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Based on observation and interview, the facility failed to assure a clean and orderly environment was maintained in that there was a lack of designated storage space, mixed storage, dual use of rooms that diminished available floor space for patient access and accumulated dust on equipment and furnishings in disrepair. The areas affected were the ultrasound exam room, clean linen storage, storage closet, patient rooms (#18,-#21, #23, #25 and #26) and the Emergency Department. Patient safety could not be assured without a clean and uncluttered physical environment. The failed practice created potential hazards for all patients who received care in the facility. The findings were:

A. During a tour of the ultrasound room on 02/03/15 at 0845 the following was observed:
1) The ultrasound exam room was utilized as the Radiology Director's office space and contained a desk with a computer and books, filing cabinet, an exam table and ultrasound monitor, as well as various other equipment and supplies stored in the room that diminished the available floor space. The diminished floor space created by the dual use of the room would impede wheelchair access and created a hazard should a patient who required a wheelchair need an ultrasound.
3) The Radiology Director was asked by Surveyor #1 on 02/03/15 at 0850 where a patient would change clothing if required, as there were no privacy curtains in the room and he stated "the bathroom." Observation of the bathroom in the Ultrasound room revealed items were stored in front and beside the toilet area. The area would not allow space for a patient walker or wheelchair.
4) At the time of the tour, the Radiology Director confirmed the room was an office and exam room.
B. Observation on 02/03/15 at 0900 of the area identified by the DON (Director of Nursing) as a "Clean Linen Storage Room" revealed multiple non-linen items stored in the room: a fan with an accumulation of dust and dirt, cloth type mop heads, and a dusty wheeled stretcher with six rips in the vinyl-type mattress surface with exposed padding, pushed against the clean linen. The plastic covering of a package of linen was open and the wheel of the stretcher was against the clean linen. The DON confirmed the contents and findings in the linen room at the time of observation.
C. Observation on 02/03/15 at 1000 revealed an accumulation of dust and dirt along the floor in front of the bottom shelf of a storage closet across from the nurses station. Cardboard boxes of patient care supplies(Oxygen masks) and an open bin with oxygen and vacuum regulators for the Respiratory Department were stored directly on the floor.
D. The "Extra Computer Room" as identified by the DON, had respiratory equipment (Bi pap and an extra respiratory ventilator) stored in the room. The items were identified by the DON as respiratory equipment and clean, however they were not labeled and had an accumulation of dust on the surface. The DON and Environmental Services Director confirmed the dust accumulation and stored items at the time of observation.
E. Observation on 02/03/15 from 1000-1020 revealed 7 of 7 patient rooms observed (#18, #19, #20, #21, #23, #25 and #26) revealed overhead light pulls made of a combination of metal chain, soiled cording and gauze bandage material tied to the light pull used by patients. The cording and gauze bandage material were soiled and could not be sanitized. The DON confirmed the light-pull findings at the time of observation.
F. Observation of the Emergency Department on 02/03/15 from 0915-0950 revealed:
1) The waiting room had an accumulation of dust along the corners and baseboard areas; the covering of the computer chair (used by patients) was ripped and torn and the covering of three chairs was ripped and exposing the padding beneath. The facility provided toys and child's table in the waiting room were dusty and had dried drops of substance.
2) Three wheelchairs for patient transport were located next to the entrance to the emergency department and had an accumulation of dust.
3) Emergency Room #1 included transfer boards standing on the short end directly on the floor surface and one was stored directly on the floor and behind the double doors in the ED corridor. The ED corridor was not designated as a storage area and could impede patient transport.
4) Emergency Room #3, identified by the DON as the room utilized the most, contained two stretchers and privacy curtains, a rolling computer on wheels; a desk with computer; a second desk with a computer for the business office staff to register patients; another desk and computer identified as the "nurses desk"; and a telemetry monitor for all the telemetry patients mounted on the wall to the right of the nurses desk. Two of three desk chairs for staff had covers that were ripped exposing the padding beneath. The dual use of Emergency Room #3 for office furnishings and computers diminished the available floor space for the clinical staff to provide emergency care to patients.
G. The Emergency Department findings were confirmed at the time of observation by the DON.

Based on observation, policy review, and interview, it was determined the facility failed to ensure the safety and security of the foods in one of one walk in freezers that was outdoors in an unlocked and unmonitored area. The failed practice created the potential for the food items in the freezer to be tampered with and could affect any patient receiving foods from that freezer. Findings follow.

