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Based on interview, record review, and policy review the Governing Body failed to ensure eight of 19 direct patient care services provided by contract were evaluated through the facility's Quality Assessment Performance Improvement (QAPI) program to ensure the services furnished were provided in a safe and effective manner and improvement opportunities were provided. This had the potential to affect all patients receiving care in the facility. The facility census was 37.

Findings included:

1. Record review of the facility policy titled, "Performance Improvement (PI) Plan," reviewed date 12/12, showed that the facility's objective was to utilize a planned, continuous ongoing systematic process to monitor and evaluate the quality of the services provided and everyone in the facility was encouraged to participate in processes and activities that make the environment of care safe and effective.

2. Record review of the facility's document titled, "Board of Trustees Minutes," dated 02/21/13 showed that the Governing Body reviewed and approved the Medical Executive Committee meeting which included a motion to approve the PI indicators for 2013 and PI goals for 2013.

The Governing Body failed to ensure all contract services were reviewed and approved in the facility PI plan.

3. Record review of the facility document titled, "Performance Improvement and Patient Safety Plan 2013," showed that the Governing Body had ultimate responsibility for the oversight function of the PI/Patient Safety Program.

The Plan failed to include all of the contracted services.

4. During an interview on 09/11/13 at 4:26 PM, Staff ZZ, Director of Quality stated that the facility failed to incorporate the following contracted services into the hospital-wide QAPI:
-EKG (electrocardiogram, a test that measures and records the electrical activity of the heart) reading;
-Medical waste disposal;
-EEG (electroencephalogram, test that measures and records the electrical activity of the brain) reading;
-Paper shredding Service;
-Dietary;
-Transportation;
-Medicaid Eligibility; and
-Medicaid consulting;

Based on observation, interview and record review the facility failed to provide evidence the patients' received their patient rights, prior to care being provided, for three patients (#1, #2, and #3) of three reviewed on the Rehabilitation (Rehab) Unit, for two patients (#12 and #13) of two reviewed in the Emergency Department (ED) and five patients (#44, #45, #46, #47 and #48) of five patients of the Infusion Therapy Unit. This had the potential to affect all patients admitted to this facility. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Patient Rights and Responsibilities," dated 03/09/12, showed the following:
-All patients should be informed of their rights in advance of furnishing care.
-All patients will be given a copy of the facility's "Patient's Rights and Responsibilities."
-The rights will be explained to the patient as appropriate and necessary.

2. During an interview, and concurrent observation, on 09/11/13 at 9:05 AM, Staff Z, Registered Nurse (RN) Manager for the Rehab Unit, stated that the nurse responsible for a patient's admission was responsible for providing an admission packet which included a booklet titled, "Patient Handbook." Staff Z stated that the handbook should include the patient rights information. However, the handbook Table of Contents showed the patient rights should be provided via an "insert," and the inserts had not been placed in the unit handbooks. Staff Z confirmed the absence of the rights brochures via review of pre-assembled admission packets stored on the unit.

3. Record review of Patient #3's Rehab record on 09/10/13 at 10:00 AM, showed no documented evidence she received a copy of the patient's rights prior to care being provided.

4. Record review of Patient #2's Rehab record on 09/10/13 at 10:04 AM showed no documented evidence she received a copy of the patient's rights prior to care being provided.

5. Record review of Patient #1's Rehab record on 09/10/13 at 1:23 PM, showed no documented evidence she received a copy of the patient's rights prior to care being provided.

6. Record review of Patient #13's ED medical record on 09/10/13 at 10:35 AM, showed it did not contain the required patient rights information sheet.
7. Record review of Patient #12's ED medical record on 09/10/13 at 1:40 PM, showed it did not contain the required patient rights information sheet.
8. During an interview on 09/10/13 at 1:25 PM, Staff HHH, ED Registration Clerk, stated that she only printed off two informational sheets to give to the patients. She stated that one sheet was Conditions of Treatment and Admission and the second was a Communication Consent for cell phone/email contact. She stated, "To my knowledge there is no sheet given for patient rights".
9. Record review of the Infusion Therapy Unit medical records showed Patients #44, #45, #46, #47, and #48 did not receive their patient rights prior to treatment.
10. During an interview on 09/12/13 at 9:30 AM in the Infusion Therapy Unit (an outpatient unit which administers a variety of services not limited to chemotherapy,blood draws,and/or injections) Staff XX, RN, stated that they did not actually give the patients a piece of paper with their patient rights. She stated that she thought they were given all the paper work including their patient rights through the private physician who was in the next office since nearly all of the referrals for treatment came from there.





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Based on observation and interview, the facility failed to provide the patient or patient's representative a valid phone number of how to lodge a complaint/grievance with the State agency. This had the potential to affect all patients and their rights at the facility. The facility census was 37.

Findings included:

1. Record review of the facility policy titled, "Patient Rights and Responsibilities", dated 07/90 showed on page one "The patient has the right to prompt resolution of a patient grievance and to know how and who to contact to file a complaint or grievance."

The information given to the patient does not include who the patient can contact or how to file a grievance.

2. Observation on 09/12/13 at 8:29 AM showed a notice at the entrance of the Infusion Therapy Unit, which gave a phone number for a patient to file a complaint/grievance. The phone number for the Department of Health and Senior Services was incorrect. When called, this number, (573) 751- 6400, was for Vital Records for the State of Missouri.

3. During an interview on 09/12/13 at 8:31 AM, Staff WW and XX, Registered Nurses, were not aware that this was an incorrect number. They stated that they did not give any information on how to file a patient complaint or grievance to the patients.

Based on interview and record review the facility failed to ensure two patients (#1 and #2) of three patients reviewed received considerate, respectful and safe care based on their abilities, needs, and preferences. This failure resulted in pain and/or injury to both patients and had the potential to affect all patients admitted to the Rehabilitation Unit (Rehab). The Rehab unit census was three, with a capacity of eight. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Patient Rights and Responsibilities," Dated 03/20/12, showed the following:
-The patient has a right to receive care in a safe environment.
-The patient has the right to participate in the implementation of a plan of care.
-The patient has the right to be treated with consideration, compassion, and respect.
-The patient has the right to protective oversight while in the hospital.
-The patient has the right to accept or refuse medical care.

