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Based on observation, interview and record review, the facility failed to ensure all emergency equipment and supplies to be used in case of an emergency were available for patients in the acute care unit. Other supplies in a locked cabinet in the emergency room were available for use, but had not been checked on a regular basis and some were not in proper operating condition. This had the potential to result in poor clinical outcomes especially during an emergency situation.

Findings:

During a tour of the hospital on 6/3/19 at 4 pm, other than the crash cart in the emergency department (ED), no other crash cart was observed in the hospital. There were two acute patients in Room 4, and had one of them needed the crash cart for an emergency, the one from ED would have been brought down, leaving the ED without a crash cart.

During an interview on 6/4/19 at 9:10 am, Purchasing staff said the prior additional crash cart which had been located in the hospital was put out of service, by one of the prior directors of nurses, who said they only needed one crash cart in the ED.

During an interview on 6/4/19 at 9:15 am, the Administrator said he did not know why there was only one crash cart now when there used to be two.

During a concurrent interview and inspection on 6/4/19 at 10:10 am, ED Registered Nurse (RN) 2 said he has checked the defibrillator (machine used to deliver electrical shock to an abnormal heart rhythm) on the crash cart but not the one kept in the locked cabinet in the ED. He said he was not sure when it had last been checked.

On 6/4/19 at 10 :25 am, an intubation (a medical procedure in which a tube is placed into the windpipe, just before the lungs, to assist breathing) tray in the ED cabinet was checked by RN 2 and all the laryngoscope blades (used to visualize the throat and put a breathing tube into the lungs), except one, did not have a functioning bulb for a light source.

Based on observation and interview the hospital failed to discard expired medications when multiple medications were found expired, ready for patient use, in the hospital medication room and the Emergency Department (ED). This failure potentially exposed patients to reduced potency medications.

Findings:

During an observation on 6/4/19 at 10:12 AM in the hospital medication room there was a bottle of Niacin 1,000 mg that had expired on 05/2019. Niacin was a medication used to treat hyperlipidemia (high fat blood levels).

During an observation on 6/04/19 at 1:50 PM in the ED the following medications were found expired and ready for patient administration:

Ambien 10 mg expired 4/2019-Medication used to reduce anxiety
Aspirin 81 mg expired 5/2019-Medication used to prevent heart attacks
Ibuprofen 100 mg/5 ml 5/2019-Medication used for pain
Chewable Aspirin 81 mg expired 5/2019-Medication used to prevent heart attacks
Aspirin 325 mg expired 10/2018- Medication used to prevent heart attacks

During an interview on 6/4/19 at 1:43 PM the Director of Nursing stated she was not aware that there were expired medications readily available for patient use in the hospital medication room and the ED. She also stated that she would discard the expired medications right away.

Based on interview and record review, the facility failed to have a governing body that assumed full legal responsibility for determining, implementing, and monitoring policies governing the hospital's total operation and for ensuring that policies were administered so as to provide quality health care in a safe environment as evidenced by:

1. The facility failed to ensure all emergency equipment and supplies to be used in case of an emergency were available and in proper operating order for patients in the acute care unit. Refer to C 204.

2. The facility failed to store drugs and biologicals properly. Refer to C 224.

3. The facility failed to have rules for storage, handling, and administration of drugs and biologicals. Refer to C 276.

4. The facility had no procedure for reporting adverse drug reactions and medication errors. Refer to C 277.

5. The facility failed to develop an effective system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients. Refer to C 278 Findings 1-5.

6. The facility failed to provide care in accordance with the needs of its patients. Refer to C 294 Findings 1-3.

7. The facility failed to ensure its electronic health record (EHR) ensured the integrity of all patients' records. Refer to C 301, 307 and 308.

8. The hospital failed to ensure the care was adequately evaluated to ensure the hospital's actual practice reflected their policies and procedures, as well as state and federal regulations and the current standard of practice. Refer to C 334 and 337.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure compliance with the statutorily mandated Organizational Structure Condition of Participation.

Based on observation, interview, and record review, the hospital failed to ensure the provision of services was done in a safe manner as evidenced by:

1. The facility failed to have rules for storage, handling, and administration of drugs and biologicals. Refer to C 276.

2. The facility had no procedure for reporting adverse drug reactions and medication errors. Refer to C 277.

3. The hospital failed to have an organized infection control system. Refer to C 278 Findings 1 - 5.

4. Dietary staff failed to ensure food was handled in a sanitary manner. Refer to C 279.

5. The facility failed to provide care in accordance with the needs of its patients when nursing staff gave morphine (a strong narcotic pain reliever) to one of 14 patients (Patient 13) without a written physician's order, and no patient reassessment was done. Refer to C 294 Finding 1.

6. The facility failed to provide care in accordance with the needs of its patients when nursing staff charted different intravenous (IV) fluids in the notes as compared to the Medication Administration Record (MAR) and administered morphine with an incomplete order that did not include the frequency of administration for one of 14 patients (Patient 12). Refer to C 294 Finding 2.

