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Based on observation, interview and policy review, the facility failed to ensure hand hygiene was used when providing care to three (#2, #3 and #23) of four patients, and failed to ensure that staff who provided patient care did not wear artificial nails. This had the potential to affect all patients. The facility census was 8.

Findings included:

1. Record review of the facility's policy titled, "Personal Appearance" revised on 01/29/08, showed that artificial nails were prohibited for all patient care staff due to infection control.

Record review of the facility's policy titled, "Hand Washing" revised on 06/10/10, showed direction for facility staff to wash their hands:
-Before and after applying gloves;
-Between handling patients or equipment;
-Before contact about the face and mouth of patients.

2. Observation on 01/28/13 at 3:40 PM, showed Staff E, Registered Nurse (RN), provide care to Patient #3. Staff E placed gloves on his hands, rummaged through a tray of medical supplies, and then attempted to initiate an intravenous (IV - in the vein) catheter with the same gloves on.

3. Observation on 01/30/13 at 9:00 AM, showed Staff F, RN, wearing artificial nails while providing care to Patient #2. Staff F placed gloves on her hands without performing hand hygiene and removed tape around the patient's IV site. Staff F then removed her gloves and did not perform hand hygiene and returned to the patient to initiate a breathing treatment (medication mixed with a saline solution which the patient inhales along with oxygen).

4. Observation on 01/30/13 at 9:50 AM, showed Staff F administer medication to Patient #23 without performing hand hygiene.

5. Observation on 01/30/13 at 9:55 AM, showed Staff F enter Patient #2's room to check the patient's oxygen level with a portable oxygen monitor. Staff F did not perform hand hygiene before entering the room, before touching the patient to place the monitor on the patient, or after checking the patient's oxygen level. Staff F then exited the room without performing hand hygiene.

6. During an interview on 01/30/13 at 10:10 AM, Staff F stated that she:
-Did not know if she was supposed to wash her hands before she put on gloves;
-Forgot to wash her hands before administering medication to Patient #23;
-Forgot to wash her hands before entering and exiting Patient #2's room to check the patient's oxygen level; and
-Has never been told that she cannot wear artificial nails.

Based on observation and interview, the facility failed to protect fresh water supply resources, ensure all floor surfaces remain in good repair and free of potential trip hazards to patients, and maintain a sanitary environment for food preparation in the kitchen of a 25 bed hospital to prevent potential contamination from human waste or infectious waste, potentially affecting the visitors, staff and census of the entire hospital. The facility census was eight.

Findings included:

1. Observation on 01/29/13 at 9:30 AM showed an ice machine in the kitchen was plumbed with hard PVC pipe with no air gap or separation between the drains out of the unit and the floor drain at the corner of the dishwashing enclosure. The drain from the icemaker and the drain from the reservoir where ice was stored were connected to the same PVC pipe. Without an air-gap or opening above the top level of drainage, a line stoppage and sudden cessation or reversal of water pressure could potentially flood the sanitary reservoirs in the ice maker and introduce contaminates into otherwise sanitary resources.

2. Observation on 01/29/13 at 10:00 AM showed black and brown dried food materials accumulated on the blade of a large hand-cranked can opener in the kitchen food preparation area.

3. During an interview on 01/29/13 at 10:00 AM Staff D, Dietary Manager stated that she understood the potential hazards and would report the findings to Maintenance for correction. She stated that she did not have a specific policy and procedure for cleaning the can opener, except the person who used it usually just cleaned it after use.

4. Observation on 01/29/13 at 10:30 AM showed the carpeted corridor areas exhibited signs of wear and tear and created potential trip hazards in certain areas where carpet had peeled or fibers unraveled as follows:
-Four inch long strip of unraveled carpet fibers and carpet peeled between seams in front of the Nurses station.
-Two, six-foot long seams at both ends of a corridor passage outside of pharmacy was frayed and unraveled.
-Frayed seams, four inches long and 24 inches long, noted at the end of the northwest corridor.

