HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for QAPI (quality assurance performance improvement) as evidenced by:

1) Failing to ensure quality indicators were measured, analyzed and tracked for all hospital services and operations as evidenced by failure to include all services, provided both directly and through contractual agreement, in the hospital's QAPI plan. (See findings under tag A-0273);

2) Failing to formulate an action plan aimed at performance improvement as evidenced by failing to institute measurable interventions to correct deficient practice areas identified through QAPI data collection. (See findings under tag A-0283);

3) Failing to employ methods to identify, measure, analyze and track medical errors as evidenced by failing to identify, measure, analyze and track near miss and close call medication errors. (See findings under tag A-0286);

4) Failure of the hospital's governing body to ensure that the hospital's QAPI program reflected the complexity of the hospital's organization and services as evidenced by failure to include all services furnished both directly and under contractual arrangement in the QAPI plan. (See findings under tag A-0308).

Based on record review, observation and interview, the hospital failed to meet the Condition of Participation for Medical Record Services as evidenced by:

1. Failing to ensure the Medical Record Department was organized, equipped, and staffed to meet the scope and complexity of the hospital's services in order to ensure the prompt completion, filing, and retrieval of medical records, and failed to ensure the Medical Record (MR) Department met the requirements of Federal and State laws and regulations. (See findings in A-0432)

2. Failing to ensure the patients' medical records were stored in a secured manner to maintain and ensure the integrity of the medical records and ensure the medical records were protected from any potential damage. (See findings in A-0438)

3. Failing to ensure the hospital had a system of coding and indexing of patients' medical records which allowed for timely retrieval of patients' medical records by diagnoses and/or procedures. (See findings in A-0440)

4. Failing to ensure all medical record entries, including verbal orders, were signed, dated and/or timed by the person responsible for ordering the services. (See findings at A-0454)

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

1) Failing to ensure there was a radiologist who supervised the radiology services of the hospital (see findings in A-0546);

2) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A (see findings in A-0535).

Based on interview, record review and observation, the hospital failed to meet the Condition of Participation for Infection Control by:

1. Failing to ensure the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S2DON (Director of Nursing) having no prior work experience or specialized training in infection control. (see Findings in A0748)

2. Failing to develop, implement and maintain an active, hospital-wide program for the prevention, control, and investigation of infections and communicable diseases as evidenced by failing to ensure patient care was provided in a sanitary environment and by failing to have policies and procedures related to Isolation Precautions to include Contact Precautions, Droplet Precautions, and Respiratory Precautions. (see Findings in A0749)

Based on record review and interview, the hospital failed to meet the Condition of Participation for Respiratory Care Services as evidenced by:

1. Failing to ensure Respiratory Care Services were under the direction of a Doctor of Medicine or Osteopathy, appointed by the Governing Body, on a full time or part time basis ( See findings in A-1153);

2. Failing to ensure personnel were qualified to perform specific respiratory care procedures. This deficient practice was evidenced by failure to maintain documentation of current skills/competency evaluations on staff responsible for provision of respiratory care services for 5 of 5 (S9RN, S13RN, S14RN, S15RN, S16RN) nursing personnel records reviewed for current respiratory skills/competency evaluations. (See Findings in A-1161)

Based on record review and interview, the governing body failed to ensure contracted services were performed in a safe and effective manner as evidenced by failing to ensure all contracted services were included in the quality assurance and performance improvement (QAPI) program.
Findings:
The list of the hospital's current contracted services, presented by S2DON, was reviewed and compared to the QAPI documentation provided by S2DON. Further review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Dialysis Services, Biomedical Services and Biohazardous Waste Disposal Services. Further review revealed Dietary Services, Housekeeping Services and Linen Services (included with the lease of the building per interview with S3ADON on 5/4/15 at 3:00 p.m.) were also not included in QAPI .
In an interview on 5/6/15 at 4:45 p.m. with S3ADON, she confirmed quality indicators for the above referenced services provided through contractual agreement and lease of the building were not included in the hospital's QAPI plan.

Based on record review and interview, the hospital failed to ensure quality indicators were measured, analyzed and tracked for all hospital services and operations as evidenced by failure to include all services, provided both directly and through contractual agreement, in the hospital's QAPI (quality assurance performance improvement) plan.
Findings:
The list of the hospital's current contracted services, presented by S2DON, was reviewed and compared to the QAPI documentation provided by S2DON. Further review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Dialysis Services, Biomedical Services and Biohazardous Waste Disposal Services. Additional review revealed the following services were also not included in QAPI: Dietary Services, Housekeeping Services and Linen Services.
In an interview on 5/6/15 at 4:45 p.m. with S3ADON, she confirmed quality indicators for the above referenced services provided both directly and through contractual agreement were not included in the hospital's QAPI plan.

Based on QAPI (quality assurance performance improvement) documentation review and interview, the hospital failed to formulate an action plan aimed at performance improvement as evidenced by failing to institute measurable interventions to correct deficient practice areas identified through QAPI data collection.

Findings:

Review of the Quality Improvement Report presented by S2DON as the hospital ' s QAPI documentation revealed data collection/analysis for the First (January, February and March), Third (July, August and September) and Fourth (October, November and December) Quarters of 2014. No documentation was provided for the Second (April, May and June) Quarter of 2014 and the First (January, February and March) Quarter of 2015.

Further review of the QAPI documentation revealed the following, in part:
First Quarter of 2014 (January, February and March):
Fallout: Medication Variances: Q (Quarter) 1: 2014-4; Q1: 2013-18; Q4: 2013-9;
Root Cause of Fallout: Medication Variances are down, which is an improvement;
Plan: Pharmacy and staff are working well together. Pharmacy is still not delivering medications on time;
Fallouts (Opportunity/Success desired):Desired success: 0 medication variances;
Anticipated completion date: ongoing/monthly;

Third Quarter of 2014 (July, August and September):
Fallout: Medication Variances: Q3: 20124-4; Q2: 2014-5; Q3: 2013-5
Root Cause of Fallout: Medication Variances are down, which is an improvement;
Plan: Pharmacy and staff are working well together. Pharmacy is still not delivering medications on time;
Fallouts (Opportunity/Success desired): Desired success: Better than last year but still needs improvement. Desired Success: 0 medication variances;
Anticipated completion date: ongoing/monthly;

Fourth Quarter of 2014 (October, November and December):
Fallout: Medication Variances: Quarter 4: 20124-14; Quarter 3: 2014-5; Q4: 2013-9
Root Cause of Fallout: Medication Variances are down, which is an improvement.
Plan: Pharmacy and staff are working well together. Pharmacy is still not delivering medications on time. Both full time day shifts needed to be replaced. DON quit;
Fallouts (Opportunity/Success desired): Desired success: Stabilize staff and address the problems. Desired Success: 0 medication variances;
Anticipated completion date: ongoing/monthly.

In an interview on 5/5/15 at 3:45 p.m. with S2DON, she agreed the above referenced quality documentation lacked an action plan that had measurable corrective interventions. She also agreed interventions had to be measurable to evaluate whether the interventions had been successful in correcting identified problems.

