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

1) Failing to develop and establish policies and procedures addressing safety standards for adequate shielding of patients and personnel. See findings in tag A-0535.

2) Failing to ensure contracted Radiologic services were supervised by a qualified Radiologist on either a full-time, part-time or consulting basis as evidenced by failing to appoint a qualified Radiologist to supervise the hospital's Radiologic Services. See findings in tag A-0546.

Based on observation, record review and interview, the hospital failed to ensure the confidentiality and/or safeguard of clinical records from unauthorized access. This was evidenced by the hospital having a binder containing documentation relative to wound care on an unsupervised cart located in the hallway of a high traffic area which was accessible to staff, patients and/or visitors. This deficient practice had the potential to effect 16 ( #1, #2, #3 #4, #5, #11, #12, #13, #16, #17, #18, #22, #23, #24, #25 and #26) of 19 patients currently admitted to the hospital. Findings:

Observation on 01/12/15 at 2:10 p.m. revealed a cart located against a wall in the hallway near nurses station (#1) with a large 3 ring binder tilted "Wound Care Photos and Documentation". The binder contained identifying information of 16 (#1, #2, #3, #4, #5, #11, #12, #13, #16, #17, #18, #22, #23, #24, #25, and #26) patients and photos of the patients' wounds and documentation relative to the wounds. Observation of the binder for 5 minutes (2:05 p.m.) revealed no hospital staff present and the binder remained on top of the cart in an unsecured/unrestricted area.

Review of the Hospital's Policy & Procedure titled" Confidentiality of Patient Information" presented by S17HIM (Health Information Management) as being current (3/1/14) read in part: "Patient charts are maintained such that non-authorized individuals do not have access to patient medical records at any time."

In an interview 01/12/15 at 2:15 p.m., S3RN indicated S5Wound Care RN (Registered Nurse) will leave the binder on top of the cart until she (S5Wound Care) has completed all scheduled wound care. S3RN removed the binder and placed it behind the nurses' station.

In an 01/1215 at 2:25 p.m., S2DON confirmed the binder with patient information should not have been left on the wound cart as the information was accessible to unauthorized staff, patient and/or visitors.

Interview on 01/14/15 at 4:15 p.m., S17 HIM ( Health Information Management) indicated that all patient information contained in the binder titled "Wound Care Photos and Documentation" contained patient information that was confidential and should have not been left unattended on the wound cart.

Based on record review and interview, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Plan.

Findings:

Review of the hospital's QAPI documentation revealed no documented evidence that the following contracted services had been included in the QAPI Plan: Linen Service and Sharps Disposal (Stericycle) Service.

In an interview on 1/15/15 at 9:00 a.m. with S2DON (Quality Director), she confirmed the following contracted services had not been included in the QAPI Plan: Linen Service and Sharps Disposal (Stericycle) Services.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the care of each patient as evidenced by failing to ensure patient intake/output was measured and documented on each shift as ordered by the patients' physician for 5 (#3, #4, #5, #14, #16) of 5 (#3, #4,#5, #14, #16) patients reviewed for intake/output documentation out of a total sample of 31 patients.

Findings:

Patient #3
Review of Patient #3 ' s medical record revealed an admission date of 1/9/15 with diagnoses including the following: Osteomyelitis left great toe and status post amputation with non healing wound.

Review of Patient #3 ' s admit orders revealed the following: Intake/Output (I&O): Measure and record every shift.

Review of Patient #3 ' s intake/output graphics revealed no intake documented on the day shift on 11/27/14, 11/29/14, 12/4/14, 12/15/14, 12/17/14 and 1/8/15.

Patient #4
Review of Patient #4 ' s medical record revealed an admission date of 12/22/14 with diagnoses including the following: Aspiration Pneumonia, Acute Respiratory Failure, Acute or Chronic Kidney Disease, Coronary Artery Disease and Dysphagia.

Review of Patient #4 ' s admit orders, dated 12/22/14, revealed the following:
Intake/Output (I&O): Measure and record every shift.

