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Based on contract review, record review, and interview, the hospital failed to ensure all physicians providing services to the hospital were credentialed and granted appropriate privileges when telemedicine services were furnished for radiological services. This deficient practice was evidenced by failure of the hospital to ensure that each physician furnishing radiological telemedicine services was granted privileges at the hospital for 2 (S13RAD,S14RAD) of 2 radiologists reviewed that had interpreted x-rays at the hospital.

Findings:

Review of the hospital's contracted services revealed a contract with an area mobile x-ray company to provide on location radiological services.

Review of Patient #9's medical record revealed the patient had x-rays dated 4/12/17 and 4/13/17 that had been interpreted by S13RAD (radiologist) and S14RAD respectively.

Review of Patient #20"s medical record revealed an admit date of 1/4/17 and a discharge date of 1/28/17. Further review revealed a radiology report dated 1/18/2017 was read by S14RAD.

Review of the list of the hospital's credentialed physicians, presented as current by S1Adm, revealed the hospital had not credentialed and privileged the above mentioned radiologists.

In an interview on 1/8/18 at 2:43 p.m. with S1Adm, she confirmed the hospital's radiological serves were provided via contract with a mobile x-ray company. S1Adm indicated the x-rays obtained by the mobile x-ray service would have been interpreted by radiologists affiliated with the mobile x-ray service. S1Adm confirmed the above referenced radiologists, who had interpreted the hospital's patients' x-rays, were not credentialed/privileged by this hospital.







38777

Based on record review and interview, the hospital failed to maintain a list of all contracted services that included the scope and nature of the services provided.

Findings:

Review of the hospital's list of contracted services revealed no documented evidence of a description of the scope and nature of the services each company provided through contractual agreement with the hospital.

In an interview on 1/10/18 at 10:18 a.m., with S2DON, she verified there was no documented description of the scope and nature of the services each company provided.

Based on record reviews, policy review, and interviews, the hospital failed to ensure that each patient was informed of all patients' rights, as set forth in the hospital's list of basic patient rights, prior to furnishing care for 6 of 10 (#1, #2, #3, #4, #7, #10) sampled patients reviewed for patient's rights out of a total of 33 sampled patient records reviewed.

Findings:

Review of the Patient Rights & Privacy (Policy 01-01-01, adopted March 2017) revealed in part:
Purpose: To ensure that all staff of "hospital" and all of its programs understand and respect the rights of all patients. Patient's Rights applies to all hospital programs including inpatient, outpatient ... services.
Procedure:
E. Written copies of the "Patient Rights" will be will be prominently displayed in all patient rooms.
F. Patients' Basic Rights - The patient has the right to the following:
1. The patient has a basic right to treatment. Provision of treatment is the physician and facility's fundamental responsibility to the patient.
2. Each patient or their designation representative shall whenever possible, receive a copy of Patient's rights in advance of admission.
3. To have a family member, chosen representative, or own physician notified of admission to the hospital.
4. To receive treatment and medical services without discrimination based on race, age, religion, national origin, sex sexual preferences, religion, handicap, diagnosis and ability to pay or source of payment.
5. Be informed of the names and functions of all physicians and other health care professionals who are providing their direct care. This will be accomplished by staff introducing themselves to patients and explaining their role and by wearing name tags.
6. The right to be treated with respect with consideration, respect and in recognition of their individuality, including the need for privacy treatment.
7. To receive the services of a translator or interpreter to facilitate communication between the patient and hospital personnel.
8. To participate in and develop their own plan of care and in its implementation.
9. To make informed decisions regarding care.
10. To be informed of their health status, be involved in care planning and treatment, to be given the option to refuse treatment. Patient refusal of treatment may not be construed as a mechanism to demand inappropriate of unnecessary medical care.
11. To not be included in experimental research without informed consent.
12. To be informed if the hospital has authorized other health care institutions to participate in their care.
13. To formulate advanced directives and to expect hospital to comply with those directives.
14. To be informed by the attending physician and other health care providers about any post-discharge health requirements.
15. To have medical records kept confidential.
16. To access information contained in their medical record within a reasonable time frame.
17. To be free from restraints that are not medically necessary or used as a means of coercion, discipline, convenience or retaliation.
18. To be free from any and all forms of abuse or harassment.
19. To receive care in a safe setting.
20. To examine and receive an explanation of the hospital bill, regardless of payment source, and financial assistance information.
21. To be informed in writing the procedure for issuing and addressing patient complaints, grievances, etc. This will be clearly posted with phone numbers and addresses.
22. To be made aware of hospital rules and expectations.
23. Transfer policy
24. Patients that have concurrent mental disorders requiring treatment during hospitalization will have rights provided in the Louisiana Mental Health Law.

Review of the admission packet provided by S7MRClerk revealed the following:
A "Data Collection Information Summary for Patients in Inpatient Rehabilitation Facilities" form that indicated in part:
This notice is a simplified plain language summary of the information contained in the attached "Privacy Act Statement-Health Care Records"
As a hospital rehabilitation inpatient, you have the privacy rights listed below.
You have the right to know why we need to ask questions.
You have the right to have your personal health care information kept confidential and secure
You have the right to refuse to answer questions
You do not have to answer any questions to get services.
You have the right to look at your personal information.

