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

1. failing to have an RN document an assessment on patients with a change in condition for 3 (#12, #21, #23 ) of 3 patients transferred for emergency conditions (See findings in A0395).

2. failing to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of an RN assessment at a minimum of every 24 hours for 5 (#2, #9, #10, #11, #12) of 20 ( #s 1-20) records reviewed for RN assessment every 24 hours (See findings in A0395).

Based on observation, record review, and interview the Governing Body failed to ensure the Administrator was responsible for ensuring the separately certified departments/units of the hospital were not operationally integrated. This deficient practice was evidenced by:
1) nursing staff assigned to both the Rehabilitation Hospital Inpatients and the SNF unit (each with a separate certification number) at the same time, and
2) admitting SNF patients in designated hospital inpatient beds, and/or a patient remaining in the same bed/room when an inpatient was discharged, as an inpatient, and admitted as a SNF patient. Findings:



1) Nursing staff assigned to both the Rehabilitation Hospital Inpatients and the SNF patients at the same time. The Rehabilitation Hospital and the SNF unit had separate CMS provider certification numbers.

In an interview 02/20/17 at 12:05 p.m. S5LPN reported he was assigned to the care of 3 inpatients and 1 SNF patient for his current shift.

A review of Daily Staffing Assignment Sheets for 02/20/17 revealed a sheet marked Rehab, in which S5LPN was assigned to the care of 3 inpatients and 1 SNF patient.

Review of nurse staffing assignment sheets for 02/15/17 through 02/22/17, provided by S2DON revealed staff with assignments of both hospital inpatient and SNF patients during their work shift as follows: (day shift - 6:00 a.m- 6:00 p.m.) (night shift 6:00 p.m.- 6:00 a.m.)
02/15/17:
Day (Shift): 1 RN Charge Nurse, 1 LPN, 1 CNA, and 1 wound care RN
Night (Shift): 1 RN Charge Nurse, 1 other RN, 1 CNA
02/16/17:
Day: 1 RN, 1 LPN, 1 CNA
Night: 1 RN Charge Nurse, 1 RN, 1 CNA
02/17/18
Day: 1 RN Charge Nurse, 1 LPN, 1 CNA, 1 wound care RN
Night: 1 RN Charge Nurse, 1 CNA
02/18/17
Day: 1 RN Charge Nurse, 1 LPN, 1 CNA
Night:1 RN Charge Nurse, 1 LPN, 1CNA
02/19/17
Day: 1 RN Charge Nurse, 1 LPN, 1 CNA
Night: 1 RN Charge Nurse, 1 LPN, 1 CNA
02/20/17
Day: 1 RN Charge Nurse, 1 LPN, 1 wound care RN
Night: 1 RN Charge Nurse, 1 other RN, 1 CNA
02/22/17
Day: 1 RN Charge Nurse, 1 CNA, 1 wound care RN

In an interview 2/21/17 at 4:45 p.m., with S2DON, S1AsstAdm, and S22VP present , S2DON confirmed nursing staff that included a Charge RN, sometimes RNs, LPNs, and CNAs were assigned to both Rehab Hospital Patients and SNF patients at the same time. She verified the wound care nurse, S4RN provided wound care to both Inpatient Rehab patients and SNF during the same hours she was on duty at the facility.

In an interview 02/22/17 at 7:50 a.m. S8RN reported she was the charge nurse for both the Skilled Nursing Unit, and the Rehabilitation Hospital inpatients for that day. She indicated this is not uncommon for her to be the charge nurse over both units.

In an interview 02/22/17 at 8:00 a.m., S4RN reported she was the wound care nurse. S4RN indicated she assessed and performed wound care for both SNF and Hospital Inpatients throughout her shift. She indicated she usually sees newly admitted patients first so they can be available for therapy, whether they are inpatients or SNF patients. S4RN verified she did not work specific and separate hours for inpatients or SNF patients.



2) Admitting SNF patients in designated hospital inpatient beds, and/or a patient remaining in the same bed/room when an inpatient was discharged, as an inpatient, and admitted as a SNF patient.

Review of a hospital census sheet revealed 23 patient rooms listed.

Review of the current census revealed Patient #R1 was in "j", and had "SKILLED" noted by her name. Further review of the census 02/20/17 revealed Patient #R1 was in "j", and had "SKILLED" noted by her name, and Patient #R2 had been in Room "o". Patient #R2 had the word "SKILLED" by his name on the census.

