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Based on interview and record review the facility failed to maintain Human Resources policies and procedures to ensure verification and authenticity of applicable credentials (including licensure, certification and/or professional registration) for facility staff and contracted staff who were required to hold and maintain specific credentialing to work in health care.

The facility census was nine.

Findings included:

1. During an interview on 02/29/12 at approximately 3:00 PM Staff T, Director of Human Resources (HR) provided copies of the facility's policy titled "Licensure/Certification" revised 02/29/12 and the facility's newly written policy titled "Verification of Licensure for Service Contractor Employees/Background Screenings" dated 02/29/12 (during the survey). Staff T confirmed she revised the original policy for license/certification requirements and wrote the new policy for contracted staff in response to the survey investigation. She confirmed the facility did not have a policy directing HR to verify the license/certification for staff or contracted staff.

During an interview on 02/29/12 at 4:30 PM Staff B, Chief Executive Officer provided a copy of the facility policy titled "Licensure/Certification" dated 01/01/11 and stated the policy was in effect prior to survey.

2. Record review of the facility's policy titled "Licensure/Certification" dated 01/01/11 and provided at exit showed the following direction:
-Facility staff whose positions required licensure by the State of Missouri were responsible for keeping their license current.
-Facility staff whose positions required membership in or registration by a professional organization were responsible for keeping their membership or registration current.
-Current copies were to be submitted by the employee to their department head and the Human Resources Director.
-Staff brought in their own documents and the facility accepted these as authentic proof of licensure/registration/certification without checking with the issuing agency.
-Contracted staff were not asked to submit any documents or proof of licensure/registration or certification.
-The policy failed to direct HR staff to verify the authenticity (by checking the free on line Missouri State professional registration web sites) of the licenses and/or certifications provided by any staff.
-The policy failed to direct contracted staff to provide licensure and/or registration to HR.
-The policy failed to direct HR staff to verify the authenticity (by checking the free on line Missouri State professional registration web sites) of licensure and/or registration for any contracted staff whose positions required State of Missouri licensure and/or registration.

Based on observation and interview the facility failed to ensure expired supplies were removed from the crash carts. This had the potential to affect all patients who might have a life threatening emergency. The facility census was nine.

Findings included:

1. Observation on 02/27/12 at 2:20 PM showed a crash cart (set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment at site of emergency for life support protocols to potentially save someone's life) in the medical/surgical nursing unit with the following expired supplies:
-One Stomach tube (a tube which enters the stomach to give nutrition and/or medication) Lot 26403964 Expiration 9/2010
-Two D 5% 500 ml (5 percent dextrose, also known as glucose, a simple sugar which is a source of energy) Expiration 11/2011
-One Atrial Blood Gas Kit (supplies which obtain blood through an artery) Expiration 10/11
-Two 10 ml Normal Saline syringes (syringes which are prefilled with Normal Saline) Expiration 10/11
-One Small Adult Anesthesia Face Mask (a plastic mask used to administer medication in surgery) Expiration 10/11
-One Endotracheal tube (a tube which is inserted into the trachea to keep the airway open) Size 9.0 Expiration 1/10
-One Endotracheal tube Size 6.0 Expiration 3/10
-One Endotracheal tube Size 7.5. Expiration 11/11
-One Endotracheal tube Size 7.0 Expiration 6/10
-One Endotracheal tube Size 5.5 Expiration 8/10
-One Endotracheal tube Size 6.5 Expiration 10/10

2. During an interview on 02/27/12 at 2:30 PM Staff C, Registered Nurse (RN), stated that all the nurses were responsible to check the supplies for expiration dates but no one was assigned on a regular basis and checking the supplies is not done on a scheduled basis.

During an interview on 02/27/12 at 2:45 PM Staff D, Respiratory Therapy (RT), stated that once the respiratory supplies were brought to the nursing unit by Central Supply and placed in the crash cart; the supplies should be checked by nursing for expiration dates.

During an interview on 02/29/12 at 4:30 PM Staff A, Chief Nursing Officer, stated that there is no existing policy for checking of expired supplies.

Based on interview and policy review the facility failed to accurately reflect the clinical capabilities of the facility by having obsolete, outdated clinical and staffing policies and procedures. The facility census was nine.

Findings included:

1. Review of the Pediatric, Nursing, Anesthesia, Physical Therapy, Registered Nurse and Licensed Practical Nursing Procedures and Swing Bed policies included:
-Obsolete policies for procedures which are no longer performed in the facility in the facility;
-Policies for staff positions which are not currently used in the facility; and
-Policies which were marked as deleted but were still in the Policy and Procedure Manual.

