HospitalInspections.org

Based on observation, record review, and staff interview, the hospital failed to maintain an effective governing body to oversee hospital functions that ensure hospital systems promote quality of care and protect the health and safety of patients.

The governing body failed to:

1) Ensure the hospital assigned a qualified person to effectively and responsibly manage the human resources department (Reference A57).

2) Ensure 36 of 43 clinical contracts and 32 of 43 non-clinical contracts have been evaluated to ensure compliance with applicable Medicare Conditions of Participation and standards (Reference A83).

3) Ensure 83 of 83 contracts were evaluated to ensure services are provided in a safe and effective manner (Reference A83).

4) Develop and maintain policies and procedures to address the emergency needs for 11 of 11 pediatric patients admitted to the facility within the past year (Reference A91).

5) Ensure the hospital complies with caregiver compliance laws in the investigation and reporting for 3 of 3 hospital staff (Reference A20, A21).

6) Protect and promote the rights of each patient (Reference A115, A130, A132, A144).

7) Develop, implement, and maintain an ongoing, comprehensive, hospital-wide quality assurance performance improvement (QAPI) program with a goal of improving hospital processes, hospital services, and hospital operations that ensure services are provided in a safe and effective manner (Reference A263, A264, A267, A275, A287, A288).

8) Maintain a well-organized nursing service that provides an adequate number of qualified and trained nursing staff to safely care for patients (A385, A386, A392, A396, A397, A404, A408)

9) Ensure the hospital has an organized dietary service, staffed by adequate qualified personnel (Reference A618, A619, A620, A622, A631).

10) Ensure building systems are constructed and maintained to provide a safe physical environment for patients (Reference A700, A709, and A724).

11) Follow it's own established surveillance plan for the prevention and control of infections; establish new policies when needed for the protection of the patient population with regard to housekeeping and laundry services; investigate and design a prevention control plan for problematic HAIs (Healthcare Associated Infections) in the patient population; and to ensure that they hired a qualified IC professional with verified IC education (Reference A747, A748, A749, A756).

12) Ensure the hospital complies with specific organ, tissue and eye procurement requirements (Reference A884, A885, A886, A891, A892, A893).


The cumulative effect of failures resulted in the breakdown of multiple hospital systems that led to the governing body's inability to operate a hospital that ensures optimal health and safety for patients.

Based on record review and staff interview, the hospital failed to protect and promote the rights of each patient as evidenced by the failure to:

1) Ensure the patient and/or family is involved in the care planning process (Reference A130).

2) Ensure the Power of Attorney for Health Care (POAHC) was activated in 1 of 1(#8) before allowing family to make decisions to allow the patient to die (Reference A132).

3) Provide a safe environment for 1 of 1 patients (Pt #33) left alone and fell while on 1:1 supervision; and failed to ensure current standards of practice are used to care for 1 of 1 pediatric patients (Pt #28) by qualified and competent staff (Reference A144).

The cumulative effect of failures resulted in the hospital's inability to ensure patient rights are protected and the health and safety of patients is maintained.

Based on review of performance improvement meeting minutes, performance improvement program, physician quality assurance meeting minutes and staff interviews, the hospital failed to develop, implement, and maintain an ongoing, comprehensive, hospital-wide quality assurance performance improvement (QAPI) program with a goal of improving hospital processes, hospital services, and hospital operations that ensure services are provided in a safe and effective manner.

The facility failed to:

1) Include all hospital departments in quality assurance performance improvement (QAPI) activities to ensure patient health and safety (Reference A264).

2) Assess hospital processes, hospital services, and hospital operations to ensure services are provided in a safe and effective manner (Reference A267).

3) Include services provided to the hospital under contract in the hospital's QAPI program to ensure services are provided in a safe and effective manner (Reference A275, A83 and A84).

4) Assess all unanticipated hospital transfers and deaths to ensure the patient received quality care based on standards of practice in a safe and effective manner (Reference A287).

5) Reassess and implement preventive actions to address an increase in the number of falls experienced by 3 of 3 patients in the hospital from January 1, 2010 to February 28, 2010 (Reference A288).

The cumulative effects of these failures led to the facility's inability to improve the quality of patient care and prevent or minimize risks to the health and safety of patients.

*This citation is being re-cited at Condition level at this full survey. (Reference complaint survey completed 1/4/10.)

Based on review of personnel files and job descriptions, hospital and contract dialysis service policies and procedures, the hospital staffing matrix, payroll sheets, 3/1/10 staffing schedules, and census reports, contract and hospital staff interviews, and e-mail communications, the hospital failed to:


1) Ensure an RN (registered nurse) in charge of the nursing service : a) was responsible for nursing policy and procedure development; b) was responsible for nursing staff training and nursing competency guidelines and; c) had authority to assume job description duties to ensure safe patient care. (A0386)

2) Provide adequate numbers of staff [RN (Registered Nurses), CNA (Certified Nursing Assistants)] to provide nursing care to acute care patients based on their scheduling matrix and patient needs. (A0392)

3) Ensure that all sampled patients had a nursing care plan that met their current physical, mental and psychosocial needs. (A0396)

4) Ensure that nursing staff were qualified to care for patients admitted into their nursing service. (A0397)

5) Ensure contracted dialysis nursing staff provided medications and biological preparations in accordance with accepted standards of nursing practice and hospital policy. (A0404)

The cumulative effects of these systemic nursing management failures created an unorganized nursing system and patient care services that did not meet the needs of the hospital's patient population

Based on personnel file review, organizational chart review, job description review, staff interviews, and observations, the hospital failed to have an organized dietary service, staffed by adequate qualified personnel as evidenced by the hospital's failure to:


1) Maintain an organized dietary service (A 619)

2) Maintain a Director of Dietetic and Food Service responsible for the day to day function of the department (A 620).

3) Maintain qualified and competent staff (A 622).

4) Maintain a current diet manual (A 631).

The cumulative effects of these systematic problems, impedes the hospital from having an organized and effective dietetic and food service department.

Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in 5 of the 5 smoke compartments, and would affect all of the 28 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies. K11 (common walls), K12 (building type), K17 (corridor walls), K18 (corridor doors), K21 (door hold opens), K33 (exit construction), K43 (egress locking) and K47 (egress signage). Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41.

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Based on surveyor observations, IC (Infection Control) policies/ procedures reviews, IC committee meeting documentation and minutes, Quality Improvement IC documentation and meeting minutes, IC logs, IC staff interview and other staff interviews, the hospital failed to maintain a sanitary environment in all hospital departments, failed to follow it's own established surveillance plan for the prevention and control of infections, failed to establish new policies when needed for the protection of the patient population with regard to housekeeping and laundry services, failed to investigate and design a prevention control plan for problematic HAIs (Healthcare Associated Infections) in the patient population, failed to ensure that they hired a qualified IC professional with verified IC education.

Findings include:

1) The hospital failed to ensure that the newly hired ICP (Infection Control Preventionist) had validated basic infection control training. The hospital failed to ensure that the ICP developed policies and procedures to prevent cross-contamination and infection in the following areas: shared toilet facilities and laundry services. (A0748)

2) The hospital's ICP (Infection Control Preventionist) failed to; 1) establish an environmental IC surveillance program for all hospital departments that would attempt to maintain a sanitary environment and prevent and control the transmission of infectious pathogens in the patient care areas and dietary department; 2) provide an active IC surveillance program that met the needs of the patient population according to the hospital's established policies by omitting the surveillance of device-related infections; 3) investigate and plan preventative measures when trending of UTIs (urinary tract infections) in the patient population became problematic. (A0749)

3) The hospital's administrative staffs [Chief Executive Officer (CEO), medical staff and Director of Nurses (DON)] failed to ensure that the hospital's infection control plan was followed and monitored through the hospital's Quality Assessment Performance Improvement (QAPI) program, and failed to ensure that contacted hospital services (dialysis, laboratory and laundry) maintained nationally recognized IC practices. (A0756)

These cumulative failures resulted in an inability to ensure that the hospital maintained a sanitary environment that identified, prevented and/or controlled sources of infection transmission.

Based on medical record review, staff interview, policy & procedure review, the hospital failed to meet the specific organ, tissue and eye procurement requirements.

Findings include:

1) The hospital failed to have written policies and procedures to address its organ procurement responsibilities. See Tag A-0885

2) The hospital failed to incorporate a complete and up to date agreement with an Organ Procurement organization (OPO).
See Tag A-0886.

3) The hospital failed to work with the OPO on educating staff on donation issues.
See Tag A-0891

4) The hospital failed to work with the OPO on reviewing death records.
See Tag A-0892

5) The hospital failed to work with the OPO on maintaining potential donors.
See Tag A-0893

The cumulative effect of these failures prevents possible donations of life saving organs.

Based on review of personnel files, review of pertinent policies and staff interview the Chief Executive Officer failed to have a qualified Director of Human Resources (HR).

Findings include:

On 03/02/10 at 9:00 a.m. a list of personnel files were requested. The requested personnel files were noted to be incomplete. Required information was missing and therefore took 3 days to review and obtain required information.

On 03/02/10 through 03/04/10 Surveyor #22198 along with HR Assistant II reviewed personnel files, and the following information was missing:

3 (E, Z and AA) staff had histories of criminal findings with violence, however HR Director VV who was responsible for personnel files failed to obtain the required evidence required per State Caregiver law to ensure that the 3 staff were safe to work as direct caregivers.

1(AA) staff that had a low rubella titer had no evidence of immunity per State requirement and hospital policy.

1(W) staff failed to have documentation of completed Hepatitis B vaccination series.

3 (Y, X and O) staff failed to have completed orientation to the departmental requirements

1 staff (W) failed to have evidence of their hospital required annual TB.

HR Director VV was unavailable during this full survey, so no interview was conducted, to address the disorganization and incomplete personnel files required by State law and hospital policy.

HR Director VV's personnel file and job descriptions that included educational requirements was reviewed by Surveyor #22198 and HR Assistant II and the following was identified:

Per Job description for Director of Human Resources, under title "Education" notes the position requires a degree in Human Resource, however review of HR Director VV's resume noted education was an Associate Degree with Administrative Assistant/Secretarial Science.

No diploma or educational content was found in HR Director VV's personnel file.

These findings were acknowledged by Administrator B at daily conference on 03/04/10 at 2:45 p.m.

Additional information was sent via e-mail from Administrative Assistant QQ on 03/09/10 and 10:10 a.m., however the material sent were from conferences attended, and did not include additional degree based education.

Based on review of governing board meeting minutes, Performance Improvement (PI) plan, and staff interview, the governing body failed to provide documentation to show 36 of 43 clinical contracts and 32 of 43 non-clinical contracts have been evaluated to ensure compliance with applicable Medicare conditions of participation and standards.

Findings include:

Per record review and staff interview conducted by Surveyor #03383:

A review of the PI plan the morning of 3/4/10 indicated the following:

"The Board of Directors of Lakeview Specialty Hospital & Rehab is ultimately responsible for assuring that high quality care is provided to our patients/clients."

A review of the facility's governing board meeting minutes on 3/3/10 beginning at 7:10 AM dated 4/22/09, 8/10/09, 10/29/09, and 2/16/10 revealed governing board minutes fail to show 36 of 43 clinical contracts and 32 of 43 non-clinical contracts were reviewed for Medicare regulatory compliance. Examples include:

Clinical Contracts:
ACL Incorporated Lab Services, All Saints Healthcare System, American Red Cross, AmerisourceBergen, Apex Radiology, Aurora Visiting Nurse, Blackhawk Technical College, Comprehensive Healthcare Medical Dictation, Concordia University of Wisconsin, Formula One Source, Gateway Technical College and Gateway Technical College District #6, Guardian Health Staff LLC, Intelistaf, KCI, LabOne, Lions Eye Bank, MATC, Medical College of Wisconsin, Medline Industries, MED-Dispense, Medical Staffing Network, Memorial Hospital of Burlington, Midwest Dialysis, Nursing Centers, Praxair Cylinder and Bulk Oxygen, Preferred Portable X-Ray Inc., Radiologist Tech, Rogers Memorial Hospital, St. Ambrose University, Top Techs, Union Grove/Burlington Special Education, University of Wisconsin Milwaukee, Visiting Nurse Association, Wisconsin Donor Network, and Wisconsin Tissue Bank.

Non-Clinical Service Contracts:
Advance Therapeutics, Ailsa Group, Amerinet, Badger Elevator, Baxter, Baymont, Biomedical Solutions, Comprehensive Healthcare Services, Culligan, DataStore, Down to Earth Mechanical, Ecolab, Eppstein Uhen Architects, Fortune Personnel Consultants, Health Care Data, Ingenix, Interstate Pump and Tank, Mark Douglas Herbert, Med-Con Inc., Medline Industries Inc., MetaStar, Mount Mary, Norway Lutheran Church, Pepsi America, Power of Attorney, Racine County Ridgewood Care Center, St. Francis, Steri-Cycle, Town of Dover, USA Mobility, Waste Management, Wellspring, WinMedia, and 3M.
Governing board meeting minutes were reviewed again beginning at 10:57 AM on 3/10/10 to confirm findings and Administrator B was asked on 3/10/10 to confirm findings at 11:33 AM. Executive Assistant QQ confirmed on 3/10/10 at 12:12 PM that 14 contracts were approved by the governing board in 2009; however also indicated "We recognize a more in-depth QA (Quality Assurance) is needed and will address immediately." Executive Assistant QQ provided a list of 14 contracts approved by the governing board. The remaining 72 contracts above are not listed.

