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Based on record reviews and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) were met as evidenced by:

1. Failing to ensure it had an ongoing quality assessment and performance improvement (QAPI) program that showed measurable improvement in indicators and measured, analyzed, and tracked quality indicators and other aspects of performance that assess processes of care, hospital services, and operations. The governing body failed to specify the frequency and detail of data collection to be used in its QAPI program. (see findings in A-0273)

2. Failing to ensure data collected to identify opportunities for improvement resulted in action taken to improve performance as evidenced by failure to track, trend and analyze medication errors, patient falls, discharge planning and hospital acquired infections and implement actions for improving processes and outcomes. (see findings in A-0283)

3. Failing to ensure patient safety as evidenced by the failure to measure, analyze and track medication errors. The hospital could not provide documentation of development and implementation of corrective interventions and ongoing evaluation of the interventions for success. (see findings in A-0286)

4. Failing to ensure its quality assessment and performance improvement (QAPI) program involved all hospital departments and services including those services furnished under contract or agreement as evidenced by failure to have quality indicators developed for dietary services, biomedical services, biohazardous waste disposal services, and linen services. (see findings in A-0308)

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

1. the hospital failed to have appropriate scope and complexity of services for medical record services as evidenced by the hospital failing to employ adequate personnel to ensure supervision of the medical record department by failing to have a Director of Health Information Management for the last 2 years. (See Findings in A0432).

2. the hospital failed to ensure medical record were protected from water and fire damage as evidenced by medical records from 2004 until 2014 being stored in cardboard boxes on the floor (approximately 1000 medical records). (See Findings in A0438)

3. the hospital failed to have discharge summaries completed within 30 days after discharge for the patients discharged from the hospital for the last year. (See Findings in A0468).

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

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

2) Failing to ensure that there was a radiologist who was a member of the medical staff who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital. (see findings in A-0546)

Based on record review, interview and observation the hospital failed to ensure the requirements for the Condition of Participation for Infection Control were met as evidenced by:
1) failing to ensure identified hospital acquired infection data was investigated, analyzed, tracked, and trended. (See findings under tag A-0749).
2) failing to ensure the designated infection control officer was qualified through education, training, experience or certification. (See findings under tag A-0748).
3) failing to ensure patients known or suspected of having MDRO (multiple drug resistant organisms) infections in wounds (#11, #21)/blood (#8) and a rule out C. difficile patient (#13) were placed on isolation precautions for 4 (#8,#11,#13,#21) of 4 (#8,#11, #13, #21) patients reviewed for initiation of isolation precautions out of a total sample of 30. (See findings under tag A-0749).
4) failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring and performance of wound care. This deficient practice is evidenced by improper hand hygiene during performance of blood glucose monitoring (Patient # 1) and wound care (Patient #6) and failing to properly disinfect a glucometer after obtaining a capillary blood glucose reading (Patient #1). (See findings under tag A-0749).
5) failing to ensure all hospital staff had been trained on providing care/management of patients requiring Contact -specific to C. difficile, Airborne and Droplet isolation precautions for 10 (S1DON, S5RN, S8LPN, S9PTA, S12PT, S13OT, S14ST S17RN, S18CNA, S19CNA) of 13 personnel records reviewed. (See findings under tag A-0749).
6) failing to ensure housekeeping staff had been trained/evaluated on cleaning/disinfecting the rooms of patients requiring Airborne, Droplet and C.difficile contact isolation for 2 (S11HK,S12HK) of 2 housekeeping employees interviewed. (See findings under tag A-0749).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Respiratory Care Services as evidenced by:

1. Failing to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services (See Findings in A-1153).

2. Failing to ensure personnel providing respiratory services were qualified as evidenced by failing to document current competencies and training of the personnel authorized to provide respiratory services for 4 (S5RN,S7RN,S8LPN,S17RN) of 4 nursing personnel files reviewed. (See Findings in A-1154).

3. Failing to designate, in writing, respiratory care policies and procedures for each type of respiratory service provided, personnel qualified to perform specific procedures, and the amount of supervision required for personnel to carry out specific procedures. (See Findings in A-1161).

Based on record review and interview, the governing body failed to ensure the medical staff was providing quality care as evidenced by failing to have physicians complete the hospital's patients' discharge summaries for the last year. Findings:

Review of the hospital's policy for Medical Record Review Plan, policy number HI 5001, revealed in part, Governor Board a. Assist the medical executive committee in determining actions to be taken for improvement in staff performance. b. Makes final decisions on medical staff disciplinary actions. 4. Governing Board a. Considers the recommendations of the medical executive committee in determining what disciplinary actions would be appropriate based on the given issues presented (i.e. letter, suspension, or removal from the medical staff). b. All disciplinary actions will strictly follow the medical staff bylaws.

Review of the hospital's Medical By-laws Rules and Regulations revealed in part, A chart shall not be considered "delinquent" until 30 days following discharge. Chart completion requirements are as follows:
All medical record shall be completed by the attending Physician within 14 days of discharge.
The only exceptions shall be: physician illness, physician on vacation or out of town, and delayed laboratory report with extenuating circumstances.
If the records are not completed during this extension period, the Health Information Department shall notify the Chairman of the Medical Records review Committee or a committee member, that all elective admissions have been suspended until such time as the records are complete.

Review of the Governing Board Meeting outlines reveals no disciplinary actions has been implemented for a physician with delinquent medical records in the last year.

An interview was conducted with S1DON (Director of Nurses) on 9/2/15 at 2:00 p.m. She reported that S3MD (Medical Director) had not completed his discharge summaries on the discharged patients in the hospital in over one year.

Based on record reviews and interview, the hospital failed to ensure it had an ongoing quality assessment and performance improvement (QAPI) program that showed measurable improvement in indicators and measured, analyzed, and tracked quality indicators and other aspects of performance that assess processes of care, hospital services, and operations. The governing body failed to specify the frequency and detail of data collection to be used in its QAPI program.
Findings:

Review of the hospital's policy titled "Performance Improvement" (policy number PI 2001), presented as a current policy by S1DON (Director of Nurses), revealed that the program is designed to facilitate an effective system of measuring, analyzing and improving the care and services provided throughout the rehab hospital. Further review revealed that data collection allows the hospital to monitor its performance. Results of the outcomes of performance improvement will be reported on a monthly/bimonthly/quarterly basis as designated.

Review of the QAPI monthly report data for the year 2015, provided and completed by S5RN, revealed a list of indicators that were being followed and monthly reports that were complied related to the indicators. Review of the monthly report for July 2015 revealed that all indicators listed as being followed were not addressed, including the summary of findings and actions for improvement. There was no documented evidence of the method and frequency of data collection for each indicator, such as chart audits or observations. Further review of the data provided revealed no evidence that the data was analyzed and tracked in order to assess processes of care, hospital services and operations.

