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Based on observation, record review and interview, the Governing Body failed to maintain the hospital ensuring the physician and nurses followed their own policies and procedures regarding restraints; implemented an effective Quality Assurance program; had enough people to have a utilization review committee, maintained the facility's physical plant that included the facility's fire alarm system in a clean, sanitary, and safe manner; and maintained an adequate infection control program. These findings resulted in the Conditions for Participation for Patient Rights (A0115); Quality Assurance (A 0263); Utilization Review (A0652); Physical Plant (A0700) and Infection Control (A0747) to not be met.

Findings:
1. Cross Reference A 0057: Based on observations, interviews and record reviews, the Governing Body failed to appoint a chief executive officer (CEO) who effectively manages the hospital.
2. Cross Reference A 0115: Based on record review, observations, and interviews, the facility failed to protect and promote the rights of residents by failing to follow their own policies and procedures regarding use of physical restraints for 2 of 2 patients in restraints and ensuring that the clinical record for 10 of 11 patients (Patients #'s 1,2,3,45,6,7,8,9,10 and 11) had information identifying advanced directives . The facility failed to ensure that restraints were not prescribed on as needed basis; that a face to face evaluation by the physician was conducted and documented prior to rewriting new orders for restraint usage; and that an assessment, prior to, during and after placing patients in restraints was conducted and documented. These failures resulted in the Condition of Participation for Patient Rights to not be met.

3. Cross Reference A 0263: Based on facility record review and interview, the facility failed to implement and maintain an effective, ongoing, hospital wide, data driven Quality Assurance and Performance Improvement(QAPI) program that involved all departments and services.


4. Cross Reference A0652: Based on interview, the hospital failed to have an effective utilization review plan that consists of the required staff members.

5. Cross Reference A0700: Based on observation and interview, the facility failed maintain the facility's physical plant in a manner that ensure the safety of all patients utilizing the facility.

6. Cross Reference A0747: Based on interviews, review of record reviews, review of policies and procedures, and infection control documentation, it was determined the acute care hospital failed to maintain an infection control program that seeks to minimize infections and communicable diseases. The acute care hospital failed to provide a functional and sanitary environment for the provision of hospital wide services by adhering to professionally acceptable standards of practice (refer to A0749 ); failed to maintain an ongoing infection control program designed to prevent, control, and investigate infections and communicable diseases and failed to consider, select and implement nationally recognized infection control guidelines as part of the program (refer to A0749 ); failed to designate a qualified professional with training in infection control to direct the program (refer to A0748)); failed to integrate the infection control program as part of the quality assessment and performance improvement program (refer to A0756); and, failed to provide a plan of action for preventing, identifying, and managing infections and communicable diseases and for immediately implementing corrective and preventive measures that result in improvement (refer to A0756). The cumulative systemic problems resulted in the condition for coverage as not being met.

Based on record review, observations, and interviews, the facility failed to protect and promote the rights of residents by failing to follow their own policies and procedures regarding use of physical restraints for 2 of 2 patients in restraints and ensuring that the clinical record for 10 of 11 patients (Patients #'s 1,2,3,45,6,7,8,9,10 and 11) had information identifying advanced directives . The facility failed to ensure that restraints were not prescribed on as needed basis; that a face to face evaluation by the physician was conducted and documented prior to rewriting new orders for restraint usage; and that an assessment, prior to, during and after placing patients in restraints was conducted and documented. These failures resulted in the Condition of Participation for Patient Rights to not be met.

Findings:

1. Cross Reference A 0132: Based on interview, clinical record review and review of the hospitals policy's and procedures; the facility failed to ensure that 10 of 11 patients (Patients #'s 1,2,3,45,6,7,8,9,10 and 11) had information located in the clinical record identifying any advance directives.

2. Cross Reference A 0167: Based on record review, observation and interview, the facility failed to follow their own policies and procedures regarding restraint usage for 2 of 11 (#5 and #8) sampled patients.

3. Cross Reference A 0169: Based on record review and interview, the facility failed to implement their own policies and procedures relating to restraints by permitting the prescribing of restraints on an as needed (PRN) basis to 1 of 11 (#5) patients.

4. Cross Reference A 0172: Based on record review, observation and interview, the facility failed to follow their own policy and procedure regarding reassessment by a physician before writing a new order for the use of restraints on 2 of 2 (#5 and #8) patients restrained.

5. Cross Reference A 0175: Based on record review, observation and interview, the facility failed to follow their own policies and procedures regarding monitoring of 2 of 2 (#5 and #8) restraint patients after placing them in restraints.

Base on facility record review and interview, the facility failed to implement and maintain an effective, ongoing, hospital wide, data driven Quality Assurance and Performance Improvement(QAPI) program that involved all departments and services. This failure resulted in the Condition of Participation for QAPI not to be met.

Findings:

1. Cross Reference A-0273: Based on facility record review and interview, the facility failed to have an ongoing Quality Assurance and Performance Improvement program. The facility failed to incorporate data, and failed to have or measure, analyze and track quality indicators. The plan failed to indicate the frequency and detail of the data collection and was not specified by the governing body.


2. Cross Reference A-0283: Based on facility document review and interview, the facility failed to use the limited data collected to identify opportunities for improvement and apply changes for improvement. The facility failed to set priorities, measure, track or take action for improvement.

3. Cross Reference A-0286: Based on facility document review and interview, the facility failed to have an ongoing Quality Assurance/Performance Improvement (QAPI) program showing measurable improvement or to have evidence of facility wide indicators for patient safety. The facility failed to set priorities, measure, track, analyze or take action for improvement for patient safety. The facility failed to take action for improvement for medical errors.

4. Cross Reference-A-0297: Based on facility document review and interview, the facility failed to have and/or conduct Quality Improvement projects.


5. Cross Reference-A-0308: Based on facility document review and interview, the hospital's governing body failed to ensure that the Quality Assurance/Performance Improvement program reflected the complexity of the hospital's organization and services; and involved all hospital departments and services.

6. Cross Reference-A-309: Based on facility document review and interview, the hospital's Governing Body failed to ensure that there is hospital wide ongoing Quality Assurance/Performance Improvement and Patient Safety program. The Governing Body failed to ensure that a distinct number of improvement projects be conducted annually.

Based on interview, the hospital failed to have an effective utilization review plan that consists of the required staff members. Due to this failure the Condition for Participation for Utilization Review has not been met.

Findings:

Reference A 0654: Based on interview, the facility failed to have a utilization review committee that consist of two practitioners.

Based on observation and interview, the facility failed maintain the facility's physical plant in a manner that ensures safety of all patients and visitors in the facility. This failure resulted in the Condition of Participation for Physical Environment not to be met.
Findings:

1. Cross Reference A 0701: Based on observation and interview, the facility failed to maintain the physical plant in a safe manner to ensure the well-being of the patient

2. Cross Reference A 0709: Based on observation and interview, the facility failed to ensure the facility was safe from the potential of fire.

3. Cross Reference A 0724: Based on observation and interview, the facility failed to ensure the diagnostic department promoted a safe environment for patients.

