The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTH METRO MEDICAL CENTER 1400 BRADEN STREET JACKSONVILLE, AR 72076 Aug. 22, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, review of privileges, document review and Medical Staff Bylaws review, it was determined the Governing Body failed to ensure the Medical Staff followed the Medical Staff Bylaws in credentialing and privileging six Physicians, one Physician Assistant, one Certified Registered Nurse Anesthetist and one Advanced Practice Nurse; did not ensure provide appropriate documentation so credential files could be established and maintained on three providers (one physician, one physician assistant and one Certified Nurse Anesthetist); did not ensure one Advance Practice Nurse was operating under a current license; did not ensure history and physicals were performed for five patients; and did not ensure surgical areas had access to current surgical privileges approved for each provider performing surgical procedures. See CMS, A-0338, A-0339, A-0356 and A-0358.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on clinical record review and interview, it was determined the Facility failed to ensure 2 (#21 and #28) of 11 patients admitted to the Transitions Unit were provided their Rights and Responsibilities, Conditions of Admission and/or their Important Message from Medicare About Your Rights as evidenced by a lack of a signature on those forms. The failed practice did not ensure Patient #21 and #28 or their Representatives were informed of their rights and responsibilities and had the potential to affect all patients admitted to the Transitions Unit. The findings follow:

A. Review of Patient #21's clinical record on 08/19/16 revealed forms titled Patient's Rights and Responsibilities and Conditions of Admission. The forms did not have a signature from the patient or their Representative indicating they had received the information. The findings were confirmed in an interview with the Transitions Program Manager on 08/19/16 at 1515.

B. Review of Patient #28's clinical record on 08/22/16 revealed forms titled Patient's Rights and Responsibilities, Conditions of Admission and An Important Message from Medicare About Your Rights. The forms did not have a signature from the patient or their Representative indicating they had received the information. The findings were confirmed in an interview with the Chief Nursing Officer on 08/22/16 at 1350.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on clinical record review and interview, it was determined the Facility failed to ensure a safe patient environment in that there was no evidence of a post fall assessment for three (#23, #29 and #32) of five (#23, #28, #29, #31 and #32) patients experiencing a fall. The failed practice did not ensure the patients were assessed after the fall to determine if the patient experienced an injury or if additional preventive measures needed to be implemented. The failed practice had the potential to affect all patients admitted to the Facility. The findings follow:

A. Review of the "Fall Prevention and Management Policy" on 08/22/16 revealed the following:
1) "VII. Post Fall Assessment. All patients who experience a fall must have a post fall assessment completed as outlined. Care for patients who experienced a fall with: No loss of consciousness; No injuries to exceed minor hematomas and lacerations."
2) "VIII. Post Fall Management. a) The Registered Nurse will complete the Patient Post Fall Assessment and notify the Physician. b) Patients experiencing a fall will be managed according to policy/protocol. c) If fall-related injury is suspected or occurs, the physician will initiate further diagnostic orders deemed necessary. d) The Quality Review Committee will review falls: Assess all factors contributing to the fall event; Recommend interventions and changes to plan of care to prevent repeat falls; Evaluate the fall prevention program and recommend improvements to the program." The findings were confirmed in an interview with Quality/Risk Manager on 08/22/16 at 1010.

B. Review of Patient #23's clinical record on 08/22/16 revealed the following:
1) Transitions Body Audit dated 05/31/16 at 2050 revealed the patient had a 1/2 cm (centimeter) laceration on their forehead.
2) Nurse's note dated 05/31/16 at 2050 revealed, "Variance report filled out and signed by House Supervisor after reviewing. Program Director notified per Charge Nurse."
3) In an interview with the Quality/Risk Manager on 08/22/16 at 1120, she stated the variance report indicated the patient experienced a fall on 05/31/16 at 2050.
4) There was no evidence of the patient experiencing a fall in the clinical record. There was no evidence of a Post Fall Assessment being performed after the patient experienced the fall. There was no evidence the physician was notified of the fall.

