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Based on observation, interview and record review, the Governing Body failed to:


A. ensure that the Chief Operating Officer(COO) had a delineation of duties on file at the facility that would outline responsibilities in managing all hospital functions, activities, and patient care. The COO had a job description on file for Director of Business Development.


Review of Staff #2's personnel file on 9-18-2018 at 1:55 PM revealed a Job Description for, "Director of Business Development". The job description was signed on 11-19-2015. There was no job description for COO. Staff #2 was listed as the COO in the organizational chart.

During an interview on 9-18-2018 Staff #25 confirmed that Staff #2 had not signed a new job description since taking the position of COO.

Staff #2 failed to ensure that medical staff followed hospital bylaws and policies on medical record compliance. Also, Staff #2 failed to ensure the facility maintained a safe physical and sanitary environment.


Review of the hospital job description for Chief Operating Officer revealed the following:

"Position Summary: The Chief Operations Officer (COO) manages, administers, coordinates, evaluates, controls, and directs all hospital related functions and activities. He/She oversees organizational compliance, advocacy, and patient satisfaction programs, establishes goals, objectives, standards and regulations of performance, develops operating policies and procedures, interprets hospital policies standards and regulations to staff, patients, and medical staff, and public. In conjunction with CEO, develops hospital strategy with and through the senior management team."






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B. ensure the chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water treatment systems.

The facility failed to ensure the Ultra-Low Total Chlorine Test Strip that are used to measure low levels of total chlorine were not used beyond the manufacture expiration date.


The facility failed to ensure the staff labeled the jug of dialysate solution with the additive of powdered potassium chloride and /or calcium chloride which were for altering concentration of the dialysate.


The facility failed to ensure the security of the dialysis supplies and products in the acute dialysis unit.


The facility failed to ensure the pick-up tubes (wands) were fitting securely to the acid and bicarbonate jugs that were being used to dialyze the patients during a dialysis treatment to prevent bacterial contamination and evaporation.


The facility failed to ensure dialysis products and supplies were not used beyond the manufacture expiration date.


The facility failed to ensure the informed consent for the dialysis treatment was signed by the physician for 4 (#11, #17, 18, and #22) of 6 hemodialysis patients. Also, the facility failed to follow their facility policy on informed consent.


The facility failed to follow the patient's dialysis prescription by using the ordered BFR (Blood Flow Rate) in 1 (#11) of 6 of the hemodialysis records reviewed. Patient #11's record showed 4 of 7 treatments where the BFR (Blood Flow Rate) did not follow the patient's dialysis prescription written by the nephrologist. The dialysis prescription was for the BFR to be ran at 350.


The facility failed to ensure 3 of 3 (#16, #17, and #19) contracted dialysis staff had been orientated to the facility.


The facility failed to ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.


The facility failed to ensure the dialysis Quality Assurance Performance Improvement (QAPI) program was developed, implemented, maintained and evaluated with focus indicators to improve the outcomes of the acute dialysis unit.

Refer to A tag 0144 for additional information.


C. to protect the patient's right to make informed decisions on their care in 6 (Patient's #2, #3, #13, #17, #18, and #19) of 11 patients reviewed. The facility failed to ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in Patient's #2, #3, #13, #17, #18, and #19. In addition, the facility failed to obtain consent for treatment on admission in 2 (Patient's #2 and #13) of 11 patient charts reviewed. Also, the facility failed to follow their own policy and procedures on Informed consent.

Refer to A tag 0131 for additional information.



D. ensure the confidentiality of medical records and personal information in 3 (Lab, Radiology, and 1st floor hallway) of 3 areas.

Refer to A tag 0147 for additional information.



E. ensure physician orders were obtained for restraint usage in 2 (Patient's #6 and #13) of 2 records reviewed.


Refer to A tag 0168 for additional information.


F. ensure identified sanitary environment deficient practices in the facility were identified and reported. The facility failed to ensure the Infection Control Officer identified, reported, and tract infection control problems in the departments. Also, the Infection Control Officer failed to ensure the quality assurance program had documentation of the infection control deficiencies and addressed the issues at the quarterly meetings.

Refer to A tag 0283 for additional information.

G. ensure the facility quality assessment and performance improvement program (QAPI) reflected all hospital services for 1 of 1 (Dialysis) contracted services. Also, the Governing body failed to ensure 35 of 35 contracted services were evaluated and provided in an effective manner.

Refer to A tag 0308 for additional information.

H. ensure sufficient Registered nurses and Certified nurse aides to provide patient care on 2 of 2 units (1st and 2nd floor units).

The facility failed to ensure enough Registered nurses were scheduled to provide supervision to Licensed vocational nurses on the 1st floor. The facility failed to allot for certified nurses aides on the 1st floor. The facility failed to address staffing numbers in their matrix for both units (1st and 2nd floor units).

Refer to A tag 0392 for additional information.


I. ensure that nursing staff had current competencies in 2 (Staff #3 and Staff #4) of 2 personnel files reviewed.

Refer to A tag 0397 for additional information.


J. ensure medications were administered in a safe manner in 5 of 11 sampled patients (Patient #'s 3, 5, 10,13, and 14).

The facility failed to ensure nursing staff who were titrating Diprivan/Propofol (An anesthetic/Sedative medication) had a valid physician's order.

The facility failed to ensure the "Warfarin Medication Order Sheet"protocol was implemented on Patient #10 on admission. Patient #10 continued to receive anticoagulant therapy when her blood work was out of range and was sent to a higher level of care for gastrointestinal bleeding.

Refer to A tag 0405 for additional information.


K. ensure blood transfusions were administered per their approved procedures in 1 of 4 patients sampled for blood administration (Patient #'s 3 and 12).

The facility failed to document the receipt time of blood from the contracted service, so they could ensure it was being transfused in the proper and safe timeframe. They failed to ensure physician's orders were complete with rate of transfusion.

The facility failed to obtain informed consent prior to administration of blood.

Refer to A tag 0409 for additional information.

L ensure physician orders were complete, timed, dated, and signed in a timely manner. The facility failed to ensure history and physicals were complete. This deficient practice was found in 8 (Patient's #1,2,3, 8, 9, 10, 12 and 13) of 30 sampled patients. Also, the facility failed to follow their own policy on verbal and telephone orders.


Refer to A tag 0450 for additional information.


M. ensure the facility maintained proper safety precautions against radiation hazards. The facility did not have a lead apron or any other barrier to use for personal protective shielding at the facility.

Refer to Tag A 0536 for additional information.


N. ensure there was a radiologist designated to supervise the ionizing radiology services at the facility. Also the facility failed to establish criteria in the Medical Staff Bylaws on designation of a Supervising radiologist.

Refer to Tag A 0546 for additional information.

O. ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who were qualified to monitor staff exposure.

Refer to Tag A 0538 for additional information.

P. ensure the dietary services was organized and directed in a manner to ensure safe food practices in 4 of 4 areas (Dietary storage area, dining room, main kitchen area, and transportation vehicle). The facility failed to:

Provide safe and clean storage for food products. Food products were stored in an area that did not have surfaces that could be sanitized. Food products were stored on rusted shelves and in cardboard boxes.

The facility failed to ensure the dining room area was cleaned and and kept up. The walls were stained with a green substance which had the appearance of mildew. The seating areas and tables were soiled with spills and dust. The windows in the room were heavily soiled with spills.

The facility failed to ensure the flooring was kept clean. The flooring had a build-up of wax and spills. The shelves which had food and dietary supplies stored on them were soiled and had a buildup of rust. Ceiling tiles had brown water stains.

The facility failed to ensure expired supplements which were stored in a card board box in the kitchen was discarded. Expired food products in the refrigerator were not being discarded.

The facility failed to ensure staff knew how to take food temperatures. Staff were taking temperatures by sticking the end of the thermometer through the plastic covering. This was increasing the risk of plastic getting in the food. Staff were not taking the temperatures of all food items on the steam table. Staff were not properly sanitizing the thermometer after checking potentially hazardous food items.

The facility failed to ensure there was a procedure for washing dishes at the facility. A bucket of bleach water was being used to wipe down items in the kitchen including the thermometer. The facility had scoops, ladles and pans which were in need of cleaning. The cleaning products were stored on the soiled kitchen floor.

The facility failed to ensure the standup refrigerator/freezer, the condiment cart, food transportation carts, plate warmer, and steam table were cleaned. They all were soiled with spills and rusted.

The facility failed to ensure the inside of the transportation van was kept clean. The van that was used to deliver patient trays had a buildup of dirt and rust. The area where the trays was unloaded was littered with trash.

The facility failed to ensure dietary staff removed soiled gloves and washed their hands in the tray prep area. They failed to ensure staff entering the kitchen wore hair coverings.

Refer to A tag 0619 for additional information.

Q. Ensure dietary staff were provided competencies to safely perform their jobs in 2 of 2 staff (Staff #'s 28 and 41). They facility did not have recent competencies on dietary staff which included their job duties.

Refer to A tag 0622 for additional information.

R. ensure a safe environment on the 1st floor hallway. There was a light cover outside Lab/Radiology that was broken and missing a corner of the plastic cover. There were rusted ceiling tile frames throughout the first floor. There were ceiling tile stained in brown color that appeared to be water stains throughout the first floor.

The facility failed to ensure a safe environment in the radiology department. There were electrical outlets hanging from a hole in the ceiling tile. There was an extension cord plugged into the outlet and laying on the floor. There were uncapped water lines laying on the floor in a darkroom closet.

The facility failed to ensure a safe environment in the CT Room. There were electrical wires hanging freely from a hole in the wall.

The facility failed to ensure a safe environment in the Laboratory. There was ceiling tile with stains that appeared to be water stains and mildew. There was an electrical outlet hanging from a hole in the ceiling that had an extension cord plugged into it and laying on the floor. There was a hole in the wall with water valves exposed.

The facility failed to ensure that the hospital maintained a safe environment in the Biomedical Room. The exit sign above the door was missing the plastic cover and the wires were exposed.

The facility failed to ensure the hospital maintained a safe environment in the Janitor closet. The ceiling tile was stained and appeared to be water stains. The vent had cracked ceiling tile and was bulging from the ceiling.

The facility failed to ensure the hospital maintained a safe environment in the Medical Gas storage room.
The E-Cylinders were stored in an unsecured manner with no physical support.

The facility failed to ensure the hospital maintained a safe environment in the Medical Record Storage room. Behind one section of boxes was an over bed light which was pulled away from the wall. It was hanging from the wall by the wiring. There were also exposed wiring behind the paper boxes which presented a fire hazard.

Refer to Tag A0701 for additional information.

S.ensure the infection control officer developed a system that maintained a clean and sanitary environment for eighteen of eighteen areas observed. The facility failed to ensure that 1st floor hallway, Radiology, Laboratory, Biomedical room, Emergency Treatment Room (ETR), Janitor room on first floor, 1st floor nursing station, Respiratory supply room, Respiratory station at Station B nurses station, Crash carts in ICU and 2nd floor, Linen carts, Central Supply, 2nd Floor supply room, 2nd Floor respiratory room, main pharmacy area, Medication room A/B Side, Nurses Station A/B Side, Equipment Storage area next to medical records were clean, sanitary and free from expired supplies.

Refer to Tag A0749 for additional information.


T.ensure rehab was organized in a manner to ensure appropriate services were provided in 3 of 3 services (Physical therapy, Speech therapy and Occupational therapy).

The facility failed to ensure physician signed orders were obtained for physical and speech therapy prior to service being provided.

The facility failed to ensure documentation that speech and physical therapy evaluations were performed timely. Staff failed to time their evaluations when performed. One speech evaluation was performed over the 72 hour timeframe.

The facility failed to ensure physician ordered occupation therapy was provided. The facility failed to ensure staff provide occupational therapy per their policy. A physician ordered occupational therapy and it was not performed.

Refer to A tag 1124 for additional information.

It was determined that the deficient practices at the Acute End-Stage Renal Disease unit posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.


Based on observation, record review, and interview, the facility failed to:


A. ensure the chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water treatment systems.


B. ensure the Ultra-Low Total Chlorine Test Strip that are used to measure low levels of total chlorine were not used beyond the manufacture expiration date.


C. ensure the staff labeled the jug of dialysate solution with the additive of powdered potassium chloride and /or calcium chloride which were for altering concentration of the dialysate.


D. ensure the security of the dialysis supplies and products in the acute dialysis unit.


E. ensure the pick-up tubes (wands) were fitting securely to the acid and bicarbonate jugs that were being used to dialyze the patients during a dialysis treatment to prevent bacterial contamination and evaporation.


F. ensure dialysis products and supplies were not used beyond the manufacture expiration date.


G. ensure the informed consent for the dialysis treatment was signed by the physician for 4 (#11, #17, 18, and #22) of 6 hemodialysis patients. Also, the facility failed to follow their facility policy on informed consent.


H. follow the patient's dialysis prescription by using the ordered BFR (Blood Flow Rate) in 1 (#11) of 6 of the hemodialysis records reviewed. Patient #11's record showed 4 of 7 treatments where the BFR (Blood Flow Rate) did not follow the patient's dialysis prescription written by the nephrologist. The dialysis prescription was for the BFR to be ran at 350.


I. ensure 3 of 3 (#16, #17, and #19) contracted dialysis staff had been orientated to the facility.


J. ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.


K. ensure the dialysis Quality Assurance Performance Improvement (QAPI) program was developed, implemented, maintained and evaluated with focus indicators to improve the outcomes of the acute dialysis unit.

This deficient practice had a risk for serious patient harm or death and was in violation of the Acute Dialysis facility and hospital policies and regulations.


Cross Refer: A0144


L. to protect the patient's right to make informed decisions on their care in 6 (Patient's #2, #3, #13, #17, #18, and #19) of 11 patients reviewed. The facility failed to ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in Patient's #2, #3, #13, #17, #18, and #19. In addition, the facility failed to obtain consent for treatment on admission in 2 (Patient's #2 and #13) of 11 patient charts reviewed. Also, the facility failed to follow their own policy and procedures on Informed consent.

Cross Refer: A0131


M. ensure the confidentiality of medical records and personal information in 3 (Lab, Radiology, and 1st floor hallway) of 3 three areas.

Cross Refer: A 0147


N. ensure physician orders were obtained for restraint usage in 2 (Patient's #6 and #13) of 2 records reviewed.

Cross Refer: A0168

Based on observation, record review, and interview:

A. the facility failed to ensure sanitary environment deficient practices in the facility were identified and reported. The facility failed to ensure the Infection Control Officer identified, reported, and tracked infection control problems in the departments. Also, the Infection Control Officer failed to ensure the quality assurance program had documentation of the infection control deficiencies and addressed the issues at the quarterly meetings.

Cross refer to tag A 283

B. the facility's Governing Body failed to ensure the facility quality assessment and performance improvement program (QAPI) reflected all hospital services for 1 of 1 (Dialysis) contracted services. Also, the Governing body failed to ensure 35 of 35 contracted services were evaluated and provided in an effective manner.

Cross refer to tag A 308

Based on observation, interview and record review, the facility failed to ensure there was an organized nursing service. The facility failed to:


A. ensure sufficient Registered nurses and Certified nurse aides to provide patient care on 2 of 2 units (1st and 2nd floor units).

The facility failed to ensure enough Registered nurses were scheduled to provide supervision to Licensed vocational nurses on the 1st floor. The facility failed to allot for certified nurses aides on the 1st floor. The facility failed to address staffing numbers in their matrix for both units (1st and 2nd floor units).

Refer to A tag 0392 for additional information.


B.ensure that nursing staff had current competencies in 2 (Staff #3 and Staff #4) of 2 personnel files reviewed.

Refer to A tag 0397 for additional information.


C. ensure medications were administered in a safe manner in 5 of 11 sampled patients (Patient #'s 3, 5, 10,13, and 14).

The facility failed to ensure nursing staff who were titrating Diprivan/Propofol (An anesthetic/Sedative medication) had a valid physician's order.

The facility failed to ensure the "Warfarin Medication Order Sheet" protocol was implemented on Patient #10 on admission. Patient #10 continued to receive anticoagulant therapy when her blood work was out of range and was sent to a higher level of care for gastrointestinal bleeding.

Refer to A tag 0405 for additional information.


D. ensure blood transfusions were administered per their approved procedures in 1 of 4 patients sampled for blood administration (Patient #'s 3 and 12).

The facility failed to document the receipt time of blood from the contracted service, so they could ensure it was being transfused in the proper and safe timeframe. They failed to ensure physician's orders were complete with rate of transfusion.

The facility failed to obtain informed consent prior to administration of blood.


Refer to A tag 0409 for additional information.

Based on observation, interview, and record review the facility failed to:

A. ensure the facility maintained proper safety precautions against radiation hazards. The facility did not have a lead apron or any other barrier to use for personal protective shielding at the facility.

Refer to Tag A 0536


B. ensure there was a radiologist designated to supervise the ionizing radiology services at the facility. Also the facility failed to establish criteria in the Medical Staff Bylaws, Rules and Regulations on designation of a Supervising radiologist.

