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Based on record review and interview the facility failed to ensure 11 of 11 inpatient Medicare beneficiaries (current & discharged) received the standardized notice "An Important Message from Medicare (IM) within two days of admission (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 13).

Findings include:

Record review of two discharged Medicare beneficiary patients (#3, 11), failed to reveal a signed and dated IM letter within the record.

Record review on 02-09-17 of nine current Medicare beneficiary patient records revealed the following:

Patient #1: admitted on 1/25/2017; no signed & dated IM letter.
Patient #2: admitted on 2/1/2017; no signed & dated IM letter.
Patient #4: admitted on 1/18/2017; no signed & dated IM letter.
Patient #5: admitted on 2/6/2017; no signed & dated IM letter.
Patient #6: admitted on 2/3/2017; no signed & dated IM letter.
Patient #7: admitted on 1/19/2017; no signed & dated IM letter.
Patient #8: admitted on 2/2/2017; no signed & dated IM letter.
Patient #9: admitted on 1/27/2017; no signed & dated IM letter.
Patient #13: admitted on 1/16/2017; no signed & dated IM letter.


Record review of the facility policy "Discharge Planning", (undated) revealed it did not address the Medicare IM letter process, including timeframes.

In an interview with the Case Manager, RN (# 13) on 2/9/2017 at 9:30 a.m., she stated "everyone gets a letter when they go home, so they are not in the patient charts. I know I gave the discharged patients (#3, 11) a letter on discharge, but I cannot find the copy in the chart. We have the letter in both English and Spanish. I do not know if we have a policy related to this, I do not have one, but the Chief Nursing Officer (CNO) would know if we have a policy".

In an interview with the CNO (#2) on 2/9/2017 at 11:00 a.m., she stated there was no policy to address the IM notice.

Based on interview and record review, the facility failed to ensure that 4 of 20 sampled patients had a properly executed informed consent ( Patients # 10, 13, # 17, # 18).

Finding include:

Patient # 13

Record review of Patient's ID# 13 medical record revealed: one (1) informed consent to surgery/ special procedures/ anesthesia dated 1/28/2017 with the procedure to be performed was left blank.

Interview with Registered Nurse(RN) ID# 8 on 2/9/2017 at 12:33 she acknowledged that the consent was not acceptable.



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Patient # 10

Record review of Patient's ID# 10 medical record revealed: no physician signature for consent for a Bronchoscopy 1/2017.

Patient # 17:

Record review of Patient's ID# 17 medical record revealed: no physician signature for consent for a Bronchoscopy 12/2016.

Patient # 18:

Record review of Patient's ID# 18 medical record revealed: No physician signature on consent for a Femoral and Venous Central Line placement 12/2016.


Interview with CHief Nursing Officer (CNO) ID # 2 on 2/9/17 at 2:30 p.m. reported that the hospital policy is a written consent form shall be completed and properly executed for all procedures and treatment, and stated," these consents were not properly handled".

Record review of hospital policy titled: " Informed Consent", dated 6/29/2016 read:"... Purpose: The doctrine of informed consent supports the patient's right to fully participate in decisions regarding his/her care, treatment and services...Informed consent is a process of providing information, ensuring shared understanding and making decisions in the context of the patient's needs. Policy:... All inpatients medical records must contain a properly executed and completed written informed consent for all procedures and treatments specified by the hospital's medical staff, and state or federal laws/regulations..."

Based on interview and record review, the facility failed to conduct a performance improvement project for 2016.

Findings include:

Record review on 02-08-17 of facility's Quality Assessment and Performance Improvement (PI) binder and meeting minutes for 2016 and 2017 failed to reveal a documented project.

Interview on 02-08-17 at 1:15 p.m. with facility Quality Assurance Staff # 8 she stated the facility did not conduct a PI Project in 2016.

Record review of facility "Performance Improvement Plan", dated 06-29-16, read:" ...7. A Multidisciplinary Process Team is formed as needed and oversite is provided by Quality Leadership Team to investigate and make recommendations when ..a process has been identified to be proactively redesigned..."

