HospitalInspections.org

Based on observations, interviews and record reviews the CAH (Critical Access Hospital) failed to ensure that sterile items and clean supplies used for patient care was stored in a building that was constructed to ensure that the sterility/cleanliness of the sterile items and clean supplies were not compromised. This failed practice was evidenced by sterile items and clean supplies used for patient care being stored in an outside building with unsealed concrete/slab floors and with no documented monitoring of the building's temperature and humidity and no scheduled housekeeping.

Findings:
A review of the hospital policy, titled,"Central Supply Department", revealed in part: The hospital will follow the AORN (Association of peri-Operative Registered Nurses) Standards and Recommended Practices, AAMI (Association for the Advancement of Medical Instrumentation) and CDC (Centers for Disease Control and Prevention) for the Central Supply areas for sterile and clean patient items.

A review of the AORN Standards and Recommended Practices for Hospitals- 2013 edition, Recommendation VIII revealed in part: Sterile items should be considered sterile until an event occurred to compromise the sterile item such as, moisture penetration or unacceptable storage conditions since the sterility of sterile items was event related and not time related. The Recommended Practice further revealed that sterile items used for patient care should be stored under environmentally controlled conditions and supply storage area temperatures should be controlled and monitored. Supply Storage areas should not exceed 75 degrees F and the humidity should not exceed 70%.

An observation on 1/27/15 of an outside building of the hospital revealed that sterile items and clean supplies, used for patient care, were being stored in a building that had unsealed concrete/slab floors. An observation on 1/27/15 at 9:00 a.m., 11:00 a.m., 1:30 p.m., and 3:15 p.m. revealed the door to the outside storage area was propped open. A further observation revealed that the concrete/slab floor had several cracks in it and was very dusty and dirty with debris. There was no temperature or humidity monitoring log available for the surveyor to review..

In an interview on 1/27/15 at 3:55 p.m. with S32MM Dir. (Materials Management Director) she indicated that she was the manager for the hospital's Materials Management Department and was responsible for the patient supplies stored in the outside Central Supply storage "shed" that contained patient sterile supplies and patient clean supplies. S32MM Dir indicated that housekeeping did not clean (sweep/dust/mop) the Central Supply storage "shed" located outside the hospital. She further indicated that the Materials Management Department staff would sweep the floor in the Central Supply storage "shed" about once a week.

In an interview on 1/28/15 at 11:10 a.m. with S12MaintDir (Maintenance Director) he indicated that the floor in the Central Supply storage "shed" was an unsealed concrete slab floor and that moisture can seep through the concrete/slab floor. He further indicated that the Central Supply storage "shed" was not monitored for humidity. S12MaintDir indicated that they try to keep the temperature in the Central Supply storage "shed" around 66 degrees Fahrenheit. S12MaintDir indicated that they would adjust the temperature control settings (heat or cool settings) before they left each day depending upon the weather forecast for that night, to try to keep the Central Supply storage "shed" around 66 degrees Fahrenheit. S12MaintDir indicated that they did not keep a temperature/humidity log for the Central Supply storage "shed".

Based on observations and interview, the CAH (Critical Access Hospital) failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds on the inpatient unit for 16 of 16 beds that had nurse call buttons in the side rails out of a total of 25 hospital beds. Findings:

On 01/26/15 from 10:45 a.m. to 11:20 a.m., observations were made on the inpatient unit and revealed the following: Room 8 was observed to have 2 beds and both beds were observed to have a button labeled "Nurse" and a picture of a nurse on the handrail of the beds. The button was noted to be non-functional as it failed to activate any type of nurse call system.
Room 6 was observed to have 1 bed and the side rails of the bed were observed to have a button labeled "Nurse" and a picture of a nurse on the handrail of the bed. The button was observed to be non-functional as it failed to activate any type of nurse call system.
Room 11 was observed to have 1 bed and the side rails of the bed were observed to have a button labeled "Nurse" and a picture of a nurse on the handrail of the bed. The button was observed to be non-functional as it failed to activate any type of nurse call system.
Room 14 was observed to have 1 bed and the side rails of the bed were observed to have a button labeled "Nurse" and a picture of a nurse on the handrail of the bed. The button was observed to be non-functional as it failed to activate any type of nurse call system.

In an interview on 01/26/15 at 12:50 p.m., S5QI/IC (Quality Improvement/Infection Control) made observations of the above patient rooms and confirmed the button labeled, "Nurse" located on the handrails of the inpatient bed was not functioning when pressed. An observation was also made of the patient bed in Room 12 which S5QI/IC indicated was a new patient bed. This bed was observed to have a nurse call button in the handrail of the bed that when pressed by S5QI/IC, failed to activate any type of nurse call system. S5QI/IC indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be sedated and/or confused to press the button on the handrail of the bed labeled "Nurse" thinking they are calling for assistance without the nursing staffs knowledge due to the call button not working, S5QI/IC indicated yes that would be possible.

In an interview on 01/26/15 at 3:15 p.m., S15MT (Maintenance Tech) made observations of the above patient rooms and confirmed the button labeled, "Nurse" located on the handrails of the inpatient beds was not functioning. S15MT indicated the only call lights functioning were the call lights on the cord. On 01/28/15 at 9:00 a.m., S15MT provided a list of patient beds and confirmed 16 inpatient beds had non-functioning call light buttons in the handrails of the bed.

26351

Based on observations and interview, the CAH (Critical Access Hospital) failed to ensure the premises was clean and orderly, as evidenced by:

1. the hospital had peeling paint and crumbling wall plaster in patient rooms for 8 (Room #6, #7, #8, #10, #11, #15, #19, #20) of 25 patient rooms.

2. the hospital's failure to provide housekeeping for the Central Supply storage "shed" and the hospital failure to maintain patient supplies stored in proper places and not stored in cardboard boxes on the floor in the Central Supply storage "shed".

3. the hospital's failure to ensure expired supplies were not available for patient use.

Findings:
1. the hospital had peeling paint and crumbling wall plaster in patient rooms.
An observation was conducted in Patient Room #15 at 1/26/15 at 10 a.m. of peeling paint on the baseboards and around the bathroom door.

An observation was conducted on 1/26/15 at 10:10 a.m. of crumbling wall plaster in Patient Rooms #19 and #20. In Room #20 there was peeling paint on the closet with evidence of scotch tape being under the paint and the air conditioner vent was on the floor under the air conditioner.

An observation was conducted on 01/26/15 at 10:45 a.m. of cracking, peeling plaster in Patient Rooms #6, #7, #8, #10 and #11.

These observations were verified by S15MT (Maintenance Tech) on 1/26/15 at 3 p.m.

2. the hospital's failure to provide housekeeping for the Central Supply storage "shed" and
the hospital failure to maintain that patient supplies were stored in proper places and not stored in cardboard boxes on the floor in the Central Supply storage "shed".

An observation on 1/27/15 of an outside building of the hospital revealed that sterile packaged items used for patient care, were being stored in cardboard boxes on the Central Supply storage "shed" floor to include in part: Central Line kits, Dressing kits, Intravenous tubing kits, Thoracentesis trays, Intravenous fluid bags, and Foley catheter kits. A further observation revealed that the Central Supply storage "shed" floor was very dusty and dirty with debris.

In an interview on 1/27/15 at 3:55 p.m. with S32MM Dir.(Materials Management Director) she indicated that she was the manager for the hospital's Materials Management Department and was responsible for the patient supplies stored in the outside Central Supply storage "shed" that contained patient sterile supplies and patient clean supplies. S32MM Dir indicated that housekeeping did not clean (sweep/dust/mop) the Central Supply storage "shed" located outside of the hospital. She further indicated that the Materials Management Department staff would sweep the floors in the Central Supply storage "shed" about once a week. S32MM Dir indicated that the cardboard boxes containing sterile packaged items used for patient care, were being stored on the Central Supply storage "shed" floor due to limited storage space.


3. the hospital's failure to ensure expired supplies were not available for patient use:
On 01/26/15 at 1:50 p.m., an observation was made of the Emergency Department (ED) with S5QI/IC (Quality Improvement/Infection Control). The following supplies were observed to be expired and available for patient use:
Vicryl suture with an expiration date of 01/2013.
3 of 4 Pleura-Vacs with an expiration date of 12/2014.
S5QI/IC confirmed the above supplies were expired and available for patient use.

On 01/26/15 at 3:15 p.m., an observation was made of the Clean Utility room on the inpatient unit with S5QI/IC. Two sterile Burn Blankets were observed to have expiration dates of 09/2012 and 1 blanket had an expiration date of 11/2012. An adult and pediatric Lumbar Puncture Tray was observed to have an expiration date of 04/2014. S5QI/IC confirmed the above supplies were expired and available for patient use.


30172

31048

Based on record review and staff interview, the Governing Body failed to ensure policies were implemented to provide quality health care in a safe environment as evidenced by:

1) the governing body failed to ensure the medical staff was reappointed according to the hospital's Medical Staff By-Laws for 2 (S35MD and S37MD) of 8 (S7MD, S35MD,
S36MD, S37MD, S38MD, S39MD, S40MD, S45MD) physicians' files reviewed, and;

2) the governing body failed to ensure the medical staff was accountable to the governing body for the quality of care provided for patients by failing to ensure patients were admitted to the hospital in accordance with medical staff bylaws for 2 of 2 (#18, #19) sampled respite patients.

Findings:

1) The governing body failed to ensure the medical staff was reappointed according to the hospital's Medical Staff By-Laws:

Review of the Medical Staff Bylaws, Revised 03/2013, presented as the current medical staff bylaws revealed, in part: 3.9 Emergency and Temporary Privileges, 3.9.1 Regardless of his/her status, in case of an emergency, the provider of care attending the patient shall be expected to do all in his/her power to save the life of the patient including the call of such consultation as may be available. For the purpose of this section, an emergency is defined as a condition in which the life of the patient is in immediate danger and in which delay in administering treatment would increase the danger.

3.9.2 The CEO/Administrator of the Hospital, after conference with the Chief of Staff, shall have the authority to grant temporary privileges to a provider of care who is not a member of the Medical Staff. The chief of Staff shall give an authoritative opinion as to the competence and ethical standing of the provider of care who desires such temporary privileges. In the exercise of such privileges, he/she shall be under direct supervision of the Chief of Staff. Should he/she desire continued temporary status, he/she shall complete an application on the format provided by the Medical Staff. This application will be reviewed and decision made by the Credentials Committee in accordance with the normal regulations of the Medical Staff.

Review of the credential file for S35MD revealed the initial appointment date was 12/01/80. Further review revealed S35MD's reappointment date was 01/28/15, and there was no documentation in the file that S35MD's reappointment had been approved by the hospital's governing body.

Review of the credential file for S37MD revealed the initial appointment date was 12/09/74. Further review revealed S37MD's reappointment date was 01/28/15, and there was no documentation in the file that S37MD's reappointment had been approved by the hospital's governing body.

In an interview on 01/29/15 at 3:30 p.m., S20MR Tech (Medical Records Technician) indicated she was the medical staff coordinator. S20MR Tech confirmed there was no documented evidence in the files for S35MD and S37MD that the reappointment to the medical staff had been approved by the governing body. S20MR Tech indicated that the governing body's meeting that was scheduled for 01/27/15 was canceled and, therefore, the governing body did not approve the reappointments for S35MD and S37MD.

Review of two documents presented by S20MR Tech on 01/29/15 for S35MD and S37MD entitled "Physician Request for Emergency Temporary Privileges" signed and dated on 01/28/15, revealed S35MD and S37MD had been granted emergency/temporary privileges.

In an interview on 01/29/15 at 4:30 p.m., S1ADM (Administrator) confirmed that the reappointments by the governing body for S35MD and S37MD were not completed in a timely manner, and the granting of emergency/temporary privileges for S35MD and S37MD was not in accordance with the hospital's medical staff bylaws.


2) The governing body failed to ensure the medical staff was accountable to the governing body for the quality of care provided for patients by failing to ensure patients were admitted to the hospital in accordance with medical staff bylaws:

Review of the Medical Staff Bylaws, Revised 03/2013, presented as the current medical staff bylaws revealed, in part: 4.3 Courtesy Staff: E. Courtesy staff members may admit patients to an active staff member who will be the primary provider of care.

Review of the credential file for S36MD revealed a governing body appointment for courtesy staff dated 06/24/13.

Review of the medical record for Patient #18 revealed the patient was admitted to the hospital on 12/06/14 for respite care. S36MD was identified as the admitting physician.

Review of the medical record for Patient #19 revealed the patient was admitted to the hospital on 11/07/14 for respite care. S36MD was identified as the admitting physician.

In an interview on 01/29/15 at 10:55 a.m., S25LPN reviewed the electronic health records of Patients #18 and #19 and confirmed the admitting physician was S36MD.

In an interview on 01/29/15 at 1:25 p.m., S20MR Tech indicated she was the medical staff coordinator. S20MR Tech confirmed S36MD had only courtesy privileges at the hospital.

In an interview on 01/29/15 at 3:00 p.m., S2DON (Director of Nursing) confirmed the Medical Staff Bylaws had not been followed when Patient #18 and Patient #19 were admitted to S36MD, who only had a courtesy appointment to the medical staff.