2. Record review of Patient #1's History and Physical (H & P) dated 08/31/13, showed the patient was admitted to the Rehab Unit on that date with a diagnosis of a recent (08/28/13) right total hip replacement. The patient required total assistance for all activities of daily living (ADL), with the exception of eating and decision-making skills. The patient had poor balance and required strengthening and balance training, and gait/transfer training.

3. Record review of the patient's functional ability scores (a form utilized to assess the patient's abilities from one shift to another) dated 09/06/13 showed the patient did less than 25% of her toileting, including transfer from bed to chair or commode (portable toilet). The patient's memory was scored as independent or intact. The patient utilized a wheelchair for locomotion. There was no documented evidence the patient had utilized a walker up this date.

4. Record review of a Physical Therapy note dated 09/06/13 showed the patient required maximum assistance to transfer from the wheelchair to the toilet. The patient had increased fears of falling. There was no documented evidence the patient had utilized a walker up this date.

5. Record review of Physician's orders from 08/23/13 through 09/12/13 showed no order for the patient to utilize a walker.

6. Record review of the patient's interdisciplinary care plan (ICP) dated 09/03/13 showed the following:
-The patient had a a history of being non-ambulatory related to her bad hip with multiple falls and a fracture prior to admission.
-The patient had a current problem of toileting with a goal to complete this task with moderate assistance by use of training during activities of daily living (ADL) and neuromuscular re-education.
-The patient had a current problem with transferring, and a goal to pivot transfer (movement of a person from one site to another such as from a bed to a wheelchair) with a front-wheeled walker by 09/23/13.
-The ICP also indicated the patient would be free of falls by 09/12/13 by utilizing fall prevention.

7. Record review of physician's progress notes from 09/03/13 through 09/06/13 showed the patient had a great fear of falling.

8. Record review of nurses' notes dated 09/04/13 showed the patient had been eased to the floor when unable to stand while transferring.

Record review of nurses' notes dated 09/06/13 showed the patient's knees buckled during a transfer for toileting and was lowered to the floor. While lowering the patient to the floor, she bumped her right shoulder on a walker and said it was "Killing me." Staff DDD, Registered Nurse (RN), administered a pain medication for pain rated a "10" on a scale of one to ten with ten being the worst pain.

9. During interviews on 09/10/13 at 9:30 AM and on 09/11/13 at 10:20 AM, Patient #1 stated the following:
-Staff DDD and Staff III, Rehab Technician, responded to a toileting request.
-Staff III told Staff DDD Patient #1 had not been using a walker.
-Staff DDD was cross with Patient #1 and insisted she transfer to the bathroom using a walker, even though she had not been using one prior.
-Staff DDD then insisted she pivot her right leg, even though she had just had surgery. The patient was very scared.
-Patient #1 told Staff DDD she had not been using a walker.
-Staff DDD was rough during the transfer.
-Patient #1 collapsed to the floor, with Staff DDD holding her under her left armpit.
-Patient #1 hit her right shoulder/collarbone on the walker, causing an injury (bruising) and pain.
-Patient #1 thought she had to do what the nurse (Staff DDD) told her to do and felt like her rights had been infringed upon.
-Patient #1 preferred Staff DDD not care for her again as she had regressed in her rehab progress since this incident.

Staff DDD failed to follow Staff III's knowledge of Patient #1's current transfer methods, and failed to abide by Patient #1's wishes and direction.

10. During an interview on 09/11/13 at 8:37 AM, Staff OO, Rehab Physician, stated that the patient's mobility had not been good and that she had a history of compression fractures (a collapse of the bones [vertebrae] in the spine), generalized weakness, and surgical pain. Staff OO confirmed the patient had not been using a walker prior this incident, and was still not using one.

11. During an interview on 09/11/13 at 9:20 AM, Staff Z, RN Rehab Manager, stated that she did not think Staff DDD realized how weak Patient #1 was, and that all staff had to show patience, and explain reasons for patient encouragement on the Rehab unit. Staff Z stated that all staff should be informed of the patient's current status via nurse-to-nurse report at shift change.

12. Review of Patient #2's H & P dated 08/23/13, showed the patient was admitted on that date with a diagnosis of post-operative spinal surgery to remove a tumor causing lower extremity weakness.

13. Review of a physician's order dated 08/25/13, showed the patient must have a back brace on before sitting up on the side of the bed.

14. During an interview on 09/10/13 at 10:04 AM, Patient #2 stated that Staff DDD rolled him back and forth, multiple times, causing pain, while trying to put his back brace on (did not remember exactly when). Patient #2 perceived this rolling as being rough, and as though Staff DDD did not know how to apply the brace. Patient #2 asked Staff DDD to stop trying because she was hurting him.

Staff DDD failed to get assistance, or instruction, in order to apply the brace in a more gentle, logical way.

15. During an interview on 09/10/13 at 1:33 PM, Staff C, Chief Nursing Executive (CNE) stated that she was unaware of either of these two incidents.

16. During an interview on 09/11/13 at 9:20 AM, Staff Z stated that Staff DDD had trouble putting the back brace on Patient #2 and she should have requested instruction on the application of the brace if she did not know how to apply it.

17. During an interview on 09/12/13 at 8:37 AM, Staff OO, stated that the back brace utilized on Patient #2 was called a Thoracic Lumbar Sacral Orthosis (TLSO). This brace was utilized to protect the patient's upper back post-operatively.

Based on observation, interview, record review and policy review the facility failed to ensure patient records, which contained protected patient information were secured in one (Post Anesthesia Care Unit), of four surgical service areas observed. This had the potential to affect all surgical patients. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Access to and Protection of Medical Records," effective on 09/04, showed all medical records will be maintained in a safe and secure manner, to protect the information from inappropriate release of information. Medical records must never be allowed to remain in an unprotected situation. Hospital Staff were permitted access to a record only if they have participated in the patient's care.

