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Based on record review, interview, and observation, the facility's governing body failed to ensure that the oversight of the Food and Nutrition Service which was performed under contract which affects all patients. This failed practice has the potential to cause harm from food borne illness as a result of lack of oversight.

The findings are:

A. Record review of "Master Services Agreement between [the name of the contract agency] and [name of hospital]" effective 12/01/2013 revealed, "6. b. Service Description: The service includes the employment, staffing, and preparation of patient meals and food/nutritional supplements per the purchaser policy and procedures, processes, and in compliance with State, Federal, and local regulations. Staff includes the department manager, food service aides, cooks, and dietitian."

B. Record review of New Mexico Environment Department "Person in Charge Fact Sheet" revised 02/29/2016 revealed, "Each food establishment is required to have one person in charge (PIC) present during all hours of operation. The person in charge is an employee that has the responsibility to oversee operations of a food establishment, its employees, making sure cross-contamination is prevented, and food safety procedures are written and followed, if required."

C. On 07/10/19 at 9:31 AM, during interview, S#18 (Director of Facilities Management) confirmed he was new to the role of director and was unsure of many of the items listed on [name of facility] "Food and Nutrition Services" policy and would have to get with the food service manager who has been on leave. No other evidence was provided during this interview to conclude a person was left in charge to manage the overall operations of the food establishment.

D. On 07/10/19 at 10:00 AM, during interview, S#4 confirmed it was a typo on the [name of facility] "Food and Nutrition Services" policy that adhered to the state of Montana and Yellowstone county regulations and it should have stated adhering to state of New Mexico and Dona Ana county regulations.

E. Record review of [name of facility] "Food and Nutrition Services" policy number FN010 Revised 05/19 revealed, "all individuals who perform any food service task are under the direction of dietary Services and do so in accordance with the standards of the state of Montana and Yellowstone County."

Based on record review, observation, and interview the facility failed to protect the confidentiality of patient records for 11 of 11 records. This failure has the potential to disclose unauthorized information.
Findings are:

A. Based on observation 7/8/2019 at 2:30 PM noted 11 Patient charts with Patient Labels facing the public eye. The Patient labels contained Patient identifiers including Birth date, Full Name and Room Number.

B. Based on interview 07/08/19 at 2:40 PM S# 2 (Director of Compliance) stated she felt the patient records were far enough from visibility by visitors not to be able to identify patient information however they try their best not to leave patient records on the nurse's counter.


C. Record Review of [Name of facility] Policy IM.010 Information Management (no date) it states Protected Health Information includes demographic data, that identifies the patient, such as name, address, birth date, and Social Security Number.


41989

Based on record review, observation, and interview, the facility failed to use the appropriate weight for dialysis treatment of 1 (P#3) of 3 patient records reviewed as appropriate for the necessary monitoring of the patient's condition. This deficient practice has the potential to result in inadequate fluid removal or excessive fluid removal during dialysis treatment, significant problems with blood pressure and possibly death. The findings are:

A. On 07/09/19 at 9:55 am during interview, P#3s significant other stated that the dialysis (cleaning the blood of waste products and excess fluid) nurse was not removing any fluid during the dialysis treatment because the significant other believed the dialysis nurse was using the weight of 196.5 lb (admission weight) listed on the dry erase board to determine fluid removal goals during the dialysis treatment.

B. On 07/09/19 at 10:00 am during observation, the weight of P#3 was transcribed on a dry erase board/vital sign board located in the patient room as 196 lb. (pounds).

C. Record review of P#3's facility "Height and Weight" data revealed the patient's weight
1. 06/29/19 recorded as 206.5
2. 6/30/19 recorded as 167.5
3. 7/1/19 recorded as 171
4. 7/2/19 recorded as 204.5
5. 7/4/19 recorded as 210.5
6. 7/5/19 recorded as 211
7. 7/6/19 recorded as 213

D. Record review of dialysis records "Acute Hemodialysis Flow Sheet" dated 06/29/19 revealed the dialysis nurse transcribed the patient weight as 196.5 pre dialysis, but the weight recorded by facility staff on that date was 206.5. P#3's post weight (after dialysis) was recorded as 196.5.

E "Acute Hemodialysis Flow Sheet" dated 07/06/19 revealed the dialysis nurse transcribed P#3's weight as 195.5 pre dialysis, but the weight recorded by facility staff on that date was 213. P#3's post weight was recorded as 196.5. Both dialysis flow sheets indicated limited fluid was removed during treatment.

F. On 7/9/19 at 11:00 am during interview, DON (Director of Nursing) confirmed weight is not being recorded accurately and the process requires re-education of staff performing the weight check. The DON confirmed that recording the correct weight was needed to ensure dialysis patients have accurate fluid removal goals when dialysis treatments are performed.

G. Review of 2019 National Kidney Foundation article reveals "If you have too much extra fluid in your body, you may need longer or more frequent hemodialysis treatments. There is a limit to how much fluid can safely be removed during each dialysis treatment."

