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730 17TH STREET

MODESTO, CA null

GOVERNING BODY

Tag No.: A0043

Based on observation, interview, clinical record, and administrative document review, the hospital failed to have an effective governing body legally responsible for the conduct of the hospital when:

1. The hospital did not protect and promote each patient's rights. The hospital had no system in place to identify and resolve patient grievances. Patients were not informed there was no medical doctor present in the hospital 24 hours a day, seven days a week and patients did not receive care in a safe setting. (refer to A 118, 131 and 144)

2. The hospital did not have an active and effective quality assurance and performance improvement (QAPI) program that collected and analyzed data and used the data to implement tracking and monitoring for the reduction of risk of infections. (refer to A 283)

3. The hospital did not have a registered nurse to supervise and evaluate nursing care in accordance with accepted standards of practice. Nursing personnel performed duties outside their scope of practice. (refer to A 395 findings 1-3)

4. The hospital did not have an organized and effective dietetic services program. There was no plan for implementation of the disaster food program. The hospital did not ensure nutritional needs were being met based on accurate assessments. There was no system in place to ensure food was handled in a safe manner, menus were followed, nutritional care plans were integrated with multidisciplinary care plans, or that trash was stored and transported properly. (refer to A 283, 620, 621, 629 and 749)

5. The hospital did not provide a safe environment for patients. Equipment was not maintained in a safe operating condition and trash was not stored and transported properly. (refer to A 701 findings 1 and 2 and 713)

6. The hospital did not ensure a system was in place for identifying, reporting, investigating, controlling infections and communicable diseases. Staff was not trained on proper hand washing techniques, use of personal protective equipment or isolation protocols. Equipment was not cleaned or maintained properly. Trash was not stored or transported properly. Food was not stored in a safe and sanitary manner. (refer to A 749 findings 1 - 8)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and professional manner.

PATIENT RIGHTS

Tag No.: A0115

Based on interview and record review, the facility failed to protect and promote each patient's rights when:

1. Unresolved patient care complaints were not identified as grievances for one of 32 sampled patients (Patient 1) (Refer to A 118)

2. Patients were not provided written notice on admission that there was no doctor of medicine or osteopathy (MD or DO) present in the hospital 24 hours per day, seven days per week (Refer to A 131)

3. Patients did not receive care in a safe setting. (Refer to A 144)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and professional manner.

QAPI

Tag No.: A0263

Based on observation interview and administrative document review, the hospital failed to develop and maintain an effective, comprehensive, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program for all department in the hospital when:

1. The hospital did not protect and promote each patient's rights. The hospital had no system in place to identify and resolve patient grievances. Patients were not informed there was no medical doctor present in the hospital 24 hours a day, seven days a week and patients did not receive care in a safe setting. (refer to A 118, 131 and 144)

2. The hospital did not have a registered nurse supervise and evaluate nursing care in accordance with accepted standards of practice. Nursing personnel performed duties outside their scope of practice. (refer to A 395)

3. The hospital did not have organized and effective dietetic services. There was no implementation of the disaster food program. The hospital did not ensure nutritional needs were being met based on accurate assessments. There was no system in place to ensure food was handled in a safe manner, menus were followed, nutritional care plans were integrated with multidisciplinary care plans, or that trash was store and transported properly. (refer to A 283, 620, 621, 629 and 749)

4. The hospital did not provide a safe environment for patients. Equipment was not maintained in a safe operating condition and trash was not stored and transported properly. (refer to A 701 findings 1 and 2 and 713)

5. The hospital did not ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases. Staff was not trained on proper hand washing techniques, use of personal protective equipment (PPE-gloves, masks, gowns) or isolation protocols. Equipment was not cleaned or maintained properly. Trash was not stored or transported properly. Food was not stored in a safe and sanitary manner. (refer to A 749 findings 1 - 8)

NURSING SERVICES

Tag No.: A0385

Based on observation, interview, and record review, the hospital failed to have a registered nurse supervise and evaluate nursing care in accordance with accepted standards of practice when:

1. Nursing personnel conducted code blue procedures, administered medications, and pronounced death without orders or direction from a medical doctor. (refer to A-395)

2. Nursing personnel discontinued cardiac monitoring without orders from a medical doctor. (refer to A-395)

An Immediate Jeopardy (IJ - when there is actual or potential harm to a patient) situation was identified on 2/22/19 at 2:46 p.m. related to findings in Nursing Services at 42 CFR 482.23, with the hospital Chief Nursing Officer, Associate Chief Nursing Officer, Quality Coordinator, Medical Director, Director of Operations, and Hospital Administrator. The IJ was called due to the serious potential harm to all patients because Registered Nurses independently initiated and conducted code blue procedures without the benefit of a physician directing the code blue. Nurses administered code blue rescue medications without determining the rationale for the administration of the code blue medication and without a Medical Doctor (MD) order. Nursing staff discontinued prescribed services, such as telemetry, without physician order and notification. The hospital submitted an acceptable Action Plan and implemented corrective actions. The Chief Nursing Officer, Hospital Administrator, Owner and Directors of Operations were present at the time the IJ was removed on 3/5/19 at 3:51 p.m.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and professional manner.

FOOD AND DIETETIC SERVICES

Tag No.: A0618

Based on observation, interview, and document review, the hospital failed to have an organized dietetic services when:

1. The hospital did not implement disaster food program that resulted in an immediate jeopardy situation. (refer to A 620)

2. The hospital did not identify accurate and ongoing nutritional assessments. (refer to A 621)

3. The hospital did not ensure integration of Food and Dietetic Services into the hospital wide Quality Assessment and Performance Improvement (QAPI) program. (refer to A 263, 283, and 620)

4. The hospital did not maintain safe food handling practices. (refer to A 620)

5. Menus were not followed. (refer to A 629)

6. Nutrition care plans were not integrated into multidisciplinary care plan. (refer to A 621)

7. Trash storage and transport did not meet infection prevention standards. (refer A 749)

An Immediate Jeopardy (IJ) situation was identified on 2/22/19 at 9:55 a.m. related to findings in Director of Dietary Services at 42 CFR 482.28 (A 620) with the hospital Chief Nursing Officer, Associate Chief Nursing Officer, and Quality Coordinator. Serious issues were identified with implementation of a disaster food program, ongoing nutritional assessments, integration of Food and Dietetics into QAPI, safe food handling practices, menus being followed, nutrition care plans, and trash storage. The hospital developed and submitted an acceptable action plan that addressed the IJ situation. The hospital implemented immediate corrective actions to address the issues, which included; education and training of leadership and dietary staff on the preparation of food for emergency preparedness, education and training of all dietary staff on safe food handling, use of care plans, following menus, and trash storage. The survey team validated training of staff before the IJ was abated on 2/26/19 at 2:30 p.m.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and sanitary environment.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observation, interview, and document review, the hospital failed to provide facilities that ensured a safe environment for patients when::

1. The hospital did not maintain mechanical facility equipment in a safe operating condition. (refer to A 701 findings 1 and 2)

2. The hospital did not ensure proper routine storage and transport of trash from the Food Service Department. (refer to A 713)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and sanitary environment.

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

LICENSURE OF HOSPITAL

Tag No.: A0022

Based on observation, interview and record review, the facility failed to comply with State licensure requirements when:

1. The first floor gym area was converted into a multi-treatment hemodialysis (a process used to purify the blood of persons whose kidneys are not working normally) unit used for hemodialysis treatments without getting proper approval.

2. Seven patient room sizes were not in accordance with Federal and State laws and regulations.

This failure had the potential for patients to be treated in unsafe patient care areas.

Findings:

1. During an interview with the Dialysis Clerk (DC) on 2/25/19 at 10:11 a.m., the DC stated the multi-treatment room can hold up to four patients for treatments at one time. The DC stated the multi- treatment room had been in use since 2017.

During an interview with Registered Nurse (RN) 9, on 2/25/19 at 11:01 a.m., RN 9 stated she had been working at the hospital for two years and the multi-treatment area has been in use the entire time. She stated the unit can have up to four patients for treatment at a time.

During an interview, with Patient Care Technician (PCT) 1, on 12/25/19 at 11:24 a.m., the PCT stated the multi-treatment room can have up to four patients at one time.

During a concurrent interview and administrative record review, with the Chief Nursing officer (CNO), on 2/26/19 at 8:06 a.m., the CNO stated she was unable to provide the floor plan of the multi-treatment room, evidence of applications to the State of California for the space to be used for dialysis treatment or evidence of contacting California's Office of Statewide Health Planning and Development (OSHPD- Unit for healthcare construction oversight and to confirm projects are in compliance with California Building Standards Codes).

During an interview with the Associate CNO (ACNO), on 2/27/19 at 12:05 p.m., the ACNO stated the multi-treatment room had been in use since 2017.

During an interview with the DC, on 2/27/19 at 2:06 p.m., the DC stated she is unable to provide documentation about the number of dialysis treatments that have been completed in the multi-treatment area. The DC stated the hospital took over dialysis services [from an outside contracted dialysis company] on 4/8/17 .

During an interview with the CNO, on 2/27/19 at 3:30 p.m., the CNO stated the hospital took over dialysis services [from an outside contracted dialysis company] for the hospital on 4/8/17.

A review of Title 22 California Code of Regulations, Article 7, Number 70805, indicated, "Spaces approved for specific uses at the time of licensure shall not be converted to other uses without written approval of the Department."

2. During an observation of the second floor patient care area, on 2/20/19 at 11:40 a.m., multiple patient rooms were noted with three and four bed capacities. The square footage (Sq Ft) of each room was then requested from the Director of Operations (DO) 2.

A review of the spreadsheet titled, "The Hospital Square Footage," (Sq Ft), indicated:

Room 180. Occupancy - three bed patient room. Floor area - 193.42 Sq Ft, 64.5 Sq Ft for each patient.

Room 179. Occupancy - two bed patient room. Floor area - 102.24 Sq Ft, 51.12 Sq Ft for each patient.

Room 128. Occupancy - one bed patient room. Floor area -108.89 Sq Ft.

Room 187. Occupancy - one bed patient room. Floor area of 84 Sq Ft.

Room 246. Occupancy - four bed patient room. Floor area of 241.51 Sq Ft, 60.3 Sq Ft for each patient.

Room 275. Occupancy - four bed patient room. Floor area of 254.40 Sq Ft, 63.6 Sq Ft for each patient.

Room 308. Occupancy - one bed patient room floor area of 91.80 Sq Ft.

During an interview, with the DO 2, on 2/27/19 at 9:37 a.m., the DO 2 stated he is aware there is a requirement for square footage of each room depending on the occupancy of each room. The DO 2 stated all the measurements are accurate and consistent with current measurements and bed capacities. The DO 2 validated the Sq Ft's of the rooms 180, 179, 128, 187, 246, 275 and 308.

A review of Title 22 California Code of Regulations, Article 7, Number 70811 indicated, "Patient Rooms. (a) Patients shall be accommodated only in rooms with the following minimum floor area: (1) Single rooms: 10.2 square meters (110 square feet) of floor area, except for private rooms in pediatric units which shall have at least 9.3 square meters (100 square feet). (2) Multi-patient rooms: 7.4 square meters (80 square feet) of floor area per bed with one meter (three feet) between beds, except in specialized units."

EMERGENCY SERVICES

Tag No.: A0093

Based on interview and record review, the hospital failed to ensure competent and appropriate staff were available to respond to cardiopulmonary emergency situations (cardiac and/or respiratory arrest) when:

1. Fifty eight out of 225 staff did not have current basic life support (BLS - interventions for the initial treatment of emergencies such as cardiac or respiratory arrest and choking) certification on file.

2. Twenty nine out of 191 staff did not have current advanced cardiovascular life support (ACLS - a set of clinical interventions for the urgent treatment of cardiac arrest, stroke, myocardial infarction, and other life-threatening cardiovascular emergencies) certification.

3. The hospital allowed a person not certifed as an ACLS instructor to teach the certification classes to staff.

4. Physicians did not direct the code blue (when heart or breathing stops) procedures.

These failures had the potential for hospital patients having cardiovascular emergencies to not receive appropriate care from qualified staff.

Findings:

1. During a concurrent interview and personnel record review with Human Resource Director (HRD) on 2/21/19 at 3:15 p.m., HRD reviewed the personnel record for Registered Nurse (RN) 8 and stated BLS certification was expired (9/20/18). HRD stated it was Human Resources (HR) responsibility to track staff competency, licensure and certification. HRD stated the facility expectation is that RN 8 should have a current BLS card or should not be on the schedule. HRD stated it is the normal practice to send letters to staff with expiring licensure and/or certification a month prior to expiration. HRD provided a license/certification tracker titled, "Acute Nursing Department" on 2/21/19 and stated this is how we track staff license and certification expiration. HRD stated the boxes highlighted in red indicate expired licenses and certifications.

During a concurrent interview and personnel record review on 2/21/19 at 6:10 p.m., personnel file for RN 8 indicated a BLS card expired on 9/20/18. The ACNO stated, "I know RN 8 has a current BLS card but she has not turned it in to HR." The ACNO stated RN 8 should not be on the schedule. Review of staffing schedules indicated RN 8 was on the schedule for 8 shifts between 1/31/19 and 3/9/19. The ACNO stated Human Resources is responsible for tracking BLS and ACLS certification.

