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Based on record reviews and interviews, the Governing Board (GB) failed to appoint a local Governing Board as required by its the Governing Board Bylaws . Review of the list for members of the GB revealed only 1 (#30) staff member out of 8 (#30,40-46 ) was a local member.


Review of the facility's GB Bylaws, dated 2013 revealed, "Governing Board Section 1. Appointment of the Facility Governing Board. The "Company" shall appoint a local Governing Board for the Facility to be known as the "Facility Governing Board" or the "local Governing Board." Notwithstanding any other provisions of these bylaws. each reference in these bylaws to the "Managers" shall refer to the Managers of the Company or it's designee; each reference to the "Governing Board" shall refer to the Governing Board so appointed by the Managers; each reference to the 'Medical Staff' shall refer to the Medical Staff organized pursuant to Article IV, Section 1 of these Bylaws.


Interview with staff #1 confirmed this was the only list of board members. Staff #1 confirmed the Governing Board that currently oversee the operations of the hospital was from the corporate office.




The Governing Body failed to:

A.) ensure the facility and medical staff were following the approved Medical Staff bylaws related to the requirements for the credentialing of physicians and practitioners.

Refer to TAG A0047


B.) provide written evidence on the appointment of the present Chief Executive Officer (CEO).

Refer to TAG A0057


C.) ensure that a contractor of services (including one for shared services) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services for patient transfers, lease agreements, and contracted ancillary services in 2 of 2 hospitals reviewed.

Refer to TAG A0083


D.) ensure that the services performed under a contract were provided in a safe and effective manner.

Refer to TAG A0084


E.) have an updated list of all contracted services.

Refer to TAG A0085


F.)


1.) ensure the facility had an updated complaint/grievance policy and procedure specific to the facility,

2.) ensure the grievance process was followed through the Governing Body or designated Grievance Committee,

3.) ensure the complaint/grievances were addressed in a timely manner and worked through the Quality Assessment Performance Improvement (QAPI) process,

4.) ensure the staff had training and a clear understanding of a complaint/grievance process.

Refer to Tag A0118


5.) ensure the hospital had trained staff to assist with the grievance process and followed the set time frames to resolve the patient issues.

Refer to Tag A0122


6.) ensure patients received appropriately executed informed consents and/or release forms in 6 (Patient #'s 1, 2, 4, 5, 12, and 14) out of 6 patients.

Refer to Tag A0131



G.)

1.) keep the patient safe from serious change in conditions and harmful injuries. The facility failed to ensure the patients were safe by reporting, monitoring, assessing, and documenting patient care in 4 (13,14, 16 and 21) of 4 patient charts reviewed. The facility failed to report a fall that resulted in a patient death in 6.5 hours. There was no follow up in the Quality Assurance Performance Improvement (QAPI) on the patient incidents or any staff education to prevent the incidents or death.

These actions place all patients in potential immediate jeopardy for the likelihood of harm, serious injury, and possibly subsequent death.

2.) ensure the nursing staff had specific technical knowledge and task skills when performing the removal of peripherally inserted central catheter (PICC) lines; to prevent patients from suffering serious harm in

Refer to Tag A0144


H.)

1.) monitor the appropriate use, administration, and documentation of restraints. Quality Assessment Performance Improvement (QAPI) failed to properly log, track, analyze, and implement a productive plan to ensure the patients were safe in restraints. Failed to ensure the physician was assessing the patient with in the 24 hour time frames and writing the orders for restraints beyond the initial order in 2 of 2(#6 and #21) charts reviewed.

2.) discontinue the restraint when the patient was sleeping with no behavioral issues documented nor documented the decision to continue in restraints due to ongoing behavioral or cognitive issues in 2 of 2(#6 and #21) patient charts reviewed.

Refer to Tag A0154


I.) document in the patients plan of care or treatment plan concerning the use of restraints in 2 of 2(#6 and #21) patient charts reviewed.

Refer to Tag A0166


J.)

1.) take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 20 out of 20 months (January 2016-August of 2017).

Refer to Tag A0283

2.)
provide an ongoing program that showed measurable improvement in indicators for which there is evidence that the program/process would identify and reduce medical errors, measure, analyze, and track adverse patient events.

Refer to Tag A0286


3.)
have performance improvements to identify problem-prone areas from the data that had been collected for 20 months (January 2016-August of 2017).

Refer to Tag A0297


K.) ensure there was a process to evaluate the medical candidates for membership, privileges, evaluations, and recommendations complied with the Medical Staff bylaws in 9 (23,24,29,30,27,26,28,31, and 32) of 9 physician credential files reviewed.

Refer to Tag A0341


L.)

1. ensure that there was a qualified Chief Nursing Officer (CNO) and the CNO was responsible for the operations of nursing services by reviewing and approving patient care policies and actively analyzing and developing staffing requirements for the hospital
See Tag A0386

2. ensure nursing services was staffed with adequately trained nursing staff in 2 out of 2 units surveyed (north campus and south campus).
See Tag A0392

3. ensure nursing services documented appropriate assessments of patient conditions on 5 patients (Patient #'s 1, 2, 4, 5, and 13) of 9 patients reviewed.
See Tag A0392

4. ensure nursing services notified the physician of critical test values in a timely manner on 2 patients (Patient #1 and Patient #4) of 9 patients reviewed.
See Tag A0392

5. initiate appropriate problem/focus areas and keep the nursing plan of care up to date on the Interdisciplinary Plan of Care for 3 patients (Patient #'s 1, 2, and 24) of 4 patients reviewed.
See Tag A0396

6. ensure nursing staff documented patient drug administration per the hospital's policies required for safe drug administration for 3 patients (Patient #s 4, 10, and 19) of 4 charts reviewed.
See Tag A0405

7. failed to ensure nursing staff followed safe practices for picking up and storing multiple units of blood at one of two locations (North Campus) and ensuring proper informed consent had been obtained.
See Tag A0409


M.) failed to maintain a current contract for off site and in-house Radiology services from 1/2017 through 8/2017.
Refer to Tag A0528


N.) provide an approved contract for the laboratory services, and could not provide policies and procedures for the laboratory services provided from 1/2017 through 8/2017

This deficient practice had the likelihood to effect all patients of the hospital.

Findings included:

On the afternoon of 8/22/2017, in the conference room an interview with staff #2 confirmed the laboratory services were provided by a contract with local hospitals for both the North and South campuses. A review of the Ancillary contract agreement revealed the agreement had expired on 11/2/2014 on the North Campus and 4/1/2010 on the South Campus.

Review of the Governing Body meeting minutes from January 2017 forward did not reflect a review, discussion or motion to re-approve the ancillary services contract for either campus. The hospital did not have a ratified contract for the Laboratory services provided at either campus.


2. provide written description of the laboratory services that were provided within the hospital from January 2017 through August 2017. This deficient practice had the likelihood to effect all patients of the hospital.

Refer to A 0584


3. provide an approved contract for the laboratory services, and could not provide policies and procedures for the laboratory services provided from 1/2017 through 8/2017. This deficient practice had the likelihood to effect all patients of the hospital.

Refer to A 0586


O.)

1. ensure the Governing Body (GB) delegated the Utilization Review Committee (URC) the authority and responsibility to carry out the Utilization Review (UR) function.
See Tag A0654


2. establish a utilization review plan that included a process for the Utilization Review Committee (URC) to review cases for medical necessity, duration of stay, and professional services provided during the patient stay, or the timeframes for reviews.
See Tag A0655

3. establish a utilization review plan that provided for the identification and process for review of extended stay cases.
See Tag A0657

4. ensure the Utilization Review Committee reviewed professional services.
See Tag A0658


P.) incorporate the plant maintenance into their hospital wide quality program from 1/2017 through 8/2017. This deficient practice had the likelihood to effect all patient of the hospital.

Refer to Tag A0700


Q.)

1. maintain a sanitary environment in 9 of 9 areas on the North campus (Housekeeping, Linen room, patient nutrition room, kitchen, general storage, dumpster, patient rooms, rehabilitation room and clean supply storage) and 6 (Pharmacy, Nurses station, Rehabilitation and gym, patient room, crash cart and nurses medication room) of 6 area observed on the South campus.

2. ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017


Refer to tag A0748


3. establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms and determine a safe effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.


Refer to tag A7049


4. ensure the Infection Control (IC) program was functional and incorporated into the hospital wide Quality Assessment Process Improvement (QAPI) program from January 2017 through August 2017.

Refer to tag A0756

Based on record reviews and interviews, the facility failed to:


A.) ensure the facility had an updated complaint/grievance policy and procedure specific to the facility.

B.) ensure the grievance process was followed through the Governing Body or designated Grievance Committee.

C.) ensure the complaint/grievances were addressed in a timely manner and worked through the Quality Assessment Performance Improvement (QAPI) process.

D.) ensure the staff had training and a clear understanding of a complaint/grievance process.

Refer to Tag A0118


E.) ensure the hospital had trained staff to assist with the grievance process and followed the set time frames to resolve the patient issues.

Refer to Tag A0122


F.) ensure patients received appropriately executed informed consents and/or release forms in 6 (Patient #'s 1, 2, 4, 5, 12, and 14) out of 6 patients.

Refer to Tag A0131


G.) keep the patient safe from serious change in conditions and harmful injuries. The facility failed to ensure the patients were safe by reporting, monitoring, assessing, and documenting patient care in 4 of 4 (13, 14, 16, and 21) patient charts reviewed. The facility failed to report a fall that resulted in a patient death within 6.5 hours. There was no follow up in the Quality Assurance Performance Improvement (QAPI) on the patient incidents or any staff education to prevent the incidents or death.

These deficient practices were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


H.) ensure the nursing staff had specific technical knowledge and task skills when performing the removal of peripherally inserted central catheter (PICC) lines; to prevent patients from suffering serious harm in

Refer to Tag A0144


I.) monitor the appropriate use, administration, and documentation of restraints. Quality Assessment Performance Improvement (QAPI) failed to properly log, track, analyze, and implement a productive plan to ensure the patients were safe in restraints. Failed to ensure the physician was assessing the patient with in the 24 hour time frames and writing the orders for restraints beyond the initial order in 2 of 2 (#6 and #21) charts reviewed.


J.) discontinue the restraint when the patient was sleeping with no behavioral issues documented nor documented the decision to continue in restraints due to ongoing behavioral or cognitive issues in 2 of 2 (#6 and #21) patient charts reviewed.

Refer to Tag A0154


K.) document in the patients plan of care or treatment plan concerning the use of restraints in 2 of 2 (#6 and #21) patient charts reviewed.

Refer to Tag A0166

Based on review and interview, the facility failed to;

1.) take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 20 out of 20 months (January 2016-August of 2017).

Refer to Tag A0283


2.) provide an ongoing program that showed measurable improvement in indicators for which there is evidence that the program/process would identify and reduce medical errors, measure, analyze, and track adverse patient events.

Refer to Tag A0286


3.) have performance improvements to identify problem-prone areas from the data that had been collected for 20 months (January 2016-August of 2017).

Refer to Tag A0297

Based on reviews and interviews, the Governing Body (GB) and Medical Executive Committee (MEC) failed to:

A.) ensure there was a process to evaluate the medical candidates for membership, privileges, evaluations, and recommendations complied with the Medical Staff bylaws in 9 of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) physician credential files reviewed.

Refer to Tag A0341

Based on review of records, observation, and interview, the facility and nursing services failed to:

A. ensure that there was a qualified Chief Nursing Officer (CNO) and the CNO was responsible for the operations of nursing services by reviewing and approving patient care policies, and actively analyzing and developing staffing requirements for the hospital
See Tag A0386


B. ensure nursing services was staffed with adequately trained nursing staff in 2 out of 2 units surveyed (north campus and south campus).
See Tag A0392


C. ensure nursing services documented appropriate assessments of patient conditions on 5 patients (Patient #'s 1, 2, 4, 5, and 13) of 9 patients reviewed.
See Tag A0392


D. ensure nursing services notified the physician of critical test values in a timely manner on 2 patients (Patient #1 and Patient #4) of 9 patients reviewed.
See Tag A0392


E. initiate appropriate problem/focus areas and keep the nursing plan of care up to date on the Interdisciplinary Plan of Care for 3 patients (Patient #'s 1, 2, and 24) of 4 patients reviewed.
See Tag A0396


F. ensure nursing staff documented patient drug administration per the hospital's policies required for safe drug administration for 3 patients (Patient #s 4, 10, and 19) of 4 charts reviewed.
See Tag A0405


G. failed to ensure nursing staff followed safe practices for picking up and storing multiple units of blood at one of two locations (North Campus) and ensuring proper informed consent had been obtained.
See Tag A0409

Based on document review and interview, the facility failed to maintain a current contract for off site and in-house Radiology services from 1/2017 through 8/2017.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On 8/21/2017 in the conference room, an interview with staff #2 confirmed the Long Term Acute Care (LTAC) hospital's radiology services were provided via a contract with local acute hospitals. The LTAC hospital had two (2) campuses, a North and South campus. Further review of the radiology services confirmed the LTAC had in-house services as well as off campus services. The in-house radiological services were listed as:

Portable x-ray capabilities, that included all x-rays where a flat plate could be used for imaging. The flat plate would be placed below or behind the patient to capture the image. For any of these x-rays it was not necessary to transferred the patient from the LTAC hospital.

For more advanced radiological services, such as CT (Computer Tomography) or MRI (Magnetic Resonance Imaging) the patient would require transfer to the contracted service provide. Which in this case was one of the local acute care hospitals.


A review of the contract for the Radiology services, that staff #1 and #2 were able to provide was not current. The Ancillary Services Agreement for Radiology services terminated as of 4/1/2010 on the South campus and on 11/2/2014 for the North campus. Review of the GB quarterly meeting minutes for 1/17 through 8/17 did not reflect a review or approval of the present radiology services agreement. The contract had not been re-approved by the LTAC's Governing Body (GB). The LTAC facility did not have a legal contract for the in-house or off site radiology services at either campus.

This was confirmed by staff #1, the Chief Executive Officer and Staff #2, the Chief Nursing Officer.

Based on document review and interview the facility failed to:


A. provide an approved contract for the laboratory services, and could not provide policies and procedures for the laboratory services provided from 1/2017 through 8/2017


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:

On the afternoon of 8/22/2017, in the conference room an interview with staff #2 confirmed the laboratory services were provided by a contract with local hospitals for both the North and South campuses. A review of the Ancillary contract agreement revealed the agreement had expired on 11/2/2014 on the North Campus and 4/1/2010 on the South Campus.

Review of the Governing Body meeting minutes from January 2017 forward did not reflect a review, discussion or motion to re-approve the ancillary services contract for either campus. The hospital did not have a ratified contract for the Laboratory services provided at either campus.


B. provide written description of the laboratory services that were provided within the hospital from January 2017 through August 2017.

This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


Refer to A 0584



C. provide an approved contract for the laboratory services, and could not provide policies and procedures for the laboratory services provided from 1/2017 through 8/2017



This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


Refer to A 0586

Based on review of record and interview, the hospital failed to:

A. ensure the Governing Body (GB) delegated the Utilization Review Committee (URC) the authority and responsibility to carry out the Utilization Review (UR) function.
See Tag A0654


B. establish a utilization review plan that included a process for the Utilization Review Committee (URC) to review cases for medical necessity, duration of stay, and professional services provided during the patient stay, or the timeframes for reviews.
See Tag A0655


C. establish a utilization review plan that provided for the identification and process for review of extended stay cases.
See Tag A0657


D. ensure the Utilization Review Committee reviewed professional services.
See Tag A0658

Based on document review and interview, the facility failed to incorporate the plant maintenance into their hospital wide quality program from 1/2017 through 8/2017.

This deficient practice had the likelihood to affect all patients of the hospital.


Findings included:


On the morning of 8/22/2017 during tour of the outside physical plant (dumpster, emergency generator, grounds) a conversation with the contracted maintenance provider and staff #3 and #4 revealed the Long Term Acute Care (LTAC) facility did not have copies of the emergency generator logs. The logs were kept by the contracted provider and were part of that hospital's quality program. Staff #3 and #4 were asked if the maintenance department was part of the LTAC's Quality Assessment Process Improvement (QAPI) program. They replied not yet. They further explained that they were not attending the QAPI meetings that would review their physical plant maintenance either.

During the tour, the contracted maintenance director explained the emergency generator was only checked to operate with a load 1 time a year.
He explained "they " didn't have to. One time a year was all that was required if the load did not generate a 30% or greater pull on the motor. The contracted maintenance director provided a clip board which confirmed only a bank test was being conducted and the fuel levels were being audited. The load capacity was only tested 1 time a year.

Staff #3 and #4 were asked if they were aware the emergency generator was not being tested monthly. Both replied "No". Staff #3 and #4 were asked if they were ever aware of the emergency generator when it was powered up. There replied "No". The staff had no way of knowing if the facility could provide emergency power to ventilator patients or any other emergency service where electrical power was required. The LTAC did not include the maintenance department and their services in the LTAC's QAPI program.

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

A. maintain a sanitary environment in 9 of 9 areas on the North campus (Housekeeping, Linen room, patient nutrition room, kitchen, general storage, dumpster, patient rooms, rehabilitation room and clean supply storage), and 6 (Pharmacy, Nurses station, Rehabilitation and gym, patient room, crash cart and nurses medication room) of 6 area observed on the South campus.


This deficient practice had the likelihood to affect all patients of the hospital.


Findings included:

On the morning of August 21, 2017 during the initial tour of the hospital's North campus, the following interviews and observation were made.

House keeping:

1. Housekeeper #7, was interviewed during the tour regarding when the patient privacy curtains were changed. She confirmed she did not change them and did not know when they were changed. She further confirmed she had not received training on a schedule or process for changing the privacy curtains out between patients. As far as she was aware the curtains were changed when the nurse told the evening house keeper to change them.

Privacy curtains in room 227 and 278 were visibly soiled with dark colored stains.

Interview with staff #2 confirmed there was no actual policy or schedule for changing the privacy curtains.


1) Rooms #225 and #226 shared one entrance. The room was designed like a "Y".

Room #225 and #226 shared a common shower and toilet area. An area of the wall, immediately prior to entering the bathroom had an area with torn plaster and a hole in the wall. The area was the size of a liquid hand sanitizer. In Room #225 a fold down seat made of wooded slats supported by a metal frame was observed with a white/gray stain on the top and bottom of the seat.

Room #226 was observed separated from #225 by a single privacy curtain. The curtain was observed with dark brown/black stains on the curtain. The curtain was observed with 3-4 holes in the mesh and a hook caught in the mesh mid way between the top of the mesh and the fabric of the curtain. The floors were heavily soiled with dark gray/black discoloration in the corners and the base boards were scratched, cracked,and stained. The patient room had a window that hinged inward and could be opened. The window ledge was visibly soiled with loose gray black debris. The arms of the wooden furniture were heavily worn and the stain was no longer visible on the arms of the chairs. Two tall trash receptacles were located at the apex between the two patients areas within the room. One was white for non biohazard trash and the other was red for bio hazard trash.


2) Room #227 and #228 were across the hall from the above mentioned rooms and the room design was the same. Room #227 was found in similar condition, however, the wall on the left side of the room where a patient would stay exhibited 6-7 long deep tracks that ran from the floor to near the ceiling. The sheet rock on this wall was deeply scarred. The paint had been torn and the room had a sign left by the house keeper indicating the room had been sanitized and was ready for the next patient. When a surface is no longer intact, it can not longer be completely sanitized. The window in the room hinged inward and upon opening the window the same dark gray debris was present. Looking out the window, trash could be seen behind the hedges below the window. Room #228 was observed to be occupied with a patient and examined.

Staff #3 was interviewed and asked what could make such deep gouges in the wall in room #227 and she replied, "Probably the bed was too close to the wall when it was elevated for the staff to work with the patient and it cut into the wall".


Linen Room:

1) A rental air mattress was observed on the floor in a fabric case, in the clean linen storage room. This was confirmed by staff #2.

Staff #2, who gave the tour, stated, "He thought the representative who worked for the company that they rented there specialty mattresses from had dropped it off in the clean linen room".


2) A Woundcare Concepts bag, which contained a Vacuum Assisted wound closure device was observed on the counter in the clean linen room. This was confirmed by staff #2.


3) The drape was pulled back on one of the two linen carts to reveal linen hanging off the shelves. The bottom shelf held assorted blue scrubs for patient use. One of the scrub pants had fallen on to the floor with only a small portion still hanging on the lower shelf. This was confirmed by staff #2.


Patient nutrition room:

1) The ice maker in the patient nutrition room, was observed with black mold below the upper surface where the ice was dispensed.

Staff #2, who gave the tour, confirmed this finding.


Kitchen:

1) The refrigerator in the kitchen was opened and two (2) meal substitutes were observed with a date expiration of 8/21/2017. One of the other meals had been partially eaten and the lid replaced. The refrigerator was identified for patient meals only. The partially eaten tray did not have a patient room label on it.


General storage:

7) A cart was observed in a hall nook. The top of the cart was waist high and had a small stack of cups on it. The cups were marked with patient room numbers. The cups were not in a protective bag or box and were exposed to surrounding contaminates. Staff #2, who gave the tour, was questioned as to what the cups were used for and why were they left on the top of the cart. He replied "He didn't know and he would have to find out". No answer was provided.

8) The blood pressure bulb of a rolling blood pressure machine was observed with heavy dust on the bulb. This was confirmed by staff #2.

9) A hydroculator (a piece of equipment used to provide moist heat to a limb observed on the floor in a clean holding room, was "ready to use" patient equipment. The hydroculator was not covered with a clean plastic cover indicating it had been sanitized and was ready for patient use. Staff #2 confirmed the hydroculator was no longer in use as evidence no longer supported its effectiveness. However it was stored with clean ready to use patient equipment.


Dumpster:

10) The facility leased space in a rehabilitation hospital and shared their dumpster on the grounds. Observation of the dumpster revealed a cinder block structure with three walls. An iron gate was open at the front of the dumpster. Behind the dumpster there was no wall for complete containment. The back of the dumpster containment was at the hospital ground level loading dock and exit doors. Behind the dumpster the area was full of equipment no longer in use. Examples: the hydroculator, over beds tables, potty chairs, a stainless steel cart loaded with steam table pans, 5 gallon buckets with lids attached, Three red heavy plastic biohazard containers that were full sealed and stacked on top of each other. Next to the three full biohazard containers were three empty containers turned upside down as if to drain.