2. Observation on 09/11/13 at 3:30 PM showed approximately 800 copies of patient surgical records in the Post Anesthesia Care Unit (PACU), in the third drawer, from the top, of a four drawer lateral file cabinet.

The staff failed to have a key to lock the cabinet.

3. Record review of a randomly chosen surgical record showed staff collected the following patient information which was assessable to anyone who entered the PACU:
-Name;
-Date of birth;
-Gender;
-Medical record number;
-Account number;
-Admission date;
-Surgical procedure;
-Description of the surgical procedure and any medication given; and
-All staff involved in the surgical procedure.

4. During an interview on 09/11/13 at approximately 3:45 PM, Staff JJJ, Environmental Services Director, stated that housekeeping cleaned in the surgical department at 6:00 AM, (allowing access to the records) unsupervised.

5. During an interview on 09/11/13 at approximately 3:50 PM, Staff EEE, Director of Surgical Services, stated that the surgical staff came in at 7:00 AM.

During and interview on 09/12/13 at approximately 8:45 AM, Staff EEE stated that the records were copies and not needed due to changes in record retention process.

6. During an interview on 09/12/13 at approximately 1:30 PM, Staff PP, Director of Health Information, stated that she was unaware that copies of the surgical record were kept in the PACU.

Based on interview, record review, and policy review the facility failed to modify one current patient (#14) of one current patient's care plan reviewed, and one discharged patient (#24) of four discharged patients' care plans reviewed, to reflect the use of restraint and/or seclusion. This had the potential to affect all patients with episodes of restraint/seclusion. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Restraint and Seclusion," revised 08/13, showed that each episode of restraint/seclusion required documentation on the need for use of restraint and/or seclusion included in the plan of care.

2. During an interview on 09/12/13 at 10:26 AM, Staff C, the Chief Nursing Executive, stated that she expected nursing staff to update a patient's care plan with restraint episodes.

3. Record review of Patient #14's History and Physical (H & P) dated 09/02/13, showed she was admitted on 09/01/13 with a diagnosis of paranoid schizophrenia (a condition characterized by hearing voices and seeing things not really there).

4. Record review of a Restraint/Seclusion Order Sheet, dated 09/07/13, showed staff held (restrained) Patient #14 related to violent behavior.

5. Record review of a Restraint/Seclusion Debriefing Form, dated 09/07/13, showed Patient #14 was afraid of an injection, refused it and became angry. This anger lead to the restraint by staff.

6. Record review of the patient's plan of care showed no evidence of any restraint episode with an obtainable goal and individualized interventions to prevent future episodes.

7. Record review of discharged Patient #24's Pre-Admission Screening, dated 08/19/13, showed she was admitted on that date with a diagnosis of suicidal ideations (thoughts of harming oneself).

8. Record review of Restraint/Seclusion Documentation, dated 08/19/13, showed staff secluded the patient, and therapeutically held the patient from 2:50 PM through 5:30 PM related to violent behaviors.

9. Record review of Patient #24's medical record showed no evidence of any restraint episode with an obtainable goal and individualized interventions to prevent future episodes.

Based on record review, and policy review the facility failed to complete an assessment within one hour after a restraint or seclusion episode for violent behaviors for one current patient (#14) and two discharged patients (#24 and #25). This had the potential to affect all patients with episodes of restraint/seclusion. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Restraint and Seclusion," revised 08/13, showed that patients placed in restraint/seclusion shall be exhibiting imminent risk of harm to self and/or others, addressing violent/self-destructive behaviors. The patient must be evaluated within one hour of initiation of the restraint/seclusion. This evaluation must be documented in the medical record within the one-hour timeframe.

2. Record review of Patient #14's History and Physical (H & P) dated 09/02/13, showed she was admitted on 09/01/13 with a diagnosis of paranoid schizophrenia (a condition characterized by hearing voices and seeing things not really there).

3. Record review of a Restraint/Seclusion Order Sheet, dated 09/07/13, showed staff held (restrained) Patient #14 related to violent behavior.

4. Record review of a Restraint/Seclusion Assessment Form, undated, showed no documented evidence of the date/time the one-hour face-to-face assessment was completed (so the one-hour timeframe could not be verified.)

5. Record review of discharged Patient #24's Pre-Admission Screening, dated 08/19/13, showed she was admitted on that date with a diagnosis of suicidal ideations (thoughts of harming oneself).

6. Record review of a Restraint/Seclusion Assessment Form, dated 08/19/13, showed staff secluded and held the patient related to violent behaviors. Staff failed to document the time this one-hour face-to-face assessment was completed (so the one-hour timeframe could not be verified).

7. Record review of discharged Patient #25's Discharge Summary, dated 05/01/13, showed the patient had been admitted on 04/19/13 with a diagnosis of attention deficit disorder (problems related to attention).

8. Record review of Restraint/Seclusion Documentation, dated 04/26/13, showed staff secluded the patient related to being a danger to himself or others, and threatening behaviors.

9. Record review of Restraint/Seclusion Assessment Form, dated 04/26/13, showed staff failed to document the time the one-hour face-to-face assessment was completed (so the one-hour timeframe could not be verified.)

Based on record review, and policy review the facility failed to evaluate patients' medical conditions during the one-hour face-to-face assessment for one patient (#14) of one current patient reviewed, and two discharged patients (#24 and #25) of four discharged patients reviewed with restraint/seclusion episodes. This had the potential to affect all patients with episodes of restraint/seclusion. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Restraint and Seclusion," revised 08/13, showed that with each episode of restraint/seclusion the staff performing the one-hour face-to-face assessment should include an evaluation of laboratory (lab) and other diagnostic tests to identify potential medical conditions responsible for behavior, and review of vital signs.

The policy failed to address a physical assessment for possible injuries related to the restraint/seclusion episode.

2. Record review of current Patient #14's History and Physical (H & P) dated 09/02/13, showed she was admitted on 09/01/13 with a diagnosis of paranoid schizophrenia (a condition characterized by hearing voices and seeing things not really there).

3. Record review of a Restraint/Seclusion Assessment Form (the form used for the one-hour face-to-face), undated, showed staff restrained Patient #14 related to violent/combative behaviors. Staff failed to document a physical assessment of the patient (to see if the patient sustained injuries) after the restraint episode.

