HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients as evidenced by medical staff members not assessing and pronouncing death for 1 (#10) of 1 (#10) sampled patients reviewed for pronouncement of death from a total sample of 20. This deficiency was written on the recertification survey on 05/18/15 also.

Findings:

Review of the hospital policies titled Emergency/Resuscitation Policy revealed in part: the deceased shall be pronounced dead by the attending practitioner or his designee within a reasonable time. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a member of medical staff or his designee.

Review of the Hospital's Medical Staff Bylaws, in Rules and Regulations, #22 revealed, "Pronouncement of death: Only a physician can pronounce a patient death. Practitioners and coroners are not authorized by the medical staff to pronounce death."

Review of Louisiana Laws Revised Statutes Title 9-Civil code-ancillaries RS9:111-Definition of death revealed in part: the medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased.

Review of Patient #10's nursing notes dated 9/27/17 revealed the following:
5:15 a.m. Unable to palpate a pulse. No audible heartbeat. Respirations are 0 at this time. Unable to get an oxygen saturation at this time.
5:38 a.m. Called S12MD on his cell phone. No answer times 2.
5:40 a.m. Received a call back from S12MD. Informed him of patients' condition. Instructed by S12MD to call the coroner and have coroner pronounce the patient expired/dead. I repeated instructions back to S12MD, at which time he replied, "yes, that's correct. Just call him."
5:45 a.m. Spoke with Investigator/Coroner on call. He informed me that it was not his duty to pronounce a patient dead/give a time of death. He stated, "Your doctor should be doing that."
5:50 a.m. Spoke with the director of nursing and she stated it was okay to get the time of death from the coroner.
6:00 a.m. Coroner proceeded to give me a time of death for the patient.
8:30 a.m. Body released to funeral home.

On 4/11/18 at 11:20 AM in an interview with S13RN, she verified she was the nurse caring for a Patient #10 on 9/27/17. She stated she called S12MD and he did not want to come to hospital. She stated she called the coroner and told him Patient #10 had no pulse and no audible breath sounds or apical pulse and the time of death was determined to be 5:20 a.m.

Based on record review and interview, the hospital failed to ensure the services performed under contract were provided in a safe and effective manner as evidenced by providing no documented evidence that all services provided by contract had been evaluated for safety and efficiency.
Findings:


Review of Governing Board Meeting Minutes dated January 31, 2018 revealed, in part, "Governing Board annual evaluation and review of Hospital Contracts-Vendors, ancillary Service Agreements and Consultants and Physician Contracts. Hospital contracts and agreements were reviewed for 2017 with the addition of the Pharmacy-Axum Medical Supplies." Further review revealed no list or identification of individual contracts reviewed, or attached evaluations.

In an interview 4/11/18 at 5:45 p.m. S3QI indicated she could not provide any supporting documentation of contract evaluations. S3QI indicated S1ADM would be the person to ask for those evaluations.

In an interview 4/11/18 at 5:47 p.m. S1ADM reported he would have to find the contract evaluations and would provide them to surveyors.

In an interview 4/11/18 at 6:30 p.m. S1ADM reported he was unable to provide any contract evaluations.

As of the survey exit 4/11/18 at 7:15 p.m. no contract evaluations had been provided.

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 related to lack of discharge summaries as an area in need of improvement to be addressed through the hospital's QAPI program.

Findings:

Review of the hospital's medical record deficiency report, provided as current by S15MR/HK, revealed the following medical record deficiencies (failure to have dictated discharge summaries) for S12MD from 6/30/17-4/11/18:

54 medical records greater than 30 days deficient;

42 medical records greater than 60 days deficient;

40 medical records greater than 90 days deficient;

33 medical records greater than 120 days deficient.

In an interview on 4/10/18 at 2:10 p.m. with S15MR/HK, she stated no written notification regarding deficient patient records had been sent to S12MD. S15MR/HK reported there had been no suspension of the physician's privileges for incomplete charts as referenced in the hospital's Medical Staff Bylaws and Rules and Regulations.

Review of the hospital wide QA plan revealed no documented evidence that delinquent medical records resulting from failure to identify issues with discharge summaries being written/transcription of discharge summaries dating back to 6/2017, had been identified as an area in need of improvement to be addressed through the hospital's QAPI program.

In an interview on 4/11/18 at 5:00 p.m. with S3QI, she confirmed delinquent medical records resulting from failure to identify issues with discharge summaries being written/transcription of discharge summaries dating back to 6/2017 had not been identified as an area in need of improvement to be addressed through the hospital's QAPI program.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:

1) Failure to perform an initial wound assessment on admission, including baseline wound measurements, on a patient (#2) who was admitted with a primary diagnosis of treatment of a Stage II sacral pressure ulcer for 1(#2) of 4 (#1, #2,#3,#4) sampled patients reviewed for wounds/wound care from a total sample of 20;

2) Failure to notify the wound care staff of a new patient requiring wound care assessment and management for 1(#2) of 4 (#1, #2,#3,#4) sampled patients reviewed for wounds from a total sample of 20;

3) Failure to obtain weights as ordered by the physician for 1(#1) of 3 (#1, #2 #3) sampled patients reviewed for weights from a total sample of 20.
This deficiency was written on the recertification survey on 05/18/15 also.
Findings:

1) Failure to perform an initial wound assessment on admission, including baseline wound measurements, on a patient (#2) who was admitted with a primary diagnosis of treatment of a Stage II sacral pressure ulcer.

Review of the hospital policy titled," Wound Care", revealed in part: a. Wound care is one aspect of the care that the patient receives while here at this facility. There is ongoing assessment of the wound and the prescribed treatment to reduce complications and promote the best possible environment for healing.
b. There is a wound care book that is kept on each patient that has a wound.
c. There are pictures taken of the wound initially and weekly, unless otherwise indicated to show progress. The wound description will include size, depth, color, drainage, odor, treatment performed, tolerance to treatment, changes and any other characteristics noted.
d. There will be an order written for any treatment performed to the wound. Any wounds that appear while in the facility will have an incident report filled out for tracking purposes.
e. The registered nurse or the physical therapist certified in wound care by experience or clinics will perform wound care to any complex wounds and the LPN may perform wound care to simple wounds.
f. The wound is assessed daily by the registered nurse or the physical therapist with documentation. The physician will be notified of any negative changes to the wound.

Review of Patient #2's medical record revealed an admission date of 4/2/18. Further review revealed the patient's primary diagnosis for admission was for culture and treatment a Stage II sacral pressure wound.

Review of Patient #2's admission orders, dated 4/2/18, revealed the following: Wound Care: weekly measurements and pictures, obtain wound culture, cleanse with normal saline and 4x4 (gauze bandage). Time date, label and initial per wound care.

Review of Patient #2's Initial Skin Assessment, performed upon admission on 4/2/18, revealed documentation indicating a Stage II sacral wound. Further review revealed no documented wound measurements and no description of the wound such as size, depth, color, drainage, and/or odor. Additional review revealed no documented evidence that pictures had been taken of the patient's wound (as set forth in hospital policy). Patient #2's heels were also documented as red and "mushy" on admission.

Additional review of Patient #2's medical record revealed as of 4/11/18 at 1:30 p.m. there had been no measurement of Patient #2's wound. The only measurements present on the patient's chart were from the transferring hospital on 4/2/18. The condition of the skin on Patient #2's heels had not been further assessed since the initial skin assessment on 4/2/18.

