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.

HARMON HOSPITAL 2170 EAST HARMON AVENUE LAS VEGAS, NV 89119 April 11, 2012
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
Based on interview and document review, the facility failed to ensure discharge planning by a contracted agency was appropriately documented and supervised.

Findings include:

On 04/04/2012 at 4:20 PM, the Administrator, stated the facility contracted with case managers from private insurance plans to perform discharge planning for most of the patients. She stated in the event that patients did not belong to a private insurance plan, the Director of Patient Care coordinated discharges.

On 04/04/2012 at 4:30 PM, the Director of Patient Care stated she did not perform discharge planning, but referred planning to social services.

Employee #5, a Licensed Social Worker, stated she was involved in discharge planning for patients of higher acuity or problems with Power of Attorney issues.

On 04/04/2012, the Chief Nursing Officer (CNO) stated the contracted case managers took "the lead in the process". The CNO explained if any other discharge planning was required the Registered Nurse discharging the patient would address the issue.

On 04/05/2012 at 11:35 AM, the administrator stated while interdisciplinary facility staff did rounds with the contracted case managers to coordinate discharge planning, the rounds were not always documented.

On 04/05/2012, the document titled "Case Management Policies and Procedures" (1/2009), was reviewed. The document indicated, "Case Management Staff will in a timely manner, coordinate and participate in the development of an interdisciplinary discharge plan for patients to an appropriate level of care".

On 04/05/2012, the document titled "Case Management Documentation Timeframes and Guidelines", documented the purpose for the procedure was to "ensure standardized Case Management documentation".
VIOLATION: DIRECTOR OF REHABILITATION SERVICES Tag No: A1125
Based on interview and document review, the facility failed to ensure the Director of Rehabilitation Services was qualified according to the job description.

Findings include:

On 04/04/2012, it was determined the Director of Rehabilitation Services, was a Physical Therapist Assistant.

On 04/05/2012, the job description "Rehabilitation Director" was reviewed. The "Required Credentials" listed were "Licensed in the state as a therapist" and "Two (2) years of experience as a therapist".

On 04/05/2012, at 9:48 AM, the Administrator, reviewed the Rehabilitation Director job description and stated the Director of Rehabilitation Services was not qualified to be the Director of Rehabilitation.
VIOLATION: DELIVERY OF SERVICES Tag No: A1132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and document review, the facility failed to provide therapy services as ordered by the physician for 4 of 40 patients reviewed (Patient #19, #20, #21 and #22).

Findings include:

Patient #2

Patient #2 was admitted to the facility on [DATE] with diagnoses that included [DIAGNOSES REDACTED]

On 04/04/2012, Patient #2's clinical record was reviewed. On 02/20/2012, "2-5" Occupational Therapy sessions per week were ordered. The Service Log Matrix for Patient #2's OT sessions indicated that she was seen on 02/20/2012, 02/23/2012, 02/27/2012, 03/06/2012, 03/07/2012, 03/12/12, 03/25/2012, and 03/28/2012.

On 04/05/2012 at 9:27 AM, the Director of Rehabilitation Services reviewed Patient #2's documentation and acknowledged the patient was "missing a few visits".

Patient #19

Patient #19 was admitted on [DATE] with diagnoses including anemia, colon cancer, status post pacemaker, hypertension, [DIAGNOSES REDACTED] and history of [DIAGNOSES REDACTED].

On 3/20/12, the physician ordered the physical therapist (PT) and occupational therapist (OT) to evaluate and treat.

The initial Occupational evaluation was completed on 3/21/12 and recommended therapy two to three times a week.

The occupational therapy flow sheet documented the patient received therapy on 3/27/12 and 4/2/12.

Patient #20

Patient #20 was admitted on [DATE] with diagnoses including right femur fracture, dementia, debility, [DIAGNOSES REDACTED] atrial fibrillation, coronary artery disease, hypertension, gastroesophageal reflux disease, glaucoma, osteoarthritis, chronic pain, [DIAGNOSES REDACTED], degenerative joint disease and dyslipidemia.

On 3/24/12, the physician ordered the PT and OT to evaluate and treat.

The initial Occupational evaluation was completed on 3/28/12 and recommended therapy two to five times a week.

There was no documented evidence the patient had occupational therapy after the initial evaluation was completed.

Patient #21

Patient #21 was admitted on [DATE] with diagnoses including multiple thoracic spine fractures secondary to motor vehicle accident, extensive fractures secondary to motor vehicle accident, deep vein thrombosis and traumatic brain injury.

On 3/17/12, the physician ordered PT do be done daily.

The physical therapy flow sheet documented the patient received therapy on 3/19/12, 3/20/12, 3/21/12, 3/22/12 and 3/23/12. There was no documented evidence found in the patient record the patient received PT services after 3/23/12.

Patient #22

Patient #22 was admitted on [DATE] with diagnoses including coronary artery disease, chronic obstructive pulmonary disease, hypertension, anxiety, depression, Parkinson, gastroesophageal reflux disease, asthma, panic disorder and history of right lower extremity deep vein thrombosis.