In an interview 2/22/17 at 10:50 a.m. S8RN, reported she was the charge nurse for both the Inpatient Unit and the SNF unit that day. S8RN indicated Rooms "a-o" were designated as Rehab Inpatient rooms, and the remaining 8 rooms were SNF patient rooms. S8RN reported the patient (R1) in Room "j" was a SNF patient , and had been a SNF patient since admitted 2/13/17. S8RN indicated Room "j" was a considered an inpatient room. S8RN reported R2 had been admitted to Room ""o" as a Rehabilitation Hospital patient on 1/15/17, was changed to a SNF patient (with a different medical record number) during his stay at the hospital, but remained in the same room until discharge on 2/21/17. S8RN indicated Room "o" was designated as an Inpatient room. S8RN confirmed R1 and R2 were both SNF patients that were in rooms that were designated for Inpatients. The charge RN reported the skilled patients and rehabilitation patients' rooms could be interchanged depending on the need.

#R1
A review of face sheet for R1 revealed she was admitted to the SNF unit 02/13/17 to room "p". Further review revealed the patient was still in room "p" at the time of the survey.

R#2
Review of the face sheet for #R2, provided by S16MR, revealed he was admitted to the hospital as an inpatient (stay type) 1/15/17 to room 114. Review of a second face revealed #R2 was admitted under a "stay type" of SNF 02/01/17 with a bed number of a SNF room. Further review of the face sheets revealed the hospital numbers for each admission was different.

In an interview 02/22/17 at 7:50 a.m. S8RN reported she was the charge nurse for both the Skilled Nursing Unit, and the Rehabilitation Hospital inpatients for that day. S8RN verified Inpatient rooms were Rooms "a-o", and the remaining 8 rooms were SNF patient rooms. S8RN indicated that #R1 had been placed in room "j" on admission and had remained there. S8RN verified the patient was, and had been a SNF patient since her admission. S8RN verified #R2, discharged yesterday, was admitted as an inpatient 1/15/17 to room "o", then was changed to a SNF patient during his stay, but stayed in room "o" throughout his stay both as an inpatient and a SNF patient, instead of changing rooms.

In an interview on 2/22/17 at 9:11 a.m. with S2DON, she said rooms "a- o" were rehabilitation unit rooms and the other 8 rooms were skilled unit rooms. S2DON said they would use the rehabilitation rooms as skilled rooms on some occasions. She said for example if there was a male family member sleeping in the room with a patient she could not admit a female patient to the other bed in the room. S2DON said in that case the staff would admit the patient to a rehabilitation room and use it as a skilled bed.





30364

Based on record review and interview, the governing body failed to ensure that services performed under a contract were provided in a safe and effective manner as evidenced by failure to have documented evidence of an evaluation of all of the hospital's services provided by contract.

Findings:

Review of the hospital's contract binder revealed contracts for medical waste, housekeeping and medical transportation.

Review of the quality data with S2DON revealed all contracted services were not including medical waste, housekeeping, and medical transportation.

In an interview on 2/22/17 at 10:45 a.m. with S2DON, she verified the quality program did not include all contracted services.

Based on record review and interview, the hospital's governing body failed to ensure the QAPI program reflected the complexity of the hospital's organization and services. This deficient practice is evidenced by combining indicators and data for quality review from two separate units with different CMS provider numbers.
Findings:

Review of the hospital's QAPI data revealed the medical records department had one set of data that was discussed in the quality meetings. The skilled nursing unit's and rehabilitation unit's medical records data was not separated and reviewed as individual entities.

In an interview on 2/22/17 at 11:03 p.m. with S16MR, she verified the skilled nursing unit's and the rehabilitation unit's medical record data for quality assurance was together and not separated. She said she had no way at the present time to separate the information of the two units. S16MR also verified the skilled nursing unit and the rehabilitation unit had different CMS provider numbers.

Based on record reviews, observations, and interviews, the Hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) failing to have an RN document an assessment on patients with a change in condition for 3 (#12, #21, #23 ) of 3 patients transferred for emergency conditions;
2) failing to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of an RN assessment at a minimum of every 24 hours for 5 (#2, #9, #10, #11, #12) of 20( #s 1-20) records reviewed for RN assessment every 24 hours; and
3) failing to weigh patients as ordered by the physician for 1 (#3) of 6 (#1-#5, #8) patients reviewed for weights as ordered.
A total of 30 patient medical records were sampled.
Findings:

1) Failing to have an RN document an assessment on patients with a change in condition.

