HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to ensure medical records for each patient were promptly completed within 30 days of discharge. (see findings at A-0438).

2) Failing to ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing the service as evidenced by physicians not authenticating medical records entries in accordance with Medical Staff Bylaws for 5 (#1, #2, #8 #13, #17) of 15 medical records reviewed for authentication of medical record entries from a total sample of 30. (see findings at A-0450).

3) Failing to ensure all verbal orders had been authenticated (signed, dated and timed) within 10 days as required by hospital policy for 5 (#1, #6, #10, #12, #13) of 10 patient's medical records reviewed for authentication of verbal orders out of a total of 30. (see findings at A-0454).

4) Failing to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent and required information areas were left blank for 4 of 4 (#1, #3, #4, #5) patients reviewed for properly executed informed consents out of a total sample of 30. (see findings at A-0466).

5) Failing to ensure all patient records included documentation of outcomes of hospitalization, disposition of care and provisions for follow-up care as evidenced by the failing to ensure the treating licensed practitioner completed a discharge summary for discharged patient records for 68 patients out of a total number of admissions of 129 patients for the year 2016 (per the deficiencey report provided by the hospital). (see findings at A-0468).

Based on record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by:
1) Failing to correctly identify and investigate/respond to a patient grievance for 1 of 1 (#18) patients reviewed for complaints/grievances;
2) Failing to ensure patient complaints related to food/dietary services were identified, investigated.

Findings:

Review of the hospital's policy titled, Patient-Family Grievances, A.1.02 revealed in part the following:
Complaints: 4. If resolution was not achieved by the actions taken by staff and the Charge Nurse, the Chief Clinical Officer will attempt to identify a solution acceptable to the patient, family member or representative. If patient, family member and/or representative are satisfied with outcome of complaint, no further action required. If patient, family member and/or family representative is still unsatisfied or if the verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is considered a grievance.

1) Failing to correctly identify and investigate/respond to a patient grievance for 1 of 1 (#18) patients reviewed for complaints/grievances:

Review of the hospital's Complaint/Grievance Log provided by S3QA on 01/03/17 revealed only 1 patient complaint was documented for the year 2016. Review of the log revealed the patient complaint involved Patient #18 and the event date was 12/26/16.

Review of the complaint/grievance report dated 12/26/16 at 6:35 a.m. revealed Patient #18 reported to S6RN that at 4:55 a.m., he was told that there was no Aide so he would have to wait until day shift to be cleaned up of stool. The report revealed the patient reported that it was the agency LPN that had told him this. Upon discovery of this, patient was cleaned up and given a shower with assistance.
Review of the Notification section of the complaint document revealed the following: S2CCO on 12/27/16 at 5:01 p.m.: "Spoke with S11RN regarding complaint. S11RN is aware this behavior is unexceptionable and at any time she needs assistance with patient care she must ask for help. Staffing for this shift was adequate." The document was signed by S2CCO on 01/04/17 at 9:21 a.m.
Review of the "Review" section revealed the following: Patient complained that Agency LPN told him that no CNA was available to clean him after he soiled himself and that he would have to wait until one was available. (Patient soiled himself at 4:55 a.m. and had to wait until 6:30 a.m. to be cleaned). When day shift rounded he told S6RN about the issue, she immediately cleaned patient and showered him. He was very satisfied with the care he was given by all staff throughout his stay. "Just this one nurse." Agency Company informed of nurse's behavior and nurse made a do not return (DNR). Corrective Actions documented were as follows: Agency notified and nurse made a DNR. The "Review" section was signed by S3QA on 01/04/17 at 11:25 a.m.
Review of the "Finalize" section of the document revealed the following:
Risk Management Review: It should be classified as a complaint.
Detailed summary: Agree with findings and Corrective Action Plan. Apology to patient, patient stated, "All staff great and treat me well, but her."
Do you want to start an investigation? No.
Severity Scale: Level 1: Occurrence: variances where the potential for litigation is thought to be non-existent. No injury or outcome that alters patient's, visitor's or employee's functions.
The "Finalize" section was signed by S3QA on 01/04/17 at 11:27 a.m.

There was no documented evidence of any investigation into the patient's complaint, or that the hospital had identified the complaint as a grievance.

In an interview on 01/04/17 at 1:10 p.m. S6RN confirmed she had received a complaint from Patient #18 as indicated above. S6RN stated the patient was alert and oriented and of sound mind and she believed what he reported. S6RN stated the stool was dried on the patient. S6RN stated she and the aide cleaned him and then the aide showered him. S6RN confirmed she had entered the patient's complaint into the hospital's ActionCue system. S6RN stated she thought it went to S2CCO for follow up. S6RN stated the next day S1CEO and S29Corporate CEO asked her about the incident. S6RN stated S29Corporate CEO told S1CEO to DNR the nurse. S6RN confirmed this patient complaint was a grievance and required an investigation.

On 01/04/17 at 1:40 p.m., an interview was conducted with S2CCO and S3QA with S1CEO present. S2CCO confirmed she had not entered the follow up information into the ActionCue system until today and stated she did not have access to the system at the time of incident. S2CCO stated she did not contact the staffing agency and she did not know anything about a do not return status for S11RN. S2CCO stated S11RN was still working at the hospital. S2CCO stated she spoke with S11RN about the incident yesterday (01/03/17) and she looked "dumbfounded." S1CEO stated he called the staffing agency and the staffing agency determined the nurse was a do not return. S1CEO stated the nurse involved was an LPN and not S11RN. S1CEO confirmed he had not documented any of his actions related to this complaint. S1CEO and S3QA stated because the patient's complaint was resolved at the time the staff was made aware of the complaint, then this was categorized as a complaint and not a grievance. S1CEO and S3QA confirmed no other investigation was done other than contact the nurse staffing agency. S1CEO, S2CCO and S3QA confirmed the documented follow up to the patient's complaint was inaccurate as the incident involved an Agency LPN and not S11RN.

In an interview on 01/05/17 at 3:05 p.m., with S1CEO, S3QA, S4RN, S2CCO, and S29Corporate CEO present, S29Corporate CEO reported that they were notified by a day Charge nurse of an allegation that an agency LPN had told a patient he would have to wait until a CNA came on duty on the next shift, when he asked to be cleaned due to having had a bowel movement. S29 Corporate CEO reported that although this was reported to the staffing agency, who said they would not send her back, there was no other investigation conducted by the hospital, they had not recognized this as neglect. S29Corporate CEO indicated that they now saw where it could be considered neglect of a patient.


2) Failing to ensure patient complaints related to food/dietary services were identified, investigated, and a patient response was provided:

Review of the hospital's Complaint/Grievance Log provided by S3QA on 01/03/17 revealed only 1 patient complaint was documented for the year 2016. There was no documented evidence of any complaints/grievances regarding food/dietary services on the log. S3QA confirmed there was only 1 patient complaint entered into the hospital's ActionCue system for the year 2016.

In an interview on 01/04/17 at 1:10 p.m., S6RN and S15LPN stated they have received many patient complaints about the food. S6RN stated the complaint were related to the lack of options, the timeliness of the meal delivery, and pureed food that was not appealing. S6RN confirmed none of the patient complaints related to food/dietary was entered into ActionCue. S6RN stated she had relayed the complaints to S7RD. S15LPN stated the patient complaints were related to receiving the same food over and over and not having meat on the meal. S6RN stated food is the number one complaint she hears and stated she had reported the complaints to S4RN. S6RN stated when the former DON was here the process was to document the patient complaint and give to the DON and he would input into the ActionCue system. S6RN confirmed she did not know if the former DON entered the complaints into the system. S6RN confirmed she had documented patient complaints and given them to the former DON.

On 01/04/17 at 1:40 p.m., an interview was conducted with S1CEO. S1CEO stated he had not received any complaints related to food services.

In an interview on 01/05/17 at 1:45 p.m., S7RD stated she had been employed at the hospital for about 6 days. S7RD confirmed she had received a complaint from the staff regarding the timing of the meals on the second day she was here. She stated the staff complained the meals were 30 minutes late. S7RD stated she had observed the pureed food and stated, "It is bad."

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Based on record review and interview, the hospital failed to ensure any incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to recognize a patient complaint, as an allegation of neglect (regarding a patient complaint that he had to lay in feces, when a nurse refused to clean him, telling him he would have to wait until the next shift assumed care, when a CNA would be staffed), report the incident within 24 hours to the Louisiana Department of Health, and investigate the allegations. Findings:

Review of La R.S. 40:2009.20 revealed the following:
A. As used in this Section, the following terms shall mean:
(2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.
B.(1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department....
Review of the hospital policy titled Suspected Abuse and Neglect, BH.1.57, revealed all instances of suspected or identified abuse or neglect within the program (by program/hospital staff) will be immediately reported to the Medical Director, the Clinical Coordinator, DON, and Administrator. The policy revealed an investigation would begin immediately and, at the discretion of the Administrator, the responsible staff member(s) may be placed on suspension pending findings of the investigation. The policy also revealed all instances of suspected abuse or neglect (whether internal or external to the program) would be investigated and reported as required by state law.

