HospitalInspections.org

Based on MR review in 5 of 5 Swing Bed Pt.s (Pt. #1, 2, 3, 4, and 5) out of a total of 31 MR reviewed, staff interview, and review of Survey and Certification (S&C) memo # 07-28 published on 7/13/2007 by the Center for Medicare and Medicaid (CMS), this facility does not ensure that Medicare beneficiaries in the Swing Bed program are receiving appropriate information regarding their discharge appeal rights. Failure to notify Medicare beneficiaries of their discharge appeal rights is in violation of their rights as a patient in this facility.

Findings include:

CMS memo 07-28 states that facilities, including Critical Access Hospitals (CAH), are to notify patients by using a standardized form the "Important Message from Medicare About Your Rights," (IMM) form, designed by CMS, of their right to appeal their discharge within 2 days of admission, and as early as possible but not before 2 days prior to discharge. For short stay hospitalizations it may be appropriate for only one form.

A MR review was completed on Pt. #1's closed Swing Bed MR on 7/12/2011 at 7:10 a.m. Pt. #1, 65 years old, was admitted to Swing Bed on 1/1/2011 and discharged on 1/8/2011. There is an IMM form dated 1/1/2011 which is signed by the patient. There is no evidence the IMM form was presented within 2 days prior to discharge.

A MR review was completed on Pt. #2's closed Swing Bed MR on 7/12/2011 at 8:20 am. Pt. #2, 71 years old, was admitted to Swing Bed on 2/21/2011 and discharged on 2/26/2011. There are no IMM forms for this inpatient Swing Bed stay. There is a "Notice of Medicare Non-coverage" form in the MR, which explains about discharge appeal rights, however this form is incomplete as it does not include a date the services will end and it is not signed by the patient.

A MR review was completed on Pt. #3's closed Swing Bed MR on 7/12/2011 at 8:53 am. Pt. #3, 70 years old, was admitted to Swing Bed on 4/16/2011 and discharged on 4/22/2011. There are no IMM forms for this inpatient Swing Bed stay. There is a "Notice of Medicare Non-coverage" form in the MR, which explains about discharge appeal rights dated 4/20/2011.

These findings were confirmed by CNO A, M-I, and MR M G on 7/13/2011 at 11:15 a.m.

A MR review was completed on Pt. #4's open Swing Bed MR on 7/12/2011 at 11:15 a.m. Pt. #4, 87 years old, was admitted to Swing Bed on 7/8/2011. There is no IMM form in the MR within 2 days of admission.

A MR review was completed on Pt. #5's open Swing Bed MR on 7/12/2011 at 11:30 a.m. Pt. #5, 75 years old, was admitted to Swing Bed on 7/8/2011. There is no IMM form in the MR within 2 days of admission.

These findings were confirmed by M-I on 7/12/2011 at 11:45 a.m.

In an interview with Case Manager (CM) AA on 7/13/2011 at approximately 1:00 p.m., in the presence of DQ B and Surveyor #18816, AA stated that the CAH is not required to give the IMM to Swing Bed patients per chapter 30 of the Medicare Claims Processing Manual (Financial Liability Protections). AA was informed by both Surveyor #26711 and #18816 that as Clinical Regulators, we have not been given any other direction other than what is stated in the S&C memo 07-28 on this matter.

Based on observation, staff interview and review of maintenance records between 7/11-7/13/2011, the facility failed to construct, install, and maintain the building system due to (i) failure to maintain corridor wall smoke-tight; (ii) corridor doors either propped open or not properly latched; (iii) a gap at the meeting edge of smoke doors; (iv) non-latching or propped open fire-rated doors in two hazardous areas; (v) lack of handrails on ramp in one means of egress; (vi) failure to maintain fire drill records; (vii) failure to install sprinkler heads at proper spacing in 3 locations; (viii) lack of proper maintenance on the automatic, supervised sprinkler system and 18 inch clearance below the sprinkler deflectors and above top of storage; (ix) objects placed in two locations of means of egress causing obstruction to access stairwell exits; (x) lack of preventive maintenance on medical vacuum system in accordance with NFPA 99 4-3.5.6.1(c); (xi) failure to supply power to battery powered lighting unit in generator location with the life safety branch of the essential power system; (xii) lack of labels on critical branch receptacles in two locations; and (xiii) inadequate negative pressure in one soiled utility room, and no ventilation in one clean medical supply room.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to K-tags K-17, K-18, K-27, K-29, K-38, K-50, K-56, K-62, K-72, K-77, K-106, K-147, and C-tag C-226 for detail.

Based on tour, review of Biomed records and interview with staff, in 3 of 13 tours, the facility failed to ensure all patient equipment is maintained for safety. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Per tour of the Gillett clinic on 7/12/11 at 11:00 AM the following Physical Therapy equipment does not have current inspections for safe use:

Ultrasound, Hi-Lo Table, Dynamometer, Iontophoresis System and Endorphic (upper body cycler). This was confirmed with DC J on 7/12/11 at 11:00 AM.

Per tour of the hospital PT area on 7/11/11 at 1:00 PM the following areas have equipment that does not have current inspections for safe use:

The Occupation Therapy room: Dynamometer (2) and Neuromuscular Stimulator System.

The private treatment room had a Hi-Lo table last inspected in 2009.

The PT gym: Iontophoresis System, Dynamometer, Neuromuscular Stimulator System (last inspected 2009), Matt table, Sportsart Cycler, Nu Step, Cybex Stair Stepper (last inspected 2009), Upper Body Ergometer (last inspected 2009), and leg press.

The above was confirmed in interview with PTM O on 7/11/11 at 1:00 PM.

