HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:

1) Failing to implement policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. (see findings in tag A-0535)

2) Failing to ensure there was a radiologist who was a member of the medical staff that supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546)

Based on record review, observation and interview, the infection control officer failed to ensure the implementation of effective policies/procedures relative to acceptable standards of Infection Control to prevent and control infections and communicable disease as evidenced by:


1) Failing to ensure staff utilized the appropriate use of personal protective equipment and hand hygiene for 7 (S9CNA, S10Housekeeping, S24PT, S26CNA, S8RN, S14LPN, S25LPN) of 10 staff observed providing direct patient care to contact isolation patients, (see findings Tag A-0749).

2) Failing to ensure correct signage was located on the doors of patients with suspected or known Clostridium Difficile for 2 (#1, #2) of 8 isolation patients sampled and failure to place a contact isolation sign on the door of a patient, with Methicillin-resistant Staphylococcus aureus (MRSA) in a wound for 1 (#8) of 8 isolation patients sampled (see findings Tag A-0749).

3) Failing to ensure patients on isolation precautions limited transport and movement outside of their rooms to medically necessary purposes for 3 (#1, #2, #8) of 8 patients observed on isolation precautions (see findings Tag A-0749).

Based on review of medical records and staff interview, the Governing Body failed to ensure the members of the medical staff were held accountable to the Governing Body for the quality of care provided to the patients as evidenced by medical staff members not assessing and pronouncing death for 2 (#8, #21) of 2 deceased patients' medical records reviewed out of a total sample of 30 (#1-30). Findings:

Review of the hospital policy titled "Imminent Death", Policy number I.A.1.12, effective date of 01/08/13, (Approved by: left blank), revealed in part the following: ....A. Death pronouncement: A physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death....

Review of the hospital's list of patient expirations for the year 2014 revealed 5 patients expired during the year.

Patient #6
Review of the medical record for Patient #6 revealed the patient was an 80 year old female admitted to the hospital on 09/26/14 with diagnoses of Acute/Chronic Respiratory Failure, Encephalopathy, Pseudomonal Pneumonia, Respirator Dependent, Morbid Obesity, Sacral Decubitus with Debridement, Gastrointestinal Hemorrhage and Convulsions. The patient expired at the hospital on 11/02/14 at 12:35 a.m. and the body was released to the funeral home at 2:50 a.m.
Review of the physician's orders revealed the following orders:
10/30/14 at 3:00 p.m. - "Do Not Resuscitate."
11/02/14 at 12:40 a.m. - "Notify ____ parish coroner" (verbal order from attending physician).
Further review of the medical record revealed no documented evidence of a pronouncement of death or a discharge summary.

An interview was conducted with S2CCO (Chief Clinical Officer) on 12/18/14 at 2:00 p.m. S2CCO reviewed the medical record for Patient #6 and confirmed there was no documented evidence of a pronouncement of death by a physician and there was no discharge summary.


Patient #10
Review of the medical record for Patient #10 revealed the patient was a 68 year old male that was admitted to the hospital on 09/12/14 for Stage III Sacral Decubitus and Intravenous antibiotic therapy. Review of the record revealed the patient was found unresponsive, CPR was initiated and 911 was called on 09/29/14 at 11:25 p.m. At 11:37 p.m. EMS (Emergency Medical Services) responded, intubated the patient and provided CPR (Cardio Pulmonary Resuscitation). The record revealed the patient was, "Pronounced dead by EMS via telephone conversation with ER doctor at Hospital D" at 12:12 a.m. on 09/30/14.

An interview was conducted with S2CCO (Chief Clinical Officer) on 12/18/14 at 3:40 p.m. S2CCO reviewed the medical record for Patient #10 and confirmed an emergency room physician from Hospital D did pronounce the death over the phone and the physician was not on the medical staff of the hospital. S2CCO confirmed there was no documented evidence the attending physician pronounced the patient.

Based on observations, record review, and interviews, the hospital failed to ensure patient's rights to privacy were protected as evidenced by failing to ensure the presence of video surveillance in the patients' rooms had been discussed with the patient/responsible party for 6 of 6 (#2, #4, #7, #9, #12, #13) patients in 6 of 8 (Rooms #a, #b, #c, #d, #e, #f, #g, #h) rooms with working video cameras.
Findings:

Observations from the nursing station on 12/17/14 at 1:00 p.m. revealed video monitors in the Patient Rooms where Patient #2, #4, #7, #9, #12 & #13 were assigned.

Review of the medical records of Patient #2, #4, #7, #9, #12 & #13 revealed no documented evidence that the presence of video surveillance in the patients' rooms had been discussed with the patient and/or responsible party.

In an interview 12/18/14 at 9:45 a.m. Patient #7, sitting in her room (#c) reported that no one had told her there was a camera in her room, but that she had found it herself. She reported that she did not know if the camera was on and working or not. Patient #7 reported that she had not only not been told about the camera, but had not agreed to be monitored by camera. An observation at the time of the interview revealed an object with a lens mounted in the upper left corner of the room (when facing into the room from the hallway), pointed at the patient's bed.

An observation was conducted on 12/17/14 at 1 p.m. in the nursing station of a monitor with video streaming from patients' rooms. One of the patients observed with a video feed from his room to the monitor in the nursing station was Patient #9. The video was of Patient #9 in his room sitting up in his bed.

Review of the medical record for Patient #9, admitted 12/7/14 at 1:30 p.m. revealed a hospital Conditions of Admission and Consent for Medical Treatment signed by Patient #9 12/7/14 at 4:37 p.m. Further review of the Consent for Medical Treatment revealed, on page 2 of 3 under "9. Consent to Photograph", the words "NO Photographs" handwritten across the printed authorization information. Review of a History and Physical by a Nurse Practitioner dictated 12/8/14 at 6:38 p.m. revealed Patient #9 was assessed as alert and oriented, with clear speech and intact vision and hearing. Further review of the medical record revealed no documentation of a discussion, notification, or education regarding the video camera in his room.

In an interview 12/18/14 at 9:50 a.m. Patient #9 reported no one had told him there was a camera in his room, but that he had discovered it himself. Patient #9 reported that when signing consents on admission he had refused to be photographed and had written such on his consent.

In an interview 12/18/14 at 9:15 a.m. in the nursing station, S2CCO (Chief Nursing Officer) reported the cameras in rooms a, b, c, d, e, f, g, and h had been installed approximately a week ago, but had not yet been used. S2CCO reported that the hospital did not yet have a policy, or consents for use of the cameras. S23UnitClerk, also present for the interview demonstrated how to activate the images for the cameras. A list of rooms was taped to the monitor base that gave the corresponding camera number for each monitored room. The unit clerk brought up the images of several rooms on the screen at the same time. She demonstrated how only one, or specific rooms could be displayed. S2CCO and S23UnitClerk verified that the monitor was not password protected, and anyone could activate the camera images on the screen. S2CCO and S23UnitClerk further verified that the images on the monitor screen could be viewed by any person in the nursing station, even those that were not involved in the patients' care or hospital staff. S2CCO and S23UnitClerk verified that 6 of the 8 rooms currently had patients in them. S2CCO and S23UnitClerk reported the cameras would be used for patients on ventilators and patients that were a high risk for falls but not compliant. S23UnitClerk reported that they (staff) could go back to see what happened, for example if a patient fell.

In an interview 12/22/14 at 8:20 a.m. S1Adm (Administrator) reported that a policy for use of surveillance cameras had not been developed or approved prior to the beginning of the survey 12/17/14. S1Adm reported that no staff education on the use of video surveillance in patient rooms had been initiated. S1Adm verified that no notices had been posted in the patient rooms and that staff had not yet informed the patients of the cameras.





26351

Based on observation, record review and interview, the hospital failed to ensure patient care was provided in a safe setting. This is evidenced by:
1) failing to observe the central telemetry monitor for 2 of 2 patients (Patient #4 and Patient #15) on central telemetry monitoring;
2) failing to monitor patients on the psychiatric unit in accordance with the orders of the practitioner and hospital policy for 2 (#16, #17) of 14 patients observed. Findings:

1. Failing to observe the central telemetry monitor for 2 of 2 patients (Patient #4 and Patient #15) on central telemetry monitoring.

Review of the hospital's policy for Telemetry Monitoring, Policy # II.K.11.06 revealed in part, This hospital provides telemetry monitoring for patients on order of the attending physician. All telemetry patients will be monitored through a central monitor located at the nurse's station by a competency verified RN, LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) or monitor tech... Cardiac rhythm will be monitored by a qualified (person) at all times. It is the responsibility of the assigned monitor technician to assure that a qualified individual covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended. Any variance from this must be reported to the DON (Director of Nurses) and physician immediately.

