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Based on Patient Safety Meeting Minutes and interview, it was determined the facility failed to ensure 6 (Central Supply, Environmental Services, Laundry, Physical Therapy, Occupational Therapy, and Speech Therapy) of 14 (Case Management, Central Supply, Dietary, Environmental Services, Health Information Management, Laboratory, Laundry, Organ and Tissue, Pharmacy, Radiology, Physical Therapy, Occupational Therapy, Speech Therapy and Respiratory Therapy) clinical contracted services were included in the facility's QA (Quality Assessment) program. The failed practice did not ensure the Governing Board was responsible for all aspects of the facility and created the potential to affect any patient utilizing contracted services. Findings follow.

A. Review of Patient Safety Meeting Minutes (Quality meetings) for October 2015 through October 2016 revealed no QA projects were being conducted for Central Supply, Environmental Services, Laundry, Physical Therapy, Occupational Therapy, and Speech Therapy.
B. During an interview on 10/11/16 at 1239, the Administrator confirmed no QA projects were currently being done for those services.

Based on observations, policy and procedure review and interview, it was determined the facility failed to protect the personal privacy of one (#27) of one (#27) patient in that the patient's genitals were not covered while waiting on the physician to arrive. Failure to protect the personal privacy of the patient did not afford him the basic right of respect and dignity. The failed practice affected Patient #27 on 10/12/16. Findings follow:

A. During observation of Patient #27's dressing change at 1500 on 10/12/16, the Wound Care Nurse was observed to remove the dressing from the lower abdomen and genitals and clean the wound. At 1515 the Wound Care Nurse stated she was waiting for the doctor to come see the patient. From 1515 to 1530 Patient #27 s genitals were left uncovered in front of Registered Nurse#5, a student nurse and Surveyor #1.
B. Review of the policy and procedure titled "Wound Dressing Change/Skin Staple and Suture Removal," numbered 500.14, received from the Chief Nursing Officer at 1300 on 10/10/16 revealed the following under ... "B.,1. Provide the patient privacy."
C. At 1525 on 10/12/16 the Chief Nursing Officer (CNO) was asked to come to Patient #27's room. Patient #27 was still uncovered upon arrival of the CNO and she visually and verbally verified the findings in A.

Based on review of clinical records, policy and procedure and interview, it was determined the facility failed to obtain a physician's order for restraints for 1 (#14) of 9 (#1, #2, #12, #14, #18, #26, #28-30) patients who were restrained. Failure to obtain a physician's order for restraints did not allow the physician to be knowledgeable regarding the patient's need for restraints and prohibited the facility from following its policy. The failed practice affected Patient #14 on 09/29/16. Findings follow:

A. Review of Patient #14's clinical record revealed the patient was restrained without a physician's order on 09/28/16. The above findings were verified by Registered Nurse #4 at 0950 on 10/13/16.
B. Review of the policy and procedure titled Restraints/Seclusion received from the Chief Nursing Officer at 1300 on 10/10/16 revealed the following under ...PROCEDURE: APPLICATION OF RESTRIANTS FOR MEDICAL SURGICAL CARE (NON VIOLENT OR NON SELF-DESTRUCTIVE BEHAVIOR): ...4.3. Acute Care Restraint Orders must be renewed daily and within one calendar week from the date of the initial order in Recuperative Care.

Based on Patient Safety Meeting Minutes and interview, it was determined the facility failed to ensure 6 (Central Supply, Environmental Services, Laundry, Physical Therapy, Occupational Therapy, and Speech Therapy) of 14 (Case Management, Central Supply, Dietary, Environmental Services, Health Information Management, Laboratory, Laundry, Organ and Tissue, Pharmacy, Radiology, Physical Therapy, Occupational Therapy, Speech Therapy and Respiratory Therapy) clinical contracted services were included in the facility's QA (Quality Assessment) program. The failed practice did not ensure the Governing Board was responsible for all aspects of the facility and created the potential to affect any patient utilizing contracted services. Findings follow.