C. The findings of B were confirmed in an interview with the Quality/Risk Manager on 08/22/16 at 1120.

D. Review of Patient #29's clinical record on 08/22/16 revealed the patient experienced a fall on 08/09/16 and 08/12/16. There was no evidence of a Post Fall Assessment being performed on 08/09/16 or 08/12/16. The findings were confirmed in an interview with the Quality/Risk Manager and the Clinical Analyst on 08/22/16 at 1009.

E. Review of Patient #32's clinical record on 08/22/16 revealed the patient experienced a fall on 07/03/16 at 1300. There was no evidence of a Post Fall Assessment being performed. The findings were confirmed in an interview with the Clinical Analyst on 08/22/16 at 1510.




Based on observations and interview, it was determined the Facility failed to ensure the safety of patients in that expired supplies were available for patient use, patient use items, trash and potentially unsafe food were accessible to all patients. The failed practice had the potential to allow expired supplies to be used in patient care and patient care supplies to be contaminated. The failed practice had the potential to affect patients in the emergency room and the Transitions Unit. Findings follow:
A. Observation in the emergency room Trauma Room revealed the following: one of one culturette expired 08/15, two of two blue top tubes expired 05/16 and 6/16 respectively, one of two purple top tubes expired 06/16. The above findings were verified by the emergency room Nurse Manager at 1445 on 08/18/16.
B. Observation in the Transitions Day Room revealed the following: a black "Stealth 50" ice chest half full of ice. During an interview with the Transitions Program Director at 1510 on 08/18/16 she stated the ice machine was broken and had been since she came to work there in January of this year. The Transitions Program Director stated only technicians and nurses were allowed to get ice but the ice chest is accessible to anyone. The second drawer under the broken ice machine was full of unwrapped black, plastic spoons used for patients. The spoons were accessible to anyone. A red pitcher containing water sitting on cabinet was dusty and had white spots on it. In the Transitions Day Room a small salad, a "Popeyes" cup, an empty water bottle and a brown paper bag of trash was sitting on the window ledge. The above findings were verified by the Transitions Program Manager at 1515 on 08/18/16.
C. Observations in the Transitions Medication Room revealed the following in the Wound Care Cart: Curad Emulsion Dressings two of eight expired 01/16, two of eight expired 02/16 and four of eight expired 04/16 verified by the CNO at 1545 on 08/18/16; one of two packages of Steri Strips by 4 opened; one of one Allevyn 6 by 6 package opened; one of one Opticell AG package opened; AG Aquacell one of one expired 09/13; Silvercel Antimicrobial Alginate Dressing two of two expired 06/15 and 10 of 10 expired 05/14 verified by the Quality/Risk Manager at 1550 on 08/18/16. During an interview with the Licensed Practical Nurse at 1525 on 08/18/16 he stated the Wound Care Cart is checked once a week.
D. Observation of the Respiratory Care Drawer revealed patient items (updraft and inhaler supplies) with medication supplies stored with unopened clean supplies. The above findings were verified by the Director of Respiratory Therapy at 1555 on 08/18/16.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
This is a continuing deficiency from the survey conducted on 07/13/16.

Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to ensure one of one (#33) patient in restraints was reassessed every two hours per policy. The failed practice did not ensure restrained patients' needs were addressed at timely intervals; did not ensure patients were released from restraints at the earliest possible time; and did not ensure the least restrictive restraint was being used. The failed practice had the potential to affect any patient in restraints. The findings follow:

A. Review of the policy "Restraints/Seclusion" on 08/19/16 revealed, "Reassess and assist the patient at least every two (2) hours to determine: i) Signs of any injury associated with the application of restraints; j) Whether patient meets criteria for release of restraints (See IV); k) Nutrition and hydration; l) Circulation and range of motion in the extremities and appropriate application; m) Hygiene and elimination; n) Physical and psychological status and comfort; o) That rights, dignity and safety of the patient are maintained; p) Whether less restrictive methods of restraint are possible."