Staff #3 and the Director of the contracted maintenance services could not determine if the biohazard containers were reused or not.



Patient Rooms:

11) Tape and tape residue was observed on all the wall switches and electrical outlets in each patient room. The surfaces were visibly soiled with dark gray discoloration.


Rehabilitation room:

1) Beneath the sink in the rehabilitation department, the surface was stained with a brown stain and a soiled cloth had been left below the sink on the floor.
2) An upper storage cabinet was observed with cleaning supplies and disinfectant stored next to the Speech pathologist supplies used for bed side swallow studies.
3. The walking surface of the parallel bars used in the rehabilitation room was worn and no longer able to be sanitized.



Clean supply storage room:

1) Observed in the clean supply storage were two pink wash basins with supplies that were opened and partially used. A bottle of Peroxide had been opened and used but no date opened was found on the bottle, two (2) partially used rolls of Medipore tape were observed with dark brown stains on the end of each roll. A colostomy bag was observed in a second wash basin. The colostomy bag was not in a sanitary container.

2) The lower shelf on the stainless steel storage carts failed to have a splash guard that protected products on the lower shelf from being contaminated during sweeping and mopping.

3) Opened card board boxes were observed placed on the lower shelf.

4) A lower cabinet was opened to reveal an expired liquid hand soap. The expiration date was 4/2010.

5) A sink was located in the clean storage room. Water was observed splashed well outside the sink.

6) The Soap dispenser was observed with dark residue below the dispenser port.


Observations on the South Campus:

Pharmacy:

1) On the first shelf of an open lower cabinet, the following was observed: salt, pepper, canned soup, multiple empty Styrofoam cups with lids and straws stacked on top of the salt, pepper and soup.

1) Interview with staff #51, the supervising pharmacist, revealed the snacks were hers. Further questions regarding the collection of used but saved Styrofoam cups, lids and straws confirmed she, "Saved them for later use". Below this stash of snacks items was a pink wash basin with non labeled sheets of blister pack medication. Staff #51 confirmed they filled and sealed their own pill packs for blister pack use. However, these medications were not identified for any patient use. Staff #51 stated she found nothing wrong with snacks in the pharmacy because all the medications were in blister packs. She indicated the medications below the snack were not in use.

2) A small stainless steel refrigerator was observed with heavy streaking. The outside of the refrigerator looked like it needed cleaning. A sign on the door read "Food Only No Drugs". An interview with staff #51 confirmed, the food, "was for the pharmacy staff". The pharmacy staff were eating in the pharmacy.

3) The pharmacy had a hood used for mixing medication. There was no door or curtain which would protect the hood and mixing area from contamination from the refrigerator and employee food in the very small pharmacy.


B. ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017


Refer to tag A0748


C. establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms and determine a safe effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.


Refer to tag A7049


D. ensure the Infection Control (IC) program was functional and incorporated into the hospital wide Quality Assessment Process Improvement (QAPI) program from January 2017 through August 2017.

Refer to tag A0756


32143


A tour of the south campus was performed on 8/25/17. The finding are listed as follows:

1.) The front nurses station.

A.) The front nurse's station desk was made of a wood substance. The wood laminate was worn and bare wood was exposed. The desk was not properly sealed and unable to be cleaned appropriately.


2.) The rehabilitation room and gym.

A.) a cabinet in the rehab room was found to have cleaning supplies and patient linen stored together.

B.) The Hydrocollator was a metal container used as a thermostatically controlled water bath for placing bentonite-filled cloth heating pads. The device was found on and full of heating pads. The top of the Hydrocollator was rusted around the knob and inside was found to have rust and hard water mineral build up on the walls. The cloth pads in the Hydrocollator were found soiled.

C.) The wooden base of the parallel bars in the rehab room was found to be soiled with dust and hair. The wood base was worn and bare wood was exposed making it difficult to properly clean.

Staff #38 confirmed the findings. Staff #38 was able to find a cleaning schedule for the Hydrocollator but was only cleaning it once a month. According to the Manufacturer guidelines, "clean and drain the tank (every two weeks). Failure to properly maintain the unit will cause premature wear and will void the warranty. Remove all deposits from interior surfaces and parts. The deposits are concentrations of minerals that will allow rusting to begin. If allowed to accumulate on the heating element, these deposits will lower the efficiency of the element and increase the power consumption of the unit. However, exercise extreme care if cleaning element or thermostat(s). These components can be easily damaged without proper care or caution. If you suspect that you have "hard water", you may need to change the water and clean the unit more frequently. Salt deposits are an indication of hard water that will eventually cause rust."


3.) The nurse's desk in the middle of the hall was found to have laminate strips chipped and missing with exposed wood. Exposed wood is porous and difficult to disinfect.


4.) The following items were found in patient room 651. The room had been designated as a room that had been terminally cleaned between patients and was ready for a new patient.

A.) The biohazard trash can was found to be soiled with dust and hair on the lid. Unidentified spills were noted on the sides of the trash can.

B.) The bedside table was found to be soiled with dust and the top was missing laminate with exposed bare wood particle board.

C.) The lounge chair was found to have worn wooden arm rest. The bare wood was exposed. The sides of the chair were soiled with unidentified substances. The back of the lounge chair was heavily soiled with dust and dirt. There was a black unidentified substance on the foot rest covered in hair and dust. The foot rest was worn, torn in several places, stuffing hanging out, and wood exposed. The foot rest was raised and a heavy film of dust, hair, dried food crumbs, and a used Kleenex was found underneath.

D.) The main door was chipped up and missing laminate exposing bare wood.

E.) The wooden base holding the sink was found to be chipped and splintered with exposed wood present. The bathroom fixture was found to have a broken lens over the sink. The metal paper towel holder was soiled on top with dust and hair.

F.) In the patient bathroom, the shower enclosure was not installed properly. A gap was found between the enclosure and the faucet fixture allowing water to run behind the shower enclosure.

G.) The toilet had a metal sprayer on the flush body. The sprayer head was found to be heavily coated in mineral deposits. The sprayer was unable to be cleaned properly. The base of the toilet was found to be soiled with a buildup of dried urine.

H.) Behind the toilet the floor was found to be coated in a yellow/orange substance, dirt, and hair.

I.) A pad was removed from the bed and a hole was found on the fitted sheet. The bed was found to have a soiled pillow case. Brown and black hairs were found on the pillow case. The top sheet was soiled with unidentifiable stains. The mattress was found to be soiled underneath with unidentifiable substance. The mattress was found to be worn and soiled, on the top, at the corners with a brown substance. The head board and foot board was soiled with dust and hair. The bedside rail and controls were found to be soiled with dirt, dust and hair.

J.) The patient bedside table was found to be soiled with dust and old tape.

K.) The light fixture above the bed was found to have dried, splattered unidentified substance on the lens. The ceiling above the bed had a brown splattered substance. The fire sprinkler in the ceiling was dusty and soiled.

L.) The patient bedside table was found to be soiled. The drawer was pulled out and inside the drawer track was heavily soiled with dried food particles, dust, and hair.


5.) The following items were found on the crash cart in the hallway by the second nurse's station;
A. The tracheal Tube was hanging off of the side of the crash cart. The tube expired on 1/2017. An open battery charger and opened exposed batteries were touching patient supplies in the crash cart. Opened empty packages were found in the supplies of the crash cart. The items were not discarded in the trash.


6.) The following items were in the nurse's medication room;

A.) The sharps container was full and currently being used.

B.) A wall telephone was found to have an extra-long cord. The cord was lying in the trash can on top of a hazardous bag and trash. The walls were dirty and soiled. Sheet rock was exposed next to the trash can.

C.) The medication pill crusher was soiled with dust and the paint was worn off exposing the metal.

D.) A drug handbook was found with mildewed pages sitting next to patient medications.

E.) A device called a CACTUS was found sitting on a small refrigerator. The device is used to discard unwanted medications or pharmaceutical waste. The device was soiled with dust, hair, and a copious brown substance in the top of the drain.

F.) A small medication refrigerator was found sitting on the floor of the medication room. The outside of the refrigerator and the top of the refrigerator was soiled with dust, hair, and unidentifiable dried white particles. The inside of the refrigerator was soiled with dust and hair. Three patient IV bags were in the refrigerator lying on the soiled surface. A patient IV bag, ready for use, was found to have a long black hair stuck to the sticker of the medication bag. The hair was wrapped around the IV bag.

G.) A review of the description of the Pyxis Medstation revealed, "The Pyxis MedStation (Trademark) automated medication dispensing system supports decentralized medication management with various features for safety and efficiency. The system helps accurately dispense medication, while supporting pharmacy workflows." The Pyxis had 2 upright cabinets with a glass front and shelves that are locked. It has a refrigerated refrigerator attached that also locked. There was a screen and key pad. The base of the Pyxis is drawers with medications. The user must type in the medication they want and a code to unlock the device.

The Pyxis was visibly soiled on the outside with dust, hair, and dried spilled substances. The Pyxis was next to a wall that had missing sheet rock and was soiled with dirt, dust, and pen marks. The key board was heavily soiled with dirt and dust. The keyboard was covered by a piece of plastic to protect the keys. It had been taped down to the base of the computer with nylon tape that was soiled with dirt and hair. The plastic cover was torn in multiple areas and heavily soiled with dirt and dust. The ends of the plastic were black in some spots. The base holding the keyboard was heavily soiled with dust and trash was found behind it. Behind the keyboard a blue open container was found to have paper rolls for the Pyxis and an instruction manual covered in a heavy dust.

The Pyxis was heavily soiled on the outside and noticed to be soiled on the inside. The pharmacists was asked to open the cabinet to view the inside to determine the cleanliness of the cabinet. The pharmacist squatted down and placed both hands on the dirty floor. The pharmacist then stood up and typed on the Pyxis keyboard, opened the cabinet, and pulled out medication bins without washing her hands after touching the soiled and dirty floor.
The Pyxis was heavily soiled on the outside and noticed to be soiled on the inside with dust, hair, and dried spilled substances. Inside the cabinet were clear plastic bins that held patient medications. The bins were soiled with dust and dirt.

H.) Under a cabinet, a large open container of normal saline flushes were found. The flushes were exposed to shipping boxes. The shipping boxes may have been exposed to outside contaminates. The cabinet was heavily soiled with dust, dirt, and hair. The cabinet doors were found heavily soiled with a dried brown dripping substance.

I.) Loose vacutainers were found in a gray plastic pan. The bottom of the pan and vacutainers were soiled with dust, dirt, and hair.

Staff #4 was witness to the findings and confirmed the findings. Staff #4 stated, "I just don't know what to say and shook her head."




B. ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017


Refer to tag A 0748



C. establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms and determine a safe effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.

This deficient practice was determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to tag A 0749


D. ensure the Infection Control (IC) program was functional and incorporated into the hospital wide Quality Assessment Process Improvement (QAPI) program from January 2017 through August 2017.

Refer to tag A 0756

Based on record reviews and interviews, the Governing Body (GB) failed to ensure the facility and medical staff were following the approved Medical Staff bylaws in 9 of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) physician credential files.

Review of the physician credential files revealed the following;

1.) Review of the physician and practitioners credential files revealed 7 ( 23, 24, 29, 30, 27, 26, and 32) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have three (3) peer references.

2.) Review of the physician and practitioners credential files revealed 6 (23, 29, 30, 26, 28, and 32) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have specific delineated privileges.

3.) Review of the physician and practitioners credential files revealed 4 (24, 23, 32, 31, ) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have completed applications for appointment or reappointments.

4.) Review of the physician and practitioners credential files revealed 7 (24, 29, 30, 27, 26, 32, and 31 ) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have an Appointment Letter or a Letter that was completed and dated from the Governing Body.

5.) Review of the physician and practitioners credential files revealed 4 (47-50) out of 4 (47-50) physician did not have a credentialing file for Emergency Services for the South Campus.




Review of the Ad Hoc Governing Board (GB) Minutes dated 8/1/17 revealed the Medical Executive Committee (MEC) had voted on 2017 medical director, advisors, and presented the Medical Staff By-Laws for 2017. The MEC members approved as medical director and advisors did not have complete credential files on hand at the facility. Review of emails sent on 8/2/17 revealed the Governing Board members approved the minutes, bylaws, and MEC members on 8/2/17.

Review of the Medical By-laws "Procedures for Appointment and Reappointment" revealed the following;

page 23 stated, "The names of at least three (3) peer references who have recent personal experience observing and working as a health care professional with the applicant and who can provide adequate information regarding the applicant's current professional competence, character, ability to work with others, health status, and ethics."


5.1 Requirement for Delineated Privileges stated, "Every Practitioner who practices in the Hospital must request and be granted specific delineated Privileges by the Governing Body, and each Practitioner may exercise only those Privileges that have been expressly granted. A current list of Privileges granted will be maintained in each Practitioner's Medical Staff file at all times."


5.1 Application for Privileges stated, "Every Application for Medical Staff appointment and reappointment must contain a written request for the specific Privileges desired by the applicant. The evaluation and granting of such requests as part of the appointment and reappointment process (or during the term of the appointment is a member applies for additional Privileges) shall be based upon that applicants medical education, medical training, experience, ability to perform Privileges requested, current competence, references and other relevant information, including an appraisal by a belonging to the same profession (physician, dentist, or podiatrist) which such Privileges are requested. The applicant shall have the burden of establishing his/her qualifications and competency to perform the Privileges requested. All Practitioner's appointed to Medical Staff shall be granted provisional Privileges for a period of at least one (1) year in the manner prescribed in theses bylaws."


4.3.7 Notification of Final Action stated, "Not later than the twentieth (20th) day after the date on which final action is taken by the Governing Body, the CEO shall give Special Notice of the Governing Body final action to the MEC and the Applicant. If the Governing Body grants the application, the notice shall include the staff category to which the applicant is appointed, a list of Privileges awarded, and any special conditions imposed on the applicant's appointment."


Review of the South Campus records revealed the facility was using the host hospitals Emergency Room (ER) and ER physicians to respond during a code for their facility. The facility had a contract to use the host hospital's physicians but there was no credential files on these physicians.

Interview with staff #1 on 8/25/17 revealed there was no credential files for staff #47-50.

An interview was conducted with staff #8 on 8/22/17 concerning physician credentialing. Staff #8 had agreed to assist the surveyor during the credentialing process. Staff #8 stated that she knew the files were incomplete. Staff #8 stated the files were with an out sourced company but they recently got them back and staff #8 is responsible for the credentialing process. Staff #8 stated that she had some instruction from staff #9 but was unaware that the Medical Staff Bylaws dictated the credentialing process. Staff #8 stated she had never seen them before and did not have a copy. Staff #8 confirmed the above findings.

An interview with staff #1 on 8/22/17 was conducted. Staff #1 reported she was aware the credential files were not complete and stated they have just recently started to look at them. The files were out sourced. Staff #1 was asked to submit the contract from the company. Staff #1 was unable to provide evidence of an out sourced company contract.

An interview with staff #30 (Medical Director) on 8/24/17 revealed staff #30 was not aware his credential file was not up to date nor was he aware other physician credential files were not up to date.

Based on record reviews and interviews, the Governing Body (GB) failed to provide written evidence on the appointment of the present Chief Executive Officer (CEO).

Review of the following Governing Board (GB) meeting minutes,

Governing Board Meeting October 27, 2016
Governing Board Meeting Ad Hoc February 2, 2017
Governing Board Meeting Ad Hoc March 30, 2017
Governing Board Meeting Ad Hoc April 25, 2017
Governing Board Meeting May 2, 2017
Governing Board Meeting Ad Hoc August 1, 2017 revealed the GB minutes had no documentation that Staff #1 (CEO) was appointed as CEO by the GB.

Review of staff #1's employee file revealed staff #1 was hired for the position of Chief Executive Officer (CEO) in February 2017.

An interview with staff #3 on 8/24/17 confirmed that staff #3 is responsible for the GB minutes and the above meeting minutes were all that she had from October 2016 to August 2017.

Based on record reviews and interviews, the Governing Body failed to ensure that a contractor of services (including one for shared services) furnished services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services for patient transfers, lease agreements, and contracted ancillary services in 2 of 2 hospital locations reviewed.

An interview with staff #1 on 8/23/17 revealed Hospital A and B contract with the hospital to service all ancillary services such as laboratory, dietary, radiology, maintenance, linen and laundry, and housekeeping.

Review of the contracted services contract revealed the following:

1.) The facility had a unit inside another hospital (will be referred to as hospital A) deemed the "South Campus." Hospital A had a contract with the facility for Termination Agreement for Ancillary Service Agreement and Patient Transfers dated initially on 4/1/2010. Review of the contract stated, "2. Effective Date. The Ancillary Services Agreement shall terminate as of 11:59 p.m. on November 2, 2014. (the "Effective Date").

An interview with staff #1 on 8/23/17 confirmed the facility did not have an updated contract with Hospital A for Ancillary Services or Patient Transfers.

Review of Hospital A's lease agreement with the facility revealed the agreement was initiated on 3/1/2009. The lease agreement expired on 3/31/17. There was no updated contract at the facility nor was one provided by the corporate office.

An interview with staff #1 on 8/23/17 confirmed the facility did not have an updated lease with Hospital A and confirmed it was expired.


2.) The facility had a unit leased from another hospital (will be referred to as hospital B) deemed as the "North Campus." Hospital B had a transfer policy with the facility dated 5/17/17. The agreement stated, "2.0 Term of Agreement. The agreement shall be for a period of one (1) year and shall be subject to approval by the Texas Department of State Health Services." There was no documentation found that the contract would automatically renew.
An interview with staff #1 on 8/23/17 confirmed the facility did not have an updated transfer contract with Hospital B and confirmed it was expired. No other contract was provided upon request.


3.) Review of the Quality Meeting Minutes for 8/11/17 under "Old Business" stated, "Yearly contract evaluations are due. After a call to Southwest Organ Transplant Alliance it was discovered we do not have a contract under Post Acute." The facility spoke with a represenative at the Transport Alliance on 7/27/17 and stated they would be working on a new agreement.

There was no current contract offered for Organ Procurement as of 8/25/17. Staff #1 confirmed it had expired and there was no viable contract to offer.

Based on record review and interviews, the Governing Body (GB) failed to ensure that the services performed under a contract were provided in a safe and effective manner.

Review of the Governing Bylaws stated, "Section 1. Contract Review and Execution. The Governing Board shall review and make recommendations on any contractual matter referred to it by the Managers regarding the Facility. The Managers shall have final authority with respect to all contracts affecting the Facility."


Review of the contracted services contract revealed the following:

1.) The facility has a unit inside another hospital (will be referred to as hospital A) deemed the "South Campus." Hospital A had a contract with the facility for Termination Agreement for Ancillary Service Agreement and Patient Transfers dated initially on 4/1/2010. Review of the contract stated, "2. Effective Date. The Ancillary Services Agreement shall terminate as of 11:59 p.m. on November 2, 2014. (the "Effective Date").

An interview with staff #1 on 8/23/17 confirmed the facility did not have an updated contract with Hospital A for Ancillary Services or Patient Transfers.

Review of Hospital A's lease agreement with the facility revealed the agreement was initiated on 3/1/2009. The lease agreement expired on 3/31/17. There was no updated contract at the facility nor was one provided by the corporate office.

An interview with staff #1 on 8/23/17 confirmed the facility did not have an updated lease with Hospital A and confirmed it was expired.

The Manager was not aware the contracts had expired. Staff #1 stated that she was responsible to oversee the contracted services to determine if services were being provided in a safe manner.

There was no documentation found in the Quality Assurance Performance Improvement (QAPI) reports to Governing Body for March 2016-July 2017 that addressed contracted services. There was evidence found of Contracted Services discussed in the QAPI meeting notes dated 8/11/17. The report revealed there were no contracts for organ procurement, house keeping or maintenance services.

An interview with staff #3 on 8/23/17 confirmed there had been no QAPI follow up on contracts and contracted services until 8/11/17.

Based on record review and interview, the Governing Body failed to have an updated list of all contracted services.

Review of the Contracted Services list revealed not all services were on the list. There was no contract for the outsource company for physician credentialing.

An interview was conducted with staff #1 on 8/23/17. Staff #1 confirmed there was no contract listed for the out sourced company for physician credentialing.

Based on review and interviews the Governing Body failed to:

A.) ensure the facility had an updated complaint/grievance policy and procedure specific to the facility,

B.) ensure the grievance process was followed through the Governing Body or designated Grievance Committee,

C.) ensure the complaint/grievance are addressed in a timely manner and worked through the Quality Assessment Performance Improvement (QAPI) process,

D.) ensure the staff had training and a clear understanding of a complaint/grievance process.


Review of the policy and procedure "Grievance Resolution Process for Patients" revealed the policy was last revised July 6, 2011. The policy is a corporate policy and not specific for this hospital. Staff #1 stated that the corporate office was in Pennsylvania.

The policy and procedure "Grievance Resolution Process for Patients" stated, "Patients may request of any staff member (either verbally or in writing) that the grievance resolution process be initiated. If the patient is unable to communicate their complaint, a patient liaison will be provided to assist. The staff member receiving the request will immediately notify their supervisor as well as the facility risk manager (or designee) and complete a Critical Incident Report if one has not been initiated."


An interview was conducted with staff #3 and #36 on 8/24/17. Staff #36 stated, she was part of the liaison team and was assigned patient room numbers that she would be responsible for. Staff #36 stated that she and the other managers had assigned room numbers to handle complaints or problems. Staff #36 stated, she goes to her assigned patient rooms daily and checks on the patients. Staff #36 stated, "If there is a complaint I will fill out a form and then I pass the complaints on to whomever the complaint is about. If it's a nursing issue, I go to the charge nurse, if it's a house cleaning issue then I go to housekeeping." Staff #36 confirmed that once she has handed the complaint off, she is done with the issue unless people just keep complaining about it. Staff #36 stated, they have meetings in the mornings and talk about patient issues. Staff #36 confirmed that she has not taken the complaints to the risk manager who was responsible for complaints and grievances. Staff #36 stated she has had no formal training on complaints and grievances. Staff #36 stated the definition of a grievance was a complaint that just keeps going on. "It just depends on if the complaint is continuous."

Staff #3 agreed that this is probably why she had only 6 complaints on her list for the last 8 months. Staff #3 was not aware of when a complaint became a grievance without the patient requesting it.


