HospitalInspections.org

Based on record review and interview, the facility failed to conduct 12 fire drills in 2013, as required by Texas Administrative Code 133.141(g). The facility conducted only 9 fire drills in 2013.

Findings include:

Texas Administrative Code 133.141(g) states: "The hospital shall conduct at least 12 fire drills each year, one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment."

Review of the facility policy, #1002, "Fire Drill," revealed the following: "Fire drills are to be conducted on a monthly basis rotating each of the two shifts." (This would require 12 fire drills per year)

Review of the facility's fire drill records revealed only 9 fire drills were conducted in 2013.

During an interview on 1/28/14 at 9:15 am in the plant operations office, staff #6 confirmed only 9 fire drills were conducted in 2013.

Based on interview and record review the facility failed to ensure have telephone numbers of all physicians on emergency call duty available.
This deficient practice had the likelihood to cause harm in all patients presenting to the emergency room.
Findings include:
Review of Physician On-call schedules from October 2013-January 2014 revealed no listed telephone numbers of the physicians.
During an interview on 01/28/2014 after 2:00 p.m., Staff #4 confirmed she did not have all the physicians telephone numbers listed.

Based on observation, record review, and interview, the facility failed to ensure all patient care equipment received annual biomedical safety inspections or be removed from patient care areas. In 2013, four pieces of patient care equipment were not found by and not inspected by the contracted biomedical service. There was no evidence these pieces of equipment were searched for and removed from patient care areas. The facility also failed to ensure expired supplies were removed from patient care areas.

Findings include:

Review of the contracted biomedical service's quality assurance report to the facility for April 2013 revealed a patient monitor on the nursing unit was not found and therefore did not receive the necessary safety inspection.

Review of the contracted biomedical service's quality assurance report to the facility for October 2013 revealed the following patient care equipment was not found and therefore did not receive the necessary safety inspection:
-telemetry transmitter in Cardiac Rehab;
-suction pump in the Specialty Clinic;
-an additional suction pump in the Specialty Clinic.

Review of facility documents revealed no evidence these pieces of equipment were searched for and removed from patient care areas.

During an interview on 1/30/14 at 9:50 am in the conference room, staff #6 reported the following:
-when equipment is not found by the biomedical service, we try to find it;
-there is no formal process to find the equipment;
-there is no documentation the equipment was removed from patient care areas until proper safety inspections could be performed.

During a tour of the endoscopy area on 1/28/14 at 1:55 pm, the following expired items were found (staff #7 confirmed these findings):
-nasopharyngeal airways in the anesthesia cart, expired 9/2011 x 1 and 11/2011 x 3;
-nasopharyngeal airways in the endoscopy cart, expired 7/2011 x 2 and 9/2011 x 3.

During a tour of the CT room on 1/28/14 at 2:45 pm, the expired items were found (staff #9 confirmed these findings):
-18 gauge IV catheter, expired 6/2002 x 1;
-18 gauge IV catheter, expired 5/2007 x 1;
-18 gauge IV catheter, expired 3/2009 x 1;
-18 gauge IV catheter, expired 7/2009 x 1;
-18 gauge IV catheter, expired 11/2009 x 1;
-18 gauge IV catheter, expired 10/2010 x 22.

During a tour of the lab on 1/28/14 at 4:15 pm, 27 grey top blood collection tubes (expired 11/2013) were found. Staff #11 confirmed this finding.






10135

During an observation on 01/28/2014 starting at 9:17 a.m. the following was found:
Nursing Unit Crash Cart
One Carbon dioxide detector in the Ambu bag which expired 10/2013;
Ten, 18 gauge IV catheters which expired 10/2013.

Nursing Unit Medication Room
Two, 24 gauge IV catheters which expired 11/2012;
Eleven, 24 gauge IV catheters which expired 11/2013;
Staff #2 confirmed the observations on the Nursing Units on 01/28/2014.

Emergency Room crash carts
One, 20 gauge IV catheter expired 01/2012;
One 20 gauge IV catheter expired 07/2012;
Three, 24 gauge IV catheters expired 11/2012;
Two, 18 gauge IV catheters expired 12/2012;
Five packets of Providone Iodine expired 02/2013;
Five, 22 gauge IV catheters expired 10/2013;
Two, 22 gauge IV catheter expired 10/2013;
Two, 20 gauge IV catheters expired 11/2013;
One, intubation stylet expired 11/2013;
One endotracheal tube and stylet set expired 04/2013;
Two packets of Providone Iodine expired 12/2013

Five sizes 2 and three size 2.5 laryngeal .mask expired 01/28/2014 and two boxes of the masks stored on the shelf in the supply room expired on 01/28/2014.
Review of the "Supplies Inspection Record" dated January 1-27, 2014 revealed nurses signed and certified that missing, usable (expired or broken) or malfunctioning items or equipment had been replaced.
During an interview on 01/28/2014 at 11:39 a.m., Staff #18 reported it would take a week to 10 days to get more of the laryngeal mask.

Based on observation, record review, and interview, the facility failed to ensure negative airflow rooms (rooms to isolate patients with airborne illness, such as tuberculosis) maintained a negative pressure gradient. Two of two negative airflow rooms had a positive pressure gradient into the nursing unit hallway.