A. During a tour of the kitchen on 02/02/15 at 1315, the walk in freezer was observed to be located outdoors, directly adjacent to the loading dock.
1) The freezer door was not locked.
2) The gate to and from the loading dock was not locked.
B. The gate had a lock available, but the Certified Dietary Manager (CDM) stated it was locked only at night.
C. When asked what was preventing someone from coming and stealing and/or tampering with food items in the freezer, the CDM stated, "Well, right now, nothing."
D. When asked if the area was monitored via a security camera the CDM stated yes. However, the camera views only the loading dock and would not be able to capture if anyone was going into the freezer. When asked if anyone ever monitors the camera footage she stated, "Yes, I did once when I thought someone was stealing."
E. During an interview with the Administrator on 02/02/15 at 1400, he stated that due to a construction project going on at the facility, the security camera cable had been cut the day before (02/01/15), thus no security cameras were working at that time.
F. Review of policy titled "Department Security" stated, "The Department of Food and Nutrition Services shall take appropriate measures to provide a protected work environment for staff, as well as to secure the environment, food supplies..."

Based on observation, Fire Alarm System and Sprinkler System inspection documentation review and interview, it was determined the facility did not meet Life Safety Code requirements related to obstructed means of egress corridors, the use of portable electric heaters, the inspection of fire and smoke dampers, and the repair of fire alarm and sprinkler system components. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of two patients on 02/02/15. See K-72, K-70, K-104, K-52, and K-62.

Based on interview, it was determined that the facility did not ensure inspections were done by the local fire department. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of two patients on 02/02/15.

In an interview on 02/04/15 at 0900, the Maintenance Director verified there was no documentation of fire department inspections available for review.

Based on observation, interview, review of personnel files during the survey 02/02-05/15, clinical records and staff schedule, it was determined the Governing Body failed to effectively discharge it's oversight responsibilities to assure quality health care was provided in a safe environment in that Unit Secretary #1 was not trained and knowledgeable in identifying cardiac arrhythmias before monitoring four of four (Patient #1, #21-#23) patients from 02/02-05/15; there was no evidence the task of telemetry monitoring was assigned to a specific individual with training and knowledge of cardiac arrhythmias for each shift; and there was no policy and procedure for telemetry. Without evidence of training, an assessment of staff competency, and a policy for staff, it could not be assured potentially lethal cardiac arrhythmia's would be recognized, interpreted and reported upon occurrence to allow prompt notification of the physician for treatment or intervention. The failure to have trained staff assigned to monitor the patients on telemetry placed Patient #1, #21-#23 at risk of Immediate Jeopardy to their health and safety and would affect all patients admitted with orders for telemetry. See C270 for further details.

Based on observation, interview, review of personnel files during the survey 02/02-05/15, clinical records and staff schedule, it was determined the Governing Body failed to effectively discharge it's oversight responsibilities to assure quality health care was provided in a safe environment in that Unit Secretary #1 was not trained and knowledgeable in identifying cardiac arrhythmias before monitoring four of four (Patient #1, #21-#23) patients from 02/02-05/15; there was no evidence the task of telemetry monitoring was assigned to a specific individual with training and knowledge of cardiac arrhythmias for each shift; and there was no policy and procedure for telemetry. Without evidence of training, an assessment of staff competency, and a policy for staff, it could not be assured potentially lethal cardiac arrhythmia's would be recognized, interpreted and reported upon occurrence to allow prompt notification of the physician for treatment or intervention. The failure to have trained staff assigned to monitor the patients on telemetry placed Patient #1, #21-#23 at risk of Immediate Jeopardy to their health and safety and would affect all patients admitted with orders for telemetry. See C270 for further details.


Based on review of policies and procedures and interview, it was determined the Governing Body failed to assure facility policies for Respiratory, Infection Control, and Nursing Services were updated to reflect the facility current practices. The Governing body could not be assured of the quality of services provided. The failed practice affected all patients admitted to the facility. The findings were:

A. Review of the facility Respiratory Department Policy and Procedure Manual on 02/05/15 at 1535 revealed the last date of review was 2013 and was signed as approved by the Respiratory Care manager and CEO. The Respiratory Care Infection Control Policy and Procedure manual was last revised May 11, 2010, as signed by the Respiratory Director. The Respiratory Director confirmed the last dates of review of the Policies and Procedures on 02/05/15 at 1540.
B. The Nursing Department Emergency and Nursing Policy Manual was reviewed on 02/04/15 at 1500 and revealed the last date of review was February 2013. The Director of Nursing confirmed the last date of review on 02/04/15 at 1540.

