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Based on record review and interview, the facility disaster plan for the emergency purchase of available bottled water from a local supplier source failed to ensure the facility will have enough water on hand during an emergency to meet the needs of the hospital's average daily census and support staff for a minimum period of 48 hours. The facility census was five.

Findings included:

1. Record review of emergency planning document titled "Emergency Back-UP Water Plan dated 12/6/05 showed that a local food store had agreed to provide "as much bottled water as possible" in the event of an emergency failure of water supply to the facility. The plan called for the water to be "picked up by hospital personnel and delivered immediately" to the hospital's address. The plan failed to ensure the supplier will reserve a calculated quantity of water in a secure location in order to provide an adequate amount of product to meet the needs of the facility average daily census and support staff for a minimum period of 48 hours.

During an interview on 02/02/12 at 10:08 AM, Staff A, CEO stated she was concerned because the facility was on the opposite side of the highway in a rural location, and potentially isolated from neighboring communities from which they could draw food, water and fuel resupply in the event of a disaster situation.

Based on observation, interview, and policy review, the facility failed to:
- Identify and/or monitor for post-procedure infections for five of six patients (#9, #11, #7,
#8 and #6) receiveing out-patient procedures (colonoscopies and esophagogastroduodenoscopies);
- Follow nationally recognized standards and the facility policy for hand hygiene for three (#2, #3 and #4) of four patients observed for hand hygiene;
- Ensure a sanitary environment was maintained in one of one patient food refrigerator on the patient care unit;
- Safely store food in clean, sealed containers to protect against cross contamination;
-Follow nationally recognized standards for endoscope storage and;
-Follow the manufacturers recomendations for endoscope cleaning.
The facility census was five.

Findings included:

1. Record review of the facility's policy titled, "Surveillance", revised 07/07/10, showed the following direction:
- Total house surveillance is performed at this facility;
- This method was chosen due to the size of the facility and to help in establishing a baseline for hospital acquired infection;
- Responsibility of data collection lies with the Infection Control Coordinator.

2. Record review on 01/31/12 between 10:00 AM and 11:30 AM of discharged Patient #9's medical record showed the patient was admitted on 11/17/11 for upper GI endoscopy (upper gastrointestinal (UGI) endoscopy, a procedure to look at the interior lining of the esophagus, stomach, and the first part of the small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope). The tip of the endoscope is inserted through your mouth and then gently moved down your throat into the esophagus, stomach, and duodenum (upper gastrointestinal tract).

Review of the Post-Procedure Follow-Up section of the Post Procedural Recovery and Discharge Summary Record showed the section was blank. Staff failed to document any follow up for signs or symptoms of infection with the patient.

Record review on 01/31/12 between 10:00 AM and 11:30 AM of discharged Patient #11's medical record showed the patient was admitted on 07/28/11 for upper GI endoscopy on 07/28/11.

Review of the Post-Procedure Follow-Up section of the Post Procedural Recovery and Discharge Summary Record showed a phone number written in to call for follow up and the box checked to show it was ok to talk with family/significant other. The rest of the form was blank. Staff failed to document any follow up for signs or symptions of infection with the patient.

Record review on 01/31/12 between 10:00 AM and 11:30 AM of discharged Patient #7's medical record showed the patient was admitted on 10/27/11 for colonoscopy (an internal examination of the colon to look at the interior lining of the large intestine (rectum and colon) with biopsy.

Review of the Post-Procedure Follow-Up section of the Post Procedural Recovery and Discharge Summary Record showed a phone number written in to call for follow-up but the rest of the section was blank. Staff failed to document any follow up with the patient.

Record review on 01/31/12 between 10:00 AM and 11:30 AM of discharged Patient #8's medical record showed the patient was admitted on 12/15/11 for colonoscopy with biopsy.

Review of the Post-Procedure Follow-Up section of the Post Procedural Recover and Discharge Summary Record showed the section was blank. Staff failed to document any follow up for signs or symptions of infection with the patient.

Record review on 01/31/12 between 10:00 AM and 11:30 AM of discharged Patient #6's medical record showed the patient was admitted on 12/15/11 for upper GI endoscopy with biopsy on 12/15/11.

Review of the Post-Procedure Follow-Up section of the Post Procedural Recovery and Discharge Summary Record showed a phone number written in to call for follow-up and box to speak to patient only was checked, but the rest of the section was blank. Staff failed to document any follow up for signs or symptions of infection with the patient.

3. During an interview on 02/01/12 at 8:50 AM, Staff N, Registered Nurse (RN), Infection Control Coordinator, stated that she had not been tracking infections in patients receiving colonoscopies (the examination of the large bowel and the distal part of the small bowel with a flexible scope) and/or esophagogastroduodenoscopies (EGDs) (a test to examine the lining of the esophagus, the tube that connects your throat to your stomach). She thought that Staff H, RN, Outpatient Clinical Services Coordinator had been doing post-procedure calls to those patients.

During an interview on 02/01/13 at 10:50 AM, Staff I, RN, Director of Patient Care Services, stated that Staff H had been tracking infections in acute care patients and outpatients, but was not aware of any tracking of infections in post-procedure patients. (Colonoscopies and EGDs).

During an interview on 02/01/12 at 10:40 AM Staff H, RN Outpatient Clinical Services Coordinator stated that the facility did not routinely do post procedure follow up with the patient.

4. Review of the CDC/HICPAC (Centers for Disease Control/Healthcare Infection Control Practices Advisory Committee) hand hygiene recommendations, dated October 2002, included:
1. Indications for hand washing and hand antisepsis
A. When hands are visibly dirty or contaminated
or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
C. Decontaminate hands before having direct contact with patients.
F. Decontaminate hands after contact with a patient's
intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during
patient care.
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
J. Decontaminate hands after removing gloves.

Review of the May 2009 AORN (Association of PeriOperative Registered Nurses) Perioperative Standards and Recommended Practices, Recommended Practices for Prevention of Transmissible Infections in the Perioperative Setting showed:
Recommendation II
Hand hygiene should be performed before and after each patient contact.
1. All personnel should practice general hand hygiene. Prompt and frequent hand antisepsis is the single most important measure to reduce the spread of microorganisms. Hand hygiene should be performed:
-At the beginning of a work shift
-Before and after patient contact
-After removing gloves
-Before and after eating
-Before and after using the restroom
-Anytime there is possibility that there has been contact with blood or other potentially infectious materials, and
-Anytime when hands may have been soiled or any time the practitioner believes his or her hands may have been soiled.

Review of the facility's policy titled, "Hand Hygiene" dated 11/15/11 showed directions for staff to perform hand hygiene:
-Before and after direct contact with patients;
-After removing gloves and;
-When moving from a contaminated body site to a clean body site during patient care.

5. Observation on 01/30/12 at 2:00 PM showed Staff C, RN entered Patient #2's room and administered medication. Staff C failed to perform hand hygiene before providing patient care.

Observation on 01/30/12 at 2:10 PM showed Staff E, Licensed Practical Nurse (LPN) entered Patient #2's room donned gloves but failed to perform hand hygiene.

Observation on 02/01/12 at 9:00 AM showed Staff B, RN completed a medication pass to Patient #4, then donned gloves without performing hand hygiene.

Observation on 01/30/12 at 3:10 PM showed Staff E, Licensed Practical Nurse (LPN), entered Patient #3's room, donned gloves, but failed to perform hand hygiene. Staff E then removed Patient #3's intravenous catheter.

6. During an interview on 02/01/12 at 9:20 AM, Staff N, RN Infection Control Coordinator, stated that she would expect staff to perform hand hygiene prior to donning gloves and would expect staff to perform hand hygiene after removing gloves.

During an interview on 02/02/12 at 9:30 AM, Staff I, RN Director of Patient Services stated that handwashing surveillance is included in their internal quality monitoring and monthly audits. Staff I stated that the monitoring is done unannounced by standing in the hallway observing staff using hand foam coming and going from patient's rooms. When questioned, Staff I stated that she did not believe the internal observations included handwashing between glove changes in patient rooms.

7. Record review of the facility's policy titled, "Operating and Cleaning the Freezers and Refrigerators," reviewed 03/25/11, showed the following direction:
- The fronts and interior of the refrigerators and freezers are cleaned daily. All spills are cleaned immediately.

8. Observation on 01/30/12 at 2:46 PM and again on 02/01/12 at 8:37 of a small refrigerator located on the Medical/Surgical floor showed dried food-stuff adhered to the bottom interior surface of the refrigerator. The food-stuff appeared to be a liquid that had dried.

During an interview on 01/30/12 at 2:47 PM, Staff E, LPN, stated that the dietary (food and nutrition) department was responsible for the refrigerator since it held patient drinks and snacks.

During an interview on 02/01/12 at 8:37 AM, Staff L, Cook, stated the refrigerator needed cleaned and that it was probably spilled food.

3. Review of Dietary Policy dated 6/21/2007, titled "Single Use Articles" states, "All single service articles are stored, handled and dispensed in sanitary condition, and used only one time."

Review of Dietary policy dated 6/21/2007, titled "Food Storage" states, "Food shall be stored to prevent contamination from any other source.

Observation in the kitchen on 01/31/12 at 2:30 PM showed oily stains and white flour and bread crumbs in four shallow cardboard box bottoms containing cooking and service utensils. The cardboard box bottoms were in two of the three drawers of a food preparation table located on the east side of the kitchen.

Observation on 01/31/12 at 2:40 PM showed more than 25 re-used plastic containers of dated and labeled leftover entrees stored in a reach-in refrigerator on the north side of the kitchen. Several containers were mottled with remnants of the original screen printed label on the side of the containers. Several thin plastic food containers were inverted on a clean dishes drying rack at the end of the automatic dishwasher. Red stains were embedded into the degraded interior surfaces on two single service plastic food containers. Four other used plastic containers with partially legible labels were stacked inverted on a drying rack. All of the single-service plastic containers used for holding leftovers were constructed of paper-thin, extruded food-grade plastic and had an inverted lip around the top rim that formed a channel where food and other contaminants could accumulate.

