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Based on interview and record review, the Governing Body failed to ensure that the Quality Assessment and Performance Improvement (QAPI) Program reflected all of the contracted services or provided evidence of QAPI monitoring for the services related to Agency Nurses and Dietary Services for four of four contracted services reviewed. This had the potential to affect all patients in the facility. The facility census was 136.

Findings included:

1. During an interview on 10/15/15 at 1:55 PM, Staff A, Director of Accreditation and Licensure, stated, "To our knowledge, we do not have a policy on contracted services".

2. Record review of the facility's document titled, "Quality-Safety Plan [QSP]," revised 07/2015, showed the following: The QSP supports an ongoing program for quality improvement and reflects the complexity of the organization, encompassing all [facility] departments and services, including contracted services.

Record review of the facility's undated document titled, "Contracted Clinical Services Evaluation FY [fiscal year] 2015," showed three separate RN Staffing Agencies that provided, or were available to provide, direct patient care. The service expectations of the agencies by the facility stated the following:
- Vendor (contracted agency) provides complete, accurate and timely documentation for staff assignments.
- Candidates pass all required testing prior to start of clinical assignments.
- Assigned staff meets clinical and interpersonal competency requirements.
- Assigned staff are present at the start of their shift.

The Evaluation Method was listed as "Review of performance reports based on indicators required in the contractual agreement and input from staff and patients".
All three RN Staffing Agencies were evaluated by Staff SS, RN, Director of Logistic Operations.

3. During concurrent interviews on 10/14/15 at approximately 2:10 PM, Staff A, Director of Accreditation and Licensure and Staff MMM, Corporate Quality and Performance Improvement, stated that Staff NNN, Manager of Nursing Standards was responsible for the QAPI of the contracted RN Staffing Agencies.

During an interview on 10/14/15 at approximately 2:20 PM, Staff NNN stated that there was no evidence of the evaluation of the contracted RN agency staff. She stated that there was no data collected, evaluated or analyzed to show that the patient care provided by the agency staff nurses was provided with acceptable standards of practice. She stated that the contracted nurses are expected to perform in the same manner as employed RN's but that she could not provide evidence that the standard was met. Staff NNN could not provide evidence of any Performance Improvement Projects that involved contracted agency nurses.

4. During an interview on 10/13/15 at approximately 4:20 PM, Staff L, Director of Dietary, stated that:
- He and Staff M, Head Clinical Registered Dietitian (RD), worked for a contracted service that managed the Dietary department.
- The Dietary department had not established any QAPI projects related to food production and service.
- He assigned the kitchen supervisors to collect data on tray accuracy (all food items ordered by the patients were on the trays) and food temperatures however, these were not collected in response to a specific food production and service problem.
- He did not know if the collected data went into a facility QAPI project.
- He did not participate in identification of any dietary department problem area to study for QAPI.
- He stated that Staff M, conducted some QAPI studies however, he was not aware of the specifics of those studies.
- He was not a member of the facility QAPI committee.
- He had no knowledge of the facility wide QAPI program.

5. Record review of the facility's undated document titled, "Contracted Clinical Services Evaluation FY [fiscal year] 2015," showed one Dietary Food Service that provided nutrition to all patients and potentially visitors and staff. The service expectations of the agency by the facility stated the following: Compliance with dietary Regulations and Quality and efficient service. The Evaluation Method was listed as "Direct observation of the provision of care, Review of periodic reports submitted by the contractor and Input from staff and patients". The Dietary Food Services were evaluated by Staff AAAA, Chief Financial Officer (CFO).

Record review of the Dietary department 2015 QAPI program information, provided by the RD (Staff M) showed no studies on aspects of food production and service such as safe, sanitary food handling.

During an interview on 10/14/15 at approximately 4:00 PM, Staff M, stated that she did no QAPI for the food production and service section of the department.





16215

Based on observation, interview and record review, the facility failed to ensure patient paper medical records were protected against unauthorized access (by individuals who were not providing care for those patients), in two of two departments (the main Health Information Services [HIS, also known as Medical Records] department and in the Outpatient Rehabilitation department. This deficient practice had the potential to permit unauthorized individuals to access, review, and/or possibly alter the documented health information in patient paper medical records stored in those areas. The facility census was 136.

Findings included:

1. Record review of the facility's policy titled, "Security of Paper Medical Records Within the Health Information Services Department," dated 09/04/13, showed directives for staff:
- The policy was in place to ensure the security, confidentiality and compliance of paper medical records located in the HIS department.
- The policy was used to prevent unauthorized individuals from accessing the paper medical records in the department.
- There was at least one HIS staff in the department at all times from Monday through Friday between 8:00 AM and 4:30 PM (to prevent unauthorized access).
- After Friday at 4:30 PM through Monday at 8:00 AM no HIS staff were on duty and the main door into the department was locked.

Record review of the facility's policy titled, Access to Medical Records-Medical Staff Members, dated 09/04/14, showed directives for staff that only physicians and health care professionals were allowed access to medical records of patients that were currently cared for or if the physician was treating the patient.

2. During an interview on 10/13/15 at 2:20 PM, Staff K, Supervisor of HIS, stated that the HIS department routinely had some staff on duty on Saturdays however, no HIS staff were assigned to work in the department on Sundays and holidays.

