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.

DOCTORS DIAGNOSTIC HOSPITAL 1017 SOUTH TRAVIS CLEVELAND, TX Jan. 30, 2013
VIOLATION: DESIGNATED REQUESTOR Tag No: A0889
Based on interview and record the facility failed to ensure there was a designated requestor to be an organ procurement representative.
Findings include:
Review of the "Organ Donation" policy /procedure, dated 04/2008, no mention of who the facility's designated organ requestor was.
Review of a facility "Organ, tissue, eye procurement Action Plan", dated 01/05/12, revealed the hospital needed an organ requestor "ASAP". There was no documented attempt to obtain one.
During an interview on 01/29/13 at 12:50p.m., Staff #17 revealed they did not have a designated organ requestor.
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
Based on interview and record review, the facility failed to ensure there was a Medical Director (MD) over 2 of 2 Emergency departments (ED).
This deficient practice could harm all patients who presented to the ED department.
Findings include:
Review of undated ED policies and procedures and listed physicians revealed no documentation of appointed ED medical directors.
During an interview on 01/29/13 at 8:15 a.m., Staff #15 reported she worked in the ED department and the medical director was the surgical coordinator #9. Surgical coordinator #9 was not a physician.
During an interview on 01/29/13 at 9:00 a.m., Staff #3 (CNO) reported there was no written or Governing Board approved physician over the ED departments. Staff #3 said Doctor #22 had recently made himself the Medical Director, but he had not been designated so by the hospital.
VIOLATION: DIRECTOR OF REHABILITATION SERVICES Tag No: A1125
Based on interview and record review, the facility failed to ensure there was a qualified director over therapy services.
This deficient practice could cause harm to all patients in need of therapy.
Findings include:
A documented titled, "Doctors Diagnostic Hospital- Purchased Service Agreement," listed Physical therapy as one of the contracted services.

Review of the admit record dated 01/17/13 revealed Patient # 30 was admitted for knee surgery and received physical therapy services during his visit.
During an interview on 01/31/13 at 9:00 a.m., Staff #3 (CNO) reported there was no director over therapy services. She meets with the therapist whenever a patient comes in and needs services. There was no set schedule or any documentation of her meetings with therapy about any concerns that need to be addressed in the Quality Assurance Committee.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure blood transfusions were infused per facility policy in 3 of 4 (#s' 14, 16, and 17) charts reviewed for blood administration.
This deficient practice could cause harm to all patients presenting to the ED and in-house.
Findings include:
1.) Review of an undated facility " Blood Administration Guidelines " revealed the following:
*Two (2) RNs or LVN shall verify and document unit number, blood band number, patient name and date of birth before transfusion. Report any discrepancies.
* At the time of transfusion, all blood components shall be identified by two appropriately licensed personnel at the patient's bedside prior to administration. These individuals should verify that all information, including the patient identifiers (complete name and date of birth), on the patient's hospital armband, blood bank armband, Patient Results Report, Compatibility Tag attached to the blood component, and the information on the blood unit itself match.
*Both individuals shall document in writing on the (nursing transfusion record) that the above information was checked and accurate. If any of the above information is not in agreement (or does not match), notify the Blood Bank and return it immediately.
*Take vital signs immediately prior to the transfusion and record in the appropriate area of the (nursing record).
*Document the date and time the transfusion is started.
*Regulate the flow and observe the patient for the first 15 minutes for any sign of an adverse reaction to the transfusion.
*Unless ordered otherwise, transfuse no more than 100mL/hour for the first 15 minutes. If there is no evidence of reaction, adjust the flow to the prescribed rate.
*Vital signs must be taken at 15 minutes and documented on (the transfusion record). Monitor and record vital signs (temperature, pulse, respiration, and blood pressure), and assess for signs and symptoms of an adverse reaction (every hour) until the transfusion is completed.
* Monitor the patient for one hour after completion of the transfusion for signs and symptoms of a possible delayed reaction.

2.) Review of an admission assessment on Patient #17 revealed he was a [AGE] year old male who (MDS) dated [DATE] with a diagnosis of profound anemia.
Review of the physician orders signed off on 03/17/12 revealed an order to cross match and transfuse 4 units of packed red blood cells (PRBC).
Review of nursing transfusion records on Patient #17 dated 03/17/12 revealed the following:
*Blood unit #1 had no nursing transfusion record completed for it. There was no documentation showing two nurses verified all required information before administering the blood. There was no documentation of the temperature being taken on the last listed vital signs on the patient. There was no documentation of the completion of the blood transfusion nor monitoring for a delayed reaction one hour after completion of the transfusion.
*Blood unit #2 revealed a RN and EMT (emergency medical technician) verified the information about the patient and blood instead of two RNs. There was no documentation on the sheet of when the blood transfusion was stopped.
*Blood unit #3 revealed a RN and EMT (emergency medical technician) verified the information about the patient and blood instead of two RNs. There was no documentation on the sheet of when the blood transfusion was stopped, post transfusion vital signs or if there was any reaction noted.
* Blood unit #4 revealed a RN and EMT (emergency medical technician) verified the information about the patient and blood instead of two RNs. There was no documentation on the sheet of when the blood transfusion was stopped, post transfusion vital signs taken or if there was any reaction noted.

3.) Review of an admission assessment on Patient #16 revealed she was a [AGE] year old female who (MDS) dated [DATE] with diagnoses of possible gastrointestinal bleeding and anemia.
Review of physician orders dated 05/25/12 revealed an order to Type and Cross match and give 2 units of PRBC
Review of nursing transfusion records on Patient #16 dated 05/24/12 revealed the following:
*Blood unit #1 was completed at 12:00 p.m. and a set of vital signs was documented. There was no documentation of monitoring for delayed reaction for one hour after completion of the blood transfusion.
*Blood unit #2 was completed at 5:00 p.m. and a set of vital signs was documented. There were no post- transfusion vital signs documented. There was no documentation of monitoring for delayed reaction for one hour after completion of the blood transfusion.
4.) Review of an admission assessment on Patient #14 dated 07/18/12 revealed she was a [AGE] year old female admitted for gall bladder surgery.
Review of physician orders dated 07/23/12 revealed an order to Type and Cross for 2 units of PRBC.
Review of the nursing blood transfusion record on Patient #14 revealed it was completely blank. There was no verification information documented, vital signs or any indication of monitoring.
*Blood unit #1
Review of nurse' s notes dated 07/24/12 revealed 2 RNs verified the unit of blood, but there was no documentation of everything they checked. The unit of blood was started at 10:15 a.m. and Patient #14 had a low grade temperature of 99.7 degrees Fahrenheit. There was documentation the blood was complete at 12:30 p.m. There was no documentation of vital signs after 15 minutes of starting, throughout the transfusion nor post-transfusion.
*Blood unit #2
Review of nurse' s notes dated 07/24/12 revealed 2 nurses verified the unit of blood, but there was no documentation of everything they checked. The unit of blood was started at 1:30 p.m. and stopped at 2:30 p.m. There were no vital signs or documented monitoring before, during or post- transfusion.
During an interview on 01/30/13 at 11:58 a.m., Staff #3 (CNO) confirmed the vital signs and monitoring information was missing on the blood transfusion sheets. The nursing blood transfusion sheets should have been used and the EMT was not supposed to be verifying blood. Staff #17 (RN) verified the blood with the EMT because of there not being another nurse there with her.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interviews, the facility failed to identify the prepping of a patient's wrong leg and the doctor surgically inserting a scope into the wrong leg as a sentinel event (an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof) and follow their Patient Safety Program policy. The facility also failed to store patient care supplies in a safe manner.


Review of the document titled, "Report of Unusual Occurrence," for patient #23 revealed an incomplete report. The report contained the date of 07/18/2012, procedure and the type of anesthesia. The reverse side of the report documented, "Investigation Report, (To be completed by Risk Manager), agency OR nurse prepped wrong leg for surgery. Pt. had scope inserted but no procedure. Dr. discovered wrong leg. (What did happen?) Everyone did not check again before stating procedure. Correct knee was marked. (Action Plan to prevent future recurrence) will be checked at three separate points. New iridescent pen to mark correct knee. Not using that agency nurse." The Risk Manager's signature space was left blank.

A review of the document titled, "Patient Safety Program," with a revision date of 04/2008, revealed, "A. Scope of Activities: 1.g. Sentinel Event an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof-including any process variation for which a recurrence would carry a significant chance of serious adverse outcome, or Sentinel Event (Please refer to the SE policy) Near Miss. B. Methodology: 1. An Interdisciplinary Safety Committee is responsible for the oversight of the Patient Safety Program. The Safety Committee Chairperson (safety officer) will have administrative responsibility for the program."

