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Based on the Life Safety Code Validation survey completed on November 2, 2012, the Condition for Physical Environment is not met. See the Division of Safety Inspection 2567 for the specific findings.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure preventative maintenance was performed on clinical equipment utilized for patient care in the rehabilitation department.

Findings include:

Review on November 14, 2012, of the facility's "Preventative Maintenance Policy," last reviewed September 24, 2012, revealed "Policy: It is the policy of Troy Community Hospital to follow and maintain a preventative maintenance program of the upkeep and proper operation of all non-clinical equipment throughout the hospital. ... The [name of hospital] Bio-Med department is responsible for the upkeep and proper operation of all clinical equipment also to follow and maintain a PM program on all such equipment. ...Procedure: 1.) Troy Community Hospital follows a preventative maintenance program that included a complete inventory of all hospital equipment. ... 2.) New Equipment: Upon delivery of any new equipment a preventative maintenance file is complied and completed by the maintenance department. ..."

Review on November 14, 2012, of the facility's "Biomedical Engineering Preventative Maintenance Service Agreement," no review date, revealed "The [name of hospital] agrees to provide Biomedical Engineering Services to the Troy Community Hospital. [Name of hospital] Biomedical Engineering will provide the following services: 1) Perform required safety and performance testing procedures for all the patient care equipment listed 2) Maintain records that document acceptable performance against stated procedures 3) Test all equipment prior to initial use and at intervals not to exceed twelve (12) months ... Troy Community Hospital will: 1) Maintain a list of all patient care equipment currently used in the hospital for diagnosis, treatment, or monitoring of patients ..."

1) Observation of the rehabilitation department on November 14, 2012, revealed an ultrasound machine, last preventative maintenance (PM) date was June 21, 2011, a gel warmer, last PM date was March 8, 2005, a Hydrocollator (a liquid heating device used to heat and store hot packs), last PM date was June 21, 2011, an intravenous (IV) pump, last PM date was January 13, 2011, an electric griddle (used to form splints), last PM date was March 8, 2005, a blood pressure/pulse machine and paraffin wax bath that did not contain the date of the last PM.

Interview with EMP7 and EMP6 on November 14, 2012, at approximately 1:30 PM revealed preventative maintenance is performed yearly on clinical equipment used on patients and the preventative maintenance was not performed yearly as required on the above clinical equipment.

2) Observation of the rehabilitation department on November 14, 2012, revealed a splint pan used to form splints for patients. Further observation revealed no date of the last PM.

Interview with EMP7 and EMP6 on November 14, 2012, at approximately 1:35 PM confirmed there was no date of the last PM performed on the splint pan. Further interview with EMP6 revealed this piece of equipment was received and put into use on May 24, 2012, and there was no safety or performance testing of this splint pan.

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Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure electrical panels were secured on the patient care unit, in the sleep lab and speech therapy department.

Findings include:

Review on November 13, 2012, of the facility's "General Safety" policy, last reviewed September 24, 2012, revealed "Policy: To adopt, implement and monitor a comprehensive hospital-wide environment control program relative to safety which ... produce safe characteristics and practices and to eliminate or reduce insofar as possible threat or harm to patients, personnel and visitors, and damage to the facility due to unsafe or unsanitary conditions. Procedure: ... B. Responsibilities of Safety Committee ... To conduct at regular intervals, hazard surveillance. ..."

1) Observation on November 13, 2012, of the facility's patient care unit revealed an open and unlocked electrical panel containing power switches for the unit.

Interview with EMP1 and EMP6 on November 13, 2012, at approximately 10:00 AM confirmed the open and unlocked electrical panel containing a power switches for the unit.

2) Observation on November 14, 2012, of the facility's sleep lab revealed an open and unlocked electrical panel containing power switches for the area.

Interview with EMP1 and EMP6 on November 14, 2012, at approximately 1:30 PM confirmed the open and unlocked electrical panel containing power switches for the area.