Review of the hospital's "Acknowledgement of Receipt of Information" form revealed in part:
I, the undersigned, acknowledge that I have received written information on the following:
A. Organ/Tissue Donation
B. Advanced Directive, including:
That I have the right to accept or refuse medical treatment;
That I have the right formulate Advance Directive ...
C. Privacy Act Statement;
D. Notice of Privacy Practices/HIPAA
E. Grievances Procedure
F. Non-Discrimination Policy

Review of the medical records for Patients #1, #2, #3, #4, #7, and #10 revealed a copy of the form titled, "Data Collection Information Summary for Patients in Inpatient Rehabilitation Facilities" and a signed copy of the hospital's "Acknowledgement of Receipt of Information" form.

On 1/8/18 at 3:30 p.m. S2DON reviewed the patient's rights set forth in the hospital's Patient's List of Basic Rights and verified the hospital had not informed the patients of the patient's rights listed above.

On 1/9/18 at 3:20 p.m., an interview was held with S17RN. She stated she had been a floor nurse for a year. She explained upon the patient's admission, the RN was responsible was obtaining consents and informing the patients of their rights followed by a written acknowledgement statements of receipt the Patient's Rights from the patients. Upon request, S17RN showed the documents that the patients signed on admit. When asked, S17RN stated she explained some of the Patient's Rights to the patients as she did not know all of them. She also stated the hospital did not provide the patients a written copy of the patient's rights. S17RN presented the same admission packet that was presented by S7MRClerk. S17RN verified Patients #1, #2, #3, and #4 were provided the "Data Collection Information Summary for Patients in Inpatient Rehabilitation Facilities" form and signed the hospital's "Acknowledgement of Receipt of Information" form.

During the exit conference on 1/10/18 at 11:50 a.m., S1Adm verified the hospital was not providing the patients with the "Patient Rights" booklet.

Based on QAPI (quality assurance performance improvement) documentation review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to identify delinquent medical records and breaks infection control practices as areas in need of improvement to be addressed through the hospital's QAPI program.

Findings:

Delinquent Medical Records:
The following delinquent medical records were identified during sampled patient record reviews:

Patient #8 - Discharged on 6/2/17. Further review revealed as of 1/8/18 at 12:15 p.m. there was no physician signature for the Physical Medicine Rehabilitation Progress Note dated 5/31/17 (222 days delinquent).

Patient #14 - Discharged on 3/3/17. Further review revealed as of 1/8/18 at 3:00 p.m. there was no physician signature for the Physical Medicine Rehabilitation Progress Note dated 2/21/17 (141 days delinquent) There was no physician signature for the Physician Discharge Orders written as a Telephone Order dated 3/3/17, (131 days delinquent).

Patient #15- Discharge date of 2/21/17. Further review revealed as of 1/8/18 at 3:00 p.m. there was no physician signature for the History and Physical Post-Admission Physician Evaluation dated 2/14/17 (148 days delinquent).

Patient #16 - Discharge date of 5/16/17. Further review revealed as of 1/8/18 at 3:35 p.m. there was no physician signature for the discharge summary dated 5/16/17 (57 days delinquent).

Patient #24 - Discharged date of 11/24/17. Further review revealed no discharge summary as of 1/9/18 (46 days delinquent).

Patient #25- Discharged on 11/28/17. Further review revealed no discharge summary as of 1/9/18 (42 days delinquent).

Patient #26- Discharged on 11/30/17. Further review revealed no discharge summary as of 1/9/18 (40 days delinquent).

Patient #27- Discharged on 11/29/17. Further review revealed no discharge summary as of 1/9/18 (41 days delinquent).

Patient #R1- Discharged on 10/9/17. Further review revealed no discharge summary as of 1/9/18 (93 days delinquent).

Patient #R2- Discharged on 9/11/17. Further review revealed no discharge summary as of 1/9/18 (121 days delinquent).

In an interview on 1/9/18 at 10:03 a.m. with S2DON, she confirmed the above referenced patient medical records were considered deficient due to the patient records remaining incomplete over thirty days after patient discharge. S2DON verified the above referenced patient medical records had not been identified as deficient prior to review by the surveyors.

In an interview on 1/9/18 at 10:40 a.m. with S1Adm, she said she had not been aware of any delinquent patient medical records. She also verified no letters had been sent to providers and no providers had been suspended for delinquencies.

Breaches in infection control practices:
The following infection control issues/breaches were observed during the survey: failure of housekeeping staff to perform hand hygiene before/after gloving and failure to change gloves and towels between tasks and failure of the staff to disinfect the glucose meter properly. These referenced findings were confirmed with S2DON/Infection Control Officer throughout the survey (1/8/18-1/10/18).

Review of the Quality Improvement Report, presented by S2DON as the hospital's QAPI documentation, revealed breaks in infection control/infection control issues observed by the team related to hand hygiene, glove usage, improper disinfection of the glucose meter, and delinquent medical records identified by the survey team had not been identified as areas in need of improvement to be addressed through the hospital's QAPI program.