Review of the complaint/grievance report dated 12/26/16 at 6:35 a.m. revealed Patient #18 reported to S6RN that at 4:55 a.m., he was told that there was no Aide so he would have to wait until day shift to be cleaned up of stool. The report revealed the patient reported that it was the agency LPN that had told him this. Upon discovery of this, patient was cleaned up and given a shower with assistance.
Review of the Notification section of the complaint document revealed the following: S2CCO on 12/27/16 at 5:01 p.m.: "Spoke with S11RN regarding complaint. S11RN is aware this behavior is unexceptionable and at any time she needs assistance with patient care she must ask for help. Staffing for this shift was adequate." The document was signed by S2CCO on 01/04/17 at 9:21 a.m.
Review of the "Review" section revealed the following: Patient complained that Agency LPN told him that no CNA was available to clean him after he soiled himself and that he would have to wait until one was available. (Patient soiled himself at 4:55 a.m. and had to wait until 6:30 a.m. to be cleaned). When day shift rounded he told S6RN about the issue, she immediately cleaned patient and showered him. He was very satisfied with the care he was given by all staff throughout his stay. "Just this one nurse." Agency Company informed of nurse's behavior and nurse made a do not return (DNR). Corrective Actions documented were as follows: Agency notified and nurse made a DNR. The "Review" section was signed by S3QA on 01/04/17 at 11:25 a.m.
Review of the "Finalize" section of the document revealed the following:
Risk Management Review: It should be classified as a complaint.
Detailed summary: Agree with findings and Corrective Action Plan. Apology to patient, patient stated, "All staff great and treat me well, but her."
Do you want to start an investigation? No.
Severity Scale: Level 1: Occurrence: variances where the potential for litigation is thought to be non-existent. No injury or outcome that alters patient's, visitor's or employee's functions.
The "Finalize" section was signed by S3QA on 01/04/17 at 11:27 a.m.

There was no documented evidence of any investigation into the patient's complaint of neglect and there was no documented evidence that the incident was reported to the Louisiana Department of Health (Health Standards Section) as required by law.

In an interview on 01/04/17 at 1:10 p.m. S6RN confirmed she had received a complaint from Patient #18 as indicated above. S6RN stated the patient was alert and oriented and of sound mind and she believed what he reported. S6RN stated the stool was dried on the patient. S6RN stated she and the aide cleaned him and then the aide showered him. S6RN confirmed she had entered the patient's complaint into the hospital's ActionCue system. S6RN stated she thought it went to S2CCO for follow up. S6RN stated the next day S1CEO and S29Corporate CEO asked her about the incident. S6RN stated S29Corporate CEO told S1CEO to DNR (do not return) the nurse. S6RN confirmed this patient complaint was a grievance and required an investigation.

On 01/04/17 at 1:40 p.m., an interview was conducted with S2CCO and S3QA with S1CEO present. S2CCO confirmed she had not entered the follow up information into the ActionCue system until today and stated she did not have access to the system at the time of incident. S2CCO stated she did not contact the staffing agency and she did not know anything about a do not return status for S11RN. S2CCO stated S11RN was still working at the hospital. S2CCO stated she spoke with S11RN about the incident yesterday (01/03/17) and she looked "dumbfounded." S1CEO stated he called the staffing agency and the staffing agency determined the nurse was a do not return. S1CEO stated the nurse involved was an LPN and not S11RN. S1CEO confirmed he had not documented any of his actions related to this complaint. S1CEO and S3QA stated because the patient's complaint was resolved at the time the staff was made aware of the complaint (Patient was bathed), then this was categorized as a complaint and not a grievance. S1CEO and S3QA confirmed no other investigation was done other than contact the nurse staffing agency.

In a telephone interview on 01/05/17 at 1:35 p.m. S8LPN reported she had, at times, worked when another nurse would refuse to help her with turning or cleaning her assigned patients. S8LPN reported on one night, over the Christmas weekend, S24RN had come back to the desk and remarked that she had told a patient he would have to wait until a CNA came in to get cleaned up after having a bowel movement. S8LPN indicated the patient called on the nurse call system, and when she went into the patient's room to answer, he told her the other nurse had told him he would have to wait to be cleaned up. S8LPN indicated she cleaned the patient and told S24RN, who said nothing. S8LPN indicated she had not reported this to anyone. S8LPN asked if she needed to report this to someone in administration. She indicated she was not sure what the hospital's procedure was for reporting complaints, grievances, or allegations of abuse or neglect.

In a telephone interview on 01/05/17 at 2:55 p.m., S24RN reported she worked at the hospital as a Charge Nurse, usually with another LPN and a CNA. S24RN denied ever refusing to provide care to any patient, and denied any knowledge of any other staff member refusing to provide care to a patient. S24RN reported she had never received any complaints from a patient or patient's family. S24RN then reported she had received complaints from a patient a few weeks ago regarding the LPN on duty with her. She indicated the patient (she couldn't remember which one) had complained about the nurse not washing her hands and when she drew blood she (the LPN) left the PICC line cap off and he bled so much he had to receive blood. She said a family member had told her once that the patient's tray had been left sitting at the bedside all day, but that was several months ago, and she couldn't remember which patient. When asked what she did with this information, she reported she told the DON, who is no longer working at the hospital. She reported she did not put anything in writing.

In an interview on 01/05/17 at 3:05 p.m., with S1CEO, S3QA, S4RN, S2CCO, and S29Corporate CEO present, S29Corporate CEO reported that they were notified by a day Charge nurse of an allegation that an agency LPN had told a patient he would have to wait until a CNA came on duty on the next shift, when he asked to be cleaned due to having had a bowel movement. S29 Corporate CEO reported that although this was reported to the staffing agency, who said they would not send her back, there was no other investigation conducted by the hospital, they had not recognized this as neglect, and therefore had not reported it to Health Standards Section (Louisiana Department of Health). S29Corporate CEO indicated that they now saw where it could be considered neglect of a patient.

Based on record review and staff interview, the hospital failed to ensure restraints were used only when less restrictive interventions have been determined to be ineffective to protect the patient from harm for 1 of 1 (#30) sampled patients reviewed for restraints out of a total sample of 30 (#1-#30). Findings:

Review of the hospital policy titled, Restraints, K.11.07, revealed in part the following: Restraints will only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others. Consideration of less restrictive means: Prior to the initiation and/or continued use of a restraint, alternative means of protecting the patient will be considered and documented.

In an interview on 01/03/17 at 10:25 a.m., S6RN, Charge Nurse stated she had been employed at the hospital since May, 2016 and restraints have not been used. S6RN stated there was no restraint log.

Patient #30
Review of the medical record for Patient #30 revealed the patient was an 87 year old patient admitted to the hospital on 11/14/16 with a diagnosis of Acute Respiratory Failure. The record revealed the patient was admitted with a tracheostomy and on a ventilator. The nurse's notes dated 11/14/16 and 11/15/16 revealed bilateral wrist restraints were in use from the time of admission until 11/15/16 at 8:30 a.m. when the restraints were discontinued.

Review of the physician orders dated 11/14/16 revealed bilateral wrist restraints were ordered. Review of the restraint order form revealed a section to check the alternatives that were attempted prior to the use of the restraints. This section was left blank with no measures checked.

Review of the initial nursing assessment dated 11/14/16 at 3:50 p.m. revealed the following: Soft bilateral wrist restraints noted and in place. Patient with a history of trying to pull tracheostomy out. Will closely monitor patient's agitation for possible discontinue of restraints, if possible. The initial assessment also included the patient's motor response was withdrawal from pain only.
Further review of the nursing documentation for 11/14/16 and 11/15/16 revealed no documentation of agitation and only patient response was withdrawal from pain.


In an interview on 01/05/17 at 1:05 p.m., S4RN, Interim CCO reviewed the patient's record and confirmed restraints had been used on Patient #30. S4RN confirmed there was no documented evidence that less restrictive measures were attempted before continuing the restraints. S4RN confirmed the hospital did not have a restraint log and she was not aware that restraints had been used for this patient.

Based on record review and staff interview, the hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 1 of 1 (#30) sampled patients reviewed for the use of restraints out of a total sample of 30 (#1-#30). Findings:

Review of the hospital policy titled, Restraints, K.11.07, revealed in part the following: The care plan will be modified to reflect the need for restraint.

In an interview on 01/03/17 at 10:25 a.m., S6RN, Charge Nurse stated she had been employed at the hospital since May, 2016 and restraints have not been used. S6RN stated there was no restraint log.

Patient #30
Review of the medical record for Patient #30 revealed the patient was an 87 year old patient admitted to the hospital on 11/14/16 with a diagnosis of Acute Respiratory Failure. The record revealed the patient was admitted with a tracheostomy and on a ventilator. The nurse's notes dated 11/14/16 and 11/15/16 revealed bilateral wrist restraints were in use from the time of admission until 11/15/16 at 8:30 a.m. when the restraints were discontinued.

Review of the patient's Interdisciplinary Plan of Care revealed the care plan was initiated on 11/14/16. There was no documented evidence that the patient's restraints or potential for injury was included in the plan of care.

