HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement as evidenced by:

1) Failing to develop quality indicators that could be used to measure, analyze, and track performance to assess processes of care and all hospital services as evidenced by failure to have identified indicators for safety, medical records, utilization management, medical staff, pharmacy, and contracted services of bio-hazardous waste, ambulance service, LOPA (Louisiana Organ Procurement Agency), laundry, food service, ultrasound services, transportation services, dialysis services, and generator maintenance as addressed in the hospital's policy for Continuous Performance Improvement (CPI). (see findings in tag A0273)

2) Failing to ensure that the hospital's Continuous Performance Improvement (CPI) Plan 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 CPI Plan. (see findings in tag A0308)

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

1) Failing to develop a system to ensure that the medical staff appointed/reappointed the medical staff every 2 years as required by the Medical Staff Bylaws as evidenced by failure to have documented evidence of current appointment/reappointment to the medical staff for 1 of 1 allied health professional (S6) from a total of 1 allied health professional on the medical staff and 5 of 5 physicians (S7, S8, S9, S10, S11) from a total of 5 physicians on the medical staff. (see findings in tag A0341)

2) Failing to implement its system for ensuring that physicians and allied health professionals appointed to the medical staff were granted specific privileges that were requested and approved by the Medical Staff for 1 of 1 allied health professional (S6) from a total of 1 allied health professional on the medical staff and 5 of 5 physicians (S7, S8, S9, S10, S11) from a total of 5 physicians on the medical staff. (see findings in tag A0363)

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

1) Failing to supervise and evaluate the nursing care of each patient as evidenced by:
a) The RN failed to ensure that the blood sugar accuchecks for patients with physician orders for sliding scale insulin was performed by a nurse and not delegated to a certified nursing assistant (CNA) as required by the Louisiana State Board of Registered Nursing's Nurse Practice Act for 2 of 2 inpatients with orders for sliding scale insulin and blood sugar accuchecks (#1, #18) from a total of 4 inpatients and for 3 of 3 discharged patients' medical records reviewed for blood sugar accuchecks and sliding scale insulin orders (#5, #7, #12) from a total sample of 20 patients.
b) The hospital failed to include in its policy the components to be included in a thorough assessment of wounds which resulted in Patient #1 having no documented evidence of a measurement of a Stage II pressure ulcer identified upon admit on 10/17/13 with no measurement documented for the following 11 days.
c) The RN failed to administer CPR (cardiopulmonary resuscitation) for a patient who expired and did not have a physician's order not to resuscitate for 1 of 1 patient's record reviewed who had expired from a total sample of 20 patients (#15). This had the potential to affect the 4 current inpatients and any future patient admitted to the hospital. (see findings in tag A0395)

2) Failing to ensure the nursing care of each patient was assigned by the registered nurse (RN) to nursing staff who were determined to be competent as evidenced by failure to have documented competency evaluations of the nursing staff prior to performing patient care for 5 of 5 RNs' (S2, S3, S4, S17, S18) and 2 of 2 LPNs' (licensed practical nurses) (S19, S20) personnel files reviewed for competency from a total of 5 employed RNs and 4 employed LPNs. (see findings in tag A0397)

3) Failing to ensure medications were administered as ordered by the physician for 1 of 4 inpatients (#1) and 1 of 5 discharged patients (#5) whose records were reviewed for medication administration from a total sample of 20 patients. This resulted in 10 medication administration errors that were identified during the survey that had not been identified by the hospital (9 errors for one inpatient in a period of 11 days). (see findings in tag A0405)

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

1) Failing to ensure that patients' medical records were stored in a manner to protect them from water damage in the event that the sprinkler system in Room "p" would activate by having medical records stored in 9 copy paper boxes (containing about 168 records) stacked on the floor in Room "p", 25 medical records stacked on a table in Room "p", and 215 medical records stored on open shelving in Room "p". There was a wooden cabinet in Room "p" that was filled with patients' medical records that was not constructed with fire-retardant or fire-proof lumber. (see findings in tag A0438)

2) Failing to have a system in place to determine which medical records were complete and which patient medical records were not completed no later than 30 days after discharge. (see findings in tag A0438)

3) Failing to ensure the medical record staff member was oriented and assessed for competency to perform the job duties required in the medical record department for 1 of 2 medical record staff members' personnel files reviewed from a total of 2 medical record staff members (S5). (see findings in tag A0432).

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 ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A0546)

2) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company B. (see findings in tag A0536)

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

1) Failing to ensure there was a designated full-time employee who served as the director of the food and dietetic services (dietary manager), was responsible for the daily management of the dietary services, and was qualified by experience or training. There was no staff member listed on the employee roster with the duty of dietary manager. (see findings in tag A0620)

2) Failing to ensure there were competent staff assigned to the duties of the dietary services provided by the hospital as evidenced by having no designated staff member trained and determined to be competent in the required tasks related to dietary services. (see findings in tag A0622)

3) Failing to develop screening criteria to identify patients at nutritional risk. (see findings in tag A0628)

4) Failing to maintain a current therapeutic diet manual approved by the dietitian and the medical staff that was readily available to all nursing personnel as evidenced by the therapeutic diet manual available to staff being from 2001. (see findings in tag A0631)

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

1) Failing to have a UR (Utilization Review) committee/group that consisted of 2 or more practitioners to carry out the UR functions. This failed practice was evidenced by no documented evidence of a hospital UR committee or a group outside of the hospital established to carry out the UR functions. (see findings in tag A0654)

2) Failing to have a UR (Utilization Review) plan that provided for review of medical necessity for Medicare /Medicaid patients in regards to admissions, duration of stay, and professional services provided. This failed practice was evidenced by no documented evidence of a UR plan. (see findings in tag A0655)

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

1) Failing to have a designated infection control officer who had specialized training in infection control. This failed practice was evidenced by no documented evidence of the infection control officer having any specialized training or previous work experience related to infection control activities. (see findings in Tag A-0748)

2) Failing to implement its system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and employees as evidenced by:
a) Failing to maintain a sanitary environment by having rooms that were identified by S1Administrator as ready for occupancy with empty glove boxes, used box of Kleenex, soiled over-bed tables, no paper towels in the bathroom, soiled toilet bowl, sink bowl with dried particles near the drain, used bath basin in the bathroom, trash baskets with used paper towels, shower room with used single-use patient items on the counter, and equipment stored in patient rooms. The gym had a loose rubber seal on the high-low table and an exercise bike seat with a one-half inch tear that prevented both items from being able to assure that they could be disinfected properly after each patient's use.
b) Failing to develop and implement a system for active surveillance of hand hygiene by the staff that resulted in an observation of breaches in hand hygiene by S4Registered Nurse (RN) during a skin assessment of Patient #1 on 10/29/13.
c) Failing to ensure that all employees received annual infection control education at the time of orientation and at least annually thereafter as required by hospital policy for 13 of 16 employees' files reviewed for infection control education from a total of 32 employees (S2, S4, S12, S13, S14, S15, S16, S17, S18, S19, S20, S21, S22).
d) Failure of the infection control officer to conduct an active infection control surveillance program by failing to develop a system for identifying, reporting, investigating and controlling infections. (see findings in tag A0749)

Based on record reviews and interviews, the governing body failed to ensure a system was developed for the appointment/reappointment of the medical staff after considering the recommendations of the existing medical staff members every 2 years as required by the Medical Staff Bylaws. The hospital failed to have documented evidence of appointment/reappointment to the medical staff for 1 of 1 allied health professional (S6) from a total of 1 allied health professional on the medical staff and 5 of 5 physicians (S7, S8, S9, S10, S11) from a total of 5 physicians on the medical staff.
Findings:

Review of the Medical Staff Bylaws and Rules and Regulations, approved by the Governing Body on 06/01/11 and presented as the current Medical Staff Bylaws by S1Administrator, revealed that initial appointments are provisional for a period of one year and may be renewed for an additional year. Reappointment will be for a period of not more than 2 years. Every initial application for staff appointment and reappointment application or application for clinical privileges must contain a request for the specific clinical privileges desired by the applicant. The granting of temporary privileges is solely discretionary and may be terminated at any time. Temporary privileges may be granted for no longer than 1 year unless renewed. Further review revealed that all applications for appointment/clinical privileges will be submitted on the form designated by the Medical Executive Committee (MEC) and the Governing Board. The application will be investigated thoroughly, and within 30 days of receipt of all relevant recommendations, the Credentials Committee will forward to the MEC the complete application, the Committee report, and a recommendation regarding staff appointment and privileges. When the recommendation of the MEC is favorable to the practitioner, the Chief Executive Officer will forward it with all supporting documentation to the Board for approval. In order to continue appointment and clinical privileges the practitioner must reapply and be reviewed every 2 years. All applications for reappointment will be submitted on the form designated by the MEC and approved by the Board. Review of the entire Medical Staff Bylaws revealed no documented evidence of what processes or sites would be queried as part of the investigation of the application.

Review of the "Medical Staff Application and Privilege Delineations Instructions" revealed the following items are required and must be submitted with the application:
1) Current copy of Curriculum Vitae
2) Current Louisiana State medical License
3) Other current state medical licenses
4) DEA (Drug Enforcement Administration) Registration
5) State Narcotics Registration
6) Malpractice Liability Information
7) Continuing Medical Education (CME) credits or certificates for the last 2 years or sign the CME attestation form.

S6NP (nurse practitioner)
Review of S6NP's credentialing file revealed an application dated 07/12/10. Further review revealed a NPDB (National Practitioner Data Bank Healthcare Integrity and Protection Data Bank) query had been processed on 07/22/10. Review of the "Letter of Approval" revealed S6NP was initially appointed 07/22/10 and privileges granted for January 2011 through January 2013. Further review revealed no documented evidence that S6NP had applied for reappointment and been approved for reappointment prior to the expiration of his initial appointment to the medical staff. There was no documented evidence of a Collaborative Practice Agreement with a supervising physician.

S7Physician
Review of S7Physician's credentialing file revealed two "Letter of Approval" forms dated 06/11, one showing an initial appointment date of 07/01/11 for temporary privileges from July 2011 through July 2012 and one showing an initial appointment of 2011, reappointment date 2013, temporary "N/A" (not applicable), and privileges granted "Yes". S7Physician's application was dated 06/07/11. There was no documented evidence that S7Physician had applied for reappointment and been approved for reappointment prior to the expiration of his initial appointment to the medical staff. Further review of his file revealed his CDS (Controlled Dangerous Substance) license had expired on 07/01/13, and his malpractice liability insurance had expired on 05/25/13.

S8Physician
Review of S8Physician's credentialing file revealed he was reappointed 02/11 with privileges granted from February 2011 through February 2013. Further review revealed his application was dated 02/15/10 with no documented evidence of a completed application for his appointment in February 2011. There was no documented evidence that S8Physician had applied for reappointment and been approved for reappointment prior to the expiration of his appointment to the medical staff in February 2013. Review of his CDS license revealed it had expired on 07/01/13.

S9Medical Director
Review of S9Medical Director's credentialing file revealed a "Letter of Approval" dated 04/13 by S1Administrator with a reappointment date of "10/2011-2013". Further review revealed her application was dated 09/30/09. There was no documented evidence of an application completed for 2011 and 2013 as required by the Medical Staff Bylaws prior to S9Medical Director being reappointed. Review of her DEA registration revealed it had expired on 06/30/13, and CDS license had expired on 06/01/13. Review of her medical license in her credentialing file revealed that it had expired on 01/31/12 (which was expired when she was reappointed in April 2013.

S10Physician
Review of S10Physician's credentialing file revealed a "Letter of Approval" dated October 2010 with privileges granted from October 2010 through October 2012. Further review revealed a "Verification of Affiliation" dated 03/20/12 and signed by S1Administrator that stated his initial appointment was 2012 and his reappointment date was 2013 (no documented evidence of the day and month). S10Physician's application for appointment was dated 10/29/09. There was no documented evidence of a current application for reappointment prior to his appointment expiring in October 2012. Further review of his file revealed that the copy of his medical license in his credentialing file had expired 05/31/13, and CDS license had expired 06/01/13.

S11Physician
Review of S11Physician's credentialing file revealed a "Letter of Approval" dated 11/01/10 with a reappointment date of November 2010 and privileges granted from November 2010 through November 2012. Review of his application for appointment revealed it was dated 11/13/09. There was no documented evidence of a current application for reappointment prior to his appointment expiring in November 2012. Further review of his file revealed the copy of his license verification showed that his medical license had expired on 05/13/13, his CDS license had expired on 08/01/13, and his malpractice liability insurance coverage had expired on 07/03/13.

In a face-to-face interview on 10/30/13 at 1:35 p.m., S1Administrator indicated that she was responsible for the credentialing of the medical staff since there had been recent staff changes. She further indicated that she had not had any training in the credentialing process. She indicated that there had been a system in place for the tracking of current licensure of the medical staff, but the person who had been assigned this duty had recently left the hospital.

Based on record reviews and interviews, the governing body failed to ensure the system for ensuring that physicians and allied health professionals appointed to the medical staff were granted specific privileges that were requested and approved by the Medical Staff was implemented for 1 of 1 allied health professional (S6) from a total of 1 allied health professional on the medical staff and 5 of 5 physicians (S7, S8, S9, S10, S11) from a total of 5 physicians on the medical staff.
Findings:

Review of the Medical Staff Bylaws and Rules and Regulations, approved by the Governing Body on 06/01/11 and presented as the current Medical Staff Bylaws by S1Administrator, revealed that every initial application for staff appointment and reappointment application or application for clinical privileges must contain a request for the specific clinical privileges desired by the applicant. Further review revealed that all applications for appointment/clinical privileges will be submitted on the form designated by the Medical Executive Committee (MEC) and the Governing Board. The application will be investigated thoroughly, and within 30 days of receipt of all relevant recommendations, the Credentials Committee will forward to the MEC the complete application, the Committee report, and a recommendation regarding staff appointment and privileges. When the recommendation of the MEC is favorable to the practitioner, the Chief Executive Officer will forward it with all supporting documentation to the Board for approval. In order to continue appointment and clinical privileges the practitioner must reapply and be reviewed every 2 years.