Based on observations, record reviews and interviews, the CAH (Critical Access Hospital) failed to meet the requirements of the Condition of Participation of the Provision of Services as evidenced by:

1) the CAH failed to ensure health care services were furnished in accordance with written policies as evidenced by:

a) failing to ensure constant visual observation was provided for PEC patients in the ED according to hospital policy for 1 of 1 (#25) current sampled PEC ED patients reviewed, and;

b) failing to follow the hospital policy for restraint/seclusion in the emergency department for 5 of 5 (#15, #16, #23, #24, #26) ED patients reviewed for restraints (see findings in C-0271).

2) the CAH failed to implement measures to ensure the provision of a safe environment consistent with nationally recognized infection control precautions as evidenced by:

A. The CAH failed to ensure the hospital's Infection Control Officer was trained and/or experienced in infection control practice and/or procedures.

B. The CAH failed to ensure all surfaces were cleaned and able to be disinfected, as evidenced by:
1. Old adhesive tape being present on medication carts, bathroom tiles, and beds.

2. Chairs in patient rooms having tears in the upholstery (Room #7, #8, #11,#14, and #15)

3. Unsealed wooden benches being in 2 shower/tub rooms on the Medicine/Surgery Floor.

4. Formica covering missing from a shelf with exposed wood (Room #14).

C. The CAH failed to ensure that sterile items and clean supplies used for patient care was stored in a building that was constructed to ensure that the sterility/cleanliness of the sterile items and clean supplies were not compromised. This failed practice was evidenced by sterile items and clean supplies used for patient care being stored in an outside building with unsealed concrete/slab floors and with no documented monitoring of the building's temperature and humidity.

D. The CAH failed to provide housekeeping for the Central Supply storage "shed" and
the hospital failure to maintain that patient supplies were stored in proper places and not stored in cardboard boxes on the floor in the Central Supply storage "shed".

E. The CAH failed to ensure that sterile instruments used for patient care was processed according to acceptable professional recommended standards and practices by failing to adhere to appropriate decontamination protocols for critical and semi-critical instruments used in patient care.

F. The CAH failed to ensure patient care supplies were stored in proper places and not in the ED soiled utility room (see findings at C-0278).


3) the CAH failed to ensure the dispensing, and administering, and storage of drugs and biologicals were implemented according to accepted professional principles.

a) The CAH failed to ensure its policies, procedures and hospital practices for dispensing and administering medications and biologicals included the pharmacists would review medication orders prior to the first dose being administered to the patient, except in emergencies. The hospital policies and practices allowed medications to be administered prior to the pharmacists' review when the pharmacy was closed or the pharmacist was not available.

b) the CAH failed to ensure stock liquid medications were stored correctly after opened, as evidenced by stock liquid medications being stored in the medication room and not being dated when opened.

c) the CAH failed to ensure expired medications were not available for patient use, opened vials of medication were dated when opened, single use vials were discarded after opened in the Emergency Department (see findings at C-0276).


4) the CAH failed to ensure dietary practices were provided in accordance with recognized dietary standards as evidenced by: 1) failing to ensure safe food storage, handling, and preparation practices, and; 2) failing to ensure the dietary manager was qualified (see findings at C-0279).


5) the CAH failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available staff. The ED (Emergency Department) RN delegated the one-to-one observation of patients under a physician emergency certificate (PEC) to contracted security guards (Sheriff's Deputies) who had not received training and had not been assessed for competency in crisis prevention and interventions for 2 of 2 (S43Deputy, S44Deputy) contracted security guards (see findings at C-0294).

Based on review of hospital policies, patient records, observations, and staff interviews, the CAH (Critical Access Hospital) failed to ensure health care services were furnished in accordance with written policies as evidenced by

1) failing to ensure constant visual observation was provided for PEC patients in the ED according to hospital policy for 1 of 1 (#25) current sampled PEC ED patients reviewed;

2) failing to follow the hospital policy for restraint/seclusion in the emergency department for 5 of 5 (#15, #16, #23, #24, #26) ED patients reviewed for restraints, and:

3) failing to develop written policies for observation patients.

Findings:

1) Failing to ensure constant visual observation was provided for PEC patients in the ED according to hospital policy:

Review of the hospital policy titled, "Patients Presenting to Emergency Department with Psychiatric Emergencies" policy number 2020 with revised date of 08/29/13 revealed in part the following: For this purpose, psychiatric emergencies are classified as those patients who present with: Suicidal, Homicidal, Gravely Disabled, or Acute Intoxication or Substance Abuse....Employees caring for patients with psychiatric emergencies will be trained in a nonviolent crisis prevention/management of an aggressive patient....Patients will have constant visual observation by nurses, __SO (Local Sheriff's Office), or CNAs (Certified Nursing Assistants. __SO may be assigned to monitor patients.

Patient #25
On 01/27/15 at 9:45 a.m., an observation was made in the Emergency Department (ED) with S3RN (ED Manager). A sheriff's deputy was observed seated outside of Patient Room 1. The patient was visible lying in the bed and the room lights were off. S3RN confirmed Patient #25 was a PEC patient. An observation of the medication room (across from Patient Room 1) was conducted with S3RN. At 10:05 a.m., upon exiting the medication room with S3RN, the Sheriff's deputy was no longer seated outside of Patient #25's room. There was no staff monitoring Patient #25 at this time. Room 1 was observed to be located near an exit door that had an automatic glass door that opened as the person neared the door. S3RN confirmed this exit door was not locked from the inside and stated this was the ambulance bay. S3RN confirmed the patient was not being monitored and stated she would check to see where the deputy was. S24RN then left the ED to look for the deputy. The deputy and S24RN returned and she stated the deputy went to get coffee.

In an interview on 01/27/15 at 10:25 a.m., S43Deputy stated Patient #25 was a PEC patient and was present in the ED when he came on duty this morning. S43Deputy stated he had not received any training from the hospital on dealing with psychiatric/PEC patients. S43Deputy confirmed he was assigned to monitor the patient and if he had to leave, the staff would monitor the patient.

Review of the ED record for Patient #25 revealed the patient presented to the ED on 01/26/15 at 10:50 p.m. by ambulance with suicidal ideations. The record revealed a PEC was signed on 01/26/15 at 11:45 p.m. due to the patient was suicidal and dangerous to self.


2) Failing to follow the hospital policy for restraint/seclusion:

Review of the hospital policy titled "Restraints Emergency Department" policy number 2140 with a revised dated of 06/26/13 revealed in part the following:
The use of restraint must be: Selected only when other less restrictive measures have been found to be ineffective to protect the patient or others from harm. These efforts must be clearly documented in the EHR (Electronic Health Record) as well as ineffectiveness.
The restraint order must: Never be written as a standing or on an as needed bases (that is, PRN)....implemented in the least restrictive manner as possible, in accordance with safe and appropriate restraining techniques, ended at the earliest possible time. The condition of the restrained patient must be continually assessed, monitored and reevaluated....
The use of behavioral restraint must be: Selected only when other less restrictive measures have been found to be ineffective to protect the patient or others form harm. (and clearly documented on the patients EHR)....A physician or other licensed independent practitioner, or delegated physician's assistant or advanced practice nurse must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of this intervention....Orders for restraint must specify the reason (medical necessity and should indicate that restraint use is to improve the patient's well-being) for the restraint, the type of restraint, the extremity or body part(s) to be restrained and the duration (time frame) for restraint application. As stated above PRN or standing orders for patient restraint are not allowed by this organization or the medical staff....The condition of the restrained patient will be continually assessed, monitored and reevaluated and observed at intervals not greater than 15 minutes. This will be documented in the EHR....Changing position and releasing soft restraints will be performed and documented at a minimum of every two (2) hours.
Restraint Flow Sheet: The restraint flow sheet will be used for each incident of restraint. Date time the patient is placed in restraints. Type of restraint and extremity restrained. Times of assessment. Time of rotation of restraint and/or time patient is removed from restraints. Assessment of the restraint, circulation, and skin condition should be done and documented every 15 minutes while the patient is physically restrained. Attention to position change, nutrition, hydration and elimination should be offered at least every (2) two hours and as needed.
Review of the above policy revealed no documented evidence of any provisions on the procedure for seclusion.

Patient #15
Review of the ED record for Patient #15 revealed the patient was a 14 year old male who presented to the ED on 2/19/14 at 08:47 with a chief complaint of Altered Mental Status. The record revealed the patient was assigned to Room 1. Review of the medical record revealed a Physician Emergency Certificate (PEC) was done on 2/19/14 at 10:30 a.m. due to the patient being suicidal, dangerous to self and unwilling to seek voluntary admission. He was transported to a psychiatric facility on 2/19/14 at 19:10.

Review of the Nursing Notes revealed in part on 2/19/14 at 15:42 the patient was walking around in room picking at things, slapped my arm when I gave him some Ativan, acting out and acting like he is going to punch us, has slapped me twice and hit ...RN in the leg.
2/19/14 at 16:00 Procedure Restraint Application/Evaluation Entry: Administration notified; The least restrictive restrain/seclusion type is: vest restraint. Areas to be restrained; the chest; Restraint reason violent/self destructive; patient is confused/disoriented; patient is demonstrating activity that posed high risk for injury; patient is exhibiting destructive and/or violent behavior; patient has impaired balance or gait; patient is exhibiting aggressive behavior toward others; patient is unaware of their own limitation;...Interventions attempted; ambulation/wheelchair ride; comfort measure; diversional activities; family/sitter present; frequent patient contact/rounds; meal/fluids offered; offer/assist with personal hygiene; provide redirection of patient focus; relocate near nurse's station, verbal de-escalation.

Review of the Physician's documentation in the ED revealed the restraint order was verbal, the order read Vest placed on pt. There was no duration ordered for the restraint as stated by hospital policy.

Review of the Restraint/Seclusion Documentation Form revealed the vest restraint was placed on Patient #15 at 1600 and the nurses documented checking on him every 30 minutes. The times the nurses checked on the patient was 16:30, 17:00, and 17:30. The vest was removed at 17:30.

Review of the MD (Medical Doctor) evaluation revealed the physician evaluated the patient's need for a restraint on 2/19/14 at 17:42. The restraint was removed at 17:30 per the nursing documentation.

An interview was conducted with S3RN, ED Nurse Manager on 1/29/15 at 10:45 a.m. With review of Patient #15's ED record, she reported the least restrictive restraint was not a vest and should not have used on the patient, the patient should had been checked on every 15 minutes by a nurse, not every 30 minutes as documented in the medical record. The physician should had evaluated the patient within an hour of the restraints being placed and the physician documented he evaluated the patient an hour and 42 minutes after the restraint was placed on Patient #15 and 10 minutes after the restraint was documented as removed.


Patient #16
Review of the ED record for Patient #16 revealed the patient was a 68 year old male with the Chief Complaint of Altered Mental Status.

Review of the Physician's Order revealed a verbal order for restraints on 05/27/14 at 12:39- Wife asked for restraint placement.

Review of the Nursing Note from the ED on 5/27/14 at 12:34 revealed in part, The least restrictive restraint/seclusion type is: soft restraint; Areas to be restrained: the right upper extremity; the right lower extremity; Restraint reason is patient attempting to remove essential medical equipment; Family requesting restraint.

Review of the Restraint/Seclusion Documentation Form revealed the restraint was initiated at 05/27/14 at 12:34 and a reevaluation was conducted on 5/27/14 at 12:46 and at 13:41. There is no documentation when the restraints were removed. The patient was transferred to the another department and an initial assessment/interview was conducted on 5/27/14 at 16:19 on the transfer unit and there was no documentation of restraints on the patient at the transfer time.

Review of the Physician Orders in the ED revealed the MD (Medical Doctor) performed a restraint evaluation on the patient on 5/27/14 at 14:06. Review of the MD evaluation revealed in part, collaborated with care team to identify ways to eliminate use of seclusion/restraints; evaluated need to continue or release restraints/seclusion; patient attempting to remove essential medical equipment; the need for restraints has been discussed with the patient and/or family; patient and/or family communicates understanding of reason/need for restraints; other patient or family education: PER WIFE'S REQUEST...

An interview was conducted with S3RN ED Manager on 1/29/15 at 10:45 a.m. She reported to place a restraint on a patient due to a wife's request was not appropriate. She further reported the patient should have been checked by the nurses every 15 minutes while in restraints according to the hospital's policy. S3RN continued to report the physician should had done his evaluation of the patient's need for restraints within an hour of placement of restraints and he should have put in his order the duration of the restraint time. S3RN ED Manager also verified there was no documentation of when the patient's restraints were removed.

Patient #23
Review of the ED record for Patient #23 revealed he was a 40 year old male who arrived at the ED on 1/25/15 at 00:42. He arrived via stretcher and was transported by Emergency Medical Service. His present illness was listed as the patient was found sleeping in a ditch. Patient was combative and speech slurred.

Review of the Nursing Notes revealed in part on 1/25/15 at 01:17; Restraint Application/Evaluation Entry. The least restrictive restraint/seclusion type is soft restraint. Areas to be restrained; both upper extremities; both lower extremities; Restraint reason is violent/self destructive; patient is confused/disoriented.

Review of the Physician's Orders revealed the restraint order was written at 01:19. Review of the MD evaluation revealed in part, the date/time is 1/25/15 at 03:50; patient is demonstrating activity that poses high risk for injury; patient is exhibiting destructive and/or violent behavior, patient is exhibiting aggressive behavior toward others; other patient or family education: pt (patient) intoxicated and combative; I have examined and evaluated the patient for their reaction to intervention, current medical and behavioral condition and have determined the need to continue the use of/use restraints/seclusion as specified by this order.