Based on record review and interview, the hospital failed to employ methods to identify, measure, analyze and track medical errors as evidenced by failing to identify, measure, analyze and track near miss and close call medication errors.

Findings:

Review of S2DON's QAPI documentation revealed the hospital had no method in place to identify, measure, analyze and track near miss and close call medication errors.
In an interview on 5/5/15 at 3:45 p.m. with S2DON, she confirmed the hospital had no method in place to identify, measure, analyze and track near miss and close call medication errors.

Based on record review and interview, the hospital's governing body failed to ensure that the hospital's QAPI (quality assurance performance improvement) program reflected the complexity of the hospital's organization and services as evidenced by failure to include all services furnished both directly and under contractual arrangement in the QAPI plan.
Findings:
Review of the hospital's governing body meeting minutes revealed no documented evidence of review of quality indicators for all services provided for the hospital both directly and through contractual agreement.
The list of the hospital's current contracted services, presented by S2DON, was reviewed and compared to the QAPI documentation provided by S2DON. Further review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Dialysis Services, Biomedical Services and Biohazardous Waste Disposal Services. Additional review revealed the following services (included with the lease of the building per interview with S3ADON on 5/4/15 at 3:00 p.m.) were also not included in QAPI: Dietary Services, Housekeeping Services and Linen Services.
In an interview on 5/6/15 at 4:45 p.m. with S3ADON, she confirmed quality indicators for the above referenced services provided both directly and through contractual agreement were not included in the hospital's QAPI plan.

Based on record review and staff interview, the hospital failed to ensure that the nursing staff developed a nursing care plan for each patient as evidenced by failing to develop an individualized nursing care plan for patients' medical problems for 5 of 5 (#3, #4, #5, #6,
#29) medical records reviewed for patient care plans of a total of 30 sampled patients.

Findings:

Review of a hospital policy titled "Patient Plan of Care", effective 5/2010, no review date, and provided by S2DON as current, revealed the following:
Purpose: The plan will be initiated on admission and will be used as a guide for care until discharged or until goals are met.... Responsibilities: The RN (Registered Nurse) shall place the care plan on the patient's chart after assessment data is received....The nursing care plan is based upon the individual needs of the patient.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted on 4/28/15 with diagnoses which included Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, Dementia, Major Depression and Seizures. Review of Care Plans for Patient #3 revealed no problem identified for Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, Dementia, Major Depression and Seizures.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted on 3/4/15 with diagnoses which included Hypertension, Diabetes Mellitus and Atrial Fibrillation. Review of Care Plans for Patient #4 revealed no problem identified for Hypertension, Diabetes Mellitus and Atrial Fibrillation.

Patient #5
Review of the medical record for Patient #5 revealed she was admitted on 3/3/15 with diagnoses which included Osteoarthritis, End Stage Renal Disease with hemodialysis, Hypertension, Hypothyroidism, Hyperlipidemia and Dementia. Review of Care Plans for Patient #5 revealed no problem identified for Dementia, Hypertension, Hyperlipidemia and Hypothyroidism.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted on 4/13/15 with diagnoses which included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and Anxiety. Review of Care Plans for Patient #6 revealed no problem identified for Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and Anxiety.

Patient #29
Review of the medical record for Patient #29 revealed she was admitted on 1/16/15 with diagnoses which included Hypertension, Depression, Anxiety, Diabetes Mellitus with Neuropathy and CAD (Coronary Artery Disease). Review of Care Plans for Patient #29 revealed no problem identified for Hypertension, Depression, Anxiety, Diabetes Mellitus with Neuropathy and CAD (Coronary Artery Disease).

In an interview 5/5/15 at 1:15 p.m. S9RN, after a review of the medical record of Patient #29 confirmed the patient's care plan did not include her diagnoses of Hypertension, Depression, Anxiety, Diabetes Mellitus with Neuropathy and CAD (Coronary Artery Disease). S9RN confirmed Patient #29's care plan should have included all of her diagnoses.

In an interview on 5/6/15 at 3:30 p.m. with S2DON she confirmed the above referenced patients' (#3, #4, #5, #6, #29) care plans should have been inclusive of all patient diagnoses.



30984

Based on record review and staff interview, the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders and hospital policy for 4 (#5, #18, # 23, & #26) of 5 (#5, #18, #23, #26 & #30) sampled patients reviewed for medication administration out of a total sample of 30 patients. Two random patients (#R1,#R2) were also reviewed for medication administration.

Findings:

Review of the hospital's policy titled "Medication Administration" presented by S2DON (Director of Nursing) as current (04/10) revealed in part:
Purpose:
Medication administration times have been established in order to assure the clients received their medications in a timely manner each day to maintain a therapeutic level in the blood stream to avoid any complications that may occur with a drop in the medication level.
Policy:
All nurses administering medications to clients at this facility will adhere to the established times using the two hour window, one hour before or one hour after the set times. The administering nurses will work with the Pharmacy to assure the medication(s) is available and/or an order will be obtained from the physician to remain in compliance with the physician orders, facility policy, and Department of Health and Hospital.
Review of the hospital's policy titled "Charting Procedure" presented by S2DON as current (05/10) revealed in part: Vital signs required with the administration of specific medications will be recorded on the MAR. A missed dose will trigger an incident report for a medication error.
Review of the hospital's policy titled "Reporting Medication Errors" presented by S2DON as current (05/10) revealed in part:
Policy:
The Department of Nursing and the (name of the contracted Pharmacy) are responsible for writing medication error reports. The monitoring of medication errors help to identify conditions that led to medication errors and indicate nurses who repeatedly make medication errors. Such monitoring helps to enhance the quality of patient care.
Procedure:
Medication errors involving wrong drug, dose, route of administration, time or administering the medication to the wrong patient. Mistake in transcription of medication orders that results in one of the above errors. All omissions of scheduled medication without reasons for the omissions. All medication errors shall be reported promptly to the attending physician. All medication Variance Reports are reviewed by a (name of contracted Pharmacy) Pharmacist. Medication errors will be documented (recorded) in the patient's medical record.

Patient #5
Review of Patient #5's Medical Record revealed she had been admitted on 03/03/15 with diagnoses of S/P (Status Post) Right Knee Replacement, Right Adhesive Capsulitis, Pseudogout, ESRD (End-Stage Renal Disease) on Dialysis and HTN (High-Blood). She was discharged on 03/13/15.
Review of Patient # 5's Physician Orders revealed an order written on 03/15 at 4:50 p.m. for Sendipar 60 mg (milligrams) po (by mouth) daily with evening meal at 5:00 p.m.
Review of Patient #5's MARs (Medication Administration Records) revealed Patient #5 was administered a total of 3 doses from 03/04/15 (8:00 a.m. & 3:00 p.m.) to 03/5/15 (8:00 a.m.). Continued review of Patient #5's medical record revealed no documentation of the medication errors in the patient's medical record. Further review revealed no documentation of the nurse's actions following the incident.

