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Based on record review and interview, the facility failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This was evidenced by:

1. Failing to ensure compliance with the Condition of Participation of Infection Control. The governing body failed to ensure a qualified staff member was designated as the infection control officer and failed to develop and implement policies governing control of infections and communicable diseases. (See findings at A0083)

2. Failing to ensure compliance with the Condition of Participation of Radiology Services. The governing body failed to ensure there was a radiologist who supervised the radiology services of the hospital and failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A. (See findings at A0083)

3. Failing to ensure compliance with the Condition of Participation of Respiratory Services. The governing body failed to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis and failing to have an adequate number of respiratory therapists and trained nursing personnel to care for patients with respiratory needs as evidenced by being unable to notify the contracted respiratory therapist of respiratory services needs and not having nursing personnel competent in respiratory care skills and procedures. (See findings at A0083)


4. Failing to ensure compliance with the Condition of Participation of Medical Records. The governing body failed to employ adequately trained personnel to ensure for the prompt completion of medical records. (See findings at A0083)

Based on record review, observation, and interview, the hospital failed to meet the Condition of Participation for Medical Record Services as evidenced by:


1. Failing to employ adequately trained personnel to ensure for the prompt completion of medical records. (See findings in A0432)

2. Failing to ensure all medical records were promptly completed as evidenced by not maintaining documentation of deficient records and by failing to suspend practitioners when medical records were not completed according to hospital policy, as set forth in the medical staff by-laws (See findings in A0438)

3. Failing to ensure medical records were protected from water and fire damage as evidenced by medical records being on open carts and on top of cabinets in a room equipped with a sprinkler system and medical records being housed in a compressed wood cabinet. (See findings in A0438)

4. Failing to have discharge summaries in discharge patients' medical records with the outcome of hospitalization, disposition of care and provisions for follow-up care for 8 (#20,#21,#22, #23, #27, #28, #29, #30) of 21 (#10- #30) discharged medical records reviewed. (See findings in A0468)

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

1) Failing to ensure there was a radiologist who supervised the radiology services of the hospital (see findings in tag A-0546);

2) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A (see findings in tag A-0536).

Based on observation, interview and record review, the hospital failed to meet the requirements for the Condition of Participation for Infection Control as evidenced by:

1) Failing to ensure a qualified staff member was designated as the infection control officer to develop and implement policies governing control of infections and communicable diseases. (see findings tag A-0748)

2) Failing to develop, implement, and maintain an active, hospital-wide program for the prevention, control, and investigation of infections and communicable diseases as evidenced by:

a) Failing to ensure the effective implementation of effective precautions for a patient with a known multi-drug resistant organism (MDRO) for 1 of 1 current patients (Patient #6) observed with positive lab culture results. (see findings tag A-0749)

b) Failing to ensure patient care was provided in a sanitary environment. (see findings tag A-0749)

Based on record review and interview, the hospital failed to meet the Condition of Participation for Respiratory Care Services as evidenced by:

1. Failing to have appropriate respiratory care services for the scope and complexity of the services offered as evidenced by allowing a respiratory therapist from a nearby facility, not employed by the hospital, to assist in the care of a patient (Patient #11) with a tracheostomy (See Findings in A-1152).

2. Failing to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services (See Findings in A-1153).

3. Failing to have an adequate number of respiratory therapists and trained nursing personnel to care for patients with respiratory needs as evidenced by being unable to notify the contracted respiratory therapist of respiratory services needs and not having nursing personnel competent in respiratory care skills and procedures (See Findings in A-1154).

Based on record review and interview, the hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This was evidenced by:

1. Failing to ensure compliance with the Condition of Participation of Infection Control. The governing body failed to ensure a qualified staff member was designated as the infection control officer and failed to develop and implement policies governing control of infections and communicable diseases. Findings:

Review of a list of staff members with titles at the hospital revealed S11RN's position was listed as Infection Control Specialist. In an interview on 4/21/15 at 10:15 a.m., S2DON said S11RN was the infection control officer at the hospital and she only came to the hospital one day a month.

A review was made of a job description provided by the hospital and signed by S11RN on 3/28/13. Further review revealed the job description titled Infection Control Officer revealed in part: The Infection Control Officer is primarily responsible for overseeing the development and implementation of the facility infection control policies and procedures. Some of the responsibilities listed included overseeing the development and implementation of a protocol to identify, report, and investigate infections, oversee the implementation of policies, monitor compliance with all policies, oversee the promotion of hand washing, and participates in quality assurance by maintaining the necessary documentation and attending the quarterly meetings.

In an interview on 4/22/15 at 7:35 a.m. with S11RN, she said she was a PRN (as needed) employee. S11RN said she was hired to help correct problems with infection control at the facility, but she said was not the person over infection control. She said S2DON was over the Infection Control Program. S11RN said the hospital has not had any infection control meetings, did not gather data for quality assurance and did not participate in quality meetings. S11RN also said there was not an effective infection control program at the hospital and they were not tracking and trending infections. She said there has not been any hand washing audits and she had not performed any audits related to infection control. She said she had given the administration recommendations and they did not follow up on them. S11RN said she generated forms for tracking various items related to infection control and they were left blank. S11RN also said she told the administration they needed to report to the NHSN (National Healthcare Safety Network) and they did not.

In an interview on 4/22/15 at 8:20 a.m., S2DON said she was not sure who the infection control officer was at the hospital. S2DON said she thought it was S11RN, but it may have been herself. S2DON said she could not locate any of her hand washing audits. S2DON said they have had problems with environmental issues, but they are not talked about in Quality meetings. S2DON said she did not have any Quality meeting minutes related to infection control. S2DON said she has not had any specialized training in infection control or experience as an infection control officer. S11RN agreed there was not an effective infection control program at the hospital.


2. Failing to ensure compliance with the Condition of Participation of Radiology Services. The governing body failed to ensure there was a radiologist who supervised the radiology services of the hospital and failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A. Findings:

Review of the hospital's organizational chart revealed no documentation of a radiologist who supervised the radiology services of the hospital.

Review of hospital policies and procedures revealed no policy and procedure for radiological services.

In an interview 4/20/15 at 10:05 a.m. S2DON (Director of Nursing) reported the hospital had no radiologist or other personnel overseeing radiological services. S2DON reported that radiological services were provided to hospital patients, in part, by a mobile X-ray service that performed portable X-rays in the hospital. The DON verified the hospital did not have any policies and procedures for radiology services.


3. Failing to ensure compliance with the Condition of Participation of Respiratory Services. The governing body failed to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis and failing to have an adequate number of respiratory therapists and trained nursing personnel to care for patients with respiratory needs as evidenced by being unable to notify the contracted respiratory therapist of respiratory services needs and not having nursing personnel competent in respiratory care skills and procedures. Findings:

Review of the Governing Body minutes for 2014-2015 revealed there was not a physician appointed to oversee the respiratory services of the hospital.

An interview was conducted with S2DON on 4/21/15 at 1:00 p.m. She reported the hospital did not have a physician appointed to oversee the respiratory services of the hospital.


Review of the hospital's policy, Respiratory Therapy General, revealed in part, The nursing staff at this facility performs all respiratory therapy. Any references to respiratory therapist may be substituted with nursing staff. We reserve the right to contract the services of a respiratory therapist as needed.

Review of the contract for S19RT (presented as the current contract for the Respiratory Therapist) revealed the contract was entered into on 11/10/05.

Patient #11
Review of Patient #11's medical record revealed he was a 44 year old male admitted on 2/3/15 with admitting diagnoses of : Anoxic Brain Injury, Lack of Coordination, HTN (Hypertension), Seizure Disorder and Tracheostomy. Review of his Physician Orders on admission revealed an order for Trach collar to room air maintain O2 (oxygen) sat (saturation) 96%, BIPAP (Bilevel Positive Airway Pressure), 14/6 at bedtime, Ipratropium-Albuterol 0.5 - 3 mg (milligrams)/ 3 ml (milliliters) (Duoneb) i (1) vial nebulizer every 6 hours, Suction trach collar prn ( as needed), and O2 2 L(Liters) min (minute) to trach collar if O2 sat less than 96 %. Review of a physician's order dated 2/3/15 at 2100 revealed Pt (Patient) may receive respiratory treatment as needed, and may be evaluated and treated by respiratory therapist. Review of the medical record for Patient #11 revealed no documentation by a respiratory therapist in the patient's medical record. Review of the Daily Nursing Documentation/Physical Assessment dated 2/3/15 at 2100 revealed Suction pt at 2130, Amount suctioned 10 ml, white, thin secretions, pt tolerated well. breath sounds clear, good cough reflex. Review of the MAR (Medication Administration Record) revealed the patient was suction on 2/4/15 at 0600, 1200, 2130, and on 2/5/15 at 0600. Review of the Nursing Notes revealed inconsistent documentation that the patient had a trach. Review of the Nursing Notes on 2/5/15 (not timed) revealed the patient did not have a trach and no assessment of the patient's trach site was documented. Review of the Nursing Notes on 2/5/15 at 0715 revealed the patient's trach site was WNL (within normal limits), but there was no documentation the patient had a trach.