Review of the "Medical Staff Application and Privilege Delineations Instructions" revealed the applicant was to check off the privileges he/she was requesting and sign the privilege forms.

S6NP (nurse practitioner)
Review of S6NP's credentialing file revealed a "Medical Staff Privileging Form" for core privileges with a check mark in the requested column and a check mark in the approved column. Further review revealed S7NP signed the form on 07/06/10, and there was no documented evidence that the form had been signed and dated as approved by the Credentials Chairman, the Medical Executive committee (MEC), and the Governing Board. Review of S6NP's file revealed no documented evidence that he had ever been granted specific privileges as a NP by the MEC and the Governing Board.

S7Physician
Review of S7Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the column for core privileges for Internal Medicine. There was no documented evidence that S7Physician had ever been granted specific privileges in Internal Medicine by the MEC and Governing Board.

S8Physician
Review of S8Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Family Medicine and a check mark in the approved column. Further review revealed the form was signed by S8Physician on 02/19/10 and the Credentials Chairman on 03/11/10. Further review revealed the date of 03/11/10 was written in the blanks for MEC and Governing Board review and approval with no documented evidence of a signature by a representative of the MEC and Governing Board. Review of S8Physician's credentialing file revealed no documented evidence that he had ever been granted specific privileges for Family Medicine by the MEC and Governing Board.

S9Medical Director
Review of S9Medical Director's credentialing file revealed her "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Physiatry (doctor who specializes in physical medicine) and a check mark in the approved column. Further review revealed the form was signed by S9Medical Director on 09/30/09 and the Credentials Chairman on 10/03/09. Further review revealed the date of 10/03/09 was written in the blanks for MEC and Governing Board review and approval with no documented evidence of a signature by a representative of the MEC and Governing Board. Review of S9Medical Director's credentialing file revealed no documented evidence that she had ever been granted specific privileges for Physiatry by the MEC and Governing Board.

S10Physician
Review of S10Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Family Medicine and a check mark in the approved column. Further review revealed the form was signed by S10Physician on 10/28/09 and the Credentials Chairman on 03/05/10. Further review revealed the date of 03/05/10 was written in the blanks for MEC and Governing Board review and approval with no documented evidence of a signature by a representative of the MEC and Governing Board. Review of S10Physician's credentialing file revealed no documented evidence that he had ever been granted specific privileges for Family Medicine by the MEC and Governing Board.

S11Physician
Review of S11Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Physical Medicine and a check mark in the approved column. Further review revealed the form was signed by S11Physician on 11/13/09 and the Credentials Chairman with no documented evidence of the date the Credentials Chairman reviewed and signed the form. Further review revealed no documented evidence that the privileges had been reviewed and approved by the MEC and Governing Board as evidenced by the lines for their signature and date being blank. Review of S11Physician's credentialing file revealed no documented evidence that he had ever been granted specific privileges for Physical Medicine by the MEC and Governing Board.

In a face-to-face interview on 10/30/13 at 1:35 p.m., S1Administrator indicated that she was responsible for the credentialing of the medical staff since there had been recent staff changes. She further indicated that she had not had any training in the credentialing process. S1Administrator offered no explanation for core privileges being used rather than specific privileges as required by the regulation and Medical Staff Bylaws.

Based on record reviews and interview, the governing body failed to develop a system to ensure that the services performed under a contract were provided in a safe and effective manner as evidenced by failure to ensure that every contracted service is evaluated through its quality assessment and performance improvement (QAPI) plan.
Findings:

Review of the "Amended Governing Board By-laws", presented as the current by-laws by S1Administrator, revealed that the Governing Board shall ensure that there is an effective, written, ongoing, hospital-wide program designed to assess and improve the quality of patient care, with participation of members of management of the hospital, shall set goals, formulate plans, and develop and implement procedures for quality assessment and continuing performance improvement of the hospital's governance, management, clinical, and support processes. Further review revealed that that all contractors of services would provide services in a safe and effective manner that permits the hospital to meet the needs of its patients and to comply with applicable federal and state laws and regulations and with professional standards for the contracted services.

Review of the hospital's CPI Plan, presented as the current plan by S1Administrator, revealed that the CPI Plan encompasses all areas of patient care and hospital services and included clinical and non-clinical areas. The Medical Staff and all hospital departments, directly and indirectly affecting patient care, shall participate in performance improvement activities including the Medical Staff, Risk Management, Safety, Infection Control, Physical Therapy, Nutritional Services, Medical Records, Nursing Services, Utilization Management, Human Resources, Respiratory Care, Pharmacy, Laboratory Services, Radiology, and other contracted services.

Review of the CPI meeting minutes presented by S1Administrator for January 2013 through September 2013 revealed no documented evidence that quality indicators had been developed for safety, medical records, utilization management, medical staff, pharmacy, and contracted services of bio-hazardous waste, ambulance service, LOPA Louisiana Organ Procurement Association), laundry, food service, ultrasound services, transportation services, dialysis services, and generator maintenance as required by the hospital's CPI Plan.

Review of the contract with Hospital A to provide lab services revealed no documented evidence that a representative of Hospital A had signed the contract when S2Director of Nursing (DON) signed the contract on 06/28/10.

Review of the contract with Company A for laundry services revealed the term of the agreement was for a period of one commencing on 09/01/09 and would automatically renew for a period of one year. There was no documented evidence that the contract had been renewed after 09/01/11 when it expired.

Review of the contract for food services with Hospital B revealed no documented evidence that a representative of Hospital B had signed the contract when S2DON had signed the contract on 12/14/09. Review of the hospital's policy titled "Dietary Procedures", contained in the manual presented by S1Administrator as the current hospital policies and procedures, revealed that food will be prepared by Nursing Home A with whom the hospital did not have a contract (food services was being provided by Hospital B).

Review of the contract for radiology services with Company B effective 10/24/05 revealed the term of the agreement would remain in effect for an initial term of one year. Unless either party elected to terminate the agreement at the end of the original or any renewal term by giving written notice at least thirty days prior to the expiration of the then-current term, the agreement shall be deemed to have automatic renewal for an additional term of one year. There was no documented evidence that the contract was renewed when it expired on 10/24/07.

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated that the contracts had not been evaluated to determine that the contracted services had been provided in a safe and effective manner. She further indicated that she was not aware of the expired contracts as listed above.

Based on record review and interview, the hospital failed to ensure its grievance policy included information relative to whom a grievance can be reported, the process for filing a grievance either verbally or in writing, the phone number and address for lodging a grievance with the State agency, and the timeframe in which the grievance will be handled.
Findings:

Review of the hospital's policy titled "Grievance/Complaint Policy (Patient, Family, Visitor)",
contained in the policy manual presented as the current policies by S1Administrator, revealed that a grievance was defined as any written complaint by a patient, family, or visitor relating to the patient care, quality of medical services, physical plan and/or staff treatment. There was no documented evidence that a grievance could be submitted verbally, to whom the patient, visitor, or family could report a grievance, the timeframe in which the grievance will be handled, and the phone number and address for lodging a grievance with the State agency.

In a face-to-face interview on 10/31/13 at 1:35 p.m., S1Administrator offered no explanation for the hospital's grievance policy not allowing a grievance to be submitted verbally, not designating with whom a grievance can be filed, the timeframe allowed for handling a grievance, and the phone number and address of the State agency for lodging a grievance.

Based on record review and interview, the hospital failed to ensure its grievance policy provided for the patient to receive written notice of its decision that contains the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.
Findings:

Review of the hospital's policy titled "Grievance/Complaint Policy (Patient, Family, Visitor)",
contained in the policy manual presented as the current policies by S1Administrator, revealed that once the investigation was complete, communication of the outcome of the investigation and response/resolution of the concern will be shared with the complainant as well as hospital and medical staff involved in the complaint. Further review of the entire policy revealed no documented evidence that the policy required the notification to the patient be in writing and included at a minimum the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

In a face-to-face interview on 10/31/13 at 1:35 p.m., S1Administrator offered no explanation for the hospital's grievance policy not including that at the conclusion of the investigation of the grievance the patient would be notified in writing the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

Based on observation and interview, the hospital failed to ensure a patient's right to privacy during a skin assessment by having the room's window blinds open with visibility from the outside into the room and having no protection from visibility by anyone walking in the public hall outside the patient's room from an approximate 2 inch by 3 foot glass panel in the room door for 1 of 1 patient observed during a dressing change from a total sample of 20 patients (#1).
Findings:

Observation on 10/29/13 at 10:30 a.m. during Patient #1's skin assessment performed by S4RN (registered nurse) revealed the window blinds were open with visibility into the room from outdoors. Further observation revealed the entrance door to the patient's room had an approximate 2 inch by 3 foot glass pane in the door that allowed one to see into the hall from the room and someone in the hall to see into the room. During the observation S4RN rolled Patient #1 to his right side with his buttocks exposed while she turned her back and stepped away to wet the cleaning cloth leaving his buttocks exposed to visibility by anyone walking in the hall through the pane of glass in the door.

In a face-to-face interview on 10/29/13 at 11:45 a.m., Patient #1 confirmed that S4RN did not ask him if he wanted visual privacy during his skin assessment.

In a face-to-face interview on 10/29/13 at 11:50 a.m., S4RN offered no comment or explanation when informed of the lack of visual privacy provided to Patient #1 during his skin assessment.

Based on record review and interview, the hospital failed to develop quality indicators that could be used to measure, analyze, and track performance to assess processes of care and all hospital services as evidenced by failure to have identified indicators for safety, medical records, utilization management, medical staff, pharmacy, and contracted services of bio-hazardous waste, ambulance service, LOPA (Louisiana Organ Procurement Agency), laundry, food service, ultrasound services, transportation services, dialysis services, and generator maintenance as addressed in the hospital's policy for Continuous Performance Improvement (CPI).
Findings:

Review of the hospital's CPI Plan, presented as the current plan by S1Administrator, revealed that the CPI Plan encompasses all areas of patient care and hospital services and included clinical and non-clinical areas. The Medical Staff and all hospital departments, directly and indirectly affecting patient care, shall participate in performance improvement activities including the Medical Staff, Risk Management, Safety, Infection Control, Physical Therapy, Nutritional Services, Medical Records, Nursing Services, Utilization Management, Human Resources, Respiratory Care, Pharmacy, Laboratory Services, Radiology, and other contracted services.

Review of the CPI meeting minutes presented by S1Administrator for January 2013 through September 2013 revealed no documented evidence that quality indicators had been developed for safety, medical records, utilization management, medical staff, pharmacy, and contracted services of bio-hazardous waste, ambulance service, LOPA, laundry, food service, ultrasound services, transportation services, dialysis services, and generator maintenance as required by the hospital's CPI Plan.

In a face-to-face interview on 10/31/13 at 12:35 p.m., S1Administrator could offer no explanation for quality indicators not being developed for all services provided by the hospital either directly or by contract.

Based on interview, the hospital failed to conduct performance improvement projects.
Findings:

In a face-to-face interview on 10/31/13 at 12:35 p.m., S1Administrator indicated the hospital had not conducted any performance improvement projects.

Based on record reviews and interview, the governing body failed to ensure that the hospital's Continuous Performance Improvement (CPI) Plan 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 CPI Plan.
Findings:

Review of the hospital's CPI Plan, presented as the current plan by S1Administrator, revealed that the CPI Plan encompasses all areas of patient care and hospital services and included clinical and non-clinical areas. The Medical Staff and all hospital departments, directly and indirectly affecting patient care, shall participate in performance improvement activities including the Medical Staff, Risk Management, Safety, Infection Control, Physical Therapy, Nutritional Services, Medical Records, Nursing Services, Utilization Management, Human Resources, Respiratory Care, Pharmacy, Laboratory Services, Radiology, and other contracted services.

Review of the CPI meeting minutes presented by S1Administrator for January 2013 through September 2013 revealed no documented evidence that quality indicators had been developed for safety, medical records, utilization management, medical staff, pharmacy, and contracted services of bio-hazardous waste, ambulance service, LOPA, laundry, food service, ultrasound services, transportation services, dialysis services, and generator maintenance as required by the hospital's CPI Plan.

In a face-to-face interview on 10/31/13 at 1:40 p.m., S1Administrator could offer no explanation for all services and departments not being included in the CPI Plan.

Based on record reviews and interviews, the hospital failed to develop a system to ensure that the medical staff appointed/reappointed the medical staff every 2 years as required by the Medical Staff Bylaws as evidenced by failure to have documented evidence of current appointment/reappointment to the medical staff for 1 of 1 allied health professional (S6) from a total of 1 allied health professional on the medical staff and 5 of 5 physicians (S7, S8, S9, S10, S11) from a total of 5 physicians on the medical staff.
Findings:

Review of the Medical Staff Bylaws and Rules and Regulations, approved by the Governing Body on 06/01/11 and presented as the current Medical Staff Bylaws by S1Administrator, revealed that initial appointments are provisional for a period of one year and may be renewed for an additional year. Reappointment will be for a period of not more than 2 years. Every initial application for staff appointment and reappointment application or application for clinical privileges must contain a request for the specific clinical privileges desired by the applicant. The granting of temporary privileges is solely discretionary and may be terminated at any time. Temporary privileges may be granted for no longer than 1 year unless renewed. Further review revealed that all applications for appointment/clinical privileges will be submitted on the form designated by the Medical Executive Committee (MEC) and the Governing Board. The application will be investigated thoroughly, and within 30 days of receipt of all relevant recommendations, the Credentials Committee will forward to the MEC the complete application, the Committee report, and a recommendation regarding staff appointment and privileges. When the recommendation of the MEC is favorable to the practitioner, the Chief Executive Officer will forward it with all supporting documentation to the Board for approval. In order to continue appointment and clinical privileges the practitioner must reapply and be reviewed every 2 years. All applications for reappointment will be submitted on the form designated by the MEC and approved by the Board. Review of the entire Medical Staff Bylaws revealed no documented evidence of what processes or sites would be queried as part of the investigation of the application.