4. Record review of discharged Patient #24's Pre-Admission Screening, dated 08/19/13, showed she was admitted on that date with a diagnosis of suicidal ideations (thoughts of harming oneself).

5. Record review of a Restraint/Seclusion Assessment Form, dated 08/19/13, showed staff secluded and held the patient (intermittently) from 2:50 PM through 5:30 PM related to violent self-destructive behaviors. Staff failed to document an assessment of the patients lab values, and failed to document a physical assessment of the patient after the restraint episode.

6. Record review of discharged Patient #25's Discharge Summary, dated 05/01/13, showed the patient had been admitted on 04/19/13 with a diagnosis of attention deficit disorder (problems keeping attention to a specific thing.)

7. Record review of Restraint/Seclusion Documentation, dated 04/26/13, showed staff secluded the patient related to being a danger to himself or others, and threatening behaviors.

8. Record review of a Restraint/Seclusion Assessment Form, dated 04/22/13, showed the patient was secluded and held related to combative behaviors, three separate times; at 7:50 PM, 9:50 PM, and at 11:25 PM. Staff failed to document an assessment of the patient's vital signs, and failed to document a physical assessment of the patient after each restraint episode. The patient was also secluded on 04/26/13 at approximately 7:00 PM, and staff failed to document an assessment of the patient's lab values, and failed to document a physical assessment of the patient after the restraint episode.

Based on interview, and policy review the facility failed to update their existing policy to reflect nondiscriminatory language and explain any restrictions for visiting. This had the potential to affect all patients and their visitors. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Entrance Security and Visiting Hours Policy," reviewed 01/13, showed the following:
-General visiting hours: No visitors under the age of ten except siblings, a patient's own children, and grandchildren.
-Department Specific visiting hours: Patients were limited from one to three visitors based on location of patient in hospital.
-On the obstetrical unit: No visitors under the age of 13, except siblings, of a newborn.

The policy failed to explain the "clinically necessary" rationale for the above limitations on visiting, and/or include nondiscriminatory language in their policy.

2. During an interview on 09/12/13 at 10:26 AM, Staff C, Chief Nursing Executive, stated that she was aware of the requirement to include rationale for visitor limitations in the facility policy and would search for another, more updated policy. Staff C failed to provide a more updated policy.

Based on interview, record review, and policy review the facility failed to incorporate eight of 34 facility services into the hospital-wide Quality Assessment Performance Improvement (QAPI). This had the potential to affect all patients receiving care in the facility. The facility census was 37.

Findings included:

1. Record review of the facility policy titled, "Performance Improvement Plan," reviewed date 12/12, showed that there was a planned, continuous ongoing systematic process to monitor and evaluate the quality of the services provided and everyone in the facility was encouraged to participate in processes and activities that make the environment of care safe and effective.

2. Record review of the facility document titled, "Performance Improvement (PI) and Patient Safety Plan 2013," showed that the leadership encourages the identification of improvement opportunities from all sources throughout the organization. Indicators must be measurable and the data collection analyzed for patterns or trends that vary from the expected outcome.

3. During an interview on 09/11/13 at 4:26 PM, Staff ZZ, Director of Quality stated that the facility failed to incorporate the following services into the hospital-wide QAPI:
-EKG (electrocardiogram, a test that measures and records the electrical activity of the heart) reading;
-Medical waste disposal;
-EEG (electroencephalogram, test that measures and records the electrical activity of the brain) reading;
-Paper shredding Service;
-Dietary services;
-Transportation;
-Medicaid Eligibility; and
-Medicaid consulting.

4. During an interview on 09/10/13 at 10:55 AM, Staff D, Director of Dietary, stated that she could not provide evidence of QAPI data. She stated, "We keep logs for food temperatures and things but we do not have formal written data".

Based on interview, record review, and policy review the facility failed to establish and implement performance improvement projects and incorporate them into the hospital-wide Quality Assessment Performance Improvement (QAPI) Program. This had the potential to affect all patients receiving care in the facility. The facility census was 37.

Findings included:

1. Record review of the facility policy titled, "Performance Improvement Plan," reviewed on 12/12, showed the facility's objective was to utilize a planned, continuous, ongoing, systematic process to monitor and evaluate the quality of the services provided and when problems or opportunities to improve were identified, action was taken and the effectiveness of that action was evaluated.

2. Record review of the facility document titled, "Performance Improvement (PI) and Patient Safety Plan 2013," showed that the facility would select a problem or process, implement a solution for the process change, review and evaluate the results of the change, and reflect and operate on the information learned. The facility would select a high-risk process to be analyzed utilizing Failure Mode and Effects Analysis (FMEA), at least annually.

3. During an interview on 09/11/13 at 9:11 AM, Staff ZZ, Director of Quality, stated that the facility had no performance improvement projects to incorporate into the hospital-wide QAPI.

Based on interview, record review, and policy review the facility staff failed to follow the facility policy for the patient's plan of care for three patients (#6, #11 and #22) of eleven patient care plans reviewed. This had the potential to affect all patients in the facility. The facility census was 37.

Findings included:

1. Record review of the facility policy titled, "Interdisciplinary Plan of Care," revised 06/12, showed that the plan of care, treatment and services shall be individualized to the patient and based on the patient's diagnosis and assessment. The plan for care, treatment and services includes Supportive care that provides treatment of symptoms using accepted professional standards.

2. Record review of Patient #11's History and Physical (H&P) dated 09/08/13, showed his admission diagnoses included diabetic ketoacidosis (a condition in which the patient's blood sugar is very high and the patient's blood becomes to acidic) and diabetes mellitus (the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body), requiring insulin.

3. Record review of Patient #11's Interdisciplinary Plan of Care for Hospitalization and Discharge showed no plan of care for medical management of the patient's diabetic ketoacidosis or diabetes mellitus.
4. During an interview on 09/10/13 at 3:35 PM, Staff BB, Registered Nurse (RN) stated that blood sugar management was not documented in the care plan and it was not a routine of the department to address blood sugar management in the plan of care.

