of whether the services rendered pursuant to such arrangement involve clearly clinical responsibilities, purely administrative responsibilities, or both clinical and administrative responsibilities.

2. During an interview on 11/01/12 at 8:25 AM Staff BBB, Chief Executive Officer (CEO) confirmed that he hired Staff I as a contractor to perform administrative duties in the ED. The CEO stated that Staff I:
-Was not licensed in the State of Missouri;
-Was not a member of the facility Medical Staff;
-Did not undergo credentialing and privileging as outlined in the Medical Staff Bylaws.

3. Record review of the facility's "Performance Improvement Program and Plan" showed it did not address the facility's 21 contracted services. Some of the 18 of 21 contracted services had data collected but failed to report the findings to the QAPI Committee or the Governing Body.

During an interview on 11/01/12 at 8:25 AM, Staff BBB stated he thought some of the physician contractors were undergoing peer review.

4. Review of the facility Plan of Correction (POC) from the most recent survey showed the facility was cited for failure to prevent patients from developing pressure ulcers and cited for failure to provide pressure ulcer assessment, care and treatment. Further review of the POC dated 09/27/12 showed nursing staff developed competencies for pressure ulcer care, staff were trained and care was audited.

5. During an interview on 11/01/12 at 8:25 AM Staff BBB, stated that:
-After the survey of 08/22/12, he held meetings twice weekly with action teams to discuss and monitor the POC;
-Weekly meetings were decreased the week of 10/22/12;
-Staff A, RN, Vice President (VP) of Nursing was a member of the action team and had oversight of monitoring the nursing care outlined in the pressure ulcer POC;
-He was unaware of the results of Staff A's monitoring and surveillance activities.
-He felt the nursing staff should be doing better with pressure ulcer assessment, care and treatment and if not, there would be some face to face meetings with him.

Based on interview and record review the facility's Governing Body failed to ensure direct patient care services provided under contract agreements were accomplished in a safe, effective manner that was systematically evaluated and integrated into the facility quality assessment and performance improvement (QAPI) program for 18 of 21 contracted services. The facility census was 48.

Findings included:

1. Review of the facility "Organization Plan for Provision of Patient Care" revised by the facility Board of Directors (governing body) on 09/24/09 showed the following direction:
-The purpose of the plan was to support improvement and innovation in the delivery of patient care including nursing practice.
-The organizational Performance Improvement Plan provided for the involvement of all services working together using the interdisciplinary model to arrive at decisions to modify and change practices.
-Management of the organizational performance improvement activities were coordinated and reviewed through the Quality Council Committee .
-The activities reviewed through the Quality Council Committee were reviewed by the Medical Executive Committee and the Board of Trustees (governing body).
-The Organization Plan for Provision of Patient Care outlined each unit, department and service with scope of service, staffing and team member qualifications.

The Plan failed to address how any contracted services or specialists would be included in the QAPI program.

2. Record review of facility's document titled, "Performance Improvement Program and Plan" dated 10/12, gave no direction or inclusion for the facility's contracted services.

3. During an interview on 10/31/12 at 10:00 AM, Staff B, Registered Nurse (RN), Director of Performance Improvement Operations and Staff KK, Medical Doctor (MD), Chief of Staff and Vice President of Quality Management, stated that there was little to no QAPI evidence for 18 of 21 contracted services which included direct patient care services.

4. During an interview on 11/01/12 at 9:50 AM Staff B stated he did not know if the Governing Board knew about the quality of work or any problems with contractors.











27029

Based on observation, interview and record review the facility failed to provide Emergency Department patients or their representatives with a notice of their patient rights before the patient received care. This had the potential to affect all patients presenting for care in the Emergency Department. The facility census was 48.

Findings included:

1. Record review of the facility's policy titled, "Patient Rights and Responsibilities" dated 05/14/12 showed:
-Administrative Responsibility: The Vice President - General Counsel is responsible for administering, interpreting and implementing this policy. All Team Members are accountable for policy compliance;
- Each patient, or their designated decision maker, shall be offered a published statement of patient rights and responsibilities and given an opportunity to discuss these rights during the patient registration process. For those patients with special needs, alternative methods of communication will be offered.

2. Observation on 10/31/12 at 8:45 AM showed a large emergency waiting room. Inside the emergency department patient care area was a large nurses' station surrounded by 18 patient care bays (rooms). There was no signage regarding patient rights posted in the emergency department waiting room or the 18 patient care rooms.

3. During an interview on 10/31/12 at 9:00 AM, Staff DDD, Emergency Department Admitting Clerk, stated that she did not give patients a notice of their Patient Rights when they registered to receive care in the emergency department. She stated that she told them if they wanted more information that it is over there - Staff DDD pointed to a wall of approximately 20 paper brochures.

4. Observation during the interview showed the wall of brochures was approximately six feet from the admission desk and faced the desk, not the waiting room. One of the brochures on the wall did contain a notice of the Patient Rights explained only in the English language.

5. During an interview on 10/31/12 at 9:15 AM, Staff JJ, RN, Director of Emergency Services, stated that the facility's patient base spoke primarily English but understood why the notice of Patient Rights should be offered in different languages should a patient present to the department that spoke another language.

Based on record review and interview the facility failed to ensure three (Patient's #15, #17 and #44) of three patients were asked if they had an advanced directive. The facility failed to promote the patients' rights to formulate an advanced directive while a patient is in the facility. This had the potential to affect all patients who are admitted to the facility. The facility census was 48.

Findings included:

1. Record review of the facility's policy titled, "Advanced Directives" dated 09/11, showed the following direction:
-How staff are to identify and communicate the presence of a patient's advanced directives;
-All patient care and registration staff are responsible for policy compliance;
-At the time of registration, all patients and/or representatives will be asked if an advanced directive has been executed by or for the patient;
-All patients not having an advanced directive will be provided written information explaining advanced directives if desired (facility punctuation.)
-When an advanced directive exists; it will be obtained by all reasonable efforts, documented, verified, placed in the chart and the patient's physician will be notified and appropriate orders will be obtained.

2. Record review on 10/29/12 at 2:40 PM of the Healthcare Directive Information sheet for Patient #15 showed a checked box marked "NO Heart-Lung Resuscitation (CPR)", and one line had a hand written word "DNR" (do not resuscitate) on an unspecified line. The form contained several blank spaces which included:
-Actions taken to obtain (the advanced directive);
-Verification;
-Verbal instructions (from patient);
-Physician notification and orders received;
-Documentation received in/to medical record.

Staff failed to obtain Patient #15's advanced directive, verify and update if necessary and inform the attending physician.

3. Record review on 10/30/12 at 1:08 PM of the Healthcare Directive Information sheet for Patient #17 showed the form was blank with only the signature of a Registered Nurse (RN).

Staff failed to obtain any information from the patient regarding his advanced directives.

4. Record review of the medical record face sheet for Patient #44 showed a section titled "ADVANCE DIRECTIVES". The advanced directive section listed the word "Guardian" and no other information. The record failed to have a Healthcare Directive Information sheet. Staff failed to obtain information related to advanced directives and make the information known to the healthcare providers or record the information in the medical record of the patient.

5. Record review of a facility's pamphlet titled, "Patient Rights & Responsibilities" dated 03/11, the pamphlet showed patients have the right to:
-An advanced directive (written or oral instructions);
-The advanced directives honored; and
-Change, withdraw, or make new advanced directives.

6. During an interview on 10/29/12 at 3:55 PM , Staff Q, Patient Registration Clerk, stated that information related to advanced directives are provided on the patient care units and that she provided advanced directive pamphlets only when requested.

