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Based on review of medical records (MR), Medical Staff Bylaws, policy and procedures and interviews, it was determined the facility failed to ensure the medical staff completed history and physicals within 24 hours of admission and completed orders for the plan of care. This affected MR # 16, 1 of 2 patients admitted to swing bed services and had the potential to negatively affect all patients treated at the facility.

Findings Include:

Medical Staff Bylaws
Dated: 9/2017

"9.6 Histories and Physicals

A medical history and physical examination shall be completed for each Hospital patient no more than thirty days before or 24 hours after admission...

The following elements are required for a history and physical:
...
A plan of care..."
****
1. MR # 16 was admitted to the facility on 7/6/18 with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease, and Muscle Weakness.

Review of the MR conducted revealed a Speech Evaluation was conducted on 7/9/18 and no physician's order was found for the Speech Evaluation.

Further review of the MR revealed no documentation of a History and Physical (H & P) for the swing bed patient.

The surveyor submitted the questions to Employee Identifier (EI) # 1, Director of Nursing, who confirmed the above findings and provided the surveyor with H & P signed by the physician on 7/18/18.

In an interview conducted on 7/19/18 AM at 11:55 AM, EI # 1 confirmed the above findings.

Based on review of medical records (MR), facility policies, and staff interviews, it was determined the facility failed to ensure staff:

a) Reported animal bites in the Emergency Department (ED) as per the facility policy. This affected MR # 6, 1of 3 records reviewed for animal bites in the ED.

b) Notified the physician of changes in patient condition per facility policy. This affected MR # 15, 1 of 1 swing-bed records reviewed with a surgical wound.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Animal Bites
NR.04.72.0
Effective: 10/17

"According To County Law:
All animal bites must be reported to Randolph County Health Department."

Facility Policy: Nursing Documentation
NR.01.096.0
Effective: 10/17

Purpose:
"To provide guidelines to ensure that events and interventions are appropriately noted in the patient care record...

IIV. Change in Patients Condition
A. The Registered Nurse will be responsible for notifying the physician of change in the patient condition communicating any pertinent information regarding the patient.

B. The information communicated to the physician will be documented in the clinical notes..."
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1. MR # 6 was admitted to the ED on 4/28/18 with a chief complaint of dog bite to the L (left) thumb.

Review of the MR revealed there was no documentation the dog bite was reported to Randolph County Health Department as directed per the facility policy.

An interview was conducted on 7/19/18 at 12:10 PM with Employee Identifier (EI) # 1, Director of Nursing, who verified the aforementioned findings.



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2. MR # 15 was admitted to the Swing Bed on 7/12/18 with diagnoses including Status Post (S/P) Left Knee Replacement.

Review of the 7/16/18 nursing note at 4:23 AM revealed the documentation of, "Blood was dripping from the bottom of the dressing. Blood cleaned up with gauze and Mepilex reinforced with another Mepilex..."

There was no documentation the nurse notified the physician at the time of the change in the patient's wound status.

In an interview conducted on 7/19/18 at 12:10 PM, EI # 1, Director of Nursing, confirmed the above findings.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure:

Food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.

...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section..."
*****

1. During a tour of the Medical/ Surgical Unit conducted on 7/17/18 at 10:05 AM, with Employee Identifier (EI) # 4, Registered Nurse, the surveyor observed 5 turkey sandwich boxes had been made 3 to 5 days earlier in the patient nourishment refrigerator.

The "Turkey Sandwich Boxes" were labeled with the good for dates of 7/12/18 to 7/19/18 (7 days), 7/14/18 to 7/21/18 (7 days), and 7/16/18 to 7/23/18 (7 days).

In an interview conducted on 7/17/18 at 10:25 AM, EI # 7, Dietary Manager, confirmed the Turkey Sandwich Boxes, should not be available for patient consumption after 3 days.

2. A tour of the Dietary Department was conducted on 7/17/18 at 10:25 AM with the EI # 7, the surveyor observed the following foods were opened and not labeled with the date opened or the date prepared.

Walk in refrigerator:

1- gallon (gal) barbeque sauce.
1- gal pickle chips.
1- gal liquid butter alternative.
1- gal Italian dressing.

Preparation refrigerator:
1- package of deli sliced turkey.
2- Jello pies.