Review of Patient #4 ' s Intake /Output graphics record revealed no documented intake for the day shift on 12/22/14, 12/23/14, 12/24/14, 12/28/14, 1/4/15, 1/5/15.

Patient #5
Review of Patient #5 ' s medical record revealed an admission date of 7/9/14 with diagnoses including the following: Severe Coronary Artery Disease, Post Cardiac Arrest and Acute Renal Failure.

Review of Patient #5 ' s admit orders, dated 7/9/14, revealed the following:
Intake/Output (I&O): Measure and record every shift.

Review of Patient #5 ' s Intake /Output graphics record revealed no documented intake/output for the day shift on 7/19/14, 8/8/14, 8/9/14 and 8/21/14.
Further review revealed no documented intake/output for the night shift on 8/22/14, 8/23/14 and 8/24/14.

Patient #14
Review of Patient #14's medical record revealed an admit date of 12/18/14 with diagnoses including congestive heart failure, diabetes and hypertension. Review of the physician's admit orders dated 12/18/14 revealed an order for Intake/Output: Measure and record every shift.

Review of Patient 14 ' s Intake /Output graphics record revealed no documented intake/output for the day shift on 12/19/14, 12/20/14, 12/22/14, 12/26/14, 12/27/14, 12/28/14 and 12/29/14.
Further review revealed no documented intake/output for the night shift on 12/21/14, 12/22/14, 12/23/14 and 1/11/15.

Patient #16
Review of Patient #16 ' s medical record revealed an admission date of 12/30/14 with diagnoses including the following: Pneumonia, Multiple Pressure Ulcers, Infected Wound and Malnutrition.

Review of Patient #16 ' s Admit orders, dated 12/30/14, revealed the following:
Intake/Output (I&O): Measure and record every shift.

Review of Patient #16 ' s Intake /Output graphics record revealed no documented intake/output for the day shift on 1/5/15. Further review revealed no documented intake/output for the day shift on 1/10/15.

On 1/14/15 at 12:15PM, interview with S2DON confirmed that the patient's intake and output was not monitored every shift as ordered by the physician.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed and maintained a current nursing care plan, based on each patient's nursing care needs and not solely on those needs related to the admitting diagnosis, as evidenced by failing to develop comprehensive, individualized care plans for 3 of 3 (#13, #19, #31 ) patients reviewed for care planning of Dialysis out of a total sample of 31 patients. Findings:

Review of the policy titled The Nursing Process Care Planning, Document Number 9-1.2.0, Revised 3/1/2014 revealed in part: The nursing plan of care provides a collaborative/systematic method of individualized care that focuses on the patient ' s response to an actual or potential alteration in health based on patient assessment. This plan reflects all disciplines involved in providing care to the patient. It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of those interventions in the medical record.

Patient #13
Review of the medical record for patient #13 revealed the patient was a 63 year old male admitted to the hospital on 12/4/2014 with a diagnosis of status/post Left Below The Knee Amputation, Gangrene of Right Foot, Wound Care, and End Stage Renal Disease (ESRD). Review of the physicians orders dated for 12/4/2014 revealed the patient had orders for Dialysis three times per week.

Review of the Interdisciplinary Plan of Care dated 12/4/2014 revealed no documented evidence of any goals or interventions to address the patient's Renal Disease or Dialysis.

Patient #19
Review of the medical record for patient #19 revealed the patient was a 63 year old female admitted to the hospital on 1/9/2015 with a diagnosis ESRD, Lung Ca, Cerebral Vascular Accident (CVA), Pneumonia, Diabetes, and Coronary Artery Disease.

Review of the Interdisciplinary Plan of Care dated 1/9/2015 revealed no documented evidence of any goals or interventions to address the patient's Renal Disease or Dialysis.

Patient #31
Review of the medical record for patient #31 revealed the patient was a 81 year old female admitted to the hospital on 12/10/2014 with a diagnosis ESRD, Acute Pericarditis, and Anemia.

Review of the Interdisciplinary Plan of Care dated 12/10/2014 revealed no documented evidence of any goals or interventions to address the patient's Renal Disease or Dialysis.