In an interview 09/02/15 at 1:15 p.m., S5RN indicated that she was responsible for the QAPI program at the hospital. S5RN further revealed that the different departments of the hospital do not contribute QAPI data to her, but she has to gather all of the data regarding each indicator being followed. S5RN revealed that she audited patient charts to collect data, but S5RN was unable to provide any specific tool or system utilized to collect the data to ensure consistency. When asked if the hospital's governing body specified the frequency and detail of data collection, S5RN stated that she was unaware of this information.

In an interview on 09/02/15 at 3:15 p.m. with S1DON, she stated that S5RN is responsible for collecting all data related to QAPI. S1DON reviewed the QAPI information presented to the survey team and confirmed that the data was not being analyzed or tracked in order to improve patient health outcomes. At this time, the governing body meeting minutes related to frequency and detail of the hospitals's QAPI data collection was requested from S1DON. As of exit of 9/3/15, S1DON confirmed she was unable to provide this information.

Based on record reviews and interview, the hospital failed to ensure data collected to identify opportunities for improvement resulted in action taken to improve performance as evidenced by failure to track, trend and analyze medication errors, patient falls, discharge planning and hospital acquired infections and implement actions for improving processes and outcomes.

Findings:

Review of the hospital policy titled "Performance Improvement" (policy number PI 2001), presented as a current policy by S1DON, revealed that performance indicators are objective and measurable and are structured to produce statistically valid performance measures of care provided.

Review of the monthly Performance Improvement report for May 2015, provided and compiled by S5RN, revealed the hospital had two patient falls for the month. Further review of the report revealed a column titled "Assessment/Improvement", which stated no injuries noted, patient educated on safety.

Review of the patient incident reports for May 2015, provided by S1DON, revealed evidence that there were five patient falls for the month. In an interview with S5RN on 09/02/15 at 1:15 p.m., she confirmed that there were five patient falls for the month of May 2015, but only two were documented on the QAPI data. She further stated that no action plans were put into place related to the patient falls.

Review of the medication variance reports, presented by S1DON, revealed one medication error for the month of February 2015. Review of the monthly Performance Improvement report for February 2015 revealed no medication variances were reported for the month. In an interview with S5RN on 09/02/15 at 1:15 p.m., she stated that she must have missed that medication variance report. Further interview with S5RN revealed that the March 2015 Performance Improvement report noted one medication error, but no action plan was put into place regarding medication errors.


Review of the infection control documentation presented by S5RN as current revealed she had collected monthly data for hospital acquired (HAI) versus community acquired infections. Further review revealed the following monthly Nosocomial (hospital acquired) Infection Documentation for 2015:
1/2015: 0% HAI , 2/2015: 33 % HAI, 3/2015: 0% HAI, 4/2015: 0% HAI, 5/2015: 14% HAI, 6/2015: 11% HAI and 7/2015: 15% HAI. Additional review revealed no documented evidence of an investigation or an action plan to address the spikes in HAIs in the months of 2/2015, 5/2015 and 7/2015.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Nurse/QA) she indicated she had not tracked, trended or investigated the spikes in infections in the months referenced above. She agreed the data collected indicating spikes in HAIs (referenced above) should have been investigated, tracked/trended and an action plan aimed at performance improvement should have been implemented to address the increases in HAIs.

In an interview on 09/02/15 at 3:15 p.m., S1DON confirmed that there was inaccurate QAPI data collected for the indicators of patient falls and medication errors. S1DON further reconfirmed that no action plans aimed at performance improvement had been implemented to address patient falls and medication errors.

An interview was conducted with S16SW (Social Worker) on 9/2/15 at 10:00 a.m. She reported she handled the discharge planning process at the hospital. She reported they formally do not track the patients readmitted in 30 days, they are a small hospital and usually they know if someone has been in the hospital before.

An interview was conducted with S1DON on 9/2/15 at 10:05 a.m. She reported the hospital has never had a issue with discharge planning so they do not look at discharge planning in Quality Improvement.


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30984

Based on record review and interview, the hospital failed to ensure patient safety as evidenced by the failure to measure, analyze and track medication errors. The hospital could not provide documentation of development and implementation of corrective interventions and ongoing evaluation of the interventions for success.
Findings:

Review of the medication variance reports for the year of 2015, provided by S1DON, revealed two medication errors were reported (2/25/15 and 3/19/15). Review of the QAPI data revealed that the medication error dated 3/19/15 was identified with a note stating, "Will continue to monitor". The medication error dated 2/25/15 was not noted on the QAPI data reports.

Further review of the variance reports and QAPI data revealed no documented evidence that the hospital analyzed the causes of the medication errors or implemented preventive actions that included feedback and learning throughout the hospital.

In an interview 09/02/15 at 3:15 p.m. S1DON confirmed that all medication errors were not identified in QAPI. She further confirmed that the she talks with nurses when they make medication errors but had no documented evidence that corrective interventions were developed and implemented related to medication errors.

Based upon record review and interview, the hospital failed to conduct performance improvement projects. This was evidenced by the failure to conduct annual distinct improvement projects related to the scope of services furnished at the hospital for 2014 and 2015. Findings:

Review of the quality assurance program data, provided by S5RN, revealed there failed to be documented evidence the hospital developed distinct quality improvement projects for 2014 and 2015.

On 09/02/15 at 1:15 p.m., interview with S5RN revealed that there were no hospital wide QA projects implemented for 2014 and 2015. S5RN further revealed that the hospital was running smoothly.

Based on record reviews and interview, the governing body failed to ensure its quality assessment and performance improvement (QAPI) program involved all hospital departments and services including those services furnished under contract or agreement as evidenced by failure to have quality indicators developed for dietary services, biomedical services, biohazardous waste disposal services, and linen services.
Findings:

The list of the hospital's current contracted services, presented by S1DON, was reviewed and compared to the QAPI documentation provided by S5RN. Further review of S5RN's QAPI documentation revealed quality indicators were not developed for the following contracted services: biomedical, biohazardous waste disposal, and linen. Additional review revealed no documented evidence of current quality indicators for dietary services (provided directly).
In an interview on 9/1/15 at 1:30 p.m. with S4Dietary Manager, she indicated she had not been participating in QAPI "for awhile". She confirmed dietary services should have been included in the hospital's QAPI plan.
In an interview on 09/02/15 at 1:15 p.m. with S5RN, she confirmed quality indicators for the above referenced services provided through contractual agreement were not included in the hospital's QAPI plan.















30984

Based on record review and interview, the governing body failed to determine the number of distinct improvement projects that would be conducted annually.
Findings:

Review of the hospital's policy titled "Performance Improvement" (policy number PI 2001), presented as a current policy by S1DON, revealed no documented evidence that the governing body determined the number of distinct improvement projects that would be conducted annually.