The policy and procedure "Grievance Resolution Process for Patients" stated, the risk manager refers the grievance to the Grievance Committee which will meet and provide written documentation to the patient within five business days from the date the grievance request was received."


Interview with staff #3 on 8/24/17 revealed there were no meeting minutes or proof there was an organized Grievance Committee. Staff #3 stated that the grievances have not been followed in the QAPI process.


Review of the Complaint and Grievance log revealed only 5 complaints. The top of the log stated, "North and South 2017." The complaints were as follows:


1.) The first complaint, patient #14, was taken on 1/8/17. The complaint stated, "c/o skin tear to hand after transfer for procedure." The complaint was not charted as resolved on the list until 1/31/17. There was no further information on the incident or any details of the complaint or resolution.

2.) The second complaint, patient #15, was taken on 3/10/17 concerning a nurse being unprofessional and was resolved on 3/10/17.

3.) The third complaint, patient #29, was taken on 3/6/17 concerning nurse not being helpful or caring and was not resolved until 3/10/17. There was no further information on the investigation.

4.) The fourth complaint, patient #27, was taken on 3/6/17 the patient complained of "not enough therapy, nursing not helpful and nursing not helping with food tray." There was no details of an investigation and the complaint was not marked as resolved. In the resolution box it stated, "met with sister several times." No further information.

5.) The fifth complaint, patient #28, was taken on 5/1/17. Patient complained of "room being dirty, not enough therapy, uncaring nursing staff." Under resolution section of the log stated, "still working with family PT resolved." There was no details on the complaint.

There was no evidence provided or found that the last two complaints were ever resolved or documented that it was in a grievance investigation.

Based on record review and interview, the Governing body failed to ensure the hospital had trained staff to assist with the grievance process and followed the set time frames to resolve the patient issues.

Review of the policy and procedure "Grievance Resolution Process for Patients" revealed the policy was last revised July 6, 2011. The policy is a corporate policy and not specific for this hospital. Staff #1 stated that the corporate office was in Pennsylvania.

The policy and procedure "Grievance Resolution Process for Patients" stated, "Patients may request of any staff member (either verbally or in writing) that the grievance resolution process be initiated. If the patient is unable to communicate their complaint, a patient liaison will be provided to assist. The staff member receiving the request will immediately notify their supervisor as well as the facility risk manager (or designee) and complete a Critical Incident Report if one has not been initiated. The risk manager refers the grievance to the Grievance Review Committee which will meet and provide written documentation to the patient within five business days from the date the grievance request was received."

An interview with staff #3 and #36 on 8/24/17. Staff #36 stated, she was part of the liaison team and was assigned patient room numbers that she would be responsible for. Staff #36 stated that she and the other managers had assigned room numbers to handle complaints or problems. Staff #36 stated, she goes to her assigned patient rooms daily and checks on the patients. Staff #36 stated, "If there is a complaint I will fill out a form and then I pass the complaints on to whomever the complaint is about. If it's a nursing issue, I go to the charge nurse, if it's a house cleaning issue than I go to housekeeping." Staff #36 confirmed once she has handed the complaint off she is done with the issue unless people just keep complaining about it. Staff #36 stated, they have meetings in the mornings and talk about patient issues. Staff #36 confirmed that she has not taken the complaints to the risk manager who was responsible for complaints and grievances. Staff #36 stated, she has had no formal training on complaints and grievances. Staff #36 stated the definition of a grievance was a complaint that just keeps going on. "It just depends on if the complaint is continuous."

Staff #3 agreed that this is probably why she had only 5 complaints on her list for the last 8 months. Staff #3 was not aware of when a complaint became a grievance without the patient requesting it.


Review of the Complaint and Grievance log revealed only 5 complaints. The top of the log stated, "North and South 2017." The complaints were as follows;

1.) The first complaint was taken on 1/8/17. The complaint stated, "c/o skin tear to hand after transfer for procedure." The complaint was not charted as resolved on the list until 1/31/17. There was no further information on the incident or any details of the complaint or resolution.

2.) The second complaint was taken on 3/10/17 concerning a nurse being unprofessional and was resolved on 3/10/17.

3.) The third complaint was taken on 3/6/17 concerning nurse not being helpful or caring and was not resolved until 3/10/17. There was no further information on the investigation.

4.) The fourth complaint was taken on 3/6/17 the patient complained of "not enough therapy, nursing not helpful and nursing not helping with food tray." There is no details of an investigation and the complaint is not marked as resolved. In the resolution box it stated, "met with sister several times." No further information.

5.) The fifth complaint was taken on 5/1/17. Patient complained of "room being dirty, not enough therapy, uncaring nursing staff." Under resolution section of the log stated, "still working with family PT resolved." There was no details on the complaint.

There was no evidence provided or found that the last two complaints were ever resolved. An unresolved complaint would be processed as a grievance. There was no documentation that it was in a grievance investigation nor within the 5 day timeline.

Interview with staff #3 on 8/24/17 revealed there were no meeting minutes or proof there was an organized Grievance Committee.

Based on review of records, the facility failed to ensure patients received appropriately executed informed consents and/or release forms in 7 (Patient #'s 1, 2, 4, 5, 12, 14, and 16) out of 7 patients.

Findings included:

A review of Patient #1's chart revealed a form titled, "Disclosure and Consent Medical and Surgical Procedures". The condition listed was, "Need to drain fluid from around lungs with needle/aspiration of fluid from right side." The procedure listed was, "Right Thoracentesis." The risks listed were, "bleeding, infection, collapsed lung, and as explained by physician". The form was signed on 8-14-2017 at 1:05 pm by the patient's representative. There was a "Witness Signature" that had been signed but was not readable. There was no signature on the form for a separate physician signature.


A review of Patient #2's chart revealed a form titled, "Disclosure and Consent Medical and Surgical Procedures." The form was signed on 7-20-2017 at 1:30 pm by two staff who received telephone consent from the patient's representative. The condition was listed as, "peripheral inserted central catheter". The procedure listed was, "peripheral inserted central catheter." The risks listed were, "infection, bleeding, DVT" (deep vein thrombosis which is a blood clot). There was a "Witness Signature" line that had been signed but was not readable. There was no signature line on the form for a separate physician signature.


A review of Patient #4's chart was made as follows:

Advanced Directive and Patient Self-Determination form was found. The form was dated 5/3/17 at 5:50 pm, the approximate time of admission. The entire form was left blank except the signature of the patient's representative and a witness signature. The witness signature is unreadable. The line for the printed name of the witness was also blank.

Acknowledgment of Receipt of Health Care Information form was found. The form was dated 5/3/17 at 5:50 pm, the approximate time of admission. The entire form was left blank except the signature of the patient's representative and a witness signature. The witness signature was unreadable. The line for the printed name of the witness was also blank.

Informed Consent for Blood Component Transfusion form was found. The form was dated 5/3/17 at 5:50 pm, the approximate time of admission. The entire form was left blank except the signature of the patient's representative and a witness signature. The witness signature was unreadable. There was no line for a printed name of witness. Blood was not ordered until 5/5/2017 and transfused on 5/6/2017, using an incomplete consent that was signed on admission prior to any need for blood product.

Authorization for Release of Information form was found. The form was dated 5/4/17 at 1:00 in the morning. The entire form was left blank except the Patient #4's signature and a witness signature. The witness signature was unreadable. There was no line for a printed name of witness.


Patient #5's chart was reviewed. Informed Consent for Blood Component Transfusion form was found. The form was dated 2/9/17 at 4:00 pm, the approximate time of admission. The entire form was left blank except the signature of the patient's representative and a witness signature. The witness signature was unreadable. There was no line for a printed name of witness.


Patient #12's chart was reviewed. Informed Consent for Blood Component Transfusion form was found. The form was dated 7/1/2017 at 4:45 and was signed by the patient's daughter. The physician's signature line was left blank. Blood was transfused on 7/1/2017 and again on 7/17/2017.


Patient #14's chart was reviewed.

Informed Consent for Blood Component Transfusion form was found. The form was dated 12/29/17 at 3:00 pm, the approximate time of admission. The entire form was left blank except the signature of the patient's representative and a witness signature. The witness signature was unreadable. There was no line for a printed name of witness.

Authorization for Release of Information form was found. The form was not dated or timed. The entire form was left blank except the signature of the patient's power of attorney. That was the only signature on the form.


Patient #16's chart was reviewed.

Patient #16 was admitted to the facility on 3/22/17. The prescreening revealed, "Patient lived w/family-Does not speak English-Speaks Cantonese." Review of the admission consents were signed by the patient but was offered in English. There was no written evidence that anyone was with the patient to interpret the consents or a phone interpreter service was used. The following consents were signed by the patient in English with no patient representative documented;

The Advanced Directive was blank with no signature.
The patient signed a blank blood consent.
Consent to Treat
Acknowledgment of receipt of health care information.
Important Message from Medicare.
Authorization for release of information.

Influenza Vaccine Order Form was signed by the patient and nurse but was blank. The nurse wrote on the form, "Unable to Understand."


Review of Medical Staff Rules and Regulations was reviewed with regard to medical and surgical consents. Medical Staff Rules and Regulations stated the following:

"B. Medical Records (MB 6.6.5, MB 13.6)

1. The responsible practitioner shall be responsible for the preparation of a complete medical record for each patient.
...
b. The medical record must also contain properly completed patient informed consents for test/treatments/surgery/blood transfusions, bedside procedures, and in those instances in which consent could not be obtained, the attending must document the reason(s). It is the physician's responsibility to obtain informed consent."

Based on review and interviews the facility failed to:

A.) keep the patient safe from serious change in conditions and harmful injuries. The facility failed to ensure the patients were safe by reporting, monitoring, assessing, and documenting patient care in 4 of 4 (13, 14, 16 and 21) patient charts reviewed. The facility failed to report a fall that resulted in a patient death within 6.5 hours of the fall. There was no follow up in the Quality Assurance Performance Improvement (QAPI) on the patient incidents or any staff education to prevent the occurrence of incidents or death.

These actions place all patients in potential immediate jeopardy for the likelihood of harm, serious injury, and possibly subsequent death.


B.) ensure the nursing staff had specific technical knowledge and task skills when performing the removal of peripherally inserted central catheter (PICC) lines. This placed all patients who had PICC lines removed at risk of harm or death.



A.) Findings included:

1.) Review of patient #13's chart revealed that he was admitted to the facility on 8/4/2017 with a diagnosis of septic left knee and a secondary diagnosis of epilepsy.

Review of patient #13's history and physical dated 8/5/17 stated, "This is a very pleasant unfortunate 40-year-old gentleman with a history of chronic back pain, chronic pain syndrome, ADHD, seizure disorder who was in a MVA about 4 weeks ago. He was found to have a torn meniscus and a meniscectomy by______ (MD Name). He subsequently developed an infection and fever and was found to have an infected knee. He came back to ______hospital ER. He had his knee aspirated and it contained 13,000 white blood cells." The patient was placed on Oxacillin (antibiotic) IV for the next four weeks.


Review of the incident log revealed patient #13 had an incident date of 8/9/2017. Under the title "Person Affected" patient #13 was listed and his date a birth. Under additional information "Non-Compliant. History of drug abuse." Under General Incident Information it asked if an injury occurred and the answer was "unknown." The form also said the patient "left without being seen." The incident report was reported by staff #34 RN. "Brief Factual Description;
Patient was seen in the parking lot upon my arrival. He was in wheelchair with his IV pole beside him. About 20 minutes later; a lifenet employee brought to the floor a wheel chair and the patients IV pole with the patient nowhere to be found on the premises. Security, MD, and administration was notified. About 5 minutes later, the patient's wife came to the nurse's desk asking where her husband was. After searching the parking lot again ;____( patient #13) was found lying in the bushes on the premises with a scratch on his ear and his picc line still intact. _____ (patient #13) was having scattered thoughts and acting bazar.(SIC) He said he didn't want to be here anymore, then started laughing and stated, "I saw you guys looking for me." I handed him the AMA papers to sign and he signed someone else's name to the papers. This was witnessed by ____ (staff #35 LVN), Security, and myself. I removed the patient's picc line and applied a pressure dressing while his wife collected his belongings. The patient and his wife left via their private auto." Staff #1 and #3 confirmed the incident forms were not part of the patients chart.

Review of the incident "follow up" was performed by staff #3 on 8/10/17. Staff #3 documented, "Patients are not to be allowed outside without assistance from a hospital employee. Employees are to keep a close eye on the patients who are ambulatory or able to wheel themselves with little assistance while in the hallway." There was no documentation of employee education of this matter.

Review of the physician discharge note dictated on 8/10/17 stated, "The patient left AMA (Against Medical Advice).

Admitting Diagnosis:

1.) Left septic knee joint.
2.) Chronic pain syndrome.
3.) Attention deficit hyperactivity disorder.
4.) Severe malnutrition.
5.) Apparent seizure disorder.
6.) Benign prostatic hypertrophy.

Hospital course: The patient was getting oxacillin 10mg every 4 hours IV for his septic knee joint. He was needing about 4 weeks of this per _____ MD from his hospitalization at _____ (previous hospital stay.) The patient did have some daily erratic behavior. He was hiding psychiatric pills from the nurses. He was leaving the grounds and was often found disconnecting his IV line. There was concern about him using his PICC line to put IV drugs in when he would disappear. The patient eventually signed out against medical advice. We did our best to address the erratic behavior, and had multiple conversations with him, and tried to restrict him from leaving the premises. The patient was extremely non complaint."

There was no documentation in the physician progress notes or nursing notes that there was a concern of the "patient putting IV drugs in his IV line when he disappeared." The only documentation found on the physician progress notes of behavior issues was on 8/8/17, "Pt doing well no complaints. He has been acting odd, most likely d/t med self-medication." There was no further comment of what medications or how it was addressed with the patient.

Review of patient #13's nurses notes revealed the following;

8/4/17 patient #13 was documented as oriented, calm and cooperative. No documentation of non-compliance.

8/5/17 patient #13 was documented as oriented, calm and cooperative. No documentation of non-compliance.

8/6/17 patient #13 was documented as oriented, calm and cooperative. No documentation of non-compliance.

8/7/17 patient #13 was documented as oriented, calm and cooperative. There was one documented "Uncooperative" checked on the 7:00PM-7:00AM shift. The nurse documented, "0055 IV tubing changed d/t pt snapping it in two, but unaware how it happened. IVF (Intravenous fluids) running on floor RN notified. 0455 PRN med c/o pain given as requested, IV abx increased, pt noted rolling pill in hand that was unfamiliar to anything I had given him. RN notified incident placed in RMPRO (computer program for incident reports). 0530 Pt up taking wash out of sink, states he had an incont. Bladder episode IV Abx noted off, but remains connected to pt picc states he just unplugged the machine, did not turn it off."(SIC) There was no RN documentation for this shift.

8/8/17 patient #13 was documented as oriented, calm and cooperative. Uncooperative was marked on the 7:00PM note with "at times" documented. The patient was documented as smoking on the outside balcony and needed to be reminded that the facility was smoke free. There was no documentation that the patient was offered alternatives to cigarettes or smoking cessation. "0015 pt outside on balcony with spouse prn pain med given, iv tubing changed again due to pt breaking line again. States he is unaware of how it happened. IVF running onto floor and shirt RN notified."

8/9/17 patient #13 was documented as oriented, calm and cooperative. Nurse documents in nursing notes at 11:00AM pt in gym with OT/PT. Pt room cleaned while pt in PT/OT. Aid found a pill under pt. pillow at this time pill placed in cup and charge nurse notified. Pt had been spoken to Dr. last night about the need to NOT self-medicate. Patient continues to be noncompliant. 1500 pt medication that was found in room wasted in CACTUS." (SIC) There was no documentation if the pill was identified, if the pharmacist was alerted to identify the medication, or that the physician was notified. There was no documentation of a patient response.

On 8/9/17 at 1950 staff #35 LVN documented, "pt not in facility ___ (illegible word) found outside as reported. Left AMA, see RMPRO.

An "Against Medical Advice" paper was found in the patients chart. The patient name signed to the form was not the patient's name. The nurse wrote above, "signed by ____ (patient #13)" The RN staff #34 and LVN staff #35 both signed the form. Under the signatures the form stated, "Please indicate that the following has occurred and documented in medical record prior to patient or authorized person signing the AMA form:

Assessment of patient's mental status
Explanation of risks of refusing treatment
Acknowledgement risks/consequences of leaving AMA
Routine discharge planning process complete
Follow up care provided."

There was no documentation that the nurse followed the above requirements. There was no documentation found in the chart of the patient incident. There was no RN or MD documentation in the chart of patient assessment after the incident on 8/9/2017. There was no physician orders to remove the PICC line. There was no documentation from the RN that a conversation was had with the physician to remove the patients PICC line or that he was leaving the facility AMA. There was no documentation from the RN that the physician was aware the patient had a change in condition and was leaving the facility in a confused state and change of condition.

An interview was conducted with staff #1, #2, and #3 concerning the incident of patient #13 on 8/24/17. Staff #2 confirmed the findings and stated that he was not sure why the RN did not document in the chart." Staff #3 was also the Risk Manager and was aware of the incident with patient #13. Staff #3 stated that the patient left AMA and there was no cause for a root cause analysis on this patient case. Staff #3 confirmed there was no patient safety program in place to follow up on patient safety issues on behaviors or AMA's. Staff #3 confirmed there was safety issue tracking in Quality except for restraint use. Staff #3 stated they talk about events that happen with the patients daily in "FLASH" meetings but there was no written evidence provided, of actions taken by the facility, to prevent patient harm.


2.) Review of patient #16's chart revealed he was admitted to the facility on 3/22/17. The prescreening revealed, "Patient lived w/family-Does not speak English-Speaks Cantonese." Review of the admission consents were signed by the patient but was offered in English. There was no written evidence that anyone was with the patient to interpret the consents or a phone interpreter service was used. The following consents were signed by the patient in English with no patient representative documented;

The Advanced Directive was blank with no signature.
The patient signed a blank blood consent.
Consent to Treat
Acknowledgment of receipt of health care information.
Important Message from Medicare.
Authorization for release of information.

Influenza Vaccine Order Form was signed by the patient and nurse but was blank. The nurse wrote on the form, "Unable to Understand."

Review of the Initial Nursing Assessment dated 3/22/17 at 12:10PM revealed the assessment was incomplete. The medication section asked if the Medication Reconciliation was completed and reviewed medication profile with patient and or family was blank. The dietary screen, psychosocial, medical/surgical history, TB screening, affect, chest pain, bowel patterns, communication/cognitive function, texture of skin, wound description, and appetite was blank. The nurse documented the patient was a diabetic but did not fill out the patients medication and what type of diabetes the patient has. The patient was also a renal patient and received dialysis. There was no documentation on what type of vascular access was used. There was no further nursing documentation for patient #16 on the 7:00AM-7:00PM shift.

On 3/22/17 at 1905 the nurse documented, "Assessment per flow sheet,-in bed watching tv.- bed in low position SR up x2 call bell in reach. No c/o voiced no s/sx pain/distress resp even/unlabored VSS- pt only speaks a couple of English words-hard for pt and staff to understand each other will continue to monitor"(SIC).There was no documentation for this shift that the nurse called for an interpreter or used the phone interpreter system to properly assess this patient.

Review of the nursing notes on 3/26/17 at 7:45AM revealed the patient was up in the hallway ambulating at shift change and fell with no injuries noted. "Educated pt on calling for assistance and not getting up without assistance. Needs to be reinforced notified family of fall. 0900 brother here to see pt. brought breakfast for him and cut his hair. Translated to patient on calling for assistance and not to get out of bed without assistance. 1200 pt got out of bed and found in floor. Assisted back to bed no injuries noted. Bed alarm placed on bed. 1445 bed alarm going off went in room to check on pt. found pts O2 tubing tied to side rail and wrapped multiple times around his neck pt's face was purple. He did open his eyes in response to me questioning why he did that. He would not answer. O2 applied, vss O2 sat 91%. Staff #61(MD) notified with new orders noted. Pts family notified, his brother came up. DON notified of situation family member or sitter to stay with pt."

Review of the physician progress report dated 3/26/17 stated, "Pt tried to hang himself with O2 tubing nursing staff caught him. Family at bedside. As before pt despondent. Reports he's going to die regardless per nursing staff. He has multiple non-curable health issues. Spoke with family members. Family to address d/c HD and Hospice."

A physician's telephone order dated 3/26/17 at 1450 stated, "psych consult. Make patient a 1:1/ sitter or family at bedside at all times."

Review of the chart revealed there was no psychiatric consult found. There was nothing found in the care plan concerning the suicide attempt or that the family or patient ever participated in the care planning process. There was no documentation found on assessing the patient's depression or will to die. There was no documentation found on patient safety, education to the sitters, or family to provide patient safety from another suicide attempt. Staff #2 and #3 confirmed there was no policy to address psychiatric patients or suicidal patients. There was no found documentation on who was sitting with the patient or when the sitter took breaks.

An interview with staff #1, 2, and 3 concerning patient #16 on 8/24/2017. Staff #1 stated that she was aware of the incident with patient #16 and he did try to hang himself with tubing. Staff #1 stated, "We put a sitter in his room to watch him. He told his family he wanted to die but they are Asian and in that culture they were just not ready to let him do that. He has family that are physicians. He just didn't want to live so we transferred him to hospice." Staff #1 reported the patient would call his family to let the staff know if he needed a pain medication or had any issues. Staff #1 stated they have a language line they can call. "We usually let their families interpret if they are available." Staff #1,2, or 3 were not aware if the language line was ever used for the patient needs.

Staff #3 stated that a root cause analysis was not done on this incident. Staff #3 stated the facility has not done a root cause analysis (RCA) for over a year. Staff #3 stated there was no written documentation of staff education concerning this event or prevention in the future.


3.) Review of patient #14's chart revealed the patient was admitted to the facility on 12/29/16. Patient #14 was admitted for left lower lobe pneumonia and a pneumothorax. Review of the chart revealed the patient had a physician order dated 1/7/17 that read, "MRI of the brain without contrast." The patient was documented as "aphasic" (unable to speak) in the nurses notes on 1/7/17.

