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Based on interview, record review, and policy review, the facility failed to:
- Provide written notice to inpatients and outpatients that there was no Doctor of Medicine (MD) or Doctor of Osteopathy (DO) on-site 24 hours a day.
- Provide the Important Message from Medicare (IMM) to two inpatients (#1 and #2) of three inpatient records reviewed for timely receipt of the IMM, and one Swing Bed patient (#15) of one Swing Bed patient record reviewed for timely receipt of the IMM.
- Ensure staff knew how to locate the dietary manual on the nursing unit.
These failed practices had the potential to affect all patients admitted to the facility, and all patients receiving inpatient and outpatient care, when patients were not provided with information necessary to make an informed decision about their care. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. During an interview on 03/06/18 at 8:45 AM, Staff T, Chief Executive Officer (CEO), stated that the facility did not have a form that patients signed, notifying the patient that there was not a MD/DO on-site 24 hours a day.

During observations on 03/06/18 at 8:50 AM, at the admissions desk, and at 11:15 AM, in the emergency department, there was no signage present that notified patients that there was not a MD/DO on-site 24 hours a day.

During an interview on 03/06/18 at 3:30 PM, Staff C, Registered Nurse (RN), Director of Nursing (DON), stated that staff verbally informed inpatients admitted to the facility that MD/DOs were not on-site 24 hours a day, but did not document that they were verbally informed.

2. Record review of the facility's policy titled, "An Important Message from Medicare," dated 10/16, showed directive for staff to issue the initial IMM upon registration as an inpatient.

During an interview on 03/06/18 at 8:45 AM, Staff S, Health Information Clerk, stated that the IMM was not required for inpatients, only observation patients, and there was no observation patients in the hospital at the time.

3. Record review on 03/06/18 at 8:40 AM of Patient #1's medical record showed there was no IMM.

Record review of Patient #2's EMR showed she was admitted to the facility on 03/03/18.

Record review of Patient #2's IMM, showed staff documented the form was given to the patient on 03/06/18, but it was not provided to the patient within the required two days of admission timeframe.

During an interview on 03/06/18 at 1:52 PM, Staff C, RN, DON, stated that Patient #2's IMM was given to, and signed by the patient after the required two days of admission timeframe.

Record review of Patient #15's Electronic Medical Record (EMR) showed he was admitted to the facility's Swing Bed program on 03/01/18 for complaints of weakness after a left hip fracture (break/broken).

Record review of Patient #15's EMR on 03/06/18, showed there was no IMM.

During an interview on 03/06/18 at 1:19 PM, Staff C, RN, DON, stated that the patient did not have an IMM for his Swing Bed admission on 03/01/18.

4. During an interview on 03/08/18 at 9:54 AM, Staff F, RN, and Staff G, Graduate Practicing Nurse (GPN), stated that they did not know how to access the diet manual and did not know its location on the Medical-Surgical Unit.

During an interview on 03/08/18 at 1:30 PM, Staff C, RN, DON, stated that the diet manual was available to staff on-line at the nurse's station.




18018







39840

Based on observation and interview, the facility failed to identify and ensure food items kept in freezers, were not in close proximity to hazardous chemicals. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. Even though requested, the facility did not provide a policy that addressed storage of hazardous chemicals near food items.

2. Observation on 03/07/18 at 10:36 AM, in the facility's main supply room (outside the dietary area), showed the following:
- Large freezers that contained multiple food items such as meat, vegetables, and bread.
- Right next to the freezers was a shelving unit which housed extra cooking utensils (crock pots), and kitchen supplies.
- Also on the shelves were two bottles of oven and grill cleaner, and four quarts of hard surface sanitizer.
- On a stool next to the freezers, and in front of the shelving unit, was two gallons of De-scaler (used to remove hard water stains).

During an interview on 03/07/18 at 2:00 PM, Staff D, Dietary Manager, stated that the freezers were in the main supply room because they lacked the room in the dietary area. Staff D stated that she understood how chemicals stored near food items could be potentially hazardous.

Record review of the Food Service Department Sanitation Checklist, dated 09/04/17, completed by a Registered Dietician, showed no identification of this hazard.

Based on interview, the facility failed to establish and maintain a policy or procedure for reporting changes in ownership to the State Agency. This deficient practice had the potential to incorrectly identify or cause a delay in identification of the owners, when their identification was required to conduct routine business with the State. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. During an interview on 03/07/18 at 9:28 AM, Staff K, Chief Information Officer, stated that the facility did not have a policy or procedure in place that directed a process for identification for a change in ownership, or for reporting that information to the State Agency.