Review of the MD orders revealed the restraints were discontinued on 1/25/15 at 01:55. Approximately 2 hours before the physician conducted his face to face evaluation for the need for restraints on the patient.

An interview was conducted with S3RN ED Manager on 1/29/15 at 1 p.m. She confirmed the MD evaluation for the need for restraints was done after the restraints were documented as discontinued and not in the one hour time frame when the restraints were placed on the patient.


Patient #24
Review of the ED record for Patient #24 revealed the patient was a 62 year old male who presented to the ED on 06/12/14 at 9:08 a.m. by EMS (Emergency Medical Services-ambulance) with a chief complaint of "Psychiatric History." The record revealed the patient was assigned to Room 1. Review of the record revealed a PEC (Physician Emergency Certificate) was signed by the ED physician on 06/12/14 at 10:30 a.m. due to the patient was violent and dangerous to others. The ED record revealed Patient #24 remained in the ED until 06/14/14 at 3:26 p.m. when he was transferred to a psychiatric hospital.

Review of the Nursing Medical Record revealed on 06/13/14 at 3:15 p.m. the patient was placed in locked seclusion. Review of the nursing documentation revealed the patient had been pacing, walking in room, in and out of room and required re-direction by staff from 6:45 a.m. on 06/13/14 until 3:15 p.m. when the patient was placed in locked seclusion. There was no documented evidence of the patient's behavior that prompted the use of seclusion. Interventions that were attempted prior to the seclusion were documented as: diversional activities, frequent patient contact/rounds, meals/fluids offered, offer/assist with personal hygiene, offer/assist with toileting, provide redirection of patient focus, reduce environmental noise, and reorientation/reassurance. The Restraint/Seclusion Documentation Form revealed the seclusion was discontinued at 3:30 p.m. Review of the physician's order for the seclusion revealed only the following: "Seclusion". There was no documented evidence the duration of the seclusion was ordered. The seclusion order was documented by S38MD, Director of the ED.

Review of the nursing documentation revealed on 06/14/14 at 2:02 a.m., the patient was placed in soft restraints to both upper extremities and a vest restraint was applied. The restraint reason was documented as violent/self destructive. The restraint alternatives tried were as follows: comfort measures, diversional activities, family/sitter present, frequent patient contact/rounds, modification of environment,meal/fluids offered, reduce environmental noise, reorientation/reassurance, verbal de-escalation. Review of the Restraint Documentation Form revealed a re-evaluation of the patient was documented at 2:30 a.m., 3:00 a.m., 4:00 a.m., and 4:30 a.m. only. There was no documented evidence the patient's condition was assessed every 15 minutes while in restraints as directed in the hospital policy. There was no documented evidence the restraints were released and the patient's position was changed after 2 hours in the restraints. Review of the record revealed the restraints were discontinued at 5:15 a.m. on 06/14/14 (3 hours 13 minutes in restraints).

Review of the physician's order for the restraint revealed the order was dated 06/14/14 at 2:01 a.m. as follows: "Restraint Orders: to prevent escape and prevent patient form hurting self or others." This order was documented as a verbal order from S42MD. Further review of the order revealed the physician's face to face evaluation was documented at 2:50 p.m. on 06/14/14 and revealed the following: I have examined and evaluated the patient for their reaction to the intervention, current medical and behavioral condition and have determined the need to continue the use of/use restraints/seclusion as specified by this order (over 12 hours after the restraint was initiated). There was no documented evidence the physician ordered the specific restraints that were used and there was no duration for the use of the restraints ordered according to hospital policy.

In an interview on 01/29/15 at 11:00 a.m., S3RN, (ED Manager) was interviewed. S3RN confirmed she had reviewed the ED record for Patient #24 after it was requested for review. S3RN stated after she reviewed the ED record, she documented written disciplinary actions on 5 nurses for not following the hospital's policy in the use of the restraints. S3RN confirmed the physician's orders for the restraints were not specific and did not include a duration for the use of the restraints. She confirmed "Restraint as necessary" was a PRN order and was not permissible. S3RN confirmed the nurses had failed to include every 15 minute assessments of the patient while in restraints and had not documented the reason for the seclusion. S3RN confirmed the documentation did not include the least restrictive restraint was used. S3RN confirmed the physician's face to face evaluation one hour after the vest restraint and the wrist restraints were applied was not documented until 12 hours later. S3RN stated restraints were not currently monitored in the ED quality improvement.


Patient #26
Review of the ED record for Patient #26 revealed the patient was a 30 year old male who presented to the ED on 01/14/15 at 1:41 p.m. by EMS with a chief complaint of found lying on the ground and smoking "Mojo." Review of the record revealed the patient was discharged on 01/14/15 at 6:38 p.m.

Review of the Nursing Medical Record revealed the patient was placed in bilateral soft wrist restraints due to attempting to remove essential medical equipment on 01/14/14 at 1:52 p.m. The record revealed the restraints were discontinued at 3:00 p.m.

Review of the physician's order for the restraints revealed a verbal order for restraints was obtained from S42MD on 01/14/14 at 1:50 p.m. There was no documented evidence of the specific restraint that was ordered, nor was there a duration ordered for the use of the restraint. Further review of the record revealed the physician documented and evaluation of the patient on 01/14/15 at 3:16 p.m, 1 hour and 20 minutes after the restraints were applied.


3) Failing to develop written policies for observation patients:
Review of the policy & procedure manuals provided as current policies revealed no documented evidence of any policies and procedures for observations services.

In an interview on 01/29/15 at 2:00 p.m., S4RN (Med-Surg Manager) stated they hospital did not have policies and procedures for observation admits. S4RN confirmed patients were admitted to the hospital under observation status.


26351

Based on record review and interview the CAH failed to ensure a policy had been developed which provided a description of services provided by the hospital. Findings:

Review of the Policy and Procedure Manuals revealed no documented evidence of a policy for the description of the services provided at the hospital.

In an interview on 01/29/15 at 3:30 p.m., S5QI/IC (Quality Improvement/Infection Control) stated the only documentation the hospital had related to the services the hospital provided was the services outlined in the Quality Improvement Plan. S5QI/IC verified there was no hospital policy that provided a written description of the services provided by the hospital.

Based on record reviews and interviews, the CAH (Critical Access Hospital) failed to ensure the dispensing, and administering, and storage of drugs and biologicals were implemented according to accepted professional principles.

1) The CAH failed to ensure its policies, procedures and hospital practices for dispensing and administering medications and biologicals were the pharmacists would review medication orders prior to the first dose being administered to the patient, except in emergencies. The hospital policies and practices allowed medications to be administered prior to the pharmacists' review when the pharmacy was closed or the pharmacist was not available.

2) the CAH failed to ensure stock liquid medications were stored correctly after opened, as evidenced by stock liquid medications being stored in the medication room and not being dated when opened.

3) the CAH failed to ensure expired medications were not available for patient use, opened vials of medication were dated when opened, single use vials were discarded after opened in the Emergency Department (ED).

Findings:

1. An interview was conducted with S41Pharmacist on 1/26/15 at 11 a.m. He reported the pharmacy hours are from 7:30 a.m. to 5:30 p.m. Monday through Friday and from 7:30 a.m. to 2 p.m. on the weekends. He also stated the pharmacists are on-call after hours. He reported the nurses and physicians will review the first time medications, when the pharmacy was closed and the pharmacist was available for any questions.

An interview was conducted with S2DON on 1/26/15 at 2:45 p.m. She reported after the pharmacy was closed the first time doses are not reviewed by the pharmacist prior to the medication being administered to the patient.

An interview was conducted with S41Pharmacist on 1/27/15 at 11 a.m. He reported the hospital currently did not have a policy approved by the Governing Body of the hospital on first dose review of medications prior to administration to the patient.

2. An observation was conducted on 1/26/15 at 11:30 a.m. of the medication room on the Medical/Surgery floor. There was approximately 10 opened bottles of assorted types of liquid medications for multiple patient use that were not dated when they were opened.

An interview was conducted with S41Pharmacist on 1/26/15 at 11:30 a.m. He reported the medications should have been dated when they were opened.

3. An observation was conducted on 01/26/15 at 1:50 p.m. with S5QI/IC (Quality Improvement/Infection Control) in the ED. The Wound Care cart was observed in the hallway outside patient room #2. An opened multidose vial of Marcaine was observed to have a hand written date of 09/11/14. The Wound Care cart also contained a bottle of Iodoform gauze with an expiration date of 09/2014. S5QI/IC stated the policy was to date vials when opened and to discard opened vials after 30 days. S5QI/IC confirmed the Marcaine vial was expired and the Iodoform gauze was expired and both should have been removed from the cart and discarded.

An observation was conducted on 01/27/15 at 9:45 a.m., with S3RN, ED Manager in the medication room in the ED. The locked controlled drug storage was observed to have 5 ampoules of Demerol 25 mg. with expiration dates of 10/01/14. S3RN confirmed the Demerol ampoules had expired on 10/01/14 and were available for patient use. Further review of the locked controlled drug storage area revealed a plastic box labeled "RSI" (Rapid Sequence Intubation). Inside the box was an vial bottle of Ketamine (Anesthetic agent) 500 mg/ml. There was no documented evidence of a date the vial was opened. Also observed in the RSI box was an opened vial of Rocuronium (Neuromuscular Blocking agent) 100 mg/10 ml. with no date when opened. S3RN confirmed the vials of Ketamine and Rocuronium were opened and not dated when opened. S3RN stated the Ketamine and Rocuronium were single use vials and should have been discarded after they were opened.

Further observation in the ED Medication Room revealed the following:
Folic Acid 5 mg/ml, 10 ml vial opened and not dated when opened
Thiamine 200 mg/2 ml vial opened and not dated when opened
S3RN confirmed the Folic Acid and Thiamine vials were opened and should have been discarded as they were single use vials. S3RN confirmed the opened vials were available for patient use.







26351

Based on record review and interview the CAH (Critical Access Hospital) failed to ensure identified medication errors were documented in the patient's medical record and the notification of the physician of the medication error was documented in the patient's medical record for 2 of 2 (Patient #9 and Patient #11) hospital identified medication errors reviewed. Findings:

Review of the hospital's policy on Medication Administration, Reference Number 3017, revealed in part, Errors in Administration of medication will be reported immediately to the attending physician and an incident report will be sent to Nursing Administration and the Pharmacy Department by the end of the shift in which the error was committed. The actual medication administered will be documented on the medical record.

Review of the Confidential Hospital Occurrence Report for Patient #9 revealed on 11/16/14 at 22:29, Patient #9 received the wrong antibiotic. The patient received Tobramycin, which was ordered for a different patient.

Review of the Patient #9's medical record revealed no documentation in the patient's medical record of the medication error or if the physician was notified of the medication error.

An interview was conducted with S14LPN on 1/28/15 at 9 a.m. She verified the medication error was not documented in Patient #9's medical record and there was no documentation in the patient's medical record the physician was notified.

Review of The Confidential Hospital Occurrence Report dated 9/18/14 for Patient #11 revealed on 9/18/14 at 2100 the patient's antibiotic, Vancomycin was not given as ordered by the physician.

Review of the Patient #11's medical record revealed no documentation of the medication error was in the medical record and if the physician was notified of the medication error.

An interview was conducted with S14LPN on 1/28/15 at 10:30 a.m. She verified the medication error was not documented in Patient #11's medical record and there was no documentation in the patient's medical record the physician was notified.

26351

Based on observations and interviews, the CAH (Critical Access Hospital) failed to implement measures to ensure the provision of a safe environment consistent with nationally recognized infection control precautions as evidenced by:
1. The CAH failed to ensure the hospital's Infection Control Officer (S5QI/IC) was trained and/or experienced in infection control practice and/or procedures

2. The CAH failed to ensure all surfaces were cleaned and able to be disinfected, as evidenced by:
a. old adhesive tape being present on medication carts, bathroom tiles, and beds.
b. Chairs in patient rooms having tears in the upholstery (Room #7,#8, #11,#14, and #15)
c. Unsealed wooden benches being in 2 shower/tub rooms on the Medicine/Surgery Floor.
d. Formica covering missing from a shelf with exposed wood (Room #14).

3. The CAH failed to ensure that sterile items and clean supplies used for patient care was stored in a building that was constructed to ensure that the sterility/cleanliness of the sterile items and clean supplies were not compromised. This failed practice was evidenced by sterile items and clean supplies used for patient care being stored in an outside building with unsealed concrete/slab floors and with no documented monitoring of the building's temperature and humidity.

4. The CAH failed to provide housekeeping for the Central Supply storage "shed" and
the hospital failure to maintain that patient supplies were stored in proper places and not stored in cardboard boxes on the floor in the Central Supply storage "shed".

5. The CAH failed to ensure that sterile instruments used for patient care was processed according to acceptable professional recommended standards and practices by failing to adhere to appropriate decontamination protocols for critical and semi-critical instruments used in patient care.

6. The CAH failed to ensure patient care supplies were stored in proper places and not in the ED soiled utility room.


Findings:
1. Review of S5QI/IC's (Quality Improvement/Infection Control) personnel/training record revealed approximately 6 hours of infection control training in last 2 years with no previous experience in infection control.

An interview was conducted with S5QI/IC on 1/29/15 at 1 p.m. She confirmed she had approximately 6 hours of infection control training and she had no previous experience with infection control prior to taking the position the Infection Control in January 2014.

