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On the days of the Hospital Validation Survey based on observation, interviews, and record reviews, the hospital failed to ensure that the contracted services (dietary), hemodialysis services, and nursing services operated in a responsible manner to ensure the safety of those patients.


The findings include:


Cross Reference to A 0063: The governing body, in accordance with, hospital policy failed to ensure that specific patient care requirements of the Dietary Service and Nursing Service were met.

Cross Reference to A 0049: The governing body failed to ensure the separateness of the Medical Staff credentialed at both the Hospital and the Host Hospital when patients admitted to the Hospital received services from the Host Hospital in the Host Hospital or at bedside by staff from the Host Hospital.

Cross Reference to A 0083: The governing body failed to ensure services furnished in the hospital whether or not those services are furnished under contracts complied with all conditions of participation. (Dietary Services and Dialysis Machine Maintenance)

Cross Reference to A 0431: The hospital failed to ensure the security and privacy of patient records when patients had procedures conducted in the Host Hospital or at bedside by staff of Host Hospital and failed to ensure physicians authenticated, timed, and dated all materials in the patient's records.

On the days of the Hospital Validation Survey based on observation, record review, and interview, the facility failed to ensure that patients received care and services in accordance with the hospital's policies and procedures and standards of practice.


The findings are:


Cross Reference to A 0386: Nursing Administration failed to delineate responsibilities for patient care for patients who undergo procedures in the Host Hospital or conducted on the hospital nursing unit by personnel from the Host Hospital while an inpatient in the hospital for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services that had procedures.

Cross Reference to A 0392: Nursing Staff failed to provide nursing care to all patients as needed for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) reviewed for care and services.

Cross Reference to A 0395: The hospital failed to ensure the supervision and oversight of nursing care when patients underwent procedures in the Host Hospital or conducted on the hospital nursing unit by personnel from the Host Hospital while an inpatient in the hospital for 3 of 21 open charts
(Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services that had procedures.

Cross Reference to A 0397: The hospital failed to ensure annual competency of its dialysis nursing staff for 2 of 2 registered nurse who work in the dialysis unit. (Registered Nurse #1 and #2)

On the days of the Hospital Validation Survey based on observations, record reviews, and interviews, the hospital failed to ensure the security and privacy of patient records when their patients had procedures conducted in the Host Hospital or at bedside by Host Hospital personnel, and failed to ensure physicians authenticated, timed, and dated all materials in the patient's records.

The findings are:


Cross Reference to A 0441: The hospital failed to ensure secure access to the medical records of patients who had procedures for 2 of 21 open patient records reviewed when the patient had a procedure (Patient 4 and 15) and 2 of 9 closed records reviewed for a patient who had a procedure. (Patient #3 and 13)

Cross Reference to A 0442: The Hospital failed to secure the medical records of patients who had procedures in the Host Hospital in that observations showed the Chief Nursing Officer(CNO) and the Charge Nurse on duty were observed as they accessed the reports identified with the Host Hospital's name from the computer system with a potential to affect all patients who receive services from the Host Hospital.

Cross Reference to A 0450: The hospital failed to ensure that all documentation in the patient records was authenticated, dated, and timed for 13 of 21 open patient records reviewed for care and services. (Patient #12, 1, 2, 21, 4, 7, 8, 11, 6, 9, 10, 19, and 20)

Cross reference to A 0454: The hospital failed to ensure that all medical orders were authenticated, dated, and signed for 7 of 21 open records (#12, 5, 7, 8 11, 19, and 20) and for 1 of 9 closed records reviewed for care and services (Patient #1)

Cross Reference to A 0457: The hospital failed to ensure that medical staff authenticate, sign, and date all verbal orders within 48 hours for 8 of 21 (#6, 4, 21, 2, 1, 14, 10 and 20) open patient records and 1 of 1 closed patient records (Patient #1) reviewed for care and services.

On the days of the Hospital Validation Survey based on observations, record reviews, interviews, and other data submitted by the hospital for review, the hospital failed to ensure that food is protected and safe at every state to include delivery to patients.


The findings are:


Cross Reference to A 0275: Hospital staff failed to consistently monitor and ensure that food temperatures were at least 140 Fahrenheit (F) degrees for hot foods and 42 F degrees for cold foods before serving the meals to patients and no evidence was presented that the hospital or contract entity completed action plans to address any variances in food temperatures identified at the point of care based on their own system requirements or ongoing sampling of food temperatures on the patient trays delivered to the nursing unit.

Cross Reference to A 0619: The hospital failed to ensure that responsibilities and lines of authority were clearly delineated for food and dietetic services, the dietitian, and other staff within the organization.

Cross Reference to A 0621: Contracted dietary staff and the Registered Dietitian failed to consistently monitor and maintain food temperatures of at least 140 degrees Fahrenheit (F) for hot foods and at 41 degrees F for cold foods before serving the meals to patients,failed to ensure a back up plan for monitoring food temperatures of meals delivered to the patient unit to ensure that temperatures of the foods were in safe ranges, and failed to produce action plans for out of range food temperatures.

Cross Reference to A 0622: The hospital failed to ensure that 1 of 1 contracted dietary associate followed infection control measures by failing to remove contaminated PPE (personal protective equipment) before exiting an isolation room and by not preventing further cross contamination to other staff and patients in delivery of patient food trays. (Dietary Associate #1)

Cross Reference to A 0726: Hospital staff, under the dietary contracted services and the Registered Dietitian failed to consistently monitor and ensure that food temperatures were maintained at 140 degrees Fahrenheit (F) for hot foods and 42 degrees F for cold foods before serving the meals to patients

Hospital policy, Number: 6.19, Issue Date: 6/21/2002, revised: 07/20/2010, "Food and Nutrition Policies and Procedures", reads, "subject: Food Handling, Policy: To define standards for the safe handling of food. Food handling standards should reflect federal, state, and local requirements. The Dietary Services Supervisor is responsible for the frequent observation of food handling techniques and, if necessary, for correcting poor methods. Food must be protected in every state - receiving, storage, preparation, serving, delivery to patients, waste disposal, utensils, flatware and china dish washing. Dietary personnel must be instructed on all food handling techniques, for example:
2. Keep food at room temperature for a minimum length of time. 3. Keep food hot (140 F or above) or cold (41 F or below).

Hospital policy, Number: 6.15, Issue date: 06/21/2002, revised 07/20/2012, "Food and Nutrition Policies and Procedures", reads, "subject: Food Preparation, "To establish general guidelines to ensure prepared food is of highest quality, flavor, appearance and temperature and bacterial contamination is minimal. 7. Proper serving temperature of food will be: Hot food: all hot food must be held at a temperature of 140 F or higher. Cold foods: All cold foods must be held at a temperature of 41 F or below.

On the days of the Hospital Validation Survey based on observations, interviews, record reviews, and other data submitted by the Hospital, the governing body failed to ensure the separateness of the Medical Staff when patients admitted to the Hospital received services such as Gastrointestinal procedures either in the Host Hospital or at the patient's bedside with Host Hospital staff in attendance or by transfer of patients to the Host Hospital without discharge orders.



The findings are:



On 6/12/12 at 1030, during a review of the Hospital's credentialing process, the Medical Record
Staff #1 reported the Hospital had 231 physicians on staff. On 6/12/12 at 1130, the Chief Executive Officer (CEO) reported the same physicians that are credentialed at the Hospital are also credentialed at the Host Hospital. The CEO reported that since patients at the Hospital have the same doctor if they transfer to the Host Hospital, the physicians don't write discharge orders. The CEO reported that this process ensures the continuity of the patient's care between the Hospital and the Host Hospital. The CEO further stated that patients are not transferred out of the Hospital's system until the patient had been in the Host Hospital for three days. The CEO reported that the Hospital operates on a bundling system, in that, if the patient in the Hospital receives a procedure performed at the Host Hospital, the Host Hospital bills the Hospital for the services. Review of patient records revealed Hospital patients had procedures performed in Host Hospital departments but the procedural documentation was on forms labeled with the Host Hospital's name. When procedures were performed at the patient bedside, staff from the Host Hospital's departments documented on forms labeled with the Host Hospital's name. Review of the Hospital's governance and Medical Staff rules and regulations did not address medical staff accountability, responsibility, or over sight as it relates to care provided either in Host Hospital departments or at the patient bedside by staff from the Host Hospital.

Review of Medical Staff Rules and Regulations, page 2, reads, A. Admissions and Discharge. 3.(a) Whenever physician responsibilities are transferred to another practitioner, a note governing the transfer of responsibility shall be entered on the order sheet in the medical record. " Medical Staff Bylaws did not have any rules and regulations related to the transfer of patients from the Hospital to the Host Hospital.

On the days of the Hospital Validation Survey through observation, facility policy review, record review, and interview, the governing body in accordance with hospital policy failed to ensure that specific patient care requirements of the nursing service, dietary service, and medical records services were met.


The findings include:


Cross Reference to A 385: The hospital failed to ensure that patients received care and services in accordance with hospital's policies and procedures and standards of practice.

Cross Reference to A 0619: The hospital failed to ensure that food is protected and safe at every state to include delivery to patients.

Cross Reference to A 0441: The hospital failed to ensure secure access to the medical records of patients who had procedures for 2 of 21 open patient records reviewed when the patient had a procedure (Patient 4 and 15) and 2 of 9 closed records reviewed for a patient who had a procedure by commingling of staff and services between the Host Hospital and the Hospital. (Patient #3 and 13)

On the days of the Hospital Validation Survey based on interview and review of contracted services, the governing body failed to ensure services furnished in the hospital whether or not those services are furnished under contracts complied with all the requirements of the Conditions of Participation. (Dietary and Gastrointestinal Services)


The findings include:


On 6/13/12 at 1600, hospital staff presented this agreement between the Hospital and the Host Hospital for review. Review of this agreement, revealed, "Purchased Services and Supplies Agreement", dated January 19, 2004 between the Host Hospital and the Hospital for a period of ten years(initial term), revealed on page 1 and 2, in section "1.3 Purchased Services and Supplies. Hospital shall purchase from [Host Hospital], the following Services and Supplies for patients of the LTACH, but only to the extent such Services and Supplies are provided within the Hospital to the general public: Anesthesia/Pain Management, Clinical Dietitian*, Electrocardiology, Employee Health*, Laboratory, MRI (Medical Resonant Imaging), Oncological Nursing*, Physical Therapy*, Recovery Room, Blood Bank Services, CT Scans (Computerized Axial Tomography), Electroencephalography*, Radiology, Laundry and Linen*, Nuclear Medicine, Operating Room, Psychological Services*, Central Supply*, Dietary/Catering*, Emergency Room, GI Services, Lithotripsy, Occupational Therapy*, Occupational Therapy*, Speech Pathology*, and Ultrasound."

From 06/11/12 through 06/15 12, based on observations of care, review of patient records, facility policies and procedures, contracts, governing body and medical staff by-laws rules and regulations and meeting minutes, Quality Assurance and Process Improvement data, Infection Control data, and other written materials and data revealed evidence of commingling of staff and services between the Hospital and the Host Hospital impacting on the determination that the Hospital ability to demonstrate independent compliance with the Conditions of Participation in Dietary, Nursing Services, and Electronic Medical Records.

(a) Dietary. [Host Hospital] shall provide dietary services and supplies to Hospital's patients including all meals .....the Dietitian will be able to attend meetings with the [Hospital] staff (including but not limited to, CQI (Continuous Quality Improvement) .....concerning dietary requirements...." . On 6/13/12 at 1600, a review of this agreement, "Purchased Services and Supplies Agreement", dated January 19, 2004 between the Host Hospital and the Hospital for a period of ten years(initial term), revealed on page 1 and 2, in section "1.3 Purchased Services and Supplies. Hospital shall purchase from [Host Hospital], the following Services and Supplies for patients of the LTACH, but only to the extent such Services and Supplies are provided within the Hospital to the general public: Clinical Dietitian and Dietary/Catering. " Review of an agreement between the Hospital and the contracted dietary service dated November 3, 2004 (initial) and August 23, 2010, reads, "1.2 Meals. ....will provide meals and other items and services from the kitchen or other areas of [Host Hospital]. Unless otherwise agreed, the meals provided by [contract service] to the operation will be based on the menu [contract service] uses in connection with the food and nutrition services [contract service] provides to [Host Hospital]. "
Cross Reference to A 0619: The hospital failed to ensure that food is protected and safe at every state to include delivery to patients.
Cross Reference to A 0275: Hospital staff failed to consistently monitor and ensure that food temperatures were at least 140 degrees for hot foods and 42 degrees for cold foods before serving the meals to patients and presented no documentation that the hospital completed action plans to address any variances in the temperatures of the food at the point of service or ongoing.