Per surveyor tour of the The Cardiac Rehab area on 7/11/11 at 2:00 the following equipment does not have current inspections for safe use: Alliance Lifefitness bike, NuStep and 2 stationary bikes. This was confirmed in interview with CNO A on 7/11/11 at 2:00 PM.

Per review of the Biomed records provided by CNO A on 7/13/11 at 4:00 PM the above items were listed as "NOT REQUIRED" for inspections.

Based on observation and interview, the facility failed to ensure safety to patients due to inadequate negative pressure in one soiled utility room, and no ventilation in one clean medical supply room in accordance with the CDC and the American Institute of Architects (AIA) guidelines, which require dirty rooms to be under negative pressure with respect to the adjacent areas, and clean support areas such as medication room and clean work/supply room to be under positive pressure. This deficient practice affected 2 of 9 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff B (RN, director of quality assurance), and Staff N (environmental services director) on 7/12/2011, Surveyor 12316 observed that (i) at 11:28 am, the Clean Medical Supply room in the Labor and Delivery Unit in the 1972 Building did not have any ventilation, the required airflow being 4 air changes per hour with all airflow occurring from the clean space to adjacent areas; and (ii) at 2:36 pm, the Soiled Utility room located in the emergency department of 2003 building did not have adequate negative pressure as evidenced by a very small quantity of airflow through the corridor door undercut into the dirty room, which was acknowledged by director of quality and safety officer, and environmental services director at the time of discovery. The small airflow quantity into the dirty room was less than 10 air changes per hour recommended by CDC and AIA Guidelines (2006) Table 2.1-2 with all air exhausted out of the space.

The lack of ventilation in the Clean Supply room, and inadequate negative pressure in the Soiled Utility room did not provide proper ventilation.

The above deficiency was confirmed with Staff Z (administrator, CEO), Staff A (chief nursing officer), and also with director of quality and safety officer, and environmental services director at the exit conference on 7/13/2011 at 4:30 pm.

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

Building 01
1. Failed to protect the life safety of patients from fire due to failure to maintain corridor wall smoke-tight;
2. Failed to protect the life safety of patients from fire due to corridor doors either propped open or not properly latched;
3. Failed to protect the life safety of patients from fire due to a gap at the meeting edge of smoke doors;
4. Failed to protect the life safety of patients from fire due to non-latching or propped open fire-rated doors in two hazardous areas;
5. Failed to protect the life safety of patients from fire due to lack of handrails on ramp in one means of egress;
6. Failed to protect the life safety of patients from fire due to failure to maintain fire drill records;
7. Failed to protect the life safety of patients from fire due to failure to install sprinkler heads at proper spacing in 3 locations;
8. Failed to protect the life safety of patients from fire due to lack of proper maintenance on the automatic, supervised sprinkler system and 18 inch clearance below the sprinkler deflectors and above top of storage;
9. Failed to protect the life safety of patients from fire due to objects placed in two locations of means of egress causing obstruction to access stairwell exits;
10. Failed to protect the life safety of patients from fire due to lack of preventive maintenance on medical vacuum system in accordance with NFPA 99 4-3.5.6.1(c);
11. Failed to protect the life safety of patients from fire due to failure to supply power to battery powered lighting unit in generator location with the life safety branch of the essential power system; and
12. Failed to protect the life safety of patients from fire due to lack of labels identifying the panelboard and circuit breaker number that supplies power to critical branch ceiling receptacles in two locations.

Refer to K-tags K-17, K-18, K-27, K-29, K-38, K-50, K-56, K-62, K-72, K-77, K-106, and K-147 for detail.

Based on tour of off site clinics, review of federal statutes, and interview with staff in 1 of 3 clinic tours (Mountain), the facility failed to ensure there is medical supervision of staff to prevent blank prescriptions being signed.

Findings include:

Per information provided by State Pharmacist FF on 7/14/11 at 3:32 PM federal statutes prohibit presigning prescriptions. Federal Controlled Substance Act: Federal law prohibits prescribers from pre-signing prescriptions. Here is the legal language: "Manner of issuance of prescriptions. (a) All prescriptions for controlled substances shall be dated as of, and signed on, the day when issued and shall bear the full name and address of the patient, the drug name, strength, dosage form, quantity prescribed, directions for use and the name, address, and registration number of the practitioner" (21 CFR, Section 1306.05).

Per surveyor 18816 tour on 7/12/11 between 9:30 AM and 10:15 AM, of the off site clinic in Mountain, an unsecured drawer in the nursing station contained 3 prescriptions pads, with PA CC's signature and no patient names or medications. This was confirmed with DC J at 9:45 AM.

Per surveyor 18816 telephone interview on 7/18/11 at 2:02 PM with PA CC's MD supervisor MD BB, MD BB confirmed PA CC has the ability to write prescriptions for narcotics and stated he was unaware PA CC was signing blank prescriptions.

Based on tour, review of P&P and interview with staff, in 6 of 13 tours, the facility failed to ensure medications, fixatives and reagents are stored and used in a safe manner, and not available to unauthorized staff and patients. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Surveyor 18816 review on 7/14/11 at approximately 10:00 AM of facility policy titled Policy on Open Medication Vials dated 11/00 states under #2 "All open multiple dose vials shall be dated as to date first opened. #3. All single dose vials must be discarded of properly immediately after use...4. Multiple dose vials will expire after 30 days from date opened or expiration date, whichever comes first."