7. The facility failed to provide care in accordance with the needs of its patients when one Registered Nurse (RN) 3 working in the Emergency Department (ED) did not have the qualifications as required by facility policy. Refer to C 294 Finding 3.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure compliance with the statutorily mandated Provision of Services Condition of Participation.

Based on observation, interview, and document reviews the hospital failed to handle medications in accordance to professional standards of practice as evidence by:

1. The hospital failed to administer medications as ordered when Norco (combination medication pain medication with Hydrocodone [opioid (narcotic) pain reliever] and Acetaminophen (Tylenol) 5 mg/325 mg was administered instead of the 10 mg/325 mg as prescribed. This failure resulted in a medication error in which Patient 1 did not receive their prescribed dose for over 42 days.

2. The hospital failed to administer Fluticasone (treat nasal congestion, sneezing, runny nose, and itchy or watery eyes caused by seasonal or year-round allergies) Nasal Inhaler (Flonase) in accordance to manufacturer specifications for one of one patient (Patient 1). This failure can potentially reduce the efficacy of the Fluticasone Nasal Inhaler.

Findings:

1. A review on 6/04/19 of Patient 1's clinical record indicated that the patient had the following physician orders written by Physician 1 on the following dates:

*1/24/19 Norco 5 mg/325 mg 1 tablet every 6 hours as needed for pain and 1 tablet twice daily for pain
*4/28/19 Discontinue Norco 5 mg/325 mg 1 tablet every 6 hours as needed for pain and 1 tablet twice daily for pain
*4/28/19 Start Norco 10 mg/325 mg 1 tablet every 6 hours as needed for pain and 1 tablet twice daily for pain.

A review on 6/4/19 of Patient 1's Medication Administration Records (MAR) dated 4/2019, 5/2019, and 6/2019 indicated, after the Norco dosage increase to 10 mg/325 the hospital nurses administered two tablets of the Norco 5 mg/325 mg. The Hydrocodone dose was the same, however the Acetaminophen was doubled what was ordered by the Physician. According to the MAR the hospital nurses administered the wrong dose for 42 days.

During an interview on 6/4/19 at 8:40 AM Licensed Vocational Nurse 1 (LVN 1) stated that she called the Pharmacy and the Pharmacy said they just recently received the Norco order change to 10 mg/325 mg and they will be delivering the Norco 10 mg/325 mg on 6/5/19. She also stated that she did not know why the dosage increase was not ordered sooner.

During an interview on 6/4/19 at 12:39 PM the Director of Nursing stated that she does not know why the Norco order changes were not sent to the Pharmacy. She also stated that the expectation for order changes would be to immediately send the order change to the Pharmacy for them to dispense the new medications. She acknowledged that waiting 42 days was not acceptable.

2. A review on 06/04/19 of the manufacturers insert for Fluticasone nasal inhaler indicated "USING THE SPRAY...Step 1. Blow your nose to clear your nostrils...Step 2. Close one nostril. Tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril...Step 3. Start to breathe in through your nose, and WHILE BREATHING IN press firmly and quickly down once on the applicator to release the spray...Wipe the nasal applicator with a clean tissue and replace the translucent cap..."

During an observation on 06/04/19 at 8:40 AM LVN 1 administered Patient 1's Fluticasone Nasal Inhaler (medication use for allergies) without following the above mentioned manufacturer recommended steps. LVN 1 did not administer or mention to Patient 1 to blow her nose before administration, tilt head forward, hold nostril, breath through the nose while pressing the medication sprayer, and did not wipe the nasal applicator with a clean tissue after administration.

During an interview on 06/04/19 at 11:30 AM LVN 1 stated that she did not follow the manufacturers insert guidelines when administering Fluticasone Nasal Inhaler to Patient 1. She also stated that she would review the manufacturers insert guidelines and would improve her technique in administering a nasal inhaler.

Based on interview and document reviews the hospital failed to develop and implement medication error policies and procedures when medication error reporting and analysis was not completed by hospital staff. This failure exposed patients to an increased risk of medication errors.

Findings:

A review on 6/5/19 of the hospital policy dated 8/1/15 and entitled MERP indicated "It is the policy of Surprise Valley Health Care District to prevent medication errors by implementing a plan to eliminate and/or substantially reduce medication related errors by following the...Medication Error Reduction Plan (MERP). The purpose of the program is the detection and reporting of errors or potential errors, the identification of the system causes and implementation of system changes to decrease or eliminate errors or potential errors..."

During an interview on 06/05/19 at 10:25 AM the Director of Nursing (DON) stated that there was no current active MERP program. She also stated that she has never been to a MERP meeting to review medication errors during the year she was a DON. (The MERP program was a program that reviewed and analyzed medication error data by reviewing 11 medication error processes (elements) that contribute to medication errors. The 11 elements include prescribing, prescription order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.) During an interview on 06/05/19 at 10:30 AM the Quality Manager stated that there was no active current MERP program.

A review on 06/05/19 of the medication error documents provided by the hospital indicated that there was no currently approved MERP that evaluated and assessed all of the eleven processes to identify weaknesses or deficiencies that could contribute to errors in the administration of medications.

