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Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education documentation, audit tools, medical records, Rules and Regulations of the Medical Staff, and policy and interview, it was determined the facility failed to:

1. Follow their own Plan of Correction for Averse Events Reporting Policy. Refer to A 286

2. Follow their own Plan of Correction for medication administration. Refer to A 392

3. Ensure the patients received all medications as ordered by the physician. Refer to A 392

4. Ensure the medical staff member countersigned verbal orders within 24 hours. Refer to A 454

5. Ensure all documentation by Registered Nurse (RN) and Registered Dietician occurred prior to the patients' discharge from the hospital. Refer to A 467

6. Follow their own Plan of Correction for the use of patients' home medications and ensure the staff followed their own policy. Refer to A 501

7. Follow their own Plan of Correction for expired medications and supplies and ensure the staff followed their own policy. Refer to A 505

8. Ensure the Registered Dietician (RD) completed an Initial Nutritional Assessment prior to the patient's discharge. Refer to A 620

9. Follow their own Plan of Correction for Hand Hygiene and ensure the staff followed their own policy. Refer to A 749

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 057

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education documentation, audit tools, Rules and Regulations of the Medical Staff, and policy and interview, it was determined the facility failed to:

1. Follow their own Plan of Correction for Averse Events Reporting Policy. Refer to A 286

2. Follow their own Plan of Correction for medication administration. Refer to A 392

3. Ensure the patients received all medications as ordered by the physician. Refer to A 392

4. Ensure the medical staff member countersigned verbal orders within 24 hours. Refer to A 454

5. Ensure all documentation by Registered Nurse (RN) and Registered Dietician occurred prior to the patients' discharge from the hospital. Refer to A 467

6. Follow their own Plan of Correction for the use of patients' home medications and ensure the staff followed their own policy. Refer to A 501

7. Follow their own Plan of Correction for expired medications and supplies and ensure the staff followed their own policy. Refer to A 505

8. Ensure the Registered Dietician (RD) completed an Initial Nutritional Assessment prior to the patient's discharge. Refer to A 620

9. Follow their own Plan of Correction for Hand Hygiene and ensure the staff followed their own policy. Refer to A 749

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 286, A 392, A 459, A 467, A 501, A 505, A 620 and A 749

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education documentation, and interview, it was determined the facility failed to follow their own Plan of Correction for Averse Events Reporting Policy. This had the potential to affect all patients served by this facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 3/27/15 at 482.21(a), (c)(2), (e)(3) revealed:

The current Adverse Events Reporting Policy and Procedure...a read and sign in-service will be completed by the Director of Nursing. All departments will be responsible for presenting the inservice to the employees of their departments. The inservice will include updated policy and procedure for reporting adverse events as well as educate the employees on near misses or close calls.

Review of the Read and Sign inservice for Adverse Events Reporting Policy and Procedure revealed no documentation the following employees completed the read and sign:

Employee Identifier (EI) # 3, Pharmacist
EI # 15, Certified Nurse Aide (CNA)
EI # 27, Dietary
EI # 28, Dietary
EI # 29, Dietary
EI # 30, Plant Operations
EI # 31, Housekeeper
EI # 32, Housekeeper

An interview was conducted on 4/15/15 at 12:00 PM with EI # 2, Director of Nursing who verified the above findings.

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education and audit documentation, and interview, it was determined the facility failed to follow their own Plan of Correction for medication administration and to ensure the patients received all medications as ordered by the physician. This affected Patient Identifier (PI) # 4, 5 and 2 (3 of 5 records reviewed) had the potential to affect all patients served by this facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 3/27/15 at 482.23(b) revealed:

...There will be daily chart checks for 6 months using visual audits and checklist to evaluate the need for improvement and to identify areas for feedback and learning. These will be monitored by the Director of Nursing or designee and will continue to be monitored every quarter.

