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Based on observation, document review and interview, the facility failed to ensure that medications are not used after their expiration dates during life saving emergencies or for any patients being treated at the facility resulting in the potential for a delay in treatment during a life threatening emergency and routine care for all patients served by the facility. Findings include:

On 8/27/13 beginning at 1030 during tour of the facility, the following expired medications were found available for patient use: open and undated Bacteriostatic saline 0.9% for injections was found on the crash cart in cardiac rehab. Opened and dated 8/19/13 Bacteriostatic saline 0.9% for injections was found in room 3 in the medical surgical unit with an expiration date that was marked 9/17/13, two days after the 28 day policy.

Review of policy titled "Safe Medication Practices" revised date 10/2010 page 3 under "Medication storage and security", states "Floor stock shall be continuously monitored by staff for expiry and dating of multiple-use vials/containers that have been open for >28 days, along with any other outdated drugs, shall be discarded...".

Interview of staff B the Chief Executive Officer (CEO) on 8/27/13 at approximately 1100 stated, "I see that the staff is not monitoring for expirations or dating multiple use vials correctly".

Based on observation and interview, the facility failed to ensure that equipment and supplies, commonly used in life-saving procedures were maintained and monitored, including manufactures' expiration dates resulting in the potential for less than optimal patient outcomes for all patients served by the facility. Findings include:

On 8/27/13 at approximately 1100 during the tour of the central supply, the following expired supplies were found: 1 box-Prolene suture 2.0 expired 1/2010, 2 boxes-Plain gut suture 4.0 expired 7/2011, 1 box-plain gut suture 2.0 expired 3/2012, 2 boxes-plain gut suture 2.0 expired 10/2012, 1 box -plain gut suture 3.0 expired 10/2012, 1 box -plain gut suture 5.0 expired 8/2012, 1 box- prolene suture 2.0 expired 7/2/13, 1 box -prolene suture 5.0 expired 7/2013, 2 boxes- plain gut suture 3.0 expired 1/2013, 2 boxes-plain gut suture 5.0 expired 1/2013.

Interview of staff G director of the central supply on 8/27/13 at approximately 1115, stated, "Those sutures are not used very often, that's how we missed the expiration dates."

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 8/26/13, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 8/29/13 for Life Safety Code violations.

Based on observation, interview and policy review, the facility failed to ensure that narcotic classified drugs are properly secured/stored resulting in the potential for diversion and failure to meet patients' pain control needs. Findings include:

On 8/27/13 at approximately 1145, during tour of the medical surgical medication room, five transfer boxes were found which are made available for nurses to use when going with patients being transferred to another facility. Each of the five boxes are stored in the locked medication room, but are only secured with plastic breakaway ties. Each transfer box contains the following narcotic classified drugs: 10 tubex-Dilaudid 2 mg/ml, 2 ampules-Fentanyl 100 mcg/2 ml, 10 tubex-Morphine 10 mg/ml, 1 vial-Valium 50 mg/10 ml, 4 vials-Versed 2 mg/2 ml.

Interview of staff B, the CEO on 8/27/13 at approximately 1200 noon stated ,"I did not realize we had to have these double locked."

Review of the policy titled "Medication Administration" revised date 9/2/2011 stated under procedure: "1. General Guidelines: ...b. Narcotics must be kept under double-lock..."

Based on observation, interview, and policy review the facility failed to provide disinfection in accordance with manufacture's instructions for all equipment available for use by patients resulting in the risk for transmission of infectious agents among all patients served by the facility. Findings include:

On 8/27/13 at approximately 1030 during tour of the cardiac/pulmonary rehab department, an unlabeled bottle of liquid was found at the sink with a dirty wash rag stored over the top of the bottle. Staff L, (respiratory therapist) when asked to identify the liquid stated, "I don't know what it is, the director takes the bottle to the kitchen to get it refilled when it gets empty." "That is what the patients use to clean the equipment after they get done exercising." "They (patients) always use that bottle to spray it (equipment) down and wipe it off with that rag." Staff L when asked about procedures related to the extension tubing used to provide patients with oxygen during exercise sessions stated, "each patient has their own extension tube, we label it and put it away after they are done for the day." "We do not wipe it down before we put it away even though it lays on the floor."

During an interview of staff E, the dietitian on 8/27/13 at approximately 1045 revealed, "the director of the rehab uses a few drops of Dawn dish soap in that bottle". "I am not aware of any specific ratios of water to soap."

Interview of staff T, infection control director, on 8/28/13 at approximately 1300 revealed, "I was unaware of the soap and water used to clean the exercise equipment and that the extension tubing was being put away unclean...., we don't have an actual policy for either procedure".

A review of the policy titled "Infectious Disease Management" revised date 12/2011 under environmental cleaning and disinfection states "use any EPA-registered hospital grade detergent-disinfectant. Follow manufacturer's recommendations for use-dilution (i.e., concentration), contact time, and care handling."



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On 8/27/13 at approximately 1645, during observation of the out-patient rehabilitation facilities, found that a red-topped Sani-wipe bottle was being used to clean the equipment between patient use, by staff and patients. According to the manufacturer's recommendation, "When using this product, wear disposable protective gloves." When staff N, (Physical Therapist) was queried as to how these wipes were handled by staff and patients while cleaning the equipment, he stated, "They are told to take a sani-wipe and wipe down the piece of equipment (they) used, then throw it away." Staff N was then asked if they (staff and patients) were told to wear gloves while using the wipes. He responded, "No, I didn't know we had to."

