HospitalInspections.org

Based on interview and personnel record review facility staff failed to ensure one staff (Z) of two nurse aides was currently certified as a nurse aide and one staff (O) of one contract dietitian reviewed had current registration of nine personnel records reviewed for required certification and professional registration. The facility failed to show both Staff Z and Staff O were qualified to be in position. This deficient practice had the potential to allow unqualified staff (without documented proof of certification or registration) to provide care to patients at the facility. The facility census was 10.

Findings included:

1. Record review of Staff Z, Nurse Aide's personnel file, showed Staff Z was hired on 01/31/14 and Human Resources (HR) staff failed to obtain proof of certification as a nurse aide.

2. During an interview on 03/07/14, Staff TT, Director of HR confirmed the facility employed only certified nurse aides and failed to obtain documentation showing that Staff Z was a certified nurse aide.

3. Record review of an email dated 03/12/14 from Staff TT showed she had confirmed Staff Z had not completed the examination to become a certified nurse aide. Staff TT further confirmed she would change Staff Z's employment status from certified nurse aide to nurse aide.

4. Record review on 03/06/14 at 2:25 PM of Staff O, contract dietitian's personnel record showed the following:
- Staff O was contracted to work in the facility on 05/12/12;
- Staff O's expired Dietitian's registration card dated 09/01/12 through 08/31/13;
- A hand written note by Staff TT, Director of HR dated 02/27/14 that Staff TT met with Staff O and directed her to provide information to update and complete her personnel record by 03/06/14.

5. During an interview on 03/06/14 at 2:30 PM, Staff TT confirmed that she had previously (on 02/27/14) asked Staff O to provide information including proof of current registration and that Staff O had not complied with the request.

Based on interview and record review the facility failed to have a completed telemedicine (use of medical information exchanged from one site to another via electronic communications using two-way video to review and improve a patient's clinical health status) agreement for Psychiatric services provided to the Behavioral Health Unit (BHU) thru Telemedicine. This deficient practice placed all patients admitted to the BHU at risk for care provided by unqualified medical staff. The facility census was 10 with six of those patients in the BHU.

Findings included:

1. During an interview on 03/05/14 at approximately 2:30 PM, Staff B, Chief Operating Officer (COO), stated that:
- The facility had an attorney draw up the Professional Services Agreement for Telemedicine for the Psychiatric unit.
- It was the intent of the facility to include Advanced Practice Registered Nurses (APRN) in the contract. and
- He was not aware that APRN were not included in Schedule 2 of the contract.

2. Record review of the Professional Services Agreement dated 02/21/14, between the facility and the Telemedicine entity showed:
- In connection with its provision of the Professional Services, Corporation (Telemedicine Entity) shall provide the Professional Services through duly licensed and certified advanced practice registered nurses (APRN), who are employed by or are otherwise engaged by Corporation, who are approved by (the facility) and who are listed on Schedule 2 attached hereto;
- Prior to performing any professional Services under this Agreement, execute an Acknowledgement and Consent agreeing to abide by the provisions of this Agreement, substantially in the form attached hereto as Schedule 2(g)(ii) for APRNs).
Further record review showed Schedule 2 did not contain the name of any APRN and there were no Schedule 2(g) (ii) signed by APRNs.

3. During an interview on 03/04/14 at 3:10 PM, Staff H, physician, stated that he had three APRNs who provided services to patients in the facility under a collaborative agreement with him.




32281

Based on observation, interview, policy review and review of the Association of periOperative Registered Nurses (AORN) guidelines, the facility failed to:
- Appropriately process and store laryngoscope blades (used to assist with the insertion of a breathing tube in the operating room and in emergency situations where a patient cannot breathe on their own). This had the potential to affect all patients in the hospital by increasing the risk of contamination and possible infection of the patient.
- Complete routine testing of crash carts' (portable carts containing emergency equipment and medications) emergency equipment. This had the potential to lead to unsafe or non-working emergency equipment and could affect all patients.
- Secure crash carts in a manner that would prevent access to and removal of crash cart contents. This had the potential to affect all patients, should emergency equipment or supplies be missing during an emergency response. The facility census was 10.

Findings included:

1. Record review of the 2013 Recommended Practices for Sterilization by AORN showed semi critical devices:
- Come in contact with mucous membranes (such as the lining of the mouth and throat);
- Require high level disinfection, and
- Include laryngoscope blades.

2. Record review of the 2013 Recommendations for Selection and Use of Packaging Systems for Sterilization by AORN showed packaging ensures the integrity of the sterilized contents until opened for use.

3. During an interview on 03/05/14 at 9:17 AM, Staff C, Chief Nursing Officer, stated that the facility did not have a policy related to the cleaning process or storage of laryngoscope blades.

4. During observation and concurrent interview on 03/04/14 at approximately 8:15 AM with Staff I, Director of Surgical Services, showed the Anesthesia cart (a set of trays/drawers/shelves on wheels used to dispense medications and supplies for the induction of anesthesia -the condition of having sensation, including the feeling of pain, blocked or temporarily taken away) contained eight laryngoscope blades and the crash cart contained two laryngoscope blades open and not packaged in the Operating Room (OR). Staff I stated that she was responsible for Central Sterile Processing and that they sterilized all reprocessed items for the facility. Staff I stated that she was not aware that laryngoscope blades were to be disinfected or sterilized and packaged between patient uses.

5. During observation and concurrent interview on 03/05/14 at approximately 4:15 PM with Staff V, Manager of Medical/Surgical (Med/Surg), showed the crash cart in Exam Room (ER) One contained five laryngoscope blades were not sterile or stored in sterile packaging. Staff V stated that he did not know laryngoscope blades were to be sterilized and packaged between patients.

6. During observation and concurrent interview on 03/07/14 at approximately 9:25 AM with Staff FFF, Emergency Department (ED) Charge Nurse, showed the crash cart in ER Two contained six laryngoscope blades were not sterile or stored in sterile packaging. Staff FFF stated that she did not know the laryngoscope blades were to be sterilized and packaged between patients.

7. Observation on 03/03/14 at 3:05 PM, showed the Med/Surg unit crash cart contained six laryngoscope blades. The laryngoscope blades were stored together inside an open plastic tray, along with two laryngoscope handles (attaches to the blade to provide a light source when in use), and were not sterile or stored in sterile packaging.

8. During an interview on 03/05/14 at 1:30 PM, Staff HH, Infection Preventionist, stated laryngoscopes were cleaned with soap and water, and did not require sterilization or storage in sterile packaging. Staff HH stated that the laryngoscope blades were stored in a "basket" inside the drawers of the crash carts.

9. Record review of the facility's policy titled, "Crash Carts" dated 01/14, showed the following:
- Every Registered Nurse (RN), Licensed Practical Nurse and Emergency Medical Technician - Paramedic must be familiar with the Crash Carts.
- All defibrillators (records the heart's electrical activity and can deliver electrical current/shock to a patient whose heart has stopped) will be fired (to test the function of the defibrillator charging and depressing a button, creating a small electrical current/shock) every shift while unplugged, and locks checked.
- Firing the defibrillator will be the responsibility of the RN assigned to the particular area.
- Keys to the crash carts will be stored in the magnetic holder on the side or back of crash cart.

10. Observation on 03/03/14 at 3:05 PM, showed the Med/Surg unit crash cart in the patient hallway with a magnetic holder containing keys to the crash cart sitting on the top of the crash cart. The crash cart did not contain an integrity seal (numbered, plastic, breakaway lock) to ensure crash cart contents had not been removed or tampered with.

11. Observation on 03/05/14 at approximately 4:15 PM showed a magnetic holder containing keys to the crash cart sitting on the top of the crash cart in ER One. The crash cart did not contain an integrity seal to ensure crash carts contents had not been removed or tampered with.

12. During an interview on 03/06/14 at 11:13 AM, Staff C, stated that crash cart keys were kept in a magnetic holder on top of the crash carts and that the crash carts were not secured with an integrity lock.

13. During observation and concurrent interview on 03/07/14 at approximately 9:25 AM with Staff FFF, ED Charge Nurse, showed a magnetic holder containing keys to the crash cart in ER two sitting on the top of the crash cart. The crash cart did not contain an integrity seal to ensure crash carts contents had not been removed or tampered with. Staff FFF demonstrated a defibrillator check with the defibrillator plugged into AC power and demonstrated checking the battery by turning off the power switch to the defibrillator and checking the battery light. Staff FFF stated that the policy was to check the defibrillator plugged in.

14. Review of the LifePak 12 Defibrillarory/Monitor - Daily Inspection and Testing Log showed the defibrillator was to be checked daily using battery power.

15. During an interview on 03/07/14 at 11:00 AM, Staff C, stated that defibrillators were to be checked unplugged. Staff C stated that review of the Daily Inspection and Testing Log sheet did not indicate that it was to be tested unplugged. Staff C stated that the policy clearly states yes, "another thing to add to my education list".

16. During an interview on 03/03/14 at 3:00 PM, Staff NW, ED Manager, stated that the ED nurse was responsible for checking all hospital crash carts, and that the crash carts were to be inspected and tested once every 12 hour shift.

17. Record review of the facility's "Defibrillator/Monitor - Daily Inspection and Testing Logs" for the Med/Surg Unit crash cart and two ED crash carts from 11/13 through 02/14, showed 18 required crash cart/defibrillator checks were missed out of a possible 335 opportunities reviewed.

18. Record review and concurrent interview on 03/04/14 at 2:15 PM showed behavioral health unit (BHU) defibrillator was not documented as checked every shift during the last two months. Six of 31 day shifts in 01/14 and eleven of 28 day shifts in 02/14 were not documented as checked. Staff E, BHU Nurse Manager stated that the defibrillator was required to be checked every day and night shift by a nurse and she acknowledged this was not completed on a regular basis during the months of 01/14 and 02/14. She also stated she did not have a policy for the requirement.






32281





31891

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure that preventative maintenance was completed on electrical equipment according to the manufacturer's guidelines to maintain the overall physical environment and ensure safety
- Establish a preventive maintenance program for periodic and regularly scheduled inspections; and
- Document test results and recertification to decrease potential maintenance and safety problems.
This had the potential to lead to malfunctioning or non-working equipment, which could affect the safety of all patients. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Medical Equipment: Inspection and Testing" dated 08/13, showed that the purpose of the policy was to meet National Fire Protection Agency (NFPA) standards for all electrical equipment through the establishment of maintenance procedure and inspection cycles while optimizing safety, effectiveness and efficiency.

2. Observation on 03/03/14 at 3:28 PM, showed a mini refrigerator in the Medical-Surgical (Med/Surg) department medication room. The refrigerator was labeled with a preventative maintenance sticker dated 08/08/12.

3. During an interview on 03/03/14 at 3:28 PM, Staff X, Pharmacy Technician, stated that the refrigerator, which had been stocked with employee influenza vaccinations, should be maintained between 36 and 46 degrees F, and that preventative maintenance of the refrigerator should have been completed annually.