A review of the document titled, "Sentinel Events," revealed, "Procedure: 1. Identifying a sentinel event: A. Root Cause Analysis would take place in the event of: 1. A near miss- did not affect an outcome, but for which a recurrence caries a significant chance of a serious adverse outcome. 8. Surgery on the wrong patient or wrong body part- all events of surgery on the wrong patient or wrong body part are reviewable under the policy, regardless of the magnitude of the procedure or the outcome."

During an interview on 1/29/13 at approximately 11:00 am, staff #3 confirmed the wrong site surgery conducted on patient #23 had not been perceived as a sentinel event by staff #3 or the facility and there had not been a Root Cause Analysis done. Staff #3 confirmed the event met the facility's definition of a sentential event.

During an interview on 1/28/13 at 11:15am, staff #3 and #7 reported that the last Safety Committee meeting was 4/4/12 and the last Environment of Care (EOC) meeting was 6/22/11.


During the tour of the facility on 01/28/2013 at approximately 12:42PM in the Central Supply Room, shipping boxes were observed being stored over open sterile supplies. During the tour of room 253, anesthesia supplies were observed stored on the floor. While touring the endoscopy processing room and the endoscopy procedure room, paper towels were observed stored at the edge of the sinks. The paper towels were not being protected from water splatter when staff washed their hands. No paper towel holders were observed in the processing or procedure rooms. During the tour of room 147, shipping boxes, greater than 30 boxes, were being stored over and along with sterile bottles of fluid. Room 147 was explained to be a pharmacy storage area. While touring the nurses' station clean supply room, five shipping boxes were being stored with clean supplies.

During the tour of the facility on 01/28/2013 at approximately 12:42PM, staff #3 and staff #9 confirmed the above findings.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on interview and record review the facility failed to ensure telephone/verbal physician orders were dated , timed and signed in 7 of 31 ( #s' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
This deficient practice could cause harm to all patients presenting to the ED and in-house.
Findings include:
Review of the "Rules and Regulations of the Medical Staff ", dated 11/16/2011 revealed the following:
* A verbal order shall include the date, time, and full signature and title of the person to whom the verbal has been given.
* The prescriber shall authenticate the verbal order within forty-eight (48) hours unless a specific hospital policy for a specific type of order requires a short time.
* The authentication of the order shall include the signature, date and time the prescriber authenticated the order.

Review of medical records revealed the following verbal orders were not timed, dated or countersigned by the physician:
Patient #1 had 2 orders;
Patient #2 had 3 orders;
Patient #6 had 2 orders;
Patient #12 had 1 order;
Patient #13 had 1 order;
Patient #21 had 3 orders;
Patient #24 had 7 orders;
During an interview on 01/28/13 at 3:28 PM, Staff #3 and #5 confirmed the findings listed above.
VIOLATION: CONTENT OF RECORD Tag No: A0458
Based on record review and interviews, it was determined that the facility medical staff failed to have history and physicals on 5 (#3, #12, #14, #16, #24) out of 6 (#13, #3, #12, #14, #16, #24) charts prior to surgical procedures.

Findings include:
Record review on 01/30/2013, revealed 5 out of 6 patient charts did not have a history and physical present before surgery.

During an interview on 1/30/2013 at 11:00 AM, staff #3 confirmed that patient #3, #12, #14, #16, and #24 did not have a history and physical before surgery.
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on record review, and interviews, it was determined that the facility failed to assure certification, competency, or training in appropriate food handling for 7 (#12, #14, #15, #16, #17, #33, #39) out of 8 (#3, #12, #14, #15, #16, #17, #33, #39) nursing staff.
Findings include;
A record review on 1/30/2013 at 1030, revealed that the facility failed to to assure certification, competency, or training appropriate for food handling in 7 (#12, #14, #15, #16, #17, #33, #39) out of 8 (#3, #12, #14, #15, #16, #17, #33, #39) nursing personnel files.
During an interview on 01/30/2013 at 3:00 PM, staff #3 reported that the facility no longer had a full time employee as director of food and dietetic services. Staff #3 confirmed there was no full time kitchen staff. Staff #3 reported the nurses were preparing and serving all meals and snacks. Staff #3 confirmed that the facility had staff serving food without a food handlers certification or training appropriate for food handling.
VIOLATION: OUTPATIENT SERVICES Tag No: A1076
Based on interview the facility failed to ensure outpatient services were organized and integrated with inpatient services. The facility failed to ensure an assigned individual was responsible for outpatient services.

This deficient practice could cause harm to all patients presenting to the hospital.

Findings include:

During an interview on 01/28/13 at 1:45 p.m., Staff #3 (CNO) reported that some of their outpatient services were Magnetic Resonance Imaging, x-rays, labs, Emergency Department, intravenous therapy, pain, and therapy services.

During an interview on 01/29/13 at 9:50 a.m., Staff #3 (CNO) reported there was no one assigned to be responsible for outpatient services. There was no formal documentation to show that outpatients services were included in the Quality Assurance Improvement Program.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on record review and interview, the facility failed to conduct the required number of fire drills per year in 2012. The facility conducted only 4 fire drills in 2012.

Findings include:

Review of policy #1038, "Fire Drill Policy," revealed the following: "Fire drills shall be conducted once per shift per quarter in each building defined as a healthcare occupancy."

Review of the facility's fire drill records revealed only 4 fire drills were conducted in 2012, as follows:
-3/22/12 at 1:25pm
-3/22/12 at 6:00pm
-7/26/12 at 4:00pm
-7/26/12 at 6:00pm

During an interview on 1/29/13 at 9:00am, staff #7 confirmed that no further fire drills had been documented.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on record review and interview, the governing body failed to develop a 2013 institutional plan and budget for the facility.

Findings include:

Review of facility records revealed no institutional plan and budget for 2013.

Review of Governing Body Meeting minutes from January 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 1/29/13 at 4:00pm in the conference room, staff #1 reported that there is no Governing Body approved 2013 institutional plan and budget.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0076
Based on record review and interview, the governing body failed to review and update the institutional plan and budget annually, as there has been no approved institutional plan and budget for 2013.

Findings include:

Review of facility records revealed no institutional plan and budget for 2013.

Review of Governing Body Meeting minutes from January 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 1/29/13 at 4:00pm in the conference room, staff #1 reported that there is no Governing Body approved 2013 institutional plan and budget.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0077
Based on record review and interview, the facility failed to prepare its institutional plan and budget with the requisite input, as there has been no approved institutional plan and budget for 2013.

Findings include:

Review of facility records revealed no institutional plan and budget for 2013.

Review of Governing Body Meeting minutes from January 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 1/29/13 at 4:00pm in the conference room, staff #1 reported that there is no Governing Body approved 2013 institutional plan and budget.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on interviews, the facility failed to employ a full time director of food services.

Findings include:

During an interview on 01/30/2013 at 3:00 PM, staff #3 reported that the facility no longer had a full time employee as director of food and dietetic services.
Staff #3 confirmed there was no full time kitchen staff. Staff #3 reported the staff nurses were preparing and serving all meals and snacks.
During an interview staff #19 confirmed that she is only contracted for 8 hours a month as a Dietician. Staff #19 reported that she is not the director of food services. Staff #19 reported that she is not preparing or serving food but has agreed to grocery shop and help with supplies if time permits.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, record review and interview, the facility failed to:

A. develop a 2013 institutional plan and budget.

Refer to tag A0073

B. review and update the institutional plan and budget annually, as there has been no approved institutional plan and budget for 2013.

Refer to tag A0076

C. prepare its institutional plan and budget with the requisite input, as there has been no approved institutional plan and budget for 2013.

Refer to tag A0077

D. require contracted services to be evaluated for safety and effectiveness by the facility's Quality Assurance Performance Improvement (QAPI) program.

Refer to Tag 0084

E. inform and/or provide a copy of patient's rights.

Refer to tag A0117

F. develop policies that protect and promote patient's right to file a grievance.

Refer to tag A0118

G. provide patients with a safe environment.

Refer to tag A0144

H. provide a process that would honor a surgical patient's, outpatient's advance directive or a process to provide information to patients wishing to formulate an advance directive.