Refer to Tag A 0546

C. ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who were qualified to monitor staff exposure.

Refer to Tag A 0538

Based on observation, interview and record review, the facility failed to ensure the dietary services was organized and directed in a manner to ensure safe food practices in 4 of 4 areas (Dietary storage area, dining room, main kitchen area, and transportation vehicle). The facility failed to:

A. Provide safe and clean storage for food products. Food products were stored in an area that did not have surfaces that could be sanitized. Food products were stored on rusted shelves and in cardboard boxes.

B. Ensure the dining room area was cleaned and kept up. The walls were stained with a green substance which had the appearance of mildew. The seating areas and tables were soiled with spills and dust. The windows in the room were heavily soiled with spills.

C. Ensure the flooring was kept clean. The flooring had a build-up of wax and spills. The shelves which had food and dietary supplies stored on them were soiled and had a buildup of rust. Ceiling tiles had brown water stains.

D. Ensure expired supplements which were stored in a cardboard box in the kitchen was discarded. Expired food products in the refrigerator were not being discarded.

E. Ensure staff knew how to take food temperatures. Staff were taking temperatures by sticking the end of the thermometer through the plastic covering. This was increasing the risk of plastic getting in the food. Staff were not taking the temperatures of all food items on the steam table. Staff were not properly sanitizing the thermometer after checking potentially hazardous food items.

F. Ensure there was a procedure for washing dishes at the facility. A bucket of bleach water was being used to wipe down items in the kitchen including the thermometer. The facility had scoops, ladles and pans which were in need of cleaning. The cleaning products were stored on the soiled kitchen floor.

G. Ensure the standup refrigerator/freezer, the condiment cart, food transportation carts, plate warmer, and steam table were cleaned. They all were soiled with spills and rusted.

H. Ensure the inside of the transportation van was kept clean. The van that was used to deliver patient trays had a buildup of dirt and rust. The area where the trays were unloaded was littered with trash.


I. Ensure dietary staff removed soiled gloves and washed their hands in the tray prep area. They failed to ensure staff entering the kitchen wore hair coverings.

Refer to A tag 0619 for additional information.

J. Ensure dietary staff were provided competencies to safely perform their jobs in 2 of 2 staff (Staff #'s 28 and 41). They facility did not have recent competencies on dietary staff which included their job duties.

Refer to A tag 0622 for additional information.

Based on observation, interview, and record review the facility failed to:

A. Ensure that the hospital environment maintained a safe environment on the 1st floor hallway. There was a light cover outside Lab/Radiology that was broken and missing a corner of the plastic cover. There were rusted ceiling tile frames throughout the first floor. There were ceiling tile stained in brown color that appeared to be water stains throughout the first floor.

B. Ensure that the hospital environment maintained a safe environment in the radiology department. There were electrical outlets hanging from a hole in the ceiling tile. There was an extension cord plugged into the outlet and laying on the floor. There were uncapped water lines laying on the floor in a darkroom closet.

C. Ensure that the hospital maintained a safe environment in the CT Room. There were electrical wires hanging freely from a hole in the wall.

D. Ensure that the hospital maintained a safe environment in the Laboratory. There was ceiling tile with stains that appeared to be water stains and mildew. There was an electrical outlet hanging from a hole in the ceiling that had an extension cord plugged into it and laying on the floor. There was a hole in the wall with water valves exposed.

E. Ensure that the hospital maintained a safe environment in the Biomedical Room. The exit sign above the door was missing the plastic cover and the wires were exposed.

F. Ensure the hospital maintained a safe environment in the Janitor closet. The ceiling tile was stained and appeared to be water stains. The vent had cracked ceiling tile and was bulging from the ceiling.

G. Ensure the hospital maintained a safe environment in the Medical Gas storage room.
The E-Cylinders were stored in an unsecured manner with no physical support.

H. Ensure the hospital maintained a safe environment in the Medical Record Storage room. Behind one section of boxes was an over bed light which was pulled away from the wall. It was hanging from the wall by the wiring. There were also exposed wiring behind the paper boxes which presented a fire hazard.



Refer to Tag A0701

Based on observation, interview, and record review, the facility failed to ensure the infection control officer developed a system that maintained a clean and sanitary environment for twenty of twenty areas observed. The facility failed to ensure that 1st floor hallway, Radiology, Laboratory, Biomedical room, Emergency Treatment Room (ETR), Janitor room on first floor, 1st floor nursing station, Respiratory supply room, Respiratory station at Station B nurses station, Crash carts in ICU and 2nd floor, Linen carts, Central Supply, 2nd Floor supply room, 2nd Floor respiratory room, main pharmacy area, Medication room A/B Side, Nurses Station A/B Side, Equipment Storage area next to medical records were clean, sanitary and free from supplies.


The facility failed to:


A. Ensure a sanitary environment on the first floor hallway. There were vents covered in dust, dirt, debris. The ceiling tile frames throughout all the hallways on the first floor were covered in rust. The ceiling tiles were stained with a brown color that appeared to be water stains. There was an alcove next to the radiology department that was in disarray. The floor had old phones, a light cover trim covered with black substance that appeared to be mold, screws, and metal trim covers laying in the corner.

B. Ensure a sanitary environment in radiology. The linoleum was stained cracked and had rust and black substance. The cabinets were covered in dirt, dust, and debris and the cabinet drawers were missing handles. There were ceiling tiles with brown stains that appeared to be water stains. There was a ceiling tile open exposing pipes in ceiling. There was equipment covered in rust. There were uncapped water lines and equipment laying on floor. The cabinets had missing trim exposing wood. There were electrical wires hanging through hole in the wall where there was missing ceiling tile.

C. Ensure a sanitary environment in the laboratory department. The floors were missing tiles and had a buildup of dust, dirt, and debris. There was a chair that had cracks in vinyl. There was a hole in ceiling that an electrical outlet was hanging from. There was a ceiling tile with brown and black stains that appeared to be a water stain and mildew. There was an open hole in the wall with water valves exposed. There was a vent standing on the floor covered in dust, dirt, and debris next to the water valves. There was a drain on floor next to vent covered in buildup of black debris. There were laboratory patient supplies covered in dust and debris. There was a metal cart in the main laboratory area that was rusted. On the cart was a cardboard box filled with blood collection supplies (butterfly needles, blood culture tubes, blood collection tubes). In the refrigerator that stored patient tissue/lab specimens, there was a box with laboratory controls that expired January 2013. The refrigerator shelves were covered in dirt, dust, and debris. The refrigerator freezer had ice packs covered in dirt, dust, and debris.

D. Ensure a sanitary environment in the Biomedical Room. There was equipment stored on carts covered in dust, dirt, and debris. The ceiling tiles had brown colored stains that appeared to be water stains. There were vents bulging from the ceiling. There was trash stored under patient equipment.

E. Ensure a sanitary environment in the Emergency Treatment Room. The drawer in the desk had broken and papers had fallen through to floor. There was a closet with a rack containing respiratory supplies that had wooden pasteboard shelves and could not be sanitized. There were blood gas controls in cardboard boxes. Sitting next to the boxes was an employee cup that contained a drink. There was a dead bug on the floor next to cart storing patient equipment. There was a wooden pallet containing PPE (personal protection supplies) stored on floor. There were expired Arterial blood sampling kits and eye wash.

F. Ensure a sanitary environment in the Janitor room. The room was in disarray. There were several wet mop heads laying in sink. There were wet floor signs laying on the floor. There was a mop bucket and wooden mop handles laying on the floor. The floor was covered in black debris. The floor sink was covered in dirt, dust, and black substance. The vent was bulging from the ceiling. The ceiling tile was cracked around the vent. The vent was covered in dirt, dust, debris.

G. Ensure a sanitary environment at the nurse's station on the first floor. There were Respiratory Oxygen Flowmeters stored in a cabinet that were not labeled clean or dirty. There was a buildup of tape residue, dirt, and dust on cabinets. The nursing station had missing/chipped laminate on desk trim. The light cover had a rusted frame. The vent had a buildup of black substance on metal that appeared to be mildew.

H. Ensure a sanitary environment in the respiratory equipment room. The trash can on the floor next to patient equipment and supplies contained tobacco spit in plastic trash bag. There were suction regulators laying on the cabinet that were not labeled clean or dirty. There were bins containing supplies that were covered in dirt, dust, and debris. One of the bins contained tracheostomy (a tube inserted in patient's trachea to assist with air exchange) cleaning supplies. The floor in the room was covered in a buildup of dirt and debris.

I. Ensure a sanitary environment at the Respiratory Station at Station B. There was a personal employee backpack sitting at the workstation next to patient equipment (Pulse oximeter). The backpack contained food. The pulse oximeters were stored with no indication if they were clean or dirty. There was an electrical panel at nursing station B covered in tape residue, dirt, and dust.

J. Ensure the crash carts were maintained in a sanitary manner and were free from expired supplies.

K. Ensure the linen was stored, transported, and kept in a sanitary manner. The linen was stored in containers with no covers. The linen was being transported to the facility in uncovered rolling carts. The ceiling tiles in the linen room had several stains that appeared to be water stains. There were outside cardboard shipping boxes of trash bags being stored on several shelves in the clean linen room. The linen carts at the nurses station did not have splashguard to protect the linen from splashes when cleaning the floor. The linen carts stored in the patient care areas had rips in the covers. The linen in the emergency treatment room was hanging off the shelf and touching the floor.

L. Ensure a sanitary environment in the Central Supply. Shelves of sterile medical supplies were stored in a room which also contained broken equipment. There were cardboard boxes stored on shelves in the room. Patient supplies were on the floor underneath the shelves. Plastic bins which contained patient supplies were soiled with spills and dust. A box which contained peel packets of surgical equipment stored in the room were stained brown. Ceiling tile in the room had brown water stains. Some of the legs on the shelves were covered with dust and spider webs. The temperature and humidity in the room storing sterile supplies was not being monitored.

M. Ensure a sanitary environment on the second floor supply room. EKG equipment, bedside toilets, and intravenous pole were all stored in a room. There was no way to tell what was clean and what was soiled. The ceiling tile above the equipment was stained with brown water stains. An air vent in the ceiling was covered with a build-up of black substance.

N. Ensure a sanitary environment in the respiratory room. The tile floor in the room had a buildup of wax, paper and dust. There was a box of oxygen regulators which were not bagged or identified as being clean equipment. One cabinet was missing the door. Respiratory equipment was stacked up in the cabinet. There was no way to tell if the equipment was clean or soiled. The metal caddy which held the oxygen tanks was covered in rust. A plastic storage unit was covered in dust and contained respiratory mask and equipment for respiratory treatments.

O. Ensure a sanitary environment in the main pharmacy area. Medication vials were stored in a bin missing the protective cap. A bag of intravenous fluids was stored on a shelf and was not in a protective overwrap. Bags of intravenous fluids were stored on a stainless steel shelf on the lower shelf that not have a splash guard down. The tile floor underneath the shelf was soiled with spills and dust. The floor tile was ripped and the subfloor underneath could be seen. Ceiling tile in the room had brown water stains.

P. Ensure a sanitary environment in the medication room on Side A of the Second floor. A medication transportation cart in the room had an open plastic container on top of it which contained medications that were soiled with spills and dust. A supply cart in the room was rusted and the inside drawers which contained patient supplies was soiled with spills and dust. The pill crusher had a build-up of medication particles, dirt and dust. Cardboard boxes of supplies were stored above open bins which contained intravenous catheters and tubing. The tile floor in the room was broken and missing and exposing the subfloor. Plastic bins in the refrigerator which contained vials of insulin was soiled with spills. The cabinet underneath the sink was soiled with dried spills and debris. The laminate on the top counter of the sink was missing and the particle board underneath was exposed.

Q. Ensure a sanitary environment in the medication room on side B of the second floor. A plastic bin which contained medication carts was soiled with dust and spills. The pill crusher had a build-up of medication particles, dirt and dust. Plastic supply bins were either covered with soiled remnants of labels or the top layer of the bins were peeling off. There were cans of a protein supplement that were expired. The tile floor in the room had a buildup of wax.

R. Ensure a sanitary environment at the nurse's station on side B of the second floor. There was a box of oxygen regulators which were not bagged or identified as being clean equipment.
The tile flooring at the baseboards was soiled with a buildup of dirt and debris. The flooring had a buildup of wax.

S. Ensure a sanitary environment in the equipment storage area next to the main medical storage room. There were bedside toilet seats, intravenous poles, pillows, walkers, wheelchairs, intravenous pumps and other patient equipment stored in the room. Some of the equipment was stacked on top of each other and the room was cluttered. There was no way to tell what was clean and what was soiled. Some of toilet seats were found to be rusted and soiled with a black and brown substance. Some of the equipment was on the floor that was soiled with paper and dust.

Refer to Tag A0749

T. Ensure the Infection Control Coordinator had been trained in infection control and how to coordinate an infection control program. The Infection Control Coordinator was not identifying and reporting areas identified as unsanitary in the facility.

Refer to Tag A0748

Based on observation, interview and record review, the facility failed to ensure rehab was organized in a manner to ensure appropriate services were provided in 3 of 3 services (Physical therapy, Speech therapy and Occupational therapy). The facility failed to:

A. ensure physician signed orders were obtained for physical and speech therapy prior to service being provided.

B. ensure documentation that speech and physical therapy evaluations were performed timely. Staff failed to time their evaluations when performed. One speech evaluation was performed over the 72 hour timeframe.

C. ensure physician ordered occupation therapy was provided. The facility failed to ensure staff provide occupational therapy per their policy. A physician ordered occupational therapy and it was not performed.

Refer to A tag 1124 for additional information.

Based on interview and record review, the facility's Governing body failed to:

A. provide adequate oversite to ensure the facility's contracted dialysis service was managed in a safe and sanitary manner.


B. ensure 35 of 35 contracted services were evaluated and provided in an effective manner.



This deficient practice had the likelihood to cause harm to all patients.


Findings include:


Observations on the afternoon of 9/17/18, in the facility's Dialysis Department revealed the following:

There were expired dialysis supplies found in acute dialysis room and in the peritoneal supply storage closet.

The physical environment of the dialysis room was unclean and safety issues were found in the dialysis room and peritoneal supply storage closet.

A review of the quality reports from the dialysis contract service revealed the only reports were for March and August of 2018. There was no report from the dialysis provider for the 2nd quarter submitted to the quality department.

A review of the quality reports submitted by the contracted dialysis provider revealed there was no indication in the data submitted that provided oversite to ensure the facility's contracted dialysis service was managed in a safe and sanitary manner.


An interview with the Quality Director for the facility on 9/19/2018 at 3:15 PM stated that quality reports are to be submitted to the facility quarterly. The Quality Director was asked was there a representative from the contracted provider at the meeting. The Quality Director stated, "No, they just submit a report to the meeting."





10135

Review of a list named "Active Contracts" revealed there was 35 active contracted services.

During an interview on 09/19/2018 after 9:00 a.m., Staff #2 confirmed that she reported the quality assurance information to the Governing body. Staff #2 reported contracted services was not being evaluated and taken through their quality programs.

Based on record review and interview, the facility failed to protect the patient's right to make informed decisions on their care in 6 (Patient's #2, #3, #13, #17, #18, and #19) of 11 patients reviewed. The facility failed to ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in Patient's #2, #3, #13, #17, #18, and #19. In addition, the facility failed to obtain consent for treatment on admission in 2 (Patient's #2 and #13) of 11 patient charts reviewed. Also, the facility failed to follow their own policy and procedures on Informed consent.


This deficient practice had the likelihood to cause harm to all patients admitted to the facility.




Findings include:

A review of Patient #2's record revealed:

There was a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The consent listed "Transfusion of Blood and Blood Products" as the procedure. There was a patient/other signature and a witness signature. The physician signature line was blank. There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.

There was a facility document titled, "Patient Consent to Treatment Admission Form". The consent had a verbal consent noted on 9/6/2018. There were two witness signatures. The was no indication why the patient was unable to sign the consent. There was no attempt to obtain consent from patient or the family after admission. There was family listed in the chart on other medical record documents.


A review of Patient #3's record revealed a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The consent listed "Blood Transfusion" as the procedure. There was a patient/other signature and a witness signature. The physician signature line was blank. There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.


A review of Patient #13's chart revealed:

There was a facility document titled, "Patient Consent to Treatment Admission Form". The consent had a verbal consent noted on 5/16/2018. There were two witness signatures. The was no note indicating who the verbal consent was from. There was no attempt to obtain consent from family after admission. There was family listed in the chart on other medical record documents.

There was a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The procedure listed was "Esophagogastroduodenoscopy with insertion of Percutaneous Endoscopic Gastrostomy feeding tube and all indicated procedures". There was no patient or representative signature. There was no witness signature. There was no physician signature. There was no documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative. A progress note on 6/15/2018 revealed the patient had a G Tube present.

There was a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The consent listed "Blood Transfusion" as the procedure. There was a signature listed for patient/other signature. There was no indication of whose signature it was. There was a witness signature. The physician signature line was blank. There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.

There was a facility document titled, "Consent for wound Debridement". The consent listed debridement as the procedure. There was a signature listed for patient/other signature. There was no indication of whose signature it was. There was a witness signature. There was no physician signature. There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.


A review of Patient #17's record revealed a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The consent listed "Blood Transfusion" as the procedure. There was a patient/other signature and a witness signature. The physician signature line was blank. There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.


