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Based on interview, the facility failed to establish and maintain either a policy or procedure for reporting changes in ownership to the State Agency. This deficient practice had the potential to incorrectly identify or cause a delay in identification of the owners, when their identification was required to conduct routine business with the State. The facility census was eight.

Findings included:

During an interview on 02/06/18 at 10:43 AM, Staff P, Chief Operating Officer, Director of Quality, stated that the facility did not have either a policy or procedure in place that directed a process for identification for a change in ownership or for reporting that information to the State Agency.

Based on interview, the facility failed to establish and maintain either a policy or procedure for reporting changes in the principal operating official (also know as the Chief Executive Officer-CEO) to the State Agency. This deficient practice had the potential to incorrectly identify or cause delay in identification of the principal operating official (CEO), when his identification was required to conduct routine business with the State. The facility census was eight.

Findings included:

During an interview on 02/06/18 at 10:43 AM, Staff P, Chief Operating Officer, Director of Quality, stated that the facility did not have either a policy or procedure that directed a process for identification of a change in the CEO and reporting that information to the State.

Based on interview, the facility failed to establish and maintain either a policy or procedure for reporting changes in the Chief Medical Officer (CMO- a physician that provides medical direction) to the State Agency. This deficient practice had the potential to incorrectly identify or cause delay in identification of the CMO, when his identification was required to conduct routine business with the State. The facility census was eight.

Findings included:

During an interview on 02/06/18 at 10:43 AM, Staff P, Chief Operating Officer, Director of Quality, stated that the facility did not have either a policy or procedure that directed a process for identification of a change in the CMO and reporting that information to the State.

Based on observation, interview, policy review and record review, the facility failed to ensure that:
- The facility had written policies and procedures (P/P) that was up-to-date and current for the Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home care) program and periodic review of P/P for the pharmacy department. Refer to C-0395 for additional information.
- Rules for storage of controlled medications (narcotics) were followed for anesthesia carts in the operating room (OR). Refer to C-0276 for additional information.
- Infection control P/P were followed for hand hygiene and glove use. Refer to C-0278 for additional information.
- Dietary staff maintained proper food temperatures for food served to patients, staff and visitors. Refer to C-0278 for additional information.
- Dietary staff utilized proper food storage practices. Refer to C-0278 for additional information.
- Staff followed sterile technique during port (a medical appliance placed under the skin used for long-term medication, fluid, and/or nutrition administration and blood withdrawal) access. Refer to C-0278 for additional information.
- Staff performed hand hygiene after touching inanimate objects in patients' rooms. Refer to C-0278 for additional information.
- Staff did not place medications and/or medical equipment/supplies on patients' over-the-bed-tables or bedside tables without a barrier or disinfection prior to use. Refer to C-0278 for additional information.
- Staff wore gloves when starting an IV (Intravenous - a needle placed into a vein used to administer medications, fluids and nutrition). Refer to C-0278 for additional information.
- Staff did not place the end of IV tubing in their mouth to remove the blue cap at the end of the tubing. Refer to C-0278 for additional information.
- Central Sterile/OR staff properly mixed enzymatic cleaner for used OR instruments. Refer to C-0278 for additional information.
- Central Sterile/OR staff maintained the internal sterilizer without debris. Refer to C-0278 for additional information.
These deficient practices had the potential to increase the risk of infections and cross contamination to all patients seeking care/treatment at the facility and to staff, visitors and contracted staff. The facility census was eight including one Swing Bed.

Refer to the 2567 for additional information.

Based on interview and policy review the facility failed to develop and/or review policies on an annual basis for the following:
- The initial comprehensive assessment process for Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home care) patients.
- The provision of assessed activities for Swing Bed patients.
- The care planning process for Swing Bed patients.
- The Swing Bed policies, overall, since March, 2012.
RBD - Three Pharmacy policies, one Emergency Department policy and one Patient Care policy.
This had the potential to affect all Swing Bed and acute care patients treated or admitted to the facility, by failing to direct the appropriate care and services. The facility census was eight, including one Swing Bed patient.

Findings included:

1. Record review of the facility's policy titled, "Control of Documents," dated 04/25/17, showed that the review period for all patient care documents was one year.

2. Record review of the Swing Bed policy manual, on 02/08/18, showed the overall Swing Bed policy manual was last reviewed and approved in March, 2012.

3. Even though requested, the facility failed to provide policies for Assessment for Activities, Swing Bed Activity Provision Documentation, and Swing Bed Care Planning.

During an interview on 02/08/18 at 10:04 AM, Staff H, Swing Bed Activity Coordinator, stated that she was unaware of any Swing Bed polices.

4. Record review of the facility's policies titled, "Standard Operating Procedures for Sterile Compounding," and "Pharmacy Cleanroom," showed that the pharmacy policies were last reviewed on 08/05/14.

5. Record review of the facility's policies titled, "Controlled Substances Distribution and Diversion Prevention," and "Medication Station," showed that the pharmacy policies were last reviewed on 05/09/16, and expired on 07/11/17.

During an interview on 02/07/18 at 3:15 PM, Staff II, Director of Pharmacy, stated that Pharmacy policies should be reviewed annually.

6. Record review of the facility's policy titled, "Scope of Services/Plan of Care," showed that the ED policy was last reviewed on 05/05/16, and expired on 05/20/17.