During an interview on 06/05/19 at 10:25 AM the Director of Nursing (DON) stated that the MERP should have been reviewed at least annually to see how effective the MERP was in reducing medication errors. The MERP annual review was to measure the performance of the hospital in reducing medication errors. The DON also stated that the hospital did not review the MERP annually. During an interview on 06/05/19 at 10:30 AM the Quality Manager stated that they had not reviewed the MERP annually.

A review on 6/05/19 of the hospital MERP documents indicated that since 2015 there was no sufficient evidence that an annual review of the MERP was completed. The hospital did not implement their plan to eliminate and/or substantially reduce medication related errors.

Based on observation, interview, and document review, the facility failed to develop an effective system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients when:

1. Sharps containers a puncture-resistant and leak-proof container with a one-way top used to dispose of needles and other sharp medical instruments) were overfull in one room in the hospital and one room in the clinic, a mattress with a peeling cover and a used bedpan were both left in a patient ready room;

2. The Infection Control Nurse (ICN) did not have adequate infection control training and education, there was no current approved antibiotic stewardship protocol, there was no infection control plan that included a detailed risk assessment of the facility, no updated infection control manual, no observations of staff performing handwashing.

3. The ICN did not place a patient with a positive TB skin test in isolation pending chest x-ray results, thereby potentially exposing other residents and patients to possible TB; and

4. The ICN had no surveillance of Environmental Services (EVS) department cleaning, was not aware of the cleaning solutions used in the hospital, by all staff including nursing and EVS, and had no oversight of the instrument cleaning in central supply or the clinic; and

5. The Physical Therapist did not indicate knowledge of proper disinfection of medical equipment.

This had the potential to result in serious infections to all patients residing in the facility as well as to staff and visitors.

Findings:

1. During an observation on 6/3/19 at 1 pm, of Room 5 (an empty patient room), a sharps container on the wall was overfull, a bedpan was on the floor in the shower and the mattress lining on Bed A was peeling.

During an observation of Room 5 and a concurrent interview on 6/3/19 at 2:55 pm, EVS supervisor (EVSS) said Room 5 was ready for patients. The sharps contained was still overfull and the bedpan was on the shower floor and the mattress with the peeling liner had been covered with linens.

During an interview on 6/3/19 at 3:20 pm, the peeling mattress cover was discussed with ICN who said it could not be adequately disinfected. ICN said the bedpan should have been thrown away.

During a concurrent observation and interview on 6/4/19 at 1:25 pm, the Clinic Manager confirmed the sharps container was past full.

2.a. During an interview on 6/4/19 at 2:40 pm, the ICN said there had been no specific risk assessment of the facility, no antibiotic stewardship protocol, and the Infection Control manual had not been updated. She explained that the former Director of Nurses had been working on that, but now that nurse worked on night shift. She said she had completed mainly National Healthcare Safety Network training modules, but had no infection control certification.

2.b. ICN said she had given handwashing classes to staff but was not sure if everyone had completed the class. She said she should probably make a list of all employees to make sure all staff get this education.

3. During an interview on 6/4/19 at 2:40 pm, ICN confirmed there was a long term care resident recently admitted who tested positive for TB and was not placed in isolation pending negative chest x-rays. She wasn't sure why he was not placed in isolation, but didn't have a physician's order and wasn't sure she could do it without one. She confirmed their medical director, MD 1, would follow up on this patient in 6/2019, but had not done so as of today.

ICN later provided a policy titled "Isolation Precautions," dated 3/1/11. It indicated, "Isolation precautions are considered a nursing assessment and judgment. Delegate authority to make infection preventionist or designees responsible for making infection control decisions concerning resident placement and assignment of transmission based precautions. A resident may be placed in Isolation Precautions without a physician's order."

ICN said if both patients in Room 4 were to have nausea and diarrhea, it would be the acute care RN and the DON who would determine if the patient needed isolation and call the physician. She would not know about this until she returned to work and she worked only two days per week.

4. During an interview on 6/5/19 at 7:20 am, EVSS stated Re-juv-nal was used inside the toilet, mop water and mattress. Re-juv-nal was also in a spray bottle for use in the ED on surfaces and gurneys. EVSS said she changed the floor mop water every one to two rooms and the mop head every two rooms.

During an interview on 6/4/19 at 2:40 pm, ICN said she has not watched a complete room cleaning by EVS from start to finish and was not sure how often mop heads or mop water was changed and unsure of what product they used for cleaning. She said she had not done any surveillance for the EVS department and has not looked at any of their policies with regards to infection. ICN also confirmed she has not observed any instrument cleaning or autoclave use. She was not aware of the chemical used, Re-juv-nal in instrument cleaning and believed that was the central supply staff's responsibility and not hers.

The Re-Juv-Nal product information from the manufacturer indicated it was approved for use on floors, walls, sinks, toilets, chairs, counters, cabinets, baths, showers, and other hard surfaces. It was not approved for use on soft surfaces such as mattresses.