An interview was conducted with S2DON on 4/21/15 at 1:00 p.m. She reported when the hospital attempted to get in touch with S19RT (contracted respiratory therapist) for Patient #11, they were unable to get in touch with him. S2DON further reported the hospital hasn't used S19RT in years. S2DON also reported Patient #11 was a patient from SNF (skilled nursing facility) "E" (located next door to the hospital) so a respiratory therapist from SNF "E" did them a favor and provided respiratory therapy services since it was their patient and they knew him. S2DON further reported they did not have a contract with SNF "E" or the respiratory therapist from SNF "E" to provide respiratory services. When questioned by the surveyor further about what services the respiratory therapist from SNF "E" provided to Patient #11, she reported he instructed the staff on the care of the patient and assessed the patient. S2DON further reported the respiratory therapist from SNF "E" did not document the assessments he performed in the patient's medical record.

An interview was conducted with S2DON on 4/23/15 at 9:30 a.m. S2DON reported she had not assessed or performed competencies for any skills related to provision of respiratory care for any of the nurses working at the facility.


4. Failing to ensure compliance with the Condition of Participation of Medical Records. The governing body failed to employ adequately trained personnel to ensure for the prompt completion of medical records. Findings:

An interview was conducted with S2DON on 4/22/15 at 8:40 a.m. S2DON reported she was over the medical records department. S2DON went on to report she had been trying to keep up with the medical records, but had been unable to keep up. S2DON also stated the hospital had in the last couple of weeks reassigned S6Office Manager to assist with the medical records. S2DON reported that herself and S6Office Manager were not Registered Health Information Managers. S2DON reported she had not been tracking delinquent medical records for the last 3 to 4 years. S2DON reported she was over the Medical Records Department, Quality Assurance and Performance Improvement, Emergency Preparedness and Nursing.

Review of the personnel files for S2DON and S6Office Manager revealed no Health Information Management experience, education and/or training.

An interview was conducted with S2DON on 4/22/15 at 8:40 a.m. She reported S6Office Manager was just recently reassigned in the last few weeks to assist her with the medical records department.


5. Failing to ensure that the hospital's QAPI (quality assurance performance improvement) program reflected the complexity of the hospital's organization and services as evidenced by failing to include all services, including contracted services, in the hospital's QAPI (quality assurance performance improvement) plan. Findings:
The list of the hospital's current contracted services, presented by S20CFO, was reviewed and compared to the QAPI documentation provided by S2DON. Further review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Respiratory Services, Dialysis Services, Biomedical Services, Biohazardous Waste Disposal Services, Mobile Radiological Services, Sign Language Services and Linen Services.
In an interview on 4/22/15 at 7:55 a.m. with S2DON, she confirmed quality indicators for the above referenced services provided through contractual agreement were not included in the hospital's QAPI plan.

6. Failing to ensure contracted biomedical services performed safety inspections on equipment annually as documented in the contractual agreement.
Findings:

Review of a contract between Company "C" and the hospital revealed , in part, that Company "C" agreed to staff, conduct, and administer a risk based Medical Equipment Management Program in the hospital. This included annual inspections of non-patient care equipment. It also included inspections of patient care equipment on an annual, biannual, and quarterly basis, depending on what was required of the equipment. Further review revealed the agreement was made on 2/22/13 and was to continue for a period of 36 months until 2/29/16, unless terminated for cause.

Observations of equipment on 4/20/15 at 9:25 a.m. revealed the following, in part:
Oxygen concentrator unit (in use by current Patient #1) with a Biomedical inspection tag dated 4/2013;
2 nebulizer units with no Biomedical inspection tags;
1 enteral feeding pump with no Biomedical inspection tag;
1 enteral feeding pump with a Biomedical inspection tag dated 4/2013.
1 portable suction machine with a Biomedical inspection tag indicating the next inspection was due 5/2011.

An observation of the Nourishment Room on 4/20/15 at 8:50 a.m. revealed the patients' refrigerator had a Biomedical inspection tag indicating the date of the next inspection was due in 4/14. The finding was confirmed by S7CNA.

In a phone interview 4/22/15 at 9:37 a.m. S15Biomed, President of Company "C"(contracted Biomedical services) reported Company "C" had a service contract with the hospital to provide the services of a biomedical department and provide a preventive maintenance and repair program. S15Biomed reported that the company went to the hospital in February, 2013, performed an assessment and wrote a program for preventive maintenance. He reported that the company returned once, he thinks in July 2013, to check defibrillators which require quarterly checks. S15Biomed reported that after numerous notices of nonpayment, the contract was terminated. S15Biomed verified the company had not provided any Biomedical and preventive maintenance services since 2013.

In an interview 4/22/15 at 10:15 a.m. S1Administrator reported that he was not aware that the hospital contract with Company "C" was no longer active and valid. S1Administrator reported he was unaware that no maintenance had been performed on the hospital's Biomedical equipment since 2013.


30984

Based on record review and interview, the governing body failed to ensure contracted services were performed in a safe and effective manner as evidenced by:
1. failing to ensure all contracted services were included in the quality assurance and performance improvement (QAPI) program;
2. failing to ensure contracted respiratory services were delivered as set forth in the contractual agreement for 1 (Patient #11) of 1 patient reviewed with a tracheostomy out of a sample of 30 patients.
Findings:

1. Failing to ensure all contracted services were included in the quality assurance and performance improvement (QAPI) program.

The list of the hospital's current contracted services, presented by S20CFO, was reviewed and compared to the QAPI documentation provided by S2DON. Further review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Respiratory Services, Dialysis Services, Biomedical Services, Biohazardous Waste Disposal Services, Mobile Radiological Services, Sign Language Services and Linen Services.
In an interview on 4/22/15 at 7:55 a.m. with S2DON, she confirmed quality indicators for the above referenced services provided through contractual agreement were not included in the hospital's QAPI plan.


2. Failing to ensure contracted respiratory services were delivered as set forth in the contractual agreement for 1 (Patient #11) of 1 patient reviewed with a tracheostomy out of a sample of 30 patients.


Review of the hospital's policy, Respiratory Therapy General, revealed in part: We reserve the right to contract the services of a respiratory therapist as needed.

Review of the contract (presented as the current contract for the Respiratory Therapist) for S19RT (Respiratory Therapist) revealed the contract was entered into on 11/10/05.


Patient #11
Review of the Patient #11's medical record revealed he was a 44 year old male admitted on 2/3/15 with admitting diagnoses of : Anoxic Brain Injury, Lack of Coordination, HTN (Hypertension), Seizure Disorder and Tracheostomy. Patient #11 was transferred to another facility on 2/7/15 due to wife's preference.

Review of his Physician Orders on admission revealed an order for Trach collar to room air maintain O2 (oxygen) sat (saturation) 96%, BIPAP (Bilevel Positive Airway Pressure), 14/6 at bedtime, Ipratinopium-Albuterol 0.5 - 3 mg (milligrams)/ 3 ml (milliliters) (Duoneb) i (1) vial nebulizer every 6 hours, Suction trach collar prn ( as needed), and O2 2 L(Liters) min (minute) to trach collar if O2 sat less than 96 %. Review of a physician's order dated 2/3/15 at 2100 revealed Pt (Patient) may receive respiratory treatment as needed, and may be evaluated and treated by respiratory therapist.

Review of the medical record for Patient #11 revealed no documentation by a respiratory therapist in the patient's medical record.

An interview was conducted with S2DON on 4/21/15 at 1:00 p.m. She reported when the hospital attempted to get in touch with S19RT for Patient #11, they were unable to get in touch with him. S2DON further reported the hospital hasn't used S19RT in years.

Based on document review and interview, the hospital failed to maintain a list of all contracted services which included the scope and nature of the services provided.
Findings:

Review of the list of contracted services, provided by S20CFO, revealed no documented evidence of a description of the scope and nature of the services each company provided through contractual agreement with the hospital.

In an interview on 4/20/15 at 10:30 a.m. with S20CFO, he confirmed the list he had presented was the current list of contracted services maintained by the governing body.

Based on record review and interview, the hospital failed to provide, in its resolution of a grievance, the patient with written notice of its decision which contained the contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This deficient practice was evidenced by no documented evidence of a written notice to the patient for 1 of 1 documented grievance for the last year.
Findings:

Review of a Grievance Procedure, provided by S2DON as the hospital 's policy, with no hospital name, effective or review date, revealed the following procedure:
1. All patients /significant others should be in writing and should contain the name and address of the person filing it and should be in writing and should contain the name and address of the person filing it and should briefly describe the grievance or complaint.
2. The Administrator or his/her designee shall conduct an investigation of the complaint and respond in writing within 15 days.

Review of a Grievance Procedure included in a packet provided to patients upon admission revealed, in part the following:
"...The Chief Executive Officer has designated the Director of Nurses and/or the Administrator to receive and initiate the investigation into the patient's grievance. The above will contact you within 48 hours and will make every effort to resolve the complaint to your satisfaction. The patient will receive a written statement within 7 working days, which will include the name of the hospital, the contact person's name and the steps taken in behalf of the patient to investigate the grievance, the grievance, the results, and the date of completion..."