A review of Patient #18's record revealed a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The consent listed "Blood Transfusion" as the procedure. There was a patient/other signature and a witness signature. The physician signature line had a note that stated, "per Dr. Shoebusoy". There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.


A review of Patient #19's record revealed a facility document titled, "Disclosure and Consent Medical and Surgical Procedures". The consent listed "Transfuse 2 units Packed Red Blood Cells Hematocrit 23.7, Hemoglobin 7.9" as the procedure. There was a patient/other signature and a witness signature. The physician signature line had a note that stated, "TORB Dr. Rehman /R. Ruben LVN 7-1-2018". There was no further documentation in the chart to indicate the physician explained the risks and benefits of the procedure to the patient or their representative.




An interview with Staff #3 on revealed the following:

Staff #3 was asked where risks and benefits that were discussed with the patient would be documented. Staff #3 stated, "If they are documented they would be in the physician progress notes". Staff #3 confirmed that the documentation should be in the physician progress notes. Staff #3 stated "the physicians do not sign the consent and there are no progress notes regarding informed consent most of the time".


A review of the facility policy titled, "Informed Consent" dated 9/1/2011 with a reviewed date of 5/2017 revealed the following:

PURPOSE

To support patient right to determine care

To define the obligations and documenting informed consent by physicians and healthcare professionals

POLICY

*Adult patients have the right to make decisions regarding their treatment and to be provided sufficient information in order to make informed decisions regarding their healthcare. Incompetent adult's rights regarding informed consent will be exercised through their legal representative. The physician performing a medical or surgical procedure on a patient is generally responsible for obtaining the patient's informed consent prior to the treatment or procedure.

" ...A medical/surgical procedure (except if need for the procedure constitutes an emergency) cannot be performed without the consent of the patient or the patient's legal representative. His/her signature on a Procedure Acknowledgement form or a treatment consent form (i.e. Blood Transfusion) verifies that consent has been provided for the performance of the medical/surgical procedure or treatment.

...Disclosure to the patient or patient's legal representative through the provision of informed consent for a medical/surgical procedure is verified by his/her signature on the Procedure Disclosure form.

...The consent becomes part of the medical record and documentation regarding the patient having signed a consent should be present in the physician and/or healthcare professionals progress/narrative notes

...Consent for procedures performed at another health care facility will be obtained by the personnel of that facility in accordance with their policies. The physician shall discuss with the patient or legal representative the purpose of such procedures and document such discussion prior to transport of the patient, except in an emergency.


...For any scheduled medical/surgical procedure or for any procedure that has potential for harm, patient or patient's legal representative will be provided with appropriate information regarding the procedure. (It is the responsibility of the medical staff to provide education; it is the responsibility of the healthcare professional to assure that the patient understands what was told to her/him.)

...Element of Informed Consent
Informed consent is a process in which the physician provides adequate information for the patient or patient's legal representative to make an informed decision on the proposed treatment, including medications or procedure. Specifically, the physician must disclose in a reasonable manner all significant medical information that the physician believes is relevant and material to making an informed decision by the patient in deciding whether or not to undergo the procedure or treatment.

...The physician must document in the medical record, or an approved hospital form when available, consent for all therapeutic and diagnostic procedures where disclosure of significant medical information, including significant and frequently occurring risks involved, would assist a patient in making an informed decision whether to undergo the proposed treatment or procedure. Such procedures include surgical and other invasive procedures, other treatments with significant risks, and transfusion of blood and/or blood products".

It was determined that the deficient practices at the Acute End-Stage Renal Disease unit posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, impairment and/or subsequent death.

Based on observation, record review, and interview, the facility failed to:


A. ensure the chlorine checks were conducted every 4 hours on the portable reverse osmosis (RO) water treatment systems.


B. ensure the Ultra-Low Total Chlorine Test Strip that were used to measure low levels of total chlorine were not used beyond the manufacture expiration date.


C. ensure the staff labeled the jug of dialysate solution with the additive of powdered potassium chloride and /or calcium chloride which were for altering concentration of the dialysate.


D. ensure the security of the dialysis supplies and products in the acute dialysis unit.


E. ensure the pick-up tubes (wands) were fitting securely to the acid and bicarbonate jugs that were being used to dialyze the patients during a dialysis treatment to prevent bacterial contamination and evaporation.


F. ensure dialysis products and supplies were not used beyond the manufacture expiration date.


G. ensure the informed consent for the dialysis treatment was signed by the physician for 4 (#11, #17, 18, and #22) of 6 hemodialysis patients. Also, the facility failed to follow their facility policy on informed consent.


H. follow the patient's dialysis prescription by using the ordered BFR (Blood Flow Rate) in 1 (#11) of 6 of the hemodialysis records reviewed. Patient #11's record showed 4 of 7 treatments where the BFR (Blood Flow Rate) did not follow the patient's dialysis prescription written by the nephrologist.

I. ensure 3 of 3 (#16, #17, and #19) contracted dialysis staff had been orientated to the facility.


J. ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.


K. ensure the dialysis Quality Assurance Performance Improvement (QAPI) program was developed, implemented, maintained and evaluated with focus indicators to improve the outcomes of the acute dialysis unit.


Findings included:

A. A review of the log titled, "Water Treatment Safety Record" for the month of August and September 2018 revealed the following:

A review of the August log dated 08/31/18 for the every 4-hour Chlorine check revealed the chlorine was checked at 8:00 AM and 13:00 (1:00 PM) which was 5 hours from the first chlorine check. There should have been a chlorine check at 12:00 PM.


A review of the September log dated 09/17/18 for the every 4-hour Chlorine check revealed the chlorine was checked at 7:45 AM and 11:45 AM and was never checked again. There should have been a chlorine check at 3:45 PM. Patient #20 and #22 were still receiving dialysis treatments at 3:45 PM.

Patient #20 was not taken off the dialysis machine until 16:51 (4:51 PM) per the contract service log, documented by Staff #16.

Patient #22 was not taken off the dialysis machine until 16:22 (4:22 PM) per the contract service log, documented by Staff #16.


A review of the acute dialysis parameter record revealed the following:

"The initial total chlorine test will be performed prior to each
treatment intitation (sic) and within the subsequent 4 hours during treatment. If more than 2 tests are performed during a treatment, document on a new line."


An interview with Staff #23 on 09/18/18 at 2:00 PM confirmed that chlorine checks were not being checked every 4 hours per the contract provider's acute dialysis parameters. Also, the parameters were not being followed by Staff #16.


B. During a tour of the Acute Dialysis unit on 09/17/18 at 4:00 PM observed that the Ultra-Low Total Chlorine Test Strip had expired in June 2018. There had been 32 days of dialysis treatments in checking the water system for chlorine with the expired strips.

A review of the hospital services policy & procedure titled, "Total Chlorine Test Using RPC Ultra Low Total Chlorine Test Strip" revealed the following:

"Do not use test strips after the manufacturer expiration date."

This deficient practice had the likelihood to expose the dialysis patients to High levels (>20 ppm) of fluoride in the water used to prepare dialysate are clearly toxic to hemodialysis patients, and have resulted in patient deaths.


An interview with Staff #16 on 09/17/18 at 4:00 PM confirmed that he had been using the expired strips since June 2018. Also, he confirmed that he was not following the facility policy or manufacturer guidelines.


C. During a tour of the facility on 09/17/18 at 4:00 PM, it was observed the jugs of dialysate solution were written on with a red marker 3K and 3Ca. When Staff#16 was asked what did that indicate. Staff #16 stated, I added potassium and calcium to the jug. In the cabinets of the acute dialysis unit were 11.5 and 5.8 grams of powdered potassium chloride additive packages. Also, there were calcium chloride 5.7 and 11.3 grams of powdered packages. These products were being used to spike the acid and calcium concentrate of the standard jugs. There was no label on the dialysate jug to know how much of the powdered potassium Chloride and calcium chloride had been added to the jug. There were labels provided by the manufacturer that determined the amount of additive that was added to the standard jug and the total amount of concentration after the additive was added. The label had a place for whom added the additive and the date and time.

An interview with hospital pharmacist #29 on 09/19/18 at 3:00 PM confirmed that the pharmacist had no knowledge that the powdered potassium chloride and calcium chloride were available in the hospital.


An interview with Staff #23 (a clinical specialist from the contracted provider) on 09/18/18 at 2:00 PM confirmed the dialysis staff should use the manufacturer labels for the additives of powdered potassium chloride and /or calcium chloride which were for altering concentration of the dialysate.



D. During a tour of the facility on 09/17/18 at 4:00 PM, observed the acute dialysis unit had a keypad entry for security and the peritoneal storage on the first floor. The housekeeping department had access to the dialysis supplies and products. Staff #16 was asked when does housekeeping enter the unit. Staff#16 stated, "During the day when I am here, but at night when we are gone to do the floors. It's been 3 years since floors were done."


An interview with Staff #24 (housekeeping supervisor) on 09/18/08 at 3:00 PM confirmed the housekeeping department had access to the acute dialysis unit and the peritoneal storage unit.

An interview with the COO #2 on 09/19/18 at 4:00 PM confirmed she did not know that dialysis products and supplies had to be secure from facility's staff members. Surveyor advised Staff #2 that this deficient practice had the likelihood to allow access to the dialysate jugs and allow additives to be added to the jugs or tampering with the dialysate jugs.


E. During a tour of the facility on 09/17/18 at 4:00 PM, observed 2 patients receiving a dialysis treatment. The pick-up tubes (wands) were hanging out of the acid and bicarbonate jugs. There was no secure connection from the pick-up tube to the opening of the acid or bicarbonate jug. This deficient practice allowed for cross contamination, acid spills, and bacterial growth in the bicarbonate jug. Acid concentrate is not susceptible to bacteria contamination, but every effort should be made to keep the system closed to prevent nonbacterial contamination and evaporation per the ANSI/AAMI standards.

An interview with Staff #20 on 09/18/18 at 9:00 AM confirmed the above findings.


F. During a tour on the afternoon of 09/17/18 of the acute dialysis unit and the peritoneal dialysis storage area, the following expired products and supplies were observed:

Acute Dialysis Unit:

1. Ultra-Low Total Chlorine test strip
Lot #L-U260-0616 X 111 expired June 2018
Lot #L-X519-0415 X 200 expired June 2018

2. Nipro Transducer Protector X 57 expired September 2017

3. Fistula Needle 15 guage x 1 ¼ X 41 expired August 2017

4. Calrite Solution/Standard solution for the use in checking the calibration or accuracy of testing devices. The following solutions had expired and were being used for checking the conductivity of the machines with phoenix meter.

QC solution 100ms/cm expired 08/17/2018
QC solution 1ms/cm expired 08/17/2018
QC solution 10.00ph expired 08/17/2018
QC solution 4.00ph expired 08/17/2018

5. E2 check blood strips 1 bottle expired 03/2018

Peritoneal Storage Area:

1. Stay Safe Cap X 40 expired 01/31/2018

2. Two Boxes of (4 units) of hemodialysis concentrate Naturalyte expired 06/30/2018

3. Delflex Peritoneal dialysis solution 4.25% Dextrose X 2 bags expired June 2018

4. Delflex Peritoneal dialysis solution 1.5% Dextrose x 1 bag expired June 2018

An interview with Staff #23 (a clinical specialist from the contracted provider) on 09/18/18 at 2:00 PM confirmed the above findings.



G. A review of the Patient #11, #17,18, and #22's record revealed the informed consent for the dialysis treatment was not signed by the physician or there was no consent on the record.

A review of Patient #11's informed consent for hemodialysis dated 09/03/18 revealed the physician had not signed the consent form. There was a place on the consent form for the physician's signature and date.

A review of Patient #17's informed consent for hemodialysis dated 08/29/18 revealed the physician had not signed the consent form. There was a place on the consent form for the physician's signature and date.

A review of Patient #18's record revealed there was no informed consent for hemodialysis.


A review of Patient #22's informed consent for hemodialysis dated 08/27/18 revealed the physician had not signed the consent form. There was a place on the consent form for the physician's signature and date.


A review of the hospital services policy & procedure titled, "Consent for Treatment" revealed the following:


Purpose: To verify that the patient and/or his/her legal representative has been given information regarding the prescribed renal replacement therapy and/or aphaeresis and has been given the opportunity to ask for and receive clarification, and has consented to the prescribed procedure(s).

POLICY:
1. Prior to the initiation of the first inpatient treatment performed by a DaVita teammate, consent for acute renal replacement therapy and/or aphaeresis must be obtained during each hospital admission.
2. Consent will be obtained and documented according to the current policies and procedures of the hospital/facility in which acute services are provided.
3. When performing outpatient aphaeresis or hemodialysis, a consent should be signed annually unless the patient's account number changes or the prescription changes.
4. The Consent for Treatment by DaVita Services, or a hospital provided consent will be used. The signed consent by the patient needs to be modality specific and include the risks, benefits and alternatives of the therapy ..."

A review of the facility's policy titled, "Informed Consent" revealed the following:

"PURPOSE

To support patient right to determine care

To define the obligations and documenting informed consent by physicians and healthcare professionals

POLICY

*Adult patients have the right to make decisions regarding their treatment and to be provided sufficient information in order to make informed decisions regarding their healthcare. Incompetent adult's rights regarding informed consent will be exercised through their legal representative. The physician performing a medical or surgical procedure on a patient is generally responsible for obtaining the patient's informed consent prior to the treatment or procedure.

A. Documentation
1. The physician must document in the medical record, or an approved hospital form when available, consent for all therapeutic and diagnostic procedures where disclosure of significant medical information, including significant and frequently occurring risks involved, would assist a patient in making an informed decision whether to undergo the proposed treatment or procedure. Such procedures include surgical and other invasive procedures, other treatments with significant risks, and transfusion of blood and/or blood products ..."


An interview with Staff #23 (a clinical specialist from the contracted provider) on 09/18/18 at 2:00 PM confirmed the consents were not signed and dated by the physician and that Patient #18 had no informed consent.


H. A review of the Patient #11's record revealed that Staff #16 did not follow the patient's dialysis prescription by using the ordered BFR (Blood Flow Rate). There were 4 of 7 treatments where the BFR (Blood Flow Rate) was ran at 300 and did not follow the patient's dialysis prescription as written by the nephrologist. The dialysis prescription for the BFR was to be ran at 350.

A review of the Patients #11 record revealed on 09/05, 09/07, 09/10, and 09/12 the BFR was ran at 300.

An interview with Staff #23 (a clinical specialist from the contracted provider) on 09/19/18 at 10:00 AM confirmed the BFR was ran at 300 and not 350 per the physician dialysis prescription.


I. A review of the personnel files for Staff#16, #17, and #19 (contracted dialysis staff) revealed there was no orientation to the facility. Further review of the personnel files revealed that all 3 Staff members were hired 05/01/17.

A review of the of the contract titled, "Hospital Services Agreement" (contract was between dialysis services and the hospital) revealed the following:

"Company staff assigned to each facility shall complete an initial orientation of the facility ("Initial Facility Orientation") at no additional cost to the hospital. In addition to the Initial Facility Orientation, each company staff may also attend up to 8(eight) hours of relevant applicable, and necessary Hospital required training ("Additional Training") per year, at no additional cost to the hospital."

An interview with Staff #23 on 09/18/18 at 11:45 AM confirmed the above findings.

J. During a tour of the acute dialysis unit and the peritoneal storage area on the afternoon of 09/17/18 observed the following infection control issues:

Acute Dialysis unit:

The unit was a large room that could hold two patients at a time to be dialyzed.

1. Observed 8 large outside shipping cardboard boxes sitting on a table in the middle of the acute dialysis unit. There were 2 patients receiving dialysis treatments.

2. There were brown stains noted on the ceiling tiles that appeared to be water stains. On one of the ceiling tiles there was a black substance around the brown stained ceiling tile.

3. In the patient's bathroom there was a ceiling tile missing and exposed wires were observed.

4. The air conditioner vent was covered in rust, a black substance and dust particles.

5. The return air conditioner vent was covered in thick dust particles.

6. Observed in the floor of the acute dialysis unit in 2 different areas discolored floor tile with a black substance stuck to the floor. The entire floor in the dialysis unit was discolored with unclean appearance.

7. The wall base was pulling apart from the wall with dust and dirt in the crack of the wall base. On the wall above the wall base was a 2 inch yellowish-brownish stain.

8. There were 2 sets of shelves in the acute unit with dialysis supplies on the shelves. The bottom shelf had no barrier to keep the dust and wet mopping from splashing on the supplies. The surveyor pulled the shelves away from the wall and observed yellowish-brown black stains with dead insects and dirt under the shelves.

9. Observed a clear plastic container sitting on a rolling bedside table beside a patient that receiving a dialysis treatment. The clear container was full of dialysis supplies. On the side of the container was large brown spot. Staff #17 was asked what was the container used for. Staff #17 stated, "The plastic container is used to carry supplies to a patient when the patient is dialyzed in the patient's room."

10. In the supply cart that was stocked with dialysis supplies observed dust and trash particles in the drawer.

11. The hinges on the cabinet door was rusted and corroded with greenish color (lime deposit). The shelf in the cabinet was covered in rust particles that had fallen from the rusted hinges.