On 3/29/12, the physician ordered the PT and OT to evaluate and treat.

The initial Occupational evaluation was completed on 3/30/12 and recommended therapy two to five times a week.

There was no documented evidence the patient had occupational therapy after the initial evaluation was completed.

On 4/4/12 at 3:00 PM, the Director of Rehabilitation explained patient's can receive therapy seven days a week, but typically the order for therapy was five days a week. The Director of Rehabilitation explained there were no patients currently receiving daily physical therapy.

The Director of Rehabilitation stated the occupational therapist was expected to write the specific amount of visits per week for each patient and not a range of visits.

Evaluation - Therapy Specific Policy (no policy number), revised 8/20/11, documented: "Policy: A therapy evaluation will be performed and documented for all patient's/resident's with written therapy orders. The evaluation is to be completed within 48 hours of receipt of the order within the normal scheduled hour of the Rehab (rehabilitation) Department..."

Intensity and Duration Policy (no policy number), revised 8/20/11, documented: "...Procedures: 1. Intensity vs. Duration: Intensity refers to the amount of therapy a patient/resident receives, i.e., the length of the session and the number of treatments received per week. Daily therapy is considered to be intense treatment; two to three sessions per week are a less intensive regimen..."





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VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, and document review, the facility failed to provide an accurate and complete nursing care plan for 11 of 40 sampled patients (Patient #9, #12, #13, #14, #15, #13, #17, #21, #24, #33, and #35).

Findings include:

Patient #9

Patient #9 was admitted [DATE] with a diagnosis including a fracture and a past medical history of [DIAGNOSES REDACTED]

1) There was no Plan of Care identified for ongoing use of restraints and specific fall precautions.

The Care Plan indicated, -"Problem: Confused, climbing out of bed when patient has 'no weight bearing';
-Problem: Patient requires restraint use d/t (due to) potential or actual disruption of medical care: Bilateral;
-Problem: Altered Mobility Re (regarding) restraint use re pulling out medical equipment lines essential to patient care; interventions: Alternatives will be attempted before restraints are used: Low bed."

The Daily Patient Care Records indicated Patient #9 was restrained with bilateral wrist restraints ongoing for the period of 3/27/12 through 4/4/12.

There was no documented evidence of additional interventions identified after the 3/27/12 care plan entry. The Physical Restraint Assessments indicated Patient #9 was restrained with bilateral wrist restraints for pulling out IV lines and trying to get out of bed without assistance. The Care Plan failed to identify that the IV lines were discontinued on 4/2/12.

2) Review of the clinical record revealed Patient #9 was on contact isolation due to Methycillin Resistant Staphyloccocus Aureus (MRSA) in the nares. There was no Plan of Care for the contact isolation precautions.

Patient #15

Patient #15 was admitted [DATE] with a diagnosis of [DIAGNOSES REDACTED]

The 4/2/12 Patient Care Notes in the Daily Patient Care Record indicated at 0300 (3:00 AM) Patient #15 was found on the floor at the bedside.

The 4/4/12 Patient Care Notes in the Daily Patient Care Record indicated, "Pt found on floor next to bed L side - stated he was going to BR (bathroom)..."

The clinical record was reviewed with the CNO on 4/4/12 at approximately 10:00 AM. The CNO verified there was no documented evidence in the Patient Care Notes that the TAB Alarm was in place on 4/4/12. In response to the question, "Is there supposed to be a Care Plan with additional measures in the patient's chart following an actual fall?" the CNO indicated, "Yes, the primary nurse is the one who is responsible to transfer the fall issue to the Care Plan after an actual fall."

The Interdisciplinary Plan of Care dated 4/1/12 indicated "High Risk of Fall: Follow Standards of Care for Fall Precautions."

There was no documentation on the Plan of Care listing additional or specific measures to protect the resident from further falls following the 4/2/12 and 4/4/12 fall incidents.

Patient #12

Patient #12 was admitted [DATE] with a diagnosis of [DIAGNOSES REDACTED]

The Daily Patient Care Notes for 3/25/12 and 3/26/12 indicated contact isolation precautions. There was no Plan of Care identified for isolation precautions due to[DIAGNOSES REDACTED].

Patient #37

Patient #37 was admitted [DATE] with a diagnosis of [DIAGNOSES REDACTED]

The Daily Patient Care Notes indicated Patient #27 was on isolation precautions for MRSA in the nares and[DIAGNOSES REDACTED] off and on for the period of 1/31/12 through 4/10/12.

There was no documented evidence of a Plan of Care identified for isolation precautions for c-dif and MRSA of the nares.

Patient #14

Patient #14 was admitted [DATE] with diagnoses including multiple syncopal episode with multiple falls, T11 compression fracture, anemia of chronic disease, history of alcohol abuse, multiple skin bruising and superficial lacerations on bilateral upper extremities, history of Sjore[DIAGNOSES REDACTED], [DIAGNOSES REDACTED], fatty liver, debility, and hyponatremia, resolved, likely from alcohol use. The History and Physical Examination dated 3/24/12 indicated, "...past medical history of [DIAGNOSES REDACTED]"

1) The Daily Patient Care Notes indicated Patient #14 was found on the floor on 3/24/12 and 3/25/12.