7. Record review of the facility's policy titled, "Care of Vascular Access Devices," showed that the Patient Care policy was last reviewed on 05/27/16, and expired on 05/27/17.

During an interview on 02/08/18 at 3:40 PM, Staff GG, Chief Nursing Officer, stated that she was aware that many policies needed to be updated/reviewed.


29047

Based on observation, interview and record review and policy review, the facility failed to secure scheduled drugs (also known as a controlled substance, drugs that pose a high risk for theft and misuse) or drugs that were managed by the facility as scheduled drugs, were secured in the Operating Room (OR) to prevent theft and misuse. This had the potential to allow for diversion (theft for personal use) of the drugs to anyone who had access to the OR. The facility census was eight. The facility performed approximately 30 procedures per month in the OR.

Findings included:

Record review of the facility's policy titled, "Security of Medications - Anesthesia Carts," dated 06/14/17, showed that scheduled drugs shall be locked within a secure area regardless of whether a patient care area is staffed or actively providing patient care.

Observation of the OR (only one OR in the facility) on 02/07/18 at 9:40 AM, showed an unlocked medication cart, which contained the following:
- Propofol (medication used to cause decreased level of consciousness and sleepiness during surgical procedures) 20 milligrams (unit of measure) per milliliter (ml, unit of measure) in a full 20 ml syringe.
- 14 bottles of unopened Propofol, measuring 20 ml each.
- Fentanyl (scheduled drug, used to provide pain relieve during surgery), 50 micrograms (mcg, unit of measure) per ml, in a full five ml syringe.

During an interview on 02/07/18 at 10:00 AM, Staff AA, Certified Registered Nurse Anesthetist (CRNA) stated that the medication cart was always locked when she was not in the OR, "because I have Propofol in here," and added that she never stored scheduled drugs inside the medication cart.

During an interview on 02/07/18 at 10:00 AM, Staff X, OR Manager, stated that Propofol was treated as a scheduled drug, and manually counted daily to prevent diversion.

During an interview on 02/06/18 at approximately 1:30 PM, Staff II, Director of Pharmacy, stated that Propofol was treated as a scheduled drug, because it was high risk for theft.

During an interview on 02/08/18 at 9:15 AM, Staff II stated that Fentanyl and Propofol should be secured in the OR when not in use by the CRNA.

Based on observation, interview, and policy review the facility failed to:
- Perform hand hygiene (wash hands with soap and water or use alcohol-based hand sanitizer) after they touched inanimate objects, and before they completed a patient care task for five patients (#2, #3, #4, #11, and #22) of seven patients observed for infection control.
- Perform hand hygiene before accessing two blood bags for one patient (#4) of one patient observed receiving a blood transfusion.
- Ensure staff did not place medications or supplies directly on two patients' (#2 and #11) contaminated over-the-bed tables or bedside table, without disinfection or barrier, out of five patients observed receiving medications, and four patients with IV's (Intravenous - a needle placed into a vein used to administer medications, fluids, blood and nutrition).
- Ensure staff wore gloves when starting an IV for two patient (#10 and #11) of three patients observed with new IV insertions.
- Ensure staff did not place the end of IV tubing in their mouth to remove the blue cap at the end of the tubing while inserting an IV for one (#11) of two patients observed with new IV insertions.
- Utilize sterile (free of bacteria or other living organisms) technique when accessing one patients (#10) port-a-cath (port, device placed under the skin of the chest, used to draw blood or administer medications), of one patient port access observed.
- Ensure proper concentration of enzymatic cleansers (cleaner used to soak surgical instrument, to remove blood and organisms, prior to the sterilization process).
- Ensure one sterilizer (used to removed all living microorganisms from surgical instruments) was clean and free of residue of one sterilizer observed.
- Kitchen food was stored at appropriate temperatures, not expired, dated with open dates, and prevented contamination through splash or spill.
- One patient test tray was served at temperatures that were palatable, of one tray tested.
- Kitchen sanitation was maintained to prevent contamination of food and items used during food preparation.
These failures had the potential to increase the rate of facility-acquired infections for all patients, visitors and staff. The facility census was eight. The Operating Room (OR) performed approximately 30 procedures per month. The kitchen served approximately seven patient meal trays per day.

Findings included:

1.Record review of the facility's policy titled, "Hand Hygiene-CDC [Centers for Disease Control] Guidelines," approved 08/29/17, showed the following:
- All staff should use hand hygiene before each patient encounter, before applying gloves, after contact with medical equipment/supplies in patient areas, and after removing gloves or facemask.
- All staff should follow standard precautions (basic infection control practices to protect patients and staff from contamination and spread of disease/infection).
- Performance Improvement activities shall be conducted to monitor organizational goals for compliance with hand hygiene.

2. Record review of Patient #4's electronic medical record (EMR) showed she was admitted to the facility on 02/05/18 with complaints of pneumonia and weakness.