Review of the hospital's policy titled, Emergency Transfer to an Acute Facility, Policy Number II.C.81.0, revealed in part, Procedures: Provide emergency intervention as dictated by the circumstances i.e. CPR, oxygen etc..., Continue to assess the patient, i.e. accuchecks, vital signs, cardiac monitor, immobilization, etc. Document the assessment in the nurse notes include notification of the physician and response, If the patient is medically unstable, the physician will order a transfer to an acute care facility,...complete a transfer form, the nurse will complete documentation in the nurse's notes and ensure all physician orders have been transcribed accurately...

Review of LSBN's "Chapter 39. Legal Standards of Nursing Practice 3901. Legal Standards" revealed that the Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the RN in the practice of nursing. The standards of nursing practice provides a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a RN or by a RN in conjunction with other licensed or unlicensed personnel.

Review of LSBN's "Chapter 37. Nursing Practice 3701. Duties of the Board Directly Related to Nursing Practice as cited in R.S. (revised statute) 37:918" revealed that assessing health status was defined as gathering information relative to physiologic, behavioral, sociologic, spiritual, and environmental impairments and strengths of an individual by means of the nursing history, physical examination, and observation, in accordance with the board's Legal Standards of Nursing Practice. Delegating nursing interventions was defined as entrusting the performance of selected nursing tasks by the RN to other competent nursing personnel in selected situations. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.


Patient #12
Review of Patient #12's medical record revealed he had a telephone order dated 2/17/17 at 2:45 p.m. to be sent to the emergency room for an evaluation of altered mental status, decreased alertness and hypotension.

Further review of Patient #12's medical record revealed the following entries on 2/17/17:
12:30 p.m. - Awakens easily to verbal stimuli. No deficits noted.
1:15 p.m. - Neurochecks performed. B/P 78/58, P 80, R 20, T 97.1, O2 96%. PERL. Unable to grasp hands. Confused, oriented x 1 to self. Will continue to monitor. Resting with eyes closed. (Written by S25LPN).
3:10 p.m. - Resident sent to ER for decreasing B/P and change in LOC. Sent to (local hospital) for evaluation. Transported via Acadian ambulance. (Written by S25LPN).

In an interview on 2/21/17 at 2:10 p.m. with S2DON, she verified a RN should have documented an assessment when Patient #12 had a decline in status.

Patient #21
Review of the medical record for Patient #21 revealed he was admitted to the hospital on 2/06/17 to build up his strength after a hospitalization for Metabolic Encephalopathy and Leptomeningeal Myelomatosis in another hospital. Review of the patient's Acute Rehab Patient Flowsheet, dated 2/10/17, revealed Patient #21 complained of chest pain at 9:00 a.m. and vitals signs were: 90/54 with a heart rate of 153. An EKG was ordered and performed on the patient and nitroglycerine paste was administered to the patient. At 3:00 p.m. on 2/10/17 an ambulance was called and the patient was transferred to a hospital for a higher level of care. Further review of the medical record on 2/10/17 revealed the patient's assessments were not performed by an RN during the patient's significant change of condition. The patient's assessments during the patient's change of condition were performed by S5LPN.

An interview was conducted with S2DON on 2/21/17 at 3:00 p.m. S2DON confirmed a RN had not assessed the patient when he experienced a change in condition and prior to his transfer to an acute care hospital for a higher level of care. S2DON also confirmed there was not a transfer form in the patient's record, which should had been completed prior to transfer to the other hospital according to the hospital's policy.

Patient #23
Review of Patient #23's nurse's notes dated 11/3/16 revealed the following entry:
6:30 a.m. - Reported to charge nurse: B/P still low. B/P 88/52, P 42, R 24, T 97.2. Pulse oximeter 98% (Written by S26LPN).
7:03 a.m. - Called to room by therapy tech to evaluate patient. Pt noted diaphoretic, skin cold, blood glucose 271, unable to register B/P, HR 39, R 18, A/O and talking. Pulse ox 81% RA. 15L non rebreather mask started at 7:07 a.m. Still unable to get a blood pressure. Manual groin pulse 39 BPM. Pt sat on non rebreather mask at 100%. EKG done at 7:15 a.m. Sinus rhythm noted and HR of 39 BPM. Pt remain alert Ambulance B arrived at 7:20 a.m. EKG was done by them and they were able to get a blood pressure of 74/45. Pt out to Hospital A by Ambulance B at 7:27 a.m. Alert and awake (written by S26LPN).