12. One the 4 rolling bedside tables in the acute dialysis unit had Walnut wood-grained laminated top that was cracked and there were dirt particles building-up inside the crack.

13. There were 4 pieces of connecting tubing in a small cup with no type of protection. One of the connecting tubes had brown substance around the opening. Staff #16 was asked how long has the connection tubing been in this cup. Staff#16 stated, "I have no idea."

Peritoneal storage Area:

1. Observed in the peritoneal storage area were expired supplies and outside cardboard shipping boxes.

2. In the corner of the room and under the shelving were dead roaches, cobwebs, trash, and dirt particles. The cob webs were full of dead insects and dust particles.

Card board boxes harbor parasites, insects, and microorganisms.

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).

Staff #16 was observed wearing his face mask under the chin going from patient to patient and using his stethoscope on a dialysis patient and then went to another patient without cleaning the stethoscope. Also, Staff #16 was cleaning the dialysis machine and dropped the bleach wipe to the floor and picked up and continued cleaning the machine. Staff #16 used the Phoenix meter and placed it back in the holder without cleaning the meter. The patient meal trays were bought to the unit and placed beside the bleach bucket on the dirty side of the counter.


An interview with Staff #24 on 09/18/18 at 9:00 AM confirmed the above findings during the tour of the facility.

K. A review of the QAPI meeting minutes February through August 2018 did not address the issues with the chlorine check logs, R/O water logs, the infection control and safety issues. The QAPI meeting minutes discussed treatment data with goals met on the two quality reports that were submitted to the facility. Staff #16 who works at acute dialysis unit full time was asked are you involved in the quality meetings. Staff #16 stated, "No".

An interview with Staff #23 on 09/19/18 at 10:00 AM confirmed the QAPI meetings did not address the infection control and safety issues found during the survey.

Based upon observation and interview, the facility failed to ensure the confidentiality of medical records and personal information in 3 (Lab, Radiology, and 1st floor hallway) of 3 three areas.


This deficient practice had the likelihood to cause harm in all patients at the facility.


During a tour 9-18-2018 after 8:30 AM the following observations were noted:

LAB

There was a room in the laboratory department that contained a pallet with patient records stored on top of it. The records contained patient names, date of birth, physician name, and the lab tests ordered for the patient. The boxes were unsecured. The room where the boxes were stored was unsecured.


RADIOLOGY

There was a dark room in the radiology department that was not in use. In the room there were boxes that contained patient order requisitions. The requisitions contained patient name, date of birth, diagnosis, physician name, and the radiology test ordered for the patient. The boxes were unsecured. The room where the boxes were stored was unlocked.


1ST FLOOR HALLWAY

There was an alcove across from the radiology department on the 1st floor. The alcove was in disarray and contained two racks. One of the racks stored patient radiology charts. The charts had the patient name, date of birth, and radiology test result reports. The other rack contained patient X-Ray folders that contained patient radiology films. The film folder had the patient name and date of birth on it. The alcove was open and anyone walking down the hallway would have been able to gain access to the patient's records.


During an interview on 9-18-2018 after 9:00 AM, Staff #40 stated, "I think these records were left in the building prior to us moving in. They are not our records. I never noticed them before. I realize they need to be removed or locked up."

Staff#40 confirmed the above findings.

Based on observation, interview and record review, the facility failed to ensure physician orders were obtained for restraint usage in 2 (Patient's #6 and #13) of 2 records reviewed.

This deficient practice had the potential to cause harm to all patients in restraints.


Findings include:


PATIENT#6

Review of medical restraint order form for 9/5/2018 to 9/6/2018 showed restraint was ordered on 9/5/2018 at 7 AM and expired 9/6/2018 at 7 AM. The physician signature line was blank. There was a signature on the side of the signature line. Staff #3 confirmed the signature was for Physician #9, There was a number 19 written under the physician name. There was no date.

Review of the medical restraint order form for 9/10/2018 to 9/11/2018 showed restraint was ordered on 9-10-2018, time was unreadable and expired on 9-11-2018. The physician signature line was blank. There was a signature on the side of the Signature line. Staff #3 confirmed the signature was for Physician #9, There was no time or date.

Review of the medical restraint order form for 9/11/2018 to 9/12/2018 showed restraint was ordered on 9/11/2018 9 PM and expired on 9/12/2018 at 9 PM. The physician signed on 9/11/2018, time was unreadable.

Review of the medical restraint order for 9/16/2018 to 9/17/2018 showed restraint was ordered on 9/16/2018 at 8 PM and expired 9/17/2018 at 8 PM. The physician signed the order on 9/16/2018 at 11 PM, 3 hours after the order started. Review of the nurses notes on restraints for 9/16/2018 confirmed the patient was in soft wrist restraints during that time.

Review of the medical restraint order for 9/18/2018 to 9/19/2018 showed restraint was ordered on 9/18/2018 8 PM and expired on 9/19/2018 at 8 PM. The physician signed the order at 4 PM on 9/18/2018, 4 hours prior to start of order. There was no evaluation noted by the physician of the patients need for continuation of restraints at that time.

Review of the medical restraint order for 9/19/2018 to 9/20/2018 showed restraint was ordered on 9/19/2018 8 PM and expired on 9/20/2018 at 8 PM. The physician signed the order at 10 AM on 9/19/2018, 10 hours prior to start of order. There was no evaluation noted by the physician of the patients need for continuation of restraints at that time.


PATIENT #13

Review of medical restraint order form for 5/21/2018 to 5/22/2018 showed restraint was ordered on 5/21/2018 at 10 AM and expired 5/22/2018 at 10 AM. The physician signature line was blank. There was a signature on the side of the signature line that was unreadable. There was a number 15 written next to the physician name.

Review of medical restraint order form for 5/22/2018 to 5/23/2018 showed restraint was ordered on 5/22/2018 at 10 AM and expired 5/23/2018 at 10 AM. The physician signature line was blank. There was a signature on the side of the signature line that was unreadable. The time written next to the physician name was 225, 4 ½ hours after the order started. Review of the nurses notes on restraints for 5/22/2018 confirmed the patient was in soft wrist restraints during that time.

Review of medical restraint order form for 5/27/2018 to 5/28/2018 showed restraint was ordered on 5/27/2018 at 7 AM and expired 5/28/2018 at 659 AM. The physician signature was unreadable. The time written next to the physician name was 1:00, 6 hours after the order started. Review of the nurses notes on restraints for 5/27/2018 confirmed the patient was in soft wrist restraints during that time.

During an interview on 9-19-2018 after 12 PM, Staff #41 was asked how the facility got the renewal orders for restraints from the physician. Staff #41 said the doctors sign when they make rounds on the patients. Staff #41 was asked if the physician wrote the order early if he wasn't going to be back in the hospital when the restraint order expired. Staff 41 confirmed that they did. Staff #41 confirmed the physicians wrote the order early and did not evaluate the patient at the time the restraint order expired to assess the need for continuation of the restraints. Staff #41 said the nurses had voiced concern to the physicians regarding this practice but they had not made any changes.

Staff #3 confirmed the above findings.

Review of the facility policy titled, "Restraint Policy" dated 9/1/2012 with a revised date of 8/14/2017 revealed the following:

" ...Restraints:
Use of restraints will be based upon the assessed needs of the patient, and
consideration of pertinent information obtained from the initial admission assessment.

...Continuation of Orders: Orders for continued restraint are to be obtained each
calendar day and are based on the physician's examination of the patient.

...Order of Restraints:
a. Must have a start time and must be time-limited.
b. One calendar day for adult patients.
c. Must be written or verbal by an independent licensed practitioner.
d Verbal orders must be authenticated within 48 hours.
e. PRN orders will not be accepted.
f. Clinical Justification"

Based on observation, interview, and record review, the facility failed to ensure sanitary environment deficient practices in the facility were identified and reported. The facility failed to ensure the Infection Control Officer identified, reported, and tracked infection control problems in the departments. Also, the Infection Control Officer failed to ensure the quality assurance program had documentation of the infection control deficiencies and addressed the issues at the quarterly meetings.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

During observation of the facility from 9/17/2018 to 9/20/2018 deficient practices in infection control were found in eighteen of eighteen areas.


Review of the facility document titled, "Safety/Infection Control Surveillance Rounds" revealed the following:

July 30, 2018 -

Medication area/Nurses Station
1. Environment is clean and orderly. The compliance in this area is marked as in full compliance.

Facility Maintenance and Housekeeping
1. Facilities are in good repair and are clean (walls, ceiling tiles, carpet, floor covering). The compliance in this area is marked as in full compliance.


August 28, 2018

Medication area/Nurses Station
1. Environment is clean and orderly. The compliance is this area is marked as in full compliance.

Facility Maintenance and Housekeeping
1. Facilities are in good repair and are clean (walls, ceiling tiles, carpet, floor covering). The compliance in this area is marked as in full compliance.


During an interview on 9/19/2018 at 8:52 AM, Staff #4 confirmed the deficient practices were not identified on the Infection Control Surveillance rounds. Staff #4 confirmed the deficient practices were not included in her quality minutes but they should have been included.


Review of the facility policy titled, "Quality/Performance Improvement Plan" dated 3/2018 revealed the following:

"QUALITY MANAGEMENT/PERFORMANCE IMPROVEMENT COMMITTEE

Under the direction of the Medical Executive Committee, The Quality Management Committee is the work force of the organizations performance improvement efforts. The primary activities of the Quality Management committee are:

Assist the organization in meeting all standards of care and achieving excellence when possible

Ongoing monitoring of all organizational functions, processes and related dimensions of care, including identifying additional area for performance improvement.

Review and forward reports on all PI activities through proper reporting channels.


...Measurements and Assessments
Infection Control Surveillance and outcomes"

Based on interview and record review, the facility's Governing Body failed to:

A. ensure the facility quality assessment and performance improvement program (QAPI) reflected all hospital services for 1 of 1 (Dialysis) contracted services.


B. ensure 35 of 35 contracted services were evaluated and provided in an effective manner.


This deficient practice had the likelihood to cause harm to all patients.


Findings include:



Observations on the afternoon of 9/17/18, in the facility's Dialysis Department revealed the following:

There were expired dialysis supplies found in acute dialysis room and in the peritoneal supply storage closet.

The physical environment of the dialysis room was unclean and safety issues were found in the dialysis room and peritoneal supply storage closet.

A review of the quality reports from the dialysis contract service revealed the only reports were from March and August of 2018. There was no report from the dialysis provider for the 2nd quarter submitted to the quality department.

A review of the quality reports submitted by the contracted dialysis provider revealed there was no indication in the data submitted that provided oversite to ensure the facility's contracted dialysis service was managed in a safe and sanitary manner.

A review of the QAPI meeting minutes February through August 2018 did not address the issues with the chlorine check logs, R/O water logs, the infection control and safety issues. The QAPI meeting minutes discussed treatment data with goals met on the two quality reports that were submitted to the facility. Staff #16 who works at acute dialysis unit full time was asked are you involved in the quality meetings. Staff #16 stated, "No".


An interview with the Quality Director for the facility on 9/19/2018 at 3:15 PM stated that quality reports are to be submitted to the facility quarterly. The Quality Director was asked was there a representative from the contracted provider at the meeting. The Quality Director stated, "No, they just submit a report to the meeting."





10135



Review of a list named "Active Contracts" revealed there was 35 active contracted services.

During an interview on 09/19/2018 after 9:00 a.m., Staff #2 confirmed that she reported the quality assurance information to the Governing body. Staff #2 reported contracted services was not being evaluated and taken through their quality programs.

Based on interview and record review, the facility failed to examine all eligible candidates for medical staff membership in accordance to their medical staff bylaws. The facility failed to ensure 6 of 8 credentialing applications were complete with references, delineation of privileges, and current Drug Enforcement Administration (DEA )and licensure information on file (Physician #'s 5, 6,7,8,9, and 10).


This deficient practice had the likelihood to cause harm to all patients.

Findings include:

Review of credentialing files revealed the following;

Physician #5 had an application dated 05/14/2018 and there was no documentation of reference checks.

Physician #6 had an application dated 07/30/2018 and there was no documentation of reference checks.

Physician #7's medical licensure on file had an expiration date of 05/31/2018.

Physician #8 made application on 08/12/16, requested privileges 08/12/16. The date of appointment was over 7 months later 03/08/17.

Physician# 9 made application on 02/28/17, requested privileges 03/01/17. The date of appointment was over 10 months later 01/18/18.

Physician #10 had a DEA on file that expired on 06/30/2018.

During an interview on 09/18/2018 after Staff #48 confirmed the information in the files and reported that the credentialing application should be processed in 120 days.


Review of "Medical Staff bylaws Rules and Regulations" dated 03/14/2018 revealed the following:

"III. 8 Procedure for Reappointment
III. 8-1. Application
At least one hundred and twenty (120) days prior to the expiration of a Member's appointment, the Chief Executive Officer shall provide each Member whose appointment is expiring with an approved "Application for Reappointment" form which should be completed and returned within thirty (30) days to the Chief Executive Officer for review ..."
III. 8-3. Applicant's Burden

A Practitioner applying for reappointment shall have the burden of producing adequate information for a proper evaluation of his current competence, character, skill, ethics, health status, ability to work with others and other qualifications, information to be available for review shall include at least the following:

a. objective evidence of the individual's professional performance, judgment and clinical and/or technical skills based on peer professional review activities, which shall include at least two letters of recommendation from peers in the same specialty, where possible, other than persons related by family or marriage;
c.reasons and supporting information for any request for change in Staff category or Clinical Privileges;
g.evidence of current licensure and DEA and applicable State registration;

III. 8-4.MEC Review and Recommendation

The MEC shall meet and review all pertinent information and make its written recommendation to the Governing Body ...

III.7-6. MEC Review and Recommendation
The MEC shall submit its written recommendation within one hundred twenty (120) days of receipt of the Completion Application, including any additional information requested, to the Governing body for consideration at its next regular meeting ..."

Based on interview and record review, the facility failed to ensure sufficient Registered nurses and Certified nurse aides to provide patient care on 2 of 2 units (1st and 2nd floor units).

The facility failed to ensure enough Registered nurses were scheduled to provide supervision to Licensed vocational nurses on the 1st floor. The facility failed to allot for certified nurses aides on the 1st floor. The facility failed to address staffing numbers in their matrix for both units (1st and 2nd floor units).

This deficient practice had the likelihood to cause harm in all patients who receive meals from the kitchen.

Findings include:


During a confidential interview it was reported that the facility was short of CNA staff.

Review of staffing from 09/09-20/2018 revealed the following:

The facility was short by 1-2 certified nurses aides (CNA) 12 out of 12 days/nights that were checked.

During an interview on 09/20/2018 after 9:00 a.m., Staff #3 reported she staffed more licensed vocational (LVN) or registered nurses (RN) when she was short CNA's. The nurses provided total care to the patients when they were short on CNA's.

Staff #3 reported that first floor unit opened on 09/18/2018 on the second shift (7p-7a). Staff #3 reported she had the following staff for the unit:

1 RN and 1 LVN and no CNAs on the first floor on 09/18,09/19, and 09/20/2018. Each nurse had 2 patients a piece.


There was no way the 1 RN could provide total care to her patients and supervise the LVN.

Staff #3 reported the charge nurse from the second floor unit was also the charge nurse for the 1st floor unit.

There was no way the 1 RN could supervise the staff on the 2nd floor and the 1st floor

Review of the facility's staffing matrix revealed no documentation of staffing for both units. The matrix did not allot for a charge nurse and CNA's for the 1st floor unit.

Based on interview and record review, the facility failed to ensure that nursing staff had current competencies in 2 (Staff #3 and Staff #4) of 2 personnel files reviewed.

This deficient practice had the likelihood to cause harm to all patients

Findings include:


A review of Staff #3's personnel file revealed the following:

Staff #3 had a job description for Chief Nursing Officer. Staff #3 was listed as Chief Nursing Officer on the organizational chart.

A competency fair test was stamped as received by Human Resources on 11-9-2017. The competency fair test had not been scored. The personnel file did not have a clinical competency that verified and validated skills for Chief Nursing Officer position.

During an interview on 9-18-2018 at 1:55 PM, Staff #25 confirmed Staff #3 had not completed the competency checklist.


A review of Staff #4's personnel file revealed the following:

Staff #4 had a job description for Quality Director and Registered Nurse. Staff #4 was listed as the Director of Quality on the organizational chart.

A competency fair test was stamped as received by Human Resources on 11-9-2017. The competency fair test had not been scored. The personnel file did not have a clinical competency that verified and validated skills for Director of Quality or Registered Nurse.

During an interview on 9-18-2018 at 1:55 PM, Staff #25 confirmed Staff #4 had not completed the competency checklist. Staff #25 said the facility did not have a policy on requirements for competencies at the facility.

Based on record review and interview, the facility failed to ensure medications were administered in a safe manner in 5 of 11 sampled patients (Patient #'s 3, 5, 10,13, and 14).

The facility failed to:

A. ensure nursing staff who were titrating Diprivan/Propofol (An anesthetic/Sedative medication) had a valid physician's order.

B. ensure the "Warfarin Medication Order Sheet"protocol was implemented on Patient #10 on admission. Patient #10 continued to receive anticoagulant therapy when her blood work was out of range and was sent to a higher level of care for gastrointestinal bleeding.


