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Based on document review, interview, and observation, it was determined that the governing body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.25 Pharmaceutical Services

CFR 482.42 Infection Control

CFR 482.56 Rehabilitation Services

A. Based on observation on January 10, 2012 at 11:45 AM, it was determined that the facility failed to conform to the Centers for disease Control and Prevention Guidelines (CDC) and Hospital Infection Control Practices Advisory Committee recommendations.

Findings include:

Reference: The Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force require hand washing/sanitizing after the removal of protective gloves and prior to application of new gloves or initiation of a new task.

1. Staff #7 did not wash his/her hands or use an antimicrobial hand sanitizer when he/she changed gloves and moved from an ultrasound procedure on the patient in Room #220 to a patient on Contact precautions in Room #240, as observed by two surveying inspectors.

B. Based on observation and interview on January 10, 2012 at 11:30 AM, it was determined that the facility failed to follow, "The Association for the Advancement of Medical Instrumentation (AAMI)" requirements, "Safe Handling and biological decontamination of medical devices in health care facilities, ST 79, (Incorporated and formerly known as Sections, ST33, ST35, ST37, ST42, & ST46) section 7.2.2 Manufacturers instructions for cleaning and decontamination processes."

Findings include:

1. Staff #7 was scheduled to perform a vascular ultrasound procedure on the patient in Room #240. Room #240 was observed with a "Contact Precautions" sign posted on the door outside of the room. Prior to performing the procedure, Staff #7 was interviewed on the cleaning of the ultrasound probe.

2. Staff #7 stated that he/she cleans the probe with a "Comfort Bath Cleansing" wash cloth which is intended for use on patient skin only, as indicated on the product label.

3. Staff #7 was unfamiliar with the required instrument cleaning and disinfection procedures of the equipment when questioned by this surveyor.

4. The manufacturers' instructions for ultrasound probe cleaning was not available for review.

5. Staff #2 stated that the probe should be cleaned and disinfected with the "PDI Super Sani" wipe cloth.

6. Upon completion of the ultrasound procedure in patient Room 240, Staff #7 proceeded to the nurse's station with the ultrasound equipment to complete charting. Following charting, Staff #7 proceeded to the exam room where he/she put away the equipment without appropriate cleaning and disinfection, providing a potential of cross contamination to patients.

C. Based on observation on January 10, 2011 at 11:00 AM, it was determined that the facility failed to ensure that environmental surfaces are maintained in clean condition.

Findings include:

1. Floors were not maintained in clean condition in the following areas:

a. The South wing clean utility.

b. The Main equipment storeroom.

2. Storage shelves were not maintained in clean condition in the following areas:

a. All of the carts storing clean and sterile supplies in the main equipment storeroom were heavily soiled with dust, dirt, and spillage.

b. Equipment storeroom tan storage bins storing clean and sterile supplies were soiled with dust and debris.

c. The Physical Therapy emergency linen cart was soiled with dust and debris.


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D. Based on observation, medical record review, and staff interview, it was determined that the facility failed to provide an environment to avoid sources and transmission of infections.

Findings include:

Reference #1: POLICY: IC III-6, titled 'Droplet Precautions' states "I. Policy The policy of the hospital is to prevent transmission to patients and health care workers of those infections transmitted by means of inhalation or contact with large-particle droplets that are produced by coughing, sneezing, or talking. ... Procedures ... B. ... 2. A sign reading "Droplet Precautions" will be posted on the door. 3. Surgical masks must be worn by all persons entering the room."

Reference #2: Policy: IC III-5, titled 'Enhanced Contact Precautions" states "The policy of the Hospital is to prevent transmission of highly transmissible or epidemiologically important infections by direct or indirect contact. ... Procedures ... B. Specific Procedures: ... 2. A sign reading "Contact Precautions" will be posted on the door and on the patient's chart. If the patient is in contact precautions for C difficile, there must be a prompt for staff to perform hand hygiene with soap and water. PPE [Personal Protective Equipment] will be available at the entrance of the room. 3. Gowns should be worn when soiling will be likely to occur or when contact with the patient of environmental surfaces that have been contaminated will occur."

1. On 1/10/12 at 11:00 AM, Room #223 was observed to have a "Droplet Precautions" sign posted outside the room on the door. Staff #5 was observed inside the patient's room without a mask or any other PPE. Staff #1 confirmed that the nurse should be wearing a mask as indicated on the posted "Droplet Precautions" sign.

a. This surveyor entered the room for observation, wearing a mask only, as indicated on the "Droplet Precautions" sign.

2. Medical Record #2, for the patient in Room 223, was reviewed and the surveyor could not find any indication for "Droplet Precautions" to be implemented for Patient #2.

a. Staff #1 stated in interview on 1/10/12 at 11:30 AM that this patient has C-Difficile and should be on "Contact Precautions," and the "Droplet Precautions" sign was placed on his/her door in error.

b. Staff #5 stated in interview on 1/10/12 at 11:35 AM that his/her morning report from the off going nurse indicated that the patient was on "Contact Precautions" for Respiratory MRSA [Methicillin Resistant Staphylococcus Aureus] and C-difficile. Staff #5 stated she did not know how long the wrong isolation sign, "Droplet Precautions" has been hanging on Patient #2's door, instead of the correct "Contact Precautions" sign.

3. By hanging the incorrect isolation sign and not implementing the information from the morning's nurse to nurse shift report, the facility staff did not communicate the correct isolation precaution for staff to utilize when caring for Patient #1.

A. Based on staff interview, review of facility documentation, and lack of Quality Assurance and Performance Improvement (QAPI) activities, it was determined that the facility failed to ensure that Rehabilitation Services are provided with acceptable standards of practice.

Findings include:

1. The facility failed to have a Director of Rehabilitation Services who is accountable for the overall operation of the service. Refer to Tag 1124.

2. The facility failed to integrate it's Rehabilitation Services into the hospital wide QAPI program.


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B. Based on staff interview and lack of facility documentation, it was determined that the facility failed to integrate it's Rehabilitation Services into the hospital wide QAPI program.

Findings include:

1. On 1/12/12 the facility's QAPI program was reviewed with Staff #1. There was no evidence of QAPI activities for the facility's Rehabilitation Services.

Based on medical record review and review of facility policy and procedure, it was determined that the facility failed to ensure that a physician or Licensed Independent Practitioner (LIP) responded within one hour of restraint application to a patient, and failed to implement it's policy and procedure for restraint.