Observation on 02/01/12 at 8:30 AM showed six single service plastic containers inverted on the drying shelf, at least one of which was stained red.

During an interview on 01/31/12 Staff U, Dietary Manager stated the plastic containers are used daily for leftovers, and repeatedly used unless they are cracked or broken. She stated that they were washed in the automatic dishwasher, same as the dishes.

9. Review of the AORN Perioperative Standards and Recommended Practices, dated May 2009, Recommendation IX showed: Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination.
IX.a. Flexible endoscopes should be stored in a closed cabinet.
Proper storage facilitates drying and decreases the potential for contamination.

Review of the undated draft guidelines for the Automatic Endoscope Reprocessor (ASP) (draft guidelines provided by the ASP company for the facility to adapt and implement as its own policy) provided by Staff A, Chief Executive Officer (CEO) on 01/30/12 as the facility policy for endoscope processing, showed directions for staff included:
Alcohol Flush: Promotes drying of channels and inhibits growth of bacteria.
1. At the end of the cycle, open the lid; insert ASP alcohol flush tubing in an open port.
2. Fill a 60 cc luer lock (type of fitting) syringe with 30cc of 70% alcohol. Use 30cc for each scope to be processed.
3. Attach to tubing set and inject. Follow with 10cc manual air flush.
4. Remove tubing set and close the lid.
5. Turn selector knob to manual air and press start button. For five minutes air will blow through the channels.

10. Observation on 01/30/12 of the sub-sterile room located off of the operating room (OR), showed the door to the room was open and there were four endoscopy scopes hanging in the room, two esophagogastroduodenoscopies (EGDs, a test to examine the lining of the esophagus, the tube that connects your throat to your stomach) of the four scopes touched the wall. There were several small brownish colored spots on the wall within inches of the first scope by the sink. Further observation showed the sink was approximately 6 inches from the first scope. There was a potential for anyone using the sink to splash and contaminate the scopes.

During an interview on 01/31/12 at 9:15 AM, Staff I, RN Director of Nursing stated that GI procedures were scheduled the fourth Thursday of the month but they had not done any procedures in January. The last date the facility had used the scopes was 12/22/11.

During an interview on 01/31/12 at 9:15 AM, Staff H, RN Outpatient Clinical Services Coordinator stated that the scopes had been cleaned after the last clinic (12/15/11) and were ready to be used.

During an interview on 02/02/12 at 10:00 AM Staff V, Radiation Technician responsible for sterilization and scope processing stated that she had never been taught to use an alcohol flush on the scopes.

Review of Staff V's ASP Competency Review: Return Demonstration dated 12/17/09 showed Staff V had been trained to perform the Alcohol flush procedure and state the rationale for the alcohol flush procedure.





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27724

Based on interview, record review and policy review, the facility failed to develop and maintain an ongoing activities program that was based on a comprehensive assessment of leisure interests and abilities and care planned for three current patients (#1, #2 & #3) and three discharged patients (#18, #20, #25) of six Swing-bed records reviewed. (A Swing-bed is a change in reimbursement status. The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing services and reimbursement.) The Swing-bed census was three. The facility census was five.

Findings included:

1. Record review of the facility's policy titled, "Care Planning", revised 11/15/11 showed the following direction:
- The plan of care shall be individualized, based on diagnosis and patient assessment;
- After the initiation of the plan of care by nursing, those disciplines consulting in the care shall contribute to the plan as appropriate to the patient's assessed needs.

2. Record review on 01/30/12 at 3:00 PM of Patient#3's medical record showed a physician order dated 01/25/12 for admission to the Swingbed program for physical therapy and occupational therapy due to weakness. The Discharge Planning and Goal Setting document dated 01/30/12 stated the patient's activity preference was television and required one-on-one visits. The facility failed to care plan for an activities program and the medical record contained no further documentation regarding the patient's activities.

During an interview on 01/30/12 at 2:20 PM, Patient #3 stated that she did not like television much and only likee to watch "Dr. Phil" sometimes. Patient #3 stated she liked to go to church, but did not enjoy the church services offered at this facility. When asked if anyone had offered other activities, the patient stated, "not really".

3. Record review on 01/30/12 at 2:10 PM of Patient #2's medical record showed a physician order dated 01/28/12 for admission to the Swingbed program for physical therapy due to generalized weakness. The Discharge Planning and Goal Setting document dated 01/31/12 stated the patient's activity preference included reading books, one-on-one visits and group activities. The facility failed to care plan for an activities program and the medical record contained no further documentation regarding the patient's activities.

During an interview on 01/31/12 at 2:20 PM, Patient #2 stated someone had talked to her about activities, but had brought her own books to read and had not been asked to participate in group activities.

4. Record review on 01/31/12 of Patient #1's History and Physical (H & P) dated 01/24/12 showed the patient was admitted to the facility's swing bed on 01/24/12 for further physical and occupational therapy strengthening. Review of the patient's "Skilled Nursing Care Discharge Planning and Goal Setting" form, showed that Staff N, Registered Nurse Case Manager and Activities Director documented the patient's activity preference as "books".

Observation on 01/31/12 from 8:30 AM to 8:45 AM showed no visible books and/or reading material in Patient #1's room.

During an interview on 01/31/12 at 8:48 AM, Patient #1 stated that she did not recall staff asking about her preference regarding activities. The patient stated that she was a retired school teacher and really liked to read and that several staff told her they would bring books but no one had.

5. Record review on 02/01/12 of Patient #18's medical record showed a physician order dated 01/20/11 for admission to the Swingbed program for physical therapy and occupational therapy due to weakness. The facility failed to complete the Discharge Planning and Goal Setting document. The facility failed to care plan for an activities program and the medical record contained no further documentation regarding the patient's activities.

6. Record review on 02/01/12 of Patient #20's medical record showed a physician order dated 01/23/12 for the patient to be admitted to the Swingbed program for physical therapy and occupational therapy due to weakness. The Discharge Planning and Goal Setting document dated 01/25/12 stated the patient's activity preference included reading, and one-on-one visits. The facility failed to care plan for an activities program and the medical record contained no further documentation regarding the patient's activities.

7. Record review on 02/02/12 of Patient #25's medical record showed a physician order dated 01/06/12 for the patient to be admitted to the Swingbed program for physical therapy and occupational therapy. The Discharge Planning and Goal Setting document dated 01/18/12 stated the patient's activity preference included reading, magazines, cards, computers, one-on-one visits, and group activities. The facility failed to care plan for an activities program and the medical record contained no further documentation regarding the patient's activities.

During an interview on 02/01/12 at 3:00 PM, Staff N, Registered Nurse (RN), Case Manager and Activity Director for the Swingbed program, stated she had not been completing an activities care plan for Swingbed patients, and did not document the patients' involvement in activities. She stated there were no progress notes specific to activities. Staff N stated there was no policy related to the activity program.



18075

Based on observation, interview and policy review, the facility failed to maintain a distribution and/or storage system providing safety and accountability of medications and/or supplies used for patient emergency. The facility census was five.

Findings included:

1. Review of the facility policy titled, "Emergency Crash Carts (cart on wheels containing life saving emergency medications and supplies)" dated 11/15/11, showed the contents of the emergency crash cart will be listed in a log on top of the cart and shall include the earliest expiration date of any drugs within the tray. Review of the content list for the crash cart showed the crash cart should contain D5W 5% (Dextrose -sugar water) 250 milliliters (ml), in glass bottles.

2. Observation on 01/30/12 at 2:20 PM of the nursing medication room crash cart showed an expired 250 ml bottle D5W expiration 12/01/11, lot 84692DW. Directions included for use with Amiodarone (medication used for irregular heart beat).

During an interview on 01/30/12 at 2:20 PM Staff B Registered Nurse (RN) stated that staff took turn restocking the crash carts and checked the carts at the end of each month.

3. Observation on 01/30/12 at 2:25 PM of the medication supply room showed:
-A 4 ounce bottle of surgical scrub solution, expiration 09/11, lot 0870463;
-A urinary catheter (tube to drain the bladder), expiration 12/11, lot 529704R002;
-Two absorbent gel wound dressing pads, expiration 09/07;
-One green top blood collection tube, expiration 12/11, lot 0341911 and;
-One blue top blood collection tube, expiration 12/11, lot 1066180.
During an interview upon the observation, Staff B, RN stated that staff used the blood collection tubes.

4. Observation on 01/31/12 at 10:07 AM of the radiology department's crash cart showed an expired 250 ml bottle D5W, expiration 12/01/11.

During an interview on 01/31/12 at 10:13 AM, Staff C, RN, stated that they have had a problem getting replacements.


27724

Based on observations, record review and interview, the facility failed to ensure minimum physical and environmental requirements were met. As a result the hospital was found to be out of compliance with 42 CFR Part 485.623, Condition of Participation: Physical Plant and Environment. The facility census was five.

Findings included:

The facility:
-Failed to ensure supplies beyond manufacturers' expiration date were removed from patient care areas in, Emergency Department, Medication Room, pre-operative/recovery area, Operating Room (OR), Sterile Processing Department. (C0222)
-Failed to establish comprehensive housekeeping and preventive maintenance programs to develop and maintain the overall physical environment, and ensure the safety and well being of patients. (C0222)
-Failed to monitor the temperature and humidity level in the Operating Room (OR). (C0226)
-Failed to ensure the facility will have enough water on hand during an emergency to meet the needs of the hospital's average daily census and support staff for a minimum period of 48 hours. (C0229)
-Failed to ensure the integrity of smoke and fire barriers provide a minimum one hour fire resistance rating in accordance with 8.3 and 18.3.7.3.(C0231/K025)
-Failed to show evidence they conducted fire drills during the past 12 months on a minimum quarterly basis in accordance with 18.7.1.2. (C0231/K050)
-Failed to establish and conduct an approved inspection, testing and maintenance program that meets Chapter 10 requirements for fire alarm systems. (C0231/K052)
-Failed to test all smoke detectors at least annually in accordance with 10.4.3 (C0231/K054)
-Failed to conduct quarterly inspection of the automatic sprinkler system in accordance with 18.3.5. (C0231/K056)
-Failed to maintain a minimum clearance to storage accordance with 8.5.6.1 between boxed items stacked on shelves and the single sprinkler head in a closet. (C0231/K056)
-Failed to maintain the facility's sole Emergency Power Supply System (EPSS) and generator in accordance with NFPA 110, chapter 6-4.2.2, (C0231/K130)

The cumulative effect of these systemic practices present multiple hazards that directly affect the safety and well-being of all occupants of the facility including visitors and staff, and pose additional hazards to sick, injured or handicapped patients.