3) Observation on November 14, 2012, of the facility's speech therapy department revealed an open and unlocked electrical closet containing power switches for the speech therapy department .

Interview with EMP7 and EMP6 on November 14, 2012, at approximately 1:45 PM confirmed the open and unlocked electrical closet containing a power switches for the speech therapy department .

Interview with EMP6 on November 14, 2012, at approximately 2:00 PM revealed that all electrical panels and closest were to be locked.

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Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure power strips were not used in the hospital's sleep lab and on the patient care unit.

Findings include:

Review on November 14, 2012, of the facility's "Electrical Safety" policy, no review date, revealed "... 3. Below are guidelines for the use of extension cords, adapters, and personal electrical devices. ...b. Adapters, devices used to reduce or modify electrical cords or systems are prohibited. ..."

1) Observation on November 14, 2012, of the facility's sleep lab revealed four electrical plugs plugged into a power strip. EMP6 identified the electrical plugs as two camera video recording plugs and two printer plugs.

Interview with EMP7 and EMP6 on November 14, 2012, at approximately 1:30 PM confirmed the power strip in the sleep lab contained two camera video recording plugs and two printer plugs. EMP6 confirmed the facility was not to use power strips as a substitute for a sufficient number of electrical outlets.

2) Observation on November 15, 2012, of the break room on the patient care unit revealed a coffee pot plugged into a power strip.

Interview with EMP6 on November 15, 2012, at approximately 3:30 PM confirmed the coffee pot in the break room on the patient care unit was plugged into a power strip. EMP6 confirmed staff were not to use power strips as a substitute for a sufficient number of electrical outlets.

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Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure portable heaters were not used in the hospital.

Findings include:

Review on November 14, 2012, of the facility's "Extension Cords and Portable Heaters" policy, no review date, revealed "Policy: ... The use of portable space heating devices at Troy Community Hospital is prohibited. (Life safety Code 31-4.7) ..."

Review on November 13, 2012, of the facility's "General Safety" policy, last reviewed September 24, 2012, revealed "... 9. Patient Safety Devices Patient safety devices include the following essential safety measures: ... use of portable heaters or similar equipment is prohibited. ..."

Observation on November 14, 2012, of the facility's cardiac stress test area revealed a portable space heater.

Interview with EMP6 on November 14, 2012, at approximately 3:45 PM confirmed there was a portable space heater in the cardiac stress test area. EMP6 confirmed the use of portable space heaters was prohibited in the hospital.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure refrigerated medications were stored separate from patient food in the occupational therapy department.

Findings include:

Review on November 14, 2012, of the facility's "Medication Storage and Security" policy, last reviewed May 29, 2012, revealed "Policy: Medications stored in the Troy Community Hospital shall be accessible only to authorized personnel. Medications shall be stored according to the manufacture's recommendations, or in the absence of such recommendations, according to the pharmacist's instructions. ... Refrigerator Medications requiring refrigeration for stability will be stored in a locked or directly supervised refrigerator. ..."

Observation on November 14, 2012, of the occupational therapy department revealed a refrigerator designated for patient food. Further observation of this refrigerator revealed four packages each containing four vials of Definity Perflutren Lipid Microspere (a contrast agent injected intravenously to enhance cardiac stress procedures) medication.

Interview with EMP7 on November 14, 2012, at approximately 2:30 PM confirmed the refrigerator in the occupational therapy department contained four packages each containing four vials of Definity Perflutren Lipid Microspere. EMP7 confirmed the medication was not to be stored in the refrigerator designated for patient food.

Based on review of facility policies, credential files (CF) and interview of staff (EMP) it was determined the facility failed to perform a National Practitioner Data Bank inquiry on all practitioners for two of eleven credential files reviewed (CF10 and CF11).

