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Based on observation, interview, and record review, the facility failed to provide a safe environment for patients in the Emergency Department (ED), Outpatient Cardiopulmonary Rehabilitation, and Surgical Departments by failing to test emergency equipment on a daily basis or as required by facility policy. These failures had the potential to affect any patients in need of emergency resuscitation in these areas of the facility. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Crash Cart Maintenance," dated 01/19/12, showed the following direction:
- The Patient Care Coordinator (PCC - Nursing Supervisor for that shift) is responsible for ensuring that the following items on each crash cart are checked each 12 hour shift:
- Crash cart is plugged into a wall outlet and that the monitor and suction machines are plugged into the crash cart;
- The "Battery Charging" LED is lit on the monitor/defibrillator (used to convert an abnormal cardiac rhythm into a normal rhythm);
- Adequate paper is present in the monitor;
- Items listed on the Inventory List for the "top of the cart" are present;
- Drug drawers are locked;
- Cart is locked;
- Lock numbers are consistent with most recent inventory list;
- Defibrillator is functioning properly; and
- Oxygen tank is full.
- The PCC is responsible for ensuring that all inventory items are present and the cart is relocked after the lock has been broken for any reason.
- The current inventory list is kept on top of each crash cart. When a new inventory list is initiated, the previous list should be routed to the Nursing Office.
- During the first week of each month, the night shift Patient Care Coordinator is responsible for opening crash cart to verify that all inventory items are present, the laryngoscope batteries are functioning and that all items with expired out-dates are replaced.

2. Observation on 03/12/12 at 2:30 PM showed two crash carts in the ED area of the facility. One cart was identified as the "Pediatric Crash Cart" and one was identified as the "Adult Crash Cart." Observation on 03/12/12 at 2:30 PM showed two crash carts in the ED area of the facility. One cart was identified as the "Pediatric Crash Cart" and one was identified as the "Adult Crash Cart." A checklist on each crash cart indicated the days of the month and provided space for staff to document what they checked during that shift. The Pediatric Crash Cart checklist showed five items to check:
- All drawers locked;
- Master lock # (the number listed on a temporary lock intended to prevent unauthorized access to the cart, but easily removable in the case of an emergency);
- Ambu bags (used to pump oxygenated air into the lungs during resuscitation) present (pediatric and infant);
- Scapehood (a protective device that fits over the head to protect the wearer from chemical, biological, radiological or nuclear particulates); and
- Pediatric drug book.
The Adult Crash Cart checklist showed seven items to check:
- Defibrillator check;
- Electrodes;
- Monitor paper;
- Cart lock #;
- Clipboard with checklist;
- Ambu bag present; and
- CPR board (a hard surface device placed under a patient during cardiac compressions).

Review of both Crash Cart checklists showed that on three days (03/02/12, 03/07/12, and 03/09/12), neither the pediatric or adult crash cart had been checked on the 7PM to 7AM shift.

3. Observation on 03/14/12 at 3:05 PM showed one crash cart in the Outpatient Cardiopulmonary Rehabilitation area of the facility. The cart had a clipboard with multiple papers (spanning the previous year) on which the following columns were handwritten: Date, Time, Lock #, Battery, and Signature.

During an interview on 03/14/12 at 3:10 PM, Staff CC, Registered Nurse (RN) stated she checked the Crash Cart when the Cardiopulmonary Rehabilitation Unit was open, which was Monday, Wednesday and Friday.

Review of the checklist showed that beginning the crash cart was not checked on 02/14/12 and 03/09/12.

During an interview on 03/14/12 at 4:00 PM, Staff A, Vice President of Patient Care Services, stated that the Outpatient Cardiopulmonary Unit should follow the "Crash Cart Maintenance" policy, and should use an approved checklist to document crash cart checks.

4. Observations in the sterile area of the operating suites on 03/12/12 at 3:55 PM showed a crash cart equipped with an automated external defibrillator (AED-a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias).

During an interview on 03/12/12 at 4:00 PM, Staff I (Operating Room Manager) stated that staff checks the unit to ensure it is operational (function test/battery charge level) and records the information on a chart. She stated that they did not check the unit regularly and it had been a while since it was last checked. She stated it is only checked on days they have surgery or do procedures in the OR. She looked on the log and stated the last time the AED had been checked was September 2011, approximately seven months ago. She stated that she did not think they had a specific policy regarding the AED's and frequency of performance capability checks.

Record review on 03/12/12 showed the facility had completed approximately 250 surgical cases since September 2011.






04467

Based on interview and record review, the facility failed to ensure that nonclinical areas of service were incorporated into the facility-wide performance improvement program when it failed to include data from Maintenance, Housekeeping and Laundry Services for review. The facility census was 11.

Findings included:

1. Record review on 3/13/12 at 10:10 AM showed the maintenance department had documented development of quality improvement projects, but failed to show evidence of on-going data collection or measurable progress on identified projects.

During an interview on 03/13/12 at 10:20 AM, Staff P, Director of Maintenance and Engineering, stated that maintenance was not currently participating in the quality assurance program. He stated that the last time he remembered doing anything with quality assurance or working on performance initiatives was in 2009. He stated that QAPI was "something that we just quit doing."

2. Record review on 3/13/12 at 10:40 AM showed Staff Q, Housekeeping and Laundry (Environmental Services Director) failed to show evidence that quality improvement projects were developed or initiated.

During an interview on 03/14/12 at 10:40 AM, Staff Q, Housekeeping and Laundry Supervisor, stated that Housekeeping and Laundry were not currently submitting any paperwork or written data scorecard information for the purpose of quality improvement. She stated that information from patient survey cards and random issues she identified during her daily tours within the facility were combined presented to her staff as "in-services" with corrective actions. She stated that survey results were submitted to the facility's Senior Vice President, but did not think this data was reported beyond the Senior Vice President's office, and did not think it was part of a facility-wide quality improvement process.

During an interview on 03/14/12, at 4:00 PM, Staff D, Senior Vice President, stated that she was responsible for tabulating patient data from Maintenance, Housekeeping-Laundry (Environmental Services), Dietary and four Rural Health Care Clinics as part of the facility's quality improvement initiative. She said that reports on Quality Assurance information have been lacking due to management changes, emphasis on retraining, and staff changes. She stated that the current process was to "roll up" data on deficient practices or complaints from patient survey results and communicate the identified issues with the responsible department.

Based on interview and record review, the facility failed to have a full time, part time, or contracted Pharmacist in charge of Pharmaceutical Services. The facility had only a verbal agreement for the Pharmacist to be in the facility two days per week. The facility did not obtain a credentialing file, personnel file or background information on the Pharmacist. The severity and cumulative effect resulted in the facility being out of compliance with 42 CFR 485.635 Condition of Participation: Provision of Services. The facility census was 11.

Findings included:

Record review of the facility organizational chart showed Staff Y, Pharm. D. (Doctor of Pharmacy), as the Director of Pharmacy for the facility.

During an interview on 03/13/12 at 1:20 PM, Staff X, Certified Pharmacy Technician and Manager in Charge, stated that Staff Y was the Director of Pharmacy and that he was present in the Pharmacy every Thursday and Friday.

During an interview on 03/13/12 at 3:35 PM, Staff A, Vice President of Patient Care, stated that Staff Y was a contracted Pharmacist but didn't know if there was a contract or not. Staff A later stated, "We do not have a contract with Staff Y."