Review of the Nursing notes on 1/8/17 at 8:34AM stated, "Patient leaving facility on stretcher via _____ (EMS) headed to _____ (hospital) for MRI of the brain. 11:02AM Patient arrived back to the facility on stretcher via____ (EMS), pt had large skin tear to right arm with blood and complained of pain in right shoulder and arm. Paramedic states MRI at ____ (hospital) said patient arrived to the facility in that condition. Nurse asked did injury occur on ambulance in transport, paramedic states he did not know b/c another medical transported pt to hospital. Skin tear was cleansed with normal saline, 4x4 kerlix was applied and ____ (MD) was notified. Orders received to obtain x-ray of patient's right arm and shoulder and administer a prn tramadol. Wife informed and will continue to follow up.

Review of patient #14's chart revealed the patient had a fracture of the right humeral head. Review of the incident report summary dated 1/18/17 stated, "Rec'd pt from ____ (local hospital) after attempted MRI. MRI had called and stated they were unable to obtain MRI as pt. would not cooperate with MRI. They stated he was flailing in machine and tossing around, after receiving pt. From hosp it was noted an abrasion on his rt. lower arm in a sling tonight and call office for apt.1/9/17. Sling was placed on r arm as ordered 1/8/17. Abrasion to r lower arm photographed and wet to dry normal saline dressing applied."(SIC) Review of the follow up on the incident report staff #3 documented "no follow-up."

An interview with staff #3 on 3/24/17 stated patient #14's incident was reported to the Corporate Risk Manager. Staff #3 stated the Corporate Risk Manager told her that since it must have happened at the transferred hospital, a RCA was not needed. Staff #3 stated the CNO (that is no longer employed at the facility) called the wife and she was fine with it. Staff #3 confirmed a RCA was not done on this case. There was no evidence found that this incident was followed through the Quality Assurance Performance Improvement process.


4.) Policy and procedure, "Restraints" revealed the policy last revised date was 2015. Review of the policy revealed, "Restraints are to be limited to situations in which an unsafe condition exists and alternative measures have been unsuccessful. The least restrictive type of restraint is to be utilized. A patient physical and situational assessment is required before applying and restraint in an effort to determine the etiology of the behaviors unless in an emergency. Seclusion, 4-point restraints, and vest restraints are not utilized at this facility."

Review of patient #21's chart revealed he was admitted to the facility with Sepsis, Acute Renal Failure, and Hypotension. Review of the nursing notes dated 7/19/17 at 9:00PM, "Pt received in room. 62y/o male admitted to____ (MD). Admitting Dx Sepsis/ARF/Hypotension. Placed on telemetry per orders. Removed old ileostomy bag cleansed and applied new ileostomy bag. V/s stable and wnl. Placed on 3L O2 per NC. Pt is placed in restraints (wrist) per orders. Pt expresses no concerns or needs at this time. CL in reach, BRx2 Bed lowered to floor. 9:30PM ____ (MD) called to notify pt was here at facility ordered medications and all new orders".

Review of the initial physician orders revealed the order was a telephone order written by the nurse at 9:30PM on 7/19/17. There was an order found for the wrist restraint on 7/19/17 by the RN and was signed and dated by the physician at 10:00PM.

Review of patient #21's nurse's notes revealed the Licensed Vocational Nurse (LVN) documented at 10:00PM, "Pt soft wrist restraints placed back on pt, Pt removing devices and getting out of bed. Will continue to monitor c/l at reach."

Review of patient #21's nurse's notes revealed the Licensed Vocational Nurse (LVN) documented at 3:00AM Pt asleep at this time no meds noted c/l in reach. 6:00AM lab attempted x 3 sticks unsuccessful repositioned pt with restraints no other needs c/l at reach(SIC)" There was no documentation on why the patient continued in restraints when he was sleeping and having no issues with pulling at lines or attempting to get out of bed.

A restraint order was found for patient #21 dated 7/20/17. The RN filled out the restraint order dated and timed at 7/20/17 at 6:00AM. The order states the nurse may only obtain a telephone order for initial restraint order only. The physician did not sign the restraint order till 7/20/17 at 10:00PM; 16 hours later. The physician had signed the order within 24 hours but the nurse wrote another telephone order for the restraint 16 hours prior.

Review of patient #21's chart on 7/21/17 revealed the nurse dated and timed the restraint order on 7/21 /17 at 6:00AM. The physician did not sign and date the order until 7/21/17 at 6:00PM; a 12 hour difference. Orders for the wrist restraints were signed and dated by the physician on 7/22/17 at 6:00AM and 7/23/17 at 6:00AM.

Review of patient #21's chart revealed a "Restraint Management Flowsheet" The flowsheet is filled out by the RN to reveal the Type of restraint used, and the following assessments performed every 2 hours;

"Patient and family education (as needed)
Restraint device on
Restraint release and reposition
Mental status
Behavior exhibited
Offer fluids /Nutrition
Offer toileting
Skin/Circulation check
Turn/Position change
Personal hygiene."

Review of patient #21's Restraint Management Flowsheets revealed the following;
7/20/17 from 1900-0600 there was no documentation of the type of restraint utilized. The LVN documented the patient care plan and family/pt education was performed every two hours but there was no mention in the patients care plan of restraints.

On 7/23/17 patient #21 was transferred to another hospital for a higher level of care. The patient was not discharged from the facility and was brought back to the facility on 7/28/17.
Review of patient #21's chart revealed he had restraint orders daily from 7/28/17- 7/31/17. Review of the record revealed the patient restraints were discontinued on 8/1/17 at 10:00PM. Nurse documented, "patient's behavior has been normal."

Review of patient #21's chart revealed on 8/3/17 11:10AM, " Pt found lying in floor beside bed lying on back wound vac intact. Colostomy intact. Pt pale white and aginal (sic) breathing. Pt assisted back to bed x3. RT ____ called to room. O2 sat 76% HR 127. Dr. ____ staff #31 notified blood gases drawn. 2 amps bicarb given. Pt placed on Bipap. At bedside continue to monitor. 1200 pt placed back in bil soft wrist restraints due to pulling at medical lines. Resp even/unlabored. No stress noted at this time."


Review of patient #21's chart on 8/3/17 revealed Staff #30MD arrived at the patient bedside at 1630. The nurse's note stated, "Dr. ____ staff #30 in at bedside to put in CVL. Family outside of pt. room aware and informed of pt condition. RT____ in at bedside. Continue to monitor. 1728 Crash cart pads attached to the pt. pt aginal(sic) breathing Dr. ___staff #30 at bedside. Determined to intubate pt ET tube 21cm lip 7.5 tube placed. Pt bagged at bedside. 1730 1 mg epi given 1732 shock performed per pt in v-fib. 1733 CPR started per _____RN alternating every 2 minutes with ____RN. CPR performed until 1741 when family asked to stop CPR and lifesaving methods. 1742 Code called per Dr.____ staff #30. 1930 Funeral home picked up body.

Patient #21's restraint flow sheet revealed the patient was still in restraints during code and at death. Review of the chart revealed there was no code sheet nor documentation of rapid response. There was no incident report concerning the patient's fall and subsequent death only 6.5 hours later. There was no RCA performed for this sentinel event.

Staff #30 was performing a bedside invasive procedure on patient #21 and staff #30 did not have a completed credential chart and his appointment had expired. An interview with staff #30 (Medical Director) on 8/24/17 revealed staff #30 was not aware his credential file was not up to date nor was he aware other physician credential files were not up to date.

Interview with staff #3 on 8/23/17 revealed there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey. Review of the list revealed patient #21 was on the list dated 7/28/17 for an order check. No other information found.

Review of the facility's policy and procedure Sentinel Event and Root Cause Analysis (RCA) stated, "Definitions
17.3.1 Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury. Serious injury specifically includes loss of limb or function.

17.3.2 Root Cause Analysis: A process for identifying the casual factors underlying variation in performance, including the occurrence, or possible occurrence, of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individuals or individual performance.

17.4.2 The corporate Risk Manager will be notified of potential sentinel events. The corporate office, in conjunction with legal counsel, will make a determination as to whether or not the event will be classed as a sentinel event and require a root cause analysis, as defined by JC standards. The corporate office will notify the facility whether or not a sentinel event will be reported to JC."



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B.) Findings included:

Patient #2's chart was reviewed. On 8-4-2017 at 1:30 pm the nurse documented, "PICC line D/Cd. Reoriented to written plan. Awaiting Lifenet to arrive for pt discharge." The nurse did not document an assessment of the site and dressing used, a pain assessment, or assessment of patient tolerance to the procedure.

Patient #13 review of nursing notes showed that patient discharged from the facility against medical advice. No documentation of patient assessment prior to discharge or removal of PICC Line was found in the nursing documentation. Nursing notes on 8-9-17 were reviewed as follows:

"1900 Report given to oncoming shift"
"1950 Pt not in facility or found outside as reported. Left AMA, see RMPro."

RMPro was a Risk Management program for documentation of Risk Management events. It was not a part of the patient's medical record.

Review of the incident report for the patient leaving AMA contained a statement that the PICC line had been removed prior to patient leaving. Review of the incident report, which was not a part of the patient's medical record, contained the following statement:

"I handed him the AMA papers to sign and he signed someone else's name to the papers. This was witnessed by ____ (staff #35LVN), Security, and myself. I removed the patient's picc line and applied a pressure dressing while his wife collected his belongings. The patient and his wife left via their private auto."

Staff #1 and #3 confirmed the incident forms were not part of the patient's medical record.

Staff #17, #37, #58, #59 and #60 were all asked to locate the policy and procedure for removing a PICC (peripherally inserted central catheter). None were able to locate the policy and procedure.

Staff #37 and #59 were able to locate American Association of Critical-Care Nurses (AACN) Procedure Manual for Critical Care. This manual had a procedure for Central Venous Catheter Removal (PICC lines are a type of Central Venous Catheters).

Staff #17 was unable to locate a policy or procedure manual. Staff #17 stated the procedure could be looked up on the internet as long as it was a reputable web site.

Staff #60 stated he thought the policy and procedure could be looked up on the hospital policy site, but he didn't look things up because he was "not good with computers". He stated he had been a nurse for over 20 years and knew how to remove PICC lines. In his description of removing a PICC line, he stated he would have the patient lay flat for "about 15 minutes or so".

Staff #59 stated he thought he had been checked off on how to remove PICC lines in his nursing competencies, but did not know where to find the policy and procedure. He stated if he had questions, he would ask a co-worker.

Review of annual nursing competencies showed that removal of PICC line was not a competency that was assessed. This was confirmed by Staff #2 and Staff #3.

Review of Policy Subject: Clinical Procedures References; Publications: NRSG 04; Reviewed/Revised Date: August 6, 2013; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE) was made as follows:

"4.1 Purpose and Scope

Post Acute Medical, LLC. (PAM) supports the use of research-based clinical procedures to provide the most effective patient care. In order to assure that clinical procedures are up-to-date and reflect best practice, all nursing procedure guidelines will be taken from current nursing resources.


4.2 Policy

Clinical procedure references will be made available on all nursing units within the system. The accepted reference manuals will be as follows:

1. Lippincott Manual of Nursing Practice, Current Edition. Published by Wolters Kluwer, Lippincott Williams & Wilkins.

2. Lippincott's Nursing Procedures, Current Edition. Published by Wolters Kluwer, Lippincott Williams & Wilkins.

3. Rehabilitation Nursing Procedures, Current Edition. Published by the Rehabilitation Institute of Chicago.

These resources will be updated when new editions of texts are published. The procedural guidelines contained in these references will serve as the standard of care for clinical procedures in PAM facilities.


4.3 Procedure

Directors of Nursing are responsible for ensuring that copies of these references are obtained for each nursing unit within their facility, and for ensuring replacement of the references when new editions are published. Nurses will refer to the publications for guidance in performing clinical procedures. Select procedures will be reviewed annually to assess clinical competence."


Interview was conducted with Staff #2. Staff #2 stated the nursing staff did not have a copy of the required reference manual for procedures. Staff #2 stated nursing staff had been using American Association of Critical-Care Nurses (AACN) Procedure Manual for Critical Care and provided a copy of the process nursing staff had been following. The procedure was for the Central Venous Catheter (CVC) Removal (PICC lines are a type of CVC). Staff #2 stated this was the only reference nursing staff had available at the nursing stations that addressed PICC line removal.

Review of the process was made. Along with specific steps for removal of the CVC, the following information was contained:


Step #18 "Maintain bed rest for at least 30 minutes after catheter removal. May decrease the risk of post procedure venous air embolus."

"Prerequisite Nursing Knowledge

Knowledge of the normal anatomy and physiology of the vasculature and cardiovascular system is necessary.
Knowledge of normal coagulation values is necessary.
Principles of aseptic technique should be known.
Advanced cardiac life support knowledge and skill are necessary.
Clinical and technical competence in central venous catheter (CVC) removal is necessary.
Knowledge of potential complications associated with the removal of the CVC is needed.
An air embolism can occur during or after the removal of the catheter as a result of air drawn in along the subcutaneous tract and into the vein. During inspiration, negative intrathoracic pressure is transmitted to the central veins. Any opening external to the body to one of these veins may result in aspiration of air into the central venous system. The pathological effects depend on the volume and rate of air aspirated. Signs and symptoms include: respiratory distress, agitation, cyanosis, gasp reflex, sucking sound, hypotension, petechiae, cardiac dysrhythmias, and altered mental status.


Patient Assessment

Assess vital signs and the neurovascular status of the extremity distal to the catheter insertion site. Rationale: This assessment provides a baseline data.
Assess the patient's current coagulation values. Rationale: If the patient has abnormal coagulation study results, hemostasis may be difficult to obtain.
Assess the catheter site for redness, warmth, tenderness, or presence of drainage. Rationale: Determines if signs or symptoms of infection are present.


Documentation

Documentation should include the following:
Patient and family education
Date and time of catheter removal
Site assessment
Pain assessment, interventions, and effectiveness
Application of air occlusive dressing
Patient tolerance of the procedure
Unexpected outcomes and interventions"

Review of the above process identified that patients could suffer serious harm if nursing staff do not possess specific technical knowledge and task skill when performing the removal of a PICC line.

Based on record reviews and interviews the facility failed to:

A.) monitor the appropriate use, administration, and documentation of restraints. Quality Assessment Performance Improvement (QAPI) failed to properly log, track, analyze, and implement a productive plan to ensure the patients were safe in restraints. The facility also failed to ensure the physician was assessing the patient with in the 24 hour time frames and writing the orders for restraints beyond the initial order in 2 of 2(#6 and #21) charts reviewed.

B.) discontinue the restraint when the patient was sleeping with no behavioral issues documented nor documented the decision to continue in restraints due to ongoing behavioral or cognitive issues in 2 of 2(#6 and #21) patient charts reviewed.


Policy and procedure, "Restraints" revealed the policy last revised date was 2015. Review of the policy revealed, "Restraints are to be limited to situations in which an unsafe condition exists and alternative measures have been unsuccessful. The least restrictive type of restraint is to be utilized. A patient physical and situational assessment is required before applying and restraint in an effort to determine the etiology of the behaviors unless in an emergency. Seclusion, 4-point restraints, and vest restraints are not utilized at this facility."


Review of patient #21's chart revealed he was admitted to the facility with Sepsis, Acute Renal Failure, and Hypotension. Review of the nursing notes dated 7/19/17 at 9:00PM, "Pt received in room. 62y/o male admitted to____ (MD). Admitting Dx Sepsis/ARF/Hypotension. Placed on telemetry per orders. Removed old ileostomy bag cleansed and applied new ileostomy bag. V/s stable and wnl. Placed on 3L O2 per NC. Pt is placed in restraints (wrist) per orders. Pt expresses no concerns or needs at this time. CL in reach, BRx2 Bed lowered to floor. 9:30PM ____ (MD) called to notify pt was here at facility ordered medications and all new orders. review of the Restraint order stated the behaviors present were history of falls, unsteady gait, confusion, bowel and bladder frequency/incontinence, climbing over side rails, combative, uncooperative. There was no documentation that the nurse tried to involve family to sit with the patient or have a sitter for the patient. There was no diversional methods or environmental modifications attempted first.

Review of the initial physician orders revealed the order was a telephone order written by the nurse at 9:30PM on 7/19/17. There was an order found for the wrist restraint on 7/19/17 by the RN and was signed and dated by the physician at 10:00PM.

Review of patient #21's nurse's notes revealed the Licensed Vocational Nurse (LVN) documented at 10:00PM, "Pt soft wrist restraints placed back on pt, Pt removing devices and getting out of bed. Will continue to monitor c/l at reach."

Review of patient #21's nurse's notes revealed the Licensed Vocational Nurse (LVN) documented at 3:00AM Pt asleep at this time no meds noted c/l in reach. 6:00AM lab attempted x 3 sticks unsuccessful repositioned pt with restraints no other needs c/l at reach(SIC)" There was no documentation on why the patient continued in restraints when he was sleeping and having no issues with pulling at lines or attempting to get out of bed.

A restraint order was found for patient #21 dated 7/20/17. The RN filled out the restraint order dated and timed at 7/20/17 at 6:00AM. The order states the nurse may only obtain a telephone order for initial restraint order only. The physician did not sign the restraint order till 7/20/17 at 10:00PM; 16 hours later. The physician had signed the order within 24 hours but the nurse wrote another telephone order for the restraint 16 hours prior.

Review of patient #21's chart on 7/21/17 revealed the nurse dated and timed the restraint order on 7/21 /17 at 6:00AM. The physician did not sign and date the order until 7/21/17 at 6:00PM; a 12 hour difference. Orders for the wrist restraints were signed and dated by the physician on 7/22/17 at 6:00AM and 7/23/17 at 6:00AM.

Review of patient #21's chart revealed a "Restraint Management Flowsheet". The flowsheet was filled out by the RN to reveal the Type of restraint used, and the following assessments performed every 2 hours;

Patient and family education (as needed)
Restraint device on
Restraint release and reposition
Mental status
Behavior exhibited
Offer fluids /Nutrition
Offer toileting
Skin/Circulation check
Turn/Position change
Personal hygiene.

Review of patient #21's Restraint Management Flowsheets revealed the following:

7/20/17 from 1900-0600 there was no documentation of the type of restraint utilized. The LVN documented the patient care plan and family/pt education was performed every two hours but there was no mention in the patients care plan of restraints.

On 7/23/17 patient #21 was transferred to another hospital for a higher level of care. The patient was not discharged from the facility and was brought back to the facility on 7/28/17.

Review of patient #21's chart revealed he had restraint orders daily from 7/28/17- 7/31/17. Review of the record revealed the patient restraints were discontinued on 8/1/17 at 10:00PM. Nurse documented, "patient's behavior has been normal."

Review of patient #21's chart revealed on 8/3/17 11:10AM, " Pt found lying in floor beside bed lying on back wound vac intact. Colostomy intact. Pt pale white and aginal (sic) breathing. Pt assisted back to bed x3. RT ____ called to room. O2 sat 76% HR 127. Dr. ____ staff #31 notified blood gases drawn. 2 amps bicarb given. Pt placed on Bipap. At bedside continue to monitor. 1200 pt placed back in bil soft wrist restraints due to pulling at medical lines. Resp even/unlabored. No stress noted at this time." The patient was pronounced dead at 1742 on 8/3/17.


Review of patient #6's chart revealed the patient had orders for a soft limb restraint for her right upper extremity. The RN wrote the order on 7/19/17 at 1620. The reason for restraint was left blank. The physician did not sign the order until 7/20/17 at 1800, 26 hours later. On 7/20/17 the nurse wrote another restraint order and dated it 7/20/17 at 0600. The physician signed the order on 7/20/17 at 1800. The physician signed the order within 24 hours but the nurse wrote the order 12 hours prior. Review of the Restraint Management flow sheet revealed the RN documented that the care plan was updated. There was no found documentation of restraints in the care plan.

Review of patient #6's chart revealed the nurse wrote the restraint orders, signed, and dated restraints 7/20/17-8/2/17 at 0600 daily. The order states, "May obtain a telephone order for initial restraint order only." The physician would sign the orders when they came to evaluate patients.

Review of the physician restraint orders were incomplete for the "reason for restraint use" on the following dates;
7/19/17
7/21/17

The Restraint Management Flowsheet was found to have no documentation of what type of restraint was used on the following dates;

7/28/17 7:00PM to 7:00AM shift
7/29/17 7:00PM to 7:00AM shift
7/31/17 7:00AM to 7:00PM shift
8/2/17 7:00PM to 7:00AM shift

Review of the Restraint Management flow sheet revealed the RN documented 7/20/17-8/2/17 that the care plan was updated. There was no found documentation of restraints in the care plan.

An interview was conducted with staff #1, #2, and #3 on 8/24/17 concerning restraints. Staff #1 and #2 confirmed the staff was instructed on restraints and provided a sign in sheet dated 6/22/17. The restraint policy and Restraint Management Flowsheet was the only training material attached. Staff #1 and #3 confirmed the restraint training was not placed in the employee's files.

Staff #3 revealed the facility was doing 100% chart audits for restraints to ensure the restraints were properly documented, ordered, and assessed. Staff #3 stated the charge nurses on each shift were to audit the charts. Review of the audit forms revealed patient #6 was on the audit tool for 7/28/17. On the section for "care plan updated" the nurse put in a check mark. Under restraints "Doc. /Order" the nurse put in N/A. Patient #6 was documented in wrist restraint with an order on this date. Staff #3 was asked if she had compiled any of this data to see what the needs or education issues were and she stated, "Well we look at it and report it in the flash meetings but there is no true breakdown."

Interview with staff #3 revealed there has been no patient death in restraints or 24 hours after restraints. Staff #3 stated there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey but there was no official log.

Interview with staff #17 RN on 8/23/17 stated that she was given training on the policy but there was no hands on training for the restraints. Staff #17 confirmed there was no check off for the skill. Staff #17 reported that if she had to write the order for the restraint she just filled it all out and the doctor would sign it when he/she came in. Staff #17 reported she thought it was within 24 hours on the initial but was not sure on the daily time frame.

Based on record reviews and interviews, the facility failed to document in the patients plan of care or treatment plan concerning the use of restraints in 2 of 2 (#6 and #21) patient charts reviewed.

Policy and procedure, "Restraints" revealed the policy last revised date was 2015. Review of the policy revealed, "Restraints are to be limited to situations in which an unsafe condition exists and alternative measures have been unsuccessful. The least restrictive type of restraint is to be utilized. A patient physical and situational assessment is required before applying and restraint in an effort to determine the etiology of the behaviors unless in an emergency. Seclusion, 4-point restraints, and vest restraints are not utilized at this facility.

Documentation:

Document the results of the comprehensive assessment in the medical record. Review options that could be used as an alternative to restraints.

