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.

WILLOUGH AT NAPLES, THE 9001 TAMIAMI TRAIL EAST NAPLES, FL June 23, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The Condition of Participation for Patient Rights is out of compliance based on observation, interview and record review, it was determined the facility failed to implement or honor patient rights for all 63 patients receiving care in this Class III Hospital. The facility failed to ensure the patients were treated with respect and dignity in regards to ensuring they were given a choice of snacks, or a choice of where the snacks were being given. The facility failed to ensure patients were living in a clean and home like environment. Facility failed to ensure that patent's receiving a Physician Prescribed therapeutic diet was receiving that diet. Facility failure to ensure proper medications were ordered, given and dispensed appropriately to the patients as prescribed by the physician. Facility Physicians continue to ignore the pharmacist recommendation as it pertained to unnecessary drugs. Facility failure to monitor the Director of Nursing supervisory skills, as it pertains to ensuring patient rights were not being violated.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure the provision of quality health care in a safe environment and assure the quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all 63 patients currently being served by this hospital.


The findings include:

Snacks:
The Director of Nursing was interviewed on 6/20/11 at 2: 00 p.m. in reference to snacks being dispensed from the nurses' station. The DON said it was easier for the facility to dispense the snacks in this manner, as they could receive the snacks while they were receiving medications. The DON also said it was difficult for snacks to be given out from the dietary department as that department was too busy and the patients at times became unruly. She further stated by nursing handing out snacks, they could monitor what each patient was taking. She was asked why, on this date, the patients were only offered a choice a Granola Bar, a Yogurt or Flax seeds, she replied because they are healthy. When asked why they were not offered fruit, she said because they are not allowed to bring fruit to their rooms. She stated the patients can not have fruit in their rooms because the fruit rots in their rooms and causes a bug problem. When ask why patient rooms are not monitored in regards to spoiled fruit, she said we do not have the time for that. My staff is too busy. The DON was then asked if she felt this was a patient right issue, and she had no answer.

On 6/21/2011 at 3:00 p.m., the Certified Dietary Manager (CDM) was questioned in regards to snacks being served from the nurses' station. The CDM said she had a system in place to serve patients during the day, distributing snack from the cafeteria line. The CDM went on to say the patients loved this it was a time for them to socialize as well. The CDM was asked if this was her idea to switch the snacks to be distributed from the nurses' station, and she confirmed it was not her idea, but the DON wanted it that way. When asked if patient's snack items were limited to Yogurt, Granola Bar, or Flaxseeds, she said no, they could have anything they wanted when they were given in the dietary department. They are limited to only three choices at the nursing station.

On 6/22/11 at 11:00 a.m., the Registered Dietitian (RD), CDM, and DON were questioned in regards to snack distribution for patients. The RD said she wanted to make sure the snacks were healthy, and of good nutritional content. The RD also confirmed it would be a more social setting to have snacks in the cafeteria area. The DON at this point continued to argue that dispensing the snacks at the nurses' station was not an issue. When asked again if the patients are given a choice as to where they receive there snacks, she had no answers. When the DON was asked again if she felt this was a Patient Right issue, she had no answer.

Environment:
The hospital failed to implement a preventative maintenance program to ensure the interior of the building was in good repair.

During a tour of the hospital, on 6/20/11 at approximately 9:40 a.m., the following observations were made:

Patient rooms on the 200 hall were noted to have unpainted plastered white areas on bedroom walls. The door jambs in patient rooms had large areas of chipped off paint. A broken drawer was observed in room 216. The front of the broken drawer had two sharp staples protruding from the front. The patient reported the drawer had been broken for about two weeks and it had been reported to staff. The bathroom in Room 216 had rust areas on the wall near the tub and the shower head is rusty. The caulking around the tub and vanity caulk was brown and cracked. In Room 214, the threshold had no floor covering and the concrete was visible. In Room 208 the toilet was continually running. In Room 201 caulk was missing around the toilet. The air conditioning vent located in the patient laundry room had a thick accumulation of dirt and dust on the air conditioning vent. In the area used for patient storage, the "Men's Sauna Room" there was a hole in the storage room which has the potential for vermin or rodent entrance. When this was pointed out to the Director of Nurses she stated the room was "only used for storage."