Based on interview, the facility failed to establish and maintain a policy or procedure for reporting changes in the principal operating official (also known as the Chief Executive Officer, CEO) to the State Agency. This deficient practice had the potential to incorrectly identify or cause delay in identification of the CEO, when their identification was required to conduct routine business with the State. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. During an interview on 03/07/18 at 9:28 AM, Staff K, Chief Information Officer, stated that the facility did not have a policy or procedure that directed a process for identification of a change in the CEO, or for reporting that information to the State.

Based on interview, the facility failed to establish and maintain a policy or procedure for reporting changes in the Chief Medical Officer (CMO, a physician that provides medical direction) to the State Agency. This deficient practice had the potential to incorrectly identify or cause delay in identification of the CMO, when their identification was required to conduct routine business with the State. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. During an interview on 03/07/18 at 9:28 AM, Staff K, Chief Information Officer, stated that the facility did not have a policy or procedure that directed a process for identification of a change in the CMO, or for reporting that information to the State.

Based on observation, interview, record review and policy review, the facility failed to ensure that:
- The facility had written policies and procedures (P/P) that were up-to-date and current, had a P/P committee in place, and an advisory group of professionals (physicians, etc.) in place to review and make recommendations for the facility's patient care P/P. (C-0272)
- Infection control P/P were followed for hand hygiene and glove use. (C-0278)
- Staff performed hand hygiene after touching inanimate objects (non-living objects such as beds, tables, etc.) in patients' rooms. (C-0278)
- A cystoscope, (small camera inserted into the body to visualize the inside of the bladder) in the procedure room was stored looped and not hanging down. (C-0278)
- Staff removed expired food and liquid items from the patient refrigerator on the Medical-Surgical Unit. (C-0278)
- Dietary staff labeled and/or developed a system for identifying expiration dates of dry spices, salad dressing and flavorings in the kitchen. (C-0278)
- Clean the top surface and equipment on two of two crash carts (a mobile cart that stores emergency medications and supplies for patient emergencies) observed for cleanliness.(C-0278)
These deficient practices had the potential to increase the risk of infections and cross contamination to all patients, staff and visitors. The facility census was four and one Swing Bed patient.

Based on interview and policy review the facility failed to:
- Develop a plan to review facility policies on an annual basis.
- Develop a policy for annual review of patient care policies.
- Incorporate a policy/procedure (P/P) committee that meets on a regular basis to review, revise and adopt patient care P/P that included committee minutes.
- Incorporate an advisory group that conducted reviews, made recommendations concerning patient care policies and have documented evidence of meeting minutes to show activities of the advisory group.
These deficient practices had the potential to adversely affect the quality and consistency of care provided to all patients. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. Record review of the facility's policies titled, "Automatic Logoff," "Record Retention," "Salvaging Water Damaged Records," and "An Important Message from Medicare," showed the last review date was 10/01/16.

2. Record review of the facility's patient care policies showed they had not been reviewed on an annual basis.

3. During an interview on 03/08/18 at 1:30 PM, Staff C, Registered Nurse (RN), Director of Nursing (DON), stated that the facility did not have a formal committee to review facility P/P and did not have a process defined for their annual review.

During an interview on 03/07/18 at 9:17 AM, Staff Y, Human Resource Coordinator, stated that the facility did not have an "official" policy committee.

During an interview on 03/07/18 at 9:33 AM, Staff R, Physician, Medical Director, stated that he was unaware if the facility had an "official" policy committee.

4. During an interview on 03/07/18 at 3:14 PM, Staff C, RN, DON, stated that:
- The facility could not provide evidence that all the patient care policies had been reviewed on an annual basis.
- The facility did not maintain documented evidence that the advisory group conducted reviews or made recommendations for patient care policies.
- The facility did not have an advisory group in place; therefore, there was no meeting minutes or recommendations for change from the group to advise the governing body and/or responsible individual on patient care policies.



