HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:

1) Failing to develop and implement policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. (see findings in tag A-0535)

2) Failing to ensure there was a radiologist who was a member of the medical staff that supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546)

Based on review of medical records and staff interview, the Governing Body failed to ensure the members of the medical staff were held accountable to the Governing Body for the quality of care provided to the patients as evidenced by medical staff members not assessing and pronouncing death for 2 (#8, #21) of 2 deceased patients' medical records reviewed. Findings:

Review of the hospital policy titled "Pronouncement of Patient Death", Policy number I.F.6.19, effective date of 12/10/14, (Approved by: left blank), revealed in part the following: ....If the code is stopped and patient has expired, EMS (Emergency Medical Services) can obtain a verbal pronouncement of death from the coroner, but not from the hospital ER physician....

Review of the Medical Staff Rules & Regulations adopted 11/07/11 revealed no documented evidence of any provisions related to the pronouncement of patient death in the hospital.

Patient #8
Review of the medical record for Patient #8 revealed the patient was a 58 year old male admitted to the hospital on 10/03/14 with diagnoses of Anoxic Brain Injury and Cerebral Vascular Accident (Stroke). The patient expired at the hospital on 10/04/14. Further review of the medical record revealed the ambulance paramedics assisted with the code and the paramedics called S27MD at Hospital A to confirm and call the code at 7:30 a.m. on 10/0414. Review of the Death Summary documented by S19MD (Physiatrist on staff at hospital) revealed the patient was pronounced dead by S27MD prior to the arrival of S19MD.

An interview was conducted with S2CCO (Chief Clinical Officer) on 12/11/14 at 2:50 p.m. S2CCO reviewed the medical record for Patient #8 and confirmed S27MD did pronounce the death over the phone and he (S27MD) was not on the medical staff of the hospital. She confirmed S27MD was an emergency room physician at Hospital A. S2CCO confirmed the hospital policy indicated hospital emergency room physicians could not pronounce patients.


Patient #21
Review of the medical record for Patient #21 revealed the patient was a 44 year old male that was admitted to the hospital on 09/26/13 for Traumatic Brain Injury with Subdural Hematoma and Respiratory Failure with Mechanical Ventilation. Review of the record revealed the patient went into respiratory arrest and a Code Blue was called on 10/12/13 at 5:00 a.m. EMS responded, intubated the patient and provided CPR & ACLS (Cardio Pulmonary Resuscitation and Advance Cardiac Life Support). The record revealed the patient was pronounced dead by the emergency room physician at Hospital A via telephone to the paramedic at 5:45 a.m.

An interview was conducted with S2CCO (Chief Clinical Officer) on 12/11/14 at 2:50 p.m. S2CCO reviewed the medical record for Patient #21 and confirmed an emergency room physician from Hospital A did pronounce the death over the phone and the physician was not on the medical staff of the hospital.

Based on record review and interview the hospital failed to establish a process for prompt resolutions of patients' grievances as evidenced by the hospital's policy on grievances stating a response letter would be sent to a concerned party within 10 days if the grievance was filed after a patient was discharged from the hospital. Findings:

Review of the facility policy titled Patient/Family Grievance, Policy Number I.A.1.02, dated 08/21/2012 revealed in part: C. Complaint/Grievance Process Post-Discharge.
1. In the event the Administrative Representative receives a complaint post discharge, then the complaint shall be handled as a grievance, as noted above in Section B. Grievance. An Event will be entered in the database and the appropriate manager will be notified for investigation.
2. Administration will be contacted and the issue will be reviewed and investigated within 10 days of receipt.
3. The Case Manager, DON (Director of Nurses) and/or Administrative Representative will send follow up letter to the concerned party regarding the concern and may follow-up with the patient via telephone..."

An interview was conducted with S2CCO on 12/10/2014 at 1:15 p.m. She reported she was in charge of handling grievances and complaints in the hospital. S2CCO verified, after reviewing the hospital's policy for Grievances and Complaints, that grievances that are filed after a patient was discharged didn't meet the federal regulation if the letter was sent to the concerned party within 10 days.

Based on record review and interview the hospital failed to ensure a written response to a grievance was provided for 2 of 3 (R4, and R5) that occurred in 2014. Findings:

Review of the facility policy titled Patient/Family Grievance, Policy Number I.A.1.02, dated 08/21/2012 revealed in part: B. Grievance.
" ... 3. The Case Manager, Director of Nurses or the Administrative Representative will review the concern and note any additional steps taken to resolve the patient/family/representative's grievance. The Event Report is submitted to the Administrator. The patient/family/representative will be kept informed of all efforts made to resolve their grievance and will receive a written acknowledgement within 5 days of receipt from the hospital Administrator (designee) ..."

Definitions
Patient/Family Complaint - is defined as a patient/family member or representative's expression of displeasure or dissatisfaction with service received. A resolution is achieved at the time of the complaint by staff present or who can quickly be at the patient's location to resolve complaint.
Patient/Family Grievance - is defined as something that affords just cause for complaint or protest; and/or an issue unresolved following the normal complaint procedure that cannot be resolved promptly by staff present. It can be submitted in written or oral form by patient and/or family member or representative, regarding patient care, abuse or neglect. Or issues related to the hospital's compliance to CMS requirements.

1. Review of the Grievance Log revealed on 7/30/2014 Patient #R4 had informed the physician of an incident that had taken place on 7/14/2014. An immediate investigation began and was categorized as a complaint not a grievance. There was no documentation of a letter sent to the patient.

An interview was conducted with S2CCO on 12/11/2014 at 3:15 p.m. She reported that she was responsible for handling grievances and complaints in the hospital. S2CCO verified the incident on 7/30/2014 was classified as a complaint and should have been a grievance and the facility's policy was not followed per definition. She confirmed there was no letter sent to the patient.

2. Review of the Grievance Log revealed on 8/01/2014 a grievance was submitted by patient R5. The incident was categorized as a complaint and an investigation was conducted. There was no documentation of a letter sent to the patient and/or family.

An interview was conducted with S2CCO on 12/11/2014 at 3:15 p.m. S2CCO reported that the incident was generated from comments received by the hospital after the patient was discharged. S2COO stated the patient was transferred to another hospital and staff at the receiving hospital reported the family's complaints to the hospital's nurse liaison. She confirmed there was no letter sent to the patient after the investigation was completed.









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Based on record review and staff interview, the hospital failed to ensure the QAPI program:
1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in reporting laboratory results after the same corrective action was unsuccessful, and;
2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level.

Findings:

1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in reporting laboratory results and medical records after the same corrective action was unsuccessful:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06 revealed in part the following: The Organizational Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services. Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optional achievements, with appropriate accountability assumed by the Governing Board, Medical Staff, Administration, and support personnel.

Review of the Performance Improvement Tracking report for the Quality Indicator of Critical Test Results-Laboratory communicated timely revealed the total compliance percentage for the past 12 months was 49%. Review of the monthly totals revealed the following:
April - 80%
May - 0% (No critical labs done)
June - 67%
July - 33%
August - 50%
September - 0% (No critical labs done)
October - 0% (No critical labs done)
November - 75%
Review of the documented corrective action plan to address the failure to meet the hospital's goal of 94% compliance with the reporting of critical lab results revealed, "Review with nurse the importance of reporting abnormal laboratory results to physician in a timely manner" was the only action identified and implemented.

In an interview on 12/10/14 at 2:30 p.m., S3IC/QA (Infection Control/Quality Assurance) confirmed she was responsible for QAPI. S3IC/QA stated the quality indicator for reporting critical lab results was chosen by the corporate office and implemented in all the affiliated hospitals. S3IC/QA verified there was no trending of the staff done and no evaluation of the causative factors related to the staff non-compliance. S3IC/QA confirmed the only corrective action was to remind the nursing staff of the importance of timely reporting. S3IC/QA confirmed the interventions implemented had not been effective.


2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level.

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06 revealed in part the following: R. Facility Specific Monitoring: The hospital will continually strive to identify areas of opportunity for improvement. As new services are implemented or opportunities for improvement are identified and corrective action is initiated; the facility will design performance improvement monitors to assure achievement of facility goals. These facility specific monitors will be dynamic and changing throughout the course of the year. These results of these monitors will be reported to the QAPI Committee during the monthly meetings until the discontinuation of the monitor.