In an interview conducted on 7/19/18 at 10:00 AM with EI # 12, Vice President of Operations, confirmed the above findings.

Based on review of facility policies and procedures, observations, and interview with staff it was determined the facility failed to ensure supplies available for patient use were not expired.
This had the potential to negatively affect all patients served by this facility.

Findings Include:

Facility Policy and Procedure
Title: Expired and Obsolete Supply Disposal
Effective: 10/4/14

Purpose:
"To establish criteria for proper removal and disposal of Expired and Obsolete supplies System-wide.

Policy: Materials Management and specified Department Director will be responsible for the proper identification and disposal of Expired and Obsolete supplies..."
*****
1. A tour of the Laboratory Department was conducted on 7/18/18 at 8:15 AM with Employee Identifier (EI) # 8, Laboratory Operations Manager.

The surveyor observed in the main lab and patient lab area 32 pink blood tubes had the expiration date of 5/31/18.

In an interview conducted by phone 7/19/18 at 10:45 AM with EI # 8, the above findings were confirmed.

Based on review of medical record (MR), policies and procedures, and interview staff, it was determined the facility failed to:

a) Develop an organized activity program for Swing-Bed patients.

b) Develop and provide Swing-Bed patients an individualized activities care plan.

This affected MR # 15 and # 16, 2 of 2 Swing-Bed records reviewed. This had the potential to negatively affect all patients admitted to Swing-Beds.

The findings include:

Facility Policies and Procedures
Subject: Activity Program
Revised: 12/21/16

Purpose: To provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physician, mental, and psychosocial well-being of each resident.

Policy: All Swing Bed patients, upon admission to the facility, will have an Activities Assessment completed. From the Activities Assessment an activity plan will be established for the individual patient based on his/her past, present, and current interests, spiritual involvements....

Procedure: The activities program will be multi-faceted and reflect the individual patient's needs. The activities program will be physically, emotionally, mentally and spiritually beneficial to the patient. Patients will receive guidance in formal activity as provided by Activities Coordinator/qualified staff.... Activities Participation documentation will be completed daily by whosoever is leading the activity.... A monthly activities calendar will be posted in the patient rooms and physical therapy/ activity room. Each swing bed patient will have a copy of the activity calendar..."
*****

1. MR # 15 was admitted to the Swing Bed on 7/12/18 with diagnoses including Post Left Knee Replacement.

Review of the 7/12/18 Admission Activity Assessment revealed no documentation an Activity Plan was conducted for the Swing Bed Patient.

Review of the 7/15/18 Activity Participation Record revealed documentation the patient refused the following activities: Art, Bible Study, Bingo, Church Services, Choral Group, Crafts, Current Events, Educational Classes, Life Review, Movies, Music Therapy, Pet Therapy, Reading, Reality Orientation, Sewing, and Table Games.

During an observation of a medication pass conducted on 7/17/18 at 12:05 PM, the surveyor noted there was no Monthly Activities Calendar posted in the patient's room. The surveyor asked MR # 15 what activities had been offered, MR # 15 stated, "We have played cards."

During a tour of the Rehabilitation (Rehab) Department conducted on 7/17/18 at 1:30 PM, revealed no Monthly Activity Calendars were posted.

The surveyor asked Employee Identifier (EI) # 6, Rehab Operations Manager, "Where are the Monthly Activity Calendars?" EI # 6 then turned to EI # 9, Occupational Therapist/ Activity Coordinator and asked, "Where are the Monthly Activity Calendars?" EI # 9 stated, "They have not been printed. I keep them in the computer."

The surveyor asked EI # 5, EI # 9, and EI # 10, Rehab Director, "Do you offer all of the activities mentioned in the 7/15/18 Activity Participation Record, that includes Pet Therapy?" The response was no.

In an interview conducted on 7/19/18 at 12:30 PM, EI # 10, confirmed the facility failed to develop an organized plan and develop and provide and organized activity plan for the patient.

2. MR # 16 was admitted to the facility on 7/6/18 with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease, and Muscle Weakness.

A review of the MR was conducted on 7/18/18 and revealed no documentation of an individualized activity plan was completed or provided to the patient.

In an interview conducted on 7/19/18 at 12:20 PM, EI # 5 confirmed the above findings.