Review of provided grievance forms for the last year revealed a grievance dated 11/25/14. Further review revealed an unnamed charge nurse reported (via phone) to S2DON (Director of Nursing) that a patient was complaining about a nursing assistant that was rude and yelling at her (the patient) and using profanity. The immediate action was the suspension of the employee pending review. The follow up was that the employee failed to return to work after the suspension as a "no call, no show", therefore was terminated. The grievance form was signed by S2DON and dated 11/15/14. On the form the question" Was grievance intervention satisfied within a reasonable amount of time?", was answered "Yes".

In an interview on 4/21/15 at 4:30 p.m. S2DON reported that the hospital had only 1 grievance in 2014 and 2015. S2DON reported that the hospital had not responded to the patient in writing because the patient was an inpatient at the time. S2DON agreed that the information documented on the form did not include information such as the name of the patient lodging the grievance or her address, the name of the staff member with the allegations lodged against them, the reporting staff member, or any actual investigation. S2DON agreed that this did not follow the provided hospital policy and procedure.

Based on record review and interview, the hospital failed to ensure quality indicators were measured, analyzed, and tracked for all hospital services and operations as evidenced by failure to include all services, including contracted services, in the hospital's QAPI (quality assurance performance improvement) plan.
Findings:

The list of the hospital's current contracted services, presented by S20CFO, was reviewed and compared to the QAPI documentation provided by S2DON. Further review of S2DON's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Respiratory Services, Dialysis Services, Biomedical Services, Biohazardous Waste Disposal Services, Mobile Radiological Services, Sign Language Services and Linen Services.
In an interview on 4/22/15 at 7:55 a.m. with S2DON, she confirmed quality indicators for the above referenced services provided through contractual agreement were not included in the hospital's QAPI plan.

Based on QAPI (quality assurance performance improvement) documentation review and interview, the hospital failed to initiate actions aimed at performance improvement as evidenced by failing to institute interventions to correct deficient practice areas identified through QAPI data collection.
Findings:

Review of the Quality Assurance Report presented by S2DON as her QAPI documentation revealed data collection/analysis for the Second and Third Quarters of 2014. No documentation was provided for the First (January, February and March) and Fourth (October, November and December) Quarters of 2014 and the First Quarter of 2015 (January, February and March).

Further review of the QAPI documentation revealed the following, in part:
Second Quarter of 2014 (April, May and June):
Medical Records Report:
Discharge Summaries completed within 30 days of discharge:
April 2014: 10%; May 2014: 33%; June 2014: 26%

All entries signed and timed:
April 2014: 40%; May 2014: 30%; June 2014: 40%

Discharge Planning:
Discharge planning remains substantially low due to lack of a fulltime discharge planner. We now have a full time social worker.

Nursing chart audits (number of charts reviewed not listed) for completion of weekly patient care plans:
April 2014: 20%; May 2014: 20%; June 2014: 10%

Third Quarter of 2014 (July, August and September):
Medical Records Report:
Discharge Summaries completed within 30 days of discharge:
July 2014: 0; August 2014: 0; September 2014: 0

All entries signed:
July 2014: 70%; August 2014: 75%; September 2014: 75%

Discharge Planning:
Discharge planning continues to be an issue due to lack of consistent person to fulfill the needs of discharge planning.

Therapy Services:
No significant therapy issues noted in performing assessments within 24 hours of admission. Improvement still needed in the timing of narrative notes, especially OT (occupational therapy). Improvement noted in PT (physical therapy).

Additional review revealed no patient chart audits for completion of weekly patient care plans for July, August, and September - Third Quarter of 2014.

Review of the hospital ' s QAPI documentation revealed no documented evidence of interventions to correct deficient practice areas identified through QAPI data collection referenced above.

In an interview on 4/22/15 at 7:55 a.m. with S2DON, she said she was responsible for QAPI. S2DON indicated discharge planning, incomplete medical records (lack of discharge summaries and failure to authenticate, date and time record entries) and therapy services were chosen as quality indicators because those areas were problematic for the hospital. S2DON also indicated the above referenced areas were always chosen for evaluation and she agreed new areas should have also been identified for evaluation/performance improvement. S2DON confirmed the hospital currently had no one performing discharge planning and no corrective interventions had been put into place. S2DON acknowledged incomplete medical records was a continued problem and no interventions had been put into place to correct that issue. She indicated the hospital was small and it was difficult to recruit/retain physicians so there had been no enforcement of consequences for delinquent medical records. S2DON also indicated discharge summary completion remained an issue and no interventions had been put into place for correction of the problem. S2DON also confirmed that a problem had been identified with patient care plans not being updated and she indicated interventions for improvement had not yet been initiated.

Based on policy review and interview, the hospital failed to ensure the QAPI (quality assessment performance improvement) program identified, analyzed, and implemented preventative actions for medication errors as evidenced by failing to track near miss medication errors.
Findings:

Review of the hospital policy titled, Medication Administration, revealed the following, in part:
Drug administration errors, adverse drug reaction and incompatibilities will be immediately reported to the attending physician.
For medication errors by personnel:
Definition of medication error: Errors including, but are not limited to, wrong medications, wrong dose, extra dose, wrong time, wrong route, and omission of ordered drug.

Review of the QAPI program documentation presented by S2DON revealed no documented evidence of tracking of near miss medication errors.

In an interview on 4/21/15 at 2:45 p.m. with S16Pharmacist (contracted Director of Pharmacy), he confirmed near misses were not identified, analyzed and tracked as part of the QAPI program.

In an interview on 4/22/15 at 7:55 a.m. with S2DON, she confirmed near misses were not identified, analyzed and tracked as part of the QAPI program.

Based on record review and interview, the hospital's governing body failed to ensure that the hospital's QAPI (quality assurance performance improvement) program reflected the complexity of the hospital's organization and services as evidenced by:
1. failure to include all services furnished under contract or arrangement in the QAPI plan;
2. failure to incorporate outpatient services (rehabilitation and behavioral) into the hospital's QAPI plan.
Findings:
1. Failure to include all services furnished under contract or arrangement in the QAPI plan:
Review of the hospital's governing body meeting minutes revealed no documented evidence of review of quality indicators for services provided for the hospital through contractual agreement.
The list of the hospital's current contracted services, presented by S20CFO, was reviewed and compared to the QAPI plan documentation provided by S2DON. Further review of S2DON's QAPI plan documentation revealed quality indicators were not included for every service provided to the hospital though contractual agreement.
2. Failure to incorporate outpatient services (rehabilitation and behavioral) into the hospital's QAPI plan.

Review of the hospital's governing body meeting minutes revealed no documented evidence of review of quality indicators for outpatient services (rehabilitation and behavioral).

Review of the QAPI plan documentation provided by S2DON revealed no quality indicators for outpatient hospital services (rehabilitation and behavioral).

In an interview on 4/22/15 at 7:55 a.m. with S2DON, she confirmed quality indicators for every service provided through contractual agreement were not included in the QAPI plan. S2DON also confirmed quality indicators for outpatient services (rehabilitation and behavioral) were not included in the QAPI plan.

Based on record review and interview, the hospital failed to ensure that nursing personnel for whom current licensure is required had a valid and current license as evidenced by failing to have documented verification of current licensure for 5 of 5 (S2DON, S3RNCharge, S11RN, S14RN, S22RNCharge) nursing personnel files reviewed for documentation of a verified current nursing license.
Findings:

No policies and procedures related to Human Resources, such as verification of licensure, were presented by the hospital as of the time of exit on 4/23/15 at 4:30 p.m.

S2DON
Review of the personnel record for S2DON (Director of Nursing) revealed her hire date was 8/1/05. Further review revealed the last documented verification of her Louisiana State Board of Nursing (LSBN) Registered Nurse license was for the year 2014. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana.

S3RNCharge
Review of the personnel file for S3RNCharge (Registered Nurse Charge) revealed her hire date was 1/7/06. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana.

S11RN
Review of the personnel file for S11RN revealed a hire date of 3/13, and a signed job description for Infection Preventionist. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana.


S14RN
Review of the personnel file for S14RN revealed a hire date of 11/13/09, and a signed job description for a staff RN. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana.

S22RNCharge
Review of the personnel file for S22RN revealed a hire date of 1/23/14. Further review revealed no documented verification of a current (2015) LSBN RN license.

In an interview on 4/22/15 at 3:45 p.m. S2DON confirmed the above referenced licensed nursing personnel files contained no documentation of verification of current licensure for the above-listed nursing staff.

Based on record review and interview, the hospital failed to ensure a registered nurse monitored a patient's care on an ongoing basis as evidenced by the nurse failing to ensure a social worker was consulted as ordered by the physician for 2 (#5, #9) of 2 patients' records reviewed for a social service consult out of a total sample of 30. Findings:

Patient #5
Patient #5 was an 86 year old male admitted to the hospital on 4/18/15 for CHF (Congestive Heart Failure) Exacerbation, Anemia, COPD (Chronic Obstructive Pulmonary Disease) and HTN (Hypertension). Review of the Physician Orders, dated 4/18/15, revealed an order for MSW (Masters of Social Work). Review of the medical record revealed as of 4/23/15 a social worker had not evaluated Patient #5.