Based on review of governing board meeting minutes, Performance Improvement (PI)plan and staff interview, the governing body failed to provide documentation to show 83 of 83 contracts were evaluated to ensure services are provided in a safe and effective manner.

Findings include:

Per record review and staff interview conducted by Surveyor #03383:

A review of the PI plan the morning of 3/4/10 indicated the following:

"The Board of Directors of Lakeview Specialty Hospital & Rehab is ultimately responsible for assuring that high quality care is provided to our patients/clients."

A review of the facility's governing board meeting minutes on 3/3/10 beginning at 7:10 AM dated 4/22/09, 8/10/09. 10/29/09, and 2/16/10 revealed governing board minutes fail to show all 83 contracts were reviewed for Medicare regulatory compliance. Examples include:

ACL Incorporated Lab Services, All Saints Healthcare System, American Red Cross, AmerisourceBergen, Apex Radiology, Aurora Visiting Nurse, Biomed Solutions, Blackhawk Technical College, Comprehensive Healthcare Medical Dictation, Concordia University of Wisconsin, DVA Renal Healthcare, Formula One Source, Gateway Technical College and Gateway Technical College District #6, Guardian Health Staff LLC, Heritage Health Care Group, Intelistaf, KCI, LabOne, Lions Eye Bank, MATC, McKesson, Medical College of Wisconsin, Medline Industries, MED-Dispense, Medical Staffing Network, Memorial Hospital of Burlington, Midwest Dialysis, MRIoA Peer Review, Nursing Centers, Odyssey Health Care, Paratech Ambulance Service, Praxair Cylinder and Bulk Oxygen, Preferred Portable X-Ray Inc., Radiologist Tech, Rogers Memorial Hospital, S&J Bus Service, Southeast Wisconsin Medical Reserve Corps, St. Ambrose University, Superior Health Linens, SureQuest Systems, Time Warner, Top Techs, Union Grove/Burlington Special Education, University of Wisconsin Milwaukee, Visiting Nurse Association, Wisconsin Donor Network, Wisconsin Tissue Bank, Advance Therapeutics, Ailsa Group, Amerinet, Badger Elevator, Baxter, Baymont, Biomedical Solutions, Comprehensive Healthcare Services, Culligan, DataStore, Down to Earth Mechanical, Ecolab, Eppstein Uhen Architects, Fortune Personnel Consultants, Health Care Data, IKON, Ingenix, Interstate Pump and Tank, Mark Douglas Herbert, Med-Con Inc., Medline Industries Inc., MetaStar, Mount Mary, Norway Lutheran Church, Pepsi America, Power of Attorney, Racine County Ridgewood Care Center, St. Francis, Steri-Cycle, Town of Dover, USA Mobility, Waste Management, Wellspring, WinMedia, and 3M.
Governing board meeting minutes were reviewed again beginning at 10:57 AM on 3/10/10 to confirm findings and Administrator B was asked on 3/10/10 to confirm findings at 11:33 AM. Executive Assistant QQ confirmed on 3/10/10 at 12:12 PM that 14 contracts were approved by the governing board in 2009; however also indicated "We recognize a more in-depth QA (Quality Assurance) is needed and will address immediately." Executive Assistant QQ provided a list of 14 contracts approved by the governing board. The remaining 72 contracts above are not listed.

Based on interview and review of the hospital's orientation, education and competencies, the governing body failed to develop and maintain policies and procedures to address the emergency needs for 10 of 10 pediatric patients admitted to the facility within the past year.

Findings include:

On 03/01/10 during the entrance conference from 9:40 AM to 10:30 AM, the hospital acknowledged it did not have a dedicated emergency department.

On 03/04/10 between 9:30 a.m. and 10:00 a.m. during open record review of Patient #28 that identified a 10 year old patient was admitted on 03/03/10.

No emergency plan of action was defined in Patient #28's record.

Interviews with Registered Nurse (RN) E, in charge of Patient #28's care on 03/04/10 at 10:00 a.m. confirmed to Surveyor #22198, that he had no education or orientation to pediatric care.

When Surveyor #22198 asked RN E what he would do in the case of an emergency with pediatric Patient #28, told Surveyor #22198, he would call "911".

RN E confirmed to Surveyor #22198, that he was not aware of any pediatric medication, or pediatric emergency equipment.

During personnel file reviews conducted by Surveyor #22198, between 03/02/10 through 03/04/10, no evidence of pediatric training or competencies were noted in 5 of 5 CNA files reviewed, or 7 of 7 direct care employees that included RN's, Licensed Practical Nurses (LPN's), therapists and therapy aids and a registered dietician.

On 03/04/10 at 11:00 a.m. during an interview with Director of Nursing (DON) A confirmed that direct care staff had not been educated on pediatric emergencies, and the hospital does not maintain pediatric emergency medication that she is aware of.

DON A told Surveyor #22198, the hospital does have a pediatric AED and pads; however the use of the pediatric AED and pads were not a part of their emergency competencies, mock drills and training.

DON A told Surveyor #22198, she has voiced her concerns to administration about the hospital advertising the treatment of the pediatric population, when none of the hospital's staff has had training, orientation or competencies to ensure that the staff are capable of safely providing pediatric care, however the hospital continues to admit pediatric patients.

DON A confirmed that on 03/03/10 the hospital admitted a 10 year old patient knowing the hospital's staff was not competency qualified to care for pediatric patients, and the hospital did not have policies and procedures to ensure the safety of the pediatric population in an emergency situation.

On 03/04/10 at 11:45 a.m. the failure to have qualified and competent staff to care for pediatric patients was confirmed and acknowledged by the current Administrator B. Administrator B confirmed he knew this prior to admitting Patient #28.

On 03/09/10 at 4:53 p.m. Administrative Secretary QQ sent additional documentation via e-mail that included a pediatric emergency policy, along with a list of an additional 9 pediatric patients ranging from 9 to 16 years of age that have been admitted to the hospital over the past 12 months. No additional documentation was provided to show staffs' education, qualification and competencies to care for pediatric patients in the hospital.

Based on policy and procedure review, record review, and staff interview, this hospital does not demonstrate that the patient and/or family is involved in the care planning process. The facility also failed to ensure the guardian/family member of 1 of 30 sampled patients (Pt #3) is allowed to participate in weekly interdisciplinary care planning conferences.

Finding include:

Hospital policy titled, "Nursing Care Plan Process" with a revision date of 1/2010 was reviewed by Surveyor #26711 on 3/2/10 at 9:23 a.m. This policy states in #2. b. that, "Patients and families will be educated on these care plans."

This process does not indicate that the patient/family are involved in the process of planning their care or that they will have input into the process of planning their care.

This information was discussed with, and confirmed by Chief Nursing Officer A on 3/2/10 at 9:35 a.m., and discussed again on 3/2/10 at 4:15 p.m. with Administrator B.


03383

Per record review and staff interview conducted by Surveyor #03383:

Per medical record review on 3/2/10 beginning at 7:30 AM:

Pt #3 was admitted to the facility on 12/4/09 to 1/13/10 to improve behavior, improve ambulation, and improve toileting skills. Pt #1 was admitted to the facility with a diagnosis of chronic HIV encephalitis, dementia with agitation, and impaired gait/mobility. Guardian SS is Pt #3's legal guardian.

Guardian SS complained via letter dated 2/5/10 that the hospital did not allow her to actively participate in Pt #3's weekly care conferences as promised.

Case management note dated 12/4/09 indicates Guardian SS will attend care conferences via teleconference. The case management note dated 12/17/09 indicates the phone system is down and Guardian SS is unable to be reached. A message was left for Guardian SS to inform her about updates of care conferences. A physician note dated 12/23/09 indicates Pt #3's condition was discussed with Guardian SS on 12/23/09. The notes does not indicate Guardian SS was notified to attend the care conference on 12/23/09. Case management note dated 12/30/09 indicates a care conference was held on 12/30/09, the same day Pt #3 was transferred to another local area hospital for rectal bleeding. Guardian SS was with Pt #3 on 12/30/09 and not able to attend. A case management note dated 1/7/10 indicates a care conference was held and no answer to Guardian SS's work number after several attempts were made. The record does not indicate Guardian SS was asked to attend the conference or whether the case manager tried to contact Guardian SS with results of the care conference.

Progress notes show the facility kept Guardian SS informed about Pt #3's condition; however, the facility failed to directly involve Guardian SS in care planning decisions through attendance of care planning conferences via teleconference as indicated on 12/4/09.

An interview with Dr. KK (personal medical doctor/PMD) on 3/8/10 beginning at 12:15 PM revealed that Guardian SS did attended one care conferences. Dr KK provided a timeline that shows Guardian SS attended one care conference.

Based on staff interviews and review of patient medical records, the hospital failed to activate 1 of 1(#8) patient's Power of Attorney for Health Care (POAHC), however allowed family to make decisions and sign documents for Patient #8.

Findings include:

On 03/02/10 at 10:30 a.m. during a record review of Patient #8's medical record, surveyor noted that a POAHC paper was in the medical record. The POAHC was not activated during his stay at the hospital from 01/08/10 on admission through 01/13/10 at discharge/death.

Admission consent and admission paper work completed on 01/08/10 by non-licensed admitting staff allowed a family member to sign admission consent noting Patient #8 was unable to sign, however failed to document why patient was unable to sign.

The remainder of admission paper work including confirmation of patient rights and responsibilities and acknowledgement of Advanced Directives was not signed by Patient #8, however was signed by a family member. Un-licensed admitting staff documented that the family who signed was "the POAHC".

On admission 01/08/10 the physician and nurse assessment indicated that Patient #8 was alert and oriented and was his own decision maker.

Case management and nurse documentation indicated that Patient #8 was able to write, however did so "slowly".

On 01/13/0 a physician signed a State of Wisconsin chapter 154 "DO NOT RESUSCITATE" (DNR) order for Patient #8. On 01/14/10 a family member signed the document on the signature line that indicated the family member was a legal guardian or Health Care Agent of an incapacitated patient.

The DNR form notes at the bottom, "The above signature and dates are required for this form to be valid and its intent carried out."

On 03/04/10 at 8:45 a.m. Surveyor #22198 during an interview and review of the findings in Patient #8's chart the Social Worker (SW)/Case Manager (CM) Staff U, confirmed that from 01/08/10 through 01/15/10 no one in the hospital documented an attempt to activate the POAHC paper work for Patient #8.

SW/CM Staff U told Surveyor #22198, that her job description is for "Case Manager" and does not work or function as a Social Worker for the hospital.

SW/CM U told Surveyor that it is the responsibility of the hospital's Chaplain to addresses Advanced Directives with Patients and families.

On 03/04/10 at 1:00 p.m. Surveyor #22198 received and reviewed the job description for the Chaplain, however failed to identify the responsibilities for Advanced Directives as a part of the job description or competency.

SW/CM Staff U confirmed that no where in Patient #8's medical record did it indicate that Patient #8 was incapacitated, or unable to make his own decisions, however staff allowed family to sign legal documents/orders for DNR.

This information was reviewed with Administrator B on 03/04/10 at 2:30 p.m.

Based on review of personnel and patient records and staff interviews, the hospital failed provide a safe environment for 1 of 1 patients (Pt #33) out of 30 sampled patient records when Pt #33 fell after staff left Pt #33 alone while Patient #33 was on 1:1 supervision. The hospital also failed to ensure 1 of 1 (#28) current pediatric patients is cared for based on current standards of practice by qualified and competent staff.

Findings include:

Per record review and interviews conducted by Surveyor #22198 from 03/02/10 through 03/04/10:

#1
On 03/03/10 at 1:00 p.m. during the review of personnel file a Registered Nurse (RN) identified as the "Wound Care" nurse had a "remedial action" for failing to document the incident on 01/09/10 when Patient #28 fell.

The Director of Nursing DON A's investigation documentation noted that Patient #33, was to be on 1:1 observation.

The RN (NN) responsible for Patient #33's care, assigned Certified Nursing Assistant (CNA) MM to this task, however CNA MM left Patient #33 alone and subsequently Patient #33 fell.

RN NN failed to complete or document a physical exam, and failed to report the fall in an incident report per the hospital's protocol.

Charge Nurse LL was also aware that RN NN had not documented the incident, however failed to report RN NN for failure to comply with hospital policies and procedures for incident reporting and standards of care for assessment of a known fall.

The Charge Nurse (LL) was also aware that CNA MM left Patient #33 alone and then Patient #33 fell. Furthermore Charge Nurse (LL) failed to report the incident or complete an assessment.

DON A completed an immediate investigation noting her findings of the alleged neglect of Patient #33 by CNA MM, RN NN and Charge Nurse RN LL and turned it over to acting administrator at this time Staff O and COO -Staff OO, however the hospital failed to complete caregiver compliance requirements and continued to keep RNs LL and NN in working status unsupervised.

No education was documented to ensure all 3 staff were aware of the magnitude of their non-compliance to prevent future failures in regulatory requirement of a hospital, patient rights and caregiver compliance.

#2
Based on current hospital census reports, and medical record review on 03/03/10 at 9:30 a.m. the hospital admitted a 10 year old pediatric patient (#28), knowing that the direct patient care staff (RNs, LPNs, CNAs, and Therapy staff) were not competency tested for pediatric care, and the hospital did not have policies and procedures to ensure safe standards of pediatric care.

Review of personnel files confirmed the hospital did not have pediatric competencies based on current standards of practice.

This was confirmed in interviews with the Director of Nursing (DON) A on 03/04/10 at 11:00 a.m., and with Administrator B and Regional Chief Operating Officer (COO) -OO on 03/04/10 at 11:45 a.m.