3. Observation 10/13/15 at 3:20 PM showed the HIS department was composed of:
- A large open area with multiple cubicles (obstructing line of sight of doorways and shelving units);
- A separate room with multiple movable, floor to ceiling shelving units all containing paper medical records;
- A storage closet with boxed paper medical records; And
- A separate office area with multiple desks.

During an interview on 10/13/15 at 3:25 PM, Staff K stated that the separate office with multiple desks;
- Was used by the facility dietitians;
- She felt there were three dietitians (there were actually five);
- The dietitians were in the area after HIS staff left; sometimes on Sunday
and holidays, when HIS staff were not on duty; And
- There was a possibility that the dietitians could access the paper patient medical records when HIS staffs were not present.

4. Observation with concurrent interview on 10/14/15 at 3:10 PM in the therapy office of the Outpatient Rehabilitation department showed:
- There were approximately 1500 patient medical records that were stored on open shelves.
- The patient's name, diagnosis, insurance name and policy numbers, date of birth, physician, and home exercise program were documented in the records.
- Staff NN, Clinical Coordinator, stated that approximately a year ago the facility switched to an electronic health record (EHR) system. The department leaders were unsure how long to keep the records and were not instructed on a process for scanning the records into the EHR. The housekeepers had a key to open the office and clean (where the records were stored and not secured) after the staff had gone for the day.

5. During concurrent observation and interview on 10/15/15 from 8:20 AM through 9:03 AM in the Outpatient Rehabilitation department, Staff WWW, Administrative Assistant for Outpatient Therapy stated the following:
- The four drawer lateral file cabinet in the alcove next to an entrance into the patient gym area was filled with medical records of currently treated patients;
- There were an unknown number of medical records in the four file drawers;
- The lateral file cabinet was not locked due to the lack of a key;
- All staff had access to the medical records including seven or eight therapists and a receptionist;
- Not all the therapists were treating each of the patients with medical records in the four drawer lateral file cabinet;
- An open shelving unit with multiple paper patient medical records was located in the area in back of the receptionist's desk;
- The easily accessed open shelving unit held paper patient medical records of discharged (from therapies) patients;
- All therapy staff had access to the patient paper medical records on the open shelving unit;
- Staff WWW stated that the information in these medical records had been scanned into the facility computer system;
- A third area included the former Audiology (branch of science that studies hearing) office area; and two large storage rooms), office area which held multiple (greater than 30) cardboard boxes and 15 standard file cabinet drawers filled with patient paper medical records;
-Staff WWW stated that the Audiology area (two rooms including one outer storeroom plus an inner office) held Audiology records for patients treated from 2009 and 2010 and the other boxes and file cabinet drawers held therapy records from 2000 through 2010;
- The Audiology office could not be locked (no lock on the door knob on the door between the two rooms);
- The fourth area included a large store room with multiple cardboard boxes of paper records; 15 lateral file cabinets plus 30 open, floor to ceiling shelving units filled with paper patient medical records;
- Staff WWW stated that the room contained patient medical records from the Outpatient Rehabilitation department; the Cardiac Rehabilitation department and some Outpatient Nutrition/Dietitian medical records;
- The records in the fourth area were dated 1999 through 2011; And
- Staff WWW stated that sometimes the Cardiac Rehabilitation staff requested to access five or six records a month. For access, Staff WWW gave the key to Cardiac Rehabilitation staff who then, retrieved records unaccompanied. Cardiac Rehabilitation staff could access or remove any record of any patient while in the storage room, even though they may not have needed to access or remove that medical record.

During an interview on 10/15/15 at 8:30 AM, Staff K, Supervisor of HIS, (who accompanied the surveyor and observed all of the Cardiac Rehabilitation areas stated that:
- Once a medical record was scanned into the facility computer system, the paper copy should be held for 90 days then, destroyed (shredded).
- Each of the cardboard boxes found in the Outpatient Rehabilitation area probably held an estimated 200 paper medical records.
- The fourth storeroom probably held 10,000 to 15,000 paper medical records.
- She did not know the staff in the Outpatient Rehabilitation department stored all of the paper patient medical records found in the four areas. And
- The staff in the Outpatient Rehabilitation department should not be holding any paper patient medical records because all records of medical care provided to any patient in the facility should be retained and secured by staff in the HIS department.











29117

Based on observation, interview and record review, the facility failed to ensure the therapeutic (restricted) diet manual was approved by the dietitian and the medical staff and the facility failed to ensure the diet manual was accessible to all nursing staff. This deficient practice had the potential to permit inappropriate foods to be served to patients on therapeutic diets. The total facility census was 136. The census of patients on therapeutic diets was 48.

Findings included:

1. Record review of the facility's policy titled, "Nutrition Care Manual," dated 04/2015 showed directives for the following:
- The Academy of Nutrition and Dietetics, Nutrition Care Manual (NCM) was the approved diet manual.
- The facility Medical Executive Committee was the approving body for the manual.
- The diet manual was readily available to staff including nursing staff on-line through the facility computer system.

2. During an interview on 10/14/15 at approximately 3:30 PM, Staff M, Head Clinical Registered Dietitian (RD) confirmed that the NCM was the facility diet manual however;
- She had not signed the manual showing her approval;
- She did not know she was required to sign it (approve it for use in the facility); and
- She did not have proof that the Medical Executive Committee had approved the diet manual.

