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Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on July 20, 2016, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated July 20, 2016 for Life Safety Code.

Based on observation, interview and policy review the facility failed to ensure that narcotic classified drug records of administration and waste are accurate and according to policy resulting in the increased risk for narcotic diversion. Findings include:

On 7/19/2016 at 1440 during the tour of the medication room the note book containing the count sheets for the secured narcotic drugs was reviewed.
The following was found: On 7/8/2016 Ativan 2 mg (milligrams) per 1 ml (milliliter) was removed at 2145, the patient was given 1 mg and 1 mg was wasted. Only one signature was present, the witness signature was missing.
On 2/11/2016 Dilaudid 2 mg per 1 ml was removed at 1210, the patient was given 0.5 mg and 1.5 mg was wasted. Only one signature was present, the witness signature was missing.

This finding was confirmed by Staff B at 1440, she stated "Yes. I can see what is missing. I will have to reeducate again."

On 7/20/2016 at 1500 the policy titled "Controlled Medications-Administration" #2500.1025 dated effective March 2009 on page two of three "VII. When a dose of a controlled medication is removed from the container for administration...but not given for any reason...It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose...The same process applies to the disposal of unused partial tablets and unused portions of single use ampules."

Based on interview and record review, the facility failed to provide a post anesthesia assessment prior to discharge for 2 of 5 (#12, #14) surgical patients reviewed for anesthesia recovery by a qualified practitioner resulting in the potential for poor outcomes from unrecognized anesthesia related problems for all surgical patients served by the facility. Findings include:

On 7/20/2016 at approximately 0855, while touring the surgical services area, Staff U was queried on the process of discharging a surgical patient after the recovery process. Staff U stated,"Every patient is seen by anesthesia (CRNA-certified registered nurse anesthetist) prior to discharge for a post-op assessment."

On 7/20/2016 between 1000-1630, electronic patient medical record reviews, including five surgical medical records, were conducted via facility provided super-user, Staff T. At approximately 1400, during Patient #12's medical record review, Staff T was asked to provide the post anesthesia assessment. Staff T stated, "There isn't one here."

On 7/20/2016 at approximately 1430, Patient #14's medical record was reviewed. Staff T was asked to provide the post anesthesia assessment. Staff T stated, "There isn't one available on this one either."

On 7/21/2016 at 0827, facility policy titled, "Anesthesia Care Postoperative" dated 1/2016, was reviewed. Under "Procedure", number three, policy states, "The anesthesia provider and the operating physician shall evaluate the patient prior to discharge from the recovery area."