39840

Based on observation, interview, record review and policy review, the facility failed to ensure:
- Staff performed hand hygiene when indicated during patient care for three inpatients (#2, #3 and #8) and one Swing Bed patient (#15), of eight patient care observations observed.
- Staff removed gloves when indicated during patient care for three inpatients (#2, #3 and #8) and one Swing Bed patient (#15), of eight patient care observations observed..
- Staff performed hand hygiene after touching inanimate objects (non-living, beds, tables, etc.) in patients' rooms for three inpatients (#2, #3 and #8) and one Swing Bed patient (#15), of eight patient care observations observed.
- Expired supplies were removed and not available for patient use in the procedure room.
- Proper separate storage for sterile and unsterile supplies in the procedure room.
- The procedure room was free of cardboard, which create dust in the procedure room.
- A cystoscope (small camera inserted into the body to visualize the inside of the bladder) in the procedure room was stored looped and not hanging down.
- Staff cleaned the top surface and equipment on two of two crash carts (a mobile cart that stores emergency medications and supplies for patient emergencies) observed for cleanliness.
- Expired food and liquid items were removed from the patient use refrigerator on the Medical-Surgical Unit.
- Dietary staff labeled and/or developed a system for identifying expiration dates of dry spices, salad dressing and flavorings in the kitchen.
These deficient practices had the potential to increase the risk of infections and cross contamination to all patients, staff and visitors. The facility census was four and one Swing Bed patient.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 07/28/17, directed staff to perform hand hygiene:
- Before and after having direct contact with patients.
- Before handling an invasive device for patient care, regardless of whether or not gloves are used.
- After contact with body fluids or excretions, mucous membranes, non-intact skin, or wounds dressings.
- If moving from a contaminated body site to a clean body site.
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
- With soap and water, when hands are visibly dirty.
- With plain or antimicrobial soap and water or rub hand with an alcohol based formulation before handling medications or preparing food.

Record review of the facility's policy titled, "Cleaning and Disinfecting Patient Care Equipment," dated 11/16/17, showed the following directives for staff:
- High-touch surfaces and equipment in patient rooms are cleaned at regular intervals, at least daily and upon discharge or transfer of the patient.
- Soiled environmental surfaces can be a source of contamination to hands or other objects which may have contact with the patient. Use a hospital-approved detergent-disinfectant regularly to clean and disinfect surfaces.
- Examples of non-critical surfaces include but are not limited to stethoscopes (a medical instrument used to listen to a person's lungs, heart and abdomen), blood pressure cuffs, bed rails and bedside tables.

2. Observation on 03/05/18 at 2:41 PM showed:
- Staff A, RN (Registered Nurse) entered Patient #3's room to start an IV (intravenous, a needle placed into a vein used to administer medications, fluids and/or nutrition).
- Staff A performed hand hygiene and put on gloves.
- Wearing the gloves, Staff A touched the bed control to raise the bed height, touched the trash can and then touched the IV tray (Intravenous supplies gathered in a carry tray).
- Wearing the same gloves, Staff A opened supplies on the bedside table prior to cleaning the surface, flushed the IV extension tubing in the package, and then reached back into the IV tray for supplies.
- Wearing the same gloves, Staff A placed a paper drape on the patients bed under his left arm and then applied the tourniquet (a device for stopping the flow of blood through a vein or artery) to his left upper arm.
- Staff A took the tourniquet off, raised the bed rail and moved to the other side of the bed.
- Wearing the same gloves, Staff A touched the IV pump (a machine used to regulate the rate of medication/fluids administered to patients), lowered the bedrail, removed an old dressing from his forearm, turned on the overhead light, put the paper drape under his right arm, placed the tourniquet on him, touched the IV pump to turn it off, opened chloraprep (antiseptic solution used to clean bacteria from skin), cleansed the skin in his antecubital (region of the arm in front of the elbow) area, reached into the IV tray and removed two alcohol wipes, opened an IV catheter (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and inserted the IV catheter into his skin.
- Wearing the same gloves, Staff A removed the IV needle from his arm, reached over to the bedside table for dry gauze and removed the tourniquet.
-Then Staff A, removed a piece of tape from the tape roll that was attached to her stethoscope (instrument used to hear heart, lung abdominal a sounds) which was hanging around her neck.
-Then Staff A, placed tape and gauze over the patients arm where the IV needle had been removed, turned IV fluids back on at IV pump, raised the bedrail, retrieved the call light, and touched the bed controls to return the bed to low position.
- Staff A, removed her gloves, but failed to perform hand hygiene.

During an interview on 03/05/18 at 2:55 PM, Staff A, RN, stated that she did not need to change her gloves and that she had performed hand hygiene appropriately.