On 12/10/14 at 1:30 p.m., the hospital's QAPI program was reviewed with S3IC/QA who indicated she was responsible for QAPI. When asked if the quality indicators being monitored were based on high-risk, high volume or problem prone activities, S3IC/QA stated the hospital was not able to identify their own indicators to address problems identified in this hospital. S3IC/QA stated the hospital's corporate office chose the quality indicators the hospital was to monitor and stated the quality indicators were the same for all the corporation's hospitals. S3IC/QA verified data was collected and entered into the Action Cue software system and the system generated reports from the quality indicator data entered by the individual departments.

Based on observations, record review, and staff interview, the hospital failed to ensure problems identified by infection control officers were addressed through QAPI program activities. Findings:

Review of the hospital policy titled, "Improving Organizational Performance Plan", Policy number I.E.5.06, effective date of 01/08/13, revealed in part the following: The Organizational Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services....To utilize results from Infection Control, Utilization Review, Risk Management, EOC (Environment of Care)) and Patient Safety to improve processes that affect patient care outcomes....

During the survey from 12/09/14 through 12/11/14 the following infection control breeches were observed:
a) An observation on 12/9/14 at 2:15 p.m. was made of S10Hskpg's cleaning cart being used for cleaning patient rooms with S10Hskpg. She was asked about the bucket of solution on her cleaning cart with the 2 (two) brushes in it. She indicated that the bucket contained the disinfectant cleaning solution used to clean patient bathrooms along with the 2 bathroom cleaning brushes. S10Hskpg indicated that she changes the bathroom cleaning solution after about every 3rd patient room and indicated that the brushes are used for about a week before they are changed. S10Hskpg further indicated that some housekeepers change the solution only once a day, but she liked to change it more often. She indicated that she was not aware of a hospital policy on cleaning patient bathrooms and that each housekeeper had their own routine.

In an interview on 12/10/14 at 9:00 a.m. with S3IC/QA she was made aware of the observation and interview with S10Hskpg. The hospital policy titled, "Cleaning of Patient Room", provided by S3IC/QA as the most current, was reviewed with S3IC/QA. S3IC/QA indicated that the hospital's policy on "Cleaning of Patient Room", did not address cleaning patient bathrooms. S3IC/QA further indicated that a fresh bathroom brush and fresh disinfectant cleaning solution should be used in each patient bathroom.

b) An observation on 12/9/14 at 2:45 p.m. was made of S10Hskpg folding laundered cleaning towels taken from the hospital's dryer. S10Hskpg indicated that housekeeping staff self-laundered the cleaning towels in the washer/dryer in the hospital.

In an interview on 12/10/14 at 9:00 a.m. with S3IC/QA she was asked about the hospital's Housekeeping Department self-laundering of the reusable cleaning towels, used for patient rooms.. S3IC/QA indicated that she was aware of this practice. She indicated that the Housekeeping Department did not always get all their cleaning towels back when they were sent to the contracted laundry, so the Housekeeping Department would self-launder the reusable cleaning towels in-house. S3IC/QA was asked if the hospital had an approved laundry facility or a policy on the self-laundering of the cleaning towels. S3IC/QA indicated that the hospital had no policy for on-site laundering and that the hospital did not have a washer and dryer that was in compliance with OSHA standards and/or with the laundry criteria established by The Joint Commission.

c) An observation on 12/11/14 at 11:15 a.m. was made of S14LPN performing a glucose blood test on Patient R3 in his room. After the glucometer was used, S14LPN placed the soiled glucometer on the patient's bedside table and then picked it up again and placed it on her procedure table. S14LPN rolled her procedure table to the nurse's desk and then got a disinfectant wipe to clean the soiled glucometer before placing it back into its container. S14LPN was not observed disinfecting the patient's bedside table or her procedure table after placing the soiled glucometer on them .

In an interview on 12/11/14 at 1:30 p.m. with S3IC/QA she was made aware of the infection control breach while the glucometer was being used by S14LPN for Patient R3. S3IC/QA indicated that S14LPN should have cleaned the glucometer immediately after patient use and should not have placed the soiled glucometer on the patient's bedside table or on her procedure table.

d) An observation on 12/9/14 at 3:15 p.m. of the Rehabilitation Therapy Department revealed the following: 3 (three) used blood pressure cuffs in the basket on the blood pressure machine located in the Therapy Department, a disposable foam cushion located in the Therapy Department's clean equipment storage area, 3 (three) noodle styrofoam cylinders located in the Therapy Department's clean equipment storage area, and a 3 inch x 3 inch x 4 inch tear on the top of the Therapy Department's patient exercise mat.

In an interview on 12/9/14 at 3:30 p.m. with S8Therapy Director, she indicated that the 3 blood pressure cuffs were used by patients, were single patient use and that they should not have been left on the blood pressure machine in the Therapy Department. S8Therapy Director was asked how the therapists disinfected the foam cushions and the styrofoam noodles after each patient use. S8Therapy Director indicated that the therapists wipe the items with an EPA disinfectant wipe after patient use. S8Therapy Director indicated that the foam cushion and the styrofoam noodles were porous and probably could not be disinfected adequately with the disinfectant wipes. She further indicated that they probably should be single patient use only and should not be reused for multiple patients. S8Therapy Director was asked how the therapists disinfected the exercise mat with the tear in it after each patient use. S8Therapy Director indicated that the torn exercise mat probably could not be disinfected adequately with the disinfectant wipes either. She further indicated that the torn patient exercise mat probably should be replaced or recovered.

e) An observation on 12/9/14 at 10:45 a.m. revealed a soiled single patient use blood pressure cuff in the basket on the blood pressure machine located in the clean equipment room. Also, observed were 2 (two) cleaned intravenous pump machines located on the floor of the clean equipment room.

f) An observation on 12/9/14 at 10:55 a.m revealed a biohazard sharps container on the nurse's medication cart filled to the full line with used sharps. Another observation on 12/11/14 at 11:00 a.m revealed the same biohazard sharps container on the nurse's medication cart filled over the full line with used sharps.

g) An observation on 12/9/14 at 11:00 a.m of the nurse's wound care cart revealed 1 out of 6 sterile steri strip adhesive packs opened and 1 out of 5 sterile iodoform bottles opened (seals broken) in the drawer of the wound care cart, available for other patient use.

h) An observation on 12/9/14 at 11:15 a.m. of the patient refrigerator revealed 14 (4 ounce) juice cups with no identifiable expiration dates on them.

In an interview on 12/9/14 at 11:30 a.m. with S3IC/QA she was made aware of the above observations (e, f, g, h). S3IC/QA indicated that the blood pressure cuffs were single patient use and should not be on the blood pressure machine for potential use by other patients. She further indicated that the cleaned intravenous pumps should not be stored on the floor after they were disinfected. S3IC/QA indicated that the biohazard sharps container should have been replaced when the full line was reached. S3IC/QA indicated that juice cups for patient use should be labeled with the expiration date or left in their original carton where the expiration dates were visible.

i) An observation on 12/9/14 at 3:00 p.m. was made of S7CNA cleaning a blood pressure machine in a patient's room with the hospital's EPA disinfectant wipes without gloves on. The directions on the EPA disinfectant wipe container revealed that personnel should wear gloves when using the product.

In an interview on 12/11/14 at 2:00 p.m. with S3IC/QA she was asked about the Infection Control Program's surveillance and monitoring. S3IC/QA indicated that the infection control indicators, that were monitored, tracked and trended, were established by the hospital's corporate office and were as followed: catheter associated urinary tract infections, clostridium difficile infections, hand hygiene and hospital acquired infections. S3IC/QA indicated that if she observed any other infection control issues or breaches, she would do an in-service with staff. S3IC/QA indicated that she would not collect data or do any analysis/tracking to identify any trends to include interventions and evaluations. S3IC/QA further indicated that she was not aware of the above infection control breaches (a, c, d, e, f, g, h, i). She indicated that she only monitored the corporate-established infection control indicators incorporated into the hospital's Infection Control Program and she was unable to edit the program or add new infection control monitoring indicators. S3IC/QA confirmed Laundry/linen services were not included in the QAPI program.

Based on record review and staff interview, the hospital failed to ensure performance improvement projects were conducted annually as evidenced by no current performance improvement project selected or conducted. Findings:

Review of the hospital policy titled, "Improving Organizational Performance Plan", Policy number I.E.5.06, effective date of 01/08/13, revealed no documented evidence of any provisions for performance improvement projects.

On 12/09/14 at 10:10 a.m., during the entrance conference, the hospital's Quality Improvement Projects were requested for review.

On 12/10/14 the hospital's QAPI plan/policy, data, reports, and minute meetings were provided for review. There was no documented evidence of a quality improvement project.