During an interview on 6/5/19 at 10:30 am, the Director of Nurses said the Re-juv-nal spray bottle in the Emergency Department was used to clean surfaces and gurneys. She was not aware it was approved for use on hard surfaces only and not on gurney mattresses.

5. During an interview on 6/5/19 at 3:20 pm, the physical therapist (P.T.) said he had no policy regarding cleaning his equipment (mattresses, walkers, wheelchairs, etc.). He said he uses whatever the EVS staff uses. He said he just sprays it then wipes it down.

On 6/5/19 at 3:20 pm, while at the clinic, he produced a bottle of solution with tape which indicated "One tablespoon to One quart." There was no name of the product. He said he sprays and gets it all wet and wipes it down. Original bottle directions indicated the surface must stay wet for 10 minutes, but P.T. indicated he did not know this.

The policy provided by ICN for portable equipment was undated and titled, "Disinfection of all Washable Materials Not Autoclavable." It had the following directions, "1, Spray item with cleaning solution or wipe with cleaning solution disinfectant. Allow disinfectant to set on item for 10 minutes, then wipe off."

Based on observation and document review, the facility failed to ensure it conformed with recognized dietary practices when the dietary staff used bare hands to pick up food which was served to patients and residents. This had the potential to result in cross contamination of food served to patients.

Findings:

During a tray line observation on 6/5/19 starting at 11:20 am, sliced bread, which had been buttered, was seen in a tray on the steam table. Dietary Staff A used bare hands to place the buttered bread on the trays for the residents and patients who were present in the facility.

The FDA Food Code 2-103.11 Person in Charge. "The person in charge shall ensure that:
(M) Except when approval is obtained from the regulatory agency as specified in 3-301.11(E), employees are preventing cross-contamination of ready-to-eat food with bare hands by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment."

Based on interview and record review, the facility failed to provide care in accordance with the needs of its patients when:

1. Nursing staff gave morphine (a strong narcotic pain reliever) to one of 14 patients (Patient 13) without a written physician's order, and no patient reassessment was done. This resulted in confusion over how much morphine Patient 13 received and may have contributed to her death.

2. Nursing staff charted different intravenous (IV) fluids in the notes as compared to the Medication Administration Record (MAR) and administered morphine with an incomplete order that did not include the frequency of administration for one of 14 patients (Patient 12). This resulted in confusion over exactly what drugs and biologicals Patient 12 received and had the potential to result in inadequate care.

3. One Registered Nurse (RN) 3 working in the Emergency Department (ED) did not have the qualifications as required by facility policy. This had the potential to result in inadequate care especially in a life threatening emergency involving pediatric patients.

Findings:

1. A review of Patient 13's record indicated she presented to the Emergency Department on 12/5/17 at 1:03 pm and was admitted to the hospital later that day at 8:30 pm, with diagnoses that included cirrhosis secondary to alcohol, lung disease, heart failure, high blood pressure, renal dysfunction, and low back pain. The MAR indicated Morphine 5 milligrams (mg) intravenous (IV) had been given on 12/6/19 at 12:40 am.

There was a nurse's note started at 12/6/17 at 07:30 am and signed at 11:41 am. This note indicated another RN called the physician at 7:50 am to request morphine for patient's continued stomach cramping. At 8:15 am morphine was given IV. Respirations were noted to be "slow and regular" at 8:30 am. "Will wait on vital signs until patient has had a chance to get a little rest."

A review of the physician's orders did not include another order for Morphine for the second dose given at 8:15 am and it was not signed as given on the MAR.

There was a physician's (MD 2) note dated 12/6/17 charted at 9:12 am and signed at 10:22 am. The note read: "This patient was found dead at 0940 when I went into the room."

During a concurrent interview and record review on 6/6/19 at 7:50 am, the Director of Nurses (DON) confirmed an order was needed for all medications including morphine and a reassessment was necessary and should have been done after any pain medication including morphine. She confirmed she did not know what "respiration slow and regular" meant since the vital signs (blood pressure, pulse, respirations) were not repeated after the morphine had been given. She confirmed since the note started at 7:30 am and was signed off at 11:41 am, there was no way to know the specific time each entry was entered into the Electronic Health Record since the individual entries are not times. The DON had earlier stated the RN who made this note was on vacation this week and unavailable.

A reassessment policy and medication administration policy was requested from the DON. She was also asked to check the narcotic drug record to determine how much morphine Patient 13 received.

During another interview on 6/6/19 at 11:45 am, the DON confirmed she was not able to find the narcotic sheets for Patient 13 and not able to find policies for patient reassessment.
She provided a policy relating to physician's orders.

The policy titled, "Doctor's Orders SNF/AC/ER," dated 7/26/17 was reviewed. It indicated, "1. Only authorized individuals may take telephone orders from authorized practitioners. These orders shall be signed with 5 days for SNF/Swing and 48 hours for acute. Telephone orders shall be read back documented as TO/RB. Place order in log book.. . .6. Orders for medications shall include A. Name and strength of drug B. Quantity or specific duration of therapy C. Dosage and frequency of administration D. Route of administration E. Reason, diagnosis, or indication for said orders. 7. Orders that do not include the above 5 points shall be clarified with the ordering practitioner prior to carrying out the order."