Review of the document titled, "Acute Nursing Department (AND)," indicated eight out of 75 RN's had expired BLS; 17 out of 72 Licensed Vocational Nurses (LVN's) had expired BLS certification (BLS); 22 out of 55 Certified Nursing Assistant's (CNA's) had expired BLS; four out of seven Dialysis RN's had expired BLS; one out of five Dialysis Technician's had expired BLS and six out of 11 Telemetry Technician's had expired BLS. The document titled, "AND," indicated a total of 58 out of 225 staff required to have BLS were not current.

Review of hospital policy titled, "Certification/Licensure, Retention of," dated 03/01/2013 indicated, "Policy: All clinical staff is required to maintain current certification and/or licensure for their specialty as required by law ...Failure to maintain current licensure or certification will result in disciplinary action up to and including discharge. Certification Guidelines: The following disciplines are hire, ACLS w/in six (6) months of hire. Respiratory Therapist - BLS upon hire, ACLS w/in six (6) months of hire. Certified Nursing Assistants - BLS w/in six (6) months of hire, ACLS not applicable. Licensed Vocational Nurse - BLS upon hire, ACLS w/in six (6) months of hire ...Purpose: ...Establish a centralized source of all clinical staff licensure and certification. Ensure current and appropriate licensure and certification for all staff. Establish cooperation between the Human Resources Department and clinical department regarding staff education, certification and licensure. Responsibility: Human Resources & Education 1. Procure a copy of the appropriate licensure and/or certification for each employee on date of hire and through employment. This is retained in the employee's personnel files..."

2. During a concurrent interview and personnel record review on 2/21/19 at 3:59 p.m., HRD reviewed the personnel record for LVN 9 and stated ACLS certification was expired (10/18/18). HRD stated RN's are required to have ACLS but LVN's are not required to have ACLS.

During a concurrent interview and personnel record review on 2/25/19 at 2:45 p.m., personnel file for RN 7 had no ACLS card on file. Review of the document titled, "AND," indicated RN 7 did not have a current ACLS certification. The document titled, "AND," indicated RN 7 was due to have ACLS by August, 2018. HRD stated when required staff do not have a current license or certification they are taken off the schedule. HRD stated, "I believe she has been working." HRD stated it is the ACNO and HRD responsibility to ensure staff are certified in ACLS. HRD stated a potential outcome for staff working without ACLS or expired ACLS is that a patient who is critically ill may not receive appropriate care.

During an interview with LVN 8 on 2/28/19 at 10:33 a.m., LVN 8 stated he has worked at the facility for four years and has participated in four to five code blues. LVN 8 stated he does not have an up to date ACLS certification.

Review of the document titled, "AND," indicated nine out of 75 RN's had expired ACLS; 17 out of 72 LVN's had expired ACLS; one out of seven Dialysis RN's had expired ACLS; and two out of 37 Respiratory Care Practitioner's (RCP's) had expired ACLS. HR records indicated a total of 29 out of 191 staff required to have ACLS were not current.

Review of hospital policy titled, "Scope of Service," dated 7/2018 indicated, "...Staffing ... All licensed nurses have BLS and ACLS training ..."

Review of hopspital policy titled, "Certification/Licensure, Retention of," dated 03/01/2013 indicated, " ...Policy: All clinical staff is required to maintain current certification and/or licensure for their specialty as required by law ...Failure to maintain current licensure or certification will result in disciplinary action up to and including discharge. Certification Guidelines: The following disciplines are hire, ACLS w/in six (6) months of hire. Respiratory Therapist - BLS upon hire, ACLS w/in six (6) months of hire. Certified Nursing Assistants - BLS w/in six (6) months of hire, ACLS not applicable. Licensed Vocational Nurse - BLS upon hire, ACLS w/in six (6) months of hire ...Purpose: ...Establish a centralized source of all clinical staff licensure and certification. Ensure current and appropriate licensure and certification for all staff. Establish cooperation between the Human Resources Department and clinical department regarding staff education, certification and licensure. Responsibility: Human Resources & Education 1. Procure a copy of the appropriate licensure and/or certification for each employee on date of hire and through employment. This is retained in the employee's personnel files ...*Note: Employees who are required by law and by the company to be licensed or certified in their specialties will not be permitted to work without a valid license or certification..."

3. During an interview with The Chief Executive Officer/Chief Nursing Officer (CEO/CNO), on 3/2/19, at 2:30 p.m., she stated RN 12 was in the process of conducting an ACLS class for the hospital clinical staff to renew their expired ACLS certifications. The CEO/CNO stated RN 12 was not an ACLS certified instructor. The CEO/CNO stated RN 12 was teaching the class because she [the CEO/CNO] was not available to teach the ACLS class.

During an interview with the CEO/CNO, on 3/2/19, at 3 p.m., she stated she would delegate ACLS Instructor responsibilities to RN 12.

During an interview with RN 12, on 3/2/19, at 3:40 p.m., she stated she taught ACLS classes from 2018 to 2019. RN 12 stated she taught all portions of the ACLS class and the CEO/CNO would submit for the ACLS certification cards. RN 12 stated she did not have an ACLS certification to teach ACLS classes.

During a concurrent interview and record review with the CEO/CNO, on 3/2/19 at 3:45 p.m., the CEO/CNO provided her ACLS certification and stated, "It is expired." The CEO/CNO's ACLS certificate had an expiration date of 2/2019. CEO/CNO stated she had a letter from the ACLS organization extending her expiration certification date for another 30 days 3/2019. The (Name of organization) letter dated 2/22/19, indicated, "This letter serves as an extension of the American Heart Association (AHA) Basic life support (BLS) and Advance Cardiac Life Support (ACLS) instructor credential for [CEO/CNO]. This extension will expire on the 31st of March 2019 ..."

4. During an interview on 2/19/19 at 10:15 a.m., CC 1 stated when a patient codes, the physician is called "as soon as we can." CC 1 stated it could be within a few minutes or up to 20 minutes before the doctor is contacted. When the physician is reached by phone he will give orders but does not come in to the hospital to care for the patient.

During a concurrent interview and record review on 2/19/19 at 11:45 a.m., the ACNO (Assistant Chief Nursing Officer) stated it was the facility practice for the RNs to run the codes because they follow ACLS protocols. The ACNO stated, "We don't really need a physician to run a code." The ACNO stated there was rarely a doctor present in the hospital, especially at night, and when they call to notify the doctors of a code, there was no expectation for the doctor to come in to the hospital for the code."

During an interview, on 2/22/19 at 4 p.m., DR 1stated he does not come into the hospital to assess patients upon notification of a code. DR 1 stated, "If the patient has not regained their baseline level of consciousness, I will transfer the patient to a higher level of care; I give a phone order to send the patient to the ED [Emergency Department]" at a nearby hospital.

During an interview, on 2/23/19 at 2:05 p.m., the physician/owner (OWN) stated, "We have physicians on-call at night and they are available by phone." The OWN validated the facility does not have a physician in the hospital 24 hours a day, seven days a week to respond to an emergency situation. The OWN stated the Medical Director (MD) is here every day at the facility however he does not provide hands on clinical care and does not have the training to participate in or direct code blue procedures.

Review of hospital policy and procedure, titled, "CODE BLUE" revised 3/23/16, indicated, "...Roles and responsibilities for code blue team responders ...Physician 1) Directs code via phone or in person, 2) Intubates or directs intubation [by Respiratory Therapist] ..."

A review of the written correspondence from President and CEO of a nationally recognized training organization, dated 3/4/19 at 1:17 p.m., indicated RN 12 was not a certified ACLS instructor and the practice of allowing non certifed ACLS Instructors can lead to serious consequences.

PATIENT RIGHTS: GRIEVANCES

Tag No.: A0118

Based on interview and record review, the facility failed to develop and implement a policy to ensure grievances were consistently identified when unresolved patient care concerns were not recognized as grievances for one of 32 patients (Patient 1).

This failure had the potential to deny patient grievances to be addressed.

Findings:

During a concurrent interview and record review on 2/23/19 at 1 p.m., the facility's grievance logs and grievance policy were reviewed with the Director of Operations (DO 3). The DO 3 stated he supervises the patient satisfaction representative whose primary role is to manage the grievance process. The DO 3 stated he is not familiar with the specific details of the policy and has not evaluated the facility's policy in terms of compliance with the regulations. Review of the 2018 and 2019 grievance logs indicated there were no grievances related to Patient 1 logged in 2018 or 2019. The DO 3 stated he was aware the family of Patient 1 had raised several patient care concerns which could not be resolved at the point of service and for that reason those concerns should have been logged and processed as a grievance.

During a concurrent interview and record review on 2/26/19 at 12:08 p.m., the Patient Satisfaction Representative (PSR) stated she does not know if the facility's grievance policy is aligned with the regulations. The PSR stated she knows the difference between a complaint and a grievance and that if a patient care complaint can't be resolved by the staff on the unit then it would be handled as a grievance. The PSR stated she was aware Patient 1's family had significant on-going concerns about Patient 1's care. Review of the grievance logs for 2018 and 2019 indicated there were five grievances processed in all of 2018 and one so far in 2019; none of them involved complaints regarding Patient 1's care. The PSR stated the complaints regarding Patient 1's care were not considered grievances. The PSR explained she was present at a meeting with Patient 1's family, case management staff, and dietary staff and thought the staff did a good job of explaining the possible reasons why Patient 1 had lost so much weight so she thought the issue was resolved. When asked if the determination of whether an issue is resolved or logged as a grievance is based on her opinion about the facility's explanation, the PSR stated, "No it is not." The PSR also confirmed it is likely Patient 1's family did not consider the issue resolved.

During a concurrent observation and interview in Patient 1's room on 2/26/19 at 3:45 p.m., Patient 1 was lying in bed on his left side with his eyes closed. Patient 1 appeared very thin with prominent bone structure and a lack of fat or muscle tone, and had visible contractures (a shortening or distortion of the muscles due to injury or disease causing restricted movement)of his arms and legs. Patient 1's family member (FM 1) stood at the bedside holding Patient 1's hand. Patient 1 opened his eyes to the sound of FM 1's voice and was able to provide a verbal response of yes or no to FM 1's questions. FM 1 stated her biggest concern right now is that the family wants Patient 1 to be able to be discharged home when 24-hour care is in place but are afraid the facility will not facilitate this because of previous family complaints regarding care issues. FM 1 stated these issues were first brought up to the facility staff months ago when the family had growing concerns regarding Patient 1's continued weight loss, care, and the staff's plan to transfer Patient 1 to another of their facilities. FM 1 described the family's frustration when they requested information, their difficulty getting someone to listen to them, and inability to access Patient 1's physician. FM 1 stated the facility has met with both FM 1 and FM 2 however these meetings were not attended by anyone managing the clinical care of Patient 1 and were focused primarily on the facility's concern about Patient 1's insurance coverage. FM 1 stated the family's concerns about Patient 1's weight loss were repeatedly disregarded by the facility staff including the dietician, who FM 1 felt "acted like we [Patient 1's family] were crazy" to suggest Patient 1 was underweight. FM 1 stated, "There is never a doctor here," to discuss Patient 1's care and requests to speak with the doctor have not made a difference. FM 1 stated the family is told there is no doctor available, the physician's assistant is covering for the doctor. FM 1 stated when the facility finally became aware of the error made in measuring Patient 1 on admission in September 2018 causing the facility to misinterpret FM 1's ideal weight and not recognize the severity of his weight loss, it had already been three months. FM 1 stated the most frustrating part is even if the staff did not believe the family about his weight loss, "All they would have to do is go look at him," to know he was not within his ideal weight range as the family was told. FM 1 stated the situation has caused both FM 1 and FM 2 an incredible amount of stress and anxiety as they are worried for Patient 1 because he is largely non-verbal and cannot access or press the nurse call light due to his condition. FM 1 stated they are afraid of retaliation from the facility staff if they raise any other concerns. FM 1 stated the family had not ever received a written response from the facility about any concerns they have raised about the care of Patient 1.

The facility policy "Complaint and Grievance Process" revised 03/16, indicated, "...a failure to afford a patient their rights in accordance with the following list of issues may constitute a complaint...Patient is not satisfied with the quality of care...this list is not inclusive of all types of complaints that may trigger a grievance process...when there are multiple minor complaints for the same patient, these complaints when taken together, would rise to the level of a grievance and trigger the grievance process..."

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on interview and record review, the facility failed to ensure patients were provided the necessary information to make informed decisions when the hospital did not disclose in writing prior to admission the fact that a doctor of medicine or osteopathy (MD or DO) is not present in the hospital 24 hours a day, seven days a week.

This failure deprived the patients of the opportunity to ask questions and/or consider other facility options.

Findings:

During an interview on 2/22/19 at 3 p.m., Patient 30's family member/durable power of attorney (FM 3) stated she or another family member were present with Patient 30 for her entire stay of over three weeks until she was transferred emergently to an area hospital. During Patient 30's stay, FM 3 stated she requested to talk to the physician numerous times and was told no doctor was at the hospital. FM 3 stated the nursing staff informed her that Patient 30's doctor came in late at night and was not available for FM 3 to talk to. FM 3 stated she also called in to the nurses station several times asking the supervisor to contact the doctor to speak with FM 3 did not receive a call. FM 3 stated the family would not have been ok with Patient 30 being admitted at this hospital if they knew there was not going to be a doctor present in the hospital at all times.