3. Observation on 02/06/18 at 1:17 PM showed:
- Staff G, Registered Nurse (RN), went into the laboratory department to retrieve blood products for the patient. Staff G and Staff EE, Laboratory Technician, put on gloves but did not perform hand hygiene prior to putting on the gloves.
- Staff EE retrieved a bag of blood from the blood bank and handed the bag to Staff G.
- After Staff EE and Staff G confirmed the blood was for the patient, Staff G took the bag of blood and exited the laboratory department and walked down the hallway and into the patient's room.
- Wearing the same pair of gloves, Staff G reached into her pocket and retrieved a pen to document on the blood administration record.
- Wearing the same gloves, Staff G cleaned off the IV port and unhooked the IV solution hanging and touched the IV pole (equipment used to hold in place the IV pump - an electronic machine that can be programmed to infuse medications, fluids, nutrition and blood products at a prescribed rate).
- Wearing the same pair of gloves, Staff G removed the IV tubing from the package for the blood and inserted the tubing into the bag of blood and primed the tubing with blood.
- Wearing the same pair of gloves, Staff G reached into her pocket and removed an alcohol wipe and cleaned the IV port and connected the tubing into the IV pump and programmed the pump to deliver the blood at the prescribed rate.
- Staff G removed her gloves but did not perform hand hygiene.
- Staff G then touched with her bare hands the patient's over-the-bed table, bed controls, assisted the patient into a sitting position and touched various pillows on the bed.
- Staff G then placed her stethoscope (a medical instrument used to listen to a patient's heart, lung sounds and abdomen) on the patient's chest and bare back. Staff G did not clean her stethoscope before or after she used it on the patient.
- Staff G then touched with her bare hands the computer screen, typed on the keyboard, computer mouse, blood pressure machine, and thermometer.
- Staff G then reached into her pocket and retrieved a pen and documented on the blood administration record the patient's vital signs (heart rate, respirations and blood pressure).
Staff G did not perform hand hygiene before she put on or removed gloves and touched numerous items in the patient's room.

During an interview on 02/06/18 at 2:25 PM, Staff G, RN, stated that hand hygiene should be performed before and after entry into a patient's room. Staff G stated that gloves should be used with any body fluids/blood. Staff G stated that she did not know if the facility's policy and procedure directed staff to perform hand hygiene after glove removal or not.

4. Observation on 02/07/18 at 9:55 AM, showed the following:
- Staff N, RN, washed her hands, gloved and entered Patient #4's room.
- Staff N put a unit of blood on the in-room computer (contaminated).
- Staff N then handled the patient's telephone, over-the-bed table, hanged an IV bag of saline (a mixture of water and salt that is most like normal body fluids), touching multiple old tubings, the IV pole and IV pump.
- Staff N then typed on the computer keyboard, handled the mouse and put the blood bag and new tubing on the over-the-bed table, without sanitizing it first.
- Staff N then removed the old tubings, used IV bags.
- Staff N accessed the blood bag with the new tubing and spike, with the same contaminated gloves. Staff N failed to remove her gloves and perform hand hygiene.

During an interview on 02/07/18 at 10:20 AM, Staff N stated that housekeeping cleaned each room daily, which included the surfaces, and computer equipment. The computer equipment was not cleaned again until the next day.

5. During an interview on 02/08/18 at 10:27 AM, Staff O, Laboratory Director, Infection Control Preventionist, stated the following:
- Staff should perform hand hygiene before handling medications and accessing a blood bag.
- Staff should perform hand hygiene when changing gloves.
- Staff had been conducting random surveillance of compliance with hand hygiene, approximately 50 observations per month, of staff entering and exiting patient rooms.
- No bedside observations of staff had been completed to determine compliance with hand hygiene.

During an interview on 02/08/18 at 10:51 AM, Staff O, stated that if the laboratory technician put on gloves to get into the blood bank, she should have performed hand hygiene before she put on the gloves.

6. Record review of Patient #22's EMR showed he was admitted to the facility on 02/08/18 for complaints of difficulty with breathing.

Observation on 02/08/18 at 10:19 AM showed:
- Staff Q, RN, entered the patient's room to draw blood and start an IV.
- Staff Q performed hand hygiene and put on a pair of gloves.
- Staff Q placed three blood tubes, IV needle and IV tubing on the patient's over-the-bed-table but did not disinfect or place a barrier on it before she placed the various medical equipment/supplies on it.
- The patient's over-the-bed-table had on it a hospital gown, the patient's cane, a can of soda pop, Kleenex box, water picture, blanket and a used Kleenex.
- Staff Q inserted the IV needle and obtained blood for the three blood tubes.
- Staff Q placed the three blood tubes on the patient's bedside table without disinfecting or placing a barrier on it before she used it.
- Staff Q removed her gloves, did not perform hand hygiene, put on another pair of gloves and obtained a nasal swab from the patient to rule out if he had the flu.
- Wearing the same pair of gloves, Staff Q pulled up the patient's shirt to assess his back due to the patient reported a rash that could be shingles (a painful nerve root infection that causes blisters and rash and is caused by the same virus as chickenpox).
- Staff Q removed the glove from the left hand but did not perform hand hygiene after she removed the glove.

During an interview on 02/08/18 at 10:51 AM, Staff O, Laboratory Director, Infection Control Preventionist, stated that staff should not place blood tubes, IV and IV equipment on patients' over-the-bed-table or bedside table without prior disinfection or a barrier before use.

During an interview on 02/08/18 at 11:27 AM, Staff Q, RN, stated that staff do not normally have a barrier on patient's over-the-bed table or bedside table when they place various medical equipment/supplies on them but probably staff should use a metal tray to place needed medical equipment/supplies on when going into a patient's room to perform a procedure. Staff Q stated that the metal trays should be cleaned before taking them into a patient's room for use. Staff Q stated that hand hygiene should be performed prior to room entry, before/after glove change and after leaving a patient's room.