Refer to tag A0132

I. ensure the nursing department was under the administrative authority of a qualified chief nursing officer (CNO).
Refer to tag A0385
J. provide Registered Nurse (RN) supervision and assessments for 5 of 5 (#s' 1, 3, 7, 17 and 25 ) patients.
Refer to tag A0386 and A0392
K. nursing services provided supervision of care to 5 of 5 (#s' 1, 3, 7, 17 and 25 ) patients.
Refer to tag A0397
L. ensure physician orders were dated , timed and signed in 8 of 31 ( #s ' 1, 5, 12, 13, 14, 15, 16, and 17 )charts reviewed.
Refer to tag A0406
M. ensure telephone /verbal physician orders were dated , timed and signed in 7 of 31 ( #s ' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
Refer to tag A0408
N. ensure blood transfusions were infused per facility policy in 3 of 4 (#s ' 14, 16, and 17) charts reviewed for blood administration.
Refer to tag A0409
O. keep medical records safe and confidential.
Refer to Tag 0146 and 0442

P. ensure telephone/verbal physician orders were dated , timed and signed in 7 of 31 ( #s' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
Refer to Tag 0450 and 0454

Q. require medical staff to have history and physicals on 5 (#3, #12, #14, #16, #24) out of 6 (#13, #3, #12, #14, #16, #24) charts prior to surgical procedures.

Refer to Tag 0458

R. employ a full time director of food services.
Refer to Tags 0620
S. assure certification, competency, or training in appropriate food handling for 7 (#12, #14, #15, #16, #17, #33, #39) out of 8 (#3, #12, #14, #15, #16, #17, #33, #39) nursing staff.
Refer to Tag 0622
T. ensure there was a written agreement with an Organ Procurement Organization which addressed all the required components.
Refer to tag A0886

U. ensure there was an agreement with a tissue bank or eye bank.
Refer to tag A0887

V. designated requestor to be an organ procurement representative.
Refer to tag A0889
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the facility failed to measure the quality of its care delivery systems. There was no quality assessment and performance improvement (QAPI) program.

Findings include:

Review of facility policy #4602, "Performance Improvement Plan," revealed the following:
"The purpose of the organizational Performance improvement Plan at the facility is to ensure that the Governing Body, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk."
AND
"Assure that the improvement process is organizationwide, monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety practices and clinical performance to resolve identified problems and improve performance. Appropriate reporting of information to the Governing Body to provide the leaders with the information they need in fulfilling their responsibility for the quality of patient care and safety is a required mandate of this plan."
AND
"The Hospital Administration and the Medical Executive Committee delegates the oversight responsibility for performance improvement activity monitoring, assessment and evaluation of patient care services provided throughout the facility to the Performance Improvement Committee.
The Performance Improvement Committee (PlC) will operate as a functional grouping of individuals in the organization who meet to evaluate and improve a specific process or system within the hospital. The PlC is comprised of members of administration, medical staff, and selected department leaders and those individuals designated from each department, as appropriate, who may have the highest degree of knowledge regarding a given PlC topic."
AND
"The organizational PlC team meets on at least six times a year to review and prioritize issues throughout the organization, which may benefit from a PI small team endeavor."
AND
"The Performance Improvement Committee will report, to the Medical Executive Committee on a quarterly basis, their analysis of the quality of patient care and services provided throughout the facility. This report will include a review of the performance improvement process as it is performed throughout the facility. The Performance Improvement Committee will provide the Governing Body with a report of the relevant findings from all performance improvement activities performed throughout the institution at least on a quarterly basis."

Review of Medical Executive Committee (MEC) Minutes for 2012 revealed no reports from the PIC. The only quality data reported in 2012 was a one page report regarding infection control in September. No departmental or contracted service quality evaluations were reported.

Review of Governing Body Minutes for 2012 revealed no reports from the PIC. The only quality data reported in 2012 was a one page report regarding infection control in September. No departmental or contracted service quality evaluations were reported.

During an interview on 1/29/13 at 2:57pm in the conference room, staff #2 reported the following:
-After reviewing the January through October 2012 MEC and Governing Body Minutes, staff #2 confirmed no departmental or contracted service quality evaluations were reported
-Staff #2 attended the November and December 2012 MEC and Governing Body meetings and no quality data were reported or discussed
-There is no evidence of quality assessment of any contracted patient care service from January 2012 to present

During an interview on 1/29/13 at 3:21pm, staff #3 reported the following:
-Staff #3 "took over" QAPI at the end of July 2012
-There is no PIC committee at present
VIOLATION: RESPIRATORY CARE SERVICES Tag No: A1151
Based on record review and interview, the facility failed to provide an organized respiratory care service to meet the needs of their patients.

Findings include:

Review of facility nursing policies revealed the following related to respiratory therapy services:
-"Handheld Nebulizer"
-"Incentive Spirometry"
-"Modalities of Aerosol Therapy"
-"Humidifier"
-"MDI-Metered Dose Inhalers"

During an interview on 1/28/13 at 1:15pm in the nurses' station, staff #3 reported the following:
-The facility does not have a respiratory therapy department, but does provide limited respiratory therapy services
-There are no respiratory therapists on staff
-The registered nurses provide respiratory therapy treatments (nebulizer treatments and chest percussion) to patients

During an interview on 1/30/13 at 8:15am in the conference room, staff #1 reported the following:
-The facility does not have a respiratory therapy department
-The facility does not have a medical director for Respiratory Therapy

Review of Medical Staff Bylaws and Medical Staff Rules and Regulations revealed no medical staff approval for nursing to provide respiratory therapy services.
VIOLATION: EMERGENCY GAS AND WATER Tag No: A0703
Based on record review and interview, the facility failed to maintain agreements with suppliers for gas and water supply during emergencies and disasters.

Findings include:

Review of the facility's emergency management plans and documents revealed no agreements with suppliers for gas and water supply during emergencies and disasters.

During an interview on 1/29/13 at 9:00am, staff #7 confirmed that the facility had no written agreements with suppliers for gas and water supply during emergencies and disasters.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on record review and interview, the governing body failed to require contracted services to be evaluated for safety and effectiveness by the facility ' s Quality Assurance Performance Improvement (QAPI) program.

Findings include:

Review of facility policy #4602, "Performance Improvement Plan," revealed the following:
"The purpose of the organizational Performance improvement Plan at the facility is to ensure that the Governing Body, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk."
AND
"Assure that the improvement process is organizationwide, monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety practices and clinical performance to resolve identified problems and improve performance. Appropriate reporting of information to the Governing Body to provide the leaders with the information they need in fulfilling their responsibility for the quality of patient care and safety is a required mandate of this plan."
AND
"The Hospital Administration and the Medical Executive Committee delegates the oversight responsibility for performance improvement activity monitoring, assessment and evaluation of patient care services provided throughout the facility to the Performance Improvement Committee.
The Performance Improvement Committee (PlC) will operate as a functional grouping of individuals in the organization who meet to evaluate and improve a specific process or system within the hospital. The PlC is comprised of members of administration, medical staff, and selected department leaders and those individuals designated from each department, as appropriate, who may have the highest degree of knowledge regarding a given PlC topic."
AND
"The organizational PlC team meets on at least six times a year to review and prioritize issues throughout the organization, which may benefit from a PI small team endeavor."
AND
"The Performance Improvement Committee will report, to the Medical Executive Committee on a quarterly basis, their analysis of the quality of patient care and services provided throughout the facility. This report will include a review of the performance improvement process as it is performed throughout the facility. The Performance Improvement Committee will provide the Governing Body with a report of the relevant findings from all performance improvement activities performed throughout the institution at least on a quarterly basis."

A document titled, "Doctors Diagnostic Hospital- Purchased Service Agreement," listed the following patient care related contracted service: Anesthesia, Pharmacy, Linen Service, Pathology, Cardiology, Food Service, Dietician, and Physical Therapy.

Review of Governing Body Minutes for 2012 revealed no reports from the PIC. The only quality data reported in 2012 was a one page report regarding infection control in September. No departmental or contracted service quality evaluations were reported.