On 6/13/12 at 1600, a review of this agreement, "Purchased Services and Supplies Agreement", dated January 19, 2004 between the Host Hospital and the Hospital for a period of ten years(initial term), revealed on page 1 and 2, in section "1.3 Purchased Services and Supplies. Hospital shall purchase from (Host Hospital), the following Services and Supplies for patients of the LTACH, but only to the extent such Services and Supplies are provided within the Hospital to the general public: "
GI Services.
Cross Reference to A 0392: Nursing Staff failed to provide nursing care to all patients as needed for 3 of 21 open charts ( Patient #4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services in the Hospital and the Host Hospital.

On 6/14/12 at 1325, during an interview with the Chief Nursing Officer (CNO), the CNO stated, "Anytime a patient is transferred from the Hospital for services in the Host Hospital, and the patient has the same physician in both hospitals, a transfer form is not completed because they (the patient) are going to be with the same physician. Transfer forms will not be seen on the patient charts." The hospital presented no policies and procedures for the coordination of the patient services and or the delineation of responsibilities in the contract between the Hospital and the Host Hospital for patient services. In the contract between the Host Hospital and the Hospital, in section, 2.2 Administrative Cooperation, reads, "[Host Hospital] shall ensure that the Hospital departments providing such Services and Supplies and the Services and Supplies provided satisfy the following: (a) a reasonable level of interface with the purchaser management; (b) A reasonable level of participation in all Continuous Quality Improvement ("CQI"), Performance Improvement Plan, emergency preparedness and infection control activities ....;(c) a reasonable level of participation in patient/family conferences, staff meetings....,(d) a reasonable level of staffing based on ...needs;". The Hospital presented no documentation to define what a "reasonable level of participation was".














30011

On 6/15/12 at 1445, a review of the hospital's dialysis unit policy and procedure showed, "Scope of Dialysis Services, Dialysis equipment is inspected and monitored daily by staff before use, and maintained by a vendor service agreement....". During an interview with the Chief Executive Officer (CEO) on 6/15/12 at 1500 revealed the hospital does not maintain a "vendor service agreement, because they are costly upfront, we don't use them." The CEO reported that an individual comes from Fresenius to inspect the equipment, but the hospital has no contract with the individual.

On the days of the Hospital Validation Survey based on interview and medical record review, the governing body failed to ensure the care provided under contract was provided in a safe and effective manner by way of delivery of food to patients and sending patients for procedures unaccompanied. (Dietary)


The findings include:

Cross Reference A-0618: The hospital failed to ensure that food is protected and safe at every state to include delivery to patients by the contracted entity.




31672

On 6-12-12 at 1530, the Chief Executive Officer (CEO) stated, "when our dietitian is not available or is going to be out longer than just a few days, we have dietitians that cover her from the Host Hospital".

On 6/12/12 at 1600, a review of the "Evaluation of Contract Services" for Dietary services, for an evaluation period dated 2010, signed by the Chief Executive Officer on January 21, 2011 showed the form had a total of 17 items with a check for "yes" by each item. Item #1 reads, "Services are provided in a safe and effective manner." Item #4 reads,"Services has a Performance Improvement Process in place." Item #14 reads,"Service takes appropriate actions to improve service, addressing all identified problems....". Item #16 reads,"Staff is current on licensure, continuing education, orientation to the facility, and competent."

Review of the Fourth Quarter 2011 annual contract services review for Dietary revealed the Dietary indicator for review of Dietary Services was identified as, "1. Timely and accurate delivery of dietary items ordered, 10 trays per month." Outcome was listed as: 1. Accuracy and timeliness of dietary items ordered: YES." Actions/Follow Up Required, reads, "Monthly audits confirmed accuracy and timely delivery of patient trays. Continued monitoring and audit of trays during 2012." There were no indicators for Food Temperatures or other safety factors related to delivery of meals to patients identified.

On the days of the Hospital Validation Survey based on observations, record reviews, interviews, review of the Hospital's policies and procedures, and other data submitted by the Hospital for review, the Hospital contracts for patient services failed to include the scope and nature and delineation of responsibility for patient services to include patient rights, nursing care, medical records, and dietary services.

The findings are:

Cross Reference to A 0083: Review of the contracts submitted for review showed the Governing Body failed to delineate the responsibilities the contract for the services furnished in the hospital whether or not those services are furnished under contracts complied with all the requirements of the Conditions of Participation. (Dietary and Gastrointestinal Services)

On the days of the Hospital Validation Survey based on observation, interview, and review of records and other data submitted by the hospital, the hospital's medical staff rules and regulations revealed written rules and regulations pertaining to a Level IV Emergency Department when the hospital had no dedicated Emergency Department.

The findings are:

On 6/13/12 at 1400, a review of the hospital's Medical Staff Rules and Regulations revealed on Page 6, B. Emergency Services , 1. The Hospital maintains a Level IV Emergency Service and provides the essential services necessary to evaluate, stabilize, within its capabilities, and transfer when necessary and appropriate, individuals who present as an out-patient with conditions of an emergent or urgent nature, The hospital's procedures and the Transfer Policy approved by the Governing Board shall be adhered to at all times. "

Observations of the fourth floor that the hospital occupied within the Host Hospital had no space designated for Emergency Services. During an interview with the Chief Executive Officer (CEO) on 6/13/12 at 1520, the CEO stated the hospital had an agreement with the Host Hospital for purchased services and supplies which included Emergency Services.

On 6/13/12 at 1600, a review of this agreement, "Purchased Services and Supplies Agreement", dated January 19, 2004 between the Host Hospital and the Hospital for a period of ten years(initial term), revealed on page 1 and 2, in section "1.3 Purchased Services and Supplies. Hospital shall purchase from (Host Hospital), the following Services and Supplies for patients of the LTACH, but only to the extent such Services and Supplies are provided within the Hospital to the general public: Emergency Room." Section 2.4 Services & (and) Supplies with Special and/or Additional Requirements, reads, (b) Emergency Room . (Host) "Hospital's emergency room shall be available to Purchaser's (Hospital) patients for emergency medical treatment on an as - needed basis. Emergency room services shall be offered at the same level as that offered to the general public." Section B. Emergency Services, 5., reads, "As part of the medical staff and hospital department Continuous Quality Improvement Program, 100% review of all Emergency Services patients will occur through the Continuous Quality Improvement, by the following criteria." The medical staff rules and regulations policies do not speak to a process for the oversight of care and management of health records provided to the hospital's patients who present in the Host Hospital's Emergency Department by the Host Hospital's medical and other staff.

On the days of the Hospital Validation Survey based on observation, interview, and review of data submitted by the hospital, no determination could be made related to the Hospital's compliance with the requirements of 482.55.


The findings are:


Cross Reference to A 0091: The hospital's medical staff rules and regulations revealed written rules and regulations pertaining to a Level IV Emergency Department when the hospital had no dedicated Emergency Department Services.

On the days of the Hospital Validation Survey based on interview and review of the hospital's policy and agreements, the hospital failed to ensure that limited English Proficient Persons were communicated with in a manner that they could understand with a potential to affect all patients presenting to the hospital with communication barriers.


The findings are:


On 6/14/12 at 1615, review of the hospital's agreement with the Language Line Services showed the agreement was signed on 06/22/06 with the term of the agreement stating "....Upon the expiration of the initial one-year period, this Agreement will be automatically renewed for similar one-year periods unless either party provides written cancellation notice to the other at least sixty (60) days prior to the expiration of the then-current one-year period....". On 06/14/12 at 1500, during an interview with the hospital's Admissions Coordinator, the Admission Coordinator revealed that when Limited English Proficient Persons present to the hospital for admissions, "we use Hospital B's (Host Hospital) staff to translate for the patient "if a family member is not present to translate for them." The Admissions Coordinator reported that he/she did not know about the existence of the Language Line. On 06/14/12 at 1600, during an interview with the Chief Executive Officer (CEO), the CEO revealed that "we have an agreement for the Language Line through AT&T but we use ....(Host Hospital) service to translate."

Hospital policy, "T02-A: Translators, Procedures for Communication with Persons of Limited English Proficiency", reads, "....When a translator is needed, the Director of Clinical Services, or a designee thereof, is responsible for contacting a representative of the AT&T Language Line Service, twenty-four hours per day, seven days per week....".

Review of the hospital's "Patient and Family Handbook", Page 16, reads, "Interpreter Services, This service is provided by the hospital at no charge to the patient. Interpreters are available for translation of sign language and several languages. Additionally, .........Hospitals have access to AT&T's Language Line, which is available 24 hours a day and can interpret more than a 100 languages and dialects."

On the days of the Hospital Validation Survey through observation, facility policy review, record review, data submitted by the facility, and interview, the facility failed to ensure the patient's right to receive care in a safe setting on the nursing unit and in the hemodialysis setting, and dietary services.


The findings are:

Cross Reference to A 0392: Nursing services failed to provide nursing care to all patients as needed for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services.

Cross Reference to A 0621: Contract Dietary staff and the Registered Dietitian failed to consistently monitor and maintain food temperatures of at least 140 degrees Fahrenheit (F) for hot foods and at 41 F degrees for cold foods before serving the meals to patients and failed to ensure a back up plan for monitoring food temperatures of meals delivered to the patient unit to ensure that temperatures of the foods were in safe ranges.

On the days of the Hospital Validation Survey based on random observation and interview, hospital staff failed to protect the patient's clinical records for 1 of 1 random observation of patient care. (Registered Nurse #3)

The findings are:

On 06/12/12 at 1110, random observation on the nursing unit revealed the patient's chart was lying unprotected on top of the wall-a-roo located in the hall while the patient's nurse, Registered Nurse #3 was observed two doors down the hallway engaging in a conversation with another staff member. On 06/12/12 at 1115, Registered Nurse #1 verified the finding and reported, "the charts should be inside the wall-a-roo." On 06/15/12 at 1615, the finding was reported to the Chief Executive Officer.

On the days of the Hospital Validation Survey based on record review, interview, and review of the hospital's policy, hospital staff failed to provide the patient with alternative interventions before applying restraints for 1 of 2 patients reviewed for restraints. (Patient #11)


The findings are:

On 06/13/12 at 1155, review of Patient #11's chart revealed the patient was admitted on 06/05/12 with respiratory failure and restrained per physician's orders dated 06/09/12. Review of the nursing restraint assessment documentation on the patient's chart showed no documentation that least restrictive interventions were used before initiating the restraint. On 06/15/12 at 1500, the finding was verified with the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO). Hospital policy "R02-N: Restraints and Seclusion", reads, ".... 2. Attempt alternative interventions prior to every application of a restraint....".

On the days of the Hospital Validation Survey based on record review, interview, and review of the hospital's policy, hospital staff failed to justify the need for restraints for 2 of 2 patient charts reviewed for restraint. (Patient #11 and #8)


The findings are:


On 06/13/12 at 1155, review of Patient #11's chart showed the patient was admitted on 06/05/12 with respiratory failure. Review of the physician orders for restraints dated 06/10/12 revealed staff had not documented any justification for the use of restraints.

On 06/14/12 at 1230, review of Patient #8's record showed the patient was admitted on 05/29/12 with pneumonia and an order for restraints. Review of the physician order dated 06/03/12 revealed staff had not documented any justification for the use of restraints. On 06/15/12 at 1500, the findings were verified with the Chief Executive Officer and the Chief Nursing Officer.

Hospital policy, " R02-N: Restraints and Seclusion", reads, "....Every use of restraints is to be documented in the patient's record. At a minimum, documentation must include:....The justification for restraints (Restraint Assessment & Physician Order)....".

