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Based on record review and interview, the hospital failed to ensure that nursing personnel were licensed, CPR, and/or ACLS certified, in that,

A) 7 of 13 nurses (Personnel #2, #9, #12, #13, #14, #15, and #17) did not have license verification,

B) 7 of 13 nurses (Personnel #2, #6, #8, #13, #14, #17, and #18) did not have CPR certification, and

C) 12 of 13 nurses (Personnel #2, #6, #8, #9, #10, #11, #12, #13, #14, #15, #17, and #18) did not have ACLS certification from 2/19/14 through 3/11/14.

Findings Included:

The following registered nurse files were reviewed on 3/11/14 at 3:00 PM:

Personnel #2's (hire date 3/11/13) record contained no RN license verification, and no CPR or ACLS card.

Personnel #6's (hire date 1/2/14) record contained no ACLS or CPR card.

Personnel #8's (hire date 4/03/13) record contained no CPR or ACLS card.

Personnel #9's (hire date 4/20/11) record contained an expired RN license verification, and no ACLS card.

Personnel #10's (hire date 9/04/13) record contained no ACLS card.

Personnel #11's (hire date 12/31/13) record contained no ACLS card.

Personnel #12's (hire date 2/18/13) record contained no RN license verification, and no ACLS card.

Personnel #13's (hire date 10/04/12) record contained an expired CPR card, ACLS card, and RN license verification.

Personnel #14's (hire date 2/15/12) record contained a CPR card, ACLS card, and RN license verification, all of which were expired.

Personnel #15's (hire date 11/06/13) record contained no RN license verification, and no ACLS card.

Personnel #17's (hire date 7/15/13) record contained a CPR card, ACLS card, and RN license verification, all of which were expired.

Personnel #18's (hire date 8/07/12) record contained an expired CPR card and an expired ACLS card.

During an interview on 3/12/14 at 12:00 PM, Personnel #2 was asked how long she had done the nursing schedule. Personnel #2 said since July 2013. When asked if she received Cardio-pulmonary Resuscitation (CPR) or Advanced Cardio-vascular Life Support (ACLS) certification expiration information on personnel, Personnel #2 said no. When asked her understanding of why expiring certification and tests were important, Personnel #2 said the personnel should not work until they were compliant.

The "Provision of Care Code Blue Policies" dated 1/05/11, required "...All registered nurses, licensed vocational nurses...are required to be trained in the latest techniques of C.P.R...training each year within one month of his/her anniversary date...Code team responsibilities...Team leader (ACLS Certified, Dysrhythmias Knowledge Required)..."

The "Nurse Staffing Plan..." revision date 2/18/13, required "...At least one person who is qualified by training to perform advanced cardiac life support and administer emergency drugs shall be on duty each shift."

Based on records review and interview, the hospital failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, in that, 12 of 12 complaint/grievance forms (Patient #2, #11, #12, #13, #14, #15, #16 and five complaints without fully identified patients) from 08/01/13 through 03/11/14 were found without the hospital following the grievance process and sending a written response to the complainant.

Findings Included:

Twelve complaint and grievance forms were reviewed from 08/01/13 through 03/11/14 by the surveyor. There were none reviewed by CEO/Quality Council. There were no written response to the complainant.

During an interview on 3/11/14 at 11:30 AM, Personnel #1 stated he had found the above listed complaints/grievance reports in a drawer and they had not been reported to the CEO or Quality Council.

In a fax received on 3/14/14 at 7:30 AM, Personnel #1 stated, "...I have had no grievances that have been formally presented to me..."

The "Patient Rights - Complaints and Grievance" policy, dated 1/5/11, required "Concerns related to a patient's care and services will be addressed in a timely, reasonable, and consistent manner...a complaint will be considered a patient grievance if...cannot be resolved at the time of the complaint by staff present...postponed for later resolution...referred to other staff for later resolution...requires investigation to substantiate the complaint...requires further actions for resolution...in no case shall a written response to the patient or patient's representative be made later than 7 days following the initial complaint..."