1.) Modify the plan of care to include:

a. The safety issue that resulted in the need for restraints.

b. Desired measurable outcome-oriented goals.

c.Interventions to minimize restraint use, including attempts to use alternatives to restraints and to end use at the earliest possible times.

d. Patient/family education regarding the need for the restraint, alternatives attempted and the plan for safe removal. "


Review of patient #21's chart revealed he was admitted to the facility with Sepsis, Acute Renal Failure, and Hypotension. Review of the nursing notes dated 7/19/17 at 9:00PM, "Pt received in room. 62y/o male admitted to____ (MD). Admitting Dx Sepsis/ARF/Hypotension. Placed on telemetry per orders. Removed old ileostomy bag cleansed and applied new ileostomy bag. V/s stable and wnl. Placed on 3L O2 per NC. Pt is placed in restraints (wrist) per orders. Pt expresses no concerns or needs at this time. CL in reach, BRx2 Bed lowered to floor. 9:30PM ____ (MD) called to notify pt was here at facility ordered medications and all new orders. review of the Restraint order stated the behaviors present were history of falls, unsteady gait, confusion, bowel and bladder frequency/incontinence, climbing over side rails, combative, uncooperative. There was no documentation that the nurse tried to involve family to sit with the patient or have a sitter for the patient. There was no diversional methods or environmental modifications attempted first.

Review of the initial physician orders revealed the order was a telephone order written by the nurse at 9:30PM on 7/19/17. There was an order found for the wrist restraint on 7/19/17 by the RN and was signed and dated by the physician at 10:00PM.

Review of patient #21's nurse's notes revealed the Licensed Vocational Nurse (LVN) documented at 10:00PM, "Pt soft wrist restraints placed back on pt, Pt removing devices and getting out of bed. Will continue to monitor c/l at reach."

Review of patient #21's nurse's notes revealed the Licensed Vocational Nurse (LVN) documented at 3:00AM Pt asleep at this time no meds noted c/l in reach. 6:00AM lab attempted x 3 sticks unsuccessful repositioned pt with restraints no other needs c/l at reach(SIC)" There was no documentation on why the patient continued in restraints when he was sleeping and having no issues with pulling at lines or attempting to get out of bed.

A restraint order was found for patient #21 dated 7/20/17. The RN filled out the restraint order dated and timed at 7/20/17 at 6:00AM. The order states the nurse may only obtain a telephone order for initial restraint order only. The physician did not sign the restraint order till 7/20/17 at 10:00PM; 16 hours later. The physician had signed the order within 24 hours but the nurse wrote another telephone order for the restraint 16 hours prior.

Review of patient #21's chart on 7/21/17 revealed the nurse dated and timed the restraint order on 7/21 /17 at 6:00AM. The physician did not sign and date the order until 7/21/17 at 6:00PM; a 12 hour difference. Orders for the wrist restraints were signed and dated by the physician on 7/22/17 at 6:00AM and 7/23/17 at 6:00AM.

Review of patient #21's chart revealed a "Restraint Management Flowsheet" The flowsheet is filled out by the RN to reveal the Type of restraint used, and the following assessments performed every 2 hours;

Patient and family education (as needed)
Restraint device on
Restraint release and reposition
Mental status
Behavior exhibited
Offer fluids /Nutrition
Offer toileting
Skin/Circulation check
Turn/Position change
Personal hygiene.

Review of patient #21's Restraint Management Flowsheets revealed the following;
7/20/17 from 1900-0600 there was no documentation of the type of restraint utilized. The LVN documented the patient care plan and family/pt education was performed every two hours. Review of the care plan revealed the patient had no mention of restraints from admission to discharge.

On 7/23/17 patient #21 was transferred to another hospital for a higher level of care. The patient was not discharged from the facility and was brought back to the facility on 7/28/17.

Review of patient #21's chart revealed he had restraint orders daily from 7/28/17- 7/31/17. Review of the record revealed the patient restraints were discontinued on 8/1/17 at 10:00PM. Nurse documented, "patient's behavior has been normal."

Review of patient #21's chart revealed on 8/3/17 11:10AM, " Pt found lying in floor beside bed lying on back wound vac intact. Colostomy intact. Pt pale white and aginal (sic) breathing. Pt assisted back to bed x3. RT ____ called to room. O2 sat 76% HR 127. Dr. ____ staff #31 notified blood gases drawn. 2 amps bicarb given. Pt placed on Bipap. At bedside continue to monitor. 1200 pt placed back in bil soft wrist restraints due to pulling at medical lines. Resp even/unlabored. No stress noted at this time." The patient was pronounced dead at 1742 on 8/3/17.


Interview with staff #3 on 8/23/17 revealed there has been no patient death in restraints or 24 hours after restraints. Staff #3 stated there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey but there was no official log.


Review of patient #6's chart revealed the patient had orders for a soft limb restraint for her right upper extremity. The RN wrote the order on 7/19/17 at 1620. The reason for restraint was left blank. The physician did not sign the order until 7/20/17 at 1800, 26 hours later. On 7/20/17 the nurse wrote another restraint order and dated it 7/20/17 at 0600. The physician signed the order on 7/20/17 at 1800. The physician signed the order within 24 hours but the nurse wrote the order 12 hours prior. Review of the Restraint Management flow sheet revealed the RN documented that the care plan was updated. There was no found documentation of restraints in the care plan.

Review of patient #6's chart revealed the nurse wrote the restraint orders, signed, and dated restraints 7/20/17-8/2/17 at 0600 daily. The order states, "May obtain a telephone order for initial restraint order only." The physician would sign the orders when they came to evaluate patients.

Review of the physician restraint orders were incomplete for the "reason for restraint use" on the following dates;
7/19/17
7/21/17

The Restraint Management Flowsheet was found to have no documentation of what type of restraint was used on the following dates;
7/28/17 7:00PM to 7:00AM shift
7/29/17 7:00PM to 7:00AM shift
7/31/17 7:00AM to 7:00PM shift
8/2/17 7:00PM to 7:00AM shift

Review of the Restraint Management flow sheet revealed the RN documented 7/20/17-8/2/17 that the care plan was updated. There was no found documentation of restraints in the care plan.

An interview was conducted with staff #1, #2, and #3 on 8/24/17 concerning restraints. Staff #1 and #2 confirmed the staff was instructed on restraints and provided a sign in sheet dated 6/22/17. The restraint policy and Restraint Management Flowsheet was the only training material attached. Staff #1 and #3 confirmed the restraint training was not placed in the employee's files. Staff #3 revealed the facility was doing 100% chart audits for restraints to ensure the restraints were properly documented, ordered, and assessed. Staff #3 stated the charge nurses on each shift were to audit the charts. Review of the Audit forms revealed patient #6 was on the audit tool for 7/28/17. On the section for "care plan updated" the nurse put in a check mark. Under restraints Doc. /Order the nurse put in N/A. Patient #6 was documented in wrist restraint with an order on this date.

Staff #3 was asked if she had complied any of this data to see what the needs or education issues were and she stated, "Well we look at it and report it in the flash meetings but there is no true breakdown."

Interview with staff #17 RN on 8/23/17 stated that she was given training on the policy but there was no hands on training for the restraints. Staff #17 confirmed there was no check off for the skill. Staff #17 reported that if she had to write the order for the restraint she just filled it all out and the doctor would sign it when he/she came in. Staff #17 reported she thought it was within 24 hours on the initial but was not sure on the daily time frame.

Based on record review and interview, the facility failed to implement performance improvement activities, measure its success, and track performance to ensure that improvements are sustained for 20 out of 20 months (January 2016-August of 2017).

Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues. Review of the data revealed the QAPI program was not following contracted services, Laboratory, and Radiology.

Review of the Quality Assessment Performance Improvement (QAPI) for 2016 and 2017 from January -August revealed the only Performance Improvements (PI) found, addressed hand hygiene and falls for September of 2016. The PI projects for June 2017 and July 2017 consisted of the following:


1.) Dated 6/2017 "HR Education files revealed deficiencies with New Hire Competencies being completed and returned."

Under analyze situation: stated, "Impact on important function of care of patients: N/A. Identify needed team: HR Director, Nurse Managers, CNO." There can be a great impact on patient care if a nurse does not have training or competencies to administer care with proper techniques. Possible patient harm or death may occur. Their HR director was no longer employed at the facility and a HR director from corporate had recently come to the facility to assess the problems. The CNO and managers had not worked to update and bring current the employee files as of 8/21/17.


2.) "High number of patients in restraints and high number." Date initiated 6/29/17. Under analyze situation: stated, "Impact on important function of care of patients:" was blank. Identified needed team CNO, Nurse Managers, Director of Quality, Charge Nurses. There was no documentation on who was on this team, what was their objective, or what time frame the PI project would be reevaluated by the team for further review or change in process.

The action plan stated, "Nurse Managers or designee will audit all restraint charts daily to verify proper documentation by nurses and physician orders. All patients in restraints will be discussed in Flash meeting to evaluate need for restraints and discuss alternatives." There was no documentation of the Flash meetings or what was discussed.

Staff #3 revealed the facility was doing 100% chart audits for restraints to ensure the restraints were properly documented, ordered, and assessed. Staff #3 stated the charge nurses on each shift were to audit the charts. Review of the audit forms revealed patient #6 was on the audit tool for 7/28/17. On the section for "care plan updated" the nurse put in a check mark. Under restraints "Doc. /Order" the nurse put in N/A. Patient #6 was documented in wrist restraint with an order on this date. Staff #3 was asked if she had compiled any of this data to see what the needs or education issues were and she stated, "Well we look at it and report it in the flash meetings but there is no true breakdown."

Interview with staff #3 revealed there had been no patient death in restraints or 24-48 hours after restraints. Staff #3 stated there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey but there was no official log.

Interview with staff #17 RN Nurse Manager on 8/23/17 stated that she was given training on the policy but there was no hands on training for the restraints. Staff #17 confirmed there was no check-off for the skill. Staff #17 reported that if she had to write the order for the restraint she just filled it all out and the doctor would sign it when he/she came in. Staff #17 reported she thought it was within 24 hours on the initial but was not sure on the daily time frame.

There had been no meetings to assign a PI team for the PI projects in place. There was no list on who was participating in the PI teams and what the plan and expectations are for this project. Staff #3 confirmed the findings.
Staff #3 stated she was no longer the QAPI director and that position had been turned over to staff #4. Staff #4 had signed a job description on 7/24/17 but was still in the training process.

Based on record review and interview, the facility failed to include an ongoing program that showed measurable improvement in indicators for identifying and reducing medical errors and that measures, analyzes, and tracks adverse patient events.

Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues.

Review of QAPI meeting for May 2017 does not address any specific PI projects or patient safety items including: tracking medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Review of the QAPI meeting for August 11, 2017 revealed the EOC Corporate officer was at the facility to check on the EOC status. The minutes stated, " Large list of items to be fixed have been received from _____Corporate EOC Officer. This will be given to maintenance department on both campuses for repairs. Will need to follow up regarding status of work orders. Will report as repairs are completed to QAPI and GB." There was no assignments, PI project or follow through for the patient safety issues. Staff #1 was asked to provide the work orders three times and failed to do so.

Review of the QAPI meeting for August 11, 2017 revealed that weekly QAPI meetings were going to be conducted starting 6/29/17 with feedback and data collected. There has been data collected but there is no evidence of a analysis on the scope of the problems or a plan.

Review of the (QAPI) program revealed there was not a clear understanding on who was the Patient Safety Officer or Risk Manager. The facility has not done a root cause analysis (RCA) for over a year. An Interview was conducted with staff #1 and #3 on 8/23/17. Staff #3 stated she was trying to do the jobs but had no official training and had not signed a job description for those positions. Staff #1 confirmed the findings and confirmed there was no job descriptions.

Based on review and interview, the facility failed to have performance improvement activities to identify problem-prone areas from the data that had been collected for 20 months (January 2016-August of 2017).


Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues. Review of the data revealed the QAPI program was not following contracted services, Laboratory, and Radiology.


Review of the Quality Assessment Performance Improvement (QAPI) for 2016 and 2017 from January -August revealed the only Performance Improvements (PI) found, addressed hand hygiene and falls for September of 2016. The PI projects for June 2017 and July 2017 consisted of the following:

1.) Dated 6/2017 "HR Education files revealed deficiencies with New Hire Competencies being completed and returned."

Under analyze situation: stated, "Impact on important function of care of patients: N/A. Identify needed team: HR Director, Nurse Managers, CNO." There can be a great impact on patient care if a nurse does not have training or competencies to administer care and techniques. Possible patient harm or death may occur. Their HR director was no longer employed at the facility and a HR director from corporate had recently come to the facility to assess the problems.


2.) "High number of patients in restraints and high number." Date initiated 6/29/17. Under analyze situation: stated, "Impact on important function of care of patients:" was blank. Identified needed team CNO, Nurse Managers, Director of Quality, Charge Nurses. There was no documentation on who was on this team, what was their objective, or what time frame the PI project would be reevaluated by the team for further review or change in process.

The action plan stated, "Nurse Managers or designee will audit all restraint charts daily to verify proper documentation by nurses and physician orders. All patients in restraints will be discussed in Flash meeting to evaluate need for restraints and discuss alternatives." There was no documentation of the Flash meetings or what was discussed.

Staff #3 revealed the facility was doing 100% chart audits for restraints to ensure the restraints were properly documented, ordered, and assessed. Staff #3 stated the charge nurses on each shift were to audit the charts. Review of the audit forms revealed patient #6 was on the audit tool for 7/28/17. On the section for "care plan updated" the nurse put in a check mark. Under restraints "Doc. /Order" the nurse put in N/A. Patient #6 was documented in wrist restraint with an order on this date. Staff #3 was asked if she had complied any of this data to see what the needs or education issues were and she stated, "Well we look at it and report it in the flash meetings but there is no true breakdown."

Interview with staff #3 revealed there has been no patient death in restraints or 24-48 hours after restraints. Staff #3 stated there is no log for patients in restraints or death in restraints. Staff #3 stated they had started listing patient in restraints on a list with blood patients so they could audit the charts as part of their plan of corrections from the last survey but there was no official log.

Interview with staff #17 RN Nurse Manager on 8/23/17 stated that she was given training on the policy but there was no hands on training for the restraints. Staff #17 confirmed there was no check off for the skill. Staff #17 reported that if she had to write the order for the restraint she just filled it all out and the doctor would sign it when he/she came in. Staff #17 reported she thought it was within 24 hours on the initial but was not sure on the daily time frame.

There had been no meetings to assign a PI team for the PI projects in place. There was no list on who was participating in the PI teams and what the plan and expectations are for this project. Staff #3 confirmed the findings.

Staff #3 stated she was no longer the QAPI director and that position had been turned over to staff #4. Staff #4 had signed a job description on 7/24/17 but was still in the training process.

Based on reviews and interviews, the Governing Body (GB) failed to ensure there was a process to evaluate the medical candidates for membership, privileges, evaluations, and recommendations complied with the Medical Executive Committee (MEC) bylaws in 9 of 9 ( 23,,24,,29,,30,,27,,26,,28,,31, and 32) physician credential files reviewed.

Review of the physician credential files revealed the following:

1.) Review of the physician and practitioners credential files revealed 7 ( 23, 24, 29, 30, 27, 26, and 32) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have three (3) peer references.

2.) Review of the physician and practitioners credential files revealed 6 (23, 29, 30, 26, 28, and 32) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have specific delineated privileges.

3.) Review of the physician and practitioners credential files revealed 4 (24, 23, 32, 31, ) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have completed applications for appointment or reappointments.

4.) Review of the physician and practitioners credential files revealed 7 (24, 29, 30, 27, 26, 32, and 31 ) out of 9 ( 23, 24, 29, 30, 27, 26, 28, 31, and 32) files did not have an Appointment Letter or a Letter that was completed and dated from the Governing Body.

5.) Review of the physician and practitioners credential files revealed 4 (47-50) out of 4 (47-50) physician did not have a credentialing file for Emergency Services for the South Campus.




Review of the Ad Hoc Governing Board (GB) Minutes dated 8/1/17 revealed the Medical Executive Committee (MEC) had voted on 2017 medical director, advisors, and presented the Medical Staff By-Laws for 2017. The MEC members approved as medical director and advisors did not have complete credential files on hand at the facility. Review of emails sent on 8/2/17 the Governing Board members approved the minutes, bylaws and MEC members on 8/2/17.


1.) Review of the Medical By-laws "Procedures for Appointment and Reappointment" revealed the following:

page 23 stated, "The names of at least three(3) peer references who have recent personal experience observing and working as a health care professional with the applicant and who can provide adequate information regarding the applicant's current professional competence, character, ability to work with others, health status, and ethics."


2.) 5.1 Requirement for Delineated Privileges stated, "Every Practitioner who practices in the Hospital must request and be granted specific delineated Privileges by the Governing Body, and each Practitioner may exercise only those Privileges that have been expressly granted. A current list of Privileges granted will be maintained in each Practitioner's Medical Staff file at all times."


3.) 5.1 Application for Privileges stated, "Every Application for Medical Staff appointment and reappointment must contain a written request for the specific Privileges desired by the applicant. The evaluation and granting of such requests as part of the appointment and reappointment process (or during the term of the appointment is a member applies for additional Privileges) shall be based upon that applicants medical education, medical training, experience, ability to perform Privileges requested, current competence, references and other relevant information, including an appraisal by a belonging to the same profession (physician, dentist, or podiatrist) which such Privileges are requested. The applicant shall have the burden of establishing his/her qualifications and competency to perform the Privileges requested. All Practitioner's appointed to Medical Staff shall be granted provisional Privileges for a period of at least one (1) year in the manner prescribed in theses bylaws."


4.) 4.3.7 Notification of Final Action stated, "Not later than the twentieth (20th) day after the date on which final action is taken by the Governing Body, the CEO shall give Special Notice of the Governing Body final action to the MEC and the Applicant. If the Governing Body grants the application, the notice shall include the staff category to which the applicant is appointed, a list of Privileges awarded, and any special conditions imposed on the applicant's appointment."


5.) Review of the South Campus records the facility was using the host hospitals Emergency Room(ER) and ER physicians to respond during a code for their facility. The facility had a contract to use the host hospitals physicians but there was no credential files on these physicians.

Interview with staff #1 on 8/25/17 revealed there was no credential files for staff #47-50.

An interview was conducted with staff #8 on 8/22/17 concerning physician credentialing. Staff #8 had agreed to assist the surveyor during the credentialing process. Staff #8 stated that she knew the files were incomplete. Staff #8 stated the files were with an out sourced company but they recently got them back and staff #8 is responsible for the credentialing process. Staff #8 stated that she had some instruction from staff #9 but was unaware that the Medical Staff Bylaws dictated the credentialing process. Staff #8 stated she had never seen them before and did not have a copy. Staff #8 confirmed the above findings.

An interview with staff #1 on 8/22/17 was conducted. Staff #1 reported she was aware the credential files were not complete and stated they have just recently started to look at them. The files were out sourced. Staff #1 was asked to submit the contract from the company. Staff #1 was unable to provide evidence of an out sourced company contract.

An interview with staff #30 (Medical Director) on 8/24/17 revealed staff #30 was not aware his credential file was not up to date nor was he aware other physician credential files were not up to date.

Based on review of records and interview, the facility failed to ensure that there was a qualified Chief Nursing Officer (CNO) and the CNO was responsible for the operations of nursing services by reviewing and approving patient care policies, and actively analyzing and developing staffing requirements for the hospital.


Findings were as follows:


Staff #2's signed job description required:

"Is available for 24-hour call. Performs duties of staff nurse as necessary."

"Master's Degree, or active progression toward a Master's Degree is required with completion of degree within 2 years of hire date."

"Current BLS and ACLS required."(Basic Life Support and Advanced Cardiac Life Support."

"Implements a clinical skills lab, based on the needs of the facility."


A letter of offer for the job was signed by Human Resources extending the requirement for completion of the Master's Degree to 3 years.

Review of the file showed that ACLS had expired 7/31/17. Annual Competencies required to work as a staff nurse had not been completed for 2016.

Interview was conducted with Staff #2 on 8-22-2017. Staff #2 provided a copy of his plan of study for the required education. The plan was for "General Studies Associate of Arts". Staff #2 stated, he was currently enrolled in an associate degree level online history course this semester, planned to take 4 associate degree level non-nursing classes online in Spring 2018. He stated he would need to take three nursing courses to be eligible for his Bachelor's Degree in Nursing. Staff #12 confirmed he had not applied to a Master's Degree Nursing Program since he did not have the pre-requisites necessary for a Master's Degree Nursing Program.


Interview was conducted with Staff #1 and Staff #5. Staff #1 was not aware that Staff #2 did not have the annual nursing competencies required to work as a staff nurse completed for 2016. Staff #5 confirmed that the ACLS was out of date. Staff #5 stated that Staff #2 was scheduled to take ACLS in September. Staff #5 stated that the facility had audited charts and identified nursing staff who did not have up-to-date annual competencies. Staff #5 stated the plan for ensuring nursing competencies were brought up to date was that new hires would have current competencies updated as they hire on. The rest of the staff missing competencies would be updated during the Annual Skills Fair that was scheduled to be held in September. Until then, nursing staff were allowed to work without current competencies.


A sample of policies used by nursing staff was made as follows:

Subject: Clinical Procedures References; Publications: NRSG 04; Reviewed/Revised Date: August 6, 2013; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: Cardiopulmonary Resuscitation; Publication: Nursing; Reviewed/Revised Date: January, 2016; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: Cardiopulmonary Resuscitation; Publication: Nursing 06; Reviewed/Revised Date: May 24, 2011; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: Nurse Staffing Plan; Publication: NRSG 07; Reviewed/Revised Date: May 24, 2011; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: Plan of Care; Publication: CL 1; Reviewed/Revised Date: (none); Effective Date: January 20, 2015, Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Title: Admission of a Patient; Policy #: CL 4; Revise/Review Date: September 2014; no information on policy on who reviewed and approved the policy

Title: Continuous Cardiac Monitory (sic) (Telemetry); Policy # CL18; Revise/Review Date: September 2014; no information on policy on who reviewed and approved the policy

Title: Critical Test Results Communication; Policy #CL 21; Revise/Review Date: September 2014; no information on policy on who reviewed and approved the policy

Subject: Invasive Procedures With and Without Sedation; Publication: CL 28; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: MAR Medication and Administration; Publication: CL 32; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: Medical Record Documentation; Publication: CL 33; Reviewed/Revised Date: (none); Effective Date: September 2013; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Subject: Medication Variance; Publication: CL 34; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Title: Physician Notification of Significant Patient Status Changes/Critical Test Results; Policy #: CL 43; Revise/Review Date: September 2014; no information on policy on who reviewed and approved the policy

Subject: Nursing Documentation; Publication: CL 39; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Title: Patient and Family Education; Policy #: CL 41; Revise/Review Date: (none); Effective Date: September 2013; no information on policy on who reviewed and approved the policy


All policies reviewed had been approved by Staff #46 at the corporate office or did not contain information had approved and reviewed the policies.