A. Review of Patient Safety Meeting Minutes (Quality meetings) for October 2015 through October 2016 revealed no QA projects were being conducted for Central Supply, Environmental Services, Laundry, Physical Therapy, Occupational Therapy, and Speech Therapy.
B. During an interview on 10/11/16 at 1239, the Administrator confirmed no QA projects were currently being done for those services.

Based on clinical record review and interview, it was determined the nursing staff failed to follow physician's orders for administration of nutritional supplements for 7 (#6, #9, #13, #15, #19, #21 and #27) of 9 (#6, #9, #13, #15, #19, #21-#23 and #27) clinical records reviewed with orders for nutritional supplements. Failure to administer nutritional supplements as ordered did not allow the patient care team to determine if care plan interventions were effective in meeting nutritional needs for calories, proteins and fluids. The failed practice affected Patients (#6, #9, #13, #15, #19, #21 and #27) and had the likelihood to affect all patients for which nutritional supplements were ordered. Findings follow:

A. Clinical record review was conducted on 10/12/16-10/13/16 from 0900-1400 and revealed no evidence of documentation of nutritional supplements administration as ordered by physician:

1) Patient #6 had an order for Pro-Stat 1 packet two times a day (b.i.d.) on 10/08/16 at 1030. Clinical record review revealed no evidence of Pro-Stat administration for 2 of 10 doses for 10/08/16-10/12/16.
2) Patient #9 had an order for Pro-Stat 1 packet b.i.d. on 10/10/16 at 1254. Clinical record review revealed no evidence of Pro-Stat administration for 1 of 6 doses for 10/10/16-10/12/16.
3) Patient #13 had an order for Ensure Enlive three times a day (t.i.d.) on 10/07/16 at 1457. Clinical record review revealed no evidence of Ensure Enlive administration for 6 of 6 doses for 10/08/16-10/09/16.
4) Patient #15 had an order for Ensure Enlive b.i.d. on 09/28/16 at 1254. Clinical record review revealed no evidence of Ensure Enlive administration for 30 of 30 doses for 09/28/16-10/12/16.
5) Patient #19 had an order for Pro-Stat 1 packet b.i.d. on 08/09/16 at 1844. Clinical record review revealed no evidence of Pro-Stat administration for 43 of 64 doses for 08/10/16-10/12/16.
6) Patient #21 had an order for Pro-Stat 1 packet t.i.d. on 08/27/16 at 0854. Clinical record review revealed no evidence of Pro-Stat administration for 69 of 141 doses for 08/27/16-10/12/16.
7) Patient #27 had an order for Mighty Shake t.i.d. on 10/03/16 at 1340. Clinical record review revealed no evidence of Mighty Shake administration for 24 of 30 doses for 10/03/16-10/12/16.
B. The findings in A were confirmed at the time of clinical record review by Registered Nurse (RN) #2 for Patient #9 and #21, Administrative RN #1 for Patient #13, #15 and #27, RN #3 for Patient #19 and Quality Manager for Patient #6.

Based on clinical record review and interview, it was determined there was no evidence the facility offerred a bath daily for 19 (#1, #2, #5-#7, #9, #10, #14-#17, #20, #21, #24, #25, and #27-#30) of 30 (#1-#30) patients. The failed practice did not ensure patients were given the opportunity to bathe and created the likelihood to affect all patients in the facility. Findings follow.