Findings include:

During a tour of the facility on 1/28/14 at 9:55 am, the following was observed:
-The doors to the two negative airflow rooms (#302 and 303) were closed;
-A minute's wait was taken for the room pressures to be stabilized;
-A 1 x 1 cm single ply of toilet tissue was placed in the gap at the bottom of the door to room 302;
-The tissue was blown into the hallway, indicating a positive pressure, rather than a negative pressure, relative to the hallway;
-A 1 x 1 cm single ply of toilet tissue was placed in the gap at the bottom of the door to room 303;
-The tissue was blown into the hallway, indicating a positive pressure, rather than a negative pressure, relative to the hallway.

During the tour, staff #6 observed this procedure and confirmed the rooms were not operating with a negative airflow.

On 1/28/14 at 11:40 am, the above procedure was repeated for the Infection Control Officer (staff #27). Staff #27 observed and confirmed the rooms were not operating with a negative airflow.

During an interview on 1/28/14 at 12:10 pm, staff #6 reported the following:
-the negative airflow rooms were tested and confirmed negative when the facility was built in 2009;
-there is no routine testing to ensure the rooms maintain a negative airflow;
-the rooms haven't been tested for negative airflow since 2009.

Based on record review and interview, the Governing Body failed to:

A. ensure completion of required documentation (credentialing application/delineation of privileges/current cardiopulmonary pulmonary resuscitation (CPR)) during the credentialing process per the Governing Body. Citing 9 of 9 medical staff files reviewed. Including (Medical Staff #21, 22, 23, 24, 25, 26, 28, 29, and 30).

Refer to tag 0241 for additional information

B. ensure respiratory medications, insulin, glucometer quality control solution and bags of IV fluids was stored properly and dated when opened on 2 of 2 units (Medical Nursing unit and Emergency room).
Refer to C 0276 for additional information.

C. ensure a sanitary environment for storage of its endoscopes. Two of two colonoscopes were found with the lumen resting the bottom of the scope storage cabinet. The facility failed to ensure supplies were protected from being soiled. Ten wire carts with patient supplies were found with no impermeable barrier on the bottom shelves. This practice failed to protect supplies stored on the bottom shelves from being contaminated from floor debris. The facility failed to ensure patient care items were not stored under sinks in three patient care areas, leading to possible contamination from leaking drains. The facility failed to ensure contaminated cardboard shipping boxes were not present in clean storage areas (19 boxes in 3 areas). The facility also failed to assure a sanitary environment for patients and employees. Unused ("clean") biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes. These boxes were then used in patient care areas, leading to possible cross-contamination. The facility failed to assure clean patient care equipment and soiled equipment were stored separately and light covers were kept free of bugs on the Nursing unit. They also failed to assure equipment used during medication for medication preparation/storage were kept sanitary.

Refer to C 0278 for additional information.

D. ensure sanitary practices were followed in food storage, dishwashing and food preparation in 1 of 1 kitchen area. They failed to ensure the dietitian approved substitutions.
Refer to C 0279 for additional information.


E. ensure patient needs were met by failing to thoroughly assess behavior to justify chemical restraint usage, dietary assessments on patients with pressure sores, and on patients representing to the emergency. The facility failed to provide turning and repositioning on patients with pressure sores. These failures were found in 4 of 4 patients ( Patient #'s 2, 9, 21 and 23).
Refer to C 0295 for additional information.

Based on record review and interview, the facility failed to ensure completion of required documentation (application/delineation of privileges/Cardiopulmonary Resuscitation (CPR)certification) during the credentialing process per the Governing Body. This includes submission of application, delineation of privileges and/or CPR certification at the time of re-appointment. The facility failed to ensure the required documentation in 9 (Staff #21, 22, 23, 24, 25, 26, 28, 29 and 30) of 9 medical staff files reviewed.

Findings include:
Review of Medical Staff credentialing files on 1/29/2014 at 9:00 am revealed the following:
1. Medical Staff #21- No documentation of current delineation of privileges found.
2. Medical Staff #22- No documentation of current credentialing application found.
3. Medical Staff #23- No documentation of signature/date on delineation of privileges found.
4. Medical Staff #24- No documentation of a current credentialing application found. No signature/date on delineation of privileges found.
5. Medical Staff #25- No documentation of a current credentialing application found. No signature/date on delineation of privileges. No documentation of current CPR certification found.
6. Medical Staff #26- No documentation of a current delineation of privileges found. No documentation of a signature/date on credentialing application found.
7. Medial Staff #28- No documentation of a current delineation of privileges found. No documentation of signature/date on credentialing application found.
8. Medical Staff #29- No documentation of a current CPR certification found.
9. Medical Staff #30- No documentation of a current credentialing application found. No documentation of delineation of privileges found.

Review of Limestone Medical Center "Bylaws of The Medical Staff" on 1/30/2014 at 10:00 am revealed the following:
Article V Clinical Privileges
5.1-Clinical Privileges- Every practitioner at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the Governing Body.
6.7- Process for Reappointment- All Medical Staff reappointment shall be for a maximum of two (2) years. Reappointment and privileges delineation shall be determined by the Governing Board at least thirty (30) days prior to the final scheduled meeting in the Medial Staff year. Reappointments and privilege applications shall be made in writing. The Medical Staff Credentials Committee shall review the application, may interview the practitioner, and shall make appropriate recommendations to the Governing Board. It may recommend non-reappointment, a change, or restriction in clinical privileges. The reasons for such recommendations shall be stated an documented and the applicant notified in writing. Should this occur, the applicant has the right to the appellate review process delineated in Article VIII.
6.8- Each recommendation concerning the reappointment and review of privileges shall be based upon, but not limited to, the following:
a. Current valid licensure and current DEA/DPS registration (if applicable).
b. Attendance at Medial Staff meeting and participation in staff affairs.
c. Continuing education and experience since prior appointment which qualifies applicant for privilege sought.
d. Documentation of participation in basic cardiopulmonary resuscitation training within the last twelve (12) months.
e. Current clinical competence.
f. Health status of the practitioner.
g. Compliance with Medial Staff Bylaws, Rules and Regulations.
h. Ethics and conduct.
i. Sanctions of any kind imposed by any other health care institution, professional health care organization, or licensing authority; and
j. Documented current competence based upon experience in categories of treatment area or procedures, the results of treatment, and the conclusions drawing from quality assurance activities.
k. Any other matter considered pertinent to the credentialing decision.