This deficient practice had the likelihood to cause harm in all patients receiving medications at the facility.


Findings include:


PATIENT #3

Review of the facility document titled, "Physician Order for Propofol (Diprivan) for IV sedation in mechanically ventilated patients" revealed the following:

Target Ramsay Score: 4
Maximum dose 50 mcg/kg/min

The order did not give an initial starting dose. The order did not give any parameter for titration of the medication.


Review of the facility document titled, "Special Vital Sign sheet" revealed the following:

9-13-18
9:00 AM Diprivan 10 mcg/kg/min
9:30 AM Diprivan increased to 12.5 mcg/kg/min
10:00 AM Diprivan increased to 15.2 mcg/kg/min

9-16-2018
09:00 35.7 Diprivan 35.7 mcg/kg/min
10:00 AM Diprivan increased 36 mcg/kg/min
8: 00 PM Propofol decreased 35.7 mcg/kg/min

9-17-2018
10:00 AM Propofol off
1:00 PM Resumed Propofol 12 cc hr (35.7 mcg/kg/min)


PATIENT #5

Review of the facility document titled, "Physician Order for Propofol (Diprivan) for IV sedation in mechanically ventilated patients" revealed the following:


Target Ramsay Score: 2-4
Maximum dose 100 mcg/kg/min
Initial dose 5 mcg/kg/min
The order did not give any parameters for titration of the medication.



Review of the facility document titled, "Special Vital Sign sheet" revealed the following:

6-21-2018

There was a notation that propofol drip was received at 40 cc/hr. There was no mcg/kg/min dosage listed. There was no date or time with this entry.

7:40 PM Propofol decreased to 54.8 mcg/kg/min


6-22-2018

1:00 AM Propofol decreased to 36.5 mcg/kg/min
7:00 PM Propofol increased to 54.8 mcg/kg/min


PATIENT #13


Review of the facility document titled, "Physician Order for Propofol (Diprivan) for IV sedation in mechanically ventilated patients" revealed the following:


Target Ramsay Score: 3-4
Maximum dose There was no dose listed
Initial dose 10 mcg/kg/min
The order did not give any parameter for titration of the medication.


Review of the facility document titled, "Special Vital Sign sheet" revealed the following:

5-16-2018

6:00 PM

6:00 PM Propofol 10 mcg/kg/min
10:00 PM Propofol increased to 20 mcg/kg/min

5-17-2018
3:00 AM Propofol decreased to 15 mcg/kg/min
7:00 AM Propofol off

5-23-2018
7:00 PM Propofol 5 mcg/kg/min started

5-24-2018
0400 AM Diprivan increased to 10 mcg/kg/min
7:00 PM Diprivan increased to 15 mcg/kg/min

5-26-2018
1200 PM Diprivan decreased to 7.35 mcg/kg/min
8:00 PM Diprivan increased to 15 mcg/kg/min

5-28-2018
0730 AM Diprivan decreased to 13.7 mcg/kg/min
0930 AM Propofol increased to 15 mcg/kg/min
8:00 PM Propofol decreased to 10.1 mcg/kg/min

5-29-2018

3:00 AM Propofol increased to 12.3 mcg/kg/min
4:30 PM Propofol decreased to 12 mcg/kg/min

6-7-2018
0600 AM Propofol started at 5 mcg/kg/min
4:00 PM Propofol Off
6:00 Propofol Discontinued


PATIENT #14

Review of the facility document titled, "Physician Order for Propofol (Diprivan) for IV sedation in mechanically ventilated patients" revealed the following:


Target Ramsay Score: 4
Maximum dose: 50 mcg/kg/min
Initial dose 10 mcg/kg/min
The order did not give any parameter for titration of the medication.


Review of the facility document titled, "Special Vital Sign sheet" revealed the following:

There was no documentation of the diprivan being initiated.

4-3-2018

9:00 PM Diprivan 29.8 mcg/kg/min

4-4-2018

4:00 AM Diprivan decreased to 26.2 mcg/kg/min
8:00 AM Diprivan decreased to 20 mcg/kg/min
9:00 AM Diprivan decreased to 17.5 mcg/kg/min
10:00 AM Diprivan increased to 20 mcg/kg/min
11:00 AM Diprivan increased to 25 mcg/kg/min
3:00 PM Diprivan decreased to 20 mcg/kg/min
5:00 PM Diprivan decreased to 15 mcg/kg/min

4-5-2018
05:00 AM Diprivan decreased to 10.4 mcg/kg/min
12:00 PM Propofol decreased to 10 mcg/kg/min


During an interview on 9-19-2018 Staff #41 confirmed that the Physician orders in the chart were incomplete. She said there was no additional orders for titration. Staff #41 said the nurses made the decision to titrate the medication based on their assessment.

Staff #3 Confirmed the above findings.


A review of the facility policy titled, "Titrating Medications" with a review date of 3/2018 revealed the following:

"PROCEDURE
Physician orders for medications that require titration must include the desired response that the physician expects to be achieved (i.e. titrate medication to achieve BP of 120/80).
The physician will define maximum dosage adjustment increments before titrating the medication. This will allow clinical staff to determine how much to increase or decrease the medication as attempts are made to obtain the desired state for the patient.
The physician will define the minimum frequency of time allowed between dosage adjustments. Titration adjustments will not occur more frequently than the minimum amount of time defined by the physician.
...Each titratable medication order must be patient specific.
Each titratable medication order is subject to maximum dose limits."


10135

Review of the clinical record of Patient #10 revealed she was a 83 year old female who had diagnoses which included cerebrovascular accident and status post aortic valve replacement.


Review of an "ADMIT/DISCHARGE MEDICATION RECONCILIATION AND ORDER SHEET" revealed a list of medications that Patient #10 was currently taking. The category for the last date and time taken was left blank. Nursing staff checked to continue with the medications on admission. Nursing signed the list as being a verbal order from the physician on 09/13/2018 at 1:00 p.m.. Three of the medications listed were anti-coagulants:

Aspirin 81 milligrams a day;
Enoxaparin (Lovenox) 60 milligram injection every 12 hours;
And Warfarin (Coumadin) 4 milligrams one tab daily.

Review of another order written on 09/13/2018 revealed some of the following instructions:

"Daily PT/INR x 5
D/C Lovenox When INR >( or equal) to 2.0
Continue with Coumadin ..."

Prothrombin Time (PT) is a blood clotting test. INR is a laboratory test called an INR (International Normalized Ratio) which measures the time it takes for blood to clot and compares it to an average.


Review of a verbal order dated 09/15/2018 revealed instructions to discontinue Lovenox INR>2.

Review of a verbal order dated 09/16/2018 revealed instructions to discontinue Lovenox.

Review of labs revealed the following:

On 09/13/2018 the PT was listed as HI at 18.8 (reference ranges being 9.2-12.0) and the INR was HI at 1.8 (reference ranges being 0.9-1.2).
On 09/14/2018 the PT was listed as HI at 19.6 (reference ranges being 9.2-12.0) and the INR was HI at 1.9 (reference ranges being 0.9-1.2).

On 09/15/2018 the PT was listed as HI at 21.4 (reference ranges being 9.2-12.0) and the INR was HI at 2.1 (reference ranges being 0.9-1.2).

Review of the medication administration records for 09/15/2018 revealed the Lovenox was stopped. The Coumadin and Aspirin were still administered.

Review of labs revealed the following:

On 09/16/2018 the PT was listed as HI at 26.1 (reference ranges being 9.2-12.0) and the INR was HI at 2.5 (reference ranges being 0.9-1.2).

On 09/17/2018 the PT was listed as HI at 28.0 (reference ranges being 9.2-12.0) and the INR was HI at 2.7 (reference ranges being 0.9-1.2).

Review of the medication administration record revealed the Coumadin and Aspirin were administered on 09/16 and 09/17/2018.

There were no parameters on the chart for administration of the Coumadin.

Review of physician progress notes dated 09/18/2018 revealed Patient #10 had been having a rough night. "The patient has become more short of breath and appears to have been tachypneic. The patient is tachycardic as well with her heart rate ranging up into the 150s. The patient was also found to have very dark melanic stools yesterday evening x 2 with some mild abdominal discomfort."

"..IMPRESSION:
1. Hypotension
2.Atrial fibrillation
3.Possible acute GI bleed
4.Posible pericardial effusion
PLAN: Given her current decompensation I have asked the staff to transfer her immediately to The Medical Center ..."

Review of an emergency record from the receiving hospital date 09/18/2018 revealed Patient #10 had a diagnosis of "GI bleed".

During an interview on 09/20/2018 after 9:00 a.m., Staff #3 confirmed the diagnosis was gastrointestinal bleed.

During an interview on 09/19/2018 after 1:00 p.m., Staff #50 reported not knowing if they had a protocol for Coumadin. Staff #50 reported later that she had just found one in a file cabinet that was supposed to be used.

Review of the "COUMDIN (WARFARIN) STANDING ORDERS" revealed that they were approved in 01/2013. Some of the following was listed on the order set.
Goal INR________ Indications for Warfarin________________

INR 2-3: Prophylaxis of venous thrombosis, treatment of venous thrombosis of PE, tissue heart valves, acute MI, valvular heart disease, atrial fibrillation)
INR 2.5-3.5: Mechanical prosthetic valves, bi-leaflet mechanical valve in aortic position.
Age:________ Height:________________ Weight:_________________

There also a "Warfarin Medication Order Sheet" at the bottom of the form with a place for the physician to sign, date and time.

This was not implemented on Patient #10.

Based on interview and record review, the facility failed to ensure blood transfusions were administered per their approved procedures in 2 of 4 patients sampled for blood administration (Patient # 12 & #3).

The facility failed to document the receipt time of blood from the contracted service, so they could ensure it was being transfused in the proper and safe timeframe. They failed to ensure physician's orders were complete with rate of transfusion.

The facility failed to obtain informed consent prior to administration of blood.


This deficient practice had the likelihood to cause harm to all patients who received blood in the facility.

Findings include:


Review of the clinical record of Patient #12 revealed he was a 74 year old male who was admitted on 09/14/2018 with diagnoses which included nausea/vomiting, oral cancer and dysphagia.

Review of a physician's order dated 09/15/2018 revealed if Patient #12 had a hemoglobin less than 8.0 they were to transfuse 2 unit of packed red blood cells. There was no timeframe written on the order as to how fast or slow to transfuse the blood.

Review of the "DISCLOSURE AND CONSENT MEDICAL AND SURGICAL PROCEDURES" for blood administration dated 09/15/2018 revealed no documentation of a witness or physician's signature.

Review of the "BLOOD/BLOOD COMPONENTS TRANSFUSION RECORD" revealed the following instructions:

"1. Hang blood/blood component within 30 minutes of arrival to unit. Do not store in unit refrigerator. Component must be transfused within 4 hours"

There was no documentation on the forms of when the blood actually arrived to the facility from the contracted company.

The first unit of blood was started at 09/16/2018 at 12:15 a.m. and ended at 3:40 a.m. and the second unit started at 3:50 a.m. and ended at 7:30 a.m.

This was a total of 7.5 hours to administer the blood without there being any tracking of when both units got to the floor.

During an interview on 09/19/2018 after 11:40 a.m., Staff #49 confirmed there was no documentation of the time the blood actually came to the floor.


Review of a facility's policy named "BLOOD ADMINISTRATION" revised 05/2017 revealed the following:


"To infuse blood products, perform the following steps:

1.Verify written physician's order, noting the indication, rate of infusion, and any premedication orders.
2.Verify informed consent was obtained from the patient.....
5.Obtain LifeShare blood shipment container with blood component.
"Do not remove blood component from shipment container until ready to transfuse.
"Ensure transfusion is started within 30 minutes of removing blood component from the blood shipment container."











39801

Review of the clinical record of Patient #3 revealed he was a 61-year-old patient of Physician #9. The diagnosis on the blood consent was anemia.


Review of the "DISCLOSURE AND CONSENT MEDICAL AND SURGICAL PROCEDURES" for blood administration dated 09/15/2018 revealed no documentation of a physician signature. There was no documentation in the physician progress notes that the risks and benefits of the blood transfusion were explained to the patient and/or family.

Review of the "BLOOD/BLOOD COMPONENTS TRANSFUSION RECORD" revealed the following instructions:

"1. Hang blood/blood component within 30 minutes of arrival to unit. Do not store in unit refrigerator. Component must be transfused within 4 hours"


The first unit of blood noted in the chart that was given was started on 10-13-2018 at 9:00 PM and completed on 10-14-2018 at 12:30 AM. There was no documentation what time the unit of blood arrived on the floor from the contract facility.

The second unit of blood noted in the chart that was given was started on 10-15-2018 at 1:30 AM and was completed on 10-15-2018 at 5:35 AM. There was no documentation what time the unit of blood arrived on the floor from the contract facility.

Based on interview and record review, the facility failed to ensure physician orders were complete, timed, dated, and signed in a timely manner. The facility failed to ensure history and physicals were complete. This deficient practice was found in 8 (Patient's #1,2,3, 8, 9, 10, 12 and 13) of 30 sampled patients. Also, the facility failed to follow their own policy on verbal and telephone orders.

This deficient practice had the likelihood to cause harm in all patients.


Findings include:


Review of Patient #1's medical record revealed the following:

A verbal order for "PICC/Midline order set" was written on 9/13/2018. A PICC line is a Peripherally Inserted Central Catheter. Physician #8 had not signed the order on 9/20/2018, 7 days later.

A verbal order for "Vancomycin protocol order set" was written on 9/13/2018. Physician #8 had not signed the order on 9/20/2018, 7 days later.

A verbal order was written on 9/11/2018 to continue all medications. There was no clarification of the medications, frequency, dosages. Physician #8 had not signed the order on 9/20/2018, 9 days later.

A telephone order for wound care was written on 9/12/2018. Physician #8 had not signed the order on 9/20/2018, 6 days later.

A telephone order for "Admission physician orders" were written on 9/11/2018. Physician #8 had not signed the orders on 9/20/2018, 9 days later.


Review of Patient #2 medical record revealed the following:

A verbal order for PICC/Midline order set was written on 9/10/2018. Physician #9 had not signed the order on 9/20/2018, 10 days later.

A verbal order for Humulin R/Novolin R sliding scale for moderate blood glucose levels was written on 9/7/2018. Physician #9 had not signed the order on 9/20/2018, 13 days later.

A verbal order for "Hypoglycemia protocol" was written on 9/7/2018. Physician #9 had not signed the order on 9/20/2018, 13 days later. A telephone order for admission physician orders were written on 9/11/2018. Physician #8 had not signed the orders on 9/20/2018, 9 days later.

A telephone order for" Admission physician orders" were written on 9/6/2018. Physician #9 had not signed the orders on 9/20/2018, 14 days later.

A verbal order for admission medications was written on 9/6/2018. There were 18 medications listed. The medications included antidepressant medications, cardiac medications, potassium, antibiotics, and seizure medications. The physician had not signed the orders on 9/20/2018, 14 days later. The current medication administration record revealed the medications were being administered.


Review of Patient #3 medical record revealed the following:

A verbal order for "Insulin sliding scale protocol" for Novolog/Humalog for moderate blood glucose levels was written on 9/14/2018. Physician #9 had not signed the order on 9/20/2018, 6 days later.

A verbal order for "Hypoglycemia protocol" was written on 9/11/2018. Physician #9 had not signed the order on 9/20/2018, 9 days later.

A telephone order for "Admission physician orders" were written on 9/7/2018. Physician #9 had not signed the orders on 9/20/2018, 13 days later.

A telephone order for wound care was written on 9/8/2018. Physician #9 had not signed the order on 9/20/2018, 12 days later.

A verbal order for" Enteral Nutrition Orders" was written on 9/22/2018 and 9/13/2018. Physician #9 had not signed the order on 9/20/2018, 7 days later.

A verbal order for Meropenem (Antibiotic medication)1 gram was written on 9/12/2018. Physician #9 had not signed the order on 9/20/2018, 8 days later.

A verbal order for admission medications was written on 9/7/2018. There were 19 medications listed. The medications included cardiac medications, Hypertensive medications, respiratory medications, blood thinners, anti-nausea medications, and anti-depressant medications. Physician #9 had not signed the orders on 9/20/2018, 13 days later.


A review of Patient #13 medical record revealed the following:

A verbal order for PICC (Peripherally Inserted Central Catheter) was written on 5/21/2018. Physician #8 had not signed the order on 9/20/2018, 4 months later.

A verbal order for Diprivan (Anesthetic, Sedative) was written on 5/23/2018. There was no dosage, frequency, titration dosage, or maximum dosage listed or clarified. Physician #9 had not signed the order 9/20/2018, 4 months later.

A verbal order for blood cultures x 2 was written on 5-25-2018. Physician #44 had not signed the order 9/20/2018, 4 months later.

During an interview on September 19, 2018 after 3:00 PM, Staff #2 said the facility had an ongoing problem with physicians signing orders and other medical record documents. Staff #2 was asked if the facility had any process for accountability with the lack of accurate physician orders. Staff #2 said she would talk to the medical staff and the physicians would improve for a while and then slack off. Staff #2 said there was no formal process for physician accountability with physician orders/medical record documentation.