Patient #18
Review of Patient #18's Medical Record revealed she had been admitted to the hospital on 02/02/15 with diagnoses of Osteoarthritis of bilateral knees with obesity, Diabetes Type 2, Dementia, Hypertension. She was discharged on 02/18/15.
Review of the Physician Orders dated 02/02/15 at 2:00 p.m. revealed the following order: Lisinopril 5 mg (milligrams) po (by mouth) daily-hold for SBP (systolic blood-pressure) less than 120. Further review revealed an order on 02/05/15 increasing Lisinopril to10 mg. daily. Additional review revealed an order on 02/03/15 for Lasix 20 mg po every a.m.
Review of Patient #18's MAR revealed no documented evidence of a blood pressure being taken prior to administration of Lisinopril on 02/07/15, 02/10/15, 02/12/15, 02/13/15, 02/14/15, & 02/15/15. Further review of the MAR revealed on 02/10/15 Lasix 20 mg po was left blank. Additional review of Patient #18's Medical record revealed no documented evidence that a physician was notified of the omission of Lasix on 02/10/15.
In an interview on 05/05/15 at 2:45 p.m., S2DON indicated blood pressures should have been taken prior to administration of each dose of Lisinopril. She indicated that on 02/10/15 Lasix 20 mg po had not been administered to Patient #18 as ordered by the physician.

Patient #23
Review of Patient #23's Medical Record revealed he had been admitted to the hospital on 02/25/15 with diagnoses of Acute Right Cerebellar Stroke, Bilateral Posterior Cerebral Artery Stenosis, and Left Ataxia with Spasticity. He was discharged on 03/18/15.
Review of Patient #23's MAR revealed Periactin 4mg po was not available for administration on 03/06/15 for the 7:00 a.m. & 11:00 a.m. doses.
In an interview on 05/05/15 at 2:45 p.m., S2DON confirmed, after review of Patient #23's MAR that Periactin had not been available for administration. She also confirmed the physician should have been notified. S2DON verified the physician had not been notified.

Patient #26
Review of Patient #26's Medical Record revealed she had been admitted to the hospital on 01/19/15 with diagnoses of Rheumatoid Arthritis with joint deformity to multiple joints, Osteoporosis, and GERD (Gastroesophageal Reflux Disease). She was discharged on 01/23/15.
Review of the patient's medical record revealed a Physician's Order, written on 01/19/15 at 1:11 p.m., for Norvasc 2.5 mg one po everyday- hold for SBP less than 120. Continued review of the Physician's Orders revealed Norvasc was discontinued on 01/22/15 at 9:30 a.m.
Review of the MARs for Patient #26 revealed Norvasc was administered on 01/20/15, 01/21/15, & 01/22/15 at 9:00 a.m. with no documentation that a blood pressure was taken prior to administration.
Review of Patient #26's Graphic Record revealed a blood-pressure reading of 90/60 was documented on 01/22/15 at 10:00 a.m.
Review of the Physician Progress notes dated 01/22/15 (no time) written by S7Physician read in part: "3. HTN (Hypertension)- BP dropped to 90/60 post meds (medications) this morning. Now normal. Will d/c (discontinue) Norvasc. Monitor.
In an interview on 05/05/15 at 2:45 p.m., S2DON confirmed a blood pressure reading should have been taken prior to administration of Norvasc.

Patient #R1
Review of Patient #R1's medical record revealed the patient was admitted to the hospital on 02/04/15 & on 02/22/15. S8Physician ordered Ritalin 2.5 mg bid (twice a day) #10.
Review of a Medication Variance Report for Patient #R1 revealed the following medication variance was discovered 02/25/15 at 11:00 a.m. Further review revealed the following: On 02/23/15 (name of contracted Pharmacy) delivered Ritalin (blister pack) 5 mg tablets (x 10). Patient #R1 was administered Ritalin 5 mg twice a day from 02/23/15 to 02/25/15 (a.m.). Patient had received 5 doses of Ritalin 5 mg as of 02/25/15. Further review of the Medication Variance Report for Patient #R1 revealed S7Physician was notified on 02/25/15 at 12:20 p.m.and the report was signed/dated by S7Physician on 02/25/15 at 12:30 p.m.
Review of Patient #R1's Narcotic Record revealed the following: Ritalin 2.5 mg (1/2 tablet) bid. Further review revealed Ritalin was documented as being administered twice a day (7:00 a.m. & 7:00 p.m.) on 2/23/15-2/25/15 (a.m.).
Review of the Progress notes for Patient #R1 dated/timed 02/25/15 at 12:45 p.m., revealed no documented evidence of the medication errors.
In a telephone interview on 05/06/15 at 10:40 a.m., S20Pharmacist indicated the above referenced error was both a dispensing (Pharmacist) error and a nursing error for lack of verifying Physician's order with medication package (right dose).
In an interview on 05/06/15 at 1:15 p.m., S3ADON(Assistant Director of Nursing) indicated S7Physician was verbally notified while making rounds of the medication error. She indicated he signed the medication variance report and Patient #R1 was examined at that time. She indicated there was no documented evidence of the medication errors in Patient #R1's medical record.

Patient #R2
Review of a Medication Variance Report for Patient #R2 revealed an order was written on 01/30/15 at 11:00 a.m. for Zyprexa 1.25 mg po every day, Zyprexa 5 mg po every hs (hour of sleep), and Zyprexa 2.5 mg po every 4: 00 p.m. Further review of the report revealed the 4:00 p.m. dose of Zyprexa 2.5 mg was not administered on 01/31/15 & 02/01/15.
Review of the MARs for Patient #R2 revealed Zyprexa 2.5 mg had a computer generated time of 4:00 p.m. A line was drawn through the 4:00 p.m. dose line and 9:00 a.m. was added with the word "Duplicate" written. On the dates of 01/31/15 & 02/01/15 a circle was noted around the 9:00 a.m. dose.
In a telephone interview on 05/06/15 at 10:40 a.m., S20Pharmacist indicated Patient #R2 was had not received the 4:00 p.m. dose of Zyprexa on 01/31/15 & 02/01/15.
In an interview on 05/06/15 at 11:30 a.m., S2DON indicated the circle was an indication that the Zyprexa was given at 9:00 a.m. & not at 4:00 p.m. as ordered by the physician. She indicated that all of the above findings were medication errors and should have been reported/documented.

Based on record review and interview, the hospital failed to ensure the Medical Record Department was organized, equipped, and staffed to meet the scope and complexity of the hospital ' s services in order to ensure the prompt completion, filing, and retrieval of medical records, and failed to ensure the Medical Record (MR) Department met the requirements of Federal and State laws and regulations.
Findings:
Review of a job description for " Director of Health Information Management " (Medical Records) revealed, in part: " The Director of Health Information Management (HIM) is responsible for the operation of the Health Information Management Department and includes the detailed analysis and assembly of charts, the legal process for release of information, timely transcription of medical dictation, the accurate coding of patient diagnosis and maintenance of regulatory requirements for the department and function. The Director of Health Information Management also serves as the hospital ' s internal Compliance and Privacy Manager and ensures the accurate completion and release of patient medical records. " Further review revealed, in part: " Qualifications, Education: An Associates ' Degree or higher in Health Information Management is required. Licenses/Certifications: Certification as a Registered Health Information Technician or Administrator is required. Experience/Skills: At least 3 to 5 years ' experience in a healthcare-based Health Information Management Department. " Other categories listed on the job description were listed as " Manages the Health Information Management Functions; Manages Release of Information; Coordinates the Hospital ' s Internal Financial Functions; Coordinates the Maintenance of Hospital Documents; Participates in the Corporate Compliance Process; Assures Compliance with All Regulations; Leadership; Resource Management; Fiscal Responsibilities; Safety; Professionalism and Customer Service; Effective use of Resources; and Other Duties. "
In an interview on 05/04/15 at 11:00 a.m., S3ADON (Assistant Director of Nursing) indicated she was the Director of the Medical Record Department at the hospital. S3ADON indicated she was asked by the previous administrator to be the Director of the Medical Record Department in 02/15 due to the resignation of the previous Medical Record Director. S3ADON indicated she had acquired this responsibility along with her other responsibilities as the ADON. S3ADON confirmed she was not RHIA (Registered Health Information Administrator) certified, and S3ADON further confirmed she had not received any training and/or certifications for the role and responsibilities for directing the Medical Record Department.