In an interview on 2/22/17 at 9:30 a.m. with S2DON, she verified there was no documented assessment by a RN when Patient #23 had a decline in status.

2) Failing to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act.

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

Review of the hospital policy titled Nursing Assessment, Policy Number II.A.9.0, revealed in part:
All patients admitted will be reassessed every nursing shift (12 hour shift) by the RN or LPN. Every rehab patient will be assessed by an RN in a 24 hour period. More frequent observations and assessments may be determined on the complexity of the care needs of the patient.

Patient #2
Review of current Patient #2's medical record revealed an admission date of 02/03/17 with admission diagnoses of metabolic Encephalopathy and failure to thrive after a fall.

Review of Patient #2's nurses notes for 02/20/17 (day and night shift) revealed there was no documented RN assessment for that 24 hour period.

Patient #9
Review of Patient #9's nursing notes revealed no documented assessment by a RN on 09/23/16 and 09/24/16 or the night shift on 09/22/16 (60 hours). Further review revealed no documented assessment by a RN on 09/18/16 through 09/19/16 (48 hours).

Patient #10
Review of current Patient #10's medical record revealed an admission date of 02/16/17 with admission diagnoses of acute kidney injury and debility.

Review of Patient #10's nursing notes documentation from 02/17/17 (day and night shift) to 02/18/17 (day and night shift) revealed there was no documented RN assessment (48 hours). Additional review revealed no documented RN assessment on 02/20/17(day and night shift).


Patient #11
Review of the medical record for Patient #11 revealed she was admitted to the hospital on 08/29/16 for rehabilitation after surgery to repair her broken right hip.

Review of Patient #11's Acute Rehab Patient Care Flow Sheet for 09/05/16 and 09/06/16 revealed a RN did not assess the patient for a 48 hour period. With further review of Patient #11's medical record revealed a RN did not assess the patient on 09/10/16 and 09/11/16, which was also a 48 hour period without a RN assessment.

Patient #12
Review of Patient #12's medical record revealed from 2/17/17 through 2/19/17 there was no documented RN assessment (48 hours).

The above findings were confirmed by S2DON at 2/21/17 at 2:00 p.m.

An interview was conducted with S2DON on 2/21/17 at 2:00 p.m. She reported the hospital's process was for a RN to assess the patient every 24 hours. The RN working on the day shift would assess part of the patients, the patients not assessed by the day RN would be assessed by the night RN that evening. The process was instituted so that every patient would have a RN assessment once every 24 hours. S2DON further reported the days the patients didn't have a RN assessment every 24 hours may have been when there was only one RN working that day.

3) Failure to weigh patients as ordered by the physician.

Review of hospital policy # II.C.88.0, titled "Obtaining Patient Weights", provided by S2DON as current, revealed in part the objective was to maintain constant control of obtaining patient weights following admission and ongoing. The procedure was as follows: "1) All patients are weighed by nursing staff on admission. Weights are to be documented on the Admission Orders form. 2) Weekly weights are to be obtained on Wednesdays by the Therapy Department and recorded in the weekly binder. 3) Daily weight checks may be ordered on patients with physical disorders..., or ordered by the physician...5) If therapy is unable to obtain a patient's weight they will notify the nurse assigned to the patient..."

Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital 2/10/17 for rehabilitation therapy for functional decline after a fall with multiple compression fractures in her spine. Co-morbidities present on admission included Congestive heart failure, COPD, neuropathy, and Atrial fibrillation. Review of admission orders, revealed her weight was to be obtained on admission and then weekly. Further review of physician orders revealed an order, dated 02/13/17, for daily weights. Review of the graphic record in Patient#3's medical record and the Monthly weight log from the Therapy Gym revealed no documented weight for 02/15/17 and 02/16/17.

In an interview 02/22/17 at 9:40 a.m. S16MR , after a review of Patient #3's medical record and Patient #3's Monthly weight log she provided, confirmed there was no evidence of a weight assessment for Patient #3 for 02/15/17 or 02/16/17. S16MR confirmed a physician's order was documented 02/13/17 for daily weights, but there was no documented evidence of a weight assessment for Patient #3 on 02/15/17 or 02/16/17.



30364




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30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 3 (#2 , #10 , #25) of 3 patients sampled for care planning out of a total sample of 30.