Continued observation on 03/05/18 at 3:00 PM for Patient #3 showed:
- Staff C, RN, DON (Director of Nursing) entered the patient's room to start an IV.
- Staff C, performed hand hygiene and put on gloves.
- Staff C, lowered the bedrail, placed the tourniquet on the patient's left upper arm, rubbed his left antecubital area with alcohol and then removed the tourniquet.
- Staff C, raised the bedrail, moved to other side of the bed, lowered the bedrail, placed the tourniquet his right upper arm, touched the IV pump to turn it off, used alcohol to wipe the area on his right forearm, and removed the tourniquet from his right upper arm.
- Wearing the same gloves, Staff C reached into the IV tray for gauze and tape.
- Staff C, placed the tourniquet on his right upper arm, used alcohol wipes on his forearm, reached into the IV tray for an IV catheter, opened the sterile extension tubing, removed the cap from the tubing, opened the syringe containing normal saline (solution used to aid transfusion) and connected the syringe to the extension tubing, flushed the tubing and left the syringe connected.
- Wearing the same gloves, Staff C inserted the IV catheter into the his right forearm.
- Staff C, connected the extension tubing to the IV catheter and began flushing, his vein immediately swelled.
- Staff C, removed the catheter and applied gauze and tape to the area that she had removed the IV catheter.
- Wearing the same gloves, Staff C raised the bedrail, fed ice chips to the patient, cleaned up the IV supplies and removed her gloves, but failed to perform hand hygiene.

During an interview on 03/06/18 at 9:18 AM, Staff C stated that when staff started and IV, hand hygiene should be performed before, after and during, if needed. Staff C stated that she would not consider objects (bedrails, IV tray, etc.) to be clean.

Observation on 03/06/18 at 8:59 AM, showed:
- Staff B, Licensed Practical Nurse (LPN), entered Patient #2's room to administer morning medications.
- Staff B brought a computer on wheels (COW) into the patient's room but did not clean/disinfect the COW before she brought it into the room.
- Staff B performed hand hygiene.
- Staff B applied the blood pressure cuff onto the patient's arm then applied gloves.
- Staff B touched the patient's arm and identification band (ID Band - contains the patient's name and date of birth) and scanned the ID band.
- Wearing the same gloves, Staff B scanned each medication, removed the medication from the packaging and placed them into a plastic medication cup.
- Wearing the same gloves, Staff B touched the computer screen and typed on the computer keyboard.
- Staff B removed the gloves but did not perform hand hygiene after she removed the gloves.
- Staff B left the patient's room but did not perform hand hygiene after she exited the room.
- Staff B did not clean/disinfect the COW after she brought it out of the patient's room or before she brought it into the next patient's room.

Observation on 03/06/18 at approximately 9:15 AM showed:
- Staff B, LPN, entered Patient #8's room to administer morning medications.
- Staff B brought the COW into the patient's room but did not clean/disinfect it before she brought it into the patient's room.
- Staff B performed hand hygiene and applied gloves.
- Staff B applied a blood pressure cuff on the patient's arm, removed her gloves but did not perform hand hygiene after she removed the gloves.
- Staff B exited the patient's room and brought the COW with her but did not clean/disinfect it after she exited the patient's room.
- Staff B re-entered the patient's room and brought the COW with her but did not clean/disinfect the COW prior to re-entry into the patient's room.
- Staff B typed on the computer keyboard, performed hand hygiene and applied gloves.
- Staff B touched the patient's left arm to scan her ID band.
- Wearing the same gloves, Staff B scanned each medication, touched the computer mouse and touched the computer screen.
- Wearing the same gloves, Staff B touched Tambocor (medication to treat irregular heartbeat) and placed the pill into a pill splitter.
- Wearing the same gloves, Staff B placed each medication into a plastic medication cup and handed each pill to the patient.
- Wearing the same gloves, Staff B touched a used Kleenex, patient's gown and blanket.
- A pill dropped on the patient's gown and wearing the same gloves, Staff B picked up the pill.
- Staff B handed the pill to the patient and she took the pill from Staff B and swallowed the pill.
- Wearing the same gloves, Staff B removed the patient's socks off the patient's feet to assess them.
- Wearing the same gloves, Staff B removed her stethoscope from around her neck and listened to the patient's lungs, heart and abdomen.
- Staff B did not clean/disinfect her stethoscope prior to placing it on the patient.
- Staff B removed her gloves, performed hand hygiene but did not clean/disinfect her stethoscope after she used it on the patient.
- Staff B exited the patient's room with the COW but did not clean or disinfect it after she exited the room.

