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Based on record review and interview, the facility staff failed to ask patients about and/or offer advanced directive information in 4 of 20 Patient's medical records reviewed (Patient #3, 4, 5, and 6).

Findings include:

Per review on 6/19/2018 at 12:10 PM of policy titled, "Advanced Directives" #1778356, dated 10/5/2015, the policy revealed, 1. Patients are given written notice upon admission to the health care facility of their decision-making rights, and policies regarding advanced directives in their state and in the institution to which they have been admitted. Patient rights include: a. The right to facilitate their own health care decisions b. The right to accept or refuse medical treatment c. The right to make an advance health care directive. Facilities must inquire as to whether the patient already has an advance directive, if so, record of the existence and location of the AD must be made in the patient's medical record.

Per review on 6/19/2018 at 9:10 AM of Patient #3 closed surgical record revealed no documentation of whether Patient #3 was asked about advanced directives.

Per review on 6/19/2018 at 10:00 AM of Patient #4 closed surgical record revealed no documentation of whether Patient #4 was asked about advanced directives.

Per review on 6/19/2018 at 10:35 AM of Patient #5 closed surgical record revealed no documentation of whether Patient #5 was asked about advanced directives.

Per interview on 6/19/2018 at 10:40 AM, Registered Nurse Operating Room Supervisor F stated, "The physicians usually document in the pre-operative History and Physical if patients have advanced directives, however there is no documentation noted for [Patient 3, 4, or 5]."

Per review on 6/19/2018 at 11:00 AM of Patient #6 closed inpatient record revealed no documentation of whether Patient #6 was asked about advanced directives.

Per interview on 6/19/2018 at 11:15 AM, Registered Nurse Medical/Surgical Supervisor A stated, "The question regarding advanced directives on the patient demographics form was not completed for [Patient #6]."

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0321 - Hazardous Areas
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0918 - Electrical Systems - Essential Electric System Maintenance and Testing

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0321 - Hazardous Areas
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0918 - Electrical Systems - Essential Electric System Maintenance and Testing

Based on observation, record review, and interview, staff failed to follow the facility's hand hygiene policy in 3 of 4 observations of patient care (Patient #1, 21 and 22), and failed to maintain equipment in an aseptic manner in 1 of 1 surgical suite.

Findings include:

Per interview with Registered Nurse Infection Preventionist D on 6/18/2018 at 10:15 AM regarding standards of practice for infection control at this facility and if hand hygiene practices were the same for all departments, Nurse D stated that hand hygiene is the same for all departments and they follow the CDC (Centers for Disease Control).

Per interview with Registered Nurse Supervisor A on 6/18/2018 at 11:10 AM regarding expectations of when to perform hand hygiene, Supervisor A stated, "In and out of rooms, before any glove application or after removal, and before and after touching a patient."

The facility policy titled, "Hand Hygiene and Gloving Practice," #366690, dated 7/17/2017, was reviewed on 6/19/2018 at 7:15 AM. The policy revealed in part, "Handwashing Soap and Water method:...3. Turn off the water with a paper towel and dispose in a proper receptacle...B. Hand Hygiene is required:...2...hands are to be washed properly, or a hand sanitizer is to be applied before gloves are donned and after they are removed."

On 6/18/2018 at 12:45 PM Registered Nurse E was observed performing a blood glucose check on Patient #1 on the Medical/Surgical unit. Patient #1 was on contact precaution isolation. After gowning, gloving and performing the glucose check, with the same gloves Nurse E used a bleach wipe to clean the glucometer and the chemstrip bottle, then placed these two items back in the case for the glucometer supplies.

Per interview with Registered Nurse Infection Preventionist D on 6/19/2018 at 7:50 AM regarding protocol for blood glucose checks, Infection Preventionist D stated, "Put on gloves, scan patient, alcohol the finger, wipe it off, squeeze for more blood, apply blood to chemstrip, dispose of supplies, remove gloves, wash hands, re-glove to wipe machine and put it away." When observations of Nurse E's blood glucose were discussed Infection Preventionist D stated, "No, that's not proper protocol. [Gender] should have changed [gender] gloves in between."