Patient #9
Patient #9 was a 63 year old male admitted to the hospital on 4/10/15 with the diagnoses of Debility, Gait Instability, Bilateral Hip Pain, Avascular Necrosis of Hip and Bilateral Hip Pain. Review of the Physician Orders, dated on 4/10/15, revealed an order for MSW (Masters of Social Work). Review of the medical record revealed as of 4/23/15 a social worker had not evaluated Patient #9.

Repeated requests for a policy related to Consults or Social Services Consults, were not provided by the hospital.

Review of S25Social Worker's contract revealed in part, Responsibilities of the Medical Social Worker are to provide services in the following categories: assess the psychosocial, emotional and environmental factors operant to the patient's life in order to estimate the capacity of the patient and family to cope with problems of daily living....To provide services within the scope and limitations prescribed in the physician's order for medical social work services....

Review of S25Social Worker's time sheet revealed the following dates she came to the hospital; 1/15/15, 1/24/15, 2/8/15, 3/1/15, 3/21/15 and 3/28/15 (no dates in 4/15).

An interview was conducted with S3RN Charge on 4/21/15 at 10:30 a.m. She reported the contract social worker comes a few times a month and as they need her. S3RN Charge confirmed Patient #5 and #9 had not had a social worker consult. S3RN Charge reported the social worker had not been notified of the consult. S3RN further reported she did the verbal admission orders and circled the order for the MSW, in case they need a social worker consult.

An interview was conducted with S2DON on 4/21/15 at 10:40 a.m. She reported the Social Worker doesn't come on the weekends, so if the consult order occurred on the weekend, it probably hadn't been completed yet. She further reported she thought the hospital policy was for the consults to be done within 24 hours. S2DON wasn't sure of the last date the social worker came to the hospital.

30364


Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 6 of 6 (#3, #6, #9, #16, #21, #30) patients sampled for care planning out of a total sample of 30.

Findings:
Review of the hospital's policy on Nursing/Nursing Care Plan revealed a nursing care plan will be initiated within 24 hours of admission to the unit. The primary nurse is responsible for carrying out the care after reviewing the care plan and revising as needed. The care plan serves as a guide for patient care and educational needs during their hospital stay. Each plan is patient specific and the goal is to achieve the highest level of functioning and health status possible prior to discharge. The registered nurse will initiate the care plan specific to the disease specific medical diagnosis and relate it to the nursing diagnosis. Interventions are checked off as related to the specific diagnosis. Goals are checked off as related to expected patient outcomes. Care plans are evaluated and revised weekly with notation as to the patient's participation in the process and the goals/plans for the next week.

Patient #3
Review of the medical records for Patient #3 revealed she was admitted on 4/13/15 with diagnoses which included Anxiety and Depression.

Review of Care Plans for Patient #3 revealed no problem identified for Depression or Anxiety. Further review revealed the care plans for Patient #3 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted on 4/9/15 with the diagnoses which included an AKA (above the knee amputation), Osteoarthritis, Chronic Pain Syndrome, Malnutrition, Spinal Cord Injury, and Frequent Falls.

Review of Care Plans for Patient #6 revealed no problem identified for falls. Further review revealed the care plans for Patient #6 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #9
Review of the medical record for Patient #9 revealed he was admitted on 4/10/15 for Avascular Necrosis of hip, Debility, Gait Instability, Bilateral Hip Pain, Bilateral Leg Weakness.

Review of his Wound documentation form revealed Patient #9 had a Stage II pressure ulcer on his sacrum.

Review of the Care Plan for Patient #9 revealed his plan of care was documented on a preprinted form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals. Patient #9's pressure ulcer was not described and no interventions for the pressure ulcer were documented on the patient's care plan, only that the patient had alteration in skin integrity.

Patient #16
Review of medical record for Patient #16 revealed she was admitted on 2/24/15 with the following diagnoses: Status Post Left Pelvic Fracture, Osteoarthritis, Gait Instability, Hypertension, Frequent Falls, Impaired Vision, History of DVT (Deep Vein Thrombosis), and Poor Balance.

Review of an Incident Report on 3/5/15 revealed the patient was found on the floor, by the bed. Patient stated she was trying to get up and go to the restroom and fell.

Review of the care plan for Patient #16 revealed the care plan was initiated on 2/24/15. Further review revealed there was no update to the patient's care plan after she fell.

Review of the care plan for Patient #16 revealed her plan of care was documented on a preprinted form with various choices for nursing diagnoses, interventions, goals and outcomes. The care plans were not specific or individualized. The plan had disease specific interventions for some, but not all identified medical diagnoses. The plan had measurable goals for some, but not all medical diagnoses.


Patient #21
Review of the medical record for Patient #21 revealed he was admitted on 10/7/14 for CV (Cerebral Vascular Accident), Osteoarthritis, Trial fibrillation , Decline in Functional Status, Weakness of both Lower Extremities, and Unsteady Gait.

Review of an Incident Report on 12/31/14 revealed the patient was found on the floor sitting. Patient stated he was trying to get up and go to the restroom and fell.

Review of the Care Plan for Patient #21 revealed the care plan was initiated on 10/7/14 and updated on 10/17/14. There was no update to the patient's care plan after he fell.

An interview was conducted with S2DON on 4/23/15 at 12:30 p.m. She confirmed Patient #21 did have a fall and the plan of care was not updated after the fall.


Patient #30
Review of the medical record for Patient #30 revealed he was admitted on 2/9/15 with the following admit diagnoses: Critical Illness Myopathy, Malnutrition, Chronic Kidney Disease Stage III, History of Hypoxic Failure, Hypertension, Diabetes Mellitus, History of Seizures, CAD (Coronary Artery Disease), HIV (Human Immunodeficiency Virus) and Hypothyroidism.

Review of Patient #30's Pre-Admission Screening Assessment revealed he had last fallen on 1/30/15. Further review revealed the patient's fall risk score was 48. A score greater than 15 indicates fall risk.

Review of an Incident Report on 2/25/15 revealed the patient was found on the floor, near the bed. Further review of the report revealed the patient had a history of falls.

Review of the care plan for Patient #30 revealed his plan of care was documented on a preprinted form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no specific diagnoses interventions or measurable goals. Additional review revealed Hypothyroidism and Chronic Kidney Disease were not addressed in the care plan.

Review of the care plan for Patient #30 revealed the plan was initiated on 2/9/15. Further review revealed the care plan was not updated after the patient fell.

An interview was conducted with S2DON on 4/23/15 at 12:30 p.m. She confirmed Patient
#30 had fallen and the plan of care had not been updated after the fall.


In an interview on 4/22/15 at 3:30 p.m. with S2DON she confirmed the above referenced patient care plans (#3, #6, #9, #16, #21, #30) were generalized plans that failed to contain individualized, specific, measurable interventions for each medical diagnoses. S2DON acknowledged the hospital's care plans were a problem and needed to be more individualized with specific interventions and measurable goals. She also acknowledged the plans should have been updated with changes in patient status.


30984

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing patient care had been evaluated as evidenced by failing to maintain documented evidence of skills competency and annual performance evaluations for 6 of 6 (S3RNCharge , S11RN, S14RN, S21LPN , S22RNCharge, S23CNA) personnel records reviewed for competencies, from a list of a total of 30 clinical staff listed.
Findings:

No policies and procedures related to Human Resources, such as requirements upon hiring, specific requirements of staff, such as certification in CPR (cardiopulmonary resuscitation), verification of licensure, competency evaluations, and performance evaluations, were presented by the hospital as of the time of exit on 04/23/15 at 4:30 p.m.


S3RNCharge (Registered Nurse)
Review of the personnel file for S3RNCharge revealed her hire date was 1/7/06. further review revealed no annual evaluation since 8/07. No evidence of documented competencies were noted. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana. The most recent CPR (Cardiopulmonary Resuscitation) certification had an issue date of 2/2/13, and a recommended renewal date of 2/15.

S11RN
Review of the personnel file for S11RN revealed a hire date of 3/13, and a signed job description for Infection Preventionist. Further review revealed no documented competencies or an evaluation. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana.

S14RN
Review of the personnel file for S14RN revealed a hire date of 11/13/09, and a signed job description for a staff RN. Further review revealed no documentation of verification of a current (2015) RN license for the state of Louisiana. Further review revealed no current competencies or evaluation, including wound care assessment and care competencies.

An interview was conducted with S2RN Charge on 4/20/15 at 3:20 p.m. She reported on Wednesday nights of every week, S14RN assesses all the wounds in the hospital and documents the patients' wounds in the wound care book.

S21LPN (Licensed Practical Nurse)
Review of the personnel file for S21LPN revealed a date of hire of 1/23/11. Further review revealed no competencies and no evaluations for S21LPN.

S22RNCharge
Review of the personnel file for S22RN revealed a hire date of 1/23/14. Further review revealed no documented verification of a current (2015) LSBN RN license. No competencies or an evaluation were documented for S22RN.

S23CNA
Review of the personnel file for S23CNA revealed a date of hire of 11/15/12. Further review of S23CNA's personnel file revealed no evaluation(s) or competencies.

In an interview on 4/22/15 at 3:45 p.m. S2DON confirmed the above referenced staff's personnel files contained no documentation of verification of current licensure, current competencies for the care and services provided, or current evaluations for the above- listed staff.