Interview with S2DON on 1/14/2015 at 12:35 p.m. confirmed that the patient's care plan should include all the patient's diagnosed medical conditions.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered according to physician's orders and hospital policy for 1 (#14) of 15 records reviewed for medication administration out of total sample of 31.

Findings:

Review of the hospital policy titled Medication Administration, Policy Number: 9-4.13.0, revealed in part:
All patient medications will be administered per a physician ' s order and documented on a Medication Administration Record (MAR).

Patient #14
Review of the medical record for patient #14 revealed an admit date of 12/18/14 with diagnoses including diabetes, acute respiratory failure and congestive heart failure. Review of the physician orders dated 1/2/15 revealed capillary blood glucose levels were to be obtained with Humulin R sliding scale insulin to be administered per the following scale:
60-150 mg/dl, no insulin
151-200 mg/dl, 4 units
201-250 mg/dl, 8 units
251-300 mg/dl, 12 units
301-350 mg/dl, 16 units
351-400 mg/dl, 20 units

Review of the diabetes record flow sheet revealed the following entries:
1/3/15 at 4:30PM, blood glucose 261 mg/dl and 8 units Humulin R administered
1/3/15 at 9:00PM, blood glucose 155 mg/dl and no insulin administered
1/5/15 at 9:00AM, blood glucose 206 mg/dl and 6 units Humulin R administered
1/6/15 at 9:00AM, blood glucose 202 mg/dl and 6 units Humulin R administered
1/7/15 at 9:00PM, blood glucose 163 mg/dl and no insulin administered
1/8/15 at 9:00PM, blood glucose 161 mg/dl and no insulin administered
1/9/15 at 9:00PM, blood glucose 326 mg/dl and no insulin administered
1/10/15 at 9:00AM, blood glucose 214 mg/dl and 4 unites Humulin R administered
1/12/15 at 9:00AM, blood glucose 185 mg/dl and no insulin administered

On 1/14/15 at 12:15PM, interview with S2DON confirmed that the patient's Humulin R sliding scale insulin was not administered per physician's orders.

Based on record review and interview, the hospital failed to ensure that medical record entries were authenticated, dated and timed, in written or electronic form, by the person responsible for providing or evaluating the service provided, and consistent with hospital policies and procedures for 7 (#4, #11, #12, #13, #16, #17 & #18) of 20 records sampled for authentication, dating and timing out of a total sample of 31 patients.

Findings:
Patient #4
Review of Patient #4 ' s medical record revealed an admission date of 12/22/14 with diagnoses including the following: Aspiration Pneumonia, Acute Respiratory Failure, Acute or Chronic Kidney Disease, Coronary Artery Disease and Dysphagia.

Review of Patient #4 ' s physician ' s orders revealed the following:
Orders not timed:
1/2/15: CXR (chest x-ray) , Chem (Chemistry)12, CBC (complete blood count) in a.m., Spot urine for Eosinophil in a.m., Seroquel 25 mg 1 p.o. (by mouth) q (every) hs (hour of sleep) prn
(as needed) sleep;
IVF (intravenous fluids) ½ NS (normal saline) at 80 cc (cubic centimeters)/hour x (times) 1 liter.
1/3/15: Chem12, CBC in a.m., IVF ½ NS at 80 cc/hr x 1 liter;
1/4/15: Chem12, CBC in am, CXR in a.m., IVF ½ NS 80 cc/hr x 1 liter

Medical orders signed but not dated or timed:
Physician Admit /Resumption of Care Orders, dated 12/22/14 at 4:00 p.m.

In an interview on 1/13/15 at 2:50 p.m. with S2DON, she confirmed all orders should have been dated, timed and signed. She said physician ' s dating and timing their orders was a problem at the hospital.

Patient #11
Review of verbal/telephone orders for Patient #11 dated 1/12/14 at 11:45 a.m. and 1:45 p.m. revealed the orders had been cosigned by the physician but the authentication had not been dated or timed.
Review of 2 verbal/telephone orders for Patient #11 dated 1/9/15 at 9:30 a.m. revealed the order had been cosigned by the physician but the authentication had not been dated or timed.

