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Based on observation, employee interview, review of medical records, and review of policy and procedures, the facility failed to ensure that an organized nursing service provides 24-hour services furnished by or supervised by a registered nurse.


Findings include:


Cross Refer to A386 for the facility's failure to ensure that the hospital had a well organized service with a plan of an administrative authority and delineation of responsibilities for patient care.


Cross Refer to A392 for the facility's failure to ensure that there are supervisory staff and personnel for each department or nursing unit to ensure, when needed, the immediate availability of Registered Nurse for bedside care of any patient.


Cross Refer to A396 for the facility's failure to ensure that the nursing staff developes and keeps current a nursing care plan for each patient.


Cross Refer to A409 for the facility's failure to ensure that Nursing staff administers blood transfusions in accordance with approved medical staff policies and procedures.

Based on employee interview, policy review, observation, infection control manual review and documentation review, the facility failed to ensure a sanitary environment to avoid sources and transmissions of infections and communicable diseases.


Findings include:


Cross Refer to A748 for the facility's failure to ensure that a person or persons was designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases.


Cross Refer to A749 for the facility's failure to ensure that a system was developed for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel


Cross Refer to A756 for the facility's failure to ensure that the Quality Assessment and Performance Improvement program addressed problem identified by infection control officer(s) and are responsible for successful corrective action plans.

Based on observation, employee interview, documentation review and policy review, the facility failed to ensure that the hospital meets the emergency needs of patients in accordance with acceptable standards of practice.


Findings include:


Cross Refer to A-1112 for the facility's failure to ensure that adequate medical and nursing personnel qualified in emergency care are available.

Based on record review, policy review and observation, the facility failed to ensure that each patient or representative was informed of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible for 13 of 22 patients' records reviewed, Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, and #14.


Findings include:


Review of the facility's "Admission Policy" policy and procedures revealed, "#2002 - Policy: Bullet #8 - The assigned nurse shall determine and record status of advance directive."


Record review for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, and #14 revealed no documented evidence that the patient or patient's representative was informed of the patient's rights prior to treatment or documentation of advance directives upon admit.

During a tour of the hospital on 12/04/13 at 2:50 p.m. there was no evidence that the facility had posted Patient Rights.

Based on documentation review and staff interview, the facility failed to ensure a quality project(s) is being conducted, failed to document the reasons why and provide measurable progress on the project(s).


Findings include:


On 11/05/13 the Quality Manager/Medical Records Director was asked what quality or performance improvement project(s) were being conducted by the facility. She stated, "The departments have their own."


Review of the facility's monthly departmental quality improvement reports revealed no documented evidence of a facility quality project(s) being conducted, the reason why or any measurable progress.

Review of the Quality Assurance/Performance Improvement Plan revealed no documented evidence of a facility quality project(s) outline in the plan.

Based on documentation review and staff interview, the facility failed to ensure the hospital quality improvement program had adequate staff to prepare quality committee minutes on a monthly basis.


Findings include:


On 11/05/13 the Quality Manager/Medical Records Director was asked how often their quality committee meets. She stated, "Monthly. I have not been able to get to the minutes since February 2013." When asked if the governing body had been made aware of this, she stated, "Oh, they get their reports, but I have not typed the minutes."


Review of the Quality Assurance/Performance Improvement (QAPI) Plan meeting minutes revealed the latest documented minutes were dated 02/27/13. No further documentation was submitted for review.


Review of the facility's Quality Assurance/Performance Improvement Plan (QAPI) revealed, "QA/PI: ...Reporting on ongoing findings, studies, recommendations, and trends to the Governing Body ...monthly ...".

Based on staff interview, the facility failed to ensure that the hospital had a well organized service with a plan of an administrative authority and delineation of responsibilities for patient care.


Findings include:


Interview with Director of Nursing (DON) on 11/05/13 at 11:00 a.m. revealed that there were no policies for staffing for the hospital's emergency department (ER), acute/swingbed unit, or ambulance service. The DON stated, "There are usually two (2) Registered Nurses (RNs) and two (2)Licensed Practical Nurses (LPNs) staffed for acute/swingbed. If there is an ambulance call, one of the LPNs, who are also Emergency Medical Technicians (EMTs), will go on the call. One (1) of the RNs will staff the ER. The DON and Assistant DON are available for backup staffing." When staffing documentation and pulls to the ER and ambulance were requested the DON stated, "We do not document it." When the assignment sheet for the hospital's ambulatory/swingbed unit was requested, the DON stated, "We do team nursing, we do not make an assignment sheet."

Based on record review, policy and procedure review and employee interview, the facility failed to ensure that there are supervisory staff and personnel for each department or nursing unit to ensure, when needed, the immediate availability of a Registered Nurse (RN) for bedside care of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14.


Findings include:


Review of the facility's "Initial Patient Assessment and Reassessment" policy revealed, "Policy ...The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay ...".