2. A review of Patient 12's record indicated she presented to the Emergency Department (ED) on 6/3/19 at 12:47 pm, treated for acute renal failure and possible sepsis and transferred to a higher level of care on 6/3/19 at 7:55 pm. A review of the physician's orders included an order for .45% normal saline solution 4000 ml, as directed, at 1:11 pm, morphine 4 mg IV, as directed, at 1:25 pm and 2:30 pm. The MAR indicated the 4000 ml .45% normal saline was given at 1:11 pm.

During a concurrent interview and record review on 6/5/19 at 9:10 am, the DON said this had been an emergency situation and the RN had received verbal orders from the physician and had entered the physician orders into the computer. She said all the orders with "as directed" were not acceptable since the ordered needed a specific frequency and time of dosage such as one time only, every two hours, etc. She confirmed the MAR indicated the IV fluids of .45% normal saline were all given at 1:11 pm and it does not include at what time each 1000 ml bag was started, as it should have. The nursing narrative notes indicated the nurse gave .9% normal saline and not .45% as was documented on the MAR.

During a later interview on 6/5/19 at 10:30 am, the DON confirmed she had spoken to the ordering physician. The order for .45% normal saline that the RN had entered into the computer was wrong and should have been .9% normal saline, which was what the physician ordered, and the patient received.

3. A copy of the Job Description for RN, revised 7/24/17 was reviewed. It required Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) required within six months of hire.

A review of RN 3's (had worked at hospital longer than two years) Human Resources (HR) file indicated her PALS card had expired 2/2019. A review of the schedule indicated she had continued to work since that time. This RN had worked 23 night shifts in 3/2019, 16 in 4/2019, and 18 in 5/2019.

During an interview on 6/6/19 at 9:55 am, the HR Director (HRD) confirmed RN 3's PALS card had expired in 2/2019. In a later interview at 11:35 am, HRD was asked why RN 3 was allowed to work with an expired PALS card. She said she had called a temporary agency to get a nurse to fill in but had been unable to get one, so it was either have no nurse at all or allow RN 3 to work with an expired PALS card.

Based on interview and record review, the facility failed to ensure its electronic health record (EHR) ensured the integrity of all patients' records.

The facility's EHR allowed medical entries to be altered by unauthorized users, entries could be altered by the original user, at a later date after the patient's discharge, and numerous individual entries in patients' records did not include the time of each entry. This had occurred since at least 12/2017 and the facility had failed to recognize these issues. (Refer to C 301 and C 307)

The facility had no policies and procedure relating to late entries, and dating and timing of entries. (Refer to C 301)

The facility was unable to locate the paper record for one of 14 patients. (Refer to C 308)

The facility's medical records supervisor did not possess the qualifications required by state law under Title 22 Section 70747(b) and the facility did not have a consultant. (Refer to C 301)

This resulted in an inability to determine what prior records, if any, had been altered, what time entries were made in records which had the potential to result in inaccurate or falsification of events and the times which they occurred, had the potential for affecting patient care that might depend on immediate response to entries, and the loss of a portion of one patient's record.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure compliance with the statutorily mandated Medical Records Condition of Participation.

Based on interview and record review the facility failed to maintain written policies and procedures that provided instructions to staff and ensured the integrity of all patients' records.

The facility's Electronic Health Record (EHR) allowed medical entries to be altered by unauthorized users, entries could be altered by the original user at a later date after the patient's discharge, and numerous entries in patients' records had no date and time of each entry. This had occurred since at least 12/2017 and the facility had failed to recognize these issues.

One of the facility's physicians also had difficulty verifying verbal orders due to a possible malfunction of the EHR for one of 14 patients (Patient 12).

The facility's medical records supervisor did not possess the qualifications required by state law and the facility had no consultant that fulfilled these qualifications.

This resulted in an inability to determine what prior records, if any, had been altered, what time entries were made in records which had the potential to result in inaccurate or falsification of events and the times which they occurred, and had the potential for affecting patient care that might depend on immediate response to entries.

Findings:

1.a. A review of Patient 12's record indicated she presented to the Emergency Department (ED) on 6/3/19 at 12:47 pm, treated for acute renal failure and possible sepsis and transferred to a higher level of care on 6/3/19 at 7:55 pm. A copy of Patient 12's EHR including nurse and physician notes was received on 6/4/19, from the Medical Records Director (MRD).

During a concurrent interview and record review on 6/5/19 at 9:10 am, with the Director of Nurses (DON) and the Administrative Assistant (AA), it was noticed the nurses note which was started on 6/3/19 at 12:47 and provided by MRD to the surveyor on 6/4/19, was different than the current note in the EHR. The DON and AA said the Registered Nurse (RN) went back into the computer and changed the notes. The current RN note, that was part of the official legal record, did not indicate that it had been changed. The start time was 6/3/19 at 12:47 pm, and the "signed by" date and time was 6/4/19 at 6:05 pm. The DON said staff should not be able to go back in and change the record and if they needed to make another note, that entry should be noted as a late entry in the EHR.