During an interview on 2/23/19 at 2:05 p.m., the physician/owner (OWN) validated the facility does not have a physician in the hospital 24 hours a day seven days a week to respond to an emergency situation. The OWN stated he has also been made aware there have been complaints regarding the absence of physicians here during the day when patients and families are here and requesting to talk to them. The OWN stated one group of physicians comes late after office hours and another one comes in early the morning and he can see "this is a problem."

During a concurrent observation and interview on 2/26/19 at 3:30 p.m. in Patient 1's room, FM 1 stated Patient 1 has been here since September 2018 and there is never a doctor here to discuss Patient 1's care. Requests to speak with the doctor have not made a difference. FM 1 stated the family is repeatedly told Patient 1's doctor is not available, the physician's assistant or nurse practitioner is on for the doctor, but the NP or PA isn't there FM 1 stated recently she was so concerned about Pt 1's condition she requested to speak to any doctor at the hospital and was told there are no doctors in the hospital. FM 1 stated the family was not informed there would not be a doctor in the hospital all of the time. FM 1 stated she did not think a hospital would not have a doctor present all of the time especially with so many sick patients.

Review of the admission paperwork provided to all patients and/or families prior to admission did not include a disclosure regarding the fact that there was not a doctor of medicine or osteopathy (MD or DO) present in the hospital 24 hours a day, 7 days a week.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation, interview, and record review, the hospital failed to ensure patients received care in a safe setting when:

1. The hospital was unable to establish and maintain an active hospital-wide infection control program to prevent the spread of communicable diseases.

2. A 30-ton chiller compressor was not maintained in safe operating condition which caused the equipment to fail on 2/19/19.

3. Crash carts used for emergency situations were not checked.

4. Lancets (small double-edged blade or needle) were left unattended and easily accessible to patients and visitors.

These failures created an unsafe hospital environment and had the potential to cause injury or death to patients.

Findings:

1. During an interview, on 2/21/19 at 9:25 a.m., the Infection Preventionist (IP) stated it was difficult to run an effective infection control program. The IP stated infection control issues identified by her during routine checks of the hospital environment and her recommendations often times were not acted upon by management. The IP stated infection control committe meetings often times lacked participation from key management personnel. The IP stated active participation from nursing was minimal.

During a review of the facility's "Meeting Minutes" dated 1/15/18, indicated, "Type of Meeting: Infection Control [IC] Comittee... Not Present: Director of Operations [DO 3], Chief Executive Officer/ Chief Nursing Officer [CEO/CNO], Medical Director [DR 1], Quality Coordinator [QC 1]..."

During a review of the facility's "Meeting Minutes" dated 4/23/18, indicated, "Type of Meeting: Infection Control [IC] Comittee... Not Present: [DR 2], [DO 3], [CEO/CNO], [QC 1]..."

During a review of the facility's "Meeting Minutes" dated 6/4/18, indicated, "Type of Meeting: Infection Control [IC] Comittee... Not Present: [DR 1] [DO 3], [CEO/CNO]..."

The facility was unable to provide additional IC Committee Meeting Minutes.

During an interview on 2/23/19 at 8:30 a.m., a staff member (SM) stated, "I appreciate your [State Agency] presence." The SM stated he was concerned for the safety of the patients admitted to the hospital. The SM stated he witnessed physicians, nurses, certified nursing assistants (CNAs), and other ancillary staff enter isolation rooms without wearing PPE and washing hands. The SM stated, "Sometimes they used hand-gel." The SM stated he had not received infection control training and thought the practice was standard. The SM stated, "Why would they [staff] think that's ok, even I know I have to wash my hands and I'm not a medical professional."

2. During a concurrent observation and interview, on 2/19/19 at 4:30 p.m., the ambient room temperature (air temperature to the immediate surroundings) in the third floor nutrition room registered 83.3 degrees Fahrenheit (F) with an infrared thermometer gun (a device used to measure temperature). The Maintenance Lead (ML) and Maintenance Staff (MS) 1 stated the temperature of the room felt too warm. The ML stated the nutrition room used a push-pull ventilation system to keep the ambient temperature of the room between 61 and 77 degrees F. The ML stated he was unsure why the temperature of the room registered 83.3 degrees F.

During a concurrent observation and interview, on 2/20/19 at 3:40 p.m., ML checked the temperature of the cabinet which held patients' tube feeding with an infrared gun. The cabinet registered 82.7 degrees F and the tube feed product registered 82 degrees F. The ML stated, "It's warm in here." The Director of Operations (DO) 2 stated the third floor depended on a 30-ton chiller unit to keep the third floor and north side of the building cool. DO 2 stated the compressor which provided cooling ventilation for the third floor was not properly working and cool air was not being pumped back into the room. DO 2 stated the fans for the chiller unit were working, but the compressor was not kicking on. DO 2 stated routine maintenance on the chiller was not done. DO 2 stated, "Normally we call [a refrigeration company] when we have a problem, we don't have a contract [for routine maintenance], we don't have a vendor on standby." DO 2 stated the refrigeration company was called and they usually took 24 hours to make repairs on the unit. DO 2 stated the refrigeration company's response time depended on the availability of their technicians.

During a concurrent observation and interview, on 2/20/19 at 3:55 p.m., the ML checked rooms and hallways on the third floor of the facility with an infrared gun. Room 326 registered 75.2 degrees F; room 320 registered 77 degrees F; room 312 registered 77.3 degrees F; room 310 registered 80 degrees F; room 314 registered 77 degrees F; room 316 registered 76 degrees F; and the long hall registered 77 degrees F. ML stated, "We're lucky it's still pretty cold outside, the [room] temperatures aren't that high, summer [season] would be a different story."

During an interview on 2/21/19 at 1:20 p.m., the Vendor's Service Technician (VST) stated the facility's 30-ton compressor chiller was old and required routine maintenance. VST stated he made several visits to the facility over the last year to repair the chiller. VST stated the most recent repair on 2/21/19 was due to a broken gasket which may have been prevented by routine maintenance.

During an interview on 2/27/19 at 9:45 a.m., DO 2 stated he did not have a user manual for the 30-ton compressor chiller unit. DO 2 stated preventative routine maintenance for the compressor chiller should have been done every six months and it was not. DO 2 stated preventative routine maintenance of the compressor chiller was important to ensure it worked properly. DO 2 stated the ambient temperature in the facility was not maintained within the acceptable range (68-75 degrees F) on 2/19/19 which affected the safety of patients, food, and supply storage.

The hospital's policy and procedure titled "Ambient Temperature Plan" dated 3/16, indicated, "POLICY: The Ambient Temperature in the building has to be between 68 to 75 degrees [F]. Maintenance will make sure the temperature is adjusted as required ... If any irregularity temperatures are found, the plant operations director will be notified ..."

The hospital's policy and procedure titled "Preventative Maintenance" dated 10/17, indicated, "POLICY: Preventative maintenance will be performed on all equipment for safe operations ... All heating, ventilation, and air conditioning [HVAC] equipment shall be maintained and logs kept ... on a monthly or quarterly basis ..."

3. During a concurrent observation, interview, and record review on 2/19/19 at 11:50 a.m., an initial tour of the third floor was conducted. The third floor crash cart located near nursing station five was observed. A review of the, "Emergency Equipment/ Crash Cart Check List," indicated a crash cart check was not documented for 11/1/18, 11/3/18, 11/5/18, 12/8/18, 12/9/18, 12/10/18, 12/11/18, 12/14/18, 12/21/18, 12/22/18, 12/26/18, 12/31/18, 1/2/19, 1/10/19, 1/19/19, 1/28/19, 1/29/19, 2/2/19, 2/13/19, and 2/16/19. Registered Nurse (RN) 2 stated crash cart checks were done every shift to ensure the emergency equipment worked properly. RN 2 stated checks were documented on the check lists for nurses to know what was checked and when. RN 2 stated the crash cart checks were not done on the dates indicated on the lists.

During a concurrent observation, interview, and record review on 2/20/19 at 10:37 a.m., the first floor crash carts one and three were observed. A review of the "Emergency Equipment/ Crash Cart Check List" indicated a crash cart check was not documented for crash cart one on 12/8/18, 12/19/18, 12/20/18, 2/5/19, 2/6/19, 2/8/19, 2/9/19 and 2/10/19. A review of the "Emergency Equipment/ Crash Cart Check List" indicated a crash cart check was not documented for crash cart three on 12/10/18, 12/19/18, 12/28/18, 1/15/19, 1/16/19, 1/22/19, 1/24/19, 1/27/19, 1/28/19, 2/2/19, 2/4/19, 2/5/19, 2/7/19, 2/14/19, and 2/16/19. Licensed Vocational Nurse (LVN) 10 reviewed the "Emergency Equipment/ Crash Cart Check Lists." LVN 10 stated blanks on the "Emergency Equipment/ Crash Cart Check Lists" meant the crash carts were not checked.

During an interview on 2/27/19 at 12:10 p.m., the Assistant Chief Nursing Officer (ACNO) stated it was her expectation the crash carts were checked daily at each shift and documented. The ACNO stated it was important to check crash carts because the carts were used in emergency situations. The ACNO stated, "There is no reason [why crash carts are not checked]."

The hospital policy titled, "EMERGENCY EQUIPMENT (CODE CART AND DEFIBRILLATOR) CHECKING PROCEDURE," dated 3/21/16, indicated, "... To ensure a regular, complete, and systematic process in checking ... of all crash carts ... that the crash cart, intubation box and defibrillator(s) are checked every shift. For expiration dates and functionality. To facilitate rapid implementation of emergency care ..."

4. During a concurrent observation and interview on 2/19/19 at 10:40 a.m., a tour of the third floor was conducted with the Utilization Review Nurse (UR). Pt 34 laid in bed with a bedside table on the right side. Lancets sat on top of the bedside table's tray. UR stated the lancets should not be left at the patient's bedside. UR stated, "It's a sharp, someone can get hurt."

During an interview on 2/20/19 at 10:15 a.m., the ACNO stated, "[Lancets] should not be left out, easily accessible to patients and visitors." The ACNO stated there was a potential for injury to patients, visitors, and staff. The ACNO stated there was a potential to spread blood borne pathogens (germs in blood).

During a concurrent observation and interview in a patient room, on 2/20/19 at 11:05 a.m., a biohazard bag filled with lancets, alcohol swabs, and glucometer strips sat on top of a sharps container. RN 3 stated she did not know why a bag filled with lancets sat on top of the sharps container. RN 3 stated lancets had the potential to cause injury and should not be left out within reach of patients and visitors.

The hospital policy titled, "PATIENT RIGHTS," dated 1/16, indicated, "... PURPOSE: To ensure that each patient/ family admitted to [hospital] is aware of their guaranteed rights and their responsibilities... SAFETY To be provided care and services at this hospital in a safe and secure environment..."

QUALITY IMPROVEMENT ACTIVITIES

Tag No.: A0283

Based on staff interview and administrative document review, the hospital failed to take action aimed at performance improvement when the quality assurance and performance improvement (QAPI) committee did not identify high-risk, high-volume, problem-prone areas affecting patient safety and quality of care.

This failure led to a delay in the implementation of necessary corrective measures resulting in continued risk of infections to patients.

Findings:

During an interview, on 2/21/19 at 9:25 a.m., the Infection Preventionist (IP) stated it was difficult to run an effective infection control program. The IP stated infection control issues identified by her during routine checks of the hospital environment were provided to the Quality Coordinator (QC) 1. The IP stated her recommendations often times were not acted upon by management. The IP stated infection control committee meetings often times lacked participation from key management personnel. The IP stated active participation from nursing was minimal.

During an interview on 2/27/19 at 1:09 p.m., the QC 1 described her role as "overseeing the quality management system." The QC 1 stated she could not remember any current performance improvement initiatives the hospital was working on. The QC 1 stated she is concerned about the hospital's rate of hospital acquired infections (HAI).

Review of the hospital's Governing Body/Management Oversight meeting minutes for the meetings from July 2018 through January 2019, indicated infection control was mentioned at one meeting (1/18/19), "... HAI's were up for the last quarter; need plan to address."

Review of the MEC/Governing Body meeting minutes for the meetings from July 2018 through January 2019, indicated a report of infection control compliance audit results were presented at the 10/10/18 meeting. The report included compliance rates for the 3rd quarter of 2018 for hand hygiene, gloves, and PPE compliance. The data reflects compliance rates of 70-75 %. There was no indication the hospital tracked the data, developed or implemented performance improvement measures.

AUTOPSIES

Tag No.: A0364

Based on interview and record review, the hospital failed to follow their own policy to ensure an autopsy was requested for two unexpected deaths, Patient 2 and Patient 26, when the nursing staff did not involve a physician in the decision after the patients' families requested an autopsy.

This failure resulted in the families not receiving an explanation as to the cause of death, and had the potential to result in a missed opportunity for the hospital to identify patient care issues and improvement opportunities.

Findings:

During a concurrent interview and record review on 2/20/19 at 5:20 p.m., Patient (Pt) 26's record was reviewed with the clinical educator (CE). Pt 26 was admitted on 1/30/19 from an area hospital after undergoing heart valve replacement and placement of a pacemaker (a small device that is placed in the chest to help control abnormal heart rhythms) on 1/17/19. The record indicated Pt 26 required a telemetry monitor and was on a ventilator (a machine that performs respirations) for the patient). The record indicated the telemetry monitoring did not continue after 2/2/19, however the record did not contain an order to discontinue the monitoring or documentation of the reason or of physician notification. The record indicated Pt 26 should have had a pulse oximeter in place in accordance with facility policy for a patient on a ventilator. The record indicated on the morning of 2/5/19, Pt 26 was found unresponsive in his bed at 07:39 a.m., by a physician and a nurse. Pt 26 did not have a pulse (heart beat) and was not breathing. There was no documentation of a pulse oximeter in use at this time. The record indicated a code blue was called and after a failed resuscitation (attempt to restore breathing and heart rate) Pt 26 was declared dead at 8:09 a.m.