Surveyor 18816 review on 7/14/11 at approximately 10:00 AM of facility policy titled Labeling and Transferring of Bulk and Multidose Containers dated 11/00 states under #2. "Proper labeling is to include the following: a. Name and address of hospital: Community Memorial Hospital Oconto Falls, WI 54154 b. Current Date c..Room Number or Prescription Number d. Patient's Full Name e. Drug Name and Strength"

Per consult with State of Wisconsin Pharmacist FF on 4/18/07 at 2:00 PM, Dexamethasone is a steroid and can be absorbed through intact skin during this type of treatment, and should be treated as any other medication that could be injected. Pharmacist I confirmed Dexamethasone is to be administered by personnel qualified to administer medications and under the supervision of a Physician.

Examples by surveyor 18816:

Clinic Tours:

Per surveyor 18816 tour of off site clinics on 7/12/11 between 8:30 AM and 12:00 PM the following was noted:

At the clinic in Mountain at 9:25 AM:
Peroxide was not secured in 4 of 6 exam rooms toured.
The procedure room has an eyewash bottle with unknown clear substance in a cupboard.
The key to the cupboard with emergency medications was kept in an unsecured drawer in the procedure room.
The above was confirmed with DC J on 7/12/11 at 9:25 AM.

At the clinic in Suring at 10:30 AM:
The procedure room had an open single dose vial of Sodium Bicarbonate dated 6/27/11, and a container of Iodoform Packing gauze was open and dated 6/9/11.
Exam room 2 had an open single dose bottle of Sterile Water dated 6/17/11.
Exam room 3 had an open single dose vial of Sodium Chloride dated 6/28/11.
The above was confirmed with DC J on 7/12/11 at 10:30 AM.

At the Gillett clinic at 11:00 AM:
Dexamethasone MDV was open and not dated in the Physical Therapy Office. This is confirmed in interview with PT HH on 7/12/11 at 11:00 AM.
Exam room 1 had an open single dose bottle of Sodium Chloride dated 7/11/11; and open hemoccult reagent with no date, and unsecured peroxide in the cupboard.
Exam room 2 had seven bottles of ThinPrep (a fixative or PAP smears) unsecured in the drawer.
Exam room 3 had an open hemoccult reagent with no date, and 6 bottles of ThinPrep unsecured in a drawer.
Exam room 4 had an open hemoccult reagent with no date, and 4 bottles of ThinPrep unsecured in a drawer.
Exam room 5 had a open Histofreezer can with no date.
Exam room 6 had an open hemoccult reagent with no date.
The above was confirmed with DC J on 7/12/11 at 11:00 AM.

Hospital tours:

Per surveyor 18816 tour of the Physical Rehab area on 7/11/11 at 1:00 PM the box containing Dexamethasone included two syringes, one with a needle attached; a bottle labeled Acetic Acid (vinegar) had no information including date placed in container, lot number, expiration date, or who prepared it. Per PT O, on 7/11/11 at 1:40 PM, the needle and syringes are reused for multiple patients to apply Dexamethasone for topical use with an Iontophoresis System

Per surveyor 18816 tour of the Cardiac Rehab area on 7/11/11 at 2:00 PM the crash cart has a breakaway tag and no lock allowing access by unauthorized staff. The cart contained 4 IV (intravenous) bags of Sodium Chloride out of original packaging and with no date. This is confirmed with CNO A on 7/11/11 at 2:00 PM.

Per surveyor 18816 tour of the Birthing Place on 7/13/11 at 12:30 PM, the emergency newborn medications are unsecured on the warmer in the nursery allowing unauthorized access. This is confirmed in interview with RNM Y on 7/13/11 at 12:45 AM.


26711

Findings by Surveyor #26711:

During a tour of the Surgery area on 7/13/2011 at 8:45 a.m., accompanied by SM V, an emergency cart (crash cart) was observed at the end of the hall equipped with break away locks.

SM V confirmed that housekeeping staff can be present at times when no other authorized surgical staff is in the department. SM V stated there are no narcotics in the cart, only "code medications."

During a conversation with CNO A on 7/13/2011 at 10:00 a.m., CNO A stated all emergency carts in the building were to be equipped with permanent locks.

Based on tours, observations, P&P review, review of professional standards of care, and staff interview, this facility failed to have effective infection control practices in 6 of 13 tours, and 3 of 4 observations (K, S and U) the facility failed to ensure there is effective surveillance of IC practices and breeches in structural integrity of the facility. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Facility policy titled, "Hand Hygiene," dated 7/2001 was reviewed on 7/13/2011 at 11:00 a.m. Section "A": Health care personnel handwashing and hand antisepsis, 2. b. and c. state [regarding when hands are to be washed], "b. After contact with a source of micro-organisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated); c. After removing gloves."

Section C. "Other aspects of hand care protection," of the same policy states in 1. b. "Gloves will be used for hand-contaminating activities."

The facility indicates APIC (Association of Professionals for Infection Control) as a reference for their hand hygiene policy. According to a publication from APIC on 7/22/2004 regarding glove use for healthcare providers, APIC states, "Wear gloves when there is a reasonable likelihood of hand contact with blood or other potentially infectious materials, mucous membranes or nonintact skin; and when handling contaminated items or surfaces. Change disposable gloves when they become contaminated, torn or punctured. Wash hands before donning AND after removing gloves."

Examples by surveyor 26711:

Medical/Surgical (M/S) unit:

A tour of the M/S unit was conducted by Surveyor #26711 on 7/12/2011 at 10:35 a.m. accompanied by M-I and CNO-A. The following are finding from this unit:

Breeches in wall integrity were noted in 3 of 12 (out of a total of 25) rooms observed. Rooms 105, 125, and 126 had breeches in the painted or wall papered surfaces of the walls rendering the cleaning of the walls ineffective for all microorganisms.