Record review for Patient #11 revealed an order dated 11/01/13 at 8:30 a.m. to check residual and call physician if it is greater than 150cc (cubic centimeter). There was no documented evidence that the residual had been checked. Interview with Employees #6 and #7 revealed that it should be documented in the narrative nursing notes. Employee #7 could not locate any documented evidence in the patient's record that the residual was checked.


Review of the facility's "Pain Assessment, Reassessment and Management" policy revealed, "Procedure - It is the responsibility of all clinical staff to assess and periodically reassess the patients for pain and response to treatment. At time of admission to the facility, the patient will be questioned regarding pain during the initial nursing assessment."


Review of medical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 revealed no documented evidence of a pain assessment or reassessment regarding location or quality of pain.


Interview with the Director of Nursing (DON) on 11/05/13 at 11:00 a.m. revealed that no staff was assigned to the Emergency Department on a daily/shift basis.

Based on record review, employee interview and policy review, the facility failed to ensure that their nursing staff developes and keeps current a nursing care plan for each patient. Four (4) of four (4) in-patient records were effected, Patient #11, #12, #13 and #14.


Findings include:


Record review for Patients #11, #12, #13 and #14 revealed no documented evidence of a nursing care plan in their medical record.


Interview with Employee #4 on 11/4/13 at 1:35 p.m. revealed that care plans were not maintained or kept current for each patient. She stated, "We do not have a care plan. We document in the discharge plan."


Interview with the Director of Nursing (DON) on 11/05/13 at 11:00 a.m. revealed, "We do team nursing, we do not make an assignment sheet."


Review of the facility's "Care Planning" policy revealed, "Procedure - "Within eight (8) hours of admission all patients shall have a care plan generated by the registered nurse or the licensed practical/vocational nurse under the direct supervision of the registered nurse."

Based on record review, observation, and policy and procedure review, the facility failed to ensure that nursing staff administer blood transfusions in accordance with approved medical staff policies and procedures and failed to ensure that Patient #11 and #19 (or Responsible Party) signed an informed consent prior to blood administration.


Findings include:


Record review for Patient #11 revealed that there was no signed informed consent on the patient's medical record prior to the administration of blood products.


Record review for Patient #19 revealed a consent for administration of blood products on the record which had not been signed by the patient or responsible party prior to the administration of blood.


Review of the facility's "Blood/Blood Component- Informed Consent" policy revealed, "Policy - It is the Policy of (hospital name) to verify, by means of the Blood/Blood Component Transfusion Consent Form, that the patient's informed consent has been obtained by the treating physician, before the patient receives a transfusion of whole blood and/or fresh frozen plasma, packed cells, platelets or cryopresipitates."


Observation of Employee #5 administering a second unit of blood to Patient #11 on 11/04/13 at 1:35 p.m. revealed that she failed to check the patient's identification prior to the administration of the blood. Interview with Employee #5 on 11/04/2013 at 2:05 p.m. revealed, "Oh, this is her second unit. I checked it with the first unit."


Review of the facility's "Patient Identification for Clinical Care and Treatment" policy revealed, "Policy - It is the policy of (Hospital) to ensure that all patients are properly identified in all areas of the hospital prior to any care, treatment or services provided."

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all entries in the medical record are complete, contain a documented date, time and signature for eight (8) of eight (8) patient's medical records reviewed; Patient #16, #17, #18, #19, #20, #21, #22 and #23.


Findings include:


Record review for Patient #16, #17, #18, #19, #20, #21, #22 and #23 revealed pages in their medical records which did not contain a patient label to identify which patient the pages belonged to.


Record review for Patient #16, #17, #18 and #22 revealed that the consent for medical treatment or blood consent had not been signed by the patient, dated, timed or witnessed.


Record review for Patient #17 and #22 revealed that the weekly interdisciplinary progress notes were not complete.


Record review for Patient #17, #19 and #22 revealed physician orders which had not been dated, timed or noted when written into the medical record. This included orders written by the physician, verbal and/or telephone orders taken by the nurse.


Record review for Patient #16, #17, #18, #19, #20, #22 and #23 revealed nursing notes, insulin blood sugar tracking forms, pain flow sheets, medication administration records, clinical evaluations, emergency room records, nursing admission history and assessments, and modified FLACC scale (pain scale for patients unable to communicate) documentation which were not completed.


Review of facility policy "Telephone, Verbal and Written Orders for Medication" revealed, "Procedure: ...All verbal and/or telephone orders for medications shall include ...Date and time the order is prescribed ... ".

Based on record review and policy and procedure review, the facility failed to ensure properly executed consent forms were documented for four (4) of nine (9) patient records reviewed, Patient #16, #17, #18 and #22.


Findings include:


Record review for Patient #16 revealed the "Conditions of Admission and(or) Emergency Room Treatment" was not signed by the patient or legal representative. The documentation stated: "patient unable to sign".