Findings include:

Review of the facility document "Troy Community Hospital Bylaws of the Medical Staff," last reviewed June 26, 2012, revealed "... 5.4 Processing the Application ... 5.4-3 Verification of Information Upon receipt of the application form, the President shall seek to collect or verify: references; inquiry form [sic] the National Practitioner Data Bank; licensure; DEA [Drug Enforcement Agency] status; and other qualifications evidence submitted. ..."

Review of the facility document "Guthrie Clinic Credentials Verification Service Agreement," dated July 2, 2007, revealed "This Agreement is to confirm the terms and conditions between the Guthrie Clinic Centralized Credentials Verification Service ("CCVS") and participating health care organizations ("Organization"). ... Appendix A: CCVS Policies ... 4. CCVS will obtain primary source verification of the following: ... Query the National Practitioner Data Bank (NPDB) at initial appointment and reappointment (each Organization will complete the forms necessary to appoint CCVS to be its authorized agent for inquiry to the NPDB). Both the CCVS and Organization understand that CCVS's authorized agent must make a separate and individual query for each and every Organization needing NPDB information on each individual Applicant. ..."

Review on November 15, 2012, of CF10 and CF11 revealed no documentation a NPDB query was obtained prior to CF10 and CF11's employment at the facility in June 2012.

Interview with EMP4 at 10:00 AM on November 15, 2012, confirmed a NPDB query was not obtained prior to CF10 and CF11's employment at the facility in June 2012. EMP4 also confirmed a NPDB query should have been completed on CF10 and CF11 prior to their employment at the facility.

Based on review of facility policies, medical records (MR) and interview of staff (EMP), it was determined the facility failed to ensure a written history and physical was on the medical record prior to surgery for two of eleven applicable medical records (MR15 and MR18).

Findings include:

Review of the facility policy "History and Physical," last reviewed March 27, 2012, revealed "Policy: It is the policy of the Troy Community Hospital Surgical Department that a complete History and Physical is completed on every patient and on the chart prior to surgery, except in the case of an emergency. ... Procedure: Prior to surgery, each patient shall have a history and physical examination completed no more than 30 days prior to surgery, appropriate to the patient's physical condition and the surgical procedure to be performed. This shall be written by a qualified physician and recorded in the patient's medical record. ..."

Review on November 16, 2012, of the facility policy "Medical Records Standards for Completion," last reviewed March 2012, revealed "Policy Statement The medical records of patients shall be maintained and completed in accordance with the rules and regulations detailed in the Medical Staff Bylaws, Medical Record Standards and various accrediting and/or regulatory agencies. Interpretation ... 5. Patients must be seen and receive an H and P [history and physical] no more than 30 days prior to/or within 24 hours after inpatient admission or registration, but prior to surgery or a procedure requiring anesthesia services. ..."

Review on November 15, 2012, of MR15 and MR18 revealed no written history and physical on the medical record prior to MR15's non-emergent surgical procedure on July 11, 2012 and MR18's non-emergent surgical procedure on November 14, 2012.

Interview with EMP3 at 9:15 AM on November 15, 2012, confirmed there was no written history and physical on the medical record prior to MR15's surgical procedure on July 11, 2012 and MR18's surgical procedure on November 14, 2012. EMP3 also confirmed the facility's policy stated a complete history and physical was to be completed on every patient and on the chart prior to surgery.

Based on review of facility documents, facility dietary menus and staff interview (EMP), it was determined the facility failed to ensure changes in dietary menus were reviewed and approved by the dietitian for nutritional values and content.

Findings include:

Review on November 14, 2012, of the facility's Nutritional Consulting Contract, last signed March 2, 2011, revealed "Contract Terms: 1.) This contractual agreement includes consultant assistance in all aspects of food service management and nutritional care. This shall include clinical nutritional care ... menu planning and review ...."