In an interview on 09/03/15 at 10:20 a.m., S1DON confirmed that she could provide no documented evidence that the governing body had determined the number of distinct improvement projects that would be conducted annually.

Based on record review, interview and observation, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1. the registered nurse failed to ensure patients were weighed according to the physician's order for 2 (Patient # 20 and Patient #22) out of 2 patients reviewed for being weighed as ordered out of a sample of 30.
2. the registered nurse failed to ensure patients assessed as high risk for falls had a chair/bed alarm as per the hospital's policy for 2 out of 2 patients reviewed (Patient #3 and Patient #22) out of a sample of 30. Findings:

1. Daily Weights

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 45 year old admitted to the hospital for ambulatory dysfunction.

Review of the physician orders dated 7/23/15 revealed the physician ordered daily weight on 7/23/15.

Review of the Graphic sheet revealed the patient's weight was not monitored on 7/23/15, 7/24/15, 7/25/15, and 7/27/15. The patient was discharged on 7/28/15.

Patient #22
Review of Patient #22's medical record revealed an admission date of 6/16/15 with diagnoses including the following: Coronary Artery Disease and Chronic Obstructive pulmonary Disease.
Review of Patient #22 's medical record revealed an MD (Medical Doctor) order on 6/19/15 for daily weights.
Further review of Patient #22 ' s MD orders through 7/3/15 (date of discharge) revealed no documented evidence of an order to discontinue daily weights.
Review of Patient #22 ' s graphic record revealed no documented daily weights on 7/1/15 and 7/2/15.

An interview was conducted with S5RN on 9/2/15 at 2:00 p.m. She confirmed with review of the medical record, the patients' weights were not monitored as per the physician's order.



2. Falls
Review of the hospital's policy titled Risk Assessment Evaluation Sheet, revealed in part, On patients scored as High Risk, the following procedures will be followed: 5. Bed/Chair exit alarm.

Patient #3
Review of Patient #3's medical record revealed she was a 42 year old admitted to the hospital on 8/26/15 with a diagnosis of Cerebral Vascular Accident.

Review of Patient #3's Fall Risk Assessment revealed the patient was assessed as high risk for falls, which the hospital policy stated the patient would have a Bed/Chair alarm.

An interview was conducted with Patient #3 on 8/31/15 at 3:30 p.m. She reported she did not have a chair/bed alarm.

An interview was conducted with S7RN on 8/31/15 at 3:35 p.m. He confirmed the patient did not have a chair/bed alarm.

Patient #7
Review of Patient #7's medical record revealed she was a 93 year old admitted to the hospital on 8/25/15 with General debility with ambulatory dysfunction and falls.

Review of Patient #7's Fall Risk Assessment revealed the patient was assessed as high risk for fall, which the hospital policy stated the patient would have a Bed/Chair alarm.

An observation was made on 9/1/15 at 1:00 p.m. of Patient #7 in her room without a bed or chair alarm.

An interview was conducted with S7RN on 9/1/15 at 1:40 p.m. He reported the patient did not have a bed/chair alarm.


30984

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for 6 (#1,#2, #5, #6, #9, #12) of 6 patient records reviewed for nursing care planning from a total sample of 30 patient records.

Findings:

Patient #1
Review of Patient #1's medical record revealed an admit date of 08/20/15 with diagnoses including the following: Toxic encephalopathy-status post Lithium Toxicity, Diabetes Mellitus, Hypertension, Schizoaffecive Disorder, Bipolar Disorder, and Ulcer.
Review of the patient's plan of care revealed Diabetes Mellitus, Hypertension, Schizoaffective Disorder, Bipolar Disorder and Ulcer had not been addressed as problems on the patient ' s plan of care.

Patient #2
Review of Patient #2's medical record revealed the patient had a fall on the night of admit, 08/26/15. Review of the patient's plan of care revealed that the fall on 08/26/15 was not identified with new interventions put in place.

Further review of the patient's medical record revealed the patient was ordered antibiotics for a urinary tract infection on 08/30/15. Review of the plan of care revealed that the urinary tract infection was not addressed.

In an interview on 09/01/15 at 8:05 a.m., S1DON confirmed that patient #2's nursing care plan had not been revised to include the patient's fall or urinary tract infection.

Patient #5
Review of Patient 5's medical record revealed an admit date of 08/28/15 with diagnoses including hypertension, stroke and history of multiple falls. Review of the patient's plan of care revealed no problems had been identified and no goals or interventions developed.

On 09/02/15 at 1:20 p.m., interview with S1DON confirmed that a care plan had not been developed to address the nursing needs of patient #5.

Patient #6
Review of Patient #6's medical record revealed an admit date of 08/28/15 with diagnoses including the following: Osteoarthritis, status post knee replacement, Anxiety and Hypertension.
Review of the patient's plan of care revealed Hypertension and Anxiety had not been addressed as problems on the patient's plan of care.

Patient #9
Review of Patient 9's medical record revealed an admit date of 08/29/15 with diagnoses including 3rd degree burns and gait dysfunction. Review of the patient's plan of care revealed no problems had been identified and no goals or interventions developed.

Patient #12
Review of Patient #12's medical record revealed an admit date of 6/5/15 with diagnoses including the following: Angiopathy, Diabetes Mellitus Type II, Hypertension and Hyperlipidemia
Review of the patient's plan of care revealed Diabetes Mellitus Type II, Hypertension, and Hyperlipidemia were not addressed as problems on the patient's plan of care.

In an interview on 9/3/15 at 10:20 a.m., with S1DON, she agreed patient care plans should have been inclusive of all of the patients' current problems.


30984

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing direct patient care had been evaluated as evidenced by failing to maintain documentation of current skills competency for 4 (S1DON,S5RN,S7RN,S8LPN) of 5 (S1DON,S5RN,S7RN,S8LPN,S17RN) nursing personnel records reviewed for competency.

Review of the personnel records of S1DON, S5RN, S7RN and S8LPN revealed no documented evidence of current skills competency evaluations.

In an interview on 9/3/15 at 9:30 a.m. with S1DON, she confirmed there were no current documented skills competencies documented for the above referenced nursing staff.

Based on record review and interview the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care as evidenced by failing to obtain a blood pressure prior to administering antihypertensive medications for 3 (#22,#23,#24) of 3 patients reviewed for vital assessment prior to administration of antihypertensive medications out of a total sample of 30 patient records reviewed.
Findings:

Review of the hospital's policy, Administration of Oral and Liquid Medications, revealed in part, 12. Blood pressures are to be taken and recorded before giving B/P (blood pressure) medications.

Patient #22
Review of the medical record for Patient #22 revealed the patient had a diagnosis of hypertension. Further review of the record revealed the patient had a physician order for Carved oral tablet 25 milligrams twice daily with food at 8:00 a.m. and 5:00 p.m.