On the days of the Hospital Validation Survey based on interview, record review, medical staff bylaws, and hospital policy and procedures, the medical staff failed to enforce adherence to medical staff bylaws and hospital policy for patient discharge for 2 of 9 closed records (Patient #7 and 6) and 1 of 21 open records (Patient #4).


The findings include:


Record review conducted on 6/14/12 at 1400 revealed Patient #7 was admitted to the hospital on 4/4/11, transferred to an intensive care bed in the host hospital on 6/2/11, and then, discharged on 6/3/11 with the diagnosis of Respiratory Failure. On 6/2/11 at 1000, the physician order, states, "please get an ICU(Intensive Care Unit) bed for patient after surgery". The patient was sent to an ICU bed in the Host Hospital but there was no documented physician discharge or transfer order from the hospital to the host hospital for the patient until 6/3/12.

On 6/13/12 at 1500, a review of Patient #6's chart showed the patient was admitted on 8/17/11 with Pneumonia. On 8/24/12, documentation showed the patient had a cardiac arrest post procedure and was sent to the critical care unit in the host hospital, but there was no documented transfer order by the physician or by nursing to nursing in the host hospital.

On 6/12/12 at 1500, a review of Patient #4's chart showed the patient went to the Gastrointestinal Lab (GI) on 6/12/12 at 1100 for a procedure in the host hospital. The patient returned from the GI Lab on 6/12/12 at 1330, with a documented temperature of 91.3 degrees Fahrenheit (F) Ax (axillary). The patient had a documented rectal temperature of 92.2 degrees F at 1520. There was no documented physician discharge- transfer orders for the procedure that was done in the host hospital, no post op orders for nursing care, and no nursing transfer information completed.

MEDICAL STAFF RULES AND REGULATIONS states, "A. ADMISSION AND DISCHARGE...14. (a) Patients shall be discharged from the Hospital only on the written order of the patient's attending practitioner. (b) Practitioners shall write discharge orders that will allow patients to be discharged from the Hospital on a timely basis...". "18. In cases of urgent need for transfer to another healthcare facility due to any acute medical condition or mental disturbance, the attending physician will make arrangements for immediate transfer to the most appropriate health care facility. The physician making the transfer should also provide any medical information necessary for the receiving physician to initiate safe and appropriate treatment."

Hospital Policy #D03-G, revised 5/01, states,"...POLICY...2. Patient discharge is made only upon written orders from the attending physician or his/her designee. The only exception to this is if a patient insists upon leaving Hospital against medical advice (refer to policy regarding leaving AMA)

On 6/14/12 at 1325, during an interview with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO), they reported, "Anytime a patient is transferred from the Hospital to Host Hospital with the same physician, the Hospital does not complete a transfer form because the patient is going to be seen by the same physician. Therefore, discharge - transfer forms will not be seen on the patients charts."

On 6/14/12 at 1345, during an interview, the CNO and CFO reported that for any procedure done at bedside in the Hospital, the patient is recovered by the Host Hospital's staff. The Hospital staff stays at the bedside but doesn't resume care of the patient until the Host Hospital 's staff is finished.

There were no policies and procedures to delineate how the continuity of patient care is evaluated between the two hospital systems for responsibilities related to nursing care, charting procedures, access to patient records, or adverse event review, or quality issues.

On the days of the Hospital Validation Survey based on observations, record reviews, interviews, and review of other data submitted for review, Nursing Administration failed to delineate responsibilities for patient care for patients who undergo procedures in the Host Hospital or for procedures that are conducted on the hospital nursing unit by personnel from the Host Hospital while an inpatient in the Hospital for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services that had procedures.


The findings are:


Cross Reference to A 0392: Nursing Staff failed to provide nursing care to all patients as needed for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services.

Cross Reference to A 0395: The hospital failed to ensure the policies and procedures, supervision, and oversight of nursing care when patients underwent procedures in the Host Hospital or conducted on the hospital nursing unit by personnel from the Host Hospital while an inpatient in the hospital for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services that had procedures.

On the days of the Hospital Validation Survey through observation, facility policy review, record review, facility log review, and interview, Nursing Staff failed to provide nursing care to all patients as needed for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services.


The findings are:


On 6/12/12 at 1500, a review of Patient #4's chart revealed the patient was admitted with a diagnosis of Altered Mental Status. On 6/12/12 at 1500, a review of the nurse notes dated 6/08/12 at 1030, revealed, "patient transported to GI (gastrointestinal) lab via stretcher." "No acute distress noted." The nurse recorded a note on 6/08/12 at 1100 that read, "Called GI lab, gave report to .... RN" ( Name of Registered Nurse in Host Hospital). "Denies questions." On 6/08/12 at 1330, the nurse recorded, "Pt (patient) returned to floor. Temp (temperature) 91.3 Ax (axillary). MD (medical doctor) notified. Temperature in room turned all the way up. Pt. covered with 5 blankets. New orders received." The nurse recorded a note on 6/08/12 at 1415 that read, "Pt transported to CT (computed tomography) at [Host Hospital]." "VSS (vital signs stable) except temp. which MD is aware of." The nurse recorded a note on 6/08/12 at 1520, that read, "Pt returned from CT. VSS except temp. 92.2 R (rectal)....". On 6/12/12 at 1600, during an interview with Registered Nurse (RN) #3, he/she revealed that the gaps in the patient's charting was related to the patient having a PEG (Percutaneous Gastrostomy) tube insertion on the 3rd floor in the GI (gastrointestinal)Lab at the Host Hospital. Then, RN #3 produced an operative report from the "Centex System" which detailed the patient's procedure that was performed in the GI lab in the Host Hospital. Prior to RN #3 obtaining the documentation from the Centex System, there was no documentation in the patient's chart pertaining to the procedure, no preoperative or post operative orders, and/or no discharge from the hospital to the Host Hospital for the procedure. On 6/14/12 at 1325, the Chief Nursing Officer (CNO) reported "any information about a patient can be accessed from the Host Hospital through the Centex (computer system) and vice versa."


On 6/14/12 at 1610, a review of Patient #15's chart revealed the patient was admitted to the Hospital for Respiratory Failure. Review of nursing documentation dated 4/30/12 at 0745 revealed,"Plan for tracheostomy today - ...husband @ (at) BS (bed side). Both understanding to procedure." Nurse notes at 1015 revealed, "Trach Procedure @ BS. Dr...../Dr.... @BS. Diprovan 5 ml (milliliters) IV (intravenous) given and Diprovan gtt (drip) started at 25 mcg/kg/min(micrograms/kilograms/minute) med (medication) effective." At 1050, the nurse documented "procedure complete. NS (Normal Saline) bolus IV (intravenous) given 500 cc (cubic centimeters) PT (patient) tolerated well. Sedation p (after) Fentanyl per pulmonary lab nurse. Diprovan to continue at 25 mg ." Documentation revealed the patient had a bedside tracheostomy due to switching the patient from an ET (Endotracheal) tube to a tracheostomy that was performed by two physicians with assistance from the "Pulmonary Lab nurse and a Registered Respiratory Therapist (RRT)" who were employees of the Host Hospital. Review of the physician's operative note and RRT's procedure notes showed the notes listed the name of the Host Hospital on all documentation forms.
At 1400, the nurse recorded, the Diprovan was decreased to 15 mcg/kg. At 1500, the nurse documented that D5W (Dextrose with water) started at 100 cc/hr. and the Diprovan was 5 mcg/kg. The nurse charted that the Diprovan was discontinued at 1600. At 1745, the nurse recorded that the patient's hemoglobin was 6.9 and a consent for an EGD (Esophagoduodenostomy) in AM was obtained.

Review of the physician orders showed "Propofol 50 mcg (micrograms) IV (intravenous) push given, Versed 150 mg (milligrams) IV push, Propofol 24 mcg/kg (kilogram)/hour x 6 (hours), then stop....".
Review of the physician operative note showed "Propofol 50 mg bolus and 25 mcg/kg/hr drip and Fentanyl 150 mg".

Review of the documentation by Host Hospital's RRT showed the notes had the name of the Host Hospital, and showed "100 mcg Fentanyl given per MD order by the RRT with no complications". On 6/14/12 at 1650, the Chief Nursing Officer revealed that the medical doctor must have written the order wrong while the two other operative notes should have read Fentanyl 150 mg instead of Versed 150 mg since Fentanyl was given. Based upon review of the physician's order, the patient received Propofol at 24 mcg/kg/hr drip x 6 hours on the nursing unit.

Review of South Carolina Board of Nursing, Advisory Opinion #27, reads, "....RNs who are not qualified anesthesia providers: 1. May not administer agents used primarily as anesthetics including but not limited to, Ketamine, Propofol, Etomides, Sodium Thiopental, Methohexital, Fentanyl*, all extrapotent opiates, nitrous oxide or inhalation agents.** The RN with specialized education and training, in settings where critical care nursing can be provided, may initiate, titrate and bolus intravenous agents with the understanding that the airway is secured and mechanically assisted. 2. May not be authorized to manage deep sedation or anesthesia for short - term diagnostic, therapeutic, or surgical procedures."



On 6/15/12 at 1340-1350, review of the closed record for Patient #1 revealed the patient was admitted to the Hospital for Malnutrition and Acute Encephalopathy and received dialysis during the hospital admission. Review of the Hemodialysis Treatment Sheets showed sections for the physician to order the dialysis prescription for the patient. However, these sections were blank and there were no physician orders for the rate of the BFR and/or DFR. Review of Patient #1's Hemodialysis Treatment Sheets for the following days showed there were no Blood flow Rate (BFR) or Dialysis Flow Rate (DFR) recorded by the physician on the the patient's dialysis prescription but nursing staff had recorded a BFR and DFR rates on the Hemodialysis Treatment Sheets:
3/14/12: BFR 300-350, 3/28/12: BFR 400, 3/30/12: BFR 400, 4/02/12:BFR 400, 4/04/12: BFR 400, 4/06/12: BFR 400, and 4/09/12: BFR 350.

Review of the patient's Hemodialysis Treatment Sheets dated 3/16/12 and 3/26/12, the Hemodialysis Treatment Sheets had no BFR on the physician prescription order but a rate of 400 was delivered on 3/16/12 and a rate of 350 was delivered on 3/26/12.
Review of the patient's Hemodialysis Treatment Sheets dated 3/18/12, 3/20/12, 3/28/12, 4/11/12, 4/13/12 and 4/15/12 had no DFRs on the physician prescription orders, but a BFR of 500 was recorded on all of the Hemodialysis Treatment Sheets.
Review of the patient's Hemodialysis Treatment Sheets dated 3/16/12, 3/23/12 and 3/26/12 showed DFRs delivered as 400-450 while DFR rates, but the physician prescription was a DFR of 500.
Review of the patient's Hemodialysis Treatment Sheets dated 4/11/12, 4/13/12 and 4/15/12 revealed BFRs ordered as 450-400 but Hemodialysis Treatment Sheets revealed BFRs of 400, 350, and 350 respectively were delivered.
On 6/15/12 at 1600, during an interview with Dialysis Registered Nurse #1, he/she revealed that when a BFR or DFR order is not written by the physician, "I think that it is in our policy book that if no DFR ordered, run the DFR at 500 unless otherwise ordered".

Review of Dialysis Manual with Dialysis Registered Nurse #1 showed the Hospital had no policy pertaining to management of the Blood Flow Rate or Dialysate Flow Rate if there is no physician order. The Hospital was unable to produce any other documentation to clarify the issue.

Hospital policy, DS201, titled, Patient Care, Assessment and Documentation Requirements Pre, Intra, and Post Hemodialysis with no date of issue, reads, "Procedure: 1. Ensure that a physician's order (Hemodialysis Orders - DS201.1) is written for each dialysis treatment which may include the following information: .....dialysis flow rate ... Heparin dose and method of administration" 4. Assess the patient during the intradialytic period and document .......Blood flow rate and Dialysate flow rate."