Record review for Patient #17 revealed the "Consent to Blood Transfusion or Blood Plasma" was not signed by the patient.


Record review for Patient #18 revealed the "Conditions of Admission and(or) Emergency Room Treatment" was not signed by the patient or legal representative.


Record review for Patient #22 revealed the "Conditions of Admission and(or) Emergency Room Treatment" was incomplete for patient signature, witness signature, date or time.

Review of the facility's "Blood/Blood Component - Informed Consent" policy revealed, "Policy: It is the policy ...to verify by means of the Blood/Blood Component Transfusion Consent Form, that the patient's informed consent has been obtained ...before the patient receives a transfusion ...Responsibilities: Hospital Personnel: ...Nursing staff are responsible for proper completion and routing of form ...".

Review of the facility's "Informed Consent" policy revealed: "Policy: ...Written verification of the informed consent, signed by the patient, physician, and witness, must be on the patient's chart prior ...Obtaining Informed Consent:..If the patient is unable to give consent, then an authorized person may sign on his/her behalf ...".

Based on employee interview, the facility failed to ensure that a person or persons was designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases.


Findings include:


Interview with the Assistant Director of Nursing (ADON) on 11/04/13 at 11:30 a.m. regarding their dedicated Infection Control Nurse revealed, "We don't have one. The DON (Director of Nurses) and myself try to take care of it."

Based on observation, policy review and employee interview, the facility failed to ensure that a system was developed for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.


Findings include:


Observation of patient care given by Employee #5 on 11/04/13 at 2:05 p.m. revealed that she did not wash her hands prior to hanging a unit of blood for Patient #11. She entered Patient #11's room with blue latex gloves on and proceeded to hang the unit of blood. When questioned about the lack of handwashing she stopped, removed her gloves, washed her hands, and then had to exited the room to retrieve more gloves.


Observation made during a tour of the ED (Emergency Department) on 11/04/13 at 2:50 p.m. with Employee #4 revealed that used electrodes were still connected to Defibrillator #1.


Review of the facility's "Mission Statement" policy (date of Origin: May 2011 and Date of review: May 2011) revealed, "Responsibilities - The Infection control committee, its chairman, and the infection control professional are responsible for the overall development, reviewing, monitoring, and evaluation of the infection control program."


Review of the facility's Infection Control manual revealed no documented evidence of current ongoing collection, review, and analysis of data pertaining to hospital acquired infections or ongoing monitoring or education of staff.

Based on observation, employee interview and review of policy and procedures, the facility failed to ensure that adequate medical and nursing personnel qualified in emergency care are available and that emergency services personnel requirements are met.


Findings include:


On 11/04/13 at 2:50 p.m. observation during tour of the ED (Emergency Department) with Employee #4 revealed no documented evidence that the defibrillators had been checked on a daily basis. Employee #4 stated that the Pharmacy Technician was responsible for that duty. The Pharmacy Technician stated that she had not checked the defibrillators. Review of the Pharmacy Tecnician's check sheet revealed no documented evidence of defibrillator checks. The Assistant Director of Nursing (ADON) stated that he also did not know how to test the defibrillators. Employee #4 attempted to test the defibrillator, but failed to put the defibrillator in test mode for the test. She stated that she would locate the users' manual for defibrillators. Review of the facility's training schedule revealed no documented evidence that the hospital's staff had been given any training for use of emergency equipment.


Review of the facility's "Defibrillator" policy revealed, "Policy - (name of hospital) requires that the defibrillator be inspected and tested each day to ensure it is working properly."


Interview with the Director of Nursing (DON) on 11/05/13 at 11:00 a.m. revealed that the hospital had no policy for staffing the Emergency Department. She stated, "There are usually two (2) RNs (Registered Nurses) and two (2)LPNs (License Practical Nurses) staffed for acute/swingbed. If there is an ambulance call, one of the LPNs which are also EMTs (Emergency Medical Technicians) will go." When asked who would staff if there was a patient in the Emergency room, she stated, One of the RNs will staff the ER."

Review of the facility's "(Name of Hospital) Triage for ER Department" revealed, "Procedure: The RN will evaluate and categorize each patient upon arrival to the ED ... ".

Based on Infection Control Manual review and documentation review, the facility failed to ensure that the Quality Assessment and Performance Improvement program addressed problems identified by infection control officer(s) and are responsible for successful corrective action plans.


Findings include:


Review of the facility's Infection Control Manual and documented information presented for review revealed that there was no program in place for identifying, reporting, investigating or controlling infections. There was no Quality Assessment and Performance Improvement in place regarding infection control or prevention of infections.

Based on employee interview, the facility failed to ensure that dental services are available to residents for obtaining routine and 24-hour emergency dental care.


Findings include:


Interview with the Director of Nursing (DON) on 11/5/13 at 1:35 p.m. revealed that the facility had no dentist available to provide services to swingbed patients. She stated, "We don't have one on staff or a contract, but we do rent space to one."