In an interview on 01/05/17 at 1:05 p.m., S4RN, Interim CCO reviewed the patient's record and confirmed restraints had been used on Patient #30 and the patient's plan of care had not been modified to include the use of restraints. S4RN confirmed the hospital did not have a restraint log and she was not aware that restraints had been used for this patient.

Based on record review and staff interview, the hospital failed to ensure staff were trained and demonstrated competency in the application of restraints and providing care for patients in restraints as evidenced by 3 of 3 (S6RN, S13LPN, S25LPN) nursing personnel records with no documented evidence of restraint training or competency evaluation. Findings:

Review of the hospital policy titled, Restraints, K.11.07, revealed in part the following: All staff that has direct patient care responsibilities shall receive initial education and training in the proper and safe use of restraints during orientation, prior to providing care for a patient in restraints and competency reassessment annually thereafter....Training and competency documentation shall be placed in the personnel records.

Review of the personnel records for S6RN, S13LPN, and S25LPN revealed the following dates of hires:
S6RN - 06/10/16
S13LPN - 10/27/16
S25LPN - 06/10/16
Further review of the personnel records for S6RN, S13LPN, and S25LPN revealed no documented evidence of restraint training and demonstrated competency in the application of restraints and providing care for patients in restraints.

In an interview on 01/05/17 at 2:45 p.m., S30HR and S3QA reviewed the above sampled personnel records and confirmed there was no documented evidence of any training or demonstrated competency in the use of restraints in the personnel records of S6RN, S13LPN, and S25LPN.

Based on record review and staff interview, the hospital failed to ensure quality indicators were measured, analyzed, and tracked as evidenced by failing to implement the monitoring activities identified in the hospital's quality improvement program. Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, E.5.06, revealed through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optional achievements, with appropriate accountability assumed by the Governing Board, Medical Staff, Administration, and support personnel.


Review of the ActionCue Report of Performance Measures for the year 2016 provided by S3QA as the updated, complete dashboard of quality indicators and data analysis revealed no documented evidence of data collection and analysis since June 2016 for medical record quality indicators of Discharge Summary Delinquency, Do Not Use Abbreviations, History & Physical Delinquency, Medical Record Delinquency, Medical Record Entries Authenticated Timely, Medical Record Entries Legible, and Verbal Orders Authenticated Timely.

Further review of the ActionCue Report revealed no documented evidence of data collection and analysis since February 2016 for medication management indicators of Adverse Drug Reaction Rate, Medication Error Rate, Medication Near Miss Rate, Medication Variance Rate, Medication Variance Severity-Median, Narcotic Count Deficiency Rate, and MDS Unnecessary Override Rate.

Review of the Organiztional Qualtiy Assurance/Performance Improvement Committee minutes revealed the only minutes available for review was dated 04/11/16. There was no documented evidence of committee meetings for the second and third quarters of 2016.

In an interview on 01/05/17 at 11:30 a.m., S3QA confirmed there was no documented evidence that the above quality indicators did not reflect any data collected or analyzed as indicated above. S3QA confirmed the QAPI program had not been implemented for medical records and medication management. S3QA confirmed the only QAPI committee meetings she could find were for 04/11/16.

Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program focused on high-risk, high-volume and/or problem-prone areas. This deficient practice was evidenced by the hospital's failure to:
1) identify and address hospital nursing staff's failure to continuously monitor cardiac rhythms as ordered by the physician, perform "Time Out" procedures, and conduct RN assessments at least every 24 hours;
2) identify and address delinquent medical records, and;
3) formulate, implement, and update corrective action plans to address identified problems.

Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, E.5.06 revealed in part the following: Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optional achievements, with appropriate accountability assumed by the Governing Board, Medical Staff, Administration, and support personnel. The organization has the responsibility of designing, measuring, assessing, and improving its performance and patient safety.

1) Identify and address hospital nursing staff's failure to continuously monitor cardiac rhythms as ordered by the physician, perform "Time Out" procedures, and conduct RN assessments at least every 24 hours:

Review of 5 (#1, #2, #7, #8, #9) of 15 patients' medical records reviewed for RN assessments revealed the RN failed to assess each patient at least every 24 hours as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of an RN assessment at a minimum of every 24 hours.

Review of 4 (#2, #9, #10, #18) of 30 patients sampled patients revealed the staff failed to ensure "Time Out" procedures for patient safety were performed by two staff members prior to the start of the procedure.

Review of 3 of 3 (#1, #4, #6) current patients on telemetry revealed the nursing staff failed to ensure patients with telemetry monitoring ordered by their physician were continuously monitored, and failed to ensure the telemetry hospital policy and procedure was followed for recording and interpreting rhythm strips.

Review of the QAPI records provided for review revealed no documented evidence that the above problems identified during the survey were identified by the QAPI program.

In an interview on 01/05/17 at 11:30 a.m., S3QA confirmed the above patient care problems had not been identified in the QAPI program.


2) Identify and address delinquent medical records:

Review of 5 (#1, #2, #8 #13, #17) of 15 medical records reviewed for authentication of medical record entries revealed the physician had failed to date, time and authenticate medical record entries.

Review of 5 (#1, #6, #10, #12, #13) of 10 patient's medical records revealed verbal orders had not been authenticated within 10 days as required by hospital policy.

Review of 4 of 4 (#1, #3, #4, #5) patients reviewed for properly executed informed consents for procedures revealed the consents were not completed in accordance with hospital policy. 4) Failing to ensure medical records included a properly executed informed consent for

Review of the medical records deficiency report revealed 68 patients records out of a total number of admissions of 129 patients for the year 2016 did not have a discharge summary completed by the treating practitioner.

Review of the QAPI records provided for review revealed no documented evidence that the above problems identified during the survey were identified by the QAPI program.

In an interview on 01/05/17 at 11:30 a.m., S3QA confirmed the above patient care problems had not been identified in the QAPI program.


3) Formulate, implement, and update corrective action plans to address identified problems:

Review of the only corrective action plans developed to address problems identified in the QAPI program revealed the following:
MDS Unnecessary Override Rate
Short Stay Outlier Discharge Rate
Medicare Case Mix Index
Medicare Length of Stay
Admission Documents Required

In an interview on 01/07/17 at 12:20 p.m., S3QA confirmed the above corrective action plans were the only current corrective action plans in place.

Based on record review and staff interview, the hospital failed to ensure performance improvement projects were conducted as evidenced by the hospital was unable to provide documented evidence of any performance improvement projects currently in progress or any project that was conducted in the past year (2016). Findings:

On 01/05/17, the QAPI documents provided for review by S3QA revealed no documented evidence of a current QAPI project and there was no documented evidence of a PI projected conducted in 2016.

Review of the hospital policy titled, Improving Organizational Performance Plan, E.5.06, revealed the Governing Body established a QAPI committee to implement the Performance Improvement Program and the QAPI committee was responsible to provide guidance to facilitate Performance Improvement teams and projects.

In an interview on 01/05/17 at 11:30 a.m., S3QA stated the hospital was supposed to have a corporate fall PI project in place but she had been unable to find documentation of that. S3QA confirmed she was unable to provide documentation of a PI project in 2016 and could not provide documentation of a current PI project.

Based on record review and staff interview, the hospital's governing body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, E.5.06, revealed the scope of the Performance Improvement Program included measurement and assessment activities which address patients served by the Medical Staff, Nursing, and ancillary services and hospital wide functions. Both clinical and non-clinical departments are included.

Review of the ActionCue Report of Quality Indicators (Dashboard) provided by S3QA as the updated, complete version of quality indicators and performance measures monitored for 2016 revealed the following services were not included in the QAPI program and no data was collected for: Dietary services, organ procurement, physical therapy, occupational therapy, and speech therapy.

In an interview on 01/05/17 at 11:30 a.m., S3QA reviewed the above ActionCue report of performance measures and confirmed dietary services, organ procurement, physical therapy, occupational therapy, and speech therapy were not included in the QAPI program for 2016.

Based on record review and interview, the medical staff failed to enforce its medical staff bylaws as evidenced by physicians with delinquent medical records and physicians who did not document a discharge summary on their patients were not referred to the Medical Executive Committee for consideration for disciplinary action as indicated in the hospital's Medical Staff Bylaws. Findings:


Review of the Medical Staff By-laws revealed in part, The attending physician shall be responsible for the preparation of a complete medical record for each patient...No medical record shall be filed until it is complete, except on order of the Medical Record Review Function with proper documentation... A medical record should be considered "delinquent" if not complete within 30 days following discharge... A practitioner with delinquent medical records shall be referred to the Medical Executive Committee for consideration of disciplinary action.

Review of the Medical Record Deficiency Rate for 2016 revealed:
S27MD had 62 deficiencies (19 being no discharge summaries) out of 24 medical records.
S18MD had 53 deficiencies (33 being no discharge summaries) out of 40 medical records.
S22NP had 9 deficiencies out of 9 medical records.
S19MD had 46 deficiencies out of 19 medical records.
S28NP had 4 deficiencies out of 3 medical records.

