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Based on observation and interview the facility failed to have a preventive maintenance program for patient care equipment to be maintained in safe operating condition.

Findings include:

During tour of the medical surgical floor on 10/28/14 a piece of equipment called "Comfort Bath-rinse free cleanser and moisturizing" was observed. Staff B, RN (Register Nurse) indicated that this equipment is pre-set to the temp of 125 degrees F (Fahrenheit). Staff B also indicated that the staff have no idea what the temperature really is because the equipment has no temperature read out. Staff utilize this equipment for shampoos and place a cap over the patient's head to keep the heat in.

Interview with Staff D, (Maintenance Manager) on 10/30/14 indicated no manufacturer's instructions with this machine and that the temperature taken was 133 degrees F. The machine was taken out of service.


18010

Observation during the initial survey tour on 10/28/14 revealed a Hydrocollator heating unit located in a corner of the patient rehabilitation department. This unit was plugged in and identified as being used for patient hot pack treatments by Staff E (Manager of Rehabilitation).

Review of the manufacturer's operation manual titled "HYDROCOLLATOR, MASTER HEATING UNITS" for this machine revealed the following "MAINTENANCE, Care and Cleaning; The Hydrocollator is equipped with an immersion type heating element and hydraulic capillary type thermostat which evenly maintains the HotPac temperature in the water and provides a ready supply of heated packs. It is critical to maintain the water level over the top of the HotPac to avoid damage to the heating element, the stainless steel or the HotPac. Water is constantly lost during operation due to evaporation. Therefore, it is essential that water be added daily. The tank should also be drained and cleaned systematically, at a minimum every two (2) weeks."

"To avoid potential rusting, ... Do regular cleaning and draining of the tank (every two weeks)...
Cleaning Tips. The interior of the unit should be scoured, usually every two weeks, using a low abrasive bathroom cleaner. Check for low or no chlorine content in your cleaner and make sure that the residue is thoroughly rinsed away with water..."

During interview and review of the Hydrocollator operation manual with Staff E on 10/30/14 at approximately 12:30 p.m., Staff E agreed that a cleaning and draining of this unit every two weeks was indicated. Staff E also agreed that there was no documented evidence found to show that this patient Hydrocollator was routinely cleaned and drained according to the manufacturer's instructions at two week intervals.

Based on observation and interview the Critical Access Hospital failed to secure biohazardous sharps containers from access by unauthorized personnel.

Findings include:

Observation on 10/31/14 at 10 a.m. revealed biohazardous sharps are removed from the nursing units by housekeeping personnel and placed in a red biohazardous waste plastic bag in a designated closet off the medical surgical unit. This room is not locked, thereby not securing sharps from access by unauthorized personnel.

Interview with Staff A, (Housekeeping Manager), on 10/31/14 at 10 a.m. confirmed the room where biohazardous sharps are stored on the nursing unit prior to moving to final destination is not locked.

Based on observation and interview the facility failed to ensure that biological's that were outdated were not being used for patient related care in 1 patient care area.

Findings include:
During tour of the Medical Surgical care area of the hospital on 10/28/14 the blood glucose testing practice was being reviewed. During this review it was observed that both control solutions being used had been dated for discard on 10/19/14. The above observation was confirmed during interview on 10/19/14 with Staff B, RN (Unit Manager).

Based on record review and interview, the hospital's "Standards of Nursing Care/Practice" policy and procedure failed to develop individualized care plans, failed to describe all the patient goals, physiological factors based on the assessment needs and interventions of the patients for 11 of 20 patients in a survey sample of 20. (Patient identifiers are #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #26.)


Findings include:

Review of the facility's "Standards of Nursing Care/Practice" with the revised date of 1/12 and reviewed date of 5/13, revealed the following:

"Purpose: To define the basic Nursing Standards for [Pronoun omitted].
Policy: [Pronoun omitted] nursing staff will practice according to the below outlined standards of nursing practice and care...4. Care Plans support the medical plan of care and address preventive, diagnostic, therapeutic, psychosocial, and supportive care needed by the patient..Procedure: Standards of Practice & Care
Standards of Practice: Standards of practice identify what every patient at [Pronoun omitted] can expect to received during their hospitalization.
I. ASSESSMENT Patients can expect that information will be collected regarding their health status at the time of admission. Standards of Care Standards of Care identify the process that hospital staff utilize in the provision of patient care at [Pronoun omitted].
I. ASSESSMENT A. An assessment will be completed at the time of admission. The comprehensive physical assessment is obtained by an RN[registered Nurse]. An LPN[Licensed practical Nurse] may assist with other areas of assessment... 6. Pain assessment...
II. REASSESSMENT Patients can except that information will be recollected through out their hospital stay.
II. REASSESSMENT A. Reassessment will be completed based on: 1. departmental specific Standards of Care 2. Speciality specific Standards of Care 3. Patient diagnosis 4. Individualized problems and needs...
IV. Goal IDENTIFICATION Patients can expect that for each active problem and/or need identified goals will be set.
IV. GOAL IDENTIFICATION A. For each active problem and/or need identified, realistic, measurable short-term goals will be set. B. Problems and/or needs, which are chronic in nature will not have short or long-term goals identified but will be monitored. Chronic pain will be addressed.
V. PLAN OF CARE patients can except that a multidisciplinary plan of care will be developed for them with collaboration from all disciplines and that the plan will be directed towards meeting the expected meeting the excepted outcomes (goals).
V. PLAN OF CARE. A. A RN or RN/LPN will initiate a multidisciplinary plan of care for each patient at the time of admission. B. The multidisciplinary plan of care will be directed toward meeting the stated goals...
VI. IMPLEMENTATION OF CARE A. Patients can expect that the individualized multidisciplinary plan of care will be implemented. patients ca expect that the following processes will routinely be implemented in addition to the care outlined in their individualized Plan of Care.
VI. IMPLEMENTATION OF CARE A. The individualized multidisciplinary plan of care will be implemented as developed...
VII. EVALUATION OF CARE. Patients can expect that the care they receive will be evaluated.
VII. EVALUATION OF CARE A. Goals and interventions will be evaluated to determine the effectiveness of the multidisciplinary plan of care. B. The frequency for which goals and interventions are evaluated is based on the departmental Standards of Practice. C. The multidisciplinary plan of care will be revised in response to the evaluation of the goals..."