Based on observation, interview, review of personnel files, job descriptions, clinical records and staff schedule on 02/02/15-02/05/15, it was determined the facility failed to assure Unit Secretary #1 was trained and knowledgeable in identifying cardiac arrhythmias before monitoring four of four (Patient #1, #21-#23) patients from 02/02-05/15; there was no evidence the task of telemetry monitoring was assigned to a specific individual with training and knowledge of cardiac arrhythmias for each shift. The failed practice did not assure potentially lethal cardiac arrhythmia's would be recognized, interpreted and reported upon occurrence to allow prompt notification of the physician for treatment or intervention. The failure to have trained staff assigned to monitor the patients on telemetry placed Patient #1, #21-#23 at risk of Immediate Jeopardy to their health and safety. The findings were:

A. The Director of Nursing (DON) stated by interview on 02/02/15 at 1020 the monitor equipment for staff to observe patients on telemetry was located at the nurses station and in the Emergency Department mounted on the wall above the RN (Registered Nurse) desk. The DON stated the Unit Secretary at the nursing station observed the telemetry and reported to the Charge Nurse. Unit Secretary #1 was observed at the nursing station without the Charge RN on the following dates and times when patients were on telemetry: 02/02/15 at 1035; 02/03/15 at 0840; 02/04/15 at 0915; and 02/05/15 at 0835.
B. Physician Orders were noted for Patient #21 for 02/04/15 at 2057 for "Telemetry Monitoring." Observation on 02/05/15 at 0908 revealed Patient #21 did not have a cardiac rhythm on the monitor and the device alarm was audible. Unit Secretary #1 stated to Surveyor #1, "I've told the nurse and she says the patient keeps taking the leads off." Observation of Patient #21 at 0910 revealed she was calm in bed with eyes closed. Surveyor #1 did not observe a cardiac rhythm on the monitor and "leads off" was on the monitor 02/05/14 at 0910, 0913, 09/20-0928 until 0955.
C. The following staff interviews were conducted:
1) In an interview on 02/03/15 at 0930 Unit Secretary #1 stated he watched the telemetry and told the nurse if the alarms went off. Review of the telemetry alarms with Unit Secretary #1 revealed the following alarm perimeters and priorities: "Priority code one is loud and alarms for Asystole, Ventricular Fibrillation, and Ventricular tachycardia; code two alarms but not as loud as code one and alarms for Bigeminy. Code 3 does not alarm audibly for #PVC(Premature Ventricular Contractions) /minute."
2) The DON stated by interview on 02/03/15 at 1300 "all Charge Nurses are ACLS (Advanced Cardiac Life Support) certified." On 02/04/15 at 1435, the DON stated "the Unit Secretaries along with the Charge Nurses watch the telemetry. Unit Secretary #1 works 0645-1530 all but one day per week and Unit Secretary #2 works 1545-0015 five days per week. There was no Unit Secretary scheduled for 0015-0645." The DON stated she did not have a staff person on the schedule specifically assigned to observe the telemetry monitor at the nurses station or in Emergency Room #3. Review of the "Nursing Work Assignment Sheet" for 02/02-05/15 and the Nursing Department schedule 08/2014-02/05/15 revealed there was no evidence a specific individual was assigned the task of telemetry monitoring. The DON confirmed the findings on 02/05/15 at 1200.
3) On 02/04/15 at 1450, the DON confirmed by interview that she did not have a policy or procedure for telemetry or telemetry monitoring.
4) On 02/05/15 at 0900 RN #1(a charge nurse) was interviewed and confirmed the Charge Nurse made the assignments, but the DON decided who worked in the Emergency Department and who worked on the in-patient floor. The Charge RN was responsible for completion of the admission paperwork and assessments for all admissions or observations, the LPN (Licensed Practical Nurse) did the medications and the technician did the vital signs. The Charge Nurse also did the discharge teaching and all patient shift assessments. "The Unit Secretary has the Telemetry monitor beside him and if he hears anything abnormal and the alarms go off, he tells the nurse and I'll check the leads or have the nursing assistant check." RN #1 stated, "I don't know if (Unit Secretary #1) has had cardiac monitoring training. I know he knows how to work the machine." RN #1 stated "Unit Secretary #1 prints off the strips and gives them to the nurse. As of yesterday, we initial the strips before we put them in the chart."
5) Patient Care Technician #1 was interviewed on 02/05/15 at 1000. She stated "The LPN puts them on telemetry. I don't know who is responsible for watching it."
6) Unit Secretary #1 was interviewed on 02/5/15 at 1012. Unit Secretary #1 stated the Charge Nurse made the assignments. The Charge Nurse did the initial admission assessment and did the shift assessment for all patients. Unit Secretary #1 stated his role with telemetry was to put the patient names in the system and "anytime it goes off I tell the nurse." Unit Secretary #1 confirmed he had not had any formal cardiac monitoring training.
7) In an interview with LPN #2 on 02/05/14 at 1030, he stated the charge nurse made the assignments. LPN #2 stated he had no formal training in cardiac monitoring.
8) In an interview on 02/05/15 at 1430, RN #2, who was assigned to the Emergency Department, stated the telemetry monitor on the wall in Emergency Department Room #3 did not have an audible alarm. The Unit Secretary on the floor was responsible to alert the Emergency Department staff if an alarm sounded on the telemetry monitor. RN#2 stated "it's back here but we don't have time to sit and watch it."
D. Personnel files were reviewed on 02/04/15 at 1500 for all RN staff listed on the "Nursing Licensure Roster" and two of two unit secretaries. Unit Secretary #1 did not have evidence of completion of a cardiac monitoring course. The findings were confirmed by the DON 02/04/15 at 1530.
E. Job descriptions were reviewed on 02/5/15 at 1220 for: Unit Secretary, DON, Patient Care Technician, Staff Registered Nurse-Emergency Room; Registered Nurse-Charge Nurse, Emergency Department Nurse Manager and Clerk. Telemetry nor cardiac monitoring was listed in the qualifications or requirements for any job description listed. This was confirmed by the DON on 02/05/15 at 1530.