An interview was conducted with S1CEO on 1/04/17 at 3:30 p.m. He reported he was only made aware of the issues with deficient medical records today and he was currently not aware of any physician referrals made to Medical Executive Committee for consideration of disciplinary actions for delinquent medical records.

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30364


Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) failing to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of an RN assessment at a minimum of every 24 hours for 5 (#1, #2, #7, #8, #9) of 15 patients' medical records reviewed for RN assessments out of a total sample of 30;

2) failing to ensure Vancomycin troughs were obtained as ordered for 3 of 3 (#2, #5, #24) patients reviewed for Vancomycin dosing out of a total sample of 30;

3) failing to ensure "Time Out" procedures for patient safety were performed by two staff members prior to the start of the procedure for 4 (#2, #9, #10, #18) of 30 patients sampled, and;

4) failing to ensure patients ordered telemetry monitoring by their physician were continuously monitored and failing to ensure the telemetry hospital policy and procedure was followed for 3 of 3 (#1, #4, #6) patients reviewed on telemetry out of a total sample of 30.

Findings:

1) Failing to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's (LSBN) Practice Act:

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Review of the hospital policy titled Assessment and Reassessment, I.9.00, revealed in part:
A RN will perform and document the initial admission assessment and thereafter a head to toe assessment in every 24 hour period.

Patient #1
Review of nursing assessments for Patient #1 revealed no documented evidence of an RN assessment on 12/10/16, 12/11/16 ( no RN assessment for 48 hours), 12/16/16, 12/22/16, 12/23/16, 12/25/16, 12/26/16 (no RN assessment for 48 hours), 12/28/16, 12/30/16 and 1/02/17.

Patient #2
Review of nursing assessments for Patient #2 revealed no documented evidence of an RN assessment on 12/30/16. There was also no documented evidence of a RN assessment from 12/26/16 until 12/28/16 (72 hours).

Patient #7
Review of Patient #7's daily nursing assessments revealed there was no documented assessment by a Registered Nurse on 1/01/17 (24 hours).

Patient #8
Review of Patient #8's daily nursing assessments revealed no documented evidence of an RN assessment on 12/28/16 and 1/02/17.

Patient #9
Review of Patient #9's daily nursing assessments revealed there was no documented assessment by a Registered Nurse on 1/02/17 or from 12/26/16 through 12/28/16 (72 hours).

In an interview on 1/04/17 at 3:25 a.m. with S3QA, she verified the patients should have had a RN assessment every 24 hours.



2) Failing to ensure Vancomycin troughs were obtained as ordered:

Patient #2
Review of a pharmacist's dosing order for Patient #2 dated 12/18/16 (not Timed) revealed an order to obtain a Vancomycin trough 30 min prior to the a.m. dose on Wednesday 12/21/16.

Review of Patient #2's MAR revealed the Vancomycin dose on 12/21/16 was scheduled for 4:00 a.m.

Review of Patient #2's Vancomycin trough revealed it had been drawn on 12/21/16 at 7:43 a.m. (3 hours and 43 minutes after the dose had been given).

In an interview on 1/05/17 at 9:00 a.m. with S4RN, she verified the trough for Patient #2 dated 12/21/16 had not been drawn 30 minutes before the dose was given.


Patient #5
Review of the pharmacist's dosing order for Patient #5 dated 12/28/16 (Not timed) revealed an order to obtain a Vancomycin Trough level on Friday, 12/30/16. Review of the laboratory results revealed no documented evidence that the Vancomycin Trough level was done on 12/30/16.

In an interview on 01/04/17 at 10:10 a.m., S6RN, Charge Nurse reviewed the medical record for Patient #5 and confirmed there was no documented evidence of the results of the Vancomycin Trough level on 12/30/16. After reviewing the Day to Day Labs log and the on-line laboratory results system, S6RN confirmed the Vancomycin Level was not done on 12/30/16 as ordered.


Patient #24
Review of Patient #24's medical record revealed a pharmacist's dosing order for Patient #24 dated 12/07/16 (not Timed) revealed an order to obtain a Vancomycin trough 30 minutes prior to the first dose on Friday 12/09/16.
Review of Patient #24's MAR revealed the Vancomycin dose on 12/09/16 was scheduled for 4:00 a.m.

Review of Patient #24's Vancomycin trough revealed it had been drawn on 12/09/16 at 7:43 a.m. (3 hours and 43 minutes after the 1st dose was scheduled).

In an interview on 01/05/17 at 9:45 a.m. with S4RN, she verified Patient #24's Vancomycin trough had not been drawn 30 minutes before the dose had been given on 12/09/16.


3) Failing to ensure "Time Out" procedures for patient safety were performed by two staff members prior to the start of the procedure:

Review of the hospital policy titled, Time Out (Universal Protocol), K.11.16 revealed in part the following: The "Time Out" is conducted immediately prior to each procedure in the location where the procedure will be done just before starting the procedure. All team members which includes the physician (as applicable) and/or 2 other clinical staff.

Patient #2
Review of Patient #2's medical record revealed a document titled Pre-Procedural Verification/"Time Out" Confirmation Form. Further review revealed the date and time of a debridement was listed as 12/23/16 at 9:15 a.m. Review of the two clinical staff signatures revealed one was timed at 9:15 a.m. and one at 7:48 a.m. (1 hour and 27 minutes prior to the procedure).

Patient #9
Review of Patient #9's medical record revealed a document titled Pre-Procedural Verification/"Time Out" Confirmation Form. Further review revealed the date and time of the debridement was listed as 12/28/16 at 4:35 p.m. Review of the two clinical staff signatures revealed one was documented at 4:35 p.m. and the other at 4:50 p.m. (15 minutes after the start of the procedure).

Patient #10
Review of Patient #10's medical record revealed a document titled Pre-Procedural Verification/"Time Out" Confirmation Form. Further review revealed the date and time of the debridement was listed as 12/03/16 at 0930. Review of the two clinical staff signatures revealed one was documented at 9:31 a.m. and the other at 9:50 a.m. (20 minutes after the start of the procedure).


Patient #18
Review of the medical record for Patient #18 revealed a document titled Pre-Procedural Verification/"Time Out" Confirmation Form. Further review revealed the date and time of the debridement was listed as 12/02/16 at 8:10 a.m. Review of the two clinical staff signatures revealed one was documented at 8:10 a.m. and the other at 9:45 a.m. (1 hour and 35 minutes after the start of the procedure).

In an interview on 01/05/17 at 12:24 p.m., S2CCO reviewed the above medical records and confirmed the time out procedure was not performed prior to the start of the procedure as directed in the hospital's policy.



4. Failing to ensure patients ordered telemetry monitoring by their physician were continuously monitored and failing to ensure the telemetry hospital policy and procedure were followed for patients on telemetry monitoring:

Review of the hospital policy titled, Telemetry Monitoring, K.11.06 revealed in part the following: All telemetry patients will be monitored through a central monitor located at the nurse's station or via bedside monitor by a competency verified RN, LPN, or monitor tech. Cardiac rhythms will be monitored by a qualified observer at all times. It is the responsibility of the assigned monitor technician to assure that a qualified observer covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended....Rhythm strips are printed every four hours on medical/surgical and High Observation patients, or as ordered and in the event of an abnormal arrhythmia. The rhythm strip will be printed and include patients name, date and time, heart rate, PR interval, QRS width, regularity and rhythm interpretation.

During an observation of the nurse's station on 01/03/17 at 10:25 a.m., S16RT (Respiratory Therapist) was observed sitting at the nurse's station in front of the cardiac monitor used for telemetry monitoring. S6RN, Charge Nurse, also present in the nurse's station at this time stated the Charge Nurse, Respiratory Therapist, or the floor nurse monitored the cardiac monitor. S6RN stated they do not have a staff member designated to monitor telemetry. S6RN confirmed theree were 4 patients currently being monitored on telemetry.

On 01/03/17 at 10:53 a.m., S16RT was observed to leave the nurse's station and proceed into a patient's room. S6RN was observed seated at the nurse's station, but was not observed to monitor the telemetry monitors.

On 01/03/17 at 11:25 a.m., S16RT was observed to leave the desk to speak with staff in the physician dictation room (located on the opposite side of the nurse's station). There was no staff observed to monitor the telemetry monitors. At 11:35 a.m., S25LPN, Wound care nurse was observed seated at the telemetry monitors, but was observed to be reviewing a binder of staffing schedules. S25LPN stated she was also responsible for nurse staffing.

On 01/03/17 at 1:48 p.m. there was no staff observed to be monitoring the telemetry monitor. At 2:25 p.m. there was no staff observed to be monitoring the telemetry monitor. From 2:40 p.m. to 2:50 p.m., there was no staff observed to be monitoring the telemetry monitor.

On 01/03/17 at 9:40 a.m., S25LPN was observed seated in front of the telemetry monitor. S25LPN was observed to make telephone calls for staffing and review staffing binder during this observation. At 11:30 a.m., the only staff member in the nursing station was S6RN and she was observed to be reviewing a record away from the telemetry monitor. At 3:00 p.m., S15LPN was observed seated in the nurse's station but not in front of the telemetry monitor. No staff member was observed monitoring the telemetry monitor.