Based on observation, interview, and policy review, the facility failed to ensure supplies with expiration dates beyond the manufacturers' expiration dates were removed from patient care areas in the pre-operative/recovery area, the operating room and the Sterile Processing Department and the facility failed to establish comprehensive housekeeping and preventive maintenance programs to develop and maintain the overall physical environment, and ensure the safety and well being of patients. The facility census was five.

Findings included:

1. Record review of the facility's policy titled, "Rotation of Stock," dated 01/12, showed the following direction:
- Stock should be checked for expiration dates and rotated biannually with the inventory process.
- Items expired or with brittle wrappers should be removed from inventory and donated or destroyed.

2. Observation of the pre-operative/recovery area showed the hand cleansing foam in four of four bays observed expired 12/11.

3. Observation on 01/30/12 at 3:10 PM of the Operating Room (OR) showed numerous expired endoscopy (a procedure that uses a flexible tube with a light and camera to view the digestive tract) supplies including:
-A Bi-Polar coagulation pole (electrosurgical device), expiration 01/10, lot W238869;
-Two Roth Net Platinum Universal (endoscopic retrieval device), expiration 06/10, lot 464231;
-One Quantum Inflation Device (used to inflate, deflate and monitor pressure of the endoscopy balloon dilators during GI balloon dilation), expiration 05/11, lot W2533242;
-One all-in-one single use syringe/gauge assembly, expiration 07/11, lot 2070708;
-One Accessory Introducer (used for introduction of balloon, electrode, closed or non-tapered end and other catheters in GI procedures), expiration 06/10, lot W23900674;
-Three Esophageal ( muscular membranous tube for the passage of food from the pharynx to the stomach) type catheters, expiration 04/11, lot 12598951;
-One Esophageal type catheters, expiration 05/11, lot 12735887;
-One Esophageal type catheters, expiration 06/11, lot 12752785;
-Two Polypectomy Snares (a device used to remove polyps), expiration 06/10, lot W23912808;
-Three Bovie grounding pads (a pad used to provide a safe return path for
electrosurgical current to ensure the patient does not receive an electric shock) expiration 01/10, reference #ESRSC1;
-Three Balloon dilators(used to open or dilate a narrowed area), expiration 03/11, lot W2509568;
-One Polypectomy snare, expiration 06/10, lot W2391997;
-One Polypectomy snare, expiration 01/08, lot W2016744;
-Two Roth Net Platinum Universal, expiration 06/10, lot 464231;
-One Quicksilver Bi-Polar Coagulation Probe,( (an electric probe which produces heat to stop bleeding) expiration 01/10, lotW238869;
-One cleaning brush, expiration 03/11, lot W23507638;
-Three endoscopic clipping devices (device used in endoscopy procedures), expiration 12/10, lot W23469926 and;
-An open bag of EKG electrodes, expiration 07/05/10, lot number unreadable.

Observation on 01/30/12 of the sub-sterile room located off of the OR showed an electro-surgical handpiece, expiration 02/11, lot 0602221 and six unopened dual dispensing electrode packages, expiration 12/09, lot 0712171.

During an interview on 01/31/12 at 9:15 AM Staff H, RN Outpatient Clinical Services Coordinator stated that the GI (gastroenterology) physician checked supplies and equipment in the operating room a day or two before the scheduled GI procedures and someone else would go through supplies after the procedure day. Staff H stated that the expired supplies were probably left in the OR to create an inventory list.

4. Observation of the Sterile Processing Department showed an expired bottle of Cidex OPA (high level disinfectant) test strips (used to verify the efficacy of Cidex OPA), expiration 02/10, with a handwritten notation, "Do not Use" dated 07/27/10

During an interview on 02/01/12 at 2:30 PM Staff H, RN Outpatient Clinical Services Coordinator stated that she did not know why staff failed to dispose of the expired test strips.

During an interview on 02/02/12 at 9:50 AM Staff V, Radiation Technician responsible for scope reprocessing stated that the facility had been using the Cidex OPA up until December 2011 and the test strips had probably expired.

5. Observations of the Emergency Department on 01/30/12 at 3:00 PM showed multiple cracks the size of a pencil lead in the vinyl floor tiles that extended across the front and full width (11.6 feet wide) of Exam Room 3 and Exam Room 4. The open cracks exposed the black vinyl material inside each tile and created a potential reservoir for infectious agents and cross-contamination.

During an interview on 02/01/12 at 11:50 AM, Staff O, Plant Operations Director, stated the cracks in the floor of the Emergency Department' Exam Room 3 and 4 appeared to be over an expansion joint in the concrete and the cracks were probably due to moisture.

6. Review of the facility Preventative Maintenance (PM) Log (included the ED, Medical/Surgical patient rooms, nurses station, storage and medication rooms, Physical Therapy, Surgery Department and Operating Room) dated 01/09/12, showed the last documented PM check on the sterilizer was September 2005 and the last documented PM check on the scope washer was undated and staff had written, "not applicable".

During an interview on 02/01/12 at 1:10 PM with Staff A, Chief Executive Officer (CEO) and Staff O Plant Operations, Staff O stated that he did not know who performed preventative maintenance checks on the sterilizer.

During an interview on 02/01/12 at 1:45 PM Staff Q, Director of Health Information stated that the bio-med checks did not include any preventative maintenance on the sterilizer or the scope washer.

During an interview on 02/01/12 at 11:50 AM, Staff O, Plant Operations Director, stated he did not have a policy, procedure, written checklists or schedules for preventive maintenance to ensure facility equipment such air handlers, medical gas systems, air compressors, vacuum systems, walls, doors, and automatic sprinkler systems remained in a high state of readiness, and in good repair in order to fully support the ongoing patient care mission of the hospital.




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18075

Based on observation, interview, policy review and review of nationally recognized standards, the facility failed to monitor the temperature and humidity level in the Operating Room (OR), failed to monitor the temperature of the medical/surgical unit's refrigerator and freezer used to store patient drinks and snacks, and failed to maintain appropriate temperature of the medical/surgical unit's freezer. The facility census was five.

Findings included:

1. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, dated May 2009, Recommendation V showed:
V.b. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.
V.b.2 Humidity should be monitored and recorded daily using a log format or documentation provided by the heating, ventilation and air conditioning (HVAC) system.
V.c. Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

2. During an interview on 01/31/12 at 11:00 AM Staff H Registered Nurse (RN) Outpatient Clinical Services Coordinator stated that no one monitored the temperature and humidity level in the OR and the facility did not have a policy to monitor the temperature and humidity level.

Review of the facility's policies and procedures throughout the survey process showed the facility did not have a policy to monitor OR temperature and humidity.

3. Record review of the facility's policy titled, "Temperature Records," dated 03/25/11, showed the following direction:
- Refrigerator and freezer temperatures are checked and recorded each morning by the cook. They are again checked and recorded by the PM cook before leaving in the evening.
- Any equipment temperature that is found out of the required range must be reported to the Dietary Manager or Maintenance Supervisor immediately.

Record review of the facility's policy titled, "Refrigerator/Freezer Thermometers and Temperatures," dated 03/25/11, showed the following direction:
- Each thermometer is checked twice daily. The morning cook checks the thermometers when she first reports for duty and the evening cook checks again before clocking out in the evening.
- Every effort is made to maintain recommended temperatures in the refrigerator and freezers:
Refrigerated foods - 33 to 40 degrees.
Frozen foods - 0 (zero) to - (minus) 10 degrees.
- If the temperature is not cool enough, contact the Dietary Manager. If she is not available, contact the maintenance department. If they are unable to correct the problem, the service company for the refrigerator/freezer is called.

4. Observation on 01/30/12 at 2:46 PM showed a small refrigerator on the medical/surgical unit holding milk, juice and other snack items. The freezer compartment had approximately one to two inches of ice built up around the edges, which could make it difficult to maintain temperature parameters and showed lack of cleaning/maintenance. The refrigerator/freezer log of temperatures was posted above the refrigerator. Staff failed to check and record the temperatures the morning of 01/17/12, 01/20/12, 01/26/12, 01/27/12 and the evening of 01/10/12. The refrigerator temperature ranges were from 40 degrees to 42 degrees. The freezer temperature ranges were from - (negative) three degrees to - (negative) 12 degrees. The log did not show the target temperature ranges.

During an interview on 01/30/12 at 2:47 PM, Staff E, Licensed Practical Nurse (LPN), stated that the Dietary (food and nutrition) department was responsible for the refrigerator and she did not know what the temperature parameters were supposed to be.

During an interview on 02/01/12 at 8:37 AM, Staff L, Cook, stated that temperature range for the refrigerator was 40 degrees and below and the temperature range for the freezer was less than 10 degrees as far as she knew. When asked about the freezer being outside of the proposed temperature range, Staff L stated that it was not within the parameters because the door had probably been opened before the temperature was checked. Staff L agreed the freezer needed defrosted and stated that they just discussed that last night and will do when there is time.

Observation on 02/01/12 at 9:45 AM showed the refrigerator log that was seen on 01/30/12 now completely filled in with no dates missing temperatures. Staff L stated that she did not know who filled in the missing temperatures.

During an interview on 02/01/12 at 9:45 AM, Staff A, Chief Executive Officer, stated that the temperature log form appeared to be falsified. Staff A stated that she believed the ball had been dropped and that staff members needed to know the correct temperature parameters and the appropriate actions when the temperature fell outside of that range.