Interview during the tour with staff revealed "things were a lot better after you guys were here, it's getting bad again."

During the tour of the 100 Hallway on 6/20/2011 at 9:49 a.m. the following was observed:

The floor in the hallway had numerous food spills on the tile floor. Further observation revealed the entire hallway floor was coated with dirt and grime.

Observation of Room 208 toilet continually ran.

Room 202 tile in shower surround did not match, and the grout between the tiles had a black substance.

Room 204 Bedroom floor dirty and soiled. Bathroom floor was soiled and dirty. There was also a lot of rust observed around plumbing fixtures.

Room 202 Observed light fixture that was changed, and the wall surrounding the fixture was not painted.

Room 201 Observed caulking missing around the toilet.

Observation of the patient's laundry room on the 100 hallway revealed the floor had a build-up of dirt and was very soiled. There was an unidentified brown substance on the floor as well. The air conditioning vent located on the ceiling had a thick accumulation of dirt and dust. When the aide was asked if the washer and drier worked, she said the driers are broken.

Therapeutic diets:
The facility failed to ensure 1 (Patient #6) of 21 sampled patients received education or counseling in regards to the importance of adhering to a diabetic regime.

Patient #6 was admitted to the facility on [DATE] with a diagnosis of Bi-Polar Disorder and Diabetes Mellitus. Further review of the clinical record revealed the patient was Insulin dependent and had a physician order date 5/16/11 to receive Accu-Checks 4 times daily at 6:00 a.m., 11:30 a.m., 5:00 p.m., and 9:00 p.m.

Review of the patient's Medical Administration Record (MAR) reveals the following notation on the back of the MAR. "5/19/11 at 11:30 Patient called for blood sugar check never showed up. Medical Doctor (MD) notified. And teaching done to patient. Will continue to monitor patient (PT) for any changes."

Notation on 5/20/11 at 11:30 a.m., reveals; "Resident still refused to have stick (meaning accu-check) for Blood sugar after all teaching done. MD is aware. Will continue to monitor pt. for any changes."

Medications:
During a review of Medication Occurrences/Error Reports on 6/22/11, it was noted the reports fail to be complete. Absent is the patient name, the nurses/pharmacists name, no investigation notes and no follow-up notations.
Examples would be as follows:

5/9/11 - Zofran 4 mg p.o. (by mouth) was discontinued on the MAR (Medication Administration Record) but the physician had not ordered it stopped. No patient name, no nurse's names, No DON signature, No Quality Improvement Directors Signature and no provision for the Risk Managers signature.

5/14/11 - Luvox 50mg PO at 0600, 1300, & 1800. When order transcribed to MAR the medication was transcribed as BID (twice a day) not three times as was ordered.
No patient name, no nurse's names, No DON signature, No Quality Improvement Directors Signature and no provision for the Risk Managers signature.

Interview with the Risk Manager on 6/21/11 revealed she does not see the medication errors as they are sent directly to the pharmacy.

Following/acknowledging pharmacist's recommendations:

During an interview with the pharmacist throughout the survey, he revealed he does in fact send out recommendations and corrections when medications do not seem like the orders are correct or sufficient. He further stated he quite often has to send out recommendations when too many medications are ordered or when too many of the same class of medications are ordered. During these interviews, he stated that one specific physician (Physician #1) as a rule, ignores his recommendations and fails to even respond to him. Examples are as follows:

1. To Physician #1 - 5/20/11.
Please review Patient's medications: Lamictal, Depakote, Keppra & Triletal (4 mood stabilizers).
Please review other meds as well:
As per our last P&T (Pharmacy and Therapeutics) meeting: Patient on 21 standing medications excluding PRN's (as necessary)

2. To Physician #1 - 5/4/11.
Please review Patient's medications: Patient on Adderall 5x a day for a total dosage of 165mg
(The combination of dextroamphetamine and amphetamine (Adderall) comes as a tablet and an extended-release (long-acting) capsule to take by mouth. The tablet is usually taken 2-3 times daily, 4-6 hours apart, with or without food. The extended-release capsule is usually taken once daily in the morning with or without food. Dextroamphetamine and amphetamine combination should not be taken in the late afternoon or evening because it may cause difficulty falling asleep or staying asleep. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take dextroamphetamine and amphetamine exactly as directed.) Physicians PDR - 2010 Edition