In an interview on 1/10/18 at 10:00 a.m. with S2DON, she confirmed the breaks in infection control/infection control issues observed by the survey team and the delinquent medical records discovered by the survey team had not been identified as areas in need of improvement to be addressed through the hospital's QAPI program.

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. This deficient practice was evidenced by failure of the hospital to include all services furnished both directly and under contractual arrangement in the QAPI plan.

Findings:

Review of the hospital's policy titled, "Scope of Services, Contract Services", Policy Number: 00-06-04, revealed in part: The governing body shall ensure that the services provided in the hospital that are provided under contract (includes joint ventures or shared services) meet the following: Contract services must be indistinguishable from hospital provided services and shall participate in the QAPI plan of the hospital.

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 S1Adm, was reviewed. Review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Dialysis Services, Patient Transport Services, Mobile Radiological Services, Linen Services, Medical Gas Services, and Biohazardous Waste Disposal Services. Additional review revealed the hospital's outpatient psychiatric services were also not included in QAPI.

In an interview on 1/10/18 at 10:30 a.m. with S1Adm, 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 interview the hospital failed to ensure the organization of the meidcal record service was appropriate to the scope and complexity of the services performed. This deficient practice was evidenced by failure of the hospital to employ a qualified director of the Medical Records Department.

Findings:

In an interview on 1/9/2018 at 9:10 a.m. with S1Adm, she verbalized S3RHIT was their Director of Medical Records.

In a telephone interview on 1/9/18 at 10:30 a.m. with S3RHIT stated she signed her contract yesterday (1/8/18) to consult for medical records at the hospital. She sais she was not the Medical Records Director. She stated she would remotely review medical records quarterly but was not supervising the staff of the Medical Records Department.

In an interview on 1/9/18 at 10:40 a.m. with S1Adm, she veriifed she had signed a contract with S3RHIT to supervise the medical records service yesterday (1/8/18) after the survey team entered. S1Adm said the hospital had not had a medical records supervisor since the end of April or the beginning of May of 2017. When told S3RHIT said she was not acting as a supervisor, S1Adm said that was news to her.

Based on record reviews and interviews, the hospital failed to ensure patient medical records were promptly completed within 30 days of discharge. This deficient practice was evidenced by failure of the hospital to identify and/or complete patient medical records delinquent for 30 days or more after patient discharge with no documented action having been taken, as set forth in the hospital's Medical Staff By-laws, to bring them into compliance for 10 (#8,#14,#15,#16, #24,#25,#26.#27, #R1,#R2) of 33 (#1-#30, #R1-#R3) sampled patient records reviewed.

Findings:

Review of the hospital's Medical Staff By-laws, adopted 3/2017, revealed in part:
Section 5: Automatic Suspension: Failure to maintain specific "appointment" criteria, including appropriate certification of insurance, shall result in an automatic suspension. Automatic suspension shall be triggered if one of the following happens: d. Failure to complete a patient's medical chart, including history and physical and/or discharge summary within 30 days of discharge. Physician shall be notified in writing at the point identified deficiency and given 14 days to correct said deficiency. If it remains deficient, the Administrator will send a letter stating the physician is suspended until medical records confirms completion.
An applicant shall remain on such suspension until compliance for the above is met. An applicant shall have 14 days to correct that above infraction before their medical staff privileges are revoked. Once medical staff privileges are completely revoked, the practitioner will have to reapply for membership and clinical privileges as would any new physician.


Review of S4MedDir's sampled patient medical records revealed the following delinquent medical records:

Patient #24
Review of Patient #24's medical record revealed he had been admitted on 11/13/17 and discharged on 11/24/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no discharge summary in the medical record (46 days delinquent).

Patient #25
Review of Patient #25's medical record revealed he had been admitted on 11/16/17 and discharged on 11/28/17. Further review revealed as of 1/9/18 at 9:30 a.m. there was no discharge summary in the medical record (42 days delinquent).

Patient #26
Review of Patient #26's medical record revealed she had been admitted on 11/15/17 and discharged on 11/30/17. Further review revealed as of 1/9/18 at 9:50 a.m. there was no discharge summary in the medical record (40 days delinquent).

Patient #27
Review of Patient #27's medical record revealed she had been admitted on 11/14/17 and discharged on 11/29/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no discharge summary in the medical record (41days delinquent).

Patient #R1
Review of Patient #R1's medical record revealed she had been admitted on 9/25/17 and discharged on 10/9/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no discharge summary in the medical record (93 days delinquent).

Patient #R2
Review of Patient #R2's medical record revealed she had been admitted on 8/28/17 and discharged on 9/11/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no discharge summary in the medical record (121 days delinquent).

Review of S4MedDir's credentilaing file revealed no documented evidence of written notification of delinquent medical records in need of correction. Further reivew revealed no documented evidence of suspension of privileges or any other type of disciplianry action having been taken in order to bring the delinquent patient medical records into compliance.