7. Record review of Patient #2's EMR showed she was admitted to the facility on 02/05/18 with complaints of Chronic Obstructive Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and influenza (a highly contagious viral infection of the respiratory passages that causes fever and severe aching).

Observation on 02/07/18 at approximately 9:00 AM showed Staff F, Licensed Practical Nurse (LPN) entered the patient's room to administer morning medications. Staff F opened four oral medications and placed them onto the patient's over-the-bed-table. The patient picked up the medications and placed them into her mouth. Staff F did not disinfect or place a barrier on the over-the-bed-table before she placed the medications on it.

During an interview on 02/08/18 at 10:51 AM, Staff O, Laboratory Director, Infection Control Preventionist, stated that nursing staff should use a medicine cup to administer medications and not placed on the patient's over-the-bed-table.

8. Observation on 02/05/18 at 4:05 PM showed:
- Staff I, Certified Nursing Assistant (CNA), performed a blood glucose test (finger stick blood sugar: FSBS a drop of blood used to test the level of sugar in a person's blood ) for Patient #2.
- Staff I assembled supplies needed for the procedure onto a metal tray.
- Staff I put on gloves but did not perform hand hygiene prior to putting on the gloves.
- Wearing the same gloves, Staff I went into the patient's room and opened up the patient's electronic medical record (EMR) on the computer.
- Staff I scanned the patient's ID (Identification Bracelet - information that identifies the patient per name and date of birth) bracelet, performed the FSBS test on the patient and typed the results into the computer.
- Wearing the same gloves, Staff I walked out of the patient's room but did not perform hand hygiene when she exited the room.
- Staff I did not clean the metal tray after she exited the patient's room.
- Staff I removed her gloves but did not perform hand hygiene before she entered the next patient's room.

9. Observation on 02/05/18 at 4:14 PM showed:
- Staff I, CNA, performed a FSBS test for Patient #3.
- Staff I assembled supplies needed for the procedure onto a metal tray.
- Staff I put on gloves but did not perform hand hygiene before she put on the gloves
- Wearing the same gloves, Staff I went into patient's room and opened up the patient's EMR on the computer.
- Staff I scanned the patient's ID bracelet, performed the FSBS test on the patient and typed the results into the computer.
- Wearing the same gloves, Staff I walked out of the patient's room but did not perform hand hygiene when she exited the room.
- Staff I did not clean the metal tray after she exited the patient's room.
- Staff I removed her gloves but did not perform hand hygiene after removal.

During interview on 02/05/17 at 4:25 Staff I stated that she did not know she should perform hand hygiene before putting on gloves or taking them off. Staff I stated that she did know to use hand sanitizer upon entering and exiting a patient's room but thought that was just when you did not wear gloves. Staff I stated that she did not know she should not touch items in the room with the same gloves she was wearing to perform the glucose check.

10. Record review of the facility's resource Lippincott Manual of Nursing Practice 10th Edition staff used for venipuncture (IV - a needle placed into a vein, used to administer mediations, fluids, nutrition and/or blood) access showed directives for staff to wear gloves during the procedure.

11. Record review of Patient #11's EMR showed she was admitted to the facility on 02/06/18 with complaints of COPD and heart failure.

Observation on 02/08/18 at 1:39 PM showed:
- Staff CC, RN, entered the patient's room to start an IV and put the IV needle, IV tubing and other supplies on the patient's over-the-bed-table without disinfection or a barrier prior to use.
- Staff CC did not put on gloves when she inserted the IV needle into the patient's skin.
- Staff CC placed the blue cap at the end of the IV tubing into her mouth to hold the tubing in place, then removed the blue cap from her mouth and from the end of the tubing and screwed the IV tubing into the IV needle used to administer fluids and medication to the patient per her vein.
- Staff CC then without gloves programmed the IV pump to infuse the medication at the prescribed rate.
- Staff CC then put on gloves but did not perform hand hygiene prior to putting on the gloves and emptied the urine hat (a medical device that measures urine output) in the patient's restroom.

During an interview on 02/08/18 at 1:39 PM, Staff CC, RN, stated that she should have worn gloves when she started the patient's IV and she should not have placed the blue cap at the end of the IV tubing in her mouth. Staff CC stated that she did not know when the last time the patient's over-the-bed-table had last been cleaned and that she probably should not have put medical equipment/supplies on it without a barrier or being cleaned first.

During an interview on 02/08/18 at 2:04 PM, Staff DD, LPN, stated that she only wiped off patients' over-the-bed-table if it was dirty.

During an interview on 02/08/18 at 1:10 PM, Staff HH, Housekeeper, stated that it was her responsibility to wipe down patients' over-the-bed-tables and bedside tables. Staff HH stated that she wiped down those surfaces daily when she cleaned the room.

During an interview on 02/08/18 at 2:34 PM, Staff O, Laboratory Director, Infection Control Preventionist, stated that:
- It would not alarm her if she saw staff starting an IV without wearing gloves or a finger outside the glove if the patient was considered a "hard stick" .
- It is not an acceptable practice for staff to place the blue cap at the end of IV tubing into their mouth to remove it and hook the tubing into the IV catheter.
- The facility does not have an environmental policy related to touching inanimate objects in a patient's room and when hand hygiene should be performed after touching various items in the room.

12. Observation on 02/05/18 at 3:10 PM, showed Staff D, Emergency Department (ED) RN changed gloves three times without performing hand hygiene, and when she drew blood from Patient #10, removed one of her gloves and then accessed the patient's vein with a needle, potentially exposing Staff D to blood.