An interview with staff #17 on 1/30/2014 at 11:00 am in the administrative conference room confirmed the findings.

Based on observation, interview and record review the facility failed to:

A. ensure respiratory medications, insulin, glucometer quality control solution and bags of IV fluids was stored properly and dated when opened on 2 of 2 units (Medical Nursing unit and Emergency room).
Refer to C 0276 for additional information.

B. ensure a sanitary environment for storage of its endoscopes. Two of two colonoscopes were found with the lumen resting the bottom of the scope storage cabinet. The facility failed to ensure supplies were protected from being soiled. Ten wire carts with patient supplies were found with no impermeable barrier on the bottom shelves. This practice failed to protect supplies stored on the bottom shelves from being contaminated from floor debris. The facility failed to ensure patient care items were not stored under sinks in three patient care areas, leading to possible contamination from leaking drains. The facility failed to ensure contaminated cardboard shipping boxes were not present in clean storage areas (19 boxes in 3 areas). The facility also failed to assure a sanitary environment for patients and employees. Unused ("clean") biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes. These boxes were then used in patient care areas, leading to possible cross-contamination. The facility failed to assure clean patient care equipment and soiled equipment were stored seperately and light covers were kept free of bugs on the Nursing unit. They also failed to assure equipment used during medication for medication preparation/storage were kept sanitary.

Refer to C 0278 for additional information.

C. ensure sanitary practices were followed in food storage, dishwashing and food preparation in 1 of 1 kitchen area. They failed to ensure the dietitian approved substitutions.
Refer to C 0279 for additional information.


D. ensure patient needs were met by failing to thoroughly assess behavior to justify chemical restraint usage, dietary assessments on patients with pressure sores, and on patients representing to the emergency. The facility failed to provide turning and repositioning on patients with pressure sores. These failures were found in 4 of 4 patients ( Patient #'s 2, 9, 21 and 23).
Refer to C 0295 for additional information.

Based on observation, interview and record review the facility failed to ensure respiratory medication, insulin, glucometer quality control solution and bags of IV fluids was stored properly and dated when opened on 2 of 2 units (Medical Nursing unit and Emergency room).
This deficient practice had the likelihood to cause harm to all patients receiving these medications/solutions.
Findings include:
During an observation of the medication room on 01/28/2014 starting at 10:23 a.m. the following was found:
Medical Nursing Unit
*An open vial of Humulin Regular insulin was found with an open date.
Review of a manufacturer letter from Lilly dated 04/11/2003 revealed either stored in the refrigerator or room temperature the insulin was good for 28 days.
*Some of the following open vials of respiratory medications were stored in open plastic containers on a shelf and were not stored in protective coatings:
Pulmicort
Review of the website, www.drugs.com revealed "Keep the strip of Pulmicort Respules in the foil envelope, until you are ready to use the medication. After tearing off one ampule, return the strip to the envelope to protect the remaining ampules from light. Store the foiled envelope upright. Once you have opened the envelope, you must use the ampules within 2 weeks."
Atrovent - Review of the instructions on the packet revealed "Protect from Light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week."
Albuterol - Review of the insert revealed "Protect from light. Store unused vials in the foil pouch."
Xopenex - Review of the insert revealed "Keep unopened vials in the foil pouch. Once the foil pouch is opened, the vials should be used within 2 weeks. Vials removed from the pouch, if not used immediately, should be protected from light and used within 1 week."
Brovana was stored on the shelf and had no open date. According to the website www.drugs.com the following was documented:
"You may store the foil pouches at room temperature but you must use them within 6 weeks."
Advair Diskus were opened and not dated.
Review of the label on the medication revealed staff was to "Discard the Diskus 1 month after removal from the overwrap. Fill in dates on the Diskus appropriately."
Staff #2, 5 and 8 confirmed the observations on 01/28/2014. Staff #5 reported some of the Advair was from previous patients. They kept the medication just in case the patients were re-admitted.
Emergency Room
During an observation of the emergency room medication storage area room on 01/28/2014 starting at 1:35 p.m. the following was found:
*Glucometer quality control solutions had no recorded open date. Review of the label on the bottles revealed to "Discard 3 months after opening or after use by date."
*Two open packets of Pulmicort Respules which had no open date. According to the label on the medication "Once the foil envelope is opened, use the RESPULES ampules within 2 weeks."
* Five vials of Atrovent were stored in a plastic bin and were not contained in their foil envelope.
According to the label on the medication "Protect from Light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week."
*An open packet of Xopenex was stored in a bin and had no recorded open date.
Review of the medication label revealed "Once the foil pouch is opened, the vials should be used within 2 weeks."
*Ten plus bags of Lactated Ringer, Dextrose 5%, and Normal Saline were stored on the shelf and were removed from their protective bags.
Review of the 2012 APIC course book revealed the following:
"Keep IV bags in plastic overwrap, until ready for use (if out, date and discard in 30 days)."
Staff #4 confirmed the observations in the Emergency room on 01/28/2014.