3. During an interview on 10/14/15 at 11:18 AM on the 5th floor unit, Staff II, Registered Nurse (RN); and Staff JJ, RN both stated that they did not know where the facility diet manual was maintained.

During observation and concurrent interview on 10/14/15 from 11:18 AM through 11:25 AM on the 5th floor unit, Staff KKK, RN, Charge Nurse stated that the diet manual was on the facility computer system however, when asked to access the diet manual on the computer, Staff KKK could not readily locate it.

4. During an interview on 10/14/15 at 3:50 PM, Staff TT, Clinical Supervisor of the Progressive Care Unit (PCU) and 2 East, stated that the diet manual was not located in the nursing units, and added that staff would reference electronic policies or Lippincott if they had any questions related to patient diets.

During an interview on 10/15/15 at 9:45 AM, Staff VVV, RN, did not know what a diet manual was, but stated that it could be located on the hospital's computer system.

Observation on 10/15/15 at 10:08 AM, showed Staff VVV was unable to locate the diet manual for the PCU.









29047

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed facility infection control polices and performed appropriate hand cleansing, glove changes, wore gowns when necessary and prevented cross contamination (spread germs) while patient care was provided and when environmental surfaces of patient care areas were touched for eight patients (#1, #20, #12, #3, #4, #6, #18, and #80) of 18 patient observations for appropriate hand hygiene and infection control measures. These failed practices of not following established policies and procedures to prevent the spread of infection had the potential to cause harm by healthcare associated infections for all patients. The facility census was 136.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 12/2014, showed directives for staff to perform hand hygiene:
- Before and after having direct contact with patients;
- After removing gloves; and
- After contact with environmental surfaces (including medical equipment) in the immediate vicinity of the patient.

Record review of Dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) Safety published by the Centers for Disease Control and Prevention titled, "Protocol for Hand Hygiene and Glove Use Observations" last updated 05/09/13, showed that in general, gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces (e.g., dialysis machine, environmental surfaces). Note: all items/surfaces at the dialysis station are considered potentially contaminated. Gloves should always be changed between patients and between clean and contaminated sites on the same patient. Holding a glove in one's hand instead of wearing it is not considered acceptable. Glove use does not preclude the need for hand hygiene after removing gloves.
Examples of situations when gloves should be changed: are after contact with blood or body fluids and after contacting a potentially contaminated site before moving to a clean site.

2. Observation on 10/14/15 at 9:10 AM in the Intensive Care Unit (ICU) showed Staff S, Registered Nurse (RN), Dialysis Nurse, in the room with Patient #1 to administer a Dialysis treatment. Staff S was prepared to attach the patient to the dialysis machine but did not have on any Personal Protective Equipment (PPE such as gown, gloves or mask) as required. Without gloves on Staff S touched the patient's head and hands then opened all sterile packaging and placed it on the patient's bed. This could potentially contaminate the sterile supplies. Staff S put on a gown but no gloves and touched the dialysis tubing (filled with the patient's blood) then reached under her gown and retrieved an ink pen out of her uniform pocket. This potentially contaminated her uniform underneath the gown. Then with contaminated bare hands and without performing hand hygiene Staff S again manipulated the dialysis tubing, the patient's gown and pillow, touched the patient's face, touched the patient's face mask, touched the buttons on the Dialysis machine, touched the patient's pillow, again touched the machine and typed on the computer keyboard and used the computer mouse. Still without gloves Staff S opened the nurse server (supply cart), pushed buttons on the Dialysis machine (the alarm would not stop sounding), then touched the blood lines, then switched the lines on the patient's access port.

During an interview on 10/15/15 at 9:40 AM Staff C, RN, Administrative Assistant for ICU, Transitional Care Unit (TCU) and Progressive Care Unit (PCU), stated that she observed the same hand hygiene and glove use problems with Staff S during Patient #1's Dialysis treatment. She stated that Staff S should have worn gloves for the procedures and performed hand hygiene and changed gloves during the procedure.

3. Record review of the facility's policy titled, "Precautions - Isolation, Standard Precautions," revised 12/2014, showed:
- Wear gloves when it can be reasonable anticipated that contact with contaminated items could occur;
- Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces;
- Perform hand hygiene after glove removal; and
- Wash hands after contact with environmental surfaces, including medical equipment, in the immediate vicinity of the patient.

4. Record review of Patient #20's lab results dated 10/12/15, showed the patient screened positive for Methicillin-Resistant Staphylococcus Aureus (MRSA, a difficult to treat infection that is highly contagious).

Observation on 10/13/15 at 2:55 PM, showed Staff XXX, RN administered medications to Patient #20, who was on contact isolation for MRSA. After Staff XXX administered the medications, she removed her hospital phone from her scrub uniform pocket, which was located underneath a protective gown, while she wore contaminated gloves. She then returned the contaminated phone to her scrub pocket, removed her gloves, and again removed the contaminated phone with her bare hands and tossed the phone on a vacant bed within the patient's room. Staff XXX then removed her contaminated gown with non-gloved hands, washed her hands, then picked up the contaminated phone with bare hands and proceeded to clean it with a cleaning wipe. Staff XXX then failed to perform hand hygiene after she handled the contaminated phone, before she exited the room.