In an observation on 12/17/14 at 12:20 p.m., no one was monitoring the central telemetry monitor in the nurses' station.
In an observation on 12/17/14 at 2:18 p.m., no one was monitoring the central telemetry monitor in the nurses' station.
In an observation on 12/22/14 at 11:20 a.m., 2 telemetry monitor tracings were observed on the monitor screen and an audible alarm was sounding. 5 nursing staff were observed seated in the nursing station, but no one was monitoring the central telemetry monitor in the nurse's station. S23Unit Clerk was observed to be seated across from the monitor with her back to the monitor. The telemetry alarm continued to be audible. As the surveyor approached the telemetry monitor, S23Unit Clerk turned around to the monitor and began adjusting the alarms.

An observation conducted 12/22/14 from 11:40 a.m. to 11:45 a.m. in the nurses station revealed 2 telemetry monitor tracings on the monitor screen. Further review revealed 3 nurses sitting at a table in the middle of the room charting, or talking with each other. S8RN, charge nurse was not present in the nursing station. S23Unit Clerk had her back to the monitor and was entering names into a patient transfer log. After completing her list, S23Unit Clerk walked to another desk area in the nursing station where the monitor was not in visual sight. At no time during this observation was anyone observed to look at the telemetry monitor screen.

In an interview on 12/17/14 at 12:20 with S8RN, she said there was one patient on telemetry monitoring. She said whoever was in the nursing station at the time watched the monitor. She verified no one person was assigned to be responsible for the monitor.

An interview was conducted with S1Adm on 12/22/14 at 9:30 a.m. When questioned on which staff member was assigned to observe the central telemetry monitor in the nurse station, she reported the charge nurse and the unit clerk are usually in the nurse station at all times. She verified no one was assigned to only monitor the central telemetry monitor at all times.

2. Failing to monitor patients on the psychiatric unit in accordance with the orders of the practitioner and hospital policy for 2 (#16, #17) of 14 patients observed.

Review of the policy titled Special Precautions, Policy Number: BH.1.33, revealed in part:
In order to provide protection to psychiatric patients, three levels of staff monitoring are provided:
A. Routine Precautions (monitoring every 15 minutes)
B. Special Precautions (monitoring on a constant basis)
II. A written physician's order is obtained for Special Precautions.
Special Precautions I: Consists of 30 minute checks by a staff member.
A. The patient is to remain visible to a staff member at all times during the day.

Review of the medical records for Patient #16 and Patient #17 revealed they had been ordered to be on Special Precautions I.

In an observation on 12/22/14 at 12:45 p.m., all of the patients except Patient #16 and Patient #17 were outside of the unit smoking with a technician. Further observation revealed there was no technician on the hall in the psychiatric unit and Patient #16 and Patient #17 were in their rooms and not in direct site of an employee.

In an interview on 12/22/14 at 12:59 p.m. with S20RN, she said the patients were in view of the technicians most of the time unless they were in their rooms.

In an interview on 12/22/14 at 1:15 p.m. with S2COO, she said the observation levels on the psychiatric unit were close observation, 1:1 and every 15 minute checks. When asked where those were defined in the policy, she said they were not. S2COO also verified the policy dictated Special Precautions I required direct observation at all times.

In an interview with S4PsychUnitManager, he verified the Special Precautions policy did not match what was actually being done on the unit. He also verified the policy required the patients to remain visible at all times which was not happening.




30420







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30364

Based on record review and staff interview, the hospital failed to ensure the QAPI program:
1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in medical records after the same corrective action was unsuccessful, and;
2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level. Findings:

1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in medical records after the same corrective action was unsuccessful:

Review of the hospital policy titled, "Improving Organizational Performance Plan", policy number I.E.5.06 revealed in part the following: The Organizational Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services. Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optional achievements, with appropriate accountability assumed by the Governing Board, Medical Staff, Administration, and support personnel....The facility utilizes the Plan-Do-Check-Act (PDCA) Performance Improvement Model.....The "Act" stage involves the following: Act to implement changes on larger scale, secure additional input on revisions, revise plan for full implementation, implement additional improvements if necessary, replicate in other areas....

Review of the Performance Improvement Tracking report for the Quality Indicator of Verbal Orders Authenticated Timely revealed the total compliance percentage for the past 12 months was 77%. Review of the monthly totals revealed the following:
December 2013 - 64%
January 2014 - 80%
February - 54%
March - 79%
April - 92%
May - 72%
June - 88%
July - 83%
August - 90%
September - 73%
October - 81%
November - 69%
The identified goal/benchmark for compliance was 90%.
The corrective action plan documented for this indicator revealed the only action identified was to, "Let doctors that do not round daily know when they are reaching the time limit." There was no documented evidence of any new approaches or corrective actions identified to address the continued non-compliance with authenticating verbal orders.

Review of the Performance Improvement Tracking report for the Quality Indicator of History & Physical Delinquency revealed the total compliance percentage for the past 12 months was 30.6%. Review of the monthly totals revealed the following:
December 2013 - 52.2%
January 2014 - 25.8%
February - 34.5%
March - 28%
April - 39.3%
May - 24.1%
June - 19.2%
July - 28.6%
August - 22.2%
September - 42.9%
October - 16.7%
November - 31.8%
The identified goal/benchmark for compliance was 10% (10% or less).
The corrective action plan documented for this indicator revealed the following:
January & February 2014 education for nurse practitioners and physicians.
May 2014 - Medical Records will verify admit time.
July & August 2014 - Staff will contact physician and nurse practitioner when patient is admitted.
October 2014 - Continue contacting doctors and nurse practitioners at time of admission.
There was no documented evidence of any new approaches or corrective actions identified to address the continued non-compliance when corrective actions failed to improve compliance.

In an interview on 12/22/14 at 2:00 p.m., S6Medical Records confirmed she was responsible for collecting medical records QAPI data and entering the data into Action Cue.
S6Medical Records confirmed medical record delinquencies of verbal order authentication and History & Physical within 24 hours of admission continue be a problem. S6Medical Records stated the corrective actions work for awhile and then the compliance decreases. S6Medical Records stated this was, "Very frustrating." When asked if the medical staff had addressed the continued non-compliance, she stated the medical record deficiencies were discussed in MEC (Medical Executive Committee), but they don't do anything else. S6Medical Records confirmed the corrective actions taken had not achieved compliance with the identified goals.


2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level:

Review of the hospital policy titled, "Improving Organizational Performance Plan", policy number I.E.5.06 revealed in part the following: R. Facility Specific Monitoring: The hospital will continually strive to identify areas of opportunity for improvement. As new services are implemented or opportunities for improvement are identified and corrective action is initiated; the facility will design performance improvement monitors to assure achievement of facility goals. These facility specific monitors will be dynamic and changing throughout the course of the year. These results of these monitors will be reported to the QAPI Committee during the monthly meetings until the discontinuation of the monitor.

On 12/22/14 at 11:30 p.m., the hospital's QAPI program was reviewed with S2CCO (Chief Clinical Officer) who indicated she was responsible for QAPI. S2CCO verified data was collected and entered into the Action Cue software system and the system generated reports from the quality indicator data entered by the individual departments. When asked if the quality indicators being monitored were based on high-risk, high volume or problem prone activities, S2CCO stated she could not add any indicators to the Action Cue system. S2CCO stated all quality indicators in Action Cue are chosen at the corporate level and are implemented across all the hospitals managed by corporate. S2CCO confirmed that some of the quality indicators this hospital monitors are not problems identified at this hospital. S2CCO stated she had identified problems with care plans and had tried several approaches to correct the problems. S2CCO confirmed this was not included in the Action Cue system. S2CCO also stated whenever she identifies a problem she does one-on-one with the staff involved and discusses the problem at staff meetings.

Based on observations, record review, and staff interview, the hospital failed to ensure problems identified by infection control officers were addressed through QAPI program activities. Findings:

Review of the hospital policy titled, "Improving Organizational Performance Plan", Policy number I.E.5.06, effective date of 01/08/13, revealed in part the following: The Organizational Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services....To utilize results from Infection Control, Utilization Review, Risk Management, EOC (Environment of Care) and Patient Safety to improve processes that affect patient care outcomes....The Monitoring and Evaluation Process will include the following activities:....8. Infection Control Surveillance....

During the survey from 12/17/14 through 12/22/14 the following infection control breeches were observed:
1) failing to ensure staff utilized the appropriate use of personal protective equipment and hand washing for 7 (S9CNA, S10Housekeeping. S24PT, S26CNA, S8RN, S14LPN, S25LPN) of 10 staff observed providing direct patient care to contact isolation patients;
2) failing to ensure correct signage was located on the doors of patients with suspected or known Clostridium Difficile for 2 (#1, #2) of 8 isolation patients sampled and failure to place a contact isolation sign on the door of a patient with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound for 1 (#8) of 8 isolation patients sampled;
3) failing to ensure patients on isolation precautions limited transport and movement outside of their rooms to medically necessary purposes for 3 (#1, #2, #8) of 8 patients observed on isolation precautions;
4). failing to maintain a sanitary environment in the kitchen as evidenced by not monitoring the chemicals and/or temperatures in the dishwasher and three compartment sink;
5). failing to ensure the in-house laundering by housekeeping staff of reusable cloth mop pads and towels used to clean rooms was regulated;
6). failing to maintain a sanitary environment as evidenced by storing a dialysis machine in the therapy room and failing to separate clean and dirty supplies.