2. During an interview on 02/29/12 at 9:30 AM Staff Q, Registered Nurse, stated that Surgical Assistants are not used in the facility but she had left the policy in the manual "just in case". She also stated that she had not reviewed the Policy & Procedures (P & P) for Surgery for this year but did send them to Medical Staff through the Chief Nursing Officer.

During an interview on 02/29/12 at 4:30 PM Staff B, Chief Executive Officer, stated that policies for all departments had been reviewed on 05/11/11. Staff B showed the survey team a separate book which listed each department and was signed by the administration as having reviewed the P&P for each department of the facility.

Based on observation, interview and record review the facility failed to ensure the Dietary department maintained current applicable policies and procedures including the following:
-Policy directing access and availability of an approved and current diet manual.
-Policy directing guidelines for safe sanitary food storage practices.
-Policy directing guidelines for serving patient meals at appropriate food temperatures.

The facility census was nine.

Findings included:

1. During an interview on 02/28/12 at 10:06 AM Staff K, Director of Dietary stated that the Missouri Diet Manual, 7th edition, 1991 was the approved facility diet manual and provided a copy of the Missouri Diet Manual from a shelf in her office.

Record review of the facility Dietary department policy titled "Diet Manual" dated 04/28/08 (provided by Staff K) showed direction for facility staff to use The Simplified Diet Manual, 10th edition, 2007 from the Iowa Dietetic Association as the guide for facility physicians to prescribe diets for patients.

During an interview on 02/29/12 at 10:40 AM Staff M, Charge Nurse stated she had been a nurse in the facility for eleven years and was not aware of an approved diet manual used as a reference for staff.

Observation on 02/29/12 at 1:00 PM in the nurses' station showed staff stored a copy of the Missouri Diet Manual, dated 2003 on a book shelf.

2. Record review of the United States Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed the following direction in Chapter 3-305.11: Food should be stored to protect against splash, dust and other contaminants and stored six inches off the floor level.

Observation on 02/27/12 at 2:40 PM in the Dietary dry food storeroom showed staff stored the following:
-Multiple cases (approximately thirty bottles) of carbonated beverages on the floor in one section of the dry food storeroom.
-Multiple cases (approximately two dozen bottles) of carbonated beverages on the floor in second section of the dry food storeroom.

Observation on 02/27/12 at 2:41 PM in the walk-in refrigerator showed staff stored a case of potatoes on the floor of the refrigerator.

During an interview on 02/27/12 at 2:41 PM Staff Y, Diet Aide stated the cases of carbonated beverages were routinely stored on the floor and the potatoes were routinely stored on the floor of the walk-in refrigerator.

During an interview on 02/29/12 at 1:15 PM Staff K stated the Dietary department did not have a policy on safe and sanitary food storage practices (directing staff not to store foods on the floor, protected from splash and dust during floor mopping and sweeping).

3. Record review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction in Chapter 3-403.11: Hot food should be at or above one hundred thirty five (135) degrees Fahrenheit.

Observation on 02/28/12 at 11:45 AM on the patient unit showed staff served a test tray with the following foods:
-Pork chop at one hundred twenty two (122) degrees Fahrenheit.
-Carrots at one hundred twenty two (122) degrees Fahrenheit.

During an interview on 02/28/12 at 11:45 AM Staff K stated she wanted hot foods to be served at or above one hundred forty (140) degrees Fahrenheit; the pork chop and carrots did not meet that temperature requirement and confirmed the department did not have a policy directing food temperature requirements.

Based on observation, interview and record review the facility failed to ensure the following:
-Paper patient medical record information stored in a room adjacent to the Cardiac Rehabilitation Clinic were protected against loss, destruction, unauthorized use and fire or water damage.
-Paper patient medical records in the Cardiac Rehabilitation unit were stored to protect against loss, destruction, unauthorized use, unauthorized access and/or tampering.
-Patient electronic medical record (EMR) information maintained on the facility computer system was routinely monitored for unauthorized viewing and access on unattended computer screens during evening, night, weekend and holiday shifts.
-Patient EMR information maintained on the facility computer system was routinely and appropriately monitored for unauthorized access in physician user homes and offices.

The facility census was nine.