5. During an interview on 01/29/13 at 3:00 PM, Staff C, Director of Facilities, stated that housekeepers tried to keep the loose fibers trimmed off and they have had to replace a few sections. He said the hospital board had discussed replacing the carpet during the planned renovation of those areas, but no date or budget had yet been determined.

Based on policy review, record review, observation and interview the facility failed to:
- Ensure sterile medications for intravenous (IV) infusion were prepared in a sterile environment for two patients (#23 and #24) of two observations made on medication reconstitution;
- Ensure pharmacist review of a patient medication profile and physicians orders prior to dispensing or administration of the medication.

These failures had the potential to cause infection control issues or medication errors and could affect all patients that required medications while cared for at the facility. The facility census was eight.

Findings included:

1. Review of the facility policy 5004 titled, "Medication Administration", dated 04/10/12 showed direction to staff that IV medication will be compounded in an area which is out of the main stream of traffic and hands will be thoroughly washed with a germicidal soap for a minimum of 30 seconds prior to reconstitution;

Review of facility policy 6009 titled, "Infection Control", dated 04/10/12 showed direction to facility staff that sterile preparations are not prepared in house.

Review of facility policy 6002 titled, "Compounding, Repackaging and Relabeling", dated 04/10/12 showed direction to facility staff that compounding, reconstitution and IV preparations are not prepared in house.

2. Observation on 01/30/13 at 9:23 AM and again at 9:48 AM, showed Staff F, Registered Nurse (RN), mix Ceftriaxone (an antibiotic used to treat infections) one gram with 100 milliliters (unit of measures) of Normal Saline (fluid used to reconstitute medication so that it can be infused into a patient's vein through an intravenous catheter) to administer to current Patients' #23 and #24. Staff F mixed the antibiotic in the facility medication room on a computer cart that had been in multiple patient rooms. Staff F did not clean the cart prior to mixing the medication and the nurse did not wash her hands prior to mixing the medication. No other precautions were taken to ensure the sterility of the admixture.

3. During an interview on 01/30/13 at 9:48 AM, Staff F stated that the staff always mixed medications in this manner and that pharmacy staff do not mix medications. Staff F stated that she forgot to wash her hands and wipe the cart down (clean) prior to mixing the medication with the Normal Saline.

4. During an interview on 01/29/13 at 1:55 PM Staff K, Director of Pharmacy, stated that all admixtures and IV medications are prepared by the nurses in the medication room at the time of administration. The pharmacy does not reconstitute or mix any medications. Staff K stated that there are no sterile preparation areas in the hospital. Staff K stated that the facility has very professional nurses and he is confident they are reconstituting medications properly. Staff K stated that he had not done any specific education with nurses regarding reconstitution of medications or written a policy to provide guidelines to nurses.

5. During an interview on 01/30/13 at 3:00 PM Staff L, Pharmacy Technician, stated that no medications are reconstituted in the pharmacy, there are no sterile preparation areas in the hospital and he is not aware of any education provided to nurses regarding sterile preparation of medication. Staff L explained that the policies state no sterile medications are prepared in house because the facility has no sterile preparation area. Staff L stated the facility intended to purchase medications that could be reconstituted without being invasively accessed by the nurse (medication would come with fluid attached and the RN has to twist the container and shake) but availability of product and cost has prevented this.

6. During an interview on 01/30/13 at 4:00 PM Staff G, Nurse Manager, stated that there is no specific education for nurses regarding medication reconstitution. Staff G stated that nurses are advised to wash hands and counters prior to reconstituting medications and that preparing medications on a mobile computer cart would not be acceptable. Staff G stated there is no specific facility policy outlining staff expectations during this process.

7. Observation on 01/30/13 of the facility medication room in the nurses' station showed an area, along the side of a sink, about 12 inches wide by 24 inches deep that Staff G stated the nurses used to prepare/reconstitute medications. The area was cluttered with many other supply items and was not visibly clean.

