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Based on interview with Patient #10, review of the Policy No.CSI-2, review of the Patient Grievance Complaint Form and Patient Grievance Investigation Form, it was determined the facility failed to protect Patient #10 from suspicions of abuse and/or harassment during the investigation conducted by the facility. That failed practice caused Patient #10 to retract her statement and had the potential to affect all 16 patients on census. The findings follow:

A. Review of the Patient Grievance Complaint form dated 09-30-10 revealed:
1) An allegation of abuse on Patient #10 was reported on 09-29-10.
2) Facility interview of Patient #10 on 09-30-10 at 1420 revealed Patient #10 stated Nurse #1 was poking around and wished he had said something. It made her feel different so she said something to a few people and it has just blown out of proportion.
3) Nurse #1 was interviewed on 10-01-10 and he said whatever he had heard was 2nd or 3rd person.
B. Review of the Patient Grievance Investigation Form dated 10-07-10 revealed:
1) Staff interviews were not conducted until 10-07-10, nine days after the initial report of possible abuse.
2) Two patient (Patient #3 and Patient #13) interviews were conducted by facility staff but there was no date or time the interviews were conducted. There was no evidence Patient #3 and Patient #13 were patients of Nurse #1.
3) Review of the Employee Counseling Record dated 10-02-10 under Action Taken "Employee reassigned (not to take care of this resident @ (at) this time.)
4) It was documented on the Patient Grievance Investigation Form dated 10-07-10, Nurse #1 did not work during the investigation. Review of the Nurse staffing sheets reflected Nurse #1 did work during the investigation on 10-02-10 and 10-05-10 and took care of patients.
The above was verified by the Director of Clinical Services 10-08-10.

Based on interview, review of staffing assignment sheets, review of current patient list and review of personnel files, the director of nursing did not assure nursing staff were assigned to care for patients based on the established acuity system and failed to assure 3 (Registered Nurse #1-#3) of 10 licensed nursing staff had completed a competency skills checklist before independently caring for patients. The failed practice had the potential to affect patients of not being evaluated for their level of care, of having staff assigned to deliver the care and receive care from competently trained staff. The failed practice had the potential to affect all 16 patients on census. The findings follow:

A. Review of Policy and Procedure No. CS8-5 Nurse Staffing (Acuity) revealed the acuity system divided patients into various classifications using different criteria, which determined the severity of illness and intensity of service each patient needed from direct care providers within the hospital. Education, experience and/or competency were summarized on the Nursing Staff Competency Form and were utilized in making patient care patterns.
B. Review of the Daily Staffing Worksheets from 09/16/10 thru 10/06/10 revealed there were no room numbers or patient names to determine which staff were assigned to which patients. There was no evidence of the patients' acuity level to assure the type and number of nursing personnel were dispersed to care for each patient.
C. At 1450 on 10-08-10, Charge Nurse #1 verified there were no staffing sheets that reflected which nursing staff was assigned to which patients. At 1455 on 10-08-10, Charge Nurse #1 verified there was no policy, form or guideline used to determine the needs of the patients or if the staff were qualified to care for the patient.
D. Review of the 10 personnel files for nursing staff revealed three files for three Registered Nurses contained no check list of skills.
Registered Nurse 1 was hired 04-06-10, Registered Nurse 2 was hired 10-30-08 and Registered Nurse 3 was hired 02-02-10. The three Registered Nurses were currently working and caring for patients.

Based on review of 16 clinical records and interview, it was determined there were not adequate numbers of licensed Registered Nurses, Licensed Practical Nurses and other personnel to provide nursing care to all patients as needed. That failed practice had the potential to affect all 16 patients on census. The findings follow:

A. Policy/Procedure No IC-20 Central Venous Access Device dated 11/11/09 reflected the following:
1) Under J. Routine Maintenance and Care: 1. Tubing and filter change every 72 hours; label the tubing with the date, time and initials.
2) Under K. Site Care and Dressing Change 1. Dressing to be changed every 7 days and PRN with occlusive dressing.
B. Patient #9 had a left CVL (Central Venous Line) placed on 08-21-10. There was no evidence the CVL tubing was changed on 08-24-10 or 08-28-10 as required by policy.
C. Patient #13 had a left CVL placed on 09-23-10. There was no evidence the CVL
tubing was changed 09-26-10, 09-29-10, 10-02-10 or 10-05-10. There was no evidence the CVL dressing was changed 09-30-10 or 10-05-10 as required by policy.
D. Patient # 6 had a left CVL on 08-18-10. There was no evidence of a tubing change on 08-22-10, 08-25-10 or 08-30-10 as required by policy. The was no evidence of a dressing change on 08-25-10 as required by policy.
E. Patient #7 had a right CVL on 09-01-10. There was no evidence of a dressing change on 09-08-10, 09-19-10 or 09-26-10 as required by policy.