Findings included:

1. Record review of the facility's policy titled, "Medical Record Confidentiality and Disclosure" revised 09/27/11 showed the following direction:
-The contents of the medical record belong to the patient, but may only be disclosed upon the express, written consent of the patient or the patient's legal representative, or as otherwise provided by the law.
-Access to the medical record may be given when appropriately requested.
-Written consent must be obtained from the patient or the patient's legal representative for access to, or release of copies of the patient's record.

2. Observation on 02/28/12 at 9:00 AM in the large storeroom adjacent to the Cardiac Rehabilitation Clinic at the Medical Mall building showed staff stored ten cardboard boxes of paper patient medical records intermingled amongst multiple cardboard boxes of documents from the county health department, envelopes of radiology films, boxes of billing records, mammography documents as well as parts of broken patient care equipment, broken lumber and plumbing parts and housekeeping supplies on a cart. Further observation showed ceiling tiles and walls of the room had browned water damage marks and black mold on some crumpled cardboard boxes on shelving.

During an interview on 02/28/12 at 9:06 AM Staff J, Director of Health Information Management (HIM) confirmed the following:
-The storeroom was used by staff from the county health department, radiology and billing to store documents.
-Maintenance department stored old equipment and parts.
-Housekeeping for the medical mall had access and used the storeroom to store their equipment and supplies.
-The storeroom had smoke detectors.
-The medical mall's hours of business were Monday through Friday from 8:00 AM through 5:00 PM (so outside those hours no one was present to hear a smoke detector alarm).

3. Observation on 02/28/12 at 9:15 AM in the Cardiac Rehabilitation Clinic showed staff stored multiple paper patient medical records in an unlocked drawer.

Record review of some of the paper records showed patient's names, diagnoses and treatment records.

During an interview on 02/28/12 at 9:15 AM Staff J stated the following:
-She had no knowledge of the records.
-Some records were for patients referred from other facilities.
-Confirmed some were paper records for patients referred from the facility.

4. During an interview on 02/29/12 from 9:28 AM through 9:50 AM Staff R, Information Technology (IT) Co-ordinator stated the following:
-Any facility staff who make entries in any patient EMR currently had access to all EMRs in their own homes (via home computers).
-All facility physicians, nurses, therapists and dietary staff can access any patient EMR through computer user name and password.
-If the staff person accessed an EMR of a patient the staff was not in direct care of, an electronic screen came up (flag) asking why they required access.
-If the staff gave a reason, the computer system then allowed access (no matter what the reason was).
-No monitoring system was in place to review the flagged EMR accesses to find who accessed what record and why.
-No monitoring system was in place to find who looked at any medical record (flagged or not).
-The IT Co-ordinator had checked medical records to see who accessed them however he does not have a routine, scheduled monitoring system to check EMR accesses (not for employees who were patients, celebrity patients, relatives of staff, ex-spouses of staff or others).
-Staff could access any portion of the EMR and "print screen" from their home computer to obtain a printed copy of a document accessed.
-The IT department was responsible for granting staff access to facility EMR.
-The IT Co-ordinator does tour the facility and visually reviewed computer monitors to see if staff have left the area and allowed information on the screen accessible.
-The building tours by the IT Co-ordinator were only done randomly Mondays through Fridays during day shift hours.
-No building tours by the IT Co-ordinator or other supervisory staff were done after day shift hours, on evening shift, night shift, weekends or holidays.
-No written documentation was done regarding the building tours of the facility computer monitors.

During an interview on 02/29/12 at 1:31 PM Staff R stated the following:
-He had now deactivated the "allow external access" ability for all staff except physicians.
-Confirmed the facility did not have a policy and procedure regarding routine monitoring of any accesses of patient EMR.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed in the facility.
Record review of 11 (Staff A, B, E, F, G, H, J, K, L, S, and X) of 15 staff personnel files showed the facility failed to effectively screen all staff by comparing the names of staff on hire and/or on a periodic basis after hire against the EDL.

The facility census was nine.

Findings included:

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

2. Record review of Staff A's personnel file showed Staff A was hired on 07/12/10 and the facility failed to check the EDL on hire and also on a periodic basis to ensure Staff A had not been added since hire.

Record review of Staff B's personnel file showed Staff B was hired on 06/05/07 and the facility failed to check the EDL on a periodic basis to ensure Staff B had not been added since hire.

Record review of Staff E's personnel file showed Staff E was hired on 05/13/08 and the facility failed to check the EDL on a periodic basis to ensure Staff E had not been added since hire.

Record review of Staff F's personnel file showed Staff F was hired on 03/01/11 and the facility failed to check the EDL on a periodic basis to ensure Staff F had not been added since hire.