7. During an interview on 10/30/12 at 8:30 AM, Staff BB, Social Worker, Director of Social Services, stated that the admissions clerk and admitting nurses provided packets to patients with a patient rights pamphlet which contained information about advanced directives. She stated that when nursing staff assessed the patient and had questions about advanced directives they enter an order in the computer for a Social Worker consultation.

8. During an interview on 10/31/12 at 3:30 PM, Staff C, RN, Licensing and Accreditation Coordinator, stated that she was unaware of a procedure for providing patients with information about their right to have their advanced directives honored. She was unaware of a facility policy and procedure that promoted or educated the patients about their rights to develop an advanced directive.

Based on record review and interview the facility failed to establish guidance to staff to protect the patient when allegations of abuse or
neglect involved facility staff and failed to provide direction for a thorough, prompt and timely investigation and process for reporting possible abuse or neglect in accordance with applicable local, State, or Federal law. The facility census was 48.

Findings included:

1. Record review of the facility policy titled, "Identification/Care of Suspected Victim of Abuse, Exploitation of Neglect" dated 05/12 showed guidance for staff to take when they identified abuse and neglect of patients from family, visitors or community but failed to provide guidance for staff when facility staff were suspected of abuse and neglect. The policy gave direction to notify the Department Manager or Clinical Coordinator and contact the appropriate community agency as directed. The facility failed to provide measures to protect the patient when allegations of abuse or neglect involve facility staff, failed to provide direction for a thorough, prompt and timely investigation and process for reporting in accordance with applicable local, State, or Federal law.

2. During an interview on 10/31/12 at 2:45 PM, Staff B, the Director of Quality and Patient Safety Officer, stated that the facility did not have a policy and procedure which provided staff guidance for what actions to take in the event they suspected another staff member has abused or neglected a patient. Staff B provided the facility policy titled, "Disciplinary Procedures" dated 07/06.

3. Record review on 10/31/12 at 3:30 PM of facility policy titled, " Disciplinary Procedures" dated 07/06 showed examples of serious offenses whereby the staff 's employment would be terminated. Examples shown in the policy were:
-Physical or verbal abuse of patients, visitors or other team members;
-Neglect or mismanagement of patients;
-Falsification of records;
-Assault.

4. During an interview on 10/31/12 at 2:45 PM, Licensing and Accreditation Coordinator, Staff C, stated that she was unaware of a policy and procedure, which provided written guidance to staff when they suspected abuse by another staff member. She stated that staff would just know to report the activity to their supervisor. Staff C stated that she did not know if during the investigation the person suspected of abuse would be assigned patient care duties.

5. During an interview on 10/31/12 at 4:00 PM, Staff B, Director of Quality and Patient Safety Officer, stated that he was unaware of a policy and procedure, which provided written guidance to staff when they suspected abuse by another staff member. He stated that the Human Resources Department would take care of issues regarding abuse and neglect and would take care of discipline and that he did not know if the person suspected of abuse would provide patient care during the investigation. He stated that the Human Resources Department would take care of reports of allegations of abuse and neglect and that he was not aware of any allegations or investigations of abuse and neglect.

Based on observation, record review and interview the facility failed to ensure the protected health information of two (Patients #44 and #45) patients was not disclosed to unauthorized persons. The facility census is 48.

Findings included:

1. Record review of a facility policy titled, "Use and Disclosure of Protected Health Information (PHI)," dated 01/10 showed that the patient's authorization is required prior to the use of disclosure of their PHI if the disclosure is not for treatment, payment, health care operations, fundraising, or required by law.

Record review of the facility's policy titled, "Request for Protected Health Information and Verification of Requestor," dated 08/11 showed that the policy purpose is to protect PHI from unauthorized disclosure and all staff are accountable for policy compliance. Policy guidance showed staff is to verify the identity of the requestor of PHI and released only to authorized persons.

2. Record review of the facility's pamphlet titled, "Notice of Privacy Practices" dated 12/09 and provided to patients at the time of registration, showed that patients will be informed, except in an emergency, of any disclosure of their PHI if other than for treatment, payment, health care operations, fundraising, or required by law.

3. Observation on 10/31/12 at 11:00 AM on the medical unit showed Staff QQ, Registered Nurse (RN), Clinical Coordinator, informed three men who were approaching (approximately 6 feet away) the nurses' station that Patient #45 was discharged "Monday". Before the visitors could provide the patients name or inquire about the patient's status, Staff QQ gave the patient's name to the visitors and gave them the patient's discharge date.

4. Observation on 10/31/12 at 11:10 AM on the medical unit showed Staff SS, RN, provided an outside agency Case Worker (not a facility staff member) the following information about Patient #44:
-Date of admission;
-Medical diagnosis;
-Surgical and procedural information;
-Prognosis;
-Expected date of discharge.

Staff SS did not verify the identity of the outside agency Case Worker and did not verify if the person was authorized to receive the PHI for Patient #44.

5. During an interview on 10/31/12 at 11:15 AM, Staff FFF, a non-facility employee Case Worker, stated that she assisted Patient #44 with housing needs in the community and did not ask for all the health information provided by Staff SS, RN. She stated she did not verify her identity to Staff SS and was not wearing visible identification. She stated she was surprised to obtain so much information about Patient #44.

6. Record review of Patient #44 medical record showed no documentation of consent or authorization of the release of PHI information to any persons.

7. During an interview on 10/31/12 at 11:25 AM, Staff QQ, RN, stated that she checks the face sheet of the patient's medical record and whomever is listed anywhere on the face sheet can have information about the patient and that she is unaware of any other form of consents obtained from the patients for releasing information about their care.

8. During an interview on 10/31/12 at 11:28 AM, Staff OO, Unit Secretary, stated that she checks the face sheet of the patient's medical record and whomever is listed anywhere on the face sheet can have information about the patient.

9. During an interview on 10/31/12 at 1:15 PM, Staff C, RN, Licensing and Accreditation Coordinator, stated that she is unaware of a policy or procedure, which provides guidance to staff regarding a process for ensuring the confidentiality of patient's medical records. She verified the information listed on the face sheet does not reflect persons who are authorized by the patient to access PHI of any patient.

Based on interview and record review the facility failed to ensure two of two Registered Nursing staff (Staff DD and Staff JJ) who were trained in the application of physical restraints were also trained in first aid techniques for patients in restraints. The facility census was 48.

Findings included:

1. Review of Staff DD's personnel file showed the staff person was a registered nurse (RN) who worked in the Intensive Care Unit (ICU). Review of Staff DD's training and education file showed she had completed annual mandatory patient restraint education dated 04/12/12.

Review of Staff JJ's personnel file showed the staff person was an RN assigned in the Emergency Department. Further review of Staff JJ's training and education file showed she had completed annual mandatory patient restraint education dated 09/22/12.

2. During an interview on 10/31/12 at 2:45 PM Staff NN and Staff MM, both Organizational Learning and Clinical Education staff confirmed nursing staff who were routinely assigned to patient units where application of restraints could be necessary were trained in application of restraints however none received training in providing first aid to a patient in restraints. Staff NN stated first aid training was not part of the annual restraint training and no specific first aid interventions were included in the annual mandatory patient restraint education (computer based training in-service).

3. Review of the annual mandatory patient restraint education (computer based training in-service program) showed first aid for a patient in a restraint was not addressed.

Based on interview and record review the facility failed to develop and maintain an effective Quality Assessment and Performance Improvement (QAPI) Program that included all hospital departments and 18 of 21 contracted services. The QAPI program failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program focused on specific indicators related to improving health outcomes.

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at 42 CFR 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

Please refer to A 0273

Based on interview and record review the facility failed to incorporate Nuclear Medicine Services, Discharge Planning Services, the Dietary Department and 18 of 21 contracted services including Dialysis Services and the Medical Director for Emergency Services into the hospital-wide Quality Assessment and Performance Improvement Program (QAPI). This had the potential to affect all patients receiving care in the facility. The facility census was 48.