Administrator B confirmed that the hospital admits pediatric patients.

Based on review of direct care staff job descriptions, and employee files and staff interviews, the hospital failed to have an RN (registered nurse) who was in charge of the nursing service that: 1)was responsible for nursing policy and procedure development, 2) was responsible for nursing staff training and nursing competency guidelines, 3) who had authority to assume job description duties to ensure safe patient care.

Findings include:

Between 03/02/10 through 03/04/10 Surveyor #22198 and Human resource (HR) Assistant II reviewed personnel files, with the following findings:

1) Administrative Assistant QQ provided Surveyor #22198 with all the employee job descriptions. The hospital had no job description to define training, education, skills or role and responsibilities of a charge nurse. This was verified by Administrative Assistant QQ on 03/04/10 at 8:00 a.m.

The 03/04/10 at 11:00 a.m. interview with Director of Nursing (DON) A confirmed to Surveyor #22198, that none of the nurses had been trained or educated in the role of charge nurse. DON A stated that all nurses were rotated into the position of "charge nurse". DON A confirmed there was no job description of competency for any nurse that assumed the role as charge nurse. When Surveyor #22198, asked how do the nurses responsible for the task of being in charge know what to do when administrative representation was not on site, she replied "good question". DON A told Surveyor #22198, that she was hired for the position as Director of Nursing, and reported directly to hospital Administrator B, however based on her job title and job description, she is not allowed to make administrative decisions for the nursing staff and is often over-ruled when making decisions.

In continued interview with DON A, at the above time, DON A stated with the lack of Administrative support, she is not allowed to make nurses staffing schedules that are based on patient census and the acuity of patients need. This is a task assigned to the FAO(Facility Administrative Officer). DON A told Surveyor #22198, that as DON, she is not allowed to have input into the department policies and procedure that govern nursing services. DON A stated she was not aware or a part of decision making for the standards of nursing practice provided in the hospital. DON A told Surveyor #22198, she is provided policies by administration and told to review and sign them, so the hospital can be compliant with the requirement for keeping policies and procedures up to date. DON A told Surveyor #22198, she is only filling a role, and does not have the authority or administrative support to ensure the position requirements are met, including failure to be involved in the nursing education based on current standards of care.

2) During open record review of Patient #28, on 03/04/10 between 9:30 a.m. and 10:00 a.m. noted Patient # 28 was a 10 year old pediatric patient. On 03/04/10 at 11:00 a.m. DON A confirmed that there has been no hospital training over hospital policies and procedures with regard to care of the pediatric patient.

The failure to have qualified and competent staff to care for pediatric patients was confirmed and acknowledged by the current Administrator B on 03/04/10 at 11:45 a.m.
Also present was Corporate Chief Operating Officer OO.

Administrator B confirmed he knew this prior to admitting Patient #28 to the hospital.

Informational list provided by the hospital on 03/09/09 at 4:53 p.m. via e-mail reflects over the past 12 months 10 pediatric patients ranging from 9 to 16 years of age have been admitted to the hospital.

The following staff interviews conducted 3/04/10 from 9:30 a.m. to 11:00a.m, confirm lack of pediatric training:

Agency RN Staff E responsible for Patient #28's (10 year old) care that day confirmed to Surveyor #22198, he did not know of any pediatric policies and was not sure what he would do if there were a pediatric emergency. RN E told Surveyor #22198, he did not know if the hospital had pediatric equipment for an emergency like; medications or Automated External defibrillator (AED) with pediatric pads. Agency RN E told Surveyor #22198, he would probably just call "911".

RN (Wound Care Nurse) G confirmed to Surveyor #22198, she did not know of any pediatric policies and was not sure what she would do if there were a pediatric emergency. RN G told Surveyor #22198, she did not know if the hospital had pediatric equipment for an emergency like; medications or AED with pediatric pads.

LPN R confirmed to Surveyor #22198, she did not know of any pediatric policies and was not sure what she would do if there were a pediatric emergency. LPN R told Surveyor #22198, she did not know if the hospital had pediatric equipment for an emergency like; medications or AED with pediatric pads.

On 03/04/10 DON A confirmed that mock drills do not include the emergency of a pediatric patient. The staff would rely on calling "911".

3) In continued interview with DON A, at the above time, Surveyor #22198 was provided with documentation of remedial action requested to terminate RN LL who was in charge on 01/09/10 when Patient #33 fell related to staff not following hospital P&P's (policies and procedures). RN LL attempted to cover up the fall by not reporting or documenting this incident.

Additional staff involved in the 01/09/10 incident were RN NN who was the RN assigned and responsible for Patient #33's care on 01/09/10 and CNA (Certified Nursing Assistant) MM.

CNA MM was directed by RN NN to stay with Patient #33 for intense supervision (1 patient to 1 staff) based on assessment and care plan, however CNA MM left Patient #33 alone, and Patient #33 fell.

RN NN was informed and refused to document the incident and failed to document an assessment of Patient #33 to ensure that no injuries had occurred. RN NN admitted during DON A's investigation she knew what the hospital's P&P were, however would not report or document the incident, noting if the Charge Nurse LL wasn't going report or document it neither was she.

Charge RN LL, also informed of the incident, refused to document the incident and failed to document an assessment of Patient #33 to ensure that no injuries had occurred. During the investigation Charge RN LL told DON A, he did not "want to look bad".

DON A's request to terminate Charge Nurse LL was denied by COO (Chief Operating Officer) OO and Former Administrator O, at the time of the incident. DON A stated the response she received from this administration was that the hospital would not terminate RN LL until he could be replaced.

Review of DON A's job description as Chief Nursing Officer confirmed:
"Key Responsibilities: ...#5. Counsels and terminates employees following established department and facility guidelines."

DON A confirmed that both RN LL and RN NN were allowed to work unsupervised after this incident, and after reporting her findings of neglect for all 3 staff involved (RN LL, CNA MM and RN NN) to the administrative staffs (COO OO and Administrator O).

4) In continued interview with DON A at the above date and time, DON A stated that she was asked by COO OO, prior to the State Agencies arrival for the full survey, to have nursing staff go back into their medical records documentation, and "fix" their documentation. DON A stated she refused to carry out this request stating it would be falsification of medical records.

Defined in DON A's job description is:
"#7: Remains current regarding federal, state and accrediting body regulations and maintains compliance with these standards.




26711

5) In an interview on 3/2/10 from 9:05 a.m.-10:20 a.m. with DON A, DON A stated that there are binders of comprehensive, pre-printed care plans on each nursing unit. The Admission Nurse is to identify diagnoses pertinent to the patient and pull the appropriate care plans and personalize them.

The DON A states that the nurses have not been educated on how to do care planning. They have been educated on the process of pulling the care plans and putting them in the medical record but the current system of care planning is new and the nursing staff have not received education on how to write care plans.

DON A also stated that the nursing staff are not to write on the Interdisciplinary Care Plan, that only the Case Management (CM) staff (discharge planning) are to write in the nursing areas. The Case Management staff is comprised of one RN and one SW (social worker). According to DON A, the SW is writing in the nursing information on this form and DON A does not believe the CM staff was educated on what needs to be done.

In interviews with LPN (licensed practical nurse) R and M on 3/2/10 in the afternoon, both indicated they were part of an inter-shift training that was mostly conducted by Staff O. LPN R stated the staff are to, "Pull the book with the care plans, look up the most pertinent, fill it out and follow it." LPN R states that she does not pull them or initiate them. LPN M states that the LPNs no longer pull and initiate the care plans.

In an interview with RN N on 3/2/10 in the afternoon, RN N states Staff O did the training they received on care plans. RN N stated that Staff O, "Explained how to fill it out for patients."

On 3/3/10 at 7:30 a.m. a conversation was taking place at the nursing station between RN N and several other unknown members of the nursing staff. RN N was heard to say, "I'm curious as to why people who are RNs haven't been trained in care planning."

This information was confirmed with Chief Nursing Officer A on 3/3/10 at 7:40 a.m. in her statement that, "RNs are not to write on the Interdisciplinary Care Plan, only the Case Managers are, one of which is a SW, RNs did not receive training on care planning. They were introduced to them and told to fill them out."

Hospital policy titled, "Nursing Care Plan Process" with a revision date of 1/2010 was reviewed by Surveyor #26711 on 3/2/10 at 9:23 a.m. This policy states in #2. that a. the "Primary Care Nurse" [nurse of the day] chooses at least two care plans [from a binder with standardized, pre-printed care plans] based on identified problem areas of the patient, and b. patients and families will be educated on these care plans.
The policy does not address how to individualize the care plan. The policy does not address how or when to update the care plan, or what to do if a particular care plan is no longer applicable to the patient.

Hospital policy titled, "Interdisciplinary Care Planning-Hospital" with a revision date of 6/05 was reviewed by Surveyor #26711 on 3/2/10 at 9:30 a.m. This policy states it is, "A collaborative, interdisciplinary approach to provide medical/rehabilitative services consistent with professional licensure laws, regulations, and certifications is used to coordinate and plan care to meet patient/client care goals and achieve optimal outcomes."

Hospital staff meeting minutes dated 2/17/10 were reviewed by Surveyor #26711 on 3/2/10 at 9:50 a.m. In #8 of the minutes it states, "Care plans are up dated weekly. The primary nurse is responsible for the care plan. MUST BE R.N." The DON A clarified that all levels of nursing attended this meeting (Registered Nurses (RN), Licensed Practical Nurses (LPNs), Social Worker (SW), Certified Nursing Assistants).

This information was verified with Administrator B on 3/3/10 at 4:15 p.m.

Based on medical record review, policy and procedure review and staff interview, this hospital failed to develop or keep current nursing care plans for 7 of 30 total sampled patients (Patient's # 2, 11, 12, 14, 15, 17 and 18 ).

Findings include:

Hospital policy titled, "Nursing Care Plan Process" with a revision date of 1/2010 was reviewed by Surveyor #26711 on 3/2/10 at 9:23 a.m. This policy states in #2. that a. the "Primary Care Nurse" [nurse of the day] chooses at least two comprehensive care plans [from a binder with standardized, pre-printed care plans] based on identified problem areas of the patient, and b. patients and families will be educated on these care plans.
The policy does not address how to individualize the care plan. The policy does not address how or when to update the care plan, or what to do if a particular care plan is no longer applicable to the patient.

Hospital policy titled, "Interdisciplinary Care Planning-Hospital" with a revision date of 6/05 was reviewed by Surveyor #26711 on 3/2/10 at 9:30 a.m. This policy states it is, "A collaborative, interdisciplinary approach to provide medical/rehabilitative services consistent with professional licensure laws, regulations, and certifications is used to coordinate and plan care to meet patient/client care goals and achieve optimal outcomes."

1) Patient #11's medical record was reviewed on 3/1/10 at 1:00 p.m. Patient #11 was admitted to the hospital on 2/11/10 with a history of being found unresponsive for an unknown period of time from a suspected drug overdose. Patient #11 had a tracheostomy (tube in the neck that allows for breathing) upon admission to this hospital.

Patient #11's Interdisciplinary Care Plan (IDCP) dated 2/24/10 does not include information regarding his nursing/medical condition, nursing goals, respiratory needs, or neuropsychology (which includes barriers to rehabilitation or discharge and problem behaviors).

2) Patient #12's medical record was reviewed on 3/1/10 at 2:15 p.m. Patient #12 was admitted to the hospital on 4/16/09 after a traumatic brain injury. Patient #12 has a history of pressure ulcers requiring surgical repair, and paraplegia (paralysis of the lower extremities) along with nerve damage from diabetes and on going brain damage.

Patient #12's IDCP dated 2/11/10 does not include information regarding his ongoing medical problems, wound care, respiratory needs, neuropsychology (which includes barriers to rehabilitation or discharge and problem behaviors), occupational therapy, speech therapy, or physical therapy status.

Patient #12's IDCP dated 2/18/10 does not include information regarding his status for neuropsychology, his status for occupational therapy, physical therapy, or speech therapy.

Patient #12's IDCP dated 2/25/10 does not include information regarding his long and short term nursing goals, neuropsychology, his status for physical therapy, or speech therapy.

3) Patient #14's medical record was reviewed on 3/2/10 at 11:00 a.m. Patient #14 was admitted to the hospital on 1/28/10 with an anoxic brain injury (not enough oxygen to the brain). Patient #14 has a history of drug abuse.

Patient #14's IDCP dated 2/24/10 does not include information regarding his long and short term nursing goals or neuropsychology.

4) Patient #15's medical record was reviewed on 3/2/10 at 1:45 p.m. Patient #15 was initially admitted to the hospital on 5/13/09 with a traumatic brain injury and readmitted on 1/10/10 after a hospitalization for decreased heart rate and increased blood pressure with mental status changes. Patient #15 also has a history of disruptive behavior and tends to become increasingly agitated and throws himself on the floor if he is under surveillance for his own safety. For these reasons a waist restraint is used on Patient #15, when he is in his chair, with good results. Patient #15's parents live in Virginia.

Patient #15's IDCP is not dated or timed to reflect a team conference that occurred on 2/25/10, does not list ongoing medical problems which includes discharge destination goals and barriers to meet those goals, does not include information regarding nursing/medical condition or long and short term nursing goals. There is no information regarding wound status, if applicable, respiratory therapy needs, neuropsychology, speech therapy, or case management.