Review of the "Medical Staff Application and Privilege Delineations Instructions" revealed the following items are required and must be submitted with the application:
1) Current copy of Curriculum Vitae
2) Current Louisiana State medical License
3) Other current state medical licenses
4) DEA (Drug Enforcement Administration) Registration
5) State Narcotics Registration
6) Malpractice Liability Information
7) Continuing Medical Education (CME) credits or certificates for the last 2 years or sign the CME attestation form.

S6NP (nurse practitioner)
Review of S6NP's credentialing file revealed an application dated 07/12/10. Further review revealed a NPDB (National Practitioner Data Bank Healthcare Integrity and Protection Data Bank) query had been processed on 07/22/10. Review of the "Letter of Approval" revealed S6NP was initially appointed 07/22/10 and privileges granted for January 2011 through January 2013. Further review revealed no documented evidence that S6NP had applied for reappointment and been approved for reappointment prior to the expiration of his initial appointment to the medical staff. There was no documented evidence of a Collaborative Practice Agreement with a supervising physician.

S7Physician
Review of S7Physician's credentialing file revealed two "Letter of Approval" forms dated 06/11, one showing an initial appointment date of 07/01/11 for temporary privileges from July 2011 through July 2012 and one showing an initial appointment of 2011, reappointment date 2013, temporary "N/A" (not applicable), and privileges granted "Yes". S7Physician's application was dated 06/07/11. There was no documented evidence that S7Physician had applied for reappointment and been approved for reappointment prior to the expiration of his initial appointment to the medical staff. Further review of his file revealed his CDS (Controlled Dangerous Substance) license had expired on 07/01/13, and his malpractice liability insurance had expired on 05/25/13.

S8Physician
Review of S8Physician's credentialing file revealed he was reappointed 02/11 with privileges granted from February 2011 through February 2013. Further review revealed his application was dated 02/15/10 with no documented evidence of a completed application for his appointment in February 2011. There was no documented evidence that S8Physician had applied for reappointment and been approved for reappointment prior to the expiration of his appointment to the medical staff in February 2013. Review of his CDS license revealed it had expired on 07/01/13.

S9Medical Director
Review of S9Medical Director's credentialing file revealed a "Letter of Approval" dated 04/13 by S1Administrator with a reappointment date of "10/2011-2013". Further review revealed her application was dated 09/30/09. There was no documented evidence of an application completed for 2011 and 2013 as required by the Medical Staff Bylaws prior to S9Medical Director being reappointed. Review of her DEA registration revealed it had expired on 06/30/13, and CDS license had expired on 06/01/13. Review of her medical license in her credentialing file revealed that it had expired on 01/31/12 (which was expired when she was reappointed in April 2013.

S10Physician
Review of S10Physician's credentialing file revealed a "Letter of Approval" dated October 2010 with privileges granted from October 2010 through October 2012. Further review revealed a "Verification of Affiliation" dated 03/20/12 and signed by S1Administrator that stated his initial appointment was 2012 and his reappointment date was 2013 (no documented evidence of the day and month). S10Physician's application for appointment was dated 10/29/09. There was no documented evidence of a current application for reappointment prior to his appointment expiring in October 2012. Further review of his file revealed that the copy of his medical license in his credentialing file had expired 05/31/13, and CDS license had expired 06/01/13.

S11Physician
Review of S11Physician's credentialing file revealed a "Letter of Approval" dated 11/01/10 with a reappointment date of November 2010 and privileges granted from November 2010 through November 2012. Review of his application for appointment revealed it was dated 11/13/09. There was no documented evidence of a current application for reappointment prior to his appointment expiring in November 2012. Further review of his file revealed the copy of his license verification showed that his medical license had expired on 05/13/13, his CDS license had expired on 08/01/13, and his malpractice liability insurance coverage had expired on 07/03/13.

In a face-to-face interview on 10/30/13 at 1:35 p.m., S1Administrator indicated that she was responsible for the credentialing of the medical staff since there had been recent staff changes. She further indicated that she had not had any training in the credentialing process. She indicated that there had been a system in place for the tracking of current licensure of the medical staff, but the person who had been assigned this duty had recently left the hospital.

Based on record reviews and interviews, the hospital failed to implement its system for ensuring that physicians and allied health professionals appointed to the medical staff were granted specific privileges that were requested and approved by the Medical Staff for 1 of 1 allied health professional (S6) from a total of 1 allied health professional on the medical staff and 5 of 5 physicians (S7, S8, S9, S10, S11) from a total of 5 physicians on the medical staff.
Findings:

Review of the Medical Staff Bylaws and Rules and Regulations, approved by the Governing Body on 06/01/11 and presented as the current Medical Staff Bylaws by S1Administrator, revealed that every initial application for staff appointment and reappointment application or application for clinical privileges must contain a request for the specific clinical privileges desired by the applicant. Further review revealed that all applications for appointment/clinical privileges will be submitted on the form designated by the Medical Executive Committee (MEC) and the Governing Board. The application will be investigated thoroughly, and within 30 days of receipt of all relevant recommendations, the Credentials Committee will forward to the MEC the complete application, the Committee report, and a recommendation regarding staff appointment and privileges. When the recommendation of the MEC is favorable to the practitioner, the Chief Executive Officer will forward it with all supporting documentation to the Board for approval. In order to continue appointment and clinical privileges the practitioner must reapply and be reviewed every 2 years.

Review of the "Medical Staff Application and Privilege Delineations Instructions" revealed the applicant was to check off the privileges he/she was requesting and sign the privilege forms.

S6NP (nurse practitioner)
Review of S6NP's credentialing file revealed a "Medical Staff Privileging Form" for core privileges with a check mark in the requested column and a check mark in the approved column. Further review revealed S7NP signed the form on 07/06/10, and there was no documented evidence that the form had been signed and dated as approved by the Credentials Chairman, the Medical Executive committee (MEC), and the Governing Board. Review of S6NP's file revealed no documented evidence that he had ever been granted specific privileges as a NP by the MEC and the Governing Board.

S7Physician
Review of S7Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the column for core privileges for Internal Medicine. There was no documented evidence that S7Physician had ever been granted specific privileges in Internal Medicine by the MEC and Governing Board.

S8Physician
Review of S8Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Family Medicine and a check mark in the approved column. Further review revealed the form was signed by S8Physician on 02/19/10 and the Credentials Chairman on 03/11/10. Further review revealed the date of 03/11/10 was written in the blanks for MEC and Governing Board review and approval with no documented evidence of a signature by a representative of the MEC and Governing Board. Review of S8Physician's credentialing file revealed no documented evidence that he had ever been granted specific privileges for Family Medicine by the MEC and Governing Board.

S9Medical Director
Review of S9Medical Director's credentialing file revealed her "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Physiatry (doctor who specializes in physical medicine) and a check mark in the approved column. Further review revealed the form was signed by S9Medical Director on 09/30/09 and the Credentials Chairman on 10/03/09. Further review revealed the date of 10/03/09 was written in the blanks for MEC and Governing Board review and approval with no documented evidence of a signature by a representative of the MEC and Governing Board. Review of S9Medical Director's credentialing file revealed no documented evidence that she had ever been granted specific privileges for Physiatry by the MEC and Governing Board.

S10Physician
Review of S10Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Family Medicine and a check mark in the approved column. Further review revealed the form was signed by S10Physician on 10/28/09 and the Credentials Chairman on 03/05/10. Further review revealed the date of 03/05/10 was written in the blanks for MEC and Governing Board review and approval with no documented evidence of a signature by a representative of the MEC and Governing Board. Review of S10Physician's credentialing file revealed no documented evidence that he had ever been granted specific privileges for Family Medicine by the MEC and Governing Board.

S11Physician
Review of S11Physician's credentialing file revealed his "Medical Staff Privileging Form" had a check mark in the requested column for core privileges for Physical Medicine and a check mark in the approved column. Further review revealed the form was signed by S11Physician on 11/13/09 and the Credentials Chairman with no documented evidence of the date the Credentials Chairman reviewed and signed the form. Further review revealed no documented evidence that the privileges had been reviewed and approved by the MEC and Governing Board as evidenced by the lines for their signature and date being blank. Review of S11Physician's credentialing file revealed no documented evidence that he had ever been granted specific privileges for Physical Medicine by the MEC and Governing Board.

In a face-to-face interview on 10/30/13 at 1:35 p.m., S1Administrator indicated that she was responsible for the credentialing of the medical staff since there had been recent staff changes. She further indicated that she had not had any training in the credentialing process. S1Administrator offered no explanation for core privileges being used rather than specific privileges as required by the regulation and Medical Staff Bylaws.

Based on observation, record reviews, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient.
1) The RN failed to ensure that the blood sugar Accuchecks for patients with physician orders for sliding scale insulin was performed by a nurse and not delegated to a certified nursing assistant (CNA) as required by the Louisiana State Board of Registered Nursing's Nurse Practice Act for 2 of 2 inpatients with orders for sliding scale insulin and blood sugar Accuchecks (#1, #18) from a total of 4 inpatients and for 3 of 3 discharged patients' medical records reviewed for blood sugar Accuchecks and sliding scale insulin orders (#5, #7, #12) from a total sample of 20 patients.
2) The hospital failed to include in its policy the components to be included in a thorough assessment of wounds which resulted in Patient #1 having no documented evidence of a measurement of a Stage II pressure ulcer identified upon admit on 10/17/13 with no measurement documented for the following 11 days.
3) The RN failed to assess patients' weight and vital signs as ordered by the physician for 3 of 3 inpatients' records reviewed for assessment of weight and vital signs (#1, #2, #3) from a total sample of 20 patients.
4) The RN failed to assess a patient's blood sugar as ordered by the physician for 2 of 4 discharged patients' medical records reviewed for blood sugar Accuchecks performed according to physician orders (#5, #12) from a total sample of 20 patients.
5) The RN failed to ensure patients had physician orders for each lab specimen drawn for 1 of 3 inpatients' records reviewed for lab tests as ordered by the physician (#1) from a total sample of 20 patients.
6) The RN failed to administer CPR (cardiopulmonary resuscitation) for a patient who expired and did not have a physician's order not to resuscitate for 1 of 1 patient's record reviewed who had expired from a total sample of 20 patients (#15).
Findings:

1) The RN failed to ensure that the blood sugar Accuchecks for patients with physician orders for sliding scale insulin was performed by a nurse and not delegated to a certified nursing assistant (CNA) as required by the Louisiana State Board of Registered Nursing's Nurse Practice Act:
Review of the Letter of Opinion (identified as "npop95.04") from the Louisiana State Board of Nursing on 02/15/95 revealed the Board reaffirmed the February 1993 position on the delegation of bedside capillary blood glucose monitoring to unlicensed personnel which was as follows: "only routine one-touch glucose monitoring may be performed by unlicensed personnel. Unlicensed personnel may not perform one-touch monitoring when insulin to scale is ordered."

Review of the hospital policy titled "Glucose Monitoring", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence which staff member (nurse or CNA) could perform the Accucheck and whether the decision was based on whether the patient had physician orders for sliding scale insulin.

Review of the hospital policy titled "Abnormal Vital Signs And Capillary Blood Glucose", contained in the policy manual presented as the current policies by S1Administrator, revealed that the RN would recheck all abnormal capillary blood glucose and document the findings in the Nursing Narrative Notes.

Review of the medical records of Patient #1 and #18, current inpatients, and Patients #5, #7, and #12, discharged patients, revealed they had physician orders to obtain blood glucose Accuchecks (capillary blood glucose monitoring) either twice a day or before meals and at bedtime.

In a face-to-face interview on 10/29/13 at 3:45 p.m. with S2Director of Nursing (DON) and S3Assistant Director of Nursing (ADON) present, S3ADON indicated that the Accuchecks were being performed by the CNA, and she didn't know that the CNA couldn't perform Acuchecks for patients with physician orders for sliding scale insulin.

2) The hospital failed to include in its policy the components to be included in a thorough assessment of wounds:
Review of the hospital policy titled "Wound Care/Skin Breakdown", contained in the policy manual presented as the current policies by S1Administrator, revealed that a thorough assessment of the patient's skin will be done by the admitting RN. Further review revealed s Stage II wound was a shallow full thickness skin lesion that involved adipose tissue with complete loss of epidermal and dermal layers of skin. Further review revealed that documentation required was to obtain an order from the physician, write the order on the physician order sheet, and transcribe the order onto the Treatment Flow Sheet with the time and initial when the treatment was done. There was no documented evidence of the components of the skin assessment that was to be included in the documentation.

Review of the "Daily Skin Assessment" form in Patient #1's medical record revealed the following directions:
"Write the date at the top. Write in treatment times i.e. (such as) tid (three times a day) 8a-2p-8p (8:00 a.m.-2:00 p.m.-8:00 p.m.). Under wound number, write in where the wound is located. In the blanks under the appropriate day, write in the treatment that was performed on the wound. On the back is a narrative where you will write the initial assessment of the wound with measurements and the initial treatment performed. After the initial assessment, document daily what the wound looks like and if it is getting better or worse and if the physician was notified. Place a picture of the wound if needed and tape to the back. Draw arrows on the figures below and indicate the type of wound to each area."

Review of Patient #1's medical record revealed he was a 71 year old male admitted on 10/17/13 with diagnoses of Osteoarthritis, Generalized weakness, Coronary Atherosclerosis, Chronic Kidney Disease, Dementia Without Behavioral Disturbance, Gout, and Uncontrolled Insulin Dependent Diabetes Mellitus. Review of his "Daily Skin Assessment" completed on 10/17/13 through 10/26/13 revealed he had sacral redness, scabs to the left shin, and a Stage II pressure ulcer to the left inner buttock. Review of the "Daily Skin Assessment" for 10/17/13 through 10/26/13 and his "Nursing Narrative Notes" for the same dates revealed no documented evidence of the measurements of the Stage II wound to the left inner buttock.

Observation on 10/29/13 at 10:30 a.m. revealed S4RN measured Patient #1's Stage II pressure ulcer to the right inner buttock (not the left inner buttock as documented). The measurement was a 2.2 centimeters (cm) by 0.6 cm reddened area with a scab 1.2 cm by 0.5 cm in the center of the area.