During an interview on 03/13/12 at 4:30 PM, Staff V, Chief Executive Officer (CEO) and Staff W, Vice President of Finance and Human Relations, Staff V stated that the facility did not have contract with Staff Y. Staff W stated that the Human Relations Department did not have a personnel file for Staff Y.

During an interview on 03/14/12 at 10:10 AM, Staff V stated that he called the former CEO of the facility and was told that Staff Y had always worked under a verbal agreement to be at the facility two days per week. A written contract or employee agreement would clearly define the responsibilities of the pharmacist and include development, supervision and coordination of all the activities of pharmaceutical services.

Based on observation, interview and record review, the facility failed to:
- Store controlled substance medications under a dual locking control system; and
- Follow the facility policy directing staff to date and time multi-use bottles after opening them to indicate an expiration date. Failure to discard solutions after a single use or discard them within a reasonable timeframe potentially exposed patients to solutions that are contaminated or ineffective. These failures had the potential to affect all patients in the facility. The facility census was 11.

Findings included:

1. Record review of the facility's policy and procedure titled, "Controlled Drug Distribution" dated 05/09/08, showed the following instructions for the purchase, storage, distribution and accounting of controlled drugs (Classification of Controlled Drugs by Schedule, including a summary of legal requirements for prescription, storage, record keeping and destruction):
Security: All controlled drugs in schedules II, III and IV will be stored in double locked security. Only licensed personnel or authorized personnel under the direct supervision of licensed personnel shall have access to controlled drugs stored within the hospital. Licensed personnel include nurses, pharmacists and physicians. Unlicensed personnel under the direct supervision of pharmacists include pharmacy technicians.

Record review of the facility's policy titled, "Use of MultiDose Vials (MDV's) dated 05/09/08, showed the following direction:
- Only injectable drugs designated as multidose drugs shall have the container used more than once. Any drugs that are designated single use that have drug remaining in the container after use shall be disposed of according to appropriate hospital procedure.
- The expiration date for MDV will be the manufacturer's recommended date listed on the vial, if not opened. After opening, the expiration will be 30 days unless insulin, which is 28 days.
- The healthcare provider will write the expiration date on the vial when it is opened for those vials that are not marked by the manufacturer.
- The Pharmacy Department shall verify that MDV's are stored and labeled correctly when inspecting medication storage areas.

2. During an interview on 03/13/12 at 1:20 PM, Staff X, Certified Pharmacy Technician and Manager in Charge made the following statements:
- When controlled substance medications were delivered to the pharmacy, she locked them in a storage container until the pharmacist was present (only on Thursdays and Fridays) to verify them for distribution. Staff X stated that Staff Y, Pharmacy Director, also had a key to the storage container. Staff X stated that she could open and lock the container by herself and it was not under dual control or supervision.
- Controlled substance medications were also stored in another location, and pointed to a large metal container by the pharmacy door. Staff X stated that she had a key and could open and close the container by herself and without supervision or a dual locking control system. Staff X stated the Pharmacist also had a key to this storage container.

3. Observation on 03/12/12 from 1:50 to 2:20 PM in the Surgical area of the facility showed the following:
- An opened injectable vial of Lidocaine HCI 2%, 20mg/ml (used for topical anesthesia) approximately 25% full in the surgery suite. The vial was not dated and timed, therefore it is unknown how long the solution had been in use and when it should be discarded.
- An opened bottle of 70% Isopropyl Alcohol (used as an antiseptic) in the surgical suite storage cabinets. The bottle's seal was broken and had approximately 10% of the solution missing. The bottle was not dated and timed so it is unknown how long the solution had been in use and when it should be discarded.

During an interview on 03/12/12 at approximately 2:10 PM, Staff I, RN (Registered Nurse), Operating Room (OR) Manager, made the following statements:
- Multidose vials were not stored or used for more than one patient.
- The opened bottle of Alcohol should not have been placed back in the cabinet after being opened.

4. Observation on 03/12/12 at 2:30 PM showed an opened bottle of Hemoccult solution (used to detect blood in stool specimens) in an Emergency Department (ED) room. The bottle was not dated and timed, therefore it was unknown how long the solution had been in use and when it should be discarded.

During an interview on 03/12/12 at 2:35 PM, Staff F, RN, stated the bottle should have been dated and timed when it was opened.

5. Observation on 03/13/12 at 1:30 PM showed Staff R, RN, changed a surgical dressing on Patient #11's abdomen. Staff R poured water from a 250 milliliter (ml) bottle onto a gauze dressing, then placed the dressing into Patient #11's wound. The bottle of water was not full when Staff R began the dressing change, and the bottle was not dated or timed. Therefore, it was unknown how long the solution had been in use and when it should be discarded.

During an interview on 03/14/12 at 2:45 PM, Staff A, Vice President of Patient Care Services, stated that the facility had a policy for multidose vials, but did not have a policy for multi-use bottles of solution. She stated she considered the standard of practice to be dating and timing multi-use bottles when they were opened, however nursing staff had not been trained to do this.


28722

Based on observation, interview and record review, the facility failed to:
- Follow hand hygiene and gloving guidelines to prevent the risk of transmission of organisms for four (#2,#3, #11, and #12) of four patients observed during nursing procedures; and
- Provide cleanable surfaces in the "Special Procedures" room located within the surgery suite, which affected all patients accessing services in that room. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," revised 06/05/11, showed the following direction:
- Decontaminate hands before and after having direct contact with patients;
- Decontaminate hands before and after using gloves;
- Decontaminate hands after contact with a patient's intact skin;
- Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing if hands are not visibly soiled;
- Decontaminate hands if moving from a contaminated body site to a clean body site during patient care.

2. Observation on 03/13/12 at 8:50 AM showed Staff K, Registered Nurse (RN), washed hands and donned gloves. Staff K prepared an inhalant solution and handed it to Patient #2. Staff K removed and discarded her gloves and documented on the computer but did not perform hand hygiene. Staff K donned another pair of gloves without performing hand hygiene and adjusted the IV (tubes within the patient's vein) line, touched her hair and face, re-adjusted the IV line and removed the gloves.

3. Observation on 03/13/12 at 9:15 AM showed Staff Z, Student Nurse and Staff AA, Nursing Instructor, adjusting an IV site on Patient #3. Staff Z donned gloves without performing hand hygiene. Staff AA removed gloves and donned a new pair of gloves without performing hand hygiene. Staff K entered the patient's room, washed hands and donned gloves. Staff K hung a bag of antibiotic IV solution and attached it to the patient's IV tubing in his arm. Staff K removed her gloves, but did not perform hand hygiene before she began typing on the computer.

4. Observation on 03/13/12 at 9:15 AM showed Staff R, RN, preparing to administer medications to Patient #11. Staff R did not perform hand hygiene before entering Patient #11's room with the medication cart. As she removed medications from the cart, Staff R repeatedly touched a computer screen attached to the cart to enter data showing what medication she was administering. Without performing hand hygiene, Staff R emptied each medication package into her bare palm, then used her fingers to transfer the medication to a pill cup. When she had opened all the medications, she presented the medication cup to Patient #11 to take. Staff R did not perform hand hygiene when she exited Patient #11's room.