In a room identified as "Soiled Utility," clean items were stored along with dirty items, increasing the potential of cross contamination of the clean items. Hand sanitizer for use in places on the unit (such as the nurses station and medication room), a hair dryer, curling iron and emery boards were being stored in cupboards/drawers. M-I confirmed these items were clean items and agreed that they should not be stored in the soiled utility room.

In a room identified as "Janitor" closet (closet for housekeeping), clean paper products for use in patient/staff/visitor areas, and clean mop heads were stored in the same space that a cart filled with bags of trash was stored. Storing clean and dirty items in the same space increases the potential for cross-contamination of the clean items. CNO A stated the cart is usually out on the unit and not in this closet.

An observation of CNA K was completed on 7/12/2011 in room 125 on the M/S unit at 11:05 a.m. CNA K performed a bedside blood glucose test on Pt. #21. After applying gloves, CNA K performed the finger poke for blood, opened the chemstrip bottle to obtain a clean strip, replaced the bottle in the case with the glucose monitor, and removed the strip containing the blood drop to discard, all with the same gloves on. At this point CNA K removed the gloves, handled the glucose monitor (which was contaminated by the gloves), put hands in pockets of scrubs, and handled K's pen to document the results before washing hands.

During this observation there were missed opportunities for glove changing and hand washing, contamination of clean items from dirty (everything touched after the blood drop was obtained), and K did not follow the facility policy regarding hand washing.

An observation of RN S was completed on 7/12/2011 in room 109 on the M/S unit at 2:15 p.m. RN S was observed administering intravenous (IV-cannula inserted into a vein for access to the blood stream) pain medication to Pt. #23. After performing the procedure, with gloved hands RN S reached into S's pockets, then left the room to obtain more alcohol wipes before re-entering the room, completing the procedure (which the alcohol wipes were needed for), and removing gloves and washing hands.

During this observation the RN was observed putting the gloved hands into the pockets of the scrubs and contaminating them, and left the room with the contaminated gloves touching other surfaces.

These findings were discussed with and confirmed by M-I and CNO A on 7/13/2011 at 11:00 a.m.

Surgery/Operating Rooms (OR):

A tour of the Surgery area and ORs was conducted by Surveyor #26711 on 7/13/2011 at 8:45 a.m. accompanied by SM V. The following are findings from these areas:

In the Central Supply area in a room identified as the "Dirty Utility room," where dirty surgical instruments go for pre-cleaning prior to sterilization, a cart holding clean supplies, scrubbers for surgery preparation, personal protective equipment, and unused sharps containers was observed. Storing clean items in the same space where contaminated items are taken to be cleaned increases the potential for cross-contamination of the clean items.

SM V and Surgical Technician (ST) W confirmed and agreed with these findings at the time of discovery.

Throughout the OR suites and the Surgery area along the hallway, there were numerous instances of breeches in the integrity of walls and doors. Breaks in the painted surfaces of the walls exposed the dry wall underneath, and the surfaces of doors was impaired revealing raw wood. These breeches in integrity render the cleaning of these surfaces ineffective for all microorganisms.

All areas were observed by SM V who stated that PSM N was aware of these areas and agreed that they should not be exposed.

Emergency Room (ER):

A tour of the ER area and was conducted by Surveyor #26711 on 7/13/2011 at 10:20 a.m. accompanied by ERM X . The following are findings from these areas:

In a room identified as "Dirty Utility," clean items were being stored. These items included two commodes, a walker, and two pump brackets for IV pumps. Storing clean and dirty items in the same space increases the potential for cross-contamination of the clean items.

ERM X verbalized understanding of these findings at the time of discovery.

Radiology Department:

During a tour of the Diagnostic Imaging area on 7/11/2011 at 1:40 p.m., accompanied by Radiology M E and Radiology Lead D, Surveyor #26711 observed the following:

In the Nuclear Medicine preparation room, under the sink, the following items were stored: patient transfer sheets (plastic sheets used to transfer patient incase of emergency), paper towels, and unused sharps containers. Storing items for patient use under the sink does not demonstrate appropriate separation of clean and dirty in the event the sink would leak and contaminate the items stored underneath.

M E, Lead D, and NMT F all verbalized understanding of this finding at the time of discovery.


18816

Examples of IC observations by surveyor 18816:

Per surveyor 18816 tour of the Mountain clinic on 7/12/11 at 9:25 AM the following was noted:

A box of toilet paper was on the floor in the housekeeping closet allowing for potential contamination.
A roll of paper towels and chux were under the sink in the procedure room, allowing for potential contamination.
2 mammogram plates were under the sink in the mammogram room, allowing for potential contamination.
The above was confirmed in interview with DC J on 7/12/11 at 9:25 AM.

Per surveyor 18816 tour of the Suring clinic on 7/12/11 at 10:30 AM the following was noted:

Boxes were on the floors in the housekeeping closet allowing for potential contamination.
EKG cords were touching the floor in the corridor, allowing for contamination.
The above was confirmed in interview with DC J on 7/12/11 at 10:30 AM.

Per surveyor 18816 tour of the Gillett clinic on 7/12/11 at 11:25 AM the following was noted:

PH L was observed holding two lab tubes filled with blood and a culture swab without the benefit of gloves allowing for potential contamination.
The above was confirmed in interview with DC J on 7/12/11 at 11:25 AM.

Per surveyor 18816 tour of the hospital on 7/11/11 at 1:00 PM the following was noted:

In the Occupational Therapy room the kitchenette had sponges and a bag of miscellaneous items under the sink allowing for potential contamination. This was confirmed in interview with PT O on 7/11/11 at 1:00 PM.

The private treatment room in PT area had a box on the floor allowing for potential contamination. This was confirmed in interview with PT O on 7/11/11 at 1:00 PM.

