HospitalInspections.org

Based on observation, record review, and interviews the facility failed to

A. have adequate staff in the Emergency Department (ED) to ensure patient safety, needs anticipated by the facility, and no clear chain of command.

See Tag A0393

B. ensure a Nursing Care Plan was developed, current, addressed physiological and psychosocial factors, and patient discharge planning for each patient in 5(#32, 31, 33, 20, and 22) out of 5(#32, 31, 33, 20, and 22) patient charts.

See Tag A0396

Based on record review and interview, the facility failed to

A. ensure the facility's medical records were kept secure and confidential.

See Tag A0441

B. follow its own policy and procedures to ensure physician orders have been signed and authenticated.

See Tag A0454

C. have History and Physical (H&P) completed and documented within 24 hours after admission.

See Tag A0458

Based on Utilization Review (UR) Meeting Minutes and interview the facility failed to
A. have a UR plan or meeting minutes or have a functioning UR committee.
See Tag A0654
B. have a functioning UR plan that provided review for medical necessity.
See Tag A0655
C. have a functioning UR plan or committee to determine that an admission or continued stay was not medically necessary.
See Tag A0656
D. have a functioning UR plan or committee to determine that an extended stay has had a periodic review.
See Tag A0657
E. have a functioning UR plan or committee to determine medical necessity and services available.
See Tag A0658

Based on interview, observation and record review the facility failed to

A. provide an Infection Control Professional (ICP) qualified by training in 1 of 1 ICP.

Reference A 0748


B. demonstrate a hospital wide infection control program evidenced by 2 of 6 departments reviewed (Dietary, and nursing).

Reference A 0749


C. provide evidence the Infection Control Program reviewed by the Quality committee and forwarded to the leadership of the hospital involved all departments (hospital wide) of the hospital.

Reference A 0756

Based on observation, staffing schedules, and interviews the facility failed to have adequate staff in the Emergency Department (ED) to ensure patient safety, needs anticipated by the facility, and no clear chain of command.

See Tag A1112

Based on record review and interview the facility failed to follow its own policy and procedures for respiratory care services.
See Tag A1152
appoint a director of respiratory care services.
See Tag A1153
appoint a director of respiratory care services, and failed to have an updated policy and procedure appropriate to the scope of service provided.
See Tag A1160
follow its own policy and procedures for respiratory care services.
See Tag A1161

Based on an interview the Governing Body failed to ensure a physician call schedule was created and posted for the facility at all times.
An interview with staff #1 on 9/4/2014 at 1:20 PM revealed there was no call schedule for physicians in the hospital. Staff #1 stated, "I have started a new call schedule and I will make sure it is kept up."

Based on interview and document review the facility failed to provide evidence of a grievance process being provided during the patient admission process for patient #1-#33 reviewed.

On 9/4/2014 at 9:30 AM in the conference room, review of Patient Medical Records for patients #1-#33 revealed a form with line items "A"-"M". Line item "M" was a statement that read "I have been given written information about my rights as a patient". In each record the patient initialed this line.

On 9/3/2014 11:00 AM in the conference room, review of the hospital's patient admission packet revealed the following; The facility provided admission information in both English and Spanish, however,

1. The English information for complaint resolution was faxed from another hospital and had not been updated to reflect accurate facility contact information. If a patient desired to submit a complaint the correct information and process was not made available to them.
2. The Spanish language admission packet held only the above mentioned Patient Rights form printed in Spanish. No other rights information was printed in Spanish and no complaint resolution was found on the form. The English version of Patient Rights form item "H" reads "I acknowledge I have received a copy of the Medicare/Champus rights". This Rights information was not provided in Spanish. The English version of line item "K" reads I have been given written materials about my rights to accept or refuse medical treatment and my rights to formulate Advanced Directives and have acknowledged whether or not I have executed an Advanced Directive..." This material was not provided in Spanish. The English version of line item "M" read "Patient Rights: I have been given written materials about my rights as a patient". This written material was not provided in Spanish.

The above findings were confirmed by staff #2.