In an interview on 01/05/17 at 11:10 a.m., S2CCO confirmed there was no staff member assigned to provide continuous telemetry monitoring. S2CCO stated she had identified this as a problem when she assumed the CCO position and stated they were hiring a monitor technician.


Patient #1
Patient #1 was admitted to the hospital on 12/08/16 for Bilateral Pneumonia. Review of his physician orders revealed an order for Telemetry Monitoring. Review of the patient's telemetry strip revealed the following days the EKG was not interpreted: 12/08/16 through 12/11/16 (3 days), 12/12/16 through 12/20/16 (8 days), 12/21/16 -12/28/16 (7 days), 12/30/16 through 1/03/17 (4 days).

An interview was conducted with S4RN on 1/05/17 at 12:30 p.m. She confirmed Patient #1's EKG strips were not interpreted on the above listed dates.


Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 12/23/16 with a diagnosis of Stage IV Sacral Decubitus.
Review of the physician orders revealed an order for Telemetry Monitoring dated 12/24/16. Review of the patient's telemetry strips revealed no documented evidence that the EKG rhythm was interpreted from 12/25/16 through 1/02/17 (8 days).

In an interview on 01/03/17 at 12:15 p.m., S6RN, Charge Nurse reviewed the medical record for Patient #4 and confirmed there was no documentation of rhythm interpretation on the above rhythm strips. S6RN was asked if the nursing staff did an interpretation of the telemetry rhythm strips. S6RN stated, "Some do and some don't."


Patient #6
Review of the medical record for Patient #6 revealed the patient was admitted to the hospital on 10/25/16 with diagnoses of Cervical Spine Fracture, Respiratory Failure, and Quadriplegia.
Review of the physician orders on admission revealed an order for Telemetry Monitoring. Review of the patient's telemetry strip revealed no documented evidence that the EKG rhythm was interpreted from 12/29/16 through 1/02/17 (5 days).

In an interview on 01/04/17 at 11:50 a.m., S2CCO reviewed the medical record for Patient #6 and confirmed the telemetry rhythm strips did not have documentation of an interpretation and confirmed the nurse should have documented an interpretation of the rhythm.

26351


Based on record reviews and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated for 4 of 4 (#3, #6, #20, #21) sampled patient medical records reviewed for a nursing care plan out of a total sample of 30 (#1-#30).

Findings:

Review of the hospital policy titled, Plan of care, 1.9.02 revealed in part the following: The admission assessment data and physician orders are the basis for the selection and individualization of the patient plan of care....The patient care plan will be personalized to meet individual patient care needs. Additional problems unique to the patient may be included and reassessed whenever warranted by the patient's condition....When possible, the nursing goals and expected patient outcomes are made with the patient and/or his/her significant other. These goals are based on the nursing assessment, reflect realistic expectations, are measurable and are consistent with the prescribed medical therapy....



30420

Patient #3
Review of the medical record for Patient #3 revealed he was admitted 12/22/16 with diagnoses that included, in part, multiple cardiovascular accidents, severe malnutrition, multiple wounds, Dysphasia, Cystitis with hematuria, Constipation, Seizures, and incontinence. Further review revealed his nursing care plans did not include nursing diagnoses, measurable goals, and interventions related to his dysphasia, pain, constipation and incontinence, or his seizure disorder.

Patient #20
Review of the medical record for Patient #20 revealed he was admitted to the hospital 11/10/16. His diagnoses included, in part Decubitus Ulcer, Diabetes Mellitus - Type I.
Further review revealed his nursing care plans did not include nursing care related to his diagnosis of Diabetes, or his receiving Insulin.


Patient #21
Review of the medical record for Patient #21 revealed he was admitted to the hospital 12/08/16 with diagnoses that included in part of Decubitus Ulcers, Malnutrition, Long term use of Anticoagulants, Dysphasia, Bed Confinement, Diabetes, history of Transient Ischemic Attacks, Long term/current use of Insulin. Further review revealed his nursing care plans did not include care related to his Diabetes and Insulin requirements, his cognitive deficit, or his bowel incontinence.

In an interview 01/05/17 at 1:30 p.m., S2CCO reviewed the medical record of Patients #3, #20, and #21 and confirmed the above noted findings regarding their plan of care.


Patient #6
Review of the medical record for Patient #6 revealed the patient was admitted to the facility on 10/25/16 with diagnoses including Quadriplegia, Cervical Spine Fracture, and Respiratory Failure with ventilator and Tracheostomy.
Review of the physician orders dated 12/22/16 at 4:30 p.m. orders for Strict Aspiration Precautions and Pureed Diet with Nectar Thick liquids given by spoon. Further review of the orders revealed the patient had been ordered to receive Fentanyl patches for pain.
Further review of the record revealed the patient was receiving sliding scale insulin four times a day.
Review of the Interdisciplinary Plan of Care from 10/25/16 to present revealed no documented evidence that the patient's pain, diet changes, aspiration precautions, and sliding scale were included in the plan of care. Further review of the Plan of Care revealed Impaired Mobility was checked as a nursing diagnosis, but there was no goal identified and the only intervention was to consult PT. The Plan of Care did not include diagnosis/goals/interventions to address the risk for impaired skin integrity.

In an interview on 01/04/17 at 11:50 a.m., S2CCO reviewed the medical record for Patient #6 and confirmed the patient's Plan of Care was not individualized, was not updated with new problems and changes in his care, and did not include all the patient's problems. S2CCO confirmed the goals identified on the Plan of Care were not measurable.

Based on observation, record reviews and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available as evidenced by failure to have documented evidence of training and competency in monitoring telemetry, wound care, and/or competency evaluations by qualified staff for 3 of 3 (S6RN, S15LPN, S25LPN) nursing personnel records reviewed.

Findings:

Review of the hospital policy titled, Staff Competency, B.2.22, revealed in part the following: In order to provide quality patient care, all employees shall be competent to fulfill their assigned responsibilities....An evaluation of a staff member's competence is conducted during the orientation process, three months post-employment and annually thereafter....The clinical competency tool is utilized by the preceptor in the department based orientation phase....At the conclusion of the ninety day probationary period, the competency skills checklist is completed and reviewed with the employee CCO or Department Director....Competency will be documented on the company approved form and once completed will be placed in the employee's HR file.

During observations of telemetry monitoring throughout the day on 01/03/17 and 01/04/17, S6RN, S15LPN, and S25LPN were observed to monitor the telemetry cardiac monitor.

S6RN
Review of the personnel record for S6RN revealed a date of hire of 06/02/16. There was no documented evidence of any nursing competency, nor was there any documented evidence of orientation. Review of the record revealed a Telemetry Monitoring Competency Test dated 01/03/17 which consisted of an identification of 10 rhythm strips. There was no documented evidence of any telemetry training. There was no documented evidence of any other nursing competencies.


S15LPN
Review of the personnel record for S15LPN revealed a date of hire of 10/27/16. Review of the record revealed a Telemetry Station Test dated 10/27/17, which consisted of 5 questions. There was no documented evidence of any telemetry training. There was no documented evidence of competency in rhythm interpretation. There was no documented evidence of orientation.


S25LPN
Review of the personnel record for S25LPN revealed a date of hire of 06/10/16. There was no documented evidence of any nursing competency, nor was there any documented evidence of orientation. Review of the record revealed a Telemetry Monitoring Competency Test dated 01/03/17 which consisted of an identification of 10 rhythm strips. The test was not scored and was not signed by the instructor. There was no documented evidence of any telemetry training. There was no documented evidence of wound care competency. There was no documented evidence of any other nursing competencies. There was no documented evidence of orientation.

In an interview on 01/03/17 at 11:35 a.m., S25LPN stated she was the wound care nurse and she performed the daily wound care on all patients. S25LPN also stated she did the nurse scheduling.

In an interview on 01/05/17 at 2:45 p.m., S3QA and S30HR reviewed the above personnel records. S30HR stated she was the interim Human Resource Director. S3QA stated they realized on Monday (01/03/17, after the survey began) that the staff did not have telemetry competencies, so they did a test. S30HR and S3QA stated they were aware the personnel records were incomplete. They both confirmed there was no documented evidence of orientation or nursing competencies as indicated above. S3QA confirmed S25LPN was the wound care nurse and there was no documentation of wound care competency in her record. Both confirmed the documents in the personnel records were the only documents they could find.

Based on record review and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were adequately supervised by an appropriately qualified hospital-employed RN as evidenced by having S11RN, a contracted RN, working as the charge nurse with no other hospital-employed RN present.
Findings:

Review of a Nursing Schedule for 12/04/16- 12/31/16 revealed S11RN was scheduled as the only RN on the night shift for December 26, 27, and 28, 2016. Further review of the Nursing Schedule for January 2017 revealed she was scheduled for a night shift on the following dates in January: 2, 3, 4, 12, 13, 14, 15, 19, 20, 23, 24, and 25. Further review of the January 2017 schedule revealed no other RN scheduled.