Based on observation and interview, the facility failed to provide a sanitary environment for storage of its endoscopes. Two of two colonoscopes were found with the lumen resting on the bottom of the scope storage cabinet. The facility failed to ensure supplies were protected from being soiled. Ten wire carts with patient supplies were found with no impermeable barrier on the bottom shelves. This practice failed to protect supplies stored on the bottom shelves from being contaminated from floor debris. The facility failed to ensure patient care items were not stored under sinks in three patient care areas, leading to possible contamination from leaking drains. The facility failed to ensure contaminated cardboard shipping boxes were not present in clean storage areas (19 boxes in 3 areas). The facility failed to assure a sanitary environment for patients and employees. Unused ("clean") biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes. These boxes were then used in patient care areas, leading to possible cross-contamination. The facility failed to assure clean patient care equipment and soiled equipment were stored separately and light covers were kept free of bugs on the Nursing unit. They also failed to assure equipment used during medication for medication preparation/storage were kept sanitary.

Findings include:

Review of the document, "Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes," by The Society of Gastroenterology Nurses and Associates revealed the following: "K. STORAGE
1. Hang the endoscope vertically with the distal tip hanging freely in a clean, well-ventilated, dust-free area."

During a tour of the scope storage area on 1/28/14 at 1:52 pm, 2 colonoscopes were found with the lumen resting on the bottom of the scope storage cabinet. This could lead to possible scope contamination. Staff #7 confirmed this finding.

During a tour of the lab on 1/28/14 at 4:00 pm, one wire storage cart containing patient supplies was found with no impermeable barrier on the bottom shelve. This could lead to possible contamination of supplies. Staff #11 confirmed this finding.

During a tour of the pharmacy on 1/29/14 at 10:55 am, 9 wire storage carts containing patient supplies were found with no impermeable barrier on the bottom shelves. This could lead to possible contamination of supplies. Staff #10 confirmed this finding.

During a tour of the radiology CT room on 1/28/14 at 2:45 pm, five pillows were found stored in the cabinet under a sink. This could lead to possible contamination from leaking drains. Staff #9 confirmed this finding.

During a tour of the radiology nuclear medicine room on 1/28/14 at 2:50 pm, patient care items were found stored in the cabinet under a sink. This could lead to possible contamination from leaking drains. Staff #9 confirmed this finding.

During a tour of the respiratory therapy department on 1/28/14 at 3:00 pm, patient care items were found stored in the cabinet under a sink. This could lead to possible contamination from leaking drains. Staff #8 confirmed this finding.

During a tour of the radiology CT room on 1/28/14 at 2:45 pm, three contaminated cardboard shipping boxes were found stored in this patient care area. Staff #9 confirmed this finding.

During a tour of the respiratory therapy department on 1/28/14 at 3:00 pm, five contaminated cardboard shipping boxes were found in the clean storage room. Staff #8 confirmed this finding.

During a tour of the pharmacy on 1/29/14 at 10:55 am, eleven contaminated cardboard shipping boxes were found in the clean storage closets. Staff #10 confirmed this finding.

During a facility tour on 1/28/14 at 9:30 am, it was observed that unused ("clean") cardboard biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes. Therefore, these boxes were soiled.

During an interview on 1/28/14 at 9:30 am, staff #6 confirmed this finding. Staff #6 also reported that the "clean" biohazard waste boxes were taken to patient care areas, where they are used and returned to the soiled biohazard waste area when full.

During a facility tour on 1/28/14 at 11:45 am, a contaminated cardboard biohazard box was found in room 303, which was occupied by a patient. Staff #27 confirmed the contaminated box was in the patient's room.

During a tour of the radiology CT room on 1/28/14 at 2:45 pm, a contaminated biohazard box was found next to the CT scanner. Staff #9 confirmed this finding.

During a tour of the rehabilitation department on 1/29/14 at 2:15 pm, a contaminated biohazard box was found in the activities of daily living training room. Staff #31 confirmed this finding.










10135

During an observation on 01/28/2014 starting at 9:17 a.m. the following was found:
Nursing Units
Five plus ceiling light covers in the hallways had dead bugs.
The clean patient supplies were stored on shelves which did not have a protective guard on the bottom. The supplies on the bottom shelves were exposed to dust and debris. There were supplies stored in shipping boxes in the room.
Two ceiling light covers had dead bugs in them. One of the lights was above the patient wash basins and briefs.

Soiled Utility Room
Open boxes of patient pamphlets were stored on a cabinet in the same room where soiled linen and trash were stored.

Nursing unit crash cart
The medication refrigerator had an approximate two inch build-up of ice and was in need of defrosting.
The off white bowl and mortar used for crushing medications had brown stains on them. The mortar was broken.
Staff #2 confirmed the observations on the Nursing Units on 01/28/2014.