Based on review of the Quality Assurance Performance Improvement (QAPI) reports and interviews the facility failed to identify problems and implement performance improvements in 14 out of 38 measures documented.
The QAPI report for July 30, 2014 revealed no reportable data, corrective actions, or performance improvement for the following;
1.) Healthcare Personnel Safety- No data for April, May, and June 2014.
2.) Pharmacy- Orders in comment field - No data for April, May, and June 2014.
3.) Pharmacy- Orders in comment field after hours- No data for April, May, and June 2014.
4.) Pharmacy- Open bottles not dated- No data for April, May, and June 2014.
5.) Pharmacy- Home narcotic sheet incomplete- No data for April, May, and June 2014.
6.) Radiology- Repeat film CR system- No data for April, May and June 2014.
7.) Housekeeping- ER Cleaning completeness - No data for April, May and June 2014.
8.) Housekeeping- Patient room cleaning completeness- No data for April, May and June 2014.
9.) Housekeeping- Sharp containers emptied in a timely manner- No data for April, May and June 2014.
10.) Human Resources- 30-60-90 day evaluations- No data for April, May and June 2014.
11.) Human Resources- Annual performance evaluations- No data for April, May and June 2014.
12.) RHC-Trinity- Non-narcotic prescriptions sent electronically- No data for April and May 2014.
13.) RHC-Trinity- Patients that are provided specific patient education resources- No data for April and May 2014.
14.) RHC-Trinity- Patients that have been provided a clinical summary- No data for April and May 2014.
Interview with Staff #1 on 9/3/14 at 10:00 AM revealed the CEO had conducted all the QAPI meetings and reported the QAPI to the board. Staff #1 stated, I'm not sure who will be picking up that piece I would guess it would be the interim administrator."
Interview with Staff #2 on 9/3/14 at 10:40 AM revealed he was not aware of who was following the QAPI.

Based on interview and record review the facility failed to provide evidence of a data driven Patient Safety Program for 3 quarters reviewed.

On 9/2/2014 at 1:30 PM in the conference room the Chief Nursing Officer staff #1 identified the hospital's safety officer was the Maintenance Supervisor.

On 9/3/2014 at 1:00 PM during environmental rounding the Maintenance Supervisor, staff #8, confirmed he was the Safety Officer. Further conversation revealed he was responsible for the physical plant maintenance, fire safety and emergency preparedness for the hospital.

Further questioning regarding the Safety Program for the hospital revealed he was not involved in patient safety other than the above mentioned duties. Staff #8 confirmed he was not involved in fall risks, medication errors, infection control risk, or adverse patient events. Staff #8 indicated the DON, Staff #1 handled all of that.

On 9/4/2014 at 9:00 AM in the conference room the meeting minutes for 3 quarters (9 months) were reviewed and revealed no evidence of a Patient Safety Program. The was no evidence of indicators to identify, and reduce patient falls, medication errors, or any other aspect of patient safety. There was no evidence data had been collected or analyzed, no evidence of measurable goals or targeted thresholds, and no evidence of a clear expectation of safety throughout the hospital.

Based on observation, staffing schedules, and interviews the facility failed to have adequate staff in the Emergency Department (ED) to ensure patient safety, needs anticipated by the facility, and no clear chain of command.
Review of the nursing schedule for the Emergency Department (ED) revealed there were two 12 hour shifts (7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM) in a 24 hour day. Each shift has one registered nurse (RN) and one licensed vocational nurse (LVN) on duty for a five bed ED. There was no staffing grid for the Emergency Department to allow the staff to fluctuate for an increase or decrease in patient census.
Review of the Governing Board Meeting Minutes on 5/15/2014 ER Report stated, "Staff #1 reported that the ER is doing good with no major problems. She said we have gone to minimal staffing to cut down on expenses."
On 9/4/2014 at 10:15 AM a tour of the ED was performed with Staff #1 and #2. There was an RN and LVN on duty. The RN must do all triages for the ED. The RN must leave the unit to go to the triage room located in the ED waiting room. The RN is out of sight and hearing range for the LVN and patients on the ED unit. The LVN is left alone with no RN supervision for at least 10 to 20 minutes.
Interview with staff #25 confirmed she leaves the LVN in the ED with no RN supervision to triage patients. Staff #25 confirmed if a patient were to decline or a Cardiac Arrest the LVN would have to leave the patient, go to a phone, and call for the RN. Staff #25 confirmed on weekends, holidays, and night shift there was no house supervisor or a designated RN in charge to make decisions. Staff #25 stated, "If we need something we have to call staff #1 and she will let us know."
Interview with staff #2 on 9/4/2014 at 11:00 AM confirmed the RN was leaving the unit unattended. Staff #2 stated, "I can see where this puts the RN, LVN, and patient at risk. I will try to move the triage room onto the unit."
Interview with staff #1 on 9/4/2014 at 11:15 AM revealed there was no staffing grid for the ED. Staff #1 stated, "I guess I didn ' t think about the RN leaving the LVN alone. I was told to decrease the staffing by the administrator." Staff #1 confirmed there was no house supervisor. Staff #1 stated, "I am on call 24/7. If they need something they just have to call me."

Based on interview and record review the facility failed to ensure the nursing department created and maintained current care plans, address psychological and psychosocial factors as well as discharge planning.This deficient practice was found in 11 (Pt. #1, #5, #6, #7, #10, #19, #20, #22, #31, #32, and #33) of 34 patients.
On 9/3/2014 at 10:45 AM in the conference room staff #1 indicated the electronic data entry program the hospital was using was not what they had hoped for and did not meet the need of the hospital or staff and did not permit documentation of nursing intervention.