5. Observation on 03/13/12 at approximately 9:20 AM showed Staff R preparing to administer medications to Patient #12. Staff R did not perform hand hygiene before entering Patient #12's room with the medication cart, but then went back to the alcohol dispenser and performed hand hygiene after this surveyor did so. As she removed medications from the cart, Staff R repeatedly touched a computer screen attached to the cart to enter data showing what medication she was administering. Without performing hand hygiene, Staff R emptied each medication package into her bare palm, then used her fingers to transfer the medication to a pill cup. Several medications required that the medication be broken in half to administer the correct dose. Without performing additional hand hygiene, Staff R used her fingers to break the tablets in half, then dropped the medication into the pill cup with the other medications. When she had opened all the medications, she presented the medication cup to Patient #12 to take.

6. During an interview on 03/13/12 at 11:20 AM, Staff J, Patient Care Coordinator (PCC - Nursing Supervisor for that shift), stated that at the beginning of a shift, the PCC was responsible for removing medications from the Omnicell (an automated pharmacy dispensing system) and loading them into a portable cart used during administration of medications to patients. Staff J stated that when he loaded the medication cart with medications in the morning, he wiped the cart, screen and handles with antiseptic wipes, but could not verify whether this was the routine of all staff performing PCC duties. He also stated that nursing staff were expected to perform hand hygiene when entering and exiting patient rooms, and stated that nursing staff should be able to drop medications out of packages directly into pill cups without handling the medications. If medications needed to be split, Staff J stated that the expectation was to perform hand hygiene just before touching the medication that had to be split.

7. Observation on 03/13/12 at 1:20 PM showed Staff R preparing to change a wound dressing for Patient #11. After removing the soiled dressing from Patient #11's abdomen, Staff R removed and discarded her soiled gloves. She then went to an intravenous solution pump that was alarming, adjusted the machine, and without performing hand hygiene, applied clean gloves before continuing with application of a clean dressing. After removing the second pair of gloves, Staff R reached into her uniform pocket to answer a cell phone. After returning the phone to her pocket, Staff R then performed hand hygiene.

During an interview on 03/14/12 at 12:50 PM, Staff A, Vice President of Patient Care Services, stated that nurses are to perform hand hygiene before and after touching patients, and should perform hand hygiene before applying gloves, after removing gloves, and between any glove changes.

8. Observation on 03/12/12 at 2:00 PM showed porous ceiling tiles in a suspended ceiling of a room identified as "Special Procedures Room" located in the surgery suite.

During an interview on 03/12/12 at 2:10 PM, Staff I, Operating Room Manager, stated that the room was used almost exclusively for endoscopy procedures (visual examination of the upper digestive system with a tiny camera on the end of a long, flexible tube) and other small outpatient surgeries requiring only local anesthetic or conscious sedation.

The 2010 guidelines for design and construction of health care facilities in chapter 2 requires that ceilings be washable or scrubbable.


27029




28722

Based on interview and record review, the facility failed to annually review and keep current policy and procedure manuals for Nutrition Services with the advice of professional personnel as required by regulation. The facility census was 11.

Findings included:

1. Record review of the Nutrition Services "Annual Review Worksheet Report," dated 05/03/11 showed the following statements:
- The manual is reviewed yearly by the department director and approved by the Senior Vice President.
- No new policies added to the department manual since the last department review.
- Policies were updated as needed to meet the needs of the department and the customers served by the department.

2. Record review of Nutrition Services' policies and procedures on 03/12/12 at 2:33 PM showed that the policies and procedures for the Nutrition Care Department were last approved on 07/01/2010 by the Registered Dietitian (RD) and the Senior Vice President of Patient Care Services.

3. During an interview on 03/12/12 at 2:33 PM, Staff E, RD, Director of Nutrition Services, made the following statements:
- She thought her policies and procedures were approved and current, but said she apparently forgot to have them approved in 2011.
- She was in the process of reviewing each policy and procedure in the manual, but had not completed the review.
- She stated there were policies and procedures that needed to be revised.
- She stated that she would not get the policies and procedures approved until she completed all revisions.

Based on interview and record review, the governing body failed to ensure that responsibility for the overall operation and management of Outpatient Services was assigned to one individual. This failure had the potential to impact all patients who accessed outpatient/ambulatory services at the facility. The facility census was 11.

Findings included:

Review of the organizational chart showed that Outpatient Services for the facility consisted of three distinct areas: Outpatient Clinics, Rehabilitation Services, and Cardiopulmonary Rehabilitation. Each of these areas had an assigned manager as well as a Medical Director. All three Outpatient areas reported to Staff A, Vice President of Patient Care Services, as did multiple other department managers. The organizational chart showed that there was no one assigned to direct the overall operation of the Outpatient Services.

During an interview on 03/15/12 at 10:00 AM, Staff A stated that Outpatient Clinics, Rehabilitation Services, and Cardiopulmonary Rehabilitation were all considered to be under the umbrella of "Outpatient Services" at the facility, however each manager reported directly to her. Staff A stated the facility did not have a mid-level manager assigned to coordinate and manage all three operational areas.

Based on interview and record review, the facility failed to authenticate (with date, time and signature) Verbal/Telephone orders in eight (#15, #16, #17, #19, #20, #21, & #23) of 19 discharged patient medical records reviewed, and one (#11) of five current patient medical records reviewed. The facility census was 11.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," revised 04/18/11, showed the following direction:
- Verbal orders must be dated, timed and signed within 48 hours by the ordering physician or other practitioner responsible for the patient's care.
- Verbal orders, if signed by a practitioner other than the ordering physician, must be signed by the ordering practitioner within 30 days of the patient's discharge.

Record review of the facility's policy titled, "Physician Orders," dated 12/29/11, showed the following direction:
- All orders should be legible, timed, dated and authenticated.
- The physician is expected to (authenticate) the orders within 48 hours of the time the order was received.
- A verbal order may be authenticated by the prescribing practitioner or another practitioner who is responsible for the care of the patient.
- It is the right and responsibility of the licensed nurse to protect the patient through the exercise of reasonable and prudent nursing judgment regarding prescriber orders which the nurse deems unclear or potentially inappropriate and to verify directly with the prescriber specific contents of the order or the validity of the order.

Record review of the facility's policy titled, "Skin Care & Wound Care Protocols," dated 12/30/11 showed the following direction:
- (The facility) has established policies, procedures and processes to prevent skin breakdown and promote tissue healing through identification of patients with "existing" wounds. These actions are completed through wound team consults as ordered by the physician or completed due to nurse findings upon assessment.
- Initial wound evaluations are to include treatment recommendations and all medical, surgical, and social history pertinent to wound care.
- If the initial wound consult is deemed necessary by the admission Registered Nurse (RN) due to skin assessment findings then the initial dressing/treatment shall be completed. Further actions surrounding recommendations will await physician approval/signature.

2. Record review of discharged Patient #15's medical record showed a physician's verbal order dated 02/15/12 at 12:48 AM. The order was not signed, dated, or timed by the physician.

3. Record review of discharged Patient #16's medical record showed a physician's verbal order dated 12/02/11 at 1:23 PM. The order was not authenticated by the physician until 12/08/11.

4. Record review of discharged Patient #17's medical record showed the following:
- A physician's verbal order dated 01/05/12 at 5:40 PM. The order was not authenticated by the physician until 02/06/11.
- A physician's verbal order dated 01/06/12 at 10:55 AM. The order was not authenticated by the physician until 02/06/11.
- A physician's verbal order dated 01/06/12 at 1:20 PM. The order was not authenticated by the physician until 02/06/11.
- A physician's verbal order dated 01/06/12 at 1:50 PM. The order was not authenticated by the physician until 02/06/11.
- A physician's verbal order dated 01/06/12 at 1:55 PM. The order was not authenticated by the physician until 02/06/11.
- A physician's verbal order dated 01/10/12 at 5:17 PM. The order was not authenticated by the physician until 02/06/11.