Patient 12's record with the two different RN notes was discussed with the Administrator (Admin) on 6/5/19 at 9:30 am. He went into his computer and confirmed he could go in and edit notes other users had made and doesn't know if that's because this patient's record has not been closed.

During a concurrent interview and record review on 6/5/19 at 10:10 am, the Medical Records Director (MRD) confirmed the RN went into the EHR on 6/4/19 at 6:05 pm, and changed the times he made on an entry on 6/3/19 and added more entries. Although the EHR verified the note was modified, the specific entries were not timed as to when each entry was charted. There was nothing to indicate why the note was modified and it was not noted as a late entry for the part that was modified. Policies and procedures for late entries and dating and timing of entries were requested from MRD. During another interview on 6/6/19 at 12 pm, MRD confirmed she had no policies for late entries and dating and timing of entries.

During a phone interview on 6/5/19 at 10:45 am, the facility's EHR customer representative (CR) said it could be seen in the EHR as to when the RN edited the note. She said there should be a reason entered for the edit although this was not done in this case. She said the security access can be removed to prevent edit capability for someone to change someone else's notes. Admin, with assistance, from CR then changed the security access to prevent that from happening.

During an interview on 6/5/19 at 11:36 am, Admin said he had also changed the security access to deny users the ability to edit notes that had already been signed. Now they could only add an addendum, to notes they previously entered.

1.b. There were verbal orders given by physician (MD) 2 dated 6/3/19, for Patient 12 for Morphine without the frequency of the dose. The dose was simply "as directed." Verbal orders dated 6/3/19, were for .45 % Normal saline intravenous (IV) fluids when the nurse charted he gave .9 % normal saline.

During an interview on 6/6/19 at 1 pm, MD 2 said he had ordered Morphine two different times with a "give now one time" frequency and ordered .9 % normal saline. Medical Records Assistant (MRA), who was present during this interview, pulled up the chart on the computer, and the orders had not been changed or verified by MD 2. MD 2 said his computer had not been working this morning so he had not been able to verify or correct the orders, but he had tried to do so.

The policy titled, "Doctor's Orders SNF/AC/ER," dated 7/26/17 was reviewed. It indicated, "Only authorized individuals may take telephone orders from authorized practitioners. These orders shall be signed with 5 days for SNF/Swing and 48 hours for acute. Telephone orders shall be read back documented as TO/RB. Place order in log book. Only authorized individuals may take verbal orders during an emergent situation and these orders shall be signed immediately thereafter. Verbal orders shall be read back and documented VO/RB."

2. During a review of Patient 12 and Patient 13's record it was noted that many of the nurses and physician notes were long continuous notes with entries that were not dated and timed as to when they were entered into the EHR system.

Patient 12's RN note had a start time on 6/3/19 at 12:47 and an ending time, the day after she was transferred out of the facility, on 6/4/19 at 6:06 pm. The first entry was timed at 12:47 pm. All other nine entries had the times events occurred but not times the entries were entered into the record.

Patient 13's admission assessment note was started on 12/5/17 at 8:30 pm and ended on 12/6/17 at 6:46 am. There were eight categories that were completed but the time each was entered into the EHR was not included. The RN note started 12/6/17 at 7:30 am and ended on 12/6/17 at 11:41 am. The first entry was timed at 7:30 am but the other nine entries which included details about Patient 13's death did not include the times they were actually entered into the EHR. All nine entries could have been entered right before the note was closed at 11:41 am.

During a concurrent interview and record review on 6/6/19 at 7:50 am, the DON confirmed there was no way to know what time each of the entries had been made in Patient 13's record.

Patient 13's record also included a physician's (MD 2) note dated 12/6/17 charted at 9:12 am and signed at 10:22 am. The note read: "This patient was found dead at 0940 when I went into the room." Although the start time of the note was at 9:12 am, the only event it referenced took place in the future, at 9:40 am.

During a concurrent interview and record review at 6/6/19 at 1:15 pm, MD 2 was asked to review his note which was timed at 9:12 am but referred to the patient's death which did not occur until 9:40 am. MD 2 said the facility's Electronic Health Record (EHR) was not very good. He said I can start a note and leave it open for days and continue to chart in the note before signing it.

During an interview on 6/5/19 at 10:40 am, the Administrative Assistant said, once a note was opened by a nurse or physician that note stayed open and other entries could be made in it, until the note was signed, and then it was closed to further entries at that time.

During a phone interview on 6/5/19 at 10:45 am, the facility's EHR representative confirmed the EHR does not include a date and time for each entry and once opened, the note is a continuous note until signed, then it is closed. Individual entries contained in the note are not timed.

During an interview starting at 10:10 am on 6/6/19, the MRD confirmed she was not aware of the issues regarding the ability for users to go in and modify their own notes or go in and modify someone else's notes, and unaware of the EHR's system of not including the date and time for each entry, dating back to at least 12/2017.