Review of the QAPI records (Action Cue reports, QAPI Monthly meeting minutes, audit forms for quality indicators) revealed the QAPI program had not identified any problems related to infection control, or the above observed breeches in infection control.

In an interview on 12/22/14 at 11:30 a.m., S2CCO (Chief Clinical Officer) verified she was responsible for the hospital's QAPI program. S2CCO confirmed she had done surveillance and had identified problems with hand hygiene and isolation practices. S2CCO stated when she is present the staff wash their hands. S2CCO stated there was no corrective action plan for hand hygiene. She stated the benchmark in Action Cue for hand hygiene was 85%. She stated the data she had entered from her surveillance was under the benchmark, so no corrective action plan was required. S2CCO stated she addressed any breeches with the individual staff. S2CCO verified the methodology used had not captured the infection control problems.

Based on record review and staff interview, the hospital failed to ensure that it conducted performance improvement projects as part of its quality assessment and performance improvement program. The hospital could provide no documented evidence of a completed performance improvement project that it had conducted as well as an ongoing project.
Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06, effective date of 01/08/2013, revealed no documented evidence of any provisions for selecting and conducting performance improvement projects, other than the QAPI committee was to provide guidance to facilitate Performance Improvement teams and projects.

Review of the hospital QAPI (Quality Assessment Performance Improvement) records revealed no documented evidence of any performance improvement projects.

In an interview on 12/22/14 at 11:30 p.m., S2CCO (Chief Clinical Officer) confirmed she was responsible for the hospital's QAPI program and confirmed the hospital had not conducted any performance improvement projects and did not have an ongoing project in place at the present time.

Based on record review and staff interview, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the QAPI Program. The governing body failed to ensure the QAPI program included monitoring of psychiatric services, bio-medical services, dialysis services, bio-hazardous waste services, contracted nursing services, organ procurement, and inpatient and respite hospice services.
Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06, effective date of 01/08/2013, revealed in part the following:....B. Scope of Activities and Services....The scope of the Performance Improvement Program includes measurement and assessment activities which address patients served by the Medical Staff, Nursing, and ancillary services and hospital wide functions. Both clinical and non-clinical departments are included...All departments shall participate in the systematic monitoring and evaluation of the quality and safety of care/services they provide. The DON (Director of Nursing) and department leaders will: 1. Submit opportunities for improvement to the QAPI Committee for prioritization. 2. Promote the development of pre-established standards of care and criteria to objectively measure the quality and safety of care/services rendered in their departments....4. Promote the integration of their department's evaluation activities with those of the Medical Staff through participation in quality improvement teams. 5. Report Performance Improvement findings and actions taken to the DON, the QAPI Committee, Medical Staff, and others as appropriate.

Review of the hospital's performance improvement records revealed no documented evidence that the hospital's psychiatric services were included in the QAPI program Further review of the QAPI documents revealed the contracted services of bio-medical, Hemodialysis, Inpatient & Respite Hospice services, contracted nurse staffing, Organ Procurement Services, and biohazard waste disposal were not included in the QAPI program.

In an interview on 12/22/14 at 12:15 p.m., S2CCO (Chief Clinical Officer) confirmed she was responsible for the hospital's QAPI program. S2CCO verified there were no quality indicators or quality monitoring done for the contracted services of Hemodialysis, Hospice services, Bio-medical, Bio-hazardous, Contracted Nursing Services, and Organ Procurement Services. S2CCO confirmed Hemodialysis was provided in the hospital by a contractor. S2CCO confirmed inpatient and respite hospice services were provided in the hospital by multiple Hospice Agencies. S2CCO stated she was not able to access the quality monitoring for the hospital's psychiatric services and stated S4Psych Unit Manager would be able to.

In an interview on 12/22/14 at 1:15 p.m., S4Psych Unit Manager stated the psych unit entered their incident reports, medication errors and restraint usage into the Action Cue system and those were monitored by the hospital's QAPI program. S4Psych Unit Manager stated all the QAPI monitoring done by the psych unit was in the Action Cue system. When asked if any QAPI monitoring of the psychiatric services provided to the patients was done, he stated a chart audit was done on current patients to ensure compliance with treatment plans, observation levels, psych evals, etc. S4Psych Unit Manager stated S27RN audited the patient records on the nights that she works. When asked if there was any documented methodology for the chart audit data collection, he stated no. He stated any deficiencies found were addressed with the individual nurse. S4Psych Unit Manager verified data from the chart audits was not reported to the QAPI program and there was no tracking or trending of the chart audit results. S4Psych Unit Manager also stated once the patient was discharged the chart audit forms were destroyed. S4Psych Unit Manager confirmed there was no QAPI quality indicators specific to the services provided to patients in the psychiatric unit.

Based on record review and staff interview, the Governing Body failed to determine the number of distinct improvement projects the hospital would conduct annually as evidenced by no performance improvement projects conducted in the last year or currently being conducted. Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, policy number I.E.5.06, effective date of 01/08/2013, revealed no documented evidence of any provisions for selecting and conducting performance improvement projects.

Review of the hospital QAPI (Quality Assessment Performance Improvement) records revealed no documented evidence of any performance improvement projects.

Review of the Governing Body Meeting Minutes for 2014 revealed no documented evidence that the Governing Body had determined or approved any performance improvement projects.

In an interview on 12/22/14 at 11:30 a.m., S2CCO (Chief Clinical Officer) confirmed the hospital had not conducted any performance improvement projects and did not have an ongoing project in place at the present time.

26351

Based on record review and interview, the hospital failed to ensure a medical history and physical examination was completed and documented within 24 hours of admission for 4 (#10, #16, #17, #24) of 30 sampled patients. Findings:

Review of the hospital's policy, Time Frames, Policy # III.O.15.15 revealed in part, History and Physical have a completion time of 24 hours.

Patient #10: Review of the closed medical record for Patient #10 revealed the patient was a 68 year old male admitted to the hospital on 09/12/14 with diagnoses of Stage III Sacral Decubitus, Pneumonia, Hypertension, and Type II Diabetes Mellitus. Further review revealed the History & Physical (H&P) was dictated on 09/16/14 at 5:47 p.m., 4 days after admission to the hospital.

In an interview on 12/18/14 at 3:40 p.m., S2CCO (Chief Clinical Officer) reviewed the medical record for Patient #10 and confirmed the H&P had not been done by the physician within 24 hours of admission to the hospital.

Patient #16: Review of the medical record on 12/22/14 at 11:00 a.m. for Patient #16 revealed he had been admitted to the facility on 12/19/14 at 2:45 p.m. Further review revealed there was not a History and Physical in the medical record.

Patient #17: Review of the medical record for Patient #17 (current patient) revealed the patient was a 49 year old female admitted to the hospital on 12/11/14 with diagnoses of Schizoaffective Disorder, Bipolar Disorder, Hypertension, Hyperlipidemia, and Diabetes Mellitus. Further review revealed the History & Physical (H&P) was dictated on 12/13/14 at 7:44 p.m., 2 days after admission to the hospital.

In an interview on 12/22/14 at 11:20 a.m., S2CCO reviewed the medical record and confirmed the H&P had not been done by the physician within 24 hours of admission to the hospital.

Patient #24: Review of the medical record for Patient #24 revealed he had been admitted to the hospital on 12/19/14 at 8:00 p.m. Further review revealed his History and Physical wasn't dictated until 12/21/14 at 11:51 a.m. and transcribed until 12/22/14.






30364

Based on record review and staff interview, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by failure to provide after life care for 1 (#10) of 2 (#6, #10) sampled death records reviewed out of a total sample of 30 (#1-#30). Findings:

Review of the hospital policy titled, "Imminent Death", Policy number I.A.1.12, effective date of 01/08/13, revealed in part the following: F. Care and identification of the body: 4. Post Mortem: All other deaths: The body should be clean. Bathe the patient if necessary. Remove all equipment, catheters, drains, tubes, etc. Apply clean surgical dressing to all wounds, if present. Change bed linens, apply disposable gown. Replace dentures if possible or place in labeled cup and send with body. Leave patient arm band in place. Remove all jewelry and give to family member. Document in nurses notes what was removed and person receiving.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 68 year old male admitted to the hospital on 09/12/14 with diagnoses of Stage III Sacral Decubitus, Pneumonia, Hypertension, and Type II Diabetes Mellitus. Review of the record revealed the patient was found unresponsive with resuscitation attempted, and expired on 09/30/14 at 12:12 a.m. in the hospital. Review of the nursing documentation revealed no documented evidence that any after life care was provided.