5. Review of discharged Patient #19's medical record showed the following:
- A physician's verbal order dated 12/16/11 at 10:55 AM. The order was signed by the physician, but was not dated or timed.
- A physician's verbal order dated 12/16/11 at 5:40 PM. The order was signed by the physician, but was not dated or timed.
- A physician's verbal order dated 12/17/11 at 11:00 AM. The order was signed by the physician, but was not dated or timed.
- A physician's verbal order dated 12/17/11 at 11:30 AM. The order was signed by the physician, but was not dated or timed.
- A physician's verbal order dated 12/17/11 at 1:05 PM. The order was signed by the physician, but was not dated or timed.

6. Review of discharged Patient #20's medical record showed the following:
- A physician's verbal order dated 01/19/12 at 5:20 PM. The order was signed by the physician, but was not dated or timed.
- A physician's verbal order dated 01/19/12 at 5:30 PM. The order was signed by the physician, but was not dated or timed.
- A physician's verbal order dated 01/20/12 at 3:40 PM. The order was signed by the physician, but was not dated or timed.

7. Review of discharged Patient #21's medical record showed the following:
- A physician's verbal order dated 12/07/11 at 3:57 PM. The order was not authenticated by the physician until 01/06/12.
- A physician's telephone order dated 12/08/11 at 9:38 AM. The order was not authenticated by the physician until 01/06/12.

8. Review of discharged Patient #23's medical record showed the following:
- A physician's verbal order dated 01/19/12 at 12:13 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/19/12 at 1:25 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/19/12 at 4:25 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/20/12 at 1:34 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/21/12 at 12:20 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/21/12 at 5:00 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/21/12 at 6:30 PM. The order was not authenticated by the physician until 02/20/12.
- A physician's verbal order dated 01/22/12 at 12:05 PM. The order was not authenticated by the physician until 02/20/12.

9. Record review of current Patient #11's medical record on 03/13/12 at 9:40 AM showed that Patient #11 was admitted to the facility on 03/11/12. He had an open wound on his abdomen from a surgical procedure on 02/14/12, and required wound care to promote closure of the wound. Admission orders by his physician, Staff HH, did not include instructions on how to care for the open wound. On 03/12/12, the wound was measured and evaluated by a Registered Nurse, and recommendations for wound care were documented on a form titled "Initial Wound Assessment." At the bottom of this form was a line for the physician to sign the document, thereby giving approval for the wound care recommendations to go into effect. The physician had not co-signed the document as of 03/13/12.

During an interview on 03/13/12 at 11:10 AM, Staff J, Patient Care Coordinator, stated that nursing staff sometimes had to provide wound care without a physician order if the physician was not timely in writing an order specifying how wounds should be dressed. Staff J stated that in this instance, the wound assessment form had been faxed to the physician's office and it was also placed prominently in the patient's medical record so that the physician would see it when he made rounds, and hopefully, review and co-sign it that day.

During an interview on 03/14/12 at 10:30 AM, Staff A, Vice President of Patient Care Services stated the facility utilized the wound care protocols contained within the "Skin Care & Wound Care Protocols" policy, but these were not considered to be "physician orders" until they were co-signed by the physician. Staff A stated that wound care recommendations were processed the same as telephone or verbal orders, and that within 48 hours, the physician was expected to either reject the recommendations and write a new order or sign, date, and time his or her acceptance of the recommendations. Staff A stated that nursing staff were obligated to assess and perform wound care while waiting for the physician to write appropriate orders, and that it was unfortunate that Staff HH was not timely in providing specific orders for wound care.

Additional review of Patient #11's medical record at 2:00 PM on 03/13/12 and again at 10:30 AM on 03/14/12 showed that Staff HH had not written wound care orders and had not co-signed the wound care recommendations written on 03/12/12. Review of nursing documentation on 03/14/12 at 10:30 AM showed that Patient #11's wound had been cleaned and redressed four times without a corresponding physician order.

10. During an interview on 03/14/12 at 3:45 PM, Staff M, Director of Health Information Management (HIM), confirmed that the facility was not in compliance with the regulations regarding authentication of physician orders.


28722

Based on interview and record review, the facility failed to keep current policy and procedure manuals for the Health Information Management Department. The facility census was 11.

Findings included:

1. Record review of the Health Information Management (HIM) Department's policies and procedures on 03/13/12 at 10:23 AM, showed that the policies and procedures for the HIM Department were last reviewed, revised and approved in 2007 by the HIM Director and the Senior Vice President of Patient Care Services.

During an interview on 03/12/12 at 2:33 PM, Staff M, Director of HIM, stated the following:
- The HIM Department did not have policies and procedures regarding the frequency of reviewing, revising and approving the department's policies and procedures.
- She had only been employed by the facility for a few months and had initiated the process of revising each policy and procedure in the manual, but had not completed the revision.
- She stated that she did not have the following outdated policies and procedures revised regarding the department's operations:
A current policy that ensured the identity of the author of each entry was correct.
A current policy that ensured staff stored and maintained medical records in locations to protect them from damage, fire, theft and flood.
A policy that addressed the compiling and retrival of data of quality assurance activities.
- She stated that she would not get the policies and procedures approved until she completed all revisions.

Based on interview, and record review, the facility failed to ensure that a history and physical was completed for each episode of care and within 24 hours of admission for two (#11 and #12) of five current patient medical records reviewed, and two (#19 and #20) of 19 discharged patient medical records reviewed. The facility census was 11.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," revised 04/18/11, showed the following direction:
- A complete physical examination and medical history shall be completed no more than 30 days before or 24 hours after admission by a physician, physician assistant, or nurse practitioner who has privileges to practice at (facility). The medical history and physical will be placed in the medical record within 24 hours of admission. When the medical history and physical are completed within 30 days before admission an updated medical record entry documenting an examination for any changes in the patient's condition will be completed and placed in the medical records within 24 hours after admission.

2. Record review of current Patient #11's medical record on 03/13/12 at 10:05 AM showed that Patient #11 was admitted to the facility on 03/11/12 after being evaluated in the Emergency Department (ED) for severe nausea and vomiting. An admitting history and physical was not present in the medical record.

3. Record review of current Patient #12's medical record on 03/13/12 at 10:30 AM showed that Patient #12 was admitted to the facility on 03/07/12 after being evaluated in the ED for uncontrolled blood sugar levels. An admitting history and physical was not present in the medical record.

4. During an interview on 03/13/12 at 11:05 AM, Staff J, Patient Care Coordinator, called the Medical Records office and was informed that a history and physical had not been dictated for either Patient #11 or Patient #12. Staff HH, physician, was the attending physician for both patients.

During an interview on 03/14/12 at 9:30 AM, Staff V, CEO, stated that he had spoken with Staff HH, and Staff HH stated he had been the physician for both patients when they were seen in the ED. Staff HH said he thought that his Emergency Room Note was sufficient for use as an admission history and physical for both patients.

Additional review of Patient #11's medical record on 03/14/12 at 10:30 AM showed that the Emergency Room note was then present in the medical record and contained sufficient information to be used as a history and physical. However, it was not transcribed until 03/13/12.