During an interview on 1/29/13 at 2:57pm in the conference room, staff #2 reported the following:
-After reviewing the January through October 2012 Governing Body Minutes, staff #2 confirmed no contracted service quality evaluations were reported
-Staff #2 attended the November and December 2012 Governing Body meetings and no quality data were reported or discussed
-There is no evidence of quality assessment of any contracted patient care services from January 2012 to present

During an interview on 1/29/13 at 3:21pm, staff #3 reported the following:
-Staff #3 "took over" QAPI at the end of July 2012
-There is no PIC committee at present
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and record review, the facility failed to:
A. ensure the nursing department was under the administrative authority of a qualified chief nursing officer (CNO).
Refer to tag A0385
B. provide Registered Nurse (RN) supervision and assessments for 5 of 5 (#s' 1, 3, 7, 17 and 25 ) patients.
Refer to tag A0386 and A0392
C. nursing services provided supervision of care to 5 of 5 (#s' 1, 3, 7, 17 and 25 ) patients.
Refer to tag A0397
D. ensure physician orders were dated , timed and signed in 8 of 31 ( #s ' 1, 5, 12, 13, 14, 15, 16, and 17 )charts reviewed.
Refer to tag A0406

E. ensure telephone /verbal physician orders were dated , timed and signed in 7 of 31 ( #s ' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
Refer to tag A0408
F. ensure blood transfusions were infused per facility policy in 3 of 4 (#s ' 14, 16, and 17) charts reviewed for blood administration.
Refer to tag A0409
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interview and record review, the facility failed to ensure the nursing department was under the administrative authority of a qualified chief nursing officer (CNO).
This deficient practice could cause harm to all patients who presented to the ED and to in-patients.
Findings include:
Review of a facility's job description for a "Chief Nursing Officer" (CNO) dated 10/22/12 revealed one of the qualifications was to have a "Master's degree in Nursing." Staff #14 signed the job description on 10/22/12, accepting the responsibility to be the CNO.
Review of the personnel file on Staff #14 revealed she did not have a Master's degree in Nursing.
During an interview on 01/29/13 at 9:00 a.m., Staff #3 reported the last CNO (Staff # 14) was one class away from receiving her Master's degree. Staff # 3 reported after Staff #14 left (about a month ago) she (Staff #3) took over the CNO position. Staff # 3 reported she did not have a Master's degree either.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to provide Registered Nurse (RN) supervision and assessments for 5 of 5 (#s' 1, 3, 7, 17 and 25 )patients.
This deficient practice could cause harm to all patients who presented to the Emergency department (ED) and in-patients.
Findings include:
1.) Review of the facility's "Title: Nurse Staffing Plan" dated 11/2011 revealed the following:
* There will be adequate number of Registered Nurses (RN), Licensed Vocational Nurses (LVN) and other support personnel to provide nursing care to all patients.
*An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations.
Review of the "Daily Census Form" revealed:
A. For the month of August 2012, on 28 of 31 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 20 of the 28 days there was one RN supervising the two units.
On the PM shift, 24 of the 28 days there was one RN supervising the two units.

For the month of August 2012, on 2 of 31 days the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 2 of the 2 days there was one RN supervising the three units.
On the PM shift, 2 of the 2 days there was one RN supervising the three units.

B. For the month of September 2012, on 23 of 30 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 11 of the 23 days there was one RN supervising the two units.
On the PM shift, 17 of the 23 days there was one RN supervising the two units.

C. For the month of October 2012, on 25 of 31 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 20 of the 25 days there was one RN supervising the two units.
On the PM shift, 19 of the 25 days there was one RN supervising the two units.

For the month of October 2012, on 3 of 31 days, the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 1 of the 3 days there was one RN supervising the three units. On the AM shift, 2 of the 3 days there were two RNs supervising the three units.
On the PM shift, 2 of the 3 days there was one RN supervising the three units. On the PM shift, 1 of the 3 days there were two RNs supervising the three units.

D. For the month of November 2012, on 19 of 30 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 15 of the 19 days there was one RN supervising the two units.
On the PM shift, 12 of the 19 days there was one RN supervising the two units.

For the month of November 2012, on 5 of 30 days, the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 3 of the 5 days there was one RN supervising the three units. On the AM shift, 1 of the 5 days there was no RN supervising the three units.
On the PM shift, 2 of the 5 days there was one RN supervising the three units. On the PM shift, 3 of the 5 days there were two RNs supervising the three units.

E. For the month of December 2012, on 22 of 31, days the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 15 of the 22 days there was one RN supervising the two units.
On the PM shift, 20 of the 22 days there was one RN supervising the two units.

For the month of December 2012, on 2 of 31 days, the facility operated three units, the Emergency Unit, Over Flow Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 1 of the 2 days there was one RN supervising the three units. On the AM shift, of the 1 of the 2 days there were two RNs supervising the three units.
On the PM shift, 1 of the 2 days there was one RN supervising the three units. On the PM shift, 1 of the 2 days there were two RNs supervising the three units.

F. For the month of January 2013, on 8 of 31, days the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 4 of the 8 days there was one RN supervising the two units.
On the PM shift, 8 of the 8 days there was one RN supervising the two units.

For the month of January 2013, on 4 of 31 days, the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 1 of the 4 days there was one RN supervising the three units. On the AM shift, of the 3 of the 4 days there were two RNs supervising the three units.
On the PM shift, 1 of the 4 days there was one RN supervising the three units. On the PM shift, 3 of the 4 days there were two RNs supervising the three units.

During an observation on 01/28/13 at 4:22 p.m., a patient in the ED treatment room needed assistant from a nurse. LVN #16 and LVN #18 were on the medical surgical unit and both reported not knowing where the RN was. LVN #16 (agency nurse) went to the ED treatment room to check on the patient. The distance between the ED department and medical-surgical unit is approximately 45 feet.

During an interview on 01/29/13 at 8:15 a.m., Staff #15 reported she was the only RN on the 6:00 a.m. - 6:00 p.m. shift on 01/28/13, along with a LVN. Staff #15 reported she was the RN for the ER and the medical/surgical unit during this timeframe. The staffing coordinator (Staff #17) came in for a while so the LVN could go to PACU, but Staff #17 left around noon. Staff #15 reported she had patients coming in through the ER and she was not on the nursing unit to provide supervision to the LVNs. Staff #15 reported they did not have two RNs working all the time and working short with one RN was just scary.

During an interview on 01/29/13 at 10:50 a.m., Staff #17 reported that she was the staffing coordinator for the past 8 months. Her staffing pattern was as follows:
*Day shift from 6:00 a.m.-6:00 p.m. there was one RN and one LVN or paramedic.
*Night shift from 6:00 p.m.-6:00 a.m. there was one RN and one LVN or paramedic.
Staff #17 reported, for safety reasons, they needed at least 3 staff working the nursing unit and ED. They had been telling the CEO, but he only wanted them to work with 2 staff because of the financial reasons. Staff #17 checked the staffing scheduled and confirmed on 01/12/13 and 01/25/13 there was one RN and one paramedic working on the night shift.
During an interview on 01/29/2013 at 4:40 PM in the conference room, staff #1 confirmed the facility was not staffing the appropriate numbers of Registered Nurses to supervise the nursing units.
During an interview on 01/29/2013 at 2:40 PM in the conference room, staff #3 confirmed the facility was not staffing the appropriate numbers of Registered Nurses to supervise the nursing units. Staff #3 revealed that multiple requests had been made of staff #1 to increase the RN coverage in the facility.

2.) Review of the facility's "Title: Assessment:Admission" dated 04/2008 revealed the following:

Initial Assessment

Nursing Assessment is to be completed by the RN. This is the patient's baseline assessment and serves to determine the patient's nursing diagnosis/problem list and to be used to formulate the patient's plan of care.

Review of an "Adult Assessment" revealed Patient #25 was a [AGE] year old female who (MDS) dated [DATE] at 7:15 p.m. with diagnoses of "pain to the center of throat" and "shortness of breath." There was documentation Patient # 25 had an elevated blood pressure of 194/76 and a pain level of 9 out 10 (pain level of 1 indicating the lowest and 10 indicating the highest).

The entire assessment and discharge was performed by Staff #40 (an emergency medical technician -EMT). There was no documented RN involvement in the assessment.

Review of a "Nursing Services Staffing Schedule" revealed Staff #40 (EMT) was the only staff scheduled for nights on 07/28/12.

3.) Review of an undated facility "Blood Administration Guidelines" revealed the following:

*Two (2) RNs or LVN shall verify and document unit number, blood band number, patient name and date of birth before transfusion. Report any discrepancies.

Review of an admission assessment on Patient #17 revealed he was a [AGE] year old male who (MDS) dated [DATE] with a diagnosis of profound anemia.

Review of the physician orders signed off on 03/17/12 revealed an order to cross match and transfuse 4 units of packed red blood cells (PRBC).

Review of nursing transfusion records on Patient #17, dated 03/17/12, revealed the initial verifications on three units of blood were performed by Staff #17 (RN) and Staff #41 (EMT).

During an interview on 01/30/13 at 11:58 a.m., Staff #3 (CNO) confirmed the EMT was not supposed to be verifying blood. RN #17 verified the blood with the EMT because of there not being another nurse there with her.

4.) Review of an "Adult Assessment" revealed Patient #1 was a [AGE] year old female who (MDS) dated [DATE] at 12:10 midnight, with a diagnoses of abdominal pain related to an abdominal mass. There was documentation Patient #1 had an elevated blood pressure of 181/88 and a current pain level of 8 ( pain level of 1 indicating the lowest and 10 indicating the highest). There was no documentation of a continued nursing assessment of the blood pressure or abdominal pain until discharge from the ED. There was no initial assessment of medications Patient #1 was currently taking. According to the ED assessment, Patient #1 was transferred to the floor over 2 hours later, at 2:45 a.m., with a blood pressure of 159/100 and pain level of 5.