5. During an interview on 09/10/13 at 3:40 PM, Staff EE, Quality Manager, stated staff failed to document a plan of care for the medical management of diabetic ketoacidosis and diabetes mellitus. Staff EE's expectation was that the staff documented the plan of care for these diagnoses.

6. Record review of Patient #22's H&P dated 09/08/13, showed her admitting diagnoses included acute, chronic systolic heart failure (defect in the expulsion of blood) and a recent myocardial infarction (blood flow to a part of the heart is blocked and the heart muscle is damaged or dies.)

7. Record review of Patient#22's Interdisciplinary Plan of Care for Hospitalization and Discharge showed no plan of care for medical management of heart failure or a recent myocardial infarction.

8. During an interview on 09/11/13 at 12:40 PM, Staff EE stated that the facility staff failed to document a plan of care for the medical management of heart failure and a recent myocardial infarction. Staff EE's expectation was that the staff documented the plan of care for these diagnoses.

9. Record review of Patient #6's H&P dated 09/09/13, showed the patient had a diagnosis of Bronchiolitis (swelling and mucus build up in the smallest air passages of the lungs.) The patient was placed on droplet Isolation Precautions (measures, such as masks and private rooms, taken to prevent others from being exposed to large droplets which could infect them.)

10. Record review of Patient #6's Interdisciplinary Plan of Care for Hospitalization and Discharge showed no plan of care for Isolation Precautions.

11. During an interview on 09/11/13 at 1:30 PM, Staff C, Chief Nursing Officer, reviewed the plan of care for Patient #6 and stated that she would expect to see Contact Isolation on the care plan and it was not on the care plan.















27727

Based on interview and record review the facility failed to ensure physicians signed, dated and/or timed their orders per the facility policy for five patients (#2, #14, #15,#54 and #55) of eight current patients reviewed and nine patients (#16, #17, #18, #24, #31, #32, #38, #39, and #40) of 21 discharged records reviewed. This had the potential to affect all patients' records. The facility census was 37

Findings included:

1. Record review of the facility's policy titled, "Verbal/Telephone Orders," dated 03/13 showed verbal or telephone orders shall include date, time of entry, and signature authentication by prescribing practitioner within 48 hours.

2. Record review of Nursing Leadership meeting minutes dated 05/14/13, showed physicians had 24-hours to sign orders.

3. Record review of current Patient #2's medical record on 09/10/13 at 10:04 AM, showed the following:
-A telephone order to initiate a probiotic (a medication used to stabilize the stomach and intestinal tract) on 08/23/13 at 4:00 PM.
-A Medication List Reconciliation and Order Form dated 08/23/13, listed nine different medications ordered for the patient on admission.
-A telephone order for Milk of Magnesia on 08/24/13 at 6:45 AM.

The above orders were not authenticated by the physician 29-30 days after the orders were written.

4. During an interview on 09/10/13 at 10:20 AM, Staff I, Registered Nurse, confirmed the physician had not signed the orders.

5. Record review of current Patient #14's medical record on 09/11/13 at approximately 1:30 PM, showed telephone orders for inpatient admission to the geriatric psychiatric unit dated 09/01/13 and a telephone order to start an antibiotic dated 09/03/13.

Neither of the above orders had been authenticated by the physician by the due dates of 09/03/13 and 09/06/13; five to eight days late per policy.

6. Record review of current Patient #15's medical record on 09/11/13, showed a physician's telephone order for suicide precautions received on 09/05/13 at 4:50 AM, that failed to show a physician's signature of authentication. In addition, the admission medication orders received by telephone on 09/05/13 at 12:45 AM were signed by a physician on 09/09/13 at 4:30 PM, exceeding the 48 hour timeframe limit, per policy.

7. Record review of current Patient #54's medical record showed eleven telephone orders dated 09/08/13 that were not dated and timed by the physician.

Record review also showed one telephone order dated 09/08/13, which was not timed by the physician.

8. Record review of current Patient #55's medical record showed three telephone orders dated 09/09/13, which were not dated and timed by the physician.

The record review also showed two written orders dated 09/08/13 and two written orders on 09/09/13, which were not timed by the physician.

9. Record review of discharged Patient #24's medical record on 09/11/13 at approximately 1:40 PM, showed a verbal order for seclusion, dated 08/19/13. The order had not been authenticated by the physician as of the date/time reviewed.

10. Record review of discharged Patient #38's medical record on 09/11/13 at 9:20 AM, showed a telephone order to initiate the Alcohol Detoxification Protocol on 07/09/13. The order was not authenticated by the physician until 07/13/13.

11. Record review of discharged Patient #39's medical record on 09/11/13 at 9:40 AM, showed the following:
-Four physician orders signed and dated but no time of signature by the physician.
-One physician order signed but no date or time entered by the physician.
-One telephone physician order signed but with no date or time entered by the physician.

12. Record review of discharged Patient #40's medical record on 09/11/13 at 10:15 AM, showed one telephone order dated 07/09/13. Physician authentication was dated 07/29/13.

13. During an interview on 09/11/13 at 10:25 AM, Staff PP, Director of Medical Records, stated that she reviewed the discharged medical records for Patient's #38 and #39 and agreed with findings of absence of date, time or a combination of both. She also verified that the authentication of an order being completed 20 days past the original order date for Patient
#40.

14. Record review of discharged Patient #16's medical record on 09/11/13, showed a physician's telephone order for therapeutic hold (physical restraint) dated 08/27/13 at 11:20 PM, that failed to show a physician's signature of authentication. In addition, there were three telephone orders for medications dated 08/27/13 (10:40 PM, 11:20 PM and 12:08 AM), that failed to show the dates and times of the physician's signature authentication.
15. Record review of discharged Patient #17's medical record on 09/11/13, showed a physician's telephone order for medication dated 09/08/13 at 2:47 PM that failed to show a physician's signature of authentication.
16. Record review of discharged Patient #18's medical record on 09/11/13, showed that the physician's admission orders were received at 09/04/13 at 4:28 PM, and failed to show a physician's signature of authentication.
17. Record review of discharged Patient #31's medical record on 09/12/13 showed a telephone order for type, cross, and transfuse two units of blood on 04/25/13. Another order for this patient was for Heparin (medication to prevent blood clotting) 5000 units subcutaneous (just under the skin) every 8 hours. The orders had not been authenticated by the physician at the time of review.