10135

Review of the clinical record of Patient #12 revealed he was a 74 year old male who was admitted on 09/14/2018 with diagnoses which included nausea/vomiting, oral cancer and dysphagia.

Review of physician orders revealed the following:

Admit physician orders which included treatment, nutrition/hydration, diagnostic, activity, and medication orders were signed off by the physician,but were not timed or dated.

DVT/PE (DEEP VEIN THROMBOSIS/PULMONARY EMBOLUS)PROPHYLAXIS ORDERS were signed off by the physician,but there was no date or time on them.

Verbal orders for wound care was written on 09/15/2018 by nursing and still had not been signed off by the physician as of 09/19/2018.

Three verbal orders were written on 09/15/2018 for medication or changes in medication by nursing staff. As of 09/19/2018 they still had not been signed off by the physician.

A verbal order to implement a potassium protocol was written on 09/16/2018. The physician signed it but did not date or time it.




Review of the clinical record of Patient #9 revealed he was a 79 year old male who was admitted on 09/13/2018 right toe complications.

Admit physician orders which included treatment, nutrition/hydration, diagnostic, activity, and medication orders were not signed off by the physician or dated.

Review of an "ADMIT/DISCHARGE MEDICATION RECONCILIATION AND ORDER SHEET" revealed a list of medications that Patient #9 was currently taking. The category for the last date and time taken was left blank. Nursing staff checked to continue with the medications on admission. At the bottom of the order sheet nursing documented a verbal order was received at 9:35 p.m. At 9:37 p.m. the form was faxed to the pharmacy. The list contained two cholesterol medications Zocor and Atorvastatin.

As of 09/19/2018 the orders had not been signed off by the physician.


Review of a physician order dated 09/13/2018 and without a time revealed the following:

"D/C Zocor"
"ID Home Meds correctly (listed are 2 Statins)??"

Review of two set of verbal orders dated 09/14/2018 revealed orders for changes in medications and one on instructions for a surgical procedure. Another order set for wound care orders was written as a verbal order on 09/14/2018.

As of 09/19/2018 the orders had not been signed off by the physician.




Review of the clinical record of Patient #8 revealed she was a 78 year old female who was admitted on 09/07/2018 with diagnoses which included anxiety and respiratory failure.

Admit physician orders which included treatment, nutrition/hydration, diagnostic, activity, and medication orders were written as verbal orders by nursing staff on 09/07/2018. The orders were signed off by the physician, but there was no date or time behind the signature.

Review of an "ADMIT/DISCHARGE MEDICATION RECONCILIATION AND ORDER SHEET" revealed a list of medications that Patient #8 was currently taking. The category for the last date and time taken was left blank. Nursing staff checked to continue with the medications on admission. Nursing signed them as being a verbal order from the physician on 09/07/2018 at 2:44 p.m..

Another verbal order was written on 09/07/2018 at 2:44 p.m., to "continue all previous facility medications ..."

The physician signed both orders but failed to date and time them.

DVT/PE (DEEP VEIN THROMBOSIS/PULMONARY EMBOLUS)PROPHYLAXIS ORDERS were on the chart. The risk and recommendations section on the orders was left blank. The physician had not completed and signed the order set.

Review of the clinical record of Patient #8 revealed she was a 78 year old female who was admitted on 09/07/2018 with diagnoses which included anxiety and respiratory failure.

Review of a history and physical which had been signed by the physician on 09/07/2018 revealed the entire form was left blank.

The physician failed to complete the form.



Review of the clinical record of Patient #10 revealed she was a 83 year old female who had diagnoses which included cerebrovascular accident and status post aortic valve replacement.

Review of an "ADMIT/DISCHARGE MEDICATION RECONCILIATION AND ORDER SHEET" revealed a list of medications that Patient #10 was currently taking. The category for the last date and time taken was left blank. Nursing staff checked to continue with the medications on admission. Nursing signed the list as being a verbal order from the physician on 09/13/2018 at 1:00 p.m.. Three of the medications listed had duplicate actions. They were anti-coagulants:

As of 09/19/2018 the orders had not been signed off by the physician.



During an interview on 09/19/2018 after 9:00 a.m., Staff #'s 31 and 32 revealed that they were auditing charts in medical records. Staff #32 provided a list of physicians who were delinquent in charting. Staff #32 reported that the information was sent to Staff #2 (Administration).

During an interview on 09/19/2018 after 3:00 p.m., Staff #3 and 4 confirmed the problems with the physicians orders. Staff #3 reported the nursing staff were dating and timing orders for the physicians. The problems have been reported to administration.

During an interview on 09/20/2018 after 9:00 a.m., Staff #2 reported having problems with the physicians and their documentation. The only thing that had been done was that they were talked to and sent a text.



Review of the facility policy titled, "Verbal and Telephone Medication Orders" dated 01/31/2007 with a revision date 12/12/2006 revealed the following:

"The use of verbal orders (including telephone or other oral orders) shall be minimized. Verbal orders shall be processed in accordance with medical staff rules and regulations and as described in this policy.

VERIFICATION of VERBAL/TELEPHONE ORDERS
Verbal or telephone orders will be verified with the prescriber by having the person receiving the order orally "reading-back" the order to the prescriber.

RECORDING VERBAL ORDERS
Verbal orders shall be immediately entered on the physician's order form or other authorized document. In addition to the information required for a written order, verbal orders shall include:
o The date and time of entry.
o The prescribing practitioner's name.
o The signature and title of the person who accepted the order.

ORDERS
Orders that are not written by a prescriber (e.g., verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 24 hours of receipt"


Review of a facility's "MEDICAL STAFF RULES AND REGULATIONS" adopted 01/01/2011 revealed the following:


".. A complete admission history and physical examination shall be recorded by the attending physician or his designee within twenty-four (24) hours (amended to forty-eight (48) hours...., of admission to the hospital. This report should include all pertinent findings resulting from an assessment of all systems of the body..

All orders for treatment and medication shall be in writing and authorized only by a licensed physician, dentist, psychologist, or podiatrist appropriately credentialed pursuant to the medical staff bylaws.

The practitioner's orders must be written clearly, legibly, and complete..

Orders shall be rewritten when a patient is transferred to a different level of care..."

Based on record review and interview, the facility failed to ensure that drugs and biological's which did not specify a time or number of doses were automatically stopped. Also, the facility failed to develop a policy that provided guidelines on stopping drugs and biological's after a reasonable time determined by the medical staff. This deficient practice was found in 2 (Patient's #25 and #26) of 2 charts reviewed.

This deficient practice had the likelihood to cause harm to all patients admitted to the facility.

Findings include:

Review of Patient #25's medical records revealed the following:

An order dated 4/24/2018 for Xopenex (A bronchodilator) by breathing treatments, dose every 6 hours was noted. The order was a verbal order from Physician #45. Physician #45 signed the order. There was no date or time with the signature.

An order dated 5/11/2018 to change nebulizer treatments to PRN (As needed) only for wheezing was noted. The order was a verbal order from Physician #45. Physician #45 signed the order. There was no date or time with the signature.

Review of the Respiratory MAR (Medication Administration Reconciliation) sheet revealed that Xopenex was a current order listed.

A review of the physician orders in the chart did not reveal any renewal of the Xopenex orders since 5/11/2018, 4 months ago.

Review of the facility treatment sheet titled, "Respiratory Therapist Record" noted a Xopenex nebulizer treatment given 9/17/2018 at 2:05 PM and 7:53 PM. Also a breathing treatment was given 9/18/2018 at 2:04 AM.


Review of Patient #26's medical record revealed the following:

An order dated 8/16/2018 for Budesonide (Inhaled Glucocorticoid) BID (Twice a day) was noted. The order was a verbal order from Staff #46. There was an unreadable signature on the reconciliation sheet. There was no date or time with the signature.

An order dated 8/16/2018 for DuoNeb breathing treatments every 6 hours was noted. The order was a verbal order from Staff #46. There was an unreadable signature on the reconciliation sheet. There was no date or time.

An order dated 8/24/2018 to change budesonide to PRN (As needed) per patient request was noted and written by Staff #46.

Review of the Respiratory MAR (Medication Administration Reconciliation sheet revealed that Xopenex and budesonide were current orders listed.

A review of the physician orders in the chart did not reveal any renewal of the order for DuoNeb since 8/16/2018, 1 month ago. There was no order renewal for budesonide since 8/24/2018, 3 ½ weeks ago.

During an interview with Staff #47 on 9-18-2018 at 1138 confirmed the above findings. Staff #47 was asked how the staff verified the medications on the MAR were current and up to date. Staff #47 said it was her understanding that the pharmacy renewed the medication orders. Staff #47 was asked to identify how the pharmacy documented that in the charts above. Staff #47 confirmed there was no documentation of the medication renewal.

During an interview with Staff #29 on 9-20-2018 after 9:00 AM, Staff #29 was asked what the facility policy was for automatic stop on mediations with no time or number of dosages listed. Staff #29 said the facility did not have a policy for that. Staff #29 said the facility had a policy for specified toxic and dangerous drugs stop order policy, but they did not have any other policy that would address automatic stop on medication outside of those parameters.

Review of the facility policies for pharmacy did not reveal any policy on Automatic Stop Medication orders with no time limit or dosages noted.

Based on observation, review, and interview, the facility failed to maintain proper safety precautions against radiation hazards. The facility did not have a lead apron or any other barrier to use for personal protective shielding at the facility.

This deficient practice had the likelihood to harm all patients and personnel at the facility.


During an observation tour on 9-18-2018 after 8:30 AM the following was revealed:

A lead apron was hanging on a rack in the Radiology department labeled A2. Review of the "Protective Devices Survey" dated 6/18/2017 revealed the lead apron had been identified with defects found.

During an interview on 9-18-2018, Staff #12 said the apron was not in use. Staff #12 was asked what the process was to remove defective lead aprons. Staff #12 said she was not sure, and would check on it. Staff #12 was asked what other lead aprons were being used in the department. Staff #12 said the department did not currently have a lead apron because it had been misplaced over the weekend. Staff #12 said they had been looking for it but had not located it as of the time of the interview. Staff #12 was asked what the staff used for personnel protection to shield from radiation. Staff #12 said they just stood back as far as they could. Staff #12 said the only X-Rays taken were done at the bedside of patients. Staff #12 confirmed the personnel taking the X-rays did not use any shielding when taking the X-Rays since 9-17-2018.

Review of the X-Ray requisitions for 9-18-2018 revealed four X-Rays had been performed at the time of the observation tour on 9-18-2018.

Staff #40 confirmed the above findings.

Review of the facility policy titled, "Radiology Department Safety" with a review date of 7/16 revealed the following:
" ...Radiation: All personnel shall use the appropriate lead aprons, shield, etc. when performing a portable x-ray.

Based on record review and interview, the facility failed to ensure that the Radiology department had a process to ensure that the radiation workers maintained a safe radiation exposure. The hospital did not have personnel who were qualified to monitor staff exposure.

This deficient practice had the likelihood to harm all staff performing radiological procedures at the facility.

Review of the facility document titled, "Radiation Dosimetry Report" revealed the following:

Staff #12 provided a report dated 1-1-2018 to 3-31-2018, 6 months ago. The report showed results for Quarter #1. Staff #12 was asked if the facility had received the report for Quarter #2. Staff #12 said they had not. Staff #12 was asked how the facility woud identify an employee that was reading high on the report. Staff #12 said the company would call the facility. Staff #12 was asked if the facility had anyone qualified to read or interpret the report. Staff #12 said she did not know of anyone, including herself.

Staff #12 said the facility did not currently have a designated Radiation Safety Officer. Staff #12 said she had sent her application in to become the safety officer but had not heard back. Staff #12 was asked if the facility had a physician designated as Radiology director. Staff #12 said the facility did not.

Staff #40 confirmed the above findings.

Review of the facility policy titled, "Radiation Dosimetry" with a review date of 07/16 revealed the following:

" ...A radiation dosimetry report is received from Landauer, quarterly.
Verification of report must be initialed by the Radiation Safety Officer. Report is reviewed by the Radiation Safety Officer.
...The most recent report is posted in the Radiology Department at Mid Jefferson Extended Care Hospital."

Based on observation and interview, the hospital failed to have a radiologist designated to supervise the ionizing radiology services at the facility. Also the facility failed to establish criteria in the Medical Staff Bylaws, Rules and Regulations on designation of a Supervising radiologist.


Findings include:

During the entrance conference on 9-17-2018 after 1:15 PM, Staff #2 said the Radiology director was Physician #44.

During an observation tour on 9-18-2018 at 11:10 AM, Staff #12 and Staff #40 said they did not have a Radiologist designated as the Radiology director.

During an interview on 9-19-2018 after 8:30 AM, Staff #2 said after checking she found out that there was no Radiologist designated as the Radiology Director for the facility.

During record review of the "Radiation Dosimeter Reports" on 9-18-2018, Staff #12 was asked how she would report abnormal levels of radiation at the facility. Staff #12 said she would just tell the acting director, Staff #40. Staff #40 was not trained nor did he have knowledge on how to interpret the results of the dosimeter report.

Staff #12 said the facility used a telemedicine radiologist to interpret all the X-Rays performed. Staff #12 was asked if the telemedicine Radiologist supervised the facility employees or the radiation services. Staff #12 confirmed they did not.

Staff #12 and Staff #40 confirmed the facility did not have any supervision over radiology services by a radiologist.

Review of the Medical Staff Rules and Regulations, dated September 1, 2011 did not reveal any criteria in the Medical Staff Bylaws on designation of a Supervising radiologist.

Based on record review and interview, the facility failed to adopt, implement, and enforce policies and procedures addressing receipt and reporting of tissue specimens.

During an observation tour on 9-18-2018 of the laboratory department no specimen log was found. Staff #12 was asked if the facility had a process to tract lab/tissue specimen obtained in the facility. Staff #12 confirmed the facility did not.

On 9-18-2018 at 12:00 PM while reviewing the Policy and Procedure Manual for the laboratory department, no Policies and Procedure were found on instructions for the transportation, receipt, and reporting of tissue specimen results in the laboratory department. There were some policies from another facility in the policy book, but no facility specific policies that addressed transportation and tracking of specimens.

During an interview on 9-18-2018 after 12:00 PM, Staff #40 said he didn't know why policies from the facility contract hospital were in the book. Staff #40 said the facility carried all their specimens to that hospital for processing, so he thought they may be in there for a reference.

During an interview on 9-18-2018 after 12:00 PM, Staff # 12 confirmed the facility did not have any log that tracked lab/tissue specimens taken to the contract facility. Staff #12 said the Lab staff reviewed specimen orders daily to ensure that results were complete, however, they did not have a process to track lab/tissue specimens obtained at the facility. Also, they did not have a process to track lab/tissue specimens that were transported to the contract facility. Staff #12 said the facility lab staff took the lab/tissue specimens over to the contract facility daily.

Based on observation, interview and record review, the facility failed to ensure the dietary services was organized in a manner to ensure safe food practices in 4 of 4 areas (Dietary storage area, dining room, main kitchen area, and transportation vehicle). The facility failed to:

A. Provide safe and clean storage for food products. Food products were stored in an area that did not have surfaces that could be sanitized. Food products were stored on rusted shelves and in cardboard boxes.

B. Ensure the dining room area was cleaned and kept up. The walls were stained with a green substance which had the appearance of mildew. The seating areas and tables were soiled with spills and dust. The windows in the room were heavily soiled with spills.

C. Ensure the flooring was kept clean. The flooring had a build-up of wax and spills. The shelves which had food and dietary supplies stored on them were soiled and had a buildup of rust. Ceiling tiles had brown water stains.

D. Ensure expired supplements which were stored in a cardboard box in the kitchen was discarded. Expired food products in the refrigerator were not being discarded.

E. Ensure staff knew how to take food temperatures. Staff were taking temperatures by sticking the end of the thermometer through the plastic covering. This was increasing the risk of plastic getting in the food. Staff were not taking the temperatures of all food items on the steam table. Staff were not properly sanitizing the thermometer after checking potentially hazardous food items.

F. Ensure there was a procedure for washing dishes at the facility. A bucket of bleach water was being used to wipe down items in the kitchen including the thermometer. The facility had scoops, ladles and pans which were in need of cleaning. The cleaning products were stored on the soiled kitchen floor.

G. Ensure the standup refrigerator/freezer, the condiment cart, food transportation carts, plate warmer, and steam table were cleaned. They all were soiled with spills and rusted.

H. Ensure the inside of the transportation van was kept clean. The van that was used to deliver patient trays had a buildup of dirt and rust The area where the trays was unloaded was littered with trash.

I. Ensure dietary staff removed soiled gloves and washed their hands in the tray prep area. They failed to ensure staff entering the kitchen wore hair coverings.


This deficient practice had the likelihood to cause harm to all patients who received food or food products from the main kitchen.

Findings include:

During an observation on 9/18/2018 after 9:00 a.m. the following was found:

DIETARY STORAGE ROOM

Containers of dietary supplements and cans of vegetables were stored on rusted shelves. The floor in the storage room had carpeting which was soiled with stains and was not a surface that could be sanitized. There was also a cardboard box stored in the room which contained plastic silverware.