Additional review of Patient #12's medical record on 03/14/12 at 10:30 AM failed to show evidence of the Emergency Room note.

5. Record review of discharged Patient #19's medical record on 03/14/12 at 2:47 PM showed that Patient #19 was admitted to the facility on 12/15/11 and discharged on 12/17/11. An admitting history and physical was not dictated by the physician until 02/05/12.

6. Record review of discharged Patient #20's medical record on 03/14/12 at 2:40 PM showed that Patient #20 was admitted to the facility on 12/05/11 and discharged on 01/20/12. An admitting history and physical was not dictated by the physician until 02/05/12.


05760

Based on interview and record review, the facility failed to authenticate (with date, time and signature) entries in three (#15, #19 & #20) of 19 discharged patients' medical records reviewed, and one (#11) of five current records reviewed. The facility census was 11.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," revised 04/18/11, showed the following direction: All medical record entries will include the date and time the entry was made.

Record review of the facility's policy, "Skin Care & Wound Care Protocols," dated 12/30/11 showed the following directions:
- Photographs should be printed and placed under the consult tab in the patient's chart with location of wound, date of evaluation, and initials of nurse/physician completing evaluation.
- Initial wound consults are to be completed upon admission by the admitting nurse or as delegated by the Patient Care Coordinator (PCC - Nursing supervisor for that shift).
- Assure all wound evaluation forms are dated and timed on date assessed.

2. Record review of discharged Patient #19's medical record on 03/14/12 at 2:47 PM showed that an admission History and Physical and physician progress notes for 12/15/11, 12/16/11 and 12/17/11 were dictated on 02/05/12, but these were not authenticated by the physician with time, date and signature.

3. Record review of discharged Patient #20's medical record on 03/14/12 at 2:40 PM showed that an admission History and Physical and one physician progress note for 01/20/12 were dictated on 02/05/12, but these were not authenticated by the physician with time, date and signature.

4. Record review of current Patient #11's medical record on 03/13/12 at 10:05 AM showed the following:
- A form titled "Initial Wound Assessment," showed the signature of the nurse completing the assessment and a re-assessment date was indicated, but the form was not dated or timed.
- A photograph showed a wound with measurements noted, but the photograph did not include the name of the patient, the location of the wound, the date and time of the photograph, or the signature of the person who took the photograph.

During an interview on 03/13/12 at 11:15 AM, Staff J, PCC, stated that although the Initial Wound Assessment form did not provide a place to record the date and time that the document was completed, this information should have been added by the nurse completing the assessment. Staff J also stated that the photograph should have been dated, timed, and signed, and should have included information to indicate the name of the patient and the location of the wound.

6. During an interview on 03/14/12 at 3:45 PM, Staff M, Director of Health Information Management (HIM), confirmed that the facility was not in compliance with the regulations.


28722

Based on observation, interview and record review, the facility failed to ensure the confidentiality of patients' medical records were safeguarded and protected from the possibility of loss, destruction or unauthorized persons reviewing them by:
- Storing archived medical records within an external building that could only be accessed by maintenance staff;
- Failing to protect medical records from water and fire damage, etc. by storing archived records in a building that was not connected to the facility's fire alarm system;
- Posting protected health information in patient rooms for 11 of 11 patients currently receiving inpatient medical care at the facility; and
- Failing to secure protected health information that was awaiting shredding in the Cardiopulmonary Unit of the facility. The facility census was 11.

Findings included:

1. Record review of the facility's policy "Patient Rights," dated 07/09/09 showed the following directions:
- The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law.
- The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties.

Record review of the facility's policy "Retention of Medical Records," dated 01/24/12 showed the following direction:
- In accordance with Missouri State Law, the facility will retain patient records for 10 years from the date of last hospitalization for that patient, or until the patient's 25th birthday, whichever is longer.

2. Observation on 03/13/12 at 2:18 PM showed Staff N, Maintenance Worker, got a key and unlocked the door to a room in the rear of the Maintenance Department where staff stored approximately 1000-3000 patients' records and boxes of personal health information (PHI). Staff stored the records on metal shelves in the room and they stored approximately 25 boxes of records on the floor spaces between the shelves and along a pathway leading into the room. Staff did not seal the boxes shut, which potentially allowed unauthorized persons to review the contents and it also allowed for contents in the boxes to fall out and become lost. Staff stacked other boxes of records loosely in open folders on the shelves, which could separate if fallen from the shelves.

Inspection of information attached to the boxes showed that the facility did not have a good system for tracking records to be destroyed. The facility had hundreds (approximately 500 or more) of records and X-Ray films past stated destroy dates.

Observation of information contained in the boxes of records showed PHI which included name, address, phone number, social security number, date of birth, age and marital status, diagnoses, treatment orders, insurance information, and billing charges.

During an interview on 03/13/12 at 2:23 PM, Staff N made the following statements:
- The room usually did not get so full that they had to store boxes on the floor, but they had recently received a large volume of boxes to store.
- Staff from a variety of Departments brought records to Maintenance Department and Maintenance staff placed the records in the storage room. Accounting, Billing, X-Ray, Lab, and Outpatient records, were included among the records stored. Only Maintenance Staff had keys to the door.
- Maintenance staff were responsible for placing records in storage and pulling the ones that needed to be shredded according to the destroy dates on the boxes.
- When staff knew that the shred truck was scheduled to make a pick up, Maintenance Staff pulled the records to be destroyed. He stated that the boxes were stacked by the door in the maintenance department so that they were ready for pick up, and that maintenance staff were present in the area from the time the records were pulled until after the truck arrived and destroyed the records.

3. During an interview on 03/13/12 at 2:11 PM, Staff M, Director of the Health Information Management (HIM) Department stated that she had only been at the facility a few months and did not know that other Departments' staff stored records in a locked room within the Maintenance Department. Staff M asked Staff O, Assistant Vice President of Patient Services, if she knew patients' records and personal information were stored in the Maintenance Department, and she stated that she was aware that the Accounting Office, Billing Office, etc. stored records there. She stated that staff from various Departments boxed their records and took them to the Maintenance Department. She stated maintenance staff unlocked the door and put the records away.

4. During an interview on 03/12/12 at 3:15 PM, Staff P, Director of Maintenance and Engineering, made the following statements:
- The storage room was not connected to the facility's fire alarm system and if a fire were to occur in the storage room, no alarm would be sounded in the facility or sent by wire to a central station, county/city dispatcher, or the fire department.
- If the storage room caught fire, observers would have to verbally relay the message or call the fire department themselves.
- All archived and closed records of past patients were filed in the storage room.
- He had the key to the padlocked storage room, and that hospital staff (usually Human Resources or Medical Records) called Maintenance to let them know to come and pick up records.
- Maintenance staff would then bring them out to the storage room and store or send them for shredding accordingly.
- He was not sure if Medical Records had a key to the storage room, because staff usually just called him.


04467

Based upon interview and record review, the Governing Body failed to:
- Ensure that there was an effective, ongoing, comprehensive, hospital-wide quality assurance/performance improvement program, responsible to the Governing Body of the hospital, which would lead to reduced medical errors, adverse events, and improved patient health outcomes;
- Clearly state the number of patient admissions, the volume of services provided, and the average length of stay in hours in their Annual Review;
- Ensure collaborative participation from both clinical and nonclinical areas of service, including those services provided directly and under contract;
- Provide for assessment and coordination of quality improvement activities through an established oversight team that meets on an established periodic basis;
- Ensure policies and procedures were reviewed and revised as necessary on an annual basis; and
- Ensure ongoing communication, reporting and documentation of patient-care issues and quality improvement activities and their effectiveness to the governing body at least quarterly.