In an interview on 12/18/14 at 3:40 p.m., S2CCO (Chief Clinical Officer) reviewed the medical record for Patient #10 and confirmed there was no documentation of after life care provided by the nurse for Patient #10.

Based on record review and interview, the facility failed to ensure the nursing staff developed and kept current a nursing care plan for 6 (#2, #7, #9, #10, #11, #12) of 20 records reviewed for care planning. Findings:
Patient #2
Review of the medical record for Patient #2 revealed he was a 39 year old man admitted on 12/12/14 with a stage II pressure ulcer to his left lower back. He had diagnosis which included paralysis, depression and substance abuse. Further review revealed he was on contact precautions for suspected Clostridium Difficile. He had a Foley catheter and a peripherally inserted central catheter (PICC).
Review of the care plans for Patient #2 revealed no problems and interventions identified for PICC lines, Clostridium Difficile, indwelling Foley catheter care, Substance Abuse or Depression.

Patient #7: Review of the medical record for Patient #7 revealed she was on sliding scale insulin for Diabetes. Review of the care plans for Patient #7 revealed no problem had been identified or interventions initiated for Diabetes.

Patient #9: Review of the medical record for Patient #9 revealed he was admitted for chronic cellulitis, debility and morbid obesity. His medical history included hypertension chronic pain. Review of a Psychiatric Evaluation dated 12/7/14 revealed Axis I diagnosis of obsessive compulsive disorder (OCD), Anxiety and Depression. Review of the care plans for Patient #9 revealed no problems identified or interventions listed for pain, Hypertension, Obsessive Compulsive Disorder, Anxiety or Depression.

Patient #11: Review of the medical record for Patient #11 revealed he was admitted to the facility on 12/13/14 for treatment to a non-healing wound on his lower back. He also had diagnosis which included Anxiety, Diabetes and Depression. Review of the care plans for Patient #11 revealed no problems identified or interventions listed for Anxiety, Diabetes and Depression.

Patient #10: Review of the closed medical record for Patient #10 revealed the patient was a 68 year old male admitted to the hospital on 09/12/14 with diagnoses of Stage III Sacral Decubitus, Pneumonia, Hypertension, and Type II Diabetes Mellitus. Further review of the medical record revealed no documented evidence of an Interdisciplinary Plan of Care.

In an interview on 12/18/14 at 3:40 p.m., S2CCO reviewed the medical record for Patient #10 and confirmed there was no documented evidence of a plan of care in the medical record.

Patient #12: Review of the medical record for Patient #12 revealed the patient was a 28 year old male admitted to the hospital on 11/22/14 (current inpatient) with diagnoses of Sacral Osteomyelitis due to Peri-rectal Fistula, Chron's Disease, Anemia secondary to blood loss with fistula, Acid Reflux, Chronic Pain and Anorexia. Review of the record revealed the patient had a colostomy and a PICC (Peripherally Inserted Central Catheter) line. The patient was diagnosed with an Upper Respiratory Infection on 12/16/14. Review of the Interdisciplinary Plan of Care revealed the only nursing diagnoses identified were, "High Risk For Infection," Impaired Skin Integrity," and "Discharge Planning Needs." Review of the plan of care revealed no goals or interventions were checked or written in to address the identified problem of Impaired Skin Integrity. There was no documented evidence the patient's problems/diagnoses of Chron's Disease, Anemia, Acid Reflux, Anorexia, and pain were addressed with goals and interventions in the plan of care. The patient's PICC line use and Colostomy were not included in the plan of care.

In an interview on 12/22/14 at 11:20 a.m., S2CCO reviewed the medical record for Patient #12 and confirmed the plan of care was not individualized to meet all of the needs of the patient and did not include all the patient's diagnoses and current treatments/interventions.

In an interview on 12/22/14 at 10:30 a.m. with S2CCO (Chief Clinical Officer), she verified the patient's care plans should be inclusive of all of the patient's medical and psychological problems.




17091

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to current nursing standards for 4 (Patient #7, Patient #15, Patient #20, Patient #21) of 10 medical records reviewed for medication administration out of a sample of 30. Findings:

Patient #7: Review of the Medication Administration Record for Patient #7 revealed Digoxin 0.125mg was given at 9:00 a.m. on 12/16/14. Further review revealed the most recent pulse had been checked at 6:00 a.m. (3 hours prior to giving the dose).

Patient #15: Review of the medical record for Patient #15 revealed the patient was admitted to the hospital on 8/18/2014 for a Venous Stasis Ulceration of the Legs and CVA (Cerebral Vascular Accident). Review of the Medication Administration Record revealed the patient had received Toprol XL 25 mg (milligrams) by mouth daily from 8/18/14 to 8/25/14. Further review of the MARs revealed the patient's heart rate and blood pressure were not monitored prior to administration.

Patient #20: Review of the medical record for Patient #20 revealed he was admitted to the hospital on 07/30/14 with a nonhealing pressure ulcer. Review of the Medication Administration Record from 08/19/14 until 8/29/14 revealed he was administered Cozaar 100 mg by mouth daily without his blood pressure being monitored prior to administration.

Patient #21: Review of the medical record for Patient #21 revealed the patient was admitted to the hosptial on 9/16/14 for Uncontrolled Diabetes Mellitus and End Stage Renal Failure. Review of the Medication Administration Record revealed she received Lisinopril 10 mg by mouth daily and Digoxin 125 mcg (micrograms) by mouth daily from 9/17/14 until 10/16/14. Further review on these dates revealed the patient's blood pressure was not documented prior to administration of Lisinopril and the patient's apical pulse was only monitored 5 times during the 30 day period prior to administration of the Digoxin.

An interview was conducted with S2CCO on 12/22/14 at 4 p.m. She reported the patient's blood pressure should be checked prior to administering blood pressure medications and the patient's pulse should be checked prior to administration of Digoxin.

Based on record review, observations and interview, the hospital failed to ensure medical record were protected from water and fire damage as evidenced by medical records from 2004 until present being stored unprotected on open shelving in the medical records room.
Findings:

Review of the hospital's policy, Policy Number III.O.15.14 revealed in part, Storage space shall be selected and maintained to protect records for unauthorized access, loss and destruction. Storage space shall be selected to meet the following specifications: protection from fire...

An observation was conducted in Medical Records on 12/18/14 at 9:30 of all the patients' medical records being on open shelving and not protected from fire or water damage. The Medical Records room was equipped with a sprinkler system.
An interview was conducted with S6Medical Records on 12/18/14 at 9:30 a.m. She reported the medical records on the open shelving are from 2004 until present (approximately 10 years worth of medical records). Also there were 16 boxes of medical records in the medical records department unprotected from water and fire damage.

Based on interview and record review, the hospital failed to ensure patient's medical records contained information to accurately describe the patient's progress and response to interventions. This is evidenced by the physician failing to document any information in the medical record about a patient being transferred to a local hospital for an advanced level of medical care for 1 (#11) of 1 patients reviewed for transfers out of a total sample of 30 patients.

Findings:

Review of the Medical Staff Rules and Regulations, Section 5.1, revealed in part:
5.1 Preparation and Completion:
5.1.1 The attending physician shall be responsible for the preparation of a complete medical record for each patient. The record shall include identification data, complaint, personal history, family history, history of present illness, physical examination, progress notes (documented at the discretion of the attending physician as the patient's condition warrants)
5.3 Progress Notes:
5.3.1 Pertinent progress notes shall be documented at the time of observation, sufficient to permit continuity of care and transferability. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of test and treatments.

Review of the medical record for Patient #11 revealed he was admitted to the facility on 12/13/14 for treatment to a non-healing wound on his lower back. He also had diagnosis which included Anxiety, Cardiac Disease, End-stage Renal Disease, Diabetes, Status post left lower extremity amputation, Depression and Shingles.

Review of the Nurse's Notes for Patient #11 dated 12/14/14 at 6:00 p.m. revealed he had been sent to Hospital "D" for a decreased blood glucose level. Review of the nursing notes from 12/16/14 at 11:20 a.m. revealed Patient #11 had returned to the hospital.

Review of the Physician ' s Orders for Patient #11 dated 12/14/14 revealed no order to send Patient #11 to the hospital.

Review of the Progress notes for Patient #11 revealed no documentation of the patient being sent to the hospital between 12/14/14 and 12/16/14.

In an interview on 12/22/14 at 4:32 p.m. with S2CCO, she stated the physician should have written a note about Patient #11 being transferred to the hospital on 12/14/14 through 12/16/14. S2CCO also said he should have written an order to transfer Patient #11.