Findings include:

Reference #1: Facility policy and procedure number: R02-N, Subject: 'Restraint and Seclusion' states "PROCEDURE: 1. [1st paragraph] Perform a comprehensive assessment, if restraint is a consideration. Use concrete, objective observations to describe the patient's behavior. Perform a physical assessment to identify medical problems that may be causing a behavioral change. ... [2nd paragraph] The initial assessment must be performed by physician, Licensed independent Practitioner, or Registered Nurse. An initial assessment performed by the RN shall be reviewed by the physician and a physician's order is issued as indicated. The physician's order indicates agreement with assessment and the plan of care to use restraints. [3rd paragraph] If a physician or LIP is not available to issue such an order, a registered nurse initiates restraint use based on an appropriate assessment of the patient. In that case, the MD/DO or LIP is notified immediately as clinically possible, of the initiation of restraint, and a telephone order is obtained from that practitioner and entered into the patient's medical record. ... 2. Alternatives a. Attempt alternative interventions prior to every application of a restraint. ... "

Reference #2: N.J.A.C Title 8 Chapter 43G, Hospital Licensing Standards, states at 18.4(d), "An emergency restraint procedure, beginning with the least restrictive alternative that is clinically feasible, shall be initiated by a registered professional nurse only when the safety of the patient or others is endangered or there is imminent risk that the patient will cause substantial property damage. The attending physician, another designated physician, a licensed physician assistant, or a nurse practitioner/clinical nurse specialist shall be notified immediately and shall respond within one hour. An order shall be given if the use of restraints is to continue beyond one hour. ..."

1. On 1/10/12, review of Medical Record #2 in the presence of Staff #1 indicated an initial restraint order for right and left mittens dated 1/6/12 and signed by the physician at 1900.

a. The restraint section of the nursing flowsheet indicated that the restraints were applied at 1900.

b. There was no evidence in the nursing notes or on the restraint order form of alternatives attempted prior to restraint use as per facility policy. There was no evidence of completion of the 'Daily Comprehensive Assessment completed by RN:' being completed by the RN as per facility policy.

c. The Restraint order form indicates the 'Clinical Justification for Restraint Use:' as "Potential for dislodging tubes" and "Poor judgement". The behaviors that warranted restraint use for the patient were not described by the RN or the ordering physician as per policy.

2. The facility's restraint policy allows for restraint application based solely on an RN assessment and a physician telephone order. This is not in compliance with state regulation in Reference #2 above, that states that a physician or LIP must respond within one hour to evaluate the patient and execute a restraint order if the restraint is to continue beyond the hour of initial application.

Based on document review and staff interview conducted on 1/12/12, it was determined that the facility failed to ensure that medications are administered in accordance with facility policies and procedures and acceptable standards of practice.

Findings include:

Reference #1: Facility policy titled "Medication Administration" states, "DOCUMENTATION...F. Pre-charting medications (charting medications in advance of drug administration) is expressly forbidden."

1. On 1/12/12 the "Controlled Substance (CDS) Use Report" from 1/11/12 and 1/12/12 was randomly compared to the corresponding electronic Medication Administration Record (eMAR). This report contains a list of all controlled substance activity from the drug dispensing device, including drug removed, patient name, and the name of nurse who removed the medication. The following discrepancies were found:

a. The removal of Clonazepam 0.5 mg tablet by Staff #20 for Patient #13 on 1/12/2012 at 09:27:18 was recorded on the CDS report. The administration of Clonazepam 0.5 mg tablet by Staff #20 on 1/12/12 at 8:00 AM was recorded on the eMAR. The medication was recorded as administered 1 hour and 27 minutes prior to removal from the drug dispensing device.

i. Upon interview, Staff #20 stated that he/she changed the administration time on the eMAR because he/she had too many medications to administer and was not able to give Patient #13 the medication at the scheduled time, which was 8:00 AM. This is not in compliance with Reference #1 stated above.

b. The removal of 2 Oxycodone/APAP 5/325 mg tablets by Staff #28 for Patient #15 on 1/12/12 at 00:05 was recorded on the CDS report. The administration of 2 Oxycodone/APAP 5/325 mg tablets by Staff #28 on 1/11/12 at 24:00 was recorded on the eMAR. This is 5 minutes before it was removed from the drug dispensing device.

c. The removal of Hydromorphone 4mg/2ml injectable by Staff #28 for Patient #15 on 1/12/12 at 5:09 was recorded on the CDS report. The administration of Hydromorphone 4mg/2ml injectable by Staff #28 on 1/12/12 at 05:00 was recorded on the eMAR. This is 9 minutes before it was removed from the drug dispensing device.

i. Staff #28 was not available for interview. Staff #16 compared the time on the computer for the eMAR and the time on the drug dispensing device and confirmed that the times matched perfectly. He/she agreed that it appeared that the medication was signed for on the eMAR prior to procuring and administering the medication to the patient. This is not in compliance with Reference #1 stated above.

Reference #2: Facility policy titled "Medication Administration Record - Generation, Charting, and Transcription (eMAR sites only)" states, PROCEDURE..."5...If the reviewing nurse identifies the need for clarification for a given order, he/she must communicate the need to the pharmacy using the eMAR correction form."

1. The removal of Diazepam 5 mg tablet by Staff #29 on 1/11/12 at 22:24 and 1/12/12 at 04:27 was recorded on the CDS use record. In both instances, the administration of Diazepam 0.5 mg by mouth was recorded on the eMAR. This is 1/10th of a tablet, a dose that cannot be accurately administered. Upon interview, Staff #16 confirmed that there was no evidence that the nurse attempted to clarify the order prior to administration, as required in Reference #2.

Based on document review, staff interview and review of 2 of 2 Medical Records (#2, #18) for patients with prescriber's orders for hemodialysis, it was determined that the facility failed to ensure that all hemodialysis verbal orders are dated, timed, and authenticated by the ordering practitioner.

Findings include:

1. Upon review, Medical Record #2 evidenced an "ACUTE TREATMENT PHYSICIAN ORDER SHEET" was signed and dated 1/11/12 by the transcribing registered professional nurse, Staff #26. In the designated area where the physician dates, times, and authenticates his/her signature, there was a date "1/11/12" and time "1205" with no physician signature.

a. During an interview on 1/11/12 at 2:05 PM, Staff #26 stated that he/she had entered the date and time on the line where the physician would date, time and authenticate his/her prescriber's verbal order.

