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Based on observation, it was determined the facility did not ensure a safe and clean environment for patients due to stained ceiling tiles throughout the facility and damaged doors in two of four patient rooms observed. The failed practice prevented the environment to be cleaned and disinfected to prevent the spread of infection. The failed practice had the potential to affect all patients, staff, and visitors in this facility with an average census of 4.06 and four of four (two in-patient and two observation) patients on census on 09/07/10. The findings follow:

A. On a tour of the facility on 09/08/10 at 0930, stained ceiling tiles were observed as follows:
1) Two brown stained ceiling tiles were observed in the Central Supply Room. The tiles also had a black substance on them.
2) Two brown stained ceiling tiles were observed in the Respiratory Therapy Room
3) In the Corridor near the X-Ray Room, two brown stained tiles were observed.
4) The gyspum board ceiling in the Vending Machine Room was damaged in one location and was stained brown.
B. On a tour of the facility on 09/08/10 at 0930 damaged patient room doors were observed as follows:
1) The door to Patient Room 116 had damaged edges with exposed wood material and splinters. The door to the patient toilet room had a long gouge across the top and the door facing was scratched.
2) The door to Patient Room 114 had damaged edges with exposed wood material and splinters. The door facing to the patient toilet was scratched.
C. The Director of Housekeeping and Laundry who was responsible for maintenance operations verified the above observations at the time they occurred.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to fire extinguisher inspection and maintenance, self-closing requirements for fire rated doors, and maintaining the one hour fire resistance rating of smoke barriers. The failed practice had the potential to affect all patients, staff, and visitors in the facility with an average census of 4.06 and four of four (two in-patient and two observation) patients on census on 09/07/10. See K-11, K-25, and K-64 for further details.

Based on observation, review of the Pharmacy Policy and Procedure Manual and interview, the facility failed to ensure outdated medications were not available for patient use in two of two (Nursing Unit, Emergency Department) nursing areas. The average daily census of 4.06 inpatients and 8.40 Emergency Department patients had the potential to receive outdated medications that could have an effect on patient safety. Findings follow:

A. The Pharmacy Policy and Procedure Manual was reviewed on 09/07/10 at 1500. The policy on "Expired Medications" stated the following: "Routine inspections of all medication storage areas are performed on a monthly basis by the pharmacist and expired and outdated medications are pulled."
B. A tour of the two nursing areas (Nursing Station and Emergency Department) was conducted on 09/07/10. The Nursing Station was toured at 1105 and the Emergency Department at 1330. The following outdated medications were observed:
Nursing Station
1) Two Acetaminophen 500 milligrams (mg) Caplets outdated 06/10;
2) One pint of Isopropyl Alcohol 70% outdated 06/10;
3) Two vials of Diphenhydramine 50mg/milliliter(ml) expired 08/10;
4) Twenty-six Chewable Orange Aspirin 81mg expired 07/10;
5) Four Acetaminophen 325mg tablets expired 06/10;
6) Two Vasopressin 20units/ml expired 06/10; and
7) One bottle Antacid Gas 200/200/20 expired 05/01/10.
Emergency Department
1) One Dextrose 50% Injection expired 07/01/10;
2) One Mapap Drops (Infant Acetaminophen) expired 08/10;
3) One Sulfamethoxazole/Trimethoprim tablet expired 09/01/10;
4) Two Actidose-Aqua expired 07/10;
5) One Actidose-Aqua expired 07/09; and
6) One Sodium Chloride 0.45% 1000ml expired 07/10.
C. In an interview with Licensed Practical Nurse (LPN) #1 at the Nursing Station on 09/07/10 at 1130, LPN #1 verified the medications observed were outdated. In an interview with the Director of Nurses (DON) on 09/07/10 at 1400, the DON verified medications observed in the Emergency Department were outdated.
D. The Director of Nurses verified through interview on 09/07/10 at 1400 the average daily inpatient census was 4.06 and the average daily number of patients seen in the Emergency Department was 8.40

Based on review of Infection Control Policy and Procedures, Infection Control Committee minutes, Quality Assurance Performance Improvement monitoring documentation and interview, it was determined the facility failed to assure the infection control policies were based on current Centers for Disease Control and Prevention (CDC) Guidelines (2007) and failed to have a system in place to monitor and evaluate staff compliance with facility infection control practices. The failure to have infection control policies based on current infection control guidelines and to monitor staff compliance with infection control practices had the potential to allow the spread of infection. The failed practice had the potential to affect two of two (#1 and #2) in-patients on census. The findings follow:

A. On 09/09/10, the facility Infection Control Manual was reviewed. A policy and procedure for "CDC Preventing the transmission of Infectious Agents" was noted with a date of 2001. The current document is the CDC "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents Healthcare Settings".
B. Review of Quality Assurance Performance Improvement documentation and Infection Control Committee Minutes from 08/18/09 to 08/10/10 revealed no documentation that staff compliance with infection control practices was monitored or evaluated.
C. In an interview on 09/09/10 at 1030, the Director of Nursing confirmed the findings and stated infection control practices in the facility are based on CDC guidelines as identified in the facility Infection Control Manual and no monitoring for staff compliance with infection control practices had occurred.

Based on clinical record review and interview, it was determined routine Medication Adminstration Records (MARs) were not maintained the the active clinical record for two of two in-patients. The failed practice affected the continuity of patient care for the two patients on census. The findings follow:

A. Routine MARs were not found in Patient #1's and Patient #2's active clinical record.
B. Interview at 1130 on 09/07/2010, Registered Nurse #2 confirmed there were no routine MARs in Patient #1's and Patient #2's clinical record. Registered Nurse #2 indicated the MARs for Patient #1 and Patient #2 were in the Medication Room.
C. Registered Nurse #2 brought routine MARs from the Medication Room for Patient #1 and Patient #2 at 1135 on 09/07/2010, for the dates of 9/6/2010 and 9/7/2010.
D. Interview at 1135 on 09/07/2010, Registered Nurse #2 indicated routine MARs for dates prior to 9/6/2010 were in the Medical Records Department.
E. Interview with the Chief Nursing Officer, Medical Records Director and Pharmacy Technician/Respiratory Therapist at 1325 on 09/08/2010, they confirmed original routine MARs were taken to the pharmacy then to the Medical Records Department and were not brought back to the active clinical record.

Based on review of the Swing-Bed Policy and Procedure Manual and interview, it was determined there were no policies and procedures to prevent the hiring or retention of individuals convicted of abuse or neglect, on staff training to identify all forms of abuse and neglect, to protect patients during the investigation process, for conducting investigations of abuse and neglect allegations and for reporting and responding to allegations of abuse or neglect. The failed practice had the potential to affect an average monthly census of six swing-bed patients and two current swing-bed patient admitted to the Swinged Program.
Findings follow:

A. There were no policies and procedures to ensure individuals were not hired or retained who had been convicted of abuse or neglect.
B. There were no policies and procedures for training staff to identify abuse and neglect.
C. There were no policies and procedures to ensure patients were protected during the investigation of abuse or neglect allegations.
D. There were no policies and procedures for conducting an investigation of abuse or neglect allegations in a timely manner.
E. There were no policies and procedures for reporting and responding to allegations of abuse or neglect.
G. Findings were confirmed in interview with the Director of Nursing at 1230 on 09/08/10.