8. Review of facility policy 6004, "Dispensing Medication- General", dated 04/10/12 showed direction to staff that after an order is written on the Physician's order Form, the order is transcribed onto the Patient's Medication Administration record by the nurse taking off the order. All orders must be sent to pharmacy. The nurse determines if the medication is on the formulary. The medication is obtained from the Pyxis (medication storage/dispensing system) and administered to the patient after checking identification.

9. During an interview on 01/29/13 at 1:55 PM, Staff K, Director of Pharmacy stated that the above policy should be updated. Staff K stated that the current process required direct order entry by the physician into the electronic system. The order goes to the pharmacy and to the patient's Medication Administration record. The nurse then verified the order, obtained medication from the Pyxis and administered to the patient. Staff K stated that he reviewers all previous orders written when he is in the facility on Tuesday's or Friday's. Staff K further stated that he does not verify physician orders prior to medication administration to the patient and he is not concerned because the nurses verify the orders and the nurses are very competent. Staff K stated that he has not done any education with nurses on how to verify an order from the pharmacy perspective. Staff K stated that he is not aware of any facility policy on how nurses verify orders or that the pharmacist should review orders or medication profile prior to administration of medication. Staff K stated that he does not have the capability to view/verify orders when he is outside the facility (electronically).

10. During an interview on 01/30/13 at 3:00 PM Staff L, Pharmacy Technician, stated that the pharmacist verified all physician orders that were written since his previous work day on Tuesday or Friday. Staff L stated that patients receive medication prior to the order being verified by the pharmacist and that very often patient's are discharged from the facility prior to the orders being reviewed by the pharmacist. Staff L stated that there is no facility policy on how nurses should verify medication orders.

11. During an interview on 01/30/13 at 4:00 PM Staff G, Nurse Manager, stated that there was no facility policy to provide nurses guidelines on how to verify physician orders from a pharmacy perspective. Staff G stated that medications are dispensed and administered prior to a review by pharmacist. Staff G stated that the Dispensing Medication policy is outdated because the facility is currently implementing an electronic medical record and the policy has not been updated to the current process.

12. Review of facility Performance Improvement report showed 11 medication error events during October, November and December 2012. Three were omission errors (medication not given), two were unauthorized drug errors (medication given was not ordered), three were improper dose errors (wrong dose of medication was given to patient), and three were administration not documented errors (medication was given to patient but not documented in record. Facility stated goal and threshold of medication errors is zero. Facility does not calculate total number of medications administered for this report.



29047

Based on interview, record review, policy review and State Regulation review, the facility failed to ensure each patient medical record contained a dated and authenticated history and physical, placed in the medical record within twenty four hours of admission for nine (#2, #3, #6, #8, #9, #12, #13, #14 and #22) of 14 patient medical records reviewed for presence of admission history and physical. The facility census was eight.

Findings included:

1. Review of State Regulation 30-20.094(18), showed that a History and Physical examination shall be completed on each inpatient within twenty- four (24) hours of admission, or a history and physical examination shall have been completed or updated within the seven (7) days prior to admission. A history and physical which is performed up to and no more than thirty (30) days before admission may be utilized provided that the patient is reassessed and an update note is written, signed and dated to reflect the patient's status within seven (7) days prior to, or within twenty-four (24) hours after, admission.

2. Review of the facility's undated Medical Staff "Rules and Regulations", showed that a complete history and physical shall be dictated or written within 24 hours of admission and shall be typed and on the chart within 48 hours of admission.

3. Review on 01/28/13 of current Patient #2's medical record, showed that the patient was admitted on 01/20/13. The medical record did not contain an authenticated (signed and dated) History and Physical.

4. Review on 01/28/13 of current Patient #3's medical record showed that the patient was admitted on 01/25/13. The medical record did not contain an authenticated History and Physical.