The severity and cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review.

Please refer to citations at C-0222, C-0276, C-0280, C-0301, C-0331, and C-0336.

Based on observation, interview and record review, the facility's Annual Review failed to state clearly the number of patient admissions, the volume of services provided, and the average length of stay in hours. The facility also failed to ensure policies and procedures were reviewed and revised as necessary on an annual basis for the Cardiopulmonary Rehabilitation unit. These failures had the potential to affect all patients accessing care at the facility. The facility census was 11.

Findings included:

1. Record review of the facility document, "Annual Review for the Year Ending March 31, 2011," showed the report failed to clearly document the patient admissions, volume of services provided, and the average length of stay in hours. Review showed that some Departments within the facility provided the necessary information, but many did not.

During an interview on 03/14/12 at 9:30 AM, Staff A, Vice President (VP) of Patient Care Services made the following statements:
- Each department director collects data pertinent to the clinical services they provide and forwards this information to Staff A, who uses the information to form the Annual Report. The Annual Report is reviewed by the Quality Council, which consists of the ED Medical Director, the VP of Patient Care Services, the Senior VP, and the CEO.
- No quality data was presented to the Governing Body since the Quality Assurance Committee ceased having meetings in August, 2009.

2. Observation on 03/14/12 at 3:05 PM showed that the policy and procedures for the Cardiopulmonary Rehabilitation Department were reviewed by the Department Manager (for the year 2010) on 08/24/10 and by the Medical Director on 03/24/11.

During an interview on 03/14/12 at 3:30 PM, Staff A stated that the Cardiopulmonary Rehabilitation Department Manager had recently changed, and that the policies had not yet been reviewed and updated. Staff A stated that the facility did not have a policy dictating the process for reviewing and revising policies and procedures, and did not have a written process dictating the timeframe in which the Department's Medical Director was to review the policies.

Based upon interview, record review, and policy review, the Governing Body failed to:
- Ensure that there was an effective, ongoing, comprehensive, hospital-wide quality assurance/performance improvement program, responsible to the Governing Body of the hospital, which would lead to reduced medical errors, adverse events, and improved patient health outcomes;
- Ensure collaborative participation from both clinical and nonclinical areas of service, including those services provided directly and under contract;
- Provide for assessment and coordination of quality improvement activities through an established oversight team that meets on an established periodic basis; and
- Ensure ongoing communication, reporting and documentation of patient-care issues and quality improvement activities and their effectiveness to the governing body at least quarterly.

Findings included:

1. Record review of the facility's policy titled, "Quality Improvement Plan," dated 03/22/11, showed the following directions:
- The scope of the Quality Assessment and Improvement activities includes:
- Monitoring and evaluation of Import Aspects of Care as developed by the clinical departments or services.
- Surgical Case Review is performed by the Medical Staff.
- Drug Usage Evaluation and Pharmacy and Therapeutics functions are performed by the Pharmacy and Therapeutics Committee.
- Medical Records Review is performed by the Medical Records Committee and the Medical Staff
- Blood Usage Review is performed by the Medical Staff.
- Utilization Review is accomplished by the Manager of Utilization Review and is reviewed by the Medical Staff.
- Infection Control is accomplished by the Infection Control Nurse and through quarterly meetings of the Infection Control Committee.
- Safety/Risk Management data and issues are reviewed at the monthly Safety Committee meetings.
- Collecting and organizing data is the responsibility of each Department Manager;
- In those cases where departments or committees discover that data fails to meet established thresholds or benchmarks, action should be taken to solve problems and improve care or service;
- When opportunities to improve care or service are identified and action has been taken, continued monitoring of the important aspect of care and indicators involved should be continued until such time as improvements are identified and sustained;
- The Quality Improvement Program should be evaluated on an ongoing basis to assure that it meets the objectives outlined previously in the plan. The plan should be reviewed annually by Quality Council. Departmental Quality Plans will be evaluated by Quality Council annually;
- Quality Council will meet monthly. The Council is composed of the Executive Staff and at least four other members appointed by the Executive Staff. Each Department Manager will report to Quality Council quarterly. The report will outline results of monitoring and improvement efforts. Quality Council will determine the number of major projects for the hospital;
- Activities of the Quality Improvement Process as it pertains to individual members of the medical Staff will be kept confidential, shared only with those Medical Staff members or Administration who has a need for such information to carry out their responsibilities as defined in the medical Staff Bylaws.

2. Record review of the facility's document titled, "Annual Review for the Year Ending March 31, 2011," which included "Critical Access Annual Review Committee Minutes," dated August 10, 2011, showed that the committee reviewed a synopsis of the scope and services and well as a summary of the quality data collected for the following areas: Social Services, Laboratory, Respiratory Care, Utilization Review, Diagnostic Imaging, Emergency Department, Outpatient Department, Cardio-Pulmonary Rehabilitation, Infection Control, Surgery, Acute and Skilled Nursing Services, Nutritional Services, Rehabilitation, Pharmacy, and Disaster Preparedness. Ancillary services such as Maintenance, Laundry and Housekeeping were not included in the annual report or analysis, nor were contracted services. Data pertaining to Incident Reports, Medication Errors, Complaint/Grievance data, Orientation and Continuing Education, etc. was not included in the annual report or analysis.

Recommendations were made to some of the departments represented in the report. There was no indication that the report was shared with the Governing Body, the CMS approved Quality Improvement Organization (QIO), or with a collaborative facility.

3. Record review of current quality monitoring throughout the facility revealed surveillance in various areas of the facility, but there was no evidence of analysis and systematic performance improvement applications. Department Directors were asked to submit their data, but the data was not always elevated to an appropriate level for review and analysis. A few Departments within the facility had no quality improvement surveillance in place, or had ineffective quality improvement activities.

4. Record review of the Pharmacy records, policies and procedures did not reflect any current quality assurance or performance improvement projects. The Pharmacist was unavailable for interview per Staff V, Chief Executive Officer.

During an interview on 03/12/12 at 1:20 PM, Staff X, Pharmacy Technician, stated that she did not know of any quality assurance or performance improvement projects for the Pharmacy. Staff X stated that the pharmacist may be doing something but she was not aware of it.

