HospitalInspections.org

Based on review of Quality Meeting Minutes, Governing Body Meeting Minutes, policy and procedures and staff interview the Governing Body failed to identify opportunities for improvement, develop and implement performance improvement plans, and evaluate the data collected for revision of improvement plans as necessary until resolution. The Governing Body failed to identify, review and trend adverse patient events and medical errors that occurred in the facility and the facility failed to ensure that the facility conduct performance improvement projects.
Refer to tag V0266, V0283, and V0286

Based on review of Pharmacy Services Controlled Substance Medication Discrepancy Reports, Pharmacy Quality Meeting Report, Quality Meeting Minutes, and staff interviews the Governing Body failed to ensure that the consulting pharmacist addressed the controlled substances medication discrepancies in a timely manner, take appropriate action to correct the narcotic discrepancy's and or loss that were occurring in the facility, and failed to ensure that the consulting pharmacist actively be involved with Quality Improvement Committee Meetings.
Refer to tag: V492 and V509

Based on staff interview and review of dietary manual the Governing Body failed to ensure the dietary supervisor maintained a disaster dietary plan for the provision of patient and staff meals in the event of a disaster.
Based on staff interview, patient medical record review, and employee files the Governing Body failed to ensure the staff was competent in their respective duties.
Cross reference tags V620, V622

Based on tour of the facility, record review, and staff interview the Governing Body failed to ensure a safe and sanitary environment.
Refer to tags: V0701 and V0724

Based on policy review and medical record review the Governing Body failed to follow their discharge planning process and ensure all patients were provided with appropriate and effective discharge planning process.
Based on medical record review, policy review, and staff interview the governing Body failed to document the discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.
Lack of discharge planning needs puts all patients at risk for not receiving appropriate referrals and knowledge of availability of resources.
Cross reference tag V806 and V823




Please also refer to photos under attachment

1. Based on review of Quality Meeting Minutes, Governing Body Meeting Minutes, policy and procedures and staff interview the facility failed to identify opportunities for improvement, develop and implement performance improvement plans, and evaluate the data collected for revision of improvement plans as necessary until resolution. The facility failed to identify, review and trend adverse patient events and medical errors that occurred in the facility and the facility failed to ensure that the facility conduct performance improvement projects.

The Findings included:

Refer to tag V0266, V0283, and V0286

Based on staff interview and review of dietary manual the hospital failed to ensure the dietary supervisor maintained a disaster dietary plan for the provision of patient and staff meals in the event of a disaster.

Based on staff interview, patient medical record review, and employee files the hospital failed to ensure the staff was competent in their respective duties.

Cross reference tags V620, V622

Based on tour of the facility, record review, and staff interview the facility failed to ensure a safe and sanitary environment.

The Findings included:

Refer to tags: V0701 and V0724

Please also refer to photos under attachment

1. Based on observations and staff interviews Community General Hospital failed to adhere to nationally recognized standards of practices in infection control aimed at reducing or eliminating bloodborne pathogens and healthcare acquired infections during blood glucose monitoring.
The findings included:
a. During an inspection of the emergency department 's equipment on 2/5/13 at 1:00 p.m. with staff member S15, she informed me that the hospital 's only glucometer was shared by the inpatient medical ward and the emergency department
b. Upon verifying this information with staff -member S7, we inspected the device at the inpatient medical ward. Staff member S11 conducted a demonstration using the only non auto-disabling lancing device and glucometer.
c. When asked if they were aware that the glucometer and finger stick device were meant for single use by one patient all staff members acknowledged they were not and could not provide evidence of a manufacture's instructions allowing multiple patient use. The device was taken out of service.

Based on policy review and medical record review the facility failed to follow their discharge planning process and ensure all patients were provided with appropriate and effective discharge planning process.
Based on medical record review, policy review, and staff interview the facility failed to document the discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.

Lack of discharge planning needs puts all patients at risk for not receiving appropriate referrals and knowledge of availability of resources.

Cross reference tag V806 and V823

Based on record review and interview, the facility failed to ensure that patients who were admitted to the hospital emergency department and/or directly admitted to the hospital provided informed consent regarding who the patient was choosing as their treating physician and/or who the facility would release their protected health information to by having the patients sign a blank Release of Doctor form, blank Disclosure and Consent form, and/or blank Communication Authorization Form in ten of nineteen closed medical records reviewed (Patients #6, #8, #10, #12, #13, #15, #16, #18, #19, and #21).

Findings included:

Record review on 02/05/13 of eight patients' closed medical records who were first seen in the facility emergency department and subsequently admitted to the facility (Patients #6, #8, #10, #12, #13, #15, #16, and #18) revealed the following form that was not completed with the name of the treating physician and did not have two witnesses signatures and the patient signature as designated on the form : Release of Doctor form that stated the following: "The undersigned requested and authorized the ______________ and its representative to contact Dr._________to see and treat in the hospital's Emergency Room. The hospital representative contacted the above mentioned doctor as requested, but I now wish of my own free will to cancel my original request for services of the above mentioned doctor and I hereby authorize the hospital representative to cancel my original request and to call:
Dr.____________ to see and treat the above mentioned patient.

Witness_____________ Signature_______________

Witness_____________ Relationship_____________


Record review on 02/13/13 of patient #19's closed medical record revealed the following form: Disclosure
and Consent that stated "I hereby agree and give my consent for the admission/treatment of (patient's name) To __________________, hereinafter referred to as the hospital, under the care of (name of doctor) , his associates, partners, assistants or designees." Patient #19 had been admitted directly into the hospital and signed this form but there was no physician's name in the designated area.

Record review on 02/05/13 of patients' # 15 and #21 Communication Authorization Form signed by the patients revealed the following statement: "When it comes to your medical treatment, we strive to communicate with you in a timely and professional manner. There are certain occasions when family members, friends, or others might be involved in your care. As a patient, you will want our staff's to be able to communicate directly with them. In order to protect the privacy of your personal health information, please share with us the names of those individuals with whom we can discuss your care and share your protected health information. Please list below those individuals with whom you authorize our office to discuss aspects related to your care." The names and relation to patients were all left bank.

Interview on 02/06/13 at 12:45 PM with Business Office Staff #1 revealed that she completes the admitting paperwork for patients admitted to the emergency room, admitted directly into the hospital or admitted to the hospital from the emergency department during the day and on some weekends. She confirmed the Release of Doctor form means the patient is giving permission for the facility emergency department physician to treat them. She was unable to state why the name of emergency room physician was left blank. She confirmed she would know who was scheduled as the emergency department physician. She was unable to state why the Disclosure and Consent Form and the Communication Authorization Forms were blank.

1. Based on review of Quality Meeting Minutes, Governing Body Meeting Minutes, policy and procedures and staff interview the facility failed to identify opportunities for improvement, develop and implement performance improvement plans, and evaluate the data collected for revision of improvement plans as necessary until resolution

The Findings included:

a. Review of the Pharmacy Quality Meeting Report for January 2012- January 2013 on 2/6/12 in the facility conference room revealed the following:

The number of times when there was no signature by the nursing staff for monitoring the effect of a medication given:
January 2012 =10
February 2012=11
March 2012=4
April 2012=10
May 2012=7
June 2012=4
September 2012=5
October 2012=15
November 2012=12
December 2012=10
January 2013=19
No documentation found that a performance improvement plan was developed for the above issue.

