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Based on observations, interviews, record reviews and policy reviews the Governing Body failed to ensure the Chief Executive Officer (CEO, appointed by the Governing Body) effectively managed the facility in order to meet applicable regulatory requirements and failed to ensure contracted services were evaluated to ensure care was provided in a safe and effective manner and for improvment opportunites through the facility's quality assessment and improvement program.

The severity and cumulative effect of this deficient practice resulted in the facility's non-compliance with the requirements found under the Condition of Participation: Governing Body.The facility census was 27.

Based on interviews and record reviews the facility failed to develop, implemented and maintain an effective Quality Assessment and Performance Improvement (QAPI) Program that included all hospital departments and approximately 46 direct or indirect patient care contracted services. The QAPI Program did not include an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program focused on specific indicators related to improving health outcomes.

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at Condition of Participation: Quality Assessment and Performance Improvement Program. Please refer to A 0309. The facility census was 27.

Based on observation, interview, record review and policy review the facility failed to ensure compliance with minimum hospital standards specific to food and nutritional services affecting patient treatment by:
- Failing to have dietetic policies and procedures approved by medical staff;
- Failing to meet minimum standards for frequency of meals served;
- Failing to follow guidelines for food galley sanitation;
- Failing to ensure the facility Diet Manual was accessible to all medical and nursing staff.

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at Condition of Participation: Food and Dietetic Services and placed all patients admitted to the facility at risk for nutritional compromise. Please refer to A 0620 and A 0631. The facility census was 27.

Based on interview, record review and policy review, the facility failed to ensure there was a current and approved Utilization Review (UR) Plan in place and failed to establish an active UR Committee to review patient medical records for appropriate care and services.

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at Condition of Participation: Utilization Review. Please refer to A653 and A654. The facility census was 27

The Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire facility including accountability for the effective oversight of the staff to comply with the requirements under the Conditions of Participation for:
- Quality Assessment and Performance Improvement;
- Utilization Review;
- Food and Dietetic Services and
- Standard level requirements including:
- Patients receive information regarding their Important Message From Medicare;
- Patients have the opportunity to participate in their own care planning;
- A care plan is developed and maintained for patients;
- Discharge planning is developed and maintained for patients that included input from the patients;
- Registered Nurse supervision of all aspects of the patient's care;
- Effective oversight and security for patient Medical Records and for controlled (narcotic) medications.
- Ensuring policies and procedures were in place to provide safe Radiology practice to protect patients and staff.

These failures had the potential to adversely affect all patients in the facility.
The facility census was 27.

Findings included:

1. The CEO failed to ensure facility staff developed an effective Quality Assessment and Performance (QAPI) program that included all departments and contracted services to identify trends for opportunities to improve patient care and safety. (Refer to tags A 263 and A309)

2. The CEO failed to ensure facility staff established an active Utilization Review Plan/Program to review patients' medical records for appropriateness of care. (Refer to tags A652, A653 and A654)

3. The CEO failed to ensure dietary staff met the needs of the facility. (Refer to tags A618, A620 and A631)

4. The CEO failed to ensure patients received information regarding their Important Message From Medicare. (Refer to tag A117)

5. The CEO failed to ensure staff developed care plans, developed and reassessed patients' discharge plans and provided patients the opportunity to participate in their plan of care. (Refer to A130 A396 and A821)

6. The CEO failed to ensure a Registered Nurse supervise patients' care. (Refer to A395)

7. The CEO failed to ensure patients' medical records remained confidential. (Refer to A147 and A441)

8. The CEO failed to ensure controlled (Narcotic) medications were kept secure from unauthorized access. (Refer to A502)

9. The CEO failed to ensure the facility developed policies and procedures for safe radiology practice to protect the patients and staff. (Refer to A535)

Based on interviews and record reviews the Governing Body failed to ensure direct patient care services provided by contract were evaluated thru the facility's quality assessment and improvement program to ensure the services furnished were provided by in a safe and effective manner and improvement opportunities were identified. The facility contracted with 88 services of which approximately 46 provided direct or indirect patient care. This had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

1. During an interview on 07/24/13 at 1:50 PM, Staff C, Director of Quality, stated that the facility did not have a policy and procedure for the facility-wide Quality Assessment and Performance Improvement (QAPI) Program.

2. Record review of the facility's unsigned and undated document titled, "Governing Board By Laws", showed:
- The Board of Managers has overall responsibility for operation of the Hospital, including contract services.
-The Hospital is committed to establishing and promoting a culture of continuous quality improvement.
- The Board of Managers has the ultimate responsibility for performance improvement, risk management and outcomes.
- The facility Performance Improvement Plan has been reviewed and approved by the Performance Improvement Committee, the Medical Executive Committee and the Governing Board.
- Priorities include patient health outcomes and high-volume, high-risk, and/or problem-prone processes.
- The Governing Board retains ultimate authority on any matter affecting the facility and the Performance Improvement Plan by exercising its oversight responsibility for the effectiveness and efficiency of patient care systems and outcomes.

Review of the 2013 PI (Performance Improvement) Priorities revealed [The Governing Body chose five of the approximately 46 contracted services to include in the Performance Improvement Plan for 2013]:
Laboratory;
Pharmacy;
Dialysis;
Nutritional Services; and
Radiology.

3. During an interview on 07/24/13 at 1:50 PM, Staff C, Director of Quality Management, stated that she collected the data that the contracted services submitted to her and reported on that data. She stated she wasn't aware that the facility was to establish projects for the contracted services or to measure and analyze the data to identify improvement opportunities for the contracted services provided to the patients. She stated that the facility did not have any other projects to assess or identify improvement opportunities for the other contracted services provided to the patients.

Based on interview, record review and policy review the facility failed to provide three patients (#10, #11 and #15) of six current Medicare patients and two patients (#20 and #21) of two discharged Medicare patients with the Important Message from Medicare (IM). This had the potential to affect all Medicare patients in the facility. The facility census was 27.

Findings included:

1. During an interview on 07/25/13 at 8:30 AM, Staff C, Director of Quality, stated that the facility had no written policy and procedure specific to the delivery of the Important Message From Medicare to patients.

Record review of the federal regulation for facilities who provided care to any Medicare beneficiary showed direction to provide the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission. The IM notices provide the patient with information to make informed decisions regarding discharge.

Also, the federal regulation required facilities to present a copy of the signed IM prior to the patient's discharge, but not more than two calendar days before the actual discharge. The facility must establish and implement policies and procedures that effectively ensure patients and/or their representatives have the information necessary to exercise their rights.

2. During an interview on 07/22/13 at 2:15 PM, Patient #11 stated he received Medicare benefits but he had not received the IM. He stated that when he was admitted on 07/03/13, he was given a blue folder that contained all his admission papers.

Record review of the patient's blue folder showed it did not contain the IM.

Record review of the patient's medical record showed no documentation that the patient had received the IM.

3. During an interview on 07/22/13 at 2:30 PM, Patient #10 stated that he was supposed to be discharged to a nursing home but he didn't want to be discharged. He stated that he didn't know if he received an IM and didn't know what information it would contain.

Record review of the patient's medical record showed no documentation that the patient had received the IM.

4. Record review of Patient #15's medical record showed no documentation that the patient had received the IM.

During an interview on 07/25/13 at 9:27 AM, Staff L, Registered Nurse (RN), confirmed there was no documentation in the patient's medical record that the patient had received the IM. Staff L further stated that the IM should have been provided to the patient by a former Nurse called a Clinical Liaison (CL), (a nurse who assisted with assessing a patient for proper placement in the facility), who no longer works for the facility.

5. Record review of discharged Patient #20's medical record showed an initial (within two days of patient admission) IM signed (accepted and acknowledged) by an unknown individual and no documentation as to why the patient did not sign. There was no final (in advance of patient's discharge but no more than two calendar days of discharge) IM in the medical record.

6. Record review of discharged Patient #21's medical record showed no initial IM in the patient's medical record.

7. During an interview on 07/24/13 at 3:10 PM, Staff M, Director of Utilization Review (UR), stated that she regularly monitored all patient medical records to ensure the IM was documented as provided to the patient by staff. Social Services staff should be documenting provision of the initial IM. Staff M further stated that she had reviewed Patient #10's medical record four times and "I didn't see that (there was no documentation of the IM). "I'm only responsible for the last one, someone else is responsible for the first one". Staff M stated that she did not know who was responsible to deliver the IM to patients on admission.

8. During an interview on 07/25/13 at 8:20 AM, Staff C stated that the initial IM was provided to patients by a CL prior to admission. She stated, "Yes, there is a break in the system with patients receiving the Important Message From Medicare".



29047

Based on interview, record review and policy review the facility staff failed to ensure every patient and/or the patient's designated representative participated in developing and implementing a comprehensive plan of care for two patients (#10 and #11) of nine patients interviewed. This failure had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

1. Record review of the facility policy titled, "Transdisciplinary Plan of Care" dated 05/12, showed:
- {The} Hospital Transdisciplinary Team meets regularly to assess patients for initial and ongoing appropriate plan(s) of care, as per established CMS {Centers of Medicare & Medicaid Services} guidelines.
- Informed decisions related to care planning also extend to discharge planning for the patient's post-acute care.
POLICY: The facility follows CMS/TJC{The Joint Commission previously known as Joint Commission on Accreditation of Healthcare Organizations or JCAHO} requirements for freedom of choice and patients' rights.

2. Record review of the document titled, "JCAHO ALERT 2012, Patient Rights and Responsibilities" showed the following:
Decision-Making
- To be notified of care to be furnished, disciplines involved, frequency of visits proposed and any changes in the plan of care
- To participate in the care planning process
- The right to receive a copy of the plan of care if requested
- To be given reasonable notice before services are terminated, to be provided a list of resources, and to have assistance in making alternative arrangements for continued care.

3. During an interview on 07/22/13 at 2:40 PM, Patient #11 stated, "They don't tell me anything about my condition or why I am still here". He stated that he had seen a different doctor every day and no one shared information with him. The patient stated that he felt he needed more physical therapy so he could go home. He also stated that he had not been involved in his plan of care, "I have no clue what the plan is and I haven't been asked".