On 9/4/2014 at 1:45 PM in the conference room the medical records for patient's #1-#34 were reviewed and revealed the following:

Pt #1 was admitted on 2/22/2014 for Asthma, Bronchitis, Chronic Obstructive Pulmonary Disease (COPD) and over weight. The initial Nursing Care Plan reflected No problem. On 2/24/2014 at 19:10 Staff RN staff #24's data entry read, Asthma-status inactive. Seven (7) days later on 3/3/2014 at 07:37 Registered Nurse, staff #20's data entry reflected "Problems associated to visit: "Congestive heart failure". There was no intervention noted or expectation of resolution. On 3/3/2014 at 15:21 Licensed Vocational Nurse (LVN), staff #23's data entry read outcomes "Effective Breathing, Effective Cardiac Output, Effective Fluid Volume and Effective Heart rate, Complete" . Patient #1 was discharged on 3/3/2014 at 15:18.

Pt #5 was admitted on 3/10/2014 at 15:04. The admitting diagnosis was "Shortness of Breath" (SOB). The initial Care plan entered by staff RN read "Problem: Dyspnea". There was no nursing interventions, not medical intervention, or outcome. There was no further Nursing Care Plan data entries. Pt #5 was discharge on 3/12/2014 The discharge summary indicated pt #5 was discharge on an increased does of oral diuretic. The discharge teaching was for SOB (Shortness of Breath).

Pt #6 was admitted on 3/13/2014 at 13:40 with the following diagnosis;Depression, uncontrolled Diabetes (admiring glucose 665 ), trace ketonuria, Azotemia, Mild dehydration, Temporomandibular joint arthralgia. cigarette abuse, Chronic Bronchitis, Elevated SGOT, Hypoalbuminemia, elevated alkaline phosphate, anemia, hypercholestrolemia, Athero- sclerotoic cardiovascular disease, History of schizophrenia vs drug related psychosis, hypertriglyceremia, hyponatremia. (seventeen (17) total contributing factors to admission. On 3/15/2014 Pt #6 ambulated outside to smoke even though the hospital and campus is a non smoking facility and fell. On 3/17/2014 the following document was located in the MR: "The Following Instructions are Recommended For You Condition: Staff/Faculty not liable for injuries d/t (do to) smoking outside. Doors may lock behind you and staff aren't responsible for opening doors. Smoking is not advised" There was no nursing care plan identified for any of the 17 previous diagnosis, the patient fall or smoking addiction.

Pt #7 was admitted on 3/23/2014 at 03:02. The admission diagnosis was fever (temperature) 102.1, rash, and headache with history indicating Lupus flare and Gout. On 3/23/2014 at 04:44 staff #26's data entry revealed nursing Care Plan problems as follows Lupus Erythematosus, Gout, Fever and headache. There were no interventions or outcomes documented. Pt #7 was discharged on 3/25/2014 with the following diagnosis: Systemic Lupus Erythematosus, Gout, West Nile virus by history, Epstein Barr virus, with resolved fever and headache.

Pt #10 was admitted on 4/13/2014 at 21:15, admitting diagnosis were Right ureteral calculi, gout and obesity. The Nursing Care Plan was initiated by staff #27 and the data entry read "Problem Name; Kidney stone". There was no intervention or resolutions identified. Pt #10 was discharged at 12:35 on 4/15/2014. On that date at 12:36 the following Expected outcome were documented; "No Falls", Effective Fluid Volume, and Effective Pain Control".

Pt #19 was admitted on 6/12/2014 at 16:45 with the following diagnosis: Hypotension-likely septic, sepsis due to multiple organ system involved, Right lower lobe pneumonia, Urinary tract infection,Hypomagnesemia. On 6/12/2014 at 18:24 the initial Nursing Care Plan was entered by staff RN #17. it read as follows: Problem Name; Low Blood Pressure, Infection, history of falls, and Dyspnea. There were no interventions noted. Data entry indicates pt #19 was discharge by transfer on 6/15/2014 at 11:20 AM to a higher level of care. The low blood pressure and infection was resolved by staff #20 on 6/15/2014 at 14:17. Then on 6/15/2014 at 14:19 Outcome details for Effective blood pressure was completed as met, effective breathing pattern was inactive and progressing, Effective heart rate was inactive and not met, No falls were completed and met, No infection was complete and met, documented by RN staff #20.