Based on observation, record review and interview, the facility failed to ensure that 4 of 4 patients (Patient #8, #9, #10, and #11) recieved care in a safe setting, in that, 2 of 2 nurses observed (Personnel #11 and #16) did not follow hand hygiene and equipment disinfection procedures on 3/11/14.

Findings Included:

During an observation of three patient's medication passes (room 221, 219 and 222) on 3/11/14 at 1:30 PM, Personnel #16 did not wash her hands or use foam (hand hygiene) when she entered or exited the med room. Personnel #16 did not complete hand hygiene when she entered room 221. Personnel #16 did not disinfect the medication administration record (MAR) and pill cutter after use in the patient's room and prior to returning them to the nurse station.

During the second med pass, Personnel #16 did not complete hand hygiene when she entered or exited the med room. Personnel #16 did not complete hand hygiene when she entered room 219. Personnel #16 did not disinfect the MAR after use in the patient's room and prior to returning them to the nurse station.

During the third med pass, Personnel #16 did not complete hand hygiene when she entered or exited the med room. Personnel #16 did not complete hand hygiene when she entered room 222. Personnel #16 took the B/P. Personnel #16 used her gloved hands to document on the MAR. Personnel #16 removed her gloves and did not complete hand hygiene. Personnel #16 did not disinfect the MAR and B/P machine after use in the patient's room and prior to returning them to the nurse station.

During an observation of a med pass for room 224 on 3/11/14 at 1:55 PM, Personnel #11 did not complete hand hygiene when she entered and exited the med room. Personnel #11 removed her gloves after the med administration and did not complete hand hygiene. Personnel #11 left the room, picked up the bottle of cleaning wipes from the sink in the hall and brought the bottle to the patient's bedside table. Personnel #11 brought the wipes back to the sink in the hall. Personnel #11 did not disinfect the MAR or the bottle of wipes after use in the patient's room.

During an interview on 3/11/2014 at 2:13 PM, Personnel #16 was informed of the observations of her not disinfecting her hands and the items taken to the room. Personnel #16 confirmed the observations and stated, "Yes ma'am, I will watch that."

During an interview on 3/11/2014 at 2:16 PM, Personnel #11 was informed of the observations of her not disinfecting her hands and items taken to the room. Personnel #11 confirmed the observations. When asked about taking the bottle of disinfection wipes into the room, Personnel #11 stated Personnel #11 should not have taken the bottle of wipes into the room.

The "Infection Prevention Plan: Scope of Services" undated, required "...the equipment must be cleaned and disinfected before use on another patient using hospital approved disinfectant...cleaned in the patient's room, then brought out and left to air dry..."

The "Universal /Standard Precautions & Hand Washing" policy, revised date 1/24/13, required "Hands must be washed ...before and after patient contact...after removing gloves...waterless hand antiseptic may be used in place of soap and water..."

Based on record review and interview, the facility failed to analyze the cause, implement preventive actions and mechanisms that include feedback for medical errors and adverse patient events from 10/01/13 through 02/11/14, in that, 43 of 43 incident reports were found not reviewed by the CEO/Quality Council.

Findings Included:

The 43 incident reports from 10/01/13 through 02/11/14 were reviewed by the surveyor including the following adverse events:

There were 13 reports including five falls (Patient #17, #18, #19, #21, and #22), seven medication errors (Patient #23, #24, #25, #26, and #27 x 3), and one other issue (Patient #20) in October.

There were 4 reports including three falls (Patient #29, #30, and #31), and one medication error (Patient #28) in November.

There were 10 reports including eight falls (Patient #14, #32 x3, #33 x 3, and #34), one skin breakdown (Patient #36), and one blood sugar of 34 not reported to the MD (Patient #35) in December.

There were 10 reports including seven falls (Patient # 14 x 3, #37, #38, #39, and #46), one unsafe condition in facility (Patient #40), and two medication errors (Patient #41 and #42) with one coming from a patient complaint in January.