Based on observation, record review, and interview, the facility failed to administer drugs on the orders of the physician for 1 (P#3) of 2 (Patients 3 and 12) records reviewed at the prescribed time indicated in the medication administration record. The deficient practice has the potential to result in adverse outcomes including high blood pressure or low blood pressure for all patients. The findings are:

A. On 07/09/19 at 11:00 am during observation, the following medications (Norvasc - used to relieve chest pain and control blood pressure and Cozaar - blood pressure control) were not administered at the scheduled time of 9:00 am for P#3 The MAR (medication administration record) was highlighted in red indicating the medications had not been given.

B. On 07/09/19 at 11:05 am during interview while doing record review, S#3 DON (Director of Nursing) confirmed the staff have a 4 hr. window to document medication administration when holding some types of medications. DON also confirmed no order could be provided which indicated the physician ordered the medications to be held.

C. Record review of the MAR dated 07/09/19 revealed documentation at 12:20 pm which indicated the nurse held the 2 medications (Norvasc and Cozaar) scheduled at 9:00 am.

D. Record review of facility policy "Medication Administration dated 03/19 revealed, "Late or Missed Administration of Medications 1. Medications missed or late (outside the window for administration) will be given as soon as possible in consultation with the physician and/or pharmacy."

F. On 07/09/19 at 2:00 pm during interview S#20 RN (Registered Nurse) confirmed the dialysis (cleaning the blood of waste products) treatment originally scheduled to be performed around 12:00 pm had been postponed until 6:00 pm. The RN confirmed the dialysis RN had other patients to dialyze.

G. Record review of "Antihypertensive Agents in Hemodialysis (high blood pressure medications in procedure to clean the blood of waste products) Patients: A Current Perspective Semin Dial. 2010 May-Jun; 23(3): 290-297. Many blood pressure agents can be dosed once daily and should preferentially be administered at night to control nocturnal blood pressure and minimize intradialytic hypotension (low blood pressure during hemodialysis-cleaning the blood of waste products)."

H. Record review of "Understanding Blood Pressure & Dialysis -Renal Support Network" website dated 03/15 revealed "The doctor may recommend postponing some medications before treatment on dialysis days, especially if a patient 's blood pressure falls during treatments. However, some medications protect the heart. Any alteration must be supervised by the doctor."

Based on record record and interview, verbal orders, also called "telephone orders" were frequently used for 1 (P#3) of 2 (P#3 and #12) patient records reviewed. The deficient practice has the potential to result in orders which are not transcribed correctly and can result in significant medication administration and treatment errors. The findings are:

A. Record review of P#3's "Medication Orders" dated 06/28/19 thru 07/08/19 revealed the following medication orders were all recorded as "Telephone Orders" Humulin Insulin, Glucagon (sugar), Apresoline (blood pressure control), Aspirin, Benadryl (allergic reaction), Cardura (blood pressure control), Cozaar (blood pressure control), Heparin (anti-coagulant to control blood clotting), Immodium (anti-diarrheal), Lactobacillus Probiotic (general digestion problems), Lipitor (cholesterol control), Lopressor (blood pressure control, Lovenox (blood clotting), Nepro Carb (liquid feeding supplement), Norvasc (blood pressure control), Peridex (mouth wash), Phoslo (binds up phosphorus - an electrolyte in the stomach), Robitussin (cough control), Rocephin (antibiotic), and Tylenol (pain control).

B. Record review of P#3's medical record revealed the Nephrologist (kidney/dialysis doctor) gave all orders for dialysis (cleaning the blood of waste products) treatment (scheduled every Monday, Wednesday and Friday) verbally from the date of P#3's admission 06/28/19 through 07/09/19.

C. Record review revealed the Nephrologist made no written documentation of a patient visit from 06/28/19 through 07/09/19.

D. On 07/10/19 at 10:00 S#3 DON (Director of Nursing) confirmed no documentation could be found which indicated the Nephrologist had been in the facility to examine P#3 or to write orders.

Based on observation and interview, the hospital failed to provide a clean and sanitary environment for patients. This failed practice could expose patients, families, and staff to potential illnesses and infections from cross contamination due to unsanitary rooms. The findings are:

A. On 07/09/19 at 2:20 pm during observation of a transfer chair reveals various tears and rips throughout the chair exposing some of the sponge material. The chair was being removed from a patient room as it had just been used for transferring a patient.

B. On 07/09/19 at 2:25 pm during interview, Staff #3 DON (Director of Nursing) confirmed that this transfer chair could not be effectively cleaned and could pose an infection control issue due to the break in the integrity of the chair.

C. On 07/10/19 at 11:30 am during inspection of hospital beds, 3 of 9 beds were found to have unknown substance on the mattress lining.

D. On 07/10/19 at 10:15 am during interview, Staff #2, Director of Compliance confirmed the substance on the mattress to be of unknown origin. Staff #2 stated that these beds needed to be cleaned and would have an environmental service personnel clean the beds.