Review of Daily Staffing Schedules for 12/26/16, 12/27/16, and 12/28/16 revealed S11RN was the only RN scheduled on the above nights. The staffing schedules for 12/26/16 and 12/28/16 had "Chg." by her name. Each night the S11RN had 1 LPN and 1 CNA scheduled with her.

Review of the "Daily Nursing Assignment Sheets" revealed S11RN worked the night shift as the charge nurse on 01/04/17, and she was the only RN on the night shift on 01/02/17. Further review revealed no other hospital-employed RN was present during these shifts.

In an interview 01/05/17 at 7:25 a.m. S11RN indicated she had just started working at the hospital, through Company "A", on 12/26/17. S11RN reported she had started an 8-week contract, through Company "A", this week on 1/02/16 as a "Charge RN". The RN indicated she was scheduled to work nights. She reported she had worked with an LPN and a CNA on her shifts. S11RN verified that she was the only RN present in the hospital during her night shifts.

In an interview 01/05/17 at 9:05 a.m. S2CCO, S4RN, and S3QA confirmed S11RN was working as an "in charge" RN at night, when there was no other hospital employed RN present to supervise her. S4RN verified S11RN was on contract through Company "A", a medical staffing agency.

30364


Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer patient medications as ordered for 4 (#4, #24, #25, #27) sampled patients out of a total sample of 30 (#1-#30).

Findings:

Review of the hospital policy titled, Administration of Medication, K.11.31, revealed in part the following: Documentation on the Medication Administration Record of medications that are NOT administered; the healthcare worker will circle the administration time on the Medication Administration Record, initial beside the circled time and document on the MAR the reason the medication was not administered. If the physician is notified that the medication was not administered, this will be noted in the narrative nurses notes....The individual administering the medication (s) must document all medications immediately after administration in the patient's medication administration record (MAR).


Patient #4
Review of the medical record for Patient #4 revealed a physician's order dated/timed 12/30/16 at 5:30 p.m. to discontinue Surfak (Stool softener). Review of the MAR revealed the Surfak was administered to the patient on 12/30/16 at 9:00 p.m. even though a diagonal line was drawn through the medication.

Further review of the physician orders and MARs revealed the patient was to receive Benztropine (Cogentin-Anticholinergic used to treat Parkinson's or side effects of antipsychotics) 0.5 mg. twice a day and Piperacillin (Zosyn-Antibiotic) 2.25 GM. IV every 6 hours since admission. Review of the MAR dated 12/29/16-12/30/16 revealed no documented evidence that the Piperacillin was administered at 3:00 a.m. and there was no documentation as to why the dose was not administered. Review of the MAR dated 12/31/16-01/01/17 revealed no documented evidence that the Cogentin was administered at 9:00 a.m. Further review of this MAR revealed the 9:00 p.m. dose was circled and "med not available" was documented beside the time.

In an interview on 01/03/17 at 12:15 p.m., S6RN reviewed the medical record for Patient #4 and confirmed the above medications were not administered as ordered by the physician. S6RN confirmed the Cogentin was not administered because the medication was not available as it had not been re-ordered timely.



Patient #24
Review of Patient #24's medical record revealed Vancomycin 1 gm. was to be given every 12 hours on 12/09/16. Further review revealed the 4:00 a.m. and the 4:00 p.m. dose had not been given without any documentation as to why the doses had been held.

In an interview on 01/05/17 at 9:45 a.m. with S4RN, she verified the Vancomycin doses were not given as ordered.


Patient #25
Review of Patient #25's medical record revealed the following medications were documented as being held on 12/07/16 at 9:00 p.m.: Calcium Acetate, Calcitriol, Calcium Carbonate, Calmoseptine, Cymbalta, Ferrous Gluconate, Floranex, Keppra, Metoprolol, Os-cal and Neurontin. Further review revealed no documentation as to why the medications were not administered as ordered and no physician's order to hold the medications.

In an interview on 01/05/17 at 10:15 a.m. with S4RN, she verified there was no order in Patient #25's medical record to hold the 9:00 p.m. doses of the above mentioned medications.


Patient #27
Review of the medical record for Patient #27 revealed Vancomycin 750 mg. was to be given every 12 hours on 10/30/16. Further review revealed the 4:00 p.m. dose had not been given without any documentation as to why the dose had been held.

In an interview on 01/05/17 at 11:10 a.m., S2CCO reviewed the medical record for Patient #27 and confirmed there was no documented evidence that the Vancomycin was administered on 10/30/16 at 4:00 p.m. when it was due.

Based on record reviews and interviews, the hospital failed to ensure medical records for each patient were promptly completed within 30 days of discharge. Findings:

Review of the Medical Staff By-laws revealed in part, The attending physician shall be responsible for the preparation of a complete medical record for each patient...No medical record shall be filed until it is complete, except on order of the Medical Record Review Function with proper documentation... A medical record should be considered "delinquent" if not complete within 30 days following discharge... A practitioner with delinquent medical records shall be referred to the Medical Executive Committee for consideration of disciplinary action.

Review of the medical record deficiency rate of the hospital provided to the surveyor by S5Medical Record Clerk, revealed the following physicians and/or Nurse Practitioners had medical record deficiencies passed 30 days:

S27MD had 62 deficiencies (19 being no discharge summaries) out of 24 medical records.
S18MD had 53 deficiencies (33 being no discharge summaries) out of 40 medical records.
S22NP had 9 deficiencies out of 9 medical records.
S19MD had 46 deficiencies out of 19 medical records.
S28NP had 4 deficiencies out of 3 medical records.

An interview was conducted on 01/04/17 at 2:15 p.m. with S5Medical Records Clerk. She confirmed the hospital does have a problem with getting physicians to complete their medical records within 30 days.

30364


Based on record reviews and interviews, the hospital failed to ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing the service as evidenced by physicians not authenticating medical records entries in accordance with Medical Staff Bylaws for 5 (#1, #2, #8 #13, #17) of 15 patient medical records reviewed for authentication of medical record entries from a total sample of 30 (#1-#30).
Findings;

Review of the Medical Staff By-laws revealed in part, all orders must be dated, timed and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by this facility. All verbal/telephone orders must be signed within 10 days.

Review of the hospital's policy, Orders: Verbal, N.14.10.03.b, revealed in part, Verbal orders (including telephone or other oral orders) shall be processed in accordance with medical staff rules and regulations and as described in this policy. Use of verbal orders shall be minimized.

Findings:
Patient #1
Review of Patient #1's medical record revealed telephone orders written by the nursing staff on 12/13/16 at 12:35 p.m., 12/12/16 at 12:42 p.m. and 12/09/16 at 3:15 p.m. Further review revealed the orders had been authenticated by a physician but the signature had not been dated or timed.

Patient #2
Review of Patient #2's medical record revealed telephone orders written by the nursing staff on 12/21/16 at 12:40 p.m., 12/22/16 at 4:00 p.m., 12/23/16 at 6:30 a.m., and 12/23/16 at 8:00 p.m. Further review revealed the orders had been authenticated by a physician but the signature had not been dated or timed.

Patient #8
Review of Patient #8's medical record revealed telephone orders written by the nursing staff on 12/19/16 at 1:10 p.m. Further review revealed the orders had been authenticated by a physician but the signature had not been dated or timed.

Patient #13
Review of Patient #13's medical record revealed telephone orders written by the nursing staff on 11/14/16 at 11:58 a.m. and 11/14/16 at 3:00 p.m. Further review revealed the orders had been authenticated by a physician but the signature had not been dated or timed.

Patient #17
Review of Patient #17's medical record revealed telephone orders written by the nursing staff on 11/18/16 at 2:30 p.m. Further review revealed the orders had been authenticated by a physician but the signature had not been dated or timed.

In an interview on 01/05/17 at 12:30 p.m. with S2CCO, she verified the physicians should have timed and dated their signatures when authenticating orders.







30420

30364


Based on record reviews and interviews, the hospital failed to ensure all verbal orders had been authenticated within 10 days for 5 (#1, #6, #10, #12, #13) of 10 patient's medical records reviewed for authentication of verbal orders out of a total of 30 (#1-#30) sampled patients reviewed.

Findings:

Review of the Medical Staff By-laws revealed in part, All verbal/telephone orders must be signed by 10 days.

Patient #1
Review of Patient #1's medical record revealed a physician's telephone orders dated 12/09/16 at 0940 a.m. that had never been authenticated by the physician.


Patient #10
Review of Patient #10's medical record revealed physician's telephone orders dated 12/12/16 at 3:00 p.m. and 12/03/16 at 12:45 p.m. that had never been authenticated by the physician.


Patient #12
Review of Patient #12's medical record revealed physician's telephone orders dated 10/1/16 at 12:00 p.m. that had never been authenticated by the physician.

Review of Patient #12's medical record revealed physician's telephone orders dated 10/10/16 at 1:15 p.m. that had never been authenticated by the physician.

Review of Patient #12's medical record revealed physician's telephone orders dated 10/11/16 at 6:40 p.m. and 7:45 p.m. that had never been authenticated by the physician.