Findings included:

1. Record review of the facility's document titled, "Performance Improvement Program and Plan" dated 10/12 gave the following direction:
- All clinical and non-clinical key processes are assessed for their level of performance to determine their stability, capability and opportunity for improvement;
- The scope of the Performance Improvement Program is hospital wide and by the selection process performed by leadership;
-Review performance data for achievement of goals to elicit possible recommendation of new priorities for planning to the Quality Council annually.

Further review showed the Plan did not address contracted services.

2. During an interview on 10/31/12 at 11:13 AM, Staff B, Registered Nurse (RN), Director of Performance Improvement Operations, stated that the Nuclear Medicine Department reviewed extravasations (escape of blood from the vessels into the tissue) data, but did not contribute to the overall hospital-wide quality program. Staff B stated that he had not requested data from Nuclear Medicine for at least seven months, or since 03/12.

3. Record review of a facility's Quality Scorecard (data collected and analyzed internally for quality improvement) for Social Services/Discharge Planning, for the year of 2012 showed the following objectives:
- Social Workers will attend and participate in care conference meetings with a goal of 89% to 94%. The goal was met and/or exceeded in all months except for May at 86%;
-Orthopedic patients receiving total joint replacement surgery will have a social service assessment with a goal of 95% to 97 %. The goal was met and/or exceeded in all months except for April at 88%, June at 73%, and July at 68%;
-Assist in achieving a PRC (patient questionnaire) score of 60% or above in overall teamwork with a goal of 60% to 65%. The goal was met all months with an average of 75%.

4. During an interview on 11/01/12 at 9:02 AM, Staff CCC, Social Worker, stated that even though they had met their goals, the same targets and objectives had been used for at least two years. Staff CCC also stated that she was not certain the Social Services quality data was elevated into the overall hospital-wide quality program.

Social Services staff failed to annually evaluate the need to continue the objectives since goals were being met.

5. During an interview on 10/30/12 at 9:42 AM Staff H, Director of Dietary stated that Dietary staff collect data regarding the food temperatures of patient trays and patient meal tray accuracy, however the data collected was never sent out of the department to the QAPI committee. Staff H stated that the Dietary Department did not have any methods to identify possible problems for inclusion into the facility wide QAPI plan.

6. During a concurrent interview on 10/31/12 at 10:00 AM, Staff B, and Staff KK, Medical Doctor (MD), Chief of Staff and Vice President of Quality Management, stated that the majority of the contracted services were not included in the hospital-wide QAPI Program. Some of the 18 of 21 contracted services had data collected but failed to report the findings to the QAPI Committee or the Governing Body.

7. During an interview on 10/31/12 at 1:55 PM, Staff B, stated that the contracted dialysis service collected data on times dialyzed and pre/post weights; however, this data was not included into the hospital-wide quality program.

8. Record review of documents provided by Staff B, Director of Quality, as evidence of QAPI activities performed by a selected few contractors showed only work orders for repair of sterilizer equipment and laser equipment and not any assessment of the quality of work provided by the contractors.

9. During an interview on 11/01/12 at 9:50 AM Staff B stated that he did not know if the Governing Board knew about the quality of work or any problems with contractors.

10. Record review of the personnel file and credentialing file for contracted physician, Staff I, Medical Director of Emergency Services, showed no documentation for education, experience, specialized training, physician license, background check, references (credentialing) or privileging (clinical procedures and treatments).

11. During an interview on 10/31/12 at 10:00 AM, Staff A, CEO, stated that Staff I was a consultant and the facility had a contract with Staff I. The CEO stated that he wasn't aware that he should have a credentialing file for the Medical Director, (Staff I.)

The Governing Board should be made aware of all facility-wide Quality Improvement Program data which should include any quality improvement activities related to the facility departments and contracted services to include the Emergency Department.




12450




16215

Based on observation, interview and record review the facility failed to:
- Prevent, identify, assess or provide nursing care for two (Patients # 6 and #30) of three patients with pressure ulcers;
- The facility failed to initiate the standardized protocol for treatment of Stage I (reddened skin that does not show good circulation when touched) or Stage II pressure ulcers (partial thickness skin loss that appears as a blister or shallow crater) for one (Patient #6) of three patients with pressure ulcers; and
- The facility failed to identify the soft deep-tissue injury (SDTI-damage to underlying tissue, presenting as a darkened, soft area-typically opens as a pressure ulcer if pressure is not relieved) for one of one patient (Patient #30) to the coccyx (tailbone) as directed by the wound care nursing (WCN) assessment. The facility census was 48.

Findings included:

1. Record review of the publication titled, "According to the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel (NPUAP-EPUAP)" dated 2009, stated the international pressure ulcer definition is: A pressure ulcer is localized injury to the skin and/or injury to the skin and/or underlying tissue usually over a bony prominence [SDTI], as a result of pressure, or pressure, in combination with shear [an applied force or pressure exerted against the surface and layers of the skin as tissues slide in opposite directions]. The publication stated that chair-bound patients should be repositioned every one-hour and should have pressure-relieving devices in the chair. The head of the bed should be maintained at the lowest degree of elevation.

The publication showed: When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities [tail bone]. As the loaded area in such cases is relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur very quickly. Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure the individual is exposed to."

2. Record review of a facility policy titled, "Pressure Ulcer Prevention and Wound Care," revised 10/12 showed the following:
-The Registered Nurse (RN) shall assess patients for alteration in skin integrity and circulatory impairment on admission and each shift;
-Document assessment (redness, irritation, swelling, tenderness, etc.);
-When Braden score (a tool utilized to determine risk for development of pressure ulcers) is found to be 12 or less, implement standing order for pressure ulcer prevention and wound care according to, "Standing Order/Protocol";
-For patients identified with Stage I or II pressure ulcers, implement "Pressure Ulcer Intervention";
-Skin barrier may be used for at-risk patients;
-The patient shall be turned at least every two hours, or position shifted;
-Ensure patient changes position while in a chair every hour.

The facility failed to identify or provide written guidance for patients with suspected deep tissue injury -SDTI.

Record review of a facility policy titled, "Admission Data and Nursing Care, Documentation of," revised 09/12, showed:
-The Braden scale and skin and wound assessment is documented in the patient's electronic medical record. A score on the Braden scale of 12 or less was considered a high risk;
-The Braden scale is completed on admission and then daily during the day shift;
-The plan of care is reviewed at least once every shift to ascertain the list (care plan) reflects the current patient needs.

3. Record review of a facility document titled, "Wound Dressing Decision Tree", undated, showed Sensicare (a white, thick skin barrier cream) was to be used on patients with Stage I and/or Stage II pressure ulcers (in order to attempt to prevent further deterioration).

4. Record review of the facility-provided Pressure Ulcer Standing Order\Protocol showed that patients identified with Stage I or Stage II pressure ulcers should be treated with Sensicare Cream twice daily and as necessary to the affected area with altered skin integrity.

5. Record review of Patient #6's History and Physical (H&P) , showed the patient was admitted to the intensive care unit (ICU) on 10/23/12 with diagnoses of severe peripheral arterial disease (poor circulation-which can increase risk for development of pressure ulcers) and right foot gangrene (local death of soft tissue).

Record review of Patient #6's nursing admission assessment dated 10/23/12, showed:
- Patient was unresponsive;
- Had no skin problems on the coccyx;
- Was confined to bed;
- Was unable to make frequent changes in position;
- Had inadequate nutrition assessment;
- Required moderate to maximum assistance to move;
- Had a Braden score of 11 or a high risk.