4. Record review of a temperature log labeled, "Medication Room" for February 2014, showed the following temperatures for the mini refrigerator:
- 60 degrees Fahrenheit (F) on 02/26/14;
- 12 degrees F on 02/27/14; and
- 15 degrees F on 02/28/14.
(The temperatures showed the refrigerator was not functioning properly.)

5. During an interview on 03/06/14 at 3:30 PM and again at 4:10 PM, Staff S, Director of Engineering, stated that:
- He was responsible for providing quality oversight to ensure that preventative maintenance was completed.
- The med/surg refrigerator was scheduled to have preventative maintenance completed annually by a contracted company.
- The scheduled maintenance of the refrigerator was missed because it was not on the preventative maintenance inventory list.

6. Record review on 03/04/14 at 1:30 PM showed no documentation of weekly or quarterly inspections of the automatic sprinkler system's alarm devices, gauges, damaged or obstructed sprinkler heads, etc.

7. During an interview on 03/04/14 at 9:00 AM, Staff S stated that:
- Biomedical Technicians inspected and tested call lights, he did not.
- He did not do random or scheduled function tests of smoke detectors (with canned smoke).
- He did not perform any tests of the automatic sprinkler system.
- He did not do daily preventive maintenance rounds to check call lights, water temperatures and functioning equipment.
- He did not have or use a formal procedure that describes regularly scheduled preventive maintenance rounds.

8. Review of the facility's policy, "Flash Sterilization" dated 01/16/14 showed:
- The flash autoclaves will be maintained on a quarterly basis.
- The results of the preventive maintenance survey will be received by the Engineering Department and the Surgery Director.
- Any problems affecting the operation of the autoclaves will be brought to the attention of the Surgery Director.
- The autoclave will not be used until the technician has completed the repairs and verified that the parameters for sterilization are being met.

9. Observation on 03/04/14 at approximately 8:30 AM showed one autoclave (device used to sterilize equipment and supplies by subjecting them to high pressure saturated steam) in the Surgery Department for reprocessing of sterile supplies and instruments for the entire facility. The maintenance sticker on the autoclave showed the autoclave had been serviced 11/13 and was due for service again on 11/14.

10. During an interview on 03/04/14 at approximately 8:30 AM, Staff I, Director of Surgical Services, stated that she did not receive copies of the preventative maintenance on the autoclave. Staff I stated that the maintenance department took care of routine maintenance of the sterilizer and was responsible for applying the preventative maintenance sticker.

11. Review of the preventative maintenance record for the autoclave in the Surgery Department showed the last preventative maintenance was done on 10/23/13 and the next preventative maintenance was to be done on 04/24/14. [The policy is quarterly, not annually.]


12. During an interview on 03/07/14 at approximately 3:00 PM, Staff S, stated that:
- The maintenance sticker on the autoclave did not contain the correct expiration date.
- He thought the autoclave should be scheduled for preventative maintenance checks every six months.
- He was not aware there was a policy that the maintenance was to be completed on the autoclave quarterly.


13. Record review of the facility's policy titled, "Medical Equipment: Adding or Removing Equipment", dated 08/13, showed:
- The Materials Manager will start the process for equipment entering the hospital by completing the equipment form.
- The form will be sent to Plant Services and Accounting for processing and Plant Services will forward to HMS Health to update inventory and initiate any necessary preventative maintenance.
- The department manager or assigned staff member, will contact HMS Health to report the new equipment as well as assistance with set-up and electrical safety check by the biomed technician.
- At that time, an equipment control number will be assigned and a sticker with an identification number will be placed on the equipment.
- This control number will be used when reporting repairs or tracking the inventory.

14. Observation and concurrent interview on 03/04/14 at approximately 8:30 AM, showed no maintenance or asset sticker on the anesthesia machine located in the Operating Room (OR). Staff I, Director of Surgical Services stated that the machine was new and had been put into service 04/13. Staff I stated that to her knowledge the machine had not had any preventative maintenance. Staff I did not know if the machine had been checked by maintenance or biomed prior to being put in to service.

15. During an interview on 03/07/14 at approximately 3:00 PM, Staff S, stated that:
- His department had not checked the anesthesia machine prior to it being put in to service;
- He thought the manufacturer had checked the machine; and
- His department did not check the machine after delivery to the facility.




32281




04467

Based on record review and interview, the facility failed to coordinate the facility emergency disaster plan with state and local authorities and failed to conduct at least one practice drill annually. These deficient practices placed all patients, in the facility, at risk for serious injury and/or death due to potential lack of appropriate action by staff during non-medical emergencies. The facility census was 10.

Findings included:

1. Review of the facility's, "Disaster Plan - Emergency Preparedness Plan", approved 06/13/09 showed the facility had an organized, approved plan for several types of disasters, both natural and man-made, including fire; tornado; bomb threat; active shooter; etc. The Plan failed to direct staff to conduct at least one disaster drill to be completed annually and complete a critique of the disaster drill performed, and failed to direct how and where command and control would be established in coordination with the local law enforcement, fire fighters and other first responders.

2. Record review showed that the last disaster drill was conducted in May of 2012 and staff failed to document subsequent drills or written critiques since that time.

3. Record review showed no current information regarding contact or planning meetings with the state, county or local first responders.

4. During an interview on 03/04/14 at 10:00 AM, Staff S, Director of Engineering, confirmed that he had not implemented a disaster drill since May of 2012. He further confirmed that no disaster training has been done since that time.

Based on interview and record review the facility's Governing Body failed to:
- Assume full responsibility for determining appropriate policies and procedures for the operation of the facility including the Medical Staff's Rules and Regulations; (Refer to C 0241)
- Ensure ongoing monitoring of the implementation and adherence to those policies and procedures including credentialing for Certified Registered Nurse Anesthetists; Certified Nurse Specialists in the Behavioral Health Unit and surgeons; (Refer to C 0241)
- Ensure the facility disaster plan directed staff to conduct at least one disaster drill annually; complete a critique of the annual disaster drill performed, and failed to direct how and where command and control would be established in coordination with the local law enforcement, fire fighters and other first responders. This deficient practice failed to assure the safety of patients in non-medical emergencies and could potentially result in serious injuries or casualties; (Refer to C 0227)
- Ensure implementation of remedial actions in response to violations of regulatory requirements, identified on recent past survey, were undertaken in a timely manner. (Refer to survey dated 01/09/14 and re-citation, in this document, of violations of regulatory requirements).

The cumulative effect of these deficient practices have the potential to adversely effect the safety and quality of care provided to all patients receiving care at the facility and resulted in facility non-compliance with the Condition of Participation: Organizational Structure.

Based on record review and interview the governing body failed to ensure the medical staff:
- Operated under current rules and policies approved by the governing body;
- Developed policies and procedures approved by the facility medical staff and governing board that ensured credentialing criteria for determining the privileges to be granted to anesthesia providers based on the practitioner's scope of practice, State law and individual competence;
- Specified credentialing criteria for one (Staff YY) of one Certified Registered Nurse Anesthetist (CRNA) and failed to ensure that one (Staff II) of three Mental Health-Advanced Practice Registered Nurses (APRN) was credentialed to admit patients to the behavioral health unit (BHU).
- Specified privileges for each category of eleven of eleven operating practitioners(surgeons) identifying the type and complexity of procedures for which they may supervise the administration of anesthesia by another practitioner;
- The governing body also failed to ensure the facility disaster plan directed staff to conduct at least one disaster drill annually; complete a critique of the annual disaster drill performed; failed to direct how and where command and control would be established in coordination with the local law enforcement, fire fighters and other first responders.
- These deficient practices failed to ensure care was provided by qualified members of the medical staff and failed to ensure a safe environment for all patients, visitors and staff. The facility census was 10.

Findings included:

1. Record review of the facility's "Medical Staff By-Laws", dated 02/10/2014, showed:
- "Medical Staff Rules and Regulations" means the rules and regulations adopted by the Medical Staff and approved by the Board.
- "Prerogative" means the right to participate, by virtue of Staff category or otherwise, granted to a Staff member or allied health professional, and subject to the ultimate authority of the Board and the conditions and limitations imposed in these Bylaws and other Hospital and Medical Staff policies.
- Obligations of Staff Membership: Comply with theses Medical Staff Bylaws, the Medical Staff Rules and Regulations, the Hospital Bylaws, policies and rules; and admit patients without limitation, except as limited by the scope of his or her Clinical Privileges granted pursuant to Article VII or otherwise as provided in the Medical Staff Rules and Regulations.
- Podiatric members of the Medical Staff may write orders within the scope of their license, as limited by applicable law, as consistent with the Medical Staff Rules and Regulations.
- Allied Health Professionals (AHP, an individual other than a licensed Physician, Dentist, or Podiatrist who functions in a medical support role to a physician or exercises independent judgment within the area of his or her professional competence provide specifically designated patient care services under the direct or ultimate (as determined by Medical Staff policy or regulations) supervision or direction of a Medical Staff member.

2. During an interview on 03/04/14 at approximately 1:05 PM, Staff WW, Medical Staff Coordinator, stated that:
- The facility did not have current Medical Staff Rules and Regulations.
- The previous Medical Staff Bylaws had something in it about medical record rules but those Bylaws were no longer in effect.
- A new set of Rules and Regulations were being developed but were in draft format and had not been approved.

3. During an interview on 03/06/14 at approximately 10:15 AM, Staff D, Chief Medical Officer (CMO), stated that the facility was trying to separate out the Medical Staff Rules and Regulations from the Bylaws. She stated that the facility had some separate policies for medical record completion but did not have current Medical Staff Rules and Regulations.

4. During an interview on 03/05/14 at approximately 2:00 PM, Staff YY, Certified Registered Nurse Anesthetist (CRNA), stated that:
- She was credentialed as a CRNA;
- The operating practitioner (surgeon) signed her records;
- When the operating practitioner was a Podiatrist the H&P must be completed by a Primary Care physician; and
- The Podiatrist signed off on her anesthesia assessment and plan, anesthesia record and orders.

5. During an interview on 03/05/14 at approximately 2:50 PM, Staff XX, Surgeon, stated that to his knowledge:
- There was nothing in writing that required oversight of the CRNA administering anesthesia for his surgical patients;
- There was nothing in writing requiring the operating practitioner to sign off on the Anesthesia assessment, plan of care or orders; and
- There was nothing in writing for privileging requirements for CRNA oversight.

6. Record review of the facility's "Delineation of Privileges of Allied Health Professional" for Staff II, APRN showed no privileges were granted by the governing body to admit patients to the BHU.

7. Record review of current Patient #28's physicians orders, dated 02/28/14, showed that Staff II, APRN, gave telephone orders to admit the patient to the BHU.

8. Record review of discharged Patient #3's physicians order, dated 12/28/13, showed that Staff II, APRN, gave telephone orders to admit the patient to the BHU.