Review of an "admission history" dated 01/28/13 revealed Patient # 1 was transferred to the floor with a diagnosis of "acute abdominal pain" at 2:45 a.m. . . . Patient #1 had a history of hypertension, respiratory problems, cancer and angina. There was documentation Patient #1's blood pressure was still elevated at 159/100, breath sounds indicated she was wheezing, and her pain level at a 6.

Review of the "Patient current medications" list revealed Patient #1 was currently on 12 medications. The list included Flonase, a respiratory agent, Metoprolol, a hypertensive agent, Warfarin, an anti-coagulant agent, and Dilaudid, a pain agent. There was no nursing assessment of the reason, last dose time, last dose date or if the medications were to be continued or stopped. There was a place on the sheet for the physician to sign and date if they were to be continued and this was not done.

Review of a nursing assessment dated [DATE] at 4:00 a.m. revealed Patient #1 had a pain level of 8.

Review of a physician orders revealed, at 4:45 a.m. on 01/28/13, the first order for pain medication was written. An order was received for Toradol 60 mg (milligrams) IM (intramuscular) every 6 hour prn (whenever needed) for pain.

Review of the medication administration record, dated 01/28/12, revealed Patient #1 received a dosage of the pain agent Toradol at 5:00a.m (over 4 hours after being admitted ).

During an interview on 01/28/13 at 3:22 p.m., Staff #3 (CNO) confirmed the nursing assessment was missing. Staff #3 reported the nurse should have addressed the medications Patient #1 was currently taking and the physician should have completed his part on the assessment also.

5.) Review of an "Adult Assessment" revealed Patient #7 was a [AGE] year old female who (MDS) dated [DATE] at 3:10 a.m. with a diagnosis of abdominal pain. The areas on the assessment form that addressed pain status, continued pain status throughout visit, vital signs, medications, and procedures were left bank. According to assessment, the physician did not come in to assess the patient until over an hour later at 4:20 a.m. and wrote orders for pain medication.

6.) Review of an "Adult Assessment" revealed Patient #3 was a [AGE] year old female who (MDS) dated [DATE] at 9:45 a.m. with a diagnosis of mid back pain. Patient #3 had a pain level of 8 out of 10. Review of the patient's current medications list revealed he was on 6 medications, which included the diabetic agent Metformin, pain agent Tramadol and muscle relaxant Flexeril.

Review of the nursing assessment revealed no documentation of the reason, last dose time, and last dose date or if the medications were to be continued or stopped. There were no continued vital signs or pain level assessments, medications while in the ED, procedures, or nursing disposition documented.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation observation, interview and record review the facility failed to ensure nursing services provided supervision of care to 5 of 5 (#s' 1, 3, 7, 17 and 25 )patients.
This deficient practice could cause harm to all patients who presented to the Emergency department (ED) and in-patients.
Findings include:
1.) Review of the facility's "Title:Nurse Staffing Plan" dated 11/2011 revealed the following:
* There will be adequate number of Registered Nurses (RN), Licensed Vocational Nurses (LVN) and other support personnel to provide nursing care to all patients.
*An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations.

Review of the "Daily Census Form" revealed:
A. For the month of August 2012, on 28 of 31 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 20 of the 28 days there was one RN supervising the two units.
On the PM shift, 24 of the 28 days there was one RN supervising the two units.

For the month of August 2012, on 2 of 31 days the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 2 of the 2 days there was one RN supervising the three units.
On the PM shift, 2 of the 2 days there was one RN supervising the three units.

B. For the month of September 2012, on 23 of 30 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 11 of the 23 days there was one RN supervising the two units.
On the PM shift, 17 of the 23 days there was one RN supervising the two units.

C. For the month of October 2012, on 25 of 31 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 20 of the 25 days there was one RN supervising the two units.
On the PM shift, 19 of the 25 days there was one RN supervising the two units.

For the month of October 2012, on 3 of 31 days, the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 1 of the 3 days there was one RN supervising the three units. On the AM shift, 2 of the 3 days there were two RNs supervising the three units.
On the PM shift, 2 of the 3 days there was one RN supervising the three units. On the PM shift, 1 of the 3 days there were two RNs supervising the three units.

D. For the month of November 2012, on 19 of 30 days, the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 15 of the 19 days there was one RN supervising the two units.
On the PM shift, 12 of the 19 days there was one RN supervising the two units.

For the month of November 2012, on 5 of 30 days, the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 3 of the 5 days there was one RN supervising the three units. On the AM shift, 1 of the 5 days there was no RN supervising the three units.
On the PM shift, 2 of the 5 days there was one RN supervising the three units. On the PM shift, 3 of the 5 days there were two RNs supervising the three units.

E. For the month of December 2012, on 22 of 31, days the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 15 of the 22 days there was one RN supervising the two units.
On the PM shift, 20 of the 22 days there was one RN supervising the two units.

For the month of December 2012, on 2 of 31 days, the facility operated three units, the Emergency Unit, Over Flow Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 1 of the 2 days there was one RN supervising the three units. On the AM shift, of the 1 of the 2 days there were two RNs supervising the three units.
On the PM shift, 1 of the 2 days there was one RN supervising the three units. On the PM shift, 1 of the 2 days there were two RNs supervising the three units.


F. For the month of January 2013, on 8 of 31, days the facility operated two units, the Emergency Unit and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 4 of the 8 days there was one RN supervising the two units.
On the PM shift, 8 of the 8 days there was one RN supervising the two units.

For the month of January 2013, on 4 of 31 days, the facility operated three units, the Emergency Unit, Over Flow Unit, and the Medical Surgical Unit for the AM and PM shifts.
On the AM shift, 1 of the 4 days there was one RN supervising the three units. On the AM shift, of the 3 of the 4 days there were two RNs supervising the three units.
On the PM shift, 1 of the 4 days there was one RN supervising the three units. On the PM shift, 3 of the 4 days there were two RNs supervising the three units.

During an observation on 01/28/13 at 4:22 p.m., a patient in the ED treatment room needed assistant from a nurse. LVN #16 and LVN #18 were on the medical surgical unit and both reported not knowing where the RN was. LVN #16 (agency nurse) went to the ED treatment room to check on the patient. The distance between the ED department and medical-surgical unit is approximately 45 feet.

During an interview on 01/29/13 at 8:15 a.m., Staff #15 reported she was the only RN on the 6:00 a.m. - 6:00 p.m. shift on 01/28/13, along with a LVN. Staff #15 reported she was the RN for the ER and the medical/surgical unit during this timeframe. The staffing coordinator (Staff #17) came in for a while so the LVN could go to PACU, but Staff #17 left around noon. Staff #15 reported she had patients coming in through the ER and she was not on the nursing unit to provide supervision to the LVNs. Staff #15 reported they did not have two RNs working all the time and working short with one RN was just scary.

During an interview on 01/29/13 at 10:50 a.m., Staff #17 reported that she was the staffing coordinator for the past 8 months. Her staffing pattern was as follows:
*Day shift from 6:00 a.m.-6:00 p.m. there was one RN and one LVN or paramedic.
*Night shift from 6:00 p.m.-6:00 a.m. there was one RN and one LVN or paramedic.
Staff #17 reported, for safety reasons, they needed at least 3 staff working the nursing unit and ED. They had been telling the CEO, but he only wanted them to work with 2 staff because of the financial reasons. Staff #17 checked the staffing scheduled and confirmed on 01/12/13 and 01/25/13 there was one RN and one paramedic working on the night shift.

During an interview on 01/29/2013 at 4:40 PM in the conference room, staff #1 confirmed the facility was not staffing the appropriate numbers of Registered Nurses to supervise the nursing units.
During an interview on 01/29/2013 at 2:40 PM in the conference room, staff #3 confirmed the facility was not staffing the appropriate numbers of Registered Nurses to supervise the nursing units. Staff #3 revealed that multiple requests had been made of staff #1 to increase the RN coverage in the facility.



2.) Review of the facility's "Title: Assessment:Admission" dated 04/2008 revealed the following:
Initial Assessment
Nursing Assessment is to be completed by the RN. This is the patient's baseline assessment and serves to determine the patient's nursing diagnosis/problem list and to be used to formulate the patient's plan of care.