In the PT area the box with Dexamethasone contained 2 syringes, one with a needle attached. Per PT O, on 7/11/11 at 1:40 PM, the needle and syringes are reused for multiple patients to apply Dexamethasone for topical use with an Iontophoresis System.

Per surveyor 18816 observation of a dressing change on 7/13/11 at 8:25 AM, the following was noted:
RN U set dressing supplies on the Pt bedside table that contained Pt items, tore pieces of tape for the dressing and attached them to the edge of the bedside table with out the benefit of cleaning the surfaces. RN U dropped the curlex (dressing) on the floor, although it was still in the sealed packaging, RN U set the curlex on the beside table with the other dressing items. RN U finished the dressing change, removed gloves, picked up the scissors used to cut and remove the old dressing with exudate, and washed it in the sink with soap without the benefit of gloves.

Per surveyor 18816 tour of the Birthing Place on 7/13/11 at 11:00 AM, labor rooms 1 and 2 had tennis balls in the drawer of the fetal monitor cart. Per interview with RN Y on 7/13/11 at 11:00 AM, the balls are used for to rub on patients back for relief of labor pain, RN Y did not know how the tennis balls would be cleaned between patients.

Observation of Laboratory Door:

Per surveyor 18816 observation on 7/13/11, the Laboratory door was open to the corridor at 8:18 AM, 8:50 AM, and 11:00 AM, allowing for potential contaminated airflow throughout the facility.

Example by surveyor 26711:

On the way to the ER on 7/13/2011 at 10:15 a.m., accompanied by ER M X, it was observed that the door to the Laboratory was propped open to the main corridor. This practice has the potential for cross-contamination from outside air entering the Laboratory and contaminating specimens within.

ER M X agreed with Surveyor #26711 at the time of discovery that the door should be closed

Based on observation and interview with staff, in 2 of 2 observations, the facility failed to ensure food safety, quality is maintained, and sanitation procedures are maintained. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Examples by surveyor 26711:

A tour of the ER area was conducted by Surveyor #26711 on 7/13/2011 at 10:20 a.m. accompanied by ERM X .

In the Pt. refrigerator a tray containing soup and a sandwich did not indicate a date for either when it was delivered, or how long the food was good for. By not indicating either of these dates, ER staff would not be able to determine that the food quality would be maintained prior to serving to a patient.

ERM X agreed that X would not serve this food, which is supplied by kitchen staff, without a date on it.


18816

Examples by surveyor 18816:

Per surveyor 18816 observation on 7/12/11 at 9:35 AM of dishwashing procedures the following was noted:

Dishwasher II prepared the soaking sink with 3 squirts of Liquid Presoak and filled the sink up to 3 inches below the top edge. Dishwasher II did not know how many gallons of water was in the sink, nor how the measurement of 1 squirt of the Presoak. The Liquid Presoak stated under instructions "1-2 oz per gallon of water." Dishwasher II pored a "splash" of Sanitizer in a gallon sized bucket, filling it 1/2 full with water. Dishwasher II did not know how much was in the "splash or how much water was in the bucket. The Sanitizer instruction stated "3 oz to 5 gallons of water." Per Dishwasher II on 7/12/11 at 9:50 AM, there were no P&P for preparing the soaking solution or sanitizer, and said the concentrations were not checked with any type of testing strip.

Dishwasher II was asked to provide surveyor 18816 a policy on how to mix presoak and sanitizers, a policy was not provided by the end of the survey.

Based on review of personnel files and interview with staff, in 1 of 1 personnel files (P) the facility failed to document training of all assigned tasks. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Per surveyor 18816 interview with RT P on 7/12/11 at 1:30 PM one task assigned is performing EEGs (electroencephalography) on patients. Per review of RT P's personnel file on 7/12/11 at approximately 2:00 PM, there is no evidence of training provided to RT P for EEGs. This was confirmed in interview with DC J on 7/13/11 at approximately 3:00 PM.

Based on MR review, review of P&P, review of R&R and interview with staff, in 4 of 26 MR with written orders (#1, 2, 10 and 16) the facility failed to ensure all verbal and telephone orders are authenticated by the MD with a signature, date and time within 48 hours of being written. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Facility policy titled, "Verbal Orders & Personal Order Sets," dated 6/2009 states on page 3 of 3, #5. "The ordering practitioner will sign, date, and time the documented verbal order as soon as possible which would be the earlier of the following: * The next time the practitioner provides care to the patient, assesses the patient, or documents in the patients medical record, OR * Within the timeframe defined in the [facility's] Medical Staff Rules and Regulations, OR *If the ordering practitioner goes off duty and is unable to sign the defined timeframe, it is acceptable for a covering practitioner to co-sign the verbal order of the ordering practitioner."

Surveyor 18816 review of Medical Staff R&R (n.d.) on 7/12/11 at approximately 2:30 PM states under Section #3 "...All verbal and telephone orders will be authenticated by the prescribing member of the Medical Staff in writing within seventy-two (72) hours of receipt." Per interview with DQ B on 7/13/11 at approximately 9:00 AM the Medical Staff are to sign orders within 48 hours, DQ B could not produce evidence Medical Staff was notified of this change in their R&R.

Examples by surveyor 18816:

Pt #10's MR reviewed by surveyor 18816 on 7/13/11 at 9:25 AM revealed telephone orders written on 5/25/11 are not authenticated by the MD within 48 hours. This is confirmed in interview on 7/13/11 at 12:30 PM.

Pt #16's MR reviewed by surveyor 18816 on 7/12 11 at 3:15 PM revealed Pt #16 arrived in the ER on 6/28/11 and was discharged on 6/28/11. Verbal orders written 6/28/11 during an ER code are not authenticated by the MD with a signature, date and time. This is confirmed in interview with CNO A on 7/12 at 4:00 PM.