2. a. An observation was conducted on 1/26/15 at 10:20 a.m. of a 6 inches by 6 inches of old adhesive stuck to the bathroom wall tiles in room #16 on the med/surg floor. This observation was confirmed by S15MT (Maintenance Tech).

An observation was conducted on 1/26/15 at 11 a.m. of the two medication carts in the medicine room on the Medicine/Surgery Unit. The drawers of the two medication carts had old adhesive tape stuck to the drawers and could not be disinfected properly. This observation was confirmed by S41Pharmacist.

An observation was conducted on 1/26/15 at 10:30. In Patient Room #15 the side rail had adhesive tape stuck to it and one of the bedrails was broken and bandage tape was used to connect the siderails back together. This observation was confirmed by S15MT (Maintenance Tech).

b. An observation was conducted on 1/26/15 at 10:30 a.m. of the following rooms having vinyl chairs in the rooms for patient use with torn areas in the vinyl making them unable to be disinfected properly (Room # 7, #8, #11, #14 and #15). This observation was confirmed by S15MT (Maintenance Tech).

c. An observation was conducted on 1/26/15 at 10:30 of unsealed wooden benches in the shower and bathtub room on the Med/Surg floor. This observation was confirmed by S15MT (Maintenance Tech).

d. An observation was conducted on 01/26/15 at 3:15 p.m with S15MT (Maintenance Tech). The shelf located in front of the window and over the Air Condition/Heating unit in Patient Room #14 was observed to have a 12 inch long area on the edge of the shelf with the Formica covering missing, with exposed wood. S15MT confirmed the Formica was missing and the exposed wood could not be disinfected.


3. The CAH failed to ensure that sterile items and clean supplies used for patient care was stored in a building that was constructed to ensure that the sterility/cleanliness of the sterile items and clean supplies were not compromised. This failed practice was evidenced by sterile items and clean supplies used for patient care being stored in an outside building with unsealed concrete/slab floors and with no documented monitoring of the building's temperature and humidity.

A review of the hospital policy, titled,"Central Supply Department", revealed in part: The hospital will follow the AORN (Association of peri-Operative Registered Nurses) Standards and Recommended Practices, AAMI (Association for the Advancement of Medical Instrumentation) and CDC (Centers for Disease Control and Prevention) for the Central Supply areas for sterile and clean patient items.

A review of the AORN Standards and Recommended Practices for Hospitals- 2013 edition, Recommendation VIII revealed in part: Sterile items should be considered sterile until an event occurred to compromise the sterile item such as, moisture penetration or unacceptable storage conditions since the sterility of sterile items was event related and not time related. The Recommended Practice further revealed that sterile items used for patient care should be stored under environmentally controlled conditions and supply storage area temperatures should be controlled and monitored. Supply Storage areas should not exceed 75 degrees F and the humidity should not exceed 70%.

An observation on 1/27/15 of an outside building of the hospital revealed that sterile items and clean supplies, used for patient care, were being stored in a building that had unsealed concrete/slab floors. An observation on 1/27/15 at 9:00 a.m., 11:00 a.m., 1:30 p.m., and 3:15 p.m. revealed the door to the outside storage area was propped open. A further observation revealed that the concrete/slab floor had several cracks in it and was very dusty and dirty with debris. There was no temperature or humidity monitoring log available for the surveyor to review..

In an interview on 1/27/15 at 3:55 p.m. with S32MM Dir. (Materials Management Director)she indicated that she was the manager for the hospital's Materials Management Department and was responsible for the patient supplies stored in the outside Central Supply storage "shed" that contained patient sterile supplies and patient clean supplies. S32MM Dir indicated that housekeeping did not clean (sweep/dust/mop) the Central Supply storage "shed" located outside the hospital.

In an interview on 1/28/15 at 11:10 a.m. with S12MaintDir (Maintenance Director), he indicated that the floor in the Central Supply storage "shed" was an unsealed concrete slab floor and that moisture can seep through the concrete/slab floor. He further indicated that the Central Supply storage "shed" was not monitored for humidity. S12MaintDir indicated that they try to keep the temperature in the Central Supply storage "shed" around 66 degrees Fahrenheit. S12MaintDir indicated that they would adjust the temperature control settings (heat or cool settings) before they left each day depending upon the weather forecast for that night, to try to keep the Central Supply storage "shed" around 66 degrees Fahrenheit. S12MaintDir indicated that they did not keep a temperature/humidity log for the Central Supply storage "shed".

4. The hospital failed to provide housekeeping for the Central Supply storage "shed" and
the hospital failure to maintain that patient supplies were stored in proper places and not stored in cardboard boxes on the floor in the Central Supply storage "shed".

An observation on 1/27/15 of an outside building of the hospital revealed that sterile packaged items used for patient care, were being stored in cardboard boxes on the Central Supply storage "shed" floor to include in part: Central Line kits, Dressing kits, Intravenous tubing kits, Thoracentesis trays, Intravenous fluid bags, and Foley catheter kits. A further observation revealed that the Central Supply storage "shed" floor was very dusty and dirty with debris.

In an interview on 1/27/15 at 3:55 p.m. with S32MM Dir.(Materials Management Director) she indicated that she was the manager for the hospital's Materials Management Department and was responsible for the patient supplies stored in the outside Central Supply storage "shed" that contained patient sterile supplies and patient clean supplies. S32MM Dir indicated that housekeeping did not clean (sweep/dust/mop) the Central Supply storage "shed" located outside of the hospital. She further indicated that the Materials Management Department staff would sweep the floors in the Central Supply storage "shed" about once a week. S32MM Dir indicated that the cardboard boxes containing sterile packaged items used for patient care, were being stored on the Central Supply storage "shed" floor due to limited storage space.


5. The hospital failed to ensure that sterile instruments used for patient care was processed according to acceptable professional recommended standards and practices by failing to adhere to appropriate decontamination protocols for critical and semi-critical instruments used in patient care.

A review of the hospital policy, titled,"Central Supply Department", revealed in part: The hospital will follow the AORN (Association of peri-Operative Registered Nurses) Standards and Recommended Practices, AAMI (Association for the Advancement of Medical Instrumentation) and CDC (Centers for Disease Control and Prevention) for the Central Supply area for all sterile processed patient items. A further review of the hospital policy, titled,"Central Supply Department" - Cleaning of Instruments", revealed in part: Soiled instruments are decontaminated, rinsed and allowed to dry prior to sterilization or high-level disinfecting.

A review of the AORN Standards and Recommended Practices for Hospitals- 2013 edition, Care of Instruments- Recommendation V, revealed in part: Cleaning and decontamination should occur as soon as possible after instruments are used to prevent the formation of biofilm. Cleaning and decontamination must be thoroughly accomplished or disinfection and sterilization may not be effective. Manufacturer's instructions for enzymatic cleaners (used in instrument decontamination) and high-level disinfectant solutions (used in instrument disinfecting) should be followed.

A review of the AORN Standards and Recommended Practices for Hospitals- 2013 edition, Recommendation VIII revealed in part: Sterile items should be considered sterile until an event occurred to compromise the sterility of the item, to include effective sterile processing and packaging, since the sterility of sterile items was event related and not time related.

A review of the manufacturer's instructions on the enzymatic cleaner used in the hospital's instrument decontamination room revealed: Dilute 1 (one) ounce per 1 (one) gallon of warm water and allow instruments to soak for 2-5 minutes before scrubbing. A review of the manufacturer's instructions on the high-level disinfectant solution used in the hospital's instrument room revealed: For high-level disinfectant of semi-critical instruments, activate the solution by adding the activator, shake well and record the date of activation. Submerge the instruments for 90 minutes at 25 degrees centigrade, then rinse with sterile water or tap water and allow to dry. Instruments should be decontaminated prior to submerging in the high-level disinfectant solution. Do not use the high-level disinfectant solution beyond 28 days or if a test strip indicated the high-level disinfectant solution was no longer activated.

In an interview on 1/28/15 at 11:30 a.m. with S23MM (Materials Management) Clerk, she indicated that since she worked in a Sterile Processing Department at another hospital many years ago that she was responsible for the Sterile Processing department of the hospital. S23MM Clerk indicated that she worked part-time on weekends. S23MM Clerk was asked about the decontamination room's protocols. S23MM Clerk indicated that soiled instruments are to be soaked in the enzymatic solution, rinsed and dried before sterile processing or high-level disinfecting. S23MM Clerk indicated that the hospital did not have a surgery department anymore and that the instruments used by the hospital were single packaged sterile instruments (hemostats, small kelly clamps, scissors, pick-ups, nasal speculums, needle holders, etc.) used by the Emergency Room (ER) physicians or by the Wound Care nurse for minor procedures. S23MM Clerk further indicated that all the instruments used in the hospital were mostly sterilized in the autoclave in the hospital. S23MM Clerk indicated that the laryngoscope blades were the only instruments that were high-level disinfected in the high-level disinfectant solution. S23MM Clerk indicated that she approximates the enzymatic solution's mixture and did not use exact measurements when preparing the enzymatic solution for instrument decontamination. S23MM Clerk further indicated that she did not test the high-level disinfectant solution prior to each use and assumed that it would remain activated for 28 days. S23MM Clerk indicated that she had not received any "updated" training on Sterile Processing since 1979. S23MM Clerk further indicated that she was not familiar with "event related vs time related sterility".

A review of S23MM Clerk's employee file revealed no documented evidence of a Sterile Central Processing job description or any competency skills checklist related to the Sterile Central Processing area. The review further revealed no documented evidence of any in-services or training in Sterile Central Processing.

In an interview on 1/27/15 at 2:00 p.m. with S22MM (Materials Management) Clerk, he indicated that he worked Monday through Friday and was mainly responsible for the ordering/distribution of the patient medical supplies in the Sterile/Clean Supply storage area, located in the building outside of the hospital, to the various hospital departments. S22MM Clerk indicated that he also helped with transporting soiled instruments to the decontamination room in the hospital. He indicated if the ER had soiled instruments, that were used on patients in the the ER by the ER physicians, he would bring them (the soiled instruments) to the decontamination room (on the weekdays) since S23MM Clerk only worked weekends. S22MM Clerk indicated that he would place the soiled instruments in the pan with the green solution (high-level disinfectant solution) for S23MM Clerk or for S5QI/IC (the infection control nurse) to clean. S22MM Clerk further indicated that he was not familiar with Sterile Processing protocols and had no training in Sterile Processing protocols. S22MM Clerk indicated that he thought the green solution was the enzymatic solution (for decontamination).

In an interview on 1/28/15 at 10:10 a.m. with S28LPN she indicated that when sterile instruments are used by physicians on the medical-surgical unit, the staff would bring the soiled instruments to the decontamination room and place them in the dirty side of the sink for S23MM Clerk or S5QI/IC to clean/decontaminate with the appropriate solutions. S28LPN further indicated that she was not familiar with Sterile Processing protocols.

In an interview on 1/29/15 at 10:40 a.m. with S5QI/IC, she indicated that she was the Infection Control nurse and was responsible for the Sterile Processing room. S5QI/IC was asked about the hospital's policies and protocols for the Sterile Processing room and the training of staff. S5QI/IC indicated that she was not very familiar with Sterile Processing and depended upon S23MM Clerk to guide her and train staff. S5QI/IC indicated that S23MM Clerk was familiar with Sterile Processing protocols from a prior position in a Sterile Processing department many years ago and that she (S23MM Clerk) was assigned to the hospital's Sterile Processing area because of her (S23MM Clerk) past experiences with Sterile Processing. S5QI/IC further indicated that she (S5QI/IC) was not familiar with "event related vs time related sterility".


6. The CAH failed to ensure patient care supplies were stored in proper places and not in the ED soiled utility room.

On 01/26/15 at an observation was made in the ED with S5QI/IC. A plastic box, labeled, "EBOLA Bin" was observed to be stored in the Soiled Utility Room. Also stored in the Soiled Utility Room were 6 spray bottles of housekeeping cleaning solutions. Soiled equipment, trash, and soiled linens were observed in the room. S5QI/IC stated the "EBOLA Bin" contained patient care supplies for isolation. S5QI/IC confirmed the isolation supplies and the housekeeping cleaners should not be stored in the soiled utility room.


30172

Based on observation, record review, and interviews, the CAH (Critical Access Hospital) failed to ensure dietary practices were provided in accordance with recognized dietary standards as evidenced by:

1) failing to ensure the dietary manager was qualified, and;

2) failing to ensure safe food storage, handling, and preparation practices.

Findings:

1) failing to ensure the dietary manager was qualified:

Review of the job description for "Dietary Manager" revealed in part, "The dietary manager shall have successfully completed an approved training program for a food service supervisor. She should have experience in hospital or related food service work."

Review of a document with employee & position information under the job qualifications section revealed, in part, "Experience: Minimum one (1) year experience."

Review of S11DM's personnel file revealed no documented specialized training of standard practices for safe food storage, handling, and preparation. Further review of S11DM's personnel file revealed no documented experience in the management of dietary services.

In an interview on 01/27/15 at 3:50 p.m., S11DM indicated she had no previous experience in the management of dietary services and no training or certifications relative to management of safe food standards and practices. S11DM indicated this was her first job managing a kitchen, and her training, upon hire, included "shadowing" the previous employee in this position for a period of two weeks. S11DM also indicated she was not familiar with all of the dietary policies and procedures, standards and practices for safe food handling, storage, and preparation.