Based on observation, interview and record review the facility failed to ensure sanitary practices were followed in food storage, dishwashing and food preparation in 1 of 1 kitchen area. They failed to ensure the dietitian approved substitutions.
This deficient practice had the likelihood to cause food- borne illnesses to all patients.
Findings include:
During observation of the kitchen on 01/29/2014 starting at 8:48 a.m., the following was found:
Storage area
Clean supplies were stored on shelves in shipping boxes. The boxes were stored above and with paper plates, straws, containers of condiments, mop heads, mixer, cash register, flash light, foil pans, and bottled water and water/tea pitchers.
The shelves were open and had no protective barrier for the bottom shelf to prevent exposure to dust and debris.
"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust (AAMI ST46-Section 5.2 Receiving Items).
Dry food storage area
Cans and boxes of food were stored on shelves in shipping boxes. The shelves were open and had no protective barrier for the bottom shelf to prevent an exposure to dust and debris.
Three 60 ounce cans of Mushrooms were dented and on stored on the shelf ready for use.
An unsealed box of biscuit mix was on the shelf.
A tray of spices had a build-up of spills on the tops and needed to be cleaned.
Cans on the shelves and an open container of onions on the bottom shelf were soiled with spills.
Walk in Freezer and Refrigerator
Boxes of meats and vegetables were stored on shelves in the freezer and refrigerator in shipping boxes. The shelves were open and had no protective barrier for the bottom shelf to prevent exposure to debris.
The vent covers in the walk-in refrigerator had a buildup of white substance. Bags of hamburger buns were stored directly underneath the vents.
A tray of thawing pork chops was stored on top of other food items in the refrigerator. When identified Staff #19 placed the tray on top of a cart where raw vegetables were stored.
Review of the refrigerator/freezer temperature log revealed from 01/06-1/14/2014 (9 days) staff failed to log temperatures.
Review of the "Food Storage" policy revealed "Temperatures are documented daily on the Temperature records."
Food Prep Area
Staff member #20 washed her hands at a sink and dried them with paper towels. Staff member #20 took the paper towel and picked up the lid of the trash can to discard the paper towel. The lid was still up so she leaned over and used her arm to put the lid down.
Staff member #20 confirmed it was hard to wash her hands without touching the lid of the trash can.
Staff was observed using a three compartment sink for washing dishes.
According to an instruction panel on the wall above the sink, the water temperature was to be 110 degrees Fahrenheit or to tolerance and there was a 150-400 ppm efficacy range for sanitation. There was also instructions on how to check the sanitizer at the sink. The facility had no logs to indicate what the water temperature or sanitizer level was running.
Staff #19 confirmed there was no temperature/sanitizer log being kept for the three compartment sink.
A tray of cups and another stack of larger plastic food containers were stored on a shelf wet. Creating a medium for bacteria growth.
Plastic tops for food containers were stored underneath the food prep tables. Some were in an uncovered plastic bin and they were soiled with food spills and dust. Others were stored directly on the shelves and they were soiled with a buildup of dust and food spills.
Ten plus cooking pans had a build-up of black carbon making them unsanitizable.
An open shelf of stainless steel cooking and steam pans were stored in a high traffic area near a door and were not covered.
The outside of the toaster was soiled and the inside had a build-up of crumbs.
The back panel on the convection was off and had a build-up of dust and a steam table pan was on the floor behind it. There was a build-up of food spills and debris behind the convection oven and stove.
The plastic covering over the storage bin for bowls was ripped and was covered with dried food particles and spills.
The inside panel of one of the food carts was rusted and soiled with food particles.
Underneath the main dishwasher, was a steam table pan on the floor, collecting water from the drainage pipe.
Staff #19 confirmed the observations and reported the drain was not put in correctly by the building company.
Upright refrigerator
Two open containers of uncooked eggs were stored above a pan of uncooked sausages and container of cheese sauce.
On the other side of the refrigerator a pan of uncooked beef was stored above bowls of salad which were ready to serve.
Food temperatures
During an observation on 01/29/2014 at 10:45 a.m., Staff #20 went over the food items that were on the steam table. There were fried pork chops, baked pork chops, beef noodle dish, two pans of cabbage, black eyed peas, zucchini casserole, tomatoes and macaroni dish and macaroni and cheese.
During an observation on 01/29/2014 at 11:20 a.m., Staff #20 took food temperatures of food items on the steam table and failed to log them. The fried pork chops and regular pan of cabbage had already been served without the temperatures being taken of these two items.
Review of a facility in-service dated 02/09/2013 revealed staff was to "Take and record temperatures of all foods."
Review of the form named "Temperature Record of Food on Standard Menu" dated December 2013 and January 2014 revealed the following:
Food temperatures were not recorded for 12/30/13 dinner, 12/31/2013 dinner, 1/27/2014 dinner and 01/28/2014 was missing for all 3 meals.
There was no documentation of temperatures being taken on all the meats, starches and vegetables served during each meal for December 2013 and January 2014.
Staff #19 confirmed all the temperatures of food items were not being logged.
Dietary substitutions
Review of "Dietary Food Substitution List" dated December 2013 and January 2014 revealed three substitutions were made. There was no documentation of the date or indication the dietitian approved of them.
During an interview on 01/28/2014 at 4:17 p.m., Staff #19 confirmed the dietitian was not approving substitutions.