Findings:

Patient #2
Review of current Patient #2's medical record revealed an admission date of 02/03/17 with admission diagnoses of Metabolic Encephalopathy and Failure to thrive after a fall. Additional review revealed Patient #2 was placed on contact isolation for C. diff (C. difficile) on 02/19/17.

Review of Patient #2's current care plan revealed actual infection (C. diff) and isolation precautions (Contact) was not addressed as a current identified problem on the patient's plan of care.

Patient #10
Review of current Patient #10's medical record revealed an admission date of 02/16/17 with admission diagnoses of Acute Kidney Injury and Debility. Additional review revealed Patient #10 was placed on contact isolation precautions for VRE positive urine culture on 02/21/17.

Review of Patient #10's current care plan revealed actual infection (VRE) and isolation precautions (Contact) was not addressed as a current identified problem on the patient's plan of care.

Patient #25
Review of current Patient #25's medical record revealed an admission date of 02/13/17 with admission diagnosis of CVA with residual weakness. Additional review revealed Patient #25 was also being treated for a co-morbid diagnosis of Rocky Mountain spotted fever.

Review of Patient #25's current care plan revealed actual infection (Rocky Mountain spotted fever) was not addressed as a current identified problem on the patient's plan of care.

In an interview on 2/22/17 at 2:20 p.m. with S2DON, she acknowledged the above referenced problems should have been addressed on the plan of care.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer medication as ordered for 2 (#7, #15) of 10 sampled patients with sliding scale insulin ordered, from a total sample of 30.
Findings:

Review of the hospital policy titled Medication Administration and Documentation, Policy Number II.D.6.0, revealed in part: Drugs shall be prepared and administered in accordance with the orders of the physicians or licensed independent practitioners responsible for the patient's care and accepted standards of practice.

Patient #7
Review of Patient #7's medical record revealed a physician's order dated 2/6/17 for the following sliding scale Regular insulin.
201-250 mg/dl - 2 units
251-300 mg/dl - 4 units
301-350 mg/dl - 6 units

Review of Patient #7's MAR revealed the following:
2/7/17 at 7:00 p.m. - 208 mg/dl - no insulin documented
2/8/17 at 7:00 p.m. - 244 mg/dl - no insulin documented
2/13/17 at 11:30 a.m. - 252 mg/dl - no insulin documented
2/15/17 at 7:00 p.m. - 269 mg/dl - no insulin documented
2/16/17 at 7:00 p.m. - 229 mg/dl - no insulin documented
2/20/17 at 7:00 p.m. - 331 mg/dl; 9:00 p.m. - 242 mg/dl - no insulin documented

Patient # 15
Review of Patient #15's medical record revealed a physician's order dated 10/6/16 for the following sliding scale Regular insulin:
201- 250 mg/dl - 2 units
251- 300 mg/dl - 4 units

Review of Patient #15"s MAR revealed the following blood glucose documented:
10/13/16 at 4:30 p.m. - 272 mg/dl - no insulin given
10/14/16 at 11:30 a.m. - 256 mg/dl - no insulin given
10/18/16 at 11:30 a.m. - 216 mg/dl - no insulin given
10/9/16 at 11:30 a.m. - 218 mg/dl - no insulin given
10/9/16 at 4:30 p.m. - 255 mg/dl - no insulin given
10/9/16 at 7:00 p.m. - 210 mg/dl - no insulin given

In an interview on 2/21/17 at 10:30 a.m. with S2DON, she verified the above mentioned insulin doses were not documented as having been given.

Based on record reviews and staff interviews, the hospital failed to ensure medical history and physical examinations were completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 3 (#3,#16, #28) of 7 (#1-5, #16, #28 ) patient medical records reviewed for completed H&P's from a total sample of 30 .
Findings:


Review of hospital policy #III.B.4.0, titled "Chart Assembly & Analysis", provided by S2DON as current, revealed, in part A History and Physical was to be completed within 24 hours of admission.

Review of the Medical Staff Rules and Regulations, provided by S2DON as current, revealed , under V. Conduct of Care, B., (2) an H&P must be recorded and placed in the medical record within 24 hours of admission or registration. Further review revealed , under (5) "Inpatient Care: A qualified Member shall perform and document and H&P within 24 hours of admission."

Patient #3

Review of the medical record for Patient #3 revealed she was admitted to the hospital 02/10/17 at 5:53 p.m. Further review revealed an H&P dated 02/13/17 at 11:23 a.m., performed by S3MedDir and dictated by S21PA.