In a face-to-face interview on 10/29/13 at 10/30 a.m., S4RN indicated the wound was a Stage II pressure ulcer.

In a face-to-face interview on 10/29/13 at 11:50 a.m. when asked how the nursing staff would know if a wound was improving or worsening, S4RN indicated that a "measurement would enhance", but she could visually see if there was improvement or not. When informed that the medical review of Patient #1's chart revealed no documented evidence of a measurement of the wound being done up to this day, S4RN offered no comment or explanation.

In a face-to-face interview on 10/29/13 at 3:45 p.m., S2DON indicated it was a "nursing impression" whether to measure a wound. When asked how one could tell if a wound was improving or getting worse without measurements, S2DON answered "by visualization."

3) The RN failed to assess patients' weight and vital signs as ordered by the physician:
Review of the hospital policy titled "Patients Weights", contained in the policy manual presented as the current policies by S1Administrator, revealed upon admission the nurse or assistant will weigh the patient, and the weight will be recorded on the graphics sheet. Weekly weights would be obtained thereafter, unless otherwise specified by the physician, and the weekly weight would be recorded on the graphics sheet. Further review revealed that weekly weights would be obtained on Saturday or Sunday.

Patient #1
Review of Patient #1's medical record revealed he was a 71 year old male admitted on 10/17/13 with diagnoses of Osteoarthritis, Generalized weakness, Coronary Atherosclerosis, Chronic Kidney Disease, Dementia Without Behavioral Disturbance, Gout, and Uncontrolled Insulin Dependent Diabetes Mellitus. Review of his physician admit orders dated 10/17/13 at 1:30 p.m. revealed orders to take vital signs every 8 hours for 24 hours, then every 12 hours, and record the vital signs on the graphic sheet. Further review revealed an order to weigh Patient #1 upon admission, weigh weekly thereafter, and record on the graphic sheet.

Review of Patient #1's "Nursing Narrative Notes" dated 10/17/13 from 6:00 a.m. to 6:00 p.m. revealed he was admitted to the unit on 10/17/13 at 1:30 p.m. Review of his graphic sheets revealed his vital signs were taken at 8:00 a.m. on 10/17/13 (patient was no admitted until 1:30 p.m.), at 8:00 p.m. on 10/17/13, and at 8:00 a.m. and 8:00 p.m. on 10/18/13. There was no documented evidence that Patient #1's vital signs were assessed as ordered by the physician at 9:30 p.m. on 10/17/13 and at 5:30 a.m. and 1:30 p.m. on 10/18/13. Further review revealed Patient #1's weight was 120 pounds on 10/17/13, and there was no documented evidence that his weight was taken weekly as ordered by his physician as evidenced by no documented weight after 8:00 a.m. on 10/17/13 (patient was not admitted until 1:30 p.m.) through 8:00 a.m. on 10/28/13.

Patient #2
Review of Patient #2's medical record revealed he was a 53 year old male admitted on 10/21/13 with diagnoses of CVA (cerebral vascular accident), Diabetes Type II, Hypertension, Hypothyroidism, Obstructive Sleep Apnea and Syncope. Review of his physician admit orders dated 10/21/13 at 7:30 p.m. revealed orders to take vital signs every 8 hours for 24 hours, then every 12 hours, and record the vital signs on the graphic sheet. Further review revealed an order to weigh Patient #2 upon admission, weigh weekly thereafter, and record on the graphic sheet.

Review of Patient #2's "Nursing Narrative Notes" dated 10/21/13 from 6:00 p.m. to 6:00 a.m. revealed he was admitted to the unit on 10/21/13 at 7:22 p.m. Review of his graphic sheets revealed his vital signs were taken at 8:00 p.m. on 10/21/13, at 8:00 a.m. on 10/22/13, and at 8:00 p.m. on 10/22/13. There was no documented evidence that Patient #2's vital signs were assessed as ordered by the physician at 4:00 a.m. on 10/22/13 and at 12:00 p.m. on 10/22/13. Further review revealed Patient #2's weight upon admit on 10/21/13 was 246 pounds, and there was no documented evidence that his weight was taken weekly as ordered by his physician as evidenced by no documented weight after 8:00 p.m. on 10/21/13 through 10/28/13.

Patient #3
Review of Patient #3's medical record revealed she was a 91 year old female admitted on 10/21/13 with diagnoses of a Right Femur Fracture, Diabetes Type II, Hypertension, CHF (congestive heart failure), CAD (coronary artery disease), Gastric Reflux and a Pacemaker Placement. Review of her physician admit orders dated 10/21/13 at 4:00 p.m. revealed orders to take vital signs every 8 hours for 24 hours, then every 12 hours, and record the vital signs on the graphic sheet. Further review revealed an order to weigh Patient #3 upon admission, weigh weekly thereafter, and record on the graphic sheet.

Review of Patient #3's "Nursing Narrative Notes" dated 10/21/13 from 6:00 a.m. to 6:00 p.m. revealed she was admitted to the unit on 10/21/13 at 4:00 p.m. Review of her graphic sheets revealed her vital signs were taken at 8:00 a.m. on 10/21/13 (patient was not admitted until 4:00 p.m. on 10/21/13), at 8:00 p.m. on 10/21/13, and at 8:00 a.m. and 8:00 p.m. on 10/22/13. There was no documented evidence that Patient #3's vital signs were assessed as ordered by the physician at 12:00 a.m. on 10/22/13 and at 4:00 p.m. on 10/22/13. Further review revealed Patient #3's weight upon admit on her "Admission Assessment Form" on 10/21/13 at 4:00 p.m. was 115 pounds and on her graphic sheet her weight was documented as 112 pounds on 10/21/13 at 8:00 a.m. (patient was not admitted until 4:00 p.m. on 10/21/13). There was no documented evidence that her weight was taken weekly as ordered by her physician as evidenced by no documented weight after 4:00 p.m. on 10/21/13 through 10/28/13.

In a face-to-face interview on 10/29/13 at 3:45 p.m. with S2DON and S3ADON present, S3ADON indicated that the nursing staff had been doing vital sign checks every 12 hours and not every 8 hours as ordered by the physician. She confirmed that Patients #1, #2, and #3 were not weighed weekly as ordered by his physician.

4) The RN failed to assess a patient's blood sugar as ordered by the physician and to notify the physician for a blood glucose level above 400:
Patient #5
Review of Patient #5's medical record revealed she was a 77 year old female admitted on 04/11/13 with diagnoses of Generalized Weakness, Diabetes Mellitus, Hypertension, Congestive Heart Failure, Hyperlipidemia, and Gait Immobility. Review of her physician orders dated 04/11/13 at 9:00 p.m. revealed an order to perform Accuchecks twice a day with Regular Insulin coverage of 15 units for blood glucose above 400 and to call the physician.

Review of Patient #5's "Nursing Narrative Notes" dated 04/14/13 from 6:00 p.m. to 6:00 a.m. (on 04/15/13) revealed her blood glucose was 476 on 04/14/13 at 8:00 p.m.. Further review revealed S17RN administered Regular Insulin 15 units, and there was no documented evidence that S17RN notified the physician as ordered.

In a face-to-face interview on 10/30/13 at 11:15 a.m., S3ADON indicated that she could find no documentation in Patient #5's medical record that S17RN notified the physician regarding the blood glucose result of 476 on 04/14/13 at 8:00 p.m.

Patient #12
Review of Patient #12's medical record revealed she was a 63 year old female admitted on 09/23/13 with diagnoses of Osteoporosis, Unsteady Gait with frequent falls, Right Shoulder Arthroplasty with Total Shoulder Replacement, Diabetes Mellitus Type II, Hypertension, GERD (Gastroesophageal Reflux Disease), Depression, Anxiety, Vertigo, Anemia, and Congestive Heart Failure. Further review revealed she had Accuchecks before meals and at bedtime with orders for Humulin R Insulin sliding scale.

Review of patient #12's Medication Administration Record (MAR) and "Nursing Narrative Notes" revealed no documented evidence that her blood glucose was assessed by the RN on 09/27/13 at 4:30 p.m. as ordered by the physician.

In a face-to-face interview on 10/29/13 at 3:45 p.m. with S2DON and S3ADON present, S3ADON indicated review of Patient #12's medical record revealed no documented evidence that her blood glucose level was checked at 4:30 p.m. on 09/27/13.

5) The RN failed to ensure patients had physician orders for each lab specimen drawn:
Patient #1
Review of Patient #1's medical record revealed he was a 71 year old male admitted on 10/17/13 with diagnoses of Osteoarthritis, Generalized weakness, Coronary Atherosclerosis, Chronic Kidney Disease, Dementia Without Behavioral Disturbance, Gout, and Uncontrolled Insulin Dependent Diabetes Mellitus. Review of his physician admit orders dated 10/17/13 at 1:30 p.m. revealed orders to draw lab specimens for CBC (complete blood count), Sedimentation Rate, Uric Acid, Chemistry 12, and Urinalysis. There was no documented evidence of a physician's order to draw a TSH (thyroid stimulating hormone). Further review of the physician orders revealed an order on 10/18/13 (no documented evidence of the time the order was written) to draw a CBC, CMP (comprehensive metabolic profile), and TSH on Monday (10/21/13).

Review of Patient #1's "Laboratory Report" revealed a TSH level was collected on 10/18/13 at 3:30 p.m. with no documented evidence of a physician's order for the test to be drawn.

In a face-to-face interview on 10/29/13 at 3:45 p.m. with S2DON and S3ADON present, S3ADON indicated review of Patient #1's record revealed no evidence of a physician order for the TSH drawn on 10/18/13. S2DON indicated that the problem identified with the lab specimen should have been caught during the RN's 24 hour chart check.

6) The RN failed to administer CPR (cardiopulmonary resuscitation) for a patient who expired and did not have a physician's order not to resuscitate:
Review of Patient #15's medical record revealed he was a 93 year old male admitted on 07/30/13 with a diagnosis of Generalized Weakness secondary to Congestive Heart Failure and Pneumonia.

Review of Patient #15's "Physician's Orders" revealed no documented evidence of a "Do Not Resuscitate" order. Review of Patient #15's "Initial Medical Consult" signed by S6Nurse Practitioner on 07/31/13 at 12:00 (no documentation whether a.m. or p.m.) revealed a notation of "DNR" (do not resuscitate). Review of all physician reports revealed no documented evidence of a discussion with Patient #15 or a responsible family member regarding what it means to not resuscitate and what were the wishes of Patient #15 and his family.

Review of the "Nursing Narrative Notes" for 08/01/13 from 6:00 p.m. to 6:00 a.m. on 08/02/13 revealed the following note by S18RN on 08/02/13:
4:30 a.m. - patient began shaking and became short of breath; patient vomited and turned to the left side to prevent aspirating;
4:37 a.m. - certified nursing assistant at bedside with patient; 911 called and informed of emergency and attempted to call S8Physician;
4:38 a.m. - patient unresponsive; airway appears clear, breaths taken sporadically; radial pulse faint, heart rate regular;
4:42 a.m. - patient unresponsive, no longer breathing; faint pulse noted;
4:45 a.m. - first responders at bedside for evaluation;
4:48 a.m. - first responders noted only pacer spikes on heart monitor;
4:50 a.m. - sheriff department contacted coroner via telephone;
5:00 a.m. - S8Physician called with no answer; voice message left informing physician patient expired.
Review of the entire medical record revealed no documented evidence that CPR was initiated by the nursing staff.

In a face-to-face interview on 10/29/13 at 3:45 p.m. with S2DON and S3ADON present, S3ADON confirmed after reviewing Patient #15's medical record that there was no physician order not to resuscitate. She further indicated that she remembered having S8Physician sign a "Do Not Resuscitate" form, but it was not on Patient #15's chart. She confirmed that CPR was not initiated by the hospital nursing staff.


30172

Based on record reviews and interviews, the hospital failed to ensure that each patient had an individualized nursing care plan as evidenced by having a "Patient Care Plan" for each patient that included patient problems, short term goals, and nursing interventions that were the same for all patients with no additional information added to individualize it for each patient for 4 of 4 inpatients' records reviewed for nursing care plans (#1, #2, #3, #18) from a total of 4 inpatients from a total sample of 20 patients.
Findings:

Review of the hospital policy titled "Nursing Care Plan Or Treatment Plan", contained in the policy manual presented as the current policies by S1Administrator, revealed the RN would initiate a nursing care plan within 24 hours of admission. Further review revealed the parts of the care plan included the following:
1. Patient Need/Problem - identifies the alteration to normal functioning, whether actual or potential and used to define which interventions would be appropriate;
2. Short term goals - list the expected behavioral outcomes related to the problem identified;
3. Interventions - a list of actions that are to be performed in order to achieve the set goal and may be altered according to the patient response;
4. Start date is the initial date that the plan was put in effect, and the date goal met is to be filled out when the desired goal was met.

Patient #1
Review of Patient #1's medical record revealed he was a 71 year old male admitted on 10/17/13 with diagnoses of Osteoarthritis, Generalized weakness, Coronary Atherosclerosis, Chronic Kidney Disease, Dementia Without Behavioral Disturbance, Gout, and Uncontrolled Insulin Dependent Diabetes Mellitus.

Review of Patient #1's "Patient Care Plan" revealed his patient problems identified were cognitive, skin and hygiene, self-care deficit, potential for injury, altered nutrition, bowel, bladder, medications, potential for infection, and discharge planning. Further review revealed the pre-printed items checked under each problem had no added information to individualize the plan for Patient #1. Further review revealed no documented evidence of the behavioral outcomes expected to be able to determine when the short term goals would be met for the following goals: patient will be able to function appropriately in his/her environment; will be able to perform activities of daily living with modified independence; increase periods of continence (bowel and bladder) by discharge; patient and/or caregiver will demonstrate knowledge of medication administration.

Patient #2
Review of Patient #2's medical record revealed he was a 53 year old male admitted on 10/21/13 with diagnoses of CVA (cerebral vascular accident), Diabetes Type II, Hypertension, Hypothyroidism, Obstructive Sleep Apnea and Syncope.