Medication Reconciliation forms that were not signed by the physician and given to pharmacy.
January 2012 = 13
February 2012=22
March 2012=17
April 2012=10
May 2012=20
June 2012=27
September 2012=19
October 2012=24
November 2012=10
December 2012=12
January 2013=29
No documentation found that a performance improvement plan was developed for the above issue.

b. Review of Governing Board Meeting Minutes on 2/12/13 at 2:30p.m. from March 30, 2012 to January 2, 2013 revealed the following statements:

April 30, 2012: The DON informed the Board that the nurses have improved in the medication management. She still wants them to improve more so that we do not have any deficiency and the standard of care rises to the highest standard.
Pharmacy: It has been reported to the Governing Board that the pharmacy is still not satisfied with the nursing compliance with the medication management. It has improved but not up to the required standard. The Board at this point instructed the DON that if the nurses need more training from outside resources then they should be sent to get the training so that they meet the standards.

June 29,2012: The DON stated the nursing staff is still given the in-services to improve the medication management which is still not up to the mark. They have improved but still needs more improvement. The Governing Board President asked the DON to make sure by the next meeting all the nursing to improve hundred present in medication management as it will not be tolerated. The DON remarked that she will work harder to make this happen.
Pharmacy: The consulting pharmacist reviews all the concerned paperwork of patients who receive medications and gives his remarks for more improvement to the DON.

September 28, 2012: The DON reports that she is continuously training and overseeing staff performance. No discussion documented on medication management.
Pharmacy: The Governing Board was informed that the Pharmacy has been reporting that all nursing staff responsible for medication errors should be given be given instructions continuously by the DON. It has been reported that there needs to be improvements required, as some of the nursing staff was briefed not to ignore the requirements for patient safety.

January 2, 2013: The DON reports that she is continuously training and overseeing the nursing staff performance.
Pharmacy: The Governing Board was informed that the Pharmacy has been reporting that all nursing staff responsible for medication errors should be given be given instructions continuously by the DON. It has been reported that there needs to be improvements required, as some of the nursing staff was briefed not to ignore the requirements for patient safety. This was also reported in the last meeting.

c. An interview conducted with (S7) on 2/6/13 at 10:30a.m. following her own review of the findings revealed she was aware of the discrepancies found. (S7) stated that the facility, at time of interview, was not working on any performance improvement projects. (S7) stated that she corrects nursing staff as issues occur verbally. (S7) confirmed that the she does have nursing staff that continue to have issues with medication management and documentation despite continued verbal counsel. (S7) stated that one of the nursing staff members that continues to fail to follow hospital policy in regards to medication management and documentation thinks she will be leaving her position for personal reasons in the near future and that will solve some of the issues. At time of interview (S7) could not produce any documentation of counseling of staff or any other disciplinary actions taken by the facility.

1. Based on review of Quality Meeting Minutes, Governing Body Meeting Minutes, and staff interview the facility failed to identify, review, and trend adverse patient events that occurred in the facility.

The Findings included:

a. Review of Quality Improvement Committee Meeting Minutes on 2/6/12 in the facility conference room for January 2012-January 2013 revealed no evidence the facility identified, reviewed, and or trended adverse patient events.

Review of Governing Board Meeting Minutes on 2/12/13 at 2:30p.m. from March 30, 2012 to January 2, 2013 revealed no evidence the facility identified, reviewed, and or trended adverse patient events.

b. An interview conducted with (S7) on 2/06/13 at 2:30p.m. following her own review of the findings revealed she was aware of the discrepancies found. (S7) confirmed that the facility does not track, trend or review adverse patient events as a committee. (S7) stated that she corrects nursing staff as issues occur. (S7) could not verbally state or produce any documentation that instructed staff on what was a reportable adverse event, how to report those events, and actions to take when adverse patient events occurred.

1. Based on review of Quality Meeting Minutes, Governing Body Meeting Minutes, and staff interview the Governing Body failed to identify, review, and trend adverse patient events and medical errors that occurred in the facility and the Governing Body failed to ensure that the facility conduct performance improvement projects.

The Findings included

a. Review of Quality Improvement Committee Meeting Minutes on 2/6/12 in the facility conference room for January 2012-January 2013 revealed no evidence the facility identified, reviewed, and or trend adverse patient events and or medical errors.

Review of Governing Board Meeting Minutes on 2/12/13 at 2:30p.m. from March 30, 2012 to January 2, 2013 revealed no evidence the facility identified, reviewed, and or trended adverse patient events and or medical errors.

b. An interview conducted with (S7) on 2/06/13 at 2:30p.m. following her own review of the findings revealed she was aware of the discrepancies found. (S7) confirmed that the facility does not track, trend or review adverse patient events and or medical errors as a committee. (S7) stated that she corrects nursing staff as issues occur. (S7) could not verbally state or produce any documentation that instructed staff on what was a reportable adverse patient events and medical error, how to report those errors, and actions to take when medical errors or adverse patient event occurred. (S7) stated that the facility, at time of interview, was not working on any performance improvement projects.

Based on medical record review, medical staff bylaws review, and staff interview the facility failed to ensure medical staff followed the facility medical staff bylaws in the care of their patients.

The findings included:
a. Medical record review of inpatient medical records at the nurses station on 2/5/13 at 10: 50 a.m. revealed 3 of 4 current patients (P24, P25, P27) did not have current physician progress notes in their patient record.
Medical record review of (P24, P25, P26, & P27) revealed the physician authentication signature was not dated or timed when the signature was written.
b. Review of Medical Staff Bylaws; Medical Records states "The attending practitioner shall be responsible for the preparation of a complete medical record for each patient. This content shall include ....progress notes.... Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability. Progress notes shall be written at least daily on critically ill patients and those where there is difficulty in diagnosis or management of the clinical problem."
Medical staff bylaws state "All written entries by a Practitioner, in the patient's medical record shall be authenticated (accurate dates, timed, and signed) by written signature by the responsible practitioner."
c. In an interview with (S10) at the nurses station on 2/5/13 at 11:45 a.m. she confirmed there were no physician progress notes in the three patient charts. She further stated the staff knows the patients and goes on rounds with the physician so they are aware of what is going on with the patients. She confirmed there is no record in case of transfer of the patient what has happened from the physician notes. (S12) stated the physicians dictate their progress notes and if done by 9:00 p.m. they are on the chart the next morning. Upon review of the medical records for (P24, P25, P27) she found no written physician progress notes. Further review by (S12) on their computer system revealed there were no outstanding progress notes for the 3 patients.
d. Review of the medical record for (P25) on 2/6/13 at 10:00 a.m. at the nurses station revealed written physician progress notes dated 2/4/13 and 2/5/13. It was confirmed with (S12) that these were not in the record on 2/5/13.