32143

Review of patient #20's chart revealed the nursing "Plan of Care Report" (Care Plan). On the Care Plan under the section "Plan of Care" stated, "No Plans Charted for Visit."
Patient #20 was admitted on 3/23/2014 at 6:11 PM. There was no short term, or long term goals. There were no details of expected outcomes and no discharge planning. Patient #20 received blood with no plan of care for blood administration.
Review of patient #22's chart revealed the nursing "Plan of Care Report" (Care Plan). On the Care Plan under the section "Plan of Care" stated, "No Plans Charted for Visit."
Patient #22 was admitted on 3/11/2014 at 2:05 PM. There was no short term, or long term goals. There were no details of expected outcomes and no discharge planning.
Review of patient #31's chart revealed the nursing "Plan of Care Report" (Care Plan). On the Care Plan under the section "Plan of Care" stated," No Plans Charted for Visit."
Patient #31 was admitted on 6/28/2014 at 4:58 AM. There was no short term or long term goals. There were no details of expected outcomes and no discharge planning.
Review of patient #32's chart revealed the nursing "Plan of Care Report" (Care Plan). On the Care Plan under the section "Plan of Care" stated," No Plans Charted for Visit." Patient #32 was admitted on 8/15/2014 at 9:10 PM. The care plan was not addressed until 8/16/2014 at 1:26 AM. There was no short term or long term goals. There were no details of expected outcomes and no discharge planning.
Review of patient #33's chart revealed the nursing "Plan of Care Report" (Care Plan). On the Care Plan under the section "Plan of Care" stated, "No Plans Charted for Visit." Patient #33 was admitted on 7/10/2014 at 6:30 PM. There was no short term, or long term goals. There were no details of expected outcomes and no discharge planning.
During an interview, Staff #1 confirmed these findings and agreed Nursing Care Plans were incomplete.

Based on interview and observation the facility failed to insure the security of patient records maintained in the Medical Records Department.

On 9/3/2014 at 2:30 PM, during a tour of the Medical Records Department, interview with the Director, staff #5, revealed volunteers worked in the department. During the subsequent conversation it was revealed that a volunteer had shredded eighteen (18) patient records that were not designated for destruction. The patients had not been made aware of the destruction of their medical record. Staff #5 confirmed the accidental destruction of patient records had not been submitted to the Quality committee for review and there had been no corrective action implemented outside of the department.

On 9/4/2014 at 11:30 Am while walking the back hallway near the Medical Records department the door to the department was observed open and a volunteer was observed filing records.

On 9/4/2014 at 1:45 PM policies for the Medical Record department revealed there was no policy identified allowing volunteers to provide their services within the department.

Staff #5 confirmed the volunteer had destroyed the eighteen patient record by mistake. The acting Administrator staff #2 was made aware of the destruction of patient records during the tour.

32143

Based on policy and procedure, medical record review reports, and interview the facility failed to follow its own policy and procedures to ensure physician orders have been signed and authenticated.

Review of the policy and procedure "Medical Records Department Procedures stated, "Verbal orders of authorized practitioners will be accepted and written or transcribed by qualified personnel if signed within 24 hours by the practitioner."

Review of the "Physician Activity Report" revealed 24 active physicians. The "Physician Activity Report" revealed discharged charts with 462 delinquent and 506 incomplete verbal and written orders ranging from 33 to 515 days.

An interview with staff #18 on 9/4/14 at 10:15 confirmed the delinquent and incomplete orders. Staff #18 stated, "We try to notify the physicians that they have delinquent orders. Sometimes we print out the orders, take them to the physicians, and scan them back in. There are no consequences for the physicians if they do not get their orders signed."

Based on medical record review and interviews the facility failed to have History and Physical (H&P) completed and documented within 24 hours after admission.

Review of the "Records Waiting for Dictation" log revealed 111 out of 839 medical records did not have a History and Physical. The "Records Waiting for Dictation" log revealed days waiting for the physician to complete a H&P ranged from 1 day to 544 days.

An interview with staff #18 on 9/4/14 at 10:15 confirmed the delinquent and incomplete H&P's. Staff #18 stated, "We try to notify the physicians that they have delinquent H&P's. There are no consequences for the physicians if they do not get their H&P's completed."

Based on observation, document review and interview the facility failed to

A. have adequately trained staff to provide pharmacy services 24 hours a day for the hospital.

Refer to A 0493

B. follow safe pharmacy guidelines in dispensing medication for all hospital patients.

Refer to A 0500

Based on interview and record review the facility failed to have adequately trained staff to provide pharmacy services 24 hours a day for the hospital.

On 9/3/2014 at 10:00 AM in the pharmacy, the pharmacy tech was interviewed and revealed the following:

Staff #9 was a Licensed Vocational Nurse who was also registered as a pharmacy tech. She had not taken the certification test to become a Certified Pharmacy Tech. Staff #9 indicated she had been the hospital's pharmacy tech for 1 month. When asked what training did she receive prior to beginning to work as the pharmacy tech she replied. "She went over the tech check off sheet with the pharmacist" and "the previous pharmacy tech told her what she needed to do, but that was done in bits and pieces as she was able to leave the floor".