27175

On 6/13/12 at 1500, a review of Patient #6's closed chart revealed the patient was admitted to to the hospital on 8/17/11 with the diagnosis of Bilateral pulmonary infiltrates thought to be secondary to healthcare - associated pneumonia and/or pulmonary edema.
Review of the nurse documentation in the patient's chart dated 8/24/11 at 0630 revealed the nurse documented "Date/time of Labs: 08/24/11 0630- Na+ (Sodium) 146, HGB (Hemoglobin) 4.7, BUN(Blood Urea Nitrogen)78, Cr (Creatinine) 1.2 BS(Blood Sugar) 169. MD (Medical Doctor) aware of labs". At 0700, the nurse documented, "patient up in chair, no distress noted, will continue to monitor."
Review of physician's verbal order dated 8/24/11 at 0700 showed CBC, BMP(Basic Metabolic Panel) Mag (Magnesium), PO4 (Phosphate), and BNP(Brain Natriuretic Peptide) in AM. Consent for bronch (bronchoscopy) now. D5 1/2 NS (normal saline) at 75 ml (milliliters) now.
At 0745, "Patient bronch per Dr, family aware consent signed, and on chart, will continue to monitor."

Review of the documentation of the patient's bronchoscopy procedure
to include the consent form and the operative report were all on forms labeled with the Host Hospital's name.

On 8/24/11 at 0755: "BP (blood pressure) 99/50; P (pulse) 90; O2 sat (O2 saturation)-100%."
8/24/11 at 0800: "BP 85/52; P 104; R (respirations) 33; T (temperature) 98.2; O2 sat 98%."
8/24/11 at 0815: "BP 107/53; P 107; O2 sat 96%"
8/24/11 at 0830: "BP 94/56; P 110; O2 sat 94%"
8/24/11 at 0845: "BP 97/57; P 113; O2 sat 93%"
8/24/11 at 0900: "BP 100/58; P 114; R 36; O2 sat 94%"
8/24/11 at 0900: "Patient noted with labored breathing opens eyes briefly (was given 2 mg (milligram) Versed for bronch) MD aware."

8/24/11 at 0915: "BP 97/56; P 115; O2 sat 92%"
8/24/12 at 0926: "BP 103/61; P 114; O2 sat 95%"
8/24/11 at 0930: "BP 92/74; P 116; O2 sat 96%"
8/24/11 at 0945: "BP 96/60; P 91; O2 sat 100%" (Physician Telephone order reads, "Get ABG (Arterial Blood Gas) this AM."

8/24/11 at 1000: "BP 121/99; P 104; R 49; O2 sat 100%"
8/24/11 at 1000: "Certified nursing assistants at the bed side giving bath, MD aware of breathing pattern."

8/24/11 at 1100: "BP 89/48; P 60; R 31; O2 sat 100%"
8/24/11 at 1100: "Patient remains with labored breathing, no changes noted, will continue to monitor."

8/24/11 at 1200: "Patient opens eyes when name called, nods no to pain, receiving breathing treatment. Temp 100.1, will continue to monitor."

8/24/11 at 1300: "BP 134/34; P 120; R 38; O2 sat 97%." (physician late entry telephone order at 1342, reads, "Get ABG".

8/24/11 at 1400: "Entered patient room respiratory therapy at bedside with machine (BiPAP) attempt suctioning via mouth small amount of beige/yellow tinged secretions MD paged, eyes fixed, pupils unequal 4 mm (millimeters) right, left 2 mm, sluggish no response when name called, BP 89/32, HR (heart rate) 120, sat 94%, R 34."

8/24/11 at 1410: "Continue to work with patient, BP 96/34, HR 122, 95% (BiPAP)."
8/24/11 at 1415: "BP decreased 37/21, no pulses found with doppler, sat 81%, charge nurse at bedside assessing patient." 8/24/11 at 1416: "Code called charge nurse, this nurse, RT at bedside." 8/24/11 at 1416: "CPR begins compression started per this nurse, RT maintaining airway, MD called back aware of code, see rapid response sheet." Review of physician telephone order at 1430 reads, "Get ABG".

8/24/11 at 1515: "Report called to RN (registered nurse) in CCU" (critical care unit) located in the Host Hospital, "patient transferred via bed assisted by RT and charge nurse." Physician order with no time, reads, "Transfer to ICU Stat. Epinephrine 1 mg IV x (times) 2 given ......".
8/24/11 at 1515: "Family aware of changes and transferred per NP (nurse practitioner)."

Review of the nursing documentation on 8/24/11 revealed Patient #6 had a pulse (104) and respirations (49) with labored breathing at 1000. Documentation showed the physician was aware of the labored breathing and aware of the 0630 lab report of the patient's hemoglobin at 4.7 but there was no documentation in the physician progress notes or discharge summary addressing the hemoglobin 4.7. There was no evidence of physician orders address the hemoglobin of 4.7 prior to or after the patient's bronch. Although the patient presented with a pulse of 104 and respirations of 49 at 1000, there was no reassessment documented by nursing until 1100 when the nurse recorded the patient's blood pressure as 89/48, pulse as 60, respirations as 31 with labored breathing. There was no documentation that the physician was notified of the assessment findings.
The only reassessment recorded at 1200 was the patient's temperature as 100.1. There was no documentation of a reassessment of the patient's blood pressure, respirations or pulse. Nursing documented the next vital signs obtained at 1300 as blood pressure 134/34, pulse 120, and respirations at 38. There was no documentation that the physician was notified of the patient's assessment. Nursing documented no reassessment of the patient until 1400, when the nurse documented, "Entered patient room respiratory therapy at bedside with machine (BiPAP) attempt suctioning via mouth small amount of beige/yellow tinged secretions MD paged, eyes fixed, pupils unequal 4 mm (millimeters) right, left 2 mm, sluggish no response when name called, BP 89/32, HR (heart rate) 120, sat 94%, R 34." At 1415, the nurse recorded "BP decreased 37/21, no pulses found with doppler, sat 81%, charge nurse at bedside assessing patient." The patient was sent to the critical care unit in the Host Hospital. the patient Review of the physician's discharge summary dictated on 8/24/11 at 1531, reads, "Throughout the day, his respiratory status and his oxygen remained acceptable. However, the patient cardiac and respiratory arrested. ...The decision was made to proceed with transfer to the intensive care area of Host Hospital for further medical management." A physician order dated but not timed recorded on 8/24/11 reads, "Transfer to ICU Stat". There was no documentation of a nursing transfer - discharge summary or of a physician discharge order to the Host Hospital.

On 6/14/12 at 1325, during an interview with the Chief Nursing Officer (CNO) & Chief Executive Officer (CEO), they reported, "Anytime a patient is transferred from the Hospital to Host Hospital with the same physician, the Hospital does not complete a transfer form because the patient is going to be seen by the same physician. Therefore, discharge - transfer forms will not be seen on the patients charts." On 6/14/12 at 1345, during an interview, the CNO and CFO reported that for any procedure done at bedside in the Hospital, the patient is recovered by the
Host Hospital's staff. The Hospital staff stay at the patient's bedside but don't resume care of the patient until the Host Hospital 's staff is finished. There were no policies and procedures to delineate how the continuity of patient care is evaluated between the two hospital systems for responsibilities related to nursing care, charting procedures, access to patient records, or adverse event review.



31395

On 06/11/12 at 1420, review of Patient #9's open chart showed the patient was admitted on 06/06/12 with wound infection/bacteremia, End Stage Renal Disease, and Septic shoulder post operative. Patient #9 had a physician order for a total dose of Heparin 6,000 units to be delivered during the patient's dialysis treatment. Review of the patient's dialysis treatment sheet dated 06/07/12 showed the total Heparin dose that the patient received was 5300 units which was 700 units less than prescribed. Review of the patient's dialysis treatment sheet dated 06/11/12 showed the total Heparin dose the patient received was 2300 units which was 3700 units less than prescribed. On 06/15/12 at 1530, the findings were verified with the Director of Dialysis.

Hospital policy, "DS 201: Assessment And Documentation Requirements Pre, Intra, and Post Hemodialysis", reads, "....4. Asses the patient during the intradialytic period and document findings and interventions on the patient's treatment flow sheet. The assessment will include at the following minimum requirements:....Heparin infusion rate....".

On the days of the Hospital validation Survey based on record review, interviews, and review of hospital policies and procedures, the hospital failed to ensure the supervision and oversight of nursing care when Hospital patients underwent procedures in the Host Hospital or had procedures performed on the hospital nursing unit by staff employed by the Host Hospital for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services that had procedures.


The findings are:


Cross Reference to A 0392: Nursing Staff failed to provide nursing care to all patients as needed for 3 of 21 open charts ( Patient 4, 15, and 1) and 1 of 9 closed patient charts (Patient #6) whose records were reviewed for care and services in the Host Hospital or on the nursing unit.

On the days of Hospital Validation Survey based on personnel record review and review of hospital policies and procedures, the hospital failed to ensure annual competency of its dialysis nursing staff for 2 of 2 registered nurse who work in the dialysis unit. (Registered Nurse #1 and #2)


The findings are:


On 6/12/12 at 1400, a review of the hospital's personnel records revealed Registered Nurse (RN) #1 was the dialysis nurse for the hospital. RN #1's personnel record revealed a skills orientation checklist for dialysis services that had no date showing when the skills required for the dialysis unit were validated. On 6/12/12 at 1430, a review of the hospital's personnel records showed RN #2 had a skills checklist required for the dialysis unit dated 3/10/10 and 4/14/10 performed by Registered Nurse #1. Neither Registered Nurse #1 nor Registered Nurse #2 had any other documentation of nursing skills to show competency in skills used specifically in the dialysis setting in their personnel files for an annual competency for dialysis.

Hospital policy, reads, "Dialysis Staff Competency, DS 104, Purpose: The purpose of this policy is to ensure that dialysis staff is deemed competent to perform hemodialysis and associated procedures after their initial orientation and annually thereafter. #4. The hemodialysis nurse will participate in annual skills competencies that are general in nature as well as specific to nursing....".

On the days of the Hospital Validation Survey based on record reviews and interviews, the hospital failed to ensure that medical staff authenticate, sign, and date all verbal orders within 48 hours for 8 of 21 (#6, 4, 21, 2, 1, 14, 10 and 20) open patient records and 1 of 1 closed patient records (Patient #1) reviewed for care and services.

The findings are:


On 6/12/12 at 1500, review of Patient #4's open chart revealed the patient was admitted to the Hospital with Altered Mental Status. Review of the following telephone orders showed the physician orders had no dates and times when the physician authenticated the telephone orders dated 5/26/12 (4 telephone orders), 5/27/12 (1 telephone order), 5/29/12 (1 telephone order), 5/30/12 (1 telephone order ), 6/1/12 (2 telephone order) and 6/2/12 (1 telephone order).

On 6/13/12 at 1430, review of Patient #21's open chart revealed the patient was admitted to the hospital with Pneumonia. Review of physician telephone orders showed the orders had no dates and/or times when the physician signatures were written: 6/2/12 (2 telephone orders) and 6/4/12 (1 telephone order).

On 6/13/12 at 1505, review of Patient #2's open chart revealed the patient was admitted to the Hospital with Osteomyelitis. Telephone orders had no dates and times when the physician signatures were written on the orders: 5/16/12 (1 telephone order), 5/17/12 (1 telephone order), 5/21/12 (1 telephone order), 5/22/12 (1 telephone order), 5/23/12 (2 telephone order), 5/28/12 (1 telephone order) and 6/6/12 (1 telephone order).

On 6/13/12 at 1605, review of Patient #1's open chart revealed the patient was admitted to the Hospital with Altered Mental Status. Review of physician telephone orders revealed the orders had no dates and times when the physician signatures were written on the orders: 6/8/12 (2 telephone orders), 6/9/12 (1 telephone orders) and 6/10/12 (2 telephone orders).

On 6/14/12 at 0950, review of Patient #14's open chart revealed the patient was admitted to the Hospital with Total Parental Nutrition (TPN) wean. Review of physician telephone orders showed the orders had no dates and times when the physician signatures were written on the orders: 6/8/12 (1 telephone order), 6/9/12 (1 telephone order) and 6/10/12 (1 telephone order). Telephone order had no time, or signature on 5/27/12 (1 telephone order).



31395

On 06/13/12 at 1115, review of Patient #6's open chart revealed the patient was admitted on 06/06/12 with the diagnosis of post operative wound care. Review of the physician verbal orders dated 06/07/12 showed the order had no time (telephone order), and review of verbal physician order dated 06/08/12 showed the order had no time.