Based on medical record review, policy review, and staff interview the facility failed to ensure the nursing staff developed and kept current a nursing care plan for each patient.

The findings included:
a. Review of medical record for (P25) on 2/5/13 at 11:00 a.m. revealed patient admitted on 2/2/13 through the emergency room with complaint of shortness of breath and chest pain; diagnosis Advanced COPD and sepsis (Urosepsis); started on intravenous antibiotics, drug nebulizer treatments and oxygen at 6 liters/min via mask; started on Amlodipine daily by mouth for angina.
Nursing Admission Assessment was performed by (S24), a licensed vocational nurse, on 2/3/13 at 1:30 a.m. and not a registered nurse until 2/4/13 at 7:30 p.m. by (S20).
Review of medical record for Plan of Care revealed it was initiated on 2/2/13 by (S24) with problem identified as Ineffective airway clearance, Breathing Pattern, and COPD. No expected outcomes were identified for each of these problemsidentified.
Interventions checked identify the following:
Activity level: Bedrest
Skin Care: Assisted
Cardiac Monitoring
Education: Teaching about Home Meds; Dietary Changes, Activity.
Per Admission Assessment:
Medical History: c/o shortness of breath; Chest Pain; Blood tinged sputum
Genitouninary: Catheter Type: 22F
Respiratory: Dyspneic
Skin: Intravenous Access: Peripheral line
Facility Plan of Care states the following: From admission data, problems have been checked with assessment. To start care plan date the problem, and add when chart checks are done each night, date review either an (O) for ongoing or (M) for needs. This is to show change or improvement in a patient.
No Plan of Care(POC) was initiated for the patient cardiac status; genitourinary needs; infection needs; or immobility needs.
No documentation of review or update of needs identified on the POC when chart checks were done each night.
b. Review of policy titled "Nursing Admission Assessment & Adult Pediatric Nursing Admission Note" states "To assure patient is assessed in all areas and provided a transfer of information to patient Care Plan Communication. Each area of assessment has blocks of care plan triggers which correspond to care plan actual problem or potential problem. RN is to complete each area and sign and date the designated area within 24 hours. Completion of admission assessment produces care plan for team, which is evaluated each 24 hours and updated as to goals met or ongoing as patient condition improves or declines, can be tracked.
c. Review of patient Plan of Care was done with (S14) on 2/6/13 at 10:25 a.m at the nurses station. (S14) reviewed the POC, Nursing Assessment, and physician orders and stated the patient POC for (P25) was lacking a plan for cardiac status, infection, genitourinary, and fluid status. (S14) further stated there was no update to the plan of care. She stated the POC should be dated as ongoing with each chart check and the POC is completed as Met oor Not Met upon discharge of the patient when closing the patient medical record.

Upon review of patient medical records for (P4, P24, P26, & P27) by (S14) on 2/6/13 at 10:55 a.m. she concurred the patien plans of care were not initiated or updated as per facility policy and procedure as stated on the patient plan of care. Review of closed records for patients (6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21) revealed the policy was not followed for updating and maintaining a current plan of care and upon discharge no goals were met.

This noncompliance with the establishment of a plan of care to provide for the identified patient care needs puts all patients at risk for unmet needs.

Based on observation, medical record review, staff interview, and staff file review the facility failed to ensure the registered nurse assigned the nursing care of patients to nursing personnel according to the patient's needs and the competence of the staff available.

The findings included:
a. During a tour of the facility on 2/5/13 at 10:15 a.m. it was observed that a patient's cardiac rhythm was being displayed on a monitor screen at an "unattended" nursing station. The monitor displayed a heart rate of 110-115beats per minute. In red letters displayed under the heart rhythm on the screen was noted "ALARMS OFF". There were several staff members in a glassed in room across a hallway.
b. Review of the medical record for the patient on telemetry, (P25) revealed the patient was admitted from the emergency room on 2/2/13 with a diagnosis of shortness of breath, chest pain, advanced COPD, and urosepsis. Review of physician orders revealed no order for the telemetry monitoring from 2/2/13 to present date. Review of the nursing notes and the patient plan of care revealed no indication the patient was on cardiac monitoring and no rhythm strips or interpretation of cardiac rhythm was noted in the chart. There was no physician order in the chart for cardiac monitoring.
c. Interview with (S10) at this time revealed that she was observing the patient rhythm from inside the other room across a hallway. When questioned if she was aware the monitor read "ALARMS OFF" in red letters she was not aware and (S10) and (S7) and (S1) went to the station to look at the monitor. (S7) stated the nurses are trained to look at the telemetry strips. Interview with (S10) and (S14) revealed they are not comfortable with reading the monitor strips as they do not know the rhythms and if something looks different they print it off and fax to the physician for interpretation.
d. Review of employee staff files revealed the nurses do not have competency skills checklists or tests to be able to interpret heart rhythms. (S10) had an expired ACLS (Advanced Cardiac Life Support) certification in her file. No employee in the facility had the training for interpreting cardiac rhythm strips for abnormal or normal rhythms. (S1) stated they would get someone to do an inservice for the staff.

The monitoring of patients on a cardiac telemetry system with no visual monitoring and no trained personnel to interpret the cardiac rhythm puts all patients on cardiac monitoring at risk for the misinterpretation or inability to recognize life threatening emergency cardiac rhythm situations.

Based on record review and interview, the facility failed to ensure that patients who were admitted to the hospital emergency department and/or directly admitted to the hospital provided informed consent regarding who the patient was choosing as their treating physician and/or who the facility would release their protected health information to by having the patients sign a blank Release of Doctor form, blank Disclosure and Consent form, and/or blank Communication Authorization Form in ten of nineteen closed medical records reviewed (Patients #6, #8, #10, #12, #13, #15, #16, #18, #19, and #21).

Findings included:

Record review on 02/05/13 of eight patients' closed medical records who were first seen in the facility emergency department and subsequently admitted to the facility (Patients #6, #8, #10, #12, #13, #15, #16, and #18) revealed the following form that was not completed with the name of the treating physician and did not have two witnesses signatures and the patient signature as designated on the form : Release of Doctor form that stated the following: "The undersigned requested and authorized the ______________ and its representative to contact Dr._________to see and treat in the hospital's Emergency Room. The hospital representative contacted the above mentioned doctor as requested, but I now wish of my own free will to cancel my original request for services of the above mentioned doctor and I hereby authorize the hospital representative to cancel my original request and to call:
Dr.____________ to see and treat the above mentioned patient.

Witness_____________ Signature_______________

Witness_____________ Relationship_____________


Record review on 02/13/13 of patient #19's closed medical record revealed the following form: Disclosure
and Consent that stated "I hereby agree and give my consent for the admission/treatment of (patient's name) To __________________, hereinafter referred to as the hospital, under the care of (name of doctor) , his associates, partners, assistants or designees." Patient #19 had been admitted directly into the hospital and signed this form but there was no physician's name in the designated area.

