HospitalInspections.org

Based on record review and interview the hospital failed to meet the Conditions of Participation for Quality Assurance as evidenced by:

1) Failure to: develop and implement a quality improvement plan which was specific to meet the needs of the patient population served by using a plan from an acute care hospital (Hospital b); delegate responsibility for the organization, aggregation and reporting of all data collected for the hospital; ensure indicators were measurable and would improve health outcomes; and ensure identified problems were trended, corrective action implemented and monitored for sustained improvement. (See findings at Tag A0265);

2) Failure to: ensure indicators were developed for all departments in the hospital to include aspects of patient care for dietary services, laboratory services, radiology services, and nursing services; develop indicators for the performance of chart audits to monitor the quality of care patients were receiving; develop quality indicators to monitor refrigerator temperatures, crash cart checks, or expired medications and/or supplies; and develop and implement a process for identification of adverse patient events (falls and medication variances) other than by relying on self reporting by the staff in order to identify problems, analyze causes and implement corrective action. (See findings at A0267);

3) Failure to prioritize its Quality Assurance/Performance Improvement Program for activities to focus on high-risk, high-volume or problem-prone areas as evidenced by failure to develop indicators related to identified problems related to staffing in the ICU (Intensive Care Unit) and medication administration. (See findings at Tag A0285);

4) Failure to ensure medication variances were tracked and trended as evidenced by relying on self reporting as the means of identification resulting in 199 unreported medication variances for 4 of 20 (#2, #3, #6, #9) reviewed medical records. (See findings at A0286); and

5) Failure to ensure the Governing Body monitored the quality assessment and performance improvement program to ensure development and implementation of an effective program which improved patient health outcomes; evaluation of the outcomes performed and reported and evaluation of the entire program performed annually. (See findings at A0313).

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


1) Failure to develop and implement a medical records department as evidenced by storing all medical records for recently discharged patients in the office of the Case Manager until completed and then transporting to Hospital "b" for processing and permanent storage. (See findings at A0432);

2) Failure to develop and maintain a system of author identification and record maintenance to ensure the integrity of authentication and security of all record entries as evidenced by allowing another hospital to maintain their medical records department. (See findings at Tag A0438);

3) Failure to ensure all medical records would be maintained in their original or legally reproduced form for a period of at least five years as evidenced by the hospital's lack of a medical records department and utilizing another hospital's medical records department which was not under the supervision of the administration of this hospital. (See findings at Tag A0439);

4) Failure to develop and implement a system of coding and indexing medical records as evidenced by allowing another hospital (Hospital "b") to maintain their medical records department and having to rely on the staff of that hospital to retrieve any needed record. (See findings at Tag A0440);

5) Failure to ensure the confidentiality of patient records as evidenced by failing to have a medical records department under the supervision of hospital staff resulting in the inability to ensure release of medical records to authorized individuals only. (See findings at Tag A0441);

6) Failure to ensure the security of patient records as evidenced by allowing another hospital (Hospital "b") to maintain their medical records department including storage and access of which the administrator of this hospital has no supervisory authority. (See findings at Tag 0442);

Based on record review and interview the Governing Body failed to ensure the Administrator was responsible for managing the entire hospital as evidenced having the medical records department managed by the administrator of Hospital "b" resulting in non-compliance with all requirements in to meet the condition of participation for medical records. Findings: (See findings in Tag A0431)

In a telephone interview on 07/22/11 at 2:10pm, MD S8 Medical Director indicated he was not aware that resources for both hospitals could not be combined since he and his two partners own both. Further S8 indicated that most of the physicians are on staff for both hospitals.

Based on record reviews ("Contract Binder #1" list of contracts and contracted service binders) and staff interviews, the hospital failed to ensure the scope and nature of the services provided were delineated as evidenced by failing to have contracts for the Respiratory Care Services, Radiological Services, Laboratory Services, Plant Ops (operations), Quality Management Services, Medical Staff Services, Housekeeping Services, Wound Care Services, Nurse Staffing Services, Biomedical Services, Educational Services, Diabetes Education Services, Chaplain Services and GI Lab Services provided by hospital "b". Findings:

Review of the contracted services binders submitted as hospital's current contract agreements on 7/21/11 at 11:55am by S1Administrator revealed there were no contracts for Respiratory Care Services, Radiological Services, Laboratory Services, Plant Ops (operations), Quality Management Services, Medical Staff Services, Housekeeping Services, Wound Care Services, Nurse Staffing Services, Biomedical Services, Educational Services, Diabetes Education Services, Chaplain Services and GI Lab Services between hospital and hospital "b" in the binder.

Review of the "Contract Binder #1" list of contracts presented as hospital's current list of contracted services on 7/21/11 at 11:55am and at 4:10pm by S1Administrator revealed there were no contracts for Respiratory Care Services, Radiological Services, Laboratory Services, Plant Ops (operations), Quality Management Services, Medical Staff Services, Housekeeping Services, Wound Care Services, Nurse Staffing Services, Biomedical Services, Educational Services, Diabetes Education Services, Chaplain Services and GI Lab Services between "b" in the binder.

During an interview on 7/21/11 at 11:30am and at 2:50pm, S1Administrator indicated there were no contracts with hospital "b" for Respiratory Care Services, Radiological Services, Laboratory Services, Plant Ops (operations), Quality Management Services, Medical Staff Services, Housekeeping Services, Wound Care Services, Nurse Staffing Services, Biomedical Services, Educational Services, Diabetes Education Services, Chaplain Services and GI Lab Services in the "Contract Binder #1". The Administrator further indicated there was a verbal agreement between the hospital and hospital "b" for Respiratory, Radiology, Laboratory, Plant Ops (operations), Quality Management (QA), Medical Staff (Credentialing/Privileging), Housekeeping, Wound Care, Nurse Staffing, Biomedical, Educational (employees upon hire), Diabetes Education, Chaplain (end of life) and GI Lab Services provided to all patients in hospital. S1Administrator verified the list of contracted services provided on 7/21/11 at 11:55am revealed a line drawn indicating there were no contracts between the hospital and hospital "b" for Respiratory Care Services, Radiological Services, Laboratory Services, Plant Ops (operations), Quality Management Services, Medical Staff Services, Housekeeping Services, Wound Care Services, Nurse Staffing Services, Biomedical Services, Educational Services, Diabetes Education Services, Chaplain Services and GI Lab Services provided to the patients at hospital.

Based on record reviews and interviews, the hospital failed to follow their policy and procedure for grievance written response time to be completed within 7 days as evidenced by failing to have written response for the patients' grievances submitted for R1 on 09/10/2010 and R2 on 12/06/10 for 2 of 2 grievances reviewed. Findings:

Patient R1
Review of the Complaint/Grievance Resolution Response Tool for 09/10/2010 revealed Patient R1's daughter filed the following grievance, "Complaint/Grievance Statement: According to pt's (patient's) daughter, pt did not have a bath since early Sun (9/12) morning; and she (the daughter) helped her take a shower. The daughter stated her mother called and no one ever responded to the call bell. Patient R1 stated that she cannot "control it" (bowel function) and when she need to get up it is urgent... Investigation: Baths are recorded in the bath book at the front desk; according to the documentation in the book she had a bath on 09/11 (day shift), on 09/12 early a.m., and 09/13 at 2000 (8:00 p.m.). Actions taken as Result of Investigation: Discussed with pt/family -assured baths would be done, also staff recently inserviced re: customer service. Did monitor staff responding to call light; lights answered promptly. Date resolved for Grievance: Written notification submitted: The date the grievance was resolved and written notification submitted was blank.

Patient R2
Review of the Complaint/Grievance Resolution Response Tool for 12/06/10 filed by Patient R2' s son. Complaint/Grievance Statement: See attached letter. The son was upset with the cost for the funeral home to pick up his mother's body. Investigation: Received letter from Patient R2's son and called him to discuss letter. "Explained that no additional charges had been incurred as a result of our delay per both funeral homes. Resolved: f/u (follow up) with son- balance $0, payments made and discounts taken. Grievance written notification:" Grievance written notification area was blank.

An interview was conducted with S3Case Manager on 07/20/11 at 5:00pm. She stated the process for grievances was she usually received the grievances and logged them into the Grievance Log and then she would give the grievances to the S1Administer or S2DON depending on the type of grievance. She further stated she had never sent written notification to the patients/families related to the resolution of the grievances. She stated the grievance log was lost currently and she was not able to find it.

An interview was conducted with S1Administrator on 07/21/11 at 10:10am. He stated the grievances for the hospital was not logged in on Hospital "b's" Grievance Log because the grievances for the hospital wasn't the hospital "b's" grievances. He confirmed that no one notified the patients by written letter of the grievance resolution. He went on to state, "It is a case of one hand not knowing what the other one is doing." S1Administration also stated there was not a grievance log for the hospital.

Review of the hospital's policy for Patient Complaint/Grievance Resolution Procedure revealed in part, "Definition: Complaint: Verbal or written expression of displeasure with a clinical process or person that can be resolved promptly by the staff present. Grievance: A formal or informal written or verbal complaint that is made by a patient/significant other when a patient's issue cannot be resolved promptly by staff person. Policy: It is the policy of this hospital to make reasonable efforts to resolve patient complaints and grievances as quickly as possible. Information obtained in resolving patient complaints and grievances will be utilized in the Hospital's Performance Improvement Process ... Procedure: Steps ....B. All grievances are documented in writing using the Complaint/Grievance Resolution Form. A patient grievance may come in the form of a phone call, letter or personal visit. In such case the employee or guest relations representative who receives the grievance will complete the Complaint/Grievance Resolution Form, attach the letter or comment of the form and forward to the quality Management Director and Patient Representative. A copy should also be sent to the Manager of Department Head where the complaint was lodged. 2. Complaints that cannot be immediately and effectively identified, investigated and resolved by an individual staff member are considered grievances and should be directed up the chain of command to the level required for the most complete resolution possible ....4. The investigation and written response to the patient must be completed within a period of seven (7) days. If more time is needed to complete the investigation, the Director or Manager will notify the complainant. The written notice to the complainant will include the name of the Hospital, contact person, steps taken to investigate the grievance, date and resolution ...".

Based on record reviews and staff interviews, the hospital failed to follow its policy and procedure for informed consent as evidenced by: 1) failing to obtain consent for medical treatment upon admit to the hospital for 8 of 8 focused medical records reviewed for authorization for medical treatment forms out of a total of 20 medical records reviewed, (#6, #12, #13, #14, #15, #16, #17, #20), and 2) failing to ensure consents for blood were appropriately completed by the physician for 2 of 2 medical records reviewed for blood transfusions, (Patient #7, #8) out of a total of 20 medical records reviewed. Findings:

1) Failing to obtain consent for medical treatment upon admit to the hospital:
Patient #6
Review of the medical record for Patient #6 revealed a 49 year old female admitted to the hospital on 06/20/11 for ARF (Acute Renal Failure) and ESRD (End Stage Renal Disease). Review of the H&P (History & Physical) dated 06/20/11 revealed #6 was alert, oriented and a very pleasant lady.

Review of the hospital Consent for Treatment dated 06/20/11 for Patient #6 revealed no documented evidence the patient or nearest relative had signed the document.

Patient #12
Review of the medical record for Patient #12 revealed he was admitted to the facility on 07/18/11 with the diagnoses of Debility, Congestive Heart Failure (CHF), Renal Insufficiency, and Diabetes Mellitus. Review of the Authorization for Medical Treatment revealed the date on the consent was 07/18/11 at 14:46 (2:46 p.m.). The area on the consent for the patient or nearest relative to sign was blank and the area for a witness to sign was also blank.

Patient #13
Review of the medical record for Patient # 13 revealed a 49 year old admitted to the hospital on 07/20/11 for continued care of multiple fractures and a leg wound. Review of the Nursing Admit Assessment dated 07/20/11 revealed #13 was alert and oriented upon admit; however a consent for treatment was not obtained as evidenced by a blank in the space provided for the patient's signature.

In a face to face interview on 07/21/11 at 11:30am, RN S9 indicated Patient #13 was admitted at 6:05pm and was not in the mood for signing paperwork, so they decided to get it later. Review of the medical record revealed the consent for treatment still was not signed by Patient #13.

In a face to face interview on 07/21/11 at 1:20pm, RN S5 verified the consent still was not signed because both of Patient #13's hands were injured and it was difficult for him to hold a pen. Further S5 indicated a verbal consent was not documented.

Patient #14
Review of the Medical record for Patient #14 revealed a 94 year old female admitted to the hospital on 07/14/11 for a resolved partial small bowel obstruction. Review of the Nursing Admit Assessment dated 07/14/11 revealed #14 was alert and oriented to person upon admit; however a consent for treatment was not obtained as evidenced by a blank in the space provided for the patient's signature.

Patient #15
Review of the Medical record for Patient #15 revealed an 81 year old male admitted to the hospital on 06/16/11 for cellulitis of the right foot. Review of the Nursing Admit Assessment dated 07/20/11 revealed #15 was alert and oriented upon admit; however a consent for treatment was not obtained as evidenced by a blank in the space provided for the patient's signature.

Patient #16
Review of the medical record for Patient #16 revealed she was admitted to the hospital on 06/06/11 with the diagnoses of Atrial fib, Hypertension, Debility, and Malnutrition. Review of the Authorization for Medical Treatment revealed the date on the consent was 06/06/11 at 14:55 (2:55 p.m.) The area on the consent for the patient or nearest relative to sign was blank and the area for a witness to sign was also blank.

An interview was conducted with S2DON on 07/21/11 at 1:30 p.m. She stated both Patient #12's and Patient #16's Authorization for Medical Treatment should have been signed and witnessed. She went on to state usually the Clerical Coordinator had the patient sign the medical consent for treatment on admission.

Patient #17
Review of the medical record for Patient #17 revealed an 83 year old female admitted to the hospital on 06/27/11 for CAD (Coronary Artery Disease) and low Rehabilitation. Review of the Nursing Admit Assessment dated 06/27/11 revealed Patient #17 was alert and oriented.

Review of the hospital Consent for Treatment dated 06/27/11 for Patient #17 revealed no documented evidence the patient or nearest relative had signed the document.

Patient #20
Review of the Medical record for the patient (#20) revealed a 61 year old female admitted to the hospital on 06/14/11 for a left rib fracture and COPD (Chronic Obstructive Pulmonary Disease). Review of the Nursing Admit Assessment dated 06/14/11 revealed #20 was alert and oriented upon admit; however a consent for treatment form was not obtained as evidenced by a blank in the space provided for the patient's signature.

In a face-to-face interview on 7/22/11 at 12:30pm and at 2:55pm, S2DON (Director of Nursing) verified the "Authorization for Medical Treatment" forms for Patient #14 and #16 were both blank. S2DON indicated both consent forms should have been signed by the patient and/or their representative on admission.

Review of the policy titled, "Informed Consent" last reviewed 04/03 and submitted by the hospital as the one currently in use revealed "...No medical or surgical procedures should be performed on a patient without obtaining consent. The Hospital Care Consent is good for the length of the patient's hospitalization and is designed to cover all routine procedures in the hospital for which a surgical or special consent is not required...".

The "Authorization for Medical Treatment" form read, "...I, the undersigned, am presenting myself for admission to Extended Care of Southwest LA, and I voluntarily consent to the rendering of such care, including diagnostic procedures and medical treatment, by the attending physician named and by the authorized agents and employees of the hospital and by its medical staff, or their designees, as may in their professional judgment be deemed necessary or beneficial. I hereby certify that I have read and fully understand this authorization for medical treatment, the reasons why my hospital admission is considered necessary, the advantages and possible complications, if any, as well as possible alternative modes of treatment which were explained to me by the admitting physician named. I also acknowledge that no guarantees or assurances have been made as to the effects of such examinations or treatment on my condition...".