2) failing to ensure safe food storage, handling, and preparation practices:

Review of the policy and procedure, VII. Policies on Purchasing, E. Storage of Supplies revealed, in part, "1.a. Stock should be systematically arranged, and inventory records should follow the same system. Place all new stock behind the old. Date all foods."

Observations on 1/27/15 at 10:00 a.m. in the dry storage food area revealed the following items were not labeled with received dates:
Three cans of Heinz Tomato Sauce (6 lbs., 7 oz)
Four cans of Imperial Sysco Stewed Tomatoes (6 lbs., 6 oz)
One box (36 ounces) of Uncle Bens Rice Pilaf
Four boxes of Herbox Granulated Broth and Seasoning Chicken Bouillon
Four envelope packages (7 ounces) of Knorr Truly Instant Brown Gravy Mix
Two containers (24 ounces) of Progresso Bread Crumbs, Plain

Further observations on 1/27/15 revealed the following items did not have expiration dates:
Three cans of Heinz Tomato Sauce (6 lbs, 7 oz)
Four cans of Imperial Sysco Stewed Tomatoes (6 lb., 6 oz)
One box (36 oz.) of Uncle Bens Rice Pilaf
Four boxes of Herbox Granulated Broth and Seasoning Chicken Bouillon
One box of McCormick Lemon & Pepper Seasoning salt, (1 lb. 12 oz)
One box of McCormick Ground Nutmeg (1 lb.)
One box McCormick's Baker's Special Cinnamon (1 lb.)
One box McCormick's Fancy Spanish Paprika (1 lb., 2 oz)
One box McCormick's Course Grind Black Pepper (1 lb.)
One box McCormick Onion Powder (1 lb., 4 oz)
Three bottles McCormick Culinary Imitation Rum Extract (16 oz.)

Further observations on 1/27/15 revealed the following items were expired:
One box Jello Chocolate Instant Pudding & Pie Filling, expired 07/13/12
One bottle Flavorite Flavored Chocolate Syrup (24 oz.), expired 06/28/14
One bottle McCormick Imitation Rum Extract (1 oz.). expired 11/23/13
One bottle of Bertolli, Vineyard Premium Collections, Marinara with Burgundy wine (24 oz.), expired 01/08/14
Nine boxes of Progresso Bread Crumbs, Plain (24 oz), expired 01/16/15
Thirteen packages of Hidden Valley Ranch Salad Dressing Mix (3.2 oz.), expired 08/05/14
Sunsweet prune juice, 6 (5.5 oz) cans, expired 07/2014
Sunsweet prune juice 4 (5.5 oz) cans, expired 09/2013
One Box of Carnation Breakfast Essentials packets, expired 04/03/14
Three boxes of Betty Crocker Gluten Free yellow cake mix, expired 04/23/14
Two bags (5 lbs.) of Sysco Reliance brownie mix, expired 09/13/14
Three bags (5 lbs.) of Sysco Reliance devil's food cake mix, expired 10/25/14
Three bags (5 lbs.) of Sysco Reliance yellow cake mix, expired 08/07/14
One bag (5 lb.) Sysco Reliance yellow cake mix, expired 07/23/13

Observations in the refrigerator revealed the following items did not have expiration dates:
Wholesome Farm eggs, one box with 15 dozen eggs, one box with 20 eggs
Three cartons (16 oz.) beef base (received 01/03/13)
One 32 oz bottle of chopped garlic (received 01/30/13)

In an interview on 1/27/15 at 11:00 a.m., S11DM (Dietary Manager) indicated she was not aware of the temperature ranges allowable for the refrigeration of foods to maintain safe food practices.

In an interview on 01/27/15 at 11:30 a.m., S11DM (Dietary Manager) indicated all dietary staff was responsible for maintaining the dry goods storage area, and there was no particular staff member identified to ensure the dry food items were stored and maintained to ensure safe food practices. S11DM confirmed the above referenced items were not labeled with received dates, not labeled with expiration dates, and the items identified were expired. S11DM confirmed all of the items should have been labeled with received dates, expiration dates, and the expired items should have been removed and not available for use in food preparation.

An observation at the walk-in freezer on 01/27/15 revealed there was no posted temperature log for the freezer.

In an interview on 01/27/15 at 1:30 p.m., S 11 DM indicated she was not aware that the temperature of the walk-in freezer needed to be monitored and recorded on a daily basis. S11DM confirmed the walk-in freezer temperatures were not being monitored or recorded.

Review of the policies and procedures presented by S11DM as current, revealed a "Weekly Cleaning Schedule."

Observations of the kitchen revealed the stove was caked up with burnt residue, the inside of the oven, including the inside of the oven door, was caked up with burnt residue, the mixer had dried food residue on its surface, and the can opener appeared to have some corrosion of the metal.

In an interview on 1/27/15 at 2:30 p.m., S11DM indicated there was no cleaning schedule for the dietary department and it's appliances. S11DM indicated the kitchen was cleaned by the person who was working in the area at the time. S11DM also indicated, when asked by the surveyor, that the oven was cleaned "about every 3 months."

An observation on 1/27/15 at 2:45 p.m. revealed the following metal cookware and bowls were stacked and stored wet:
1 (2.7 quart) pan
2 (6.1 quart) pans
1 (21 quart) pan
3 (8.3 quart) pans
5 metal bowls of various sizes

In an interview on 1/27/15 at 3:00 p.m., S11DM indicated the method used for drying dishes was leaving them out on the counter tops and/or wiping them dry with towels. S11DM also indicated she was not aware of the problem with stacking and storing dishes while they were still wet. S11DM confirmed the above-referenced dishes were stacked and stored wet.

An observation on 1/27/15 at 3:15 p.m. revealed a food temperature chart posted for January, 2015. Review of the food temperature log revealed no temperatures recorded for breakfast menu items except for eggs.

In an interview on 1/27/15 at 3:15 p.m., S11DM indicated the food temperatures were taken while the food was cooking and while the food was still in the cooking container. She also indicated the food items did not make it to the steam table a lot of the times, and the food temperatures were not typically checked on the steam table. S11DM further indicated she was not aware of the practice of checking the food temperatures while on the steam table.

Based on record review (list of contracted services) and interview, the CAH failed to ensure there was a written list containing all of the services provided to the hospital by agreement and/or contract in place for services provided to the Radiology Department.

Review of the list of contracts provided revealed no documentation of Company A on the list as having an agreement or contract with the hospital to provide services and maintenance of the radiation department's equipment.

Review of the radiology equipment maintenance reports revealed Company A was providing radiology equipment maintenance for the hospital.

In an interview on 01/27/15 at 9:05 a.m., S9ADM Asst (Administrative Assistant) confirmed the hospital did not have a contract or agreement with Company A on file, and Company A was not on the list of contracts/agreements presented as the current list.

Based on observation, record review, and staff interview, the CAH failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available staff. The ED (Emergency Department) RN delegated the one-to-one observation of patients under a physician emergency certificate (PEC) to contracted security guards (Sheriff's Deputies) who had not received training and had not been assessed for competency in crisis prevention and interventions for 2 of 2 (S43Deputy, S44Deputy) contracted security guards. Findings:

Review of the hospital policy titled, "Emergency Department Security" policy number 5030, effective 07/24/12, revealed in part the following: All Emergency Department and Security Department personnel shall receive aggression management training and special training on handling disruptive and violent persons during orientation and annually thereafter.

In an interview and observation of the ED on 01/26/15 at 1:50 p.m., S5QI/IC (Quality Improvement/Infection Control) stated Room #1 was used for PEC patients and a security guard sits outside the door. She stated someone was at the room at all times. S5QI/IC stated if needed a CNA (Certified Nursing Assistant) from the inpatient unit can come to ED and monitor PEC patients. She stated all nursing staff have certification in management of aggressive behavior (MOAB).

On 01/27/15 at 9:45 a.m., an observation was made in the ED with S3RN (ED Manager). A sheriff's deputy was observed seated outside of Patient Room 1. The patient was visible lying in the bed and the room lights were off. S3RN confirmed Patient #25 was a PEC patient. An observation of the medication room (across from Patient Room 1) was conducted with S3RN. At 10:05 a.m., upon exiting the medication room with S3RN, the Sheriff's deputy was no longer seated outside of Patient #25's room. There was no staff monitoring Patient #25 at this time. Room 1 was observed to be located near an exit door that had an automatic glass door that opened as the person neared the door. S3RN confirmed this exit door was not locked from the inside and stated this was the ambulance bay. S3RN confirmed the patient was not being monitored and stated she would check to see where the deputy was. S24RN then left the ED to look for the deputy. The deputy and S24RN returned and she stated the deputy went to get coffee.

In an interview on 01/27/15 at 10:25 a.m., S43Deputy stated Patient #25 was a PEC patient and was present in the ED when he came on duty this morning. S43Deputy stated he had not received any training from the hospital on dealing with psychiatric/PEC patients.

Review of the ED record for Patient #25 revealed the patient was under a PEC for suicidal ideations and that a deputy was assigned to monitor the patient one-on-one.

In an interview on 01/27/15 at 2:00 p.m., S3RN manager of the ED stated the hospital did not have a personnel record, or any training or orientation records for any of the Sheriff's Deputies contracted to provided security for the hospital. S3RN confirmed the hospital did not do any training or orientation for the contracted deputies. S3RN provided a contract with the local Sheriff's department and a list of 40 deputies that were currently contracted to provide security for the hospital. Review of the contract revealed a 1 page document dated 06/26/14. There was no documented evidence in the contract of the one-on-one observations of PEC patients, and there was no documentation of the education/training requirements for the deputies.


Review of the incident report log revealed Patient #R3 was sprayed with "Freeze" (Chemical Pepper Spray used by law enforcement) on 09/18/14. Review of the ED record for Patient #R3 revealed the patient was under a PEC. The record revealed on 09/18/14 at 10:15 a.m., the patient was combative, belligerent, and attempted to hit S44Deputy. The record revealed S44Deputy sprayed a small amount of "freeze" on the patient and the patient immediately calmed down. The record revealed at 10:29 a.m., the patient's eyes were irrigated. Review of the record revealed a deputy was assigned one-on-one observation of the patient during the ED stay.

In an interview on 01/28/15 at 11:00 a.m., S3RN reviewed the incident report and ED record for Patient #R3 dated 09/18/14 and confirmed the Sheriff's deputy sprayed the patient with "Freeze" when she attempted to hit him. S3RN confirmed no action had been taken by the hospital after this incident.

26351


Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by a nurse failing to report a patient's change in condition to the patient's physician for 3 (#3, #4, #10) out of 20 (#1-#14, #17-#22) inpatient records reviewed out of a total sample of 30.

Findings:

Patient #3

Review of the medical record for Patient #3 revealed he was a 91 year old male admitted to the hospital on 1/25/15 for pneumonia.

Review of his Vital Signs on 1/25/15 at 18:44 revealed a temperature of 101.3 degrees Fahrenheit.

Review of the Patient #3's Nurses' Notes revealed no documentation the physician was aware or notified of the patient's elevated temperature.

An interview was conducted with S14LPN on 1/28/15 at 10:40 a.m. She reported with review of the patient's electronic medical record she was unable to find any documentation that the physician was aware of the patient's elevated temperature.


Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 09/24/14 as a swing bed patient with a diagnoses of Congestive Heart Failure and Pneumonia.
Review of the physician's orders and the Medication Administration Records (MAR) revealed Nitrobid ointment 0.5 inch (Angina medication which lowers blood pressure) topical every 8 hours was administered from 09/24/14 to 09/29/14. Review of the MAR revealed the Nitrobid was held due to low blood pressure on the following days:
09/27/14 at 10:15 p.m. to 09/29/14 at 2:05 p.m.(5 doses).
Review of the record revealed no documented evidence that the nurse notified the physician that the Nitrobid ointment was held due to the patient's low blood pressure.

In an interview on 01/27/15 at 1:40 p.m., S4RN reviewed the electronic health record and confirmed the MAR revealed the nurse held the Nitrobid on the above dates/times due to the patient's low blood pressure. S4RN confirmed there was no documentation that the nurse notified the physician that the medication was being held due to the patient's blood pressure.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 69 year old male admitted to the hospital as a swing bed patient on 12/23/14 with diagnoses of Open Reduction Internal Fixation of the Right Hip, Pressure Ulcer to Left Buttock, Type II Diabetes Mellitus, and Cancer of the Sinus.

Review of the physician's orders revealed Coumadin (Anticoagulant medication) 5 mg. by mouth every bedtime was ordered on 12/24/14.
Review of the PT/INR (Prothrombin Time/International Normalized Ration) results dated 01/01/15 at 6:30 a.m. revealed the patient's PT/INR was 47.7/5.11 (Critical High on lab report) (Reference range is PT: 11.6-14.3, INR: 2.00-3.00). Review of the physician's orders revealed an order to hold the Coumadin on 01/01/15 at 7:37 a.m. Review of the PT/INR results dated 01/02/15 at 8:05 a.m. revealed the patient's PT/INR was 49.2/5.32 and the nurse was notified at 8:06 a.m. There was no documented evidence that the nurse notified the physician of the results of the PT/INR.