Review of an "Adult Assessment" revealed Patient #25 was a [AGE] year old female who (MDS) dated [DATE] at 7:15 p.m. with diagnoses of "pain to the center of throat" and "shortness of breath." There was documentation Patient # 25 had an elevated blood pressure of 194/76 and a pain level of 9 out 10 (pain level of 1 indicating the lowest and 10 indicating the highest).
The entire assessment and discharge was performed by Staff #40 (an emergency medical technician -EMT). There was no documented RN involvement in the assessment.
Review of a "Nursing Services Staffing Schedule" revealed Staff #40 (EMT) was the only staff scheduled for nights on 07/28/12.


3.) Review of an undated facility "Blood Administration Guidelines" revealed the following:
*Two (2) RNs or LVN shall verify and document unit number, blood band number, patient name and date of birth before transfusion. Report any discrepancies.
Review of an admission assessment on Patient #17 revealed he was a [AGE] year old male who (MDS) dated [DATE] with a diagnosis of profound anemia.
Review of the physician orders signed off on 03/17/12 revealed an order to cross match and transfuse 4 units of packed red blood cells (PRBC).
Review of nursing transfusion records on Patient #17, dated 03/17/12, revealed the initial verifications on three units of blood were performed by Staff #17 (RN) and Staff #41 (EMT).
During an interview on 01/30/13 at 11:58 a.m., Staff #3 (CNO) confirmed the EMT was not supposed to be verifying blood. RN #17 verified the blood with the EMT because of there not being another nurse there with her.

4.) Review of an "Adult Assessment" revealed Patient #1 was a [AGE] year old female who (MDS) dated [DATE] at 12:10 midnight, with a diagnoses of abdominal pain related to an abdominal mass. There was documentation Patient #1 had an elevated blood pressure of 181/88 and a current pain level of 8 ( pain level of 1 indicating the lowest and 10 indicating the highest). There was no documentation of a continued nursing assessment of the blood pressure or abdominal pain until discharge from the ED. There was no initial assessment of medications Patient #1 was currently taking. According to the ED assessment, Patient #1 was transferred to the floor over 2 hours later, at 2:45 a.m., with a blood pressure of 159/100 and pain level of 5.
Review of an "admission history" dated 01/28/13 revealed Patient # 1 was transferred to the floor with a diagnosis of "acute abdominal pain" at 2:45 a.m. . . . Patient #1 had a history of hypertension, respiratory problems, cancer and angina. There was documentation Patient #1's blood pressure was still elevated at 159/100, breath sounds indicated she was wheezing, and her pain level at a 6.
Review of the "Patient current medications" list revealed Patient #1 was currently on 12 medications. The list included Flonase, a respiratory agent, Metoprolol, a hypertensive agent, Warfarin, an anti-coagulant agent, and Dilaudid, a pain agent. There was no nursing assessment of the reason, last dose time, last dose date or if the medications were to be continued or stopped. There was a place on the sheet for the physician to sign and date if they were to be continued and this was not done.

Review of a nursing assessment dated [DATE] at 4:00 a.m. revealed Patient #1 had a pain level of 8.
Review of a physician orders revealed, at 4:45 a.m. on 01/28/13, the first order for pain medication was written. An order was received for Toradol 60 mg (milligrams) IM (intramuscular) every 6 hour prn (whenever needed) for pain.
Review of the medication administration record, dated 01/28/12, revealed Patient #1 received a dosage of the pain agent Toradol at 5:00a.m (over 4 hours after being admitted ).
During an interview on 01/28/13 at 3:22 p.m., Staff #3 (CNO) confirmed the nursing assessment was missing. Staff #3 reported the nurse should have addressed the medications Patient #1 was currently taking and the physician should have completed his part on the assessment also.

5.) Review of an "Adult Assessment" revealed Patient #7 was a [AGE] year old female who (MDS) dated [DATE] at 3:10 a.m. with a diagnosis of abdominal pain. The areas on the assessment form that addressed pain status, continued pain status throughout visit, vital signs, medications, and procedures were left bank. According to assessment, the physician did not come in to assess the patient until over an hour later at 4:20 a.m. and wrote orders for pain medication.

6.) Review of an "Adult Assessment" revealed Patient #3 was a [AGE] year old female who (MDS) dated [DATE] at 9:45 a.m. with a diagnosis of mid back pain. Patient #3 had a pain level of 8 out of 10. Review of the patient's current medications list revealed he was on 6 medications, which included the diabetic agent Metformin, pain agent Tramadol and muscle relaxant Flexeril.
Review of the nursing assessment revealed no documentation of the reason, last dose time, and last dose date or if the medications were to be continued or stopped. There were no continued vital signs or pain level assessments, medications while in the ED, procedures, or nursing disposition documented.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
Based on interview and record review, the facility failed to ensure physician orders were dated , timed and signed in 8 of 31 ( #s' 1, 5, 12, 13, 14, 15, 16, and 17 ) charts reviewed.
This deficient practice could cause harm to all patients presenting to the ED and in-house.
Findings include:
Review of the Rules and Regulations of the Medical Staff dated 11/16/2011 revealed the following:
"All orders must be entered in the patient's record, dated, timed and signed by the responsible practitioner."
Review of medical records revealed the following were not timed, dated or either signed by the practitioner:
Patient #1 had 2 orders;
Patient #5 had 3 orders;
Patient #12 had 3 orders;
Patient #13 had 1 order;
Patient #14 had 8 plus orders;
Patient #15 had 2 orders;
Patient #16 had 7 orders;
Patient #17 had 1 order.
During an interview on 01/28/13 at 3:28 p.m., Staff #3 (CNO) confirmed the orders were not timed, dated or had the physician's signature.
VIOLATION: VERBAL ORDERS Tag No: A0408
Based on interview and record review the facility failed to ensure telephone/verbal physician orders were dated , timed and signed in 7 of 31 ( #s' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
This deficient practice could cause harm to all patients presenting to the ED and in-house.
Findings include:
Review of the "Rules and Regulations of the Medical Staff ", dated 11/16/2011 revealed the following:
* A verbal order shall include the date, time, and full signature and title of the person to whom the verbal has been given.
* The prescriber shall authenticate the verbal order within forty-eight (48) hours unless a specific hospital policy for a specific type of order requires a short time.
* The authentication of the order shall include the signature, date and time the prescriber authenticated the order.

Review of medical records revealed the following verbal orders were not timed, dated or countersigned by the physician:
Patient #1 had 2 orders;
Patient #2 had 3 orders;
Patient #6 had 2 orders;
Patient #12 had 1 order;
Patient #13 had 1 order;
Patient #21 had 3 orders;
Patient #24 had 7 orders;
During an interview on 01/28/13 at 3:28 p.m., Staff #3 (CNO) confirmed these verbal orders were not countersigned by the physician within 48 hours.
VIOLATION: TISSUE AND EYE BANK AGREEMENTS Tag No: A0887
Based on interview and record review the facility failed to ensure there was an agreement with a tissue bank or eye bank.

Findings include:

Review of the "Organ Donation" policy /procedure, dated 04/2008, revealed instructions on what to do in the event a patient meets the criteria for organ donation. There was no mention of the agreements the facility had with at least (1) tissue bank and (1) eye bank.
Review of a facility "Organ, tissue, eye procurement Action Plan" dated 01/05/12 revealed the hospital needed a written agreement with an Organ Procurement Organization.
During an interview on 01/29/13 at 12:50p.m., Staff #17 revealed they did not have an agreement with a tissue bank or eye bank.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on observation, document review and interview, the facility failed to develop a patient grievance process.

During an observation of the registration process for patient #32 on 01/29/2013 at approximately 8:40 AM, staff #11 placed several documents in front of the patient and pointed out areas for the patients to sign. The only instructions given were these are consents for treatment. No information regarding patient rights or contact information for filing a grievance was provided to the patient. The patient left the admission area with no paperwork in hand.

During a review of the documents staff #11 had patient #32 sign revealed the patient had been given a copy of patient rights. Further review of the documents provided to the patient for signature revealed no information of the grievance process or whom to contact if a grievance needed to be filed.

During an interview with staff #10, the staff member was asked to review with surveyor the admission process and show what signatures are requested of the patient. Three admission packets were reviewed, surgery pack, outpatient pack and inpatient/emergency room packet. None of the three packets contained references to the grievance process or who to contact if a grievance needed to be filed. Staff confirmed patients did not receive information of the facility's grievance process. Each packet reviewed contained the statement, "I hereby acknowledge that I received a copy on the Center's Patient Rights." Staff acknowledged that all patients sign this statement. The surveyor asked for a copy of the "Patient Rights." Staff member asked, "What Patient Rights?"

An interview with staff #5 confirmed patients were not receiving a copy or information regarding Patient Rights or the facility's grievance process.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on observation, document review and interview, the facility failed to inform or provide patients with their rights.