4. During an interview on 07/22/13 at 2:30 PM, Patient #10 stated that he was scheduled to be discharged but he didn't want to leave at this time. He stated that no one had asked him what he wanted. He had asked to speak with the Social Worker so he could give her the name of his representative. He stated that he had never been shown his plan of care (TPC) but he would like to see it.

5. During an interview on 07/24/13 at 10:50 AM, Staff L, Registered Nurse (RN), stated that patients were not included in care plan development or in care plan meetings.






32281





27727

Based on observations and policy reviews the facility failed to provide privacy for one patient (#1) of one patient's whose peri area (the genital area) was exposed to the hall way while receiving nursing care and when one patient (#2) of one patient whose abdomen, groin and leg were exposed to anyone from the hallway while receiving nursing care. The facility census was 27.
Findings included:
1. Record review of the facility's policy titled, "Right to Respect and Dignity" revised 07/12, showed the patient will be interviewed and examined in surroundings designed to assure reasonable audio-visual privacy. Visual barriers will be used to minimize visual exposure of the patient.
2. Observation on 07/23/13 at 8:46 AM, showed Staff B, Registered Nurse (RN), raised Patient #2's gown and exposed her abdomen, right groin and right upper leg to administer an injection of Insulin (a diabetic medication). The patient was sitting in a chair directly in front of the open door to her room with her right side toward the door. Her exposed body could be viewed by anyone walking in the hallway.
3. Observation on 07/24/13 at 11:00 AM, showed Staff CC, RN, in Patient #1's room. She stood at the head of the bed. The patient's penis (external male sex organ) and lower legs were uncovered/exposed. The door of the room was open and allowed anyone walking in the hallway, full view of the exposed patient.








32281

Based on observations, interviews and policy reviews the facility failed to ensure confidentiality of personal information for three patients (#2, #5, and #32) of three patients when their medical records were left open on the satellite nursing desk without staff present to prevent unauthorized persons from viewing them. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Security of Information Systems" dated 10/12, showed that staff security consciousness emphasized through orientation of new employees and on-site continuing education programs for veteran employees on the principles of records security and confidentiality. In-service programs stress employees' responsibility for records in their possession and their duty not to disclose confidential information. In addition, staff members sign agreements verifying their understanding of the policies and procedures concerning records retention, security and disclosure, stating that they will adhere to these policies and procedures and that they understand they face disciplinary action if they fail.

2. Observation on 07/22/13 at 1:40 PM showed Patient #2's open medical record on the desk showing personal and medical information about the patient. There were no staff observed to be in the area. There were visitors in close proximity of the desk.
3. Observation on 07/23/13 at 9:38 AM showed Patient #5's open medical record on the desk showing personal and medical information about the patient. There were no staff observed to be in the area. There were visitors in close proximity of the desk.
4. Observation on 07/22/13 at 1:40 PM showed Patient #32's open kardex (a system which allows quick reference for certain aspects of nursing care; such as diseases, medication or allergies) on the nursing desk. There were no staff present and visitors were in close proximity of the desk.
5. During an interview on 07/23/13 at 10:30 AM, Staff B, RN, stated that medical records should be kept closed and out of reach/sight of visitors and/or unauthorized persons.


29047

Based on observation, interview, record review and policy review the facility failed to ensure restraint orders were present and/or signed by the physician within each calendar day for one patient (#9) of one patient in restraints. This deficient practice had the potential to violate the rights of any patient placed in restraints; placed restrained patients at risk for safety and can potentially affect all restrained patients in the facility.The facility census was 27.

Findings included:

1. Record review of the facility's undated, "Medical Staff Rules and Regulations," showed that orders for restraints were time limited. The physician must sign, date, and time the restraint order according to facility policy.

2. Record review of the facility's policy titled, "Safety: Restraints - Non-Violent" dated 04/02/12, showed the following:
- The purpose of this policy is to promote and protect the individual person's maximum freedom, functional ability, rights, dignity, safety and well being.
- Orders for restraint are time limited. The physician must sign, date and complete the physician order after a face-to-face evaluation of the patient's physical and mental status within each calendar day.
- Continued use of restraints is renewed every calendar day before 00:00
by written physician order, telephone order and or verbal order after face-to face evaluation of the patient's physical and mental status.

3. Observation on 07/22/13 at 2:30 PM showed Patient #9 sitting in a chair in the room with bilateral (both right and left wrists) soft wrist restraints.

During an interview on 07/22/13 at 2:30 PM, the patient's ex-husband stated that he was there every day and that she had the restraints on because she pulled out her tracheostomy collar (surgically made opening in the wind pipe so a tube can be placed in it to help with breathing) and urinary catheter (a tube inserted in the bladder to drain urine).

Record review of the patient's medical record showed multiple failures of the physician to follow the facility policy:
- The initial telephone order (TO) for bilateral mittens dated 07/17/13 at 10:20 PM. The order was not signed, dated or timed by the physician.
- An order for bilateral soft wrist restraints dated 07/18/13 at 7:05 PM. The order was not signed, dated or timed by the physician.
- No restraint order was found in the medical record for 07/19/13.
- A TO bilateral soft wrist restraints dated 07/20/13 at 4:30 AM. The order was not signed, dated or timed by the physician.
- A TO for bilateral soft wrist restraints dated 07/21/13 at 10:00 PM. The order was not signed, dated or timed by the physician.

4. During an interview on 07/23/13 at 3:24 PM, Staff N, Director of Medical Records, stated that restraint orders should be signed by the physician within 24 hours of the order being initiated.



29047

Based on observation, interviews and record review the facility's Governing Body and the Chief Executive Officer (CEO, who was appointed by the Governing Body) failed to ensure that all of the facility's departments, direct or indirect patient care contracted services (approximately 46) and adverse patient events were included in the Quality Assessment and Performance Improvement (QAPI) Program and were defined, implemented and maintained to promote improved services and safety of patients. This had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

1. Record review of the facility's unsigned and undated document titled, "Governing Board By-Laws", showed:
- The Board of Managers has overall responsibility for operation of the Hospital, including contract services.
-The Hospital is committed to establishing and promoting a culture of continuous quality improvement.
- The Board of Managers has the ultimate responsibility for performance improvement, risk management and outcomes.
- The facility Performance Improvement Plan has been reviewed and approved by the Performance Improvement Committee, the Medical Executive Committee and the Governing Board.
- Priorities include patient health outcomes and high-volume, high-risk, and/or problem-prone processes.

2. Record review of the facility's unsigned and undated document titled, "Performance Improvement Plan 2013", showed:
- The Governing Board retains ultimate authority on any matter affecting the facility and the Performance Improvement Plan by exercising its oversight responsibility for the effectiveness and efficiency of patient care systems and outcomes.
The 2013 PI (Performance Improvement) Priorities identified:
- Case Management and Social Work;
- Use of blood and blood components;
- Utilization Review;

Record review of the Contractual Quality Control Data showed the Governing Body chose five of the approximate 46 direct or indirect patient care contracted services to include in the Performance Improvement Plan 2013 and to be monitored for quality control included:
-Laboratory;
-Pharmacy;
-Dialysis;
-Nutritional Services; and
-Radiology.

3. Record review of the facility's document titled, "2013 Incident Log", showed the following:
- 01/17/13; 01/20/13; 02/11/13 Dressing change not completed. Details: Dressing changes not completed as ordered;
- 01/21/13 Decubitus Ulcer (caused by lying in one position too long so that the circulation in the skin is compromised by the pressure) developed after admission;
- 02/15/13 Decubitus Ulcer - Patient not turned as often as needed;
- 05/01/13 Decubitus Ulcer - Patient left in chair too long at a time.
These examples of direct patient care and staff failures had not been identified as negative health outcomes resulting in opportunities for improvement and had not been included in the QAPI Program.

4. Record review of the facility's "Performance Improvement Dashboard" dated 01/13 through 06/13 showed no quality data reported for the contracted services Dialysis and Nutritional Services.

5. Record review of the facility's document titled, "Performance Improvement Dashboard" dated 01/01/13 through 06/30/13 showed patient food refrigerator temperature logs were documented at 100 percent for each month reported for the last six months for Environment of Care (Dietary Services), a contracted service.

Observation on 07/24/13 showed the food refrigerator temperature logs were consistently incomplete (missing entries) and/or was out of the temperature ranges for compliance with food safety regulation.

6. During an interview on 07/24/13 at 9:05 AM, Staff U, Registered Dietician, stated that the Dietary Services QAPI initiatives consisted of the dietician following the results of the patient satisfaction survey question related to patient satisfaction with food service, but no remedial actions or projects to improve any aspect or identified trends.

7. During an interview on 07/24/13 at 1:50 PM, Staff C, Director of Quality, stated that:
-There were no policies and procedures regarding the facility wide QAPI Program.
-There were no projects for contracted services and no projects related to adverse events.
-She collected data that the contracted services submitted to her and reported on that data.
-She stated that the facility did not have any other projects to assess or identify improvement opportunities for the contracted services provided to the patients.
-There were no lists of performance improvement projects reflecting the scope and services provided by the facility thus no improvement in care could be identified hospital-wide.
-The 2013 Incident Log was the same as the Sentinel Event Log.
-There was not a separate log for Sentinel Events.
-The logs were not used to identify trends in patient care.

This could result in the facility not recognizing an opportunity to improve patient care and safety.

Based on observation, interview, record review and policy review, the facility failed to ensure that a registered nurse supervised the nursing care for patients when staff failed to provide routine oral care to two patients (#14 and #15) of four patients reviewed for this concern. This had the potential to affect all patients. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Basic Personal Hygiene and Grooming" revised 08/12, showed that the transdisciplinary team will provide, teach, and help the patient maintain good standards of hygiene and grooming including bathing, brushing teeth, caring for hair and nails, and using the toilet. The policy showed direction for the facility staff to provide personal hygiene if the patient is unable to provide this care for themselves.

2. Record review of the facility's undated form titled "Standards of Care" showed that patients should receive mouthcare (oral care) every six hours if no artificial airway (a tube like device placed in the nose or mouth to provide a way for patients to breathe) is in place.

3. Record review of Patient #14's medical record showed no documentation of oral care since her admission on 07/10/13. Further review of the patient's medical record showed that the patient was morbidly obese with decreased range of motion and general weakness. She required the assistance of one or two staff members to get out of bed. (This indicated that she would not be able to brush her teeth without some type of assistance in the set-up of oral care supplies.) The patient's plan of care directed staff to provide interventions including frequent oral hygiene.