The Interdisciplinary Plan of Care dated 3/23/12 included: "Patient Problem: High risk of fall", but did not include any interventions.

There was no documentation on the Plan of Care listing additional or specific measures to protect the resident from further falls following the 3/24/12 and 3/25/12 incidents.

2) Physician's Orders dated 4/4/12 indicated, "+ (positive) stool for[DIAGNOSES REDACTED] toxin without diarrhea over last 5 days. To be conservative will tx (treat) for 10-14 days".

The Daily Patient Care Record indicated isolation precautions for[DIAGNOSES REDACTED] off and on for the period of 3/27/12 through 4/1/12.

There was no documented evidence of a Plan of Care identifying isolation precautions for[DIAGNOSES REDACTED].

Patient #35

Patient #35 was admitted [DATE] with diagnoses including history of hypertension, stroke, asthma, infrarenal abdominal aneurysm repair, and an assessment of acute renal failure on chronic kidney disease, anemia, and infraabdominal aortic aneurysm repair.

The Daily Patient Care Records indicated isolation precautions for[DIAGNOSES REDACTED] off and on for the period of 3/20/12 through 4/4/12.

There was no documented evidence of a Plan of Care identifying isolation precautions for[DIAGNOSES REDACTED].

Patient #13

Patient #13 was admitted [DATE] with diagnoses including anterior chest wall pain secondary to multiple rib fractures, bilateral pneumonitis, hypoxemia with respiratory effort acidosis, hypercapnia, acute respiratory insufficiency, history of deep vein thrombosis to the right side with IVC (Intravenous Catheter) in place.

The Daily Patient Care Notes indicated isolation precautions for[DIAGNOSES REDACTED] and KLEB in the urine off and on for the period of 2/13/12 through 4/3/12.

There was no documented evidence of a Plan of Care identifying isolation precautions for[DIAGNOSES REDACTED].

The Care Plan Policy (No effective date, Approved by the Governing Body 9/15/11) indicated the following:
"Purpose: To identify the Nurse's responsibility in the patient care planning process.
Policy: The Nursing Care Plan created for the patient is a tangible product of a dynamic, ongoing process. This Nursing process is a pattern of investigation, assessment, observations, and critical thinking, which forms the basis for the formulation of the Plan of Care. The Registered Nurse (RN) will develop an individualized Plan of Care based on the patient's medical, emotional, age-specific, spiritual, and cultural needs.
Procedure:
1. The Nursing care for each individual patient is planned and coordinated by a Registered Nurse (RN).
2. Nursing care is based on identified Nursing diagnoses and/or patient care needs and patient care standards...
...4. A standardized Nursing Care Plan is used to individualize care based on the patient's care needs.
5. For complex medical patients, a Care Plan may be independently developed based on the clinical goals of treatment.
6. Nursing Staff members collaborate with physicians and other clinical disciplines when making decisions regarding each patient's need for nursing care.
7. The Nursing Care Plan is initiated within 24 hours of the patient's admission and updated on a daily basis...

The Policy and Procedure ("Restraints", revised 12/16/2008) indicated as follows:

"...2....The restraint order will not be written as a standing order or as needed order. It will be in accordance with an immediate written modification to the care plan, i.e. (such as) it will be used only in an exception, in response to a plan of care that was modified after the use of normal care procedures failed; and all direct care staff will have ongoing education and training in the proper and safe use of restraints...





Patient #17

Patient #17 was admitted on [DATE] with diagnoses including hypokalemia, [DIAGNOSES REDACTED] and chronic debility with frequent falls.

The history and physical, dated 4/1/12 indicated the patient had debility status post secondary to subsequent falls secondary to functional decline.

There was no documented evidence on the patient care plan; dated 1/31/12 the patient was at risk for falls.

Patient #21

Patient #21 was admitted on [DATE] with diagnoses including multiple thoracic spine fractures secondary to motor vehicle accident, extensive fractures secondary to motor vehicle accident, deep vein thrombosis and traumatic brain injury.

There was no documented evidence on the patient care plan; dated 3/6/12 the patient was placed in isolation for clostridium difficile (C-diff) on 3/25/12.

Patient #24

Patient #24 was admitted on [DATE] with diagnoses including acute renal injury secondary to vancomycin, left ankle osteo[DIAGNOSES REDACTED], history of Charcot foot, coronary artery disease, hypertension and history of [DIAGNOSES REDACTED].

There was no documented evidence on the patient care plan; dated 3/10/12 the patient was placed in isolation for clostridium difficile (C-diff) on 3/31/12.

Patient #33

Patient #33 was admitted on [DATE] with diagnoses including right lower lobe pneumonia, dementia and chronic right foot swelling.

