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Based on record review, Medical Staff By-Law review and interview, the facility failed to have evidence of re-credentialing for four physician staff (#O, #P, #Q and #R) of four physicians files reviewed. Based on interview and record review the facility failed to ensure that all employees received criminal background checks and that a check of the employee disqualification list was done before hire for three of seven personnel records reviewed.
The facility census was three.

Findings included:

1. Record review of the facility By-Law Amendment titled, "Medical Staff Membership", provided by Staff N, Administrative Assistant, showed the following direction under Section 3. Conditions and Duration of Appointment:
*Reappointments shall be for a period of two calendar years.
*All applicants must complete an application stating the privileges requested by the applicant. Applicant shall only be entitled to those privileges which have been specifically requested by the applicant and approved by the Board of Trustees.
*The Credentialing Coordinator will receive all applications and will be responsible for gathering information in accordance with credentialing policy which will allow the medical staff and board of trustees to evaluate the applicant's character, qualifications, and professional standing.
*The Chief of Staff will report the medical Staff's decision to accept, defer or reject the application to the Credentialing Coordinator.
*The Credentialing Coordinator will refer the application as well as the Medical Staff's decision to the Board of Trustees for final action. When final action has been received, the Credentialing Coordinator shall be authorized to transmit this decision to the candidate and if he/she is accepted, to secure his signed agreement that he/she will be governed by these By-Laws and Rules and Regulations.

2. Record review of Physician #O's medical staff file on 03/29/11 showed Physician #O was re-credentialed and privileged as an active member of the Medical Staff from 08/23/07 to 08/23/09. Physician #O's file contained no evidence of re-credentialing after 08/23/09.

3. Record review of Physician #Q's medical staff file on 03/29/11 showed Physician #Q was re-credentialed and privileged as an active member of the Medical Staff from 09/19/07 to 09/19/09. Physician #Q's file contained no evidence of re-credentialing after 09/19/09.

4. Record review of Physician #P's medical staff file on 03/29/11 showed Physician #P was re-credentialed and privileged as an active member of the Medical Staff from 01/31/09 to 01/31/11. Physician #P's file contained no evidence of re-credentialing after 01/31/11.

5. Record review of Physician #R's medical staff file on 03/29/11 showed Physician #R was re-credentialed and privileged as an active member of the Medical Staff from 03/16/09 to 03/16/11. Physician #R's file contained no evidence of re-credentialing after 03/16/11.

6. During an interview on 03/29/11, Staff N stated that he/she had no other evidence of physician re-credentialing for Physician's #O, #P, #Q and #R. Staff N stated that they have the procedure, but it has not been followed.



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7. Missouri State Law provides the following requirements for a check of the employee disqualification list (EDL) and criminal background checks (CBC):
Prior to allowing any person who has been hired to have any contact with any patient or resident, "providers" are required to make an inquiry to the Department of Health and Senior Services whether an individual is on the EDL. Section 660.317 does not prohibit the provider from employing anyone on the EDL; it simply says the provider has to inquire.
CBC's of employees are required when--persons with criminal history not to be hired, when, penalty--failure to disclose, penalty--improper hirings, penalty--definitions--rules to waive hiring restrictions.
Entities defined as 'providers' under Section 660.317:
1. Licensed as operator under Chapter 198
2. Provide in-home services under contract with the department
3. Temporary nurse staffing agencies
4. Licensed under Chapter 197 (hospitals, ambulatory surgical centers,
hospices, home health agencies)
5. Public or private facility, day program, residential facility or specialized service operated, funded or licensed by the department of mental health
6. Licensed adult day care.

8. Seven personnel records were reviewed on 3/30/11. Three personnel records showed:
Staff B did not have a CBC or check of the EDL in his/her personnel file prior to beginning employment at the facility.
Staff S did not have a check of the EDL in his/her personnel file since being re-hired at the facility. Staff S had a previous check of the EDL on his/her initial hire in the personnel file, but then had left the employment of the facility. Upon Staff S's re-hire and current employment no check of the EDL had been done.
Staff T did not have a CBC or check of the EDL in his/her personnel file prior to beginning employment at the facility.

Based on observation the facility failed to ensure that hot water temperatures remained within a safe range for hand wash sinks in patient rooms for three rooms tested. The facility census was three.

Findings included:

1. Temperatures of hand wash sinks were taken from room 407 and 410 on 3/29/11 and the thermometer used showed the temperatures of the hot water to be 128 degrees Fahrenheit in both rooms. Neither room had patients at this time.
2. Temperatures were taken from rooms 401 and 407 on 3/30/11 and thermometer used showed the temperature of the hot water to be 134 degrees Fahrenheit in room 401, and 125 degrees Fahrenheit in room 407. Neither room had patients at this time.
3. During an interview on 3/30/11 at 11:08 AM, staff on duty (nurse and aide) at the nurse's station stated that none of the patients that day could independently use the hot water and would need staff assistance for this task.