In an interview on 1/9/18 at 10:03 a.m. with S2DON, she confirmed, after review of their electronic medical records, that Patients #24, #25, #26, #27, #R1, and #R2 had no discharge summaries in their medical records as of 1/9/18. She also confirmed the patient medical records were considered deficient due to the patients having been discharged over thirty days prior to the date of the record review. S2DON verified the above referenced patient medical records had not been identified as deficient (incomplete for 30 days or more after patient discharge) prior to review by the surveyors. S2DON reported she had spoken to S4MedDir and he had indicated he had fallen behind on entering patient discharge summaries in the electronic medical records.


Review of S5MD's sampled patient medical records revealed the following delinquent medical records:

Review of Patient #14's medical record revealed an admit date of 2/17/17 and discharge date of 3/3/17. Further review revealed as of 1/8/18 at 3:00 p.m there was no physician signature for the Physical Medicine Rehab Progress Note dated 2/21/17 (141days delinquent) There was no physician signature for the Physician Discharge Orders written as a Telephone Order dated 3/3/17, (131 days delinquent).

Review of Patient #15's medical record revealed an admit date of 2/13/17 and discharge date of 2/21/17. Further review revealed as of 1/8/18 at 3:00 p.m. there was no physician signature for the History and Physical Post-Admission Physician Evaluation date 2/14/17 (148 days delinquent).

Review of Patient #16's medical record revealed an admit date of 4/30/17 and discharge date of 5/16/17. Further review revealed as of 1/8/18 at 3:35 p.m. there was no physician signature for the discharge summary dated 5/16/17 (57 days delinquent).

Review of the July 12, 2017 Governing Board Meeting Minutes revealed S5MD was changed to inactive status.

Review of S12MD's sampled patient medical records revealed the following delinquent medical records.

Review of Patient #8's medical record revealed an admit date of 5/17/17 and discharge date of 6/2/17. Further review revealed as of 1/8/18 at 12:15 p.m. there was no physician signature for the Physical Medicine Rehab Progress Note dated 5/31/17 (222 days delinquent).

In an interview on 1/9/18 at 10:40 a.m. with S1Adm, she said she had not been aware of any delinquent patient medical records. She verified she had just signed a contract with S3RHIT to supervise the medical records service on 1/9/18. She said she had not had a supervisor since the end of April or the beginning of May of 2017. When told S3RHITsaid she was not acting as a supervisor, S1Adm said that was news to her. She also verified no letters had been sent to providers and no providers had been suspended for delinquencies.



















38777

Based on record reviews and interviews, the hospital failed to ensure patient discharge summaries describing the outcome of the patient's hospitalization, disposition of care, and provisions for follow-up care was in the patient's record within 30 days of discharge for 6 (#24, #25,#26,#27, #R1,#R2) of 6 ( #24, #25,#26,#27, #R1,#R2) patient medical records reviewed out of 33 (#1-#30, #R1-#R3) total sampled patient records reviewed.

Findings:

Review of the hospital's Medical Staff By-laws, adopted 3/2017, revealed in part:
Section 5: Automatic Suspension: Failure to maintain specific "appointment" criteria, including appropriate certification of insurance, shall result in an automatic suspension. Automatic suspension shall be triggered if one of the following happens: d. Failure to complete a patient's medical chart, including history and physical and/or discharge summary within 30 days of discharge.


Review of S4MedDir's sampled patient medical records revealed the following records failed to have discharge summaries completed within 30 days of discharge:

Patient #24
Review of Patient #24's medical record revealed he had been admitted on 11/13/17 and discharged on 11/24/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no discharge summary in the medical record (46 days delinquent).

Patient #25
Review of Patient #25's medical record revealed he had been admitted on 11/16/17 and discharged on 11/28/17. Further review revealed as of 1/9/18 at 9:30 a.m. there was no discharge summary in the medical record (42 days delinquent).

Patient #26
Review of Patient #26's medical record revealed she had been admitted on 11/15/17 and discharged on 11/30/17. Further review revealed as of 1/9/18 at 9:50 a.m. there was no discharge summary in the medical record (40 days delinquent).

Patient #27
Review of Patient #27's medical record revealed she had been admitted on 11/14/17 and discharged on 11/29/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no d/c summary in the medical record (41days delinquent).

Patient #R1
Review of Patient #R1's medical record revealed she had been admitted on 9/25/17 and discharged on 10/9/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no d/c summary in the medical record (93 days delinquent).

Patient #R2
Review of Patient #R2's medical record revealed she had been admitted on 8/28/17 and discharged on 9/11/17. Further review revealed as of 1/9/18 at 10:00 a.m. there was no d/c summary in the medical record (121 days delinquent).

In an interview on 1/9/18 at 10:03 a.m. with S2DON, she confirmed the above referenced patients had no discharge summaries in their medical records as of 1/9/18. She also confirmed the patient medical records were considered deficient due to the patients having been discharged over thirty days prior to the date of the record review. S2DON reported she had spoken to S4MedDir and he had indicated he had fallen behind on entering patient discharge summaries in the electronic medical records.

Based on policy review, observation, and interview the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable federal and state laws and regulations, and with applicable standards of practice as evidenced by the facility failing to monitor and record the medication refrigerator temperatures.

Findings:

Review of the hospital policy titled "Quality Assessment and Performance Improvement Infection Control", Policy Number 02-02-03, revealed in part: Refrigerator, freezer, dishwasher and food temperatures will be checked and recorded daily.

