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Based on interviews, record reviews, policy review and procedure reviews the facility failed to have systemic practices in place to ensure that:
- All contracted services were included into the facility-wide Quality Assurance and Performance Improvement (QAPI) with data collection, analysis, monitoring and reporting to provide patients with quality care and safety (A-0309);
- When QAPI data was collected and it was not within established quality parameters, the failures were reported and interventions were put in place to correct the failures and ensure the quality and safety of the patients (A-0283).
- When QAPI data was collected that it was analyzed for opportunities to improve the quality and safety of the service (A-0286).
- Pharmaceutical Services had QAPI for high risk, problem prone processes included in the facility wide QAPI Program (A-0286).
- The Governing Body had established an ongoing program for improved health outcomes to maintain quality improvement and patient safety (A-0309).
The facility census was three.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.21 - Condition of Participation: QAPI and resulted in the facility's failure to ensure quality health care and safety.

Based on observation, interview, record review, and policy review the facility failed to:
- Ensure that staff followed blood administration policies and stopped blood administration when Patient #4 exhibited signs of an adverse blood reaction (an unexpected occurrence). (Refer to A-410)
- Ensure care plans were revised and individualized for two of two current patients (#23 and #2) and one of one discharged patient (#8). (Refer to A-396)
- Ensure adequate evaluation of patient's safety needs and increase the level of observation and nursing supervision for one of one discharged patient (#8) after he removed/pulled out his Intravenous (IV, within the vein needle/tubing); removed/pulled out his urinary catheter; attempted to assault a nurse; had two falls; and made a suicidal statement and gesture. (Refer to A-395)

These deficient practices had the potential to affect all patients when the needs of patients were not being met and could result poor patient care and serious harm. The facility census was three.
The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.23 - Condition of Participation: Nursing Services and resulted in the facility's failure to ensure quality and safe nursing care.

Based on interview and record review the hospital's Governing Body failed to ensure
that all contracted services were included in the Quality Assurance and Performance Improvement Program (QAPI). The facility also failed to ensure that QAPI data was analyzed, reported, and evaluated to improve the quality of services provided to patients.

This had the potential to put all patients at risk for substandard quality care and compromise their health and safety. The facility census was three.

Findings included:

1. Record review of the facility's document titled, "Amended and Restated Bylaws," dated 01/2014, stated:
- The affairs of the Corporation will be managed by the Board of Directors of the Corporation.
- The Board shall be authorized to: Oversee the Corporations quality and patient safety;
- Ensure regulatory compliance and accreditation for the Corporation.
- The Corporation shall have a Quality Committee, which shall be a standing committee, and which shall be responsible for overseeing activities related to monitoring and ensuring that the health care services provided by the Corporation are performed safely and at the highest levels of quality that are achievable within the Corporation's capabilities and resources.

2. Record review of the list of contracted services provided by Staff B, Director of Quality/Risk, Infection Control, HIPAA (Health Insurance Portability and Accountability Act of 1996) and Employee Health, showed the following contracted services that affected patient care:
- Radiology;
- Emergency physicians;
- Dietitians;
- Social Workers;
- Bio-medical waste;
- Medical transcription records;
- Ultrasound imaging; and
- Case Management.

During an interview on 03/23/16 at 3:35 PM, Staff B stated that the only contracted service that collected data for QAPI was the Dietitians but that data was not analyzed or reported.

Based on interview and record review the facility failed to ensure that all contracted services were included in the facility-wide Quality Assurance and Performance Improvement (QAPI) Program and that data collected resulted in activities to improve the care, safety or services provided to all patients. The facility also failed to act upon data that they collected that were out of the quality parameters for patient safety. This had the potential to put all patients at high risk for sub-standard quality of health care and adverse outcomes. The facility census was three.

Findings included:

1. Record review of the list of contracted services provided by Staff B, Director of Quality/Risk, Infection Control, HIPAA (Health Insurance Portability and Accountability Act of 1996) and Employee Health, showed the following contracted services that affected patient care:
- Radiology;
- Emergency physicians;
- Dietitians;
- Social Workers;
- Bio-medical waste;
- Medical transcription records;
- Ultrasound imaging; and
- Case Management.

During an interview on 03/23/16 at 3:35 PM, Staff B stated that the only contracted service that collected data for QAPI was the Dietitians.

2. Record review of the facility document titled, "PATIENT SAFETY AND PERFORMANCE IMPROVEMENT PLAN," dated 12/10/2010, stated: To ensure data is collected to monitor performance, systematically aggregated, trended, and analyzed, acted upon in response to analysis and evaluated for sustained improvement or needed modifications.

3. Record review of the Dishmachine Temperatures and Sanitizing logs from the Food and Nutritional Services Department showed that Chlorine PPM's (parts per million) should be no less than 50 PPM's at the minimum level and that the water temperature should be 121 degrees Fahrenheit (F) minimum. The logs for 10/2015 through 02/2016 showed that the Chlorine PPM added by staff, never varied from 200 PPM's shift after shift, day after day, month after month, which is of concern as the variables that affect the amount of Chlorine used for sterilization include water temperature, contact time and pH (a measure of how acidic basic water is). Since the water temperature for the same period of time varied from 114 to 140 degrees F and the Chlorine added never varied and the water pH was not data that was monitored - the facility could not ensure that anything run through the dish machine was disinfected and safe. These failures put patients at high risk for infection and cross contamination.

During an interview on 03/22/16 at 12:00 PM, Staff A, Food Service Manager, reported that the expectation was for Dietary staff to alert her if temperatures were greater than 150 degrees F, or lower than 120 degrees F on the dishmachine. Staff A acknowledged that no notification from staff regarding out of range temperatures had occurred and no interventions had been done to improve the accuracy of the temperature on the dishmachine. This failure had the potential to affect all patients receiving meals in the facility at great risk for contamination and cross contamination of infectious diseases.

Based on observation, interview and record review the facility failed to have Quality Assurance and Performance Improvement (QAPI) processes in place for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas. The facility failed to:
- Track a high risk process for one of one current patient (#4) observed during a blood transfusion;
- Ensure Pharmacy tracked high risk medication processes that included supervision of re-packaged medications and access to pharmacy after-hours; and
- Track an adverse patient event for one of one discharged patient (#8) who made a suicide attempt/gesture. The facility census was three.

Findings included:

1. Record review of the Quality Management document titled, "Patient Safety and Performance Improvement Plan," dated 12/21/10, stated that the Patient Safety and Performance Improvement Philosophy had chosen Continuous Quality Improvement (CQI) as the performance improvement approach. CQI is the examination of all work processes in order to continuously improve patient safety, service and outcomes for the benefit of patients. The objectives of this plan is to assess, monitor, improve and preserve the delivery of safe and quality patient care.

2. Record review of the facility's nursing policy titled, "Incident - Event Report," dated 07/23/15 showed that an incident/event was a hospital related occurrence not consistent with the desired operation of the hospital and all staff were responsible to complete incident/event reports.

Record review of the facility's administrative policy titled, "Incident Report," dated 03/2010, directed staff to submit incident reports to Quality Management (QM).