In an interview on 05/04/15 at 1:00 p.m., S5MR (Transcriptionist) indicated she was a part-time transcriptionist for S7Physician. S5MR indicated she was not a full-time member of the Medical Record Department, but she did assist in the Medical Record Department when help was needed. S5MR indicated some of the typical duties she performed to assist included such tasks as assembling charts and assisting with chart analysis. S5MR confirmed she had no certification/training for the operations of a Medical Record Department.

In an interview on 05/05/15 at 1:45 p.m., S11COO (Chief Operating Officer) indicated S10RHIA was the RHIA (qualified person) responsible for the Medical Record Department at the hospital. S11COO also indicated the hospital had a contract with another RHIA, but was not sure if the contract was currently in place or if the contracted RHIA still provided services for the hospital. S11COO confirmed S10RHIA had been in the position as the qualified person to oversee the Medical Record Department at the hospital for about 2 weeks.

Review of the personnel file for S10RHIA revealed a job description entitled, " Name of Hospital A, Job Description, Director of Health Information Management. " Further review of the job description revealed no documentation of the designated facilities S10RHIA was responsible for other than Hospital A as indicated by the name of the hospital on top of the page. Further review of the personnel file for S10RHIA revealed no documentation of the designated facilities S10RHIA was responsible for in providing directorship of the Medical Record Departments.

In an interview on 05/06/15 at 10:40 a.m., S10RHIA indicated her start date with the company was 11/11, and she was hired as the Health Information Management (HIM) Director at Hospital B. S10RHIA indicated in 12/12 she transferred to Hospital A as the full-time HIM Director. S10RHIA indicated she was made the Regional Director during the summer of 2014. S10RHIA further indicated she was the Regional Director for HIM for the following facilities: Hospital A, Hospital B, Outpatient C, Outpatient D, and Outpatient E.

S10RHIA indicated starting in 01/14 she was asked to come to the hospital to assess the MR Department at which time the hospital was contracted with another RHIA. S10RHIA indicated she was also asked to assist with quarterly medical record audits and assist with other tasks such as breaking down medical records, assisting with medical record analysis, etc. S10RHIA indicated she reported her quarterly medical record audit results to the hospital administrator and the corporate office. She also indicated she had been at the hospital approximately 8 times since 01/14.

S10RHIA indicated S3ADON was the Director of Medical Records at the hospital, and S3ADON did not report to her, but reported to the hospital administrator. S10RHIA confirmed she had never received any reports or any statistical data from the hospital concerning the operations and functions of the MR Department, and had never participated in quality assurance and performance improvement activities, developing/approving policies and procedures, enforcement and monitoring of compliance with policies and procedures and the Medical Staff By-Laws for the hospital. S10RHIA also confirmed she was not appointed as the director or regional director for the hospital. S10RHIA further confirmed she was not aware of any plans to hire a qualified MR Director for the hospital.

Delinquent Medical Records

In an interview on 05/04/15 at 1:30 p.m., S3ADON indicated she had to manually go through the charts to be able to compile a hand-written list of the 30-60-90-day delinquency rates when the surveyor requested the report. S3ADON indicated the delinquency rates had not been tracked and monitored since the previous MR Director separated from service at the hospital in 02/11, due to time limitations with her other roles and responsibilities as ADON.

Review of a document provided on 05/06/15 at 10:00 a.m. revealed the 30-60-90-day delinquency rates for the months of 02/15, 03/15, and 04/15 were 100%.

In an interview on 05/06/15 at 10:05 a.m., S3ADON confirmed the delinquency rates at the 30-60-90-day intervals were 100% for the months of 02/15, 03/15, and 04/15. When surveyor questioned S3ADON at what point was a medical record considered delinquent, she responded it was 30 days. Surveyor questioned S3ADON regarding the accuracy of the delinquency rate for 04/15, since it had not been thirty days since the last discharge date in 04/15. S3ADON confirmed the 04/15 delinquency rate could not be accurate, and agreed to calculate the delinquency rate for 01/15.

Review of a document provided on 05/06/15 at 3:00 p.m. revealed the delinquency rates for 01/15 at the 30-60-90-day intervals were 100%.

In an interview on 05/06/15 at 3:30 p.m., S3ADON indicated she was not aware if there were any plans to hire a qualified MR Director for the hospital.

Based on observation and interview, the hospital failed to ensure the patients' medical records were stored in a secured manner to maintain and ensure the integrity of the medical records and ensure the medical records were protected from any potential damage.
Findings:
An observation of the Medical Record Department on 05/04/15 at 1:00 p.m. revealed patients' paper medical records were stored on open stationery wall shelving and rolling carts inside the Medical Record Department. The paper medical records were covered with thin white opaque garbage bags which were torn open and draped over the top of each medical record stack. The torn garbage bags placed over the top of each stack of medical records did not completely cover all portions of the medical records and were not secured adequately to cover the medical records.
In an interview on 05/04/15 at 1:00 p.m., S3ADON (Assistant Director of Nursing) who was also the Medical Record (MR) Department Director indicated the patients' medical records were protected from water with the thin plastic garbage bags draped over the top of the medical records. S3ADON agreed the paper medical records would probably have some water damage if the sprinkler system was activated. S3ADON agreed the patients' medical records were not fully protected from any potential damage in the manner in which they were currently stored.

Based on interview, the hospital failed to ensure the hospital had a system of coding and indexing of patients' medical records which allowed for timely retrieval of patients' medical records by diagnoses and/or procedures.
Findings:
In an interview on 04/05/15 at 4:00 p.m., S3ADON (Assistant Director of Nursing) indicated she was not aware of an indexing method utilized by the hospital by which patients' medical records could be retrieved, in a timely manner, by diagnoses and/or procedures. S3ADON confirmed the only method she was aware of to provide this information would be to manually go through paper records and documents, provided on a weekly, monthly, or quarterly basis, and manually compile a list of the patients' diagnoses and procedures, and/or manually go through patients' medical records to compile a list of patients' diagnoses and procedures.