There were 6 reports including four falls (Patient #42 x 2, #44, and #45), one patient injury due to care given (Patient #42), and one employee injury (Personnel #21) in February.

These 43 reports were not reviewed by the CEO/Quality Council within 30 days of notice required by the policy.

During an interview on 3/11/14 at 11:30 AM, Personnel #1 was informed of the above findings. Personnel #1 stated he had found the above listed incident reports in a drawer and they had not been reported to Quality Council.

The "Patient Rights and Admission" policy, dated 1/05/11, required "...to treat patients...protect those rights as defined in the attached Patient's Bill of Rights..." The attached Bill of Rights, undated, required "...the right to receive care in a safe setting."

The "Patient Safety Plan" revised date 1/31/13, required "...Once the health care worker has reported internally. The Quality/safety officer will conduct an investigation...provide the CEO with the results of its investigation no later than thirty (30) days after receiving notice..."

Based on record review and interview, the hospital failed to verify valid and current licensure, in that, 7 of 13 nurse files (Personnel #2, #9, #12, #13, #14, #15, and #17) did not contain current license verification.

Findings Included:


The following registered nurse files were reviewed on 3/11/14 at 3:00 PM:

Personnel #2's (hire date 3/11/13) record contained no RN license verification.

Personnel #9's (hire date 4/20/11) record contained an expired RN license verification.

Personnel #12's (hire date 2/18/13) record contained no RN license verification.

Personnel #13's (hire date 10/04/12) record contained an expired RN license verification.

Personnel #14's (hire date 2/15/12) record contained an expired RN license verification.

Personnel #15's (hire date 11/06/13) record contained no RN license verification.

Personnel #17's (hire date 7/15/13) record contained an expired RN license verification.
During an interview on 3/11/14 at 11:30 AM, Personnel #1 was informed of the above findings, Personnel #1 confirmed the findings.

Based on observation, record review and interview, the facility failed to ensure an acceptable level of safety and quality for the facility and equipment was maintained, in that,

A) the 2 of 2 negative pressure isolation rooms (Room 214 and 216) were not maintained with adequate negative pressure,

B) the Domestic hot water temperature for hand washing sinks (daily random sink checks) was not maintained at 105 degrees Fahrenheit (*F) from 12/1/13 through 3/07/14,

C) the fire drills were not performed for 2 of 2 quarters of 2013 (3rd and 4th quarters of 2013),

D) the code blue drills were not performed for 2 of 2 quarters of 2013 (3rd and 4th quarters of 2013), and

E) the infection control meeting had not been held for 3 of 3 quarters of 2013 (2nd, 3rd, and 4th quarters of 2013).

Findings Included:

A) During a tour and interview on 3/11/14 at 10:10 AM, Personnel #3 reported that Room 214 and 216 were negative pressure rooms. When asked about the negative pressure monitoring and the maintenance records of the air exchange in these rooms, Personnel #3 said he had no records of either.

B) During a tour and interview on 3/11/14 at 10:10 AM, Personnel #3 reported randomly checking daily domestic hot water temperatures on the nursing floor. The random check was observed on 3/11/14 at 10:29 AM, the temperature was 113 *F in room 216.

The domestic hot water temperature log was reviewed from 12/1/13 through 3/07/14. The temperature log sheet showed the temperature < & > 105 *F, not 105 *F.

The "Domestic Hot Water Temperature Inspections" policy, dated 1/5/11, required "The operating hot water temperature for the facility shall be 105 degrees. Daily tests at point of use shall be performed and recorded..."

C) The last fire drill was dated 7/19/13. There were no fire drills since 7/19/13.

During an interview on 3/12/14 at 4:00 PM, Personnel #3 was informed the last fire drill record was from 7/19/13. Personnel #3 stated yes.

The "Environment of Care Emergency Operations Plan Overview" policy, dated 1/05/11, required "CODE RED - Fire...drills...at least once per quarter per shift..."