Review of Patient #2's "Patient Care Plan" revealed his patient problems identified were cognitive, skin and hygiene, self-care deficit, potential for injury, altered nutrition, bowel, bladder, sleep/rest, medications, potential for infection, emotional and family adjustment, vocational /avocational and discharge planning. Further review revealed the pre-printed items checked under each problem had no added information to individualize the plan for Patient #2. Review revealed no documented evidence of the behavioral outcomes expected to be able to determine when the short term goals would be met. Further review of the nursing interventions for Patient #2's plan of care revealed the pre-printed items checked under each nursing intervention had no added information to individualize the plan of care for Patient #2 nor any documented evidence on how each nursing intervention would be evaluated in order to meet the patient's goal.

Patient #3
Review of Patient #3's medical record revealed she was a 91 year old female admitted on 10/21/13 with diagnoses of a Right Femur Fracture, Diabetes Type II, Hypertension, CHF (congestive heart failure), CAD (coronary artery disease), Gastric Reflux and a Pacemaker Placement.

Review of Patient #3's "Patient Care Plan" revealed her patient problems identified were cognitive, skin and hygiene, self-care deficit, potential for injury, altered nutrition, bowel, bladder, medications and discharge planning. Further review revealed the pre-printed items checked under each problem had no added information to individualize the plan for Patient #3. Review revealed no documented evidence of the behavioral outcomes expected to be able to determine when the short term goals would be met. Further review of the nursing interventions for Patient #3's plan of care revealed the pre-printed items checked under each nursing intervention had no added information to individualize the plan of care for Patient #3 nor any documented evidence on how each nursing intervention would be evaluated in order to meet the patient's goal.

Patient #18
Review of Patient #18's medical record revealed she was a 61 year old female admitted on 10/29/13 with a diagnosis of Cerebrovascular Accident with Right-Sided Weakness.

Review of Patient #18's "Patient Care Plan" revealed his patient problems identified were cognitive, skin and hygiene, self-care deficit, potential for injury, altered nutrition, bowel, bladder, sleep/rest, medications, potential for infection, emotional and family adjustment, vocational/avocational, and discharge planning. Further review revealed the pre-printed items checked under each problem had no added information to individualize the plan for Patient #18. Further review revealed no documented evidence of the behavioral outcomes expected to be able to determine when the short term goals would be met for the following goals: patient will be able to function appropriately in his/her environment; will be able to perform activities of daily living with modified independence; patient and/or caregiver will demonstrate knowledge of medication administration; keep lines of communication open between family and staff; maintain leisure activities.

In a face-to- face interview on 10/29/13 at 3:45 p.m. with S2Director of Nursing (DON) and S3 Assistant DON (ADON) present, neither S2DON nor S3ADON offered an explanation for the patients' nursing care plans not having measurable goals and not being individualized for each patient. When informed that review of the care plans revealed that each patient's care plan was the same, meaning no additional information added to individualize the pre-printed selection of goals and interventions, S2DON indicated "I understand."


30172

Based on record reviews and interviews, the hospital failed to ensure the nursing care of each patient was assigned by the registered nurse (RN) to nursing staff who were determined to be competent as evidenced by failure to have documented competency evaluations of the nursing staff prior to performing patient care for 5 of 5 RNs' (S2, S3, S4, S17, S18) and 2 of 2 LPNs' (licensed practical nurses) (S19, S20) personnel files reviewed for competency from a total of 5 employed RNs and 4 employed LPNs.
Findings:

Review of the hospital policy titled "Nursing Staff Competency", contained in the policy manual presented as the current policies by S1Administrator, revealed that it is the responsibility of the Director of Nursing (DON) or the Chief Operating Officer to ensure that each staff member has proven the necessary skills or abilities to perform their assigned duties. Further review revealed that each nurse will complete a skills checklist demonstrating identified necessary skills, and this documentation will be kept in the personnel file of each employee. Further review revealed that each employee would participate in annual competency testing. Review of the entire policy revealed no documented evidence that a qualified nursing staff member would observe the nurse performing job duties to attest to their competency in performing the skills required of the job.

Review of the hospital policy titled "Supervision And Evaluation Of Staff", contained in the policy manual presented as the current policies by S1Administrator, revealed the Administrator would evaluate the Director of Nurses, and the DON will evaluate each RN, LPN, and nursing assistant no less often than annually to evaluate performance, patient care, coordination of services, organization and time management, documentation and other aspects of performance as indicated. Further review revealed that staff performance appraisals shall be completed no less often than annually.

Review of the hospital policy titled "Confirming State Registration Of Licensed Nursing Personnel", contained in the policy manual presented as the current policies by S1Administrator, revealed all RNs and LPNs must be currently and actively licensed by the State Board of Nursing. Verification is made by the DON or the Chief Operating Officer. Further review revealed that verification will be by visual inspection of the license, a photocopy stamped COPY of the license, and telephone verification with the respective board for active/inactive status.

Review of the "Skills Check Off" revealed the skills included Accucheck, vital signs, logs (refrigerator, Accucheck, bath, infection tracking, blood transfusion, restraint, blood), respiratory equipment, washer/dryer, drug expiration check, infection control, dietary procedure, call light, room set up, chart checks, admission procedure, discharge procedure, accucheck machine, linen service, housekeeping responsibilities, phone system/paging, safety/fire protocol, pharmacy procedure, lab procedure. Further review revealed that the person witnessing or educating the staff member must sign in the appropriate section (satisfactory/unsatisfactory) and date the form, and refer to the DON if additional education was needed. Review of the entire form revealed no documented evidence that the nursing staff would be oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints.

S2DON
Review of S2DON's personnel file revealed he was hired on 06/01/04. Further review revealed an "Orientation Skills Checklist" was completed on 05/26/11 with no documented evidence whether his competency assessment was satisfactory or unsatisfactory as evidenced by the columns for each being blank. There was no documented evidence of the staff member who assessed the competency of S2DON. Further review revealed the copy of the license in the file had expired on 01/31/12, and his CPR (cardiopulmonary resuscitation) certification had expired 05/31/12. There was no documented evidence that competency evaluations were performed annually, and there was no documented evidence of an annual performance appraisal performed by S1Administrator.

S3ADON (Assistant Director of Nursing)
Review of S3ADON's personnel file revealed she was hired on 08/23/09. Review of her "Skills Check Off" revealed it was performed on 05/18/11 by S1Administrator who is not a nurse. There was no documented evidence in her file that she had been oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints. There was no documented evidence in her file that she had been assessed for competency annually and had a performance appraisal annually as required by the hospital's policy.

S4RN
Review of S4RN's personnel file revealed she was hired in May 2013. Review of her "Skills Check Off" revealed no documented evidence of the date the assessments were done and the signature of the evaluator. Further review revealed no documented evidence that she was assessed for competency in performing Accuchecks, using respiratory equipment, and the pharmacy procedure as evidenced by the column for these skills being blank. There was no documented evidence in her file that she had been oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints. Review of the copy of her CPR certification in her file revealed that it had expired 05/31/13.

S17RN
Review of S17RN's personnel file revealed he was hired on 01/18/13. Review of his "Skills Check Off" revealed no documented evidence of the signature of the evaluator. There was no documented evidence in his file that he had been oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints. There was no documented evidence that he had received a 90-day performance evaluation.

S18RN
Review of S18RN's personnel file revealed she was hired on 04/05/13. Review of her "Skills Check Off" revealed no documented evidence of the signature of the evaluator. There was no documented evidence in her file that she had been oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints. There was no documented evidence that she had received a 90-day performance evaluation.

S19LPN
Review of S19LPN's personnel file revealed she was hired on 01/24/13. Further review revealed no documented evidence that she had been oriented to the hospital and her nursing unit as evidenced by the "Orientation Skills Checklist" having no dates orientation. Review of her "Skills Check Off" revealed no documented evidence of the signature of the evaluator. There was no documented evidence in her file that she had been oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints. There was no documented evidence that she had received a 90-day performance evaluation.

S20LPN
Review of S20LPN's personnel file revealed she was hired on 05/29/13. Further review revealed no documented evidence that she had been oriented to the hospital and her nursing unit as evidenced by the "Orientation Skills Checklist" having no dates orientation. Review of her "Skills Check Off" revealed no documented evidence that she had been evaluated for competency as evidenced by the entire form being blank of writing. Review of a form in her file titled "Orientation Period" revealed that upon completion of the 90-day orientation a performance evaluation would be conducted. There was no documented evidence in S20LPN's file that she had received a 90-day performance evaluation. There was no documented evidence in her file that she had been oriented to and assessed for competency related to rehabilitation nursing, patient rights, the hospital's grievance procedure, and the demonstrated application of restraints.

In a face-to-face interview on 10/31/13 at 11:35 a.m., S2DON indicated that a 90 day evaluation and annual performance appraisals were required, but he wasn't sure if it was addressed in a policy. He further indicated that all direct care staff were required to be certified in CPR. S2DON offered no explanation for his personnel file not having a current license verification and CPR certification. He further indicated that he as the DON was responsible for the orientation and competency evaluations of the nursing staff.

Based on record reviews and interviews, the hospital failed to ensure medications were administered as ordered by the physician for 1 of 4 inpatients (#1) and 1 of 5 discharged patients (#5) whose records were reviewed for medication administration from a total sample of 20 patients. This resulted in 10 medication administration errors that were identified during the survey that had not been identified by the hospital (9 errors for one inpatient in a period of 11 days).
Findings:

Review of the hospital policy titled "Medication Administration", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence of the procedure to be followed for documentation of any medication not administered as ordered on the medication administration record (MAR).

Patient #1
Review of Patient #1's medical record revealed he was a 71 year old male admitted on 10/17/13 with diagnoses of Osteoarthritis, Generalized weakness, Coronary Atherosclerosis, Chronic Kidney Disease, Dementia Without Behavioral Disturbance, Gout, and Uncontrolled Insulin Dependent Diabetes Mellitus.

Review of Patient #1's "Physician's Orders" revealed an order on 10/17/13 at 1:30 p.m. for Humalog 10 units subcutaneously before meals if the blood sugar is above 120 and 5 units if the blood sugar is between 90 and 120. Further review revealed an order (no documented evidence of the date or time the order was written) for Aricept 10 milligrams (mg) orally every day. The order for Aricept was written on the order sheet after an order written on 10/18/13 at 7:30 a.m. and prior to an order written on 10/18/13 at 5:10 p.m. Further review revealed an order to discontinue Aricept was written on 10/19/13 at 5:50 p.m.

Review of Patient #1's "Nursing Graphic Sheet" revealed his blood sugar was 113 at 4:30 p.m. on 10/18/13 and 119 on 10/19/13 at 4:30 p.m. Review of his MAR revealed Humalog 5 units was not administered as ordered for a blood sugar between 90 and 120 at 4:30 p.m. on 10/18/13 and 10/19/13 as evidenced by the time being circled on the MAR. Review of Patient #1's "Nursing Graphic Sheet" revealed his blood sugar was 137 at 7:30 a.m., 142 at 11:30 a.m., and 180 at 4:30 p.m. on 10/26/13 and 194 at 7:30 a.m., 254 at 11:30 a.m., and 212 at 4:30 p.m. on 10/27/13. Review of his MAR revealed no documented evidence that Humalog 10 units was administered at 7:30 a.m., 11:30 a.m., and 4:30 p.m. on 10/26/13 and 10/27/13 as ordered by the physician as evidenced by the time being circled on the MAR. Review of the MAR revealed no documented evidence that Aricept 10 mg was administered at 9:00 a.m. on 10/19/13 as evidenced by the time being circled on the MAR.

In a face-to-face interview on 10/29/13 at 3:45 p.m., S3ADON (Assistant Director of Nursing) indicated there had been confusion about the order for Regular Insulin and Humalog Insulin since they were both short-acting insulins. She further indicated that the nursing staff was administering one or the other but not both as ordered. She confirmed that the order was never clarified with the physician, but a discussion had been held with the physician on 10/28/13, and the physician said that he wanted both insulins to be given as ordered. S3ADON indicated a family member of Patient #1 had told her about a reaction that Patient #1 had encountered with Aricept, so she reported to the night nurse but did not contact the physician. She confirmed that the Aricept was not administered as ordered at 9:00 a.m. on 10/19/13, and the order to discontinue it was received after the time it was due to be administered.

Patient #5
Review of Patient #5's medical record revealed she was a 77 year old female admitted on 04/11/13 with diagnoses of Generalized Weakness, Diabetes Mellitus, Hypertension, Congestive Heart Failure, Hyperlipidemia, and Gait Immobility.

Review of Patient #5's "Physician's Orders" revealed an order on 04/11/13 at 9:00 p.m. to perform blood sugar accuchecks twice a day with Regular Insulin coverage as follows: 0-60 give orange juice or 1 ampoule Dextrose 50, 60-200 no insulin, 201-250 give 3 units, 251-300 give 6 units, 301-350 give 9 units, 351-400 give 12 units, and greater than 400 give 15 units and call the physician.

Review of Patient #5's "Nursing Narrative Notes" dated 04/15/13 at 9:00 p.m. revealed his accucheck reading was 205, and he was given 2 units of regular Insulin rather than 3 units as ordered. Review of his MAR revealed his blood sugar on 04/15/13 at 9:00 p.m. was 476, and he was given 15 units Regular Insulin.

In a face-to-face interview on 10/30/13 at 11:15 a.m., S3ADON confirmed that Patient #1's nursing notes revealed he was given 2 units of Regular Insulin on 14/15/13 at 9:00 a.m., and his MAR had his blood sugar reading as 476 with 15 units Regular Insulin given. She indicated that the MAR must have been an error, because Patient #1's blood sugar at 9:00 p.m. on 04/14/13 was 476 and he was given 15 units Regular Insulin at that time.

Based on record review and interview, the hospital failed to ensure the medical record staff member was oriented and assessed for competency to perform the job duties for 1 of 2 medical record staff members' personnel files reviewed from a total of 2 medical record staff members (S5).
Findings:

Review of the hospital policy titled "Supervision And Evaluation Of Staff", contained in the policy manual presented as the current policies by S1Administrator, revealed the Administrator was responsible for evaluating all administrative-clerical staff as well as all ancillary services directors.