In an interview 02/22/17 at 9:40 a.m. S16MR, after a review of Patient #3's medical record verified the H&P was dictated 2 1/2 days after the patient's admission, and not within 24 hours of admission the hospital's P&P and Medical Staff Bylaws required.

Patient #16

Review of Patient #16's medical record revealed an admission date of 8/31/16 with an admission diagnosis of status post left total knee replacement. Additional review revealed Patient #16's History and Physical had not been completed until 9/2/16 (48 hours after admission).

Patient #28

Review of Patient #28's medical record revealed an admission date of 1/27/17 with an admission diagnosis of critical illness Myopathy status ankle fracture open reduction and internal fixation. Additional review revealed Patient #28's History and Physical had not been completed until 1/30/17 (36 hours after admission).

In an interview 02/22/17 at 9:50 a.m. S16MR, after a review of Patient #16 and Patient #28's medical records, verified the H&P's were not dictated within 24 hours of admission as per the hospital's P&P and Medical Staff Bylaws requirement.


30984

Based on record review and interview, the hospital failed to ensure drug administration errors were documented in the patient's medical record for 1 (#17) of 1 patients reviewed for medication errors.

Findings:

Review of the hospital policy titled," Management of Medication Variances", Policy Number: I.E.9.0, revealed in part: Procedure: 1) Reporting: Employees are expected to report medication variances and potential medication variances via the Incident Report Form. The DON shall be responsible for investigating and documenting the circumstances of the error. Additional review of the policy revealed no directive for documentation of medication errors in patient medical records.

Review of the hospital's Incident Reports revealed a medication error involving Patient #17. Further review revealed Patient #17 had missed a scheduled 7:00 a.m. dose of 24 units of subcutaneous Lantus insulin on 10/18/16.

Review of Patient #17's entire medical record revealed no documented evidence of an account of the medication error referenced in the Incident Report dated 10/18/16.

In an interview on 02/21/17 at 3:59 p.m. with S2DON, she indicated medication errors were documented on Incident Reports. S2DON confirmed documentation of medication errors in the patient's medical record was not part of the Hospital's medication variance reporting policy/procedure.

Based on record review and interview, the hospital failed to ensure the composition of the Utilization Review Committee included at least two physician members.

Findings:

Review of the Utilization Review Committee documentation, presented as current by S2DON, revealed S18MD was the only physician member of the Utilization Review Committee.

In an interview on 2/22/17 at 1:45 p.m. with S2DON, she confirmed the Utilization Review Committee had only one physician member and that member was S18MD.

In an interview on 2/22/17 at 1:50 p.m. with S1AsstAdm, she also confirmed S18MD was the only physician member of the Utilization Review Committee.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices as evidenced by:
1) failure to maintain a sanitary environment;
2) failure to ensure the hospital's policy for isolation precautions was implemented as evidenced by having no signage for Enhanced Contact Precautions on a patient's (#2) door who was on ordered contact isolation precautions for a diagnosis of C.diff. for 1 (#2) of 2 (#2,#10) patients on contact isolation out of a total sample of 30 patients.
3) failure to ensure staff providing services to a patient (#2) on contact isolation precautions for C.diff adhered to infection control practices, and;
4) failure to have evidence of hospital laundry cleaned and processed as per their policy and procedure, and by CDC standards.
Findings:


1) failure to maintain a sanitary environment;

Review of hospital policy # III.D.45.0, titled "Cleaning Patient Care Equipment", provided by S1AsstAdm as current, revealed in part that non-critical patient equipment should be cleaned between use on different patients, and whenever visibly soiled. This included equipment that comes into contact with the patient's skin, but didn't enter into cavities or contact mucous membranes. This also included equipment such as wheelchairs, walkers, and other durable medical equipment or adaptive devices Equipment designed for single patient use would not be cleaned and used for another patient. Further review revealed procedure for cleaning of non-critical equipment included the following, in part: "A. When visibly soiled:...Obtain hospital approved germicidal wipes, wipe equipment entirely,, include cords, stands, rolling poles, etc...B. After patient use: ... Transport equipment to soiled utility room...Wipe equipment entirely including cords, stands, rolling poles, etc., allow to stand for 10 minutes, cover with clear plastic bag ...store in designated clean equipment storage area. C. Between Patient Use: Items such as ...hand weights, etc that are not designated to a single patient will be cleaned between patient usages...wipe equipment entirely..."