Record review of Staff G's personnel file showed Staff G was hired on 06/08 and the facility failed to check the EDL on a periodic basis to ensure Staff G had not been added since hire.

Record review of Staff H's personnel file showed Staff H was hired on 07/29/09 and the facility failed to check the EDL on a periodic basis to ensure Staff H had not been added since hire.

Record review of Staff J's personnel file showed Staff J was hired on 01/03/07 and the facility failed to check the EDL on hire and also on a periodic basis to ensure Staff J had not been added since hire.

Record review of Staff K's personnel file showed Staff K was hired on 04/26/10 and the facility failed to check the EDL on a periodic basis to ensure Staff K had not been added since hire.

Record review of Staff L's personnel file showed Staff L was hired on 02/07/11 and the facility failed to check the EDL on a periodic basis to ensure Staff L had not been added since hire.

Record review of Staff S's personnel file showed Staff S (a contractor) was hired on 08/26/06 and the facility failed to check the EDL on a periodic basis to ensure Staff S had not been added since hire.

Record review of Staff X's personnel file showed Staff X was hired on 11/01/76 and the facility failed to check the EDL on a periodic basis to ensure Staff X had not been added since hire.

3. During an interview on 02/29/12 at 1:25 PM Staff T, Human Resources Manager confirmed the facility usually checked the EDL on hire but, did not periodically check the names of current staff against the quarterly EDL updates because she was not aware of that requirement.


27727

Based on interview, record review and policy review, the facility failed to develop and maintain an ongoing activities program that was based on a comprehensive assessment of leisure interests and abilities with goals for three patients (#8,#9,#13) of three Swing Bed records reviewed. (A Swing bed is a change in reimbursement status. The patient goes from receiving acute care services and reimbursement to receiving skilled nursing services and reimbursement). This had the potential to affect all patients in Swing Beds. The Swing Bed census was three. The facility census was nine.

Findings included:

1. Record review of the facility policy titled "Activity Assessment, Planning, Implementation and Documentation" revised 04/09 showed the following direction:
-To establish a comprehensive program which provides benefits in all activities of daily living and to provide adequate supplies for these activities.
-To define documentation requirements and to demonstrate compliance with licensing regulations.
-Activities will be provided to meet the special needs of the short-term skilled nursing patient.
-Activities Director or designated alternate is responsible for establishing an activity program for each swing bed patient based on the Activities Assessment

Procedure:
1. Each Swing Bed patient will be offered a minimum of one designated, structured activity period each day, appropriate to their needs, interests and abilities.
2. Activity therapy will be documented in the medical record and integrated into the patient's plan of care.
4. An Activity Assessment Form will be completed on all Swing Bed patients. This will help the Activity Director to plan tentative goals and plan for discussion at the team conference.
5. Documentation of all activities is to be done, using objective and measurable terms, in the patient's medical record. This documentation should include but not be limited to:
A. Patient' ability to tolerate activity
B. Any problems
C. Patient refusal
D. Patient's progress toward goals set
E. Date, time signed

2. Record Review of Patient #8's medical record showed the patient was admitted to a Swing Bed on 02/27/12 for Physical Therapy, Occupational Therapy and Speech Therapy after a fracture of the left pubic rami (pubic bone).

Record review of the Swing Bed Activity Assessment dated 02/27/12 stated that the patient usual habits include other interests or hobbies, spends most of time alone or watching TV, stays busy with hobbies or fixed daily routine, talking or conversing and watching TV or movies. Pets in the home are Dog-Poodle. Activity plan will be provide 1:1 interactions, and provide in room activities and possibly go outdoors if weather permits. The facility failed to individualize activities and no goals were documented.

Record review of the Swing Bed Activity Flowsheet dated 02/28/12 at 10:10 PM showed that the patient was watching TV, socializing with peers/staff, and staff visit in patient's room. No documentation of planned 1:1 activity was documented. No goals were documented.

Record review of the Swing Bed Activity Flowsheet dated 02/29/12 at 10:40 AM showed the patient was watching TV, current events, socializing with peers/staff, and staff visit in patient's room and performed Massage therapy on shoulders, hands, and feet. No goals were documented.

During an interview on 02/28/12 at 8:40 AM Patient #8 stated that she was unable to do much due to the pain and immobility caused by the fracture. She stated that she had been visited by the Activities Director and she would be doing massage therapy. She stated that she didn't know when or how many times a week and did not know what else was planned.