During an interview on 02/06/18 at 9:28 AM, Staff D stated that she should have performed hand hygiene between glove changes, and that removing her glove when she accessed Patient #10's vein to draw blood, was not an approved procedure.

During an interview on 02/08/18 at 3:51 PM, Staff GG, RN, Chief Nursing Officer, stated that:
- There is room for improvement with infection control observations.
- Her expectation from nursing staff when starting an IV was that staff should wear gloves.
- She expected staff to administer medications per medication cups and not place medications on patients' over-the-bed-table.
- She expected staff to either use a metal tray or IV caddy (container that holds various items needed to start an IV) and not place IV equipment/supplies on either the patient's over-the-bed-table or bedside table.

Although requested, the facility failed to provide a policy related to the proper technique to be used when a port-a-cath was accessed.

13. Observation on 02/05/18 at 3:10 PM, showed Staff D, ED RN:
- Put on sterile gloves and then touched a non-sterile syringe, which made her gloves no longer sterile.
- Placed a sterile port access device on a non-sterile stainless steel stand, which made the access device no longer sterile.
- Accessed Patient #10's port with the non-sterile gloves and non-sterile access device.

During an interview on 02/18/18 at 9:00 AM, Staff D stated that she managed port access as a aseptic technique (clean, and not sterile), like she would for an IV catheter. Staff D stated that she accessed one to two ports per month.

14. Record review of the facility's policy titled, "Infection Prevention and Control Plan," approved on 08/29/17, showed the following:
- One of the facility's goals is to improve compliance with hand hygiene.
- Surveillance will be conducted to monitor the handwashing practices of direct care staff.
- The Infection Preventionists, in coordination with hospital staff, shall continuously review and evaluate infection prevention and control practices.

Record review of the facility's policy titled, "Infection Prevention and Control Measures - Surgical Services," dated 10/30/17, showed that all surgical instruments shall be sterilized according to published guidelines.

Observation on 02/07/18 at 11:00 AM of Sterile Processing, along with concurrent interview, showed Staff LL, Sterile Processing Technician, demonstrated the mixing of the enzymatic cleanser to soak surgical instruments. Staff LL stated that she mixed three pumps of the enzymatic cleanser to seven gallons of water, as per the manufacturer's instructions. Observation of the cleanser bottle showed mixing instructions for one-half ounce of cleanser to one gallon of water. There was no water line marked on the soak sink to ensure the concentration was correct, and when Staff LL measured three pumps, it equaled three ounces, which should have been mixed with six gallons of water and not seven, as she previously stated.

During an interview on 02/07/18 at approximately 11:10 AM, Staff JJ, OR RN and Infection Preventionist, stated that the sink in Sterile Processing should be marked with a water line to ensure accurate concentration.

Record review of facility policies showed no policies related to the cleanliness of the sterilizer.

Observation on 02/07/18 at approximately 11:20 AM of Sterile Processing, along with concurrent interview, showed the interior of the sterilizer to contain multiple (greater than five), various sized reddish, blackened areas, that when wiped with a damp cloth removed reddish colored residue. Staff X, OR Manager, believed the areas were tape that had adhered to the inside of the sterilizer, and were not of concern.

Record review of the facility's form titled, "Infection Prevention Goals," dated 2017, showed that Infection Prevention surveillance would be conducted two times per year, in each department, by Staff O, Laboratory Director and Infection Control Practitioner and Staff JJ, OR RN and Infection Preventionist.

Record review of the facility's form titled, "Environmental Rounds Worksheet for Infection Prevention - OR," dated 04/2017, showed that a second Environmental Round was not completed for the 2017 year, as indicated would be done per the Infection Prevention Goals.

16. Record review of the facility's policy titled, "Food Storage," dated 10/27/15, showed that:
- All containers of food were to be stored above the floor, 12 inches or above, to be protected from splash and other contamination.
- Cool storage facilities must be constructed, insulate and installed as to insure the maintenance of a temperature range of 33-40 degrees.
- The temperature of all cool storage facilities should be checked and the temperature recorded on the temperature log form every 24 hours. Any deviations from the normal temperature are reported and action recommended or taken.
- A storage guide for perishables showing approximate storage life is available at the end of this policy (there was no guide provided with the policy or as an attachment to the policy).

Observation on 02/08/18 at 9:30 AM, of the facility kitchen, with concurrent interviews with Staff V, Director of Dietary and Staff KK, Dietary Manager, showed the following:
- One bag of marshmallows, opened, without an open date;
- Three boxes of instant potatoes which expired on 01/2018;
- Three onions, uncovered in a bin, stored approximately six inches above the floor, and not protected from splash or spill;
- Five bowls of cereal, stored in individual serving bowls, without open dates;
- Pans stored inverted on a wire rack approximately six inches above the floor, which were not protected from splash;
- Six individually wrapped pieces of bread without open dates;
- One opened tub of ham salad dated "2/3" as the open date (five days old), which per Staff KK would be good until the manufacturer's expiration date of 03/01/18, as printed on the tub.
- An uncovered, handmade, wooden box which was not a smooth, cleanable surface, and contained dirt and debris in the bottom along with stored pot and pan lids.
Staff KK added that the facility did not have a guide as to how long opened foods were good for, because the leftover foods were used so quickly.