31672

On 6-12-2012 at 1045, review of Patient #1's closed record revealed the patient was admitted on 3-13-2012 with debility, low blood sugar, End Stage Renal Disease, and Peripheral Vascular Disease. Further review of the patient's record revealed:
On 3-19-12: Physician Telephone Order had no time noted by the physician; On 3-19-12: Physician Telephone Order had no physician signature, date or time; On 3-20-12: Physician Telephone Order revealed the physician signed the order greater ( >) than 48 hours, specifically 9 days later; On 3-20-12: Physician Telephone Orders had no time noted, and the physician signed the telephone order more than 48 hours later, specifically 20 days later; and On 3-21-12: Physician Telephone Order had no time noted by the physician.

On 6-13-12 at 1130, review of Patient #10's open record revealed the patient was admitted on 6-5-12 with Bacterial endocarditis. Further review
of the patient's record revealed: On 6-6-12: Physician's Orders had no time or date noted by physician (telephone verbal order),

On 6-14-12 at 1535, review of Patient #20's open record revealed the patient was admitted on 5-24-12 with a wound infection. Further review of the record revealed on 5 -27-12: Physician's Orders- had no date or time noted by physician (telephone verbal order).

Facility policy, Medical Staff Rules and Regulations, reads, " ....D. General Conduct Of Care"- 1.... the responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate such order within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours....".

Facility policy, Collaborative Practice Agreement to Supervise Dependent Allied Health Practitioner, reads, "....6. The Allied Health Practitioner (AHP) shall be accountable to date and sign each entry in the medical record with the applicable designation behind their name. Medical record entries shall be countersigned to show agreement by the supervising physician. All medical records are expected to be completed by the AHP and the supervising physician in accordance with the Rules and Regulations of the Medical Staff....".

On the days of the Hospital Validation Survey based on observations, record review and interview, the hospital failed to ensure secure access to the medical records of patients who had procedures for 2 of 21 open patient records reviewed when the patient had a procedure (Patient 4 and 15) and 2 of 9 closed records reviewed for a patient who had a procedure. (Patient #3 and 13)

The findings are:

On 6/12/12 at 1500, a concurrent review of Patient #4"s nursing notes dated 6/08/12 at 1030, revealed, "patient transported to GI (gastrointestinal) lab via stretcher." "No acute distress noted." The nurse recorded a note on 6/08/12 at 1100, read, "Called GI lab, gave report to .... RN (Registered Nurse). Denies questions." Nurse note on 06/08/12 at 1415 reads, "PT (Patient) transported to CT (Computed Tomography). VSS (Vital signs stable) except temp. (temperature) which MD (medical doctor) is aware". There was no report from either procedure on the patient's chart. On 6/12/12 at 1600, during an interview with Registered Nurse (RN) #3, he/she revealed that the missing documents in the patient's records was because the patient had the Percutaneous Gastroscopy (PEG) tube insertion on the 3rd floor in the GI (gastrointestinal)Lab located in the Host Hospital. Observation on 6/12/12 at 1530 showed RN #3 produced the patient's operative report from the Hospital's "Centrex System" (computer system). The report had the name of the Host Hospital and the details of the procedure that was performed in the Host Hospital's GI lab. On 6/14/12 at 1325, the Chief Nursing Officer (CNO) reported "any information about a patient can be accessed from the Host Hospital through the Centrex (computer system) and vice versa." The CNO reported that if a patient has a service that is provided by the Host Hospital, the Hospital can access those records for three days.

On 6/12/12 at 1545, a closed record review of Patient #3's chart revealed a nurse note dated 1/14/12 at 2250 that reads, "......aware of CT orders". At 2300, the nurse documented that he/she obtained medication (Keppra) for the patient from the Host Hospital pharmacy. The patient's chart had a detailed report of the patient's CT scan dated 1/15/12 at 1232 AM labeled with the Host Hospital's name.

On 6/12/12 at 1630, a review of Patient #13's closed revealed a consent for a feeding tube placement on the Hospital's consent form dated 5/26/12. Review of the patient's chart revealed the patient had a Esophagogastroduodenoscopy report dated 6/11/12 and KUB (Kidney Ureter Bladder) dated 6/7/12 that had the Host Hospital's name as the identifying entity where the procedure were performed.

On 6/14/12 at 1610, a review of Patient #15's chart revealed the patient was admitted to the Hospital for Respiratory Failure. Review of nursing documentation dated 4/30/12 at 0745 revealed,"Plan for tracheostomy today - ...husband @ (at) BS (bed side). Both understanding to procedure." Nurse notes at 1015 revealed, "Trach Procedure @ BS. Documentation revealed the procedure was performed at the patient's bedside two physicians with assistance from the Host Hospital's "Pulmonary Lab nurse and a Registered Respiratory Therapist (RRT)". Review of the physician's operative note and RRT's procedure notes showed the notes listed the name of the Host Hospital on all the forms. The reports were obtained from the computer system by the Charge Nurse.

On 6/14/12 at 1325, the Chief Nursing Officer (CNO) reported "any information about a patient can be accessed from the Host Hospital through the Centrex (computer system) and vice versa." The CNO reported that if a patient has a service that is provided by the Host Hospital, the Hospital can access those records for three days.

On the days of the Hospital Validation Survey based on record review, interview, and facility policy and procedure review, the hospital failed to ensure that all documentation in the patient records was authenticated, dated, and timed for 13 of 21 open patient records reviewed for care and services. (Patient #12, 1, 2, 21, 4, 7, 8, 11, 6, 9, 10, 19, and 20)

The findings are:

On 6/12/12 at 1500, review of Patient #4's open chart revealed the patient was admitted to the Hospital with Altered Mental Status. Review of a Consultation report dictated on 5/29/12 at 1207 and transcribed on 5/29/12 at 1316 had no signature, date, or time. Review of a Consultation report dictated on 5/30/12 at 1505 and transcribed on 5/30/12 at 1842 had no date or time. Review of a Consultation report dictated on 6/7/12 at 1747 and transcribed on 6/8/12 at 1005 had no signature, date or time. Review of Progress notes showed no dates and times on progress notes recorded from 5/29/12 to 6/13/12.

On 6/13/12 at 1430, review of Patient #21's open chart revealed the patient was admitted to the hospital with Pneumonia. Review of Progress notes dated 6/4/12, 6/5/12, 6/6/12, 6/7/12, 6/8/12, 6/11/12, 6/12/12, 6/13/12 and 6/14/12 showed no dates and times.

On 6/13/12 at 1505, review of Patient #2's open chart revealed the patient was admitted to the Hospital with Osteomyelitis. Review of the patient's History and Physical (H&P) dictated on 5/15/12 at 1645 and transcribed on 5/15/12 at 1728 had no date and time.

On 6/13/12 at 1605, review of Patient #1's open chart revealed the patient was admitted to the Hospital with Altered Mental Status. Review of the patient's H&P dictated on 6/8/12 at 1157 and transcribed on 6/8/12 at 1208 has no signature, date and time.

On 6/14/12 at 0950, review of Patient #14's open chart revealed the patient was admitted to the Hospital with Total Parental Nutrition (TPN) wean. Review of the patient's H&P dictated on 5/24/12 at 1454 and transcribed on 5/24/12 at 1521 showed no signature, date, and time. Review of the Consultation report dictated on 5/25/12 at 1617 and transcribed on 5/25/12 at 1631 had no signature, date, and time. Review of the operative report dictated on 6/4/12 at 1151 and transcribed on 6/4/12 at 1201 had no date and time. Review of Progress notes dated: 5/25/12, 5/26/12, 5/28/12, 5/29/12, 6/1/12, 6/4/12, 6/5/12, 6/6/12, 6/7/12, 6/8/12, 6/11/12 and 6/13/12 had no times.






31395

On 06/11/12 at 1420, review of Patient #9's open record revealed the was admitted on 06/06/12 with a wound infection/Bacteremia, End Stage Renal Disease, and Septic shoulder post operative. Review of the patient's hemodialysis physician orders dated 06/07/12 and 06/10/12 had no Dialysis Flow Rate prescribed. Review of physician progress notes dated 06/07/12 had no physician signature, no date, and no time recorded. Review of physician progress notes dated 06/07/12 and 06/08/12 had no time the note was recorded.

On 06/13/12 at 1115, review of Patient #6's open chart revealed the patient was admitted on 06/06/12 with the diagnosis of post operative wound care revealed the patient's History and Physical dated 06/06/12 had no physician signature, no date, and no time recorded. Review of physician progress notes dated 06/07/12, 06/11/12, and 06/12/12 had no time recorded.

On 06/13/12 at 1155, review of Patient #11's open chart revealed the patient was admitted on 06/05/12 with respiratory failure. Review of physician progress notes dated 06/06/12, 06/11/12, 06/12/11, and 06/13/12 had no time recorded. Review of the patient's History and Physical dated 06/05/12 had no date and time recorded.

On 06/13/12 at 1230, review of Patient #8's open chart revealed the patient was admitted on 05/29/12 with Pneumonia. Review of the patient's History and Physical dated 05/29/12 had no date and time recorded. Review of physician progress notes dated 05/30/12, 05/31/12, 06/01/12, 06/04/12, 06/05/12, 06/06/12, 06/07/12, 06/11/12, and 06/12/12 had no time recorded.

On 06/13/12 at 1455 record review of Patient #7's open chart revealed that the patient was admitted on 06/08/12 with the diagnosis of Osteomyelitis. Review of the patient's history and physical dated 06/08/12 had no date and time recorded. Review of a physician consultation report dated 06/11/12 revealed the report had no physician signature, date, or time recorded. Review of physician progress notes dated 06/08/12, 06/11/12, and 06/12/12 had no time recorded.

On 06/13/12 at 1600, review of Patient #5's chart revealed the patient was admitted on 05/31/12 with Acute Respiratory Failure. Review of the patient's History and Physical dated 05/31/12 had no date or time recorded. Review of physician progress notes dated 06/07/12, 06/09/12, 06/10/12, 06/11/12, 06/12/12, and 06/13/12 had no times recorded.

On 06/14/12 at 1110, review of Patient #12's chart revealed the patient was admitted on 06/05/12 with cellulitis. Review of physician progress notes dated 06/08/12, 06/11/12, and 06/12/12 had no times recorded.

Hospital policy, "DS 201: Assessment And Documentation Requirements Pre, Intra and Post Hemodialysis", reads, "....Ensure that a physician's order (Hemodialysis Orders-DS 201.1) is written for each dialysis treatment which may include the following information:....Dialysis Flow Rate....".

Hospital policy, "Collaborative Practice Agreement to Supervise Dependent Allied Health Practitioner", reads, "....6. The Allied Health Practitioner (AHP) shall be accountable to date and sign each entry in the medical record with the applicable designation behind their name. Medical record entries shall be countersigned to show agreement by the supervising physician. All medical records are expected to be completed by the AHP and the supervising physician in accordance with the Rules and Regulations of the Medical Staff....".