Review of the patient's medication administration record and nurses notes revealed no documented evidence that the patient's blood pressure was obtained prior to administering the anti-hypertensive medication except for a single documented blood pressure on 6/27/15.

Patient #23
Review of the medical record for Patient #23 revealed the patient had a diagnosis of hypertension. Further review of the record revealed the patient had a physician order for Lopressor 25 mg (milligrams) i (1) tab p.o.(by mouth) BID (twice a day).

Review of the patient's medication administration record (MAR) and nurses notes revealed no documented evidence that the patient's blood pressure was obtained prior to administering the anti-hypertension medication except for a blood pressure documented on 5/11/15.

Patient #24
Review of the medical record for Patient #24 revealed the patient had a diagnosis of hypertension. Further review of the record revealed the patient had a physician order for Metoprolol 12.5 mg twice a day. Review of the patient's medication administration record and nurses notes revealed no documented evidence that the patient's blood pressure was obtained prior to administering the anti-hypertensive medication.

An interview was conducted on 9/3/15 at 9:30 a.m. with S1DON (Director of Nurses). She reported blood pressures should be taken on the patients being administered blood pressure medications right before the medication is administered and documented on the MAR (Medication Administration Record).


30984

Based on record review and interview the hospital failed to have appropriate scope and complexity of services for medical record services as evidenced by the hospital failing to employ adequate personnel to ensure supervision of the medical record department and prompt completion records. Findings:

Review of the hospital's policy, Storage and Retrieval, HI 4001, revealed in part, Records shall be filed and maintained in the HIM (Health Information Management) department under the direction of the Director of HIM.

An interview was conducted with S1DON (Director of Nurses) on 8/31/15 at 2:00 p.m. She reported the hospital did not have an individual overseeing the medical records in the hospital. She reported the hospital had not had a person supervising medical records in a couple of years. She further reported no one was reviewing the medical records for incomplete records and no one was monitoring the deficiency rates in the medical records. S1DON reported S5RN was reviewing the records for her Quality Assurance indicators only.

Based on record review, observations and interview, the hospital failed to ensure medical record were protected from water and fire damage as evidenced by medical records from 2004 until 2014 being stored in cardboard boxes on the floor.
Findings

Review of the hospital policy on Storage and Retrieval of Health Information, Policy HI 4001, revealed in part, A. Storage space shall be selected and maintained to protect records from unauthorized access, loss, and destruction. Storage space shall be selected to meet the following specifications: Protection against fire, including sprinkler system. Freedom from hazards, such flooding or damage from broken water pipes.

An observation was conducted on 8/31/15 at 2:00 p.m. of approximately 100 cardboard boxes with approximately 10-13 patient medical records (over 1000 medical records) in each box lined up on the floor in a storage room in the hospital. The medical records were from 2004 to 2014.

An interview was conducted with S2Adm (Administrator) on 8/31/15 at 2:00 p.m. He reported he was aware the medical records needed to be protected from destruction of water and fire and he confirmed the medical records were not protected.

Based on record review and interview, the hospital failed to ensure all patients' medical record entries were authenticated, dated and timed by the person responsible for providing the service for 4 (#1, #2, #3,#5) of 4 patients' medical records reviewed out of a total sample of 30.

Findings:

Patient #1
Review of the medical record revealed Patient #1 had the following orders that were authenticated, but not dated or timed:

Telephone order taken on 8/23/15 at 05:00 a.m. Authenticated by prescribing practitioner but not dated and timed.
Telephone order taken on 8/25/15 at 05:30 a.m. Authenticated by prescribing practitioner but not dated and timed.
Verbal order, taken by a RN, dated 8/20/15 at 6:00 p.m. Authenticated by prescribing practitioner, but not dated or timed.

Further review revealed the following verbal order not authenticated by the prescribing practitioner within 10 days:
Verbal orders for admission of Patient #1 taken on 8/20/15 at 2:40 p.m. The admission order was not authenticated by the prescribing practitioner as of 8/31/15.

Patient #2
Review of the medical record revealed Patient #2 had verbal orders obtained on 08/26/15 that were authenticated by S3MD (Medical Director), but not dated and timed.

Patient #3
Review of the medical record revealed Patient #3 had verbal orders obtained on 8/26/15 and on 8/29/15 that were signed by the S3MD (Medical Director), but not dated and timed.

Patient #5
Review of the medical record revealed patient #5 had two different verbal orders obtained on 08/28/15 that were authenticated by S3MD, but not dated or timed.

An interview was conducted with S1DON (Director of Nurses) on 9/2/15 at 10:00 a.m. She confirmed S3MD (Medical Director) did not always date and time when he signed his physician's orders.


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30984

Based on record review and interview the hospital failed to have discharge summaries completed within 30 days after discharge for 4 out of 4 patient records (Patient #10, #11, #12, and #13) reviewed for discharge summaries out of a sample of 30. Findings:

Review of the hospital policy for Documentation Completion Time Frames, Policy Number HI 5005, revealed in part, When data entries are not completed by the time of discharge, the following time frames and definitions shall apply: Incomplete status: any record not complete within 30 days of discharge. Delinquent status: any record not complete beyond the initial 30 days. Discharge summaries: Completion Time: 30 days.

Review of the following patients' medical record revealed no discharge summaries in the medical record:
Patient #10 -Discharge date 3/27/15
Patient #11- Discharge date 2/17/15
Patient #12- Discharge date 6/19/15
Patient #13-Discharge date 6/2/15

An interview was conducted with S1DON (Director of Nurses) on 9/2/15 at 2 p.m. She reported S3MD (Medical Director) had not completed a discharge summary in over a year on the hospital's patients. S1DON could not give the date of when S3MD stopped performing discharge summaries on the patients.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the hospital pharmacy's policies and procedures revealed no evidence that a pharmacist would review all medication orders prior to the first dose being administered.

On 08/31/15 at 2:45 p.m., interview with S7RN revealed that the hospital uses a local retail pharmacy to obtain the patients' medications. S7RN stated that after that pharmacy closes at 6:00 p.m., any new medications ordered would be removed from the hospital's stock medication cabinet. S7RN further revealed that a pharmacist does not review these medication orders prior to the nurses administering the first dose of the medication to the patients.

On 09/02/15 at 9:30 a.m., interview with S15Pharmacist revealed that if the nurses obtain a physician order for a new medication after pharmacy hours (6:00 p.m.), the nurses will administer the first dose of the medication from the stock cabinet and a pharmacist will review the medication order that next day. S15Pharmacist confirmed that all medication orders were not reviewed by the pharmacist prior to the first dose being administered.