An observation was made of patient #2's wound care on 4/11/18 at 2:15 p.m. This was the first assessment performed by S14WC as she had not been notified that Patient #2 required wound care by the hospital's nursing staff. The patient was noted to have an open pressure ulcer that was measured to be 3 centimeter in circumference. The tissue was observed to be beefy red in color with surrounding skin color noted to be bright red in spots and dark red/purple in spots. The surrounding tissue was noted to be excoriated and macerated. S14WC confirmed the pressure ulcer on Patient #2's sacrum was a Stage II pressure ulcer. S14WC also confirmed, upon examination, that the patient's heels were red and soft/boggy to touch and would require cushioning due to potential for breakdown.

In an interview on 4/11/18 at 4:47 p.m. with S2DON, she confirmed Patient #2 had not had wound measurements performed since admission on 4/2/18. She further confirmed the measurements obtained by S14WC at 2:15 p.m. on 4/11/18 had been the first measurements obtained. S2DON also confirmed no photos had been taken of Patient #2's wounds, on admission, as directed per hospital wound care policy. S2DON reported the RN performing the admission assessment should have obtained baseline wound measurements and should have taken baseline pictures of the wounds.


2) Failure to notify the wound care staff of a new patient requiring wound care assessment and management.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 3/30/18 with diagnosis that included post right hip revision surgery. Further review of Patient #1's initial patient's nursing assessment revealed Patient #1 had three stage II pressure ulcers one to left buttock, one to right buttock, and one to coccyx.

Review of Patient #1's medical record revealed no documentation of wound care or physician notification of the pressure ulcers.

On 4/10/18 at 1:30 p.m. in an interview with S2DON, she stated staff was unaware Patient 1# had 3 stage II pressure ulcers as documented on admission nursing assessment 3/30/18. When questioned about pictures of the wound wound she stated they may still be in camera.


Patient #2
Review of Patient #2's medical record revealed an admission date of 4/2/18. Further review revealed the patient's primary diagnosis for admission was for culture and treatment of a Stage II sacral pressure wound. Additional review revealed an order dated 4/3/18 at 12:30 p.m. for a wound care consult.

Review of Patient #2's entire medical record revealed no documented evidence that the order for the wound care consult had been communicated to the hospital's wound care staff member (S14WC). Further review revealed the patient's medical record had no documented evidence of an assessment by the hospital's wound care staff member (S14WC).

In an interview on 4/11/18 at 1:40 p.m. with S14WC, she reported the hospital staff usually called her to notify her when a patient had an ordered wound care consult. S14WC confirmed she had not been notified Patient #2 had an order for a wound care consult and she she had no idea the patient had a Stage II sacral pressure ulcer.

3) Failure to obtain weights as ordered by the physician.

Review of hospital policy titled Patient Weight, provided by S8HR as current, revealed in part, "Patients will be weighed on admission and weekly unless ordered more frequently. Patient weight is assessed to determine the effectiveness of prescribed diets, pathophysiological conditions as well as adverse effect of new, changed or discontinued medications..."

Review of Patient #1's medical record revealed she was admitted on 3/30/18 with diagnosis that included post right hip revision surgery, diabetes, and urinary tract infection. Further review of the medical record revealed a note on 4/8/18 by S20RD which stated Patient #1 had a diagnosis of metabolic Syndrome, morbidly obese, protein energy malnutrition, inadequate nutrient intake and hypoalbuminemia. Additionally she documented Patient #1 had a down-grade from a full-liquid diet to a clear liquid diet with boost breeze clear.

In an interview on 4/10/18 at 11:22 with S2DON, she verified weekly weights should be done on all patients. She also verified the documentation of weight not conducted on Patient #1 "due to medical condition" of Patient #1 was not a valid reason for not obtaining a weighing. S2DON stated Patient #1 uses a hoyer lift and weights can be done with assistance of wheelchair. Patient #1 was in a wheelchair and able to leave hospital today for a physician's appointment.



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39791


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Based on record review and interview., the hospital failed to ensure the nursing staff developed, and kept current, a comprehensive care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 3 (#1, #2,#5) of 5(1, #2, #3, #4, #5) sampled patients reviewed for care plans of a total sample of 20.

Findings:

Review of the hospital policy titled," Professional Plan of Care", revealed in part: An individualized nursing plan of care shall be initiated within 24 hours of admission. Other disciplines will be notified of the physician's orders that require their professional assessment. The plan must include: Specific individualized measurable goals and interventions, specific services to be provided including the frequency, and action steps to achieve the goals. Care plans should be reviewed and updated on an ongoing basis.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 3/30/18 with diagnosis that included post right hip revision surgery, diabetes, and urinary tract infection. Further review of the medical record revealed Patient #1 had diabetes and accuchecks 4 times per day. Additional review revealed Patient #1 is on Lovenox and Coumadin.

Review of Patient #1's care plan revealed risk for bleeding due to anticoagulant therapy and diabetes were not initiated.

Patient #2
Review of Patient #2's medical record revealed an admission date of 4/2/18. Further review revealed the patient was admitted for treatment for a Stage II pressure wound. Additional review revealed the patient had a co-morbid condition of Atrial Fibrillation that was being treated with Lovenox (anti-coagulant). Patient #2 was also receiving Aspirin (blood thinner) therapy daily.

Review of Patient #2's care plan revealed risk for bleeding due to anticoagulant therapy had not been addressed on the patient's plan of care.


Patient #5
Review of Patient #5's medical record revealed an admission date of 2/23/18 with an admission diagnosis of
Chronic Idiopathic Thrombocytopenia Purpera- a coagulation disorder.

Review of Patient #5's plan of care revealed alteration in health maintenance related to Thrombocytopenia was identified as a current problem, but the plan of care had no nursing interventions related to this identified problem such as signs and symptoms of bleeding.

In an interview on 4/11/18 at 4:40 p.m. with S2DON, she confirmed risk for bleeding due to anticoagulant therapy and nursing interventions for identification of signs and symptoms of bleeding should have been included in the above referenced plans of care.










39791

Based on record review and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the specialized qualifications and competence of the nursing staff available . This deficient practice was evidenced by the hospital's failure to have evidence of competencies for 4 (S9LPN, S10RN, S14WC, S18CNA) of 6 (S2DON, S9LPN, S10RN, S16DM, S14WC, S18CNA) personnel files reviewed for clinical competencies, from a total sample of 10 personnel files reviewed.

Findings:

Review of the personnel file for S9LPN revealed a hire date of 6/14, and no competencies documented since before 2017.

Review of the personnel file for S10RN revealed a hire date of 1/2002 , and no competencies documented since before 2017.

Review of the personnel file for S14WC revealed , and no competencies documented since before 2017 for Physical Therapy and no competencies for wound care.

An observation was conducted 4/11/18 at 2:15 of S14WC providing wound care to Patient #2. S14WC reported she was the wound care staff, and the nurses perform wound care when she did not come to the hospital. She reported she had wound care training as part of Physical Therapy training in Florida, where she received her training.

Review of the personnel file for S18CNA revealed a hire date of 3/15, and no competencies documented since before 2017.

In an interview 4/11/8 at 6:40 p.m. S8HR verified that clinical competencies had not been done in 2017 or 2018 for any clinical staff.




30984

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the physician's orders for 1 (#1) of 5 (#1,#2, #3, #4, #5) current patients sampled for administration of drugs from a total sample of 20. This deficiency was written on the recertification survey on 05/18/15 also.

Findings:

Review of the hospital policy titled 24 Hour Chart Check revealed in part, if physician orders are not followed, this is considered a delay in treatment and an incident report should be filled out.

Review of Patient #1's medical record revealed in part an order for Xarelto 20 mg by mouth daily. Further review revealed Patient #1's Xarelto was not documented as administered on 4/5/18, 4/6/18 and 4/7/18.

In an interview on 4/9/18 at 3:45 PM with S2DON, she verified Xarelto was not given to Patient #1 on 4/5/18, 4/6/18, and 4/7/18.