3. To Physician #1 - 7/27/10
Please review Patient's medications:
1. Restoril 30mg HS (bedtime) 2. Ambien 10mg HS 3. Xanax 0.5mg HS

4. To Physician #1 - 7/22/10
Please review Patient's medications: Mobic 7.5mg TID (three times a day for a total 22.5 mg daily)
In adults, the maximum recommended daily oral dose of Mobic is 15mg regardless of formulation. In patients with hemodialysis, a maximum daily dosage of 7.5mg is recommended (pharmacist's notes)

5. To Physician #1 - 4/10/11
Please review Patient's medications: Neurontin, Tegretol and Lamictal (3 mood stabilizers)
The physician failed to respond to the pharmacists and continued dosages/medications as he ordered.

Nursing Services:
1. Observation of medication administration on 6/20/11 and 6/21/11 on Unit 100 and Unit 200 shows at 6:00 a.m., nursing staff place patient medications in a cup which is then placed in the patient's medication drawer. The Over the Counter (OTC) medications are put in a paper cup with the patient's initials. These OTC medications are not identified or labeled by the pharmacist. The prescribed medications do not remain in the plastic container with prescription instructions prior to being given to the patient. Review of the hospital Policy and Procedure for Medication Administration, NUR.7:011 dated 2/21/06 and revised 2/24/11 shows medications will not be double poured. The policy does not show medications are taken to the patient without the prescription instructions. The Director of Nurses was asked on 6/20/11 why the nurses administer medications in this manner. She stated she set up the process of putting the medications in a cup prior to medication administration time. It saves the nurse's time. The nursing policy and Procedure for Medication Administration was not revised and approved for the current nursing practice of medication administration.

2. The Director of Nursing failed to evaluate the registered nurse for the quality of care being administered to the facility population. She failed to examine the provision of nursing care and its effects on patients.

On 6/21/11 at approximately 4:00 p.m. the DON (Director of Nursing) was asked if she evaluated the nurses for competency for medication administration and patient care. She said that she did and provided competency checklists. Review of these checklists shows they were not completed by the DON. Nursing staff completed them on each other and no deficiencies were noted. There was no DON signature to show she had reviewed or validated the competency checklists. She also stated all nurses were in-serviced on medication administration and this was confirmed by the pharmacist. The pharmacist provided the in-service material and it was all inclusive of administering medications, ordering refills of prescriptions, pharmacist contact information, documentation, proper medication storage and physician orders. T he in-service was held in early May 2011. No follow up to the in-service had been implemented to ensure that the nursing staff was complying with the standards of practice and the hospital policies.

The DON failed to have any documentation of her competency validations for the nursing staff.
VIOLATION: MEDICAL STAFF Tag No: A0338
The Condition of Participation is out of compliance based on observations, clinical record reviews and interviews, the Medical Staff has failed to ensure coordination of activities and general policies and procedures of the various departments as demonstrated by lack of coordination between pharmacy and the medical staff, nursing and the medical staff. The hospital failed to implement a system to ensure that the hospital's infection control program provided for the surveillance and control of patient infections.

This facility is a Class III Psychiatric Hospital. This deficient practice violates patient rights, does not meet a standard of care and has the potential of causing physical harm as well as emotional distress in those 63 patients receiving treatment in this facility.


The findings include:

1. The facility physicians failed to respond to recommendations made by the pharmacist whose job it is to monitor medications to avoid medications overdosing and or the possibility of duplication of classes of medications

Failure to follow/acknowledging pharmacist's recommendations:

During an interview with the pharmacist throughout the survey, he revealed that he does in fact send out recommendations and corrections when medications do not seem like the orders are correct or sufficient. He further stated he quite often has to send out recommendations when too many medications are ordered or when too many of the same class of medications are ordered. During these interviews, he stated that one specific physician (Physician #1) as a rule, ignores his recommendations and fails to even respond to him. Examples are as follows:

A. To Physician #1 - 5/20/11.
Please review Patient's medications: Lamictal, Depakote, Keppra & Triletal (4 mood stabilizers).
Please review other meds as well:
As per our last P&T (Pharmacy and Therapeutics) meeting: Patient on 21 standing medications excluding PRN's (as necessary)