During an observation of the registration process for patient #32 on 01/29/2013 at approximately 8:40 AM, staff #11 placed several documents in front of the patient and pointed out areas for the patient to sign. The only instructions given were that these are consents for treatment. No information regarding patient rights or contact information for filing a grievance was provided to the patient. The patient left the admission area with no paperwork in hand.

During a review of the documents staff #11 had patient #32 sign revealed the patient had been given a copy of patient rights. Further review of the documents provided to the patient for signature revealed no information of the grievance process or whom to contact if a grievance needed to be filed.

During an interview with staff #10, the staff member was asked to review with the surveyor the admission process and show what signatures are requested of the patient. Three admission packets were reviewed, surgery pack, outpatient pack and inpatient/emergency room packet. None of the three packets contained references to the grievance process or who to contact if a grievance needed to be filed. Staff confirmed patients did not receive information of the facility's grievance process. Each packet reviewed contained the statement, "I hereby acknowledge that I received a copy on the Center's Patient Rights." Staff acknowledged that all patients sign this statement. The surveyor asked for a copy of the "Patient Rights." Staff member asked, "What Patient Rights?"

An interview with staff #5 confirmed patients were not receiving a copy or information regarding Patient Rights or the facility's grievance process.
VIOLATION: OPO AGREEMENT Tag No: A0886
Based on interview and record review, the facility failed to ensure there was a written agreement with an Organ Procurement Organization which addressed all the required components.

Findings include:

Review of the "Organ Donation" policy /procedure, dated 04/2008, revealed instructions on what to do in the event a patient meets the criteria for organ donation. There was no mention of the definition of "timely notification" or permission of access to death records by the OPO, tissue bank and eye bank.
VIOLATION: ORGAN, TISSUE, EYE PROCUREMENT Tag No: A0884
Based on interview and record review the facility failed to:

A. ensure there was a written agreement with an Organ Procurement Organization which addressed all the required components.
Refer to tag A0886


B. ensure there was an agreement with a tissue bank or eye bank.
Refer to tag A0887


C. designated requestor to be an organ procurement representative.
Refer to tag A0889
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on interview and record review, the facility failed to ensure physicians made visits to assess patients within 30 minutes in 1 of 2 Emergency departments (EDs).
This deficient practice could cause harm to all patients who present to the ED.
Findings include:

Review of the "Title:Transfer Policy", dated 04/2008, revealed:
"Each patient who arrives at the hospital is:
A. Evaluated by a physician who is present in the facility at the time the patient presents or is presented or evaluated by a physician on call who is :
i.physically able to reach the patient within 30 minutes after being informed that a patient is present at the facility who requires immediate attention"

Review of the ED central log revealed the following physician visits were over 30 minutes - 2 hours late:
*October 2012 there were 13 late visits.
* November 2012 there was 19 late visits.
*December 2012 there were 23 late visits.
*January 2013 there were 18 late visits.

During an interview on 01/29/13 at 11:35 a.m., Staff #17 reported they call some of the ED doctors when they get a patient in the ED. They come to the hospital and do an assessment on the patient, but it is not effective. Their in-house policy gives them 30 minutes to get there, but it is taking over an hour for them to get there. Last week a patient went AMA because it was taking the doctor too long to see them.
During an interview on 01/30/13 at 8:35 a.m., staff #3 (CNO) checked the central log and confirmed the physician visits were late.
A letter by Staff #1 (CEO), dated 01/30/13, titled, "emergency room Protocol," was reviewed by the surveyor. According to documentation, the physicians were informed of the importance of total 24 hours coverage in the ER. "It had been documented that physicians on duty have left the facility. This behavior could jeopardize patient care in an emergency situation. Leaving the hospital while on duty is unacceptable and will not be tolerated by this facility!"
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on document review and interview, the facility failed to provide to surgical patients or outpatients information about their rights to formulate an advance directive.

During an observation of the registration process for the surgical patient #32 on 01/29/2013 at approximately 8:40 AM, staff #11 placed several documents in front of the patient and pointed out areas for the patients to sign. The only instructions given to the patient were these are consents for treatment. No information regarding patient rights to formulate an advance directive was given or offered. The staff did not ask if there was an advance directive. The patient left the admission area with no paperwork in hand.

A review of the medical record for surgical patient #32 revealed no documents addressing the advance directive.

A review was done of the surgery pack and outpatient pack that the registration clerks provide to patients for signature. The packets contained no references to the patient's advance directive.

An interview with staff #5 confirmed surgical and outpatient patients were not receiving a copy or information regarding Patient Rights, the facility's grievance process or asked or provided information about advance directives.
VIOLATION: UTILIZATION REVIEW Tag No: A0652
Based on record review and interviews it was determined that the facility Governing Body (GB) failed to enforce or establish a Utilization Review Plan (UR) or a performance of Utilization Review activities.
Findings include:
Review of GB and Medical Executive Committee (MEC) minutes from January 2012-January 2013 revealed the following:
The MEC agenda for 01/09/2012 had an old business agenda for UR Plan update. The Plan was not in the GB minutes for discussion or approval.
During an interview on 01/30/2013 at 3:00 PM, staff #3 reported the facility did not have a UR program. Staff #5 also reported that there was no UR program in place at this time.
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
Based on record review, interviews, and observations, the facility failed to:
A. follow the policy and procedures for diet ordering, tray delivery, and accommodations for non-routine nutritional services.
Review of facility policy, "Identification Systems for Diet and Patient," revealed the following:
"An identification system is used when readying and delivering patient meal trays. PROCEDURE: Prior to meal service, a diet card for each patient is prepared containing: A) Patient name, B) Patient room number and C) Diet order. 2) Each patients meal, along with the corresponding diet card will be placed on a tray. 3) As the tray is delivered to the patients room, the person delivering the meal will verify that the patient in the room is the patient to receive the tray. The room number cannot be the identifier."
Food preparation and delivery by staff #15 was observed on 01/29/2013 at 12:00 PM. Staff #15 did not have a current food handlers certification. Staff #15 did not use diet cards to prepare or serve the food. Staff #15 did not follow the daily menu. Staff #15 delivered the trays to the patients' rooms without checking the identification of the patient with a meal card.
During an interview on 01/29/2013 at 12:00 pm, staff #15 reported that the facility was out of the meal on the menu. She picked another frozen dinner to serve. Staff #15 stated, "They dont always have the fruit or desserts to serve from the menu so I just pick something else."

B. maintain minimal standards specified by federal and state guidelines, providing kitchen sanitation and acceptable hygiene practices.
Review of facility policy, "Food Supply," revealed the following:
"Food supplies are purchased and stored under sanitary, safe, and secure conditions as required to meet federal, state, and local laws."
Observation of food storage on 1/29/2013 at 9:00 AM, revealed refrigerator #1 had opened packages of ham and cheese with no dates marked on the open packages. Five expired fruit cups and 2 bottles of expired condiments were identified in refrigerator #1. Freezer #2 had 10 sacks of pre-cooked microwavable eggs in zip lock bags, labeled with only the date transferred to the bag. There were open packages of bacon, sausage, and biscuits in freezer #2 with no dates, nutritional value, or expiration dates. Condiments were stored in open shipping boxes in the back storage room.
Review of facility policy, "Food Safety Procedures," revealed the following:
"Prepared foods are purchased, stored, and served in a safe and sanitary manner."
Food preparation by staff #15 was observed on 01/29/2013 at 12:00 pm, revealing the following;
-Staff #15 failed to check the temperature of the meals with a thermometer. The meals were transferred to a paper plate and covered with plastic. No patient identification cards were used.
- The food cart was brought in from the dirty area without being cleaned.
- Staff #15 had to leave the clean area to throw trash away.The trash was placed in the "dirty side" trash can with the same gloves she was preparing food. Gloves were not changed.
- Staff # 15 put on a cloth apron over her uniform, which she had been wearing in patient rooms. Staff #15 continued to wear the apron outside of the kitchen to deliver the trays into patient rooms.The apron was hung back up on the wall for reuse again in the clean prep area.
- While delivering food, staff #15 touched a tray table, patients, and doors. She wore the same gloves in two of the patients' rooms without washing her hands in between.
-The floors in the clean preparation area had food crumbs and dirt on them. Countertops had crumb build up. Microwaves were soiled with food and liquid substances on the inside. There was no cleaning schedule for the clean preparation area.
- Cooking utensils were stored 6 inches from the floor and were covered in dust.
During an interview on 1/30/2013 at 2:30 PM, staff #3 and staff #17 confirmed expired items were present in refrigerator #1. Staff #3 and staff #17 also confirmed that dishes and utensils for cooking were stored improperly on bottom shelves and were covered with dust. Staff #3 and staff #17 confirmed the microwaves, floors, and countertops were dirty.