2. Upon review, Medical Record #18 evidenced an "ACUTE TREATMENT PHYSICIAN ORDER SHEET" was signed and dated 1/11/12 by the transcribing registered professional nurse, Staff #24. In the designated area where the physician dates, times, and authenticates his/her signature, there was a date "1/11/12" and time "7:50" with no physician signature.

a. During an interview on 1/11/12 at 2:15 PM, Staff #24 stated that he/she had entered the date and time on the line where the physician would date, time and authenticate his/her prescriber's verbal order.

3. Upon review, the facility "ORDERS PHYSICIAN" policy and procedures does not ensure that verbal orders are dated, timed, and authenticated by the ordering practitioner.

Based on document review, it was determined that the facility failed to ensure implementation of Medical Staff Rules and Regulations addressing verbal orders.

Findings include:

Reference: Medical Staff Rules and Regulations, under General Conduct of Care states, "1...The responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate such order [verbal or telephone order] within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours and failure to do so shall be brought to the attention of the Medical Staff for appropriate action..."

1. The following telephone orders in Medical Record #14, reviewed on 1/12/12 at 1:00 PM, had not been authenticated by the physician:

a. 12/30/11 admission orders and medication orders

b. 1/3/12 order for Aranesp

c. 1/5/12 order for Nephro

d. 1/5/12 order for Robitussin

e. 1/9/12 order for PICC line insertion

2. On 1/12/12 at 1:00 PM the following orders, which were recorded as verbal or telephone orders, in Medical Record #14, were not signed by the prescriber:

a. 1/11/12, 1/9/12, 1/6/12, and 1/4/12 orders for hemodialysis treatment.

b. Orders for Physical Therapy and Occupational Therapy Evaluation and Treatment noted by the nurse on 12/30/11.

c. An order for MRSA Screening noted by the nurse on 12/30/11.

3. Review of Medical Record #1 on 1/12/12 contained the following telephone that were not signed by the prescriber:

a. A telephone order dated 12/31/11 at 5:00 PM.

b. A telephone order dated 1/1/12 at 4:00 PM.

c. A telephone order dated 1/2/12 at 10:00 AM.

4. Review of Medical Record #5 on 1/11/12 contained the following telephone orders that were not signed by the prescriber:

a. A telephone order dated 10/11/11 at 5:30 PM.

b. A telephone order dated 10/13/11 at 7:00 PM.

c. A telephone order dated 10/18/11 at 4:00 PM.

5. Review of Medical Record #8 on 1/12/12 contained the following telephone orders that were not signed by the prescriber:

a. A telephone order dated 8/20/11 at 2:00 PM.

b. A telephone order dated 8/24/11 at 2:00 PM.

c. A telephone order dated 8/29/11 at 5:00 PM.

d. A telephone order dated 8/31/11 at 5:00 PM

e. A telephone order dated 9/1/11 at 9:00 AM.

f. A telephone order dated 9/7/11 at 10:00 AM.

6. Review of Medical Record #12 on 1/12/12 contained the following telephone orders that were not signed by the prescriber:

a. A telephone order dated 1/1/12 at 7:00 PM.

b. A telephone order dated 1/4/12 at 10:10 PM.


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7. Review of Medical Record #3, reviewed on 1/11/12, contained the following telephone orders that were not signed by the prescriber:

a. Telephone order dated 9/28/11 at 1355.

b. Telephone order dated 9/29/11 at 1857.

c. Telephone order dated 9/29/11 (no time on order).

8. Review of Medical Record #4, reviewed on 1/11/12, contained the following telephone orders that were not signed by the prescriber:

a. Telephone order dated 9/13/11 (no time on order).

b. Telephone orders dated 9/15/11 at 1840 and 2210.

c. Telephone order dated 9/16/11 at 1800.

9. Review of Medical Record #9, reviewed on 1/11/12, contained the following telephone orders that were not signed by the prescriber:

a. Telephone order dated 10/14/11 at 2:30 PM.

b. Telephone order dated 10/15/11 at 1600.

c. Telephone order dated 10/20/11 at 0700.

d. Telephone order dated 10/25/11 at 0800.

10. Review of Medical Record #11, reviewed on 1/11/12, contained the following telephone orders that were not signed by the prescriber:

a. Telephone order dated 11/26/11 at 1730.

b. Telephone orders dated 11/28/11 at 12:27 and 1830.

c. Telephone order dated 12/1/11 at 1455.

d. Telephone order dated 12/5/11 at 1800.

e. Telephone order dated 12/6/11 at 1800.

f. Telephone order dated 12/7/11 at 11:35.

g. Telephone order dated 12/10/11 at 1300.

h. Telephone order dated 12/12/11 2000.

i. Telephone order dated 12/14/11 at 1430.

j. Telephone order dated 12/15/11 1445.

k. Telephone order dated 12/16/11 at 1600.

l. Telephone orders dated 12/19/11 at 1:15 AM and 1440.

Based on observation and staff interview, it was determined that the facility failed to ensure that the weekly patient weight report contained documentation to monitor the patient's condition.

Findings include:

1. Upon review on 1/12/12 at 12:35 PM in the presence of Staff #2, the weekly weight report failed to show evidence of a weight for all patients or an explanation as to why a weight could not be obtained. Upon discussing the bed equipped with scales, Staff #2, stated that the high low bed is used for patients who are at risk for falls and it is not equipped with a scale.

a. The weekly patient weights sheet dated 12/11/11, 7 p/7a showed no evidence of a weight for 9 patients. For 7 of the 9 entry notes, there was documentation that stated either, "not working or bed scale not on." For 1 of the 9 entry notes, there was documentation that stated, "high low bed." There was no documentation noted if another alternative method to obtain the patient's weight was considered. For 1 of the 9 entry notes, there was no explanation as to why a weight of the patient was not taken.

b. The weekly patient weights sheet dated 12/18/11, 7 p/7a showed no evidence of a weight for 9 patients. For 7 of the 9 entry notes, there was documentation that stated either, "not working, no power, or broken." For 1 of the 9 entry notes, there was documentation that stated, "lower bed." There was no documentation noted if another alternative method to obtain the patient's weight was considered. For 1 of the 9 entry notes, there was no explanation as to why a weight of the patient was not taken.

c. The weekly patient weights sheet dated 12/25/11, 7 p/7a showed no evidence of a weight for 6 patients. For 4 of the 6 entry notes, there was documentation that stated either, "not working, bed don't work or bed not working." For 1 of the 6 entry notes, there was documentation that stated, "lights don't work." For 1 of the 6 entry notes, there was documentation that stated, "low bed/no wt." There was no documentation noted if another alternative method to obtain the patient's weight was considered.

d. The weekly patient weights sheet dated 1/8/12, 7 p/7a showed no evidence of a weight for 12 patients. For 5 of the 12 entry notes completed, there was documentation that stated, "bed is not working or not working." For 7 of the 12 entries, there was no explanation as to why a weight of the patient was not taken.

