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Based on a review of hospital policy, observations and interviews for one patient who received medications through a gastric tube (Patient #2) nursing staff failed to maintain the patient's privacy. The findings include:

Patient #2's diagnoses included Quadriplegia and status post gastrostomy tube (G- tube). Physician orders dated 11/3/10 directed that all oral medications be administered via the G-tube except for Simethicone, which was to be given orally. Observation of the medication pass on 12/14/10 at 10:25 AM noted that LPN #1 administered medications through the patient's G-tube while the patient sat in the chair with the door open rendering the patient and administration procedure visible from the hallway. The observation also noted that the patient's medication record was left in the open position on the medication cart in the hallway that was occupied by both staff and patients. Review of the hospital policy for rights and responsibilities of veterans identified that the veteran had the right to considerate, respectful care at all times and under all circumstances with recognition of his/her personal dignity. The veteran is assured consideration, respect and full recognition of his/her dignity and individuality, including privacy and treatment and care of his/her personal needs. The veteran is assured confidential treatment of all medical and personal information.

Based on observation, review of facility policy and interview the hospital failed to maintain a safe environment for patients who smoked. The findings include:
Review of the hospital smoking policy identified that smoking was permitted between 5 AM and 11 PM in designated outside areas located 50 feet away from the building. Facility documentation indicated that 23 patients did not require supervision when smoking and 11 of the 23 patients had no restrictions on smoking materials. Observations on 12/14/10 at 9:40 AM and/or 12/15/10 at 9:45 AM identified ambulatory and wheelchair bound patients exited the lower level to a gazebo smoking area that was approximately 50 feet away from the building. The walkway to the gazebo area was uncovered and the gazebo had netted side screening. Interview with Patient #28 on 12/15/10 at 9:45 AM noted that patients had to endure the elements (rain, snow, sleet etc...) in order to get to the smoking area. H/she further indicated that once inside the gazebo, the screening offered little protection (from rain and wind). Interviews with hospital staff on 12/15/10 identified that they were aware of the patient's issues involving the smoking area and were currently discussing options to help address the problem.

Based on a review of hospital policy, observations and interviews for one patient who received medications through a gastric tube (Patient #2) nursing staff failed to maintain confidentiality of the patient's medical record. The findings include:

Patient #2's diagnoses included Quadriplegia and status post gastrostomy tube (G- tube). Physician orders dated 11/3/10 directed that all oral medications be administered via the G-tube except for Simethicone, which was to be given orally. Observation of the medication pass on 12/14/10 at 10:25 AM noted that the patient's medication record was left in the open position on the medication cart in the hallway that was occupied by both staff and patients as LPN #1 administered medications through the patient's G-tube. Review of the hospital policy for rights and responsibilities of veterans identified that the veteran is assured confidential treatment of all medical and personal information.

Based on medical record reviews, review of facility policies and interviews for one of four patients reviewed for pain medication administration (Patient #22), and/or for one of two patients who required urinary bladder catheterization (Patient #31) and/or for one of three patients who had a pressure ulcer (Patient #4) and/or for one patient who received medications through a gastric tube (Patient #2) nursing staff failed to accurately assess the patient and/or appropriately administer medications to the patient. The findings include:

Patient #22 had diagnoses of back pain and severe osteoporosis. Physician orders dated 12/7/10 and 12/14/10 directed immediate release Oxycodone 5mg by mouth for pain levels 1- 5 and 10mg for pain levels 6- 10 every 4 hours as needed. The Record of Narcotics sheet identified that the patient received Oxycodone 10mg on 12/8/10 at 4 AM, 9:40 AM and 1:45 PM, on 12/11/10 at 1:40 AM, 8:20 AM, 9 AM, and 8 PM, on 12/12/10 at 8:45 AM, 4:45 PM, 8:30 PM and on 12/13/10 at 9 AM. Review of the patient's pain medication kardex with the Nursing Supervisor on 12/14/10 at 2PM noted that an assessment of the patient's pain was not documented before or after each medication was administered.
In addition, further review of the patient's pain medication kardex with the Nursing Supervisor on 12/14/10 at 2PM indicated that the patient's pain was not reassessed after pain medication was administered on 12/7/10 at 9:08 AM, 12/8/10 at 9:50 PM, 12/9/10 at 9 AM, 12/10/10 at 2PM, 7PM and 12 midnight, 12/13/10 at 8:35 PM and 12/14/10 at 8:55 AM. The hospital pain management policy directed to obtain a pain intensity rate on verbal patients using the scale of 1-10. The result(s) of any as needed medication given to a patient will be noted and recorded on the appropriate pain medication kardex.