Review of S5Medical Records Administrative Assistant's personnel file revealed she was hired on 09/16/13. Further review revealed a list of "Things to Know" signed by S5Medical Records Administrative Assistant on 09/23/13. Review of the list revealed that it included log in data for the computer and various web sites, things to do when she first arrives each morning, how to break down and assemble a chart, how to flag the chart's deficiencies, and how to handle copying records for requests. There was no documented evidence of any signature on the list other than S5Medical Records Administrative Assistant. Review of the entire personnel file revealed no documented evidence that S5Medical Records Administrative Assistant was oriented to the hospital and assessed for competency to perform the duties required of the medical record staff.

In a face-to-face interview on 10/31/13 at 12:30 p.m., S1Administrator indicated that she had the prior medical record staff member who had just resigned come back to provide some training for S5Medical Records Administrative Assistant. When informed that the "Things to Know" list had no evidence of a signature of the person who provided training and no evidence of whether S5Medical Records Administrative Assistant was competent to perform the job duties required of her, S1Administrator offered no comment or explanation.

Based on observations, record reviews, and interviews, the hospital failed to:
1) ensure that patients' medical records were stored in a manner to protect them from water damage in the event that the sprinkler system in Room "p" would activate by having medical records stored in 9 copy paper boxes (containing about 168 records) stacked on the floor in Room "p", 25 medical records stacked on a table in Room "p", and 215 medical records stored on open shelving in Room "p". There was a wooden cabinet in Room "p" that was filled with patients' medical records that was not constructed with fire-retardant or fire-proof lumber.
2) have a system in place to determine which medical records were complete and which patient medical records were not completed no later than 30 days after discharge.
Findings:

1) Ensure that patients' medical records were stored in a manner to protect them from water damage in the event that the sprinkler system in Room "p" would activate by having medical records stored in 9 copy paper boxes (containing about 168 records) stacked on the floor in Room "p", 25 medical records stacked on a table in Room "p", and 215 medical records stored on open shelving in Room "p". There was a wooden cabinet in Room "p" that was filled with patients' medical records that was not constructed with fire-retardant or fire-proof lumber:
Observation on 10/28/13 at 11:30 a.m. in Room "p" revealed 9 copy paper boxes filled with approximately 168 patient records that was stacked on the floor of Room "p". Further observation revealed 25 patient records stacked on the table in Room "p" that was exposed to the sprinkler system in the room. Further observation revealed 215 patient records stored on open shelving in Room "p" that was exposed to the sprinkler system. There was a wooden cabinet in Room "p" that was filled with patients' medical records that was not constructed with fire-retardant or fire-proof lumber.

In a face-to-face interview on 10/28/13 at 11:30 a.m., S1Administrator confirmed that the above-listed patients' medical records were not protected from water damage in the event that the sprinkler system in the room would activate. She indicated that she didn't think the wooden cabinet was constructed of fire-retardant or fire-proof wood.

2) Have a system in place to determine which medical records were complete and which patient medical records were not completed no later than 30 days after discharge:
Review of the Medical Staff Bylaws and Rules and Regulations, approved by the Governing Body on 06/01/11 and presented as the current Medical Staff Bylaws by S1Administrator, revealed no documented evidence that the rules and regulations addressed the timeframe for the completion of patient's medical records by the physician no later than 30 days after discharge.

In a face-to-face interview on 10/28/13 at 11:30 a.m. with S5Medical Records Administrative Assistant and S1Administrator present, S5Medical Records Administrative Assistant indicated she didn't know the hospital's current delinquency rate.

In a telephone interview on 10/31/13 at 9:20 a.m., S22Coder indicated that her original role at the hospital had been as the Director of the Health Information Management Department, and there had been a trained coordinator in the department until recently. She further indicated that about 5 months prior to this interview, she had reduced her work to that of coding. When asked if she was responsible for the oversight of the Medical Records Department, S22Coder answered that she didn't see her role as responsible for the department as a whole but just for coding. S22Coder indicated that she didn't know the hospital's current delinquency rate.

Based on record review and interviews, the hospital failed to ensure:
1) all medication orders, except in an emergency situation, were reviewed for appropriateness by a pharmacist before the first dose is dispensed as evidenced by hospital policy not addressing the requirement that all medication orders be reviewed by a pharmacist before the first dose being dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications and
2) medications were administered as ordered by the physician for 1 of 4 inpatients (#1) and 1 of 5 discharged patients (#5) whose records were reviewed for medication administration from a total sample of 20 patients. This resulted in 10 medication administration errors that were identified during the survey that had not been identified by the hospital (9 errors for one inpatient in a period of 11 days).
Findings:

1) All medication orders, except in an emergency situation, were reviewed for appropriateness by a pharmacist before the first dose is dispensed as evidenced by hospital policy not addressing the requirement that all medication orders be reviewed by a pharmacist before the first dose being dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications:
Review of the hospital policy titled "Medication Administration", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence that the pharmacist was required to review all medication orders for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications prior to the first dose being administered except in emergencies.

In a telephone interview on 10/31/13 at 8:35 a.m., S23Contract Pharmacist indicated if a drug needed to be given before it was delivered by pharmacy, the nurse was supposed to call the pharmacist for review of the order. He further indicated that the pharmacist is not documenting when a first dose drug review is done. He further indicated that he would have to check with the other pharmacists to see if the nurses were calling for first dose drug reviews, because the pharmacy did not have a system in place for documentation of this process.

In a telephone interview on 10/31/13 at 9:45 a.m., S23Contract Pharmacist indicated the pharmacists told him that the hospital nursing staff was not consistently calling the pharmacists for a first dose drug review.

2) Medications were administered as ordered by the physician for 1 of 4 inpatients (#1) and 1 of 5 discharged patients (#5) whose records were reviewed for medication administration from a total sample of 20 patients. This resulted in 10 medication administration errors that were identified during the survey that had not been identified by the hospital (9 errors for one inpatient in a period of 11 days):
Review of the hospital policy titled "Medication Administration", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence of the procedure to be followed for documentation of any medication not administered as ordered on the medication administration record (MAR).

Patient #1
Review of Patient #1's medical record revealed he was a 71 year old male admitted on 10/17/13 with diagnoses of Osteoarthritis, Generalized weakness, Coronary Atherosclerosis, Chronic Kidney Disease, Dementia Without Behavioral Disturbance, Gout, and Uncontrolled Insulin Dependent Diabetes Mellitus.

Review of Patient #1's "Physician's Orders" revealed an order on 10/17/13 at 1:30 p.m. for Humalog 10 units subcutaneously before meals if the blood sugar is above 120 and 5 units if the blood sugar is between 90 and 120. Further review revealed an order (no documented evidence of the date or time the order was written) for Aricept 10 milligrams (mg) orally every day. The order for Aricept was written on the order sheet after an order written on 10/18/13 at 7:30 a.m. and prior to an order written on 10/18/13 at 5:10 p.m. Further review revealed an order to discontinue Aricept was written on 10/19/13 at 5:50 p.m.

Review of Patient #1's "Nursing Graphic Sheet" revealed his blood sugar was 113 at 4:30 p.m. on 10/18/13 and 119 on 10/19/13 at 4:30 p.m. Review of his MAR revealed Humalog 5 units was not administered as ordered for a blood sugar between 90 and 120 at 4:30 p.m. on 10/18/13 and 10/19/13 as evidenced by the time being circled on the MAR. Review of Patient #1's "Nursing Graphic Sheet" revealed his blood sugar was 137 at 7:30 a.m., 142 at 11:30 a.m., and 180 at 4:30 p.m. on 10/26/13 and 194 at 7:30 a.m., 254 at 11:30 a.m., and 212 at 4:30 p.m. on 10/27/13. Review of his MAR revealed no documented evidence that Humalog 10 units was administered at 7:30 a.m., 11:30 a.m., and 4:30 p.m. on 10/26/13 and 10/27/13 as ordered by the physician as evidenced by the time being circled on the MAR. Review of the MAR revealed no documented evidence that Aricept 10 mg was administered at 9:00 a.m. on 10/19/13 as evidenced by the time being circled on the MAR.

In a face-to-face interview on 10/29/13 at 3:45 p.m., S3ADON (Assistant Director of Nursing) indicated there had been confusion about the order for Regular Insulin and Humalog Insulin since they were both short-acting insulins. She further indicated that the nursing staff was administering one or the other but not both as ordered. She confirmed that the order was never clarified with the physician, but a discussion had been held with the physician on 10/28/13, and the physician said that he wanted both insulins to be given as ordered. S3ADON indicated a family member of Patient #1 had told her about a reaction that Patient #1 had encountered with Aricept, so she reported to the night nurse but did not contact the physician. She confirmed that the Aricept was not administered as ordered at 9:00 a.m. on 10/19/13, and the order to discontinue it was received after the time it was due to be administered.

Patient #5
Review of Patient #5's medical record revealed she was a 77 year old female admitted on 04/11/13 with diagnoses of Generalized Weakness, Diabetes Mellitus, Hypertension, Congestive Heart Failure, Hyperlipidemia, and Gait Immobility.

Review of Patient #5's "Physician's Orders" revealed an order on 04/11/13 at 9:00 p.m. to perform blood sugar accuchecks twice a day with Regular Insulin coverage as follows: 0-60 give orange juice or 1 ampoule Dextrose 50, 60-200 no insulin, 201-250 give 3 units, 251-300 give 6 units, 301-350 give 9 units, 351-400 give 12 units, and greater than 400 give 15 units and call the physician.

Review of Patient #5's "Nursing Narrative Notes" dated 04/15/13 at 9:00 p.m. revealed his accucheck reading was 205, and he was given 2 units of regular Insulin rather than 3 units as ordered. Review of his MAR revealed his blood sugar on 04/15/13 at 9:00 p.m. was 476, and he was given 15 units Regular Insulin.

In a face-to-face interview on 10/30/13 at 11:15 a.m., S3ADON confirmed that Patient #1's nursing notes revealed he was given 2 units of Regular Insulin on 14/15/13 at 9:00 a.m., and his MAR had his blood sugar reading as 476 with 15 units Regular Insulin given. She indicated that the MAR must have been an error, because Patient #1's blood sugar at 9:00 p.m. on 04/14/13 was 476 and he was given 15 units Regular Insulin at that time

Based on observations and interview, the hospital failed to ensure that all drugs and biologicals were kept secured and locked as evidenced by having the door to Room "a" propped open with a door stop for 3 minutes on 10/28/13 from 12:45 p.m. to 12:48 p.m. with no licensed nurse or physician present in the nursing station.
Findings:

Observation on 10/28/13 at 12:45 p.m. while standing in the nursing station with no staff member present revealed the door to Room "a" was propped open with a door stop.

In a face-to-face interview on 10/28/13 at 12:48 p.m. upon S4RN (registered nurse) returning to the nursing station, S4RN indicated that she should have closed the door to Room "a" when she went down the hall to check a patient's call light. She further indicated that the medications contained in Room "a" were not secured from access by unlicensed staff members and the public while the door was propped open.

Based on observations, record reviews, and interviews, the hospital failed to ensure that outdated or otherwise unusable drugs and biologicals were not available for use as evidenced by having opened medications greater than 30 days from the date of opening, medications not dated when opened, and bags of intravenous fluids not contained in the original plastic wrap available for use.
Findings:

Review of the hospital's policy titled "Medication Administration", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence that the policy addressed the conditions that would make a drug or biological unusable.

Review of the "Medication Room Inspection Report" completed by S23Contract Pharmacist during his monthly inspections revealed multi-dose vials of medications were required to be initialed and dated when opened and removed and destroyed when opened for more than 30 days.

Observation Room "a" on 10/28/13 at 9:55 a.m. revealed the following expired or unusable drugs and biologicals:
1) Normal Saline 8.5 fluid ounces opened and not dated and initialed when opened that had expired on 08/19/13;
2) Hydrogen Peroxide Solution 8 fluid ounces not dated and initialed when opened;
3) 1000 milliliter bag of 0.9% (per cent) Sodium Chloride intravenous (IV) solution without the original plastic wrap;
4) 10 milliliter Humulin R Insulin (100 units per milliliter) in the medication refrigerator was opened on 09/23/13 (more than 30 days since opened).
All observations were confirmed at the time of the observation by S4RN (registered nurse).

In a face-to-face interview on 10/28/13 at 10:00 a.m., S4RN indicated a multi-dose medication can be used for 30 days once it's opened and then must be discarded. She confirmed that the multi-dose vials of medications were to be initialed and dated when opened to be able to determine when they were no longer usable and that she couldn't verify that IV fluids not contained in a plastic wrap had not been tampered with.

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

Review of the hospital's only policy related to radiology services titled "Radiology And EKG (electrocardiogram) Services", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence that it addressed procedures for proper safety precautions against radiation hazards such as adequate shielding for patients and personnel and determining that a female patient was not pregnant prior to performing the procedure.

Review of the contracts provided by S1Administrator revealed the hospital had a contract with Company B to provide mobile x-ray and EKG services.

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated that Company B took the patient's x-ray when ordered in the hospital setting. She confirmed the above-listed policy was the only policy for radiology services.

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

Review of the list of credentialed physicians on the Medical Staff, presented as a current list by S1Administrator, revealed no documented evidence that a radiologist was credentialed and privileged as a member of the Medical Staff.

Review of the contracts provided by S1Administrator revealed the hospital had a contract with Company B to provide mobile x-ray and EKG (electrocardiogram) services.

In a face-to-face interview on 10/29/13 at 3:10 p.m., S1Administrator indicated that the hospital did not have a credentialed and privileged Radiologist to supervise the radiology services, and the radiologist interpreting the mobile x-rays was not credentialed and privileged by the hospital's Medical Staff and Governing Body.

Based on observations, record reviews, and interview, the hospital failed to ensure that supplies required to obtain blood specimens were not expired as evidenced by having expired Vacutainer tubes available for use by the staff. The hospital had a contract with Hospital A to provide laboratory services, and the hospital policy stated that Company C was to pick up specimens and supply the lab slips and equipment needed.
Findings:

Review of the contracts presented by S1Administrator revealed the hospital had a contract with Hospital A to perform and result requested laboratory tests.