2. On 1/12/12 in the presence of Staff #2, it was observed at 12:50 PM that the bed scale in Room #224-A was not working. The scale registered a weight of 9.1 kg with the patient in the bed.

3. On 1/12/12 in the presence of Staff #2, it was observed at 1:00 PM that the bed scale in Room #230 was not working. The scale registered a weight of 3.1 kg with the patient in the bed.

4. Facility policy, "Bed Scale Weights Sling Scale Bed Weights" does not specify how often patient weights should be taken.

Based on document review, staff interview, and observation conducted on 1/11/12 and 1/12/12, it was determined that the facility failed to ensure that pharmaceutical services that meet the needs of the patients.

Findings include:

1. The facility failed to ensure that medications are dispensed in accordance with facility policies and procedures and applicable State regulations. Refer to Tag A491.

2. The facility failed to ensure proper accountability of controlled drug substances. Refer to Tag A494.

3. The facility failed to ensure proper maintenance of the code carts. Refer to Tag A500.

4. The facility failed to ensure that medications dispensed by the pharmacy are labeled in accordance with State regulations. Refer to Tag A501.

5. The facility failed to ensure that medications are dispensed in a manner that is safe and meet the needs of the patient. Refer to Tag A501.

6. The facility failed to ensure after-hours access to drugs in accordance with facility policy. Refer to Tag A506.

Based on observation, document review and staff interview conducted on 1/11/12, it was determined that the facility failed to ensure that medications were dispensed in accordance with facility policies and procedures and applicable State regulations.

Findings include:

Reference #1: Facility policy titled "Drug Dispensing System - Manner of Issuance" states, "Policy Statement: A routine order filling cycle will be used to prepare and deliver drugs to patient care areas..." and "Procedure:...3 Once the unit dose fill list is generated, a pharmacist or pharmacy technician will fill patient-specific supplies of medications, placing them in patient-specific drawers/bins Drug supplies will be sufficient to cover the time period accounted for by the batch fill..."

1. The above policy and procedure addresses a unit dose drug delivery system with individual patient cassettes or bins. Through direct observation and interview with Staff #16, it was confirmed that the facility did not utilize the unit dose cassette exchange system described in this policy. The facility utilized an Automated Drug Dispensing Cabinet.

Reference #2: Facility policy titled "Automated Drug Cabinetry" states, "Procedure...8. Pharmacists or persons who are authorized to administer drugs to patients may remove drugs from the cabinet for administration to patients, provided that they have access to the cabinetry. The following rules apply: a. Only drugs that are needed at the time that the cabinet is accessed should be removed from it. That is, if a drug will be administered multiple times in a given day, only the amount needed for a specific dose should be removed when that dose is due."

Reference #3: N.J.A.C. (New Jersey Administrative Code) 8:43G-23.6(b) (Hospital Licensing Standards) states, "The hospital shall have in effect a unit dose drug distribution system with individual cassettes or containers which bear the patient's identification..."

Reference #4: A letter to the facility from the Director of the Certificate of Need and Healthcare Facility Licensure Unit of the NJ Department of Health and Senior Services, dated November 19, states, "Based on the aforementioned information provided and upon recommendation by Department pharmacy staff within the Office of Assessment and Survey, I am approving your waiver from the requirement of N.J.A.C. 8:43G-23.6(b) authorizing the hospital to use the Med-Dispense System with the following conditions:...2. The medications are to be removed from the automated drug dispensing devices and immediately administered to the patient. Nurses cannot "fill cassettes" from the dispensing device for later administration..."

1. Medications were found in the following areas during a tour of the facility on 1/11/12 at 11:30 AM:

a. The first unlabeled drawer of the mobile computer unit ROC MOBILE 03 contained a Transderm Scop patch and one Metoprolol 25 mg unit dosed (UD) tablet.

b. The fifth unlabeled drawer of the mobile computer unit ROC MOBILE 03 contained a Heparin 5000 Unit syringe and one Metronidazole 500 mg UD tablet.

c. The sixth unlabeled drawer of the mobile computer unit ROC MOBILE 03 contained 4 Renvela 800 mg UD tablets and 1 Midodrine 5 mg tablet.

2. Upon interview, Staff #16 stated that the nurses are allowed to take medications for their patients from the Med Dispense drug dispensing device for up to a four hour period. The nurse is allowed to place the medications in the cassette drawers on the mobile computer unit. He/she stated that the drawers should be labeled with a room number.

3. This practice is not in compliance with the facility policy stated in Reference #2 and the waiver from the NJ Department of Health and Senior Services as stated in Reference #4.

Based on document review and staff interview conducted on 1/12/12, it was determined that the facility failed to ensure proper accountability of controlled drug substances (CDS).

Findings include:

1. The removal of one Diazepam 5mg tablet, a Schedule IV CDS on 1/12/12 at 04:27 for Patient #16 was recorded on the Med-Dispense Controlled Drug History report. The administration of Diazepam 0.5mg tablet at 04:27 was recorded on the Medication Administration Record. The destruction of the remaining medication along with a witness was not documented on the Controlled Drug History report. Upon interview, Staff #16 confirmed that wastage of a CDS must be documented in the Med-Dispense.

2. On 1/12/12 at 1:30 PM Staff #19 was asked if the destruction of a Fentanyl patch, a Schedule II CDS, is documented with a witness upon removal from the patient. He/she stated that just the removal was documented on the Medication Administration Record, but a witness was not needed. Staff #16 confirmed that the wastage of any CDS required the signature of a witness.

Based on observation, staff interview, and document review conducted on 1/11/12, it was determined that the facility failed to ensure, that emergency medications and supplies in the code carts, were provided in accordance with facility policies and procedures.