Based on interview and record review the facility failed to ensure patient needs were met by failing to thoroughly assess behavior to justify chemical restraint usage, dietary assessments on patients with pressure sores, and on patients representing to the emergency. The facility failed to provide turning and repositioning on patients with pressure sores. These failures were found in 4 of 4 patients ( Patient #'s 2, 9, 21 and 23).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
*Review of an "Emergency Physician Record" dated 01/15/2014 revealed Patient #21 was a 56 year old female who presented with Schizophrenia, AMS escalating and combative.
Review of Nursing Assessments revealed the following:
9:15 a.m., Patient came from the nursing home with complaint of worsening psychosis ...Patient Geodon (psychotropic) was increased as of 01/09/13. Patient is alert and talkative with staff. Patient calm/cooperative at this time.
9:30 a.m., Patient climbed out of bed, states she wants to be at nursing station. Patient was redirected to room and given Geodon 10 milligrams IM. After the redirection there was no documentation showing the intervention did not work, prior to administration of the Geodon.
10:10 a.m. (40 minutes later), Ativan given IM, There was documented reason for administration of the psychotropic.
10:30 a.m., (20 minutes later) Patient walking around in room and in the ER nursing station area. Patient redirected to room and was given IM Geodon.
10:55 a.m., staff spoke to the primary care physician who recommended finding placement for evaluation and medication adjustment.
11:30 a.m., Pt becoming increasingly agitated and yelling. Patient able to redirected back to room.
11:38 a.m., Versed (sedative) given IM.. Patient now agreeable to having vital signs done at this time. There was no documented reason for administering the Versed.
2:35 p.m., multiple attempts to redirect and calm patient. Patient given IM Versed.
4:15 p.m., Patient very agitated yelling that she does not want to go back to the nursing home. Patient threw meat tray at staff hitting the sliding glass door. Multiple attempts to calm patient with limited success. Patient given IM Versed.
6:30 p.m. 2 mg Versed IM to bilateral deltoids.
10:05 p.m., rash present to posterior legs bilaterally, medicated per orders. Benadryl 50 mg IM to left deltoid. Versed and Geodon held due to unknown origin or rash.
Review of physician orders revealed the first order for Geodon 10 milligram injection time's one dose was received at 9:51 a.m... Two doses of the Geodon were administered without having an order at 9:15 a.m. and 9:30 a.m.
Review of physician orders revealed at 6:16 p.m. an order was written for Versed 2mg IM x 1 dose. There was no physician order justify giving Versed 2mg IM to bilateral deltoids as documented in the nursing notes at 6:30 p.m..
During an interview on 01/30/2014, after 8:39 a.m., Staff #4 and 15 confirmed the problems with the medication.
Review of a policy and procedure named "Treatment of Psychiatric Patient" dated 03/08/2011 revealed:
"Whenever possible, the same nurse should be responsible for assessing, treating, and communicated with the patient."
"If patient becomes violent or actions present a threat to patient's safety or that of others, restraint may be necessary. Receive order for physical or chemical restraints from ER physician."

*Review of a nursing assessment dated 01/27/2014 revealed Patient #23 was a 27 year old female who presented to the ED at 5:38 p.m. with the following problems:
"6 weeks pregnant, spotting started today, had a gush a blood and tissue earlier today and has been spotting since... There was a documented medical gynecological history. There was no documented nursing assessment of what the bleeding looked and if there was current vaginal discharge.
Review of the nursing assessment notes at 5:55 p.m. the patient was placed in exam room after being triaged. Patient saw her OB on Friday for bleeding, blood drawn done and sent home. She had small amount of bleeding today with small tissue passed, when she called her OB she was told to go to the ER. ... ....Upon talking to the Patient and her husband they decided to go home and monitor the bleeding and if it got worst they will got the ER.
According to the Discharge information the patient left on 01/27/2014 at 6:08 p.m., the category for left without being seen was checked not AMA. There was also documentation on the form an AMA form was completed.
During an interview on 01/30/2014 at 10:03 a.m. Staff #4 and 15 confirmed there was no thorough assessment of the problem the patient presented to the ER with.

*Review of a "Record of Admission" dated 11/29/2013 revealed Patient #9 was a 60 year old female admitted with a diagnosis of a urinary tract infection.
Review of physician orders dated 11/29/13 revealed Patient #9 also had diagnoses of diabetes mellitus and dementia and was on a clear liquid diet. On 11/30/2013 the patient was changed to an ADA diet.
Review of an "Initial Physical Assessment" dated 11/29/2013; 9:35 p.m. revealed Patient #9's peri-area was red and scaly. There was a large purple area to the right buttock which was leaking fluid.
Review of the "Nutrition Scale" revealed Patient #9 was at high risk for nutritional problems.
Review of the record revealed no initiation of a dietary assessment to address the increased nutritional needs from the infection, skin breakdown and therapeutic diet.
During an interview on 01/30/2014 after 10:03 a.m., Staff #15 confirmed the assessment was not done. Staff #15 reported nursing did not make the correct selection in the computer to initiate a dietary assessment.