Review of Patient #1's medical record revealed in part an order for Phenergan 12.5 mg IV every 6 hours as needed for nausea and vomiting if Zofran is not available. Further review revealed Phenergan was administered IV Push and Zofran was available.

On 4/11/18 at 10:10 AM in an interview with S11RN, she verified Patient #1's order was to give Phenergan if Zofran was unavailable. She verified Zofran was available. She administered Phenergan IV Push over 5 minutes although Zofran ODT was available. She stated she did not call the physician when she did not administer the medication as ordered. She verified she did not follow physician's orders.

Based on record review and interview the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures. This deficient practice was evidenced by failure of the hospital to ensure patient medical records were promptly completed as set forth in the hospital's policies for completion of medical records and failure to enforce consequences for delinquent medical records as set forth in the hospital's Medical Staff Bylaws and Rules and Regulations.

Findings:

Review of the hospital's Medical Staff Rules and Regulations revealed the following, in part: 16. The discharge summary (clinical; resume) shall be written or dictated on all medical records of patients hospitalized. Discharge summaries shall be completed within 30 days of discharge. Discharge summaries not completed within this timeframe are considered delinquent. Responsible physician will receive report of delinquencies.

Further review of the Medical Staff bylaws revealed the following: Temporary suspension results from technical violations of the Bylaws, Rules and Regulations and does not entitle practitioner to hearing procedures. The following are grounds for temporary suspension, of admitting or other privileges including, but not limited to consultation, writing order, discharging patients, and may also be the basis for further corrective action. Repeated temporary suspensions may be grounds for further corrective action. 1. Temporary suspension of clinical privileges effective until medical records are completed shall be imposed following warning of delinquency for failure to complete medical records for a patient's discharge in accordance with the Medical Staff Rules and Regulations.

Review of the hospital's policy titled,"Timely Entries in Medical Records", revealed in part: Entries in patient medical records shall be timely to ensure accurate communication and continuity of care between disciplines involved in a patient's course of treatment. The Discharge Summary must be hand written or dictated, transcribed, and placed in the medical record within 30 days of the patient's discharge. If the discharge summary is not completed in 30 days the medical record is classified as delinquent. The Executive Committee will be notified of delinquent records. If the records remain delinquent for a period of 30 days the Administrator will send the attending physician a warning letter allowing 3 days for completion of the delinquent record (s). If the physician does not comply, a temporary suspension letter will be sent to the physician via registered mail. The physician's privileges will be suspended until the records are complete.

Review of the hospital's medical record deficiency report, provided as current by S15MR/HK, revealed the following medical record deficiencies (failure to have dictated discharge summaries) for S12MD from 6/30/17-4/11/18:

54 medical records greater than 30 days deficient;

42 medical records greater than 60 days deficient;

40 medical records greater than 90 days deficient;

33 medical records greater than 120 days deficient.

In an interview on 4/10/18 at 2:10 p.m. with S15MR/HK, she stated no written notification regarding deficient patient records had been sent to S12MD. S15MR/HK reported there had been no suspension of the physician's privileges for incomplete charts as referenced in the hospital's Medical Staff Bylaws and Rules and Regulations.

30984

Based on record review and interview, the hospital failed to ensure all order authentications had been dated and timed promptly by the ordering practitioner, in accordance with hospital policies for 3 (#3 #12,#13) of 3 sampled patient records reviewed for dating and timing of order authentications from a total sample of 20. This deficiency was written on the 05/18/15 recertification survey also.

Findings:

Review of the hospital's policy titled,"Timely Entries in Medical Records", revealed in part: Entries in patient medical records shall be timely to ensure accurate communication and continuity of care between disciplines involved in a patient's course of treatment. All verbal orders must be signed by the ordering physician within 10 days of dictating the order.

Patient #3
Review of the medical record for Patient #3 revealed the following verbal or telephone orders that had been authenticated, but not dated and/or timed, or not authenticated:

Admission orders dated 3/20/18 at 9:30 p.m., written as a VORB by the nurse per the NP/S12MD was authenticated by S12MD on 3/25/18 with no time on the first of 2 pages, and authenticated on the 2nd page with no date or time.

Order dated 3//20//18 at 9:30 p.m. written as TO (telephone order) by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 3/21/18 at 5:30 p.m. written as VORB by the nurse, authenticated by S12MD with no date or time.

Order dated 3//22//18 at 1:00 p.m. written as TORB by the nurse, with no authentication.

Order dated 3//25//18 at 3:50 p.m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 3//25//18 at 3:55 p.m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 3//26/18 at 6:45 a..m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 3//26/18 at 12:30 p.m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 3/31/18 at 3:00 p.m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.


Patient #12
Review of Patient #12's medical record revealed the following verbal/telephone orders that had been authenticated, but not dated or timed:

Admit order dated 8/1/17 at 5:30 p.m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 8/7/17 at 03:00 a.m. written as TO by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 8/15/17 at 11:40 a.m. written as VORB by the nurse, authenticated by S12MD, but not dated or timed.

Order dated 8/15/17 at 11:40 a.m. written as TORB by the nurse, authenticated by S12MD, but not dated and timed.


Patient #13
Review of Patient #13's medical record revealed the following verbal/telephone orders that had been authenticated, but not dated or timed:

Order dated 1/22/18 at 8:00 p.m. written as TO per the nurse, authenticated by S12MD but not dated and timed.

Order dated 1/24/18 at 6:00 p.m. written as VORB per the nurse, authenticated by S12MD, but not dated or timed.

Order dated 1/25/18 at 1:00 p.m. written as VORB per the nurse, authenticated by S12MD, but not dated or timed.

Order dated 1/26/18 at 5:30 p.m. written as VORB per the nurse, authenticated by Dr. Jonathon Roberts but not dated and timed.

Order dated 1/26/18 at 5:45 p.m. written as VORB per the nurse, authenticated by S12MD, but not dated or timed.

Order dated 1/26/18 at 8:15 p.m. written as VORB per the nurse authenticated by S12MD, but not dated and timed.

Order dated 1/27/18 at 7:50 a.m. written as TORB per the nurse authenticated by S12MD, but not dated and timed.

In an interview on 4/11/18 at 5:00 p.m. with S3QI (Quality Improvement) she confirmed all orders, including verbal orders, should have been authenticated, dated, and timed.

Based on record review and interview, the hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care, and provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure a completed discharge summary was on all patient records within 30 days of discharge for 6 (#5,#6,#8,#9,#18, #19) of 6 sampled patient records reviewed for discharge summaries from a total sample of 20.

Findings:

Review of the hospital's Medical Staff Rules and Regulations revealed the following, in part: 16. The discharge summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized. Discharge summaries shall be completed within 30 days of discharge. Discharge summaries not completed within this timeframe are considered delinquent.

Review of the hospital's policy titled,"Timely Entries in Medical Records", revealed in part: Entries in patient medical records shall be timely to ensure accurate communication and continuity of care between disciplines involved in a patient's course of treatment. The Discharge Summary must be hand written or dictated, transcribed, and placed in the medical record within 30 days of discharge. If the discharge summary is not completed in 30 days, the medical record will be classified as delinquent.

Patient #5
Review of Patient #5's medical record revealed an admission date of 2/23/18 and a discharge date of 2/26/18.
Further review of the patient's medical record revealed that as of 4/10/18 (date of the record review) there was no discharge summary in the patient's medical record.

Review of a master list documenting patient discharge summary status, presented as current by S15MR/HK (medical records/housekeeping), revealed no discharge summary had been dictated or transcribed for Patient #5.

