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Based on the manner and degree of deficiencies cited and review of policies/procedures and other facility documents, the hospital failed to be in compliance with the Condition of Participation of Governing Body. The governing body failed to ensure that contracted services were detailed in a complete list that described the nature of the contracted services. The governing body also failed to adequately evaluate the services provided by contract to ensure that they were provided in a safe and effective manner. Finally, the governing body failed to ensure that the policies/procedures and formulary for the hospital accurately reflected to services provided.

The findings were:

1. Policies/procedures and formulary specific to the services provide by the hospital:

Review of the formulary provide by the pharmacist on 9/21/11 revealed that the formulary contained a full category of oncology/chemotherapy medications, despite the fact that the pharmacist from both locations stated that the facility did not administer chemotherapy medications in the facility. The pharmacist at the southern campus site confirmed on 9/20/11 at approximately 2:30 p.m., that the hospital do not administer chemotherapy medications and the hospital pharmacies did not stock those medications. On 9/21/11 at approximately 3:45 p.m., the director of pharmacy for both campuses also confirmed that the the hospital did not administer chemotherapy medications and did not stock them in their pharmacies.

Review of the policies and procedures for the pharmacy on 9/19/11 revealed that the manual did contain policies/procedures on administration of chemotherapy medications. Evidence that the policies/procedures were reviewed and approved by the governing body was found in the governing body meeting minutes for 3/3/11.

Review on 9/21/11 of the policy/procedure titled "Emergency Room Level IV," which was found in the governing body-approved policy/procedure manual claimed that the facility maintained a Level IV Emergency Room, even though the hospital did not have an emergency department.

Review on 9/22/11 of hospital's document titled "Patient Safety Plan," contained language on the 5th page which implied it was the policy/procedure/document of another hospital organization. The language included the proper name of that hospital organization in the text.

Interviews with multiple staff during the survey confirmed that the hospital relied on its corporate management to provide policies/procedures and those were reviewed and approved by the governing body, even if they did not apply to the hospital being surveyed.

2. In addition, the facility failed to be in compliance with the following standards under the Condition of Governing Body:

Tag A 084 Contracted Services - the facility failed to ensure that all contracted services were provided in a safe and effective manner.

Tag A 085 Contracted Services - the facility failed to ensure that a complete list of all contracted services, including a description of the nature of services provided.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Medical Staff. The hospital failed to ensure that it had an organized medical staff that operated under bylaws approved by the governing body. Specifically, the hospital failed to ensure that all providers caring for patients directly or through contracted services were credentialed and privileged by the hospital's governing body to do so.

The facility failed to be in compliance with the following standard:

A 0355: Medical Staff Privileging - the facility failed to ensure that physicians involved in the care of patients were granted privileges to do so. This failure created the potential for negative patient outcome.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Nursing Services. The facility failed to ensure that it had an organized nursing service that ensured that each patient had an individualized care plan and that the nursing service included documented orientation and verification of competence of both agency nursing staff.

The facility failed to be in compliance with the following standards:

A 0396: Nursing Care Plan - the hospital failed to ensure that each patient had a nursing care plan that was kept current and that was individualized to the patient's specific care needs. Specifically, the facility utilized a common care plan for all patients that did not allow nurses to individualize the interventions and goals for each patient. This failure created the potential for a negative patient outcome.

A 0398: Supervision of Contract Staff - the facility failed to ensure that non-employee licensed nurses who were working in the hospital adhered to the policies and procedures of the hospital. The director of nursing service failed to provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occurred within the responsibility of the nursing services of the facility. Specifically, the facility failed to maintain a complete personnel file that included an orientation to the facility, validation of the non-employee licensed nurses' competencies, and evaluation of the performance of the non-employee licensed nurses' care. Additionally, the facility failed to ensure that non-employee respiratory therapists who were working in the facility had evaluations in their files.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Medical Record Services. The facility failed to ensure that it had a medical record service that had administrative responsibility for medical records. Specifically, the hospital failed to ensure that records were maintained secure and confidential.

The facility failed to be in compliance with the following standards:

A 0441: Confidentiality of Medical Records - the facility failed to ensure the confidentiality of patient records. Specifically, the facility utilized "walleroos," nurse servers outside of each patient room that contained information about the patients, which were unlocked thus not ensuring the protection of the patients' information. This failure created the potential for a negative patient outcome.

A 0442: Security of Medical Records - the hospital failed to ensure that unauthorized individuals could not gain access to or alter patient records.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Physical Environment. The facility failed to ensure that the hospital locations were arranged and maintained to ensure the safety of the patients and to provide facilities for diagnosis and treatment for special hospital services appropriate to the needs of the patients. Specifically, the hospital failed to ensure that all supplies and equipment were stored on shelves or carts, rather than on the floor, that preventive maintenance (PM) inspections were routinely completed on all equipment, that emergency equipment on the emergency resuscitation cart and in the medication room were clean and free of dust/debris, that temperatures were monitored in medication refrigerators, that pallets of delivered supplies did not obstruct safe egress in patient care unit hallways and that food trays from previous meals were removed timely from the dirty utility storage areas.

The facility failed to be in compliance with the following standards under the Condition of Physical Environment:

Tag A 724 Facilities, Supplies, Maintenance of Equipment - failure to ensure that the environment and equipment were safe, clean and well maintained.

Tag A 726 Ventilation, Light and Temperature Controls - failure to ensure that medication refrigerator temperatures were monitored.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Discharge Planning. The hospital failed to ensure that it had in effect a discharge planning process that applies to all patients that included written policies and procedures. Specifically, the hospital failed to ensure that documentation existed of choice being provided for post-discharge services and for arrangements made for post-discharge dialysis.

The facility failed to be in compliance with the following standards:

A 0827: Discharge Planning Document - the hospital failed to document in the patient's medical record that a list of available home health agencies was presented to the patient or the individual acting on the patient's behalf in two (Sample patients #1 and #14) of 30 records.

A 0837: Transfer or Referral - the facility failed to document arrangements for outpatient dialysis for a new hemodialysis patient that was discharged to a skilled nursing facility.

A 0843: Reassessment of Discharge Planning Process - the facility failed to ensure a clear and evident process for the reassessment of its discharge planning program. This failure created the potential for a negative outcome.

Based on tour/observation, staff interview, review of facility documents and policies/procedures, the governing body failed to adequately evaluate contracted services to ensure that they were provided in a safe and effective manner, in the areas of food and dietary, radiology, laboratory, preventive maintenance, rented medical equipment and stocking and maintenance of the emergency resuscitation carts. The failures created the potential for negative patient outcomes.

The findings were:

1. Food and Dietary Services:

Review of the list of contracted services on 9/19/11 confirmed that the facility utilized the host hospital's food and dietary service in the south campus site. This was confirmed by interviews during the tour of that site on 9/20/11 at approximately 11:30 a.m. by the hospital administrator. During the tour of the site the hospital administrator and the unit nurse manager discussed problems that they had been attempting to address related to concerns about the food provided. The administrator stated that the food provided was not of the overall quality, including variety and appeal, compared to the food provided at the north campus location by a different host hospital. S/he stated that their patients often had poor nutrition that led to skin breakdown. They needed to have an appetizing and varied selection of high protein menu items. S/he stated that s/he had been working with food and dietary at the host hospital at the south campus site, but felt that they had not yet accomplished the improvement s/he would like to see.

Reference Tag A 724 for addition findings related to lack of timely removal of meal trays from dirty utility room on the south campus patient care unit.

Review of the facility report provided to the governing body titled "Annual Contract Services Review," which was the most recent contract review for the current year, revealed the evaluation did not include the issues of food quality/satisfaction and timely removal of trays from the floor after meals. Review of the document revealed the following findings, in pertinent parts:
"...Contract
Dietary
Indicator
1. Timely and accurate delivery of dietary items ordered.
2. Contractor samples 10 trays per month for food temperature:
a. Cold Food temperatures between 40-60 degrees
b. Hot Food temperature between 90-110 degrees
Outcome
1. Accuracy and timeliness of dietary items as ordered:
No issues
2. Contractor samples 10 trays per month for food temperature between 40-60 degrees - No issues
Hot Food temperature between 90-110 degrees - No issues
Actions/Follow-up Required
Continue to follow..."

2. Radiology Services:

Review of the list of contracted services on 9/19/11 revealed that the hospital had contracts with each of the host hospitals to provide all radiology services for their patients.

Review of the facility report provided to the governing body titled "Annual Contract Services Review," which was the most recent contract review for the current year, revealed the evaluation did not include issues such as accuracy of readings, need for repeat testing because of problems, staff interactions with patients, safety procedures for patients, turn around times for non-urgent procedures and monitoring of staff for radiation exposure.

Review of the document revealed the following findings, in pertinent parts:
"...Contract
Radiology
Indicator
1. Turn around time for STAT procedures as specified in contract
2. Techs use appropriate PPE (Personal Protective Equipment) when taking films.
Outcome
1. Turn around time for STAT procedures as specified in contract:
No issues
2. Techs use appropriate PPE when taking films:
Yes
Actions/Follow-up Required
Continue to follow..."

3. Laboratory Services

Review of the list of contracted services on 9/19/11 revealed that the hospital had contracts with each of the host hospitals to provide all laboratory services for their patients.

Review of the facility report provided to the governing body titled "Annual Contract Services Review," which was the most recent contract review for the current year, revealed the evaluation did not include issues such as lost specimens, sample collection and turn around time for non-urgent testing.
Review of the document revealed the following findings, in pertinent parts:
"...Contract
Laboratory
Indicator
1. STAT lab results available per contract time frame.
Outcome
1. Findings of Critical Test Results Audit (NPSG grid):
No issues
Actions/Follow-up Required
Continue to follow..."