Observation on 03/06/18 at 9:44 AM, showed:
- Staff B, LPN, entered Patient #15's room to administer morning medications.
- Staff B brought the COW into the patient's room but did not clean/disinfect it prior to bringing it into the room.
- Staff B performed hand hygiene and applied gloves.
- Staff B applied the blood pressure cuff and pulse oximetry (medical device used to measure oxygen levels in the blood) onto the patient.
- Wearing the same gloves, Staff B reached into her pocket and brought out a pen to document the patient's blood pressure and pulse oximetry.
- Wearing the same gloves, Staff B reached into the COW and retrieved the patient's medications that she had placed into a plastic medication cup and placed it on top of the COW.
- Wearing the same gloves, Staff B touched the computer, removed the blood pressure cuff and pulse oximetry.
- Wearing the same gloves, Staff B removed the cover off liquid medication and handed it to the patient to take.
- Staff B removed her gloves, performed hand hygiene, applied gloves, retrieved a syringe with medication from the COW and placed it without a barrier onto the arm rest of the patient's chair.
- Staff B then administered the medication in the syringe into the patient's upper arm.
- Wearing the same gloves, Staff B reached into her pocket and retrieved a pen.
- Wearing the same gloves, Staff B removed her stethoscope from around her neck and listened to the patient's lungs, heart and abdomen.
- Staff B did not clean/disinfect her stethoscope prior to placing it on the patient.
- Wearing the same gloves, Staff B removed the patient's socks, assessed his pedal pulses (pulse located onto of the foot), checked for swelling in his feet and ankles then applied lotion to both feet.
- Staff B removed her gloves but did not perform hand hygiene and placed a pillow under the patient's leg.
- Staff B did not clean/disinfect the COW before she exited the patient's room.

During an interview on 03/06/18 at 4:18 PM, Staff B, LPN, stated that:
- Hand hygiene should be performed upon entry into a patient's room, upon exiting a patient's room, before a task and before putting on gloves.
- Glove changes should be performed after hand hygiene and when gloves are visibly soiled and/or dirty.
- Stethoscopes should be cleaned before and after each patient use.
- Blood pressure machines should be wiped down before and after being in patients' rooms.
- She should not have given Patient #8 the pill after it had been dropped on the patient's gown.

3. Observation on 03/07/18 at 1:15 PM, in the procedure room showed:
- A portable heater and a white oscillating fan, setting on a cardboard box behind the door.
- A cardboard banker's box located on the floor next to the cabinet along the right wall.
- A cabinet located along the right wall contained seven items packaged with dates of 12/04/12, 07/08/11, 01/02/12, 08/12/12, 01/24/10, 02/26/13, and 02/26/11.
- The shelf also contained one wrapped tray labeled Sterile Vasectomy Tray Vasectomy (a surgical procedure for male sterilization [refers to any process that eliminates, removes, kills, or deactivates all forms of life] with or permanent contraception) date of 11/25 (unable to determine if date included year), and one suture package with an expiration date of 12/2015.
- Two cardboard cases of formalin (preservative used for specimens) in the cabinet along the left wall, stacked on a pile of clean gowns, on the shelf below biopsy forceps (instruments used to remove small tissue samples from the body).

During an interview on 03/07/18 at 1:15 PM, Staff N, RN, Outpatient Department Manager, stated that the facility did not have a policy for cardboard being in the procedure room. Staff N acknowledged that expired items should not be used. Staff N stated that she was unaware of an issue with storage related to formalin and sterile supplies and the facility had no policy for formalin storage.

4. Observation on 03/07/18 at 1:15 PM of the procedure room showed a cystoscope was stored looped and not hanging straight down.

During an interview on 03/07/18 at 1:05 PM, Staff N, Registered Nurse (RN), Outpatient Manager, stated that the vendor informed her that the cystoscope did not have to be hung straight after disinfection due to the scope being so long.

Although requested, the facility was unable to provide vendor documentation that the cystoscope could be looped during storage.

5. Observation on 03/05/18 at 2:05 PM, showed the crash cart in the Emergency Department (ED) had dust on the suction machine, canister and tubing

During an interview on 03/05/18 at 2:05 PM, Staff H, ED Paramedic, acknowledged that the ED's crash cart had dust on the suction machine, canister and tubing. Staff H stated that the ED did not have a procedure for cleaning the crash cart and/or equipment.

Observation on 03/07/18 at 9:24 AM, showed the crash cart on the Medical-Surgical Unit had dust on the suction machine, canister and tubing.

During an interview on 03/07/18 at 9:37 AM, Staff G, Licensed Practical Nurse (LPN), stated that there was no policy related to cleaning of the crash cart and acknowledged that the suction machine, canister and tubing on the crash cart was dusty.

6. Observation on 03/06/18 at 1:05 PM of the patient use refrigerator on the medical/surgical unit, showed one unopened grapefruit juice with an expiration date of 02/26/18; one unopened Ensure Clear best before 03/01/18; and in the freezer, 24 whole fruit cups best by 01/20/18.