A. During an interview on 10/13/16 at 0845, when asked how often patients were expected to be given a bath, the Chief Nursing Officer stated "daily." The facility did not have a policy stating how often bathing should be done.
B. Review of clinical records revealed the following:
1) Patient #1 was admitted 07/25/16 through 08/21/16. There was no evidence a bath was offered on five days (07/30/16, 08/03/16, 08/06/16, 08/12/16, and 08/19/16).
2) Patient #2 was admitted 08/03/16 through 08/22/16. There was no evidence a bath was offered on 10 days ( 08/05/16 through 08/10/16, 08/16/16, 08/18/16, 08/20/16, and 08/21/16).
3) Patient #5 was admitted 09/08/16 through 09/15/16. There was no evidence a bath was offered on three days (09/12/16 through 09/14/16)
4) Patient #6 was admitted on 10/08/16 and was an inpatient at the time of record review on 10/12/16. There was no evidence a bath was offered on one day (10/09/16).
5) Patient #7 was admitted on 10/07/16 and was an inpatient at the time of record review on 10/12/16. There was no evidence a bath was offered on one day (10/11/16).
6) Patient #9 was admitted on 10/07/16 and was an inpatient at the time of record review on 10/13/15. There was no evidence a bath was offered on two days (10/09/16 and 10/12/16).
7) Patient #10 was admitted on 10/03/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on three days (10/06/16, 10/09/16, and 10/12/16).
8) Patient #14 was admitted on 09/27/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on four days (09/28/16 through 09/30/16, and 10/03/16).
9) Patient #15 was admitted on 09/27/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on seven days (09/28/16, 09/30/16, 10/02/16, 10/07/16, 10/09/16, 10/10/16, and 10/12/16).
10) Patient #16 was admitted on 09/26/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on four days (09/28/16, 10/02/16, 10/07/16, and 10/09/16).
11) Patient #17 was admitted on 09/16/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on nine days (09/18/16, 09/23/16, 09/30/16 through 10/04/16, 10/09/16, and 10/12/16).
12) Patient #20 was admitted on 09/16/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on six days (09/17/16, 09/19/16, 09/22/16 through 09/24/16, and 09/26/16).
13) Patient #21 was admitted on 08/22/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on 14 days (08/23/16, 08/29/16 through 08/31/16, 09/02/16, 09/04/16, 09/05/16, 09/07/16, 09/11/16, 09/12/16, 09/14/16, 09/21/16, 09/27/16, and 10/01/16).
14) Patient #24 was admitted on 09/14/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on 15 days (09/15/16, 09/18/16, 09/19/16, 09/21/16, 09/23/16, 09/25/16, 09/26/16, 09/28/16, 09/29/16, 10/01/16, 10/04/16, 10/09/16, 10/10/16, 10/11/16, and 10/12/16).
15) Patient #25 was admitted on 09/08/16 and was an inpatient at the time of record review on 10/13/16. There was no evidence a bath was offered on 17 days (09/10/16, 09/15/16 through 09/20/16, 09/23/16, 09/24/16, 09/26/16, 09/28/16, 10/02/16, 10/04/16, 10/05/16, 10/07/16, 10/09/16, and 10/12/16).
16) Patient #27 was admitted on 08/04/16 and was an inpatient at the time of record review on 10/12/16. There was no evidence a bath was offered on 33 days (08/07/16 through 08/09/16, 08/16/16, 08/17/16, 08/19/16 through 08/24/16, 08/27/16 through 08/29/16, 09/02/16, 09/03/16, 09/11/16, 09/14/16, 09/16/16 through 09/20/16, 09/22/16, 09/23/16, 09/28/16, 09/29/16, 10/02/16 through 10/04/16, 10/07/16 through 10/09/16, and 10/11/16).
17) Patient #28 was admitted on 09/21/16 and was an inpatient at the time of record review on 10/12/16. There was no evidence a bath was offered on 11 days (09/22/16, 09/24/16, 09/26/16, 09/30/16, 10/02/16 through 10/05/16, 10/08/16, 10/09/16, and 10/11/16).
18) Patient #29 was admitted on 09/19/16 and was an inpatient at the time of record review on 10/12/16. There was no evidence a bath was offered on seven days (10/01/16, 10/02/16, 10/04/16, 10/05/16, 10/07/16, 10/09/16, and 10/11/16).
19) Patient #30 was admitted on 08/26/16 and was an inpatient at the time of record review on 10/12/16. There was no evidence a bath was offered on 18 days )08/27/16, 08/29/16, 09/02/16 through 09/05/16, 09/09/16 through 09/11/16, 09/15/16, 09/17/16, 09/19/16, 09/20/16, 09/23/16, 09/24/16, 09/26/16, 09/27/16, and 10/02/16).
C. The lack of baths being offered was confirmed by the Administrative RN (Registered Nurse) #1 for Patient #20 on 10/13/16 at 1346; for Patients #1, #2, #5, and #27-#30 during record review from 0900 to 1130 and 1230 to 1500 on 10/12/16; and for Patients #10, #15, #17, #24 and #25 during record review from 0900 to 1100 on 10/13/16.
D. During an interview on 10/13/16 at 1346, RN #4 confirmed the lack of baths offered for Patient #14.
E. During record review on 10/12/16 from 1300-1500, the Director of Quality confirmed the missing baths for Patients #6 and #7.
F. During record review on 10/13/16 from 0900-1400, RN #2 confirmed the lack of baths offered for Patients #9 and #21.