5. During an interview on 03/14/12 at 9:30 AM, Staff A, Vice President (VP) of Patient Care Services made the following statements:
- Each department director collects data pertinent to the clinical services they provide. The data is reviewed by the Medical Director, and then the Medical Director presents the data at the Medical Staff meeting, which meets every other month. The Chief of Staff chairs this meeting;
- The Emergency Department (ED) has its own committee, in which quality data is reviewed before being presented to the Medical Staff. The ED committee includes representation from the Admissions office, Laboratory, Emergency Preparedness Coordinator, Social Worker, and nursing staff;
- The Outpatient Services department has its own committee in which quality data is reviewed before being presented to the Medical Staff;
- Surgical Services has its own committee in which quality data is reviewed before being presented to the Medical Staff. Staff from the Surgery and Anesthesia Departments attend those meetings.
- Infection Control has its own committee in which quality data is reviewed before being presented to the Medical Staff;
- Data presented to Staff A is compiled into a packet, and the packet is sent to the members of the Medical Staff prior to their meeting;
- This data is later compiled into the Annual Report, which is reviewed by the Quality Council. The Council includes the ED Medical Director, the VP of Patient Care Services, the Senior VP, and the CEO;
- Non-clinical department directors (e.g., Housekeeping, Maintenance and Dietary) collect their quality data and present this information to Staff D, Senior Vice President. Staff D then presents this data at the Quality Assurance meeting;
- Members of the Quality Assurance Committee include all facility Vice Presidents, the CEO, Director of Information Technology, the facility Dietitian, and a member of the medical staff. The Quality Assurance is chaired by Staff A, and the meeting is stated to occur quarterly. However, the facility has not held a meeting since August, 2009 due to a variety of reasons including a change in the facility's CEO and the programming and implementation of the facility's electronic medical records (EMR) system, for which Staff A was assigned primary responsibility;
- Data that has been reviewed by the Quality Assurance Committee is then presented to the Governing Body, which meets monthly. However, no quality data has been presented to the Governing Body since the Quality Assurance committee ceased having meetings in August, 2009.


27029

Based on interview and record review, the facility failed to:
- Develop and maintain an ongoing activities program that was based on a comprehensive assessment of leisure interests and abilities of Swing-bed patients. (A Swing-bed is a change in reimbursement status. The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing services and reimbursement);
- Designate a qualified professional as the Director of Activities; and
- Ensure that Initial Activity Assessments were completed in a timely manner and utilized to form the basis for a personalized activity calendar for each patient in the swing bed program.
These failures affected all patients admitted to the facility's swing bed program. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Swing Bed" revised 07/19/11, showed the following:
ACTIVITIES:
- The Swing Bed program provides for an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident;
- The Activity Director will complete an "Initial Activity Assessment" for each resident of the Swing Bed program. Using the information obtained through the initial assessment, the Activity Director, in conjunction with the interdisciplinary team, will participate in the development of a plan of care as it pertains to activities;
- The Activity Director will document activity interactions on the Resident Interaction Record;
- The Activity Director will participate in the weekly multi-disciplinary team conference.

2. Observation on 03/12/12 at 1:20 PM showed Swing-bed Patient #3 in bed with his spouse at the bedside. Staff BB, Activity Technician, entered the room and spoke to the patient, who did not respond. She continued to talk to the patient, who then closed both eyes. Staff BB stated she would turn on the radio or television in the afternoon for the patient.

During an interview on 03/12/12 at 1:25 PM, Patient #3's spouse stated the patient hated television and staff had never asked what activities the patient preferred. The spouse stated Patient #3 was diagnosed with Alzheimer's and the spouse was the Power of Attorney. The spouse stated that the patient couldn't express his activity preferences, and that he sometimes smiled and sometimes didn't, but stated he had never liked television.

Record review of Patient #3's care plan showed no documentation regarding preferred activities or goals.

3. During an interview on 03/13/12 at 9:45 AM, Patient #11 stated that staff talked to her about activities, but she didn't really like the choices offered to her - which included listening to a radio, watching TV, reading a newspaper or magazine, and completing a "circle the word" puzzle.

During an interview on 03/13/12 at 11:00 AM, Staff S, Activity Director, stated she had not entered her Initial Activity Assessment for Patient #11 into the electronic medical record (EMR), because she was unsure how and where to document it. She explained that the new EMR was implemented on 02/28/12 and that some components were still not fully operational. Staff S denied having a paper assessment report that could be added to the patient's medical records in the interim. (In an interview on 3/15/12 at 9:15 AM, Staff S admitted she had not yet completed an initial assessment for Patient #11.)

4. During an interview on 03/14/12 at 4:00 PM, Staff S stated her title was Activities Director and Unit Secretary Supervisor, but the Unit Secretary Supervisor was her full time position. Staff S stated her training was as a CNA (certified nursing assistant) and she had not completed a training course approved by the State for the designation of qualified activities professional.

Record review of the facility's Organizational Chart showed Staff S's official title as Unit Secretary Supervisor.

Record review of the personnel file for Staff S in the Human Relations Department showed her title as Unit Secretary Supervisor, not Director of Activities. Staff S's employee orientation reflected orientation as a Unit Secretary, and not Director of Activities. Staff S's annual appraisal reflected only an appraisal of Unit Secretary Supervisor, with no documentation for her performance as Director of Activities.

During an interview on 03/14/12 at 4:00 PM, Staff S stated she had been in the position of Director of Activities for seven years, but did not know where the policies and procedures were for the Activities Department. She stated that she had never attended a multidisciplinary care plan meeting, did not plan the activities calendar and did not participate in any facility committees. Staff S also stated that she had never seen or read the regulations for Swing-bed Patients in a Critical Access Hospital.

5. During an interview on 03/15/12 at 9:37 AM, Staff BB, Activities Technician, stated she worked in the Outpatient Clinic five days a week from 8:00 AM to 5:00 PM. She stated that when the Outpatient Clinic was slow she went to the Swing-bed area to offer activities to patients. Staff BB stated, "I don't think there are any activities on the weekends for swing-bed patients."

Record review of the personnel file for Staff BB in the Human Relations Department showed her title as Outpatient Technician, not Activities Technician. Staff BB's employee orientation reflected orientation as an Outpatient Technician, and not Activities Technician. Staff BB's annual appraisal reflected only an appraisal of her performance in the Outpatient Clinic completed by the Director of Outpatient Services.


28722

Based on interview, observation, and record review, the facility failed to:
- Ensure that a comprehensive, individualized, nursing care plan was developed and kept current for two patients (#3 and #24) of five swing bed medical records reviewed for care plan;
- Provide daily activities for swing bed patients based on a comprehensive assessment of leisure interests and abilities for five patients (#3, #11, #13, #14 and #17) of five swing bed medical records reviewed for activity therapy;
- Include activity therapy on the care plan for five patients (#3, #11, #13, #14 and #17) of five swing bed medical records reviewed for care plan; and
- Include discharge planning interventions on the care plan for four patients (#3, #11, #14 and #17) of five swing bed medical records reviewed for care planning. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Swing Bed," revised 07/19/11, showed the following direction:
- The Director of Nursing, the Nurse Manager on call and Patient Care Coordinator (PCC - Nursing supervisor for that shift) are responsible for ensuring that daily nursing care is provided according to the plan of care.
NURSING SERVICES:
- Using the information obtained through the admission assessment process the Registered Nurse (RN) will develop a plan of care which involves all available resources needed for the resident.
- Daily documentation will include notation of cares and assessments provided on the Swing Bed Nursing Care Flow Sheet. At least one narrative note per week will be completed which addresses the care plan.
ACTIVITIES:
- The Swing Bed program provides for an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident.
- The Activity Director will complete an "Initial Activity Assessment" for each resident of the Swing Bed program. Using the information obtained through the initial assessment, the Activity Director, in conjunction with the interdisciplinary team, will participate in the development of a plan of care as it pertains to activities;
SOCIAL SERVICES:
- The Social Worker (SW) will complete an initial assessment of the resident.
- The SW will document interventions and contacts as needed.
MULTI-DISCIPLINARY CARE CONFERENCE:
- The Multi-disciplinary care conference is held weekly. Residents who are new to the program or who have been in the Swing Bed program for 14 days or 30 days are reviewed during the conference. Documentation will be completed on the care plan.
- The SW or designee will discuss the plan of care and obtain the patients agreement with the plan of care and goals each week.