Findings include:

Reference: Facility policy titled "Emergency Drug Supplies" states the following: "POLICY STATEMENT: Emergency drug supplies will be maintained in patient care areas at all time...It is a pharmacist responsibility to maintain these supplies."
"Procedure: 1. Emergency medication supplies are maintained in sealed carts and/or boxes in designated areas throughout the hospital. These carts contain medications and supplies approved by the Pharmacy and Therapeutics Committee that are commonly used in emergencies. The carts are standardized throughout the hospital with respect to placement of the drugs and supplies within the drawers to enhance patient safety.
2. A nursing staff member must verify that the seal on the emergency cart/box is intact at least once per day. If the seal has been broken, the nursing staff member must notify a pharmacist immediately so that the medication contents can be checked and the cart/box can be resealed.
3. The entire contents of the code cart are checked monthly for outdated and improperly stored medication. Any sealed cart/box will bear a label indicating the expiration date of the first drug/supply therein that will expire.
4. The contents of each cart/box, as determined above, are listed on the outside of the cart/box.
5. When a cart/box is used to treat a patient, the nursing staff will notify the pharmacy. The pharmacy staff will determine the identity of the patient for whom the cart/box was used and will post the appropriate charges.
6. The pharmacy staff will then refill the cart/box or provide a sealed replacement drawer before the final seal is replaced and the cart/box returned to service."

1. On 1/11/12 at approximately 10:30 AM, Code Cart #1 was found unsecured. Staff #30 stated that the code cart had been opened to remove Magnesium Sulfate 1gm/100ml for a patient during the night. Staff #16 stated that he/she had not been notified that the cart had been opened. On 1/12/12 at 10:00 AM, pharmacy Staff #16 was unable to provide the name of the patient who had been administered the Magnesium Sulfate. This is not in compliance with Procedure #5 referenced above.

2. On 1/11/12 at approximately 10:30 AM, it was noted that the "first to expire" date on the outside of Code Cart #1 medication tray was 2/1/12. The first medication to expire on the medication tray were two (2) Dobutamine 250mg/20ml, expiration date 1/12, not 2/1/12. This is not in compliance with Procedure #3.

3. The contents of the code cart was not listed on the outside of the cart as required in Procedure #4. Upon request, Staff #2 and Staff #16 were unable to provide a list of the contents.

4. There was no evidence that the entire contents of the code cart had been checked monthly. Procedure #3 referenced above states that the contents will be checked monthly, and the Policy Statement referenced above states that it is a pharmacist responsibility to maintain these supplies. Upon interview, pharmacy Staff #16 stated that pharmacy was only responsible for the medications, not the supplies. Nursing Staff #2 confirmed that nursing was just checking to make sure that the cart was secured and the the expiration date on the outside of the cart was not beyond the current date.

5. Review of the contents of Code Cart #1 on 1/11/12 revealed the following:

a. The "Crash Cart Contents" sheet placed inside the medication tray had the following discrepancies:

i. Lidocaine 100mg #3 had an expiration of 2/1/12. The actual expiration date of the medication in the tray was 10/1/12.

ii. Dobutamine 250mg/20ml #2 had an expiration date of 4/13. The actual expiration date of the medication in the tray was 1/12.

iii. Levofed 4mg/4ml #2 had an expiration date of 9/1/12. The actual expiration date of the medication in the tray was 8/1/12.

iv. There were many expired supplies and a nonfunctioning mechanical suction machine (Refer to Tag A0724).

A. Based on observation, document review, and staff interview conducted on 1/11/12 and 1/12/12, it was determined that the facility failed to ensure that medications dispensed by the pharmacy are labeled in accordance with State regulations.

Findings include:

Reference #1: New Jersey State Board of Pharmacy regulation N.J.A.C. 13:39-11.10 states "Information required to appear on prescription label (a) The dispensed container for any compounded preparation shall bear a permanently affixed label with at least the following information:.."

Reference #2: N.J.A.C. (New Jersey Administrative Code) 8:43G-23.3(b) (Hospital Licensing Standards) states, "A pharmacist licensed to practice pharmacy in New Jersey shall be responsible for compounding, preparing, labeling, transferring between containers, and dispensing drugs..."

1. Intravenous solutions of Ciprofloxacin 200 mg, Milrinone Lactate 40 mg, Levaquin 750 mg, and Levaquin 500 mg with the pharmacy labeling partially affixed to the outerwrap of the packages were found in the medication room on 12/11/12 at 11:45 AM. Upon interview, Staff #2 stated that the pharmacy partially affixes the label to the outerwrap and the nurse removes the pharmacy label and affixes it to the medication bag prior to administration. This was confirmed by Staff #16. This practice is not in compliance with N.J.A.C. 8:43G-23.3(b) referenced above. Only pharmacy staff is permitted to label medications. Once a pharmacist initials the label to indicate he/she has checked the product, that label cannot be transferred to another container by a nurse. A policy and procedure addressing the practice of transferring pharmacy labels was not available for review.

2. While reviewing patient specific intravenous medications in the medication room on 1/11/12, it was noted that the pharmacy labels have 2 parts. The label itself is attached to a backing that is then affixed to the medication container. The label easily peels off the backing. At 11:45 AM, a pharmacy label for Diltiazem was partially affixed to an intravenous solution of Milrinone Lactate 40mg/200ml. An intravenous solution of Diltiazem with just the backing label was found in the same bin. By not having the labels permanently affixed to the medications, pharmacy cannot ensure that medications are properly labeled as required in N.J.A.C. 8:43G-23.3(b) referenced above.

3. The same pharmacy labels described above were also found on compounded intravenous solutions. This label in not in compliance with the New Jersey State Board of Pharmacy regulation referenced above. This regulation requires that labels are permanently affixed to the compounded intravenous solution.

B. Based on document review and staff interview conducted on 1/12/12, it was determined that the facility failed to ensure that medications are dispensed in a manner that is safe and meets the needs of the patient.

Findings include:

1. Medical Record #16 contained a telephone order, dated 1/8/12, for "diazepam 0.5 mg po BID prn anxiety [0.5 milligrams by mouth twice daily as needed for anxiety]." The order was profiled by the pharmacy for Diazepam 5 mg tablets to take 0.5 mg by mouth twice daily for anxiety.

a. The dose ordered is 1/10th of the tablet dispensed. This cannot be accurately administered. The pharmacist failed to dispense the medication in a ready to administer form.

C. Based on medical record review, document review and staff interview conducted on 1/12/12, it was determined that the facility failed to ensure that orders containing unapproved abbreviations are clarified by the pharmacist.

Findings include:

Reference #1: Facility Medical Staff Rules and Regulations state under General Conduct of Care, "15. Symbols and abbreviations may be used only when they have been approved by the Medical Staff."

