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Based on observation, interview, and record review the facility failed to ensure the nursing care plan is kept current for 2 out of 31 (SP)Sample Patients(SP#15,SP#19).

The findings include:
(1.) Observation during the tour with the Infection Control Nurse conducted on 03-15-12 at 1:10 pm revealed that the SP#15 was on contact isolation precaution.

Clinical record review of the nurses' note dated 03-01-12 revealed that SP#15 was positive for MRSA (Methicillin Resistant Staphylococcus Aureus).

Further review of the clinical record revealed an absence of a plan of care regarding the MRSA infection and the intervention for contact isolation precaution. Review of the daily nurses' notes from 03-01-12 thru 03-06-12 showed no documentation regarding MRSA infection and contact isolation precaution.
Interview with the Chief Nursing Officer conducted on 03-08-12 at 10:00 am confirmed above findings that there is no plan of care and daily nurses' notes regarding MRSA infection and contact isolation precaution.

(2.) Observation during the tour with the Infection Control Nurse conducted on 03-15-12 at 1:10 pm revealed that the SP#19 was on droplet isolation precaution.

Clinical record review conducted on 03-07-12 of SP#19 revealed that the patient was admitted on 02-29-12 with admitting diagnosis of Pneumonia and Flu. Review of the clinical record revealed an absence of a plan of care regarding the Flu infection and the intervention for droplet isolation precaution. Review of the daily nurses' notes from 02-29-12 thru 03-05-12 showed no documentation regarding Flu infection and droplet isolation precaution.
Interview with the Charge Nurse of 2 North East Unit conducted on 03- 05-12 at 1:15pm confirmed above findings that there was no plan of care and daily nurses' notes regarding Flu infection and droplet isolation precaution.

Review of the Hospital Policy and Procedure" Nursing Process" conducted on 03-08-12 confirmed above findings that the facility failed to follow its policy and procedure regarding the Nursing Process. The policy showed under Procedure II: Planning (1.) "The registered nurse will formulate a medical care plan based on the patient assessment; (2.) The patient problem list will reflect the date the problems were identified, resolved or alleviated; (3.) Nursing documentation will also include: (a)an Assessment of problem or need, (b.) the Nursing interventions, (c.) and an Evaluation of the interventions and re-assessments."

Based on record review and interview, the facility failed to ensure that documentation of the discharge planning evaluation is included in the patient's medical record in 4 out of 11 Sample Patients (SP) selected for Discharge Planning-focused record review. SP#8, SP#10, SP#16, and SP#21.

The findings include:

(1). Clinical record review of SP# 8 conducted on 03-06-2012 revealed an admission date of 03-03-2012 and the admitting diagnosis is left intertrochanteric hip fracture. Review of the Admission History and Physical Examination form dated 03-04-2012 revealed an entry Discharge Plan: Discharge home or rehabilitation center.
Interview with the Director of Case Management (Dir. of CM) conducted on 03-06-2012 at 2:30 pm revealed that this entry or documentation was written by the House Physician who also functions as a Case Manager. The Dir. of CM also stated that this documentation is considered as the initial discharge planning notes for SP#8. The Dir. of CM then stated that discharge planning of all the patients are done on daily clinical rounds and also on discharge planning meetings which are conducted three (3) times a week.

(2). Clinical record review of SP#10 conducted on 03-06-2012 revealed an admission date of 03-02-2012 and the admitting diagnosis is right lower extremity cellulitis. Review of the Admission History and Physical Examination form dated 03-03-2012 revealed an entry Discharge Plan: Discharge home.
Interview with the Director of Case Management (DCM) conducted on 03-06-2012 at 2:30 pm revealed that this entry or documentation was written by the House Physician who also functions as a Case Manager and the DCM stated that this documentation is considered as the initial discharge planning notes for SP#10. The DCM stated that discharge planning of all the patients are done on daily clinical rounds and also on discharge planning meetings which are conducted 3 times a week.

(3). Clinical record review of SP#16 conducted on 03-07-2012 revealed an admission date of 02-07-2012 and the admitting diagnosis is exacerbation of congestive heart failure.
Interview with the DCM on 03-07-2012 at 10:40 am pm revealed that the initial discharge planning notes are written by the House Physician who also functions as a Case Manager and the initial discharge planning notes are documented in the Admission History and Physical form.
Review of SP#16's Admission History and Physical form does not show any documentation of the initial discharge planning. The DCM stated that discharge planning of all the patients are done on daily clinical rounds and also on discharge planning meetings which are conducted 3 times a week.