4. Preventive Maintenance:

During multiple interviews with the administrator and the materials manager during the survey, it was determined that the hospital had a contract with an outside company to provide preventive maintenance on their medical equipment. The materials manager also stated that the company providing rental equipment was supposed to do preventive maintenance inspections and provide documentation to the hospital.

Reference Tag A 724 for findings related to failure to ensure that preventive maintenance was conducted on all hospital owned and rented medical equipment.

Review of the facility report provided to the governing body titled "Annual Contract Services Review," which was the most recent contract review for the current year, revealed the following findings, in pertinent parts:
"...Contract
Bio-medical
Indicator
1. Contractor presents updated PM inventory quarterly to the Safety officer. Safety Officer reviews to ensure completeness and follow-up.
2. 10 pieces of equipment will be reviewed during EOC (Environment of Care) rounds to determine appropriate label and PM current.
Outcome
1. Contractor presents updated PM inventory quarterly to the Safety Officer:
Materials Management forwards to Safety Officer - Maintained in Materials Management at both sites.
January - Yearly Yes
2. 10 pieces of equipment will be reviewed during EOC rounds to determine appropriate label and PM current:
Yes
Actions/Follow-up Required
Continue to follow..."

5. Emergency Resuscitation Cart

Reference Tag A 724 for findings related to the failure to ensure that all equipment on the emergency resuscitation cart was clean when supplied to the hospital under contractual arrangement at the south campus site.

Based on staff interview and review of facility documents the facility failed to maintain a list of all contracted services. The list the facility maintained was not complete and did not include the scope and nature of the services provided.

The findings were:

Upon entering the facility on 9/19/2011, the facility was requested to provide a list of all contracted services. Subsequently, a list of contracts was provided to the surveyors on 9/19/2011. The hospital had two lists, one for each location. The list for the "Main" campus had four columns which were titled: "Contract", "Date", "Purchased Service", and "Location". It was noted that neither list contained a listing for the biomedical engineering company that was used to perform preventative maintenance on the facility's equipment. The lists did not contain the contracted dialysis service at the "South" campus. The lists did not contain the contracted off-site medical record storage facility. The list did not include the scope and nature of the services provided for all of the contracted services.

An interview with the facility's Chief Executive Officer conducted on 9/19/2011 at approximately 9:30 AM revealed that the list contained "the current ones [contracts]" and that there were no additional lists to review.

Based upon review of policies and procedures, staff interviews, and tours of the facility, it was determined that the facility failed to ensure that expired supplies were not used for patient care. This failure created the potential for potential harm.
The findings were:

Review of Policy and Procedure Number: "D01-N, DIABETES MELLITUS ROUTINE CARE AND HYPOGLYCEMIA PROTOCOL" with a revision date of 4/1/2011 stated in pertinent part..." 3. To ensure accuracy of results when performing and monitoring hospital bedside testing of patient blood glucose the procedure is to test.
5. Quality Control: A. Refer to product manual. In the General Orientation for Clinical Services the documented purpose for monitoring glucose quality control is: To ensure accuracy of results when performing point of care testing of patient blood glucose. "Quality Control : Refer to product manual. The Precision Xceed Pro Operator's Manual documents in pertinent part..." Operating Guidelines for Control Solution Testing. When opening a new bottle, write the discard date on the bottle label. Each bottle of control solution is stable for 90 days after opening or until the expiration date printed on the label, whichever comes first. Do not use control solutions after the expiration date printed on the bottled and the box. After the bottle has been opened, do not use after the discard date written on the bottle." The Operating Guidelines states when "Troubleshooting Out-of-Range Control Test Results Check that the bottles of control solutions have not been open for more than ninety days."

A tour of the facility South campus was conducted on 9/20/11 at approximately 12:45 p.m. with the Director of Nursing. Observations of the facility's glucometers used to check patient blood sugars revealed that the facility failed to label two sets of control solutions used daily to test the accuracy of the glucometers; there were no opening dates labeled on the bottle to determine the 90-day expiration per facility policy and procedure.

A tour of the facility's North Campus was conducted on 9/19/11 at approximately 1:00 p.m. with the Director of Nursing. Upon observations of the facility's glucometers used to check patient blood sugars, it evidenced that three sets (one low control and one high control) of control solutions, used daily to test the accuracy of the glucometers, were expired per facility policy and procedure. The first set expired 9/14/11, the second set expired 8/24/11, and the third set expired 4/28/11. These observations with confirmed with the Director of Nursing, who stated that the controls expired 90 days after opening and were labeled with the expiration date upon opening.

The tour at the south facility also revealed that there were expired Vacutainer blood specimen collection tubes; 32 expired 8/2011, 2 expired 6/2011, 8 expired 3/2011, 2 expired 2/2011.

This Standard is NOT met as evidenced by:

Based on review of the hospital's policies/procedures, staff interview, and medical record review the hospital failed to ensure that each patient had a nursing care plan that was kept current and that was individualized to the patient's specific care needs. Specifically, the facility utilized a common care plan for all patients that did not allow nurses to individualize the interventions and goals for each patient including the facility use of restraint and seclusion. This failure created the potential for a negative patient outcome.

The findings were:
A reviewed facility policy and procedure which was revised 06/10 "R02-N Restraints and Seclusion" stated in pertinent part:
"Modification of the patient's treatment plan related to restraint use, patient's response to restraint, and plan for reduction/elimination is included in the patient's medical record. Interdisciplinary Team Member documentation must:

? State behavior/condition (justification) necessitating use of protective restraints (q shift & prn) (Restraint Assessment & Physician order and Restraint Record and Plan of Care);
? State alternatives to protective restraint evaluated and result (q shift & prn) (Restraint Assessment & Physician order and Restraint Record and Plan of care):
? State type of device applied and patient response (shift and prn) (Restraint Record and Plan of Care):
? State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting - to include removal of restraints at least 10 minutes every 2 hours or more often (observations every two hours for medical restraints and every 15 minutes for behavioral restraints) (Restraint Record & Plan of Care).
? State plan of care (at implementation & q day) (Restraint Record and Plan of Care); and
? State Patient/family education (application & prn) (24 Hour Flowsheet - Education section)."

An interview with the hospital's Chief Nursing Officer was conducted on 9/21/2011 at approximately 12:55 PM. The interview revealed that nurses were expected to document on the same pre-printed 24-Hour Patient Record and Plan of Care for all patients. S/he confirmed on that form was the only area restraint care planning was documented.

Written documentation contained in the worksheet titled "24 Hour Patient Record & Plan of Care" reviewed for 2 out of 29 patient charts revealed:

The plan of care, dated 9/21/2011 for sample Patient #3, documented the patient had diagnoses of Respiratory Failure, Stroke, and Renal Failure, was at risk for self removal of "trach" (breathing tube), and indicated that patient was restrained. Documentation in "Nurses Progress/Narrative Notes" by R.N. timed "7 p.m. to 7 a.m. attempt to pull at trach. LUE (left upper extremity) cont.(continues) in restraint". A review of the patient's "24 hour Patient Record and Plan of Care" for 9/21/2011 revealed that the form had no individualized care plans other than those listed for all patients.

The plan of care dated 9/20/2011 for Patient #4 who was suffering from Respiratory Failure, Hemiparesis (weakness on one side of the body), and Heart Disease and was at risk for self removal of "tubes", indicated that patient was restrained. Documentation in the "Nurses Progress/Narrative Notes" in pertinent part by the R.N. timed "20:00 (8:00 p.m.) Lt. (left) Arm in restraints to keep tubes in place" and at "00:30 a.m. Patient still remains in left wrist restraint to keep tube in place". At "05:00 a.m. Pt remained w/Lt. (with left) wrist restraints to help keep tubes in place". A review of the patient's "24 hour Patient Record and Plan of Care" for 9/20/2011 revealed that the form had no individualized care plans other than the ones already listed for all patients.

In summary:
Restraint documentation in the "Plan of Care" failed to record observations, findings, or variance in interventions related to the required every 2 hour assessment (check) of Skin Integrity and Circulation, Patient/Family Education, Reorientation, Person at Bedside, Line of View, and Removal of Restraints for 10 minutes every 2 hours.

It was determined the facility failed to assure appropriate restraint documentation and did not follow their Policy & Procedure "Restraints and Seclusion" for written modification to the patent's Plan of Care.

Based on medical record review, facility records, staff/physician interviews, the facility failed to ensure that physicians involved in the care of patients were granted privileges to do so. This failure created the potential for negative patient outcome.

The findings were:

1. An interview with the facility's Director of Quality Management on 9/19/2011 at approximately 9:35 AM revealed that the facility did not grant privileges or maintain credential files on radiologists of the contracted service unless the physician performed interventional radiology. S/he stated that the facility did grant privileges to the interventional radiologists because they may come to the floor and see patients and write orders.