During a concurrent interview and record review on 2/21/19 at 9:10 a.m., Pt 2's record was reviewed with the ACNO. The record indicated Pt 2 was admitted in October 2018 and died on 12/5/18 at 11:43 p.m. following an unsuccessful resuscitation attempt after being found pulseless and not breathing at 11:14 p.m. The record indicated Patient 2 was supposed to have a continuous pulse oximeter on at all times per policy, however there was no documentation in the record indicating a pulse oximeter was on and functioning properly at the time of her arrest (stopped breathing). The ACNO stated if the pulse oximeter had been on Pt 2 and her heart rate dropped or the oxygen level dropped, the alarm would sound loudly. The ACNO stated if the monitor became dislodged from Pt 2's finger, then the alarm would have also sounded loudly to alert the nurses. The ACNO stated it is not known when the pulse oximeter was removed or by whom.

During a concurrent interview and record review on 2/25/19 at 2:30 p.m., Patient 26's clinical record was reviewed with the Assistant Chief Nursing Officer (ACNO). Review of the progress record indicated the patient's Registered Nurse (RN) 10 documented on 2/5/19 at 9:35 a.m., "Family came. Upset with what happened and requested an autopsy. Advised family that we cannot do an autopsy and he is not a coroner's case and if they want to pursue they will have to tell the mortuary and they will recommend who can do it. The social worker confirmed by calling the coroner's office and we were advised that the patient is not a coroner's case." There was no indication in the record the physician was notified of the family's request for an autopsy. The ACNO stated she was aware of this issue and was in fact present for this conversation with the RN and the social worker. The ACNO stated since it was not a coroner's case and "we do not do autopsies" they called a company and got a price of over $3,000 dollars and informed the family. The ACNO stated she was not aware of any reason an autopsy should be performed other than if the death is a coroner's case. The ACNO confirmed the physician was not involved in the autopsy discussion with the staff or family.

During a concurrent interview and record review on 2/25/19 at 2:40 p.m., the document titled, "Code Blue Record," for Patient 2 was reviewed with the ACNO. The ACNO confirmed the box is marked indicating the coroner was notified of this death. The ACNO stated this box was checked in error; the coroner was not notified. Review of the 12/5/18 case management notes indicated the patient's daughter came to the hospital with questions regarding the circumstances of her mother's death and wanted answers and the medical records. The ACNO stated she knew the daughter was concerned and received the medical records. The record also indicated the daughter inquired about an autopsy. The ACNO confirmed the record does not indicate the physician was notified of the family's concern regarding the circumstances surrounding her death or her wish for an autopsy.

The policy titled, "AUTOPSY", revised 1/2016, was reviewed with the ACNO. The ACNO stated she was unaware, until now, of what constituted an "unexpected death" and would require consideration of an autopsy per their policy or that the physician must be involved. The ACNO stated she did not consider the fact that there were identified nursing care issues regarding the monitoring of these two patients at the time they were found to determine that these deaths were not unexpected. The ACNO stated she had not thought of these deaths as unexpected because the patients had co-morbidities (diseases or medical conditions that coexist with primary diseases). When asked, the ACNO validated all of the patients admitted to their hospital have co-morbidities. The ACNO validated these two patients had unexpected deaths per the criteria in their policy.

During an interview on 2/26/19 at 10:30 a.m., the physician owner (OWN) stated he was not familiar with the details of the policy for autopsies and was unaware the facility was not following its own policy. When asked if he was aware of the incidences of unexpected deaths at the facility the OWN stated there was not a formal process for review of unexpected deaths but that, "They do discuss them."

The hospital titled, "AUTOPSY" revised 1/19/16, indicated," ...It is the policy of [Name of Hospital] to request an autopsy when required by state law or regulation; when a patient has died of an "Unexpected Death" [as defined by this Policy] ...an unexpected death includes but is not limited to the following: the death was unexpected or unanticipated; the cause of death is unknown; the cause of death is not known with certainty on clinical grounds ...the physician will discuss the consent to autopsy with the next of kin...contact the pathologist to inform him/her about the autopsy ...."

The hospital policy titled, "AFTER DEATH, CARE OF PATIENT", revised 3/13/16, indicated, " ...the attending physician must be notified immediately when one of his/her patient dies. The attending physician ...should assess the patient and make a pronouncement of death, if appropriate ...the physician should determine if an autopsy is required. It is the responsibility of the attending physician ...to request permission for an autopsy in non-medical examiner cases ...."

ORGANIZATION OF NURSING SERVICES

Tag No.: A0386

Based on observation, interview, and record review, the hospital failed to follow their policies and procedures for "Crash Carts (a cart stocked with emergency medical equipment, supplies, and drugs for use during a medical emergency)" when crash carts on nursing units were not checked by nursing staff every shift.

This failure had the potential for crash carts to have malfunctioning equipment, missing and/or expired supplies which could lead to serious consequences in an medical emergency.

Findings:

During a concurrent observation, interview, and record review on 2/19/19 at 11:50 a.m., an initial tour of the third floor was conducted. The third floor crash cart located near nursing station five was observed. A review of the, "Emergency Equipment/ Crash Cart Check List," indicated a crash cart check was not documented for 11/1/18, 11/3/18, 11/5/18, 12/8/18, 12/9/18, 12/10/18, 12/11/18, 12/14/18, 12/21/18, 12/22/18, 12/26/18, 12/31/18, 1/2/19, 1/10/19, 1/19/19, 1/28/19, 1/29/19, 2/2/19, 2/13/19, and 2/16/19. Registered Nurse (RN) 2 stated crash cart checks were done every shift to ensure the emergency equipment worked properly. RN 2 stated checks were documented on the check lists for nurses to know what was checked and when. RN 2 stated the crash cart checks were not done on the dates indicated on the lists.

During a concurrent observation, interview, and record review on 2/20/19 at 10:37 a.m., the first floor crash carts one and three were observed. A review of the "Emergency Equipment/ Crash Cart Check List" indicated a crash cart check was not documented for crash cart one on 12/8/18, 12/19/18, 12/20/18, 2/5/19, 2/6/19, 2/8/19, 2/9/19 and 2/10/19. A review of the "Emergency Equipment/ Crash Cart Check List" indicated a crash cart check was not documented for crash cart three on 12/10/18, 12/19/18, 12/28/18, 1/15/19, 1/16/19, 1/22/19, 1/24/19, 1/27/19, 1/28/19, 2/2/19, 2/4/19, 2/5/19, 2/7/19, 2/14/19, and 2/16/19. Licensed Vocational Nurse (LVN) 10 reviewed the "Emergency Equipment/ Crash Cart Check Lists." LVN 10 stated blanks on the "Emergency Equipment/ Crash Cart Check Lists" meant the crash carts were not checked.

During an interview on 2/27/19 at 12:10 p.m., the Assistant Chief Nursing Officer (ACNO) stated it was her expectation the crash carts were checked daily at each shift and documented. The ACNO stated it was important to check crash carts because the carts were used in emergency situations. The ACNO stated, "There is no reason [why crash carts are not checked]."

The hospital policy titled, "EMERGENCY EQUIPMENT (CODE CART AND DEFIBRILLATOR) CHECKING PROCEDURE," dated 3/21/16, indicated, "... To ensure a regular, complete, and systematic process in checking ... of all crash carts ... that the crash cart, intubation box and defibrillator(s) are checked every shift. For expiration dates and functionality. To facilitate rapid implementation of emergency care ..."

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on observation, interview, and record review, the hospital failed to have a registered nurse (RN) supervise and evaluate nursing care in accordance with accepted standards of practice when:

1. Nursing personnel conducted a code blue, administered medications, and pronounced death without direction or orders from a medical doctor.

2. Nursing personnel discontinued treatments prescribed by a physician, without orders to do so.

3. Nursing personnel did not ensure patient monitoring equipment was in place and functioning properly, which had the potential to compromise the healthcare status of patients requiring cardiac monitoring.

These failures placed all patients at risk for serious negative health outcomes when nurses practiced outside their scope of practice.

An Immediate Jeopardy (IJ - when there is actual or potential harm to a patient) situation was identified on 2/22/19 at 2:46 p.m. related to findings in Nursing Services at 42 CFR 482.23, with the hospital Chief Nursing Officer, Associate Chief Nursing Officer, Quality Coordinator, Medical Director, Director of Operations, and Hospital Administrator. The IJ was called due to the serious potential harm to all patients because Registered Nurses independently initiated and conducted code blue procedures without the benefit of a physician directing the code blue. Nurses administered code blue rescue medications without determining the rationale for the administration of the code blue medication and without a Medical Doctor (MD) order. Nursing staff discontinued prescribed services, such as telemetry, without physician order and notification. The hospital submitted an acceptable Action Plan and implemented corrective actions. The Chief Nursing Officer, Hospital Administrator, Owner and Directors of Operations were present at the time the IJ was removed on 3/5/19 at 3:51 p.m.

Findings:
1. During an interview on 2/19/19 at 10:15 a.m., Clinical Coordinator (CC) 1 described the facility practice when a patient "codes" (experiences a cardiac or respiratory arrest). CC 1 stated the "code team" of RNs, and a Respiratory Therapist (RT) respond and all nursing staff have a role in the resuscitation. CC 1 stated an ACLS (Advanced Cardiovascular Life Support) certified RN, usually the supervisor, would, "run" the code following ACLS protocols. CC 1 stated when a patient codes, the physician is called, "As soon as we can." CC 1 stated it could be within a few minutes or up to 20 minutes before the doctor is contacted. CC 1 stated if the doctor doesn't answer the phone, the staff call another doctor. CC 1 stated the nurses can take care of the patients in a code without a doctor present because, "We are all ACLS certified." When the physician is reached by phone he will give orders but does not come in to the hospital to care for the patient.

During an interview, on 2/19/19 at 11:45 a.m., the ACNO (Assistant Chief Nursing Officer) stated all of the nursing staff at the facility were ACLS certified so they were able to function independently in a code blue situation. The ACNO stated it was the facility practice for the RNs to run the codes because they follow ACLS protocols. The ACNO stated, "We don't really need a physician to run a code," because of this training. The ACNO stated there was rarely a doctor present in the hospital, especially at night, and when they call to notify the doctors of a code, there was no expectation for the doctor to come in to the hospital for the code or to perform death pronouncement if the resuscitation was unsuccessful.

During an interview on 2/28/19 at 11:50 a.m., RN 4 stated the physician will pronounce the patient dead but does not come to the hospital. When the physician is unable to come to the bedside two of the most experienced RN's will assess verifying the patient is deceased. The MD calls the time of death based on the nursing assessment.

During an interview, on 2/28/19 at 12:09 p.m., House Supervisor (HS) 2 stated she has worked at the facility for five years. She stated when a code blue is unsuccessful two RN's will assess the patient to determine death. The patient the findings are then reported to the patients doctor and based on the finding of the two RN's the doctor will pronounce the patient dead. HS 2 stated she is not certified to pronounce the patient's deaths.

Review of hospital policy and procedure, titled, "CODE BLUE" revised 3/23/16, indicated, " ...employees discovering the arrest should ...begin cardiopulmonary resuscitation [CPR] as needed ...the responding code team will be directed by the responding ACLS/RN, following approved American Heart Association Guidelines for resuscitation, until the physician arrives or is available via phone ...the physician or ACLS/RN (approved for standardized procedure protocol) will designate roles of responders upon arrival and initiate standardized procedures ...Roles and responsibilities for code blue team responders ...Physician 1) Directs code via phone or in person, 2) Intubates or directs intubation [by Respiratory Therapist] ..."

The hospital policy titled, "DETERMINATION OF DEATH BY A REGISTERED NURSE," revised 1/14/16, indicated," ...RN's certified to perform death pronouncement may do so only if the following conditions exists ...the physician has documented a do not resuscitate order [DNR] in the patient's chart ...the purpose of the protocol: to outline the nursing responsibilities related to death pronouncement in a Do Not Resuscitate/No code patient ..."