3. Record review of Patient #9's medical record showed the patient was admitted to a Swing Bed on 02/16/12 for weakness after a fall and would receive physical and occupational therapy.

Record review of the Swing Bed Activity Assessment dated 02/17/12 at 10:56 AM showed the patient likes jigsaw puzzles and will be provided 1:1 interaction in her room. No goals were documented.

Record review of the Swing Bed Activity Flowsheet dated 02/26/12 at 6:57 AM, 02/27/12 6:05 AM, 02/27/12 at 10:38 AM, and 02/28/12 at 7:20 PM showed the patient was watching TV, socializing with peers/staff, and staff visit in patient's room. No goals were documented.

During an interview on 02/28/12 at 9:00 AM Patient #9 mumbled one word responses which were not understood to some of the surveyor's questions and did not answer some questions. No jigsaw puzzles were observed in the room.

4. Record review of Patient #13's medical chart showed the patient was admitted to a Swing Bed on 02/02/12 for fracture of the right femur (leg) with repair. The patient was to receive physical therapy.

Record review of the Swing Bed Activity Assessment dated 02/06/12 at 1:11 PM showed the patient spends most of time alone or watching TV, talking or conversing. Happiest when around her grandbaby. Enjoys word searches and talking on phone. Not a people person. Repetitive health complaints nearly daily. Reduced social interaction nearly daily. Activity plan will be provide 1:1 interactions, and provide in-room activities. No goals were documented.

Record review of the Swing Bed Activity Flowsheets dated 02/27/12, 02/29/12 showed no planned individualized activity with 1:1 interactions by the Activity Director.

During an interview on 02/28/12 at 9:25 AM Staff G, Activities Director, stated that she visits with each Swing Bed patient within the first 24 hours to assess their needs. She stated that all activities are 1:1 as there are no planned group activities and no calendar to show when activities with the patients will occur.

Based on interview, record review and policy review, the facility failed to develop and maintain and/or keep current plans of care to ensure patient care, treatment and/or services were appropriately planned to meet the patient's needs and to have measurable goals for two patients (#9,#13) of three Swing Bed patients' plans of care reviewed. (A Swingbed is a change in reimbursement status. The patient goes from receiving acute-care services and reimbursement to receiving skilled nursing services and reimbursement). The swing bed census was three. The facility census was nine.

Findings included:

1. Record review of the facility policy titled "Comprehensive Care Plans - Development" reviewed 05/11/12 showed the following direction:
- The multidisciplinary team, in conjunction with the patient, family or healthcare representative, develops quantifiable objectives that the patient may be expected to obtain;
-The Care plan must reflect steps for each outcome objective;
-Staff will use these objectives to follow the patient's progress;
-The comprehensive care plan is periodically reviewed and revised by the multidisciplinary team after each assessment.

2. Review of Patient #9's medical record showed she was admitted to the facility as a Swing Bed patient on 02/16/12 for weakness and falls. The medical record showed the following:
- High fall risk with a score of 40 (a patient is considered a high fall risk with a score over 34)
-Oxygen per nasal cannula (supplemental oxygen which is delivered by a device consisting of a plastic tube which fits behind the ears, and a set of two prongs which are placed in the nostrils. Oxygen flows from these prongs)
-Insulin dependent diabetic
-Incontinent of urine (involuntary leakage of urine)
-Hard of hearing
-Speech therapy for impaired swallowing
-Respiratory therapy for ordered treatments
-Physical therapy for strength/endurance
-Pressure ulcer precautions

2. Review of patient #13's medical chart showed the patient was admitted to the facility as a Swing Bed patient on 02/02/12 for a fracture of the right femur (long bone in the leg) with repair. The medical record showed the following:
-High fall risk with a score of 100
-Oxygen per nasal cannula
-Heparin (anticoagulant) protocol
-Assist of one with other Activities of Daily Living (toileting, dressing)
-Pain
-Foley catheter (a tube which goes into the bladder to drain urine)

Review of the Patients #9 and #13 care plans did not address these individual needs and therefore the plan of care did not meet the needs of the patients.

3. During an interview on 02/29/12 at 10:14 AM Staff A, DON, stated that she completed the care plans for each patient.
She stated the following:
-A multidisciplinary team meets weekly to discuss any changes in the patient's condition;
-The nurses are to review and initial the care plan daily;
-The care plan is a means for the nurses to know what they are supposed to be doing for the patient;
-If the nurses want to know what the other disciplines such as Physical Therapy or Occupational Therapy were doing; they are to look under that disciplines documentation in another part of the medical record.