5. Review of current Patient #22's medical record showed that the patient was admitted on 01/19/13. The medical record did not contain an authenticated History and Physical.

6. Review of discharged Patient #8's medical record showed that the patient was admitted on 10/12/12. The medical record did not contain an authenticated History and Physical.

7. Review of discharged Patient #12's medical record showed that the patient was admitted on 11/29/12. The medical record did not contain an authenticated History and Physical.

8. Review of discharged Patient #13's medical record showed that the patient was admitted on 12/01/12. The medical record did not contain an authenticated History and Physical.

9. Review of discharged Patient #14's medical record showed that the patient was admitted on 11/17/12. The medical record did not contain an authenticated History and Physical.

10. Review of discharged Patient #6's medical record showed that the patient was admitted on 10/20/12. The medical record did not contain an authenticated History and Physical.

11. Review of discharged Patient #9's medical record showed that the patient was admitted on 01/08/13. The History and Physical was signed and dated on 01/11/13, greater than 24 hours after the patient was admitted.

12. During an interview on 01/29/13 at 10:10 AM, Staff M, Business Office Clerk stated that the patient's History and Physical is required to be signed and dated and placed in the medical record within one day of the patient admission.

Based on interview, record review and policy review, the facility failed to ensure orders were properly authenticated (signed, dated and timed) within time limits established by the facility for four (#5, #6, #8 and #14) of 11 records reviewed for order authentication. The facility census was eight.

Findings included:

1. Record review of the facility's policy titled, "Verbal and Written Medication Orders by the Physician" reviewed 04/10/12, showed that the physician will "sign the verbal order with date and time no longer than 24 hours".

2. Record review of the facility's undated Medical Staff "Rules and Regulations", showed that a patient's chart shall be completed within 30 days of discharge and that all clinical entries in the patient's medical record shall be accurately dated and authenticated.

3. Review of discharged Patient #5's medical record showed that the patient was admitted on 11/07/12 and discharged on 11/10/12. An admission order dated 11/07/12, completed by a nurse practitioner, was signed by the admitting physician, but did not include a date or time of the physician's signature. A telephone order dated 11/07/12 for Lomotil (medication to alleviate diarrhea) was signed by the physician, but did not include a date or time of the physician's signature.

4. Review of Discharged Patient #6's medical record showed that the patient was admitted on 10/20/12 and discharged on 10/21/12. The following orders were signed by a physician, but did not include a date or time of the physician's signature:
-Verbal order on 10/20/12 for insulin;
-Telephone order on 10/20/12 for Lasix (medication that removes excess fluid from the body);
-Verbal order on 10/21/12 to discharge the patient.

5. Review of Discharged Patient #8's medical record showed that the patient was admitted on 10/10/12 and discharged on 10/16/12. The following orders were signed by a physician, but did not include a date or time of the physician's signature:
-Telephone order on 10/10/12 for continuous positive airway pressure (CPAP - pressurized air to keep airways in the lungs open);
-Telephone order on 10/11/12 to advance the patient's diet;
-Verbal order on 10/12/12 to make the patient an inpatient as of 10/10/12;
-Telephone order on 10/14/12 to stop intravenous (IV, in the vein) fluids.

6. Review of discharged Patient #14's medical record showed that the patient was admitted on 11/17/12 and discharged on 11/20/12. Verbal orders taken on 11/17/12 at 12:15 PM for IV fluid rate clarification and diet, and 12:25 PM for multiple medications, were signed by the physician but did not include a date or time of the physician's signature.

7. During an interview on 01/30/13 at approximately 4:15 PM, Staff G, Nurse Manager stated that the physician's sometimes forget to write the date and time of a verbal or telephone order when they review it.

8. During an interview on 01/29/13 at 10:10 AM, Staff M, Business Office Clerk, stated that the facility completes Quality Monitoring of physician orders, and that all orders require a date and time when the order is signed. Staff M stated that there have been no quality issues with the physician signing, dating and timing their orders.