On 02/05/15 at 1250, the DON and Administrative Assistant were informed there was Immediate Jeopardy to patient health and safety related to failure to assure telemetry was monitored by staff trained in arrhythmia interpretation. A 23 day termination process was recommended.

After a written plan was received from the facility on 02/05/15 at 1540, the Immediate Jeopardy was removed. The 23 day termination was reduced to a 90 day termination with the following plan in place:

"Plan of Action to Address Concern of Immediate Jeopardy to Patients on Telemetry or Cardiac Monitoring: A nurse or Respiratory Therapist certified in ACLS (Advanced Cardiac Life Support), or a clerk who has had Basic Cardiac Monitoring class will be at the Nurses Station observing the Cardiac Monitor Station at all times (24 hours a day, 7 days a week). A memo to this effect will be posted and emailed immediately. Nursing Staff and Respiratory Therapy Staff currently on duty have been informed of this change in policy. A schedule has been established for the following 2 weeks. This process will be in effect unit training classes can be scheduled. The (named) educator has been contacted to arrange scheduling of classes."

Based on review of Emergency Department (ED) clinical records, review of policy, review of 2015 Nursing Drug Handbook and interview, it was determined the ED failed to give discharge instructions regarding administration instructions of Tylenol and Motrin for 2 (#7 and 10) of 5 (#5, 7, 10, 11 and 12) ED patients discharged to home/work. By not providing complete discharge instructions, the facility could not assure the patients were knowledgeable about their own after treatment care/instructions to prevent harm or a readmission. The failed practice had the likelihood to affect all patients discharged from the ED. Findings follow:

A. Review of discharge instructions from ED clinical records on 02/05/15 revealed the following:
1) Patient #7's discharge instructions stated "Tylenol 1000 mg (milligram) every 4 hours as needed for fever or pain. Motrin 600 mg every 4 hours for discomfort."
2) Patient #10's discharge instructions read "Tylenol 1000 mg every 4 hours for hours for fever or pain. Motrin 600 mg every 4 hours for discomfort."
B. Review of Emergency Department Policies and Procedures; Emergency Standards of Nursing Care on 02/05/15 revealed the following: "Standard VI: Appropriate discharge instructions" revealed "The Emergency patient can expect the attending nurse to provide both oral and a copy of written discharge instructions issued by the physician, to the understanding of the patient/family. The ER patient or significant other will be ask to sign the instructions verifying their understanding."
C. During an interview on 02/05/15 at 1315, when asked what drug information source the nurses are expected to use, the Director of Nurses responded "A new Nursing Drug Handbook that is on the desk in the ED."
D. Review of 2015 Nursing Drug Handbook, from the ED's Nurses' Station revealed the following recommended doses:
1) Acetaminophen (Tylenol) For mild pain or fever: 325 to 650 mg P.O. (by mouth) every 4 to 6 hours. Or, two extended-release caplets P.O. every 8 hours. Maximum, 4g (grams) daily (immediate release) or 3g daily (500mg strength) or 3.9g daily (650mg strength).
2) Ibuprofen (Motrin) For Mild to moderate pain: 400mg P.O. every 4 to 6 hours p.r.n. (as needed).
E. During an interview on 02/05/15 at 1315, the Director of Nurses verified Patient #7 and10's discharge instructions included dose recommendations that were higher than recommended.

Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood (per United States Pharmacopeia Chapter 797, 2008). By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. IV Admixture competencies were requested at the entrance conference on 02/02/15 and Surveyor #3 did not receive any.
B. During an interview with the Director of Pharmacy on 02/02/15 at 1230, the Director stated they did not have competencies, policies or procedures for annual competencies (ie: media fill tests or didactic exams) of the personnel trained to compound medications in the Laminar Flow Hood.

Based on review of policy, review of Incident Detail Report Forms and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication error for three (medication errors #1, #3 and #5) of the eight (Medication Error #1-8) incidents in 2014. By not reporting medication errors to the prescribing physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of policy titled Medication Errors stated "The physician is to be notified and any orders for follow-up care noted."
B. Review of Incident Detail Report Forms from 01/01/14 through 12/31/14 revealed Medication Error #1, #3 and #5 were not reported to the prescribing physician.
C. During an interview on 02/02/15 at 1410, the Director of Nursing verified the policy of the facility was to notify the physician and three of eight variances were not reported to the physician.

Based on review of Physician Credential Files and interview, it was determined there was no evidence the facility had a means to identify and control infections in that 8 (#2-#6 and #9-#11) of 11 (#1-#11) Physicians did not have a current TB (tuberculin) skin test. The failed practiced created the potential for an exposure to TB to go unnoticed and could affect any patient being treated by those physicians. Findings follow.

A Review of Physician Credential Files revealed Physicians #2-#6 and #9-#11 did not have a current TB skin test.
B. During an interview on 02/04/15 at 0945, the Director of Medical Records confirmed the physicians did not have current TB skin tests.

Based on observation, policy review, and interview, it was determined the facility failed to ensure food items in the walk in freezer were labeled and dated so as to ensure first-in-first-out rotation of foods was utilized. The failed practice created the potential for outdated foods to be served and could affect any patient receiving foods from the freezer. Findings follow.

A. During a tour of the freezer on 02/02/15 at 1315, the following items were observed to not be labeled and dated:
1) Green beans-four of four bags
2) Peas and carrots-11 of 11 bags
3) Okra-nine of nine bags
4) Brussels sprouts-two of two bags
5) Bahama vegetable blend-four of four bags
6) Turnip greens-12 of 12 bags
7) Broccoli-three of three bags
B. Review of policy titled "Food Production Policies and Procedures" stated "All items used in the Department of Food and Nutrition Services will be properly rotated to ensure freshness. Rotation will be done by first products received and will be the first products used."
C. Review of policy titled "Infection Control: Dietary Department" stated "Stock will be rotated to facilitate prompt usage and avoid exceeding the expiration date."
B. During an interview on 02/02/15 at 1315, the Certified Dietary Manager confirmed the food items were not labeled and dated.

Based on observation, interview, review of personnel files, job description, clinical records and staff schedule on 02/02/15-02/05/15, it was determined the facility failed to assure Unit Secretary #1 was trained and knowledgeable in identifying cardiac arrhythmias before monitoring four of four (Patient #1, #21-#23) patients from 02/02-05/15; there was no evidence the task of telemetry monitoring was assigned to a specific individual with training and knowledge of cardiac arrhythmias for each shift.
The failed practice did not assure potentially lethal cardiac arrhythmia's would be recognized, interpreted and reported upon occurrence to allow prompt notification of the physician for treatment or intervention. The failure to have trained staff assigned to monitor the patients on telemetry placed Patient #1, #21-#23 at risk of Immediate Jeopardy to their health and safety. See C 270 further details.