27724

Based on observations, interviews, and record reviews the facility;
-Failed to ensure the integrity of smoke and fire barriers provide a minimum one hour fire resistance rating in accordance with 8.3 and 18.3.7.3. (K025)
-Failed to record and show evidence they conducted fire drills during the past 12 months on a minimum quarterly basis in accordance with 18.7.1.2. (K050)
-Failed to establish and conduct an approved inspection, testing and maintenance program that meets the Chapter 10 requirements of the Code for inspection, testing and maintenance of fire alarm systems. (K052)
-Failed to test all smoke detectors at least annually in accordance with 10.4.3 of NFPA 72. (K054)
-Failed to maintain clearance from sprinklers in accordance with 8.5.6.1. (K062)
-Failed to conduct the last quarterly inspection of the automatic sprinkler system in accordance with 18.3.5. (K069)
-Failed to maintain the facility's sole Emergency Power Supply System and generator in accordance with NFPA 110, chapter 6-4.2.2, which requires an annual load bank test. (K0130)

This Life Safety Standard is deficient based on the combined severity of findings and in conjunction with the overall Condition of Participation for Physical Plant and Environment, due to the widespread and cumulative effect of these deficient practices throughout the facility, which present multiple hazards that directly affect the safety and well-being all patients, visitors and staff, and pose additional hazards to sick, injured or handicapped patients.

Based on record review and interview, the facility failed to ensure four of four physicians and three of three Family Nurse Practitioners on the medical staff are subject to a regular ongoing program of Peer Review. The facility census was five.

Findings included:

1. Record review of the facility's approved Medical Staff Bylaws, dated March 2009, paragraph 7.3, Investigation/Peer Review Process, showed: "Peer Review may be initiated in response to circumstances in a single case, or to investigate a pattern or trend in performance. Either the Medical Executive Committee of the Board may request an investigation. The Medical Executive Committee may conduct such an investigation, or the Medical Executive Committee may assign the task to a Medical Staff officer, ad hoc committee or other organizational component."

2. During an interview on 2/1/12 at 10:00 AM, Staff S, Administrative Assistant, stated that she gathers information and processes the credentialing files on physicians. She acknowledged that the current medical staff physicians are not conducting peer reviews on each other and have not coordinated with any medical practitioners outside of the facility or with those of a similar hospital in the region to form an unbiased Peer Review Committee.

During an interview on 02/02/12 at 10:15 AM, Staff A, Cheif Executive Officer, stated the physicians are currently not doing peer reviews of their fellow practitioners. She stated the physicians or practitioners who have privileges are not critically reviewed for performance until they are considered for renewal of privileges. She stated the Peer Review process at the hospital has been off and on during the past couple of years, and a regular program or working Peer Review Committee has not been established.

3. The Investigation/Peer Review Process, as described in 7.3 shows a prevalence toward investigation and peer review as a punitive process that governs and reviews physicians by exception rather than making it a regular process that provides a qualitative, ongoing program of mutual evaluation that holds each practitioner accountable to a fellow practitioner and member of the medical staff, who is qualified to evaluate the quality of services provided to patients by the evaluated practitioner and forward approval or recommendations for sanction to a Peer Review Committee or Medical Executive Staff of the Governing Body.

Based on observation and interview, the facility failed to ensure expired medications were not available for patient use in the Operating Room and Physical Therapy Department. The facility census was five.

Findings included:

1. Observation on 01/30/12 at 3:10 PM of the Operating Room (OR) showed:
-An open bottle of infant gas relief drops dated opened 11-18 (there was no year documented), expiration 08/2009 and;
-Four Normal Saline (NS) 10 milliliter (ml) flushes (used to flush an intravenous [IV] line) expiration 07/2011, lot 8214249.

Observation on 02/01/12 at 2:55 PM of the Physical Therapy Department showed:
- Sixteen vials of Prednisone with an expiration date of 08/11.

2. During an interview on 02/01/12 at 3:00 PM, Staff R, Physical Therapist, Director of Physical Therapy, stated that he and his staff were responsible for checking their department for expired medications. He stated the Prednisone was used for Iontophoresis (a medical technique in which an electric current is used to drive ions of chemicals through the skin and into the body tissues).





13695

Based on record review and interview, the facility failed to specify the scope and complexity of radiological services offered in a written document approved by the medical staff and governing body and the facility failed to ensure radiologic supplies with expiration dates beyond the manufacturers' expiration dates were removed and not available for patient use. The facility census was five.

Findings included:

1. Record review of Radiology services showed no written documentation, approved by the hospital's medical staff and governing body, that stated an overview or complete scope and complexity of radiological services offered to patients.

During an interview on 01/31/12 at 9:00 AM, Staff F, Radiology Manager, stated that she had updated and re-written all the outdated policies and procedures for the hospital during the last year. She stated that she did not have anything written or approved by the board to serve as a comprehensive mission statement that included the scope and complexity of services offered by her department, including those services offered by the two contracted tele-radiology groups (physicians group in a distant location who read and interpret images from client hospitals to over nights, weekends and holidays when no Radiologist physician is on site to read and interpret images).

2. Observation on 01/30/12 at approximately 3:30 PM in the Radiology department's Computed Tomography (CT, a type of diagnostic imaging test) room showed the following expired supplies:
- Optimark (contrast agent used in diagnostic tests), 20 milliliters (ml), four bottles, expired 09/11.

During an interview on 01/30/12 at approximately 3:30 PM, Staff F, Radiology Director, stated that the expired Optimark was separated on the shelf from the Optimark bottles that had not expired and staff would know not to use.

Observation on 01/31/12 at 10:13 AM in the Radiology department's Ultrasound (equipment that uses sound waves for diagnostic testing) room showed the following expired supplies:
- Easy III Solution (used in laboratory tests), 16 ounce (oz), two bottles, expired 01/10;
- Easy III Fixative (used in laboratory tests), 16 oz, expired 02/10.

During an interview on 01/31/12 at 10:13 AM, Staff F stated that she did not know why the Easy III Solution and Easy III Fixative bottles were in the Ultrasound room.

Based on record review, interview and policy review the facility failed to ensure physicians' verbal and/or telephone orders for medications were authenticated (signed, dated and timed) by the physician within 24 hours for three (#1, #2 & #3) of five current patients and eight (#7, #8, #9, #10, #11, 15, #16 & #19) of nine discharged patients. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Required Documentation"-Outpatient Clinic/Surgery Department" showed direction for staff for required documentation included:

-Preoperative: Evaluation will be documented on the pre-anesthesia assessment.-All documentation will include the date and time that it is written.
-Documentation will include a pre-anesthetic assessment and evaluation immediately prior to induction of anesthesia and will include; pre-operative orders.

Record review of the facility's policy titled "Verbal and Written Orders", reviewed 11/15/11, showed the following direction:
- Only verbal/telephone orders by the approved licensed independent practitioner (LIP) will be taken;
- The order will be written on the Physician Order Sheet by the person receiving the order and noting the date and time received, the name of the LIP issuing the order and the receiver's name and title;
- The prescriber shall co-sign the order within 24 hours.

Record review of the facility's policy titled, "Physician Services," dated 11/23/10 showed the following direction:
- All physician's verbal and telephone orders are to be immediately recorded in the medical record, and include the date, time, physician order, signature of licensed nurse, pharmacist or physician accepting the order, and the name of the physician giving the order.

2. Record review of discharged Patient #9's medical record showed the patient was admitted for upper GI endoscopy (a procedure to look at the interior lining of the esophagus, stomach, and the first part of the small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope) on 11/17/11.

Review of the Physician Orders dated 11/17/11 showed the physician signed the order sheet but failed to date and time the orders.

3. Record review of discharged Patient #11's medical record showed the patient was admitted on 07/28/11 for upper GI endoscopy on 07/28/11.

Review of the Physician Orders dated 07/28/11 showed the physician ordered Normal Saline (NS) intravenously (IV). The physician signed the order but failed to document the date and time.

4. Record review of discharged Patient #10's medical record showed the patient was admitted on 07/28/11 for upper GI endoscopy followed by dilation of esophagus on 07/28/11.

Review of the Physician Orders dated 07/28/11 showed the physician ordered Normal Saline IV.. The physician signed the order but failed to document the date and time.

5. Record review of discharged Patient #7's medical record showed the patient was admitted on 10/27/11 for colonoscopy (an internal examination of the colon to look at the interior lining of the large intestine (rectum and colon) with biopsy.

Review of the Physician Orders dated 10/27/11 showed the physician signed the orders but failed to document the date and time.

6. Record review of discharged Patient #8's medical record showed the patient was admitted on 12/15/11 for colonoscopy with biopsy.

Review of the Physician Orders dated 12/15/11 showed the physician ordered Lactated Ringers (LR) fluids. The physician signed the order but failed to document the date and time.

During an interview on 02/01/12 at 10:40 AM Staff H, Registered Nurse (RN) Outpatient Clinical Services Coordinator stated that physicians are to sign and date orders.

7. Review of discharged Patient #15's medical record showed a telephone order to continue a narcotic pain medication. The RN failed to date and time the telephone order. In addition, the medical record showed a telephone order taken on 08/04/11 for wound care that included medication for the patient's feet. The RN failed to document the time the order was taken.

During an interview on 01/31/12 at 2:38 PM, Staff I, RN, Director of Patient Services, stated that the nurse failed to document the date and time the telephone order was taken on Patient #15.

During an interview on 02/01/12 at 11:25 AM, Staff Q, HIM (Health Information Management - medical records) Director, stated that they did not have a policy on medical record entries needing dated, timed and signed.

8. Review of current Patient #2's medical record on 01/31/12 at 9:20 AM showed:
- Telephone order dated 01/25/12 at 8:45 AM for six medications. The physician signed the order, but failed to date and time the signature to show when it was signed.
- Telephone order dated 01/27/12 at 11:40 AM for medication. The physician signed the order, but failed to date and time the signature to show when it was signed.