18. Record review of discharged Patient #32's medical record on 09/12/13 showed an admission order dated 08/19/13 for no home meds (medication) and FeSO4 (ferrous sulphate and iron supplement) 325 mg PO bid (by mouth twice a day.) The order had not been authenticated by the physician at the time of review.




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Based on observation and interviews the facility staff failed to follow their policy when unauthorized persons entered medication rooms without supervision. This potentially could allow theft or diversion of drugs. The facility census was 37.
Findings included
1. Record review of the facility policy titled, "Pharmacy Access Medication Removal", revised 05/09/11, showed direction to the staff that only approved Registered Nurses were allowed to enter the Pharmacy and medication rooms without supervision.
2. Observation on 09/12/13 at 9:40 AM, showed Staff KKK, Housekeeper, entered the medication (med) room of the nursing unit by accessing the key pad. She entered the medication room room to clean the room. There was no nursing staff supervising.
3. During an interview on 09/12/13 at 9:40 AM, Staff KKK stated that she was given the code and has always gone into the med room unsupervised.
Per the facility policy housekeeping was not approved to enter without supervision of approved staff and should not have had the code to enter the medication room.
4. During an interview on 09/12/13 at 9:44 AM, Staff JJJ, Environmental Services Director, stated that the housekeepers cleaned in the med rooms (such as Infusion Therapy) after the nursing staff had gone for the day.
5. During an interview on 09/12/13 at 9:49 AM, Staff MM, Director of Pharmacy, stated that he did not know that housekeeping had the code for the med rooms and did not know they cleaned the med rooms without supervision.

Based on interviews and record reviews, the facility failed to ensure the Director of Dietary was qualified by experience or training as required by the Missouri State Hospital Regulations and the contracted services job description. This had the potential to affect all patients in the facility. The facility census was 37.

Findings included:

1. Record review of the Missouri State Hospital Regulations at 19 CSR 30-20.090(1) showed that the Director of Dietary Services is qualified by education, training and experience in food service management and nutrition through an approved course for certification by the Dietary Managers Association or registration by the Commission on Dietetic Registration of the American Dietetic Association, or an associate degree in dietetics or food systems management.

2. Record review of the personnel file for Staff D contracted services job description titled, "Director of Food and Nutrition Services" dated 05/23/06, showed the following:
QUALIFICATIONS:
- Education: B.S. [bachelor's] Degree in Food Services Technology/Management or related field; or A.S. [associates] Degree plus five years of directly related experience.
EXPERIENCE:
- Minimum of five to seven years of hospital or nursing home experience, depending upon formal degree and training.
Licensure/Certification: Serv Safe certification. Certified Dietary Manager and/or Licensed/Registered Dietitian or five years or greater Food and Nutrition Services management.
- Further review showed that she did not possess an associate or bachelor's degree and did not have evidence of certification or registration in food service management.

3. During an interview on 09/10/13 at 9:10 AM, Staff D, Director of Dietary Services, stated that she had been through the training but hadn't taken the test to become certified or registered.

Based on interview and record review, the facility failed to have a dietary manual approved by the dietitian and medical staff and failed to have the manual readily available to medical, nursing, and food service personnel. This had the potential to affect all patients in the facility. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Review and Approval of Diet Manual revised 09/13 showed:
APPROVAL
- Obtain necessary signatures on the diet manual approval form and place in front of the diet manual;
DISTRIBUTION
- Manual must be accessible to each patient care unit;
- Maintain a copy of the distribution form on file.

2. Record review of the Approval Form of the Dietary Manual titled, "The Morrison Manual of Clinical Nutrition Management" dated 07/01/13, showed one signature of Staff C, Chief Nursing Officer (CNO), as Medical Staff Member. Staff C, Registered Nurse (RN), CNO, is not a member of the Medical Staff; therefore no Medical Staff member signed the dietary manual approval form. The Registered Dietitian Consultant, Staff LLL, had not signed the Approval Form.

3. Record review of the facility's document titled, "Medical Executive Committee" dated 08/28/13, showed the following:
- Approval of diet Manual;
- Our dietitian, Staff D, has voiced her full support of the use of this manual.
- Motion was made, seconded and passed unanimously, to approve the use of the internet-based diet manuals as recommended.
- Staff C, to oversee education and implementation.

4. During a concurrent interview on 09/10/13 at 10:45 AM, Staff D, Director of Dietary, and Staff II, Regional Director, Operations of the contracted Dietary Service, stated that the only copy of the dietary manual was stored inside the Director's office in the Dietary Department. They stated that there were no other copies of the dietary manual in other facility departments and it was not available electronically to facility personnel.

5. Even though all of the above statements appeared in the Medical Executive Committee Meeting minutes, Staff D was not a dietitian as portrayed by Staff C to the Committee. The motion to accept the dietary manual was approved as an internet-based tool; however the manual was never approved by the Registered Dietitian Consultant and was never internet-based as described in the meeting.

Based on observation and interview the facility failed to maintain all areas in a clean and orderly manner. This deficient practice has the potential to affect all patients and staff. The facility census was 37.

Findings included:

1. Observation and concurrent interview during a tour of the facility, conducted on the afternoon of 09/10/13, showed the following:
- At 1:20 PM, a gouged out area, approximately two inches wide by eight inches in length, in a wall of the Soiled Linen room on the fourth floor Geriatric Unit.
- At 1:25 PM, a four foot by two foot ceiling tile to be buckled downward and not secured in the ceiling mounted grids in patient room 407.
- At 1:38 PM, the plastic corner guards on the door frames to patient rooms number five and number six on the third floor Intensive Care Unit (ICU) were loose, cracked and splintering, which exposed sharp edges.
- At 1:42 PM, the paint on the door frame and window frame at the nurses station was chipped and flaking away on the third floor Adult Behavioral Unit.
- At 2:35 PM, a plastic corner guard on the door frame to Operating Room #2 was loose, cracked and splintered, which exposed sharp edges.
- At 2:55 PM, approximately thirteen one foot square floor tiles either partially or completely missing around the freezer, approximately thirty floor tiles either partially or completely missing around the serving tray line and approximately thirteen floor tiles either partially or completely missing around the stove and deep fryer in the kitchen.
- At 2:59 PM, the wall covering in the kitchen dry storage room to be chipped and peeling away in three locations.