During an interview on 03/06/18 at 1:05 PM, Staff H, ED Paramedic, confirmed that the refrigerator was checked by dietary.

Observation on 03/07/18 at 9:13 AM of the patient use refrigerator on the medical/surgical unit showed five lime jello cups expired on 03/06/18; six prune juice with no expiration date (packaging with expiration date was removed); and in the freezer, ten prune juice with no expiration dates (packaging with expiration date was removed).

During an interview on 03/07/18 at 2:00 PM, Staff C, Dietary Manager stated that the cook checks the refrigerator every night for outdates.

7. Even though requested, the facility failed to provide a policy that included how to label and/or determine the expiration dates of spices, flavorings and salad dressings.

Observation on 03/06/18 at 9:48 AM, showed the following:
- Eight 21-ounce opened containers of dry spices that had no expiration dates on them.
- One 32-ounce opened bottle of vanilla marked with the date received, but no expiration date.
- One gallon jug of opened Italian salad dressing with the date received, but no expiration date.

During an interview on 03/06/18 at 1:19 PM, Staff D, Dietary Manager, stated that there was no specific policy that dictated when dry spices, flavorings, or dressings expired. Staff D stated that all dates written on food/liquid containers were the date received, not expiration dates. Staff D stated that she had no way of knowing when these items expired.




18018





39840

Based on observation, interview, record review, and policy review, the facility failed to obtain a physician's order for a dressing change for one patient (#8) of one patient dressing change observed. This failed practice had the potential to affect all patients receiving dressing changes. The facility census was four inpatients and one Swing Bed patient

Findings included:

1. Record review of the facility policy titled, "Physician Orders," dated 03/06/18, showed that licensed healthcare providers may accept written, verbal, and telephone orders at the facility from credentialed (authorized) providers.

2. Record review of Patient #8's electronic medical record (EMR) showed no orders for a dressing change.

Observation on 03/07/18 at 10:24 AM showed Staff F, Registered Nurse (RN) changed Patient #8's right wrist dressing.

During an interview and concurrent record review on 03/07/18 at 10:24 AM, Staff F, RN, stated that she received in report that Patient #8's dressing was to be changed per the treatment protocol every two days, and today was the day it should be changed. The treatment protocol for dressing change was requested and Staff F referred to the Lippincott manual. The Lippincott manual showed no protocol for non-adherent dressing change.

During an interview on 03/08/18 at 11:40 AM, Staff C, RN Director of Nursing, that there should be an order for a dressing change.

Staff failed to ensure that a physician's order was on the patient's EMR prior to changing the dressing and therefore, changed the dressing without direction from the physician.


39840

Based on interview, record review and policy review, the facility failed to ensure:
- A completed History and Physical (H&P) was in the patient's record prior to a procedure;
- A properly executed informed consent was completed;
- An operative report included the times of the procedure and pre-operative and post-operative diagnosis; and
- A current and active policy or procedure for patient identification related to the "timeout" procedure (a process performed prior to a procedure, to verify the correct patient, correct procedure, etc) for six discharged patients (#17, #18, #19, #20, #21, and #22) of six discharged patients reviewed. These failures had the potential to compromise the safety and health of all patients undergoing procedures at the facility. The facility census was four and one Swing Bed patient.

The severity and cumulative effects of these deficient practices resulted in the facility's overall non-compliance with requirements set forth at 42 CFR 485.639 Conditions of Participation (COP): Surgical Services.

Findings included:

1. Record review of the facility's policy titled, "Procedural Sedation and Analgesia," dated 05/25/17, showed directives for staff to:
- Verify a complete history and physical are completed and documented;
- Ensure a pre-sedation assessment was completed and documented; and
- Verify informed consent was completed and documented.

2. Review of Patient #17's Operative Report showed that the H&P element was contained within the report. The Operative Report was dictated on 01/10/18 at 10:13 AM by the performing physician, and transcribed on 01/11/18 at 9:33 AM. The physician did not document the H&P prior to the procedure. The procedure start time was missing from the document.

Review of Patient #18's Operative Report showed that the H&P element was contained within the report. The Operative Report was dictated on 01/17/18 at 4:35 PM by the performing physician and transcribed on 01/18/18 at 9:06 AM. The physician did not document the H&P prior to the procedure. The Anesthesia record showed the procedure start time on 01/17/18 at 10:18 AM.