Based on record review and interview, the facility failed to ensure all medical record entries, including verbal orders, were signed, dated and/or timed by the licensed practitioner responsible for providing the service/prescription for 5 (#5, #6, #9, #16, #29) of 5 patients reviewed for incomplete medical record entries out of a total sample of 30 patients' records reviewed.
Findings:
Review of the hospital's Medical Staff Rules and Regulations, presented as current, revealed, in part: "VI. Medical Records and Orders; A. Preparation and Contents; 3. All clinical entries and summaries in the patient's medical record must be legible, accurately dated and timed and authenticated. Authentication for purposes of this rule, means written signature or initials. D. Medical Orders, 1.b. An order will also be considered to be "in writing and signed in ink" if it is dictated by a Physician in person or over the telephone to an authorized person, recorded and signed by that person on the appropriate order sheet, and countersigned by the ordering Physician within 48 hours."
Review of a policy/procedure entitled, "Authentication of Medical Record, presented as current, revealed, in part: "All entries in the medical record must be dated, timed, and authenticated with credentials (if applicable) by the author of the entry."
Patient #5
Review of the telephone discharge orders received on 3/12/15 at 9:25 a.m. for Patient #5 revealed S7Physician had not authenticated, dated or timed his verbal order.
Further review of Patient #5's medical record revealed the following verbal/telephone orders had been authenticated but not dated or timed by the prescribing practitioner:
3/6/15 11:08 a.m.: D/C (discontinue) Metoprolol ER (extended release), Lopressor 25 mg (milligrams) p.o. (by mouth) BID (twice a day). TO/RB (telephone order/ read back) S8Physician;
3/6/15 11:10 a.m.: Order clarification: D/C Metoprolol ER, Lopressor 25 mg p.o. BID. Hold for SBP (systolic blood pressure) less than 100 and DBP (diastolic blood pressure) less than 60 TO/RB S8Physician.
Patient #6
Review of Patient #6's medical record revealed the following verbal/telephone orders had not been authenticated, dated, or timed by the prescribing practitioner:
4/24/15, no time: Give additional Lisinopril 10 mg now x (times) 1 for total dose of 20 mg. VORB (verbal order read back), S7Physician;
4/24/15 19:18 (7:18 p.m.): Patient to follow up with urologist after discharged. TO/RB S7Physician;
4/25/15 16:50 (4:50 p.m.): Ampicillin 500 mg p.o. q (every) 6 hours x 3 days. TO/RB S7Physician;
4/27/15 10:20 a.m.: d/c (discontinue) oxycodone on discharge 4/28/15. Have lab perform a sensitivity to Cipro/Ampicillin as it relates to urine culture. If sensitive to Ampicillin continue for 7 days from start date (start date 4/26/15 1st dose at midnight). Verified/RB PO (phone order) S7Physician.
Patient #9
Review of Patient #9's medical record revealed the following verbal/telephone order had not been authenticated, dated, or timed by the prescribing practitioner:
1/18/15 (12:25 p.m.): 1. X-ray of abdomen; 2. Tylenol 325, 2 by mouth or per rectum for elevated temperature.
1/18/15 (12:45 p.m.): 1. Send to ER (Emergency Room) for evaluation and treatment for abdominal pain, nausea/vomiting, and increased temperature.
Patient #16
Review of Patient #16's medical record revealed the following verbal/telephone order had not been authenticated, dated, or timed by the prescribing practitioner:
4/2/15 14:00 (2:00 p.m.): 1. BMP (basic metabolic profile) in a.m.; 2. Follow up with PCP (primary care physician) next week; 3. CBC (complete blood count), BMP next week forward results to PCP TO/RB S7Physician.
Patient #29
Review of Patient #29's medical record revealed the following orders had been authenticated but not dated or timed by the prescribing practitioner:
1/19/15 19:00 (7:00 p.m.): 1. Increase Lantus to 18 units SQ (subcutaneously) q day at 16:00 (4:00 p.m.); 2. D/C Crestor; 3. Start Pravacol 20 mg p.o. q hs (hour of sleep); 4. AST/ALT (liver enzymes) Monday 1/26/15; 5. Atarax 25 mg po q h.s.; 6. Debrox otic solution 3-4 drops/ear q h.s. x 7 days, then gently irrigate ear canals with warm water after 7 th day;
1/19/15 2002 (8:02 p.m.): Okay to start Pravacol, Atarax and debrox on 1/20/15; Order clarification: Debrox otic solution 4 drops /ear q h.s. x 7 days then gently irrigate ear canals with warm water after 7th day. TO/RB S8Physician.
1/24/15 16:45 (4:45 p.m.): Hold Lantus 18 units 16:00 (4:00 p.m.) dose today; Give Lantus 9 units SQ x 1 dose now. TO/RB S8Physician.
In an interview on 5/5/15 at 3:50 p.m. with S2DON she confirmed completion of medical record entries had been recognized, by Quality, as a problem for the hospital. She agreed all entries in the patients ' medical records should have been authenticated, dated and timed.





31048

Based on record review and interview, the hospital failed to ensure errors in medication administration, and adverse reactions were tracked for analysis and identification of trends and a system was in place to identify, track and analyze near misses and close calls.
Findings:
1. Failed to ensure errors in medication administration & adverse drug reactions were tracked for analysis and identification of trends.
Review of the hospital's policy titled Review of the Hospital's Policy titled "Reporting Medication Errors" presented by S2DON(Director of Nursing) as being current (05/10) revealed in part:
Policy:
The Department of Nursing and the (name of the contracted Pharmacy) are responsible for writing medication error reports. The monitoring of medication errors help to identify conditions that led to medication errors and indicate nurses who repeatedly make medication errors. Such monitoring helps to enhance the quality of patient care.
Procedure:
Medication errors involving wrong drug, dose, route of administration, time or administering the medication to the wrong patient. Mistake in transcription of medication orders that results in one of the above errors. All omissions of scheduled medication without reasons for the omissions. All medication errors shall be reported promptly to the attending physician. All medication Variance Reports are reviewed by a (name of contracted Pharmacy) Pharmacist. Medication errors will be documented (recorded) in the patient's medical record.
Review of the hospital's medication variance reports (requested for 12 months) revealed a binder with 5 reported variances : 02/15-3 medication variances & 03/15-2 medication variances. Further review of the medication variance reports revealed no documented evidence that adverse drug reactions were being tracked.
In a telephone interview on 05/06/15 at 10:40 a.m, S20Pharmacist revealed medication errors were tracked monthly by the Pharmacist & Nursing Director. He was unable to explain why only 5 medication variances had been documented for the last 12 months. He indicated that he had no system in place for tracking adverse drug reactions for analysis and identification of trends.
In an interview on 05/06/15 at 11: 30 a.m., S2DON indicated that after review of all of the above occurrences the hospital failed to have an effective system in place for reporting, tracking, trending, and for implementing corrective actions for medication errors and adverse drug reactions.

2. Failed to ensure a system was in place to identify, track and analyze near misses and close calls.

Review of the Quality Assurance/Performance Improvement documentation presented by S2DON revealed no documented evidence of a system to track and analyze near miss/close call medication errors.

In an interview with S2DON on 5/6/15 at 3:45 p.m. she confirmed the hospital had no system in place to track and analyze near miss/close call medication errors.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by a contracted x-ray service.