Patient #13
Review of Patient #13's medical record revealed a physician's telephone order dated 11/14/16 that had never been authenticated by the physician.

In an interview on 01/05/17 at 12:31 p.m. with S2CCO, she verified verbal orders should have been signed within 10 days by the ordering physician.


Patient #6
Review of the medical record for Patient #6 revealed physician's telephone orders had not been authenticated by the ordering practitioner as follows:
11/13/16 at 4:45 p.m.
11/18/16 at 6:45 a.m.
11/18/15 at 11:15 a.m.
11/21/16 at 1:00 p.m.
11/24/16 at 10:45 a.m.
12/01/16 at 8:27 a.m.
12/12/16 at 5:30 p.m.
12/16/16 at 2:00 p.m.
12/21/16 at 5:03 p.m.
12/22/16 at 9:30 a.m.

In an interview on 01/04/17 at 11:50 a.m., S2CCO reviewed the medical record for Patient #6 and confirmed the above verbal orders had not been authenticated by the physician within 10 days as directed in the medical staff by-laws.








30420

26351


Based on record review and interview, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy, when information required was omitted in the informed consent and required information areas were left blank for 4 of 4 (#1, #3, #4, #5) patients reviewed for properly executed informed consents out of a total sample of 30 (#1-#30). Findings:

Review of the hospital policy #A.1.18, titled "Informed Consent", provided by S4RN as current, revealed in part Informed Consents would be obtained by the physician or the clinician authorized to perform the procedure (PICC insertions, excisional wound debridements). The informed consent would include: explanation of patient's current medical condition requiring procedure or treatment, the risks and benefits of the transfusion/procedure, any therapeutic alternatives to the procedure or treatment and the risks and benefits of those alternatives, the opportunity to ask questions, and be provided response(s) to those questions. All informed consents would be presented in a way that was understandable to those receiving the information (i.e. taking into account education levels, literacy, and language barriers.)


Patient #1
Review of Patient #1's medical record revealed he was admitted to the hospital on 12/08/16 with the diagnosis of Bilateral Pneumonia with physician orders for wound care. Further review of the Patient #1's medical record revealed an informed consent for Serial Excisional Wound Debridements signed by the patient on 12/11/16. The consent did not list the reasonable therapeutic alternatives and the risks associated with such alternatives. The area provided on the consent form to include alternative treatments was left blank.

An interview was conducted with S2CCO on 01/05/17 at 12:00 p.m. She confirmed the informed consent was not complete.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted 12/22/16 with diagnoses that included, in part, multiple cardiovascular accidents, severe malnutrition, and treatment of multiple wounds. The patient had orders for wound care and the insertion of a PICC line. Further review revealed most of his consents were obtained as verbal consent from Patient #3's wife, related to his expressive aphasia and inability to sign consents. A consent for serial excisional wound debridements had a blank for the patient's diagnoses or condition for which the procedure was indicated and recommended, Additional risks (if any) associated with the medical treatment (debridement) particular to the patient because of a complicating medical treatment was blank, Reasonable therapeutic alternatives and the risks associated with such alternatives was blank. The consent was signed by S22NP 12/23/16 at 9:00 a.m., and witnessed by the contracted wound care nurse at 12/23/16 at 9:00 a.m. A note documenting verbal consent was obtained from Patient #5's spouse. A section with notation of: "If consent is signed by someone other than the patient, state the reason why: __" was blank. Further review revealed a consent for the insertion of a PICC line. The line that read, "My catheter will be inserted by__" had the scripted name of a nurse contracted to insert PICC lines. It was noted that the patient "gave verbal consent", and was witnessed by two staff nurses. A blank was noted in the middle of the consent that read, "Alternative vascular access device options_______of giving my medication have been explained to me and I have chosen this one."

In an interview 01/05/17 at 1:30 p.m. S2CCO reviewed the medical record of Patient #3 and confirmed the above noted findings regarding his informed consents.


Patient #4
Review of medical record for Patient #4 revealed the patient was admitted to the hospital on 12/23/16 with the diagnosis of Stage IV Sacral Decubitus. Review of the record revealed an informed consent for Serial Excisional Wound Debridements with telephone consent obtained from the patient's daughter on 12/28/16. The consent did not list the reasonable therapeutic alternatives and the risks associated with such alternatives. The area provided on the consent form to include alternative treatments was left blank. The line that indicated the name of the Physician authorized to perform the procedure was left blank. The lines for documentation of the reason the consent was signed by someone other than the patient was also left blank.

In an interview on 01/03/17 at 12:15 p.m., S6RN reviewed the medical record for Patient #4 and confirmed the consent for Serial Excisional Wound Debridements dated 12/28/16 was incomplete and did not include therapeutic alternatives and the risks associated with such alternatives. S6RN confirmed the above indicated sections of the consent form were left blank.


Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 12/16/16 with the diagnosis of Ventral Hernia Repair with Abdominal Wound. Further review of the medical record revealed an informed consent for Serial Excisional Wound Debridements signed by the patient on 12/23/16. The consent did not list the reasonable therapeutic alternatives and the risks associated with such alternatives. The area provided on the consent form to include alternative treatments was left blank.

In an interview on 01/04/17 at 11:50 a.m., S2CCO reviewed the medical record for Patient #5 and confirmed the consent for Serial Excisional Wound Debridements signed by the patient on 12/23/16 was incomplete and did not include therapeutic alternatives and the risks associated with such alternatives.






30420

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 as evidenced by the failing to ensure the treating licensed practitioner completed a discharge summary for discharged patient records for 68 patients out of a total number of admissions of 129 patients for the year of 2016 (per the deficiencey report provided by the hospital).
Findings:

Review of the Medical Staff By-laws revealed in part, Discharge summary: A discharge summary shall be recorded at the time of discharge unless awaiting test results. Any patient that dies in the hospital shall have a recorded death summary... A clinical discharge summary shall be included in the medical record of all patients except those that stay twenty-four hours or less. The discharge summary should contain the following: Admitting Diagnoses, Discharge Diagnoses, reason for hospitalization, Hospital Course, significant findings, procedures performed, care, treatment, and services provided. Instructions given to the patient and family at discharge, and the patient's condition at discharge.

Review of medical record deficiency rate for January 2016 until November 2016, provided to the surveyor by S5Medical Record Clerk, revealed 68 patients did not have discharge summaries documented in their medical records.

An interview was conducted with S5Medical Record Clerk on 1/04/17 at 2:15 p.m. She reported she went back retrospectively and put together a medical record deficiency report for January 2016 to November 2016. She went on to report she was new to the position and the previous medical record clerk had not maintained a deficiency log.

Review of Patient #14's record revealed she was discharged on 9/29/16. With further review of her medical record revealed no documentation of a discharge summary being performed.

An interview was conducted with S5Medical Record Clerk on 1/04/17 at 2:30 p.m. She confirmed Patient #14 did not have a discharge summary documented and with review of the deficiency rate report revealed Patient #14 was not included in the deficiency rate report. S5Medical Record Clerk confirmed the deficiency rate report for 2016 was incomplete and not accurate.

An interview was conducted S1CCO on 01/04/17 at 3:00 p.m. He reported the total number of patients admitted to the hospital in 2016 was 129 patients. According to the deficiency rate report 68 patients didn't have discharge summaries for 2016, but with review of the deficiency report it was determined the list was incomplete/inaccurate since Patient #14 was not included in the report.

Based on occurrence report reviews, record review and interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records for 2 (#22, #23) of 2 patients reviewed with known medication errors.

Findings:

Review of the hospital policy titled Medication Errors, N.14.14.03, revealed in part:
The medication administered in error or omitted in error and the action taken shall be properly recorded in the patient's medical record.

Patient #22
Review of an incident report for Patient #22 revealed on 7/19/16 he should have received 40 mg of Simvastatin as a substitution for 20 mg of Atorvastatin. Further review revealed he received 20 mg of Simvastatin.

Review of the medical record for Patient #22 revealed no documentation of the medication error on 7/19/16 or notification of the error to the attending physician.

Patient #23
Review of an incident report for Patient #23 revealed on 4/26/16 she received 2 mg of Xanax instead of the 4 mg ordered.

Review of the medical record for Patient #23 revealed no documentation of the medication error on 4/26/16 or notification of the error to the attending physician.

In an interview on 01/04/17 at 3:00 p.m. with S3QA, she verified the above mentioned medical errors should have been documented in the patients' medical records along with notification to the physician, but had not been.

Based on record review and staff interview, the Hospital failed to ensure a UR committee carried out the UR function as evidenced by no provisions in the UR plan for a committee, no documented evidence of UR committee meeting minutes/records, and failing to ensure a committee consisted of at least two physicians. Findings:

Review of the hospital's policy titled, Utilization Management Plan, E.5.07 revealed in part the following: Utilization Management is a function of the medical staff and is responsible to the Medical Executive Committee (MEC) and the Governing Board. Membership shall consist of sufficient members to afford, insofar as feasible, representation from the major services. No less than (2) members of the Utilization Management Function shall be physicians....
Committee Records: The Utilization Management Function of the QAPI Committee will maintain written records of all its activities. Minutes of each committee meeting shall be documented and will include: ....Summary of reviews of admissions, continued stays and all subsequent reviews which will include: Committee action for cases not approved, Copies of written notification letters sent, cases discussed, worksheets used for Committee review function, recommendations of the Committee....
Each quarter, a copy of the QAPI Minutes will be forwarded to the Medical Executive Committee.