An interview was conducted with Staff #2. Staff #2 stated he did not review and approve policies. Staff #2 confirmed that if he needed a policy, he would contact a corporate staff member to obtain the needed policy. Staff #2 stated if a new policy or change in policy was needed, he had to go through the corporate office and they would have to approve or deny any changes he requested. Staff #2 confirmed that the corporate office provided the staffing matrix and the hospital was staffed to that matrix.

Staff #2 confirmed that the only staffing plan he had was the nurse staffing matrix provided by the corporate office and the following policy:

Subject: Nurse Staffing Plan; Publication: NRSG 07; Reviewed/Revised Date: May 24, 2011; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE)

Review of this policy was as follows:

"7.1 Purpose and Scope

The Nursing Services Department of Post Acute Medical, LLC. (PAM) supports the provision of patient care in a safe, cost-effective manner by appropriately using qualified and skilled personnel. The staffing plan is determined during budgetary process based on historical data; projections for future program development and expansion; analysis of clinical practice patterns; and staff input into the needs of the patients, unit and staff.

7.2 Policy

7.2.1 Each hospital shall adopt, implement, and enforce a written staffing plan as outlined in the Texas Department of Health Code, Section 133.41.

7.2.2 The staffing plan will be reviewed annually, and will be retained for a period of two years. It will include a process for identification of concerns about adequacy of the plan and prohibition of retaliation for reporting such concerns.

7.2.3 An advisory committee will be established for each hospital consisting of direct care RNs employed by the facility, a representative from infection control or risk management, and the director of nursing at the facility. The committee will receive input from staff nurses regarding the development, ongoing monitoring and evaluation of the staffing plan. The records and review relating to the evaluation of outcomes and indicators are confidential and not subject to disclosure.

7.2.4 The committee will meet to review indicators defined by TDH and to review instances when staffing concerns were raised or when staffing levels were outside of established intervals.

7.2.5 On an annual basis, a report is submitted to the governing board, including an evaluation of the staffing plan and recommendations for changes.

7.2.6 The plan will establish adequate numbers of registered nurses (RNs), licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients.

7.2.7 The plan will ensure that RN coverage will be immediately available to assist and supervise patient care, as well as respond to emergency situations.

7.2.8 Patient care assignments will take into consideration:
a. the training, experience and capability of the person to whom the task is delegated;
b. the degree and availability of supervision for the staff member
c. the condition of the patient, the patient's identified needs, and complexity of assessment and care required by each patient;
d. patient safety and infection control issues
e. breaks, meals, and in-service education and hospital committee commitments of the staff; and
f. The number of admissions and discharges planned during the course of the shift.

Staff #2 stated he had attempted to form an Advisory Committee, but did not have enough voluntary attendance to have an effective meeting. He had scheduled another meeting, but did not have a list of nursing staff who had volunteered or been assigned to the committee.

An interview was conducted with Staff #1. Staff #1 stated that policies are to be reviewed every two years by corporate. Staff #1 stated the hospital would review new policies once they were issued by the corporate office, but did not have process to review, revise, and approve policies through a hospital process.

Based on review of record and interview, the hospital failed to ensure:

A. nursing services was staffed with adequately trained nursing staff in 2 out of 2 units surveyed (north campus and south campus).

B. nursing services documented appropriate assessments of patient conditions on 5 patients (Patient #'s 1, 2, 4, 5, and 13) of 9 patients reviewed.

C. nursing services notified the physician of critical test values in a timely manner on 2 patients (Patient #1 and Patient #4) of 9 patients reviewed.


A. Personnel files for nursing were reviewed.

Staff #17 and Staff #58 did not have completed and current nursing competencies in their personnel file.

Staff #2's signed job description required:

"Is available for 24-hour call. Performs duties of staff nurse as necessary."

"Current BLS and ACLS required."(Basic Life Support and Advanced Cardiac Life Support."

Review of the Staff #2's file showed that ACLS had expired 7/31/17. Annual Competencies required to work as a staff nurse had not been completed for 2016.

Interview was conducted with Staff #1 and Staff #5. Staff #1 was not aware that Staff #2 did not have his competencies completed for 2016. Staff #5 confirmed that the ACLS was out of date. Staff #5 stated that Staff #2 was scheduled to take ACLS in September. Staff #5 stated that they had audited charts and identified nursing staff who did not have up-to-date annual competencies. Staff #5 stated the plan for updating competencies was that new hires would have current competencies updated as they hire on. The rest of the staff missing competencies would be updated during the Annual Skills Fair that was scheduled to be held in September.

Staff #17, #37, #58, #59 and #60 were all asked to locate the policy and procedure for removing a PICC (peripherally inserted central catheter). None were able to locate the policy and procedure. Staff #37 and #59 were able to locate American Association of Critical-Care Nurses (AACN) Procedure Manual for Critical Care. This manual had a procedure for removing PICC lines. Staff #17 was unable to locate a policy or procedure manual. Staff #17 stated the procedure could be looked up on the internet as long as it was a reputable web site. Staff #60 stated he thought it could be looked up on the hospital policy site, but he didn't look things up because he was "not good with computers". He stated he had been a nurse for over 20 years and knew how to pull PICC lines. Staff #59 stated he thought he had been signed off on how to pull PICC lines in his competencies, but did not know where to find the policy and procedure. He stated if he had questions, he would ask a co-worker.


Review of Policy Subject: Clinical Procedures References; Publications: NRSG 04; Reviewed/Revised Date: August 6, 2013; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE) was made as follows:

"4.1 Purpose and Scope

Post Acute Medical, LLC. (PAM) supports the use of research-based clinical procedures to provide the most effective patient care. In order to assure that clinical procedures are up-to-date and reflect best practice, all nursing procedure guidelines will be taken from current nursing resources.


4.2 Policy

Clinical procedure references will be made available on all nursing units within the system. The accepted reference manuals will be as follows:

1. Lippincott Manual of Nursing Practice, Current Edition. Published by Wolters Kluwer, Lippincott Williams & Wilkins.

2. Lippincott's Nursing Procedures, Current Edition. Published by Wolters Kluwer, Lippincott Williams & Wilkins.

3. Rehabilitation Nursing Procedures, Current Edition. Published by the Rehabilitation Institute of Chicago.

These resources will be updated when new editions of texts are published. The procedural guidelines contained in these references will serve as the standard of care for clinical procedures in PAM facilities.


4.3 Procedure

Directors of Nursing are responsible for ensuring that copies of these references are obtained for each nursing unit within their facility, and for ensuring replacement of the references when new editions are published. Nurses will refer to the publications for guidance in performing clinical procedures. Select procedures will be reviewed annually to assess clinical competence."

Interview was conducted with Staff #2. Staff #2 stated the nursing staff did not have a copy of the required reference manual for procedures. Staff #2 stated nursing staff had been using American Association of Critical-Care Nurses (AACN) Procedure Manual for Critical Care and provided a copy of the process nursing staff had been following.




B. Patient #1's chart was reviewed. On 8-4-2017, patient vital signs had been documented at noon. At 1:20pm, the nurse charted that the patient was going to a procedure via transport. At 4:00 pm no vital signs were documented. The vital sign spot at 4:00 pm was documented with "gone". Vital signs were documented at 5:00 pm. The nurse charted in the narrative note that she gave medications "per MAR" (medication administration record). No documentation was found of the time of return, type of procedure the patient had, or an assessment of the patient's condition upon return from the procedure.


Patient #2's chart was reviewed. On 8-4-2017 at 1:30 pm the nurse documented, "PICC line D/Cd. Reoriented to written plan. Awaiting Lifenet to arrive for pt discharge." The nurse did not document an assessment of the site and dressing used, a pain assessment, or assessment of patient tolerance to the procedure.

Patient #2 was admitted on 7-14-2017 and discharged on 8-4-2017. Review of the interdisciplinary education record showed that nursing had not documented any assessments of the patient's educational needs in the section titled "Specific Area of Instruction 1. Nursing" during the entire patient stay.


Patient #4 was admitted on 5-3-2017. The Initial Nursing Assessment form, Section III. Medical/Surgical History was not complete, with multiple blocks not addressed.

Patient #4 Medication Administration Record (MAR) for 5-6-2017 documented that PRN (as needed) pain medication was given at 5:05 pm and again at 9:00 pm. Review of "Pain Assessment and Intervention" and "Evaluation of Effectiveness" showed that the nurse had documented "all over" pain at 5:05 pm. No further assessment of pain rating, quality of pain, intervention used and assessment of effectiveness of intervention was documented. No documentation of patient reporting pain or assessment of pain was documented for the 9:00 pm administration of pain medications.

Patient #4 Medication Administration Record (MAR) for 5-10-2017 documented that PRN pain medication was given at 9:00 pm. Review of "Pain Assessment and Intervention" and "Evaluation of Effectiveness" showed no documentation of pain or intervention. Review of the nursing narrative note at 9:00 pm documented, "Medication administration. Patient complaint." No assessment was found of the initial pain or effectiveness of the medication.

Patient #4 Medication Administration Record (MAR) for 5-16-2017 documented that PRN pain medication was given at 5:35 am. Review of "Pain Assessment and Intervention" and "Evaluation of Effectiveness" showed no documentation of pain or intervention. Review of the nursing narrative note at 5:40 am documented, "AM meds given, 0 other needs" No assessment was found of the initial pain or effectiveness of the medication.

Patient #4's nursing notes for 5-24-2017 at 10:30 am the nurse documented, "PICC line D/Cd with cath tip intact. Pressure held for 8 min. 4X4 and tape applied." The nurse did not document an assessment of the site, a pain assessment, or assessment of patient tolerance to the procedure.


Patient #5 Medication Administration Record (MAR) for 2-9-2017 documented that PRN (as needed) pain medication was given at 6:45 pm, 9:00 pm, and on 2-10-2017 at 3:00 am. Review of "Pain Assessment and Intervention" and "Evaluation of Effectiveness" for that time period showed no assessments or interventions documented. No Nursing Narrative note was found documented at 6:45 pm. At 9:00 pm, the nurse documented, "Pm meds given" but did not document a pain assessment. At 3:00 am, the nurse documented, "Lab drawn as ordered. C/O (complaint of) generalized pain. Request pain med. Request granted." No assessment of the pain or the effectiveness of interventions was found in chart.


Patient #13 review of nursing notes showed that patient discharged from the facility against medical advice. No documentation of patient assessment prior to discharge or removal of PICC Line was found in the nursing documentation. Nursing notes on 8-9-17 were reviewed as follows:

"1900 Report given to oncoming shift"
"1950 Pt not in facility or found outside as reported. Left AMA, see RMPro."

RMPro was a Risk Management program for documentation of Risk Management events. It was not a part of the patient's medical record.

Review of the incident report for the patient leaving AMA contained a statement that the PICC line had been removed prior to patient leaving. Review of the incident report, which was not a part of the patient's medical record, contained the following statement:

"I handed him the AMA papers to sign and he signed someone else's name to the papers. This was witnessed by ____ (staff #35 LVN), Security, and myself. I removed the patient's picc line and applied a pressure dressing while his wife collected his belongings. The patient and his wife left via their private auto."

Staff #1 and #3 confirmed the incident forms were not part of the patient's medical record.




C. Patient #1 chart was reviewed.

On 8-13-2017 at 0210, in the MD orders section of the chart, a sticker for Critical Value/test result Gram negative rods in anaerobic bottle was noted for MD notified, "Already told not to call until 0630." Nurse charted on a form dated 8-12-2017 at 0210 that the critical value was received. At 0715 on the same form, nurse noted that physician had been called, but "No answer received. Msg was left AM charge nurse aware @ pm charge nurse".

"LTRAX Pre-Admission Screening" form printed on 8/11/2017 at 4:58 pm, page 2 of 4 lists patient temperature as 98. Initial nursing assessment, dated 8-11-2017 at 7:22 pm, section I. General Information, lists temperature as 95.2. No record of physician notification of temperature change was found in chart.




Review of Patient #4's chart was made. Lab report dated 5-16-2017 indicated that Patient #4 had a Critical High level of Vancomycin in the patient's blood sample. The lab notified Staff #57 at 9:00 pm of this value. Staff #57 was the RN who received the lab notification, but was not the nurse assigned to the patient that night. No documentation was found that the nurse caring for this patient was notified, nor was there documentation that the physician was notified of this Critical High lab value.


The following policy was reviewed: Title: Critical Test Results Communication; Policy #CL 21; Revise/Review Date: September 2014; no information on policy on who reviewed and approved the policy.

Under "Procedure" the policy states:

"2. Once notified, the nursing staff will have 10 minutes to initiate notification to the ordering physician.
3. The nursing staff will have no greater than 60 minutes to communicate and transfer critical result to the ordering physician."


The following policy was reviewed: Title: Physician Notification of Significant Patient Status Changes/Critical Test Results; Policy #: CL 43; Revise/Review Date: September 2014; no information on policy on who reviewed and approved the policy.

Under "Procedure" the policy states:

I. Notification Procedure/ Criteria: A. *This list is not all inclusive* ... Change in vital signs, especially if accompanied by any of the following: Diaphoresis (sweating), Nausea, Vomiting, Shortness of breath, or New onset or recurrent pain which has not been eliminated within 20 minutes ...Critical Lab Values *Results must be read back and verified. Document timeliness of notification."

Interview was conducted with Staff #1. Staff #1 verified that the physician is expected to be notified of critical values and changes in patient status. Staff #1 stated she was unaware that any physicians had told staff not to call until 6:30 am.

Based on review of records and interview, nursing services failed to initiate appropriate problem/focus areas and keep the nursing plan of care up to date on the Interdisciplinary Plan of Care for 3 patients (Patient #'s 1, 2, and 24) of 4 patients reviewed.


Patient #1 was admitted on 8/11/2017 and discharged on 8/16/2017. The patient was noted to have a temperature of 95.8 degrees upon admission. The patient remained hypothermic throughout her stay. This was not addressed on the Interdisciplinary Plan of Care.

On 8-11-17 Initial Nursing Assessment identified Patient #1 at risk of skin breakdown on page 3 of 4, section X. Skin Assessment. Review of Interdisciplinary Plan of Care did not include Problem/Focus Area Item 17, High Risk for Impaired Skin. Subsequent skin breakdown was noted on 8-14-17.

Review of physician orders on 8-14-2017 showed that nursing received an order to "offload bil (bilateral-both) heels on pillow Apply Calazime to sacrum tid (3 times per day) and prn (as needed)". Review of the Interdisciplinary Plan of Care, item 16, Impaired Skin Integrity under the heading "Problem/Focus Area", had "sacrum" and "bil heels" listed in the "location" section. Initiate Date, Goals, and Interventions were not identified and the Problem/Focus Area was never reviewed.

Review of Patient #1's History and Physical dated 8/12/2017 stated the patient was admitted with shortness of breath. Patient #1 had a pleural effusion (fluid around the lung) and heart failure that contributed to her shortness of breath. Review of the Interdisciplinary Plan of Care did not show documentation of how nursing would address the shortness of breath during the daily care of the patient.

A nutrition assessment was completed on 8-15-2017 for Patient #1 by the dietician. A resulting nutrition diagnosis of Inadequate Energy Intake was identified. On 8-15-2017 at 1229, an order was received for the patient to have Boost Plus (a supplement to patient's diet) bid (2 times per day). Review of the Interdisciplinary Plan of Care showed no documentation of Problem/Focus Area concerning patient nutritional needs.


Review of Patient #2's chart was made. 0n 7-21-2017 at 7:10 pm, nursing staff charted "Patient remains on contact isolation". No order for contact isolation found. The Interdisciplinary plan of care showed no documentation of Problem/Focus Area concerning contact isolation.

On 7-25-2017 the nursing assessment for Patient #2 showed the stool described as soft and brown. On 7-26-2017 nursing assessments showed the only description as incontinent, no color or character of stool was listed. Physician wrote order on 7-26-2017 to collect stool sample to check for a possible infection. On 7-29 at 0520 the nurse charted, "pt (patient) has excoriation (An abrasive or tearing injury to the skin) to buttocks from constant dirrehea (sic)". This new Problem/Focus Area was not updated on the Interdisciplinary Plan of Care.


Review of Patient #24's chart was made. Patient #24 was admitted on 6/28/2017 and discharged on 7/27/2017. Review of the History and Physical from 6/29/2017 contained the following information under History of Present Illness:

"While admitted it was determined that he had sinus bradycardia with the dropping into the 30s. He was assessed by (name of physician). (Name of Physician) did not see any need for acute intervention, however, did recommend close observation for a few more days. He is admitted now to Post Acute Medical Hospital for management of his rhabdomyolysis, bradycardia, and syncope."

Review of the Interdisciplinary Plan of Care do not contain identified Problem/Focus Areas addressing the nursing plan of care for bradycardia or syncope.


Review of Policy Subject: Plan of Care; Publication: CL 1; Reviewed/Revised Date: (none); Effective Date: January 20, 2015, Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE) was made as follows.

"Purpose and Scope

The purpose of this policy is to establish guidelines for providing individualized patient care that is multidisciplinary, consistent, coordinated, and high quality.

To provide guidelines for initiating, customizing, and following a goal-directed plan of care based on best practice.

Policy

The care plan for each individual patient shall be coordinated with his/her medical provider plan of care and will indicate what nursing care is needed and how it can best be achieved using evidenced based practice.

Procedure

A care plan is to be initiated by a RN for each patient during the admission process.

The care plan will be individualized of the identified patient problems, the goals, and the interventions to be used. The care plan is the first step in discharge planning.

The plan of care will be reviewed and updated daily.

The Care Plan will serve as the Interdisciplinary plan of care also and will be discussed in IDT weekly and updated by appropriate disciplines.
The care plan will be used by nursing staff and current interventions will be documented."

Interview was conducted with Staff #3 and Staff #4. Both confirmed that nursing staff were presented with an In-Service on 6-22-2017 on the requirements of the Interdisciplinary Plan of Care.

Based on review of medical records and hospital policy, nursing services failed to ensure nursing staff documented patient drug administration per the hospital's policies required for safe drug administration for 3 patients (Patient #s 4, 10, and 19) of 4 charts reviewed.


Patient #4's Medication Administration Record (MAR) was reviewed as follows:

5/4/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am and 9:00 pm. Heart Rate and Blood Pressure was not documented on the MAR for these administrations.

The 9:00 am administration of Lasix (diuretic), Cozaar (a blood pressure medication), Cefepime HCL (an antibiotic), and the 6:00 pm dose of Vancomycin HCL (and antibiotic) were marked "Hold" on the MAR. Review of nursing notes showed an entry at 9:15 am that read, "Meds per MAR. 0 needs or changes." No explanation was found for holding these medications.
The 9:00 pm administration of Cozaar was given. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR


5/5/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR


5/6/2017
Coreg (a blood pressure medication given twice a day) was given at 10:20 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
PRN pain medication was given at 5:05 pm and 9:00 pm. Assessment of patient pain and evaluation of effectiveness was not documented on MAR or in nursing notes.
Lovenox (to prevent blood clots) injection site not documented on MAR


5/7/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR


5/8/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 pm. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR


5/9/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 pm. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR.
PRN pain medication was given at 10:00 pm. Assessment of patient pain and evaluation of effectiveness was not documented on MAR or in nursing notes.


5/10/2017
Lovenox (to prevent blood clots) injection site not documented on MAR.
PRN pain medication was given at 11:00 pm. Assessment of patient pain and evaluation of effectiveness was not documented on MAR or in nursing notes. Nursing note was made at 11:00 pm that read, "Medication administration. Patient complaint."


5/11/2017
Lovenox (to prevent blood clots) injection site not documented on MAR.


5/12/2017 - 5/13/2017 - 5/14/2017 - 5/15/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR.


5/16/2016
PRN pain medication was documented on the MAR as given at 5:35 am. Assessment of patient pain and evaluation of effectiveness was not documented on MAR or in nursing notes. A nursing note was made at 5:40 am that read, "AM meds given, 0 other needs".

Coreg (a blood pressure medication given twice a day) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR.


5/17/2017
Lovenox (to prevent blood clots) injection site not documented on MAR.


5/18/2017 - 5/19/2017 - 5/20/2017 - 5/21/2017 - 5/22-2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR.


5/23/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am and 9pm. Heart Rate and Blood Pressure was not documented on the MAR for these administrations.
Lovenox (to prevent blood clots) injection site not documented on MAR.


5/24/2017
Coreg (a blood pressure medication given twice a day) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration.
Lovenox (to prevent blood clots) injection site not documented on MAR.





Patient #10's Medication Administration Record (MAR) was reviewed as follows:

8/17/2017
All 9:00 am medications were given at 10:30 am to include Levimir (insulin pen). No explanation for delay in giving medications was found on MAR or in nursing notes.
PRN tramadol (pain medication) 50 milligram was charted as given at 4:30 pm. Assessment of patient pain and evaluation of effectiveness was not documented on MAR or in nursing notes.


8/19/2017
Anti-anxiety medication scheduled to be given at 9:00 am was held. Review of nursing note entered at 9:00 am read, "Meds given per MAR". No explanation was found for holding scheduled medications.
Pain medication scheduled to be given at 5:00 pm was held. Review of nursing note entered at 5:00 pm read, "Pt stable 0 c/o" (patient stable no complaint of). No explanation was found for holding scheduled medications.

Throughout patient stay, Patient #10 received insulin injections. Documentation of injection site was not found on MAR or in nursing notes.



Patient #19's MAR was reviewed as follows:

8/23/2017

Bemetanide (a diuretic) was given at 9:00 am. Heart Rate and Blood Pressure was not documented on the MAR for this administration as indicated by preprinted section for documentation.

Throughout patient stay, Patient #19 received insulin injections. Documentation of injection site was not found on MAR.