During an interview on 10/13/15 at 4:00 PM, Staff XXX stated that she should not have removed the phone from her pocket and should not have removed her gloves before she removed her protective gown. Staff XXX stated that she realized she contaminated her scrubs, hands and additional surfaces when she:
- Removed the phone from her pocket with contaminated gloves;
- Returned the phone to her pocket with contaminated gloves;
- Removed her gloves before she removed her contaminated gown;
- Removed the contaminated phone from her pocket with her bare hands; and
- Failed to wash her hands after cleaning the contaminated phone and before she exited the room.

5. Record review of Patient #12's medical record showed the following:
- Physician History and Physical (H&P) dated 10/11/15 showed an admission diagnoses of Urinary Tract Infection (UTI) with hematuria (blood in the urine).
- Physician progress notes documentation dated 10/12/13 and 10/13/15 of a multiple drug resistant organism (MDRO, germs that cause potentially life-threatening infections and not easily killed by multiple antibiotics) present in the patient's urine.
- A urinary catheter (a tube inserted into the body, through an external body opening to provide continuous urine drainage) was inserted on 10/11/15 and connected to a collection bag.

Observation on 10/13/15 at 3:45 PM of the Medical/Surgical Unit showed Patient #12 awake, alert and restless in bed. The patient attempted to remove the urinary catheter with his hands when he touched his penis and multiple areas of the urinary catheter tubing. The patient then touched the blankets and handrails of his bed.

Observation on 10/13/15 at 3:45 PM showed Staff Q, RN in Patient #12's room while she provided care and administered a medication. With gloved hands, Staff Q touched the patient's hands, the urinary catheter tubing, patient's skin surfaces around the catheter, the bed rails and repositioned the patient's blankets multiple times. With the same gloved hands (she did not remove the dirty gloves, clean her hands and put on new gloves) from the patient's bedside tray table, she picked up and removed an oral medication (a pill) from a sealed container, cut the pill in half, picked the pill up with her two gloved fingers and placed the pill into the patient's mouth with a poking motion. Her fingers became wet with saliva when she touched the patient's tongue and lips. Staff Q contaminated (spread germs) to and from the patient and the environment when she placed her fingers in the patient's mouth after she touched the patient's blankets, skin, urine catheter tubing, bed rails and bedside tray table.

During an interview on 10/13/15 at 3:50 PM, Staff Q stated that she forgot to change gloves and perform hand hygiene before she put the pill in the patient's mouth (with her fingers).

During an interview on 10/13/15 at 4:07 PM, Staff O, RN Clinical Supervisor of the Medical/Surgical Unit, stated that Staff Q, administered medications to Patient #12 with contaminated hands. She stated that after Staff Q touched the patient and/or the contaminated environmental surfaces she should have performed hand hygiene (changed gloves and disinfected her hands) and then administered the medication from a pill cup. Staff Q stated that the Standard of Care for medication administration was to administer oral medications to patients with the use of medication cups and that they should not put their fingers in patients' mouths, especially if contaminated.

6. Observation on 10/14/15 at 8:50 AM showed that Staff R, RN, entered the room of Patient #3 in the ICU to perform perineal (the area between the anus and the scrotum in the male and between the anus and the opening to the vagina in the female) care. Wearing clean gloves the nurse turned the patient to her back but failed to spread her legs and the perineal/urinary catheter and the catheter tubing could not be visualized. Failure to spread the patient's legs could not ensure that the area was clean and didn't harbor bacteria. Staff R used a washcloth, rinse cloth and dry cloth to clean the peri area from front to back until her last stroke which was back to front (anus to vagina). This procedure was the same for all three cloths and increased the risk to introduce stool and bacteria to the catheter tubing and increased the potential of high risk for infection. After Staff R performed peri care for the patient she changed her gloves and performed hand hygiene but then she touched the patients head and hair, IV tubing, moved her pillow, turned off the alarm at the end of the bed and straightened her blanket all with the same gloves and did not change them or perform hand hygiene after touching an inanimate object and before touching the patient.

During an interview on 10/15/15 at 9:10 AM Staff C, RN, stated that she observed the peri care by Staff R and that the nurse should have had a visual of the catheter tubing and perineal area of the patient and that Staff R wiped the area from back to front and that was not the correct procedure. During an interview on 10/15/15 at 9:40 AM Staff C stated that she observed Staff R touched the patient and inanimate objects without changing her gloves or performing hand hygiene.

During an interview on 10/15/15 at 9:40 AM Staff R stated that not all patients' legs are flexible and can be spread apart. She did state that she should have gone in a downward motion from the catheter tubing and peri area toward the anus when cleaning the perineal area.

7. Observation on 10/14/15 at 8:30 AM showed that Staff YYY, RN, entered the room of Patient #4 in the ICU to replace a medication on the IV (intravenous or within the vein) pole. With clean gloves on she typed on the computer keyboard, touched the patient's bare skin near the patient's identification band, typed on the computer keyboard, again touched the patient's bare skin, typed again on the computer keyboard, hung the bottle of IV medication on the IV pole and spiked the IV tubing into the medication. She continued to prime the IV tubing (filling the tubing with solution) and program the IV machine for infusion without changing her gloves and performing hand hygiene. Failure to change gloves and perform hand hygiene between touching the patient and inanimate objects in the environment increase the potential of cross contamination of infectious agents.