9. During a telephone interview on 03/07/14 at 10:40 AM, Staff II, APRN, stated that she was unaware she could not give telephone orders to admit patients to the BHU.

10. Review of the facility's "Disaster Plan - Emergency Preparedness Plan", dated 06/13/09 showed the facility had an organized, approved plan for both natural and man-made disaster, including fire, tornado, bomb threat, active shooter, etc. The Plan failed to direct at least one disaster drill be conducted annually; a critique of the drill performed; and that staff were monitored and evaluated for knowledge and skills required for each type of disaster.

11. Record review showed that the facility last conducted a disaster drill in May 2012 and no other drills had been documented or critiques written since that date.

12. During an interview on 03/04/14 at 10:00 AM, Staff S, Director of Engineering, confirmed that he had not implemented a disaster drill, as directed by the facility's plan since May 2012. He further confirmed that no disaster drills had been done since that time.







32281




31891

Based on record review and interview, the facility failed to ensure the medical care rendered by three of three advanced practice registered nurses (APRN) (Staff II, Staff JJ and Staff KK) was periodically reviewed by a physician. This failure to provide oversight of APRNs had the potential to place all patients treated in the facility by APRNs at risk for unsafe, ineffective care. The facility census was 10.

Findings included:

1. During a telephone interview on 03/05/14 at 3:00 PM, Physician H stated that he had collaborative practice agreements with three APRNs, Staff II, Staff JJ and Staff KK. The physician stated that he did not co-sign any entries by the APRNs and he had no process for documentation of review of care given by them.

2. Record review of the collaborative practice agreement dated 03/26/07 for APRN Staff II showed the physician was required to review the work, records and practice of the nurse practitioner at least once every two weeks and document the review.

3. Record review of the collaborative practice agreement dated 05/10/13 for APRN Staff JJ showed the physician and the APRN would make a good faith effort to jointly review the work, records and practice activities performed by Staff JJ at least once every two weeks and would be documented.

4. Record review of the collaborative practice agreement dated 08/03/10 for APRN Staff KK showed that the physician shall review the work, records and practice of health care delivered by the APRN at least once every two weeks and shall by documented by the physician.

5. During a telephone interview on 03/07/14 at 10:45 AM, Staff II stated that she did not know of any documentation related to the physician review of her patient care and that the physician did not co-sign her documentation in the patient records.

Based on observations, interviews and record reviews facility staff failed to:
- Ensure security of medications and supplies in mobile medication carts and anesthesia carts (a set of trays/drawers/shelves on wheels used to dispense medications and supplies for the induction of anesthesia; temporary blocking of pain) in various locations in the facility (the Emergency Department, Medical/Surgical Unit and in the Operating room); (Refer to C 0276)
- Ensure expired medications and supplies were removed from patient care areas to ensure those were not used in patient care; (Refer to C 0276)
- Establish policies that directed Pharmacy Department inventory management and inspection; (Refer to C 0276)
- Ensure multi-dose vials of patient medication were appropriately labeled; (Refer to C 0276)
- Ensure the movement of narcotic and dangerous drugs was tracked through the facility; (Refer to C 0276)
- Ensure medications errors were tracked and trended overtime; (Refer to C 0277)
- Ensure soiled mops and cleaning cloths were laundered to prevent cross contamination of patient clothing; (Refer to C 0278)
- Ensure furniture used in the Behavioral Health Unit (BHU) common patient areas was easily sanitized and the surfaces were intact; (Refer to C 0278)
- Ensure BHU staff used appropriate hand hygiene and gloving techniques while providing patient care; (Refer to C 0278)
- Ensure BHU staff used appropriate infection control techniques for medication that had been on the floor; (Refer to C 0278)
- Ensure BHU staff had access to hand hygiene supplies while providing care to patients; (Refer to C 0278)
- Ensure BHU patients had access to soap for personal hygiene (especially hand hygiene) throughout the day; (Refer to C 0278)
- Ensure foods stored in the BHU refrigerator and in the Outpatient Department refrigerator were maintained at an appropriate temperature; (Refer to C 0279)
- Ensure foods stored in the BHU patient refrigerator; in the Medical/Surgical Unit patient refrigerator and in the Outpatient refrigerator were labeled and dated; (Refer to C 0279)
- Ensure the BHU staff and the Dietary Department staff had access to the facility Diet Manual for use in patient care to use as a reference (Refer to C 0279).

The cumulative effect of these deficient practices had the potential to place patients treated in the facility at risk for adverse medication administration; risk of infection from multiple sources; risk for food borne illness and inaccurate diet therapy. These deficient practices resulted in the facility's non-compliance with the specific requirements found under the Condition of Participation: Provision of Services.

The facility census was 10 with six of those on the BHU.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure that the movement of scheduled drugs (controlled substance - medications that are highly addictive and can alter thought process, mood and perception) were tracked throughout the hospital.
- Appropriately label opened, multiple dose medications for three patients (#16, #18 and #26) of five patients' medication storage bins observed.
- Ensure that when the Surgery department was closed that the Operating Room (OR) and Surgery Department were locked and the anesthesia Pyxis (automated medication dispensing machine) was secure.
These failed practices had the potential to affect all patients in the hospital by increasing the risk of administering patient's medication to the wrong patient and by increasing the risk of administering a medication that was expired and no longer effective and also had the potential to allow for diversion (removal or theft of controlled substances for personal consumption) of patients' prescribed scheduled drugs, which could affect the patients' outcome as well as the quality of care provided by staff. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Controlled Substances - Pharmacy" revised 11/14/13, showed the following:
- The Pharmacy Director is responsible for the proper safeguarding of controlled substances within the hospital.
- The Pharmacy Director is responsible for the purchase, storage, accountability and proper dispensing of controlled substances.
- All discrepancies (when actual amounts of the medication is more or less than what was expected) must be reconciled (reason for discrepancy is investigated and corrected) immediately.

2. Record review of 17 event reports between 02/09/14 and 02/17/14 showed the following controlled substances were removed for patient administration, but not documented in numerous patients' electronic medical records as administered:
- Four Clonazepam (benzodiazepine - sedative) 1 milligram (mg);
- 10 Lorazepam (benzodiazepine - anxiety reducer) 1 mg;
- 12 Hydrocodone (opioid - narcotic pain medication) 5/325 mg;
- One Hydrocodone 10/325 mg.

3. During an interview on 03/05/14 at 3:06 PM, Staff X, Pharmacy Technician and Staff BBB, Pharmacy Technician, stated that the event reports were completed by Staff BBB when she compared controlled substances pulled from the medication dispensary (electronic medication storage bins that hold numerous patient medications, but designed to release only patient specific medications when prompted) to nurse documentation of patient administration in the electronic medical record (EMR). Staff BBB stated that she did not reconcile the medications with the patient's medication administration records (MAR) that were on paper. Staff BBB stated that when she found a discrepancy, she completed an event report and sent the event report to Staff AA, Risk Manager, but Staff AAA, Pharmacist, did not review them. Staff BBB stated that she did not know if the event reports had been followed up on, or if the medication discrepancies had been investigated.

4. During an interview (with concurrent review and comparison of the 17 medication event reports to patients' paper MAR) on 03/05/14 at approximately 4:00 PM, Staff BBB stated that she was still unable to account for two Clonazepam 1 mg tablets, that were removed from the medication dispensary on 02/14/14.

5. During an interview on 03/05/14 at 4:50 PM, Staff AA stated that she reviewed the event reports related to the controlled substance discrepancies. Staff AA stated that Staff C, Chief Nursing Officer (CNO), had informed her that the controlled substances weren't missing, but that a new nurse was having problems with documentation, and failed to document the medication administration in the EMR.

6. During an interview on 03/06/14 at 11:13 AM, Staff C stated that she was aware the hospital had doses of Lorazepam missing (actual missing drug was Clonazepam, which is different than Lorazepam), that Staff E, Behavioral Health Unit Nurse Manager, had been informed by (unknown) psychiatric nursing staff that the missing Lorazepam had been wasted (properly discarded under the observation of two licensed professionals), but there was no documentation of the wastes, and no further investigation was done.

7. During an interview on 03/05/14 at 4:45 PM, Staff E stated that she investigated the missing Lorazepam, that staff had informed her that they had wasted the medications, but there was no documentation of the waste, no documentation of the investigation, and no further investigation was completed.

8. During an interview on 03/06/14 at 9:25 AM, Staff AAA stated that he did not review medication discrepancy event reports, that he was not aware of the 17 event reports related to the controlled substance discrepancies, and that the discrepancies were primarily a nursing issue. Staff AAA added that the pharmacy did not keep a record of unreconciled controlled substances, because there were none.

9. During an interview on 03/05/14 at 9:17 AM, Staff C stated that the facility did not have a policy related to labeling requirements for opened, multiple dose medications.

10. Observation on 03/03/14 at 3:52 PM of the Medical/Surgical (Med/Surg) unit's medication room showed the following:
- Patient #18's medication storage bin contained an open, multiple dose vial of Humulin R Insulin (medication to regulate the body's blood sugar). The medication was not labeled with the patient's name, did not indicate the date it was opened, and did not identify who opened the vial.
- Patient #16's medication storage bin contained open, multiple dose vials of Lantus Insulin and Humulin R Insulin. The medications were not labeled with the patient's name, did not indicate the date they were opened, and did not identify who opened the vials.
- Patient #26's medication storage bin contained an open, multiple dose tube of Proctosol HC 2.5% (steroid cream used to decrease inflammation or irritation of the skin). The medication did not indicate the date it was opened and did not identify who opened the tube.

11. During an interview on 03/03/14 at 3:52 PM, Staff X stated that opened, multiple dose medications should be labeled with identifying patient information, and should include the date it was opened and the initials of the nurse who opened the medication. Staff X stated it was the responsibility of the nurse who opened the medication to ensure the medication was labeled with this information.

12. During an interview on 03/06/14 at 11:13 AM, Staff C stated that when multiple dose medications were opened, the medication should be immediately labeled with a patient "label" (sticker which contains patient specific identification information), the date the medication was opened and the initials of the nurse who opened the medication. Staff C stated that the reason for labeling the medication with an open date, was because open medications expire after one month, and should be discarded.

13. Review of the American Society of Anesthesiologist, "Statement on Security of Medications in the Operating Room" dated 10/13, showed security of medication in the operating room suite is essential for patient safety. Access to operating room suites must be strictly limited to authorized persons.

14. During observation and concurrent interview on 03/04/14 at approximately 8:15 AM with Staff I, Director of Surgical Services, showed an anesthesia Pyxis machine in the OR inside the Surgery Department.
Staff I stated that neither the OR or Surgery Department were locked when there was no one working in the OR and that the facility had no policy for security of the Surgery Department during unstaffed hours.