There was no documented evidence on the patient care plan; dated 1/31/12 the patient was placed in isolation for[DIAGNOSES REDACTED] on 3/24/12.

Care Plan Policy 05-1012 approved 9/15/2011 documented:

"...Procedure: 2. Nursing care is based on identified Nursing diagnoses and/or patient care needs and patient care standards"

"...7. The Nursing Care Plan is initiated within 24 hours of the patient's admission and updated on a daily basis..."

"...9. The Nurse evaluates the effectiveness of nursing actions and revises the Plan as the needs of the patients are met or changed..."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview and document review the infection control officer failed to develop and implement a system for maintaining a sanitary environment to minimize the spread of pathogenic organisms.

Findings include:

On 04/03/12 at 9:00 AM a tour of the 400 and 500 halls were conducted. The following observations were made:
1. In room 403: Contact Isolation Room: There was an accumulation of trash on the floor which included used tape. A contaminated bloody gauze pad was lying on the patient's bedside table. The patients Foley catheter bag was lying on the floor by the patient's bed. The floor was dusty and dirty with brown grime stains located by the patients bed.
2. In room 515, the wall behind the patient's bed had extensive gouging marks and holes in the dry wall. Plaster from the drywall was peeling and falling onto the floor. The trash can in the bathroom was overflowing with trash. Urine stains were observed on the toilet seat in the bathroom.
3. In room 518, there was an accumulation of trash on the floor of the room which included discarded medication cups, thermometer probes, tissue, used straws and trash. A partially smoked cigarette was located lying on a nightstand table. The trash can in the bathroom was overflowing with trash.
4. In room 519, red stains were located on the bathroom floor by the toilet. Urine stains were located on the rim of the toilet bowl. Trash was overflowing from the bathroom trash can. The floor in the bathroom was covered with black grime.
5. In room 521, the bathroom trash can was overflowing. The bedside commode had urine inside. There was a strong odor of urine coming from the bedside commode. The floor in the patient's room was covered in brown grime. The patient reported being in the hospital for 4 days and only seeing a housekeeper mop the floor once.
On 4/4/12 at 8:30 AM, Registered Nurse (RN) #1 (600 hall) explained a disposable stethoscope was to be used for each patient on isolation precautions.

On 4/4/12 at 8:40 AM, Certified Nursing Assistant (CNA) #1 (600 hall) explained Super Sani Clot was to be used to clean the blood pressure machine between patients in isolation precautions for C-diff. The CNA explained a disposable stethoscope was to be used for each patient. The CNA was unable to produce a disposable stethoscope for the patients in Room 629 identified with C-diff.

On 4/4/12 at 8:55 AM, the Charge RN for the 600 hall acknowledged a red stethoscope was to be used on all patients in isolation. The Charge RN explained the blood pressure machine should be cleaned with the Super Sani Cloth wipes between patients in isolation for C-diff.

On 4/4/12 at 9:20 AM, RN #2 (500 hall) explained the blood pressure machine was to be cleaned with Super Sani Cloth wipes between patients in isolation for C-diff.

On 4/4/12 at 9:25 AM, there were three rooms identified with patients diagnosed with C-diff. There were no disposable stethoscopes observed in Room 518, Room 517 and Room 520.

On 4/4/12 at 9:30 AM, a manager in training for housekeeping was observed exiting a patient room identified with C-diff. The manager in training for housekeeping stated Clorox wipes were to be used for cleaning surfaces in patient rooms with C-diff. The manager in training for housekeeping had only Super Sani Cloth wipes on the housekeeping cart.

On 4/11/12 at 7:45 AM, a tour of the 600 Hall revealed two patients in contact isolation (Room 625 and 628). There were no red stethoscopes identified in either isolation room.

On 4/11/12 at 9:10 AM, Licensed Practical Nurse (LPN) #6 (on the 600 hall) explained kill time was the length of time from when a surface was cleaned to when the surface was non-contaminated. The LPN was not aware of the kill time for Clorox wipes or Super Sani Cloth wipes.

On 4/11/12 at 9:35 AM, Registered Nurse (RN) #4 described kill time as the time after wiping a surface needed to wait for the surface to dry. The RN stated the kill time for Clorox wipes was five minutes.

On 4/11/12 at 10:05 AM, LPN #5 (on the 600 hall) described kill time as the time it takes for the area to dry. The LPN was unable to identify the specific kill time for Clorox or Super Sani Wipes.

On 4/11/12 at 10:25 AM, Certified nursing assistant (CNA) #5 (on 600 hall) described kill time as how many minutes to disinfect, wipe the area and let it air dry. The CNA was unable to identify the specific kill time for Clorox or Super Sani Wipes.