*Review of physician orders dated 01/24/2014, 10:15a.m., revealed Patient #2 was a 78 year old male admitted after a right femur fracture and status post ORIF.
Review of the "Initial Physical Assessment" form dated 01/24/2014 revealed Patient #2 was at a normal-low risk for pressure sore breakdown. The patient's skin was intact and there was no recorded breakdown. The interventions documented on the assessment was to turn the patient frequently.
Review of Patient #2's record revealed the following documentation of times turned from 01/24-01/27/2014:
01/24/2014 at 7:10 p.m.;
01/25/2014 at 7:05 a.m. and again at 7:00 p.m.;
01/27/2014 at 6:58 p.m. and again at 10:32 p.m...
There was no documentation of every 2 hours turning.
Review of "Physicians progress notes" dated 01/27/2014 revealed the patient had developed a Stage II sacral decub.
During an interview on 01/29/2014 at 5:00 p.m. Staff #5 confirmed there was no every 2 hour turning documented and the patient having a Stage II pressure sore.
Review of physician orders dated 01/24/2014, 10:15 a.m., revealed Patient #2 was on a Cardiac diet.
Review of the "Nutrition Scale" revealed Patient #2 was at risk for nutritional problems.
Review of the record revealed no dietary assessment on the chart.
During an interview on 01/29/2014 at 5:00 p.m., Staff #2 and #15 confirmed there was no dietary assessment done.
Review of The National Pressure Ulcer Advisory Panel , http:www.npuap.org, the following pressure sore information was provided:
Category Stage II: Partial thickness
"Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. Bruising indicates deep tissue injury.
Consider nutritional supplementation/support for nutritionally compromised persons consistent with overall goals of care.
Reposition bed-bound persons at least every two hours and chair-bound persons every hours consistent with overall goals of care."

Based on record review an interview, the facility failed to ensure verbal orders were complete, dated, timed, and authenticated. Citing 7 of 8 patient medical records reviewed, including (Patient's #15, 16, 19, 34, 35, 37, and 38).

Findings include:
Review of patient medical records on 1/29/2014 at 10:00 am revealed the following:
1. Medical record for patient #15- Four (4) verbal orders with no documentation of physician signature and/or date/time of authentication found.
2. Medical record for patient #16- Five (5) verbal orders with no documentation of physician signature and/or date/time of authentication found.
3. Medical record for patient #19- Three (3) verbal orders with no documentation physician signature and/or date/time of authentication found.
4. Medical record for patient #34- Five (5) verbal orders with no documentation of physician signature and/or date/time of authentication found.
5. Medical record for patient #35- Two (2) verbal orders with no documentation of physician date/time of authentication found.
6. Medical record for patient #37- Six (6) verbal orders with no documentation of physician date/time of authentication found.
7. Medical record for patient #38- Three (3) verbal orders with no documentation of physician date/time of authentication found.

Review of the Limestone Medical Center Bylaws of the Medical Staff on 1/30/2014 at 11:00 am revealed the following:
"Rules and Regulations:
"5. All physician's orders must be written legibly on the "Physician's Order Sheet" or the "Emergency Room Record". Only a licensed nurse may receive verbal and telephone orders, and they must be written at the time they are reviewed. Verbal orders will only be accepted in a life-threatening situation. The physician must write the orders in all other situations when he is present in the hospital. Telephone orders will be accepted when the physician is unable to come to the hospital and write his own orders. Verbal and telephone orders must be signed by the physician within a twenty-four (24) hour period of being written. Orders must have date, time, and signature."

An interview with staff #2 on 1/29/2014 at 1:00 pm confirmed the findings.

Based on interview and record review the facility failed to ensure 1 of 5 patients on the Swing bed unit received resident rights and consent for treatment (Patient #2).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of physician orders dated 01/24/2014, 10:15 a.m., revealed Patient #2 was a 78 year old male admitted after a right femur fracture and status post ORIF.
Review of the record revealed no documented evidence of patient right information or consent for treatment being obtained on 01/24/2014.
During an interview on 01/29/2014 after 5:00 p.m., Staff #14 confirmed the admission information was not obtained. She worked Monday -Fridays and the patient came in late on last Friday (01/24/2014). She would get it today.
During an interview on 01/30/2014 after 10:03 a.m., Staff #15 reported the nurses did not complete the admission information on the weekends. If they got an admission there was other administrative staff in the building to obtain it.