Patient #4 had a diagnosis of paraplegia and pressure ulcers. The plan of care dated 11/23/10 identified unstageable pressure ulcers to include the left heel. The pressure ulcer staging tool and weekly tracking record noted that the patient had an unstageable pressure ulcer on the left heel that was intact and the skin of the left heel was brownish-black in appearance. Documentation by the Wound Nurse identified the left heel ulcer as a Stage II pressure ulcer on 11/29/10 and a Stage II pressure ulcer with stable eschar on 12/13/10. An assessment of the left heel ulcer for 12/6/10 was not documented in the patient's record. Review of the patients record and interview with the Nursing Supervisor on 12/14/10 at 11:15 AM indicated that the Wound Nurse assessed ulcers every Monday, documented an assessment of Patient #4's right lower leg ulcer on 12/6/10 and may have forgotten to document the assessment of the left heel ulcer on 12/6/10. Interview with the Advance Practice Registered Nurse (APRN) #1 on 12/14/10 at 11:30 AM noted that the patient had an unstageable pressure ulcer on the left heel. The hospital wound and skin ulcer policy identified that a member of the Skin Integrity Team (includes Wound Nurse) will document the progress of the wound weekly on the appropriate tracking sheet form. Interview with APRN #1 on 12/15/10 at 3PM indicated that pressure ulcers are never "down staged".

Patient #2's diagnoses included quadriplegia and status post gastrostomy tube (G- tube). Physician orders dated 11/3/10 directed that all oral medications be administered via the G-tube except for Simethacone, which was to be given orally. Observation of the medication pass on 12/14/10 at 10:20 AM noted that LPN #1 combined 9 medications (liquid and crushed medication) into a cup with warm water. LPN #1 administered 30 to 40cc of water followed by the contents of the cup with the medications via gravity through a syringe into the patient's G-tube via and without the benefit of verifying the G- tube placement prior to the procedure. Interview with LPN #1 on 12/14/10 at 10:20 AM indicated that h/she did not "normally" check for G-tube placement prior to administering medications. The hospital policy for medication via a gastric tube directed use of a diluent cup for mixing medication; to mix crushed tablets or liquid medication with the diluent, however, failed to address protocols for administration of multiple medications. According to the American Journal of Health Systems Pharmacology, 2008 Dec 15, "Medication Administration Through Enteral Feeding Tubes," " feeding tubes should be properly flushed with water before and after each medication is administered." According to Kozier and Erbs, Techniques in Clinical Nursing, Fifth Edition 2002, if administering more than one medication, flush with 15 to 30ml of tap water between each medication. The hospital policy for medication via a gastric tube did not include a measure or measures to verify the gastric tube tip location. According to the National Guideline Clearinghouse, Enteral access devices: selection, insertion, and maintenance, for maintenance considerations, " do not rely on the auscultory method to differentiate between gastric and intestinal tube placement. Mark the exit site of the feeding tube at the time of the initial radiograph; observe for a change in external tube length " .

Patient #31 had a diagnosis of atonic bladder. The physician's order dated 11/18/10 directed intermittent catheterization every shift using sterile technique. The treatment record and/or nursing narratives from 11/18/10 to 12/15/10 lacked documentation that the patient was catheterized on the day shift on 11/26/10, 12/10/10, 12/14/10 and the evening shift on 12/2/10. Review of the treatment record with the nursing supervisor on 12/15/10 at 9 AM noted that the back and/or front of the treatment record did not include information as to whether the patient refused the treatment and/or why the patient was not catheterized. Interview with the Nursing Supervisor on 12/15/10 at 9 AM indicated that the treatment Kardex was utilized by nursing to document treatments and this included catheterizations. The facility policy for treatment transcription and documentation identified that if a treatment was missed, initial the appropriate space, circle the initials and explain why on the back of the Treatment Administration Record when a standing treatment is not administered.

Based on a tour of the hospital, observations and review of hospital policy, the hospital staff failed to ensure that medications in 1 of 5 medication refrigerators had not expired. The findings include:

A tour of the D Upper unit was conducted on 12/14/10 at 12:50 PM. Observation of the medication refrigerator with the Nursing Supervisor on 12/14/10 at 12:50 PM identified an opened multidose vial of Lantus Insulin and an opened multidose vial of Novalog Insulin with the date of 11/11/10 written on the outside of each vial. Interview with the Nursing Manager on 12/14/10 at 12:50 PM indicated that the nurse would write the date that the insulin was initially opened on the outside of the insulin vial. h/she further indicated that the vial of insulin would expire after 28 days. The hospital policy for medication expiration date checks identified that multidose vials- all medications- must be dated and initialed when opened and discarded 28 days after the first puncture unless instructed otherwise by the manufacturer.

Based on a review of hospital policy, observation and interviews the hospital failed to ensure that medications were secured. The findings include:

Tours of the B Upper, C Upper and D Upper units were conducted on 12/14/10 between 9:30 AM and 2:30 PM with the day shift Nursing Supervisor. Observations between 9:30 AM and 2:30 PM on 12/14/10 noted that the Nursing Supervisor used a key to access the medication rooms on each unit and although cabinets that contained stock medications had keys noted in the locks, the cabinets were left unlocked. Observation of the D Upper unit on 12/14/10 at 12:50 PM indicated that the medication cart that was located in the medication room was unlocked. Interview with the Nursing Supervisor on 12/14/10 and/or the Administrator on 12/15/10 identified that all five medication rooms in the facility were accessible using the master key and security staff, nursing staff and the Superintendant of the hospital could access medication rooms. Further interview with the Administrator on 12/15/10 11:45 AM indicated that the hospital did not have a policy regarding access to medication rooms by ancillary staff and security staff would have no need to access a medication room.