2) Failing to ensure consents for blood were appropriately completed by the physician:
Patient #7
Review of the medical record for Patient #7 revealed a 75 year old female admitted to the hospital on 05/10/11 for a hematoma of the right hip post right hip replacement. Review of the Physician's Orders dated 06/11/11 revealed..... "T&M (Type and Crossmatch) ii (two) units PRBS (Packed Red Blood Cells) and transfer when ready".

Review of the Blood Transfusion Flowsheet for Patient #7 dated 06/11/11 revealed two units of packed red blood cells were transfused on 06/11/11 from 2145 (9:45 p.m.) through 06/12/11 at 0045 (12:45 a.m.) and 06/12/11 at 0140 (1:40 a.m.) through 0430 (4:30 a.m.).

Review of the Blood Transfusion Consent Form for Patient #7 dated 06/11/11 at 1949 (7:49 p.m.) revealed no documented evidence the alternative therapies to transfusion were discussed with the patient. Further review revealed no documented evidence the consent was obtained by the physician as evidenced by a blank in the space provided for the signature of the physician.

Patient #8
Review of the medical record for Patient #8 revealed a 81 year old male admitted to the hospital on 04/12/11 for an epidural abscess. Review of the Physician's Orders dated 06/14/11 revealed "...T&M (Type and Crossmatch) ii (two) units PRBS (Packed Red Blood Cells) stat and transfer when available...".

Review of the Blood Transfusion Flowsheet for Patient #8 dated 06/14/11 revealed two units of packed red blood cells were transfused on 06/14/11 from 1715 (5:15 p.m.) through 06/14/11 at 2000 (8:00 p.m.) and 06/14/11 at 2000 (8:00 p.m.) through 2300 (11:00 p.m.).

Review of the Blood Transfusion Consent Form for Patient #7 dated 06/14/11 at 1300 (1:00 p.m.) revealed no documented evidence the alternative therapies to transfusion were discussed with the patient. Further review revealed no documented evidence the consent was obtained by the physician as evidenced by a blank in the space provided for the signature of the physician.

The policy titled, "Informed Consent", last reviewed 04/03, and submitted by the hospital as the one currently in use revealed "... Informed Consent: It is the physician's responsibility to give the patient sufficient information regarding the planned procedure so that the patient gives an informed legal consent...".

Based on record review and interview, the hospital failed to ensure medication variances were tracked and trended as evidenced by relying on self reporting as the means of identification resulting in 199 unreported medication variances for 4 of 20 (#2, #3, #6, #9) reviewed medical records. Findings: (See findings at Tag A0404)

In a face-to-face interview on 07/22/11 at 2:00pm, RN S2 DON indicated chart audits are not being performed and the hospital relies on self reporting by the nursing staff for medication variances.

Based on record reviews and interview, the hospital failed to conduct a performance improvement project. Findings:

Review of the Governing Body Board Meeting Minutes dated 02/18/10 (the only one submitted to the survey team) and the Quality Assurance Committee Meeting minutes for 2010 through 02/11/11, revealed no documented discussion of a performance improvement project.

In a face to face interview on 07/22/11 t 2:00pm S2 DON Director of Nursing indicated no performance improvement project was performed.

Based on record reviews and interview the hospital failed to ensure all physicians practicing on staff were credentialed as evidenced by relying on the compliance of the credentialing process at Hospital "b" resulting in no documented evidence of credentialing files for physicians practicing at this hospital. Findings:

In a face-to-face interview on 07/22/11 at 3:00pm, S1 Administrator indicated the staff at Hospital "b" credentials all of the physicians who are the same at both this hospital and Hospital "b". The personnel/credentialing files are stored at Hospital "b". The Governing Body of this hospital and Hospital "b" are the same and approval of the appointments and re-appointments are put on the agenda.

Review of the Governing Body Board of Directors (Governing Body) Agenda for 02/18/10 revealed "...3. "Approval of Credentials: a. Initial Appointments and b. Re-appointments...".

Review of the Board of Directors (Governing Body) Meeting Minutes dated 02/18/10 revealed no documented evidence Item 3 "Approval of Credentials" had been discussed and approved.

Based on record reviews and interviews, the hospital failed to ensure: 1) the unit was staffed with registered nurses with documented evidence of competency assessment, training, education or experience in the care of intensive care patients for 7 of 7 Registered Nurse personnel files reviewed (S7, S9, S10, S11, S12, S13, S14); and 2) adequate nurse-patient ratio as evidenced by assigning 2 ICU patients and 1 patient located outside of the ICU unit to one nurse resulting in the Respiratory Therapist having to monitor the ICU patients in his/her absence. Findings:

1) ICU was staffed with nursing staff with no documented evidence of competency assessment, training, education or experience in the care of intensive care patients:
In a face to face interview on 07/20/11 at 11:00am RN 2 DON (Director of Nursing) indicated Hospital "b" takes care of orientation and annual competency. Further S2 indicated all employee personnel files are kept in the Human Resource Department at Hospital "b". S2 indicated she would have to request the files from Hospital "b" and transported to this facility (the LTAC). When asked how assignments are made according to the needs of the patients and the specialized qualifications of the available nursing staff, S2 had no response.

Review of the Job Description titled, "Registered Nurse" and submitted as the one currently in use revealed no documented evidence that care of intensive care patients was included.

Review of the personnel file for RN S7, an employee of the hospital revealed no documented evidence of an application or resume in the file. Further review revealed no documented evidence S7 was assessed for competency in the care of the intensive care patient.

Review of the personnel file for RN S9, an agency nurse, revealed work experience in ICU at Hospital "b". Further review revealed no documented evidence of orientation or annual competency assessment for care of the ICU patient.

Review of the personnel file for RN10, an employee of the hospital revealed no documented evidence of an application or resume in the file. Further review revealed no documented evidence S10 was assessed for competency in the care of the intensive care patient.

Review of the personnel file for RN11, an employee of the hospital since 04/15/10 revealed no documented evidence of an application or resume in the file. Further review revealed no documented evidence S10 was assessed for competency in the care of the intensive care patient or had training in ACLS (Advanced Certification in Life Support).

Review of the personnel file for RN12, an agency nurse with 1.5 years of nursing experience revealed no documented evidence S12 was assessed for competency in the care of the intensive care patient or had training in ACLS (Advanced Certification in Life Support).

Review of the personnel file for RN13, an employee of the hospital since 04/15/10 revealed no documented evidence of an application or resume in the file. Further review revealed no documented evidence S10 was assessed for competency in the care of the intensive care patient.

Review of the personnel file for RN14, an agency nurse, revealed no documented evidence of an application or resume in the file. Further review revealed no documented evidence S14 was assessed for competency in the care of the intensive care patient.

3) Adequate nurse-patient ratio as evidenced by assigning 2 ICU patients and 1 patient located outside of the ICU unit to one nurse resulting in the Respiratory Therapist having to monitor the ICU patients in her absence:
Observation on 07/19/11 at 11:00am of the designated ICU unit revealed a room located on one of the two patient care wings capable of caring for three patients ( Beds were identified as 40, 41 and 42). It had a nursing station equipped with a phone with all patients visible for observation as well as a second desk assigned to the respiratory therapist. Further observation revealed that when leaving the ICU area to enter a room, even across the hall, it was not possible to visualize any patient in the ICU Unit or the monitors.

Review of the Nursing Staffing Pattern for the hospital revealed the ICU Unit was staffed only when a patient was admitted. Further review revealed the hospital staffed each shift with a charge nurse RN (Registered Nurse); however besides the duties as charge nurse he/she may be assigned as many as 6 patient.

Review of the Daily Assignment Sheets for 06/05/11 through 06/14/11 revealed the following ICU Nurse - patient assignments:
06/07/11 7P shift - Hospital Census 18, 2 CNAs (Certified Nursing Assistants) 4 RNs (1 of which was agency and the Charge Nurse was assigned 5 patients
RN S11 assigned ICU 40 (close observation), 41 (ICU care) and Room 15
06/08/11 7A shift - Hospital Census 18, 3 CNAs, 4 RNs (2 of whom are agency)
RN S13 assigned ICU 40 41 (ICU care) and Room 18
06/08/11 7P shift - Hospital Census 18, 2 CNAs, 4 RNs (2 of whom are agency)
RN S10 assigned ICU 40 41 (ICU care) Room 21, 31 and charge nurse responsibilities
06/09/11 7A shift - Hospital Census 18, 3 CNAs, 4 RNs (2 of whom are agency)
RN S13 assigned ICU 40 41 (ICU care) and Room 31
06/09/11 7P shift - Hospital Census 18, 2 CNAs, 4 RNs (2 of whom are agency)
RN S10 assigned ICU 40 41 (ICU care) Room 21, 31 and charge nurse responsibilities
06/10/11 7A shift - Hospital Census 18, 3 CNAs, 3 RNs (1 of whom are agency) and 1 LPN
RN S7 assigned ICU 40 41 (ICU care) and Room 17 and 31
06/10/11 7P shift - Hospital Census 18, 2 CNAs, 4 RNs (2 of whom are agency)
Agency Nurse assigned ICU 40 41 (ICU care) Room 19, 31
06/11/11 7A shift - Hospital Census 18, 2 CNAs, 3 RNs (1 of whom are agency) and 1 LPN
RN S7 assigned ICU 40 41 (ICU care) and Room 17 and 31
06/11/11 7P shift - Hospital Census 18, 2 CNAs, 3 RNs (2 of whom are agency) and 1 agency LPN Agency Nurse assigned ICU 40 41 (ICU care) Room 19, 31
06/12/11 7A shift - Hospital Census 16, 2 CNAs, 3 RNs (1 of whom are agency) and 1 LPN
RN S7 assigned ICU 40 41 (ICU care) and Room 17
06/12/11 7P shift - Hospital Census 16, 2 CNAs, 3 RNs (2 of whom are agency) and 1 LPN Agency Nurse assigned ICU 40 41 (ICU care) Room 17
06/13/11 7A shift - Hospital Census 16, 2 CNAs, 4 RNs (1 of whom are agency)
RN S13 assigned ICU 40 41 (ICU care) and Room 17 and charge nurse responsibilities

During a face-to-face interview on 07/21/11 at 8:30am, RN S2 DON (Director of Nursing) indicated sometimes not all of the patients in ICU are true ICU patients, but usually just needs closer observation. In that situation, she usually assigns another patient to the nurse assigned the ICU patient located in a bed outside of the designated ICU unit. RN S2 indicated when the nurse has to leave the ICU unit, the Respiratory Care Therapist watches the patient(s). S2 indicated she does not feel this is the ideal situation and has expressed this to management.

In a face-to-face interview on 07/22/11 at 2:00pm, RN S7 a Registered Nurse who is routinely assigned to the ICU unit, indicated she had 5 years of ICU experience 25 years ago when she first got out of nursing school and has had no further training since. When asked about caring for ICU patients and being assigned another patient on the floor she indicated it was difficult to monitor and provide care to the patient when you are not physically in the room.

In a telephone interview on 07/22/11 at 2:10pm, MD S8 Medical Director indicated that many of the patients admitted to Long Term Acute Care come directly from ICU (Intensive Care Unit) Units of acute care hospitals because most of the patients requiring long term care are very ill with multiple problems. Further he indicated he knows that other LTACs are not required to have ICU trained nurses. When asked about the scope of care and admission criteria used at the hospital, MD S8 verified the ICU manual was that of Hospital "b" and adopted by the hospital. MD 8 indicated the hospital designated the ICU unit in order to care for those patients who needed closer observation and sometimes were not necessarily an "ICU" patient. Further he indicated he had no problem with a nurse taking care of additional patients on the floor while being assigned a patient in ICU and that many hospitals practice a nurse-patio ratio > then 2 to 1; however he did say the additional patient given to the nurse was within the ICU unit. MD S8 indicated he was not aware the RNs had not been assessed for competency.

26351


Based on record reviews (fall policy, nursing documentation policy, incidents and accident reports and policy, vital sign policy, accucheck policy, weighing patient policy, and medical record reviews), and staff interviews, the Registered Nurse:
1) failed to ensure an assessment for injury was performed after patients falls involving injury to the head for 2 of 2 patients, (#9, #17) with head injuries sustained from a fall in the facility out of a total of 20 sampled medical records reviewed,
2) failed to supervise and evaluate the nursing care for a patient was ongoing as evidenced by having no documentation of routine vital signs, weekly weights, and/or accuchecks recorded for Patient #19 from 06/09/11 through 06/22/11 as ordered by the physician and as per policy for 1 of 20 sampled records reviewed.
Findings:

1) Failed to ensure an assessment for injury was performed after patients falls involving injury to the head for 2 of 2 patients, (#9, #17) with head injuries sustained from a fall in the facility, (#9, #17):
Patient #9
Review of the medical record revealed Patient #9 was admitted to the hospital on 06/29/11 with the diagnoses of Left elbow dislocation and fracture of the vertebral column. Review of the Admission Assessment Report dated 06/29/11 revealed under the neuromuscular assessment she was alert, follows commands, and she was oriented to person, place, and time. Her Morse Fall Scale Assessment indicated she scored a Level III, with a score of 61+.

An interview was conducted with Patient #9 on 7/20/11 at 3:30pm. She stated she had fallen at home and broke her elbow and her back. She also stated she had fallen at the hospital the other day trying to get up and go to the bathroom. She stated she had tucked and rolled and she had a lump on the back of her head from the fall.

Review of the Progress Notes from the physician dated on 07/18/11 revealed the physician documented on 07/18/11, "Light headed/orthostatic this a.m. Fell while attempting to transfer to W/C (wheelchair)."

An interview was conducted with S7RN on 07/22/11 at 9:30am. She stated she was the nurse taking care of the patient when she fell on 07/18/11. She further stated she didn't document an assessment of the patient after the fall and she did not fill out an incident and accident report. She went on to state she planned to do it the next day, but forgot.

Review of the nurse's Daily Focus Assessment Report from 7/18/11 7:10 to 19:00 revealed no documentation of the fall or of an assessment of the patient after the fall.

An interview was conducted with S2DON on 07/20/11 at 4:00pm. When asked to review the Incident and Accident Report for Patient #9's fall on 07/18/11, she stated the nurse did not fill out one on the fall, so there was not an Incident and Accident Report on the fall.

Patient #17
Review of the medical record for Patient #17 revealed an 83 year old female admitted to the hospital on 06/27/11 for low level rehabilitation and medication management post CABG (Coronary Artery Bypass Graft). Further review revealed #6 had a history of CAD (Coronary Artery Disease), Atrial Fibrillation, Renal Insufficiency, HTN (Hypertension) and CVA (Cerebral Vascular Accident).

Review of an Incident Report dated 07/07/11 at 6:30am revealed Patient #17 was found on the floor of her room with a hematoma to her right scalp. Further review revealed no documented evidence that a neuro assessment was performed on Patient #17.

Review of a CT of the head without contrast for Patient #17 dated 07/07/11 revealed " ...History: Fell and hit head. Impression: Right occipitoparietal scalp hematoma noted...".

Review of the Nursing Notes dated 0700 (7:00am) revealed an entry at 0800 (8:00 a.m.) indicating Patient #17 was confused; eyes opened spontaneously; verbally oriented, alert, appropriate; motor - obeys commands and at 2010 (8:10 p.m.) periorbital swelling; oriented to person, place; easy to arouse; eyes open spontaneously; verbally alert, appropriate; and motor-obeys commands. Further review of the Nursing assessment revealed no documented evidence a neuro-assessment was performed on Patient #17.

Review of the nursing policy and procedure manual submitted by the hospital as the one currently in use revealed no documented evidence neuro-assessments were included. This was verified by RN S2 DON (Director of Nursing) on 07/22/11 at 2:30pm.