Patient #12
Review of Patient #12's medical record revealed the following incomplete entries:
History and Physical dated 12/18/14 signed by physician, but not dated or timed.
Occupational therapy orders dated 12/18/14 not signed, dated and/or timed by the physician.
Physician verbal order dated 1/8/15 signed by physician, but not dated or timed.

Patient #13
Review of Patient #13's medical record revealed the following incomplete entries:
Physician Admit/Resumption of Care orders dated 12/04/2014 not authenticated by the physician.
Wound care orders dated 12/04/2014 not authenticated by the physician.
Dialysis medication orders dated 12/04/2014 not authenticated by the physician.

Patient #16
Review of Patient #16 ' s medical record revealed an admission date of 12/30/14 with diagnoses including the following: Pneumonia, Multiple Pressure Ulcers, Infected Wound and Malnutrition.

Review of Patient #16 ' s Admit orders, written 12/30/14 as RBTO ( read back telephone order) had not been signed as of 1/14/15 (per hospital policy verbal orders must be signed within 10 days of being written).

In an on 1/14/15 at 1:30 p.m. interview with S2DON she confirmed all verbal orders must be signed by the physician within 10 days of being written.

Patient #17
Review of Patient #17's medical record revealed the following incomplete entries:
Physician Admit/Resumption of Care Orders dated 12/29/14 had been authenticated by the physician, but was not dated and/or timed.
Medication reconciliation form had been authenticated by the physician, and was not dated and/or timed.
Operative Note dated 01/12/15 had not been authenticated by the physician.
Verbal/telephone orders dated 01/12/15 revealed the orders had been authenticated by the physician but had not been dated and/or timed.

Patient #18
Review of Patient #18's medical record revealed the following incomplete entries:
Occupational Therapy orders dated 12/31/2014 not signed, dated, and/or timed by the physician.
Physical Therapy orders dated 1/6/2015 not signed, dated, and/or timed by the physician.

Interview with S2DON on 1/14/2015 at 2:10 p.m. confirmed that all orders should be authenticated dated and timed.


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30984




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Based on record review and staff interview, the hospital failed to ensure the completion of History & Physical examinations within 24 hours of admission for 2 (#16, #18) of 20 patients reviewed for History & Physical examinations out of a total sample of 31 patients.

Findings:

Patient #16
Review of the medical record for Patient #16 revealed an admission date of 12/30/2014 with the following diagnoses: Pneumonia, Multiple Pressure Ulcers, Infected Wound, and malnutrition.

Further review of the medical record revealed the admit History and Physical was dictated on 1/3/15 and transcribed on 1/4/15. The History and Physical was signed by the physician on 1/5/15.

Patient #18
Review of the medical record for patient #18 revealed the patient was a 65 year old male admitted to the hospital on 12/30/2014 with diagnoses of Pneumonia, Pressure Ulcer, Hypertension, and Pleural Effusion.

Further review of the medical record revealed the admit History and Physical was dictated and transcribed on 1/3/2015. The History and Physical was signed by the physician on 1/4/2015.

Interview with the S2DON on 1/14/2015 at 1:15 p.m. confirmed the admit History and Physical on Patient #16 and #18 should have been completed within 24 hours of admission.


30984

Based on policy review, observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area and locked. This is evidenced by a crash cart and a medication cart being unlocked in an unsupervised area.

Findings:

Review of the hospital policy titled Storage and Control of Medications, Policy Number: 9-4.14.0, revealed in part:
All medications including nonprescription medications are kept in a locked room, locked automated medication dispensing cabinet or locked medication cart that is located near the nurses ' station to ensure appropriate surveillance by hospital personnel.