Based on interview and record review, the facility failed to ensure that all services were included into their Quality Assessment Performance Improvement(QAPI) program.

Contracted services of radiology and laboratory were not integrated into the facility QAPI program.

Findings include:

Record review on 02-08-17 of facility's Quality Assessment and Performance Improvement (PI) binder and meeting minutes for 2016 and 2017 revealed documentation of numbers of radiology procedures performed.

Interview on 02-07-17 at 11:00 a.m. with facility Chief Nursing Officer (CNO) # 2 she stated that radiology and laboratory were contracted services.

Interview on 02-08-17 at 1:15 p.m. with facility Quality Assurance Staff # 8 she said the facility did track any PI indicators for laboratory or radiology services, such as turn around time /response times.

Record review of facility "Performance Improvement Plan", dated 06-29-16, read:"Purpose:...Performance improvement requires the active engagement of all members of the healthcare team..." The PI Plan did not address the inclusion of contracted services.

Based on interview and record review the facility failed to ensure that an RN supervised and evaluated the care for 2 of 9 current patients ( Patients # 1, # 19) .

Nursing failed to weight patient daily per physician order.
Nursing failed to administer medication per physician order

Findings include:

Patient #1:

Record review on 2/7/17 of physician orders for patient #1 revealed an order dated 2/5/17 that read "weigh patient daily".

Further review of Patient # 1's clinical record failed to reveal documentation of daily weights for February 5 and 6, 2017.

Interview on 2/9/17 at 2:30 with Chief Nursing Officer (CNO) #2 stated the nurses knew to follow the physician orders and in this case that was not done.

Patient # 19

Record review of physician order for Patient # 19 revealed an order dated 1/21/17 that read Gordon 20 mg (milligrams) IM (intramuscular) for agitation now and RN.

Record review of Patient # 19 Medication Administration Record (MAR) dated 1/21/17 dose revealed Geodon 10 milligrams (mg), IM (intramuscular) was administered at 1/22/17 at two different times.

Record review of policy: " Medication Administration", dated 6/29/2016, revealed:Medications shall be administered only upon the order of physicians, dentists, or podiatrists, who are members of the medical staff, are authorized memmbers of the house staff or have been granted clinical privileges to write such orders and the guidelines of their respective scopes of practice...The individual administering the medication shall verify the "medication selected for administration is the correct medication based on the medication order and the medication product label".

Interview with the CNO # 2, on 2/9/17 at 2:30 PM stated: " this was a medication error; nurses cannot decide to split medication dosage."

Based on interview and record review the facility failed to ensure that five (5) of twenty-three (23) clinical medical records were signed by physicians per the Medical Staff Rules and Regulations (Patient's # 3, #4, #6, #9, #22)

Findings include:

Record review of 23 medical records revealed the following:

Patient ID# 3 Physician orders not signed 2/2/2017, Consult 1/25/17 Not signed

Patient ID#4 No physican signature Telephone orders 1/2016

Patient ID# 6 A physician progress note dated 2/8/17 was not signed by a physician.

Patient ID# 9 Three (3) physician Consults from January 2017, no signature , no date

Patient ID#22 No physician signatures on (9) Physician Progness Notes, No physician signature on Consult from August 2016.

Interview with the Chief Nursing Officer (CNO), ID # 2, on 2/9/17 at 2:30 pm she revealed that Medical Staff are responsible for signatures on any patient information they initiated in the chart.

Record review of facility plicy titled: " Rules and Regulations of The Medical Staff", undated, : "SECTION 3 Medical Records Policy...C) Medical records must be completed, including signatures within thirty (30) days after discharge.. (3) . All verbal orders must be dated, timed and authenticated within 48 hours by the ordering practitioner or another practitioner who is responsible for the care of the patient...4. Progress Notes 1) All medical staff progress notes shall be dated signed by the physician who recorded them and should give a pertinent chronological order of the patient's course in the hospital..."

Based on observation, interview and record review, the facility failed to maintain an effective on-going program to to prevent infections in the bronchoscope cleaning room and two (2) of two (2) patient care areas.