Patient #15 also has a comprehensive plan of care titled "PHYSICAL RESTRAINTS RAP." There is no identifying information as to who initiated this care plan, the care plan does not indicate any information that would individualize it to the patient, and four employees (the unit secretary, the nurse case manager, RN (Registered Nurse) N and LPN (Licensed Practical Nurse) M had never seen this form before and did not know how it got into the chart.

5) Patient #17's medical record was reviewed on 3/3/10 at 7:15 a.m. Patient #17 was admitted to the hospital on 2/3/10 for her recovery phase after a stroke. Patient #17 has a history of high blood pressure, diabetes and lupus.

Patient #17's comprehensive care plans for Nutrition, and Pressure Ulcers do not indicate who initiated the care plans. The Nutrition care plan does not indicate the individual diet and/or supplements Patient #17 is to have. The Pressure Ulcer care plan does not have a date as to when it was initiated.

6) Patient #18's medical record was reviewed on 3/3/10 at 8:52 a.m. Patient #18 was admitted to the hospital on 10/18/09 with a traumatic brain injury.

Patient #18's IDCP indicates 8 nursing goals: 4 short term goals (remains free from falls/injuries, remains free from s/s [signs and symptoms] of infection, skin remains intact, and [patient] remains cooperative with all cares), and 4 long term goals (d/c [discharge] to appropriate facility, no pain, no infection, remains safe in environment).

Patient #18 only has one comprehensive plan of care which addresses constipation (not dated or signed by whoever initiated it). DON (Director of Nurses) A was unable to state where the information from the IDCP was taken from if the patient only had one comprehensive care plan, and it did not match any of the goals listed on the IDCP.

The above findings were discussed with and confirmed by DON A on 3/3/10 at 4:30 p.m.






03383

7) Per record review conducted by Surveyor #03383:

Patient #2's Interdisciplinary Care Plan dated 3/3/10 lacks input by the registered nurse (RN) under Nursing/Medical Condition, short-term and long-term goals, and wound care. Pt #2 has multiple pressure ulcers, two of them are stage IV, chronic respiratory insufficiency, neurogenic bladder, anxiety and depression and was recently placed on hospice care.

This was verified with Administrator B and Chief Operating Officer OO on 3/9/10 at approximately 3 p.m.

Based on review of personnel files, review of hospital census and staff interviews, the nursing service failed to have staff qualified to care for 1 of 1 (Patient #28) pediatric patients, in a total sample of 30 patients.

Findings include:

Record review of 3/04/10 reflects the following:
On 03/03/10, the hospital admitted a 10 year old female patient. Review of the hospital's nursing staff employee competencies for hospital and contracted nursing staff confirm the hospital does not have pediatric competencies.

There was no documented evidence of pediatric training or competencies noted in the job description/competencies for all direct care staff provided by Administrative Secretary QQ on 03/04/10 at 8:00 a.m.

Contract Agency Registered Nurse (RN) E in charge of Patient #28's care on 03/04/10 confirmed to Surveyor 03/04/10 at 10:30 a.m. he did not have experience or education in pediatric care. RN E confirmed that even though Patient #28 was a planned admission for 03/02/10 and did not arrive until 03/03/10, the nursing staff did not have a basic care plan to provide care for a pediatric patient. RN E told Surveyor #22198, he would have to call 911 for a pediatric emergency, and confirmed he would not know what to do for a pediatric emergency. RN E told Surveyor #22198, he was not aware of any pediatric policies and procedures to ensure safe and current standards of practice.

RN G Wound Care Nurse confirmed on 03/04/10 at 10:25 a.m. she was not provided training or education for pediatric patient care from the hospital.

Licensed Practical Nurse (LPN) R On 03/04/10 at 10:15 a.m. confirmed the hospital did not provide education or orientation for pediatric patients.

On 03/04/10 at 11:00 a.m. during an interview with Director of Nursing (DON) A confirmed the hospital does not have nursing staff that are competency-verified in the care of pediatric patients. DON A acknowledged the hospital's protocol for admitting pediatric patients even though staffs were as not qualified. DON A confirmed that mock drills do not include the emergency of a pediatric patient.

On 03/04/10 at 11:45 a.m., Administrator B, in the presence of COO (Chief Operating Officer) OO, confirmed that he allowed the admission of pediatric Patient #28 knowing that the staff was not competency- qualified in pediatric patient care.

Informational list provided by the hospital on 03/09/09 at 4:53 p.m. via e-mail reflects over the past 12 months 10 pediatric patients ranging from 9 to 16 years of age have been admitted to the hospital.

Based on review of medical records, review of medical staff by-laws and staff interviews the nurses along with a Certified Occupational Therapist Assistants (COTA), Speech and Language Pathologists (SLP) and Dieticians had written orders in 13 of 36 (#5, 6, 7, 8, 10, 11, 12, 15, 16, 17, 18, 19 and 20) medical records, not in compliance with the Medical Staff By-Laws and State Licensure.

Findings include:

On 03/02/10 at 9:30 a.m. during an interview and departmental review of the dietetic services and medical record findings for Patient #8, Dietician H confirmed that as the dietician she was allowed to write dietary orders in patient's medical records.

Dietician H told Surveyor #22198, this was common acceptable practice in the hospital among nursing, therapists and the dietician. Dietician H told Surveyor #22198 she has been in this role for about a year.

Dietician H told Surveyor #22198, that writing orders was not a part of the dietician's licensing and registration codes, and had brought this to the attention of the administration, however the practice had not changed.

Review of dietary orders written in Patient #8s medical record confirmed that the dietician, therapists and nurses were writing dietary orders.

Review of Medical Staff By-laws confirmed qualified personnel may take verbal orders, however they are to be documented as a verbal order.

Per Surveyor #22198
Record review for Patient #8 conducted on 03/02/10 identified dietary orders written by staff that are not physician or Licensed Independent Practitioner (LIPs). Staff identified as writing orders were the dietician, therapists, and nurses. Also identified and confirmed were physician orders documented as "per protocol" were written by nurses, however nurses were initiating the protocol without a verbal order from the physician or LIP.

Per Surveyor #12145
Record review of Patients #11, 12, 15, 16, 17, 18, 19 and 20 from 03/01/10 through 03/03/10 contained orders written by staff that are not physician or qualified Licensed Independent Practitioner (LIPs). Staff identified as writing order were nurse dietitian and speech therapy, however licensure and/or certification does not qualify these disciplines to write patient medical orders.

Per Surveyor #26390
Record review of Patients #5, 6, 7, and 10 from 03/02/10 through 03/03/10 contained orders written by staff that were not physician or qualified Licensed Independent Practitioner (LIPs). Staff identified as writing orders were the dietician, and a Certified Occupational Therapy Assistant (COTA)

This was confirmed by the Director of Nursing (DON) A on 03/04/10 at 11:00 a.m.

Based on review of the hospital's Medical Staff Rules and Regulations, medical record review, and staff interview, this hospital does not ensure that entries into the medical record for 17 out of 30 patients in a total universe of 30 (Patient's #4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 20, 26, 29 ) are properly authenticated.

Findings include:

The hospital's Medical Staff Rules and Regulations were reviewed by Surveyor #26711 on 3/1/10 in the afternoon. On page 5 of 10, section B. Medical Records. #5 states, "All clinical entries in the patient's medical record shall be accurately dated and authenticated. The medical record should be clear, concise, complete, and current."

1) Patient #4's closed medical record was reviewed on 3/1/10 at 12:55 p.m. Patient #4's History and Physical (H&P), Discharge Summary and 10 progress notes from 9-16-2009 to 10-2-2009 do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

2) Patient #5's closed medical record was reviewed on 3/2/10 at 10:00 a.m. Patient #5's H&P, Discharge Summary and 1 progress note on 10-9-2009 do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

3) Patient #6's closed medical record was reviewed on 3/1/10 at 3:00 p.m. Patient #6's H&P, Discharge Summary and 1 progress note do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

4) Patient #7's closed medical record was reviewed on 3/2/10 at 9:40 a.m. Patient #7's H&P, Discharge Summary and 6 progress notes from 12-21-2009 to 12-30-2009 do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

5) Patient #9's closed medical record was reviewed on 3/1/10 at 12:55 p.m. Patient #9's H&P, Discharge Summary and 1 progress note do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

6) Patient #10's closed medical record was reviewed on 3/1/10 at 3:00 p.m. Patient #10's H&P, Discharge Summary and 5 progress notes from 2-2-2010 to 2-8-2010 do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

7) Patient #11's open medical record was reviewed on 3/1/10 at 1:00 p.m. Patient #11's H&P and 13 progress notes between 2/11/10 and 3/1/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.

8) Patient #12's open medical record was reviewed on 3/1/10 at 2:15 p.m. Patient #12's H&P and 21 progress notes between 2/1/10 and 3/1/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

9) Patient #14's open medical record was reviewed on 3/2/10 at 10:20 a.m. Patient #14's H&P, psychiatric evaluations, and 18 progress notes between 2/1/10 and 3/2/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

10) Patient #15's open medical record was reviewed on 3/2/10 at 1:45 p.m. Patient #15's H&P and 36 progress notes between 1/5/10 and 2/28/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

11) Patient #16's open medical record was reviewed on 3/2/10 at 2:30 p.m. Patient #16's H&P and 33 progress notes between 1/22/10 and 2/28/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

12) Patient #17's open medical record was reviewed on 3/3/10 at 7:15 a.m. Patient #17's H&P and 17 progress notes between 2/5/10 and 2/28/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

13) Patient #18's open medical record was reviewed on 3/3/10 at 8:52 a.m. Patient #18's H&P and 13 progress notes between 2/1/10 and 2/28/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

14) Patient #20's open medical record was reviewed on 3/3/10 at 3:00 p.m. Patient #20's H&P and 1 progress notes between 2/17/10 and 3/1/10 do not contain signatures for the electronically submitted dictation. These findings were confirmed by CNO A on 3/3/10 a 4:30 p.m.

15) Patient #29's open medical record was reviewed on 3/4/10 at 8:20 a.m. Patient #29's H&P and 1 progress note on 2-27-2010 do not contain signatures for the electronically submitted dictation. These findings were confirmed by Chief Nursing Officer (CNO) A on 3/3/10 a 4:30 p.m.







22198

Per Surveyor #22198

16) On 03/02/10 at 11:00 a.m. during a record review of Patient #8's medical record the following was identified:

On 01/10/10 (Sunday) an order was written for Monday/Wednesday/Friday weights to be completed.
01/11/10 (Monday) no weight was documented.
On 01/11/10 at 10:00 a.m. Patient #8 was changed to daily weights related to increased weight loss, however on 01/11/10 no weight was documented.
On 01/12/10 no weight was documented.
On 01/14/10 no weight was documented.
On 01/15/10 no weight was documented.

On 01/15/10 "Notice of Removal of a Human Corpse" form was incomplete:
Box #7 was not completed that defines if the patient was "under hospice care", however box #9a notes that a hospice registered nurse (RN) pronounced the death.
Box 10a was incomplete.
01/08/10 dictated History and Physical ' s authentication was not dated or timed.
01/18/10 dictated Discharge Summary's authentication was not dated or timed.
Dictated Physician Progress Notes dated 01/11/10 at 9:00, 01/13/10 at 11:00 a.m., 01/13/10 at 11:30 a.m. and 01/15/10 at 9:30 a.m. had been authenticated by a physician however the physician failed to date and time his signature.
Daily Food Intake Record was not authenticated to identify the writer.







09948

Surveyor 09948 reviewed 2/25/10, 2/26/10, 3/1/10 and 3/3/10 hemodialysis assessment forms on 3/8/10 and identified that there were no times for the pre- and post assessments recorded.

17) The 2/25/10 hemodialysis assessment reflects that Patient #26's lung sounds were "diminished". There was no documentation in the post- dialysis assessment about this abnormal findings.

Surveyor 09948 verified these findings with Administrator B and COO (Chief Operating Officer) OO on 3/9/10 at approximately 4 p.m.

Based on review of organizational chart, job description and staff interviews the hospital failed to have an organized dietary service.

Findings include:

On 03/02/10 a review of the organization chart by Surveyor #22198 did not indicate the hospital had a qualified Director for the dietetic and food service department.

On 03/02/10 at 9:00 a.m. Dietician H confirmed her job description and role as a dietician does not include oversight of the dietetic and food services.

Dietician H confirmed that she has updated the dietary policies and procedures based on current standards of practice she uses, however these were not approved by the governing board.

Dietician H confirmed as a dietician she collects data and makes improvements based on the data she identifies as problem areas, however H was not sure what happened with the data provided to the Program Improvement Director (JJ), because as the dietician she is not provided feedback on the trending from Director of Program Improvement JJ.

On 03/03/10 at 8:45 a.m. during an interview and review of kitchen data collected, Kitchen Manager I confirmed his qualifications and job description did not include dietary manager.

Kitchen Manager I confirmed to Surveyor #22198, he does not have oversight or in-put in to the policies and procedures for the kitchen and is unaware of accepted dietary and kitchen standards used for the service.

Kitchen Manager I confirmed that the data collected in the kitchen like cleaning, temperature logs, outdates, equipment checks was collected regularly, however was not provided to PI Director JJ, therefore there were no systemic changes being made to show program improvement of the food service area.

Kitchen Manager I, told Surveyor #22198 when he identifies a problem he corrects it; however, failed to incorporate his data into the hospital's Quality Assurance program to ensure trending of the problems and implement systemic process changes.

Kitchen Manager I acknowledged fixing something prior trending out systemic patterns is a quick fix to a potential bigger problem.

Kitchen Manager I confirmed to Surveyor #22198, that review of education provided to the hospital food service staff was not based on Hospital regulatory guidelines but rather Long Term Care.