Based on observation, review of Medical Records policy, review of a list of delinquent Medical Records and interview, the facility failed to ensure Physician #6 completed 51 delinquent clinical records within 30 days as required by policy. By not completing Medical Records in a timely matter, the facility could not ensure the Patients records were complete. The failed practice had the likelihood to affect all Patients. Findings follow:

A. During a tour of Medical Records on 02/04/15 at 1010, observation revealed shelves with delinquent Medical Records.
B. Review of Medical Records policy revealed "The patient's medical record shall be complete and contain all required signed documentation no later than thirty (30) days following the patient's discharge date.
C. Review of a list of Delinquent Medical Records provided by the Medical Records Director on 02/04/15 at 1329 revealed 51 incomplete charts of Physician #6; 6 charts greater than 30 days, 1 chart greater than 90 days and 44 charts greater than 120 days.
D. During an interview on 02/04/15 at 1329, the Medical Records Director verified a chart was considered delinquent if not completed in 30 days and Physician #6 had 51 charts that were delinquent.

Based on review of clinical records, review of Medical Staff Bylaws and interview, it was determined the facility failed to have medical history and physical (H&P) examination completed within twenty-four (24) hours of admission to any level of care and prior to any surgical or invasive procedure performed except in an emergency in 7 (#1, 2, 15, 17, 18, 19 and 20) of 8 (#1,2 and 15-20) in-patients. By not having the information in the chart, the facility could not assure the patient's course of treatment was not compromised by the lack of information. The failed practice had the likelihood to affect all patients. Findings follow:

A. Review of clinical records revealed the following:
1) Patient # 1 was admitted on 01/29/15; there was no H&P as of 02/05/15;
2) Patient # 2 was admitted on 01/31/15; there was no H&P as of 02/05/15;
3) Patient # 15 was admitted on 01/31/15; there was no H&P as of 02/05/15;
4) Patient # 17 was admitted on 01/13/15; there was no H&P as of 02/03/15;
5) Patient # 18 was admitted on 01/08/15; there was no H&P as of 02/03/15;
6) Patient # 19 was admitted on 01/07/15; there was no H&P as of 02/03/15; and
7) Patient # 20 was admitted on 01/19/15; there was no H&P as of 02/04/15.
B. Review of Medical Staff Bylaws stated "History and Physicals are completed within twenty-four (24) hours of admission to any level of care and prior to any surgical or invasive procedure being performed except in an emergency."
C. During an interview on 02/05/15 at 1240, Unit Secretary #1 verified Patients #1 and 2's H&Ps were not in the clinical record.
D. During an interview on 02/05/15 at 0845, Unit Secretary #1 verified Patient # 15's H&P was not in the clinical record.
E. During an interview on 02/03/15 at 1420, RN #1 verified Patient #17's H&P was not in the clinical record.
F. During an interview on 02/03/15 at 1435, RN #1 verified Patient #18's H&P was not in the clinical record.
G. During an interview on 02/03/15 at 1550, RN #1 verified Patient #19's H&P was not in the clinical record.
H. During an interview on 02/04/15 at 1015, RN #1 verified Patient #20's H&P was not in the clinical record.

Based on observation and interview, it was determined the facility failed to provide Surveyor #2 with a copy of the current Quality Assessment and Improvement Plan. The failed practice did not ensure the facility had evaluated their Quality Assessment (QA) program and did not ensure the facility was knowledgeable as to what QA projects were to be conducted and had the potential to effect any patient in the facility due to lack of QA procedures. Findings follow.

A. Review of the Quality Assessment and Improvement Plan presented to Surveyor #2 revealed a cover page dated 07/12/2012.
B. During an interview on 02/04/15 at 1005, the Director of Home Health stated, "That is the most current plan we have. If we have another one, then it is in someone's office or on their computer and we can't access it."

Based on interview and review of policies and Procedures, it was determined the facility failed to have evidence of a contractual agreement with a dentist. A dentist may not be available to provide emergency dental needs for patients without a contractual agreement in place or by employing a dentist on staff. The findings had the potential to affect any patient admitted to a Swing-bed. The findings follow:

Review of the Swing-Bed Policy and Procedure Manual revealed there was no evidence of a contractual agreement with a dentist. During an interview with the Director of Nursing and Swing-Bed Coordinator on 02/05/15 at 1200 revealed there was no contractual agreement with a dentist at that time.