Based on interview and record review, the facility failed to perform a comprehensive post fall root cause analysis to evaluate effectiveness of nursing care and fall prevention interventions and implement facility wide corrective actions for two (Patients #6 and #7) of two patients reviewed for falls and accidents out of a total sample of 23, resulting in the potential for similar reoccurrances.
On 7/20/16 at 0900, Resident #6 ' s clinical record, a facility " Patient/Resident Occurrence Report ( I&A) for a fall on 5/10/16 at 0805 by Patient #6, and the attached " Occurrence Reporting Follow up " , dated 5/10/16 were reviewed with Staff B, and revealed the following:
The I & A documented that Patient #6 was admitted to a swing bed with diagnoses which included Dementia, Urinary Tract Infection (UTI) and Pneumonia. The report documented that prior to the fall, Patient #6 was at high risk for falls (fall risk score of 11 or higher), had a bed alarm (personal safety device which alarms when a patient gets up) and a tab (clipped to clothing) alarm, and was agitated/combative pre-fall. Documentation noted that Patient #6 was unattended in the bathroom, unsupervised by staff, with the patient ' s spouse at the room door. The report documented, " patient has dementia. Had tab alarm on while in bed. Nursing got patient up for morning care (in the bathroom) and thought wife would help him. " Post fall risk reduction measures were documented as, " Nursing to assist patient to bathroom and stay with him instead of assuming wife will help. "
Review of patient demographics for Patient #6 revealed the patient was admitted to a swing bed in the facility on 5/9/16.
Review of Patient #6 ' s Nursing Admission assessment dated 5/9/6 documented that Patient #6 was at risk for falls with a fall risk score of 20. A Nursing Care Plan for Patient #6 documented that Patient #6 was at risk for falls related to dementia.
Review of a Physical Therapy (PT) assessments for patient #6 dated 5/10/16, and 5/12/16 revealed , " Patient is confused at this time, cannot follow simple commands, at risk for falls, ambulates (walks) with assistance only, decreased balance. "
An Occupational Therapy (OT) assessment dated 5/11/16 documented, " wife reports that he has fallen at home, Transfers to the toilet: contact guard assistance and assistive device (needed). The OT plan included, " safety awareness training. "
On 7/20/16 at 0930, when asked whether staff should leave confused Patients at high risk for falls unattended in the bathroom, and assume that a spouse would provide supervision, Staff B stated, " Most of our patients are completely oriented. It probably wasn ' t a good idea to assume that an 82 year old spouse would provide adequate supervision. " When asked whether nursing staff had provided supervision instructions to the spouse, Staff B was unable to report this had been done, and was unable to provide documentation of this upon request. When asked how root cause analysis of factors contributing to Patient #6 ' s fall, and post fall evaluation of Patient #6 ' s pre fall safety interventions and fall prevention nursing care were evaluated, and what facility wide corrective measures were put in place to prevent similar occurrences, Staff B stated, " I didn ' t do a root cause analysis. You ' ll have to ask (Staff C). " When asked whether the facility had evaluated staff education needs regarding dementia care and fall prevention, Staff B stated that Patient #6 ' s assigned nurse had received a one on one education, but was unable to provide documentation of this.
On 7/20/16 at 1000, review of Patient #7 ' s clinical record, a facility " Patient/Resident Occurrence Report ( I&A) for a fall on 5/29/16 at 2300, and the attached " Occurrence Reporting Follow up " , dated 6/1/16 were reviewed with Staff T, and revealed the following:
A Physician ' s History and Physical, dated 5/24/16 revealed that Patient #7 was readmitted to a swing bed in the facility on 5/23/16 with diagnoses which included Left Hip Fracture from a fall at home.
A Nursing Admission assessment dated 5/23/16 documented that Patient #7 was at high risk for falls with a score of 23, with an unsteady gait, needed assistance with ambulation, and was oriented and cooperative. When asked, Staff C stated that a fall risk score equal to or greater than 6 indicated the patient was at risk for falls.
A Nursing documentation/Care Plan dated 5/26/16 documented that patient #7 was prescribed an antibiotic to treat a Urinary Tract Infection (UTI).
Review of Nursing Notes for Patient #7 from 5/23/16 through 5/30 16 revealed documentation that the patient was intermittently confused on multiple occasions. When queried, Staff T stated, " A 92 year old with A UTI, often the first sign that they have a UTI is confusion and delirium. "
Review of a facility " Patient/Resident Occurrence Report ( I&A) for a fall by Patient #7 on 5/29/16 at 2300, and the attached " Occurrence Reporting Follow up " , dated 6/1/16 revealed Patient #7 was found on the floor. The report noted that Patient #7 did not have personal safety alarms and was confused at the time of the fall, and did not use the call light to call for assistance. Patient diagnoses were listed as Left hip replacement (ORIF), confusion, multiple falls, and osteoporosis. When asked whether a root cause analysis was done to evaluate the effectiveness of Patient #7 ' s facility fall prevention and nursing safety interventions, and potential staff knowledge deficits, Staff T deferred to Staff B and Staff C
On 7/20/16 at 1205 Staff B was asked whether a root cause analysis was done to evaluate the effectiveness of Patient #7 ' s facility fall prevention and nursing safety interventions, and potential staff knowledge deficits, and stated, " We didn ' t do a root cause analysis. I sent an email out to all staff about the need to watch an elderly patient more carefully if they have periods of confusion. " Documentation of this was requested but not provided by exit. Staff B stated that facility staff were not used to caring for patients with confusion, and that personal safety alarms were not readily available, as staff needed to obtain them when needed from the adjacent long term care facility.
On 7/21/16 at 1045, Staff C was asked whether a root cause analysis was done to evaluate the effectiveness of Patient #7 ' s facility fall prevention and nursing safety interventions, and potential staff knowledge deficits, and stated, " We have a good fall investigation tool that goes more into a root cause analysis of contributing factors. We need to get something like that here. We look at falls in the Quality Assurrance committee, but we don ' t evaluate root causes. I know we have work to do for that. " When asked, Staff C stated that there were two falls for swing bed patients during the month of May of 2016, out of a total of nine May swing bed patients.