2. A review of the facility's Medical Staff Bylaws and Rules & Regulations revealed the following, in pertinent parts:

"...Definitions:...
(3) 'Clinical Privileges' or 'Privileges' means the authorization granted by the Governing Board to a Medical Staff member or other Independent Practitioner to render specific patient care services in the Hospital within defined limits...
(8) 'Medical Staff' means those physicians, dentists, and podiatrists who are given privileges to treat patients in the Hospital...
2.D: Contracted Staff
(1) The Contracted Staff shall consist of those physicians, dentists, and podiatrists who: (a) satisfy the criteria set forth in Article 2.A of the Credentialing Policy; (b) who perform occasional work in the Hospital by virtue of a contractual relationship to provide clinical services in the Hospital; and (c) have been granted clinical privileges at the Hospital...
Credentialing Policy of the Medical Staff...
2.A: Qualifications for Medical Staff Appointment
2.A.1. General:
Appointment to the Medical Staff is a privilege, which shall be extended only to professionally competent individuals who consistently meet the qualifications, standards, and requirements set forth in this policy. Applications for appointment will be reviewed and processed in a timely manner or, where applicable, in accordance with state statute or regulation...
2.C: Contracted Services
Individuals applying for Medical Staff membership by virtue of a contractual relationship to provide clinical services in the Hospital shall follow the same procedure outlined in Article II in applying for membership and clinical privileges as an individual without such a relationship...
Article IV Clinical Privileges
4.A: Clinical Privileges
4.A.1. General:...
(b) Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those clinical privileges specifically granted by the Governing Board...
Rules and Regulations of the Medical Staff...
1. Only practitioners granted Medical Staff appointment and Clinical Privileges may admit patients to this Hospital...Only practitioners granted Clinical Privileges may treat patients at this Hospital. All practitioners with authority to admit patients shall be governed by the official admitting policy of the Hospital...
C. Medical Records...
19. All radiological studies with the exceptions of those modalities used for feeding tube placement evidence, require an interpretation by a physician credentialed in Radiology..."

3. A review of 30 medical records conducted from 9/19/2011 through 9/22/2011 revealed that 13 of 30 sample patients had physicians involved in their care that were not credentialed or granted privileges by the hospital. The medical records revealed the following, in pertinent parts:

Sample patient #1 was an adult patient admitted on 8/31/2011 and remained an inpatient during the medical record review on 9/21/2011. A report of a peripherally inserted central catheter (PICC) placement was dictated on 9/1/2011 by Physician #1.

Sample patient #2 was an adult patient admitted on 8/23/2011 and remained an inpatient during the medical record review on 9/22/2011. A review of the 9 imaging reports performed between 8/30/2011 and 9/18/2011, while the patient was an inpatient, revealed that 8 physicians (Physicians 2, 3, 4, 5, 6, 7, 8, & 9) dictated the reports (Physician #6 interpreted 2 studies).

Sample patient #3 was an adult patient admitted on 9/16/2011 and remained an inpatient during the medical record review on 9/22/2011. A review of the 5 imaging reports performed between 9/16/2011 and 9/20/2011, while the patient was an inpatient, revealed that 4 physicians (Physicians 3, 5, 10, & 11) dictated the reports (Physician #3 interpreted 2 studies).

Sample patient #4 was an adult patient admitted on 9/15/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of the 1 imaging report performed on 9/18/2011, while the patient was an inpatient, revealed that Physician #12 dictated the report.

Sample patient #8 was an adult patient admitted on 8/24/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of the 2 imaging reports performed between 8/31/2011 and 9/10/2011, while the patient was an inpatient, revealed that 2 physicians (Physician #9 & 13) dictated the reports.

Sample patient #9 was an adult patient admitted on 8/26/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of the 6 imaging reports performed between 8/28/2011 and 9/16/2011, while the patient was an inpatient, revealed that 6 physicians (Physicians 3, 6, 11, 13, 14, & 15) dictated the reports.

Sample patient #10 was an adult patient admitted on 8/30/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of the 2 imaging reports performed between 9/5/2011 and 9/7/2011, while the patient was an inpatient, revealed that 2 physicians (Physician #8 & 13) dictated the reports.

Sample patient #11 was an adult patient admitted on 9/1/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of the 1 imaging report performed on 9/6/2011, while the patient was an inpatient, revealed that Physician #9 dictated the report. Documentation by Physician #16 was also present in the record on 9/9/2011 as a surgical consult as well as a telephone order on 9/9/2011.

Sample patient #16 was an adult patient admitted on 9/14/2011 and remained an inpatient during the medical record review on 9/20/2011. A review of the 3 imaging reports performed between 9/14/2011 and 9/17/2011, while the patient was an inpatient, revealed that 3 physicians (Physician #16, 17 & 18) dictated the reports.

Sample patient #17 was an adult patient admitted on 9/2/2011 and remained an inpatient during the medical record review on 9/20/2011. A review of 3 of the 7 imaging reports performed between 9/11/2011 and 9/15/2011, while the patient was an inpatient, were interpreted by 2 physicians (Physician #19 and #20) who dictated the reports (Physician #19 interpreted 2 studies).

Sample patient #18 was an adult patient admitted on 8/27/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of the 2 imaging reports performed between 9/9/2011 and 9/13/2011, while the patient was an inpatient, revealed that 2 physicians (Physician #18 and #20) dictated the reports.

Sample patient #22 was an adult patient admitted on 9/7/2011 and remained an inpatient during the medical record review on 9/21/2011. A review of an imaging report performed on 9/7/2011, while the patient was an inpatient, revealed that physician #24 dictated the report. A progress note was written in the chart by Allied Health Provider #23.

Sample patient #24 was an adult patient admitted on 9/15/2011 and remained an inpatient during the medical record review on 9/20/2011. A review of 2 of the 4 imaging reports performed between 9/15/2011 and 9/20/2011, while the patient was an inpatient, were interpreted by 2 physicians (Physicians #21 and #22) who dictated the reports.

4. On 9/21/2011 at approximately 4:00 PM, the Director of Health Information Management, who was the individual responsible for the maintenance of the physician credentialing files, was interviewed to inquire if the physicians that had interpreted radiology studies, performed interventional radiology procedures, and wrote progress notes and orders were granted privileges at the hospital. S/he confirmed that the list provided to the surveyors of the physicians and allied health professionals that were granted privileges was complete and that the physicians and allied health professionals referenced above were not currently credentialed or granted privileges by the hospital.

Based on review of the hospital's policies/procedures, staff interview, and medical record review the hospital failed to ensure that each patient had a nursing care plan that was kept current and that was individualized to the patient's specific care needs. Specifically, the facility utilized a common care plan for all patients that did not allow nurses to individualize the interventions and goals for each patient. This failure created the potential for a negative patient outcome.

The findings were:

A facility policy titled "Nursing Care Plan" last revised 11/2008 revealed the following, in pertinent parts:
"Purpose...
6. The key issues that Nursing has primary responsibility for in the CCIS (Chronic Critically Ill) patient include:
a. Assessment and management of delirium
b. Prevention and early recognition of Sepsis
c. Safety and prevention of in-hospital injury
d. Mobility plan (outside of Rehab interventions)
e. Wound prevention and management
f. Management of discomfort and pain
7. To simplify the care planning process for Nursing, the care plan along with relevant internal and external bundles and standard assessment formats have been incorporated into the 24 Hour Patient Record and Plan of Care. This allows for Nursing Priorities to be maintained "top of mind" and to prompt critical thinking and standard approaches.
8. Additional problems can be noted on the Care Plan Kardex, if necessary. In addition, the Kardex serves as a road map for the shift. Nutrition, Mobility, Glycemic Control, Bowel and Bladder Plans are noted. This tool is also available for handoff communication in shift report.
9. The elements of care planning include:
a. Assessment
b. Problem identification
c. Intervention
d. Evaluation
e. Communication
Procedure...
2. On the 24-Hour Patient Record and Plan of Care, the nurse will implement and document approaches related to key nursing care issues...
4. Evaluation will be noted on the flow sheet. Documentation formats can include: APIE notes, SOAP notes or simple narrative notes..."

An interview with the hospital's Chief Nursing Officer conducted on 9/21/2011 at approximately 12:55 PM revealed that nurses were expected to document on the same pre-printed 24 Hour Patient Record and Plan of Care for all patients. S/he stated that the nursing care plan was expected to be on that form. S/he stated that the Kardex was not a part of the medical record and was only used for reporting purposes. S/he stated that if nurses identified any additional problems that needed to be addressed as a part of a care plan that it would be documented in the nurses' progress notes which were also on the 24-Hour Patient Record. S/he stated that the facility expected nurses to "document by exception" which meant that if there was an exception of a change of condition it would be noted in the progress notes. S/he stated that additional goals for patients apart from what was pre-printed on the form could be documented by nurses in the progress notes "but that is a pretty encompassing flow sheet" and that "the only thing that may not be in [the plan of care/flowsheet] is discharge planning and that [the discharge planning] should be in the IDT [Interdisciplinary Discharge Team] notes."

A review of the 24-Hour Patient Record and Plan of Care form was conducted with the Chief Nursing Officer during the interview which revealed that the patient goals for all of the patients were listed on the top of the sections. Those same seven goals for each patient included: "Successful implementation of protein & caloric intake. Adequate Nutrition," "Recognition and return to baseline mental status," "Early recognition and interventions for abnormal findings," "Maintain skin integrity. Promote wound healing," "Promote early recognition of s/s [signs and symptoms] of infection. Employ early interventions. Prevent HAI [Healthcare Acquired Infections]," "Reduce injury and risk of harm," and "Pain rating <4. Environment conducive to rest. Patient/family communication, emotional, spiritual & cultural needs are met. Patient/family involved in plan of care." S/he stated that the goals were "optimally wanting to get [patients] back to their baseline."

When the DON was asked how patients with specific problems such as respiratory issues would have an individualized care plan, s/he stated that the goal would be for the patient to have a normal assessment. When asked how the care plan listed interventions for respiratory issues, s/he stated that the "interventions would be on the graphics, which would be at the bedside."

The Chief Nursing Officer continued by stating, "our goals are pretty much the same" which included goals of "optimal skin integrity and optimal pain control."

When asked how short term and long term goals were documented in the plan of care, s/he stated that the "flowsheet is just for 24 hours" and that long term goals would be documented on the IDT form.