On 04/11/12 at 1:30 PM the Housekeeping Manager acknowledged the facility did not track or trend patient complaints regarding patient rooms and bathrooms not being cleaned properly. The Housekeeping Manager reported he had not received any patient grievances or complaints from the hospital administration regarding patient rooms and bathrooms not being clean and sanitary. The Housekeeping Manager reported the facility staffed only one housekeeper to perform housekeeping tasks and clean patient rooms and bathrooms in the hospital daily from 10:00 PM to 6:00 AM.
On 04/11/12 at 1:30 PM the Infection Control Coordinator acknowledged the cleanliness and sanitation of patient rooms and bathrooms were rarely included in infection control environmental rounds at the facility. The Infection Control Coordinator reported environmental rounds conducted by the infection control staff were not documented and no environmental round reports for the year 2011 or 2012 could be provided to surveyors for review. The Infection Control Coordinator reported complaints regarding unsanitary environment were not documented, tracked or trended by the facility.
On 04/11/12 at 4:10 PM the Director of Quality and Compliance acknowledged environmental rounds were not being conducted on a consistent basis by infection control staff. The Director of Quality and Compliance had not received any completed infection control surveillance reports or environmental round reports since taking over the position of Director of Quality in January of 2012.
A review of the facility's undated Daily Patient Room Cleaning Policy included the following:
Follow the 5-step room cleaning method.
1. Empty trash out of all rooms first thing. Wipe basket-if necessary replace liner.
2. Horizontal dusting with a cloth and disinfectant wipe all horizontal surfaces.
3. Spot clean with a cloth and disinfectant spot clean all vertical surfaces.
4. Dust mop floor. Use a dust mop to gather all trash and debris on floor. Sweep to the door; pick up with a dust pan.
5. Damp mop floor with germicide solution. Damp mop floor working from back corner to door.
Additional information:
Check sharps container and empty when full.
Infection control is the goal of an effective room cleaning technique.





On 4/11/12 at approximately 7:30 AM, there was a sign which indicated contact isolation precautions on the door of Room #333. The dialysis technician (from an outside agency) was observed. Upon leaving the room, the technician removed his gloves and gown, picked up the patient's chart, and walked to the nursing station. The technician did not wash his hands. Shortly afterwards the technician went back into the patient's room, at which time he did not don a gown and gloves. The technician remained in the room for a few minutes, came out of the room, and applied foam sanitizer to his hands and went back to the nursing station without washing his hands.

At approximately 7:50 AM the technician was interviewed. The technician indicated he did not know the reason for the patient's isolation precautions. He acknowledged he did not put on a gown and gloves upon returning to the room.

On 4/11/12 in the morning, licensed nurses on the 300 Hall and the 400 Hall were interviewed regarding the "kill time" for the Clorox wipes. A Charge Nurse on the 300 Hall responded, "3 minutes?" Two nurses in the 400 Hall indicated they did not know how long it takes for the Clorox to disinfect a surface. One nurse on the 300 Hall stated the Clorox wipes were effective as soon as contact was made to the surface.

The facility's policy and procedure "Standards & Transmission Based Precautions Policy, revised 4/3/11" indicated the following:
"Hand Hygiene: a1) Hands must be washed with soap and water or 'alcohol based hand rubs'. 2) following any direct contact with a patient's skin, mucous membranes, body fluids, and any contaminated patient-care items. 3) Wash hands after touching blood body fluids, secretion, excretions and contaminated items, whether or not gloves are worn. 4) Wash hands immediately after gloves are removed, before and after patient/resident contact, and when otherwise indicated to avoid transfer of microorganisms. 5) May be necessary to prevent cross-contamination of different body sites...b1) Wear gloves (clean, non-sterile gloves) when touching blood, body fluids, secretions, excretions, or contaminated items...4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient/resident. 5) Wash hands immediately before applying and after removing gloves..."

The facility's policy and procedure "Prevention and Control of Clostridium Difficile, reviewed and accepted by executive council 1/11/12" indicated the following:
"Purpose: To prevent and control the transmission of Clostridium difficile among hospitalized patients in (facility)...
...C. Disposable blood pressure cuffs, stethoscopes, and thermometers must be assigned to patients on CO and must be discarded when the patient is discharged or contact precautions are removed.
D. Equipment (wheelchairs, gurneys, Dopplers, X-ray jmachines, etc.) used for patients on ECP will be disinfectedc with a 1:10 dilution of sodium hypochlorite prior to use on other patients.

On 4/5/12 at 9:00 AM, the Infection Control Coordinator (ICC) indicated the following:

-"The patient on isolation precautions should have their own blood pressure cuff and scope kept in the room."
-"DME (Durable Medical Equipment) should be cleaned with bleach, not with the super sani wipes."






On 04/11/2012, a tour of unit 100 was conducted. At 8:20 AM, Certified Nurse Assistant (CNA) #4, was observed serving breakfast trays to two patients in room 104. Both patients were noted to be on Enteric Precautions. CNA #4 was noted to appropriately wear Personal Protective Equipment (PPE) while serving the patient in 104 B bed. She then discarded her PPE and used sanitizing foam to cleanse her hands. She donned new PPE and served the patient in 104 A bed his tray.

On 04/11/2012 at 8:30 AM, Registered Nurse #7 stated CNA #4 should have washed her hands after she had served the patient in 104 B bed, and before she served the patient in 104 A bed.