During an interview on 07/22/13 at 1:50 PM, the patient stated that oral care had never been offered to her or completed by staff the entire time she had been a patient at the facility (12 days).

Observation on 07/23/13 at 9:23 AM, showed Patient #14 informed Staff K, Registered Nurse (RN), that she had not had her teeth brushed during her entire stay at the facility. Staff K replied, "We can get that done later this afternoon".

During an interview on 07/23/13 at 1:50 PM, the patient stated that she still had not had her teeth brushed or had been offered oral care for the day.

During an interview on 07/23/13 at 2:10 PM, Staff L, Charge Nurse, was informed that Patient #14 had not had her teeth brushed during her stay at the facility. Staff L stated that he would ensure it was taken care of.

During an interview on 07/24/13 at 10:35 AM, Patient #14 stated that she had her teeth brushed by staff for the first time in the late afternoon of 07/23/13, but has not had her teeth brushed since that time .

4. Record review of Patient #15's medical record showed that the patient had not received oral care during the previous seven days.
Observation on 07/23/13 at 10:30 AM in Patient #15's room showed a toothbrush, still in the protective wrapper, other personal care items such as deodorant, bathing supplies and two unopened tubes of travel size toothpaste. The patient was bedfast and only able to get up out of bed with the assistance of two staff members.

During an interview on 07/22/13 at 2:30 PM, the patient, along with her family members, stated that oral care had never been provided to the patient by staff.

5. During an interview on 07/24/13 at 4:42 PM, Staff OO, Patient Care Technician (PCT), stated that he was responsible for completing oral care every day on his assigned patients. Staff OO stated that he completed his patients' oral care every morning, usually before breakfast, and documented it in the patients' care sheet. Staff OO stated that he did not offer to complete oral care for Patients #14 or #15 and did not have a reason why.

6. During an interview on 07/22/13 at 3:02 PM, Staff J, RN, stated that oral care was the responsibility of PCTs, and should be documented on the Patient Care checklist which the PCTs carry in their pockets. Staff J stated that after the PCTs' shift ends, the PCTs put the checklist in the patient's medical record but it was not reviewed by the RN to ensure that the care was done.

7. During an interview on 07/23/13 at 2:10 PM, Staff L, stated that charge nurses did not monitor whether or not patients received oral care.

Based on interview, record review and policy review, the facility failed to develop and maintain a comprehensive, individualized care plan (called Transdisciplinary Plan of Care by the facility) for nine current patients (#1,#3, #4, #5, #6, #11, #14, #15 and #17) of 29 patient care plans reviewed. This had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Transdisciplinary Plan of Care" revised 05/12, showed that the Transdisciplinary Team (made up of a physician, nursing staff, a dietician and therapy staff) meet regularly to assess patients for initial and ongoing appropriate plan(s) of care (care plan). Documentation about the team's patient-focused discussion and recommendations is maintained in the patient's permanent medical record. The discussion items may include goals, discharge considerations and ways to overcome identified barriers. (This was the only policy provided by the facility related to the nursing care plan.)
2. Record review of a blank form titled, "Transdisciplinary Plan of Care," showed a 20 page form. The first page included areas to document the date the care plan was initiated, the initial conference dates, signature lines for the members of the care planning team, and the estimated length of the patients stay. Possible options used to identify the patient's care plan, to be selected by health care staff included the following:
-Primary treatment identified on admission;
-Significant problems or barriers to the patient's discharge;
-Where the patient was expected to discharge to;
-Expected outcomes (goals), date of the expected outcomes and interventions by the health care team to assist the patient in reaching those outcomes.
Additional pages showed separate pages listing patient care clinical and functional care needs.
Further review of the form showed that the last two pages of the care plan titled, "Plan of Care Narratives/Updates", were used to document that the patient's plan of care had been reviewed and revised by nursing staff to ensure that the care provided to the patient was based on the patients' current needs.
3. Record review of Patient #1's medical record showed a document titled, "Transdisciplinary Plan of Care" (TPC) which had only the dietician's signature on the first page. The patient was admitted on 07/11/13.
Further review of the medical record showed there were patient care clinical and functional care needs listed on the Transdisciplinary Plan of Care including:
- Bowel and Bladder was signed by a nurse as initiated on 7/12/13 with no update since admission.
- Infection was signed by a nurse as initiated on 7/12/13 with no update since admission.
- Pulmonary/Respiratory was signed by a nurse as initiated on 07/12/13 with no update since admission.
- Skin integrity was signed by a nurse as initiated on 07/12/13 with no update since admission.
- Pain management was signed by a nurse as initiated on 07/12/13 with no update since admission.
- Safety was signed by a nurse as initiated on 07/12/13 with no update since admission.
The first page of the TPC form showed no patient primary treatment needs identified on admission, no significant problems/barriers to discharge identified and no projected discharge destination was identified. The TPC had not been updated, and no new care needs were added after the admission notations on 07/12/13.
4. Record review of Patient #3's medical record showed a TPC with a blank first page. The patient was admitted on 07/09/13.
Further review of the medial record showed there were patient care clinical and functional care needs listed on the Transdisciplinary Plan of Care including::
- Bowel and Bladder Function was signed by a nurse as initiated on 7/10/13 with no update since admission even though the patient had a Foley (urinary) catheter on admission which had been removed.
- Fluid and Electrolyte (compounds found in the blood that allow for normal function of bodily organs), Functional Mobility and Restraints were signed by a nurse as initiated on 7/10/13 with no update since admission for either.
- Infection was signed by a nurse as initiated on 7/10/13 with no update since admission even though the patient was diagnosed with suspected Clostridium difficile (also known as C difficile or C. diff, a bacteria that causes severe diarrhea and other intestinal disease)
- Nutritional Status was signed by a dietician as initiated on 7/10/13 with no update since admission even though the patient had refused his supplemental tube feedings and had episodes of diarrhea.
- Pain Management, Swallowing and Safety were signed by a nurse as initiated on 7/10/13 with no update since admission.
- Psychological Adjustment was blank even though patient had recently lost his home and he and his wife had to move in with family and, subsequent to his recent hospitalization, he had also lost his job. He was being treated with anxiety relieving medication.
- Pulmonary /Respiratory was signed by a nurse as initiated on 7/10/13 with no update since admission even though the patient was on mechanical ventilation when admitted, had been weaned and was now on supplemental Oxygen.
- Self Care was signed by a nurse as initiated on 7/10/13 with no update since admission even though the patient had progressed from total assistance with activities of daily living (ADLs) to ambulating to the shower with assistance.
- Skin Integrity was signed by a nurse as initiated on 7/10/13 with no update since admission. The physician's history and physical (H&P) showed the patient had a wound on the dorsal (under) side of his penis which was not noted by nursing staff.
- The Plan of Care Narrative Notes/Updates page signed by nursing staff on 07/11/13, 07/14/13, 07/15/13, 07/18/13, 07/19/13, 07/20/13, 07/21/13, 07/22/13, and 07/23/13 that showed that the TPC had been reviewed and there were no changes in the patient's care. (However the medical record clearly indicated changes had occurred and the TPC had not been updated.)

The first page of the TPC form showed no patient primary treatment needs identified on admission, no significant problems/barriers to discharge identified and no projected discharge destination was identified. The TPC was not updated, and no new care needs were added after the admission notations on 07/09/13.
5. Record review of Patient #4's medical record showed TPC initiated 07/18/13, however the patient was admitted on 07/09/13. The Primary Transdisciplinary Team Members section and Date Evaluated section were blank. Discharge destination projected upon admission was identified as a Rehabilitation Hospital however the patient and the Social Worker identified the discharge destination as home.

The patient's primary treatment needs identified on admission were:
- Physical Rehabilitation;
- Nutritional Support;
- Treatment of Respiratory Failure;
Significant problems/barriers to discharge identified were Functional Mobility and Pulmonary Respiratory Function however the care plan was blank.

Further review of the medial record showed there were patient care clinical and functional care needs not listed on the TPC until 07/18/13:
- Bowel and Bladder Function was initiated on 07/18/13 due to urinary incontinence and not updated since.
- Cardiovascular Function; Fluid and Electrolyte Status and Pain Management were initiated on 07/18/13 and not updated since.
- Infection was initiated on 07/18/13 due to a tracheostomy (an incision on the neck and an opening that allows a person to breathe without the use of his or her nose or mouth) and a feeding tube and had not been updated since.
- Safety was initiated on 07/18/13 due to the need for assistance with ambulation and had not been updated since.
- Skin Integrity was initiated on 07/18/13 due to wounds on her right and left elbows and not updated since.

There was no care planning initiated for:
-Nutritional Status, even though it was identified as a primary treatment need on admission and the patient was receiving chemotherapy, was on a liquid diet, and receiving tube feeding on admission;
- Communication, even though there was documentation in the admission H&P that the patient had aphasia (a disturbance of the comprehension and formulation of words caused by brain dysfunction and ranges from having difficulty remembering words to losing the ability to speak, read, or write), a tracheostomy on admission, and need for Speech Therapy.

6. Record review of Patient #5's medical record showed a TPC initiated 07/17/13. The Primary Transdisciplinary Team Members section had only the signature of the RN.

The patient's primary treatment needs identified on admission were:
- Physical Rehabilitation;
- Treatment for Infection;
- Wound Care.
Significant problems/barriers to discharge identified:
- Communication; Functional Mobility; Cognition (mental processes including attention, memory, speaking and understanding language, learning, reasoning, problem solving, and decision making) and Skin Integrity were all initiated on 07/17/13 and had not been updated since.
- Infection was initiated on 07/17/13 with no updates since, even though the patient was admitted due to an infection in his left hip requiring a wound vac (technique using a vacuum dressing to promote healing in acute or chronic wounds), which had since been discontinued.

There was no care planning initiated for:
- Bowel and Bladder Function was blank even though the patient was incontinent (involuntary excretion) of urine.
- Nutritional Status was blank even though the dietician assessed the patient as needing increased nutrient needs for protein and calories related to need for wound healing.
- Pain Management was blank even though the patient complained of pain frequently requiring medication.
- Psychological Adjustment; Safety; and Pulmonary/ Respiratory were initiated on 07/17/13 with no updates since.
- Self Care was blank even though the patient required assistance with all ADLs.
-Neurological Status was blank even though the patient had random seizures.