In a face to face interview on 07/22/11 at 3:15pm RN S2 DON indicated she would expect neuro checks to be performed on any patient who had sustained a head injury. Further S2 indicated Patient #17 should have had a neuro-assessment performed and at the least should have been assessed at least every two hours and documented in the nursing notes.

Review of the Fall Risk Management for the hospital revealed in part, "...2. Each Patient is assessed on initial assessment and reassessed PRN (as needed) as situations change. The Nurses Notes must address the interventions appropriate to each patient... " .

Review of the hospital's policy for Incident Reporting review in part revealed, " ...III. Patient Incident Protocol ... A. Supervisor and Physician Notification: 1. The employee first discovering the incident immediately checks patient for visible signs of injury and assures the safety of the patient ...".

Review of the policy and procedure for Nursing Documentation that was presented to the surveyors as the current one in use revealed in part " ...2. The head to toe assessment is completed on admission, every 8 hours or with licensed personnel change. If it is initial assessment, mark the box " Initial Assessment. " ...3. A. Document the time of reassessment ... C. If the assessment is changed then mark the box " changes " and describe the changes in the narrative section on the last page of the flow record or in space provided ....4. For additional finding required, mark " see narrative " and document in narrative. 5. Document patient's progress toward the expected outcome, nursing interventions, and response to care based on needs of the patient at least once per 8 hour shift and/or as warranted by patient condition ... " .

2) Failing to supervise and evaluate the nursing care for a patient was ongoing as evidenced by having no documentation routine vital signs, weekly weights, and/or accuchecks recorded for Patient #19 from 06/09/11 through 06/22/11 as ordered by the physician and as per policy for 1 of 20 sampled records reviewed:
Review of the medical record for Patient #19 revealed he was a 65 year old male admitted on 06/07/11 for CVA (cerebrovascular accident), Apraxia, and HTN (hypertension) and a past medical/surgical history of OSA (osteoarthritis), CAD (coronary artery disease), and a hx (history) of a + (positive) PPD (Purified Protein Derivative).

Review of the "Admission Order" verbal order dated/timed 06/07/11 at 1120 (11:20 a.m.) for Patient #19 read in part, " ...2. Vital Signs every Routine ...4. Weigh weekly ...15. Sliding scale insulin protocol with regular insulin using: Low dose protocol and accuchecks AC & HS (before meals and at bedtime)...". Further review revealed a "Physician's Order" for 06/12/11 with no time the order was written read, "...1. (decrease) accuchecks to BID (two times a day) fasting 2hr (hours) /p (after) noon meal ...".

Review of the "Graphic Chart" Records for Patient #19 from 06/07/11 through 06/21/11 revealed there was one (1) vital sign assessment missing on 06/09/11, 06/11/11, 06/12/11. There were two (2) vital sign assessments missing on 06/10/11 and 06/21/11 for Patient #19. Further review revealed there were three (3) missing vital sign assessments from 06/14/11 through 06/20/11.

The "Graphic Chart" Records for Patient #19 from 06/07/11 through 06/21/11 revealed the admission weight of the patient was 214 pounds on 06/07/11. On 06/13/11, Patient #19 weighed 213.7 pounds. Further review revealed there was no documentation the patient (#19) was weighed weekly on 06/20/11 as ordered by the physician and as per policy.

Review of the "Diabetic Flow Sheet" for Patient #19 revealed there was one (1) accu check missing on 06/08/11, 06/14/11 and 06/23/11 as compared to the physician order and as per policy. Further review revealed there were two (2) accu checks missing for #19 from 06/15/11 through 06/22/11 as compared to the physician order and as per policy.

In an interview on 07/21/11 at 5:30pm, S2DON indicated routine vital signs are performed every eight (8) hours as per policy. S2 verified Patient #19's routine vital signs were not performed as ordered " routine " by the physician from 06/09/11 through 06/20/11. The DON confirmed there was one (1) vital sign assessment missing on 06/09/11, 06/11/11, 06/12/11; S2 verified there were two (2) vital sign assessments missing on 06/10/11 and 06/21/11. S2 confirmed there were three (3) missing vital sign assessments for #19 from 06/14/11 through 06/20/11. S2DON indicated the Registered Nurse failed to supervise and evaluate the nursing care for Patient #19 on an ongoing basis by not following the physician' s order for "routine vital signs" from 06/09/11 to 06/21/11 and as per policy.

During the same interview on 07/21/11 at 5:30pm, S2DON verified there was no documentation the patient (#19) was weighed weekly on 06/20/11. S2 indicated the nurse did not supervise and evaluate the nursing care for Patient #19 by not following the physician's order for the patient to be weighed weekly and as per policy. S2 confirmed there was one (1) accucheck missing on 06/08/11, 06/14/11 and 06/23/11 for Patient #19. The DON verified there were two (2) accuchecks missing for #19 from 06/15/11 through 06/22/11. S2 indicated the nurse did not supervise and evaluate the nursing care for Patient #19 by not following the physician ' s order for accuchecks AC & HS from 06/08/11 to 06/11/11 and BID from 06/12/11 through 06/22/11 and as per policy. S2DON further indicated all physician's orders must be followed as per policy.

The policy titled, "Vital Signs" submitted as the hospital's current "Vital Sign Assessment" policy indicated vital signs will be taken on all patients and documented. Physician's orders will be followed for taking vital signs...".

Review of the policy titled, "Weighing Patients", presented as the hospital's current "Weight" policy read in part, "...All patients are weighed on admission and then according to MD (physician) order. Weights MUST be documented on the graphic sheet ...Weighing patients assures an accurate weight on admission, and as ordered per the physician to enhance therapeutic and nutritional interventions...".

The policy titled, "Blood Glucose Monitoring (ACCU-CHEK INFORM)" indicated a (R.N., L.P.N., Extern) may perform blood glucose monitoring using the Glucose Test Station: Accu-Chek Inform. For a nurse to initiate blood glucose monitoring there must be a written order from the physician. The nurse is also responsible for properly documenting the patient's blood glucose level on the Diabetic Flow Sheet in the patient's chart.

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Based on medical record reviews and hospital's policy and procedures, and staff interviews, the hospital failed to ensure the nursing plan of care was developed and updated/revised based on the patient care needs as evidenced by:
1) failing to update the care plan for Patient #9 after a fall in the facility for 1 of 20 sampled records reviewed;
2) failing to perform walking rounds every 2 hours to monitor a patient who had sustained a head injury after a fall as ordered by the physician for Patient #17 for 1 of 20 sampled records reviewed;
3) failing to have admitting diagnosis of hypertension or diabetes initiated on the care plan with interventions that reflected Patient #19's care needs on 06/07/11 for 1 of 20 sampled records reviewed;
4) failing to have admitting diagnosis of left rib fracture, Hepatitis C, and COPD initiated on the care plan with interventions to reflect the Patient #20's care needs on 06/14/11 for 1 of 20 sampled records reviewed;
5) failing to have the admission assessment skin lesion to the left hand scab, Stage I (one) red sacrum, or PICC line initiated on the care plan with interventions that reflected the Patient #20's care needs on 06/14/11 for 1 of 20 sampled records reviewed;
5) failing to have toileting with assistance/bedside commode initiated on Patient #20's care plan on 06/14/11 (the day of admission) and failing to have incontinent skin care/bedside commode updated/revised to reflect Patient #20's care needs on 06/17/11 for 1 of 20 sampled records reviewed; and
6) failing to have appropriate interventions for Patient #20's blind functional status to reflect the patient's care needs on the plan from 06/14/11 through 06/22/11 for 1 of 20 sampled records reviewed. Findings:

1) Patient #9
Review of the Fall Risk Management for the hospital revealed in part, "All hospitalized individuals have the right to a safe environment from harm or injury that may occur as a result of diagnosis, weakness, incontinence, unfamiliar surroundings, confusion, or other barriers to safe transfers and ambulation. Patients will be assessed: On admission to the facility, on transfer from one unit to another with the facility, following a fall, and every 8 hours ....Procedure: 1. A. All patients are to be evaluated on admission and at least every 8 hours for fall risk using the Modified Morse Fall Risk Assessment tool. B. Specialty Units may utilize their own Fall Assessment tool and interventions. 2. Score the assessment and refer to the interventions using the score-determined Fall-Risk Level to determine interventions. Interventions are to be assessed on patient rounds and documented. 3. Note teaching on the Patient/Family Education form and address Level II and Level III on the patient's Plan of Care ...2. Each Patient is assessed on initial assessment and reassessed PRN (as needed) as situations change. The Nurses Notes must address the interventions appropriate to each patient...
Fall Risk Plan:
Level I Interventions:
Thorough orientation to immediate surroundings
Remove unnecessary furniture from patient's room
Call light in reach
One side rail up or as assessment indicated (documents changes in nurses' notes)
Nonslip footwear while ambulating
Keep bed in lowest position
Brakes on
Walk way free of clutter
Lighting adequate for activity
Patient and family education
Environmental review every hour (using Intake and Output/Activity/Rounding tool)
Provide assistance with elimination (if ordered or indicated by nursing assessment).
Regularly check patients on laxatives or diuretics
Night light/Bathroom light on at 2100
Instruct the patient to make frequent position changes and do so slowly
Teach make patient prone to dizziness to void while sitting
Document education on Patient Education Flow Sheet
Ensure patient has a Patient Hand book with falls education in it
Instruct patient to request assistance as needed
Reinforce teaching as needed
Document noncompliance and reassess for fall risk
Keep needed items within reach

Level II Interventions
All of Level I
Place fall risk band
Place fall risk star
Non-skid socks
Non-skid pads for bedside chairs
Evaluate patient need to move closer to nurses' station
Reorient to environment frequently
Include the patient and patient's family in the development of individualized safety plan
Side rails up at all times (half or all up as patient assessment indicates)
Use assistive devices as appropriate to patient needs
Elimination needs assessed and attended to every hour while awake
Medication review conducted with physician and/or pharmacist as appropriate
Bedside commode as appropriate
Reinforce teaching as needed including repeating activity limits
Consider Physical Therapy to improve mobility/flexibility and/or appropriate use of aides
Bedpan/urinal within easy reach as appropriate
Do not leave patient unattended in diagnostic or treatment areas
Ensure patients being transported by stretcher/bed have all side rails in the up position during transport, or if left unattended briefly while awaiting tests or procedures

Level III Interventions

All of Level I and II
Use low boy bed frame and perimeter pads.
Take patient to bathroom every 2 hours around the clock.
Assess for appropriateness of room placement, staffing, unit
Assess for sitter use (encourage family members to stay with patient)
As a last resort assess for restraint needs."

Review of the medical record revealed Patient #9 was admitted to the hospital on 06/29/11 with the diagnoses of Left elbow dislocation and fracture of the vertebral column. Review of the Admission Assessment Report dated 06/29/11 revealed under the neuromuscular assessment she was alert, follows commands, and she was oriented to person, place and time. Her Morse Fall Scale Assessment indicated she scored a Level III, with a score of 61+.
An interview was conducted with Patient #9 on 7/20/11 at 3:30 p.m. She stated she had fallen at home and broke her elbow and her back. She also stated she had fallen at the hospital the other day trying to get up and go to the bathroom. She stated she had tucked and rolled and she had a lump on the back of her head from the fall.
Review of the Progress Notes from the physician dated on 07/18/11 revealed the physician documented on 07/18/11, "Light headed/orthostatic this a.m. Fell while attempting to transfer to W/C (wheelchair)".
Review of the Patient Care Plan Report in part revealed a problem of "Freedom from danger, physical injury or immune system damage, preservation from loss and protection of safety and security. (Actual) Maintain optimal level of safety." The goal was evaluated on 06/30/11 to 07/20/11 with progressing toward goal documented on every day. Completed modified morse fall risk assessment was discontinued on 07/18/11, which was the day of her fall in the hospital. There was no documentation of the fall on 07/18/11 on the care plan and no documentation of an evaluation and change in the fall prevention interventions for the patient.
An interview was conducted with S2DON on 07/22/11 at 9:30am. She confirmed the patient was assessed by the Morse fall scale as a Level III indicating according to the facility's policy, she should had been in a low bed with perimeter pads around the bed. She further stated the patient was not in a low bed with perimeter pads, but needed to be in one. She reviewed the care plan for the patient related to falls and confirmed the care plan was not updated with new interventions for the fall on 07/18/11. She also stated the morse fall risk assessment should not have been discontinued on 07/18/11.
Another interview was conducted with S2DON on 07/22/11 at 3:30pm. She stated the Falling Star Program was not being utilized in the hospital as indicated by the policy. The Falling Star policy includes placing stars above the patient's bed and on the patient's door to indicate they are at risk for falls.
Patient #17
Review of the medical record for Patient #17 revealed an 83 year old female admitted to the hospital on 06/27/11 for low level rehabilitation and medication management post CABG (Coronary Artery Bypass Graft). Further review revealed #17 had a history of CAD (Coronary Artery Disease), Atrial Fibrillation, Renal Insufficiency, HTN (Hypertension) and CVA (Cerebral Vascular Accident).

Review of an Incident Report dated 07/07/11 at 6:30am revealed Patient #17 was found on the floor of her room with a hematoma to her right scalp.

Review of the Physician's Orders for Patient #17 dated 07/07/11 revealed " ...Walking rounds q (every) 2 hours times 24 hours ... " .

Review of the Nursing Notes and the Plan of Care dated 07/07/11 through 07/08/11 for Patient #17 revealed no documented evidence walking rounds for Patient #17 were performed as ordered. This was confirmed by RN, S2DON (Director of Nursing) when reviewing the medical record on 07/22/11.

Patient #19
Review of the medical record for Patient #19 revealed a 65 year old male admitted to the hospital on 06/07/11 at 1120 (11:20am) for CVA (cerebral vascular accident), Apraxia, HTN (hypertension), CAD (coronary artery disease), OSA (osteoarthritis) and a history of PPD. Review of the " Progress Notes " for Patient #19 dated 06/07/11 with no time documented the notes were written read, " ...ADDM ... " indicating the patient was diabetic.

Review of the " Admission Orders " for Patient #19 dated/timed 06/07/11 at 1120 (11:20am) revealed a verbal order for a sliding insulin protocol with regular insulin using: Low dose protocol and accuchecks AC & HS (before meals and at bedtime).

Review of the Plan of Care dated 06/21/11 through 06/22/11 revealed no documented evidence the Patient #19's diabetes or hypertension was updated on the care plan.

In an interview on 07/22/11 at 3:05pm, S2DON verified Patient #19's care plan on 06/21/11 through 06/22/11 revealed there was no documented evidence the plan was updated to include the patient's admitting diagnosis of hypertension or diabetes. The DON indicated the care plan must be updated with interventions for the patient's admitting diagnosis of hypertension and diabetes as per policy.

Patient #20
Review of the medical record for Patient #20 revealed a 61 year old female admitted to the hospital on 06/14/11 at 16:16 (4:16pm) for ? (right) Rib Fx (fracture), CAD (coronary artery disease), and Hep C (Hepatitis C). Further review revealed the Patient #20 had an IV site documented as a PICC line with the date of insertion on 5/26/11. Review of the " History and Physical " Assessment dated 06/15/11 with no time documented indicated Patient #19 had a social history of being Blind.