Based on interview and record review,
1. the facility failed to ensure all medical record entries by the person responsible for providing the service were signed, dated and timed for 6 (#3, #7, #6, #10, #12, #14) of 30 records reviewed; and
2. the facility failed to ensure all telephone orders were written according to hospital policy for 3 (#18, #17, #16) out of 3 patients reviewed for correctly written telephone admission orders out of a total sample of 30.

Findings:
1. The facility failed to ensure all medical record entries by the person responsible for providing the service were signed, dated and timed.

Review of the hospital policy for Verbal Orders, Policy Number: N.14.10.03.a revealed in part, Verbal orders will be received by authorized professional with their scope of practice, immediately reduced to writing (on the physician's order form or other authorized document) and read back to the prescriber to confirmed and/or clarify. In addition to their information required for a written order, verbal orders shall include:
A. The date and time of entry
B. The prescribing practitioner's name
C. The signature and title of the person who accepted the order.

Authentication (Verification) of verbal orders: Orders that are not written by a prescriber (e.g., verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within the time period specified by the medical staff rules and regulations.
Persons who may transmit verbal orders: Verbal orders shall be transmitted only by authorized prescribers designated in medical staff rules and regulations and only consistent with federal laws and the laws and regulations of the state.

Review of the Medical Staff Rules & Regulations, provided by S1Adm (Administrator) as current, revealed in part the following: 5.8.9 All verbal/telephone orders must be signed within 10 days.

Patient #3: Review of a document in Patient #3's medical record titled Urgent Communication revealed the physician had signed the document but had not timed or dated his authentication.

Patient #7: Review of Patient #7's medical record revealed the History and Physical had been signed by a physician but had not been dated or timed.

Patient #14: Review of the medical record for Patient #14 revealed 5 documents dated 12/11/14 titled Medication Communication Form that had been signed by the physician but his authentications had not been timed.


In an interview on 12/22/14 at 10:30 a.m. with S2CCO (Chief Clinical Officer), she verified the physician's signatures should be dated and timed in the medical record.

Patient #6: Review of the closed medical record for Patient #6 revealed the patient was admitted to the hospital on 09/26/14 with diagnoses of Acute/Chronic Respiratory Failure, Encephalopathy, Pseudomonad Pneumonia, Respirator Dependent, Morbid Obesity, Sacral Decubitus with Debridement, Gastrointestinal Hemorrhage and Convulsions.

Review of the physician's orders revealed the following verbal orders were not authenticated by the physician:
09/27/14 - Orders for respiratory treatments and chest x-ray,
10/13/14 - Orders to change ventilator settings,
10/13/14 - Orders to hold vancomycin,
10/14/14 - Orders for portable chest x-ray,
10/18/14 - Orders for blood cultures,
10/19/14 - Orders for Intravenous fluids and lab tests,
10/20/14 - Orders for lab tests,
10/22/14 - Orders for respiratory treatments,
10/24/14 - Orders for chest x-ray, and
10/26/14 - Orders for lab tests.

An interview was conducted with S2CCO on 12/18/14 at 2:00 p.m. S2CCO reviewed the medical record for Patient #6 and confirmed the above verbal orders were not signed by the physician.

Patient #10: Review of the closed medical record for Patient #10 revealed the patient was admitted to the hospital on 09/12/14 for Stage III Sacral Decubitus and Intravenous antibiotic therapy.
Review of the physician's orders revealed the following:
09/12/14 - Medication Reconciliation and Order Form signed by the physician but not dated or timed by the physician.
09/12/14 - Verbal Orders for Sliding Scale Insulin and wound care signed by the physician, but not dated or timed when authenticated.
09/12/14 - Verbal Orders for Intravenous antibiotics signed by the nurse practitioner, but not dated or timed when authenticated.
09/13/14 - Verbal Orders to hold Coumadin, administer Vitamin K 10 mg. now and repeat at 6:00 p.m., and labs in a.m. signed by the physician, but not dated/timed when authenticated.
09/13/14 - Verbal Order to discontinue in & out catheter to obtain urine specimen signed by the physician, but not dated/timed when authenticated.
09/14/14 - Verbal Orders to hold Coumadin, administer Vitamin K 10 mg. now and labs in a.m. signed by the physician, but not dated/timed when authenticated.
09/14/14 - Verbal Orders for Speech Therapy to evaluate & treat signed by the physician, but not dated/timed when authenticated.
09/14/14 - Verbal Orders for diet change signed by the physician, but not dated/timed when authenticated.
09/14/14 - Verbal Orders for Tylenol signed by the physician, but not dated/timed when authenticated.
09/19/14 - Physician orders for medication changes and physical therapy not timed by the physician.
09/15/15 - Verbal Orders for Vancomycin trough and creatinine signed by the nurse practitioner, but not dated/timed when authenticated.
09/16/14 - Verbal Orders for supplements and medication changes signed by the physician but not dated/timed when authenticated.
09/23/14 - Verbal Orders for continuation of Intravenous antibiotics signed by the nurse practitioner, but not dated/timed when authenticated.
09/23/14 - Physician orders for x-ray and pain medication not timed by the physician.
09/24/14 - Verbal Orders for intravenous Potassium, labs, and transfusion signed by the physician, but not dated or timed when authenticated.
09/24/14 - Physician order for swallowing study not timed by the physician.
09/26/14 - Verbal Orders for Lasix and Foley Catheter signed by the physician, but not dated/timed when authenticated.
09/29/14 - Verbal Orders for wound care signed by the physician, but not dated/timed when authenticated.

An interview was conducted with S2CCO on 12/18/14 at 3:40 p.m. S2CCO reviewed the medical record for Patient #10 and confirmed the above verbal orders were not dated and/or timed by the physician upon authentication. S2CCO also confirmed the above physician orders had not been timed by the physician when the physician entered them into the medical records.

Patient #12: Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 11/22/14 (current inpatient) with a diagnoses of Sacral Osteomyelitis due to Peri-rectal Fistula, Chron's Disease, Anemia secondary to blood loss with fistula, Acid Reflux, Chronic Pain and Anorexia.

Review of the physician's orders revealed the following:
11/23/14 - Orders for medication changes written by the physician but not timed.
11/25/14 - Verbal Orders for medications not authenticated by the physician.
11/26/14 - Verbal Orders for PICC (Peripherally Inserted Central Catheter) line placement signed by the physician but not dated or timed when authenticated.
11/26/14 - Orders for medications written by the physician but not timed.

In an interview on 12/22/14 at 11:20 a.m., S2CCO reviewed the medical record for Patient #12 and confirmed the above verbal orders were not signed by the physician and the above physician's orders were not timed when written by the physician.


2. The facility failed to ensure all telephone orders were written according to hospital policy.

Patient #16: Review of the medical record for Patient #16 revealed the Psychiatric Admit Orders had been written on 12/19/14 at 2:45 p.m. by a Registered Nurse. The signature did not indicate the orders were written as a verbal or telephone order. Further review revealed the physician signed the order on 12/20/14 at 1:25 p.m.

Patient #17: Review of the medical record for Patient #17 revealed the patient was admitted to the psych unit of the hospital on 12/11/14 with diagnoses of Schizoaffective Disorder and Bipolar Disorder. Review of the Psychiatric Admit Orders revealed the orders were written by a Registered Nurse on 12/11/14 at 2:35 p.m. The signature did not indicate the orders were written as a verbal or telephone order. Further review revealed the physician signed the order on 12/12/14 at 4:00 p.m.


Patient #18: Review of the medical record for Patient #18 revealed the patient was admitted to the hospital on 12/16/14 for Schizophrenia. Review of Patient #18 Psychiatric Admit Orders dated 12/16/14 revealed a RN (registered nurse) signed the admission orders on admit (12/16/14) to the hospital and the physician didn't sign the orders until 12/20/14 at 1300.

An interview was conducted with S2CCO at 12/22/14 at 2 p.m. S2CCO reported the RN incorrectly documented a telephone order (verbal order) from the physician.





17091




26351

Based on observation, record review, and interview the hospital failed to meet the Condition of Participation for Pharmaceutical Services as evidenced by:

1) Failing to ensure the consulting pharmacist was responsible for supervising and coordinating all the activities of the pharmacy services. (See findings at A-492)


2) Failing to ensure all compounding of drugs and biologicals was performed under the supervision of a pharmacist, as evidenced by Bactrim IV (Intravenous) being mixed by staff nurses in the hospital setting, as required by hospital policy. (See findings at A-501).