Record review on 10/29/12 of the patient's care plan showed the patient underwent a below-the-knee amputation of the right leg on 10/24/12. The care plan directed staff to provide wound care protocol as ordered.

Record review of a skin assessment dated 10/28/12, at 7:23 AM, showed Patient #6 had no pressure ulcers or redness on the coccyx.

Record review of a skin assessment dated 10/28/12, at 8:12 PM, showed the patient had a Stage II pressure ulcer on the coccyx that measured 1.0 centimeter (cm) by 1.0 cm.

Record review of Patient #6's Braden score dated 10/29/12 showed he still had a score of 11.

Observation on 10/29/12 at 1:55 PM showed Patient #6 had a pea-sized Stage II pressure ulcer on the coccyx. Observaton showed no white cream or dressing on the coccyx area.

The staff failed to assess and/or treat Patient #6, a high risk patient, according to the Standing\Order Protocol on 10/28/12 and 10/29/12.

5. During a telephone interview on 10/31/12 at 8:57 AM, Staff DD, RN, stated that she did not initiate the Sensicare protocol when the Stage II pressure ulcer was first identified, as directed by the facility policy and could not say why. Staff DD did say she should have done so.

6. During an interview on 10/30/12 at 9:59 AM, Staff N, RN Manager of the ICU, stated that the nurses can implement the Sensicare protocol prior to the physician ordering and signing the protocol.

7. During an interview on 10/30/12 at 12:55 PM, Staff V, Wound Care Nurse, stated that she could not say how Patient #6's coccyx area went from intact to a Stage II. Staff V stated that she felt the nurses should have implemented Sensicare as a preventative measure prior to the patient developing a Stage II ulcer (since the patient was considered high risk.) But, at least immediately when the Stage II ulcer was identified.

Staff failed to initiate the Sensicare protocol until 10/30/12 at 3:00 PM more than 24-hours after initial identification.

8. During an interview on 11/01/12 at 8:35 AM, Staff A, Chief Nursing Officer, stated that she expected nurses to follow the pressure ulcer protocol and preventative care.

9. During an interview and record review of the facility's pressure ulcer log on 10/30/12 at 12:55 PM, Staff V, Wound Care Nurse, stated that Patient #30 had an extensive SDTI on her bottom. Staff V stated that she directed staff to allow the patient up in a chair for one hour at a time, to provide a pressure relieving cushion and to keep the patient turned while in bed.

Record review on 10/30/12 at 2:20 PM of Patient #30's H&P showed the patient was admitted to the facility on 10/29/12 with severe weakness and Urosepsis (a secondary infection that occurs when a urinary infection caused by bacteria spreads to the bloodstream).

Record review on 10/30/12 of the Interdisciplinary Plan of Care dated 10/29/12 showed Patient #30 with a SDTI bilaterally (both right and left sides) of her coccyx and buttocks, which extended to her upper thighs. The problem list for Protection for Potential Alteration in Skin Integrity showed the following interventions:
-A skin assessment every shift;
-Monitor for signs of infection;
-Monitor laboratory results and vital signs .

Staff failed to include interventions for pressure ulcer treatment or prevention such as being turned, repositioned or using pressure relieving cushions.

Observation on 10/30/12 at 1:50 PM showed Patient #30 awake and alert sitting upright in a recliner with her feet on the floor. Staff assisted Patient #30 to a standing position. Observation showed darkened maroon (very dark red to near black) colored skin which extended bilaterally from the uppermost area of the coccyx, throughout the buttocks and into the upper thighs (size of a basketball). Bony prominences at the hips showed varying degrees of redness (which could be indicative of a Stage I pressure ulcer).

10. During an interview on 10/30/12 at approximately 2:30 PM, while sitting upright in a recliner, Patient #30 stated that she had been sitting upright in the recliner since 10:30 AM (four-hours) that same morning. She stated that staff did not ask her if she would like to get out of the chair and the patient denied that she had been repositioned while in the chair except when she was put on the commode. She reported that she was not able to move herself from side to side or get out of the chair to get herself back into the bed and that her "bottom" hurt.

Staff failed to follow the direction of the Wound Care Nurse by not restricting time in the chair to one hour.

11. During an interview on 10/30/12 at approximately 1:50 PM, Staff PP, RN who was assigned the care of Patient #30, stated that the goal of care was to build the patient's strength and treat the Urosepsis. She stated that the patient also had a deep tissue injury and that the patient was being turned and repositioned every two hours rather than every one hour.

12. Observation on 10/31/12 at 10:35 AM showed Patient #30 in bed lying on her back with the head of the bed raised approximately 30 degrees (this elevation increases pressure to the coccyx).

Record review of the hourly rounding log for Patient #30 on 10/31/12 at 10:35 AM showed documentation that the patient was repositioned at 6:00 AM and 9:00 AM.

Staff failed to turn the patient every two hours as directed.





17863

Based on interview and record review the facility failed to ensure physician orders were dated, timed and signed within forty-eight hours by the physician giving the order for three of five current (Patients #2, #3, #8) and three of ten discharged (Patients #23, #24, #27) patient's medical records reviewed. The facility census was 48.

Findings included:

1. Record review of the facility document titled, "Medical Staff Rules and Regulations", revised 10/07/11, showed the following direction for physicians:
-Verbal and telephone orders must be authenticated by the prescribing practitioner or another practitioner who is responsible for the care of the patient within forty-eight (48) hours;
-All entries in the medical record must be dated, timed, and authenticated, in written or electronic format, by the person responsible for providing or evaluating the services provided. All medical records shall be completed within thirty (30 days of discharge).

2. During an interview on 10/29/12 at 1:30 PM Staff G, Director of Health Information Management (HIM) stated physicians were asked to date, time and sign all orders and verbal or telephone orders were to be signed within forty-eight hours by the physician giving the order.

3. Record review of current Patient #2's physician's orders showed the following orders were not signed by the physician:
- A telephone order dated 10/21/12 at 6:10 PM for Ambien (sedative used for the short- term treatment of sleeplessness) 5 mg tab (tablet), 2 each = 10 mg oral at Q HS PRN (every bedtime as needed);
- A telephone order dated 10/21/12 at 2:50 PM for Furosemide (a diuretic used to treat swelling and hypertension) 40 mg IV (within the vein) one time this afternoon;
- Potassium chloride (used to reduce sodium in the body) 10 meq (milliequivalents) by mouth one time this evening;
- A telephone order dated 10/22/12 at 10:45 AM for:
- CXR (chest x-ray)-PA (posterior/anterior), Lat (lateral) for fluid;
- Urine for Na (sodium), Cr (creatinine - measures the rate of urinary excretion), Urea (measures how well the kidneys and liver are working);
- Increase TopRol XL (used to treat Hypertension) to 100 mg daily;
- A telephone order dated 10/22/12 at 2:21 PM for "May use hospital BIPAP (a bi-level positive airway pressure device, used to help patients keep their airways open) setting per RT (respiratory therapy);

4. Record review of current Patient #3's physician's orders showed the following orders were not signed by the physician:
- A telephone order dated 10/25/12 at 11:32 PM for Digabind (treats massive heart medication overdose) per pharmacy dosage; and
- K+ (symbol for Potassium) level now.