Kitchen Manager I confirmed changes made in the department over previous years were based on his analysis, and changes made based on hospital wide changes were not incorporated into the new staff education or staff competencies for ongoing compliance.

On 03/03/10 during daily exit these findings were reviewed with Administrator B, who acknowledged not having a director for the service, things were not getting done.

Based on review of personnel files, organizational chart and job description and staff interviews the hospital failed to have a full-time employee responsible for the daily management of the dietetic and food service.

Findings include:

On 03/02/10 a review of the organization chart by Surveyor #22198 did not indicate the hospital had a qualified Director for the dietetic and food service department.

On 03/02/10 at 9:00 a.m. Dietician H confirmed her job description and roles as a dietician does not include oversight of the dietetic and food services.

On 03/03/10 at 8:45 a.m. during an interview Kitchen Manager I confirmed to Surveyor #22198, his qualifications and job description did not include dietary manager.

Between 03/03/10 through 03/04/10 during a review of personnel files and job descriptions, Surveyor confirmed the job descriptions for dietician and kitchen manager did not include the responsibilities of a food service/dietetic manager.

On 03/03/10 during daily exit these findings were reviewed Administrator B acknowledged the hospital did not have a full-time staff responsible based on education and qualification as the director for food and dietetic services.

Based on review of personnel files, job competencies and education, staff interviews and observations the dietetic and food services failed to have administrative and technical staff qualified by current standards of practice and competencies.

Findings include:

On 03/02/10 a review of the organization chart by Surveyor #22198 did not indicate the hospital had a qualified Director for the dietetic and food service department.

On 03/02/10 at 9:00 a.m. Dietician H confirmed her job description and roles as a dietician does not include oversight of the dietetic and food services.

Dietician H confirmed the hospital has a diet manual over 10 years old, and would not meet current standards.

Dietician H confirmed that she has updated the dietary policies and procedures based on current standards of practice she uses, however these were not approved by the governing board.

On 03/03/10 at 8:45 a.m. during an interview and review of kitchen data collected, Kitchen Manager I confirmed his qualifications and job description did not include dietary manager.

Kitchen Manager I confirmed to Surveyor #22198, he does not have oversight or in-put in to the policies and procedures for the kitchen so he does not know the accepted dietary and kitchen standards used for the service.

Kitchen Manager I told Surveyor #22198, when he identifies a problem he corrects it, however acknowledged fixing something prior trending out systemic patterns is a quick fix to a potential bigger problem.

During observation of the food service department and staff on 03/03/10 between 8:00 a.m. and 8:45 a.m. Surveyor #22198 along with Kitchen Manager I confirmed the following observation for Cook T:

Hand washing was not done between glove changes; not current with the hospital policy and CDC recommendation.
Multitasking with the same gloves from food preparation and food handling to touching multiple clean and dirty surfaces all with the same pair of gloves.

Additional observations on 03/03/10 between 8:00 a.m. and 8:45 a.m.:
Dirty cupboards, dirty exterior surfaces, dirty kitchen equipment, freezer and refrigerator had food debris and packaging on the floor.
Dishwashing room was unclean and equipment was broken and leaking, however continued to be used.

Kitchen Manager I confirmed to Surveyor #22198, that review of education provided to the hospital food service staff was not based on Hospital regulatory guidelines but rather Long Term Care.

Kitchen Manager I confirmed over the past years changes he made in the department based on his analysis, and the changes made based on hospital wide changes were not incorporated into the new staff education or staff competencies for ongoing compliance.

On 03/03/10 during daily exit these findings were reviewed and acknowledged by Administrator B.











26711

Per observation made by Surveyor #26711 on 3/1/10 at 3:05 PM:

In the freezer, there are three open boxes of individual serving ice cream cups that are not dated as to how long they have been open.
In a cupboard in the kitchenette there are 2 cans of "Thickit" (a product used to thicken liquids for people who may choke on regular liquids) that are opened but not dated as to when they were opened.

These finding were confirmed with CNO A on 3/1/10 as she accompanied Surveyor #26711 on the tour and discussed on 3/2/10 with Administrator B around 4:15 p.m.

Based on review of the diet manual and staff interview the hospital failed to have a current therapeutic diet manual approved by the dietitian and medical staff.

Findings include:

On 03/02/10 at 9:00 a.m. during an interview with the Dietician Staff H confirmed the diet manual being used within the hospital was entitled "Manual of Clinical Dietetics" that was released 10/15/2000.

Dietician H confirmed this was 10 years old.

Dietician H could not confirm that the diet manual being used was approved by the governing board. Dietician H acknowledged she was not aware of the requirement.

Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in 5 of the 5 smoke compartments, and would affect all of the 28 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies. K11 (common walls), K12 (building type), K17 (corridor walls), K18 (corridor doors), K21 (door hold opens), K33 (exit construction), K43 (egress locking) and K47 (egress signage). Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41.

______________________________________

Based on surveyor observations, the hospital failed to provide safe medical equipment (reclining chair) for 1 of 21 current in-patient records (Patient #15) in a total sample of 30 patients.

Findings include:

Surveyor observations of a reclining chair outside of Patient #15's room on 3/4/10 at approximately 11:50 p.m. while accompanied by ICP (Infection Control Preventionist) Y and Director of Environmental services B, reflects that it is a brown metal framed chair with blue vinyl padded seat and back. The chair's side panel (connecting the chair arm to the seat base) on the right side was missing, exposing rounded metal holding brackets that protruded up from the seat frame and down from the right chair arm. These protruding brackets caused a potential accident hazard for Patient #15, who was known by the hospital to have neurologically-based violent episodes with thrashing movements.
The brown metal square frame on the left and right sides of the seat was open (not capped with vinyl covers) potentially exposing the patient's lower extremities to rough edges.

This observation was verified by the ICP (Infection Control Preventionist) Y and Director of Environmental services B at the time above.

Interview with Physical Therapist (PT) K at 12:30 p.m. on 3/4/10, who was identified and verified that she provided this chair to Patient #15, stated that she feels that this chair is "unsafe" for this patient, and stated that Patient #15 had broken 4 other chairs like this during his hospital stay. PT K stated that "we don't have any other options", meaning that there was no other seating devices in the hospital that the patient could use.

This observational information was shared with COO (Chief Operating Officer) OO at the 3/4/10 daily exit at approximately 4:30 p.m., who stated the use of this equipment is "unacceptable".

Based on ICP (Infection Control Preventionist) employee file review, review of hospital IC (Infection Control) policies and procedures and staff interviews, the hospital failed to ensure that the newly hired ICP had validated basic infection control training; and failed to ensure that the ICP developed policies and procedures to prevent cross-contamination and infection in the laundry/linen storage area, and failed to develop policies that used nationally recognized standards of practice with regard to handwashing technique.

Findings include:

1) Interview with ICP Y on 3/3/10 at approximately 11 a.m. reflects that she was hired approximately two weeks ago, and that she is responsible for the hospital, CBRF (community-based residential facility) and 2 RCC (residential care center) facilities. ICP Y stated that she was not yet certified in infection control, but had prior experience in a large urban hospital. ICP Y states that she has no mentor, but that a ICP consultant was in the hospital prior to her hire and provided information. ICP Y states she was brought in (hired) to get an effective infection control program initiated in the hospital.

Review of ICP Y's employee file on 3/4/10 at approximately 3 p.m. reflects that the hospital has not verified her epidemiology /infection control training courses (2 basic courses 101 and 201) through APIC (American Professionals for Infection Control). There is no information in her employee file regarding what her specific role was in the urban hospital or whether she had experience initiating a IC hospital program.

This information was given to the Hospital Administrator B and COO (Chief Operating Officer) OO at the daily exit conference at approximately 4:30 p.m. on 3/4/10, without rebuttal.

2) During interview and walking tour with Environmental Service Director C on 3/3/10 at approximately 9:45 a.m., Director C stated that the facility had 2 washing machines and two dryers in the facility that were used to wash the hospital patient's personal clothing, mop heads, rags, shower curtains and privacy curtains. Director C stated that these washers and dryers were also used by the RCC and CBRF staffs to wash resident clothing.

Director C verified that the hospital had no policies or procedures to disinfect or clean the washers or dryers between loads, and that there were no policies to ensure routine cleaning/ disinfection at periodic intervals.

3) The 3/11/2010 review of the Feb. 18th 2009 infection control committee report
reflects a 1/19/09 infection control committee meeting minutes documenting an increase in C-diff in the hospital. The Jan. log shows that 10 Hospital Aquired Infections (HAI)s were identified, with 4 as C-diff. infections. The "intervention" documented by former ICP RR was to post "Wash hands ONLY signs on the gel dispensers" ( in C-diff. infected patient rooms). Under "discussion/conclusion" it documents: "main concerned (sic) is HAI C-diff. reported, roommates transmitted, soap and water needed, gel is not effective". 1) If soap not used by direct care they are not following procedure, discipline needed...Commode liners, shared bathrooms (sic). CNO (Chief Nursing Officer) A to re-educate staff, South (patient care unit) to rinse soiled laundry and East (patient care unit) to bag (identify and label) yellow bagged (SIC) ." The above re-education given to the South patient care unit is contradictory to CDC infection control recommendations.

According to the "CDC Guidelines for Environmental Infection Control in Health- Care Facilities under Recommendations-Laundry and Bedding, III. Routine Handling of Contaminated Laundry " states " A. Handle contaminated texiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and person. Catagory IC; B. Bag or otherwise contain contaminated texiles and fabrics at the point of use. Catagory IC."

This information was given to the Hospital Administrator B and COO (Chief Operating Officer) OO at the daily exit conference at approximately 4:30 p.m. on 3/4/10, without rebuttal.




26711

4) Hospital policy titled, "Hand Washing/Cleansing" states in 1. A. 11. that hands must be washed and/or cleansed, "After gloves are removed."

In section 1. C. 3. of the same policy it states, "Double and triple gloving during patient/resident care may be appropriate depending on the circumstances to maintain clean procedures rather than attempting to wash/cleanse hands between tasks."

According to nursing standards of practice and the Center of Disease Control, this practice is not recognized as being safe or effective to prevent infection transmission and cross-contamination.

Based on surveyor observations, review of IC (Infection Control) policies and other hospital policies and IC and other staff interviews, the hospital's ICP (Infection Control Preventionist) failed to: 1) maintain a sanitary environment through environmental cleanliness and nursing staff practices that prevent and control the transmission of infectious agents in the dietary department and the patient care units, 2) establish an environmental IC surveillance program for all hospital departments that would attempt to maintain a sanitary environment and prevent and control the transmission of infectious pathogens; 3) provide an active IC surveillance program that met the needs of the patient population according to the hospital's established policies, including the surveillance of device-related infections; 4) investigate and plan preventative measures when trending of UTIs (urinary tract infections) in the patient population when it became problematic.

Findings include:

1) During interview and walking tour of the East patient care unit with Environmental Service Director C and ICP Y on 3/4/10 from approximately 11:30 a.m. through 12:30 p.m. the following rooms were entered on the South unit (2030, 2034 and 2058). Room 2030 and 2031 shared a common bath centered between the rooms. Interview with Director C reflects that housekeeping staff clean rooms once daily, and as needed if nursing staff make request. Director C states that the hospital does not have housekeeping staff available after 3:30 p.m. on any day of the week, and that nursing staff are responsible for cleaning the patient units after housekeeping staff leave.

Surveyor 09948 observed, during tour at time listed above, a soiled (brown stains and dried debris along the seat edge) bedside commode next to the toilet, 1 sink that was soiled (gray debris along rim edge), a walk-in shared shower that had broken tiles along the floor and wall base, and a white plastic shower curtain with reddish brown dried liquid stains on it's inner surface.

The 3/8/10 review of "Policy: Infection Control Program, 6.120 , last reviewed 2/10 reflects under "procedure" that ...
11) Staff will handle used resident care equipment soiled with bloody, body fluids and secretions in a manner that prevents skin and mucous membranes exposures, contamination of clothing, and transfer of microorganisms to other residents, other equipment, and environmental surfaces.
12) Staff will ensure that reusable equipment is not used for the care of another resident until it has been cleaned appropriately or sterilized when needed...".
This policy does not instruct nursing or other staff how to clean/ sanitize and store patient equipment in shared bathrooms.

Director C and ICP Y, verified in the above interview, that to their knowledge the hospital had no infection control policies that covered the use of shared bath facilities. There were no policies or procedural instructions to nursing staff on what cleaning chemical to use or how to use chemical cleaners to sanitize toilet facilities between patient use or how to identify if shared equipment in shared patient baths (bedside commodes, shower stalls and curtains) was sanitized between patient use.

2) Continued environmental walking tour and interview with Environmental Service Director C and ICP Y on 3/4/10 from approximately 11:30 a.m. through 12:30 p.m. reflects the following on the East patient care unit:

There is a large build-up of dark dried crusted debris on the patient hallway floors where the floor meets the wall, along the entire hall, on both sides of the hall. There is increased build-up of dark brown black dried debris on the floor surfaces behind the fire doors. The hall floor tiles are cracked and broken/missing in multiple areas of this hallway, preventing thorough cleaning. The floor surface under the public water fountain had a large build-up of greasy dark dried debris on the tiles, and the top and sides of the water fountain are rusted and contain crusted debris and liquid stains. There were dust clusters (bunnies) identified in the patient care unit nursing station, and in the clean utility room where the medication cart was stored. Several ceiling tiles were ajar leaving the unit open to the above debris. Tour of the soiled utility room reflects that there are no towels in the dispenser at the sink, and that the towel dispenser on the adjacent wall (approximately 2-3 feet away from the sink) is blocked by soiled patient care equipment. There are clean patient care supplies (diapers and paper incontinent pads) co-mingled with dirty patient care supplies.