On 2/20/17 at 11: 10 a.m. - 12:25 p.m. an observation was made of the hospital. The following issues were observed:
Wheelchair Storage Room:
Wheelchair pad covers, wheelchair leg pieces and foam wedge covers were noted to be placed in a pile on the floor.

Supply Storage Room:
24- 8 ounce cans of Glucerna 1.0 Calorie Oral Supplement- all expired on 2/1/17
3- 8 ounce cans of 1.2 Calorie Jevity Oral Meal Supplement noted to have large dents.

Housekeeping Storage Room
An observation was conducted on 2/20/17 at 11:15 a.m. of the housekeeping storage room. Clean uncovered supplies of paper towels and toilet paper were stored with the dirty housekeeping cart, mops and dusters. The floor of the housekeeping storage room had dirt and debris on the floor.

Therapy Gym
An observation was conducted on 2/20/17 at 11:25 a.m. of the therapy gym. The physical therapy parallel bars had dust and encrusted dirt on the platform of the parallel bars. The tilt table had dust on the edges of the table. The ramp of the wheelchair scale had dirt and dust on the ramp, electrical tape was wrapped around the wiring of the digital scale and the metal pole holding the digital reader was missing a bolt to secure the digital reader to the ramp. Dust and old adhesive was on the cycle table. The upper extremity exercise equipment for wheelchair bound patients had dust and dirt on the platform. The Hydrocollator cloth covers were stored on an open shelf above the hydrocollator and were not covered.
Oxygen concentrator filter surface completely covered with a white powdery film.

Patient Area
An observation was conducted on 2/20/17 at 12:00 p.m. in the patient room hallway. The baseboards in the hallway were caked with a thick layer of dust down the entire hallway. The floors were dirty with darkened areas down the hallway. The 3 medication carts had fluid drips on the side of the medication cart with debris and fluid spots on the top of the medication carts. Two (2) black vinyl chairs in the patient care area hallways had torn areas in the vinyl and were unable to be disinfected properly. The hand gel dispenser in the nurses' station had a black sticky adhesive on the dispenser area where the nurses press to obtain hand gel. The front of the nurses' station had old adhesive stuck on the side in numerous areas.
Patient Room "k:":
Multiple dead winged insects noted in the patient overbed light fixture
Patient Rooms "k" and "l":
Multiple dead winged insects noted in the overhead light fixture

In an interview on 2/20/17 at 12:25 p.m. S1AsstAdm confirmed the above referenced findings. S1AsstAdm had been present throughout the observation period, accompanying the survey team.


Kitchen
An observation was conducted in the kitchen on 2/21/17 at 9:00 a.m. with S9DirDietary. The 3 compartment sink and a one compartment sink in the cooking area had a heavy buildup of a sticky black substance on the outside of sinks that could be removed by scrapping the black substance. Three (3) cooking sheets and 3 pots had a heavy buildup of grease on the outside of the cooking ware. Two (2) 3 tier shelf carts were located in the kitchen with debris and liquid spills on the carts. The kitchen floor had debris and dirt on the floor.

An interview was conducted with S9DirDietary on 2/21/17 at 9:30 a.m. S9DirDietary confirmed the above observations and reported the dietary staff were responsible for cleaning the floors in the kitchen area.


2) Failure to ensure the hospital's policy for isolation precautions was implemented as evidenced by having no signage for Enhanced Contact Precautions on a patient's (#2) door who was on contact isolation precautions for a diagnosis of C.difficile (C.diff).

Review of the hospital's policy titled," Guidelines for Transmission Based Precautions", Policy Number: III.A.10.0, revealed in part: A. Contact Precautions: Use Contact precautions for patients with a known or suspected infection or evidence of syndromes that represent an increased risk for contact transmission. Appropriate signage with staff and visitor instructions shall be posted on the patient's door. Appropriate hand hygiene shall be performed upon entering and exiting the patient's room.

Review of Patient #2's medical record revealed an admission date of 02/03/17 with admission diagnoses of Metabolic Encephalopathy and Failure to thrive after a fall. Further review of Patient #2's medical record revealed the patient had a positive stool culture for C.diff on 02/05/17. Additional review revealed the patient had been removed from contact precautions, but became symptomatic again and contact precautions for C. diff were resumed on 02/19/17.