2. During a concurrent interview and record review on 2/20/19 at 5:20 p.m., the medical record of Patient (Pt) 26 was reviewed with the clinical educator (CE). Pt 26 was admitted on 1/30/19 from an area hospital after undergoing heart valve replacement and placement of a pacemaker (a small device that is placed in the chest to help control abnormal heart rhythms) on 1/17/19. The physician's orders, dated 1/30/19 at 5:47 p.m., indicated Pt 26 was a full code (initiate resuscitative efforts). Pt 26 was on a ventilator (machine that performs respirations for a patient) at the time of admission and was to have a continuous telemetry (monitors heart rate and rhythm) monitor in place. The medical record indicated Pt 26 had a telemetry monitor on from 1/30/19 until sometime on 2/2/19. The last telemetry strip in Pt 26's medical record was dated 2/2/19 at 7:45 p.m. The CE stated a telemetry monitoring is continuous and twice a shift the staff print a strip showing the heart rate and rhythm which is saved in the medical record. The record did not contain an order to discontinue the telemetry monitoring, and there was no documentation in the record indicating at what time the monitoring was discontinued, the reason the monitor was discontinued, or that the physician was aware. The medical record also indicated at 7 p.m. Pt 26's IV was not functioning, was removed, and was not restarted. The nurse's notes, dated 2/2/19 on night shift indicated the IV was not needed when the telemetry monitoring was discontinued. There was no documentation the physician was notified Pt 26's IV was discontinued. The medical record also indicated Pt 26 had a continuous pulse oximeter (CPO- a device secured to a patient's finger to measure the percentage of oxygen in the blood) in place per hospital policy for patients on a ventilator. The documentation in the medical record reflected the presence of a CPO on 2/3/19, 2/4/19, and 2/5/19 during the night however the CE could not find documentation it was in place on the morning of 2/5/19. The CE stated he did not know why Pt 26 did not have telemetry monitoring after 2/2/19 as written on the physician's order. The record indicated on the morning of 2/5/19, Pt 26 was found unresponsive in his bed at 07:39 a.m., by a physician and a nurse. There was no documentation of a pulse oximeter in use at this time. Pt 26 did not have a pulse (heart beat) and was not breathing. The record indicated a code blue was called and after a failed resuscitation (attempt to restore breathing and heart rate) Pt 26 was declared dead at 8:09 a.m. The code blue record indicated some of the emergency medications were given intra-osseous (directly into the bone), because Pt 26 did not have an IV in place. The code record did not indicate who administered the intra-osseous medication.

During a concurrent interview and record review, on 2/21/19 at 9 a.m., Pt 26's record was reviewed with the ACNO. The ACNO stated the record did not indicate why the telemetry monitor was removed. The ACNO stated the facility did not have enough telemetry monitors for every patient. The house supervisor may decide, based on the patient's condition, to discontinue a monitor in order to use that monitor for another patient. The ACNO stated if there were not enough telemetry monitors and the supervisor made the decision to take a patient off a monitor because another patient had a greater need, it would not be documented in the medical record. The house supervisor would document that in the "Tele log" book. The ACNO checked the "Tele log book" and stated Pt 26's telemetry monitoring was discontinued on 2/2/19 sometime after 10 p.m., due to the need for telemetry monitoring for a patient being admitted. The ACNO confirmed there was no order in Pt. 26's record discontinuing the telemetry monitor. When asked how the decision was made to accept an admission requiring telemetry monitoring when the hospital had no available telemetry monitors, the ACNO stated she did not know, that decision was made by the pre-admission staff and administration.

Review of the clinical record indicated Registered Nurse (RN) 10 completed and signed the form, "PHYSICIAN'S PROGRESS NOTES, DEATH PRONOUNCEMENT PROGRESS NOTE" including the assessment. The form indicated a physician's signature was required. The form did not contain a physician signature. The ACNO stated she was not aware until recently the policy indicated nurses cannot perform death pronouncements if the patient did not have a "Do Not Resuscitate" (DNR) status/order prior to the code.

Review of the hospital policy titled, "PULSE OXIMETRY," dated 5/18, indicated, " ... PURPOSE: Pulse oximetry...used to determine the gas exchange status of oxygen ... V. Duration of Procedure B. Continuous SPO2 [amount of oxygen in blood] monitoring is for the duration as ordered by the physician.

3. During a concurrent interview and record review on 2/21/19 at 9:10 a.m., Pt 2's record was reviewed with the ACNO. The record indicated Pt 2 was admitted in October 2018 for rehabilitation and respiratory care after suffering a stroke. Patient 2 had a tracheostomy (Trach- an opening surgically created through the neck into the windpipe to assist in breathing) in place on admission and the admission orders on 10/17/19 indicated Patient 2 was a full code (initiate resuscitative efforts). A review of the clinical document (code record) dated 12/5/18 indicated Pt 2 was found by a nurse pulseless and not breathing at 11:14 p.m. Cardiopulmonary Resuscitation (CPR) was initiated at 11:15 p.m., Pt 2 was shocked (electricity transmitted from an external device to restore a normal heart rhythm in patients with an abnormal heart rhythm noted on the EKG monitor) twice, and three doses of medication were given prior to the physician being notified by telephone. The code record indicated the physician was called a second time after 26 minutes of unsuccessful resuscitation and the code was called (stopped). The time of death was 11:43 p.m. The physician did not come in to the hospital and two RNs completed and signed the physician's progress note and determination of death note. The code blue record did not have the name of the staff members present, what tasks they performed and at what time, the indication for the medications given, or copies of the monitoring strips from the code showing the heart rhythm. The ACNO stated, on 12/5/18 Pt 2 was on the second day of the process to evaluate readiness for removal of the tracheostomy tube in preparation for eventual discharge. The ACNO validated the process to evaluate trach removal which involved capping the trach and closely monitoring of Pt 2's tolerance (to having trach capped). The ACNO stated during this capping trial, Pt 2 must have a continuous pulse oximeter, per facility policy. The ACNO also stated when Pt 2 was found, the cap was on her tracheostomy and there was no documentation in the record indicating a pulse oximeter was on and functioning properly at the time of her arrest (stopped breathing). The ACNO stated if the pulse oximeter had been on Pt 2 and her heart rate dropped or the oxygen level dropped, the alarm would sound loudly. The ACNO stated if the monitor became dislodged from Pt 2's finger, then the alarm would have also sounded loudly to alert the nurses. The ACNO also stated she was not aware until recently the policy indicated nurses cannot perform death pronouncements if the patient did not have a "Do Not Resuscitate" (DNR) status/order prior to the code.

During an interview on 2/22/19 at 9:20 a.m., RN 4 stated she participated in code blues. RN 4 stated the House Supervisor ran the codes when physicians were not present. RN 4 stated ACLS protocol was followed to determine which medication to administer and when. RN 4 stated she had administered emergency medications during codes. RN 4 stated, "I'm ok with administering medications without a physician's order."

Review of the hospital policy titled, "TRACHEOSTOMY CAPPING," revised 5/18, indicated, " ...Assure patient is on pulse oximetry/cardiopulmonary monitor with set and patent alarms as ordered ...observe the patient for signs of respiratory distress ...Monitor the patient closely for changes ...discontinue capping use immediately if significant changes in heart rate, respiratory rate, oxygen saturation, or increased respiratory effort are noted ..."

Review of the hospital policy titled, "PULSE OXIMETRY," dated 5/18, indicated, " ... PURPOSE: Pulse oximetry...used to determine the gas exchange status of oxygen ... V. Duration of Procedure B. Continuous SPO2 [amount of oxygen in blood] monitoring is for the duration as ordered by the physician.

MEDICAL RECORD SERVICES

Tag No.: A0450

Based on interview and record review, the hospital failed to ensure that entries in to the patients' medical records were dated, timed, and accurately reflected the care provided for nine of 32 sampled patients (Pt 1, 13 14, 15, 16, 17, 19, 22 and 25) when:

Interdisciplinary team (IDT) meeting notes and plans of care were not documented and/or scanned into the patients' medical records.

These failures had the potential to result in lack of continuity of care among providers and errors due to miscommunication.

Findings:

During an interview on 2/23/19 at 1:15 p.m., the Interdisciplinary Team (IDT) meeting process and documentation was discussed with the Director of Operations (DO) 3. The DO 3 stated he was aware there are issues with a lack of documentation of the IDT meeting content and any physician involvement. The DO 3 stated the Medical Director is the one who holds these meetings but does not document his involvement in the record despite being offered assistance to do so. The DO 3 is aware the record reviews indicate the forms are not completed as intended or minimally completed, and confirmed there is no other documentation in the record of an interdisciplinary plan of care, or of the Medical Director participation. The DO 3 stated this is a problem and the documentation should reflect the plan for the patient. Leaving the forms incomplete does not facilitate continuity of care among the care providers.

During a review of the clinical record for Pt 15 titled, "Interdisciplinary Plan of Care," the following areas of the form were left blank: IDT date, Respiratory Therapy, Wound Care, IDT Meeting recommendation, and signatures from representatives of the following departments: Respiratory, Wound care, and Clinical.

During a concurrent interview and record review on 2/26/19 at 11:30 a.m., a Medical Records (MR) representative assisted with the review of Pt 16's clinical record. Patient care planning during the IDT conference was not documented in Pt 16's clinical record. MR stated, "It doesn't look like they [IDT team] discussed anything, IDT's are held on Wednesdays, if they [IDT team] did it there would be a form [in Pt 16's clinical record], both [forms] are blank."

During an interview on 2/27/19 at 3 p.m., the Director of Operations (DO) 3 stated the patients' weekly IDT conferences were not documented on the appropriate form and evidence of the IDT conferences could not be found in the patients' electronic health record (EHR). DO 3 stated the process for using the IDT form was changed one and a half years ago which created a clinical problem. DO 3 stated IDT conference notes were not scanned into the patients' EHR for nursing and other departments to read. DO 3 stated, "It [IDT notes] needs to be in the medical record." DO 3 stated concerns were brought to the Quality Management (department seeking to improve the effectiveness and quality of treatments). DO 3 stated no action was taken.

During a review of the clinical record for Pt 16 titled, "Interdisciplinary Plan of Care," the following areas of the form were left blank: respiratory Therapy, Wound Care, IDT Meeting recommendation, and signatures from representatives of the following departments: Respiratory, Wound Care, and Clinical.

During a concurrent interview and record review on 2/26/19 at 1 p.m., the Quality Coordinator (QC) 2 stated IDT meetings are supposed to be done weekly for each patient. QC 2 validated there were no IDT meeting documentation in the clinical record for Pt 13. QC 2 validated Pt 13's admit date was 2/5/19 and there should have been at least two IDT meetings held.

During a concurrent interview and record review on 2/27/19 at 9 a.m., QC 2 validated Pt 25's admit date was 2/13/19 and there was no IDT meeting documentation in the clinical record; for Pt 14, the "Interdisciplinary Plan of Care" dated 2/20/19 indicated Case Management (CM) and Social services (SS) documentation and lacked the documentation of additional members of the IDT; for Pt 17, the "Interdisciplinary Plan of Care" dated 2/14/19, indicated CM and SS documentation and lacked doumentation of the additional members of the IDT; for Pt 17, the "Interdisciplinary Plan of Care" dated 2/20/19, indicated CM and SS documentation and lacked doumentation of the additional members of the IDT; for Pt 19, the "Interdisciplinary Plan of Care" dated 2/6/19, indicated CM documentation and lacked the documentation of additional members of the IDT, and for Pt 22, the "Interdisciplinary Plan of Care" dated 2/13/19, indicated CM and SS documentation and lacked the documentation of additional members of the IDT.

During an interview and record review on 2/27/19 at 3:40 p.m., the Interdisciplinary Team (IDT) meeting process was discussed with the Medical Director (MD). The MD stated he was made aware by the Director of Operations (DO 3) there was a lack of documentation in the record of his involvement in the process and of consistent involvement of other disciplines such as dietary, nursing, PT, wound care, etc. The MD stated the IDT "conference" takes place every Wednesday and he (the MD) participates in each patient's review. The MD stated the facility form titled "Interdisciplinary Plan of Care" is supposed to be filled out by each discipline: Nursing, wound care, respiratory therapy (RT) in advance of the IDT meeting. At the bottom of the form is a section to document "IDT meeting recommendations." MD 1 stated he takes extensive notes about each patient and makes recommendations but confirmed he does not document this in the medical record. The MD provided examples of his handwritten notes he completed for some of the patients over an extended period of time. The MD stated these notes are not at the nurses station or in the charts but since he is there every day someone could ask him. MD 1 was provided an example of Pt 1 who has been at the hospital since September 2018. The Interdisciplinary Plan of Care forms for nine (9) meetings occurring in the time period between September 2018 and January 2019 were reviewed and out of those nine forms, six of nine were not dated, nine of nine had no evidence of physician participation, eight of nine had no documentation in the "IDT Meeting Recommendations" section, seven of nine had no RN signature and the other two were illegible, and zero of nine forms were completed by all disciplines involved. Additionally the form did not include a place for the registered dietician to participate.

The facility policy and procedure titled, "NURSING CARE PLAN" dated 1/16 indicated "...4. The team includes: the physician, nursing, respiratory therapy, rehabilitation services, pharmacy, and dietician. 5. Each discipline develops a plan of care. Each discipline is responsible to review goals and progress with patient and approve significant others. The team meets together weekly in the Interdisciplinary Team Meeting to review the overall care and progress ..."

The facility policy and procedure titled, "INTERDISIPLINARY TEAM CONFERENCE" dated 3/16, indicated "PURPOSE To formalize responsibilities with the Interdisciplinary team conference (IDT) its preparation and post conference activities ...POLICY As the designated Team Leader, the Case Manager acts as the coordinator and facilitator overseeing the integrating the overall plan of care for each patient ...The IDT conference agenda is to be forward focus ...proactive and goal-oriented. Identifying barriers to goal and promoting discussion until concrete solution are determined is the group facilitator role of the Case Manager ...Documentation is the responsibility of the entire team. Each member will document on their professional component of the treatment plan for each patient ... The interdisciplinary care conferences will be held within 7 days of a patient's admission. Follow-up interdisciplinary care conferences should be held but not limited to every 7 days ... A copy of the Team Conference Report is filed in the patient's Medical Record."

The facility policy and procedure titled "CASE MANAGEMENT MEDICAL RECORD DOCUMENTATION AND DOCUMENTATION RETENTION" dated 3/16, indicated, " ... Case Management (CM) is responsible to document case-based activities for the following reasons: Evidence of Case Management treatment plan ... communication with physicians and the interdisciplinary team ..."