An observation on 1/9/18 at 1:36 p.m. revealed the refrigerator temperature logs dated January 1, 2017 through December 31, 2017 had 6 days without temperatures recorded out of the 30 days for the month of June and 18 days without temperatures recorded out of 31 days for the month of December.

In an interview on 1/9/18 at 1:40 p.m. with S17RN and S10LPN they verified 6 days for June 2017 and 18 days for December 2017 were not recorded on the medication temperature logs. They also confirmed the December 2017 temperature log was completed on the Staff Food Refrigerator log sheet instead of the Medication Refrigerator Temperature log sheet.

In an interview on 1/9/18 at 1:55 p.m. with S1Adm, she verified the medication refrigerator temperature logs for June 2017 were missing signatures for 6 days and the December 2017 temperature logs were missing signatures for 18 days. She also verified the staff had inappropriately utilized the Staff Food Refrigerator temperature log instead of the Medication Refrigerator temperature log for the month of December 2017.

Based on observations and interviews, the hospital failed to ensure all drugs and biologicals were kept locked to prevent unmonitored access by unauthorized individuals. This deficient practice was evidenced by failure of the nurse to ensure the medication cart was not left unlocked and unsecured while passing medications.

Findings:

On 1/8/18 at 9:10 a.m. an observation was conducted of the medication cart being utilized by S17RN. S17RN was observed walking away from the medication cart, leaving the cart unattended, and secured with only one lock on the narcotic drawer (leaving the narcotics under single lock and not under double lock).

In an interview on 1/8/18 at 9:15 a.m. with S17RN, she stated she locked the narcotics drawer but not the other medication drawers when she was passing medications.

In an interview on 1/8/18 at 1:18 p.m. with S11Pharmacist, he verified the medication cart should "absolutely" be locked if the nurse stepped away from the cart.

Based on observations and interviews, the hospital failed to ensure unscheduled and schedule IV medications were locked within a secure area. This deficient practice was evidenced by 1) failure of the nurse to secure the medication cart while passing medications; and 2) failure of the nurse to ensure vials of Ativan were stored securely under double lock.

Findings:

1) Failure of the nurse to secure the medication cart while passing medications.

On 1/8/18 at 9:10 a.m. an observation was conducted of the medication cart being utilized by the S17RN. S17RN was observed walking away from the medication cart, leaving the cart unattended and unsecured except for one lock on narcotic drawer (leaving the narcotics under single lock and not double locked).

In an interview on 1/8/18 at 9:15 a.m. with S17RN, she stated she locked the narcotics drawer but not the other medication drawers when she was passing medications (leaving the narcotics under single lock and not double locked).

In an interview on 1/8/18 at 1:18 p.m. with S11Pharmacist, he verified the medication cart should "absolutely" be locked if the nurse steps away from the cart.

2) Failure of the nurse to ensure vials of Ativan were stored securely under double lock.

On 1/9/18 at 1:30 p.m. an observation was conducted of the Nurses' Station Medication Refrigerator. During the observation, 2 vials of 2mg/ml Ativan were noted to be located in an unsecured, small, locked black metal box on the top shelf of the unlocked refrigerator.

In an interview on 1/9/18 at 1:33 p.m. S17RN and S10LPN verified 2 vials of 2mg/ml Ativan were stored in the unlocked refrigerator in the small black locked metal box that was not secured to the refrigerator.

Based on observation, interview, and policy review the hospital failed to ensure unlabeled, outdated, or expired medications were not available for administration to patients. This deficient practice was evidenced by having unlabeled, outdated medications and medications from a discharged patient available for use in the wound care cart and medication emergency medication box.

Findings:

Review of the hospital policy titled "Pharmacy: Storage and Administration", Policy Number 03-03-07, revealed in part: All discharged patient medications will be pulled and sent home with the patient unless the medication has been discontinued. Any medication not sent home with the patient for whatever reason will be pulled from available inventory and placed in the locked cabinet for med destruction via Stericycle Sterisafe program.

Review of the hospital policy titled "Pharmacy Medication Procurement", Policy Number 03-03-02, revealed in part: At least monthly, outdated, mislabeled or otherwise unusable drugs will be separated from the stock and double locked in Stericycle container in med room until logged and destroyed according to state and federal law.

On 1/8/18 at 8:40 a.m. an observation of the red wound care cart in the hallway near the nurse's station revealed the following:
a. The first drawer -1 tube of opened, undated Mupironcin Ointment 2% with a partial patient label for Patient #R3.
b. The second drawer - 1 tube of opened and undated Diclofenac Sodium Topical 1% without a patient
label and 1 bottle Curad ½"x 5 yards packing strip opened and undated without a patient label.
c. The third drawer - 1 opened, undated stock tube of 1% Triple Antibiotic Ointment.

On 1/8/ 18 at 8:43 a.m. an observation was made of the locked emergency medication box located on top of the Wound Care Cart. The observation revealed 4 vials of 0.4 milligram/ milliliter Naloxone - expired on 1/1/18.

In an interview on 1/8/18 at 8:45 a.m. with S8PT, he stated Patient #R3 was discharged several days before the survey and the medication should not have been in the drawer.