When asked how the care plans were individualized to patients, s/he stated that "if you look on an assessment, every patient may not get the same intervention...not everyone will be on enhanced fall precautions...the flowsheets may be standard structure, but each flowsheet would be different." S/he continued by stating that the patient's progress was documented on an ongoing basis and that with "every change in the patient's condition the charting should reflect that." When asked for clarification about the entire chart and documentation by nursing in multiple locations, the Chief Nursing Officer confirmed that "all of the charting is the care plan" and that "it is a multitude interdisciplinary approach."

Sample patient #3 was an adult patient admitted to the hospital on 9/16/2011 from an acute care hospital after suffering from a stroke and having mental status changes and pneumonia. The patient was admitted to the hospital with a diagnosis of respiratory failure and renal failure. The patient had a tracheostomy and was on a ventilator as well as receiving dialysis for his/her renal failure. A review of the patient's "24 hour Patient Record and Plan of Care" for 9/21/2011 revealed that the form had no additional plans other than the ones already listed for all patients.

Review of sample #12 revealed s/he was an adult patient admitted to the hospital on 9/15/11 from an acute care hospital. Upon admission, the patient had Fournier gangrene, a nonhealing decubitus ulcer, osteomyelitis requiring antibiotics, a suprapubic catheter, and a chronic state of C6 paraplegia. The patient was admitted for extensive wound care treatment, therapy, and continued antibiotic treatment. A review of the patient's "24 hour Patient Record and Plan of Care" for 9/20/2011 revealed that the form had no additional plans other than the ones already listed for all patients. Additionally, the nurse's documentation for the entire day of 9/20 did not state the patient's level of mobility or specifics about the patient's paraplegia. The only documentation evidenced was under the mobility section and stated the patient was "non-weight bearing," was "dependent min assist x2," and the patient's mobility level was "complete bedrest & ROM." On the day shift, the nurse documented "no" under "conditions effecting gait" but the night shift documented "yes" under the same section and "incomp. quad." The skin section of the flow sheet stated to "see wc orders and documentation." The wound care documentation on a separate form stated the location of the wound was "ischials," however the wound location was not labeled/circled on the forms. The wound documentation areas, including "protect peri-wound skin:" "apply primary dressing:" "apply secondary dressing:" and "secure with:" were not filled out with instructions, details, or any documentation. It was documented that the patient had a wound vac and a change frequency was to be "M-W-F" by the "wd care team." However, no documentation stated the size of the patient's wounds, the specific locations, and the "wound bed" was documented to be "black, yellow, brown, red, and bone" on 9/16, but on 9/19 a nurse documented that the assessment was done by the wound care nurse was the bed was now only "red."

Based on personnel file review and staff interview the facility failed to ensure that non-employee licensed nurses who were working in the hospital adhered to the policies and procedures of the hospital. The director of nursing service failed to provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occurred within the responsibility of the nursing services of the facility. Specifically, the facility failed to maintain a complete personnel file that included an orientation to the facility, validation of the non-employee licensed nurses' competencies, and evaluation of the performance of the non-employee licensed nurses' care. Additionally, the facility failed to ensure that non-employee respiratory therapists who were working in the facility had evaluations in their files.

The findings were:

A review of the facility's policies/procedures revealed that the facility's policy titled "Agency Files: Standards and Requirements" stated the following, in pertinent parts:
"...4. The HRC [Human Resources Coordinator] under the supervision of the DCS [Director of Clinical Services] will assemble a file that contains:
a. The executed contract
b. The approved method of competency assessment...
d. Independent license validation (performed by Select)...
e. Evidence of orientation to Select...
f. Evidence of performance appraisal after first scheduled shift and once per year thereafter
5. An individual file will be maintained for every agency- contract staff that provides service or could potentially provide service.
6. Files will be reviewed minimally one time per year for completion by the HRC and DCS..."

A review of the facility's personnel files revealed the following:
The facility furnished a list of non-employee licensed nurses, nurse aides, and respiratory therapists that had provided care for patients in the facility since 1/1/2011 when requested to do so. A sample of personnel files were reviewed on 9/20/2011 for three of the non-employee licensed nurses and nurse aides (staff members #1, #2, and #3).

A review of staff member #1's file revealed that the last evaluation from the facility was dated 7/22/2009. A list compiled by the facility revealed that staff member #1 worked at the facility on 3/13/11, 3/20/11, 3/26/11, 3/27/11, and 3/30/11.

A review of staff member #2's file revealed that the last evaluation from the facility was from August 2010. A list compiled by the facility revealed that staff member #2 worked at the facility on 7/15/2011 and 7/22/2011.

A review of staff member #3's file revealed that there was not a facility orientation, a signed job description, or an evaluation from the facility. A list compiled by the facility revealed that staff member #3 worked at the facility on 6/3/2011 and 6/4/2011.

The above findings were confirmed with the facility's Human Resources Coordinator in an interview on 9/20/2011 at approximately 11:40 AM. S/he stated that the facility had in the past required each agency staff member (Nurses, Respiratory Therapists, and Nurses Aides) to be oriented to the facility, have a facility job description signed, and an evaluation from the facility on their first shift and annually thereafter if returning. S/he stated that recently the facility had identified that their files were missing expected documentation and that the facility had developed an action plan which included conducting a written evaluation after every shift for all agency staff members.

Another list of agency staff members was requested which included the past 2 months (August and September 2011). A sample of personnel files were reviewed for four additional non-employee nurses and respiratory therapists.

A review of staff member #7's file revealed that the last evaluation from the facility was dated 12/30/2009. A list compiled by the facility revealed that staff member #7 worked at the facility on 8/12/2011 and 8/13/2011. The facility was able to produce an evaluation dated 7/8/2011 but none for 8/12/2011 or 8/13/2011.

A subsequent interview on 9/20/2011 at approximately 4:20 PM revealed that the action plan discussed previously had gone into effect on 9/8/2011.

Based on facility tour/observations, policy/procedure, and staff interviews, the facility failed to ensure the confidentiality of patient records. Specifically, the facility utilized "walleroos," nurse servers outside of each patient room that contained information about the patients, which were unlocked thus not ensuring the protection of the patients' information. This failure created the potential for a negative patient outcome.

The findings were:

A tour of the facility North campus was conducted on 9/19/11 at approximately 12:45 p.m. with the Director of Nursing(DON). It was observed that the facility utilized nurse servers outside each patient room, which they called "walleroos." The walleroo were wall cabinets outside the patient rooms in the hallways which could be opened to be used as a writing station or closed to be used as a small storage area. Each walleroo was equipped with a keyed lock. The facility placed the patient's "bedside charts" in the walleroos. Room #5203 was opened and the bedside chart was observed to contain the following: a Kardex with any new orders or nurse updates, current labs, the History and Physical, the most recent telemetry rhythm, the nurse's admission handwritten report, the 24-hour assessment flow sheet, the current Medication Administration Record (MAR) as well as previous days MARs, the patient weight log, glucose form, and "if a wound care patient, they'd have wound care orders and skin assessment," stated the DON. When asked if the nurse servers/walleroos were locked, the DON and Nurse Manager both stated, 'They are never locked, but they are always in view."

On 9/20/11 at approximately 8:00 a.m., when asked if the facility had a policy on the usage of their "walleroos," the Director of Quality Management stated s/he did not think there was one. Later, a policy labeled "SELECT MEDICAL CORPORATION POLICY AND PROCEDURE" with a subject of "Federal Health Insurance Portability and Accountability Act (HIPAA) and titled "Safeguarding Protected Health Information (PHI) was provided. The policy was reviewed and did not specifically mention the usage of nurse servers or walleroos. The policy's main statement was as follows: "It is the policy of Select Medical Corporation that reasonable safeguard will be put in place to protect individuals' protected health information (PHI) and personally identifiable information (PH) from any intentional or unintentional use or disclosures in violation of HIPAA."

An interview was conducted on 9/20/11 at approximately 12:30 p.m. with the facility's North campus Medical Records Tech. When asked about the "walleroos," the Tech stated that s/he closes them whenever s/he notices that they are open when s/he is present at the facility, which is during the day, five days a week.

On 9/22/11 at approximately 11:00 a.m., a surveyor attempted to retrieve a bedside chart from a "walleroo" outside room #5215 and was informed by the Director of Nursing that all the "walleroos" had been locked that morning. However, further observation of the "walleroo" outside room #5215 revealed that it was still not locked.

Based on tour of the facility, staff interviews, and review of policies/procedures, the facility failed to ensure drugs were stored in accordance with accepted professional principles and in accordance with their own polices and procedures. Specifically, the facility had open, unlabeled, and/or expired medications in several areas throughout their north campus. This failure created the potential for a negative outcome.

The findings were:

A tour of the facility's north campus was conducted on 9/19/11 at approximately 1:00 p.m. with the Director of Nursing. The facility's "Bronchoscopy Cart" was observed to have one 20 ml open vial of 2% Lidocaine 20 mg/ml that was unlabeled and undated. It also contained one open container of ACMI endoscopic instrument lubricant which was without its cap/lid. Additionally, it contained a tube of racepinephrine inhalation 2.25% that contained a manufacturer's expiration date of August 2010. When asked who was responsible for the cart, the Director of Nursing stated, "RT is responsible for checking this cart." When asked the facility's policy on multi-use vials, the Director of Nursing stated they expired 28 days after opening. S/he continued, "They should be labeled after opened from the date of open to the date of expiration."