Patient #6
Review of Patient #6's medical record revealed an admission date of 1/28/18 and a discharge date of 2/23/18.
Further review of the patient's medical record revealed that as of 4/10/18 (date of the record review) there was no discharge summary in the patient's medical record.

Review of a master list documenting patient discharge summary status, presented as current by S15MR/HK (medical records/housekeeping), revealed the discharge summary had been dictated 2/28/18 but had not been transcribed yet for Patient #6.

Patient #8
Review of Patient #8's medical record revealed an admission date of 11/8/17 and a discharge date of 11/9/17.
Further review of the patient's medical record revealed that as of 4/10/18 (date of the record review) there was no discharge summary in the patient's medical record.

Review of a master list documenting patient discharge summary status, presented as current by S15MR/HK (medical records/housekeeping), revealed no discharge summary had been dictated or transcribed for Patient #8.

Patient #9
Review of Patient #9's medical record revealed an admission date of 10/4/17 and a discharge date of 10/6/17.
Further review of the patient's medical record revealed that as of 4/10/18 (date of the record review) there was no discharge summary in the patient's medical record.

Review of a master list documenting patient discharge summary status, presented as current by S15MR/HK (medical records/housekeeping), revealed no discharge summary had been dictated or transcribed for Patient #9.

Patient #18
Review of Patient #18's medical record revealed an admission date of 11/9/17 and a discharge date of 12/4/17. Further review of the patient's medical record revealed that as of 4/11/18 (date of the record review) there was no discharge summary in the patient's medical record.

Review of a master list documenting patient discharge summary status, presented as current by S15MR/HK (medical records/housekeeping), revealed no discharge summary had been dictated or transcribed for Patient #18.


Patient #19
Review of Patient #19's medical record revealed an admission date of 1/2/18 and a discharge date of 1/25/18.
Further review of the patient's medical record revealed that as of 4/11/18 (date of the record review) there was no discharge summary in the patient's medical record.

Review of a master list documenting patient discharge summary status, presented as current by S15MR/HK, revealed no discharge summary had been dictated or transcribed for Patient #19.

Further review of the master list documenting patient discharge summary status revealed there were a total of 82 charts, greater than 30 days delinquent, that had no discharge summary on the charts.

In an interview on 4/10/18 at 2:10 p.m. with S15MR/HK, she confirmed she was the hospital's medical records clerk and transcriptionist. She indicated S3QI (Quality Improvement) was the staff member she reported to. S15MR/HK reported "a couple of months ago the computer crashed and the dictation the tapes didn't play right after that." 15MR/HK further reported the dictated discharge summary tapes in need of transcription "go back awhile, to 6/2017." S15MR/HK reported patient discharge summaries were dictated/recorded and there were no handwritten discharge summaries. S15MR/HK further reported the majority of patient discharge summaries have not been dictated.

Based on observations, review of hospital documentation and interviews , the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. This was evidenced by:

1. Failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by:
1) failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care; and
2) failure to maintain an equipment maintenance program, as evidenced by no inspections and preventive maintenance by qualified personnel in over 2 1/2 years. (See findings at A-724)

2. Failure to ensure adequate light was maintained in patient care areas to ensure accurate assessments of patients and proper visualization of procedures performed. This deficient practice was evidenced by patient rooms, bathrooms, and patient tub room that were very dark with all room lights on. (See findings at A-726)

Based on record review, observation, and interview the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by:
1) failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care; and
2) failure to maintain an equipment maintenance program, as evidenced by no inspections and preventive maintenance by qualified personnel in over 2 1/2 years.
This deficiency was written on the 05/18/15 recertification survey also.
Findings:


1) Failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care.

Review of a hospital policy titled "Physical Environment" (1/2/01), provided by S8HR as current, revealed in part the hospital maintained adequate facilities to ensure the health and safety of patients and staff. Regular inspection by the Director of Maintenance was to be performed and reported to the Administrator. All equipment was stored and maintained to ensure the health and safety of patients and staff.


Observations of the hospital's physical plant on 4/9/18 from 9:50 a.m. to 11:52 a.m. , with S2DON and S15MR/HK, revealed the following:

Central Supply room:
a. covered rubber container of supplies had droplets of dark brown liquid on top of container, identified by S15MR/HK, as a spill of a soft drink. The soft drink can was observed sitting, opened and partially empty, on a counter near the container;
b. 3 x 3 inch piece of tape and old tape residue with brown coloration on edges on work counter;
c. soiled areas on cabinet doors;
d. 7 ceiling tiles with stains, identified by S15MR/HK as water stains;
e. small debris of brownish material in medium sized empty plastic baskets lined on counter tops, verified by S15MR/HK and identified as baskets used to store supplies;

Clean equipment room:
a. Oxygen concentrator noted to have a coat of grayish powdery substance;
b. 3 wheelchair leg pieces piled one on top of the other in a basket, noted to have rusted areas on the metal surface, and covered in a coat of grayish powdery substance.
c. 3 rolling IV poles with numerous rough brownish-red areas, identified as rust by S15MR/HK;
d. several large cracks in plastered walls. S15MR/HK verified the cracks prevented proper cleaning/disinfection of the walls in the Clean equipment room.
e. 7 ceiling tiles with rings of light brownish discoloration;
f. 1 ceiling tile loose and partially fallen from the ceiling tile frame;
g. 1 ceiling light not working, with dim lighting in others;
h . 3 wheelchairs with cracks or tears in the arm padding, with foam exposed on 2 of them. One wheelchair had a missing arm pad.
i. shower chair with rusted areas.


Storage Room on Hallway A:
a. numerous black plastic bags, open, with clothing in them, medium sized tote bags with clothes in them, piled so that they were stacked and covered the floor in the front part of the room. To walk into the middle and back of the room, some bags had to be moved or stepped over. The sinks in the room were filled with open black plastic bags to approximately a foot above the sinks.
b. open boxes of holiday decorations piled on counters and the floor. A medium sized artificial Christmas tree was leaned against a counter.
c. a full prosthetic leg, with a sock and tennis shoe on the leg was standing in the middle of the back section of the room identified by S15MR/HK as left by a former patient some time ago;
d. extremity splints and cast shoes, some uncovered, one previously used as evidenced by outline of a foot drawn in permanent marker;
e. cardboard boxes, one filled with used paperback books;
f. dirty coffee cups on shelf;
g. numerous extremity splints, cloth extremity immobilizes, all open without any packaging, with no way from observation to tell if they had been previously used as they were covered with a fine powdery dust.
S15MR/HK reported this room contained clothes and belonging from patients who had been discharged, left the belongings, and had not returned to claim them. She indicated she did not know just how long the belongings had been collecting in the storage room. S15MR/HK verified the observations and agreed the current room condition and arrangement of contents could be conducive to pests living and nesting in the room.


Hallway "A"
a. ceiling tiles noted to be buckling
b. outer door hinge of biohazard room bent and broken and paint was chipped off of doorframe
c. baseboards noted to be buckling, separating from the wall in the hallway
d. air vent stained with rust colored spots, metal surface rusted, and coated with grayish powdery substance
e. wooden doorway threshold piece leading into clean supply room was broken
f. baseboard outside of clean linen room buckling and separating from the wall.
g. hole in the sheetrock wall behind the door leading to the gym
h. air vent stained with rust colored spots, metal surface rusted, and coated with grayish powdery substance
i. 2 window air conditioning units secured in the windows with duct tape and a piece of cloth that was stained with rust colored marks and the fabric was stiff to touch. The louvered windows above the window units were taped shut with duct tape.