B. Review of Patient #33's clinical record on 08/19/16 revealed the patient had orders for restraints from 08/04/16 at 0410 to 08/13/16 at 1200. There was no evidence Patient #33 was reassessed every two hours on 08/12/16 at 1000, 1200, 1400, 1600 and 1800; and on 08/13/16 at 0800 and 1000. Physician's order dated 08/18/16 at 0630 revealed, "D/C (discontinue) bilateral soft wrist restraints on 08/13/16 at 1200." ICU (Intensive Care Unit) Alternative/Restraint Form dated 08/19/16 at 1406 revealed the restraints were discontinued 08/13/16 at 1200. This was the first note to indicate the restraints were discontinued on 08/13/16 at 1200. The findings were confirmed in an interview with the Clinical Analyst on 08/19/16 at 1410.

C. Review of Patient #33's Restraint Audit Forms from 08/04/16 to 08/13/16 revealed the following:
1) On 08/12/16: There was no evidence of a Restraint Audit Form.
2) On 08/13/16: "No doc (documentation) since 08/13/16 at 0600."

D. The findings of A, B and C were confirmed in an interview with the Quality/Risk Manager on 08/19/16 at 1430.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on interview, review of privileges, document review and policy and procedure review, it was determined the Facility failed to follow Medical Staff Bylaws in credentialing and privileging six Physicians, one Physician Assistant, one Certified Registered Nurse Anesthetist and one Advanced Practice Nurse; did not ensure appropriate documentation so credential files could be established and maintained on three providers (one physician, one physician assistant and one Certified Nurse Anesthetist); did not ensure one Advance Practice Nurse was operating under a current license; did not ensure history and physicals were performed for five patients; and did not ensure surgical areas had access to current surgical privileges approved for each provider performing surgical procedures. See CMS A-0339, A-0356 and A-0358.
VIOLATION: COMPOSITION OF THE MEDICAL STAFF Tag No: A0339
Based on review of Medical Staff Bylaws, provider credential files and interview it was determined the Facility failed to credential six (#1, #2, #6, #7, #12 and #13) of 13 physicians, one (#2) of two Physician Assistants (PA), one (#2) of two Certified Registered Nurse Anesthetists (CRNA), one (#2) of two Advanced Practice Nurses (APN) and did not have files on three (Physician #4, PA #1 and CRNA #1) providers. Failure to credential and maintain credential files for active providers did not ensure the Facility was allowing licensed, competent providers to practice and did not allow guidance for procedures the providers were allowed to perform in the Facility. The failed practice affected all patients who received care from or at the direction of Physician #1, #2, #4, #6, #7, #12 and #13, PA #1 and #2, #1 and #2 CRNA and #2 APN. Findings follow:
A. A list of current providers was requested at 0830 on 08/17/16 and were received from the Quality/Risk Manager at 0845 on 08/17/16.
B. Medical Staff Bylaws were requested at 0830 on 08/17/16 and was received from the Executive Assistant at 1000 on 08/17/16. Review of the Medical Staff Bylaws revealed the following under the numbered sections:
...3.5-3 Appointment to Staff Category
Upon completion of provisional appointment the physician shall be appointed to the category of medical staff to which the individual is seeking appointment subject to meeting the requirements set forth for the category. Thereafter appointments to the Medical Staff shall be on a bi-annual basis and subject to restrictions for that category of the medical staff as set forth in these bylaws...
...5.4-2 Transmittal for Evaluation
The applicant shall deliver the application of the Medical Staff Services who shall, after determining that the application is complete and all pertinent materials have been secure, transmit the completed form and all supporting materials to the chairman of the department in which the applicant seeks privileges before the next scheduled departmental meeting for his review. After review by the chairman of the department, the completed application form and all of the supporting materials shall be forwarded to the appropriate department of the Medical Staff for approval...
...5.4-4 Credentialing
Within 120 days after receipt of the completed application for membership, the appropriate department shall make a verbal report of its investigation to the medical executive committee. Prior to making this report, the appropriate department shall examine the evidence of the character, professional competence, qualifications and ethical standing of the physician and shall determine, through information contained in references given by the physician and from sources available to the department, including an appraisal from the department chairman in which privileges are sought, whether the physician has established and meets all of the necessary qualifications for the category of medical staff membership and the clinical privileges requested. Together with this report, the appropriate department shall transmit to the medical executive committee the competed application and a recommendation that the physician be either provisionally appointed to the Medical Staff with specific privileges or rejected for Medical Staff membership, or that the application be deferred for further consideration.