Review of the "Daily Focus Assessment Report" dated/timed 06/14/11 at 1615 (4:15pm) revealed the section titled, " Wound 1 " read, " Patient has several skin tears to upper extremities; L (left) hand, scab across anterior portion of hand, pt (patient) states she "hit it" (,) Eccymosis noted to L upper portion of back, L hip(,) Red, Stage I sacrum ...". Further review revealed the section titled, " Skin Lesions " read, "...Arm, Lower Left Posterior Skin Tear(,) Arm, Right Posterior Skin Tear(,) Back, Upper Left Bruise(,) Hip, Left Bruise(,) ...". The " Functional Assessment " section read, "...patient is blind(,) Toileting Assist Bedside Commode(,) ...". The section titled, "Cardiovascular" read, "...Right PICC line; started on 5/23/11 at (hospital "b" named)...". Further review revealed the section titled, "Respiratory" read, "Breath Sounds (Left) (and) (Right) Rales/Crackles...". Further review revealed on 06/17/11 at 07:45 (7:45am), the section titled, "Genitourinary" read, "...Interventions Incontinent skin care(,) Bedside Commode...".

Review of the Plan of Care dated 06/14/11 through 06/22/11 revealed no documented evidence the Patient #20's admitting diagnosis of Right Rib Fracture, CAD, or Hep C was updated on #20's care plan. Further review revealed there was no documentation the care plan was updated on admission with the Wound I assessment with several skin tears to upper extremities; L (left) hand, scab across anterior portion of hand, pt (patient) states she "hit it" (,) Eccymosis noted to L upper portion of back, L hip(,) Red, Stage I sacrum on admission, 06/14/11. There was no documented evidence #20's care plan was updated with the Skin Lesions documented on the Arm, Lower Left Posterior Skin Tear(,) Arm, Right Posterior Skin Tear(,) Back, Upper Left Bruise(,) Hip, Left Bruise(,) upon admission on 06/14/11. Further review revealed there was no documentation Patient #20's PICC line was updated on the care plan on 06/14/11. Further review revealed there was no documented evidence #20's Rales/Crackles to both lungs was updated on the care plan on 06/14/11. There was no documented evidence the patient's Toileting with Assistance and a bedside commode was updated on the plan on 06/14/11 or revised on the care plan on 06/17/11. Further review revealed there was no documentation #20's Incontinent Skin Care/ bedside commode was updated/revised that reflected the patient's care on 06/17/11.

Review of Patient #20's "Plan of Care" initiated on 06/15/11 at 03:32 (3:32 a.m.) last evaluated on 06/22/11 at 15:34 (3:34 p.m.) section titled, "Functional/Activity (Actual)" read,
"...Activity Level Will Be Maintained Within Limits of Patient's Capability and Recovery limits(:)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Encourage ADL (activity of daily living) Participation(:)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Provide Adequate Rest Periods(:)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Progress Activity Within Limits of Patient's Capability(:)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Maintain Safe Environment During Activity(:)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Mobility Impairment Related To Restrictive Devices(:)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Activity As Ordered By Physician(:)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Physical therapy referral(:) (and)
Frequency: PRN (as needed)
Reason: pt (patient) discharged home with family, able to ambulate with assistance(,)
Occupational therapy referral(:)
Frequency: ONCE ...".

In an interview on 07/22/11 at 3:05pm, S2DON verified Patient #20's care plan on 06/14/11 through 06/22/11 revealed no documented evidence the plan was updated/revised with the patient's admitting diagnosis of ? (right) Rib Fx (fracture), CAD (coronary artery disease), and Hep C (Hepatitis C). S2 confirmed the care plan was not updated with the patient's IV site of a PICC line. The DON indicated the care plan was not updated with #20's "Wound 1 Assessment" of several skin tears to upper extremities, left hand scab across the anterior portion of the hand, eccymosis to the left upper back portion of the left hip, and/or the Stage I sacrum noted red upon admission on 06/14/11. S2DON stated there was no documentation of the Skin Lesions to both arms (Lower Left Posterior Skin Tear and Right Posterior Skin Tear), Back, Upper Left Bruise, or Left Hip Bruise initiated/updated on the care plan upon that reflected #20's care needs on 06/14/11. S2 confirmed Patient #20's blind functional status care plan initiated on 06/15/11 at 03:32 (3:32am) had inappropriate interventions that did not reflect the patient's care needs provided during hospital stay from 06/14/11 to 06/22/11. The DON reported Patient #20's Toileting with Assistance/bedside commode was not updated/initiated to reflect the patient's care on 06/14/11 nor updated/revised as the patient's care needs changed from Toileting with assistance/bedside commode on 06/14/11 to Incontinent Skin Care/Bedside commode on 06/17/11 to reflect the patient s care needs from 06/14/11 through 06/17/11. S2DON indicated Patient #2' s care plan did not reflect the care the patient was being provided during hospital stay from 06/14/11 through 06/22/11 as per policy. S2DON further indicated there are no policies regarding the electronic medical record system used for documenting/updating/revising the
"Care Plan Reports" for the patients at the hospital as of today, 07/22/11.

Review of the policy and procedure for Nursing Documentation that was presented to the surveyors as the current one in use revealed in part, "...2. The head to toe assessment is completed on admission, every 8 hours or with licensed personnel change, If it is initial assessment, mark the box "Initial Assessment."...4. For additional finding required, mark "see narrative" and document in narrative. 5. Document patient's progress toward the expected outcome, nursing interventions, and response to care based on needs of the patient at least once per 8 hour shift and/or as warranted by patient condition. 6. Based on assessment of the patient, evaluate and revise Plan of Care by adding or resolving problems/needs and interventions to meet those needs, as appropriate...".

Based on observation and interviews, the hospital failed to have a medical records department as evidenced by all medical records for recently discharged patients stored in the office of the Case Manager until completed and then transported to Hospital "b" for processing and permanent storage. Findings:

Observation on 07/19/11 at 3:00pm revealed medical records of recently discharged patients were stored in the office of the Case Manager in closed metal files and on rolling carts.

In a face-to-face interview on 07/19/11 at 3:00pm, RN S2 DON (Director of Nursing) indicated one employee was designated to work on the medical records in order to make sure the physicians complete all required documentation and then the records are sent to "Hospital "b". If the records are needed, someone has to go and pick it up; however hospital (Hospital "b" was only about 10 minutes away. Further S2 indicated the hospital uses Hospital "b"'s policy and procedures for medical records and verified no statistical data is kept on delinquent records.

In a telephone interview on 07/22/11 at 2:10pm, MD S8 Medical Director indicated he was not aware that resources for both hospitals (this hospital and Hospital "b") could not be combined since he and his two partners own both. Further S8 indicated that most of the physicians are on staff for both hospitals.

Based on observation, record review, and interview, the hospital failed to develop and maintain a system of author identification and record maintenance to ensure the integrity of authentication and security of all record entries as evidenced by allowing another hospital to maintain their medical records department. Findings:

Observation on 07/19/11 at 10:15am of the Case Manager's office revealed a metal storage cabinet and a rolling cart with medical records to be completed by the physicians.

The hospital could not submit any policies and procedures pertaining to medical records, a physician and staff signature verification form or a system of how medical records were tracked in-house.

In a face-to-face interview on 07/22/11 at 2:00pm, the RN S2 DON (Director of Nursing) verified when a chart is needed the hospital must notify the medical records department of Hospital "b".

Based on interview, the hospital failed to ensure all medical records would be maintained in their original or legally reproduced form for a period of at least five years as evidenced by the hospital's lack of a medical records department and utilizing another hospital's medical records department which was not under the supervision of the administration of this hospital. Findings:

In a face-to-face interview on 07/22/11 at 3:00pm, the Administrator (S1) verified all medical records were sent to Hospital "b" and were processed and stored by the staff not employed by this hospital and therefore not under his supervision.

Based on observation and interview, the hospital failed to develop and implement a system of coding and indexing medical records as evidenced by allowing another hospital (Hospital "b") to maintain their medical records department and having to rely on the staff of that hospital to retrieve any needed record. Findings:

Observation on 07/19/11 at 10:15am revealed medical records were stored in the office of the case Manager.

In a face-to-face interview on 07/21/11 at 2:45pm, Case Manager S3 indicated when charts were needed the medical records department at Hospital "b" was contacted.

Based on interview, the hospital failed to ensure the confidentiality of patient records as evidenced by failing to have a medical records department under the supervision of hospital staff resulting in the inability to ensure release of medical records to authorized individuals only. Findings:

In a face-to-face interview on 07/22/11 at 3:00pm, Administrator S1 verified the medical records of this hospital are transferred to Hospital "b" after being completed by the physicians at the hospital. Further S1 verified he does not supervise the staff of Hospital "b".

Based on record reviews and interview, the hospital failed to have their own policy and procedures for Medical Records. Findings:

Review of the policy and procedures for Medical Records presented to the surveyors as the current ones in use revealed they were the Medical Records Department of Hospital "b".

An interview was conducted with S3 Case Manager on 07/20/11 at 3:35pm. She stated the medical records of the recently discharged patients are kept in her office and when the records are completed they are picked up and stored at Hospital "b". She further stated they did not have a Medical Records Department.

Based on record reviews and interviews, the hospital failed to follow their policy and procedure for physician orders as evidenced by physician's orders written without being timed for 4 of 4 focused records, (Patient #6, #7, #8, #17) out of a total of 20 sampled medical records reviewed. Findings:

Patient #6
Review of the Physician's Orders for Patient #6 revealed physician orders written without a documented time as follows: 06/22/11 for Normal saline infusion written as a verbal order by Nurse Practitioner; 06/23/11 - Increase Nepro to TID (three times a day), Promod 30 mls po bid, Megace 400 mg po daily, d/c Zestril; 06/26/11 - Consult for PT (Physical Therapy); 06/29/11 - Juven i packet po BID with 6 ounces of water taken as a verbal order by the Nurse Practitioner; and 06/30/11 - Resume Levaquin & Primaxin taken as a verbal order by the Nurse Practitioner.

Patient #7
Review of the Physician's Orders for Patient #7 revealed physician orders written without a documented time as follows: 06/23/11 - order for soft diet; 06/23/11 - D/C (Discontinue) O2 (Oxygen) per NC (Nasal Cannula) if SAT (Saturation) > (Greater than) 90%, hep lock, Colace 100mg po (by mouth) BID (Twice a Day) and ?(increase) Neurontin to 300mg po tid (three times a day); 06/25/11 - Zeasorb to perineal area BID and prn (as needed); 06/25/11- Phazyme 80mg po qid (four times a day) and Chem 8 in AM; 06/26/11 - Megace 400mg po daily, Minoxidil 5mg po q (every) AM (Morning), Chem 8 in the AM and K Dur 40meq po now then q4? x 2 (every 4 hour times 2); 07/04/11 - Therapeutic pass times 4 hours; 07/06/11 - D/C Levonox; 07/07/11 - D/C Megace; 07/08/11 - ? Minoxidil to 10mg po q AM and Chem 8 in the AM; 07/08/11 - Lasix 20mg po daily; 07/09/11 - Chem 8 on Monday; 07/12/11 - Lisinopril 40mg po once daily; 07/14/11 Metoprolol 25mg po BID; 07/15/11 - Continue prophylactic Macrobid indefinitely; 07/10/11 - D/C every other staple; 07/10/11 Hold Lasix, Lopressor, Zestril, Hydrazaline and Minoxidil and remove Catapres patch; 07/17 - Solumedrol 80 IVP (Intravenous Push) x 1.

Patient #8
Review of the Physician's Orders for Patient #8 revealed physician orders written without a documented time as follows: 05/11/11 - Metformin 500mg po bid; 05/12/11 - Chloroseptic Spray at bedside; 05/13/11 Claritin D i po now then daily prn; 05/14/11 - Miralax 17gm with 8 ounces of juice daily taken as a verbal order by the Nurse Practitioner; 05/16/11 - Change accucheck to BID (fasting 2 hours after noon meal) taken as a verbal order by the Nurse Practitioner; 05/18/11 - d/c Catapress taken as a verbal order by the Nurse Practitioner; 05/18/11 Hold Minocin, Stool for C-Diff, hold Miralax, Immodium 2mg po after each loose stool; and 05/19/11 NG tube to low intermittent suction, NPO (Nothing by mouth).

Patient #17
Review of the Physician's Orders for Patient #17 revealed physician orders written without a documented time as follows: 07/07/11 - Lasix 60mg po this AM (morning) x 1, Walking rounds every 2 hours x 24 hours, CT head without contrast, Chem 8 in am; 07/08/11 - d/c (discontinue accuchecks; 07/08/11 - CBC, Pre-Albumin, 3-day calorie count; 07/08/11 Dulcolax suppository today; 07/09/11 - Promod 30 mls po bid; 07/10/11 - Lactulose 30mls po daily, d/c Peridex, Elevate right lower extremity as much as possible, Bilateral knee high ted hose when out of bed, d/c amiodorone.

Review of the Medical Staff Rules and Regulations submitted by the hospital as the ones currently in use revealed "...5. All clinical entries in the patient's medical record shall be accurately dated and authenticated...".

In a face-to-face interview on 07/22/11 at 3:00pm, S1 Administrator indicated all physician orders should be dated, timed, and signed by the physician.

26351


Based on record reviews and staff interviews, the hospital failed to ensure verbal and telephone orders were signed, dated, and timed within 10 days as per hospital policy for 6 of 6 medical records reviewed for verbal orders, (#1, #2, #4, #7, #8, #20) out of 20 sampled medical records reviewed. Findings:

Patient #1
Review of the medical record on for Patient #1 revealed the Admission Orders were not signed by the physician within 10 days after the telephone order was documented on 06/28/11 at 1411 (2:11pm). The Admission Orders, as of the date of the review of the medical record on 07/20/11, were not signed by the physician. The following physician telephone orders were not signed by the physician within 10 days also for Patient #1: 06/28/11 at 1600 (4:00pm), 06/29/11 at 1600 (4:00pm), and 07/3/11. As of the review of the medical record on 07/20/11, the physician had not signed these telephone orders.

An interview was conducted with S2DON on 07/20/11 at 1:00pm. She confirmed the verbal physician orders for Patient #1 had not been signed by the physician within 10 days and were not signed at all by the physician.

Patient #7
Review of the medical record for Patient #7 revealed the Admission Orders were not signed by the physician within 10 days after the telephone order was documented on 05/10/11 at 1105 (11:05 a.m.). On review of the Admission Orders on 07/20/11, there was no physician's signature. The following physician telephone orders were not signed by the physician within 10 days for Patient #7: 05/13/11at 1630 (4:30 p.m.), 05/19/11 at 1600 (4:00 p.m.), and 06/10/11 at 2020 (8:20 p.m.). As of review of the medical chart on 07/20/11, these telephone orders were not signed by a physician.

Patient #8
Review of the medical record for Patient #8 revealed the following verbal/telephone orders were not signed by the physician within 10 days 04/13/11 at 0400 (4:00 a.m.), 04/26/11 at 0751 (7:51 a.m.), 06/07/11 at 2230 (9:30 p.m.), 06/11/11 at 1345 (1:45 p.m.), 06/13/11 at 1500 (3:00 p.m.), 06/14/11 at 1345 (1:45 p.m.), and 06/15/11 at 0520 (5:20 a.m.).

In a face-to-face interview on 07/20/11 at 1:00pm, RN S2 DON indicated all verbal orders should be signed by the physician with 10 days.

Patient #2
Review of the medical record for Patient #2 revealed the Admission Orders were not signed by the physician within 10 days after the verbal order was documented on 05/18/11 at 1430 (2:30pm). The following physician verbal/telephone orders were not signed by the physician within 10 days for Patient #2: 05/21/11at 0430 (4:30 a.m.), 05/21/11 at 1055 (10:55 a.m.), 05/30/11 at 1530 (3:30 p.m.), 06/01/11 at 1440 (2:40 p.m.), 06/01/11 at 1820 (6:20 p.m.), 06/04/11 with no time documented the telephone order was given by the physician), 06/06/11 with no time documented the verbal order was given by the physician, 06/07/11 with no time documented that the verbal order was given by the physician, 06/08/11 at 0935 (9:35 a.m.), 06/13/11 at 1525 (3:25 p.m.), 06/13/11 at 2200 (10:00 p.m.), 06/17/11 with no time the verbal order was given by the physician, 06/23/11 with no time documented the verbal order was given by the physician, 06/28/11 with no time documented the telephone order was given by the physician, 06/30/11 at 1300 (1:00 p.m.), and 07/07/11 with no time documented the verbal order was given by the physician.