Based on interview and record review, the facility failed to accurately track and trend facility acquired infections, accurately calculate facility acquired infection rates, determine a threshold for corrective action, and comprehensively evaluate facility wide antibiotic therapy for six (January 2016-June 2016) of six months of the Infection Control Program reviewed, resulting in the potential failure to effectively evaluate facility infection control practices and unnecessary antibiotic use, and implement facility wide corrective measures, with the potential to affect all patients admitted to the facility. Findings include:
On 7/21/16 at 0915, the facility infection control program was reviewed with Staff Y, who was also interviewed at this time. The following was noted:
Review of the Acute Care " Statistical Infection Control Report " for the first and second quarters of 2016 revealed documentation of one healthcare associated infection (HAI) in January 2016, zero HAI in February of 2016, zero in March of 2016, one HAI in April 2016, two HAI in May 2016 and four HAI in June 2016.
When queried, Staff Y reported that the rate of HAI was not calculated based on the month's census. When asked, Staff Y was unable to explain how she would know if an increase in HAI was due to increased census or an infection control problem. When asked how the facility's HAI rates were evaluated, and what the threshold for corrective action was, Staff Y reported that she did not know what the facility threshold for HAI was, and stated that the Infection Control Quarterly summary was taken to the quarterly Medical Staff Meeting, but that she did not attend, and was unaware of any national statistics for HAI.
Review of Infection control worksheets for the four HAI documented for June 2016 revealed three of the four HAI listed had been present upon admission into the facility, and were included in the patient's admitting diagnoses. When asked about this, Staff Y stated, "This patient got the infection in another hospital, this one got the infection in an extended care facility, and this one got one from surgery in another hospital, so all these are HAI because they were acquired in a healthcare facility." When asked, Staff Y stated she counted every infection that was acquired in any healthcare facility as part of this facility's acquired infections. When asked, Staff Y was unable to explain how this would help the facility evaluate it's own infection control practices determine necessary corrective measures.
Review of the infection rates for June 2016 revealed infection rates were as follows:
Urinary tract Infection (UTI) - 21%
Gastro-Intestinal Infections (GI) - 7%
Upper Respiratory Infections (URI) - 7%
Surgical Infections (Surg) - 7%
When asked how these rates were calculated, Staff Y stated that community acquired (CAI), and Healthcare Acquired (HAI) infections were added together to get the total number of infections, and the total number of infections of each type, both CAI and HAI, were added together and then divided by the total number of infections to get the percentage. When asked, Staff Y was unable to explain how this would help the facility identify evaluate their own infection control practices, or why the facility would need to evaluate infections that originated outside the facility, or how the facility could implement corrective measures for infections that originated outside the facility. When asked, Staff Y was unable to explain how a percentage of infections calculated this way could help the facility evaluate facility patient care practices.
On 7/21/16 at 0950, Staff Y was asked how the facility evaluated for unnecessary or ineffective antibiotic therapy. Staff Y stated that she did not provide the medical staff or quality assurance programs with data regarding unnecessary or ineffective antibiotic therapy for the acute care (inpatient) departments or for the swing beds, but that she did a quarterly report on appropriate antibiotic use in the Emergency Room (ER). A report dated 4/28/16, entitled, "Infection Prevention and Control Audit: Emergency Room for Appropriate Anti-Infective Therapy" for the assessment period of January, February and March of 2016 was provided for review and documented that antibiotic therapy in the ER was evaluated by the facility.
On 7/21/16 Staff B was interviewed regarding evaluation of HAI by the facility and stated, "Our HAI rate shouldn't include infections from other facilities." When asked about facility evaluation of unnecessary and or ineffective antibiotic therapy in the acute care or swing beds, Staff B said, "We have to be doing it. I'll ask (Staff Y)." Documentation of this was requested but not provided by exit.
On 7/20/16 at 1045, Staff C was asked to provide documentation that the facility evaluated antibiotic therapy in the acute care and swing beds for unnecessary and/ or ineffective antibiotic use, but this was not received by exit.