In an interview on 12/10/14 at 1:45 p.m., S3IC/QA (Infection Control/Quality Assurance) verified she was responsible for QAPI. S3IC/QA stated the hospital had no documentation of any current or past Quality Improvement Projects.

In an interview on 12/11/14 at 11:40 a.m. S2CCO (Chief Clinical Officer) stated she was responsible for quality improvement up until November 2014. S2CCO stated the hospital had a Quality Improvement Project for Vancomycin usage. S2CCO stated the project started sometime after 2/20/13 and stated the project was ongoing. S2CCO further stated the project was selected based on a conference call with the hospital's corporate office and the representative from the quality improvement software program. S2CCO stated the corporate office offered several options for a project. S2CCO stated she had noticed a lot of Vancomycin use, so when corporate mentioned the Vancomycin usage project, she chose that one. After reviewing the ActionCue (QAPI software program) quality indicators, S2CCO confirmed the quality indicator for Vancomycin Use was 100% compliance for the months from December 2013 to November 2014. S2CCO confirmed Vancomycin use was no longer a problem and stated they needed to select a new QAPI project. S2CCO confirmed the hospital did not have a current performance improvement project.

Based on records review and interview, the hospital failed to ensure that its quality assessment and performance improvement (QAPI) program reflected the complexity of the hospital's organization and services as evidenced by failure of the hospital to include all hospital departments and clinical care services provided by contract or arrangement in its QAPI monitoring.
Findings:

Review of the hospital policy titled, "Improving Organizational Performance Plan", Policy number I.E.5.06, effective date of 01/08/13, revealed in part the following: B. Scope of Activities and Services. All improvement activities performed will cover the patient focused functions and organizational functions. These activities are designed to assess key functions of patient care and to identify, study, and correct problems and improvement opportunities found in the process of patient care delivery. The scope of the Performance Improvement Program includes measurement and assessment activities which address patients served by the Medical Staff, Nursing, and ancillary services and hospital wide functions. Both clinical and non-clinical departments are included.

Review of the Performance Measures for the past 12 months revealed there was no documented evidence that quality monitoring was conducted for the hospital service of Respiratory Therapy. Further review of the Performance Measures revealed there was no documented evidence of any quality monitoring for the contracted services of Laundry/linen, PICC (Peripherally Inserted Central Catheters) Insertion, Biohazard Waste, and Hemodialysis.

In an interview on 12/10/14 at 2:00 p.m., S3IC/QA (Infection Control/Quality Assurance) confirmed she was responsible for QAPI. S3IC/QA confirmed respiratory services was provided by the hospital directly and respiratory therapy was not included in the quality improvement program. S3IC/QA further confirmed the contracted services of Laundry/linen, PICC Insertion, Biohazard Waste, and Hemodialysis were not included in the QAPI program.

Based on records review and interview, the hospital failed to ensure that the governing body, medical staff, and administrative officials assured that the quality assessment and performance improvement (QAPI) program was implemented and maintained as evidenced by:
1) the governing body failing to review QAPI data and reports as directed by hospital policy;
2) the medical staff failing to review and report QAPI data and reports as directed by hospital policy;
3) failing to ensure QAPI meeting minutes were documented and maintained as directed in hospital policy, and;
4) failing to ensure distinct performance improvement projects were conducted annually.

Findings:

Review of the hospital policy titled, "Improving Organizational Performance Plan", Policy number I.E.5.06, effective date of 01/08/13, revealed in part the following:
D. Governing Board: The Governing board shall require review and evaluation of patient care activities to assess, preserve, and improve the overall quality, safety and efficiency of patient care and services in the hospital. While maintaining overall responsibility, the Board delegates operational authority to the Medical Staff and Administration....The Board will receive, review, and accept or reject periodic reports on findings, actions, and results of the program activities, and recommend prioritization and reprioritization of performance improvement needs....
E. Medical Executive Committee (MEC)....The Committee delegates the responsibility for the monitoring and evaluation functions to the QAPI Committee. A report of the MEC will be forwarded to the Board of Directors for review and approval at least quarterly. This includes a summary of the findings and actions of all quality improvement activities.
J. QAPI Committee: The QAPI Committee is a multidisciplinary committee that oversees all aspects of the Quality Improvement efforts throughout the facility. This includes....7. Maintains permanent record of its proceedings.


1) The governing body failing to review QAPI data and reports as directed by hospital policy:
Review of the Governing Body meeting minutes provided as the minutes for the past year revealed the following:
04/16/14 - Regular meeting of the governing body with no documented evidence of any review/approval of QAPI data or reports.
05/06/14 - Special meeting of the governing body with no documented evidence of any review/approval of QAPI data or reports.
06/03/14 - Regular meeting of the governing body with no documented evidence of any review/approval of QAPI data or reports.
06/25/14 - Special meeting of the governing body with no documented evidence of any review/approval of QAPI data or reports.
08/20/14 - Regular meeting of the governing body with documentation of a review and approval of the Performance Improvement Plan and a review/approval of the 2nd Quarter Performance Improvement Dashboard and the 2nd quarter Compliance report.
10/14/14 - Regular meeting of the governing body with no documented evidence of any review/approval of QAPI data or reports.

In an interview on 12/10/14 at 9:00 a.m., S2CCO (Chief Clinical Officer) reviewed the above Governing Body minutes and confirmed the only documented review of QAPI data by the Governing Body was in the 08/20/14 meeting.

In an interview on 12/11/14 at 9:30 a.m., S1ADM (Administrator) stated he attended the Governing Body minutes since his employment in June. S1ADM stated QAPI data was presented at the June Governing Body meeting but there was not a true discussion. S1ADM stated the Governing Body members were given information to review later. S1ADM confirmed the above minutes did not include documentation of QAPI review/approval by the Governing Body.


2) The medical staff failing to review and report QAPI data and reports as directed by hospital policy:
During the entrance conference on 12/09/14 at 10:10 a.m., the MEC meeting minutes for the past 12 months were requested for review.

On 12/10/14 at 9:00 a.m., the MEC meeting minutes for the past 12 months were again requested for review.
At 10:00 a.m., MEC meeting minutes dated 10/13/14 were provided for review. Review of the minutes revealed Quality Data was reviewed. No other MEC meeting minutes were provided for review.

In an interview on 12/10/14 at 12:35 p.m., S1ADM stated that prior to October 2014, the MEC was combined with the Governing Body and stated he did not have any other MEC minutes to provide for review. S1ADM confirmed there was no documented evidence that the Governing Body meeting minutes were combined with MEC and the only documentation of QAPI review by the Governing Body was the 08/20/14 meeting.


3) Failing to ensure QAPI meeting minutes were documented and maintained as directed in hospital policy:
During the entrance conference on 12/09/14 at 10:10 a.m., the QAPI Committee meeting minutes for the past 12 months were requested for review.

In an interview on 12/10/14 at 9:35 a.m., S3IC/QA (Infection Control/Quality Assurance) stated they have no minutes from any QAPI meetings conducted this year. S3IC/QA stated there was a new administrative secretary and she did not document the minutes from the QAPI meetings.

In an interview on 12/11/14 at 12:30 p.m., S2CCO provided, "Quality Assurance Meeting" minutes for 7/18/13 and 10/16/13. S2CCO stated she was unable to provide any QAPI meeting minutes after 10/16/13. S2CCO stated the meetings were conducted but the minutes were not documented.


4) Failing to ensure distinct performance improvement projects were conducted annually:
On 12/10/14 the hospital's QAPI plan/policy, data, reports, and minute meetings were provided for review. There was no documented evidence of a quality improvement project.

In an interview on 12/10/14 at 1:45 p.m., S3IC/QA (Infection Control/Quality Assurance) verified she was responsible for QAPI. S3IC/QA stated the hospital had no documentation of any current or past Quality Improvement Projects.

In an interview on 12/11/14 at 11:40 a.m. S2CCO (Chief Clinical Officer) stated she was responsible for quality improvement up until November 2014. S2CCO confirmed the hospital did not have a current performance improvement project.

Based on record review and staff interview, the hospital failed to ensure the Medical Executive Committee (MEC) followed the medical staff bylaws, rules & regulations as evidence by the MEC failing to meet quarterly and maintain a record of its proceedings:
Findings:

Review of the Medical Staff Bylaws adopted 11/07/11 and provided as current by S2CCO, revealed the MEC would meet at least quarterly and would maintain a record of its proceedings and actions.

During the entrance conference on 12/09/14 at 10:10 a.m., the MEC meeting minutes for the past 12 months were requested for review.

On 12/10/14 at 9:00 a.m., the MEC meeting minutes for the past 12 months were again requested for review. At 10:00 a.m., MEC meeting minutes dated 10/13/14 were provided for review. No other MEC meeting minutes were provided for review.