31672

On 6-13-12 at 1130, review of Patient #10's open record revealed the patient was admitted on 6-5-12 with Bacterial endocarditis. Further review of the patient's record revealed:
On 6-6-12: Progress notes had no time noted by Hospitalist,
On 6-6-12: Progress notes had no time noted by Infectious Disease physician,
On 6-7-12: Progress notes had no time noted by Hospitalist,
On 6-11-12: Progress notes had no time noted by Hospitalist
On 6-12-12: Progress notes had no time noted by Hospitalist

On 6-14-12 at 1500, review of Patient #19's open record revealed the patient was admitted on 5-22-12 with cellulitis. Further review of the patient's record revealed incomplete History and Physical, Physician's Orders, Progress notes, Admission Orders and Insulin (Subcutaneous) Physician Order Set. Details as follows:
History and Physical not signed, dated or timed by the physician
5-25-12- Progress notes- no time noted by the physician
5-27-12- Progress notes- no time noted by the physician
5-30-12- Progress notes- no time noted by the ID physician
5-30-12- Progress notes- no time noted by the Hospitalist
5-31-12- Progress notes- no time noted by the physician
6-1-12- Progress notes- no time noted by the physician
6-4-12- Progress notes- no time noted by the physician


On 6-14-12 at 1535, review of Patient #20's open record revealed the patient was admitted on 5-24-12 with a wound infection. Further review of the record revealed incomplete physician's orders, consultant reports, progress notes, wound progress notes, admissions orders and history and physical as follows:
Consultation report not signed, dated or timed by physician
History and Physical not signed, dated or timed by physician
5-25-12- Progress notes- no time noted by physician
5-27-12- Physician's Orders- no date or time noted by physician (telephone verbal order)
5-28-12- Progress notes- no time noted by physician
5-29-12- Progress notes- no time noted by physician
5-30-12- Progress notes- no time noted by physician
5-31-12- Progress notes- no time noted by physician
6-1-12- Wound Progress Note- no date or time noted by physician
6-1-12- Progress notes- no time noted by physician
6-4-12- Progress notes- no time noted by physician
6-5-12- Progress notes- no time noted by physician
6-6-12- Progress notes- no time noted by physician
6-7-12- Progress notes- no time noted by physician
6-11-12- Progress notes- no time noted by physician
6-12-12- Progress notes- no time noted by physician
6-13-12-Progress notes- no time noted by physician

Facility policy, Medical Staff Rules and Regulations, reads, " ....D. General Conduct Of Care"- 1.... the responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate such order within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours....".

Facility policy, Collaborative Practice Agreement to Supervise Dependent Allied Health Practitioner, reads, "....6. The Allied Health Practitioner (AHP) shall be accountable to date and sign each entry in the medical record with the applicable designation behind their name. Medical record entries shall be countersigned to show agreement by the supervising physician. All medical records are expected to be completed by the AHP and the supervising physician in accordance with the Rules and Regulations of the Medical Staff....".

On the days of the Hospital Validation Survey based on record review and interview, the hospital failed to ensure that all medical orders were authenticated, dated, and signed for 7 of 21 open records (#12, 5, 7, 8 11, 19, and 20) and for 1 of 9 closed records reviewed for care and services (Patient #1)


The findings are:


On 06/13/12 at 1155, review of Patient #11's open chart revealed the patient was admitted on 06/05/12 with respiratory failure. Review of the physician orders dated 06/05/12, 06/06/12, 06/06/12, 06/07/12, 06/08/12, 06/10/12, 06/10/12, 06/11/12, and 06/12/12 had no date and time recorded. Review of physician orders for restraints dated 06/05/12 and 06/06/12 had no date and time recorded. Review of physician orders for restraints dated 06/10/12 had no time recorded.

On 06/13/12 at 1230, review of Patient #8's open chart revealed the patient was admitted on 05/29/12 with Pneumonia. Review of physician orders dated 05/30/12 and 06/04/12 had no time recorded.

On 06/13/12 at 1455 record review of Patient #7's open chart revealed that the patient was admitted on 06/08/12 with the diagnosis of Osteomyelitis. Review of physician orders dated 06/08/12 showed the physician order had no date or time recorded. Review of the physician order dated 06/09/12 and 06/12/12 showed the physician orders had no time recorded.

On 06/13/12 at 1600, review of Patient #5's open chart revealed the patient was admitted on 05/31/12 with Acute Respiratory Failure. Review of physician orders dated 05/31/12, 06/01/12, 06/05/12, 06/07/12, and 06/09/12 had no times recorded. Review of physician orders dated 06/02/12, 06/05/12, 06/06/12, 06/07/12, 06/10/12, and 06/11/12 had no dates or times recorded. Review of the patient's physician restraint orders dated 06/02/12, 06/04/12, and 06/11/12 had no times recorded.

On 06/14/12 at 1110, review of Patient #12's open chart revealed the patient was admitted on 06/05/12 with cellulitis. Review of the physician orders dated 06/05/12, 06/09/12, 06/10/12, 06/11/12, 06/12/12, 06/13/12, 06/13/12 had no times recorded.

Facility policy, Medical Staff Rules and Regulations, reads, " ....D. General Conduct Of Care"- 1.... the responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate such order within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours....".


Facility policy, Collaborative Practice Agreement to Supervise Dependent Allied Health Practitioner, reads, "....6. The Allied Health Practitioner (AHP) shall be accountable to date and sign each entry in the medical record with the applicable designation behind their name. Medical record entries shall be countersigned to show agreement by the supervising physician. All medical records are expected to be completed by the AHP and the supervising physician in accordance with the Rules and Regulations of the Medical Staff....".





31672

On 6-12-2012 at 1045, review of Patient #1's closed record revealed the patient was admitted on 3-13-2012 with debility, low blood sugar, End Stage Renal Disease, and Peripheral Vascular Disease. Further review of the patient's record revealed: On 3-23-12, Restraint Order/ Assessment Sheet showed the Physician signed the order 24 days after the 48 hour period. On 3-27-12, Physician Orders had no time noted by the physician.
On 3-31-12, Physician's Orders had no time noted by the physician and the physician signed the order 5 days after the 48 hour period.

On 6-14-12 at 1500, review of Patient #19's open record revealed the patient was admitted on 5-22-12 with cellulitis. Further review of the patient's record revealed on 5-22-12, Admission Orders had no time noted by the physician and orders on 5-22-12, Insulin (subcutaneous) Physician Order Set, had no time noted by the physician.

On 6-14-12 at 1535, review of Patient #20's open record revealed the patient was admitted on 5-24-12 with a wound infection. Further review of the record revealed orders on 5-24-12, Admission Orders had no time noted by physician, and orders on 6-3-12, Physician's Orders had no date or time noted by physician ( telephone verbal order).

On the days of the Hospital Validation Survey based on record reviews and interviews, the hospital failed to ensure that medical staff authenticate, sign, and date all verbal orders within 48 hours for 8 of 21 (#6, 4, 21, 2, 1, 14, 10 and 20) open patient records and 1 of 1 closed patient records (Patient #1) reviewed for care and services.

The findings are:


On 6/12/12 at 1500, review of Patient #4's open chart revealed the patient was admitted to the Hospital with Altered Mental Status. Review of the following telephone orders showed the physician orders had no dates and times when the physician authenticated the telephone orders dated 5/26/12 (4 telephone orders), 5/27/12 (1 telephone order), 5/29/12 (1 telephone order), 5/30/12 (1 telephone order ), 6/1/12 (2 telephone order) and 6/2/12 (1 telephone order).

On 6/13/12 at 1430, review of Patient #21's open chart revealed the patient was admitted to the hospital with Pneumonia. Review of physician telephone orders showed the orders had no dates and/or times when the physician signatures were written: 6/2/12 (2 telephone orders) and 6/4/12 (1 telephone order).

On 6/13/12 at 1505, review of Patient #2's open chart revealed the patient was admitted to the Hospital with Osteomyelitis. Telephone orders had no dates and times when the physician signatures were written on the orders: 5/16/12 (1 telephone order), 5/17/12 (1 telephone order), 5/21/12 (1 telephone order), 5/22/12 (1 telephone order), 5/23/12 (2 telephone order), 5/28/12 (1 telephone order) and 6/6/12 (1 telephone order).

On 6/13/12 at 1605, review of Patient #1's open chart revealed the patient was admitted to the Hospital with Altered Mental Status. Review of physician telephone orders revealed the orders had no dates and times when the physician signatures were written on the orders: 6/8/12 (2 telephone orders), 6/9/12 (1 telephone orders) and 6/10/12 (2 telephone orders).

On 6/14/12 at 0950, review of Patient #14's open chart revealed the patient was admitted to the Hospital with Total Parental Nutrition (TPN) wean. Review of physician telephone orders showed the orders had no dates and times when the physician signatures were written on the orders: 6/8/12 (1 telephone order), 6/9/12 (1 telephone order) and 6/10/12 (1 telephone order). Telephone order had no time, or signature on 5/27/12 (1 telephone order).



31395

On 06/13/12 at 1115, review of Patient #6's open chart revealed the patient was admitted on 06/06/12 with the diagnosis of post operative wound care. Review of the physician verbal orders dated 06/07/12 showed the order had no time (telephone order), and review of verbal physician order dated 06/08/12 showed the order had no time.


31672

On 6-12-2012 at 1045, review of Patient #1's closed record revealed the patient was admitted on 3-13-2012 with debility, low blood sugar, End Stage Renal Disease, and Peripheral Vascular Disease. Further review of the patient's record revealed:
On 3-19-12: Physician Telephone Order had no time noted by the physician; On 3-19-12: Physician Telephone Order had no physician signature, date or time; On 3-20-12: Physician Telephone Order revealed the physician signed the order greater ( >) than 48 hours, specifically 9 days later; On 3-20-12: Physician Telephone Orders had no time noted, and the physician signed the telephone order more than 48 hours later, specifically 20 days later; and On 3-21-12: Physician Telephone Order had no time noted by the physician.

On 6-13-12 at 1130, review of Patient #10's open record revealed the patient was admitted on 6-5-12 with Bacterial endocarditis. Further review
of the patient's record revealed: On 6-6-12: Physician's Orders had no time or date noted by physician (telephone verbal order),

On 6-14-12 at 1535, review of Patient #20's open record revealed the patient was admitted on 5-24-12 with a wound infection. Further review of the record revealed on 5 -27-12: Physician's Orders- had no date or time noted by physician (telephone verbal order).

Facility policy, Medical Staff Rules and Regulations, reads, " ....D. General Conduct Of Care"- 1.... the responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate such order within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours....".

Facility policy, Collaborative Practice Agreement to Supervise Dependent Allied Health Practitioner, reads, "....6. The Allied Health Practitioner (AHP) shall be accountable to date and sign each entry in the medical record with the applicable designation behind their name. Medical record entries shall be countersigned to show agreement by the supervising physician. All medical records are expected to be completed by the AHP and the supervising physician in accordance with the Rules and Regulations of the Medical Staff....".

On the days of Hospital Validation Survey based on observation and review of facility policy and procedure, the hospital failed to remove expired medications and supplies from patient stock for usage.

The findings are:

On 6/11/12 from 1340-1400, random observations of hospital supplies revealed: 14 Optimental Tube Feedings, 1 liter bottles that expired 6/1/12, 1- 8 ounce (oz) bottle Povidone Iodine that expired 08/11, and 1 can Hurricane Spray that expired 1/12. The findings were verified by Safety Officer on 6/11/12 at 1400.





31395

On 06/11/12 at 1350, random observations revealed ten 1000 milliliter bags of Lactated Ringers with Dextrose 5% that expired on 06/01/12. On 06/11/12 at 1405, random observation revealed one bottle of Betadine that expired on 04/2012.

On the days of the Hospital Validation Survey based on observation, interview, review of hospital policy and procedures, hospital contracts, and review of the hospital reports of test tray sampling, the hospital failed to ensure that responsibilities and lines of authority were clearly delineated for food and dietetic services, the dietitian, and other staff within the organization.


The findings include:


Cross Reference to A0621:The Registered Dietitian failed to consistently monitor and maintain food temperatures of at least 140 Fahrenheit (F) degrees for hot foods and at 41 degrees F for cold foods before serving the meals to patients and failed to present a back up plan in the case of absences for monitoring food temperatures of meals delivered to the patient unit to ensure that temperatures of the foods were in safe ranges prior to serving patients.

Cross Reference to A0622: The hospital failed to ensure that 1 of 1 contracted dietary associate followed infection control measures by failing to remove contaminated PPE (personal protective equipment) before exiting an isolation room and by not preventing further cross contamination to other staff and patients in delivery of patient food trays. (Dietary Associate #1)

Cross Reference to A 0726: Contracted Dietary Staff and the Registered Dietitian failed to consistently monitor and ensure that food temperatures were maintained at 140 degrees Fahrenheit (F) for hot foods and 42 degrees F for cold foods before serving the meals to patients.

On the days of the Hospital Validation Survey based on observations, interviews, and review of records, the Registered Dietitian failed to consistently monitor and maintain food temperatures of at least 140 degrees Fahrenheit (F) for hot foods and at 41 F degrees for cold foods before serving the meals to patients, failed to ensure a back up plan for monitoring food temperatures of meals delivered to the patient unit to ensure that temperatures of the foods were in safe ranges, and failed to produce action plans for out of range food temperatures per the hospital's policy.