5. Record review on 10/30/12 at 10:30 AM of current Patient #8's physician's orders showed the following orders were not signed by the physician:
- A telephone order dated 10/23/12 at 3:17 PM for Ocean (moisturizing water) spray nasal, one spray each nostril PRN (as needed);
- A telephone order dated 10/23/12 at 4:34 PM to:
- Start Heparin (anti-blood clotting medication) drip (within the vein) as per protocol (for a blood clot in both lungs) no bolus (not all at once);
- Draw baseline Anti Xa (lab test which monitors Heparin level in the blood);
- A telephone order dated 10/24/12 at 2:43 PM for:
- Coumadin (used to prevent or treat a blood clot) 5 mg po (by mouth) daily.
- Start today; Daily PT (prothrombin time, a test to measure blood clotting ability) and INR (International Normalized Ratio, lab test used to standardize PT time).
- A telephone order dated 10/25/12 at 8:55 AM to:
- Decrease k cl (Potassium Chloride) to 10 meq po daily;
- Heme (Hemoccult, to test blood in the stool) test stools x3 (three times);
- DC ASA (Aspirin);
- CBC (complete blood count test);
- BMP (basic metabolic panel, tests for seven or eight blood components);
- Mg (Magnesium, a blood test) 10/26.
- A telephone order dated 10/26/12 at 8:50 AM to:
- DC Levaquin (antibiotic) after today's dose;
- Echocardiogram (an ultrasound image of the heart), Cardiologist to read.

6. During interviews on 10/27/12 at 2:30 PM and 10/30/12 at 10:30 AM, Staff A, Registered Nurse (RN), Vice President of Patient Care, stated that the physician telephone orders for Patients #2, #3 and #8 had not been signed within the 48 hours as directed by policy and procedure.

7. Record review of discharged Patient #23's physician's orders showed the following:
-A partially illegible telephone order dated 08/10/12 at 5:50 PM for "(Illegible) series tomorrow morning for diagnosis of bowel obstruction" and signed by the ordering physician on 08/17/12.
-A telephone order dated 08/19/12 for "Scopolamine (medication for nausea, vomiting, motion sickness, depression) patch per pharmacy dosing" and signed by the ordering physician on 09/21/12.

During an interview on 10/30/12 at 1:20 PM Staff G, Director of HIM, reviewed the patient's verbal/telephone orders and confirmed the physician failed to sign the two orders within forty-eight hours as required.

8. Record review of discharged Patient #24's physician's orders showed the following:
-A telephone order dated 08/10/12 at 7:15 PM to "Have the nursing supervisor telephone a specific physician" and signed by the ordering physician on 09/26/12.
-A clarification telephone order dated 08/11/12 at 1:55 PM for "Chest x-ray, two views, today for cough/infiltrate. May leave Foley (urinary catheter) in for Lasix (medication to remove fluid from tissue) intravenously for now" and signed by the ordering physician on 09/15/12.
-A telephone order dated 08/11/12 at 2:10 PM for "May give FFP (fresh frozen plasma, a portion of blood) via a twenty-two gauge intravenous (route)" and signed by the ordering physician on 09/15/12.
-A telephone order protocol titled "Propofol (Diprivan) Infusion Orders for Sedation of Intubated Adult Patients on Mechanical Ventilation" dated 08/12/12 at 8:00 AM and signed by the ordering physician on 09/12/12.
-A telephone order dated 08/12/12 at 8:50 AM for "STAT (immediately) KUB (x-ray of the kidney, ureter, and bladder area) after line placement" and signed by the ordering physician on 09/26/12.
-A telephone clarification order dated 08/12/12 at 1:01 PM to "Change Primaxin (antibiotic) to five hundred milligrams intravenously every eight hours" and signed by the ordering physician on 09/12/12.
-A telephone order dated 08/12/12 at 1:20 PM for "Five hundred milliliters of normal saline (salt solution) intravenously now bolus (all at once). Normal saline at seventy-five milliliters per hour after the bolus is completed. Notify physician if MD (medical physician, however probably an error and should have been Na for sodium) still low" and signed by the ordering physician on 09/12/12.
-A telephone order protocol titled "Adult Critical Care Electrolyte Replacement Protocol" dated 08/12/12 at 1:35 PM and signed by the ordering physician on 09/12/12.
-A telephone order protocol titled "Dopamine (Intropin) Orders for Adults" dated 08/12/12 at 1:59 PM and signed by the ordering physician on 09/12/12.
-A telephone order dated 08/12/12 at 3:59 PM for "SCDs (sequential compression devices or booties applied to feet for circulation) for DVT (deep vein thrombosis or blood clots prophylaxis. May start dopamine (neurotransmitter used in the brain for movement) to keep SBP greater than 90 (systolic blood pressure greater than ninety millimeters of mercury). Start at five micrograms per kilogram of body weight per minute to a maximum dose of 20 micrograms per kilogram per minute (amount of medication per body weight infused per minute into the patient)" and signed by the ordering physician on 09/12/12.
-A telephone order dated 08/12/12 at 5:20 PM to start "Neosynephrine. Titrate Dopamine off" and signed by the ordering physician on 09/12/12.
-A telephone order dated 08/12/12 at 5:50 PM to obtain a "STAT ABG (arterial blood gas or measurement of oxygen and carbon dioxide in the blood)" and signed by the ordering physician on 09/12/12.
-A telephone order dated 08/13/12 at 7:50 PM to "Give one ampoule (small vial of a medication) of D50 (fifty percent dextrose solution) now. Stop normal saline (salt) bolus" and signed by the ordering physician on 09/21/12.
-A telephone order dated 08/13/12 at 4:45 PM to "Taper propofol off by 5:00 AM 08/14/12. Discontinue daily Lasix (medication to help remove fluid from the body) 40 milligrams intravenously. Hold tube feedings (liquid food given through a tube) for now" and signed by the ordering physician on 09/21/12.
-A telephone order dated 08/13/12 at 6:50 PM to "Give four ampoules of sodium bicarbonate (can be used for acidosis) now. Give one ampoule of D50. Start D10 (ten percent dextrose solution) at 50 milliliters per hour. Increase sodium bicarbonate to 200 milliliters per hour. Check accuchecks (check blood sugars) every six hours" and signed by the ordering physician on 09/21/12.

9. During an interview on 10/30/12 at 1:30 PM Staff G reviewed the physicians orders for Patient #24 and confirmed all sixteen verbal/telephone orders were not signed by the physician within forty-eight hours as required.

10. Review of discharged Patient #27's physician's orders showed the following:
-A telephone order dated 08/01/12 at 5:10 PM for a "STAT (immediately) EKG (electrocardiogram, a measurement of the electrical activity of the heart) with any chest pain as needed. If no EKG changes and if chest pain persists then give Vicodin (pain medication) 5/500, one tablet as needed every four hours" and signed 09/28/12.
-A telephone order dated 08/02/12 at 8:00 PM for "Ativan (antianxiety medication) 1-2 milligrams, intravenous (through the vein) every four hours as needed" and signed by the physician on 09/21/12.
-A telephone order dated 08/02/12 at 8:00 PM for "Do Not Resuscitate" and signed by the physician on 09/21/12.
-A telephone order dated 08/02/12 at 1:25 PM for "Phenergan 12.5 milligrams intravenously every six hours as needed for nausea and Zofran four to eight milligrams intravenously every six hours as needed for nausea" and signed by the physician on 09/21/12.
-A telephone order dated 08/21/12 at 12:09 AM for "Xanax (antianxiety medication) 0.5 milligrams orally every six hours as needed for anxiety. First dose now". The telephone order was signed by the physician on 09/21/12.

During an interview on 10/30/12 at 2:00 PM Staff G reviewed Patient #27's verbal/telephone orders and confirmed the physician failed to sign the five orders within forty-eight hours as required.




27029

Based on interview and record review the facility failed to ensure patient medical records were completed within thirty days of the patient's discharge for two of ten discharged (Patients #20 and #24) reviewed. The facility census was 48.

Findings included:

1. Review of the facility's policy titled, "Physician Completion of Records" dated 08/11, showed direction for staff to complete patient medical records with a discharge summary within thirty days from the patient's discharge.