7. Record review of Patient #6's medical record showed a TPC initiated 07/09/13. The Date Evaluated section was blank, the Primary Transdisciplinary Team Members section had only the dietician's signature, and the discharge destination projected upon admission was blank.

Further review of the TPC showed that the patient's primary treatment needs identified on admission were:
- Mechanical ventilator weaning but the patient's progress had not been updated on the plan of care since the day of admission 07/09/13;
- Physical rehabilitation but Physical Therapy was not included in the patient's plan of care
- Nutritional Support because the patient was NPO (nothing to by mouth) and receiving tube feedings on admission 07/09/13. The patient had progressed to a solid diet as of 07/23/13 but the patient's progress had not been updated on the plan of care since 07/10/13.
Significant problems/barriers to discharge identified were:
- Communication had not been evaluated since the date of admission on 07/09/13.
- Fluid and Electrolyte Status had not been updated since the date of admission on 07/09/13.
- Safety had not been documented since the date of admission on 07/09/13 when the patient was identified as being at high risk for falls.
- Pulmonary Respiratory Function had not been updated since the date of admission on 07/09/13 even though the patient had been weaned from mechanical ventilation.
- Bowel/Bladder Function had not been updated since the date of admission on 07/09/13
- Pain Management had not been updated since the date of admission on 07/09/13
- Skin Integrity had not been updated since the date of admission on 07/09/13
- Restraint had not been updated since the date of admission on 07/09/13.

There was no care planning initiated for:
- Cognition when the staff had repeatedly documented that the patient was confused at times, anxious and impulsive.
- Functional Mobility even though the patient was admitted with a primary treatment need for physical rehabilitation, required total assistance with all ADLs, such as self feeding, bathing, dressing, grooming, work, homemaking, and leisure) and was assessed as being at high risk for falls.
- Fall Risk Care Plan even though the patient was at high risk for falls.

8. Record review of Patient #11's medical record showed a TPC on the date of admission, 07/15/13:
- The Primary Transdisciplinary Team Members signature section was blank.

Further review of the TPC showed that the patient's primary treatment needs identified on admission were:
- Bowel and Bladder Function had not been updated since 07/15/13 (according to the patient's H&P, the patient had just discontinued dialysis (the process of cleansing the blood by passing it through a special machine. Dialysis is used when the kidneys cannot filter the blood) just two weeks prior to admission);
- Cognition had not been updated since 07/15/13 even though the H&P showed the patient had a history of seizures (Uncontrolled electrical activity in the brain, which may produce a physical convulsion, minor physical signs, thought disturbances, or a combination), was currently on a seizure medication and had a history of multiple brain surgeries after a motor vehicle accident.
- Functional Mobility had not been updated since the date of admission on 07/15/13 even though the H&P showed neuromuscular weakness (muscles produce less than would be expected force) and a plan to continue physical and occupational therapies;
- Pulmonary/Respiratory had not been updated since the date of admission on 07/15/13 even though the H&P showed he had just been taken off the mechanical ventilator (just over 48 hours) and currently had an aerosol tracheostomy collar (Surgically made opening in the wind pipe for the insertion of a tube to facilitate breathing);
- Safety page had not been updated since the date of admission on 07/15/13.

There was no care planning initiated for:
- Fluid/Electrolyte Status even though the H&P showed "Malnourished" (poorly fed or having a poor or inadequate diet);.
- Infection even though the H&P showed the patient was recovering from Legionella (caused by bacteria found in the environment) pneumonia (lung infection) and had been on antibiotics for two weeks prior to admission;
- Nutritional Status even though the H&P showing the patient had "malnutrition";
- Palliative Care (medical care provided by physicians, nurses and social workers that specializes in the relief of the pain, symptoms and stress of serious illness) even though the the H&P showed he was recovering from acute respiratory failure requiring mechanical ventilation (controlled ventilation using mechanical devices that cycle automatically to generate airway pressure) and acute kidney failure requiring dialysis at age 28 with a wife and two small children;
- Psychological Adjustment even though H&P showed a 28 year old, with severe health problems and mobility limits, with a wife and two small children
- Skin Integrity even though the H&P showed the patient had a fresh surgical procedure for the tracheostomy collar.
- Swallowing even though the H&P showed the patient had recently been on a mechanical ventilator and currently had an aerosol tracheostomy collar and a diagnosis of malnutrition.
- The Plan of Care Narrative Notes/Updates page had been documented daily by an RN from 07/16/13 to 07/22/13. All entries were written as, "Reviewed, no changes". (However the medical record clearly indicated changes had occurred and the TPC had not been updated.)

9. Record review of Patient #14's medical record showed a TPC and that the patient's primary reasons for admission were wound care and pain management.
There was no care planning initiated for:
-Pain management even though it was listed as primary reason for admission.
- Bowel and Bladder even though the patient required assistance for toileting.
- Oral care even though the patient required frequent oral hygiene.
- Safety and Transfers even though the patient was morbidly obese, had edema to both legs, required assistance with turning in bed, required assistance to get up out of bed and required assistance with mobility

10. Record review of Patient #15's medical record showed a TPC.
There was no care planning initiated for:
- Cardiovascular even though the patient had a history of congestive heart failure (heart cannot pump enough blood to the body organs and tissues)
- Contractions (shortening of the tendons creating a loss of joint movement) of the hands, rheumatoid arthritis and deconditioning (loss of muscle tone due to extended illness or hospitalization) with joint stiffness and joint deformities, but promoting range of motion exercises and assistance with feeding were not part of the patient's TPC;
- Pulmonary Respiratory Function even though the patient received DuoNeb treatments (medication that is inhaled into the lungs to manage diseases that cause difficulty in breathing).
- Nutrition and Safety even though a feeding tube (tube placed through the abdomen and into the stomach for the administration of liquid nutrition) was placed on 07/02/13.

During an interview on 07/23/13 at 2:50 PM, Staff K, Registered Nurse (RN), stated that a patients' plan of care focused more on specific patient illnesses as opposed to overall care. Staff K stated that Patient #15 had some difficulty with communication, however, communication was not part of her TPC because it was not a priority.

11. Record review of Patient #17's medical record showed a TPC.
There was no care planning initiated for:
- Bowel and bladder even though the patient had a history of constipation, incontinence, and took laxatives.
- Cardiovascular even though the patient had a history of high blood pressure, significant blood loss (affects the heart's pumping effectiveness) requiring blood transfusions and a heart rate greater than normal limits
- Fluid and Electrolyte Status even though the patient had a low sodium (affects the fluid and electrolyte balance in the body).
- Functional Mobility even though the patient required assistance with toileting and mobility.
- Nutrition even though the patient had a feeding tube and received liquid nutrition through the tube at night, a poor appetite and unintentional weight loss.
- Psychological Adjustment even though the patient had a poor prognosis with terminal lung and thyroid cancer.
- Self Care even though the patient required assistance with bathing and hygiene and dressing and grooming.

12. During an interview on 07/24/13 at 9:55 AM, Staff R, Rehabilitation Manager, was asked about her involvement in comprehensive TPCs and stated, "Oh yeah, we don't do that".

13. During an interview on 07/24/13 at 10:05 AM, Staff C, Director of Quality, stated that she wasn't aware that patient TPCs were not being utilized. She stated that Staff M, Director of Utilization Review was responsible for patients TPCs.

14. During an interview on 07/24/13 at 1:10 PM, Staff G, Social Worker, stated that the Plan of Care hadn't been done for several months, "We sign the TDM (Transdisciplinary Meeting Notes). I never understood how to complete the Psychosocial Evaluation in the Plan of Care, I asked the DON (Director of Nursing) but she couldn't tell me".

15. During an interview on 07/24/13 at 3:10 PM, Staff M, Director of Utilization Review, stated that:
- During her orientation at the facility over three years ago, she was trained to review patients' TPCs during the facility's weekly Transdisciplinary Meeting (TDM);
- She directed the TDMs;
- She contacted the corporate office to request stopping the TPC review during these meetings because she believed the care plans were worthless and nothing but busy work.
- She stated that the corporate office did not want to make any changes to the meeting process.
- She stated that it was her decision to discontinue the TPC review as part of the Transdisciplinary Meetings for all patients and she had not sought the facility's corporate office approval for her decision.


16. During an interview on 07/25/13 at 11:58 AM, Staff Y, Chief Executive Officer (CEO), stated that he supervised Staff M. Staff Y stated that he attended one Transdisciplinary meeting every month, but was not aware that patient TPCs were no longer reviewed during these meetings. He stated he was not aware that patient TPCs were not being reviewed until yesterday (07/24/13).







27029




32281




27727

Based on interview, record review and policy review, the facility failed to ensure medical records were protected from unauthorized access. This had the potential to affect all patient medical records stored in the medical records department.The facility censes was 27.
Findings included:
1. Record review of the facility's policy titled, "Security of Information Systems" dated 02/06, showed that areas where protected health information is stored or maintained are restricted to authorized personnel only.
2. During an interview on 07/23/13 at 3:24 PM, Staff N, Director of Medical Records, stated that housekeeping staff had access to the Medical Records Department for cleaning, after the department was closed and Medical Records staff had left for the day.

3. During an interview on 07/25/13 at 10:37 AM, Staff V, Housekeeper, stated that housekeeping staff were routinely scheduled to clean the Medical Records Department after hours. Staff V stated that hospital security staff would let housekeeping staff into the Medical Records department. Security staff left while the department was being cleaned. Staff V stated that in the past, she had cleaned the department during business hours without any problems, and didn't know why the housekeepers weren't regularly scheduled to clean the Medical Records Department while it was open and staffed.