Based on observations and interview, the hospital failed to have an inventory management system that ensured that outdated drugs and biologicals were not available for patient use. Findings:

An observation was conducted on 8/31/15 at 1:15 p.m. of the central supply room with the following expired intravenous fluids:
10 liter bags of D5W 1/2NS that expired in 1/2015
2 liter bags of D5W 1/2NS that expired in 7/2015
1 liter bag of. 9%NS that expired in 3/2015 and another liter that expired in 3/2015
2 liter bags of D5W that expired in 4/2015
1 liter bag of Lactated Ringers that expired in 3/2015
1 liter bag of Lactated Ringer D5 that expired in 3/2015

An interview was conducted with S1DON (Director of Nurses) on 8/31/15 at 1:15 p.m. She reported they have been busy and hadn't had time to go through the supplies for expiration dates.

Based on record review and interview, the facility failed to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 2 of 2 (#10, #11) sampled patients with medication variances reviewed with known medication errors out of a total sample of 30. Findings:

Review of the hospital policy titled Medication Errors revealed it did not indicate that nurses were to document drug administration errors in the patients' medical records.

Review of two medication variance reports, provided by S1DON, revealed that patient #10 and patient #11 were administered incorrect medications by the nursing staff. Review of the medical records for patients #10 and #11 revealed no documented evidence that the medication errors or physician notifications of the errors were documented.

In an interview on 09/02/15 at 10:40 a.m., S1DON confirmed that the above medication errors and physician notification of the errors were not documented in the patient's medical records. Further interview with S1DON confirmed that the errors should have been documented in the medical record, but the hospital policy did not address this.

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

Findings:
A review of the contracts provided by S1DON revealed the hospital had a contract with a mobile medical service to provide mobile radiology services for in-patients.

A review of the hospital's Policy and Procedure Manual provided by S1DON, and presented as current, revealed no documented evidence of any policies and procedures related to radiology services that addressed safety precautions against radiation hazards for the safety of staff and patients during radiological procedures performed in the hospital.

In an interview on 09/01/15 at 1:10 p.m. with S1DON, she was asked if the hospital had any policies and procedures for safety precautions against radiation hazards for staff and patients when radiological services were performed on in-patients in the hospital setting. S1DON indicated that the hospital had a contract with a mobile radiology service, but confirmed that no policies and procedures were in place that related to radiology services or to the safety precautions against radiation hazards for staff and personnel during radiology procedures in the hospital.

Based on record review and interview, the hospital failed to ensure that there was a radiologist who was a member of the medical staff and who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital.
Findings:

A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S1DON as a current list, revealed no documented evidence that a radiologist was identified as the Director of Radiology or the Supervising Radiologist.

A review of the Governing Body meeting minutes revealed no documentation of the appointment of a radiologist as the Director of Radiology or the Supervising Radiologist for the hospital.
A review of the hospital's organizational chart revealed no documentation of a radiologist as the Director of Radiology or the Supervising Radiologist for the hospital.
A review of the contracts provided S1DON revealed the hospital had a contract with a mobile medical company to provide radiology services.

In an interview on 09/01/15 at 1:10 p.m. with S1DON, she was asked for documentation of the appointment of a Director of Radiology for the hospital. S1DON revealed that the hospital had a contract in place for radiology services and she was unaware that the hospital needed a Director of Radiology. S1DON further confirmed that the hospital did not have an appointed Director of Radiology services who was a member of the medical staff and who supervised the radiology services for the hospital.

Based on record review and interview, the hospital failed to ensure the designated infection control officer was qualified through education, training, experience or certification.

Findings:

Review of S5RN's (desiganted Infection Control Officer) personnel file revealed no documented evidence of infection control education, training, experience or certification.

In an interview on 9/2/15 at 9:44 a.m. with S5RN, she indicated her nursing background was in skilled care. S5RN said she had no experience as an infection control nurse. She also indicated she had not received any formal training related to organizing and establishing an infection control program.

Based on record review, observation, and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:
1) failing to ensure patients known or suspected of having MDRO (multiple drug resistant organisms) infections in wounds (#11, #21)/blood (#8) and a rule out C. difficile patient (#13) were placed on isolation precautions for 4 (#8,#11,#13,#21) of 4 (#8,#11, #13, #21) patients reviewed for initiation of isolation precautions out of a total sample of 30.
2) failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring and performance of wound care. This deficient practice is evidenced by a. improper hand hygiene during performance of blood glucose monitoring (Patient # 1) and wound care (Patient #6) and b. failing to properly disinfect a glucometer after obtaining a capillary blood glucose reading (Patient #1).
3) failing to ensure all employees were screened for TB (tuberculosis) for 8 (S1DON, S5RN, S6RT, S8LPN, S16SW, S17RN, S18CNA, S19CNA) of 8 employees ' reviewed for TB health screening.
4) failing to ensure identified hospital acquired infection data was investigated, analyzed, tracked, and trended.
5) failing to ensure all hospital staff had been trained on providing care/management of patients requiring Contact -specific to C. difficile, Airborne and Droplet isolation precautions for 10 (S1DON, S5RN, S8LPN, S9PTA, S12PT, S13OT, S14ST S17RN, S18CNA, S19CNA) of 13 personnel records reviewed.
6) failing to ensure housekeeping staff had been trained/evaluated on cleaning/disinfecting the rooms of patients requiring Airborne, Droplet and C.difficile contact isolation for 2 (S11HK,S12HK) of 2 housekeeping employees interviewed.

7) failing to ensure a sanitary environment was maintained to avoid sources and transmission of infections and communicable diseases as evidenced by having dead insects, spiderwebs, dust and expired supplies in the environment of care.

Findings:
1)Failing to ensure patients known or suspected of having MDRO (multiple drug resistant organisms) infections in wounds/blood and a rule out C. difficile patient were placed on contact isolation precautions.
Review of the hospital policy titled, "Isolation Guidelines -written by: Centers for Disease Control and Prevention- adapted for this hospital " revealed the following, in part:

D. Contact Precautions:
In addition to standard precautions, use Contact Precautions for patients known or suspected of having serious illnesses easily transmitted by direct patient contact with items in the patient's environment. Examples include: Gastrointestinal, respiratory, skin or wound infections or colonization with multidrug-resistant bacteria.

Appendix A: Clinical Syndromes or Conditions Warranting Additional Precautions to Prevent Transmission of Epidemiological Important Pathogens Pending Confirmation of Diagnosis:
Risk of Multidrug-Resistant Micro-organisms:
1. History of infection or colonization with multidrug-resistant organisms; Potential pathogen: Resistant bacteria; Precautions: Contact.

Appendix B: Multidrug Resistant Microbes: General Precautions:
Resistant microbes are defined as:
Methicillin Resistant Staphylococcus Aureus
Contact isolation is required for any of the above multi-drug resistant organisms.

Appendix C: Type and Duration of Precautions Needed for Selected Infections and Conditions:
Multidrug-resistant organisms-infection or colonization: Skin, wound or burn; Type of Isolation: Contact; Duration: until off of antibiotics and culture negative.