3. Observation of blood transfusion on 03/21/16 at 5:30 PM of Patient #4 showed Staff E, Registered Nurse (RN) began blood transfusion therapy. Within four minutes after the blood entered the vein, the patient complained of tightness in her chest, and placed her hand on her chest. She also had an increase in blood pressure (a sign of a potential transfusion reaction).

There was no documentation found in Patient #4's Transfusion Report or other areas of the medical record of the blood transfusion event.

During a concurrent interview on 03/23/16 at 1:45 PM, Staff B, Director of Quality/Risk, Infection Control, HIPAA (Health Insurance Portability and Accountability Act of 1996) and Employee Health, stated that she was not aware that a blood transfusion reaction was observed on 03/21/16.

During an interview on 03/24/16 at 2:30 PM, Staff G, Chief Nursing Officer, stated that she discussed the event with Staff E and acknowledged that Staff E should have documented the transfusion reaction and completed an event report, and did not.

4. Observation of the Pharmacy and the Emergency Department currently on 03/23/16 at approximately 10:20 AM, showed unapproved (by the Pharmacist) and mislabeled (by the Pharmacy Technician) repackaged medications.

During an interview on 04/12/16 at 8:14 AM, Staff T, Pharmacist, stated that he did not have a QAPI measure to monitor re-packaged medications to assure they were accurately labeled and approved.

5. Record review of a Pharmacy Medication Removal Log showed the after-hours access of the Pharmacy and procurement of medications by non-pharmacy staff was not signed off by a witness per policy.

During an interview on 04/12/16 at 8:14 AM, Staff T, stated that he did not have a QAPI measure to monitor after-hours access of the Pharmacy.

6. Record review of discharged Patient #8's progress notes dated 01/01/16, showed that at 5:25 PM the patient had oxygen tubing wrapped around his neck four times and stated he was trying to hang himself.

During an interview on 03/23/16 at 3:50 PM, Staff E, RN, stated that she found the patient with oxygen tubing looped four times around his neck and that he stated he was trying to kill himself and laughed. She did not complete an event report.

During an interview on 03/24/16 at 2:00 PM, Staff Z, Regulation Compliance, stated that she had no knowledge of Patient #8's suicidal gesture and had no event report.

During a concurrent interview on 03/23/16 at 1:45 PM, Staff B, Director Quality/Risk, stated that suicide attempts/precautions are part of the nursing assessment and that the nursing daily flow sheet includes a Psychosocial Evaluation/Needs to address patient behaviors or psychiatric issues. Staff B stated that she was not aware of any suicide attempts in the last 12 months. She stated that there is no retrospective medical chart review of patient records that would alert administration of near misses or adverse events.





31891

Based on observation, interview and record review the Governing Body failed to ensure:
- Patient safety was clearly established;
- The Quality Assurance and Performance Improvement (QAPI) program had data that was completed, analyzed, reported, and evaluated to improve the quality of services provided to patients;
- That all contracted services were included in the QAPI Program and were evaluated to ensure the quality of services provided to patients.
This had the potential to put all patients at risk for substandard quality care and compromise their health and safety. The facility census was three.

Findings included:

1. Record review of the facility's document titled, "Amended and Restated Bylaws," dated 01/2014, stated:
- The affairs of the Corporation will be managed by the Board of Directors of the Corporation.
- The Board shall be authorized to: Oversee the Corporation's quality and patient safety;
- Ensure regulatory compliance and accreditation for the Corporation.
- The Corporation shall have a Quality Committee, which shall be a standing committee, and which shall be responsible for overseeing activities related to monitoring and ensuring that the health care services provided by the Corporation are performed safely and at the highest levels of quality that are achievable within the Corporation's capabilities and resources.

2. Observation on 03/21/16 at 5:30 PM showed a patient with a blood transfusion reaction within four minutes of the blood entering the vein. The nurse did not document the reaction, create an adverse event report or take measures to ensure the safety of the patient.

3. Record review of a patient's progress note showed that on 01/01/16 a nurse found a patient with oxygen tubing looped four times around his neck and that he stated he was trying to kill himself and laughed. She stated she did not take it seriously and did not consider the need for additional supervision or suicide precautions. She did not report it to a physician or supervisor and did not complete an incident report.

During an interview on 03/23/16 at 1:45 PM, Staff B, Director of Quality/Risk, Infection Control, HIPAA (Health Insurance Portability and Accountability Act of 1996) and Employee Health, stated that she was not aware of any suicide attempts in the last 12 months. She stated that there is no retrospective medical chart review of patient records that would alert administration of near misses or adverse events.

4. Record review of the list of contracted services provided by Staff B showed the following contracted services that affected patient care:
- Radiology;
- Emergency physicians;
- Dietitians;
- Social Workers;
- Bio-medical waste;
- Medical transcription records;
- Ultrasound imaging; and
- Case Management.

During an interview on 03/23/16 at 3:35 PM, Staff B stated that the only contracted service that collected data for QAPI were the Dietitians.

5. Record review of the facility's document titled, "Patient Safety and performance Improvement Plan," dated 12/10/10, did not contain the contracted services and did not include the contracted services in the annual plan for performance improvement and patient safety.



31891

Based on interview, record review and policy review the facility failed to ensure adequate evaluation of safety needs and failed to increase the level of observation and supervision for one of one discharged patient (#8) when he:
- Removed/pulled out his Intravenous tubing (IV, within the vein) seven times;
- Removed/pulled out his urinary catheter;
- Attempted to assault a nurse;
- Attempted to get out of bed while on fall precautions;
- Had two falls; and
- Made a suicidal statement and gesture.
The lack of adequate evaluation and supervision of patient safety needs had the potential to affect all patients. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Charge Nurse Responsibilities (Registered Nurse, RN) - Care Plans Included," dated 08/06/15, showed that each shift a nurse was designated as Charge Nurse to ensure continuity of care and utilize the nursing process. The RN was accountable to the Chief Nursing Officer (CNO) and directed to:
- Be responsible for the coordination of patient care and assignments to nursing personnel to best serve the patient's needs;
- Consider the complexity of patient needs when making patient care assignments;
- Correct problems; and
- Request CNO intervention as needed to solve problems.

Record review of the facility's policy titled, "Suicide Precautions," dated 08/06/15, showed that:
- A nursing mental health assessment was provided by nurses during the Initial Interview and a Nursing Daily Shift Assessment every 12 hours.
- Staff had knowledge to identify various patient characteristics such as depression, unwilling to participate in or problems coping with activities of daily living (such as performing hygiene and eating), anger directed toward self or others, stress and irritability, verbalization to commit suicide, took action to harm self such as inflicting an injury, intent to harm self, agitated and loud, and mood changes.
- Patients who demonstrated verbal statements, physical actions, and threats to self were transferred to a mental health facility as soon as possible.
- Staff were directed to assure the safety of patients who voiced or showed suicidal behavior or attempts and provide the care necessary until the patient was transferred to a mental health facility.
- Suicidal patients were assigned one-to-one staff monitoring by staff until transferred.

Record review of the facility's policy titled, "Behavioral Emergencies (Mental Health) Nursing Management," dated 08/06/15, showed that behavioral emergencies included disturbed and uncooperative behavior, anxiety and panic like states, assaultive and destructive behavior and impulses (patient may be noisy or disturbed from acute alcohol or drug intoxication), and signs of depression. Suicidal behaviors required someone in constant attendance with the patient and measures to prevent self-injury.