The findings include:


On 6-13-12 at 1215, random observations of the meal trays delivered to the patient unit revealed the hospital's Registered Dietitian obtaining the food temperatures of the foods on the sample test tray delivered to the patient unit in a food cart. The following food temperatures were obtained by the Registered Dietitian: Roast beef - 128 degrees F, roasted potatoes - 133 degrees F, carrots- 127 degrees F, and peach cobbler - 130 degrees F. On 6-13-12 at 1040, the Registered Dietitian, stated, "part of my job responsibility is to check the temperature of patient meal trays and to make sure the correct diet is being sent. However, I haven't been checking these things since I have been back from maternity leave." The dietitian, also revealed, "my six month old baby has been sick, that's why I wasn't here yesterday". The Dietitian presented no back up plan for obtaining food temperatures on the sample teat trays during his/her absence. On 6-12-12 at 1530, the Chief Executive Officer stated "when our dietitian is not available or is going to be out longer than just a few days, we have dietitians that cover her from the Host Hospital." Review of the Hospital's contract for Dietary Services agreement with an initial date of November 3, 2004 failed to identify who had the responsibility for training staff.

Cross Reference to A 0275: Hospital staff failed to consistently monitor and ensure that food temperatures were at least 140 degrees F for hot foods and 42 degrees F for cold foods before serving the meals to patients and no evidence that the hospital completed action plans to address any variances at the point of care or ongoing.

Hospital policy, Number 6.27, Issue Date: 06/21/2002, titled, "Food and Nutrition Policies and Procedures", reads, "Subject: Responsibilities of the Dietitian", In general, the responsibilities of the Dietitian are as follows: 2. Maintaining high standards in the quality of food services and the training of staff. 3. Planning and implementing programs for patient and employee education. 5. Delegating duties and responsibilities to competent individuals. " There was no responsibility listed for Dietitian's participation in the hospital's quality assurance program.

Hospital policy, Number: 6.19, Issue Date: 6/21/2002, revised: 07/20/2010, titled, "Food and Nutrition Policies and Procedures", reads, "subject: Food Handling, Policy: To define standards for the safe handling of food. Food handling standards should reflect federal, state, and local requirements. The Dietary Services Supervisor is responsible for the frequent observation of food handling techniques and, if necessary, for correcting poor methods. Food must be protected in every state - receiving, storage, preparation, serving, delivery to patients, waste disposal, utensils, flatware and china dish washing. Dietary personnel must be instructed on all food handling techniques, for example:
2. Keep food at room temperature for a minimum length of time. 3. Keep food hot (140 F or above) or cold (41 F or below).

Hospital policy, Number: 6.15, Issue date: 06/21/2002, revised 07/20/2012, "Food and Nutrition Policies and Procedures", reads, "subject: Food Preparation, "To establish general guidelines to ensure prepared food is of highest quality, flavor, appearance and temperature and bacterial contamination is minimal. 7. Proper serving temperature of food will be: Hot food: all hot food must be held at a temperature of 140 F or higher. Cold foods: All cold foods must be held at a temperature of 41 F or below.

On the days of the Hospital Validation Survey based on observation, interview, and review of hospital policy and procedures, the hospital failed to ensure that 1 of 1 contracted dietary staff followed infection control guidelines by failing to remove contaminated PPE (Personal Protective Equipment) before exiting an isolation room. (Dietary Associate #1)


The findings include:


On June 13, 2012 at 1241, random observations of the Dietary Associate #1 delivering patient meal trays on the patient unit revealed he/she entered a patient isolation room wearing PPE (Personal Protection Equipment), delivered the patient tray, exited the patient isolation room, went to the communal meal cart located on the patient unit with the same PPE worn in the patient isolation room, poured a glass of tea from the communal tea pitcher located on the food cart, and then, re-entered the patient isolation room. On June 15, 2012 at 1142, the Infection Control Officer/Quality Manager, stated, "contract personnel are held to the same responsibility as the hospital but the Host Hospital is held responsible for dietary contact employee training". Review of the Hospital's contract for Dietary Services agreement with an initial date of November 3, 2004 failed to identify who had the responsibility for training staff related to infection control requirements.

Facility policy,IC III-5, reads, "Enhanced Contact Precautions, Principles: A. Sufficient precautions to control cross-infection in this category of isolation include proper hand hygiene, handling of linen, dressings and contaminated instruments, and the use of gowns, masks and gloves when stipulated....#6. Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room.... Hospital B (Host Hospital) is responsible for training of contract dietary employees."

Hospital policy, Number 6.27, Issue Date: 06/21/2002, titled, "Food and Nutrition Policies and Procedures", reads, "Subject: Responsibilities of the Dietitian", In general, the responsibilities of the Dietitian are as follows: 2. Maintaining high standards in the quality of food services and the training of staff. 3. Planning and implementing programs for patient and employee education. 5. Delegating duties and responsibilities to competent individuals. " There was no responsibility for participation in the hospital's quality assurance program.

On the days of the Hospital Validation Survey based on observations, interviews, and review of records, Contracted Dietary Staff and the hospital's Registered Dietitian failed to consistently monitor and ensure that food temperatures were maintained at 140 degrees Fahrenheit (F) for hot foods and 42 degrees F for cold foods per the hospital's policy.


The findings include:


On 6-13-12 at 1215, random observations of meal trays delivered to the patient unit showed the Registered Dietitian obtaining the temperatures of foods on a sample test tray provided by the hospital's dietary services. The following food temperatures were obtained: Roast beef - 128 degrees F, roasted potatoes - 133 degrees F, carrots- 127 degrees F, and peach cobbler - 130 degrees F.

On 6-13-12 at 1040, the Registered Dietitian, stated, "part of my job responsibility is to check the temperature of patient meal trays and to make sure the correct diet is being sent. However, I haven't been checking these things since I have been back from maternity leave." The dietitian, also revealed, "my six month old baby has been sick, that's why I wasn't here yesterday". The Dietitian stated that the contracted dietary services sampled test trays in his/her absence. On 6-12-12 at 1530, the Chief Executive Officer stated, "when our dietitian is not available or is going to be out longer than just a few days, we have dietitians that cover her from .... (Host Hospital)".

On 6-13-12 at 1630, during an interview with the Regional Director of Operations with the contracted Dietary entity, he/she stated, "we do test tray evaluations and the test tray is always checked last". The Director produced the reports of the test tray evaluations for December 2011, January 2012, March 2012, May 2012, and June 2012.

On 06/13/12 at 1215, after the Registered Dietitian obtained the the temperatures of the foods on the test tray delivered for the morning meal revealed the temperatures were not within safe recommended dietary guidelines, dietary staff submitted forms labeled, "Food and Nutrition Services Test Tray Evaluation" dated 12/28/11, 1/17/12, 3/23/12, 5/19/12, and 6/13/12 (evening meal) that showed the dietary department monitors the food temperatures on sample meal trays when the trays are delivered to the patient unit. The form showed the date, the day, the nursing unit, name of sampler, and the diet type, e.g. renal. The form had the instructions for sampling a test tray for temperatures. Labeled sections on the form are: Temp (temperature), Taste/Aroma, Portion, Appearance, Delivery and Overall Appearance, and Score. The over all test score was calculated by adding the points from the food temperatures to the quality items such as appearance and aroma. The forms were signed either by a Registered Dietitian or other personnel.

Review of the sample test meal tray evaluation form dated 12/28/11 showed the test tray was a morning meal tray delivered to the patient unit. The following food temperatures were recorded: Scrambled eggs = 140.9, Pancakes = 141.8, Strawberries = 60.8 with a note:"Strawberries looked anemic, were gritty in texture", coffee = 153.9. Staff recorded a score of 81%(poor). Staff added the scores received for Taste/Aroma, Portion, and Appearance which increased the over all score. The instructions on the form reads, "8. develop action plan for overall evaluation of score of <90%, but staff submitted no action plan for review. There was no data to ascertain if the food trays were or were not served to the patients. There was no evidence of an immediate follow up . The next sample test tray report was dated 1/17/12.

Review of the sample test tray evaluation dated 01/17/12 showed the test tray was a morning meal tray delivered to patient unit. The following food temperatures were recorded: Skim milk=39.4, scrambled eggs = 145.9, grits= 141.8, Bacon wasn't tested, Biscuit wasn't tested, and coffee = 159.7. When added with all the other factors, a score of 100% was recorded although two items were not tested. The next sample test tray report was dated 3/23/12.

Review of the sample test tray evaluation dated 03/23/12 showed the test tray was a morning meal tray delivered to the patient unit. The following food temperatures were recorded: Skim milk (47.3), Yogurt (54.1), fruit (57.2), Rice (nothing recorded), and coffee(162.1). When added with all the other factors, a score of 83% was recorded. Three of the four foods items were out of range temperatures(25%). There was no action plan or evidence of follow up of the out of range scores. Instructions on the form reads, "8. develop action plan for overall evaluation of score of <90%, staff submitted no action plan for review. There was no data to ascertain if the food trays were or were not served to the patients. There was no evidence of an immediate follow up. The next sample test tray report was dated 5/19/12.

Review of the sample test tray evaluation dated 05/19/12 showed the sample test tray was a morning meal tray delivered to the patient unit. The following food temperatures were recorded: milk (39.6), fruit (57.7), scrambled eggs and Canadian bacon sandwich (131.7), and coffee(159.3). When added with all the other factors, a score of 90% was recorded although two of the four foods items tested out of range (50%). There was no action plan or evidence of follow up of the out of range scores. When added with all the other factors, a score of 90% was recorded. The next sample test tray meal tray report was dated 6/13/12.

Review of the sample test tray evaluation dated 6/13/12 showed the test tray was an evening tray delivered to the patient unit after a morning test tray, observed by the surveyor, had variances. The following food temperatures were recorded: Grilled Chicken Breast (154), Yellow Rice (158), sugar snap peas (56), ice tea(31). When added to all other factors, a score of 100% was recorded.

Documentation submitted by staff for sampling of food temperatures on patient trays delivered to the hospital patient unit by the contracted food service showed that sampling food temperatures for the meal trays delivered to the patient unit was not conducted in a systematic routine, showed staff failed to follow up reports of out of range temperature findings with an action plan, failed to immediately take action when daily food temperature results on the sample test meal tray were out of range, the total results for the test for food temperatures were skewed when the results of the food temperatures were added to other quality parameters on the form giving a higher score, samples were consistently obtained only on morning meal test trays, produced no plan to sample food temperatures in the absence of the Registered Dietitian in that no sample test tray evaluations were presented for February 2012 and May 2012. Further, the Registered Dietitian reported that he/she did not participate in the hospital's Quality Assurance program. These factors have the potential to adversely affect the health of any patient served meals.
On 6-13-12 at 1630, the Regional Director of Operations with the dietary contracted entity, stated "we do test tray evaluations and the test tray is always checked last".

Hospital policy, Number: 6.19, Issue Date: 6/21/2002, revised: 07/20/2010, "Food and Nutrition Policies and Procedures", reads, "subject: Food Handling, Policy: To define standards for the safe handling of food. Food handling standards should reflect federal, state, and local requirements. The Dietary Services Supervisor is responsible for the frequent observation of food handling techniques and, if necessary, for correcting poor methods. Food must be protected in every state - receiving, storage, preparation, serving, delivery to patients, waste disposal, utensils, flatware and china dish washing. Dietary personnel must be instructed on all food handling techniques, for example: 2. Keep food at room temperature for a minimum length of time. 3. Keep food hot (140 F or above) or cold (41 F or below).

Hospital policy, Number: 6.15, Issue date: 06/21/2002, revised 07/20/2012, "Food and Nutrition Policies and Procedures", reads, "subject: Food Preparation, "To establish general guidelines to ensure prepared food is of highest quality, flavor, appearance and temperature and bacterial contamination is minimal. 7. Proper serving temperature of food will be: Hot food: all hot food must be held at a temperature of 140 F or higher. Cold foods: All cold foods must be held at a temperature of 41 F or below.

Cross Reference to A 0083: The governing body failed to ensure services furnished in the hospital whether or not those services are furnished under contracts complied with all conditions of participation.