Completion Date: 04/01/2015

1. PI # 4 was admitted to the facility with diagnosis of Kidney Disease on 4/9/15 and was transferred to another acute care facility on 4/12/15.

Review of the physician's order dated 4/10/15 revealed an order for Neomycin and Polymycin B Sulfate and Dexamethasone Opthalmic Ointment to both eyes 4 time a day.

Review of the Medication/I.V. (Intravenous) Sol. (solutions) Charge Sheet dated 4/11/15 revealed the Neomycin and Polymycin B Sulfate and Dexamethasone Opthalmic Ointment was administered at 8:00 AM, 2:00 PM, and 10:00 PM. There was no documentation of the 4th dose being administered.

Review of the Record Review Worksheet audit tool dated 4/12/15 revealed no documentation the auditor noted the above missed medication.

An interview was conducted on 4/15/15 at 1:25 PM, with Employee Identifier # 2, Director of Nursing Service who verified the above findings.

2. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.

Review of the physician's orders dated 3/30/15 revealed an order for Metoprolol 50 mg (milligrams) by mouth twice a day.

Review of the Medication/I.V. Sol. Charge Sheet dated 4/1/15 revealed documentation the Metoprolol was given once.

The surveyor requested all the chart audit tools that were completed as per Plan of Correction. There was no documentation of a audit tool for PI # 5.

An interview was conducted on 4/15/15 at 1:30 PM with EI # 2, who verified the above findings.

3. PI # 2 was admitted to the facility on 4/13/15 for dehydration.

Review of the physician's order dated 4/13/15 revealed an order for Miralax 37 grams once a day.

Review of the Medication/I.V. Sol. Charge Sheet dated 4/14/15 revealed no documentation the patient received the Miralax.

Review of the Medication/I.V. Sol. Charge Sheet dated 4/15/15 revealed the patient received Miralax 17 grams and not the 37 the physician ordered.

An interview with EI # 12, Licensed Practical Nurse verified there was no documentation the patient received the Miralax on 4/14/15.




26187

Based on the review of the Rules and Regulations of the Medical Staff and medical record and interview, it was determined the facility failed to ensure the medical staff member countersigned verbal orders within 24 hours. This affected Patient Identifiers (PI) # 2 and 5 (2 of 5 records reviewed) and had the potential to affect all patients served by this facility.

Findings include:

Rules and Regulations of the Medical Staff

Section 4.2 - Physicians' Orders

4.2.1 - All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if dictated to a Registered Nurse, to a Licensed Practical Nurse...

4.2.2 - Such orders shall be signed by the person to whom dictated, with the name of the staff member giving the orders per his or her own name, and countersigned by the staff member within twenty-four (24) hours.

1. PI # 2 was admitted to the facility on 4/13/15 with a diagnosis of dehydration. Review of the verbal order received from the physician by Employee Identifier (EI) # 22, Registered Nurse (RN) at 1:25 PM revealed no documentation of the physician countersigning when record was reviewed on 4/15/15.

2. PI # 5 was admitted to the facility on 3/30/15 and discharged 4/2/15.

Review of the verbal order dated 3/30/15 which was received from the physician by EI # 10, RN at 7:55 PM revealed no documentation of the physician countersigning when record was reviewed on 4/15/15.

Review of the verbal order dated 4/2/15 which was received from the physician by EI # 10, RN at 12:15 AM revealed no documentation of the physician countersigning when record was reviewed on 4/15/15.

An interview was conducted on 4/15/15 at 1:45 PM with EI # 33, Administrator who verified the physicians had 24 hours to countersign a verbal order.

Based on record review and interview, it was determined the facility failed to ensure all documentation by Registered Nurse (RN) and Registered Dietician occurred prior to the patients' discharge for the hospital. This affected Patient Indentifer (PI) #s 4 and 5 (2 of 2 discharged medical records) and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 4 was admitted to the facility with diagnosis of Kidney Disease on 4/9/15 and was transferred to another acute care facility on 4/12/15.