3. A review of the list of contracted services did not include a Registered Health Information Technician or a Registered Health Information Administrator as supervisor or consultant of the Medical Records Department.

During an interview starting at 10:10 am on 6/6/19, the MRD confirmed she was not a Registered Health Information Technician or a Registered Health Information Administrator as required by state regulation and had never asked for any type of exception or flex, from the state.

Based on interview and record review, the facility failed to ensure all entries by the physician were dated and timed. This had the potential for affecting patient care that might depend on immediate response to entries and possible inaccurate entries.

Findings:

A review of Patient 13's record indicated she presented to the Emergency Department on 12/5/17 at 1:03 pm and was admitted to the hospital later that day at 8:30 pm. There was a physician's (MD 2) note dated 12/6/17 with a start time at 9:12 am and signed at 10:22 am. The note read: "This patient was found dead at 0940 when I went into the room."

During a concurrent interview and record review at 6/6/19 at 1:15 pm, MD 2 was asked to review his note which was timed at 9:12 am but referred to the patient's death which did not occur until 9:40 am. MD 2 said the facility's Electronic Health Record (EHR) was not very good. He said I can start a note and leave it open for days and continue to chart in the note before signing it.

During an interview on 6/5/19 at 10:40 am, the Administrative Assistant said once a note is opened by a nurse or physician that note stays open and other entries can be made in it until the note was signed and then it was closed to further entries at that time.

During a phone interview on 6/6/19 at 10:45 am, the facility's EHR customer representative confirmed the EHR does not include a date and time for each entry and once opened, the note is a continuous note until signed, then it is closed. Individual entries contained in the note are not timed.

Based on interview and record review the facility filed to provide adequate safeguards against the loss or destruction of one of 14 patients' records (Patient 13). This resulted in the facility being unable to locate Patient 13's paper record which should include copies of advance directives (spells out decisions about end of life care ahead of time) or Physician Orders for Life Sustaining Treatment (POLST) form.

Findings:

A review of Patient 13's record indicated she presented to the Emergency Department on 12/5/17 at 1:03 pm and was admitted to the hospital later that day at 8:30 pm. The nurse's admission note charted at 8:30 pm on 12/5/17, indicated a Do Not Resuscitate (DNR) on file. A review of the Electronic Health Record (EHR) did not include a copy of the DNR or a physician's order for a DNR.

During an interview on 6/5/19 at 4 pm, the Administrative Assistant said a copy of the advance directive or POLST should be in the paper copy of the chart. The Medical Records Director (MRD) was asked to provide a copy of the paper chart. The Medical Records Assistant (MRA) said she would look in the storage shed where old records were kept.

During an interview on 6/5/19 at 4:30 pm, MRD said she and MRA were the only ones who could access the medical records stored in the shed, in back of the hospital. If charts were needed after hours one of them needed to be called to come in to the facility.

During an interview on 6/5/19 starting at 4:45 pm, both MRD and MRA said they were unable to find the paper copy of Patient 13's chart. They said a former employee may have scanned in some documents, but if she did, they do not have access to it. By the time of the exit on 6/6/19 at 2 pm, the record still had not been found.

Based on interview and record review, the hospital failed to ensure the care was adequately evaluated to ensure the hospital's actual practice reflected their policies and procedures, as well as state and federal regulations and the current standard of practice as evidenced by:

1. Health care policies were not evaluated, reviewed, and revised as part of the annual program evaluation. Refer to C 334.

2. Serious widespread issues regarding medical records were identified during the survey and had been occurring since at least 2017 and the QA committee had failed to recognize these issues. Refer to C 301, C 307, C 308, and C 337.

2. Quality indicators in the Human Resources department had not reached their expected goal since 1/2018 and the QA committee came up with a plan that could not be implemented. Refer to C 337.

3. Widespread issues regarding infection control and cleaning chemicals had been identified during this survey and a prior survey. The QA committee had failed to recognize these issues and act upon them. Refer to C 278 and C 337.

4. Issues regarding rules for storage, handling, and administration of drugs and biologicals and revising the emergency department policy and procedure manual had been identified in this survey and prior surveys (2018 and 2016) and the plans still had not been implemented. Refer to C 276 and C 337.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure its compliance with the statutorily mandated Quality Review and Periodic Evaluation Condition of Participation.

Based on interview and record review, the hospital failed to ensure that health care policies were evaluated, reviewed, and revised as part of the annual program evaluation. This resulted in lack of pertinent policies and policies not being current with State and Federal laws and current standards of practice which could result in patients not receiving adequate care.

Findings:

On 6/6/19, the Governing Body minutes were reviewed for the past 12 months. The minutes contained evidence of an annual review and revision of policies for the lab department only and a few policies relating to the skilled nursing part of the hospital and one hand hygiene policy.

Several specific policies were requested during the survey that were not provided including: reassessment policy for Emergency Department (ED), acute, and swing patients, ED triage, Emergency Medical Treatment and Active Labor Act (EMTALA)/Transfer, infection control policies relating to antibiotic stewardship, use of cleaning chemicals, cleaning of patient rooms, medical records policies relating to late entries and dating and timing of entries.