26711

Findings by Surveyor #26711:
A tour of the MR department was conducted on 7/11/11 at 2:00 p.m. with CNO A and MR M G. An interview with MR M G was also completed at this time.

During the interview, MR M G stated that verbal orders/telephone orders are to be signed as soon as possible, but within 48 hours.

A MR review was completed on Pt. #1's closed MR on 7/12/2011 at 7:10 a.m. Pt. #1 was admitted on 1/1/2011 and the admission orders were taken as telephone orders. These orders were not signed by the MD until 1/8/2011, more than 48 hours.

Pt. #1 also had telephone orders obtained on 1/2/11 and 1/5/11 that were not signed by the MD until 1/8/11. These telephone orders were not signed within 48 hours.

A MR review was completed on Pt. #2's closed MR on 7/12/2011 at 8:20 a.m. Pt. #2 was admitted on 4/16/2011 and the admission orders were written by the MD but do not include the time they were written.

On 4/18/2011 there is a telephone order that has an illegible date/time stamp from the MD as it was placed over the top of another stamp in the MR, rendering it unable to determine the date and time of the MD signature.

On 4/19/2011 there are telephone orders for Pt. #2 written by nursing that were not signed by the MD until 4/22/2011. These orders were not signed within 48 hours.

Based on review of MRs, review of P&Ps, and interview with staff, in 5 of 21 medical records with POC (Pt. #1, 2, 3, 4, 5), the facility failed to ensure nursing staff developed and kept current an individualized POC. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Facility policy titled, "Nursing Clinical Pathways," dated 1/2009 was reviewed on 7/13/2011 at 12:30 p.m. The policy states on page 2 of 2, under Policy, #3. "Each pathway will serve as the nursing plan of care specific to the individual patient. It includes nursing diagnosis, expected outcomes, and daily nursing interventions along with daily expected outcomes."

In this same policy under Procedure, #9 states, "Each pathway should be individualized to the patient."

MR reviews were completed by Surveyor #26711 on 7/12/2011 between 7:10 a.m. and 11:30 a.m. for Pt.'s #1-5. All of these MRs were from Swing Bed Pt.'s. Pt. 1-3 were closed records, Pt. 4 and 5 were open records.

All of these MRs contained Nursing POCs that were incomplete and had blanks where nursing staff were to write in the reason the nursing diagnosis was pertinent to the Pt. According to M-I, there should be no blanks on the nursing POC.

Leaving blanks on standardized care plans does not demonstrate individualizing the pathway for the patient.

The findings for the open MRs were confirmed by M-I on 7/12/2011 at the time of discovery.

The findings for the closed MRs were confirmed by M-I, CNO A, and M-G on 7/13/2011 at 11:15 a.m.

Based on MR review, P&P review, R&R review, and interview with staff, in 12 of 31 MR (#6, 7, 9, 10, 13, 14, 15, 16, 27,28, 29 and 30), the facility failed to ensure MRs have complete documentation. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Surveyor 18816 review on 7/14/11 at approximately 10:00 AM of facility policy titled Surgical Site Verification dated 4/10 does not include confirming the skin prep is dry prior to draping.

Surveyor 18816 review of Medical Staff R&R (n.d.)on 7/12/11 at approximately 2:30 PM states under Section #11 (a) "An emergency services record shall be maintained on every patient who registers for emergency services. The record shall contain: (1) Sufficient patient identification (2) An accurate recording of arrival time and means and/or by whom transported; (3) Pertinent history of the injury or illness, physical findings, vital signs; (4) Emergency care provided prior to the patient's arrival at the hospital; (5) Diagnostic and therapeutic orders; (6) Clinical observations and all care and treatment provided in the Emergency Department; (7) Reports of procedures, tests, and results; (8) Diagnostic impression; (9) Final Disposition and a precise statement of the condition of the patient upon discharge or transfer; (10) A detailing of all instructions given to the patient and/or family regarding necessary follow-up care; (11) Patient's leaving against medical advice; (12) All required transfer paper work." Under Section #14 (b) "A medical record is considered delinquent when it has not been completed within fifteen (15) days after the patient's discharge...(c) The Medical Record Department shall regularly compile and relay information to the Chief Executive Officer concerning all physicians, dentists and podiatrists with delinquent records. The Chief Executive Officer (or designee) shall notify physicians, dentists, and podiatrists by U.S. mail of existence of delinquent records, as outlined in approved hospital policy and procedures."

Examples by surveyor 18816:

Incomplete records:

Pt #7's MR reviewed by surveyor 18816 on 7/12/11 at 8:00 PM revealed there is no documentation regarding Advanced Directives. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #9's MR reviewed by surveyor 18816 on 7/13/11 at 9:08 AM revealed an obstetric consent for surgery in the MR was incomplete for MD name and procedure. The consent for an epidural/intrathecal was incomplete missing the name of who explained the risks and benefits. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #10's MR reviewed by surveyor 18816 on 7/13/11 at 9:25 AM revealed telephone orders written on 5/25/11 are not authenticated by the MD within 48 hours. The ER Algorithm for RN Screen of Obstetrical Patient is not dated and timed by the ER nurse. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #13's MR reviewed by surveyor 18816 on 7/13/11 at 9:18 AM revealed the Newborn Admission Transitional Period record that requires a vital sign and stability check at 4 hours out from delivery. Pt #13 was delivered at 6:21 PM, the four hour check scheduled for 8:20 PM is not documented. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #14's MR reviewed by surveyor 18816 on 7/13/11 at 4:15 PM revealed Pt #14 had a circumcision on 5/30/11 at 10:40 AM. The Newborn Assessment record has no documentation of the circumcision assessment or required treatments between 11:30 AM 5:00 PM the time of discharge. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #16's MR reviewed by surveyor 18816 on 7/12 11 at 3:15 PM revealed Pt #16 arrived in the ER on 6/28/11 and was discharged on 6/28/11. Verbal orders written 6/28/11 during an ER code are not authenticated by the MD with a signature, date and time. This is confirmed in interview with CNO A on 7/12 at 4:00 PM.