9. Review of current Patient #3's medical record on 01/31/12 at 10:00 AM showed:
- Telephone order dated 01/28/12 at 9:00 PM for medication. The physician signed the order, but failed to date and time the signature to show when it was signed.

During an interview on 02/02/12 at 9:00 AM, Staff I, RN, Director of Patient Services, stated that physicians were to authenticate telephone orders and should include the date and time the order was signed.

10. Record review of discharged Patient #16's medical record on 01/31/12 showed the patient was admitted to the facility on 04/18/11 for an allergic reaction and cellulitis (infection). Review of a physician's admission order dated by the nurse on 04/18/11 with no time documented, showed the following medication orders:
- Aspirin (blood thinning medication) 81 mg (milligrams) PO (by mouth) daily;
- Plavix (blood thinning medication) 75 mg PO daily;
- Lipitor (cholesterol lowering medication) 40 mg PO daily;
- Nexium (medication to reduce stomach acid) 40 mg PO daily; and
- Metformin (medication to help control blood sugar level) 500 mg two every morning.
The physician signed the order but failed to document the date and time.

Review of a physician's telephone order dated by the nurse on 04/18/11 with no time documented, showed an order for Eucerin cream (skin softening) to feet during day; Vaseline to feet at night and cover with socks; and to change Nexium to Prilosec (medication to reduce stomach acid) 20 mg PO daily per hospital formulary. The physician signed the order but failed to document the date and time.

11. Record review of discharged Patient #19's medical record on 01/31/12 showed the patient was admitted to the Swingbed program for rehabilitation services on 12/27/11. Review of a physician's telephone order dated by the nurse on 12/28/11 at 4:40 PM showed an order for Lovenox (blood thinning medication) 40 mg subcutaneous (injected into the skin) daily. The physician signed the order but failed to document the date and time.

Review of a physician's telephone order dated by the nurse on 12/30/11 at 10:55 AM showed a clarification order for MVI (multi-vitamin) one PO daily Ca/VitD (Calcium/Vitamin D) 250 mg/125mg. The physician signed the order but failed to document the date and time.

12. Record review of current Patient #1's medical record on 01/31/12 showed the patient was admitted to the Swingbed program for rehabilitation services on 01/23/12. Review of a physician's telephone order dated by the nurse on 01/25/12 at 3:50 PM showed an order for Nystatin (antifungal medication) swish (in mouth) and swallow 5 milliliters (ml) PO QID (4 times a day). The physician signed the order but failed to document the date and time.

Review of a physician's telephone order dated by the nurse on 01/27/12 at 7:00 AM showed an order to hold one-a-day vitamin. The physician signed the order but failed to document the date and time.

During an interview on 02/02/12 at 9:30 AM, Staff I, Registered Nurse Director of Patient Services stated that the provider is required to sign verbal and/or telephone orders within twenty-four hours, otherwise the provider signs at the time they write the orders. Staff I stated that admission orders being signed and dated are monitored and tracked as part of their internal quality audits but they do not monitor orders past admission.


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27724

Based on interview, record and policy review the facility failed to develop and/or keep current plans of care to ensure patient care, treatment and/or services were appropriately planned to meet the patient's needs for one patient (#4) of six plans of acute care reviewed. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Care Planning" dated 11/15/11 showed direction for facility staff to:
-Provide an individualized, interdisciplinary plan of care for all patients within 24 hours;
-Shall be individualized based on the diagnosis and patient assessment;
-Shall address the learning needs of the patient and/or family;
-Shall be updated daily and;
-All staff using the plan of care are responsible for interdisciplinary collaboration to establish goals and appropriate interventions as well as ongoing evaluations and revisions.

2. Record review of Patient #4's medical record on 01/30/12 showed the patient was admitted on 01/29/12 with pneumonia and exacerbation (worsen) Chronic Obstructive Pulmonary Disease (COPD). The patient's past medical history included Diabetes.

Review of the physician admission orders on 01/29/12 showed:
-Diet-NPO (nothing by mouth) except medications;
-Accucheck (blood sugar test) twice daily and;
-Sliding Scale Insulin (medication given depending on blood sugar level).
Review of other physician orders dated 01/30/12 showed:
-2000 calorie ADA (American Dietetic Association-organization of food and nutrition professionals) diet (recommended for diabetics).

During an interview on 01/31/12 at 9:00 AM the patient stated that he ate what he wanted at home and did not take insulin at home.

During an interview on 02/01/12 at 2:15, Staff E, Licensed Practical Nurse (LPN) stated that staff would normally care plan diabetes but might not focus on diabetes if the patient's problem was unrelated such as respiratory distress. She stated that they probably should have implemented a plan of care for diabetes since the patient was on steroid medications (these medications could potentially affect blood sugar levels).

During an interview on 02/01/12 at 2:20 PM Staff B, Registered Nurse (RN) confirmed staff failed to implement a plan of care for diabetes for the patient.

Based on record review, interview and policy review the facility failed to ensure:
-Physician documentation is signed, dated and timed for six of six discharged patient (#9, #11, #10, #7, #8 and #6) records reviewed;
-Post anesthesia notes were timed for four of six discharged patients (#9, #7, #8 and #6) records reviewed;
-Physician orders included orders to start an IV (intravenous access into a vein) when ordering IV medications for four of six discharged patients (#10, #11, #8 and #6) records reviewed and;
-Medical records were completed promptly for two of six discharged patients (#8 and #6) records reviewed. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Required Documentation"-Outpatient Clinic/Surgery Department" showed direction for staff for required documentation included:
-Preoperative: Evaluation will be documented on the pre-anesthesia assessment.
-All documentation will include the date and time that it is written.
-Documentation will include a pre-anesthetic assessment and evaluation immediately prior to induction of anesthesia and will include; airway exam, pre-operative orders.
-Intraoperative documentation will include: record of any unusual occurrence during anesthesia and status of patient at conclusion of anesthesia.
-Postoperative documentation will include: unusual events or postoperative complications, status of patient on admission to post anesthesia care unit.
-Discharge: physicians written order for discharge and presence or absence of any anesthesia complications.

2. Record review of discharged Patient #9's medical record showed the patient was admitted for upper GI endoscopy(gastrointestinal endoscopy is a procedure that allows the physician to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope) on 11/17/11.

Review of the facility's form titled, "Consent for Operation or Other Medical Procedures" showed a section titled, "To Be Completed By Physician", showed the physician signed and dated the form but failed to document a time. The form had a line labeled, "Date and Time".

Review of the Physician Orders dated 11/17/11 showed the physician signed the order sheet but failed to date and time the orders.

Review of the Procedure Note dated 11/17/11 showed the physician signed the Procedure Note but failed to date and time the note.

Review of the Post Anesthesia Note showed the physician and the Certified Registered Nurse Anesthestist (CRNA) signed and dated the Post Anesthesia Note but failed to document the time.

3. Record review of discharged Patient #11's medical record showed the patient was admitted for upper GI endoscopy on 07/28/11.

Review of the facility's form titled, "Consent for Operation or Other Medical Procedures" showed a section titled, "To Be Completed By Physician" showed the physician signed and dated the form but failed to document a time. The form had a line labeled, "Date and Time".

Review of the Physician Orders dated 07/28/11 showed the physician ordered staff administer Normal Saline (NS) intravenously (IV). The physician signed the order but failed to document the date and time.

Review of the Procedure Note dated 07/28/11 showed the physician signed the Procedure Note but failed to date and time the note.

4. Record review of discharged Patient #10's medical record showed the patient was admitted for upper GI endoscopy followed by dilation of esophagus (stretching of the tube that carries food, liquids and saliva from the mouth to the stomach) on 07/28/11.

Review of the facility's form titled, "Consent for Operation or Other Medical Procedures" showed a section titled, "To Be Completed By Physician" showed the physician signed and dated the form but failed to document a time. The form had a line labeled, "Date and Time".

Review of the Physician Orders dated 07/28/11 showed the physician ordered staff administer Normal Saline (NS) IV but failed to document an order to start an IV. The physician signed the order but failed to document the date and time.

Review of the Procedure Note dated 07/28/11 showed the physician signed the Procedure Note but failed to date and time the note.

5. Record review of discharged Patient #7's medical record showed the patient was admitted on 10/27/11 for colonoscopy with biopsy.

Review of the Physician Orders dated 10/27/11 showed the physician signed the order but failed to document the date and time.

Review of the Procedure Note dated 10/27/11 showed the physician signed the Procedure Note but failed to date and time the note.

6. Record review of discharged Patient #8's medical record showed the patient was admitted on 12/15/11 for colonoscopy with biopsy.

Review of the facility's form titled, "Consent for Operation or Other Medical Procedures" showed a section titled, "To Be Completed By Physician" showed the physician signed and dated the form but failed to document a time. The form had a line labeled, "Date and Time".

Review of the Physician Orders dated 12/15/11 showed the physician ordered Lactated Ringers (LR-type of IV fluid) but did not order an IV. The physician signed the order but failed to document the date and time.

Review of the Procedure Note dictated 12/15/11 showed the physician did not sign, date and time the note.

Review of the Anesthesia Record showed staff documented they administered IV fluids. The Physician and CRNA signed and dated the record but failed to document the time.

7. Record review of discharged Patient #6's medical record showed the patient was admitted on 12/15/11 for upper GI endoscopy with biopsy on 12/15/11.

Review of the facility's form titled, "Consent for Operation or Other Medical Procedures" showed a section titled, "To Be Completed By Physician" showed the form had lines labeled, "Physician Signature" and "Date and Time". The physician failed to sign, date and time the consent.

Review of the Physician Orders dated 12/15/11 showed the physician did not order an IV to be started but ordered IV fluids be administered. The physician signed the order but failed to document the date and time.

Review of the Procedure Note dictated 12/15/11 showed the physician did not sign or date the note.

Review of the Anesthesia Record showed:
- The CRNA and the physician signed and dated the Post Anesthesia Note but failed to document the time.