Record review of the facility's policy titled, "Discharge Planning," dated 06/01/11, showed the following direction:
- Completion of the Discharge Planning process is an inter-disciplinary action, but the Nurse Managers are responsible for ensuring the duty of Discharge Planning is completed as outlined in this policy and for coordinating the actions of the interdisciplinary team.
- The SW in conjunction with the PCC will develop or supervise the development of a discharge plan if the discharge planning screen indicates a need for a discharge plan.
- The SW or PCC will request involvement in the discharge plan by any inter-disciplinary team member needed, involving disciplines with specific expertise as dictated by the needs of the patient. Each member of the interdisciplinary team who participates in the discharge plan will document that involvement in the Medical Record.
- The PCC or the SW, with input from the patient or the patient's representative and those disciplines involved in the discharge plan, will reevaluate the patient's discharge needs periodically.

2. Record review of Patient #11's medical record on 03/13/12 at 10:30 AM showed the following information:
- A Social Worker Assessment was completed on 03/12/12, but review of the care plan did not show discharge planning interventions or goals.
- There was no evidence of an Initial Activity Therapy Evaluation. Review of the care plan showed an entry that read "Activity Participation Assessment," but did not show that an activity plan had been implemented.

During an interview on 03/13/12 at 11:00 AM, Staff S, Activity Director, made the following statements:
- She was responsible for completing patient assessments, and Staff BB, Activity Therapist, did activities with patients.
- It was difficult to plan activities for swing bed patients because they usually stayed a very short period of time and most did not want to leave their rooms for meals. She said there was a multi-purpose room where patients could gather to eat or to perform group activities, but this option was seldom utilized.
- She had not entered activity therapy information into the electronic medical record (EMR) for Patient #11 because she was unsure how and where to document. She explained that the new EMR was implemented on 02/28/12 and that some components were still not fully operational.

During an additional interview on 03/15/12 at 9:15 AM, Staff S made the following statements:
- She attempted to do initial activity assessments "as soon as possible after admission" and stated the assessment was required within the first seven days after admission. Staff S then stated she had not completed an Initial Activity Assessment for Patient #11 yet (day eight).
- Regarding her failure to complete an Initial Activity Assessment, Staff S said that Patient #11 was admitted on 03/07/12. She attempted to do an activity assessment on 03/09/12, but Patient #11 refused. Patient #11 also refused an assessment on 03/12/12 and 03/13/12. There was no documentation in the medical record to indicate these attempts were made.
- Staff BB, Activity Therapist, attended all Multi-Disciplinary Team meetings on behalf of Activity Therapy, and also visited patients every afternoon to offer activities. There was no documentation in the medical record to indicate daily activity therapy interactions.
- On the weekends, nursing staff offered swing bed patients newspapers or other reading materials as their activity therapy for that day. There was no documentation in the medical record to indicate weekend activity therapy interactions.

During an interview on 03/14/12 at 1:45 PM, Staff DD, Social Worker, stated that although she had completed a discharge assessment for Patient #11, discharge planning had not been added to Patient #11's care plan because that module hadn't been built yet. Staff DD stated that she tried to enter daily notes after completing her initial assessment for discharge planning, but didn't always get that accomplished.

3. Record review of Patient #13's medical record showed the patient was admitted on 03/12/12 and the Initial Activity Assessment was completed on 03/13/12, but the record did not reflect any documentation of the patient's preferred activities or goals.

4. Record review of Patient #14's medical record showed the patient was admitted on 03/05/12 and the Initial Activity Assessment was completed on 03/08/12, but the record did not reflect any documentation of the patient's preferred activities or goals.

5. Record review of Patient #17's medical record showed the patient was admitted on 03/07/12 but the Initial Activity Assessment had not been completed as of 03/15/12. The record did not reflect any documentation of the patient's preferred activities or goals.

During an interview on 03/13/12 at 2:50 PM, Staff B, RN, Acute Care Swing-bed Night Shift Supervisor, stated, "We don't develop a care plan, per se [Latin phrase meaning "in itself"], we develop it over 48 to 72 hours and we don't have a policy and procedure for acute care plans".

During an interview on 03/14/12 at 1:30 PM, Staff A, Vice President of Patient Care Services, stated that the facility had seven days to complete a care plan for Swing-bed patients and most of the patients weren't here long enough to complete it because the average length of stay was 2.7 days. Staff A stated that Patient #17 had not received an Initial Activity Assessment, but did not offer the reason for the omission.

During an interview on 03/14/12 at 4:00 PM, Staff S, Director of Activities, stated she was aware that Swing-bed Patient #17 did not have an Initial Activity Assessment and stated that Staff A was aware of it also.


27029

Based on interview and record review, the facility failed to follow its written policy for Discharge Planning for two (#2 and #3) of five current patients medical records reviewed for discharge planning, and five (#4, #5, #6, #7 and #8) of five discharged patients medical records reviewed for discharge planning. Discharge planning is required to ensure appropriateness of discharge, locating and coordinating post discharge services, educational needs and, if necessary, continuing care for the patients. These failures had the potential to affect all patients being discharged from the facility. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled, "Discharge Planning," dated 06/01/11, showed the following direction:
- The initial discharge planning screen should be completed within twelve hours of admission. The screen will include an evaluation of the likelihood of the patient needing post-hospital services and of the availability of the services, the likelihood of the patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which the patient entered the hospital;
- The discharge planning screen will be completed by a Registered Nurse as part of the Admission process and will be documented on the Nursing Admission Data Base;
- Regardless of the outcome of the discharge planning screen, a discharge plan will be developed as ordered by the patient's physician;
- Prior to discharge, the nurse assigned to the patient will be responsible for ensuring the outlined plan for discharge is completed and the plan for discharge is still appropriate for the patient prior to releasing the patient;
- The Discharge Planning Process will be evaluated annually by the interdisciplinary team members or more often if necessary to determine the effectiveness of the program;
- The Patient Care Coordinator (PCC - Nursing supervisor for that shift) and/or Social Worker (SW) will arrange for and supervise the initial implementation of the patient's discharge plan including arranging for necessary post-hospital services and care, and educating patients/family/caregivers/community providers about post-hospital care plans.
- The PCC or the SW, with input from the patient or the patient's representative and those disciplines involved in the discharge plan, will reevaluate the patient's discharge needs periodically.

2. Record review of current Patient #2's medical record showed the patient was admitted on 03/09/12 for COPD (Chronic Obstructive Pulmonary Disease). There was no documentation of discharge planning in the medical record. The medical record reflected the patient had a knowledge deficit related to the disease process but no teaching had been documented. The care plan stated the teaching would be completed by the time the patient was discharged.

3. Record review of current Patient #3's medical record showed the patient was 88 years old and was admitted on 12/09/12 from a skilled nursing facility. The medical record did not reflect any documentation for discharge planning.

4. Record review of discharged Patient's #4, #5, #6, #7 and #8 medical records showed no evidence of discharge summary or discharge planning.

5. During an interview on 03/13/12 at 1:15 PM, Staff A, Vice President of Patient Care Services, stated, "Thanks for finding that, we didn't know it [the discharge planning module] wasn't in the [electronic medical record] system until now". Staff A stated that the Electronic Medical Record (EMR) system was implemented on 02/28/12 and the module for discharge planning had not been included. Staff A explained that if the discharge planning module was not in the EMR then it was also not included in the patients' care plan.