Examples of MR missing dry time in time outs:

Pt #6's MR reviewed by surveyor 18816 on 7/12/11 at 7:00 PM revealed Pt #6 had a Cesarean Section on 4/19/11. The OR intraoperative record indicates an alcohol based disinfectant, DuraPrep was used. The record does not include documentation the prep was dry prior to draping in the time out. This is confirmed with RN Y on 7/13/11 at 12:30 PM.

Pt #7's MR reviewed by surveyor 18816 on 7/12/11 at 12:00 PM revealed Pt #7 had a Cesarean Section on 12/23/10. The OR intraoperative record indicates an alcohol based disinfectant, DuraPrep was used. The record does not include documentation the prep was dry prior to draping in the time out. This is confirmed with RN Y on 7/13/11 at 12:30 PM.

Example of ER records:

Pt #16's MR reviewed by surveyor 18816 on 7/12 11 at 3:15 PM revealed Pt #16 arrived in the ER on 6/28/11 and was discharged on 6/28/11. Verbal orders written 6/28/11 during an ER code are not authenticated by the MD with a signature, date and time. This is confirmed in interview with CNO A on 7/12 at 4:00 PM.

Surveyor 18816 review on 7/12/11 in the AM of the ER log, the following "LWOBS" (left without being seen) records were requested, #15, 27, 28, 29 and 30.

Pt #15 arrived in the ER on 3/31/11 at 3:13 PM, was triaged at 8:15 PM, discharged at 8:30 PM, and is documented on the ER log as LWOBS and sent to another facility. There is no other record of Pt #15 visit, including transfer forms and AMA document. This is confirmed in interview with RN B on 7/12/11 at 3:10 PM.

Pt #27 arrived in the ER on 6/4/11 at 1:52 PM , triaged at 2:07 PM, discharged at 2:40 PM, and is documented on the ER log as LWOBS. The RN triage form states Pt #27 had a painful lump in her breast and includes a note stating "Pt chooses not to be seen by the ER doctor." There is no documentation an MD saw Pt #27, and no documentation of a signed AMA form. This is confirmed in interview with Outpt Analysis T on 7/12/11 at 4:45 PM.

Pt #28 arrived in the ER on 3/11/11 at 10:38 PM, triaged at 10:40 PM, discharged at 10:40 PM and is documented in the ER log as LWOBS. There is no other record of Pt #28's visit, including the triage document and AMA form. This is confirmed in interview with Outpt Analysis T on 7/12/11 at 4:45 PM.

Pt #29 arrived in the ER on 6/6/11 at 12:01 PM, triaged at 12:10 PM, discharged at 12:15 PM and is documented in the ER log as LWOBS. There is no other record of Pt #28's visit, including the triage document and AMA form. This is confirmed in interview with Outpt Analysis T on 7/12/11 at 4:45 PM.

Pt #30 arrived in the ER on 4/2/11 at 1:03 PM, triaged at 1:11 PM, and is documented in the ER log as LWOBS. The ER log does not include discharge time. The RN triage form states Pt #30 had a fever and congestion for 12 days, there is no note regarding Pt #30 leaving nor and AMA form. This is confirmed in interview with Outpt Analysis T on 7/12/11 at 4:45 PM.


26711

Findings by Surveyor #26711:

A tour of the MR department was conducted on 7/11/11 at 2:00 p.m. with CNO A and MR M G. An interview with MR M G was also completed at this time.

MR M G stated that this facility requires that MRs are complete by day 30 after a Pt. has been discharged. MR staff go through delinquent records weekly and call practitioner's to remind them to complete the records. After 10 days a letter is to be sent to the practitioner. If a practitioner is still delinquent after 30 days, the administrator is notified and a letter is sent to the practitioner signed by the administrator.

During the tour of the MR department, it was observed that Medical Doctor (MD) EE had numerous delinquent records waiting for completion. On closer inspection, these records dated back to May 7th, 2011, more than 60 days delinquent.

On 7/13/2011 at 4:45 p.m., MR M G provided a tracking form showing contact with MD EE regarding delinquent records on 9 separate occasions dating back to 5/14/11.

In an interview with CEO Z after reviewing the tracking form, CEO Z does not recall signing a letter for this practitioner to complete delinquent work.

MR M G was able to confirm in an e-mail received from CNO A on 7/14/2011 at 10:10 a.m., that as of 7/14/2011, no letter has been sent to MD EE.

Based on tour, review of P&P, and interview with staff, in 2 of 13 tours the facility failed to ensure patient records are not accessible to unauthorized staff. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Per surveyor 18816 review, on 7/14/11 at approximately 10:00 AM, of facility policy titled Safeguarding of Patient Medical Records dated 12/00 states under Policy "The hospital shall safeguard the information in the medical record against loss, defacement, tampering, or use of unauthorized persons." Under #3 "Access to health records is restricted to authorized personnel and the medical staff."

Per surveyor 1886 tour of the PT area on 7/11/11 at 1:45 PM, the MR are stored in a cabinet that is not locked in the reception area, the area is cleaned my housekeeping when staff are not present. This is confirmed in interview with PT O on 7/11/11 at 1:45 PM.