3) Failing to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 3 (#25, #26, #29) of 3 patient's reviewed with known medication errors. (See findings at A-508)

Based on record review and interview, the hospital failed to ensure the consulting pharmacist was responsible for supervising and coordinating all the activities of the pharmacy services.
Findings:

Review of a document titled "Special" GB (Governing Body) Meeting dated 12/5/14 revealed, in part, the meeting was called as a special meeting for clarification of Directors of each department. Further review revealed S18RPh (Registered Pharmacist) was documented as Director of Pharmacy. The discussion/assessment was documented as, "Review responsibility and oversight of department, including staffing (adequate and competent), policy and procedures, financial responsibility.

In an interview 12/22/14 at 8:55 a.m., S1Adm (Administrator) reported that S18RPh had been appointed as the Director of Pharmaceutical Services. S1Adm reported that there was no hospital policy or agreement with the pharmacist that described the responsibilities of the Director of Pharmaceutical Services.

In a telephone interview 12/22/14 at 4:00 p.m., S18RPh reported that, yes, he guessed he was the Director of the pharmacy. He reported that he was on the P & T Committee (Pharmacy and Therapeutics), but never attended meetings. He reported that he would, of course attend, if invited. S18RPh further reported that he was not involved in the identification, tracking, and trending of medication errors. He stated that the Director of Nursing at the hospital did that (collected and analyzed data on med errors), and he only reviewed the errors if they were made on the pharmacy side, that is, errors made by the pharmacy staff, as opposed to the nurses or hospital staff. When asked if he was aware that nurses were injecting IV (Intravenous) Bactrim to IVPB ( Intravenous Piggyback) bags of fluid, he reported that he was not aware that nurses could not compound or prepare admixtures. S18RPh directed the surveyor to speak with another pharmacist at the contracted pharmacy. The Pharmacist reported that the contracted pharmacy company was actually two different companies under the one main name. He further reported that one of those companies was the IV Therapy section, and the surveyor would need to speak to the pharmacist over that section of the pharmacy services since she would know more about anything to do with IV medications.

In an interview on 12/22/14 at 4:20 p.m., information provided by S18RPh was provided to S1Adm and S2CCO (Chief Clinical Officer). S1Adm reported that S18RPh did not attend meetings for the hospital and couldn't remember the last time he had attended. S1Adm also reported that he (S18RPh) did not review or provide any input with regards to Pharmacy policy and procedures. S1Adm reported that the pharmacist had access to Action Cue (Quality Data system) and should be reviewing all medication errors. S2CCO reported that the only time S18RPh came to the hospital was monthly for his medication audits and record keeping.

Based on observations, record review and interview, the hospital failed to ensure all compounding of drugs and biologicals was performed under the supervision of a pharmacist, as evidenced by Bactrim IV (Intravenous) being mixed by staff nurses in the hospital setting, as required by hospital policy.
Findings:

Review of hospital policy # N.14.11.01, titled "Dispensing: General" with an effective date of 3/1/14, provided by S1Adm as current revealed, in part, ..."Only a pharmacist, or authorized pharmacy personnel under the direction and direct supervision of a pharmacist, shall fill and label containers from which medications are to be distributed or dispensed, ...or transfer medications to different containers."

Review of hospital policy #N.14.01.02.c titled "Medication Dispensing" with an effective date of 3/1/14 and provided by S1Adm as current, revealed, in part, "The pharmacy dispenses medications and IV's in a unit dose format. IV preparation is provided in a controlled environment (IV Hood and IV Room) using aseptic technique.

An observation on 12/22/14 at 1:50 p.m. of the medication room, with S8RN (Registered Nurse), revealed 2 unlabeled and unopened vials of Bactrim IV 10 ml MDV (Multidose Vial) in a clear plastic storage container. S8RN reported that when Bactrim IVPB (Intravenous Piggy Back) is ordered, the nurses mix the IVPB, by injecting the ordered dose into a IVPB bag of fluid, and those must be extra vials. S8RN reported that she was not aware that nurses should not compound medications. Further observation revealed the vials did not contain instructions on mixing the medication, but only read "must be diluted with 5% dextrose". S8RN reported that the Bactrim vial usually came in with a patient label and directions for mixing.

In a telephone interview 12/22/14 at 4:00 p.m. S18RPh (Registered Pharmacist) reported that, yes, he guessed he was the Director of the pharmacy. When asked if he was aware that nurses were injecting IV (Intravenous) Bactrim to IVPB ( Intravenous Piggyback) bags of fluid, he reported that he was not aware that nurses could not compound or prepare admixtures.

Based on observation and interview, the hosptial failed to have drugs and biologicals in a secure area. This was evidenced by the crash cart, where emergency medications are located, being unlocked in the physical therapy room. Findings:

An observation was conducted on 12/17/14 at 12:50 p.m. in the Physical Therapy room. Two patients were observed unsupervised playing domino's approximately 4 feet from the crash cart. The crash cart was unlocked with the following medications available to the patients; Adenosine, Amiodarone, Atropine, Calcium Chloride, Digoxin, Diphenhydramine, Dobutamine, Dopamine, Epinepherine, Romazecon, Furosemide, Lidocaine, Magnesium Sulfate, Lopressor, Nalozone, Nitroglycerine, Sodium Bicarb, and Vaopressin.
An interview was conducted with S2CCO at 12/17/14 at 12:55 p.m. She reported the crash cart was unlocked due to the pharmacist had been restocking the cart, but the medication should be secured.

30364


Based on record review and interview, the facility failed to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 3 (#25, #26, #29) of 3 patient's reviewed with known medication errors out of a total sample of 30 patients.

Findings:
Review of the policy titled Medication Variances, Policy Number: I.E.5.01 revealed in part:
II. Procedure:
4. The attending physician will be notified of all medication errors.
Further review revealed no mention in the policy of documenting the medication variance in the patient's medical record.


Patient #25: Review of the Physician's Orders for Patient #25 dated 7/27/14 at 2:10 p.m. revealed an order to increase Levothyroxine to 125 mcg (micrograms) 1 every day.

Review of a medication variance report revealed Patient #25 had received 175 mcg of Levothyroxine on 7/28/14 at 6:30 a.m. instead of the 125 mcg that had been ordered.

Review of the medical record for Patient #25 revealed no documentation of physician notification of the error on 7/28/14 or no documentation of the medication error itself.


Patient #26: Review of Physician's Orders for Patient #26 dated 10/12/14 at 8:00 a.m. revealed an order for Gabapentin (anticonvulsant) 100 mgs (milligrams) TID (three times per day).

Review of a medication variance report revealed Patient #26 had received 900 mg of Gabapentin instead of 100mg on 10/12/14 at 8:00 a.m. and 3:30 p.m. Patient #26 then received 800 mgs of Gabapentin on 10/12/14 at 9:00 p.m. and 800 mgs on 10/13/14 at 8:00 a.m.

Review of the medical record for Patient #26 revealed no documentation of physician notification of the error on 10/12/14 or no documentation of the medication error itself.

In an interview on 12/22/14 at 5:15 p.m. with S2CCO (Chief Clinical Officer), she verified there was no documentation in Patient #25 and/or Patient #26's medical record about physician notification of the above mentioned medication errors or the actual errors.


Patient #29: Patient #29 was a 66 year old male admitted to the hospital on 10/08/14 for Cellulitis of the Left Foot.

Review of the Physician Orders for Patient #29 on 10/11/14 at 1100 revealed an order for .9% NS (Normal Saline) at 50 ml/l (milliliter per liter).

Review of a Physician Orders for Patient #29 on 10/11/14 at 1340 revealed an order to D/C (discontinue) NS IV(intravenous) D5W at 50 cc/hr (cubic centimeter per hour).

Review of a Physician Order for Patient #29 on 10/11/14 at 1550 revealed an order to D/C D5W at 50 cc/hr, NS at 50 cc/hr.

Review of the hospital's Medication Variance Report revealed orders were written for Patient #29 for 0.9% NS (Normal Saline) at 50 cc/hr (cubic centimeters per hour) by MD (Medical Doctor) at 11 a.m, changed by charge nurse to D5W at 50 cc/hr at 1340. Then changed back to 0.9% NS at 50 cc/hr at 1550. Day charge nurse hung D5W, but reported that she took it down and put up correct fluids when she realized mistake. Night shift nurse reported correct bag was not hanging when shift changed at 1800. Night shift nurse hung correct fluids and reported to charge nurse.

Review of the patient's medical record revealed no documentation of the medication error or documentation the physician was notified of the medication error.

An interview was conducted on 12/22/14 at 5 p.m. with S2CCO and with review of the medical record, she reported the medication error was not reported to the physician and the medication error was not documented in the medical record.

Based on record review and staff interview, the hospital failed to implement policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. Findings:

Review of the contracts provided by S1Adm (Administrator) revealed the hospital had a contract with Company B to provide mobile radiological services.

Review of the hospital's policy titled, "Radiology Services", policy number II.K,11.69, effective date of 01/08/13, revealed the policy outlined the procedure for obtaining X-rays from the contracted service, but there was no documented evidence of any provisions related to safety precautions during radiological procedures conducted in the hospital.