Record review of a document provided by the facility titled, "Food Storage Guide," dated 01/2018, showed that bread was good for three days, and prepared deli vacuum-packed products (ex: ham salad) was good for three to five days once it was opened.

Record review of the form titled, "Daily Temperature Record: Walk-in-Cooler," dated 2018, showed that the expected temperature range was between +32 to 40 degrees, and to report immediately if the temperature was above 40 degrees or below 34 degrees. If the temperature was above 40 degrees, a "Corrective Action Form" was to be completed. The following dates showed out of range temperatures without supporting documentation that it was reported or corrected:
- 01/02/18 - 41 degrees;
- 01/05/18 - 42 degrees;
- 01/08/18 - 41 degrees;
- 01/18/18 - 41 degrees;
- 01/25/18 - 42 degrees; and
- 01/27/18 - no temperature recorded.

During an interview on 02/08/18 at approximately 10:30 AM, Staff V, Dietary Director, stated that:
- All items should be labeled with an open date, once they are opened.
- The expired instant potatoes should have been removed from stock and discarded.
- All food should be stored eight inches off the floor.
- She did not realize that the facility policy stated food should be stored 12 inches or above.
- She had not thought about the risk of splash to the inverted pans stored on the wire rack approximately six inches off the floor.
- Opened meat salads (such as ham salad), would not be good until the manufacture's date as stated by Staff KK. Once it was opened, the ham salad would be good for three to four days.
- Kitchen staff had overlooked the wooden box and the dirt and debris inside, and it needed to be removed from use.
- Temperature variances were likely because the temperature was checked after the door of the cooler door had been opened.

Record review of the facility's form titled, "Infection Prevention Goals," dated 2017, showed that Infection Prevention surveillance would be conducted two times per year, in each department, by Staff O, Laboratory Director and Infection Control Practitioner and Staff JJ, OR RN and Infection Preventionist.

Record review of the facility's form titled, "Environmental Rounds Worksheet for Infection Prevention - Dietary," dated 05/2017, showed the following findings:
- Missing (cooler or freezer) temperatures;
- No corrective action on cooler temperatures greater than 40 degrees; and
- "How do they check temperatures when the patient gets their food?"
A second Environmental Round was not completed for the 2017 year, as indicated would be done per the Infection Prevention Goals.

Observation on 02/07/18 at 11:50 AM, along with concurrent interview of Staff KK, Dietary Manager, showed a patient meal tray, with the following temperatures outside of the normal range of 140 or greater, as verified by Staff KK:
- Ham Steak 117 degrees;
- Sweet potato 115 degrees;
- Cabbage 129 degrees.
Staff KK stated that they had received patient complaints about food not being hot enough, and although they previously tested patient trays for temperatures, had stopped doing it for unknown reasons.



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29047

Based on interview and record review the facility failed to:
- Complete a comprehensive quality of life activities assessment which identified specific, individualized, activity interests for one of one current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home care) patient (#12) reviewed and for four of four discharged Swing Bed patients reviewed (#10, #14, #15, and #21).
- Provide specific, individualized activity interests that stimulated the patient's physical and mental well-being for one of one current Swing Bed patient (#12) reviewed and for four of four discharged Swing Bed patients reviewed (#10, #14, #15, and #21).
- Document the provision of individualized, stimulating activities for one of one current Swing Bed patient (#12) reviewed and for four of four discharged Swing Bed patients reviewed (#10, #14, #15, and #21).
- Develop a monthly activity calendar.
This had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census was eight, including one Swing Bed patient.

Findings included:

1. Even though requested, the facility failed to provide policies regarding the assessment, provision, and documentation of Swing Bed activities.

2. Record review and concurrent interview on 02/08/18, at 10:04 AM, showed the following:
- Staff H, Activity Coordinator, stated that she did not develop a monthly, overall patient activity calendar.
- Staff H was not aware of any Swing Bed policies that direct the assessment, provision or documentation of activities.
- Staff H worked Monday through Friday, and nursing was to complete her duties in her absence.
- Staff H asked each patient what kinds of hobbies/interests would pass the time while hospitalized. Staff H failed to assess pre-hospitalization physical activities such as shopping, crafts, swimming, choir, dining out, walking, golf, gardening, traveling, volunteer work, etc.
- The average Swing Bed census was six to eight patients monthly, with average length of stay of two weeks.
- An activity assessment form, that identified hobbies/interests and appropriate activities, was not included and/or documented as part of the patient's record.

3. Record review of current Patient #12's History and Physical (H&P) showed:
- He was admitted to the Swing Bed Unit on 02/02/18 for care, to include physical and occupational therapy, following a pulmonary embolism.
- He was alert and oriented.
- He was capable of activities as tolerated.

Record review of the patient's initial activity assessment dated 02/02/18 showed he liked to watch westerns and golf on television, read the newspaper, and magazines.

Record review of the patient's activity participation documentation showed:
- On 02/05/18 the patient was visiting with friends and relatives by telephone.
- He watched television when not in therapy, date unknown .
- On 02/06/18 his wife was visiting.

4. Record review of discharged Patient #14's H&P dated 09/07/17, showed the following:
- She was admitted to Swing Bed on 09/06/17 for incisional care related to a recent heart surgery, and physical/occupational therapy (strengthening of upper/lower body).
- She was alert and oriented.
- She was capable of activities as tolerated.