8. During an interview on 02/01/12 at 10:40 AM Staff H, Registered Nurse (RN) Outpatient Clinical Services Coordinator stated that:
- Physicians are to sign and date their entries;
-Technically the physician did not have to sign the consent and because the physician signature was not required he did not have to date or time the consent and;
-The physician does not sign the procedure notes until the next GI clinic (usually one month later).

Based on interview, record review, and policy review, the facility failed to follow facility policy to ensure physician's treatment orders were signed, dated and timed by the physician within 24 hours for one current patient (#2) and four discharged patients (#11,#19, #20 & #15) of six medical records reviewed for order authentication. The facility census was five.

Findings included:

1. Record review of the facility's policy titled "Verbal and Written Orders", reviewed 11/15/11, showed the following direction:
- Only verbal/telephone orders by the approved licensed independent practitioner (LIP) will be taken;
- The order will be written on the Physician Order Sheet by the person receiving the order and noting the date and time received, the name of the LIP issuing the order and the receiver's name and title;
- The prescriber shall co-sign the order within 24 hours.

Record review of the facility's policy titled, "Physician Services," reviewed 11/23/10, showed the following direction:
- The prescribing or covering practitioner shall authenticate the verbal order within twenty-four (48) [sic, as written in the policy] hours of the order being written.

Record review of the facility's Medical Staff Rules and Regulations Part II Orders (no date) showed that all diagnostic and therapeutic verbal orders must be signed and dated by a practitioner within seventy-two (72) hours.

2. Record review of discharged Patient #11's medical record showed the patient was admitted on 07/28/11 for upper GI endoscopy (upper gastrointestinal (UGI) endoscopy is a procedure to look at the interior lining of the esophagus, stomach and the first part of the small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope) on 07/28/11.

Review of the Outpatient Order Form dated 07/28/11 showed the physician ordered blood work. The physician signed and dated the order but failed to document the time.

Review of an undated Outpatient Order Form showed the physician ordered an ultrasound of the patient's abdomen. The physician signed the order but failed to document a date and time.

During an interview on 02/01/12 at 10:40 AM Staff H, Registered Nurse (RN) Outpatient Clinical Services Coordinator stated tha physicians are to sign and date orders.

3. Review of current Patient #2's medical record on 01/31/12 at 9:20 AM showed:
- Telephone order dated 01/26/12 at 4:20 PM for a PET scan (a radiological test used to evaluate and stage lung cancer and other diseases). The physician signed the order, but failed to date and time his signature to show when it was signed.

4. Review of discharged Patient #20's medical record on 02/02/12 at 9:15 AM showed:
- Telephone order dated 01/25/12 at 8:35 AM for medications, occupational and physical therapy consults, and to discharge patient to a nursing home. The physician signed the order, but failed to date and time his signature to show when it was signed.

During an interview on 02/02/12 at 9:00 AM, Staff I, RN, Director of Patient Services, stated that physicians were to authenticate telephone orders and should include the date and time the order was signed.

5. Review of discharged Patient #15's medical record on 01/31/12 showed a telephone order written on 08/04/11 for dressing changes to the patient's feet. The physician signed the order but failed to date and time the signature.

During an interview on 01/31/12 at 2:38 PM, Staff I, stated that the physician failed to document the date and time of their signature on Patient #15.

6. During an interview on 02/01/12 at 11:25 AM, Staff Q, HIM (Health Information Management - medical records) Director, stated that they did not have a policy on medical record entries needing dated, timed, and signed.

7. Record review of discharged Patient #19's medical record on 01/31/12 showed the patient was admitted to the Swingbed program for rehabilitation services on 12/27/11.

Review of an untimed physician's order dated by the occupational therapist on 12/28/11, showed an order for therapy five times a week times 14 days for training to increase tolerance for ADLs (activities for daily living [bathing, dressing, etc]). The physician signed the order but failed to document the date and time.

Review of an untimed physician's order dated by the physical therapist nurse on 12/28/11 showed an order for therapy seven times a week twice a day during hospital stay for physical strengthening (to prevent falling, decrease weakness, increase endurance, etc). The physician signed the order but failed to document the date and time.

Review of a telephone order dated by the nurse on 01/10/12 at 1:50 PM showed a physician's order for Home Health for PT/OT (physical therapy and occupational therapy). The physician signed the order but failed to document the date and time.

During an interview on 02/02/12 at 9:30 AM, Staff I, Registered Nurse Director of Patient Services stated that the provider is required to sign verbal and/or telephone orders within twenty-four hours, otherwise the provider signs at the time they write the orders. Staff I stated that admission orders being signed and dated are monitored and tracked as part of their internal quality audits but they do not monitor orders past admission.



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Based on interview and policy review, the Health Information Management (HIM) department failed to protect unauthorized access of all patients' medical records. The records included all patients seen at the facility since it opened in 2005. This could affect all patients who had been seen at the facility. The facility census was five.

Findings included:

1. Record review of the facility's policy titled, "Medical Record Security," dated 09/09/11, showed the following direction:
- A key to the Health Information Management Department will be provided to each Health Information Management employee.
- The Health Information Management Department will be kept locked at all times that a Health Information Management Department employee is not present.
(The policy did not list other employees who would have access to the department).

2. During an interview on 01/30/12 at 10:25 AM, Staff Q, HIM Director, stated that the Registered Nurses (RN), Licensed Practical Nurses (LPN), Administrator, Director of Patient Services, Pharmacist, and Maintenance Director have access to the HIM department. During a later interview at 3:10 PM, Staff Q stated that the Physical Therapist, all laboratory staff, the Radiology Director, and Information Technologist had access to the HIM department. Staff Q initially stated they did not have a policy on access to the HIM department but later located the above referenced policy. Staff Q stated that the policy did not include employees having access to the HIM department other than those who work in that department.

During an interview on 01/30/12 at 2:25 PM, Staff E, LPN, stated that she worked on the medical/surgical unit and had access to the HIM department. Staff E stated that if a record was needed when the HIM staff members were not there, she would go to Medical Records and retrieve a patient's medical record.

During an interview on 01/30/12 at 2:33 PM, Staff K, RN, stated that he worked in the Emergency Department and had access to the HIM department. Staff K stated that if a record was needed when the HIM staff members were not there, he would go to Medical Records and retrieve a patient's medical record.

An unannounced on-site survey was conducted on 01/30/12-02/02/12. As a result the hospital was found to be out of compliance with 42 CFR Part 485.639, Condition of Participation: Surgical Services.

Based on observation, interview, and policy review, the facility failed to:
-Have policies and procedures governing surgical care based on nationally based guidelines, including, aseptic surveillance and practice, identification of infected and non-infected cases, housekeeping requirements, fire safety, and acceptable operating room attire;
-Have documented bio-medical checks for the scope reprocessor (equipment for washing scopes) and the sterilizer;
-Implement policies and procedures governing surgical care based on nationally based guidelines, including, aseptic surveillance and practice, identification of infected and non-infected cases, housekeeping requirements, fire safety, and acceptable operating room attire; and
-Document bio-medical checks for the scope reprocessor (equipment for washing scopes) and the sterilizer.


The cumulative effect of these systemic practices has the potential to affect all surgical patients. The facility census was five.

Findings included:

1. Review of the Centers for Medicare & Medicaid Services (CMS) showed CMS's definition of surgery is:
Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system, is also considered to be surgery. (This does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous, when ordered by a physician.) All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical procedure are not eliminated by using a light knife or laser in place of a metal knife, or scalpel.

2. Record review of the facilities, "Same Day Surgery Register", from 10/27/11 through 12/15/11 showed 13 of 17 patients had polyps (growth inside the colon) removed. (The polyp is snared with a hot wire and removed whole through an endooscope) or had biopsies (removal and examination of a sample of tissue) performed.

Record review of discharged Patient #9's medical record showed the patient was admitted for upper GI endoscopy (upper gastrointestinal [UGI] endoscopy is a procedure to look at the interior lining of the esophagus, stomach and the first part of the small intestine [duodenum] through a thin, flexible viewing instrument called an endoscope) with biopsy on 11/17/11.

Record review of discharged Patient #11's medical record showed the patient was admitted on 07/28/11 for upper GI endoscopy with biopsy on 07/28/11.

Record review of discharged Patient #7's medical record showed the patient was admitted on 10/27/11 for colonoscopy (an internal examination of the colon to look at the interior lining of the large intestine (rectum and colon) with biopsy (the removal of a small piece of tissue for laboratory examination).

Record review of discharged Patient #8's medical record showed the patient was admitted on 12/15/11 for colonoscopy with biopsy.

Record review of discharged Patient #6's medical record showed the patient was admitted on 12/15/11 for upper GI endoscopy with biopsy on 12/15/11.

3. During an interview on 01/30/12 at 1:00 PM, upon during the entrance conference, Staff A, Chief Executive Officer (CEO) stated that the facility did not offer surgical services.

4. Review of the facility internet web site on 01/31/12 at 8:30 PM showed in, "A Note from the CEO", the facility advertised itself as a full service hospital and provided care in the Endoscopy and Surgery Clinic in addition to other areas.

During an interview on 02/01/12 at 4:20 PM Staff A, CEO stated that she did not write the "Note from the CEO" on the facility website and was not aware that it showed the facility offered a "surgical clinic". Staff A viewed the web site and agreed the web site showed the facility offered a surgical clinic and stated that the web site information was wrong. Staff A stated that she did not feel the procedures performed in the facility were surgical services.

5. Review of the AORN (Association of Peri-Operative Nurses) Perioperative Standards and Recommended Practices, dated 2009, Guidance Statement: Fire Prevention in the Operating Room, showed:
-Ignition sources are anything that produces heat, the two most common sources are the electrosurgical unit (ESU, small probe with an electric current running through it used to burn or destroy tissue) and laser, other sources include fiber optic light cables, hand held cautery devices and defibrillators.
-Fuel sources include oxygen, linens, drapes, gowns, the patient's body hair and body gases;
-Primary oxidizers in the surgical environment are oxygen and nitrous oxide. Fires can occur when the oxygen level in the atmosphere rises above the ambient air. Oxygen can escape into the air when patients are given mask or nasal oxygen.