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Based on observations review of hospital policies and interviews, the facility failed to ensure that safe practices for food handling were maintained: The findings include:

1. Observations during a tour of the dietary department with the Food Service Supervisor on 12/15/10 at 8:25AM identified 3 dietary staff members without the benefit of hair covering. A review of the Food Service Procedure identified that head and facial hair are to be covered with a hairnet, cap or other restraint.

2. Further observations during a tour of the dietary department with the Food Service Supervisor on 12/15/10 at 8:30 AM identified an ice machine with visible red discoloration on the exterior of the drop tray. Interview with the Food Service Supervisor at the time identified that the ice machine is cleaned by the dietary staff every Tuesday, however the daily cleaning assignment sheet for Tuesday December 14 lacked documentation that the ice machine was cleaned. Subsequent to surveyor inquiry, the ice machine was emptied and cleaned by the dietary staff.

3. The reach-in refrigerator in the dietary department was noted to contain two trays of peaches that were not dated, and the walk-in refrigerator and/or freezer contained thawing juices that were not dated and ice cream that was not dated. Although the facility policy does not address the dating of food items, interview with the Supervising Dietician on 12/15/10 at 8:30 AM identified that all items stored in the refrigerator should be dated and used within 3 days. She further identified that the juices and ice cream that are delivered to the facility arrive in a labeled box that contain a date. However, the items are then removed from the original box for storage and distribution to patients and the individual containers do not contain an expiration date.

4. Observations on 12/14/10 on the B lower and C Upper nursing units identified several staff meals in the patient's nourishment refrigerator. Observations of all five patient pantry nourishment refrigerators on 12/14/10 and/or 12/15/10 noted that single serve juices and ice cream did not contain an expiration date. Interview with the utilization review coordinator at the time indicated that it is the facility policy to store staff food items in the staff dining room and that the 11-7 nursing staff is responsible for cleaning the nourishment refrigerators. The hospital policy for food and snack storage on patient units identified that the nourishment refrigerator is only for nourishments and patient food.

5. A tour of the D Upper unit was conducted with the nursing Supervisor on 12/14/10 12:50 PM and 7 cartons of nectar-thickened milk were observed in the patient's nourishment refrigerator. Two of the 7 cartons had the expiration dated of 7/15/10 located on the outside of the carton. The cartons were immediately removed by the nursing Supervisor and discarded. Interview with the Nursing Supervisor at this time indicated that the refrigerators were cleaned by the night nursing staff every Sunday and the staff was responsible to check for expired items. The hospital policy for food and snack storage on patient units identified that sealed dietary nourishments may be stored and used up to 5 days past the "sell by" date.

1. Based on observation, review of hospital policy and interview with hospital personnel, the hospital failed to ensure that the emergency supply of oxygen was checked on a daily basis in accordance with policy. The findings include:

During tour of the hospital on 12/14/10, the "B" clinic crash cart was observed to store an oxygen tank. Review of the crash cart documentation failed to reflect that the level of oxygen was checked on a daily basis. Surveyor check of the oxygen level reflected a level equal to 1400 PSI. Although a review of the hospital policy reflected that the oxygen tank should be full and checked daily, the crash cart record utilized in the clinic failed to provide an area to record that check. During interview on 12/14/10, the Chief Respiratory Therapist stated that full oxygen tanks are important secondary to the general lack of access to oxygen in that area.



2. Based on observation, review of the hospital policy and interview with hospital personnel, the hospital failed to ensure that the hyrdroculator utilized in physical therapy met hospital policy. The findings include:

Observation of the hydroculator located in the physical therapy department on 12/14/10 identified that the water was murky and a random test of the water temperature registered 170 degrees F. The Surveyor requested to review the log for temperature monitoring and was informed by staff that no such log existed and that although staff cleaned the hydroculator every two months, documentation to support this could not be provided. Review of the hospital policy identified that the hydroculator should be cleaned every month and that the temperature should be between 150 to 160 degrees.

Based on review of facility documentation, review of infection control policies and interviews, the hospital failed to adequately monitor/evaluate staff compliance with infection control policies and/or practices of asepsis. The findings include:

A review of the hospitals infection control program was conducted with the Infection Practitioner on 12/15/10 at 1:30 PM. The hospital's policies included policies for the prevention of site infections (i.e. IV, wound, urinary catheter) and communicable diseases in accordance with current standards of practice. Review of documentation and interview with the Infection Practitioner on 12/15/10 at 1:30 PM identified that h/she monitored staff compliance for hand washing and adherence to isolation precautions on the day shift and monitoring was not conducted on the evening or night shifts. H/she also indicated that monitoring of additional nursing procedures for adherence to proper infection control technique was monitored during the orientation period upon hire and additional monitoring was not conducted. The hospital infection Control Practitioner job description identified duties that included to monitor patient/client care activities to identify methods, techniques, equipment, supplies, new products and/or specific policies/procedures which may constitute a risk of originating or transmitting infections.