Findings:

Review of hospital policies and procedures revealed no safety policy and procedure for radiological services.

In an interview 5/5/15 at 1:25 p.m. S1Administrator verified the hospital had no radiologist or other personnel overseeing radiological services. S1Administrator reported that radiological services were provided to hospital patients by a mobile X-ray service that performed portable X-rays in the hospital. S1Administrator verified the hospital did not have any policies and procedures for radiology services.

Based on record review and interview, the hospital failed to have a radiologist who supervised the radiology services of the hospital.

Findings:

Review of a list of credentialed physicians and providers provided by the hospital revealed no credentialed radiologist.

Review of the governing body meeting minutes revealed no documentation of the appointment of a radiologist who supervised the radiology services of the hospital.

Review of the hospital's organizational chart revealed no documentation of Radiological Services.

In an interview 5/5/15 at 1:25 p.m.,S1Administrator reported the hospital had no radiologist overseeing radiological services. S1Administrator reported that radiological services were provided to hospital's patients by a mobile X-ray service that performed mobile X-rays in the hospital.

Based on record review and interview, the hospital failed to ensure food and dietetic services were under the direction of a full time employee, qualified by experience or training, as evidenced by failure to employ a Director of Food Services.

Findings:

Review of the hospital's organizational chart revealed no documented evidence of a Director of Food Services.

In an interview on 05/05/15 at 4:15 p.m., S2DON verified that the hospital had no Director of Food Services.

Based on observation and interview, the hospital failed to ensure the physical plant and the overall hospital environment was maintained to ensure the safety and well-being of it's patients.

Findings:

Observations made 5/4/15 during a hospital tour between 11:25 a.m. and 12:25 p.m., accompanied by S3ADON, included, in part, the following:

- 2 holes, approximately 1 and 1/2 inches in diameter, in floor tiles in the dining room in walking pathways.

- Community patient shower room: Tiles missing along the outer edge of tiled area under shower nozzle, where patients showered. The missing/broken tiles extended approximately a foot down each side from the outer corner toward the center of the room; brown stained tiles on the floor of the shower; shower nozzle ring completely rusted and rust stains noted on shower wall from dripping shower head; shower head covered with white, chalky residue; paper shredding machine noted in the corner of the shower room; brooms and mops leaned against the wall of the shower room; extra rolls of brown paper towels stored in the shower room;

-Room "b": Oblong plastic tray used to cover the top of the toilet tank due to porcelain top being broken (confirmed by S3ADON at the time of the observation); bathroom floor baseboards by toilet stained brown and noted to have peeling paint; paint peeling on handrail in the shower; Pink, moist residue on the top, front and down the sides of the shower head; Sharp pitted edges of surface of hot/cold temperature lever in the shower; Water dripping in a steady stream from the shower head; Metal ring securing shower head to wall hanging loosely leaving an open hole approximately the size of a half dollar in the wall;

-Room "c": Open gouges in the floor tiles;

-Room "e": ceiling leak noted near the sliding door to the outside patio area;

-Room "f": 4 sets of vertical blinds with cords attached stored in patient belongings closet;
coating on top of bedside table rough to touch with peeling edges;

-Room "g": 2 broken beds stored in patient room;

-Room "h": rust and open gouges in the floor tiles by the window; 2 phone receivers with cords, extra call bells, IV (intravenous) pole for a patient bed, a box of VCR (video) tapes, a non-functional clock and a window squeegee piled on top of each other in one of the patient closets; metal ring on doorknob (inside entry door) loose.

-6 patient beds with non-functional nurse call buttons on the siderail of the bed. All 3 current patients were using a bed with a non-functional nurse call button on the bed siderail.

-Handrail by front entrance to the hospital on the left side (upon entry to hospital) noted to be loose, moveable with light pressure; brackets securing handrail to wall were loose.

The above noted observations were confirmed at the time of observation by S3ADON, present during the observations on 5/4/15 from 11:25 a.m. to 12:25 p.m. S3ADON indicated the hospital was short on storage space and equipment was routinely stored in the third closet of patient rooms and in the shower room. She confirmed the equipment remained stored in the closet of the patient rooms whether the room was occupied by a patient or not. S3ADON also confirmed the hospital had no soiled utility room.


30984

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality as evidenced by patients' beds having a nurse call feature on the handrails that was non-functional for 6 of 10 patient beds.

Findings:

Observations made 5/4/15 during a hospital tour between 11:25 a.m. and 12:25 p.m., accompanied by S3ADON, revealed 6 patient beds with non-functional nurse call buttons on the siderail of the bed. All 3 current patients were using a bed with a non-functional nurse call button on the bed siderail.

In an interview on 5/4/15 at 11:50 a.m. with S3ADON, she verified 6 of hospital's patients' beds had nurse call buttons on the handrails that were non-functional. She said patients were instructed to use the call button on the cord. S3ADON confirmed the hospital admitted patients with Dementia, Confusion and/or Mental Health Issues. She agreed having a non-functional nurse call feature on the handrail could cause confusion for the patient when attempting to call a nurse for assistance.

Based on interview and record review, the hospital failed to ensure the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S2DON (Director of Nursing) having no prior work experience or specialized training in infection control.

Findings:

In an interview 5/5/15 at 8:30 a.m. S2DON reported that she had assumed the position of Infection Control Coordinator when she started as the DON 2 weeks ago. S2DON confirmed she had no specialized training or work experience in Infection Control.

Review of the personnel file of S2DON revealed no documentation of specialized training or work experience in Infection Control.

Based on record review, observation and interview, the hospital failed to develop, implement, and maintain an active, hospital-wide program for the prevention, control, and investigation of infections and communicable diseases as evidenced by:
1) Failing to ensure patient care was provided in a sanitary environment;
2) Failing to have policies and procedures related to the following:
a. construction, renovation, maintenance, demolition, and repair, including the requirement for an infection control (IC) risk assessment (ICRA) to define the scope of the project and need for barrier measures before a project gets underway; and
b. Isolation Precautions to include Contact Precautions, Droplet Precautions, and
Respiratory Precautions;
3) Failing to include all departments in the data for Infection Control;
4) Failing to insure safe injection practices were followed as per hospital policy and procedure as evidenced by needle boxes being overfilled in 4 ( "b", "d", "e", "f") of 8 ("a", "b", "c", "d", "e", "f", "g", "h", "i") patient rooms.

Findings:

1) Failing to ensure patient care was provided in a sanitary environment.

Observations made on a tour of the hospital 5/4/15, accompanied by S3ADON, from 11:25 a.m. to 12:30 p.m. revealed the following:
-a walker in the bathroom just outside the therapy gym. S3ADON reported the walker was stored in the bathroom for anyone that might need a walker;

-dark yellow, thick dried substance about 1 foot in diameter on the floor at the base of the toilet, which was easily removed by S3ADON using a wet paper towel;

-1 of 3 wheelchairs stored in the ADL (Activities of Daily Living) Room which had a tear in one arm with the padding exposed;

-sharps containers that were overfilled to capacity in 4 patient rooms (Rooms "b", "d", "e", "f");

-Room "b": toilet plunger wrapped in a thin plastic bag, stored in the patient shower;

-Room "d": 2 patient bed pans, unlabeled and not bagged individually, stored on the floor in the patient bathroom which was shared by 2 patients. S3ADON confirmed, in interview during the observation (5/4/15 at 12:00 p.m.), that the bedpans should have been labeled with the patients' names, bagged individually, and should have been stored separately; Surface of bedside table peeling with rough edges. S3ADON also confirmed at the time of observation that the non intact surface of the bedside table could not be properly disinfected.