29047

Based on observation, interview, record review and policy review, the facility failed to ensure that medication errors were tracked and reported in a manner to identify medication error trends and failed to ensure a proactive approach to reduce the risk of medication errors. This had the potential to place all patients in the hospital at increased risk for medication errors, which could lead to negative patient outcomes. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Medication Errors" revised 11/14/13, showed that the organization had a process to respond to actual or potential medication errors and defined the following as medication errors:
- Wrong: drug, dose, route (method in which the dose was administered - by mouth, injection or intravenously - in the vein), time or patient;
- Omissions (not administered before next scheduled dose); and
- Unordered dose.

2. Observation on 03/04/14 from 8:00 AM to 8:44 AM, showed Staff Y, Licensed Practical Nurse (LPN), removed medications from a medication dispensary (electronic medication storage bins that hold numerous patient medications but designed to release only patient specific medications when prompted) for medication administration to three patients. During the medication removal, the nurse referred to the patient's electronic medication list on a portable computer, and typed three or four letters of the drug name into the medication dispensary. Any medication beginning with the same letters typed into the medication dispensary, including medications and medication doses that were not prescribed for the patient, were listed as an option for the nurse to select and remove for administration to the patient.

3. Record review of an event report dated 02/21/14, showed that the medication Hydralazine HCL (used to treat high blood pressure) 25 milligrams (mgs) was prescribed for discharged Patient #49, but the patient was administered two Hydrochlorothiazide (diuretic - water pill) 25 mgs. Record review of two event reports dated 02/15/14, showed that the medication Hydrocodone/APAP (opioid - narcotic pain medication) two 5/325 mg tablets were prescribed for discharged Patient #50, but the patient was administered one Hydrocodone/APAP 10/325 mg tablet. Further review of event reports dated 02/11/14 through 02/23/14 showed the following medication errors:
- Five missed medication doses;
- Six wrong dose administrations; and
- One wrong route.

4. During an interview on 03/05/14 at 3:00 PM, Staff X, Pharmacy Technician and Staff BB, Pharmacy Technician, stated that event reports were completed for all medication errors and forwarded to Staff AA, Risk Management, and were not reviewed by Staff AAA, Pharmacist. Staff X added the following:
-The current version of the electronic medical record (EMR) would alter the physician prescribed dose of a medication, either increasing or decreasing the dose. This resulted in a non-prescribed dose appearing to nursing staff when they removed a medication from the medication dispensary for administration to the patient.
- Two physician prescribed medication dosages were altered on 03/05/14 by the EMR, but were found before administered.
-The pharmacy was waiting for an EMR update to electronically profile (allows only prescribed medications for a specific patient to be available for the nurse to remove from the medication dispensary) patient medications, that she did not know when the EMR update would occur, because it was previously scheduled for 01/14 but was canceled.
- She wasn't aware if the pharmacy could manually enter only the patients' prescribed medications into the medication dispensary, to prevent nursing staff from removing and administering the wrong medication or dose.

5. During an interview on 03/05/14 at 3:47 PM, Staff FF, EMR Project Manager, stated that the EMR "had a bug" that caused medication dosages to round up or down. Staff FF confirmed it happened with two different medications on 03/05/14.

6. Record review of an email dated 03/10/14 at 1:35 PM, showed Staff JJJ, medication dispensary representative, wrote that patient medication profiling was able to be completed manually by the hospital pharmacy and "is still an option that most hospitals utilize".

7. During an interview on 03/06/14 at 9:25 AM, Staff AAA stated that:
- He believed that the medication dispensary could be manually profiled for patient medications.
- Without profiling the patients' medications, there was nothing in the medication dispensary that would prevent or warn the nurse that they were removing the wrong medication or dosage for patient administration.
- He was aware of the medication error when Hydrochlorothiazide was administered instead of Hydralazine HCL.
- He was aware that the EMR altered physician prescribed medication dosages to an incorrect dose.
- He was "waiting for EMR glitches to be out of there".
- He didn't track or trend medication errors.
- He didn't review medication error event reports.
- He believed the medication errors were "primarily a nursing issue" and the responsibility of Staff C, Chief Nursing Officer.

8. During an interview on 03/06/14 at 11:30 AM, Staff C stated that if the patients' medications were profiled, "We could eliminate a lot of med (medication) errors". Staff C added that medication errors were tracked by a total number of errors from month to month and not a measurable percentage, and was not able to indicate an expected goal, indicators in improvement or decline, or trends.

9. During an interview on 03/05/14 at 4:50 PM, Staff AA stated that she reviewed all medication event reports, but they were not measurable and were not trended.

10. During an interview on 03/07/14 at 3:20 PM, Staff A, Chief Executive Officer and Staff B, Chief Operating Officer, stated the following:
- They "absolutely" expect the Pharmacist to have oversight of the facility's medication errors.
- They don't receive information related to medication errors or the hospital's medication error rate.
- Because they don't receive the medication error information or rates, that information wasn't reported to the hospital's Governing Board or the Medical Staff.

Based on observation, interview, record review, and policy review the facility failed to:
-Ensure hand hygiene and glove use was used when staff provided care to two patients (#1 and #2) of three patients observed;
-Have hand hygiene supplies readily available for staff providing direct care on the unit and have soap readily available for patient use;
-Dispose of medication that became contaminated from falling on the floor;
-Ensure that infection control procedures were followed when patient medications were contaminated prior to administration for two patients (#14 and #16) of three patient medication passes observed;
-Launder environmental mop heads and cleaning cloths in a washer and dryer not used for Behavioral Health Unit (BHU) patient clothing; and
-Ensure that three of three upholstered lounge chairs in the Behavioral Health Unit were maintained with cleanable surfaces so they would not have the potential to harbor infectious material.
These failed practices increased the risk of infection and cross contamination and placed all patients at risk for hospital acquired infections and contracting communicable diseases. The Behavioral Health Unit census was six and the facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Infection Prevention and Control" dated 02/24/14, showed that nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. This was accomplished by practicing good aseptic techniques and observing infection prevention and control policies and procedures.

Record review of the facility's policy titled, "Infection Control - Hand Hygiene," revised 10/31/12, directed staff to use hand hygiene:
-When hands are visibly dirty or in contact with contaminated material;
-Before direct contact with a patient;
-After taking off gloves; and
-After contact with body fluids.

Record review of the facility's policy, "Personal Hygiene" effective 02/24/14, showed that articles for grooming and personal hygiene were available and accessible to patients.

Record review of facility policies showed no policies related to infection control practices during medication administration.

2. Observation on 03/04/14 at 8:00 AM showed Staff Q, Registered Nurse (RN) failed to:
-Perform hand hygiene after she administered medication and took off her gloves for Patient #2.
-Dispose of a unit dose medication for Patient #1 that dropped out of her hand and fell to floor when walking to the medication room; and
-Prevent cross-contamination by placing the contaminated medication in the pharmacy return bin for restocking.

3. During an interview on 03/04/14 at 4:10 PM, Staff Q, RN stated that she failed to perform hand hygiene after removing her gloves because she was late giving medications. She also stated that she did not dispose of the medication that dropped to the floor because it was an oversight.

4. During an interview on 03/04/14 at 1:20 PM, Staff BB, BHU Security Technician, stated that staff were unable to wash their hands in the patient care areas because there was no soap contained in the patient rooms dispensers and hand sanitizer was only available at the nurse's station. They also did not carry hand sanitizer on their person.

5. Observation on 03/04/14 at 8:00 AM showed Staff Y, Licensed Practical Nurse (LPN), remove packaged medications from a medication dispensary (electronic medication storage bins that holds numerous patient medications but designed to release only patient specific medications when prompted) to administer to Patient #14. Staff Y placed the patient's packaged medications inside a plastic cup before taking the medications into the patient's room. Staff Y then removed the patient's packaged medications from the plastic cup and opened the medications into the same cup she had placed the packaged medications in, and administered them to the patient.

Observation on 03/04/14 at 8:44 AM showed Staff Y removed the medications from the medication dispensary and administered the medications to Patient #16 using the same technique she used when she administered Patient #14's medications.

6. During an interview on 03/04/14 at approximately 8:50 AM, Staff Y stated that she never considered pill packaging to be contaminated, but realized that it could be contaminated when she thought about it.

7. During an interview on 03/05/14 at 1:30 PM, Staff HH, Infection Preventionist, stated that Staff Y should have used a second cup to dispense the opened pills into and not the same cup that she had placed the packaged medications in, to prevent contamination.

8. Observation on 03/03/14 at 3:05 PM of the BHU washer and dryer area showed multiple cloth mop heads and cleaning cloths lying on top of the dryer.

9. During an interview on 03/03/14 at 3:05 PM, Staff G, Security Technician stated that he washed all the facility's mop heads and cleaning cloths in the BHU washer. He stated he used to wash them in an environmental washer but that washer was not working and he had been using the BHU washer and dryer. He stated that he ran a cleaning cycle through the washer about once a week but not after every load of washing the facility mop heads and cleaning cloths. He stated that he had no documentation of running a cleaning cycle. He acknowledged that the BHU washer and dryer were also used for patient clothing.

10. During an interview on 03/04/14 at 3:40 PM, Staff E, stated that clothing and scrubs for BHU patients were laundered in the unit's washer and dryer. She also stated there was no policy for laundering patient clothing and scrubs.

11. During an interview on 03/05/14 at 1:35 PM, Staff HH, Director of Quality Improvement, Infection Control and Patient Safety stated that she thought the washer and dryer used for washing the facility mop heads and cleaning cloths was an environmental washer and dryer. She stated that she did not know staff washed patient clothing in the same washer as the mop heads. Staff HH stated, "We will have to fix that. That should not be happening."

12. Observation and concurrent interview 03/03/14 at 3:10 PM with Staff E, BHU Nurse Manager showed three of three upholstered lounge chairs in the patient television room on the BHU with varying size of tears (averaging about one inch in length) on the armrests. Staff E stated she was not aware of the torn furniture and that she thought it was already replaced.
With the torn upholstery in the three chairs, the facility was unable to ensure that the they were sanitized and did not harbor infectious material.





29047












19957

Based on observations, interviews, record reviews and policy review the facility failed to ensure the following:
- Behavioral Health Unit (BHU) patient foods were stored in a safe, sanitary manner by failing to ensure the temperature of the BHU patient food refrigerator was accurately monitored and that patient foods stored in the refrigerator were dated and timed;
- Outpatient Department patient foods were stored in a safe, sanitary manner by failing to ensure patient's beverages were labeled with the date opened and the temperature of the patient food refrigerator was accurately monitored;
- Patients' food and beverage containers on the Medical/Surgical (Med/Surg) unit were labeled with the date the food container was opened;
- Nutritional care/diet therapy was provided on the BHU in accordance with an approved diet manual;
- Dietary Department staff and BHU nursing staff had access to the approved online diet manual so it could be used as a reference.

These deficient practices had the potential to adversely affect the quality of food service and the accuracy of diet therapy provided to all patients in the facility. The facility census was 10 with six of those on the BHU.