Review of the nursing documentation revealed on 01/02/15 at 5:07 a.m., the patient was found to have a nose bleed. There was no documented evidence that the physician was notified of the patient's nosebleed. A nursing entry at 6:57 a.m. revealed the patient had bloody drainage from his nose, but there was no documentation that the physician was notified. The record revealed at 7:53 a.m., the patient called the nurse to the room with a complaint of a nose bleed. The nurse documented the PA (Physician Assistant) and the NP (Nurse Practitioner) were notified. The physician's orders revealed a Vitamin K 10 mg. injection was ordered by the PA on 01/02/15 at 9:02 a.m.

There was no documented evidence the physician was notified of the patient's nose bleed when the patient had a critical high PT/INR until 7:53 a.m., over 2 hours after the nose bleed began. There was no documented evidence the physician was notified of the PT/INR results on 01/02/15 at 8:06 a.m. when the results were reported to the nurse as high critical.

In an interview on 01/28/15 at 9:40 a.m., S4RN (Med-Surg Manager) reviewed the electronic health record and confirmed the nurse should have notified the physician when the patient's nose bleed began on 01/02/15 at 5:07 a.m. S4RN confirmed there was no documented evidence that the nurse reported the critical high PT/INR results on 01/02/15 to the physician. S4RN stated the 24 hour chart checks should have identified this. S4RN confirmed the incident had not been reported to her.

Based on record review and staff interview, the CAH failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 3 (#10, #13, #17) of 7 (#1, #5, #6, #7, #10, #13, #17) current swing bed patients out of a total sample of 20 inpatients (#1-#14, #17-#22). Findings:

Review of the hospital policy titled, "Medication Errors" policy number 3022 with an effective date of 07/24/12 revealed in part the following: All actual or potential errors identified will be documented through the hospital's risk management system. Types of medication errors include: Wrong: drug, dose route or time. Omission (not administered before next schedule dose due). Unordered dose. When a medication error occurs the following should occur in this order: Notify the physician and evaluate the patient. Perform any necessary clinical interventions.... Record the medication as given in the medical record. Record the observed and assessed outcome of the patient in the medical record. Record notification of physician in the medical record with any resultant orders....The practitioner who identifies an error will document all relevant particulars on the incident report form....

Review of the hospital policy tilted, "Standardized Hours For Drug Distribution" policy number 6044, with no date, revealed there was a 1 hour prior to and 1 hour after window in which to administer medication.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 69 year old male admitted to the hospital as a swing bed patient on 12/23/14 with diagnoses of Open Reduction Internal Fixation of the Right Hip, Pressure Ulcer Left Buttock. Type II Diabetes Mellitus and Cancer of Sinus.

Review of the medical record revealed a physician's order dated 01/05/15 for Augmentin 875 mg. by mouth twice a day. Further review of the medical record revealed the Medication Administration Record (MAR) did not have documentation that the 9:00 p.m. dose of Augmentin had been administered to Patient #10 on 01/08/15. Review of the medical record revealed no physician orders to omit this dose of medication, and revealed no documentation by the hospital staff as to why this dose was not administered as ordered. Further review of the medical record revealed no documentation that the physician was contacted regarding the missed dose of Augmentin.

In an interview on 01/28/15 at 9:40 a.m., S4RN, Med-Surg Manager reviewed the electronic health record and confirmed the 9:00 p.m. dose of Augmentin was not administered on 01/08/15. S4RN stated the charge nurse does a 24 hour chart check and should have found this error when the chart check was done. S4RN stated all medication errors are sent to her and she had not received an incident report on this error. S4RN confirmed the physician had not been notified of the medication error.


Patient #13
Review of the medical record for Patient #13 revealed the patient was an 84-year-old female admitted to the hospital on 12/05/14 at 3:57 p.m. with the diagnoses of decubitus ulcers and malnutrition.
Review of the medical record revealed a physician's order dated 12/08/15 for Fortaz, 1 gram, to be administered intravenously every 8 hours. Further review of the medical record revealed the MAR did not have documentation that the third dose of Fortaz, scheduled to be administered at 10:00 p.m., had been administered to Patient #13 on 12/11/14. Review of the medical record revealed no physician orders to omit this dose of medication, and revealed no documentation by the hospital staff as to why this dose was not administered as ordered. Further review of the medical record revealed no information that the physician was contacted regarding the missed dose of Fortaz.
In an interview on 01/28/15 at 11:30 a.m., S25LPN (Licensed Practical Nurse and electronic medical record assistant) confirmed that there was no documentation that Patient #13 had been administered the 10:00 p.m. dose of Fortaz on 12/11/14, and the dose of Fortaz should have been administered to Patient #13 on 12/11/14 at 10:00 p.m.

Patient #17
Review of the medical record for Patient #17 revealed the patient was a 76 year old male admitted to the hospital as a swing bed patient on 01/23/15 with diagnoses of Sacral Decubitus, Osteomyelitis, Type II Diabetes Mellitus and Heart Failure.

Review of the medical record revealed a physician's order dated 01/23/15 for Vancomycin, 1 gram, to be administered intravenously every 12 hours. Further review of the medical record revealed the MAR did not have documentation that the 9:00 p.m. dose of Vancomycin, had been administered to Patient #10 on 01/25/15. Review of the medical record revealed no physician orders to omit this dose of medication, and revealed no documentation by the hospital staff as to why this dose was not administered as ordered. Further review of the medical record revealed no documentation that the physician was contacted regarding the missed dose of Vancomycin. Further review of the medical record revealed Cipro 500 mg twice a day was ordered on 01/23/15. Review of the MAR revealed the 9:00 p.m., dose on 01/25/15 was administered at 11:06 p.m. There was no documented evidence of why the medication was administered 2 hours after the scheduled time.

In an interview on 01/28/15 at 2:40 p.m., S25LPN reviewed the electronic health record for Patient #17 and confirmed the Vancomycin was not administered as ordered on 01/25/15 when the 9:00 p.m. dose was not given. S25LPN confirmed there was no documented evidence of a physician's order to hold the Vancomycin and there was no evidence the physician was notified of the missed dose. S25LPN confirmed the Cipro was administered 2 hours after the scheduled time on 01/25/15 and this was considered a medication error. S25LPN stated the hospital policy allows administration of medications 1 hour before to 1 hour after the scheduled time.

Based on record review and interview the CAH (Critical Access Hospital) failed to develop and keep a current nursing care plan for 1(#8) out of 3 (#3, #8, #20) current medical inpatients reviewed for care plans. Findings:

Patient #8
Review of the Medical Record for Patient #8 revealed she was admitted on 1/26/15 for a productive cough and fever.

Review of her Physician's Nursing Order Report revealed she was placed in Reverse Isolation.

Review of her Nursing Care plan revealed 3 problems were identified with no interventions documented. The three problems were identified were; Pattern of Ineffective r/t (related to) Bronchitis, Fall r/t decreased Mobility, and Planning.

An interview was conducted with S4RN Medicine/Surgery Nurse Manager on 1/27/15 at 3:30 p.m. She confirmed the patient being in Reverse Isolation was not care planned and there were no interventions listed in the patient's care plan for any of her identified problems.

Based on interviews and record reviews the CAH (Critical Access Hospital) failed to establish an accurate system for delinquency data collection and analysis of medical records by the Medical Record Department. This failed practice was evidenced by no accurate documentation, data and analysis, of medical record delinquencies by the Medical Record department staff.

Findings:
A review of the Medical Record Policy and Procedure Manual, provided by S19HIM Dir as the most current, revealed in part: The Medical Staff By-laws states that all History and Physicals (H&P) will be completed within 24 hours after admission. A verbal order (V.O.) is expected to be authenticated (signed, dated, timed) within 48 hours. The Medical Staff By-Laws require that a discharge summary (D/C) be completed within 30 days of discharge (no revised date noted on this policy). A further review of the Medical Record Policy and Procedure Manual, revealed that it is expected that the physicians authenticate (signed, dated, timed) a verbal order within 10 days (revised date noted as 6/30/09 on this policy).

A review of the "Statistics of Deficiencies" computerized worksheet completed by the Medical Record Department staff revealed in part: 5 (five) columns- column #1 was labeled "comp"(complete) ; column #2 was labeled "dict"(dictated); column #3 was labeled "tran"(transcribed); column #4 was labeled "write"(write); column #5 was labeled "sign'"(signature)..

In an interview on 1/27/15 at 12:05 p.m. with S20MR Tech and S21MR Tech, they indicated that they audit current medical records daily and that they input the information into the "Statistics of Deficiencies" computerized worksheet. S20MR Tech and S21MR Tech indicated that they do not look for incomplete (delinquent) medical records according to the Medical Record Policy and Procedure Manual, just incomplete medical records in general. S20MR Tech indicated that when she completed the statistics in column #1 on the worksheet, it meant that "something" in the medical record was not completed (a H&P, V.O., D/C, signature, date or time entry). S20MR Tech further indicated that the statistics documented in column # 4, "write" ,could also mean that "something" was not documented/completed in the medical record (a H&P, V.O., D/C, signature, date or time entry). S21MR Tech indicated that she completed the "Statistics of Deficiencies" computerized worksheet in basically the same way. S21MR Tech further indicated that they (S20MR Tech and S21MR Tech) each coded the statistics for column #1 and column #4, a little differently. S21MR Tech further indicated that there was no written policy in the Medical Record Policy and Procedure Manual that addressed how the "Statistics of Deficiencies" computerized worksheet was to be calculated. S21MR Tech indicated that an incomplete medical record statistic on the "Statistics of Deficiencies" computerized worksheet was not necessarily an indication of a delinquent medical record, just that "something" was missing. S21MR Tech further indicated that there was a "discrepancy " in the Medical Record Policy and Procedure Manual as to when a V.O. needed to be authenticated and that it was either 3 days or 10 days.

In an interview on 1/27/15 at 12:30 p.m. with S19HIM Dir, she indicated that she was responsible for the medical staff's "delinquency" statistics that were reported to the Quality Improvement (QI) committee each month. S19HIM Dir indicated that the hospital has not had any delinquent medical records for the last year. S19HIM Dir indicated that she based the analysis of the delinquent medical record statistics on the Medical Record staff's daily input on the "Statistics of Deficiencies" computerized worksheet reports. S19HIM Dir was asked about the V.O. policy discrepancies in the Medical Record Policy and Procedure Manual and the Medical Record staff's understanding of the V.O. policy. S19HIM Dir indicated that the Medical Record Policy and Procedure Manual had been reviewed on 7/14/14 and that the the new revisions were in the process of being updated. S19HIM Dir had no further information on the revisions as of 1/27/15. S19HIM Dir indicated that she used the "Statistics of Deficiencies" computerized worksheets when she analyzed medical staff delinquencies for the QI committee. S19HIM Dir was asked how she accurately analyzed the data for medical staff delinquencies imputed by S20MR Tech and S21MR Tech on the "Statistics of Deficiencies" computerized worksheets. S19HIM Dir was present during the interviews with S20MR Tech and S21MR Tech. S19HIM Dir had no response.

Based on record review and staff interview, the CAH failed to ensure a history & physical exam (H&P) was obtained in accordance with the medical staff bylaws as evidenced by H&Ps not done and included in the patient's record within 24 hours of admission for 3 (#13, #18, #19) of 20 (#1-#14, #17-#22) sampled inpatient records reviewed out of a total sample of 30 (#1-#30). Findings:

Review of the Medical Staff Bylaws, dated 03/25/13, revealed in part the following: 1.2 Medical Records: 1.2-1 A complete legible medical record on every patient admitted to the Hospital is the sole responsibility of the attending practitioner....The history and physical examination shall be completed within twenty-four (24) hours of admission.


Patient #13
Review of the medical record for Patient #13 was an 84-year-old female admitted to the hospital on 12/05/14 at 3:57 p.m. as a swing bed patient with the diagnoses of decubitus ulcers and malnutrition.
Review of the medical record revealed the History and Physical (H & P) was performed on 12/08/14 at 11:54 a.m., 3 days after admission. Further review revealed the H & P was electronically signed by S34FNP (Family Nurse Practitioner) on 12/09/14 at 10:07 a.m., and was signed by S35MD (Medical Doctor) on 12/10/14 at 9:15 a.m.
In an interview on 1/28/15 at 10:30 a.m., S25LPN (Licensed Practical Nurse and electronic medical record assistant) confirmed the H&P for Patient #13 was not performed until 12/08/14 at 11:45 a.m., 3 days after admission.

Patient #18
Review of the medical record for Patient #18 revealed the patient was a 77 year old female admitted to the hospital on 12/06/14 for hospice respite services by S36MD. The patient's diagnosis was After Effects of CVA (Stroke). Review of the electronic medical record on 01/29/15 at 10:40 a.m. with S25LPN revealed no documented evidence of an H&P. S25LPN confirmed she had reviewed the scanned in documents and the electronic documents and there was no evidence of a H&P.

Patient #19
Review of the medical record for Patient #19 revealed the patient was an 82 year old female admitted to the hospital on 11/07/14 for hospice respite services by S36MD (Hospice Physician). The patient's diagnosis was Progressive Dementia. Review of the electronic medical record on 01/29/15 at 10:55 a.m. with S25LPN revealed no documented evidence of an H&P. S25LPN confirmed she had reviewed the scanned in documents and the electronic documents and there was no evidence of a H&P.
In an interview on 01/29/15 at 1:25 p.m., S20MR Tech (Medical Records Technician) stated if S36MD is the admitting physician, they don't get a H&P. She stated they do not track respite records for H&Ps or discharge summaries, but do try to get physician signatures on orders.