During an interview on 10/15/15 at 9:40 AM Staff C stated she observed that Staff YYY touched the patient and inanimate objects without changing her gloves or performing hand hygiene.

8. Observation on 10/13/15 at 3:50 PM, in the Emergency Department (ED), showed Staff E, RN and ED Clinical Supervisor, administered IV medication to Patient #6. After the medication was administered but before the IV line was flushed (pushed additional salt water into IV line so that medication did not remain in the tubing) Staff E utilized foam cleanser while her gloves remained on her hands.

During an interview on 10/13/15 at 3:55 PM, Staff E stated that if she would have touched anything other than the flush she would have changed her gloves. Staff E stated that this is her normal practice.

During an interview on 10/13/15 at 4:05 PM, Staff G, RN and ED Educator, stated that she educated staff to remove gloves, clean hands and put on new gloves. Staff G stated that staff should not clean hands with gloves in place.

9. Observation on 10/14/15 at 11:30 AM, in the ED, showed Staff G prepared to start an IV on Patient #18. After the supplies to be used were obtained and opened, Staff G removed gloves and put on new gloves but failed to clean hands in between glove change.

During an interview on 10/14/15 at 11:35 AM, Staff G stated that she should have cleaned hands in between glove change, she stated, "I forgot."
During an interview on 10/15/15 at 1:25 PM, Staff CCC, Infection Preventionist, stated that staff had been trained to change gloves and clean their hands when they were soiled and that they "should have known better" than to touch any environmental surface or a patient if their hands had been potentially soiled. She stated that the standard of infection control for all patient care areas was to prevent contamination by adhering to strict hand hygiene (hand washing and/or disinfection), isolation precautions, and wearing the appropriate protection over clothing and skin if the possibility of contamination is present, all to prevent spreading infection from person to person. She stated that the safety of all patients, visitors and staff depend on following good infection control measures.

10. Record review of the facility's policy titled, "Patient Specific Medication," dated 10/2015, showed direction for facility staff to remove the medication container from the plastic medication bag and leave the bag in the medication room. After administration, staff should wipe down the medication container with a hospital approved disinfectant, place the medication container back into the plastic bag in the medication room, and replace the bagged medication into the patient specific bin in the automated medication system.

11. Observation with concurrent interview on 10/15/15 at 9:10 AM in Patient #80's room on the Rehabilitation Unit showed:
- Staff ZZZ, RN, placed medications on the computer key board and key board holder.
- After the medication administration, Staff ZZZ replaced one of the medications, Mirlax (for treatment of difficulty having a bowel movement), which was refused by the patient, into the medication room, and into the automated medication system potentially for administration to another patient.
- Staff ZZZ returned a cream, an ointment and one medication that the patient refused, into the patient's bin in the automated medication system.
- Staff ZZZ stated that returned medication (after being in the patient's room) was an infection control issue, but this was their process.

During an interview on 10/15/15 at 9:45 AM Staff QQ, Nurse Manager Rehabilitation Unit, stated that she expected that staff remove the creams, ointments, or medication from the plastic bags prior to taking the medication into the patient's room. Then staff should place the medication back into the plastic bags, take them into the medication room and place them into the automated medication system.











27029




29047




29117










29511

Based on interview and record review, the Governing Body failed to ensure that the Quality Assessment and Performance Improvement (QAPI) Program reflected all of the contracted services or provided evidence of QAPI monitoring for the services related to Agency Nurses and Dietary Services for four of four contracted services reviewed. This had the potential to affect all patients in the facility. The facility census was 136.

Findings included:

1. During an interview on 10/15/15 at 1:55 PM, Staff A, Director of Accreditation and Licensure, stated, "To our knowledge, we do not have a policy on contracted services".

2. Record review of the facility's document titled, "Quality-Safety Plan [QSP]," revised 07/2015, showed the following: The QSP supports an ongoing program for quality improvement and reflects the complexity of the organization, encompassing all [facility] departments and services, including contracted services.

Record review of the facility's undated document titled, "Contracted Clinical Services Evaluation FY [fiscal year] 2015," showed three separate RN Staffing Agencies that provided, or were available to provide, direct patient care. The service expectations of the agencies by the facility stated the following:
- Vendor (contracted agency) provides complete, accurate and timely documentation for staff assignments.
- Candidates pass all required testing prior to start of clinical assignments.
- Assigned staff meets clinical and interpersonal competency requirements.
- Assigned staff are present at the start of their shift.

The Evaluation Method was listed as "Review of performance reports based on indicators required in the contractual agreement and input from staff and patients".
All three RN Staffing Agencies were evaluated by Staff SS, RN, Director of Logistic Operations.

3. During concurrent interviews on 10/14/15 at approximately 2:10 PM, Staff A, Director of Accreditation and Licensure and Staff MMM, Corporate Quality and Performance Improvement, stated that Staff NNN, Manager of Nursing Standards was responsible for the QAPI of the contracted RN Staffing Agencies.

During an interview on 10/14/15 at approximately 2:20 PM, Staff NNN stated that there was no evidence of the evaluation of the contracted RN agency staff. She stated that there was no data collected, evaluated or analyzed to show that the patient care provided by the agency staff nurses was provided with acceptable standards of practice. She stated that the contracted nurses are expected to perform in the same manner as employed RN's but that she could not provide evidence that the standard was met. Staff NNN could not provide evidence of any Performance Improvement Projects that involved contracted agency nurses.