Per surveyor 18816 tour of the RT area on 7/11/11 at 1:30 PM an accordion file with orders is left out on top of a cabinet and not secured, the area is cleaned by housekeeping when staff are not present. This is confirmed in interview with RT P on 7/11/11 at 1:30 PM.

Based on MR review, and interview with staff, in 3 of 8 MR requiring anesthesia services, (7, 8 and 9) the facility failed to ensure a post anesthesia evaluation is competed after anesthesia recovery, and includes at minimum: Cardiopulmonary Status, Level of Consciousness, follow up care or observations and complications. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

Per survyeor 26711 interview with Certified Registered Nurse Anesthetist (CRNA) GG was conducted on 7/13/11 at 7:40 AM. CRNA GG stated that post-anesthesia evaluations are conducted usually anywhere from 5 minutes to within 24 hours of post-anesthesia and are supposed to contain documentation regarding the vital signs (saying VSS [vitals signs stable] is acceptable), pulse oximetry, level of consciousness, orientation, regional anesthetic notes if applicable, any complications, a comment on pain, and a comment when it is appropriate to discharge from the post anesthesia care unit.

Examples by surveyor 18816:
Pt #7's MR reviewed by surveyor 18816 on 7/12/11 at 8:00 AM revealed Pt #7 had a Cesarean Section, with a spinal, on 12/24/10. The surgery ended at 2:49 AM with anesthesia services ending at 2:55 AM. The post anesthesia note timed 2:55 AM. There is no other post anesthesia note including documentation Pt #7 recovered from the spinal. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #8's MR reviewed by surveyor 18816 on 7/13/11 at 12:00 PM revealed Pt #8 had a labor epidural on 5/21/11. Pt #8 delivered at 6:19 PM, the post anesthesia note does not include the return of sensation directly related to an epidural anesthetic. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Pt #9's MR reviewed by surveyor 18816 on 7/13/11 at 9:08 AM revealed Pt #9 had a labor epidural on 5/28/11. Pt #9 delivered at 8:54 PM, the post anesthesia note does not include the return of sensation directly related to an epidural anesthetic. This is confirmed in interview with RN Y on 7/13/11 at 12:30 PM.

Based on review of QAPI program and interview with staff, in 1 of 1 interview (C) the facility failed to include all departments and contracted services in the QAPI reporting structure and planning. This deficiency affects all 27 Pts treated at the facility during the survey.

Findings include:

In an interview with MMM C on 7/11/11 at 11:30 a.m., C was unable to confirm the process the contracted laundry service uses to clean laundry carts prior to returning clean linens. This process, from a contracted vendor, has not been monitored through the QAPI process. There is no policy to maintain surveillance of this vendor related to cart cleaning.

A review of the QAPI program was completed on 7/13/2011 at 1:00 p.m. with DQ B and QC H.

DQ B confirmed that although Infection Control reporting is interwoven within each department as it is applicable, it is not reported on separately as a department.

Based on P&P review, MR review, and interview with staff, in 3 of 3 closed Swing Bed MRs (#1, 2, and 3) out of a total of 31 MRs reviewed, the facility failed to provide a written notification to Swing Bed patients regarding their rights prior to transfer or discharge.

Findings include:

Facility policy titled, "Transfer and Discharge Rights," dated 7/2010, was reviewed on 7/13/2011 at 11:30 a.m. by Surveyor #26711. The policy does list the above criteria specifying that it must notify the Pt. and family as applicable, of the reasons for the move in writing.

Per M-I and DQ B on 7/12/2011 at 3:00 p.m., in an interview regarding the Swing Bed program, it was identified that items i-iv of the above items were located in various parts of the patient record, i-iii if the Pt. was going to a Skilled Nursing Facility, but vi, and vii were not addressed.

MR reviews were conducted on the closed Swing Bed MRs for Pt.s 1-3 on 7/12/2011 between 7:10 a.m.-8:53 a.m. There is no indication on any of these MRs that a notice prior to discharge from the Swing Bed program was received.

Per Nurse Case Manager (NCM) AA on 7/13/11 at 11:30 a.m., there is not a separate notice given to Pt.s prior to discharge that would notify them, in writing, of all of the items specified above.

Based on MR review, review of R&R, and staff interview, in 2 of 3 closed Swing Bed (SB) MR (Pt. # 1 and 3) out of a total of 31 MR reviewed, the facility failed to ensure a discharge summary (DC) is a complete and final summary of the Pt.s stay in the Swing Bed program.

Findings include:

Surveyor 18816 review on 7/12/11 at approximately 2:30 PM of Medical Staff R&R (n.d.) states under Section 12 (c) "The discharge summary shall include: (1) The reason for hospitalization; (2) Significant findings; (3) Any complications; (4) The procedures performed and treatment rendered; (5) The condition of the patient on discharge; and (6) Any specific, pertinent instructions given to the patient or patient's representative, including instructions relating to physical activity, medication, diet, and follow-up care."

A MR review was completed on Pt. #1's closed MR on 7/12/2011 at 7:10 a.m.. Pt. #1 was discharged from the SB program on 1/8/2011. A DC summary was completed on 1/8/2011 by Medical Doctor (MD) DD. The DC summary does not include compiled information for the period of SB status (1/1/11-1/8/11) and does not identify a post discharge plan.

A MR review was completed on Pt. #3's closed MR on 7/12/2011 at 8:53 a.m.. Pt. #3 was discharged from the SB program on 4/22/2011. A DC summary was completed on 4/22/2011 by MD DD. The DC summary does not include compiled information for the period of SB status (4/16/11-4/22/11) and does not identify a post discharge plan.

In an interview with M-I and CNO A on 7/13/2011 at 11:15 a.m., the content of the DC summaries were discussed and both agree that they do not meet the minimum criteria for a DC summary.