On 6/19/2018 at 8:15 AM Registered Nurse I was observed performing preparation and administration of intravenous medication to Patient #21, an outpatient with osteomyelitis (bone infection), on the Medical/Surgical unit. On 4 occasions (8:19 AM, 8:22 AM, 8:24 AM, and 8:28 AM) Nurse I was observed performing hand hygiene at a sink and used clean hands to shut off the water faucet, thereby potentially recontaminating Nurse I's hands.

At 8:28 AM on 6/19/2018, after cleaning off the computer with a bleach wipe and removing gloves, Nurse I exited Patient #21's room and failed to perform hand hygiene after glove removal and exiting the room.

At 9:30 AM on 6/19/2018 an observation of Emergency Room Doctor J providing wound laceration care to Patient #22 was conducted in the emergency room. The following observations were made during this procedure:
At 9:36 AM, after explaining the procedure to Patient #22, Doctor J exited the room and failed to perform hand hygiene.
At 9:38 AM Doctor J re-entered the room, did not perform hand hygiene, applied gloves and proceeded to inject medication into Patient #22's finger in preparation for sutures.
At 9:44 AM Doctor J removed gloves, did not perform hand hygiene, exited the room and went into the dictation room.

These observations were discussed with and confirmed per interview by Supervisors A and B, Quality Director L, Quality Nurse Specialist M, Safety Officer N and Chief Administrative Officer O on 6/19/2018 at 1:30 PM.


29963

Per observation on 6/18/2018 at 12:35 PM in the surgical area, open yankauer suction tips (oral suctioning tool used in medical procedures) were observed in the following areas: (1) in the pre-operative area, (1) in the anesthesia cart of operating room 1, (1) in operating room 2, (2) in the recovery area. No surgeries were scheduled to take place.

Per interview on 6/18/2018 at 1:00 PM, Registered Nurse Operating Room Supervisor F stated, "We open the packages and hook up the tips to the suction tubing so they are ready to be used, but I understand the yankauer suction tip is packaged clean and if the package is open it is no longer considered clean."

Based on record review and interview, the staff failed to complete a nutritional evaluation on 1 of 10 patients admitted to the facility in a total universe of 20 medical records reviewed (Patient #7).

Findings include:

Per review on 6/19/2018 at 1:11 PM of policy titled, "Nutritional Assessment, Intervention, Monitoring and Evaluation, #4532792, dated 2/3/2017, revealed, "A nutrition screen will be completed within 24 hours of admission by the nursing staff."

Per review on 6/19/2018 at 12:45 PM of Patient #7's closed inpatient medical record revealed an admission on 3/16/2018 at 12:46 PM with complaints of pressure in the back of head, and a history of diabetes. Patient #7 was discharged on 3/18/2018. There was no documentation of a nutritional screen being completed.

Per interview on 6/19/2018 at 1:15 PM, Medical/Surgical Registered Nurse Supervisor A stated, "There is no nutritional assessment completed, it should be completed within 24 hours per policy."

Based on record review and interview, nursing staff failed to document evaluation of wound status in 1 of 1 patient with wounds (Patient #19), and failed to document re-assessment pain levels following pain medication administration for 2 of 8 closed inpatient medical records in a total universe of 20 (Patient #6 and 7).

Findings include:

The facility policy titled, "Infected Wound Assessment and Treatment," #2211645, dated 4/28/2016, was reviewed on 6/19/2018 at 12:50 PM. The policy revealed in part, "Document B. Ongoing wound documentation to include location, type of wound/stage of ulcer, wound bed, drainage, odor, peri-wound skin and pain. C. Wound measurements are completed weekly, at time of discharge (unless contraindicated) and/or with significant improvement or decline."

Per review on 6/19/2018 at 12:30 PM of policy titled, "Pain Management" #4909442, dated 5/4/2018 revealed, "4. Assessment: Ongoing b. Pain and the effectiveness of pain management interventions are reassessed and documented using assessment tools appropriate to the patient. i. Pain is reassessed at a suitable interval following drug and non-drug interventions. ii. For pharmacologic interventions, the timing of reassessment should consider: drug, route, and dosage."