1) Review on November 14, 2012, of the facility's Fall/Winter cycle: Week One Tuesday revealed the facility removed the original typed menu items and hand wrote cream chicken, biscuit, broccoli and cookie. Further review revealed the serving size for the regular diet, the soft/bland diet, the mechanical soft diet, the pureed diet, the no milk product diet, the two gram sodium diet, the pureed consistent carbohydrate diet, the consistent carbohydrate diet, the 1000 calorie diet, the 1200 calorie diet, the 1500 calorie diet and the 1800 calorie diet were changed. There was no documentation the dietitian reviewed this change for nutritional value and content.

2) Review on November 14, 2012, of the facility's Fall/Winter cycle: Week One Wednesday revealed the facility removed the original typed menu items and hand wrote meatball with roll, potatoes, tossed salad and dressing. Further review revealed the serving size for the regular diet, the soft/bland diet, the mechanical soft diet, the pureed diet, the no milk product diet, the two gram sodium diet, the pureed consistent carbohydrate diet, the consistent carbohydrate diet, the 1000 calorie diet, the 1200 calorie diet, the 1500 calorie diet and the 1800 calorie diet were changed. There was no documentation the dietitian reviewed this change for nutritional value and content.

Interview with EMP8 on November 14, 2012, at approximately 1:15 PM confirmed the facility made changes to the Fall/Winter cycle: Week One Tuesday and Fall/Winter cycle: Week One Wednesday. Further interview with EMP8 confirmed the dietitian did not review these changes for nutritional value and content.

Based on review of facility documents, medical records (MR) and interview of staff, it was determined the facility failed to ensure all medical records were completed within 30 days of discharge for 12 of 12 applicable medical records reviewed (MR50, MR51, MR52, MR53, MR54, MR55, MR56, MR57, MR58, MR59, MR60 And MR61).

Findings include:

Review on November 16, 2012, of the facility policy "Medical Records Standards for Completion," last reviewed March 2012, revealed "Policy Statement The medical records of patients shall be maintained and completed in accordance with the rules and regulations detailed in the Medical Staff Bylaws, Medical Record Standards and various accrediting and/or regulatory agencies. Interpretation 1. Authorized contributors to the medical record bear the common responsibility to document legibly, timely and completely. Authorized individuals are those involved in the management of the patient who provide care, treatment, assessment, and support to the patient relative to their scope of practice. These individuals include but are not limited to physicians, mid-levels, nurses, therapists, students, chaplains, dietary staff, case management staff, etc. ..."

Review of facility policy "Delinquent Medical Record," reviewed March 2012, revealed "Policy Statement Timely documentation within the medical record promotes accuracy, completeness and specificity. ... Interpretation 1. The Medical Records Department informs physicians weekly of missing reports/documentation recorded on the incomplete chart list encompassing all records that have been audited. Delinquent records are defined as follows: a. Any discharged record 22 days or over that is missing a diagnosis or signature. b. Any record missing an interval note, history and physical, operative report, procedure note, discharge summary, or consultation 15 calendar days after discharge. c. Any chart not entirely completed within 30 days of patient discharge. ..."

Review on November 16, 2012, of the facility's "Troy Community Hospital Chart Completion" report identified by the facility as the medical record delinquent report for CF4, dated November 16, 2012, revealed CF4 had 12 delinquent medical records that were 30 days or greater from the patient's date of discharge. CF4's delinquent medical record list included the following: MR61 was discharged on September 30, 2012; MR60 was discharged on October 1, 2012; MR59, MR58, and MR57 were discharged on October 3, 2012; MR56 and MR55 were discharged on October 4, 2012; MR54 and MR53 were discharged on October 5, 2012; MR52 was discharged on October 6, 2012; MR51 was discharged on October 9, 2012 and MR50 was discharged on October 17, 2012.

Interview with EMP5 at 10:15 AM on November 16, 2012, confirmed CF4 had 12 delinquent medical records that were not completed within 30 days of the patient's discharge date. EMP5 also confirmed medical records were to be completed within 30 days of a patient's discharge date.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the swing bed patient participated in determining a code status for two of 10 swing bed program medical records reviewed (MR32 and MR33).