Patient #4
Review of the medical record for Patient #4 revealed the Admission Orders were not signed by the physician within 10 days after the verbal order was documented on 05/26/11 at 1500 (3:00 p.m.). The following physician verbal/telephone orders were not signed by the physician within 10 days for Patient #4: 06/01/11 with no time documented the verbal order was given by the physician, 06/02/ at 1010 (10:10 a.m.), 06/02/11 at 1300 (1:00 p.m.), 06/03/11 with no time documented the telephone order was given by the physician, 06/04/11 with no time documented the telephone order was given by the physician, 06/05/11 at 1510 (3:10 p.m.), 06/05/11 at 1430 (2:30 p.m.), 06/05/11 at 1600 (4:00 p.m.), 06/05/11 at 1640 (4:40 p.m.), 06/05/11 at 1700 (5:00 p.m.), 06/05/11 at 1800 (6:00 p.m.), 06/06/11 with no time documented the verbal order was given by the physician, 06/06/11 at 1910 (7:10 p.m.), 06/07/11 with no time documented the verbal order was given by the physician, and 06/12/11 with no time documented the verbal order was given by the physician.

Patient #20
Review of the medical record for Patient #20 revealed the Admission Orders were not signed by the physician within 10 days after the verbal order was documented on 0614/11 at 1500 (3:00 p.m.). The following physician verbal/telephone orders were not signed by the physician within 10 days for Patient #20: 06/16/11 with no time documented the verbal order was given by the physician, 06/16/11 with no time documented the telephone order was given by the physician, and 06/04/11 with no time documented the telephone order was given by the physician.

During a face-to-face interview conducted on 07/22/11 at 12:05pm, at 2:55pm and at 3:15pm, S2DON verified the patients (#2, #4, #20) did not have the verbal/telephone orders countersigned by the physician as per policy.
The hospital's policy for Medical Record Content Guidelines/Policy revealed in part, "...All entries will be legible and must be authenticated and dated by the person who is responsible for ordering, providing or evaluating the medications or services. Verbal or telephone orders must be countersigned by the healthcare provider issuing the order within 10 days, according to Louisiana law. This signature must be accompanied by date of authentication...".

Based on record reviews and interview, the hospital failed to review all professional services utilized in providing care to its patients as evidenced by no documentation of review. Findings:

Review of the Utilization Report for 2010 submitted to the Quality Assurance Committee and the Governing Board revealed no documented evidence any professional services were reviewed.

In a face-to-face interview on 07/20/11 at 4:20pm, RN 3 Case Manager indicated her role in Utilization Review was to collect the statistics and was not aware of any reviews.

Based on record reviews and interviews, the hospital failed to maintain a safe environment for the patients being care for as evidenced by: 1) failing to develop and implement an Emergency Management Plan specific to the needs of the hospital and the population served by relying on Hospital "b", located approximately six minutes away, for direction of all emergency services; 2) failing to maintain the hydrolator in the physical therapy room by not monitoring the temperature of the water of the cleanliness of the container; and 3) failing to ensure preventative maintenance and activities were included in the hospital's Quality Assurance Program. Findings:

1) Failing to develop and implement an Emergency Management Plan:
During a face-to-face interview on 07/21/11 at 9:50am, RN S2 DON (Director of Nursing) indicated emergency preparedness was under the direction of Hospital "b".

In a face-to-face interview on 07/22/11 at 2:30pm, S1 Administrator indicated Hospital "b" and this hospital have the same owners. Further S1 indicated Hospital "b"'s Emergency Disaster Plan Manual was approved for the use of this hospital (the LTAC) by the Medical Director and Administrator of Hospital "b".

Review of the Emergency Preparedness Plan for Hospital "b" last reviewed 12/08 and submitted as the one currently in use revealed the Table of Contents, which listed all Unit/Department Specific Plans, did not list this hospital as part of the plan. Further review of the Disaster Plan revealed no documented evidence it contained information which could efficiently direct emergencies in the patient population and in the physical plant of this hospital

2) Failing to maintain the hydrolator in the physical therapy room:
Observation on 07/19/11 at 10:15 am of the Physical Therapy (PT) Room revealed a hydrolator and which was accessible to patients using the PT room. Further review revealed the hydrolator was on, no thermometer monitoring the temperature, with bugs floating in the water. The top and sides of the hydrolator had signs of rust and dust.

In a face-to-face interview on 07/19/11 at 10:20 am, S4 Physical Therapist indicated she was new and does not use the hydrolator in the treatment of her patients. Further S4 indicated the temperature is not monitored and as long as she has been employed (a couple of months) the hydrolator has never been cleaned.

3) Failing to ensure preventative maintenance and activities were included in the hospital's Quality Assurance Program:
In a face-to-face interview on 07/22/11 at 3:30pm, Administrator S1 indicated the hospital uses the maintenance staff from Hospital "b". Further he indicated the data for QA would be reported in this hospital's QA program.

Review of the Quality Assurance Meeting Minutes and data collected for 2010 through 02/11 revealed no documented evidence preventative maintenance was included in the QA program for this hospital.

Based on record reviews and staff interviews, the hospital failed to ensure the infection control officer (ICO) was designated in writing to manage and oversee the infection control program as evidenced by: a) failing to have a current contract agreement signed by the designee, S16RN, the contracted ICO to oversee this hospital's infection control program and b) failing to have documentation S16RN, the contracted ICO and/or S2DON were qualified through education, training, experience, or certification to oversee the infection control program by failure to have documented evidence of training, experience, continuing education or certification in infection control for the contracted ICO, S16RN and/or S2DON. Findings:

Review of the "Contract Service Agreement" between this hospital and hospital "b" dated 07/01/08 indicated the agreement was for the management and oversight of the infection control program that included the delineation of services for documentation, reporting, policy and procedure review and update, surveillance and employee health. Further review revealed the agreement was signed by S15RN, a formal employee of hospital "b". There was no documented evidence S16RN, the contracted ICO was designated in writing as the contracted ICO for the hospital.

In a face-to-face interview conducted on 07/21/11 at 11:30am, S1Administrator verified the contracted infection control program with hospital "b" was agreed by S15RN, a formal employee of hospital "b". The Administrator reported the contract agreement with hospital "b" was signed by hospital "b"'s designee, which was the infection control officer. S1Administrator confirmed there was no documented evidence S16RN, contracted ICO signed and agreed to provide the hospital with the delineation of services for documentation, reporting, policy and procedure review and update, surveillance and employee health as indicated in the contract for the management and oversight of the infection control program with this hospital . S1 indicated the hospital did not have a system in place to ensure the ICO (S16RN) contracted by hospital "b" had a current agreement. S1 further indicated all personnel files are kept at hospital "b". The Administrator stated this hospital does not have personnel files for its employees and/or contracted employees like S16RN, hospital "b" contracted ICO.

During the survey conducted from 7/19/11 through 7/22/11, there was no personnel file presented by this hospital for S16RN, the contracted ICO presented to the surveyors. Further review revealed there was no documented evidence presented by this hospital of S16RN's, the contracted ICO's ongoing education, training, experience, continued education or certification to oversee the infection control program at this hospital presented to the surveyors during the survey conducted from 7/19/11 to 7/22/11.

There was no personnel file for S2DON presented during the survey conducted from 7/19/11 to 7/22/11. There was no documentation of ongoing education, training, experience, continued education or certification in infection control presented for S2DON to oversee this hospital's infection control program presented to the surveyors from 7/19/11 through 7/22/11.

In face-to-face interviews conducted on 07/21/11 at 11:30am and at 11:55am, S1Administrator verified the contracted infection control program with hospital "b" was dated 07/01/08. S1 indicated S15RN, a formal employee of hospital "b" signed on the agreement as hospital "b"'s designee agreeing to manage and oversee the infection control program for the LTAC hospital on 07/01/08. The Administrator further indicated the contract agreement between both hospitals, (LTAC and "b") dated 07/01/08 was signed by hospital "b"'s designee, the infection control officer (ICO) that agreed to manage and oversee the infection control program for the this hospital . S1 stated the designee is the contracted ICO for this hospital . S1Administrator confirmed there was no documented evidence S16RN, the contracted ICO signed and agreed to manage and oversee the infection control program for this hospital . S1 verified there was no documentation S16RN agreed to provide the delineation of services for documentation, reporting, policy and procedure review and update, surveillance and employee health for this hospital on the contract agreement between both hospitals dated 07/01/08. The Administrator stated there was no documentation S16RN signed a contract agreement to manage and oversee the infection control program for the LTAC hospital as of today, 7/21/11. S1 indicated there was no system in place to ensure the contracted ICO, S16RN would manage and oversee the infection control program for this hospital as of today, 7/21/11. S1 further indicated all personnel files are kept at hospital "b". The Administrator stated the hospital does not have personnel files for its employees and/or contracted services with hospital "b". The Administrator reported the LTAC hospital does not have a personnel file for the contracted ICO, S16RN. S1Administrator indicated this hospital did not have documentation of S16RN's ongoing education, training, experience or certification to oversee the infection control program for this hospital . During another interview on 7/21/11 at 3:15pm, S2DON indicated she functioned as this hospital's infection control officer. S2 further indicated she did not have documented evidence of training, education, experience, continued education, or certification to oversee this hospital's infection control program.







26351

Based on record reviews, tour observations, and staff interviews, the hospital's infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases in the hospital . This was evidenced by the hospital's:
1) failing to evaluate and revise the infection control program when indicated as evidenced by: a) failing to develop policies for the infection control program, b) failing to have documented evidence of monitoring for infection control compliance by non-contracted nurses from hospital "b", agency nurses and/or employees, and c) failing to have documentation the program was evaluated and revised when indicated;
2) failing to ensure the Intensive Care Unit (ICU) of the hospital did not have available for use: a)two (2) expired bottles of hydrogen peroxide (expired 6/11) and one (1) of rubbing alcohol (expired 12/10) and b) and one (1) opened eye flush water container and a suction canister by one of the ICU beds with approximately one (1) inch of clear liquid in the bottom of the canister; and
3) failing to maintain a sanitary environment in the ICU area as evidenced by having a storage bin observed covered with gray substance on the outer edges and corners of the shelves and the white paper recording/printing the patient ' s heart rhythms covered with gray debris.
Findings:
1) Failed to evaluate and revise the infection control program when indicated as evidenced by: a) failing to develop policies for the infection control program, b) failing to have documented evidence of monitoring for infection control compliance by non-contracted nurses from hospital "b", agency nurses and/or employees, and c) failing to have documentation the program was evaluated and revised annually as when indicated:
During the survey conducted from 7/19/11 through 7/22/11, there was no "Infection Control" policy and procedure manual for the hospital presented to the surveyors.
There was no documented evidence of the infection control compliance monitoring for the non-contracted nurse staffing and/or employees presented during the survey from 7/19/11 to 7/22/11.
During the survey from 7/19/11 through 7/22/11, there was no documentation that the infection control program for the hospital was evaluated. There was no documented evidence presented during the survey of when the last evaluation of the program for the hospital was performed. There was no documented evidence of revisions needed as a result of the last evaluation of the infection control program presented during the survey conducted from 7/19/11 through 7/22/11.
In an interview on 07/21/11 at 8:30am, S2DON indicated there were no policies developed for the hospital's infection control program. S2 reported the infection control data, logs and information are not kept at this hospital. The DON stated she had conducted handwashing observations of employees of the hospital last month and two (2) months prior. S2DON did not present the handwashing observations for the hospital's employees during the survey. S2 indicated she as well as the contracted ICO (S16RN) both conducted the monitoring of infection control practices at this hospital. The DON reported there was no documented evidence from the contracted ICO, (S16RN) and/or S2 of the monitoring of infection control compliance for the non-contracted nurse staffing from hospital "b". S2DON indicated she was the officer that did the infection control monitoring at the hospital for the non-contracted nurses as well as this hospital's employees. S2 denied knowledge of what the compliance rate was last month for this hospital's employees regarding handwashing. The DON denied knowledge of what the infection control rate was last month. S2 did not have knowledge of what the infection control rate was last quarter. S2DON indicated she did not have documented evidence of the infection control compliance monitoring for the non-contracted nurses from hospital "b" and/or for the employees providing direct patient care to the patients at the hospital. S2 indicated there was no documented evidence of when the last evaluation of the infection control program for this hospital was conducted. S2 denied knowledge of when the last evaluation of the program was conducted. S2DON agreed the evaluation of the program should have identified there was no policy and procedures for this hospital's infection control program. S2 indicated there was no documented evidence of any revisions identified and implemented during the last evaluation of the hospital's infection control program.
2) Failed to ensure the Intensive Care Unit (ICU) of the hospital did not have available for use: a) expired bottles of hydrogen peroxide (expired 6/11) and rubbing alcohol (expired 12/10) and b) an opened eye flush water container and a suction canister with approximately one (1) inch of clear liquid in the bottom of the canister:
An observation and tour was made on 07/19/11 at 12:20pm in the Intensive Care Unit (ICU) of the hospital. During the tour, two (2) 118 ml (milliliters) bottles of opened hydrogen peroxide with an expiration date of 6/11 and one opened bottle of 16 ounces of rubbing alcohol with an expiration date of 12/10 was discovered. The eye flush water container was open and according to an interview with S2DON on 07/19/11 at 12:25pm, the container should have been disposed of once it was opened and used. A suction canister by one of the ICU beds had approximately 1 inch of a clear liquid in the bottom of the canister. The S2DON confirmed on 7/19/11 at 12:30pm the suction canister should had been disposed of when the patient was discharged from the ICU.
3) Failed to maintain a sanitary environment in the ICU area as evidenced by having a storage bin observed covered with gray substance on the outer edges and corners of the shelves and the white paper recording/printing the patient's heart rhythms covered with gray debris:
A tour of the ICU area of the hospital was conducted on 07/19/11 from 12:05pm through 12:40pm with S2DON. At 12:10pm, there were a total of eighteen (18) shelves on the stacked storage bin located on the back wall of the unit. The storage bin contained supplies used by the nursing staff for oral airways, tracheal, surgery, corrugated tubing, oxygen sensors, nebulizer oxygen connectors and tubing, aerosol mask, suction canisters, 340 milliliter bags of sterile water, and isolation gowns. Further observation revealed the outer edges and corners of the shelves were covered with a gray substance. S2DON indicated the storage bin was dirty at this time. At 12:40pm, the "Central Monitor" had gray debris observed on top of the white paper that recorded and printed the patients' heart rhythms. S2DON indicated the "Central Monitor" is used by all nursing staff to record/print the patients' heart rhythms while in ICU. The DON confirmed the white paper was covered with gray debris. S2DON indicated all equipment must be clean at all times as per policy.



26351

Based on record reviews and staff interviews, the infection control officer failed to maintain a log of incidents related to infections and communicable diseases as evidenced by failure to have a system in place for the increased rate of Urinary Tract Infections (UTIs) that was 14.2% above the goal rate (18.2%) in 2010 and 12.4% above the goal rate (16.4%) in 2011 as evidenced by failing to implement active surveillance, tracking and trending of the care provided by non-contracted staff from hospital "b" (wound care nurses and nurses) or by this hospital's employees. Findings:

Review of the of the Infection Control Information dated 01/01/10 through 12/31/10 revealed combined statistical data for both this hospital and hospital "b" which included Antibiogram, MRSA Rate, VRE Rate, Strep Pneumonae Rate, Pseudomonas Rate, and Acinobactor Rate. Determination could not be made of the exact rates for this hospital due to the combined statistics.