Based on record review and staff interview, the CAH failed to ensure the patient's medical record included authenticated physician's orders, progress notes, and a discharge summary for 2 of 2 (#18, #19) sampled hospice respite patients out of a total sample of 20 sampled inpatients (#1-#14, #17-#22) . Findings:

Review of the Medical Staff Bylaws, dated 03/25/13, revealed in part the following: 1.2 Medical Records: 1.2-1 A complete legible medical record on every patient admitted to the Hospital is the sole responsibility of the attending practitioner....The portion of the record the practitioner is responsible for shall include: Clinical observations: progress notes by practitioner....Discharge summary will include: Brief and concise statements of H&P, course in the hospital including treatment, condition on discharge, final diagnosis, instruction to the patient....1.2-3 Progress notes shall be recorded with sufficient frequency to cover all events, complications and treatments, and to ensure comprehensiveness of the record in the event of transfer of responsibility for cares. 1.3-3 Verbal orders shall be entered on the order sheet, signed by the person giving the order. The responsible member shall authenticate such orders within seventy-two (72) hours....

Review of the contract dated 11/08/12,between the CAH and Company B (Hospice agency for Patients #18 and #19) revealed in part the following: Article 8 Records: Each record shall completely, promptly and accurately document all services provided to, and events concerning, each Hospice Patient, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Facility, physician orders entered pursuant to this Agreement and discharge summaries....


Patient #18
Review of the medical record for Patient #18 revealed the patient was a 77 year old female admitted to the hospital on 12/06/14 for hospice respite services by S36MD. The patient's diagnosis was After Effects of CVA (Stroke). Review of the electronic medical record on 01/29/15 at 10:40 a.m. with S25LPN revealed no documented evidence of physician progress notes or a discharge summary. Further review of the record revealed the discharge order dated 12/10/14 was not signed by S36MD. S25LPN confirmed she had reviewed the scanned in documents and the electronic documents and there was no evidence of physician's progress notes or a discharge summary. S25LPN confirmed the discharge order dated 12/10/14 had not been signed by S36MD.

Patient #19
Review of the medical record for Patient #19 revealed the patient was an 82 year old female admitted to the hospital on 11/07/14 for hospice respite services by S36MD (Hospice Physician). The patient's diagnosis was Progressive Dementia. Review of the electronic medical record on 01/29/15 at 10:55 a.m. with S25LPN revealed the physician's admission orders were documented as verbal orders from S36MD. There was no documented evidence the physician authenticated the verbal orders. Further review of the electronic record revealed no documented evidence of physician progress notes or a discharge summary. There was no documented evidence of a discharge order. S25LPN confirmed she had reviewed the scanned in documents and the electronic documents and there was no evidence of physician progress notes, discharge order, discharge summary, and the physician had not signed the verbal admit orders dated 11/07/14. S25LPN confirmed the patient was discharged from the hospital on 11/11/14.
In an interview on 01/29/15 at 1:25 p.m., S20MR Tech (Medical Records Technician) stated if S36MD is the admitting physician, they do not track respite records for H&Ps or discharge summaries, but do try to get physician signatures on orders.

Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure an annual evaluation of its total program was conducted. Findings:

Review of the hospital QA (Quality Assurance) reports revealed no documented evidence of an annual evaluation of the hospital's total program.

In an interview on 01/29/15 at 1:40 p.m., S5QI/IC stated the evaluation of 2014 has not been done yet. The evaluation of 2013 was requested for review.

In an interview on 01/29/15 at 5:30 p.m., S5QI/IC stated she could not find the 2013 annual evaluation.

Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the quality assurance (QA) program was effective as evidenced by the QA program failed to identify problems in sterile processing, restraint usage, dietary, and failed to develop corrective action plans for medications errors and identified monitoring aspects. Findings:

Review of the hospital's Quality Improvement Plan revealed the purpose of the hospital's Quality Improvement Plan was to ensure patients are provided quality care in an environment of minimal risk. This plan provides the hospital with a mechanism to identify opportunities for improvement in care and services. The plan revealed the Goals were as follows: Shift the primary focus of the performance of individuals to the performance of the organization's system and processes....Assure the improvement process is hospital-wide and the monitoring, assessing, and evaluating of patient care clinical performance will resolve problems and improve performance.
There was no documented evidence of any provisions for corrective actions in the plan.

Review of the Quality Assurance Policy and Procedure, (no number or date) revealed in part the following: All departments shall develop appropriated, clinically significant critical indicators to use as occurrence screens in their unit. All departments shall decide on a few clinically significant volume indicators for trending purposes in their unit. All departments shall monitor these critical indicators on a regular basis, recording the numerical data on a monthly basis and reporting the data on a monthly basis....

Review of the ED (Emergency Department) records for 5 of 5 sampled ED patients with restraint usage revealed the hospital's policy was not followed for the use of restraints (see findings in C-0271). Review of the ED Monthly QI (Quality Improvement) reports from June 2014 to December 2014 revealed restraint application/evaluation, restraint flow sheet documentation, and least restrictive measures were identified indicators to monitor. Further review of the Monthly QI reports revealed there were no patient records with restraints reviewed from July to December and the review was a peer review. Review of the Restraint Log for the ED revealed 2 patients were restrained in June, 1 in July, and 1 in September.

Observation and interview in the dietary department revealed dietary practices were not provided in accordance with recognized dietary standards as evidenced by failing to ensure food was stored, handled, and prepared in a safe manner (see findings in C-0279). Review of the dietary quality monitoring revealed the diet orders were monitored. There was no documented evidence the storage of food, temperature logs, and the cleanliness of the kitchen was monitored in the QA program.

Review of the Nursing Services Department Monthly QI reports revealed the following:
June 2014 - 6 medication errors
July 2014 - 6 medication errors
August 2014 - 4 medication errors
September 2014 - 10 medication errors
October 2014 - 11 medication errors
November 2014 - 9 medication errors
December 2014 - 6 medication errors
Review of the monthly reports revealed there was no documented evidence of any corrective actions identified to address the hospital's medication errors.

Further review of the the above nursing monthly reports revealed the "Monitoring Aspects" of Height and Weight addressed on admission, IV Tubing dated on Random Admissions, IV sites dated on admission, and Fall problem listed on admission were below the compliance threshold for the months of June-December 2014. Review of the corrective actions documented revealed the only action was, "Problems brought to the attention of the individual employee/s and they were educated."

In an interview on 1/29/15 at 10:40 a.m. with S5QI/IC she indicated that she was the hospital's Quality Improvement (Assurance) officer and the hospital's Infection Control officer. S5QI/IC was asked for the Quality Indicators for the Sterile Processing Department. S5QI/IC indicated that she only monitored the autoclave results in the Sterile Processing Department and the annual maintenance on the autoclaves. S5QI/IC indicated that she did not monitor any other Sterile Processing protocols/processes or any infection control practices in the Sterile Processing Department.


In an interview on 01/29/15 at 1:40 p.m., S5QI/IC (Quality Improvement/Infection Control) confirmed the hospital's QA program had failed to identify problems with restraints and confirmed the random record reviews had not reviewed any patient records that had restraint usage. S5QI/IC confirmed the record review was done by ED nurses (peers). S5QI/IC confirmed the quality monitoring for the dietary department had not identified any of the problems found in that department during the survey. S5QI/IC confirmed there was no documented evidence of corrective actions for identified medication errors. S5QI/IC stated she had done training and inservices related to medication errors. She confirmed the corrective action for the monitoring aspects in nursing services was to address the problem with the individual staff. S5QI/IC confimed the QA program had not been effective in identifying and correcting the above problems.


30172

Based on interviews and record review, the CAH (Critical Access Hospital) failed to ensure that all patient care services affecting patient care were evaluated. This failed practice was evidenced by no documented evidence of quality indicators for the Sterile Processing Department, Hemodialysis, Wound Care Services, Therapy Services, Hospice Services, Security, Bio-medical, and Organ Procurement.

Findings:

Review of the hospital's Quality Improvement Plan revealed the purpose of the hospital's Quality Improvement Plan was to ensure patients are provided quality care in an environment of minimal risk. This plan provides the hospital with a mechanism to identify opportunities for improvement in care and services. The plan revealed the Goals were as follows: Shift the primary focus of the performance of individuals to the performance of the organization's system and processes....Assure the improvement process is hospital-wide and the monitoring, assessing, and evaluating of patient care clinical performance will resolve problems and improve performance.

Review of the Quality Assurance Policy and Procedure, (no number or date) revealed in part the following: All departments shall develop appropriated, clinically significant critical indicators to use as occurrence screens in their unit. All departments shall decide on a few clinically significant volume indicators for trending purposes in their unit. All departments shall monitor these critical indicators on a regular basis, recording the numerical data on a monthly basis and reporting the data on a monthly basis....

In an interview on 1/29/15 at 10:40 a.m. with S5QI/IC, she indicated that she was the hospital's Quality Improvement (Assurance) officer and the hospital's Infection Control officer. S5QI/IC was asked for the Quality Indicators for the Sterile Processing Department. S5QI/IC indicated that she only monitored the autoclave results in the Sterile Processing Department and the annual maintenance on the autoclaves. S5QI/IC indicated that she did not monitor any other Sterile Processing protocols/processes or any infection control practices in the Sterile Processing Department.

Review of the Quality Assurance reports from June 2014 to December 2014 revealed no documented evidence that the following services were included in the hospital's QA program:
Wound Care Services - Contracted wound care company provided wound care to current sampled in-patients and outpatients.
Therapy - Physical, Occupational, and Speech services were provided to current sampled patients and there was no evidence the services were monitored in the QA process.
Hemodialysis - Hemodialysis was currently provided by contract to inpatients.
Security - Security officers from the local Sheriff's Office were contracted to provide security and were used to provide one on one observation of psychiatric patients in the ED.
Organ Procurement - Hospital was contracted with organ, tissue & eye banks.
Bio-Medical - Hospital was contracted with Bio-Medical Company for patient care equipment monitoring.

In an interview on 01/25/15 at 1:40 p.m., S5QI/IC confirmed the above services were current patient care services and they were not included in the hospital's QA program.


17091

Based on record review (personnel files) and interview, the CAH (Critical Access Hospital) failed to ensure that mid-level practitioners had documentation of an evaluation by the medical staff of the hospital for 1 (S33PA) of 2 mid-level practitioners' personnel files reviewed.

Review of S33PA (Physician's Assistant) personnel file revealed his initial appointment was 11/04/13. Further review revealed a document entitled "Designation of Locum Tenens (LT) Physician" whereby the documented supervising physician for S33PA was S35MD; and there was no documentation in S33PA's file that an evaluation had been performed for S33PA by a member of the medical staff.

In an interview on 1/29/15 at 3:00 p.m., S33PA indicated to surveyor that DHH (Department of Health and Hospitals) had no jurisdiction over the requirements for physician assistants, and the Louisiana State Board of Medical Examiners was the entity with jurisdiction over physician assistants. S33PA further stated that if the surveyor would provide documentation that DHH had jurisdiction over physician assistants, then he would provide documentation concerning any evaluations by the hospital's medical staff.

Based on record review and staff interview, the CAH failed to ensure the quality and appropriateness of the diagnosis and treatment furnished by physicians was evaluated as evidenced by failing to have an agreement with an outside entity to evaluate physician services. Findings:

Review of the hospital's quality improvement program revealed no documented evidence that a review of the quality and appropriateness of the diagnosis and treatment provided by the physicians was evaluated by an outside entity.

In an interview on 01/29/15 at 1:40 p.m., S5QI/IC (Quality Improvement/Infection Control) confirmed she was responsible for the hospital's quality assurance program. S5QI/IC stated she did not know if the hospital had an agreement with a QIO (Quality Improvement Organization) to review physician services. S5QI/IC confirmed the hospital was not a member of a network of hospitals.

In an interview on 01/29/15 at 5:30 p.m., S1ADM (Administrator) confirmed the hospital did not have an agreement with an outside entity for the evaluation of the quality and appropriateness of physician services.

Based on interviews and record reviews the CAH (Critical Access Hospital) failed to ensure that policies were developed that incorporated the OPO (Organ Procurement Organization) and the hospital's definition of Clinical Triggers, Imminent Death and Timely Notification in order to identify potential donors as agreed upon by the hospital's OPO contract and in accordance with the Louisiana Uniform Anatomical Gift Act. This failed practice was evidenced by no documentation in the hospital's "Organ and Tissue Donation" policy that included a definition of Clinical Triggers, Imminent Death and Timely Notification.

Findings:
A review of the hospital's OPO signed contract, provided by S2DON, as the current contract, revealed in part: By entering into this agreement, the Donor Hospital agrees to meet all the obligations set forth by the Louisiana Uniform Anatomical Gift Act and CMS. Timely referral is defined as within 2 hours or less of when a Donor Hospital identifies a patient that meets the criteria for medically established "Clinical Triggers/ Imminent Death" for organ donation evaluation as established by the Donor Hospital's definition of "Clinical Triggers/Imminent Death".

A review of the hospital policy titled, "Organ/Tissue/Eye Donation-Nursing Staff Responsibilities", as provided by S2DON as the most current, revealed in part: The hospital has an agreement with an OPO for identification and referral of potential organ, tissue and eye donors. Upon the death of any patient, the charge nurse or designee will notify the OPO. There was no other verbiage noted in the policy defining "Clinical Triggers, Imminent Death and Timely Notification". A further review of the policy revealed that the hospital will offer educational in-services concerning organ procurement to staff and shall collaborate these in-services with the OPO.