The following Board of Pharmacy requirements for Pharmacy tech trainee's were reviewed

(2) instruction in the following areas and any additional areas appropriate to the duties of pharmacy technicians and pharmacy technician trainees in the pharmacy:
(A) Orientation;
(B) Job descriptions;
(C) Communication techniques;
(D) Laws and rules;
(E) Security and safety;
(F) Prescription drugs:
(i) Basic pharmaceutical nomenclature;
(ii) Dosage forms;
(G) Drug orders:
(i) Prescribes;
(ii) Directions for use;
(iii) Commonly-used abbreviations and symbols;
(iv) Number of dosage units;
(v) Strengths and systems of measurement;
(vi) Routes of administration;
(vii) Frequency of administration; and
(viii) Interpreting directions for use;
(H) Drug order preparation:
(i) Creating or updating patient medication records;
(ii) Entering drug order information into the computer or typing the label in a manual system;
(iii) Selecting the correct stock bottle;
(iv) Accurately counting or pouring the appropriate quantity of drug product;
(v) Selecting the proper container;
(vi) Affixing the prescription label;
(vii) Affixing auxiliary labels, if indicated; and
(viii) Preparing the finished product for inspection and final check by pharmacists;
(I) Other functions;
(J) Drug product prepackaging;
(K) Written policy and guidelines for use of and supervision of pharmacy technicians and pharmacy technician trainees; and
(L) Confidential patient medication records.

When asked if she had been given any time with the pharmacist for education in Board of Pharmacy training requirements she replied "no". Review of Staff #9 Employment file revealed a certificate as a Registered Pharmacy Tech and a Job description for Pharmacy tech.

Further interview revealed there was no one on call for the pharmacy after staff #9 clocked off her shift. The previous pharmacy tech had been on call but they (hospital leadership) did not want to continue that when she began working in the pharmacy. The facility did not have a position for a house supervisor after hours. If a physician ordered something the PYXIS (Automated medication storage and dispensing unit) did not have he would have to change the order to something the PYXIS did have or discontinue the order.

Based on observation, interview and document review the facility failed to follow safe pharmacy guidelines in dispensing medication for all hospital patients.

On 9/2/2014 at 2:00 PM during a tour of the inpatient care unit the following prescription medications were observed in a cabinet above the sink in the medication room:

One (1), 100 count bottle of 250 mg (Milligram) Amoxicillin. (Antibiotic)The manufacturer's seal was broken. There was no "date opened" on the bottle. The bottle had no label other than what came from the manufacturer.

One (1), 100 count Mexilitine Hydrochloride 200 mg. (Antiarrythmic) The manufacturer's seal was broken. There was no "date opened" on the bottle. There was no label other than the manufacturers information.

Triamcinolone Cream (TAC) 80 G (grams). (Corticosteroid) This medication was not opened but attached to the tube was a hand written label that read "multi dose put into cup".

One (1), 100 count bottle of Fluconozole. (Antifungal) The manufacturer's seal was broken. There was no "date opened" on the bottle. There was no label other than what came form the manufacturer.

One (1), 100 count bottle of Bumetadine 1 mg. (Loop diuretic) The manufacturer's seal was broken. There was no "date opened" on the bottle. There was no label other than what came from the manufacturer.

One (1), 100 ML (milli liter) bottle of Viscous Lidocain 2%. (Oral Xylocain) The manufacturer's seal was broken. There was no "date opened" on the bottle. There was no label other than what came from the manufacturer was on the bottle. Staff #1 was unable to explain the opened multi dose bottles of prescription medication, found above the sink.

On 9/3/2014 at 10:00 AM in the pharmacy staff #9 was interviewed and confirmed the above listed bulk medications were prescriptions drugs for inpatient use.

The following was reviewed with the pharmacy tech:

State Board of Pharmacy
(A) Distribution records for Schedule II-V controlled substances floor stock shall include the following information
(i) patient's name;
(ii) prescribing or attending physician
(iii) name of controlled substance, dosage, form and strength;
(iv) time and date of administration to patient;
(v) quantity administered;
(vi) name, initials, or electronic signature of the individual administering drug;

On 9/3/2014 at 10:30 AM in the pharmacy, staff #9 confirmed the bulk drugs were not labeled in compliance with state pharmacy requirements and there was no record of who received the medications that were removed form the bulk medication bottles or how much was removed and administered.

Based on document review and interview the facility failed to incorporate tracking of medication errors in the Quality committee meeting minutes for 3 months of 2014.

On 9/3/2014 at 4:00 PM in the conference room, the Quality committee meeting minutes were reviewed and the following was revealed:

The facility failed to identify problems and implement performance improvements in 4 of pharmacy related measures documented.
The QAPI report for July 30, 2014 revealed no reportable data, corrective actions, or performance improvement for the following;

1.) Pharmacy- Orders in comment field - No data for April, May, and June 2014.