Record review of the patient's initial activity assessment dated 09/07/17, showed she liked to watch television, and read.

Record review of the patient's activity participation documentation showed the following:
- On 09/07/17, Staff H, provided wordfind puzzles for the patient to work on.
- Family and friends visited, date unknown.
- The patient received several cards in the mail, date unknown.
- On 09/12/17, the patient's husband visited.
- On 09/13/17, a newspaper was provided.
- On 09/14/17, the patient's husband visited.
- On 09/15/17, the patient was packing up to go home.

5. Record review of discharged Patient #15's H&P dated 08/09/17, showed the following:
- He was admitted to Swing Bed on 08/08/17 for a recent stroke and physical/occupational therapy.
- He was alert and oriented.
- He was capable of activities as tolerated, out of bed with assistance.

Record review of the patient's initial activity assessment dated 08/08/17, showed he liked to watch television, and read.

Record review of the patient's activity participation documentation showed the following:
- On 08/08/17, Staff H provided sudoku puzzles, and took a radio into the patient's room.
- The patient was sitting up in a chair, date unknown.
- The patient was assisted back to bed, date unknown.
- On 08/09/17, the patient was assisted to the toilet and back to bed.
- The patient was assisted up in a chair, date unknown.
- On 08/09/17, a newspaper was provided.
- The patient had lots of company, date unknown.
- The patient's wife visited, date unknown.

6. Record review of discharged Patient #10's H&P showed:
- She was admitted to the Swing Bed Unit on 01/09/18 for care, to include physical and occupational therapy, following a Craniotomy (surgical removal of a portion of skull bone to access the brain) due to cancer that had spread to her brain.
- She was alert and oriented
- She was capable of activities as tolerated.

Record review of the patient's initial activity assessment dated 01/10/18 showed she liked to watch the hallmark channel on television, play solitaire on her tablet, read the newspaper, and magazines.

Record review of patient's activity participation documentation showed:
- 01/11/18, the patient's husband visited.
- 01/12/18, mail was delivered and she was visiting with a friend on the phone.
- 01/13/18, sitting up in recliner made comfortable with pillows.
- 01/14/18, sitting up in recliner.
- 01/15/18, patient's husband is here to visit.
- 01/16/18, delivered mail to patient.
- 01/19/18, patient received mail today
- 01/22/18, on phone with friend today
- 01/23/18, patient's husband took her home for occupational therapy home survey.
- 01/24/18, delivered weekly newspaper for patient to read.

7. Record review of Patient #21's H&P showed:
- She was admitted to the Swing Bed Unit on 11/19/17 for care, to include physical and occupational therapy, following right total hip arthroplasty (surgical procedure to replace the hip joint).
- She was alert and oriented.
- She was capable of activities as tolerated.

Record review of the patient's initial activity assessment dated 11/20/17 showed she liked to watch television, read the newspaper, read magazines, do word find puzzles and have family visiting.

Record review of patient's activity participation documentation showed:
- 11/21/17, patient was up in her chair watching television.
- 11/22/17, patient's husband was visiting.
- 11/27/18, patient's husband was visiting and she received mail today.

Facility staff failed to identify that the activities they provided were repetitive, non-specific, and not individualized for each patient.




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SSBased on interview, record review and policy review the facility failed to develop individualized, pertinent interdisciplinary plans of care (IPOC), with updates specific to assess care needs in the Swing Bed Unit (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home care) for one current Patient (#12) and four discharged Patients (#10, #14, #15, and #21) of five care plans reviewed. This failure had the potential to affect all patients admitted as care was not planned. The facility census was eight including one Swing Bed patient.

Findings included:

1. Review of the facility policy titled, "Care Planning," dated 01/05/18 showed the following:
- Care, treatment and services are planned to ensure they are individualized to the patient's needs.
- A Registered Nurse (RN) will develop a plan of care for each patient within twenty four hours of admission.
- Care planning shall be implemented through the integration of assessment findings, prescribed treatment plan and development of goals.
- The plan of care will be individualized, based on diagnosis, patient assessment and personal goals of patient and family.
- The plan of care will be updated each shift with revisions reflecting the reassessment of the patient.
-There will be interdisciplinary collaboration to establish goals, interventions, evaluations and revisions.
- Problems identified in the Interdisciplinary morning meetings, will be added to the plan of care.

2. Review of Electronic Medical Record (EMR) for current Patient #12 showed she was admitted to the facility's Swing Bed Unit on 02/02/18 at 10:03 AM following a Pulmonary Embolism (blood clot in the lung).

Review of the patient's History and Physical (H&P) dated 02/02/18 showed:
- Hypertension (high blood pressure), COPD (congestive obstructed pulmonary disease - chronic inflammatory lung disease that causes obstructed airflow form the lungs), Blood clots in the legs and lungs, Vena Cava filter (an implanted filter to catch blood clots that in a large vein carrying blood into the heart from the body), GI (GI - gastrointestinal - stomach) Bleed, Urinary Retention (inability to completely empty the bladder), and Hypokalemia (a low level of potassium in the blood).
- The patient used a machine at home to prevent obstructive sleep apnea (an absence of breathing while sleeping).
- Medications included Avodart (medication to treat urinary retention), Potassium Chloride (medication to treat low Potassium levels), Qvar Redihaler (inhaled medication to treat shortness of breath), Serevent (inhaled medication to treat shortness of breath), Spiriva (medication to treat shortness of breath), Torsemide (medication to treat fluid retention), and Diltiazem (medication to treat high blood pressure).