...5.4-5 Medical Executive Committee (MEC)
At its next regular meeting, after receipt of the application and the report and recommendation of the appropriate department, the medical executive committee shall determine whether to recommend to the governing body that the physician be provisionally appointed to the medical staff, that the physician be rejected for medical staff membership, or that the application be deferred for further consideration. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may be qualified by probationary conditions relating to such clinical privileges...
...5.4-6 Governing Body
Favorable Decision
When the Governing Body's decision is favorable, notice of such decision shall be sent through the chief executive officer to the physician for his/her approval and signature within seven (7) working days...
...6.1 Exercise of Privileges
Every physician or allied health professional providing direct clinical services or telemedicine services at this hospital by virtue of medical staff membership or otherwise, shall in connection with such practice and except as provided in Section 6.5 be entitled to exercise only those clinical privileges or provide patient care services as are specifically granted by the governing body.
...6.2 Delineation of Privileges
...6.2-1 Requests
Each application for appointment and reappointment to the medical staff must contain a request for the specific privileges desired by the applicant. A request by a medical staff member for a modification of privileges must be supported by documentation and training and experience supportive of the request.
...6.2-2 Bases for Privileges Determination
Requests for clinical privileges shall be evaluated on the basis of the physician's education, training, performance, demonstrated ability and judgment. The basis for privileges determination to be made in connection with periodic reappointment or otherwise shall include documentation of observed clinical performance and the documented result of appropriateness of care review and other quality assessment activities required by these bylaws and the hospital bylaws.
Clinical privileges granted or modified on initial appointment, reappointment or otherwise shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and healthcare settings where a physician exercises clinical privileges. This information shall be added to and maintained in the medical staff file established for a medical staff member.
C. During an interview with the Executive Assistant at 0900 on 08/18/16 she was asked where the credential files for Physician #4, PA #1 and CRNA #1 were. The Executive Assistant stated there was no credential file for Physician #4, PA #1 and CRNA #1 in the facilities file room. The Executive Assistant stated she has been unable to get clinical privileges signed by appropriate staff even though the MEC has met every month but May for 2016. Review of the MEC meeting minutes verified the previous statement.
D. Physician credential files were selected from the list of current providers provided by the Quality/Risk Manager at 0845 on 08/17/16. Review of the Facility credential files revealed the following:
Physician #1- list of privileges was not signed by the Department Chairman.
Physician #2 - no approval for additional privileges added on 04/12/16 after initial approval date of 02/28/16. The additional privileges form was signed by the emergency room Medical Director and not received in Administration until 06/01/16.
Physician #4 - no credential file presented.
Physician #6 - review of the form titled Internal Medicine Review Form revealed check marks under the privileges requested column, but no marks under the privileges granted column and the form was not signed by the Department Chairman. Review of the untitled form with the initial heading of Special Medical Procedures revealed Physician #6 signed it 06/06/16; the form was received in Administration on 06/15/16 but was unsigned by the Department Chairman. Review of the Credentialing Process Form revealed Physician #6's signature dated 06/18/16. The Medical Staff Department, MEC, Board of Directors and Chief Executive Officers (CEO) sections were unsigned.