In an interview on 01/04/17 at 4:00 p.m., S3QA was requested to have all Utilization Committee minutes, Committee Roster, and related documents available for review on 01/05/17.

On 01/05/17 at 9:00 a.m., no documents other than the Utilization Management Policy were provided for review.

Review of the QAPI minutes dated 04/11/16 provided by S3QA as the only QAPI minutes for the year 2016 revealed the only physician in attendance was S18MD. There was no documented evidence that a case manager or UR staff attended the meeting. Review of the minutes revealed only UR statistics was reported. There was no documented evidence of the cases discussed, worksheets used for the review function, and there were no recommendations documented.

In an interview on 01/05/17 at 9:20 a.m., S31CM confirmed she was responsible for Utilization Review. S31CM stated there was no committee minutes available to provide for review. When asked if there was a UR committee, S31CM stated she thought it was just her doing utilization review. S31CM stated if there was a problem, she goes to S1CEO. S31CM stated she had been employed at the hospital since May 2016 and there was no QAPI or UR committee meeting since she has been here. S31CM stated she does not have 2 physician reviewers and no physicians were involved in the current UR process. S31CM reviewed the 04/11/16 QAPI meeting minutes and stated the statistics documented in the minutes could be obtained from running a report. She confirmed the minutes did not contain the documentation outlined in the UR policy. When asked who was responsible for UR before her, she stated, "There was a gap."

In an interview on 01/05/17 at 11:15 a.m., S3QA stated 2 physicians were assigned to Utilization Review but the physicians had not med or reviewed any UR. S3QA confirmed the policy did not delineate a UR committee. S3QA confirmed the only QAPI meeting minutes she could find were dated 04/11/16.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices as evidenced by:
1) failure of staff to perform hand hygiene according to CDC Guidelines;
2) failure to disinfect a glucometer before and after use on a patient;
3) failure ensure all hospital staff were free of TB in a communicable state. This deficient practice was evidenced by 5 of 5 (S18MD, S19MD, S20MD, S23MD, S27NP) credentialed/privileged staff files reviewed with no documented current TB screening;
4) failure to ensure the patient nourishment refrigerator temperatures were monitored per policy; and
5) failure to ensure surveillance of infection control activities in the hospital were conducted to identify problem areas and develop corrective actions.
Findings:



1)Failure of staff to perform hand hygiene according to CDC Guidelines.

Review of CDC Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, indications for hand washing and hand antisepsis included decontamination of hands before patient contact, decontamination of hands after contact with inanimate objects (including medical equipment in the immediate vicinity of the patient) decontamination of hands after removing gloves, decontaminate hands after contact with a patient's intact skin.

An observation on 01/03/17 at 1:50 p.m. revealed S14CNA walked into the room of Patient #6, pulled a pair of gloves from the box on the wall, moved the over-bed table closer to the patient's bed, then donned the gloves. S14CNA assisted Patient #6 with eating. S14CNA was observed not to perform hand hygiene before donning gloves and feeding Patient #6.

2) Failure to disinfect a glucometer before and after use on a patient.

Review of hospital policy and procedure #R.18.37, titled "Cleaning of Non-Critical, Reusable Patient Care Equipment" ( Effective date 2/2013, last revision date 4/2016), and provided by S3QA as current, revealed in part, all equipment must be cleaned immediately after use on patients regardless of cleaning schedule. Patient care equipment should be cleaned, disinfected and/or reprocessed before reuse with another patient or before placed in storage. Glucometers must be cleaned between each patient or before going into storage.

An observation on 01/03/17 at 10:20 a.m. revealed S13RN performed a capillary blood glucose via a glucometer at the bedside of Patient #5. The RN set the glucometer on the patient's bed, then moved it to the bedside table. After completing the test, the RN placed the glucometer in her uniform pockets, went to the supply room, obtained tubing, and returned to the patient's room. S13RN removed the glucometer from her pocket and placed it on the over-bed table, while she removed a saline flush and alcohol wipes from her same pocket. After setting up and starting the administration of the patient's IV medication, S13RN removed her gloves, performed hand hygiene, then picked up the uncleaned/undisinfected glucometer with her bare hands and returned it to the glucometer storage box at the nurse's station.

In an interview on 01/03/17 at 10:45 a.m. S13RN confirmed that she had not cleaned and disinfected the glucometer before going into Patient #5's room, or after use on Patient #5, before returning it to its storage box. S13RN agreed that all supplies in her pocket and her uniform pocket were now contaminated since she had placed the uncleaned and disinfected glucometer in her uniform pocket, and her hands were dirty after handling the machine before it was cleaned and disinfected. The RN indicated she should have cleaned the machine, before and after she used it on Patient #5, with the disinfectant wipes on the countertop at the nurse's desk.

3) Failure to ensure all hospital staff were free of TB in a communicable state.

Review of hospital policy #R.18.24, titled TB Exposure Control Plan, provided by S3QA as current, revealed, in part all employees would participate in the TB Exposure Control Plan. Pre-employment screening/baseline testing was required for all new employees and they would have an initial Tuberculin Skin test prior to work assignments, and could begin work assignments after the initial negative skin test. Further review revealed, TB symptom screens would be performed annually with a TB symptoms screen and completion of a symptom screen questionnaire at 12 month intervals.

Review of the credentialing files for S18MD, S19MD, S20MD, S23MD, and S27NP revealed no current TB test or TB screening results.

In an interview 01/05/17 at 3:00 p.m., S3QA verified there was no documented evidence of a current TB screening/testing results for S18MD, S19MD, S20MD, S23MD, or S27NP.

4) Failure to ensure patient nourishment refrigerator temperatures were monitored per policy.

Review of the hospital policy titled Refrigeration, Freezing and Warming, N.14.09.05.b, revealed in part:
Refrigerator, freezer and warmer temperatures containing medications shall be monitored daily when the department is open.

Review of patient nourishment refrigerator/ freezer temperature logs on 01/03/17 revealed no temperatures had been documented in January 2017. Review of December 2016 logs revealed no documentation of refrigerator temperatures from 12/01/16 - 12/04/16, 12/08/16, 12/09/16, 12/12/16- 12/23/16, 12/25/16, 12/26/16, 12/30/16 and 12/31/16. There were no documented freezer temperatures from 12/01/16 - 12/23/16, 12/25/16, 12/26/16, 12/30/16 and 12/31/16.

In an interview on 01/05/17 at 8:38 a.m. with S4RN, she verified the refrigerator temps on the patient nourishment refrigerator and the medication refrigerator should have been recorded daily.

5) Failure to ensure surveillance of infection control activities in the hospital were conducted to identify problem areas and develop corrective actions.

Review of the Infection Control Surveillance Audit forms provided by S3QA included surveillance for 12/01/16, 12/08/16 and 12/14/16. Each type of observation had the documentation choice of Y (yes), N (no), or na (not applicable). The following entries had a "no" checked for 2 of the 3 observations: * Visitors compliant with isolation precautions as posted including wearing of PPE and hand washing, *Staff compliant with isolation precautions as posted including proper use of PPE, handling of linen and cleaning of medical equipment and supplies, *Refrigerator temperature logs up to date without gaps or missing data. Readings outside range were reported and action taken recorded, * Isolation precaution signage is consistent with required precautions as result of cultures obtained, * Isolation carts stocked with PPE and dedicated equipment per policy, * Patient and employee food stored separately- dated per policy, * Supply rooms neat and tidy. No boxes on the floor. Bottom shelves solid. 18 inches from sprinkler heads. No expired supplies, * Nutrition room clean-refrigerator cleaned routinely. No expired food. (beside a check mark the work "frozen" was written on all 3 entries), * Medical equipment "bagged and tagged", * Clean and dirty supplies and equipment are kept separate. Clean and dirty areas visibly identified with appropriate signage. Further review revealed page 3, with space for documentation under " Opportunities for Improvement- be sure to date and time your notes" was blank. No information was specified as to what specifically was deficient, or where the deficiency was located, or the identity and/or discipline observed. No time for the observer was documented.

In an interview 01/05/17 at 9:15 a.m. S3QA reported she was the Infection Control Coordinator. S3QA verified the above referenced findings on the Infection Control Surveillance Audit form. She agreed that the information on the Infection Control Surveillance Audit Form did not provide information needed to track and trend problems, and to formulate a plan for corrective action. S3QA was unable to provide surveillance documentation for hand hygiene. S3QA indicated no surveillance was being conducted of staff providing sterile or aseptic procedures in the hospital such as insertion and access of PICC or Central IV catheters, Urinary catheter insertion and care, wound care, or respiratory therapy care.