Therapy/Patient Gym:
a. crack in floor tile in the gym near door leading to the back of dietary department;
b. numerous areas of loose vinyl baseboards with open areas and crumbling sheetrock behind baseboards;
c. Air Conditioning window unit with stiff linen, with light brown stains/discoloration in uneven pattern, duct taped in place between air conditioner and window, around the perimeter of the unit.
d. rolling stool with crack in top of vinyl covering;
e. large therapy table with soiled areas and fine debris in areas;
f. pipes and facets in wall were sink had been removed with splatters of discolored, dried liquids, as was the wall surrounding the pipes;
g. used, soiled, uncovered foam positioning wedge pitted with missing areas of foam, sitting on large therapy bed;
h. Hydrocollator filled with clear liquid, and containing two fabric packs. One pack was discolored with numerous small spots of black around the middle (where it wrapped over a vertical piece of metal within the Hydrocollator). The Hydrocollator was not on or warm. S2DON, present for the tour reported it had been a long time since the Hydrocollator or the packs had been used. S2DON indicated the black spots on the cloth heating pad looked like mold to her.

Patient Shower Room
a. air conditioning vent separated from wall;
b. air vent in ceiling rusted, covered with a powdery gray substance;
c. spotted white coating noted on shower head;
d. surface of shower stall noted to be pitted;
e. lighting in shower room very dim, surveyor had to use flashlight to observe the shower room;
f. dark gray coating noted on shower curtain surface;
g. wheels on shower chair rusted.


Patient Tub Room
a. former shower stall noted to have large open holes in both sides of the sheetrock, exposing plumbing pipes.

Hallway between nurses' station and courtyard:
a. Ceiling tile noted to be wet, due to an active leak, and half of the ceiling tile had fallen down revealing circular shaped disk-like material and fluffy off-white material.

Patient Room #2
a. vinyl molding around base of walls not attached around bathroom door, with exposed areas behind with debris and crumbled wall material;
b. lighting not bright with all lights turned on.

Patient Room #3
a. baseboards contained peeling paint;
b. fluorescent light in patient room flickering;
c. window noted to have a 1/4 inch to 1/8 inch gap, unable to close window completely;
d. fitted bed sheet noted to have holes;
e. 2 fluorescent lights with 4 bulbs in each light in patient bathroom with only 1 bulb working. Bathroom lighting very dim, dark even though the observation was conducted at mid-day.

Patient Room #7
a. toilet with no toilet seat;
b. baseboards separating from the wall;
c. air conditioning unit vents noted to have a fine layer of gray powdery substance;
d. end of over-bed fluorescent light fixture missing;
e. brownish/rust colored drip marks noted in streaks on the wall by the patient bed;
f. bed with regular fabric (absorbent) mattress with no cleanable mattress cover;
g. lighting very dim with all lights turned on;
h wall-mounted sharps box filled to top with exposed butterfly needle with blood in tubing and dark brownish red smears and splatter marks on outside of box.

S2DON, present for the observation, verified the sharps box was overfilled and should have been replaced before being filled to the present contents. S2DON indicated the smears and splatters on the outside of the box looked like blood to her and should have been cleaned and disinfected when they occurred. S2DON also verified the light was very dim and an accurate assessment of a patient could not be made in the present lighting. S2DON reported the bed in Room 7 was for patient family members. S2DON verified that the mattress was not able to be disinfected after use in a patient's room and should have had a mattress cover on it.

Patient Room #9
a. patient bed mattress contained an approximately 5 inch tear in the upper part of the top surface;
b. wall-mounted sharps box was filled above the line indicating it should be changed;
c. window screen with tears in it;
d. the toilet lid was worn with exposed fiberboard.

Patient Room #10
-Semi-private room
a. 2 large kitchen-sized rubber/plastic trash cans and 1 small (approximately 2 1/2 gallon sized per S2DON) trash can noted. Of these trash cans, 1 large can was approximately 3/4 full, of a clear liquid slowly dripping from the ceiling tiles. The other large trash can was approximately 1/3 full, and the 3rd smaller can was approximately 2/3 full;
b. a used foam positioning device in closet;
c. straight-backed chair with 3 tears in the vinyl covering, and exposed foam padding;
d. wall-mounted sharps box filled above the "change" line;

Patient Room #12
a. lighting very dark in room with all lights turned on;
b. lighting in bathroom very dark with all lights turned on;
c. electrical cords for television loose across walk path around foot of bed to dresser, upon which the television sat, and plugged into and electrical power strip loose on floor;
d. floor covered in dark brownish black material that was easily removed by S15MR/HK with a disinfectant wipe;
e. plastic utensil handle (spoon or fork end broken off) was taped, with silk tape which was soiled, to the outer edge of the strike plate in the doorframe. S2DON verified the observations, including the tape holding the plastic utensil handle was soiled.

Patient Room 13
a. baseboards buckling, separating from the wall;
b. electrical box missing faceplate, exposing wires;
c. non- functioning air conditioning unit with broken vents;
d. fluorescent bulbs burned out in overhead light fixture;
e. cords draped from corner to corner, hanging from the ceiling, unsecured;
f. a large spiderweb was noted in the upper left corner of the room, near the ceiling;
g. hole in the flooring/floor tile;
h. Styrofoam ice chest cover used to secure window air conditioning unit in the window, taped with duct tape.

Doorframe leading to staff breakroom coated in a layer of grayish powdery substance the entire length of the doorframe.


In an interview 4/9/18 at 11:45 a.m. S2DON and S15MR/HK , both present for the tour of the hospital areas, verified the above observations.

The above referenced findings were verified with S15MR/HK and S2DON during the observation on 4/9/18.
In an interview 4/9/18 at 11:30 a.m. S2DON, when asked about the lighting in most patient rooms, confirmed she would not be able to accurately determine a patient's skin appearance in the lighting available (observations made with all room lights turned on) to determine if they were cyanotic (having bluish or purplish discoloration of the skin or mucous membranes due to decreased oxygen) or jaundiced (yellowing of the skin or whites of eyes). S2DON indicated she did not know how long the lighting in the majority of patient rooms and patient care areas such as the shower room had been dim or if a work request had been submitted. S15MR/HK reported the hospital did not have a Facilities Manager. S15MR/MK indicated that the owners of the building would be called for maintenance, or an individual that would sometimes come do some maintenance and repairs.

In an interview 4/11/18 at 3:20 p.m. S1ADM indicated he was not aware of the problems, identified by surveyors, in the patient care environment prior to this survey.

After numerous requests for copies of maintenance work requests and orders on 4/9/18 and 4/11/18 no copies of these documents were provided by the end of the survey.

Review of a lease agreement revealed the following:
Lease for the property at the hospital's current signed March 22, 2001, for 5 years ,with option to renew for 5 years with notice within 120 days of expiration. Further review revealed lessor's responsibilities included :Conditions of premises: responsible for maintenance of roof, gutters, downspouts, exterior wall, foundation and components parts of the Leased Premises. ..repairs of the heating , ventilation and air condition. Further review revealed no responsibility by the lessor for repairs to the interior of the building.

In an interview 4/11/18 at 10:00 a.m. S1ADM reported the lease was still in effect, and was auto renewing from year to year. The lease was reviewed with the administrator and pointed out the lease read that it would be in effect for 5 years with an option to renew for another 5 years, if notification was given within 120 days of its expiration, with signatures dated 2001. A request was made for a letter from the company from who the hospital leased the property and building, or a phone number for the surveyor to contact the company in order to verify the lease was still active.

Review of a letter dated 4/11/18, provided by S1ADM from the CPA representing the estate of the original party of the lease, revealed in regards to the property of the present site of the hospital, it was owned by Corp. "a" , but there was not an active lease agreement between the Corp. "a" and Southeast Regional Medical Center, and current agreement was on a month to month basis.