Reference #2: Facility policy titled "Orders, Physician" under Procedure 4.H states, "The licensed nurse or appropriate clinical discipline will contact the physician if an order is in any way incomplete or questionable."

Reference #3: The facility's "Official 'Do Not Use' List", provided by Staff #16 includes MgSO4 with the direction to write "magnesium sulfate" in order to not confuse it with Morphine Sulfate.

1. Medical Record #13 contained orders for "Mg Sulfate" dated 1/1/12, 1/2/12, 1/3/12, 1/4/12, 1/6/12, 1/7/12, 1/8/12, and 1/9/12. Upon interview Staff #16 confirmed that the pharmacist had not clarified the orders (Mg should be written out to prevent confusion with morphine) prior to dispensing the medication.

2. Medical Record #14 contained an order, dated 1/6/11, for "MgSO4" and an order, dated 1/8/11 for "Mg Sulfate." Upon interview, Staff #16 confirmed that the pharmacist had not clarified the orders prior to dispensing the medication.

Based on observation and document review conducted on 1/11/12, it was determined that the facility failed to ensure that outdated drugs and biologicals were not available for patient use.

Findings include:

Reference: Facility policy titled "Emergency Drug Supplies" states the following: "POLICY STATEMENT: Emergency drug supplies will be maintained in patient care areas at all time...It is a pharmacist responsibility to maintain these supplies..."
"Procedure: 3. The entire contents of the code cart are checked monthly for outdated and improperly stored medication ..."

1. Review of the contents of Code Cart #2 on 1/11/12 at approximately 11:00 AM revealed the following:

a. Two (2) Heparin Lock flush USP 100 units per milliliter (ml) had expiration dates of 10/09.

b. Two (2) Dynarex Povidone Iodine swabs had expiration dates of 2/06.

c. Aplicare Iodine tincture 2% had an expiration date of 2/08.

Based on observation, document review and staff interview conducted on 1/11/12, it was determined that the facility failed to ensure implementation of policies and procedures addressing drug distribution when the pharmacy is closed.

Findings include:

Reference: Facility policy titled "Drug Distribution When Pharmacy is Closed" states, "Policy Statement: Drug supplies will be available, as approved by the Pharmacy and Therapeutics Committee, for after-hours use when the pharmacy is closed. These supplies will be accessible to authorized persons in a "night cabinet."

1. Code Cart #1 was found unsecured on 1/11/12 at 10:30 AM. Staff #30 stated that the cart had been opened during the night in order to remove Magnesium Sulfate 1gm/100ml for a patient. This in not in compliance with the facility policy referenced above. The code cart is not listed as a source for medications for when the pharmacy is closed.

Based on staff interview, document review and review of 2 of 2 Medical Records (#9 and #18) for patients receiving speech language pathology services, it was determined that the facility failed to ensure that therapeutic diets are prescribed by the practitioner or practitioners responsible for the care of the patient.

Findings include:

Reference: Facility "ORDERS, PHYSICIAN" policy and procedure, "...2. Verbal or telephone orders may be taken by: (Therapists can only take verbal orders for their discipline.)...G. Speech-language pathologists, ...4. Accuracy of verbal/telephone orders shall be verified as follows: A. The person receiving the order shall write the complete order, B. The written order shall be repeated as written to the physician, C. The physician shall confirm the accuracy of the order as written, ..."

1. In Medical Record #9, there was an order dated and timed by the Speech-language pathologists 10/25/11 at 18:30 that stipulated, "Speech Language Pathology, Initiate p.o. feeding" with "regular diet and thin liquids for pleasure purpose only." The order on the "PHYSICIAN'S ORDERS" sheet did not have the name of the prescribing physician. There was no physician signature. The order was not prescribed by the physician nor was it completed in accordance with facility policy, "ORDERS, PHYSICIAN."

2. In Medical Record #18, there was an order dated and timed by the Speech-language pathologists 12/29/11 at 12:30 that stipulated, "Speech Language Pathology, Initiate p.o. feeding for pleasure purpose only" with "pureed diet and thin liquids, Maintain aspiration precaution." The order on the "PHYSICIAN'S ORDERS" sheet did not have the name of the prescribing physician. There was a single letter entry on the line for the physician to date and time his/her entry. The order was signed and dated by the registered professional nurse on 12/29/11 at 1700. The order was not prescribed by the physician nor was it completed in accordance with facility policy, "ORDERS, PHYSICIAN."

3. On 1/12/11 at 2:10 PM, Staff #25, who wrote the above entries, confirmed that he/she is able to write therapeutic diet orders.

4. Upon review, the "Medical Executive Committee (MEC) Meeting Minutes dated January 18, 2011 states, "Cno requests permission from Medical Executive committee to allow dietician to recommend, and then write order for the appropriate tube feeding solution and rate." There was no action noted on this document. This request for change in procedure does not grant permission for the above request.

A. Based on observation, staff interview and medical record review, it was determined that the facility failed to ensure that patient's receive their nutritional needs in accordance with prescriber's orders
Findings include:

1. Upon review on 1/12/12 in the presence of Staff #21, Medical Record #17 contained a prescriber's order dated 1/4/12 that stipulated, "Nutritional Consult re: low albumin + --------- ---------." The two words after the plus sign are illegible. The nutrition note dated 1/4/12, written by Staff #21, did not acknowledge the physician consult to evaluate the albumin level.

2. Medical Record #18 contained a dietary and tube feeding prescriber's order undated by the physician that stipulated, "Nepro @ 30 ml/hr."

a. On 1/12/12 at 2:45 PM in Room #216, in the presence of Staff #2, it was observed that Patient #18 was receiving Nepro at 35 cc per hour and not the prescribed tube feeding "Nepro @ 30 ml/hr." Upon request, Staff #2 could show no evidence of a prescriber's order for Nepro at 35 cc per hour.

b. During an interview on 1/12/12 at 2:50 PM, Staff #21 stated that the physician for Patient #18 did not want to increase the tube feeding, secondary to a PEG site infection.

c. There was evidence in the medical record that tube feeding of Nepro for Patient #18 was increased to 35 cc per hour on the 7 PM to 7 AM shift on 1/7/12. The nursing notes did not document who ordered a change in the tube feeding rate.

B. Based on document review and medical record review, in the presence of Staff #21 on 1/12/12, it was determined that the facility failed to ensure that facility policy "Interdisciplinary Team Conference" was implemented by the dietitian.