Review of the hospital acquired catheter infection for 2010 revealed the hospital acquired catheter infections were related to urinary tract infections (UTIs). There was a high rate of infections related to urinary tract infections (UTIs) recorded for this quarter. Further review revealed there was documentation for the months that this data was collected and recorded for 2010. The UTI rate for this quarter was 18.2%. The UTI "Goal Rate" was to be less than 4.0%. The UTI rate was 14.2% above the goal rate in 2010. There was documentation the high rate of hospital acquired catheter infections was related to UTIs in direct relation to a low number of catheter days. However, in an effort to lower the UTI rates the silver-coated catheters were implemented the end of June at the hospital. There was no documentation of the year (2010 or 2011) that the silver-coated catheter was implemented at the hospital for the increased goal rate of 14.2% in 2010.

Review of the "Hospital 1st Quarter 2011" hospital acquired catheter infections revealed there was a high rate of infections related to urinary tract infections (UTIs) for this quarter. There was no documented evidence of the months that the data was collected and recorded for this quarter in 2011. Further review revealed the UTI rate for this quarter was 16.4%. The UTI "Goal Rate" was to be less than 4.0%. The UTI rate was 12.2% higher than the goal rate in 2011. There was documentation the high rate of hospital acquired catheter was related to the UTIs in direct relation to low number of catheter days. However, in an effort to lower the UTI rates the silver-coated catheter was implemented the end of June at the hospital. There was no documented evidence of the year (2010 or 2011) that the silver-coated catheter was implemented at the hospital as a result of the 2011 increased rate of 12.2% higher than the goal rate for this quarter, 2011.

There was no "Infection Control Log" presented for the hospital's increased UTI goal rates of 14.2% above the goal rate (18.2%) in 2010 and 12.4% above the goal rate (16.4%) in 2011 presented during the survey from 7/19/11 through 7/22/11. There was no active surveillance, tracking and/or trending of the care provided by non-contracted staff from hospital "b" (wound care nurses and nurses) or by the LTAC hospital employees for 2010 or 2011 presented during the survey. Further review revealed there was no documented evidence what year in June (2010 or 2011) that the silver-coated catheters were implemented by the hospital for the high UTI rates identified in 2010 and 2011 presented during the survey conducted from 7/19/11 to 7/22/11.

In an interview on 7/21/11 at 3:15pm, S2DON indicated there was no "Infection Control Log" for this hospital. S2 reported there was no active surveillance of handwashing and/or the wound care provided to the patients by hospital "b" (non-contracted) nursing staff for 2011. The DON indicated there was no documentation of handwashing observations conducted for all the hospital's employees that provide direct patient care for 2011. S2DON denied knowledge of what the hospital's infection rate was for the month of June, 2011. S2 did not have knowledge of what the infection rate was the last quarter. The DON indicated the rate of UTIs increased last quarter. S2DON was not able to state what the UTI rate was last quarter. S2DON reviewed the infection rates for 1st Quarter 2011. S2 verified the UTI rate was 12.4% higher than the goal rate in 2011. The DON was not able to state what interventions were implemented by the contracted ICO (S16RN) or herself (S2) regarding the 12.4% increased rate of UTIs. S2 denied knowledge of what year the silver-coated catheters were implemented at the hospital related to the increased UTI rates of 14.2% in 2010 and 12.4% in 2011. S2 stated there was no tracking and trending initiated by her (S2) and/or the contracted ICO, (S16RN) after the UTI rates of 14.2% was identified in 2010 and 12.4% was identified in 2011. S2DON stated the hospital uses nurses from hospital "b" (non-contracted) for wound care and nurse staffing and agency nurses as needed to staff this hospital. S2 indicated there was no active surveillance, tracking or trending of the care provided by the non-contracted nurses, agency nurses and/or employees of the hospital implemented after the increased rate of 12.4% UTIs was identified last quarter, 2011. The DON stated she was the ICO at this hospital that monitored all staff including this hospital's employees, hospital "b" (non-contracted) nurses and agency nurses to determine whether or not the staff are in compliance with infection control practices. S2 indicated there was no documentation for monitoring of compliance for infection control practices conducted for hospital "b" (the non-contracted nurses) providing direct patient care and wound care for 2011. The DON stated there was no documented evidence for monitoring of infection control practices of the agency nurses and/or the hospital employees providing direct patient care for 2011. S2DON indicated there was no documentation from the contracted ICO (S16RN) for the monitoring of infection control practices by hospital "b" (the non-contracted nurses), agency nurses and/or this hospital's employees from 2010 through July of 2011.

Based on record reviews and interviews, the hospital failed to ensure occupational therapy was provided to the patients with physician orders for occupational therapy for 2 out of 20 sampled records reviewed, (#1, # 9). Findings:

Review of the Policy for Extended Care of Southwest Louisiana Occupational Therapy revealed in part, "Occupational Therapy services will be provided by qualified occupational therapy personnel on the basis of physician referral only. Services will be initiated within 24 hours of the time of the referral .. "
Review of the medical record of Patient #1 revealed the patient was admitted on 06/28/11 with the diagnoses of Lung cancer, Sacral Decubitus, Parkinson's, and Peripheral Neuropathy. Review of his admission orders for 06/28/11 revealed an order for consultation for PT/OT/ET (Physical therapy, Occupational therapy and Enterostomal Therapy). Review of the Physician progress notes dated 07/02/11 revealed in part, "Cont current tx/therapy." Review of the Physician Progress Notes dated 07/03/11 revealed in part, "Debility-PT/OT." Review of the Physician Progress Notes dated 07/04/11 revealed in part, "Debility-PT/OT.Cont wound care/ rehab efforts." Review of the Physician Progress Notes dated 07/18/11 revealed in part, "Increase rehab as tolerated".
Review of the medical record for Patient #9 revealed she was admitted to the hospital on 06/29/11 with the diagnoses of Left elbow dislocation, COPD (Chronic Obstructive Pulmonary Disease), Osteoporosis, Diabetes Mellitus, and Hypertension. Review of her Admission orders dated 06/29/11 revealed an order for PT/OT to evaluate and treat.
An interview was conducted with S2DON on 07/19/11 at 10:50am. She stated the hospital had been without an occupational therapist for a couple of months, but they were in the process of hiring one now.

An interview was conducted with S4PT on 07/19/11 at 3:55pm. She stated there were no OT services at the hospital and the patients were not receiving occupational therapy. She further stated she had been at the hospital for about 3 months and to her understanding the facility did not have an OT a couple of months prior to her being hired.

An interview was conducted with S1Administrator on 07/19/11 at 3:55pm. He stated the facility had been without an occupational therapist since the end of April or the beginning of May 2011 and he had verbally spoken to all the physicians and they were aware the hospital did not currently have an occupational therapist. When questioned about documentation related to the communication with the physicians, he stated he did not have anything documented.

Based on record reviews and interviews, the hospital failed to: 1) develop and implement a quality improvement plan which was specific to meet the needs of the patient population served; 2) delegate responsibility for the organization, aggregation and reporting of all data collected data for the hospital; 3) ensure indicators were measurable and would improve health outcomes; and ensure identified problems were trended, corrective action implemented and monitored for sustained improvement. Findings:

1) Develop and implement a quality improvement plan which was specific to meet the needs of the patient population served:
Review of the Quality Assurance Plan revealed it was written for Hospital "b" (Acute Care Hospital) and adopted by this hospital, an LTAC (Long Term Acute Care) hospital. Further review revealed no documented evidence that changes were made to meet the population served, the staff employed or the services provided. The Plan included information for surgery, anesthesia, post-anesthesia, etc. which the LTAC facility does not treat. In addition duties were listed for staff positions (Director of Risk Management, Director of Maintenance, Director of Quality Management etc) who are not on staff of the LTAC.

2) Delegate responsibility for the organization, aggregation and reporting of all data collected data for the hospital:
In a face-to-face interview on 07/22/11 at 2:00pm, RN S2 DON (Director of Nursing) indicated the members of the QA Committee bring their own information and it is reported at the meeting. Further she indicated the hospital does not have a person on staff assigned the duties for quality assurance.

3) Ensure indicators were measurable and would improve health outcomes; and ensure identified problems were trended, corrective action implemented and monitored for sustained improvement:
Review of the quality assurance data dated 2010 through 02/11 revealed no documented evidence indicators were reported in measurable terms, problems identified or corrective actions taken.

In a face-to-face interview on 07/22/11 at 2:00pm, RN S2 DON (Director of Nursing) indicated an infection control problem with urinary tract infections had been identified; however no corrective actions have been taken as of yet.

Based on record reviews and interviews, the hospital failed to: 1) ensure indicators were developed for all department in the hospital to include aspects of patient care for dietary services, laboratory services, radiology services, and nursing services; 2) develop indicators for the performance of chart audits to monitor the quality of care patients were receiving; 3) develop quality indicators to monitor refrigerator temperatures, crash cart checks, or expired medications and/or supplies; and 4) complete investigations for adverse patient events (falls and medication variances) by relying on self reporting only in order to analyze their cause and implement corrective action. Findings:

1) Ensure indicators were developed for all department in the hospital to include aspects of patient care for dietary services, laboratory services, radiology services, and nursing services:
Review of the Performance Improvement data collected by the Quality Management for 2010 through 02/11/11 revealed no documented evidence of participation of the following departments via measurable indicators: Dietary Services, Laboratory Services, Radiology Services, Human Resources, Medical Records, and Nursing Services.

Review of the Quality Assurance Plan, written for Hospital "b" and adopted by this hospital revealed all services providing patient care must be integrated into the QA system.

2) Develop indicators for the performance of chart audits to monitor the quality of care patients were receiving:
Review of the Performance Improvement data collected by the Quality Management for 2010 through 02/11/11 revealed no documented evidence chart audits were performed. This was confirmed in an interview with RN S2 DON (Director of Nursing) on 07/22/11 at 2:00pm.

Review of the chart reviews performed by the survey team revealed the following: informed consents were not obtained for medical treatment upon admit to the hospital for 8 of 8 focused medical records reviewed for authorization for medical treatment forms out of a total of 20 sampled patients (#6, #12, #13, #14, #15, #16, #17, #20) and consents for blood were not appropriately completed by the physician for 2 of 2 patients receiving blood (Patient #7, #8) out of a total of 20 patient medical records reviewed;

3) Develop quality indicators to monitor refrigerator temperatures, crash cart checks or expired medications and/or supplies:
Review of the Performance Improvement data collected by the Quality Management for 2010 through 02/11/11 revealed no documented evidence temperature checks for the refrigerator in which medications were stored for patient use was monitored for compliance.

Review of the Performance Improvement data collected by the Quality Management for 2010 through 02/11/11 revealed no documented evidence crash cart compliance was included as part of the QA process.

Observation on 07/19/11 at 12:20pm in the Intensive Care Unit (ICU) of the hospital revealed there were two (2) 118 ml (milliliters) bottles of opened hydrogen peroxide with an expiration date of 6/11 and one opened bottle of 16 ounces of rubbing alcohol with an expiration date of 12/10. Further review revealed an open water container used for eye flushes.

In a face-to-face interview on 07/19/11 at 12:30pm, RN S2 DON (Director of Nursing) indicated all of the expired and open containers should have been thrown away and not left for use by a patient or employee. Further she indicated infection control rounds are done on a monthly basis at which times these things would be checked.

4) Complete investigations for adverse patient events (falls and medication variances) in order to analyze their cause and implement corrective action:
Review of the chart reviews performed by the survey team revealed the following; medication being left at the patient's bedside (Patient #9), medications not administered due to inability to obtain an IV access (Patient #3), orders not clarified for a patient receiving dialysis resulting in a patient not receiving any of her daily medications (Patient #6), medications not administered due to the unavailability of the drug in the hospital (Patient #9) for 3 of 20 patients administered medications.

Review of the members of the Quality Assurance Committee revealed the following members:
Administrator, Director of Nursing, Nurse Practitioner, Medical Director, Pharmacist, Social Worker and Facilities Manager.

In a face-to-face interview on 07/21/11 at 2:00pm, S2 DON indicated information was compiled by each discipline and discussed at the QA meeting. S2 further indicated each discipline compiled their own information and presented the data at the meeting.

Based on record reviews and interview, the hospital failed to prioritize its Quality Assurance/Performance Improvement Program for activities to focus on high-risk, high-volume or problem-prone areas as evidenced by failure to develop indicators related to identified problems related to staffing in the ICU (Intensive Care Unit) and medication administration. Findings:

Review of the Quality Assurance Meeting Minutes for 2010 through 02/11 and the meeting minutes for the Governing Body dated 02/18/10 (the only one submitted to the survey team), revealed no documented evidence Quality Assurance activities were prioritized.

In a face-to-face interview on 07/22/1 at 2:00pm, RN S2 DON (Director of Nursing) indicated the hospital does not have a QA Coordinator.
.
See findings at Tag A0393 and A0404.

Based on record reviews and interview, the hospital failed to implement a process to identify problems, implement corrective actions, measure success and ensure improvements made were sustained. Findings:

Review of the data and the meeting minutes of the Quality Assurance Program submitted by the hospital revealed no documented evidence problems were identified from the statistical data presented or corrective actions taken; therefore no success could be measured or improvements identified as sustained.

Review of the statistical data for the completed year of 2010 revealed identified problems of patient falls and employee injuries. Review of all of the data and meeting minutes submitted by the hospital for 2010 revealed no documented evidence the data was discussed, trended or corrective action implemented.

Based on record review and interview, the governing body of the hospital failed to determine the number of improvement projects to be conducted annually as evidenced by no documentation of any discussion in the meeting minutes for 2010 and 2011. Findings:

Review of the Governing Body Board Meeting Minutes dated 02/18/10 (the only one submitted to the survey team) revealed no documented evidence of any discussion determining the need for or number of improvement projects needed on an annual basis.


In a face to face interview on 07/22/11 t 2:00pm S2 DON Director of Nursing indicated no performance improvement project was performed.

26351


Based on record reviews, and staff interviews, the hospital failed to ensure all medication was administered according to physician's orders as per policy as evidenced by:
1) medication being left at the patient's bedside for 2 of 20 medical records reviewed, (#9, #2);
2) medication not administered due to inability to obtain an IV access for 2 of 20 sampled records reviewed, (#3, #2);
3) orders not clarified for a patient receiving dialysis resulting in a patient not receiving any of her daily medications for 1 of 20 medical records reviewed, (#6);
4) medication not administered due to the unavailability of the drug in the hospital for 2 of 20 sampled records reviewed, (#9, #2);
5) medication not administered as ordered by the physician for 2 of 20 sampled records reviewed, (#10, #2);
6) medication not administered with documentation "refused" for 1 of 20 sampled records reviewed for medication administration, (#2); and
7) medication not administered with documentation "in dialysis", "at dialysis", "to be given p (after) dialysis" or "will be given @ (at) dialysis" for 1 of 20 sampled records reviewed, (#2). Findings:

1) Medication being left at the patient's bedside, (#9, #2):
Patient #9
Review of Patient #9's Admission orders revealed an order for Ferrous Sulfate 5 grams po (by mouth) BID (twice a day). Review of her MAR dated 07/19/11 revealed Ferrous Sulfate Tablet Delayed Release oral twice daily with meals timed and documented as given at 07:30 and 17:30.

An interview was conducted with Patient #9 on 07/20/11 at 3:30pm. She stated the nurse that took care of her last night had left her iron tablet at her bedside because her supper had not arrived yet.