Based on staff interviews, review of administrative records,personnel records, policies and procedures, and infection control documentation, it was determined the acute care hospital failed to maintain an infection control program that seeks to minimize infections and communicable diseases. The acute care hospital failed to provide a functional and sanitary environment for the provision of hospital wide services by adhering to professionally acceptable standards of practice (refer to A0749 ); failed to maintain an ongoing infection control program designed to prevent, control, and investigate infections and communicable diseases and failed to consider, select and implement nationally recognized infection control guidelines as part of the program (refer to A0749 ); failed to designate a qualified professional with training in infection control to direct the program (refer to A0748); failed to integrate the infection control program as part of the quality assessment and performance improvement program (refer to A0756); and, failed to provide a plan of action for preventing, identifying, and managing infections and communicable diseases and for immediately implementing corrective and preventive measures that result in improvement (refer to A0756). The cumulative systemic problems resulted in the condition of participation not being met.

Findings include:

1. An interview was conducted on 10/17/2012 at 2:20 PM with the Director of Nurses. The Director of Nurses (DON) acknowledged that she is new to the position and is currently in training. She further stated that the person who was orienting and training her for the position is no longer employed by the facility. During the inquiry regarding the hospitals' Infection Control Program, the following information was obtained. the DON stated: "I have been in this position (DON) for a couple of weeks and I have been told that I am taking over the Infection Control Program. They said they were going to send me for some training. I need to sign up and go for some education. There was a nurse who was compiling the information, but she has been out on medical leave since May. Currently, I do have a log of infections and we do call the patients who were treated in the Emergency Room if their cultures come back and they need another antibiotic. I am unaware if any information is being reported to the Quality Assurance Program and if there are any measures in place for analyzing the data regarding infection surveillance."

2. review of the governing body minutes did not provide any documentation as to the appointment of a qualified person to direct the infection control program.

3. At the time of exit on 10/18/2012 at 4:00 PM, the facility failed to provide any documentation identifying a designated person responsible for the oversight of the Infection Control Program.

4. No information was provided indicating that the infection control program for the hospital incorporated guidelines and professionally acceptable standards in developing policies and procedures for governing control of the program.

5. At the time of exit on 10/18/2012 at 4:00 PM, no written documentation was provided regarding a plan of action for preventing, identifying and managing infections and communicable disease and for immediately implementing corrective and preventive measures.


6. A review was completed of the facility's Quality Assurance Committee Meetings for July and August 2012. The facility was unable to provide documentation for any other meetings in 2012. The following information related to infection control is documented in the meetings.

07/26/2012 - "Focus for future Q.A. studies: Medical Floor- infection control"
08/30/2012- "Future Focus: Infection Control Protocol will be implemented as a workable tool for in-house hospital concerns. A lengthy review of current protocol and required protocol will be done with a forward focus"

The facility was unable to provide any Quality Assurance (QA) studies or any workable tools related to inhouse concerns.

7. Review of the Quality Assurance committee meetings did not indicate that the CEO or medical director were in attendance or involved in the infection control /Q.A. process. In addition, the current Director of Nurses (DON), who indicates she is the person designated as the Infection Control Officer was not in attendance for these meetings. The facility was unable to furnish any information related to the training of staff in infection control measures. Personnel file reviews did not reveal any infection control training for employees. The personnel files revealed an 11 question test regarding infection control, there is no indication that these tests were graded as to pass or fail. There were no educational inservices provided to indicate that employees get "on hire" and annual training related to infection control.

8. An interview was conducted with the charge nurse, Registered Nurse (RN), (employee # 5, hired 08/07/12) on 10/15/2012 at 11:00 AM. The charge nurse could not remember any specific infection control training offered by the facility. She stated,"I am a new nurse and recent graduate. I received my training in school and plan on taking continuing education courses."

9. An additional interview was conducted on 10/15/2012 at 10:45 AM with the Physician Assistant (PA) who is responsible for overseeing the patient care in the Emergency Room. The PA indicated that he was not directly involved in the Infection Control Program for the hospital. He was unaware of any system in place for overseeing the program.

10. On 10/17/2012 at 2:25 PM, the Director of Nurses produced a form titled, "Infection Control , Quality Assurance Statistics 2012". She indicated this form had not been completed since May 2012 when the nurse who was logging infections left on medical leave. She further stated,"This form is specific to the types of infections identified monthly. I do not know whether this form has been submitted to the committee as we can not locate any minutes prior to July 2012. I am aware that these statistics have not been compiled since the nurse went on Medical leave in May. I have not attended any QA meetings at this point, I'm assuming the former Director of Nurses was in attendance."

Based on observations, interviews and record reviews, the Governing Body failed to appoint a chief executive officer (CEO) who effectively manages the hospital.

Findings:

1. Cross Reference A 0167: Based on record review, observation and interview, the facility failed to follow their own policies and procedures regarding implementing restraints to 2 of 11 (#5 and #8) sampled patients.
2. Cross Reference A0619: Based on record review and interview, the facility failed to ensure they followed their own policies and procedures regarding prescribing restraints to 1 of 11 (#5) patients restraints on an as needed (PRN) basis.
3. Cross Reference A0172: Based on record review, observation and interview, the facility failed to follow their own policy and procedure regarding reassessment by a physician before writing a new order for the use of restraints on 2 of 2 (#5 and #8) patients restrained.
4. Cross Reference A0263: Based on facility record review and interview, the facility failed to implement and maintain an effective, ongoing, hospital wide, data driven Quality Assurance and Performance Improvement(QAPI) program that involved all departments and services. This failure resulted in the Condition of Participation for QAPI not to be met.
5. Cross Reference A0622: Based on observation, record review and interview, the facility failed to ensure 3 of 3 kitchen cooks were competent in their respective duties.

6. Cross Reference A0701: Based on observation and interview, the facility failed to maintain the physical plant in a safe manner to ensure the well-being of the patients and visitors.

7. Cross Reference A0709: Based on observation and interview, the facility failed to ensure the facility was safe from the potential of fire.

8. Cross Reference A0724: Based on observation and interview, the facility failed to ensure the diagnostic department promoted a safe environment for patients.

Cross Reference A0748: Based on staff interviews, review of quality assurance committee and governing body meeting minutes and record review it was determined the facility failed to ensure the infection control program was under the direction of a designated and qualified professional who had training in infection control as evidenced by the absence of infection control documentation in the personnel record and an interview with the infection control professional who was unable to produce documentation of position designation or infection control training.

Cross Reference: A0749: Based on staff interviews and review of administrative records, policies and procedures, observation and infection control documentation, it was determined the acute care hospital failed to maintain an infection control program that provided a plan of action for preventing, identifying and managing infections and communicable diseases and for immediately implementing corrective and preventive measures that would result in improvement as evidenced by the lack of an ongoing infection control program.

Based on interview, clinical record review and review of the hospitals policy's and procedures, the facility failed to ensure that 10 of 11 patients (Patients #'s 1,2,3,45,6,7,8,9,10 and 11) had information located in the clinical record identifying any advance directives.