Based on record review and interview, the hospital failed to be organized and staff in accordance with the complexity of a 14 bed rehabilitation hospital by failing to employ adequately trained personnel to ensure for the prompt completion of medical records.
Findings

An interview was conducted with S2DON on 4/22/15 at 8:40 a.m. S2DON reported she was over the medical records department. S2DON went on to report she had been trying to keep up with the medical records, but had been unable to keep up. S2DON also stated the hospital had in the last couple of weeks reassigned S6Office Manager to assist with the medical records. S2DON reported that herself and S6Office Manager were not Registered Health Information Managers. S2DON reported she had not been tracking delinquent medical records for the last 3 to 4 years. S2DON reported she was over the Medical Records Department, Quality Assurance and Performance Improvement, Emergency Preparedness and Nursing.

Review of the personnel files for S2DON and S6Office Manager revealed no Health Information Management experience, education and/or training.

An interview was conducted with S2DON on 4/22/15 at 8:40 a.m. She reported S6Office Manager was just recently reassigned in the last few weeks to assist her with the medical records department.

Based on record review, interview and observation, the hospital failed to
1) ensure all medical records were promptly completed as evidenced by not maintaining documentation of deficient records and by failing to suspend practitioners when medical records were not completed according to hospital policy, as set forth in the medical staff by-laws and

2) ensure medical records were protected from water and fire damage as evidenced by medical records being on open carts and on top of cabinets in a room equipped with a sprinkler system and medical records being housed in a compressed wood cabinet.
Findings:

1. failed to ensure all medical records were promptly completed as evidence by not maintaining documentation of deficient records and by failing to suspend practitioners when medical records were not completed according to hospital policy, as set forth in the medical staff by-laws.

Review of the hospital's policy on Information Management, Monthly Review of Medical Records revealed, The Medical Records Department will complete a monthly record indicating all incomplete medical records. A copy of the report will be submitted to the Administrator and the Quality Improvement Coordinator. The facility will adopt JCAHO's (Joint Commission Accreditation on Healthcare Organizations) average which states, "the average number of records delinquent for any reason must be less than or equal to thirty percent (30%) of the average monthly discharges. The chart completion log will be used to monitor incomplete medical records. The log will be updated by auditing chart completion summary forms. A log will be maintained for each month. A Medical Record Report will be completed monthly by the 15th of the following month. The Medical Record Report will include: Number of Delinquent Records-deficiencies exceeding 15 days post discharge. Reason/Circumstances surrounding delinquent records. Percent of delinquent records. Percent of delinquent records compared to total discharges for the month (Delinquency Rate).

Review of the hospital's policy for Information Management/Incomplete/Delinquent Medical Records revealed the Medical Records Department will make every reasonable effort to assure the timely completion of medical records. Physicians will be notified of deficiencies upon completion of the discharge analysis. A medical record must be completed within 30 days of the patient's discharge. The administrator will send a letter to any physician noncompliant after thirty (30) days allowing a three (3) days response. The letter will be sent by registered mail. If the physician remains delinquent, the physician's privileges will be suspended until the medical record(s) are complete. Exception for suspension shall be observed as indicated in the Medical Staff Bylaws and Rules and Regulations.

An interview was conducted with S2DON on 4/22/15 at 8:40 a.m. She reported there has been no tracking of delinquent medical records in the last 3 to 4 years and she has been the manager over Medical Records at the hospital and has been unable to monitor the medical records department adequately. She further stated none of the physicians has been disciplined related to incomplete medical records

2) ensure medical records were protected from water and fire damage as evidenced by medical records being on open carts and on top of cabinets in a room equipped with a sprinkler system and medical records being housed in a compressed wood cabinet.
Findings:

Review of the hospital's policy on Information Management/Medical Records-Creation/Control and Confidentiality revealed in part, the medical records will be safe guarded against loss, defacement, tampering or destruction by fire or water or use by unauthorized persons.

An observation was conducted of the medical records department on 4/20/15 at 2:00 p.m. Approximately 50 medical records were stored on two rolling open carts, approximately another 50 medical records were stored on top of a filing cabinet and on the top of 2 metal cabinets. Approximately 100 medical records were stored in a compressed wood cabinet. The room was equipped with a sprinkler system; however, there were no safeguards in place to protect the medical records from water.

An interview was conducted with S2DON on 4/20/15 at 2:00 p.m. She reported the hospital ran out of space in the metal cabinets and need to acquire more cabinets to accommodate more medical records. S2DON verified the medical records were not protected from fire and water damage.

Based on record review and interview, the facility failed to ensure all medical record entries were signed, dated and/or timed by the person responsible for providing the service for 6 (#1, #6, #12, #14, #16, #27) of 6 patients reviewed for incomplete medical record entries out of a total sample of 30 patients' records reviewed.
Findings:

Review of the hospital's policy on Information Management/Content of All Medical Records revealed in part, Medical Records shall be confidential, secure, current, authenticated, legible and complete... All entries in the medical record must be dated and authenticated, and a method established to identify the author of entries. The parts of the medical record that are the responsibility of the medical practitioner shall be authenticated by him.

Review of the hospital's policy on Health Information/ Signature Identification and Signature Stamps revealed in part, All entries made into the record by any staff shall be legible, fully dated and signed with the functional or professional title of the staff completing the entry.

Review of the hospital's policy on Information Management/Concurrent Review revealed in part, The Medical Records Department will conduct concurrent review on inpatient records to validate authentication and completion of a medical record with a specified time frame.

Review of the hospital's policy on Information Management/Timely Entries in Medical Records revealed in part, All verbal and telephone orders must be signed by the ordering physician within 48 hours of dictating the order.

Patient #1
Review of Patient #1's medical record revealed the patient' s History and Physical, dated 4/3/15 at 9:00 a.m., had been authenticated by the patient' 's physician, but the entry had not been timed or dated.

Patient #6
Review of the admission orders dated 4/9/15 at 3:45 p.m. for Patient #6 revealed the physician had authenticated the verbal order, but did not time or date his authentication.

A review of an order for Patient #6 dated 4/11/15 for Zosyn 4.5 gm (grams) IVP (intravenous piggyback) q 3H (every 3 hours) x (times) 3 days. The order had not been timed by the physician.

Patient #12
Review of the Physician's Admission Orders for Patient #12 dated 3/3/15 at 10:45 a.m. revealed the physician had authenticated the verbal order, but had not timed or dated his authentication.

Patient #14
Review of Patient #14's medical record revealed the patient ' s History and Physical, dated 2/3/15 at 4:00 p.m., had been authenticated by the patient ' s physician, but the entry had not been timed or dated.

Further review of Patient #14's medical record revealed the following incomplete entries:

3/5/15, no time, Proctofoam HC- apply to rectal area BID (twice a day) and PRN (as needed). The order was authenticated and dated, but not timed.

3/17/15, no time, Discharge to home. F/U (follow up) with doctor within one week. The order was authenticated and dated, but not timed.

Patient #16
Review of Patient #16's medical record revealed the patient's History and Physical, dated 2/25/15 at 8:30 a.m. had been authenticated by the patient's physician, but the entry had not been timed or dated.

Patient #27
Review of Patient #27's medical record revealed the patient's History and Physical, dated
9/30/14 at 3:00 p.m. had been authenticated by the patient's physician, but the entry had not been timed or dated.

In an interview on 4/23/15 at 9:20 a.m. with S2DON, she confirmed the hospital had a problem with physicians/practitioners signing, timing and dating entries/orders in the patients' medical records.


30364




30984

Based on record review and interview, the hospital failed to have discharge summaries in discharged patients' medical records with the outcome of hospitalization, disposition of care and provisions for follow-up care for 8 (#20,#21,#22, #23, #27, #28, #29, #30) of 21 (#10- #30) discharged patients' records reviewed.
Findings:

Review of the hospital's policy on Information Management, Content of Discharge Summary, revealed the discharge summary will contain the essential elements as required by regulatory agencies. The discharge summary will serve as a comprehensive overview of the patient's course of treatment during the hospitalization. The discharge summary will serve to promote continuity of care for subsequent admissions and for other health care providers utilized by the patient after discharge.

Review of the hospital's policy on Information Management, Timely Entries in Medical Record revealed in part, A discharge summary will be completed on all patients hospitalized over 24 hours. The discharge summary must be hand written or dictated, transcribed, and placed in the medical record within 15 days of discharge. The report is to be signed within 48 hours. If the discharge summary is not completed in 15 days of the patient's discharge, the medical record with be delinquent.

Review of the hospital's Medical Staff General Rules and Regulations revealed in part:
C. Medical Records.
8. Discharge Summary: a. The discharge summary should include a statement concerning each of the following items when applicable: 1. Admission and discharge date. 2. Procedure. 3. Significant labs and x-ray findings. 4. Treatment. 5. Complications. 6. Specific instructions to patient and/or family. 7. All pertinent data including chief complaint, history, physical examination, progress notes, disposition, follow-up plans, condition on discharge, prognosis, procedures and final diagnosis.

Review of the Quality Assurance Report presented by S2DON as her QAPI documentation revealed data collection/analysis for the Second and Third Quarters of 2014. No documentation was provided for the First (January, February and March) and Fourth (October, November and December) Quarters of 2014 and the First Quarter of 2015 (January, February and March).