4. During an interview on 10/13/15 at approximately 4:20 PM, Staff L, Director of Dietary, stated that:
- He and Staff M, Head Clinical Registered Dietitian (RD), worked for a contracted service that managed the Dietary department.
- The Dietary department had not established any QAPI projects related to food production and service.
- He assigned the kitchen supervisors to collect data on tray accuracy (all food items ordered by the patients were on the trays) and food temperatures however, these were not collected in response to a specific food production and service problem.
- He did not know if the collected data went into a facility QAPI project.
- He did not participate in identification of any dietary department problem area to study for QAPI.
- He stated that Staff M, conducted some QAPI studies however, he was not aware of the specifics of those studies.
- He was not a member of the facility QAPI committee.
- He had no knowledge of the facility wide QAPI program.

5. Record review of the facility's undated document titled, "Contracted Clinical Services Evaluation FY [fiscal year] 2015," showed one Dietary Food Service that provided nutrition to all patients and potentially visitors and staff. The service expectations of the agency by the facility stated the following: Compliance with dietary Regulations and Quality and efficient service. The Evaluation Method was listed as "Direct observation of the provision of care, Review of periodic reports submitted by the contractor and Input from staff and patients". The Dietary Food Services were evaluated by Staff AAAA, Chief Financial Officer (CFO).

Record review of the Dietary department 2015 QAPI program information, provided by the RD (Staff M) showed no studies on aspects of food production and service such as safe, sanitary food handling.

During an interview on 10/14/15 at approximately 4:00 PM, Staff M, stated that she did no QAPI for the food production and service section of the department.





16215

Based on observation, interview and record review, the facility failed to ensure patient paper medical records were protected against unauthorized access (by individuals who were not providing care for those patients), in two of two departments (the main Health Information Services [HIS, also known as Medical Records] department and in the Outpatient Rehabilitation department. This deficient practice had the potential to permit unauthorized individuals to access, review, and/or possibly alter the documented health information in patient paper medical records stored in those areas. The facility census was 136.

Findings included:

1. Record review of the facility's policy titled, "Security of Paper Medical Records Within the Health Information Services Department," dated 09/04/13, showed directives for staff:
- The policy was in place to ensure the security, confidentiality and compliance of paper medical records located in the HIS department.
- The policy was used to prevent unauthorized individuals from accessing the paper medical records in the department.
- There was at least one HIS staff in the department at all times from Monday through Friday between 8:00 AM and 4:30 PM (to prevent unauthorized access).
- After Friday at 4:30 PM through Monday at 8:00 AM no HIS staff were on duty and the main door into the department was locked.

Record review of the facility's policy titled, Access to Medical Records-Medical Staff Members, dated 09/04/14, showed directives for staff that only physicians and health care professionals were allowed access to medical records of patients that were currently cared for or if the physician was treating the patient.

2. During an interview on 10/13/15 at 2:20 PM, Staff K, Supervisor of HIS, stated that the HIS department routinely had some staff on duty on Saturdays however, no HIS staff were assigned to work in the department on Sundays and holidays.

3. Observation 10/13/15 at 3:20 PM showed the HIS department was composed of:
- A large open area with multiple cubicles (obstructing line of sight of doorways and shelving units);
- A separate room with multiple movable, floor to ceiling shelving units all containing paper medical records;
- A storage closet with boxed paper medical records; And
- A separate office area with multiple desks.

During an interview on 10/13/15 at 3:25 PM, Staff K stated that the separate office with multiple desks;
- Was used by the facility dietitians;
- She felt there were three dietitians (there were actually five);
- The dietitians were in the area after HIS staff left; sometimes on Sunday
and holidays, when HIS staff were not on duty; And
- There was a possibility that the dietitians could access the paper patient medical records when HIS staffs were not present.

4. Observation with concurrent interview on 10/14/15 at 3:10 PM in the therapy office of the Outpatient Rehabilitation department showed:
- There were approximately 1500 patient medical records that were stored on open shelves.
- The patient's name, diagnosis, insurance name and policy numbers, date of birth, physician, and home exercise program were documented in the records.
- Staff NN, Clinical Coordinator, stated that approximately a year ago the facility switched to an electronic health record (EHR) system. The department leaders were unsure how long to keep the records and were not instructed on a process for scanning the records into the EHR. The housekeepers had a key to open the office and clean (where the records were stored and not secured) after the staff had gone for the day.