Based on interview and record review, the facility failed to ensure that physician orders were authenticated with a date, time and signature for six patients (#9, #11, #14, #15, #17 and #22) of 32 patient medical records reviewed. This had the potential to affect all patients in the facility. The facility census was 27.
Findings included:
1. Record review of the facility's policy titled, "Accurate and Complete Medical Records" revised 07/12, showed that each entry in the medical record is dated and timed by the care provider.
2. Record review of the facility's policy titled, "Authentication of Medical Record Entries" revised 07/12, showed that all entries in the medical record will include a signature with appropriate title of the individual making the entry and that all entries in the medical record will be timed and dated.
3. Record review of the facility's undated, "Medical Staff Rules and Regulations," showed that all orders must be dated, timed, and signed by the ordering physician or advanced practice professional responsible for the patient's care.
4. Record review of Patient #9's medical record showed a physician's written order that had been signed but not dated and timed and a verbal order dated 07/20/13 but the order had not been signed, dated and timed by the physician.
5. Record review of Patient #11's medical record showed verbal orders dated 07/09/13, 07/11/13 and 0720/13 that were not signed, dated or timed by the physician.

6. Record review of Patient #14's medical record showed physician orders on 07/13/13 and 07/19/13 which did not contain a physician's signature. Further review showed two orders between 07/13/13 and 07/19/13 which did not include the time of the physician's order.
During an interview on 07/24/13 at 11:05 AM, Staff LL, Patient Care Coordinator, stated that she was unable to determine what physician had written the patient's orders on 07/13/13 and 07/19/13, because the physician didn't sign the orders.
7. Record review of Patient #15's medical record showed four physician orders between 07/12/13 and 7/16/13, which were signed and dated by the physician, but did not include the time of the physician's signature.
8. Record review of Patient #17's medical record showed two physician orders dated 07/21/13 which were signed but not timed.

9. Record review of Patient #22 medial record showed an order on 07/13/13 which was not dated or timed by the physician and one physician's order dated 07/13/13 which was not timed. Medial record showed two orders on 07/19/13 one was not dated or timed and one was not timed.

11. During an interview on 07/23/13 at 3:24 PM, Staff N, Director of Medical Records, stated that all physician orders should contain a date, time and physician's signature to be complete.



27727




27029

Based on observations, interviews and policy reviews the facility failed to ensure unauthorized staff did not have access to the nursing medication room and the narcotics in the pharmacy. The facility census was 27.
Fincluded:
1. Record review of the facility's policy titled, "Controlled Drugs: Storage and Distribution and Accountability (General)" dated 01/10, showed the Director of Pharmacy should ensure adequate storage and security for controlled drugs in accordance with federal and state statutes. And drugs listed in Schedules 11,111,1V, and V (narcotic drugs which are available only by prescription) of the C.D.A.P. (Comprehensive and Drug Abuse Prevention) Act of 1970 must be locked in a secure area and only authorized personnel may access.
2. During an interview on 07/23/13 at 2:00 PM, Staff DD, Pharmacy Technician, stated that she had worked in the pharmacy for a year and the key to the narcotic closet had always been kept in an unlocked drawer in the pharmacy. She stated that none of the pharmacy technicians were authorized to use the key to the narcotic closet and didn't but that it was accessible to them.
3. Observation on 07/23/13 at 2:30 PM, Staff OO, Pharmacist, pulled open the unlocked cabinet drawer and removed a key. He used the key to unlocked the narcotics closet.
During an interview on 07/23/13 at 230 PM Staff OO stated that the key to the narcotics closet was routinely kept in the unlocked drawer.
4. During an interview on 07/24/13 at 10:45 AM, Staff S, Pharmacist, stated that the narcotics closet key had always been kept in the unlocked drawer in the pharmacy. He stated it was accessible to all pharmacists and technicians. He also stated that the technicians were not authorized to open the narcotics closet and access narcotic medication.
5. Observation on 07/24/13 at 10:00 AM showed Staff V, Housekeeper, entered the code for the medication room and entered the room.
6. During an interview on 07/24/13 at 1:30 PM, Staff V, stated that she was given the code for the medication room several months ago by the previous Lead Housekeeper. She stated she entered the room to wipe down the counters and mop the floors. She stated that she did not have any supervision by authorized staff while she was cleaning in the room.

Based on interview the facility failed to adopt policies and procedures to provide for the safety of patients and personnel during radiology procedures. This deficient practice affects all patients in the facility who receive a radiology procedure.

The facility census was 27.

Findings included:

During an interview on 07/24/13 at 1:25 PM, Staff Y, Chief Executive Officer, stated that the facility did not have policies and procedures for the hospital radiology personnel to follow when performing radiology procedures on patients.

Based on interview and record review the facility failed to have the portable x-ray machine inspected on a periodic basis by a medical physicist. This deficient practice affects all patients in the facility who under go a radiology procedure. The facility census was 27.

Findings included:

1. Record review of the untitled preventive maintenance records for the portable x-ray machine, showed there was no documentation of an inspection being conducted on the portable x-ray machine by a medical physicist.

2. During an interview on 07/24/13 at 9:50 AM, Staff O, Materials Manager, confirmed that there was no documentation of an inspection being conducted on the portable x-ray machine by a medical physicist.

Based on observation, interview, record review and policy review the facility dietician, responsible for daily management of Dietary Services, failed to ensure compliance with minimum hospital standards specific to food and nutritional services by:
-Failing to have dietetic policies and procedures approved by medical staff;
-Failing to meet minimum standards for frequency of meals served for three patients (#2, #4 and #7) of three patients interviewed for meal service;
-Failing to follow guidelines for food galley sanitation;
-Failing to integrate food and dietetic services into the hospital-wide Quality Assessment and Performance Improvement (QAPI).
These failed practices placed all patients admitted to the facility at risk for nutritional compromise. The facility census was 27.

Findings included:
1. Record review of the facility's policies titled "Dietary Department Policy and Procedure Manual" dated 09/09 showed the policy and procedure manual had not been updated and had not been presented to or approved by the facility medical staff.
2. During an interview on 07/24/13 at 9:05 AM, Staff U, Registered Dietician (RD), stated that the dietary policies and procedures had not been approved by the medical staff and that she was not aware of the need to have them approved by the medical staff.
3. Record review of the facility's policy titled, "Menu Planning and Meal Distribution" dated 09/09, showed patient meals were served at the following times: breakfast at 7:00 AM, lunch at 12:00 PM, and dinner at 5:00 PM.
4. Observation on 07/24/13 at 5:15 PM, showed the food trays were delivered to the facility for the dinner meal. Observation on 7/25/13 at 8:15 AM, showed the food trays were delivered for the breakfast meal. The timing between dinner and breakfast left the patients 15 hours between meals.
5. During an interview on 07/24/13 at 9:05 AM, Staff U, RD, stated that:
- The facility had a contract with another hospital to provide meal trays.
- The meal delivery times were: breakfast 8:15 AM, lunch 12:45 AM, and dinner 5:30 PM (inconsistent with the facility policy).
- Meal delivery times vary depending on the census at the contract hospital because they finished their meal delivery prior to making the trays for our facility.
- When patients were not able to take their meal tray at the time of delivery the trays were placed in a warming cabinet to maintain temperature or warmed in the microwave to a minimum temperature of 135 degrees for warm food.

6. During an interview on 07/22/13 at 1:45 PM, Patient #2 stated that she had just received her lunch because she had a Physical Therapy treatment when lunch arrived and that her soup was barely warm.

7. During an interview on 07/22/13 at 2:15 PM, Patient #4 stated that meals were served very late, usually breakfast at 9:30 AM, lunch at 1:30 PM and dinner around 6:30 PM. She stated that she was used to eating breakfast early and 9:30 AM is too late for her, she gets very hungry in the morning.

8. During an interview on 07/22/13 at 3:00 PM, Patient #7 stated that meal times vary but was usually breakfast at 8:30-9:00 AM, lunch around 1:00 and dinner at 6:30-7:00 PM.

9. Record review of the facility's policy titled, "Daily Cleaning of the Hospital" dated 08/11, showed the galley (area for bulk food storage and where meal trays were delivered to the facility) and dietary would be cleaned on a daily basis.

10. Record review of the facility's policy titled, "Food and Nutritional Role in Infection Control" dated 09/09, showed all personnel would comply with infection transmission reduction methods including cleaning and sanitizing of equipment used in food preparation and serving.
11. Record review of the facility's policy titled, "Cleaning Procedures" dated 06/13, showed direction for cleaning of refrigerators in patient care zones to be checked monthly and cleaned and sanitized as needed.
12. Observation on 07/23/13 at 9:30 AM of the facility galley showed:
- The food warming cabinet contained a metal tray with numerous crusted and burnt food particles and crumbs. The bottom of the warming cabinet also contained numerous dried and burnt food particles and crumbs.
- Three used and crumpled paper towels were laying on the food preparation counters between the microwaves.
- The waste can for disposal of food and paper items from patients' trays was located in front of and immediately adjacent to the microwave and clean counter space used for food warming.
- The floor in the food storage closet was visibly soiled with pieces of dust accumulated in corners and between shelves and there was a greasy residue on the floor around the legs of the carts.
- One storage cart had an open wire bottom with food stored on the bottom shelf.

13. During an interview on 07/24/13 at 9:30 AM, Staff U, RD, stated that the Housekeeping staff damp mopped the galley area daily and that cleaning of the refrigerators and food warmer in the galley was the responsibility of the Housekeeping staff.
14. During an interview on 07/25/13 at 8:35 AM, Staff KK, RD, stated that she was not sure who was suppose to defrost the refrigerators and clean the warming cabinet.
15. During an interview on 07/23/13 at 10:55 AM, Staff V, Housekeeper, stated that:
- The day shift Housekeeping staff emptied trash, checked the refrigerator temperature logs, swept and damp mopped, and cleaned the countertops and sinks in the galley on a daily basis.
- Maintenance staff was responsible for defrosting the refrigerators.
- She did not know who was responsible for cleaning the warming cabinet; and
- She had damp mopped the galley area including the storage area that morning.

16. During an interview on 07/25/13 at 11:00 AM, Staff Y, Chief Executive Officer (CEO,) stated that he supervised housekeeping staff who had been assigned to clean the facility food galley, but had only focused on the cleanliness of patient rooms and had not inspected the galleys where the patients' food was stored until it was served. He was unaware that dietary was to keep logs which reflected the cleaning of the galley. He said he had not reviewed the dietary policies.

17. Record review of the facility's document titled "2013 Performance Improvement Dashboard" dated 01/13 through 06/13, did not show a performance measure for food or dietetic services.