The facility failed to ensure:

*the proper disinfection and documentation of high level disinfection of bronchoscopes

*staff utilized proper transmission-based precautions [hand hygiene / personal protective equipment (PPE)]

*indwelling urinary catheters were secured

*expired items were not available for use

*proper storage of clean linen

* dietary: food and supply storage

Findings include:

Bronchoscope High level Disinfection Issues:

Record review of the facility procedure log for 2017 revealed two (2) bronchoscope procedures were performed in the month of January 2017 on Patients ID#s 10 and 11.

Record review of the bronchoscope high level disinfection log for 2017 revealed documentation of one (1) Patient ID # 11.

Record review of the facility policy titled: "Use and Care of Bronchoscopes and related accessories" (undated) revealed the following information:"...All respiratory personnel will demonstrate knowledge related to proper handling, inspection, testing, use and processing of bronchoscopes, accessories, and related equipment....Quality Monitoring: A permanent log is maintained for each procedure with: patient's name, medical record number, procedure, date, pulmonologist, type of scope, identification number (serial number) and person processing the scope and testing results...."

Record review of employee file for respiratory therapist ID# 9 revealed no evidence of training or documentation of competency for high level disinfection for bronchoscopes.

Interview with respiratory therapist ID #9 on 2/8/2017 at 9:10 AM revealed that he did process the bronchoscope for Patient ID # 10, but failed to document it on the log.

Observation of the bronchoscope cleaning room on 2/8/2017 at 8:00 AM revealed an opened bottle of Medline Dual Enzymatic Detergent and Presoak along with a measuring cup used to measure detergent.

Interview with lead respiratory therapist ID# 9 at the time of the observation revealed that he used " a couple of gallons of water to two (2) ounces of detergent." When asked by the surveyor how he knew how much two (2) gallons was, he stated " I do not measure it, I just eyeball it."

Record review of "Medline Dual Enzymatic Detergent and Presoak instructions" for use revealed the following:
"For instrument holding solution, endoscopic channel flush or manual scope cleaning use one-half (1/2) to one (1) ounce of concentrated solution per gallon of water."

Observation in the bronchoscope cleaning room on 2/7/2017 at 9:26 AM revealed the bottom of the bronchoscope storage cabinet contained visible dust and debris.

Interview with Infection Control nurse ID# 8 at the time of observation revealed that the respiratory therapists are responsible for the cleaning this area. It was not know if there was a schedule of when the cabinet is to be cleaned.

Record review of the facility policy titled:" Use and Care of Bronchoscopes and related accessories ," (undated) revealed the following information: "...3. All respiratory personnel will inspect all bronchoscopes, accessories and all related equipment at all stages of handling..."

Transmission-Based Precautions/ Hand hygiene/ PPE: :

Patient # 13:

Observation on 2/8/2017 at 9:30 AM of the High Observation Unit (HOU) Isolation Room #1 revealed a posted sign identifying Patient ID# 13 as being on contact isolation. Contract staff member ID # 17 was observed removing PPE: gown and gloves, immediately touching his cellular phone and laptop computer on patient's bedside table, then packing up medical equipment and exiting the room to the nurses station. He was then prompted by infection control nurse ID# 8 to sanitize his hands.

Interview with contract staff member ID # 17 at the time of observation revealed that he was performing an ultrasound on Patient ID#13. He was aware of the isolation precautions for the facility; he thought he had sanitized his hands.

Infection Control Nurse ID# 8 at the time of observation acknowledged contract staff member ID# 17 broke protocol.

Record review of the facility policy titled: "Transmission Based Precautions -Isolation Precautions" (undated) revealed the following information: "Policy: Transmission-Based Precautions be used in addition to Standard Precautions to prevent the spread of infection throughout the hospital....Contact precautions...Gloves shall be worn whenever touching the patient's intact skin or surfaces and article in close proximity to the patient (i.e. medical equipment, bed rails). Gloves shall be donned upon entry into the patient's room or cubicle.