2. During an interview on 10/29/12 at 2:50 PM, Staff G, Director of Health Information Management (HIM) stated patient medical records should be completed with a discharge summary within thirty days of the patient's discharge from the facility.

3. Record review of Patient #20's discharge summary showed the patient expired on 08/23/12 and the physician completed the patient's discharge summary on 10/03/12.

During an interview on 10/30/12 at 12:42 PM Staff G reviewed the patient's discharge summary and confirmed the physician failed to complete the medical record with discharge summary within thirty days after the patient's death.

4. Record review of Patient #24's discharge summary showed the patient expired on 08/13/12 and the physician completed the discharge summary on 10/10/12.

During an interview on 10/30/12 at 1:30 PM Staff G reviewed the patient's discharge summary and confirmed the physician failed to complete the medical record with discharge summary within thirty days after the patient's death.

Based on observation, interview and record review the facility Dietary staff failed to clean and maintain kitchen equipment to protect foods used in patient food service from cross contamination. The facility census was 48.

Findings included:

1. Review of the Dietary department's policy titled "Sanitation Program" dated 09/12, showed the following:
-The Dietary department maintained a sanitation program for a clean, safe environment.
-Cleaning schedules and procedures were developed for all equipment, food preparation and service areas and storage areas.
-All department team members were trained regarding proper cleaning procedures and their scheduled cleaning responsibilities.

2. Observation on 10/30/12 from 9:50 AM through approximately 10:20 AM showed the following:
-Four metal canned food racks, each with eight levels of rails soiled with black dust and unknown debris easily removed by finger tip and in direct contact with the rims of multiple cans stored on the racks.
-Three bulk food bins covered with spilled granular foods and dried food splashes on the lids and around the rims of the containers on which the covers rested.
-Two table mounted can openers covered with blackened gummy food debris and unknown food debris around the blade, gears, behind the blade and the mounting plate.

3. During an interview on 10/30/12 at 10:10 AM Staff UU, Dietary Aide looked at the table mounted can opener near the cook's area and stated the can opener was not clean enough.

4. During an interview on 10/30/12 at 10:10 AM Staff H, Director of Food/Nutrition Services, confirmed the canned food racks, bulk bins and can openers were soiled and should be cleaned.

Based on observation, interview and record review, the facility failed to ensure:
- Staff performed hand hygiene between glove changes for two of two observations (Patients #9 and #11);
- Appropriate hand hygiene was used by Dietary staff during meal tray assembly and service on the units;
- Dietary staff removed jewelry (finger rings with raised settings) prior to handling food.
- Staff tied isolation gowns at the waist during care for one of one (Patient #6);
- Staff dated, timed and initialed intravenous (IV-within the vein) tubing for ten (Patients #1, #6, #8, #9, #10, #11, #15, #19, #30, and #42) of eleven IVs observed;
- Urinals were stored away from food and other clean surfaces for two (Patients #2 and #9) of nine observed;
- Mattress surfaces were intact without tape residue, which could not be cleaned or disinfected and could harbor or spread bacteria from patient to patient for five of six observations in the Critical Decision Unit (CDU) and the Emergency Department; and the facility failed to ensure
- Two (Patients #9 and #11) of two in contact isolation had dedicated equipment for their care. The facility census was 48.

Findings included:

1. Record review of the Centers for Disease Control and Prevention Guidelines titled, "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" showed:
- Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. In the absence of a point-source outbreak, it is difficult to determine how indirect transmission occurs. However, extensive evidence cited in the Guideline for Hand Hygiene in Health-Care Settings suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission. Examples of opportunities for indirect contact transmission include:
- Hands of healthcare personnel may transmit pathogens after touching an infected or colonized (inactive infection) body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient.
- Patient-care devices (e.g., electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients.
- Instruments that are inadequately cleaned between patients before disinfection or sterilization (e.g., surgical instruments) or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial and viral pathogens.
- Clothing, uniforms, laboratory coats, or isolation gowns used as personal protective equipment (PPE, isolation gowns, gloves and/or masks) may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent, (such as Methicillin Resistant Staphylococcus Aureus, MRSA, a type of staph bacteria that is resistant to certain antibiotics).

2. Review of the facility's Infection Control Plan for 2012, showed the following:
- CDC references were used for isolation guidelines;
- MRSA was often associated with health associated infection transmission and could potentially cause increased cost and length of stay for patients;
- Hand hygiene was the number one way to prevent the spread of infection;

3. Review of the facility's policy titled, "Multiple Drug Resistant Organisms (MDRO, an organism that is resistant to one or more classes of antimicrobial [antibiotics used to kill bacteria] agents)," revised 12/11 showed the following:
- MRSA is in this classification;
- Patients actively infected with a MDRO will be placed in appropriate isolation and it will continue until the infection is resolved;
- MDROs are transmitted, usually via the hands of healthcare workers.

Record review of the facility's policy titled, "MRSA Protocol ...," revised 08/12, directed staff to follow appropriate isolation precautions.

Record review of the facility's policy titled, "Isolation," revised 12/11, showed the following:
- Dedicate the use of non-critical patient care equipment and items, discard or adequately clean and disinfect before use on another patient;
- Disinfect equipment used when outside the room;
- Contact isolation required gloves and gown. Staff are to ensure their personal clothing does not contact contaminated surfaces to avoid transfer to other patients;
- Droplet precautions required gloves, gown and mask;

The policy failed to direct staff as to when/where to apply gloves and gown (at entrance to patient's door, in hallway, etc.).

Record review of the facility's policy titled, "Personal Protective Equipment (PPE, isolation gowns, gloves and/or mask)" revised 06/10, directed staff to tie the belt at the gown's waist.

4. Record review of Patient #6's History and Physical (H&P) showed he was admitted to the intensive care unit (ICU) on 10/23/12 with a diagnoses of severe peripheral arterial disease (poor circulation, which can increase risk for development of pressure sores), right foot gangrene (local death of soft tissue) and a recent history of amputated toes on the right foot.

Record review of the physician's orders dated 10/28/12 showed an order for a dressing change to the right leg due to a below-the-knee amputation.

Record review of the patient's care plan dated 10/23/12, showed the patient had a current infection, received antibiotics, and was in contact isolation.

5. Observation and concurrent interview on 10/29/12 at 1:55 PM showed:
- Staff P, Registered Nurse (RN), and Staff O, RN Charge Nurse entered Patient #6's room;
- Staff P stated that the patient was in contact isolation related to MRSA in the stump of the amputated right foot/leg;
- Staff P entered the patient's room and wandered around the room while putting a gown and gloves on, was in close proximity of the patient, and touched furniture and other inanimate objects. Staff P failed to put the gown and gloves on prior to entering the room. Staff P and Staff O failed to tie their contact isolation gowns at the waist while caring for Patient #6.

Observation on 10/30/12 at 9:51 AM, showed Staff P leaned over Patient
#6, provided care and failed to tie her isolation gown at the waist.

During an interview on 10/30/12 at 1:45 PM, Staff P stated that she did not know what the facility policy was on tying the waist of PPE gowns. Staff P stated that she thought the boundary for wearing PPE for an isolation patient was within three feet of the patient.

6. Observation on 10/30/12 at 8:30 AM in the Progressive Care Unit (PCU), showed Patient #9 was on contact isolation precautions for MRSA that required staff to wear PPE when they enter the room for patient care.

Staff S, RN, donned (put on) PPE of disposable gown and gloves. Staff S removed the glove on her right hand and reached under her PPE gown into her uniform pocket and retrieved a pair of scissors and put them on the patient's bedside table. Without performing hand hygiene or cleaning the scissors she donned another glove and used the scissors (that may have been contaminated by another bacteria) to cut a bandage off of the patient's arm around an IV insertion site.