2.) Pharmacy- Orders in comment field after hours- No data for April, May, and June 2014.3.)

3.)Pharmacy- Open bottles not dated- No data for April, May, and June 2014.

4.) Pharmacy- Home narcotic sheet incomplete- No data for April, May, and June 2014.

On 9/3/2014 at 10:00 AM in the pharmacy staff #9 indicated she had been the pharmacy tech for one (1) month and had not submitted data for a quality meeting.

Based on Utilization Review (UR) Meeting Minutes and interview the facility failed to have a functioning UR committee.
Review of the Utilization Review (UR) Meeting Minutes revealed the last UR meeting was on 10/30/2012.
An interview with Staff #1 on 9/3/14 at 10:08 AM confirmed the last date of the UR meeting was on 10/30/12. Staff #1 revealed there were no reviews or meetings being held for UR nor was there a UR medical director.

Based on Utilization Review (UR) Meeting Minutes and interview the facility failed to have a functioning UR plan that provided review for medical necessity.
Review of the Utilization Review (UR) Meeting Minutes revealed the last UR meeting was on 10/30/2012.
An interview with Staff #1 on 9/3/14 at 10:08 AM confirmed the last date of the UR meeting was on 10/30/12. Staff #1 stated, "When the case manager is here I think she looks at the medical necessity but when she is not here the nurses on the floor review it."
An interview with staff #17 and #21 on 9/3/14 at 11:30 AM revealed no knowledge of UR review for medical necessity.

Based on Utilization Review (UR) Meeting Minutes and interview the facility failed to have a functioning UR plan or committee to determine that an admission or continued stay was not medically necessary.
Review of the Utilization Review (UR) Meeting Minutes revealed the last UR meeting was on 10/30/2012.
An interview with Staff #1 on 9/3/14 at 10:08 AM confirmed the last date of the UR meeting was on 10/3/12. Staff #1 stated, "When the case manager is here I think she looks at the medical necessity but when she is not here the nurses on the floor review it. The case manager is on vacation so I can't really answer this."
An interview with staff #17 and #21 on 9/3/14 at 11:30 AM revealed no knowledge of UR review for medical necessity.
No continued stay or admission reviews were offered after multiple requests.

Based on Utilization Review (UR) Meeting Minutes and interview the facility failed to have a functioning UR plan or committee to determine that an extended stay has had a periodic review.
Review of the Utilization Review (UR) Meeting Minutes revealed the last UR meeting was on 10/30/2012.
An interview with Staff #1 on 9/3/14 at 10:08 AM confirmed the last date of the UR meeting was on 10/30/12. Staff #1 stated, "When the case manager is here I think she looks at the medical necessity but when she is not here the nurses on the floor review it. The case manager is on vacation so I can't really answer this."
An interview with staff #17 and #21 on 9/3/14 at 11:30 AM revealed no knowledge of UR review for medical necessity.
No continued stay or admission reviews were offered after multiple requests.

Based on Utilization Review (UR) Meeting Minutes and interview the facility failed to have a functioning UR plan or committee to determine medical necessity and services available.
Review of the Utilization Review (UR) Meeting Minutes revealed the last UR meeting was on 10/30/2012.
An interview with Staff #1 on 9/3/14 at 10:08 AM confirmed the last date of the UR meeting was on 10/3/12. Staff #1 revealed there were no reviews or meetings being held for neither UR or review of professional services provided.

Based on interview and document review the facility failed to provide an Infection Control Professional (ICP) qualified by training in 1 of 1 ICP.

On 9/2/2014 at 3:00 PM in the conference room interview with the Infection Control Profession, staff #12, revealed she was a Licensed Vocational Nurse but had not received basic Infection Control training.

On 9/3/2014 review of the employment file revealed no evidence the hospital provided training or detailed job description for the Infection Control position staff #12 had accepted.

Based on observation, interview and record review the facility failed to demonstrate a hospital wide infection control program evidenced by 2 of 6 departments reviewed (Dietary, and Nursing)

Dietary:
On 9/3/2013 at 9:00 AM tour of the dietary department revealed the following:

A dark greasy coating on surfaces not routinely sanitized. This included the stainless steel shelving in the cooking area of the kitchen, condiments stored above the pre tables, stainless steel racks for storage of clean pots and pans and stainless steel refrigerators and warmers.

Also three in-floor drains with grates, measuring 8 inches by 3 feet were observed with build up of dark residue on the grate and below in the drains. One of these drains and grates was located within the dietary department cooking area, one in the dish room area and one was located below the ice machine at the dining room service line. Without sanitation the dark residue served as a medium for bacterial build up in the kitchen.