Based on observation, interviews and record review the facility failed to provide patient care and/or interventions in accordance with the patient needs assessment and facility protocol in one of one Patient (#2) admitted with pressure ulcers. The facility census was three.
Findings included:

1. Review of the facility policy and procedure titled "Decubitus Care Protocol" reviewed 03/16/2011 showed that on admission, the patient skin status will be evaluated. The decubitus staging and treatment record will be implemented on any patient identified with decubitus. The facility decubitus care procedure required the following:
Stage I: Inflammation or reddening of skin (not broken)
- Utilize egg crate mattress (a mattress overlay to help prevent skin breakdown)

Stage II: Superficial skin break with redness of surrounding area
- Place on egg crate mattress
- Wash decubitus and surrounding areas using 4X4 gauze soaked with Normal Saline, apply Silvadene Cream to 4X4, and secure with tape to decubitus. Repeat every 8 hours for 3 days.
- After 3 days, if decubitus still present, apply DuoDerm and change every 7 days.

2. Review of Patient #2's medical record showed the patient was admitted on 03/27/2011 with the diagnosis of pneumonia and congestive heart failure. The physician's admission orders included: Activity - bed rest, and wound care to legs twice a day with peroxide, cover with Telfa pads and wrap in Kerlix.

The initial admission skin assessment completed on 03/27/2011 by a registered nurse showed the following wound assessments and treatment:
Site A: (right lower shin [leg]) Stage II (superficial skin break with redness of surrounding area), size 1 centimeter (cm) by 0.5 cm with blood drainage. Documented treatment showed: culture obtained, cleansed with hydrogen peroxide, Telfa pad and Kling wrap reapplied;
Site B (right second toe) Stage I (inflammation or reddening of the skin), size 1.7 cm by 1.8 cm, no drainage or odor. Documented treatment showed: open to air;
Site C (coccyx or tailbone area) Stage II, size 6 cm by 5.5 cm, no drainage or odor. Documented treatment showed: no orders for medication or treatment; and
Site D (crease of right buttock), Stage II, size 5.5 cm by 2.2 cm, no drainage or odor. Documented treatment showed: no orders for medication or treatment.
The wound care treatment documentation on 03/28/2011 showed the same as above for sites A, B and C and for site D, applied Telfa pad.

3. Observation on 03/30/2011 at approximately 9:20 AM, showed Staff F Registered Nurse, (RN) performed wound care to Patient #2's right lower shin (site A) and upon surveyor's request, a skin assessment of sites B, C & D was completed by Staff F. All four sites showed improvement (measurement size was decreased, areas were less red and continued with no drainage).

4. During an interview on 03/30/2011 at approximately 10:00 AM, Staff F stated that they did not have a special mattress for Patient #2 and that they did not have an egg crate mattress on the bed. Staff F stated that they were performing wound treatments twice a day on the patient's right lower leg, but were not doing any treatments to the other two Stage II areas (the patient's coccyx or right buttock crease). Staff F stated that they were assessing these areas, keeping the patient turned and repositioned and that these areas seemed to be improving.

5. During an interview on 03/30/2011 at approximately 1:25 PM, Staff A, Chief Nursing Officer, (CNO) confirmed that Patient #2's bed did not have an egg crate mattress overlay. Staff A stated that the nurses should assess the patient and call the physician to get an order per protocol. Staff A said, "They should follow the protocol as written and this applies to obtaining orders for the egg crate mattress and treatments of the Stage II ulcers".

6. During an interview on 03/30/2011 at approximately 1:30 PM, Staff D (Registered Nurse, Quality Improvement Manager) also confirmed that Patient #2's bed did not have an egg crate mattress and said, "but it should have". Staff D stated that the egg crate mattresses were kept in-house and were available for use as needed. Staff D stated that the nurses were responsible to assess the patients (initially and ongoing); to call the physician for orders per protocol; and to obtain the egg crate mattress overlays and skin/wound treatments per protocol.

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Based on observation, interviews, record reviews and review of the facility policy and procedure the facility failed to develop and/or keep current plans of care to ensure patient care, treatment and/or services were appropriately planned to meet the patient's needs for at least six patients (two current and four discharged) of 12 acute medical patients (#2, #6, #8, #9, #11 and #12) plans of care reviewed. The facility census was 3.

Findings included:

1. Review of the facility policy and procedure titled "Care Planning" dated 03/07/2011 showed that care, treatment and services were planned to ensure they were appropriate to meet the patient's needs. It was the facility policy to provide an individualized, interdisciplinary plan of care for all patients that was appropriate to the patient's needs, strengths, limitations and goals. The facility care planning procedure required the following:
- Within twenty four (24) hours of an acute admission, all patients shall have a plan of care generated by the registered nurse or the licensed practical/vocational nurse under the direct supervision of the registered nurse;
- The plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family.