Review of the Nursing Notes revealed a General Assessment Nurse Note dated 4/13/15 at 8:25 AM. The patient left the hospital on 4/12/15 at 7:30 PM.

An interview was conducted on 4/15/15 at 1:25 PM with Employee Identifier # 2, Director of Nursing Service who verified the above findings.

2. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.

Review of the Nursing Notes revealed a General Assessment Nurse Note dated 4/2/15 at 6:00 PM. The patient left the hospital on 4/2/15 at 1:00 PM.

Review of the physician's order dated 3/30/15 revealed the patient was to receive a soft 2 gm (gram) sodium diet.

Review of the Initial Nutritional Assessment revealed it was completed on 4/9/15 (7 days after discharge). The Registered Dietician (RD) recommended a soft 2 gm sodium renal diet due to the patients kidney disease.

An interview was conducted on 4/15/15 at 1:30 PM with EI # 2 who verified the above finding. When the surveyor asked why the RD completed the Initial Nutritional Assessment 7 days after discharge, the response was, "The RD comes 1 time a month."

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education and audit documentation, and policy, observations and interview, it was determined the facility failed to:

1. Follow their own Plan of Correction for use patients' home medications and ensure the staff followed their own policy. Refer to A 501

2. To follow their own Plan of Correction for expired medications and supplies and ensure the staff followed their own policy. Refer to A 505

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 501 and A 505.

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education and audit documentation, and policy, observations and interview, it was determined the facility failed to follow their own Plan of Correction for use patients' home medications and ensure the staff followed their own policy. This affected Patient Identifier(PI) # 2 (1 of 2 medication pass observed) and had the potential to affect all patients served by this facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 3/27/15 at 482.25(b)(1) revealed:

The policy for use of patient's home medications will be revised by the Pharmacist and the Director of Nursing Service to reflect the following: The hospital will not use the patient's home mediations. Non-formulary medications will be obtained from the local pharmacy. If the medication is unavailable from the local pharmacy the patient's home medications may be used once positively identified by a Physician or the Pharmacist. A read and sign inservice will be prepared by the Pharmacist and the Director of Nursing Service to advise nursing and clinical staff of this change. The Pharmacist and Director of Nursing Service will monitor the medication cabinet for home medications each month to ensure the home medications have been positively identified.

Completion Date 04/01/2015


Facility Policy: Administration of Medication: Patient's Personal Medications

Effective/Review Date: 03/28/2015

Policy:

The use of patient's personal medication is discouraged. A patient's personal medication shall not be administered to the patient unless specifically authorized by the prescribing practitioner responsible for the patient and the agent/medication can be positively identified.

Identification of Patients' Personal Medications:

Medications brought into the facility by patients shall not be administered unless the medications have been absolutely identified, their quality and integrity is not questionable, and there is a written order from the responsible prescribing practitioner to administer the medications.

Supplemental Labels:

The pharmacist or responsible physician should affix a supplemental label to the container to indicate that the medication has been identified, matches the label and that visual evaluation of its integrity is confirmed. The supplemental label must not obscure essential information on the original label.

An observation of a medication pass for PI # 2, was conducted on 4/15/15 at 8:00 AM with Employee Identifier (EI) # 12, Licensed Practical Nurse (LPN). EI # 12 went into the medication cabinet and obtained PI # 2's home medication bottle of Lithium 300 mg (milligrams). EI # 12 obtained the correct dosage and administered the medication to PI # 2.

The surveyor went with EI # 12 back to the medication room and asked how the pharmacist or responsible physician had labeled the medication identified, matched the label and that visual evaluation of its integrity had been completed. EI # 12 stated there was no evidence of a label on the medication.

Review of PI # 2 physician's orders on 4/15/15 at 9:00 AM, revealed no documentation of specific authorization by the prescribing practitioner for the staff to administer the patient's home medication of Lithium.