Positive Wound Cultures-MRSA:
Patient #11
Review of the medical record for patient #11 revealed the patient was admitted on 01/30/15 with diagnoses including status post lumbar laminectomy. The nurses notes dated 02/06/15 at 11:30 p.m. revealed the physician visited with new orders to culture drainage from the patient's back incision.
Review of the preliminary culture lab results, dated 02/08/15 at 1:51 p.m., revealed moderate Staph Aureus in the back wound. Physician orders were obtained for Vancomycin intravenous for five days.
Review of the final culture lab result, dated 02/09/15 at 11:22 a.m., revealed moderate Staph Aureus (Methicillin Resistant) grew out of the patient's back wound.
There was no documented evidence in the record that patient #11 was put on contact precautions after culture results revealed moderate Staph Aureus (Methicillin Resistant) was grown out of the patient's back incision. In an interview with S5RN on 09/02/15 at 9:44 a.m., she stated that the patient should have been placed on contact precautions after the positive culture result.


Patient # 21
Review of Patient #21 's medical record revealed he was admitted on 6/29/15 and discharged on 7/11/15. Patient #21 had an admission diagnosis of Multiple Sclerosis.

Review of Patient #21's medical record revealed the patient had a positive wound culture (right thigh abscess) for MRSA (Methicillin Resistant Staphylococcus Aureus) collected on 7/3/15 and resulted on 7/5/15.

Review of Patient #21's MD (medical doctor) orders revealed the patient was started on Vancomycin on 7/5/15 at 6:22 a.m. and Rifampin on 7/5/15 at 3:15 p.m.

Additional review of the patient's MD orders revealed no documented evidence of Patient #21 being placed on contact precautions.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Officer), she agreed patient 's with positive wound cultures for MRSA should have been placed in contact isolation.

In an interview on 9/2/15 at 11:06 a.m. with S1DON she indicated patients with positive cultures for MRSA were not necessarily placed on contact precautions. She said all patients were on standard precautions already.

Positive blood cultures-MRSA
Patient #8
Review of the medical record for patient #8 revealed the patient was admitted on 08/21/15 with diagnoses including status post left total hip and left knee replacement and open reduction internal fixation of the left femur. Nurses notes dated 08/23/15 at 10:15 p.m. revealed fluid was drawn from the patient's left knee per the physician. New orders (dated 08/23/15) for Gentamicin and Vancomycin intravenous were obtained, as well as blood cultures times two.
Review of the nurses notes dated 08/24/15 at 4:50 p.m. revealed the lab company called with a critical lab value indicating gram positive cocci resembling Staph had grown out of the patient's blood culture. Review of the final culture results, dated 08/26/15 at 8:47 a.m., revealed MRSA (Methicillin Resistant Staph Aureus) grew from the patient's blood culture.
There was no documented evidence in the record that the patient was placed on contact precautions after the positive culture result. In an interview with S5RN on 09/02/15 at 9:44 a.m., she stated that the patient should have been placed on contact precautions after MRSA was cultured out of the blood.

Rule out C.Difficile cultures:
Review of the hospital policy titled, "Isolation Guidelines -written by: Centers for Disease Control and Prevention- adapted for this hospital " revealed the following, in part:

D. Contact Precautions:
In addition to standard precautions, use Contact Precautions for patients known or suspected of having serious illnesses easily transmitted by direct patient contact with items in the patient ' s environment. Examples include: Gastrointestinal, respiratory, skin or wound infections or colonization with multidrug-resistant bacteria; Enteric infections with a low infectious dose or prolonged environmental survival, including: C.difficile.

Appendix A: Clinical Syndromes or Conditions Warranting Additional Precautions to Prevent Transmission of Epidemiological Important Pathogens Pending Confirmation of Diagnosis:
Risk of Multidrug-Resistant Micro-organisms:
1. Diarrhea: Potential pathogen: C. difficile; Precautions: Contact.

Appendix C: Type and Duration of Precautions Needed for Selected Infections and Conditions:
C. difficile: Type of Isolation: Contact; Duration: Duration of illness.
Patient #13
Review of Patient #13's medical record revealed she was a 75 year old admitted to the hospital on 5/23/15 with the diagnosis of debility. During her hospitalization the patient was documented as having episodes of diarrhea. The physician ordered a stool sample for C Difficile. Further review of the medical record revealed the patient was not put on isolation while the results for the C. Difficile were pending.
In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Officer), she agreed patients being tested to rule out C.difficile should be placed in contact isolation until it is determined that they are not infected with C.difficile.
2) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring and performance of wound care.
a. Improper hand hygiene during performance of blood glucose monitoring and wound care
Review of the hospital policy titled, " Isolation Guidelines- written by: Centers for Disease Control and Prevention, adapted for this hospital " revealed the following, in part:
Handwashing:
Handwashing is the single most important means of preventing the spread of infection. Personnel must wash their hands even when they use gloves. They must wash their hands: 5. After removal of gloves, 6. Between all patients contact and contact with the patient ' s environment.
Wearing gloves does not replace the need for hand washing because: 1. gloves may have small inapparent defects or be torn during use, 2. hands can become contaminated during removal of gloves.

Patient #6
Review of patient #6 ' s medical record revealed an admission date of 8/28/15 with an admission diagnosis of OA (Osteoarthritis) - s/p (status post) left knee replacement.

On 9/1/15 at 10:10 a.m. an observation was made of S7RN performing wound care for Patient #6.
S7RN failed to perform hand hygiene before donning the first pair of gloves worn for removing the bandage from the wound. He changed gloves 3 times throughout the procedure and failed to perform hand hygiene with each glove change. S7RN also failed to perform hand hygiene after completing the procedure and prior to exiting Patient #6 ' s room.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 8/20/15 with an admission diagnosis of Toxic encephalopathy. Further review revealed the patient also had a diagnosis of Diabetes Mellitus.

On 9/1/15 at 11:32 a.m. an observation was made of S8LPN performing blood glucose monitoring on Patient #1. S8LPN failed to perform hand hygiene before donning her gloves prior to obtaining the capillary blood glucose sample from Patient #1. S8LPN also failed to perform hand hygiene after removing her gloves after obtaining the capillary blood glucose.

In an interview on 9/2/15 at 11:06 a.m. with S1DON she confirmed staff should be performing hand hygiene before, after and in-between glove changes. She also indicated staff should be washing their hands upon entry and prior to leaving the patient ' s rooms, before and after providing patient care.

b. Failing to properly disinfect a glucose meter
Review of the hospital policy titled, " How to Clean Accucheck (glucose) Meter " , Policy #: PC6027, revealed the following, in part:
Policy: The Accucheck meter will be cleaned after each use on a patient.
Procedure: 3. Gently wipe the meter's surface with 70% alcohol prep.

Patient #1
On 9/1/15 at 11:32 a.m. an observation was made of S8LPN performing blood glucose monitoring on Patient #1. S8LPN was observed cleaning the glucose meter with alcohol after she had obtained the patient's capillary blood glucose sample.