Review of the patient's EMR dated 02/02/18 showed:
- Initial activity assessment dated 02/02/18 at 11:09 AM showed the patient liked to watch westerns and golf on television, read weekly news and some magazines.
- No IPOC for activities.
- No IPOC for Blood Clots, Urinary Retention, Sleep Apnea, and breathing issues related to heart disease and fluid retention.
- No collaboration between Nursing, Physical Therapy, and Occupational Therapy (strengthening of upper/lower body).
- No reports or changes to IPOC from morning Interdisciplinary meetings.
- No documentation of patient and family involvement in planning.


3. Review of medical record for discharged Patient #10 showed she was admitted to the facility's Swing Bed Unit on 01/09/18 at 1:54 PM following a Craniotomy (surgical removal of a portion of skull bone to access the brain).

Review of the patient's H&P dated 01/09/18 showed the patient was admitted with a history of endometrial cancer (cancer located in the uterus), lung metastasis (cancer that has developed in other places of the body), lung nodules (growth in the lungs), bilateral pulmonary embolism (blood clots affecting both sides of the lung), left leg deep vein thrombosis (a blood clot within a deep vein), multiple radiation treatments, chemotherapy, left elbow dislocation, left arm bone chips removed, knee surgery, urinary tract infection (UTI), and partial colon resection. Medications included Hydrocodone (pain medication), Heparin (blood thinning medication), Lovenox (blood thinning medication), Keppra (seizure medication), Neurontin (seizure medication), Bactrim DS (antibiotic to treat urinary tract infection), Senokot (medication to treat constipation), and Colace (medication to treat constipation).

Review of the patient's medical record dated 01/09/17 showed:
- Initial activity assessment dated 01/10/18 at 15:17 PM showed the patient liked to play solitaire on her tablet, watch the hallmark channel on television, read the newspaper and magazines.
- No IPOC for activities.
- No IPOC for wounds, UTI, diet related to blood thinning medications, injury related to blood thinning medications, blood clots, seizure precautions, or constipation.
- No collaboration between Nursing, Physical Therapy, and Occupational Therapy.
- No documentation of patient and family involvement in planning.
- No changes or updates to IPOC on 1/10/18 when Patient complained of chest pain.

4. Review of medical record for discharged Patient #21 showed she was admitted to the facility's Swing Bed Unit on 11/19/17 at 2:17 PM following a right total hip arthroplasty (surgical procedure to replace the hip joint).

Review of the patient's H&P dated 11/19/17 showed she was admitted with a medical history of Bilateral Pulmonary Emboli (blood clot in both lungs), Atrial Fibrillation (an irregular and rapid heart rate that causes poor blood flow), Pressure Sore to sacrum (injury to skin and underlying tissue resulting from prolonged pressure on the skin), post-operative urinary retention (inability to completely empty the bladder) and constipation.
Medications for this admission included Aspirin (assist with thinning blood), Venelex Ointment (treatment for pressure sores), Meloxicam (treatment for inflammation), Flomax (treat urinary retention), Amiodarone (treatment for atrial fibrillation), Miralax (treat constipation), Lovenox (injection to thin the blood), Ciprofloxacin (antibiotic to treat urinary tract infection), and Macrodantin (medication to treat urinary tract infection).

Review of the patient's medical record dated 11/19/17 at 12:52 PM showed:
- Initial activity assessment dated 11/20/17 at 11:50 AM showed the patient liked to watch television, read weekly news, magazines, and do some wordfinds.
- No IPOC for activities.
- No IPOC for wounds, impaired skin, infection related problems, diet related to blood thinning medications, injury related to blood thinning medications, blood clots, atrial fibrillation, or constipation.
- No interventions for problems that were listed.
- No documentation of patient and family involvement in planning.
- No reports or changes to IPOC from morning Interdisciplinary meetings.

During an interview on 02/05/18 at 3:00 PM Staff J, RN, stated that the IPOC did not address the patient's cardiac and lung issues. Staff J, stated that the IPOC should be addressed every shift with updates and interventions.

5. Review of discharged Patient #14's H&P dated 09/07/17, showed the following:
- She was admitted to Swing Bed on 09/06/17 for incisional care related to a recent heart surgery, and physical/occupational therapy.
- She was alert and oriented.
- She was capable of activities as tolerated.

Review of the patient's initial activity assessment dated 09/07/17, showed she liked to watch television, and read.

Review of the patient's IPOC dated 09/07/17, showed staff failed to identify activities as a problem, with a goal, and interventions to address the patient's activity interest needs.

6. Review of discharged Patient #15's H&P dated 08/09/17, showed the following:
- He was admitted to Swing Bed on 08/08/17 for a recent stroke and physical/occupational therapy.
- He was alert and oriented.
- He was capable of activities as tolerated, out of bed with assistance.

Review of the patient's initial activity assessment dated 08/09/17, showed he liked to watch television, and read.

Review of the patient's IPOC dated 08/09/17, showed staff failed to identify activities as a problem, with a goal, and interventions to address the patient's activity interest needs.

During an interview on 02/08/18 at 11:00 AM Staff Q, RN, Medical/Surgical Manager, stated that she was aware there was issues with the department's IPOC, the Electronic Care Plan was difficult to use, not everyone understood how to use it and there was identified issues with the IPOC's program.






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