Further review of PI # 2's physician orders revealed the staff may use the patient's home medication of Risperidone and Seroquel. The surveyor went to the medication cabinet and obtained the patient's home medication of Risperidone and Seroquel. There was no evidence on the home medication bottles that indicated the pharmacist or responsible physician had labeled the medication as identified, matched the label and that visual evaluation of its integrity had been completed.

An interview was conducted on 4/15/15 at 12:15 AM with EI # 2, Director of Nursing Services who verified the home medications were not labeled.

There was no evidence presented that the Pharmacist or Director of Nursing Service monitored the medication cabinet for home medications per the facility's Plan of Correction. The completion dated was 4/1/15.

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education and audit documentation, Guidelines from the CDC (Center for Disease Control) and observations and interview, it was determined the facility failed to follow their own Plan of Correction for expired medications and supplies and ensure the staff followed their own policy. This had the potential to affect all patients served by this facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 3/27/15 at 482.25(b)(3) revealed:

A. A policy has been created by the Director of Nursing Services to ensure that expired supplies are removed and unavailable for use by staff when providing care to hospital patients. All supply areas will be checked each month by nursing service employees, expired supplies removed and discarded and appropriately documented. This will be monitored by the Director of Nursing Services and the assistant Director of Nursing Services for six months by visual audit of the supplies and documentation. The visual audits will continue to be conducted every quarter. (The Administrator will further ensure this policy is followed.

C. The pharmacist will ensure that all expired drugs or soon to expire drugs are removed from the Pharmacy. The Administrator will further ensure this policy is followed by conducting visual audits each month with the Director of Nursing Services or the Assistant Director of Nursing Service. This will be monitored and documented by the Director of Nursing Service each month for six months and then monitored every quarter.

Completion Date 04/01/2015.

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"Basic Safe Injection Practice Messages by the CDC

If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

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A tour of The Emergency Department was conducted on 4/14/15 at 10:30 AM. The surveyor noted the following expired supplies:

1 - 1/2 inch 5 yards of Iodoform gauze expired in March 2011
2 - Transparent Semi Permeable Dressings 2 3/8 inches by 2 3/4 inches expired 09/28/2009
5 - Tegaderm Dressings expired in March 2015

An interview was conducted on 4/14/15 at 10:50 AM with Employee Identifier (EI) # 1, Assistant Director of Nursing Service, who verified the above findings.

A tour of the nursing medication room was conducted on 4/14/15 at 10:55 AM. The surveyor observed the following expired drugs:

1 - Metoclopramide 5 mg(milligrams)/mL (milliliter) 2 mL vial expired 3/1/15

6 - Metoclopramide 5 mg(milligrams)/mL (milliliter) 2 mL vial expired 4/1/15

5 - Metoclopramine 5 mg(milligrams)/mL (milliliter) 2 mL vial expired 4/1/14

3 - Verapamil 2 ml/5 mg expired 3/1/15

10 - Heparin 5,000 units/ml 1 ml syringe expired 5/2014

7 - Cyanocobalamin expired 01/2015

5 - Propranolol 1 ml expired 12/2013

5 - Haldol 5 mg expired 3/2015


The following multi dose vials were open and not labeled with the date opened, initial of staff who opened and time:

2 - Depo medrol 80 mg/ml 3 ml vial
1 - Xylocaine 2% 50 ml vial
1 - Dexamethasone 10 ml vial

An interview was conducted on 4/14/15 at 11:15 AM with EI # 22, Registered Nurse, who verified the above findings.

A tour of the Pharmacy was conducted on 4/15/15 at 1:20 PM. The surveyor observed 6 Enoraprin Sodium syringe with 30 mg which expired 03/2015.

Review of the facility's education and audit tools revealed there was no documentation of a visual audit for the expired supplies and medication. The surveyor requested the audit tool and none were presented.