In an interview on 12/10/14 at 12:35 p.m., S1ADM stated that prior to October 2014, the MEC was combined with the Governing Body and stated he did not have any other MEC minutes to provide for review. Review of the Governing Body meeting minutes provided for review revealed no documented evidence that the MEC meeting was included. S1ADM confirmed there was no documented evidence that the Governing Body meetings were combined with MEC meetings.

Based on record review and staff interview the hospital failed to ensure History and Physical examinations were completed within 24 hours after admission to the hospital for 3 of 3 (#21, #24, #29) sampled patient records reviewed for History & Physical completion out of a total sample of 30 (#1-#30) . Findings:

Review of the Medical Staff Bylaws, Rules & Regulations adopted 11/07/11 revealed in part the following: 5.2.1 A complete history and physical examination shall in all cases be recorded within twenty-four (24) hours of admission of the patient by a practitioner or an allied health professional who has been granted privileges to do so....

Patient #21
Review of the medical record for Patient #21 revealed the patient was a 44 year old male admitted to the hospital on 09/26/13 with diagnoses of Traumatic Brain Injury and Respiratory Failure. Review of the record revealed the History and Physical and Post Evaluation was not completed until 09/30/13 (4 days after admission) by S11Medical Director.

In an interview on 12/11/14 at 3:00 p.m., S2CCO (Chief Clinical Officer) reviewed the medical record for Patient #21 and confirmed the History & Physical was not documented and on the patient's record within 24 hours of admission. S2CCO stated S11Medical Director had been delinquent in completing History & Physicals within 24 hours.


Patient #24
Review of the medical record for Patient #24 revealed the patient was an 84 year old female admitted to the hospital on 10/27/2014 with diagnoses of Polyarthritis with multiple joint involvement, and Osteoarthritis.

Further review of the medical record revealed the History and Physical and Post Evaluation was not completed until 10/29/2014.

Patient #29
Review of the medical record for Patient #29 revealed the patient was an 78 year old male admitted to the hospital on 12/8/2014 with diagnoses of CHF and COPD.

Further review of the medical record revealed the History and Physical and Post Evaluation was not completed, signed and dated until 12/10/2014.

Based on record review and staff interview, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by failure to provide after post mortem care for 2 of 2 (#8, #21) sampled death records reviewed out of a total sample of 30 (#1-#30). Findings:

Review of the hospital policy titled, "Imminent Death", Policy number I.A.1.12, effective date of 01/08/13, revealed in part the following: F. Care and identification of the body: 4. Post Mortem: All other deaths: The body should be clean. Bathe the patient if necessary. Remove all equipment, catheters, drains, tubes, etc. Apply clean surgical dressing to all wounds, if present. Change bed linens, apply disposable gown. Replace dentures if possible or place in labeled cup and send with body. Leave patient arm band in place. Remove all jewelry and give to family member. Document in nurses notes what was removed and person receiving.

Review of the hospital policy titled, "After Life Care", Policy number I.A.1.22, effective date of 05/2008 revealed in part the following: Document: Care of the body.

Patient #8
Review of the medical record for Patient #8 revealed the patient was a 58 year old male admitted to the hospital on 10/03/14 with diagnoses of Anoxic Brain Injury and Stroke. Review of the record revealed the patient went into respiratory failure and expired on 10/04/14 in the hospital. Review of the nursing documentation revealed no documented evidence that any post mortem care was provided.

Patient #21
Review of the medical record for Patient #21 revealed the patient was a 44 year old male admitted to the hospital on 09/26/13 with diagnoses of Respiratory Failure, Traumatic Brain Injury, and Schizophrenia. Review of the record revealed the patient went into cardio pulmonary arrest and expired on 10/12/13 in the hospital. Review of the nursing documentation revealed no documented evidence that any post mortem care was provided.

In an interview on 12/11/14 at 3:00 p.m., S2CCO (Chief Clinical Officer) reviewed the medical records for Patient #8 and Patient #21 and confirmed post mortem care of the bodies had not been documented by the nurse.

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Based on record reviews and interviews the hospital failed to ensure that the nursing staff developed and maintained a current nursing care plan, based on each patient's nursing care needs and not solely on those needs related to the admitting diagnosis, as evidenced by failing to develop comprehensive, individualized care plans for 5 (#1, #2, #6, #17, #24) of 19 (#1, #2, #3, #4, #6, #7, #9, #10, #13, #14, #15, #16, #17, #23, #24, #26, #29, #30) sampled patients reviewed for care planning out of a total sample of 30. Findings:
Review of the hospital policy titled, "Individual Plan of Care", Policy number I.C.3.38, effective date of 11/27/12, revealed in part the following: All patients will have an individualized plan of care that is individually tailored, integrated and coordinated. Each individual treatment plan is developed through the initial evaluation and team conference process in coordination with the attending physician and interdisciplinary team. The individual treatment plan include the following information presently behavioral: The individual's functional limitations and presenting needs, the patient's stated goals, the type of treatment and/or services to be provided, and revised when appropriate....

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 62 year old male admitted to the hospital on 11/15/14 with diagnoses of Severe Peripheral Vascular Disease with bilateral above the knee amputations, Myasthenia Gravis, Diabetes Mellitus, Hypertension, and Chronic Obstructive Pulmonary Disease.
Review of the record revealed the patient was receiving sliding scale insulin, wound care for an open wound to the Left Stump, and the patient sustained a fall on 12/03/14.
Review of the nursing care plan revealed only the following problems were identified and addressed with interventions and goals: Self-care deficit in bathing, toileting, dressing and grooming; Impaired physical mobility, and High Fall Risk Protocol. Review of the nursing care plan revealed no documented evidence that the care plan included the patient's problem of Diabetes Mellitus and sliding scale insulin use, or wound care for the Left Stump Wound. There was no documented evidence the nursing care plan was updated with new interventions after the patient sustained a fall on 12/03/14.

In an interview on 12/11/14 at 3:10 p.m., S2CCO (Chief Clinical Officer) reviewed the patient's record and confirmed the nursing care plan did not include the Diabetes Mellitus with sliding scale insulin administration and stated it should have been included. S2CCO) confirmed the patient was receiving wound care for the open wound on the Left Stump and the nursing care plan did not include interventions and goals for the wound. S2CCO also confirmed the care plan was not updated after the patient sustained a fall on 12/03/14. S2CCO confirmed patient care plans were to be updated with new interventions after the patient sustained a fall.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 69 year old female admitted to the hospital on 12/4/2014 with diagnoses of Left Sub-acute Parietal Infarct, Right AKA (Above the Knee Amputation), and CHF (Congestive Heart Failure). The patient had multiple wounds, right stump incision, left posterior heel, abdominal drain site, left medial heel, right gluteal, and right great toe.

Review of the Nursing Care Plans for Patient #2 revealed areas addressed were Impaired Physical Mobility, Pain, and Self Care Deficit. There was no documented evidence of any goals or interventions related to her wounds.

In an interview on 12/11/2014 at 1:50 p.m. with S2CCO indicated that a patient's care plan should include all the patient's diagnosed medical conditions. She confirmed that all nurses were responsible for updating or revising a patient's care plan. She further indicated that Patient #2's care plan should have included a care plan for wound care.

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 85 year old male admitted to the hospital on 11/21/14 with Spinal Stenosis, History of Lung Caner, and COPD (Chronic Obstructive Pulmonary Disease) with Acute Exacerbation.
Review of the Nursing Plan of Care for Patient #6 revealed the following Problems were identified: Skin Integrity, Impaired Physical Mobility, Self Care Deficit (Dressing, Grooming and Bathing) and Pain. There was no documented evidence of goals and interventions for his Acute Exacerbation of his Chronic Obstructive Pulmonary Disease (COPD).
An interview was conducted with S2CCO on 12/11/14 at 12:45 p.m. S2CCO reported all the patient's current medical issues should be included in the patient's care plan.

Patient #17
Review of the medical record for Patient #17 revealed the patient was a 77 year old male admitted to the hospital on 12/3/2014 with diagnoses of CVA (Cerebral Vascular Accident), Morbid Obesity, ESRD (End Stage Renal Disease), and Hypertension. The patient was on a 2gm (gram) Na (Sodium) Renal diet with 1000 cc (cubic centimeter) fluid restriction per day. The patient was to receive dialysis Monday-Wednesday-Friday at 4:00 p.m.

Review of the Nursing Care Plans for Patient #17 revealed areas addressed were Impaired Physical Mobility, Pain, and Self Care Deficit. There was no documented evidence of any goals or interventions related to his dialysis.