An interview and pharmacy tour with the Director of Pharmacy for both campuses was conducted on 9/20/11 at approximately 12:15 p.m. An observation of one of the shelves in the pharmacy revealed several drugs that the Director stated were non-formulary medications. One of those medications was drawn up into individual syringes meant for oral usage. However, each syringe was not labeled with the medication name, dosage, or who pre-drew them. The Director stated that the bin in which the medications were stored was labeled with the correct information and that the syringes would be labeled prior to being taken to the floor for patient distribution. The drug was Rapamune/Sirolimus with a labeled expiration of 3/29/12. There were a total of 53 syringes and each syringe contained 0.75 ml of medication.

An additional observation in the pharmacy revealed a vial of the medication hydromorphone 20 ml (2 mg/ml) in the narcotics cabinet. The vial was not labeled with an open date, expiration, or evidence of who opened the drug. When asked about the medication, s/he stated, "Once the vials are open, we go by the manufacturer's expiration date on all controlled. If non-controlled, it is 28 days - like Insulin."

An additional interview with the Director of Pharmacy was conducted on 9/21/11 at approximately 3:45 p.m. When asked if s/he had found an literature to support not following USP's 28 day rule for controlled medications, s/he stated, "You were right, it is 28 days for all medications. I will say that drug is expired because I don't know when it was opened." When asked about the expired medication on the bronchoscopy cart, s/he stated, "The respiratory therapist are probably taking out the drugs and not using them, then putting them on the bronch cart." S/he stated that all the observations made upon survey relating to medication had been fixed, that respiratory therapy had been talked to at the north campus and that s/he would talk with the one at the south campus as well.

Several different policies provided by the facility referenced the practice of 28-day expiration for multi-dose vials. One such policy was titled "BARRIER ISOLATOR: STANDARD OPERATING PROCEDURE," last revised 1/2009, and stated the following, in pertinent part: "2. Aseptic Technique for Vials... h. Multi-Dose Vials may be used for up to 28 days or as directed by the manufacturer...5. Final check...j. Extended beyond use dating - Dating may not exceed the above USP guidelines unless sterility testing is performed according to USP Chapter 71: Sterility Tests. If sterility test are performed, the product can be assigned beyond-use dating based on the maximum chemical stability of the drug in solution as permitted by valid references..."

An additional policy titled "DRUG STORAGE IN THE PHARMACY," last revised 4/2011, stated the following, in pertinent part: "Multi-dose injection vials may be used for 28 days unless otherwise specified by the manufacturer provided they are stored according to manufacturer's recommendations and are not obviously contaminated on visual inspection. The manufacturer may set a beyond use date after puncture less that 28 days or greater than 28 days in the product literature. The expiration date on the vial cannot be used as the beyond use date unless the product literature specifically states the expiration date and beyond use date are the same..."

The policy titled, "LABELING OF MEDICATION," last revised 7/2011, stated the following, in pertinent part: "...When product repackaging is necessary in order to provide unit dose (UD) or Unit-of-use (UU) products, the pharmacy will include at least the following information on each dose or unit:

a. The Hospital's name...b. The drug's generic name and brand name...c. The product's strength or concentration; d. The product's manufacturer; e. The pharmacy-assigned expiration date...f. The pharmacy-assigned control number; g. The quantity of drug in the package; h. The identity of the person who package the drug..."

Based on staff interview and review of the Medical Staff Rules/Regulations as well as facility policy, the facility failed to ensure that drugs and biologicals not specifically prescribed as to time or number of does were automatically stopped after a reasonable time that was predetermined by the medical staff. The facility failed to be in compliance with its own policies and procedures. This failure created the potential for a negative outcome.

The findings were:
An interview and pharmacy tour with the Director of Pharmacy for both campuses was conducted on 9/20/11 at approximately 12:15 p.m. When asked about the use of stop orders, s/he stated, "Drugs will be reviewed weekly at rounds - every Wednesday. Every week, I go through the meds. We do not do stop orders unless there is an order to discontinue the medication. As long as I've been a pharmacist anywhere that has not been the practice." Later that day at 1:00 p.m., the Director was informed of the Medical Staff Rules and Regulations and the facility's policy on stop orders. S/he acknowledged that the practice in place differed from the documents and stated, "I'll change that. I'll make it so it complies."

The facility's "RULES AND REGULATIONS OF THE MEDICAL STAFF" were reviewed on 9/20/11 and stated the following, in pertinent part: "...5. In those cases where deviation of treatment is indefinite or unspecified, the following classes of drugs are subject to automatic review and must be reviewed or discontinued piror to the expiration of the times specified in the Hospital's pharmacy policies:

(a) The following drugs shall be reviewed for renewal or discontinuation in accordance with Hospitals pharmacy policies:
1. Antibiotics/Antifungals/Antivirals 2. Anticoagulants 3. Antineoplastics 4. C-II Drugs 5. Cold/Cough Preparations contained narcotics 6. Dermatologicals 7. Total parenteral nutrition.

The ordering physician shall be notified of the potential expiration of a drug order at least twenty-four (24) hours prior to the expiration of that order. If the attending physician has not given further instruction the Pharmacist or Nurse shall attempt to contact the ordering physician or his designee prior to the expiration of the order, as stated above. If the ordering physician does not specifically renew the order, the drug shall not be continued until the physician renews or discontinues the order..."

The facility's policy titled "AUTOMATIC DISCONTINUATION OF DRUG ORDERS," last revised 01/10, stated the following, in pertinent part:
"PROCEDURE:
The following chart summarizes the automatic discontinuation schedules for selected medications as outlined in the Medical Staff Rules and Regulations. A physician may override this system by specifying "ongoing order" or "no automatic D/C" when writing the original or a renewal order. Alternatively, a specific time period may be included in the original or renewal order."

The chart thereafter stated the order type and the "Automatic D/C After" timeframe. It stated the following:

"Controlled Substances - 14 Days
Antibiotics - 7 Days
Antifungals - 7 Days
Antivirals - 7 Days
Anticoagulants - 99 Days
Corticosteroids - 99 Days
Other orders - 99 Days"
The policy continued, in pertinent part:
"The following procedures will be used to manage automatic discontinuation of drug orders.
1. Drug orders will be entered into the pharmacy computer system in a manner that places them in a queue for automatic discontinuation at the appropriate interval.
2. The pharmacist is responsible for requesting a report on a regular basis from the computer that indicates impending discontinuations.
3. The pharmacist will use the report to notify the physician, at least 24 hours in advance, that a given order will be discontinued unless a renewal order is written.
4. If the physician wishes to continue therapy, a renewal order must be written. The renewal order must be written according to the "Drug Order" Policy and Procedure.
5. Renewed drug orders will be placed back in the discontinuation queue unless the physician indicates otherwise.
6. If the physician does not respond to the notice, pharmacy or nursing will notify the physician of the order pending discontinuation.
7. All discontinuations, with the exception of Antibiotics, Antifungals, and Antivirals, in the pharmacy computer are to be 'soft stops' until the physician responds to the notification of discontinuation. By definition, a 'soft stop' is one in which the order is 'flagged' as a discontinued order, but the drug is still supplied until a decision is made by the physician whether or not to continue therapy...
8. Discontinuation orders will not apply in the following situations:
a. Antiviral used to treat chronic disease - HIV, Hepatitis B, etc.
b. Therapy for a specific condition when the physician gives a specific duration of therapy - osteomyelitis, endocarditis, vancomycin taper, etc."

Based on tours/observations, staff interviews, review of policies/procedures, the hospital failed to ensure that all equipment and supplies (including emergency equipment) and all areas of the facility were routinely inspected for safety, cleanliness, and functionality. Specifically, the facility failed to ensure that all supplies and equipment were stored on shelves or carts, rather than on the floor, that preventive maintenance (PM) inspections were routinely completed on all equipment, that emergency equipment on the emergency resuscitation cart and in the medication room were clean and free of dust/debris, that pallets of delivered supplies did not obstruct safe egress in patient care unit hallways and that food trays from previous meals were removed timely from the dirty utility storage areas. The failures created the potential for negative patient outcomes.

The findings were:

1. Safe Egress in Hallways:

On 9/20/11 at approximately 8:15 a.m., upon entry onto the patient care unit at the southern campus location, it was observed that the first door on the left entering the unit was a medical supply storage area. Just across from the doorway to the supply storage room, a large full-sized wooden pallet with a large stack of boxes of supplies was stored on the floor, partially obstructing the hallway. It was observed that two staff members were attempting to navigate a patient in his/her hospital bed past the pallet of supplies. They made several attempts and were finally able to move the patient bed past the pallet of supplies, when they pulled the bed back and put all rails down and out of the way and then there was enough room to move the bed past the pallet and off the unit. The supplies were stacked higher than the patient's head as s/he was lying in his/her bed as it moved past the stack of supplies.

The administrator, who was present when the situation was observed, acknowledged that was the only entrance to the unit/access to the elevator bank adjacent to the unit. Later tours/observations of the unit confirmed that there were no alternate hallways or elevator banks on the unit providing alternate egress when the pallet of supplies was delivered. During a later tour of the supply room on 9/20/11 at approximately 11:00 a.m., the materials management staff member for that location was interviewed and stated that the morning delivery was larger than usual and had contained 72 boxes/cases. By the time of the tour, the number of boxes remaining on the pallet was only stacked at approximately knee level, but with the same stack footprint that was the size of the pallet sitting on the floor. S/he stated that the deliveries usually happened approximately two times per week and the supplies were unpacked and stored in the storage room to clear the hallway. S/he stated that the supplies were usually brought up on a pallet and delivered by a pallet pull cart. It was observed on the next day 9/21/11 at approximately the same time that another delivery was sitting in the hallway being unpacked and stored in the supply room.