These observations were all verified by Director C and ICP Y, during the tour and time above.

3) Continued environmental walking tour and interview with Environmental Service Director C and ICP Y on 3/4/10 from approximately 11:30 a.m. through 12:30 p.m. reflects that Director C states that "Environment of Care rounds" are conducted at the hospital. Surveyor 09948 requested to review the environmental care rounding information that the former ICP RR used for infection control surveillance. This information was requested from the facility three times.

On 3/11/10, Surveyor received "7/15/09 Environment of Care Survey Tool" for East and South patient care units. Executive Assistant QQ wrote an e-mail on 3/11/10 stating that the ICP consultant provided environmental rounding findings during a daily visit on November 4th, 2009 and December 3, 2009, and verified that this information was all the hospital had.

There was no documented evidence that the hospital had established an active environmental surveillance program that continually assessed infection control methods and hospital sanitation/ cleanliness in all hospital departments/ areas.

The 3/11/2010 review of "Policy: Infection Control Program, 6.120 , last reviewed 2/10 reflects under "procedure" that ...
10) Environmental and safe practices surveys will be conducted. All units will have adequate procedures for routine care, cleaning, and disinfection of environmental surfaces, beds and bed rails...
14) Quality Assurance Infection Control Rounds will be conducted by members of the Infection Control Lead Team. All units will undergo Quality Assurance Infection Control Rounds.
This policy does not address all hospital departments, only patient care units.

The above issues were shared and verified with Administrator B and COO (Chief Operating Officer) OO on 3/8/10 at the daily exit meetings. On 3/8/10 COO OO stated that she was aware that the hospital was not getting what they needed from the former ICP and that is why they hired a new ICP.

4) The 3/8/2010 review of "Policy: Infection Control Plan: 6.270, last reviewed 2/10" reflects:
" 2. The Infection Control program at this Hospital incorporates the following in continuing cycle:
A. Surveillance , prevention and control of infections throughout the organization...
Activities:
1. Infection Control activities include the following:
A. Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management.
1. Hospital acquired infections;
2. Admission infections;
3. Device-related infections;
4. Antibiotic resistant organisms;
5. Other communicable diseases;
6. Employee health trends;
7. Ventilator associated pneumonias(VAPs).

The 3/4/2010 through 3/8/2010 review of the infection control logs from March 2009 through Feb. 2010 reflects that none of the respiratory infections identified contained information on whether the infection was device related (ventilator or tracheostomy associated) or not. There was no documented information in the analysis data (documented analysis or graph trending rates) submitted with the monthly logs that respiratory device related infection data was identified, evaluated and reported, even though the hospital is a long term care hospital specializing in the care of medically complex ventilated/trached patients.

The 3/4/2010 through 3/8/2010 review of the infection control logs from March 2009 through Feb. 2010 reflects that UTI (urinary tract infections) were not always identified as device- related or non-device related. There was no documented information in the analysis data (documented analysis or graph trending rates) submitted with the monthly logs that UTI device related data was identified, analyzed or reported.

The 3/4/2010 through 3/8/2010 review of the infection control logs from March 2009 through Feb. 2010 reflects that intravenous catheter-related infections were not identified, analyzed or reported. There was no documented information in the analysis data (documented analysis or graph trending rates) submitted with the monthly logs for catheter-related infections.

The above issues were shared and verified with Administrator B and COO (Chief Operating Officer) OO on 3/8/10 and 3/9/10 at the daily exit meetings. On 3/8/10 COO OO stated that she was aware that the hospital was not getting what they needed from the former ICP and that is why they hired a new ICP.

5) The 3/8/10 review of the infection control logs and the attached infection control committee reports reflects the following:

The "April 28th, 2009 - PI (Performance Improvement) /Infection Control Patient Safety" meeting minutes record March 2009 logged data:
March 2009 logs- There were 12 HAIs (Healthcare Associated Infections= infections that occurred during hospitalization) recorded for the month, 8 of those were HAI UTI(urinary tract infections) infections caused by bacterial organisms [4 E.coli. (Escherichia coli) , 1 Serr. Marc. (Serratia Marcescens), 1 Kleb. pneu.(Klebsiella Pneumoniae), 1 citrobacter (Acinetobacter)]. Review of notes by former ICP RR reflect no documented analysis of UTI infections being device-related or non device related. There was no documented analysis to identify causation or surveillance plan designed to eliminate risk of patient care related UTI transmission.

The "June 30th, 2009 - PI (Performance Improvement) /Infection Control Patient Safety" meeting minutes record May 2009 logged data:
May 2009 logs shows 6 HAI, of which 5 were UTIs (3 catheter related, 2 were documented as unknown source), 3 of the 5 UTIs were Kleb. pneu.. There was no documented analysis of trends or patterns for these findings, only a history of each infected patient was documented. There continued to be no documented analysis to identify causation or surveillance plan designed to eliminate risk of patient care related UTI transmission.

The "July 28th, 2009 - PI (Performance Improvement) /Infection Control Patient Safety" meeting minutes record June 2009 logged data:
The June 2009 log documents 3 HAIs for the month, and shows that former ICP RR was not counting patients with onset symptoms/new positive cultures for the month that had a history of infections on admission, for example:
a) Patient #35 was admitted on 5/14/09 with a "hx of UTI on admit", but had new MRSA UTI onset date (date infection identified) start of infection recorded on 6/1/09 with June log documenting treatment with Levaquin and Vancomycin (antibiotics). May logs show this patient was admitted on 5/15/09 with MRSA in the nasal passages only.
b) Patient #12 was admitted on 4/16/09 with an enterococcus (gram positive bacteria) UTI treated with antibiotic. The June log shows a Enterococcus UTI with a new onset date of 6/4/09, reflecting that this was not a colonized organism or continued infection since 4/16/09.
c) Patient #36 was admitted on 5/15/09 with a history of UTI. The June log reflects an E. Coli UTI with an onset date of 6/30/09 being treated with amoxicillin, reflecting that this was not a colonized organism or continued infection from admission.

The "August 26th, 2009 - PI (Performance Improvement) /Infection Control Patient Safety" meeting minutes had the following attachment:
"2009 Infection Control Goal based on Risk Assessment...the Infection Control goal for 2009 at Lakeview is to reduce the HAI spread in our different units. Per CMS (Centers for Medicare /Medicaid) mandate, we will particularly watch ventilator-associated pneumonia, wound infections, catheter associated urinary tract infections, MRSA (Methicillin resistant Staphylococcus aureus), Clostridium-difficile, VRE (Vancomycin resistant enterococcus) infections, EBSL (extended spectrum beta lactamase) resistant organisms (sic) will be monitored as well. We will use the CDC (Centers for Disease control) guidelines for the major source of guidance and literature review. We will do surveillance for upward trends in occurrence, increased resistant organisms prevalence, distribute education material for good practice procedures for the facility departments, and stress education of good hand hygiene for employees and visitors."

There was no documented/attached timetable or plan or initiation of this risk assessment. There was no documented evidence in the infection control committee meeting minutes, logs, or other QAPI (Quality Assurance Performance Improvement) information that a plan for this risk assessment had been initiated as of the review of 3/11/2010. The logs reviewed for the time period above (March 2009 through Feb. 2010) do not reflect device-related infections being recorded or analyzed.

Review of the logged data for July 2009 reported in the "August 26th, 2009 - PI (Performance Improvement) /Infection Control Patient Safety" shows 10 HAIs with 7 were HAI UTIs (2 Pseudomonas aeruginosa, 3 E. coli., 3 Enterococcus species). There was no documentation of analysis or trending of the UTIs or prevention associated interventions.
This monthly ICP documentation explained the history of the patient infections and why they were added/ counted in the log, but does not analyze problematic trends /patterns of the disease processes. It was recorded that an inservice given to CNA (certified nursing assistant) staff for not double-bagging of infectious linens, but there was no documentation on how this was tied to these infectious processes.

The above issues were shared and verified with Administrator B and COO (Chief Operating Officer) OO on 3/8/10 at the daily exit meetings. On 3/8/10 COO OO stated that she was aware that the hospital was not getting what they needed from the former ICP and that is why they hired a new ICP.

6) Surveyor observations of a reclining chair outside of Patient #15's room on 3/4/10 at approximately 11:50 p.m. while accompanied by ICP (Infection Control Preventionist) Y and Director of Environmental services B, reflects that it is a brown metal framed chair with blue vinyl padded seat and back. The blue vinyl on the upper left hand corner of the back of the chair is cracked and missing exposing cotton batting making it unable to be sanitized. There is large dried liquid stains and dried food debris coated and stuck to the chair's left side panel (connecting the chair arm to the seat base) and on the left side of the chair's vinyl seat.

These observations were verified by the ICP (Infection Control Preventionist) Y and Director of Environmental services B at the time above.




26711

7) A tour of the hospital was completed by Surveyor #26711 accompanied by Chief Nursing Officer (CNO) A on 3/1/10 at 3:00 p.m.

On the east wing of the hospital, observation findings include:
Seven out of Nine shared patient bathrooms had evidence of black mold in various areas-in the shower, behind toilets, along the top of ceramic tiled areas.

On the south wing of the hospital, observation findings include:
Seven out of nine patient bathrooms had floors that appeared dirty and generally unclean, especially in the corners and behind waste baskets where dirt was allowed to build up and debris was not cleared away.

In the "tub room" (room designated for showers and baths on this wing as there are not individual showers in all the rooms) there was a large area (approximately 1 inch by 24 inches) along the top of the radiator that is rusted and without a painted surface. This renders the radiator unable to be cleaned.

8) At 4:10 p.m. on 3/1/10, Surveyor #26711 observed Certified Nursing Assistant (CNA) F remove a patient food tray from the room of a patient in isolation (Patient #19) and carry that tray into the employee break room, thereby contaminating everything from the time she left the patient room without removing her gown or washing her hands.

These finding were confirmed with CNO A on 3/1/10 as she accompanied Surveyor #26711 on the tour, and discussed on 3/2/10 with Administrator B around 4:15 p.m.

9) An observation of a bed bath procedure by Surveyor #26711 with CNA P took place on 3/3/10 at 9:00 a.m. on Patient #20. During the procedure CNA P missed 4 opportunities to wash her hands between glove changes (gloves were removed, hands were not washed, new gloves were reapplied). CNA P discarded soiled laundry (patient gown and used wash cloths) onto the floor instead of into a laundry bag or other receptacle. CNA P used the same wash cloth to wash Patient #20's thigh and lower leg as the healing incision on his knee after a total knee replacement. First CNA P washed the thigh, then washed over the incision, then washed lower leg and foot, and ended by washing over the incision again.

These findings were discussed with CNO A on 3/3/10 after the observation of the procedure was completed, and again on 3/3/10 around 4:15 p.m. with Administrator B.




22198

10) Surveyor #22198's observations on 03/02/10 between 9 a.m. and 10 a.m., and on 3/3/10 between 8 a.m. and 8:45 a.m., during a tour of the kitchen with Kitchen Manager I and Dietician H identified the following unsanitary conditions:

Interview with Kitchen Manager I told Surveyor #22198, that the Infection Control Preventionist did not have in-put or oversight to the kitchen area or process.

The following observations were confirmed during the tour:

Dust and debris noted in the closed cupboards that housed the clean pots, pans and dishes for cooking and serving food.

Exterior washable surfaces of the cabinets, cupboards, refrigerators and stoves were visibly dirty with dust, and grease streaks.

Under the fryer, was food debris and grease build-up.

The freezer and coolers had food and wrappers on the floor.

The freezer had ice build- up on the ceiling and floor.

11) On 03/03/10 during a morning food preparation the following observations were made:

Staff T (Cook II) was observed removing gloves, however failed to wash her hands before donning a new pair of gloves. Staff T was then observed multi tasking with the same pair of gloves without the benefit of handwashing between task stations. Staff T was observed going through paper work, going into a heated cabinet for plates, serving food, taking temperatures of food, retrieving lunch meat out of a refrigerator, placing it on a plate, opening a microwave to heat the lunch meat, going back to the hot food table and continued to prepare and serve food off the steam table. When staff who performed patient tray preparation left the kitchen to take prepared breakfast trays/meals to the floor, Staff T was observed to go to the tray set up area and prepared a complete tray with juice she obtained from the refrigerator, make thickened coffee out of a packet, leave the kitchen to go out to the dining area to retrieve hot water from a dispenser, and come back into the kitchen and again test food temperatures without the benefit of glove change or handwashing. Staff T returned to the kitchen to clean up the steam table and tray line, removing garbage can lid placing on dish washing counter. These multiple tasks were all performed wearing one pair of gloves.

Staff T was observed to place a thermometer in prepared eggs and obtain a reading of 180 degrees Fahrenheit. Surveyor #22198 observed and audibly noted that the metal thermometer was sitting up against the metal pan that was submersed in the steamer table hot water. This was confirmed by Kitchen Manager I, who then obtained a temperature reading at 138 degree Fahrenheit. Kitchen Manager I stated that the hospital policy defines food temperatures need to be 140 degrees Fahrenheit in order to be served safely.