2) Failure to maintain an equipment maintenance program, as evidenced by no inspections and preventive maintenance by qualified personnel in over 2 1/2 years.

Review of a list of contracts and agreements revealed a contract with Company "b" for biomedical inspection and maintenance. As the date on the agreement was several years old, a phone number for the Company "b", or verification from Company "b", on official letterhead, to verify a current agreement. A list of equipment with the preventive maintenance for 2017 and 2018, if already performed was again requested.

Review of a list of hospital patient care equipment and inspection dates provided 4/11/18 at 3:15 p.m., revealed the last inspection done by company "b" was 6/15/15. The documents were provided by the Administrator, who verified the last time the equipment was inspected was in June of 2015.

In an interview 4/11/18 at 3:20 p.m. S1ADM confirmed the contract with Biomedical company from 2013 was not current because of nonpayment, and the hospital did not have any other contract or agreement for the provision of preventive maintenance of medical equipment. S1ADM confirmed the hospital's medical equipment had not been inspected and/or serviced since June of 2015.


30984

Based on record review, observation and interview the hospital failed to ensure adequate light was maintained in patient care areas to ensure accurate assessments of patients and proper visualization of procedures performed. This deficient practice was evidenced by patient rooms, bathrooms, and patient tub room that were very dark with all room lights on.
Findings:

Review of a hospital policy titled "Physical Environment" (1/2/01), provided by S8HR as current, revealed in part the hospital maintained adequate facilities to ensure the health and safety of patients and staff. Regular inspection by the Director of Maintenance was to be performed and reported to the Administrator.

A tour of the hospital was conducted 4/9/18 from 9:50 a.m. to 11:52 a.m. , with S2DON and S15MR/HK. The following observations were made related to lighting in the patient care areas.

Patient Room #2
An observation in Room #2 revealed the lighting was very dim with all lights turned on.

Patient Room #3
An observation of Patient Room #3 revealed 2 fluorescent lights with 4 bulbs in each light in patient bathroom with only 1 bulb working. Bathroom lighting was observed to be very dim, dark even though the observation was conducted at mid-day.

Patient Shower Room
An observation of the Patient Shower Room revealed lighting in shower room was very dim,; surveyor had to use flashlight to observe the shower room.

Patient Room #7
An observation of Patient Room #7 revealed the lighting very dim with all lights turned on.

Patient Room #9
An observation in Patient Room #9 revealed the lighting was very dim with all lights turned on both in the patient room and the bathroom.

Patient Room #10
-Semi-private room
An observation in Patient Room #10 revealed the room was very dim with all the lights turned on in both patient bed areas.

Patient Room # 12
An observation of Patient Room #12 revealed the lighting was very dark in room with all lights turned on. Further review revealed the lighting in the bathroom was very dark with all lights turned on.

In an interview 4/9/18 at 11:45 a.m. S2DON and S15MR/HK , both present for the tour of the hospital areas, verified the above referenced observations. S15MR/HK reported the hospital did not have a Director of Maintenance. S15MR/HK reported that the facility was maintained by the owners of the building from whom it was leased. S15MR/HK further reported that the hospital had a man that would come and make some repairs when he was called.

In an interview 4/9/18 at 11:30 a.m. S2DON, when asked about the lighting in most patient rooms, confirmed she would not be able to accurately determine a patient's skin appearance in the lighting available (will all room lights turned on) to determine if they were cyanotic (having bluish or purplish discoloration of the skin or mucous membranes due to decreased oxygen) or jaundiced (yellowing of the skin or whites of eyes). S2DON indicated she did not know how long the lighting in the majority of patient rooms and patient care areas such as the shower room had been dim or if a work request had been submitted.

In an interview 4/11/18 at 3:20 p.m. S1ADM indicated he was not aware of the problems, identified by surveyors, in the patient care environment prior to this survey.

After numerous requests for copies of maintenance work requests and orders on 4/9/18 and 4/11/18 no copies of these documents were provided by the end of the survey.

Based on observations, record reviews, and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice as evidenced by:

1) failure to ensure surveillance and training were adequate to ensure staff compliance with hand hygiene and PPE use practices, as evidenced by multiple hand hygiene and PPE use breaches observed;
2) failure to clean and disinfect the hospital glucometer after performing a capillary blood glucose on a patient before returning it to the carry case and placing in the medication workroom;
3) failure to maintain a sanitary environment in the hospital, evidenced by observations of equipment and practices that did not provide infection control during a hospital tour;
4) failure to ensure expired labor supplies were not available for use, as evidenced by blood culture collection bottles and urine culture sets with expiration dates prior to observations.
5) failure to ensure sharps disposal boxes were replaced before they were filled beyond "fill to line".
6) failure to have a current pest control/prevention program in place.
This deficiency was written on the recertification survey dated 05/18/15 also.
Findings:

1) hand hygiene breeches by staff providing patient care.

An observation conducted 4/10/18 at 3:05 p.m. to 3:55 p.m. revealed S9LPN and S10RN providing care to Patient #1. The nurses were provided a dressing change, hygiene, and pericare. S2DON was present for the care provided. The following observations of infection control breaches related to hand hygiene and glove use during the provision of care were observed by surveyors:

A capillary blood glucose test was performed on Patient #1 by S9LPN, using a portable glucometer. The glucometer was taken into the patient's room in a small plastic carrier which also contained gauze squares, alcohol wipes, and individual lancing devices (to prick the finger). After obtaining the glucose reading from the glucometer, S9LPN returned the glucometer to the carrier without disinfecting the machine. She then removed her gloves (no hand hygiene performed) and retrieved some wound care supplies from a rolling wound care cart located in the hallway,just outside the patient's door. After retrieving the wound care supplies S9LPN donned another pair of gloves (without hand hygiene). S10RN had rolled the patient to one side to expose a long surgical bandage on her hip and upper leg, and was holding her in position for the dressing change. S9LPN removed the bandage, with the help of S10RN. S2DON donned a pair of gloves to assist (without hand hygiene before donning the gloves). The stapled surgical wound was assessed by the nurses, and was noted to have some clear, reddish fluid running from the upper part of the incision. S10RN touched the wound and pressed on the surrounding area. S2DON opened a packed of sterile sponges and poured some sterile saline into the sponge container, from which S10RN took the sponges and proceeded to clean the wound (without changing gloves after removing the soiled bandage and touching the wound.) The LPN, after donning a clean pair of gloves, opened the new bandages and put her hands into her scrub pockets, looking for some scissors, and when she didn't find them, opened the patient's bedside table drawer, reached in and moved around some items, then went to the wound care cart, where clean supplies are kept, and opened a drawer and retrieved some scissors, and proceeded to cut the bandage to the needed size (without changing gloves after contamination in her pocket, patient's bedside drawer, or before reaching into the wound care cart containing clean supplies.) S10RN changed her gloves during this time (without performing hand hygiene) and lay the used gloves on the patient's bedsheet, near her head. S9LPN then touched her own hair with her bare hands, pushing it back, then opened and cut a clean/sterile clear occlusive dressing to cover and protect the clean bandage . S9LPN handed the occlusive bandages to S10RN to apply over the new dressing (without performing hand hygiene). After completion of the dressing change, the nurses changed the underpads under Patient #1, and performed pericare. S10RN cleaned a small amount of stool from the patient's buttocks, and applied barrier cream (protective cream) to the patient's buttocks and anal area (still without changing gloves),rolled the soiled and wet underpad, and placed the rolled clean one under the patient. S10RN and S9LPN rolled the patient to the opposite side, then S9LPN opened the bedside table (with the same gloves she had used to roll and hold patient while pericare was given by S10RN) and retrieved a bottle of lotion which she applied to the patient's skin on her buttocks. When S9LPN removed a wipe from a package held by S2DON, she (S9LPN) steadied the bottom of the package with one hand (with contaminated gloves), while removing a wipe with the other gloved hand . After cleaning the patient's other side of her buttock, S9LPN retrieved some barrier cream from the tube, wiping her hand across the top of the tube with her contaminated gloves.
Without changing gloves, S10RN retrieved 2 clean pillows from a chair and positioned them under the patient's feet, and one between her ankles for positioning. S10RN retrieved a fresh bedsheet and spread it over Patient #1 and positioned her, still with the same contaminated pair of gloves used for the dressing change, and pericare. With gloves removed and hand hygiene performed, S9LPN rolled the wound care cart back to the hallway just outside of the nurse's station. The LPN picked up the plastic carrier containing the glucometer and supplies and put it on the counter in the the medication/workroom attached to the nurse's station without disinfecting the glucometer or the carrier.