In an interview on 9/1/15 at 11:40 a.m. with S8LPN, she indicated she had been taught to clean the glucose meter with alcohol prior to and after each use.

In an interview on 9/1/15 at 3:43 p.m. with S1DON, she indicated the staff had been instructed to clean the glucose meter with 70% alcohol wipes. She also indicated she had been unaware that 70% alcohol was not acceptable for cleaning the glucose meter.

Documentation found at FDA.gov relative to Blood Glucose Monitoring Systems revealed the following under the section of "Validated cleaning and disinfection procedures": "Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens".


3. Failing to ensure all employees were screened for TB
Review of the hospital policy titled, " Health Requirements " , Policy #: IC6004, reviewed/revised: 12/2014, revealed the following, in part:
Health Requirements: It shall be the policy of this hospital to require the following examinations, at the designated time, on employees, as indicated.
Time of Employment-All employees: 1. PPD (purified protein derivative- skin test to detect exposure to TB [Tuberculosis]) or chest x-ray, if indicated.
Follow-up Testing Requirements-All employees: 1. PPD (purified protein derivative- skin test to detect exposure to TB [Tuberculosis]) or chest x-ray, if indicated (to be done annually, from date of last testing).
Review of personnel files for S1DON, S5RN, S6RT, S8LPN, S16SW, S17RN, S18CNA and S19CNA revealed no documented evidence of health screening for TB (tuberculosis).
In an interview on 9/1/15 at 9:48 a.m. with S1DON, she confirmed she had no documented evidence of S6RT 's TB status.
In an interview on 9/2/15 at 3:30 p.m. with S1DON, she indicated TB skin testing had not been conducted at the hospital since 2013. She also confirmed there were no documented health screens for TB for the above referenced employees.

4) failing to ensure identified hospital acquired infections were investigated, analyzed, tracked and trended.
Review of the hospital policy titled," Performance Improvement plan, Policy#: IC1008, revealed the following, in part:
Responsibility and Scope of Service:
The infection control practitioner has overall responsibility for the department performance assessment and improvement plan and follow-up for the quality of care/service provided to all customers of the department. The infection control practitioner will be responsible for coordinating data collection and the evaluation of data.
Description of services provided:
1) Investigation of positive cultures, clusters of pathogens, inpatients and personnel involved.
2) Evaluation of confirmed infectious cases to assure correct implementation of appropriate barriers.
3) Employee Health related issues and in-service education related to infection control practices.
Priority areas:
Systematic, coordinated and continuous approach to improving performance, focusing on surveillance, prevention, and control of infections throughout the organization.
Assure functioning, coordinated process to reduce the risk of Nosocomial (hospital acquired) infections in patients and staff.
Education of personnel regarding infection control.

Review of the infection control documentation presented by S5RN as current revealed she had collected monthly data for hospital acquired (HAI) versus community acquired infections. Further review revealed the following monthly Nosocomial (hospital acquired) Infection Documentation for 2015:
1/2015: 0% HAI , 2/2015: 33 % HAI, 3/2015: 0% HAI, 4/2015: 0% HAI, 5/2015: 14% HAI, 6/2015: 11% HAI and 7/2015: 15% HAI. Further review revealed no documented evidence of an investigation, tracking and trending of the spikes in HAIs. Additional review revealed no documented evidence of an action plan to address the spikes in HAIs in the months of 2/2015, 5/2015 and 7/2015.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Nurse/QA) she indicated she had not tracked, trended or investigated the spikes in infections in the months referenced above. She agreed the data collected indicating spikes in HAIs (referenced above) should have been investigated, tracked/trended and an action plan aimed at performance improvement should have been implemented to address the increases in HAIs.

5) Failing to ensure all hospital staff had been trained on providing care/management of patients requiring Contact -specific to C. difficile, Airborne and Droplet Isolation Precautions:

Review of the hospital policy titled," Performance Improvement Plan, Policy#: IC1008, revealed the following, in part:
Responsibility and Scope of Service:
The infection control practitioner has overall responsibility for the department performance assessment and improvement plan and follow-up for the quality of care/service provided to all customers of the department.
Description of services provided:
3) Employee Health related issues and in-service education related to infection control practices.
Priority areas:
Education of personnel regarding infection control.

Review of personnel records for S1DON, S5RN, S8LPN, S9PTA, S12PT, S13OT, S14ST S17RN, S18CNA, S19CNA, revealed no documented evidence of training for providing care/management of patients requiring the following types of isolation precautions: Contact -specific to C. difficile, Airborne and Droplet.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Officer), she confirmed the above referenced staff had received no training for providing care/management of patients requiring the following types of isolation precautions: Contact -specific to C. difficile, Airborne and Droplet.S5RN also indicated the above referenced staff had no documented skills competency evaluations regarding the types of PPE (personal protective equipment) required for each type of isolation precaution.

In an interview on 9/2/15 at 12:48 p.m. with S9PTA, she confirmed she had not received training for providing care/management of patients requiring Airborne and Droplet isolation. She also indicated she had not received training regarding care/management of patients on contact precautions for C. difficile.


6) failing to ensure housekeeping staff had been trained/evaluated on cleaning/disinfecting the rooms of patients requiring Airborne, Droplet and C.difficile contact isolation precautions:

Review of infection control documentation presented by S5RN (Infection Control Officer) revealed no documented evidence of any type of housekeeping audits for evaluation of cleaning/disinfection of patient rooms.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Officer), she confirmed housekeeping staff had not received training for cleaning/disinfecting the rooms of patients requiring Airborne, Droplet and C.difficile contact isolation. S5RN also indicated the housekeeping staff had no documented skills competency evaluations regarding the types of PPE (personal protective equipment) required for each type of isolation precaution. S5RN confirmed the hospital had no system in place to audit proper cleaning/disinfection of patient rooms.

In an interview on 9/2/15 at 1:10 p.m. with S10HK (housekeeping) and S11HK, they confirmed they had not received training for cleaning/disinfecting the rooms of patients requiring Airborne and Droplet isolation. They also indicated they had not received training for cleaning/disinfecting the rooms of patients on contact precautions for C. difficile.

7) failing to ensure a sanitary environment was maintained

Unsanitary Conditions
An observation was conducted in room a on 8/31/15 at 1:30 p.m. Multiple dead winged insects were on the white bed covering and the white window blinds were noted to have a thick coating of dust.

An observation was conducted in the nurses' station on 8/31/15 at 1:45 p.m. of dead winged insects around the window unit in the nurses' station and a dust caked fan blowing in the nurses station where patient supplies are located. Further observations in the nurses station revealed the plastic containers on the side of medication cart that held cups, spoons and medication cups had dead winged insects in the bottom.