Further review of the QAPI documentation revealed the following, in part:
Second Quarter of 2014 (April, May and June):
Medical Records Report:
Discharge Summaries completed within 30 days of discharge:
April 2014: 10%; May 2014: 33%; June 2014: 26%

Discharge Planning:
Discharge planning remains substantially low due to lack of a fulltime discharge planner. We now have a full time social worker.

Third Quarter of 2014 (July, August and September):
Medical Records Report:
Discharge Summaries completed within 30 days of discharge:
July 2014: 0; August 2014: 0; September 2014: 0

Discharge Planning:
Discharge planning continues to be an issue due to lack of consistent person to fulfill the needs of discharge planning.


Patient #20
Review of the medical record for Patient #20 revealed she was admitted on 12/08/14 and discharged on 12/22/14. Further review revealed she did not have a discharge summary.

Patient #21
Review of the medical record for Patient #21 revealed he was admitted on 10/07/14 and discharged on 10/31/14. Further review revealed he did not have a discharge summary.

Patient #22
Review of the medical record for Patient #22 revealed he was admitted on 10/13/14 and
discharged on 11/03/14. Further review revealed he did not have a discharge summary.

Patient #23
Review of the medical record for Patient #23 revealed she was admitted on 7/24/14 and discharged on 8/15/14. Further review revealed she did not have a discharge summary.

Patient #27
Review of the medical record for Patient #27 revealed she was admitted on 9/30/14 and discharged on 10/23/14. Further review revealed she did not have a discharge summary.

Patient #28
Review of the medical record for Patient #28 revealed he was admitted on 1/2/15 and
discharged on 1/29/15. Further review revealed he did not have a discharge summary.

Patient #29
Review of the medical record for Patient #29 revealed he was admitted on 02/12/15 and
discharged on 3/2/15. Further review revealed he did not have a discharge summary.

Patient #30
Review of the medical record for Patient #30 revealed he was admitted on 02/9/15 and discharged on 2/26/15. Further review revealed he did not have a discharge summary.

In an interview on 4/22/15 at 7:55 a.m., S2DON said she was responsible for QAPI. S2DON indicated discharge planning and incomplete medical records (lack of discharge summaries and failure to authenticate, date and time record entries) were chosen as quality indicators because those areas were problematic for the hospital. S2DON also indicated the above referenced areas were always chosen for evaluation and she agreed new areas should have also been identified for evaluation/performance improvement. S2DON confirmed the hospital currently had no one performing discharge planning and no corrective interventions had been put into place. S2DON acknowledged incomplete medical records was a continued problem and no interventions had been put into place to correct that issue. S2DON indicated the hospital was small and it was difficult to recruit/retain physicians so there had been no enforcement of consequences for delinquent medical records. S2DON also indicated discharge summary completion remained an issue and no interventions had been put into place for correction of the problem.


A phone interview was conducted with S9MedicalDirector on 4/23/15 at 1:20 p.m. When the surveyor inquired why the discharge summaries on the patients were not being done, S9MedicalDirector replied that at one point there was confusion about whether to dictate the discharge summary or hand write the summary. S9MedicalDirector reported it was too expensive to dictate patient discharge summaries so the hospital had decided to convert to Electronic Medical Records soon. She also reported the hospital had not told her there were delinquent medical records. She went on to state she would actively find a way to correct the delinquent medical records and she took full responsibility for the delinquencies. S9MedicalDirector reported she understood the importance of keeping up with the patients' medical records and ensuring discharge summaries were completed on all patients.


30364

Based on observation and interview, the hospital failed to ensure unusable and undated multidose drugs and biologicals were unavailable for patient use as evidenced by:
1. outdated intravenous fluids being available for patient use in central supply and
2. undated multidose stock liquid medications being found on the medication cart.
Findings:

An observation was conducted on 4/20/15 at 10:20 a.m. in the central supply room revealing four (4) one liter bags of D5 1/2 NS (Dextrose 5% 1/2 Normal Saline) IVF (intravenous fluids) dated with the expiration date of 10/1/2012 and one (1) bag of 250 ml (milliliters) of D5W (5%Dextrose) IVF with the expiration date of 1/9/2014.

An interview was conducted with S3RNCharge on 4/20/15 at 10:25 a.m. S3RNCharge confirmed the bags of IVFs were expired and should have not been available for patient use.

2. An observation was conducted on 4/20/15 at 10:30 a.m. of the following stock liquid multidose medications being opened in the medication cart without the date of when the medications were opened for patient use: Tylenol, Promod, Lactulose (1 quart), and Milk of Magnesia (12 ounce bottle). Also in the medication cart was 1 vial of single patient use 30 cc (cubic centimeter) 1% Lidocaine Intravenous that had been opened and not dated when the vial was opened.

An interview was conducted with S4LPN on 4/20/15 at 10:30 a.m. S4LPN confirmed the above findings.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A.
Findings:

Review of hospital policies and procedures revealed no policy and procedure for radiological services.

In an interview 4/20/15 at 10:05 a.m. S2DON (Director of Nursing) reported the hospital had no radiologist or other personnel overseeing radiological services. S2DON reported that radiological services were provided to hospital patients, in part, by a mobile X-ray service that performed portable X-rays in the hospital. The DON verified the hospital did not have any policies and procedures for radiology services.

Based on record review and interview, the hospital failed to have a radiologist who supervised the radiology services of the hospital.
Findings:

Review of a list of credentialed physicians and providers provided by the hospital revealed no credentialed radiologist.

Review of the governing body meeting minutes revealed no documentation of the appointment of a radiologist who supervised the radiology services of the hospital.

Review of the hospital's organizational chart revealed no documentation of a radiologist who supervised the radiology services of the hospital.

In an interview 4/20/15 at 10:05 a.m., S2DON (Director of Nursing) reported the hospital had no radiologist overseeing radiological services. S2DON reported that radiological services were provided to hospital patients, in part, by a mobile X-ray service that performed mobile X-rays in the hospital.

Based on record review and interview, the hospital failed to ensure food and dietetic services were under the direction of a full time employee, qualified by experience or training, as evidenced by failure to employ a Director of Food Services.
Findings:

Review of the hospital's organizational chart revealed no documented evidence of a Director of Food Services.

In an interview on 4/22/15 at 7:55 a.m., S2DON verified that the hospital had no Director of Food Services.

Based on record review and interview, the hospital failed to ensure a current therapeutic diet manual, approved by the dietitian and medical staff, was readily available to all medical, nursing, and food service personnel as evidenced by failure to have an approved dietary manual.
Findings:

Review of the hospital's manuals presented to the survey team as current revealed no documented evidence of a therapeutic dietary manual.

In an interview on 4/20/15 at 11:00 a.m. with S2DON, she said the hospital had a therapeutic dietary manual in the past but she was not sure if the hospital had a current dietary manual. S2DON was unable to produce a current therapeutic dietary manual prior to the survey team's exit.

Based on record review, observation and interview, the hospital failed to ensure equipment was maintained in a manner to ensure an acceptable level of safety and quality as evidenced by contracted Biomedical services not being performed in the hospital for over a year as per agreement.
Findings:

Review of the hospital policy and procedure manual revealed no documented evidence of policies relative to equipment maintenance and biomedical safety checks. No preventive maintenance/biomedical policies could be provided by hospital staff to the survey team prior to exit on 4/23/15 at 4:30 p.m.

Observations of the clean equipment storage room on 4/20/15 at 9:25 a.m. revealed the following:
Oxygen concentrator unit (in use by current Patient #1) with a Biomedical inspection tag dated 4/2013;
2 nebulizer units with no Biomedical inspection tags;
1 enteral feeding pump with no Biomedical inspection tag;
1 enteral feeding pump with a Biomedical inspection tag dated 4/2013.
1 portable suction machine with a Biomedical inspection tag indicating the next inspection was due 5/2011.

An observation of the Nourishment Room on 4/20/15 at 8:50 a.m. revealed the patients' refrigerator had a Biomedical inspection tag indicating the date of the next inspection was due 4/14. The finding was confirmed by S7CNA.




30984

Based on record review and interview, the hospital failed to ensure a qualified staff member was designated as the infection control officer to develop and implement policies governing the control of infections and communicable diseases.
Findings:

Review of a list of staff members with titles at the hospital revealed S11RN's position was listed as Infection Control Specialist. In an interview on 4/21/15 at 10:15 a.m., S2DON said S11RN was the infection control officer at the hospital and she only came to the hospital one day a month.

A review was made of a job description provided by the hospital and signed by S11RN on 3/28/13. Further review revealed the job description titled Infection Control Officer revealed in part: The Infection Control Officer is primarily responsible for overseeing the development and implementation of the facility infection control policies and procedures. Some of the responsibilities listed included overseeing the development and implementation of a protocol to identify, report, and investigate infections, oversee the implementation of policies, monitor compliance with all policies, oversee the promotion of hand washing, and participates in quality assurance by maintaining the necessary documentation and attending the quarterly meetings.