Findings include:

1. A clinical record review was completed for Patient #'s 1,2,3,5,6,7,8,9,10 and 11. All patients were admitted to the facility for emergency care or inpatient treatment in September 2012 or October 2012. Admitting forms labeled, "Advanced Directive Information" were present in each clinical record reviewed. The following information was obtained from the form:
"Florida lawmakers have expressed concern about the number of people in this State who lack the capacity to make a decision concerning their health care. These people may not have a family member or guardian who can make decisions for them. Therefore, a law (Florida Statute, Chapter 765) was enacted which requires Florida hospitals to as the following questions:
1. Do you have a living will? Yes or No
If yes, is there a copy attached.
2. Do you have a Durable Power of Attorney? Yes or No
If yes , is there a copy attached?
3. Have you completed a legal document designating someone other than your family or a guardian to make health decisions on your behalf in the event you are incapacitated and could not make those decisions yourself? Yes or No
If yes, name and phone number
4. Is the person listed above aware of your choice? Yes or No
5. Advance Directive information has been given to the patient
Information given by - hospital staff initials
Patient signature"

All clinical records for patients 1, 2, 3, 5, 6, 7, 8, 9, 10, and 11 reviewed lacked any documentation regarding the advance directives, All yes and no questions noted on the above form were unanswered thus not revealing any information related to the patients' desires or designation of health care surrogates.

2. Review of the facility's policy and procedure, reviewed and revised 05/2012, revealed that each patient shall provide information upon admission related to advance directives in writing and the information will become a part of the patient's clinical record.

3. An interview was conducted with Patient #2 who is receiving emergency room care on 10/16/2012 at 10:00 AM. Patient #2 stated that she was not provided with any information regarding advance directives. She further stated,"They gave me a lot of forms on admission and told me to sign them; I was not required to fill out all the information."

4. An additional interview was conducted with the Director of Nurses on 10/17/2012 at 2:45 PM. The Director of Nurses (DON) confirmed that most patients admitted to the facility come in through the emergency room and are given a standard packet of information to sign. She stated,"The clerical staff is responsible for getting the signatures and admission forms completed. We should be providing patients with information related to advance directives and the forms should be completed in their entirety." The DON conferred that Patient #'s 1,2,3,5,6,7,8,9,10 and 11 had incomplete forms and no information related to their advance directive wishes located in their records.

Based on record review, observation and interview, the facility failed to follow their own policies and procedures regarding implementing restraints to 2 of 11 (#5 and #8) sampled patients.

Findings:

1.) Review of patient #5's record revealed a physician's order for left and right arm and right ankle restraints "at all times," on 9/27/2012 at 0600; however, no rational for ordering the restraints was identified. Further review of the physician's orders revealed this order was repeated on 9/30/12, 10/3/12 at 0620, 10/4/12 at 0615; 10/5/12, 10/6/12, and 10/7/12 at 0606. On 10/8/12, the order was changed to "left and right wrist restraints per [verbal order]". On 10/9/12 at 0620, the order was changed back to right and left wrist restraints and right ankle restraints. On 10/10/12 at 0950, the order was changed to "[bilateral] wrist restraints and right ankle restraint at all times unless someone is with patient". This order was repeated on 10/11/12 at 0500 and 10/12/12 at 0600. On 10/13/12 at 0605, the order was changed to left and right wrist and right ankle restraint at all times and repeated on 10/14/12 at 0600. On 10/15/12, the order was changed to "wrist bilateral restraints. [Right] leg restraint as needed" and the order was repeated on 10/16/12 at 0700. None of these orders indicated why the patient was being placed in restraints. There was no documentation that the physician assessed the patient prior to or after ordering the restraints. There was no documentation that the nursing staff were assessing the patient prior to, during or after removing the restraints. There was no documentation that the patient had the restraints removed at any time. No orders for restraints could be found for 10/17/12.

Observation of patient #5 on 10/17/12 from 10:20 AM - 10:40 AM revealed the patient was wearing bilateral wrist restraints and her right leg was restrained with a soft restraint. The patient was observed to be able to touch her face and legs while still in the restraints.

Interview with the Activities staff on 10/17/12 at 10:35 AM revealed that the patient became confused and began to pull at all of her tubes and then attempted to climb out of bed which is the reason for the use of the restraints.

2.) Review of patient #8's physician's orders revealed a telephone order on 9/21/12 at 0600 for "[Left] wrist restraint at all times". This order was repeated on 9/22/12 at 0600, and on 9/23/12 at 0600. On 9/27/12, an order was written for "[left] wrist restraint at all times unless someone is at bedside [with patient]." On 9/28/12 at 0500, the order was back to left wrist restraints at all times and repeated on 9/30/12, 10/3/12 at 0620, 10/4/12 at 0615, 10/5/12, 10/6/12 at 0635, and 10/7/12 at 0800. On 10/8/12, the order just states "[Left] wrist restraint", this order was repeated on 10/9/12. On 10/10/12 at 0950, the order was changed to "[left] wrist restraint [at] all times unless someone is with patient". This order was repeated on 10/11/12 at 0500. No other restraint orders were found on this date. None of these orders indicated why the patient was being placed in restraints. There was no documentation that the physician assessed the patient prior to or after ordering the restraints. There was no documentation that the nursing staff were assessing the patients prior to, during or after removing the restraints. There was no documentation that the patient had the restraints removed at any time.

Observation of patient # 8 on 10/18/12 at 8:58 AM revealed the restraints were still on the left bed rail of the bed, but the restraint was not on the patient. The patient was observed to be sleeping.


3.) Review of the facility's Restraint Policy (last reviewed 6/6/11) revealed the following information:

a.) Under the section, Physician's Order- the policy states that orders for restraints "Cannot be written as '[as needed]'".

b.) Under the section, "Staff Roles & Responsibilities"- the policy states that the patient needs to be assessed. According to this policy, "The assessment is done prior to the initiation of restraint and is documented. Assessment will include: Risk/Potential for harm to self and others. Current treatment, condition and ability to cooperate". According to the policy, "Trained staff must examine the patient in restraints at the initiation of restraints and at least every 15 minutes for the duration of restraint order to ensure that the patient's vital signs and conditions are not deteriorating as a result of restraint use".

c.) Under the section, Physician's Order item #6 indicates: "Time Limitations for Initial Orders are as follows: Primary Medical Maximum limitations of 24 hours. To renew these orders requires a 'face to face' assessment by the physician to determine if renewal is necessary".

4.) Interview with the Director of Nursing on 10/17/12 at 2:30 PM revealed that they had informed the Clinical Service Director about needing a Restraint Assessment form, but he has never provided them with one.

Based on record review and interview, the facility failed to implement their own policies and procedures relating to restraints by permitting the prescribing of restraints on an as needed (PRN) basis to 1 of 11 (#5) patients.
Findings:Review of patient #5's record revealed a physician's order dated 10/15/12 at 1000 (10:00 AM) which stated, "Wrist Bilateral restraint. [Right] leg restraint as needed." Further review of patient #5's physician's orders revealed that this order was repeated on 10/16/12 at 0700 (7:00 AM).

Review of the facility's Restraint Policy (last reviewed 6/6/11) revealed under the section, Physician's Order orders for restraints, "Cannot be written as 'PRN'".

Interview with the Chief Executive Officer on 10/18/12 at 3:30 PM failed to reveal the reason why the order was written PRN.

Based on record review, observation and interview, the facility failed to follow their own policy and procedure regarding reassessment by a physician before writing a new order for the use of restraints on 2 of 2 (#5 and #8) patients restrained.