5. During concurrent observation and interview on 10/15/15 from 8:20 AM through 9:03 AM in the Outpatient Rehabilitation department, Staff WWW, Administrative Assistant for Outpatient Therapy stated the following:
- The four drawer lateral file cabinet in the alcove next to an entrance into the patient gym area was filled with medical records of currently treated patients;
- There were an unknown number of medical records in the four file drawers;
- The lateral file cabinet was not locked due to the lack of a key;
- All staff had access to the medical records including seven or eight therapists and a receptionist;
- Not all the therapists were treating each of the patients with medical records in the four drawer lateral file cabinet;
- An open shelving unit with multiple paper patient medical records was located in the area in back of the receptionist's desk;
- The easily accessed open shelving unit held paper patient medical records of discharged (from therapies) patients;
- All therapy staff had access to the patient paper medical records on the open shelving unit;
- Staff WWW stated that the information in these medical records had been scanned into the facility computer system;
- A third area included the former Audiology (branch of science that studies hearing) office area; and two large storage rooms), office area which held multiple (greater than 30) cardboard boxes and 15 standard file cabinet drawers filled with patient paper medical records;
-Staff WWW stated that the Audiology area (two rooms including one outer storeroom plus an inner office) held Audiology records for patients treated from 2009 and 2010 and the other boxes and file cabinet drawers held therapy records from 2000 through 2010;
- The Audiology office could not be locked (no lock on the door knob on the door between the two rooms);
- The fourth area included a large store room with multiple cardboard boxes of paper records; 15 lateral file cabinets plus 30 open, floor to ceiling shelving units filled with paper patient medical records;
- Staff WWW stated that the room contained patient medical records from the Outpatient Rehabilitation department; the Cardiac Rehabilitation department and some Outpatient Nutrition/Dietitian medical records;
- The records in the fourth area were dated 1999 through 2011; And
- Staff WWW stated that sometimes the Cardiac Rehabilitation staff requested to access five or six records a month. For access, Staff WWW gave the key to Cardiac Rehabilitation staff who then, retrieved records unaccompanied. Cardiac Rehabilitation staff could access or remove any record of any patient while in the storage room, even though they may not have needed to access or remove that medical record.

During an interview on 10/15/15 at 8:30 AM, Staff K, Supervisor of HIS, (who accompanied the surveyor and observed all of the Cardiac Rehabilitation areas stated that:
- Once a medical record was scanned into the facility computer system, the paper copy should be held for 90 days then, destroyed (shredded).
- Each of the cardboard boxes found in the Outpatient Rehabilitation area probably held an estimated 200 paper medical records.
- The fourth storeroom probably held 10,000 to 15,000 paper medical records.
- She did not know the staff in the Outpatient Rehabilitation department stored all of the paper patient medical records found in the four areas. And
- The staff in the Outpatient Rehabilitation department should not be holding any paper patient medical records because all records of medical care provided to any patient in the facility should be retained and secured by staff in the HIS department.











29117

Based on observation, interview and record review, the facility failed to ensure the therapeutic (restricted) diet manual was approved by the dietitian and the medical staff and the facility failed to ensure the diet manual was accessible to all nursing staff. This deficient practice had the potential to permit inappropriate foods to be served to patients on therapeutic diets. The total facility census was 136. The census of patients on therapeutic diets was 48.

Findings included:

1. Record review of the facility's policy titled, "Nutrition Care Manual," dated 04/2015 showed directives for the following:
- The Academy of Nutrition and Dietetics, Nutrition Care Manual (NCM) was the approved diet manual.
- The facility Medical Executive Committee was the approving body for the manual.
- The diet manual was readily available to staff including nursing staff on-line through the facility computer system.

2. During an interview on 10/14/15 at approximately 3:30 PM, Staff M, Head Clinical Registered Dietitian (RD) confirmed that the NCM was the facility diet manual however;
- She had not signed the manual showing her approval;
- She did not know she was required to sign it (approve it for use in the facility); and
- She did not have proof that the Medical Executive Committee had approved the diet manual.

3. During an interview on 10/14/15 at 11:18 AM on the 5th floor unit, Staff II, Registered Nurse (RN); and Staff JJ, RN both stated that they did not know where the facility diet manual was maintained.

During observation and concurrent interview on 10/14/15 from 11:18 AM through 11:25 AM on the 5th floor unit, Staff KKK, RN, Charge Nurse stated that the diet manual was on the facility computer system however, when asked to access the diet manual on the computer, Staff KKK could not readily locate it.

4. During an interview on 10/14/15 at 3:50 PM, Staff TT, Clinical Supervisor of the Progressive Care Unit (PCU) and 2 East, stated that the diet manual was not located in the nursing units, and added that staff would reference electronic policies or Lippincott if they had any questions related to patient diets.

During an interview on 10/15/15 at 9:45 AM, Staff VVV, RN, did not know what a diet manual was, but stated that it could be located on the hospital's computer system.

Observation on 10/15/15 at 10:08 AM, showed Staff VVV was unable to locate the diet manual for the PCU.









29047

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed facility infection control polices and performed appropriate hand cleansing, glove changes, wore gowns when necessary and prevented cross contamination (spread germs) while patient care was provided and when environmental surfaces of patient care areas were touched for eight patients (#1, #20, #12, #3, #4, #6, #18, and #80) of 18 patient observations for appropriate hand hygiene and infection control measures. These failed practices of not following established policies and procedures to prevent the spread of infection had the potential to cause harm by healthcare associated infections for all patients. The facility census was 136.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 12/2014, showed directives for staff to perform hand hygiene:
- Before and after having direct contact with patients;
- After removing gloves; and
- After contact with environmental surfaces (including medical equipment) in the immediate vicinity of the patient.

Record review of Dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) Safety published by the Centers for Disease Control and Prevention titled, "Protocol for Hand Hygiene and Glove Use Observations" last updated 05/09/13, showed that in general, gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces (e.g., dialysis machine, environmental surfaces). Note: all items/surfaces at the dialysis station are considered potentially contaminated. Gloves should always be changed between patients and between clean and contaminated sites on the same patient. Holding a glove in one's hand instead of wearing it is not considered acceptable. Glove use does not preclude the need for hand hygiene after removing gloves.
Examples of situations when gloves should be changed: are after contact with blood or body fluids and after contacting a potentially contaminated site before moving to a clean site.