Review of the hospital policy titled "Laboratory Services", contained in the policy manual presented as the current policies by S1Administrator, revealed Company C will be called and notified of the specimen to be picked up for processing and will provide the lab slips and the equipment needed for attaining blood specimens as per their contract. Review of the contracts presented by S1Administrator revealed no documented evidence of a contract with Company C.

Observation in Room "a" on 10/28/13 at 10:10 a.m. revealed 3 blue top Vacutainers (2 milliliter 9NC Coagulant Sodium Citrate 3.2 per cent) had expired 07/31/13, and 22 red top Vacutainers (9 milliliters Z Serum Clot Activator) had expired 08/31/13. These observations were confirmed at the time by S1Administrator who was present during the observation.

Observation of the crash cart revealed the second drawer contained the following expired Vacutainers:
1 red/gray top BD Vacutainer 8.5 milliliters (ml) expired 07/31/10;
1 red top 10 ml Vacutainer expired 03/31/11;
1 purple top 4 ml Vacutainer expired 09/30/10;
1 blue top 27 ml Vacutainer expired 12/31/09;
3 BD needles expired 04/30/12.

In a face-to-face interview on 10/28/13 at 11:00 a.m. indicated that the hospital has a policy stating that the crash cart is not used. She confirmed that the above-mentioned Vacutainers were expired.

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated that the nurses draw the lab specimen, and the specimen is sent to Hospital A according to their contract.

Based on record reviews and interviews, the hospital failed to ensure there was a designated full-time employee who served as the director of the food and dietetic services (dietary manager), was responsible for the daily management of the dietary services, and was qualified by experience or training. There was no staff member listed on the employee roster with the duty of dietary manager.
Findings:

Review of the "Employee Compliance Log", presented by S25Receptionist as the current up-to-date list of employees, revealed no documented evidence that a staff member had the role of Dietary Manager.

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated that the hospital did not have a specific staff member assigned the duties of Dietary Manager. She further indicated that no current staff member had received training or had experience to serve as Dietary Manager.


30172

Based on observation and interview, the hospital failed to ensure there were competent staff assigned to the duties of the dietary services provided by the hospital as evidenced by having no designated staff member trained and determined to be competent in the required tasks related to dietary services.
Findings:

An observation on 10/29/13 at 12:30 p.m. was made in the dining area of patients eating lunch with S27CNA (certified nursing assistant) present.

In an interview on 10/29/13 at 12:45 p.m. with S27CNA, she indicated she was not the dietary personnel and indicated that the hospital did not have dietary personnel. S27CNA indicated that patient's meals were picked up from the contracted dietary service at another location by a CNA, housekeeping, maintenance, or whoever was available. S27CNA indicated that a CNA was assigned to assist with patients' meals in the dining area each day and indicated that the CNAs only helped patients with meal set-up and recorded how much they consumed or drank for that meal. S27CNA indicated that she did not check food temperatures when the meals arrived and indicated that food temperatures were probably checked at the contracted service provider. She further indicated that she would routinely re-warm the meals in the microwave and did not check the temperatures after the meals were removed from the microwave. S27CNA indicated that she had no specialized training in dietary services.

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated that the hospital did not have a specific staff member assigned to the duties of the dietary service department. She further indicated that no current staff member had received training or had experience in dietary services. S1Administrator indicated that either the housekeeper or a certified nursing assistant would get the meals from Hospital B and set the meals in the dining room.


30172

Based on record review and interview, the hospital failed to maintain a current therapeutic diet manual approved by the dietitian and the medical staff that was readily available to all nursing personnel as evidenced by the therapeutic diet manual available to staff being from 2001. Findings:

Review of the therapeutic diet manual available to the nursing staff revealed it was dated 2001.

Review of the "American Dietetic Association's Nutrition Care Manual" revealed the manuals are Internet-based manuals for Registered Dietitians, Dietetic Technicians Registered, and allied health professionals. Further review revealed the following topics were available in October 2011: normal nutrition, developmental disabilities, and general guidance and advanced diabetes practice for Diabetes Mellitus.

In a telephone interview on 10/31/13 at 8:50 a.m., S24RD indicated that she thought the current diet manual that was published was from 2009, but she wasn't sure. When informed that the diet manual at the hospital was from 2001, S24RD indicated that she thought the hospital had a more recent manual that 2001, but "anyway Hospital B has one."

Based on interviews and record reviews, the hospital failed to have a UR (Utilization Review) committee/group that consisted of 2 or more practitioners to carry out the UR functions. This failed practice was evidenced by no documented evidence of a hospital UR committee or a group outside of the hospital established to carry out the UR functions.
Findings:

Review of the UR policy, provided by S1Administrator as the most current, revealed a 2 page policy on the different components of the UR process as the tasks listed for the review physician, the review committee, the attending physician, and the assigned review coordinator. The review of the UR policy revealed no evidence of a UR plan, the composition the UR committee, a delineation of the responsibilities and authority for those involved in the performance of the UR activities, procedures for review of the medical necessity of admissions, the appropriateness of the setting, the medical necessity of extended stays, nor the medical necessity of professional services.

In an interview on 10/29/13 at 9:00 a.m. with S26UR, she indicated that she was the Intake Coordinator for Admissions and Utilization Review. S26UR indicated that she collected data on a spread sheet for Medicare and Medicaid admissions for LOS (length of stay), obtained insurance authorizations for all patient admissions, assisted with patient discharge planning, and assisted with medical record diagnosis coding. S26UR indicated that this information was given to S1Administrator for the hospital's monthly governing body/medical staff meetings. S26UR further indicated that she did not always attend those meetings. S26UR indicated she did not have any documented UR meetings nor did she have any UR minutes. S26UR was unable to provide any documentation of a UR plan, UR activities, UR reviews, UR meeting minutes, or evidence of a UR committee. S26UR indicated that she did not know who comprised the UR committee and that S1Administrator would be better able to discuss the hospital's UR activities.

In an interview on 10/29/13 at 2:45 p.m. with S1Administrator, she indicated that the hospital did not have a separate UR committee nor was there a group outside of the hospital that was established to carry out UR functions. S1Administrator indicated that on 02/07/13 at the hospital's monthly governing body/ medical staff meeting, the governing board approved to combine the CPI (Continuous Performance Improvement), the UR (Utilization Review) and the QA (Quality Assurance) committees into one committee due to the hospital's size and personnel. S1Administrator was asked about the members who carried out the UR functions, the UR reports,, the UR reviews, the professional service reviews, and a copy of the hospital's UR plan. S1Administrator was unable to provide any documentation of a UR plan, UR activities, UR reviews, UR reports, or evidence of any practitioners who carried out UR functions..

Based on interviews and record reviews, the hospital failed to have a UR (Utilization Review) plan that provided for review of medical necessity for Medicare /Medicaid patients in regards to admissions, duration of stay and professional services provided. This failed practice was evidenced by no documented evidence of a UR plan.
Findings:

Review of the UR policy, provided by S1Administrator as the most current, revealed a 2 page policy on the different components of the UR process as the tasks listed for the review physician, the review committee, the attending physician and the assigned review coordinator. The review of the UR policy revealed no evidence of a UR plan, the composition the UR committee, a delineation of the responsibilities and authority for those involved in the performance of the UR activities, procedures for review of the medical necessity of admissions, the appropriateness of the setting, the medical necessity of extended stays, nor the medical necessity of professional services.

In an interview on 10/29/13 at 9:00 a.m. with S26UR, she indicated that she was the Intake Coordinator for Admissions and Utilization Review. S26UR indicated that she collected data on a spread sheet for Medicare and Medicaid admissions for LOS (length of stay), obtained insurance authorizations for all patient admissions, assisted with patient discharge planning and assisted with medical record diagnosis coding. S26UR indicated that this information was given to S1Administrator for the hospital's monthly governing body/medical staff meetings. S26UR further indicated that she did not always attend those meetings. S26UR indicated she did not have any documented UR meetings nor did she have any UR minutes. S26UR was unable to provide any documentation of a UR plan, UR activities, UR reviews, UR meeting minutes or evidence of a UR committee. S26UR indicated that she did not know who comprised the UR committee and that S1Administrator would be better able to discuss the hospital's UR activities.

In an interview on 10/29/13 at 2:45 p.m. with S1Administrator, she indicated that the hospital did not have a separate UR committee nor was there a group outside of the hospital that was established to carry out UR functions. S1Administrator indicated that on 02/07/13 at the hospital's monthly governing body/ medical staff meeting, the governing board approved to combine the CPI (Continuous Performance Improvement), the UR (Utilization Review) and the QA (Quality Assurance) committees into one committee due to the hospital's size and personnel. S1Administrator was asked about the members who carried out the UR functions, the UR reports,, the UR reviews, the professional service reviews and a copy of the hospital's UR plan. S1Administrator was unable to provide any documentation of a UR plan, UR activities, UR reviews, UR reports or evidence of any practitioners who carried out UR functions.

Based on interviews and record reviews, the hospital failed to have a designated infection control officer who had specialized training in infection control. This failed practice was evidenced by no documented evidence of the infection control officer having any specialized training or previous work experience related to infection control activities.

Findings:
Review of the "Infection Control Surveillance" policy revised on 06/01/11, provided by S1Administrator as the most current, revealed the Director of Nursing (DON) would be the infection control officer and would administer the activities of the infection control surveillance program..

Review of S2DON's employee file revealed no documented evidence of any specialized training or previous work experience related to infection control activities.

In an interview on 10/29/13 at 2:15 p.m. with S1Administrator, she indicated that S2DON was the infection control officer for the hospital. S1Administrator indicated she was not sure if S2DON had any specialized training or previous work experience related to infection control activities.

In an interview on 10/29/13 at 5:30 p.m. with S2DON, he indicated he was the infection control officer for the hospital. S2DON further indicated he was not aware that he needed any specialized training or previous work experience related to infection control activities other than participation in the hospital's annual in-services.

Based on observation, record reviews, and interviews, the hospital failed to implement its system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and employees as evidenced by:
1) Failing to maintain a sanitary environment by having rooms that were identified by S1Administrator as ready for occupancy with empty glove boxes, used box of Kleenex, soiled over-bed tables, no paper towels in the bathroom, soiled toilet bowl, sink bowl with dried particles near the drain, used bath basin in the bathroom, trash baskets with used paper towels, shower room with used single-use patient items on the counter, and equipment stored in patient rooms. The gym had a loose rubber seal on the high-low table and an exercise bike seat with a one-half inch tear that prevented both items from being able to assure that they could be disinfected properly after each patient's use.
2) Failing to develop and implement a system for active surveillance of hand hygiene by the staff that resulted in an observation of breaches in hand hygiene by S4Registered Nurse (RN) during a skin assessment of Patient #1 on 10/29/13.
3) Failing to ensure that all employees received annual infection control education at the time of orientation and at least annually thereafter as required by hospital policy for 13 of 16 employees' files reviewed for infection control education from a total of 32 employees (S2, S4, S12, S13, S14, S15, S16, S17, S18, S19, S20, S21, S22).
4) Failure of the infection control officer to conduct an active infection control surveillance program by failing to develop a system for identifying, reporting, investigating and controlling infections.
Findings:

1) Failing to maintain a sanitary environment by having rooms that were identified by S1Administrator as ready for occupancy with empty glove boxes, used box of Kleenex, soiled over-bed tables, no paper towels in the bathroom, soiled toilet bowl, sink bowl with dried particles near the drain, used bath basin in the bathroom, trash baskets with used paper towels, shower room with used single-use patient items on the counter, and equipment stored in patient rooms. The gym had a loose rubber seal on the high-low table and an exercise bike seat with a one-half inch tear that prevented both items from being able to assure that they could be disinfected properly after each patient's use:
Observation on 10/28/13 at 10:25 a.m. revealed Room "b" had an empty box of gloves in the glove box holder and an opened box of Kleenex on the bedside table. Further observation revealed the over-bed table had a smeared substance on it, and there was no paper towels in the bathroom dispenser Observation of Room "c" revealed the bathroom wastebasket had used paper towels in it, the glove holder in the room had an open box of Kleenex in it, and the toilet had dried brown substance in the toilet bowl that looked like feces.

In a face-to-face interview on 10/28/13 at 10:25 a.m., S1Administrator indicated the rooms were ready for occupancy. She further indicated that each patient gets a new admit kit, so there shouldn't be an open box of Kleenex in the rooms. She confirmed the other findings listed above.

Observation on 10/28/13 at 10:35 a.m. revealed Room "d" had dried particles in the sink bowl near the drain, a strand of hair on the toilet seat, and an open plastic bag with a bath basin in the bag that was located in the bathtub. Further observation revealed no gloves in the glove box, a soiled over-bed table, and particles stuck to the inside of the garbage liner. Room "e" had an empty box of gloves. S1Administrator who was present during the observation indicated the rooms were ready for occupancy and confirmed the observed findings.

Observation on 10/28/13 at 11:05 a.m. revealed Room "i" had a long strand of hair in the sink, dried spots on the counter, and the trash basket had a large quantity of used paper towels in it. This observation was confirmed by S1Administration at the time of the observation.

Observation of Room "j" on 10/28/13 at 11:10 a.m. revealed opened containers of skin ointment with aloe, hand and body lotion, shaving cream, baby powder, tearless body wash and shampoo, body moisturizer, personal cleanser, and a box of multiple razors.

In a face-to-face interview on 10/28/13 at 11:10 a.m., S1Administrator indicated that the items were to be used by one patient and were not for multiple patient use. She further indicated that they should not have been left in Room "j".

Observation on 10/28/13 at 11:15 a.m. revealed Room "l" had a walker soiled with stains folded against the wall with one of the tennis balls used on the leg of the walker lying on the floor. Further observation revealed the entrance to Room "m" had a large yellow stain that looked like it was dried wax build-up. Further observation revealed the bed did not have a mattress. Observation revealed Room "n" had an empty box of gloves in the holder, no call light, 3 wheelchairs, 2 over chair tables, 2 paddings for the over chair table, 1 rolling walker, and a bedside commode stored in the room. Further observation revealed Room "o" had an empty box of gloves in the holder and no call light.