In an interview on 1/9/18 at 9: 35 a.m. with S2DON, she verified the wound care cart and the emergency medication box contained outdated, opened and or undated medications above. S2DON removed the items from the cart.

Based on record review and interview, the hospital failed to ensure drug administration errors were documented in the patients' medical records for 1 (#30) of 1 (#30) patients reviewed from a total of one reported patient medication variance.

Findings:

Review of the hospital policy titled, "Medication Errors, Adverse Reactions and Drug Incompatability", revealed in part: Policy: This hospital maintains a medication error reporting system that will serve to define, identify, and report all medication errors and potential medication errors. Once reported medication errors will be reviewed. Any event, suspected to result from drug administration shall be reported to the physician, DON, and contracted pharmacy for investigation, follow-up, and reporting to appropriate groups and individuals. Procedure: Medication Errors: Medication errors will be reported as follows: an entry in the medical record will note that the physician was notified of the medication error.

Review of the hospital's occurrence reports revealed one reported medication variance that had involved Patient #30. Further review revealed the medication variance had been discovered on 10/31/17. Additional review revealed on 10/27/17 at 8:27 p.m. Patient #30 had received Norco 5-325 (ordered as 1 tablet by mouth as needed q 6 hours). A written notation was observed on the MAR that the medication had been discontinued.

Review of Patient #30's physician's orders revealed Norco 5-325 had been discontinued on 10/27/17 at 8:15 p.m.

Review of Patient #30's Nurses Notes for 10/31/17 (date of discovery) revealed the medication variance and physician notification were not documented in the patient's record.

In an interview on 1/8/18 at 2:51 p.m. with S2DON, she reported the hospital staff completed a medication variance report upon discovery of medication variances. S2DON confirmed the hospital's current practice for medication variance documentation had not included charting of the variance in the patient's medical record.

Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist was appointed to supervise the radiology services at the hospital.

Findings:

Review of a list of credentialed physicians and providers provided by the hospital failed to reveal a credentialed radiologist.

In an interview on 1/8/18 at 2:35 p.m. with S1Adm, she verified S4Med Dir was the Radiology Director; however, he was not a Radiologist. S1Adm reported that radiological services were provided to hospital patients by a mobile X-ray service that performed mobile X-rays in the hospital.

Based on observations, policy review, and interviews, the hospital failed to maintain the physical plant and overall hospital environment in such a manner to ensure the safety and well-being of patients.

Findings:

Review of the hospital's "Physical Environment of Facility" policy revealed in part:
Purpose: Our purpose is to provide patients in the rehabilitation hospital & rural health clinics with a safe and accommodating environment.
Policy: Accord Rehab Hospital will maintain safe environment in accordance with all applicable state and federal regulations.

On 1/8/18 from 8:10 a.m. - 8:55 a.m. an observation was conducted of the hospital and the following findings were revealed:

1. The bathroom doors for 3 (Rooms 400, 402, 406) of 9 patient's rooms did not close completely.
2. The window blinds for in patient Rooms 402, 403, 404, 406, and 408 were broken and/or missing individual blinds.
3. A hole approximately the size of a baseball was noted in the wall behind the head of the bed in Room 400.
4. The electrical outlets in Room 403 was not secured to the wall.
5. The air conditioning vent cover was not attached to the main air conditioning unit in Room 403.
6. A rip was observed in the mattress in Room 405 which was currently occupied.
7. A biohazard room (located in the hospital lobby) containing unsecured sharps and needles was observed to be unlocked.
8. A gray furry substance was observed on a black oscillating fan in the Central Supply room.
9. Dead insects were observed in the overhead light fixtures in Room 409.
10. The closet door in Room 409 was missing a knob.
11. Room 409 ( a semi-private room) was missing a privacy curtain.
12. A red string of yarn which can not be disinfected was attached was to the emergency call switch in Room 409.
13. The water sprinkler head located in the hallway between Rooms 407 and 408 was observed to be dangling from the ceiling.
14. The community shower room contained the following:
-Shower chair with 4 rusted metal castor wheels
-Shower tile floor containing black and grey debris
-Gray furry substance on the vent
-5 shelf open metal racks, covered with rust, containing clean patient shower supplies
-A spray bottle containing yellow fluid (identified as cleaning solution by S6HK) hanging on rusted open metal rack.
- 1 box of 200 square feet of clear saran wrap
- A brown stain smeared on shower chair (no mesh back or toilet seat). There were 2 additional shower chairs with toilet seats and mesh back
-1 bedside commode
-1 bucket used to catch human waste stored on the open metal rack containing clean patient supplies.
-1 low stool/chair stored on top of bedside commode
-1 shower chair with a black seat cushion that contained a dry, white colored substance on top and a small round tear in the cover of the cushion, exposing the cushion.
-1 wooden therapy board

On 1/9/18 at 3:15 p.m., S2DON toured the shower room with the surveyor. S2DON stated due to the lack of storage space the extra shower chairs were stored in the shower room. She stated the seat cushion and the wooden therapy board should not have been stored in the shower room. She also stated the spray bottle containing disinfectant cleaner should have been stored in the housekeeping area and should not have been kept in the shower room. S2DON verified the above findings and stated the room should have been cleaned and the shower chair containing the brown stain should have been cleaned and disinfected.