Based on interview and record review, the facility failed to ensure that patients admitted to swing beds were provided written information regarding their right to form an advanced directive, for two (Patients #22 and #23) of five swing bed patients reviewed, out of a total sample of 23, resulting in a potential missed opportunity to make and document advance directive care choices. Findings include:
On 7/20/16 at 1430, Patient #22 ' s clinical record was reviewed with Staff T, who was also interviewed at this time, and the following was noted;
A 5/18/16 admission demographics page noted that Patient #22 did not have an advance directive. Review of admission documents revealed that Patient #22 was her own responsible party, and signed her own consents for treatment. There was no documentation to indicate that Patient #22 had been offered information about advanced directive rights.
A Physician ' s History and Physical, dated 5/8/16 documented that Patient #22 was admitted to a swing bed in the facility for diagnoses which included Sepsis (bloodstream infection) from a perforated diverticuli with abscess (boil/ infection resulting in a hole in the large intestine) after surgery. When asked, Staff T stated that Patient #22 had abdominal surgery in another hospital, and was admitted to the facility with an " infected, draining abdominal wound. " Staff T reported that Patient #22 was alert and oriented.
A Physician ' s discharge progress note for Patient #22, dated 6/3/16 documented that Patient #22 was a " full code " (wanted cardio-pulmonary resuscitation if her heart stopped), but there was no documentation of what her choices would be regarding mechanical ventilation, tube feeding, or patient advocate in case she became incapacitated. When asked about this, Staff T stated, " Patients are given written information about advanced directives by (Staff W) when they ' re admitted. It ' s in their admission packet. "
A review of Social Work Progress notes for Patient #22 from 5/18/16 through 6/6/16 did not reveal documentation that advance directives were discussed, or that written information was provided to Patient #22 regarding advanced directives.
On 7/20/16 at 1445, the Executive Director of Acute Care Services, Staff B was interviewed, and requested to provide documentation that Patient #22 was given information regarding advanced directives. Staff B assisted with review of Patient #22 ' s clinical records, and was unable to provide any additional information. Staff B stated, " They didn't address advance directives. She should have been offered advance directives by Admissions, Social Work, and Nursing. I don ' see anything.
On 7/20/16 at 1450, review of all physician ' s orders from admission into the facility through discharge from the facility, for all recorded admissions into the facility for Patient #22 with Staff B and Staff T revealed no order for code status (what to do in case the patient ' s heart stopped). Staff B stated, " There ' s no order for full code, and no order for no code. I can ' t find it at this point. "
On 7/20/16 at 1500, Patient #23 ' s clinical record was reviewed with Staff B and Staff T, who were also interviewed at this time.
Review of a demographics page dated 4/1/16 revealed that Patient #23 was admitted to a swing bed in the facility on 4/1/16, and had no advanced directive. There was no documentation of what Patient #23 ' s choices would be regarding mechanical ventilation, tube feeding, or patient advocate in case he became incapacitated. A Physician ' s discharge summary dated 4/13/16 documented patient #23 was " Full Code " .
A Physician ' s History and Physical for Patient #23, dated 4/4/16 revealed diagnoses included Fall with Rib Fracture (broken rib), and anemia. A Physician ' s discharge summary dated 4/13/16 documented that Patient #23 was discharged to a long term care facility on 4/4/16. Review of consents and admission documents revealed Patient #23 was his own responsible party, and had signed his own consents for treatment and admission documents. When requested, Staff B and Staff T were unable to provide documentation that Patient 23 had been informed of his advance directive rights, either verbally or in writing.
On 7/20/16 at 1515, the Health Information Technology staff (Medical Records), Staff V was requested to provide documentation that Patient #23 and Patient #22 were informed of their advance directive rights, and was unable to provide any additional documentation or information.
On 7/20/16 at 1520, Staff G was asked how patients were advised of their advance directive rights, and stated, " It ' s in their admission packet. (Staff W) gives them a patient rights packet when they ' re admitted. " Staff G was asked to provide any documentation available that advance directives were discussed with Patients #22 and #23, but this was not received by the end of survey.
On 7/20/16 at 1530, Staff W was interviewed in the presence of Staff G. Staff G stated that patients who were admitted into facility swing beds were not provided the hospital admission patient rights packet, but received a swing bed packet, which was provided for review. Review of an undated facility document entitled, " Swing Bed Program " with Staff G and Staff W revealed no mention of advance directives. Review of the included section entitled, " Patient ' s Rights in Swing Beds (undated) revealed 19 rights described, but no mention of advance directives. " The last page in the packet included, " I have been informed of and received written information as follows: 1. Swing bed guide, 2, Physician Choice, 3. Patient swing bed rights, and 4. Patient swing bed contract. " Advanced Directives were not included.
On 7/20/16 at 1535, Staff W was interviewed in the presence of Staff G and said, We don ' t necessarily give swing bed patients the Patient Rights booklet. They get it if they ' re admitted through the ER (emergency room), or when they ' re admitted to an acute care bed. " When asked when Patients admitted directly into a swing bed from another hospital without going through the ER would get the booklet containing the Advanced Directive information, Staff W said, " I don ' t give it to them if they ' re admitted directly into a swing bed from another hospital. They still initial that they ' ve received advance directive rights, even if I don ' t give it to them, because everyone gets the booklet in the ER. " At this time, Staff W and Staff G were asked to provide documentation that Patient #22 and #23 did initial a document that they were given information on advanced directives, but this was not received by exit of survey.