2. Supplies Stored on the Floor:

On 9/20/11 at approximately 11:00 a.m., a tour of the south campus patient care unit was conducted with the unit nurse manager, the administrator, the unit safety officer, the infection control nurse and the administrator. Tour/observations in the medical supply storage area revealed that there were four plastic boxes with drawers that contained some supplies (bandaids, alcohol wipes and some plastic tubing/catheters in wrappers) found on the floor underneath the metal racks. The materials manager stated that the boxes were only being stored and were not in use. Another one of those boxes was found on one of the metal shelves and contained stored supplies. The administrator directed that the boxes be taken off the floor and discarded and several of them were removed from the room during the tour. In addition, approximately 6-7 cases of supplies were stacked on the floor in a corner of the room. The administrator directed that they be removed from the floor during the tour. S/he acknowledged that storage of the supplies directly on the floor was not acceptable from an infection control perspective.

A tour of the facility's north campus was conducted on 9/19/11 at approximately 12:45 p.m. with the Director of Nursing (DON). Observations revealed patient supplies stored on the floor in the patient primary storage unit as well as in the hallway outside the storage unit. The Supplies Coordinator stated, "I get shipments daily. Tuesday and Fridays are the larger shipments." Observed on the floor were the following items:
1) four boxes of Chux (absorbant disposable cloths)
2) four boxes of Hospira 0.9% Sodium Chloride 2000 ml which the DON stated was "for hemodialysis"
3) one box of bedpans
4) five boxes of wound vac supplies
5) one box of moisturizing hand cream
6) one box of wound vac supplies
Stacked atop these boxed supplies were several other boxes.

The DON confirmed the observations and acknowledged that the items should be placed on an elevated surface and not the floor.

3. Preventive Maintenance Inspections:

On 9/20/11 at approximately 11:00 a.m., a tour of the south campus patient care unit was conducted with the unit nurse manager, the administrator, the unit safety officer, the infection control nurse and the administrator. Observations in various storage rooms and closets revealed that some pieces of facility-owned and rented medical equipment did not have current preventive maintenance (PM) stickers.

During a tour of the main medical equipment storage room, the following equipment were observed not to have current PM inspection stickers:
- infusion pump with PM sticker that expired 1/11
- a piece of respiratory equipment (CO2 SMO) that expired 8/09
- an O2 meter with no PM sticker
- a HEPA airmate with infection control hood with no PM sticker
- 4 rented portable oxygen concentrators with no PM stickers.

During a tour of the supply storage closets by the shower room, additional observation revealed 2 rented pumps for air mattresses that had stickers that expired 1/11. The room contained more mattresses and pumps, which were not checked, because they were difficult to access due to the volume of mattress/pump storage in the closet. During a tour of the rest of the unit, an infusion pump was found in one of the patient rooms, that was toured because the patient had just been discharged and the room had yet to be cleaned and cleared of equipment. The infusion pump was found to have a PM sticker that expired 1/11. All expired or absent PM sticker findings were confirmed with the staff accompanying the surveyors on the tour.

A tour of the facility's north campus was conducted on 9/19/11 at approximately 12:45 p.m. with the Director of Nursing (DON). Observations in one of the storage rooms revealed six portable oxygen units that were property of an outside company. Two of the units had scan/barcodes on them and were without dates. One of the units had a Preventative Maintenance (PM) sticker on it with a due date of 12/17/09. The other units were without barcodes or PM stickers. Also observed was a transport ventilator which had a PM date of done on 12/09 and due on 6/10. The Materials Manager acknowledged the observations and stated the portable oxygen units were provided by a rental company. "We rent from them and they do the PM and keep at their headquarters. If ever requested, they would send the PM's electronically...Some of them have a different company," s/he stated. S/he continued that their contracted company did the PM's on the ventilator. S/he stated they they "didn't put a new sticker on" but that they come by once a year to do the PMs.

A later interview with the Materials Manager (MM) was conducted at approximately 3:15 p.m. In regards to the portable ventilator, s/he stated that after further investigation, "That one they actually didn't get PM'd...I sent out a call to have it PM'd." When asked who keeps track of the PMs, s/he stated, "Generally that is me at the local level. I have an active list. I just had missed that ventilator, that is all." An additional interview was conducted with the MM on 9/20/11 at approximately 1:30 p.m. S/he stated that s/he called the local rep for the portable oxygen units and that rep stated, "they don't do a pre-inspection as issued out because they are issues as new. As things get reported they do a one for one swap. I have a call in to our corporate person about this issue..." When asked if the units were never used if they ever got assessed, s/he stated, "No probably not. We use them all the time though." The MM confirmed that none of the portable rental units had been PM'd.

An additional interview was conducted with the MM on 9/21/11 at approximately 3:00 p.m. When asked further about the PMs on the portable oxygen units, s/he stated, "Corporate just said they've got their corporate looking into it." When asked how these units are usually monitored, s/he stated, "If we run into an issue, I call the rental company and they fax it over to us." S/he continued, "The loaner supplies come in and go to materials management...I've never had the issue before. The oxygen regulator company says they don't need to be inspected. They provide information of inspection upon delivery or if I request...Once delivered, I don't look to see when last PM'd..." When asked further about the PMs on other equipment that the facility owns, s/he stated, "We don't routinely keep the inspections of our own rental equipment. [The company that we contract with to conduct our PMs] sends them electronically as they do them. Before the inspection guy leaves, he gives a verbal report. I don't keep the hard copy, but anything I can get electronically, I do." He continued, "The issue we had was [the contracted company] uses a paper sticker and as people clean them, the paper sticker comes off." When asked about the old paper stickers that were present on the equipment at the south campus which revealed expired dates, s/he stated, "That is something I need to look into."

The facility's policy entitled "MEDICAL EQUIPMENT MANAGEMENT ACTIVITIES," with a revision date of January 2008, stated the following, in pertinent part:
"...C. Equipment Rental:
All equipment is approved for safe patient use by an external contractor, and labeled as such. Documentation is maintained by the Materials Manager. Notify the Materials Manager once the equipment is no longer needed. This will ensure charges are stopped and the rental agency picks up the equipment...
II. Preventative Maintenance (PM) System
All patient related equipment is maintained and checked on a periodic basis by an external contractor.
A. A preventive maintenance schedule is maintained for all patient care electrical equipment per manufacturer's recommendations.
B. All medical equipment obtains a preventive maintenance check per the schedule and then has a sticker placed on it when the check is successfully complete. Documentation is maintained by the contractor and available thru the business office.
C. An inventory as well as maintenance history is kept on each piece of equipment..."
In addition, the policy did mention cleaning of equipment and stated the following, in pertinent part:
"Cleaning of Equipment
A. Daily equipment rounds will be made.
B. All soiled equipment will be collected and taken to the soiled utility area for cleaning and storage..."

4. Ensuring Cleanliness of Equipment:

On 9/20/11 at approximately 11:00 a.m., a tour of the south campus patient care unit was conducted with the unit nurse manager, the administrator, the unit safety officer, the infection control nurse and the administrator. During the tour, the emergency resuscitation cart was inspected. The portable suction machine/pack located on the top of the cart was found to be covered with a very thick colored dust/lint/debris on the white plastic top of the suction collection container. The presence of the dust/lint/debris was confirmed by the staff accompanying the surveyors on the tour. The unit nurse manager stated that the cart was provided by the host hospital under the purchased service agreement and was maintained by the host hospital pharmacy. S/he stated that the host hospital pharmacy had just brought up a newly stocked cart within the last day or so. S/he also confirmed that the procedure involved one of the nurses on the unit accepting and signing for the cart and that the condition of the suction machine should have been noticed at the time of receipt of the cart or at subsequent routine cart checks.

During the tour of the south campus, the medication room was also inspected and two boxes of emergency supplies, including intubation supplies, were sitting on the window ledge in the room. Both plastic tackle-type boxes were closed and secured, but appeared to have dust and one them had particles of a white debris which appeared to be like plaster chips or ceiling tile fragments on the top of it. The unit nurse manager confirmed that the housekeeping staff from the host hospital was responsible for cleaning the room and allowed to enter the room and clean it in the presence of one of the unit nursing staff.

The facility's policy entitled "Equipment Cleaning" stated the following, in pertinent part: "Purpose: Equipment can serve as a vehicle for transmitting pathogens. This policy specifies a process for reducing that risk..." The policy did not specify how items like crash carts would be routinely cleaned.

The facility's policy entitled "MEDICAL EQUIPMENT MANAGEMENT ACTIVITIES," with a revision date of January 2008, stated the following, in pertinent part:
"Cleaning of Equipment
A. Daily equipment rounds will be made.
B. All soiled equipment will be collected and taken to the soiled utility area for cleaning and storage..."

5. Timely Removal of Meal Trays From Dirty Utility Room:

On 9/20/11 at approximately 12:00 p.m., a tour of the south campus patient care unit was conducted with the unit nurse manager, the administrator, the unit safety officer, the infection control nurse and the administrator. During the tour, the dirty utility room was inspected. One of the accompanying staff apologized for the unpleasant odor that appeared to be from old food trays that were stacked on an open vertical tray rack located in the room. Observation of the trays indicated that they trays contained debris from that morning's breakfast, as well as the previous evening meal. The unit nurse manager and the administrator acknowledged that there had been problems with timely retrieval of the dirty trays by the host hospital's food and dietary department as a part of the services provided under the purchased services agreement with that hospital. They stated the issue had been addressed with the host food/dietary service, but had yet to be resolved.

Based on tour/observation, staff interview and review of policies/procedures, the hospital failed to ensure that all medications storage refrigerators temperature logs were maintained daily as required.