Record review of the facility's policy titled, "Falls - Safety Risk," dated 08/09/15, showed that the "Morse Scale for Fall Risk Assessment" was used by nurses to identify patients at risk and to initiate fall/safety risk protocol (procedures). A score less than 25 showed no risk, 25-50 showed low risk, and over 50 showed a high risk. After a fall, a nurse assessed the patient for signs of injury, notified the physician, treated injuries, assessed the patient for potential causes, and completed an event report.

Record review of the facility's policy titled, "Fall Prevention Program," dated 02/2015, showed that the facility assessed a patient's risk for falls, took action to reduce the risk of fall, and reduced the risk of injury when a patient fell.

2. Record review of discharged Patient #8's Discharge Summary, dated 01/06/16, showed that the patient was admitted on 12/19/15 with diagnoses of pneumonia (a lung infection that causes a cough, fever, and makes it difficult to breath), hyponatremia (a condition that occurs when the level of sodium, salt, in the blood is too low), and confusion; and had a history of chronic pain issues. He participated little in his care, refused care, and had behavioral issues.

3. Record review of nursing progress notes dated 12/20/15, showed at:
- 12:57 AM: The patient did not know where he was and thought he saw a dog running down the hallway. He had a high fall risk score of 110 (a score over 50 was a high fall risk) and placed on high risk fall precautions that required every two hour monitoring/interventions. He pulled off telemetry leads (wires affixed to the skin for heart monitoring). He was anxious, uncooperative, and disoriented, unable to follow instructions.
- 1:11 AM: He pulled out his IV and pulled off his telemetry leads.
- 1:00 PM: Found sitting on edge of bed, disoriented, and urinated on the bed and the floor.
- 1:09 PM: Anxious and agitated; encouraged to get back in bed.
- 5:24 PM: He pulled off telemetry leads several times.
- 7:20 PM: He had a high fall risk score of 125. He was agitated and disoriented and pulled off telemetry and oxygen tubing frequently. Large bruise noted on left hip/buttock area. (There was no documenation or record of how the patient received the bruise.)
- 8:12 PM: He pulled out his IV and was agitated and disoriented. New IV started.
- 9:30 PM: Became more agitated and confused; pulled at IV tubing.
-10:10 PM: He was confused and agitated. He pulled off gown, and swung at nursing staff when being turned.
- 10:23 PM: Uncooperative with care and pulled oxygen tubing off face.

On 12/20/15 staff failed to evaluate the patient's needs and assign an increased level of observation/supervision to prevent harm to self or others for Patient #8 after he pulled out his IV, tried to get out of bed, and swung at staff.

4. Record review of the patient's progress notes dated 12/31/15, showed at:
- 4:04 AM: The patient was more agitated and pulled at his urinary catheter and oxygen tubing.
- 7:30 AM: He was confused and had a high fall risk score of 125.
- 2:00 PM: He pulled out his IV.
- 3:02 PM: The patient's alarm sounded. He was found sitting at the bedside and he wanted to get up in a chair.
- 3:20 PM: The patient was placed on bedside commode per request. Staff instructed him to use the call light when he was finished.
- 7:30 PM: He was confused, agitated, and uncooperative; he thought the call light was a cigarette and tried to smoke it. He had a fall risk score of 125.
- 7:40 PM: He was pulling at his urinary catheter and the bed alarm and cursed when he could not have cigarettes.

5. Record review of a fall event report dated 12/31/15 at 4:00 PM, showed that Patient #8 was found sitting on the floor after being last seen on the commode. He was unable to give an account of the events leading up to the fall.

On 12/31/15, staff failed to evaluate the patient's needs and assign an increased level of observation/supervision for his potentially harmful behavior. At 3:20 PM he was left unattended on the commode; and at 4:00 PM he was found on the floor next to the commode. In addition, the fall was not documented in the medical record.

6. Record review of the patient's progress notes dated 01/01/16, showed at:
- 2:30 AM: The patient was very agitated, tried to get out of bed, and stated that he wanted to pay his electric bill and smoke a cigarette.
- 7:23 AM: He had a high fall risk score of 130.
- 11:00 AM: The patient's IV was found out and restarted.
- 1:18 PM: Nurse found that patient had pulled out his urinary catheter.
- 5:25 PM: Patient had oxygen tubing wrapped around his neck four times and stated that he was trying to hang himself.
- 7:00 PM: Patient had pulled off clothing and IV tubing.
- 7:30 PM: Patient was confused, disoriented, agitated, and unable to follow instructions. He had a high risk fall score of 135. He voiced feelings of depression.

On 01/01/16 staff failed to evaluate the patient's needs and assign an increased level of observation/supervision for Patient #8 to prevent harm to self after he:
- Had a high risk for falls and attempted to get out of bed on his own;
- Pulled out his IV;
- Pulled out his urinary catheter;
- Found with oxygen tubing around his neck and stated he was trying to kill himself;
- Was confused, agitated and unable to follow instructions; and
- Voiced feelings of depression.

During an interview on 03/23/16 at 3:50 PM, Staff E, RN, stated that:
- She was the Charge Nurse on 01/01/16 from 7:00 AM to 7:00 PM.
- On that date she was supervising Staff BB, RN, who was in new employee orientation.
- He reported to her that Patient #8 fell from the bedside commode.
- She gave him paperwork and instructions for documentation but did not recall reviewing his work.
- When she left the shift he was still working on the event report.
- She did not recall if the patient pulled out his IV or urinary catheter.
- She found patient with oxygen tubing looped, not tight, four times around his neck and that he stated he was trying to kill himself and laughed. She did not take it seriously and did not consider the need for additional supervision or suicide precautions. She did not report it to a physician or supervisor, but did report it to the next shift.

Staff E failed to document the fall, evaluate the potential for suicide and initiate one-to-one supervision per policy, and report the suicide attempt/gesture to a physician and a supervisor.

During an interview on 03/24/16 at 11:45 AM, Staff BB, RN, stated that:
- He was in orientation when Patient #8 fell from the bedside commode.
- He was directed to document the fall on an event report but was not directed to document it in nursing progress notes.
- He later heard that the patient fell a second time but had not heard of any suicidal attempt, gesture or statement made by the patient.
- If a patient made a suicide attempt, gesture, or statement he would not have left the patient alone, would have yelled out for help or used the call button, notified a physician, and initiated one-to-one staff supervision.

7. Record review of the patient's progress notes dated 01/02/16, showed at:
- 12:24 AM: The patient had pulled his IV out of his left arm.
- 5:35 PM: The patient pulled out his IV and had oxygen tubing wrapped around his arm.
- 7:09 PM: His bed alarm was sounding. He was found fidgeting and rolling around in bed. Oxygen tubing was lying on the bed. He was disoriented to time and place. He had a fall risk score of 130.
- 7:45 PM: The patient's bed alarm was sounding and he was found moving around in the bed. He drew his fist at a nurse when she was repositioning him.
- 8:09 PM: The patient's bed alarm was sounding and he was trying to get out of bed and stated he was going to his house.
- 8:40 PM: The patient was found sitting on the floor next to his bed. He had pulled the alarm apart and unclipped it from his gown so the alarm was not sounding. The patient had his hand to his right forehead when asked if it hurt. There was a medium size purple knot found on his right brow.