On 8/31/15 at 1:48 p.m. an observation was made of the IV (intravenous) supply caddy. The caddy was noted to have small Styrofoam cups with individual IV supplies such as IV catheters and clearlink IV access caps. Dead winged insects were noted in the bottoms of the individual cups.

On 8/31/15 at 1:49 p.m. an observation was made of 10 supply bins located in the nurses' station. The bins contained IV fluids, IV flush syringes, IV tubing, IV flowmeters, suction tubing and oxygen tubing. Dust and dead winged insects were noted in the above referenced bins.

On 08/31/15 at 1:50 p.m., observation of the dietary storage room on the hall, which contained plates, plate covers and serving utensils, revealed multiple dead bugs on the floor and spider webs in all corners.

An observation was conducted on 8/31/15 at 1:50 p.m. in room B. S1DON (Director of Nurses) reported the room was ready to accept a new admission. The bedside table and night stand had a sticky substance on the top of both tables and a spider web was observed in the room's closet.

Expired Items
An observation was conducted in the central supply room on 8/31/15 at 1:30 p.m. The following expired items were found during the observation:
4 sterile debridement trays-expired 11/2012;
5 sterile debridement trays-expired 9/2013;
1 box of lever lock cannulas-expired 9/2013;
20 one ml (milliliter) syringes-expired 07/2014;
65 three ml individually packaged, pre-filled normal saline flush syringes-expired 7/21/14;
10 Shiley inner cannulas (for tracheostomies)-expired 9/2014;
50 Tincture of Benzoin Swabs-expired 6/2015.

The above referenced expired supply findings were verified, by interview with S1DON, as the observations were made on 8/31/15 at 1:30 p.m.


26351




17450

Based on record review and interview, the hospital failed to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services.

Findings:
Review of the hospital's organization chart revealed no documented evidence of an appointed physician Director of Respiratory Services.

An interview was conducted with S1DON on 8/31/15 at 2:00 p.m. She reported the hospital did not have a physician appointed to oversee the respiratory services of the hospital.

Based on record review and interview, the hospital failed to ensure personnel providing respiratory services were qualified as evidenced by failing to document current competencies and training of the personnel authorized to provide respiratory services for 4 (S5RN,S7RN, S8LPN,S17RN) of 4 nursing personnel files reviewed.

Findings:

Review of 4 (S5RN,S7RN, S8LPN,S17RN) of 4 nursing personnel files revealed there was no documented evidence of current competencies and training related to the provision of respiratory care services.

In an interview on 09/1/15 at 1:59 p.m., with S1DON, she indicated the nursing staff administered nebulizer treatments, monitored oxygen administration, suctioned patients and performed incentive spirometry. She also indicated the hospital admitted patients with "old" (stable) tracheotomies. S1DON also confirmed the above referenced nursing personal had no current documented competencies and training related to the provision of respiratory care services.

Based on record review and interview, the hospital failed to designate, in writing, respiratory care policies and procedures for each type of respiratory service provided, personnel qualified to perform specific procedures, and the amount of supervision required for personnel to carry out specific procedures.

Findings:

Review of the hospital's policies and procedures revealed the type of respiratory services provided, the personnel qualified to perform each type of respiratory service/procedure and the amount of supervision required for personnel to carry out specific procedures was not designated, in writing.

In an interview on 09/1/15 at 1:59 p.m., with S1DON, she indicated the nursing staff administered nebulizer treatments, monitored oxygen administration, suctioned patients and performed incentive spirometry. She also indicated the hospital admitted patients with "old" (stable) tracheotomies. She confirmed the type of respiratory services provided, the personnel qualified to perform each type of respiratory service/procedure and the amount of supervision required for personnel to carry out specific procedures was not designated, in writing.

Based on record review and interview, the chief executive officer, medical staff, director of nursing and infection control officer failed to ensure that the hospital wide QAPI (Quality Assessment and Performance Improvement) program identified infection control problems as evidenced by: 1) failing to ensure identified hospital acquired infections were investigated, analyzed, tracked and trended and 2) failing to identify hand hygiene and accepted standards of practice for infection control were not being followed during blood glucose monitoring and performance of wound care.
Findings:
1) Failing to ensure identified hospital acquired infections were investigated, analyzed, tracked and trended.
Review of the infection control documentation presented by S5RN as current revealed she had collected monthly data for hospital acquired (HAI) versus community acquired infections. Further review revealed the following monthly Nosocomial (hospital acquired) Infection Documentation for 2015:
1/2015: 0% HAI , 2/2015: 33 % HAI, 3/2015: 0% HAI, 4/2015: 0% HAI, 5/2015: 14% HAI, 6/2015: 11% HAI and 7/2015: 15% HAI. Further review revealed no documented evidence of an investigation, tracking and trending of the spikes in HAIs. Additional review revealed no documented evidence of an action plan to address the spikes in HAIs in the months of 2/2015, 5/2015 and 7/2015.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Nurse/QA) she indicated she had not tracked, trended or investigated the spikes in infections in the months referenced above. She agreed the data collected indicating spikes in HAIs (referenced above) should have been investigated, tracked/trended and an action plan aimed at performance improvement should have been implemented to address the increases in HAIs.


2) Failing to identify hand hygiene and accepted standards of practice for infection control were not being followed during blood glucose monitoring and performance of wound care.
Patient #6
Review of patient #6 ' s medical record revealed an admission date of 8/28/15 with an admission diagnosis of OA (Osteoarthritis) - s/p (status post) left knee replacement.

On 9/1/15 at 10:10 a.m. an observation was made of S7RN performing wound care for Patient #6.
S7RN failed to perform hand hygiene before donning the first pair of gloves worn for removing the bandage from the wound. He changed gloves 3 times throughout the procedure and failed to perform hand hygiene with each glove change. S7RN also failed to perform hand hygiene after completing the procedure and prior to exiting Patient #6 ' s room.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 8/20/15 with an admission diagnosis of Toxic encephalopathy. Further review revealed the patient also had a diagnosis of Diabetes Mellitus.

On 9/1/15 at 11:32 a.m. an observation was made of S8LPN performing blood glucose monitoring on Patient #1. S8LPN failed to perform hand hygiene before donning her gloves prior to obtaining the capillary blood glucose sample from Patient #1. S8LPN also failed to perform hand hygiene after removing her gloves after obtaining the capillary blood glucose.

In an interview on 9/2/15 at 11:06 a.m. with S1DON she confirmed staff should be performing hand hygiene before, after and in-between glove changes. She also indicated staff should be washing their hands upon entry and prior to leaving the patient ' s rooms, before and after providing patient care.

In an interview on 9/2/15 at 9:44 a.m. with S5RN (Infection Control Nurse/QA) she indicated she had not performed hand hygiene audits to evaluate staff performance of hand hygiene. She also indicated hand hygiene performance was not a Performance Indicator for QAPI.