18. During an interview on 07/24/13 at 9:05 AM, Staff U, RD, stated that the Dietary Services QAPI initiatives consisted of the dietician following the results of the patient satisfaction survey question related to patient satisfaction with food service, but no remedial actions or projects to improve any aspect or identified trends

Based on observation, interview and policy review the facility failed to ensure the facility Diet Manual was approved by the medical staff and that all medical and nursing staff knew that the Diet Manual was accessible on the facility intranet for use as guidance for ordering patient diets. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Diet Manual" dated 09/09, showed a current and applicable diet manual was available to the staff on-line and unless otherwise indicated, the Diet Manual would be approved every two years by the Nutrition Services Department and the Medical Executive Committee.

2. During concurrent interview and observation on 07/23/13 at 2:15 PM, at the 200 Wing nurses' station, Staff A, Licensed Practical Nurse (LPN), stated that:
- She had been employed at the facility for two years.
- She did not know where the Diet Manual was kept.
- She assumed it was located at the Central nurses' station with the other manuals.
- She would use the computer to look up questions related to diets using the internet and do a web search to print off patient material.
- Observation showed Staff A was unable to locate any diet related reference material during the interview.

3. During an interview on 07/23/13 at 2:45 PM on the 200 Wing, Staff B, Registered Nurse (RN), stated that:
- He had been employed by the facility for four weeks.
- He had never seen the Diet Manual.
- He did not know if there was a facility Diet Manual.

4. During concurrent interview and observation on 07/23/13 at 2:47 PM on the 200 Wing, Staff P, RN, stated that:
- She had been employed by the facility since 05/09/12.
- She thought the Diet Manual was kept in the file cabinet at the central nurses' station because that was where other reference manuals were maintained.
- Observation showed Staff P went to the file cabinet and retrieved several files of diet specific menus.
- Staff P stated that she was not aware of an actual Diet Manual;
- If she needed patient education material she would do an Internet search and print the materials.

5. During an interview on 07/24/13 at 9:05 AM Staff U, Registered Dietician (RD), stated that:
- The Diet Manual was on the facility intranet and accessible to staff at any facility computer.
- The facility staff had been in-serviced on how to access the Diet Manual.
- The medical staff did not have input into the Diet Manual.
- The Diet Manual was not approved by the medical staff or the Medical Executive Committee.
- She was not aware the Diet Manual needed to be approved by the medical staff.

Based on interview, record review and policy review, the facility failed to develop and maintain a current and approved Utilization Review (UR) plan. This deficient practice had the potential to affect all patients. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Appendix B [facility] Utilization Review Plan/Program" reviewed 09/12, showed that the Utilization Management Program/Plan (also known as the UR plan) will be reviewed and approved annually by the Quality Management Department, Administrator/Chief Executive Officer (CEO), Medical Executive Committee (MEC) and the Governing Board.

2. During an interview on 07/24/13 at 3:10 PM, Staff M, UR Director, stated that there was no current, approved UR Plan. Staff M stated that she believed the UR Plan should be reviewed and approved every year but didn't believe a plan had been re-approved since the facility opened on 09/09.

3. During an interview on 07/25/13 at 8:50 AM and again at 10:07 AM, Staff C, Director of Quality, stated that she was not sure how often a UR Plan should be reviewed and approved but assumed it was annually since other hospital plans were reviewed annually. Staff C added that the UR Plan had been updated by the corporate office sometime over the last year but that Staff M, UR Director did not realize she was working with an older version of the plan until Staff C showed her how to access the revised plan on the computer.

4. Record review of the facility's "Plan for Utilization Management" revised 03/13, did not contain signatures by the Quality Management Department, the CEO, the MEC or the Governing Board which indicated approval by those staff or groups.

5. During an interview on 07/25/13 at 11:58 AM, Staff Y, Chief Operating Officer (CEO), stated that he supervised Staff M and her work performance. Staff Y stated that Staff M had failed to develop and maintain a current, approved facility UR Plan.

Based on interview, the facility failed to ensure an active Utilization Review (UR) Committee was in place to review patient medical records and ensure appropriate care and services for optimal patient care. This had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

1. The facility failed to provide the survey team a Utilization Review (UR) Committee policy.
2. During an interview on 07/24/13 at 1:10 PM, Staff M, Utilization Review (UR) Director, stated that:
- There was no active facility UR committee.
- There had not been an active UR committee for some time.
- She was responsible for conducting all UR functions for the facility.
- The reason there had not been an active UR committee was she had been too busy and because there was a large turnover in facility physicians.
3. During an interview on 07/25/13 at 11:58 AM, Staff Y, Chief Executive Officer (CEO) stated that:
- He supervised Staff M and her performance.
- Staff Y stated that he was a member of the UR Committee but, there had been no UR Committee meetings since he had been employed with the facility in 08/12.
- He didn't know if or how often the committee was required to meet.

Based on observation and interview the facility failed to ensure outdated supplies were not available for patient use and refrigerator/freezer temperatures were monitored to ensure an acceptable level of quality and protection against deterioration. These failures had the potential to affect all patients. The facility census was 27.
Findings included:
1. During an interview on 07/25/13 at 12:40 PM, Staff C, Director of Quality, stated that the facility did not have a policy which addressed handling of outdated supplies.
2. Observation on 07/23/13 at 10:45 AM showed the following outdated supplies in the crash cart (a set of trays/drawers/shelves on wheels used in hospitals for medical/surgical emergencies to potential save someone's life) of 200 hall:
-Six Sodium Chloride (fluid which has equal proportions of salt and water and used to flush an IV) 10 cc Syringes expired on 07/01/13;
-One IV [Intravenous] Start Kit(a collection of items used for preparation for intravenous access) expired 05/01/13;
-Two IV Start Kits expired 02/11/12;
-Two IV Start Kits expired 06/13;
-One Provent Arterial Blood Sampling Kit with dry Lithium Heparin for Gases & Electrolytes (a collection of items used to withdraw blood from an artery) expired 02/13 and two expired 08/12;
-Two Vacutainers (a sterile blood collection tube) for typing and crossing of blood (withdrawing blood in order to determine what donor blood would match) expired 10/12;
-One Vacutainer (blue) (used for testing of platelet function and coagulation) expired 04/07/13 and one 03/08/13;
-One Vacutainer (red and black) (used for serum separation) expired 04/04/12;
-One Vacutainer (navy) expired 01/11/12 and two which expired 03/12.
3. During an interview on 07/23/13 at 10:50, Staff L, Charge Nurse, confirmed the supplies were outdated and potentially could have been used in an emergency situation like a code (cardiac or respiratory distress). He stated nursing staff was responsible for checking the crash cart for out dated supplies after the cart had been used.
4. Record review of the facility's policy titled, "Food and Nutritional Role in Infection Control", dated 09/09, showed direction for:
- Ensuring food is stored, prepared, and served at proper temperatures in a safe and sanitary manner.
- All personnel strictly adhere to departmental policies and procedure on food handling.
- A maximum refrigerator temperature of 40 degrees or lower should be maintained and checked daily with a thermometer.

5. Record review of the facility's policy titled, "Refrigerator Temperatures" reviewed 08/11, showed direction for:
- All refrigerators to have a calibrated thermometer in place that would be checked daily and documented.
- Housekeeping staff was responsible for monitoring and documenting the temperature on the Thermometer/Refrigerator Verification Log.
- The refrigerator temperature will be maintained between 35 and 40 degrees Fahrenheit at all times.
- If the temperature is not maintained between 35 and 40 degrees Fahrenheit, food and/or medications will be removed and stored in another refrigerator or discarded.

6. Observation on 07/14/13 at 9:30 AM of the food galley (area where meals are delivered to the facility and bulk food is stored) showed the refrigerator and freezer logs to have multiple areas of missed documentation.
- Dietary Refrigerator logs were missing documentation on 06/12/13, 06/13/13, 06/14/13, 07/21/13.
- Seven of the days documented showed the refrigerator temperature was recorded as being below the minimum range of 34 degrees with no documentation of action taken.
- Dietary Freezer logs were missing temperature documentation 06/12/13, 06/13/13, 06/14/13, 06/17/13, 07/21/13, and 07/22/13.

7. Observation on 07/14/13 at 9:45 AM, of the refrigerator logs from the Patient Care unit galley showed missing temperature documentation 07/01/13, 07/02/13, 07/03/13, 07/04/13, 07/05/13, 07/07/13, 07/14/13, 07/20/13, and 07/21/13.
8. During an interview on 07/24/13 at 9:30 AM, Staff U, Registered Dietician (RD), stated that it was Housekeeping staff's responsibility to check the refrigerator/freezer temperatures daily and document them on the log. She could not explain why there were multiple dates on the logs with no documentation and was not aware the refrigerator temperatures were out of range.

9. During an interview on 07/24/13 at 10:55 AM, Staff V, Housekeeper, confirmed that Housekeeping staff was responsible for checking and documenting the refrigerator/freezer temperatures daily.




32281

Based on observation, interview, record review and policy review the Infection Control Practitioner failed to develop and maintain a system for identifying, investigating and controlling infections for 13 patients (#1,#2, #3, #4, #5, #10, #12, #13, #14, #15, #16, #24, #31) of 27 patients by:
-Failing to ensure hand hygiene and glove use standards were followed during medication pass and wound care;
-Failing to ensure standards for maintenance of a sanitary hospital environment were followed;
-Failing to ensure standards for techniques and use of isolation
precautions (special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases) were followed.
These failed practices increased the risk of spreading disease and cross contamination and placed all patients and personnel at risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was 27.
Findings included:
1. Record review of the facility's policy titled, "Hand Hygiene" dated 02/13, showed:
- All facility healthcare personnel would follow CDC (Centers for Disease Control and Prevention) guidelines on Hand Hygiene (hand cleaning) and would be knowledgeable regarding hand washing procedures and comply with the procedures as required. Hands must be cleansed by hand washing with soap and water or by hand asepsis with alcohol-based rubs (if hands not visibly soiled):
- Before and after contact with all patients;
- After contact with the source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated);
- After removing gloves.