On 01/02/16, staff failed to evaluate the patient's needs and assign an increased level of observation/supervision for the patient's harmful behavior that included pulling out his IV, attempt to get out of bed without assistance, and a fall that resulted in injury. There were no additional prevention measures documented to prevent a fall recurrence and to prevent further harm to self.

During an interview on 03/23/16 at 2:45 PM, Staff G, CNO, stated that:
- She had no knowledge that the patient had wrapped oxygen tubing around his neck and made a suicidal statement.
- Staff E should have notified a physician and her, initiated suicide precautions with one-to-one nursing assignment until discharge/transfer, and completed an event report per policy.
- Staff never received a request from staff that they needed additional supervision with a one-to-one staff for Patient #8, per policy.

Based on observation, interview, record review, and policy review the facility failed to ensure care plans were revised and individualized for two current patients (#2 and #23) of two current patients; and one discharged patient (#8) of one discharged patient. This had the potential to affect all patients when the needs of patients were not being met and could result in poor patient care and serious harm. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Charge Nurse Responsibilities (Registered Nurse, RN) - Care Plans Included," dated 08/06/15, showed that each shift a nurse was designated as Charge Nurse to ensure continuity of care and utilize the nursing process. The RN was accountable to the Chief Nursing Officer (CNO) and directed to:
- Formulate a care plan based on physiological and psychosocial factors identified through nursing assessment.
- Develop, implement, and revise the care plan throughout the patient's stay.
- Review the care plan each shift and update when another problem is identified.

2. Record review of current Patient #2's History and Physical, dated 03/20/16, showed she was admitted on 03/20/16 for acute pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract) and hyponatremia (a low sodium, salt, level in the blood). The patient had a fever, shortness of breath and confusion.

Record review of a physician note and order dated 03/21/16 at 12:30 AM showed Patient #2 had a high risk for formation of thromboembolism (a blood clot that could travel and obstruct a blood vessel.) The physician ordered anticoagulant prophylactic medication (to prevent blood clots).

Patient #2's medical record showed no individualized care plan was developed for the patient's high risk for thromboembolism.

3. Observation and concurrent interview on 03/23/16 at 11:10 AM, of Patient #23 showed that she had a certified nurse assistant (CNA) at the bedside. Staff G, Chief Nursing Officer (CNO), stated that prior to admission the patient made suicidal statements and since admission she had staff assigned to her for one-to-one staff observation, per policy.

Record review of current Patient #23's Emergency Room Note dated 03/22/16, showed she was brought to the facility by law enforcement to obtain medical clearance for 96-hour hold (involuntary mental health detention for potential danger to self or others) and showed mental status changes that included confusion and disorientation. She was diagnosed with dehydration and a urinary tract infection (UTI), not medically cleared, and admitted for treatment.

Record review of the Patient's (#23) nursing progress notes showed:
- On 03/22/16, she was confused, anxious, and disoriented. She had a CNA in the room for behavioral observation.
- On 03/23/16, she was confused, anxious, disoriented and assessed at a high risk for falls.
- Nurse discussed statements she made to shelter staff and police about wanting to hurt herself and others. She voiced feelings of depression.
- On 03/24/16, she was anxious, confused, and voiced feelings of depression and had no family support. She was assessed at a high risk for falls.

Record review of the patient's care plan showed no problem and goals for threats to harm to self and others, and high fall risk.

4. Record review of discharged Patient #8's record throughout hospitalization showed that:
- Upon admission (12/20/16) the patient anxious, uncooperative, and disoriented, unable to follow instructions; and had visual hallucinations of a dog running down the hallway.
- He was confused and was a high fall risk.
- He attempted to get out of bed and fell on two occasions. One fall resulted in a medium purple size knot on his right brow.
- He pulled out his IV (can cause excessive bleeding) seven times.
- He pulled out his urinary catheter (can cause damage to bladder and urinary tract).
- He was very agitated, drew a fist, and swung at nursing staff when being turned.
- He had oxygen tubing wrapped around his neck and stated that he was trying to hang self.

The care plan was not revised to meet his individual care needs, prevent a fall recurrence, prevent further harm to self, and address his potential for suicide.

During an interview on 03/23/16 at 3:50 PM, Staff E, RN, stated that she found the patient with oxygen tubing looped, not tight, four times around his neck and that he stated he was trying to kill himself and laughed. She did not take it seriously, did not consider the need for additional supervision or suicide precautions, and did not update his care plan.

During an interview on 03/23/16 at 2:45 PM, Staff G, CNO, stated that the nurse should have updated the care plan to include suicide precautions with one-to-one nursing assignment. She also stated that the patient's falls and self removal of his urinary catheter required a revised care plan with additional nursing interventions.

Based on observation, interview, record review, and policy review the facility failed to ensure that staff followed blood administration policies and standards for patient care for one of one patient (#4) observed. The facility failed to:
- Stop blood administration immediately when Patient #4 exhibited signs of an adverse blood reaction.
- Notify the physician.
- Document the event in the patient's record.
- Complete an event report.
These deficient practices had the potential for serious patient harm for all patients who received blood. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Blood Transfusion (through a blood vessel) Administration," dated 08/08/15, directed staff to:
- Provide safe transfusion (the process of receiving blood/blood products intravenously, IV, in the blood vessel) therapy through select patient assessment and nursing interventions.
- Obtain vital signs for baseline purposes before transfusion.
- Assess the clinical condition of the patient.
- Infuse (introduce into the body) blood slowly for the first 15 minutes while observing for adverse reactions including changes in vital signs such as increased or decreased BP.
- Complete the transfusion form.

Record review of the facility's policy titled, "Blood Transfusion Reaction," dated 08/08/15, directed staff to:
- Implement measures for rapid detection, treatment, and reporting of transfusion reactions.
- Contact a physician after starting a blood transfusion and update the physician with the patient's status and vital signs.
- Stop the transfusion immediately if the patient's condition changes.
- Leave the needle in place with slow normal saline (solution used to aid transfusion) infusing.
- Begin transfusion investigation, complete an event report, and enter all information into the patient's record.

2. Observation of blood transfusion on 03/21/16 at 5:30 PM of Patient #4 and concurrent interview with Staff E, Registered Nurse (RN) showed:
- She began blood transfusion therapy at 5:30 PM.
- Within four minutes after the blood entered the vein, the patient complained of tightness in her chest and placed her hand on her chest.
- The nurse told the patient she would watch her and within one minute she applied the blood pressure cuff and obtained vital signs. She then went to a table and documented vital signs on a piece of paper.
- The vital signs documented showed: BP of 161/59 (systolic/diastolic, a measurement of the pressure of blood flow in two different parts of the heart), Pulse of 60, Temperature of 98.2 degrees Fahrenheit (° F) and Oxygen 98% (level of oxygen in the blood taken from a device that is applied to finger).
- A transfusion record form was on the table with no documentation that included vital signs taken before blood administration (baseline).
- When questioned she could not recall the patient's baseline vital signs and stated they were at the nurse's station.
- A nurse brought in pre-vital sign recordings documented on a piece of scratch paper that showed, BP 125/52, Pulse 60, Oxygen 98 %, and Temperature 98° F.