Based on interview, record review and Medical Staff Rules and Regulations, the facility failed to ensure medical record entries were dated, timed and authenticated for seven (#5, #6, #7, #8, #12, #13 and #14) of seven medical records reviewed for dated, timed and authenticated entries. The facility census was eight.

Findings included:

1. Record review of the facility's undated Medical Staff "Rules and Regulations" showed that a patient's chart shall be completed within 30 days of discharge and that all clinical entries in the patient's medical record shall be accurately dated and authenticated. The attending physician shall countersign the history, physical examination and preoperative note when they have been recorded by paramedical personnel approved by the Credentials committee.

2. Review of discharged Patient #13's medical record showed that the patient was admitted on 12/01/12 and discharged on 12/05/12. A physician progress note, which was dictated on 12/03/12 and transcribed on 12/04/12, was signed but did not include a date or time. A physician progress note, which was dictated on 12/04/12 and transcribed on 12/05/12, was not signed or dated or timed.

3. Review of discharged Patient #12's medical record showed that the patient was admitted on 11/27/12 and transferred to another facility on 11/29/12. The following medical record entries were not complete:
-A physician progress note, which was dictated on 11/28/12 and transcribed on 11/2/12, was signed but not dated or timed;
-A physician progress note, which was dictated on 11/29/12 and transcribed on 11/29/12, was signed but not dated or timed;
-A progress note completed by a nurse practitioner, which was dictated on 11/29/12 and transcribed on 12/01/12, was signed but not dated or timed.

4. Review of Discharged Patient #8's medical record showed that the patient was admitted on 10/10/12 and discharged on 10/16/12. The following medical record entries were not complete:
-A physician progress note, which was dictated on 10/11/12 and transcribed on 10/12/12, was signed but not dated or timed;
-A physician progress note, which was dictated on 10/12/12 and transcribed on 10/13/12, was signed but not dated or timed;
-A physician progress note, which was dictated on 10/13/12 and transcribed on 10/14/12, was signed but not dated or timed;
-A physician progress note, which was dictated on 10/15/12 and transcribed on 10/16 12, was signed but not dated or timed;
-A physician progress note, which was dictated on 10/16/12 and transcribed on 10/17/12, was signed but not dated or timed.

5. Review of Discharged Patient #6's medical record showed that the patient was admitted on 10/20/12 and discharged on 10/21/12. A discharge summary, which was dictated on 10/21/12 and transcribed on 10/22/12, was signed but not dated.

6. Review of discharged Patient #5's medical record showed that the patient was admitted on 11/07/12 and discharged on 11/10/12. A physician progress note, which was dictated on 11/08/12 and transcribed on 11/09/12, was electronically signed, but not dated or timed. A physician progress note, which was dictated on 11/09/12 and transcribed on 11/10/12, was electronically signed, but not dated or timed.

7. Review of discharged Patient #7's medical record showed that the patient was admitted on 12/19/12 and discharged on 12/24/12. A progress note, completed by a nurse practitioner, dictated on 12/24/12 and transcribed on 12/25/12, was not signed, dated or timed by the nurse practitioner.

8. Review of discharged Patient #14's medical record showed that the patient was admitted on 11/17/12 and discharged on 11/20/12. A physician progress note dictated on 11/18/12 and transcribed on 11/19/12, was electronically signed, but not dated or timed.

9. During an interview on 01/30/13 at approximately 4:15 PM, Staff G, Nurse Manager, stated that the physicians sometimes forget to write the date and time when they review an entry and sign it. Staff G added that the facility didn't realize the electronic medical record didn't auto stamp a date and time when a physician reviewed and signed a dictated report.