In an interview on 12/22/14 at 9:00 a.m., S1Adm provided a policy titled Mobile Radiation Safety and stated in a special meeting of the governing body on 12/19/14 (after start of the survey), the policy was approved. S1Adm confirmed the policy had not been implemented with the hospital staff.

Based on record review and interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff that supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis.
Findings:

Review of the organization chart presented as a current by S1Adm (Administrator) revealed no documented evidence of a Director of Radiology.

Review of the Medical Staff Roster provided by S1Adm as current revealed 52 consulting radiologists. There was no documented evidence that any of the consulting radiologists were designated as the Director of Radiology.

Review of the contracts provided by S1Adm revealed the hospital had a contract with Company B to provide radiology services.

In an interview on 12/18/14 at 3:35 p.m., S1Adm provided Governing Body minutes dated 12/05/14 that revealed S22MD was appointed as director of radiology. S1Adm stated S22MD was not a radiologist, but was the hospital's medical director. S1Adm confirmed the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiology services.

Based on record review and interview, the hosptial failed to ensure at least two (2) members of the Utilization Review Committee were doctors of medicine or osteopathy. Findings:

Review of the hospital policy for Utilization Management Plan, Policy Number: I.E.5.078, revealed in part, No less than (2) members of the Utilization Management Function shall be physicians.

Review of the hospital's list of committee members for their Utilization Review Committee revealed the hospital had only one physician on the committee, S22MD.

An interview was conducted with S1Adm on 12/22/14 at 3 p.m. S1Adm reported the second physician that was on the committee no longer participated in the committee and they only had one physician on the Utilization Review Committee presently.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety and quality. This was evidenced by failing to ensure the functionality of a call button labeled with a picture of a nurse, which was located on the hand rails of 12 patients' beds. Finding:

An observation was conducted on 12/18/14 at 11 a.m. of a patient bed having a call bell with a picture of a nurse on the handrail, which was not functioning.

An interview was conducted with S2CCO on 12/18/14 at 1 p.m. S2CCO reported the hospital had 12 beds in use with nonfunctioning call bells on the handrails of the beds.

30364


Based on record review, observation and interview, the infection control officer failed to ensure the implementation of effective policies/procedures relative to acceptable standards of Infection Control to prevent and control infections and communicable disease as evidenced by:

1) failing to ensure staff utilized the appropriate use of personal protective equipment and hand hygiene for 7 (S9CNA, S10Housekeeping. S24PT, S26CNA, S8RN, S14LPN, S25LPN) of 10 staff observed providing direct patient care to contact isolation patients;
2) failing to ensure correct signage was located on the doors of patients with suspected or known Clostridium Difficile for 2 (#1, #2) of 8 isolation patients sampled and failure to place a contact isolation sign on the door of a patient with Methicillin-resistant Staphylococcus aureus (MRSA) in a wound for 1 (#8) of 8 isolation patients sampled;
3) failing to ensure patients on isolation precautions limited transport and movement outside of their rooms to medically necessary purposes for 3 (#1, #2, #8) of 8 patients observed on isolation precautions;
4) failing to maintain a sanitary environment in the kitchen as evidenced by not monitoring the chemicals and/or temperatures in the dishwasher and three compartment sink;
5) failing to ensure the in-house laundering by housekeeping staff of reusable cloth mop pads and towels used to clean rooms was regulated;
6) failing to maintain a sanitary environment as evidenced by storing a dialysis machine in the therapy room and failing to separate clean and dirty supplies.


Findings:

1) failing to ensure staff utilized the appropriate use of personal protective equipment and hand hygiene, as per hospital policy :

Review of the hospital policy titled Guidelines for Transmission Based Isolation Precautions, Policy Number: III.R.18.09, revealed in part:
A. Contact Precautions:
Use of Personal Protective Equipment (PPE)
1. Gloves: Wear gloves whenever touching patient's skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room or cubicle.
2. Gowns: Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. DON gown upon entry into the room or cubicle.
3. Removal of PPE: Remove gloves then gown and observe hand hygiene before leaving the patient-care environment.

Review of the hospital policy titled Clostridium Difficile Guidelines, Policy Number: III.R.18.43, revealed in part:
II. B. Clostridium Difficile is a spore-forming bacterium. Alcohol based hand rubs may not be as effective against spore-forming bacteria; therefore after doffing gloves, hands should be washed with soap and water after contact that involves touching the patient or contact with the patient's environment.


S9CNA
Review of a list of patients on isolation precautions provided by S2CCO revealed Patient #1 was on contact precautions (on 12/2/14 Proteus Mirabilis culture from right hip wound and Providencia stuartii. On 12/18/14 his stool was positive for Clostridium Difficile).

In an observation on 12/17/14 at 12:30 p.m., a sign on the door of Patient #1's room indicated he was on contact precautions which required staff to wear gloves and a gown when coming in contact with the patient or their immediate surroundings. S9CNA was leaning on the bedrail and bed while feeding Patient #1. S9CNA was not wearing gloves or a gown. S9CNA left the room without washing or sanitizing her hands and went to a common patient nourishment refrigerator and obtained a container of food. S9CNA then returned to Patient #1's room and began feeding him again without donning gloves or a gown. S9CNA then left Patient #1's room and went down a hallway without washing or sanitizing her hands.

Review of a list of patients on isolation precautions provided by S2CCO revealed Patient #15 was on contact precautions (multi drug resistant organisms, sputum Stenotrophomonas).

In an observation on 12/17/14 at 12:40 p.m., a sign on Patient #15's door indicated he was on contact precautions. S9CNA was observed touching Patient #15 and his bedrail without gloves or a gown. S9CNA took Patient #15's tray and placed it on a common cart in the hall. S9CNA then went into Patient #23's room without washing or sanitizing her hands.

S10Housekeeping
Review of a list of patients on isolation precautions provided by S2CCO revealed Patient #2 was on contact precautions (suspected Clostridium Difficile).
In an observation on 12/17/14 at 1:00 p.m., Patient #2 had a sign on his door indicating he was on contact precautions. S10Housekeeping went into Patient #2's room to empty his trash wearing gloves but no gown. S10Housekeeping exited the room with her gloves on and entered Patient #7's room. S10Housekeeping exited Patient #7's room with the same gloves on and opened the door to the mop sink room. S10Housekeeping then removed her gloves but did not wash or sanitize her hands.

S24PT
In an observation on 12/18/14 at 11:00 a.m., S24PT was touching Patient #2 (suspected Clostridium Difficile) and his chair with no gloves or gown.

S26CNA, S8RN, S14LPN, S25LPN
In an observation on 12/18/14 at 8:10 a.m., Patient #2 (suspected Clostridium Difficile) had fallen transferring from his bed to his wheelchair. S26CNA called the nurse's station to get assistance helping Patient #2 back into the bed. S8RN, S14LPN and S25LPN went into the room to help S26CNA. None of the 4 staff members that lifted Patient #2 into the bed were wearing gowns and S25LPN and S14LPN were not wearing gloves. When she exited, S25LPN was observed using hand sanitizer instead of washing her hands with soap and water.
In an interview on 12/18/14 at 2:00 p.m. with S2CCO, she said employees should have been wearing gowns and gloves when coming in contact with the patient or their surroundings when on contact isolation. S2CCO verified staff handling patients with suspected or positive for Clostridium Difficile should have washed their hands with soap and water after contact with the patient.

S14LPN
In an observation on 12/18/14 at 1:35 p.m., S14LPN was observed to enter Patient #4's room, put on gloves only, walk to the opposite side of the patient's bed, and touch the patient's bed linens and IV site. S14LPN was then observed to enter her uniform pockets and retrieve an alcohol wipe with the contaminated gloves still on. The door to the patient's room was noted to have a sign indicating the patient was on Contact Precautions, requiring the use of gloves and gowns. S14LPN was interviewed at this time and stated she was an agency nurse and today was her second day here. When asked why the patient was on Contact Precautions, S14LPN stated the patient had Sepsis, but she was not sure of the organism the patient had. S14LPN verified she had retrieved the alcohol prep from her pocket with contaminated gloves on.


2) Failing to ensure correct signage was located on the doors of patients with suspected or known Clostridium Difficile and failure to place a contact isolation sign on the door of a patient with Methicillin-resistant Staphylococcus aureus (MRSA) as per hospital policy;

Review of the hospital policy titled Clostridium Difficile Guidelines, Policy Number: III.R.18.43, revealed in part:
II. B. Clostridium Difficile is a spore-forming bacterium. Alcohol based hand rubs may not be as effective against spore-forming bacteria; therefore after doffing gloves, hands should be washed with soap and water after contact that involves touching the patient or contact with the patient's environment.
II. E. A contact Precaution-Enteric or Contact Precautions PLUS sign will be placed on patient's door.