C. employ a full time director of food services.
Refer to Tags 0620

D. assure certification, competency, or training in appropriate food handling for 7 (#12, #14, #15, #16, #17, #33, #39) out of 8 (#3, #12, #14, #15, #16, #17, #33, #39) nursing staff.
Refer to Tag 0622
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review and interview, the facility failed to:

A. inform and/or provide a copy of patient's rights.

Refer to tag A0117

B. develop policies that protect and promote patient's right to file a grievance.

Refer to tag A0118

C. provide patients with a safe environment

Refer to tag A0144

D. provide a process that would honor a surgical patient's, outpatient's advance directive or a process to provide information to patients wishing to formulate an advance directive.

Refer to tag A0132
VIOLATION: ANESTHESIA SERVICES Tag No: A1000
Based on document review and interview, the facility failed to provide anesthesia policies or evidence of participation as part of the hospital's QAPI program.

Multiple request were made of staff#1, staff #2 and staff#3 for policies and procedures and evidence of an organized Anesthesia Department, along with evidence of anesthesia participation in the hospital's QAPI program. No policies and procedures were provided to the surveyors. No evidence anesthesia participation in the hospital's QAPI program was provided.

Review of Medical Executive Committee (MEC) Minutes for 2012 revealed no reports from the PIC. The only quality data reported in 2012 was a one page report regarding infection control in September. No departmental or contracted service quality evaluations were reported.

Review of Governing Body Minutes for 2012 revealed no reports from the PIC. The only quality data reported in 2012 was a one page report regarding infection control in September. No departmental or contracted service quality evaluations were reported.

During an interview on 1/29/13 at 2:57pm in the conference room, staff #2 reported the following:
-After reviewing the January through October 2012 MEC and Governing Body Minutes, staff #2 confirmed no departmental or contracted service quality evaluations were reported
-Staff #2 attended the November and December 2012 MEC and Governing Body meetings and no quality data were reported or discussed
-There was no evidence of quality assessment of any contracted patient care services from January 2012 to present

During an interview on 1/29/13 at 3:21pm, staff #3 reported the following:
-Staff #3 "took over" QAPI at the end of July 2012
-There was no PIC committee at present

An interview with staff #1 and staff #2 on 01/28/2013 at approximately 2:33PM in the conference room revealed there were no anesthesia policies.
VIOLATION: OPERATING ROOM REGISTER Tag No: A0958
Based on document review and interview, the facility failed to maintain an operating room register that contained the following required elements: patient's name, patient's hospital identification number, date of the operation, inclusive or total time of the operation, name of the surgeon and any assistant(s), name of nursing personnel (scrub and circulating), type of anesthesia used and name of person administering it, operation performed, pre and post-op diagnosis, age of patient.

A review of the operating room register revealed the missing elements of: inclusive or total time of the operation, name of nursing personnel (scrub and circulating), name of person administering anesthesia, pre and post-op diagnosis.

An interview with staff #3 on 01/29/2013 at approximately 2:00PM in the conference room confirmed the missing elements form the operating room register.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0146
Based on interviews and observations, it was determined that the facility failed to keep medical records safe and confidential.
Findings include:

During a tour of the facility on 01/28/2013 at 9:00am, room 253 was found unlocked with 45 boxes filled with patient medical records from a closed Emergency Department, owned by Doctors' Hospital. A locked closet attached to the GI laboratory also has multiple boxes of closed patient files that could be accessed through a window in the GI laboratory.

An interview with staff #7 on 1/28/2013 at 9:20am confirmed the patient files were stored in unlocked/unsecured rooms.
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on interviews and observations, it was determined that the facility failed to keep medical records safe and confidential.
Findings:

During a tour of the facility on 01/28/2013 at 9:00 AM, room 253 was found unlocked with 45 boxes filled with patient medical records from a closed Emergency Department owned by Doctors' Hospital. A locked closet attached to the GI laboratory also had multiple boxes of closed patient files that could be accessed through a window in the GI laboratory.

An interview with staff #7 on 1/28/2013 at 9:20 AM, confirmed the patient files were stored in unlocked/unsecured rooms.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record review and interviews, the facility failed to:
A. provide policy and procedures for the medical records department.
The facility was unable to provide policy and procedures for medical records.
During an interview on 01/31/2013 at 3:00 PM, staff #5 confirmed the findings above.
During an interview on 01/28/2013 at 1:20 PM, staff #20 stated, "I haven't seen any policy and procedures for medical records."

B. keep medical records safe and confidential.
Refer to Tag 0146 and 0442


C. ensure telephone/verbal physician orders were dated , timed and signed in 7 of 31 ( #s' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
Refer to Tag 0450 and 0454


D. require medical staff to have history and physicals on 5 (#3, #12, #14, #16, #24) out of 6 (#13, #3, #12, #14, #16, #24) charts prior to surgical procedures.

Refer to Tag 0458
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on interview and record review the facility failed to ensure telephone/verbal physician orders were dated , timed and signed in 7 of 31 ( #s' 1, 2, 6, 12, 13, 21, and 24 )charts reviewed.
This deficient practice could cause harm to all patients presenting to the ED and in-house.
Findings include:
Review of the "Rules and Regulations of the Medical Staff ", dated 11/16/2011 revealed the following:
* A verbal order shall include the date, time, and full signature and title of the person to whom the verbal has been given.
* The prescriber shall authenticate the verbal order within forty-eight (48) hours unless a specific hospital policy for a specific type of order requires a short time.
* The authentication of the order shall include the signature, date and time the prescriber authenticated the order.
Review of medical records revealed the following verbal orders were not timed, dated or countersigned by the physician:
Patient #1 had 2 orders;
Patient #2 had 3 orders;
Patient #6 had 2 orders;
Patient #12 had 1 order;
Patient #13 had 1 order;
Patient #21 had 3 orders;
Patient #24 had 7 orders;
During an interview on 01/28/13 at 3:28 PM, Staff #3 and #5 confirmed the findings listed above.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on document review and interview, the facility failed to ensure the competence of contract and agency nurses.
A review of the document titled, "Contract/ Agency Employee Orientation," revealed, "It is the policy to, when needed and appropriate; utilize contract, agency and/or shared personnel in order to provide patient care and services. When these individuals are utilized, the hospital will ensure that they are competent to perform assigned duties by verifying current CPR, professional licensure/certification and other credentials required by federal and state law or hospital policy. The hospital will ensure that all contract, agency and shared employees are oriented to the hospital's policies and procedures including:
* Fire Safety Plan
* Electrical Safety
* Body Mechanics
* Hazardous Materials Communication
* Personal Protective Equipment
* Protect Yourself Handling Sharps
* Reporting Exposure Incidents
* Maintaining a Secure Workplace
* Hospital Codes I-low to Report
* Safe Medical Devices Act
* Infection Control
* Blood borne Pathogens
* TB Control
* Occurrence Reporting
* Keeping Risk of Exposure in Perspective
* Preventing Medication Errors
* Emergency Preparedness Plan Outline
* Other General Information
Documentation regarding the utilization and orientation of all nursing contract and agency employees will be maintained in Nursing Administration."

On 01/29/2013 at approximately 11:00AM in the conference room an interview with staff #3 and staff #6 confirmed the facility did use agency nurses. The interview further confirmed the facility did not follow the policy, "Contract/ Agency Employee Orientation." The facility did not maintain personnel files or documentation regarding the utilization and orientation of the contract and agency nurses.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interview, the facility failed to maintain patient care supplies by allowing the supplies to expire beyond the use date.

During the tour of the facility on 01/28/2013 at approximately 12:42PM expired supplies were found in the Nurses Clean Supply Room. The found supplies were:
Support Tray X4 expired 10/2012
Ultrasite Additive/IV administration set X1 expired 5/11/2011
Braslow Pediatric Emergency System Kits X 4 kits expired 9/2012
Braslow Pediatric Emergency System Kits X 10 kits expired 12/2012

During the tour of the facility on 01/28/2013 at approximately 1:00PM expired supplies were found in the Endoscopy processing room and the Endoscopy procedure room. The found supplies were:
Formalin Solution X2 bottles expired 1/20/2010
70% alcohol X1 bottle expired 8/2011
Blood Draw Butterfly's X 3 boxes expired 07/2012
60 cc syringe expired 12/2012

Other patient care items found thoughout the tour were:
Endocervical Speculums X17 expired 1/31/2008
Tracheamonis X9 expired 1/2008

During the tour of the facility on 01/28/2013 at approximately 12:42PM, staff #3 and staff #9 confirmed the above expired patient care items.