Observed in the clean side of the dish room, the stainless steel surface at the bend of the splash guard exhibited rust making sanitation unlikely.

During the review of the food storage areas, the refrigerators were observed to have food times not given a date opened or uses by date. This was also observed in the freezer area and food that had been thawed and portions removed or cooked and portions removed were not given a use by or opened date. This practice places at risk for spoilage foods that have unknown use by dates which could be served to patients.

Nursing:

1. On 9/3/2014 in the conference room staff #12 revealed two (2) confirmed cases of tuberculin exposure had occurred in the nursing department during the past 6 months.

On 9/4/2014 at 1:00 PM during a tour of the building, the Maintenance Supervisor, staff 8, indicated the facility had two (2) negative pressure air flow rooms for use when isolation required such. Those rooms were, room #2 in the Emergency Department (ED) and room 115 on the nursing unit. While checking the rooms for negative air flow it was discovered that room #2, in the ED was a positive air flow room. Room #115 on the nursing unit was in fact a negative air flow room.

Staff #8 was questioned if he had ever checked to insure the negative air flow status. He replied "no". Staff #8 was asked if he knew how to check for negative air flow in a room and he stated "no". After inservice using a small piece of tissue Staff #8 confirmed ED room #2 was positive air flow and not safe for isolation.

On 9/4/2014 during investigation of rooms in the ED, it was discovered that Trauma rooms #2 & #3 were in fact negative air flow rooms. Staff #2 explained these two rooms had once been surgery suites and later converted to ED trauma suites. The hospital actually had three negative air flow rooms, two of which were in the ED but nursing staff did not know it.

2. On 9/4/2014 during a tour of the ED all mattresses were found to have cracks, or tears in the covering, making them unable to be properly sanitized between patients. This wound place patients placed in the two (2) trauma rooms at a high exposure risk. This was confirmed by staff #2.

Based on observation, staffing schedules, and interviews the facility failed to have adequate staff in the Emergency Department (ED) to ensure patient safety, needs anticipated by the facility, and no clear chain of command.
Review of the nursing schedule for the Emergency Department (ED) revealed there were two 12 hour shifts (7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM) in a 24 hour day. Each shift had one registered nurse (RN) and one licensed vocational nurse (LVN) on duty for a five bed ED. There was no staffing grid for the Emergency Department to allow the staff to fluctuate for an increase or decrease in patient census.
Review of the Governing Board Meeting Minutes on 5/15/2014 ER Report stated, "Staff #1 reported that the ER is doing good with no major problems. She said we have gone to minimal staffing to cut down on expenses."
On 9/4/2014 at 10:15 AM a tour of the ED was performed with Staff #1 and #2. There was an RN and LVN on duty. The RN must do all triages for the ED. The RN must leave the unit to go to the triage room located in the ED waiting room. The RN is out of sight and hearing range for the LVN and patients on the ED unit. The LVN is left alone with no RN supervision for at least 10 to 20 minutes.
Interview with staff #25 confirmed she leaves the LVN in the ED with no RN supervision to triage patients. Staff #25 confirmed if a patient were to decline or a Cardiac Arrest, the LVN would have to leave the patient, go to a phone, and call for the RN. Staff #25 confirmed on weekends, holidays, and night shift there was no house supervisor or a designated RN in charge to make decisions. Staff #25 stated, "If we need something we have to call staff #1 and she will let us know."
Interview with staff #2 on 9/4/2014 at 11:00 AM confirmed the RN was leaving the unit unattended. Staff #2 stated, "I can see where this puts the RN, LVN, and patient at risk. I will try to move the triage room onto the unit."
Interview with staff #1 on 9/4/2014 at 11:15 AM revealed there was no staffing grid for the ED. Staff #1 stated, "I guess I didn ' t think about the RN leaving the LVN alone. I was told to decrease the staffing by the administrator." Staff #1 confirmed there was no house supervisor. Staff #1 stated, "I am on call 24/7. If they need something they just have to call me."