Review of the Food and Drug Administration (FDA) Safety Communication: Preventing Surgical Fires, dated 10/13/2011 showed:
The FDA is advising health care professionals and health care facility executives and staff on factors that increase the risk of surgical fires, particularly the delivery of supplemental oxygen to patients. The FDA is recommending practices to help prevent these fires including the safe use of medical products used during surgical procedures. The FDA is launching a surgical fire prevention initiative to promote safer practices and to share fire prevention resources. Surgical fires can occur at any time all three elements of the fire triangle are present:
-Ignition source (e.g., ESUs, lasers, and fiber optic light sources)
-Fuel source (e.g., surgical drapes, alcohol-based skin preparation agents, the patient)
-Oxidizer (e.g., oxygen, nitrous oxide, room air).
Most surgical fires occur in oxygen-enriched environments, when the concentration of oxygen is greater than in ordinary room air. When supplemental oxygen is delivered to the patient, an oxygen-enriched environment can be created. An open oxygen delivery system, such as nasal cannula (plastic tube with two prongs inserted in the patients nose, used to deliver oxygen) or mask, presents a greater risk of fire than a closed delivery system, such as a laryngeal mask. In an oxygen-enriched environment, materials that may not normally burn in room air can ignite and burn.
Recommendations to reduce the risk of surgical fires:
? Conduct a fire risk assessment at the beginning of each procedure.
? Use supplemental oxygen safely.
-Evaluate if supplemental oxygen is needed for each patient. Any increase in oxygen concentration in the surgical field increases the chance of fire.
-If supplemental oxygen is necessary:
-Deliver the minimum concentration of oxygen needed to maintain adequate oxygen saturation for your patient.
-Use a closed oxygen delivery system such as an endotracheal tube or laryngeal mask whenever possible, especially if high concentrations of supplemental oxygen (greater than 30 percent) are being delivered.
-Take additional precautions to exclude oxygen from the field if using an open delivery system. These precautions include draping techniques that avoid accumulation of oxygen in the surgical field, the use of incise or fenestrated drapes which may help isolate oxygen from the surgical site, blowing air to wash out excess oxygen, or alternatively, scavenging oxygen from the field.
-Use devices and other surgical equipment safely.
-Encourage communication among members of your surgical team.
-Plan how to manage a surgical fire. For example, understand how to extinguish a fire burning on a patient, develop evacuation procedures, conduct fire drills, and keep saline handy to put out a fire.

Review of the American College of Surgeons Committee on Perioperative Care, dated 1997 showed:
-In the United States, there are approximately 2,260 reported hospital fires per year, resulting in about one death and 130 injuries. Of these, between 20 and 30 occur in the operating room. The incidence of fires in the operating room has substantially decreased over the past 40 years, as awareness of these situations predisposing to fires starting has increased:
-Fire causes
-For any fire to occur, three factors must be present. These are an oxygen source, a fuel source, and an ignition mechanism. In the operating room these are all abundantly available.
-The use of additional oxygen in the operating room makes it an oxygen-rich environment, priming the arena to fires of greater intensity than those without oxygen supplementation. The additional sources of oxygen can include that from nasal cannula and oxygen cylinders. To diminish the possibilities of a fire in the operating room, extreme care must be used to contain any oxygen source and keep it from an ignition source.
-The use of the lowest possible inspired oxygen concentration that still ensures adequate oxygen saturation is an effective means of controlling excess oxygen accumulation.
-There are a variety of possible sources that can serve as fuel for fires in the operating room, some relatively obvious and others more obscure. More obvious sources include paper and cloth drapes, endotracheal (tube inserted in the throat) tubes, and other breathing apparatuses such as nasal cannulae and plastic masks. Cloth and paper drapes are by far the most implicated fuel for fires and have been shown to be ignitable by such common operating room utensils as electrocautery (ECU).
-Disposable drapes burn more readily. Although often treated with flame retardant materials, once ignited the flames spread with alarming speed.
-Endotracheal tubes can also serve as a source of fuel to a potentially devastating fire.
-Hydrogen and methane are extremely flammable gases produced by bacteria in the gastrointestinal tract in quantities of up to 200 ml per day. Forty percent of these gases are contained in the large bowel. Human flatus (gas generated in or expelled from the digestive tract) contains approximately 44 percent hydrogen and 30 percent methane. If in an environment of at least 5 percent oxygen, hydrogen can explode at concentrations of between 4 percent and 72 percent, while methane can explode at concentrations of between 5 percent and 15 percent. In the colon the concentration of oxygen is approximately 5 percent, but this level is increased when oxygen or nitrous oxide is administered during anesthesia.
-Many ignition mechanism are in the operating room including, electrocautery (monopolar, bipolar, and battery-operated ( an apparatus for surgical dissection and hemostasis (to control bleeding), using heat generated by a high-voltage, high-frequency alternating current passed through an electrode) units are renowned culprits. The temperature at the tip of the cautery unit can reach several hundred degrees, easily enough heat to start a fire. Other sources include lasers, overhead and fiberoptic light sources. The temperature at the distal end of a fiberoptic light source can reach levels well above the ignition temperature of most surgical drapes.
-With adequate knowledge of the factors precipitating operating room fires and sound plans regarding evacuation, injuries from these situations can be avoided. Fire safety translates into decreased morbidity and mortality for patients and staff.

6. Review of the GI Clinic Policy and Procedure Manual showed the facility had a Fire Safety policy for the Nursing department included in the manual but the policy did not address ways to minimize surgical fires.

7. During an interview on 01/31/12 at 11:00 AM Staff H Registered Nurse (RN) Outpatient Clinical Services Coordinator stated that:
-Patient's used oxygen during procedures ;
-There was no policy to minimize surgical fires and;
-The facility used grounding pads for cautery type of forceps (surgical procedure involving bipolar cautery uses electrical current through a medical device, which generally cuts through human tissue and/or seals bleeding vessels. The cauterization device is usually comprised of a forceps type instrument, and high frequency electrical current runs from one tip to the other. The power source of the bipolar cautery device generally has multiple frequency settings, allowing surgeons to cut, cauterize or perform a combination of functions with the same instrument).

During an interview on 02/01/12 at 2:15 PM Staff O, Plant Operations stated that the facility did not have a policy to minimize surgical fires in the OR.

8. Review of AORN Recommended Practices, Surgical Attire, Recommendation #1, dated May 2009 showed the following direction:
-IF scrubs are worn into the institution from the outside, they should be changed before entering semi-restricted or restricted areas to minimize the potential for contamination.
-Home laundering of surgical attire is not recommended however, if home laundering is required, suggested minimum criteria for home laundering soiled surgical attire should include:
*Using an automatic washer and hot air dryer;
*Using water temperature of 100 to 125 degrees;
*Using chlorine bleach
*Using detergent according to manufacturer's instructions;
*Laundering surgical attire as the last load after all other items have been laundered;
*Keeping laundry items completely submerged during the entire wash and rinse cycle;
*Avoiding placing hands or arms in the laundry or rinse water;
*Thoroughly cleaning the door and lid of the washing machine before removing laundry to prevent contamination on clean attire;
Using the highest drying setting;
*Promptly removing attire when dry and;
*Laundered surgical attire should be protected from contamination during transfer and storage. Freshly laundered surgical attire should be fully protected during transport to the practice setting.

9. During an interview on 01/31/12 at 11:00 AM Staff H Registered Nurse (RN) Outpatient Clinical Services Coordinator stated that the facility did not have a policy for OR attire and the facility allowed staff to wear home laundered scrubs.

10. Record review of the facility GI Clinic Policy and Procedure Manual dated 06/22/11 showed the facility policies by the corresponding department included:
-Surgical Services-Discharge Following Endoscopy Procedures;
-Surgical Services-Administration of Conscious Sedation-Purpose: To provide for the safe administration of Intravenous (IV) Conscious Sedation and monitoring during endoscopy and other surgical procedures.
- Outpatient Clinic/Surgery- IV Protocol for Anesthesia
- Outpatient Clinic/Surgery-Moderate Sedation: Purpose: To describe the care of the patient who receives moderate sedation for the purpose of completing a short-term diagnostic, therapeutic or surgical procedure.
- Outpatient Clinic/Surgery-Time Out Policy: Purpose: To promote correct patient, correct procedure, and correct surgical and invasive procedures through pre-operative invasive procedural verification, surgical marking (when required) and formal "Time Out" process prior to surgery or invasive procedure.
-Additional policies were labeled: Nursing Department.
The facility did not have policies for aseptic surveillance and practice, identification of infected and non-infected cases and housekeeping requirements in the OR.

During an interview on 01/31/12 at 11:00 AM Staff H Registered Nurse (RN) Outpatient Clinical Services Coordinator stated that the facility did not have policies for aseptic surveillance and practice, identification of infected and non-infected cases and housekeeping requirements in the OR.

11. Review of the facility Preventative Maintenance (PM) Log (including for the Surgery Department and Operating Room) dated 01/09/2012, showed the last documented PM check on the sterilizer (equipment used to kill bacteria) was September 2005 and the last documented PM check on the scope washer (equipment used to clean endoscopes) was undated and staff had written, "not applicable".

During an interview on 02/01/12 at 1:10 PM with Staff A, Chief Executive Officer (CEO) and Staff O Plant Operations, Staff O stated that he did not know who performed preventative maintenance checks on the sterilizer.

During an interview on 02/01/12 at 11:50 AM, Staff O, Plant Operations Director, stated did not have a policy, procedure, written checklists or schedules for preventive maintenance.

During an interview on 02/01/12 at 1:45 PM Staff Q, Director of Health Information stated that the bio-med checks did not include any preventative maintenance on the sterilizer or the scope washer.