In an interview on 12/11/2014 at 1:50 p.m. with S2CCO indicated that a patient's care plan should include all the patient's diagnosed medical conditions. She confirmed that all nurses were responsible for updating or revising a patient's care plan. She further indicated that Patient #17's care plan should have included a care plan for dialysis.

Patient #24
Review of the medical record for patient #24 revealed the patient was an 84 year old female admitted to the hospital on 10/27/2014 with diagnoses of Polyarthritis with multiple joint involvement, and Osteoarthritis. The patient had wound care to her left foot great toe.

Review of the Nursing Care Plans for Patient #24 revealed areas addressed were Impaired Physical Mobility, Pain, Toileting, and Self Care Deficit. There was no documented evidence of any goals or interventions related to her wound care.

In an interview on 12/11/2014 at 1:50 p.m. with S2CCO indicated that a patient's care plan should include all the patient's diagnosed medical conditions. She confirmed that all nurses were responsible for updating or revising a patient's care plan. She further indicated that patient #24's care plan should have included a care plan for wound care.







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Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to current nursing standards and physician orders for 5 (#6, #12, #18, #22, #28) of 21 (#1, #2, #3, #4, #6, #7, #9, #10, #12, #13, #14, #15, #16, #17, #18, #23, #24, #26, #28, #29, #30) medical records reviewed for medication administration out of a sample of 30. Findings:

Review of the hospital's policy, Medication Management, Policy # II.N.14.00, reveled in part, Digitalis and derivatives-All patients receiving digitalis or any derivatives thereof shall have pulse check daily before administration and recorded on the medication sheet. If pulse is below 60 the drug shall be withheld and the physician shall be notified.

Patient #6
Review of the medical record for Patient #6 revealed he was a 85 year old male admitted to the hospital on 11/21/14 with Severe Spinal Stenosis.

Review of his Physicians Orders revealed an order for Metoprolol Succinate SR 50 mg (milligrams) po (by mouth) q (every) a.m.

Review of his Medication Administration Record (MAR) for 12/1/14, 12/2/14, 12/3/14, 12/5/14, 12/6/14, 12/7/14,12/8/14, and 12/9/14 revealed Metoprolol was administered at 0900. There was no documentation of his blood pressure and pulse being monitored before administration. A reminder was preprinted on the MAR to remind the nurses to record the patient's blood pressure and pulse prior to administration of the medication.


Patient #12
Review of the medical record for Patient #12 revealed she was a 85 year old female admitted to the hospital on 9/18/14 for Large Ischemic Stroke.

Review of the Physician Orders for 9/19/14 revealed an order for Lisinopril 10 mg po
(by mouth) q (every) day.

Review of the Medication Administration Record (MAR) revealed Lisinopril 10 mg was administered at 0900 on 9/21/14 and 9/26/14 without the patient's pulse or blood pressure being monitored. A reminder was preprinted on the MAR to remind the nurses to record the patient's blood pressure and pulse prior to administration of the medication.

Patient #16
Review of the medical record for patient #16 revealed the patient was admitted to the hospital on 11/28/2014 with diagnoses of Polyarthritis, and CVA.

Review of the Physician's Orders dated 11/28/2014 revealed an order for Metoprolol 25 mg (milligram) BID (twice a day), and Digoxin 0.125 mg q (every) day.

Review of Patient #16's MAR (Medication Administration Record) revealed Metoprolol 25mg was administered on 12/2 at 9:00 p.m., 12/3 at 9:00 a.m., 12/4 at 9:00 a.m. and 9:00 p.m., and 12/10 at 9:00 a.m. without the patient's blood pressure and pulse being assessed. Digoxin 0.125 mg was administered on 12/4/14 at 9:00 a.m. and 12/7/14 at 9:00 a.m. without the patient's apical pulse being assessed.

In an interview on 12/11/2014 at 2:20 p.m. with S2CCO confirmed the nurses should be documenting blood pressure and heart rates for those medications listed on the MAR. She further confirmed that pharmacy put reminders on the MARS for those medications requiring a blood pressure and/or heart rate.

Patient #18
Review of the medical record for Patient #18 revealed the patient was a 66 year old male admitted to the hospital on 06/24/14 for a Comminuted Femur Fracture, S/P (Status Post)Nail Placement in Left Femur and Parkinson's Disease.

Review of his Physician Orders dated 06/24/14 revealed an order for Metoprolol 50 mg. ER every morning.

Review of the Medication Administration Records for 06/25/14, 06/26/14, and 06/27/14, revealed the patient's blood pressure and pulse was not taken prior to the administration of the 9:00 a.m. doses. A reminder was preprinted on the MAR to remind the nurses to record the patient's blood pressure and pulse prior to the administration of the medication.


Patient #22
Review of the medical record for Patient #22 revealed he was 57 year old male admitted to the hospital on 10/8/14 for Anoxic Encephalopathy secondary to Respiratory Failure.

Review of his Physician Orders dated 10/8/14 revealed an order for Coreg 6.25 mg (milligrams) po (by mouth) with breakfast and supper. Also on the Physician orders was an order for Catapres 0.2 mg po by BID (twice daily).

Review of the Medication Administration Record for 10/08/14 at 2100 and 10/10/14 at 0730 and 0900 revealed the patient's blood pressure and pulse was not taken prior to the administration of his Coreg 6.25 mg. and his Catapres 0.2 mg. A reminder was preprinted on the MAR to remind the nurses to record the patient's blood pressure and pulse prior to administration of the medication.


Patient #23
Review of the medical record for Patient #23 revealed the patient was admitted to the hospital on 9/18/2014 with diagnoses of Peripheral Artery Disease, Bilateral AKA, Lupus, and DJD.

Review of the Physician's Orders dated 9/18/2014 revealed an order for Amlodipine 10 mg q day.

Review of Patient #23's MAR (Medication Administration Record) revealed Amlodipine 10 mg was administered at 9:00 a.m. on 9/21, 9/22, 9/23, 9/24, and 9/25 without the patient's blood pressure and pulse being assessed.

In an interview on 12/11/2014 at 2:20 p.m. with S2CCO confirmed the nurses should be documenting blood pressure and heart rates for those medications listed on the MAR. She further confirmed that pharmacy put reminders on the MARS for those medications requiring a blood pressure and/or heart rate.

Patient #24
Review of the medical record for Patient #24 revealed the patient was admitted to the hospital on 10/27/2014 with diagnoses of Polyarthritis, and Osteoarthritis.

Review of the Physician's Orders dated 10/27/2014 revealed an order for Metoprolol 50 mg (milligram) BID (twice a day).

Review of Patient #24's MAR (Medication Administration Record) revealed Metoprolol 50 mg was administered on 10/27 at 9:00 a.m. and 9:00 p.m., 10/30 at 9:00 a.m. and 9:00 p.m., 10/31 at 9:00 a.m. and 9:00 p.m., 11/2 at 9:00 a.m. and 9:00 p.m., 11/3 at 9:00 a.m. and 9:00 p.m., 11/4 at 9:00 p.m., and 11/5 at 9:00 a.m. without the patient's blood pressure and pulse being assessed.

In an interview on 12/11/2014 at 2:20 p.m. with S2CCO confirmed the nurses should be documenting blood pressure and heart rates for those medications listed on the MAR. She further confirmed that pharmacy put reminders on the MARS for those medications requiring a blood pressure and/or heart rate.

Patient #28
Review of the medical record for Patient #28 revealed the patient was a 71 year old female admitted to the hospital on 12/04/14 for a Comminuted Femur Fracture, S/P Nail Placement in Left Femur and Parkinson's Disease.

Review of his Physician Orders dated 12/04/14 revealed an order for Metoprolol 25 mg. ER at bed time.

Review of the Medication Administration Record for 12/10/14 at 2100 revealed the patient's blood pressure and pulse was not taken prior to the administration of the 9:00 p.m. dose. A reminder was preprinted on the MAR to remind the nurses to record the patient's blood pressure and pulse prior to the administration of the medication.

In an interview on 12/11/14 at 3:00 p.m., S2CCO (Chief Clinical Officer) reviewed the above patient medical records and confirmed the nurse failed to document the patients' blood pressure and heart rate as directed on the MAR prior to administering the medications. S2CCO confirmed her expectation was for the nursing staff to document the patient's vital signs on the MAR as prompted by the pharmacy.