During an interview on 01/29/13 at 10:10 AM, Staff M, Business Office Clerk, stated that the facility completes Quality Monitoring of physician entries, and that all entries require a date and time when the entries are signed. Staff M stated that there have been no quality issues with the physicians signing, dating and timing their entries.

Based on interview, record review, policy review and the Patient Self Determination Act of 1990, the facility failed to clearly document and/or have knowledge of the patient's wishes as determined through an Advanced Health Care Directive for two (#2 and #4) of two current patient's who's medical records contained Advanced Healthcare Directives. The facility census was 8.

Findings included:

1. Review of the Patient Self Determination Act of 1990, showed that facilities are to ensure that rights regarding the patient's decision toward their own medical care are to be communicated by the healthcare provider. Specifically, the rights ensured are those of the patient to dictate their future care should they become incapacitated.

2. Review of the facility's policy titled "Advance Directives" revised on 06/10/10, showed that:
-Advanced Directives ensure that each patient's ability and right to participate in medical decision making is maximized and not compromised as a result of admission for care through the facility;
-An Advanced Directives information packet should be provided to patients as part of the admission process;
-Admitting personnel would document in the medical record whether the patient has completed an Advanced Directive and that information concerning Advanced Directives has been given to the patient/significant other during the admission process;
-If an Advanced Directive was present in a previous medical record, the nursing staff will have the responsibility to review the existing advance directive with the patient/significant other to validate its current status;
-Any expression by the patient of a revision in previous Advanced Directive desires will be documented by the nursing personnel in the nursing progress notes.

3. During an interview on 01/29/13, Staff G, Registered Nurse Manager, stated that the facility does not have a Code Status (indicates if a patient is or is not to be resuscitated) policy.

4. Review of Patient #2's "Consent for Treatment" showed that the patient did not have an Advanced Healthcare Directive or Living Will. There was no Code Status order found in the record.

5. During an interview on 01/28/13 at approximately 3:00 PM, Staff G and Staff E, Registered Nurse (RN), stated that Patient #2 was considered a full code (to be resuscitated) based on her history with the facility.

6. Review of Patient #2's Health Care Directive (Advanced Directive), provided by Staff G on 01/29/13 at 9:15 AM (after it was found in an older admission record.) The Advanced Directive, which was signed on 03/12/05 (Notary signature showed it was dated 03/12/04), showed that the patient wanted cardio-pulmonary resuscitation (CPR) to be withheld, which indicated that the nursing staff had not reviewed the existing Advanced Directive.

7. During an interview on 01/29/13 at 9:15 AM, Staff G stated that Patient #2 was still considered a full code because she had talked with the patient multiple times about resuscitation and the patient wanted to be resuscitated. Staff G stated that she did not document the conversations or provide or assist the patient in completing a new or revised Advanced Directive.

8. Review of current Patient #4's medical record, showed that it did not contain a "Consent for Treatment Form" and therefore did not indicate if the patient had an Advanced Directive or Living Will, or if the patient had made any changes to an Advanced Directive or Living Will since the last admission to the facility. The patient's "face sheet" (includes demographic information on the patient) indicated that the patient did have an Advanced Directive (electronically populated based on previous information). There was no Code Status order found in the record.

9. During an interview on 01/28/13 at approximately 3:47 PM, Staff G stated that she had looked at Patient #4's previous admission records dating back to 2009 and there was no Advanced Directive or Living Will found. Staff G stated that she believed the demographic sheet information, which showed that the patient had an Advanced Directive, was incorrect.

During an interview and concurrent record review on 01/29/13 at 9:15 AM, Staff G stated she found Patient #4's Living Will in an older admission record, which indicated that the nursing staff had not reviewed the existing Advanced Directive. The Living Will was signed and notarized on 08/19/09 and indicated that the patient did not want to be put on Life Support, but did not indicate if the patient wanted to be resuscitated. Staff G stated the patient would be considered a full code regardless of the Living Will because the patient "didn't really know or understand" the questions or her answers when she completed it.