DINING ROOM AREA

A brick wall in the room had an original color of tan, but had areas which had turned green in color (appearance of mildew). The window panes in the room were heavily soiled with dried spills. You could barely see out the windows. The metal frames which held up the seats were covered in a layer of dust. One of the seats was broken off and missing.
Another tan colored brick wall in the room and lines of dried brown glue on it.


MAIN KITCHEN AREA
The tile flooring, baseboard and frame at the entry door to the kitchen were soiled with dirt.

The step stool inside the kitchen was soiled with a build-up of dirt and dust.

Containers of dietary supplements were stored on a bottom wire shelf which did not have a splash guard down. The shelf that the containers were stored on were rusted and could not be sanitized. The floor underneath the shelves was soiled with spills. A container of the supplement had fallen on the floor underneath a shelf.

A cardboard box containing bottles of tube feeding formula was stored in the kitchen. The bottles of formula expired on 09/01/2018.

Cardboxes containing food products was stored on top of a prep table next to the microwave. The based and shelf area underneath the prep table were covered in rust. The drain area on top of the table was soiled with a buildup of spills and dust.

The tile flooring behind the standup freezer was soiled with spills. The inside of the freezer doors, hinges and shelves were soiled with dried spills and build-up. The fans in the freezer were soiled and had a build-up of rust. Cardboard boxes of food products were stored inside the freezer.

Inside of the freezer doors had areas which had cracked open. Some were covered with tape.

There were muffins stored in the freezer and were dated 09/09/2018 (9 days ago). A loaf of bread was dated 09/10/2018 (8 days ago)

The bins which contained condiments and plasticware was soiled with spills. The carts everything was stored on was soiled with dried brown spills and rusted. There was food products stored directly underneath the fans.

The base and legs of the steam table were rusted. The tile flooring underneath and in the kitchen area was soiled with a buildup of spills, wax and grease.
Plates and steam table pans and other supplies were stored on a bottom shelf underneath the steam table. The shelves were not covered or enclosed and were soiled with spills.
Ladles and scoops used for serving were stored in a plastic bin underneath the steam table. The inside of the plastic bin was soiled with spills.
A used stainless steel scrub pad was found underneath the steam table. The reused scrubbing pad was an environment for bacteria growth.
Bottles of cleaning products were stored on the floor. Next to them was a 10 gallon bucket turned upside down. On top of the 10 gallon bucket was a container which had bleach, water and towels in it. A steam table top was propped on the bucket behind it. Staff #28 was observed to remove the towel from the bucket and clean off the top of the steam table.
The drain in the floor had a buildup and floor underneath the sink had a build-up of dirt and grease.

The inside of the plate warmer was soiled with spills.

The inside pan of the toaster oven had a buildup of crumbs and black carbon stuck to it.

Ceiling tile in the area had brown water stains.

The hallway and outside area where the food was delivered was littered with trash. Soiled steam table pans and dishes were stored on the floor in the hallway.

The inside of the food transportation van was soiled with a build-up of dirt and rust.

The stainless steel carts used to transport trays on were rusted.

Staff #27 and 28 confirmed the observations. Staff #28 confirmed there was no process for washing dishes that were there at the facility. Staff #28 confirmed not knowing how many days food was suppose to remain in the refrigerator./freezer after being opened. Staff #28 reported she guessed she would go by the label from the contracted facility which was placed on other food items of 3 days.

MEAL SERVICE

Staff #28 was observed to take temperatures of food on the steam table. Staff #28 stuck the end of her thermometer through the plastic covering instead of removing the plastic. Staff #28 took the temperature of the following food in this order:
greens beans, roast, carrots,potatoes and vegetable with rice.

Staff #28 failed to cleanse the thermometer between the food items. The thermometer was dipped in the bucket of water and bleach that was used to clean the steam table off after the temperatures were taken.

Staff #28 was questioned about taking temperatures on the rest of the food items that remained on the steam table. Staff #28 reported that she only takes temperatures on 4 items off the steam table each meal. Staff #28 reported that she was told to do it that way by the last dietitian they had.

The remaining food items on the steam table were fish, soup, gravy, chopped beef, chopped fish, pureed beef and pureed carrots.

Review of the facility's "Food Temperature Log" for August and September 2018 revealed only 3 -4 food items listed with the temperatures checked for each meal. The following was listed on the log: " Regulation Requirements for Hot Holding: All foods should be held at 140* or higher"

HANDWASHING AND HAIR COVERING

Staff #28 was observed to donn a pair of gloves and pick up a plastic container. The top of the container fell on the floor and Staff #28 picked it up and threw it in the trash. With the same gloves on Staff #28 open up a can of soup and warmed it up in the microwave. Staff #28 was observed to discard the plastic container that was used in the trashcan. The top of the trashcan was touched with her gloved hand. Staff #28 picked up the receiver to the phone and held it with her gloved hand. Staff #28 took her gloved hand and reached into the bleach water and removed a towel and clean off the steam table.

Two certified nurse aides (#'s 38 and 39) entered the kitchen and came all the way back to the steam table area before they put any kind of head cover on.

Review of the policy named "Kitchen Services" dated 05/2018 revealed the following;

"..Hot foods will be brought in bulk to be heated to the correct temperature. All food must be held at a safe temperature to reduce food borne illness risk..
2. Dietary staff should place all steamtable food in appropriate slots, take temperatures, and record in hot temp, binder. Serving staff is responsible for plating food..
5. The dietary staff is responsible for disposing of all leftover food and trash from the kitchen, at least once a day.
6. The contract facility is responsible for returning all used equipment, trays, utensils to the contract facility to clean and sanitize before next meal time service.."

There was no policy on labeling food, dish washing at the facility or the need for hair coverage in the kitchen.

Based on observation, interview and record review, the facility failed to ensure dietary staff were provided competencies to safely perform their jobs in 2 of 2 staff (Staff #'s 28 and 41).

This deficient practice had the likelihood to cause harm in all patients who receive meals from the kitchen.

Findings include:



During an observation on 9/18/2018 after 9:00 a.m., Staff #28 was found to not know the correct procedures for taking food temperatures, handwashing, food storage and kitchen sanitation practices.


Review of September and October 2017 competencies on Dietary Staff #'s 28 and 41 revealed no documentation of training on dietary duties.

During an interview on 09/18/2018 after 9:00 a.m., Staff #28 revealed not having recent competencies for her job duties.

During an interview on 09/18/2018 after 4:00 p.m., Staff #25 revealed that the dietary staff did not have competencies related to their job duties.

Based on observation, interview, and record review the facility failed to ensure that the condition of the overall hospital environment was maintained in a safe manner for all patients in eight (1ST Floor hallway, Radiology, CT Room, Laboratory, Biomedical room, Janitor room, Medical Gas Storage room, and Medical Record Storage) of eight areas observed.

The facility had rusted, cracked, water stained and bulging ceiling tiles and vents throughout the hospital. The ceilings and walls had missing ceiling tiles and holes exposing wires. The medical gas storage room had E-Cylinders stored in an unsecured manner. The trash dumpster area had plastic covers that were open and exposed the grounds to contaminates. There were employees smoking and cigarette buds found around the trash and medical gas storage room (non-smoking areas) which could be a potential fire hazard.


This deficient practice had the likelihood to cause harm in all patients at the facility.

During an observation tour on 9-18-2018 at 1543, the following observations were made:


1ST FLOOR HALLWAY
There was a light cover outside Lab/Radiology that was broken and missing a corner of the plastic cover. There were rusted ceiling tile frames throughout the first floor. There was ceiling tile throughout the first floor stained in brown color that appeared to be water stains.


RADIOLOGY
There was an electrical outlet hanging from a hole in the ceiling tile. There was an extension cord plugged into the outlet and laying on the floor. There was a closet in the radiology department that stored darkroom equipment. There were uncapped water lines laying on the floor in the darkroom.

CT ROOM
There was a room that stored CT (Computed Tomography) equipment that was not in use. In this room there was a hole in the wall. There were electrical wires hanging freely and unprotected from that hole.


LABORATORY
There was a room on the left when you entered the department that had ceiling tile with brown colored stains that appeared to be water stains. There was a hole in ceiling that an electrical outlet was hanging from. Plugged into the outlet was an extension cord that was laying on floor plugged into wall. Next to the hole in the ceiling there was a ceiling tile with brown and black stains that appeared to be a water stain and mildew.

There was an open hole in the wall with water valves exposed.


BIOMEDICAL ROOM

The EXIT sign above the door was missing the plastic cover and the wires were exposed. The sign was not working.


JANITOR ROOM ON 1ST HALLWAY

The vent was bulging from the ceiling. The ceiling tile was cracked around the vent. The ceiling tile had a brown stain that appeared to be water stains.


MEDICAL GAS STORAGE ROOM

There were four Oxygen E-Cylinders stored on the left in the front of the room. The cylinders were not secured. The chain that was supposed to secure them was broke and laying on floor. There was an E-Cylinder on the right in the front of the room that was unsecured. The E-Cylinder was sitting next to a fire extinguisher.

Staff #2 and Staff #36 confirmed the above findings.

Review of the ASHE (The American Society for Healthcare Engineering of the American Hospital Association article dated 2012 regarding NFPA (National Fire and Protection Act) regulations revealed the following:

"2. General Storage Requirements for all Medical Gas Cylinders
2.3 All medial gas cylinders including E-Cylinders must be physically supported either in a stand or rack or chained or strapped to the wall. This requirement is intended to prevent mechanical hazards caused by sudden release of gas if tank falls over."




During an interview on 9-18-2018 at 1543, Staff #36 confirmed the facility had an ongoing issue with water leaks. Staff #36 said they had repaired the roof several times. Staff #36 said he presented a proposal for repairs to seal the building and prevent water leaks to administration on July 31, 2018. Staff #36 said he had not received any approval for the proposal as of 9-20-2018, 2 months later.

During an interview with Staff #2 on 9-20-2018 after 9:00 AM, Staff #2 confirmed the facility had an ongoing problem with leaks. Staff #2 said the area had received rain the weekend prior to the survey and a lot of water leaks were noted. Staff #2 was asked what the facility was doing to repair the problems. Staff #2 said they just repair leaks as they find them and replace ceiling tile. Staff #2 was asked if she was aware of the proposal sent to administration to repair the building. Staff #2 said she was aware of it.



10135

During an observation on 09/19/2018 after 10:00 a.m., a room in the closed section of the building was being used for medical record storage. The medical records were stored on shelves in cardboard boxes. Behind one section of the boxes was an over bed light which was pulled away from the wall. It was hanging from the wall by the wiring. There were also exposed wiring behind the paper boxes which presented a fire hazard.

Staff #31 and 32 confirmed the observation

Based on observation and interview the facility failed to demonstrate safe storage of trash at the facility.

This deficient practice had the likelihood to cause harm to all patients at the facility.

During an observation tour on 9-18-2018 at 1543, the following observations were
made:


There were two trash dumpster's sitting outside the facility next to the medical gas storage room. The plastic covers were left open exposing the environment to contaminates and animal scavenging. The trash dumpster was located in the same area that linen was being transported into the facility.

There was a metal trash can on the ground next to the dumpster's that did not have a lid. The trash can was full of trash.

There was a table sitting next to the dumpsters that was secured by a metal pole in a 5-gallon bucket. The 5-gallon bucket was full of trash and cigarette buds.

There were linen carts sitting on the back dock uncovered.

There were employees smoking around the trash dumpters and medical gas storage area (non-smoking areas) which could be a potential fire hazard. Also, cigarette buds were found around the generator area.



During an interview on 9-18-2018 at 1543, Staff #36 confirmed the above findings.

Based on record review and interview, the facility failed to ensure the Infection Control Coordinator had been trained in infection control and how to coordinate an infection control program. The Infection Control Coordinator was not identifying and reporting areas identified as unsanitary in the facility.


This deficient practice had the likelihood to cause harm in all patients.


Findings include:

During observation of the facility from 9/17/2018 to 9/20/2018 deficient practices in infection control were found in of twelve of twelve areas in the hospital.

Review of the facility document titled, "Safety/Infection Control Surveillance Rounds" revealed the following:

July 30, 2018 -

Medication area/Nurses Station
1. Environment is clean and orderly. The compliance is this area is marked as in full compliance.

Facility Maintenance and Housekeeping
1. Facilities are in good repair and are clean (walls, ceiling tiles, carpet, floor covering). The compliance in this area is marked as in full compliance.


August 28, 2018

Medication area/Nurses Station
1. Environment is clean and orderly. The compliance is this area is marked as in full compliance.

Facility Maintenance and Housekeeping
1. Facilities are in good repair and are clean (walls, ceiling tiles, carpet, floor covering). The compliance in this area is marked as in full compliance.


Review of the personnel file for Staff #4 revealed no evidence that Staff #4 had been trained as infection control coordinator or Infection control program.

The facility provided training on basic infection control but could not provide documentation of the infection control training that covered how to reduce infections and surveillance of the infection control program.

Staff #4 confirmed the above findings.

Based on observation, interview, and record review, the facility failed to ensure the infection control officer developed a system that maintained a clean and sanitary environment for eighteen of eighteen areas observed. The facility failed to ensure that 1st floor hallway, Radiology, Laboratory, Biomedical room, Emergency Treatment Room (ETR), Janitor room on first floor, 1st floor nursing station, Respiratory supply room, Respiratory station at Station B nurses station, Crash carts in ICU and 2nd floor, Linen carts, Central Supply, 2nd Floor supply room, 2nd Floor respiratory room, main pharmacy area, Medication room A/B Side, Nurses Station A/B Side, Equipment Storage area next to medical records were clean, sanitary and free from expired supplies.

This deficient practice had the likelihood to cause harm in all patients.



Findings include:


During an observation tours on 9-17-2018 after 1:30 PM and 9-18-2018 after 9:00 AM, the following observations were made:


1st FLOOR HALLWAY

The hallway outside the Lab/Radiology department observed a vent that was covered in dust, dirt, debris.
The ceiling tile frames throughout all the hallways on the first floor were covered in rust. The ceiling tiles were stained with a brown color that appeared to be water stains. There was an alcove next to the radiology department that was in disarray. The floor had old phones, a light cover trim covered with black substance that appeared to be mold, screws, and metal trim covers laying in the corner.


RADIOLOGY

The linoleum was stained with rust and black substance. The linoleum was not sealed and had cracks between squares. The cabinets in the radiology department were covered in dirt, dust, and debris. Cabinet drawers were covered in dust, dirt, and debris. A cabinet door was missing a handle, exposing wood pasteboard. The trim was loose on cabinet door exposing wood pasteboard. There was a ceiling tile open exposing pipes in ceiling.
In a cabinet next to the view box, radiation safety barriers were found covered in dust, debris, and blood tinged stains. A metal light cover next to the entrance door in radiology was covered in rust. A view box for x-ray films in radiology was covered in rust, dirt, debris. A closet that stored darkroom equipment had a drain on floor covered in black substance. There were uncapped water lines and equipment laying on floor. A room next to radiology that housed Cat Scan (radiology) equipment not used, had cabinets missing trim exposing wood. There were electrical wires hanging from a hole in wall. There was a room on 1ST Floor hallway that housed old radiology equipment. The room had patient positioning devices. Above the devices there was missing ceiling tiles that created an opening in the ceiling. The missing ceiling tile exposed electrical conduit. There was an x-ray film processor. The wall at the base of the processor had a hole in it exposing sheetrock.

LABORATORY

The floor at the technician station was covered in dust, dirt, debris. Linoleum was cracked in the seams and covered in a black colored buildup of dust, debris. There was a chair that had cracks in vinyl covering.

In a room off the technician station, there was a hole in ceiling that an electrical outlet was hanging from. Plugged into the outlet was an extension cord that was laying on floor plugged into wall. Next to the hole in the ceiling there was a ceiling tile with brown and black stains that appeared to be a water stain and mildew. There was an open hole in the wall with water valves exposed. There was a vent standing on the floor covered in dust, dirt, and debris next to the water valves. There was drain on floor next to vent covered in buildup of black debris. The edges of linoleum around the drain were torn and cracked. There was a fan sitting on floor with trash on top of it. The fan was covered in dirt, dust, and debris.

The floor in the main laboratory room was missing tile exposing cement and wood, and had cracks in linoleum. The tiles were covered in black debris. There was no way the floor could be cleaned. There were white blood collection tube holders covered in dust and debris. Lying next to the holders were blood culture collection bottles. There was a metal cart in the main laboratory area that was rusted. The cart was storing a cardboard box filled with blood collection supplies (butterfly needles, blood culture tubes, blood collection tubes). Under a sink in the main laboratory room there was a cabinet covered in dirt, dust, and debris.
In the refrigerator, a box with laboratory controls was found that expired January 2013. The refrigerator stored patient specimens. The refrigerator shelves were covered in dirt, dust, and debris. The refrigerator freezer had with ice packs covered in dirt, dust, and debris.


BIOMEDICAL STORAGE ROOM

There was an IV pole with IV tubing spiked into IV bags and left hanging on pole. There was a cart covered in paint, dirt, debris with equipment stored on top it. There was equipment stored in a chair next to the cart. There was a table with patient equipment stored next to a Styrofoam cup with a liquid drink in it. The ceiling tile was with bulging from the ceiling. The vent was covered in dirt, dust, and debris. The ceiling tile around the vent had brown stains that appeared to be water stained and had cracks. There was patient lift machine with cardboard box full of trash stored under it.