Findings:

1.) Review of patient #5's record revealed a physician's order for left and right arm and right ankle restraints "at all times," on 9/27/2012 at 0600; however, no rational for ordering the restraints was identified. Further review of the physician's orders revealed this order was repeated on 9/30/12, 10/3/12 at 0620, 10/4/12 at 0615; 10/5/12, 10/6/12, and 10/7/12 at 0606. On 10/8/12, the order was changed to "left and right wrist restraints per [verbal order]". On 10/9/12 at 0620, the order was changed back to right and left wrist restraints and right ankle restraints. On 10/10/12 at 0950, the order was changed to "[bilateral] wrist restraints and right ankle restraint at all times unless someone is with patient". This order was repeated on 10/11/12 at 0500 and 10/12/12 at 0600. On 10/13/12 at 0605, the order was changed to left and right wrist and right ankle restraint at all times and repeated on 10/14/12 at 0600. On 10/15/12, the order was changed to "wrist bilateral restraints. [Right] leg restraint as needed" and the order was repeated on 10/16/12 at 0700. There was no documentation that the physician assessed the patient prior to re-ordering the restraints.

Observation of patient #5 on 10/17/12 from 10:20 AM - 10:40 AM revealed the patient was wearing bilateral wrist restraints and her right leg was restrained with a soft restraint. The patient was observed to be able to touch her face and legs while still in the restraints.

Interview with the Activities staff on 10/17/12 at 10:35 AM revealed that the patient became confused and began to pull at all of her tubes and then attempted to climb out of bed which is the reason for the use of the restraints.

2.) Review of patient #8's physician's orders revealed a telephone order on 9/21/12 at 0600 for "[Left] wrist restraint at all times". This order was repeated on 9/22/12 at 0600, and on 9/23/12 at 0600. On 9/27/12, an order was written for "[left] wrist restraint at all times unless someone is at bedside [with patient]." On 9/28/12 at 0500, the order was back to left wrist restraints at all times and repeated on 9/30/12, 10/3/12 at 0620, 10/4/12 at 0615, 10/5/12, 10/6/12 at 0635, and 10/7/12 at 0800. On 10/8/12, the order just states "[Left] wrist restraint", this order was repeated on 10/9/12. On 10/10/12 at 0950, the order was changed to "[left] wrist restraint [at] all times unless someone is with patient". This order was repeated on 10/11/12 at 0500. No other restraint orders were found on this date. None of these orders indicated why the patient was being placed in restraints. There was no documentation that the physician assessed the patient prior to or after ordering the restraints. There was no documentation that the nursing staff were assessing the patients prior to, during or after removing the restraints. There was no documentation that the patient had the restraints removed at any time.

Observation of patient # 8 on 10/18/12 at 8:58 AM revealed the restraints were still on the left bed rail of the bed, but the restraint was not on the patient. The patient was observed to be sleeping.


3.) Review of the facility's Restraint Policy (last reviewed 6/6/11) revealed under the section, Physician's Order item #6 indicates: "Time Limitations for Initial Orders are as follows: Primary Medical Maximum limitations of 24 hours. To renew these orders requires a 'face to face' assessment by the physician to determine if renewal is necessary".

4.) Interview with the Chief Executive Officer on 10/18/12 at 3:30 PM failed to reveal any evidence regarding the lack of reassessments.

Based on record review, observation and interview, the facility failed to follow their own policies and procedures regarding monitoring 2 of 2 (#5 and #8) restraint patients after placing them in restraints.

Findings:

1.) Review of patient #5's record revealed a physician's order for left and right arm and right ankle restraints "at all times," on 9/27/2012 at 0600; however, no rational for ordering the restraints was identified. Further review of the physician's orders revealed this order was repeated on 9/30/12, 10/3/12 at 0620, 10/4/12 at 0615; 10/5/12, 10/6/12, and 10/7/12 at 0606. On 10/8/12, the order was changed to "left and right wrist restraints per [verbal order]". On 10/9/12 at 0620, the order was changed back to right and left wrist restraints and right ankle restraints. On 10/10/12 at 0950, the order was changed to "[bilateral] wrist restraints and right ankle restraint at all times unless someone is with patient". This order was repeated on 10/11/12 at 0500 and 10/12/12 at 0600. On 10/13/12 at 0605, the order was changed to left and right wrist and right ankle restraint at all times and repeated on 10/14/12 at 0600. On 10/15/12, the order was changed to "wrist bilateral restraints. [Right] leg restraint as needed" and the order was repeated on 10/16/12 at 0700. None of these orders indicated why the patient was being placed in restraints. There was no documentation that the physician assessed the patient prior to or after ordering the restraints. There was no documentation that the nursing staff were assessing the patient prior to, during or after removing the restraints.

Observation of patient #5 on 10/17/12 from 10:20 AM - 10:40 AM revealed the patient was wearing bilateral wrist restraints and her right leg was restrained with a soft restraint. The patient was observed to be able to touch her face and legs while still in the restraints.

Interview with the Activities staff on 10/17/12 at 10:35 AM revealed that the patient became confused and began to pull at all of her tubes and then attempted to climb out of bed which is the reason for the use of the restraints.

2.) Review of patient #8's physician's orders revealed a telephone order on 9/21/12 at 0600 for "[Left] wrist restraint at all times". This order was repeated on 9/22/12 at 0600, and on 9/23/12 at 0600. On 9/27/12, an order was written for "[left] wrist restraint at all times unless someone is at bedside [with patient]." On 9/28/12 at 0500, the order was back to left wrist restraints at all times and repeated on 9/30/12, 10/3/12 at 0620, 10/4/12 at 0615, 10/5/12, 10/6/12 at 0635, and 10/7/12 at 0800. On 10/8/12, the order just states "[Left] wrist restraint", this order was repeated on 10/9/12. On 10/10/12 at 0950, the order was changed to "[left] wrist restraint [at] all times unless someone is with patient". This order was repeated on 10/11/12 at 0500. No other restraint orders were found on this date. None of these orders indicated why the patient was being placed in restraints. There was no documentation that the physician assessed the patient prior to or after ordering the restraints. There was no documentation that the nursing staff were assessing the patients prior to, during or after removing the restraints. There was no documentation that the patient had the restraints removed at any time.

Observation of patient # 8 on 10/18/12 at 8:58 AM revealed the restraints were still on the left bed rail of the bed, but the restraint was not on the patient. The patient was observed to be sleeping.

3.) Review of the Facility's policies and procedure related to restraints revealed that under the section, "Staff Roles & Responsibilities"- the policy states that the patient needs to be assessed. According to this policy, "The assessment is done prior to the initiation of restraint and is documented. Assessment will include: Risk/Potential for harm to self and others. Current treatment, condition and ability to cooperate". According to the policy, "Trained staff must examine the patient in restraints at the initiation of restraints and at least every 15 minutes for the duration of restraint order to ensure that the patient's vital signs and conditions are not deteriorating as a result of restraint use".

4.) Interview with the Director of Nursing (DON) on 10/17/12 at 2:30 PM revealed that they had informed the Clinical Service Director about needing a Restraint Assessment form, but he has never provided them with one.

Based on facility record review and interview, the facility failed to have an ongoing Quality Assurance and Performance Improvement program (QAPI). The facility failed to incorporate data, and failed to have or measure, analyze and track quality indicators. The plan failed to indicate the frequency and detail of the data collection and was not specified by the governing body.

Findings:

1. Review of the Quality Assurance Plan revealed no evidence of quality indicators or measures for improvement. It lacks a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no documentation of an annual Quality Assurance/Improvement Plan for 2012.