2. Observation on 10/14/15 at 9:10 AM in the Intensive Care Unit (ICU) showed Staff S, Registered Nurse (RN), Dialysis Nurse, in the room with Patient #1 to administer a Dialysis treatment. Staff S was prepared to attach the patient to the dialysis machine but did not have on any Personal Protective Equipment (PPE such as gown, gloves or mask) as required. Without gloves on Staff S touched the patient's head and hands then opened all sterile packaging and placed it on the patient's bed. This could potentially contaminate the sterile supplies. Staff S put on a gown but no gloves and touched the dialysis tubing (filled with the patient's blood) then reached under her gown and retrieved an ink pen out of her uniform pocket. This potentially contaminated her uniform underneath the gown. Then with contaminated bare hands and without performing hand hygiene Staff S again manipulated the dialysis tubing, the patient's gown and pillow, touched the patient's face, touched the patient's face mask, touched the buttons on the Dialysis machine, touched the patient's pillow, again touched the machine and typed on the computer keyboard and used the computer mouse. Still without gloves Staff S opened the nurse server (supply cart), pushed buttons on the Dialysis machine (the alarm would not stop sounding), then touched the blood lines, then switched the lines on the patient's access port.

During an interview on 10/15/15 at 9:40 AM Staff C, RN, Administrative Assistant for ICU, Transitional Care Unit (TCU) and Progressive Care Unit (PCU), stated that she observed the same hand hygiene and glove use problems with Staff S during Patient #1's Dialysis treatment. She stated that Staff S should have worn gloves for the procedures and performed hand hygiene and changed gloves during the procedure.

3. Record review of the facility's policy titled, "Precautions - Isolation, Standard Precautions," revised 12/2014, showed:
- Wear gloves when it can be reasonable anticipated that contact with contaminated items could occur;
- Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces;
- Perform hand hygiene after glove removal; and
- Wash hands after contact with environmental surfaces, including medical equipment, in the immediate vicinity of the patient.

4. Record review of Patient #20's lab results dated 10/12/15, showed the patient screened positive for Methicillin-Resistant Staphylococcus Aureus (MRSA, a difficult to treat infection that is highly contagious).

Observation on 10/13/15 at 2:55 PM, showed Staff XXX, RN administered medications to Patient #20, who was on contact isolation for MRSA. After Staff XXX administered the medications, she removed her hospital phone from her scrub uniform pocket, which was located underneath a protective gown, while she wore contaminated gloves. She then returned the contaminated phone to her scrub pocket, removed her gloves, and again removed the contaminated phone with her bare hands and tossed the phone on a vacant bed within the patient's room. Staff XXX then removed her contaminated gown with non-gloved hands, washed her hands, then picked up the contaminated phone with bare hands and proceeded to clean it with a cleaning wipe. Staff XXX then failed to perform hand hygiene after she handled the contaminated phone, before she exited the room.

During an interview on 10/13/15 at 4:00 PM, Staff XXX stated that she should not have removed the phone from her pocket and should not have removed her gloves before she removed her protective gown. Staff XXX stated that she realized she contaminated her scrubs, hands and additional surfaces when she:
- Removed the phone from her pocket with contaminated gloves;
- Returned the phone to her pocket with contaminated gloves;
- Removed her gloves before she removed her contaminated gown;
- Removed the contaminated phone from her pocket with her bare hands; and
- Failed to wash her hands after cleaning the contaminated phone and before she exited the room.

5. Record review of Patient #12's medical record showed the following:
- Physician History and Physical (H&P) dated 10/11/15 showed an admission diagnoses of Urinary Tract Infection (UTI) with hematuria (blood in the urine).
- Physician progress notes documentation dated 10/12/13 and 10/13/15 of a multiple drug resistant organism (MDRO, germs that cause potentially life-threatening infections and not easily killed by multiple antibiotics) present in the patient's urine.
- A urinary catheter (a tube inserted into the body, through an external body opening to provide continuous urine drainage) was inserted on 10/11/15 and connected to a collection bag.

Observation on 10/13/15 at 3:45 PM of the Medical/Surgical Unit showed Patient #12 awake, alert and restless in bed. The patient attempted to remove the urinary catheter with his hands when he touched his penis and multiple areas of the urinary catheter tubing. The patient then touched the blankets and handrails of his bed.

Observation on 10/13/15 at 3:45 PM showed Staff Q, RN in Patient #12's room while she provided care and administered a medication. With gloved hands, Staff Q touched the patient's hands, the urinary catheter tubing, patient's skin surfaces around the catheter, the bed rails and repositioned the patient's blankets multiple times. With the same gloved hands (she did not remove the dirty gloves, clean her hands and put on new gloves) from the patient's bedside tray table, she picked up and removed an oral medication (a pill) from a sealed container, cut the pill in half, picked the pill up with her two gloved fingers and placed the pill into the patient's mouth with a poking motion. Her fingers became wet with saliva when she touched the patient's tongue and lips. Staff Q contaminated (spread germs) to and from the patient and the environment when she placed her fingers in the patient's mouth after she touched the patient's blankets, skin, urine catheter tubing, bed rails and bedside tray table.

During an interview on 10/13/15 at 3