After Staff E obtained the patient's pre-transfusion vital signs that showed an increase in blood pressure, she failed to stop blood administration and notify a physician per policy.

3. Record review of Patient #4's medical record on 03/22/16 at 9:00 AM, showed the patient was admitted on 03/21/16 at 3:39 PM for anemia and receipt of a blood transfusion on an outpatient basis. Staff E's documentation on a form titled "Transfusion Report" (a preprinted form that included spaces for a nurse to document vital signs, transfusion reactions, and other difficulties experienced) showed a pre-transfusion (baseline) BP of 125/52 and a 15 minute BP of 163/58. On the Transfusion form Staff E documented "N/A" (generally known as not applicable) for a reaction.

No documentation was found on the Transfusion Report or other areas of the medical record of the event (four to five minutes after start of blood transfusion) that included the patient's complaint of tightness in her chest, vital signs recordings, and her response to the change in the patient's blood pressure reading.

During an interview on 03/24/16 at 2:30 PM, Staff G, Chief Nursing Officer (CNO), stated that she discussed the event with Staff E and acknowledged that Staff E should have:
- Documented the pre-vital signs (baseline) and had them with her, and did not.
- Stopped the blood transfusion and did not.
- Documented the transfusion reaction, reported it to the physician, completed an event report, and notified the CNO; and did not.

During a concurrent interview on 03/23/16 at 1:45 PM, Staff B, Director of Quality/Risk, Infection Control, HIPAA (Health Insurance Portability and Accountability Act of 1996) and Employee Health, stated that she was not aware that a blood transfusion reaction was observed on 03/21/16. She stated that there was no process for a QAPI review of blood transfusions. Staff Z, Regulatory Compliance, stated that Staff E should have stopped the transfusion immediately and called the patient's physician. Staff B stated that the current policy and procedures for "Blood Transfusion Reaction," did not specify calling the patient's physician.



27029

Based on observation, interview and policy review, the facility failed to ensure patient paper medical records were protected against unauthorized access (by individuals who were not authorized to access records) in two areas (Inpatient Unit Nurses Station and Registration Offices) of two areas observed in the main hospital. The facility also failed to ensure that keys to locked bins where documents that contained health information were placed to be shredded were kept secured.
These deficient practices had the potential to permit unauthorized individuals to access patients' paper medical records. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Confidentiality of Records," dated 10/2013, showed that all medical information shall be confidential, secure, current, authenticated, legible, and complete.

2. Observation of the Registration Offices, and concurrent interview on 03/22/16 at 10:00 AM with Staff Q, Registration Clerk, showed the following:
-A stack of medical records that contained both outpatient and Emergency Department patient charts were lying face down on a tray located under a window utilized by staff and patients to communicate with the Registration Staff.
-The stack was within reach of anyone at the window to either view or pick up and/or remove.
-Staff Q stated that Medical Records picked up the stacks near the window every day except the weekends.
-A large white box was located in the office that had a small slit in the top
for papers to be passed through, and the top was locked. Staff Q stated that it was used for medical records/confidential items that needed to be shredded.
-The key to the box was located on top of the registration desk in a desktop organizer that was not secured.
-Staff Q stated that all staff that worked in registration had access to the key.

3. Observation of the Inpatient Unit and concurrent interview on 03/22/16 at 10:15 AM with Staff G, Chief Nursing Officer, showed a cabinet in the nurses station that was labeled Medical Records. The cabinet was not locked. Staff G stated that the items in the cabinet were picked up by Medical Records every day except the weekend. Staff G stated that documents from the chart that were picked up by Medical Records were kept in the unlocked and labeled cabinet. Staff G also stated that nursing and providers were in this area of the nurse's station, as well as respiratory staff, pharmacy staff, and housekeeping staff.

During an interview on 03/22/16 at 11:00 AM, Staff O, Housekeeper, stated that:
-She was responsible to pick up the confidential items that were required to be shredded from the locked boxes throughout the hospital.
-She had keys to all the locked boxes (approximately five boxes throughout the facility). Those keys were kept in her unlocked drawer in an unlocked office.
-She brought the confidential documents to the Maintenance area where she utilized an industrial shredder to shred them, and then bagged the shredding for disposal.
-She was trained on confidentiality and the Health Insurance Portability and Accountability Act (a law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers).
-She did shred the papers but didn't look at them.

Staff D, Chief Executive Officer, was present throughout the interview with Staff O, Housekeeper, and confirmed the processes for documents that were required to be shredded.

Based on interview, record review, and policy review the facility failed to ensure that:
- Twenty of 20 repackaged medications (tablets) were reviewed and signed off by a pharmacist prior to being made available for patient use. (Refer to A-501)
- All repackaged medications were labeled with the correct strength. (Refer to A- 501)
- Staff followed its policy for procurement of medication after hours. (Refer to A- 506)
These deficient practices of inadequate pharmacist supervision had the potential risk of harm for all patients. The facility census was three.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.25 - Condition of Participation: Pharmaceutical Services and resulted in the facility's failure to ensure quality, safe medication practices.

Based on interview, record review, and policy review the facility failed to ensure that 20 of 20 repackaged medications (tablets) were reviewed and signed off by a pharmacist and that all repackaged tablets were labeled with the correct strength. This deficient practice had the potential risk of harm to all patients without accurate verification, labeling, and approval of repackaged medications before they were available for patient use. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Compounding, Re-Packaging, and Re-Labeling," dated 02/16/16, directed pharmacy staff to:
- Follow a standardized process and repackage a limited number of oral medications.
- Tablets/capsules were transferred to a unit dose package kit and sealed.
- Preprinted labels were affixed to the seal by the technician and logged.
- All materials were left for the pharmacist to check.
- The pharmacist checked all aspects of the preparation and initialed the log sheet.

2. Record review of a form titled, "Pharmacy Unit Dose Pre-Pack Log," showed entries for medications repackaged from 01/15/16 to 03/04/16. An entry dated 03/04/16 showed Diphenoxylate and Atropine 2.5/0.025 milligram (mg, a measure of dosage strength) tablets (a controlled medication, which has a potential for abuse, used to treat diarrhea and commonly known as Lomotil), quantity of 20, lot number 3056903, repackaged and initialed by a technician, and without a Pharmacist authentication (initials of approval).

During an interview on 03/23/16 at 10:00 AM, Staff U, Pharmacy Technician (Pharm Tech), stated that:
- He acknowledged the pharmacist had not reviewed and signed the repackaged medications listed in the entry dated 03/04/16.
- He had not dispensed the medication to an automated dispensing machine (ADM, medication cart.)
- The medications were locked in the controlled substance cabinet and only the pharmacist had access to the cabinet.

3. Observation on 03/23/16 at 10:20 AM, and concurrent interview, showed Staff U, Pharmacy Technician, accessed the Emergency Department ADM to review the current stock of Diphenoxylate and Atropine on hand for patient administration. The medication bin showed eight tablets of Diphenoxylate and Atropine 0.025/2.5 mg with a lot number 3056903. The medication strength was labeled differently than documented on the repackaging log in the Pharmacy. Staff U acknowledged that the tablets were mislabeled with the incorrect strength.