2. At the time of each observation, Staff HH, Plant Operations, confirmed the need for repair.

Based on observation, interview, record review and policy review the facility failed to:
-Follow their policy for hand hygiene (wash hands with hand sanitizer or with soap and water) for three patients (#11, #12 and #22) of three patients observed and follow their policy for glove use for three patients (#4,#42 and #45) of three patients observed .
-Ensure hand hygiene was performed by pharmacy and dietary staff for four staff (O, MMM, NNN and D) of four staff observed, after coughing into hands or preparing patient food.
-Accurately measure cleaning solutions in three of four surgical service areas observed. They were the Gastrointestinal (GI) lab, Post Anesthesia Care Unit (PACU), and Central Sterile (unit where instruments were sterilized) observed. This had the potential to affect all patients receiving care in the facility. The facility census was 37.

Findings included:

1. Record review of the policy titled, "Hand Hygiene - Healthcare Worker (HCW)." Revised on 02/12, showed the following:
-When hands are visibly dirty or contaminated, wash hands with soap and water.
-When hands are not visibly soiled, staff may use alcohol based hand rub to decontaminate hands.
-Staff must use the appropriate hand washing to decontaminate hands in the following clinical situations:
a. Before having direct contact with patients;
b. Before donning sterile gloves when inserting a central intravascular catheter;
c. Before inserting indwelling urinary catheters (a tube placed in the bladder to drain urine), peripheral vascular catheters (a small flexible tube placed in a peripheral vein, such as in the legs, arms or feet), or other invasive devices that do not require a surgical procedure;
d. After contact with a patient's intact skin (examples are taking a pulse, blood pressure, or lifting a patient)
e. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings;
f. If moving from a contaminate-body site to a clean-body site during patient care;
g. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient;
h. After removing gloves.

2. Observation on 09/10/13 at 10:05 AM showed Staff U, Respiratory Therapist (RT), entered Patient #12's room in the Emergency Department to administer a nebulizer treatment (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs). Staff U put on gloves and removed her stethoscope (a medical device used to listen to the internal sounds of the human body) from around her neck and listened to the patient's lungs. She then prepared the medications and administered the nebulizer treatment to the patient. Wearing the same gloves, Staff U reached into her right pants pocket and answered her phone. After she replaced the phone to her pocket, she continued to assist the patient with her nebulizer treatment and made notes onto a paper flow sheet. After the nebulizer treatment was completed, Staff U removed her stethoscope from around her neck and listened to the patient's lungs.
3. During an interview on 09/10/13 at 10:25 AM, Staff U, RT, stated that she did not realize that she should have removed her gloves and performed hand hygiene. She stated she didn't think it was necessary when working with the same patient.
4. Observations on 09/10/13 at 9:50 AM, 10:10 AM and 10:35 AM showed Staff FFF, Social Worker, enter Patient #11's room, touched the patient's bedrails, and exchanged paperwork with the patient, but did not perform hand hygiene prior to leaving the patient's room.

5. During an interview on 09/10/13 at 11:22 AM, Staff FFF stated that she was aware she failed to perform hand hygiene when she entered Patient #11's room. Staff FFF stated that the facility policy was to perform hand hygiene prior to leaving each patient's room.

6. Observation on 09/10/13 at 1:45 PM showed Staff X, Registered Nurse (RN), entered Patient #22's room to discontinue the needle access to the patient's port (a small medical appliance that is installed beneath the skin that connects into a vein, most commonly used to instill chemotherapy to cancer patients). Staff X put on gloves and placed supplies on top of the patient's bed linens, including Staff X's phone. During the removal of the needle access, Staff X answered her phone then placed it back on top of the patient's bed linens and completed the removal of the needle from the patient's port. While still wearing the same gloves, Staff X gathered up used supply packages and her phone from the patient's bed and placed the phone into her pocket and discarded the used packages into the trash then removed her gloves.
7. During an interview on 09/10/13 at 1:56 PM, Staff X, RN, stated that she was supposed to clean her phone after leaving a patient's room. She stated "when it is on the bedside table or the sink it is in contact with potential germs". When asked if the patient's bed had potential germs she stated that yes it would have and that she should have cleaned her phone and probably shouldn't have laid it on the patient's bed in the first place.

8. Record review of the facility policy titled" Infection Control Policy and Procedure Manual: Subject Isolation - Standard and Transmission Based Precautions" dated 03/04, directed staff that gloves should be worn when touching blood, body fluids, secretions, excretions and contaminated items.

9. Observation on 09/10/13 at 9:47 AM showed Staff H, Registered Nurse (RN), entered the room of Patient #4 to remove an indwelling urinary catheter. After emptying the catheter bag and removing the catheter, she removed her gloves. She did not perform hand hygiene. She handed the patient a wet wash cloth and instructed him to cleanse his penis. He did so and handed the wash cloth back to her which she accepted with her ungloved hands.
10. During an interview on 09/10/13 at 9:52 AM, Staff HH stated that she was caught unaware and took the contaminated wash cloth before she could think. She stated that she should have said something like "Wait a minute and I will put some gloves on".
11. Observation on 09/11/13 at 9:02 AM in the Outpatient Department showed Staff BBB, RN, entered the room of Patient #42 to remove an IV (intravenous) catheter from the patient's right hand. Staff BBB applied a bandage to the site after removing the dressing and the IV. She then removed her gloves and performed no hand hygiene. She disposed of the dirty IV catheter and moved the bedside tray. The site was bleeding and she applied pressure to the bandaged site wearing no protective gloves. This had the potential to contaminate the site.
12. During an interview on 09/11/13 at 9:15 AM, Staff BBB, stated that she did not put gloves on to put pressure on the patient's bleeding IV site but should have.
13. Observation on 09/12/13 at 8:24 AM Staff WW, RN, drew blood from a vein of Patient #45. She then removed her gloves and carried the vials of blood to the nursing desk to place them in a plastic bag. This potentially left her exposed to blood if one of the vials broke.
14. During an interview on 09/11/13 at 9:45 AM, Staff WW, stated that she had not ever had a vial break but now saw the potential and would wear gloves for protection.
15. Observation on 09/10/13 at 10:28 AM, showed Staff O, Pharmacy Technician (Tech), cough into hands while closing the drawer of the medication cart in the adult psychiatric unit. She failed to perform hand hygiene after the episode and touched inanimate objects while leaving the nurse's station.