Review of hospital policy Subject: MAR Medication and Administration; Publication: CL 32; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE) was made as follows:

"Procedure
...
III Documentation of Scheduled Medications

A. Upon administration of medications, the nurse will document in the MAR at assigned time slots.

B. Current B/P (blood pressure) must be documented along with time administered in assigned time slots when administering cardiovascular drugs.

C. Heart rate must be documented along with time administered in time slot when administering Digoxin.

D. Medication requiring documentation of vital signs should have vital signs documented on the graphic sheet.

E. Scheduled doses not given are circled and initialed in the MAR with the reason not given.

F. Injection sites are noted in MAR.

G. If the medication is given at a time greater than 1 hour before or 1 hour after the scheduled time, document in the medication administration record (MAR) as to why the medication was not given at the scheduled time.


IV. Reassessment and documentation of patient response to prn medications:

A. Patient response to prn medications will be assessed 1 hour after administration.

B. Patient response to prn medications will be documented in nursing note (or flowsheet for pain medications)."


Review of hospital policy Subject: Medication Variances; Publication: CL 34; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE) was made as follows:

"Procedure
...
13. Vital signs shall be documented prior to the administration of certain medications (i.e. cardiovascular and antihypertensive medications). If the drug is held due to a vital sign obtained that contraindicates the administration of that drug, then this shall be entered into the medical record."

Review of hospital policy Subject: Medication Timely Administration; Publication: CL 35; Reviewed/Revised Date: September 2014; Approved by Staff #46 (ORGINAL SIGNATURE ON FILE AT CORPORATE OFFICE) was made as follows:

"Policy
...

2. Medications that are deemed "time-critical medication will be given a 1-hour window (30 minutes before or after the scheduled due time).
3. Time-critical medication are defined as those where early or delayed administration of maintenance doses greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect.
...

Procedure

...
4. Medications which should be included on the Time-Critical Drug List:

A. Antibiotics
B. Anticoagulants
C. Insulin
D. Immunosuppressive agents
E. Medication with dosing schedule more frequent than every 4 hours
F. Scheduled (not PRN) pain medications

..."

Based on review of records and interview, nursing services failed to ensure nursing staff followed safe practices for picking up and storing multiple units of blood at one of two locations (North Campus) and ensuring proper informed consent had been obtained.


Review of Patient #4 chart as follows:

Patient #4 was an 82 year old male, who was admitted on 5-3-2017 after an amputation of toe on the left foot and the resulting non-healing surgical wound. He had also had surgery on 4-26-2017 to remove colon cancer. The patient was admitted to Staff #30 at the time of admission.

Hospital staff had the patient's wife sign a consent for blood products on 5-3-2017 at 5:50 PM at the time of admission for the patient to receive blood products. No blood products had been ordered at that time. The physician's name was not written on the consent. A physician had not signed the informed consent.

On 5-5-2017 at 1130, an order was written to consult Staff #56. On 5-5-2017 at 2:00 pm, Staff #56 wrote an order "T&C (identify the type of blood and crossmatch it the appropriate units of blood) 2 units PRBC (packed red blood cells) and transfuse over 2-3 (symbol for hours)" Review of the lab report showed that blood unit number W036517512910 and blood unit number W036517513162 were picked up at the contracted lab that did not belong to the admitting hospital. The lab was on the same campus as the admitting hospital and had a contract to provide blood products. The lab slip indicated that both units of blood were issued in a cooler for transportation on 5/6/2017 at 1:19 am. Review of the blood transfusion record showed that the nurse received unit number W036517512910 at 2:00 am and began the transfusion at 2:10 am, 51 minutes after the lab had issued the blood. The record showed that the nurse received unit number W036517513162 at 5:10 am and began the transfusion at 5:10 am, 3 hours and 51 minutes after the lab issued the blood. The transfusion ended at 8:50 am, 3 hours and 40 minutes after transfusion began. The total time from lab issuing the blood to transfusion completion was 7 hours and 31 minutes lapsed.

Records did not identify where or how the blood was stored for those 3 hours and 51 minutes from the time the blood was issued to the time the transfusion of unit number W036517513162 began.

Interview was conducted with Staff #18 on 8-22-2017. When asked how blood was picked up and stored if patients needed multiple units, Staff #18 stated that only 1 unit at a time was picked up because they did not have a blood refrigerator or procedures for picking up and storing multiple units of blood products. Staff #18 stated that if a patient was in need of multiple units of blood to be issued at once, the patient would be transferred to the acute care hospital on campus until stable enough to come back to the long term acute care setting.


Policy Title: Blood Transfusion Policy; Policy # CL 12; Effective March 2015; Scope: Texarkana - Site Specific; Reference: The Lippincott Manual of Nursing Practice, 9th Edition (April 2009), AABB (American Association of Blood Banks) Technical Manual, 17th Edition 2011; no information on policy on who reviewed and approved the policy was reviewed.

The policy did not address procedures for picking up more than one unit of blood product at one time. The policy stated:

"NOTE: Maximum time blood product can be unrefrigerated before hanging is 30 minutes, leave blood/blood product in cooled storage container until ready for infusion (north campus)."

It did not address the risk of leaving blood products in a cooler for extended periods of time such as 3 hours and 51 minutes after the lab issued the blood.


The policy stated under "Procedures":

"Patient/representative must sign consent before procedure is initiated."


Review of Medical Staff Rules and Regulations stated the following:

"B. Medical Records (MB 6.6.5, MB 13.6)

1. The responsible practitioner shall be responsible for the preparation of a complete medical record for each patient.

...
b. The medical record must also contain properly completed patient informed consents for test/treatments/surgery/blood transfusions, bedside procedures, and in those instances in which consent could not be obtained, the attending must document the reason(s). It is the physician's responsibility to obtain informed consent."

Based on medical record review and interview, the facility failed to maintain an accurate and authenticated medical record for 4 of 5 patients (Pt #6, #7, #8, and #25 of #6, #7, #8, #9, and #25 ) from 5/2017 to 8/2017

This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


During the week of 8/212017 through 8/25/2017 medical records (MR/MR'S) for patients (Pt/pt) #6, #7, #8, #9, and #25 were reviewed and revealed the following:


Pt #6: Was a pt on the South Campus.

On 7/29/2017 87 year old (y/o) pt #6 received one unit of platelets-leukocyte reduced. The form identified in pt #6's MR was titled (Name of hospital) "Transfusion Record". The start time for the transfusion was:

1325; pre vitals signs (V/S, blood pressure "B/P", pulse "P", respirations "R" and temperature "T") were recorded. In 15 minutes,

1340 V/S were documented. In 30 minutes,

1355 (Sic) V/S were documented (Although there was only 5 minutes between the last V/S recorded). In 1 hour,

1455 No V/S were recorded.

1655 No V/S were recorded

1755 No vital signs were recorded

The transfusion was recorded as completed at 1355 and V/S were recorded.

One hour post transfusion the V/S were incomplete with only the T,P and R recorded. Pt #'s B/P was not rechecked or recorded.


On 7/19/2017 at 2130 type "O" positive Red Blood Cells-Luekocyte reduced was started, expiration date 8/23/2017 at 23:19.

2130 V/S recorded pre transfusion

2145 V/S were recorded (15 minutes)

2200 V/S were recorded (15 minutes).

2230 V/S were recorded (30 minutes)

2330 V/S were recorded (1 hour)

2350 V/S were recorded, transfusion was completed.

The one hour post transfusion V/S were not documented


On 7/20/2017 at 0016 type "O" positive, Red Blood Cells-Luekocyte reduced was started, expiration date 5/23/2017 at 23:59

0016 V/S were recorded pre transfusion

0031 V/S were recorded (15 minutes)

0046 V/S were recorded (15 minutes)

0116 V/S were recorded (30 minutes)

0216 V/S were recorded (1 hour)

0240 V/S were recorded, transfusion was completed.

The one hour post transfusion V/S were recorded.


Review of the Facility's "Blood Transfusion Pre and Post" policy read:

f. "During transfusion vitals (sic) signs must be taken Q (every) 15 minutes x 4 then 30 minutes x 2 then Q 60 x 2 (or as defined by the facilities blood bank form and documented on the Blood Transfusion Monitoring Record. The first set of Vitals signs at Q 15 must also be recorded on he Transfusion Record."

The "Transfusion Record" was printed for "pre V/S, 15 minute V/S x 1, 30 minute V/S x 1, Q hour V/S x 3 and 1 hour post completion of transfusion". The Registered Nurse, (RN) failed to follow the policy for accurate V/S pre, during, and post blood transfusion.

Further review revealed restraints were applied on Pt #6:

8/6/2017 the "Restraint Management Flow sheet" indicated pt #6 had soft restraints applied to both his right and left upper extremities. The "Restraint Management Flow sheet" did not record a change in mental status requiring restraint and no behaviors were demonstrated that would warrant restraint.

This pattern was observed on the flow sheets for
8/8/2017
8/9/2017
8/10/2017
8/12/2017
8/13/2017
No flow sheet was identified for 8/14/2017
8/15/2017



Pt #7:

MR review revealed 83 y/o pt #7, had a "Request, Disclosure and Consent for Medical and Surgical Procedures-Department of Radiology" consent to place a Dobhoff feeding tube. The consent was observed with "Telephone consent by (Name) son". One RN, as the witness signed the consent. The "reason patient is unable to sign" "Disoriented". The physician had not signed,dated, or timed the consent. The Long Term Acute Care hospital leased the 6th floor from a host hospital. The pt signed a consent that was a copy of the acute host hospital's consent to treat.


Pt #8:

MR review revealed 76 y/o pt #8, had a PICC (Peripherally Inserted Central Catheter) inserted 8/1/2017. The MR document "PICC/Midline Insertion record", indicated the placement had been verified by Chest X-ray, (CXR) the verification had not been signed by a Registered Nurse (RN). The "Disclosure and Consent, Medical and Surgical Procedure", for the PICC had not been signed/dated/timed by the physician staff #32. Documentation indicated Pt#8 suffered from respiratory failure on 7/25/2017. The consent to perform a tracheostomy had not been sign/dated/Timed by the Physician staff #59. On 8/21/2017 pt #8 was placed in restraint. The "Restraint Order" failed to indicated what type of resistant was utilized and failed to indicate why the restraint was used. The restraint order, dated 8/13/2017 failed to indicate why the restraint was used and failed to indicate what "Invasive interventions that apply to the patient" which would require restraint. The restraint order, 8/12/2017 failed to indicate why the restraint was used. The restraint order dated, 7/30/2017 failed to indicate the "Type of Restraint Utilized" and failed to indicate the "Reason for Restraint Used". The Admission orders for pt 8 were signed by physician #32's Advanced Practice Nurse, staff #55, who signed but failed to date and time the orders.


Pt #25: Was a pt on the South campus.

MR review revealed 73 y/o pt #25 was admitted 5/9/2017 the "History and Physical" (H&P) was dictated by physician #60 on 5/9/2017 at 14:07. The H&P was signed dated and time, but was illegible, and clearly not within 30 days on dictation. A telephone order from physician #60 dated 6/1/2017 remained unsigned dated or timed on 8/25/2017. The "Initial Nursing Assessment", dated 6/1/2017 reflected a score of "0" on pt #25's nutritional screening. Any score would have triggered a Nutritional evaluation by a registered Dietician. "The Dietary screen", failed to reflect pt #26 had a sacral wound. Wound treatment orders were noted on the admission orders. Also the dietary screen failed to reflect pt #25 was on a mechanical soft diet indicating chewing and/or swallowing problems. Had the RN captured these two items pt #25 would have received a nutritional evaluation from the RD. Pt #25 weighed 250 pounds upon admission She was diagnosed with stage 4 kidney disease. Her nutritional screening was incomplete because the RN failed to complete the evaluation for malnutrition when she failed to score the wound and chewing/swallowing deficit. The RN scored pt #25 at "14" on the Braden scale. If below "16", the "Skin Assessment" instructed "If less than 16, skin precautions Implemented and Wound Care team notified". The RN checked the box "N/A (Not Applicable) NO WOUNDS OBSERVED/IDENTIFIED". Pt #25 was admitted with orders for "Medihoney treatment daily to Sacral Wound". Below the Skin Assessment was the "Wound Description" the RN documented a "stage II sacral wound". The Nursing Daily Flow Sheet" dated 6/2/2017 failed to reflect a low air loss mattress was in use for pt #25. The admission physician's orders included "Turn Q 2, low air loss mattress". Pt #25 was discharge on 6/16/2017, the use of a low air loss mattress was never documented.

Based on review of records, the facility failed to ensure telephone orders (TO) were properly authenticated in a timely manner for 5 out 5 patient charts reviewed (Patient #s 1, 2, 3, 4, 5, and 10).

Findings were as follows:

Patient #1

Admission Orders TORB (Telephone Order Read Back) on 8-11-17 at 9:00 pm were not signed by admitting physician until 8-21-17 at 12:45 pm.

8-14-17 at 2:00 pm, nursing received a telephone order "offload bil (bilateral-both) heels on pillow. Apply Calazime to sacrum tid (3 times per day) and prn (as needed)". This order was not signed by the practitioner as of 8-21-2017.

8-14-2017 at 9:30 pm, nursing received a telephone order to place the patient on telemetry (heart monitoring). This order was not signed by the practitioner as of 8-21-2017.

8-15-2017 at 9:30 am, nursing received a telephone order for a portable chest x-ray to be taken on the morning of 8-16-2017. This order was not signed by the practitioner as of 8-21-2017.


Patient #2

Admission Orders TORB on 7/14/2017 at 6:00 pm. Signed by MD, but not dated or timed.

Home medication order on 7-14-2017 at 8:50 pm TORB. Signed by MD, but not dated or timed.

7-16-17 at 5:25 pm TORB for GI Procedures. Signed by MD, but not dated or timed.

7-20-17 at 12:35 pm, PICC (Peripherally Inserted Central Catheter) line orders not counter signed by MD until 7-30-17.


Patient #4

Admission 5-3-2017 orders TORB not signed by MD until 6-6-2017

5-4-2017 order for diet TORB. MD signed and date stamped. Date was stamped and read "May 00 2017". Not timed.

5-5-2017 order for MD consult due to increased creatinine TORB. MD countersignature not dated or timed.

5-4-17 at 3:45 pm TORB for medications not countersigned by MD until 5-8-2017 not timed.


Patient #5

2-12-17 at 2:35pm, nursing received a telephone order for labs to be drawn every 6 hours. MD signed but did not date and time signature.


Patient #10

8-16-17 TORB at 6:40 pm and 9:00 pm for medication. Neither was signed by MD.

8-16-2017 TORB at 9:45 am for equipment. Was signed by MD but signature was not dated or timed.

8-15-2017 TORB at 5:15 pm for admission medications, signed by MD but signature was not dated or timed.

8-15-2017 TORB at 5:15 pm for insulin was not signed by MD.


Medical Staff Rules and Regulations were reviewed as follows:

"C. General Conduct of Care:

1. Patients shall be seen on a daily basis by the attending physician or make arrangements with another physician designee to see the patient(s) and is not the emergency room physician.

2. All inpatient and outpatient orders for medication, treatment procedures, diagnostic services or therapy shall be recorded in the medical record. Physicians may issue orders by telephone only to persons authorized by Medical Staff and state law. Nursing may take any type of verbal or telephone order. Dieticians, Respiratory, occupational, speech and physical therapists and pharmacists may only take verbal or telephone orders pertaining to their specialty and only if allowed by state law. All verbal or telephone orders shall be transcribed in the medical record and shall be countersigned by the practitioner in a time frame that complies with State regulations. Countersignature for medication or treatment orders must be obtained within 24 hours. ..."

Based on observation and interview, in one of two pharmacy areas (the North Campus), the Pharmacist failed to ensure unit dose dispense packs (blister packs for repackaging oral medications) were stored in a sanitary manner. This deficient practice placed all patients receiving re-packaged unit dose medications at risk of harm.

On 8-23-2017 at approximately 3:30 pm, a tour of the pharmacy area on the North Campus was made. New unit dose blister dispense packs for re-packaging oral medications were observed opened and loose. They were stack under a counter top, in a cabinet without a door. The blister packs were being stored on three shelves inside of this open lower cabinet. The shelves were wooden and appeared to be unfinished and soiled. A paper label that was torn and soiled was on the top shelf, labeled "Medi-Cup Plus Nultraviolet Mini Green Blisters, 2000 Doses / 80 Sheets." A plastic bin on the top shelf was labeled "Medi-Cup Plus Nultraviolet Deeper Green Blisters, 1000 Doses / 40 Sheets." The plastic bin was visibly dusty. The laminate facing around the cabinet opening was visibly soiled.

The countertop over the open cabinet had the following items stored on it:

One backpack belonging to a staff member with a thermos in an outer mesh pocket.

New uniforms for the staff.

Notebooks

Hardware for mounting items to a wall.

In front of the open cabinet and leaning up against the cabinet were three new whiteboards.

Interview was conducted with Staff #10 and Staff #22. Both confirmed the observations above and that the blister packs were being used to re-package oral medications.

Staff #10 stated that the pharmacy area was the only area available to the pharmacy staff. Staff #10 stated there was no other area for storage of pharmacy staff's personal items and food items, storage of office supplies, or office workspace. Storage of personal items and office activities were being conducted inside the pharmacy. Staff #10 acknowledged that given the conditions, the blister packs should have been stored differently.

Based on document review and interview, the facility (Long Term Acute Care, LTAC) failed to maintain Radiology policies and procedure that were specific to the services provided within the facility from 1/2017 through 8/2017.

This deficient practice had the likelihood to effect all patients if the hospital.

Findings included:


On 8/22/2017 in the conference room an interview with staff #2 occurred. Staff #2 was asked to bring the policies for the Radiology services for review. After a period of time staff #2 confirmed there were no policies found specific to the LTAC. When asked how were the radiology services provided, Staff #2 confirmed the Radiology services were contracted with the local acute hospital.

On 8/22/2017 in the afternoon, an interview with staff #3, confirmed the policies for Radiology were provided by the contracted hospital. A review of the Governing Board (GB) meeting minutes for the LTAC, from the first quarter or 2017 (January, February and March) found no mention of policies or procedures specific to the LTAC being discussed or approved. Review of the second quarter GB meeting minutes for April, May, and June found no documentation that specific policies and procedures for the Radiological services that were provided within the LTAC had been discussed or approved.


The LTAC facility had no approved policies and procedure for the Radiology service provided to patients within their care.

Based on interview and document review, the facility failed to provide written description of the laboratory services that were provided within the hospital from January 2017 through August 2017.

This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On the afternoon 8/23/2017, an interview with staff #2 revealed the nursing staff provided the blood draw for the laboratory services. The blood was then transported to the contracted laboratory services for processing. Request was made for the description of the services that the nursings staff would provide. Staff #2 confirmed there really was no description of services. When asked how the nurses knew what color tube would be needed for certain blood test, staff #2 said the nurses could call the contracted lab to clarify. The nurses did not have a reference chart or other written explanation of what they were responsible to draw. The nurses would draw whatever the physician ordered.


On the afternoon of 8/23/2017, in the conference room, the contract for the ancillary service for laboratory services was found to have expired 4/1/2010 on the South campus and 11/2/2014 on the North campus. Review of the documentation from the Governing Body meeting minutes from January 2017 through August 2017 did not reveal documentation of discussion, review or approval of a re-approved ancillary services contract. The facility had no valid contract, and no written description of the service for routine and stat laboratory test.

Based on document review and interview, the facility failed to provide an approved contract for the laboratory services, and could not provide policies and procedures for the laboratory services provided from 1/2017 through 8/2017



This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On the afternoon of 8/22/2017, in the conference room an interview with staff #2 confirmed the laboratory services were provided by a contract with local hospitals for the South campus.


Further interview with staff #2 revealed that blood draws were performed by the nursing staff and transported to the contracted hospital lab for processing. Staff #2 was asked to provide the policies and procedures guiding the nursing staff of how to draw the patient blood, which blood tubes to use, how to safely package the blood for transport to the contracted lab service. None were provided. Staff #2 confirmed there were no policies for the nursing staff to refer to.


Review of the South campus lease agreement with the laboratory service provider revealed the agreement was initiated on 3/1/2009. The lease agreement had expired on 3/31/17. There was no updated contract at the facility nor was one provided by the corporate office.


An interview with staff #1 on 8/23/17 confirmed the South campus contract for laboratory services had expired. The South campus did not have a contract for laboratory services.

Based on review of records and interview, the hospital failed to ensure the Governing Body (GB) delegated the Utilization Review Committee (URC) the authority and responsibility to carry out the Utilization Review (UR) function.

Governing Body meeting minutes and the written Utilization Review Plan were reviewed for evidence of delegation of authority and responsibility.

Review of Governing Body meeting minutes as follows:

Governing Board Meeting October 27, 2016
Governing Board Meeting Ad Hoc February 2, 2017
Governing Board Meeting Ad Hoc March 30, 2017
Governing Board Meeting Ad Hoc April 25, 2017
Governing Board Meeting May 2, 2017

The Governing Board Meeting Ad Hoc August 1, 2017 showed that Staff #30 and Staff #32 were approved as co-chairs of the UR Council but did not include the delegation to the URC the authority and responsibility to carry out the UR function.

There was no evidence in the above meeting minutes that a UR Plan for 2017 had been approved that delegated to the URC the authority and responsibility to carry out the UR function. The hospital was not in possession of a 2017 UR plan that delegated to the URC the authority and responsibility to carry out the UR function.

The "Post Acute Specialty Hospital of Texarkana Annual Utilization Review Evaluation/Plan 2016" was reviewed. There was no Policy Number associated with the plan. It did not have a signature page or approval page to show that it had ever been approved for use.

The UR plan did not include who was to be a member of the URC or what roles and authority they were to have.

Interview was conducted with Staff #19. Staff #19 stated he didn't know about a UR Plan. He stated that a new Case Management Director had been hired and that the new Director was responsible for that.

Interview was conducted with Staff #2. Staff #2 stated the new UR Director was in New Employee Orientation. Staff #2 provided a copy of "Post Acute Specialty Hospital of Texarkana Annual Utilization Review Evaluation/Plan 2016". Staff #2 stated that was the only plan there was.

Based on review of records and interview, the hospital failed to establish a utilization review plan that included a process for the Utilization Review Committee (URC) to review cases for medical necessity, duration of stay, and professional services provided during the patient stay, or the timeframes for reviews.