Based on record review, observations and interview, the hospital failed to ensure medical records were promptly completed and protected from water and fire damage. The hospital failed:
1. to protect approximately 260 medical records from water and fire damage. This was evidenced by approximately 200 medical records in the Medical Record Department being stored on top of desks, carts, and shelving. Approximately 60 medical charts were stored on open shelving in the dictation room awaiting physicians to dictate the medical information.

2. to promptly complete medical records. This was evidenced by failing to have discharge summaries completed for patients from January 2013 to January 2014.
Findings:

Review of the hospital policy, Health Information Management Plan, Policy III.O.15.00, revealed in part, I. Protection: 1. Records and information are protected against loss, destruction, tampering, and unauthorized access or use.

1. Failed to protect approximately 260 medical records from water and fire damage.

An observation was conducted on 12/9/14 at 11 a.m. of approximately 200 medical records in the Medical Records Department being on top of shelving, desks, and on open carts.

An interview was conducted with S17HIM on 12/9/14 at 11 a.m. She confirmed the medical records were not protected from water and fire damage. She went on to report the medical records had been recently brought from storage due to a backlog project.

An observation was made on 12/11/15 at 1 p.m. of approximately 60 medical records in the dictation room unprotected from fire and water damage.

An interview was conducted with S17HIM on 12/11/14 at 1:15 p.m. She confirmed the medical records in the dictation room were unprotected from fire and water damage.

2. Failed to have discharge summaries completed for patients from January of 2013 to January 2014.

Review of the medical record deficiency rate for 2013 revealed a medical record deficiency rate of 98.7%.

An interview was conducted with S17HIM on 12/19/14 at 8:45 a.m. When questioned about the medical record deficiency rate from 2013 of 98.7%, she reported the discharge summaries were not completed by S11Medical Director for her patients from January 2013 to January 2014. She went on to report there was an Action Plan put in place by the Hosptial in conjuction with S11MD and S11MD was currently catching up on the backlog of discharge summaries. When questioned why S11MD was so far behind in her discharge summaries, S17HIM stated she was new to the position and was not sure. Currently the delinquency rate for medical records was for September 2014: 41.7%; October 2014: 21.6%; November 2014 8.5 %. These percentage do not reflect the discharge summaries not completed from January 2013 to January 2014.

An interview was conducted on 12/10/14 at 12:45 p.m. with S1ADM, he reported a Plan of Action was put in place for S11Medical Director for completion of her medical records. The timeline for completion was 1/31/15. He further reported the problem started when there was a change in the dictation system, and some of S11Medical Director's dictation became irretrievable. S1ADM reported S11Medical Director has hired practitioners to assist her and a computer portal has been implemented for her use at home. The hospital has taken 50% of the blame for the issue. At the next Medical Executive Committee meeting the situation will be assessed and the timeline may need to be extended.

A phone interview was conducted with S11Medical Director on 12/11/14 at 1:30 p.m. She reported she became behind in her dictation of discharge summaries when the hospital contracted with a new company and did not inform her. She further stated the number to log in to dictation system was incorrect at the nurses' station and when she dictated her medical records her dictation went to an archived site and could not be retrieved. She reported she should be caught up with all her dictation by the end of 2014 (approximately 3 weeks).

Review of the medical record for Patient #21 revealed the patient expired at the hospital on 10/12/13. Review of the medical record revealed no documented evidence of a Discharge Summary.

In an interview on 12/11/14 at 3:00 p.m., S2CCO (Chief Clinical Officer) reviewed the medical record for Patient #21 and confirmed there was no discharge summary. S2CCO stated S11Medical Director was the patient's physician and she had not completed her delinquent records.

Based on record review, observation and interviews, the hospital failed to ensure the medication automated distribution unit (Omnicell) was stored in a secure area to prevent unauthorized individuals unmonitored access. This was evidenced by the Omnicell being located in a common area between two (2) hallways with patients' rooms and located directly across from where patients and visitors are provided/offered self-serve coffee. Findings:

Review of the hospital's policy, Storage General, Policy Number .14.09.01, revealed in part, Medications and devices shall be stored to ensure their integrity, stability, and effectiveness. Medications and biologicals will be stored so that only authorized personnel have access. Medication dispensing, administration, and storage areas shall be well lighted, neat, organized, and located where personnel preparing medications for dispensing or administration will not be interrupted. All drugs and biological must be stored in a manner to prevent access by non-authorized personnel.

An observation was conducted on 12/9/14 at 10:30 a.m. of the medication automated distribution unit (Omnicell) being located in a common area between 2 hallway with patients' rooms and located directly across from where patients and visitors are provided/offered self-service coffee.

Numerous observations were conducted on 12/9/14, 12/10/14, and 12/11/14 of patients in wheelchairs in the common hallway while nurses were withdrawing medications from the Omnicell in the common hallway.

A phone interview was conducted with S24Director of Pharmacy on 12/10/14 at 10:30 a.m. He reported he was familiar with where the Omnicell was located in the hospital and he confirmed the Omnicell was not located in a secure area. He further reported the medications were locked by a password/logon in.

An interview was conducted with S1ADM on 12/11/14 at 11 a.m. and he verified the Omnicell was not in a secure area in which to prevent unauthorized individuals unmonitored access.

Based on record review, observations and interview, the hospital failed to ensure narcotics were kept locked within a secure area This was evidenced by narcotics being stored in the Medication Automated Distribution Unit (Omnicell), which was located in a common area between two (2) hallways with patients' rooms and directly across from the area where patients and visitors are provided/offered self-serve coffee. Findings:

Review of the hospital's policy, Storage General, Policy Number .14.09.01, revealed in part, Medications and devices shall be stored to ensure their integrity, stability, and effectiveness. Medications and biologicals will be stored so that only authorized personnel have access. Medication dispensing, administration, and storage areas shall be well lighted, neat, organized, and located where personnel preparing medications for dispensing or administration will not be interrupted. All drugs and biological must be stored in a manner to prevent access by non-authorized personnel.

An observation was conducted on 12/9/14 at 10:30 a.m. of the medication automated distribution unit (Omnicell) being located in a common area between 2 hallway with patients' rooms and located directly across from where patients and visitors are provided/offered self-service coffee.

Numerous observations were conducted on 12/9/14, 12/10/14, and 12/11/14 of patients in wheelchairs in the common hallway while nurses were withdrawing medications from the Omnicell in the common hallway.

An interview was conducted with S6Pharmacist on 12/9/14 at 12 p.m. She reported the narcotics in the Omnicell was locked once and the medication had to be witnessed, but she reported the Omnicell was not located in a secure area.

A phone interview was conducted with S24Director of Pharmacy on 12/10/14 at 10:30 a.m. He reported he was familiar with where the Omnicell was located in the hospital and he confirmed the Omnicell was not located in a secure area. He further reported the medications were locked by a password/logon in.

An interview was conducted with S2CCO on 12/10/14 at 10:35 a.m. She reported the narcotics within the Omnicell were not located in a secure area with unmonitored access by unauthorized individuals.

An observation and interview was conducted with S13RN on 12/10/14 at 10 a.m. She was observed removing a narcotic from the Omnicell by putting in her code, doing a count of the narcotic and entering the count in the Omnicell. While she was removing the narcotic from the Omnicell a patient was in a wheelchair directly behind her in the common hallway.

Based on record review and interview, the hospital:
1. failed to ensure a patient's refusal of a medication was reported to the physician for 1 out of 1 medication errors (Patient #22) identified by the surveyor in a medical record not previously identified by the hospital.

2. failed to document in the patient's medical record a medication error that was identified by the hospital for 1 out 1 medication errors (Patient #12) reviewed out of a total sample of 30 patients. Findings:

Review of the hospital's policy, Medication Management, Policy # II.N.14.00, revealed in part, Report a variance in medication immediately to the nurse in charge. Medication variances are reported on the occurrence report.

1. Review of the medical record for Patient #22 revealed he was 57 year old male admitted to the hospital on 10/8/14 for Anoxic Encephalopathy secondary to Respiratory Failure. On his admission to the hospital Heparin 5,000 units S.C. (subcutaneously) q (every) 12 hours was ordered by S11Medical Director.

Review of Patient #22's Medication Administration Record (MAR) for 10/10/14, 10/11/14, 10/12/14, 10/13/14 and 10/14/14 revealed the patient refused Heparin 5,000 Units S.C. q 12 hours.

Review of the MAR, Physician Progress Notes, and the Nurse Notes for 10/10/14 through 1014/14 revealed no documentation the physician was notified that Patient #22 was refusing his Heparin injections routinely.