In an observation on 1/12/15 at 2:10 p.m. of a crash cart on the back hall, there was a lock on the cart, but the drawers were still able to be opened without breaking the lock. The top drawer contained the following medications:

six Epinephrine 1:10,000, two 2% Lidocaine 0.1mg (milligrams)/ml 9 milliliter), four Atropine Sulfate 0.1mg/ml, 2-8.4% Sodium Bicarbonate 1mEq (milliequivalent)/ml, 2-50% Dextrose 0.5 g (grams)/ml, 2-10% Calcium Chloride, 2-Verapamil 5mg/2ml, Diphenhydramine 50mg/ml, 3- Levophed 1mg/ml, 2- Etamidate 20mg/ 10ml, 4-Pitressin 20u/ml, 3- Metoprolol 1mg/ml, Neostigmine, 2- Naloxone HCl 0.4mg/ml, 2- Magnesium Sulfate 1gm/2ml, Phenylephrine Hydrochloride 10mg/ml, 9- Amodorone 150mg/3ml, and 2- Procainamide 1gm/10ml.

In an observation on 1/12/15 at 2:30 p.m. of a medication cart on the back hallway, there was no nurse in the hallway near the cart. The drawers were able to be opened and 1 drawer contained 1-20ml vial of Acetylcystine. Another drawer contained Azelastine Hydrochloride and Polyethylene Glycol.

In an interview on 1/12/15 at 2:14 p.m. with S3RN, she verified the crash cart could be opened without breaking the lock. S3RN also verified patients, visitors and staff had unsupervised access to the hallway and the crash cart.

In an interview on 1/12/15 at 2:35 p.m. with S7LPN, she verified the medication carts should not have been unlocked when staff was not present.

Based on policy review, observation and interview, the hospital failed to ensure opened multi dose medications were dated and timed when opened to ensure they were not used beyond the expiration date as per hospital policy.
Findings:
Review of the hospital policy titled Storage and Control of Medications, Policy Number: 9-4.14.0, revealed in part:
Medications are accurately labeled with expiration dates.
Multiple use sterile products shall be initiated and dated with the " beyond use date " when first opened or entered. The " beyond-use date " after initially entering or opening a multiple use sterile product is a maximum of 28 days unless the manufacturer recommends a shorter time period.
Non-sterile multi-dose containers shall be initiated and dated with the "beyond-use date" when first opened or entered. The "beyond-use date" after initially entering or opening a bulk multi-dose container is a maximum of 90 days unless the manufacturer recommends a shorter time period.

An observation of the medication room on 1/12/15 at 2:00 p.m. revealed a vial of Regular Insulin that had been opened but not dated or timed.

An observation of the wound care cart revealed 2- Gentamycin Sulfate Creams and a Solosite Wound Gel that had been opened but not dated or timed.

In an interview on 1/12/15 at 2:05 p.m. with S4RN/ADON, he verified the above mentioned medications should have been timed and dated when opened.

Based on policy review, record review and interview, the hospital failed to ensure medication errors and physician notifications of errors were documented in the patient ' s medical record for 2 (#R1, #R2) of 2 known medical errors reviewed.

Findings:

Review of the hospital policy titled Medication Variance, Policy Number: 9-4.15.0, revealed in part:
Protocol for Reporting Medication Variances: The drug administered in error/omitted and the action taken should be documented in the patient ' s medical record.

Review of a hospital Document titled Risk Management revealed in part:
Patient #R1- On 8/7/14 when rounding found wrong medication hanging on IV (intravenous) pole (bag was empty with another patient's sticker on it).
Patient #R2 - On 9/15/14 the nurse administered Ampicillin IVPB (Intravenous Piggy Back) ½ bag to this pt (patient) in error. This med (medication) was not ordered for this pt.

Review of the medical records for Patient #R1 and #R2 revealed no documentation of the above mentioned medication errors or physician notification.

Based on record reviews and staff interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards for the safety of staff and patients during radiological procedures performed in the hospital by Hospital A. Findings:

Review of the contracts provided by S2DON revealed the hospital had a contract with Company A to provide Radiology services to the hospital.

Review of the hospital's policy and procedure manuals provided by S2DON as the hospital's current policies revealed no documented evidence of any policies and procedures related to radiology services.