16. During an interview on 09/10/13 at 10:30 AM, Staff O, stated that she did not know why she didn't perform hand hygiene and that she should have used hand gel after she coughed into her hands.

17. Record review of the contracted Dietary Services policy titled, "SANITATION AND INFECTION CONTROL" revised 11/09, showed the following:
- All employees associated with the handling of food shall wash hands.
- Hands are washed with soap and water at the following times: Before putting on gloves; After touching hair, skin, beard or clothing; After removing gloves; Before handling food or clean utensils/dishes/equipment.
- Disposable gloves must be changed when dirty or ripped and when moving from one task to another.

18. Observation on 09/10/13 at 11:30 AM showed Staff MMM cooking grilled cheese sandwiches on the stove. She put on gloves and was turning the sandwiches in the pan with her gloved hands. She touched all six knobs on the stove front to regulate the heat of the pan then reached in the pan and turned the sandwiches to the other side with the same gloved hand. She changed gloves but did not perform hand hygiene.

19. Observation on 09/10/13 at 11:37 AM to 12:30 PM showed Staff NNN at the head of the patient tray service line. She put on gloves but did not perform hand hygiene. She put a food thermometer in the soup and wiped it off with her gloved hand and put it in the cooked chicken. She made a hamburger and reached in the hamburger bun package with the same gloves that touched every plate, patient tray and counter. Staff NNN needed some cheese and left the food service line and went into the cooler, touched the outside handle, entered the freezer, left the freezer and shut the door, returned to the food service line with a package of cheese slices, opened the package and removed a piece of cheese. All of these tasks were completed with the same gloves. She put the slice of cheese on the hamburger patty, reached into the package of hamburger buns, and put the hamburger on the patient plate.

Observation on 09/10/13 at 12:30 PM showed Staff NNN touched chicken strips with her gloved hands - the same gloves she has been wearing since she started the service line at 11:30 AM. She took her gloved left little finger and put it in her left ear in a circular motion then continued with the food service line with the same gloved hands.

20. Observation on 09/10/13 at 12:20 PM showed Staff D, Director of Dietary, put on gloves without performing hand hygiene. She picked up the package of cheese and put it back into the cooler, touched the cooler handle, removed the gloves but did not perform hand hygiene.

21. During an interview on 09/10/13 at 3:15 PM, Staff F, Infection Control Officer, stated that she had never been in the Dietary Department and had not assessed opportunities for improvement.

22. During an interview on 09/12/13 at 8:50 AM, Staff II, Contracted Food Service Regional Manager, stated that he observed the food service line on 09/11/13 and observed the same infection control concerns regarding hand hygiene and glove use with Staff NNN.

23. Record review of the facility policy titled, "Cleaning and processing of Instruments," revised on 02/13, showed that all instruments to be used for patient care and procedures must be appropriately processed to ensure they are free from infectious bacteria.

24. Record review of the facility policy titled, "Cleaning/Disinfection/Sterilization of Endoscopes" (an instrument that can be introduced into the body to give a view of its internal parts),
revised on 08/13, showed that high level disinfectant, when used according to manufacturer's instructions, destroys all microorganisms.

25. Record review of the facility policy titled, "Cleaning the Autoclaves,"(a device that uses steam to sterilize equipment) revised on 08/01/12, showed facility staff direction to make up a small pan of water with a mixture of the cleaning agent per manufacturer recommendations.

26. During an interview on 09/12/13 at 9:35 AM, Staff AAA, Surgical Tech, stated that she added three to five squirts of cleaning agent to enough water to cover the endoscopes.

27. Record review of the manufacturer's guidelines showed instructions to mix one half ounce of cleaning agent with one gallon of water to clean the endoscopes in the GI lab.

28. Observation at 09/12/13 at 9:35 AM of the bucket used for endoscope cleaning showed no measurement lines.

29. During an interview on 09/12/13 at 9:55 AM, Staff AAA, stated that the same cleaning agent product was used to wash the operating room instruments as used for endoscopes. Staff AAA stated that to clean the instruments she used one to two squirts of cleaning agent to a basin of water. Staff AAA stated that she failed to measure the cleaning agent and the amount of water.

30. During an interview on 09/12/13 at 10:05 AM, Staff BBB, Sterile Tech, stated that she cleaned the autoclave and mixed a scoop of cleaning agent with a basin of water and failed to measure the cleaning agent or the water.

31. Record review of the manufacturer's guidelines showed to mix one half ounce of cleaning agent to a gallon of water to clean the autoclave.

32. During an interview on 09/12/13 at approximately 10:20 AM, Staff EEE, Director of Surgical Services, stated that the facility failed to obtain appropriate measuring tools.



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Based on interview and policy review, the facility failed to develop surgical service policies that assured the achievement and maintenance of high standards of medical practice and patient care. This had the potential to affect all patients requiring surgical services. The facility census was 37.
Findings included:
1. Record review of facility's surgical services policies failed to show policies related to the identification of infected and non-infected cases; duties of circulating nurse and scrub personnel; and outpatient surgery post-operative care planning and coordination, and provisions for follow-up care.
2. During an interview on 09/12/13 at 1:00 PM, Staff ZZ, Director of Quality, stated that there were no policies for identification of infected and non-infected cases, duties of the circulating nurse and scrub personnel, and outpatient surgery post-operative planning and coordination, and provisions for follow-up.