Findings include:

Review on November 15, 2012, of the facility's "Do Not Resuscitate Policy," last reviewed May 14, 2012, revealed "Policy Statement: Troy Community Hospital shall provide full resuscitative measures for patients in cardiopulmonary arrest unless the patient has previously expressed the desire not to have such treatment and/or unless a Do Not Resuscitate (DNR) order is written. Interpretation 1. Definitions Do Not Resuscitate: Cardiopulmonary resuscitation will not be performed in the event of a cardiopulmonary arrest. Cardiopulmonary resuscitation includes measures to restore cardiac function or to support ventilation in the event of a cardiac or respiratory arrest ... D. Documentation of the Order 1. The DNR order must be: Clearly written on the physician's order sheet; Communicated to all care-givers; and Documented in the progress notes. This documentation should briefly summarize the discussion held with the patient or the patient's family members(s). When a family member is used, a note documenting the patient's lack of capacity should also be present. 2. The order should be written by the physician who participated in the discussion with the patient or family member(s). ..."

1) Review of MR32 on November 15, 2012, revealed this patient was admitted to the facility's swing bed program on November 10, 2012, and was alert and oriented. Continued review of MR32 revealed a physician order for Do Not Resuscitate (DNR). There was no documentation in MR32 indicating the physician discussed the DNR status with MR32 or the patient participated in the decision of the DNR status.

2) Review of MR33 on November 15, 2012, revealed this patient was admitted to the facility's swing bed program on November 1, 2012, and was alert and oriented. Review of MR33 revealed a physician order for Do Not Resuscitate (DNR). There was no documentation the physician discussed the DNR status with MR33 or the patient participated in the decision of the DNR status.

Interview with EMP10 and EMP2 on November 15, 2012, at approximately 11:30 PM confirmed MR32 and MR33 were admitted to the facility's swing bed program and were alert and oriented. MR32 and MR33's physicians wrote DNR status for these patients, and there was no documentation in these patient's medical records indicating a physician discussion regarding the DNR status or that these patients participated in the decision for a DNR status.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to have an activities program directed by a qualified professional.

Findings include:

Review on November 15, 2012, of the facility's "Social Worker - MSW/Activities/Volunteer Director" job description, last revised May 2012, revealed "Main function: To assist in meeting the psycho-social needs of patients ... To provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each Swing Patient. ... Essential Functions: ... 22. Supervises the activities coordinator to assure an activities program is completed on a regular basis and meets all regulatory and licensing guidelines. ...."

Interview with EMP9 on November 15, 2012, at approximately 2:00 PM confirmed this employee is not a certified therapeutic recreation specialist or an activities professional. Further interview with EMP9 confirmed this employee did not meet the qualifications to direct the facility's activities program.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the social service department failed to assess, identify and document patient discharge needs in five of 10 applicable swing bed patient medical records reviewed (MR28, MR29, MR30, MR31 and MR62).

Findings include:

Review on November 15, 2012, of the facility "Social Worker - MSW/Activities/Volunteer Director" job description, last revised May 2012, revealed "... Essential Functions: ... 7. Assesses, identifies and facilitates patient's past discharge needs for institutional care, home care, outpatient services or specialized care. Assists with arrangements and ability to formulate and complete all necessary referral procedures related to a patient's particular treatment plan; skilled nursing home placement, physical rehab placement, personal care home transfer, ambulance transfer, referral to area nursing services for home care, home aide services; set-up of home oxygen needs via referral to area home medical equipment supplies, etc. ... 12. Attends weekly Interdisciplinary meeting to identify patients/families in need of intervention and to collaborate on discharge planning status of patients previously referred. ... 16. Documents in patient medical record all relevant interactions ...."

1) Review of MR28 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on August 13, 2012, and discharged to home on August 27, 2012. There was no documentation in MR28 indicating social services assessed, identified and documented MR28's discharge needs.

2) Review of MR29 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on August 19, 2012, and discharged to another acute care facility on September 15, 2012. There was no documentation MR29 indicating social services assessed, identified and documented MR29's discharge needs.