In an interview on 4/22/15 at 7:35 a.m. with S11RN, she said she was a PRN (as needed) employee. S11RN said she was hired to help correct problems with infection control at the facility, but she said was not the person over infection control. She said S2DON was over the Infection Control Program. S11RN said the hospital has not had any infection control meetings, did not gather data for quality assurance and did not participate in quality meetings. S11RN also said there was not an effective infection control program at the hospital and they were not tracking and trending infections. She said there has not been any hand washing audits and she had not performed any audits related to infection control. She said she had given the administration recommendations and they did not follow up on them. S11RN said she generated forms for tracking various items related to infection control and they were left blank. S11RN also said she told the administration they needed to report to the NHSN (National Healthcare Safety Network) and they did not.

In an interview on 4/22/15 at 8:20 a.m., S2DON said she was not sure who the infection control officer was at the hospital. S2DON said she thought it was S11RN, but it may have been herself. S2DON said she could not locate any of her hand washing audits. S2DON said they have had problems with environmental issues, but they are not talked about in Quality meetings. S2DON said she did not have any Quality meeting minutes related to infection control. S2DON said she has not had any specialized training in infection control or experience as an infection control officer. S11RN agreed there was not an effective infection control program at the hospital.

Based on record review, observation and interview, the hospital failed to develop, implement, and maintain an active, hospital-wide program for the prevention, control, and investigation of infections and communicable diseases as evidenced by:

1) Failing to ensure the effective implementation of effective precautions for a patient with a known multi-drug resistant organism (MDRO) for 1 of 1 current patients (Patient #6) observed with positive lab culture results.

2) Failing to ensure patient care was provided in a sanitary environment.

3). Failing to ensure capillary blood glucose monitoring was performed with correct hand hygiene and glucometer disinfection procedures.

Findings:

1) Failing to ensure the effective implementation of effective precautions for a patient with a known multi-drug resistant organism (MDRO) for 1 of 1 current patients (Patient #6) observed with positive lab culture results.

Review of Centers for Disease Control and Prevention (CDC) guidelines for Contact Precautions revealed the following measures to be taken by persons entering the room of a patient on Contact Precautions:
-Before entering, perform hand hygiene
-Gowns and gloves must be worn to enter the room
-Disposable equipment is to be used when possible and dedicated to the patient
-Clean and disinfect all equipment before removing from the room.
-Patient Transport should be for essential purposes only
-For transport the patient must perform hand hygiene and wear a clean gown. For direct contact with the patient, a gown should be worn. Notify receiving area.
-Before leaving the patient's room remove gloves and gown, then perform hand hygiene.

Review of a laboratory report dated 4/20/15 at 11:03 a.m. revealed Patient #6's urine culture collected on 4/18/15 had greater than 1,000,000 CFU/Ml (colony forming unit per milliliter) of Pseudomonas aeruginosa. Further review revealed the report listed the organism as a Multi-drug or Pan-resistant organism and potential pathogen that mandates the institution of contact precautions. This report also listed notification of the results had been called to S4LPN at the hospital on 4/20/15 at 11:03 a.m.

Observations in the hospital on 4/20/15 at 3:00 p.m. revealed Patient #6 had no signage on his door indicating any type of special precautions.

In an interview on 4/20/15 at 3:00 p.m. with S3RNCharge, she said Patient #6 had not been placed on contact precautions as of yet because she was waiting on word from the doctor. S3RNCharge said the lab had called earlier and had indicated Patient #6 needed to be on precautions because he had "bugs" in his urine. S3RNCharge said she was not sure exactly when the lab had called with Patient #6's positive culture results.

In an interview on 4/20/15 at 4:00 p.m. with S18OT, she said she was the occupational therapist at the hospital. S18OT indicated Patient #6 had received occupational therapy from 12:00 p.m. until 1:30 p.m. and physical therapy from 1:30 p.m. until 3:00 p.m. that day (4/20/15). S18OT said they were not told Patient #6 had needed to be on contact precautions until almost the end of the therapy sessions and the staff had not used any types of contact precautions while working with him.

Review of Patient #6's medical record revealed a telephone order dated 4/20/15 at 2:00 p.m. to place Patient #6 on Contact Isolation.

In an observation on 4/21/15 at 12:07 p.m., Patient #6 was observed in the cafeteria sitting at a table with Patient #5, Patient #7 and Patient #3. S7CNA was observed assisting Patient #6 with his meal. Neither S7CNA nor Patient #6 were wearing gowns and S7CNA was not wearing gloves.

In an interview on 4/21/15 at 12:10 p.m., S7CNA said she thought Patient #6 was just put on isolation precautions. S7CNA said she did not wear gloves or a gown when feeding Patient #6 because she just took him into the dining room to eat and took him straight back to his room.
In an interview on 4/21/15 at 10:30 a.m. with S2DON, she said Patient #6 should have been placed on isolation precautions soon after notification by the lab of positive culture results on 4/20/15 at 11:03 a.m. She verified waiting several hours to begin precautions was too long and the nurses did not need to wait on a physician's order to begin precautions.


2). Failing to ensure patient care was provided in a sanitary environment;

Bathroom:
Observation of a bathroom in an empty patient room on 4/20/15 at 9:40 a.m. revealed saturated towels soiled with feces on the floor of the shower, the shower bench, and the bathroom floor. This finding was confirmed by S2DON. S2DON also confirmed the above referenced room was empty and indicated she had no idea how long it had been since a patient had occupied the room. She indicated she had no explanation for the above referenced findings.

Nourishment Room:

An observation was conducted on 4/20/15 at 9:00 a.m. of the Patient Nourishment Room. The microwave had dried food adhering to the inside of the microwave. A dried purple liquid spill was on the table next to the microwave. There was a large, uncovered garbage can overflowing with trash that was spilling onto the floor. A large jar of open mayonnaise was noted on an open shelf and was unrefrigerated. In the refrigerator, labeled for patient food only, were uncovered cups of a red liquid (juice), approximately 4 cups. Also in the refrigerator was an unlabeled (no patient name) package of hot pockets.

An interview was conducted with S7CNA on 4/20/15 at 9:15 a.m. She confirmed the findings in the Nourishment Room. She reported she knew it was a mess and the room shouldn't be like it was and she would clean it up.

Room D:
An observation was conducted on 4/20/15 at 9:30 a.m. of Room D's bathroom. The patient room had Christmas supplies, bedside tables, chairs, and mattresses stored in the room. The toilet in the bathroom in Room D was full of a brown substance (bowel movement) and a white towel and/or paper towels.

An interview was conducted with S5Housekeeper on 4/20/15 at 9:45 a.m. S5Housekeeper reported he would have to replace the toilet; he had been unable to repair the toilet.

Clean Equipment Storage Room:
Observations of the clean equipment storage room on 4/20/15 at 9:30 a.m. revealed the following:
2 enteral feeding pumps with enteral feeding residue noted on both the front and back surfaces;
Spider webs between the air conditioning unit and the floor;
Dead insects (3) noted on the floor;
Dust and debris and 2 plastic bags on the floor;
2 lancets, capped, one on the sink rim and 1 on the floor;

An interview was conducted with S3RNCharge at the time of the observation (4/20/15 at 9:30 a.m.) and she confirmed the above referenced findings. She agreed the clean storage room was dirty and should have been cleaned prior to storing clean equipment in the room. She also agreed dirty equipment should have been cleaned prior to storage in the clean equipment room.

Unclean toilets in patient rooms:

An observation was conducted in Patient #1 and Patient #2's bathrooms on 4/20/15 at 9:00 a.m. The toilets had a dark brownish yellow ring in the toilet bowls.

An interview was conducted with S5Housekeeping on 4/20/15 at 9:30 a.m. He reported he was the housekeeper for the hospital and worked Monday through Friday. He also reported he was off on the weekends and there was no housekeeping staff working weekends. When he was asked to see if the dark rings in the toilets could be removed, he reported it was difficult due to the minerals in the water. S5Housekeeper was observed cleaning the toilets and the rings in the toilets were removed after cleaning was completed.

Soiled Utility Room:
Observation of the soiled utility room on 4/20/15 at 9:45 a.m. revealed multiple garbage bags stacked in front of the opened door and overflowing into the hallway. S5Housekeeper confirmed the above referenced findings.

Central Supply:
An observation was conducted on 4/20/15 at 10:20 a.m. of the central supply room. Stored on the floor of the central supply room was 1 box of water pitchers for patient use, 7 boxes of paper towels, 3 boxes of toilet paper, and 2 boxes of hand soap stored on the floor under a sink. These findings were confirmed by S2DON.


3). Failing to ensure capillary blood glucose monitoring was performed with correct hand hygiene and glucometer disinfection procedures.

Review of a document provided by the hospital titled Point of Care Devices/Blood Glucose Monitor, revealed in part:
All devices will be used according to the manufacturer's guidelines unless otherwise specified by an authoritative body with the knowledge base to override the manufacturer's specifications for use.
When performing a blood glucose check, the staff member will wash hands before and after the procedure. Gloves are to be worn when performing a finger stick and removed after completed.

Review of a document provided by the hospital titled Infection Control/Hand washing Without Water Procedure, revealed in part:
Purpose: To cleanse the hands of germs and prevent contamination between patients and employees.
Hands should always be washed: before and after each contact with a patient; after removing gloves.