Based on review of Medication Event Reports and interview, it was determined the facility failed to have evidence of notification of the practitioner who ordered the medication of the medication event (medication administration error or adverse drug reaction) for 68 (# 7,13,14,16,17,21, 23-26, 33, 35-37, 40, 42-44, 46,47, 49, 52, 55, 57, 59,60, 66, 67, 70-73, 79, 88, 89, 95, 96, 98, and 103-105) of 109 (Medication errors #1-109) Medication Events reviewed. By not reporting medication errors to the prescribing physician responsible for the patient's care, the patients' physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of Medication Event Reports for events from 12/01/15 through 09/25/16 revealed Medication Events #7,13,14,16,17,21, 23-26, 33, 35-37, 40, 42-44, 46,47, 49, 52, 55, 57, 59,60, 66, 67, 70-73, 79, 88, 89, 95, 96, 98, and 103-105 were not reported to the prescribing physician.
C. During an interview on 10/10/16 at 1415, the Director of Pharmacy verified the lack of evidence of notification of the practitioner who ordered the medication of the medication event.

Based on observations and interview, it was determined the facility failed to ensure only currently dated supplies of nutritional supplements and milk products were available for patient use in one of one refrigerator. Failure to ensure only currently dated items were available for patient use had the potential to make any patient ill who consumed the expired products. Findings follow:

Observation of one of one patient refrigerator revealed the following: Nepro one can expired 06/01/16, two cans expired 07/01/16, two cans expired 09/01/16 of 13 cans total; two of seven cartons of skim milk expired 09/27/16 and one of one carton of chocolate milk expired 10/09/16. The findings were verified by the Chief Nursing Officer at 0900 on 10/12/16.

Based on observation, it was determined the Wound Care Nurse failed to adhere to aseptic technique in the performance one of one (#27) patient's dressing change in that while the wound was open to air, the Wound Care Nurse fanned herself with two packages of 4x4s (four by four gauze). The failed practice had the potential to create an environment to potentially transmit micro-organisms to the open wound. The failed practice affected Patient #27 on 10/12/16. Findings follow:

During observation of a dressing change for Patient #27 at 1500 on 10/12/16, the Wound Care Nurse failed to maintain aseptic technique in tht she was observed to pick up two unopened packages of 4x4s and fan herself with the packages while standing immediately next to the uncovered wound.


36533

Based on observation and interview, it was determined the Infection Control Officer failed to prevent and control infections in that two of two cleaned and disinfected patient beds observed had an accumulation of dust on the bed frame. Failure to remove dust from bed frames did not assure the patient beds were free from contamination and sources of infection. The failed practice had the potential to affect all patients admitted to the facility.

A. Observation on 10/10/16 at 1049 revealed patient room 1047, which was clean and ready to receive patients, contained two (A and B) beds. Patient Bed A and B were examined and both revealed an accumulation of dust on the bed frame.