B. To Physician #1 - 5/4/11.
Please review Patient's medications: Patient on Adderall 5x a day for a total dosage of 165mg
(The combination of dextroamphetamine and amphetamine (Adderall) comes as a tablet and an extended-release (long-acting) capsule to take by mouth. The tablet is usually taken 2-3 times daily, 4-6 hours apart, with or without food. The extended-release capsule is usually taken once daily in the morning with or without food. Dextroamphetamine and amphetamine combination should not be taken in the late afternoon or evening because it may cause difficulty falling asleep or staying asleep. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take dextroamphetamine and amphetamine exactly as directed.) Physicians PDR - 2010 Edition

C. To Physician #1 - 7/27/10
Please review Patient's medications:
1. Restoril 30mg HS (bedtime) 2. Ambien 10mg HS 3. Xanax 0.5mg HS

D. To Physician #1 - 7/22/10
Please review Patient's medications: Mobic 7.5mg TID (three times a day for a total 22.5 mg daily)
In adults, the maximum recommended daily oral dose of Mobic is 15mg regardless of formulation. In patients with hemodialysis, a maximum daily dosage of 7.5mg is recommended (pharmacist's notes)

E. To Physician #1 - 4/10/11
Please review Patient's medications: Neurontin, Tegretol and Lamictal (3 mood stabilizers)
The physician failed to respond to the pharmacists and continued dosages/medications as he ordered.
2. Lack of communication between the medical staff and the nursing department related to notification, in a timely manner, of lab results identifying an infectious patient.

On 6/20/11 at about 11:20 a.m., an interview with Patient #15 revealed he had just been told that he was positive for Hep-C. Asked if he was a needle user, he stated "no way, I am here because I am a schizo. I figure I got it from all these tattoos my cousin used doing these in his basement." Patient was observed to have numerous visible tattoos.

Review of the clinical record for this patient (Patient #15) revealed his physician, on 6/4/11, ordered a Hepatitis panel and HIV testing. The diagnosis listed was "unprotected sex". The results of those tests were sent to facility on 6/10/11. On 6/13/11, Dr. ________ reviewed the results which show the patient to be reactive to the Hep-C panel. He was negative for HIV. The patient was not told of the results until 1 week later (6/20/11).

An interview with the Director of Nursing at about 1:30 p.m., on 6/20/11 revealed she was unaware of the test results. She was asked what precautions were being taken and what staff education has been done and she stated "I'm working on it."

3. During a review of Medication Occurrences/Error Reports on 6/22/11, it was noted that the reports fail to be complete. Absent is the patient name, the nurses/pharmacists name, no investigation notes and no follow-up notations.
Examples would be as follows:

5/9/11 - Zofran 4 mg p.o. (by mouth) was discontinued on the MAR (Medication Administration Record) but the physician had not ordered it stopped. No patient name, no nurse's names, No DON signature, No Quality Improvement Directors Signature and no provision for the Risk Managers signature.

5/14/11 - Luvox 50mg PO at 0600, 1300, & 1800. When order transcribed to MAR the medication was transcribed as BID (twice a day) not three times as was ordered.
No patient name, no nurse's names, No DON signature, No Quality Improvement Directors Signature and no provision for the Risk Managers signature.

Interview with the Risk Manager on 6/21/11 revealed she does not see the medication errors as they are sent directly to the pharmacy.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on clinical record reviews, interviews, and review of policies and procedures, it was determined the hospital does not have an effective organized Nursing Department that provides 24-hour services to maintain the health, safety, and well-being of the patients it serves as it relates to this Condition of Participation.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment and assure the quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

The findings include:

1. The record review conducted on 6/22/11, for Patient #4 shows the patient was admitted on [DATE]. The patient's diagnoses include, but are not limited to, Anxiety, Diabetes and Hypercholestremia. On 6/4/11 at 4:30 p.m., the patient's Advanced Registered Nurse Practitioner (ARNP) wrote an order for Pravachol 40 mg. tablet, take 1 ? tablet (60 mg.) daily for high cholesterol. The order was signed by the nurse as noted on 6/4/11 at 6:45 p.m. The patient's Medication Administration Record (MAR) shows the order was transcribed to the form on 6/4/11 and the time for administration is 9:00 p.m. From 6/5/11 through 6/12/11 the MAR is marked as "NA" (not available) for the prescribed Pravachol. No documentation is noted for the dates of 6/13, 6/14 and 6/15/11. On 6/16/11 and 6/17/11 the medication is initialed as being administered. On 6/12/11 the patient was given a prescription for Simvastatin 20 mg. by mouth daily and the Pravachol was discontinued. Both medications are used to lower cholesterol blood levels. Documentation shows that the patient received Pravachol and Simvastin on 6/16/11 and 6/17/11. Nursing staff failed to discontinue the Pravachol as ordered when the alternate medication, Simvastatin, was ordered. On 6/20/11 the Director of Nurses said that they do not have Pravachol here and they should have substituted it. She was asked to investigate the medication omission. On 6/21/11 at 9:25 a.m., the DON returned and said that the nurses did not recognize the generic name of the Pravachol. S he said the pharmacy had sent 20 mg. tablets of the Pravachol, not the 40 mg. tablets that was on the order. She stated the Pravachol had been replaced with Simvastatin and that the patient did get both Pravachol and Simvastatin for two days.

Nursing staff failed to notify the physician that the patient's Pravachol was not administered as ordered and failed to clarify the order with the pharmacy or physician for the Pravachol. They failed to administer Pravachol as ordered and to discontinue the Pravachol when the replacement medication, Simvastatin, was ordered.

2. On 6/22/11 a record review for Patient #12 shows the patient was admitted on [DATE]. The patient has diagnoses of, but not limited to, Bipolar Disorder and Alcohol Dependency. The patient had physician orders for Phenergan 25 mg. P.O. (by mouth) or IM (intramuscularly) every four hours as needed for nausea/vomiting. The patient's Medication Administration Record (MAR) shows the patient received injections of Phenergan on 6/15/11 at 2130, 6/19/11 at 1100 and 6/22/11 at 1800. The patient also had an order for Phenergan 25 mg. by mouth every four hours as needed for nausea/vomiting. A tablet of Phenergan was given 6/16/11 at 1030, 6/14/11 at 2230 and at 0310 and given on 6/18/11 at 0900 and 2130. Review of the nursing progress notes and MAR's shows the nursing staff did not document the patient's complaint prior to administration nor did they document the effectiveness of the Phenergan. In addition, a dose of Phenergan is documented as being given on 6/16/11, at 2125 and the route of administration is not documented.

Patient #12 also had physician orders for Tylenol Extra Strength 1000 mg. every 4 hours as needed for pain, which was given twice and Ibuprofen, 400 mg. one tablet as needed for headache, malaise, or menses. He Ibuprofen was given three times. No nursing documentation is found to identify the location of the patient's pain or the effectiveness of the medication to relieve the patient's pain.

During an interview with the hospital Pharmacist on 6/22/11 at 3:30 p.m., the pharmacist stated he had identified that nursing staff needed to improve signing out of PRN (as needed) medications and documenting the effectiveness of the medication. An in-service was given to nursing staff in May 2011.

Review of the nursing progress notes on 6/22/11 shows at 2200 on 6/17/11 the nurse documented the patient was administered Phenergan 25 mg. p.o. at 2100. This medication administration was not documented on the MAR. The effectiveness of administering the Phenergan is also not documented.

The patient was also prescribed Mylanta II, 30 cc. every 4 hours as needed and Mylanta II, 2 tablets every 4 hours as needed. The patient received one dose of the liquid and on dose of the tablets on 6/14/11. Nursing staff did not document the patient's complaint prior to administration nor did they document the effectiveness of the Mylanta II.

3. Record review on 6/21/11 for Patient #16 shows the patient was admitted on [DATE] with a diagnosis of Depression. He patient is alert and oriented. The record shows the patient had a prescription dated 6/15/11 for Thorazine 25 mg. two tablets (50 mg.) three times daily. The Medication Administration Record shows the times of administration at 10:00 a.m., 2:00 p.m., and 9:00 p.m.