Record review on 02/05/13 of patients' # 15 and #21 Communication Authorization Form signed by the patients revealed the following statement: "When it comes to your medical treatment, we strive to communicate with you in a timely and professional manner. There are certain occasions when family members, friends, or others might be involved in your care. As a patient, you will want our staff's to be able to communicate directly with them. In order to protect the privacy of your personal health information, please share with us the names of those individuals with whom we can discuss your care and share your protected health information. Please list below those individuals with whom you authorize our office to discuss aspects related to your care." The names and relation to patients were all left bank.

Interview on 02/06/13 at 12:45 PM with Business Office Staff #1 revealed that she completes the admitting paperwork for patients admitted to the emergency room, admitted directly into the hospital or admitted to the hospital from the emergency department during the day and on some weekends. She confirmed the Release of Doctor form means the patient is giving permission for the facility emergency department physician to treat them. She was unable to state why the name of emergency room physician was left blank. She confirmed she would know who was scheduled as the emergency department physician. She was unable to state why the Disclosure and Consent Form and the Communication Authorization Forms were blank.

1. Based on review of Pharmacy Services Controlled Substance Medication Discrepancy Reports, Pharmacy Quality Meeting Report, Quality Meeting Minutes, and staff interviews the facility failed to ensure that the consulting pharmacist addressed the controlled substances medication discrepancies in a timely manner, take appropriate action to correct the narcotic discrepancy's and or loss that were occurring in the facility, and failed to ensure that the consulting pharmacist actively be involved with Quality Improvement Committee Meetings.

The Findings included:

To note: The Average Daily Censes for the hospital is documented as 3-4 patients per day which include the pediatric patients.

Refer to tag: V492 and V509

1. Based on review of Pharmacy Services Controlled Substance Medication Discrepancy Reports, Pharmacy Quality Meeting Report, Quality Meeting Minutes, and staff interviews the facility failed to ensure that the consulting pharmacist address the controlled substances medication discrepancies in a timely manner and the facility failed to ensure that the consulting pharmacist actively be involved with Quality Improvement Committee Meetings.

The Findings included:

To note: The Average Daily Censes for the hospital is documented as 3-4 patients per day which include the pediatric patients.

a. Review of Pharmacy Services Controlled Substances Medication Discrepancy Reports from January 2012 to January 2013 on 2/6/12 in the facility conference room revealed 51 narcotic discrepancy's for a facility with an average patient censes of 3-4. The Report was as followed:

01/13/12- Restoril 15mg tab not charted on MAR by (S19)
01/17/12- Lortab 5mg tab not charted on MAR by (S19)
01/26/12- Nubain 10mg not charted on MAR by (S20)
03/05/12- Morphine 2 mg not charted on MAR by (S20)
03/18/12- Restoril 15mg not charted on MAR by (S21)
03/19/12- Restoril 15mg not charted on MAR by (S21)
04/09/12- Librium 25mg cap not charted on MAR by (S22)
04/28/12- Lortab 5/500mg tab not charted on MAR by (S20)
05/15/12- Morphine 2mg not charted on MAR by (S22)
05/24/12- Lortab5/500mg not charted on MAR by (S23)
05/25/12- Zolpidem 10 mg No physician order to use by (S20)&(S23)
05/25/12- Lortab 5 mg Not charted on MAR correctly by (S19)
05/27/12- Nubain 5mg not charted on MAR by (S21)
06/19/12- Lortab 7.5/500mg not charted on MAR by (S20)
07/03/12- Ativan 0.5mg not charted on MAR by (S19)
07/12/12- Ativan not charted on MAR by (S23)
08/01/12- Morphine 2mg not charted on MAR by (S23)
08/03/12- Morphine 2mg not charted on MAR by (S23)
08/04/12- Percocet 5/325mg tab not charted on MAR by (S19)
08/06/12- Xanax 0.25mg not charted on MAR by (S20)
08/09/12- Percocet 5/325mg tab not charted on MAR by (S19)
08/09/12- Morphine 2mg not charted on MAR by (S19)
08/09/12- Morphine 2mg not charted on MAR by (S19)
08/10/12- Lortab 7.5mg not charted on MAR by (S19)
08/12/12- Lortab 7.5mg not charted on MAR by (S21)
10/15/12- Percocet 5/325mg not charted on MAR by (S24)
10/17/12- Percocet 5/325mg Physician order states to give two tabs only one given (S22)
11/10/12- Morphine 2mg not documented on MAR by (S24)
11/12/12- Percocet 5/325mg tab not documented on MAR by (S19)
11/13/12- Percocet 5/325mg tab not documented on MAR by (S19)
11/18/12- Alprazolam 0.25mg tab not documented on MAR by (S20)
11/28/12- Percocet 5/325mg tab not documented on MAR by (S19)
11/28/12- Percocet 5/325mg tab not documented on MAR by (S19)
12/03/12- Morphine 2mg not documented on MAR by (S20)
12/05/12- Percocet 5/325mg no patient name by (S22)
12/06/12- Alprazolam medication not charted on CSAR by (S22)
12/07/12- Ativan 0.5mg not charted on MAR by (S19)
12/07/12- Alprazolam not charted on CSAR by (S19)
12/08/12- Alprazolam not charted on CSAR by (S24)
12/12/12- Percocet 5/325mg not charted on MAR by (S19)
12/16/12- Restoril 15mg not charted on MAR by (S24)
12/21/12- Xanax 0.5mg not documented on MAR by (S19)
12/25/12- Percocet 5/325mg extra tablet taken out by (S24)
01/05/13- Lorazepam 0.5mg not documented on CSAR by (S24)
01/05/13- Percocet 5/325mg not documented on MAR by (S26)
01/05/13- Percocet 5/325mg not documented on MAR by (S24)
01/05/13- Percocet 5/325mg not documented on MAR by (S26)
01/06/13- Percocet 5/325mg not documented on MAR by (S24)
01/16/13- APAP #3 not documented on CSAR by (S25)
01/17/13- APAP#3 not documented on CSAR by (S23)
01/21/13- Percocet 5/325mg not documented on MAR by (S25)

To summarize the controlled substance report:
S19 had 17 discrepancies
S20 had 8 discrepancies
S21 had 4 discrepancies
S22 had 5 discrepancies
S23 had 6 discrepancies
S24 had 8 discrepancies
S25 had 2 discrepancies
S26 had 2 discrepancies

b. Review of the Pharmacy Quality Meeting Report for January 2012- January 2013 on 2/6/12 in the facility conference room revealed the following:
The number of nursing signatures that were missing from the narcotic sheets that needed to be doubled signed
January 2012 =12
February 2012=0
March 2012=10
April 2012=0
May 2012=0
June 2012=19
July 2012 no data reviewed
August 2012 no data reviewed
September 2012=2 with 3 nurses signed out narcotics late
October 2012=19 with 2 nurses signed out narcotics late
November 2012=17 with 2 nurses signed out narcotics late
December 2012=3
January 2013=2 with 2 patients names missing in the narcotic sheet after the nurse signed out the medication

c. Review of Quality Improvement Committee Meeting Minutes on 2/6/12 in the facility conference room for January 2012-January 2013 revealed no evidence that the consulting pharmacist attended the Quality Improvement Committee Meetings.

d. An interview conducted with (S7) on 2/6/13 at 10:30a.m. following her own review of the findings revealed she was aware of the discrepancies found. (S7) stated that she corrects nursing staff as issues occur verbally. (S7) confirmed that the she does have nursing staff that continue to have issues with medication management and documentation even with continued verbal counsel. (S7) stated that one of the nursing staff members that continues to fail to follow hospital policy in regards to medication management and documentation thinks she will be leaving her position for personal reasons in the near future and that will solve some of the issues. At time of interview (S7) could not produce any documentation of counseling of staff or any other disciplinary actions taken by the facility.