On 04/11/12 at 8:35 AM, the Infection Control Coordinator, was stated that CNA #4 should have washed her hands between serving the two patients.

On 04/11/2012 at 8:40 AM, the Infection Control Coordinator, observed patient room #105. The patient in room #105 was on Enteric Precautions. The Infection Control Coordinator indicated the patient needed a dedicated stethoscope in accordance with facility policy. A dedicated stethoscope could not be found in his room.

Complaint #NV 283
Complaint #NV 352
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and document review, the facility staff failed to administer medications and treatments per the physician order for 7 of 40 patients (Patient #18, #19, #20, #21, #22, #23 and #38) and one unsampled patient (Patient #43).

Findings include:

Patient #18

Patient #18 was admitted on [DATE] with diagnoses including gallstone pancreatitis, hypertension, small right lower lobe pulmonary embolism and prior healthcare-associated pneumonia.

On 3/27/12, a physician order was written to cleanse the coccyx wound with normal saline, pat dry and apply silvasorb once a day by the nursing staff.

There was no documented evidence on the medication administration record (MAR) wound care was provided on 4/1/12 and 4/2/12.

Patient #19

Patient #19 was admitted on [DATE] with diagnoses including anemia, colon cancer, status post pacemaker, hypertension, [DIAGNOSES REDACTED] and history of [DIAGNOSES REDACTED].

On 3/29/12, an order to apply Neosporin ointment to the abdominal wound daily was written.

There was no documented evidence on the MAR wound care was provided on 3/31/12.

Patient #20

Patient #20 was admitted on [DATE] with diagnoses including right femur fracture, dementia, debility, [DIAGNOSES REDACTED] atrial fibrillation, coronary artery disease, hypertension, gastroesophageal reflux disease, glaucoma, osteoarthritis, chronic pain, [DIAGNOSES REDACTED], degenerative joint disease and dyslipidemia.

On 3/28/12, a physician order was written to change the hip dressing once a day by the nursing staff.

There was no documented evidence on the medication administration record (MAR) the hip dressing was changed on 3/29/12, 3/30/12, 3/31/12, 4/1/12 and 4/2/12.

Patient #21

Patient #21 was admitted on [DATE] with diagnoses including multiple thoracic spine fractures secondary to motor vehicle accident, extensive fractures secondary to motor vehicle accident, deep vein thrombosis and traumatic brain injury.

On 4/1/12, the physician wrote an order for Lasix 20 milligrams (mg) to be administered orally for three days. The order was not noted by the Registered Nurse (RN). There was no documented evidence on the MAR the patient received Lasix as ordered.

On 4/3/12 at 2:35 PM, the Director of Pharmacy acknowledged the order for Lasix had not been noted by the RN and the patient had not received the Lasix as ordered.

On 3/16/12, an order to cleanse the right forearm wound with normal saline and apply triple antibiotic ointment daily by the nurse was written.

There was no documented evidence on the MAR the wound care was provided on 4/2/12.

Patient #22

Patient #22 was admitted on [DATE] with diagnoses including coronary artery disease, chronic obstructive pulmonary disease, hypertension, anxiety, depression, Parkinson, gastroesophageal reflux disease, asthma, panic disorder and history of right lower extremity deep vein thrombosis.

On 3/29/12, the physician wrote an order to apply xenaderm to the decubitus daily by nursing staff.

There was no documented evidence on the MAR the xenaderm was applied on 3/30/12, 4/1/12 and 4/2/12.

Patient #23

Patient #23 was admitted on [DATE] with diagnoses including hypertension, diabetes mellitus II, kidney disease Stage III, gastroesophageal reflux disease, diverticulosis colon, history of esophageal stricture and osteoarthritis.

On 4/1/12, the physician wrote an order to cleanse the abdominal incision site with normal saline, pat dry, apply calcium alginate and cover with a clean dry dressing once a day by nursing.

There was no documented evidence on the MAR wound care was provided on 4/2/12 and 4/3/12.

On 4/5/12 at 12:20 PM, the Wound Care Licensed Practical Nurse (LPN) acknowledged she was aware the nurses were not routinely providing wound care.

On 4/4/12 at 8:15 AM, observation of the medication pass for the patient in Room 519B was initiated. It was observed there was no identification on the intravenous (IV) fluid identifying the patient, the date the fluid was hung or the rate the fluid was to be administered. The IV tubing had not been labeled with the date and time the tubing needed to be changed.

On 4/4/12 at 8:30 AM, Registered Nurse (RN) #3 acknowledged the intravenous fluid did not have a patient label and the tubing had not been labeled. The RN explained the intravenous fluid label should have been retrieved from the Pxysis (automated medication dispenser) and taped to the intravenous fluid. The RN acknowledged the intravenous tubing should have been labeled with a green sticker identifying when the tubing was opened and when the tubing needed to be changed.