In an interview 4/10/18 at 3:55 p.m. S9LPN verified she had not cleaned and disinfected the glucometer after use on the patient. The LPN acknowledged by placing the contaminated glucometer in the carrier with the other clean supplies before disinfecting it, the inside of the carrier and other clean supplies were now contaminated. S9LPN acknowledged hand hygiene breaches and missed opportunities, as well as beaches in aseptic technique during the observed patient care. S9LPN verified that she had acrylic nails on her hands, and indicated was not supposed to work with acrylic nails.

In an interview 4/10/18 at 3:47 p.m. S10RN, after reviewing hand hygiene, use of PPE , and aseptic techniques observed, nodded her head and said nothing.

In an interview 4/10/18 at 3:50 p.m., after a review of observations made of Patient #1's care, S2DON acknowledged all breaches and indicated she made the same observations. S2DON reported she had noticed the acrylic nails on S9LPN during the observed care, and indicated staff were not allowed to wear acrylic nails.

In an interview 4/11/18 at 1:00 p.m. S5IC indicated she was not aware of the infection control issues observed by surveyors. She reported she made environmental rounds monthly with S4IC, and performed surveillance of hand hygiene. S5IC verified she only observed 1, occasionally 2 staff members per month for hand hygiene and PPE use. After being informed of the observations of infection control breaches made by surveyors, S5IC indicated the 1 or 2 observations monthly were probably not enough.


2) failure to clean and disinfect the hospital glucometer after performing a capillary blood glucose on a patient before returning it to the carry case and placing in the medication workroom.

Review of hospital policy and procedure titled "Glucose Monitoring", provided by S5IC as current, revealed disinfection of the glucometer after use was not documented as part of the procedure. No other policy and procedure was provided that addressed when and how the glucometer was to be cleaned and disinfected.

An observation conducted 4/10/18 at 3:05 p.m. to 3:55 p.m. revealed S9LPN performed a capillary blood glucose test on Patient #1 , using a portable glucometer. The glucometer was taken into the patient's room in a small plastic carrier which also contained gauze squares, alcohol wipes, and individual disposable lancing devices. After obtaining the glucose reading f, S9LPN returned the glucometer to the carrier without disinfecting the machine. After assisting in other care for Patient #1, S9LPN took the plastic carrier containing the glucometer and supplies and put it on the counter in the the medication/workroom attached to the nurse's station without disinfecting the glucometer or the carrier.

In an interview 4/10/18 at 3:55 p.m. S9LPN acknowledged that by placing the contaminated glucometer in the carrier with the other clean supplies before disinfecting it, the inside of the carrier and other clean supplies were now contaminated.


3) Failure to maintain a sanitary environment in the hospital.

An observation of the hospital by surveyors on 4/9/18 from 9:50 a.m. to 11:52 a.m. , with S2DON and S15MR/HK, revealed the following:
Central Supply room:
a. covered rubber container of supplies had droplets of dark brown liquid on top of container, identified by S15MR/HK, as a spill of a soft drink. Further observation revealed a soft drink can, opened and partially empty, on counter near container;
b. 3 x 3 inch piece of tape and old tape residue with brown coloration on edges stuck on work counter;
c. soiled areas on cabinet doors;
d. 7 ceiling tiles with light rust-colored stains, identified by S15MR/HK as water stains;
e. small debris of brownish material in medium sized empty baskets lined on counter tops, verified by S15MR/HK and identified as baskets used to store supplies;
f. bottom shelf of shelving unit, containing 17 packages of bath wipes and 12 cans of shaving cream, was approximately 1 inch from floor with a front that covered the small space to the flooring.

Clean equipment room:
a. Oxygen concentrator noted to have a coat of grayish powdery substance;
b. 3 wheelchair leg pieces piled one on top of the other in a basket, noted to have rusted areas on the metal surface, and covered in a coat of grayish powdery substance.
c. 3 rolling IV poles with numerous rough brownish-red areas, identified as rust by S15MR/HK;
d. several large "cracks in plastered walls. S15MR/HK verified the cracks prevented proper cleaning/disinfection of the walls in the Clean equipment room.
e. 7 ceiling tiles with rings of light brownish discoloration;
f . 3 wheelchairs with cracks or tears in the arm padding, with foam exposed on 2 of them. One wheelchair had a missing arm pad.
g. shower chair with rusted areas.


Storage Room on Hallway A:

a. numerous black plastic bags, open, with clothing in them, medium sized tote bags with clothes in them, piled so that they were stacked and completely covered the floor in the front and middle parts of the room. To walk into the middle and back of the room, some bags had to be moved or stepped over. The double sink in the room was filled with black plastic bags to approximately a foot above the sinks.
b. open boxes of holiday decorations piled on counters and the floor. A medium sized artificial Christmas tree was leaned against a counter.
c. a full prosthetic leg, with a sock and tennis shoe on the leg was standing in the middle of the back section of the room;
d. extremity splints and cast shoes, some uncovered, one previously used as evidenced by outline of a foot drawn in permanent marker and unwrapped;
e. cardboard boxes, one filled with used and dusty paperback books;
f. soiled coffle cups on shelf;
g. numerous extremity splints, cloth extremity immobilizes, all open without any packaging, with no way determine if they had been previously used as they were covered with a fine powdery dust.

S15MR/HK reported this room was called the "junk room" which contained clothes and belonging from patients who had been discharged, left the belongings, and not returned to claim them. She indicated she did not know just how long the belongings had been collecting in the storage room, but "for a while". S15MR/HK verified the observations and agreed the current room condition and arrangement of contents could attract pests.

Hallway "A"

a. air vent stained with rust colored spots, metal surface rusted, and coated with grayish powdery substance
b. baseboard outside of clean linen room buckling and separating from the wall.
c. hole in the sheetrock wall behind the door leading to the gym
d. air vent stained with rust colored spots, metal surface rusted, and coated with grayish powdery substance
e. 2 window air conditioning units secured in the windows with old duct tape and a piece of cloth that was stained with rust colored marks and the fabric was stiff to touch. The louvered windows above the window units were taped shut with duct tape that had the top layer of tape cracking and peeling off, leaving heavy tape residue on large areas taped.


Therapy/Patient Gym:
a. crack in tile in the gym floor near door leading to the back of dietary department;
b. numerous areas of loose vinyl baseboards with open areas behind the loose baseboards,and debris and crumbling sheetrock behind baseboards;
c. Air Conditioning window unit with stiff linen, bearing light brown stains/discoloration in an uneven pattern, duct taped in place between air conditioner and window, around the perimeter of the unit.. rolling stool with crack in top of vinyl covering;
d. large therapy table with soiled areas and fine debris in areas;
e. pipes and facets in wall were sink had been removed with splatters of discolored, dried liquids, as was the wall surrounding the pipes.
f. used, soiled, uncovered foam positioning wedge pitted with missing areas of foam, sitting on large therapy bed;
g. Hydrocollator filled with clear liquid, and containing two fabric packs. One pack was discolored with numerous small spots of black around the middle (where it wrapped over a vertical piece of metal within the Hydrocollator). The Hydrocollator was not on or warm. The DON, present for the tour reported it had been a long time since the Hydrocollator or the packs had been used. The DON indicated the black spots on the cloth heating pad looked like mold to to her..