(4). Clinical record review of SP#21 conducted on 03-07-2012 revealed an admission date of 03-02-2012 and the admitting diagnosis is right lower lobe pneumonia and hypokalemia.
Interview with the Director of Case Management DCM on 03-06-2012 at 2:30 pm revealed that the initial discharge planning notes are written by the House Physician who also functions as a Case Manager and the initial discharge planning notes are documented in the Admission History and Physical form.
Review of SP#21's Admission History and Physical form does not show any documentation of the initial discharge planning. The DCM stated that discharge planning of all the patients are done on daily clinical rounds and also on discharge planning meetings which are conducted 3 times a week.

There are no documentation that could be located in each of the sample patients (SP #8, #10, #16, and #21) medical records at the time of the survey as evidence of a discharge planning evaluation to assess the needs of the patients, nor were there any documentation of an ongoing evaluation of their discharge needs .

The discharge planning evaluations would assist in determining an appropriate discharge plan for each of the sample patients.

The above findings were confirmed with the Director of Case Management DCM on 03-08-2012 at 9:40 am that there was failure to maintain documentation of the discharge planning evaluation as well as ongoing evaluation of the discharge planning needs of the sampled patients as stated in the facility's policy and procedure.




The facility's policy and procedure on "Daily Clinical Rounds and Discharge Planning" states : to facilitate discharge or transfer, the hospital assesses the patient's needs, plans for discharge or transfer, and that
discharge planning needs and outcomes shall be documented in the multidisciplinary section of the medical record, as well as the Case Management/House Physician concurrent review worksheet.

Based on observation, record review and interview, the facility failed to ensure that one nurse, sample employee (SE#24), provide care in accordance with the Infection Control Policies to assure the achievement and maintenance of high standards of medical practice and patient care, as evidence by using inappropriate aseptic technique when preparing the surgical skin site in 1 out 31 sampled patients (SP#23).

The findings include:

Observation tour of the operating room (OR#1) located at the Perioperative Services Department (SE# 16) was conducted on March 6, 2012 from 10:40 am to 12:10 pm in the presence of the Director of Perioperative Services. During observation of the patient's skin preparation to right lower extremity, the surveyor observed that SE#24 opened and set up sterile Povidone gel 10% (percent) preparation kit on a side table. Then, SE#24 proceeded to prepare skin site (right lower extremity) using sponge moistened with the Povidone gel 10% preparation. After each time SE#24 cleaned the surgical skin area, SE#24 put the used sponge back in the sterile field instead of discarding the (four) used sponges in a garbage receptacle. Furthermore, surveyor noticed that orderly who was elevating right lower extremity touched with non-sterile gloves the already prepared surgical skin site. Surveyor intervened by informing the Director of Perioperative Services that aseptic technique was not maintained as evidenced by the soiled sponges being put back in the sterile field and the orderly touching the already "prepared" site. The Director of Perioperative Services firmed the findings . At this time, the Director of Perioperative Services (SE#16) informed the surgical team to await and asked SE#24 to prepare surgical skin site again.

Record review of the facility's policy on Skin Preparation of Surgical Patients stated the purpose of skin preparation is "To remove as much bacteria, dirt and skin oil as possible from the operative site and surrounding are to reduce the chance of wound infection".


Interview with the Director of Perioperative Services (SE#16) conducted on March 7, 2012 at 11:30 am, re-confirmed above findings. Furthermore, SE#16 stated that he addressed the issue with SE#24. The facility failed to ensure that SE#24 provides care in accordance to Infection Control standards which can predispose patients to complications such as infection or septicemia.

Based on record review and interview, the facility failed to ensure that 2 of the respiratory care Personnel sample employees(SE) (SE # 4, SE #27) who are qualified to perform specific procedures maintained a current Basic Life Support (BLS) certification requirement.

The findings include:

Review of the BLS certification of 2 (two) Certified Respiratory Therapists conducted on 03-05-2012 at 2:15 pm revealed that their certification for CPR has expired.
Interview with the Director of Cardiopulmonary Services conducted on 03-05-2012 at 2:30 pm stated that the two Respiratory Therapists have been removed from direct patient care. The present schedule showed that the above-mentioned employees are not on the schedule to work. The Director of Cardiopulmonary Services further stated that the concerned staff are scheduled to take the BLS class this month.

The above findings were confirmed with the Director of Cardiopulmonary Services on 03-05-2012 at 2:30 pm that there was failure to ensure that the respiratory care staff maintained a current BLS certification.