When Staff S, RN finished care for Patient #9, she started to remove the PPE at the patient's bedside, walked around a pulled bed curtain and finished removing the PPE. There was no trash can available between the curtain and the door to dispose of the soiled PPE. Staff A, RN, Vice President of Patient Care, left the room, obtained a trash container and placed it inside the door. Staff S then deposited the contaminated PPE into the trash.

At 10:00 AM, Staff T, RN, Assistant Nursing Director, walked in Patient
#9's room and pulled back the curtain without donning PPE or using hand hygiene and then exited the room. The curtain in a contact isolation room was considered contaminated.

During an interview on 10/31/12 at 9:30 AM, Staff T, RN stated that she thought it was okay to enter Patient #9's room without PPE because she wasn't going to do patient care and she wasn't that close to the patient.

At 9:55 AM (10/30/12), Staff U, Respiratory Therapist, entered Patient #9's room to administer respiratory therapy and donned PPE. After the treatment, she removed her gloves and gown at the patient's bedside, which exposed her clothing to potential infection, and deposited the soiled PPE in an overflowing trash can. She pushed the trash down further into the trash can with her bare hand. She then used hand hygiene gel and exited the room into the common hallway.

7. During an interview on 10/31/12 at 9:35 AM, Staff A, RN, Vice President of Patient Care, stated that the facility's policy and procedure should be more explicit in giving staff direction on contact isolation parameters and trash containers should be available in the patient's room.

8. During an interview on 10/31/12 at 3:15 PM, Staff TT, RN, Infection Preventionist stated that the threshold for contact isolation precautions is more than three feet from the patient. She stated that PPE should be worn in the immediate environment of the contact isolation patient and should not be removed within that area. Staff TT stated that the patient in isolation should have a pair of dedicated scissors that would not be in the nurse's pocket or be used for a different patient.

9. Record review of the facility's policy titled, "Hand Washing Procedure," revised 06/10, directed staff to wash hands before and after removing gloves, and after touching inanimate sources that are likely to be contaminated.

10. Record review of Patient #11's H&P 10/29/12 showed the patient was admitted on 10/29/12 with a large Stage IV (full thickness skin loss, including muscle, and bone) pressure ulcer on his right hip and sacrum (lower spine.) The patient tested positive for MRSA in his sputum and the test results were unclear if MRSA was present in the pressure ulcer (wound).

Observation and concurrent interview on 10/30/12 at 9:58 AM, showed:
- Staff W, RN, stated that Patient #11 was in contact and droplet isolation related to MRSA in his sputum, blood and wound;
- Staff W, RN, and Staff V, RN, Wound Care Nurse changed the wound dressing on Patient #11;
- Staff W changed gloves three times and handled medication bottles and wound cleansers without performing hand hygiene between glove changes. Staff W also reached under her PPE gown into her uniform pocket, and retrieved a pair of scissors. Staff W used the scissors during the dressing changes. This action could have exposed the clothes under her PPE gown with MRSA bacteria.
- Staff V changed her gloves one time without performing hand hygiene between glove changes.

During an interview on 10/30/12 at 12:55 PM, Staff W stated that usually there was dedicated equipment for a patient in isolation; however, there were no scissors in Patient #11's isolation room. Staff W stated that she was not aware of the facility policy regarding hand hygiene between glove changes.

11. Review of the US Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed the following direction for food handlers;
-Chapter 2-301.14: Food Handlers shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and after touching are body parts other than clean hands; before donning gloves for working with food and any other activity that contaminate the hands.
-Chapter 2-303.11: Except for a plain wedding band, while preparing food, food employees may not wear jewelry (including medical information jewelry) on their arms and hands.

12. Record review of the facility's Dietary Department policy titled, "Personal Hygiene" revised 09/12 showed hands and fingernails should be scrupulously clean at all times. Hands should be washed frequently and as necessary specific times as well as after touching the face.

Record review of the facility's policy titled, "Hand Washing Procedure" revised 06/14/10 gave the following direction:
-Hand Washing Technique, How to Wash Hands: Apply ample amount of antimicrobial soap working it into a lather. Treat each finger individually with special attention to nails and spaces between fingers.
-Alcohol-based hand rubs. Rub all hand surfaces together until they are dry.

13. During an interview on 10/30/12 at 9:45 AM Staff H stated Staff TT, Infection Control Nurse had never been to the kitchen to observe hand hygiene or review any food sanitation practices.

14. Observation on 10/31/12 from 6:30 AM through 7:15 AM in the facility kitchen showed the following:
-Staff WW wore two finger rings with raised settings on each hand while touching unwrapped silver ware, condiments, napkins, menus, juice and cereal to prepare patient breakfast trays.
-Staff NY touched her face then without hand hygiene handled two pitchers of tea for patient meal service.
-Staff CZ touched her face then without hand hygiene touched the rim of the iced tea pitchers used for patient meal service.
-Staff AAA without hand hygiene, stacked and nested (one inside the other) cleaned plastic beverage cups, touched the rims of each cup and carried the stacked cups to the tray assembly line.
-Staff VV removed soiled gloves, retrieved foods for tray service e then without any hygiene, reapplied gloves and worked on the patient tray assembly line.
-Staff ZZ filled coffee carafes measured the temperature of the coffee, touched her face with the back of her hand then, without and hygiene finished filling the carafe and place it on the food cart.

Observation on 10/31/12 at 7:16 AM on the second floor showed Staff YY delivered multiple meal trays to patients, used alcohol foam applied only to the back of the hand and the palm of the hand and failed to spread alcohol foam between the fingers each time.

15. Review of the facility's policy titled, "Intravenous Therapy, Standards for," revised 06/11, showed:
- Primary IV (into the vein) tubing should be changed every 72-hours;
- Intermittent IV (an IV fluid or medication administered at specific times) tubing should be changed every 24-hours;
- All IV tubing should be flagged with the appropriate day or date to be changed.

The policy failed to direct staff to include the time on the tubing to ensure staff would know when the tubing should be replaced after either 24 or 72 hours.

16. Observation on 10/29/12 at 1:55 PM showed three IV tubings for Patient #6 had labels marked to change on Monday or Tuesday, but staff failed to label the time and date when they changed the tubing.

17. During an interview on 10/30/12 at 1:52 PM, Staff M, RN, stated that many nurses don't time IV tubing labels so she never knows exactly when the 24 or 72 hours are up. Staff M stated that she did not know what the facility policy was regarding this practice.

This failure to label the tubing and the date and time could lead to a delay in changing tubing which could result in infection control concerns.

18. Observation on 10/27/12 at 2:10 PM in the Critical Decision Unit (CDU), showed Patient #1 had two IV lines with a label marked, "Change on Wednesday". Staff failed to date, time and initial when they changed the tubing.

19. Observation on 10/28/12 at 8:30 AM in the PCU, showed Patient #8 had two IV lines with a label marked, "Change on Tuesday". Staff failed to date, time and initial when they changed the tubing.

20. Observation on 10/28/12 at 8:30 AM in the PCU, showed Patient #9 had two IV lines with a label marked "Change on Tuesday". Staff failed to date, time and initial when they changed the tubing.

21. Observation on 10/28/12 at 8:30 AM in the PCU, Patient #10 had two IV lines with a label marked, "Change on Wednesday". Staff failed to date, time and initial when the changed the IV tubing.

22. Observation on 10/30/12 at 9:58 AM in the ICU, showed Patient #11 had one IV line with a label marked, "Change on Thursday". Staff failed to date, time and initial when they changed the tubing.

23. Observation on 10/30/12 at 9:25 AM in the Medical Unit, showed Patient #15 had one IV line marked, "Change on Thursday". Staff failed to date, time and initial when they changed the tubing.