In an interview on 01/14/15 at 10:30 a.m., S1Administrator confirmed the hospital had no Policies and Procedures that addressed proper safety of staff and patients during radiological procedures preformed in the hospital by Hospital A.

Based on record review and interview, the hospital failed to ensure contracted Radiologic services were supervised by a qualified Radiologist on either a full-time, part-time or consulting basis as evidenced by failing to appoint a qualified Radiologist to supervise the hospital's Radiologic Services.

Findings:

Review of the hospital's organizational chart revealed no documented evidence that a credentialed Radiologist had been appointed by the Governing Body to supervise Radiology Services.

In an interview 1/12/15 at 2:00 p.m. with S1Administrator, she confirmed the Governing Body had not appointed a Medical Director of Radiology. She indicated that the service was provided through contractual agreement and was not aware that a Director of Radiology was required for this contracted service.

Based on policy review, observation and interview, the infection control officer failed to implement a system for identifying and controlling infections. This deficient practice is evidenced by:
1) failing to ensure staff performed hand hygiene before donning or after removing gloves;
2) failing to ensure sharps containers were emptied to prevent potential needle sticks.

Findings:

1) Failing to ensure staff performed hand hygiene before donning or after removing gloves.

In an observation on 1/12/15 at 2:25 p.m., S9MD was examining Patient #17 without wearing gloves. S9MD left Patient #17 ' s room and did not sanitize or wash his hands. He then returned to the nurse ' s station and began charting.

In an observation on 1/12/15 at 2:30 p.m. S10HK(housekeeping) was carrying a trash bag into the dirty linen room. S10HK then removed her gloves and did not wash or sanitize her hands.

An observation on 1/13/15 at 10:00 a.m. revealed S11LPN did not wash his hands before performing a blood glucose level on a patient.

In an observation on 1/13/15 at 10:50 a.m., S5WoundCare was changing dressings on Patient #11 ' s right and left foot. S5WoundCare alternated between clean and dirty activities multiple times during the procedure. S5WoundCare changed her gloves 32 times during the procedure but washed / sanitized her hands only once.

In an observation on 1/13/15 at 3:52 p.m., S18RT suctioned Patient #17. He then removed his gloves and donned new gloves without washing or sanitizing his hands. He then started a respiratory treatment on Patient #17 ' s tracheostomy. S18RT then removed his gloves and removed a piece of paper from his pocket. S18RN then donned new gloves and discontinued the respiratory treatment.

In an observation on 1/14/15 at 12:35 p.m., S14RT provided tracheostomy care to Patient #17. S14RT did not wash or sanitize her hands before donning gloves or after removing her gloves.

An observation on 1/14/15 at 12:40 p.m. revealed S12RN exited Patient #13 ' s room who was on contact precautions for Vancomycin Resistant Enterococcus and Acinetobacter. S12RN was not wearing gloves or a gown and was holding Patient #13 ' s food tray against her chest. She then placed the tray on a shelf used for charting before bringing it to a dirty supply cart.

In an interview on 1/14/15 at 12:45 p.m. with S2DON, she said S12RN should have been wearing gloves while she handled Patient #13 ' s tray. S2DON also verified staff should have washed their hands when removing gloves.

2) Failing to ensure sharps containers were emptied to prevent potential needle sticks.

An observation of the medication room on 1/12/15 at 2:00 p.m. revealed a sharps container that was full to the opening. Further observation revealed the sharps containers in the nurse ' s station, Room 312, Room 318, Room 319 and the medication cart were full above the fill line.

In an interview on 1/12/15 at 2:05 p.m. with S4RN/ADON, he verified the sharps containers should not have been filled above the fill line.

In an interview on 1/12/15 at 3:34 p.m. with S2DON, she said she thought there was a contract with a local company to empty the sharps containers twice per week.

In an interview on 1/13/14 at 10:23 a.m. with S6HKSup, he verified he was the supervisor of the contracted housekeeping service for the hospital. He said there was a miscommunication between housekeeping and the hospital. S6HKSup said he thought the contracted company emptied the sharps containers on the unit twice per week, but in reality the hospital should have called housekeeping to collect the containers when they were full.