During a telephone interview on 04/12/16 at 8:15 AM, Staff T, Pharmacist, stated that:
- Staff U, Pharmacy Technician (PT), telephoned him on 03/23/16 and reported that eight mislabeled tablets of Diphenoxylate and Atropine were found in the ED's ADM.
-The strengths should have been labeled with the strength of 2.5/0.025 mg and instead the strength was inverted and labeled 0.025/2.5 mg.
- He stated that he had reviewed and approved 20 repackaged tablets (expiration dates of 03/31/17) as documented on the log form. He stated that he did not notice the mislabeled dosage and he gave the PT verbal approval of his repackaging, but failed to sign the log form.
- He verified that there were eight mislabeled medications in the ED's ADM. He stated that he was responsible for the accurate labeling of three tablets that had expiration dates of 03/31/17. He stated that a former pharmacist was responsible for the accurate labeling of five tablets that had expiration dates of 06/30/16.
- Out of the 20 repackaged medications he approved; two were administered to patient(s), three were in the ED's ADM, and 15 were in the pharmacy's controlled drug cabinet.
- He did not know if one patient received two tablets or if the two patients received one tablet each.
- He had not double checked all repackaged medication to assure that they were labeled appropriately.
- He had not completed an event report or notified the Medical Director.
- He stated that completing and submitting an event report was the facility's method to report errors to Quality Assurance and Performance Improvement (QAPI) staff and committee.
- He stated that he did not have a QAPI measure to monitor re-packaged medications.

The facility failed to ensure that all repackaged medications were accurately labeled.

Based on interview, record review, and policy review, the facility failed to ensure that staff followed the facility policy for procurement (the act of obtaining) of medication after hours for three of three after hour entries into the pharmacy. This deficient practice had the potential risk of harm to patients if an incorrect medication was procured for patient administration. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Procurement of Pharmaceuticals After Hours," dated 02/16/16, directed staff:
- In the event medication was needed from the pharmacy after hours, the Charge Nurse (CN) with another staff present (witness) removed the pharmacy key from the unit automated dispensing system (ADM).
- The CN obtained the desired medication from the pharmacy with a witness.
- The patient name as well as the name, strength, dosage, and amount of medication was documented on the Pharmacy Medication Removal Log by the CN. The CN and witness signed the log.

2. During an interview and concurrent record review on 03/22/16 at 11:20 AM, showed:
- Staff T, Pharmacist, stated that access to the pharmacy after hours required the CN and a second staff member to witness the procurement of medication after hours for security and accountability.
- Staff U, Pharmacy Technician, stated that a new policy was implemented in February requiring the CN and a second staff member to witness the process of obtaining medication from the pharmacy. After completing the process, the CN and witness were expected to sign the Pharmacy Medication Removal Log.
- Record review of the log showed three entries of staff to procure medication from the pharmacy from 02/29/16 to 03/13/16. All three entries showed no signature of a witness.
- Staff U stated that he didn't know why they did not follow the policy, which went into effect 02/16/16.
- Staff T stated he had not reviewed the form and had no knowledge of the omission.

During an interview on 03/23/16 at 9:15 AM, Staff G, Chief Nursing Officer, stated that she met with nurses monthly, she addressed the new policy on 03/17/16, and she did not know why she didn't educate prior to the policy's effective date.

During an interview on 04/12/16 at 8:14 AM, Staff T, stated that he did not have a Quality Assurance and Performance Improvement (QAPI) measure to monitor after hours access of the pharmacy because it was so rare.

Based on observation, interview and record review, the facility failed to ensure that the meals served by the Dietary Staff, purchased from an outside company, met the nutritional needs of each individual patient, and specifically those patients that fell outside of the assessment referral criteria for the Registered Dietician (RD). The Food and Nutrition Services Department also failed to follow the policy related to Fluid Restriction for one patient (#2) of one observed. These deficient practices had the potential to cause nutritional deficiency, and/or the possibility of worsening already diagnosed acute conditions. The facility census was three.

Findings included:

1. During an interview on 03/21/16 at 3:00 PM, Staff A, Dietary Manager, stated the following:
- The facility had discontinued cooking meals for patients.
- The facility purchased meals from a company that shipped them pre-packaged.
- The meals arrived to the facility frozen, and were reheated by kitchen staff in the oven, removed from the plastic containers, and placed on plates before being served to the patients.
- The facility dietician signed off on the analysis (the process of determining the nutritional content of foods and food products) of the meals prior to the start of service to the patients.

During an interview on 03/22/16 at 9:30 AM, Patient #6 stated that he had been in the hospital for four days and had not been offered any choices for meals. He stated that the food did not taste very good.

During a telephone interview on 03/23/16 at 10:00 AM, Staff L, Registered Dietician, stated that:
- In regards to the Recommended Daily Allowances of the pre-packaged meals; she was concerned about the calories. She thought that they could choose and would pick a higher calorie option possibly later in the day.
- She had reviewed the Nutrient Analysis of the pre-packaged meals.
- Not all patients received a nutritional assessment by the Dietician. The assessment was triggered by a nursing referral based on certain criteria.
- Based on the lower percentages of calories, patients who did not get assessed by the dietician to have added calories put on their meal trays, could be at risk of improper nutrition.
- They were meeting the needs of two out of three patients.
- "The patients I don't see could be at risk."

The pre-packaged meals did not meet 100% of the recommended daily allowance of calories and nutrients for the average patient.
The facility failed to realize the potential for inadequate nutrition for all patients in the facility, including those that were not assessed by the RD.

2. Record review of the facility policy titled, "Fluid Restriction," dated 10/09/2014, stated the following:
- Dietary will limit total fluid as per the physician order with an allowance for nursing of 240 milliliters (measurement of capacity) for medication pass.
- The physician will write a diet order for fluid restriction.
- The fluid volume allowed per each meal will be printed on the patient's tray card which is printed or filled out by the dietary staff based on the physician's orders.

3. Record review on 03/24/16 of Patient #2's medical record showed that Patient #2 was admitted on 03/21/16 with the diagnosis of pyelonephritis (an inflammation of the kidney as a result of a bacterial infection) and hyponatremia (a condition that occurs when the level of sodium, an element in the fluid surrounding cells, in your blood is abnormally low.) Physician orders dated for 03/22/16 at 09:22 AM, showed an order of a 1000 ml Fluid Restriction.

4. Observation of meal preparation on 03/22/16 at 12:00 PM showed the following:
- Staff S, Dietary Staff, prepared the tray for Patient #2.
- Staff S poured half of a large glass of lemonade which was not measured (estimated at 120 ml), and added ice for Patient #2.
- Staff S added a carton of milk (approximately 240 ml) for patient #2.

5. Review of document titled, "Patient Diets by Room," showed that the report was run on 03/22/16 at 11:30 AM. Patient #2 was documented to receive a Regular Diet with a 1000 ml Fluid Restriction. There was no breakdown of the fluids needed specific to the lunch meal that was being prepared.

During a telephone interview on 03/23/16 at 10:00 AM, Staff L, Registered Dietician, stated that:
- "Dietary knows how much they get and nursing gets the rest."
- She was not aware that the fluid volumes per meal were not broken out on the individual meal tickets that dietary received.
- Lemonade that included ice as well as milk; "sounds like too much and they should not have given ice."
- "Fluid restrictions are an important part of the diet and we should not take it lightly."