A review of the ED and Infection control manual contained policies that were outdated, some as far back as 2000.

During an interview on 6/4/19 at 2:40 pm, the Infection Control Nurse said the former Director of Nurses had started to update the policy manual but that nurse now worked on night shift.

During an interview on 6/6/19 at 9 am, the Administrator said when he retired in 2014, they used to bring all policies for each department to the Board every year for review. He said this has not been done for the past five years. He said "paperwork like this is not high on my priority list. I'm trying to keep this facility open for the community."

Based on interview and record review, the facility failed to have and effective quality assurance (QA) program to evaluate the quality of the treatment furnished in the facility when:

1. Serious widespread issues regarding medical records were identified during the survey and had been occurring since at least 2017 and the QA committee had failed to recognize these issues. Refer to C 300, C 301, C 307, and C 308

2. Quality indicators in the Human Resources department had not reached their expected goal since 1/2018 and the QA committee came up with a plan that could not be implemented.

3. Widespread issues regarding infection control and cleaning chemicals had been identified during this survey and a prior survey. The QA committee had failed to recognize these issues and act upon them. Refer to C 278

4. Issues regarding a medication error reduction plan and revising the emergency department policy and procedure manual had been identified in this survey and prior surveys (2018 and 2016) and the plans still had not been implemented. Refer to C 277

These failures resulted in an inability of the facility to recognize and identify problems and/or formulate a plan that could correct problems that were identified.

Findings:

1. During a concurrent document review and interview on 6/6/19 starting at 10:10 am, Quality Assurance Manager (QAM) confirmed she was also the Medical Record Director. She said they had their current Electronic Health Record (EHR) for at least the past three years. She said she was not aware of any problems identified during the survey including revision of nursing notes at a later date, the ability of unauthorized users to edit other staff's nursing notes, and the lack of dating and timing of each entry into the EHR. The Administrative Assistant confirmed during an interview on 6/5/19 at 10:40 am, and Physician 1 confirmed during an interview on 6/6/19 at 1:15 pm, that they knew about the issue of lack of timing of each entry that was made into the EHR.

2. During a concurrent document review interview on 6/6/19 starting at 10:10 am, the Quality Assurance Manager (QAM) confirmed the quality indicators for the Human Resources (HR) department included PPD (TB skin test) staff vaccination status. The compliance rate had ranged from 94% in 1/2018 to 89% in 3/2019. She said the expected compliance rate was 100%. Another quality indicator for the HR department included RN certification and competencies being updated. Compliance rate ranged from 94% to 75% in 2018 and 90 % in 2019. The goal was 100%. She was unable to explain the reason for the various compliance rates and could not explain how the above data was analyzed. She said the plan from the QA committee to fix these issues was starting in 5/2019 and staff were taken off the schedule if not up to date on TB test and not up to date on their certifications. She said the HR director (HRD) tracks this and referred to her.

A review of the job description for a RN included certification for Pediatric Advance Life Support (PALS). A review of RN 3's (had worked at hospital longer than two years) Human Resources (HR) file indicated her PALS card had expired 2/2019. A review of the schedule indicated she had continued to work since that time. This RN had worked 23 night shifts in 3/2019, 16 in 4/2019, and 18 in 5/2019.

During an interview on 6/6/19 at 9:55 am, the HR Director (HRD) confirmed RN 3's PALS card had expired in 2/2019. In a later interview at 11:35 am, HRD was asked why RN 3 was allowed to work with an expired PALS card. She said she had called a temporary agency to get a nurse to fill in but had been unable to get one so it was either have no nurse at all or allow RN 3 to work with an expired PALS card. She agreed the QA plan could not be implemented because of their staffing situation.

3.a. During a concurrent document review interview on 6/6/19 starting at 10:10 am, QAM said during the quality meetings the infection control nurse (ICN) would discussed the infections involving the acute care patients and the antibiotics used. The other quality indicators relating to infection control related to the skilled nursing unit only. She said she got the quality indicators for infection control from the ICN and that was what the quality meeting focused on. She confirmed she had not received any infection control surveillance data from the ICN for handwashing for the QA committee or infection control subcommittee. She confirmed she did not know anything about revision of the infection control manual even though that had been a deficiency in a prior survey and the QA committee was supposed to monitor to make sure it had been done.

3.b. During a concurrent document review interview on 6/6/19 starting at 10:10 am, QAM confirmed the quality indicators since 1/2018 for the housekeeping department included keeping chemicals locked up and deep cleaning of rooms. QAM was unaware the chemical housekeeping was using was not approved for all surfaces or items. It was her understanding that central supply provided housekeeping with its chemicals.

4. During a concurrent document review interview on 6/6/19 starting at 10:10 am, QAM said they had discussed the medication error reduction plan in some of the QA meetings but she had nothing specific to report about it and its development. She also confirmed the QA committee need to review the Emergency Department policy manual because it's old, but they haven't been able to arrange that yet. These had been identified in prior surveys with QA to monitor a plan of action but it had not been done.