An interview was conducted with S2CCO on 12/11/14 at 12:45 p.m. S2CCO reviewed the medical record and confirmed there wasn't any documentation in the medical record the physician was aware the patient was refusing his Heparin injections. S2CCO reported the physician should had been made aware and this was considered a medication error.

2. Review of the medical record for Patient #12 revealed she was a 85 year old female admitted to the hospital on 9/18/14 for a Large Ischemic Stroke.

Review of the medication error documented in the hospital's Quality Improvement Electronic System, Action Cue, revealed a Medrol dose was ordered by the physician on 9/23/14 for the patient. On day #3 of the dose pack, 1 tablet before breakfast, 1 tablet after lunch, 1 tablet after supper, and the 1 tablet at bedtime were not administered. On day #4 one tablet before breakfast and one tablet after lunch were not administered also.

An interview was conducted with S2CCO on 12/10/14 at 2:45 p.m. With review of the Patient #12's medical record she confirmed the medication error was never documented in Patient #12's medical record.

Based on record review and staff interview, the hospital failed to develop and implement policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. Findings:

Review of the contracts provided by S2CCO (Chief Clinical Officer) revealed the hospital had a contract with Company B to provide mobile radiological services.

Review of the hospital's policy titled, "Radiology Services", policy number II.K,11.69, provided by S2CCO as the hospital's policy related to radiology services, revealed the policy outlined the procedure for obtaining X-rays from the contracted service, but there was no documented evidence of any provisions related to safety precautions during radiological procedures conducted in the hospital.

In an interview on 12/09/14 at 3:00 p.m., S2CCO confirmed the policy titled, "Radiology Services" did not include any mention of safety precautions. S2CCO stated they were working on a policy for radiation safety and confirmed the policy had not been approved by the Governing Body and the policy had not been implemented with the hospital staff.

Based on record review and interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff that supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis.
Findings:

Review of the Governing Body Bylaws provided as current by S2CCO (Chief Clinical Officer) revealed the Governing Body was responsible granting privileges for medical staff membership. Review of the Medical Staff bylaws provided as current by S2CCO revealed in part the following: "No Physician, Osteopath, OD, Podiatrist, Dentist or AHP, including those in a medical administrative position by virtue of contract with the hospital, shall admit or provide medical or health-related services to patients in the hospital unless he or she has been granted privileges, in accordance with the procedures set forth in these Bylaws...."

Review of the organization chart presented as a current by S2CCO revealed no documented evidence of a Director of Radiology.

Review of the contracts provided by S2CCO revealed the hospital had a contract with Company A and Company B to provide radiology services.

In an interview on 12/09/14 at 3:20 p.m., S2CCO confirmed the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiology services. S2CCO stated the hospital relied on the Director of the contracted service to oversee the radiology services.

Based on record review and interviews the hospital failed to have two or more practitioners on the Utilization Committee to carry out the Utilization Review functions. Findings:

Review of the hospital policy Utilization Management Plan, Policy Number: I.E.5.07, revealed in part, Utilization Management is a function of the medical staff and is responsible to the Medical Executive Committee (MEC) and the Governing Board. Membership shall consist of sufficient members to afford, insofar as feasible, representation from the major services. No less then (2) members of the Utilization Management Function shall be physicians.

An interview was conducted with S25Director of UR on 12/11/14 at 10:30 a.m. She reported the members of the UR committee, were herself, S1ADM, S2CCO and S11Medical Director.

Review of the Disclosure of Ownership form provided by the hospital revealed S11Medical Director had 5% ownership in the hospital. Review of the patient census revealed S11Medical Director was listed as the admitting physician on most of the patients in the hospital.

An interview was conducted with S2CCO on 12/11/14 at 11 a.m. She reported the members of the UR committee were herself, S25Director of UR and S1ADM. When questioned if S11Medical Director was on the committee, she reported she was not due to her being the admitting physician on most of the patients in the hospital and having ownership in the hospital. SCCO reported there was no physician on the UR committee.

Based on record reviews and interview, the hospital failed to ensure that the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S3IC/QA having no prior work experience or specialized training in infection control.

Findings:
A review of S3IC/QA prior work history revealed that she was an RN (Registered Nurse) with specialty experience in medical-surgical nursing, telemetry, and rehabilitation nursing. There was no documented evidence that she had worked in a position related to Infection Control.

A review of S3IC/QA's personnel file revealed that she had participated in annual hospital required in-services for nurses in bloodborne pathogens, clostridium difficile, hand hygiene, personnel protective equipment, and preventing needle stick injuries. A further review of S3IC/QA's personnel file revealed that she had attended a one day training seminar in "Infectious Disease Epidemiology". There was no other documented evidence that S3IC/QA had any other specialized training or in-services in Infection Control.

In an interview on 12/11/14 at 12:05 p.m. with S3IC/QA she indicated that she had been the hospital's Infection Control Officer for a little over a year. She further indicated that she was not certified in infection control, had no prior work experience in infection control, and had received no specialized training in infection control other than the annual in-services required for all nursing staff. S3IC/QA indicated that she only attended a one day training seminar in "Infectious Disease Epidemiology".

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Based on observations, interviews and record reviews, the hospital failed to ensure that the infection control officer developed an effective system that included identification, reporting, investigation, and controlling of infections and communicable diseases of patients and personnel by failure to maintain a sanitary environment according to CDC (Center for Disease Control) guidelines as evidenced by:
1) failure to have staff adhere to acceptable infection control practices in the cleaning of patient rooms and patient care equipment and patient nourishment for:
a) housekeeping department reusing bathroom disinfectant solutions and brushes for multiple patient rooms,
b) housekeeping department laundering reusable cleaning towels, used for patient rooms, in-house without established hospital policies and procedures for in-house laundering,
c) 1 of 1 (S14LPN) nursing staff failing to disinfect/clean a multiple patient use glucometer immediately after patient use,
d) therapy department reusing porous therapy equipment for multiple patient use without being able to adequately disinfect the porous equipment between patient use, therapy department reusing patient single use blood pressure cuffs, and therapy department's patient exercise mat having a 3 inch x 3 inch x 4 inch tear in it,
e) storing of clean patient equipment (intravenous pumps x 2) on the floor in the clean equipment room and storing a soiled single patient use blood pressure cuff on a clean blood pressure machine in the clean equipment room,
f) a biohazard sharps container with used sharps over the full line,
g) the hospital's wound care cart containing opened patient sterile supplies available for other patient use
h) the patient's refrigerator containing juice cups for patient use that had no expiation dates on them,
i) 1 of 1 (S7CNA) nursing staff disinfecting a soiled blood pressure machine with an EPA disinfectant wipe without gloves on;

2) failure to have an infection control surveillance/monitoring system in place to identify other infection control breaches other than the hospital's established infection control indicators already in place, and;

3) failure to have physicians and mid-level practitioners screened annually for Tuberculosis (TB).



Findings:
A review of the hospital's policy titled, "Infection Control Plan", as provided by S3IC/QA as the most current, revealed in part: The Infection Control Program will operate under those standards set forth by the CDC, OSHA (Occupational Safety and Health Administration, and TJC (The Joint Commission).

1) failure to have staff adhere to acceptable infection control practices in the cleaning of patient rooms and patient care equipment for:

a) housekeeping department reusing bathroom disinfectant solutions and brushes for multiple patient rooms,
An observation on 12/9/14 at 2:15 p.m. was made of S10Hskpg's cleaning cart being used for cleaning patient rooms.
In an interview on 12/9/14 at 2:15 p.m. with S10Hskpg she was asked about the bucket of solution on her cleaning cart with the 2 (two) brushes in it. She indicated that the bucket contained the disinfectant cleaning solution used to clean patient bathrooms along with the 2 bathroom cleaning brushes. S10Hskpg indicated that she changes the bathroom cleaning solution after about every 3rd patient room and indicated that the brushes are used for about a week before they are changed. S10Hskpg further indicated that some housekeepers change the solution only once a day, but she liked to change it more often. She indicated that she was not aware of a hospital policy on cleaning patient bathrooms and that each housekeeper had their own routine.

In an interview on 12/10/14 at 9:00 a.m. with S3IC/QA she was made aware of the observation and interview with S10Hskpg. The hospital policy titled, "Cleaning of Patient Room", provided by S3IC/QA as the most current, was reviewed with S3IC/QA. S3IC/QA indicated that the hospital's policy on "Cleaning of Patient Room", did not address cleaning patient bathrooms. S3IC/QA further indicated that a fresh bathroom brush and fresh disinfectant cleaning solution should be used in each patient bathroom.

b) housekeeping department laundering reusable cleaning towels, used for patient rooms, in-house without established hospital policies and procedures for in-house laundering,
An observation on 12/9/14 at 2:45 p.m. was made of S10Hskpg folding laundered cleaning towels taken from the hospital's dryer.
In an interview on 12/9/14 at 2:45 p.m. with S10Hskpg she indicated that housekeeping staff self-laundered the cleaning towels in the washer/dryer in the hospital.