2. Review of the data from Pharmacy; Laboratory and Radiology revealed information being gathered in these departments; however, the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments was not available.

3. Review of the Quality Assurance Minutes for July 26, 2012 and August 30,2012, revealed reports of data collection from some departments, but does not reflect an ongoing or active tracking or trending for a Quality Improvement (QI) program.

4. Interview with the Director of Nursing (DON) on 10/17/12 at approximately 3:30 PM revealed she was not aware of any current QI activity; however she has only been here for 6 months. She further stated she knew there was no QI activity for nursing.

5. Upon further interview with the DON on 10/17/12 at 4:10 PM, it was revealed that the Clinical Service Director came in during the night and was in his office with the door closed and would not let anyone in. Nobody saw him come in or leave and a few things have been noted to be missing. He resigned on 10/16/12.

Based on facility document review and interview, the facility failed to use the limited data collected to identify opportunities for improvement and apply changes for improvement.
The facility failed to set priorities, measure, track or take action for improvement.

Findings:

1. There was no documentation of an annual Quality Assurance/Improvement Plan for 2012.

2. Review of the data from Pharmacy; Laboratory and Radiology revealed information being gathered in these departments; however the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments was not available.

3. Review of the Quality Assurance Minutes for July 26, 2012 and August 30,2012, revealed reports of data collection from some departments, but does not reflect an ongoing or active tracking or trending for a Quality Improvement (QI) program.

4. Interview with the Director of Nursing (DON) on 10/17/12 at approximately 3:30 PM revealed she was not aware of any current QI activity; however she has only been here for 6 months. She further stated she knew there was no QI activity for nursing.

5. Upon further interview with the DON on 10/17/12 at 4:10 PM, it was revealed that the Clinical Service Director came in during the night and was in his office with the door closed and would not let anyone in. Nobody saw him come in or leave and a few things have been noted to be missing. He resigned on 10/16/12.

Based on facility document review and interview, the facility failed to have an ongoing Quality Assurance/Performance Improvement (QAPI) program showing measurable improvement or to have evidence of facility wide indicators for patient safety. The facility failed to set priorities, measure, track, analyze or take action for improvement for patient safety. The facility failed to take action for improvement for medical errors.


Findings:

1. Review of the Quality Assurance Plan revealed no evidence of quality indicators or measures for improvement. It lacks a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no designated annual plan for 2012.

2. Review of the data from the Pharmacy revealed information being gathered in this department; however the data was not incorporated into the hospital wide program. No data assessment or analysis was found for the limited data collected or actions for improvement.

3. Review of the Quality Assurance Minutes for July 26, 2012 and August 30, 2012 revealed report of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QI) program.

4. Interview with the Director of Nursing (DON) on 10/17/12 at approximately 3:30 PM revealed she was not aware of any current QI activity; however she has only been here for 6 months. She further stated she knew there was no QI activity for nursing.

5. Upon further interview with the DON on 10/17/12 at 4:10 PM, it was revealed that the Clinical Service Director came in during the night and was in his office with the door closed and would not let anyone in. Nobody saw him come in or leave and a few things have been noted to be missing. He resigned on 10/16/12.

Based on facility document review and interview, the facility failed to have and/or conduct Quality Improvement projects.


Findings:

1. Review of the Quality Assurance Plan revealed no evidence of quality indicators or measures for improvement. It lacks a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no designated annual plan for 2012.

2. Review of the data from Pharmacy; Laboratory and Radiology revealed information being gathered in these departments; however the data was not incorporated into the hospital wide program. No data assessment/ analysis was found for the limited data collected or actions for improvement. Data collection from other departments was not available.

3. Review of the Quality Assurance Minutes for July 26, 2012 and August 30,2012, revealed reports of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QI) program.

4. Interview with the Director of Nursing (DON) on 10/17/12 at approximately 3:30 PM revealed she was not aware of any current QI activity; however she has only been here for 6 months. She further stated she knew there was no QI activity for nursing.

5. Upon further interview with the DON on 10/17/12 at 4:10 PM, it was revealed that the Clinical Service Director came in during the night and was in his office with the door closed and would not let anyone in. Nobody saw him come in or leave and a few things have been noted to be missing. He resigned on 10/16/12.

Based on facility document review and interview, the hospital's governing body failed to ensure that the Quality Assurance/Performance Improvement program reflected the complexity of the hospital's organization and services; and involved all hospital departments and services.

Findings:

1. Review of the Quality Assurance Plan revealed no evidence of quality indicators or measures for improvement. It lacks a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no documentation of an annual Quality Assurance/Improvement Plan for 2012.

2. Review of the data from Pharmacy; Laboratory and Radiology revealed information being gathered in these departments; however the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments was not available.

3. Review of the Quality Assurance Minutes for July 26, 2012 and August 30,2012, revealed report of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QI) program.

4. Review of the Governing Body Minutes for August 10,2012 revealed that the last Quality Assurance report was read and that the previous QA/QI meeting have been approved.

5. Interview with the Director of Nursing (DON) on 10/17/12 at approximately 3:30 PM revealed she was not aware of any current QI activity; however she has only been here for 6 months. She further stated she knew there was no QI activity for nursing.

6. Upon further interview with the DON on 10/17/12 at 4:10 PM, it was revealed that the Clinical Service Director came in during the night and was in his office with the door closed and would not let anyone in. Nobody saw him come in or leave and a few things have been noted to be missing. He resigned on 10/16/12.

Based on facility document review and interview, the hospital's Governing Body failed to ensure that there is hospital wide ongoing Quality Assurance/Performance Improvement and Patient Safety program. The Governing Body failed to ensure that a distinct number of improvement projects be conducted annually

Findings:


1. Review of the Quality Assurance Plan revealed no evidence of quality indicators or measures for improvement. It lacks a systematic process to collect data on process outcomes and priority issues chosen for improvement. The plan does not include Utilization Review or Patient Safety. There was no documentation of an annual Quality Assurance/Improvement Plan for 2012.

2. Review of the data from Pharmacy; Laboratory and Radiology revealed information being gathered in these departments; however the data was not incorporated into the hospital wide program. No data assessment was found for the limited data collected or actions for improvement. Data collection from other departments was not available.

3. Review of the Quality Assurance Minutes for July 26, 2012 and August 30,02012, revealed reports of data collection from some departments, but does not reflect ongoing or an active tracking or trending for a Quality Improvement (QI) program.

4. Review of the Governing Body Minutes for August 10,2012 revealed that the last Quality Assurance report was read and that the previous QA/QI meeting have been approved.

5. Interview with the Director of Nursing (DON) on 10/17/12 at approximately 3:30 PM revealed she was not aware of any current QI activity; however she has only been here for 6 months. She further stated she knew there was no QI activity for nursing.

6. Upon further interview with the DON on 10/17/12 at 4:10 PM, it was revealed that the Clinical Service Director came in during the night and was in his office with the door closed and would not let anyone in. Nobody saw him come in or leave and a few things have been noted to be missing. He resigned on 10/16/12.

Based on review of medical records, facility policy and interview, the facility failed to ensure for 4 of 11 patients sampled (#1, #4, #10, #11) that a nursing assessment was completed appropriately at the time of admission and a care plan established with interventions and goals. The facility also failed to ensure that the patient's condition at discharge was documented.