Per review on 6/19/2018 at 12:45 PM of [Hospital] Frequently Used Pain Medications, updated 12/14/2017 revealed, "Tylenol PO (by mouth) onset 30-60 minutes, peak 30-60 minutes, duration 3-4 hours. Tramadol PO onset 60 minutes, peak 120 minutes, duration 9 hours. Morphine PO onset 30-60 minutes, peak 60-90 minutes, duration 3-6 hours."

Patient #19's closed medical record was reviewed on 6/19/2018 at 9:27 AM accompanied by Registered Nurse Supervisor B who confirmed the following findings: Patient #19 was admitted to swing bed status on 2/6/2018 with diagnoses of Sepsis (diffuse infection throughout the blood stream), a diabetic foot ulcer, cellulitis (tissue infection), and had a peripherally inserted central catheter (PICC) line inserted for intravenous antibiotics. Patient #19 was discharged on 3/14/2018. On 2/6/2018 there was an order for a wound care consult and there were wound care orders to change the dressing to the left foot wound three times per week with Aquacel Ag (silver impregnated dressing) and mepilex (cushioned cover dressing). This same order was written on 2/19/2018 and again on the discharge instructions 3/14/2018.

No wound care consult was completed for the duration of the swing bed stay.

There was no documentation of wound measurements or a description of the actual wound from admission through discharge.

Nursing documentation on the flow sheets start out describing the wound as a stage III (described as a sore that has gone through the second layer of skin) pressure ulcer upon admission 2/6/2018, and documents the wound as such through 2/8/2018. On 2/9/2018 there is no documentation on the flow sheet about the wound, and on 2/10/2018 nursing staff start describing the wound as a non-pressure, non-surgical wound. The wound is continually documented as a non-pressure/non-surgical wound between 2/10/2018-2/24/2018.

Between 2/25/2018 through 3/1/2018 there is no documentation of any wounds on the flow sheets.

On 3/1/2018 the wound was identified as a pressure wound.

From 3/2/2018-3/14/2018 the wound was identified as a callous, non-pressure wound, however on 3/9/2018 there was no wound documentation.

Per interview with Medical/Surgical Supervisor A on 6/19/2018 at 12:00 PM regarding the wound care documentation and lack of documentation regarding the wound measurements, Supervisor A stated, "I would expect to see wound measurements documented somewhere."


29963

Per review on 6/19/2018 at 11:00 AM of Patient #6's medical record accompanied by Medical/Surgical Registered Nurse Supervisor A who confirmed the following findings: Patient #6 was admitted with complaints of rib area pain due to diagnosis of Pleurisy (inflammation of the membranes that surround the lungs and line the chest cavity). Patient #6 was given Tramadol on 3/11/2018 at 12:00 PM, a pain re-assessment was not completed until 2:27 PM. Morphine Sulfate was given on 3/10/2018 at 11:59 PM, a pain re-assessment was not completed until 3:00 AM.

Per review on 6/19/2018 at 12:45 PM of Patient #7's medical record accompanied by Medical/Surgical Registered Nurse Supervisor A who confirmed the following findings: Patient #7 was admitted with complaints Severe fatigue and headache. Patient #7 was given Tylenol on 3/17/2018 at 12:45 PM, a pain re-assessment was not completed until 2:00 PM. Tylenol was given on 3/16/2018 at 9:30 PM, a pain re-assessment was not completed until 11:59 PM.

Per interview on 6/19/2018 at 1:00 PM, Registered Nurse Supervisor Medical/Surgical A stated, "The staff did not re-assess pain levels following the administration of pain medication per policy."

Based on record review and interview, staff failed to obtain required authentication of date/time/and/or signature for all verbal orders within the guidelines of facility policy in 1 of 8 patients admitted to the facility out of a total of 20 medical records reviewed (Patient #19).

Findings include:

The facility Medical Staff Rules and Regulations, dated June 2017, were reviewed on 6/19/2018 at 7:30 AM. The Rules and Regulations revealed in part, "C. General Conduct of Care 2...The ordering provider shall authenticate (sign) such orders [referring to verbal orders] within forty-eight (48) hours indicating the date and time of such authenticating signature."