Based on review of policies and procedures, review of 16 clinical records and interview, it was determined a Registered Nurse failed to supervise and evaluate the nursing care in that the central venous line (CVL) tubing and dressing change were not changed per facility policy and procedure for three of three (#6, #7 and #9) patients with CVL. The failed practice had the potential to cause an infection and the central line insertion site or bacteremia. The failed practice had the potential to affect all 16 patients on census. The findings follow:

A. Policy/Procedure No IC-20 Central Venous Access Device dated 11/11/09 reflected the following:
1) Under J. Routine Maintenance and Care: 1. Tubing and filter change every 72 hours; label the tubing with the date, time and initials.
2) Under K. Site Care and Dressing Change 1. Dressing to be changed every 7 days and PRN with occlusive dressing.
B. Patient #9 had a left CVL (Central Venous Line) placed on 08-21-10. There was no evidence the CVL tubing was changed on 08-24-10 or 08-28-10 as required by policy.
C. Patient #13 had a left CVL placed on 09-23-10. There was no evidence the CVL
tubing was changed 09-26-10, 09-29-10, 10-02-10 or 10-05-10. There was no evidence the CVL dressing was changed 09-30-10 or 10-05-10 as required by policy.
D. Patient # 6 had a left CVL on 08-18-10. There was no evidence of a tubing change on 08-22-10, 08-25-10 or 08-30-10 as required by policy. The was no evidence of a dressing change on 08-25-10 as required by policy.
E. Patient #7 had a right CVL on 09-01-10. There was no evidence of a dressing change on 09-08-10, 09-19-10 or 09-26-10 as required by policy.

Based on review of Policy No. CS7-9, review of the Negative Pressure Monitoring Log and interview it was determined the facility failed to conduct pressure readings daily and failed to provide corrective action when negative pressure readings were positive. That failed practice had the potential to spread airborne infections to all employees, visitors and patients on census. The findings follow:

A. Policy No CS7-9 Negative Pressure Log was reviewed. The policy reflected the negative pressure in rooms 2221 and 2222 would be monitored daily. The records for the Negative Air Pressure Log were produced for review. The Negative Pressure Log revealed only documentation of one reading. There was no way of knowing from 12/01/09 to 10/08/10 whether the negative pressure reading were for room 2221 or 2222.
B. The Negative Pressure Log reflected the following:
01) December 2009-16 of 31 days reflected no pressure readings. Of the 15 days recorded 5 readings were recorded as + (positive) readings with no corrective action.
02) January 2010-23 of 31 days reflected no pressure readings.
03) February 2010-27 of 28 days reflected no pressure readings.
04) March 2010-18 days reflected no pressure readings. Of the 13 days recorded 1 reading reflected a + reading with no corrective action.
05) April 2010-10 of 30 days reflected no pressure readings.
06) May 2010-21 of 31 days reflected no pressure readings. Of the 10 recorded readings 1 of the readings reflected a + reading with no corrective action.
07) June 2010-27 of 30 days reflected no pressure readings.
08) July 2010- 27 of 31 days reflected no pressure readings.
09) August 2010-2 of 31 days reflected no pressure readings.
10) September 2010- 14 of 30 days reflected no pressure readings.
11) October 2010 -3 of 8 days reflected no pressure readings.
C. The Infection Control Nurse verified the above findings on 10-07-10 at 1320.

Based on review of Incident Accident Reports, review of policies and procedures, review of clinical records and interview, it was determined adverse patient events were not reported, analyzed and tracked. Review of 16 of 16 clinical records revealed three of three (Patient #1-#3) adverse patient events were not reported. Failure to report, analyze or track adverse patient events prevented the facility from identifying root cause and implement correction action to improve patient outcome. The failed practice had the potential to affect all 16 patients on census and patients admitted to the facility. Findings follow:

A. Policy and Procedure No.CS-1 Accident and Incident Occurrence Reporting revealed:
1) "Definition: An occurrence is an unusual event or accident involving patients, visitors, staff or other persons or property."
2) Procedure: "1. f. The Hospital employee who identifies the occurrence is responsible for initiating the occurrence report and reporting it to the immediate Supervisor or other appropriate person."
3) Reporting Patient Occurrences: "a. All occurrences must be reported, in writing, by the employee involved or the employee who discovers the unusual event. If there are serious adverse consequences, the Risk Manager must be notified immediately."
B. Review of 3 discharged patients (#4, #8 and #9) and 13 current patients (1, #2, #3, #5, #6, #7, #10, #11, #12, #13, #14, #15 and #16) revealed 4 (#8, #5 and #10) adverse patient events were not reported.
1) Patient #8: Review of the Nurses Notes dated 04-26-10 at 1200 revealed patient wanted out of chair and tried to get up by himself. A technician went in to help and prevented the patient from falling by easing him to the floor. More help was called for and a nurse went into room. The patient could not help with standing up so two more people came in and they got the patient back to bed.
2) Patient #5: Review of the Interdisciplinary Progress Notes on 10-07-10 (no time noted) revealed the patient slide out of bed.
3) Patient #10: Review of the Nurses Notes dated 08-25-10 at 0130 revealed the patient was found sitting on the floor near the bed asleep. The patient stated she was trying to get to a cooler place.
C. On 10-07-10 all incident and accident reports were requested for the past six months for review. Four reports were presented for review dated 04-11-10, 05-07-10, 09-30-10 and 10-04-10 which did not include the adverse events for Patient #5, #8 and #10.