DIRECTOR OF DIETARY SERVICES

Tag No.: A0620

Based on observation, interview, and document review, the hospital failed to ensure the fulltime Director of Food and Dietetics Services was responsible for daily management of the dietary services when:

1. Emergency food plan was not accessible to all hospital staff for implementation in an emergency, which had the potential for increasing the risk of malnutrition / starvation for all patients and staff during an emergent event.

2. Food service staff did not follow safe practices for cooling foods, which had the potential of increasing the risk for bacterial contamination for all patients.

3. There was no development of a Quality Assessment and Performance and Improvement (QAPI) program, identifying dietary services.

4. Staff did not have knowledge of proper storage for shredded cheese, which increased the risks of bacterial infection for all patients.

An Immediate Jeopardy (IJ) situation was identified on 2/22/19 at 9:55 a.m. related to findings in Director of Dietary Services at 42 CFR 482.28 (A 620) with the hospital Chief Nursing Officer, Associate Chief Nursing Officer, and Quality Coordinator. Serious issues were identified with implementation of a disaster food program, ongoing nutritional assessments, integration of Food and Dietetics into QAPI, safe food handling practices, menus being followed, nutrition care plans, and trash storage. The hospital developed and submitted an acceptable action plan that addressed the IJ situation. The hospital implemented immediate corrective actions to address the issues, which included; education and training of leadership and dietary staff on the preparation of food for emergency preparedness, education and training of all dietary staff on safe food handling, use of care plans, following menus, and trash storage. The survey team validated training of staff before the IJ was abated on 2/26/19 at 2:30 p.m.

Findings:

1. During a concurrent interview and document review on 2/21/19 at 5:27 p.m., disaster food program was reviewed with Registered Dietitian (RD) 1 and Food Service Manager (FSM). The hospital's food disaster plan consisted of freeze dried meals with complete, nutritionally balanced meals designed for institutional emergency preparedness. This disaster product requires rehydration with water before serving. RD 1 and FSM, validated this product was purchased in 11/2017 as the food disaster plan for the Hospital. RD 1 stated there had been no training of the food service staff or the hospital staff who would be responsible for the preparation of the dehydrated products in disaster plan.

During an interview on 2/22/19 at 9 a.m., RD 1 stated there had been a disaster drill, "I wanted to be part of but was not included."

The hospital policy titled, "Menu Policies 2009 National Purchasing Corp (Menu company", had sections for Disaster emergency menus and Disaster/Emergency Checklist which indicated, "...All employees will be oriented and updated to the facilities' policy and procedures on disaster menus, the location of the menu, and food storage areas ..."

The hospital policy titled, "Hospital Emergency Management Plan NO 1.1," revised 10/2018, had no mention of the food service emergency food or location, directions, or required staff education for implementation.

2. During a concurrent observation and interview on 2/19/19 at 9:30 a.m., the walk in freezer contained a four-gallon container dated 2/6. FSM identified the frozen product as soup, either cream of broccoli or clam chowder, that will be used for patients on Friday. FSM stated the product was cooled on ice and temperatures monitored before storing in freezer. FSM stated there was no documentation of the temperature monitoring. FSM stated the soup would be discarded as it would not be safe to serve.

During an interview on 2/19/19 at 9:40 a.m., Food Server (FS) stated the soup should have been documented on the cool down log.

The hospital policy titled, "Cooling and Reheating Potentially hazardous Foods (causing illness) NO 66," undated, indicated, "...When cooling down food, use the Cool Down Log to document proper procedure..."

3. During a concurrent interview and document review on 2/22/19 at 11:39 a.m., review of Quality meeting minutes for the past year was conducted. There were no QAPI programs submitted from the Food and Nutrition Department for either the food service or clinical nutrition departments. Quality 1 stated the department [the Food and Nutrition Department] is notified of the meetings and are requested to bring corrective action plans. Quality 1 stated these departments should have submitted quality plans but nothing was submitted. Quality 1 stated, "Some departments submit and some do not." Quality 1 stated those departments who failed to submit a quality plan were reported to leadership.

Review of the Director of Clinical Nutrition Services and Director of Food and Nutrition Services Job Descriptions, it indicated duties which included, "... Manages the quality improvement program ..."

4. During a concurrent observation and interview, in the kitchen, on 2/19/19 at 9.35 a.m., five bags of shredded cheese were observed in the dairy walk in refrigerator with pack dates of 12 Nov 18, 1/3/19, and 1/18.19. FSM stated the cheese could be kept for three weeks. FSM acknowledged he did not know how long the shredded cheeses could be stored and the November of 2018 shredded cheese should be discarded.

The hospital policy titled "Food Storage NO 39," undated, did not give direction on length of time to store shredded cheese.

The administrative document titled, "Shelf Life of Cheese," undated, indicated, "... Shredded hard cheese stated storage was 1 to 2 months past printed pack date [pack date is the imprinted date on a product's packaging] ..."

An Immediate Jeopardy (IJ) situation was identified on 2/22/19 at 9:55 a.m. related to findings regarding Director of Dietary Services at 42 CFR 482.28.

QUALIFIED DIETITIAN

Tag No.: A0621

Based on staff interview and patient record review, the Hospital dietitian failed to monitor the nutrition aspects of patient care for three of 32 patients (Patient 1, Patient 24, and Patient 25) when:

1. Patient 1 had significant errors in assessing nutritional status for three months, when height on admission was incorrectly entered into the medical record and Registered Dietitians (RD) responsible for patient's assessment did not observe the patient for 3 months.

2. A. Patient 24 did not have nutritional care plans in the electronic medical record.

B. Patient 25 did not have nutritional care plans in the electronic medical record.

An Immediate Jeopardy (IJ) situation was identified on 2/22/19 at 9:55 a.m. related to findings in Director of Dietary Services at 42 CFR 482.28 (A 620) with the hospital Chief Nursing Officer, Associate Chief Nursing Officer, and Quality Coordinator. Serious issues were identified with implementation of a disaster food program, ongoing nutritional assessments, integration of Food and Dietetics into QAPI, safe food handling practices, menus being followed, nutrition care plans, and trash storage. The hospital developed and submitted an acceptable action plan that addressed the IJ situation. The hospital implemented immediate corrective actions to address the issues, which included; education and training of leadership and dietary staff on the preparation of food for emergency preparedness, education and training of all dietary staff on safe food handling, use of care plans, following menus, and trash storage. The survey team validated training of staff before the IJ was abated on 2/26/19 at 2:30 p.m.

Findings:

1. Review of Patient 1's medical record indicated Patient 1 was admitted on 9/15/18. The document titled, "Nutrition assessment," dated 9/17/18, indicated Patient 1 was at high nutritional risk, height of 62 inches, weight of 124 pounds, and BMI (nutrition status measure) of 21.2 (normal). Patient 's ordered diet was tube feeding at 1800 calories from previous placement. Nutrition assessment continued to assess calorie needs and nutritional status based on a height of 62 inches from admission to 12/20/18. On 12/20/18, in response to family concerns, the height was re-measured to 72 inches.

During an interview with RD 2 on 2/20/219 at 3:00 p.m., stated that on 12/20/198 the nutrition assessments were revised to the corrected height and them Body Mass Index (BMI- a measure which shows whether people have the right weight for their height) was calculated to 15.1 (underweight). (World Health Organization defines BMI less than 18.5 as underweight and possible cause is malnutrition.) RD 2 stated the incorrect height of 62 inches gave the appearance that Patient 1's BMI was normal..
RD 2 stated that she or RD 3 had been responsible for the nutrition evaluations for Patient 1 since admission. RD 2 stated they had not physically observed the patient and solely evaluated his nutrition care based on the incorrect BMI, weekly weight history and height of 62 inches.

2. A. During a record review on 2/20/19, Patient 24's medical record indicated Patient 24 was admitted on 2/13/19 with diagnoses of Chronic diastolic heart failure (congestive heart disease), Body Mass Index (BMI) 40 (obese-grossly overweight), hypertensive (high blood pressure) heart disease. Final diagnosis was Acute and chronic respiratory failure.

Review of nutrition assessment dated 2/17/19 indicated nutrition status as high risk with poor oral intake. Diet was therapeutic controlled carbohydrate diet puree consistency.

Review of the Interdisciplinary Plan of Care meeting dated 2/18/19 showed adequate intake for and adequate intake for estimated energy and protein needs. The care plan meeting for Patient 24 was nine days after admission. The plan did not address nutritional issues such as weight goals, patient education needs,

Review of electronic medical record showed no nutrition plan of care in multidisciplinary care
plans.

B. Review of Medical Record for Patient 25, on 2/20/19, showed admission date of 2/8/19 with diagnosis of lobar (lung) pneumonia, unspecified. Body Mass Index (BMI) 70 (defined overweight status), unspecified atrial fibrillation (irregular heart beat), and heart failure. Current diagnosis includes Acute and chronic respiratory failure (inability to breath).
Review of Diet Order by Room list, dated 2/20/19, Patient 25's Diet order, 2-gram sodium, low fat and low cholesterol.
Review of nutrition assessment dated 2/11/19 showed nutrition status as high risk and recommended slow controlled gradual weight loss.
Review of the Interdisciplinary Plan of Care meeting form dated 2/18/19 showed overall nutrition assessment was moderate depleted, adequate intake for and adequate intake for estimated energy and protein needs.
The care plan meeting for Patient 25 was 12 days after admission.
Review of the policy Titled Interdisciplinary Team Conference NOCM005, stated the IDT conference was not to be report-oriented. Review of the nutrition documentation was only including date of the diet, with goals of adequate intake. There were no specific nutrition goals developed to address the nutritional status of gradual weigh loss or diet education or plan to achieve weight loss. Concurrent interview with RD 2 stated nutrition care plan was included in the Interdisciplinary care plan meeting. RD2 stated there was no place in the electronic medical record to enter the nutrition care plan that integrated with the other disciplines; RD2 stated the Care Plan Meeting met one time each week on Wednesdays.
Concurrent interview regarding Patient 24 and Patient 25, RD2 stated nutrition care plans were included in the Interdisciplinary Care Plan Meeting document of meeting. RD2 stated there was no place in the electronic medical record to enter the nutrition care plan that integrated with the other disciplines; RD2 stated the Care Plan Meeting met one time each week on Wednesdays. The care plan meeting for Patient 25 was 12 days after admission. The care plan Meeting for Patient 24 was 5 days after admission

Review of Policy Titled Patient Care Plans NO 22 stated "RD shall document the care plan when patient is in a high or moderate nutritional risk category or is prescribed a medical diet. The purpose was "to ensure that the patient receives the appropriate nutritional interventions. The interventions needed to achieve the objective or goals are stated and may be made by multiple disciplines, thus integrating the plan."

THERAPEUTIC DIETS

Tag No.: A0629

Based on observation, staff interview, and document review, the Hospital failed to ensure menus met the needs of patients when:

1. Menu was not served as written for the 10 puree diets and 22 mechanical modified diets,

2. Meal substitutes were not of equal nutritional value.

These failures put patients at risk of compromised nutrition.

Findings:

1. During a concurrent observation and interview on 2/19/19 at 11:55 a.m., Food Server (FS) served pureed Salisbury steak with a #8 scoop (1/2 cup) portion and ground and diced meat with 2 ounce spoodle (measured serving utensil). The Food Service Manager (FSM) stated the FS was not serving these diets correctly according to the menu. The puree served should have been 6 ounces. FSM stated he had not reviewed the menu with FS to ensure the ground and diced diets were served as equivalent portions to the Salisbury Steak.

Review of the, "Tuesday Week 2 menu," indicated the puree should have been served with two #12 scoops (1/3 cup each); total portion should be 2/3 cup or 6 ounces.

Review of the, " Tuesday Week 2 menu," indicated the serving size of the Salisbury steak was, "One piece." The mechanical diets (ground and diced) had no serving size designated.

Review of the Salisbury Steak product information showed portion size was 3 ounces.

Review of the master diet list for Tuesday 2/19/19 showed 10 puree diets and 22 mechanical diets.

2. During a concurrent observation and interview on 2/19/19 at 12:00 p.m., preparation of grilled cheese sandwich, which was being substituted for another menu item, was observed using two slices of cheese. The two slices of cheese were weighed and measured a total of one ounce. The FSM stated this was the correct portion of cheese for the sandwich.

Review of the menu spread sheet indicated the portion size of the entrée should have been three ounces.

FSM 1 validated the portion of cheese for the grilled cheese sandwich to be used for a substitution should have been three ounces cheese.

RD 1 was asked for a policy defining how menu substitutions were to be prepared. RD 1 stated they did not have a policy that defined the preparation or nutrition equivalency of substitutions.

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on observation, interview, and record review, the hospital failed to maintain mechanical facility equipment in a safe operating condition when:

1. A 30-ton compressor chiller unit (a ventilation machine that removes heat and moisture and supplies cool air) was not maintained and failed to work on 2/19/19.

2. Ice machines were not maintained per manufacturer's instructions.

These failures to maintain the facility mechanical equipment resulted in the breakdown of the compressor chiller unit and had the potential to create an unsafe environment for the patients.