12) On 03/03/10 at 8:30 a.m. Kitchen Manager I and Surveyor #22198 observed a patient from a non-hospital treatment facility perform garbage disposal. This patient was observed to overload the outside garbage containers and then compress it, however containers, wrappers and debris from the overfill fell to the ground. The patient was observed approximately 5 feet from the recyclable containers throwing recyclable plastics into the recyclable bin, however not all plastics containers went it. Kitchen Manager I confirmed that this person was not correctly handling garbage/recyclables, and these duties were performed unsupervised. Kitchen Manager I confirmed this was not acceptable because of the potential to attract animals and rodents.

13) On 03/03/10 at 8:30 a.m. Kitchen Manager I and Surveyor #22198 observed the dish washing room and process and the following was identified and confirmed:

Dish washing room had floor tiles that had gouges in them.

Ceiling tiles were stained and had debris.

The soap dispenser for the dish washing machine was dirty with old soap/chemicals and dust.

The staff soap/gel dispensers were dirty with old chemical build up and dust under the handle and at the point of dispensing.

The dish washing machine had yellow flaking debris/build up around the frame and temperature gauges.

The dish washing machine leaked in 2 areas. There was a large opening on the top of the machine at the seam, and a open space at the machines name plate on the side. This was evidenced by the streaking/staining on the machine and during a wash cycle water was observed coming out of both areas.

The walls in the dish room were dirty and streaked.

Washable surfaces on the exterior of the dish washing machine, and counters were dirty.

Based on staff interview, policy & procedure review, review of the hospital and OPO (organ procurement organization) agreement, the hospital failed to establish written policies and procedures to address all of its organ procurement responsibilities.

Findings include:

On 3-3-2010 at 9:10 AM interview with Chief Nursing Officer, A revealed A is unfamiliar with all of the hospital responsibilities for the OPO agreement, stating " never been involved with organ procurement " . Surveyor #26390 asked for the hospital protocol to allow the OPO to review the hospitals death records, A replied " I don't know that they have ever been here " and explained she was unaware of a written protocol for record review. Chief Nursing Officer A, explained the hospital does not have written protocols for maintaining a potential donor because the hospital does not have that capability. Also the hospital does not have a designated requestor.

On 3-3-2010 at 9:30 AM review of the OPO agreement with Chief Nursing Officer, A was completed. Surveyor #26390 presented A with the agreement, A stated, " I have never seen this before ". A confirmed the agreement was from 2003 with an automatic annual renewal. The agreement states in part the hospital will be responsible for providing necessary supplies and staff to maintain a potential organ donor, inform the family of each potential donor of its option to donate organs, to work with the OPO to educate hospital staff on donation issues, to provide access to medical records.

On 3-3-2010 at 11:30 AM review of Policy & Procedure titled, " Organ and Tissue Donations " shows last revision was done 11/2003 and last reviewed 2/2010. The policy & procedure does not address how the hospital will meet the requirement to maintain a potential donor, how the hospital will provide for record review by the OPO, how staff will be trained regarding organ/tissue procurement, does not state what documentation is required by the OPO within the medical record, how the hospital will determine it's donor potential, how the hospital will identify the opportunities for the OPO and hospital staff performance improvement, and how to complete an evaluation of the OPO and hospitals compliance with donation legislation.

On the afternoon of 3-3-2010 Administrator B did not have additional information.

Based on review of the OPO (Organ Procurement Organization) hospital agreement, staff interview, and 4 out of 7 record reviews, the hospital failed to incorporate a complete agreement with the OPO.

Findings include:

On 3-3-2010 at 9:10 AM Chief Nursing Officer(CNO) A was interviewed. CNO A explained that the nursing department makes a phone call to the OPO after a patient has died; however, they do not call if death is imminent. CNO A explained that training issues are brought up at the staff meetings. CNO A supplied a document titled Staff Meeting, dated 2/17/2010 that showed the hospitals OPO education- it stated "12) Donor Network get called no matter what! It's the law."

On 3-3-2010 at 9:30 AM CNO A and Surveyor #26390 reviewed the OPO agreement. Surveyor #26390 presented CNO A with the agreement, CNO A stated, " I have never seen this before." CNO A confirmed the agreement was from 2003 with an automatic annual renewal. The agreement states in part the hospital will be responsible for providing necessary supplies and staff to maintain a potential organ donor, inform the family of each potential donor of its option to donate organs, to work with the OPO to educate hospital staff on donation issues, to provide access to medical records. CNO A explained the hospital does not have written protocols for maintaining a potential donor because the hospital does not have that capability. The agreement does not contain definitions for imminent death, or timely notification, criteria for referral, how the OPO will be notified, how the OPO will be involved in the hospitals QAPI program. The agreement does not state it is the OPO's responsibility to determine medical suitability for organ donation.

1) On 3-1-2010 at 12:55 PM review of closed medical record for patient (pt.) #9 revealed pt. #9 was admitted to the hospital on 1-27-2010 and died at the hospital on 1-30-2010. Nursing Progress note dated 1/30/10 at 4:00 AM states " blood samples obtained for medical examiner, post mortem cares ok with medical examiner. At 4:40 AM note states, "Body released with personal belongings". Medical record does not show the OPO was notified of imminent death or death.

2) On 3-1-2010 at 3:35 PM review of closed medical records for pt. #10 revealed pt. #10 was admitted to the hospital on 1-29-2010 and died at the hospital on 2-9-2010. Nursing progress note dated 2-8-2010 at 10:29 PM states, " at 10:03 PM patient pronounced " . Nursing progress note dated 2-9-2010 at 2:05 AM states in part, " funeral home here, body released " . Medical record does not show the OPO was notified of imminent death or death.

3) On 3-2-2010 at 8:00 AM review of closed medical record for pt. #4 revealed pt. #4 was admitted to the hospital on 9-14-2009 and died at the hospital on 10-4-2009. Nursing progress notes dated 10-3-2009 at 9:00 PM states in part, " orders received for Hospice " . No notification of the OPO of imminent death documented in the medical record. Nursing progress note dated 10-4-2010 at 12:45 PM states in part, " patient without pulse, respirations, or blood pressure. " No notification of the OPO of death documented in the medical record. Nursing progress note dated 10-4-2010 at 6:50 PM states, " corpse left the building with funeral director. "

4) On 3-2-2010 at 9:40 AM review of closed record for pt. #7 revealed pt. #7 was admitted to the hospital on 12-17-2009 and died at the hospital on 1-1-2010. Nursing progress note dated 1-1-2010 at 3:00 AM states in part, " Wisconsin Donor Network called, no eye donation. " No documentation of OPO contact.

On the afternoon of 3-3-2010 Administrator B did not have additional information.

Based on staff interview, policy & procedure review, and meeting minute review the hospital failed to work with the OPO in ensuring staff education on donation issues and protocols.

Findings include:

On 3-3-2010 at 9:30 AM Chief Nursing Officer, A and surveyor #26390 reviewed the OPO agreement. Surveyor #26390 presented A with the agreement, A stated, " I have never seen this before". A confirmed the agreement was from 2003 with an automatic annual renewal. The agreement states in part the hospital will be responsible to work with the OPO to educate hospital staff on donation issues. Chief Nursing Officer A, explained she has " never been involved with organ procurement." Chief Nursing Officer (CNO) A, explained the staff do not receive training from the OPO. CNO, A produced meeting minutes to show the training she does with nursing staff.

On 3-3-2010 at 11:30 AM review of Policy & Procedure titled, " Organ and Tissue Donations " shows last revision was done 11/2003 and last reviewed 2/2010. The policy & procedure does not address how staff will be trained by OPO personnel regarding organ/tissue procurement.

On the afternoon of 3-3-2010 Administrator B, had no additional information.

Based on staff interview, policy & procedure review the hospital failed to develop protocols for the review of death records by the OPO and work with the OPO on review of death records.

Findings include:

On 3-3-2010 at 9:10 AM interview with Chief Nursing Officer (CNO) A, revealed CNO A, was not aware of written protocols for the OPO to review the hospitals death records. CNO A, stated, " I don't know that they have ever been here. "

On 3-3-2010 at 9:30 AM review of the OPO agreement revealed the hospital will be responsible for providing the OPO access to medical records for review.

On 3-3-2010 at 11:30 AM review of Policy & Procedure titled, "Organ and Tissue Donations" shows last revision was done 11/2003 and last reviewed 2/2010. The policy & procedure does not address how the hospital will meet the requirement to provide for record review by the OPO.

Based on staff interview, OPO and hospital agreement review the hospital failed to ensure the maintenance of potential donors.

Findings include:

On 3-3-2010 at 9:10 AM Chief Nursing Officer (CNO) A was interviewed. CNO A explained that training issues are brought up at the staff meetings. CNO A, supplied a document titled Staff Meeting, dated 2/17/2010 that showed the hospitals OPO education- it stated "12) Donor Network gets called no matter what! It's the law."

On 3-3-2010 at 9:30 AM CNO A and Surveyor #26390 reviewed the OPO agreement. Surveyor #26390 presented A with the agreement, A stated, " I have never seen this before, " CNO A confirmed the agreement was from 2003 with an automatic annual renewal. The agreement states in part the hospital will be responsible for providing necessary supplies and staff to maintain a potential organ donor. CNO A explained the hospital does not have written protocols for maintaining a potential donor because the hospital does not have that capability.

On the afternoon of 3-3-2010 Administrator B, had no additional information.

Based on review of Performance Improvement (PI) plan and committee Minutes, Physician Quality Assurance (QA) meeting minutes, and staff interview, the facility failed to include all hospital departments in quality assurance performance improvement (QAPI) activities to ensure patient health and safety.

Findings include:

Record review and interview conducted by Surveyor #03383:

Per review of Performance Improvement Plan 2010 the morning of 3/9/10:

Sections of the PI Plan indicated the following:

"All employees of Lakeview Specialty Hospital & Rehab will participate in ongoing and systemic quality improvement efforts. Our quality improvement efforts will focus on direct patient/client delivery processes and support processes that promote optimal patient/client outcomes and effective business practices. The Performance Improvement Committee provides oversight and functions as the central clearinghouse for quality data and information collected throughout the facility. The PI committee tracks, trends, and aggregates data from all sources to prepare reports for the governing board and the medical staff."

A review of the facility's performance improvement/patient safety and physician quality assurance (QA) meeting minutes on 3/3/10 beginning at 7:10 AM revealed the following:

Performance Improvement (PI) meeting minutes dated 7/30/09, 8/26/09, 9/22/09, 11/3/09, 12/1/09, 12/29/09, 1/26/10, and 2/25/10; and Physician QA minutes dated 1/29/09, 3/4/09, 7/1/09, 9/2/09, 12/2/09, 1/6/10, 1/20/10, and 1/27/10 revealed the following:

Performance Improvement meeting minutes from 7/30/09 to 2/25/10 and Physician QA from 1/29/09 to 1/27/10 fail to show the hospital is collecting data, analyzing, and developing a plan of action to prevent or minimize the number of hospital-acquired pressure ulcers . The facility failed to collect data to determine the scope of patients experiencing pressure ulcers.

Three patient medical records (Pt #1, Pt #2, and Pt #3) reviewed as a result of a complaint investigation on 3/1/10 through 3/3/10 revealed all three patients developed pressure ulcers after admission to the hospital. PI LPN JJ confirmed the afternoon of 3/8/10 that Pt #1, #2, and #3 developed pressure ulcers after admission to the hospital.








22198

Per Surveyor #22198
On 03/02/10 9:00 a.m. during an interview Dietician H confirmed her job description and roles as a dietician does not include oversight of the dietetic and food services, however she does collect data for program improvement.

Dietician H confirmed to Surveyor #22198, that she does her own data collection to make improvements as a dietician, based on problems she identifies.

Dietician H confirmed the Program Improvement Director (JJ) does not provide guidance or direction for data collection.

Dietician H was not sure what happened with the data provided to the Program Improvement Director (JJ), because H is not provided feedback on the trending from Director of Program Improvement JJ.

On 03/03/10 at 8:45 a.m. during an interview and review of kitchen data collected, Kitchen Manager I confirmed his qualifications and job description did not include oversight to the dietary department, however he did collect data for the kitchen.

Kitchen Manager I confirmed that the data collected in the kitchen like cleaning, temperature logs, outdates, equipment checks was being collected regularly, however there was no documented evidence that Kitchen Manager I was providing the collected data to the QAPI Committee or Director of Program Improvement JJ.

Kitchen Manager I told Surveyor #22198, when he identifies a problem he corrects it, however acknowledged fixing something prior trending out systemic patterns is a quick fix to a potential bigger problem.

On 03/03/10 at 11:00 a.m. during an interview with Registered Nurse (RN) Case Manager (CM) V confirmed their department collects data from satisfaction surveys, however was uncertain what was done with it.

RN/CM V confirmed there is not Case Management/Discharge Planning Director responsible for the oversight of the department.

RN/CM V confirmed Program Improvement Director JJ did not provide feedback from the data collection done for Case Management.

RN/CM V told Surveyor #22198 that any changes to the Case Management system came from V or U the only two staff in that department, however the fixes were "quick" fixes, and nothing is put in place for policy changes education, competencies or monitoring to ensure compliance and on-going compliance.

This information was also confirmed in an interview with Social Worker (SW) /CM U.

Based on review of performance improvement/patient safety meeting minutes, performance improvement (PI) program, physician quality assurance meeting minutes and staff interview, the hospital failed to assess hospital processes, hospital services, and hospital operations to ensure services are provided in a safe and effective manner.