In an interview on 1/28/15 at 10:20 a.m. with S27RN she indicated that she worked the Medical -Surgical unit at the hospital and was the charge nurse for 1/28/15. S27RN indicated that she was recently a part time employee and became full time a month ago. S27RN indicated that she received orientation upon hire and did not remember if OPO policies were discussed in orientation or annually. S27RN was asked about the hospital's OPO policy and the clinical triggers that identified possible "imminent death" patients and the timeliness of notifying the hospital's OPO of possible "imminent death" patients in regard to potential organ donation. S27RN indicated that she did not remember the hospital's OPO policy on "imminent death" or if the hospital had a policy that defined "imminent death". She further indicated that they (staff) did not notify the OPO until after the patient had died and was not aware of an OPO agreement/requirement to notify the OPO of a patient's "imminent death". S27RN further indicated that they (staff) try to call the OPO in a timely manner after a patient had died and was not sure if the hospital policy specified an exact time frame.

In an interview on 1/29/15 at 11:40 a.m. with S31RN she indicated that she worked the Medical -Surgical unit at the hospital and was the charge nurse for 1/29/15. S31RN indicated that she was recently hired and was a full time employee. S31RN indicated that she received orientation upon hire and did not remember if OPO policies were discussed in orientation. S31RN was asked about the hospital's OPO policy and the clinical triggers that identified possible "imminent death" patients and the timeliness of notifying the hospital's OPO of possible "imminent death" patients in regard to potential organ donation. S31RN indicated that she did not remember the hospital's OPO policy on "imminent death" or if the hospital had a policy that defined "imminent death". She further indicated that they (staff) did not notify the OPO until after the patient had died and was not aware of an OPO agreement/requirement to notify the OPO of a patient's "imminent death". S31RN further indicated that they (staff) try to call the OPO in a timely manner after a patient had died and was not sure if the hospital policy specified an exact time frame.

In an interview on 1/29/15 at 1:55 p.m. with S4RN, Medical-Surgical Manager, she indicated that she was involved in the orientation of new staff. S4RN was asked about the hospital's orientation of new staff on the OPO policy and the clinical triggers that identified possible "imminent death" patients and the timeliness of notifying the hospital's OPO of possible "imminent death" patients in regard to potential organ donation. S4RN indicated that the orientation program only went over the necessary forms, contained in the hospital's "death packet", that the nurse was required to complete and it did not review specifics regarding clinical triggers, imminent death, and the timeliness of notifying the hospital's OPO of possible "imminent death" patients in regard to potential organ donation

In an interview on 1/29/15 at 3:30 p.m. with S2DON, she was made aware of the interviews with S4RN, S27RN, and S31RN. S2DON indicated that the hospital's OPO policy needed to be revised to include the definitions on "Clinical Triggers, Imminent Death and Timely Notification". She further indicated that staff and physicians needed more detailed in-services on the hospital's OPO contract/policy.

26351

Based on record review and interview the CAH (Critical Access Hospital) failed to ensure a comprehensive care plan was developed for each resident that described the services that were to be furnished to attain/maintain the resident's highest practicable physical, mental and psychosocial well-being for 3 out of 3 (#5, #6, #9) swing bed patients reviewed for care plans out of a total of 11 sampled swing bed patients (#1, #4, #5, #6, #7, #9, #10, #11, #13, #17, #22).
Findings:

Review of the hospital policy titled, "Care Planning" number 8025, with no date, revealed in part the following: Care, treatment and services are planned to ensure that they are individualized to the patient's needs. The nursing staff shall provide a nursing plan of care that is appropriate to the patient's needs, strengths, results of diagnostic testing, limitations and goals. The nursing staff shall develop a plan of care for each patient within 24 hours of admission. The plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 67 year old female admitted to the hospital as a swing bed patient on 01/23/15 with diagnoses of End Stage Renal Disease with Hemodialysis, Bacteremia, Deconditioning, and a Stage II pressure ulcer to Left Heel.

Review of Patient #5's care plan revealed the following identified problems; Discharge Planning, Fall Risk r/t(related to) altered mental status, and activity intolerance. There was no documentation that the patient's hemodialysis, pressure ulcer/wound care, or deconditioning was identified as a problem in the plan of care. There were no interventions listed for the problems the CAH identified.

In an interview on 01/27/15 at 2:30 p.m., S4RN, Med-Surg Manager confirmed all of the patient's problems were not identified in the care plan and there were no interventions identified for any of the patient's problems.


Patient #6
Review of Patient #6 History and Physical revealed he was a 69 year old male admitted to the CAH on 1/21/15 with the diagnoses of Intra-Abdominal Abscess Drainage, Wound Dehiscence of Abdomen, Malnutrition, Stage III Sacral Wound, Ileostomy Care, Motor Aphasia, and Peg Placement.

Review of Patient #6's care plan revealed the following identified problems; Planning, Injury/Fall r/t(related to) generalized weakness, old CVA (Cerebral Vascular Accident), Impairment of Skin Integrity r/t bed bound, noncompliant, and Intolerance-agitated. There was no documentation of his extensive wounds, malnutrition, Ileostomy, and peg tube. There were no interventions listed for the problems the CAH identified.

An interview was conducted with S4RN Medicine/Surgery Manager on 1/27/15 at 3:30 p.m. She confirmed all the patient's problems were no identified on the plan of care and there were no interventions listed.


Patient #9
Review of the medical record for Patient #9 revealed she was a 81 year old female admitted on 11/6/14 with the diagnoses of Multiply Decubitus Pressure Ulcerations and Dementia. With further review of the medical record Patient #9 had Four (4) Stage IV pressure ulcers.

Review of the Patient #9's care plan revealed the following problems; Impaired Bed Mobility, Self-Care Deficit, and Fall at risk r/t (related to) history of falls, confusion, bed bound status. There were no interventions listed for any of her identified problems and her pressure ulcers and dementia were not addressed in her plan of care.

An interview was conducted with S14LPN on 1/28/14 at 10 a.m. She confirmed not all Patient #9's problems were identified on the patient's plan of care and no interventions were listed on her identified problems.

26351

Based on record review and interview the CAH failed to ensure the comprehensive care plans for swing bed patients were prepared by an interdisciplinary team that included the attending physician for 7 of 7 (#1, #5, #6, #7, #10, #13, #17) sampled current swing bed patients. Findings:

Review of the hospital policy titled, "Swing Bed Interdisciplinary Team Meeting (Staffing)" number 8459, with no date, revealed in part the following: Interdisciplinary Team Meetings (Staffing's) will be held periodically. Also attending the meetings may include: 11. Attending Physician/Physician Assistant.

Review of Patients #1, #5, #6, #7, #10, #13, and #17's Interdisciplinary Team Meeting Notes revealed no documentation the patients' physician attended the Interdisciplinary Meetings.

An interview was conducted with S4RN Medicine/Surgery Manager on 1/27/15 at 1:30 p.m. She reported an Interdisciplinary Team Meeting was held on the Swing Bed patients every Wednesday. She further reported the following disciplines are included: herself, S2DON, Activities Director, Dietary, Respiratory and Physical Therapy (if patient receiving services)and S33PA. She reported the patients' physician did not attend the Interdisciplinary Team Meeting.

26351


Based on record review and interview the CAH (Critical Access Hospital) failed to provide quality services that meet standards of practice as evidenced by:
1) failing to ensure pressure wounds were assessed on admission and weekly for 3 (#9, #10, #13) out 5 (#5, #9, #10, #13, #17) swing bed patients reviewed for wounds;
2) failing to ensure a patient's blood pressure was monitored prior to administrating of a blood pressure medication for 3 (#1, #4, #5) out of 4 (#1, #4, #5, #17) swing bed patients reviewed for blood pressure monitoring prior to medication administration.
Findings:
1) Wound Assessments:
Review of the CAH policy for Wound Vac, Reference 8230, revealed in part, Wounds are assessed with dressing changes. Guidelines for wound assessment and measuring: Uses an appropriate anatomical position: Ex: 3 cm x 2 cm- the first number indicates superior to inferior measurements. The second number indicates a lateral to medial measurement...Photographs are taken weekly or with significant changes per MD order/mid-level assessments.

Patient #9
Patient #9 was an 81 year old female admitted to the hospital on 11/6/14 with Multiple Pressure Ulcers and Dementia.
Review of the Pressure Ulcer/Wound Location dated 11/8/14 at 08:07 revealed the following; Site A: Location RLE (Right Lower Extremity), Site B: Left hip, Site C: Right hip and Site D: Sacral decubitus.
Review of Wound Vac Procedure Note from 11/8/14 revealed the following wound description; Rt (right) Trochanter: 5 cm (centimeters) x 7 cm. x 2 cm., Lt (left) trochanter: 5 cm. x 5 cm. x 1 cm., Sacrum: 5 cm. x 5 cm. x 1 cm.
With further review of the electronic medical record revealed the first measurement for Right Lower Extremity was on 11/18/14 when the contracted wound company measured the wound. The measurements were listed as; Stage IV Rt (right) lat (lateral) foot 2.0 cm. x 1.3 cm. x .3 cm.
An interview was conducted with S14LPN on 1/27/15 at 10:30 a.m. She confirmed the first measurement found in the medical record for the patient's right and left trochanter wounds and sacral wound was on 11/8/14 and the first measurement for the right foot wound was 11/18/14.
An interview was conducted with S2DON on 1/29/15 at 10:30 a.m. She reported wound assessments should be done on admission along with photos taken. The wound then should be assessed and measured when wound care is performed.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 69 year old male admitted to the hospital as a swing bed patient on 12/23/14 with diagnoses of Open Reduction Internal Fixation to the Right Hip, Pressure Ulcer to Left Buttock, Type II Diabetes Mellitus. Review of the H&P dated 12/23/14 revealed the patient had a Stage II Sacral wound and right heel breakdown. There was no documented evidence of an assessment of the patient's wounds until 01/17/15.

In an interview on 01/28/15 at 8:35 a.m., the electronic medical record was reviewed with S4RN, Med-Surg Manager. S4RN confirmed there was no documentation of any wound assessments by the hospital staff until 01/17/15, 25 days after admission. S4RN was able to provide photos of the patient's wounds, but was unable to confirm the date the photos were taken.

Patient #13
Review of the medical record for Patient #13 revealed the patient was an 84-year-old female admitted to the hospital on 12/05/14 at 3:57 p.m. with the diagnoses of decubitus ulcers and malnutrition.
Review of the medical record revealed an initial wound assessment with documentation of wound measurements was completed on Patient #13 when she was admitted to the hospital by the hospital nursing staff. Further review of the medical record revealed no further wound assessment with documentation of wound measurements was performed and/or documented for Patient #13 until 01/18/15 by the hospital nursing staff.
In an interview on 1/28/15 at 3:30 p.m., S16LPN (Licensed Practical Nurse and nurse chart auditor) confirmed Patient #13 did not have documentation of a wound assessment with wound measurements from the date of admission (12/05/14) until 01/18/15 by the hospital nursing staff, and Patient #13 should have had wound assessments with wound measurements documented at least every week.

2) Blood Pressure Medications:
Patient #1
Patient #1 was a 91 year old male admitted to the hospital on 1/6/15 to present for Weakness and Debility. He had a Foley catheter, surgical wound and peg tube.
Review of his Medications revealed he was on Lopressor 50 mg (milligrams) three times a day.
Review of his Medication Administration Record, Vital Sign Record and Nursing Progress Notes revealed his blood pressure was not being monitored prior to the administration of the Lopressor.

An interview was conducted with S4RN, Medicine/Surgery Manager on 1/27/15 at 10 a.m. She confirmed the nurses were not checking the patient's blood pressure prior to administration of his blood pressure medication, Lopressor.

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 09/24/14 as a swing bed patient with a diagnoses of Congestive Heart Failure and Pneumonia.
Review of the physician's orders and the Medication Administration Records (MAR) revealed Nitrobid ointment 0.5 inch (Angina medication which lowers blood pressure) topical every 8 hours was administered from 09/24/14 to 09/29/14. Review of the MAR revealed the Nitrobid was held due to low blood pressure on the following days:
09/25/14 at 2:09 p.m.
09/25/14 at 9:32 p.m.
09/27/14 at 10:15 p.m. to 09/29/14 at 2:05 p.m.
Review of the MAR revealed the Nitrobid was administered as scheduled except for the above dates/times and there was no documented evidence the nurse monitored the patient's blood pressure prior to administering the Nitrobid.

In an interview on 01/27/15 at 1:40 p.m., S4RN reviewed the electronic health record and confirmed the MAR revealed the nurse held the Nitrobid on the above dates/times due to the patient's low blood pressure. S4RN confirmed there was no documentation of the patient's blood pressure when the medication was administered.

Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 01/23/15 as a swing bed patient with a diagnoses of End Stage Renal Disease, Bacteremia, and Deconditioning.
Review of the physician's orders and the Medication Administration Records (MAR) revealed Metoprolol 25 mg. (Blood pressure medication) by mouth twice a day was administered from admission to present. Review of the MAR and the nursing documentation revealed a blood pressure was documented prior to the medication administration on 01/27/15 at 1:33 p.m. only.

In an interview on 01/27/15 at 2:30 p.m., S4RN reviewed the electronic health record and confirmed there was no documented evidence the nurse checked the patient's blood pressure prior to administering Metoprolol from 01/23/15 to 01/26/15.