Patient Shower Room
a. air vent in ceiling rusted, covered with a powdery gray substance
b. spotted white coating noted on shower head
c. dark gray coating noted on shower curtain surface.
d. wheels on shower chair rusted


Patient Tub Room
a. former shower stall , located in open tub room, noted to have large open holes in both sides of the sheetrock, exposing plumbing pipes, large enough for a child to fit into.

Hallway between nurses' station and courtyard:
a. Ceiling tile noted to be wet, due to an active leak, and half of the ceiling tile had fallen down revealing circular shaped disk-like material and fluffy off-white material.
b. Doorframe leading to staff breakroom (next to nurse's station) coated in a layer of grayish powdery substance the entire length of the doorframe.

Patient Room #2
a. vinyl molding around base of walls not attached around bathroom door, with exposed areas behind with debris and crumbled wall material;

Patient Room# 3
a. baseboards peeling paint
b. window noted to have a 1/4 inch to 1/8 inch gap, unable to close window completely
c. floor visibly dirty

Room #7
a. bed with regular fabric (absorbent) mattress with no mattress cover on;
b. wall-mounted sharps box filled to top with exposed butterfly needle with blood in tubing and dark brownish red smears and splatter marks on outside of box.
c. baseboards separating from the wall, with exposed gap at bottom of wall with pieces of debris and crumbled sheetrock;
d. air conditioning unit vents noted to have a fine layer of gray powdery substance;
e. brownish/rust colored drip marks noted in drip pattern on the wall by the patient bed;

S2DON, present for the observation ,verified the sharps box was overfilled and should have been replaced before being filled to the present contents. S2DON indicated the smears and splatters on the outside of the box looked like blood to her and should have been cleaned and disinfected when they occurred. The DON verified that the mattress was not able to be disinfected after use in a patient's room and should have had a mattress cover on it.

Room #9
a. patient bed mattress contained an approximately 5 inch tear in the upper part of the surface on which a patient would lie.
b. window screen with tears in it. The window opened and shut easily.
c. the toilet lid was worn, exposing areas with exposed fiberboard.

Room 10
-Semi-private room
a. 2 large kitchen-sized rubber/plastic trash cans and 1 small (approximately 2 1/2 gallon sized per S2DON) trash can noted. Of these trash cans, 1 large can was approximately 3/4 full, of a clear liquid slowly dripping from the ceiling tiles. The second large trash can was approximately 1/3 full, and the 3rd smaller can was approximately 2/3 full.
b. a used foam positioning device in closet;
c. straight-backed chair with 3 tears in the vinyl covering, and exposed foam padding.
.
Patient Room 12
a. Fabric draperies with thin fabric lining and batting between layers, cut and unhemmed to fit around portable window air conditioner in window.
b. floor covered in dark brownish black material that was easily removed by S15MR/HK with a disinfectant wipe;
c. plastic utensil handle (spoon or fork end broken off) was taped, with silk tape which was soiled, to the outer edge of the strike plate in the doorframe. S2DON verified the observations, including the tape holding the plastic utensil handle was soiled.

Patient Room 13
a. baseboards buckling, separating from the wall, leaving hole behind vinyl baseboard exposed;
b a large spiderweb was noted in the upper left corner of the room, near the ceiling
c. hole in the flooring/floor tile
d. Styrofoam ice chest cover used to secure window air conditioning unit in the window, taped in place with duct tape, with areas of direct exposure to outside.

In an interview 4/9/18 at 11:45 a.m. S2DON and S15MR/HK , both present for the tour of the hospital areas,verified the above observations and agreed these identified observations represented Infection Control issues.



4) failure to ensure expired labor supplies were not available for use, as evidenced by blood culture collection bottles and urine culture sets with expiration dates prior to observations.

An observation 4/9/18 during a hospital tour, accompanied by S2DON and S15MR/HK, from 9:50 a.m. to 11:52 a.m., revealed, in the medication/nursing work room off the nurse's station, 2 urine culture kits containing vacutainer specimen tubes with an expiration date of 1/2018. Further observation revealed 2- 30 ml. aerobic blood culture bottles with one expiration date 12/9/17 and the other 3/29/18. 5-30 ml. anaerobic blood culture bottles had expiration dates of 2/21/18 or 1/05/18. S9LPN, present during the observations verified the findings and indicated the lab supplies should have been removed to prevent use of the expired bottles and vacutainers.


5) failure to ensure sharps disposal boxes were replaced before they were filled beyond "fill to line".

Observations may during a tour of the hospital on 4/9/18 from 9:50 a.m. to 11:52 a.m., with S2DON, revealed the wall-mounted sharps containers in Patient Rooms #7, #9, and #10 were filled well above a line that instructed not to fill beyond it (the line).

In an interview during the tour S2DON, present for the tour verified the sharps boxes were overfilled, and should have been replaced by nursing staff when they were at or getting near the fill line located on each box. .


6) failure to have a current pest control/prevention program in place.

Review of a list of hospital contracts and agreements revealed the hospital had an agreement with Company "c" for pest control services. Further review of a contract binder revealed no current contract or agreement with Company "c".

In an interview 9/11/18 at 10:10 a.m. S1ADM reported the hospital did have a current pest control contract. A request was made to provide a current agreement/contract between the company and the hospital. Invoices for the last 6 months of pest control services were also requested at that time.

Review of a service agreement, provided by S8HR 4/11/18 at 5:10 p.m. , revealed the agreement was signed 4/11/18 by a representative from Company "c" and S1ADM. In an interview at this same time, S8HR was asked if this agreement was just signed and began as of today. S8HR replied, "I think so, this morning." A request was made for any invoices or other documentation, for the last 6 months, of any pest control services provided in/to the hospital.

In an interview 4/11/18 at 6:30 p.m. S1ADM was asked if he could provide any documentation of pest control services performed in the hospital. S1ADM indicated he had not found any.

No documentation showing the hospital had received pest control services during 2017 or 2018 was provided by the end of the survey.


30984

Based on interview and record review, the hospital failed to ensure respiratory services were provided by personnel qualified to perform those services. This deficient practice was evidenced by no documented competencies for 5 of 5 (S2DON, S5IC, S7RT, S9LPN, S10RN) personnel files reviewed for respiratory competencies, of 16 listed personnel who, by their discipline would be in a position to provide respiratory services. This deficiency was written on the recertification survey on 05/18/15 also.

Findings:

Review of personnel files for S2DON, S5IC, S7RT, S9LPN, and S10RN revealed no respiratory competencies.

In an interview 4/11/18 at 10:40 a.m. S17LPN reported S7RT comes to the hospital for any patient with respiratory needs, assesses them, then asks the provider for orders. She reported the LPNs and RNs administered the respiratory treatments ordered for patients.

In an interview on 4/11/18 at 6:35 p.m., with S2DON, she indicated the nursing staff administered nebulizer treatments, monitored oxygen administration, suctioned patients and performed incentive spirometry. S2DON confirmed S7RT would come to the hospital and evaluate newly admitted patients that required Respiratory Services and make recommendations for the providers. She confirmed the type of respiratory services provided, and that nurses (RNs and LPNs) provided the respiratory treatments. S2DON verified there were no verified competencies for S7RT or any of the nurses on staff.