A written statement provided by (S17) on 02/15/13 stated the following:
" On 2/01/13 at around 12:45p.m. I saw (S7) at the nurses ' station and called her into the pharmacy. I told her I was seeing a lot of sloppy narcotic charting. Doses not charted on the MAR, doses charted on the CSAR that did not match the order, multiple doses given from the same single vial, messy CSAR ' s etc. I told her in my 7 years there, I had not seen it that bad. It seemed that (S19) ' s name seem to be involved in a lot of these but that (S18) had been writing up all these discrepancies so she could look at them. She acknowledged seeing those. I showed her some examples of the messy CSAR ' s. She said she would speak with the nurses that happened to be there about the problem.
On 2/8/13 at about 12:30p.m.I ran into (S1) in the hallway. We were discussing the State visit when I mentioned to him the narcotic charting problems and the frequency that (S19) seemed to be involved. I cannot remember if we discussed whether or not nurses were getting written up for these, but he did indicate that they were going to start writing them up and get rid of nurses that were unable to do the job properly. That sounded good to me.
Going forth, I am directing (S18) to route all discrepancy reports through (S1) so he can direct (S7) as to any disciplinary action to be taken. It seems obvious none has been taken by (S7) up to now. "

An interview conducted with (S1) on 2/12/13 at 4:05p.m. following his own review of the findings revealed he was aware of the discrepancies found. (S1) stated that the pharmacist has "impressed on me for about three months that the nursing staff was not listening or following procedures in regards to narcotic documentation." (S1) stated that he discussed the discrepancies with (S19) about two weeks ago. (S1) stated that (S19) confirmed that the Director of Nursing had been calling her at home to discuss the continued narcotic discrepancies. (S1) stated that (S19) threatened to contact Department of State Health Services in regard to issues at the hospital if disciplinary issues were taken against her. (S19) also stated she wanted the Director of Nursing to leave her alone and do her own job. At time of interview (S7) could not produce any documentation of counseling of staff or any other disciplinary actions taken by the facility

1. Based on review of Pharmacy Services Controlled Substance Medication Discrepancy Reports, Pharmacy Quality Meeting Report, Quality Meeting Minutes, and staff interviews the facility failed to take appropriate action to correct the narcotic discrepancy's and or loss that were occurring in the facility.

The Findings included:

To note: The Average Daily Censes for the hospital is documented as 3-4 patients per day which include the pediatric patients.

a. Review of Pharmacy Services Controlled Substances Medication Discrepancy Reports from January 2012 to January 2013 on 2/6/12 in the facility conference room revealed 51 narcotic discrepancy's for a facility with an average patient censes of 3-4. The Report was as followed:

01/13/12- Restoril 15mg tab not charted on MAR by (S19)
01/17/12- Lortab 5mg tab not charted on MAR by (S19)
01/26/12- Nubain 10mg not charted on MAR by (S20)
03/05/12- Morphine 2 mg not charted on MAR by (S20)
03/18/12- Restoril 15mg not charted on MAR by (S21)
03/19/12- Restoril 15mg not charted on MAR by (S21)
04/09/12- Librium 25mg cap not charted on MAR by (S22)
04/28/12- Lortab 5/500mg tab not charted on MAR by (S20)
05/15/12- Morphine 2mg not charted on MAR by (S22)
05/24/12- Lortab5/500mg not charted on MAR by (S23)
05/25/12- Zolpidem 10 mg No physician order to use by (S20)&(S23)
05/25/12- Lortab 5 mg Not charted on MAR correctly by (S19)
05/27/12- Nubain 5mg not charted on MAR by (S21)
06/19/12- Lortab 7.5/500mg not charted on MAR by (S20)
07/03/12- Ativan 0.5mg not charted on MAR by (S19)
07/12/12- Ativan not charted on MAR by (S23)
08/01/12- Morphine 2mg not charted on MAR by (S23)
08/03/12- Morphine 2mg not charted on MAR by (S23)
08/04/12- Percocet 5/325mg tab not charted on MAR by (S19)
08/06/12- Xanax 0.25mg not charted on MAR by (S20)
08/09/12- Percocet 5/325mg tab not charted on MAR by (S19)
08/09/12- Morphine 2mg not charted on MAR by (S19)
08/09/12- Morphine 2mg not charted on MAR by (S19)
08/10/12- Lortab 7.5mg not charted on MAR by (S19)
08/12/12- Lortab 7.5mg not charted on MAR by (S21)
10/15/12- Percocet 5/325mg not charted on MAR by (S24)
10/17/12- Percocet 5/325mg Physician order states to give two tabs only one given (S22)
11/10/12- Morphine 2mg not documented on MAR by (S24)
11/12/12- Percocet 5/325mg tab not documented on MAR by (S19)
11/13/12- Percocet 5/325mg tab not documented on MAR by (S19)
11/18/12- Alprazolam 0.25mg tab not documented on MAR by (S20)
11/28/12- Percocet 5/325mg tab not documented on MAR by (S19)
11/28/12- Percocet 5/325mg tab not documented on MAR by (S19)
12/03/12- Morphine 2mg not documented on MAR by (S20)
12/05/12- Percocet 5/325mg no patient name by (S22)
12/06/12- Alprazolam medication not charted on CSAR by (S22)
12/07/12- Ativan 0.5mg not charted on MAR by (S19)
12/07/12- Alprazolam not charted on CSAR by (S19)
12/08/12- Alprazolam not charted on CSAR by (S24)
12/12/12- Percocet 5/325mg not charted on MAR by (S19)
12/16/12- Restoril 15mg not charted on MAR by (S24)
12/21/12- Xanax 0.5mg not documented on MAR by (S19)
12/25/12- Percocet 5/325mg extra tablet taken out by (S24)
01/05/13- Lorazepam 0.5mg not documented on CSAR by (S24)
01/05/13- Percocet 5/325mg not documented on MAR by (S26)
01/05/13- Percocet 5/325mg not documented on MAR by (S24)
01/05/13- Percocet 5/325mg not documented on MAR by (S26)
01/06/13- Percocet 5/325mg not documented on MAR by (S24)
01/16/13- APAP #3 not documented on CSAR by (S25)
01/17/13- APAP#3 not documented on CSAR by (S23)
01/21/13- Percocet 5/325mg not documented on MAR by (S25)