2. Record review of the facility's policy titled, "Standard Precautions" dated 02/13, showed:
- Standard Precautions is a processes that reduces the risk of transmission of pathogens (a germ that causes disease) from blood and moist body substances.
- Applied to all patients receiving care, regardless of their diagnosis or presumed infection status.
- Standard Precautions would be carried out by all healthcare personnel to protect them from possible exposure to blood borne pathogens or other infectious agents.
- Hand washing was the single most important means of preventing the spread of infection.
- Disposable gloves would be worn when touching blood, body fluids, secretions contaminated items.
- Gloves would be changed after performing a contaminated procedure and prior to performing a clean procedure on the same patient.
- Gloves would be removed promptly after use and hands washed thoroughly before touching non-contaminated items or surfaces and before going to another patient.
- Items contaminated with infective material would be wiped off with approved cleaner before leaving the patient care room.

3. Record review of the facility's policy titled, "Transmission-Based Precautions" dated 02/10, showed:
- Transmission-Based Precautions (where germs are spread by direct contact or droplet) will apply to any patients known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens (infectious agents that are easily transmitted with healthcare facilities, resistant to therapy and associated with serious and often fatal disease). Transmission-based precautions do not replace but are used in addition to Standard Precautions. Three types of Transmission-Based Precautions can be utilized, Contact Precaution, Droplet or Airborne.
- Contact Precaution (infection is spread by contact with the patient or with the environmental surfaces or patient care equipment:
- Place the patient in a private room.
- All persons entering and leaving the room must adhere to strict hand washing.
- When gloves are worn upon entry into the room change after contact with infective material, remove and discard before leaving the room, and wash hands immediately after removing gloves.
- When an isolation gown is worn upon entry into the room, a clean gown should be worn each time and removed prior to leaving the patient room.
- Ensure that after removing gown, gloves and hand washing that hands and clothing do not contact potentially contaminated environmental surfaces.
- Patient care equipment such as stethoscopes, thermometers and blood pressure cuffs shall be assigned to a single patient.
- The patient is to leave the room only when necessary. Precautions must be maintained during transport to minimize the risk of transmission to other patients, equipment and surfaces.

4. Record review of the Enteric Precautions (avoid any contact with bodily fluids of a patient due to germs that can be transmitted via these fluids) sign posted for patients suspected of having Clostridium difficile (also known as, C. difficile or C. Diff, a bacteria that causes mild to severe diarrhea and intestinal conditions like inflammation of the colon) showed the precautions were used in addition to Contact Precautions including:
- Visitors-Report to the Nurses' Station before Entering the Room.
- Perform hand hygiene before entering the room and wash hands with SOAP and WATER before leaving the room.
- Wear gown and gloves anytime you enter the room.
- Remove gown and gloves before leaving the room.

5. Observation on 07/23/13 at 9:20 AM showed Staff A, Licensed Practical Nurse (LPN), prepared medications for Patient #1:
- Pre-packaged oral medications were removed from the dispensing machine and placed in a paper medicine cup and she prepared the injectables (medications administered with needle and syringe).
- Staff A removed a multi-dose bottle of Benefiber (powdered form of dietary fiber) from the patient's medication bin and proceeded to his room with all the medications.
- Staff A placed the patient's medications on the bedside table beside his meal tray and put on gloves.
- Staff A then took the bottle of Benefiber from the bedside table to the sink, measured the dose in the bottle cap and mixed it with water.
- The patient choked on the Benefiber requiring Staff A to perform oral suctioning using the wall mounted suction set up.
- Staff A put down the suction and without removing her gloves and without performing hand hygiene, opened a drawer containing clean supplies and moved around items in the drawer, returned to the patient's bedside and continued suctioning.
- Staff A then removed her gloves, used the alcohol based hand sanitizer and put on a clean pair.
- Staff A removed the packages of pills from the paper medicine cup and opened each one individually back into the paper medicine cup and administered the contaminated pills to the patient.
- Staff A picked up the bottle of Benefiber and returned it to the medication room without wiping off the bottle.

During an interview on 07/24/13 at 10:45 AM, Staff S, Pharmacist, stated that any medication which was kept in the nursing medication room should not be taken into the patient's room unless it was wiped down to remove germs before taking back into the medication room. Otherwise the medication should be dispensed in the medication room into an individual cup and taken into the patient's room.
During an interview on 07/23/13 at 2:15 PM, Staff A, LPN, stated that:
- She had been employed by the facility for two years.
- She did not recall the specifics of her orientation.
- Hand Hygiene consisted of:
- Hand washing or alcohol based sanitizer on entering a room and between glove changes;
- Changing gloves during dressing changes when going from dirty to clean and before doing anything else;
- Hand washing is required for patients with C. diff or when visibly soiled.
- Gloves are not required for giving oral medications;
- Believes it is the facility policy to wear gloves when helping patients eat or drink and when giving injections.
- Staff A stated that she should have changed her gloves between suctioning Patient #1 and looking for supplies in the cabinet.

6. During an interview on 07/23/13 at 2:50 PM, Staff C, Director of Quality and Infection Control, stated that:
- The facility had no policy for infection control during medication pass;
- When dispensing pills to the patient placing the packets of pills in a med cup and then later opening the pills into the same med cup was wrong. The expectation was to place the pills in a clean med cup. The expectation for hand hygiene was to wash or use alcohol based gel:
- When entering a patient room;
- Dirty to clean, same episode of care;
- When changing gloves;
- When exiting a patient room;
- When caring for patients with C. Difficile must wash hands with soap and water.

7. Observation on 07/23/13 at 8:46 AM, showed Staff B, RN:
- Removed pre-packaged oral medications from the dispensing machine and placed them in a paper medicine cup without performing hand hygiene. - He entered Patient #2's room, placed the medicine cup and a syringe containing medication on the bedside table, washed his hands and put on gloves.
- He removed the pills from the paper med cup and dropped one on the floor. He picked the packaged pill up from the floor and placed it with the other pills on the patient beside table then proceeded to open each pill package individually into the paper med cup and administered the contaminated pills to the patient. Without changing gloves or performing hand hygiene, he administered the injections and then, removed his gloves and washed his hands.

During an interview on 07/23/13 at 1:20 PM, Staff B, RN, stated that:
- He had been an employed by the facility for four weeks.
- He had received Infection control training during his orientation.
- It is routine to place packaged medication in the medication cup to take them to the patient room, then remove the pill from the protective package and place back into the medicine cup.
- Standard Precautions included:
- Washing hands upon entering a patient room;
- After touching a patient;
- Before starting a procedure,
- Wash hands before and after gloving; and
- Contact with body fluids.

When asked about picking a pill up off the floor and continuing medication administration Staff B stated that he should have disposed of the pill and got a replacement from pharmacy and he should have changed gloves.

8. Observation on 07/22/13 at 2:15 PM, showed Staff B, RN, entered Patient #3's room. There was no Contact/Enteric Precaution sign on the door and no isolation cart (cart containing gowns, masks, gloves and other supplies necessary when isolation precautions are implemented) outside the room. Staff B did not perform hand hygiene, wear a gown or gloves, and he did not convey to this surveyor that the patient was on Contact/Enteric Precautions due to a pending (awaiting confirmation) result of the C. Diff culture (a lab test to show the cause of an Infectious disease).

Record review of the patient's medical record showed:
- A physician progress note dated 07/20/13 at 7:40 AM, to obtain a stool specimen to check for C. Diff.
- An entry on the Nursing 24 Hour Flow Sheet dated 07/22/13 under Precautions that showed the patient was on Contact Precautions for suspected C. Diff. The entry had been marked thru with a notation that it was not applicable (N/A).
- An entry on the Nursing 24 Hour Flow Sheet narrative dated 07/22/13 at 3:00 PM, showed the patient had a pending C. Diff culture. "Contact and Enteric Precautions have been initiated until results are returned".
- An entry on the 24 Hour Flow Sheet dated 07/23/13 at 9:56 AM, showed that the patient was on Contact Precautions, C. diff still pending.
- An entry on the 24 Hour Flow Sheet narrative dated 07/22/13 at 10:00 AM, showed that the patient was transferred to another facility for a scheduled CT scan (computerized tomography combines a series of X-rays, taken from different angles and computer processing to crate cross-sectional images of the bones and soft tissues). (The facility did not identify the patient was on isolation precautions and therefore the patient was transferred without the other facility's knowledge of the needed isolation precautions.)
- A final pathology (the precise study and Medical diagnosis) report dated 07/23/13 at 1:18 PM, for C. Difficile Toxin showed the C.Diff culture was collected on 07/20/13 at 8:39 AM, and the result was negative.

During an interview on 07/25/13 at 10:30 AM, Staff L, RN, Charge Nurse, stated that patients that were cultured for suspected C Difficile were placed on isolation precautions until the culture results come back negative.

During an interview on 07/25/13 at 11:55 AM, Staff C, stated that patients that were suspected of having C. Diff were placed on both Contact Precautions and Enteric Precautions when the culture was obtained.

9. Observation on 07/22/13 at 2:00 PM in Patient #4's room showed:
- Staff B, RN entered the room with a paper medicine cup in his hand.
- He placed the medicine cup on the bedside table, washed his hands with soap and water and put on gloves then proceeded to remove three pill packages from the medicine cup.
- He opened each pill packet individually back into the medicine cup and administered the contaminated pills to the patient.

10. Observation on 07/23/13 at 1:45 PM, showed Staff A, LPN, gathered supplies from the medication room and supply closet for a dressing change on Patient #5. Staff A entered Patient #5's room and she opened a sterile package of dressing, poured Dakin's solution (an antiseptic solution developed to treat infected wound) over the dressing and placed the bottle of solution on the counter next to the sink. After completing the dressing change she picked up the Dakin's solution from the counter and returned it to the patient bin in the medication room without wiping the bottle. The patient bin also contained nasal sprays and bulk oral medications.

11. Observation on 07/22/13 at 2:35 PM, showed Patient #10's bedside table with a glass of drinking water sitting next to a partially full urinal (a vessel for holding urine). The urinal was contaminated and could possibly come in contact with the the drinking water.

A subsequent observation on on 07/23/13 at 10:30 AM, showed the patient's urinal next to the telephone on the bedside table which could cause contamination if it came into contact with the patient's hands and face. This put the patient at increased risk for infection.