Findings included:

1. Record review of the facility's policy titled "Infection Prevention and Control," dated 02/24/14, directed staff to maintain proper storage of perishable foods at or below 40 degrees Fahrenheit and to cover and date foods stored in opened original containers.

2. Record review of the facility's form titled "Refrigerator and Freezer Temperature" found taped to the BHU refrigerator showed the following:
- The form was dated March, 2014;
- Instructions printed on the bottom of the form directed that refrigerator temperatures should be 33 degrees to 41 degrees Fahrenheit.
- Dietary staff had recorded temperatures for the first through fourth of the month as 26 and 28 degrees Fahrenheit during the day shift;
- Nursing staff had recorded temperatures for the same period as 27, 29 and 30 degrees Fahrenheit during the night shift.

3. During an interview on 03/04/14 at 9:00 AM on the BHU, Staff M Certified Nurse Aide (CNA) stated that she recorded temperatures of the BHU refrigerator on the "Refrigerator and Freezer Temperature" form however had not noticed that the temperatures were not within the temperatures as directed on the bottom of the form.

4. Observation and concurrent interview on 03/03/14 at 3:10 PM showed the BHU patient refrigerator containing two Styrofoam containers with patient foods that were not dated. Staff E, Nurse Manager stated that she was not aware of this and that they should be dated.

5. Observation on 03/03/14 of the Med/Surg Nutrition room showed the following open food/beverage containers, that were not labeled with the date they were opened:
- 46 ounce (oz - unit of measure) prune juice carton;
- 46 oz orange juice;
- 46 oz grape juice;
- 46 oz cranberry juice; and
- 16 oz jar of peanut butter.

6. During observation on 03/04/14 of the Outpatient Department's patient refrigerator showed the following beverage items in multiple serving containers that were not labeled with the date opened: 46 oz. grape juice and two 64 oz. apple juice.

7. Review of the Outpatient Department's patient refrigerator temperature log showed no entries for checking the refrigerator temperature from 02/02/14 thru 02/26/14, 19 days.

8. During an interview on 03/06/14 at 3:10 PM, Staff J, Director of Dietary, stated that per the Dietary Department's policy, food should be labeled with the date it was opened, but added that she had never thought about the need for labeling the juice cartons with an open date because the juice cartons never last more than one day in the kitchen.

9. Review of the facility's policy titled, "Diet Manual" dated 02/24/14 showed the diet manual was available to staff online at each nurse's station and in the Dietary Department office.

10. During an interview on 03/03/14 at 3:20 PM, Staff J, stated the following:
- That the facility diet manual was available online and accessible to nursing staff at the nurse's stations;
- The Dietary Department staff does not have access to the facility diet manual online or in paper because they had never been trained to access the information;
- The Chief Medical Officer had not approved the facility diet manual because she did not believe the online version was really a diet manual.

11. During an interview on 03/06/14 at 11:00 AM, Staff GG BHU Registered Nurse (RN) was asked to show the facility diet manual and stated the facility diet manual was online however, the BHU maintained a hard copy. Staff GG stated, "We have this book".

12. Record review of the book provided by Staff GG showed the following:
- A loose leaf binder with a few pages of diet information from various sources.
- The first few pages had the name of the Registered Dietitian (RD) who was previously employed by the facility (current RD was identified by the Director of Dietary);
- One of the pages in the loose leaf binder was from an unknown facility.

13. During an interview on 03/06/14 at 11:05 AM, Staff E, BHU Nurse Manager, reviewed the first few pages of the loose leaf binder and erroneously stated the RD listed there was the current dietitian employed in the facility.

14. Observation on 03/06/14 at 11:06 AM showed Staff GG, BHU RN, after extensive prompting by Staff E, BHU Nurse Manager was able to access and open the online facility diet manual.

15. During an interview on 03/06/14 at 11:06 AM, Staff RR, BHU RN, stated she had never had an in-service on accessing the facility diet manual.

16. During an interview on 03/06/14 at approximately 11:45 AM, Staff J, reviewed the BHU loose leaf binder and stated that:
- She did not recognize the content of the loose leaf binder from the BHU;
- She again identified that the RD listed in the loose leaf binder was not the currently employed RD;
- She felt the loose leaf binder must have been compiled at least three years ago, prior to her employment as Director of Dietary;
- She confirmed the information in the loose leaf binder was not the facility diet manual.







29047





31891

Based on interview, record review, and policy review the facility failed to ensure that Providers (Physician or other authorized practitioners) authenticated (signed and dated) telephone orders of the Provider in four (#2, #28, #29, and #30) of six patient medical records reviewed on the Behavioral Healthcare Unit (BHU) and failed to ensure all entries in the medical record including verbal orders were authenticated for six (#4, #5, #6, #7, #11, #13) of six surgical records reviewed. The delayed authentication of medical entries and provider telephone orders had the potential for treatment errors. The BHU census was six. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Physician Orders," reviewed 01/14, showed that all telephone/verbal orders must be signed by the physician within 48 hours.

2. Record review of the facility's policy titled, "Physician Requirements for Behavioral Health Medical Records," effective 02/24/14 showed the following:
- Telephone or verbal orders of the physician or other authorized provider are written in the medical record by a nurse or other professional in accordance with State law and facility policy.
- Telephone or verbal orders are authenticated, dated and timed by the ordering provider.
- The ordering provider must date and time the telephone/verbal order as soon as possible, which would be the earliest of the following: No later than facility policy, or the next time the prescribing provider assesses the patient or documents information in the patient's medical record.

3. Record review of Patient #2's medical record showed:
- A physician's telephone order for a medication change, dated 02/18/14.
- The patient received daily services by the psychiatrist (02/19/14, 02/20/14, 02/21/14, 02/22/14, and 02/23/14) following the order.
- The psychiatrist signed and dated the telephone order on 02/24/14.

4. Record review of Patient #28's medical record showed:
- An advanced practice registered nurse (APRN) telephone order for admission, dated 02/28/14.
- The patient received daily services by the APRN (03/01/14, 03/02/14, and 03/03/14) following the order.
- The order was not cosigned by the APRN as of the date the record was reviewed (03/05/14).

5. Record review of Patient #29's medical record showed:
- An APRN telephone order for medications dated 02/28/14.
- The patient received daily services by the APRN (03/01/14, 03/02/14, and 03/03/14) following the order.
- The APRN signed and dated the telephone order on 03/04/14.

6. Record review of Patient #30's medical record showed:
- A physician's telephone order for admission and other treatment, dated 02/24/14.
- The patient received services by the psychiatrist on 02/25/14 and 02/26/14.
- The psychiatrist signed and dated the telephone order on 02/27/14.

7. During an interview on 03/03/14 at 3:25 PM, Staff E, BHU Nurse Manager, stated that telephone orders were faxed to the provider for signature and returned to the facility.

8. During a telephone interview on 03/04/14 at 3:10 PM, Staff H, Psychiatrist, stated that orders were sent to him, he signed them and returned them by fax. He stated he started signing telephone orders today (03/04/14).

9. Review of the facility's "Medical Staff Bylaws", dated 02/11/14 showed:
- The Podiatrist is responsible for the podiatric care (medical care of the human foot) of the patient, including the podiatric history and physical examination and all appropriate elements of the patient's record.
-Surgical procedures performed by Podiatrists shall be under the overall supervision of a Reviewing Physician.
- A Physician member of the Medical Staff shall also be responsible for the medical care of a patient during the Patient's hospitalization and will advise on the risk and effect of any procedure on the patient's total health status.
- The Podiatrist may write orders within the scope of his or her license, as limited by applicable statutes and as consistent with the Medical Staff Rules and Regulations.

10. Review of the facility's policy titled, "Physician Requirements for Outpatient Procedure Medical Records" undated, showed providers are responsible for the following documentation:
- The written verbal order must be legible and include the date, time, the order, and the name of the ordering practitioner and the signature of the accepting individual.
- Telephone or verbal orders will be authenticated, dated, and timed by the ordering provider.
- The ordering provider must date and time the order at the time he or she signs the order and must sign a verbal order as soon as possible, which would be the earlier of the following: the next time the prescribing provider provides care to the patient, assesses the patient, or documents information in the patient's medical record.
A procedure report is required for all procedures and will be signed, dated, and timed by the physician performing the procedure.
Procedure reports must be electronically entered, dictated, or hand written immediately following the procedure.

11. Record review of Patient #4's surgical chart for 02/24/14 showed:
- Pre-operative surgery orders as verbal orders, not signed, dated and timed by the operating surgeon and post operative surgery orders signed and dated but not timed.
- Pre and post anesthesia orders, plan of care and anesthesia record signed by the operating surgeon (Podiatrist), not dated or timed;
- Immediate post procedure note signed by the podiatrist, not timed; and
- Anesthesia record initialed by the Certified Registered Nurse Anesthetist (CRNA), not dated or timed.

12. Record review of Patient #5's surgical chart for 02/13/14 showed:
- Pre-operative surgery orders as verbal orders, not signed, dated or timed by the surgeon.
- Outpatient Post-op orders signed by the surgeon, dated and not timed;
- Pre and post anesthesia orders, plan of care and anesthesia record signed by the operating surgeon, not dated or timed; and
- Anesthesia record initialed by the CRNA, not dated or timed.

13. Record review of Patient #6's surgical chart for 01/03/14 showed:
- Post operative orders signed and dated by the surgeon but not timed;
- Pre and post anesthesia orders, plan of care and anesthesia record signed by the operating surgeon, not dated or timed;
- Operative Procedure report not signed, dated or timed by the surgeon; and
- Anesthesia record initialed by the CRNA, not dated or timed.

14. Record review of Patient #7's surgical chart for 01/03/14 showed:
- Pre-operative surgery orders as verbal orders signed but not dated or timed by the surgeon.
- Outpatient Post-op orders signed by the surgeon, dated and not timed;
- Pre and post anesthesia orders, plan of care and anesthesia record signed by the operating surgeon, not dated or timed;
- Anesthesia record initialed by the CRNA, not dated or timed; and
-Operative report and discharge summary signed by the surgeon, not dated or timed.

15. Record review of Patient #11's surgical chart for 01/27/14 showed:
- Pre and post-operative outpatient surgery orders signed and dated by the surgeon, not timed;
- Pre and post anesthesia orders, plan of care and anesthesia record signed by the operating surgeon (Podiatrist) and not dated or timed;
- Immediate post-op note signed by the operating surgeon but not timed;
- Operative procedure report not signed; and
- Anesthesia record initialed by the CRNA, not dated or timed.

16. Record review of Patient #13's surgical chart for 01/27/14 showed:
- Pre -operative outpatient surgery orders signed but not dated or timed;
- Post-operative outpatient surgery orders signed and dated by the surgeon, not timed;
- Pre and post anesthesia orders, plan of care and anesthesia record signed by the operating surgeon, not dated or timed; and
- Anesthesia record initialed by the CRNA, not dated or timed.