To summarize the controlled substance report:
S19 had 17 discrepancies
S20 had 8 discrepancies
S21 had 4 discrepancies
S22 had 5 discrepancies
S23 had 6 discrepancies
S24 had 8 discrepancies
S25 had 2 discrepancies
S26 had 2 discrepancies

b. Review of the Pharmacy Quality Meeting Report for January 2012- January 2013 on 2/6/12 in the facility conference room revealed the following:
The number of nursing signatures that were missing from the narcotic sheets that needed to be doubled signed
January 2012 =12
February 2012=0
March 2012=10
April 2012=0
May 2012=0
June 2012=19
July 2012 no data reviewed
August 2012 no data reviewed
September 2012=2 with 3 nurses signed out narcotics late
October 2012=19 with 2 nurses signed out narcotics late
November 2012=17 with 2 nurses signed out narcotics late
December 2012=3
January 2013=2 with 2 patients names missing in the narcotic sheet after the nurse signed out the medication

c. Review of Quality Improvement Committee Meeting Minutes on 2/6/12 in the facility conference room for January 2012-January 2013 revealed no evidence that the consulting pharmacist attended the Quality Improvement Committee Meetings.

d. An interview conducted with (S7) on 2/6/13 at 10:30a.m. following her own review of the findings revealed she was aware of the discrepancies found. (S7) stated that she corrects nursing staff as issues occur verbally. (S7) confirmed that the she does have nursing staff that continue to have issues with medication management and documentation even with continued verbal counsel. (S7) stated that one of the nursing staff members that continues to fail to follow hospital policy in regards to medication management and documentation thinks she will be leaving her position for personal reasons in the near future and that will solve some of the issues. At time of interview (S7) could not produce any documentation of counseling of staff or any other disciplinary actions taken by the facility.

A written statement provided by (S17) on 02/15/13 stated the following:
" On 2/01/13 at around 12:45p.m. I saw (S7) at the nurses ' station and called her into the pharmacy. I told her I was seeing a lot of sloppy narcotic charting. Doses not charted on the MAR, doses charted on the CSAR that did not match the order, multiple doses given from the same single vial, messy CSAR ' s etc. I told her in my 7 years there, I had not seen it that bad. It seemed that (S19) ' s name seem to be involved in a lot of these but that (S18) had been writing up all these discrepancies so she could look at them. She acknowledged seeing those. I showed her some examples of the messy CSAR ' s. She said she would speak with the nurses that happened to be there about the problem.
On 2/8/13 at about 12:30p.m.I ran into (S1) in the hallway. We were discussing the State visit when I mentioned to him the narcotic charting problems and the frequency that (S19) seemed to be involved. I cannot remember if we discussed whether or not nurses were getting written up for these, but he did indicate that they were going to start writing them up and get rid of nurses that were unable to do the job properly. That sounded good to me.
Going forth, I am directing (S18) to route all discrepancy reports through (S1) so he can direct (S7) as to any disciplinary action to be taken. It seems obvious none has been taken by (S7) up to now. "

An interview conducted with (S1) on 2/12/13 at 4:05p.m. following his own review of the findings revealed he was aware of the discrepancies found. (S1) stated that the pharmacist has "impressed on me for about three months that the nursing staff was not listening or following procedures in regards to narcotic documentation." (S1) stated that he discussed the discrepancies with (S19) about two weeks ago. (S1) stated that (S19) confirmed that the Director of Nursing had been calling her at home to discuss the continued narcotic discrepancies. (S1) stated that (S19) threatened to contact Department of State Health Services in regard to issues at the hospital if disciplinary issues were taken against her. (S19) also stated she wanted the Director Of Nursing to leave her alone and do her own job. At time of interview (S7) could not produce any documentation of counseling of staff or any other disciplinary actions taken by the facility

1. Based on staff interview and review of dietary manual the hospital failed to ensure the dietary supervisor maintained a disaster dietary plan for the provision of patient and staff meals in the event of a disaster.

The findings included:

a. Interview with (S6) on 2/5/13 at 9:45 a.m. in the facility kitchen revealed (S6) was unaware of a dietary disaster plan to provide for the dietary needs of the patients and staff in the event of a disaster.
b. Review of the dietary manual on 2/5/13 at 2:00 p.m. revealed no evidence of provisions for a disaster dietary plan to be used in the event of a disaster.
c. On 2/6/13 at 10:00 a.m. (S1) presented a Dietary Disaster Plan to the surveyors. (S6) stated that she had found the disaster diet manual by 5:00 p.m. on 2/5/13 but the surveyors had already left for the day.
Noted on the pages was that it had been faxed from another facility on 2/5/13 at 1634 p.m. (S1) stated since they now had it would it be cited as a deficiency.

2. Based on dining storage inspection and interview with staff this requirement was not met as follows:

Findings:

a. During the inspection of the the dining facility storage spaces to include the freezer and regrigerated storage spaces, found food that was not dated or labeled and could not detemine the date of receipt in order to determine first in and first out for use.

b. In an intereview with staff #1 Food Service Director 1:30 p.m. on February 6, 2012 in the dining hall, she agreed that the food found in the storage spaces to include freezer and refrigerated spaces was not completely labeled to easily identify which food to use first, she explained that all food is taken out of space and new food is put at the back of the shelf or in the bottom of the freezer and then old food is put in front of shelf or on top of freezer for first use. She was not able to provide any evidence of compliance with this requirement.

Based on staff interview, patient medical record review, and employee files the hospital failed to ensure the staff was competent in their respective duties.

The findings included:

a. In an interview with (S6) on 2/12/13 at 2: 00 p.m. she stated that she talks to the patients and does diet instruction and history for the patients that are on coumadin diets. (S6) stated when the Joint Commission surveyor's were here they told her she needed to do it since she was the one who knew what they should be eating and knew the foods provided on their diet meal plans.
b. Medical record review of (P38) who was on a coumadin diet reveals documentation on the Education Record under "Topic-Food and Drug Interactions" has written "Talk to patient he said he eat everything he eat leafy food coumadin patient." 10-1-12 JG No further documentation was found in the patient medical record as to indicate any food/drug interaction in regard to coumadin or education to the patient for education.
c. Review of the employee file for (S6) contained no documentation that (S6) had received training on diet instruction and food/drug interaction. (S6) could provide no evidence of training to provide dietary counseling to the patients regarding food/drug interactions.

Based on staff interview, interview with outside vendor, and maintenance record review the facility failed to ensure the emergency generator was performing when tested under a load.