An interview was conducted with S5RN on 07/20/11 at 3:55pm. She stated after questioned about if any medication have been left at Patient #9's bedside, she said she had found Ferrous Sulfate by her bedside today and it must have been the 7/19/11 evening dose. When questioned if it was hospital policy to leave medicine at the patient's bedside for the patient to take, she stated not that she was aware of.

An interview was conducted with S2DON on 07/20/11 at 4 p.m. She stated the nurses are supposed to watch the patients take their medications and not leave the medication at the bedside.

Patient #2
Review of the medical record for Patient #2 revealed he was admitted on 05/18/11 at 1430 (2:30pm) with the admitting diagnosis of renal insufficiency and sepsis.

The "Physician's Order" for 05/18/11 with no time documented the orders were given by the physician read, "Nepro i (one) can tid (three times a day)". Further review revealed a verbal order written on 06/07/11 with no time given, the order was written to increase Nepro to five (5) cans daily and Boost pudding TID (three times a day) /c (with) meals.

Review of the MAR revealed "at bedside" was documented by the administration time for the Nepro Supplement on 06/09/11 at 18:00 (6:00pm) for Patient #2. Review of the MAR dated 06/09/11 and 06/18/11 revealed "at bedside" was documented for the Boost Supplement administrations at 1730 (5:30pm).

Patient #2 had a total of three (3) missed medication administrations/medication errors on 06/09/11 and 06/18/11.

In a face-to-face interview on 07/22/11 at 12:05pm, S2DON confirmed there was no documented evidence Patient #2 was administered the Nepro and Boost Supplements as ordered by the physician on 06/09/11 or 06/18/11. S2 indicated no medication including supplements should be left at the patient's bedside. The DON further indicated the nurse is to remain with the patient until the supplements have been administered to the patient as per policy. S2 indicated Patient #2 had a total of three (3) missed medication administrations/medication errors on 06/09/11 and 06/18/11. S2DON reported there were no medication variance reports completed for Patient #2's three (3) missed medication administrations/medication errors on 06/09/11 and 06/18/11 as per policy.

2) Medications not administered due to inability to obtain an IV access, (#3):
Patient #3 was admitted to the hospital on 06/16/11 with the diagnoses of Diabetic Abscess to right foot with gangrene, crush injury and Diabetic Mellitus. Review of the MAR dated 07/17/11 revealed the Piperacillin-Tazobactam (Zosyn) intravenous every 6 hours was circled at 02:00 and "no IV access refused venipuncture" was handwritten beside the circled 02:00. The 08:00 dose was also circled and handwritten beside the circled 08:00 was "no IV access".

An interview was conducted with S2DON on 07/21/11 at 9:30 a.m. She confirmed the circled times on the MAR meant the medication was not given. She stated on 07/17/11 the nurses were unable to obtain IV access because the patient refused and the doses were missed. She further stated she thinks the nurses notified Nurse Practitioner (NP), but she stated there was no documentation that the NP was aware or the physician was aware of the missed doses.

3) Orders not clarified for a patient receiving dialysis, (#6):
Review of the medical record for Patient #6 revealed a 49 year old female admitted to the hospital on 06/17/11 for ARF (Acute Renal Failure) and ESRD (End Stage Renal Disease). Further review revealed Patient #6 has a history of hypertension, atrial fibrillation, congestive heart failure, cardiomyopathy and chronic diabetes mellitus.

Review of the Admission Orders for patient #6 dated/timed 06/17/11 at 6:45pm revealed the following medication orders: Spironolactone 25mg 1 po BID (twice a day); B-Complex-Vitamin C-Folic Acid Capsule Renal 1 oral every day; Protonix 40mg delayed release 1 daily; Coreg 3.125mg i po twice a day; Sensispar 30mg 1 po daily; and Zyvox 600mg 1 po twice a day.

Review of the MAR (Medication Administration Record) for Patient #6 dated 07/18/11 revealed a circle around the 9:00 dose time and "at dialysis" of the following medications: Spironolactone 25mg 1 po BID (twice a day); B-Complex-Vitamin C-Folic Acid Capsule Renal 1 oral every day; Protonix 40mg delayed release 1 daily; Coreg 3.125mg i po twice a day; Sensispar 30mg 1 po daily; and Zyvox 600mg 1 po twice a day. Further review no documented evidence of the initials for nurse responsible for withholding the medications. Sodium Thiosulfate 125mg IV was documented as being given at 9:00am.

Review of the Hemodialysis Sheet from hospital "b" dated 07/18/11 revealed Patient #6 was dialyzed beginning at 0837 (8:37am). Further review of the dialysis flowsheet revealed Patient #6 received Thiosulfate 125mg IV (no time documented); however there was no documented evidence any po (by mouth) medication was administered during the time she was at the dialysis unit.

4) Medications not administered due to the unavailability of the drug in the hospital, (#9, #2):
Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital on 06/29/11 with the diagnoses of Left elbow dislocation, COPD (Chronic Obstructive Pulmonary Disease), and Hypertension. Review of her Admission Orders for 06/29/11 revealed a physician order for Wechol 625 mg po (oral) daily. Review of the MAR for 07/01/11 revealed Wechol timed administration of 9 am (9:00 a.m.) was circled and an "H" recorded by the time. Review of the key at the bottom of the MAR, revealed an "H" indicating the drug was not available. Review of the MAR for 07/04/11 revealed Wechol timed administration of 9am was circled and unavailable was written by the circled 9 am time.

An interview was conducted with S2DON and S5RN at 07/21/11 at 1:30pm. They stated the Wechol was not given on 07/01 and 07/04. S5RN stated the bottle for Wechol was usually on top of the medication cart, but it was not there on those days.

Patient #2
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 05/18/11 at 1430 (2:30pm) with the diagnoses of renal insufficiency and sepsis.

The "Physician's Order" on 05/24/11 with no time documented the order was written read, "...Peridex oral care TID (three times a day)...".

Review of the "Physician's Order" dated 05/30/11 with no documented time the physician gave the order for Augmentin 875mg po BID X (times) 7 days.

The "Physician's Order" dated 05/18/11 with no time documented the orders were given by the physician read, "Nepro i (one) can tid (three times a day)". Further review revealed a verbal order written on 06/07/11 with no time the order was written to increase Nepro to five (5) cans daily and Boost pudding TID (three times a day) /c (with) meals.

Review of the MAR revealed "not available" or "out of stock" was handwritten under the circled time of administration for: Peridex oral care on 05/24/11 at 1400 (2:00pm), Augmentin medication on 05/30/11 at 1500 (3:00pm) and 2300 (11:00pm) and Nepro Supplement on 06/02/11 at 1400 (2:00pm).

Patient #2 had five (5) missed medication administrations for medications not administered due to unavailability of the drug in the hospital on 05/24/11, 05/30/11 and 06/02/11.
In a face-to-face interview on 07/22/11 at 12:05pm, S2DON confirmed the Peridex oral care on 05/24/11, Augmentin on 05/30/11 and Nepro Supplement on 06/02/11 had "not available" or "out of stock" documented for the times of administrations. The DON was unaware the Peridex, Augmentin and Nepro Supplement were not available for administration on 05/24/11, 05/30/11 and 06/02/11. S2DON indicated there were no problems reported regarding medications unavailable for administration from the pharmacy for May or June of 2011. S2DON stated Patient #2 had 5 missed medication administrations/medication errors for Peridex, Augmentin and Nepro on 05/24/11, 05/30/11 and 06/02/11. S2 reported there were no medication variance reports completed for the missed medication administrations/medication errors for Peridex, Augmentin and Nepro in May and/or June as per policy.

5) Medication not administered as ordered by the physician for 2 of 20 sampled records reviewed, (#10, #2):
Patient #10
Review of the medical record for Patient #10 revealed the "Physician Progress Notes-Page 1 of 1" dated 07/11/11 with no time documented read, " transfer to LTAC by ambulance". Review of the "Admission Orders" did not have a date/time documented that the verbal order was given by the physician to admit the patient into the hospital. Further review revealed the patient was admitted into the hospital with the following medication orders: Avapro 300 milligrams (mg) oral (po) daily and Norvasc 10mg po every am (morning). Review of the "Physician's Order" for 07/14/11 with no time documented the order was written read, "...2. Promod 30 mililiters (mls) oral (po) BID (twice a day)...". Further review of the "Physician's Order" revealed no documentation the physician wrote an order to hold the Promod medication on 07/18/11. Review of the "Physician's Order" dated 07/15/11 with no time documented the order was written read, "...4. Hold Norvasc...". Further review of the "Physician's Order" revealed no documented evidence the order concerning Norvasc was clarified by the attending physician to hold the medication from 07/16/11 to 07/19/11. Review of the "Physician's Order" dated 07/15/11 with no time given that the order was written read, "1. Hold Avapro". Further review revealed there was no documented evidence the Avapro medication order was clarified by the attending physician to hold the medication from 07/16/11 through 07/19/11. There was no documented medication reordered by the attending physician. Review of the MARs from 07/16/11 to 07/19/11 revealed the following: the Avapro and/or Norvasc medications were not administered to Patient #10 from 07/16/11 through 07/19/11; and the Promod medication was not administered to Patient #10 on 07/18/11 at 1900 (7:00pm) as ordered by the physician.

In an interview on 07/22/11 at 3:15pm, S2DON verified Patient #10 was not administered the Avapro or Norvasc medications from 07/16/11 to 07/19/11 as ordered by the physician. S2DON confirmed Patient #10 was not administered the Promod supplement as ordered by the physician on 07/18/11. The DON indicated these are medication errors for Patient #10 for the month of July. S2DON further indicated there was no medication variance reports submitted for the missed medication administrations of Avapro, Norvasc or Promod for Patient #10 as per policy.

Patient #2
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 05/18/11 at 1430 (2:30pm) with the diagnoses of renal insufficiency and sepsis.

Review of medical record for Patient #2 revealed no documented evidence of an order was written for Ampicillin-Sulbactam Intravenous to be administered to Patient #2 on 06/13/11, 07/04/11, or 07/21/11. Further review revealed no documentation the Selenium Sulfide Lotion was ordered for Patient #2 on 05/18/11. There was no documented evidence the physician ordered Heparin (Porcine) injection on 07/01/11.

The "Physician's Order" dated 05/18/11 recopied with no time documented the orders were given by the physician read, "...Lovenox 30mg po daily, Renal Cap (B Complex-Vitamin C-Folic Acid Capsule) i po daily, Procrit 10,000 units MWF /p (after) dialysis, Lac-hydrin lotion apply BID (two times a day), Nepro i (one) can tid (three times a day), D/C Selenium Sulfide Lotion, Duoneb tid, and Aspirin 81mg po daily...".

Review of the "Admission Orders" recopied on 05/18/11 at 1430 revealed an order for :
Procrit 10,000 units MWF (Monday, Wednesday, Friday) /p (after) dialysis and Lac-hydrin lotion topical BID (two times a day).

The "Physician Orders" dated 05/18/11 with no time documented the orders were recopied read, "Nepro i (one) can tid (three times a day)". Further review revealed a verbal order written on 06/07/11 with no time the order was written to increase Nepro to five (5) cans daily and Boost pudding TID (three times a day) /c (with) meals.

A "Physician's Order" dated/timed 05/20/11 at 1310 (1:10pm) revealed an order for Primaxin 500mg IV q 12 hours.

Review of the "Physician's Order" dated 05/24/11 with no time the order was written revealed an order for Triple abx (antibiotic) ointment ? right medial calf BID (two times a day) and Peridex oral care TID (three times a day).

A "Physician's Order" dated 06/02/11 with no time documented the order was written read, " Gentamycin IV per pharmacokinetic. Further review revealed a second order was written for Gentamycin 100mg IVPB post dialysis on 06/02/11 with no time indicating the time the order was written. Another order to increase Gentamycin to 150mg IV post dialysis was written as a verbal order on 06/06/11 with no time that the order was written.

Review of the Medication Administration Records revealed the medication administration times had a circle around the time or the administration time was left blank indicating Patient #2 was not administered the medication as ordered by the physician as follows:
Ampicillin-Sulbactam Intravenous on 06/13/11 at 2200 (10:00pm), on 07/04/11 at 1000 (10:00am), on 07/21/11 at 2200;
Atrovent inhalation treatment on 07/01/11 at 2300 (11:00pm), on 07/13/11 at 1500 (3:00pm);
B Complex-Vitamin C-Folic Acid Capsule on 05/18/11 at 0900 (9:00am);
Boost Supplement on 06/12/11 at 0730 (7:30am), at 1230 (12:30pm), and at 1730 (5:30pm), on 06/13/11 at 0730, 06/17/11 at 1730 (5:30pm), on 06/20/11 at 1730 (5:30pm), on 06/25/11 at 0730, at 1230 and at 1730, on 06/27/11 at 1230 and at 1730, on 07/04/11 at 0730, at 1230 and at 1730, on 07/07/11 at 1730, 07/09/11 at 0730, at 1230, and at 1730;
Gentamycin IV (intravenous) on 06/02/11 at 1200 (12:00pm), on 07/15/11 at 0900;
Heparin (Porcine) injection on 07/01/11 at 0900;
Lac-Hydrin topical lotion on 05/18/11 at 0900 (9:00am); on 05/21/11 at 0900 (9:00am), on 05/25/11 at 0900 (9:00am), on 07/04/11 at 0900, on 07/21/11 at 2100 (8:00pm);
Levenox on 05/18/11 at 0900 (9:00am), on 06/05/11 at 0900 (9:00am);
Neosporin Topical on 05/25/11 at 0900 (9:00am), on 06/02/11 at 0900 (9:00am), on 06/28/11 at 0900 and at 2100 (9:00pm), on 07/04/11 at 0900 and at 2100 (8:00pm), on 07/07/11 at 0900;
Nepro Supplement on 05/20/11 at 14:00 (2:00pm) and 1900 (7:00pm), on 05/23/11 at 2100 (9:00pm), on 05/25/11 1400 (2:00pm), on 05/27/11 at 2100 (9:00pm), on 05/28/11 at 1900 (7:00pm), on 06/03/11 at 1400 (2:00pm) and 1900 (7:00pm), on 06/08/11 at 1400 (2:00pm) and at 1800 (6:00pm), on 06/09/11 at 2200 (10:00pm), on 06/10/11 at 0600 (6:00am), on 06/13/11 at 1400 and at 1800 (6:00pm), on 06/15/11 at 0600 and at 1400, on 06/27/11 at 1400, 07/04/11 at 1000 (10:00am), on 07/08/11 at 1400, 07/13/11 at 2100;
Peridex oral care on 05/24/11 at 2200 (10:00pm), on 05/25/11 at 1400 (2:00pm), on 05/28/11 at 0600 (6:00am), on 05/29/11 at 0600 (6:00am), on 06/01/11 at 0600 (6:00am), on 06/10/11 at 0600 (6:00am), on 06/13/11 at 1400, on 06/14/11 at 1400, on 06/15/11 at 0600, on 0617/11 at 1400, on 06/27/11 at 1400, on 07/05/11 at 0600, on 07/10/11 at 2200, on 07/13/11 at 1400 and at 2200, on 07/14/11 at 0600 and at 2200, on 07/15/11 at 0600, on 07/21/11 at 1400 and at 2200;
Primaxin IV (intravenous) 500mg on 05/21/11 at 0600 (6:00am);
Procrit injection on 06/03/11 at 0900 (9:00am), on 06/15/11 at 0900, on 07/01/11 at 0900, on 07/15/11 at 0900;
Selenium Sulfide topical on 05/18/11 at 0900 (9:00am); and
Ventolin nebulizer treatment on 07/01/11 at 2300 (11:00pm), on 07/13/11 at 1500 (3:00pm).

Patient #2 had a total of 85 missed medication administrations/medication errors from 05/18/11 to 07/21/11.