The policy directed facility staff as follows:
- Care planning is based on data collected from patient assessments with integration of those assessment findings in the care planning process.
- Developing a plan for care, treatment and services that includes patient care goals that are reasonable and measurable.
- The plan of care will be individualized to the needs of the patient.
- The plan of care will be continually evaluated based on the patient's clinical condition, care goals and the plan for treatment, care and services, and revised as needed to meet the needs of the patient's changing condition.

2. Review of Patient #2's current medical record showed the patient was admitted on 03/27/2011 with a diagnosis of pneumonia and congestive heart failure. The patient's past medical history included end-stage congestive heart failure, hypertension and diabetes. The patient lived at a local nursing home.

Review of the physician admission orders included the following:
- Activity - bed rest
- Indwelling urinary catheter (a tube inserted into the bladder to assist with urination)
- Blood sugar checks four times a day with orders for sliding scale insulin
- Wound care to legs twice a day with peroxide, telfa pads and kerlix wrapping.

Observations on 03/29/2011 at approximately 9:15 AM, and on 03/30/2011 at 9:35 AM, showed Patient #2 lay in bed with labored breathing. Observations showed the patient was on complete bed rest (unable to get out of bed on her/his own and unable to re-position in bed without assistance due to weakness and difficulty breathing); and with a Foley catheter. Observation showed a skin assessment was conducted on 03/30/2011 at 9:35 AM. This skin assessment confirmed numerous areas of skin breakdown and wound care was provided to Patient #2's right lower leg.

Record review showed no documentation included in Patient #2's plan of care for activity of bed rest, Foley catheter care, diabetes with blood sugar checks and/or skin breakdown with wound care. After the surveyor brought this to the attention of facility staff, plans of care were initiated on 03/30/2011 for Patient #2 for diabetes and risk for infection related to the indwelling Foley catheter, but the plans of care failed to address the patient's activity of bed rest and/or skin breakdown and wound treatments.

3. Review of Patient #6's medical record on 03/30/11 showed no plan of care included in his/her medical record.

During an interview on 03/30/11 at 1:15 PM, Staff D, Quality Assurance Coordinator, confirmed there was no plan of care in Patient #6's medical record.

4. Review of Patient #8's closed medical record showed the patient was admitted on 10/12/2010 with the diagnoses of pneumonia and coronary artery disease. Patient #8 was discharged from the acute care unit on 10/15/2010. During record review on 03/30/2011, there was no plan of care found in Patient #8's medical record.

5. Review of Patient #9's medical record on 03/30/11 showed the patient was admitted with right lower quadrant pain and depression. Record review showed no plan of care for, or addressing depression.

6. Review of Patient #11's closed medical record showed the patient was admitted on 01/30/2011 status post fall with ongoing and increasing right hip and pelvis pain. Patient #11 complained of increased weakness, the inability to ambulate, a decreased ability to care for her/himself independently, and shortness of breath with exertion. An x-ray for Patient #11 showed a subtrochanteric fracture of the patient's right hip, non-displaced and possible loosening of her/his hip prosthesis.

Record review showed no documentation of an individualized plan of care based on the diagnosis and/or assessment and did not include personal goals or interventions for Patient #11 regarding their right hip fracture and possible loosening of the prosthesis.

7. Review of Patient #12's closed medical record showed the patient was admitted on 12/29/2010 for mental status changes, possible sepsis and cellulitis to the right upper extremity and right breast. Documentation showed Patient #12's spouse discovered the patient was quite confused. The physician's orders included activity level based on fall precautions, neurological checks (to assess confusion) every shift and Lovenox (a blood thinning medication to help prevent blood clots) injections twice a day.

Record review showed no plan of care addressing Patient #12's mental status changes and/or confusion, neurological checks, activity level to include fall precautions, and a potential risk of bleeding due to blood thinning medications.

8. During an interview on 03/30/2011 at 12:45 PM, Staff A confirmed the plans of care were not currently in the medical records and no additional plans of care were found.

9. During an interview on 03/30/2011 at 1:25 PM, Staff D confirmed the plans of care were not in the medical records and there were no additional plans of care found. Staff D stated that their quality reviews do not include whether plans of care are appropriately completed as far as she/he is aware. Staff D stated that the system has not changed for many years. Staff D stated that the charge nurse carries the plans of care on their clip boards and updates them throughout the shift as needed. Once the patient's are discharged, the plans of care are added to the patient's chart prior to closing the charts. Staff D stated that she/he did not have any answers as to why some of the medical records did not have any plans of care.