Based on record review and interview, the facility failed to follow its own policy and procedures for respiratory care services.
Review of the policy and procedure "Respiratory Service Department Scope of Service" dated 7/5/2010 stated, "The Respiratory Department is a comprehensive service that provides personnel and equipment with specialized areas for all phases of Respiratory Therapy. Respiratory Department will be under the direction of a Registered and /or Certified Respiratory Therapist and will be staffed by Registered Nurses (RN's) and Licensed Vocational Nurses (LVN's). All nursing staff have been cross trained and have documented competency in respiratory care."
A memo was attached to the policy and procedure dated November 6, 2013 from the previous CEO that states,"We will no longer have a Cardio Pulmonary Department. Staff #12 is responsible for infection control and will now be responsible for our Core Measures as well moving forward. Staff #12 will be responsible for ABG's until a changeover to lab can take place. Other duties which are currently completed by Cardio Pulmonary will be changed and staff #1 will communicate those changes as they need to happen."
Review of the Medical Executive Committee (MEC) Meeting minutes on 1/28/ 2014 revealed no documentation found on the closure of the Cardio Pulmonary Department.
Review of the Governing Board (GB) Meeting minutes revealed the next GB meeting held after 11/6/2013 was 5/15/2014. There was no documentation found on the closure of the Respiratory Department.
An interview with staff #1 on 9/2/2014 at 3:00 PM revealed there is no Cardio Pulmonary Department. Staff #1 stated, "The nurses administer respiratory services. We have done training with them at the last health fair."
Review of personnel files for staff #21, 17, 23, and 24 revealed no written test or documentation of specific respiratory training found.

Based on interviews the facility failed to appoint a director of respiratory care services.
Interview with staff #1 and #2 confirmed there were no physician appointed as the director of respiratory services.

Based on policy and procedures, and interviews the facility failed to appoint a director of respiratory care services, and failed to have an updated policy and procedure appropriate to the scope of service provided.
Review of the policy and procedure "Respiratory Service Department Scope of Service" dated 7/5/2010 stated, "The Respiratory Department is a comprehensive service that provides personnel and equipment with specialized areas for all phases of Respiratory Therapy. Respiratory Department will be under the direction of a Registered and /or Certified Respiratory Therapist and will be staffed by Registered Nurses (RN's) and Licensed Vocational Nurses (LVN's). All nursing staff have been cross trained and have documented competency in respiratory care.
Services Offered To These Customers
Pulmonary- Oxygen Therapy, Medication Aresol Therapy, Arterial Blood Gas Analysis, Chest Physiotherapy, multi dose inhalers.
Cardiac- Electrocardiograph (EKG), Cardiac holter Monitor."
A memo was attached to the policy and procedure dated November 6, 2013 from the previous CEO that states, "We will no longer have a Cardio Pulmonary Department. Staff #12 is responsible for infection control and will now be responsible for our Core Measures as well moving forward. Staff #12 will be responsible for ABG's until a changeover to lab can take place. Other duties which are currently completed by Cardio Pulmonary will be changed and staff #1 will communicate those changes as they need to happen."
There was no updated policy and procedures to perform respiratory services found.
Interview with staff #1 and #2 on 9/3/2014 confirmed there were no physicians appointed as director of respiratory services. Staff #1 confirmed this was the last updated respiratory policy and procedure.

Based on review of policy and procedures, personnel files, and interview the facility failed to follow its own policy and procedures for qualified and supervised respiratory personnel.
Review of the policy and procedure "Respiratory Service Department Scope of Service" dated 7/5/2010 stated, "The Respiratory Department is a comprehensive service that provides personnel and equipment with specialized areas for all phases of Respiratory Therapy. Respiratory Department will be under the direction of a Registered and /or Certified Respiratory Therapist and will be staffed by Registered Nurses (RN's) and Licensed Vocational Nurses (LVN's). All nursing staff has been cross trained and have documented competency in respiratory care."
A memo was attached to the policy and procedure dated November 6, 2013 from the previous CEO that states, "We will no longer have a Cardio Pulmonary Department. Staff #12 is responsible for infection control and will now be responsible for our Core Measures as well moving forward. Staff #12 will be responsible for ABG's until a changeover to lab can take place. Other duties which are currently completed by Cardio Pulmonary will be changed and staff #1 will communicate those changes as they need to happen."
An interview with staff #1 on 9/2/2014 at 3:00 PM revealed there is no Cardio Pulmonary Department. Staff #1 stated, "The nurses administer respiratory services. We have done training with them at the last health fair."
An Interview with staff #12 on 9/4/2014 at 10:15 AM confirmed she was responsible for respiratory services in the facility. Staff #12 stated, "we had done some training at the health fair a couple of months ago. They should also be getting the training during new hire orientation. I think there is documentation in the personnel files."
Review of personnel files for staff #21, 17, 23, and 24 revealed no written test or documentation of specific respiratory training found.

Based on interview and record review the facility failed to provide evidence the Infection Control Program reviewed by the Quality committee and forwarded to the leadership of the hospital involved all departments (hospital wide) of the hospital.

On 9/4/2014 at 11:00 in the conference room, the quality committee meeting minutes for the last two quarters in 2014 were reviewed and revealed no data was submitted that reflected infection control by department or an overall infection control plan that addressed potential department/hospital wide concerns.

Further review identified no actual data or raw data to reveal how percentages were obtained or thresholds determined for infection rates and contamination rates that were reflected in the nursing component of the infection control data. This data was the only reference to infection control for the hospital wide data driven Infection Control Program.