An interview with the patient on 6/21/11, at approximately 1:30 p.m., revealed on Monday, 6/20/11 the patient received her 10:00 a.m. dose of Thorazine 50 mg. but forgot to go to the Nursing Station for her 2:00 p.m. dose. She said that usually someone would remind her but she was in group. On 6/20/11 at approximately 3:45 p.m., the patient's physicians wrote an order to reduce the Thorazine to 50 mg. twice a day. Review of the patient's MAR shows the nurse who gave the patient her 10:00 a.m. dose of Thorazine also had initialed the 2:00 p.m. dose as being administered. Per the patient, the evening nurse refused to give her a Thorazine 50 mg. tablet at 9:00 p.m., as she usually had, telling the patient that she had already gotten it at 2:00 p.m. ,and that makes two doses for the day.

No documentation is in the record to show that nursing staff made any attempt to verify that the day nurse gave the Thorazine at 2:00 p.m. T he physician was not informed the patient missed her 2:00 p.m., dose.

4. Medication administration observations on 6/20/11 at approximately 9:30 a.m., and 12:00 p.m., for the 200 hall showed that the patient medications had already been pulled and placed in medicine cups stored in the patient drawer of the medication cart. Over the Counter medications were placed in a white paper cup and had the cup labeled with the patient's initials. Medications were not prepared immediately prior to administration and all nursing staff did not inform the patients of the name and dose of the medication being given to them.
On 6/20/11 an observation of medication administration on the 100 hall at 10:15 a.m., with LPN med. nurse. The observation included the nurse removing from the patient drawer (in the medications cart) a clear plastic cup with the patient name written on it in black ink. Contained in this container were medications in their original single dose package. The nurse then proceeded to add to this cup additional medications (vitamins B-12 and fish oil). The patient produced his/her identification wrist band and the medications were then, individually, checked off the MAR (Medication Administration Record), the patient was told what the medication was (not dosage or why prescribed) and pills were then removed from packaging and placed back in the clear cup. When this process was completed for all medications, the container was handed to the patient who then consumed them. This process was repeated a total of 5 times during this observation.

The nurse was asked when she had prepared the "cups" of medications and she stated she does this at 6:00 a.m., so they are all ready for the 10:00 a.m., medication pass. She was asked why she did not verify each and every medication with the order and original packaging, labeled from the pharmacy, at the time of administration. She only looked at the portion of the MAR where the time of administration was. She did not verify the package with the actual order. She stated she did all the verification at 6:00 a.m., when she removed the packages from the container dispensed by the pharmacy. She was asked if she knew if she was dispensing according to policy, she did not know what the policy was.

Observation of the same nurse on the 100 hall on 6/21/11 found the same practice being used as on 6/20/11.

Interview with the pharmacist on 6/20/11 at about 11:30 a.m., revealed he was not aware the nurses were pre-pouring medications. He stated he would be in the facility tomorrow morning to observe medication administration practices.

Interview with the Director of Nursing revealed she was aware of the practice and stated "my nurses would never get the medications passed if they had to follow a different standard then what they are currently doing. There just are too many patients. How can you expect 2 nurses to administer medications to 60+ patients at 10:00 a.m.?"

The hospital Policy and Procedure for Medication Administration shows that double pouring will not be done. Nursing staff placed the medication package in the cup and then when it was to be administered, opened the package and placed in the medication back in the cup. On 6/20/11, the DON stated that she changed the process of preparing medications for administration to make it quicker for the nurses to give out medications. The change in procedure was not updated in the Policy and Procedure for Medication Administration.

5. On 6/21/11 at approximately 4:00 p.m. the DON was asked if she evaluated the nurses for competency for medication administration. She said that she did and provided competency checklists. Review of these checklists show that they were not completed by the DON. Nursing staff completed them on each other and no deficiencies were noted. There was no DON signature to show that she had reviewed or validated the competency checklists. She also stated that all nurses were in-serviced on medication administration and this was confirmed by the pharmacist. The pharmacist provided the in-service material and it was all inclusive of administering medications, ordering refills of prescriptions, pharmacist contact information, documentation, proper medication storage and physician orders. The in-service was held in early May 2011. No follow up to the in-service had been implemented to ensure that the nursing staff was complying with the standards of practice and the hospital policies.