Review of Patient #19's Operative Report showed that the H&P element was contained within the report. The Operative Report was dictated on 02/07/18 at 10:26 AM by the performing physician and transcribed on 02/07/18 at 1:57 PM. The physician did not document the H&P prior to the procedure. The Anesthesia record showed the procedure start time on 02/07/18 at 10:06 AM.

Review of Patient #20's Operative Report showed that the H&P element was contained within the report. The Operative Report was dictated on 02/21/18 at 6:24 PM by performing physician and transcribed on 02/22/18 at 9:44 AM. The physician did not document the H&P prior to the procedure. The Anesthesia record showed the procedure start time on 02/21/18 at 8:51 AM.

Review of Patient #21's Operative Report showed that the H&P element was contained within the report. The Operative Report was dictated on 12/06/17 at 5:21 PM by the performing physician and transcribed on 12/07/17 at 11:18 AM. The physician did not document the H&P prior to the procedure. The Anesthesia record showed the procedure start time on 12/06/17 at 8:46 AM.

Review of Patient #22's Operative Report showed that the H&P element was contained within the report. The Operative Report was dictated on 12/06/17 at 5:22 PM by the performing physician and transcribed on 12/07/17 at 11:27 AM. The physician did not document the H&P prior to the procedure. The Anesthesia record showed the procedure start time on 12/06/17 at 9:53 AM.

3. Review of six discharged patients' records (#17, #18, #19, #20, #21, and #22), showed the Consent for Surgery/Procedure did not include the name and signature of the person who explained the procedure to the patient, which is a required element for a properly executed consent form.

4. Review of six discharged patients' records (#17, #18, #19, #20, #21, and #22), showed the Operative Reports did not include times of the procedure, or pre and post-operative diagnosis.

During an interview on 03/07/17 at 3:15 PM, Staff N, Registered Nurse, Outpatient Department Manager, stated that the facility did not perform a timeout prior to procedures and the facility had no policy or procedure for timeout prior to procedures.


39840

Based on interview and record review the facility failed to ensure that anesthesia risks were documented prior to the delivery of anesthesia for six discharged patients' records (#17, #18, #19, #20, #21, and #22), of six discharged patients' records reviewed. This failure had the potential to affect all patients receiving anesthesia by not documenting the risks of anesthesia prior to the procedure. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. Record review of six discharge patients' records (#17, #18, #19, #20, #21, and #22), of six discharged patients' records reviewed, showed there were no anesthesia risks documented on the anesthesia record.

During an interview on 03/15/18 at 1:35 PM, Staff X, Certified Registered Nurse Anesthetist (CRNA), stated that:
- She interviewed the patient prior to the procedure and completed her assessment on the anesthesia record.
- She reviewed the patient's electronic medical record (EMR) for the History and Physical (H&P).
- She acknowledged that the H&P in the EMR was from a previous visit and was sometimes from an office visit.
- She did tell the patient about the risks of anesthesia but did not document the risks on the anesthesia record.




18018

Based on interview and record review, the facility failed to have an effective Quality Assessment and Performance Improvement (QAPI) program that included problem identification and prevention, identification and implementation of corrective action plans, and evaluation of the effectiveness of corrective action plans for the Outpatient Clinic and Swing Bed Program. These deficient practices had the potential to adversely affect the safety and quality of care provided to Outpatients and Swing Bed patients. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. Record review of the facility's QAPI Report showed that there were no indicators and/or projects with data for the Outpatient Clinic or the Swing Bed Program.

During an interview on 03/07/18 at 1:14 PM, Staff N, Registered Nurse (RN), Outpatient Manager, stated that she has been the Outpatient Manager for two years. Staff N stated that the Outpatient Clinic did not have any QAPI indicators and/or projects, and she had not collected any data.

During an interview on 03/08/18 at 9:17 AM, Staff P, Swing Bed Manager, stated that the QAPI indicators for the Swing Bed program was the same indicators that the program had looked at for the last several years.



12450

Based on interview, record review and policy review, the facility failed to develop comprehensive care plans that included activity interest with short/long term goals, and timeframes with interventions to assist the patient in attaining their highest level of functioning for two current Swing Bed patients (#8 and #15) of two current Swing Bed patient's activity care plans reviewed, and for three discharged Swing Bed patients (#16, #25 and #26) of three discharged patients' Swing Bed activity care plans reviewed. This had the potential to affect all Swing Bed patients that required an activity care plan in the facility's Swing Bed program. The facility census was four inpatients and one Swing Bed patient.