29511

Based on observation and interview, the facility failed to ensure the current Therapeutic Diet Manual was available to patient care staff to use as a diet reference on the inpatient unit. This deficient practice had the potential to permit staff to serve patients placed on therapeutic diets, inappropriate or unapproved foods. The facility census was three.

Findings included:

1. Observation and concurrent interview on 03/22/16 at 3:15 PM on the Inpatient Unit, showed Staff J and Staff K, both Registered Nurses (RN):
- Searched through loose-leaf binders on a shelf near the front desk of the unit as well as the back office of the nurse's station where other resources were kept;
- Were unable to locate the Therapeutic Diet Manual; and
- Stated that they did not know where one was located, but that they were always able to call the dietary manager if they had any questions.

2. During an interview on 03/22/16 at 4:34 PM, Staff A, Dietary Manager, stated that the Therapeutic Diet Manual was not located on the unit because staff were able to access it online. Staff A stated that the nursing staff often forgot this resource, but that they would be re-educated.

Based on observation, interview, record review, and policy review, the facility failed to ensure that the appropriate temperature standards were met on the dishwasher located within the dietary department. This failure increased the risk of food-borne illnesses to all patients admitted to the facility. In addition, the facility failed to ensure that opened containers were labeled with the date they should be discarded and that expired supplies were removed from the Emergency Department (ED) treatment area. These failures had the potential to cause ineffective or harmful products to be used for patient care. The facility census was three. The ED evaluates approximately 20 patients per day.

Findings included:

1. Record review of the facility's policy titled, "Isolation Trays," revised 02/2013, showed the directive regarding dishwashing machine temperatures. The minimum wash temperature was listed as 120 degrees, and the minimum rinse temperature was listed as 120 degrees.

2. Record review of documents titled,"Dishmachine Temperatures and Sanitizing Parts Per Million (the strength of the sanitization solution)", showed that the temperatures were found to be below 120 degrees approximately 46 times from 10/01/15 through 03/22/16. The document had a notation located at the bottom which directed staff in the following: "If the temperature is higher than 150 degrees or lower than 120 degrees, contact Supervisor."

During an interview on 03/22/16 at 12:00 PM, Staff A, Food Service Manager, stated that the standard was for Dietary staff to alert her if dishwashing machine temperatures were out of range. Staff A stated that Dietary staff had not alerted her to any out of range temperatures.

3. Record review of the facility's policy titled, "Dating of Sterile Containers," dated 08/07/15, showed the directive for staff to label a container with the date to discard 28 days from when it was opened and to discard products 28 days after opening.

4. Observation in the facility ED on 03/21/16 at 3:00 PM showed a total of seven opened containers of povidine/iodine solution (a liquid used to decontaminate skin of germs), that contained at least half of the original 16 ounces, in the ED treatment rooms. In addition, there were five opened containers of 0.9% normal saline (a liquid used to clean skin/wounds) for irrigation (process when solution was poured into wound to clean), 500 milliliters (ml, a unit of measure), in the ED treatment rooms. The contents that remained in the containers, ranged from approximately one quarter to three quarters of the original amount. None of the opened containers were labeled with a date opened or a date to discard.

During an interview on 03/21/16 at 3:15 PM, Staff B, Quality/Infection Control Registered Nurse (RN), stated that the opened containers should be labeled with the date they should be discarded.
Even though requested, the facility failed to provide an expired supply policy.

5. Observation in the ED on 03/21/16 at 3:45 PM showed a sterile over pack (bundle of supplies wrapped in blue paper and enclosed in plastic to indicate the contents had been sterilized) marked, "ED kit." The pack was labeled, "expires 05/15," (sterility of contents could only be assured until 05/15).

During an interview on 03/21/16 at 3:55 PM, Staff B, stated that the ED kit contained sterile towels, instruments, bowls and gauze pads. Staff B stated that these kits were not currently used in the ED and she wasn't sure why it was still there.






29511

Based on observation, interview, and policy review the facility failed to ensure that staff followed infection control policies and standards for patient care when they failed to:
- Perform hand hygiene after touching contaminated environmental objects and prior to administration of medication by mouth for one patient (#2) of one patient observed.
- Perform hand hygiene (wash hands with soap and water or use hand sanitizer) and change gloves after touching contaminated inanimate objects (areas/equipment that were not clean) and prior to administration of medication through a nebulizer (a device that turns liquid medication into a mist for inhalation into the lungs), for one patient (#3) of one patient nebulizer treatments observed.
- Document the date, time, and staff initials on intravenous (IV) catheter (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) dressing for one of one patient (#2) and failed to label the IV tubing for two of two patients (#2 and #5).
- Maintain aseptic technique (free from germs that cause disease) when nebulizer treatment was administered to one patient (#6) of one patient nebulizer treatment observed.
- Change gloves throughout the process of food being prepared by one dietary staff (S) of one observed.
- Cover all hair completely while food was prepared by two staff (S and A) of two observed.
- Perform appropriate hand hygiene during meal delivery by one staff (S) of one observed.
- Maintain appropriate temperatures for patient food trays.
- Clean shared exercise equipment between patient use potentially exposing all rehabilitation patients to communicable diseases, cross contamination and high risk for infection.
These deficient practices had the potential to increase the risk of infection and cross contamination and placed all patients, visitors, and staff at risk for infection. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Infection Prevention and Control Plan," dated 01/24/11, directed staff to follow the Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene in Healthcare Settings.

Record review of the CDC's "Guideline for Hand Hygiene in Health-Care Settings," dated 10/25/02, showed that healthcare providers should practice hand hygiene at key points in time to disrupt the transmission (transfer) of microorganisms (organisms, such as bacteria, too small for the naked eye) to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings).

Record review of the facility's policy titled "Hand Sanitizing and Glove Use," dated 08/16/15, directed staff to remove gloves whenever they became soiled, and perform hand hygiene and change gloves if they became contaminated.

2. Observation on 03/21/16, at 3:30 PM, showed Staff E, Registered Nurse (RN), failed to perform hand hygiene after she touched Patient #2's contaminated armband, armband scanner, and computer keyboard, prior to administration of medication by mouth.

During an interview on 03/22/16 at 10:10 AM, Staff G, Chief Nursing Officer (CNO), stated that she expected Staff E, RN, to perform hand hygiene after touching computer equipment, before administering medication.

3. Observation on 03/21/16 at 4:20 PM, showed Staff C, Respiratory Therapist (RT), while he was preparing to administer medication to Patient #3 through a nebulizer, touched the contaminated computer keyboard, the patient's skin, and inside his jacket pockets. Without removing gloves and performing hand hygiene he inserted the nebulizer into the patient's mouth and administered medication.

During an interview on 03/22/16 at 3:15 PM, Staff C, RT, stated that his standard procedure was to perform hand hygiene and glove when entering a patient's room and perform hand hygiene after removing gloves when leaving a patient's room. He did not know that his hands/gloves were contaminated after touching a patient, items in his pockets, and environmental equipment.

During an interview on 03/24/16 at 10:38 AM, Staff B, Director of Quality/Risk, Infection Control, Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Employee Health, stated, "If we are bringing things in from the outside and putting our hands in and out of our pockets we could be contaminating the patient's environment. I've not been paying enough attention and we should be performing hand hygiene before putting on gloves, after taking them off, and after exposure to inanimate objects".