6. Record review and patient interview on 6/20/11 revealed that Patient #7 did not have a repeat ammonia level drawn on 6/15/11 per physician order. Nursing staff documented that the patient asked for an extension and asked the patient why she refused to have it drawn. The patient stated that she did not refuse or want to put off the ammonia blood level as she was very worried about it. The patient said that the Lab Technician told her that she couldn't do it because she did not have a butterfly. Interview with the Unit Clerk on 6/21/11 at approximately 1:30 p.m., revealed that the lab slip was made out for the lab to be drawn on 6/20/11 but someone wrote "Wednesday" 6/20/11 so it was missed on 6/20/11. Nursing failed to notify the physician of the delay in the implementation of the order for an ammonia level.

7. A tour of the medication room on the 200 Hall was conducted on 6/21/11 at approximately 2:45 p.m. All shelves and medications stored on the shelves had a layer of dust covering them. A cabinet for storage of injectable medications had a layer of dust on the shelves and the bins holding medications had debris, hair and dust inside. A brown dried liquid was on the right hand wall and the open shelving next to the wall. Nursing staff stated that there is not a schedule for cleaning the medication room. The refrigerator for medications was rusty on the outside. When the DON was informed she stated " What do you want me to do about it, it's on the outside." Rusted areas have the potential to harbor bacteria.

8. On 6/23/11 a notice was noted to be hanging on the wall in the medication room. The notice stated that all vitamins would be administer at HS (bedtime).

An interview with the DON revealed she had made this decision in order to make the 10:00 a.m. med pass easier as most patients received multiple vitamin. "If the nurses don't have to contend with the vitamins, the pass would go much quicker."

Interview with the Administrator at about 10:00 a.m. on 6/23/11 revealed he was not aware of this change. It had not been approved by the P&T (pharmacy and therapeutics) committee and physicians had not been made aware (he is one of the facility physicians).

Interview with the pharmacist on 6/23/11 at about 11:30 a.m. verified that vitamins are normally given in the a.m. and given with food in the system. "Vitamins are sometimes difficult to digest and could cause problems with a HS (hour of sleep - bed time) delivery."

9. Random interviews with patients on the 100 and 200 halls during the survey from 6/22/11 through 6/23/11, patients have stated that when they request their PRN medications they are often told by the nursing staff that they are too busy to give them their medications. Various random patients state they are not assessed for their pain levels or for the need of the PRN medications.

During an interview with the Director of Nursing on 6/22/11, she asked how we expect her nurses to administer all those medications to 63 patients with only 2 nurses. She further commented that if they needed their PRN medications, they should request them during their scheduled medication administration times.

In an effort to ease the load on her nurses, the DON posted a notice that all vitamins would now be given at HS (bed time). This was done without consultations of the physicians or the P&T (Pharmacy and Therapeutics) committee or the Pharmacists.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, patient interview and staff interview the hospital failed to implement a preventative maintenance program to ensure that the interior of the building was in good repair.

Findings include:

During a tour of the hospital, on 6/20/11 at approximately 9:40 a.m., the following observations were made:

Patient rooms on the 200 hall were noted to have unpainted plastered white areas on bedroom walls. The door jambs in patient rooms had large areas of chipped off paint. A broken drawer was observed in room 216. The front of the broken drawer had two sharp staples protruding from the front. The patient reported that the drawer had been broken for about two weeks and that it had been reported to staff. The bathroom in Room 216 had rust areas on the wall near the tub and the shower head is rusty. The caulking around the tub and vanity caulk was brown and cracked. In Room 214, the threshold had no floor covering and the concrete was visible. In Room 208 the toilet was continually running. In Room 201 caulk was missing around the toilet. The air conditioning vent located in the patient laundry room had a thick accumulation of dirt and dust on the air conditioning vent. In the area used for patient storage, the "Men's Sauna Room" there was a hole in the storage room which has the potential for vermin or rodent entrance. When this was pointed out to the Director of Nurses she stated the room was "only used for storage." Interview during the tour with staff revealed that "things were a lot better after you guys were here, it's getting bad again."

During the tour of the 100 Hallway on 6/20/2011 at 9:49 a.m. the following was observed:

The floor in the hallway had numerous food spills on the tile floor. Further observation revealed that entire hallway floor was coated with dirt and grime.

Observation of Room 208 toilet continually ran.

Room 202 tile in shower surround did not match, and the grout between the tiles had a black substance.