Review of an isolation precautions list provided by the hospital revealed Patient #1 and Patient #2 were on contact isolation for a suspected Clostridium Difficile infection (Patient #2) and a known Clostridium Difficile infection (Patient #1). Further review revealed Patient #8 was on contact isolation for Methicillin-resistant Staphylococcus aureus.

Observation on 12/18/14 at 1:19 p.m. revealed the isolation signs on Patient #1 and Patient #2's doors were not Precaution-Enteric or Contact Precautions PLUS as indicated by the hospital policy.

Review of Patient #8's door revealed he had no sign indicating he was on contact precautions.

In an interview on 12/28/14 at 2:11 p.m., S2COO verified the signs on Patient #1 and Patient #2's doors were not Precaution-Enteric or Contact Precaution PLUS signs but should have been. S2COO also verified Patient #8 should have had a contact isolation sign on his door to alert staff and visitors.


3) Failing to ensure patients on isolation precautions limited transport and movement outside of their rooms to medically necessary purposes.

Review of the policy titled Guidelines for Transmission Based Isolation Precautions, Policy Number: III.R.18.09 revealed in part:
Patient Transport:
1. Limit transport and movement of patients outside of room to medically necessary purposes.

Patient #1
Review of the hospital isolation log for Patient #1 revealed he was on contact precautions on 12/17/14 and tested positive for Clostridium Difficile on 12/18/14.

In an observation on 12/17/14 at 1:45 p.m., Patient #1 was in the hallway sitting in a wheelchair in front of the nurse's station. Patient #1 was not wearing personal protective equipment.

Patient #2
Review of the hospital isolation log for Patient #2 revealed he was on contact precautions for suspected Clostridium Difficile.

In an observation on 12/17/14 at 12:55 p.m., Patient #2 was outside of the facility smoking. Another observation revealed he was in a wheelchair in the hall returning from the common area snack machine. Patient #2 was not wearing personal protective equipment either time.

Patient #8
Review of the hospital isolation log for Patient #8 revealed he was on contact precautions for having MRSA.

In an observation on 12/17/14 at 12:43 p.m., Patient #8 was in the hall in a wheelchair. Patient #8 was then observed playing dominos in the therapy room. Patient #8 was not wearing personal protective equipment.

In an interview on 12/17/14 at 2:30 p.m., S2COO said the hospital did not take any special precautions for contact isolation patients leaving their rooms as long as their wounds were covered. S2COO said patients with Clostridium Difficile should have been limited to their rooms unless necessary.


4) Failing to maintain a sanitary environment in the kitchen as evidenced by not monitoring the chemicals and/or temperatures in the dishwasher and three compartment sink.

An observation was conducted in the kitchen of the dish machine running a cycle. The surveyor requested the S15Kitchen, to check the sanitizer and S15Kitchen was unable to get the strips to show there was sanitizer in the water.
Review of the Dish Machine Log revealed no temperature documented from the 12/15/14 until present 12/17/14 on the dish machine. With further review there was no place on the form to document the reading on the sanitizer indicator and had not been documented in the last 6 months.
In an observation on 12/17/14 at 2:00 p.m. of the three compartment sink in the kitchen, there were no temperature logs or chemical logs. Observation of a set of instructions on the wall near the sink indicated the 1st compartment of the sink should have had detergent and a temperature of at least 110 degrees Fahrenheit. The second sink should have had clean water with a water temperature of 120 degrees Fahrenheit. The third sink should have had a temperature of 90 degrees and a portion of the water being a chemical. The amount of chemical (parts per million) was determined by the specific chemical used.

In an interview on 12/17/14 at 2:05 p.m., S13Kitchen indicated she was responsible for washing the dishes in the sink that day. S13Kitchen said the kitchen had been out of the chemical test strips for several days and she never had tested the temperature of the water. S13Kitchen also said she could not locate the chemical logs to show the staff had been testing the chemicals in the 3 compartment sink. When asked what the chemical was in the 3rd sink to determine how many parts per million it should have been based on a scale on the wall, S13Kitchen could not identify the chemical.

An interview was conducted on with S7Company A representative on 12/18/14 at 9:15 a.m. He reported the sanitizer in the dish washer was working; the strips to check the sanitizer had gotten wet and were ineffective. He also reported he provided the hospital indicators to check the sanitizer in the 3 compartment sink, because the hospital didn't have any.
An interview was conducted with S5Dietican on 12/18/14 at 3 p.m. S5Dietican confirmed the kitchen staff has not been checking the sanitizer in the dish washer and there was no place on their form to document when the staff checks for the sanitizer in the dish washer.

5) Failing to ensure the in-house laundering by housekeeping staff of reusable cloth mop pads and towels used to clean rooms was regulated.

Observation of a laundry room inside of the hospital revealed a washer and a dryer in use by the housekeeping staff. Further observation revealed no temperature logs or chemical logs for the washing machine or dryer.

In an interview on 12/18/14 at 8:10 a.m., S11Housekeeping indicated the washer and dryer were used to wash the cloth pads used to mop the patient's floors and the rags used to clean the patient's rooms. S11Housekeeping said sometimes the mop heads were also washed and dried using the washer and dryer. S11Housekeeping verified there were no logs kept of the water temperatures, dryer temperatures or chemicals used. S11Housekeeping also said a powder detergent was the only chemical she used to wash the items.

6) Failing to maintain a sanitary environment as evidenced by storing a dialysis machine in the therapy room and failure to separate clean and dirty supplies.

In an observation on 12/17/14 at 12:55 p.m. a dialysis machine was being stored in the therapy room against a wall. Patient #8 and Patient #23 were at a table approximately 3 feet away playing Dominos. Patient #8 was on contact precautions for MRSA.

In an interview on 12/17/14 at 2:00 p.m. with S2COO, she verified the dialysis machine should not have been stored in the therapy room.

In an observation on 12/17/14 at 1:10 p.m. of the clean linen room on the psychiatric unit, there were 3 dirty buffer pads, 4 dirty sheets, a used mop head and debris on the floor. This observation was verified by S4PsycUnitManager.

Based on observations, record review, and staff interview, the Chief Executive Officer, Medical Staff, and Director of Nursing services failed to ensure problems identified by infection control officers were addressed through QAPI program activities. Findings:

Review of the hospital policy titled, "Improving Organizational Performance Plan", Policy number I.E.5.06, effective date of 01/08/13, revealed in part the following: The Organizational Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services....To utilize results from Infection Control, Utilization Review, Risk Management, EOC (Environment of Care) and Patient Safety to improve processes that affect patient care outcomes....The Monitoring and Evaluation Process will include the following activities:....8. Infection Control Surveillance....

During the survey from 12/17/14 through 12/22/14 the following infection control breeches were observed:
1) failing to ensure staff utilized the appropriate use of personal protective equipment and hand hygiene for 7 (S9CNA, S10Housekeeping. S24PT, S26CNA, S8RN, S14LPN, S25LPN) of 10 staff observed providing direct patient care to contact isolation patients;
2) failing to ensure correct signage was located on the doors of patients with suspected or known Clostridium Difficile for 2 (#1, #2) of 8 isolation patients sampled and failure to place a contact isolation sign on the door of a patient with Methicillin-Resistant Staphylococcus aureus (MRSA) in a wound for 1 (#8) of 8 isolation patients sampled;
3) failing to ensure patients on isolation precautions limited transport and movement outside of their rooms to medically necessary purposes for 3 (#1, #2, #8) of 8 patients observed on isolation precautions;
4). failing to maintain a sanitary environment in the kitchen as evidenced by not monitoring the chemicals and/or temperatures in the dishwasher and three compartment sink;
5). failing to ensure the in-house laundering by housekeeping staff of reusable cloth mop pads and towels used to clean rooms was regulated;
6). failing to maintain a sanitary environment as evidenced by storing a dialysis machine in the therapy room and failing to separate clean and dirty supplies (see findings at A-0749).

Review of the QAPI records (Action Cue reports, QAPI Monthly meeting minutes, audit forms for quality indicators) revealed the QAPI program had not identified any problems related to infection control, or the above observed breeches in infection control.

In an interview on 12/22/14 at 11:30 a.m., S2CCO (Chief Clinical Officer) verified she was responsible for the hospital's QAPI program. S2CCO confirmed she had done surveillance and had identified problems with hand hygiene and isolation practices. S2CCO stated when she is present the staff wash their hands. S2CCO stated there was no corrective action plan for hand hygiene. She stated the benchmark in Action Cue for hand hygiene was 85%. She stated the data she had entered from her surveillance was under the benchmark, so no corrective action plan was required. S2CCO stated she addressed any breeches with the individual staff. S2CCO verified the methodology used had not captured the infection control problems.