D) The code blue drill records for 9/13/12, 2/20/13, and 5/22/13 were reviewed. There had been no code blue drills since 5/22/13.

During an interview on 3/12/14 at 12:00 PM, Personnel #2 was asked about the hospital code blue drills. Personnel #2 stated the drills were quarterly. When asked why the last drill was 5/22/13, Personnel #2 stated she did not get them done.

E) The infection control minutes were reviewed for 4/18/13. There had been no infection control meeting since 4/18/13.

The surveyor asked for infection control minutes since 4/18/13, none were provided.

Based on record review and interview, the facility failed to ensure adequate nursing personnel were qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility from 2/19/14 through 03/11/14, in that,

A) the nursing personnel files did not include ACLS cards for 11 of 12 nurses (Personnel #6, #8, #9, #10, #11, #12, #13, #14, #15, #17, and #18), and CPR cards for 6 of 12 nurses (Personnel #6, #8, #13, #14, #17, and #18) from 2/19/14 through 03/11/14,

B) the staffing schedule did not include a verified ACLS nurse for 32 of 42 AM and PM patient care shifts from 2/19/14 through 03/11/14.

Findings Included:

A) The registered nurse files were reviewed on 3/11/14 at 3:00 PM:

Personnel #6's (hire date 1/2/14) record contained no ACLS or CPR card.

Personnel #8's (hire date 4/03/13) record contained no CPR or ACLS card.

Personnel #9's (hire date 4/20/11) record contained no ACLS card.

Personnel #10's (hire date 9/04/13) record contained no ACLS card.

Personnel #11's (hire date 12/31/13) record contained no ACLS card.

Personnel #12's (hire date 2/18/13) record contained no ACLS card.

Personnel #13's (hire date 10/04/12) record contained an expired CPR and ACLS card.

Personnel #14's (hire date 2/15/12) record contained an expired CPR and ACLS card.

Personnel #15's (hire date 11/06/13) record contained no ACLS card.

Personnel #17's (hire date 7/15/13) record contained an expired CPR and ACLS card.

Personnel #18's (hire date 8/07/12) record contained an expired CPR and ACLS card.

B) The staffing reports from 2/19/14 through 3/11/14 were reviewed. The shifts that did not have a staffed ACLS nurse included 2/19/14 PM, 2/20/14 AM and PM, 2/21/14 PM, 2/22/14 AM and PM, 2/23/14 AM and PM, 2/24/14 AM and PM, 2/25/14 PM, 2/26/14 PM, 2/27/14 AM and PM, 2/28/14 AM and PM, 3/01/14 PM, 3/02/14 PM, 3/03/14 AM and PM, 3/04/14 AM and PM, 3/05/14 AM and PM, 3/06/14 PM, 3/07/14 PM, 3/08/14 AM and PM, 3/09/14 AM and PM, 3/10/14 PM, and 3/11/14 PM. Twelve nurses had been charge/code team lead during this period. Personnel #6, #8, #9, #10, #11, #12, #13, #14, #15, #17, and #18 were not ACLS certified from 2/19/14 through 03/11/14. Personnel #6, #8, #13, #14, #17, and #18 were not CPR certified from 2/19/14 through 03/11/14.

During an interview on 3/12/14 at 12:00 PM, Personnel #2 was informed of the above nurses without ACLS certification, and the lack of an ACLS nurse scheduled for each shift. When asked about the nurse's expired ACLS certifications and the nurses without ACLS certification, Personnel #2 said, "We don't have to have an ACLS nurse each shift."

The "Provision of Care Code Blue Policies" dated 1/05/11, required "...All registered nurses, licensed vocational nurses...are required to be trained in the latest techniques of C.P.R...training each year within one month of his/her anniversary date...Code team responsibilities...Team leader (ACLS Certified, Dysrhythmias Knowledge Required)..."

The "Nurse Staffing Plan..." revision date 2/18/13, required "...At least one person who is qualified by training to perform advanced cardiac life support and administer emergency drugs shall be on duty each shift."