On 1/10/18 at 9:18 a.m., an interview was held with S1Adm. She stated the facility had been without maintenance staff for 3 months. After being made aware of the findings in the physical environment, S1Adm stated, "I'm not surpised".

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality and safety as evidenced by:
1) Patients' beds having a nurse call feature on the handrails that was non-functional for 4 of 10 patient beds; and
2) Patient's rooms having a nurse call feature on the wall that was non- functional for 2 of 9 patient rooms.

Findings:

1) Patients' beds having a nurse call feature on the handrails that was non-functional.

Observations of the hospital patient care unit were made on 1/8/18 from 8:10 a.m. - 8:55 a.m. The observations revealed 4 patient beds with non-functional nurse call features on the siderail of the bed. The nurse call feature on the beds' siderails was pressed during the observation and no alert of any type was generated when it was pressed. S9CNA confirmed, during the observation, that the nurse call feature was non-functional on the siderails of the patient beds.

In an interview on 1/9/18 at 3:00 p.m. with S1Adm, she verified 4 of the hospital's patients' beds had nurse call features on the handrails that were non-functional. S1Adm reported patients and their families were instructed to use the call button on the cord.

2) Patient rooms having a nurse call feature on the wall that was non- functional.

On 1/8/18 at 8:15 a.m. upon initial walkthrough and inspection patient Room 409, a semi-private room per S1Adm, revealed the call bell attached to the wall for the first bed in the room was not operational.

On 1/8/18 at 8:35 a.m. observation of Room 408 revealed the wall call bell system had two call bell buttons in place and the call bell on the left was not functioning.

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 ensure hospital staff adhered to hospital infection control policies during performance of their duties;

3) failing to ensure equipment was free of breaks in integrity that would impair either cleaning or disinfection;

4) failing to ensure the patient's nourishment refrigerator was cleaned, maintained and free of expired food items;

5) failing to ensure the biohazard room remained locked preventing access to sharps needles and expired blood tubes were not available for use; and

6) failing to ensure the glucometer was properly cleaned with the approved disinfecting agents in between patient use.

Findings:

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

Observations made of the hospital on 1/8/18 from 8:10 a.m. - 8:55 a.m. revealed the following:
a. 3 bedside commodes stored in the community patient shower room.
b. Room 403 : 2 patient bed pans, unlabeled and not bagged individually, stacked one on top of the other, stored on the floor in the patient bathroom. The bed pan positioned on top contained visible stool. Further observation revealed a package of personal hygiene wipes, a pop-up contained of disinfecting wipes, and an open roll of toilet paper were stroed on top of the bedside commode. The above referenced findings were confirmed by S9CNA during the observation. S9CNA agreed that the bedpans should have been labeled with the patients' names, bagged individually, and should have been stored separately.
c. Room 404: P-trap missing from the sink in the room leaving the sink plumbing open and draining. A towel was noted on the floor with a blue pad on top of the towel to catch drain off when the sink was used. This finding was confirmed with S6HK (housekeeping) during the observation.
d. Room 407: 2 linen carts were observed to be uncovered. Further observation revealed 1 oscillating fan covered with grey fluffy matter

2) Failing to ensure hospital staff adhered to hospital infection control policies during performance of their duties.

Review of the hospital policy titled, "Quality Assessment and Performance Improvement: Infection Control", Policy Number: 02-02-03, revealed in part: Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves.

On 1/8/18 at 8:40 a.m. an observation was made of S6HK cleaning patient rooms. During the observation, S6HK was observed cleaning the toilet in Room 402 with a cloth towel sprayed with disinfectant spray. S6HK left the room with the same gloves on, went to the cleaning supply cart, retrieved paper towels, and proceeded to clean the sink and the mirror with the same gloves on. S6HK was then observed entering Room 404 with the same gloves on. She mopped the floor, then cleaned the bedside table and bedside cabinet with the same gloves and towels. S6HK was not observed performing hand hygiene or changing her gloves when going from task to task throughout the observation.

In an interview on 1/10/18 at 11:00 a.m. with S2DON, she indicated it was her expectation that staff would perform hand hygiene before and after glove usage and when changing tasks. She also indicated staff should have been changing gloves and towels between tasks.

3) Failing to ensure equipment was free of breaks in integrity that would impair either cleaning or disinfection.

Review of the hospital policy titled "Quality Assessment and Performance Improvement Infection Control", Policy Number 02-02-03, revealed in part: Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/ sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned, and disinfected or sterilized.

On 1/8/18 at 10:20 a.m. an observation was made of a stand assist device with a torn padding cover and exposed padding.

In an interview on 1/9/18 at 9:40 a.m. S8PT stated the stand assist device was used for patients and the exposed padding could not be appropriately cleaned.

In an interview on 1/9/18 at 10:50 a.m. S2DON stated the stand assist device could not be appropriately cleaned and would need re-covering.

4). Failing to ensure the patient's nourishment refrigerator was cleaned, maintained and free of expired food items.