In a face-to-face interview on 10/28/13 at 11:25 a.m., S1Administrator confirmed the above-mentioned rooms were ready for occupancy and confirmed the observed findings. She indicated that the hospital has a problem with storage space and has a lot of rehabilitation equipment since it is a rehabilitation hospital.

Observation in Room "q" on 10/28/13 at 11:25 a.m. revealed the high-low table had a loose rubber seal.

In a face-to-face interview on 10/28/13 at 11:28 a.m., S16OT (occupational therapist) indicated that the seal was not secure and confirmed that it would present a problem for disinfecting after patient use.

Observation of Room "s" on 10/28/13 at 11:45 a.m. revealed the exercise bike seat had a one-half inch tear. This observation was confirmed by S1Administrator who also confirmed that it would be difficult to assure disinfection of the seat after use.

2) Failing to develop and implement a system for active surveillance of hand hygiene by the staff that resulted in an observation of breaches in hand hygiene by S4Registered Nurse (RN) during a skin assessment of Patient #1 on 10/29/13:
Review of the hospital policy titled "Employee Health Policy", contained in the policy manual presented as the current policies by S1Administrator, revealed hands were to be washed before eating, drinking, or handling food, before and after using the toilet, blowing nose or covering a sneeze, after handling garbage or soiled material, before touching eyes and after hands become obviously soiled, and before and after using gloves.

Observation on 10/29/13 at 10:30 a.m. during Patient #1's skin assessment performed by S4RN revealed S4RN washed her hands and donned gloves, cleaned Patient #1's buttock area, removed her gloves, washed her hands, and reapplied gloves. Further observation revealed after measuring Patient #1's Stage II pressure ulcer, S4RN, while wearing the same gloves used to measure Patient #1's pressure ulcer and touch his buttock area, removed ointment from its box and applied the ointment to the wound. Further observation revealed S4RN removed a second application of ointment with her gloved finger and applied it to his wound. While wearing the same gloves used to apply ointment to Patient #1's wound, S4RN opened the drawer of the bedside table, removed a pen from her uniform pocket, wrote on the box of ointment, placed the box of ointment in the drawer, closed the drawer, removed her gloves, and reapplied gloves without washing her hands or using hand sanitizer.

In a face-to-face interview on 10/29/13 at 11:50 a.m., S4RN offered no comment or explanation when informed of the observed breaches in hand hygiene during her skin assessment and wound care performed on Patient #1.

3) Failing to ensure that all employees received annual infection control education at the time of orientation and at least annually thereafter as required by hospital policy:
Review of the hospital policy titled "Employee Health Policy", contained in the policy manual presented as the current policies by S1Administrator, revealed in-service education in infection control would be provided to all employees at the time of orientation and at least annually thereafter. Further review revealed the education would include Employee Health and Infection Control, Standard Precautions, and Bloodborne Pathogens Exposure Plan.

Review of the "Infection Inservice" contained in employees files revealed the contents included factors associated with infection and transmission of infection. There was no documented evidence that the in-service included information on standards precautions and a bloodborne pathogen exposure plan as required by hospital.

Review of the personnel files of S2DON, S4RN, S12PT, S13COTA, S14PTA, S15SLP, S16OT, S17RN, S18RN, S19LPN, S20LPN, S21RT, and S22RHIA (registered health information administrator) revealed no documented evidence to determine that infection control education was provided at the time of orientation and annually. Review of the files revealed a document titled "Infection Inservice" that was not dated and not signed by the person presenting the in-service. Further review revealed an "Infection Control Post Test" that was not dated, not signed by the employee taking the test, and no documented evidence that the test was reviewed for correct or incorrect answers that could determine competency of infection control practices.

In a face-to-face interview on 10/31/13 at 11:35 a.m., S2DON indicated he was the Infection Control Officer for the hospital. He could offer no explanation for the hospital staff not having evidence of infection control training upon hire and annually as required by hospital policy.

4) Failure of the infection control officer to conduct an active infection control surveillance program by failing to develop a system for identifying, reporting, investigating and controlling infections:
Review of the "Infection Control Surveillance" policy revised on 06/01/11, provided by S1Administrator as the most current policy, revealed that the activities of the infection control surveillance program included monitoring, data collection, data analysis, reporting of outcomes and follow-up activities. The policy further revealed that the Director of Nursing would administer the surveillance program and would report surveillance outcomes to the C.P.I. (Continuous Performance Improvement) committee on a monthly basis.

In an interview on 10/29/13 at 5:30 p.m. with S2DON, he indicated he was the Infection Control Officer for the hospital. S2DON indicated the infection control policy titled, "Infection Control Surveillance" was the most current policy and had not been reviewed or revised since 06/01/11. S2DON indicated he maintained the hospital's infection control log which consisted of urine cultures, a few wound cultures, and a few chest x-rays (for pneumonia) since January 2013. S2DON indicated the data collected on the infection control log included: the patient's name and admit date, whether the culture was urine or from a wound, when the culture or x-ray (for pneumonia) was taken, the organism(s) grown, the antibiotics used, the re-culture date, and the date the infection was resolved. S2DON further indicated the infection control log did not indicate whether the infection was present upon admit or hospital acquired. S2DON indicated he had not analyzed the data or investigated the data in order to identify infection control concerns or evaluate the infection control program. S2DON further indicated that the infection control report to the C.P.I. committee consisted only of reporting the number of clinical labs completed and the number of x-rays completed. S2DON indicated that the report to the C.P.I. committee did not include any other data, analysis, outcomes, or follow-ups. S2DON indicated that he had no other documented infection control data, data analysis, reports, surveillance, or any other infection control activities to show the surveyors.


30172

Based on record review and interview, the hospital failed to ensure it had a contract with a tissue and eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of tissues and eyes when appropriate.
Findings:

Review of the contracts, presented as the hospital's current contracts by S1Administrator, revealed no documented evidence that the hospital had a contract with a tissue and eye bank to provide services if needed.

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated the tissue and eye bank contract should have been in the contract binder. S1Administrator was informed during the interview that no such contract had been seen in the binder, and she should present the contract to the survey team before exit if she found it. S1Administrator did not present a tissue and eye bank contract to the survey team by 10/31/13 at 1:40 p.m. at the time of the exit conference.

Based on interview, the hospital failed to ensure there was a director of rehabilitation services to properly supervise and administer the services as evidenced by not having a rehabilitation staff member designated as the director of rehabilitation services with the responsibility to supervise and administer the services provided to patients.
Findings:

In a face-to-face interview on 10/29/13 at 2:15 p.m., S1Administrator indicated no one had been assigned the role and duties of Director of Rehabilitation Services. She further indicated that the physical therapist is the lead therapist.

Based on record reviews and interviews, the hospital failed to ensure that the rehabilitation staff were oriented and assessed for competency in performing their rehabilitation job duties as evidenced by having no documented evidence of orientation and competency evaluations related to rehabilitation functions but rather the same competency evaluation completed for the nursing staff for 1 of 1 physical therapist's (PT) personnel file reviewed (S12) from a total of 1 employed PT, 1 of 1 Certified Occupational Therapy Assistant's (COTA) personnel file reviewed (S13) from a total of 1 employed COTA, 1 of 1 Physical Therapy Assistant's (PTA) personnel file reviewed (S14) from a total of 1 employed PTA, 1 of 1 Speech and Language Pathologist's (SLP) personnel file reviewed (S15) from a total of 1 employed SLP, and 1 of 1 Occupational Therapist's (OT) personnel file reviewed (S16) from a total of 2 employed OTs. Findings:

Review of the personnel files for S12PT, S13COTA, S14PTA, S15SLP and S16OT revealed no documented evidence of orientation to the rehabilitation department. Further review revealed each file had a copy of the competency skills checklist used by the nursing staff. There was no documented evidence of an evaluation of competency relative to the duties of a PT, PTA, COTA, OT and SLP in each their respective personnel files.

In a face-to-face interview on 10/31/13 at 11:35 a.m. with S1Administrator and S2DON (Director of Nursing) present, S2DON indicated that the department head is responsible for each department's competency evaluations and orientation when asked who was responsible for orientation and evaluation. He further indicated that he was responsible for the nursing department and S16OT was responsible for the rehabilitation department. When informed that the rehabilitation personnel file reviews revealed no evidence of orientation and competency evaluations related to rehabilitation services, S2DON indicated that the rehabilitation department fell under the general orientation and competency policies. He offered no explanation for the personnel files not having documented evidence of an evaluation of competency for performing the duties required by a PT, PTA, OT, COTA, and SLP.

Based on record review and interview, the hospital failed to ensure that the scope of diagnostic and/or therapeutic respiratory services was defined in writing and approved by the Medical Staff as evidenced by failure to have the Governing Body By-laws designate Respiratory Services as one of the clinical and ancillary services provided by the hospital. The Medical Staff By-laws failed to include approval of the scope of diagnostic and/or therapeutic respiratory services provided by the hospital.
Findings:

Review of the Governing Body By-laws, presented as the current amended by-laws by S1Administrator, revealed that Respiratory Services was not listed as clinical and ancillary service offered by the hospital. Review of the Medical Staff By-laws revealed no documented evidence that respiratory services was addressed in the by-laws.

Review of the hospital policy titled "Respiratory Therapy", contained in the policy manual presented as the current policies by S1Administrator, revealed that the nursing personnel would administer nebulizer treatments and oxygen therapy as ordered by the physician, and a respiratory therapist may be used on an as needed basis for treatments and assessments.

In a face-to-face interview on 10/31/13 at 11:35 a.m., S2Director of Nursing (DON) indicated that the nursing staff administer the respiratory treatments to patients, and they have a respiratory therapist available if needed.

Based on record review and interview, the hospital failed to ensure:
1) the respiratory services policy designated the amount of supervision that was required for the personnel who performed respiratory therapy procedures and
2) the nurses and respiratory therapist performing respiratory therapy treatments had been oriented and evaluated for competency to perform these procedures as evidenced by failure to have documented evidence of competency evaluations for providing respiratory treatments in 1 of 1 respiratory therapy personnel file reviewed (S21) from a total of 1 respiratory therapist (RT) employed and 5 of 5 RNs' (S2, S3, S4, S17, S18) and 2 of 2 LPNs' (licensed practical nurses) (S19, S20) personnel files reviewed for competency for providing respiratory treatments from a total of 5 employed RNs and 4 employed LPNs.
Findings:

1) The respiratory services policy designated the amount of supervision that was required for the personnel who performed respiratory therapy procedures:
Review of the hospital policy titled "Respiratory Therapy", contained in the policy manual presented as the current policies by S1Administrator, revealed no documented evidence of the amount of supervision that was required for the personnel who performed respiratory therapy procedures.

In a face-to-face interview on 10/31/13 at 11:35 a.m., S2Director of Nursing (DON) indicated that the nursing staff administer the respiratory treatments to patients, and they have a respiratory therapist available if needed. There was no explanation offered relative to the amount of supervision required.

2) The nurses and respiratory therapist performing respiratory therapy treatments had been oriented and evaluated for competency to perform these procedures as evidenced by failure to have documented evidence of competency evaluations for providing respiratory treatments in their personnel files:

Review of the personnel files of S21RT, S2DON, S3ADON (assistant director of nursing), S4RN, S17RN, S18RN, S19LPN (licensed practical nurse) and S20LPN revealed no documented evidence of any training and evaluation of competency on performing respiratory treatments and administering oxygen. The skills checklist addressed the respiratory equipment and not the performance of specific procedures.

In a face-to-face interview on 10/31/13 at 11:35 a.m. S2DON indicated that the nurses administer respiratory treatments as well as the RT. He offered no explanation for not having evidence of competency evaluations conducted relative to the nurses' and the RT's ability to competently administer oxygen and respiratory treatments.

Based on observation, record reviews, and interviews, the hospital failed to: 1) ensure that current menus provided by the hospital were posted and 2) develop screening criteria to identify patients at nutritional risk.
Findings:

1) Ensure that current menus provided by the hospital were posted:
Observations throughout the survey from 10/28/13 through 10/31/13 revealed no evidence that menus for meals provided to patients in the hospital were posted.

In a telephone interview on 10/31/13 at 8:50 a.m., S24Contracted Registered Dietitian (RD) indicated that she was not involved in menu planning. She further indicated the meals were provided by Hospital B.

2) Develop screening criteria to identify patients at nutritional risk:
Review of the hospital policy titled "Dietary Procedures", contained in the policy manual presented as the current policies by S1Administrator, revealed that the RD is on contract and will see patients that require dietary intervention, especially tube feed patients and wound care patients as the physician orders dictate. Review of the entire policy and all policies contained in the policy manual presented as the current policies by S1Administrator revealed no documented evidence of screening criteria to identify patients at nutritional risk. There was no documented evidence of a time interval in which the nutritional assessment had to be performed by the RD once a physician's order was written.

Review of the "Admission Assessment Form" completed by the Registered Nurse for each patient admitted revealed the following information was gathered related to the patient's nutritional needs: gag reflex, dietary diet, supplements, presence of dentures or if edentulous, appetite, swallowing difficulties, whether the patient was NPO (nothing by mouth), had a PEG tube (percutaneous esophageal gastrostomy), or had a nasogastric tube, whether overweight or underweight, whether there had been a recent weight loss or gain and how many pounds. Further review revealed no direction to the nurse to determine if any of these assessments required the physician to be contacted for a dietary consult.

In a telephone interview on 10/31/13 at 8:50 a.m., S24RD indicated, when asked if she's required to assess all patients' nutritional risk and need, she should but sometimes the patients' stays aren't long enough. When asked if there were any criteria developed that would trigger the need for a nutritional assessment by her, S24RD indicated some things would be if the patient was morbidly obese, his/her age, the length of stay, and the diagnosis. When asked if the nursing staff was aware of these criteria, she indicated that she didn't know if there was a policy that addressed the criteria.