Findings include:

Facility policy, "Interdisciplinary Team Conference: stipulates, "Documentation is the responsibility of the entire team. Each member will document on their professional component of the treatment plan for each patient using the "INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form. ..."

1. In Medical Record #17, the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form dated 1/10/12 was not completed by the dietitian.

2. In Medical Record #17, the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form dated 11/22/11 was not completed by the dietitian.

3. In Medical Record #17, the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form dated 11/29/11 was not completed by the dietitian.

4. In Medical Record #18, the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form dated 1/10/12 was not completed by the dietitian.

5. In Medical Record #19, the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form dated 1/10/12 was not completed by the dietitian.

6. In Medical Record #21, the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" form dated 1/10/12 was not completed by the dietitian.

7. During an interview on 1/12/12 at 11:25 AM, Staff #21 stated that he/she just returned from a leave of absence and that per diem dietitians were covering on 11/22/11 and 11/29/11. Staff #21 added that he/she had not yet gotten to the INTERDISCIPLINARY PLAN OF CARE DISCHARGE BARRIER UPDATE" dated 1/10/12 since returning.

Based on document review and observation, it was determined that the current diet manual was not available to all food service personnel.

Findings include:

1. Upon request to review the current therapeutic diet manual on 1/12/12, Staff #21, clinical nutrition manager, provided to the surveyor the "MANUAL OF CLINICAL DIETETICS, SIXTH EDITION."

2. Upon review on 1/12/12, the facility policy titled, "Diet Manual" with a revised date of 2/26/09 states that the "ADA NUTRITION CARE MANUAL" is the approved diet manual at the facility.

Based on observation and review of facility policy and procedure, it was determined that the facility failed to provide alcohol-rub hand sanitizer at each alcohol-rub hand sanitizer station, for ease and availability, for staff to comply with hand hygiene per policy.

Findings include:

Reference: Facility policy and procedure number: H02-G, Policy: IC III-2, titled 'Hand Hygiene' states "Introduction: Effective Hand Hygiene is considered the basis for an effective Infection Control Program. Research has demonstrated that Hand Hygiene compliance is based upon: [3rd bullet] Ease and availability ... Policy: [1st bullet] There are two methods of hand hygiene: soap(detergent) and water and an alcohol based hand rub. ... [3rd bullet] alcohol rub: apply generous amount according to product recommendations. Vigorously rub hands, (sic) between fingers until hands are dry. ... When ... [2nd bullet] Before every patient contact [3rd bullet] Between patient care activities within same episode of care if not using gloves or if integrity of gloves is compromised [4th bullet] At the termination of a patient contact ..."

1. On 1/10/12 at approximately 11:00 AM, during a tour of the LTAC patient unit in the presence of Staff #1, it was observed that the following wall mounted hand sanitizers were empty and not available for use:

a. Two in patient Room #223

b. One in a hallway alcove outside Room #223

c. One between Rooms #226 and #228

2. On 1/10/12 at 11:00 AM in Room #225, the alcohol-based hand rub dispenser located adjacent to the door did not contain alcohol-based hand rub solution.


3. On 1/11/12 at 10:50 AM in Room #218, the alcohol-based hand rub dispenser located adjacent to bed A, where Patient #17 was receiving his/her hemodialysis treatment, did not contain alcohol-based hand rub solution.

A. Based on observation and staff interview conducted on 1/11/12, it was determined that the facility failed to ensure that expired supplies were not available for patient use and that equipment was maintained to ensure an acceptable level of safety and quality.

Findings include:

1. The following expired or opened sterile supplies were found in Code Cart #1 on 1/11/12 at 10:30 AM:

a. Defibrillator pads, expiration date 3/11

b. One Shiley Fenestrated Low Pressure Cuffed Tracheostomy Tube - 6.4mm, 10.8mm, 76.0mm, expiration date 4/11

c. One Shiley Fenestrated Low Pressure Cuffed Tracheostomy Tube - 7.6mm, 10.8mm, 76.0mm, expiration date 8/11

d. One green Vacutainer, expiration date 12/11 and one blue vacutainer, expiration date 9/11

e. Four (4) blunt plastic cannulas, expiration date 4/10

f. Three (3) 22 Gauge (GA), 1 inch (") IV catheters; 2 with an expiration date of 1/11 and one with an expiration date of 3/10

g. One 18 GA 1.16" IV catheter, expiration date 1/07

h. Six (6) insulin U-100 syringes, expiration date 10/11

i. Three (3) milliliter (ml) syringe, one each with an expiration dates of 12/11 and 11/10

j. One opened 1 ml syringe, expiration date 4/11

k. Four (4) 21 GA 1 1/2" needle, 3 with an expiration date of 2/09 and one with an expiration date of 9/09

l. One Scalp Vein Set, expiration date 6/11

m. One 18 GA 1 1/2" Eclipse needle, expiration date 12/10

n. One Esophageal tracheal airway-rolling kit, expiration date 6/11

2. A battery powered suction machine was found in Code Cart #1 on 1/11/12 at 10:30AM. There was no evidence that the equipment had received a biomedical inspection. In addition, the cord needed to plug the machine into an outlet was missing, rendering the equipment unusable. This was confirmed by Staff #3.

3. The following expired or opened sterile supplies were found in Code Cart #2 on 1/11/12 at 11:00 AM:

a. Two (2) Shiley Fenestrated Low Pressure Cuffed Tracheostomy Tube 6.4mm, 10.8mm, 76.0mm, one with an expiration date of 10/08 and one with an expiration date of 1/09

b. Four (4) Arterial Blood Sampling Kits; one with an expiration date of 11/08, 2 with an expiration date of 4/10 and one with an expiration date of 4/11

c. Two (2) 23 GA 1 1/2" Eclipse needle, expiration date 9/11

d. One 25 GA Eclipse injection needle, expiration date 12/10

e. Four (4) Scalp Vein Set, expiration date 6/11

f. One Multi-Lumen Central Venous Catheterization Kit, expiration 2/10

g. One 37 Fr. Esophageal Tracheal Airway Roll up Kit, expiration 4/11

h. Two (2) Portex First Breath Adult Venturi Oxygen Mask, expiration date 6/11

i. One 22 Gauge Autoguard Shielded catheter, expiration date 8/10

j. Five (5) 18 Gauge Angiocath Autoguard Shield IV catheter one with expiration date 1/07, 3 with expiration date of 10/09 and one with an expiration date of 10/11.

k. Two (2) green Vacutainers, one with the expiration date 7/09 and one with the expiration date 4/11. Two (2) blue Vacutainers, one with the expiration date 5/09 and one with the expiration date 8/11. Three (3) red Vacutainers, two with the expiration date 6/09 and one with the expiration date 7/11 and two (2) yellow Vacutainers, one with the expiration date 5/09 and one with the expiration date 11/11.