On 4/11/12 at 7:55 AM, five separate intravenous medication tubing were noted to be unlabeled for with the date and time the tubing needed to be changed for Patient #43 (an unsampled patient). Three 250 milliliter (ml) bags of Vancomycin, one empty bag of blood and one 250 ml bag of 0.9% sodium chloride (NaCl). The 0.9% NaCl was not labeled with the patient's name.

The three bags of fluid identified with Vancomycin did not have the date or time the medication was hung for administration. One bag of Vancomycin was dated by pharmacy for 4/8/12, 4/9/12 and 4/10/12. The bags of Vancomycin dated 4/8/12 and 4/9/12 were observed to have fluid remaining in the bags.

On 4/11/12 at 8:00 AM, the Chief Nursing Officer (CNO) and Licensed Practical Nurse (LPN) #5 acknowledged the medication tubing were not labeled with the date and time and the NaCl was not labeled with the patient's name.

On 4/11/12 at 8:10 AM, the CNO measured the amount of fluid in the Vancomycin bags dated 4/8/12 and 4/9/12. The pharmacy had documented there was a total of 256.25 ml of fluid when initially prepared. There was 45 ml of fluid remaining in the bag dated 4/8/12 and 90 ml of fluid remaining in the bag dated 4/9/12.

On 4/11/12 at 8:30 AM, 1000 ml of 0.9% NaCl was observed being administered to Patient #19. There was no identification on the intravenous fluid identifying the patient, the date the fluid was hung or the rate the fluid was to be administered. The IV tubing was not labeled with the date and time the tubing needed to be changed.

On 4/4/12 at 11:00 AM, LPN #3 explained if an IV was not identified and the tubing was not labeled, the IV would be discarded and a new IV administered.

On 4/4/12 at 11:25 AM, LPN #4 acknowledged when an IV bag was hanging and not tagged or marked with the patient name or date hung, the IV bag should be discarded.

On 4/4/12 at 2:35 PM, LPN #5 explained if an IV bag was hanging and not tagged with the patient name or date hung, the entire IV set up and tubing would be required to be changed. The LPN explained all the IV bags are to be labeled. The label comes from the Pxysis.




Patient #38

Patient #38 was admitted to the facility on [DATE], with diagnoses including hypertension, chronic kidney disease, congestive heart failure, and osteoarthritis.

On 04/06/2012, Patient #38's physician ordered the medication Norco, 5/325 milligrams, to be given by mouth every four hours, as needed for pain. She was to receive one tablet for a pain score of one to five, or two tablets for a pain score of six to ten. Patient #38's Nurse's Medication Notes, dated 04/07/2012, indicated Patient #38 received one tablet of the medication for a complaint of head pain, with a pain score of eight of ten.

On 04/11/2012, the Director of Pharmacy stated documentation from the Pyxis indicated two tablets were withdrawn. She stated documentation from the Pyxis should have indicated one tablet was required to be docvumented as wasted.

Nursing Medication Administration Policy 05-Clincial Services reviewed 9/14/11 documented: "...Policy: ...18. IV tubing will be changed every (7) days and "flagged" with the date, time and initials of the nurse..."
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and staff interview, the facility failed to ensure that the overall physical environment of the hospital was maintained in a manner supporting the safety and well being of all patients. The facility was missing one of six required nurse call annunciator panels.

Findings include:

Patients requiring immediate medical attention in Hall 500, could only be identified by a visible signal at the patient's door, possibly resulting in delayed care affecting their safety and well-being. A door to a patient room was noted to be blocked.

On 4/5/12 during a tour of the facility, it was observed there was no audible nurse call annunciator panel at the nurses station in Hall 500. The visual call light system wa the only indicator patients required assistance from the nursing staff.

On 4/5/12, the Maintenance Supervisor indicated the annunciator was no longer in service, and both repair and replacement options were not possibilities due to the age of the damaged unit.

On 04/11/2012 at 10:20 AM, Employee #33, a housekeeper, was observed to place a biohazard container in front of the opened door of patient room #214.

Employee #34, a Registered Nurse, was interviewed on 04/11/2012 at 10:30 AM. She stated after observing the container in front of the door, that the door should not be blocked.

Complaint #NV 352
VIOLATION: RESPIRATORY SERVICES Tag No: A1164
Based on chart review and interview, respiratory care orders were not documented as required.

Findings include:

Employee #37 confirmed that two out of three respiratory care orders from 2/16/12 through 3/28/12 in Patient #40's chart did not include order times. An order for O2 (oxygen) written on 2/26/12 did not include the order time. An order for Pulmicort and bi-pap written on 2/20/12 did not include the order time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review, and document review, the facility failed to ensure accurate assessments were conducted and the least restrictive, appropriate, and safe restraints were utilized for 1 of 40 sampled patients (Patient #9).

Findings include:

Patient #9

Patient #9 was admitted [DATE] with a diagnosis including a fracture and a past medical history of spinal fracture and impressions including right hip fracture secondary to mechanical fall status post (s/p) pinning of the right femoral neck, and advanced Alzheimer dementia.

On 4/4/12, Patient #9 was sitting in a wheelchair with her eyes closed and her head slumped forward from 10:30 AM until 11:00 AM.