The facility policy titled, "Telephone and Verbal Orders, #4928645, dated 5/9/2018 was reviewed on 6/19/2018 at 12:38 PM. The policy revealed in part, "The responsible practitioner shall authenticate verbal and telephone orders, including signature, date and time, within twenty-four (24) hours."

Patient #19's closed medical record was reviewed on 6/19/2018 at 9:27 AM accompanied by Registered Nurse Supervisor B who confirmed the following findings: Patient #19 was admitted to swing bed status on 2/6/2018. On 2/6/2018 and 2/17/2018 there are verbal orders from a nurse practitioner that did not include a date or time they were signed by the provider. Per interview with Supervisor B at the time of the record review regarding presence of a date and time for the signatures on these orders, Supervisor B stated, "No, I don't see it."

Based on record review and interview, staff failed to develop and/or maintain an individualized care plan for patients admitted to the facility in 7 of 10 out of a total of 20 medical records reviewed (Patient #1, 7, 8, 11, 12, 19 and 20).

Findings include:

Per interview with Registered Nurse Supervisor A on 6/18/2018 at 11:10 AM regarding patient care plans, Supervisor A stated that the nursing staff initiate them and the primary and secondary diagnoses are addressed in the care plans. Staff are to look at the care plan daily and address each goal indicating if it is met or not met. Supervisor A stated that there is a list of goals under the appropriate diagnoses and staff are to pick the appropriate ones for the patient they are setting up the care plan for. Supervisor B stated that there is an option to free text to individualize the goal to the patient.

The facility policy titled, "Patient Centered Electronic Documentation-Acute Care Using Centricity," #3576530, dated 5/31/2017, was reviewed on 6/19/2018 at 12:35 PM. The policy revealed in part, "2. Plan of Care: a. An individualized plan of care is initiated by the RN [registered nurse] within eight hours of admission. b. Elements of the plan of care may be recorded on separate forms, or integrated together. The elements may be handwritten, computerized, or preprinted, but all are individualized to describe the patient's unique needs...4. The patient will receive education and training specific to the patient's abilities as appropriate to the care, treatment and services provided by [facility]. Patient/family educational needs, readiness to learn, learning preferences/abilities, methods of teaching, and responses to teaching are recorded in the Patient's Education Record."

Per review of Patient #1's medical record on 06/19/2018 at 11:00 AM, Patient #1 was admitted on 06/17/2018, #1's nursing care plan included a goal of "Verbal understanding of diagnosis, tx (treatment), dc (discharge) plan. Charting on this goal did not indicate what Patient #1 understood. 06/18/2018 3:00 PM charting states; "Patient verbalized understanding of diagnosis and plan of care. Continue to educated patient on progress." Per interview with staff A on 06/19/2018 at 11:50 AM the above findings were confirmed. Staff A stated, "More detail is expected when charting on care plan goals."

Per review on 6/19/2018 at 12:45 PM of Patient #7's medical record accompanied by Medical/Surgical Registered Nurse Supervisor A who confirmed the following findings: Patient #7 was admitted to the hospital for severe fatigue, headache, and a diagnosis of diabetes mellitus. The care plan for Patient #7 does not address a problem, intervention, or goal for pain or diabetes.

Per review of Patient #8's medical record on 06/18/2018 at 2:40 PM, Patient #8 was admitted on 02/26/2018, #8's nursing care plan included a goal of "Verbal understanding of diagnosis, tx (treatment), dc (discharge) plan. Charting on this goal did not indicate what Patient #1 understood. 02/27/2018 3:00 PM charting states; "The patient understands [gender] diagnosis and will continue to be taught on [gender] diagnosis at least daily and as needed." Per interview with staff A on 06/19/2018 at 11:50 AM the above findings were confirmed.

Per review of Patient #11's medical record on 06/19/2018 at 10:00 AM, Patient #11 was admitted on 06/17/2018, #1's nursing care plan included a goal of "Verbal understanding of diagnosis, tx (treatment), dc (discharge) plan. Charting on this goal did not indicate what Patient #1 understood. 06/18/2018 3:00 PM charting states; "Patient states verbal understanding of diagnosis and plan of care. Continue to monitor." Per interview with staff A on 06/19/2018 at 11:50 AM the above findings were confirmed.

