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Based on interview and record review, it was determined that the hospital did not ensure that there is an infection control surveillance program that includes specific measures for prevention, early detection, control, education, or investigation of infections and communicable diseases.

Findings include:

1. On 2/24/10, an interview was completed with DON (Director of Nursing) with regard to who at the hospital was in charge of their infection control program. The DON stated that they didn't really have a lot of infection control tracking going on, but that the assistant DON (Employee 4) was promoted in January 2010 to be the infection control officer and would be attending the Rocky Mountain Infection Control training in March 2010. She stated that the employee health records were currently being updated, but that "not much else was being done regarding infection control." The surveyor asked the DON if she knew the number of nosocomial infections for the previous year, the DON stated she did not.

2. On 2/24/10, an interview was completed with Employee 4, the newly appointed infection control director, with regard to infection control activities being conducted at the hospital. She stated that there was no infection control log and that, "There was nothing much done on infection control." She stated that her responsibilities included being the assistant DON; she had to work the floor to cover vacations; she was responsible to complete nursing schedules and long-term care recertifications and care plans; and that she didn't have enough time to get everything done. The infection control director stated that she had received a flyer advertising the Rocky Mountain infection control seminar in March, but she didn't know if she could attend due to family conflicts. Employee 4 later that day told the surveyor she had looked at the infection control seminar flyer once again, and the infection control seminar was going to be held in May 2010, not March 2010 as she had previously thought, but that she had a possible conflict with the May date as well.

3. The state surveyor requested and received a copy of the job description for the infection control nurse. The job description states, "A report will be completed by the infection control nurse and presented to the monthly Medical Staff/hospital committee meeting." Medical Staff minutes were reviewed and there were no infection control reports made monthly.

4. Employee 4's personnel records were reviewed, and there was no evidence of specific infection control training in the record other than the initial infection control information given to all employees upon hire.

5. The hospital's infection control committee policy was reviewed. The policy stated that the infection control committee should meet once a month to report findings which included nosocomial rates on acute and long term care. There were no minutes of any infection control committee meetings.

6. Nursing Quality Assurance Report dated 2/16/10 evidenced that Employee 4 had been hired as the assistant DON and would be assuming the responsibilities of Infection Control Officer and Employee Health. The report evidenced that the infection control officer was "currently updating TB testing and hepatitis immunizations. Tracking of hospital infections has been minimal."

Based on interview and medical record review it was determined that the facility did not administer medications with current written physician orders for 3 out of 5 residents. (Resident identifiers: 1, 2, 4.)

Findings include:

1. Resident 1 was admitted to the facility on 10/26/2010 with diagnoses that included Parkinson's Disease, coronary artery disease, hypothyroidism and chronic obstructive pulmonary disease.

On 2/23/2010, resident 1's "Skilled Nursing Recertification/Continuation of Medical Orders" (SNRCMO) form that was signed and dated by the physician on 12/7/09 was reviewed. At the bottom of the form just above the physician's signature the following was documented; "I certify that I have reviewed and approved this patient's plan of care and that inpatient services are necessary for this patient. Please continue the above orders for this patient for 90 days." It was documented that resident 1 was to be administered "Spironolactone 25 mg (milligrams) PO (by mouth) BID (twice a day).

On 2/23/2010, resident 1's medication administration record (MAR) for February of 2010 was reviewed. It was documented that the resident was being administered "Spironolactone 50 mg 1 PO BID."

On 2/23/2010, the DON was interviewed. She stated that resident 1 should be getting the 50 mg dose of the Spironolactone and that it was an oversite that the increased dose was not recorded on resident 1's most current SNRCMO.

2. Resident 2 was admitted to the facility on 9/3/09 with diagnoses that included Myelodysplasia cancer, arthritis, hypertension, essential tremor and coronary artery disease.

On 2/23/2010, resident 2's MAR for February of 2010 was reviewed. It was documented that the resident was being administered Zofran 8 mg IM (intramuscular)TID (three times a day) and Lasix 20 mg 1 PO qd (every day).

On 2/23/2010, resident 2's SNRCMO form that was signed and dated by the physician on 2/18/2010 was reviewed. At the bottom of the form just above the physician's signature the following was documented; "I certify that I have reviewed and approved this patient's plan of care and that inpatient services are necessary for this patient. Please continue the above orders for this patient for 90 days." There was no documentation on the SNRCMO that resident 2 was to be administered Zofran 8 mg IM TID" nor was there an order for Lasix 20 mg 1 po QD.

On 2/23/2010, the DON was interviewed. She stated that resident 2 should be getting the Lasix and the 8 mg order of Zofran and that it was an oversite that these drug orders were not recorded on resident 2's most current SNRCMO

3. Resident 4 was admitted to the facility on 6/25/09 with diagnoses that included hypertension, congestive heart failure, anxiety and chronic obstructive pulmonary disease.

On 2/23/2010, resident 4's MAR for February of 2010 was reviewed. It was documented that the resident was being administered Theophylline 200 mg PO qd and Symbicort 160/4.5 mcg (micrograms) 2 puffs BID with a spacer.

On 2/23/2010, resident 4's SNRCMO form that was signed and dated by the physician on 12//7/09 was reviewed. At the bottom of the form just above the physician's signature the following was documented; "I certify that I have reviewed and approved this patient's plan of care and that inpatient services are necessary for this patient. Please continue the above orders for this patient for 90 days." There was no documentation on the SNRCMO that resident 4 was to be administered Theophylline 200 mg PO qd and Symbicort 160/4.5 mcg (micrograms) 2 puffs BID with a spacer.

On 2/23/2010, the DON was interviewed. She stated that resident 4 should be getting Theophylline 200 mg PO qd and Symbicort 160/4.5 mcg (micrograms) 2 puffs BID with a spacer and that it was an oversite that these drug orders were not recorded on resident 4's most current SNRCMO.

Based on interview it was determined that the facility did not have written policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Findings include:

On 2/23/2010 at 2:00 PM, the Director of Nursing (DON) was interviewed. She stated that the facility did not have written policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property. In addition, the DON was unaware that if staff were to treat a patient in an abusive manner that they would need to prevent further abuse from occurring while investigating, to thoroughly investigate the abuse and then report this to the State survey and certification agency within 5 working days of the incident.

On 2/24/2010 at approximately 10:00 AM, the Assistant DON (ADON) was interviewed. She was unaware that if staff were to treat a patient in an abusive manner that they would need to prevent further abuse from occurring while investigating, to thoroughly investigate the abuse and then report this to the State survey and certification agency within 5 working days of the incident.