Physician #7 - privilege expiration date of 06/30/16 on letter dated 06/25/14. Last list of requested privileges signed by Physician #7 on 03/02/16 and the form was unsigned by Department Chairman. Review of the untitled form with the initial heading of Special Medical Procedures revealed Physician #7 signed the form 03/02/16, the form was received in Administration on 05/16/16 but was unsigned by the Department Chairman. Review of the Credentialing Process Form revealed Physician #7's signature dated 03/02/16 and the Medical Staff Department, MEC, Board of Directors and CEO sections were unsigned.
Physician #10 - medical license was only item presented.
Physician #11 -- medical license was only item presented.
Physician #12 - privilege expiration date of 05/31/16 on letter dated 05/21/14. Last list of privileges dated 04/15/14 by physician #12 and 05/21/14 by Department Chairmen. Review of the Credentialing Process Form revealed Physician #12's signature dated 02/04/16 and the Medical Staff Department, MEC, Board of Directors and CEO sections were unsigned.
Physician #13 - privilege expiration date of 06/17/16 on letter dated 02/18/16. Review of the untitled form with the initial heading of Special Medical Procedures revealed Physician #13 signed the form 01/26/16, and the undated signature of Physician #14 in the MEC section. Review of the Credentialing Process Form revealed Physician #13's signature dated 01/26/16, Physician #14's undated signature on the MEC Section, and the Medical Staff Department, the Board of Directors and the CEO Sections were unsigned.
Physician Assistant #1 - no credential file presented.
Physician Assistant #2 - license in credential file expired 05/31/16. Review of the form titled Delineation of Clinical Privileges revealed under the requested column check marks, under the granted column no marks. The form was signed by PA #2 on 03/02/16. There were no signatures from the Sponsoring Physician or the Department Chairman. Review of the Credentialing Process Form revealed PA#2's signature dated 03/02/16 and Physician #14's undated signature on the MEC Section, the CEO's undated signature in the CEO Section; the Medical Staff Department and Board of Directors Sections were unsigned.
CRNA #1 - no credential file was presented.
CRNA #2 - privilege expiration date of 06/30/16 on letter dated 06/25/14. Review of the form titled Credentialing Process Form revealed all Sections with signatures dated 05/14/14 through 06/25/14.
APN #2 - privilege expiration date of 07/31/16 on letter dated 07/20/14. Review of the form titled Credentialing Process Form revealed all Sections signed with signatures dated 04/08/14 through 07/30/14.
The findings in D were verified by the Executive Assistant in an interview at 0950 on 08/18/16.
E. During an interview with the CEO at 0955 on 08/18/16 he stated Physician #4 was not appropriate for this Facility, PA #1 and CRNA #1 are not here and should not be on the active provider list. The CEO stated Physician #2's privileges should have been signed by the Cardiopulmonary Medical Director or the Chief Of Staff, not by the emergency room Director. The CEO also stated that all credentialing and privileging forms should have been signed at MEC meetings.
VIOLATION: ORGANIZATION OF MEDICAL STAFF Tag No: A0356
Based on interviews and review of surgical privileges, it was determined the Facility failed to ensure two of two (Cath Lab and Operating Room) Surgical Departments had access to surgical procedures each surgeon was approved to perform. The failed practice did not allow surgical staff to access therefor enforce that only the procedures approved by the Medical Staff Department, the Medical Executive Committee and the Governing Body were performed. Failure to ensure surgical staff had access to approved surgical procedures had the potential to allow unprivileged providers to perform procedures they were not credentialed to perform. Findings follow:
A. During an interview with the Cath Laboratory Nurse Manager at 1515 on 08/17/16 he stated he has not been given a roster of surgeon privileges or procedures physicians were credentialed and approved to perform despite numerous requests.
B. During an interview with the Scheduler at 1525 on 08/17/16 she stated she did not have a list of privileges or procedures physicians were credentialed and approved to perform.
C. During an interview with the Operating Room (OR) Scheduler at 1540 on 08/17/16 she stated she did not have a list of privileges or procedures physicians were credentialed and approved to perform.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, clinical record review and interviews, it was determined there was no evidence a history and physical was performed for 5 (#24, #25, #29-31) of 13 (#21-33) patients and 1 (#22) of 13 (#21-33) patient's history and physical was not performed within 24 hours of admission. The failed practice did not allow other practitioners to be knowledgeable of the patient's past and current medical and surgical problems. The failed practice affected Patients #22, #24, #25 and #29-31 on 08/22/16. Findings follow:

A. Review of the Transitions Policy and Procedure, Policy 10, titled, "History and Physical" received from the Transitions Nurse Manager at 1045 on 08/22/16 revealed the following under Policy: 1. A complete history and physical must be completed within twenty-four (24) hours of the patient's admission...".

B. Review of Patient #22's clinical record revealed an admission date of [DATE] and revealed the history and physical performed and dated 05/25/16.

C. Review of Patient #24's clinical record revealed no evidence of a history and physical. The findings were confirmed by Clinical Analyst at 1402 on 08/22/16.

D. Review of Patient #25's clinical record revealed no evidence of a history and physical. The findings were confirmed by the Chief Nursing Officer (CNO) and the Quality Risk Manager at 1045 on 08/22/16.

E. Review of Patient #29's clinical record revealed no evidence of a history and physical. The findings were confirmed by the Clinical Analyst at 1010 on 08/22/16.

F. Review of Patient #30's clinical record revealed no evidence of a history and physical. The findings were confirmed by the Clinical Analyst at 1030 on 08/22/16.

G. Review of Patient #31's clinical record revealed no evidence of a history and physical. The findings were confirmed by the Clinical Analyst at 1305 on 08/22/16.

H. During an interview with the Transitions Nurse Manager at 1010 on 08/19/16 she stated Transitions patients come to the emergency room for medical clearance, then a medical history and physical is performed by a Hospitalist.

G. During a group interview at 1310 on 08/22/16, the Clinical Analyst and the Quality Risk Manager stated all Transitions patients should have a medical history and physical in addition to the psychiatric evaluation.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and interview, it was determined the nursing staff failed to follow physician's orders for dressing changes for three of three (#22, #28 and #30) patients reviewed with orders for dressing changes. The failed practice did not promote the healing of the patient's wounds and had the potential to affect all patients on which dressing changes were ordered. The findings follow:

A. Review of Patient #22's clinical record on 08/22/16 revealed the following:
1) Physician's order dated 05/22/16 at 0830 revealed to apply Hydrogel dressing to the reddened area on the patient's left buttock and to change the dressing every three days and as needed for soiling or dislodgment.
2) There was no evidence the dressing was applied or changed as ordered.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 08/22/16 at 1305.

B. Review of Patient #28's clinical record on 08/22/16 revealed the following:
1) Physician's order dated 07/26/16 at 1615 revealed to apply Telfa to left heel blister and wrap with Kerlix and secure with tape and to change every day and as needed.
2) There was no evidence the dressing was applied or changed as ordered except on 07/28/16 at 0507.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 08/22/16 at 1335.

C. Review of Patient #30's clinical record on 08/22/16 revealed the following:
1) Patient #30 was admitted to the facility on [DATE].
2) The Transitions Body Audit Tool, identified as the admission audit by the Clinical Analyst on 08/22/16 at 1040, revealed the patient had a sacral ulcer and a right buttock wound that was not staged.
3) Nursing Note dated 08/13/16 at 0825 revealed the patient had a Stage II pressure ulcer with a referral to the physician.
4) Nursing Note dated 08/14/16 at 2225 revealed the dressing was changed to the Stage II on bottom related to diarrhea episode.
4) Physician's order dated 08/15/16 at 0342 revealed to cleanse the patient's buttock wound with Saline and to apply a wet-to-dry dressing twice daily and cover with 4 x 4 gauze and tape.
5) Physician's order dated 08/17/16 at 0440 revealed to discontinue the wet-to-dry dressings to the decubiti on the buttocks and to apply Mepilex Border to buttocks twice daily.
6) Physician's order dated 08/17/16 at 1130 revealed to apply Santil to the wounds as needed.
7) There was no evidence of treatment to the patient's Stage II skin breakdown until 08/14/16 at 2225. There was no evidence the physician's orders were followed for 08/15/16 and the dressing was only changed once on 08/16/16.
8) The patient was discharged on [DATE].
9) The findings were confirmed in an interview with the Clinical Analyst on 08/22/16 at 1040.




Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to implement the Pressure Ulcer Treatment Set for three (#22, #25 and #28) of four (#22, #25, #28 and #31) patients identified as having a Stage I skin breakdown. The failed practice did not promote the reduction in the risk of the skin breakdown becoming worse. The failed practice had the potential to affect all patients with a Stage I breakdown and who are at high risk of skin breakdown. The findings follow:

A. Review of the "Skin Care Policy: Management, Treatment, and Prevention of Decubitus Ulcers" on 08/22/16 revealed the following:
1) "All patients will be assessed for skin integrity on admission and every shift. Transitions patients will have body audit documentation using the body audit upon admission, discharge and transfer in or out of the Unit. In addition, Transitions patients will have weekly body audit documentation using the body audit form. Preventive measures will be instituted on patients with a risk factor of greater than 14. Alterations in skin integrity will be treated according to NMMC's (North Metro Medical Center's) Pressure Ulcer Treatment Order Set or specific physicians orders. Alterations in skin integrity will be documented in the skin assessment plan of care."
2) "Upon initiation of NMMC's Pressure Ulcer Treatment Set for patients with Stage I decubitus or greater, orders will be followed by all nursing staff caring for that patient."