32281

Based on observation, interview and policy review the facility failed to protect the confidentiality of paper patient medical records stored in a shed from unauthorized access by Maintenance staff and from loss and destruction by fire and water. These deficient practices had the potential to adversely affect the privacy of anyone who had paper medical records stored in the shed or who required historical information contained in those stored records. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Secure Filing of Medical Records" dated 01/03/14 showed direction for the Health Information Management (HIM or Medical Records) department to safeguard both the record and it's informational content against loss, defacement, tampering and prevent damage from fire and water.

2. During an interview on 03/04/14 at 9:40 AM, Staff N, Director of HIM, stated that the facility staff protected patient paper medical records behind locked doors and that paper medical records of patients who were not recently treated in the facility were stored in a shed behind the facility.

3. Observation on 03/04/14 at 10:49 AM with Staff S, Director of Engineering (Maintenance), showed:
- A wood framed structure (unprotected combustible construction) with metal siding and used by Maintenance staff as a garage and workshop;
- The interior of the structure was sheet rocked and divided down the middle to close off and secure an area for storage of patient records;
- The medical records section of the shed was behind a locked door;
- The door knob had a key locking mechanism;
- Multiple paper file boxes of paper patient medical records stored on the floor and on shelving in the closed off section;
- There was no fire suppression equipment; no sprinklers; no smoke detectors; no fire alarms or connection with the main building (so if there were a fire in the closed off section, no staff in the main building would be alerted to the problem).

4. During an interview on 03/24/14 at 12:35 PM, Staff S stated that:
- The one key that could be used to open the door to the Medical Records section of the shed was kept in a master key box in the main facility;
- The master key box was accessible by himself plus four other Maintenance staff who worked in the department.
- He and his staff could access the paper medical records stored in the shed.



16215

Based on observation, interview, record review and policy review the facility failed to ensure Surgical Services were performed in a safe manner in accordance with applicable regulations and guidelines governing surgical services as well as standards and recommendations promoted by the Association of periOperative Registered Nurses (AORN) and the Association for the Advancement of Medical instrumentation (AAMI) by failing to ensure current policies for Surgical Services were written, implemented and enforced including:
- A complete history and physical (H&P) examination conducted and the written document placed on the medical record prior to surgery for five patients (#4, #5, #6, #7, #11) of five patient records reviewed;
- A properly executed and complete informed consent form prior to surgery for five patients (#4, #5, #6, #7, #11) of five patient records reviewed;
- Limiting immediate use steam sterilization (IUSS, formerly known as flash sterilization);
- Processing of vendor/loaner instrumentation (reusable surgical instruments that are not owned or stored in the healthcare facility); and
- Shelf life of reprocessed items in accordance with acceptable standards of practice.
The facility also failed to ensure current standard of practice for patient safety in Surgical Services including aseptic surveillance and practice and transfer of patients from the Operating Room (OR) to the Post Anesthesia Care Unit (PACU).

The severity and cumulative effect of these deficient practices resulted in the facility's overall non-compliance with the requirement found at CFR 485.639 Condition of Participation: Surgical Services.

These deficient practices put all patients receiving surgical care at the facility at risk for care in an unsafe environment and at risk for hospital acquired infection. The facility performs an average of 28 surgical cases per month.

Findings included:

1. Review of the facility's "Medical Staff Bylaws", dated 02/11/14 showed:
- The Podiatrist is responsible for the podiatric care (medical care of the human foot) of the patient, including the podiatric H&P examination and all appropriate elements of the patient's record.
-Surgical procedures performed by Podiatrists shall be under the overall supervision of a Reviewing Physician.
- A Physician member of the Medical Staff shall also be responsible for the medical care of a patient during the patient's hospitalization and will advise on the risk and effect of any procedure on the patient's total health status.
- The Podiatrist may write orders within the scope of his or her license, as limited by applicable statutes and as consistent with the Medical Staff Rules and Regulations.

2. Review of the facility's policy titled, "Physician Requirements for Outpatient Procedure Medical Records" undated, showed:
- A H&P appropriate to the procedure shall be recorded on all procedure records and will be the responsibility of an active staff member.
- This shall be accomplished prior to onset of a procedure except for infrequent emergency cases at which time a note shall appear on the medical record with appropriate date, pre-op diagnosis, condition, mental and physical risk factors, allergies, current medications and recent vitals (blood pressure, heart rate, respirations and temperature).
- When the above is not satisfied the surgery shall be canceled.
- A H&P performed up to and no more than thirty (30) days before admission may be utilized, however the physician must reassess the patient and an updated note must be written, signed, and dated to reflect the patient's status within 24 hours prior to the procedure.

3. Record review of discharged Patient #4's surgical chart for 02/24/14 showed a H&P completed by the operating surgeon (Podiatrist) dated 06/24/13, signed with no date or time and not updated; and a consent for anesthesia with no patient name filled in and the operating surgeon co-signed but did not date or time when signed.

4. Record review of discharged Patient #5's surgical chart for 02/13/14 showed:
- A H&P signed but no date or time noted on the record;
- A surgical consent form signed by the surgeon, not dated or timed;
- A consent for anesthesia with no patient name filled in and the operating surgeon co-signed but did not date or time when signed.

5. Record review of discharged Patient #6's surgical chart for 01/03/14 showed a surgical consent signed by the surgeon but not dated or timed; and a consent for anesthesia with no patient name filled in and the operating surgeon co-signed but did not date or time when signed.

6. Record review of discharged Patient #7's surgical chart for 01/03/14 showed:
- A H&P signed but no date or time noted on the record;
- A surgical consent form signed by the surgeon, not dated or timed; and
- A consent for anesthesia with no patient name filled in and the operating surgeon co-signed but did not date or time when signed.

7. Record review of discharged Patient #11's surgical chart for 01/27/14 showed a surgical consent form signed by the surgeon (Podiatrist), not dated or timed; and a consent for anesthesia with no patient name filled in and the operating surgeon co-signed for the CRNA and did not date or time when signed.

8. Review of AORN "periOperative Standards and Recommended Practices", 2013 showed:
- Use of flash sterilization (IUSS; Immediate Use Steam Sterilization) should be kept to a minimum. Flash sterilization should be used only in selected situations and in a controlled manner.
- Flash sterilization should not be used as a substitute for sufficient instrument inventory.
- Loaner instruments should be requested when the surgery is scheduled and delivered to the health care organization with sufficient time available before the surgical procedure to allow inspection and inventory of the instruments and to perform reprocessing in the same manner as a facility-owned instrument.
- Policies and procedures serve as operational guidelines and establish authority, responsibility and accountability within the organization.

9. Review of the Centers for Disease Control (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) "Guideline for Disinfection and Sterilization in Healthcare Facilities", 2008 showed:
-Flash sterilization is used when there is insufficient time to sterilize an item by the preferred package method.
-Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.
-It is not recommended as a routine sterilization method because of the lack of timely biological indicators (a device used to indicate that all the parameters necessary for sterilization were present) to monitor performance and the sterilization cycle parameters (i.e., time, temperature, pressure) are minimal.

10. During a combined interview on 03/04/14 at approximately 8:30 AM:
- Staff I, Director of Surgical Services, stated that the facility used an outside vendor for cataract cases.
- Staff I stated the vendor brings two sets of instruments that are flash sterilized.
- Staff U, Sterile Processing Technician, stated that cataract instruments were flash sterilized unless the vendor delivered them with enough time before the surgery to wrap the instruments for the first case.
- Staff U stated that instruments would be flash sterilized for the subsequent cases.
- Staff I stated that the facility performs two to three cataract cases per month.
- Staff I stated that the facility did not have a policy for vendor instrumentation that required vendors to deliver instruments in a time frame that allowed for a full sterilization cycle to be performed.

11. Review of the facility's policy, "Flash Sterilization" dated 01/16/14, showed the policy outlined the procedure for adequate sterilization of surgical instruments and equipment using flash sterilization (immediate use steam sterilization) in the instance of emergency situations and/or when there is insufficient time to sterilize an item by the preferred prepackaged method and/or manufactures' recommendations. Immediate use steam sterilization or IUSS should be kept to a minimum.

12. Review of the AAMI "Comprehensive guide to steam sterilization and sterility assurance in health care facilities", dated 2010, showed the shelf life of a packaged sterile item is event-related and depends on the quality of the packaging material, the storage conditions, and the conditions during transport, and the amount of handling.
There should be written policies and procedures for how shelf life is determined and how it is indicated on the product.

13. Review of AORN "Recommended Practices for Selection and
Use of Packaging Systems for Sterilization", 2013, showed policies and procedures for the selection and use of packaging systems should be written, reviewed periodically, and readily available within the practice setting.

14. During an interview on 03/04/14 at approximately 8:30 AM, Staff I, Director of Surgical Services stated that the facility did not have a written policy on the shelf life of packaged sterile items and no policy or manufacturers recommended practice for the use of sterilization wraps or packaging.

15. Review of the AAMI "Comprehensive guide to steam sterilization and sterility assurance in health care facilities" dated 2010 showed:
- Open storage may be used but requires special attention to traffic control, area ventilation, and housekeeping.
- Sterile items should be stored in a manner that reduces the potential for contamination.
-Traffic should be controlled to limit access to sterile items to those individuals who know how to handle them properly.

16. Review of AORN "Recommended Practices for Traffic Patterns in the PeriOperative Practice Setting", 2013, showed clearly defined and enforced traffic control practices protect personnel, patients, supplies, and equipment from potential sources of cross contamination.

17. Observation on 03/04/14 at approximately 8:30 AM, showed multiple sterile wrapped instrument trays stored on open wire racks in the OR entry corridor and patient holding area immediately adjacent to where patient care activities were performed.

18. During an interview on 03/04/14 at approximately 8:30 AM, Staff I, Director of Surgical Services stated that large sterile instrument trays were stored on the open wire racks and taken to the OR when needed. Staff I stated that the facility did not have a policy for who could access Sterile Processing Department and the Surgery Department to obtain supplies when the departments were closed.

19. Record review of the facility's policy titled, "Traffic Patterns", dated 01/16/14 showed it is the policy of this facility to have clearly defined and enforced traffic patterns to protect personnel, patients, supplies, and equipment from potential sources of cross-contamination and the movement of clean and sterile supplies and equipment should be separated from the contaminated supplies, equipment and waste by space, time or traffic patterns.

20. Review of the American Society of Anesthesiologist's "Standards of Post-anesthesia Care", showed a patient transported to the Post Anesthesia Care Unit (PACU) shall be accompanied by a member of the Anesthesia care team who is knowledgeable about the patient's condition. The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient's condition.

21. During an interview and concurrent observation on 03/04/14 at approximately 8:30 AM, Staff I, Director of Surgical Services stated that Surgery patients were transported from the OR to the Outpatient area for recovery unless they had multiple patients to recover simultaneously. Staff I stated that the second patient would be recovered in a small room adjacent to the OR that was otherwise used for storage of supplies. The outpatient department, was at the other side of the hospital, approximately 1800 feet (approximately .3 miles) from the OR, and required movement through three sets of double doors including two that were secured and required badge entry. Staff I stated that patients were not placed on a monitor for transport to recovery.