On 02/20/17 at 11:45 a.m. an observation was made of Patient #2's room. An over the door isolation caddy was observed with personal protective equipment (gowns, gloves, masks). No signage was noted on the patient's door to indicate the type of isolation the patient was on.

In an interview on 02/20/17 at 11:45 a.m., during the observation, with S1AsstAdm she confirmed Patient #2 was on contact isolation precautions for a diagnosis of C. diff. She also confirmed there was no signage on the door indicating that the patient was on contact precautions for C. Diff.


3) Failure to ensure staff providing services to a patient (#2) on contact isolation precautions for C.diff adhered to infection control practices.

Review of the hospital's policy titled," Guidelines for Transmission Based Precautions", Policy Number: III.A.10.0, revealed in part: A. Contact Precautions: Use Contact precautions for patients with a known or suspected infection or evidence of syndromes that represent an increased risk for contact transmission. Appropriate signage with staff and visitor instructions shall be posted on the patient's door. Appropriate hand hygiene shall be performed upon entering and exiting the patient's room.
Use of PPE 1. Gloves: wear gloves whenever touching patient's intact skin or surfaces and articles in close proximity to the patient (medical equipment, bedrails). Don gloves upon entry into the room or cubicle. 2. Gowns: Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle. 3. Removal of PPE: Remove gloves then gown and observe hand hygiene before leaving the patient care environment.
B. Enhanced Contact Precautions: Use Enhanced Contact Precautions for patients who are positive for C.difficile. Utilize all precautions as described above in : "Contact Precautions" with the exception of hand sanitizer for hand hygiene. Hand hygiene must be performed with soap and water using CDC Guidelines for handwashing upon entering and exiting the patient's room. Appropriate signage with staff and visitor instructions shall be posted on the patient's door. Instruct all family members and visitors of appropriate handwashing while patient is in Enhanced Contact Precautions.

In an observation on 02/20/17 at 12:25 p.m. S24CNA (contracted aide) was observed delivering Patient #2's lunch tray. Patient #2 was on Enhanced Contact Isolation Precautions for a diagnosis of C.diff. S24CNA did not wear a gown nor did she wear gloves to deliver the meal tray into the patient's room. S24CNA was observed using hand gel after exiting the patient's room. She did not wash her hands after exiting the patient's room. S24CNA was then observed retrieving a lunch tray from the food tray cart and delivering a lunch tray into another patient's room.

In an interview on 02/20/17 at 12:29 p.m. with S1AsstAdm, she confirmed Patient #2 was on Enhanced Contact Isolation Precautions for C. diff. S1AsstAdm indicated it was her expectation that all staff, including staff entering the patient's room to deliver a lunch tray, should don a gown and gloves as per hospital policy for patients on Enhanced Contact Isolation Precautions. S1AsstAdm confirmed S24CNA should have washed her hands instead of performing hand hygiene with hand sanitizer. S1AsstAdm indicated S24CNA was contracted staff. S1AsstAdm indicated contracted staff got a brief overview of hospital procedures, but did not get a full orientation. S1AsstAdm agreed all staff, including contracted staff, should adhere to the hospital's infection control practices.


4) Failure to have evidence of hospital laundry cleaned and processed as per their policy and procedure.

Review of hospital policy #III.D.45.0, titled "Soiled & Clean Linen Distribution", provided by S1AsstAdm as current, revealed the following, in part: "...8) The Infection Control Nurse will make periodic facility tours of the laundry process to ensure proper guidelines are followed and met. 9) Soiled linens shall be washed with detergent in water with a temperature of at least 180 degree Fahrenheit for 25 minutes. Periodic review of water temperature and soap levels will be monitored by Therapy Techs and recorded in the cleaning logs.

An observation 02/21/17 at 3:40 p.m. of the Laundry rooms ( soiled/wash, and clean), accompanied by S1AsstAdm and S7HK, revealed no logs or documentation of monitoring temperatures or length of wash in the commercial washing machines. S7HK reported she processed the hospital linens and only kept a daily log of cleaning the dryer lint traps. S1AsstAdm, also coordinator of the Infection Control Program, and S7HK confirmed the hospital could not provide documented evidence that hospital laundry process met the required temperature and length of wash time, as per their policy and procedure. S1AsstAdm indicated she did not monitor or perform any surveillance on the laundry process to ensure it was done by standards or by their policy and procedure. S1AsstAdm indicated the hospital's Infection Control Policies and Procedures were based on CDC guidelines.



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