The "Post Acute Specialty Hospital of Texarkana Annual Utilization Review Evaluation/Plan 2016" was reviewed. There was no Policy Number associated with the plan. It did not have a signature page or approval page to show that it had ever been approved for use.

It was written as follows:

"Utilization Review Plan

Plan or Scope

The Utilization Review (UR) Plan provides guidelines for maximizing the quality and cost efficiency of health care services. Through regular reviews and audits, the plan ensures that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays.

Analysis

The UR Plan includes the following:

Audits of blood usage matched with established parameters set by the MEC/GB
Pharmacy audits of medication usage and substitutions
Clinical management and reporting of use of high cost items
Pre-screening by business development staff re high cost needs prior to acceptance for admission
Resource management to control costs of needed items
Case management review of outpatient procedures needed and their relevance during the patient's inpatient stay
Pre-screening by business development staff re unplanned readmission rates
Identification and monitoring those patients categorized as IPPS vs PPS in collaboration with business development and case mgmt (onsite began December 2015)

Outcomes regarding surveillance efforts:

Blood usage averaging between 31 units. Compliance with meeting transfusion criteria was 98% for the year 2015. Will continue to monitor trends.

High cost outliers were responsible for 22% of our inpatient stays during 2014. And in 2015 continue to be the same at 22%. With careful screening at pre-admit and throughout the inpatient stay, length of stay is constantly monitored and discharge planning remains our focus.

Evaluation and Plan:

Continue monitoring measures per corporate scorecard measures
Continue UR with monthly meetings
With the advent of IPPS in January 1, 2016, add FTE to manage volume and turnover of patients
Monitor trends for 30 day unplanned readmissions
Improve format and planning for utilization committee meetings
Discharge planning occurs daily at morning FLASH meeting. Case management begins discharge planning on admit and follows up with MD notification and chart discharge planning worksheet. Weekly interdisciplinary rounds with key depts is performed and includes patient and caregivers directly in the planning process. Documentation of rounding is placed in the patient chart."

Interview was conducted with Staff #19. Staff #19 stated he didn't know about a UR Plan. He stated that a new Case Management Director had been hired and that the new Director was responsible for that.

Interview was conducted with Staff #2. Staff #2 stated the new UR Director was in New Employee Orientation. Staff #2 provided a copy of "Post Acute Specialty Hospital of Texarkana Annual Utilization Review Evaluation/Plan 2016". Staff #2 stated that was the only plan there was.

A review of the URC meeting minutes for 2017 were reviewed. Meetings were conducted on April 7, 2017 and July 14, 2017. Both meetings were called to order at 11:00 am and adjourned at 11:30 am. Only 1 physician was listed as present and no-one was listed as absent.

Only four items were listed under "New Business" for each meeting. They were:

"PPS CMI" (prospective payment system case mix index)
"IPPS CMI" (inpatient prospective payment system case mix index)
"Short Stays"
"LOS" (length of stay)

Minutes reflected that Staff #2 reported data to the committee. Minutes did not reflect that any other member of the URC provided input. Minutes did not show any other discussion of the data or any review of specific cases. The "Actions/Improvements" for each item was "Continue to monitor". The minutes did not contain information on review of cases for medical necessity, duration of stay, and professional services provided during the patient stay, other than to report short stays and average length of stay between the two hospital campuses.

The following Governing Board Meeting minutes were reviewed:

Governing Board Meeting Ad Hoc February 2, 2017
Governing Board Meeting Ad Hoc March 30, 2017
Governing Board Meeting Ad Hoc April 25, 2017
Governing Board Meeting May 2, 2017
Governing Board Meeting Ad Hoc August 1, 2017

Review of Governing Board Meeting minutes for 2017 did not include reports from the hospital URC meetings.

An interview was conducted with Staff #1 on 8-29-2017. Staff #1 explained that any patient that discharges before the length of stay assigned to the Diagnostic Related Group (DRG - a code assigned based on diagnosis that is used as part of the determination of how much the facility it to be paid) is reported to the URC. Staff #1 clarified that Case Management Director collects the data and reports it to the URC. Staff #1 stated that the physicians who write the order know that they have a short stay and why. Physicians don't review short stay charts. The information is collected and reviewed by the Case Management department and reported to the URC.

Based on review of records and interview, the hospital failed to establish a Utilization Review (UR) Plan that provided for the identification and process for review of extended stay cases.

The "Post Acute Specialty Hospital of Texarkana Annual Utilization Review Evaluation/Plan 2016" was reviewed. There was no Policy Number Associated with the plan. It did not have a signature page or approval page to show that it had ever been approved for use. The plan did not contain information about the identification of and process for review of extended stay cases.

Interview was conducted with Staff #2. Staff #2 provided a copy of "Post Acute Specialty Hospital of Texarkana Annual Utilization Review Evaluation/Plan 2016". Staff #2 stated that was the only plan there was.

A review of the Utilization Review Committee (URC) meeting minutes for 2017 were reviewed. Meetings were conducted on April 7, 2017 and July 14, 2017. Both meetings were called to order at 11:00 am and adjourned at 11:30 am. Only 1 physician was listed as present and no-one was listed as absent.

Only four items were listed under "New Business" for each meeting. They were:

"PPS CMI" (prospective payment system case mix index)
"IPPS CMI" (inpatient prospective payment system case mix index)
"Short Stays"
"LOS" (length of stay)

URC meeting minutes did not contain a section for reporting of extended stay data or reviews.

Based on review of records and interview, the hospital failed to ensure the Utilization Review Committee reviewed professional services.

A review of the URC meeting minutes for 2017 were reviewed. Meetings were conducted on April 7, 2017 and July 14, 2017. Both meetings were called to order at 11:00 am and adjourned at 11:30 am. Only 1 physician was listed as present and no-one was listed as absent.

Only four items were listed under "New Business" for each meeting. They were:

"PPS CMI" (prospective payment system case mix index)
"IPPS CMI" (inpatient prospective payment system case mix index)
"Short Stays"
"LOS" (length of stay)

URC meeting minutes did not contain a section for the review of professional services by the committee.

An interview was conducted with Staff #1 on 8-29-2017. Staff #1 clarified that Case Management Director collects the data and reports it to the URC. Staff #1 stated that physicians don't review charts during in the URC meeting. Information is collected and reviewed by the Case Management department and reported to the URC.

Based on document review and interview, the facility failed to provide evidence the emergency generator would function in the event of an emergency.

This deficient practice had the likelihood to affect all patients of the hospital.


Findings included:


On the morning of 8/24/2017, the contracted maintenance director provided a tour of the emergency generator. The Emergency generator was fueled by diesel. The maintenance Director stated the generator was load tested only 1 time a year. The Director further stated they (the contracted service) were only required to test the emergency generator one time a year because the long term acute care facility did not create a greater than 30% pull on the emergency generator.

The Director stated a circuit test was done regularly. The circuit test would ensure the electrical circuits worked to the emergency generator in the event of the lost of electrical power to emergency electrical outlets and other critical areas which required electricity. However, a circuit test would not ensure the generator itself would start and run with a load for the needed length of time.

The "NFPA 99 (National Fire Protection Associate), guidelines instruct that, the 10 second or less full load, must be tested annually. The NFPA further states an extended time of greater than 10 seconds is permissible for monthly emergency generator test. During the monthly test the full load capacity is not required. The facility has the authority to determine what load capacity it chooses to test monthly with the annual full load test done once a year".

The NFPA 99 guidelines indicated a greater than 10 second time laps for monthly generator tests was permissible. The afore mentioned guideline indicated a monthly generator test should be conducted, with weekly circuit switch tests done weekly. A load test must be conducted for at least 30 minutes each month to ensure the emergency generator will switch over to emergency power once the hospital looses electrical power.

Interview with the safety officer for the hospital , staff #3 confirmed no one from the hospital sat on the safety committee at the contracted services facility, and no one from the contracted facility attended the safety meetings for the hospital. The safety officer had never been privileged to the information related to their own emergency generator. The hospital's safety committee had not determined safety parameters that were suited for their facility. They completely relied on the contracted service to tell them what they needed. The Safety officer had never investigated what the requirements actually were. The hospital could not provide evidence of emergency generator power.
The hospital did not have evidence to support emergency power capability in the event of a power outage.

Based on observation and interview, the facility failed to maintain a sanitary environment around their dumpster from 8/21/2017 through 8/25/2017.


This deficient practice had the likelihood to effect all patient (Pt/pt) of the hospital.


Findings included:


On the afternoon of 8/21/2017 in the conference room, an interview with staff #3 confirmed the facility leased second story space from a rehabilitation hospital. Staff #3 also confirmed the two facilities shared the same dumpster.


On the morning of 8/22/2017, observation revealed, the dumpster was contained in a cinder block structure with three walls. An iron gate was open at the front of the dumpster. Behind the dumpster there was no wall and no complete containment. The area behind the dumpster was at the hospital ground level loading dock and exit doors. The area immediately behind the dumpster was full of discarded equipment no longer in use. Examples: the hydroculator, over beds table, potty chairs, a stainless steel cart loaded with steam table pans, 5 gallon buckets, with lids attached, two office chairs, one rolling pole, three heavy red plastic biohazard containers that were full sealed and stacked on top of each other. Next to the three full biohazard containers were three empty containers turned upside down as if to drain.

Staff #3 and the maintenance Director were asked if the facility reused the heavy duty red biohazard containers. Staff #3 and the Director of the contracted maintenance services could not determine if the biohazard containers were reused or not. Further both staff indicated all the unused equipment was waiting to be picked up.

Staff #3 stated they had to share the dumpster with the other facility and most of the equipment belonged to the rehabilitation hospital as well as the biohazard bin.

It was discussed with both staff that the trash was not secure if the front gate was locked but the back wall was gone. Any scavenger, person or animal had ready access to the dumpster trash, the bio hazard boxes or the equipment that was not longer in use.

Staff #3 confirmed the safety committee had never assessed the trash service, storage of trash or the disposal of trash.

Later in the day an interview with staff #1 revealed, they had their biohazard removed from the floor by the biohazard company, however the same large red heavy duty biohazard bins were identified on the second floor leased space.

Based on observation, interview, and document review, the facility failed to ensure the Infection Control Professional had specific infection control training prior to Directing the Infection Control program form January 2017 through August 2017

This deficient practice had the likelihood to affect all patients of the hospital.


Findings included:


On the morning of 8/22/2017, in the conference room an interview with staff #3 confirmed she was the acting infection control professional (ICP). A review of staff #3's employee file revealed she did not have a signed job description to serve as the ICP. Further review revealed there was no evidence in her employee file to indicate staff #3 had received IC training sufficient to direct the IC program.

A review of the "Infection Control Program", last updated 1/22/2015, indicated "Policies and Procedures are based on the following":

APIC (Association for Professionals in Infection Control)
SHEA (Society for Healthcare Epidemiology of America)
CDC (Centers for Disease Control)
State Regulations
OSHA (Occupational Safety and Health Administration)
CMS (Centers for Medicare and Medicaid Service)
Joint Commission Requirements.

Further interview with Staff #3 confirmed she had completed online modules offered from her corporate offices, but did not know if they were provided through any of the above listed organizations that the hospitals Policies and Procedures were based on. Further she could not provide evidence she completed the training.

Staff #2 was asked to provide the written Infection Control Program she was using. Staff #3 provided a written document that was titled Infection Prevention and Control Plan, last reviewed 1/22/2015". When asked if the document provided was the most current, staff #3 confirmed it was.

The facility had no documentation that staff #3 had received Infection Control training from a nationally recognized infection control organization, had not signed a job description indicating staff #3 was aware of the requirements and responsibilities of the IC professional, and had provided staff #3 with an outdated Infection Prevention and Control Plan as guidance to implement the Infection Control program for the hospital.


The facility did not have a qualified ICP.

Based on observation, interview, and document review, the facility failed to establish and maintain a process for identifying, and evaluating patients with Multi Drug Resistant Organisms (MDRO) and determine a safe, effective process for isolation room assignments to ensure all patients safety from 8/212017 through 8/25/2017 survey.

Failure to ensure and maintain a sanitary environment put patients at risk for infections, re-infections, or possible death. These deficient practices placed all patients at risk for the likelihood of harm, injury, or subsequent death.



Findings included:

On 8/21/2017, on the North campus, the following infection control concerns were identified:

On the afternoon of 8/21/2017, in the conference room, the medical record (MR) for patient's (Pt/pt)#10 and #11 were reviewed. Pt #11 had a open wound. Pt #11 was in isolation with positive MRSA (Methocillin Resistant Staph Aurus). A privacy curtain separated pt #11 and her room mate.


Review of patient #10's MR revealed: Patient #10 was a 65 year old woman, who had several conditions that complicated her ability to fight infection. She was diabetic, had muscular dystrophy and was bed bound, had heart disease with heart failure, and had a non-healing wound.

Review of Patient #10's chart from current admission showed that she was admitted to Long Term Acute hospital on 8-15-2017. The History and Physical (H&P) dictated on 8/16/2017 indicated the surgical debridement of patient's wound occurred on 8-10-2017 in the acute hospital. The H&P did not mention any active MRSA infections. The H&P did not mention any positive blood cultures or address the patient receiving Vancomycin for positive blood cultures. The Discharge Summary from 8-22-2017 did not mention treatment for MRSA or positive blood cultures.

Review of the Admission Orders did not reveal an order or reason for the patient to be placed in isolation precautions. Admission medication orders included "Clindamycin 300 mg PO BID" (300 milligrams by mouth twice a day) and "PICC Line" (peripherally inserted central catheter is an IV line that is inserted into a deep vein and usually used for patient with poor shallow veins or for long term IV medication administration). The order for Clindamycin did not give the indication (reason) for the antibiotic. Chart review showed that no PICC line was ever placed.

An interview was conducted with Staff #3 on 8-22-2017. Staff #3 stated, she did not know why the patient was on oral Clindamycin. Staff #3 was not able to locate in the chart any information such as lab results and cultures concerning an active MRSA infection.

Patient #10 was placed in a room with a patient #11, who had an active MRSA infection.



Staff #3 was interviewed in the late morning, of 8/23/2017. She confirmed, she was on vacation and was not in the house when patient #11 and patient #10 were placed in the same room. Staff #3 confirmed, she was the acting Infection Control Nurse. Staff #3 was asked if she had a method for identifying and tracking patients with infections that required isolation. She indicated she used the daily nurses patient roster which told each patient and their diagnosis. The nurses roster for 8/23/2017 was reviewed with staff #3 and it was brought to her attention that the list did not capture patients whose diagnosis changed mid shift, related to lab results that came in late or when the nurse failed to update the patient roster and diagnosis list. She confirmed she was not aware the nurse's patient roster was incomplete and that patients with infections requiring antibiotics and or isolation were not captured. She confirmed, she didn't have an on-going Infection Control record where each patient's infection was logged or tracked. She tallied the patients with infections at the end of each month.


On the afternoon of 8/23/2017 in the conference room, staff #1, #2, and the corporate nurse were present for interviews. The leadership was asked how were patient room assignments determined? Staff #2 indicated staff #3 made the room assignments.

Staff #2 was reminded that staff #3 was on vacation and not in the building when patient #10 and patient #11 were placed in the same room. Staff #2 then indicated the floor nurses knew how to co-habitate patients.

Staff #2 was then asked who had the final say where patients were placed and who they were placed with. Staff #2 confirmed, He did , as the Chief Nursing Officer.

An interview with Registered Nurse, staff #31 indicated, "she knew how to put the right patient in the right room", however, she could not explain the process. Staff #31 couldn't remember if she had been in-serviced regarding choosing room for isolation patients.


A review of the policy , "MDRO (Multi drug Resistant Organism) Contact Isolation" revealed:

Policy:

"19.2.1 Patients colonized or infected with MDRO will be evaluated on individual basis for containability of infective substance and mental-cognitive status.

19.2.2 Patients identified with MDRO will be cohorted or placed in a private room. Otherwise, place patient in a room with another patient who:

19.2.2.1 is not immuno-compromised, (cancer, getting chemotherapy, HIV (Human Immuno Virus) positive, autoimmune disorder, etc)

19.2.2.2 does not have tubes, (Indwelling Foley Catheter, suprapubic catheter, IV (Intravenous) access, Peg, (Percutanious gastrostomy), NF (Naso gastric) tracheostomy, etc).

19.2.2.3 does not have open wounds".

A review of the Infection Control program for the facility revealed the program had not been approved by the Governing Body since 2015. The infection Control program had not been updated.


Staff #2 and staff #1 were not familiar with their hospitals policy and had not followed the policy. Staff #1 and #2 had not educated their staff on the above mentioned policy. Both staff #2 and staff #3 indicated there "should be" a physician's order for isolation. Staff #1 confirmed they did not have a clear method of determining isolation and who would be co-habitated when infections were present that required isolation. Staff #1, #2, and #3 were made aware their Infection Control Plan had not been approved by the Governing Body since 2015.


Patient #10, in an already immuno-compromised condition, had an open wound, IV access, and co-morbidities that had the likelihood to place this patient at risk of re-infection when she was co-habited with pt #11.

The hospitals leadership demonstrated a lack of knowledge related to the hospitals Infection Control Plan, as well as, policies and procedures. The nursing department demonstrated a lack of initiative in advocating for patient health and safety.


This deficient practice posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Based on record review and interview, the facility failed to have an updated contract for Organ and Tissue Donation, failed to have approved policy and procedures, and was not integrated into the hospital's QAPI program.

Review of the facility's contracted services revealed there was no current contract offered for Organ Procurement. Staff #1 confirmed it had expired and there was no viable contract to offer on 8/23/17.

Review of the facility's policy titled "Organ and Tissue Donation" revealed the last date it was revised was September 2014. There was no evidence found that the policy and procedures have been revisited by the Governing body from August 2016 to August 2017.

Interview with staff #1 on 8/23/17 revealed the policy and procedures are reviewed by corporate every two years and then sent to the facility. There was no evidence provided that the facility's governing body had approved the policy and procedure.

Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes and data revealed there was no mention found that the organ, tissue and eye donation program was integrated into the hospital's QAPI program.


Interview with staff #3 on 8/23/17 confirmed there was no evidence of organ, tissue and eye donation program integration into the hospital's QAPI program.

An interview was conducted with the charge nurse, staff #17, on 8/23/17. Staff #17 was not aware of the organ, tissue and eye donation program. Staff #17 stated she was not aware and needed to go ask someone.

Based on record review and interviews, the facility failed to have a written agreement available for the organ, tissue and eye donation program.

Review of the contract list provided by staff #1 revealed an Organ/Tissue Donor Agreement was listed but Staff #1was unable to provide a copy of the contract.. Staff #1 confirmed she did not have the contract on 8/23/17.

Based on interview and document review, the facility failed to ensure the Infection Control (IC) program was functional and incorporated into the hospital wide Quality Assessment Process Improvement (QAPI) program from January 2017 through August 2017.



This deficient practice had the likelihood to effect all patients (Pt/pt) of the hospital.


Findings included:


On the morning of 8/22/2017, in the conference room an interview with staff #3 confirmed she was the acting infection control professional (ICP). A review of staff #3's employee file revealed she did not have a signed job description to serve as the ICP. Further review revealed there was no evidence in her employee file to indicate staff #3 had received IC training sufficient to direct the IC program.

A review of the "Infection Control Program", last updated 1/22/2015, indicated "Policies and Procedures are based in the following":

APIC (Association for Professionals in Infection Control)
SHEA (Society for Healthcare Epidemiology of America)
CDC (Centers for Disease Control)
State Regulations
OSHA (Occupational Safety and Health Administration)
CMS (Centers for Medicare and Medicaid Service)
Joint Commission Requirements.

Further interview with Staff #3 confirmed she had completed online modules offered from her corporate offices, but did not know if they were provided through any of the above listed criteria for their hospitals Policies and Procedures. Further she did not have any evidence she competed the training.

On the afternoon of 8/22/2017 in the conference room an interview with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) had not ensured copies of staff #3's IC training had been saved to her employee file to ensure evidence of training in IC.

Review of the January 2017 through 8/2017, Medical Executive meeting minutes also failed to document evidence of staff #3's infection Control training.

Further review of the IC program revealed:

"The Hospital Infection Control Professional has the authority over the program. The Infection Control Professional and the Infectious Disease Physician Chairperson are responsible got the following:

Developing policies governing control of infections and communicable disease.

Implementing policies governing control of infections and communicable diseases.

Developing a system for identifying, reporting, investigating, and controlling infections and communicable diseases.

To institute appropriate prevention and or control measures or studies and recommend corrective action with any department when there is considered to be a danger to any patient or personnel.

The nurse on the unit has the authority to initiate any appropriate precautions according to policy".


Further interview with staff #3 confirmed there was no infectious disease physician who chaired the ICP. She continued that she chaired the meeting and presented the information during the QAPI meeting and then to the MEC and Governing Body (GB). A request was made to review the IC meeting minutes. Staff #3 provided two meetings with attached minutes.

Meeting dated May 31/2017 was titled Safety/EOC (Environment of Care). A review of the IC data presented during that meeting is found below.

Infection Control Data: discussion/conclusions see attached infection Control Scorecard (No scorecard was provided)

Recommendation and Actions: were listed as. Continue PI (Process Improvement) Projects for hand hygiene and PPE (Personal Protective Equipment) 90% monthly compliance.

Implement PI Project: to decrease F/C (Foley Catheter) ratio usage.

Meeting dated July 14, 2017 was titled Safety/EOC. A review of the IC data presented during that, meeting is found below.

Infection Control Data: See attached infection control scorecard. (No scorecard was provided). Implement PI Project to decrease F/C ratio usage. (6 weeks had passed since the recommendation to implement the decreased F/C ration usage. The PI had not been implemented). The recommendation was "Contact the CNO from *another facility* for suggestions for criteria for a protocol to remove F/C" the responsible party was identified as the DQM (Director of Quality Management) and it was on-going.

Further interview with staff #3 revealed there was no IC Committee. She collected information throughout the month and presented it during the QAPI meeting. Staff #3 was the QAPI nurse for the North campus.

Review of the ICP revealed "The IC Committee will, annually determine the type and scope of surveillance to be used based on the results of data trend analysis, effectiveness of prevention and control intervention strategic strategies, and recommendations of best practice guidelines".


The facilities CEO, CNO, MEC had not established, monitored, or maintained an active ICP.