The findings were:

1. On 9/20/11 at approximately 11:30 a.m., during a tour of the south campus site, it was observed that the locked refrigerator attached to the automated medication dispensing system had a temperature log for the current month (9/11), which had no temperature checks logged on the sheet.

2. On 9/20/11 at approximately 1:00 p.m., the pharmacy technician for the south campus pharmacy contacted this surveyor and stated that s/he had been checking all of the medication refrigerators, but had not been recording the temperatures on the refrigerator attached to the automated medication dispensing system. S/he apologized for not documenting the temperatures, which s/he said had all been within the acceptable range. S/he had no alternate documentation to validate his/her statement that all temperatures had been in range during the month.

3. On 9/20/11 at approximately 11:30 a.m., during the tour of the south campus site medication room, it was observed that the medication refrigerator in the room had a temperature check log that indicated that the temperature had not been checked on 9/8/11. Related to that finding was the observation that the temperature had been out of range on the two preceding days (9/6 and 9/7/11) when it had been checked. When the temperature was finally checked again on 9/9/11, the refrigerator temperature was back in range. During the tour, the lead nurse for that campus site stated that if staff determine that the refrigerator is out of range they adjust it to bring it back in range.

4. Review of pharmacy policies/procedures on 9/21/11 revealed the following findings:
Review of the Pharmacy Policy/Procedure titled "Drug Storage in the Pharmacy," stated the following, in pertinent parts:
"PURPOSE:
To promote efficient, safe storage of pharmaceuticals.
POLICY STATEMENT:
All products will be stored according to manufacturers' recommendations to promote maximum potency and quality. Storage must also promote dispensing efficiency and decrease the potential for errors.
PROCEDURE:
1) All drugs must be stored in a temperature controlled environment. General temperature ranges include:
...b) Refrigerated, 2 degrees to 8 degrees C.
c) Frozen, less than -14 degrees C..."
Review of the Pharmacy Policy/Procedure titled "Pharmacy Infection Control," stated the following, in pertinent parts:
"...4. The pharmacy medication refrigerator (and freezer if applicable) will be inspected monthly and cleaned as necessary. The pharmacy will also inspect any refrigerators in patient care areas used for medication storage monthly and cleaned as necessary..."

Based on review of medical records, policies/procedures and staff interviews, the facility failed to document arrangements for outpatient dialysis for a new hemodialysis patient that was discharged to a skilled nursing facility.

The findings were:

1. Review of the medical record of Sample patient #18 on 9/21/11 revealed that the patient was admitted to the facility on 8/27/11 with the diagnosis of renal failure with complications. The patient was transferred from an acute care hospital. During the hospitalization, the patient received hemodialysis from a contracted dialysis service located in the facility's host hospital. In addition, the patient had a more permanent central line catheter placed for ongoing hemodialysis. The patient was discharged to a skilled nursing facility on 8/20/11. Further review of the medical record revealed no documentation of arrangements for outpatient hemodialysis in any of the discharge planning and case management notes contained in the medical record. The "Care Coordination Conference and Discharge Planning Documentation" form in the record contained the name of the receiving skilled nursing facility, the pharmacy and the oxygen supply company, but no information about arrangements for outpatient hemodialysis.

2. On 9/21/11 at approximately 11:00 a.m., the director of case management was interviewed by telephone because s/he was at the other campus of the facility. S/he was interviewed about the discharge plans arranged for Sample patient #18. His/her signature was on the "Care Coordination Conference and Discharge Planning Documentation" found in the medical record. S/he stated that the arrangements had been made for the patient to go to an outpatient ESRD (End Stage Renal Dialysis) facility for 3 times per week. S/he stated that ESRD arrangements should have been included in the discharge plan. S/he stated that the information was part of the discharge information faxed to the receiving skilled nursing facility. The information was not located in the chart and s/he stated that the information might have been placed in his/her mailbox at the facility after it was copied and sent by the unit secretary. The infection control officer, who was assisting the surveyors at the south campus location that cared for Sample patient #18, attempted to locate the discharge information that was to have been sent to the skilled nursing facility. S/he was unable to locate or provide the discharge information at that location or in the patient's medical record.

3. On 9/21/11, the facility policy/procedures related to discharge planning were reviewed and revealed the following findings:

Clinical Services Policy and Procedure #D03-G titled "Discharge, Discharge Planning and Instruction Form," contained the following, in pertinent parts:
"...PURPOSE:
To plan and provide a smooth and efficient transition which ensures that each patient is referred to the proper environment to maintain safety and continuity of care. This environment shall be able to meet the patient with the ability to reach his/her optimal level of care.
To provide documentation of instructions given to a patient before dismissal...
PROCEDURE FOR DISCHARGE AND DISCHARGE PLANNING:
...2. Discharge plans will include either termination of therapy upon discharge, the recommendation of continued treatment as an outpatient, or referral for continued treatment through an outside source as appropriate, to ensure continuity of care...
4. Upon receipt of the physician's order for discharge, nursing will notify the internal case manager. The case manager will insure that arrangements for transportation, and home care if necessary are complete and that all necessary parties are notified...
B. Inform unit secretary of records that need to accompany the patient if patient is being transferred to another facility.
1) Appropriate records will be photocopied as instructed by the case manager.
2) The records shall be placed in a sealed envelope with the patient's name.
3) The envelope shall be placed in the patient's medical record until the discharge takes place.
4) The case manager may fax some initial information to the receiving institution along with a confidential cover letter..."

Based on review of facility documentation and staff interviews, the facility failed to ensure a clear and evident process for the reassessment of its discharge planning program. This failure created the potential for a negative outcome.

The findings were:

On 9/21/11 at approximately 11:00 a.m., when the "Lead" of Discharge Planning was asked how the hospital reassesses its discharge planning process on an on-going basis, s/he stated, "Everything is in the OIC meeting."

A review of the facility's August OIC (Organization Improvement Committee) was conducted on 9/20/11. There was no specific data noted in regards to discharge planning. There was, however, data in regards to Utilization Review pertaining to costs of length of stays.

An interview with the Director of Quality Management was conducted on 9/21/11 at approximately 8:30 a.m. When asked what projects discharge planning is doing for quality assessment and performance improvement, s/he stated that discharge planning does weekly meeting with the leadership team to look at DRGs (Diagnosis Related Groups), but that minutes are not kept of that meeting. S/he also stated that they are involved in the C3 meetings, which are done weekly to inform the patients of the hospital expectations. When asked the information that filters into the Quality Assessment and Performance Improvement (QAPI) Plan from discharge planning, s/he stated, "UR information is at OIC and charging info." Further interview with the Director revealed that purely financial data in regards to discharge planning was filtered into the QAPI Plan/facility's OIC. However, at 11:00 a.m., the Director stated that discharge planning is responsible for "getting the patient satisfaction scores."

An interview was conducted with the Chief Nursing Officer on 9/21/11 at approximately 9:45 a.m. S/he stated that discharge planning is discussed at the weekly interdisciplinary team rounds (IDT). S/he continued, "If it is a hard discharge due to financial's, it is not discussed in rounds but then discussed in the PPS (prospective payment system)...In IDT or PPS meetings, we discuss what clinically happens with the patient: plan, barriers, goals. Case Management gets the team together on the same page and says this is what we need to do." These meetings, per interview, were identified to only address current patients and their discharge planning.

An interview with the Chief Executive Officer (CEO) was conducted on 9/21/11 at approximately 3:15 p.m. When asked if there was a process in place for the reassessment of the facility's discharge planning, s/he stated, "Because our discharges are mostly to SNFs (Skilled Nursing Facilities), we routinely discuss with them after discharges..." S/he stated there were three Clinical Liaisons and one Marketing Rep and that they were "constantly in the referring hospitals and they interact predominantly with the Case Managers." However, it was revealed that these individuals' roles were not to assess their former patients' discharge planning but to essentially network with the accepting facilities for future patient acceptance. The CEO stated that they would know if the discharges were inappropriate because of that facility contact and interaction.

An additional interview with the Director of Quality was conducted on 9/21/11 at approximately 4:30 p.m. When asked if there was a reassessment of the facility's discharge planning process, s/he stated "When we do any review of the chart, we look at it as a whole...Is there a specific checklist? No. We look at it with PPS and IDT meetings. In OIC, it is a lot of utilization review. Like they do the nursing and respiratory therapy chart audits, we don't do that type of audit with discharge planning." The Director stated that "Lead" of discharge planning was primarily down at the south campus, but that information about discharge planning, such as UR info, patient satisfaction data, and "reviewing to make sure C3s are done" did come to him/her. S/he stated, "I do review case management."

In summary, despite the facility's claims that there was a reassessment of the discharge planning process, such was not clearly evident. Chart audits did not occur to specifically to assess patients had appropriate discharge planning. The "Lead" of discharge planning stated the reassessment process occurred via the facility's Quality Program, however that program only assessed patient satisfaction scores and utilization review financial data. There was no formal process within the facility in order to reassess discharge planning such as to ensure patient needs were identified timely, the quality of discharge evaluation and plans were assessed, or discharge planners maintained complete and accurate documentation.

Based on staff interview, review of facility documents and meeting minutes, the facility failed to ensure preventative action and mechanisms that included feedback and learning throughout the hospital. Specifically, although the facility maintained methods of annual competencies and educational newsletters, staff meetings were not evident within each department and the general meeting that was held was attended primarily by nurses. Additionally, there was no clear knowledge by the executive staff of the education occurring within each department. This failure created the potential for a negative outcome in the instance staff were not aware of new changes or current events within their departments that may be related to preventive actions and mechanisms in place through the facility's Quality Assessment and Performance Improvement Program.