Findings included:

1. Record review of the facility's policy titled, "Activities Program," dated 12/15/17 showed the following directives for staff:
- Activities are to be individualized and offered at hours that are convenient to the patient.
- Activity Plan - Part of Patient Care Plan - reviewed weekly at Swing Bed Multidisciplinary meeting.
- An initial assessment of each patient's recreational and social needs will be made upon admission to the Swing Bed Program. This assessment will include an outline of the patient's needs, abilities, and interest, with a realistic goal stated.
- The Patient Care Plan for each patient will also include an activity plan that outlines specific problems and/or needs, a short-term goal, and an approach or plan to meet it. This will be reviewed no less than weekly.

2. Record review of Patient #15's Electronic Medical Record (EMR) showed he was admitted to the facility's Swing Bed program on 03/01/18 with complaints of weakness after a left hip fracture.

Record review of the patient's EMR Swing Bed Activity Assessment dated 03/01/18, showed he liked/enjoyed the following activities:
- Newspaper and magazines;
- Word search puzzles;
- Movies and/or TV;
- Sit outdoors;
- House work; and
- Pets.

Record review of the patient's Patient Plan of Care dated 03/01/18, showed staff failed to identify activities as a problem with short term goals and timeframes with interventions to address his activity interest needs while in the facility's Swing Bed program.

Record review of Patient #8's EMR showed that she was admitted to the facility's Swing Bed program on 03/05/18 with complaints after a fall, and weakness.

Record review of the patients EMR Swing Bed Activity Assessment dated 03/06/18 showed she liked/enjoyed the following activities:
- Read;
- Church activities;
- Movies and/or TV;
- Travel;
- Pets; and
- Word search puzzles.

Record review of the patient's Patient Plan of Care showed staff failed to identify activities as a problem with short term goals and timeframes with interventions to address her activity interest needs while in the facility's Swing Bed program.

Record review of Patient #16's EMR showed that she was admitted to the facility's Swing Bed program on 12/20/17 with complaints of physical deconditioning (decline in function due to prolonged bed rest following an injury or long-term disease process) after a fall, with right humerus (long bone of the arm) fracture.

Record review of the patient's EMR Swing Bed Activity Assessment dated 12/21/17, showed she liked/enjoyed the following activities:
- Church activities and music;
- Movies and/or TV;
- Walks, sports, and house work;
- Dominoes;
- Plants/gardening; and
- Reminiscence.

Record review of the patient's Patient Plan of Care dated 12/20/17, showed staff failed to identify activities as a problem with short term goals and timeframes with interventions to address her activity interest needs while in the facility's Swing Bed program.

Record review of Patient #25's EMR showed he was admitted to the facility's Swing Bed program on 01/16/18 with complaints of deconditioning from pneumonia, Congestive Heart Failure (CHF, weakness of the heart that leads to a buildup of fluids in the lungs and surrounding tissues) and advanced age.

Record review of the patient's EMR Swing Bed Activity Assessment dated 01/16/18, showed he liked/enjoyed the following activities:
- Newspaper and magazines;
- Movies and/or TV;
- Sit outdoors; and
- Reminiscence.

Record review of the patient's Patient Plan of Care dated 01/16/18, showed staff failed to identify activities as a problem with short term goals and timeframes with interventions to address his activity interest needs while in the facility's Swing Bed program.

Record review of Patient #26's EMR showed he was admitted to the facility's Swing Bed program on 02/12/18 with complaints of pneumonia, Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and weakness.

Record review of the patient's EMR Swing Bed Activity Assessment dated 02/12/18, showed he liked/enjoyed the following activities:
- Church activities;
- Movies and/or TV;
- Pets; and
- Sit outdoors.

Record review of the patient's Patient Plan of Care dated 02/13/18, showed staff failed to identify activities as a problem with short term goals and timeframes with interventions to address his activity interest needs while in the facility's Swing Bed program.

3. During an interview on 03/06/18 at 1:54 PM, Staff C, Registered Nurse (RN), Director of Nursing (DON), acknowledged that Patient #15's EMR Patient Plan of Care did not have an activities care plan.

During an interview on 03/08/18 at 8:47 AM, Staff O, Social Service Designee, stated that she did not develop a care plan that addressed Swing Bed patients' activity interest. Staff O stated that she was not sure what the facility failed to do.

During an interview on 03/08/18 at 9:17 AM, Staff P, Swing Bed Manager, stated that the facility did not have a policy specific to activities care planning. Staff P stated that she did not enter activity care plans for patients admitted to the Swing Bed program into the EMR Patient Plan of Care.


18018