Gowns shall be worn whenever it is anticipated that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Gown shall be removed and hand hygiene performed before leaving the patient care environment."


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Patient # 2:

Observation on 2/7/17 at 10:30 a.m. revealed wound care nurse /Licensed Vocational Nurse (LVN) # 3 performed wound care on Patient # 2. Further observation revealed a sign on Patient # 2's door that read " Contact Precautions."

LVN # 3 failed to remove her contaminated gloves and sanitize or wash her hands after removing Patient # 2's soiled dressing.

While wearing the same contaminated gloves, LVN # 3 repositioned the patient's legs; rearranged the bed covers; and then opened the patient's door. LVN # 3 stepped outside the doorway while wearing both contaminated gloves and gown. She disposed of the bagged soiled dressing into the container on the side of the wound care cart.

In an interview with LVN # 3 at time of observation, she stated she should have removed her gloves, sanitized hands and regloved before proceeding with straightening the bed covers and patient. She also reported she should not have walked to the door and opened the door with same contaminated gloves and gown.


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Patient # 9:

Observation on 02-07-17 at 10:25 a.m. revealed wound care nurse LVN # 3 prepared to perform wound care on Patient # 9.

LVN # 3 initialed and dated several pieces of tape and placed them on the side of the wound care cart outside the patient's room. LVN # 3 then wheeled the cart into Patient #9's room.

Continued observation revealed LVN # 3 transferred the initialed tape strips from the wound cart to the edge of Patient # 9's bedside table.

LVN # 3 then utilized the contaminated tape strips to secure Patient # 9's clean dressing.

During an interview with LVN # 3 immediately after the observation, she stated she always places the tape on the wound cart and then transfers the tape to the patient's table because "using a pen inside patient's room to time, date, and initial tape was an infection control issue."

Patient # 1

Observation on 02-02-17 at 10:45 a.m. revealed Registered Nurse (RN) # 5 donned exam gloves prior to entering Patient # 1's room to assist with a mechanical lift transfer. RN #5 failed to sanitize her hands prior to donning the gloves and entering the patient's room.

In an interview on 02-03-17 at 11:00 a.m. with Infection Control RN # 8 she stated staff should sanitize hands prior to donning gloves and after removing them.

Record review of facility policy titled " Wound Dressings" dated 06-29-16, read: " Policy:...aseptic/clean technique will be utilized when applying dressings..PROCEDURE: 1. Obtain order 2. Validate patient identification....4. Wash hands.... . discard removed dressing in biohazard bag 8. Remove gloves, wash hands, then reapply clean gloves."

Facility policy titled "Hand Hygiene- CDC (Center for Disease Control) Guidelines", dated: 2002 revealed the following: POLICY: All staff shall use the hand-hygiene techniques, as set forth in the following procedure...
a. Before coming on duty
b. When hands are soiled
c. Before each patient encounter
d. Before applying sterile gloves...
g. After working on a contaminated body site and then moving to a clean body site on the same patient.." [In addition, CDC Guideline For Hand Hygiene (2002) included hand hygiene after removing gloves ]

Record review of facility policy titled" Transmission-Based Precautions ", dated 06-29-16, read:"..Contact Precautions...Gloves shall be donned upon entry into the patient's room...gowns shall be worn whenever it is anticipated that clothing will have direct contact with the patient...Gowns shall be donned upon entry into the room...gown shall be removed and hand hygiene performed before leaving the patient-care environment.."

Indwelling urinary catheters unsecured:

Patient # 1

Observation on 02-02-17 at 10:45 a.m. revealed Patient # 1 awake, alert , and laying in bed. Patient # 1 had a urinary catheter drainage bag connected to the lower bed frame. Further observation revealed staff assisted Patient # 1 from the bed to a chair by means of a mechanical lift. It was noted that the indwelling urinary catheter tubing was not secured to Patient # 1's leg. Interview at the time of observation with RN # 5, she stated the catheter tubing should be secured to the patient's leg with a with a "statlock."