EMERGENCY TREATMENT ROOM

There was a desk in the corner. The drawer in the desk had broken and papers had fallen through to floor.
There was a closet with a rack containing respiratory supplies. The rack had wooden pasteboard shelves and could not be sanitized. There was a table that had Blood Gas Cartridges and controls stored on top of it. The Blood gas controls were in cardboard boxes. Sitting next to the boxes there was an employee cup that contained a drink.
There was a dead bug on the floor next to cart storing patient equipment. There was a wooden pallet containing PPE (personal protection supplies) stored on floor.


JANITOR ROOM

The room was in disarray. There were several wet mop heads laying in sink. There were wet floor signs laying on the floor. There was a mop bucket and wooden mop handles laying on the floor. The floor was covered in black debris. The floor sink was covered in dirt, dust, and black substance. The vent was bulging from the ceiling. The ceiling tile was cracked around the vent. The vent was covered in dirt, dust, debris.



NURSE STATION 1ST FLOOR

There were Respiratory Oxygen Flowmeters stored in a cabinet that were not labeled clean or dirty. There was a buildup of tape residue, dirt, and dust on cabinets. The nursing station had missing/chipped laminate on desk trim. The light cover had a rusted frame. The vent had a buildup of black substance on metal that appeared to be mildew.


RESPIRATORY SUPPLY ROOM

The trash can contained tobacco spit in plastic trash bag. The trash can was on the floor next to patient equipment and supplies. There were suction regulators laying on the cabinet that were not labeled clean or dirty. There were bins containing supplies were covered in dirt, dust, and debris. One of the bins contained tracheostomy (a tube inserted in patient's trachea to assist with air exchange) cleaning supplies. The floor in the room was covered in a buildup of dirt and debris.


RESPIRATORY STATION AT STATION B

There was a Personal employee backpack sitting at the workstation next to patient equipment (Pulse oximeter). The backpack contained food. The pulse oximeters were stored with no indication if they were clean or dirty. There was an electrical panel at nursing station B covered in tape residue, dirt, and dust.


ICU CRASH CART

The following supplies were found stored on the crash cart that had expired:

IV catheter's x2 expired 3-2017
Salem sump Tube (Gastric Tube)- expired 3-2017
Nellcor Co2 detector - expired 8-2016

Staff #52 confirmed the expired items.


2ND FLOOR CRASH CART

The following supplies were found stored on the crash cart that had expired:

Braun IV Introcan Catheter 22 gauge - expired 12-2016
Flex-Tip Stylet - expired 03-2012
Murphy oral/nasal airway size 6.5 - expired 09-2011

There were two Endotracheal tubes, size 6.0 and 6.5 that had torn packages. There was human hair on the top of the crash cart.

Staff #41 confirmed the above findings.


During an interview with Staff #24 on 9-19-2018 after 9:00 AM, Staff #24 said the facility had been short staffed in housekeeping. Staff #24 said the facility had cut hours for staff and they were doing the best they could to keep up.

During an interview on 9-20-2018 after 9:00 AM, Staff#2 confirmed the above unsanitary areas. Staff #2 said she had interviewed a contract company to come into the facility and help get it cleaned up.




29191


During an observation tour of the facility on of 09/17/2018 at 1:55 PM the following was observed:

Linen and Laundry Area:

In the room where clean linen was stored; there were holes in the ceiling tile and there several large brown stains on the ceiling tiles that appear to be water stains. There was a part of the ceiling that was dipping down from the rest of the ceiling frame.

The linen was being stored in the rolling cart that comes on the textile truck that was delivered to the facility. The cart has no cover over the clean linen. The facility was using a large sheet to cover the clean linen. Some of the linen carts had no type of cover over the clean linen.

There were outside cardboard shipping boxes of trash bags being stored on several shelves in the clean linen room.

1st floor (ICU)

During the tour of the facility on the 1ST floor nursing unit (ICU) the linen cart had a plastic cover, but the zipper was broken and cover was open allowing the clean linen to be contaminated by staff traffic and housekeeping sweeping and mopping the floor. There was no barrier on the bottom shelf of the linen cart which allowed the linen to be in the splash zone from the cleaning of the floors.

2nd floor

On the 2nd floor nurses station there was linen cart with no barrier on the bottom shelf which allowed the linen to be in the splash zone from the cleaning of the floors.

Emergency Treatment Room

In the emergency treatment room there was a linen cart with the linen hanging off the bottom shelf touching the floor. The plastic wrap used to cover the linen was ripped.

A review of the log titled, "Safety/Infection Control Surveillance Rounds" revealed the following:

The assessment element was as followed:

"1. Linen in the public areas is covered (the cover is not ripped).
Clean linen maintained in clean/dry area."

A review of the rounding sheet dated 07/30/18 revealed the facility was in full compliance.

A review of the rounding sheet dated 08/28/18 revealed the facility was in full compliance.

An interview with Staff #24 on 09/19/18 at 11:00 AM confirmed the plastic wrap covering the clean linen was ripped and that the infection control audit did not address the ripped covering on the clean linen.

Card board boxes harbor parasites, insects, and microorganisms.

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).



10135

During a tour of the facility on 09/17/2018 after 1:30 p.m.. the following was found:

CENTRAL SUPPLY

Shelves of sterile medical supplies were stored in a room which also contained broken equipment. There were cardboard boxes stored on shelves in the room also. Patient supplies were on the floor underneath the shelves. Plastic bins which contained patient supplies were soiled with spills and dust.
Sterile supplies were stored in the room on shelves such as surgical instruments, chest tube insertion kits, intravenous needles, thoracentesis trays, dressings, oxygen mask and Foley catheter kits.
A box which contained peel packets of surgical equipment was stored in the room. The packets were stained brown.

Ceiling tile in the room had brown water stains.

Some of the legs on the shelves were covered with dust and spider webs.

Staff #24 reported they were not taking temperature and humidities in the room. Staff #24 reported that staff were bringing broken equipment to the room and leaving it there.

Review of American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI) ST79:2017 revealed the following:

"11.1 Sterile Storage

Sterile items should be stored under environmentally controlled condition that reduces the potential for contamination ...

Supplies should be removed from external and web-edged shipping container before transport to any restricted area ..."


EMERGENCY TREATMENT ROOM


Arterial blood sampling kit expired 07/2018;
Eyesaline eyewash expired 10/2017




SECOND FLOOR SUPPLY ROOM

EKG equipment, bedside toilets, and intravenous pole were all stored in a room. There was no way to tell what was clean and what was soiled. The ceiling tile above the equipment was stained with brown water stains. An air vent in the ceiling was covered with a build-up of black substance.





SECOND FLOOR RESPIRATORY ROOM

The tile floor in the room had a buildup of wax, paper and dust.
There was a box of oxygen regulators which were not bagged or identified as being clean equipment.

One cabinet was missing the door. All kind of respiratory equipment was stacked up in the cabinet. There was no way to tell if the equipment was clean or soiled.

The metal caddy which held the oxygen tanks was covered in rust.

A plastic storage unit was covered in dust and contained respiratory mask and equipment for respiratory treatments.



During a tour of the facility on 09/18/2018 after 9:00a.m. the following was found:


MAIN PHARMACY

Vials of sodium bicarbonate were stored in a bin. One of the vials was missing the protective cap.

A bag of intravenous fluids was stored on a shelf and was not in a protective overwrap.
Bags of intravenous fluids were stored on a stainless steel shelf in the room. The bottom shelf did not have a splash guard down. The tile floor underneath the shelf was soiled with spills and dust.

An approximate 3 feet area of floor tile was ripped and the subfloor underneath could be seen. There was no way the floor could be cleaned in that condition.

Ceiling tile in the room had brown water stains.
Staff #29 confirmed the observation.


MEDICATION ROOM ON THE A SIDE OF THE SECOND FLOOR

A medication transportation cart in the room had an open plastic container on top of it which contained medications. The bins in the container were soiled with spills and dust.

A supply cart in the room was rusted and the inside drawers which contained patient supplies was soiled with spills and dust.

The pill crusher had a build-up of medication particles, dirt and dust.

Cardboard boxes of supplies were stored above open bins which contained intravenous catheters and tubing.

The tile floor in the room was broken and missing an exposing the subfloor.

Plastic bins in the refrigerator which contained vials of insulin was soiled with spills.

The cabinet underneath the sink was soiled with dried spills and debris. The laminate on the top counter of the sink was missing and the particle board underneath was exposed. The surface could be not cleaned in that condition.

Staff #42 confirmed the observation.



MEDICATION ROOM ON THE B SIDE OF THE SECOND FLOOR


A plastic bin which contained medication carts was soiled with dust and spills.

The pill crusher had a build-up of medication particles, dirt and dust.
Plastic supply bins were either covered with soiled remnants of labels or the top layer of the bins were peeling off.

A can of Two cal supplement was stored in a cabinet and it expired 03/01/2018.

Four containers of Vital high protein supplement was stored in a cabinet and they expired 07/01/2018.

The tile floor in the room had a buildup of wax.

.

NURSES STATION ON THE B SIDE OF THE SECOND FLOOR

There was a box of oxygen regulators which were not bagged or identified as being clean equipment.
The tile flooring at the baseboards was soiled with a buildup of dirt and debris. The flooring had a buildup of wax.



EQUIPMENT STORAGE AREA NEXT TO THE MAIN MEDICAL RECORD STORAGE ROOM

During an observation on 09/19/2018 after 10:00 a.m. the following was found:

There was bedside toilet seats, intravenous poles, pillows, walkers, wheelchairs, intravenous pumps and other patient equipment stored in the room. Some of the equipment was stacked on top of each other and the room was cluttered. There was no way to tell what was clean and what was soiled. Some of toilet seats were found to be rusted and soiled with a black and brown substance. Some of the equipment was on the floor which was soiled with paper and dust.

Staff #43 confirmed the observation and reported that everything in the room was supposed to be clean.

Based on observation, interview and record review, the facility failed to ensure rehab was organized in a manner to ensure appropriate services were provided in 3 of 3 services (Physical therapy, Speech therapy and Occupational therapy). The facility failed to:

A. ensure physician signed orders were obtained for physical and speech therapy prior to service being provided.

B. ensure documentation that speech and physical therapy evaluations were performed timely. Staff failed to time their evaluations when performed. One speech evaluation was performed over the 72 hour timeframe.

C. ensure physician ordered occupation therapy was provided. The facility failed to ensure staff provide occupational therapy per their policy. A physician ordered occupational therapy and it was not performed.


This deficient practice had the likelihood to cause harm in all patients receiving therapy services.

Findings include:



Review of the clinical record on Patient #28 revealed she was an 88 year old female who was admitted on 09/12/2018.

Review of "REHABILITATION ADMIT TREATMENT CLARIFICATION ORDER" revealed physical therapy services was checked on the form, daily, 3-5 days per week until discharge from service. The therapist signed the orders and dated them on 09/12/2018 at 1:30 p.m. The physician failed to sign the orders.

Review of the "PHYSICAL THERAPY INITIAL ASSESSMENT" form revealed it was completed on 09/12/2018.

Review of the "PHYSICAL THERAPY TREATMENT RECORD" form revealed Patient #28 received therapy services on 09/14/2018 and 09/15/2018.

During an observation on 09/19/2018 after 9:00 a.m., Patient #28 was observed in physical therapy receiving services.


Staff #34 reported they have standing protocol to assess every patient on admission. Staff #34 confirmed the physician's orders had not been signed off yet approving the therapy as of 09/19/2018. Staff #34 reported that they did not provide OT services. If a physician ordered it PT did as much as they could in that area for the patients.


Review of the clinical record of Patient #12 revealed he was a 74 year old male who was admitted on 09/14/2018 with diagnoses which included nausea/vomiting, oral cancer and dysphagia.

Review of the undated"Admit Physician Orders" revealed an order for PT (physical therapy) and ST (speech therapy).

Review of a hand written order dated 09/15/2018 revealed orders for "ST/PT/OT evals"

Review of a hand written order dated 09/17/2018 revealed another order for a speech eval.

Review of the record revealed the PT eval and ST evals were performed on 09/17/2018. There was no time on the orders to indicate what time they were performed.
Review of the chart revealed no documentation of an OT (occupational therapy) evaluation being performed.

During an interview on 09/19/2018 after 10:50 a.m., Staff #35 confirmed the missing times on the assessments. Staff #35 reported they have 72 hours to get the evaluations done from admission. Staff #35 confirmed there was no OT evaluation and reported that they did not have OT services.




Review of the clinical record of Patient #9 revealed he was a 79 year old male who was admitted on 09/13/2018 right toe complications.

Admit physician orders which had a stamped date of 09/13/2018 revealed orders for PT and ST to "Eval & Treat."

The PT eval was performed on 09/14/2018 and the ST eval was performed on 09/17/2018 (over 72 hours).
The orders had not been signed by the physician as of 09/19/2018.



Review of the clinical record of Patient #8 revealed she was a 78 year old female who was admitted on 09/07/2018 with diagnoses which included anxiety and respiratory failure.

"Admit Physician Orders" which included an order for PT and ST to "Eval & Treat" were written as verbal orders by nursing staff on 09/07/2018. The orders were signed off by the physician, but there was no date or time behind the signature.

The PT eval was performed on 09/10/2018 and the ST eval was performed on 09/10/2018. Neither assessment was timed to indicate it was performed within 72 hours.




Review of the "REHABILITATION ADMIT TREATMENT CLARIFICATION ORDERS" dated 09/10/2018 revealed the therapist signed the form but failed to time it. The physician signed but failed to date and time the form.


Review of a facility's policy named" INITIAL EVALUATION" dated 06/2016 revealed the following:

"PURPOSE:
To ensure each patient receives appropriate therapy services in a timely manner.
POLICY:
Every patient will be seen and evaluated within 72 hours of admission by Physical and Speech Therapy services. At this time, the hospital provides Physical and Speech Therapy services on a full time basis, however, Occupational Therapy services will be provided on a specific, as needed/PRN basis.
PROCEDURE:
1. Upon admission to the hospital the Admit Physician Order Forms will be checked marked for Physical and Speech Therapy services.
2. The appropriate therapists will perform initial evaluation within 72 hours of admission ...
4. Upon completion of the initial evaluation a treatment Clarification Order form will be completed with the appropriate treatment, frequency, and POC. This form will be signed by the evaluating therapist and treating physician and placed in the orders ..."

Based on interview and record review, the facility failed to develop an emergency preparedness communication plan which included a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.

This deficient practice had the likelihood to cause harm to all patients.


Findings include:

Review of the facility policy and procedure manuals updated March 2018 revealed no documentation in the emergency plan which addressed the facility's plan to cooperate and collaborate with local, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency.


An interview with Staff #36 on September 18, 2018 at 3:43 PM revealed the following:

Staff #36 said he received notice of community drills but confirmed the facility did not participate in those drills.


Staff #36 confirmed not knowing who the emergency preparedness coordinator for the area was and that the facility had not made any attempt to coordinate or collaborate with the local emergency coordinator on develop of a communication plan.

Based on observation, interview, and record review, the facility failed to ensure there was a policy and plan that included a means for sheltering all patients, staff, and volunteers who remained in the facility during a disaster when evacuation could not be achieved.


This deficient practice had the likelihood to affect all patients who needed provisions provided during a disaster and/or emergency.


During an interview with Staff #36 on September 18, 2018 at 3:43 PM the following was revealed:

Staff #36 confirmed the facility did not have any plan that included a means for sheltering patients, staff, and volunteers who remained in the facility. The facility did not have emergency supplies, food or water to accommodate sheltering patients, staff, and volunteers. Staff #36 said the facility had water stored but did not have the means to store food items because the facility did not have coolers for food storage. Staff #36 said the disaster plan did not address what supplies would be stored in the facility if patients were sheltered in place during a disaster. Staff #36 said the facility did shelter patients in place during recent hurricane.


Review of the facility policy titled, "Severe Weather Response" dated 02/21/2013 with a review date of March 14, 2018 revealed the following:

" ...Food Supplies/Re-Supplies
c. Because these individuals may be confined to the hospital for extended periods of time, it will be important to provide them with meals.

...Functions of the Food and Nutrition Services Department will include:
c. Provisions of meals to patients will continue.

...Inventories and Menus planned for emergencies
The menus may change based on the availability of food supplies ..."

Based on interview and record review, the facility failed to develop an emergency preparedness testing and training program to 8 of 8 staff (Staff #'s 2,3,4,12,13,14,15,18) reviewed.


This deficient practice had the likelihood to cause harm to all patients.


Findings include:

Review of personnel files on Staff #'s 2,3,4,12,13,14,15,18 revealed no documentation of testing and training on the facility's emergency preparedness program. The only training found was from skills fair in September 2017 and October 2018. A competency test found in the personnel file asked questions about safety and disaster code and call back procedures. The test did not include emergency preparedness.

During an interview on 09/18/2018 at 3:43 PM, Staff #36 confirmed he had not provided any training for the staff on emergency preparedness. Staff #36 confirmed he was the coordinator for the disaster/emergency preparedness plan at the facility.