Based on interview, record review and policy review, the facility failed to train staff members to be designated requestors (individuals with specific training) on asking a patient or family member for organ/tissue/eye donation for two patients (#13 and #15) of four deceased medical records reviewed. This could potentially affect all patients who die at this facility, their family members, and individuals waiting for organ/tissue/eye donation. The facility census was five.

Findings included:

1. Record review of the facility's policy titled, "Organ, Tissue and Eye Donation," dated 04/19/11 showed the following direction:
- The I-70 Medical Center will make available to the families of deceased patients the option of donating organs, tissues and eyes and facilitate the recovery of organs, tissues and eyes for transplantation, education, or research.
- Referral of Potential organ donors:
Physician and/or hospital staff introduces Midwest Transplant Network staff and participates in collaborative discussion of donation with family.
Midwest Transplant Network (the Organ Procurement Organization) coordinator requests donation.
- Referral of potential eye and tissue donors:
Midwest Transplant Network coordinator or the designated hospital requestor discusses the option of donation with the family at the appropriate time. (If no designated requestors are available, a Midwest Transplant Network coordinator will facilitate consent by phone).
Designated requestors are trained and certified by the Midwest Transplant Network and other agencies as appropriate. Designated requestors must be recertified every year.
The Midwest Transplant Network will provide requestor training.

Record review of the facility's agreement with Midwest Transplant Network , effective 05/04/09, showed the following direction:
- No Physician or member of Hospital staff, including Hospital nursing staff, shall ask a patient or a patient's family to authorize donation, unless they have been trained as a "designated" requestor by Midwest Transplant Network
- The authorization for organ donation is a discussion with the next of kin conducted by Midwest Transplant Network staff.
- Midwest Transplant Network shall provide qualified medical and other personnel with specialized training in transplantation, donor evaluation and management, donation request, medical/social history interview techniques, and organ recovery and preservation to perform organ procurement activities at the Hospital. The Hospital shall cooperate with Midwest Transplant Network by permitting the personnel provided by Midwest Transplant Network to use its facilities and by providing necessary support personnel for them.

2. Record review of deceased Patient #13's medical record showed the 17-year old patient was pronounced dead at the facility on 04/29/11. The form titled, "Referral Notification and Donation Evaluation," showed the boxes checked for "Patient is a candidate for tissue donation" and "Patient is a candidate for eye donation." The form showed "I (Staff I) have discussed the opportunity for tissue/eye donation with (legal next-of-kin)."

During an interview on 01/31/12 at 2:38 PM, Staff I, Registered Nurse (RN), Director of Patient Services, stated that she did not speak to Patient #13's family about donation opportunities. Staff I stated that Staff K (RN Emergency Department) wrote her name on that form. During a later interview on 02/01/12 at 12:45 PM, Staff I stated that she was not present when Patient #13's family was approached about donation opportunities and that she left after the patient died.

3. Record review of deceased Patient #15's medical record showed the 57-year old patient died at the hospital on 08/07/11. The form titled, "Referral Notification and Donation Evaluation," showed, "I (Staff W, RN) have discussed the opportunity for tissue/eye donation with (legal next-of-kin)."

During an interview on 01/31/12 at 2:35 PM, Staff I stated that Staff W resigned from the hospital in 09/11. Staff I stated that it was possible that the next-of-kin approached the nurse about organ donation since Patient #15 was an inpatient and suffered from a terminal illness.

4. During an interview on 02/01/12 at 8:25 AM, Staff K, RN, Emergency Department, stated that the nurses in the Emergency Department or the Director of Patient Services approached family members about possible organ/tissue/eye donation after a death in the Emergency Department. Staff K stated that the facility or Midwest Transplant Network had not trained him in how to approach a potential donor or donor's family.

5. During an interview on 02/01/12 at 10:02 AM, Staff I stated that the facility's staff members had not been trained on approaching a patient and/or family member about possible organ/tissue/eye donation because Midwest Transplant Network wanted to be the primary requestor (first person to approach a family regarding possible donation). Staff I stated that the facility staff members did not approach the patient and/or family about possible donations. During a later interview on 02/02/12, Staff I stated that she had contacted Midwest Transplant Network regarding training and they responded they would not provide the training due to the facility having a low volume.

Based on interview, record review, and policy review, the facility failed to notify the patient of discharge and the reason for discharge in writing prior to discharge from the Swing-bed program (A Swing-bed is a change in reimbursement status. The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing services and reimbursement) for two current patients (#2, #3) and three discharged Swing-bed patients (#18, #20, #25) of five Swing-bed records reviewed for discharge notice. The Swing-bed census was two. The facility census was five.

Findings included:

1. Record review on 01/30/12 at 3:00 PM of Patient #3's medical record showed a physician order dated 01/30/12 for the patient to be discharged from the facility Swing-bed program on 01/30/12. The medical record did not contain written notification or the reason for discharge to the patient.

During an interview on 01/30/12 at 2:20 PM, Patient #3 stated that the facility did not provide her with written notification of discharge. Patient #3 said she was informed verbally by her nurse at approximately 2:00 PM that he/she would be discharge that afternoon.

2, Record review on 01/31/12 at 9:20 AM of Patient #2's medical record showed a physician order dated 01/30/12 for the patient to be discharged from the Swing-bed program on 01/31/12. The medical record did not contain written notification or the reason for discharge to the patient.

During an interview on 01/31/12 at 2:20 PM, Patient #2 stated she was informed verbally by the nurse that she may be discharged 02/01/12, but had not received anything in writing.

3. Record review on 02/01/12 of Patient #18's medical record showed a physician order dated 02/04/11 for the patient to be discharged from the Swing-bed program on 02/05/11. The medical record did not contain written notification or the reason for discharge to the patient.

Record review on 02/01/12 of Patient #20's medical record showed a physician order dated 01/25/12 for the patient to be discharged from the Swing-bed program. The medical record did not contain written notification or the reason for discharge to the patient.

Record review on 02/02/12 of Patient #25's medical record showed a physician order dated 01/18/12 for the patient to be discharged from the Swing-bed program. The medical record did not contain written notification or the reason for discharge to the patient.

4. During an interview on 02/01/12 at 3:30 PM, Staff A, Chief Executive Officer and Staff I, Registered Nurse (RN), Director of Patient Services, both stated that they were unaware that the regulation required the patient to be notified in writing of discharge from the Swing-bed program and the facility did not have a policy in regard to written notice of discharge. Staff A and Staff I stated that facility staff were not notifying patients in writing of discharge from the Swing-bed program.

Based on interview, record review, and policy review the facility failed to develop and/or keep current plans of care to ensure patient care, treatment and/or services were appropriately planned to meet the patient's needs for one current Swing-bed patient (#1) and two discharged Swing-bed patients (#18 & #19) of five Swing-bed patients' plans of care reviewed. (A Swing-bed is a change in reimbursement status. The patient swings from receiving acute-care services and reimbursement to receiving skilled nursing services and reimbursement). The Swing-bed census was two. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Care Planning" dated 11/15/11 showed direction for facility staff to:
-Provide an individualized, interdisciplinary plan of care for all patients within 24 hours;
-Shall be individualized based on the diagnosis and patient assessment;
-Shall address the learning needs of the patient and/or family;
-Shall be updated daily and;
-All staff using the plan of care are responsible for interdisciplinary collaboration to establish goals and appropriate interventions as well as ongoing evaluations and revisions.

2. Record review of Patient #19's medical record on 01/31/12 showed the patient was admitted to the Swing-bed program on 12/27/11 for physical therapy, following a right hip fracture and repair. The patient's history & physical (H & P) showed she continued taking Oxycodone (pain medication), had recent crying spells and was started on Celexa (medication to treat depression), had an indwelling urinary catheter, started bladder training and removed the catheter as tolerated, wore SCDs (Sequential Compression Device [to increase circulation and prevent blood clots]) while in bed and took Lovenox (a blood thinning medication to prevent blood clots). Review of the patient's nursing care plans did not address these individual needs and therefore, did not reflect the patient's care plan for her pain, recent onset of depression, urinary catheter and bladder training, risk of bleeding due to taking blood thinning medication and/or the need to wear SCDs to help prevent blood clots.

3. Record review of Patient #1's medical record on 01/31/12 showed the patient was admitted to the Swing-bed program on 01/24/12 for physical and occupational therapy strengthening. The patient's H & P showed she had a rash underneath her left breast and started treatment with Nystatin (antifungal) powder; took Coumadin (blood thinning medication to help prevent blood clots), wore SCDs while in bed or in chair and continued Levaquin (medication to decrease bacteria) due to urinary tract infection. Review of the patient's nursing care plans did not address these individual needs and therefore, did not reflect the patient's care plan for her skin rash, risk of bleeding due to taking blood thinning medication, the need to wear SCDs to help prevent blood clots and/or the her urinary tract infection.

During an interview on 02/01/12 at 2:20 PM, Staff I, Registered Nurse/Director of Patient Services stated that nursing staff should implement and update the patient's care plans per nursing assessment. Staff I confirmed the care plans for the above patient's did not address the individual needs or updates as shown.

4. Record review of Patient #18's medical record on 02/01/12 showed the patient was admitted to the Swing-bed program on 01/20/11 with admitting diagnosis of weakness, alcohol abuse and cellulitis. The patient's past medical history included diabetes.

The patient's admission orders dated 01/20/11 included a 2,000 Calorie diet (American Dietetic Association-organization of food and nutrition professionals diet recommended for diabetics), and orders for sliding scale insulin (medication given depending on blood sugar level) to include accuchecks (blood glucose monitoring)before meals and at bedtime.
The patient's glucose level recordings from 01/20/11 - 02/05/11 showed glucose levels ranging from 55 to 282, (normal glucose levels are 60 - 120) which required nursing interventions and/or insulin injections as
ordered.
Facility staff failed to implement these problems into the patient's plan of care.

During an interview on 02/01/12 at 3:00 PM Staff I, Registered Nurse (RN), Director of Patient Care Services confirmed staff failed to implement a plan of care for diabetes, alcohol abuse and cellulitis.





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