Findings:

1. During a concurrent observation and interview on 2/19/19 at 4:30 p.m., the ambient room temperature (air temperature to the immediate surroundings) in the third floor nutrition room registered 83.3 degrees Fahrenheit (F) with an infrared thermometer gun (a device used to measure temperature). The Maintenance Lead (ML) and Maintenance Staff (MS) 1 stated the temperature of the room felt too warm. The ML stated the nutrition room used a push-pull ventilation system to keep the ambient temperature of the room within range. The ML stated he was unsure why the temperature of the room registered 83.3 degrees F.

During a concurrent observation and interview on 2/20/19 at 3:40 p.m., the Director of Operations (DO) 2 stated the third floor depended on a 30-ton chiller unit to keep the third floor and north side of the building cool. DO 2 stated the compressor which provided cooling ventilation for the third floor was not properly working and cool air was not being pumped back into the room. DO 2 stated the fans for the chiller unit were working, but the compressor was not kicking on. DO 2 stated routine maintenance on the chiller was not done. DO 2 stated, "Normally we call [a refrigeration company] when we have a problem, we don't have a contract [for routine maintenance], we don't have a vendor on standby." DO 2 stated the refrigeration company was called and they usually take 24 hours to make repairs on the unit. DO 2 stated the refrigeration company's response time depended on the availability of their technicians.

During an interview on 2/20/19 at4:30 p.m., DO 1 stated he was unaware of any issues with the compressor chiller unit. DO 1 stated, "It would have been nice if someone told me."

During a concurrent observation and interview on 2/20/19 at 3:55 p.m., the ML checked the third floor rooms and hallways with an infrared gun. Room 326 registered 75.2 degrees F; room 320 registered 77 degrees F; room 312 registered 77.3 degrees F; room 310 registered 80 degrees F; room 314 registered 77 degrees F; room 316 registered 76 degrees F; and the long hall registered 77 degrees F. The ML stated, "We're lucky it's still pretty cold outside, the [room] temperatures aren't that high, summer would be a different story."

During an interview on 2/21/19 at 1:20 p.m., the Vendor's Service Technician (VST) stated the facility's 30-ton compressor chiller was old and required routine maintenance. VST stated he made several visits to the facility over the last year to repair the chiller. The VST stated the most recent repair on 2/21/19 was due to a broken gasket which may have been prevented by routine maintenance.

During an interview on 2/27/19 at 9:45 a.m., DO 2 stated he did not have a user manual for the 30-ton compressor chiller unit. DO 2 stated preventative routine maintenance for the compressor chiller should have been done every six months and it was not. DO 2 stated preventative routine maintenance of the compressor chiller was important to ensure it worked properly. DO 2 stated the ambient temperature in the facility was not maintained within the acceptable range (68-75 degrees F) on 2/19/19 which affected the safety of patients, food, and supply storage.

The hospital's policy and procedure titled "Ambient Temperature Plan" dated 3/16, indicated, "POLICY: The Ambient Temperature in the building has to be between 68 to 75 degrees [F]. Maintenance will make sure the temperature is adjusted as required ... If any irregularity temperatures are found, the plant operations director will be notified ..."

The hospital's policy and procedure titled "Preventative Maintenance" dated 10/17, indicated, "POLICY: Preventative maintenance will be performed on all equipment for safe operations ... All heating, ventilation, and air conditioning [HVAC] equipment shall be maintained and logs kept ... on a monthly or quarterly basis ..."

2. During an observation on 2/19/19 at 11 a.m., the ice machine in the second floor nutrition room had a large area of white deposits on the front surface of the machine from the chute down to the collection pan at the bottom. There was an approximately two inch wide piece of trim extending across the front edge of the machine with visible cracks on the corners. Several layers of different kinds of tape had been placed over the cracked edges. The tape was frayed and the edges lifted.

During a concurrent observation and interview, on 2/19/19 at 11:15 a.m., in the second floor nutrition room, the ML stated there should not be standing water in the tray. The ML stated the machine needed to be checked to see why it was not draining. The ML stated the white particles floating in the standing water could be hard water deposits and should not be there. The ML stated the maintenance department cleaned the inside of the machine but there was not a schedule for cleaning or inspecting the outside.

During a concurrent observation and interview on 2/19/19 at 11:25 a.m., in the second floor nutrition room, MS 1 stated the ice machine needed to be cleaned and the standing water was a problem because bacteria could grow in the collection pan. MS 1 stated several kinds of tape had been used to try to secure the broken trim which was not what should have been done. If the machine needed to be fixed the hospital would usually order a part. MS 1 stated the taped areas could not be cleaned.

During a concurrent observation and interview with the ML and MS 1, on 2/19/19 at 4:30 p.m., the ice machine in the third floor nutrition room had an orange-brown residue on the inside portion of the upper lid. MS 1 stated, "I would say that's rust." ML stated there was no vendor contracted to maintain the ice machines. The ML stated the facility did not follow the manufacturer's recommended maintenance schedule or cleaning solutions. The ML stated a vendor was called when a problem with the ice machines developed.

Review of the hospital policy, titled, "Maintenance, Sanitation and Hygiene-Refrigerator, Freezer, and Ice Machine," dated 3/16, indicated, " ...Policy: All equipment and appliances shall be properly cleaned, maintained and stored ... Purpose: To maintain ... Ice machines in clean working order ..."

DISPOSAL OF TRASH

Tag No.: A0713

Based on observation, staff interview, and administrative document review, the hospital failed to ensure proper routine storage and transport of trash from the Food Service Department.

This failure had the potential to lead to of infestations of insects and vermin.

Findings:

During a concurrent observation, interview and administrative document review, on 2/19/19 at 10:35 a.m., there was a blue cart in the basement hall outside the kitchen entrance. The cart was not covered and contained a bag of trash. Food Service Manager (FSM) stated they did not have a cover for the transport cart. FSM stated the kitchen staff just added the kitchen trash to the housekeeping trash bags in the cart. FSM stated the cart was left in the hall area and when the cart was full it was transported uncovered to the trash compactor area.

During an interview, on 2/21/19 at 9:10 a.m., IP stated she was unaware there was uncovered trash being stored in the hall outside the kitchen. IP stated she was unaware how trash was transported.

Review of the Food and Drug Association (FDA) Food Code Annex 3 - Public Health Reasons/Administrative Guidelines indicated:
"Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. Storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents."

Review of hospital policy titled, "Waste-Regular Waste handling, NO W-04", indicated, " ...Always close the cover when transporting cart..."

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, interview, and record review, the hospital failed to ensure a system was in place for identifying and tracking infections and communicable diseases when:

1. Staff failed to follow hospital policies for proper use of Personal Protective Equipment, which had the potential of compromising the healthcare status of all patients (PPE: gloves, masks, gowns, etc.).

2. Staff failed to follow hospital policies for proper hand hygiene practices, which had the potential of compromising the healthcare status of all patients.

3. Respiratory equipment was observed without a date to indicate when it was opened, which had the potential of compromising the healthcare status of all patients requiring the use of respiratory equipment.

4. Isolation precautions did not accurately reflect patient status and protocols were not followed to minimize the risk of transmission of communicable diseases, which had the potential of compromising the healthcare status of all patients.

5. Three of six ice machines, located in various areas of the hospital, were not maintained in a sanitary manner and hospital staff did not follow manufacturer's instructions for maintenance, which had the potential of compromising the healthcare status of all patients.

A. The ice machines in the first and second floor nutrition rooms were visibly dirty.

B. The ice machine in the third floor nutrition room had an orange-brown residue on the inside portion of the upper lid.

6. A Registered Nurse (RN) did not follow manufacturer's recommendation for the cleaning of the glucometer (a device that measures the amount of sugar in the blood) after patient care use, which had the potential of compromising the healthcare status of all patients who require the use of a glucometer.

7. A cart filled with waste was not covered while being stored or transported near the kitchen, which had the potential of compromising the healthcare status of all patients.

8. Tube feeding containers (nutrition administered through a tube) located in the third floor nutrition room were not stored in a safe and sanitary manner, which had the potential of compromising the healthcare status of all patients requiring the use of tube feeding.

An Immediate Jeopardy (IJ) situation was identified on 2/21/19 at 12 p.m. related to findings in Infection Control in 42 CFR 482.42 [A-749], in the presence of the hospital Chief Nursing Officer, Associate Chief Nursing Officer, Quality Coordinator, Infection Preventionist and Hospital Administrator. Serious issues were identified with the proper use of PPE; hand hygiene; open undated supplies; recognition and implementation of isolation precautions; ice/water machines used for patients, staff and visitors and recommended use and dwell times for cleaning solutions. All identified issues had the potential of compromising the healthcare status of all patients.

The hospital failed to develop and implement an acceptable action plan that addressed the IJ situation. An exit conference was conducted on 2/27/19 at 4:30 p.m. without removing the IJ situation. The Chief Nursing Officer, Hospital Administrator, Owner and Directors of Operations were present at the time of exit.

The hospital implemented acceptable corrective actions to address the issues and the IJ was removed on 3/2/19 at 5:14 p.m.

Findings:

1. During a concurrent observation and interview on 2/20/19 at 11:40 a.m., Patient Care Technician (PCT) 2 walked out of a patient's room who was receiving dialysis (removal of certain substances from the blood while it is being circulated outside the body in a special machine) treatment without removing PPE. PCT 2 then reentered patient's room wearing the same PPE.

During a concurrent observation and interview on 2/20/19 at 11:55 a.m., RN 8 walked out of a patient's room who was receiving dialysis treatment without removing PPE. RN 8 then reentered patient's room wearing the same PPE. RN 8 removed gloves outside patient's room and put on a new pair of gloves without performing hand hygiene, before reentering patient room. RN 8 stated she was supposed to take off PPE before exiting a patient's room and wash her hands before changing gloves.

During a concurrent observation and interview on 2/22/19 at 9:08 a.m., Housekeeper (HK) 3 walked out of PT 33's room, who was on contact (when touching a patient) isolation precautions for Clostridium Difficile (C. diff. - is an extremely contagious bacterium that causes diarrhea and more serious intestinal conditions), pushing an empty bed wearing PPE. HK 3 removed PPE after leaving contact isolation room. HK 3 removed gloves outside patient's room and continued to push empty bed without performing hand hygiene. HK 3 stated she attended an in-service the night before regarding infection control and learned to remove her gown inside the threshold of the room. HK 3 stated she did not follow the training she received the day before.

During a concurrent observation and interview on 2/22/19 at 4:15 p.m., LVN 13 provided care to Pt 25 in an enteric (relating to or occurring in the intestines) isolation room. LVN 13's isolation gown was untied at the neck. LVN 13's neck and upper shoulders were exposed. LVN 13's used a stethoscope (medical instrument) hanging in Pt 25's room to listen to his chest and stomach. LVN 13's completed her physical assessment and wrapped the stethoscope around her neck. LVN 13's completed patient care, hung the stethoscope in Pt 25's room, and removed her PPE. LVN 13's stated, "I used that stethoscope on purpose, we keep it in the room because he [patient] is on isolation, I guess I shouldn't have put it on my neck, now I'm contaminated and I'll spread it [germs] to other patients."

During a concurrent observation and interview on 2/22/19 at 4:50 p.m., Housekeeper (HK) 5 cleaned Pt 33's room was on [type isolation]. HK 5's isolation gown was untied in the back and the gown fell off HK 5's shoulders while she removed soiled linen and trash from the containers. HK 5 repositioned the gown several times while she wore the same pair of used gloves. HK 5 stated she was not trained on how to apply PPE. HK 5 stated, "I know I have to look at the signs, I try to follow the pictures." HK 5 stated she was unsure of when to wash hands and change gloves. HK 5 stated, "Sometimes I wash my hands."

During a concurrent observation and interview on 2/24/19 at 12:55 p.m., a Dietary Aide (DA) was observed wearing PPE in a contact isolation room, writing on a clipboard with a pen. DA removed gown and gloves, holding clipboard under her arm and pen under her chin. DA picked up the pen she was writing with, washed her hands with gel and then picked up the pen again. DA did not sanitize pen or clipboard after leaving contact isolation room.

Review of the administrative document, titled, "Isolation Precautions," undated, indicated, "... Perform hand hygiene before and after each patient encounter ..."

Review of the hospital policy titled, "Hand Hygiene," dated 3/13/13, indicated, "... Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene ... Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections ... Decontaminate hands before having direct contact with patients ... decontaminate hands after contact with a patient's intact skin ... decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

2. During a concurrent observation, interview and record review, on 2/20/19 at 12:05 p.m., Certified Nursing Assistant (CNA) 2, donned PPE, entered an isolation room, provided care to patient (Pt) 25, touched curtain with gloved hand, removed gloves, opened curtain with ungloved hands, reached outside the room for clean gloves, donned clean gloves, provided care to Pt 22, removed PPE, picked up a meal tray, walked outside the room and carried the tray down the hall to a closed storage room. CNA did not perform hand hygiene between tasks and caring for patients. CNA 2 stated she knew Pt 22 and 25 were in isolation but was not aware they were being isolated for Clostridium difficile (C-Diff- a spore forming bacterium that causes diarrhea and more serious intestinal conditions and rarely death), or of the precautions (gloves and gown worn by all who enter room beyond threshold of curtain; hand washing soap and water required), as outlined in the, "Isolation Precautions" signage posted outside the isolation room.

During an interview, on 2/20/19 at 2:51 p.m., Infection Preventionist (IP) (specializing in Infection Standard of Practices) stated hand hygiene with soap and water needed to be performed with C-difficile patients after removing gloves and before caring for another patient.