Review of a document provided by the hospital titled Truetrack Quality Assurance/ Quality Control Manual, revealed in part:
Meter Care, Cleaning/Disinfection- To clean and disinfect Meter, use PDI Super Sani-Cloth Germicidal Disposable wipes (active ingredients- 55% Isopropyl alcohol/Isopropanol, 5,000 PPM (Parts Per Million) quarternary ammonium chlorides) Viraguard/Virahold wipes (active ingredient- 70% Isopropyl alcohol/isopropanol) or disinfectants with identical active ingredients.

An observation made 4/23/15 at 11:00 a.m. revealed S17LPN performed a capillary blood glucose (CBG) test on Patient #1. S17LPN donned a pair of gloves and cleaned the glucometer with alcohol wipes, then picked up the glucometer and proceeded to Patient #1's room without removing her gloves. S17LPN performed the capillary blood glucose on Patient #1, then returned to the medication cart at the nurses station. S17LPN then removed the gloves she had donned prior to cleaning the glucometer and performing the CBG. S17LPN then donned a glove on her right hand and cleaned the glucometer with alcohol wipes. After removing that (single) glove, S17LPN then went into the staff bathroom to wash her hands. In an interview after she completed her handwashing, S17LPN reported that she normally would wear two gloves to clean the glucometer. The LPN verified her procedure for cleaning the glucometer was to use alcohol.

In an interview on 4/23/15 at 12:20 p.m. S2DON reported that she was unaware that the instruction booklet for the hospital's glucometer had separate guidelines for professional use, that outlined disinfection of the glucometer with a disinfectant cloth. S2DON reported that S17LPN should have changed gloves after cleaning the glucometer, before patient care, and should have performed hand hygiene with each glove change, as well as before and after patient care.


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Based on record review and interview, the respiratory care services of the hospital were inappropriate for the scope and complexity of the services offered as evidenced by allowing a respiratory therapist from a nearby facility, not employed by the hospital, to assist in the care of 1 of 1 patient (Patient #11) with a tracheostomy out of a total sample of 30. Findings:

Review of the hospital's policy, Respiratory Therapy General, revealed in part, The nursing staff at this facility performs all respiratory therapy. Any references to respiratory therapist may be substituted with nursing staff. We reserve the right to contract the services of a respiratory therapist as needed.

Review of the contract for S19RT (presented as the current contract for the Respiratory Therapist) revealed the contract was entered into on 11/10/05.

Patient #11
Review of Patient #11's medical record revealed he was a 44 year old male admitted on 2/3/15 with admitting diagnoses of : Anoxic Brain Injury, Lack of Coordination, HTN (Hypertension), Seizure Disorder and Tracheostomy. Patient #11 was transferred to another facility on 2/07/15 due to wife's preference.

Review of his Physician Orders on admission revealed an order for Trach collar to room air maintain O2 (oxygen) sat (saturation) 96%, BIPAP (Bilevel Positive Airway Pressure), 14/6 at bedtime, Ipratropium-Albuterol 0.5 - 3 mg (milligrams)/ 3 ml (milliliters) (Duoneb) i (1) vial nebulizer every 6 hours, Suction trach collar prn ( as needed), and O2 2 L(Liters) min (minute) to trach collar if O2 sat less than 96 %. Review of a physician's order dated 2/3/15 at 2100 revealed Pt (Patient) may receive respiratory treatment as needed, and may be evaluated and treated by respiratory therapist.

Review of the medical record for Patient #11 revealed no documentation by a respiratory therapist in the patient's medical record.

Review of the Daily Nursing Documentation/Physical Assessment dated 2/3/15 at 2100 revealed Suction pt at 2130, Amount suctioned 10 ml, white, thin secretions, pt tolerated well. breath sounds clear, good cough reflex. Review of the MAR (Medication Administration Record) revealed the patient was suction on 2/4/15 at 0600, 1200, 2130, and on 2/5/15 at 0600. Review of the Nursing Notes revealed inconsistent documentation that the patient had a trach. Review of the Nursing Notes on 2/5/15 (not timed) revealed the patient did not have a trach and no assessment of the patient's trach site was documented. Review of the Nursing Notes on 2/5/15 at 0715 revealed the patient's trach site was WNL (within normal limits), but there was no documentation the patient had a trach.

An interview was conducted with S2DON on 4/21/15 at 1:00 p.m. She reported when the hospital attempted to get in touch with S19RT (contracted respiratory therapist) for Patient #11, they were unable to get in touch with him. S2DON further reported the hospital hasn't used S19RT in years. S2DON also reported Patient #11 was a patient from SNF (skilled nursing facility) "E" (located next door to the hospital) so a respiratory therapist from SNF "E" did them a favor and provided respiratory therapy services since it was their patient and they knew him. S2DON further reported they did not have a contract with SNF "E" or the respiratory therapist from SNF "E" to provide respiratory services. When questioned by the surveyor further about what services the respiratory therapist from SNF "E" provided to Patient #11, she reported he instructed the staff on the care of the patient and assessed the patient. S2DON further reported the respiratory therapist from SNF "E" did not document the assessments he performed in the patient's medical record.

An interview was conducted with S2DON on 4/23/15 at 9:30 a.m. S2DON reported she had not assessed or performed competencies for any skills related to provision of respiratory care for any of the nurses working at the facility.

Based on record review and interview, the hospital failed to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services. Findings:

Review of the hospital's policy, Respiratory Therapy General revealed, the Director of Respiratory Therapy, who is a physician , will monitor the outcomes of the respiratory therapy and provide input as needed.

Review of the Governing Body minutes for 2014-2015 revealed there was not a physician appointed to oversee the respiratory services of the hospital.

An interview was conducted with S2DON on 4/21/15 at 1:00 p.m. She reported the hospital did not have a physician appointed to oversee the respiratory services of the hospital.

Based on record review and interview, the hospital failed to have an adequate number of respiratory therapists and trained nursing personnel to care for patients with respiratory needs as evidenced by being unable to notify the contracted respiratory therapist of respiratory services needs and not having nursing personnel competent in respiratory care skills and procedures. Findings:

Review of the hospital's policy, Respiratory Therapy General, revealed in part, The nursing staff at this facility performs all respiratory therapy. Any references to respiratory therapist may be substituted with nursing staff. We reserve the right to contract the services of a respiratory therapist as needed.

Review of the contract for S19RT (presented as the current contract for the Respiratory Therapist) revealed the contract was entered into on 11/10/05.

Patient #11
Review of Patient #11's medical record revealed he was a 44 year old male admitted on 2/3/15 with admitting diagnoses of : Anoxic Brain Injury, Lack of Coordination, HTN (Hypertension), Seizure Disorder and Tracheostomy. Patient #11 was transferred to another facility on 2/7/15 due to his wife's preference.

Review of his Physician Orders on admission revealed an order for Trach collar to room air maintain O2 (oxygen) sat (saturation) 96%, BIPAP (Bilevel Positive Airway Pressure), 14/6 at bedtime, Ipratropium-Albuterol 0.5 - 3 mg (milligrams)/ 3 ml (milliliters) (Duoneb) i (1) vial nebulizer every 6 hours, Suction trach collar prn ( as needed), and O2 2 L(Liters) min (minute) to trach collar if O2 sat less than 96 %. Review of a physician's order dated 2/3/15 at 2100 revealed Pt (Patient) may receive respiratory treatment as needed, and may be evaluated and treated by respiratory therapist.

Review of the medical record for Patient #11 revealed no documentation by a respiratory therapist in the patient's medical record.

Review of the Daily Nursing Documentation/Physical Assessment dated 2/3/15 at 2100 revealed Suction pt at 2130, Amount suctioned 10 ml, white, thin secretions, pt tolerated well. breath sounds clear, good cough reflex. Review of the MAR (Medication Administration Record) revealed the patient was suction on 2/4/15 at 0600, 1200, 2130, and on 2/5/15 at 0600. Review of the Nursing Notes revealed inconsistent documentation that the patient had a trach. Review of the Nursing Notes on 2/5/15 (not timed) revealed the patient did not have a trach and no assessment of the patient's trach site was documented. Review of the Nursing Notes on 2/5/15 at 0715 revealed the patient's trach site was WNL (within normal limits), but there was no documentation the patient had a trach.

An interview was conducted with S2DON on 4/21/15 at 1:00 p.m. She reported when the hospital attempted to get in touch with S19RT (contracted respiratory therapist) for Patient #11, they were unable to get in touch with him. S2DON further reported the hospital hasn't used S19RT in years. S2DON also reported Patient #11 was a patient from SNF (skilled nursing facility) "E" (located next door to the hospital) so a respiratory therapist from SNF "E" did them a favor and provided respiratory therapy services since it was their patient and they knew him. S2DON further reported they did not have a contract with SNF "E" or the respiratory therapist from SNF "E" to provide respiratory services. When questioned by the surveyor further about what services the respiratory therapist from SNF "E" provided to Patient #11, she reported he instructed the staff on the care of the patient and assessed the patient. S2DON further reported the respiratory therapist from SNF "E" did not document the assessments he performed in the patient's medical record.

An interview was conducted with S2DON on 4/23/15 at 9:30 a.m. S2DON reported she had not assessed or performed competencies for any skills related to provision of respiratory care for any of the nurses working at the facility.