Findings include:

Per record review and staff interview conducted by Surveyor #03383:

Per review of Performance Improvement Plan 2010 the morning of 3/9/10:

Sections of the PI Plan indicated the following:

"All employees of Lakeview Specialty Hospital & Rehab will participate in ongoing and systemic quality improvement efforts. Our quality improvement efforts will focus on direct patient/client delivery processes and support processes that promote optimal patient/client outcomes and effective business practices. This is accomplished through peer review, clinical outcome review, variance analysis, performance appraisals, and other appropriate quality improvement techniques. The Board of Directors of Lakeview Specialty Hospital & Rehab is ultimately responsible for assuring that high quality care is provided to our patients/clients. The Performance improvement Committee provides oversight and functions as the central clearinghouse for quality data and information collected throughout the facility. The PI committee tracks, trends, and aggregates data from all sources to prepare reports for the governing board and the medical staff."

A review of the facility's performance improvement/patient safety and physician quality assurance (QA) meeting minutes on 3/3/10 beginning at 7:10 AM revealed the following:

Performance Improvement (PI) meeting minutes dated 7/30/09, 8/26/09, 9/22/09, 11/3/09, 12/1/09, 12/29/09, 1/26/10, and 2/25/10 show the following: hospital, community based residential facility (CBRF) and residential area data is co-mingled. Infection control data collection and analysis is not reflected in meeting minutes dated 9/22/09, 11/3/09, 12/1/09, 12/29/09, 1/26/10, and 2/25/10. Patient satisfaction surveys result reported in 11/3/09 meeting indicate a decline in questions being answered. The minutes also indicate difficulty qualifying the hospital measures without benchmarks of satisfaction within similar settings and that PI LPN JJ will research these benchmarks for inclusion in the future. PI minutes dated 12/2/09, 12/29/09, 1/26/10, and 2/25/10 fail to mention follow-up to benchmark concern.

PI meeting minutes dated 1/26/10 under Special Interventions Team for restraint usage indicates: Hospital Data - analysis of restrictive procedures and not misapplying them when needed. To perform analysis of hospital data and report monthly. PI meeting minutes dated 2/25/10 the Special Interventions Team for restraint usage and reduction data indicates: "Review of data submitted data sheets indicates possible incomplete data set. PI Committee recommends review be performed to ascertain accuracy." The minutes fail to show actual measurement for restraint usage data, appropriateness of restraint usage, implementation of ways to prevent or decrease the use of restraints, and evaluation of the process.


Physician QA minutes dated 1/29/09, 3/4/09, 7/1/09, 9/2/09, 12/2/09, 1/6/10, 1/20/10, and 1/27/10 show Hospital, CBRF and residential issues are co-mingled. Physician QA minutes fail to mention infection control data collection and analysis. The minutes fail to show the death of Pt #5 and #8 were peer reviewed to ensure care received was adequate. No root cause analysis (RCA) or peer review were found for Pt #1 after she became unresponsive while undergoing dialysis treatment on 12/14/09. Pt #1 was transferred to another area hospital after this incident occurred.

Dr. KK (Medical Director) was interviewed on 3/8/10 at 12:04 PM indicated Lakeview does not have a formalized process for peer review. Dr. KK indicated peer review is usually conducted on unexpected deaths, unanticipated transfers, and family complaints; however, Dr. KK can not show Pt #1's unexpected transfer on 12/14/09 was reviewed. Dr. KK cannot show the death of Pt #5 (died 11/7/09) and the death of Pt #8 (died 1/13/10) was reviewed for quality of care issues.

Administrator B indicated to Surveyor #03383 during a conversation on 3/1/10 beginning at 10:00 AM that the hospital is actively in search of a quality assurance performance improvement (QAPI) person to hire because the current QAPI person is not qualified for the position.

An interview with QAPI LPN JJ on 3/4/10 at 10:15 AM confirmed that medication error data graphs reflect the entire facility, not just hospital data. QAPI LPN JJ also confirmed that PI activities conducted in subcommittees is not always reflected in PI committee meeting minutes and governing board meeting minutes.

Based on review of performance improvement/patient safety meeting minutes, performance improvement (PI) program, physician quality assurance meeting minutes and staff interview, the hospital failed to assess all unanticipated hospital transfers and deaths to ensure the patient received quality care based on standards of practice in a safe and effective manner.

Findings include:

Per record review and staff interview conducted by Surveyor #03383:

Per review of Performance Improvement Plan 2010 the morning of 3/9/10:

Sections of the PI Plan indicated the following:

"Our quality improvement efforts will focus on direct patient/client delivery processes and support processes that promote optimal patient/client outcomes and effective business practices. This is accomplished through peer review, clinical outcome review, variance analysis, performance appraisals, and other appropriate quality improvement techniques."

A review of the facility's performance improvement/patient safety, physician quality assurance (QA) meeting minutes, and minutes of MRIoA (Contract peer review agency) peer review results on 3/3/10 beginning at 7:10 AM revealed the following:

Physician QA minutes dated 1/29/09, 3/4/09, 7/1/09, 9/2/09, 12/2/09, 1/6/10, 1/20/10, Physician QA minutes fail to show the death of Pt #5 and #8 were peer reviewed to ensure care received was adequate. No root cause analysis (RCA) or peer review were found for Pt #1 after she became unresponsive while undergoing dialysis treatment on 12/14/09. Pt #1 was transferred to another area hospital after this incident occurred and never returned.

Dr. KK (Medical Director) was interviewed on 3/8/10 at 12:04 PM indicated Lakeview does not have a formalized process for peer review. Dr. KK indicated peer review is usually conducted on unexpected deaths, unanticipated transfers, and family complaints; however, Dr. KK can not provide documentation needed to verify Pt #1's unexpected transfer on 12/14/09 was reviewed. Dr. KK cannot show the death of Pt #5 (died 11/7/09) and the death of Pt #8 (died 1/13/10) was reviewed for quality of care issues. Dr. KK confirmed that peer review was not done on Pt #1, Pt #5 or Pt #8. Chief Nursing Officer also indicated on 3/3/10 at 11:12 AM that Patient #1's medical record has not been reviewed.

Based on review of incident reports, performance improvement/patient safety meeting minutes, Fall subcommittee meeting minutes, performance improvement (PI) program, and staff interview, the hospital failed to reassess and implement preventive actions to address an increased number of falls experienced by 3 of 3 patients (Pt #15, #30, #34) in the hospital from January 1, 2010 to February 28, 2010.

Findings include:

Per record review and staff interview conducted by Surveyor #03383:

Per review of Performance Improvement Plan 2010 the morning of 3/9/10:

The PI Plan indicates the following:

"Our quality improvement efforts will focus on direct patient/client delivery processes and support processes that promote optimal patient/client outcomes and effective business practices. This is accomplished through peer review, clinical outcome review, variance analysis, performance appraisals, and other appropriate quality improvement techniques."

A review of incident reports on 3/4/10 beginning at 7:30 AM revealed an upward trend in the number of falls occurring in the hospital between 1/1/10 to 2/28/10. Pt. #15 fell on 1/4/10, 1/14/10, 1/19/10, 1/21/10, 1/26/10, 1/29/10, fell twice on 1/30/10, and 2/8/10; Pt #34 fell on 1/12/10, 1/15/10, 1/18/10, 1/19/10, 1/20/10, 1/21/01, 1/23/10, and fell three times on 2/9/10; Pt #30 fell on 1/18/10, 2/8/10, 2/10/10, and 2/28/20.

A total of 19 of 55 incident reports for falls that occurred between 1/3/10 to 2/28/10 fail to show follow-up to address fall prevention in the hospital by the facility.

A review of the Falls subcommittee reports on 3/4/10 at 8:15 AM revealed that trending by patient was not found. Reassessment and implementation of new measures to prevent or reduce the number of future falls was not was not found for January and February 2010.

A review of the facility's 2/25/10 Performance Improvement/Patient safety meeting minutes on 3/3/10 beginning at 7:10 AM does not show the Falls subcommittee submitted a report to the PI committee to analyze and develop an action plan for the increased number of falls in the hospital in January and February 2010.

An interview with QAPI LPN JJ on 3/4/10 beginning at 10:10 AM confirmed that falls increased in the hospital in January 2010 and fall data was not analyzed in January and February to initiate preventive measures.

Based on medical record review, review of contract dialysis service policy, and contract dialysis staff interview, the hospital failed to ensure that contracted dialysis staff provided biological preparations (normal saline doses used during hemodialysis) in accordance with physician's orders in 1 of 2 patients (Patient #26) receiving in-patient hemodialysis in the hospital, in a total sample of 30 patients.

Findings include:

Per medical record review, review of contract dialysis service policy, and contract dialysis staff interview conducted by Surveyor #09948 the afternoon of 3/8/10:

The 3/8/10 review of the contracted dialysis service "Policy:7-06-04, Titled: Anticoagulation" states on page 3 of 5 under "Use of saline flushes: 15. Saline flushes are administered per physician's order. Order is to include order date and time, patient name, route, frequency and volume of saline flushes."

The 3/8/10 review of the 2/25/10 hemodialysis treatment sheet reflects that Patient #26 received 2 -100 cc boluses (doses) of normal saline during the hemodialysis. Upon the review of the patient's medical record, there is no documented evidence that a physician's medical order was obtained for administration of this medical treatment.

The 3/8/10 review of the 2/26/10 hemodialysis treatment sheet reflects that Patient #26 received 1 -100 cc bolus (dose) of normal saline during the hemodialysis treatment. Upon the review of the patient's medical record, there is no documented evidence that a physician's medical order was obtained for administration of this medical treatment.

The 3/8/10 interview with Dialysis RN TT at approximately 3:15 p.m., who gave the fluid boluses on 2/25/10 and 2/26/10 , stated that boluses were given because Patient #26 runs (dialyzed) heparin- free (medication that keeps the blood from clotting while being cleaned).

Findings were verified with Administer B and Chief Operations Officer OO on 3/8/10 at approximately 4:00 PM

Based on review of IC (Infection Control) policies and procedures, IC committee meeting minutes and Quality Assessment Performance Improvement (QAPI) program meeting minutes and staff interviews, the hospital's administrative staff [Chief Executive Officer CEO), medical staff and Director of Nurses (DON)] failed to ensure that the hospital's infection control plan was followed and monitored through the hospital's Quality Assessment Performance Improvement (QAPI) program, and failed to ensure that contracted hospital services (dialysis, laboratory and laundry) maintained nationally recognized IC (Infection Control) practices.

Findings include:

1) The hospital administrative staff failed ensure the hospital approved "Infection Control Plan" policy was followed by their Infection Control Preventionist who was responsible for the tracking/ trending and reporting of device-related infections. Per hospital policy, they should have recognized that monthly/quarterly IC reports reflected no data collection, analysis or reporting on this data. (Reference A0749, example #4)

2) The 3/8/10 review of the "December 22, 2009- Infection Control Committee" report (named changed from PI (Performance Improvement) /Infection Control Patient Safety) had the following attachment which was reviewed by the hospital's administrative staff:
"Infection Control program Plan December 2009" from an hired ICP consultant agency reflects that a contracted ICP consult came into the facility on November 4, 2009 from 9 a.m. to 3:30 p.m. and December 3, 2009 from 8:30 a.m. to 3:30 p.m. to identify infection control program needs. The attached "infection control program plan" per the contract consultant ICP identified problems in 3 major areas: 1) surveillance processes to identify health care associated infections and current statistics, 2) IC policies, and 3)isolation practices. The contracted consultant ICP recommended follow-up visits for mentorship and continued policy review. There is no documented evidence that this contract consultant ICP returned. There was no documented evidence that a QAPI plan (interventional directives for assigned staff with goal dates) was generated to address these identified issues.

Interview with Administrator B and COO (Chief Operating Officer) OO on 3/8/10 at approximately 3 p.m. verified that they had no IC information regarding this contracted service findings.

3) Interview with Environmental Service Director C on 3/3/10 at approximately 9:30 a.m. reflects that all laundry, except patient's personal clothing, mop heads, shower and privacy curtains and cleaning rags, are sent to a contracted laundry service. Director C stated that to his knowledge their was no infection control review of the contracted laundry service to ensure that the laundry was being cleaned, handled, stored and transported in a sanitary manner according to nationally recognized disease control guidelines.

Interview with Administrator B and COO (Chief Operating Officer) OO on 3/8/10 at approximately 3 p.m. verified that they had no IC information regarding this contracted service.

4) The 3/8/10 review of the IC committee meeting minutes, and QAPI reports for March 2009 through Feb. 2010 reflect no information regarding the contracted dialysis services being provided in the hospital. There was no documented evidence that the administrative staffs or the ICP reviewed the contracted dialysis service to ensure water and dialysate met quality standards according to AAMI (Association of Advancement of Medical Instrumentation). There was no documented evidence that the hospital's administrative staff developed a QAPI program to ensure that contracted dialysis services were provided according to current IC standards of practice.

Interview with Administrator B and COO (Chief Operating Officer) OO and Medical Director KK on 3/8/10 at approximately 3 p.m. verified that the hospital's former and present administrative staffs had not been reviewing IC practices provided by the contracted dialysis service.

5) The 3/8/10 review of the IC committee meeting minutes, and QAPI reports for March 2009 through Feb. 2010 reflect no information regarding the contracted laboratory services being provided in the hospital. There was no documented evidence that the contracted service had been reviewed to ensure that laboratory techniques, such as venipunctures, blood handling and storage and use of the hospital's hematology equipment was provided using current IC standards of practice.

Interview with Administrator B and COO (Chief Operating Officer) OO on 3/8/10 at approximately 3 p.m. verified that the hospital's former and present administrative staffs had not been reviewing IC practices provided by the contracted dialysis service.