On 4/4/12 at 11:00 AM, Patient #9 was sitting in her room in a wheelchair with bilateral wrist restraints tied to the lower portion of the arms of the chair and wound around the back of the chair. The 400 Hall licensed practical nurse (LPN #6) loosened both wrist restraints at 11:00 AM. The wrist restraints were tight, allowing the patient no more than 4 inches of slack / flexibility from the chair. The patient's right wrist had red marks. The Patient Daily Care Notes for 4/4/12 indicated the most recent time the restraint was checked and removed was at 10:00 AM on 4/4/12.

On 4/4/12 at approximately 11:30 AM, LPN #6 indicated:
-Patient #9 had wrist restraints "because she's confused and keeps getting out of bed and she's a high risk of falls."
-The last time Patient #9 had an IV (intravenous) line was on 4/2/12 at 1:05 PM.
-Sometimes the bed alarm is used..."But I'm not sure why it's not being used right now. We just use the wrist restraints."

The Care Plan indicated, -"Problem: Confused, climbing out of bed when patient has 'no weight bearing';
-Problem: Patient requires restraint use d/t (due to) potential or actual disruption of medical care: Bilateral;
-Problem: Altered Mobility Re (regarding) restraint use re pulling out medical equipment lines essential to patient care; interventions: Alternatives will be attempted before restraints are used: Low bed."

The Physical Restraint Assessments indicated Patient #9 was restrained with bilateral wrist restraints for pulling out IV lines and trying to get out of bed without assistance. The IV lines were discontinued on 4/2/12.

The Daily Patient Care Records indicated Patient #9 was restrained with bilateral wrist restraints ongoing for the period of 3/27/12 through 4/4/12.

The Policy and Procedure ("Restraints", revised 12/16/2008) indicated as follows:

"Restraint: The use of any method physically restricting a person's freedom of movement, physical activity, or normal access to his or her body, as either part of an approved protocol or by physician's orders...STANDARD: 1. Restraint use will be limited to clinically appropriate and adequately justified situations. The patient's rights, dignity, and well-being will be preserved and protected whenever restraints are used. The use of the least restrictive method that meets patient needs will be applied only after alternative methods have been attempted and failed to meet patient needs. Initial assessment, reassessment, and alternatives must be documented as outlined by this policy. The overall goal of restraints is to protect and safeguard patients from injuring themselves or other patients...2....The restraint order will not be written as a standing order or as needed order. It will be in accordance with an immediate written modification to the care plan, i.e. it will be used only in an exception, in response to a plan of care that was modified after the use of normal care procedures failed..."

On 4/4/12 at approximately 12:00 PM, the Chief Nursing Officer (CNO) acknowledged the bilateral wrist restraints were being used for prevention of a patient getting out of bed. The CNO indicated, "That's wrong. Wrist restraints should not be used for preventing a patient from getting out of bed or out of the wheelchair."

On 4/4/12 at 5:00 PM, the Director of Education indicated it was not acceptable for a patient to be restrained with bilateral wrist restraints for the purpose of preventing the patient from getting out of bed or out of a wheelchair. The Director of Education indicated the nurses had to use judgement, but should use the bed alarms and low beds first. The Director of Education verified there was no specific information or documentation in the restraint training materials whether a patient should be tied to the bed or wheelchair by the wrists to prevent the patient from getting up.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review, and document review, the facility failed to ensure a physician's order was obtained for a restraint for 1 of 40 sampled patients (Patient #11).

Findings include:

Patient #11

Patient #11 was admitted [DATE] at 3:40 AM with a diagnosis of malignant neoplasm of the breast.

On 4/3/12 at approximately 11:30 AM, Patient #11 was observed wearing a posey vest.

There was no documented evidence of a physician's order for the restraint.

On 4/3/12 at approximately 1:30 PM, a second licensed nurse in the 300 Hall indicated Patient #11 had been restrained with the posey vest since 10:00 AM. The nurse indicated she did take and write down a verbal order from the physician prior to 10:00 AM, however, she further indicated she shredded the order. The nurse stated the facility's policy was to always document a physician's order prior to using a restraint on a patient.

The Policy and Procedure ("Restraints", revised 12/16/2008) indicated as follows:

STANDARD: 1. Restraint use will be limited to clinically appropriate and adequately justified situations. The patient's rights, dignity, and well-being will be preserved and protected whenever restraints are used. The use of the least restrictive method that meets patient needs will be applied only after alternative methods have been attempted and failed to meet patient needs. Initial assessment, reassessment, and alternatives must be documented as outlined by this policy. The overall goal of restraints is to protect and safeguard patients from injuring themselves or other patients...18. Documentation: The following will be documented in the medical record whenever medical restraint is applied: A description of the patient's actions and condition that indicated the initial and/or continued use of restraint will be documented on the 'Physical Restraint Assessment'. The alternative or less restrictive interventions attempted will be documented on the 'Physical Restraint Assessment'. Physician orders for restraint on the 'Physicians Order Sheet'..."