During an interview, on 2/21/19 at 10:50 a.m., House Supervisor (HS) 2, stated C-diff was very contagious and washing hands with soap should have been performed after providing care for one patient and before providing care for another. HS 2 stated, "[not washing hands between patients] That's a big No-No."

Review of the administrative document, titled, "Isolation Precautions," undated, indicated, "... Perform hand hygiene before and after each patient encounter ..."

Review of the hospital policy titled, "Hand Hygiene," dated 3/13/13, indicated, "... Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene ... Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections ... Decontaminate hands before having direct contact with patients ... decontaminate hands after contact with a patient's intact skin ... decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

3. During an observation and interview, on 2/19/19 at 10:10 a.m., the following respiratory equipment was observed without a date to indicate when it was opened: ventilation tubing; humidification bottle attached to an oxygen source and an oral suctioning device. Respiratory Manager (RM), Respiratory Technician (RT) 1 and Associate Chief Nursing Officer (ACNO) validated all opened respiratory equipment should be dated.

During an interview on 2/21/19 at 3:10 p.m., House Supervisor (HS) 3 stated she expected nurses to notify respiratory therapy when respiratory equipment was unlabeled and undated. HS 3 stated it was an infection control issue. HS 3 stated all nurses shadowed a RT during their (nurses) new hire orientation and nurses should be aware of the expectation; using outdated equipment may result in a spread of infectious diseases.

During an interview on 2/27/19 at 9:20 a.m., RM validated all respiratory equipment should be dated to indicate when opened and when the equipment should be changed to minimize the risk of respiratory infection.

During an interview, on 2/27/19 at 12:10 p.m., ACNO stated it was a nursing responsibility to check dates on all open respiratory equipment.

A policy was requested regarding dating of respiratory equipment. The hospital was unable to provide a policy by the time of exit.

4. During a concurrent observation, interview and record review, on 2/19/19 at 11:05 a.m., a Contact Isolation Precautions sign was posted outside Pt 18's room. Concurrent Nurse and Utilization Review (UR) stated the "Isolation Precautions" sign should be marked "droplet precautions" (the prevention of the spread of germs when an infected person talks, coughs, or sneezes.), not "contact precautions" (the prevention of the spread of germs by skin-to-skin contact and physical transfer of germs from person to person). UR stated the sign was posted to alert staff and visitors and it should be marked correctly.

During an interview, on 2/20/19 at 11:15 a.m., Housekeeper (HK) 3 stated she depended on signs posted outside the patients' isolation rooms. HK 3 stated the PPE she chose to put on was based on the type of contact isolation. HK 3 stated, "I dress wrong if the sign is wrong, I can spread germs."

During an interview, on 2/20/19 at 12:20 p.m., the Physical Therapist (PT) stated patients on droplet (isolation) precautions can attend therapy sessions in the main physical therapy room. Therapists follow Isolation Precautions signs in order to determine what PPE is required when transporting patients between departments.

During an interview, on 2/21/19 at 3:10 p.m., Infection Preventionist (IP) stated patients on droplet precautions were permitted to go to Physical Therapy, but movement throughout the hospital should be limited, they should wear PPE, and they should attend therapy sessions at the end of the day to minimize the risk of transmitting infection to other patients or staff.

During a review of Pt 18's clinical record, titled, "History and Physical", dictated on 2/3/19 at 3:13 p.m., indicated the patient was admitted with Multi Drug Resistant Organism (MDRO - germs resistant to medicine) ... in the sputum.

During a concurrent observation and interview on 2/22/19 at 9:10 a.m., Patient (Pt) 15 ambulated the third floor hallway while he wore an isolation gown. Pt 15 touched the walls, handrails, and wall postings with bare hands as he walked the hall. Pt 15 stated he was told by nurses to wear a gown each time he left his room. Pt 15 stated he was unsure why an isolation gown was required. Pt 15 stated he wore the same gown until it tore or was visibly soiled. Pt 15 stated, "I just lay it on my bed 'til I'm ready to go out." Pt 15 stated he did not wash hands when he left his room. Pt 15 stated, "No one told me I had too." Pt 15 stated nurses frequently allowed him to leave his room.

During a review of the clinical record for Pt 15, the "History and Physical" dated 2/13/19 at 8:51 p.m., indicated Pt 15 was admitted to the hospital on 2/12/19 with a diagnoses which included right leg cellulitis (skin infection).

During a review of the clinical record for Pt 15, the "Physician Orders" dated 2/12/19 indicated Pt 15 had methicillin- resistant staphylococcus aureus (MRSA- a germ resistant to antibiotics).

During an interview, on 2/22/19 at 9:20 a.m., RN 4 stated Pt 15 was on contact precautions for MRSA to his right leg wound. RN 4 stated, "We struggle with him [Pt 15], he [Pt 15] has the right to leave his room." RN 4 stated she provided Pt 15 with extra isolation gowns for him to wear. RN 4 stated, "I did not give him [any] instruction." RN 4 stated she assumed the previous nurses provided Pt 15 education regarding MRSA and contact precautions. RN 4 could not provide evidence of MRSA, contact precautions, required personal protective equipment, and hand hygiene instructions given to Pt 15.

During a concurrent observation and interview on 2/28/19 at 9:58 a.m., RN 4 was observed exiting a contact isolation room with IV tubing exposed and carrying the tubing with her ungloved hands. RN 4 stated she did not take bag into the room because then the bag will become contaminated.

During an interview with the ACNO 2/28/19 at 10:07 a.m., the ACNO stated when providing care in the isolation room the nurse should have taken a biohazard bag into the room to dispose of any items used inside the room. The ACNO stated anything coming out of the isolation needs to be bagged and contained to prevent spread of infection.

The administrative document [a sign posted outside patient's room], titled, "Isolation Precautions", undated, indicated, "Contact [Precautions]", when it should have indicated, "Droplet Precautions."

Review of the hospital policy titled, "Droplet Precautions," dated 1/16, indicated, "...Purpose: It is the intent of this facility to use droplet precautions to decrease the risk of droplet transmission of infectious agents ..."

The hospital policy titled, "FACT SHEET: METHICILLIN- RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)," dated 1/16, indicated, "... (MRSA) ... the main mode of transmission to other patients is through human hands ... become contaminated with MRSA by contact with infected or colonized [carrier of germs in or on the body] patient ... Contact Precautions are mandatory for-Heavy draining wound ... Poor hygiene ... difficult behaviors ..."

A review of the hospital policy titled, "CONTACT PRECAUTIONS," dated 1/16, indicated, " ... Contact Precautions shall be used in addition to standard precautions for patients with infections that can be easily transmitted by direct or indirect contact ... hand hygiene should be completed prior to donning [putting on] gloves ... gloves should be changed after having contact with infectious material ... hands should not touch potentially contaminated environmental surfaces or items ... the gown should be removed before leaving the patient's room ... Activities of the patient may need to be limited ... If patient leaves the room, precautions should be maintained to minimize the risk of transmission of microorganisms [germs] to other patients and contamination of environmental surfaces or equipment ...Dedicated patient- care equipment should be considered for the patient..."

5. A. During an observation on 2/19/19 at 11 a.m., the ice machine in the second floor nutrition room had a large area of white deposits on the front surface of the machine from the chute down to the collection pan at the bottom. The collection pan contained approximately one inch of standing room temperature water with white particles floating on the surface of the water. There was an approximately two-inch-wide piece of trim extending across the front edge of the machine with visible cracks on the corners. Several layers of different kinds of tape had been placed over the cracked edges. The tape was frayed and the edges lifted.

During a concurrent observation and interview, on 2/19/19 at 11:15 a.m., in the second floor nutrition room, the Maintenance Lead (ML) stated the front of the ice machine needed to be cleaned. The ML stated there should not be standing water in the tray. The ML stated the machine needed to be checked to see why it was not draining. The ML stated the white particles floating in the standing water could be hard water deposits and should not be there. The ML stated the maintenance department cleaned the inside of the machine but not the outside and there was not a schedule for cleaning or inspecting the outside.

During a concurrent observation and interview, on 2/19/19 at 11:25 a.m., in the second floor nutrition room, Maintenance Staff (MS) stated the ice machine needed to be cleaned and the standing water was a problem because bacteria could grow in the collection pan. The MS stated several kinds of tape had been used to try to secure the broken trim which was not what should have been done. If the machine needed to be fixed the hospital would usually order a part. The MS stated the taped areas could not be cleaned.

During a concurrent observation and interview, on 2/19/19 at 4:28 p.m., the ice machine in the first floor nutrition room had a whitish orange residue on the front surface of the machine from the chute down to the collection pan at the bottom. License Vocational Nurse (LVN) 5 stated the ice machine looked dirty and she did not know who to contact to clean it.

B. During a concurrent observation and interview with ML and MS, on 2/19/19 at 4:30 p.m., the ice machine in the third floor nutrition room had an orange-brown residue on the inside portion of the upper lid. MS stated, "I would say that's rust." ML stated there is no vendor contracted to maintain the ice machines. ML stated the facility does not use the manufacturer's recommended cleaning solution.

Review of the hospital policy, titled, "Maintenance, Sanitation and Hygiene-Refrigerator, Freezer, and Ice Machine," dated 3/16, indicated, " ...Policy: All equipment and appliances shall be properly cleaned, maintained and stored ... Purpose: To maintain ... Ice machines in clean working order ..."

Review of the hospital policy, titled, "Ice Chest and Ice Machines," dated 1/16, indicated, " ...Policy: The following policy should be followed to reduce the likelihood of contamination ... ice machines ... V. Clean, disinfect, and maintain ..."

6. During a concurrent observation and interview, on 2/20/19 at 5:16 p.m., RN 1 exited an isolation room with a glucometer (a device that measures the amount of sugar in the blood). RN 1 sanitized the glucometer with a chlorine based wipe and let it stand for six seconds. RN 1 stated the dwell time (amount of time, the solution needs to stay on the item) was three seconds.

On 2/20/19, the survey team requested a specific policy for cleaning the glucometer. The facility was unable to provide a policy and procedure by the time of exit from the facility.

Review of the hospital policy titled, "Equipment Cleaning Process," dated 6/18, indicated, " ... III. [dwell time for bleach based wipes] 3 minutes ... IV. 4. Dwell Time - amount of time, the solution needs to stay on the item."

Review of the product guide titled, "Chlorine based wipes manufacturer's product guide," print date 2/21/19, indicated, " ... kill ... C. difficile spores in 3 minutes ..."

Review of the glucometer manufacturer's, "Operator's Manual," dated 2009, indicated, " ...Cleaning the Exterior Surface: Follow your facility's policy and procedure for infection control ... Bleach ... not recommended ..."

7. During a concurrent observation, interview and administrative document review, on 2/19/19 at 10:35 a.m., there was a blue transport cart in the basement hall outside the kitchen entrance. The transport cart was not covered and contained a bag of trash. Food Service Manager (FSM) stated the transport cart was not equipped with a cover. FSM stated the kitchen staff just added the kitchen trash to the housekeeping trash bags in the cart. FSM stated the cart was left in the hall area and when the cart was full it was transported uncovered to the trash compactor area.

During an interview, on 2/21/19 at 9:10 a.m., IP stated she was unaware there was uncovered trash being stored in the hall outside the kitchen. IP stated she was unaware how trash was transported.

Review of the hospital policy titled, "Waste-Regular Waste handling, NO W-04", indicated, "... Always close the cover when transporting cart..."

8. During a concurrent observation and interview on 2/19/19 at 12:10 p.m., a tour of the third floor nutrition room was conducted with the Utilization Review Nurse (UR). A cabinet used for nutritional tube feeding storage contained six 1000 milliliter (ml- unit of measure) plastic bottles and six eight- ounce (oz.- unit of measure) cartons of tube feed product. The cabinet was warm inside and a brown sticky residue was adhered to the right corner of the bottom shelf. The UR stated, "It's dirty, kitchen [staff] should have cleaned it."

During a concurrent observation and interview on 2/19/19 at 3:40 p.m., the Lead Environmental Services (LEVS) stated housekeeping was responsible for only cleaning the outside of the cabinets. The LEVS stated kitchen staff should keep the inside of the tube feed storage cabinet clean. The LEVS stated the sticky brown residue had the potential to attract bugs. The LEVS stated it should be cleaned and maintained.

During a concurrent observation and interview on 2/19/19 at 4:30 p.m., the Maintenance Lead (ML) stated the nutrition room felt too warm and took the room's temperature with an infrared laser gun (a device used to measure temperature). The ML stated the temperature inside the nutrition room was 83.3 degrees Fahrenheit (F). The ML stated room temperatures should remain between 61 and 77 degrees F. The temperature inside the cabinet registered 85.2 degrees F. The tube feed product registered 84.5 degrees F. The ML stated the cabinet had the potential to be too warm for the tube feed product. The ML stated temperatures inside the cabinet were not monitored.

During an interview on 2/20/19 at 3:40 p.m., Director of Operations (DO) 2 stated the chiller compressor unit (a ventilation machine) which provided cooling ventilation for the third floor was not properly working and cool air was not being pumped back into the nutrition room.

The hospital policy titled, "TUBE FEEDING/ FOOD STORAGE," dated 3/16, indicated, "... To ensure food is handled and stored in a safe and sanitary manner. To ensure that food is not contaminated ... 1. Maintain proper temperatures in food storage areas ... 2. All foods not requiring refrigeration shall be stored on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning in a ventilated room not subject to contamination by waste water backflow, condensation, leakage, rodents, or vermin ..."