Findings:

1. Review of the medical record for patient #1, a pediatric patient, revealed that the patient was admitted on 10/15/12 with a diagnosis of Urinary Tract Infection, and discharged on 10/16/12. The Interdisciplinary Plan of Care on the record was blank, and did not even have the patient's name on it.

2. Review of patient #5's record revealed an admission date of 09/25/2012. The patient has been admitted into the facility's swing bed. Review of the facility's record revealed the only assessment was a fall risk assessment dated 09/25/12, the date of admission.

3. Review of the medical record for patient # 10 revealed the patient was admitted on 10/14/12 with a diagnosis of Hypoglycemia, hypertension, Chronic Heart Failure and Urinary Tract Infection. The Nursing Admission Assessment/Interview dated 10/14/12 was incomplete. The first page is left blank except for a notation on NKA (no known allergy). Information regarding advanced directives, social services and vitals signs are not documented. The Interdisciplinary Plan of Care had the date of admission on 5 of the problems listed with a 3 next to it indicating that it should be addressed prior to discharge. No interventions or outcomes are listed and no indication if the goals were achieved by discharge are noted. The patient was discharged on 10/18/12.

4. Review of the medical record for patient # 11 revealed the patient was admitted on 10/15/12. The Interdisciplinary Plan of Care revealed the date of admit on one of the problems listed with a #1 indicating it to be addressed every shift and a second problem with a #2 indicating it to be addressed every 24 hours. No interventions or outcomes are listed and no indication if the goals were achieved by discharge was noted. The patient was discharged on 10/18/12.

5. Review of the Policy and Procedure: Assessment and Reassessment of the Patient, MS 100010, states under Policy: The initial assessment, including the patients history and physical, nursing assessment, and other screening assessment is to be started immediately upon contact with the health care system (on arrival to the patient care unit, or clinic, or setting) and documented within 24 hours. Under the Disciplinary Grid, Nursing, Time frame-started within 1 hour of admission. Completed within 12 hours of admission.

6. Review of Policy and Procedure: Plan of Care, MS 10190, states under 2. Using the Patient Care Plan Form. 2. Within 24 hours of admission, an RN [Registered Nurse] will initiate the care plan, document and review age related factors to be considered.

Based on observation, medical record review, review of facility policy and interview, the facility failed to ensure that the administration of drugs was in accordance with the orders of the practitioner.

Findings:

1. Observation of medication pass for patient # 10 on 10/17/12 at 9:00 AM with Registered Nurse (RN) #A revealed the following: Medications were brought to the cart from the pharmacy in the bubble packages in a plastic medicine cup. RN # A verified the medication with the Medication Administration Record (MAR) and then allowed the surveyor to write down the medications. They were as follows:
Potassium Chloride 10 Meq (was not in package, RN #A showed surveyor the multidose container it came from)
Simvastatin 20 milligram (mg) tablet (tab)
Coumadin 1 mg tab
Coumadin 5 mg tab
Carvedilol 3.125 mg tab
Lisinopril 5 mg tab
Digoxin 250 mcg tab

RN # A then took the unopened packages to patient # 10's room. Washed her hands, put on gloves, checked the patient identification band, opened the bubble packages with the pills and poured them into the plastic cup and gave the cup to the patient with water.

Upon reconciliation of the medication pass, it was noted that the order for Digoxin on the medical record was for Digoxin 0.125 mcg every day.

2. Observation of medication pass for patient # 11 on 10/17/12 at approximately 9: 20 AM with RN # A revealed the following: The RN had the medications in a plastic medicine cup in the patient drawer in the medicine cart. She took them and checked them against the Medication Administration Record. The medications were still in the bubble packaging and she allowed the surveyor to write down the medications. They were as follows:
Metoprolol 25 mg tab
Omeprazole 20 mg tab
Aspirin 81 mg (Was from a multidose container, not in a bubble package)

RN #A requested the blood pressure from the Certified Nursing Assistant (CNA) and it was 139/89. She then took the plastic medicine cup with the pills still in the packages and went into patient # 11's room. She checked the patient's identification band, washed her hands, put gloves on. She then took the pills out of the bubble packages and put them in the medicine cup and handed them to the patient with water.

Upon reconciliation of the medication pass, it was noted that the order for Metoprolol was for 12.5 mg twice a day.

Interview with RN # A at 11:50 AM on 10/17/2012 revealed she had come out of the room to cut the medication in half after taking them out of the bubble package. That was not observed during medication pass.

3. Review of Policy MS 10125 on Administration of Medication and MS 10230 on Standard of Nursing Practice did not address the correct administration of medication by nursing.

Based on record review and interview, the facility failed to ensure that 6 of 11 patients (#5, #6, #7, #8 and #10 and #11) had medical history and physical (H & P) exams within 24 hours of admissions. Findings:

1. Review of patient #5's medical record revealed the patient was admitted in to the hospital on 9/25/12. Further record review failed to reveal a H & P in the record.
2. Review of patient #6's closed record revealed she was admitted 9/21/12 and discharged from the facility on 10/4/12. Further record review failed to reveal a H & P. Review of the medical record's, "Deficiency Slip" revealed the record was missing the history and physical exam.

3. Review of a medical record for patient #7 with an admission date of 08/06/12 and discharge on 08/13/12 failed to reveal a History & Physical documented in the record. The patient's previous admission dates of 05/22/12 and 06/21/12 also has no History and Physical.

4. Review of patient #8's record revealed an admission date of 9/20/12. Further review of this patient's record failed to reveal a H&P.

5. Review of the medical record on 10/18/12 for patient # 10 with an admission date of 10/14/12 and patient #11 with an admission date of 10/16/12 also revealed no evidence of a History and Physical in the record within 24 hours.

6. Review of the Policy and Procedure: Assessment and Reassessment of the Patient, MS 100010, states under Policy: The initial assessment, including the patients history and physical, nursing assessment, and other screening assessment is to be started immediately upon contact with the health care system (on arrival to the patient care unit, or clinic, or setting) and documented within 24 hours. Under the Standard of Practice: 1.2.2. The physician's history and physical will be on the patient's medical record within 24 hours.

7. Interview with the Medical Record staff member on 10/18/12 at 10:10 AM revealed the physician usually completes his H& P when he does the patient's Discharge Summary.

Based on record review and interview, 1 of 11 (#7) patients discharge records failed to have a discharge summary within 30 days of discharge.

Findings;

1. Review of a medical record for patient #7 with an admission date of 08/06/12 and discharge on 08/13/12 failed to reveal a History & Physical or Discharge Summary documented in the record. The patient's previous admission dates of 05/22/12 and 06/21/12 also had no History and Physical and no Discharge Summary.

2. Interview with the medical records' personnel on 10/18/12 at 10:10 AM revealed that when a patient
is discharged from the facility, the nurses take apart the record and put all of the contents inside the nursing assessment booklet for that patient. Every morning she goes on to the floor and takes all of the discharged patients' records to the billing department. According to the medical record personnel, when the billing department is finished with the patients' records, they return them to her and she goes through them. She then checks off what is missing on the "Deficiency Slip" and returns the record to the physician for the discharge summary.

Based on record review and interview 1 of 11 (#7) patients discharge records failed to have a final diagnosis on the discharge summary within 30 days of discharge.