The findings included:

a. During a tour of the facility on 2/5/13 at 9:45 a.m. it was observed that an outside vendor was working on the emergency generator. When (S4) was asked what was being done to the generator he stated the following "They are doing annual maintenance." When the surveyor talked to the outside vendor technician he stated he was from a company that had been called to come out and work on the generator because it was not working. The surveyor asked him if they provided routine maintenance under a contract with the hospital he stated they no longer had a contract with the hospital for routine maintenance and the facility called when they needed work on the generator.
b. Review of the maintenance and testing records for the generator on 2/12/13 at 3:30 p.m. revealed the generator was tested monthly by (S4). Review indicated from the testing done in November 2012, December 2012, January 2013, and February 2013 the generator load was not performing at the required performance testing. The generator repair company was called on 2/4/13 at 4:44 p.m. after testing performed on 2/4/13 indicated the generator would not stay on.
c. Interview with (S4) on 2/12/13 at 3:30 p.m. revealed he was the person who did the monthly testing on the generator. He stated he did not have training to do the testing and did not have any maintenance manuals or operation manuals for the generator. When asked how he knows what to look for he said he had watched when the technicians came out and he followed the same readings as they did for checking the load. (S4) stated that for the generator to be functioning properly at start up the reading would be at 25 and after 30 minutes of running it should be up to 50. He stated if not at 50 it would not be operating as needed to hold the load. He stated the log sheets for the monthly testing was accurate for the readings. When asked if the readings for November 2012-February 2013 were written by him he said they were. He did state again that the reading had to be at least 50 after running for 30 minutes for the generator to operate sufficiently. He stated in February the generator would not stay on without holding the switch and a new switch was installed by the maintenance repair company on 2/6/13 and it was now operational. (S1) and (S4) had no answer as to why the readings for November 2012-January 2013 were below the minimum of 50 that (S4) told the surveyor was required for the generator to function.

This deficiency put all patients at risk during this period of time for the emergency generator to not be able to provide for emergency power to the emergency room of the facility in case of a power failureat the hospital.


30377

Based on tour of the facility, record review, and staff interview the following areas reviewed revealed expired supplies, expired medications, expired electrical safety checks on equipment, inappropriate storage of employees personal belongings, and inappropriate storage of soiled linen and biohazard waste creating an environment that is unsafe and unsanitary to staff and patients.

The Findings Included:

a. Based on a tour of the facility on 2/4/13 at approximately 1:25p.m. to 4:25p.m. accompanied by (S1), (S4), (S7), and (S18) the following discrepancies were observed:

Inpatient Nursing Floor Crash Cart:

Review of Crash Cart log on 2/4/13 at 1:30p.m.for the month of January 1, 2013 to February 4, 2013 revealed that the nursing staff sign off that the crash cart was supplied and in working condition daily.

Review of the crash cart content on 2/4/13 at 1:35p.m. revealed that following expired supplies:
Nasopharyngeal Airway expired 2006
Endotracheal Tube 6.5 expired 2007
Endotracheal tube expired November 2011
Endotracheal introducer expired November 2011
Intubation Stylet expired January 2012

Room 107 the Electrical Safety Check on the IV pump revealed the following:
Date Checked: 08/2012
Next Checked: 08/2012

Placed on top of the clean linen supply cart were several pillows that were stained. The plastic covering had several large areas of tears that exposed the cloth covering.

Food and Drinks at the nurses ' station belonging to staff

Personnel belongings in clean patient supply areas like used deodorant, purses on clean carts and counters.

Emergency Room

Crash Cart:

Review of Crash Cart log on 2/4/13 at 2:30p.m.for the month of January 1, 2013 to February 4, 2013 revealed that the nursing staff sign off that the crash cart was supplied and in working condition daily.

Review of the crash cart content on 2/4/13 at 2:35p.m. revealed that following expired supplies:
(2) Pedi-Cap CO2 sensors expired 08/2012
Kendall ECG Defibrillator leads were pre-opened and dried out contrary to large print manufactures instructions "Do not open prior to immediate use''.

Supply Cabinets: (ready for use)
Individual Sterile gloves expired November 2007.
Female Catheter Kit expired 08/2008
(2)Female Specimen Catheter Kit expired 11/2008
Urology Catheter expired 06/2010
(3) Endotracheal tube introducer expired 06/2010
Female specimen Catheter Kit expired 11/2012
Ipratropium Bromide Inhalation expired 07/2012
Respiratory ventilation machine last maintenance check expired in July 2012.
IV Pump last maintenance check expired in August 2012

Medications (Labetatol, hydrochloride, Levophed) and other emergency supplies such as intravenous fluids were found expired from immediate use locations as well as the crash cart and the medication storage room.

The medication storage room had holes in the ceiling and medication cabinets were not secured.

The plastic covering the mattress on three gurneys had large cracks and no longer provided a barrier from liquids or body fluids.

Oxygen Tank Regulator found in cabinet with food products (krispy crackers, pepper packets)
Soiled Utility Room
Large yellow laundry storage bin contained soiled linen that was not bagged. Several used gloves were also found in the bin.
2 pillows (with areas of missing plastic covers) were placed on chair side commodes
Maintenance storage building / Work area
Large part of the work space is located outside with equipment exposed to outdoor elements (file cabinets, furniture, mop and mop buckets, wheelchairs, computer parts, paint cans, IV poles)
Inside the storage building revealed a very thick layer of dirt on the floor. Large cracks in the cement floor. During tour of the storage area (S4) stated that the ceiling did not leak but when it rained water will flow into storage building.
Multiple (at least 7) Red Biohazard Bags were full and placed on top shelves. (S4) stated the bags did not contain biohazard material he stated he used the biohazard bags as storage containers.
Biohazard Storage Building:
The signs that labeled the building as " Biohazard Waste " was located face down on the ground next to a discarded mop head.
The storage building continued brick walls with a large open metal pipe that opened to the outside with no screen which could provide an entry way for a small animal.
A biohazard box that was torn that contained an open sharps container laying on top of a red biohazard bag. The sharps container was not closed correctly and the contents (syringes with exposed needles and glass vials) were lying on top of the red biohazard bags. (S4) stated that the biohazard waste was picked up earlier in the day with the torn box not being picked up because of the needle stick hazard. To note on 2/5/13 approximately 11:00a.m. the syringes with the exposed needles remained in the torn box on top of the red biohazard bag. A large wood board was placed over the torn box.
Grounds of the Hospital
During a tour of the grounds of the hospital on 2/5/13 at 10:30 a.m . revealed several metal hospital beds(one flipped over) large mattress, commode, opened card board boxes, metal shelves, pipes, & wood crates were laying in the grass. The grass was approximately 12 to 15 inches high in some areas were old supplies/equipment were being discarded. (S4) stated when asked why these items were on the grounds of the hospital (S4) stated that they were items that had to be hauled off because it could not be disposed of in the regular trash.

1. Based on inspections, reviews of policies and procedures, and staff interviews Community General Hospital failed to conduct periodic equipment maintenance checks, maintain the building from decline and ensure supplies were stored safely
The findings included:
a. An inspection of the emergency department conducted on 2/5/13 at 1:00 p.m. with S1 and S15 revealed the hospital's respiratory ventilation machine last maintenance check expired in July 2012. Defibrillator leads were pre-opened and dried out contrary to large print manufactures instructions "Do not open prior to immediate use''. The plastic covering the mattress on the gurney had large cracks and no longer provided a barrier from liquids or body fluids.
b. Medications (labetatol,hydrochloride, levophed) and other emergency supplies such as intravenous fluids were found expired from immediate use locations as well as the crash cart and the medication storage room.
c. The medication storage room had holes in the ceiling and medication cabinets were not secured.