In an interview on 12/10/14 at 9:00 a.m. with S3IC/QA she was asked about the hospital's Housekeeping Department self-laundering of the reusable cleaning towels, used for patient rooms.. S3IC/QA indicated that she was aware of this practice. She indicated that the Housekeeping Department did not always get all their cleaning towels back when they were sent to the contracted laundry, so the Housekeeping Department would self-launder the reusable cleaning towels in-house. S3IC/QA was asked if the hospital had an approved laundry facility or a policy on the self-laundering of the cleaning towels. S3IC/QA indicated that the hospital had no policy for on-site laundering and that the hospital did not have a washer and dryer that was in compliance with OSHA standards and/or with the laundry criteria established by The Joint Commission.

c) 1 of 1 (S14LPN) nursing staff failing to disinfect/clean a multiple patient use glucometer immediately after patient use,
An observation on 12/11/14 at 11:15 a.m. was made of S14LPN performing a glucose blood test on Patient R3 in his room. After the glucometer was used, S14LPN placed the soiled glucometer on the patient's bedside table and then picked it up again and placed it on her procedure table. S14LPN rolled her procedure table to the nurse's desk and then got a disinfectant wipe to clean the soiled glucometer before placing it back into its container. S14LPN was not observed disinfecting the patient's bedside table or her procedure table after placing the soiled glucometer on them .

In an interview on 12/11/14 at 1:30 p.m. with S3IC/QA she was made aware of the infection control breach while the glucometer was being used by S14LPN for Patient R3. S3IC/QA indicated that S14LPN should have cleaned the glucometer immediately after patient use and should not have placed the soiled glucometer on the patient's bedside table or on her procedure table.

d) therapy department reusing porous therapy equipment for multiple patient use without being able to adequately disinfect the porous equipment between patient use, therapy department reusing patient single use blood pressure cuffs, and therapy department's patient exercise mat having a 3 inch x 3 inch x 4 inch tear in it,
An observation on 12/9/14 at 3:15 p.m. of the Rehabilitation Therapy Department revealed the following: 3 (three) used blood pressure cuffs in the basket on the blood pressure machine located in the Therapy Department, a disposable foam cushion located in the Therapy Department's clean equipment storage area, 3 (three) noodle styrofoam cylinders located in the Therapy Department's clean equipment storage area, and a 3 inch x 3 inch x 4 inch tear on the top of the Therapy Department's patient exercise mat.

In an interview on 12/9/14 at 3:30 p.m. with S8Therapy Director, she indicated that the 3 blood pressure cuffs were used by patients, were single patient use and that they should not have been left on the blood pressure machine in the Therapy Department. S8Therapy Director was asked how the therapists disinfected the foam cushions and the styrofoam noodles after each patient use. S8Therapy Director indicated that the therapists wipe the items with an EPA disinfectant wipe after patient use. S8Therapy Director indicated that the foam cushion and the styrofoam noodles were porous and probably could not be disinfected adequately with the disinfectant wipes. She further indicated that they probably should be single patient use only and should not be reused for multiple patients. S8Therapy Director was asked how the therapists disinfected the exercise mat with the tear in it after each patient use. S8Therapy Director indicated that the torn exercise mat probably could not be disinfected adequately with the disinfectant wipes either. She further indicated that the torn patient exercise mat probably should be replaced or recovered.

e) storing of clean patient equipment (intravenous pumps x 2) on the floor in the clean equipment room and storing a soiled single patient use blood pressure cuff on a clean blood pressure machine in the clean equipment room
An observation on 12/9/14 at 10:45 a.m. revealed a soiled single patient use blood pressure cuff in the basket on the blood pressure machine located in the clean equipment room. Also, observed were 2 (two) cleaned intravenous pump machines located on the floor of the clean equipment room.

f) a biohazard sharps container with used sharps over the full line,
An observation on 12/9/14 at 10:55 a.m revealed a biohazard sharps container on the nurse's medication cart filled to the full line with used sharps. Another observation on 12/11/14 at 11:00 a.m revealed the same biohazard sharps container on the nurse's medication cart filled over the full line with used sharps.

g) the hospital's wound care cart containing opened patient sterile supplies available for other patient use
An observation on 12/9/14 at 11:00 a.m of the nurse's wound care cart revealed 1 out of 6 sterile steri strip adhesive packs opened and 1 out of 5 sterile iodoform bottles opened (seals broken) in the drawer of the wound care cart, available for other patient use.

h) the patient refrigerator containing juice cups for patient use that had no expiation dates on them
An observation on 12/9/14 at 11:15 a.m. of the patient refrigerator revealed 14 (4 ounce) juice cups with no identifiable expiration dates on them. .

In an interview on 12/9/14 at 11:30 a.m. with S3IC/QA she was made aware of the above observations (e, f, g, h). S3IC/QA indicated that the blood pressure cuffs were single patient use and should not be on the blood pressure machine for potential use by other patients. She further indicated that the cleaned intravenous pumps should not be stored on the floor after they were disinfected. S3IC/QA indicated that the biohazard sharps container should have been replaced when the full line was reached. S3IC/QA indicated that juice cups for patient use should be labeled with the expiration date or left in their original carton where the expiration dates were visible.

i) 1 of 1 (S7CNA) nursing staff disinfecting a soiled blood pressure machine with an EPA disinfectant wipe without gloves on:
An observation on 12/9/14 at 3:00 p.m. was made of S7CNA cleaning a blood pressure machine in a patient's room with the hospital's EPA disinfectant wipes without gloves on. The directions on the EPA disinfectant wipe container revealed that personnel should wear gloves when using the product.


2) failure to have an infection control surveillance/monitoring system in place to identify other infection control breaches other than the hospital's established infection control indicators already in place.
In an interview on 12/11/14 at 2:00 p.m. with S3IC/QA she was asked about the Infection Control Program's surveillance and monitoring. S3IC/QA indicated that the infection control indicators, that were monitored, tracked and trended, were established by the hospital's corporate office and were as followed: catheter associated urinary tract infections, clostridium difficile infections, hand hygiene and hospital acquired infections. S3IC/QA indicated that if she observed any other infection control issues or breaches, she would do an in-service with staff. S3IC/QA indicated that she would not collect data or do any analysis/tracking to identify any trends to include interventions and evaluations. S3IC/QA further indicated that she was not aware of the above infection control breaches (a, c, d, e, f, g, h, i). She indicated that she only monitored the corporate-established infection control indicators incorporated into the hospital's Infection Control Program and she was unable to edit the program or add new infection control monitoring indicators.


3) Failure to have physicians and mid-level practitioners screened annually for Tuberculosis (TB):
Review of the hospital's policy titled, "TB Screening" Policy number III.R.18.25, effective date of 11/13/12 revealed in part the following: All employees, volunteers, agency, and long-term contracted personnel will receive screening for tuberculosis (TB) infection yearly. Licensed independent practitioners (LIPs) will also be offered yearly screening for TB....

Review of the hospital's policy titled, "TB Exposure Control Plan" Policy number III.R.18.24, effective dated of 11/13/12, revealed in part the following: 7. Employee Screening: All employees will participate in the TB Exposure Control Plan by screening for the presence of inactive or active TB at the time of employment, annually, and exposure to a non-isolated patient having active tuberculosis....

Review of the credentialing records for annual TB screening revealed the following:
S11Medical Director - TB screening documented on 02/18/13.
S20MD - TB screening documented on 02/19/13.
S21PA (Physician Assistant) - TB screening documented on 03/26/12.
S22APRN - TB screening documented on 02/13/13.

In an interview on 12/11/14 at 3:20 p.m., S17HIM (Health Information Management) confirmed annual TB screening for the above physicians and mid-level practitioners had not been done annual. S17HIM stated TB screenings were not due since re-appointment was not due.

Based on record review and interview, the hospital failed to have a Director of Respiratory Care Services to supervise and administer the service properly. Finding:

Review of the Governing Board minutes revealed there was not a physician appointed as the Director of Respiratory.

An interview was conducted with S5RT on 12/10/14 at 11 a.m. He reported there was not a physician over the respiratory department.

An interview was conducted with S2CCO 12/10/14 at 1:45 p.m. She reported there was not a physician overseeing the respiratory services of the hospital.