3) Review of MR30 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on August 15, 2012, and discharged to home on September 20, 2012. Social service completed an initial social service assessment on September 14, 2012; MR30 was discharged on September 20, 2012. The was no documentation social services assessed, identified and documented MR30's discharge needs when admitted to the swing bed program on August 15, 2012.

4) Review of MR31 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on August 28, 2012, and discharged to a personal care home on October 3, 2012. There was no documentation in MR31 indicating social services assessed, identified and documented MR31's discharge needs.

5) Review of MR62 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on November 1, 2012, and discharged to home on November 10, 2012. There was no documentation in MR62 indicating social services assessed, identified and documented MR62's discharge needs.

Interview with EMP9 on November 15, 2012, at approximately 3:00 PM confirmed social services did not assess, identify and document patient discharge needs for MR28, MR29, MR31 and MR62. EMP9 confirmed MR30 was admitted on August 15, 2012, and that social service did not complete an initial social service assessment until September 20, 2012.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to assess, measure and document skin admitted to the facility swing bed program for three of 10 swing bed medical records reviewed (MR33, MR34 and MR35).

Findings include:

Review on November 15, 2012, of the facility's "Swing Bed Program" policy, no review date, revealed "Policy: The swing bed program at TCH [Troy Community Hospital] will provide continuity of nursing care as patients transition from acute care to discharge to either home or long-term care. ...Procedure to Transfer from Acute Care to Swing Bed Program ... 5. ... Complete the initial assessment .... Assess the patient ..."

1) Review of MR33 on November 15, 2012, revealed the facility admitted this patient to the swing bed program on November 1, 2012, with skin breakdown on the left knee, inner forearm and right upper arm. Further review of MR33 revealed nursing staff did not assess, measure or document this patient's areas of skin breakdown until November 6, 2012.

2) Review of MR34 on November 15, 2012, revealed the facility admitted this patient to the swing bed program on November 6, 2012, with skin breakdown on the left inner thigh, right inner thigh, right buttocks, right outer abdomen and left lower abdomen. Further review of MR34 revealed nursing staff did not assess, measure or document this patient's areas of skin breakdown until November 12, 2012.

3) Review of MR35 on November 15, 2012, revealed the facility admitted this patient to the swing bed program on October 10, 2012, with skin breakdown on the left shoulder, left lower abdomen and coccyx area. Further review of MR35 revealed nursing staff did not assess, measure or document this patient's areas of skin breakdown until October 16, 2012.

Interview with EMP10 and EMP2 on November 15, 2012, at approximately 2:00 PM confirmed MR33, MR34 and MR35 were admitted to the facility swing bed program with skin breakdown and that nursing staff did not assess, measure and document these patients's areas of skin breakdown on admission.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a discharge summary reflecting a recapitulation of the patients acute care stay was included in the medical record upon the patient's discharge from acute care status and admission to the swing bed program for two of 10 swing bed medical records reviewed (MR32 and MR62).

Findings include:

Review on November 15, 2012, of the facility's "Swing Bed Program Admission of Patient" policy, no review date, revealed "Policy: This facility is operated with the regulations of the State Department of Health. ... Procedure: .... 2. Pre-admission data required: ... b. Discharge summary (hospital patient) ..."

Review of MR32 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on November 10, 2012. Further review of MR32 revealed no documentation of a discharge summary reflecting a recapitulation of this patients acute care stay in MR32's swing bed medical record.

Review of MR62 on November 15, 2012, revealed this patient was admitted to the facility swing bed program on November 1, 2012. Further review of MR62 revealed no documentation of a discharge summary reflecting a recapitulation of this patients acute care stay in MR62's swing bed medical record.

Interview with EMP10 and EMP2 on November 15, 2012, at approximately 1:30 PM confirmed there was no discharge summary reflecting a recapitulation of MR32 and MR62's acute care stay in the swing bed medical record.