4. Record review of the facility's policy titled, "IV Therapy Insertion-Staff Training," dated 08/18/15, directed nursing staff to label IV dressings with the date and their initials.

5. Observation on 03/21/16 at 4:10 PM, showed Patient #2's IV dressing with no date, time, or initials, and her IV tubing was not labeled.

6. Observation on 03/22/16 at 10:25 AM, showed Patient #5's IV tubing not labeled.

During an interview on 03/21/16 at 4:15 PM, Staff G, CNO, stated that she expected nurses to label IV dressings with the date, time, and initials, and label IV tubing with the date it needed to be changed.

7. Record review of the facility's undated policy titled, "Aerosolized Medication Therapy," showed directives for staff to assemble the equipment using aseptic technique and return the nebulizer circuit (mouthpiece and tubing) to the patient's equipment bag (plastic bag at the head of bed where nebulizer was stored in between use).

8. Observation on 03/22/16 at 9:10 AM showed Staff C, RT, prepared to administer Patient #6 a nebulizer treatment. Prior to being utilized, the nebulizer mouthpiece was located in the patient's equipment bag, however, about six inches of the oxygen tubing, including the hub (part of the tubing that attached to the oxygen port), laid on the floor. Staff C administered the nebulizer treatment to Patient #6. After the treatment Staff C removed the mouthpiece, rinsed it, returned it to the equipment bag, removed the oxygen tubing from the port and allowed it to drop back on the floor.

During an interview on 03/22/16 at 9:40 AM, Staff C stated that he never noticed that the tubing was on the floor prior to, or after, the treatment. Staff C returned to the room and confirmed that the tubing was on the floor. Staff C stated, "I know better than that" and threw the nebulizer circuit into the trash.
During an interview on 03/24/16 at 10:38 AM, Staff B stated, "That shouldn't have happened. The tubing is to be kept in a bag until needed and then put back into the bag. The tubing should never touch the floor and then be used on a patient".

9. Record review of the Food and Nutrition Services policy titled, "Glove Wearing," revised 02/2013, showed staff direction to change gloves when changing job tasks, and also to change gloves if they become contaminated from touching one's hair or face with a gloved hand.

Record review of the Food and Nutrition Services policy titled, "Hair Restraints," revised on 02/2013, showed that all hair must be covered by a hair restraint while in the kitchen area.

Record review of the Food and Nutrition Services policy titled, "Hand Washing/Hand Sanitizing," revised 02/2013, instructed staff using hand antiseptic to wet hands thoroughly with product and allow drying.

10. Observation of Staff S, Dietary, on 03/22/16 at 12:13 PM, showed no glove change for the following:
-Removed lemonade from the refrigerator, poured the lemonade, and covered the drinks prior to placing on the trays.
-Removed milk from the refrigerator and placed on the trays.
-Removed instruments from drawers.
-Numerous times touched the side of the cart that delivered the trays to patients.
-Removed the trays from the oven.
-Reached up and wiped her face with her gloved hand during the time she removed food from the trays and placed it on plates.
-On numerous occasions touched a tub of paper thermometers, and reached into this tub to remove them for each food item.
-Touched food with gloved hands as she arranged it on a plate.

11. Observation on 03/22/16 at 12:12 PM showed Staff S, and Staff A, Dietary Manager, in the kitchen with hair coverings. The hair covering for Staff S did not completely cover the side of her head, and loose strands were exposed. The hair covering for Staff A did not cover the bottom of her head, and hair was exposed.

12. Observation on 03/22/16 at 12:29 PM showed Staff S, utilized hand sanitizer and only cleansed the palms of her hands. This occurred outside of a patient care room on the inpatient unit prior to entering the room with the meal tray, and also occurred upon the exit from the room.

During an interview on 03/22/16 at 12:33 PM with Staff D, Chief Executive Officer, confirmed that the hand hygiene practiced by Staff S was inappropriate and did not follow policy.

13. Record review of the "United States Department of Health and Human Services Food Code," dated 08/2015, stated that food that is cooked and received hot shall be at a temperature of 135 degrees Fahrenheit or above.

14. Observation and concurrent interview on 03/22/16 at 12:35 PM showed Staff A, Dietary Manager, monitored the temperature for food items on a Test Tray (a meal tray not utilized for consumption, but prepared for the purpose of testing the temperature of the meal that has been served to the patients). The tray contained Broccoli, Sweet Potatoes, and Chicken with recorded temperatures that ranged from 120 degrees to 131 degrees. Staff A stated that she expected temperature for the Broccoli, Sweet Potatoes, and Chicken should be at least 135 degrees.

15. Record review of the Centers for Disease Control and Prevention (CDC), Guide to Infection Prevention for Outpatient Settings, Minimum Expectations for Safe Care showed key recommendations for cleaning and disinfection of environmental surfaces in ambulatory care settings were to establish policies and procedures for routine cleaning and disinfection of environmental surfaces in ambulatory care settings, and focus on those surfaces in proximity to the patient and those that are frequently touched.

16. Observation on 03/22/16 at 3:20 PM of the Inpatient/Outpatient rehabilitation facility showed several pieces of exercise equipment used for muscle strengthening and rehabilitation. There were also wooden stairs with rails and a vinyl covered platform the size of a large bed.

During concurrent interviews on 03/22/16 at 3:20 PM, Staff X, Director of Rehabilitation and Home Health, and Staff Y, Physical Therapy Assistant, stated that the exercise equipment was cleaned at the end of the day and as necessary. They stated that they did not clean the shared equipment after each use and did not have policies and procedures for cleaning the rehabilitation equipment.

During an interview on 03/23/16 at 3:30 PM, Staff B, Infection Control Officer, stated that she had never gone to the Inpatient/Outpatient Rehabilitation facility to observe patient care or infection control practices. She agreed that the rehabilitation exercise equipment should be cleaned after each patient use.



27029









29511









36474

Based on interview and record review the facility failed to have a Director of Rehabilitation Services qualified by knowledge or experience to oversee and evaluate the services provided to patients. This had the potential to adversely affect the quality of rehabilitation services provided to all patients seeking rehabilitative services. The facility census was three.

Findings included:

1. Record review of the personnel file for Staff X, Director of Rehabilitation (Rehab) and Home Health, showed that Staff X was a Registered Nurse (RN) and had no training, license or certification in rehabilitative services.

2. Record review of the Job Description for Director of Rehab Services showed that the qualifications/requirements for this position included performance of all essential responsibilities of a staff therapist regarding patient care. Graduate of an accredited educational program with minimum of a Bachelor's degree in rehabilitation related field - prefer Masters or further credentials in the health care field.

During an interview on 03/22/16 at 3:20 PM, Staff X stated that she was the only nurse for Home Health Services and spent most of her time providing care to patients in their homes. She stated that the former Director of Rehabilitation Services left about two years ago and she was given the title of Director of Rehab at that time. Staff X stated that she supervises two Physical Therapists and one Physical Therapist Assistant. She stated that they have not provided Occupational Therapy since 12/2014 or Speech Therapy for six months. She stated that she is not a therapist but an RN and is not involved with the inpatient or outpatient rehabilitation.