On the days of the Hospital Validation Survey based on observation, interview, and reviews of hospital policy and procedures, the hospital failed to ensure that 1 of 1 contracted dietary associate (#1) followed infection control guidelines by failing to remove contaminated PPE (personal protective equipment) before exiting an isolation patient room (Dietary Associate #1), and 1 of 1 Registered Nurses administering medications to a patient on contact isolation who failed to remove soiled gloves. (Registered Nurse #2)


The findings include:


On June 13, 2012 at 1241, random observations of Dietary Associate (#1) delivering patient meal trays on the hospital's patient unit revealed Dietary Associate #1 entered the isolation patient room wearing PPE (Personal Protection Equipment) and delivered the food tray. Dietary Associate #1 was observed as he/she exited the isolation room, went to the communal meal cart located on the patient unit wearing the same PPE the he/she had worn in the patient isolation room, poured a glass of tea from the communal tea pitcher located on the food cart, and then, re-entered the patient isolation room. On June 15, 2012 at 1142, the Infection Control Officer/Quality Manager, stated, "contract personnel are held to the same responsibility as the hospital, but the Host Hospital is responsible for dietary contract employee training". Review of the Hospital's contract for Dietary Services agreement with an initial date of November 3, 2004 failed to identify who had the responsibility for training staff related to infection control requirements.
Review Hospital policy, Food and Nutrition Policies and Procedures, Number 6.19, Issue Date: 6/21/2002, Revised: 07/20/2010, reads, "Subject: Food Handling, Policy: To define standards for the safe handling of food. Food handling standards should reflect federal, state, and local requirements. The Dietary Services Supervisor is responsible for the frequent observation of food handling techniques and if necessary, for correcting poor methods. Food must be protected at every state - receiving, storage, preparation, serving, delivery to patients, waste disposal, utensils, flatware, and china dish washing."

On 06/11/12 at 1250, random observations revealed Registered Nurse #2 administering medications to a patient on isolation precautions. Observation showed Registered Nurse #2 donned gloves and a gown, took the wireless medication/identification scanner into the patient's room, scanned the patient's identification bracelet, wiped the medication/identification scanner with a Saniwipe, returned the wireless scanner back to the holder on the portable computer, started typing on the computer, and then re-entered the patient's room without hand hygiene or changing his/her gloves during the entire process. On 06/11/12 at 1255, during an interview with the Respiratory Manager/Safety Manager who was present during the observation, the Safety Manager reported, "masks are optional for staff to wear during the care of patients on contact precautions, but you got us on the gloves." On 6/11/12 at 1255, the finding was verified with Respiratory Manager/Safety Manager.

Hospital policy "IC III-5: Enhanced Contact Precautions", reads, "....Gloves must be removed before leaving the room....".
Hospital policy, IC III-5, reads, "Enhanced Contact Precautions, Principles: A. Sufficient precautions to control cross-infection in this category of isolation include proper hand hygiene, handling of linen, dressings and contaminated instruments, and the use of gowns, masks and gloves when stipulated....#6. Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room....".

On the days of the Hospital Validation Survey based on observations, interviews, and review of hospital data, hospital staff failed to consistently monitor and ensure that food temperatures were at least 140 degrees for hot foods and 42 degrees for cold foods before serving the meals to patients and presented no documentation that the hospital completed action plans to address any variances at the point of care or ongoing.


The findings include:


On 6-13-12 at 1215, random observation of the Registered Dietitian
obtaining the temperature of the foods on the sample test tray sent by dietary revealed: roast beef - 128 degrees Fahrenheit (F), roasted potatoes - 133 degrees F, carrots- 127 degrees F, and peach cobbler - 130 degrees F.

On 6-13-12 at 1040, the Registered Dietitian, stated, "part of my job responsibility is to check the temperature of patient meal trays and to make sure the correct diet is being sent. Although I haven't been checking these things since I have been back from maternity leave." When the Registered Dietitian was queried about her department's role in the hospital wide Quality Assurance Process Improvement program, the dietitian stated, "what is QAPI"? When explained that it is the hospital's process improvement program , the Dietitian stated, "I am not involved in that".

On 06/13/12 at 1215, dietary staff submitted forms labeled "Food and Nutrition Services Test Tray Evaluation" dated 12/28/11, 1/17/12, 3/23/12, 5/19/12, and 6/13/12 (evening meal) to show the dietary department monitors food temperatures on trays on a random basis when the meal trays are delivered to the patient unit. The form showed the date, the day, the nursing unit, name of sampler, and the diet type on the sample test tray. The form had the instructions for the sampling of the test tray for temperatures of the foods. The sections on the form were labeled: Temp (temperature), Taste/Aroma, Portion, Appearance, Delivery and Overall Appearance, and Score. The over all score was calculated by adding the points obtained from the food temperature scores to the scores from the appearance and aroma. The forms were either signed by the Registered Dietitian or other dietary personnel.

Review of the test tray evaluation form dated 12/28/11 showed the test tray was a morning meal tray delivered to the 4th floor unit at the Hospital. The following food temperatures were recorded: Scrambled eggs = 140.9, Pancakes = 141.8, Strawberries = 60.8 with a note:"Strawberries looked anemic, were gritty in texture", coffee = 153.9. Staff recorded a score of 81%(poor). Although the instructions on the form reads, "8. develop action plan for overall evaluation of score of <90%, staff submitted no action plan during the survey for review. There was no data to ascertain if the food trays were or were not served to the patients that day. There was no evidence of an immediate follow up with another sample test tray, and the next sample test tray form was dated 1/17/12.

Review of the sample test tray evaluation dated 01/17/12 showed the sample test tray was also a morning meal tray delivered to the fourth floor of the Hospital. The following food temperatures were recorded: Skim milk=39.4, scrambled eggs = 145.9, grits= 141.8, Bacon wasn't tested, Biscuit wasn't tested, and coffee = 159.7. A score of 100% was recorded although two food items were not tested. Although the instructions on the form reads, "8. develop action plan for overall evaluation of score of <90%, staff submitted no action plan for review because of the 100% score. There was no evidence of an immediate follow up with the replacing the milk. The next sample test tray was dated 3/23/12.

Review of the sample test tray evaluation dated 03/23/12 showed the sample test tray was also a morning meal tray delivered to the fourth floor of the Hospital. The following food temperatures were recorded: Skim milk (47.3), Yogurt (54.1), fruit (57.2), Rice (nothing recorded), and coffee(162.1). A score of 83% was recorded although three of the four foods were out of range (milk, yogurt, and fruit). There was no action plan or evidence of follow up of the out of range scores. Although the instructions on the form reads, "8. develop action plan for overall evaluation of score of <90%, staff submitted no action plan for review. There was no data to ascertain if the food trays were or were not served to the patients. There was no evidence of an immediate follow up with the milk, yogurt and fruit . The next sample test tray was dated 5/19/12.

Review of the sample test tray evaluation dated 05/19/12 showed the sample test tray was also a morning meal tray delivered to the fourth floor of the Hospital. The following food temperatures were recorded: milk (39.6), fruit (57.7), scrambled eggs, Canadian bacon sandwich, (131.7) and coffee(159.3). A score of 90% was recorded although two of the four foods were out of range . There was no action plan or evidence of follow up of the out of range scores. Although the instructions on the form reads, "8. develop action plan for overall evaluation of score of <90%, staff submitted no action plan for review because the over all score was 90%. There was no data to ascertain if the food trays were or were not served to the patients. There was no evidence of an immediate follow up . The next sample test tray was dated 6/13/12.

Review of the sample test tray evaluation dated 6/13/12 showed the test tray was an evening tray delivered to the fourth floor of the Hospital. This was after the 6/13/12 morning test tray observed by the surveyor for the morning meal and listed above. The following food temperatures were recorded: Grilled Chicken Breast (154), Yellow Rice (158), sugar snap peas (56), ice tea(31). When added to all other factors, a score of 100% was recorded.

Documentation submitted by staff for sampling of food temperatures on sample patient trays delivered to the hospital patient unit by the contracted food service entity showed that sampling food temperatures for the meal trays that were delivered to the patient unit did not occur in a systematic routine, showed staff failed to recognize and/or follow up reports of out of range temperature reports with an action plan, failed to immediately take action when a daily temperature for any food result was out of range, the results of the test for food temperatures were skewed when the results of the food temperatures were added to other parameters on the form, samples were consistently obtained on a morning meal test tray, and there was no plan in the hospital's system to sample food temperatures in the absence of the Registered Dietitian in that no sample tray documentation was presented for February 2012 and May 2012, and the Registered Dietitian reported that he/she did not participate in the hospital's Quality Assurance program. These factors have the potential to adversely affect the health of any patient served meals with out of range temperatures.

On 6-13-12 at 1630, interview with the Regional Director of Operations with the contracted food services entity, stated, "we do test tray evaluations and the test tray is always checked last".

Review of the hospital's Fourth Quarter 2011 annual contract services for Dietary revealed the indicators: "1. Timely and accurate delivery of dietary items ordered, 10 trays per month." Outcome is listed as, ... Accuracy and timeliness of dietary items ordered: YES." Actions/Follow Up Required, reads, "Monthly audits confirmed accuracy and timely delivery of patient trays. Continued monitoring and audit of trays during 2012." There were no indicators for Food Temperatures.

Hospital policy, Number: 6.19, Issue Date: 6/21/2002, revised: 07/20/2010, "Food and Nutrition Policies and Procedures", reads, "subject: Food Handling, Policy: To define standards for the safe handling of food. Food handling standards should reflect federal, state, and local requirements. The Dietary Services Supervisor is responsible for the frequent observation of food handling techniques and, if necessary, for correcting poor methods. Food must be protected in every state - receiving, storage, preparation, serving, delivery to patients, waste disposal, utensils, flatware and china dish washing. Dietary personnel must be instructed on all food handling techniques, for example:
2. Keep food at room temperature for a minimum length of time. 3. Keep food hot (140 F or above) or cold (41 F or below).

Hospital policy, Number: 6.15, Issue date: 06/21/2002, revised 07/20/2012, "Food and Nutrition Policies and Procedures", reads, "subject: Food Preparation, "To establish general guidelines to ensure prepared food is of highest quality, flavor, appearance and temperature and bacterial contamination is minimal. 7. Proper serving temperature of food will be: Hot food: all hot food must be held at a temperature of 140 F or higher. Cold foods: All cold foods must be held at a temperature of 41 F or below.

On the days of the Hospital Validation Survey based on record review and interview, the hospital failed to ensure that dialysis patients with physician orders for Heparin received the ordered dose of Heparin for 2 of 2 patients receiving Heparin. (Patient #9 and #4)


The findings are:


On 06/11/12 at 1420, review of Patient #9's chart showed the patient was admitted on 06/06/12 with wound infection/bacteremia, End Stage Renal Disease, and Septic shoulder post operative. Patient #4 had a physician order for a total dose of Heparin 6,000 units to be delivered during the patient's dialysis treatment. Review of the patient's dialysis treatment sheet dated 06/07/12 showed the total Heparin dose that the patient received was 5300 units which was 700 heparin units less than prescribed. Review of the patient's dialysis treatment sheet dated 06/11/12 showed the total Heparin dose the patient received was 2300 units which was 3700 units less than prescribed. On 06/15/12 at 1530, the findings were verified with the Director of Dialysis.

Hospital policy, "DS 201: Assessment And Documentation Requirements Pre, Intra, and Post Hemodialysis", reads, "....4. Asses the patient during the intradialytic period and document findings and interventions on the patient's treatment flow sheet. The assessment will include at the following minimum requirements:....Heparin infusion rate....".

On the days of the Hospital Validation Survey based on observation, record reviews, and interviews, the Hospital failed to secure the medical records of patients who had procedures in the Host Hospital in that observations showed the Chief Nursing Officer(CNO) and the Charge Nurse on duty were observed as they accessed the reports identified with the Host Hospital's name from the computer system with a potential to affect all patients who receive services from the Host Hospital.


The findings are:


Cross Reference to A 0441: The hospital failed to ensure secure access to the electronic medical records of patients who had procedures for 2 of 21 open patient records reviewed when the patient had a procedure (Patient 4 and 15) and 2 of 9 closed records reviewed for a patient who had a procedure. (Patient #3 and 13).