24. Observation on 10/30/12 at 9:50 AM in the Surgical Pre-Operative holding area, showed Patient #19 had Lactated Ringers (an intravenous solution used for hydration) infusing through unlabeled IV tubing.

25. Observation on 10/30/12 at 1:50 PM in the Medical Unit, showed Patient #30 had one IV line marked, "Change on Thursday". Staff failed to date, time and initial when they changed the tubing.

26. Observation on 10/31/12 at 8:35 AM, in the ICU, showed Patient #42 had two IV lines marked, "Change on Thursday and/or Friday". Staff failed to date, time and initial when they changed the tubing.

27. During an interview on 10/28/12 at 10:30 AM, Staff S, RN, stated that normally the IV labels should be marked with the date, time and initials when the IV lines are initiated. She stated that when the labels aren't marked with the date, time and initials she replaced the IV tubing with new tubing , "Because, you can't tell how old they are."

28. During an interview on 10/31/12 at 2:30 PM, Staff TT, RN, Infection Preventionist, stated that it is an understood practice that the IV lines are changed at the beginning of the day marked on the label. She stated that there is no facility policy or procedure directing staff to this practice or that the label, date, time and initial spaces should be completed.

29. Observation on 10/28/31 at 2:30 PM in Patient #2's room, showed a urinal sitting on the bedside table next to his water glass.
30. Observation on 10/30/12 at 8:30 AM in Patient #9's room, showed a urinal sitting on the bedside table next to his water glass.

31. During an interview on 10/31/12 at 2:30 PM, Staff TT, RN, Infection Preventionist, stated that the urinals were probably placed there by patients but should be removed by staff and are an infection control concern.

32. Observation on 10/27/31 at 1:45 PM on the CDU in Rooms #1206 and #1208 showed mattresses that had broken surface integrity that could not be cleaned and could harbor or spread bacteria from patient to patient.

33. Observation on 10/31/12 at 8:45 AM in the Emergency Department in rooms #14 and #16 showed mattresses that had torn/broken surface integrity that could not be cleaned and could harbor or spread bacteria from patient to patient.

34. During an interview on 10/31/12 at 8:45 AM, Staff JJ, RN, Director of Emergency Services, confirmed the mattress were torn and had tape residue.

35. During an interview on 10/31/12 at 2:30 PM, Staff TT, RN, Infection Preventionist, stated that the mattresses were new but she was aware that torn mattress covers and tape residue could harbor bacteria.

36. Observation and concurrent interview on 10/31/12 at 9:42 AM, showed a mattress on a procedure bed in an intervention room utilized by radiology had a black vinyl surface that was torn at the seams and corners. Staff GG agreed the torn surface of the mattress allowed bacteria to enter the mattress, which is an infection control issue.

37. During an interview on 10/31/12 at 8:35 AM, Staff A, Vice President of Patient Care, agreed with infection control findings. Staff A confirmed gowns needed to be tied at the waist, hand hygiene needed to be performed between glove changes, and patients in isolation rooms needed scissors to be dedicated to patients with infections and/or disinfected prior to and after use.




12450




17863




16215

Based on record review and interview, the facility failed to ensure discharge criteria were developed, approved and signed by the Medical Staff who admitted patients to the Post Anesthesia Care Unit (PACU) and the Ambulatory Care Unit (ACU) for two (Patients #14, and #18) of four current patients and two (Patients #32 and #39) of four discharged patients. The facility census was 48.

Findings included:

1. Record review of facility policy on 10/30/12 at 4:30 PM titled, "Admission and Discharge Criteria Ambulatory Care Unit (ACU)," dated 09/12, showed an approval signature by Staff EEE, Director of Surgical Services who is a Registered Nurse (RN). The policy provided staff medical criteria for discharging patients.

The facility failed to have the policy developed, approved and signed by a member of the medical staff with admitting privileges to the ACU.

Record review of facility policy on 10/30/12 at 4:30 PM, titled, "Discharge Criteria Post Anesthesia Unit (PACU)," dated 01/12 showed guidance for discharging patients after the patient received anesthesia. Staff EEE, RN, signed the policy.

The facility failed to have the policy for discharge criteria developed, approved and signed by a member of the medical staff with admitting privileges to the PACU.

2. During an interview on 10/31/12 at 2:45 PM, Staff C, RN, Licensing and Accreditation Coordinator, stated that the facility does not have medical staff meeting minutes or medical executive committee meeting minutes which contained the approval of discharge criteria for the ACU or PACU.

3. Record review on 10/30/12 at 1:30 PM of surgical record for Patient #14 showed the patient had a left total knee replacement on 10/29/12. Review of the pre-printed PACU physician orders showed an order to "Discharge from PACU when criteria met".

4. Record review on 10/30/12 at 3:30 PM of the medical record for Patient #18 showed a surgical procedure to the right knee to remove a foreign object on 10/30/12. Review of the pre-printed PACU orders showed an order to "Discharge from PACU when criteria met".

5. Record review on 10/30/12 at 3:35 PM of the medical record for Patient #32 showed the patient had a right fractured arm repair on 10/11/12. Review of the pre-printed PACU orders showed a physician order to"Discharge from PACU when criteria met".

6. Record review on 10/30/12 at 3:35 PM of the medical record for Patient #39 showed the patient had a fractured right hip repair performed on 10/16/12. Review of the pre-printed PACU orders showed a physician order to "Discharge from PACU when criteria met".

7. During an interview on 11/01/12 at 8:20 AM, Staff KK, Medical Doctor (MD), President of the Medical Staff and Vice President of Medical Affairs, stated that medical staff is required to develop and establish all discharge criteria before implementation. The criteria are required to be specific to the respective department and approved through the appropriate chain of command including the medical executive committee. He stated that it was inappropriate for an RN to approve and sign a policy for discharge criteria.

Based on interview and record review the facility failed to ensure that Emergency Services were supervised at all times by a qualified Medical Director that was a member of the Medical Staff. The facility also failed to establish specific criteria consistent with State law, regulations, and guidelines stating the qualifications a medical staff member must possess in order to be granted privileges for the supervision of the provision of Emergency Services. This had the potential to affect all patients presenting for care or receiving care in the Emergency Department. The facility census was 48.

Findings included:

1. During an interview on 10/31/12 at 8:45 AM, Staff JJ, Registered Nurse (RN), Director of Emergency Services, stated that the Emergency Department operated 24 hours per day, seven days per week. She stated that the Medical Director of the department was Staff I and frequented the department 16 hours per week but would stay another day if necessary.

2. Record review showed no personnel file or credentialing file for Staff I, Medical Doctor (MD), Medical Director of Emergency Services, for review and documentation for education, experience, specialized training, physician license, background check, references, etc.

3. During an interview on 10/31/12 at 2:30 PM, Staff I stated that he was not a member of the Medical Staff and did not possess a physician license in the state. He stated that he had a current license in another state but had been the acting Medical Director for Emergency Services at this facility on a consultant basis since 03/12. Staff I stated that he had a contract with the facility to be in the Emergency Department 16 to 24 hours per week.

4. During an interview on 11/01/12 at 8:25 AM, Staff BBB, Chief Executive Officer (CEO), stated that Staff I, MD, was Medical Director of Emergency Services on a consultant basis per contract and that he did not possess a physician's license in this state. He stated his primary duty was to conduct peer review of emergency room physicians. He stated that there was no oversight of the peer review process unless Staff I determined a disciplinary review should be considered for one of the physicians.

Staff BBB stated that he could not provide evidence in the Medical Staff Bylaws that specific criteria consistent with State law, regulations, and guidelines delineating the qualifications a medical staff member must possess in order to be granted privileges for the supervision of the provision of Emergency Services.