Room 204 Bedroom floor dirty and soiled. Bathroom floor was soiled and dirty. There was also a lot of rust observed around plumbing fixtures.

Room 202 Observed light fixture that was changed, and the wall surrounding the fixture was not painted.

Room 201 Observed caulking missing around the toilet.

Observation of the patient's laundry room on the 100 hallway revealed the floor had a build-up of dirt and was very soiled. There was an unidentified brown substance on the floor as well. The air conditioning vent located on the ceiling had a thick accumulation of dirt and dust. When the aide was asked if the washer and drier worked, she said the driers are broken.
VIOLATION: INFECTION CONTROL Tag No: A0747
This Condition of Participation is not met based on observation, staff interview and hospital record review the hospital failed to ensure that the hospital's infection program included a system for the surveillance and ongoing evaluation of the environmental sanitation of the hospital and failed to respond promptly to institute precautions for 1 of 21 patients sampled (Patient # 15) who was identified as having a Hepatitis C infection. The hospital failed to implement a system to ensure that the hospital's infection control program provided for the surveillance and control of patient infections.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure the provision of quality health care in a safe environment and assure the quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

The findings include:

1. On 6/20/11 at about 11:20 a.m., an interview with Patient #15 revealed he had just been told that he was positive for Hep-C. Asked if he was a needle user, he stated "no way, I am here because I am a schizo. I figure I got it from all these tattoos my cousin used doing these in his basement." Patient was observed to have numerous visible tattoos.

Review of the clinical record for this patient (Patient #15) revealed his physician , on 6/4/11, ordered a Hepatitis panel and HIV testing. The diagnosis listed was "unprotected sex". The results of those tests were sent to facility on 6/10/11. On 6/13/11, Dr. ________ reviewed the results which show the patient to be reactive to the Hep-C panel. He was negative for HIV. The patient was not told of the results until 1 week later (6/20/11).

An interview with the Director of Nursing at about 1:30 p.m. on 6/20/11 revealed that she was unaware of the test results. She was asked what precautions were being taken and what staff education has been done and she stated "I'm working on it."

Staff education had not occurred. Precautions had not been put into place and patient education had not taken place as of 6/23/11 at about 4:45 p.m. when the survey was concluded.

2. On 6/20/11, from approximately 9: 45 a.m. 11:00 a.m., a tour of the hospital 200 Wing was conducted. Findings in patient rooms included black stained grout and missing grout in patient bathrooms, dirt on bedroom and bathroom walls, rusted medicine cabinets and bathroom fixtures, soiled carpets, a hole in the wall in room 214, food spills on tile floors, torn fabric on chairs and a buildup of dirt and soil on the patient laundry floor.

On 6/22/11 at approximately 4:20 p.m. observations were made in the Lab Supply Room. The shelves of the room were covered with a thick layer of dust. Boxes on the counter were dusty. The Air Conditioning vent had a large amount of dust covering each slat.

On 6/21/11 at approximately 2:45 p.m., observations in the medication room on the 200 Hall showed a layer of dust covered the shelving and the supplies stored on the shelves. A cabinet for storage of injectable medications had a layer of dust on the shelves and the plastic bins holding medications had debris, hair and dust inside. A brown dried liquid was on the right hand wall and the open shelving next to the wall. Nursing staff present in the medication room were asked if there was a schedule to clean the medication room and they stated that there is not but they let the housekeeper and she sweeps and mops. One nurse stated that he had dusted the room a few days ago and there is always dust getting in. The refrigerator for medication storage was rusty on the outside. When the DON was informed she stated "What do you want me to do about it, it's on the outside." She was told that rusted areas have the potential to harbor bacteria.

The Contracted Infection Control Nurse (ICN) was interviewed on 6/21/11 at approximately 11:10 a.m. She said that she has noted the condition of the medication rooms and had planned to speak to staff. The ICN was informed of the sanitation findings in patient rooms.

Review of the infection control program and data with the ICN shows that monthly monitoring does not include environmental observations to ensure a sanitary environment. When interviewed on 6/21/11 at approximately 1:30 p.m. the Housekeeping Supervisor said that she checks the housekeepers work. She provided completed monitoring forms of her staff performance. No deficiencies were noted on the forms. This monitoring did not appear to identify the sanitation issues pervasive in the 200 hall.