Based on record review and interview, it was determined the facility failed to ensure the Registered Dietician (RD) completed an Initial Nutritional Assessment prior to the patient's discharge. This affect Patient Identifier (PI) # 5 (1 of 1 records reviewed with an Initial Nutritional Assessment ) and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.

Review of the physician's order dated 3/30/15 revealed the patient was to receive a soft 2 gm (gram) sodium diet.

Review of the Initial Nutritional Assessment revealed it was completed on 4/9/15 (7 days after discharge). The RD recommended a soft 2 gm sodium renal diet due to the patients kidney disease.

An interview was conducted on 4/15/15 at 1:30 PM with EI # 2 who verified the above finding. When the surveyor asked why the RD completed the Initial Nutritional Assessment 7 days after discharge, the response was, "The RD comes 1 time a month."

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education and audit documentation, and policy, observations and interview, it was determined the facility failed to follow their own Plan of Correction for Hand Hygiene and ensure the staff followed their own policy. This had the potential to affect all patients served by this facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 3/27/15 at 482.42(a)(1) revealed:

A read and sign in service has been developed by the Infection Control Coordinator and will be given to patient care staff reviewing the Policy and Procedure for Hand Hygiene and the Policy and Procedure for Cleaning, Disinfection and Sterilization of non-critical patient care items between patients. There will be weekly monitoring of employees beginning immediately using direct visual inspection (including condition of nails, length and type) and checklist. This will be monitored weekly for at least 6 months by the Infection Control Coordinator or designee and continued monitoring every quarter by visual inspection.

A read and sign in service has been developed regarding the proper inspection and disposal of sharps containers...

Completion date 04/01/15

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Facility Policy Handwashing Technique
Revised 06/2008

Purpose:

To define guidelines that includes recommendations that should make hand hygiene simpler, safer, and more effective in order to prevent the spread of infections.

Policy:

Handwashing will be performed before and after contact with patients...

B. ... Rinse hands with warm water and dry well with a disposable towel. Use the paper towel to turn off the faucet.

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Review of the Read and Sign inservices on 4/14/15 revealed no documentation of an inservice for the sharps containers.

Further review of the Read and Sign inservices revealed no documentation the following employees completed the Read and Sign inservice for Hand Hygiene:

Employee Identifier (EI) # 4, Radiology
EI # 5, Radiology
EI # 6, Radiology
EI # 7, Laboratory
EI # 8, Laboratory
EI # 9, Laboratory
EI # 15, Certified Nurse Aide (CNA)

Review of the Visual Audits for Hand Hygiene revealed a visual audit dated 4/9/15 for EI # 18, Registered Nurse (RN) and another dated 4/13/15 for EI # 19, RN.

Observation of care was conducted on 4/15/15 at 8:10 AM. The surveyor was observing a medication pass for Patient Indentifer (PI) # 2 when EI # 22, RN came into the room. EI # 22 performed washed his/her hands and turned the faucet off the his/her hands before drying them.

Observation of care was conducted on 4/15/15 at 8:20 AM. The surveyor observed EI # 12, Licensed Practical Nurse (LPN) enter PI # 1's room and did not perform hand hygiene. EI # 12 left the PI # 1's room to obtain water for the patient. EI # 12 entered PI # 1's room again without performing hand hygiene and administered the PO (by mouth) medication.

Observation of a bed bath for PI # 3 was conducted on 4/15/15 at 9:15. EI # 22 washed his/her hands and turned the faucet off the his/her hands before drying them twice. EI # 11, CNA also washed his/her hands and turned the faucet off with his/her hands before drying them.

The surveyor asked EI # 2, Director of Nurses on 4/15/15 at 12:00 PM where the other Hand Hygiene Visual Audits were and the reply was, "That is all I have done."

The facility failed to follow their own plan of correction for infection control and ensure the staff followed their own policy for hand hygiene.

Tonya Blankenship, RN