Per review of Patient #12's medical record on 06/19/2018 at 10:30 AM, Patient #12 was admitted on 06/18/2018, #12's nursing care plan included a goal of "Verbal understanding of diagnosis, tx (treatment), dc (discharge) plan. Charting on this goal did not indicate what Patient #1 understood. 06/18/2018 3:00 PM charting states; "Patient states understanding of diagnosis and plan of care." Per interview with staff A on 06/19/2018 at 11:50 AM the above findings were confirmed.

Patient #19's closed medical record was reviewed on 6/19/2018 at 9:27 AM accompanied by Registered Nurse Supervisor B who confirmed the following findings: Patient #19 was admitted to swing bed status on 2/6/2018 with diagnoses of Sepsis (diffuse infection throughout the blood stream), and a diabetic foot ulcer, cellulitis (tissue infection), and had a peripherally inserted central catheter (PICC) line inserted for intravenous antibiotics. Patient #19 was discharged on 3/14/2018. The goal on Patient #19's care plan that can be correlated to these diagnoses is a standardized computer generated goal that has not been individualized and revealed, "Free from signs/symptoms of infection." The goal does not specify what type or where the issues of infection might be. There was no mention of Patient #19's diabetic foot wound or PICC line throughout the "charting results and comments" between 2/616/2018 and 3/14/2018. Cellulitis is mentioned on 2 occasions (2/22/18 and 3/7/18).

Patient #20's closed medical record was reviewed on 6/19/2018 at 12:55 PM accompanied by Registered Nurse Supervisor B who confirmed the following findings: Patient #20 was admitted to swing bed status on 2/16/2018 for strengthening and care following surgery of the digestive tract and a recent hemorrhoidectomy on 2/15/2018. Patient #20's goals, which were standardized computer generated statements that were not individualized, revealed: "Amb [ambulate]/transfers indep. [independently] or patient baseline; Pain is at an acceptable level for pt [patient]; Resume mobility/ADLs [activities of daily living] to baseline level; Vrbl [verbal] undrstndng [understanding] of diagnosis, tx [treatment], dc [discharge] plan."

Patient #20 was discharged from swing bed on 2/15/2018 for acute care hospitalization for a hemorrhoidectomy and readmitted on 2/16/2018. There was no re-evaluation from physical therapy identifying goals for Patient #20, and the first physical therapy note following the readmission was not documented until 2/22/2018.

Per interview with Supervisor B on 6/19/2018 at 1:15 PM regarding the goals, Supervisor B agreed the goals were vague and not individualized, and stated that the facility is working on improvement in this area." Per interview with Registered Nurse Case Manager D on 6/19/2018 at 1:20 PM regarding physical therapy doing a new evaluation with goals, Nurse D stated, "Yes, they should have done a new eval [evaluation]."


20878




29963

Based on record review and interview, staff failed to ensure that the medical record was completed per facility expectation by failing to have discharge orders for 1 of 4 surgical patients (Patient #4) and failing to obtain a signature on a consent in 1 of 10 patients admitted to the facility (Patient #8) out of total of 20 medical records reviewed.

Findings include:

Per review on 6/19/2018 at 11:30 AM of Medical Staff Rules and Regulations, dated 6/2017 revealed, C. General Conduct of Care 2. All orders for treatment must be in writing.

Per review on 6/19/2018 at 9:30 AM of Patient #4's surgical record, an epidural steroid injection was performed on 5/14/2018. There was no documentation of discharge orders following the procedure.

Per interview on 6/19/2018 at 10:15 AM, Registered Nurse Operating Room Supervisor F stated, "The surgeon writes the discharge order following the procedure but I can not find any discharge orders for [Patient #4]."


20878

Per review on 06/18/2018 at 2:30 PM of Patient #8's medical record, Patient #8 was admitted on 02/26/2018 and did not sign the "Patient Care/Admission agreement" until 02/28/2018, 2 days into the hospital admission. This was confirmed per interview with Staff A on 06/18/2018 at 2:30 PM. A stated consents should be signed at the time of admission.