Based on observation, document review and interview, the facility failed to provide a current therapeutic diet manual. Findings include:

On 8/27/13 at approximately 1530, during observation in the kitchen, staff E, (the dietitian) was asked to provide the current approved diet manual. A review of the diet manual on 8/27/13 at approximately 1540 revealed that update was last done by the facility on "3/14/2012." Staff E stated, "I forgot to have it reviewed and updated".

Interview of staff A, (Director of Quality) on 8/28/13 at approximately 1100 stated, "we do review of all policies annually... it is the responsibility of the department director to present their policies for review, the diet manual was overlooked during the move to the new facility".

Based on record review and interview, the facility failed to develop comprehensive care plans with goals, time frames and interventions for 1 of 1 (#9) inpatient swing beds and 4 of 4 discharged swing bed patients, resulting in the potential for unidentified needs and unmet goals. Universe of swing bed records was a total of 21. Findings include:

On 08/27/2013 at 1100, during a review of the medical record for patient #9 revealed a document titled "Swingbed Interdisciplinary Group" (SIG). The document identified the different disciplines involved to help patients meet their needs along with the specified individualized goals, expected time frames and interventions (plan of care for the patient during their hospital stay). The documentation entered by the Physical Therapist and Respiratory Therapist contained interventions but lacked goals and time frames for achieving the goals.

On 08/28/2013 at 1000, a review of the medical record for patient #20 revealed the document titled "SIG.". On the SIG document, the Occupational Therapist had entered a goal for the patient and a timeframe to attain the goal. However, there were no interventions documented as to how the goal would be attained. Goals were identified for the patient on the SIG document by Dietary, Physical Therapy, Respiratory Therapy and Social Work; however, all lacked timeframes for completing the goals.

On 08/28/2013 at 1030, a review of the medical record for patient #21, revealed the document titled "SIG." Although the patient had an identified diagnosis of "diabetes Mellitus" and admission orders contained a referral for "diabetic education" the SIG document lacked goals, timeframes and interventions for diabetic education for the patient. The SIG document also contained goals identified by Physical Therapy; however, there were no timeframes entered for attaining the goals identified. The SIG document lacked nursing goals, timeframe and interventions even though the patient was identified by the documented "Swingbed Coordinator Initial Assessment," as needing assistance with bathing, transfers and walking. The SIG document also lacked any goals, timeframe or interventions, from the Social Worker in regards to discharge preparations for the patient.

On 08/28/2013 at 1100, a review of the medical record for patient #22, revealed the document titled "SIG," on which the Occupational Therapist had entered a goal for the patient and a timeframe to attain the goal. However, there were no interventions documented as to how the goal was to be attained.

On 08/28/2013 at 1300, during interview with staff A, all of the above findings were reviewed and confirmed. When staff A was shown the documents and asked to show where some of the documents contained interventions, she stated, "They don't." When asked to identify the stated timeframes to attain some of goals she stated, "I can't, because they are not there." Staff A requested and was provided copies of the documents reviewed.

The findings were discussed again with facility executive staff, (Chief Executive Officer, Director of Nursing, Social Worker, and the Director of Quality and Risk Management) who were present at the exit conference on 08/29/2013 at 0815.

Based on record review and interview, the facility failed to develop a comprehensive plan of care for 1 of 4 (#23), previously discharged, swing bed patients reviewed in a universe of 21 swing bed patients, resulting in the potential for unidentified and unmet patient needs. Findings include:

On 08/28/2013 at 1700, a review of the medical record for patient #23 and an interview with staff R (Director Medical Records), revealed that the patient's medical record ( Patient #23) lacked a plan of care developed for this swing bed patient. Staff R searched the electronic/computer information for the patient's swing bed admission, and was unable to locate a plan of care for the dates of 06/13/13-06/17/13.

The findings were discussed with all facility staff (Chief Executive Officer, Director of Nursing, Social Worker, Director of Quality and Risk Management) who were present at the exit conference on 08/29/2013 at 0815.

Based on document review and interview, the facility failed to provide services for 1 of 1 swing bed patients (#21) identified with "dental issues," resulting in the potential for unmet patient needs. The review consisted of 5 swing bed records with a universe of 21 swing bed patients identified by the facility. Findings include:

On 08/28/2013 at 1530, a review of the medical record for patient #21 revealed a document titled "Swingbed Coordinator Initial Assessment". The section identified as "Eating Pattern" contained a check mark in the section of "Dental Problems". There was no documentation in the patient's medical record, where the facility offered services to the patient in regards to the dental problem issues, or that the primary care physician was made aware of and addressed the dental problem issue.

On 08/28/2013 at 1600, a review of a document provided by staff A and titled "Services Provided," lacked documentation about the facility providing any type of dental services.

On 08/28/2013 at 1645 during interview with staff A, she confirmed these findings regarding failure to provide dental services in the record for patient #21 and stated, "we have a fully credentialed dentist on staff. I don't know why he was not notified of the patient's dental issues".