Findings;

1. Review of a medical record for patient #7 with an admission date of 08/06/12 and discharge on 08/13/12 failed to reveal a History & Physical or Discharge Summary documented in the record. The patient's previous admission dates of 05/22/12 and 06/21/12 also had no History and Physical and no Discharge Summary.

2. Interview with the medical records' personnel on 10/18/12 at 10:10 AM revealed that when a patient
is discharged from the facility, the nurses take apart the record and put all of the contents inside the nursing assessment booklet for that patient. Every morning she goes on to the floor and takes all of the discharged patients' records to the billing department. According to the medical record personnel, when the billing department is finished with the patients' records, they return them to her and she goes through them. She then checks off what is missing on the "Deficiency Slip" and returns the record to the physician for the discharge summary.

Based on observation and interview, the facility failed to ensure that outdated and mislabeled drugs and biologicals are not available for patient use.

Findings;

1. An observation tour was done of the facility on 10/15/2012 between 10:00 AM and 12 Noon. All areas which house medications, including refrigerators,pharmacy,medication carts, medication rooms and stock medication cabinets were inspected. The following drugs/biological's were observed to be out of date or lacking the proper label to indicate when opened or needs to be discarded:

EMERGENCY ROOM:
1000 cc Lactated Ringers X 2 expired 06/12
1000 cc Lactated Ringers- expired - 08/12
The above located in the warmer
Promethegan 25 mg suppository expired 09/12 (kept in medication refrigerator)

The following were opened and not dated:
Eyewash solution 141 ml
2 % viscous Lidocaine 100 ml
Prednisone oral solution 5 mg/ ml 120 ml bottle

Humulin (Insulin) R U-100 (opened and dated with an illegible date)

2.An interview was conducted with the emergency room Registered Nurse (RN) on 10/15/2012 at 10:30 AM. The RN confirmed that the above listed medications were expired and/or labeled incorrectly and should not be available for patient use. She further stated," We are supposed to date the medications with a discard date when we open them, I will discard all the IV fluids and other medications."

3. Review of the facility's policy and procedure related to medication storage and dated July 2011 documents the following:"Expired, damaged and/or contaminated medications will be removed from drug storage areas within the hospital during the pharmacy inspection and will be returned to the Pharmacy Department for proper disposal."

4. A review was done of the monthly reports furnished by the consultant pharmacist. The report dated June 2012 reveals the following information,"Areas of the hospital in which drugs are stored were inspected. Outdated items were removed and restocked," Additional information provided by the pharmacist included the most recent Medication Area Inspection dated October 16, 2012, the second day of the survey. The October 2012 report the following information,"Some undated vials removed and discarded."

5. An interview was conducted on 10/15/2012 at 11:45 AM with the consulting pharmacist who performs quality checks for the medications on a monthly basis and who completes written reports that are provided to the Director of Nursing (DON) with the results of these inspections. The pharmacist stated,"I check monthly, the nurses should be checking on a daily basis and removing pharmaceuticals which are not labeled properly or expired."

Based on observation, record review and interview, the facility failed to ensure 3 of 3 kitchen cooks were competent in their respective duties.
Findings:
1. Observation of the kitchen on 10/15/12 at 11:12 AM revealed Cook #1 was going to prepare all of the meal for the patients on this date.

Review of the lead cook's employee record revealed a hired date of 9/8/12. Further review of the record revealed she was a Certified Food Safety Manager. No training was found in her employee record.
2. Interview with the facility's Dietitian on 10/17/12 at 9:00 AM revealed this was only his second time in the facility. Further interview revealed that Cook # 1 is in charge of the kitchen (the lead cook).

3. Observation of the kitchen on 10/17/12 at 8:30 AM revealed Cook #2 was cooking and serving breakfast.

Review of Cook #2's record revealed she was hired as a housekeeper on 12/19/11. Further review of the record revealed she was moved in to the kitchen on 2/5/12. Further review of her employee record revealed she has an expired Florida Food Manager certification which expired 10/3/05, a SerSage Certification from the National Restaurant Association Educational Foundation that expired 7/18/12 and has received blood borne pathogens training on 1/24/12, but no kitchen training was found in the employee's record.
4. Review of Cook #3's record revealed a hired date of 7/23/12 as a cook. Further review of the employee's record failed to reveal any safe food handling, portion control, waste disposal, diet instruction, modified diets or anything having to do with actual kitchen/cooking training.

5. In interview with the Chief Executive Officer (CEO) on 10/17/12 at 2:15 PM, all three employees' records were shown to him. The CEO confirmed the expired certification and lack of nutritional training for the three cooks.

Based on interview, the facility failed to have a utilization review committee that consist of two practitioners.

Findings:

Interview with the Chief Executive Office on 10/18/12 at 3:55 PM revealed that he does not believe he has a utilization review committee. Further interview, at this time, revealed they have only had one practitioner for a long time, so they did not have enough practitioners to meet the requirement for the review committee.

Based on observation and interview, the facility failed to maintain the physical plant in a safe manner to ensure the well-being of the patient.

Findings:

1. Tour of the kitchen on 10/15/12 at 11:12 AM, revealed the freezer was not working. Interview with the lead cook and the maintenance employee at this time revealed the freezer has been broken since 10/5/12. Someone came out, but did not fix the freezer and would not return their calls. They indicated that a second repair man called was too expensive and the third got sick and has not been able to come out.

2. Tour of the Emergency Room (ER) on 10/18/12 at 8:35 AM revealed a square ceiling tile that had a U shaped dark brown matter, under that U was a lighter shade of brown matter, and under that U was gray fuzzy matter.

Observation at 12:50 PM on 10/18/12 revealed the ceiling tile right above the entrance to the medical record's area was ? covered in fuzzy gray matter

Interview with the ER Registered Nurse at 8:35 AM on 10/18/12 revealed he would like to explain what was going on with the tile, but he could not. He recalled that during this surveyor's last visit, that same tile had been replaced.

In interview with the new investor's representative at 9:55 AM on 10/18/12, the ER tile was observed. According to the representative, he has obtained quotes for roof repair. He indicates that the roof is not leaking, but that water collects on the roof and seeps in anywhere it can.

3. Observation of the second Triage room at 8:46 AM on 10/18/12 revealed what appeared to be an Intravenous (IV) bag with tubing in the regular trash can. The red biohazard trash can was located next to the regular trash can. Interview with the ER staff at this same time revealed that the IV tubing did not include the needle, but it should have been thrown in the biohazard waste can. When the ER staff opened the red biohazard trash can, there were other IV bags and tubing in this trash can.

4. Observation of patients rooms beginning at 9:05AM on 10/18/2012 revealed the following:

a. Observation of room 105 at 9:05 AM revealed the room was currently being occupied by a patient. Further observation revealed the sink room located before the entrance to the patient's room was missing the sink. Pipes were sticking out of the wall, but it was not attached to a sink. A red chair and a green chair were observed next to the pipes.

b. Room 120 was observed to have two IV bags with tubing in the regular garbage can. The red biohazard can was found next to the regular garbage can.

c. Observation of room 124 revealed the shower floor had a green stain. A patient was observed in this room.

d. Room 125 was observed to have gray fuzzy matter inside the air conditioner vents. The shower floor was also observed to have a green stain.

e. Observation of room 126 revealed the air conditioning unit has large size fuzzy gray matter in the vent portion of the air conditioner. The bathroom's base boards were coming off the wall. The baseboards were covered in brown matter. The ceiling tile dividers were covered with gray specs. The oxygen was also leaking out of the fixture in the wall.

f. Room 127 was observed to have one patient in the bed closest to the window. Observation of this room revealed the wall paper was peeling off the wall, behind the patient bed closest to the door.