During the same face-to-face interview on 07/22/11 at 12:05pm, S2DON confirmed Patient #2 had a total of 85 missed medication administrations/medication errors from 05/18/11 to 07/21/11. S2 indicated there were no medication variance reports completed for the missed medication administrations/medication errors for Patient #2 from 05/18/11 through 07/21/11 as per policy.

6) Medication not administered with documentation "refused" for 1 of 20 sampled records reviewed for medication administration, (#2):
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 05/18/11 at 1430 (2:30pm) with the diagnoses of renal insufficiency and sepsis. Review of the " Admission Orders " recopied on 05/18/11 at 1430 revealed an order for Aspirin 81 mg po daily and Synthroid 250mg (milligrams) po (oral) qam (every morning).

The "Physician's Orders" dated 05/18/11 with no time documented the orders were written revealed medication orders for: Renal Caps (B Complex-Vitamin C-Folic Acid Capsule) i po daily, Synthroid 250mcg (micrograms) po / (every) AM (morning), Nepro i (one) can tid (three times a day), and Aspirin 81mg po daily.

Review of the "Physician's Orders" dated 05/18/11 with no time documented the orders were written revealed orders for "Nepro i (one) can tid (three times a day)". Further review revealed a verbal order written on 06/07/11 with no time the order was written to increase Nepro to five (5) cans daily and Boost pudding TID (three times a day) /c (with) meals.

The "Physician's Orders" dated 05/18/11 with no time documented the orders were written revealed an order for Nexium 40mg po daily. Further review revealed "Physician's Orders" written on 05/19/11 with no time documented the order was written revealed a therapeutic substitution for Protonix 40mg oral qd (everyday) was interchanged for the Nexium medication.

Review of the "Physician's Orders" dated 05/24/11 with no time the order was written revealed an order for Peridex oral care TID (three times a day).

The "Physician's Orders" dated/timed 05/31/11 at 1330 (1:30pm) revealed an order for Megace 400mg po daily.

Review of the MAR for Patient #2 revealed the medication administration section had "refused" documented for the medication administration time as follows:
Aspirin on 06/05/11 at 0900 (9:00am);
B Complex-Vitamin C-Folic Acid Capsule on 06/03/11 at 0900 (9:00am);
Boost Supplement on 06/09/11 at 1230 (12:30pm) and at 1730 (5:30pm), on 06/11/11 at 0730 (7:30am), at 1230 (12:30pm) and at 1730, on 06/11/11 at 0730, at 1230, and at 1730, on 06/26/11 at 0730, at 1230, and at 1730, on 06/29/11 at 0730, at 1230, and at 1730, on 06/30/11 at 0730, at 1230 and at 1730, on 07/10/11 at 0730, at 1230, and at 1730, on 07/13/11 at 0730, at 1230, and at 1730, on 07/14/11 at 0730, at 1230 and at 1730;
Nepro Supplement on 05/31/11 at 1400 (2:00pm) and at 1900 (7:00pm), on 06/03/11 at 1000 (10:00am) and at 1900 (7:00pm), on 06/09/11 at 1400 (2:00pm) and at 1900 (7:00pm), on 06/15/11 at 1800 (6:00pm);
Megace oral on 06/05/11 at 0900;
Peridex on 06/05/11 at 1400 (2:00pm), on 06/25/11 at 1400 (2:00pm) and at 2200 (10:00pm), on 06/26/11 at 0600 (6:00am), at 1400, and at 2200, on 06/28/11 at 1400 and at 2200, on 06/29/11 at 1400 and at 2200, on 06/30/11 at 0600, at 1400, and at 2200, on 07/01/11 at 0600, 07/04/11 at 1400 and at 2200, on 07/10/11 at 0600 and at 1400, on 07/14/11 at 1400;
Protonix on 06/03/11 at 0900; and
Synthroid on 06/03/11 at 0900 (9:00am).

Patient #2 had a total of 61 missed medication administrations/medication errors from 05/31/11 through 07/14/11.

In the same face-to-face interview on 07/22/11 at 12:05pm, S2DON confirmed Patient #2 had a total of 61 missed medication administrations/medication errors from 05/31/11 through 07/14/11. The DON indicated there were no medication variance reports completed for the missed medication administrations/medication errors for Patient #2 from 05/31/11 to 07/14/11 as per policy.

7) Medication not administered with documentation "in dialysis", "at dialysis", "to be given p (after) dialysis", or "will be given @ (at) dialysis" for 1 of 20 sampled records reviewed, (#2):
Review of the medical record for Patient #2 revealed he was admitted on 05/18/11 at 1430 (2:30pm) with the admitting diagnosis of renal insufficiency and sepsis.

A "Physician's Order" dated 06/02/11 with no time documented the order was written read, " Gentamycin IV per pharmacokinetic. Further review revealed a second order was written for Gentamycin 100mg IVPB post dialysis on 06/02/11 with no time indicating the time the order was written. Another order to increase Gentamycin to 150mg IV post dialysis was written as a verbal order on 06/06/11 with no time that the order was written.

The "Physician's Orders" dated 05/18/11 with no time documented the orders were written revealed orders for "Nepro i (one) can tid (three times a day)". Further review revealed a verbal order written on 06/07/11 with no time the order was written to increase Nepro to five (5) cans daily and Boost pudding TID (three times a day) /c (with) meals.

Review of the "Physician's Orders" dated 05/24/11 with no time the order was written revealed an order for Peridex oral care TID (three times a day).

The "Physician's Orders" dated 05/18/11 with no time documented the orders were recopied revealed an order for Procrit 10,000 units MWF /p (after) dialysis.

The Vancomycin i (one) gm (gram) IV (intravenous) now then i gm iv q M, W, F /p dialysis was ordered by the physician on 05/20/11 at 1310 (1:10pm). Another order for Vancomycin (1) gm IV p dialysis today was written on 06/06/11 with no time the order was written. Review of the "Physician's Orders" dated 06/13/11 with no time the order was written revealed an order for Vancomycin i gm IV q (every) dialysis.

Review of the "Physician's Orders" for Patient #2 revealed no documentation of an order written for Zemplar 5mcg/1ml Intravenous MON/WED/FRI.

Review of the MAR for Patient #2 revealed "in dialysis", "at dialysis", "to be given p (after) dialysis", "will be given @ dialysis", or "sent to dialysis" was handwritten under the medication administration times circled for the following medications:
Gentamycin Intravenous on 06/06/11 at 0900 (9:00am), on 06/08/11 at 0900 (9:00am), on 06/10/11 at 0900 (9:00am), on 06/13/11 at 0900, 06/15/11 at 0900, on 06/20/11 at 0900, 07/04/11 at 0900, on 07/08/11 at 0900, on 07/13/11 at 0900;
Nepro Supplement on 05/20/11 at 1000 (10:00am), 05/23/11 at 1400 (2:00pm), on 05/25/11 at 1900 (7:00pm), on 05/27/11 at 1400 (2:00pm), on 06/01/11 at 1400 (2:00pm), 06/03/11 at 1400 (2:00pm);
Peridex oral care on 05/27/11 at 1400 (2:00pm), on 06/01/11 at 1400 (2:00pm), on 06/20/11 at 1400;
Procrit injection on 05/24/11 at 1400 (2:00pm), on 06/06/11 at 0900 (9:00am), on 06/06/11 at 1400 (2:00pm), on 06/08/11 at 0900 (9:00am), on 06/10/11 at 0900 (9:00am), on 06/13/11 at 0900, on 06/17/11 at 0900, on 06/20/11 at 0900, on 06/29/11 at 0900, on 07/04/11 at 0900, on 07/08/11 at 0900, on 07/13/11 at 0900;
Vancomycin on 05/23/11 at 0900 (9:00am), on 06/15/11 at 0900; and
Zemplar Intravenous on 07/13/11 at 0900, on 07/15/11 at 0900.

Patient #2 had a total of 35 missed medication administrations/medication errors from 05/20/11 to 07/15/11.

During the same face-to-face interview on 07/22/11 at 12:05pm, S2DON verified Patient #2 had a total of 35 missed medication administrations/medication errors from 05/20/11 to 07/15/11. The DON indicated there were no medication variance reports completed for the 35 missed medication administrations/medication errors for Patient #2 from 05/20/11 to 07/15/11 as per policy. S2 did not know what the medication error rate was for May, June or July of 2011. S2DON indicated the medication error rates for May, June and July of 2011 were inaccurate due to the 189 missed medication administrations/medication errors identified by the surveyor from 05/18/11 through 07/21/11.

The policy titled, "Medication Administration", presented to the surveyors as the current one in use, revealed in part, "...1. Medication will be give to a patient only upon the order of a member of the medical staff of LCMH or other individual who has been granted clinical privileges to write such orders ...3. Licensed nursing staff will monitor each patient's response to medications according to the clinical needs of the patient and address the patient's response to prescribed medications and actual or potential medication-related problems. ..6. Documentation of administration or non-administration of medications will be on the MAR (Medication Administration Record). When medications are given based on pulse or blood pressure, the value will be charted under the time column of the MAR ....15. Any potential or actual medication error should be reported on the MERF (medication error reporting form) ...Medication Administration Record (MAR) 1. All medications are charted on the MAR. 2. A MAR and IT therapy flow sheet is printed every 24 hours, with the new day beginning at midnight. 3. At the beginning of the 11-7 shift the nurse is responsible for checking the MAR for the last 24 hours with the physician's orders and placing his/her initials in the lower right corner of medication entry column of the MAR. The nurse then initials date and times the right hand side of the most recent physician order as a 24 hour chart check. 4. At the end of a 24 hour period, place the completed MAR in the patient's chart and the current MAR is placed in the appropriate medication binder. Insulin administration is document on Diabetic Flow Sheet. Notify Pharmacy if MAR does not comply with the physician's order. Complete variance sheet and return it to Pharmacy on 11-7 shift...".
Review of the policy titled, "Medication Administration", presented to the surveyors as the current one in use, revealed in part, "...Medication Error Reporting 1. Medication administration errors, adverse drug reaction, and medication incompatibilities are reported to the attending physician, immediately when possible. 2. Notify Pharmacy of Medication Error phoning Pharmacy and by using Medication Error Report form located under Form. 3. Place completed Medication Error form in Manager's box for Supervisor completion and subsequent routing to Pharmacy...".

Based on interview, the hospital failed to ensure the security of patient records as evidenced by allowing another hospital (Hospital "b") to maintain their medical records department including storage and access of which the administrator of this hospital has no supervisory authority. Findings:

In a face-to-face interview on 07/22/11 at 3:00pm, the Administrator, S1 verified the medical records of this hospital are transferred to Hospital "b" after being completed by the physicians at the hospital. Further S1 verified he does not supervise the staff of Hospital "b".

Based on record reviews and staff interview, the responsibilities of chief executive officer, medical staff and director of nursing services failed to ensure the hospital-wide quality assurance program addressed problems identified by the infection control officer (S16RN, the contracted ICO) and failed to implement a corrective action plan for the problems identified with the increased rate of Urinary Tract Infections (UTIs) of 14.2% above the goal rate (18.2%) in 2010 and of 12.4% above the goal rate (16.4%) in 2011 as evidenced by having no documentation of active surveillance, tracking or trending of the care provided by hospital "b" non-contracted) nurses, agency nurses, or employees of the LTAC hospital. Findings:

Review of the hospital acquired catheter infection for 2010 revealed the hospital acquired catheter infections were related to urinary tract infections (UTIs). There was a high rate of infections related to urinary tract infections (UTIs) recorded for this quarter. Further review revealed there was documentation for the months that this data was collected and recorded for 2010. The UTI rate for this quarter was 18.2%. The UTI "Goal Rate" was to be less than 4.0%. The UTI rate was 14.2% above the goal rate in 2010. There was documentation the high rate of hospital acquired catheter infections was related to UTIs in direct relation to a low number of catheter days. However, in an effort to lower the UTI rates the silver-coated catheters were implemented the end of June at the hospital. There was no documentation of the year (2010 or 2011) that the silver-coated catheter was implemented at the hospital for the increased goal rate of 14.2% in 2010.

Review of the "Hospital's 1st Quarter 2011" hospital acquired catheter infections revealed there was a high rate of infections related to urinary tract infections (UTIs) for this quarter. There was no documented evidence of the months that the data was collected and recorded for this quarter in 2011. Further review revealed the UTI rate for this quarter was 16.4%. The UTI "Goal Rate" was to be less than 4.0%. The UTI rate was 12.2% higher than the goal rate in 2011. There was documentation the high rate of hospital acquired catheter was related to the UTIs in direct relation to low number of catheter days. However, in an effort to lower the UTI rates the silver-coated catheter was implemented the end of June at the hospital. There was no documented evidence of the year (2010 or 2011) that the silver-coated catheter was implemented at this hospital as a result of the 2011 increased rate of 12.2% higher than the goal rate for this quarter, 2011.

There was no "Infection Control Log" presented for the hospital's increased UTI goal rates of 14.2% above the goal rate (18.2%) in 2010 and 12.4% above the goal rate (16.4%) in 2011 presented during the survey from 7/19/11 through 7/22/11. There was no active surveillance, tracking and/or trending of the care provided by non-contracted staff from hospital "b" (wound care nurses and nurses) or by the LTAC hospital's employees for 2010 or 2011 presented during the survey. Further review revealed there was no documented evidence what year in June (2010 or 2011) that the silver-coated catheters were implemented by the hospital for the high UTI rates identified in 2010 and 2011 presented during the survey conducted from 7/19/11 to 7/22/11.

In an interview on 7/21/11 at 3:15pm, S2DON indicated there was no "Infection Control Log" for the hospital . S2 reported there was no active surveillance of handwashing and/or the wound care provided to the patients by hospital "b" (non-contracted) nursing staff for 2011. The DON indicated there was no documentation of handwashing observations conducted for all this hospital's employees that provide direct patient care for 2011. S2DON denied knowledge of what the hospital's infection rate was for the month of June, 2011. S2 did not have knowledge of what the infection rate was the last quarter. The DON indicated the rate of UTIs increased last quarter. S2DON was not able to state what the UTI rate was last quarter. S2DON reviewed the infection rates for 1st Quarter 2011. S2 verified the UTI rate was 12.4% higher than the goal rate in 2011. The DON was not able to state what interventions were implemented by the contracted ICO (S16RN) or herself (S2) regarding the 12.4% increased rate of UTIs. S2 denied knowledge of what year the silver-coated catheters were implemented at the hospital related to the increased UTI rates of 14.2% in 2010 and 12.4% in 2011. S2 stated there was no tracking and trending initiated by her (S2) and/or the contracted ICO, (S16RN) after the UTI rates of 14.2% was identified in 2010 and 12.4% was identified in 2011. S2DON stated the hospital uses nurses from hospital "b" (non-contracted) for wound care and nurse staffing and agency nurses as needed to staff the hospital. S2 indicated there was no active surveillance, tracking or trending of the care provided by the non-contracted nurses (Hospital "b"), agency nurses and/or employees of this hospital implemented after the increased rate of 12.4% UTIs was identified last quarter, 2011. The DON stated she was the ICO at this hospital that monitored all staff including the hospital employees, hospital "b" (the non-contracted) nurses and agency nurses to determine whether or not the staff are in compliance with infection control practices. S2 indicated there was no documentation for monitoring of compliance for infection control practices conducted for hospital "b" (the non-contracted) or agency nurses providing direct patient care and wound care for 2011. The DON stated there was no documented evidence for monitoring of infection control practices of the agency nurses and/or the hospital employees providing direct patient care for 2011. S2DON indicated there was no documentation from the contracted ICO (S16RN) for the monitoring of infection control practices by hospital "b" (the non-contracted nurses), agency nurses and/or the employees of the hospital from 2010 through July of 2011.