Based on record review and interview, the staff failed to include a time when authenticating medical records and/or ensured records are timed prior to procedures for 2 of 4 patients who had surgical procedures (Patient #4 and 5) in a total universe of 20 medical records reviewed.

Findings include:

Per review on 6/19/2018 at 11:30 AM of Medical Staff Rules and Regulations, dated 6/2017 revealed, "B. Medical Records 8. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated with a signature."

Per review on 6/19/2018 at 9:30 AM of Patient #4's medical record revealed a consent for pain management procedure that did not include a time with the authentication. The history and physical was completed on 5/11/2018 and signed, dated, and timed (2:00 PM). The epidural steroid injection procedure occurred at 1:37 PM. The history and physical was timed after the procedure ended (1:49 PM).

Per review on 6/19/2018 at 10:35 AM of Patient #5's medical record revealed surgical orders dated for 4/26/2018 for a left knee arthroscopy procedure on 5/11/2018, the form has a physician signature and date, the orders do not include a time the orders were written and signed. The post anesthesia evaluation is signed by the certified registered nurse anesthetist and dated, the assessment is not timed.

Per interview on 6/19/2018 at 10:50 AM, Registered Nurse Operating Room Supervisor F stated, "I will have to talk to the surgeons to make sure they are timing documents appropriately."

Based on record review and interview the swing bed program failed to give swing bed patients the choice to choose their own provider in 1 of 1 swing bed program reviewed.

Findings include:

The patient rights for swing bed patients were reviewed on 6/19/2018 at 6:30 AM. The rights did not include that swing bed patients have the right to choose a personal attending physician while in the swing bed program.

Per interview with Medical/Surgical Registered Nurse Supervisor A and Case Management Registered Nurse D on 6/19/2018 at 7:20 AM, Nurse D stated, "Well, we only have the one provider, a nurse practitioner, so no, they wouldn't get a choice."

Based on record review and interview swing bed patients at this facility are not given the choice of choosing to, or not to, work for the facility in 1 of 1 swing bed program reviewed.

Findings include:

The patient rights for swing bed patients were reviewed on 6/19/2018 at 6:30 AM. The rights did not reflect that swing bed patients may choose to work, or may choose to refuse to work, while in the swing bed program at this facility.

Per interview with Medical/Surgical Registered Nurse Supervisor A and Case Management Registered Nurse D on 6/19/2018 at 7:20 AM, after reviewing the swing bed brochure and patient rights pamphlet Nurse D stated, "No, it doesn't talk about that."

Based on record review and interview married swing bed patients at this facility are not given the choice of choosing to, or not to, room with their spouse in 1 of 1 swing bed program reviewed.

Findings include:

The patient rights for swing bed patients were reviewed on 6/19/2018 at 6:30 AM. The rights did not reflect that swing bed patients may choose to, or refuse to, room with their spouse if the situation presented itself.

Per interview with Medical/Surgical Registered Nurse Supervisor A and Case Management Registered Nurse D on 6/19/2018 at 7:20 AM, after reviewing the swing bed brochure and patient rights pamphlet Nurse D stated, "No, it doesn't talk about that."

Based on record review and interview, staff did not ensure that Swing Bed patients had the required information needed at the time of transfer or discharge in 2 of 2 closed swing bed patient records (Patient #19 and 20) out of a total of 20 medical records reviewed.

Findings include:

The facility's notice given to Swing Bed patients upon transfer/discharge was reviewed on 6/18/2018 at 2:30 PM. The notice was a Medicare Notice of Non-Coverage form and did not include language that would inform the patient of the right to know where they would be discharged or transferred to should this occur.

The notice does not include information about the Long Term Care Ombudsman, or include information regarding who to contact for patients with developmental disabilities and/or mental illness.

Per interview with Case Management Registered Nurse D on 6/18/2018 at 2:40 PM, Nurse D stated that the required information is not on the form swing bed patients receive.

Per review of Patient #19 and 20's closed swing bed medical records on 6/19/2018 between 9:27 AM and 1:15 PM, the records had the Medicare Notice of Non-Coverage form, however the form did not have all the information required.