5. Observation of the Radiology (X-Ray room) on 10/17/12 at 8:40 AM revealed a layer of dust on the square component and the tube behind the X-Ray table. The Contrast warmer in the CT-Room also was found to have a layer of dust on it.

6. During the life safety portion of the survey on 10/18/12, the life safety surveyor observed that there was a wire left unconnected from the fire alarm system.

According to the facility's maintenance employee, on July 25, 2012 at 1:30 PM, the fire alarm malfunction, all of the wires were disconnected. The facility did not have the finances to repair the system. A facility employee reconnected the alarm one by one until the alarm sounded. According to the facility maintenance employee, the wire that resulted in the alarm sounding, was left unconnected to the alarm system.
During the test of the facility's fire alarm on 10/18/12 at approximately 1:30 PM, 4 of 5 fire doors failed to close automatically when the alarm was activated.

Based on observation and interview, the facility failed to ensure the facility was safe from the potential of fire.
Findings:

During the life safety portion of the survey on 10/18/12, the life safety surveyor observed that there was a wire left unconnected from the fire alarm system.

According to the facility's maintenance employee, on July 25, 2012 at 1:30 PM, the fire alarm malfunction, all of the wires were disconnected. The facility did not have the finances to repair the system. A facility employee reconnected the alarm one by one until the alarm sounded. According to the facility maintenance employee, the wire that resulted in the alarm sounding, was left unconnected to the alarm system.
During the test of the facility's fire alarm on 10/18/12 at approximately 1:30 PM, 4 of 5 fire doors failed to close automatically when the alarm was activated.

Based on observation and interview, the facility failed to ensure the diagnostic department promoted a safe environment for patients.
Findings:

Observation on 10/17/12 at 8:40 AM of the X-Ray room revealed an Oxygen tank standing in the alcove where the technician goes to take the patients' X-Rays.

Interview with diagnostic technician at this same date and time, revealed the oxygen should be in a holder.

Based on staff interviews, and review of facility documentation, it was determined the facility failed to ensure the infection control program was under the direction of a designated and qualified professional who had training in infection control as evidenced by the absence of infection control documentation in the personnel record and an interview with the infection control professional who was unable to produce documentation of position designation or infection control training.

Findings include:

1. An interview was conducted on 10/17/2012 at 2:20 PM with the Director of Nurses. The Director of Nurses(DON) acknowledged that she is new to the position and is currently in training. She further stated that the person who was orienting and training her for the position is no longer employed by the facility. During the inquiry regarding the hospital's Infection Control Program the following information was obtained. "I have been in this position (DON) for a couple of weeks and I have been told that I am taking over the Infection Control Program. They said they were going to send me for some training. I need to sign up and go for some education. There was a nurse who was compiling the information but she has been out on medical leave since May. Currently I do have a log of infections and we do call the patients who were treated in the Emergency Room if their cultures come back and they need another antibiotic. I am unaware if any information is being reported to the Quality Assurance Program and if there are any measures in place for analyzing the data regarding infection surveillance."

2. Review of the governing body minutes did not provide any documentation as to the appointment of a qualified person to direct the infection control program.

3. At the time of exit on 10/18/2012 at 4:00 PM, the facility failed to provide any documentation identifying a designated person responsible for the oversight of the Infection Control Program.

Based on staff interviews and review of administrative records, it was determined the acute care hospital failed to maintain an infection control program that provided a plan of action for preventing, identifying and managing infections and communicable diseases and for immediately implementing corrective and preventive measures that would result in improvement as evidenced by the lack of an ongoing infection control program.

Findings include:

1. An interview was conducted with the Director of Nurses (DON) on 10/17/2012 at 2:20 PM. The DON indicated that she is new to the position and is currently in the training process. She further indicated that she had been asked to oversee the Infection Control Program hospital wide but that she had not received any specialized training nor was she familiar with any program descriptions or specific policies. The DON stated,"We do log our infections in logs; one for ER and one for med-surg. The only follow up is done for patients treated in the emergency room on an out patient basis. These patients are contacted if their lab cultures do not indicate that the antibiotics ordered will provide sufficient coverage. I have not attended any Quality Assurance Meetings and do not provide any reports for infection surveillance and analysis. I am unaware of what information was provided by the former Director of Nurses related to infection control."

2. No information was provided indicating that the infection control program for the hospital incorporated guidelines and professionally acceptable standards in developing policies and procedures for governing control of the program.

3. At the time of exit on 10/18/2012 at 4:00 PM, no written documentation was provided regarding a plan of action for preventing, identifying and managing infections and communicable disease and for immediately implementing corrective and preventive measures.

Based on staff interview and review of administrative records, personnel records, policies and procedures, and infection control documentation, it was determined the acute care hospital failed to integrate the infection control program as part of the quality assessment and performance improvement program as evidenced by failing to maintain a quality improvement program that included infection control measures and activities.

Findings include:

1. A review was completed of the facility's Quality Assurance Committee Meetings for July and August 2012. The facility was unable to provide documentation for any other meetings in 2012. The following information related to infection control is documented in the meetings.

07/26/2012 - "Focus for future Q.A. studies: Medical Floor- infection control"
08/30/2012- "Future Focus: Infection Control Protocol will be implemented as a workable tool for in-house hospital concerns. A lengthy review of current protocol and required protocol will be done with a forward focus"

The facility was unable to provide any Quality Assurance (QA) studies or any workable tools related to inhouse concerns.

2. Review of the Quality Assurance committee meetings did not indicate that the CEO or medical director were in attendance or involved in the infection control /Q.A. process. In addition, the current Director of Nurses (DON), who indicates she is the person designated as the Infection Control Officer was not in attendance for these meetings. The facility was unable to furnish any information related to the training of staff in infection control measures.

3. Personnel file reviews did not reveal any infection control training for employees. The personnel files revealed an 11 question test regarding infection control, there is no indication that these tests were graded as to pass or fail. There were no educational inservices provided to indicate that employees get "on hire" and annual training related to infection control.

4. An interview was conducted with the charge nurse, Registered Nurse (RN), (employee # 5, hired 08/07/12) on 10/15/2012 at 11:00 AM. The charge nurse could not remember any specific infection control training offered by the facility. She stated,"I am a new nurse and recent graduate. I received my training in school and plan on taking continuing education courses."

5. An additional interview was conducted on 10/15/2012 at 10:45 AM with the Physician Assistant (PA) who is responsible for overseeing the patient care in the Emergency Room. The PA indicated that he was not directly involved in the Infection Control Program for the hospital. He was unaware of any system in place for overseeing the program.

6. On 10/17/2012 at 2:25 PM, the Director of Nurses produced a form titled, "Infection Control , Quality Assurance Statistics 2012". She indicated this form had not been completed since May 2012 when the nurse who was logging infections left on medical leave. She further stated,"This form is specific to the types of infections identified monthly. I do not know whether this form has been submitted to the committee as we can not locate any minutes prior to July 2012. I am aware that these statistics have not been compiled since the nurse went on Medical leave in May. I have not attended any QA meetings at this point, the former Director of Nurses was in attendance."