22. Record review of the facility's policy, "Transport of Patients" dated 01/16/14 showed direction for transporting the patient in a safe, comfortable, convenient method. The policy did not give direction for monitoring patients being transported from the OR to PACU post anesthesia.

Based on interview, record review, and policy review the facility failed to develop policies and procedures that ensure credentialing criteria for determining the privileges to be granted to anesthesia providers based on the practitioner's scope of practice and individual competence and specified credentialing criteria for one (Staff YY) of one Certified Registered Nurse Anesthetist (CRNA). These deficient practices failed to ensure care was provided by qualified medical staff and failed to ensure a safe environment for all patients presenting to the facility for surgical care. The facility performs approximately 28 surgical cases per month. The facility census was 10.

Findings included:

1. Record review of the facility's "Medical Staff By-Laws", dated 02/10/14, showed:
- Podiatric members of the Medical Staff may write orders within the scope of their license, as limited by applicable law, as consistent with the Medical Staff Rules and Regulations.
- Allied Health Professionals (AHP, an individual other than a licensed Physician, Dentist, or Podiatrist who functions in a medical support role to a physician or exercises independent judgment within the area of his or her professional competence provide specifically designated patient care services under the direct or ultimate (as determined by Medical Staff policy or regulations) supervision or direction of a Medical Staff member.
- The medical staff By-laws did not designate a medical staff category for CRNAs, credentialing criteria for CRNA or specify privileges for the 11 operating practitioners (surgeons) who supervised the administration of anesthesia by the CRNA.

2. During an interview on 03/04/14 at approximately 1:05 PM, Staff WW, Medical Staff Coordinator, stated that the facility did not have current Medical Staff Rules and Regulations.

3. During an interview on 03/06/14 at approximately 10:15 AM, Staff D, Chief Medical Officer (CMO), stated that the facility medical staff had some separate policies for medical record completion but did not have current Medical Staff Rules and Regulations. Staff D stated that she was not aware the medical staff had to designate privileges to the operating practitioner for oversight of the CRNA.

4. During an interview on 03/05/14 at approximately 2:00 PM, Staff YY, Certified Registered Nurse Anesthetist (CRNA), stated that:
- She was credentialed as a CRNA;
- The operating practitioner (surgeon) signed her records;
- When the operating practitioner was a Podiatrist the H&P must be completed by a Primary Care physician; and
- The Podiatrist signed off on her anesthesia assessment and plan, anesthesia record and orders.

5. During an interview on 03/05/14 at approximately 2:50 PM, Staff XX, General Surgeon, stated that to his knowledge:
- There was nothing in writing that required oversight of the CRNA administering anesthesia for his surgical patients;
- There was nothing in writing requiring the operating practitioner to sign off on the Anesthesia assessment, plan of care or orders; and
- There was nothing in writing for privileging requirements for CRNA oversight.

Based on interview and record review the facility failed to develop policies and procedures that specified the responsibilities of the operating practitioner for the supervision of the administration of anesthesia by a Certified Registered Nurse Anesthetist (CRNA). This deficient practice failed to ensure anesthesia care was monitored by qualified medical staff and failed to ensure a safe environment for all patients presenting to the facility for surgical care. The facility performed approximately 28 surgical cases per month. The facility census was 10.

Findings included:

1. Record review of the facility's "Medical Staff By-Laws", dated 02/10/2014, showed:
- Podiatric members of the Medical Staff may write orders within the scope of their license, as limited by applicable law, as consistent with the Medical Staff Rules and Regulations.
- Allied Health Professionals (AHP, an individual other than a licensed Physician, Dentist, or Podiatrist who functions in a medical support role to a physician or exercises independent judgment within the area of his or her professional competence provide specifically designated patient care services under the direct or ultimate (as determined by Medical Staff policy or regulations) supervision or direction of a Medical Staff member.
- The medical staff By-laws did not designate oversight requirements for CRNAs providing anesthesia services.

2. During an interview on 03/05/14 at approximately 2:00 PM, Staff YY, CRNA, stated that:
- She was credentialed as a CRNA;
- She was employed by an anesthesiologist that contracted her services to the facility but the anesthesiologist was not on-site and had no oversight of her practice.
- The operating practitioner (surgeon) signed her records;
- When the operating practitioner was a Podiatrist the H&P must be completed by a Primary Care physician; and
- The Podiatrist signed off on her anesthesia assessment and plan, anesthesia record and orders.

3. During an interview on 03/05/14 at approximately 2:50 PM, Staff XX, General Surgeon, stated that to his knowledge there was nothing in writing that required oversight of the CRNA administering anesthesia for his surgical patients and there was nothing in writing requiring the operating practitioner to sign off on the Anesthesia assessment, plan of care or orders.

4. During an interview on 03/06/14 at approximately 10:15 AM, Staff D, Chief Medical Officer (CMO), stated that the facility medical staff had some separate policies for medical record completion but did not have current Medical Staff Rules and Regulations. Staff D stated that she was not aware the medical staff had to delegate the responsibility for oversight of the CRNA providing anesthesia services to the operating practitioner.

Based on interviews and record reviews the facility failed to develop, implement and maintain an effective Periodic Evaluation and Quality Assurance Review program, which included all direct and indirect patient care services. The program did not include an effective, ongoing, facility wide, data driven review program focused on specific indicators related to improving health outcomes.

The cumulative effect of these deficient practices had the potential to adversely effect the safety and quality of care provided to all patients receiving care at the facility and resulted in facility non-compliance with the Condition of Participation: Periodic Evaluation and Quality Assurance Review.

Please refer to C332, C333, C334, C335, C337, C339.

Based on record review and interview, the facility failed to ensure the Periodic Evaluation included the number of patient admissions for the past fiscal year and the volume of services provided. This lack of review of the volume of utilization of services could prevent identification of problems with patient care and services and affect the quality of care for all patients. The facility census was 10.

Findings included:

1. Record review of the facility's document titled, "Quality & Performance Improvement Annual Review Summary" for fiscal year 07/01/12 through 06/30/13 showed the goal was to provide safe, effective, patient centered, timely, efficient and fiscally responsible care with high patient satisfaction.

Review of the summary showed the report failed to document the total number of patients served and the average length of stay or service for all areas of the facility.

2. During an interview on 03/07/14 at 9:30 AM, Staff HH, Director of Quality Improvement, Infection Control and Patient Safety confirmed that the annual summary did not address the number of patients served by the facility or the volume of services provided.

Based on interviews and record review the facility failed to have written criteria utilized in the quality of care review for 10 percent (representative sample) of current and discharged medical records as part of the annual Periodic Evaluation and Quality Assurance Review. This had the potential to affect the quality of care for all patients. The facility census was 10.

Findings included:

1. Record review of the Quality & Performance Improvement Annual Review Summary dated 12/12/13, showed no criteria for review of current or discharged patient records.

2. During an interview on 03/07/14 at 9:40 AM, Staff HH, Director of Quality Improvement, Infection Control and Patient Safety, stated that she reviewed 10 percent of current and 10 percent of discharged patient medical records and included the results of the review in a packet sent to the Medical Staff for review in January 2014. Staff HH stated that she could not say how the reviewed records were representative of services provided by the facility.

Staff HH stated that she could not provide specific criteria used for the review and she stated that there was no follow up from any of the Medical Staff regarding the record review. Staff HH stated there was no policy related to the review of current and discharged patient records.

Based on interview and record review the facility failed to ensure patient care policies were reviewed annually as part of the program evaluation. This failure to review and evaluate the policies had the potential to affect the quality of care for patients. The facility census was 10.

Findings included:

1. Record review of the Quality & Performance Improvement Annual Review Summary dated 12/12/13, showed no evidence of review of the facility's policies.

2. Record review of the facility's Quality & Performance Improvement Plan for the fiscal year 07/01/13 through 06/30/14 showed the facility would focus on direct patient care delivery processes and support processes that promoted optimal patient outcomes and their commitment to improve the quality of care delivered to patients.

3. During an interview on 03/07/14 at 9:30 AM, Staff HH, Director of Quality Improvement, Infection Control and Patient Safety confirmed that she did not review facility patient care polices as part of the Annual Review Summary. Staff HH stated that there was no policy to direct policy reviews as part of the Annual Review.

Based on interview and record review the facility failed to establish a policy, which directed a complete review of services in order to determine if the utilization of the facility services were appropriate. This failure to review policies had the potential to prevent the facility opportunities for improved quality of care provided to all patients. The facility census was 10.


Findings included:

1. Record review of the facility's document titled, "Quality & Performance Improvement Plan" (Periodic Evaluation and Quality Assurance Review) for the fiscal year 07/01/13 through 06/30/14, showed the facility's Quality & Performance Improvement Plan would be evaluated by the Quality & Performance Improvement Committee on an annual basis for effectiveness in achieving the goal of assuring that safe, quality care was provided to patients. A summary of activities, improvements made, care delivery processes modified, projects in progress and recommendations for changes to the Quality & Performance Plan would be compiled and forwarded to the Medical Staff, CEO (Chief Executive Officer) and the Board of Trustees for action.

2. Record review of the Quality & Performance Improvement Annual Review Summary dated 12/12/13, showed the facility had a Quality & Performance Improvement Plan for the organized, ongoing and systematic hospital wide approach for quality and performance improvement activities but failed to document a review of all services provided. The annual plan showed only a review of electronic medical records and the facility reporting to the Patient Safety Organization on events with adverse outcomes. The plan did not document the use of the adverse outcome data to analyze or revise any patient care services and did not document if all department policies were established, followed or needed revisions.

3. During an interview on 03/07/14 at 9:50 AM, Staff HH, Director of Quality Improvement, Infection Control and Patient Safety stated that she had not evaluated the services provided by the facility and had not included any evaluation of existing department policies in the annual review.

Based on interview and record review the facility failed to:
-Ensure that all direct and indirect services affecting patient health and safety were included in the facility wide quality and performance improvement plan (QPIP).
-Have an effective QPIP program for the Behavioral Health Unit (BHU) due to the failure to evaluate and take actions to improve nursing care related to pain management;
-Perform QPIP of safety risk procedures (such as, restraint and seclusion), and health and safety risks (such as; suicide, homicide, and sexual assault) in the BHU.
-Ensure that the contracted Registered Dietitian (RD) was included in the facility wide QPIP.
-Ensure that Post Anesthesia Care Unit was included in the facility wide QPIP.
-Ensure that the organ procurement program (obtaining an organ for transplantation) was included in the facility wide QPIP.
These deficient practices had the potential to adversely affect the quality of care provided for pain management, psychiatric services, surgical services, nutritional care/diet therapy and organ procurement for all patients. The facility census was 10.