Based on tour of the facility, record review, and staff interview the facility failed to maintain an environment that was safe and sanitary.

The Findings Included:

a. Based on a tour of the facility on 2/4/13 at approximately 1:25p.m. to 4:25p.m. accompanied by (S1), (S4), (S7), and (S18) the following discrepancies were observed:

Inpatient Nursing Floor Crash Cart:

Placed on top of the clean linen supply cart were several pillows that were stained. The plastic covering had several large areas of tears that exposed the cloth covering.

Food and Drinks at the nurses ' station belonging to staff

Personnel belongings in clean patient supply areas like used deodorant, purses on clean carts and counters.

Emergency Room

Food and Drinks at the nurses ' station belonging to staff

The plastic covering the mattress on three gurneys had large cracks and no longer provided a barrier from liquids or body fluids.

Oxygen Tank Regulator found in cabinet with food products (krispy crackers, pepper packets)
Soiled Utility Room
Large yellow laundry storage bin contained soiled linen that was not bagged. Several used gloves were also found in the bin.
2 pillows (with areas of missing plastic covers) were placed on chair side commodes
Maintenance storage building / Work area
Large part of the work space is located outside with equipment exposed to outdoor elements (file cabinets, furniture, mop and mop buckets, wheelchairs, computer parts, paint cans, IV poles)
Inside the storage building revealed a very thick layer of dirt on the floor. Large cracks in the cement floor. During tour of the storage area (S4) stated that the ceiling did not leak but when it rained water will flow into storage building.
Multiple (at least 7) Red Biohazard Bags were full and placed on top shelves. (S4) stated the bags did not contain biohazard material he stated he used the biohazard bags as storage containers.
Biohazard Storage Building:
The signs that labeled the building as " Biohazard Waste " was located face down on the ground next to a discarded mop head.
The storage building continued brick walls with a large open metal pipe that opened to the outside with no screen which could provide an entry way for a small animal.
A biohazard box that was torn that contained an open sharps container laying on top of a red biohazard bag. The sharps container was not closed correctly and the contents (syringes with exposed needles and glass vials) were lying on top of the red biohazard bags. (S4) stated that the biohazard waste was picked up earlier in the day with the torn box not being picked up because of the needle stick hazard. To note on 2/5/13 approximately 11:00a.m. the syringes with the exposed needles remained in the torn box on top of the red biohazard bag. A large wood board was placed over the torn box.
Grounds of the Hospital
During a tour of the grounds of the hospital on 2/5/13 at 10:30 a.m . revealed several metal hospital beds(one flipped over) large mattress, commode, opened card board boxes, metal shelves, pipes, & wood crates were laying in the grass. The grass was approximately 12 to 15 inches high in some areas were old supplies/equipment were being discarded. (S4) stated when asked why these items were on the grounds of the hospital (S4) stated that they were items that had to be hauled off because it could not be disposed of in the regular trash.

Based on medical record review, policy review, and staff interview the facility failed to document the discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.

The findings included:

a. Review of 15 closed medical records on 2/5/13 at 10:30 a.m. and 2/6/13 at 10:00 a.m. in an office beside the medical record room revealed that 7 of 14 patients reviewed had nothing documented or checked under discharge planning on the form in the patient medical record titled "Interdisciplinary Patient & Family Education Record". The discrepancies were noted in patient's medical records for (P8, P9, P10, P13, P14, P19, and P38).
Review of 4 open records revealed 2 of the 4 patients (P25 & P28) had no documentation in the patient record to reveal the patient had been evaluated for discharge needs even though both patients were receiving continuous oxygen therapy and both were receiving respiratory therapy nebulizer treatments.
b. Review of facility policy titled "Discharge Planning Policy" on 2/6/13 in an office in the facility revealed the policy states "Discharge planning is an integral part of the medical care process and begins upon admission. The discharge planning process involves constant communication among patients, families, staff, and community agencies. It is through such a discharge planning program that the medical care process can be documented and assessed as to its quality and organization. Discharge planning must begin at the time of admission and be considered throughout the hospital course of treatment.
c. In an interview with (S14) on 2/6/13 at 10:25 a.m. in the nurses station (S14) indicated there was a patient she had assisted the family in setting up hospice care. (S14) indicated there would be documentation in the patient medical record to indicate the communication between the nursing staff and the family in regard to the discharge planning process in setting up hospice care for the patient upon discharge.
d. Review of the entire medical record for (P38) revealed there was no indication of discharge planning information or community resource information provided to the patient or the family.

(S14) confirmed the lack of discharge planning notes and documentation for (P38).

Lack of discharge planning needs puts all patients at risk for not receiving appropriate referrals and knowledge of availability of resources.

Based on patient medical record review, policy review, and staff interview the hospital failed to include in the discharge plan a list of home health agencies or skilled nursing facilities that are available to the patient that serve the geographic area in which the patient resides, or in the geographic area requested by the patient.

The findings included:

a. Review of the entire medical record for (P38) revealed there was no indication of discharge planning information or community resource information provided to the patient or the family.
b. Review of facility policy titled "Discharge Planning Policy" on 2/6/13 in an office in the facility revealed the policy states "Discharge planning is an integral part of the medical care process and begins upon admission. The discharge planning process involves constant communication among patients, families, staff, and community agencies. It is through such a discharge planning program that the medical care process can be documented and assessed as to its quality and organization. Discharge planning must begin at the time of admission and be considered throughout the hospital course of treatment.
c. In an interview with (S14) on 2/6/13 at 10:25 a.m. in the nurses station (S14) indicated there was a patient she had assisted the family in setting up hospice care. (S14) indicated there would be documentation in the patient medical record to indicate the communication between the nursing staff and the family in regard to the discharge planning process in setting up hospice care for the patient upon discharge. (S14) stated the hospital does not keep a list of community agencies to give to the patients to have a choice. She further stated if patients do not have an agency that is currently seeing them they ask the family if they are aware of any agencies they want to use.

(S14) confirmed the lack of discharge planning notes and documentation for (P38).

Lack of discharge planning needs puts all patients at risk for not receiving appropriate referrals and knowledge of availability of resources.

1. Based on review of Quality Meeting Minutes, Governing Body Meeting Minutes, and staff interview the facility failed to identify, review, and trend medical errors that occurred in the facility.

The Findings included:

a. Review of Quality Improvement Committee Meeting Minutes on 2/6/12 in the facility conference room for January 2012-January 2013 revealed no evidence the facility identified, reviewed, and or trended medical errors.

Review of Governing Board Meeting Minutes on 2/12/13 at 2:30p.m. from March 30, 2012 to January 2, 2013 revealed no evidence the facility identified, reviewed, and or trended medical errors.

b. An interview conducted with (S7) on 2/06/13 at 2:30p.m. following her own review of the findings revealed she was aware of the discrepancies found. (S7) confirmed that the facility does not track, trend or review medical errors as a committee. (S7) stated that she corrects nursing staff as issues occur. (S7) could not verbally state or produce any documentation that instructed staff on what was a reportable medical error, how to report those errors, and actions to take when medical errors occurred.