-Room "g": - Open coffee creamer container, open sugar container and loose styrofoam cups for patient and staff use stored on a bedside table. S3ADON confirmed during the observation that the referenced items were for both staff and patient use.

-Community patients' shower room (only 1 of 10 patient rooms contained a shower in the room) contained a large shred box (box in which to put papers that needed to be shredded), brooms and dust mops, an open, uncovered plastic basket of soiled linen, and 3 large unused rolls of brown paper toweling, broken tiles with missing grout, missing tile transition on shower floor. S3ADON confirmed during the observation that the broken tiles could not be properly disinfected because the surface was not intact;

-large amount of brownish build-up around the base of walls in patient rooms, patient bathrooms, and in patient shower room. This was reported , by S3ADON, as wax build-up. S3ADON agreed that the wax build-up on the floor could not be disinfected appropriately.

The above noted observations were confirmed at the time of observation by S3ADON, present during the observations on 5/4/15 from 11:25 a.m. to 12:25 p.m. S3ADON indicated the hospital was short on storage space and equipment was routinely stored in the third closet of patient rooms and in the shower room. She confirmed the equipment remained stored in the closet in the patient rooms whether it was occupied by a patient or not. S3ADON also confirmed the hospital had no soiled utility room.

An observation on 05/04/15 at 11:20 a.m. in the patients' dining room revealed a refrigerator designated for patient use only. Obervation inside the refrigerator door revealed condiments that were labeled as employees' item, some of which had expired. Further observation revealed the two bottom drawers inside the refrigerator were labeled as "Employee Use Only." An observation of the shelves designated for the patients' food revealed three items labeled with a current patient's name and a date written on a piece of paper that was placed near the items, but the items were not dated individually. Further observation of the interior of the patients' refrigerator revealed dried food particles and liquids on the shelves of the refrigerator.

In an interview on 05/04/15 at 11:20 a.m., S2DON confirmed the practice of placing employee items and patients' items in the same refrigerator, and she also confirmed the interior of the refrigerator was dirty. S2DON further confirmed the employee and patient items should not have been placed in the same refrigerator and the refrigerator was not clean and it should have been cleaned, and the employee and patient food items should not be placed in the same refrigerator.

2) Failing to have policies and procedure related to the following:
a. construction, renovation, maintenance, demolition, and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measures before a project gets underway.

Review of the provided hospital policies and procedures revealed no policy or procedure related to the construction, renovation, maintenance, demolition, and repair of the hospital. No hospital policy and procedure was included for requiring an ICRA prior to the implementation of construction, renovation, maintenance, demolition, or repair of the hospital.

In an interview 5/5/15 at 8:30 a.m. S2DON confirmed the hospital did not have an IC policy and procedure related to construction, renovation, maintenance, demolition, and repair of the hospital.


b. Failing to have policies and procedure related to isolation precautions to include
Contact Precautions, Droplet Precautions, and Respiratory Precautions.

Review of a hospital policy titled " Guidelines for Isolation Precautions", latest revision date of 1/4/14, and provided by S2DON as current, revealed the routes of transmission were defined and included "Contact Transmission", " Droplet Transmission", and "Airborne Transmission". Further review revealed no procedure(s) for the different types of transmitted infections. Isolation precautions listed were standard precautions and Respiratory Hygiene/Cough Etiquette. Respiratory Hygiene/Cough Etiquette included the following:
"A. Source control measures are needed to contain respiratory secretions and prevent droplet and fomite transmission of respiratory pathogens, especially during seasonal outbreaks...C. Source control measures include signs with instructions to patients/others with symptoms of a respiratory infection to cover their mouths/noses when coughing or sneezing...and offering masks ...to coughing patients and other persons with suspected respiratory tract infection." Further review revealed no specific actions/procedures that were to be put into place in the event a patient was to be put on Contact , Droplet, or Respiratory Precautions/Isolation.

In an interview 5/5/15 at 1:15 p.m. S9RN reported that she was the Charge Nurse on the patient care unit. S9RN was unable to locate any documentation of the procedures to be followed in the event a patient was placed in any type of isolation. S9RN was able to locate 1 sign the read, "Contact Isolation:" The RN was unable to locate any sign for Droplet Precautions or Respiratory Isolation. S9RN reported that she just knew what to do from her years of nursing. S9RN reported that the policies and procedures could not be accessed from the patient care unit. S9RN agreed that with no signs for Droplet or Respiratory/Airborne Precautions and no required precautions noted on the Contact Isolation signage that other staff such as housekeeping, CNAs (certified nursing assistants), providers, visitors, etc, would be able to implement the appropriate precautions/interventions.

In an interview 5/5/15 at 8:30 a.m. S2DON confirmed that the Guidelines for Isolation policy and procedure did not provide specific precautions/actions to be taken for each type of isolation, or the procedure for placing a patient on isolation. The DON confirmed there was no policy or procedure for the use of a N-95 mask or other respiratory protection in the event a patient was on Airborne Precautions required for a diagnosis such as Tuberculosis.



3) Failing to include all departments in the data for Infection Control.

A review of IC surveillance and data collection revealed not all departments and personnel were included in the IC program. No documented evidence of surveillance of hand hygiene for any personnel providing services in the hospital was noted in the documentation. Further review revealed no documentation of surveillance or infection control data related to other departments, including contracted services, such as therapy, housekeeping, dietary, laboratory, or radiology services.

In an interview 5/5/15 at 8:30 a.m. S2DON verified that the only IC data collected, provided to her on hire two weeks ago, was for Hospital Acquired Infections and Physical Rounds. S2DON verified that no data could be located for corrective actions planned, taken, or monitored for any physical environment findings that had been made in the past.



4) Failing to insure safe injection practices were followed as per hospital policy and procedure.

Review of hospital policy/procedure titled "Syringe, Needle and Sharp Disposal", effective 5/2010, (no review date), provided by S2DON as current revealed, in part: "...Routine precautions require that employees.....do not overfill containers... Procedure:...* When the sharps container is 2/3 full it will be closed securely and placed in the biohazard waste container located in the soiled utility room. *New disposal containers will be obtained from Central Supply and immediately placed in the patient's room..."

An observation was made 5/4/15 from 11:25 a.m. to 12:25 p.m. of the nursing unit, accompanied by S3ADON. Further observation revealed wall-mounted sharps (needle) boxes completely filled with needles in patient rooms "b", "d", "e", and "f". S3ADON, present during the observation, verified the sharps boxes were full and filled beyond the 2/3 mark. S3ADON reported the charge nurses should have changed the sharps boxes. S3ADON reported a check is done on discharge. Terminal cleaning is done by Housekeeping and a paper is turned into nursing. The Charge Nurse then checked the room after cleaning had been completed and the sheet had been turned in by housekeeping.