Findings included:

1. Record review of the Quality & Performance Improvement Plan for the fiscal year 07/01/13 through 06/30/14 showed the scope of the review was to achieve the goal of delivering high quality care. The Plan documented that all employees were given the responsibility and authority to participate in the quality and performance improvement program. The program included, but was not limited to all direct and indirect services affecting patient health and safety. The scope of the plan showed 32 direct and indirect patient care services.

2. Record review of the 32 services listed in the Plan showed no data submitted to the facility wide QPIP program for the following departments:
-Activities and Swing Bed
-Business Office
-Corporate Compliance
-Information Technology
-Peer Review
-Safety Committee
-Social Services/Discharge Planning
-Surgery
-Utilization Review
One service not listed in the Plan but also lacking any data collection was Organ Procurement.

3. During an interview and concurrent review of the Quality & Performance Improvement Committee meeting minutes on 03/07/14 at 10:05 AM, Staff HH, Director of Quality Improvement, Infection Control and Patient Safety stated that the above services had not submitted any data to the Committee for the fiscal year of 2013. Record review of the Committee minutes confirmed the same.

4. During an interview on 03/06/14 at approximately 11:00 AM, Staff E, BHU Nurse Manager, stated that she had quality assurance measures for the unit and they were limited to pain management and medical record review of admissions and discharges.

5. Record review of the annual "Quality Assurance report for Inpatient Psychiatry," dated 2013 showed:
- Twenty-nine percent compliance for as needed (PRN) pain medication use documentation.
- Zero percent compliance for pain scale (a rating scale reflecting the degree of pain the patient experienced) documentation.
- Zero percent compliance for reevaluation of patient's pain following medication use.
The report failed to show that effective actions were taken throughout the year to improve the nursing care provided to patients with pain. In addition, there were no measures or reports for safety risk procedures that may affect the health and safety of patients (such as; seclusion or restraint use) and there were no measures or reports for health and safety risks in the psychiatric environment (such as; suicide, homicide, or sexual assault).

6. Record review of the Consultant RD's contract agreement dated 05/12/12 directed the RD to develop a quality assurance program with measurable standards.

7. Record review of the "Monthly Consultant Report" forms dated 11/13 and 12/13 (the most recent reports available) showed the RD documented a check mark on the line for "quality improvement/assurance" under "summary of activities" section of the form. She documented that she performed QPIP activities during on-site visits on 11/07/13; on 11/21/13; on 12/05/13 and on 12/19/13.

8. During an interview on 03/03/14 at approximately 3:45 PM, Staff J, Director of Dietary, stated the following:
- That the only QPIP study the department was doing involved assessing diet orders to ensure all elements were included (like the patient's name, diet, date, room number);
- That the information was submitted to the facility wide QPIP committee every three months with the next submission on 03/14/14;
- That the diet orders study was the only QPIP study from the Dietary Department;
- That she was not aware of any QPIP studies done by the contracted RD;
- The contracted RD gave reports to the Chief Executive Officer (CEO) and Staff J did not know if the reports to the CEO contained any QPIP information.

9. During a telephone interview on 03/05/14 at 11:36 AM, Staff O, contracted RD, stated that:
- Her QPIP studies were review of the patient medical records to see if Staff J, Director of Dietary had completed nutrition screenings (Staff O did not report the diet order study as one of the Dietary Department's QPIP studies);
- She was unsure of whom (what staff person), she submitted her QPIP studies to for review and inclusion in the facility wide QPIP plan;
- She could not recall when she last completed a QPIP study;
- She could not recall if she had completed any QPIP studies in the past six months.
- She could not recall who the staff person was in charge of QPIP data collection;
- She stated she did not have a supervisor in the facility (to submit QPIP studies to) because she was a contracted consultant.

10. During an interview on 03/04/14 at approximately 8:30 AM, Staff I, Director of Surgical Services stated that there was no quality plan and no quality indicators tracked, measured or reported for the post-anesthesia recovery services (PACU, also called recovery room, part of Surgical Services.)
11. During an interview on 03/05/14 at 4:20 PM, Staff C, Chief Nursing Officer, stated that was no QPIP for the organ procurement program.






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Based on collaborative practice review, record review and interview, the facility failed to ensure a physician evaluated the quality and appropriateness of care furnished by three advanced practice registered nurses (Staff II, Staff JJ and Staff KK) of three advanced practice registered nurses (APRN) files reviewed. This failed practice had the potential to place all patients treated in the facility by APRN's at risk for unsafe, ineffective care. The facility census was 10.

Findings included:

1. Record review of the collaborative practice agreement for APRN Staff II showed the physician was required to review the work, records and practice of the nurse practitioner at least once every two weeks and document the review.

2. Record review of Staff II's credentialing file showed there was no documented review or evaluation of clinical practice by a physician.

3. During a telephone interview on 03/07/14 at 10:45 AM, Staff II stated that she did not know of any documentation related to the physician review of her work.

4. Record review of APRN Staff JJ's and Staff KK's credentialing files showed no quality evaluation of clinical practice by a physician.

5. During a telephone interview on 03/05/14 at 3:00 PM, Physician H stated that he had collaborative practice agreements with three APRN's (Staff II, Staff JJ and Staff KK) and supervised them by holding two training sessions per month. He stated he verbally addressed any concerns with care rendered by the APRN's but does not have a documented process for review.

Based on interview and record review the facility failed to have an agreement with an Organ Procurement Organization (OPO, an organization responsible to evaluate and obtain human organs for transplantation), which included the definition of "imminent death" and included that the facility was not required to grant credentialing privileges to members of an organ recovery team.
This failure had the potential to affect all potential donors and/or families who had a desire to donate organ(s) or patients who might benefit from a transplant. The facility census was 10.

Findings included:

1. Record review of the agreement between the facility and the OPO dated 05/11/09 showed no definition of imminent death. The review showed the agreement did not include information that the facility was not required to grant credentials or privileges to any members of the organ recovery team.

2. During an interview on 03/06/14 at 2:45 PM, Staff C, Chief Nursing Officer confirmed the agreement between the facility and the OPO did not contain a definition of imminent death and did not document the facility was not required to grant privileges of any kind to members of an organ recovery team. Staff C stated that the facility had no policies or procedures for staff to follow for organ procurement.

Based on interview and record review, the facility failed to train staff members on how to work with the Organ Procurement Organization (OPO, an organization responsible to evaluate and obtain human organs for transplantation.) This could potentially affect all patients who die at this facility, their family members, and individuals waiting for organ donation. The facility census was 10.

Findings included:

1. Record review of the agreement between the facility and the OPO dated 05/11/09 showed that the OPO would provide training programs designed to train staff and physicians who would introduce the subject of eye and tissue donation to the next of kin of a deceased patient. The agreement showed the OPO would provide in-service training of the facility personnel concerning death notification and organ procurement procedures.

2. During an interview on 03/06/14 at 2:45 PM, Staff C, Chief Nursing Officer stated that she had been in charge of the facility organ procurement program for the past seven years and in that time neither the facility nor the OPO had provided any education to staff regarding the program. She stated that the nursing staff just knew what to do when there was a death in the facility. She stated that a new nurse learned what to do from a more seasoned nurse when a patient died. Staff C stated that the facility had not developed any policies or procedures for staff to follow for organ procurement.

Based on interview and record review, the facility failed to identify through a comprehensive assessment, or provide a program of activities appropriate for each resident for four (#14, #16, #17 and #26) of four Swing Bed (a type of reimbursement for a facility in which beds may be used for either skilled nursing or acute care on an as needed basis) resident records reviewed. This failure to identify each residents interests had the potential to deny all Swing Bed residents the ability to reach their highest level of physical, mental and psychosocial well being. The facility census was 10, with four of those being Swing Bed residents.

Findings included:

1. Record review of a resident packet given to all Swing Bed residents showed the facility would provide an ongoing program of activities and medically related social services designed to meet the interests and the physical, mental and psychosocial well being of each resident.

2. During an interview on 03/05/14 Staff AA, Activity Director (AT) stated that she had been the AT Director for the Swing Bed unit for two years. She stated she did not do a formal assessment of residents interests. She stated that she talked with the residents and offered them the activities documented on an AT calendar. She stated that the unit had no policies related to completing an assessment with each resident regarding their interests.

3. Record review of the March 2014 AT calendar showed activities such as popcorn and movie night every Saturday, music in the dining room every Sunday, card games or one-on-one visits every Monday, crossword/word search puzzles every Tuesday and Friday, newspaper reading every Wednesday and board games every Thursday.

4. Record review of Swing Bed Resident #14's physician's admission orders dated 02/25/14 showed the resident was admitted for physical therapy after a total left hip replacement.

5. Record review of the resident's nursing notes showed staff did not complete an assessment of Resident #14's leisure interests or physical ability to participate in an activity.

6. Record review of the resident's weekly interdisciplinary team meeting dated 03/05/14 showed staff recorded Resident #14 enjoyed reading magazines and newspapers.

7. During an interview on 03/06/14 at approximately 1:30 PM, Resident #14 stated that he enjoyed playing cards and fishing. He stated that the staff offered to take him to the dining room to see a movie one time but the staff offered no other activities.

8. Record review of Swing Bed Resident #16's physician's admission orders dated 02/24/14 showed the resident was admitted for physical therapy and strength building following a coronary stent procedure (a tube placed in the arteries of the heart to keep the blood flow open and help reduce the chance of a heart attack.) The admission record showed the resident had limited cognitive ability (the ability to think, reason and problem solve) possibly due to dementia.

9. Record review of the resident's nursing notes showed staff did not complete an assessment of Resident #16's leisure interests or physical or cognitive ability to participate in an activity.

10. Record review of the resident's weekly interdisciplinary team meeting dated 02/28/14 showed staff recorded the resident needed to be encouraged to be active.
Due to the residents decreased cognitive ability, the resident was unavailable for interview.

11. Record review of Swing Bed Resident #17's physician's admission orders dated 02/18/14 showed the resident was admitted for physical therapy and strength building following a coronary artery bypass graft (CABG, a surgical procedure to restore blood flow to the heart muscle by diverting the flow of blood around a section of a blocked artery in the heart).

12. Record review of Resident #17's nursing notes showed staff did not complete an assessment of the resident's leisure interests or physical ability to participate in an activity.

13. Record review of the resident's weekly interdisciplinary team meeting dated 03/05/14 showed staff recorded the resident enjoyed reading magazines and doing puzzles.

The resident declined an interview with the surveyor.

14. Record review of Swing Bed Resident #26's physician's admission orders dated 02/21/14 showed the resident was admitted for physical therapy and strength building due to weakness and shortness of breath with physical exertion (exercise.)

15. Record review of Resident #26's nursing notes showed staff did not complete an assessment of the resident's leisure interests or physical ability to participate in an activity.

16. Record review of the resident's weekly interdisciplinary team meeting dated 02/26/14 showed staff recorded the resident enjoyed drawing.