The findings were:

Upon entrance to the facility on 9/19/11 at approximately 8:30 a.m., the staff meeting minutes for each department were requested. A binder labeled "All Staff Meetings" was provided. When asked who attends the meeting, the Director of Quality and Nursing stated all disciplines would and that there were four opportunities to attend the meeting. However, after review of the meetings and sign-ins, it was evidenced that not every discipline/department staff member signed in for the meetings. When asked again about the all staff meeting on 9/20/11 at approximately 10:50 a.m., the Director of Discharge Planning stated, "Normally Discharge Planning does not come..." S/he stated there was a CEO's Meeting where the leads of all departments meet as an "Administrative Team," but that meeting minutes were not maintained for those meetings, which was confirmed with the CEO on 9/21/11. S/he continued, "The Administrative Meeting is very informal...The Staff Meeting is for Nursing, Respiratory, Rehab, Dietary, Pharmacy, and Infection Control."

An interview with the facility's north campus Nurse Manager was conducted on 9/20/11 at approximately 11:30 a.m. In regards to the all staff meetings, s/he stated, "Sometimes Discharge Planning comes." When asked who is required to go, s/he stated, "CNAs, RNs, and LPNs...Depending on the topic, sometimes therapy comes...It is primarily a nursing meeting." Review of the meeting minutes reflected evidence of such. S/he continued, "Not every discipline is addressed every month...I think that the other disciplines do have their own meetings." The Director of Quality was present for the interview and stated, "I usually give them an update on QAPI. I also do a monthly newsletter called the 'Quality Corner.' I present it in the staff meeting, it is posted, and it is reviewed in the [nursing/respiratory] huddle." The Nurse Manager later stated at 11:45 a.m., "Therapy (Rehab) does meet quarterly and have sign-in forms...The CEO says Respiratory Therapy does meet but [s/he] wasn't aware of how frequently or if minutes were kept.

An interview with the Director of Pharmacy was conducted on 9/20/11 at approximately 12:15 p.m. When asked if s/he conducted department meetings, s/he stated that the pharmacists at each facility "talk daily. I usually go to both places daily. We e-mail a lot. I give inservices at the nursing staff meeting and I post it on the 'Nursing Must Read' board in the break room."

An interview with a respiratory therapist, as the Director was not present the week of the survey, was conducted on 9/21/2011 at approximately 1:00 PM. S/he stated that respiratory therapists had their own meetings monthly which covered documentation changes, issues with equipment, scheduling. When asked about the all staff meeting, s/he stated that respiratory therapists were not required to attend the "all staff meetings" but that s/he did attend the meetings.

An interview was conducted with the Director of Nursing on 9/21/11 at approximately 9:40 a.m. S/he stated, "Sometimes we combine staff meetings with inservices...Respiratory does have a monthly staff meeting...Rehab meets with the team and [their Director] types up an agenda...My understanding is that [s/he] could not produce those notes..."

The Rehab "VERIFICATION OF INSERVICE" sign-in forms and minimal agendas were reviewed for the dates of 3//7/11 and 6/14/11. The Respiratory "staff meeting" minutes were reviewed for the March 2011 meeting. As the Respiratory Director was off, the DON stated s/he was not able to obtain any further meeting minutes for that department.

An additional interview with the DON was conducted at approximately 2:30 p.m. S/he stated, "At the All staff meetings, all clinical staff are expected to attend: Rehab, RT, Nursing. They are expected to come if they can, if possible. We have four meetings (two at each facility). Both [Nurse Managers] post all the meetings. The staff is expected to get there and know it." It was pointed out that all staff had not signed the sign-in sheets. S/he stated, "Even if their signature isn't on there (the sign-in), they are expected to know it. The sign-in sheets give us an idea of performance evaluations."

The facility's policy titled, "EDUCATION, STAFF" last revised 1/1/10, was reviewed on 9/22/11 and stated the following, in pertinent part:
"...1. All employees are required to complete specified mandatory continuing education programs every calendar year...
3. Staff is encouraged to attend educational offerings that Hospital provides that offer continuing educational credit.
4. Educational calendar is established annually based upon staff needs assessment.
5. Staff must obtain approval for attendance from their manager to facilitate scheduling."

The Chief Nursing Officer (CNO) was asked about this policy on 9/22/11 at approximately 11:20 a.m. S/he stated "The 'educational offerings that Hospital provides (#3)' is just a general statement. We don't offer CEUs here." In regards to #4, s/he stated, "The calendar is corporate mandated. It tells us who needs to do what competencies and when." The calendar was requested. The CNO stated there was not a specific calendar, but rather competencies that were required every quarter. S/he later provided evidence of such competencies, which were different for each type of profession. When asked how it was ensured that these competencies were done, as not all were computer based, s/he stated, "We have separate sign-ins for both hospitals...HR (Human Resources) if the final gatekeeper for ensuring these are all done but myself and the Nurse Managers also look because it is our staff."


29147

Based on review of the policies and procedure, observation, and interviews it was determined the facility failed to assure security of Medical Records. This failure could result in a potentially negative outcome.
The findings were:

Review of facility policy revised 1/02/09 titled "Security and Accessibility of Medical Records" stated in pertinent parts: "The Health Information Management Department (Medical Records Department) shall be considered a secured area. The department shall be keyed separately...and only accessible by authorized personnel during the absence of Medical staff. Authorized personnel shall be defined as...Nursing supervisor, housekeeping, Administration, and security".

An interview with the director of Q.A. was conducted on 9/20/2011 at approximately 9:30 a.m. s/he stated Housekeeping does not have access to Medical Record Storage room. As noted by contract, security is provided by the host hospital and each security officer has a Keyring/master key. The Key ring/master key is signed off by security each shift at each host hospital. S/he stated only one key is kept in Automated Dispensing Cabinet (ADC) (which is locked and secure access) and requires a log in for special access. Special access was limited to the pharmacist and the charge nurse. The CEO (Chief Executive Officer) also has a key. The medical records tech at each facility and the Health Information/Credentialing Manager each have a key. An interview with the Pharmacist on 9/20/2011 at approximately 3:45 p.m. verified s/he had access to all drawers of the ADC. S/he verified a re-stock list is printed by the ADC when the key to medical records is accessed. The re-stock list notifies the pharmacist to verify by visually checking that the key is present in the ADC and if it is missing to begin the search to find the missing key to secure medical records. The ADC tracks the name of the person who has accessed the key and when. An interview with the facility's Director of Health Information Management and the facility's Charge Nurse conducted on 9/22/2011 at approximately 9:45 a.m. revealed that only charge nurses had the ability to remove the key to the Medical Records Department from the ADC. A demonstration was conducted with a staff nurse that was present which demonstrated that the staff nurse did not have the privileges in the ADC to perform an "Override" which was necessary to remove the Medical Records Department key.

An interview on 9/20/2011 at approximately 4:15 p.m. with the Health Information/Credentialing Manager was conducted. S/he stated that the contracted security personnel (involving 2 host hospitals) had 7- 8 keys for each in order to gain entry into the medical records room in case of a fire or water break. The Health Information/Credentialing Manager also verified that in the past the Medical records tech "found the medical record key in the front desk drawer." "Pharmacist had to run report (from medication dispense unit) to see who had removed the key for medical records".
In summary:
There was no routine check to visually document the key was in the medication dispense unit drawer and no mechanism in place to avoid defeating the system. It was determined that unauthorized individuals could potentially gain access to stored medical records and were not safeguarded against loss, defacement, tampering, or use by unauthorized individuals.

It was determined that potentially 12 keys were unsecured. Four keys for the staff and 7 to 8 keys held by security at each host hospital thus not providing security of patient medical records.

Based on Medical Record review, staff interview, and review of the hospital's Policies and Procedures the hospital failed to document in the patient's medical record that a list of available home health agencies was presented to the patient or the individual acting on the patient's behalf in two (Sample patients #1 and #14) of 30 records.

The findings were:

On 9/21/2011 review of the medical record of Sample patient #1 revealed that the Case Manager had arranged home health for the patient upon discharge. There was no documentation in the record that a list of all qualified, available home health agencies was presented to the patient or to the individual acting on the patient's behalf. The lack of documentation was confirmed by the Chief Nursing Officer on 9/21/2011 at approximately 3:00 p.m.

On 9/22/2011 review of the medical record of Sample patient #14 revealed that the Case Manager had arranged home health for the patient upon discharge. There was no documentation in the record that a list of all qualified, available home health agencies was presented to the patient or to the individual acting on the patient's behalf. The lack of documentation was confirmed by both the Chief Nursing Officer and the Case Manager on 9/22/2011 at approximately 12:10 p.m.

An interview with the Director of Case Management conducted via telephone on 9/21/2011 at approximately 3:15 p.m. revealed that in regards to Sample Patient #1 a choice of available providers was expected to be documented on a form that is signed by the patient or the patient's representative that mentions that a choice was provided and that the patient or the patient's representative had chosen the provider on the form. S/he stated that another place that choice was to be documented was on the weekly progress notes from case management.

An interview with the Case Manager for Sample patient #14 conducted on 9/22/2011 at approximately 12:10 p.m. revealed that s/he was not aware of the requirement to document the choice presented to patients or the individuals acting on behalf of the patients. S/he stated that choice was provided to patients and the individuals acting on behalf of patients. S/he stated that choice would be documented in the future.

An interview with the Chief Nursing Officer on 9/21/2011 at approximately 2:15 p.m. revealed that the facility did not have a policy or procedure that stated that a list needed to be provided to patients when a choice was presented for home health or facilities.