On 1/8/18 at 4:02 p.m., the patient's refrigerator located in the dining room was observed with S2DON. The following was identified:
a. Dried sticky red, orange and brown stains on the shelves
b. 5 individual cartons of Skim Milk with dated with "Best by 1/4/18"
c. 1 individual carton of Vitamin D Milk dated with "Best by 1/6/18"
d. 3 - 8 oz. Glucerna Strawberry Shakes dated 12/1/2017

During the observation, S2DON verified the expired food items should have been discarded and the refrigerator should have been cleaned.

5). Failing to ensure the biohazard room remained locked preventing access to sharps/needles and expired blood tubes were not available for use.

On 1/9/18 at 1:30 p.m., S2DON showed the surveyor the hospital's biohazard room that was located in the front lobby of the hospital. S1Adm was sitting the office area next to the biohazard room. Upon entering the room, the door to the biohazard room was unlocked. When asked, S1Adm stated everyone including the public has access to the lobby during business hours. The following observations were made:
1 - Red top blood tube - expired 1/2015
11 - Red top blood tubes - expired 10/8/17
18 - Red top blood tubes - expired 9/2017
50 - Gray top blood tubes - expired 3/2017
25 - Gray top blood tubes - expired 9/2015
15 - Purple top blood tubes -expired 7/2016
50 - Blue top blood tubes - expired 5/9/17
50 - Blue top blood tubes - expired 12/2016
38 - Blue top blood tubes - expired 8/2015
11 - Green top blood tubes - expired 8/2015
3 - Hemocult cards - expired 7/2014
5 ½ boxes of used Vacutainer Blood Collection needles unsecured

During the observation, S2DON stated the door remained unlocked at all times due to not having a key to lock the door. S2DON also verified the items listed above should have been discarded and not available for use.

6). Failing to ensure the glucometer was properly cleaned with an approved disinfecting agent in between patient use.

Review of the hospital's "Quality Assessment & Performance Improvement: Infection Control" policy, revealed in part:
Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices
Process noncritical patient-care devices using a disinfectant and the concentration of germicide. Disinfect noncritical medical devices ...with an EPA registered hospital disinfectant using the label's safety precautions and use directions .... Ensure that, at a minimum, noncritical patient-care devices are disinfected on a regular basis (after use on each patient).

Review of the EVENCARE G2 manufacturer's recommendation guide revealed in part:
Cleaning and Disinfecting your EVENCARE G2 Meter
...The following products are validated for disinfecting the EVENCARE G2 meter ....:
- Dispatch Hospital Cleaner Disinfectant Towels with Bleach ....
- Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol ....
- Clorox Healthcare Bleach Germicidal and Disinfectant Wipes ....
- Medline Micro-Kill Bleach Germicidal Bleach Wipes ....
Other EPA registered wipes may be used for disinfecting the EVENCARE G2 system ....

On 1/9/18 at 3:20 p.m., an interview was held with S17RN. S17RN stated the glucometer was cleaned with an alcohol pad.

On 1/9/18 at 3:30 p.m., an interview was held with S10LPN. He stated he cleaned the glucometer with alcohol pads after each patient use.

On 1/9/18 at 3:50 p.m., S10LPN was observed performing an accuchek on Patient #2. S10LPN gathered the necessary items including the glucometer out of the top drawer of the medication cart. While gathering the equipment, S17RN had told S10LPN not to forget to clean the glucometer with an alcohol pad. After obtaining Patient #2's blood sample, the LPN cleaned only the end of glucometer where the test strip was inserted with a 2 x 2 alcohol pad.

On 1/9/18 at 4:05 p.m., S10LPN was observed repeating the same procedure referenced above on Patient #1. After obtaining Patient 1#'s blood sample and completing the procedure, S10LPN cleaned only the end of glucometer where the test strip was inserted with a 2 x 2 alcohol pad.

On 1/9/18 at 4:35 p.m., an interview was held with S2DON. S10LPN was present during the interview. After review of the manufacturer's recommendations, she verified S10LPN should not have used an alcohol pad to clean and disinfect the glucometer. S2DON also verified the S10LPN should have cleaned the entire glucometer instead of a portion of it.



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Based on record review and interview, the hospital failed to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preserving, storage and distribution of eyes of potential donors.

Findings:

Review of the hospital's list of contracts revealed no documented evidence of a contractual agreement with an eye bank.

In an interview on 1/10/18 at 10:46 a.m. with S1Adm, she verified there was no eye bank contract prior to the beginning of the survey on 1/8/18.

Based on record reviews and interview, the hospital failed to ensure a physician was appointed as the Director of the hospital's Respiratory Care Services.

Findings:

Review of S4MedDir's credentilaing file revealed no documented evidence that he had been appointed to serve as the hospital's Director of Respiratory Care Services.

In an interview on 1/10/18 at 11:00 a.m., with S1Adm, she stated S4MedDir was to be named the hospital's Director of Respiratory Care Services. She explained S16MD was the former director, however, she was no longer working at the hospital as of December 20, 2017. S1Adm confirmed the governing board had not yet met to appoint S4MedDir as the Director of Respiratory Care Services.