Based on observation, interview and record review the facility failed to ensure there were complete physician orders, nursing interventions, releasing /repositioning, and clinical justification for restraint usage in 3 of 3 sampled patients (#'s 2, 9 and 21).
This deficient practice had the likelihood to cause harm in all patients restrained.
Findings include:
*Review of an "Emergency Physician Record" dated 01/15/2014 revealed Patient #21 was a 56 year old female who presented with Schizophrenia, AMS escalating and combative.
Review of Nursing Assessments revealed the following:
9:15 a.m., Patient came from the nursing home with complaint of worsening psychosis ...Patient Geodon (psychotropic) was increased as of 01/09/13. Patient is alert and talkative with staff. Patient calm/cooperative at this time.
9:30 a.m., Patient climbed out of bed, states she wants to be at nursing station. Patient was redirected to room and given Geodon 10 milligrams IM. After the redirection there was no documented assessment of the behavior which justified administration of the Geodon.
10:10 a.m. (40 minutes later), Ativan given IM, There was no documented assessment of the behavior giving justification for administration of the psychotropic.
10:30 a.m., (20 minutes later) Patient walking around in room and in the ER nursing station area. Patient redirected to room and was given IM Geodon. There was no documentation of an assessment of the behavior which justified the administration of the Geodon.
10:55 a.m., staff spoke to the primary care physician who recommended finding placement for evaluation and medication adjustment.
11:30 a.m., Patient becoming increasingly agitated and yelling. Patient able to redirected back to room.
11:38 a.m., Versed (sedative) given IM... Patient now agreeable to having vital signs done at this time. There was no documented reason for administering the Versed.
2:35 p.m., multiple attempts to redirect and calm patient. Patient given IM Versed.
4:15 p.m., Patient very agitated yelling that she does not want to go back to the nursing home. Patient threw meat tray at staff hitting the sliding glass door. Multiple attempts to calm patient with limited success. Patient given IM Versed.
6:30 p.m. 2 mg Versed IM to bilateral deltoids. There was documented assessment of the behavior which justified the administration of Versed.
10:05 p.m., rash present to posterior legs bilaterally, medicated per orders. Benadryl 50 mg IM to left deltoid. Versed and Geodon held due to unknown origin or rash.
Review of physician orders revealed the first order for Geodon 10 milligram injection time's one dose was received at 9:51 a.m... Two doses of the Geodon were administered without having an order at 9:15 a.m. and 9:30 a.m.
Review of physician orders revealed at 6:16 p.m. an order was written for Versed 2 mg IM x 1 dose. There was no physician order justify giving Versed 2 mg IM to bilateral deltoids as documented in the nursing notes at 6:30 p.m..
During an interview on 01/30/2014, after 8:39 a.m., Staff #4 and 15 confirmed the problems with the medication.
Review of a policy and procedure named "Treatment of Psychiatric Patient" dated 03/08/2011 revealed:
"Whenever possible, the same nurse should be responsible for assessing, treating, and communicated with the patient."
"If patient becomes violent or actions present a threat to patient's safety or that of others, restraint may be necessary. Receive order for physical or chemical restraints from ER physician."
*Review of a "Record of Admission" dated 11/29/2013 revealed Patient #9 was a 60 year old female admitted with a diagnosis of a urinary tract infection. Review of physician orders dated 11/29/13 revealed Patient #9 also had diagnoses of diabetes mellitus and dementia.
Review of an "Initial Physical Assessment" dated 11/29/2013, 9:35 p.m. revealed Patient #9 had side rails up x 4 and bed alarms were placed on. According to the assessment the patient was up ad lib with assist. Patient #5 was at extreme high risk for falls.
Review of a telephone orders dated 12/01/2013, 11:00 a.m. revealed the following:
"Change Ativan 2 mg IVP/IM q 6 hour prn agitation. Use wrist restraints as needed."
The orders did not have parameters or justification listed and they were written on an as needed basis.
Review of "Patient Progress Notes" dated 12/01/2013, at 11:10 a.m. revealed Patient #9 pulled her IV out ....orders received for restraints. At 12:10 p.m. Wrist restraints applied to keep patient from pulling IV and Foley out.
Review of another set of physician orders revealed an order was written for soft wrist/ankle restraints on 12/01/2013 at 1:00 p.m. This set of orders did not give complete parameters for usage. On 12/02/2013 a telephone order was received for wrist restraints, but the physician did not sign it. There was no way to tell if the order was renewed within a maximum 24 hour timeframe. On 12/03/2013 another wrist restraint order was received. None of the physician orders had parameters listed for when to release and reposition.
Review of the Restraint Protocol sheet on Patient #9 revealed she was in wrist restraints from 12/01/2013 at 1:04 p.m. -12/03/2013, 12:00 p.m. There was no documentation of releasing and repositioning on the form for a 30.5 hour during a 3 day timeframe.
* Review of physician orders dated 01/24/2014, 10:15 a.m., revealed Patient #2 was a 78 year old male admitted after a right femur fracture and status post ORIF. There was an order for physical activity as tolerated.
Review of the "Initial Physical Assessment" form dated 01/24/2014 at 12:30 p.m., revealed Patient #2 was at extreme high risk for falls. One of the interventions on the assessment was to use side rails X 4.
Review of "Patient Progress Notes" revealed side rails X 4 were to being used on the following dates/times:
01/24/2014 at 7:10 p.m.
01/25/2014 at 7:05 a.m. and 7:01 p.m.;
01/26/2014 at 705 a.m. and 7:00 p.m.;
01/27/2014 at 1:15 p.m. bed alarm on and at 6:59 p.m. side rails up x 4.
Review of the record revealed no physician orders for restraint usage.
Review of Patient #2's record revealed the following documentation of turning from 01/24-01/27/2014:
01/24/2014 at 7:10 p.m.;
01/25/2014 at 7:05 a.m. and again at 7:00 p.m.;
01/27/2014 at 6:58 p.m. and again at 10:32 p.m...
There was no documentation of every 2 hours turning, repositioning and releasing from restraints.
During an interview on 01/29/2014 at 5:00 p.m. Staff #5 confirmed there was no every 2 hour turning documented. Staff #2 confirmed they considered the side rails to be restraints, but there was no orders written on Patient #2.
Review of the policy named "Restraints" dated 10/17/2011 revealed the following:
All patients have the right to be free from restraints that are not medically necessary or used for purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not a substitute for less restrictive forms of protective needs of the patient prior to the application or restraints or medical protective device.
The order must:
Never be written as a standing or on an as needed basis (that is, PRN)
Orders for restraint must specify the reason (medical necessity and should indicate that restraint use is to improve the patient's well-being) for the restraint, the type of restraint, the extremity or body part(s) to be restrained and the duration (timeframe) for restraint application .....
The condition of the restrained patient must be continually assessed, monitored and reevaluated.
Restraint orders shall be rewritten at a maximum of every 24 hours after a face to face evaluation by the patient's treating physician, delegated physician's assistant or advance practice nurse, and continued restraint use id fount to be clinically justified.
Each written order for a physical restraint or seclusion is limited a time frame of:
Four (4) hours for adults
The patient plan of care should indicate that restraints are in use and refer the caregiver to the restraint flow sheet.
Changing position and releasing soft restraints will be performed at a minimum of every two (2) hours.