12. Observation on 07/23/13 at 8:40 AM, showed Staff J, RN, prepared to administer medications to Patient #12 (the patient had a diagnosis of Neutropenia, very low immunity causing inability to fight off infections) and the patient was in reverse isolation (protection against acquiring serious infections from everyone else). Staff J typed on the keyboard in the medication room and removed seven medications from the medication distribution machine. She was not wearing gloves and did not perform hand hygiene during these tasks. She opened drawers in the medication room and cut one of the pills in half. Then she removed scissors from her pocket and cut open one of the medication packages. She placed all of the contaminated packaged and unpackaged medications in a paper drinking cup. She carried the paper drinking cup to Patient #12's room. She put on an isolation precaution gown, gloves and mask. She entered the room and put all of the medications on the patient's bedside table, opened the medications and put them back into the same paper cup and gave the contaminated pills to the patient to take by mouth. The nurse picked up a cup of juice that had been sitting next to the urinal on the bedside table and handed it to the patient. The contaminated medications and potentially contaminated cup of juice were ingested by the patient and put him at a higher risk for infection.

13. Observation on 07/22/13 at 2:10 PM, showed Staff F, RN, in Patient #13's room to reposition the patient in bed. Staff F put on gloves but did not perform hand hygiene. She turned the patient from the right to left side and applied lotion to the patient's buttocks. Staff F continued to wear the same gloves to cover the patient with a gown and bed sheet and adjust her pillow. With the same soiled gloves she moved the patient's bedside table and picked up an opened juice bottle and placed it within the patient's reach before removing her soiled gloves which increases the potential for contamination.

14. Observation on 07/23/13 at 9:15 AM, showed Staff K, RN, administered medication to Patient #14. Staff K removed the packages of pills from a paper cup and opened the pills then placed the pills back into the a same cup containing the packaged pills, then administered the contaminated pills to the patient.
15. Observation on 07/23/13 at 8:43 AM, showed Staff K, wearing gloves administered medications to Patient #15. Staff K removed the packages of pills from a paper cup and opened the pills then placed the pills back into the same cup containing the packaged pill;, then administered the contaminated pills to the patient. Staff K then removed a cap from an intravenous line (IV - in the vein) located on the patient's chest while wearing gloves. With the soiled gloves on, Staff K opened a drawer, rummaged through medical supplies, then returned to the patient's IV and replaced the IV cap with a new one.

During an interview on 07/23/13 at 1:55 PM, Staff K stated that she should have used a second cup to dispense the opened pills into, rather than using the cup with the packaged pills inside. Staff K denied that moving from Patient #15's IV site, to inanimate objects such as drawers and supplies, and back to the IV site without changing gloves was an infection control concern.

16. Observation on 07/22/13 at 1:42 PM, showed Staff I, Patient Care Technician (PCT), entered Patient #16's room and put on gloves without performing hand hygiene, before providing care to the patient.
During an interview on 07/22/13 at 1:47 PM, Staff I stated that hand hygiene should be performed every time staff enter a patient room.

17. Observation on 07/23/13 at 9:20 AM, Staff CC, RN, entered Patient #24's room. While wearing gloves, Staff CC picked up a blood pressure cuff from the floor; adjusted the patients gown then, applied the blood pressure cuff to the patient's left arm. While wearing the same soiled gloves, she cleaned the blood from around the patient's tracheostomy (a surgically created opening in the patient's neck to assist the patient to breathe). She then removed the gloves and placed them in the trash. She regloved and without performing hand hygiene she flushed the patient's PEG (percutaneous endoscopic gastrostomy, a tube passed through the abdominal wall into the stomach for nutrition and/or administering mediation) tube. This placed the patient at increased risk for infection.

18. Observation on 07/23/13 at 4:00 PM, Staff GG, Wound Nurse, entered Patient #31's room to assess and perform wound care. With gloved hands, she lifted the patient's left leg and removed the dressing from a wound. While wearing the same dirty gloves, she then picked up a camera to photograph the wound. She removed her gloves and did not perform hand hygiene. She put on gloves and opened and applied a dressing to the left leg. She removed the gloves and without performing hand hygiene, she put on gloves and then proceeded to remove the dirty dressings from the sacrum (the bony area at the base of the spine). She touched the open wounds with her gloved finger and picked up the camera with the dirty gloves to photograph the wound. She removed the gloves and regloved without perform hand hygiene and replaced the dressing on the sacrum. She reached into her pocket and retrieved a pen to date and time the dressing. She removed the gloves and regloved without performing hand hygiene. She removed the dressing and packing from the groin wound (the fold or hollow on either side of the front of the body where the legs meet the stomach) and removed her gloves. Without performing hand hygiene, she regloved. She opened the closet door and retrieved normal saline (a sterile solution) and cleansed the groin wound. She then touched the wound with her gloved finger and photographed the wounds with the camera wearing the same dirty gloves.
During an interview on 07/24/13 at 10:30 AM, Staff GG, stated that she did not realize she had contaminated the wounds when she wore the same gloves to examine each wound and when taking photos of the wounds. She stated that she didn't remember removing her gloves and applying gloves without performing hand hygiene. She stated that she was overwhelmed with the amount and severity of the wounds.














27727




27029




29047

Based on interview, record review and policy review, the facility failed to ensure that patients' discharge plans were reassessed for appropriateness for seven patients (#4, #9, #10, #11, #13, #15 and #17) of 32 discharge plans reviewed. This had the potential to affect all patients in the facility. The facility census was 27.
Findings included:
1. Record review of the facility's policy titled, "Discharge Process" dated 07/08, showed that the discharge plan is frequently updated to keep current with the patient's progress and related to overcoming any issues surrounding discharge.
2. During an interview on 07/24/13 at 1:10 PM, Staff G, Social Worker, stated that the Initial Social Service Evaluation should occur for every patient within three business days of admission or sooner. Staff G stated that Staff M, Director of Utilization Review, monitored patient medical records to ensure patients were assessed within three days of admission and reassessed at least weekly for updates. She stated, "Staff M will let us know if we don't meet the time frames".
3. During an interview on 07/24/13 at 1:50 PM, Staff C, Director of Quality, stated that the expectations for Social Workers were that the initial patient assessment was completed within three days of admission and then updated at least weekly. She stated that she hadn't had time to update the policy and procedure to reflect these time frames.

4. During an interview on 07/25/13 at 11:58 AM, Staff Y, Chief Executive Officer (CEO), stated that he supervised Staff M, Director of Utilization, who was the Social Workers' supervisor. Staff Y stated that Social Workers should complete the discharge planning process. Staff Y stated that discharge planning for patients should occur initially (on admission), weekly and upon discharge.

5. Record review of Patient #4's medical record showed that she was admitted to the facility on 07/09/13. The one initial Social Work note dated 07/10/13, regarding discharge plan stated that the patient will plan discharged to home. There was no follow-up documentation found in the record between 07/10/13 and 07/24/13.
Record review of the patient's care plan dated 07/18/13, showed the projected discharge destination was a rehabilitation hospital.
During an interview on 07/22/13 at 2:00 PM, the patient stated that no one had really discussed discharge plans with her.
6. Record review of Patient #9's medical record showed an initial Social Service note dated 06/26/13 and a follow up Social Service note dated 07/18/13. The discharge plan, Social Worker's responsibility, was not included in the care plan and the patient's medical record did not show documentation that the patient had been reassessed for discharge planning since admission.

7. During an interview on 07/22/13 at 2:30 PM, Patient #10 stated that he was supposed to be discharged to a nursing home but he didn't want to be discharged. He didn't know what to do. He asked the nurse to see if the Social Worker would come and visit him.

Record review of the patient's medical record showed an initial Social Service note dated 07/03/13 and a Social Service note dated 07/23/13. The patient had not been reassessed for discharge plans since admission.

8. During an interview on 07/22/13 at 2:40 PM, Patient #11 stated, "They don't tell me anything about my condition or why I am still here". He stated that he had seen the Social Worker one time on admission on 07/15/13. Patient #11 stated that he (was able to perform self care) made his own bed, walked and toileted himself and needed to get back home to take care of his family. He stated "I have no clue what the plan is and I haven't been asked".
Record review of the patient's medical record showed the patient had been admitted on 07/02/13 but there was no Social Work documentation in the medical record regarding the discharge plan.

9. Record review of Patient 13's medical record showed the patient had been admitted on 06/20/13. No initial or follow up Social Work notes were documented in the medical record. No discharge assessments had been documented for this patient.

10. Record review of Patient #15's medical record, showed admission on 05/09/13. There was no documentation of an Initial Social Service Evaluation in the record and no Follow-up Social Services Notes between 05/22/13 and 06/04/13 (13 days); or between 06/18/13 and 07/05/13 (17 days) found in the record. The last Social Services Note was dated 07/05/13 (18 days).

11. Record review of Patient #17's medical record showed that he was admitted on 07/12/13. There was an Initial Social Service Note dated 07/18/13, six days after the patient was admitted.

During an interview on 07/23/13 at 10:45 AM, the patient's family member stated that Staff H, Social Worker, doesn't ever come around. The family member stated, "We usually have to go find him," if the family had concerns. The family member, who stayed with the patient, stated that she didn't remember that she had spoken with Staff H.
12. During an interview on 07/24/13 at 3:10 PM, Staff M stated that she regularly monitored the patient medical records to ensure Social Workers were documenting as required. She stated that she didn't evaluate the Social Worker's work and evaluation of the Social Worker's work was the Chief Executive Officer's (CEO) responsibility.



27029




32281

Based on interview and policy review the facility Respiratory Department failed to outline specific qualifications and duties that the Respiratory staff could perform without supervision and the qualifications of personnel who provided supervision to the Respiratory staff. This had the potential to affect all patient who required and received respiratory care. The facility census was 27.
Findings included:
1. Record review of the facility's policy, "Cardiopulmonary {Respiratory department} Scope of Service" revised 07/12, showed that medical direction of the Cardiopulmonary Therapy Department is provided by a member of the medical staff who has a special interest and knowledge in the diagnosis, treatment, and assessment of pulmonary disease.
2. During an interview on 07/25/13 at 8:25 AM, Staff QQ, Respiratory Care Manager, stated that after review of the policy, it (the policy) did not address qualifications of staff; if they could perform their duties unsupervised or who could provide supervision to the Respiratory staff.