B. Review of the "Skin Protocol Stage I" orders on 08/22/16 revealed the following:
1) "Heel and elbow pads if indicated. Turn every 2 hrs (hours). Lotion bony prominences every shift, document on MAR (Medication Administration Record). Thin duoderm to reddened areas. Change every 3-5 days or PRN (as needed)."
2) "Up in chair if indicated not more than 1 hour, ambulate/exercise as able."
3) "Force fluid 240 cc (cubic centimeters) every 2 hours unless fluid restriction. I&O (Intake and Output) every 8 hours."
4) "Incontinent care products PRN."

C. Review of Patient #22's clinical record on 08/22/16 revealed the following:
1) Physician's order dated 05/22/16 at 0830 revealed, "Apply Hydrogel drsg (dressing) to reddened area L (left) buttock. Change Q3d (every three days) and PRN." In an interview with the Chief Nursing Officer on 08/22/16 at 1305, he confirmed the order was for a Stage I skin breakdown.
2) There was no evidence the Skin Protocol Stage I order set was initiated.
3) The findings were confirmed in an interview with the Chief Nursing Officer on 08/22/16 at 1305.

D. Review of Patient #25's clinical record on 08/22/16 revealed the following:
1) Transitions Body Audit performed on admitted d 06/04/16 revealed the buttocks area of the picture was circled and labeled as "Red". In an interview with the Transitions Nurse Manager on 08/22/16 at 1025, she confirmed that area indicated the patient had a Stage I skin breakdown.
2) There was no evidence the Skin Protocol Stage I order set was initiated.
3) The findings were confirmed in an interview with the Transitions Nurse Manager on 08/22/16 at 1025.

E. Review of Patient #28's clinical record on 08/22/16 revealed the following:
1) Transitions Body Audit performed on admitted d 07/20/16 revealed the sacral area of the picture was labeled as "excoriated and red". In an interview with the Clinical Analyst and the Quality/Risk Manager on 08/22/16 at 1520, they confirmed that area indicated the patient had a Stage I skin breakdown.
2) There was no evidence the Skin Protocol Stage I order set was initiated.
3) The findings were confirmed in an interview with the Clinical Analyst and the Quality/Risk Manager on 08/22/16 at 1520.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, policy and procedure review and interview, it was determined the Facility failed to have a procedure in place for the disposal of medications that were prepared for administration but were not given to two of two (#34 and #35) patients in that cups of opened oral medications were sitting in the patient's medication drawers. The failed practice did not ensure Patient #34 and #35 received the medications that were prescribed and had the potential to affect all patients admitted to the Facility. The findings follow:

A. Observation on 08/18/16 at 1545 revealed Patient #34 and #35's medication drawers contained a medication cup with opened oral medications in the drawer. The medications were out of their packaging and it could not be determined what the medications were. The findings were confirmed in an interview with the Quality/Risk Director on 08/18/16 at 1545.

B. In an interview with Registered Nurse #1 on 08/18/16 at 1545, when asked what the medications were in the medication cup, she stated they were medications she had attempted to administer to the patient, but the patient was asleep. When asked what she was going to do with the medications, Registered Nurse #1 stated she was going to give the medications to the patient when she woke up.

C. Review of the policy "Administration of Medication" on 08/18/16 revealed, "Procedure: C. Obtain, draw up or pour correct dose following the three checks. 1. Check when getting med (medication) out of drawer or narc (narcotic) cabinet. 2. Check when selecting or preparing to pour/draw up. 3. Check before discarding packet or placing container back in storage. G. If meds are not given for any reason; initial and circle on MAR (Medication Administration Record) and document in Nurses Notes the reason why."

D. In an interview with the Quality/Risk Director on 08/19/16 at 0900, she confirmed the policy was not clear as to what to do with the medications if not given and not clear if the oral medication packets are to be opened at the patient's bedside.