Interview with Staff C (Registered Nurse) on 10/28/14, Staff C confirmed that the patient care plans did not reflect the care and interventions and that the care plans were not individualized for each patient. Staff C stated, "The care plans were 'canned' care plans."

Interview with Staff B, RN, on 10/31/14 at 1:30 p.m., indicated that the care plans needed work and that they were not individualized.

Based on record review, interview and review of the hospital's "Documentation Standards" policy and procedure, it was determined that the hospital failed to ensure that the patient medical record was complete and accurate for 10 out of 20 patients in a survey sample of 20 patients. (Patient identifiers are #6, #29, #30, #33, #34, #35, #36, #37 #39 and #42.

Findings include:

Review of the Critical Access Hospital (CAH) policy and procedure titled "Documentation Standards" revealed the following:
" ... E. Nurses' documentation will include notes concerning:
1. Specific times for each entry.
2. All nursing observations and interventions.
3. Reasons for PRN and stat drugs and their effectiveness.
4. Treatments
5. Patient's reaction to nursing interventions and medication administration.
6. Signs and symptoms displayed.
7. Signatures with title for completed entry on paper forms.
8. Completion of all forms used in the documentation of the patient's care, leaving no blank spaces..."

Record review on 10/28/14 through 10/31/14 revealed that the hospital failed to complete a pain assessment at the time of admission, failed to assess the effectiveness of administered medications, failed to complete a pain assessment/rating at the time of discharge and failed to document a nursing note for the pronouncing of the death for 1 patient in the medical record as evidenced by the following findings:

Patient #6 medical record revealed no documentation of a pain assessment completed. Review of the Care Plan indicated in the section titled "Pain, Pain will be at acceptable level for patient ". No documentation of an acceptable level of pain for Patient #6 could be found. Further record review revealed that Patient #6 was pronounced on 1/21/14 by Staff H (Registered Nurse).

During interview with Staff G (Director of Nursing) and Staff H on 10/31/14 at approximately 1:30 p.m., Staff G verbalized that there was no pain assessment completed, no assessment for the effectiveness of pain medication and no documented evidence of a nursing note for the pronouncing at the time of death for Patient #6. Staff H was present at the time of this interview and Staff H verbalized that she "forgot" to write a nursing note at the time of death to pronounce Patient #6.

Patient #29 record review revealed that the ED (Emergency Department) Triage Report Pain Assessment section was blank.

Patient #30 record review revealed that the ED Triage Report Pain Assessment section was blank.

Patient #33 record review revealed that the ED Triage Report Pain Assessment section had a score of 8/10 - Scale was numeric-Location was left blank and the rest of the pain assessment was also blank. Further record review revealed that Toradol, Acetaminophen and Morphine was given with no pain rating for the effectiveness after the second dose was given.

Patient #34 record review revealed complaints of back pain on admission to the Emergency Room (ER). The ED Triage Report Pain Assessment section was blank. Further record review revealed that Valium and Toradol were given with no effectiveness of these medications documented.

Patient #35 record review revealed complaints of headache and painful urination on admission to the ER. The ED Triage Report Pain Assessment section was blank.

Patient #36 record review revealed complaints of back pain on admission to the ER. The ED Triage Report Pain Assessment section was blank. Further record review revealed Toradol was given with no effectiveness of this medication documented and no pain rating found at the time of discharge.

Patient #37 record review revealed complaints of right knee injury on admission to the ER. The ED Triage Report Pain Assessment section was blank.

Patient #39 record review revealed complaints of shortness of breath on admission to the ER. The ED Triage Report Pain Assessment section was blank and there was no documented evidence of a pain assessment completed prior to transfer to another acute hospital.

Patient #42 record review revealed complaints of nausea/vomiting, no bowel movement for ... (6 days) and status post Hysterectomy (5 days earlier). The ED Triage Report Pain Assessment section was blank and there was no documented evidence of a pain assessment completed prior to transfer to another acute hospital.

Based on record review and interview the Critical Access Hospital failed to distinctly discharge patients from acute status and then admit to swing bed status in 5 of 6 patients admitted to Swing Bed status in a standard survey sample of 20 patients. (Patient identifiers are #1, #2, #9, #12, and #13).

Findings include:

Review of clinical records revealed that 5 patients were admitted to acute care and then transferred to swing bed status and lacked a distinct physician order discharging the patient from actue care and admitting to Swing Bed status. A clear physcian order to admit to Swing Bed status was not found. The only physician order found was for transfer to Swing Bed status.

Interview on 10/31/14 with Staff B, (Unit Manager), and Staff C, RN, confirmed the absence of a distinct order to discharge patient from acute care and admit the patient to Swing Bed status.