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B. Based on observation, staff interview, review of facility documentation, and review of equipment manufacturer's recommendations, it was determined that the facility failed to ensure that all equipment is maintained at an acceptable level of safety and quality.

Findings include:

Reference #1: Manufacturer of 'Naturalyte Sodium Bicarbonate Liquid Concentrate' states, "WARNINGS: Once this product is opened, the bicarbonate concentrate must be used within 24 hours."

1. On 1/10/12 at 10:35 AM, one undated bottle of 'Naturalyte Sodium Bicarbonate Liquid Concentrate' was observed being utilized during a dialysis treatment in patient Room #221. When Staff #9 was questioned as to why the opened bottle was not dated, he/she stated that the bottle was leftover from yesterday's treatment on 1/9/12 and was uncertain as to when the bottle was opened.

2. Review of treatment records from 1/9/12 revealed that the first bottle of bicarbonate concentrate was opened during the first patient treatment which started at 7:50AM. Staff #9 and Staff #10 both stated that a policy and procedure on 'Sodium Bicarbonate Liquid Concentrate' has not been developed to ensure that the bicarbonate concentrate is used within 24 hours, once opened, as required by the manufacturer.Reference #2: Manufacturer of 'Serim Guardian Bicarb pH II' test strips states, "3. Interpret the results by comparing the indicator pad to the color chart on the bottle label ... The acid/bicarbonate color blocks indicate pH readings at 6.5, 7.0, 7.5, 8.0 and 8.5."

Reference #3: Facility's policy #7-12-37 titled, 'Testing pH and Conductivity of Proportioned Dialysate' states, "Acceptable range for proportioned dialysate pH is 6.9 - 7.6."

1. On 1/10/12, pH values of 7.3 were recorded by Staff #9 for both dialysis patients being treated in Room #220 and Room #221.

2. The pH strips are only capable of indicating readings from 6.5 to 8.5, in .5 intervals.

The facility has a total of 4 Gambro 'WRO 300' portable reverse osmosis machines available for use. When the manufacturer's preventive maintenance manual for 'WRO 300' portable reverse osmosis was requested from Staff #10, he/she stated that the book was not available for review onsite.


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C. Based on observation and staff interview, it was determined that the facility failed to maintain its blood glucose monitoring systems within an acceptable level of quality control.

Findings include:

Reference: The Procision Xceed Pro glucose monitoring system's operator's manual states "... 4. Control Test ... This chapter describes the steps for running a control test with control solutions. Control tests verify the performance of the Procision Xceed Pro Monitor and Test strips. The quality control features of the monitor can be customized to fit the requirements of each facility. The monitor can be set to require: ... Tests of control solutions at relative times (e.g. every 24 hours) or fixed times (e.g. at 6:00 AM, 2:00 PM, and 10:00 PM ... When to Test Control Solutions [1st bullet] As required by your facility's quality policy or local regulatory requirements."

1. On 1/10/12, the in patient unit was toured in the presence of Staff # 1. Staff #1 stated that the glucometers QC (quality control) checks, with the high and low control solutions, are checked everyday on the night shift.

a. Staff #4 stated in interview on 1/10/12 at 10:45 AM, that the certified nursing assistants (CNAs) check the glucometers on the night shift, and the glucometers need to be checked for QC every 24 hours. He/she explained that if the glucometers were not checked, then the machine/glucometer would indicate that it requires it's 24 hour QC check and will not function until the QC test is done. Staff #4 stated the process of the QC check automatically is entered in the glucometer machine which is downloaded to the lab.

2. Staff #1 stated in interview on 1/10/12, that the facility does not have a policy and procedure for the quality control checks for the glucometers, but that they follow the manufacturers instructions.

a. Review of the manufacturer's instructions for The Procision Xceed Pro glucose monitoring system indicates that the Control Solutions are to be tested as required by facility policy.

b. On 1/30/12, facility policy Number: D01-N, Subject: Diabetes Mellitus, Routine Care and Hypoglycemia was faxed to the Department by Staff #1. The policy states under PROCEDURE: 5. "Glucometers A. Please refer to the manufacturer's guidelines as to use and maintance of the equipment."

i. The facility was unable to provide the above policy on site during the survey. The policy does not indicate the process or the frequency of quality assurance checks or routine maintenance, as per the manufacturer's guidelines referenced above.

3. Review of a 'Data Listing' that identifies the glucometers' Instrumental Serial No.', was compared to the glucometers currently in use on the LTAC unit. This indicated that the following two of the four glucometers on the unit were not tested within 24 hours, or on the nightshift for 1/10/11, as per interview with Staff #1 and Staff #4:

a. Unit Instrumental serial No. XP0951B023-8212.

b. Unit Instrumental serial No. XP1145B044-5200.

c. Staff #1 confirmed the above on 1/10/12.

Based on document review and staff interview, it was determined that the facility failed to ensure that the Rehabilitation services has a Director that oversees the hospital wide operation of that service.

Findings include:

1. Upon interview on 1/12/12 at approximately 11:00 PM, Staff #3 stated that the facility does not have a Director for Rehabilitation Services. Rehabilitation services (Physical Therapy, Occupational Therapy and Speech Therapy) falls under the supervision of the Chief Nursing Officer (CNO).

2. The credential file for Staff #2 was reviewed on 1/12/12. There was no evidence in the credential file that Staff #2 possess the experience or capabilities to properly supervise the overall operation of the Rehabilitation Services.

Based on review of the Lead Respiratory Therapist's job description and resume, it was determined that the facility failed to ensure that Lead Respiratory Therapist (RT) met the facility's position qualifications for this job title.

Findings include:

1. On 1/12/12 at 2:00 PM during tour of the LTAC patient unit, Staff #31 stated in interview that he/she started at the facility on 10/31/11. He/she stated that as the Lead RT he/she will be reporting to the director of nursing and performing the other RT's job evaluations.

a. Review of Staff #31's job description for the position title of Lead RT indicates under the 'Position Qualifications' that "... at least two years experience as a respiratory therapy supervisor within the last five years is required." There was no evidence on the resume of Staff #31 that indicated he/she has acted in a supervisory capacity within the last 5 years of his/her previous employment.