Patient # 13

Observation on 2-3-17 at 9:45 a.m. revealed Patient #13 awake and oriented; laying in bed . Patient # 13 received oxygen at 2 liters per minute via nasal cannula and enteral feedings per gastroscopy tube at 40 cc (cubic centimeters) an hour per pump. Further observation revealed Patient # 13 had a right femoral IV site and an indwelling urinary catheter. The indwelling urinary catheter was not secured to patient # 13's leg.

Interview at the time of observation with RN # 16, she stated the catheter tubing should be secured to the patient's leg with a with a "statlock."

Review of facility policy titled "Indwelling Urinary Catheter Insertion and Maintenance-Female and Male," dated 06-29-16, read: "...For indwelling urinary catheter....tape catheter tubing to the upper thigh, allowing some slack between meatus and tape ..."



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Expired Supplies:

Observation of crash cart in the exam room on 2/7/2017 at 9:35 AM revealed two (2) Adult calometric Carbon Dioxide (CO2) detectors with the expiration date of 9/2016.

Observation of crash cart located in High Observation Unit (HOU) on 2/8/2017 at 9:40 AM revealed one (1) scalpel size #15 with expiration date of 2/2015 and one (1) sterile scalpel size #10 with package torn, compromising sterility of product.

Interview with Infection Control nurse ID# 8 on 2/8/2017 at 9:43 AM revealed that the crash cart contents are checked monthly by materials management. The nursing staff checks the functionality of the equipment on top twice each day.

Record review of facility policy titled: "Emergency Crash Carts", (undated) revealed the following: "After the emergency crash cart has been used, the nursing staff or Nursing Supervisor shall be responsible for placing all the used instruments on the cart, clearing all disposable items, immediately delivering the cart to Central Service and returning to the patient care unit with a replacement completely equipped and standardized emergency crash cart. The defibrillator, oxygen tank, and back board shall be kept on the patient care unit while the cart is exchanged."

Observation on 2/9/17 in the laboratory room at 10:30 a.m. the Registered Respiratory Therapist (RRT), ID # 20 revealed expired blood collection tubes during tour of the laboratory storage/procedure room. The following expired items were observed: six (6) Navy Blue tops - dated 8/2016;two (2) Grey tops - dated 1/2017.

During an interview with RRT # 20 at time of observation, she acknowledged the tubes were expired and disposed of them.

Record review of policy titled: "Clinical Laboratory Specimens-Collection and Care", dated 6/29/2016 revealed the following: POLICY: Standard Precautions shall be adhered to during collection of specimens..PROCEDURE: Collect in sterile test tube..."

Linen Storage:

Observation during initial facility tour of the Storage Supply Room next to the patient exam room on 2/7/2017 at 9:30 AM revealed three (3) linen bundles stored on top of patient ventilator.

In an interview at the time of observation with Infection Control nurse ID# 8 she stated that "clean linen is to be stored in the linen cart that is in the patient exam room, not in this closet."

Observation on 02-09-17 at 10:30 a.m. in the clean supply room in the High Observation Unit revealed a linen cart . The cart was covered with a heavy plastic-type cover. The cover was frayed and worn, with several small torn areas visible. Interview at the time of observation with RN # 16 she stated the cover needed replacing; linen could become contaminated.

Kitchen Issues:

Unlabeled Food:

Observation on 02-02-17 at 10:30 a.m. in the kitchen revealed an upright refrigerator labeled "Patient Food Only". Further observation revealed the following, unlabeled in this refrigerator:

one (1) large plastic bag of shredded yellow cheese
one ( 1) large plastic bag of whipped topping
one (1) large bottle of opened salad dressing

During an interview at the time of observation with Director of Food Services # 19 she stated the food should be labeled and dated.

Further observation in the kitchen revealed a storage room with shelving that contained multiple packages of paper food service supplies: plates , cups, etc... Some of the packages were opened. Stored immediately next to the shelving unit was a large trash can and a broom and dust pan.

Interview at the time of observation with Director of Food Services # 19 she acknowledged the paper dinner ware was used for patients and should not be stored in a manner in which it could become contaminated.