In an interview 5/5/15 at 1:25 p.m. S9RN reported that the nurses usually check the sharps boxes for being filled to the 2/3 line, and the need to be replaced . S9RN offered no explanation as to why the full sharps boxes had not been replaced. S9RN verified that 2 of the 4 rooms with full needle boxes were currently occupied by patients.


31048

Based on record review and interview, the hospital failed to ensure the documentation of the implementation of the discharge plans for 3 (#11, #24, #25) of 5 (#11, #20, #21, #24, #25) closed records reviewed for implementation of the discharge plans from a total sample of 30 (#1-#30).

Findings:

Review of a policy/procedure entitled " Discharge Planning/Continuum of Care Policy " for Case Management, provided as current, revealed in part: " Discharge Planning Process, 7. Case Managers utilize the Discharge Planning Assessment Form to document information obtained via the patient interview and planned follow-up. Additional documentation will be noted in the physician ' s progress note section of the medical record. "

Review of a policy/procedure entitled "Discharge Policy" for Nursing Services, provided as current, revealed in part: " Procedure ...The Discharge Summary shall include but not limited to: the date of discharge, reason for discharge, status of problems identified at admission and subsequently, a narrative summary of services provided, the patient ' s course and progress or deterioration, the status of the patient at the time of discharge, any continuing care needs, instructions for referrals regarding the needs. "

In an interview on 05/05/15 at 4:00 p.m., S1Administrator indicated there is not a Case Manager currently employed at the hospital, and the date of separation for the previous Case Manager was in 02/15. S1Administrator also indicated since the position had been vacated, she and the charge nurses had been responsible for and had been performing discharge planning activities for patients. S1Administrator also indicated the " Case Management Assessment and Discharge Planning Form " was not being utilized by the hospital staff.


Patient #11
A review of Patient #11 ' s medical record revealed Patient #11 was a 69-year -old female admitted on 2/5/15 and discharged home on 2/24/15 with home health services ordered. Diagnoses included Muscle Weakness, Osteoarthritis, and Gait Instability.

Further review of Patient #11's medical record revealed no documentation the home health agency received the faxed information and no documentation Patient #11 was accepted for home health services by the agency.

Patient #24
A review of Patient #24's medical record revealed Patient #24 was a 51-year-old male admitted on 1/5/15 and discharged home on 1/16/15 with home health services and a rolling walker ordered. Diagnoses included Osteoarthritis, Muscle Weakness, and Unsteady Gait.

Further review of Patient #24's medical record revealed no documentation the home health agency had been notified of the referral for home health and Patient #24 was accepted for home health services by the agency. There was no documentation in Patient #24's medical record that the rolling walker had been ordered and obtained for Patient #24 at discharge.

Patient #25
A review of Patient #25's medical record revealed Patient #25 was a 91-year-old male admitted on 01/05/15 and discharged on 1/27/15 with orders for a nebulizer for home and home health services. Diagnoses included Weakness, Recurrent Falls, Acute CHF (Congestive Heart Failure), and Hypertension. Further review of Patient #25's medical record revealed no documentation that a nebulizer for home use had been ordered for Patient #25 at discharge.

In an interview on 05/05/15 at 5:00 p.m., S1Administrator confirmed there was no documentation in the medical records for Patient #11, Patient #24, and Patient #25 that the above-referenced orders for home health services and durable medical equipment had been ordered and provided for the patients at discharge. S1Administrator indicated there should have been documentation in the medical records regarding implementation of the discharge planning process and orders.

In an interview on 05/05/15 at 5:30 p.m., S18RN confirmed there was no documentation in Patient #25's medical record that a nebulizer had been ordered for Patient #25 at discharge, and there should have been documentation regarding the implementation of the discharge planning process and orders.

Based on record review and interview, the hospital failed to ensure the discharge planning process was assessed and reassessed on an ongoing basis to ensure the hospital's discharge planning process met the needs of its patients upon discharge.

Findings:

Review of a document presented by S1Administrator entitled "(Name of Hospital) Performance Improvement Scorecard 2014 " revealed, in part, a document with statistical data for individual indicators under the following categories/programs for the 12-month period of 2014: Case Management: Statistics Inpatient, Statistics-IOP (Intensive Outpatient Program), Statistics-PHP (Partial Hospitalization Program), Discharge Planning-Inpatient, Discharge Planning-IOP, Discharge Planning-PHP. Under the section, Discharge Planning-Inpatient the following indicators were listed: Number (No.) of Total Discharges; No. Discharged Home; No. Discharged to SNF (Skilled Nursing Facility); No. Discharged to Nursing Homes (NH); No. Discharged Other; No. Discharged Acute Outs; No. of Psych (Psychiatric); No. Expired. The above-referenced indicators had numbers documented relative to the indicator for each month.

In an interview on 05/05/15 at 3:15 p.m., S1Administrator indicated the above-referenced data provided was the only information reviewed on a regular basis regarding discharged patients or the discharge planning process at the hospital. S1Administrator also indicated she was not aware of a process that monitored and evaluated readmissions to the hospital. S1Administrator confirmed there was no other data monitored for discharged patients from the hospital or the discharge planning process other than the data provided on the Performance Improvement Scorecard. S1Administrator also confirmed the indicators monitored regarding discharged patients did not provide the hospital with information regarding whether the discharge planning process at the hospital met the needs of the patients at discharge and did not provide a method for quality assurance and performance improvement analysis on the discharge planning process.

Based on record review and interview, the hospital failed to ensure Respiratory Care Services were under the direction of a Doctor of Medicine or Osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services.

Findings:

Review of a hospital organizational chart revealed no Respiratory Services listed.
Review of the hospital's provided contract(s) binder revealed no contract for Respiratory Services or a Respiratory Director.
Review of the Governing Body meeting minutes for 2014 revealed no discussion or appointment of a Director of Respiratory Services.

In an interview on 5/5/15 at 1:25 p.m. S1Administrator, reported she was not sure if the hospital had a Director of Respiratory Services. S1Administrator reported she had been in her position for 2 weeks, and would have to look for a contract for Respiratory Services.

In an interview 5/6/15 at 3:30 p.m. S11COO (Chief Operations Officer) confirmed the hospital did not have a Director of Respiratory Services.

Based on record review and interview, the hospital failed to ensure personnel were qualified to perform specific respiratory care procedures being provided to patients. This deficient practice was evidenced by failure to maintain documentation of current skills/competency evaluations on staff responsible for provision of respiratory care services for 5 of 5 (S9RN, S13RN, S14RN, S15RN, S16RN) nursing personnel records reviewed for current respiratory skills/competency evaluations.

Findings:


Review of the personnel files for S9RN, S13RN, S14RN, S15RN, S16RN revealed no documented evidence of current skills/competency evaluations (based upon return demonstrations of the skills) for respiratory therapy services provided by hospital staff to patients being admitted to the facility.


In an interview 5/6/15 at 3:25 p.m. S3ADON verified there was no documentation of respiratory training or competencies in the personnel files of the above listed personnel. S3ADON confirmed the hospital did not have any respiratory therapist employed or contracted.